Professional Documents
Culture Documents
PNLE Pre Board With Rationale 1
PNLE Pre Board With Rationale 1
1. Nurse Betty is assigned to the following clients. The client that the nurse would see first after
endorsement?
a. A 34 year-old post operative appendectomy client of five hours who is complaining of pain.
b. A 44 year-old myocardial infarction (MI) client who is complaining of nausea.
c. A 26 year-old client admitted for dehydration whose intravenous (IV) has infiltrated.
d. A 63 year-old post operative’s abdominal hysterectomy client of three days whose incisional dressing
is saturated with serosanguinous fluid.
2. Nurse Gail places a client in a four-point restraint following orders from the physician. The client care
plan should include:
3. A male client who has severe burns is receiving H2 receptor antagonist therapy. The nurse In-charge
knows the purpose of this therapy is to:
4. The doctor orders hourly urine output measurement for a postoperative male client. The nurse Trish
records the following amounts of output for 2 consecutive hours: 8 a.m.: 50 ml; 9 a.m.: 60 ml. Based on
these amounts, which action should the nurse take?
6.The physician prescribes a loop diuretic for a client. When administering this drug, the nurse
anticipates that the client may develop which electrolyte imbalance?
a. Hypernatremia
b. Hyperkalemia
c. Hypokalemia
d. Hypervolemia
7.She finds out that some managers have benevolent-authoritative style of management. Which of the
following behaviors will she exhibit most likely?
8. Nurse Amy is aware that the following is true about functional nursing
9.Which type of medication order might read "Vitamin K 10 mg I.M. daily × 3 days?"
a. Single order
b. Standard written order
c. Standing order
d. Stat order
10.A female client with a fecal impaction frequently exhibits which clinical manifestation?
a. Increased appetite
b. Loss of urge to defecate
c. Hard, brown, formed stools
d. Liquid or semi-liquid stools
11.Nurse Linda prepares to perform an otoscopic examination on a female client. For proper
visualization, the nurse should position the client's ear by:
12. Nurse Michelle is assessing a 24 year old client with a diagnosis of hydatidiform mole. She is aware
that one of the following is unassociated with this condition?
a. Excessive fetal activity.
b. Larger than normal uterus for gestational age.
c. Vaginal bleeding
d. Elevated levels of human chorionic gonadotropin.
13. A pregnant client is receiving magnesium sulfate for severe pregnancy induced hypertension (PIH).
The clinical findings that would warrant use of the antidote , calcium gluconate is:
a. Urinary output 90 cc in 2 hours.
b. Absent patellar reflexes.
c. Rapid respiratory rate above 40/min.
d. Rapid rise in blood pressure.
14. During vaginal examination of Janah who is in labor, the presenting part is at station plus two. Nurse,
correctly interprets it as:
a. Presenting part is 2 cm above the plane of the ischial spines.
b. Biparietal diameter is at the level of the ischial spines.
c. Presenting part in 2 cm below the plane of the ischial spines.
d. Biparietal diameter is 2 cm above the ischial spines.
15. A pregnant client is receiving oxytocin (Pitocin) for induction of labor. A condition that warrant the
nurse in-charge to discontinue I.V. infusion of Pitocin is:
16. Calcium gluconate is being administered to a client with pregnancy induced hypertension (PIH). A
nursing action that must be initiated as the plan of care throughout injection of the drug is:
a. Ventilator assistance
b. CVP readings
c. EKG tracings
d. Continuous CPR
17. A trial for vaginal delivery after an earlier caesareans, would likely to be given to a gravida, who had:
a. First low transverse cesarean was for active herpes type 2 infections; vaginal culture at 39 weeks
pregnancy was positive.
b. First and second caesareans were for cephalopelvic disproportion.
c. First caesarean through a classic incision as a result of severe fetal distress.
d. First low transverse caesarean was for breech position. Fetus in this pregnancy is in a vertex
presentation.
18.Nurse Ryan is aware that the best initial approach when trying to take a crying toddler’s temperature
is:
a. Talk to the mother first and then to the toddler.
b. Bring extra help so it can be done quickly.
c. Encourage the mother to hold the child.
d. Ignore the crying and screaming.
19.Baby Tina a 3 month old infant just had a cleft lip and palate repair. What should the nurse do to
prevent trauma to operative site?
20. Which action should nurse Marian include in the care plan for a 2 month old with heart failure?
21.Nurse Hazel is teaching a mother who plans to discontinue breast feeding after 5 months. The nurse
should advise her to include which foods in her infant’s diet?
23. Nurse Monett is caring for a client recovering from gastro-intestinal bleeding. The nurse should:
a. Plan care so the client can receive 8 hours of uninterrupted sleep each night.
b. Monitor vital signs every 2 hours.
c. Make sure that the client takes food and medications at prescribed intervals.
d. Provide milk every 2 to 3 hours.
24. A male client was on warfarin (Coumadin) before admission, and has been receiving heparin I.V. for
2 days. The partial thromboplastin time (PTT) is 68 seconds. What should Nurse Carla do?
25. A client undergone ileostomy, when should the drainage appliance be applied to the stoma?
27.While monitoring a male client several hours after a motor vehicle accident, which assessment data
suggest increasing intracranial pressure?
28.Mrs. Cruz, 80 years old is diagnosed with pneumonia. Which of the following symptoms may appear
first?
29. A male client has active tuberculosis (TB). Which of the following symptoms will be exhibit?
30. Mark, a 7-year-old client is brought to the emergency department. He’s tachypneic and afebrile and
has a respiratory rate of 36 breaths/minute and has
a nonproductive cough. He recently had a cold. Form this history; the client may have which of the
following conditions?
a. Acute asthma
b. Bronchial pneumonia
c. Chronic obstructive pulmonary disease (COPD)
d. Emphysema
31. Marichu was given morphine sulfate for pain. She is sleeping and her respiratory rate is 4
breaths/minute. If action isn’t taken quickly, she might have
which of the following reactions?
a. Asthma attack
b. Respiratory arrest
c. Seizure
d. Wake up on his own
32. A 77-year-old male client is admitted for elective knee surgery. Physical examination reveals shallow
respirations but no sign of respiratory distress. Which of the following is a normal physiologic change
related to aging?
33. Tracy is receiving combination chemotherapy for treatment of metastatic carcinoma. Nurse Ruby
should monitor the client for the systemic side effect of:
a. Ascites
b. Nystagmus
c. Leukopenia
d. Polycythemia
34. Norma, with recent colostomy expresses concern about the inability to control the passage of gas.
Nurse Oliver should suggest that the client plan to:
35. Nurse Ron begins to teach a male client how to perform colostomy irrigations. The nurse would
evaluate that the instructions were understood when the client states, “I should:
a. Administer Kayexalate
b. Restrict foods high in protein
c. Increase oral intake of cheese and milk.
d. Administer large amounts of normal saline via I.V.
37. Mario has burn injury. After Forty48 hours, the physician orders for Mario 2 liters of IV fluid to be
administered q12 h. The drop factor of the tubing is 10 gtt/ml. The nurse should set the flow to provide:
a. 18 gtt/min
b. 28 gtt/min
c. 32 gtt/min
d. 36 gtt/min
38.Terence suffered form burn injury. Using the rule of nines, which has the largest percent of burns?
39. Herbert, a 45 year old construction engineer is brought to the hospital unconscious after falling from
a 2-story building. When assessing the client, the nurse would be most concerned if the assessment
revealed:
a. Reactive pupils
b. A depressed fontanel
c. Bleeding from ears
d. An elevated temperature
40. Nurse Sherry is teaching male client regarding his permanent artificial pacemaker. Which
information given by the nurse shows her knowledge deficit about the artificial cardiac pacemaker?
a. take the pulse rate once a day, in the morning upon awakening
b. May be allowed to use electrical appliances
c. Have regular follow up care
d. May engage in contact sports
41.The nurse is ware that the most relevant knowledge about oxygen administration to a male client
with COPD is
42.Tonny has undergoes a left thoracotomy and a partial pneumonectomy. Chest tubes are inserted,
and one-bottle water-seal drainage is instituted in the operating room. In the postanesthesia care unit
Tonny is placed in Fowler's position on either his right side or on his back. The nurse is aware that this
position:
43. What is Nurse John likely to note in a male client being admitted for alcohol withdrawal?
a. Perceptual disorders.
b. Impending coma.
c. Recent alcohol intake.
d. Depression with mutism.
44. Aira has taken amitriptyline HCL (Elavil) for 3 days, but now complains that it “doesn’t help” and
refuses to take it. What should the nurse say or do?
a. Withhold the drug.
b. Record the client’s response.
c. Encourage the client to tell the doctor.
d. Suggest that it takes awhile before seeing the results.
45. Dervid, an adolescent has a history of truancy from school, running away from home and
“barrowing” other people’s things without their permission. The adolescent denies stealing, rationalizing
instead that as long as no one was using the items, it was all right to borrow them. It is important for the
nurse to understand the psychodynamically, this behavior may be largely attributed to a developmental
defect related to the:
a. Id
b. Ego
c. Superego
d. Oedipal complex
46. In preparing a female client for electroconvulsive therapy (ECT), Nurse Michelle knows that
succinylcoline (Anectine) will be administered for which therapeutic effect?
a. Short-acting anesthesia
b. Decreased oral and respiratory secretions.
c. Skeletal muscle paralysis.
d. Analgesia.
47. Nurse Gina is aware that the dietary implications for a client in manic phase of bipolar disorder is:
a. Serve the client a bowl of soup, buttered French bread, and apple slices.
b. Increase calories, decrease fat, and decrease protein.
c. Give the client pieces of cut-up steak, carrots, and an apple.
d. Increase calories, carbohydrates, and protein.
48.What parental behavior toward a child during an admission procedure should cause Nurse Ron to
suspect child abuse?
a. Flat affect
b. Expressing guilt
c. Acting overly solicitous toward the child.
d. Ignoring the child.
49.Nurse Lynnette notices that a female client with obsessive-compulsive disorder washes her hands for
long periods each day. How should the nurse respond to this compulsive behavior?
a. By designating times during which the client can focus on the behavior.
b. By urging the client to reduce the frequency of the behavior as rapidly as possible.
c. By calling attention to or attempting to prevent the behavior.
d. By discouraging the client from verbalizing anxieties.
50.After seeking help at an outpatient mental health clinic, Ruby who was raped while walking her dog is
diagnosed with posttraumatic stress disorder (PTSD). Three months later, Ruby returns to the
clinic, complaining of fear, loss of control, and helpless feelings. Which nursing intervention is most
appropriate for Ruby?
a. Recommending a high-protein, low-fat diet.
b. Giving sleep medication, as prescribed, to restore a normal sleepwake cycle.
c. Allowing the client time to heal.
d. Exploring the meaning of the traumatic event with the client.
14. Answer: (C) Presenting part in 2 cm below the plane of the ischial spines.
Rationale: Fetus at station plus two indicates that the presenting part is 2 cm below the plane of the
ischial spines.
17. Answer: (D) First low transverse caesarean was for breech position. Fetus in this pregnancy is in a
vertex presentation.
Rationale: This type of client has no obstetrical indication for a caesarean section as she did with her
first caesarean delivery.
18. Answer: (A) Talk to the mother first and then to the toddler.
Rationale: When dealing with a crying toddler, the best approach is to talk to the mother and ignore the
toddler first. This approach helps the toddler get used to the nurse before she attempts any procedures.
It also gives the toddler an opportunity to see that the mother trusts the nurse.
19. Answer: (D) Place the infant’s arms in soft elbow restraints.
Rationale: Soft restraints from the upper arm to the wrist prevent the infant from touching her lip but
allow him to hold a favorite item such as a blanket. Because they could damage the operative site, such
as objects as pacifiers, suction catheters, and small spoons shouldn’t be placed in a baby’s mouth after
cleft repair. A baby in a prone position may rub her face on the sheets and traumatize the operative site.
The suture line should be cleaned gently to prevent infection, which could interfere with healing and
damage the cosmetic appearance of the repair.
22. Answer: (A) Call for help and note the time.
Rationale: Having established, by stimulating the client, that the client is unconscious rather than sleep,
the nurse should immediately call for help. This may be done by dialing the operator from the client’s
phone and giving the hospital code for cardiac arrest and the client’s room number to the operator, of if
the phone is not available, by pulling the emergency call button. Noting the time is important baseline
information for cardiac arrest procedure.
23. Answer: (C) Make sure that the client takes food and medications at prescribed intervals.
Rationale: Food and drug therapy will prevent the accumulation of hydrochloric acid, or will neutralize
and buffer the acid that does accumulate.
34. Answer: (C) Avoid foods that in the past caused flatus.
Rationale: Foods that bothered a person preoperatively will continue to do so after a colostomy.
35. Answer: (B) Keep the irrigating container less than 18 inches above the stoma.”
Rationale: This height permits the solution to flow slowly with little force so that excessive peristalsis is
not immediately precipitated.
41. Answer: (A) Oxygen at 1-2L/min is given to maintain the hypoxic stimulus for breathing.
Rationale: COPD causes a chronic CO2 retention that renders the medulla insensitive to the CO2
stimulation for breathing. The hypoxic state of the client then becomes the stimulus for breathing.
Giving the client oxygen in low concentrations will maintain the client’s hypoxic drive.
44. Answer: (D) Suggest that it takes awhile before seeing the results.
Rationale: The client needs a specific response; that it takes 2 to 3 weeks (a delayed effect) until the
therapeutic blood level is reached.
49. Answer: (A) By designating times during which the client can focus on the behavior.
Rationale: The nurse should designate times during which the client can focus on the compulsive
behavior or obsessive thoughts. The nurse should urge the client to reduce the frequency of the
compulsive behavior gradually, not rapidly. She shouldn't call attention to or try to prevent the behavior.
Trying to prevent the behavior may cause pain and terror in the client. The nurse should encourage the
client to verbalize anxieties to help distract attention from the compulsive behavior.
50. Answer: (D) Exploring the meaning of the traumatic event with the client.
Rationale: The client with PTSD needs encouragement to examine and understand the meaning of the
traumatic event and consequent losses. Otherwise, symptoms may worsen and the client may become
depressed or engage in self-destructive behavior such as substance abuse. The client must explore the
meaning of the event and won't heal without this, no matter how much time passes. Behavioral
techniques, such as relaxation therapy, may help decrease the client's anxiety and induce sleep. The
physician may prescribe antianxiety agents or antidepressants cautiously to avoid dependence; sleep
medication is rarely appropriate. A special diet isn't indicated unless the client also has an eating
disorder or a nutritional problem.
Nursing Practice I -Foundation of Professional Nursing Practice
1. The nurse In-charge in labor and delivery unit administered a dose of terbutaline to a client without
checking the client’s pulse. The standard that would be used to determine if the nurse was negligent is:
2. Nurse Trish is caring for a female client with a history of GI bleeding, sickle cell disease, and a platelet
count of 22,000/μl. The female client is dehydrated and receiving dextrose 5% in half-normal saline
solution at 150 ml/hr. The client complains of severe bone pain and is scheduled to receive a dose of
morphine sulfate. In administering the medication, Nurse Trish should avoid which route?
a. I.V
b. I.M
c. Oral
d. S.C
3. Dr. Garcia writes the following order for the client who has been recently admitted “Digoxin .125 mg
P.O. once daily.” To prevent a dosage error, how should the nurse document this order onto the
medication administration record?
4. A newly admitted female client was diagnosed with deep vein thrombosis. Which nursing diagnosis
should receive the highest priority?
5. Nurse Betty is assigned to the following clients. The client that the nurse would see first after
endorsement?
a. A 34 year-old post operative appendectomy client of five hours who is complaining of pain.
b. A 44 year-old myocardial infarction (MI) client who is complaining of nausea.
c. A 26 year-old client admitted for dehydration whose intravenous (IV) has infiltrated.
d. A 63 year-old post operative’s abdominal hysterectomy client of three days whose incisional dressing
is saturated with serosanguinous fluid.
6. Nurse Gail places a client in a four-point restraint following orders from the physician. The client care
plan should include:
a. Assess temperature frequently.
b. Provide diversional activities.
c. Check circulation every 15-30 minutes.
d. Socialize with other patients once a shift.
7. A male client who has severe burns is receiving H2 receptor antagonist therapy. The nurse In-charge
knows the purpose of this therapy is to:
a. Prevent stress ulcer
b. Block prostaglandin synthesis
c. Facilitate protein synthesis.
d. Enhance gas exchange
8. The doctor orders hourly urine output measurement for a postoperative male client. The nurse Trish
records the following amounts of output for 2 consecutive hours: 8 a.m.: 50 ml; 9 a.m.: 60 ml. Based on
these amounts, which action should the nurse take?
a. Increase the I.V. fluid infusion rate
b. Irrigate the indwelling urinary catheter
c. Notify the physician
d. Continue to monitor and record hourly urine output
9. Tony, a basketball player twist his right ankle while playing on the court and seeks care for ankle pain
and swelling. After the nurse applies ice to the ankle for 30 minutes, which statement by Tony suggests
that ice application has been effective?
a. “My ankle looks less swollen now”.
b. “My ankle feels warm”.
c. “My ankle appears redder now”.
d. “I need something stronger for pain relief”
10.The physician prescribes a loop diuretic for a client. When administering this drug, the nurse
anticipates that the client may develop which electrolyte imbalance?
a. Hypernatremia
b. Hyperkalemia
c. Hypokalemia
d. Hypervolemia
11.She finds out that some managers have benevolent-authoritative style of management. Which of the
following behaviors will she exhibit most likely?
a. Have condescending trust and confidence in their subordinates.
b. Gives economic and ego awards.
c. Communicates downward to staffs.
d. Allows decision making among subordinates.
12. Nurse Amy is aware that the following is true about functional nursing
a. Provides continuous, coordinated and comprehensive nursing services.
b. One-to-one nurse patient ratio.
c. Emphasize the use of group collaboration.
d. Concentrates on tasks and activities.
13.Which type of medication order might read "Vitamin K 10 mg I.M. daily × 3 days?"
a. Single order
b. Standard written order
c. Standing order
d. Stat order
14.A female client with a fecal impaction frequently exhibits which clinical manifestation?
a. Increased appetite
b. Loss of urge to defecate
c. Hard, brown, formed stools
d. Liquid or semi-liquid stools
15.Nurse Linda prepares to perform an otoscopic examination on a female client. For proper
visualization, the nurse should position the client's ear by:
16. Which instruction should nurse Tom give to a male client who is having external radiation therapy:
17.In assisting a female client for immediate surgery, the nurse In-charge is aware that she should:
18. A male client is admitted and diagnosed with acute pancreatitis after a holiday celebration of
excessive food and alcohol. Which assessment finding reflects this diagnosis?
19. Which dietary guidelines are important for nurse Oliver to implement in caring for the client with
burns?
20.Nurse Hazel will administer a unit of whole blood, which priority information should the nurse have
about the client?
21. Nurse Michelle witnesses a female client sustain a fall and suspects that the leg may be broken. The
nurse takes which priority action?
22.A male client is being transferred to the nursing unit for admission after receiving a radium implant
for bladder cancer. The nurse in-charge would take which priority action in the care of this client?
23.A newly admitted female client was diagnosed with agranulocytosis. The nurse formulates which
priority nursing diagnosis?
a. Constipation
b. Diarrhea
c. Risk for infection
d. Deficient knowledge
24.A male client is receiving total parenteral nutrition suddenly demonstrates signs and symptoms of an
air embolism. What is the priority action by the nurse?
25.Nurse May attends an educational conference on leadership styles. The nurse is sitting with a nurse
employed at a large trauma center who states that the leadership style at the trauma center is task-
oriented and directive. The nurse determines that the leadership style used at the trauma center is:
a. Autocratic.
b. Laissez-faire.
c. Democratic.
d. Situational
26.The physician orders DS 500 cc with KCl 10 mEq/liter at 30 cc/hr. The nurse in-charge is going to hang
a 500 cc bag. KCl is supplied 20 mEq/10 cc. How many cc’s of KCl will be added to the IV solution?
a. .5 cc
b. 5 cc
c. 1.5 cc
d. 2.5 cc
27.A child of 10 years old is to receive 400 cc of IV fluid in an 8 hour shift. The IV drip factor is 60. The IV
rate that will deliver this amount is:
a. 50 cc/ hour
b. 55 cc/ hour
c. 24 cc/ hour
d. 66 cc/ hour
28.The nurse is aware that the most important nursing action when a client returns from surgery is:
29. Which of the following vital sign assessments that may indicate cardiogenic shock after myocardial
infarction?
30.Which is the most appropriate nursing action in obtaining a blood pressure measurement?
a. Take the proper equipment, place the client in a comfortable position, and record the appropriate
information in the client’s chart.
b. Measure the client’s arm, if you are not sure of the size of cuff to use.
c. Have the client recline or sit comfortably in a chair with the forearm at the level of the heart.
d. Document the measurement, which extremity was used, and the position that the client was in during
the measurement.
31.Asking the questions to determine if the person understands the health teaching provided by the
nurse would be included during which step of the nursing process?
a. Assessment
b. Evaluation
c. Implementation
d. Planning and goals
32.Which of the following item is considered the single most important factor in assisting the health
professional in arriving at a diagnosis or determining the person’s needs?
33.In preventing the development of an external rotation deformity of the hip in a client who must
remain in bed for any period of time, the most appropriate nursing action would be to use:
a. Trochanter roll extending from the crest of the ileum to the midthigh.
b. Pillows under the lower legs.
c. Footboard
d. Hip-abductor pillow
34.Which stage of pressure ulcer development does the ulcer extend into the subcutaneous tissue?
a. Stage I
b. Stage II
c. Stage III
d. Stage IV
35.When the method of wound healing is one in which wound edges are not surgically approximated
and integumentary continuity is restored by granulations, the wound healing is termed
36.An 80-year-old male client is admitted to the hospital with a diagnosis of pneumonia. Nurse Oliver
learns that the client lives alone and hasn’t been eating or drinking. When assessing him for
dehydration, nurse Oliver would expect to find:
a. Hypothermia
b. Hypertension
c. Distended neck veins
d. Tachycardia
37.The physician prescribes meperidine (Demerol), 75 mg I.M. every 4 hours as needed, to control a
client’s postoperative pain. The package insert is “Meperidine, 100 mg/ml.” How many milliliters of
meperidine should the
client receive?
a. 0.75
b. 0.6
c. 0.5
d. 0.25
38. A male client with diabetes mellitus is receiving insulin. Which statement correctly describes an
insulin unit?
39.Nurse Oliver measures a client’s temperature at 102° F. What is the equivalent Centigrade
temperature?
a. 40.1 °C
b. 38.9 °C
c. 48 °C
d. 38 °C
40.The nurse is assessing a 48-year-old client who has come to the physician’s office for his annual
physical exam. One of the first physical
signs of aging is:
41.The physician inserts a chest tube into a female client to treat a pneumothorax. The tube is
connected to water-seal drainage. The nurse in-charge can prevent chest tube air leaks by:
42.Nurse Trish must verify the client’s identity before administering medication. She is aware that the
safest way to verify identity is to:
a. 30 drops/minute
b. 32 drops/minute
c. 20 drops/minute
d. 18 drops/minute
44.If a central venous catheter becomes disconnected accidentally, what should the nurse in-charge do
immediately?
45.A female client was recently admitted. She has fever, weight loss, and watery diarrhea is being
admitted to the facility. While assessing the client, Nurse Hazel inspects the client’s abdomen and notice
that it is slightly concave. Additional assessment should proceed in which order:
46. Nurse Betty is assessing tactile fremitus in a client with pneumonia. For this examination, nurse Betty
should use the:
a. Fingertips
b. Finger pads
c. Dorsal surface of the hand
d. Ulnar surface of the hand
47. Which type of evaluation occurs continuously throughout the teaching and learning process?
a. Summative
b. Informative
c. Formative
d. Retrospective
48.A 45 year old client, has no family history of breast cancer or other risk factors for this disease. Nurse
John should instruct her to have
mammogram how often?
49.A male client has the following arterial blood gas values: pH 7.30; Pao2 89 mmHg; Paco2 50 mmHg;
and HCO3 26mEq/L. Based on these values, Nurse Patricia should expect which condition?
a. Respiratory acidosis
b. Respiratory alkalosis
c. Metabolic acidosis
d. Metabolic alkalosis
50.Nurse Len refers a female client with terminal cancer to a local hospice. What is the goal of this
referral?
51.When caring for a male client with a 3-cm stage I pressure ulcer on the coccyx, which of the following
actions can the nurse institute
independently?
52.Nurse Oliver must apply an elastic bandage to a client’s ankle and calf. He should apply the bandage
beginning at the client’s:
a. Knee
b. Ankle
c. Lower thigh
d. Foot
53.A 10 year old child with type 1 diabetes develops diabetic ketoacidosis and receives a continuous
insulin infusion. Which condition represents the greatest risk to this child?
a. Hypernatremia
b. Hypokalemia
c. Hyperphosphatemia
d. Hypercalcemia
54.Nurse Len is administering sublingual nitrglycerin (Nitrostat) to the newly admitted client.
Immediately afterward, the client may experience:
a. Throbbing headache or dizziness
b. Nervousness or paresthesia.
c. Drowsiness or blurred vision.
d. Tinnitus or diplopia.
55.Nurse Michelle hears the alarm sound on the telemetry monitor. The nurse quickly looks at the
monitor and notes that a client is in a ventricular tachycardia. The nurse rushes to the client’s room.
Upon reaching the client’s bedside, the nurse would take which action first?
56.Nurse Hazel is preparing to ambulate a female client. The best and the safest position for the nurse in
assisting the client is to stand:
57.Nurse Janah is monitoring the ongoing care given to the potential organ donor who has been
diagnosed with brain death. The nurse determines that the standard of care had been maintained if
which of the following data is observed?
58. Nurse Amy has an order to obtain a urinalysis from a male client with an indwelling urinary catheter.
The nurse avoids which of the following, which contaminate the specimen?
a. Wiping the port with an alcohol swab before inserting the syringe.
b. Aspirating a sample from the port on the drainage bag.
c. Clamping the tubing of the drainage bag.
d. Obtaining the specimen from the urinary drainage bag.
59.Nurse Meredith is in the process of giving a client a bed bath. In the middle of the procedure, the unit
secretary calls the nurse on the intercom to tell the nurse that there is an emergency phone call. The
appropriate nursing action is to:
a. Immediately walk out of the client’s room and answer the phone call.
b. Cover the client, place the call light within reach, and answer the phone call.
c. Finish the bed bath before answering the phone call.
d. Leave the client’s door open so the client can be monitored and the nurse can answer the phone call.
60. Nurse Janah is collecting a sputum specimen for culture and sensitivity testing from a client who has
a productive cough. Nurse Janah plans to implement which intervention to obtain the specimen?
a. Ask the client to expectorate a small amount of sputum into the emesis basin.
b. Ask the client to obtain the specimen after breakfast.
c. Use a sterile plastic container for obtaining the specimen.
d. Provide tissues for expectoration and obtaining the specimen.
61. Nurse Ron is observing a male client using a walker. The nurse determines that the client is using the
walker correctly if the client:
a. Puts all the four points of the walker flat on the floor, puts weight on the hand pieces, and then walks
into it.
b. Puts weight on the hand pieces, moves the walker forward, and then walks into it.
c. Puts weight on the hand pieces, slides the walker forward, and then walks into it.
d. Walks into the walker, puts weight on the hand pieces, and then puts all four points of the walker flat
on the floor.
62.Nurse Amy has documented an entry regarding client care in the client’s medical record. When
checking the entry, the nurse realizes that incorrect information was documented. How does the nurse
correct this error?
63.Nurse Ron is assisting with transferring a client from the operating room table to a stretcher. To
provide safety to the client, the nurse should:
64.Nurse Myrna is providing instructions to a nursing assistant assigned to give a bed bath to a client
who is on contact precautions. Nurse Myrna instructs the nursing assistant to use which of the following
protective items when giving bed bath?
65. Nurse Oliver is caring for a client with impaired mobility that occurred as a result of a stroke. The
client has right sided arm and leg weakness. The nurse would suggest that the client use which of the
following assistive devices that would provide the best stability for ambulating?
a. Crutches
b. Single straight-legged cane
c. Quad cane
d. Walker
66.A male client with a right pleural effusion noted on a chest X-ray is being prepared for thoracentesis.
The client experiences severe dizziness when sitting upright. To provide a safe environment, the nurse
assists the client to which position for the procedure?
67.Nurse John develops methods for data gathering. Which of the following criteria of a good
instrument refers to the ability of the instrument to yield the same results upon its repeated
administration?
a. Validity
b. Specificity
c. Sensitivity
d. Reliability
68.Harry knows that he has to protect the rights of human research subjects. Which of the following
actions of Harry ensures anonymity?
a. Descriptive- correlational
b. Experiment
c. Quasi-experiment
d. Historical
70.Nurse Ronald is aware that the best tool for data gathering is?
a. Interview schedule
b. Questionnaire
c. Use of laboratory data
d. Observation
71.Monica is aware that there are times when only manipulation of study variables is possible and the
elements of control or randomization are not attendant. Which type of research is referred to this?
a. Field study
b. Quasi-experiment
c. Solomon-Four group design
d. Post-test only design
72.Cherry notes down ideas that were derived from the description of an investigation written by the
person who conducted it. Which type of reference source refers to this?
a. Footnote
b. Bibliography
c. Primary source
d. Endnotes
73.When Nurse Trish is providing care to his patient, she must remember that her duty is bound not to
do doing any action that will cause the patient harm. This is the meaning of the bioethical principle:
a. Non-maleficence
b. Beneficence
c. Justice
d. Solidarity
74.When a nurse in-charge causes an injury to a female patient and the injury caused becomes the proof
of the negligent act, the presence of the injury is said to exemplify the principle of:
a. Force majeure
b. Respondeat superior
c. Res ipsa loquitor
d. Holdover doctrine
75.Nurse Myrna is aware that the Board of Nursing has quasi-judicial power. An example of this power
is:
a. The Board can issue rules and regulations that will govern the practice of nursing
b. The Board can investigate violations of the nursing law and code of ethics
c. The Board can visit a school applying for a permit in collaboration with CHED
d. The Board prepares the board examinations
76. When the license of nurse Krina is revoked, it means that she:
a. Is no longer allowed to practice the profession for the rest of her life
b. Will never have her/his license re-issued since it has been revoked
c. May apply for re-issuance of his/her license based on certain conditions stipulated in RA 9173
d. Will remain unable to practice professional nursing
77.Ronald plans to conduct a research on the use of a new method of pain assessment scale. Which of
the following is the second step in the conceptualizing phase of the research process?
78. The leader of the study knows that certain patients who are in a specialized research setting tend to
respond psychologically to the conditions of the study. This referred to as :
79.Mary finally decides to use judgment sampling on her research. Which of the following actions of is
correct?
80. The nursing theorist who developed transcultural nursing theory is:
a. Florence Nightingale
b. Madeleine Leininger
c. Albert Moore
d. Sr. Callista Roy
81.Marion is aware that the sampling method that gives equal chance to all units in the population to
get picked is:
a. Random
b. Accidental
c. Quota
d. Judgment
84.Ms. Garcia is responsible to the number of personnel reporting to her. This principle refers to:
a. Span of control
b. Unity of command
c. Downward communication
d. Leader
85.Ensuring that there is an informed consent on the part of the patient before a surgery is done,
illustrates the bioethical principle of:
a. Beneficence
b. Autonomy
c. Veracity
d. Non-maleficence
86.Nurse Reese is teaching a female client with peripheral vascular disease about foot care; Nurse Reese
should include which instruction?
87.A client is admitted with multiple pressure ulcers. When developing the client's diet plan, the nurse
should include:
88.The nurse prepares to administer a cleansing enema. What is the most common client position used
for this procedure?
a. Lithotomy
b. Supine
c. Prone
d. Sims’ left lateral
89.Nurse Marian is preparing to administer a blood transfusion. Which action should the nurse take
first?
a. Arrange for typing and cross matching of the client’s blood.
b. Compare the client’s identification wristband with the tag on the unit of blood.
c. Start an I.V. infusion of normal saline solution.
d. Measure the client’s vital signs.
90.A 65 years old male client requests his medication at 9 p.m. instead of 10 p.m. so that he can go to
sleep earlier. Which type of nursing intervention is required?
a. Independent
b. Dependent
c. Interdependent
d. Intradependent
91.A female client is to be discharged from an acute care facility after treatment for right leg
thrombophlebitis. The Nurse Betty notes that the client's leg is pain-free, without redness or edema.
The nurse's actions reflect which step of the nursing process?
a. Assessment
b. Diagnosis
c. Implementation
d. Evaluation
92.Nursing care for a female client includes removing elastic stockings once per day. The Nurse Betty is
aware that the rationale for this intervention?
93.Which nursing intervention takes highest priority when caring for a newly admitted client who's
receiving a blood transfusion?
94.A male client complains of abdominal discomfort and nausea while receiving tube feedings. Which
intervention is most appropriate for this problem?
95.Nurse Patricia is reconstituting a powdered medication in a vial. After adding the solution to the
powder, she nurse should:
a. Do nothing.
b. Invert the vial and let it stand for 3 to 5 minutes.
c. Shake the vial vigorously.
d. Roll the vial gently between the palms.
96.Which intervention should the nurse Trish use when administering oxygen by face mask to a female
client?
97.The maximum transfusion time for a unit of packed red blood cells (RBCs) is:
a. 6 hours
b. 4 hours
c. 3 hours
d. 2 hours
98.Nurse Monique is monitoring the effectiveness of a client's drug therapy. When should the nurse
Monique obtain a blood sample to measure the trough drug level?
99.Nurse May is aware that the main advantage of using a floor stock system is:
100. Nurse Oliver is assessing a client's abdomen. Which finding should the nurse report as abnormal?
5. Answer: (B) A 44 year-old myocardial infarction (MI) client who is complaining of nausea.
Rationale: Nausea is a symptom of impending myocardial infarction (MI) and should be assessed
immediately so that treatment can be instituted and further damage to the heart is avoided.
12. Answer: (A) Provides continuous, coordinated and comprehensive nursing services.
Rationale: Functional nursing is focused on tasks and activities and not on the care of the patients.
17. Answer: (C) Assist the client in removing dentures and nail polish.
Rationale: Dentures, hairpins, and combs must be removed. Nail polish must be removed so that
cyanosis can be easily monitored by observing the nail beds.
18. Answer: (D) Sudden onset of continuous epigastric and back pain.
Rationale: The autodigestion of tissue by the pancreatic enzymes results in pain from inflammation,
edema, and possible hemorrhage. Continuous, unrelieved epigastric or back pain reflects the
inflammatory process in the pancreas.
24. Answer: (B) Place the client on the left side in the Trendelenburg position.
Rationale: Lying on the left side may prevent air from flowing into the pulmonary veins. The
Trendelenburg position increases intrathoracic pressure, which decreases the amount of blood pulled
into the vena cava during aspiration.
30. Answer: (A) Take the proper equipment, place the client in a comfortable position, and record the
appropriate information in the client’s chart.
Rationale: It is a general or comprehensive statement about the correct procedure, and it includes the
basic ideas which are found in the other options
33. Answer: (A) Trochanter roll extending from the crest of the ileum to the mid-thigh.
Rationale: A trochanter roll, properly placed, provides resistance to the external rotation of the hip.
38. Answer: (D) It’s a measure of effect, not a standard measure of weight or quantity.
Rationale: An insulin unit is a measure of effect, not a standard measure of weight or quantity. Different
drugs measured in units may have no relationship to one another in quality or quantity.
50. Answer: (B) To provide support for the client and family in coping with terminal illness.
Rationale: Hospices provide supportive care for terminally ill clients and their families. Hospice care
doesn’t focus on counseling regarding health care costs. Most client referred to hospices have been
treated for their disease without success and will receive only palliative care in the hospice.
51. Answer: (C) Using normal saline solution to clean the ulcer and applying a protective dressing as
necessary.
Rationale: Washing the area with normal saline solution and applying a protective dressing are within
the nurse’s realm of interventions and will protect the area. Using a povidone-iodine wash and an
antibiotic cream require a physician’s order. Massaging with an astringent can further damage the skin.
58. Answer: (D ) Obtaining the specimen from the urinary drainage bag.
Rationale: A urine specimen is not taken from the urinary drainage bag. Urine undergoes chemical
changes while sitting in the bag and does not necessarily reflect the current client status. In addition, it
may become contaminated with bacteria from opening the system.
59. Answer: (B) Cover the client, place the call light within reach, and answer the phone call.
Rationale: Because telephone call is an emergency, the nurse may need to answer it. The other
appropriate action is to ask another nurse to accept the call. However, is not one of the options. To
maintain privacy and safety, the nurse covers the client and places the call light within the client’s reach.
Additionally, the client’s door should be closed or the room curtains pulled around the bathing area.
60. Answer: (C) Use a sterile plastic container for obtaining the specimen.
Rationale: Sputum specimens for culture and sensitivity testing need to be obtained using sterile
techniques because the test is done to determine the presence of organisms. If the procedure for
obtaining the specimen is not sterile, then the specimen is not sterile, then the specimen would be
contaminated and the results of the test would be invalid.
61. Answer: (A) Puts all the four points of the walker flat on the floor, puts weight on the hand pieces,
and then walks into it.
Rationale: When the client uses a walker, the nurse stands adjacent to the affected side. The client is
instructed to put all four points of the walker 2 feet forward flat on the floor before putting weight on
hand pieces. This will ensure client safety and prevent stress cracks in the walker. The client is then
instructed to move the walker forward and walk into it.
62. Answer: (C) Draws one line to cross out the incorrect information and then initials the change.
Rationale: To correct an error documented in a medical record, the nurse draws one line through the
incorrect information and then initials the error. An error is never erased and correction fluid is never
used in the medical record.
63. Answer: (C) Secures the client safety belts after transferring to the stretcher.
Rationale: During the transfer of the client after the surgical procedure is complete, the nurse should
avoid exposure of the client because of the risk for potential heat loss. Hurried movements and rapid
changes in the position should be avoided because these predispose the client to hypotension. At the
time of the transfer from the surgery table to the stretcher, the client is still affected by the effects of
the anesthesia; therefore, the client should not move self. Safety belts can prevent the client from
falling off the stretcher.
66. Answer: (D) Left side-lying with the head of the bed elevated 45 degrees.
Rationale: To facilitate removal of fluid from the chest wall, the client is positioned sitting at the edge of
the bed leaning over the bedside table with the feet supported on a stool. If the client is unable to sit up,
the client is positioned lying in bed on the unaffected side with the head of the bed elevated 30 to 45
degrees.
75. Answer: (B) The Board can investigate violations of the nursing law and code of ethics
Rationale: Quasi-judicial power means that the Board of Nursing has the authority to investigate
violations of the nursing law and can issue summons, subpoena or subpoena duces tecum as needed.
76. Answer: (C) May apply for re-issuance of his/her license based on certain conditions stipulated in RA
9173
Rationale: RA 9173 sec. 24 states that for equity and justice, a revoked license maybe re-issued provided
that the following conditions are met: a)
the cause for revocation of license has already been corrected or removed; and, b) at least four years
has elapsed since the license has been revoked.
79. Answer: (B) Determines the different nationality of patients frequently admitted and decides to get
representations samples from each.
Rationale: Judgment sampling involves including samples according to the knowledge of the investigator
about the participants in the study.
89. Answer: (A) Arrange for typing and cross matching of the client’s blood.
Rationale: The nurse first arranges for typing and cross matching of the client's blood to ensure
compatibility with donor blood. The other options,
although appropriate when preparing to administer a blood transfusion, come later.
93. Answer:(A) Instructing the client to report any itching, swelling, or dyspnea.
Rationale: Because administration of blood or blood products may cause serious adverse effects such as
allergic reactions, the nurse must monitor the client for these effects. Signs and symptoms of life-
threatening allergic reactions include itching, swelling, and dyspnea. Although the nurse should inform
the client of the duration of the transfusion and should document its administration, these actions are
less critical to the client's immediate health. The nurse should assess vital signs at least hourly during the
transfusion.
94. Answer: (B) Decrease the rate of feedings and the concentration of the formula.
Rationale: Complaints of abdominal discomfort and nausea are common in clients receiving tube
feedings. Decreasing the rate of the feeding and the concentration of the formula should decrease the
client's discomfort. Feedings are normally given at room temperature to minimize abdominal cramping.
To prevent aspiration during feeding, the head of the client's bed should be elevated at least 30 degrees.
Also, to prevent bacterial growth, feeding containers should be routinely changed every 8 to 12 hours.
95. Answer: (D) Roll the vial gently between the palms.
Rationale: Rolling the vial gently between the palms produces heat, which helps dissolve the medication.
Doing nothing or inverting the vial wouldn't help dissolve the medication. Shaking the vial vigorously
could cause the medication to break down, altering its action.
96. Answer: (B) Assist the client to the semi-Fowler position if possible.
Rationale: By assisting the client to the semi-Fowler position, the nurse promotes easier chest
expansion, breathing, and oxygen intake. The nurse should secure the elastic band so that the face mask
fits comfortably and snugly rather than tightly, which could lead to irritation. The nurse should apply the
face mask from the client's nose down to the chin — not vice versa. The nurse should check the
connectors between the oxygen equipment and humidifier to ensure that they're airtight; loosened
connectors can cause loss of oxygen.
99. Answer: (A) The nurse can implement medication orders quickly.
Rationale: A floor stock system enables the nurse to implement medication orders quickly. It doesn't
allow for pharmacist input, nor does it minimize transcription errors or reinforce accurate calculations.
1. May arrives at the health care clinic and tells the nurse that her last menstrual period was 9 weeks
ago. She also tells the nurse that a home pregnancy test was positive but she began to have mild cramps
and is now having moderate vaginal bleeding. During the physical examination of the client, the nurse
notes that May has a dilated cervix. The nurse determines that May is experiencing which type of
abortion?
a. Inevitable
b. Incomplete
c. Threatened
d. Septic
2. Nurse Reese is reviewing the record of a pregnant client for her first prenatal visit. Which of the
following data, if noted on the client’s record, would alert the nurse that the client is at risk for a
spontaneous abortion?
a. Age 36 years
b. History of syphilis
c. History of genital herpes
d. History of diabetes mellitus
3. Nurse Hazel is preparing to care for a client who is newly admitted to the hospital with a possible
diagnosis of ectopic pregnancy. Nurse Hazel develops a plan of care for the client and determines that
which of the following nursing actions is the priority?
a. Monitoring weight
b. Assessing for edema
c. Monitoring apical pulse
d. Monitoring temperature
4. Nurse Oliver is teaching a diabetic pregnant client about nutrition and insulin needs during pregnancy.
The nurse determines that the client understands dietary and insulin needs if the client states that the
second half of pregnancy require:
5. Nurse Michelle is assessing a 24 year old client with a diagnosis of hydatidiform mole. She is aware
that one of the following is unassociated with this condition?
7. During vaginal examination of Janah who is in labor, the presenting part is at station plus two. Nurse,
correctly interprets it as:
8. A pregnant client is receiving oxytocin (Pitocin) for induction of labor. A condition that warrant the
nurse in-charge to discontinue I.V. infusion of Pitocin is:
9. Calcium gluconate is being administered to a client with pregnancy induced hypertension (PIH). A
nursing action that must be initiated as the plan of care throughout injection of the drug is:
a. Ventilator assistance
b. CVP readings
c. EKG tracings
d. Continuous CPR
10. A trial for vaginal delivery after an earlier caesareans, would likely to be given to a gravida, who had:
a. First low transverse cesarean was for active herpes type 2 infections; vaginal culture at 39 weeks
pregnancy was positive.
b. First and second caesareans were for cephalopelvic disproportion.
c. First caesarean through a classic incision as a result of severe fetal distress.
d. First low transverse caesarean was for breech position. Fetus in this pregnancy is in a vertex
presentation.
11.Nurse Ryan is aware that the best initial approach when trying to take a crying toddler’s temperature
is:
13. Which action should nurse Marian include in the care plan for a 2 month old with heart failure?
14.Nurse Hazel is teaching a mother who plans to discontinue breast feeding after 5 months. The nurse
should advise her to include which foods in her infant’s diet?
15.Mommy Linda is playing with her infant, who is sitting securely alone on the floor of the clinic. The
mother hides a toy behind her back and the infant looks for it. The nurse is aware that estimated age of
the infant
would be:
a. 6 months
b. 4 months
c. 8 months
d. 10 months
16.Which of the following is the most prominent feature of public health nursing?
a. It involves providing home care to sick people who are not confined in the hospital.
b. Services are provided free of charge to people within the catchments area.
c. The public health nurse functions as part of a team providing a public health nursing services.
d. Public health nursing focuses on preventive, not curative, services.
17.When the nurse determines whether resources were maximized in implementing Ligtas Tigdas, she is
evaluating
a. Effectiveness
b. Efficiency
c. Adequacy
d. Appropriateness
18.Vangie is a new B.S.N. graduate. She wants to become a Public Health Nurse. Where should she
apply?
a. Department of Health
b. Provincial Health Office
c. Regional Health Office
d. Rural Health Unit
a. Mayor
b. Municipal Health Officer
c. Public Health Nurse
d. Any qualified physician
20.Myra is the public health nurse in a municipality with a total population of about 20,000. There are 3
rural health midwives among the RHU personnel. How many more midwife items will the RHU need?
a. 1
b. 2
c. 3
d. The RHU does not need any more midwife item.
21.According to Freeman and Heinrich, community health nursing is a developmental service. Which of
the following best illustrates this statement?
a. The community health nurse continuously develops himself personally and professionally.
b. Health education and community organizing are necessary in providing community health services.
c. Community health nursing is intended primarily for health promotion and prevention and treatment
of disease.
d. The goal of community health nursing is to provide nursing services to people in their own places of
residence.
22.Nurse Tina is aware that the disease declared through Presidential Proclamation No. 4 as a target for
eradication in the Philippines is?
a. Poliomyelitis
b. Measles
c. Rabies
d. Neonatal tetanus
23.May knows that the step in community organizing that involves training of potential leaders in the
community is:
a. Integration
b. Community organization
c. Community study
d. Core group formation
24.Beth a public health nurse takes an active role in community participation. What is the primary goal
of community organizing?
a. Pre-pathogenesis
b. Pathogenesis
c. Prodromal
d. Terminal
26.The nurse is caring for a primigravid client in the labor and delivery area. Which condition would
place the client at risk for disseminated
intravascular coagulation (DIC)?
27.A fullterm client is in labor. Nurse Betty is aware that the fetal heart rate would be:
a. 80 to 100 beats/minute
b. 100 to 120 beats/minute
c. 120 to 160 beats/minute
d. 160 to 180 beats/minute
28.The skin in the diaper area of a 7 month old infant is excoriated and red. Nurse Hazel should instruct
the mother to:
29.Nurse Carla knows that the common cardiac anomalies in children with Down Syndrome (tri-somy
21) is:
a. Anemia
b. Decreased urine output
c. Hyperreflexia
d. Increased respiratory rate
31.A 23 year old client is having her menstrual period every 2 weeks that last for 1 week. This type of
menstrual pattern is bets defined by:
a. Menorrhagia
b. Metrorrhagia
c. Dyspareunia
d. Amenorrhea
32.Jannah is admitted to the labor and delivery unit. The critical laboratory result for this client would
be:
a. Oxygen saturation
b. Iron binding capacity
c. Blood typing
d. Serum Calcium
33.Nurse Gina is aware that the most common condition found during the second-trimester of
pregnancy is:
a. Metabolic alkalosis
b. Respiratory acidosis
c. Mastitis
d. Physiologic anemia
34.Nurse Lynette is working in the triage area of an emergency department. She sees that several
pediatric clients arrive simultaneously. The client who needs to be treated first is:
35.Maureen in her third trimester arrives at the emergency room with painless vaginal bleeding. Which
of the following conditions is suspected?
a. Placenta previa
b. Abruptio placentae
c. Premature labor
d. Sexually transmitted disease
36.A young child named Richard is suspected of having pinworms. The community nurse collects a stool
specimen to confirm the diagnosis. The nurse should schedule the collection of this specimen for:
37.In doing a child’s admission assessment, Nurse Betty should be alert to note which signs or symptoms
of chronic lead poisoning?
38.To evaluate a woman’s understanding about the use of diaphragm for family planning, Nurse Trish
asks her to explain how she will use the appliance. Which response indicates a need for further health
teaching?
a. “I should check the diaphragm carefully for holes every time I use it”
b. “I may need a different size of diaphragm if I gain or lose weight more than 20 pounds”
c. “The diaphragm must be left in place for atleast 6 hours after intercourse”
d. “I really need to use the diaphragm and jelly most during the middle of my menstrual cycle”.
a. Drooling
b. Muffled voice
c. Restlessness
d. Low-grade fever
40.How should Nurse Michelle guide a child who is blind to walk to the playroom?
a. Without touching the child, talk continuously as the child walks down the hall.
b. Walk one step ahead, with the child’s hand on the nurse’s elbow.
c. Walk slightly behind, gently guiding the child forward.
d. Walk next to the child, holding the child’s hand.
41.When assessing a newborn diagnosed with ductus arteriosus, Nurse Olivia should expect that the
child most likely would have an:
42.The reason nurse May keeps the neonate in a neutral thermal environment is that when a newborn
becomes too cool, the neonate requires:
43.Before adding potassium to an infant’s I.V. line, Nurse Ron must be sure to assess whether this infant
has:
44.Nurse Carla should know that the most common causative factor of dermatitis in infants and younger
children is:
a. Baby oil
b. Baby lotion
c. Laundry detergent
d. Powder with cornstarch
45.During tube feeding, how far above an infant’s stomach should the nurse hold the syringe with
formula?
a. 6 inches
b. 12 inches
c. 18 inches
d. 24 inches
46. In a mothers’ class, Nurse Lhynnete discussed childhood diseases such as chicken pox. Which of the
following statements about chicken pox is correct?
a. The older one gets, the more susceptible he becomes to the complications of chicken pox.
b. A single attack of chicken pox will prevent future episodes, including conditions such as shingles.
c. To prevent an outbreak in the community, quarantine may be imposed by health authorities.
d. Chicken pox vaccine is best given when there is an impending outbreak in the community.
47.Barangay Pinoy had an outbreak of German measles. To prevent congenital rubella, what is the BEST
advice that you can give to women in the first trimester of pregnancy in the barangay Pinoy?
48.Myrna a public health nurse knows that to determine possible sources of sexually transmitted
infections, the BEST method that may be undertaken is:
a. Contact tracing
b. Community survey
c. Mass screening tests
d. Interview of suspects
49.A 33-year old female client came for consultation at the health center with the chief complaint of
fever for a week. Accompanying symptoms were muscle pains and body malaise. A week after the start
of fever, the client noted yellowish discoloration of his sclera. History showed that he waded in flood
waters about 2 weeks before the onset of symptoms. Based on her history, which disease condition will
you suspect?
a. Hepatitis A
b. Hepatitis B
c. Tetanus
d. Leptospirosis
50.Mickey a 3-year old client was brought to the health center with the chief complaint of severe
diarrhea and the passage of “rice water” stools. The client is most probably suffering from which
condition?
a. Giardiasis
b. Cholera
c. Amebiasis
d. Dysentery
51.The most prevalent form of meningitis among children aged 2 months to 3 years is caused by which
microorganism?
a. Hemophilus influenzae
b. Morbillivirus
c. Steptococcus pneumoniae
d. Neisseria meningitidis
52.The student nurse is aware that the pathognomonic sign of measles is Koplik’s spot and you may see
Koplik’s spot by inspecting the:
a. Nasal mucosa
b. Buccal mucosa
c. Skin on the abdomen
d. Skin on neck
53.Angel was diagnosed as having Dengue fever. You will say that there is slow capillary refill when the
color of the nailbed that you pressed does not return within how many seconds?
a. 3 seconds
b. 6 seconds
c. 9 seconds
d. 10 seconds
54.In Integrated Management of Childhood Illness, the nurse is aware that the severe conditions
generally require urgent referral to a hospital. Which of the following severe conditions DOES NOT
always require urgent referral to a hospital?
a. Mastoiditis
b. Severe dehydration
c. Severe pneumonia
d. Severe febrile disease
55.Myrna a public health nurse will conduct outreach immunization in a barangay Masay with a
population of about 1500. The estimated number of infants in the barangay would be:
a. 45 infants
b. 50 infants
c. 55 infants
d. 65 infants
56.The community nurse is aware that the biological used in Expanded Program on Immunization (EPI)
should NOT be stored in the freezer?
a. DPT
b. Oral polio vaccine
c. Measles vaccine
d. MMR
a. Use of molluscicides
b. Building of foot bridges
c. Proper use of sanitary toilets
d. Use of protective footwear, such as rubber boots
58.Several clients is newly admitted and diagnosed with leprosy. Which of the following clients should
be classified as a case of multibacillary leprosy?
a. Macular lesions
b. Inability to close eyelids
c. Thickened painful nerves
d. Sinking of the nosebridge
60.Marie brought her 10 month old infant for consultation because of fever, started 4 days prior to
consultation. In determining malaria risk, what will you do?
61.Susie brought her 4 years old daughter to the RHU because of cough and colds. Following the IMCI
assessment guide, which of the following is a danger sign that indicates the need for urgent referral to a
hospital?
a. Inability to drink
b. High grade fever
c. Signs of severe dehydration
d. Cough for more than 30 days
62.Jimmy a 2-year old child revealed “baggy pants”. As a nurse, using the IMCI guidelines, how will you
manage Jimmy?
63.Gina is using Oresol in the management of diarrhea of her 3-year old child. She asked you what to do
if her child vomits. As a nurse you will tell her to:
64.Nikki a 5-month old infant was brought by his mother to the health center because of diarrhea for 4
to 5 times a day. Her skin goes back slowly after a skin pinch and her eyes are sunken. Using the IMCI
guidelines, you will classify this infant in which category?
a. No signs of dehydration
b. Some dehydration
c. Severe dehydration
d. The data is insufficient.
65.Chris a 4-month old infant was brought by her mother to the health center because of cough. His
respiratory rate is 42/minute. Using the Integrated Management of Child Illness (IMCI) guidelines of
assessment, his breathing is considered as:
a. Fast
b. Slow
c. Normal
d. Insignificant
66.Maylene had just received her 4th dose of tetanus toxoid. She is aware that her baby will have
protection against tetanus for
a. 1 year
b. 3 years
c. 5 years
d. Lifetime
67.Nurse Ron is aware that unused BCG should be discarded after how many hours of reconstitution?
a. 2 hours
b. 4 hours
c. 8 hours
d. At the end of the day
68.The nurse explains to a breastfeeding mother that breast milk is sufficient for all of the baby’s
nutrient needs only up to:
a. 5 months
b. 6 months
c. 1 year
d. 2 years
69.Nurse Ron is aware that the gestational age of a conceptus that is considered viable (able to live
outside the womb) is:
a. 8 weeks
b. 12 weeks
c. 24 weeks
d. 32 weeks
70.When teaching parents of a neonate the proper position for the neonate’s sleep, the nurse Patricia
stresses the importance of placing the neonate on his back to reduce the risk of which of the following?
a. Aspiration
b. Sudden infant death syndrome (SIDS)
c. Suffocation
d. Gastroesophageal reflux (GER)
71.Which finding might be seen in baby James a neonate suspected of having an infection?
a. Flushed cheeks
b. Increased temperature
c. Decreased temperature
d. Increased activity level
72.Baby Jenny who is small-for-gestation is at increased risk during the transitional period for which
complication?
73.Marjorie has just given birth at 42 weeks’ gestation. When the nurse assessing the neonate, which
physical finding is expected?
74.After reviewing the Myrna’s maternal history of magnesium sulfate during labor, which condition
would nurse Richard anticipate as a potential problem in the neonate?
a. Hypoglycemia
b. Jitteriness
c. Respiratory depression
d. Tachycardia
75.Which symptom would indicate the Baby Alexandra was adapting appropriately to extra-uterine life
without difficulty?
a. Nasal flaring
b. Light audible grunting
c. Respiratory rate 40 to 60 breaths/minute
d. Respiratory rate 60 to 80 breaths/minute
76. When teaching umbilical cord care for Jennifer a new mother, the nurse Jenny would include which
information?
a. Simian crease
b. Conjunctival hemorrhage
c. Cystic hygroma
d. Bulging fontanelle
78.Dr. Esteves decides to artificially rupture the membranes of a mother who is on labor. Following this
procedure, the nurse Hazel checks the fetal heart tones for which the following reasons?
79.Which of the following would be least likely to indicate anticipated bonding behaviors by new
parents?
a fourth-degree laceration. Which of the following would be contraindicated when caring for this client?
a. Applying cold to limit edema during the first 12 to 24 hours.
b. Instructing the client to use two or more peripads to cushion the area.
c. Instructing the client on the use of sitz baths if ordered.
d. Instructing the client about the importance of perineal (kegel) exercises.
81. A pregnant woman accompanied by her husband, seeks admission to the labor and delivery area.
She states that she's in labor and says she attended the facility clinic for prenatal care. Which question
should the nurse Oliver ask her first?
84. A baby girl is born 8 weeks premature. At birth, she has no spontaneous respirations but is
successfully resuscitated. Within several hours she develops respiratory grunting, cyanosis, tachypnea,
nasal flaring, and retractions. She's diagnosed with respiratory distress syndrome, intubated, and placed
on a ventilator. Which nursing action should be included in the baby's plan of care to
prevent retinopathy of prematurity?
86. Nurse John is knowledgeable that usually individual twins will grow appropriately and at the same
rate as singletons until how many weeks?
a. 16 to 18 weeks
b. 18 to 22 weeks
c. 30 to 32 weeks
d. 38 to 40 weeks
87. Which of the following classifications applies to monozygotic twins for whom the cleavage of the
fertilized ovum occurs more than 13 days after fertilization?
a. conjoined twins
b. diamniotic dichorionic twins
c. diamniotic monochorionic twin
d. monoamniotic monochorionic twins
88. Tyra experienced painless vaginal bleeding has just been diagnosed as having a placenta previa.
Which of the following procedures is usually performed to diagnose placenta previa?
a. Amniocentesis
b. Digital or speculum examination
c. External fetal monitoring
d. Ultrasound
89. Nurse Arnold knows that the following changes in respiratory functioning during pregnancy is
considered normal:
90. Emily has gestational diabetes and it is usually managed by which of the following therapy?
a. Diet
b. Long-acting insulin
c. Oral hypoglycemic
d. Oral hypoglycemic drug and insulin
91. Magnesium sulfate is given to Jemma with preeclampsia to prevent which of the following
condition?
a. Hemorrhage
b. Hypertension
c. Hypomagnesemia
d. Seizure
92. Cammile with sickle cell anemia has an increased risk for having a sickle cell crisis during pregnancy.
Aggressive management of a sickle cell crisis includes which of the following measures?
a. Antihypertensive agents
b. Diuretic agents
c. I.V. fluids
d. Acetaminophen (Tylenol) for pain
93. Which of the following drugs is the antidote for magnesium toxicity?
94. Marlyn is screened for tuberculosis during her first prenatal visit. An intradermal injection of purified
protein derivative (PPD) of the tuberculin bacilli is given. She is considered to have a positive test for
which of the following results?
a. Asymptomatic bacteriuria
b. Bacterial vaginosis
c. Pyelonephritis
d. Urinary tract infection (UTI)
96. Rh isoimmunization in a pregnant client develops during which of the following conditions?
97. To promote comfort during labor, the nurse John advises a client to assume certain positions and
avoid others. Which position may cause maternal hypotension and fetal hypoxia?
a. Lateral position
b. Squatting position
c. Supine position
d. Standing position
98. Celeste who used heroin during her pregnancy delivers a neonate. When assessing the neonate, the
nurse Lhynnette expects to find:
99. The uterus returns to the pelvic cavity in which of the following time frames?
100. Maureen, a primigravida client, age 20, has just completed a difficult, forceps-assisted delivery of
twins. Her labor was unusually long and required oxytocin (Pitocin) augmentation. The nurse who's
caring for her should stay alert for:
a. Uterine inversion
b. Uterine atony
c. Uterine involution
d. Uterine discomfort
Answer and Rationale- Nursing Practice II- Community Health Nursing and Care of the Mother and
Child
7. Answer: (C) Presenting part in 2 cm below the plane of the ischial spines.
Rationale: Fetus at station plus two indicates that the presenting part is 2 cm below the plane of the
ischial spines.
11. Answer: (A) Talk to the mother first and then to the toddler.
Rationale: When dealing with a crying toddler, the best approach is to talk to the mother and ignore the
toddler first. This approach helps the toddler get used to the nurse before she attempts any procedures.
It also gives the toddler an opportunity to see that the mother trusts the nurse.
12. Answer: (D) Place the infant’s arms in soft elbow restraints.
Rationale: Soft restraints from the upper arm to the wrist prevent the infant from touching her lip but
allow him to hold a favorite item such as a blanket. Because they could damage the operative site, such
as objects as pacifiers, suction catheters, and small spoons shouldn’t be placed in a baby’s mouth after
cleft repair. A baby in a prone position may rub her face on the sheets and traumatize the operative site.
The suture line should be cleaned gently to prevent infection, which could interfere with healing and
damage the cosmetic appearance of the repair.
16. Answer: (D) Public health nursing focuses on preventive, not curative, services.
Rationale: The catchments area in PHN consists of a residential community, many of whom are well
individuals who have greater need for
preventive rather than curative services.
21. Answer: (B) Health education and community organizing are necessary in providing community
health services.
Rationale: The community health nurse develops the health capability of people through health
education and community organizing activities.
24. Answer: (D) To maximize the community’s resources in dealing with health problems.
Rationale: Community organizing is a developmental service, with the goal of developing the people’s
self-reliance in dealing with community
health problems. A, B and C are objectives of contributory objectives to this goal.
34. Answer: (D) A 2 year old infant with stridorous breath sounds, sitting up in his mother’s arms and
drooling.
Rationale: The infant with the airway emergency should be treated first, because of the risk of
epiglottitis.
38. Answer: (D) “I really need to use the diaphragm and jelly most during the middle of my menstrual
cycle”.
Rationale: The woman must understand that, although the “fertile” period is approximately mid-cycle,
hormonal variations do occur and can result in early or late ovulation. To be effective, the diaphragm
should be inserted before every intercourse.
40. Answer: (B) Walk one step ahead, with the child’s hand on the nurse’s elbow.
Rationale: This procedure is generally recommended to follow in guiding a person who is blind.
46. Answer: (A) The older one gets, the more susceptible he becomes to the complications of chicken
pox.
Rationale: Chicken pox is usually more severe in adults than in children. Complications, such as
pneumonia, are higher in incidence in adults.
47. Answer: (D) Consult a physician who may give them rubella immunoglobulin.
Rationale: Rubella vaccine is made up of attenuated German measles viruses. This is contraindicated in
pregnancy. Immune globulin, a specific prophylactic against German measles, may be given to pregnant
women.
62. Answer: (A) Refer the child urgently to a hospital for confinement.
Rationale: “Baggy pants” is a sign of severe marasmus. The best management is urgent referral to a
hospital.
63. Answer: (D) Let the child rest for 10 minutes then continue giving Oresol more slowly.
Rationale: If the child vomits persistently, that is, he vomits everything that he takes in, he has to be
referred urgently to a hospital. Otherwise, vomiting is managed by letting the child rest for 10 minutes
and then continuing with Oresol administration. Teach the mother to give Oresol more slowly.
76. Answer: (C) Keep the cord dry and open to air
Rationale: Keeping the cord dry and open to air helps reduce infection and hastens drying. Infants aren’t
given tub bath but are sponged off until the cord falls off. Petroleum jelly prevents the cord from drying
and encourages infection. Peroxide could be painful and isn’t recommended.
80. Answer: (B) Instructing the client to use two or more peripads to cushion the area
Rationale: Using two or more peripads would do little to reduce the pain or promote perineal healing.
Cold applications, sitz baths, and Kegel
exercises are important measures when the client has a fourth-degree laceration.
81. Answer: (C) “What is your expected due date?”
Rationale: When obtaining the history of a client who may be in labor, the nurse's highest priority is to
determine her current status, particularly her due date, gravidity, and parity. Gravidity and parity affect
the duration of labor and the potential for labor complications. Later, the nurse should ask about
chronic illnesses, allergies, and support persons.
82. Answer: (D) Aspirate the neonate’s nose and mouth with a bulb syringe.
Rationale: The nurse's first action should be to clear the neonate's airway with a bulb syringe. After the
airway is clear and the neonate's color improves, the nurse should comfort and calm the neonate. If the
problem recurs or the neonate's color doesn't improve readily, the nurse should notify the physician.
Administering oxygen when the airway isn't clear would be ineffective.
83. Answer: (C) Conducting a bedside ultrasound for an amniotic fluid index.
Rationale: It isn't within a nurse's scope of practice to perform and interpret a bedside ultrasound under
these conditions and without
specialized training. Observing for pooling of straw-colored fluid, checking vaginal discharge with
nitrazine paper, and observing for flakes of vernix are appropriate assessments for determining whether
a client has ruptured membranes.
96. Answer: (B) Rh-positive fetal blood crosses into maternal blood, stimulating maternal antibodies.
Rationale: Rh isoimmunization occurs when Rh-positive fetal blood cells cross into the maternal
circulation and stimulate maternal antibody
production. In subsequent pregnancies with Rh-positive fetuses, maternal antibodies may cross back
into the fetal circulation and destroy the fetal blood cells.
1. Nurse Michelle should know that the drainage is normal 4 days after a sigmoid colostomy when the
stool is:
a. Green liquid
b. Solid formed
c. Loose, bloody
d. Semiformed
2. Where would nurse Kristine place the call light for a male client with a right-sided brain attack and left
homonymous hemianopsia?
3. A male client is admitted to the emergency department following an accident. What are the first
nursing actions of the nurse?
4. In evaluating the effect of nitroglycerin, Nurse Arthur should know that it reduces preload and
relieves angina by:
5. Nurse Patricia finds a female client who is post-myocardial infarction (MI) slumped on the side rails of
the bed and unresponsive to shaking or shouting. Which is the nurse next action?
6. Nurse Monett is caring for a client recovering from gastro-intestinal bleeding. The nurse should:
a. Plan care so the client can receive 8 hours of uninterrupted sleep each night.
b. Monitor vital signs every 2 hours.
c. Make sure that the client takes food and medications at prescribed intervals.
d. Provide milk every 2 to 3 hours.
7. A male client was on warfarin (Coumadin) before admission, and has been receiving heparin I.V. for 2
days. The partial thromboplastin time (PTT) is 68 seconds. What should Nurse Carla do?
8. A client undergone ileostomy, when should the drainage appliance be applied to the stoma?
9. A client undergone spinal anesthetic, it will be important that the nurse immediately position the
client in:
10.While monitoring a male client several hours after a motor vehicle accident, which assessment data
suggest increasing intracranial pressure?
11.Mrs. Cruz, 80 years old is diagnosed with pneumonia. Which of the following symptoms may appear
first?
12. A male client has active tuberculosis (TB). Which of the following symptoms will be exhibit?
a. Acute asthma
b. Bronchial pneumonia
c. Chronic obstructive pulmonary disease (COPD)
d. Emphysema
14. Marichu was given morphine sulfate for pain. She is sleeping and her respiratory rate is 4
breaths/minute. If action isn’t taken quickly, she might have
which of the following reactions?
a. Asthma attack
b. Respiratory arrest
c. Seizure
d. Wake up on his own
15. A 77-year-old male client is admitted for elective knee surgery. Physical examination reveals shallow
respirations but no sign of respiratory distress. Which of the following is a normal physiologic change
related to aging?
16. Nurse John is caring for a male client receiving lidocaine I.V. Which factor is the most relevant to
administration of this medication?
a. Decrease in arterial oxygen saturation (SaO2) when measured with a pulse oximeter.
b. Increase in systemic blood pressure.
c. Presence of premature ventricular contractions (PVCs) on a cardiac monitor.
d. Increase in intracranial pressure (ICP).
17. Nurse Ron is caring for a male client taking an anticoagulant. The nurse should teach the client to:
19. Nurse Michelle is caring for an elderly female with osteoporosis. When teaching the client, the nurse
should include information about which major complication:
a. Bone fracture
b. Loss of estrogen
c. Negative calcium balance
d. Dowager’s hump
20. Nurse Len is teaching a group of women to perform BSE. The nurse should explain that the purpose
of performing the examination is to discover:
a. Cancerous lumps
b. Areas of thickness or fullness
c. Changes from previous examinations.
d. Fibrocystic masses
21. When caring for a female client who is being treated for hyperthyroidism, it is important to:
22. Nurse Kris is teaching a client with history of atherosclerosis. To decrease the risk of atherosclerosis,
the nurse should encourage the client to:
23. Nurse Greta is working on a surgical floor. Nurse Greta must logroll a client following a:
a. Laminectomy
b. Thoracotomy
c. Hemorrhoidectomy
d. Cystectomy.
24. A 55-year old client underwent cataract removal with intraocular lens implant. Nurse Oliver is giving
the client discharge instructions. These instructions should include which of the following?
26. A male client undergone a colon resection. While turning him, wound dehiscence with evisceration
occurs. Nurse Trish first response is to:
27. Nurse Audrey is caring for a client who has suffered a severe cerebrovascular accident. During
routine assessment, the nurse notices Cheyne- Strokes respirations. Cheyne-strokes respirations are:
28. Nurse Bea is assessing a male client with heart failure. The breath sounds commonly auscultated in
clients with heart failure are:
a. Tracheal
b. Fine crackles
c. Coarse crackles
d. Friction rubs
29. The nurse is caring for Kenneth experiencing an acute asthma attack. The client stops wheezing and
breath sounds aren’t audible. The reason for this
change is that:
30. Mike with epilepsy is having a seizure. During the active seizure phase, the nurse should:
a. Place the client on his back remove dangerous objects, and insert a bite block.
b. Place the client on his side, remove dangerous objects, and insert a bite block.
c. Place the client o his back, remove dangerous objects, and hold down his arms.
d. Place the client on his side, remove dangerous objects, and protect his head.
31. After insertion of a cheat tube for a pneumothorax, a client becomes hypotensive with neck vein
distention, tracheal shift, absent breath sounds, and diaphoresis. Nurse Amanda suspects a tension
pneumothorax has occurred. What cause of tension pneumothorax should the nurse check for?
32. Nurse Maureen is talking to a male client, the client begins choking on his lunch. He’s coughing
forcefully. The nurse should:
a. Stand him up and perform the abdominal thrust maneuver from behind.
b. Lay him down, straddle him, and perform the abdominal thrust maneuver.
c. Leave him to get assistance
d. Stay with him but not intervene at this time.
33. Nurse Ron is taking a health history of an 84 year old client. Which information will be most useful to
the nurse for planning care?
35. A 77-year-old male client is admitted with a diagnosis of dehydration and change in mental status.
He’s being hydrated with L.V. fluids. When the nurse takes his vital signs, she notes he has a fever of
103°F (39.4°C) a cough producing yellow sputum and pleuritic chest pain. The nurse suspects this client
may have which of the following conditions?
36. Nurse Oliver is working in a out patient clinic. He has been alerted that there is an outbreak of
tuberculosis (TB). Which of the following clients entering the clinic today most likely to have TB?
37. Virgie with a positive Mantoux test result will be sent for a chest X-ray. The nurse is aware that
which of the following reasons this is done?
38. Kennedy with acute asthma showing inspiratory and expiratory wheezes and a decreased forced
expiratory volume should be treated with which of the following classes of medication right away?
a. Beta-adrenergic blockers
b. Bronchodilators
c. Inhaled steroids
d. Oral steroids
39. Mr. Vasquez 56-year-old client with a 40-year history of smoking one to two packs of cigarettes per
day has a chronic cough producing thick sputum, peripheral edema and cyanotic nail beds. Based on this
information, he most likely has which of the following conditions?
Situation: Francis, age 46 is admitted to the hospital with diagnosis of Chronic Lymphocytic Leukemia.
40. The treatment for patients with leukemia is bone marrow transplantation. Which statement about
bone marrow transplantation is not correct?
41. After several days of admission, Francis becomes disoriented and complains of frequent headaches.
The nurse in-charge first action would be:
42. During routine care, Francis asks the nurse, “How can I be anemic if this disease causes increased my
white blood cell production?” The nurse in-charge best response would be that the increased number of
white blood cells (WBC) is:
a. Predominance of lymhoblasts
b. Leukocytosis
c. Abnormal blast cells in the bone marrow
d. Elevated thrombocyte counts
44. Robert, a 57-year-old client with acute arterial occlusion of the left leg undergoes an emergency
embolectomy. Six hours later, the nurse isn’t able to obtain pulses in his left foot using Doppler
ultrasound. The nurse immediately notifies the physician, and asks her to prepare the client for surgery.
As the nurse enters the client’s room to prepare him, he states that he won’t have any more surgery.
Which of the following is the best initial response by the nurse?
45. During the endorsement, which of the following clients should the on-duty nurse assess first?
a. The 58-year-old client who was admitted 2 days ago with heart failure, blood pressure of 126/76 mm
Hg, and a respiratory rate of 22 breaths/minute.
b. The 89-year-old client with end-stage right-sided heart failure, blood pressure of 78/50 mm Hg, and a
“do not resuscitate” order
c. The 62-year-old client who was admitted 1 day ago with thrombophlebitis and is receiving L.V.
heparin
d. The 75-year-old client who was admitted 1 hour ago with new-onset atrial fibrillation and is receiving
L.V. dilitiazem (Cardizem)
46. Honey, a 23-year old client complains of substernal chest pain and states that her heart feels like
“it’s racing out of the chest”. She reports no history of cardiac disorders. The nurse attaches her to a
cardiac monitor and notes sinus tachycardia with a rate of 136beats/minutes. Breath sounds are clear
and the respiratory rate is 26 breaths/minutes. Which of the following drugs should the nurse question
the client about using?
a. Barbiturates
b. Opioids
c. Cocaine
d. Benzodiazepines
47. A 51-year-old female client tells the nurse in-charge that she has found a painless lump in her right
breast during her monthly self-examination. Which assessment finding would strongly suggest that this
client's lump is cancerous?
48. A 35-year-old client with vaginal cancer asks the nurse, "What is the usual treatment for this type of
cancer?" Which treatment should the nurse name?
a. Surgery
b. Chemotherapy
c. Radiation
d. Immunotherapy
49. Cristina undergoes a biopsy of a suspicious lesion. The biopsy report classifies the lesion according to
the TNM staging system as follows: TIS, N0, M0. What does this classification mean?
a. No evidence of primary tumor, no abnormal regional lymph nodes, and no evidence of distant
metastasis
b. Carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant metastasis
c. Can't assess tumor or regional lymph nodes and no evidence of metastasis
d. Carcinoma in situ, no demonstrable metastasis of the regional lymph nodes, and ascending degrees of
distant metastasis
50. Lydia undergoes a laryngectomy to treat laryngeal cancer. When teaching the client how to care for
the neck stoma, the nurse should include which instruction?
51. A 37-year-old client with uterine cancer asks the nurse, "Which is the most common type of cancer
in women?" The nurse replies that it's breast cancer. Which type of cancer causes the most deaths in
women?
a. Breast cancer
b. Lung cancer
c. Brain cancer
d. Colon and rectal cancer
52. Antonio with lung cancer develops Horner's syndrome when the tumor invades the ribs and affects
the sympathetic nerve ganglia. When assessing for signs and symptoms of this syndrome, the nurse
should note:
a. miosis, partial eyelid ptosis, and anhidrosis on the affected side of the face.
b. chest pain, dyspnea, cough, weight loss, and fever.
c. arm and shoulder pain and atrophy of arm and hand muscles, both on the affected side.
d. hoarseness and dysphagia.
53. Vic asks the nurse what PSA is. The nurse should reply that it stands for:
a. prostate-specific antigen, which is used to screen for prostate cancer.
b. protein serum antigen, which is used to determine protein levels.
c. pneumococcal strep antigen, which is a bacteria that causes pneumonia.
d. Papanicolaou-specific antigen, which is used to screen for cervical cancer.
54. What is the most important postoperative instruction that nurse Kate must give a client who has just
returned from the operating room after receiving a subarachnoid block?
55. A male client suspected of having colorectal cancer will require which diagnostic study to confirm
the diagnosis?
a. Stool Hematest
b. Carcinoembryonic antigen (CEA)
c. Sigmoidoscopy
d. Abdominal computed tomography (CT) scan
56. During a breast examination, which finding most strongly suggests that the Luz has breast cancer?
57. A female client with cancer is being evaluated for possible metastasis. Which of the following is one
of the most common metastasis sites for cancer cells?
a. Liver
b. Colon
c. Reproductive tract
d. White blood cells (WBCs)
58. Nurse Mandy is preparing a client for magnetic resonance imaging (MRI) to confirm or rule out a
spinal cord lesion. During the MRI scan, which of the following would pose a threat to the client?
59. Nurse Cecile is teaching a female client about preventing osteoporosis. Which of the following
teaching points is correct?
a. Obtaining an X-ray of the bones every 3 years is recommended to detect bone loss.
b. To avoid fractures, the client should avoid strenuous exercise.
c. The recommended daily allowance of calcium may be found in a wide variety of foods.
d. Obtaining the recommended daily allowance of calcium requires taking a calcium supplement.
60. Before Jacob undergoes arthroscopy, the nurse reviews the assessment findings for
contraindications for this procedure. Which finding is a contraindication?
a. Joint pain
b. Joint deformity
c. Joint flexion of less than 50%
d. Joint stiffness
61. Mr. Rodriguez is admitted with severe pain in the knees. Which form of arthritis is characterized by
urate deposits and joint pain, usually in the feet and legs, and occurs primarily in men over age 30?
a. Septic arthritis
b. Traumatic arthritis
c. Intermittent arthritis
d. Gouty arthritis
62. A heparin infusion at 1,500 unit/hour is ordered for a 64-year-old client with stroke in evolution. The
infusion contains 25,000 units of heparin in 500 ml of saline solution. How many milliliters per hour
should be given?
a. 15 ml/hour
b. 30 ml/hour
c. 45 ml/hour
d. 50 ml/hour
63. A 76-year-old male client had a thromboembolic right stroke; his left arm is swollen. Which of the
following conditions may cause swelling after a stroke?
65. Which of the following statements explains the main difference between rheumatoid arthritis and
osteoarthritis?
66. Mrs. Cruz uses a cane for assistance in walking. Which of the following statements is true about a
cane or other assistive devices?
67. A male client with type 1 diabetes is scheduled to receive 30 U of 70/30 insulin. There is no 70/30
insulin available. As a substitution, the nurse may give the client:
68. Nurse Len should expect to administer which medication to a client with gout?
a. aspirin
b. furosemide (Lasix)
c. colchicines
d. calcium gluconate (Kalcinate)
69. Mr. Domingo with a history of hypertension is diagnosed with primary hyperaldosteronism. This
diagnosis indicates that the client's hypertension is caused by excessive hormone secretion from which
of the following glands?
a. Adrenal cortex
b. Pancreas
c. Adrenal medulla
d. Parathyroid
70. For a diabetic male client with a foot ulcer, the doctor orders bed rest, a wetto- dry dressing change
every shift, and blood glucose monitoring before meals and bedtime. Why are wet-to-dry dressings used
for this client?
71. Nurse Zeny is caring for a client in acute addisonian crisis. Which laboratory data would the nurse
expect to find?
a. Hyperkalemia
b. Reduced blood urea nitrogen (BUN)
c. Hypernatremia
d. Hyperglycemia
72. A client is admitted for treatment of the syndrome of inappropriate antidiuretic hormone (SIADH).
Which nursing intervention is appropriate?
73. A female client tells nurse Nikki that she has been working hard for the last 3 months to control her
type 2 diabetes mellitus with diet and exercise. To determine the effectiveness of the client's efforts, the
nurse should check:
74. Nurse Trinity administered neutral protamine Hagedorn (NPH) insulin to a diabetic client at 7 a.m. At
what time would the nurse expect the client to be most at risk for a hypoglycemic reaction?
a. 10:00 am
b. Noon
c. 4:00 pm
d. 10:00 pm
76. On the third day after a partial thyroidectomy, Proserfina exhibits muscle twitching and
hyperirritability of the nervous system. When questioned, the client reports numbness and tingling of
the mouth and fingertips. Suspecting a lifethreatening electrolyte disturbance, the nurse notifies the
surgeon immediately. Which electrolyte disturbance most commonly follows thyroid surgery?
a. Hypocalcemia
b. Hyponatremia
c. Hyperkalemia
d. Hypermagnesemia
77. Which laboratory test value is elevated in clients who smoke and can't be used as a general indicator
of cancer?
78. Francis with anemia has been admitted to the medical-surgical unit. Which assessment findings are
characteristic of iron-deficiency anemia?
79. In teaching a female client who is HIV-positive about pregnancy, the nurse would know more
teaching is necessary when the client says:
80. When preparing Judy with acquired immunodeficiency syndrome (AIDS) for discharge to the home,
the nurse should be sure to include which instruction?
81. Nurse Marie is caring for a 32-year-old client admitted with pernicious anemia. Which set of findings
should the nurse expect when assessing the
client?
82. After receiving a dose of penicillin, a client develops dyspnea and hypotension. Nurse Celestina
suspects the client is experiencing anaphylactic shock. What should the nurse do first?
83. Mr. Marquez with rheumatoid arthritis is about to begin aspirin therapy to reduce inflammation.
When teaching the client about aspirin, the nurse discusses adverse reactions to prolonged aspirin
therapy. These include:
a. weight gain.
b. fine motor tremors.
c. respiratory acidosis.
d. bilateral hearing loss.
84. A 23-year-old client is diagnosed with human immunodeficiency virus (HIV). After recovering from
the initial shock of the diagnosis, the client expresses a desire to learn as much as possible about HIV
and acquired immunodeficiency syndrome (AIDS). When teaching the client about the immune system,
the nurse states that adaptive immunity is provided by which type of white blood cell?
a. Neutrophil
b. Basophil
c. Monocyte
d. Lymphocyte
85. In an individual with Sjögren's syndrome, nursing care should focus on:
a. moisture replacement.
b. electrolyte balance.
c. nutritional supplementation.
d. arrhythmia management.
86. During chemotherapy for lymphocytic leukemia, Mathew develops abdominal pain, fever, and
"horse barn" smelling diarrhea. It would be most important for the nurse to advise the physician to
order:
87. A male client seeks medical evaluation for fatigue, night sweats, and a 20-lb weight loss in 6 weeks.
To confirm that the client has been infected with the human immunodeficiency virus (HIV), the nurse
expects the physician to order:
a. E-rosette immunofluorescence.
b. quantification of T-lymphocytes.
c. enzyme-linked immunosorbent assay (ELISA).
d. Western blot test with ELISA.
88. A complete blood count is commonly performed before a Joe goes into surgery. What does this test
seek to identify?
a. Potential hepatic dysfunction indicated by decreased blood urea nitrogen (BUN) and creatinine levels
b. Low levels of urine constituents normally excreted in the urine
c. Abnormally low hematocrit (HCT) and hemoglobin (Hb) levels
d. Electrolyte imbalance that could affect the blood's ability to coagulate properly
89. While monitoring a client for the development of disseminated intravascular coagulation (DIC), the
nurse should take note of what assessment parameters?
90. When taking a dietary history from a newly admitted female client, Nurse Len should remember that
which of the following foods is a common allergen?
a. Bread
b. Carrots
c. Orange
d. Strawberries
91. Nurse John is caring for clients in the outpatient clinic. Which of the following phone calls should the
nurse return first?
a. A client with hepatitis A who states, “My arms and legs are itching.”
b. A client with cast on the right leg who states, “I have a funny feeling in my right leg.”
c. A client with osteomyelitis of the spine who states, “I am so nauseous that I can’t eat.”
d. A client with rheumatoid arthritis who states, “I am having trouble sleeping.”
92. Nurse Sarah is caring for clients on the surgical floor and has just received report from the previous
shift. Which of the following clients should the nurse see first?
a. A 35-year-old admitted three hours ago with a gunshot wound; 1.5 cm area of dark drainage noted on
the dressing.
b. A 43-year-old who had a mastectomy two days ago; 23 ml of serosanguinous fluid noted in the
Jackson-Pratt drain.
c. A 59-year-old with a collapsed lung due to an accident; no drainage noted in the previous eight hours.
d. A 62-year-old who had an abdominal-perineal resection three days ago; client complaints of chills.
93. Nurse Eve is caring for a client who had a thyroidectomy 12 hours ago for treatment of Grave’s
disease. The nurse would be most concerned if which of the following was observed?
94. Julius is admitted with complaints of severe pain in the lower right quadrant of the abdomen. To
assist with pain relief, the nurse should take which of the following actions?
96. Nurse Jannah teaches an elderly client with right-sided weakness how to use cane. Which of the
following behaviors, if demonstrated by the client to the nurse, indicates that the teaching was
effective?
a. The client holds the cane with his right hand, moves the can forward followed by the right leg, and
then moves the left leg.
b. The client holds the cane with his right hand, moves the cane forward followed by his left leg, and
then moves the right leg.
c. The client holds the cane with his left hand, moves the cane forward followed by the right leg, and
then moves the left leg.
d. The client holds the cane with his left hand, moves the cane forward followed by his left leg, and then
moves the right leg.
97. An elderly client is admitted to the nursing home setting. The client is occasionally confused and her
gait is often unsteady. Which of the following actions, if taken by the nurse, is most appropriate?
a. Ask the woman’s family to provide personal items such as photos or mementos.
b. Select a room with a bed by the door so the woman can look down the hall.
c. Suggest the woman eat her meals in the room with her roommate.
d. Encourage the woman to ambulate in the halls twice a day.
98. Nurse Evangeline teaches an elderly client how to use a standard aluminum walker. Which of the
following behaviors, if demonstrated by the client, indicates that the nurse’s teaching was effective?
a. The client slowly pushes the walker forward 12 inches, then takes small steps forward while leaning
on the walker.
b. The client lifts the walker, moves it forward 10 inches, and then takes several small steps forward.
c. The client supports his weight on the walker while advancing it forward, then takes small steps while
balancing on the walker.
d. The client slides the walker 18 inches forward, then takes small steps while holding onto the walker
for balance.
99. Nurse Deric is supervising a group of elderly clients in a residential home setting. The nurse knows
that the elderly are at greater risk of developing sensory deprivation for what reason?
a. Increased sensitivity to the side effects of medications.
b. Decreased visual, auditory, and gustatory abilities.
c. Isolation from their families and familiar surroundings.
d. Decrease musculoskeletal function and mobility.
100. A male client with emphysema becomes restless and confused. What step should nurse Jasmine
take next?
Answers and Rationale- NURSING PRACTICE III- Care of Clients with Physiologic and Psychosocial
Alterations Nursing
6. Answer: (C) Make sure that the client takes food and medications at prescribed intervals.
Rationale: Food and drug therapy will prevent the accumulation of hydrochloric acid, or will neutralize
and buffer the acid that does accumulate.
10. Answer: (C) The client is oriented when aroused from sleep, and goes back to sleep immediately.
Rationale: This finding suggest that the level of consciousness is decreasing.
16. Answer: (C) Presence of premature ventricular contractions (PVCs) on a cardiac monitor.
Rationale: Lidocaine drips are commonly used to treat clients whose arrhythmias haven’t been
controlled with oral medication and who are having PVCs that are visible on the cardiac monitor. SaO2,
blood pressure, and ICP are important factors but aren’t as significant as PVCs in the situation.
21. Answer: (C) Balance the client’s periods of activity and rest.
Rationale: A client with hyperthyroidism needs to be encouraged to balance periods of activity and rest.
Many clients with hyperthyroidism are hyperactive and complain of feeling very warm.
24. Answer: (D) Avoiding straining during bowel movement or bending at the waist.
Rationale: The client should avoid straining, lifting heavy objects, and coughing harshly because these
activities increase intraocular pressure. Typically, the client is instructed to avoid lifting objects weighing
more than 15 lb (7kg) – not 5lb. instruct the client when lying in bed to lie on either the side or back. The
client should avoid bright light by wearing sunglasses.
27. Answer: (A) A progressively deeper breaths followed by shallower breaths with apneic periods.
Rationale: Cheyne-Strokes respirations are breaths that become progressively deeper fallowed by
shallower respirations with apneas periods. Biot’s respirations are rapid, deep breathing with abrupt
pauses between each breath, and equal depth between each breath. Kussmaul’s respirations are rapid,
deep breathing without pauses. Tachypnea is shallow breathing with increased respiratory rate.
29. Answer: (B) The airways are so swollen that no air cannot get through
Rationale: During an acute attack, wheezing may stop and breath sounds become inaudible because the
airways are so swollen that air can’t get through. If the attack is over and swelling has decreased, there
would be no more wheezing and less emergent concern. Crackles do not replace wheezes during an
acute asthma attack.
30. Answer: (D) Place the client on his side, remove dangerous objects, and protect his head.
Rationale: During the active seizure phase, initiate precautions by placing the client on his side,
removing dangerous objects, and protecting his head from injury. A bite block should never be inserted
during the active seizure phase. Insertion can break the teeth and lead to aspiration.
32. Answer: (D) Stay with him but not intervene at this time.
Rationale: If the client is coughing, he should be able to dislodge the object or cause a complete
obstruction. If complete obstruction occurs, the nurse should perform the abdominal thrust maneuver
with the client standing. If the client is unconscious, she should lay him down. A nurse should never
leave a choking client alone.
34. Answer: (C) Place the client in a side lying position, with the head of the bed lowered.
Rationale: The client should be positioned in a side-lying position with the head of the bed lowered to
prevent aspiration. A small amount of toothpaste should be used and the mouth swabbed or suctioned
to remove pooled secretions. Lemon glycerin can be drying if used for extended periods. Brushing the
teeth with the client lying supine may lead to aspiration. Hydrogen peroxide is caustic to tissues and
should not be used.
40. Answer: (A) The patient is under local anesthesia during the procedure
Rationale: Before the procedure, the patient is administered with drugs that would help to prevent
infection and rejection of the transplanted cells such as antibiotics, cytotoxic, and corticosteroids.
During the transplant, the patient is placed under general anesthesia.
44. Answer: (A) Explain the risks of not having the surgery
Rationale: The best initial response is to explain the risks of not having the surgery. If the client
understands the risks but still refuses the nurse should notify the physician and the nurse supervisor and
then record the client’s refusal in the nurses’ notes.
45. Answer: (D) The 75-year-old client who was admitted 1 hour ago with new-onset atrial fibrillation
and is receiving L.V. dilitiazem (Cardizem)
Rationale: The client with atrial fibrillation has the greatest potential to become unstable and is on L.V.
medication that requires close monitoring. After assessing this client, the nurse should assess the client
with thrombophlebitis who is receiving a heparin infusion, and then the 58- year-old client admitted 2
days ago with heart failure (his signs and symptoms are resolving and don’t require immediate
attention). The lowest priority is the 89-year-old with end stage right-sided heart failure, who requires
time-consuming supportive measures.
49. Answer: (B) Carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant
metastasis
Rationale: TIS, N0, M0 denotes carcinoma in situ, no abnormal regional lymph nodes, and no evidence of
distant metastasis. No evidence of primary tumor, no abnormal regional lymph nodes, and no evidence
of distant metastasis is classified as T0, N0, M0. If the tumor and regional lymph nodes can't be assessed
and no evidence of metastasis exists, the lesion is classified as TX, NX, M0. A progressive increase in
tumor size, no demonstrable metastasis of the regional lymph nodes, and ascending degrees of distant
metastasis is classified as T1, T2, T3, or T4; N0; and M1, M2, or M3.
52. Answer: (A) miosis, partial eyelid ptosis, and anhidrosis on the affected side of the face.
Rationale: Horner's syndrome, which occurs when a lung tumor invades the ribs and affects the
sympathetic nerve ganglia, is characterized by miosis, partial eyelid ptosis, and anhidrosis on the
affected side of the face. Chest pain, dyspnea, cough, weight loss, and fever are associated with pleural
tumors. Arm and shoulder pain and atrophy of the arm and hand muscles on the affected side suggest
Pancoast's tumor, a lung tumor involving the first thoracic and eighth cervical nerves within the brachial
plexus. Hoarseness in a client with lung cancer suggests that the tumor has extended to the recurrent
laryngeal nerve; dysphagia suggests that the lung tumor is compressing the esophagus.
53. Answer: (A) prostate-specific antigen, which is used to screen for prostate cancer.
Rationale: PSA stands for prostate-specific antigen, which is used to screen for prostate cancer. The
other answers are incorrect.
54. Answer: (D) "Remain supine for the time specified by the physician."
Rationale: The nurse should instruct the client to remain supine for the time specified by the physician.
Local anesthetics used in a subarachnoid block don't alter the gag reflex. No interactions between local
anesthetics and food occur. Local anesthetics don't cause hematuria.
56. Answer: (B) A fixed nodular mass with dimpling of the overlying skin
Rationale: A fixed nodular mass with dimpling of the overlying skin is common during late stages of
breast cancer. Many women have slightly asymmetrical breasts. Bloody nipple discharge is a sign of
intraductal papilloma, a benign condition. Multiple firm, round, freely movable masses that change with
the menstrual cycle indicate fibrocystic breasts, a benign condition.
58. Answer: (D) The client wears a watch and wedding band.
Rationale: During an MRI, the client should wear no metal objects, such as jewelry, because the strong
magnetic field can pull on them, causing injury to the client and (if they fly off) to others. The client must
lie still during the MRI but can talk to those performing the test by way of the microphone inside the
scanner tunnel. The client should hear thumping sounds, which are caused by the sound waves
thumping on the magnetic field.
59. Answer: (C) The recommended daily allowance of calcium may be found in a wide variety of foods.
Rationale: Premenopausal women require 1,000 mg of calcium per day. Postmenopausal women
require 1,500 mg per day. It's often, though not always, possible to get the recommended daily
requirement in the foods we eat. Supplements are available but not always necessary. Osteoporosis
doesn't show up on ordinary X-rays until 30% of the bone loss has occurred. Bone densitometry can
detect bone loss of 3% or less. This test is sometimes recommended routinely for women over 35
who are at risk. Strenuous exercise won't cause fractures.
66. Answer: (C) The cane should be used on the unaffected side
Rationale: A cane should be used on the unaffected side. A client with osteoarthritis should be
encouraged to ambulate with a cane, walker, or other assistive device as needed; their use takes weight
and stress off joints.
67. Answer: (A) a. 9 U regular insulin and 21 U neutral protamine Hagedorn (NPH).
Rationale: A 70/30 insulin preparation is 70% NPH and 30% regular insulin. Therefore, a correct
substitution requires mixing 21 U of NPH and 9 U of regular insulin. The other choices are incorrect
dosages for the prescribed insulin.
70. Answer: (C) They debride the wound and promote healing by secondary intention
Rationale: For this client, wet-to-dry dressings are most appropriate because they clean the foot ulcer by
debriding exudate and necrotic tissue, thus promoting healing by secondary intention. Moist,
transparent dressings contain exudate and provide a moist wound environment. Hydrocolloid dressings
prevent the entrance of microorganisms and minimize wound discomfort. Dry sterile dressings protect
the wound from mechanical trauma and promote healing.
79. Answer: (D) "I'll need to have a C-section if I become pregnant and have a baby."
Rationale: The human immunodeficiency virus (HIV) is transmitted from mother to child via the
transplacental route, but a Cesarean section delivery isn't necessary when the mother is HIV-positive.
The use of birth control will prevent the conception of a child who might have HIV. It's true that a
mother who's HIV positive can give birth to a baby who's HIV negative.
80. Answer: (C) "Avoid sharing such articles as toothbrushes and razors."
Rationale: The human immunodeficiency virus (HIV), which causes AIDS, is most concentrated in the
blood. For this reason, the client shouldn't share personal articles that may be blood-contaminated,
such as toothbrushes and razors, with other family members. HIV isn't transmitted by bathing or by
eating from plates, utensils, or serving dishes used by a person with AIDS.
82. Answer: (B) Administer epinephrine, as prescribed, and prepare to intubate the client if necessary.
Rationale: To reverse anaphylactic shock, the nurse first should administer epinephrine, a potent
bronchodilator as prescribed. The physician is likely to order additional medications, such as
antihistamines and corticosteroids; if these medications don't relieve the respiratory compromise
associated with anaphylaxis, the nurse should prepare to intubate the client. No antidote for penicillin
exists; however, the nurse should continue to monitor the client's vital signs. A client who
remains hypotensive may need fluid resuscitation and fluid intake and output monitoring; however,
administering epinephrine is the first priority.
88. Answer: (C) Abnormally low hematocrit (HCT) and hemoglobin (Hb) levels
Rationale: Low preoperative HCT and Hb levels indicate the client may require a blood transfusion
before surgery. If the HCT and Hb levels decrease during surgery because of blood loss, the potential
need for a transfusion increases. Possible renal failure is indicated by elevated BUN or creatinine levels.
Urine constituents aren't found in the blood. Coagulation is determined by the presence of appropriate
clotting factors, not electrolytes.
89. Answer: (A) Platelet count, prothrombin time, and partial thromboplastin time
Rationale: The diagnosis of DIC is based on the results of laboratory studies of prothrombin time,
platelet count, thrombin time, partial thromboplastin time, and fibrinogen level as well as client history
and other assessment factors. Blood glucose levels, WBC count, calcium levels, and potassium levels
aren't used to confirm a diagnosis of DIC.
91. Answer: (B) A client with cast on the right leg who states, “I have a funny feeling in my right leg.”
Rationale: It may indicate neurovascular compromise, requires immediate assessment.
92. Answer: (D) A 62-year-old who had an abdominal-perineal resection three days ago; client
complaints of chills.
Rationale: The client is at risk for peritonitis; should be assessed for further symptoms and infection.
93. Answer: (C) The client spontaneously flexes his wrist when the blood pressure is obtained.
Rationale: Carpal spasms indicate hypocalcemia.
94. Answer: (D) Use comfort measures and pillows to position the client.
Rationale: Using comfort measures and pillows to position the client is a non-pharmacological methods
of pain relief.
96. Answer: (C) The client holds the cane with his left hand, moves the cane forward followed by the
right leg, and then moves the left leg.
Rationale: The cane acts as a support and aids in weight bearing for the weaker right leg.
97. Answer: (A) Ask the woman’s family to provide personal items such as photos or mementos.
Rationale: Photos and mementos provide visual stimulation to reduce sensory deprivation.
98. Answer: (B) The client lifts the walker, moves it forward 10 inches, and then takes several small steps
forward.
Rationale: A walker needs to be picked up, placed down on all legs.
99. Answer: (C) Isolation from their families and familiar surroundings.
Rationale: Gradual loss of sight, hearing, and taste interferes with normal functioning.
100. Answer: (A) Encourage the client to perform pursed lip breathing.
Rationale: Purse lip breathing prevents the collapse of lung unit and helps client control rate and depth
of breathing.
a. Psychotherapy
b. Alcoholics anonymous (A.A.)
c. Total abstinence
d. Aversion Therapy
2. Nurse Hazel is caring for a male client who experience false sensory perceptions with no basis in
reality. This perception is known as:
a. Hallucinations
b. Delusions
c. Loose associations
d. Neologisms
3. Nurse Monet is caring for a female client who has suicidal tendency. When accompanying the client to
the restroom, Nurse Monet should…
4. Nurse Maureen is developing a plan of care for a female client with anorexia nervosa. Which action
should the nurse include in the plan?
5. A client is experiencing anxiety attack. The most appropriate nursing intervention should include?
6. A female client is admitted with a diagnosis of delusions of GRANDEUR. This diagnosis reflects a belief
that one is:
a. Being Killed
b. Highly famous and important
c. Responsible for evil world
d. Connected to client unrelated to oneself
7. A 20 year old client was diagnosed with dependent personality disorder. Which behavior is not likely
to be evidence of ineffective individual coping?
8. A male client is diagnosed with schizotypal personality disorder. Which signs would this client exhibit
during social situation?
a. Paranoid thoughts
b. Emotional affect
c. Independence need
d. Aggressive behavior
9. Nurse Claire is caring for a client diagnosed with bulimia. The most appropriate initial goal for a client
diagnosed with bulimia is?
10. Nurse Tony was caring for a 41 year old female client. Which behavior by the client indicates adult
cognitive development?
a. Respiratory difficulties
b. Nausea and vomiting
c. Dizziness
d. Seizures
12.A 75 year old client is admitted to the hospital with the diagnosis of dementia of the Alzheimer’s type
and depression. The symptom that is unrelated to depression would be?
13.Nurse Trish is working in a mental health facility; the nurse priority nursing intervention for a newly
admitted client with bulimia nervosa would be to?
14.Nurse Patricia is aware that the major health complication associated with intractable anorexia
nervosa would be?
a. Increasing stimulation
b. limiting unnecessary interaction
c. increasing appropriate sensory perception
d. ensuring constant client and staff contact
16.A 39 year old mother with obsessive-compulsive disorder has become immobilized by her elaborate
hand washing and walking rituals. Nurse Trish recognizes that the basis of O.C. disorder is often:
17.Mario is complaining to other clients about not being allowed by staff to keep food in his room.
Which of the following interventions would be most appropriate?
18.Conney with borderline personality disorder who is to be discharge soon threatens to “do
something” to herself if discharged. Which of the following actions by the nurse would be most
important?
19.Joey a client with antisocial personality disorder belches loudly. A staff member asks Joey, “Do you
know why people find you repulsive?” this statement most likely would elicit which of the following
client reaction?
a. Depensiveness
b. Embarrassment
c. Shame
d. Remorsefulness
20.Which of the following approaches would be most appropriate to use with a client suffering from
narcissistic personality disorder when discrepancies exist between what the client states and what
actually exist?
a. Rationalization
b. Supportive confrontation
c. Limit setting
d. Consistency
21.Cely is experiencing alcohol withdrawal exhibits tremors, diaphoresis and hyperactivity. Blood
pressure is 190/87 mmhg and pulse is 92 bpm. Which of the medications would the nurse expect to
administer?
a. Naloxone (Narcan)
b. Benzlropine (Cogentin)
c. Lorazepam (Ativan)
d. Haloperidol (Haldol)
22.Which of the following foods would the nurse Trish eliminate from the diet of a client in alcohol
withdrawal?
a. Milk
b. Orange Juice
c. Soda
d. Regular Coffee
23.Which of the following would Nurse Hazel expect to assess for a client who is exhibiting late signs of
heroin withdrawal?
24.To establish open and trusting relationship with a female client who has been hospitalized with
severe anxiety, the nurse in charge should?
25. Nurse Monette recognizes that the focus of environmental (MILIEU) therapy is to:
26.Nurse Trish would expect a child with a diagnosis of reactive attachment disorder to:
a. Have more positive relation with the father than the mother
b. Cling to mother & cry on separation
c. Be able to develop only superficial relation with the others
d. Have been physically abuse
27.When teaching parents about childhood depression Nurse Trina should say?
a. Scanning speech
b. Speech lag
c. Shuttering
d. Echolalia
29.A 60 year old female client who lives alone tells the nurse at the community health center “I really
don’t need anyone to talk to”. The TV is
my best friend. The nurse recognizes that the client is using the defense mechanism known as?
a. Displacement
b. Projection
c. Sublimation
d. Denial
30.When working with a male client suffering phobia about black cats, Nurse Trish should anticipate that
a problem for this client would be?
31.Linda is pacing the floor and appears extremely anxious. The duty nurse approaches in an attempt to
alleviate Linda’s anxiety. The most therapeutic question by the nurse would be?
33.Nurse Benjie is communicating with a male client with substance-induced persisting dementia; the
client cannot remember facts and fills in the gaps with imaginary information. Nurse Benjie is aware that
this is typical of?
a. Flight of ideas
b. Associative looseness
c. Confabulation
d. Concretism
34.Nurse Joey is aware that the signs & symptoms that would be most specific for diagnosis anorexia
are?
35.A characteristic that would suggest to Nurse Anne that an adolescent may have bulimia would be:
36.Nurse Monette is aware that extremely depressed clients seem to do best in settings where they
have:
a. Multiple stimuli
b. Routine Activities
c. Minimal decision making
d. Varied Activities
37.To further assess a client’s suicidal potential. Nurse Katrina should be especially alert to the client
expression of:
38.A nursing care plan for a male client with bipolar I disorder should include:
39.When planning care for a female client using ritualistic behavior, Nurse Gina must recognize that the
ritual:
40.A 32 year old male graduate student, who has become increasingly withdrawn and neglectful of his
work and personal hygiene, is brought to the psychiatric hospital by his parents. After detailed
assessment, a diagnosis of schizophrenia is made. It is unlikely that the client will demonstrate:
41.A 23 year old client has been admitted with a diagnosis of schizophrenia says to the nurse “Yes, its
march, March is little woman”. That’s literal you know”. These statement illustrate:
a. Neologisms
b. Echolalia
c. Flight of ideas
d. Loosening of association
42.A long term goal for a paranoid male client who has unjustifiably accused his wife of having many
extramarital affairs would be to help the client develop:
a. Insight into his behavior
b. Better self control
c. Feeling of self worth
d. Faith in his wife
43.A male client who is experiencing disordered thinking about food being poisoned is admitted to the
mental health unit. The nurse uses which communication technique to encourage the client to eat
dinner?
44.Nurse Nina is assigned to care for a client diagnosed with Catatonic Stupor. When Nurse Nina enters
the client’s room, the client is found lying on the bed with a body pulled into a fetal position. Nurse Nina
should?
45.Nurse Tina is caring for a client with delirium and states that “look at the spiders on the wall”. What
should the nurse respond to the client?
46.Nurse Jonel is providing information to a community group about violence in the family. Which
statement by a group member would indicate a need to provide additional information?
47.During electroconvulsive therapy (ECT) the client receives oxygen by mask via positive pressure
ventilation. The nurse assisting with this procedure knows that positive pressure ventilation is necessary
because?
a. Anesthesia is administered during the procedure
b. Decrease oxygen to the brain increases confusion and disorientation
c. Grand mal seizure activity depresses respirations
d. Muscle relaxations given to prevent injury during seizure activity depress respirations.
48.When planning the discharge of a client with chronic anxiety, Nurse Chris evaluates achievement of
the discharge maintenance goals. Which goal would be most appropriately having been included in the
plan of care requiring evaluation?
49.Nurse Tina is caring for a client with depression who has not responded to antidepressant
medication. The nurse anticipates that what treatment procedure may be prescribed.
a. Neuroleptic medication
b. Short term seclusion
c. Psychosurgery
d. Electroconvulsive therapy
50.Mario is admitted to the emergency room with drug-included anxiety related to over ingestion of
prescribed antipsychotic medication. The most important piece of information the nurse in charge
should obtain initially is the:
2. A . Hallucinations are visual, auditory, gustatory, tactile or olfactory perceptions that have no
basis in reality.
3. D . The Nurse has a responsibility to observe continuously the acutely suicidal client. The Nurse
should watch for clues, such as communicating suicidal thoughts, and messages; hoarding
medications and talking about death.
4. B . Establishing a consistent eating plan and monitoring client’s weight are important to this
disorder.
5. C . Appropriate nursing interventions for an anxiety attack include using short sentences,
staying with the client, decreasing stimuli, remaining calm and medicating as needed.
6. B . Delusion of grandeur is a false belief that one is highly famous and important.
8. A . Clients with schizotypal personality disorder experience excessive social anxiety that can
lead to paranoid thoughts
9. B . Bulimia disorder generally is a maladaptive coping response to stress and underlying issues.
The client should identify anxiety causing situation that
stimulate the bulimic behavior and then learn new ways of coping with the anxiety.
12. C . With depression, there is little or no emotional involvement therefore little alteration in
affect.
13. D . These clients often hide food or force vomiting; therefore they must be carefully
monitored.
14. A . These clients have severely depleted levels of sodium and potassium because of their
starvation diet and energy expenditure, these electrolytes are
necessary for cardiac functioning.
16. C . Ritualistic behavior seen in this disorder is aimed at controlling guilt and inadequacy by
maintaining an absolute set pattern of behavior.
17. D . The nurse needs to set limits in the client’s manipulative behavior to help the client
control dysfunctional behavior. A consistent approach by the staff is necessary to decrease
manipulation.
18. B . Any suicidal statement must be assessed by the nurse. The nurse should discuss the
client’s statement with her to determine its meaning in terms of
suicide.
19. A . When the staff member ask the client if he wonders why others find him repulsive, the
client is likely to feel defensive because the question is belittling. The natural tendency is to
counterattack the threat to self image.
20. B . The nurse would specifically use supportive confrontation with the client to point out
discrepancies between what the client states and what actually exists to increase responsibility
for self.
21. C . The nurse would most likely administer benzodiazepine, such as lorazepan (ativan) to the
client who is experiencing symptom: The client’s experiences symptoms of withdrawal because
of the rebound phenomenon when the sedation of the CNS from alcohol begins to decrease.
22. D . Regular coffee contains caffeine which acts as psychomotor stimulants and leads to
feelings of anxiety and agitation. Serving coffee top the client may add to tremors or
wakefulness.
23. D . Vomiting and diarrhea are usually the late signs of heroin withdrawal, along with muscle
spasm, fever, nausea, repetitive, abdominal cramps and backache.
24. D . Moving to a client’s personal space increases the feeling of threat, which increases
anxiety.
25. A . Environmental (MILIEU) therapy aims at having everything in the client’s surrounding area
toward helping the client.
26. C . Children who have experienced attachment difficulties with primary caregiver are not able
to trust others and therefore relate superficially
27. A . Children have difficulty verbally expressing their feelings, acting out behavior, such as
temper tantrums, may indicate underlying depression.
29. D . The client statement is an example of the use of denial, a defense that blocks problem by
unconscious refusing to admit they exist
30. A . Discussion of the feared object triggers an emotional response to the object.
31. B . The nurse presence may provide the client with support & feeling of control.
32. D . Experiencing the actual trauma in dreams or flashback is the major symptom that
distinguishes post traumatic stress disorder from other anxiety disorder.
33. C . Confabulation or the filling in of memory gaps with imaginary facts is a defense
mechanism used by people experiencing memory deficits.
34. A . These are the major signs of anorexia nervosa. Weight loss is excessive (15% of expected
weight)
36. B . Depression usually is both emotional & physical. A simple daily routine is the best, least
stressful and least anxiety producing.
37. D . The expression of these feeling may indicate that this client is unable to continue the
struggle of life.
38. A . Structure tends to decrease agitation and anxiety and to increase the client’s feeling of
security.
39. B . The rituals used by a client with obsessive compulsive disorder help control the anxiety
level by maintaining a set pattern of action.
40. C . A person with this disorder would not have adequate self-boundaries
41. D . Loose associations are thoughts that are presented without the logical connections usually
necessary for the listening to interpret the message.
42. C . Helping the client to develop feeling of self worth would reduce the client’s need to use
pathologic defenses.
43. B . Open ended questions and silence are strategies used to encourage clients to discuss their
problem in descriptive manner.
44. C . Clients who are withdrawn may be immobile and mute, and require consistent, repeated
interventions. Communication with withdrawn clients
requires much patience from the nurse. The nurse facilitates communication with the client by
sitting in silence, asking open-ended question and pausing
to provide opportunities for the client to respond.
45. D . When hallucination is present, the nurse should reinforce reality with the client.
48. C . Recognizing situations that produce anxiety allows the client to prepare to cope with
anxiety or avoid specific stimulus.
49. D . Electroconvulsive therapy is an effective treatment for depression that has not responded
to medication
50. B . In an emergency, lives saving facts are obtained first. The name and the amount of
medication ingested are of outmost important in treating this
potentially life threatening situation.
1. Following spinal injury, the nurse should encourage the client to drink fluids to avoid:
2. The client is transferred from the operating room to recovery room after an open-heart surgery. The
nurse assigned is taking the vital signs of the client. The nurse notified the physician when the
temperature of the client rises to 38.8 ºC or 102 ºF because elevated temperatures:
3. After radiation therapy for cancer of the prostate, the client experienced irritation in the bladder.
Which of the following sign of bladder irritability is correct?
A) Hematuria
B) Dysuria
C) Polyuria
D) Dribbling
4. A client is diagnosed with a brain tumor in the occipital lobe. Which of the following will the client
most likely experience?
A) Visual hallucinations.
B) Receptive aphasia.
C) Hemiparesis.
D) Personality changes.
5. A client with Addison’s disease has a blood pressure of 65/60. The nurse understands that decreased
blood pressure of the client with Addison’s disease involves a disturbance in the production of:
A) Androgens
B) Glucocorticoids
C) Mineralocorticoids
D) Estrogen
6. The nurse is planning to teach the client about a spontaneous pneumothorax. The nurse would base
the teaching on the understanding that:
A) Inspired air will move from the lung into the pleural space.
B) There is greater negative pressure within the chest cavity.
C) The heart and great vessels shift to the affected side.
D) The other lung will collapse if not treated immediately.
7. During an assessment, the nurse recognizes that the client has an increased risk for developing cancer
of the tongue. Which of the following health history will be a concern?
8. The client in the orthopedic unit asks the nurse the reason behind why compact bone is stronger than
cancellous bone. Which of the following is the correct response of the nurse?
A) Compact bone is stronger than cancellous bone because of its greater size.
B) Compact bone is stronger than cancellous bone because of its greater weight.
C) Compact bone is stronger than cancellous bone because of its greater volume.
D) Compact bone is stronger than cancellous bone because of its greater density.
9. The nurse is reviewing the laboratory results of the client. In reviewing the results of the RBC count,
the nurse understands that the higher the red blood cell count, the :
10. The physician advised the client with Hemiparesis to use a cane. The client asks the nurse why cane
will be needed. The nurse explains to the client that cane is advised specifically to:
11. The nurse is conducting a discharge teaching regarding the prevention of further problems to a client
who undergone surgery for carpal tunnel syndrome of the right hand. Which of the following instruction
will the nurse includes?
12. A female client is admitted because of recurrent urinary tract infections. The client asks the nurse
why she is prone to this disease. The nurse states that the client is most susceptible because of:
13. A 55-year-old client is admitted with chest pain that radiates to the neck, jaw and shoulders that
occurs at rest, with high body temperature, weak with generalized sweating and with decreased blood
pressure. A myocardial infarction is diagnosed. The nurse knows that the most accurate explanation for
one of these presenting adaptations is:
A) Catecholamines released at the site of the infarction causes intermittent localized pain.
B) Parasympathetic reflexes from the infarcted myocardium causes diaphoresis.
C) Constriction of central and peripheral blood vessels causes a decrease in blood pressure.
D) Inflammation in the myocardium causes a rise in the systemic body temperature.
14. Following an amputation of a lower limb to a male client, the nurse provides an instruction on how
to prevent a hip flexion contracture. The nurse should instruct the client to:.
15. The physician scheduled the client with rheumatoid arthritis for the injection of hydrocortisone into
the knee joint. The client asks the nurse why there is a need for this injection. The nurse explains that
the most important reason for doing this is to:
16. The nurse is assigned to care for a 57-year-old female client who had a cataract surgery an hour ago.
The nurse should:
A) Advise the client to refrain from vigorous brushing of teeth and hair.
B) Instruct the client to avoid driving for 2 weeks.
C) Encourage eye exercises to strengthen the ocular musculature.
D) Teach the client coughing and deep-breathing techniques.
17. A client with AIDS develops bacterial pneumonia is admitted in the emergency department. The
client’s arterial blood gases is drawn and the result is PaO2 80mmHg. then arterial blood gases are
drawn again and the level is reduced from 80 mmHg to 65 mmHg. The nurse should;
18. An 18-year-old college student is brought to the emergency department due to serious motor
vehicle accident. Right above-knee-amputation is done. Upon awakening from surgery the client tells
the nurse, “What happened to me? I cannot remember anything?” Which of the following would be the
appropriate initial nursing response?
A) “You sound concerned; You’ll probably remember more as you wake up.”
B) “Tell me what you think happened.”
C) “You were in a car accident this morning.”
D) “An amputation of your right leg was necessary because of an accident.”
19. A 38-year-old client with severe hypertension is hospitalized. The physician prescribed a Captopril
(Capoten) and Alprazolam (Xanax) for treatment. The client tells the nurse that there is something
wrong with the medication and nursing care. The nurse recognizes this behavior is probably a
manifestation of the client’s:
20. Before discharge, the nurse scheduled the client who had a colostomy for colorectal cancer for
discharge instruction about resuming activities. The nurse should plan to help the client understands
that:
A) After surgery, changes in activities must be made to accommodate for the physiologic changes
caused by the operation.
B) Most sports activities, except for swimming, can be resumed based on the client’s overall physical
condition.
C) With counseling and medical guidance, a near normal lifestyle, including complete sexual function is
possible.
D) Activities of daily living should be resumed as quickly as possible to avoid depression and further
dependency.
21. A client is scheduled for bariatric surgery. Preoperative teaching is done. Which of the following
statement would alert the nurse that further teaching to the client is necessary?
A) “I will be limiting my intake to 600 to 800 calories a day once I start eating again.”
B) “I’m going to have a figure like a model in about a year.”
C) “I need to eat more high-protein foods.”
D) “I will be going to be out of bed and sitting in a chair the first day after surgery.”.
22. The client who had transverse colostomy asks the nurse about the possible effect of the surgery on
future sexual relationship. What would be the best nursing response?
23. A 75-year-old male client tells the nurse that his wife has osteoporosis and asks what chances he had
of getting also osteoporosis like his wife. Which of the following is the correct response of the nurse?
24. An older adult client with acute pain is admitted in the hospital. The nurse understands that in
managing acute pain of the client during the first 24 hours, the nurse should ensure that:
25. A nurse is caring to an older adult with presbycusis. In formulating nursing care plan for this client,
the nurse should expect that hearing loss of the client that is caused by aging to have:
26. The nurse is reviewing the client’s chart about the ordered medication. The nurse must observe for
signs of hyperkalemia when administering:
A) Furosemide (Lasix)
B) Hydrochlorothiazide (HydroDIURIL)
C) Metolazone (Zaroxolyn)
D) Spironolactone (Aldactone)
27. The physician prescribed Albuterol (Proventil) to the client with severe asthma. After the
administration of the medication the nurse should monitor the client for:
A) Palpitation
B) Visual disturbance
C) Decreased pulse rate
D) Lethargy
28. A client is receiving diltiazem (Cardizem). What should the nurse include in a teaching plan aimed at
reducing the side effects of this medication?
A) Take the drug with an antacid.
B) Lie down after meals.
C) Avoid dairy products in diet.
D) Change positions slowly.
29. A client is receiving simvastatin (Zocor). The nurse is aware that this medication is effective when
there is decrease in:
A) The triglycerides
B) The INR
C) Chest pain
D) Blood pressure
30. A client is taking nitroglycerine tablets, the nurse should teach the client the importance of:
31. The physician prescribes Ibuprofen (Motrin) and hydroxychloroquine sulfate (Plaquenil) for a 58-
year-old male client with arthritis. The nurse provides information about toxicity of the
hydroxychloroquine. The nurse can determine if the information is clearly understood if the client
states:
32. The client with an acute myocardial infarction is hospitalized for almost one week. The client
experiences nausea and loss of appetite. The nurse caring for the client recognizes that these symptoms
may indicate the:
33. A client with a partial occlusion of the left common carotid artery is scheduled for discharge. The
client is still receiving Coumadin. The nurse provided a discharge instruction to the client regarding
adverse effects of Coumadin. The nurse should tell the client to consult with the physician if:
A) Swelling of the ankles increases.
B) Blood appears in the urine.
C) Increased transient Ischemic attacks occur.
D) The ability to concentrate diminishes.
34. Levodopa is ordered for a client with Parkinson’s disease. Before starting the medication, the nurse
should know that:
35. In making a diagnosis of myasthenia gravis Edrophonium HCI (Tensilon) is used. The nurse knows
that this drug will cause a temporary increase in:
A) Muscle strength
B) Symptoms
C) Blood pressure
D) Consciousness
36. The nurse can determine the effectiveness of carbamazepine (Tegretol) in the management of
trigeminal neuralgia by monitoring the client’s:
A) Seizure activity
B) Liver function
C) Cardiac output
D) Pain relief
37. Administration of potassium iodide solution is ordered to the client who will undergo a subtotal
thyroidectomy. The nurse understands that this medication is given to:
38. A client with Addison’s disease is scheduled for discharge. Before the discharge, the physician
prescribes hydrocortisone and fludrocortisone. The nurse expects the hydrocortisone to:
39. A client with diabetes insipidus is taking Desmopressin acetate (DDAVP). To determine if the drug is
effective, the nurse should monitor the client’s:
A) Arterial blood pH
B) Pulse rate
C) Serum glucose
D) Intake and output
40. A client with recurrent urinary tract infections is to be discharged. The client will be taking
nitrofurantoin (Macrobid) 50 mg po every evening at home. The nurse provides discharge instructions to
the client. Which of the following instructions will be correct?
41. A client with cancer of the lung is receiving chemotherapy. The physician orders antibiotic therapy
for the client. The nurse understands that chemotherapy destroys rapidly growing leukocytes in the:
A) Bone marrow
B) Liver
C) Lymph nodes
D) Blood
42. The physician reduced the client’s Dexamethasone (Decadron) dosage gradually and to continue a
lower maintenance dosage. The client asks the nurse about the change of dosage. The nurse explains to
the client that the purpose of gradual dosage reduction is to allow:
43. The nurse is assigned to care for a client with diarrhea. Excessive fluid loss is expected. The nurse is
aware that fluid deficit can most accurately be assessed by:
44. Which of the following is the most important electrolyte of intracellular fluid?
A) Potassium
B) Sodium
C) Chloride
D) Calcium
45. Which of the following client has a high risk for developing hyperkalemia?
A) Crohn’s disease
B) End-Stage renal disease
C) Cushing’s syndrome
D) Chronic heart failure
46. The nurse is reviewing the laboratory result of the client. The client’s serum potassium level is 5.8
mEq/L. Which of the following is the initial nursing action?
47. Potassium chloride, 20 mEq, is ordered and to be added in the IV solution of a client in a diabetic
ketoacidosis. The primary reason for administering this drug is:
48. A female client is brought to the emergency unit. The client is complaining of abdominal cramps. On
assessment, client is experiencing anorexia and weight is reduced. The physician’s diagnosis is colitis.
Which of the following symptoms of fluid and electrolyte imbalance should the nurse report
immediately?
50. The nurse is reviewing the laboratory result of the client. An arterial blood gas report indicates the
client’s pH is 7.20, PCO2 35 mmHg and HCO3 is 19 mEq/L. The results are consistent with:
A) Metabolic acidosis
B) Metabolic alkalosis
C) Respiratory acidosis
D) Respiratory alkalosis
1. A. Clients in the early stage of spinal cord damage experience an atonic bladder, which is
characterized by the absence of muscle tone, an enlarged capacity, no feeling of discomfort with
distention, and overflow with a large residual. This leads to urinary stasis and infection. High fluid
intake limits urinary stasis and infection by diluting the urine and increasing urinary output.
2. D. The temperature of 102 ºF (38.8ºC) or greater lead to an increased metabolism and cardiac
workload.
3. B. Dysuria, nocturia, and urgency are all signs an irritable bladder after radiation therapy.
5. C. Mineralocorticoids such as aldosterone cause the kidneys to retain sodium ions. With
sodium, water is also retained, elevating blood pressure. Absence of this hormone thus causes
hypotension.
6. B. As a person with a tear in the lung inhales, air moves through that opening into the
intrapleural and causes partial or complete collapse of the lungs.
8. D. The greater the density of compact bone makes it stronger than the cancellous bone.
Compact bone forms from cancellous bone by the addition of concentric rings of bones
substances to the marrow spaces of cancellous bone. The large marrow spaces are reduced to
haversian canals.
9. A. Viscosity, a measure of a fluid’s internal resistance to flow, is increased as the number of
red cells suspended in plasma.
10. C. Hemiparesis creates instability. Using a cane provides a wider base of support and,
therefore greater stability.
11. D. Manual stretching exercises will assist in keeping the muscles and tendons supple and
pliable, reducing the traumatic consequences of repetitive activity.
12. C. The length of the urethra is shorter in females than in males; therefore microorganisms
have a shorter distance to travel to reach the bladder. The proximity of the meatus to the anus in
females also increases this incidence.
13. D. Temperature may increase within the first 24 hours and persist as long as a week.
14. C. The hips are in extension when the client is prone; this keeps the hips from flexing.
15. C. Steroids have an anti-inflammatory effect that can reduce arthritic pannus formation.
16. A. Activities such as rigorous brushing of hair and teeth cause increased intraocular pressure
and may lead to hemorrhage in the anterior chamber.
17. C. This decrease in PaO2 indicates respiratory failure; it warrants immediate medical
evaluation.
18. C. This is truthful and provides basic information that may prompt recollection of what
happened; it is a starting point.
19. D. Clients adapting to illness frequently feel afraid and helpless and strike out at health team
members as a way of maintaining control or denying their fear.
20. C. There are few physical restraints on activity postoperatively, but the client may have
emotional problems resulting from the body image changes.
21. B. Clients need to be prepared emotionally for the body image changes that occur after
bariatric surgery. Clients generally experience excessive abdominal skin folds after weight
stabilizes, which may require a panniculectomy. Body image disturbance often occurs in
response to incorrectly estimating one’s size; it is not uncommon for the client to still feel fat no
matter how much weight is lost.
22. D. Surgery on the bowel has no direct anatomic or physiologic effect on sexual performance.
However, the nurse should encourage verbalization.
23. C. Osteoporosis is not restricted to women; it is a potential major health problem of all older
adults; estimates indicate that half of all women have at least one osteoporitic fracture and the
risk in men is estimated between 13% and 25%; a bone mineral density measurement assesses
the mass of bone per unit volume or how tightly the bone is packed.
24. A. Around-the-clock administration of analgesics is recommended for acute pain in the older
adult population; this help to maintain a therapeutic blood level of pain medication.
25. C. Generally, female voices have a higher pitch than male voices; older adults with
presbycusis (hearing loss caused by the aging process) have more difficulty hearing higher-
pitched sounds.
27. A. Albuterol’s sympathomimetic effect causes cardiac stimulation that may cause tachycardia
and palpitation.
28. D. Changing positions slowly will help prevent the side effect of orthostatic hypotension.
29. A. Therapeutic effects of simvastatin include decreased serum triglyceries, LDL and
cholesterol.
30. C. Nitroglycerine is sensitive to light and moisture ad must be stored in a dark, airtight
container.
31. A. Visual disturbance are a sign of toxicity because retinopathy can occur with this drug.
32. B. Toxic levels of Lanoxin stimulate the medullary chemoreceptor trigger zone, resulting in
nausea and subsequent anorexia.
33. B. Warfarin derivatives cause an increase in the prothrombin time and INR, leading to an
increased risk for bleeding. Any abnormal or excessive bleeding must be reported, because it
may indicate toxic levels of the drug.
37. C. Potassium iodide, which aids in decreasing the vascularity of the thyroid gland, decreases
the risk for hemorrhage.
40. B. To prevent crystal formation, the client should have sufficient intake to produce 1000 to
1500 mL of urine daily while taking this drug.
41. A. Prolonged chemotherapy may slow the production of leukocytes in bone marrow, thus
suppressing the activity of the immune system. Antibiotics may be required to help counter
infections that the body can no longer handle easily.
42. A. Any hormone normally produced by the body must be withdrawn slowly to allow the
appropriate organ to adjust and resume production.
43. B. Dehydration is most readily and accurately measured by serial assessment of body weight;
1 L of fluid weighs 2.2 pounds.
44. A. The concentration of potassium is greater inside the cell and is important in establishing a
membrane potential, a critical factor in the cell’s ability to function.
45. B. The kidneys normally eliminate potassium from the body; hyperkalemia may necessitate
dialysis.
46. C. Vital signs monitor cardiorespiratory status; hyperkalemia causes serious cardiac
dysrhythmias.
47. A. Once treatment with insulin for diabetic ketoacidosis is begun, potassium ions reenter the
cell, causing hypokalemia; therefore potassium, along with the replacement fluid, is generally
supplied.
48. C. Potassium, the major intracellular cation, functions with sodium and calcium to regulate
neuromuscular activity and contraction of muscle fibers, particularly the heart muscle. In
hypokalemia these symptoms develop.
49. A. Because IV solutions enter the body’s internal environment, all solutions and medications
utilizing this route must be sterile to prevent the introduction of microbes.
50. A. A low pH and bicarbonate level are consistent with metabolic acidosis.
CANCER NURSING
1. You are caring for a patient with esophageal cancer. Which task could be delegated to the
nursing assistant?
2. A 56-year-old patient comes to the walk-in clinic for scant rectal bleeding and
intermittent diarrhea and constipation for the past several months. There is a history of
polyps and a family history for colorectal cancer. While you are trying to teach about
colonoscopy, the patient becomes angry and threatens to leave. What is the priority
diagnosis?
a. Metastasis
b. Limited local spread
c. Cancer in situ
d. Tumor limited to tissue of origin
e. Extensive local and regional spread
_____, _____, _____, _____, _____
5. In assigning patients with alterations related to gastrointestinal (GI) cancer, which would
be the most appropriate nursing care tasks to assign to the LPN/LVN, under supervision of
the team leader RN?
7. The physician tells the patient that there will be an initial course of treatment with
continued maintenance treatments and ongoing observation for signs and symptoms over a
prolonged period of time. You can help the patient by reinforcing that the primary goal for
this type of treatment is:
a. Cure
b. Control
c. Palliation
d. Permanent remission
8. For a patient who is experiencing side effects of radiation therapy, which task would be
the most appropriate to delegate to the nursing assistant?
9. For a patient on the chemotherapeutic drug vincristine (Oncovin), which of the following
side effects should be reported to the physician?
a. Fatigue
b. Nausea and vomiting
c. Paresthesia
d. Anorexia
a. WBC
b. PT and PTT
c. Electrolytes
d. BUN
11.For care of a patient who has oral cancer, which task would be appropriate to delegate to
the LPN/LVN?
12.When assigning staff to patients who are receiving chemotherapy, what is the major
consideration about chemotherapeutic drugs?
13.You have just received the morning report from the night shift nurses. List the order of
priority for assessing and caring for these patients.
14.In monitoring patients who are at risk for spinal cord compression related to tumor
growth, what is the most likely early manifestation?
a. Maintenance
b. Induction
c. Intensification
d. Consolidation
_____, _____, _____, _____
16.Which set of classification values indicates the most extensive and progressed cancer?
a. T1 N0 M0
b. Tis N0 M0
c. T1 N1 M0
d. T4 N3 M1
17.For a patient with osteogenic sarcoma, you would be particularly vigilant for elevations in
which laboratory value?
a. Sodium
b. Calcium
c. Potassium
d. Hematocrit
19.What do you tell patients is the most important risk factor for lung cancer when you are
teaching about lung cancer prevention?
a. Cigarette smoking
b. Exposure to environmental/occupational carcinogens
c. Exposure to environmental tobacco smoke (ETS)
d. Pipe or cigar smoking
20.Following chemotherapy, a patient is being closely monitored for tumor lysis syndrome.
Which laboratory value requires particular attention?
a. Platelet count
b. Electrolytes
c. Hemoglobin
d. Hematocrit
21.Persons at risk are the greater target population for cancer screening programs. Which
asymptomatic patient(s) needs extra encouragement to participate in cancer screening?
(Choose all that apply).
23.In caring for a patient with neutropenia, what tasks can be delegated to the nursing
assistant? (Choose all that apply).
24.A primary nursing responsibility is the prevention of lung cancer by assisting patients in
smoking/tobacco cessation. Which tasks would be appropriate to delegate to the LPN/LVN?
1. ANSWER A – Oral hygiene is within the scope of responsibilities of the nursing assistant. It is
the responsibility of the nurse to observe response to treatments and to help the patient deal
with loss or anxiety. The nursing assistant can be directed to weigh the patient, but should not be
expected to know when to initiate that measurement.
2. ANSWER D – The patient’s physical condition is currently stable, but emotional needs are
affecting his or her ability to receive the information required to make an informed decision. The
other diagnoses are relevant, but if the patient leaves the clinic for interventions may be delayed
or ignored.
3. ANSWER A – Pancreatic cancer is more common in blacks, males, and smokers. Other links
include alcohol, diabetes, obesity, history of pancreatitis, organic chemicals, a high-fat diet, and
previous abdominal radiation.
4. ANSWER C, D, B, E, A – This classification system is based on the extent of the disease rather
than the histological changes, Stage 0: cancer in situ, stage I: tumor limited to tissue of origin,
stage II: limited local spread, stage III: extensive local and regional spread, stage IV: metastasis.
5. ANSWER B – Administering enemas and antibiotics is within the scope of practice for
LPN/LVNs. Although some states may allow the LPN/LVN to administer blood, in general, blood
administration, pre-operative teaching, and assisting with central line insertion are the
responsibilities of the RN>
7. ANSWER B – The physician has described a treatment for controlling cancer that is not curable.
When the goal is cure, the patient will be deemed free of disease after treatments. In palliation,
the treatment is given primarily for pain relief. Permanent remission is another term to describe
cure.
8. ANSWER C – The nursing assistant can observe the amount that patient eats (or what is gone
from the tray) and report to the nurse. Assessing patterns of fatigue or skin reaction is the
responsibility of the RN. The initial recommendation for exercise should come from the
physician.
9. ANSWER C – Paresthesia is a side effect associated with some chemotherapy drugs such as
vincristine (Oncovin). The physician can modify the dose or discontinue the drug. Fatigue,
nausea, vomiting, and anorexia are common side effects for many chemotherapy medications.
The nurse can assist the patient by planning for rest periods, giving antiemetics as ordered, and
encouraging small meals with high-protein and high-calorie foods.
10. ANSWER A – WBC count is especially important because chemotherapy can cause decreases
in WBCs, particularly neutrophils, which leaves the patient vulnerable to infection. The other
tests are important in the total management, but less directly specific to
chemotherapy.
11. ANSWER C – Giving medications is within the scope of practice for the LPN/LVN. Assisting the
patient to brush and floss should be delegated to the nursing assistant. Explaining
contraindications is the responsibility of the RN. Recommendations for saliva substitutes should
come from the physician or pharmacist.
12. ANSWER A – Ideally, chemotherapy drugs should be given by nurses who have received
additional training in how to safely prepare and deliver the drugs and protect themselves from
exposure. The other options are a concern but the general principles of drug administration
apply.
14. ANSWER A – Back pain is an early sign occurring in 95% of patients. The other symptoms are
later signs.
15. ANSWER B, C, D, A – Induction is the initial aggressive treatment to destroy leukemia cells.
Intensification starts immediately after induction, lasting for several months and targeting
persistent, undetected leukemia cells. Consolidation occurs after remission to eliminate any
remaining leukemia cells. Maintenance involves lower doses to keep the body free of leukemia
cells.
16. ANSWER D – T (tumor) 0-4 signifies tumors increasing size. N (regional lymph nodes) 0-3
signifies increasing involvement of lymph nodes. M (metastasis) 0 signifies no metastasis and 1
signifies distal metastasis.
17. ANSWER B – Potentially life-threatening hypercalcemia can occur in cancers with destruction
of bone. Other laboratory values are pertinent for overall patient management but are less
specific to bone cancers.
18. ANSWER B, D – Debulking of tumor and laminectomy are palliative procedures. These
patients can be placed in the same room. The patient with low neutrophil count and the patient
who has had a bone marrow harvest need protective isolation.
19. ANSWER A – Cigarette smoking is associated with 80-90% of lung cancers. Occupational
exposure coupled with cigarette smoking increases risks. ETS increases risk by 35%. Cigar
smoking provides higher risk than pipe smoking, but both are lower risks than cigarette smoking.
20. ANSWER B – Tumor lysis syndrome can result in severe electrolyte imbalances and potential
renal failure. The other laboratory values are important to monitor for general chemotherapy
side effects, but are less pertinent to tumor lysis syndrome.
21. ANSWER A, C – After age 18, females should annual Pap smears, regardless of sexual activity.
African-American males should begin prostate-specific antigen testing at age 45. Annual
mammograms are recommended for women over the age of 40. Annual fecal occult blood
testing is recommended starting at age 50.
23. ANSWER A, B, D,F – Vital signs and reporting on specific parameters, good hand washing, and
gathering equipment are within the scope of duties for an nursing assistant. Assessing for
symptoms of infection/superinfections is the responsibility of the RN.
24. ANSWER B – The LPN/LVN is versed in medication administration and able to teach patients
standardized information. The other options require more in-depth assessment, planning, and
teaching, which should be performed by the RN.
Medical-Surgical Emergencies
1. You are the charge nurse in an emergency department (ED) and must assign two staff
members to cover the triage area. Which team is the most appropriate for this
assignment?
2. You are working in the triage area of an ED, and four patients approach the triage desk
at the same time. List the order in which you will assess these patients.
4. A 56-year-old patient presents in triage with left-sided chest pain, diaphoresis, and
dizziness. This patient should be prioritized into which category?
a. High urgent
b. Urgent
c. Non-urgent
d. Emergent
5. The physician has ordered cooling measures for a child with fever who is likely to be
discharged when the temperature comes down. Which of the following would be appropriate
to delegate to the nursing assistant?
6. It is the summer season, and patients with signs and symptoms of heat-related illness
present in the ED. Which patient needs attention first?
a. An elderly person complains of dizziness and syncope after standing in the sun for several
hours to view a parade
b. A marathon runner complains of severe leg cramps and nausea. Tachycardia,
diaphoresis, pallor, and weakness are observed.
c. A previously healthy homemaker reports broken air conditioner for days. Tachypnea,
hypotension, fatigue, and profuse diaphoresis are observed.
d. A homeless person, poor historian, presents with altered mental status, poor muscle
coordination, and hot, dry, ashen skin. Duration of exposure is unknown.
7. You respond to a call for help from the ED waiting room. There is an elderly patient lying
on the floor. List the order for the actions that you must perform.
8. The emergency medical service (EMS) has transported a patient with severe chest pain.
As the patient is being transferred to the emergency stretcher, you note unresponsiveness,
cessation of breathing, and no palpable pulse. Which task is appropriate to delegate to the
nursing assistant?
a. Chest compressions
b. Bag-valve mask ventilation
c. Assisting with oral intubation
d. Placing the defibrillator pads
10.An experienced traveling nurse has been assigned to work in the ED; however, this is
the nurse’s first week on the job. Which area of the ED is the most
appropriate assignment for the nurse?
a. Trauma team
b. Triage
c. Ambulatory or fats track clinic
d. Pediatric medicine team
11.A tearful parent brings a child to the ED for taking an unknown amount of children’s
chewable vitamins at an unknown time. The child is currently alert and asymptomatic. What
information should be immediately reported to the physician?
12.In caring for a victim of sexual assault, which task is most appropriate for an LPN/LVN?
13.You are caring for a victim of frostbite to the feet. Place the following interventions in the
correct order.
14.A patient sustains an amputation of the first and second digits in a chainsaw accident.
Which task should be delegated to the LPN/LVN?
15.A 36-year-old patient with a history of seizures and medication compliance of phenytoin
(Dilantin) and carbamazepine (Tegretol) is brought to the ED by the MS personnel for
repetitive seizure activity that started 45 minutes prior to arrival. You anticipate that the
physician will order which drug for status epilepticus?
16.You are preparing a child for IV conscious sedation prior to repair of a facial laceration.
What information should you immediately report to the physician?
17.An intoxicated patient presents with slurred speech, mild confusion, and uncooperative
behavior. The patient is a poor historian but admits to “drinking a
few on the weekend.” What is the priority nursing action for this patient?
18.When an unexpected death occurs in the ED, which of the following tasks is most
appropriate to delegate to the nursing assistant?
19.Following emergency endotracheal intubation, you must verify tube placement and
secure the tube. List in order the steps that are required to perform this function?
20.A teenager arrives by private car. He is alert and ambulatory, but this shirt and pants
are covered with blood. He and his hysterical friends are yelling and trying to explain that
that they were goofing around and he got poked in the abdomen with a stick. Which of the
following comments should be given first consideration?
21.A prisoner, with a known history of alcohol abuse, has been in police custody for 48
hours. Initially, anxiety, sweating, and tremors were noted. Now,
disorientation, hallucination, and hyper-reactivity are observed. The medical diagnosis is
delirium tremens. What is the priority nursing diagnosis?
22.You are assigned to telephone triage. A patient who was stung by a common honey bee
calls for advice, reports pain and localized swelling, but denies any respiratory distress or
other systemic signs of anaphylaxis. What is the action that you should direct the caller to
perform?
a. Call 911.
b. Remove the stinger by scraping.
c. Apply a cool compress.
d. Take an oral antihistamine.
24.You are assessing a patient who has sustained a cat bite to the left hand. The cat is up-
to-date immunizations. The date of the patient’s last tetanus shot is unknown. Which of the
following is the priority nursing diagnosis?
25.These patients present to the ED complaining of acute abdominal pain. Prioritize them in
order of severity.
27.In a multiple-trauma victim, which assessment finding signals the most serious and life-
threatening condition?
a. A deviated trachea
b. Gross deformity in a lower extremity
c. Decreased bowel sounds
d. Hematuria
28.A patient in a one-car rollover presents with multiple injuries. Prioritize the interventions
that must be initiated for this patient.
29.In the work setting, what is your primary responsibility in preparing for disaster
management that includes natural disasters or bioterrorism incidents?
30.You are giving discharge instructions to a woman who has been treated for contusions
and bruises sustained during an episode of domestic violence. What is your priority
intervention for this patient?
RATIONALE
MEDICAL – SURGICAL EMERGENCIES
1. ANSWER C – Triage requires at least one experienced RN. Pairing an experienced RN with
inexperienced RN provides opportunities for mentoring. Advanced practice nurses are qualified
to perform triage; however, their services are usually required in other areas of the ED. An
LPN/LVN is not qualified to perform the initial patient assessment or decision making. Pairing an
experienced RN with a nursing assistant is the second best option, because the assistant can
obtain vital signs and assist in transporting.
2. ANSWER B, A, D, C – An irritable infant with fever and petechiae should be further assessed for
other meningeal signs. The patient with the head wound needs additional history and
assessment for intracranial pressure. The patient with moderate abdominal pain is
uncomfortable, but not unstable at this point. For the ankle injury, medical evaluation can be
delayed 24 – 48 hours if necessary.
4. ANSWER D – Chest pain is considered an emergent priority, which is defined as potentially life-
threatening. Patients with urgent priority need treatment within 2 hours of triage (e.g. kidney
stones). Non-urgent conditions can wait for hours or even days. (High urgent is not commonly
used; however, in 5-tier triage systems, High urgent patients fall between emergent and urgent
in terms of the time lapsing prior to treatment).
5. ANSWER A – The nursing assistant can assist with the removal of the outer clothing, which
allows the heat to dissipate from the child’s skin. Advising and
explaining are teaching functions that are the responsibility of the RN. Tepid baths are not
usually performed because of potential for rebound and shivering.
6. ANSWER D – The homeless person has symptoms of heat stroke, a medical emergency, which
increases risk for brain damage. Elderly patients are at risk for
heat syncope and should be educated to rest in cool area and avoid future similar situations. The
runner is having heat crams, which can be managed with rest and fluids. The housewife is
experiencing heat exhaustion, and management includes fluids (IV or parenteral) and cooling
measures. The prognosis for recovery is good.
7. ANSWER B, D, A, C, E – Establish unresponsiveness first. (The patient may have fallen and
sustained a minor injury.) If the patient is unresponsive, get help and have someone initiate the
code. Performing the chin lift or jaw thrust maneuver opens the airway. The nurse is then
responsible for starting CPR. CPR should not be interrupted until the patient recovers or it is
determined that heroic efforts have been exhausted. A crash cart should be at the site when the
code team arrives; however, basic CPR can be effectively performed until the team arrives.
8. ANSWER A – Nursing assistants are trained in basic cardiac life support and can perform chest
compressions. The use of the bag-valve mask requires practice and usually a respiratory therapist
will perform this function. The nurse or the respiratory therapist should provide PRN assistance
during intubation. The defibrillator pads are clearly marked; however, placement should be done
by the RN or physician because of the potential for skin damage and electrical arcing.
9. ANSWER C – The patient is hyperventilating secondary to anxiety, and breathing into a paper
bag will allow rebreathing of carbon dioxide. Also, encouraging slow breathing will help. Other
treatments such as oxygen and medication may be needed if other causes are identified.
10. ANSWER C – The fast track clinic will deal with relatively stable patients. Triage, trauma, and
pediatric medicine should be staffed with experienced nurses who know the hospital routines
and policies and can rapidly locate equipment.
11. ANSWER A – Iron is a toxic substance that can lead to massive hemorrhage, coma, shock, and
hepatic failure. Deferoxame is an antidote that can be used for severe cases of iron poisoning.
Other information needs additional investigation, but will not change the immediate diagnostic
testing or treatment plan.
12. ANSWER C – The LPN/LVN is able to listen and provide emotional support for her patients.
The other tasks are the responsibility of an RN or, if available, a SANE (sexual assault nurse
examiner) who has received training to assess, collect and safeguard evidence, and care for these
victims.
13. ANSWER C, B, D, A – The victim should be removed from the cold environment first, and then
the rewarming process can be initiated. It will be painful, so give pain medication prior to
immersing the feet in warmed water.
14. ANSWER C – The only correct intervention is C. the digits should be gently cleansed with
normal saline, wrapped in sterile gauze moistened with saline, and placed in a plastic bag or
container. The container is then placed on ice.
15. ANSWER B – IV Lorazepam (Ativan) is the drug of choice for status epilepticus. Tegretol is
used in the management of generalized tonic-clonic, absence or mixed type seizures, but it does
not come in an IV form. PO (per os) medications are inappropriate for this emergency situation.
Magnesium sulfate is given to control seizures in toxemia of pregnancy.
16. ANSWER C – Parent refusal is an absolute contraindication; therefore, the physician must be
notified. Tetanus status can be addressed later. The RN can
restart the IV and provide information about conscious sedation; if the parent still notsatisfied,
the physician can give more information.
17. ANSWER D – The patient presents with symptoms of alcohol abuse and there is a risk for
Wernicke’s syndrome, which is caused by a thiamine deficiency. Multiples drug abuse is not
uncommon; however, there is nothing in the question that suggests an opiate overdose that
requires naloxone. Additional information or the results of the blood alcohol level are part of the
total treatment plan but should not delay the immediate treatment.
18. ANSWER C – Postmortem care requires some turning, cleaning, lifting, etc., and the nursing
assistant is able to assist with these duties. The RN should take responsibility for the other tasks
to help the family begin the grieving process. In cases of questionable death, belongings may be
retained for evidence, so the chain of custody would have to be maintained.
19. ANSWER C, D, B, A – Auscultating and confirming equal bilateral breath sounds should be
performed in rapid succession. If the sounds are not equal or if the sounds are heard over the
mid-epigastric area, tube placement must be corrected immediately. Securing the tube is
appropriate while waiting for the x-ray study.
20. ANSWER B – An impaled object may be providing a tamponade effect, and removal can
precipitate sudden hemodynamic decompensation. Additional history including a more definitive
description of the blood loss, depth of penetration, and medical history should be obtained.
Other information, such as the dirt on the stick or history of diabetes, is important in the overall
treatment plan, but can be addressed later.
21. ANSWER A – The patient demonstrates neurologic hyperactivity and is on the verge of a
seizure. Patient safety is the priority. The patient needs chlordiazepoxide (Librium) to decrease
neurologic irritability and phenytoin (Dilantin) for seizures. Thiamine and haloperidol (Haldol) will
also be ordered to address the other problems. The other diagnoses are pertinent but not as
immediate.
22. ANSWER B – The stinger will continue to release venom into the skin, so prompt removal of
the stinger is advised. Cool compresses and antihistamines can follow. The caller should be
further advised about symptoms that require 911 assistance.
23. ANSWER D – The asymptomatic patient is currently stable but should be observed for
delayed pulmonary edema, cerebral edema, or pneumonia. Teaching and care of critical patients
is an RN responsibility. Removing clothing can be delegated to a nursing assistant.
24. ANSWER A – Cat’s mouths contain a virulent organism, Pasteurella multocida, that can lead
to septic arthritis or bacteremia. There is also a risk for tendon damage due to deep puncture
wounds. These wounds are usually not sutured. A tetanus shot can be given before discharge.
25. ANSWER D, B, C, A – The patient with a pulsating mass has an abdominal aneurysm that may
rupture and he may decompensate suddenly. The 11-year-old boy needs evaluation to rule out
appendicitis. The woman needs evaluation for gallbladder problems that appear to be
worsening. The 35-year-old man has food poisoning, which is usually self-limiting.
26. ANSWER D – At least one representative from each group should be included because all
employees are potential targets fro violence in the ED.
27. ANSWER A – A deviated trachea is a symptoms of tension pneumothorax. All of the other
symptoms need to be addressed, but are of lesser priority.
28. ANSWER C, B, D, A, E, F, G – For a multiple trauma victim, many interventions will occur
simultaneously as team members assist in the resuscitation. Methods to open the airway such as
the chin lift or jaw thrust can be used simultaneously while assessing for spontaneous
respirations. However, airway and oxygenation are priority. Starting IVs for fluid resuscitation is
part of supporting circulation. (EMS will usually establish at least one IV in the field.) Nursing
assistants can be directed to take vitals and remove clothing. Foley catheter is necessary to
closely monitor output.
29. ANSWER A – In preparing for disasters, the RN should be aware of the emergency response
plan. The plan gives guidance that includes roles of team members, responsibilities, and
mechanisms of reporting. Signs and symptoms of many agents will mimic common complaints,
such as flu-like symptoms. Discussions with colleagues and supervisors may help the individual
nurse to sort through ethical dilemmas related to potential danger to self.
30. ANSWER A – Safety is a priority for this patient, and she should not return to a place where
violence could reoccur. The other options are important for the long term management of this
care.