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Name: _________________________________________________________________ Date:_______________

1. Elizabeth Kubler-Ross identified five stages of death and dying. Loss, grief, and intense
sadness are symptoms of which stage?
a. Denial and isolation
b. Depression
c. Anger
d. Bargaining
RATIONALE: According to Kübhler-Ross, the five stages of death and dying are denial and isolation,
anger, bargaining, depression, and acceptance. In denial, the client denies aspects of the illness and
death. Loss, grief, and intense sadness indicate depression. In anger, the client has hostility that may
be directed to family members, God, heath care workers, and others. In bargaining, the client asks
God for more time, and in return promises to do something good.

2. To help minimize calcium loss from a hospitalized client's bones, the nurse should:
a. reposition the client every 2 hours.
b. encourage the client to walk in the hall
c. provide the client daily products at frequent intervals
d. provide supplemental feedings between meals.
RATIONALE: Calcium absorption diminishes with reduced physical activity because of decreased bone
stimulation. Therefore, encouraging the client to increase physical activity such as by walking the hall,
helps minimize calcium loss. Turning or repositioning the client every 2 hours wouldn’t increase
activity sufficiently to minimize bone loss, Providing dairy products and supplemental feedings
wouldn't lessen calcium loss - even if the dairy products and feedings contained extra calcium —
because the additional calcium doesn’t increase bone stimulation or osteoblast activity.

3. Which statement regarding heart sounds is correct?


a. S1 and s2 sound equally loud over the entire cardiac area.
b. S1 and sound fainter at the apex than at the base.
c. S and 2 sound fainter at the base than at the apex.
d. S1 is loudest at the apex, and S2 is loudest at the base.
Rationale: The S1 sound — the “lub” sound — is loudest at the apex of the heart. It sounds longer,
lower, and louder there than the S2 — the “dub” sound — is loudest at the base. It sounds shorter,
sharper, higher, and louder there than the S1.
4. A client has a nursing diagnosis of Ineffective airway clearance related to poor coughing.
When planning this client’s care, the nurse should include which intervention?
a. Increasing fluids to 2,500 ml/day
b. Teaching the client how to deep-breathe and cough
c. Improving airway clearance
d. Suctioning the client every 2 hours
RATIONALE: Interventions should address the etiology of the client's problem — poor coughing.
Teaching deep breathing and coughing addresses this etiology. Increasing fluids may improve the
client’s condition, but this intervention doesn't address poor coughing. Improving airway clearance is
too vague to be considered an appropriate intervention. Suctioning isn't indicated unless other
measures fail to clear the airway.

5. A nurse is using the computer when a client calls for pain medication. Which action by the
nurse is the best?
a. Staying logged on, leaving the terminal on, and administering the medication
immediately
b. telling the client that he’ll have to wait 15 minutes while she completes the entry
c. Asking a coworker to log out for her and administering the medicine right away
d. Logging out of the computer, then administering the pain medication
RATIONALE: A nurse should meet a client’s request for pain medication as quickly as possible after she
logs out of the computer. A nurse shouldn't ask a client to wait for as long as 15 minutes for requested
pain medication. If the nurse leaves the terminal without logging out, others may view confidential
information or use her password. Asking a coworker to log her out isn't safe computer practice.

6. What is the most appropriate nursing diagnosis for the client with acute pancreatitis?

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a. Deficient fluid volume
b. Excess fluid volume
c. Decreased cardiac output
d. Ineffective gastrointestinal tissue perfusion
RATIONALE: Clients with acute pancreatitis often experience deficient fluid volume, which
can lead to hypovolemic shock. Vomiting, hemorrhage (in hemorrhagic pancreatitis), and
plasma leaking into the peritoneal cavity may cause the volume deficit. Hypovolemic shock
will cause a decrease in cardiac output. Gastrointestinal tissue perfusion will be ineffective if
hypovolemic shock occurs, but this wouldn't be the primary nursing diagnosis.

7. One aspect of implementation related to drug therapy is:


a. developing a plan of care
b. documenting drugs given.
c. establishing outcome criteria.
d. setting realistic client goals.
RATIONALE: Athough documentation isn't a step in the nursing process, the nurse is legally
required to document activities related to drug therapy, including the time of administration,
the quantity, and the client's reaction. Developing a plan of care, establishing outcome
criteria, and setting realistic client goals are parts of planning rather than implementation.
8. A nurse notes that a client’s I.V. insertion site is red, swollen, and warm to the touch.
which action should the nurse take first?
a. Discontinue the I.V. infusion.
b. Apply a warm, moist compress to the I.V. site.
c. Assess the I.V. infusion for patency.
d. Apply an ice pack to the I.V. site.
RATIONALE: Because redness, swelling, and warmth at an I.V. site are signs of infection, the
nurse should discontinue the infusion immediately and restart at another site. After doing
this, the nurse should apply warmth to the original site. Checking infusion patency isn't
warranted because assessment findings suggest infection and inflammation, not infiltration.
Heat, not cold is the appropriate treatment for inflammation.

9. A nurse is caring for a client with a history of falls. The nurse's first priority when caring
for a client at risk for falls is:
a. placing the call light for easy access.
b. keeping the bed in the lowest possible position.
c. instructing the client not to get out of the bed without assistance
d. keeping the bedpan available so that the client doesn’t have to get out of bed.
RATIONALE: Keeping the bed at the lowest possible position the first priority for clients at
risk for falling. Keeping the call light easy accessible is important but isn’t a top priority.
Instructing the client not to get out of bed may not effectively prevent falls — for example, if
the client is confused. Even when the client needs assistance to get out of bed, the nurse
should place the bed in the lowest position. The client may not require a bedpan.

10. A nurse is caring for a client who is exhibiting signs and symptoms characteristic of a
myocardial infarction (MI). which statement describes priorities the nurse should establish
while performing the physical assessment?
a. Assess the client's level of pain and administer prescribed analgesics.
b. Assess the client’s level of anxiety and provide emotional support.
c. Prepare the client for pulmonary artery catheterization.
d. Ensure that the client's family is kept informed of his status.
RATIONALE: The cardinal symptom of MI is persistent, crushing substernal pain or pressure.
The nurse should first assess the client's pain and prepare to administer nitroglycerin or
morphine for pain control. The client must be medically stabilized before pulmonary artery
catheterization can be used as a diagnostic procedure. Anxiety and a feeling of impending
doom are characteristic of MI, but the priority is to stabilize the client medically. Although
the client and his family should be kept informed at every step of the recovery process, this
action isn’t the priority when treating a client with a suspected MI.

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11. A nurse is monitoring a client for adverse reactions during barbiturate therapy. What is
the major disadvantage of barbiturate use?
a. Prolonged half-life
b. Poor absorption
c. Potential for drug dependence
d. Potential for hepatotoxicity
RATIONALE: Clients can become dependent on barbiturates, especially with prolonged use.
Because of the rapid distribution of some barbiturates, no correlation exists between
duration of action and half-life. Barbiturates are absorbed well and don't cause
hepatotoxicity, but because barbiturates are metabolized in the liver, existing hepatic
damage does require cautious use of these drugs.
12. A nurse is caring for a client who required chest tube insertion for a pneumothorax. To
assess for pneumothorax resolution, the nurse anticipates that the client will require:
a. monitoring of arterial oxygen saturation ,
b. arterial blood gas (ABG) studies.
c. chest auscultation.
d. a chest x-ray.
Rationale: Chest x-ray confirms diagnosis by revealing air or fluid in the pleural space. SaO2
values may initially decrease with a pneumothorax but typically return to normal within 24
hours. ABG studies may show hypoxemia, possibly with respiratory acidosis and
hypercapnia not related to a pneumothorax. Chest auscultation will determine overall lung
status, but it's difficult to determine if the chest has reexpanded sufficiently.

13. During her morning assessment, a nurse notes that a client has severe dyspnea, his
respirations are 34 breaths/minute and labored. Oxygen saturation is 79% on 3L of oxygen.
The nurse remembers that the client's chart includes his living will, When considering best
practice, the nurse should:
a. withhold all potentially life-prolonging treatments in accordance with the client's living will

b. increase the oxygen flow rate to 4L, but avoid initiating other interventions
c. call the client’s family and ask what they think is best.
d. initiate potentially life-prolonging treatment unless the client refuses.
RATIONALE: A living will doesn't go into effect unless the client is unable to make his own
decisions. A nurse shouldn't withhold care for an alert client unless he specifically refuses
care. The nurse should give all appropriate care while also maintaining the client's right to
refuse treatment. Increasing the oxygen flow rate might be an appropriate response, but
isn't the best action at this time. The family isn't responsible for determining care at this
time.
14. A client is to receive a glycerin suppository. Which nursing action is appropriate when
administering a suppository?
a. Removing the suppository from the refrigerator 30 minutes before insertion
b. Applying a lubricant to the suppository
c. Dissolving the suppository in 3 ml of warm water
d. Instructing the client to bear down during insertion
RATIONALE: A suppository must be lubricated before insertion. Because suppositories melt
at body temperature, they usually require refrigeration until administration. It isn’t
appropriate to dissolve a suppository in warm water. It should remain in a solid state.
Instructing the client to bear down would cause the anal sphincter to contract, making
insertion difficult.

15. A physician orders regular insulin 10 units LV. along with 50 ml of dextrose 50% for a
client with acute renal failure. What problem is this client most likely experiencing?
a. Hypercalcemia
b. Hypernatremia
c. Hyperglycemia
d. Hyperkalemia
Rationale: Administering regular IV concomitantly with 50 ml of dextrose 50% helps shift
potassium from the extracellular fluid into the cell, which normalizes serum potassium levels
in the client with hyperkalemia. This combination doesn't he reverse the effects of
hypercalcemia, hypenatremia, or hyperglycemia.

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16. A nurse identifies a client’s responses to actual or potential health problems during
which step of the nursing process?
a. Assessment
b. Diagnosis
c. Planning
d. Evaluation
RATIONALE: The nurse identifies human responses to actual or potential health problems
during the diagnosis step of the nursing process, which encompasses the nurse’s ability to
formulate a nursing diagnosis. During the assessment step, the nurse systematically collects
data about the client or his family. During the planning step, she develops strategies to
resolve or decrease the client’s problem. During the evaluation step, the nurse determines
the effectiveness of the care plan.

17. In a client with a urine specific gravity of 1.040, a subnormal serum osmolality, and a
serum sodium level of 128 mEq/L, the nurse should question an order for which I.V. fluid?
a. dextrose 5% in half-normal saline solution.
b. normal saline solution.
c. dextrose 5% on water (D5W)
d. lactated Ringer’s solution.
RATIONALE: An elevated urine specific gravity, a subnormal serum osmolality, and a
subnormal serum sodium level indicate that the client is excreting too many solutes.
Because the client is in a hypotonic state, the nurse shouldn't give him a hypotonic I.V.
solution. D5W, also referred to as free water, is hypotonic when given I.V. and can further
hemodilute the clent. Dextrose 5% half-normal saline solution is hypertonic, normal saline
solution is isotonic, and lactated Ringer's solution is isotonic. For this client, each of these
three choices are more acceptable than D5w.

18. A 10-year-old child with rheumatic fever must have his heart rate measured while he's
awake and while he’s sleeping. Why are two readings necessary?
a. To obtain a heart rate that isn't affected by medication
b. To eliminate interference from the jerky movements of chorea
c. To ensure that the child can't consciously raise or lower his heart rate
d. To compensate for activity's effects on the child’s heart rate
RATIONALE: Tachycardia may be a sign of heart failure. The nurse can detect mild
tachycardia more easily when the child is asleep than when he's awake because activity can
increase his heart rate. Medications given for rheumatic fever and rheumatic heart disease,
such as digoxin (Lanoxin), exert their influence both day and night. Chorea, a symptom of
rheumatic fever, is the loss of voluntary muscle control. It doesn't affect pulse because the
child would be sitting quietly while the nurse measured his heart rate and wouldn't be
involved in purposeful movement. A 10-year-old child probably doesn't know how to
consciously raise or lower his heart rate.

19. A nurse preparing to administer a sustained-release capsule to a client. Which is an


appropriate nursing intervention?
a. Administering the capsule whole with a glass of water
b. Crushing the capsule and mixing the medication with applesauce
c. Opening the capsule, shaking the contents into water, and administering it to the client
d. Having the client chew the capsule before swallowing

20. After receiving an I.M. injection, a client complains of burning pain at the injection site.
which nursing action would be most appropriate at this time?
a. Applying a cold compress to decrease swelling
b. Applying a warm compress to dilate the blood vessels
c. Massaging the area to promote absorption of the drug
d. Instructing the client to tighten his gluteal muscles to promote better absorption of the
drug
RATIONAI.E: Applying heat increases blood flow to the area, which, in turn, increases
medication absorption. Cold decreases pain but allows the medication to remain in the
muscle longer. Massage is a good intervention, but applying a warm compress is better.
Tightening the gluteal muscles may cause additional burning if the drug irritates muscular
tissues.

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21. A client undergoes a total abdominal hysterectomy. When assessing the client 10 hours
later, the nurse identifies which finding as an early sign of shock?
a. Confusion
b. Pale, warm, dry skin
c. Heart rate of 110 beats/minute
d. Urine output of 30 ml/hour
RATIONALE: Early in shock, inadequate perfusion leads to anaerobic metabolism, which
causes metabolic acidosis. As the respiratory rate increases to compensate, the client’s
carbon dioxide level decreases, causing alkalosis and subsequent confusion and
combativeness. Inadequate tissue perfusion causes pale, cool, clammy skin (not pale, warm,
dry skin). An above-normal heart rate is a late sign of shock. A urine output of 30 ml/hour is
within normal limits.
REFERENCE: Smeltzer, S.C., and Bare, B. Brunner&Suddarth’s Texthook of MedicalSurgical
Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 2526.

22. Cross-tolerance to a drug is defined as:


a. one drug that can prevent withdrawal symptoms from another drug.
b. an allergic reaction to a class of drugs.
c. one drug reduces response to another drug.
d. one drug increases another drug’s potency.
RATIONALE: Cross-tolerance occurs when a drug with a similar action causes a decreased
response to another drug. A drug that can prevent withdrawal symptoms from another drug
describes cross-dependence. Cross-tolerance isn't an allergic reaction to a class of drugs. A
drug's ability to increase the potency of another drug describes potentiating effects.

23. A nurse caring for a client wth a fecal impaction should watch for:
a. liquid or semiliquid stools.
b. hard, brown, formed stools.
c. loss of urge to defecate.
d. increased appetite.
RATIONALE: Passage of liquid or semiliquid stools results from seepage of unformed bowel
contents around the impacted stool in the rectum. Clients with fecal impaction don’t pass
hard, brown, formed stools because the feces can't move past the impaction. These clients
typically report the urge to defecate (although they can't pass stool) and decreased
appetite.

24. A physician orders an intestinal tube to decompress a client's GI tract. when gathering
equipment for this procedure, a nurse should obtain a:
a. Sengstaken-Blakemore tube.
b. Miller-Abbott tube.
c. Levin tube.
d. Salem sump tube.
RATIONALE: A Miller-Abbott tube is an intestinal tube. A Sengstaken-8lakemore tube is an
esophageal tube. Levin tubes and Salem sump tubes are nasogastric tubes.
REFERENCE: Smeltzer, S.C., and Bare, B. Brunner & Suddarth’s Textbook of Medical Surgica
Nursing, 2008, p. 1175.
25. A client has a blood pressure of 152/86 mm Hg. The nurse should document the client’s
pulse pressure as:
a. 66mm Hg.
b. 238 mm Hg.
c. 86 mm Hg.
d. 152 mm Hg.
RATIONALE: Pulse pressure is the difference between the systolic and diastolic pressures —
in this case, 66 mm Hg.

26. A client has a nursing diagnosis of Risk for Injury related to adverse effects of potassium-
wasting diuretics. What is a correctly written client outcome for this nursing diagnosis?
a. “By discharge, the client correctly identifies three potassium-rich food
sources.”
b. “The client knows the importance of consuming potassium-rich foods daily.”
c. “Before discharge, the client knows which food sources are high in potassium.”
d. “The client understands all complications of the disease process."
RATIONALE: A client outcome must be measurable, objective, concise, realistic for the client,
and attainable through nursing management. For each client outcome, the nurse should
include only one client behaviour. She should express that behaviour in terms of client
expectations and should indicate a time frame in which to accomplish. Knowing the
importance of consuming potassium-rich foods and knowing which foods are high in

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potassium aren't measurable outcomes. Understanding all complications of a disease
process isn't measurable or specific to the nursing diagnosis listed.

27. When caring for a client with a 3-cm stage I pressure ulcer on the coccyx, which action
may the nurse institute independently?
a. Using a povidone-iodine wash on the ulceration three times per day
b. Using normal saline solution to clean the ulcer and applying a protective
dressing as necessary
c. Applying an antibiotic cream to the area three tines per day
d. Massaging the area with an astringent every 2 hours

28. A client with burns on his groin has developed blisters. As the client is bathing, a few
blisters break. The best action tor the nurse to take is to:
a. remove the raised skin because the blister has already broken.
b. wash the area with soap and water to disinfect it.
c. apply a weakened alcohol solution to clean the area.
d. clean the area with normal saline solution and cover it with a protective
dressing.
RATIONALE: The nurse should clean the area with a mild solution such as normal saline, and
then cover it with a protective dressing. Soap and water and alcohol are too harsh. The
body's first line of defense broke when the blisters opened: removing the skin exposes a
larger area to the risk of infection.

29. A nurse is assisting with a subclavian vein central be insertion when the client's oxygen
saturation drops rapidly. He complains of shortness of breath and becomes tachypneic. The
nurse suspects the chent has developed a pneumothorax. Further assessment findings
supporting the presence of a pneumothorax include:
a. diminished or absent breath sounds on the affected side
b. paradoxical chest wall movement with respirations.
c. tracheal deviation to the unaffected side.
d. muffled or distant heart sounds.
RATIONALE: In the case of a pneumothorax, auscultating for breath sounds will reveal
absent or diminished breath sounds on the affected side. Paradoxical chest wall movements
occur in flail chest conditions. Tracheal deviation occurs in a tension pneumothorax. Muffled
or distant heart sounds occur in cardiac tamponade.

30. During a meal, a client with hepatitis B dislodges her IV line and bleeds onto the surface
of the overbed table. It would be most appropriate for the nurse to instruct a housekeeper to
clean the table with:
a. alcohol.
b. ammonia.
c. acetone.
d. bleach.
RATIONALE: Blood infected with the hepatitis B virus should be removed from the table or
other surfaces with bleach. Alcohol, ammonia, and acetone are less effective n destroying
the hepatitis B virus.
31. A nurse determines that a client has 20/40 vision. Which statement about this client’s
vision is true?
a. The client can read the entire vision chart at a distance of 40 feet.
b. The client can read from a distance of 20 feet what a person with normal vision
can read at a distance of 40 feet.
c. The client can read the vision chart from a distance of 20 feet with the right eye and from
40 feet with the left eye.
d. The client can read at a distance of 40 feet what a person with normal vision can read at a
distance of 20 feet.
RATIONALE: The numerator, which is always 20, is the distance in feet between the vision
chart and the client. The denominator indicates from what distance a person with normal
vision can read the chart.

32. For the past few days, a client has been having calf pain and notices that the painful calf
is larger than the other one. The right calf is red, warm, achy, and tender to touch. Which
question about the pain should a nurse include in the assessment?
a. “Does the pain worsen when you get up in the morning?”

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b. “Does the pain increase with activity and lessens with rest?"
c. “Is the pain relieved when you change position?”
d. “Is the pain worse when you point your toes toward your knee?”
RATIONALE: The client's symptoms indicate deep vein thrombosis (DVT). Pointing toes
toward the knee will cause discomfort in a client with DVT. Time of the day doesn’t influence
the pain associated with DVT. A client with intermittent claudication experiences pain that
increases during activity and decreases with rest. A dependent position, not a position
change, will increase venous stasis and the pain associated with DVT.

33. A physician orders the following preoperative medications to be administered to a client


by the I.M. route: meperidine (Demerol), 50 mg: hydroxyzine pamoate (Vistaril), 25 mg; and
glycopyrrolate (Robinul), 0.3 mg. The medications are dispensed as follows: meperidine, 100
mg/ml; hydroxyzine pamoate, 100 mg/2 ml; and glycopyrrolate, 0.2 mg/ml. How many
milliliters in total should the nurse administer?
a. 5ml
b. 2 ml
c. 2.5 ml
d. 3.8 ml
Computation:
0.5 ml + 0.5 ml + 1.5 ml = 2.5 ml

34. What is a common source of airway obstruction in an unconscious client?


a. A foreign object
b. Saliva or mucus
c. The tongue
d. Edema
RATIONALE: In an unconscious client, the muscles controlling the tongue commonly relax,
causing the tongue to obstruct the airway. When this situation occurs, the nurse should use
the head-tilt, chin-lift maneuver to cause the tongue to fall back into place. If she suspects
the client has a neck injury she must perform the jaw-thrust maneuver.

35. After undergoing small-bowel resection, a client is ordered Metronidazole (Flagyl) 500
mg IV The mixed IV solution contains 100 ml. The nurse is to run the drug over 30 minutes.
The drip factor of the available IV tubing is 15 gtts/ml. What is the drip rate? Round your
answer to the nearest whole number.
a. 50 gtt/min
b. 45 gtt/min
c. 48 gtt/min
d. 40 gtt/min
Rationale: Use the following equation: 100 ml/30 minutes x 15 gtt/1 ml = 49.9 gtt/minute
(50 gtt/minute)
36. An elderly client who experiences several adverse drug reactions may benefit from:
a. reduced drug dosages.
b. nursing home placement.
c. increased drug doses at longer intervals.
d. frequent visits to the physician.
RATIONALE: In older clients, diminished hepatic and renal function commonly reduces drug
metabolism and excretion. Because adverse reactions are frequently related to drug blood
level, the client may benefit from reduced drug dosages. Adverse drug reactions don’t
represent a reason for nursing home placement. Increased drug doses at longer intervals
may increase adverse reactions rather than decrease them. Although frequent visits to the
physician may benefit the client, the visits themselves won't alter how the client's body
reacts to the drug.

37. When examining a client who has abdominal pan, a nurse should assess:
a. any quadrant first.
b. the symptomatic quadrant first.
c. the symptomatic quadrant last.
d. the symptomatic quadrant either second or third.
Rationale: The nurse should systematically assess all areas of the abdomen, if time and the
client's condition permit, concluding with the symptomatic area. Otherwise, the nurse may
elicit pain in the symptomatic area, causing the muscles in other areas to tighten. This
tightening would interfere with further assessment.

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38. A nurse is teaching a group of nursing assistants about infection-control measures. The
nurse tells the group that the first line of intervention for preventing the spread of infection
is:
a. wearing gloves.
b. administering antibiotics.
c. washing hands.
d. assigning clients to private rooms.
RATIONALE: Hand washing is the first line of intervention for preventing the spread of
infection. Wearing gloves and assigning private rooms for clients can also decrease the
spread of infection and should be implemented according to standard precautions.
Antibiotics should be initiated when a causative organism is identified.

39. A nurse caring for a client who has suffered a severe stroke. During routine assessment,
the nurse notices Cheyne-Stokes respirations. Cheyne-Stokes respirations are:
a. progressively deeper breaths followed by shallower breaths with apneic
periods.
b. rapid, deep breaths with abrupt pauses between each breath.
c. rapid, deep breaths and irregular breathing without pauses.
d. shallow breaths with an increased respiratory rate.
RATIONALE: Cheyne-Stokes respirations are breaths that become progressively deeper
followed by shallower respirations with apneic periods. Biot’s respirations are rapid, deep
breaths with abrupt pauses between each breath, and equal depth between each breath.
Kussmaul’s respirations are rapid, deep breaths without pauses. Tachypnea is abnormally
rapid respirations.
40. When positioned properly, the top of a central venous catheter should lie in the:
a. superior vena cava.
b. basilic vein.
c. jugular vein.
d. subclavian vein.
RATIONALE: When positioned correctly, the top of a central venous catheter lies in the
superior vena cava, inferior vena cava, or right atrium — that is, in the central venous
circulation. Blood flows unimpeded around the tip, allowing the rapid infusion of large
amounts of fluid directly into circulation. The basilic, jugular, and subclavian veins are
common insertion sites for central venous catheters.

41. A nurse reviews the arterial blood gas (ABG) values of a client admitted with pneumonia:
pH, 7.51, PaCO2, 28 mm Hg; PaO2, 70 mm Hg: and HCO3, 24 mEq/L. What do these values
indicate?
a. Metabolic acidosis
b. Metabolic alkalosis
c. Respiratory acidosis
d. Respiratory alkalosis
RATIONALE: A client with pneumonia may hyperventilate in an effort to increase oxygen
intake. Hyperventilation leads to excess carbon dioxide (Co2) loss, which causes alkalosis —
indicated by this client's elevated pH value. with respiratory alkalosis, the kidneys’
bicarbonate (HCO3-) response is delayed, so the client's HCO3- level remains normal. The
below-normal value for the partial pressure of arterial carbon dioxide (PaCO2) indicates CO2
loss and signals a respiratory component. Because the HCO3- level is normal, this imbalance
has no metabolic component. Therefore, the client is experiencing respiratory alkalosis.

42. The ear canal of an infant or young child:


a. slants upward.
b. slants downward.
c. is horizontal.
d. slants backward.
Rationale: The ear canal slants up in a younger child and down in an older child or adult.

43. When a central venous catheter dressing becomes moist or loose, what should a nurse
do first?
a. Draw a circle around the moist spot and note the date and time.
b. Notify the physician.
c. Remove the catheter, check for catheter integrity, and send the tip for culture.
d. Remove the dressing, clean the site, and apply a new dressing.
Rationale: A nurse maintaining a central venous catheter should change the dressing every
72 hours or when it becomes soiled, moist, or loose. After removing the soiled dressing, the

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nurse should use sterile technique to clean around the site in accordance with facility policy.
After the cleaning solution has dried, the nurse should cover the site with a transparent
semipermeable dressing. A nurse who notes drainage on a wound dressing should draw a
circle around the moist spot and note the date and time. She should notify the physician if
she observes any catheter-related complications. Only a nurse with the appropriate
qualifications may remove a central venous catheter, and a moist or loose dressing isn’t a
reason to remove the catheter.
References: Smeltzer, S.C., and Bare, B. Brunner&Suddarth’s Texthook of MedicalSurgical
Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1005

44. A nurse is assigned to care for a client with a tracheostomv tube. How can the nurse
communicate with this client?
a. By providing a tracheostomy plug to use for verbal communication
b. By placing the call button under the client's pillow
c. By supplying a magic slate or similar device
d. By suctioning the client frequently
RATIONALE: The nurse should use a nonverbal communication method, such as a magic
slate, note pad and picture boards (if the client can’t write or speak English). The physician
orders a tracheostomy plug when a client is being weaned off a tracheostomy; it doesn’t
enable the client to communicate. The call button, which should be within reach at al times
for all clients, can summon attention but doesn't communicate additional information.
Suctioning clears the airway but doesn't enable the client to communicate.

45. Chokie underwent diagnostic test and he result of the blood examination are back. On
reviewing the result, the nurse notice which of the following as an abnormal finding?
a. Neutophil 60% c. Iron 75mg/100ml
b. ESR 39mm/hr d. WBC 9000/mm

45. A client with viral infection will most likely manifest which of the following during the
illness stage of infection?
a. Oral temperature shows fever
b. Client was exposed to the infection 2 days ago but without any symptoms
c. Acute symptoms are no longer visible
d. Client feel sick but can do normal activities

45. Among the clients you are assigned to take care of, who is most susceptible to infection?
a. Client with burns c. Diabetic Client
b. Client with Myocardial Infarction d. Client with pulmonary emphysema

45. Surgical asepsis is observed when:


a. Placing a dirty soiled linen in moisture resistant bag
b. Disposing of syringe and needle in puncture proof containers
c. Inserting an Intravenous catheter
d. Washing hands before changing wound dressing

45. Which of the following laboratory test results indicate presence of infectious process?
a. ESR: 12mm/hr
b. Iron 90g/100ml
c. Neutrophils 67%
d. WBC: 18000/mm3

45. A diabetic hypertensive client, Mrs. Charuz, needs a change in diet to improve her health
status. She should be referred to a:
a. Nutritionist c. Dietician
b. Physician d. Medical Pathologist

46. When collaborating with other health team members, the best description of a nurses’
role is:
a. Shares and implements order of the health team to ensure quality care

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b. Encourage the client’s involvement in his care
c. She listen to the individual views of the team members
d. Help the client sets goal of care and discharge

47. A nurse is successful on collaborating with the health team members about the care of
his patient. This is because she has the following competencies
a. Conflict management, Trust and Negotiation
b. Negotiation, Decision Making
c. Communication, Trust and Decision Making
d. Mutual respect, Negotiation and Trust

48. Your client is concerned that he cannot pay his hospital bills and professional fees. You
refer him to a:
a. Bookkeeping Department c. Social Worker
b. Nurse Supervisor d. Physician

49. A patient with lung cancer is undergoing chemotherapy. He is referred by the oncology
nurse to a self-help group of clients with cancer to:
a. To be a part of the research team c. Receive emotional report
b. Provide financial assistance d. Assist with chemotherapy

50. A sputum specimen has been ordered for Mr. Buenaventura, a 75-year-old patient
admitted with possible pneumonia of the right lower lobe. Mr. Buenaventura is not able
to cough. The nurse is aware that for patients who cannot expectorate sputum from
deep in the bronchial tree, Nebulization was done, the specimen must be collected by:
a. Orotracheal suctioning
b. Tracheal suctioning
c. Oropharyngeal suctioning
d. Percussion and suctioning

45. To obtain a 24-hour urine specimen, the patient should be given which of the following
instructions?
a. Collect each voiding in separate containers for the next 24 hours
b. Discard the first voided specimen and then collect the total volume of each
voiding in 24 hours
c. For the next 24 hours, retain a 30ml specimen of each voiding after recording
the amount voided
d. Keep a record of the time and amount of each voiding for 24 hours

46. Ms. Cristobal, age 72, has an indwelling urinary catheter. A sterile urine specimen has
been ordered for a culture and sensitivity. The sterile specimen should be obtained by:
a. Obtaining 60ml of urine from the collection bag
b. Removing the present catheter, having the patient void, and then
recatheterizing
c. Disconnecting the tubing from the catheter and draining 2ml of urine
d. Aspirating 10ml of urine with a sterile syringe from the tubing port

47. Mr. Lagman, age 46, is seen by the physician for recurrent symptoms of cystitis. He is to
have a urine culture and sensitivity determination and a 24-hour urine collection for
laboratory analysis. Mr. Lagman should be informed that a urine culture study is required
to:
a. Identify the causative organism
b. Determine the presence of malignant cells
c. Analyze the elements present in the urine
d. Localize the site of the inflammatory process

48. How would you prepare for the accuracy of the occult blood examination?
a. Meatless diet for 72 hours prior to collection of the specimen
b. Fluid intake is increased an hour before the collection of the specimen
c. Fluid intake is limited only to 1 liter per day
d. NPC for 9 hours prior to collection of specimen

Situation: Nurse Jennica, a newly hired nurse, is asked to take over an absent
nurse in another unit. She will take care of the client wit various condition

49. She is giving instructions to Michelle, the daughter of a comatose patient, to give sponge

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bath. While Michelle is giving sponge bath, what action of Michelle needs correction?
a. Lining the patient on the left side with slightly elevated
b. Answering the phone while wearing gloves used for sponge bath
c. Rolling the patient like a log to do back rub
d. Lining the rubber mat with bed sheet as incontinence pad for the client

50. Joey sustained a fracture of the ulna and cast will be applied. What nursing action before
cast application is most important for Nurse Jennica to do?
a. Use baby powder to reduce irritation under the cast
b. Evaluate the skin temperature in the area
c. Assess sensation of each arm
d. Check radial pulse bilaterally and compare

51. Which of the following client condition should be nurse Jennica’s priority in the pediatric
unit?
a. The infant who is brought in for upper respiratory tract infection whose
temperature is slightly elevated
b. The baby whose fontanel s bulging and firm while asleep
c. The baby who is wailing after being awakened by the banging of the door
d. A baby boy whose circumcision has yellowish exudates

52. When suctioning the endotracheal tube, the nurse should:


a. Insert catheter until resistance is met, then withdraw slightly, applying suction
intermittently a catheter is withdrawn
b. Hyperoxygenate client than insert catheter using back and forth motion
c. Insert suction catheter four inches into the tube, suction 30 seconds using twirling
motion as catheter is withdrawn
d. Explain procedure to the patient, insert the catheter gently applying suction.
Withdrawn using twisting motion

53. To obtain specimen for sputum culture and sensitivity, which of the following instruction
is best?
a. Cough after pursed lip breathing
b. Save sputum for two days in covered container
c. Upon waking up, cough deeply and expectorate into the container
d. After respiratory treatment, expectorate into a container

Situation: The vital or cardinal signs are body temperature, pulse, respiration and
blood pressure

54. Ms. Avila is 48-years-old. During a routine physical her blood pressure is noted a 180/90.
She fears she is hypertensive. The nurse would explain that the diagnosis of
hypertension is made when there is a sustained elevated blood pressure of over:
a. 160/100
b. 140/90
c. 130/70
d. 120/80

55. Mr. Jimenez, age 44, is undergoing antibiotic therapy for pneumonia. His rectal
temperature reading is 101.6°F. His oral temperature would be considered as:
a. 101.6°F
b. 100.6°F
c. 99.6°F
d. 97.6°F

56. Ms. Pascual, age 66, suddenly develops rectal hemorrhaging, her radial pulse is difficult
to palpate even with slight pressure. This type of pulse would be described as:
a. Absent
b. Nonpalpable

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c. Thready
d. Bounding

57. Mr. Zamora, RN, has been assigned several patients. Which one of the following patients
would most likely have a higher than normal temperature?
a. The depressed, apathetic patient
b. The patient addressed with hemorrhage
c. The patient who is recovering from surgery
d. The patient experiencing strong emotions

58. The physician has ordered an orthostatic blood pressure measurement. Which of the
following is correct concerning the orthostatic method of assessing blood pressure?
a. The measurement is taken in the lying position, then sitting up and last when
the patient is standing.
b. The measurement is taken first with the patient sitting up and then lying down.
c. The nurse should wait 5 minutes between assessing the blood pressure in the
sitting position from the lying position.
d. The patient should be lying down for at least 10 minutes before the nurse
performs the procedure.

Situation: You are assigned to work in an orthopedic ward where clients are
expected to have problems in mobility and immobility

59. Mark asks to be assisted to move up in bed. Which of the following should the nurse do
first?
a. Lock the wheels of the bed
b. Raise the bed rails opposite the nurse
c. Adjust the bed to a flat position
d. Move the patient to the edge of the bed near the nurse

60. Which of the following supportive devices can be sued most effectively by the nurse to
prevent external rotation of the right leg?
a. Firm Mattress c. Sand Bag
b. Pillow d. High Foot Board

61. Jerome right leg is injured and Nurse Apple has to move him from the bed to a wheel
chair. Which of the following is the appropriate nursing action of the nurse?
a. Face the client and place the wheelchair at her back
b. Put the client o n the edge of the bed and place the wheelchair on the client’s left
side
c. Put the client on the edge of the bed and place the wheelchair on the other side
of the bed
d. Put the client on the edge of the bed and place the wheelchair at her back

62. Gilbert has to be maintained on a dorsal recumbent position. Which of the following
should be prevented?
a. Adduction of the shoulder
b. Hyperextension of the knees
c. Anterior flexion of the lumbar curvature
d. Lateral flexion of the sternocleidomastoid muscle

63. Mikckey prefers to be in high fowler’s position most of the time. The nurse should
prevent which of the following?
a. Adduction of the shoulder
b. Internal Rotation of the shoulder
c. Posterior flexion of the lumbar curvature
d. External Rotation of the hip

Situation: As you begin to wok in the hospital where you are on probation, you
are tasked to take care of few patients. The client have varied needs and you are
expected to provide care for them.

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64. You are preparing a plan of care who is experiencing pain related to incisional swelling
following laminectomy. Which of the following should be included in the nursing care
plan?
a. Ambulate the client in the ward premises every twenty minutes
b. Encourage the client to do self care
c. Encourage the client to roll when turning
d. Instruct the client to do deep breathing exercise

65. Mr. Pineda, 55 years old executive, is recovering from sever myocardial infarction. For
the past 3 days, Mr. Pineda’ hygiene and grooming needs have been met by the nursing
staff. Which of the following activities should be implemented to achieve the goal of
independence for Mr. Lozano?
a. Meeting his need till he is ready to perform self care
b. Involving the patient in his care
c. Preparing a day to day list to be followed by the client
d. Involving family members in meeting client’s personal needs

66. An ambulatory client, Mr. June, is being prepare for bed. Which of the following nursing
action promote safety for the client?
a. Raising the side rails
b. Placing the bed in high position
c. Turning off the lights to promote sleep and rest
d. Instructing the client about the use of the call system

45. Mr. Villaruel is terminally ill and he chose to be home with his family. What nursing action
are best initiated to prepare the family of Mr. Villaruel?
a. Provide support to the family members by teaching ways to care for their loved ones
b. Convince the client to stay in the hospital for professional care
c. Talk with the family members about the advantage of staying in the hospital for
proper care
d. Tell the client to be with his family

45. Jessica, a 28 year old female client, is admitted with right lower quadrant abdominal
pain. The physician diagnosed the client with acute appendicitis and an emergency
appendectomy was performed. Twelve hour following surgery, the patient complained of
pain. Which of the following is the most appropriate nursing diagnosis?
a. Impaired immobility related to pain secondary to abdominal incision
b. Severe pain related to surgery
c. Impaired mobility related to surgery
d. Impaired movement related to pain due to surgery

46. In the teaching instruction for a client with hypoparathyroidism, the nurse would include:
a. A high calcium, high phosphorus diet
b. A high-calcium, Low phosphorus diet
c. A high-protein, high calorie diet
d. A low-calcium, low protein diet

47. The nursing diagnosis Impaired Urinary Elimination has been assigned to client with
hyperparathyroidism. To address this diagnosis, the nurse would:
a. Withhold acidic juices in the diet
b. Force fluid
c. Encourage the client to start and stop the urine stream
d. Not administer fluid with meals

48. The nurse interpret a Mantoux test reaction as “O millimeters” a negative test. The client
tells the nurse, “It’s good to know that I definitely don’t have TB” The correct response
would be:
a. “A negative test simply means that you do not need treatment at this time”
b. “A negative test does not always mean that TB is not present”
c. “A negative Mantoux test means that you have not been exposed to TB”
d. “This means that you do not have active TB at this time”

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49. A client experiencing Hepatic Encephalopathy is receiving Lactulose. An irate family
member asks, “Why in the wolr would the doctor give my husband something that gives
him diarrhea when he is already sick?” The nurses’ response would include that the
purpose of the lactulose is to:
a. Reduce fluid retention c. Change ammonia to urea
b. Eliminate Ascites d. Empty the bowel of protein

50. The nurse would assess a knowledge deficit relative to hepatitis immunization when the
client who is recovering from hepatitis A says:
a. “I have an active immunity from hepatitis A.”
b. “Anti-HAV antibodies make me immune form hepatitis A.”
c. “Since I’ve had hepatitis A, I’m Immune from hepatitis B and C.”
d. “Now that I’ve had Hepatitis A, I’m Immune from Hepatitis A.”

Situation: You are taking care of Ms. Quiambao, a 50 year old women who is
unconscious after a cerebrevascular accident. You are aware that there are many
physical complication due to immobility

51. Proper positioning of an immobilized unconscious client is important for the following
reason except:
a. Maintain skin integrity
b. facilitate rest and sleep
c. Promotes optimal lung expansion
d. Prevent injuries and deformities of the musculo-skeletal system

52. You should be alert for the following complication she may experience, Except:
a. Impaired mobility
b. Hypostatic Pneumonia
c. Pressure sores
d. Contracture and muscle atrophy

53. After moving Ms. Quiambao to the desired position, which of the following action will you
avoid?
a. Raise bed rails
b. Avoid friction between bony prominence
c. Place pillows to position client’s extremities
d. Apply restraints

54. When positioning your client, you should observe good body mechanics for your self and
the client. Thes means that the nurse:
a. Assumes correct body alignment and efficient use of muscle to avoid injury
b. Uses Back muscle
c. Uses large muscle only
d. Observes rhythmic movement when moving about

55. You are going to move Ms. Quiambao who weight 150 lbs, unconscious, Some principle is
use when moving the client include the following except:
a. Maintain wide base of support with feet and knees flexed.
b. Prepare to move the client by taking deep breath and tightening abdominal and
gluteal muscle
c. Push and full using arm and legs instead of lifting
d. Move close to the object to be moved leaning or bending at the waist

Situation: The nurse supervisor is observing the staff nurse in her hospital to see
how quality care provide to clients can be improved

56. To check if the nurses under her supervision use critical thinking. Ms. Belen observes if
the nurse act responsibly when at work. Which of the following actions of a nurse
demonstrate the attitude of responsibility?
a. Planning other approached for patient care
b. Thinking of alternative method of nursing care
c. Sharing ideas regarding patient care

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d. Following standards of practice

57. The staff nurses discusses with the novice nurse the type of wound dressing that I best
to use for the client. Together, they observe how well the dressing absorb the drainage.
In what step of decision making process are they?
a. Testing option c. Making Final decision
b. Defining the problem d. Considering affects on result

58. The nurse who makes clinical judgment can depend upon to improve the quality of care
to clients. Nurse Xandra uses such good clinical judgment when she provides priority
care to his client?
a. Mr. Tan, a client who needs instruction fro home medication
b. Felix, A client who is ambulatory and for surgery tomorrow
c. A post-operative client, Angel, who has a blood pressure of 90/50 mmHg
d. April, a client who received pain medication 5 minutes ago

59. The Nurse supervisor is not satisfied with bed bath that is provided by Nurse Josie. To
improve the care provided to the patient in the unit Nurse Josie, the nurse supervisor
should:
a. Ask another staff nurse to do the bed bath instead
b. Bring the staff nurse to a client’s room and demonstrate a cleansing bath
c. Tell the nurse how to give bed baths correctly
d. Ask another staff nurse to do the bed bath instead

60. A good nursing care plan is dependent on a correctly written nursing diagnosis. It defines
a client’s problem and its possible cause. The following is an example of a well written
nursing diagnosis:
a. Acute pain related to altered skin integrity secondary to hysterectomy
b. Altered nutrition related to high fat intake secondary to obesity
c. Knowledge deficit related to proctosigmoidoscopy
d. Electrolyre imbalance related to hypocalcemia

Situation: Nursing Process is utilized in any health care setting whether a nurse is
on a community or clinical settings.

61. A patient was admitted at the hospital with a chief complaint of difficulty of breathing,
proper assessment was done. The type of assessment applicable at this time would be?
a. Initial assessment c. Emergency assessment
b. On- going assessment d. Time-lapsed assessment

45. The nursing diagnosis of your patients consist of statements of:


a. Health problems
b. Medical impression
c. Response to illness
d. Alteration of health

46. Which patient outcome statement meets the necessary criteria?


a. The patient will identify the types of foods to include in a high-fiber diet
b. The nurse will teach the patient about constipation prevention
c. The nurse will increase total fluids during hospitalization
d. The patient will have a soft, formed bowel movement on the third day after
nursing interventions

47. A woman who has had four children comes to the clinic. She tells the nurse that when
she laughs or coughs she “wets her underwear.” The nurse discusses with the patient
exercises that are helpful to reduce the stress incontinence. The nurse teaches the
patient to perform Kegel exercises 25 times a day with 4 to 6 repetitions each time. The
underlined words indicate :
a. The nursing process
b. A nursing diagnosis
c. An outcome statement

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d. A nursing order

48. Which of the following is not a component of a POMR


a. Data base
b. Problem List
c. Medication Sheet
d. Progress Notes

45. The nurse is about to administer Demerol 50mg and Vistaril 50mg IV to the patient.
Demerol is available in a multidose vial labeled 100mg/ml while Vistaril comes in an
ampule labeled 50 mg/ml. You are to give both medication in one injection. You will:
a. Inject air into the vial, then to the ampule
b. Withdraw the medication from the vial then from the ampule
c. Inject air into the ampule, aspirate desired dose, then into the vial
d. Withdraw medication from the ampule then from the vial

21.

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22.B

23.A 43.B 63.A

24.A 44.B 64.D

25.C 45.D 65.A

26.D 46.A 66.D

27.C 47.A 67.B

28.A 48.C 68.D

29.C 49.B 69.C

30.C 50.B 70.B

31.C 51.C 71.B

32.D 52.D 72.C

33.B 53.B 73.C

34.D 54.A 74.D

35.A 55.A 75.D

36.A 56.B 76.C

37.B 57.B 77.B

38.C 58.B 78.D

39.B 59.C 79.C

40.A 60.D 80.B

41.C 61.C 81.A

42.B 62.B

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