July 2011 Nurse Licensure Examination Result - July 2011 Nurse Board Exam Result
ABOUT BREAST FEEDING
I. Physiology of Breast milk production
As soon as delivery of the placenta is over there will be an abrupt decrease on both
Estrogen and Progesterone -----> this will stimulate the APG to secrete PROLACTIN.
note: Be aware that sucking also stimulates Prolactin secretion as this will stimulate the
nerves and impulse will travel from the nipple to the Hypothalamus
PROLACTIN will act on the acini cells (alveolar cells) of the breast to produce milk. This milk
is called FOREMILK and is stored in the lactiferous sinus. FOREMILK is continously being
produced.
What happens next?
When the baby sucks on the breast of the mother OXYTOCIN is stimulated and oxytocin will
act on 2 organs.
1. Breast (Let down reflex)
2. Uterus (promotes Involutions)
OXYTOCIN will cause the mammary glands to contract and push the milk forward making it
available for the baby.
What will stimulate the Let Down reflex?
1. Sucking of the baby
2. Sound of the baby's cry
note: After the Let Down Reflex a new milk will be formed and this is called HINDMILK and
this contains more FATS that is needed for the growing newborn
.STAGES OF BREASTMILK:
1. Colostrum - 2-4 days present
-content: decrease fats, increase IgA, dec CHO, dec CHON, inc minerals, -inc fat soluble
minerals
2. Transitional milk- 4 – 14 days
-content: inc lactose, inc water soluble vit., inc minerals
3. Mature milk- 14 & up
-content: inc fats (linoleic acid) – resp for devt of brain & integrity of skin
-inc CHO- lactose – easily digested, baby not constipated.- esp of sour milk smelling odor of
stool.
-Lactose intolerance- deficiency of enzyme LACTASE that digest LACTOSE
-Decrease CHON- lactalbumin
Difference with cow's milk
Cows milk
–inc fats -Dec CHO
-Inc CHON – casing- has curd that’s hard to digest.
-Inc minerals–traumatic effect on kidneys of babies. Can trigger stone formation.
-Inc phosphorusnote:
Note Baby who are breastfed are least likely to develop tetany. It is seen that botlle fed
infants have more difficulty in regulating calcium and phosporus. Because cow's milk have
more fat contents, this fatty acids may bind with calcium in the GIT causing more decrease
in calcium.
Note: Breast feeding can be iniated
if had Cesarian Section- after 4 hours
if NSD, ASAP
Advantages of Breast feeding
1. Economical
2. Always available
3. Breastfed babies have higher IQ than bottle fed babies.
4. It facilitates rapid involution
5. Decrease incidence of breast cancer.
6. Has antibodiesI(gA), lactoferrin, lyzozymes and interferon (inhibit and/or destroy
pathogenic bacteria and viruses)
7. Has lactobacillius bifidus- interferes with attack of pathogenic bacteria in GIT
8. Has macrophages
Store milk- plastic storage container
Store milk – good for 6 months from freezer- put rm temp. don’t heat
Disadvantages:
1. Possibility of transfer HEP B, HIV, cytomegalo virus.
2. No iron
3. Father can’t feed & bond as well
Proper breast feeding technique
1. Be in a comfortable position
(Most appropriate is Upright sitiing for this position avoids tension)
2. Entire body of teh baby should be turned towards the mother's breast.
3. Initiate feeding by stimulating the Rooting reflex- by touching the side of lips/cheeks then
baby will turn to stimulus. Disappear by 6 weeks- by 6 weeks baby can focus. Reflex will be
gonePurpose rooting- to look for food.
Sucking Mechanism (breast)
a. Lips of the infant should clamp a C-shape
b. The tounge thrusts forward to grasp nipple and areola
c. The nipple is brought against the ahrd palate as the tounge pulls the areola into the
mouth
d. the gums compresses the areola, squezing milk at the back of the throat
Sucking mechanism (bottle)
The large rubber nipple strikes the soft palate and interferes with the action of the tounge.
The tounge moves forwards against the gum to control overflow of milk in the espphagous
(same reason why dental malocllusion is prone to bottle fed babies, because they thrust
their tounge FORWARD causing problem in the formation of the dental arch)
4. Burp or Bubble the baby during and after feeding to allow escape of air (preventing
colic). Sit infant on lap, flexed forward, then rub or pat the back (note: avoid jarring the
infant)
Criteria of Effective Sucking
a.) Baby’s mouth is hiked up to areola
b.) Mom experiences after pain.
c.) Other nipple is also flowing with milk.
NOTE: Make sure that the mother feeds the baby at the same breast she last feed her baby.
THis is to facilitated complete emptying of the breast and thereby promote complete filling
of milk.
Contra Indications in Breast Feeding:
a. Maternal Conditions:
1. HIV, CMV, Hepa B
2. Recieving Coumadin, Lithium or Methotrexate
3. has breast cancer
4. has herpes lesion on breast
b.Newborn Condition - Inborn errors of metabolism such as Erythrobastosis Fetalis – Rh
incompatibility, Hydrops Fetalis, Phenylketonuria, Galactosemia, Tay Sachs disease
Problems experienced in Breastfeeding :
3RD day changes in breast post partuma.1
1)Engorged breast- feeling of fullness & tension in breast. - sometimes accompanied by
fever known as MILK FEVER.
Mgt:Warm compress- for breastfeeding momCold compress
– for bottle feeding & wear supportive bra.
When is involution of breast- 4 weeks
b.) Sore nipple – cracked with painful nipple
Mgt: 1.) exposure to air – remove bra & wear dress, if not, expose to 20 Watt bulbavoid
wearing plastic liner bra-will create moisture, cotton only
c.) Mastitis- inflammation of breast : staphylococcus aureus
Factors:
1. Improper breast emptying
2. Unhealthy sexual practices
- manually express inflamed breastfeed on unaffected breast- give antibiotics
– can still feed on unaffected breast
Type of stools with different milk products:
1. Transitional stool - - green loose & shiny, like diarrhea to the untrained eye
2. Breastfed stool
- golden yellow, soft, mushy with sour milk smell, frequently passed
- recur every feeding
3.. Bottlefed stool –
- pale yellow, formed hard with typical offensive odor, seldom passed, 2–3 x/day
- with food added -brown & odorous
15 ITEMS ACLS DRILL
1. To confirm proper placement of tracheal tube through 5-point auscultation, which of the
following observations are appropriate? Check all that apply.
__
__
__
__
check breath sounds in the left and right lateral chest and lung bases
auscultate breath sounds in the left and right anterior sides of the chest
listen for gastric bubbling noises front the epigastrium
ensure equal and adequate chest expansion bilaterally
2. Which of the following is true about an oropharyngeal airway?
a. it eliminates the need to position the head of the unconscious patient
b. it eliminates the possibility of an upper airway obstruction
c. it is of no value once a tracheal tube is inserted
d. it may stimulate vomiting or laryngospasm if inserted in the semiconscious patient
3. Which of the following is an indication for tracheal intubation?
a. difficulty encountered by qualified rescuers in ventilating an apneic patient with a bagmask device
b. a respiratory rate of less than 20 breaths per minute in a patient with severe chest pain
c. presence of premature ventricular contractions
d. to provide airway protection in a responsive patient with an adequate gag reflex
4. Which of the following is the most important step to restore oxygenation and ventilation
for the unresponsive, breathless submersion (near drowning) victim?
a. attempt to drain water from breathing passages by performing the Heimlich maneuver
b. begin chest compressions
c. provide cervical spine stabilization because a diving accident may have occurred
d. open the airway and begin rescue breathing as soon as possible even in the water
5. You respond with 2 other rescuers to a 50 year old man who is unresponsive, pulseless,
and not breathing. What tasks would you assign the other rescuers while you set up the
AED?
a. one rescuer should call rescue assistance and the others rescuer should begin CPR
b. both rescuers should help set up the AED and provide CPR
c. one rescuer should open the airway and begin rescue breathing, and the second rescuer
should begin chest compressions
d. recruit additional first responders to help
6. An AED hangs on the wall suddenly a code is called, you grab the AED and run to the
room where the resuscitation is ongoing. A colleague has begun CPR and confirms that the
patient is in pulseless arrest. As you begin to attach the AED, you see a transdermal
medication patch on the victim’s upper right chest, precisely where you were going to place
an AED electrode pad. What is your most appropriate action?
a. ignore the medication patch and place the electrode pad in the usual position
b. avoid the medication patch and place the second electrode pad on the victim’s back
c. remove the medication patch, wipe the area dry, and place the electrode pad in the
correct position
d. place the electrode pad on the victim’s right abdomen
7. A patient who has Ventricular Fibrillation has failed to respond to 3 shocks. Paramedics
started an IV and inserted a tracheal tube, confirming proper placement. Which of the
following drugs should this patient receive first?
a. Amiodarone 300 mg IV push
b. Lidocaine 1 to 1.5 mg/kg IV push
c. Procainamide 30 mg/min up to a total dose of 17 mg/kg
d. Epinephrine 1 mg IV push
8. After giving epinephrine 1 mg IV and a fourth shock, a patient remains in VF. You want to
continue to administer epinephrine at appropriate doses and intervals if the patient remains
in VF. Which epinephrine dose is recommended under these conditions?
a. give the following epinephrine dose sequence, each 3 minutes apart: 1 mg, 3 mg, and 5
mg
b. give a single high dose of epinephrine: 0.1 to 0.2 mg/kg
c. give epinephrine 1 mg IV, then in 5 minutes start vasopressin 40 U IV every 3 to 5
minutes
d. give epinephrine 1 mg IV; repeat 1 mg every 3 to 5 minutes
9. Which of the following therapies is the most important intervention for VF/pulseless VT
with the greatest effect on survival to hospital discharge?
a. Epinephrine
b. Defibrillation
c. Oxygen
d. Amiodarone
10. A 60 yr old man persists in VF arrest despite 3 stacked shocks at appropriate energy
levels. Your code team, however, has been unable to start an IV or insert a tracheal tube.
Therefore administration of IV or tracheal medications will be delayed. What is the most
appropriate immediate next step?
a. deliver additional shocks in an attempt to defibrillate
b. deliver a precordial thump
c. perform a venous cut-down to gain IV access
d. administer intramuscular epinephrine 2 mg
11. A 75 year old homeless man is in cardiac arrest with pulseless VT at a rate of 220 bpm.
After CPR, 3 shocks in rapid succession, 1mg IV epinephrine, plus 3 more shocks, the man
continues to be in polymorphic pulseless VT. He appears wasted and malnourished. The
paramedics recognize him as a chronic alcoholic known in the neighborhood. Because he
remains in VT after 6 shocks, you are considering an antiarryhthymic. Which of the following
agents would be most appropriate for this patient at this time?
a. Amiodarone
b. Procainamide
c. Magnesium
d. Diltiazem
12. You are called to assist in the attempted resuscitation of a patient who is demonstrating
PEA. As you hurry to the patient’s room, you review the information you learned in the
ACLS course about management of PEA. Which one of the following about PEA is true?
a. chest compressions should be administered only if the patient with PEA develops a
ventricular rate of less than 50 bpm
b. successful treatment of PEA requires identification and treatment of reversible causes
c. atropine is the drug of choice for treatment of PEA, whether the ventricular rate is slow or
fast
d. PEA is rarely caused by hypovolemia, so fluid administration is contraindicated and
should not be attempted
13. For which of the following patients with PEA is sodium bicarbonate therapy (1 mEq/kg)
most likely to be most effective?
a. the patient with hypercarbic acidosis and tension pneumothorax treated with
decompression
b. the patient with a brief arrest interval
c. the patient with documented severe hyperkalemia
d. the patient with documented severe hypokalemia
14. Which of the following is the correct initial drug and dose for treatment of asystole?
a. epinephrine 2mg IV
b. atropine 0.5 mg IV
c. lidocaine 1mg/kg IV
d. epinephrine 1mg IV
15. You are considering transcutaneous pacing for a patient in asystole. Which of the
following candidates would be most likely to respond to such a pacing attempt?
a. the patient in asystole who has failed to respond to 20 minutes of BLS and ACLS therapy
b. the patient in asystole following blunt trauma
c. the patient in asystole following a defibrillatory shock
d. the patient who has just arrived in the emergency department following transport and
CPR in the field for persistent asystole after submersion
40 ITEMS COMPREHENSISE NCLEX REVIEW
1. Which individual is at greatest risk for developing hypertension?
A) 45 year-old African American attorney
B) 60 year-old Asian American shop owner
C) 40 year-old Caucasian nurse
D)55 year-old Hispanic teacher
The correct answer is A: 45 year-old African American attorney The incidence of
hypertension is greater among African Americans than other groups in the US. The
incidence among the Hispanic population is rising.
2. A child who ingested 15 maximum strength acetaminophen tablets 45 minutes ago is
seen in the emergency department. Which of these orders should the nurse do first?
A) Gastric lavage PRN
B) Acetylcysteine (mucomyst) for age per pharmacy
C) Start an IV Dextrose 5% with 0.33% normal saline to keep vein open
D) Activated charcoal per pharmacy
The correct answer is A: Gastric lavage PRN Removing as much of the drug as possible is
the first step in treatment for this drug overdose. This is best done by gastric lavage. The
next drug to give would be activated charcoal, then mucomyst and lastly the IV fluids.
3. Which complication of cardiac catheterization should the nurse monitor for in the initial
24 hours after the procedure?
A) angina at rest
B) thrombus formation
C) dizziness
D) falling blood pressure
The correct answer is B: thrombus formation Thrombus formation in the coronary arteries is
a potential problem in the initial 24 hours after a cardiac catheterization. A falling BP occurs
along with hemorrhage of the insertion site which is associated with the first 12 hours after
the procedure.
4. A client is admitted to the emergency room with renal calculi and is complaining of
moderate to severe flank pain and nausea. The client’s temperature is 100.8 degrees
Fahrenheit. The priority nursing goal for this client is
A) Maintain fluid and electrolyte balance
B) Control nausea
C) Manage pain
D) Prevent urinary tract infection
The correct answer is C: Manage pain The immediate goal of therapy is to alleviate the
client’s pain.
5. What would the nurse expect to see while assessing the growth of children during their
school age years?
A) Decreasing amounts of body fat and muscle mass
B) Little change in body appearance from year to year
C) Progressive height increase of 4 inches each year
D) Yearly weight gain of about 5.5 pounds per year
The correct answer is D: Yearly weight gain of about 5.5 pounds per year School age
children gain about 5.5 pounds each year and increase about 2 inches in height.
6. At a community health fair the blood pressure of a 62 year-old client is 160/96. The client
states “My blood pressure is usually much lower.” The nurse should tell the client to
A) go get a blood pressure check within the next 48 to 72 hours
B) check blood pressure again in 2 months
C) see the health care provider immediately
D) visit the health care provider within 1 week for a BP check
The correct answer is A: go get a blood pressure check within the next 48 to 72 hours The
blood pressure reading is moderately high with the need to have it rechecked in a few days.
The client states it is ‘usually much lower.’ Thus a concern exists for complications such as
stroke. However immediate check by the provider of care is not warranted. Waiting 2
months or a week for follow-up is too long.
7. The hospital has sounded the call for a disaster drill on the evening shift. Which of these
clients would the nurse put first on the list to be discharged in order to make a room
available for a new admission?
A) A middle aged client with a history of being ventilator dependent for over 7
years and admitted with bacterial pneumonia five days ago
B) A young adult with diabetes mellitus Type 2 for over 10 years and admitted with
antibiotic induced diarrhea 24 hours ago
C) An elderly client with a history of hypertension, hypercholesterolemia and lupus, and was
admitted with Stevens-Johnson syndrome that morning
D) An adolescent with a positive HIV test and admitted for acute cellulitus of the lower leg
48 hours ago
The correct answer is A: A middle aged client with a history of being ventilator dependent
for over 7 years and admitted with bacterial pneumonia five days ago The best candidate for
discharge is one who has had a chronic condition and is most familiar with their care. This
client in option A is most likely stable and could continue medication therapy at home.
8. A client has been newly diagnosed with hypothyroidism and will take levothyroxine
(Synthroid) 50 mcg/day by mouth. As part of the teaching plan, the nurse emphasizes that
this medication:
A) Should be taken in the morning
B) May decrease the client's energy level
C) Must be stored in a dark container
D) Will decrease the client's heart rate
The correct answer is A: Should be taken in the morning Thyroid supplement should be
taken in the morning to minimize the side effects of insomnia
9. A 3 year-old child comes to the pediatric clinic after the sudden onset of findings that
include irritability, thick muffled voice, croaking on inspiration, hot to touch, sit leaning
forward, tongue protruding, drooling and suprasternal retractions. What should the nurse do
first?
A) Prepare the child for x-ray of upper airways
B) Examine the child's throat
C) Collect a sputum specimen
D) Notify the healthcare provider of the child's status
The correct answer is D: Notify the health care provider of the child''s status These findings
suggest a medical emergency and may be due to epiglottises. Any child with an acute onset
of an inflammatory response in the mouth and throat should receive immediate attention in
a facility equipped to perform intubation or a tracheostomy in the event of further or
complete obstruction.
10. In children suspected to have a diagnosis of diabetes, which one of the following
complaints would be most likely to prompt parents to take their school age child for
evaluation?
A) Polyphagia
B) Dehydration
C) Bed wetting
D) Weight loss
The correct answer is C: Bed wetting In children, fatigue and bed wetting are the chief
complaints that prompt parents to take their child for evaluation. Bed wetting in a school
age child is readily detected by the parents
11. A client comes to the clinic for treatment of recurrent pelvic inflammatory disease. The
nurse recognizes that this condition most frequently follows which type of infection?
A) Trichomoniasis
B) Chlamydia
C) Staphylococcus
D) Streptococcus
The correct answer is B: Chlamydia Chlamydial infections are one of the most frequent
causes of salpingitis or pelvic inflammatory disease.
12. An RN who usually works in a spinal rehabilitation unit is floated to the emergency
department. Which of these clients should the charge nurse assign to this RN?
A) A middle-aged client who says "I took too many diet pills" and "my heart feels like it is
racing out of my chest."
B) A young adult who says "I hear songs from heaven. I need money for beer. I quit
drinking 2 days ago for my family. Why are my arms and legs jerking?"
C) An adolescent who has been on pain medications for terminal cancer with an
initial assessment finding of pinpoint pupils and a relaxed respiratory rate of 10
D) An elderly client who reports having taken a "large crack hit" 10 minutes prior to walking
into the emergency room
The correct answer is c: An adolescent who has been on pain medications for terminal
cancer with an initial assessment finding of pinpoint pupils and a relaxed respiratory rate of
10 Nurses who are floated to other units should be assigned to a client who has minimal
anticipated immediate complications of their problem. The client in option C exhibits opoid
toxicity with the pinpoint pupils and has the least risk of complications to occur in the near
future.
13. When teaching a client with coronary artery disease about nutrition, the nurse should
emphasize
A) Eating 3 balanced meals a day
B) Adding complex carbohydrates
C) Avoiding very heavy meals
D) Limiting sodium to 7 gms per day
The correct answer is C: Avoiding very heavy meals Eating large, heavy meals can pull
blood away from the heart for digestion and is dangerous for the client with coronary artery
disease.
14. Which of these findings indicate that a pump to deliver a basal rate of 10 ml per hour
plus PRN for pain break through for morphine drip is not working?
A) The client complains of discomfort at the IV insertion site
B) The client states "I just can't get relief from my pain."
C) The level of drug is 100 ml at 8 AM and is 80 ml at noon
D) The level of the drug is 100 ml at 8 AM and is 50 ml at noon
The correct answer is C: The level of drug is 100 ml at 8 AM and is 80 ml at noon The
minimal dose of 10 ml per hour which would be 40 ml given in a 4 hour period. Only 60 ml
should be left at noon. The pump is not functioning when more than expected medicine is
left in the container.
15. The nurse is speaking at a community meeting about personal responsibility for health
promotion. A participant asks about chiropractic treatment for illnesses. What should be the
focus of the nurse’s response? A) Electrical energy fields
B) Spinal column manipulation
C) Mind-body balance
D) Exercise of joints
The correct answer is B: Spinal column manipulation The theory underlying chiropractic is
that interference with transmission of mental impulses between the brain and body organs
produces diseases. Such interference is caused by misalignment of the vertebrae.
Manipulation reduces the subluxation.
16. The nurse is performing a neurological assessment on a client post right CVA. Which
finding, if observed by the nurse, would warrant immediate attention?
A) Decrease in level of consciousness
B) Loss of bladder control
C) Altered sensation to stimuli
D) Emotional lability
The correct answer is A: Decrease in level of consciousness A further decrease in the level
of consciousness would be indicative of a further progression of the CVA.
17. A child who has recently been diagnosed with cystic fibrosis is in a pediatric clinic where
a nurse is performing an assessment. Which later finding of this disease would the nurse not
expect to see at this time?
A) Positive sweat test
B) Bulky greasy stools
C) Moist, productive cough
D) Meconium ileus
The correct answer is C: Moist, productive cough Option c is a later sign. Noisy respirations
and a dry non-productive cough are commonly the first of the respiratory signs to appear in
a newly diagnosed client with cystic fibrosis (CF). The other options are the earliest findings.
CF is an inherited (genetic) condition affecting the cells that produce mucus, sweat, saliva
and digestive juices. Normally, these secretions are thin and slippery, but in CF, a defective
gene causes the secretions to become thick and sticky. Instead of acting as a lubricant, the
secretions plug up tubes, ducts and passageways, especially in the pancreas and lungs.
Respiratory failure is the most dangerous consequence of CF.
18. The home health nurse visits a male client to provide wound care and finds the client
lethargic and confused. His wife states he fell down the stairs 2 hours ago. The nurse should
A) Place a call to the client's health care provider for instructions
B) Send him to the emergency room for evaluation
C) Reassure the client's wife that the symptoms are transient
D) Instruct the client's wife to call the doctor if his symptoms become worse
The correct answer is B: Send him to the emergency room for evaluation This client requires
immediate evaluation. A delay in treatment could result in further deterioration and harm.
Home care nurses must prioritize interventions based on assessment findings that are in the
client''s best interest.
19. Which of the following should the nurse implement to prepare a client for a KUB
(Kidney, Ureter, Bladder) radiograph test?
A) Client must be NPO before the examination
B) Enema to be administered prior to the examination
C) Medicate client with Lasix 20 mg IV 30 minutes prior to the examination
D) No special orders are necessary for this examination
The correct answer is D: No special orders are necessary for this examination No special
preparation is necessary for this examination.
20. The nurse is giving discharge teaching to a client 7 days post myocardial infarction. He
asks the nurse why he must wait 6 weeks before having sexual intercourse. What is the
best response by the nurse to this question?
A) "You need to regain your strength before attempting such exertion." B) "When you can
climb 2 flights of stairs without problems, it is generally safe."
C) "Have a glass of wine to relax you, then you can try to have sex."
D) "If you can maintain an active walking program, you will have less risk."
The correct answer is B: "When you can climb 2 flights of stairs without problems, it is
generally safe." There is a risk of cardiac rupture at the point of the myocardial infarction for
about 6 weeks. Scar tissue should form about that time. Waiting until the client can tolerate
climbing stairs is the usual advice given by health care providers.
21. A triage nurse has these 4 clients arrive in the emergency department within 15
minutes. Which client should the triage nurse send back to be seen first?
A) A 2 month old infant with a history of rolling off the bed and has buldging fontanels with
crying
B) A teenager who got a singed beard while camping
C) An elderly client with complaints of frequent liquid brown colored stools
D) A middle aged client with intermittent pain behind the right scapula
The correct answer is B: A teenager who got singed a singed beard while camping This
client is in the greatest danger with a potential of respiratory distress, Any client with singed
facial hair has been exposed to heat or fire in close range that could have caused damage to
the interior of the lung. Note that the interior lining of the lung has no nerve fibers so the
client will not be aware of swelling.
22. While planning care for a toddler, the nurse teaches the parents about the expected
developmental changes for this age. Which statement by the mother shows that she
understands the child's developmental needs?
A) "I want to protect my child from any falls."
B) "I will set limits on exploring the house."
C) "I understand the need to use those new skills."
D) "I intend to keep control over our child."
The correct answer is C: "I understand the need to use those new skills." Erikson describes
the stage of the toddler as being the time when there is normally an increase in autonomy.
The child needs to use motor skills to explore the environment.
23. The nurse is preparing to administer an enteral feeding to a client via a nasogastric
feeding tube. The most important action of the nurse is
A) Verify correct placement of the tube
B) Check that the feeding solution matches the dietary order
C) Aspirate abdominal contents to determine the amount of last feeding remaining in
stomach
D) Ensure that feeding solution is at room temperature
The correct answer is A: Verify correct placement of the tube Proper placement of the tube
prevents aspiration.
24. The nurse is caring for a client with a serum potassium level of 3.5 mEq/L. The client is
placed on a cardiac monitor and receives 40 mEq KCL in 1000 ml of 5% dextrose in water
IV. Which of the following EKG patterns indicates to the nurse that the infusions should be
discontinued? A) Narrowed QRS complex
B) Shortened "PR" interval
C) Tall peaked T waves
D) Prominent "U" waves
The correct answer is C: Tall peaked T waves A tall peaked T wave is a sign of
hyperkalemia. The health care provider should be notified regarding discontinuing the
medication.
25. A nurse prepares to care for a 4 year-old newly admitted for rhabdomyosarcoma. The
nurse should alert the staff to pay more attention to the function of which area of the body?
A) All striated muscles
B) The cerebellum
C) The kidneys
D) The leg bones
The correct answer is A: All striated muscles Rhabdomyosarcoma is the most common
children''s soft tissue sarcoma. It originates in striated (skeletal) muscles and can be found
anywhere in the body. The clue is in the middle of the word and is “myo” which typically
means muscle.
26. The nurse anticipates that for a family who practices Chinese medicine the priority goal
would be to
A) Achieve harmony
B) Maintain a balance of energy
C) Respect life
D) Restore yin and yang
The correct answer is D: Restore yin and yang For followers of Chinese medicine, health is
maintained through balance between the forces of yin and yang.
27. During an assessment of a client with cardiomyopathy, the nurse finds that the systolic
blood pressure has decreased from 145 to 110 mm Hg and the heart rate has risen from 72
to 96 beats per minute and the client complains of periodic dizzy spells. The nurse instructs
the client to A) Increase fluids that are high in protein
B) Restrict fluids
C) Force fluids and reassess blood pressure
D) Limit fluids to non-caffeine beverages
The correct answer is C: Force fluids and reassess blood pressure Postural hypotension, a
decrease in systolic blood pressure of more than 15 mm Hg and an increase in heart rate of
more than 15 percent usually accompanied by dizziness indicates volume depletion,
inadequate vasoconstrictor mechanisms, and autonomic insufficiency.
28. A client has a Swan-Ganz catheter in place. The nurse understands that this is intended
to measure
A) Right heart function
B) Left heart function
C) Renal tubule function
D) Carotid artery function
The correct answer is B: Left heart function The Swan-Ganz catheter is placed in the
pulmonary artery to obtain information about the left side of the heart. The pressure
readings are inferred from pressure measurements obtained on the right side of the
circulation. Right-sided heart function is assessed through the evaluation of the central
venous pressures (CVP).
29. A nurse enters a client's room to discover that the client has no pulse or respirations.
After calling for help, the first action the nurse should take is
A) Start a peripheral IV
B) Initiate closed-chest massage
C) Establish an airway
D) Obtain the crash cart
The correct answer is C: Establish an airway Establishing an airway is always the primary
objective in a cardiopulmonary arrest.
30. A client is receiving digoxin (Lanoxin) 0.25 mg. Daily. The health care provider has
written a new order to give metoprolol (Lopressor) 25 mg. B.I.D. In assessing the client
prior to administering the medications, which of the following should the nurse report
immediately to the health care provider?
A) Blood pressure 94/60
B) Heart rate 76
C) Urine output 50 ml/hour
D) Respiratory rate 16
The correct answer is A: Blood pressure 94/60 Both medications decrease the heart rate.
Metoprolol affects blood pressure. Therefore, the heart rate and blood pressure must be
within normal range (HR 60-100; systolic B/P over 100) in order to safely administer both
medications.
31. While assessing a 1 month-old infant, which finding should the nurse report
immediately?
A) Abdominal respirations
B) Irregular breathing rate
C) Inspiratory grunt
D) Increased heart rate with crying
The correct answer is C: Inspiratory grunt Inspiratory grunting is abnormal and may be a
sign of respiratory distress in this infant.
32. The nurse practicing in a maternity setting recognizes that the post mature fetus is at
risk due to
A) Excessive fetal weight
B) Low blood sugar levels
C) Depletion of subcutaneous fat
D) Progressive placental insufficiency
The correct answer is D: Progressive placental insufficiency The placenta functions less
efficiently as pregnancy continues beyond 42 weeks. Immediate and long term effects may
be related to hypoxia.
33. The nurse is caring for a client who had a total hip replacement 4 days ago. Which
assessment requires the nurse’s immediate attention? A) I have bad muscle spasms in my
lower leg of the affected extremity.
B) "I just can't 'catch my breath' over the past few minutes and I think I am in
grave danger."
C) "I have to use the bedpan to pass my water at least every 1 to 2 hours." D) "It seems
that the pain medication is not working as well today."
The correct answer is B: "I just can''t ''catch my breath'' over the past few minutes and I
think I am in grave danger." The nurse would be concerned about all of these comments.
However the most life threatening is option B. Clients who have had hip or knee surgery are
at greatest risk for development of post operative pulmonary embolism. Sudden dyspnea
and tachycardia are classic findings of pulmonary embolism. Muscle spasms do not require
immediate attention. Option C may indicate a urinary tract infection. And option D requires
further investigation and is not life threatening.
34. A client has been taking furosemide (Lasix) for the past week. The nurse recognizes
which finding may indicate the client is experiencing a negative side effect from the
medication?
A) Weight gain of 5 pounds
B) Edema of the ankles
C) Gastric irritability
D) Decreased appetite
The correct answer is D: Decreased appetite Lasix causes a loss of potassium if a
supplement is not taken. Signs and symptoms of hypokalemia include anorexia, fatigue,
nausea, decreased GI motility, muscle weakness, dysrhythmias.
35. A client who is pregnant comes to the clinic for a first visit. The nurse gathers data
about her obstetric history, which includes 3 year-old twins at home and a miscarriage 10
years ago at 12 weeks gestation. How would the nurse accurately document this
information?
A) Gravida 4 para 2
B) Gravida 2 para 1
C) Gravida 3 para 1
D) Gravida 3 para 2
The correct answer is C: Gravida 3 para 1 Gravida is the number of pregnancies and Parity
is the number of pregnancies that reach viability (not the number of fetuses). Thus, for this
woman, she is now pregnant, had 2 prior pregnancies, and 1 viable birth (twins).
36. The nurse is caring for a client with a venous stasis ulcer. Which nursing intervention
would be most effective in promoting healing?
A) Apply dressing using sterile technique
B) Improve the client's nutrition status
C) Initiate limb compression therapy
D) Begin proteolytic debridement
The correct answer is B: Improve the client''s nutrition status The goal of clinical
management in a client with venous stasis ulcers is to promote healing. This only can be
accomplished with proper nutrition. The other answers are correct, but without proper
nutrition, the other interventions would be of little help.
37. A nurse is to administer meperidine hydrochloride (Demerol) 100 mg, atropine sulfate
(Atropisol) 0.4 mg, and promethizine hydrochloride (Phenergan) 50 mg IM to a preoperative client. Which action should the nurse take first?
A) Raise the side rails on the bed
B) Place the call bell within reach
C) Instruct the client to remain in bed
D) Have the client empty bladder
The correct answer is D: Have the client empty bladder The first step in the process is to
have the client void prior to administering the pre-operative medication. The other actions
follow this initial step in this sequence: 4 3 1 2
38. Which of these statements best describes the characteristic of an effective rewardfeedback system?
A) Specific feedback is given as close to the event as possible
B) Staff are given feedback in equal amounts over time
C) Positive statements are to precede a negative statement
D) Performance goals should be higher than what is attainable
The correct answer is A: Specific feedback is given as close to the event as possible
Feedback is most useful when given immediately. Positive behavior is strengthened through
immediate feedback, and it is easier to modify problem behaviors if the standards are
clearly understood.
39. A client with multiple sclerosis plans to begin an exercise program. In addition to
discussing the benefits of regular exercise, the nurse should caution the client to avoid
activities which
A) Increase the heart rate
B) Lead to dehydration
C) Are considered aerobic
D) May be competitive
The correct answer is B: Lead to dehydration The client must take in adequate fluids before
and during exercise periods.
40. During the evaluation of the quality of home care for a client with Alzheimer's disease,
the priority for the nurse is to reinforce which statement by a family member?
A) At least 2 full meals a day is eaten.
B) We go to a group discussion every week at our community center.
C) We have safety bars installed in the bathroom and have 24 hour alarms on the
doors.
D) The medication is not a problem to have it taken 3 times a day.
The correct answer is C: We have safety bars installed in the bathroom and have 24 hour
alarms on the doors. Ensuring safety of the client with increasing memory loss is a priority
of home care. Note all options are correct statements. However, safety is most important to
reinforce.
60 Item Medical Surgical Nursing : Musculoskeletal
Examination Answers
1. A client is 1 day postoperative after a total hip replacement. The client should be placed
in which of the following position?
a. Supine
b. Semi Fowler's
c. Orthopneic
d. Trendelenburg
2. A client who has had a plaster of Paris cast applied to his forearm is receiving pain
medication. To detect early manifestations of compartment syndrome, which of these
assessments should the nurse make?
a. Observe the color of the fingers
b. Palpate the radial pulse under the cast
c. Check the cast for odor and drainage
d. Evaluate the response to analgesics
3. After a computer tomography scan with intravenous contrast medium, a client returns to
the unit complaining of shortness of breath and itching. The nurse should be prepared to
treat the client for:
a. An anaphylactic reaction to the dye
b. Inflammation from the extravasation of fluid during injection.
c. Fluid overload from the volume of the infusions
d. A normal reaction to the stress of the diagnostic procedure.
4. While caring for a client with a newly applied plaster of Paris cast, the nurse makes note
of all the following conditions. Which assessment finding requires immedite notification of
the physician?
a. Moderate pain, as reported by the client
b. Report, by client, the heat is being felt under the cast
c. Presence of slight edema of the toes of the casted foot
d. Onset of paralysis in the toes of the casted foot
5. Which of these nursing actions will best promote independence for the client in skeletal
traction?
a. Instruct the client to call for an analgesic before pain becomes severe.
b. Provide an overhead trapeze for client use
c. Encourage leg exercise within the limits of traction
d. Provide skin care to prevent skin breakdown.
6. A client presents in the emergency department after falling from a roof. A fracture of the
femoral neck is suspected. Which of these assessments best support this diagnosis.
a.
b.
c.
d.
The client reports pain in the affected leg
A large hematoma is visible in the affected extremity
The affected extremity is shortenend, adducted, and extremely rotated
The affected extremity is edematous.
7. The nurse is caring for a client with compound fracture of the tibia and fibula. Skeletal
traction is applied. Which of these priorities should the nurse include in the care plan?
a.
b.
c.
d.
Order a trapeze to increase the client's ambulation
Maintain the client in a flat, supine position at all times.
Provide pin care at least every hour
Remove traction weights for 20 minutes every two hours.
8. To prevent foot drop in a client with Buck's traction, the nurse should:
a. Place pillows under the client's heels.
b. Tuck the sheets into the foot of the bed
c. Teach the client isometric exercises
d. Ensure proper body positioning.
9. Which nursing intervention is appropriate for a client with skeletal traction?
a. Pin care
b. Prone positioning
c. Intermittent weights
d. 5lb weight limit
10. In order for Buck's traction applied to the right leg to be effective, the client should be
placed in which position?
a. Supine c. Sim's
b. Prone d. Lithotomy
11. An elderly client has sustained intertrochanteric fracture of the hip and has just returned
from surgery where a nail plate was inserted for internal fixation. The client has been
instructed that she should not flex her hip. The best explanation of why this movement
would be harmful is:
a. It will be very painful for the client
b. The soft tissue around the site will be damaged
c. Displacement can occur with flexion
d. It will pull the hip out of alignment
12. When the client is lying supine, the nurse will prevent external rotation of the lower
extremity by using a:
a.
b.
c.
d.
Trochanter roll by the knee
Sandbag to the lateral calf
Trochanter roll to the thigh
Footboard
13. A client has just returned from surgery after having his left leg amputated below the
knee. Physician's orders include elevation of the foot of the bed for 24 hours. The nurse
observes that the nursing assistant has placed a pillow under the client's amputated limb.
The nursing action is to:
a. Leave the pillow as his stump is elevated
b. Remove the pillow and elevate the foot of the bed
c. Leave the pillow and elevate the foot of the bed
d. Check with the physician and clarify the orders
14. A client has sustained a fracture of the femur and balanced skeletal traction with a
Thomas splint has been applied. To prevent pressure points from occurring around the top
of the splint, the most important intervention is to:
a.
b.
c.
d.
Protect the skin with lotion
Keep the client pulled up in bed
Pad the top of the splint with washcloths
Provide a footplate in the bed
15. The major rationale for the use of acetylsalicylic acid (aspirin) in the treatment of
rheumatoid arthritis is to:
a. Reduce fever
b. Reduce the inflammation of the joints
c. Assist the client's range of motion activities without pain
d. Prevent extension of the disease process
16. Following an amputation, the advantage to the client for an immediate prosthesis fitting
is:
a. Ability to ambulate sooner
b. Less change of phantom limb sensation
c. Dressing changes are not necessary
d. Better fit of the prosthesis
17. One method of assessing for sign of circulatory impairment in a client with a fractured
femur is to ask the client to:
a. Cough and deep breathe
b. Turn himself in bed
c. Perform biceps exercise
d. Wiggle his toes
18. The morning of the second postoperative day following hip surgery for a fractured right
hip, the nurse will ambulate the client. The first intervention is to:
a. Get the client up in a chair after dangling at the bedside.
b. Use a walker for balance when getting the client out of bed
c. Have the client put minimal weight on the affected side when getting up
d. Practice getting the client out of bed by having her slightly flex her hips
19. A young client is in the hospital with his left leg in Buck's traction. The team leader asks
the nurse to place a footplate on the affected side at the bottom of the bed. The purpose of
this action is to:
a. Anchor the traction
b. Prevent footdrop
c. Keep the client from sliding down in bed
d. Prevent pressure areas on the foot
20. When evaluating all forms of traction, the nurse knows the direction of pull is controlled
by the:
a. Client's position
b. Rope/pulley system
c. Amount of weight
d. Point of friction
21. When a client has cervical halter traction to immobilize the cervical spine counteraction
is provided by:
a. Elevating the foot of the bed
b. Elevating the head of the bed
c. Application of the pelvic girdle
d. Lowering the head of the bed
22. After falling down the basement steps in his house, a client is brought to the emergency
room. His physician confirms that his leg is fractured. Following application of a leg cast, the
nurse will first check the client's toes for:
a. Increase in the temperature
b. Change in color
c. Edema
d. Movement
23. A 23 year old female client was in an automobile accident and is now a paraplegic. She
is on an intermittent urinary catheterization program and diet as tolerated. The nurse's
priority assessment should be to observe for:
a. Urinary retention
b. Bladder distention
c. Weight gain
d. Bower evacuation
24. A female client with rheumatoid arthritis has been on aspirin grain TID and prednisone
10mg BID for the last two years. The most important assessment question for the nurse to
ask related to the client's drug therapy is whether she has
a. Headaches
b. Tarry stools
c. Blurred vision
d. Decreased appetite
25. A 7 year old boy with a fractured leg tells the nurse that he is bored. An appropriate
intervention would be to
a.
b.
c.
d.
Read a story and act out the part
Watch a puppet show
Watch television
Listen to the radio
26. On a visit to the clinic, a client reports the onset of early symptoms of rheumatoid
arthritis. Which of the following would be the nurse most likely to asses:
a.
b.
c.
d.
Limited motion of joints
Deformed joints of the hands
Early morning stiffness
Rheumatoid nodules
27. After teaching the client about risk factors for rheumatoid arthritis, which of the
following, if stated by the client as a risk factor, would indicate to the nurse that the client
needs additional teaching?
a.
b.
c.
d.
History of Epstein-Barr virus infection
Female gender
Adults between the ages 60 to 75 years
Positive testing for human leukocyte antigen (HLA) DR4 allele
28. When developing the teaching plan for the client with rheumatoid arthritis to promote
rest, which of the following would the nurse expect to instruct the client to avoid during the
rest periods?
a. Proper body alignment
b. Elevating the part
c. Prone lying positions
d. Positions of flexion
29. After teaching the client with severe rheumatoid arthritis about the newly prescribed
medication methothrexate (Rheumatrex 0), which of the following statements indicates the
need for further teaching?
a. "I will take my vitamins while I am on this drug"
b. "I must not drink any alcohol while I'm taking this drug"
c. I should brush my teeth after every meal"
d. "I will continue taking my birth control pills"
30. When completing the history and physical examination of a client diagnosed with
osteoarthritis, which of the following would the nurse assess?
a. Anemia c. Weight loss
b. Osteoporosis d. Local joint pain
31. At which of the following times would the nurse instruct the client to take ibuprofen
(Motrin), prescribed for left hip pain secondary to osteoarthritis, to minimize gastric mucosal
irritation?
a. At bedtime c. Immediately after meal
b. On arising d. On an empty stomach
32. When preparing a teaching plan for the client with osteoarthritis who is taking celecoxib
(Celebrex), the nurse expects to explain that the major advantage of celecoxib over
diclofenac (Voltaren), is that the celecoxib is likely to produce which of the following?
a.
b.
c.
d.
Hepatotoxicity
Renal toxicity
Gastrointestinal bleeding
Nausea and vomiting
33. After surgery and insertion of a total joint prosthesis, a client develops severe sudden
pain and an inability to move the extremity. The nurse interprets these findings as
indicating which of the following?
a.
b.
c.
d.
A developing infection
Bleeding in the operative site
Joint dislocation
Glue seepage into soft tissue
34. Which of the following would the nurse assess in a client with an intracapsular hip
fracture?
a. Internal rotation c. Shortening of the affected leg
b. Muscle flaccidity d. Absence of pain the fracture area
35. Which of the following would be inappropriate to include when preparing a client for
magnetic resonance imaging (MRI) to evaluate a rupture disc?
a. Informing the client that the procedure is painless
b. Taking a thorough history of past surgeries
c. Checking for previous complaints of claustrophobia
d. Starting an intravenous line at keep-open rate
36. Which of the following actions would be a priority for a client who has been in the
postanesthesia care unit (PACU) for 45 minutes after an above the knee amputation and
develops a dime size bright red spot on the ace bondage above the amputation site?
a. Elevate the stump
b. Reinforcing the dressing
c. Calling the surgeon
d. Drawing a mark around the site
37. A client in the PACU with a left below the knee amputation complains of pain in her left
big toe. Which of the following would the nurse do first?
a. Tell the client it is impossible to feel the pain
b. Show the client that the toes are not there
c. Explain to the client that the pain is real
d. Give the client the prescribed narcotic analgesic
38. The client with an above the knee amputation is to use crutches until the prosthesis is
being adjusted. In which of the following exercises would the nurse instruct the client to
best prepare him for using crutches?
a. Abdominal exercises
b. Isometric shoulder exercises
c. Quadriceps setting exercises
d. Triceps stretching exercises
39. The client with an above the knee amputation is to use crutches until the prosthesis is
properly lifted. When teaching the client about using the crutches, the nurse instructs the
client to support her weight primarily on which of the following body areas?
a. Axillae
b. Elbows
c. Upper arms
d. Hands
40. Three hours ago a client was thrown from a car into a ditch, and he is now admitted to
the ED in a stable condition with vital signs within normal limits, alert and oriented with
good coloring and an open fracture of the right tibia. When assessing the client, the nurse
would be especially alert for signs and symptoms of which of the following?
a. Hemorrhage
b. Infection
c. Deformity
d. Shock
41. The client with a fractured tibia has been taking methocarbamol (Robaxin), when
teaching the client about this drug, which of the following would the nurse include as the
drug's primary effect?
a.
b.
c.
d.
Killing of microorganisms
Reduction in itching
Relief of muscle spasms
Decrease in nervousness
42. A client who has been taking carisoprodol (Soma) at home for a fractured arm is
admitted with a blood pressure of 80/50 mmHg, a pulse rate of 115bpm, and respirations of
8 breaths/minute and shallow, the nurse interprets these finding as indicating which of the
following?
a. Expected common side effects
b. Hypersensitivity reactions
c. Possible habituating effects
d. Hemorrhage from GI irritation
43. When admitting a client with a fractured extremity, the nurse would focus the
assessment on which of the following first?
a.
b.
c.
d.
The area proximal to the fracture
The actual fracture site
The area distal to the fracture
The opposite extremity for baseline comparison
44. A client with fracture develops compartment syndrome. When caring for the client, the
nurse would be alert for which of the following signs of possible organ failure?
a. Rales c. Generalized edema
b. Jaundice d. Dark, scanty urine
45. Which of the following would lead the nurse to suspect that a client with a fracture of
the right femur may be developing a fat embolus?
a. Acute respiratory distress syndrome
b. Migraine like headaches
c. Numbness in the right leg
d. Muscle spasms in the right thigh
46. The client who had an open femoral fracture was discharged to her home, where she
developed, fever, night sweats, chills, restlessness and restrictive movement of the
fractured leg. The nurse interprets these finding as indicating which of the following?
a. Pulmonary emboli
b. Osteomyelitis
c. Fat emboli
d. Urinary tract infection
47. When antibiotics are not producing the desired outcome for a client with osteomyelitis,
the nurse interprets this as suggesting the occurrence of which of the following as most
likely?
a.
b.
c.
d.
Formation of scar tissue interfering with absorption
Development of pus leading to ischemia
Production of bacterial growth by avascular tissue
Antibiotics not being instilled directly into the bone
48. Which of the following would the nurse use as the best method to assess for the
development of deep vein thrombosis in a client with a spinal cord injury?
a. Homan's sign c. Tenderness
b. Pain d. Leg girth
49. The nurse is caring for the client who is going to have an arthogram using a contrast
medium. Which of the following assessments by the nurse are of highest priority?
a. Allergy to iodine or shellfish
b. Ability of the client to remain still during the procedure
c. Whether the client has any remaining questions about the procedure
d. Whether the client wishes to void before the procedure
50. The client immobilized skeletal leg traction complains of being bored and restless. Based
on these complaints, the nurse formulates which of the following nursing diagnoses for this
client?
a. Divertional activity deficit
b. Powerlessness
c. Self care deficit
d. Impaired physical mobility
51. The nurse is teaching the client who is to have a gallium scan about the procedure. The
nurse includes which of the following items as part of the instructions?
a. The gallium will be injected intravenously 2 to 3 hours before the procedure
b. The procedure takes about 15 minutes to perform
c. The client must stand erect during the filming
d. The client should remain on bed rest for the remainder of the day after the scan
52. The nurse is assessing the casted extremity of a client. The nurse assesses for which of
the following signs and symptoms indicative of infection?
a. Coolness and pallor of the extremity
b. Presence of a "hot spot" on the cast
c. Diminished distal pulse
d. Dependent edema
53. The client has Buck's extension applied to the right leg. The nurse plans which of the
following interventions to prevent complications of the device?
a.
b.
c.
d.
Massage the skin of the right leg with lotion every 8 hours
Give pin care once a shift
Inspect the skin on the right leg at least once every 8 hours
Release the weights on the right leg for range of motion exercises daily
54. The nurse is giving the client with a left cast crutch walking instructions using the three
point gait. The client is allowed touchdown of the affected leg. The nurse tells the client to
advance the:
a. Left leg and right crutch then right leg and left crutch
b. Crutches and then both legs simultaneously
c. Crutches and the right leg then advance the left leg
d. Crutches and the left leg then advance the right leg
55. The client with right sided weakness needs to learn how to use a cane. The nurse plans
to teach the client to position the cane by holding it with the:
a.
b.
c.
d.
Left hand and placing the cane in front of the left foot
Right hand and placing the cane in front of the right foot
Left hand and 6 inches lateral to the left foot
Right hand and 6 inches lateral to the left foot
56. The nurse is repositioning the client who has returned to the nursing unit following
internal fixation of a fractured right hip. The nurse uses a:
a. Pillow to keep the right leg abducted during turning
b. Pillow to keep the right leg adducted during turning
c. Trochanter roll to prevent external rotation while turning
d. Trochanter roll to prevent abduction while turning
57. The nurse has an order to get the client out of bed to a chair on the first postoperative
day after a total knee replacement. The nurse plans to do which of the following to protect
the knee joint:
a. Apply a knee immobilizer before getting the client up and elevate the client's
surgical leg while sitting
b. Apply an Ace wrap around the dressing and put ice on the knee while sitting
c. Lift the client to the bedside change leaving the CPM machine in place
d. Obtain a walker to minimize weight bearing by the client on the affected leg
58. The nurse is caring for the client who had an above the knee amputation 2days ago. The
residual limb was wrapped with an elastic compression bandage which has come off. The
nurse immediately:
a. Calls the physician
b. Rewrap the stump with an elastic compression bandage
c. Applies ice to the site
d. Applies a dry sterile dressing and elevates it on a pillow
59. The nurse has taught the client with a below the knee amputation about prosthesis and
stump care. The nurse evaluates that the client states to:
a. Wear a clean nylon stump sock daily
b. Toughen the skin of the stump by rubbing it with alcohol
c. Prevent cracking of the skin of the stump by applying lotion daily
d. Using a mirror to inspect all areas of the stump each day
60. The nurse is caring for a client with a gout. Which of the following laboratory values
does the nurse expect to note in the client?
a. Uric acid level of 8 mg/dl
b. Calcium level of 9 mg/dl
c. Phosphorus level of 3 mg/dl
d. Uric acid level of 5 mg/dl
SITUATION : Epidemiology and Vital statistics is a very important tool that a nurse
could use in controlling the spread of disease in the community and at the same
time, surveying the impact of the disease on the population and prevent it’s future
occurrence.
1. It is concerned with the study of factors that influence the occurrence and
distribution of diseases, defects, disability or death which occurs in groups or
aggregation of individuals.
A. Epidemiology
B. Demographics
C. Vital Statistics
D. Health Statistics
2. Which of the following is the backbone in disease prevention?
A. Epidemiology
B. Demographics
C. Vital Statistics
D. Health Statistics
3. Which of the following type of research could show how community expectations
can result in the actual provision of services?
A. Basic Research
B. Operational Research
C. Action Research
D. Applied Research
4. An outbreak of measles has been reported in Community A. As a nurse, which of
the following is your first action for an Epidemiological investigation?
A. Classify if the outbreak of measles is epidemic or just sporadic
B. Report the incidence into the RHU
C. Determine the first day when the outbreak occurred
D. Identify if it is the disease which it is reported to be
5. After the epidemiological investigation produced final conclusions, which of the
following is your initial step in your operational procedure during disease outbreak?
A. Coordinate personnel from Municipal to the National level
B. Collect pertinent laboratory specimen to confirm disease causation
C. Immunize nearby communities with Measles
D. Educate the community in future prevention of similar outbreaks
6. The main concern of a public health nurse is the prevention of disease,
prolonging of life and promoting physical health and efficiency through which of the
following?
A. Use of epidemiological tools and vital health statistics
B. Determine the spread and occurrence of the disease
C. Political empowerment and Socio Economic Assistance
D. Organized Community Efforts
7. In order to control a disease effectively, which of the following must first be
known?
1.
2.
3.
4.
The conditions surrounding its occurrence
Factors that do not favor its development
The condition that do not surround its occurrence
Factors that favors its development
A. 1 and 3
B. 1 and 4
C. 2 and 3
D. 2 and 4
8. All of the following are uses of epidemiology except:
A. To study the history of health population and the rise and fall of disease
B. To diagnose the health of the community and the condition of the people
C. To provide summary data on health service delivery
D. To identify groups needing special attention
9. Before reporting the fact of presence of an epidemic, which of the following is of
most importance to determine?
A. Are the facts complete?
B. Is the disease real?
C. Is the disease tangible?
D. Is it epidemic or endemic?
10. An unknown epidemic has just been reported in Barangay Dekbudekbu. People
said that affected person demonstrates hemorrhagic type of fever. You are
designated now to plan for epidemiological investigation. Arrange the sequence of
events in accordance with the correct outline plan for epidemiological investigation.
1. Report the presence of dengue
2. Summarize data and conclude the final picture of epidemic
3. Relate the occurrence to the population group, facilities, food supply and carriers
4. Determine if the disease is factual or real
5. Determine any unusual prevalence of the disease and its nature; is it epidemic,
sporadic, endemic or pandemic?
6. Determine onset and the geographical limitation of the disease.
A. 4,1,3,5,2,6
B. 4,1,5,6,3,2
C. 5,4,6,2,1,3
D. 5,4,6,1,2,3
E. 1,2,3,4,5,6
11. In the occurrence of SARS and other pandemics, which of the following is the
most vital role of a nurse in epidemiology?
A. Health promotion
B. Disease prevention
C. Surveillance
D. Casefinding
12. Measles outbreak has been reported in Barangay Bahay Toro, After conducting
an epidemiological investigation you have confirmed that the outbreak is factual.
You are tasked to lead a team of medical workers for operational procedure in
disease outbreak. Arrange the correct sequence of events that you must do to
effectively contain the disease
1.
2.
3.
4.
5.
6.
Create a final report and recommendation
Perform nasopharyngeal swabbing to infected individuals
Perform mass measles immunization to vulnerable groups
Perform an environmental sanitation survey on the immediate environment
Organize your team and Coordinate the personnels
Educate the community on disease transmission
A. 1,2,3,4,5,6
B. 6,5,4,3,2,1
C. 5,6,4,2,3,1
D. 5,2,3,4,6,1
13. All of the following are function of Nurse Budek in epidemiology except
A. Laboratory Diagnosis
B. Surveillance of disease occurrence
C. Follow up cases and contacts
D. Refer cases to hospitals if necessary
E. Isolate cases of communicable disease
14. All of the following are performed in team organization except
A. Orientation and demonstration of methodology to be employed
B. Area assignments of team members
C. Check team’s equipments and paraphernalia
D. Active case finding and Surveillance
15. Which of the following is the final output of data reporting in epidemiological
operational procedure?
A. Recommendation
B. Evaluation
C. Final Report
D. Preliminary report
16. The office in charge with registering vital facts in the Philippines is none other
than the
A. PCSO
B PAGCOR
C. DOH
D. NSO
17. The following are possible sources of Data except:
A. Experience
B. Census
C. Surveys
D. Research
18. This refers to systematic study of vital events such as births, illnesses,
marriages, divorces and deaths
A. Epidemiology
B. Demographics
C. Vital Statistics
D. Health Statistics
19. In case of clerical errors in your birth certificate, Where should you go to have it
corrected?
A. NSO
B. Court of Appeals
C. Municipal Trial Court
D. Local Civil Registrar
20. Acasia just gave birth to Lestat, A healthy baby boy. Who are going to report
the birth of Baby Lestat?
A. Nurse
B. Midwife
C. OB Gyne
D. Birth Attendant
21. In reporting the birth of Baby Lestat, where will he be registered?
A. At the Local Civil Registrar
B. In the National Statistics Office
C. In the City Health Department
D. In the Field Health Services and Information System Main Office
22. Deejay, The birth attendant noticed that Lestat has low set of ears,
Micrognathia, Microcephaly and a typical cat like cry. What should Deejay do?
A. Bring Lestat immediately to the nearest hospital
B. Ask his assistant to call the nearby pediatrician
C. Bring Lestat to the nearest pediatric clinic
D. Call a Taxi and together with Acasia, Bring Lestat to the nearest hospital
23. Deejay would suspect which disorder?
A. Trisomy 21
B. Turners Syndrome
C. Cri Du Chat
D. Klinefelters Syndrome
24. Deejay could expect which of the following congenital anomaly that would
accompany this disorder?
A. AVSD
B. PDA
C. TOF
D. TOGV
26. Which presidential decree orders reporting of births within 30 days after its
occurrence?
A. 651
B. 541
C. 996
D. 825
25. These rates are referred to the total living population, It must be presumed that
the total population was exposed to the risk of occurrence of the event.
A. Rate
B. Ratio
C. Crude/General Rates
D. Specific Rate
26. These are used to describe the relationship between two numerical quantities or
measures of events without taking particular considerations to the time or place.
A. Rate
B. Ratios
C. Crude/General Rate
D. Specific Rate
27. This is the most sensitive index in determining the general health condition of a
community since it reflects the changes in the environment and medical conditions
of a community
A. Crude death rate
B. Infant mortality rate
C. Maternal mortality rate
D. Fetal death rate
28. According to the WHO, which of the following is the most frequent cause of
death in children underfive worldwide in the 2003 WHO Survey?
A. Neonatal
B. Pneumonia
C. Diarrhea
D. HIV/AIDS
29. In the Philippines, what is the most common cause of death of infants according
to the latest survey?
A. Pneumonia
B. Diarrhea
C. Other perinatal condition
D. Respiratory condition of fetus and newborn
30. The major cause of mortality from 1999 up to 2002 in the Philippines are
A. Diseases of the heart
B. Diseases of the vascular system
C. Pneumonias
D. Tuberculosis
31. Alicia, a 9 year old child asked you “ What is the common cause of death in my
age group here in the Philippines? “ The nurse is correct if he will answer
A. Pneumonia is the top leading cause of death in children age 5 to 9
B. Malignant neoplasm if common in your age group
C. Probability wise, You might die due to accidents
D. Diseases of the respiratory system is the most common cause of death in
children
32. In children 1 to 4 years old, which is the most common cause of death?
A. Diarrhea
B. Accidents
C. Pneumonia
D. Diseases of the heart
33. Working in the community as a PHN for almost 10 years, Aida knew the
fluctuation in vital statistics. She knew that the most common cause of morbidity
among the Filipinos is
A. Diseases of the heart
B. Diarrhea
C. Pneumonia
D. Vascular system diseases
34. Nurse Aida also knew that most maternal deaths are caused by
A. Hemorrhage
B. Other Complications related to pregnancy occurring in the course of
labor, delivery and puerperium
C. Hypertension complicating pregnancy, childbirth and puerperium
D. Abortion
SITUATION : Barangay PinoyBSN has the following data in year 2006
1. July 1 population : 254,316
2. Livebirths : 2,289
3. Deaths from maternal cause : 15
4. Death from CVD : 3,029
5. Deaths under 1 year of age : 23
6. Fetal deaths : 8
7. Deaths under 28 days : 8
8. Death due to rabies : 45
9. Registered cases of rabies : 45
10. People with pneumonia : 79
11. People exposed with pneumonia : 2,593
12. Total number of deaths from all causes : 10,998
The following questions refer to these data
35. What is the crude birth rate of Barangay PinoyBSN?
A. 90/100,000
B. 9/100
C. 90/1000
D. 9/1000
36. What is the cause specific death rate from cardiovascular diseases?
A. 27/100
B. 1191/100,000
C. 27/100,000
D. 1.1/1000
37. What is the Maternal Mortality rate of this barangay?
A. 6.55/1000
B. 5.89/1000
C. 1.36/1000
D. 3.67/1000
38. What is the fetal death rate?
A. 3.49/1000
B. 10.04/1000
C. 3.14/1000
D. 3.14/100,000
39. What is the attack rate of pneumonia?
A. 3.04/1000
B. 7.18/1000
C. 32.82/100
D. 3.04/100
40. Determine the Case fatality ratio of rabies in this Barangay
A. 1/100
B. 100%
C. 1%
D. 100/1000
41. The following are all functions of the nurse in vital statistics, which of the
following is not?
A. Consolidate Data
B. Collects Data
C. Analyze Data
D. Tabulate Data
42. The following are Notifiable diseases that needs to have a tally sheet in data
reporting, Which one is not?
A. Hypertension
B. Bronchiolitis
C. Chemical Poisoning
D. Accidents
43. Which of the following requires reporting within 24 hours?
A. Neonatal tetanus
B. Measles
C. Hypertension
D. Tetanus
44. Which Act declared that all communicable disease be reported to the nearest
health station?
A. 1082
B. 1891
C. 3573
D. 6675
45. In the RHU Team, Which professional is directly responsible in caring a sick
person who is homebound?
A. Midwife
B. Nurse
C. BHW
D. Physician
46. During epidemics, which of the following epidemiological function will you have
to perform first?
A. Teaching the community on disease prevention
B. Assessment on suspected cases
C. Monitor the condition of people affected
D. Determining the source and nature of the epidemic
47. Which of the following is a POINT SOURCE epidemic?
A. Dengue H.F
B. Malaria
C. Contaminated Water Source
D. Tuberculosis
48. All but one is a characteristic of a point source epidemic, which one is not?
A. The spread of the disease is caused by a common vehicle
B. The disease is usually caused by contaminated food
C. There is a gradual increase of cases
D. Epidemic is usually sudden
49. The only Microorganism monitored in cases of contaminated water is
A. Vibrio Cholera
B. Escherichia Coli
C. Entamoeba Histolytica
D. Coliform Test
50. Dengue increase in number during June, July and August. This pattern is called
A. Epidemic
B. Endemic
C. Cyclical
D. Secular
SITUATION : Field health services and information system provides summary data
on health service delivery and selected program from the barangay level up to the
national level. As a nurse, you should know the process on how these information
became processed and consolidated.
51. All of the following are objectives of FHSIS Except
A. To complete the clinical picture of chronic disease and describe their
natural history
B. To provide standardized, facility level data base which can be accessed for more
in depth studies
C. To minimize recording and reporting burden allowing more time for patient care
and promotive activities
D. To ensure that data reported are useful and accurate and are disseminated in a
timely and easy to use fashion
52. What is the fundamental block or foundation of the field health service
information system?
A. Family treatment record
B. Target Client list
C. Reporting forms
D. Output record
53. What is the primary advantage of having a target client list?
A. Nurses need not to go back to FTR to monitor treatment and services to
beneficiaries thus saving time and effort
B. Help monitor service rendered to clients in general
C. Facilitate monitoring and supervision of services
D. Facilitates easier reporting
54. Which of the following is used to monitor particular groups that are qualified as
eligible to a certain program of the DOH?
A. Family treatment record
B. Target Client list
C. Reporting forms
D. Output record
55. In using the tally sheet, what is the recommended frequency in tallying
activities and services?
A. Daily
B. Weekly
C. Monthly
D. Quarterly
56. When is the counting of the tally sheet done?
A. At the end of the day
B. At the end of the week
C. At the end of the month
D. At the end of the year
57. Target client list will be transmitted to the next facility in the form of
A. Family treatment record
B. Target Client list
C. Reporting forms
D. Output record
58. All but one of the following are eligible target client list
A. Leprosy cases
B. TB cases
C. Prenatal care
D. Diarrhea cases
59. This is the only mechanism through which data are routinely transmitted from
once facility to another
A. Family treatment record
B. Target Client list
C. Reporting forms
D. Output record
60. FHSIS/Q-3 Or the report for environmental health activities is prepared how
frequently?
A. Daily
B. Weekly
C. Quarterly
D. Yearly
61. Nurse Budek is preparing the reporting form for weekly notifiable diseases. He
knew that he will code the report form as
A. FHSIS/E-1
B. FHSIS/E-2
C. FHSIS/E-3
D. FHSIS/M-1
62. In preparing the maternal death report, which of the following correctly codes
this occurrence?
A. FHSIS/E-1
B. FHSIS/E-2
C. FHSIS/E-3
D. FHSIS/M-1
63. Where should Nurse Budek bring the reporting forms if he is in the BHU
Facility?
A. Rural health office
B. FHSIS Main office
C. Provincial health office
D. Regional health office
64. After bringing the reporting forms in the right facility for processing, Nurse
Budek knew that the output reports are solely produced by what office?
A. Rural health office
B. FHSIS Main office
C. Provincial health office
D. Regional health office
65. Mang Raul entered the health center complaining of fatigue and frequent
syncope. You assessed Mang Raul and found out that he is severely malnourished
and anemic. What record should you get first to document these findings?
A. Family treatment record
B. Target Client list
C. Reporting forms
D. Output record
66. The information about Mang Raul’s address, full name, age, symptoms and
diagnosis is recorded in
A. Family treatment record
B. Target Client list
C. Reporting forms
D. Output record
67. Another entry is to be made for Mang Raul because he is in the target client’s
list, In what TCL should Mang Raul’s entry be documented?
A. TCL Eligible Population
B. TCL Family Planning
C. TCL Nutrition
D. TCL Pre Natal
68. The nurse uses the FHSIS Record system incorrectly when she found out that
A. She go to the individual or FTR for entry confirmation in the Tally/Report
Summary
B. She refer to other sources for completing monthly and quarterly reports
C. She records diarrhea in the Tally sheet/Report form with a code FHSIS/M-1
D. She records a Child who have frequent diarrhea in TCL : Under Five
69. The BHS Is the lowest level of reporting unit in FHSIS. A BHS can be considered
a reporting unit if all of the following are met except
A. It renders service to 3 barangays
B. There is a midwife the regularly renders service to the area
C. The BHS Have no mother BHS
D. It should be a satellite BHS
70. Data submitted to the PHO is processed using what type of technology?
A. Internet
B. Microcomputer
C. Supercomputer
D. Server Interlink Connections
SITUATION : Community organizing is a process by which people, health services
and agencies of the community are brought together to act and solve their own
problems.
71. Mang ambo approaches you for counseling. You are an effective counselor if
you
A. Give good advice to Mang Ambo
B. Identify Mang Ambo’s problems
C. Convince Mang Ambo to follow your advice
D. Help Mang Ambo identify his problems
72. As a newly appointed PHN instructed to organize Barangay Baritan, Which of
the following is your initial step in organizing the community for initial action?
A. Study the Barangay Health statistics and records
B. Make a courtesy call to the Barangay Captain
C. Meet with the Barangay Captain to make plans
D. Make a courtesy call to the Municipal Mayor
73. Preparatory phase is the first phase in organizing the community. Which of the
following is the initial step in the preparatory phase?
A. Area selection
B. Community profiling
C. Entry in the community
D. Integration with the people
74. the most important factor in determining the proper area for community
organizing is that this area should
A. Be already adopted by another organization
B. Be able to finance the projects
C. Have problems and needs assistance
D. Have people with expertise to be developed as leaders
75. Which of the following dwelling place should the Nurse choose when integrating
with the people?
A. A simple house in the border of Barangay Baritan and San Pablo
B. A simple house with fencing and gate located in the center of Barangay Baritan
C. A modest dwelling place where people will not hesitate to enter
D. A modest dwelling place where people will not hesitate to enter located
in the center of the community
76. In choosing a leader in the community during the Organizational phase, Which
among these people will you choose?
A. Miguel Zobel, 50 years old, Rich and Famous
B. Rustom, 27 years old, Actor
C. Mang Ambo, 70, Willing to work for the desired change
D. Ricky, 30 years old, Influential and Willing to work for the desired
change
77. Which type of leadership style should the leaders of the community practice?
A. Autocratic
B. Democratic
C. Laissez Faire
D. Consultative
78. Setting up Committee on Education and Training is in what phase of COPAR?
A. Preparatory
B. Organizational
C. Education and Training
D. Intersectoral Collaboration
E. Phase out
79. Community diagnosis is done to come up with a profile of local health situation
that will serve as basis of health programs and services. This is done in what phase
of COPAR?
A. Preparatory
B. Organizational
C. Education and Training
D. Intersectoral Collaboration
E. Phase out
80. The people named the community health workers based on the collective
decision in accordance with the set criteria. Before they can be trained by the
Nurse, The Nurse must first
A. Make a lesson plan
B. Set learning goals and objective
C. Assess their learning needs
D. Review materials needed for training
81. Nurse Budek wrote a letter to PCSO asking them for assistance in their feeding
programs for the community’s nutrition and health projects. PCSO then approved
the request and gave Budek 50,000 Pesos and a truckload of rice, fruits and
vegetables. Which phase of COPAR did Budek utilized?
A. Preparatory
B. Organizational
C. Education and Training
D. Intersectoral Collaboration
E. Phase out
82. Ideally, How many years should the Nurse stay in the community before he can
phase out and be assured of a Self Reliant community?
A. 5 years
B. 10 years
C. 1 year
D. 6 months
83. Major discussion in community organization are made by
A. The nurse
B. The leaders of each committee
C. The entire group
D. Collaborating Agencies
84. The nurse should know that Organizational plan best succeeds when
1.
2.
3.
4.
People sees its values
People think its antagonistic professionally
It is incompatible with their personal beliefs
It is compatible with their personal beliefs
A. 1 and 3
B. 2 and 4
C. 1 and 2
D. 1 and 4
85. Nurse Budek made a proposal that people should turn their backyard into small
farming lots to plant vegetables and fruits. He specified that the objective is to save
money in buying vegetables and fruits that tend to have a fluctuating and cyclical
price. Which step in Community organizing process did he utilized?
A. Fact finding
B. Determination of needs
C. Program formation
D. Education and Interpretation
86. One of the critical steps in COPAR is becoming one with the people and
understanding their culture and lifestyle. Which critical step in COPAR will the Nurse
try to immerse himself in the community?
A. Integration
B. Social Mobilization
C. Ground Work
D. Mobilization
87. The Actual exercise of people power occurs during when?
A. Integration
B. Social Mobilization
C. Ground Work
D. Mobilization
88. Which steps in COPAR trains indigenous and informal leaders?
A. Ground Work
B. Mobilization
C. Core Group formation
D. Integration
89. As a PHN, One of your role is to organize the community. Nurse Budek knows
that the purposes of community organizing are
1. Move the community to act on their own problems
2. Make people aware of their own problems
3. Enable the nurse to solve the community problems
4. Offer people means of solving their own problems
A. 1,2,3
B. 1,2,3,4
C. 1,2
D. 1,2,4
90. This is considered the first act of integrating with the people. This gives an in
depth participation in community health problems and needs.
A. Residing in the area of assignment
B. Listing down the name of person to contact for courtesy call
C. Gathering initial information about the community
D. Preparing Agenda for the first meeting
SITUATION : Health education is the process whereby knowledge, attitude and
practice of people are changed to improve individual, family and community health.
91. Which of the following is the correct sequence in health education?
1. Information
2. Communication
3. Education
A. 1,2,3
B. 3,2,1
C. 1,3,2
D. 3,1,2
92. The health status of the people is greatly affected and determined by which of
the following?
A. Behavioral factors
B. Socioeconomic factors
C. Political factors
D. Psychological factors
93. Nurse Budek is conducting a health teaching to Agnesia, 50 year old breast
cancer survivor needing rehabilitative measures. He knows that health education is
effective when
A. Agnesia recites the procedure and instructions perfectly
B. Agnesia’s behavior and outlook in life was changed positively
C. Agnesia gave feedback to Budek saying that she understood the instruction
D. Agnesia requested a written instruction from Budek
94. Which of the following is true about health education?
A. It helps people attain their health through the nurse’s sole efforts
B. It should not be flexible
C. It is a fast and mushroom like process
D. It is a slow and continuous process
95. Which of the following factors least influence the learning readiness of an adult
learner?
A. The individuals stage of development
B. Ability to concentrate on information to be learned
C. The individual’s psychosocial adaptation to his illness
D. The internal impulses that drive the person to take action
96. Which of the following is the most important condition for diabetic patients to
learn how to control their diet?
A. Use of pamphlets and other materials during instructions
B. Motivation to be symptom free
C. Ability of the patient to understand teaching instruction
D. Language used by the nurse
97. An important skill that a primigravida has to acquire is the ability to bathe her
newborn baby and clean her breast if she decides to breastfeed her baby, Which of
the following learning domain will you classify the above goals?
A. Psychomotor
B. Cognitive
C. Affective
D. Attitudinal
98. When you prepare your teaching plan for a group of hypertensive patients, you
first formulate your learning objectives. Which of the following steps in the nursing
process corresponds to the writing of the learning objectives?
A. Planning
B. Implementing
C. Evaluation
C. Assessment
99. Rose, 50 years old and newly diagnosed diabetic patient must learn how to
inject insulin. Which of the following physical attribute is not in anyway related to
her ability to administer insulin?
A. Strength
B. Coordination
C. Dexterity
D. Muscle Built
100. Appearance and disposition of clients are best observed initially during which
of the following situation?
A. Taking V/S
B. Interview
C. Implementation of the initial care
D. Actual Physical examination
50 item Pharmacology Exam
1. A client with myasthenia gravis reports the occurrence of difficulty chewing. The
physician prescribes pyridostigmine bromide (Mestinon) to increase muscle strength
for this activity. The nurse instructs the client to take the medication at what time,
in relation to meals?
a. after dinner daily when most fatigued
b. before breakfast daily
c. as soon as arising in the morning
d. thirty minutes before each meal
2. A client is advised to take senna (Senokot) for the treatment of constipation asks
the nurse how this medication works. The nurse responds knowing that it:
a. accumulates water in the stool and increases peristalsis
b. stimulates the vagus nerve
c. coats the bowel wall
d. adds fiber and bulk to the stool
3. A client is receiving heparin sodium by continuous intravenous infusion. The
nurse monitors the client for which adverse effect of this therapy?
a. decreased blood pressure
b. increased pulse rate
c. ecchymoses
d. tinnitus
4. A client is being treated for acute congestive heart failure (CHF) and the client’s
vital signs are as follows: BP 85/50 mm Hg; pulse, 96 bpm; respirations, 26 cpm.
The physician prescribes digoxin (Lanoxin). To evaluate a therapeutic effectiveness
of this medication, the nurse would expect which of the following changes in the
client’s vital signs?
a. BP 85/50 mm Hg, pulse 60 bpm, respirations 26 cpm
b. BP 98/60 mm Hg, pulse 80 bpm, respirations 24 cpm
c. BP 130/70 mm Hg, pulse 104 bpm, respirations 20 cpm
d. BP 110/40 mm Hg, 110 bpm, respirations 20 cpm
5. Diazepam (Valium) is prescribed for a client with anxiety. The nurse instructs the
client to expect which side effect?
a. incoordination
b. cough
c. tinnitus
d. hypertension
6. A client receives oxytocin (Pitocin) to induce labor. During the administration of
the oxytocin, it is most important for the nurse to monitor:
a. urinary output
b. fetal heart rate
c. central venous pressure
d. maternal blood glucose
7. A clinic nurse is performing assessment on a client who is being seen in the clinic
for the first time. When asking about the client’s medication history, the client tells
the nurse that he takes nateglinide (Starlix). The nurse then questions the client
about the presence of which disorder that is treated with this medication?
a. hypothyroidism
b. insomnia
c. type 2 diabetes mellitus
d. renal failure
8. A client who is taking rifampin (Rifadin) as part of the medication regimen for the
treatment of tuberculosis calls the clinic nurse and reports that her urine is a redorange color. The nurse tells the client to:
a. come to the clinic to provide a urine sample
b. stop the medication until further instructions are given by the physician
c. take the medication dose with an antacid to prevent this adverse effect
d. expect a red-orange color in urine, feces, sweat, sputum, and tears as a
harmless side effect
9. A nurse is caring for a client with a tracheostomy that has been diagnosed with a
respiratory infection. The client is receiving vancomycin hydrochloride (Vancocin)
500 mg intravenously every 12 hours. Which of the following would indicate to the
nurse that the client is experiencing an adverse effect of the medication?
a. decreased hearing acuity
b. photophobia
c. hypotension
d. bradycardia
10. A nurse is caring for a client with a diagnosis of metastatic breast carcinoma
who is receiving tamoxifen citrate (Nolvadex) 10 mg orally twice daily. Which of the
following would indicate to the nurse that the client is experiencing a side effect
related to the medication?
a. hypetension
b. diarrhea
c. nose bleeds
d. vaginal bleeding
11. A client has just been given a prescription for diphenoxylate with atropine
(Lomotil). The nurse teaches the client which of the following about the use of this
medication?
a. drooling may occur while taking this medication
b. irritability may occur while taking this medication
c. this medication contains a habit-forming ingredient
d. take the medication with a laxative of choice
12. A nurse is gathering data from client about the client’s medication history and
notes that the client is taking tolterodine tartrate (Detrol LA). The nurse determines
that the client is taking the medication to treat which disorder?
a. glaucoma
b. renal insufficiency
c. pyloric stenosis
d. urinary frequency and urgency
13. A client has an order to receive psyllium (Metamucil) daily. The nurse
administers this medication with:
a. a multivitamin and mineral supplement
b. a dose of an antacid
c. applesauce
d. eight ounces of liquid
14. A nurse is teaching a client taking cyclosporine (Sandimmune) after renal
transplant about medication information. The nurse tells the client to be especially
alert for:
a. signs of infection
b. hypotension
c. weight loss
d. hair loss
15. A nurse reinforces dietary instruction for the client receiving spironolactone
(Aldactone). Which food would the nurse instruct the client to avoid while taking
this medication?
a. crackers
b. shrimp
c. apricots
d. popcorn
16. Oral lactulose (Chronulac) is prescribed for the client with a hepatic disorder
and the nurse provides instructions to the client regarding this medication. Which
statement by the client indicates a need for further instructions?
a. “I need to take the medication with water’”
b. “ I need to increase fluid intake while taking the medication”
c. “ I need to increase fiber in the diet”
d. “I need to notify the physician of nausea occurs”
17. A home care nurse provides instructions to a client taking digoxin (Lanoxin)
0.25 mg daily. Which statement by the client indcates a need for further
instructions?
a. “I will take my prescribed antacid if I become nauseated”
b. “It is important to have my blood drawn when prescribed”
c. “I will check my pulse before I take my medication”
d. “I will carry a medication identification card with me”
18. A client with anxiety disorder is taking buspirone (BuSpar) and tells the nurse
that it is difficult to swallow the tablets. The nurse tells the client to:
a. dissolve the tablet in a cup of coffee
b. crush the tablet before taking it
c. call the physician for a change in medication
d. mix the tablet uncrushed in custard
19. A nurse is caring for a child with CHF provides instructions to the parents
regarding the administration of digoxin (Lanoxin). Which statement by the mother
indicates a need for further instructions?
a. “If my child vomits after I give the medication, I will not repeat the dose”
b. “I will check my child’s pulse before giving the medication”
c. “I will check the dose of the medication with my husband before I give the
medication”
d. “I will mix the medication with food”
20. A nurse provides instructions to a client who will begin an oral contraceptives.
Which statement by the client indicates the need for further instructions?
a. “I will take one pill daily at the same time every day”
b. “I will not need to use an additional birth control method once I start these pills”
c. “If I miss a pill I need to take it as soon as I remember”
d. “If I miss two pills I will take them both as soon as I remember and I will take
two pills the next day also”
21. A nurse provides instructions to a client taking clorazepate (Tranxene) for
management of an anxiety disorder. The nurse tells the client that:
a. drowsiness is a side effect that usually disappears with continued therapy
b. if dizziness occurs, call the physician
c. smoking increases the effectiveness of the medication
d. if gastrointestinal disturbances occur, discontinue the medication
22. A client with Parkinson’s disease has begun therapy with levodopa (L-dopa).
The nurse determines that the client understands the action of the medication if the
client verbalizes that results may not be apparent for:
a. 24 hours
b. Two to three days
c. One week
d. Two to three weeks
23. A nurse in a physician’s office is reviewing the results of a client’s phenytoin
(Dilantin) level drawn that morning. The nurse determines that the client has a
therapeutic drug level if the client’s result was:
a. 3 mcg/ml
b. 8 mcg/ml
c. 15 mcg/ml
d. 24mcg/ml
24. A nurse is caring for a client with a genitourinary tract infection receiving
amoxicillin (Augmentin) 500 mg every 8 hours. Which of the following would
indicate to the nurse that the client is experiencing an adverse effect related to the
medication?
a. hypertension
b. nausea
c. headache
d. watery diarrhea
25. A nurse is caring for a client with glaucoma who receives a daily dose of
acetazolamide (Diamox). Which of the following would indicate to the nurse that the
client is experiencing an adverse effect of the medication?
a. constipation
b. difficulty swallowing
c. dark-colored urine and stools
d. irritability
26. A nurse is caring for a client with a diagnosis of meningitis who is receiving
amphotericin B (Fungizone) intravenously. Which of the following would indicate to
the nurse that the client is experiencing an adverse effect related to the
medication?
a. nausea
b. decreased urinary output
c. muscle weakness
d. confusion
27. A nurse has formulated a nursing diagnosis of Disturbed Body Image for a client
who is taking spironolactone (Aldactone). The nurse based this diagnosis on
assessment of which side effect of the medication?
a. edema
b. weight gain
c. excitability
d. decreased libido
28. A nurse is caring for the client with a history of mild heart failure who is
receiving diltiazem hydrochloride (Cardizem) for hypertension. The nurse would
assess the client for:
a. bradycardia
b. wheezing
c. peripheral edema and weight gain
d. apical pulse rate lower than baseline
29. The wound of a client with an extensive burn injury is being treated with the
application of silver sulfadiazine (Silvadene). Which symptom would indicate to the
nurse that the client is experiencing a side effect related to systemic absorption?
a. pain at the wound site
b. burning and itching at the wound site
c. a localized rash
d. photosensitivity
30. A nurse is caring for a client with a diagnosis of rheumatoid arthritis who is
receiving sulindac (Clinoril) 150 mg po twice daily. Which finding would indicate to
the nurse that the client is experiencing a side effect related to the medication?
a. diarrhea
b. photophobia
c. fever
d. tingling in the extremities
31. The nurse notes that the client is receiving filgrastim (Neupogen). The nurse
checks which of the following to determine medication effectiveness?
a. neutrophil count
b. platelet count
c. blood urea nitrogen
d. creatinine level
32. A nurse is monitoring a client who is taking fluphenazine decanoate (Prolixin)
for signs of leucopenia. Which finding indicates a sign of this blood dyscrasia?
a. blurred vision
b. constipation
c. sore throat
d. dry mouth
33. A nurse is administering amphotericin B (Fungizone) to a client intravenously to
treat a fungal infection. The nurse monitors the result of which electrolyte study
during therapy with this medication?
a. sodium
b. potassium
c. calcium
d. chloride
34. A clinic nurse asks a client with diabetes mellitus being seen in the clinic for the
first time to list the medications that she is taking. Which combination of
medications taken by the client should the nurse report to the physician?
a. Acetohexamide (Dymelor) and trimethoprim-sulfamethoxazole (Bactrim)
b. Chlorpropamide (Diabenase) and amitriptyline (Elavil)
c. Glyburide (DiaBeta) and Lanoxin (Digoxin)
d. Tolbutamide (Orinase) and amoxicillin (Amoxil)
35. A nurse is caring for a client receiving streptogramin (Synercid) by intravenous
intermittent infusion for the treatment of a bone infection develops diarrhea. Which
nursing action would the nurse implement?
a. administer an antidiarrheal agent
b. notify the physician
c. discontinue the medication
d. monitor the client’s temperature
36. A client has been taking fosinopril (Monopril) for 2 months. The nurse
determines that the client is having the intended effects of therapy if the nurse
notes which of the following?
a. lowered BP
b. lowered pulse rate
c. increased WBC
d. increased monocyte count
37. A client is taking labetalol (Normodyne). The nurse monitors the client for which
frequent side effect of the medication?
a. tachycardia
b. impotence
c. increased energy level
d. night blindness
38. An older client has been using cascara sagrada on a long-term basis. The nurse
determines that which laboratory result is a result of the side effects of this
medication?
a. sodium 135 mEq/L
b. sodium 145 mEq/L
c. potassium 3.1 mEq/L
d. potassium 5.0 mEq/L
39. A client has an order to begin short-term therapy with enoxaparin (Lovenox).
The nurse explains to the client that this medication is being ordered to:
a. dissolve urinary calculi
b. reduce the risk of deep vein thrombosis
c. relieve migraine headaches
d. stop progression of multiple sclerosis
40. Quinidine gluconate (Dura Quin) is prescribed for a client. The nurse reviews
the client’s medical record, knowing that which of the following is a contraindication
in the use of this medication?
a. complete atrioventricular (AV) block
b. muscle weakness
c. asthma
d. infection
41. A client has been taking benzonatate (Tessalon) as ordered. The nurse tells the
client that this medication should do which of the following?
a. take away nausea and vomiting
b. calm the persistent cough
c. decrease anxiety level
d. increase comfort level
42. Auranofin (Ridaura) is prescribed for a client with rheumatoid arthritis, and the
nurse monitors the client for signs of an adverse effect related to the medication.
Which of the following indicates an adverse effect?
a. nausea
b. diarrhea
c. anorexia
d. proteinuria
43. A nurse is providing instructions to a client regarding quinapril hydrochloride
(Accupril). The nurse tells the client:
a. to take the medication with food only
b. to rise slowly from a lying to a sitting position
c. to discontinue the medication if nausea occurs
d. that a therapeutic effect will be noted immediatedly
44. A female client tells the clinic nurse that her skin is very dry and irritated.
Which product would the nurse suggest that the client apply to the dry skin?
a. glycerin emollient
b. aspercreame
c. myoflex
d. acetic acid solution
45. A client with advanced cirrhosis of the liver is not tolerating protein well, as
eveidenced by abnormal laboratory values. The nurse anticipates that which of the
following medications will be prescribed for the client?
a. lactulose (Chronulac)
b. ethacrynic acid (Edecrin)
c. folic acid (Folvite)
d. thiamine (Vitamin B1)
46. A nurse is planning dietary counseling for the client taking triamterene
(Dyrenium). The nurse plans to include which of the following in a list of foods that
are acceptable?
a. baked potato
b. bananas
c. oranges
d. pears canned in water
47. A client is taking famotidine (Pepcid) asks the home care nurse what would be
the best medication to take for a headache. The nurse tells the client that it would
be best to take:
a. aspirin (acetylsalicylic acid, ASA)
b. ibuprofen (Motrin)
c. acetaminophen (Tylenol)
d. naproxen (Naprosyn)
48. A nurse has taught a client taking a xanthine bronchodilator about beverages to
avoid. The nurse determines that the client understands the information if the client
chooses which of the following beverages from the dietary menu?
a. chocolate milk
b. cranberry juice
c. coffee
d. cola
49. A client with histoplasmosis has an order for ketoconazole (Nizoral). The nurse
teaches the client to do which of the following while taking this medication?
a. take the medication on an empty stomach
b. take the medication with an antacid
c. avoid exposure to sunlight
d. limit alcohol to 2 ounces per day
50. A nurse is preparing the client’s morning NPH insulin dose and notices a clumpy
precipitate inside the insulin vial. The nurse should:
a. draw up and administer the dose
b. shake the vial in an attempt to disperse the clumps
c. draw the dose from a new vial
d. warm the bottle under running water to dissolve the clump
50 item Integumentary Exam
1. A nurse is caring for a burn client who has sustained thoracic burns and smoke
inhalation and is risk for impaired gas exchange. The nurse avoids which action in
caring for this client?
a. repositioning the client from side to side every 2 hours
b. maintaining the client in a supine position with the head of the bed elevated
c. suctioning the airway as needed
d. providing humidified oxygen as prescribed
2. A client sustains a burn injury to the entire right arm, entire right leg, and
anterior thorax. According to the rule of nine’s the nurse determines that what body
percent was injured?
Answer: ______________________________________
3. A nurse assesses a burn injury and determines that the client sustained a fullthickness fourth-degree burn if which of the following is noted at the site of injury?
a. a wet shiny weeping wound surface
b. a dry wound surface
c. charring at the wound site
d. blisters
4. A client is brought to the emergency room following a burn injury. In assessment
the nurse notes that the client’s eyebrow and nasal hairs are singed. The nurse
would identify this type of burn as:
a. thermal
b. electrical
c. radiation
d. chemical
5. A nurse assesses the carbon monoxide level of a client following a burn injury
and notes that the level is 8%. Based on this level, which finding would the nurse
expect to note during the assessment of the client?
a. tachycardia
b. tachypnea
c. coma
d. impaired visual acuity
6. A nurse assesses the client’s burn injury and determines that the client sustained
a partial-thickness superficial burn. Based on this determination, which finding did
the nurse note?
a. a wet, shiny, weeping wound
b. a dry wound surface
c. charring at the wound site
d. absence of wound sensation
7. A nurse assesses the client’s burn injury and determines that the client sustained
a partial-thickness deep burn. Based on this determination, which finding did the
nurse note?
a. a wet, shiny, weeping wound surface
b. a dry wound surface
c. charring at the wound site
d. total absence of wound sensation
8. On assessment of a child, the nurse notes the presence of white patches on the
child’s tongue and determines that they may be indicative of candidiasis (thrush).
The nurse understands that the white patches of candidiasis (thrush):
a. adhere to the tongue even when scraped with tongue blade
b. cause the tongue to bleed continuously around the patch
c. produce a red circle in the center of the white lesion
d. will occur only in the tongue
9. On assessment, a nurse notes a flat brown circular nevi on the skin of a client
that measures less than one centimeter. The client asks, “Is this cancer?” The
nurse makes which response to the client?
a. “These are likely to be benign moles.”
b. “These require immediate attention because they are probably cancer.”
c. “These indicate malignancy.”
d. “These are probably verrucae.”
10. A nurse is performing a skin assessment on a client. The nurse understands
that moles with variegated color, irregular borders, and/or an irregular surface
should be considered:
a. suspicious
b. normal
c. common
d. benign
11. A client is diagnosed with herpes zoster (shingles). Which pharmacological
therapy would the nurse expect to be prescribed to treat this disorder?
a. tetracycline hydrochloride (achromycin)
b. erythromycin base (e-mycin)
c. acyclovir (zovirax)
d. indomethacin (indocin)
12. A nurse reviews the record of a client diagnosed with pemphigus and notes that
the physician has documented the presence of Nikolsky’s sign. Based on this
documentation, which of the following would the nurse expect to note?
a. client complains of discomfort behind the knee on forced dorsiflexion of the foot
b. a spasm of the facial muscles elicited by tapping the facial nerve in the region of
the parotid gland
c. carpal spasm elicited by compressing the upper arm
d. the epidermis of the client’s skin can be rubbed off by slight friction or injury
13. A hospitalized client is diagnosed with scabies. Which of the following would a
nurse expect to note on inspection of the client’s skin?
a. the appearance of vesicles or pustules
b. the presence of white patches scattered about the trunk
c. multiple straight or wavy threadlike lines beneath the skin
d. patchy hair loss and round, red macules with scales
14. A client is seen in the health care clinic and the physician suspects herpes
zoster. The nurse prepares the items needed to perform the diagnostic test to
confirm this diagnosis. Which item will the nurse obtain?
a. a biopsy kit
b. a wood’s light
c. a culture swab and tube
d. a patch test kit
15. A nurse reviews the health care record of a client diagnosed with herpes zoster.
Which finding would the nurse expect to note as characteristic of this disorder?
a. a generalized red body rash that causes pruritus
b. small blue-white spots with a red base noted on the extremities
c. a fiery red edematous rash on the cheeks and neck
d. clustered and grouped skin vesicles
16. A client returns to the clinic for a follow-up treatment following a skin biopsy of
a suspicious lesion performed 1 week ago. The biopsy report indicated that the
lesion is a squamous cell carcinoma. The nurse plans care knowing that which of
the following describes the characteristic of this type of a lesion?
a. it is highly metastatic
b. it does not metastasize
c. it is characterized by local invasion
d. it is encapsulated
17. A nurse reviews the record of a client scheduled for removal of a skin lesion.
The record indicates that the lesion is an irregularly shaped, pigmented papule with
a blue-toned color. The nurse determines that this description of the lesion is
characteristic of:
a. melanoma
b. basal cell carcinoma
c. squamous cell carcinoma
d. actinic keratosis
18. A nurse is reviewing the nursing care plan for a client for whom a stage 4
decubiti ulcer has been documented. Which of the following would the nurse expect
to note on assessment of the client?
a. a reddened area that returns to a normal skin color after 15 to 20 minutes of
pressure relief
b. intact skin
c. an area in which the top layer of skin is missing
d. a deep ulcer that extends into muscle and bone.
19. A nurse notes documentation of a stage 3 pressure ulcer in a client’s record.
Which of the following would the nurse expect to note on assessment of the client?
a. a deep ulcer that extends into muscle and bone
b. a deep ulcer that extends into the dermis and the subcutaneous tissue
c. an area in which the top layer of skin is missing
d. a reddened area that returns to normal skin color after 15 to 20 minutes of
pressure relief
20. A client is in the health care clinic for complaints of pruritus. Following
diagnostic studies, it has been determined that there is not a pathophysiological
process causing the pruritus. The nurse prepares instructions for the client to assist
in reducing the problem and tells the client to:
a. use a dehumidifier in the home
b. ensure that the temperature in the home is high, especially during the winter
months
c. use a cool-mist vaporizer, especially during the winter months
d. avoid use of skin moisturizers following a bath
21. A client is seen in the health care clinic because of complaints of lesions on the
elbows and the knees. The lesions are red raised papules, and large plaques
covered by silvery scales are also noticed on the elbows and the knees. Psoriasis is
diagnosed and the nurse provides information about treatment to the client. The
nurse determines that the client needs additional information if the client states
that which of the following is a component of the treatment plan?
a. tar baths
b. ultraviolet light treatments
c. topical lubricants
d. systemic corticosteroids
22. A client is seen in the health care clinic and a biopsy is performed on a skin
lesion that the physician suspects malignant melanoma. The nurse prepares a plan
of care for the client based on which characteristics of this type of skin cancer?
a. it is an aggressive cancer that requires aggressive therapy to control its rapid
spread
b. it is a slow-growing cancer and seldom metastasizes
c. it can grow so large that an entire area, such as the nose, the lip, or the ear
must be removed and reconstructed if it occurs on the face
d. it is the most common form of skin cancer
23. A nurse is caring for a client brought to the emergency room following a burn
injury that occurred in the basement of the home. Which initial finding would
indicate the presence of inhalation injury?
a. expectoration of sputum tinged with blood
b. the presence of singed nasal hair
c. absent breath sounds in the lower lobes bilaterally
d. tachycardia
24. A nurse is caring for a client who arrives at the emergency room with the
emergency medical services team following a severe burn injury from an explosion.
Once the initial assessment has been performed by the physician and lifethreatening dysfunctions have been addressed, the nurse reviews the physician’s
orders anticipating that which pain medication will be prescribed?
a. intravenous (IV) morphine sulfate
b. aspirin with oxycodone (percodan) via nasogastric tube
c. acetaminophen (tylenol) with codeine sulfate
d. morphine sulfate by the subcutaneous route
25. A nurse is assessing the operative site in a client who underwent a breast
reconstruction. The nurse is inspecting the flap and the areola of the nipple and
notes that the areola is a deep red color around the edge. The nurse takes which
action first?
a. document the findings
b. elevate the breast
c. encourage nipple massage
d. notify the physician
26. A nurse performs a skin assessment on an assigned client and notes the
presence of lesions that are red-tan scaly plaques. The nurse documents this
findings as:
a. seborrhea
b. xerosis
c. pruritus
d. actinic keratoses
27. A community health nurse has provided fire safety instructions to a group of
individuals who are part of a disaster response team. Which statement by a group
member indicates a need for further instructions?
a. “the victim may be rolled on the ground to extinguish the flames”
b. “a blanket or another cover can be used to smother the flames”
c. “flames should be doused with water”
d. “keep the victim in standing position so flames won’t spread to other parts of the
body”
28. A community health nurse is providing a teaching session to firefighters in a
small community regarding care to a victim at the scene of a burn injury. The
community health nurse instructs the firefighters that in the event of a tar burn the
immediate action would be to:
a. cool the injury with water
b. remove all clothing immediately
c. remove the tar from the burn injury
d. leave any clothing that is saturated with tar in place
29. The client who sustained an inhalation injury arrives in the emergency
department. On assessment of the client, the nurse notes that the client is very
confused and combative. The nurse determines that the client is experiencing:
a. anxiety
b. fear
c. hypoxia
d. pain
30. The client is diagnosed with stage 1 of Lyme disease. The nurse assesses the
client for the hallmark characteristic of this stage. Which assessment finding would
the nurse expect to note?
a. dizziness and headaches
b. enlarged and inflamed joints
c. arthralgias
d. skin rash
31. The emergency department nurse is performing an assessment on a client who
has sustained circumferential burns of both legs. Which assessment would be the
priority in caring for this client?
a. assessing peripheral pulses
b. assessing neurological status
c. assessing urine output
d. assessing blood pressure
32. The nurse is reviewing the discharge instructions for a client who had skin
biopsy. Which statement by the client indicates a need for further instructions?
a. “I will watch for any drainage from the wound”
b. “I will return tomorrow to have the sutures removed”
c. “I will use antibiotic ointment as prescribed”
d. “I will keep the dressing dry”
33. The nurse preparing to assist the physician to examine the client’s skin with a
Wood’s light would do which of the following?
a. obtain an informed consent
b. tell the client that the procedure is painless
c. shave the skin site
d. prepare a local anesthetic
34. The nurse provides discharge instructions to a client following patch testing.
Which instruction would the nurse provide to the client?
a. return to the clinic in 2 weeks for the initial reading
b. reapply the patch if it comes off
c. continue all current activities
d. keep the test sites dry
35. A nurse is preparing a client for skin grafting and notes that the physician has
documented that the client is scheduled for heterograft. The nurse understands that
the heterograft used for the burn client is skin from:
a. another species
b. a cadaver
c. the burned client
d. a skin bank
36. Following assessment and diagnostic evaluation, it has been determined that
the client has Stage II of Lyme disease. The nurse expects to note which
assessment finding that is most indicative of this stage?
a. erythematous rash
b. cardiac conduction defects
c. arthralgias
d. enlargement of joints
37. The clinic nurse reads the chart of a client that was seen by the physician and
notes that the physician has documented that the client has Stage III of Lyme
disease. Which clinical manifestation would the nurse expect to note in the client?
a. a generalized skin rash
b. a cardiac dysrhythmia
c. complaints of joint pain
d. paralysis in the extremity where the tick bite occurred
38. A female client arrives at the health care clinic and tells the nurse that she was
bitten by a tick and would like to be tested for Lyme disease. The client tells the
nurse that she removed the tick and flushed it down the toilet. Which nursing action
is appropriate?
a. refer the client for a blood test immediately
b. inform the client that the tick is needed to perform the test
c. inform the client that she will need to return in 6 weeks to be tested because
testing before this time is not reliable
d. ask the client about the size and color of the tick
39. The client suspected of having Stage I of Lyme disease is seen in the health
care clinic and is told that the Lyme disease test is positive. The client asks the
nurse about the treatment for the disease. The nurse responds to the client,
anticipating which of the following to be part of the treatment plan?
a. no treatment unless symptoms develop
b. a 3-week course of oral antibiotic therapy
c. treatment with intravenous penicillin G
d. ultraviolet light therapy
40. The client with acquired immunodeficiency syndrome (AIDS) is suspected of
having cutaneous Kaposi’s sarcoma. The nurse prepares the client for which test
that will confirm the presence of this type of sarcoma?
a. sputum culture
b. liver biopsy
c. punch biopsy of the lesion
d. white blood cell count
41. The client who is newly admitted to the hospital for treatment of acute cellulitis
of the lower left leg asks the nurse about the nature of the disorder. The nurse
would respond that cellulitis is actually:
a. a skin infection into the deep dermis and subcutaneous fat
b. an acute superficial infection
c. an inflammation of the epidermis
d. an epidermal infection caused by Staphylococcus
42. A nurse is preparing a plan of care for a client with a diagnosis of acute cellulitis
of the lower leg. The nurse anticipates which measure will be prescribed to treat
this condition?
a. warm moist compresses to the affected area
b. cold compresses to the affected area
c. heat lamp treatments 4 times daily
d. alternating hot to cold compresses every 2 hours
43. A clinic nurse provides instructions to a client who will be taking isotretinoin
(Accutane) for severe cystic acne. Which statement by the client indicates the need
for further instructions?
a. “I need to return to the clinic for a blood test to check my triglyceride level”
b. “The medication may cause my lips to burn”
c. “The medication may cause dryness and burning in my eyes”
d. “I need to take vitamin A supplements to improve the effectiveness of this
treatment”
44. A client sustained full-thickness burns to both hands from scalding water. A
sheet graft was surgically applied to the wounds. The nurse tells the client that this
type of graft is indicated for which of the following primary purposes?
a. better adherence to the wound bed
b. better cosmetic result
c. better donor site availability
d. easier to care for initially
45. A client sustained a major burn is beginning to take an oral diet again. The
nurse plans to encourage the client to eat variety of which of the following types of
foods to best help in continued wound healing and tissue repair?
a. high carbohydrate and low protein
b. high fat and low carbohydrate
c. high protein and high fat
d. high protein and high carbohydrate
46. A client with a major burn is admitted to the emergency department. The nurse
anticipates that which of the following routes will be ordered for analgesics for this
client?
a. intramuscular
b. intravenous
c. oral
d. subcutaneous
47. A nurse is performing a skin assessment of a client who is immobile and notes
the presence of partial thickness skin loss of the upper layer of the skin in the
sacral area. The nurse documents these findings as a:
a. stage 1 pressure ulcer
b. stage 2 pressure ulcer
c. stage 3 pressure ulcer
d. stage 4 pressure ulcer
48. A student nurse is instructed by the registered nurse to monitor a client who
has dark skin for cyanosis. The registered nurse determines that the student needs
instructions regarding physical assessment techniques for the dark-skinned client if
the student states that the best area to assess for cyanosis was in the:
a. nail beds
b. lips
c. sclera of the eye
d. tongue
49. A client with severe psoriasis has a nursing diagnosis of Chronic Low SelfEsteem. The nurse uses which therapeutic strategy when working with this client?
a. listening attentively
b. pretending not to notice affected skin areas
c. keeping communications brief
d. approaching the client in a formal manner
50. A nurse caring for a client who sustained a high-voltage electrical injury
analyzes the client’s test results. Which finding would the nurse interpret as
increasing the client’s risk of developing acute tubular necrosis?
a. myoglobin in the urine
b. carbonaceous sputum
c. hyperkalemia
d. cloudy cerebrospinal fluid
100 item Comprehensive Exam with Answers and Rationale
1. The nurse enters the room as a 3 year-old is having a generalized seizure. Which
intervention should the nurse do first?
A) Clear the area of any hazards
B) Place the child on the side
C) Restrain the child
D) Give the prescribed anticonvulsant
The correct answer is B: Place the child on the side
Protecting the airway is the top priority in a seizure. If a child is actively convulsing, a
patent airway and oxygenation must be assured.
2. A client has just returned to the medical-surgical unit following a segmental lung
resection. After assessing the client, the first nursing action would be to
A) Administer pain medication
B) Suction excessive tracheobronchial secretions
C) Assist client to turn, deep breathe and cought
D) Monitor oxygen saturation
The correct answer is B: Suction excessive tracheobronchial secretions
Suctioning the copious tracheobronchial secretions present in post-thoracic surgery clients
maintains an open airway which is always the priority nursing intervention.
3. A nurse from the surgical department is reassigned to the pediatric unit. The charge
nurse should recognize that the child at highest risk for cardiac arrest and is the least likely
to be assiged to this nurse is which child?
A) Congenital cardiac defects
B) An acute febrile illness
C) Prolonged hypoxemia
D) Severe multiple trauma
The correct answer is C: Prolonged hypoxemia
Most often, the cause of cardiac arrest in the pediatric population is prolonged hypoxemia.
Children usually have both cardiac and respiratory arrest.
4. Which of the following would be the best strategy for the nurse to use when teaching
insulin injection techniques to a newly diagnosed client with diabetes?
A) Give written pre and post tests
B) Ask questions during practice
C) Allow another diabetic to assist
D) Observe a return demonstration
The correct answer is D: Observe a return demonstration
Since this is a psychomotor skill, this is the best way to know if the client has learned the
proper technique.
5. The nurse is assessing a 2 year-old client with a possible diagnosis of congenital heart
disease. Which of these is most likely to be seen with this diagnosis?
A) Several otitis media episodes in the last year
B) Weight and height in 10th percentile since birth
C) Takes frequent rest periods while playing
D) Changing food preferences and dislikes
The correct answer is C: Takes frequent rest periods while playing
Children with heart disease tend to have exercise intolerance. The child self-limits activity,
which is consistent with manifestations of congenital heart disease in children.
6. The nurse is reassigned to work at the Poison Control Center telephone hotline. In which
of these cases of childhood poisoning would the nurse suggest that parents have the child
drink orange juice?
A) An 18 month-old who ate an undetermined amount of crystal drain cleaner
B) A 14 month-old who chewed 2 leaves of a philodendron plant
C) A 20 month-old who is found sitting on the bathroom floor beside an empty bottle of
diazepam (Valium)
D) A 30 month-old who has swallowed a mouthful of charcoal lighter fluid
The correct answer is A: An 18 month-old who ate an undetermined amount of crystal drain
cleaner. Drain cleaner is very alkaline. The orange juice is acidic and will help to neutralize
this substance.
7. A 23 year-old single client is in the 33rd week of her first pregnancy. She tells the nurse
that she has everything ready for the baby and has made plans for the first weeks together
at home. Which normal emotional reaction does the nurse recognize?
A) Acceptance of the pregnancy
B) Focus on fetal development
C) Anticipation of the birth
D) Ambivalence about pregnancy
The correct answer is C: Anticipation of the birth
Directing activities toward preparation for the newborn''s needs and personal adjustment
are indicators of appropriate emotional response in the third trimester.
8. Upon examining the mouth of a 3 year-old child, the nurse discovers that the teeth have
chalky white-to-yellowish staining with pitting of the enamel. Which of the following
conditions would most likely explain these findings?
A) Ingestion of tetracycline
B) Excessive fluoride intake
C) Oral iron therapy
D) Poor dental hygiene
The correct answer is B: Excessive fluoride intake
The described findings are indicative of fluorosis, a condition characterized by an increase in
the extent and degree of the enamel''s porosity. This problem can be associated with
repeated swallowing of toothpaste with fluoride or drinking water with high levels of
fluoride.
9. Which of the following should the nurse teach the client to avoid when taking
chlorpromazine HCL (Thorazine)?
A) Direct sunlight
B) Foods containing tyramine
C) Foods fermented with yeast
D) Canned citrus fruit drinks
The correct answer is A: Avoid direct sunlight
Phenothiazine increases sensitivity to the sun, making clients especially susceptible to
sunburn.
10. The nurse is discussing dietary intake with an adolescent who has acne. The most
appropriate statement for the nurse is
A) "Eat a balanced diet for your age."
B) "Increase your intake of protein and Vitamin A."
C) "Decrease fatty foods from your diet."
D) "Do not use caffeine in any form, including chocolate."
The correct answer is A: "Eat a balanced diet for your age."
A diet for a teenager with acne should be a well balanced diet for their age. There are no
recommended additions and subtractions from the diet.
11. The nurse is caring for a child who has just returned from surgery following a
tonsillectomy and adenoidectomy. Which action by the nurse is appropriate?
A) Offer ice cream every 2 hours
B) Place the child in a supine position
C) Allow the child to drink through a straw
D) Observe swallowing patterns
The correct answer is D: Observe swallowing patterns
The nurse should observe for increased swallowing frequency to check for hemorrhage.
12. The nurse is caring for a client with acute pancreatitis. After pain management, which
intervention should be included in the plan of care?
A) Cough and deep breathe every 2 hours
B) Place the client in contact isolation
C) Provide a diet high in protein
D) Institute seizure precautions
The correct answer is A: Cough and deep breathe every 2 hours
Respiratory infections are common because of fluid in the retro peritoneum pushing up
against the diaphragm causing shallow respirations. Encouraging the client to cough and
deep breathe every 2 hours will diminish the occurrence of this complication.
13. The nurse is caring for a client with trigeminal neuralgia (tic douloureaux). To assist the
client with nutrition needs, the nurse should
A) Offer small meals of high calorie soft food
B) Assist the client to sit in a chair for meals
C) Provide additional servings of fruits and raw vegetables
D) Encourage the client to eat fish, liver and chicken
The correct answer is A: Offer small meals of high calorie soft food
If the client is losing weight because of poor appetite due to the pain, assist in selecting
foods that are high in calories and nutrients, to provide more nourishment with less
chewing. Suggest that frequent, small meals be eaten instead of three large ones. To
minimize jaw movements when eating, suggest that foods be pureed.
14. A client treated for depression tells the nurse at the mental health clinic that he recently
purchased a handgun because he is thinking about suicide. The first nursing action should
be to
A) Notify the health care provider immediately
B) Suggest in-patient psychiatric care
C) Respect the client's confidential disclosure
D) Phone the family to warn them of the risk
The correct answer is A: Notify the health care provider immediately
The health care provider must be contacted immediately as the client is a danger to self and
others. Hospitalization is indicated.
15. The initial response by the nurse to a delusional client who refuses to eat because of a
belief that the food is poisoned is
A) "You think that someone wants to poison you?"
B) "Why do you think the food is poisoned?"
C) "These feelings are a symptom of your illness."
D) "You’re safe here. I won’t let anyone poison you."
The correct answer is A: "You think that someone wants to poison you?"
This response acknowledges perception through a reflective question which presents
opportunity for discussion, clarification of meaning, and expressing doubt.
16. A client has just been admitted with portal hypertension. Which nursing diagnosis would
be a priority in planning care?
A) Altered nutrition: less than body requirements
B) Potential complication hemorrhage
C) Ineffective individual coping
D) Fluid volume excess
The correct answer is B: Potential complication hemorrhage
Esophageal varices are dilated and tortuous vessels of the esophagus that are at high risk
for rupture if portal circulation pressures rise.
17. The nurse in a well-child clinic examines many children on a daily basis. Which of the
following toddlers requires further follow up?
A) A 13 month-old unable to walk
B) A 20 month-old only using 2 and 3 word sentences
C) A 24 month-old who cries during examination
D) A 30 month-old only drinking from a sippy cup
The correct answer is D: A 30 month-old only drinking from a sippy cup
A 30 month-old should be able to drink from a cup without a cover.
18. Which of the following conditions assessed by the nurse would contraindicate the use of
benztropine (Cogentin)?
A) Neuromalignant syndrome
B) Acute extrapyramidal syndrome
C) Glaucoma, prostatic hypertrophy
D) Parkinson's disease, atypical tremors
The correct answer is C: Glaucoma, prostatic hypertrophy
Glaucoma and prostatic hypertrophy are contraindications to the use of benztropine
(Cogentin) as the drug is an anticholinergic agent.
19. A 15 year-old client with a lengthy confining illness is at risk for altered growth and
development of which task?
A) Loss of control
B) Insecurity
C) Dependence
D) Lack of trust
The correct answer is C: Dependence
The client role fosters dependency. Adolescents may react to dependency with rejection,
uncooperativeness, or withdrawal.
20. The nurse is caring for a client with cirrhosis of the liver with ascites. When instructing
nursing assistants in the care of the client, the nurse should emphasize that
A) The client should remain on bed rest in a semi-Fowler's position
B) The client should alternate ambulation with bed rest with legs elevated
C) The client may ambulate and sit in chair as tolerated
D) The client may ambulate as tolerated and remain in semi-Fowlers position in bed
The correct answer is B: The client should alternate ambulation with bed rest with legs
elevated. Encourage alternating periods ambulation and bed rest with legs elevated to
mobilize edema and ascites. Encourage and assist the client with gradually increasing
periods of ambulation.
21. In providing care to a 14 year-old adolescent with scoliosis, which of the following will
be most difficult for this client?
A) Compliance with treatment regimens
B) Looking different from their peers
C) Lacking independence in activities
D) Reliance on family for their social support
The correct answer is B: Looking different from their peers
Conformity to peer influences peaks at around age 14. Since many persons view any
disability as deviant, the client will need help in learning how to deal with reactions of
others. Treatment of scoliosis is long-term and involves bracing and/or surgery.
22. The nurse is preparing to perform a physical examination on an 8 month-old who is
sitting contentedly on his mother's lap. Which of the following should the nurse do first?
A) Elicit reflexes
B) Measure height and weight
C) Auscultate heart and lungs
D) Examine the ears
The correct answer is C: Auscultate heart and lungs
The nurse should auscultate the heart and lungs during the first quiet moment with the
infant so as to be able to hear sounds clearly. Other assessments may follow in any order.
23. Which of these principles should the nurse apply when performing a nutritional
assessment on a 2 year-old client?
A) An accurate measurement of intake is not reliable
B) The food pyramid is not used in this age group
C) A serving size at this age is about 2 tablespoons
D) Total intake varies greatly each day
The correct answer is C: A serving size at this age is about 2 tablespoons
In children, a general guide to serving sizes is 1 tablespoon of solid food per year of age.
Understanding this, the nurse can assess adequacy of intake.
24. The nurse is assessing a client with delayed wound healing. Which of the following risk
factors is most important in this situation?
A) Glucose level of 120
B) History of myocardial infarction
C) Long term steroid usage
D) Diet high in carbohydrates
The correct answer is C: Long term steroid usage
Steroid dependency tends to delay wound healing. If the client also smokes, the risk is
increased.
25. Which of the following nursing assessments indicate immediate discontinuance of an
antipsychotic medication?
A) Involuntary rhythmic stereotypic movements and tongue protrusion
B) Cheek puffing, involuntary movements of extremities and trunk
C) Agitation, constant state of motion
D) Hyperpyrexia, severe muscle rigidity, malignant hypertension
The correct answer is D: Hyperpyrexia, severe muscle rigidity, malignant hypertension,
hyperpyrexia, sever muscle rigidity, and malignant hypertension are assessment signs
indicative of NMS (neuroleptic malignant syndrome).
26. A client with HIV infection has a secondary herpes simplex type 1 (HSV-1) infection. The
nurse knows that the most likely cause of the HSV-1 infection in this client is
A) Immunosuppression
B) Emotional stress
C) Unprotected sexual activities
D) Contact with saliva
The correct answer is A: Immunosuppression
The decreased immunity leads to frequent secondary infections. Herpes simplex virus type 1
is an opportunistic infection. The other options may result in HSV-1. However they are not
the most likely cause in clients with HIV.
27. The nurse measures the head and chest circumferences of a 20 month-old infant. After
comparing the measurements, the nurse finds that they are approximately the same. What
action should the nurse take?
A) Notify the health care provider
B) Palpate the anterior fontanel
C) Feel the posterior fontanel
D) Record these normal findings
The correct answer is D: Record these normal findings
The question is D. The rate of increase in head circumference slows by the end of infancy,
and the head circumference is usually equal to chest circumference at 1 to 2 years of age.
28. At a routine clinic visit, parents express concern that their 4 year-old is wetting the bed
several times a month. What is the nurse's best response?
A) "This is normal at this time of day."
B) "How long has this been occurring?"
C) "Do you offer fluids at night?"
D) "Have you tried waking her to urinate?"
The correct answer is B: "How long has this been occurring?"
Nighttime control should be present by this age, but may not occur until age 5. Involuntary
voiding may occur due to infectious, anatomical and/or physiological reasons.
29. A client was admitted to the psychiatric unit after refusing to get out of bed. In the
hospital the client talks to unseen people and voids on the floor. The nurse could best
handle the problem of voiding on the floor by
A) Requiring the client to mop the floor
B) Restricting the client’s fluids throughout the day
C) Withholding privileges each time the voiding occurs
D) Toileting the client more frequently with supervision
The correct answer is D: Toileting the client more frequently with supervision
With altered thought processes the most appropriate nursing approach to alter the behavior
is by attending to the physical need.
30. The nurse is caring for a client with a sigmoid colostomy who requests assistance in
removing the flatus from a 1 piece drainable ostomy pouch. Which is the correct
intervention?
A) Piercing the plastic of the ostomy pouch with a pin to vent the flatus
B) Opening the bottom of the pouch, allowing the flatus to be expelled
C) Pulling the adhesive seal around the ostomy pouch to allow the flatus to escape
D) Assisting the client to ambulate to reduce the flatus in the pouch
The correct answer is B: Opening the bottom of the pouch, allowing the flatus to be
expelled. The only correct way to vent the flatus from a 1 piece drainable ostomy pouch is
to instruct the client to obtain privacy (the release of the flatus will cause odor), and to
open the bottom of the pouch, release the flatus and dose the bottom of the pouch.
31. The nurse is teaching parents of an infant about introduction of solid food to their baby.
What is the first food they can add to the diet?
A) Vegetables
B) Cereal
C) Fruit
D) Meats
The correct answer is B: Cereal
Cereal is usually introduced first because it is well tolerated, easy to digest, and contains
iron.
32. When counseling parents of a child who has recently been diagnosed with hemophilia,
what must the nurse know about the offspring of a normal father and a carrier mother?
A) It is likely that all sons are affected
B) There is a 50% probability that sons will have the disease
C) Every daughter is likely to be a carrier
D) There is a 25% chance a daughter will be a carrier
The correct answer is D: There is a 25% chance a daughter will be a carrier
Hemophilia A is a sex-linked recessive trait seen almost exclusively in males. With a normal
father and carrier mother, affected individuals are male. There is a 25% chance of having
an affected male, 25% chance of having a carrier female, 25% chance of having a normal
female and 25% chance of having a normal male.
33. When teaching a client with chronic obstructive pulmonary disease about oxygen by
cannula, the nurse should also instruct the client's family to
A) Avoid smoking near the client
B) Turn off oxygen during meals
C) Adjust the liter flow to 10 as needed
D) Remind the client to keep mouth closed
The correct answer is A: Avoid smoking near the client
Since oxygen supports combustion, there is a risk of fire if anyone smokes near the oxygen
equipment.
34. The nurse is caring for a post-op colostomy client. The client begins to cry saying, "I'll
never be attractive again with this ugly red thing." What should be the first action by the
nurse?
A) Arrange a consultation with a sex therapist
B) Suggest sexual positions that hide the colostomy
C) Invite the partner to participate in colostomy care
D) Determine the client's understanding of her colostomy
The correct answer is D: Determine the client''s understanding of her colostomy. One of the
greatest fears of colostomy clients is the fear that sexual intimacy is no longer possible.
However, the specific concern of the client needs to be assessed before specific suggestions
for dealing with the sexual concerns are given.
35. A schizophrenic client talks animatedly but the staff are unable to understand what the
client is communicating. The client is observed mumbling to herself and speaking to the
radio. A desirable outcome for this client’s care will be
A) Expresses feelings appropriately through verbal interactions
B) Accurately interprets events and behaviors of others
C) Demonstrates improved social relationships
D) Engages in meaningful and understandable verbal communication
The correct answer is D: Engages in meaningful and understandable verbal communication.
Data support impaired verbal communication deficit. The outcome must be related to the
diagnosis and supporting data. No data is presented related to feelings or to thinking
processes.
36. A 7 year-old child is hospitalized following a major burn to the lower extremities. A diet
high in protein and carbohydrates is recommended. The nurse informs the child and family
that the most important reason for this diet is to
A) Promote healing and strengthen the immune system
B) Provide a well balanced nutritional intake
C) Stimulate increased peristalsis absorption
D) Spare protein catabolism to meet metabolic needs
The correct answer is D: Spare protein catabolism to meet metabolic needs
Because of the burn injury, the child has increased metabolism and catabolism. By providing
a high carbohydrate diet, the breakdown of protein for energy is avoided. Proteins are then
used to restore tissue.
37. The parents of a 7 year-old tell the nurse their child has started to "tattle" on siblings.
In interpreting this new behavior, how should the nurse explain the child's actions to the
parents?
A) The ethical sense and feelings of justice are developing
B) Attempts to control the family use new coping styles
C) Insecurity and attention getting are common motives
D) Complex thought processes help to resolve conflicts
The correct answer is A: The ethical sense and feelings of justice are developing. The child
is developing a sense of justice and a desire to do what is right. At seven, the child is
increasingly aware of family roles and responsibilities. They also do what is right because of
parental direction or to avoid punishment.
38. A school nurse is advising a class of unwed pregnant high school students. What is the
most important action they can perform to deliver a healthy child?
A) Maintain good nutrition
B) Stay in school
C) Keep in contact with the child's father
D) Get adequate sleep
The correct answer is A: Maintaining good nutrition
Nurses can serve a pivotal role in providing nutritional education and case management
interventions. Weight gain during pregnancy is one of the strongest predictors of infant birth
weight. Specifically, teens need to increase their intake of protein, vitamins, and minerals
including iron. Pregnant teens who gain between 26 and 35 pounds have the lowest
incidence of low-birth-weight babies.
39. A client continually repeats phrases that others have just said. The nurse recognizes this
behavior as
A) Autistic
B) Ecopraxic
C) Echolalic
D) Catatonic
The correct answer is C: Echolalic
Echolalic - repeating words heard.
40. A client is admitted for hemodialysis. Which abnormal lab value would the nurse
anticipate not being improved by hemodialysis?
A) Low hemoglobin
B) Hypernatremia
C) High serum creatinine
D) Hyperkalemia
The correct answer is A: Low hemoglobin
Although hemodialysis improves or corrects electrolyte imbalances it has not effect on
improving anemia.
41. The nurse is caring for a 7 year-old child who is being discharged following a
tonsillectomy. Which of the following instructions is appropriate for the nurse to teach the
parents?
A) Report a persistent cough to the health care provider
B) The child can return to school in 4 days
C) Administer chewable aspirin for pain
D) The child may gargle with saline as necessary for discomfort
The correct answer is A: Report a persistent cough to the health care provider. Persistent
coughing should be reported to the health care provider as this may indicate bleeding.
42. The nurse is caring for a 14 month-old just diagnosed with Cystic Fibrosis. The parents
state this is the first child in either family with this disease, and ask about the risk to future
children. What is the best response by the nurse?
A) 1in 4 chance for each child to carry that trait
B) 1in 4 risk for each child to have the disease
C) 1in 2 chance of avoiding the trait and disease
D) 1in 2 chance that each child will have the disease
The correct answer is B: 1 in 4 risk for each child to have the disease
Cystic Fibrosis is an autosomal recessive transmission pattern. In this situation, both
parents must be carriers of the trait for the disease since neither one of them has the
disease. Therefore, for each pregnancy, there is a 25% chance of the child having the
disease, 50% chance of carrying the trait and a 25% chance of having neither the trait or
the disease.
43. The nurse is performing an assessment on a client with pneumococcal pneumonia.
Which finding would the nurse anticipate?
A) Bronchial breath sounds in outer lung fields
B) Decreased tactile fremitus
C) Hacking, nonproductive cough
D) Hyperresonance of areas of consolidation
The correct answer is A: Bronchial breath sounds in outer lung fields
Pneumonia causes a marked increase in interstitial and alveolar fluid. Consolidated lung
tissue transmits bronchial breath sounds to outer lung fields.
44. During seizure activity which observation is the priority to enhance further direction of
treatment?
A) Observe the sequence or types of movement
B) Note the time from beginning to end
C) Identify the pattern of breathing
D) Determine if loss of bowel or bladder control occurs
The correct answer is A: Protect the client from injury
It is a priority to note, and then record, what movements are seen during a seizure because
the diagnosis and subsequent treatment often rests solely on the seizure description.
45. Which of the following statements describes what the nurse must know in order to
provide anticipatory guidance to parents of a toddler about readiness for toilet training?
A) The child learns voluntary sphincter control through repetition
B) Myelination of the spinal cord is completed by this age
C) Neuronal impulses are interrupted at the base of the ganglia
D) The toddler can understand cause and effect
The correct answer is B: Myelination of the spinal cord is completed by this age. Voluntary
control of the sphincter muscles can be gradually achieved due to the complete myelination
of the spinal cord, sometime between the ages of 18 to 24 months of age.
46. A client complaining of severe shortness of breath is diagnosed with congestive heart
failure. The nurse observes a falling pulse oximetry. The client's color changes to gray and
she expectorates large amounts of pink frothy sputum. The first action of the nurse would
be which of the following?
A) Call the health care provider
B) Check vital signs
C) Position in high Fowler's
D) Administer oxygen
The correct answer is D: Administer oxygen
When dealing with a medical emergency, the rule is airway first, then breathing, and then
circulation. Starting oxygen is a priority.
47. The nurse is caring for a client with benign prostatic hypertrophy. Which of the following
assessments would the nurse anticipate finding?
A) Large volume of urinary output with each voiding
B) Involuntary voiding with coughing and sneezing
C) Frequent urination
D) Urine is dark and concentrated
The correct answer is C: Frequent urination
Clients with Benign Prostatic Hypertrophy have overflow incontinence with frequent
urination in small amounts day and night.
48. An anxious parent of a 4 year-old consults the nurse for guidance in how to answer the
child's question, "Where do babies come from?" What is the nurse's best response to the
parent?
A) "When a child asks a question, give a simple answer."
B) "Children ask many questions, but are not looking for answers."
C) "This question indicates interest in sex beyond this age."
D) "Full and detailed answers should be given to all questions."
The correct answer is A: "When a child asks a question, give a simple answer." During
discussions related to sexuality, honesty is very important. However, honesty does not
mean imparting every fact of life associated with the question. When children ask 1
question, they are looking for 1 answer. When they are ready, they will ask about the other
pieces.
49. A 3 year-old child is treated in the emergency department after ingestion of 1ounce of a
liquid narcotic. What action should the nurse do first?
A) Provide the ordered humidified oxygen via mask
B) Suction the mouth and the nose
C) Check the mouth and radial pulse
D) Start the ordered intravenous fluids
The correct answer is C: Check the mouth and radial pulse
The first step in treatment of a toxic exposure or ingestion is to assess the airway, breathing
and circulation; then stabilize the client. The other nursing actions will follow.
50. The charge nurse on the eating disorder unit instructs a new staff member to weigh
each client in his or her hospital gown only. What is the rationale for this nursing
intervention?
A) To reduce the risk of the client feeling cold due to decreased fat and subcutaneous tissue
B) To cover the bony prominence and areas where there is skin breakdown
C) So the client knows what type of clothing to wear when weighed
D) To reduce the tendency of the client to hide objects under his or her clothing
The correct answer is D: To reduce the tendency of the client to hide objects under his or
her clothing. The client may conceal weights on their body to increase weight gain.
51. In teaching parents to associate prevention with the lifestyle of their child with sickle
cell disease, the nurse should emphasize that a priority for their child is to
A) Avoid overheating during physical activities
B) Maintain normal activity with some restrictions
C) Be cautious of others with viruses or temperatures
D) Maintain routine immunizations
The correct answer is A: Avoid overheating
Fluid loss caused by overheating and dehydration can trigger a crisis.
52. The nurse understands that during the "tension building" phase of a violent relationship,
when the batterer makes unreasonable demands, the battered victim may experience
feelings of
A) Anger
B) Helplessness
C) Calm
D) Explosive
The correct answer is B: Helplessness
The battered individual internalizes appropriate anger at the batterer’s unfairness and
instead feels depressed with a sense of helplessness, when the partner explodes in spite of
best efforts to please the batterer.
53. A parent has numerous questions regarding normal growth and development of a 10
month-old infant. Which of the following parameters is of most concern to the nurse?
A) 50% increase in birth weight
B) Head circumference greater than chest
C) Crying when the parents leave
D) Able to stand up briefly in play pen
The correct answer is A: 50% increase in birth weight
Birth weight should be doubled at 6 months of age, tripled at 1 year, and quadrupled by 18
months.
54. The nurse has been assigned to these clients in the emergency room. Which client
would the nurse go check first?
A) Viral pneumonia with atelectasis
B) Spontaneous pneumothorax with a respiratory rate of 38
C) Tension pneumothorax with slight tracheal deviation to the right
D) Acute asthma with episodes of bronchospasm
The correct answer is C: Tension pneumothorax with slight tracheal deviation to the right.
Tracheal deviation indicates a significant volume of air being trapped in the chest cavity with
a mediastinal shift. In tension pneumothorax the tracheal deviation is away from the
affected side. The affected side is the side where the air leak is in the lung. This situation
also results in sudden air hunger, agitation, hypotension, pain in the affected side, and
cyanosis with a high risk of cardiac tamponade and cardiac arrest.
55. The nurse is assessing a 4 year-old for possible developmental dysplasia of the right
hip. Which finding would the nurse expect?
A) Pelvic tip downward
B) Right leg lengthening
C) Ortolani sign
D) Characteristic limp
The correct answer is D: Characteristic limp
Developmental dysplasia produces a characteristic limp in children who are walking.
56. A 2 year-old child has recently been diagnosed with cystic fibrosis. The nurse is teaching
the parents about home care for the child. Which of the following information is appropriate
for the nurse to include?
A) Allow the child to continue normal activities
B) Schedule frequent rest periods
C) Limit exposure to other children
D) Restrict activities to inside the house
The correct answer is A: Allow the child to continue their normal activities Physical activity is
important in a two year-old who is developing autonomy. Physical activity is a valuable
adjunct to chest physical therapy. Exercise tends to stimulate mucous secretion and help
develop normal breathing patterns.
57. The nurses on a unit are planning for stoma care for clients who have a stoma for fecal
diversion. Which stomal diversion poses the highest risk for skin breakdown
A) Ileostomy
B) Transverse colostomy
C) Ileal conduit
D) Sigmoid colostomy
The correct answer is A: Ileostomy
Ileostomy output contains gastric and enzymatic agents that when present on skin can
denuded skin in several hours. Because of the caustic nature of this stoma output adequate
peristomal skin protection must be delivered to prevent skin breakdown.
58. A client is unconscious following a tonic-clonic seizure. What should the nurse do first?
A) Check the pulse
B) Administer Valium
C) Place the client in a side-lying position
D) Place a tongue blade in the mouth
The correct answer is C: Place the client in a side-lying position
Place the client in a side-lying position to maintain an open airway, drain secretions, and
prevent aspiration if vomiting occurs.
59. The nurse is teaching a client who has a hip prostheses following total hip replacement.
Which of the following should be included in the instructions for home care?
A) Avoid climbing stairs for 3 months
B) Ambulate using crutches only
C) Sleep only on your back
D) Do not cross legs
The correct answer is D: Do not cross legs
Hip flexion should not exceed 60 degrees.
60. A nurse who travels with an agency is uncertain about what tasks can be performed
when working in a different state. It would be best for the nurse to check which resource?
A) The state nurse practice act in which the assignment is made
B) With a nurse colleague who has worked in that state 2 years ago
D) The Nursing Social Policy Statement within the United States
C) The policies and procedures of the assigned agency in that state
The correct answer is A: The state nurse practice act in which the assignment is made. The
state nurse practice act is the governing document of what can be done in the assigned
state.
61. Parents of a 7 year-old child call the clinic nurse because their daughter was sent home
from school because of a rash. The child had been seen the day before by the health care
provider and diagnosed with Fifth Disease (erythema infectiosum). What is the most
appropriate action by the nurse?
A) Tell the parents to bring the child to the clinic for further evaluation
B) Refer the school officials to printed materials about this viral illness
C) Inform the teacher that the child is receiving antibiotics for the rash
D) Explain that this rash is not contagious and does not require isolation
The correct answer is D: Explain that this rash is not contagious and does not require
isolation. Fifth Disease is a viral illness with an uncertain period of communicability (perhaps
1 week prior to and 1 week after onset). Isolation of the child with Fifth Disease is not
necessary except in cases of hospitalized children who are immunosuppressed or having
aplastic crises. The parents may need written confirmation of this from the health care
provider.
62. What principle of HIV disease should the nurse keep in mind when planning care for a
newborn who was infected in utero?
A) The disease will incubate longer and progress more slowly in this infant
B) The infant is very susceptible to infections
C) Growth and development patterns will proceed at a normal rate
D) Careful monitoring of renal function is indicated
The correct answer is B: The infant is very susceptible to infections
HIV infected children are susceptible to opportunistic infections due to a compromised
immune system.
63. While teaching a client about their medications, the client asks how long it will take
before the effects of lithium take place. What is the best response of the nurse?
A) Immediately
B) Several days
C) 2 weeks
D) 1 month
The correct answer is C: 2 weeks
Lithium is started immediately to treat bipolar disorder because it is quite effective in
controlling mania. Lithium takes approximately 2 weeks to effect change in a client’s
symptoms.
64. The nurse is caring for a 12 year-old with an acute illness. Which of the following
indicates the nurse understands common sibling reactions to hospitalization?
A) Younger siblings adapt very well
B) Visitation is helpful for both
C) The siblings may enjoy privacy
D) Those cared for at home cope better
The correct answer is B: Visitation is helpful for both
Contact with the ill child helps siblings understand the reasons for hospitalization and
maintains the relationship.
65. Following a cocaine high, the user commonly experiences an extremely unpleasant
feeling called
A) Craving
B) Crashing
C) Outward bound
D) Nodding out
The correct answer is B: Crashing
Following cocaine use, the intense pleasure is replaced by an equally unpleasant feeling
referred to as crashing.
66. One reason that domestic violence remains extensively undetected is
A) Few battered victims seek medical care
B) There is typically a series of minor, vague complaints
C) Expenses due to police and court costs are prohibitive
D) Very little knowledge is currently known about batterers and battering relationships
The correct answer is B: There is typically a series of minor, vague complaints. Signs of
abuse may not be clearly manifested and a series a minor complaints such as headache,
abdominal pain, insomnia, back pain, and dizziness may be covert indications of abuse
undetected. Complaints may be vague.
67. When making a home visit to a client with chronic pyelonephritis, which nursing action
has the highest priority?
A) Follow-up on lab values before the visit
B) Observe client findings for the effectiveness of antibiotics
C) Ask for a log of urinary output
D) As for the log of the oral intake
The correct answer is C: Ask for a log of urinary output
The nurse must monitor the urine output as a priority because it is the best indictor of renal
function. The other options would be done after an evaluation of the urine output.
68. When a client is having a general tonic clonic seizure, the nurse should
A) Hold the client's arms at their side
B) Place the client on their side
C) Insert a padded tongue blade in client's mouth
D) Elevate the head of the bed
The correct answer is B: Place the client on their side
This position keeps the airway patent and prevents aspiration.
69. The nurse is teaching a client with dysrhythmia about the electrical pathway of an
impulse as it travels through the heart. Which of these demonstrates the normal pathway?
A) AV node, SA node, Bundle of His, Purkinje fibers
B) Purkinje fibers, SA node, AV node, Bundle of His
C) Bundle of His, Purkinje fibers, SA node , AV node
D) SA node, AV node, Bundle of His, Purkinje fibers
The correct answer is D: SA node, AV node, Bundle of His, Purkinje fibers
The pathway of a normal electrical impulse through the heart is: SA node, AV node, Bundle
of His, Purkinje fibers.
70. Clients with mitral stenosis would likely manifest findings associated with congestion in
the
A) Pulmonary circulation
B) Descending aorta
C) Superior vena cava
D) Bundle of His
The correct answer is A: Pulmonary circulation
Congestion occurs in the pulmonary circulation due to the inefficient emptying of the left
ventricle and the lack of a competent valve to prevent back flow into the pulmonary vein.
71. In assessing the healing of a client's wound during a home visit, which of the following
is the best indicator of good healing?
A) White patches
B) Green drainage
C) Reddened tissue
D) Eschar development
The correct answer is C: Reddened tissue
As the wound granulates, redness indicates healing.
72. The nursing intervention that best describes treatment to deal with the behaviors of
clients with personality disorders include
A) Pointing out inconsistencies in speech patterns to correct thought disorders
B) Accepting client and the client's behavior unconditionally
C) Encouraging dependency in order to develop ego controls
D) Consistent limit-setting enforced 24 hours per day
The correct answer is D: Consistent limit-setting enforced 24 hours per day
Treatment approaches that include restructuring the personality, assisting the person with
developmental level and setting limits for maladaptive behavior such as acting out.
73. A client has received her first dose of fluphenazine (Prolixin) 2 hours ago. She suddenly
experiences torticollis and involuntary spastic muscle movement. In addition to
administering the ordered anticholinergic drug, what other measure should the nurse
implement?
A) Have respiratory support equipment available
B) Immediately place her in the seclusion room
C) Assess the client for anxiety and agitation
D) Administer prn dose of IM antipsychotic medication
The correct answer is A: Have respiratory support equipment available
Persons receiving neuroleptic medication experiencing torticollis and involuntary muscle
movement are demonstrating side effects that could lead to respiratory failure.
74. The nurse asks a client with a history of alcoholism about the client’s drinking behavior.
The client states "I didn’t hurt anyone. I just like to have a good time, and drinking helps
me to relax." The client is using which defense mechanism?
A) Denial
B) Projection
C) Intellectualization
D) Rationalization
The correct answer is D: Rationalization
Rationalization is justifying illogical or unreasonable ideas, actions, or feelings by developing
acceptable explanations that satisfies the teller as well as the listener.
75. The nurse is teaching a smoking cessation class and notices there are 2 pregnant
women in the group. Which information is a priority for these women?
A) Low tar cigarettes are less harmful during pregnancy
B) There is a relationship between smoking and low birth weight
C) The placenta serves as a barrier to nicotine
D) Moderate smoking is effective in weight control
The correct answer is B: There is a relationship between smoking and low birth weight.
Nicotine reduces placental blood flow, and may contribute to fetal hypoxia or placenta
previa, decreasing the growth potential of the fetus.
76. The nurse is caring for a client with end stage renal disease. What action should the
nurse take to assess for patency in a fistula used for hemodialysis?
A) Observe for edema proximal to the site
B) Irrigate with 5 mls of 0.9% Normal Saline
C) Palpate for a thrill over the fistula
D) Check color and warmth in the extremity
The correct answer is C: Palpate for a thrill over the fistula
To assess for patency in a fistula or graft, the nurse auscultates for a bruit and palpates for
a thrill. Other options are not related to evaluation for patency.
77. Which therapeutic communication skill is most likely to encourage a depressed client to
vent feelings?
A) Direct confrontation
B) Reality orientation
C) Projective identification
D) Active listening
The correct answer is D: Active listening
Use of therapeutic communication skills such as silence and active listening encourages
verbalization of feelings.
78. The nurse walks into a client's room and finds the client lying still and silent on the floor.
The nurse should first
A) Assess the client's airway
B) Call for help
C) Establish that the client is unresponsive
D) See if anyone saw the client fall
The correct answer is C: Establish that the client is unresponsive
The first step in CPR is to establish unresponsiveness. Second is to call for help. Third is
opening the airway.
79. What is the best way for the nurse to accomplish a health history on a 14 year-old
client?
A) Have the mother present to verify information
B) Allow an opportunity for the teen to express feelings
C) Use the same type of language as the adolescent
D) Focus the discussion of risk factors in the peer group
The correct answer is B: Allow an opportunity for the teen to express feelings
Adolescents need to express their feelings. Generally, they talk freely when given an
opportunity and some privacy to do so.
80. A new nurse on the unit notes that the nurse manager seems to be highly respected by
the nursing staff. The new nurse is surprised when one of the nurses states: "The manager
makes all decisions and rarely asks for our input." The best description of the nurse
manager's management style is
A) Participative or democratic
B) Ultraliberal or communicative
C) Autocratic or authoritarian
D) Laissez faire or permissive
The correct answer is C: Autocratic or authoritarian
Autocratic leadership style is suggested in this situation. It is appropriate for groups with
little education and experience and who need strong direction, while participative or
democratic style is usually more successful on nursing units.
81. A 2 year-old child is being treated with Amoxicillin suspension, 200 milligrams per dose,
for acute otitis media. The child weighs 30 lb. (15 kg) and the daily dose range is 20-40
mg/kg of body weight, in three divided doses every 8 hours. Using principles of safe drug
administration, what should the nurse do next?
A) Give the medication as ordered
B) Call the health care provider to clarify the dose
C) Recognize that antibiotics are over-prescribed
D) Hold the medication as the dosage is too low
The correct answer is A: Give the medication as ordered
Amoxicillin continues to be the drug of choice in the treatment of acute otitis media. The
dose range is 20-40 mg/kg/day divided every 8 hours. 15kg x 40mg = 600mg, divided by 3
= 200 mg per dose. The prescribed dose is correct and should be given as ordered.
82. The nurse is performing a developmental assessment on an 8 month-old. Which finding
should be reported to the health care provider?
A) Lifts head from the prone position
B) Rolls from abdomen to back
C) Responds to parents' voices
D) Falls forward when sitting
The correct answer is D: Falls forward when sitting
Sitting without support is expected at this age.
83. The nurse is participating in a community health fair. As part of the assessments, the
nurse should conduct a mental status examination when
A) An individual displays restlessness
B) There are obvious signs of depression
C) Conducting any health assessment
D) The resident reports memory lapses
The correct answer is C: Conducting any health assessment
A mental status assessment is a critical part of baseline information, and should be a part of
every examination.
84. The nurse caring for a 14 year-old boy with severe Hemophilia A, who was admitted
after a fall while playing basketball. In understanding his behavior and in planning care for
this client, what must the nurse understand about adolescents with hemophilia?
A) Must have structured activities
B) Often take part in active sports
C) Explain limitations to peer groups
D) Avoid risks after bleeding episodes
The correct answer is B: Often take part in active sports
Establish an age-appropriate safe environment. Adolescent hemophiliacs should be aware
that contact sports may trigger bleeding. However, developmental characteristics of this age
group such as impulsivity, inexperience and peer pressure, place adolescents in unsafe
environments.
85. When assessing a client who has just undergone a cardioversion, the nurse finds the
respirations are 12. Which action should the nurse take first?
A) Try to vigorously stimulate normal breathing
B) Ask the RN to assess the vital signs
C) Measure the pulse oximetry
D) Continue to monitor respirations
The correct answer is D: 4. Continue to monitor respirations
12 respirations per minute is tolerated post-operatively. A range from 8 to 10 gives cause
for concern. At that point pulse oximetry is taken, as that rate could be tolerated. Vigorous
stimulation is not indicated beyond deep breathing and coughing. It is not necessary to ask
the RN to check findings.
86. In order to enhance a client's response to medication for chest pain from acute angina,
the nurse should emphasize
A) Learning relaxation techniques
B) Limiting alcohol use
C) Eating smaller meals
D) Avoiding passive smoke
The correct answer is A: Learning relaxation techniques
The only factor that can enhance the client''s response to pain medication for angina is
reducing anxiety through relaxation methods. Anxiety can be great enough to make the
pain medication totally ineffective.
87. The primary nursing diagnosis for a client with congestive heart failure with pulmonary
edema is
A) Pain
B) Impaired gas exchange
C) Cardiac output altered: decreased
D) Fluid volume excess
The correct answer is C: Cardiac output altered: decreased
All nursing interventions should be focused on improving cardiac output. Increasing cardiac
output is the primary goal of therapy. Comfort will improve as the client improves and the
respiratory status will improve as cardiac output increases.
88. After talking with her partner, a client voluntarily admitted herself to the substance
abuse unit. After the second day on the unit the client states to the nurse, "My husband told
me to get treatment or he would divorce me. I don’t believe I really need treatment but I
don’t want my husband to leave me." Which response by the nurse would assist the client?
A) "In early recovery, it's quite common to have mixed feelings, but unmotivated people
can’t get well."
B) "In early recovery, it’s quite common to have mixed feelings, but I didn’t know you had
been pressured to come."
C) "In early recovery it’s quite common to have mixed feelings, perhaps it would be best to
seek treatment on an outclient bases."
D) "In early recovery, it’s quite common to have mixed feelings. Let’s discuss the
benefits of sobriety for you."
The correct answer is D: "In early recovery, it’s quite common to have mixed feelings. Let’s
discuss the benefits of sobriety for you." This response gives the client the opportunity to
decrease ambivalent feelings by focusing on the benefits of sobriety. Dependence issues are
great for the client fostering ambivalence.
89. Clients taking which of the following drugs are at risk for depression?
A) Steroids
B) Diuretics
C) Folic acid
D) Aspirin
The correct answer is A: Steroids
Adverse medication effects can cause a syndrome that may or may not remit when the
medication is discontinued. Examples include: phenothiazines, steroids, and reserpine.
90. The nurse is assessing a client on admission to a community mental health center. The
client discloses that she has been thinking about ending her life. The nurse's best response
would be
A) "Do you want to discuss this with your pastor?"
B) "We will help you deal with those thoughts."
C) "Is your life so terrible that you want to end it?"
D) "Have you thought about how you would do it?"
The correct answer is D: "Have you thought about how you would do it?"
This response provides an opening to discuss intent and means of committing suicide.
91. The nurse is caring for a client 2 hours after a right lower lobectomy. During the
evaluation of the water-seal chest drainage system, it is noted that the fluid level bubbles
constantly in the water seal chamber. On inspection of the chest dressing and tubing, the
nurse does not find any air leaks in the system. The next best action for the nurse is to
A) Check for subcutaneous emphysema in the upper torso
B) Reposition the client to a position of comfort
C) Call the health care provider as soon as possible
D) Check for any increase in the amount of thoracic drainage
The correct answer is A: Check for subcutaneous emphysema in the upper torso.
Continuous bubbling in the water seal chamber is an abnormal finding 2 hours after a
lobectomy. Further assessment of appropriate factors was done by the nurse to rule out an
air leak in the sytem. Thus the conclusion is that the problem is one of an air leak in the
lung. This client may need to be returned to surgery to deal with the sustained air leak.
Action by the health care provider is required to prevent further complications.
92. The nurse is caring for a newborn who has just been diagnosed with hypospadias. After
discussing the defect with the parents, the nurse should expect that
A) Circumcision can be performed at any time
B) Initial repair is delayed until ages 6-8
C) Post-operative appearance will be normal
D) Surgery will be performed in stages
The correct answer is D: Surgery will be performed in stages
Hypospadias, a condition in which the urethral opening is located on the ventral surface or
below the penis, is corrected in stages as soon as the infant can tolerate surgery.
93. A client has been receiving lithium (Lithane) for the past two weeks for the treatment of
bipolar illness. When planning client teaching, what is most important to emphasize to the
client?
A) Maintain a low sodium diet
B) Take a diuretic with lithium
C) Come in for evaluation of serum lithium levels every 1-3 months
D) Have blood lithium levels drawn during the summer months
The correct answer is D: Have blood lithium levels drawn during the summer months.
Clients taking lithium therapy need to be aware that hot weather may cause excessive
perspiration, a loss of sodium and consequently an increase in serum lithium concentration.
94. When an autistic client begins to eat with her hands, the nurse can best handle the
problem by
A) Placing the spoon in the client’s hand and stating, "Use the spoon to eat your
food."
B) Commenting "I believe you know better than to eat with your hand."
C) Jokingly stating, "Well I guess fingers sometimes work better than spoons."
D) Removing the food and stating "You can’t have anymore food until you use the spoon."
The correct answer is A: Placing the spoon in the client’s hand and stating "Use the spoon to
eat your food." This response identifies adaptive behavior with instruction and verbal
expectation.
95. A client develops volume overload from an IV that has infused too rapidly. What
assessment would the nurse expect to find?
A) S3 heart sound
B) Thready pulse
C) Flattened neck veins
D) Hypoventilation
The correct answer is A: Auscultation of an S3 heart sound
Auscultation of an S3 heart sound. This is an early sign of volume overload (or CHF)
because during the first phase of diastole, when blood enters the ventricles, an extra sound
is produced due to the presence of fluid left in the ventricles.
96. A neonate born 12 hours ago to a methadone maintained woman is exhibiting a
hyperactive MORO reflex and slight tremors. The newborn passed one loose, watery stool.
Which of these is a nursing priority?
A) Hold the infant at frequent intervals.
B) Assess for neonatal withdrawl syndrome
C) Offer fluids to prevent dehydration
D) Administer paregoric to stop diarrhea
The correct answer is B: Assess for neonatal withdrawl syndrome
Neonatal withdrawl syndrome is a cluster of findings that signal the withdrawal of the infant
from the opiates. The findings seen in methadone withdrawal are often more severe than
for other substances. Initial signs are central nervous system hyper irritability and gastrointestinal symptoms. If withdrawal signs are severe, there is an increased mortality risk.
Scoring the infant ensures proper treatment during the period of withdrawal.
97. While planning care for a preschool aged child, the nurse understands developmental
needs. Which of the following would be of the most concern to the nurse?
A) Playing imaginatively
B) Expressing shame
C) Identifying with family
D) Exploring the playroom
The correct answer is B: Expressing shame
Erikson describes the stage of the preschool child as being the time when there is normally
an increase in initiative. The child should have resolved the sense of shame and doubt in the
toddler stage.
98. A depressed client who has recently been acting suicidal is now more social and
energetic than usual. Smilingly he tells the nurse "I’ve made some decisions about my life."
What should be the nurse’s initial response?
A) "You’ve made some decisions."
B) "Are you thinking about killing yourself?"
C) "I’m so glad to hear that you’ve made some decisions."
D) "You need to discuss your decisions with your therapist."
The correct answer is B: "Are you thinking about killing yourself?"
Sudden mood elevation and energy may signal increased risk of suicide. The nurse must
validate suicide ideation as a beginning step in evaluating seriousness of risk.
99. The nurse is caring for 2 children who have had surgical repair of congenital heart
defects. For which defect is it a priority to assess for findings of heart conduction
disturbance?
A) Artrial septal defect
B) Patent ductus arteriosus
C) Aortic stenosis
D) Ventricular septal defect
The correct answer is D: Ventricular septal defect
While assessments for conduction disturbance should be included following repair of any
defect, it is a priority for this condition. A ventricular septal defect is an abnormal opening
between the right and left ventricles. The atrioventricular bundle (bundle of His), a part of
the electrical conduction system of the heart, extends from the atrioventricular node along
each side of the interventricular septum and then divides into right and left bundle
branches. Surgical repair of a ventricular septal defect consists of a purse-string approach
or a patch sewn over the opening. Either method involves manipulation of the ventricular
septum, thereby increasing risk of interrupting the conduction pathway. Consequently,
postoperative complications include conduction disturbances.
100. The nurse is caring for a post myocardial infarction client in an intensive care unit. It is
noted that urinary output has dropped from 60 -70 ml per hour to 30 ml per hour. This
change is most likely due to
A) Dehydration
B) Diminished blood volume
C) Decreased cardiac output
D) Renal failure
The correct answer is C: Decreased cardiac output
Cardiac output and urinary output are directly correlated. The nurse should suspect a drop
in cardiac output if the urinary output drops.
>
100 item Comprehensive Exam II with Answers and Rationale
1. In a child with suspected coarctation of the aorta, the nurse would expect to find
A) Strong pedal pulses
B) Diminishing cartoid pulses
C) Normal femoral pulses
D) Bounding pulses in the arms
The correct answer is D: Bounding pulses in the arms
Coarctation of the aorta, a narrowing or constriction of the descending aorta, causes
increased flow to the upper extremities (increased pressure and pulses)
2. The nurse is caring for a child receiving chest physiotherapy (CPT). Which of the following
actions by the nurse would be appropriate?
A) Schedule the therapy thirty minutes after meals
B) Teach the child not to cough during the treatment
C) Confine the percussion to the rib cage area
D) Place the child in a prone position for the therapy
The correct answer is C: Confine the percussion to the rib cage area
Percussion (clapping) should be only done in the area of the rib cage.
3. A client was admitted to the psychiatric unit with major depression after a suicide
attempt. In addition to feeling sad and hopeless, the nurse would assess for
A) Anxiety, unconscious anger, and hostility
B) Guilt, indecisiveness, poor self-concept
C) Psychomotor retardation or agitation
D) Meticulous attention to grooming and hygiene
The correct answer is C: Psychomotor retardation or agitation
Somatic or physiologic symptoms of depression include: fatigue, psychomotor retardation or
psychomotor agitation, chronic generalized or local pain, sleep disturbances, disturbances in
appetite, gastrointestinal complaints and impaired libido.
4. A victim of domestic violence states to the nurse, "If only I could change and be how my
companion wants me to be, I know things would be different." Which would be the best
response by the nurse?
A) "The violence is temporarily caused by unusual circumstances; don’t stop hoping for a
change."
B) "Perhaps, if you understood the need to abuse, you could stop the violence."
C) "No one deserves to be beaten. Are you doing anything to provoke your spouse into
beating you?" D) "Batterers lose self-control because of their own internal reasons,
not because of what their partner did or did not do."
The correct answer is D: "Batterers lose self-control because of their own internal reasons,
not because of what their partner did or did not do."
Only the perpetrator has the ability to stop the violence. A change in the victim’s behavior
will not cause the abuser to become nonviolent.
5. A nurse is to present information about Chinese folk medicine to a group of student
nurses. Based on this cultural belief, the nurse would explain that illness is attributed to the
A) Yang, the positive force that represents light, warmth, and fullness
B) Yin, the negative force that represents darkness, cold, and emptiness
C) Use of improper hot foods, herbs and plants
D) A failure to keep life in balance with nature and others
The correct answer is B: Yin, the negative force that represents darkness, cold, and
emptiness. Chinese folk medicine proposes that health is regulated by the opposing forces
of yin and yang. Yin is the negative female force characterized by darkness, cold and
emptiness. Excessive yin predisposes one to nervousness.
6. A polydrug user has been in recovery for 8 months. The client has began skipping
breakfast and not eating regular dinners. The client has also started frequenting bars to
"see old buddies." The nurse understands that the client’s behavior is a warning sign to
indicate that the client may be
A) headed for relapse
B) feeling hopeless
C) approaching recovery
D) in need of increased socialization
The correct answer is A: headed for relapse
It takes 9 to 15 months to adjust to a lifestyle free of chemical use, thus it is important for
clients to acknowledge that relapse is a possibility and to identify early signs of relapse.
7. At the day treatment center a client diagnosed with Schizophrenia - Paranoid Type sits
alone alertly watching the activities of clients and staff. The client is hostile when
approached and asserts that the doctor gives her medication to control her mind. The
client's behavior most likely indicates
A) Feelings of increasing anxiety related to paranoia
B) Social isolation related to altered thought processes
C) Sensory perceptual alteration related to withdrawal from environment
D) Impaired verbal communication related to impaired judgment
The correct answer is B: Social isolation related to altered thought processes
Hostility and absence of involvement are data supporting a diagnosis of social isolation. Her
psychiatric diagnosis and her idea about the purpose of medication suggests altered
thinking processes.
8. A client is admitted with the diagnosis of meningitis. Which finding would the nurse
expect in assessing this client?
A) Hyperextension of the neck with passive shoulder flexion
B) Flexion of the hip and knees with passive flexion of the neck
C) Flexion of the legs with rebound tenderness
D) Hyperflexion of the neck with rebound flexion of the legs
The correct answer is B: Flexion of the hip and knees with passive flexion of the neck. A
positive Brudzinski’s sign—flexion of hip and knees with passive flexion of the neck; a
positive Kernig’s sign—inability to extend the knee to more than 135 degrees, without pain
behind the knee, while the hip is flexed usually establishes the diagnosis of meningitis.
9. Post-procedure nursing interventions for electroconvulsive therapy include
A) Applying hard restraints if seizure occurs
B) Expecting client to sleep for 4 to 6 hours
C) Remaining with client until oriented
D) Expecting long-term memory loss
The correct answer is C: Remaining with client until oriented
Client awakens post-procedure 20-30 minutes after treatment and appears groggy and
confused. The nurse remains with the client until the client is oriented and able to engage in
self care.
10. The nurse is talking to parents about nutrition in school aged children. Which of the
following is the most common nutritional disorder in this age group?
A) Bulimia
B) Anorexia
C) Obesity
D) Malnutrition
The correct answer is C: Obesity
Many factors contribute to the high rate of obesity in school aged children. These include
heredity, sedentary lifestyle, social and cultural factors and poor knowledge of balanced
nutrition.
11. The nurse assesses a client who has been re-admitted to the psychiatric in-patient unit
for schizophrenia. His symptoms have been managed for several months with fluphenazine
(Prolixin). Which should be a focus of the first assessment?
A) Stressors in the home
B) Medication compliance
C) Exposure to hot temperatures
D) Alcohol use
The correct answer is B: Medication compliance
Prolixin is an antipsychotic / neuroleptic medication useful in managing the symptoms of
Schizophrenia. Compliance with daily doses is a critical assessment.
12. The nurse admits a client newly diagnosed with hypertension. What is the best method
for assessing the blood pressure?
A) Standing and sitting
B) In both arms
C) After exercising
D) Supine position
The correct answer is B: In both arms
Blood pressure should be taken in both arms due to the fact that one subclavian artery may
be stenosed, causing a false high in that arm.
13. The nurse is caring for a client who has developed cardiac tamponade. Which finding
would the nurse anticipate?
A) Widening pulse pressure
B) Pleural friction rub
C) Distended neck veins
D) Bradycardia
The correct answer is C: Distended neck veins
In cardiac tamponade, intrapericardial pressures rise to a point at which venous blood
cannot flow into the heart. As a result, venous pressure rises and the neck veins become
distended.
14. At the geriatric day care program a client is crying and repeating "I want to go home.
Call my daddy to come for me." The nurse should
A) Invite the client to join the exercise group
B) Tell the client you will call someone to come for her
C) Give the client simple information about what she will be doing
D) Firmly direct the client to her assigned group activity
The correct answer is C: Give the client simple information about what she will be doing.
The distressed disoriented client should be gently oriented to reduce fear and increase the
sense of safety and security. Environmental changes provoke stress and fear.
15. When teaching adolescents about sexually transmitted diseases, what should the nurse
emphasize that is the most common infection?
A) Gonorrhea
B) Chlamydia
C) Herpes
D) HIV
The correct answer is B: Chlamydia
Chlamydia has the highest incidence of any sexually transmitted disease in this country.
Prevention is similar to safe sex practices taught to prevent any STD: use of a condom and
spermicide for protection during intercourse.
16. A 38 year-old female client is admitted to the hospital with an acute exacerbation of
asthma. This is her third admission for asthma in 7 months. She describes how she doesn't
really like having to use her medications all the time. Which explanation by the nurse best
describes the long-term consequence of uncontrolled airway inflammation?
A) Degeneration of the alveoli
B) Chronic bronchoconstriction of the large airways
C) Lung remodeling and permanent changes in lung function
D) Frequent pneumonia
The correct answer is C: Lung remodeling and permanent changes in lung function
While an asthma attack is an acute event from which lung function essentially returns to
normal, chronic under-treated asthma can lead to lung remodeling and permanent changes
in lung function. Increased bronchial vascular permeability leads to chronic airway edema
which leads to mucosal thickening and swelling of the airway. Increased mucous secretion
and viscosity may plug airways, leading to airway obstruction. Changes in the extracellular
matrix in the airway wall may also lead to airway obstruction. These long-term
consequences should help you to reinforce the need for daily management of the disease
whether or not the patient "feels better".
17. The mother of a 15 month-old child asks the nurse to explain her child's lab results and
how they show her child has iron deficiency anemia. The nurse's best response is
A) "Although the results are here, your doctor will explain them later."
B) "Your child has less red blood cells that carry oxygen."
C) "The blood cells that carry nutrients to the cells are too large."
D) "There are not enough blood cells in your child's circulation."
The correct answer is B: "Your child has less red blood cells that carry oxygen." The results
of a complete blood count in clients with iron deficiency anemia will show decreased red
blood cell levels, low hemoglobin levels and microcytic, hypochromic red blood cells. A
simple but clear explanation is appropriate.
18. Privacy and confidentiality of all client information is legally protected. In which of these
situations would the nurse make an exception to this practice?
A) When a family member offers information about their loved one
B) When the client threatens self-harm and harm to others
C) When the health care provider decides the family has a right to know the client's
diagnosis
D) When a visitor insists that the visitor has been given permission by the client
The correct answer is B: When the client threatens self-harm and harm to others. Privacy
and confidentiality of all client information is protected with the exception of the client who
threatens self harm or endangering the public.
19. At a well baby clinic the nurse is assigned to assess an 8 month-old child. Which of
these developmental achievements would the nurse anticipate that the child would be able
to perform?
A) Say 2 words
B) Pull up to stand
C) Sit without support
D) Drink from a cup
The correct answer is C: Sit without support
The age at which the normal child develops the ability to sit steadily without support is 8
months.
20. First-time parents bring their 5 day-old infant to the pediatrician's office because they
are extremely concerned about its breathing pattern. The nurse assesses the baby and finds
that the breath sounds are clear with equal chest expansion. The respiratory rate is 38-42
breaths per minute with occasional periods of apnea lasting 10 seconds in length. What is
the correct analysis of these findings?
A) The pediatrician must examine the baby
B) Emergency equipment should be available
C) This breathing pattern is normal
D) A future referral may be indicated
The correct answer is C: This breathing pattern is normal
Respiratory rate in a newborn is 30-60 breaths/minute and periods of apnea often occur,
lasting up to 15 seconds. The nurse should reassure the parents that this is normal to allay
their anxiety.
21. A 30 month-old child is admitted to the hospital unit. Which of the following toys would
be appropriate for the nurse to select from the toy room for this child?
A) Cartoon stickers
B) Large wooden puzzle
C) Blunt scissors and paper
D) Beach ball
The correct answer is B: Large wooden puzzle
Appropriate toys for this child''s age include items such as push-pull toys, blocks, pounding
board, toy telephone, puppets, wooden puzzles, finger paint, and thick crayons.
22. A 2 year-old child has just been diagnosed with cystic fibrosis. The child's father asks
the nurse "What is our major concern now, and what will we have to deal with in the
future?" Which of the following is the best response?
A) "There is a probability of life-long complications."
B) "Cystic fibrosis results in nutritional concerns that can be dealt with."
C) "Thin, tenacious secretions from the lungs are a constant struggle in cystic
fibrosis."
D) "You will work with a team of experts and also have access to a support group that the
family can attend."
The correct answer is C: "Thin, tenacious secretions from the lungs are a constant struggle
in cystic fibrosis." All of the options will be concerns with cystic fibrosis, however the
respiratory threats are the major concern in these clients. Other information of interest is
that cystic fibrosis is an autosomal recessive disease. There is a 25% chance that each of
these parent''s pregnancies will result in a child with systic fibrosis.
23. A mother asks the nurse if she should be concerned about the tendency of her child to
stutter. What assessment data will be most useful in counseling the parent?
A) Age of the child
B) Sibling position in family
C) Stressful family events
D) Parental discipline strategies
The correct answer is A: Age of the child
During the preschool period children are using their rapidly growing vocabulary faster than
they can produce their words. This failure to master sensorimotor integrations results in
stuttering. This dysfluency in speech pattern is a normal characteristic of language
development. Therefore, knowing the child''s age is most important in determining if any
true dysfunction might be occurring.
24. During an examination of a 2 year-old child with a tentative diagnosis of Wilm's tumor,
the nurse would be most concerned about which statement by the mother?
A) My child has lost 3 pounds in the last month.
B) Urinary output seemed to be less over the past 2 days.
C) All the pants have become tight around the waist.
D) The child prefers some salty foods more than others.
The correct answer is C: Clothing has become tight around the waist
Parents often recognize the increasing abdominal girth first. This is an early sign of Wilm''s
tumor, a malignant tumor of the kidney.
25. A client is admitted with a pressure ulcer in the sacral area. The partial thickness wound
is 4cm by 7cm, the wound base is red and moist with no exudate and the surrounding skin
is intact. Which of the following coverings is most appropriate for this wound?
A) Transparent dressing
B) Dry sterile dressing with antibiotic ointment
C) Wet to dry dressing
D) Occlusive moist dressing
The correct answer is D: Occlusive moist dressing
This wound has granulation tissue present and must be protected. The use of a moisture
retentive dressing is the best choice because moisture supports wound healing.
26. A 65-year-old Hispanic-Latino client with prostate cancer rates his pain as a 6 on a 0-to10 scale. The client refuses all pain medication other than Motrin, which does not relieve his
pain. The next action for the nurse to take is to
A) Ask the client about the refusal of certain pain medications
B) Talk with the client's family about the situation
C) Report the situation to the health care provider
D) Document the situation in the notes
The correct answer is A: Ask the client about the refusal of certain pain medications. Beliefs
regarding pain are one of the oldest culturally related research areas in health care. Astute
observations and careful assessments must be completed to determine the level of pain a
person can tolerate. Health care practitioners must investigate the meaning of pain to each
person within a cultural explanatory framework.
27. The nurse is caring for a client with an unstable spinal cord injury at the T7 level. Which
intervention should take priority in planning care?
A) Increase fluid intake to prevent dehydration
B) Place client on a pressure reducing support surface
C) Use skin care products designed for use with incontinence
D) Increase caloric intake to aid healing
The correct answer is B: Place client on a pressure reducing support surface
This client is at greatest risk for skin breakdown because of immobility and decreased
sensation. The first action should be to choose and then place the client on the best support
surface to relieve pressure, shear and friction forces.
28. A client is experiencing hallucinations that are markedly increased at night. The client is
very frightened by the hallucinations. The client’s partner asked to stay a few hours beyond
the visiting time, in the client’s private room. What would be the best response by the nurse
demonstrating emotional support for the client?
A) "No, it would be best if you brought the client some reading material that she could read
at night."
B) "No, your presence may cause the client to become more anxious."
C) "Yes, staying with the client and orienting her to her surroundings may
decrease her anxiety."
D) "Yes, would you like to spend the night when the client’s behavior indicates that she is
frightened?"
The correct answer is C: "Yes, staying with the client and orienting her to her surroundings
may decrease her anxiety."Encouraging the family or a close friend to stay with the client in
a quiet surrounding can help increase orientation and minimize confusion and anxiety.
29. The nurse is caring for residents in a long term care setting for the elderly. Which of the
following activities will be most effective in meeting the growth and development needs for
persons in this age group?
A) Aerobic exercise classes
B) Transportation for shopping trips
C) Reminiscence groups
D) Regularly scheduled social activities
The correct answer is C: Reminiscence groups
According to Erikson''s theory, older adults need to find and accept the meaningfulness of
their lives, or they may become depressed, angry, and fear death. Reminiscing contributes
to successful adaptation by maintaining self-esteem, reaffirming identity, and working
through loss.
30. Which type of accidental poisoning would the nurse expect to occur in children under
age 6?
A) Oral ingestion
B) Topical contact
C) Inhalation
D) Eye splashes
The correct answer is A: Oral ingestion
The greatest risk for young children is from oral ingestion. While children under age 6 may
come in contact with other poisons or inhale toxic fumes, these are not common.
31. A mother wants to switch her 9 month-old infant from an iron-fortified formula to whole
milk because of the expense. Upon further assessment, the nurse finds that the baby eats
table foods well, but drinks less milk than before. What is the best advice by the nurse?
A) Change the baby to whole milk
B) Add chocolate syrup to the bottle
C) Continue with the present formula
D) Offer fruit juice frequently
The correct answer is C: Continue with the present formula
The recommended age for switching from formula to whole milk is 12 months. Switching to
cow''s milk before the age of 1 can predispose an infant to allergies and lactose intolerance.
32. A nurse is conducting a community wide seminar on childhood safety issues. Which of
these children is at the highest risk for poisoning?
A) 9 month-old who stays with a sitter 5 days a week
B) 20 month-old who has just learned to climb stairs
C) 10 year-old who occasionally stays at home unattended
D) 15 year-old who likes to repair bicycles
The correct answer is B: Twenty month-old who has just learned to climb stairs. Toddlers
are at most risk for poisoning because they are increasingly mobile, need to explore and
engage in autonomous behavior.
33. The nurse assesses delayed gross motor development in a 3 year-old child. The inability
of the child to do which action confirms this finding?
A) Stand on 1 foot
B) Catch a ball
C) Skip on alternate feet
D) Ride a bicycle
The correct answer is A: Stand on 1 foot
At this age, gross motor development allows a child to balance on 1 foot.
34. The nurse is making a home visit to a client with chronic obstructive pulmonary disease
(COPD). The client tells the nurse that he used to be able to walk from the house to the
mailbox without difficulty. Now, he has to pause to catch his breath halfway through the
trip. Which diagnosis would be most appropriate for this client based on this assessment?
A) Activity intolerance caused by fatigue related to chronic tissue hypoxia
B) Impaired mobility related to chronic obstructive pulmonary disease
C) Self care deficit caused by fatigue related to dyspnea
D) Ineffective airway clearance related to increased bronchial secretions
The correct answer is A: Activity intolerance caused by fatigue related to chronic tissue
hypoxia. Activity intolerance describes a condition in which the client''s physiological
capacity for activities is compromised.
35. A nurse is caring for a client with multiple myeloma. Which of the following should be
included in the plan of care?
A) Monitor for hyperkalemia
B) Place in protective isolation
C) Precautions with position changes
D) Administer diuretics as ordered
The correct answer is C: Precautions with position changes
Because multiple myeloma is a condition in which neoplastic plasma cells infiltrate the bone
marrow resulting in osteoporosis, client’s are at high risk for pathological fractures.
36. A client was admitted to the psychiatric unit with a diagnosis of bipolar disorder. He
constantly bothers other clients, tries to help the housekeeping staff, demonstrates
pressured speech and demands constant attention from the staff. Which activity would be
best for the client?
A) Reading
B) Checkers
C) Cards
D) Ping-pong
The correct answer is D: Ping-pong
This provides an outlet for physical energy and requires limited attention.
37. What is the most important aspect to include when developing a home care plan for a
client with severe arthritis?
A) Maintaining and preserving function
B) Anticipating side effects of therapy
C) Supporting coping with limitations
D) Ensuring compliance with medications
The correct answer is A: Maintaining and preserving function
To maintain quality of life, the plan for care must emphasize preserving function. Proper
body positioning and posture and active and passive range of motion exercises important
interventions for maintaining function of affected joints.
38. A pre-term newborn is to be fed breast milk through nasogastric tube. Why is breast
milk preferred over formula for premature infants?
A) Contains less lactose
B) Is higher in calories/ounce
C) Provides antibodies
D) Has less fatty acid
The correct answer is C: Provides antibodies
Breast milk is ideal for the preterm baby who needs additional protection against infection
through maternal antibodies. It is also much easier to digest, therefore less residual is left
in the infant''s stomach.
39. Which of the following nursing assessments in an infant is most valuable in identifying
serious visual defects?
A) Red reflex test
B) Visual acuity
C) Pupil response to light
D) Cover test
The correct answer is A: Red reflex test
A brilliant, uniform red reflex is an important sign because it virtually rules out almost all
serious defects of the cornea, aqueous chamber, lens, and vitreous chamber.
40. Which nursing action is a priority as the plan of care is developed for a 7 year-old child
hospitalized for acute glomerulonephritis?
A) Assess for generalized edema
B) Monitor for increased urinary output
C) Encourage rest during hyperactive periods
D) Note patterns of increased blood pressure
The correct answer is D: Note patterns of increased blood pressure
Hypertension is a key assessment in the course of the disease.
41. The nurse should recognize that physical dependence is accompanied by what findings
when alcohol consumption is first reduced or ended?
A) Seizures
B) Withdrawal
C) Craving
D) Marked tolerance
The correct answer is B: Withdrawal
The early signs of alcohol withdrawal develop within a few hours after cessation or reduction
of alchohol intake.
42. The nurse is preparing a 5 year-old for a scheduled tonsillectomy and adenoidectomy.
The parents are anxious and concerned about the child's reaction to impending surgery.
Which nursing intervention would be best to prepare the child?
A) Introduce the child to all staff the day before surgery
B) Explain the surgery 1 week prior to the procedure
C) Arrange a tour of the operating and recovery rooms
D) Encourage the child to bring a favorite toy to the hospital
The correct answer is B: Explain the surgery 1 week prior to the procedure
A 5 year-old can understand the surgery, and should be prepared well before the procedure.
Most of these procedures are "same day" surgeries and do not require an overnight stay.
43. During the evaluation phase for a client, the nurse should focus on
A) All finding of physical and psychosocial stressors of the client and in the family
B) The client's status, progress toward goal achievement, and ongoing reevaluation
C) Setting short and long-term goals to insure continuity of care from hospital to home
D) Select interventions that are measurable and achievable within selected timeframes
The correct answer is B: The client''s status, progress toward goal achievement, and
ongoing re-evaluation. Evaluation process of the nursing process focuses on the client''s
status, progress toward goal achievement and ongoing re-evaluation of the plan of care.
44. The client who is receiving enteral nutrition through a gastrostomy tube has had 4
diarrhea stools in the past 24 hours. The nurse should
A) Review the medications the client is receiving
B) Increase the formula infusion rate
C) Increase the amount of water used to flush the tube
D) Attach a rectal bag to protect the skin
The correct answer is A: Review the medications the client is receiving
Antibiotics and medications containing sorbitol may induce diarrhea.
45. A client is receiving nitroprusside IV for the treatment of acute heart failure with
pulmonary edema. What diagnostic lab value should the nurse monitor in relation to this
medication?
A) Potassium
B) Arterial blood gasses
C) Blood urea nitrogen
D) Thiocyanate
The correct answer is D: Thiocyanate
Thiocyanate levels rise with the metabolism if nitroprusside and can cause cyanide toxicity.
46. The nurse is talking with a client. The client abruptly says to the nurse, "The moon is
full. Astronauts walk on the moon. Walking is a good health habit." The client’s behavior
most likely indicates
A) Neologisms
B) Dissociation
C) Flight of ideas
D) Word salad
The correct answer is C: Flight of ideas
Flight of ideas - defines nearly continuous flow of speech, jumping from 1 topic to another.
47. The nurse is assessing a child for clinical manifestations of iron deficiency anemia.
Which factor would the nurse recognize as cause for the findings?
A) Decreased cardiac output
B) Tissue hypoxia
C) Cerebral edema
D) Reduced oxygen saturation
The correct answer is B: Tissue hypoxia
When the hemoglobin falls sufficiently to produce clinical manifestations, the findings are
directly attributable to tissue hypoxia, a decrease in the oxygen carrying capacity of the
blood.
48. A Hispanic client in the postpartum period refuses the hospital food because it is "cold."
The best initial action by the nurse is to
A) Have the unlicensed assistive personnel (UAP) reheat the food if the client wishes
B) Ask the client what foods are acceptable or bad
C) Encourage her to eat for healing and strength
D) Schedule the dietitian to meet with the client as soon as possible
The correct answer is B: Ask the client what foods are acceptable
Many Hispanic women subscribe to the balance of hot and cold foods in the post partum
period. What defines "cold" can best be explained by the client or family.
49. In planning care for a child diagnosed with minimal change nephrotic syndrome, the
nurse should understand the relationship between edema formation and
A) Increased retention of albumin in the vascular system
B) Decreased colloidal osmotic pressure in the capillaries
C) Fluid shift from interstitial spaces into the vascular space
D) Reduced tubular reabsorption of sodium and water
The correct answer is B: Decreased colloidal osmotic pressure in the capillaries. The
increased glomerular permeability to protein causes a decrease in serum albumin which
results in decreased colloidal osmotic pressure.
50. A client is admitted with a diagnosis of hepatitis B. In reviewing the initial laboratory
results, the nurse would expect to find elevation in which of the following values?
A) Blood urea nitrogen
B) Acid phosphatase
C) Bilirubin
D) Sedimentation rate
The correct answer is C: Bilirubin
In the laboratory data provided, the only elevated level expected is bilirubin. Additional liver
function tests will confirm the diagnosis.
51. The nurse is monitoring the contractions of a woman in labor. A contraction is recorded
as beginning at 10:00 A.M. and ending at 10:01 A.M. Another begins at 10:15 A.M. What is
the frequency of the contractions?
A) 14 minutes
B) 10 minutes
C) 15 minutes
D) Nine minutes
The correct answer is C: 15 minutes
Frequency is the time from the beginning of one contraction to the beginning of the next
contraction.
52. A recovering alcoholic asked the nurse, "Will it be ok for me to just drink at special
family gatherings?" Which initial response by the nurse would be best?
A) "A recovering person has to be very careful not to lose control, therefore, confine your
drinking just at family gatherings."
B) "At your next AA meeting discuss the possibility of limited drinking with your sponsor."
C) "A recovering person needs to get in touch with their feelings. Do you want a drink?"
D) "A recovering person cannot return to drinking without starting the addiction
process over."
The correct answer is D: "The recovering person cannot return to drinking without starting
the addiction process over." Recovery is total abstinence from all drugs.
53. Which of the actions suggested to the RN by the PN during a planning conference for a
10 month-old infant admitted 2 hours ago with bacterial meningitis would be acceptable to
add to the plan of care?
A) Measure head circumference
B) Place in airborne isolation
C) Provide passive range of motion
D) Provide an over-the-crib protective top
The correct answer is A: Measure head circumference
In meningitis, assessment of neurological signs should be done frequently. Head
circumference is measured because subdural effusions and obstructive hydrocephalus can
develop as a complication of meningitis. The client will have already been on airborne
precautions and crib top applied to bed on admission to the unit.
54. A victim of domestic violence tells the batterer she needs a little time away. How would
the nurse expect that the batterer might respond?
A) With acceptance and views the victim’s comment as an indication that their marriage is
in trouble
B) With fear of rejection causing increased rage toward the victim
C) With a new commitment to seek counseling to assist with their marital problems
D) With relief, and welcomes the separation as a means to have some personal time
The correct answer is B: With fear of rejection causing increased rage toward the victim.
The fear of rejection and loss only serve to increase the batterer’s rage at his partner.
55. A nurse is assigned to a client who is a new admission for the treatment of a frontal lobe
brain tumor. Which history offered by the family members would be anticipated by the
nurse as associated with the diagnosis and communicated?
A) "My partner's breathing rate is usually below 12."
B) "I find the mood swings and the change from a calm person to being angry all
the time hard to deal with."
C) "It seems our sex life is nonexistant over the past 6 months."
D) "In the morning and evening I hear complaints that reading is next to impossible from
blurred print."
The correct answer is B: "I find the mood swings and the change from a calm person to
being angry all the time hard to deal with."
The frontal lobe of the brain controls affect, judgment and emotions. Dysfunction in this
area results in findings such as emotional lability, changes in personality, inattentiveness,
flat affect and inappropriate behavior.
56. A client who has been drinking for five years states that he drinks when he gets upset
about "things" such as being unemployed or feeling like life is not leading anywhere. The
nurse understands that the client is using alcohol as a way to deal with
A) Recreational and social needs
B) Feelings of anger
C) Life’s stressors
D) Issues of guilt and disappointment
The correct answer is C: Life’s stressors
Alcohol is used by some people to manage anxiety and stress. The overall intent is to
decrease negative feelings and increase positive feelings.
57. The nurse would expect the cystic fibrosis client to receive supplemental pancreatic
enzymes along with a diet
A) High in carbohydrates and proteins
B) Low in carbohydrates and proteins
C) High in carbohydrates, low in proteins
D) Low in carbohydrates, high in proteins
The correct answer is A: High in carbohydrates and proteins
Provide a high-energy diet by increasing carbohydrates, protein and fat (possibly as high as
40%). A favorable response to the supplemental pancreatic enzymes is based on tolerance
of fatty foods, decreased stool frequency, absence of steatorrhea, improved appetite and
lack of abdominal pain.
58. The nurse is discussing nutritional requirements with the parents of an 18 month-old
child. Which of these statements about milk consumption is correct?
A) May drink as much milk as desired
B) Can have milk mixed with other foods
C) Will benefit from fat-free cow's milk
D) Should be limited to 3-4 cups of milk daily
The correct answer is D: Should be limited to three to four cups of milk daily
More than 32 ounces of milk a day considerably limits the intake of solid foods, resulting in
a deficiency of dietary iron, as well as other nutrients.
59. A postpartum mother is unwilling to allow the father to participate in the newborn's
care, although he is interested in doing so. She states, "I am afraid the baby will be
confused about who the mother is. Baby raising is for mothers, not fathers." The nurse's
initial intervention should be what focus?
A) Discuss with the mother sharing parenting responsibilities
B) Set time aside to get the mother to express her feelings and concerns
C) Arrange for the parents to attend infant care classes
D) Talk with the father and help him accept the wife's decision
The correct answer is B: Set time aside to get the mother to express her feelings and
concerns.
Non-judgmental support for expressed feelings may lead to resolution of competitive
feelings in a new family. Cultural influences may also be revealed.
60. A client with emphysema visits the clinic. While teaching about proper nutrition, the
nurse should emphasize that the client
A) Eat foods high in sodium increases sputum liquefaction
B) Use oxygen during meals improves gas exchange
C) Perform exercise after respiratory therapy enhances appetite
D) Cleanse the mouth of dried secretions reduces risk of infection
The correct answer is B: Use oxygen during meals improves gas exchange
Clients with emphysema breathe easier when using oxygen while eating.
61. The nurse is assigned to a client who has heart failure . During the morning rounds the
nurse sees the client develop sudden anxiety, diaphoresis and dyspnea. The nurse
auscultates, crackles bilaterally. Which nursing intervention should be performed first?
A) Take the client's vital signs
B) Place the client in a sitting position with legs dangling
C) Contact the health care provider
D) Administer the PRN antianxiety agent
The correct answer is B: Place the client in a sitting position with legs dangling
Place the client in a sitting position with legs dangling to pool the blood in the legs. This
helps to diminish venous return to the heart and minimize the pulmonary edema. The result
will enhance the client’s ability to breathe. The next actions would be to contact the heath
care provider, then take the vital signs and then the administration of the antianxiety agent.
62. Based on principles of teaching and learning, what is the best initial approach to pre-op
teaching for a client scheduled for coronary artery bypass?
A) Touring the coronary intensive unit
B) Mailing a video tape to the home
C) Assessing the client's learning style
D) Administering a written pre-test
The correct answer is C: Assessing the client''s learning style
As with any anticipatory teaching, assess the client''s level of knowledge and learning style
first.
63. An eighteen month-old has been brought to the emergency room with irritability,
lethargy over 2 days, dry skin and increased pulse. Based upon the evaluation of these
initial findings, the nurse would assess the child for additional findings of
A) Septicemia
B) Dehydration
C) Hypokalemia
D) Hypercalcemia
The correct answer is B: Dehydration
Clinical findings dehydration include lethargy, irritability, dry skin, and increased pulse.
64. A nurse is doing preconceptual counseling with a woman who is planning a pregnancy.
Which of the following statements suggests that the client understands the connection
between alcohol consumption and fetal alcohol syndrome?
A) "I understand that a glass of wine with dinner is healthy."
B) "Beer is not really hard alcohol, so I guess I can drink some."
C) "If I drink, my baby may be harmed before I know I am pregnant."
D) "Drinking with meals reduces the effects of alcohol."
The correct answer is C: "If I drink, my baby may be harmed before I know I am pregnant."
Alcohol has the greatest teratogenic effect during organogenesis, in the first weeks of
pregnancy. Therefore women considering a pregnancy should not drink.
65. The nurse is performing an assessment on a child with severe airway obstruction. Which
finding would the nurse anticipate finding?
A) Retractions in the intercostal tissues of the thorax
B) Chest pain aggravated by respiratory movement
C) Cyanosis and mottling of the skin
D) Rapid, shallow respirations
The correct answer is A: Retractions in the soft tissues of the thorax
Slight intercostal retractions are normal. However in disease states, especially in severe
airway obstruction, retractions become extreme.
66. The father of an 8 month-old infant asks the nurse if his infant's vocalizations are
normal for his age. Which of the following would the nurse expect at this age?
A) Cooing
B) Imitation of sounds
C) Throaty sounds
D) Laughter
The correct answer is B: Imitation of Sounds
Imitation of sounds such as "da-da" is expected at this time.
67. The nurse is planning to give a 3 year-old child oral digoxin. Which of the following is
the best approach by the nurse?
A) "Do you want to take this pretty red medicine?"
B) "You will feel better if you take your medicine."
C) "This is your medicine, and you must take it all right now."
D) "Would you like to take your medicine from a spoon or a cup?"
The correct answer is D: "Would you like to take your medicine from a spoon or a cup?"
At 3 years of age, a child often feels a loss of control when hospitalized. Giving a choice
about how to take the medicine will allow the child to express an opinion and have some
control.
68. The nurse is providing instructions to a new mother on the proper techniques for breast
feeding her infant. Which statement by the mother indicates the need for additional
instruction?
A) "I should position my baby completely facing me with my baby's mouth in front of my
nipple."
B) "The baby should latch onto the nipple and areola areas."
C) "There may be times that I will need to manually express milk."
D) "I can switch to a bottle if I need to take a break from breast feeding."
The correct answer is D: I can switch to a bottle if I need to take a break from breast
feeding.
Babies adapt more quickly to the breast when they aren''t confused about what is put into
their mouths and its purpose. Artificial nipples do not lengthen and compress the way the
human nipples (areola) do. The use of an artificial nipple weakens the baby''s suck as the
baby decreases the sucking pressure to slow fluid flow. Babies should not be given a bottle
during the learning stage of breast feeding.
69. Which of these parents’ comment for a newborn would most likely reveal an initial
finding of a suspected pyloric stenosis?
A) I noticed a little lump a little above the belly button.
B) The baby seems hungry all the time.
C) Mild vomiting that progressed to vomiting shooting across the room.
D) Irritation and spitting up immediately after feedings.
The correct answer is C: Mild emesis progressing to projectile vomiting
Mild regurgitation or emesis that progresses to projectile vomiting is a pattern of vomiting
associated with pyloric stenosis as an initial finding. The other findings are present, though
not initial findings.
70. The nurse prepares for a Denver Screening test with a 3 year-old child in the clinic. The
mother asks the nurse to explain the purpose of the test. What is the nurse’s best response
about the purpose of the Denver?
A) It measures a child’s intelligence.
B) It assesses a child's development.
C) It evaluates psychological responses.
D) It helps to determine problems.
The correct answer is B: It assesses a child''s development.
The Denver Developmental Test II is a screening test to assess children from birth through
6 years in personal/social, fine motor adaptive, language and gross motor development. A
child experiences the fun of play during the test.
71. The school nurse suspects that a third grade child might have Attention Deficit
Hyperactivity Disorder. Prior to referring the child for further evaluation, the nurse should
A) Observe the child's behavior on at least 2 occasions
B) Consult with the teacher about how to control impulsivity
C) Compile a history of behavior patterns and developmental accomplishments
D) Compare the child's behavior with classic signs and symptoms
The correct answer is C: Compile a history of behavior patterns and developmental
accomplishments
A complete behavioral, and developmental history plays an important role in determining
the diagnosis.
72. Immediately following an acute battering incident in a violent relationship, the batterer
may respond to the partner’s injuries by
A) Seeking medical help for the victim's injuries
B) Minimizing the episode and underestimating the victim’s injuries
C) Contacting a close friend and asking for help
D) Being very remorseful and assisting the victim with medical care
The correct answer is B: Minimizing the episode and underestimating the victim’s injuries
Many abusers lack an understanding of the effect of their behavior on the victim and use
excessive minimization and denial.
73. The nurse, assisting in applying a cast to a client with a broken arm, knows that
A) The cast material should be dipped several times into the warm water
B) The cast should be covered until it dries
C) The wet cast should be handled with the palms of hands
D) The casted extremity should be placed on a cloth-covered surface
The correct answer is C: The wet cast should be handled with the palms of hands
Handle cast with palms of the hands and lift at 2 points of the extremity. This will prevent
stress at the injury site and pressure areas on the cast.
74. The nurse is caring for a toddler with atopic dermatitis. The nurse should instruct the
parents to
A) Dress the child warmly to avoid chilling
B) Keep the child away from other children for the duration of the rash
C) Clean the affected areas with tepid water and detergent
D) Wrap the child's hand in mittens or socks to prevent scratching
The correct answer is D: Wrap the child''s hand in mittens or socks to prevent scratching
A toddler with atopic dermatitis need to have fingernails cut short and covered so the child
will not be able to scratch the skin lesions, thereby causing new lesions and possible a
secondary infection.
75. In evaluating the growth of a 12 month-old child, which of these findings would the
nurse expect to be present in the infant?
A) Increased 10% in height
B) 2 deciduous teeth
C) Tripled the birth weight
D) Head > chest circumference
The correct answer is C: Tripled the birth weight
The infant usually triples his birth weight by the end of the first year of life. Height usually
increases by 50% from birth length. A 12 month- old child should have approximately 6
teeth. ( estimate number of teeth by subtracting 6 from age in months, ie 12 – 6 = 6). By
12 months of age, head and chest circumferences are approximately equal.
76. In taking the history of a pregnant woman, which of the following would the nurse
recognize as the primary contraindication for breast feeding?
A) Age 40 years
B) Lactose intolerance
C) Family history of breast cancer
D) Uses cocaine on weekends
The correct answer is D: Uses cocaine on weekends
Binge use of cocaine can be just as harmful to the breast fed newborn as regular use.
77. The nurse enters a 2 year-old child's hospital room in order to administer an oral
medication. When the child is asked if he is ready to take his medicine, he immediately
says, "No!". What would be the most appropriate next action?
A) Leave the room and return five minutes later and give the medicine
B) Explain to the child that the medicine must be taken now
C) Give the medication to the father and ask him to give it
D) Mix the medication with ice cream or applesauce
The correct answer is A: Leave the room and return five minutes later and give the
medicine
Since the nurse gave the child a choice about taking the medication, the nurse must comply
with the child''s response in order to build or maintain trust. Since toddlers do not have an
accurate sense of time, leaving the room and coming back later is another episode to the
toddler.
78. A mother asks about expected motor skills for a 3 year-old child. Which of the following
would the nurse emphasize as normal at this age?
A) Jumping rope
B) Tying shoelaces
C) Riding a tricycle
D) Playing hopscotch
The correct answer is C: Riding a tricycle
Coordination is gained through large muscle use. A child of 3 has the ability to ride a
tricycle.
79. A 4 year-old child is recovering from chicken pox (varicella). The parents would like to
have the child return to day care as soon as possible. In order to ensure that the illness is
no longer communicable, what should the nurse assess for in this child?
A) All lesions crusted
B) Elevated temperature
C) Rhinorrhea and coryza
D) Presence of vesicles
The correct answer is A: All lesions crusted
The rash begins as a macule, with fever, and progresses to a vesicle that breaks open and
then crusts over. When all lesions are crusted, the child is no longer in a communicable
stage.
80. A home health nurse is caring for a client with a pressure sore that is red, with serous
drainage, is 2 inches in diameter with loss of subcutaneous tissue. The appropriate dressing
for this wound is
A) A transparent film dressing
B) Wet dressing with debridement granules
C) Wet to dry with hydrogen peroxide
D) Moist saline dressing
The correct answer is D: Moist saline dressing
This wound is a stage III pressure ulcer. The wound is red (granulation tissue) and does not
require debridement. The wound must be protected for granulation tissue to proliferate. A
moist dressing allows epithelial tissues to migrate more rapidly.
81. A diabetic client asks the nurse why the health care provider ordered a glycolsylated
hemoglobin (HbA) measurement, since a blood glucose reading was just performed. You will
explain to the client that the HbA test:
A) Provides a more precise blood glucose value than self-monitoring
B) Is performed to detect complications of diabetes
C) Measures circulating levels of insulin
D) Reflects an average blood sugar for several months
The correct answer is D: Reflects an average blood sugar for several months Glycosolated
hemoglobin values reflect the average blood glucose (hemoglobin-bound) for the previous
3-4 months and is used to monitor client adherence to the therapeutic regimen.
82. The nurse is caring for a client with COPD who becomes dyspneic. The nurse should
A) Instruct the client to breathe into a paper bag
B) Place the client in a high Fowler's position
C) Assist the client with pursed lip breathing
D) Administer oxygen at 6L/minute via nasal cannula
The correct answer is C: Assist the client with pursed lip breathing Use pursed-lip breathing
during periods of dyspnea to control rate and depth of respiration and improve respiratory
muscle coordination.
83. A 24 year-old male is admitted with a diagnosis of testicular cancer. The nurse would
expect the client to have
A) Scrotal discoloration
B) Sustained painful erection
C) Inability to achieve erection
D) Heaviness in the affected testicle
The correct answer is D: Heaviness in the affected testicle
The feeling of heaviness in the scrotum is related to testicular cancer and not epididymitis.
Sexual performance and related issues are not affected at this time.
84. After successful alcohol detoxification, a client remarked to a friend, "I’ve tried to stop
drinking but I just can’t, I can’t even work without having a drink." The client’s belief that
he needs alcohol indicates his dependence is primarily
A) Psychological
B) Physical
C) Biological
D) Social-cultural
The correct answer is A: Psychological
With psychological dependence, it is the client ‘s thoughts and attitude toward alcohol that
produces craving and compulsive use.
85. The nurse is planning care for a 2 year-old hospitalized child. Which of the following will
produces the most stress at this age?
A) Separation anxiety
B) Fear of pain
C) Loss of control
D) Bodily injury
The correct answer is A: Separation anxiety
While a toddler will experience all of the stresses, separation from parents is the major
stressor.
86. A 9 year-old is taken to the emergency room with right lower quadrant pain and
vomiting. When preparing the child for an emergency appendectomy, what must the nurse
expect to be the child's greatest fear?
A) Change in body image
B) An unfamiliar environment
C) Perceived loss of control
D) Guilt over being hospitalized
The correct answer is C: Perceived loss of control
For school age children, major fears are loss of control and separation from friends/peers.
87. In preparing medications for a client with a gastrostomy tube, the nurse should contact
the health care provider before administering which of the following drugs through the tube?
A) Cardizem SR tablet (diltiazem)
B) Lanoxin liquid
C) Os-cal tablet (calcium carbonate)
D) Tylenol liquid (acetaminophen)
The correct answer is A: Cardizem SR tablet (diltiazem)
Cardizem SR is a "sustained-release" drug form. Sustained release (controlled-release;
long-acting) drug formulations are designed to release the drug over an extended period of
time. If crushed, as would be required for gastrostomy tube administration, sustainedrelease properties and blood levels of the drug will be altered. The health care provider
must substitute another medication.
88. The nurse is assigned to care for a client newly diagnosed with angina. As part of
discharge teaching, it is important to remind the client to remove the nitroglycerine patch
after 12 hours in order to prevent what condition?
A) Skin irritation
B) Drug tolerance
C) Severe headaches
D) Postural hypotension
The correct answer is B: Drug tolerance
Removing a nitroglycerine patch for a period of 10-12 hours daily prevents tolerance to the
drug, which can occur with continuous patch use.
89. What is the major developmental task that the mother must accomplish during the first
trimester of pregnancy?
A) Acceptance of the pregnancy
B) Acceptance of the termination of the pregnancy
C) Acceptance of the fetus as a separate and unique being
D) Satisfactory resolution of fears related to giving birth
The correct answer is A: Acceptance of the pregnancy
During the first trimester the maternal focus is directed toward acceptance of the pregnancy
and adjustment to the minor discomforts.
90. The nurse is caring for a depressed client with a new prescription for an SSRI
antidepressant. In reviewing the admission history and physical, which of the following
should prompt questions about the safety of this medication?
A) History of obesity
B) Prescribed use of an MAO inhibitor
C) Diagnosis of vascular disease
D) Takes antacids frequently
The correct answer is B: Prescribed use of an MAO inhibitor
SSRIs should not be taken concurrently with MAO inhibitors because serious, lifethreatening reactions may occur with this combination of drugs.
91. The nurse detects blood-tinged fluid leaking from the nose and ears of a head trauma
client. What is the appropriate nursing action?
A) Pack the nose and ears with sterile gauze
B) Apply pressure to the injury site
C) Apply bulky, loose dressing to nose and ears
D) Apply an ice pack to the back of the neck
The correct answer is C: Apply bulky, loose dressing to nose and ears.
Applying a bulky, loose dressing to the nose and ears permits the fluid to drain and provides
a visual reference for the amount of drainage.
92. A nurse aide is taking care of a 2 year-old child with Wilm's tumor. The nurse aide asks
the nurse why there is a sign above the bed that says DO NOT PALPATE THE ABDOMEN?
The best response by the nurse would be which of these statements?
A) "Touching the abdomen could cause cancer cells to spread."
B) "Examining the area would cause difficulty to the child."
C) "Pushing on the stomach might lead to the spread of infection."
D) "Placing any pressure on the abdomen may cause an abnormal experience."
The correct answer is A: "Touching the abdomen could cause cancer cells to spread."
Manipulation of the abdomen can lead to dissemination of cancer cells to nearby and distant
areas. Bathing and turning the child should be done carefully. The other options are similar
but not the most specific.
93. The nurse is caring for a client with a deep vein thrombosis. Which finding would require
the nurse's immediate attention?
A) Temperature of 102 degrees Fahrenheit
B) Pulse rate of 98 beats per minute
C) Respiratory rate of 32
D) Blood pressure of 90/50
The correct answer is C: Respiratory rate of 32
Clients with deep vein thrombosis are at risk for the development of pulmonary embolism.
The most common symptoms are tachypnea, dyspnea, and chest pain.
94. A client admits to benzodiazepine dependence for several years. She is now in an
outpatient detoxification program. The nurse must understand that a priority during
withdrawal is
A) Avoid alcohol use during this time
B) Observe the client for hypotension
C) Abrupt discontinuation of the drug
D) Assess for mild physical symptoms
The correct answer is A: Avoid alcohol use during this time
Central nervous system depressants interact with alcohol. The client will gradually reduce
the dosage, under the health care provider''s direction. During this time, alcohol must be
avoided
95. The nurse will administer liquid medicine to a 9 month-old child. Which of the following
methods is appropriate?
A) Allow the infant to drink the liquid from a medicine cup
B) Administer the medication with a syringe next to the tongue
C) Mix the medication with the infant's formula in the bottle
D) Hold the child upright and administer the medicine by spoon
The correct answer is B: Administer the medication with a syringe next to the tongue
Using a needle-less syringe to give liquid medicine to an infant is often the safest method. If
the nurse directs the medicine toward the side or the back of the mouth, gagging will be
reduced.
96. A client refuses to take the medication prescribed because the client prefers to take selfprescribed herbal preparations. What is the initial action the nurse should take?
A) Report the behavior to the charge nurse
B) Talk with the client to find out about the preferred herbal preparation
C) Contact the client's health care provider
D) Explain the importance of the medication to the client
The correct answer is B: Talk with the client to find out about the preferred herbal
preparation
Respect for differences is demonstrated by incorporating traditional cultural practices for
staying healthy into professional prescriptions and interventions. The challenge for the
health-care provider is to understand the client''s perspective. "Culture care preservation or
maintenance refers to those assistive, supporting, facilitative or enabling professional
actions and decisions that help people of a particular culture to retain and/or preserve
relevant care values to that they can maintain their well-being, recover from illness or face
handicaps and/or death".
97. The nurse is teaching diet restrictions for a client with Addison's disease. The client
would indicate an understanding of the diet by stating
A) "I will increase sodium and fluids and restrict potassium."
B) "I will increase potassium and sodium and restrict fluids."
C) "I will increase sodium, potassium and fluids."
D) "I will increase fluids and restrict sodium and potassium."
The correct answer is A: "I will increase sodium and fluids and restrict potassium."
The manifestation of Addison''s disease due to mineralocorticoid deficiency resulting from
renal sodium wasting and potassium retention include dehydration, hypotension,
hyponatremia, hyperkalemia and acidosis.
98. A nurse arranges for a interpreter to facilitate communication between the health care
team and a non-English speaking client. To promote therapeutic communication, the
appropriate action for the nurse to remember when working with an interpreter is to
A) Promote verbal and nonverbal communication with both the client and the
interpreter
B) Speak only a few sentences at a time and then pause for a few moments
C) Plan that the encounter will take more time than if the client spoke English
D) Ask the client to speak slowly and to look at the person spoken to
The correct answer is A: Promote verbal and nonverbal communication with both the client
and the interpreter
The nurse should communicate with the client and the family, not with the interpreter.
Culturally appropriate eye contact, gestures, and body language toward the client and
family are important factors to enhance rapport and understanding. Maintain eye contact
with both the client and interpreter to elicit feedback and read nonverbal cues
99. The most common reason for an Apgar score of 8 and 9 in a newborn is an abnormality
of what parameter?
A) Heart rate
B) Muscle tone
C) Cry
D) Color
The correct answer is D: Color
Acrocyanosis (blue hands and feet) is the most common Apgar score deduction, and is a
normal adaptation in the newborn.
100. The nurse is caring for several 70 to 80 year-old clients on bed rest. What is the most
important measure to prevent skin breakdown?
A) Massage legs frequently
B) Frequent turning
C) Moisten skin with lotions
D) Apply moist heat to reddened areas
The correct answer is B: Frequent turning
Frequent turning will prevent skin breakdown.
Nursing Practice (Integrated Exam) with Answer Keys
Nursing Practice (Integrated Exam)
Degree of Question’s Difficulty
(3) – Difficult question
(2) – Average question
(1) – Easy question
Situation 1: Mr. Santiago has a long history of smoking; he is currently diagnosed with
COPD. He is admitted for a pulmonary work up.
1. His arterial blood gas results are PO2 of 85, PCO2 of 40 and HCO3 of 24. Which of the
following should be initiated? (3)
a. Administer O2 at 2L to prevent him from becoming hypoxic.
b. No action is necessary; this is within normal range for a COPD client.
c. Anticipate the development of metabolic acidosis and administer Na HCO3.
d. Position him in high Fowler’s and anticipate him to need assisted ventilation
2. He finds that after smoking or exercise, he experiences difficulty of breathing, headaches
and nausea. These are symptoms of: (2)
a. Increased level of carbon dioxide
b. Decreased level of arterial oxygen
c. Decreased level of carbon dioxide
d. Very rapid breathing and metabolic acidosis
3. To encourage proper breathing exercises, which of the following should the nurse teach?
(1)
a. Encourage pursed lip breathing
b. Inhalation should be 2 to 3x that of exhalation
c. Encourage high abdominal breathing using the muscles of the diaphragm
d. Inhale through the mouth and out through the nose.
4. Which set of blood gases would indicate respiratory acidosis? (2)
a. pH 7.0; PCO2 42mmHg; HCO3 21mEq/L
b. pH 7.46; PCO2 38mmHg; HCO3 28mEq/L
c. pH 7.35; PCO2 44mmHg; HCO3 25mEq/L
d. pH 7.32; PCO2 48mmHg; HCO3 22mEq/L
5. He is to receive an IV of Lactated Ringer’s, 1000 cc to run for 8 hours. The drip factor is
10 gtt/cc. How many drops per minute should you regulate the IV? (1)
a. 24 gtt/min
b. 12 gtt/min
c. 21 gtt/min
d. 30 gtt/min
Situation 2: Nurse Jeddah is the staff nurse assigned in the Medical Ward of a secondary
hospital.
6. The physician ordered reverse isolation for Mr. Perez with second degree burns. While
performing reverse isolation technique, Nurse Freud should understand that: (2)
a. it is not necessary to use sterile linen if the linen has been properly washed.
b. only some persons who come in direct contact with the client need to wear gloves
andmask
c. sterile gown and gloves must be worn while caring for Mr. Perez
d. it is not necessary to wear a mask
7. During the stage of diuresis, there is resorption of fluid into the intravascular
compartment and increase urinary output. Which electrolyte imbalance is most frequently
associated with this stage? (3)
a. hypernatremia, hyperkalemia, carbonic acid deficit
b. hyponatremia, hyperkalemia, bicarbonate excess
c. hyponatremia, hypokalemia, bicarbonate deficit
d. hypernatremia, hypokalemia, carbonic acid excess
8. The priority nursing care for patient suffering from stroke during acute phase is to: (3)
a. maintain respiratory and cardiac functions
b. prevent contracture and deformities
c. maintain optimal nutrition
d. provide sensory stimulation
9. The nurse in the clinic would assess a 4-month-old who is in acute respiratory distress
when which of the following is observed? (2)
a. resting respiratory rate of 35 breaths/min
b. flaring of nares
c. diaphragmatic respiration
d. bilateral breath sounds
10. In assessing patient for signs of impending respiratory failure, an early symptom that
the nurse should look for is: (1)
a. Kussmaul’s respiration
b. cyanosis
c. tachypnea
d. bradypnea
Situation 4: Nurse Kitchie is caring to clients with tuberculosis at San Lazaro Hospital
11. Which of the following symptoms is common in clients with tuberculsosis? (1)
a. Mental status changes
b. Increased appetite
c. Dyspnea on exertion
d. Weight loss
12. Nurse Kitchie obtains a sputum specimen from a client for laboratory study. Which of he
following laboratory techniques is most commonly used to identify tubercle bacilli in
sputum? (1)
a. Dark-field illumination
b. Sensitivity Testing
c. Acid – fast staining
d. Agglutination
13. A client has a positive Mantoux test. Nurse Kitchie correctly interprets this reaction to
mean that the client has: (2)
a. active tuberculosis
b. had contact with Mycobacterium tuberculosis
c. developed a resistance to tubercle bacilli
d. developed passive immunity to tuberculosis
14. Nurse Kitchie should teach clients that the most common route of transmitting tubercle
bacilli from person to person is through contaminated: (1)
a. dust particles
b. droplet nuclei
c. water
d. eating utensils
15. The client is to be discharged home with a community health nursing follow – up. Of the
following interventions, which would have the highest priority? (2)
a. Offering the client emotional support
b. Teaching the client about the disease and treatment
c. Coordinating various agency services
d. Assessing the clients environment for sanitation
Situation 4 Mang Tomas with advanced chronic obstructive pulmonary disease (COPD)
reports steady weight loss and being “is too tired from just breathing to eat, is admitted in
the hospital.
16. Which of the following physical assessment findings would Nurse Pepsi expect to find for
Mang Tomas? (2)
a. Increased anteroposterior chest diameter
b. Underdeveloped neck veins
c. Collapsed neck veins
d. Increased chest excursions with respiration
17. Which of the following nursing diagnoses would be most appropriate when planning
nutritional interventions? (1)
a. Altered Nutrition: Less than body requirements r/t fatigue
b. Activity Intolerance r/t dyspnea
c. Weight loss related to COPD
d. Ineffective breathing pattern r/t alveolar hypoventilation
18. Nurse Pepsi’s priority goal for Mang Tomas is: (2)
a. Maintaining functional ability
b. Minimizing chest pain
c. Increasing carbon dioxide levels in the blood
d. Treating infectious agents
19. Which of the following diets would be most appropriate for Mang Tomas? (2)
a. Low fat, low cholesterol
b. Bland, soft diet
c. High calorie, high CHON
d. Low sodium diet
20. When developing a discharge plan to manage the care for Mang Tomas, Nurse Pepsi
should anticipate that the client will do which of the following? (3)
a. Develop infections easily
b. Maintain current status
c. Require less supplemental oxygen
d. Show permanent improvement
Situation 5: Tuberculosis (TB) has been declared a global emergency in 1993 by the WHO.
21. TB ranks sixth in the leading causes of morbidity. Nurse Miranda recognizes that the
most hazardous periods for development of clinical disease is: (1)
a. 1 year
b. 2 ½ years
c. 3 months
d. 6 months
22. Which of the following statements is the primary preventive measure for PTB? (2)
a. Provide public health nursing and outreach services
b. BCG vaccination of newborn, infants and grade 1 or school entrants
c. Make available medical, laboratory and x –ray facilities
d. Educate the public in mode of spread and methods of control
23. The source of infection in PTB is through which of the following? (1)
a. Contamination of potable water
b. Direct connection with injected persons
c. Crowded living patterns
d. Sexual intercourse
24. In TB control program, DOH has specific objectives, one on prevention is another
program focused on children. Which one below is the program? (1)
a. Sputum collection and examination
b. Tuberculin for skin testing
c. EPI for BCG vaccine
d. Maternal and child health nursing
25. BCG is given to protect the baby from infection at what age? (1)
a. At birth
b. At 1 month
c. At 2 month
d. At 9 month
Situation 6: The national objectives for maintaining the health of all Filipinos is a primary
responsibility of the Department of Health.
26. The Department of Health Program has a mission which includes all of the following,
except: (1)
a. Ensure accessibility
b. Quality of health care
c. Improve quality of life
d. Health for all Filipinos in the year 2020
27. Which of the following are primary strategies to achieve health goals? (1)
a. Assurance of health care
b. Development of national standards and objectives
c. Support to local health system development
d. All of the above
28. Which of the following statements best describes the DOH vision? (1)
a. Ensure accessibility
b. Achievement of quality health care for all
c. Health for all Filipinos
d. Promotion of health education
29. Which of the following is the mission of the DOH? (1)
a. Promote healthy lifestyle
b. Ensure accessibility and quality of health care
c. Reduce morbidity and mortality
d. Improve general heath status of the people
30. Which of the following is not a primary strategy to achieve health goals? (1)
a. Support of local health system
b. Development of national standards for health
c. Assurance of health care for all
d. Funding from non – government organizations
3Situation 7: Asthma results in diffuse obstructive and restrictive airway disease of
inflammation and bronchoconstriction. With increasing pollution in our environment, both
children and adults are now affected with asthma.
31. As a nurse you know that there are many elements that provoke the attack. Which
among the elements is a common allergen to both the children and adult patients? (1)
a. Cigarette smoke
b. Dust – mite
c. Perfume
d. Flowers
32. If a child has asthma, what nursing diagnosis can you make that will direct your nursing
intervention? (2)
a. Parental anxiety r/t respiratory distress in child
b. Child fear r/t asthma
c. Impaired breathing mechanisms r/t bronschospasm
d. Fatigue r/t respiratory distress
33. As a nurse, what body organs and sense can you utilize in rural areas that can crudely
assess presence of asthma in children? (2)
a. heart, eyes and ears
b. eyes and mind
c. eyes, ears and touch
d. ears and heart
34. In case of asthmatic attack, what position can a nurse advise patients to take? (1)
a. Semi – fowler’s
b. Sitting
c. Lying down in bed
d. Prone lying
35. Of what use is the Peak Expiratory Low Rate (PEFR) as a monitoring device for nurses?
(3)
a. Guide to respiratory therapy with medications
b. Help in planning of an appropriate therapeutic regimen
c. Monitor breathing capacity
d. Know adequate transfer of gases across alveolar capillaries
Situation 8: Fear and anxiety are conditions that bring about acid-base imbalances.
36. What is the primary nursing responsibility when a patient presents respiratory distress?
(2)
a. Get ready with complete ECG cart at the side
b. Life-threatening measures are readied
c. History taking and keen assessment of respiratory problem
d. Positioning and oxygen therapy on hand
37. When a patient is fearful and anxious, what is the condition indicative of? (3)
a. Respiratory alkalosis
b. Metabolic acidosis
c. Metabolic alkalosis
d. Respiratory acidosis
38. When a patient shows manifestation of an acid-base imbalance, what is the nursing
responsibility? (2)
a. Explain procedure and protocol of care
b. Take arterial blood gases every hour
c. Assess respiratory and neurologic status every 2-4 hours
d. Administer medication to help ventilation
39. Chow, 2-year-old has difficulty of breathing without any previous cause. What can a
nurse do at this very moment? (2)
a. Positional nursing care – head part higher
b. Administer oxygen and fluids
c. Hook to mechanical ventilation
d. Monitor intake and output
40. If Chow asks for food and drink, which among the following will you give him? (3)
a. Soft drinks
b. Ice cream
c. Hot milk and crackers
d. Warm congee
Situation 9: “Acute Respiratory Infection (ARI) especially pneumonia leads as the cause of
illness and death among Filipino children”, claims the Department of Health.
41. Which of the following is the main factor that contributes to the problem of getting sick
of pneumonia among children below 5 years old? (3)
a. Poor follow-up compliance to treatment
b. Lack of advocates to gain local government support
c. Inability of health worker to refer immediate treatment
d. Failure of mother to recognize early signs and symptoms
42. What is the program mandated to reduced mortality of acute respiratory illness? (1)
a. Pneumonia control program
b. Stop pneumonia
c. Control of ARI (CARI)
d. “Ask, Look and Listen”
43. Which classification of pneumonia has the child if 3 or more danger signs are present?
(2)
a. Severe
b. Pneumonia
c. No Pneumonia
d. Very severe
44. When the child is to receive antibiotic, where should the first dose be given? (1)
a. In the school
b. In the health center
c. In the home
d. In the referral system
45. Which of the following is your topic for health teaching to mothers of children with
pneumonia? (2)
a. Breastfeeding
b. Family planning
c. Use of Assess Card
d. Play therapy
Situation 10: The Tochan family is in crisis situation. Mr. Tochan, 60-year-old has
emphysema and is in ZMDH. He was admitted last September 5, 2006. His wife Vina, 50year-old is taking care of her husband in the hospital. He is under close observation with O2
inh/NC @ 2LPM.
46. Upon auscultation, rales are heard in Mr. Tochan’s left lower lung segment. One of the
orders in the care and treatment of Mr. Tochan was postural drainage once a day. To
perform the procedure it would involve placing Mr. Tochan on: (2)
a. back with a pillow under his hips
b. left side with a pillow under his hips
c. right side with a pillow under his hips
d. abdomen with a pillow under his chest
47. Mr. Tochan’s condition resulted in COPD. His blood pH is 7.33 and he is restless.
Accordingly, her nursing care plan should include: (3)
a. increasing his O2 flow rate
b. removing his secretions from his respiratory tract
c. limiting his fluid intake
d. administering hypnotics as ordered
48. Most of the time Mr. Tochan is allowed to rest. At 12 noon CBC & ABG were done. The
results showed PaO2 - 92%, PCO2 - 46, RBC- 4.8 mx10, WBC - 11000, Hgb.-12g/dl. The
best nursing action would be: (2)
a. monitor Mr. Tochan
b. Increase O2 inh
c. call the MD
d. start an antibiotic
449. He complained of inability to produce sputum. “I feel I have something in my lungs
that I need to cough out.” Nurse Pia would be most helpful if she: (2)
a. calls the physician
b. administer mucolytic
c. give health teaching
d. limit fluid intake
50. Chest physiotherapy and deep breathing exercises were encouraged for Mr. Tochan.
When is the most appropriate time to perform such procedure? (1)
a. after lunch, before napping
b. before breakfast
c. after breakfast, before am care
d. time element is not important
Situation 11: At around 7:30 am the following day, Nurse Pia endorsed Mr. Tochan to Nurse
Vega as having a temperature reading of 38.8ºC/ax. She also endorsed that he’d been
restless during the night.
51. The most appropriate nursing action would be: (3)
a. check vital signs
b. call the physician
c. administer cooling measures
d. administer antipyretics
52. One of the nurses came at the bedside of Mr. Tochan and states: “You look like you are
having difficulty of breathing.” The nurse’s statement is: (3)
a. appropriate because difficulty of breathing is expected from COPD
b. appropriate because it states what the nurse is observing
c. inappropriate because the nurse made a conclusion without validating
d. inappropriate because the nurse should wait for the client to speak first
53. Later that day, Mr. Tochan had bouts of productive cough. The most effective infection
control is for the nurse to: (1)
a. monitor the temperature
b. push oral fluids
c. have the client cover his mouth when coughing
d. do not allow visitors for the client
54. In respiratory infection, the sputum is highly contagious. In the chain of infection the
sputum is: (1)
a. portal of entry
b. infectious agent
c. reservoir
d. portal of exit
55. The following conversation took place at Mr. Tochan’s bedside while the morning shift
nurse was making her rounds:
Nurse: “Mr. Tochan, I will be teaching you deep breathing exercises.”
Tochan: “I would prefer that we wait for my wife. She knows what to do.”
Nurse: “You should not rely on your wife. I will show you how to do it effectively.”
The nurse’s last statement is: (2)
a. displaying a value of judgment
b. appropriate because it encourage independence
c. the client must realize that the wife has other things to do
d. inappropriate because patients are always right
Situation 12: The Department of Health promotes use of herbal drugs. As a public health
nurse, you implement the program on traditional medicine in the community.
56. To promote the use of herbal medicines, which of the following projects would you
encourage the people in the community to do? (1)
a. Backyard herbal gardening
b. Plant a tree today
c. Save Mother Earth
d. Clean and Green
57. Which of the following herbal plants is used for respiratory problems such as asthma,
cough and fever? (1)
a. Lagundi
b. Sambong
c. Niyog-niyogan
d. Yerba Buena
58. Which of the following aromatic herbs for body pain, rheumatism and arthritis is used by
older persons? (1)
a. Sambong
b. Yerba Buena
c. Carmona-rosa
d. Alusimang Bato
59. Which of the following herbal plants is used for mild non-insulin dependent diabetes
mellitus? (1)
a. Alusimang Bato
b. Bawang
c. Carmona-rosa
d. Ampalaya
60. In the use of herbal medicines, which of the following statement is incorrect? (2)
a. Avoid the use of insecticides as these may leave poison on plants
b. Use only the part of the plant being advocated
c. In preparation, use a clay pot and cover it while boiling at low heat
d. Follow accurate dose of suggested preparation
Situation 13: Mr. Ang Lee has chronic cough and dyspnea. Her physician made a diagnosis
of Acute Pulmonary Emphysema.
61. He has dyspnea with mild exertion. What is the probable cause of this? (2)
a. Impaired diffusion between the alveolar air and blood
b. Thrombic obstruction of pulmonary arterioles
c. Decrease tone of the diaphragm
d. Lowered oxygen carrying capacity of the RBC
62. Which of the following tissue changes is a characteristic of emphysema? (2)
a. Overdistention, inelasticity and rupture of alveoli
b. Accumulation of pus in the pleural space
c. Filling of air passage by inflammatory alveoli
d. Accumulation of fluids in the pleural sac
63. While waiting for the resident-on-duty to perform the physical examination, Mr. Lee
would be most comfortable in which position? (1)
a. Sitting on edge of bed
b. Lying flat on bed
c. Reclining in his left side
d. Supine with head elevated
64. The primary objective of your nursing care management for him is to improve her
quality of life. Which of the following would not be included in your therapeutic approach?
(3)
a. Prevention of infection
b. Prompt treatment of infection
c. Providing supportive care
d. Maintenance of a conducive environment
65. Which of the following hygienic care would be most appropriate for Mr. Lee? (2)
a. Proper care of finger and toenails
b. Not allowing him to have daily baths
c. Checking the VS every four hours
d. Providing oral care at least three times a day
5Situation 14: Mrs. Meow, 46-year-old with asthmatic attack is admitted in the medical
ward of Rico Hospital.
66. Your finding in your assessment would include the following, except: (1)
a. Ability only to speak a few words without taking a deep breath
b. Tachycardia, cool and moist skin
c. Air hunger and presence of wheezing sounds
d. Tachycardia, warm and moist skin
67. With your assessment, which of these symptoms would you expect to develop later? (2)
a. Nasal flaring
b. Lips pursed in an effort to exhale
c. Cyanosis
d. Use of accessory muscles for breathing
68. Which has the fewer tendencies to precipitate or trigger asthmatic attack? (1)
a. Air pollution
b. Cold weather
c. Changes in climate
d. Mold, house dust
69. The least of nursing care that you would do with Mrs. Meow is to: (2)
a. Give Bricanyl tablet to ease breathing
b. Keep his back always dry
c. Keep the siderails up at all times
d. Force fluids to liquefy the secretions
70. The most comfortable position for Mrs. Meow to assume during asthmatic attack is: (1)
a. Sitting
b. Orthopneic
c. Fowler’s
d. Supine
Situation 15: Mr. Kaldero, age 38, is referred to the local hospital clinic after his tuberculin
skin test was found to be positive. He is admitted for further diagnosis and evaluation.
Medications ordered for Mr. Cordero are 300 mg Isoniazid (INH) p.o. daily, 300 mg
Rifampicin p.o. daily, 100 mg Pyridoxine (Vitamin B6) p.o. daily, regular diet and bed rest.
71. Which would most likely confirm Mr. Kaldero’s diagnosis of tuberculosis? (1)
a. Creatinine kinase test
b. Chest x-ray
c. Sputum smear and culture
d. White blood cell count
72. Which clinical manifestations would the nurse expect in a patient with TB? (2)
a. Hemoptysis and weight gain
b. Productive cough and afternoon elevated temp
c. Dry cough and blood streaked sputum
d. Night sweats and urticaria
73. Which nursing activity would be most therapeutic while Mr. Kaldero is on bed rest? (2)
a. Encouraging family and friends to visit 3x a day
b. Assisting him in walking to the lounge
c. Assisting him with ROM exercises
d. Encouraging him to visit other patients
74. Possible adverse effects of Isoniazid therapy include: (2)
a. Peripheral neuritis, tachycardia, and insomnia vertigo
b. Fever and GI dysfunction
c. Hepatic dysfunction, headache and
d. Hepatic dysfunction and kidney damage
75. After a week in the hospital, Mr. Kaldero is ready for discharge. When providing
discharge instructions, the nurse should discuss all of the following, except:
a. The plan for regular follow-up care
b. The possible adverse effects of his medications
c. The need to discontinue INH if nausea occurs
d. The need to cover his nose and mouth when coughing
Situation 16: Reason Blade, R.N., is the staff nurse on duty at the Medical Ward of Aquinas
University Hospital.
76. In Bed No. 1 is Mr. Monterey, a 50-year-old client with asthma. Your nursing
management for him is: (2)
a. Administer Alevaire inhalation to soften secretions
b. Force fluids
c. Administer Bricanyl
d. Give fruit juice
77. To ease his breathing, which position would make him most comfortable? (1)
a. Dorsal recumbent
b. Sim’s
c. Orthopneic
d. Fowler’s
78. Mr. Tatad, who is in Bed No. 3 is suffering from COPD. You informed him that the most
effective bronchodilator is: (2)
a. Lukewarm lemonade
b. Deep breathing
d. Steam inhalation
d. Mild mucolytic agent
79. What diet is best recommended for him considering his existing Valsalva maneuver
problem? (2)
a. Full liquid diet
b. Bland diet
c. High in fiber and bulk
d. Soft, high in protein
80.Which of the following will not promote effective clearing of Mr. Tatad’s tracheobronchial
secretions? (2)
a. Assuming postural drainage
b. Administering Alevaire medications
c. Doing deep breathing exercises every 2 hours
d. Doing coughing technique effectively
Situation 17: In a developing country like the Philippines, accumulation of fluid in the
pleural cavity commonly results from tuberculosis.
81. Anatomically, the inner part of the thoracic cavity is lined by the parietal membrane,
while the membrane that envelops the lung is called: (1)
a. visceral membrane
b. cell membrane
c. plasma membrane
d. pulmonary membrane
82. Mang Jose is prepared for CTT. Nurse A would know that CTT stands for: (2)
a. Chest Tube Thoracostomy
b. Central Thoracic Test
c. Critical Terminal Treatment
d. Close Tube Thoracostomy
83. The correct position of Mang Jose to assume during CTT is: (1)
a. supine position
b. sitting on a chair, leaning on the back rest
c. high fowler’s with arm of affected side above the head
d. side lying on high fowler’s at the side of the bed
84. During the rounds, Nurse A noticed that the chest tube was accidentally removed by the
client. The best appropriate nursing action Nurse A should take is: (3)
a. shout for help
b. reinsert the chest tube immediately
c. apply vaselinized sterile gauze and pressure dressing and notify surgeon immediately
d. ignore it, the client can reinsert it by himself
685. Nursing responsibilities in caring for patients with CTT are the following except: (3)
a. ensure that the drainage bottle is at the level of the patient’s chest
b. monitor water-seal drainage bottle to ensure fluid level is above drain tube
c. coil tubing carefully to avoid kinking
d. prepare two clamps at bedside and take with patient when brought out of the room
Situation 18: Calamares, 25-year-old, employee was brought to the ER because of severe
allergic reaction. She complained of difficulty of breathing. Oxygen inhalation 3L was
ordered stat. Intravenous solution started.
86. Which of the following physiologic needs has the highest priority for Calamares? (1)
a. Fluid
b. Nutrition
c. Oxygen
d. Low Temperature
87. A symptomatic patient like Calamares would consider which of the following as her most
important needs? (2)
a. Relief from her health problem
b. Assistance with family and financial responsibilities
c. Understanding of her personal concern
d. Solution for the office problem
88. Illness prevention activities are generally designed to help client attain which of the
following? (2)
a. Promote habits related to good health
b. Identify disease symptoms
c. Manage stress
d. Hospitalization
89. Nurse Lavigña provided Calamares and her family with information regarding the client’s
care. This constitute as: (1)
a. Patient advocate role
b. Surrogate role
c. Educator role
d. Counselor role
90. Which of the following is the most important precautionary measure in administering
oxygen inhalation to be observed that will benefit the client in particular and hospital in
general? (2)
a. Setting up a bottle of sterile water to humidify the oxygen before it is administered to
client
b. “Crack” the oxygen tank before it is wheeled/brought to client’s room
c. Lubricate the tip of the catheter with mineral oil that is water soluble
d. Hang a “No Smoking” sign on the oxygen tank and a similar warning at the door.
Situation 19: Mr. Murdocks, a 65-year-old retired steel mill worker, is admitted to the unit
with dyspnea-upon-exertion. He has a long history of smoking. Initial assessment findings
include barrel chest, ankle edema, persistent cough with copious sputum production and
variable wheezing on expiration.
91. Mr. Murdocks’ ankle edema and respiratory problems should make the nurse suspect
hypertrophy of which heart chamber? (2)
a. Left atrium
b. Right atrium
c. Left ventricle
d. Right ventricle
92. The physician orders an Aminophylline IV drip for Mr. Murdocks. The nurse should be
alert for which sign of drug toxicity? (2)
a. Depression
b. Lethargy
c. Tachycardia
d. Cyanosis
93. ABG measurements reveal a ph of 7.25, PaCO2 of 52 mmHg and a HCO3 level of 25
mEq/L. The result indicates what acid-base imbalance? (2)
a. Respiratory alkalosis, uncompensated
b. Respiratory acidosis, uncompensated
c. Metabolic alkalosis, compensated
d. Metabolic acidosis, compensated
94. Mr. Murdocks is unable to exhale efficiently and becomes short of breath. The best
nursing intervention would be, to teach him: (1)
a. Pursed lip breathing
b. Coughing technique
c. Postural drainage
d. Relaxation technique
95. The physician orders postural drainage. Which statement about postural drainage is
most accurate? (2)
a. Postural drainage uses gravity to augment mucociliary clearing mechanisms and drain
retained secretions
b. All patients with COPD are positioned the same way during postural drainage
c. Postural drainage involves rhythmic clapping of the chest wall with cupped hands
d. postural drainage is effective only when performed for 1 hour or longer
Situation 20: Marisse, a BSN student was assigned in the medical ward. She is to administer
medication under the supervision of her clinical instructor.
96. When administering drugs, the nurse compares the label of the drug container with the
medicine card correctly except: (2)
a. Before removing the container from the drawer or shelf
b. As the amount of drug ordered is removed from it
c. Before resuming the container to the storage
d. Before directly administering the drug
97. What is the best way of identifying the right client ideally? (1)
a. Check the medicine tickets against the client’s identification
b. Nurse speaks the name of the client
c. Nurse ask the client’s relative to state the full name
d. Nurse consults the physician
98. If the doctors orders q8h, what does this mean? (1)
a. The medication should be given during the waking hours
b. The medication should be given round the clock
c. Both a and b
d. None of the above
99. The expectorant guiafenesin (Robitussin) 300 mg p.o. has been ordered. The bottle is
labeled 100mg/5mL. How many mL should be given? (2)
a. 13 mL
b. 14 mL
c. 15 mL
d. 16 mL
100. The physician orders: Administer Ampicillin 50 mg. oral suspension p.o q6 hours for 7
days. Stock dose is 125 mg/5mL in 30 mL bottle. How many bottles of the medication will
you request? (3)
a. 5 bottles
b. 4 bottles
c. 3 bottles
d. 2 bottles