A nurse is a health care professional who is focused on caring for individuals, families and communities, ensuring that

they attain, maintain, or recover optimal health and functioning.

1. The quality assurance nurse reads several nurses notes from different records that refer to clients moods.
Examples of these notes are. "The client is good spirits today. The client feels depressed today and "The client is
withdrawn today, "Based on the quality assurance nurses findings. Which of the following would be the best action to
take?

a. Report the findings to the joint commission on Accreditation of Health Care Organization
b. Communicate the findings to the agency's Nursing Staff Development Department
c. Do nothing as this is acceptable documentation practice
d. Communicate the findings to nursing administration

2. Before going off duty, a nurse is reviewing the notes written for a client. The nurse discovers that there has been an
omission of important assessment findings. Which of the following nursing actions is most appropriate at this time?
a. Verbally relay the assessment finding during shift report and leave the record unchanged
b. Recopy the entire section, include the the missing missing data and throw the original data away
c. Record the time of the entry, the time of the assessment, and missing data,
d. Insert the omitted data in the appropriate area

3. Which Which of of the following statements heard by a nurse during intershift report provides the most ful
information related to priority setting for the upcoming shift
a. A client who is alert and oriented for the upcoming shift
b. A client who had catheter removed 8 hours ago has not urinated
c. A client who is 3 days post-operative is experiencing incision pain
d. A client admitted for congestive heart failure has a blood pressure of 138/80

4. . An insurance company has required a copy of the clients chart from the doctor's office in order to emedical care
received by the client. Which of the following is the most compensate the physician n for the appropriate nursing
action by the office nurse?
a. Copy the clients record and send to the insurance company
b. Explain that the clients medical record is confidential
c. Tell the doctor of the insurance company's request
d. Refer the insurance company to the office manager
5. An acute care nurse discharge to home a client who will need services from a home health nurse. What discharge
information is most important for the acute care nurse to give to the referral agency nurse?
a. Vital sign on discharge
b. Surgical report
c. Clients current self care abilities
d. Medication last administered

During a physical examination, a health care provider studies your body to determine if you do or to do not have a
physical problem.

6. A client who is alert and responsive was admitted directly from the physician's office with a diagnosis of rule out
acute myocardial infarction. Of the following alterations found on the initial assessment, which is of greatest concern
to the nurse?
a. Temperature is 99.8 °F
b. Respirations are 29 and laboured
c. Blood pressure supine is 138/76
d. There are infrequent missed apical beats

7. The nurse would use which of the following methods of examination to assess for the presence of a bruit in the
abdomen? ENT
a. Inspection
b. Palpation-thrill
c. Auscultation
d. Percussion

8. Which of the following statement made by the client indicates and understanding of how the nurse performs the
Romberg test?
a.You want me to stand with my feet together and eyes closed for a short time
b.You want me to bend over so you can inspect my spine for curvature
c. I am going to walk five or six steps on my toes only, then my heels
d. I need to touch my toes without bending my knees is possible

9. A normal thyroid assessment would be documented by the nurse as which of the following?
a Thyroid is midline, smooth, no nodules can be palpated
b. Thyroid is midline with parathyroid glands palpated bilaterally
c. Thy Thyroid is slightly deviated d to the left, eft, no nodules can be palpa be palpated
d. Thyroid is slightly deviated to the right with pea sized nodules at the base
10. The nurse examines the ocular motility of a client who recently experiences a cerebrovascular accident follow-up
documentation would describe the function of which of the following nerves?
a. II AND IV
b. I, III AND IV
c. III V VI
d. IV. VII

Emergency Nursing is a nursing specialty concerned with the care of patients who are experiencing emergencies or
who are critically III or injured. The following questioned apply.

11. The 2010 AHA guidelines for CPR and ECC recommended a change in t the BLS sequence of steps for adults,
children and i 1 infants. The change in CPR sequence requires sre-education of everyone who has learned CPR. The
change is likely to improve survival. The new sequence should include.
a. Breathing, airway, chest compression
b. Chest compression, airway, breathing CABD
c. Airway, breathing, chest compression
d. Airway, chest compression, breathing

12. Which of the following is not part of the 2010 AHA guideline update/
a. The routine use of cricoids pressure application during cardiac arrest is not anymore used
b. Manual defibrillator is preferred than AED for infants
c. Changing of the CPR sequence from CAB to ABC
d. Emphasis on high quality CPR

13. What is the depth of chest compression for adults?

a.Two cms
b. Four cms
c. Two inches
d. Four cms

14. How about about for the child?

a.Two cms
b. Four cms
c. Two inches
d. Four cms

15. How about about for the infants?

a.Two cms
b. Four cms
c. Two inches
d. Four cms

Sleep is a condition of body and mind such as that which typically recurs for several hours every night, in which the
nervous

16. Which factor has the most influence on an individual's sleep-wake.cycle?

a: Bedtime rituals
b. Daylight and darkness
c. Body's need for 8 hours of sleep
d. The circadian rhythm

17. Which natural chemical does the body produce at night to decrease wakefulness and promote sleep?
a. Melatonin
b. Serotonin
c. Dopamine
d. Endorphins

18 A patient tells the nurse that she often has a difficult time falling asleep at night. What suggestion offered by the
nurse may assist the patient in achieving sleep?
a. A snack containing carbohydrates and fats
b. A snack containing carbohydrates and protein
c. It is bed to avoid snack prior or to bed bedtime
d. A snack containing protein and fat

19. For the last three weeks, a nurse in a long-term care facility has administered a sedative-byphotic to a client who
complains of insomnia. The patient does not seem to be responding to the drug and is now laying awake at night.
Which of the following is the most likely explanation?
a. The nurse needs to administer another drug such as diphenhydramine for effectiveness
b. Most sedative-hypnotic lose th their effect one to two weeks of administration
c. The patients daily activity is interfering with the drug
d. The patient is eating carbohydrates prior to bedtime
20. Which of the following characteristics is association with REM sleep?
a. The individuals is readily aroused
b. The patient is having large muscle immobility
c. The muscle is jerking that may awaken the individual
d. The individuals is transitioning from Wakefulness to sleep

The national pressure ulcer advisory panel (NPUAP) defines a pressure ulcer as an area of unrelieved pressure over
a defined area, usually over a bony prominence; resulting in ischemia, cell death and tissue necrosis

21. Which of the following in untrue about the causes of bed sore?
a. Friction happens patient is being dragged pulled or pushed rather for being lift
b. Shearing is the combination of pressure and friction
c. Immobility is the number one cause of bed sore
d. Pressure is the primary cause of bed sore

22. The perpendicular force acting on the skin that causes ischemia, hence tissue damage is called
a. Friction
b. Shearing
c. Pressure
d. All of the above

23 . Which of the following dressing is use for stage i bed sore?

a. Dry sterile gauze
b. Dry to wet gauze
c. Transparent dressing
d. Hydrocolloid dressing

24. How about stage Il bed sore?

a. Dry sterile gauze
b. Dry to wet gauze
c. Transparent dressing
d. Hydrocolloid dressing

25. What is the herald sign of pressure ulcer?

a. Pressure
b. Blister formation
c. A sore that does not heat
d. Redness that does not go away

Nursing theory is defined as a creative and rigorous structuring and systematic view of ph of phenomena of ideas that
project a tentative purposeful

26. Which statement would the nurse include in a report on jean Watsons theory of human caring?
a. There should be guidelines for including the family in client care
b. There are ten adaptive mec mechanisms commonly used by clients
c. There are environment factors related to client care
d. There are creative factors related to human care

27. The nurse is evaluating t of nursing theories. Which would the nurse rule out as a purpose of nursing theories:
a. To help build a common nursing terminology
b. To promote enhanced salaries and benefits for nurses
c. To help establish criteria to measure quality of nursing care
d To offer a framework for generating knowledge and new ideas

28. When utilizing Feininger's cultural theory, it would be important for the nurse to remember what concept of woman
caring? Leiningers
a. It varies among cultures and is largely culturally derived
b. The nurse should teach it be the clients family member
c. It is universal and same a cultures
d. It is absent in some cultures

29. Which intervention would the nurse use to implement Imogene kings theory of goal of attainment?
a. Listing self care deficits
b. Purposeful transactions
c. Interactions with the environment
d. Determining how the client adapts to stress

30. Virginia Henderson, a nursing pioneer, conceptualizes the nurse role in assisting the client to achieve
Independence. Henderson's defined nursing as it focused on which of the following fundamental needs:
 a. Breathing normally (14 basic needs)
b. Providing self-care (Abdellah 21)
c. Behaving as a totality
d. Sleeping without resting

Therapeutic communication is defined as the face-to-face process of interacting that focuses on advancing the
physical and emotional well-being of a patient. Nurses use therapeutic communication techniques to provide support
and Information to patients.

31. During the introductory phase of communication with a client, the nurse becomes acquainted with the client and
does which and hich th of the following?
a. identifies goals and objectives
b. Prepare for the interview
c. Refers client to offer care provider for follow-up
d. Provides the client with advice

32. A nurse enters the room of a female client and asks her how she is doing. The client states "I am a little
nervous this moming." the nurses best reply would be which of the following?
a. What do you mean the word nervous
b. Why are you feeling nervous
c. Can I give you a backrub to calm your nerves
d. You certainly look like you are nervous

33. A client tells the nurse that her husband is an alcoholic and has worked for the three months. The nurse best
respond would be which of the following?
a.You sound worried, I think you should talk to the chaplain.
b. What have you done before to cope with the problem?
c. Have you tried At Anon meeting?
d. I'm reality sorry to hear that

34. Which of the following methods would be most effective for an ambulatory care nurse to use when trying to
determine the priority health related needs of a client?
a. Ask the chant what learning needs he or she has about current state of health.
b. Conduct a thorough nursing assessment
c. Determine the amount of time required to present the information
d.Carefully review the physicians order

35. Using a mannequin, the nurse has demonstrated wound care for a client. To promote client teaching. Which of the
following would be the best nursing action?
a. Watch a video explaining sterile technique that will be used for the client wound care
b. Complete the wound care on the client, explaining the procedure while performing it
c. Ask the client to review written literature and perform the care at a later time
d. Have the client perform the wound care with the nurse present to supervise-return demonstration

Sleep is a universal function common to all people and must be expressed during health teaching to a client.

36. What stage is associated with the transition from wakefulness to sleep?
a. Light sleep
b. Deep sleep
c. Very light sleep
d. Very deep sleep

37. The following are characteristics of NREM stage of sleep EXCEPT:

a. PNS dominates
b. Restores the body physically
c. Vital functions are decreased
d. Brain Brain is highly active and drearning occurs -REM

38. Which of the following substances may relieve pain and promote sleep?
a. Histamine
b. Tryptophan
c. Bradykinin
d. Prostaglandin

39. The primary center of wakefulness and regulates sleep is:

a. Cerebellum
b. Medulla
c. Reticular activating system
d. Pons

40. Which of the following beverage my induce sleep?

 a. Coffee
b. Tea
c. Fruits juice
d. Milk contains tryptophan

While working in a female medical ward, you are assigned to do physical assessment on several clients under the
supervision of a staff nurse. You basic knowledge in anatomy and physiology as well as scientific basics for certain
nursing produce l is important.

41. Mrs. Pats, 53 years old, is your client. She had complains of generalized weakness and is in the ward for
observation and evaluation. During physical assessment, you ask the client to make her chin touch the chest s. Pats
performs the movements as instructed, you assess the function of which of muscle? As Mrs.
a. Trapezius
b. Deltoid muscle area
c. Supraspinatus muscle
d. Sternocleidomastoid-neck mustle

42 . When you auscullate the client's chest and you are also perform breast palpation. Which of the following
regions of the abdomen will you consider?
a. Epigastic area
b. Umbilical area
c. Left hypochondriac area
d. Right lumbar area palpation.

43. You will assess the client chest and you are also performing breast, Which of the following is the most appropriate
position of the client?
a. Sim's position
b. Sitting position
c. Supine position
d. Semi-Fowler's position

44. While inspecting the jugular veins of Mrs. Pat's for distension, you should place her in which BEST position? (
a. Semi-Fowlers position
b. Dorsal recumbent
c. High-fowler's position
d. Lateral position

45. Mrs. Pats confesses that she has a lump on her left breast. Which of the following is the appropriate action of the
nurse?
a. Assess the breast with the lump first
b. Start assessment of the normal breast
c. Palpate both breast simultaneously to compare
d. Lift hand to palpate the breast where she noted the lump.

Nursing is a profession on within the health care sector focused on the care of individuals, families and communities
so they may attain, maintain or recover optimal health and quality of life.

46. What would the nurse role to be when utilizing/parse's human becoming theory?
a. Accepting the expression of positive and negative feelings
b. Serving as an authority figure for the client and family
c. Assisting with the gratification of human needs
d. Helping individuals and familles

47. What central theory was the basis for Florence nightingale's definition of nursing and is integrated in all aspects of
nursing as we know it today
a. Unitary human being
b. Environment theory
c. Interpersonal relation mode
d. Goal attainment theory

48. Nursing theory articulate the relationship among person, environment, health and nursing. What term would a
nurse use when referring to those four concepts collectively?"
a. Metaparadigm
b. Paradigm
c. Conceptual model
d. Grand theories

49. Using Betty Neumann'e-system model, the nurse assesses the client's stressors. Which stressor would the nurse
indicate as as intrapersonal?
a. Sleep deprivation
b. Recent loss of job
c. A desire to be everything to everyone
 d. An incision infection

50. Nurse is considered a practice discipline. What should the nurse be aware in the main difference between this
and a research theory discipline?
a. Nursing is not considered a practice discipline and therefore does not utilize research.
b. Non practice disciplines have a central focus of performance of a professional role
c. Non practice disciplines do not utilized theory in development of their focus
d. Nursing uses theory and research to help understand its focus.

A client diagnosed with active tuberculosis. Airborne is observed and he is placed in isolation. He resents the
isolation and appears angry

51. Which of the following interventions must be carried out by the nurse to improve the client sensory stimulation
during isolation?
a. Provide a telephone inside the isolation room
b. Provide the personal items needed by the client
c. Talk with family members to avoid expression of disgust
d. Maintain a clean and pleasant environment and allow recreational activities

52. Research has shown that the most effective infection control procedure is:
a. Hand washing before and after the client contact
b. Wearing ing gloves and masks for direct client care
c. Broad spectrum prophylactic antibiotics
d. Isolation precautions

53. The client was visited by friends. What instruction should you give the visitors who will come in contact with the
client?
a. Wear gloves entering the room
b. Talk with the relatives outside the client room
c. Perform hand hygiene after coming in contact with the client
d. Leave the facility immediately to avoid long exposure with the client

54. Your best nursing intervention for the behaviours manifested by the client is to
a. Explain the isolation procedure and provide meaningful stimulation
b. Limit the visitors to reduce the risk of spreading the infection
c. Provide a quiet and non-stimulating environment.

55. The psychological implication if isolation to the client includes which of the following?
a. Sense of loneliness due to disruption of normal social environment
b. Accepts the isolation technique for the protection of the family
c. Depresses and rejected
d. Altered body image

Pressure ulcers area of skin is placed placed under pressure. They are sometimes known as "bedsores "or pressure
sores.

56. A client with deep wounds undergone hydrocolloid dressing. Which of the following is true with regards to an
injury that breaks down the skin and underlying tissue. They are caused when an these dressings?
a. They can be moulded to uneven skin surfaces, thus best used in pressure sores
b. The client could not bathe nor shower with such dressing.
c. They could last Indefinitely wounds heal ot bathe nor ir shower with such dressing Indefinite
d. They provide good wound visibility

57. A client has a pressure ulcer with a swallow partial skin thickness, broded area but no necrotic tissue. The nurse
would treat the area with which of the following dressings?
a. Dry gauze
b. Alginate
c. Transparent dressing
d. Hydrocolloid

58. Which of the following best describes stage III pressure ulcer?
a. Characterized by erythema, does resolve win minutes of pressure relief. Skin remains intact (1st)
b. Fully thickness skin loss with extensive damage through the subcutaneous tissue to t may involve muscle
layers, joints and/or bones (4th)
c. Thickness loss which goes through the the fascia and dermis to the subcutaneous tissue but does not
extend through the underlying fascia Appears as a crater and may include undermining (3rd)
d. Partial thickness loss of skin involving the epidermis or dermis (may involve both the ulcer is superficial
and may present as s a blister, abrasion or shallow crater, Free of eschar (2nd)

59. Which statement, if made by the client or family member would indicate the need for further teaching?
a. Putting fo foam pads under the heels or other bony areas can help decrease pressure
 b.The skin should be washed wittyonly warm (not hot) and lotion put on while it is still wet
c. If a skin gets red but then the red doesn't go away after tuming, I should report it to the nurse
d. is a person cannot tum himself for herself in bed, some should help the person change position as
frequent as every two hours and as seldom as to five-six times per day

60. Which of the following are primary risk factors for pressure ulcers?

a. Low protein diet, insomnia, length surgical procedure, fever, sleeping on water bed
b. Low protein diet, lengthy surgical procedure, fever, sleeping on water bed
c. Low protein diet, intochnia, lengthy surgical procedure
d. Low protein diet, lengthy surgical procedure fever

Nursing assessment Is the gathering of information about a patients psychological, physiological., sociological and
spiritual status.

61. The nurse believes that the dosage of medication ordered by the physician is unsafe of the client weight and age.
The nurse should take which of the following actions?
a. Administer the medication as ordered by the physician
b. Give the cilent half of the dosage and document accordingly
c. Call the physician to discuss the order of nurse concern
d. Administer the medication, but chart the nurse concern about the dosage

62. Twenty minutes s after administering istering a pain medication to the client, the nurse return to ask if the clients
level of pain has-decreased. The nurse is engaging in which phase of the nursing process?
a. Planning
b. Diagnosing
c. Evaluating
d. Implementing

63. What is the problem with the e following outcome goal? Client will statepain is 1 sless or equal to a three on a
zero to ten pain scale?
a. No target time is given
b. It is not measurable
c. None, goal is not written correctly .
d. Client behaviour is missing

64. In giving a change change of shift report, which type of client information given by the nurse is most informative
and complete?
a. Client avoided 250 ml of urine 2 hours after urinary catheter was removed
b. Client is pleasant, alert and oriented times three.
c. The chest X-ray results were negative
d. Vital signs are stable

65. Which activity would be appropriate to delegate to an unlicensed nursing assistant?

a. Evaluating client outcome goals
b. Adjusting the rate of an infusion pump
c. Taking vital signs of client on the nursing unit
d. Assisting the physician with an invasive procedure

The nursing process uses clinical judgment to strike a balance of epistemology (knowledge) between personal
interpretation and research evidence int which critical thinking may play a part to categorize the clients issue and
course of action

66. Which of the following represents a professionally appropriate response by the nurse when a more stringent
policy for the use of restraints in introduced on a surgical unit?
a. Obey the policy but continue to voice disapproval of the policy to co-workers
b. Use the previous, less restrictive policy with consciousness
c. Verbally attack the policy is disagreement
d. Ask for the rationale behind the new policy

67. The nurse documents the following outcome goal on the care plan. Anxiety will be relieved within twenty to forty
minutes following administration of Lorazepam ativan). The nurse has just performed an activity in which of the
following phases of the nursing process?
a. Planning
b. Evaluation
c. Assessment
d. Implementation

68. The makes the following entry of the clients care plan. Goal not met. Client refuses to ambulate, stating "I'm too
afraid I will fall. They should take which of the following actions?
a. Re-assigned the client to another nurse
b. Re-examine the nursing order
 c. Write a new nursing diagnosis
d. Notify the physician

69. When the client resists on taking liquid medication that is essential to treatment, the nurse demonstrates critical
thinking by doing which of the following first?
a. Notifying the physician that the nurse wan unable to give the client this medication
b. Omitting this dose of medication and waiting until the client is more cooperative
c. Asking the nurse manager about how to approach the situation
d. Suggesting the medication can be diluted in a beverage

70. The nurse reassesses a client's anxiety level thirty minutes after administering Lorazapem (ATIVAN). This is an
example of which type of evaluation?
a. Routine
b. Ongoing
c. Intermittent
d. Terminal

A health assessment is a plan of care that identifies the specific needs of a person and how those needs will be
addressed by the healthcare system or skilled nursing facility. Health assessment is the evaluation of the health
status by performing a physical exam after taking a health history.

71. Which of the following nursing diagnosis would most likely be associated with the absence of hair on a seventy
year old male client-legs?
a. Risk for infection
b. Fluid volume deficit
c. Tissue perfusion, altered, peripheral
d. Altered nutrition, less than body requirements

72. To adequately inspect the extemal ear canal of an adult client, the nurse should do which of the following prior to
inserting the otoscope.
a. Pull the pinna top and back
b. Use an applicator to remove cerumen
c. Have the client lie down to promote comfort
d. Require that all earring's be removed for safety purposes

73. The nurse is preparing to palpate the abdomen as a part of the physical examination. Which of the following steps
is appropriate?
a. Depress the abdominal wall six to ten cms during deep palpation
b. Palpate with the palms of the hands rather than the fingers
c. Omit palpitation when bowel sounds are absent
d. Palpate sensitive areas of the abdomen last

74. The nurse should place the client into which of the following positions in order to assess a jugular vein distension?
a, Side lying position with no pillows under the head
b. Supine with head of bed elevated thirty degrees
C. Supine with neck placed downward on chest
d. High prowler's with head elevated upwards

74. The nurse should place the client into which of the following positions in order to assess a jugular vein distension?
a. Side lying position with no pillows under the head
b. Supine with head of bed elevated thirty degrees
c. Supine with neck placed downward on chest
d. High prowler's with head elevated upwards

75. In which of the following positions would it be best to place the client so the nurse can inspect and palpate the
bartholin's glands?
a. Sim's
b. Prone
c. Semi-fowler's
d. Lithotomy

The nursing process is goal-oriented method of caring that provides a framework to nursing care. It involves major
steps.

76. Which of the following is a correctly written nursing diagnosis that should be added to a client plan of care?
a. Impaired gas exchange related to aspiration of foreign matter
b. Impaired physical mobility related to impaired mobility
c. Altered nutrition more than body requirements
d. Cancer related to cigarette smoking

77. The client states, "My chest hurts and my left arm feels numb. What is the type and source of this data?
a. Subjective data from a secondary source
 b. Subjected data from a primary source
c. Objective data from a secondary source
d. Objective data from a primary source

78. A nurse knows that the nursing diagnosis of impaired skin integrity involves disruption of the skin surface and may
be caused by immobility. The nurse assesses the skin of a very thin, bedfast, client for signs of Impending skin
disruption or breakdown. What kind of reasoning is the nurse using?
a. Deductive-general to specific
b. Inductive-Specific to general
c. Trial and error
d. Intuitive

79. The nurse documents the nursing diagnostic statement, Risk for impaired skin integrity related to malnutrition, on
the care plan. What is the risk factor?
a. Immobility
b. Malnutrition
c. Impaired skin integrity
d. Alteration in nutrition

80. Which nurse is demonstrating the assessment phase of the nursing process?
a. The nurse who asks the client how much lunch was eaten
b. The nurse who works with the client to set desired outcome goal
c. The nurse who change the bed linens after the client is incontinent of feces
d. The nurse who observes that the clients pain was relieved with pain medication

The nursing process is a series of organized steps designed for nurses to provide excellent care.

81. Which of the following demonstrates that the nurse is participating in critical thinking?
a. The nurse find a quick and logical answer, even to complex questions
b. The nurse accepts without a question the values acquired in nursing school
c. The nurse admits he/she does not know how to do a procedure and request help
d. The nurse makes his/her point with clever and persuasive remarks to win an argument

82. A client come to a walk in clinic with complains of abdominal pain and diarrhea. The nurse takes the clients vital
signs. The nurse is implementing which phase of nursing process?
a. Implementation
b. Planning
c. Assessment
d. Diagnosis

83. The nurse is measuring the client's urine output and straining the urine to assess the stones. Which
of the following should the nurse record as objective data?
a. The client urine output was 450 ml
b. The client is complaining of abdominal pain
c. The client stated" I feel like I have passed a stone
d. The client stated "I didn't see any stones in my urine

84. When evaluating an adult blood pressure reading the nurse considers the client age. This is an example of which
of the following?
a. Clustering data
b. Determining gaps in the data
c. Differentiating cues and inferences
d. Comparing data against standards

85. What is missing from the following outcome goal written in a care plan by the nurse? The client will transfer from
bed to chair with two assists."
a. Target time
b. Client behaviour
c. Conditions or modifiers.
d. Performance criteria

Assessment Is a key component of nursing practice, required for planning and provision of patient and family
centered care.

86. The nurse should do which of the following in order to increase the likelihood of obtaining quality data when doing
a complete physical assessment?
a. Outline the process in detail prior to the examination
b. Ask the family members or significant others to wait outside the room
c. Identify each place of equipment used with the appropriate medical term
d. Provide a comfortable environment t for the interview and physical assessment
87. When taking a health history, the nurse should focus on which of the following?
a. Using good communication skills to identify the clients healthcare status
 b. Attempting to have no interruption from family members present
c. Documenting objective data using the clients own words
d. Completing the process in a timely manner

88. The nurse would document which of the following in the medical record as objective data obtained during client
assessment?
a. Loss of hair on bilateral lower legs
b. Report of scalp itching each moming
c. Detailed description of pain in an extremity
d. Complaints of numbness of the right hand

89. Before palpating the abdomen during an assessment, the nurse should do which of the following
a. Percuss all four quadrants
b. Put on sterile gloves
c. Auscultate bowel sounds
d. Elevate the client head

90. The nurse would attempt to gather which of the following information while obtaining a health history from the
client?
a. Reaction to past hospitalization
b. Personal goals related to health care
c. Type of insurance and financial concems
d. Physical, psychological and spiritual well-being

The health history is a current collection of organized information unique to an Individual. Relevant aspects of the
history include blographical, demographic, physical, mental, emotional, sociocultural, sexual and spiritual data.

91. The nurse would conduct a health history on a newly admitted client primary to accomplish which of the
following?
a. Identify several ways in which the client can maintain a healthier lifestyle
b. Obtain data, both overt and subtle, from the client and/or the family
c. Demonstrate concern for the client situation
d. Determine the client correct health status.

92. Ask the client describes the chief complain, the nurse should do which of the following?
a. Refrain for note taking to appear focused
b. Ask the client to repeat the data to assure reliability
c. Paraphrase in the nurse own words that the problem is
d. Document verbatim what the client has to say about the problem

93. The nurse selects which of the following pieces of equipment to test for a cremasteric reflex?
a. Percussion hammer
b. Cotton applicator
c. Blood pressure cuff
d. Sharp end of a needle

94. Prior to taking the health history the nurse should first do which of the following
a. Ask the client to disrobe and put on a gown
b. Establish that insurance coverage exists
c. Offer the clients beverage of choice
d. Establish a rapport with the client

95. The nurse would use which of the following skills when examining the abdomen of the client?
a. Inspection
b. Palpation
c. Auscultation
d. Percussion

Cardiopulmonary resuscitation (CPR) is a lifesaving technique useful in many emergencies, including heart attack or
near drowning in which someone's breathing or heartbeat has stopped.

96.High quality CPR improves a victim's chances of survival. One of the critical characteristic of high quality CPR
includes:
a. Push hard, push fast: compress at a rate of more than 100/m with a depth of at least ee inches for adults,
approximately three inches for children and two inches for infants.
b. Push hard, push fast; compress at a rate of at least 100/m with a depth of at least two inches for adults,
approximately two inches for children and one point five inches for infants
c. Push hard, push fast compress at a rate of at least 100/m with a depth of at least two point five inches for
adults approximately two inches for children and one point five inches for infants
d. Push hard, push fast compress at a rate of more than 100/m with a depth of less than or at least two
inches for adults. Approximately two inches for children and one point five inches for infants
97. Interruption in Cardiopulmonary Resuscitation should be minimized to around
a. < ten seconds
b. < twenty seconds
c. < thirty seconds
d. < forty seconds

98 . The American Heart Association has adopted, supported and helped develop the concept of Emergency
Cardiovascular Care system for many years. The five links in the adult chain of survival are
a. Early CPR with emphasis on chest compressions, immediate recognition of cardiac arrest and activation
of the emergency response system, effective advanced life support and integrated post cardiac arrest care
b. Rapid defibrillation, early CPR with emphasis on chest compression immediate recognition of cardiac
arrest and activation of the emergency response system, effective advanced life support and integrated post
cardiac arrest care c. Immediate recognition of cardiac arrest and activation of the emergency response
system, early CPR with a an emphasis of chest compressions, rapid fibrillations, effective advanced life
support and integrated post cardiac arrest care
d. Early CPR with an emphasis on chest compression, immediate recognition of cardiac arrest and
activation of the emergency response system, rapid-defibrillation, effective advanced life support and
Integrated post cardiac arrest care.

99. How often should compressors rotate?

a. Every two minutes (or five cycles)
b. Every four minutes
c. Every three cycles
d. Every two cycles

100. The correct application of ventilation with advanced airway is

a. One breath every eight to ten seconds
b. One breath every sex to eight seconds
c. One breath every ten to twelve seconds
d. One breath every twelve to twenty seconds