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Maternal and Child Health Nursing

1. Accompanied by her husband, a patient seeks admission to the labor and delivery area. The
client states that she is in labor, and says she attended the hospital clinic for prenatal care.
Which question should the nurse ask her first?
a. Do you have any chronic illness?
b. Do you have any allergies?
c. What is your expected due date?
d. Who will be with you during labor?
2. A patient is in the second stage of labor. During this stage, how frequently should the nurse in
charge assess her uterine contractions?
a. Every 5 minutes
b. Every 15 minutes
c. Every 30 minutes
d. Every 60 minutes
3. A patient is in last trimester of pregnancy. Nurse Jane should instruct her to notify her primary
health care provider immediately if she notices:
a. Blurred vision

b. Hemorrhoids
c. Increased vaginal mucus
d. Shortness of breath on exertion
4. The nurse in charge is reviewing a patients prenatal history. Which finding indicates a genetic
risk factor?
a. The patient is 25 years old
b. The patient has a child with cystic fibrosis
c. The patient was exposed to rubella at 36 weeks gestation
d. The patient has a history of preterm labor at 32 weeks gestation
5. A adult female patient is using the rhythm (calendar-basal body temperature) method of
family planning. In this method, the unsafe period for sexual intercourse is indicated by;
a. Return preovulatory basal body temperature
b. Basal body temperature increase of 0.1 degrees to 0.2 degrees on the 2nd or 3rd day of
c. 3 full days of elevated basal body temperature and clear, thin cervical mucus
d. Breast tenderness and mittelschmerz
6. During a nonstress test (NST), the electronic tracing displays a relatively flat line for fetal
movement, making it difficult to evaluate the fetal heart rate (FHR). To mark the strip, the
nurse in charge should instruct the client to push the control button at which time?
a. At the beginning of each fetal movement
b. At the beginning of each contraction
c. After every three fetal movements
d. At the end of fetal movement
7. When evaluating a clients knowledge of symptoms to report during her pregnancy, which
statement would indicate to the nurse in charge that the client understands the information
given to her?
a. Ill report increased frequency of urination.
b. If I have blurred or double vision, I should call the clinic immediately.

c. If I feel tired after resting, I should report it immediately.

d. Nausea should be reported immediately.
8. When assessing a client during her first prenatal visit, the nurse discovers that the client had a
reduction mammoplasty. The mother indicates she wants to breast-feed. What information
should the nurse give to this mother regarding breast-feeding success?
a. Its contraindicated for you to breast-feed following this type of surgery.
b. I support your commitment; however, you may have to supplement each feeding with
c. You should check with your surgeon to determine whether breast-feeding would be
d. You should be able to breast-feed without difficulty.
9. Following a precipitous delivery, examination of the clients vagina reveals a fourth-degree
laceration. Which of the following would be contraindicated when caring for this client?
a. Applying cold to limit edema during the first 12 to 24 hours
b. Instructing the client to use two or more peripads to cushion the area
c. Instructing the client on the use of sitz baths if ordered
d. Instructing the client about the importance of perineal (Kegel) exercises
10. A client makes a routine visit to the prenatal clinic. Although shes 14 weeks pregnant, the
size of her uterus approximates that in an 18- to 20-week pregnancy. Dr. Diaz diagnoses
gestational trophoblastic disease and orders ultrasonography. The nurse expects
ultrasonography to reveal:
a. an empty gestational sac.
b. grapelike clusters.
c. a severely malformed fetus.
d. an extrauterine pregnancy.
11. After completing a second vaginal examination of a client in labor, the nurse-midwife
determines that the fetus is in the right occiput anterior position and at 1 station. Based on
these findings, the nurse-midwife knows that the fetal presenting part is:

a. 1 cm below the ischial spines.

b. directly in line with the ischial spines.
c. 1 cm above the ischial spines.
d. in no relationship to the ischial spines.
12. Which of the following would be inappropriate to assess in a mother whos breast-feeding?
a. The attachment of the baby to the breast.
b. The mothers comfort level with positioning the baby.
c. Audible swallowing.
d. The babys lips smacking
13. During a prenatal visit at 4 months gestation, a pregnant client asks whether tests can be done
to identify fetal abnormalities. Between 18 and 40 weeks gestation, which procedure is used
to detect fetal anomalies?
a. Amniocentesis.
b. Chorionic villi sampling.
c. Fetoscopy.
d. Ultrasound
14. A client, 30 weeks pregnant, is scheduled for a biophysical profile (BPP) to evaluate the
health of her fetus. Her BPP score is 8. What does this score indicate?
a. The fetus should be delivered within 24 hours.
b. The client should repeat the test in 24 hours.
c. The fetus isnt in distress at this time.
d. The client should repeat the test in 1 week.
15. A client whos 36 weeks pregnant comes to the clinic for a prenatal checkup. To assess the
clients preparation for parenting, the nurse might ask which question?
a. Are you planning to have epidural anesthesia?

b. Have you begun prenatal classes?

c. What changes have you made at home to get ready for the baby?
d. Can you tell me about the meals you typically eat each day?
16. A client whos admitted to labor and delivery has the following assessment findings: gravida
2 para 1, estimated 40 weeks gestation, contractions 2 minutes apart, lasting 45 seconds,
vertex +4 station. Which of the following would be the priority at this time?
a. Placing the client in bed to begin fetal monitoring.
b. Preparing for immediate delivery.
c. Checking for ruptured membranes.
d. Providing comfort measures.
17. Nurse Roy is caring for a client in labor. The external fetal monitor shows a pattern of
variable decelerations in fetal heart rate. What should the nurse do first?
a. Change the clients position.
b. Prepare for emergency cesarean section.
c. Check for placenta previa.
d. Administer oxygen.
18. The nurse in charge is caring for a postpartum client who had a vaginal delivery with a
midline episiotomy. Which nursing diagnosis takes priority for this client?
a. Risk for deficient fluid volume related to hemorrhage
b. Risk for infection related to the type of delivery
c. Pain related to the type of incision
d. Urinary retention related to periurethral edema
19. Which change would the nurse identify as a progressive physiological change in postpartum
a. Lactation
b. Lochia

c. Uterine involution
d. Diuresis
20. A 39-year-old at 37 weeks gestation is admitted to the hospital with complaints of vaginal
bleeding following the use of cocaine 1 hour earlier. Which complication is most likely
causing the clients complaint of vaginal bleeding?
a. Placenta previa
b. Abruptio placentae
c. Ectopic pregnancy
d. Spontaneous abortion
21. A client with type 1 diabetes mellitus whos a multigravida visits the clinic at 27 weeks
gestation. The nurse should instruct the client that for most pregnant women with type 1
diabetes mellitus:
a. Weekly fetal movement counts are made by the mother.
b. Contraction stress testing is performed weekly.
c. Induction of labor is begun at 34 weeks gestation.
d. Nonstress testing is performed weekly until 32 weeks gestation
22. When administering magnesium sulfate to a client with preeclampsia, the nurse understands
that this drug is given to:
a. Prevent seizures
b. Reduce blood pressure
c. Slow the process of labor
d. Increase dieresis
23. Whats the approximate time that the blastocyst spends traveling to the uterus for
a. 2 days
b. 7 days

c. 10 days
d. 14 weeks
24. After teaching a pregnant woman who is in labor about the purpose of the episiotomy, which
of the following purposes stated by the client would indicate to the nurse that the teaching was
a. Shortens the second stage of labor
b. Enlarges the pelvic inlet
c. Prevents perineal edema
d. Ensures quick placenta delivery
25. A primigravida client at about 35 weeks gestation in active labor has had no prenatal care and
admits to cocaine use during the pregnancy. Which of the following persons must the nurse
a. Nursing unit manager so appropriate agencies can be notified
b. Head of the hospitals security department
c. Chaplain in case the fetus dies in utero
d. Physician who will attend the delivery of the infant
26. When preparing a teaching plan for a client who is to receive a rubella vaccine during the
postpartum period, the nurse in charge should include which of the following?
a. The vaccine prevents a future fetus from developing congenital anomalies
b. Pregnancy should be avoided for 3 months after the immunization
c. The client should avoid contact with children diagnosed with rubella
d. The injection will provide immunity against the 7-day measles.
27. A client with eclampsia begins to experience a seizure. Which of the following would the
nurse in charge do first?
a. Pad the side rails
b. Place a pillow under the left buttock

c. Insert a padded tongue blade into the mouth

d. Maintain a patent airway
28. While caring for a multigravida client in early labor in a birthing center, which of the
following foods would be best if the client requests a snack?
a. Yogurt
b. Cereal with milk
c. Vegetable soup
d. Peanut butter cookies
29. The multigravida mother with a history of rapid labor who us in active labor calls out to the
nurse, The baby is coming! which of the following would be the nurses first action?
a. Inspect the perineum
b. Time the contractions
c. Auscultate the fetal heart rate
d. Contact the birth attendant
30. While assessing a primipara during the immediate postpartum period, the nurse in charge
plans to use both hands to assess the clients fundus to:
a. Prevent uterine inversion
b. Promote uterine involution
c. Hasten the puerperium period
d. Determine the size of the fundus

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
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
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
4. A client is admitted to the emergency room with renal calculi and is complaining
of moderate to severe flank pain and nausea. The clients 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
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

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
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
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 clients energy level
C) Must be stored in a dark container
D) Will decrease the clients heart rate
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 childs throat
C) Collect a sputum specimen

D) Notify the healthcare provider of the childs status

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
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
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 terminal cancer with an initial
assessment finding 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
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

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 cant 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
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 nurses response?
A) Electrical energy fields
B) Spinal column manipulation
C) Mind-body balance
D) Exercise of joints
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 ability
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

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 clients health care provider for instructions
B) Send him to the emergency room for evaluation
C) Reassure the clients wife that the symptoms are transient
D) Instruct the clients wife to call the doctor if his symptoms become worse
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
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."
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 bulging
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
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 childs 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."
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) D) Ensure that feeding solution is at room temperature
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
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
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
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) D) Limit fluids to non-caffeine beverages
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
29. A nurse enters a clients 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
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
31. While assessing a 1 month-old infant, which finding should the nurse report
A) Abdominal respirations
B) Irregular breathing rate
C) Inspiratory grunt
D) Increased heart rate with crying
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
33. The nurse is caring for a client who had a total hip replacement 4 days ago.
Which assessment requires the nurses immediate attention?
A) I have bad muscle spasms in my lower leg of the affected extremity.
B) "I just cant 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."
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

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
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 clients nutrition status
C) Initiate limb compression therapy
D) Begin proteolytic debridement
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 pre-operative 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) D) Have the client empty bladder
38. Which of these statements best describes the characteristic of an effective
reward-feedback 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
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
40. During the evaluation of the quality of home care for a client with Alzheimers
disease, the priority for the nurse is to reinforce which statement by a family
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.

1. The nursery nurse is putting erythromycin ointment in the newborns eyes to prevent
infection. She places it in the following area of the eye:
a. under the eyelid
b. on the cornea.
c. in the lower conjunctival sac
d. by the optic disc.
2. The physician orders penicillin for a patient with streptococcal pharyngitis. The nurse
administers the drug as ordered, and the patient has an allergic reaction. The nurse checks
the medication order sheet and finds that the patient is allergic to penicillin. Legal
responsibility for the error is:
a. only the nursesshe should have checked the allergies before administering the
b. only the physiciansshe gave the order, the nurse is obligated to follow it.
c. only the pharmacistshe should alert the floor to possible allergic reactions.
d. the pharmacist, physician, and nurse are all liable for the mistake
3. James Perez, a nurse on a geriatric floor, is administering a dose of digoxin to one of his
patients. The woman asks why she takes a different pill than her niece, who also has heart
trouble. James replies that as people get older, liver and kidney function decline, and if
the dose is as high as her nieces, the drug will tend to:
a. have a shorter half-life.
b. accumulate.
c. have decreased distribution.
d. have increased absorption.

4. The nurse is administering Augmentin to her patient with a sinus infection. Which is the
best way for her to insure that she is giving it to the right patient?
a. Call the patient by name
b. Read the name of the patient on the patients door
c. Check the patients wristband
d. Check the patients room number on the unit census list
5. The most important instructions a nurse can give a patient regarding the use of the
antibiotic Ampicillin prescribed for her are to
a. call the physician if she has any breathing difficulties.
b. take it with meals so it doesnt cause an upset stomach.
c. take all of the medication prescribed even if the symptoms stop sooner.
d. not share the pills with anyone else.
6. Mr. Jessie Ray, a newly admitted patient, has a seizure disorder which is being treated
with medication. Which of the following drugs would the nurse question if ordered for
a. Phenobarbitol, 150 mg hs
b. Amitriptylene (Elavil), 10 mg QID.
c. Valproic acid (Depakote), 150 mg BID
d. Phenytoin (Dilantin), 100 mg TID
7. Mrs. Jane Gately has been dealing with uterine cancer for several months. Pain
management is the primary focus of her current admission to your oncology unit. Her
vital signs on admission are BP 110/64, pulse 78, respirations 18, and temperature 99.2 F.
Morphine sulfate 6mg IV, q 4 hours, prn has been ordered. During your assessment after
lunch, your findings are: BP 92/60, pulse 66, respirations 10, and temperature 98.8. Mrs.
Gately is crying and tells you she is still experiencing severe pain. Your action should be
a. give her the next ordered dose of MS.
b. give her a back rub, put on some light music, and dim the lights in the room.
c. report your findings to the RN, requesting an alternate medication order
d. be obtained from the physician.
e. call her daughter to come and sit with her.
8. When counseling a patient who is starting to take MAO (monoamine oxidase) inhibitors
such as Nardil for depression, it is essential that they be warned not to eat foods
containing tyramine, such as:
a. Roquefort, cheddar, or Camembert cheese.
b. grape juice, orange juice, or raisins.
c. onions, garlic, or scallions.
d. ground beef, turkey, or pork.
9. The physician orders an intramuscular injection of Demerol for the postoperativepatients
pain. When preparing to draw up the medication, the nurse is careful to remove the
correct vial from the narcotics cabinet. It is labeled
a. simethicone.
b. albuterol.
c. meperidine.
d. ibuprofen.

10. The nurse is administering an antibiotic to her pediatric patient. She checks the patients
armband and verifies the correct medication by checking the physicians order,
medication kardex, and vial. Which of the following is not considered one of the five
rights of drug administration?
a. Right dose
b. Right route
c. Right frequency
d. Right time
11. A nurse is preparing the clients 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
12. 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. b. take the medication with an antacid
c. c. avoid exposure to sunlight
d. d. limit alcohol to 2 ounces per day
13. 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
14. 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. b. ibuprofen (Motrin)
c. c. acetaminophen (Tylenol)
d. d. naproxen (Naprosyn)
15. 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. b. bananas
c. c. oranges
d. d. pears canned in water
16. 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)

17. 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
18. 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 immediately
19. 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. b. diarrhea
c. c. anorexia
d. d. proteinuria
20. 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

1. C. The ointment is placed in the lower conjunctival sac so it will not scratch the eye
itself and will get well distributed.
2. D. The physician, nurse, and pharmacist all are licensed professionals and share
responsibility for errors.
3. B. The decreased circulation to the kidney and reduced liver function tend to allow
drugs to accumulate and have toxic effects.
4. C. The correct way to identify a patient before giving a medication is to check the
name on the medication administration record with the patients identification band. The
nurse should also ask the patient to state their name. The name on the door or the census
list are not sufficient proof of identification. Calling the patient by name is not as
effective as having the patient state their name; patients may not hear well or understand
what the nurse is saying, and may respond to a name which is not their own.

5. C. Frequently patients do not complete an entire course of antibiotic therapy, and the
bacteria are not destroyed.
6. B. Elavil is an antidepressant that lowers the seizure threshold, so would not be
appropriate for this patient. The other medications are anti-seizure drugs.
7. C. Morphine sulfate depresses the respiratory center. When the rate is less than 10, the MD
should be notified.
8. A. Monoamine oxidase inhibitors react with foods high in the amino acid tyramine to
cause dangerously high blood pressure. Aged cheeses are all high in this amino acid; the
other foods are not.
9. C. The generic name for Demerol is meperidine.
10. C. The five rights of medication administration are right drug, right dose, right route,
right time, right patient. Frequency is not included.
11. C. The nurse should always inspect the vial of insulin before use for solution changes
that may signify loss of potency. NPH insulin is normally uniformly cloudy. Clumping,
frosting, and precipitates are signs of insulin damage. In this situation, because potency is
questionable, it is safer to discard the vial and draw up the dose from a new vial.
12. C. The client should be taught that ketoconazole is an antifungal medication. It should
be taken with food or milk. Antacids should be avoided for 2 hours after it is taken
because gastric acid is needed to activate the medication. The client should avoid
concurrent use of alcohol, because the medication is hepatotoxic. The client should also
avoid exposure to sunlight, because the medication increases photosensitivity.
13. B. Cola, coffee, and chocolate contain xanthine and should be avoided by the client
taking a xanthine bronchodilator. This could lead to an increased incidence of cardiovascular
and central nervous system side effects that can occur with the use of these types of
14. C. The client is taking famotidine, a histamine receptor antagonist. This implies that
the client has a disorder characterized by gastrointestinal (GI) irritation. The only
medication of the ones listed in the options that is not irritating to the GI tract is
acetaminophen. The other medications could aggravate an already existing GI problem.
15. D. Triamterene is a potassium-sparing diuretic, and clients taking this medication should
be cautioned against eating foods that are high in potassium, including many vegetables,
fruits, and fresh meats. Because potassium is very water-soluble, foods that are prepared in
water are often lower in potassium.
16. A. The client with cirrhosis has impaired ability to metabolize protein because of liver
dysfunction. Administration of lactulose aids in the clearance of ammonia via the

gastrointestinal (GI) tract. Ethacrynic acid is a diuretic. Folic acid and thiamine are
vitamins, which may be used in clients with liver disease as supplemental therapy.
17. A. Glycerin is an emollient that is used for dry, cracked, and irritated skin. Aspercreame
and Myoflex are used to treat muscular aches. Acetic acid solution is used for irrigating,
cleansing, and packing wounds infected by Pseudomonas aeruginosa.
18. B. Accupril is an angiotensin-converting enzyme (ACE) inhibitor. It is used in the
treatment of hypertension. The client should be instructed to rise slowly from a lying to
sitting position and to permit the legs to dangle from the bed momentarily before standing
to reduce the hypotensive effect. The medication does not need to be taken with meals. It
may be given without regard to food. If nausea occurs, the client should be instructed to
take a noncola carbonated beverage and salted crackers or dry toast. A full therapeutic
effect may be noted in 1 to 2 weeks.
19. D. Auranofin (Ridaura) is a gold preparation that is used as an antirheumatic. Gold
toxicity is an adverse effect and is evidenced by decreased hemoglobin, leukopenia,
reduced granulocyte counts, proteinuria, hematuria, stomatitis, glomerulonephritis,
nephrotic syndrome, or cholestatic jaundice. Anorexia, nausea, and diarrhea are frequent
side effects of the medication.
20. B. Benzonatate is a locally acting antitussive. Its effectiveness is measured by the degree
to which it decreases the intensity and frequency of cough, without eliminating the cough

1. The parents of a child, age 5, who will begin school in the fall ask the nurse for anticipatory
guidance. The nurse should explain that a child of this age:
a. Still depends on the parents
b. Rebels against scheduled activities
c. Is highly sensitive to criticism
d. Loves to tattle
2. While preparing to discharge an 8-month-old infant who is recovering from gastroenteritis
and dehydration, the nurse teaches the parents about their infants dietary and fluid requirements.
The nurse should include which other topic in the teaching session?
a. Nursery schools
b. Toilet Training
c. Safety guidelines
d. Preparation for surgery
3. Nurse Betina should begin screening for lead poisoning when a child reaches which age?
a. 6 months
b. 12 months

c. 18 months
d. 24 months
4. When caring for an 11-month-old infant with dehydration and metabolic acidosis, the nurse
expects to see which of the following?
a. A reduced white blood cell count
b. A decreased platelet count
c. Shallow respirations
d. Tachypnea
5. After the nurse provides dietary restrictions to the parents of a child with celiac disease,
which statement by the parents indicates effective teaching?
a. Well follow these instructions until our childs symptoms disappear.
b. Our child must maintain these dietary restrictions until adulthood.
c. Our child must maintain these dietary restrictions lifelong.
d. Well follow these instructions until our child has completely grown and developed.
6. A parent brings a toddler, age 19 months, to the clinic for a regular check-up. When
palpating the toddlers fontanels, what should the nurse expects to find?
a. Closed anterior fontanel and open posterior fontanel
b. Open anterior and fontanel and closed posterior fontanel
c. Closed anterior and posterior fontanels
d. Open anterior and posterior fontanels
7. Patrick, a healthy adolescent has meningitis and is receiving I.V. and oral fluids. The nurse
should monitor this clients fluid intake because fluid overload may cause:
a. Cerebral edema
b. Dehydration
c. Heart failure
d. Hypovolemic shock
8. An infant is hospitalized for treatment of nonorganic failure to thrive. Which nursing action
is most appropriate for this infant?
a. Encouraging the infant to hold a bottle
b. Keeping the infant on bed rest to conserve energy
c. Rotating caregivers to provide more stimulation
d. Maintaining a consistent, structured environment
9. The mother of Gian, a preschooler with spina bifida tells the nurse that her daughter sneezes
and gets a rash when playing with brightly colored balloons, and that she recently had an allergic
reaction after eating kiwifruit and bananas. The nurse would suspect that the child may have an
allergy to:
a. Bananas
b. Latex
c. Kiwifruit
d. Color dyes

10. Cristina, a mother of a 4-year-old child tells the nurse that her child is a very poor eater.
Whats the nurses best recommendation for helping the mother increase her childs nutritional
a. Allow the child to feed herself
b. Use specially designed dishes for children for example, a plate with the childs favorite
cartoon character
c. Only serve the childs favorite foods
d. Allow the child to eat at a small table and chair by herself
11. Nurse Roy is administering total parental nutrition (TPN) through a peripheral I.V. line to a
school-age child. Whats the smallest amount of glucose thats considered safe and not caustic to
small veins, while also providing adequate TPN?
a. 5% glucose
b. 10% glucose
c. 15% glucose
d. 17% glucose
12. David, age 15 months, is recovering from surgery to remove Wilms tumor. Which
findings best indicates that the child is free from pain?
a. Decreased appetite
b. Increased heart rate
c. Decreased urine output
d. Increased interest in play
13. When planning care for a 8-year-old boy with Down syndrome, the nurse should:
a. Plan interventions according to the developmental level of a 7-year-old child because thats
the childs age
b. Plan interventions according to the developmental levels of a 5-year-old because the child
will have developmental delays
c. Assess the childs current developmental level and plan care accordingly
d. Direct all teaching to the parents because the child cant understand
14. Nurse Victoria is teaching the parents of a school-age child. Which teaching topic should
take priority?
a. Prevent accidents
b. Keeping a night light on to allay fears
c. Explaining normalcy of fears about body integrity
d. Encouraging the child to dress without help
15. The nurse is finishing her shift on the pediatric unit. Because her shift is ending, which
intervention takes top priority?
a. Changing the linens on the clients beds
b. Restocking the bedside supplies needed for a dressing change on the upcoming shift
c. Documenting the care provided during her shift
d. Emptying the trash cans in the assigned client room

16. Nurse Alice is providing cardiopulmonary resuscitation (CPR) to a child, age 4. the nurse
a. Compress the sternum with both hands at a depth of 1 to 2 (4 to 5 cm)
b. Deliver 12 breaths/minute
c. Perform only two-person CPR
d. Use the heel of one hand for sternal compressions
17. A 4-month-old with meningococcal meningitis has just been admitted to the pediatric unit.
Which nursing intervention has the highest priority?
a. Instituting droplet precautions
b. Administering acetaminophen (Tylenol)
c. Obtaining history information from the parents
d. Orienting the parents to the pediatric unit
18. Sheena, tells the nurse that she wants to begin toilet training her 22-month-old child. The
most important factor for the nurse to stress to the mother is:
a. Developmental readiness of the child
b. Consistency in approach
c. The mothers positive attitude
d. Developmental level of the childs peers
19. An infant who has been in foster care since birth requires a blood transfusion. Who is
authorized to give written, informed consent for the procedure?
a. The foster mother
b. The social worker who placed the infant in the foster home
c. The registered nurse caring for the infant
d. The nurse-manager
20. A child is undergoing remission induction therapy to treat leukemia. Allopurinol is
included in the regimen. The main reason for administering allopurinol as part of the clients
chemotherapy regimen is to:
a. Prevent metabolic breakdown of xanthine to uric acid
b. Prevent uric acid from precipitating in the ureters
c. Enhance the production of uric acid to ensure adequate excretion of urine
d. Ensure that the chemotherapy doesnt adversely affect the bone marrow
21. A 10-year-old client contracted severe acute respiratory syndrome (SARS) when traveling
abroad with her parents. The nurse knows she must put on personal protective equipment to
protect herself while providing care. Based on the mode of SARS transmission, which personal
protective should the nurse wear?
a. Gloves
b. Gown and gloves
c. Gown, gloves, and mask
d. Gown, gloves, mask, and eye goggles or eye shield

22. A tuberculosis intradermal skin test to detect tuberculosis infection is given to a high-risk
adolescent. How long after the test is administered should the result be evaluated?
a. Immediately
b. Within 24 hours
c. In 48 to 72 hours
d. After 5 days
23. Nurse Oliver s teaching a mother who plans to discontinue breast-feeding after 5 months.
The nurse should advise her to include which foods in her infants diet?
a. Iron-rich formula and baby food
b. Whole milk and baby food
c. Skim milk and baby food
d. Iron-rich formula only
24. Gracie, the mother of a 3-month-old infant calls the clinic and states that her child has a
diaper rash. What should the nurse advise?
a. Switch to cloth diapers until the rash is gone
b. Use baby wipes with each diaper change.
c. Leave the diaper off while the infant sleeps.
d. Offer extra fluids to the infant until the rash improves.
25. Nurse Kelly is teaching the parents of a young child how to handle poisoning. If the child
ingests poison, what should the parents do first?
a. Administer ipecac syrup
b. Call an ambulance immediately
c. Call the poison control center
d. Punish the child for being bad
26. A child has third-degree burns of the hands, face, and chest. Which nursing diagnosis takes
a. Ineffective airway clearance related to edema
b. Disturbed body image related to physical appearance
c. Impaired urinary elimination related to fluid loss
d. Risk for infection related to epidermal disruption
27. A 3-year-old child is receiving dextrose 5% in water and half-normal saline solution at 100
ml/hour. Which sign or symptom suggests excessive I.V. fluid intake?
a. Worsening dyspnea
b. Gastric distension
c. Nausea and vomiting
d. Temperature of 102F (38.9 C)
28. Which finding would alert a nurse that a hospitalized 6-year-old child is at risk for a severe
asthma exacerbation?
a. Oxygen saturation of 95%
b. Mild work of breathing

c. Absence of intercostals or substernal retractions

d. History of steroid-dependent asthma
29. Nurse Mariane is caring for an infant with spina bifida. Which technique is most important
in recognizing possible hydrocephalus?
a. Measuring head circumference
b. Obtaining skull X-ray
c. Performing a lumbar puncture
d. Magnetic resonance imaging (MRI)
30. An adolescent who sustained a tibia fracture in a motor vehicle accident has a cast. What
should the nurse do to help relieve the itching?
a. Apply cool air under the cast with a blow-dryer
b. Use sterile applicators to scratch the itch
c. Apply cool water under the cast
d. Apply hydrocortisone cream under the cast using sterile applicator.

1. Which of the following would be inappropriate when administering chemotherapy to a child?
a. Monitoring the child for both general and specific adverse effects
b. Observing the child for 10 minutes to note for signs of anaphylaxis
c. Administering medication through a free-flowing intravenous line
d. Assessing for signs of infusion infiltration and irritation
2. Which of the following is the best method for performing a physical examination on a toddler
a. From head to toe
b. Distally to proximally
c. From abdomen to toes, the to head
d. From least to most intrusive
3. Which of the following organisms is responsible for the development of rheumatic fever?
a. Streptococcal pneumonia
b. Haemophilus influenza
c. Group A -hemolytic streptococcus

d. Staphylococcus aureus
4. Which of the following is most likely associated with a cerebrovascular accident (CVA)
resulting from congenital heart disease?
a. Polycythemia
b. Cardiomyopathy
c. Endocarditis
d. Low blood pressure
5. How does the nurse appropriately administer mycostatin suspension in an infant?
a. Have the infant drink water, and then administer mycostatin in a syringe
b. Place mycostatin on the nipple of the feeding bottle and have the infant suck it
c. Mix mycostatin with formula
d. Swab mycostatin on the affected areas
6. A mother tells the nurse that she is very worried because her 2-year old child does not finish
his meals. What should the nurse advise the mother?
a. make the child seat with the family in the dining room until he finishes his meal
b. provide quiet environment for the child before meals
c. do not give snacks to the child before meals
d. put the child on a chair and feed him
7. The nurse is assessing a newborn who had undergone vaginal delivery. Which of the
following findings is least likely to be observed in a normal newborn?
a. uneven head shape
b. respirations are irregular, abdominal, 30-60 bpm
c. (+) moro reflex
d. heart rate is 80 bpm
8. Which of the following situations increase risk of lead poisoning in children?

a. playing in the park with heavy traffic and with many vehicles passing by
b. playing sand in the park
c. playing plastic balls with other children
d. playing with stuffed toys at home
9. An inborn error of metabolism that causes premature destruction of RBC?
a. G6PD
b. Hemocystinuria
c. Phenylketonuria
d. Celiac Disease
10. Which of the following blood study results would the nurse expect as most likely when
caring for the child with iron deficiency anemia?
a. Increased hemoglobin
b. Normal hematocrit
c. Decreased mean corpuscular volume (MCV)
d. Normal total iron-binding capacity (TIBC)
11. The nurse answers a call bell and finds a frightened mother whose child, the patient, is
having a seizure. Which of these actions should the nurse take?
a. The nurse should insert a padded tongue blade in the patients mouth to prevent the
child from swallowing or choking on his tongue.
b. The nurse should help the mother restrain the child to prevent him from injuring
c. The nurse should call the operator to page for seizure assistance.
d. The nurse should clear the area and position the client safely.
12. At the community center, the nurse leads an adolescent health information group, which
often expands into other areas of discussion. She knows that these youths are trying to find
out who they are, and discussion often focuses on which directions they want to take in
school and life, as well as peer relationships. According to Erikson, this stage is known as:

a. identity vs. role confusion.

b. adolescent rebellion.
c. career experimentation.
d. relationship testing
13. The nurse is assessing a 9-month-old boy for a well-baby check up. Which of the following
observations would be of most concern?
a. The baby cannot say mama when he wants his mother.
b. The mother has not given him finger foods.
c. The child does not sit unsupported.
d. The baby cries whenever the mother goes out.
14. Cheska, the mother of an 11-month-old girl, KC, is in the clinic for her daughters
immunizations. She expresses concern to the nurse that Shannon cannot yet walk. The nurse
correctly replies that, according to the Denver Developmental Screen, the median age for
walking is:
a. 12 months.
b. 15 months.
c. 10 months.
d. 14 months.
15. Sally Kent., age 13, has had a lumbar puncture to examine the CSF to determine if bacterial
infection exists. The best position to keep her in after the procedure is:
a. prone for two hours to prevent aspiration, should she vomit.
b. semi-fowlers so she can watch TV for five hours and be entertained.
c. supine for several hours, to prevent headache.
d. on her right sides to encourage return of CSF
16. Bucks traction with a 10 lb. weight is securing a patients leg while she is waiting for
surgery to repair a hip fracture. It is important to check circulation- sensation-movement:

a. every shift.
b. every day.
c. every 4 hours.
d. every 15 minutes.
17. Carol Smith is using bronchodilators for asthma. The side effects of these drugs that you
need to monitor this patient for include:
a. tachycardia, nausea, vomiting, heart palpitations, inability to sleep, restlessness, and
b. tachycardia, headache, dyspnea, temp . 101 F, and wheezing.
c. blurred vision, tachycardia, hypertension, headache, insomnia, and oliguria.
d. restlessness, insomnia, blurred vision, hypertension, chest pain, and muscle weakness.
18. The adolescent patient has symptoms of meningitis: nuchal rigidity, fever, vomiting, and
lethargy. The nurse knows to prepare for the following test:
a. blood culture.
b. throat and ear culture.
c. CAT scan.
d. lumbar puncture.
19. The nurse is drawing blood from the diabetic patient for a glycosolated hemoglobin test. She
explains to the woman that the test is used to determine:
a. the highest glucose level in the past week.
b. her insulin level.
c. glucose levels over the past several months.
d. her usual fasting glucose level.
20. The twelve-year-old boy has fractured his arm because of a fall from his bike. After the
injury has been casted, the nurse knows it is most important to perform all of the following
assessments on the area distal to the injury except:

a. capillary refill.
b. radial and ulnar pulse.
c. finger movement
d. skin integrity


1. B. When administering chemotherapy, the nurse should observe for an anaphylactic reaction
for 20 minutes and stop the medication if one is suspected. Chemotherapy is associated with both
general and specific adverse effects, therefore close monitoring for them is important.
2. D. When examining a toddler or any small child, the best way to perform the exam is from
least to most intrusive. Starting at the head or abdomen is intrusive and should be avoided.
Proceeding from distal to proximal is inappropriate at any age.
3. C. Rheumatic fever results as a delayed reaction to inadequately treated group A -hemolytic
streptococcal infection.
4. A. The child with congenital heart disease develops polycythemia resulting from an
inadequate mechanism to compensate for decreased oxygen saturation
5. D. Mycostatin suspension is given as swab. Never mix medications with food and formula.
6. C. If the child is hungry he/she more likely would finish his meals. Therefore, the mother
should be advised not to give snacks to the child. The child is a busy toddler. He/she will not
able to keep still for a long time.
7. D. Normal heart rate of the newborn is 120 to 160 bpm. Choices A, B, and C are normal
assessment findings (uneven head shape is molding).
8. A. Lead poisoning may be caused by inhalation of dusk and smoke from leaded gas. It may
also be caused by lead-based paint, soil, water (especially from plumbings of old houses).
9. A. Glucose-6-phosphate dehydrogenase deficiency (G6PD) is an X-linked recessive hereditary
disease characterised by abnormally low levels of glucose-6-phosphate dehydrogenase
(abbreviated G6PD or G6PDH), a metabolic enzyme involved in the pentose phosphate pathway,
especially important in red blood cell metabolism.

10. C. For the child with iron deficiency anemia, the blood study results most likely would reveal
decreased mean corpuscular volume (MCV) which demonstrates microcytic anemia, decreased
hemoglobin, decreased hematocrit and elevated total iron binding capacity.
11. D. The primary role of the nurse when a patient has a seizure is to protect the patient from
harming him or herself.
12. A. During this period, which lasts up to the age of 18-21 years, the individual develops a
sense of self. Peers have a major big influence over behavior, and the major decision is to
determine a vocational goal.
13. C. Over 90% percent of babies can sit unsupported by nine months. Most babies cannot say
mama in the sense that it refers to their mother at this time.
14. A. By 12 months, 50 percent of children can walk well.
15. C. Lying flat keeps the patient from having a spinal headache. Increasing the fluid intake
will assist in replenishing the lost fluid during this time.
16. C. The patient can lose vascular status without the nurse being aware if left for more than 4
hours, yet checks should not be so frequent that the patient becomes anxious. Vital signs are
generally checked q4h, at which time the CSM checks can easily be performed.
17. A. Bronchodilators can produce the side effects listed in answer choice (A) for a short time
after the patient begins using them.
18. D. Meningitis is an infection of the meninges, the outer membrane of the brain. Since it is
surrounded by cerebrospinal fluid, a lumbar puncture will help to identify the organism involved.
19. C. The glycosolated hemoglobin test measures glucose levels for the previous 3 to 4 months.
20. D. Capillary refill, pulses, and skin temperature and color are indicative of intact circulation
and absence of compartment syndrome. Skin integrity is less important.


1. The nurse is performing her admission assessment of a patient. When grading arterial
pulses, a 1+ pulse indicates:
a. Above normal perfusion.
b. Absent perfusion.
c. Normal perfusion.
d. Diminished perfusion.
2. Murmurs that indicate heart disease are often accompanied by other symptoms such as:
a. Dyspnea on exertion.
b. Subcutaneous emphysema.
c. Thoracic petechiae.

d. Periorbital edema.
3. Which pregnancy-related physiologic change would place the patient with a history of
cardiac disease at the greatest risk of developing severe cardiac problems?
a. Decrease heart rate
b. Decreased cardiac output
c. Increased plasma volume
d. Increased blood pressure
4. The priority nursing diagnosis for the patient with cardiomyopathy is:
a. Anxiety related to risk of declining health status.
b. Ineffective individual coping related to fear of debilitating illness
c. Fluid volume excess related to altered compensatory mechanisms.
d. Decreased cardiac output related to reduced myocardial contractility.
5. A patient with thrombophlebitis reached her expected outcomes of care. Her affected leg
appears pink and warm. Her pedal pulse is palpable and there is no edema present. Which
step in the nursing process is described above?
a. Planning
b. Implementation
c. Analysis
d. Evaluation
6. An elderly patient may have sustained a basilar skull fracture after slipping and falling on
an icy sidewalk. The nurse knows that basilar skull factures:
a. Are the least significant type of skull fracture.
b. May have cause cerebrospinal fluid (CSF) leaks from the nose or ears.
c. Have no characteristic findings.
d. Are always surgically repaired.
7. Which of the following types of drugs might be given to control increased intracranial
pressure (ICP)?
a. Barbiturates
b. Carbonic anhydrase inhibitors
c. Anticholinergics
d. Histamine receptor blockers
8. The nurse is teaching family members of a patient with a concussion about the early signs
of increased intracranial pressure (ICP). Which of the following would she cite as an
early sign of increased ICP?
a. Decreased systolic blood pressure
b. Headache and vomiting
c. Inability to wake the patient with noxious stimuli
d. Dilated pupils that dont react to light
9. Jessie James is diagnosed with retinal detachment. Which intervention is the most
important for this patient?
a. Admitting him to the hospital on strict bed rest
b. Patching both of his eyes
c. Referring him to an ophthalmologist
d. Preparing him for surgery
10. Dr. Bruce Owen, a chemist, sustained a chemical burn to one eye. Which intervention
takes priority for a patient with a chemical burn of the eye?

a. Patch the affected eye and call the ophthalmologist.

b. Administer a cycloplegic agent to reduce ciliary spasm.
c. Immediately instill a tropical anesthetic, then irrigate the eye with saline solution.
d. Administer antibiotics to reduce the risk of infection
11. The nurse is assessing a patient and notes a Brudzinskis sign and Kernigs sign. These
are two classic signs of which of the following disorders?
a. Cerebrovascular accident (CVA)
b. Meningitis
c. Seizure disorder
d. Parkinsons disease
12. A patient is admitted to the hospital for a brain biopsy. The nurse knows that the most
common type of primary brain tumor is:
a. Meningioma.
b. Angioma.
c. Hemangioblastoma.
d. Glioma.
13. The nurse should instruct the patient with Parkinsons disease to avoid which of the
a. Walking in an indoor shopping mall
b. Sitting on the deck on a cool summer evening
c. Walking to the car on a cold winter day
d. Sitting on the beach in the sun on a summer day
14. Gary Jordan suffered a cerebrovascular accident that left her unable to comprehend
speech and unable to speak. This type of aphasia is known as:
a. Receptive aphasia
b. Expressive aphasia
c. Global aphasia
d. Conduction aphasia
15. Kelly Smith complains that her headaches are occurring more frequently despite
medications. Patients with a history of headaches should be taught to avoid:
a. Freshly prepared meats.
b. Citrus fruits.
c. Skim milk
d. Chocolate
16. Immediately following cerebral aneurysm rupture, the patient usually complains of:
a. Photophobia
b. Explosive headache
c. Seizures
d. Hemiparesis
17. Which of the following is a cause of embolic brain injury?
a. Persistent hypertension
b. Subarachnoid hemorrhage
c. Atrial fibrillation
d. Skull fracture
18. Although Ms. Priestly has a spinal cord injury, she can still have sexual intercourse.
Discharge teaching should make her aware that:

a. She must remove indwelling urinary catheter prior to intercourse.

b. She can no longer achieve orgasm.
c. Positioning may be awkward.
d. She can still get pregnant.
19. Ivy Hopkins, age 25, suffered a cervical fracture requiring immobilization with halo
traction. When caring for the patient in halo traction, the nurse must:
a. Keep a wrench taped to the halo vest for quick removal if cardiopulmonary
resuscitation is necessary.
b. Remove the brace once a day to allow the patient to rest.
c. Encourage the patient to use a pillow under the ring.
d. Remove the brace so that the patient can shower.
20. The nurse asks a patients husband if he understands why his wife is receiving
nimodipine (Nimotop), since she suffered a cerebral aneurysm rupture. Which response
by the husband indicates that he understands the drugs use?
a. Nimodipine replaces calcium.
b. Nimodipine promotes growth of blood vessels in the brain.
c. Nimodipine reduces the brains demand for oxygen.
d. Nimodipine reduces vasospasm in the brain.
21. Many men who suffer spinal injuries continue to be sexually active. The teaching plan for
a man with a spinal cord injury should include sexually concerns. Which of the following
injuries would most likely prevent erection and ejaculation?
a. C5
b. C7
c. T4
d. S4
22. Cathy Bates, age 36, is a homemaker who frequently forgets to take her carbamazepine
(Tegretol). As a result, she has been experiencing seizures. How can the nurse best help
the patient remember to take her medication?
a. Tell her take her medication at bedtime.
b. Instruct her to take her medication after one of her favorite television shows.
c. Explain that she should take her medication with breakfast.
d. Tell her to buy an alarm watch to remind her.
23. Richard Barnes was diagnosed with pneumococcal meningitis. What response by the
patient indicates that he understands the precautions necessary with this diagnosis?
a. Im so depressed because I cant have any visitors for a week.
b. Thank goodness, Ill only be in isolation for 24 hours.
c. The nurse told me that my urine and stool are also sources of meningitis
d. The doctor is a good friend of mine and wont keep me in isolation.
24. An early symptom associated with amyotrophic lateral sclerosis (ALS) includes:
a. Fatigue while talking
b. Change in mental status
c. Numbness of the hands and feet
d. Spontaneous fractures
25. When caring for a patient with esophageal varices, the nurse knows that bleeding in this
disorder usually stems from:

a. Esophageal perforation
b. Pulmonary hypertension
c. Portal hypertension
d. Peptic ulcers
26. Tiffany Black is diagnosed with type A hepatitis. What special precautions should the
nurse take when caring for this patient?
a. Put on a mask and gown before entering the patients room.
b. Wear gloves and a gown when removing the patients bedpan.
c. Prevent the droplet spread of the organism.
d. Use caution when bringing food to the patient.
27. Discharge instructions for a patient who has been operated on for colorectal cancer
include irrigating the colostomy. The nurse knows her teaching is effective when the
patient states hell contact the doctor if:
a. He experiences abdominal cramping while the irrigant is infusing
b. He has difficulty inserting the irrigation tube into the stoma
c. He expels flatus while the return is running out
d. Hes unable to complete the procedure in 1 hour
28. The nurse explains to the patient who has an abdominal perineal resection that an
indwelling urinary catheter must be kept in place for several days afterward because:
a. It prevents urinary tract infection following surgery
b. It prevents urine retention and resulting pressure on the perineal wound
c. It minimizes the risk of wound contamination by the urine
d. It determines whether the surgery caused bladder trauma
29. The first day after, surgery the nurse finds no measurable fecal drainage from a patients
colostomy stoma. What is the most appropriate nursing intervention?
a. Call the doctor immediately.
b. Obtain an order to irrigate the stoma.
c. Place the patient on bed rest and call the doctor.
d. Continue the current plan of care.
30. If a patients GI tract is functioning but hes unable to take foods by mouth, the preferred
method of feeding is:
a. Total parenteral nutrition
b. Peripheral parenteral nutrition
c. Enteral nutrition
d. Oral liquid supplements
31. Which type of solution causes water to shift from the cells into the plasma?
a. Hypertonic
b. Hypotonic
c. Isotonic
d. Alkaline
32. Particles move from an area of greater osmelarity to one of lesser osmolarity through:
a. Active transport
b. Osmosis
c. Diffusion
d. Filtration
33. Which assessment finding indicates dehydration?

a. Tenting of chest skin when pinched

b. Rapid filling of hand veins
c. A pulse that isnt easily obliterated
d. Neck vein distention
34. Which nursing intervention would most likely lead to a hypo-osmolar state?
a. Performing nasogastric tube irrigation with normal saline solution
b. Weighing the patient daily
c. Administering tap water enema until the return is clear
d. Encouraging the patient with excessive perspiration to dink broth
35. Which assessment finding would indicate an extracellular fluid volume deficit?
a. Bradycardia
b. A central venous pressure of 6 mm Hg
c. Pitting edema
d. An orthostatic blood pressure change
36. A patient with metabolic acidosis has a preexisting problem with the kidneys. Which
other organ helps regulate blood pH?
a. Liver
b. Pancreas
c. Lungs
d. heart
37. The nurse considers the patient anuric if the patient;
a. Voids during the nighttime hours
b. Has a urine output of less than 100 ml in 24 hours
c. Has a urine output of at least 100 ml in 2 hours
d. Has pain and burning on urination
38. Which nursing action is appropriate to prevent infection when obtaining a sterile urine
specimen from an indwelling urinary catheter?
a. Aspirate urine from the tubing port using a sterile syringe and needle
b. Disconnect the catheter from the tubing and obtain urine
c. Open the drainage bag and pour out some urine
d. Wear sterile gloves when obtaining urine
39. After undergoing a transurethral resection of the prostate to treat benign prostatic
hypertrophy, a patient is retuned to the room with continuous bladder irrigation in place.
One day later, the patient reports bladder pain. What should the nurse do first?
a. Increase the I.V. flow rate
b. Notify the doctor immediately
c. Assess the irrigation catheter for patency and drainage
d. Administer meperidine (Demerol) as prescribed
40. A patient comes to the hospital complaining of sudden onset of sharp, severe pain
originating in the lumbar region and radiating around the side and toward the bladder.
The patient also reports nausea and vomiting and appears pale, diaphoretic, and anxious.
The doctor tentatively diagnoses renal calculi and orders flat-plate abdominal X-rays.
Renal calculi can form anywhere in the urinary tract. What is their most common
formation site?
a. Kidney
b. Ureter

c. Bladder
d. Urethra
41. A patient comes to the hospital complaining of severe pain in the right flank, nausea, and
vomiting. The doctor tentatively diagnoses right ureter-olithiasis (renal calculi). When
planning this patients care, the nurse should assign highest priority to which nursing
a. Pain
b. Risk of infection
c. Altered urinary elimination
d. Altered nutrition: less than body requirements
42. The nurse is reviewing the report of a patients routine urinalysis. Which of the following
values should the nurse consider abnormal?
a. Specific gravity of 1.002
b. Urine pH of 3
c. Absence of protein
d. Absence of glucose
43. A patient with suspected renal insufficiency is scheduled for a comprehensive diagnostic
work-up. After the nurse explains the diagnostic tests, the patient asks which part of the
kidney does the work. Which answer is correct?
a. The glomerulus
b. Bowmans capsule
c. The nephron
d. The tubular system
44. During a shock state, the renin-angiotensin-aldosterone system exerts which of the
following effects on renal function?
a. Decreased urine output, increased reabsorption of sodium and water
b. Decreased urine output, decreased reabsorption of sodium and water
c. Increased urine output, increased reabsorption of sodium and water
d. Increased urine output, decreased reabsorption of sodium and water
45. While assessing a patient who complained of lower abdominal pressure, the nurse notes a
firm mass extending above the symphysis pubis. The nurse suspects:
a. A urinary tract infection
b. Renal calculi
c. An enlarged kidney
d. A distended bladder
46. Gregg Lohan, age 75, is admitted to the medical-surgical floor with weakness and leftsided chest pain. The symptoms have been present for several weeks after a viral illness.
Which assessment finding is most symptomatic of pericarditis?
a. Pericardial friction rub
b. Bilateral crackles auscultated at the lung bases
c. Pain unrelieved by a change in position
d. Third heart sound (S3)
47. James King is admitted to the hospital with right-side-heart failure. When assessing him
for jugular vein distention, the nurse should position him:
a. Lying on his side with the head of the bed flat.
b. Sitting upright.

c. Flat on his back.

d. Lying on his back with the head of the bed elevated 30 to 45 degrees.
48. The nurse is interviewing a slightly overweight 43-year-old man with mild emphysema
and borderline hypertension. He admits to smoking a pack of cigarettes per day. When
developing a teaching plan, which of the following should receive highest priority to help
decrease respiratory complications?
a. Weight reduction
b. Decreasing salt intake
c. Smoking cessation
d. Decreasing caffeine intake
49. What is the ratio of chest compressions to ventilations when one rescuer performs
cardiopulmonary resuscitation (CPR) on an adult?
a. 15:1
b. 15:2
c. 12:1
d. 12:2
50. When assessing a patient for fluid and electrolyte balance, the nurse is aware that the
organs most important in maintaining this balance are the:
a. Pituitary gland and pancreas
b. Liver and gallbladder.
c. Brain stem and heart.
d. Lungs and kidneys.


1. Answer: D
A 1+ pulse indicates weak pulses and is associated with diminished perfusion. A 4+ is
bounding perfusion, a 3+ is increased perfusion, a 2+ is normal perfusion, and 0 is absent
2. Answer: A
A murmur that indicates heart disease is often accompanied by dyspnea on exertion,
which is a hallmark of heart failure. Other indicators are tachycardia, syncope, and chest
pain. Subcutaneous emphysema, thoracic petechiae, and perior-bital edema arent
associated with murmurs and heart disease.
3. Answer: C
Pregnancy increase plasma volume and expands the uterine vascular bed, possibly
increasing both the heart rate and cardiac output. These changes may cause cardiac stress,
especially during the second trimester. Blood pressure during early pregnancy may
decrease, but it gradually returns to prepregnancy levels.
4. Answer: D
Decreased cardiac output related to reduced myocardial contractility is the greatest threat
to the survival of a patient with cardiomyopathy. The other options can be addressed once
cardiac output and myocardial contractility have been restored.

5. Answer: D
Evaluation assesses the effectiveness of the treatment plan by determining if the patient
has met the expected treatment outcome. Planning refers to designing a plan of action
that will help the nurse deliver quality patient care. Implementation refers to all of the
nursing interventions directed toward solving the patients nursing problems. Analysis is
the process of identifying the patients nursing problems.
6. Answer: B
A basilar skull fracture carries the risk of complications of dural tear, causing CSF
leakage and damage to cranial nerves I, II, VII, and VIII. Classic findings in this type of
fracture may include otorrhea, rhinorrhea, Battles signs, and raccoon eyes. Surgical
treatment isnt always required.
7. Answer: A
Barbiturates may be used to induce a coma in a patient with increased ICP. This
decreases cortical activity and cerebral metabolism, reduces cerebral blood volume,
decreases cerebral edema, and reduces the brains need for glucose and oxygen. Carbonic
anhydrase inhibitors are used to decrease ocular pressure or to decrease the serum pH in a
patient with metabolic alkalosis. Anticholinergics have many uses including reducing GI
spasms. Histamine receptor blockers are used to decrease stomach acidity.
8. Answer: B
Headache and projectile vomiting are early signs of increased ICP. Decreased systolic
blood pressure, unconsciousness, and dilated pupils that dont reac to light are considered
late signs.
9. Answer: A
Immediate bed rest is necessary to prevent further injury. Both eyes should be patched to
avoid consensual eye movement and the patient should receive early referral to an
ophthalmologist should treat the condition immediately. Retinal reattachment can be
accomplished by surgery only. If the macula is detached or threatened, surgery is urgent;
prolonged detachment of the macula results in permanent loss of central vision.
10. Answer: C
A chemical burn to the eye requires immediate instillation of a topical anesthetic
followed by irrigation with copious amounts of saline solution. Irrigation should be done
for 5 to 10 minutes, and then the pH of the eye should be checked. Irrigation should be
continued until the pH of the eye is restored to neutral (pH 7.0): Double eversion of the
eyelids should be performed to look for and remove ciliary spasm, and an antibiotic
ointment can be administered to reduce the risk of infection. Then the eye should be
patched. Parenteral narcotic analgesia is often required for pain relief. An
ophthalmologist should also be consulted.
11. Answer: B
A positive response to one or both tests indicates meningeal irritation that is present with
meningitis. Brudzinskis and Kernigs signs dont occur in CVA, seizure disorder, or
Parkinsons disease.
12. Answer: D
Gliomas account for approximately 45% of all brain tumors. Meningiomas are the second
most common, with 15%. Angiomas and hemangioblastomas are types of cerebral
vascular tumors that account for 3% of brain tumors.

13. Answer: D
The patient with Parkinsons disease may be hypersensitive to heat, which increases the
risk of hyperthermia, and he should be instructed to avoid sun exposure during hot
14. Answer: C
Global aphasia occurs when all language functions are affected. Receptive aphasia, also
known as Wernickes aphasia, affects the ability to comprehend written or spoken words.
Expressive aphasia, also known as Brocas aphasia, affected the patients ability to form
language and express thoughts. Conduction aphasia refers to abnormalities in speech
15. Answer: D
Patients with a history of headaches, especially migraines, should be taught to keep a
food diary to identify potential food triggers. Typical headache triggers include alcohol,
aged cheeses, processed meats, and chocolate and caffeine-containing products.
16. Answer: B
An explosive headache or the worst headache Ive ever had is typically the first
presenting symptom of a bleeding cerebral aneurysm. Photophobia, seizures, and
hemiparesis may occur later.
17. Answer: C
An embolic injury, caused by a traveling clot, may result from atrial fibrillation. Blood
may pool in the fibrillating atrium and be released to travel up the cerebral artery to the
brain. Persistent hypertension may place the patient at risk for a thrombotic injury to the
brain. Subarachnoid hemorrhage and skull fractures arent associated with emboli.
18. Answer: D
Women with spinal cord injuries who were sexually active may continue having sexual
intercourse and must be reminded that they can still become pregnant. She may be fully
capable of achieving orgasm. An indwelling urinary catheter may be left in place during
sexual intercourse. Positioning will need to be adjusted to fit the patients needs.
19. Answer: A
The nurse must have a wrench taped on the vest at all times for quick halo removal in
emergent situations. The brace isnt to be removed for any other reason until the cervical
fracture is healed. Placing a pillow under the patients head may alter the stability of the
20. Answer: D
Nimodipine is a calcium channel blocker that acts on cerebral blood vessels to reduce
vasospasm. The drug doesnt increase the amount of calcium, affect cerebral vasculature
growth, or reduce cerebral oxygen demand.
21. Answer: D
Men with spinal cord injury should be taught that the higher the level of the lesion, the
better their sexual function will be. The sacral region is the lowest area on the spinal
column and injury to this area will cause more erectile dysfunction.
22. Answer: C
Tegretol should be taken with food to minimize GI distress. Taking it at meals will also
establish a regular routine, which should help compliance.

23. Answer: B
Patient with pneumococcal meningitis require respiratory isolation for the first 24 hours
after treatment is initiated.
24. Answer: A
Early symptoms of ALS include fatigue while talking, dysphagia, and weakness of the
hands and arms. ALS doesnt cause a change in mental status, paresthesia, or fractures.
25. Answer: C
Increased pressure within the portal veins causes them to bulge, leading to rupture and
bleeding into the lower esophagus. Bleeding associated with esophageal varices doesnt
stem from esophageal perforation, pulmonary hypertension, or peptic ulcers.
26. Answer: B
The nurse should wear gloves and a gown when removing the patients bedpan because
the type A hepatitis virus occurs in stools. It may also occur in blood, nasotracheal
secretions, and urine. Type A hepatitis isnt transmitted through the air by way of
droplets. Special precautions arent needed when feeding the patient, but disposable
utensils should be used.
27. Answer: B
The patient should notify the doctor if he has difficulty inserting the irrigation tube into
the stoma. Difficulty with insertion may indicate stenosis of the bowel. Abdominal
cramping and expulsion of flatus may normally occur with irrigation. The procedure will
often take an hour to complete.
28. Answer: B
An indwelling urinary catheter is kept in place several days after this surgery to prevent
urine retention that could place pressure on the perineal wound. An indwelling urinary
catheter may be a source of postoperative urinary tract infection. Urine wont
contaminate the wound. An indwelling urinary catheter wont necessarily show bladder
29. Answer: D
The colostomy may not function for 2 days or more (48 to 72 hours) after surgery.
Therefore, the normal plan of care can be followed. Since no fecal drainage is expected
for 48 to 72 hours after a colostomy (only mucous and serosanguineous), the doctor
doesnt have to be notified and the stoma shouldnt be irrigated at this time.
30. Answer: C
If the patients GI tract is functioning, enteral nutrition via a feeding tube is the preferred
method. Peripheral and total parenteral nutrition places the patient at risk for infection. If
the patient is unable to consume foods by mouth, oral liquid supplements are
31. Answer: A
A hypertonic solution causes water to shift from the cells into the plasma because the
hypertonic solution has a greater osmotic pressure than the cells. A hypotonic solution
has a lower osmotic pressure than that of the cells. It causes fluid to shift into the cells,
possibly resulting in rupture. An isotonic solution, which has the same osmotic pressure
as the cells, wouldnt cause any shift. A solutions alkalinity is related to the hydrogen
ion concentration, not its osmotic effect.
32. Answer: C
Particles move from an area of greater osmolarity to one of lesser osmolarity through

diffusion. Active transport is the movement of particles though energy expenditure from
other sources such as enzymes. Osmosis is the movement of a pure solvent through a
semipermeable membrane from an area of greater osmolarity to one of lesser osmolarity
until equalization occurs. The membrane is impermeable to the solute but permeable to
the solvent. Filtration is the process by which fluid is forced through a membrane by a
difference in pressure; small molecules pass through, but large ones dont.
33. Answer: A
Tenting of chest skin when pinched indicates decreased skin elasticity due to
dehydration. Hand veins fill slowly with dehydration, not rapidly. A pulse that isnt easily
obliterated and neck vein distention indicate fluid overload, not dehydration.
34. Answer: C
Administering a tap water enema until return is clear would most likely contribute to a
hypo-osmolar state. Because tap water is hypotonic, it would be absorbed by the body,
diluting the body fluid concentration and lowering osmolarity. Weighing the patient is the
easiest, most accurate method to determine fluid changes. Therefore, it helps identify
rather than contribute to fluid imbalance. Nasogastric tube irrigation with normal saline
solution wouldnt cause a shift in fluid balance. Drinking broth wouldnt contribute to a
hypo-osmolar state because it doesnt replace sodium and water lost through excessive
35. Answer: D
An orthostatic blood pressure indicates an extracellular fluid volume deficit. (The
extracellular compartment consists of both the intravascular compartment and interstitial
space.) A fluid volume deficit within the intravascular compartment would cause
tachycardia, not bradycardia or orthostatic blood pressure change. A central venous
pressure of 6 mm Hg is in the high normal range, indicating adequate hydration. Pitting
edema indicates fluid volume overload.
36. Answer: C
The respiratory and renal systems act as compensatory mechanisms to counteract-base
imbalances. The lungs alter the carbon dioxide levels in the blood by increasing or
decreasing the rate and depth of respirations, thereby increasing or decreasing carbon
dioxide elimination. The liver, pancreas, and heart play no part in compensating for acidbase imbalances.
37. Answer: B
Anuria refers to a urine output of less than 100 ml in 24 hours. The baseline for urine
output and renal function is 30 ml of urine per hour. A urine output of at least 100 ml in 2
hours is within normal limits. Voiding at night is called nocturia. Pain and burning on
urination is called dysuria.
38. Answer: A
To obtain urine properly, the nurse should aspirate it from a port, using a sterile syringe
after cleaning the port. Opening a closed urine drainage system increases the risk of
urinary tract infection. Standard precautions specify the use of gloves during contract
with body fluids; however, sterile gloves arent necessary.
39. Answer: C
Although postoperative pain is expected, the nurse should ensure that other factors, such
as an obstructed irrigation catheter, arent the cause of the pain. After assessing catheter
patency, the nurse should administer an analgesic such as meperidine as prescribed.

Increasing the I.V. flow rate may worse the pain. Notifying the doctor isnt necessary
unless the pain is severe or unrelieved by the prescribed medication.
40. Answer: A
Renal calculi most commonly from in the kidney. They may remain there or become
lodged anywhere along the urinary tract. The ureter, bladder, and urethra are less
common sites of renal calculi formation.
41. Answer: A
Ureterolithiasis typically causes such acute, severe pain that the patient cant rest and
becomes increasingly anxious. Therefore, the nursing diagnosis of pain takes highest
priority. Risk for infection and altered urinary elimination are appropriate once the
patients pain is controlled. Altered nutrition: less than body requirements isnt
appropriate at this time.
42. Answer: B
Normal urine pH is 4.5 to 8; therefore, a urine pH of 3 is abnormal and may indicate such
conditions as renal tuberculosis, pyrexia, phenylketonuria, alkaptonuria, and acidosis.
Urine specific gravity normally ranges from 1.002 to 1.032, making the patients value
normal. Normally, urine contains no protein, glucose, ketones, bilirubin, bacteria, casts,
or crystals.
43. Answer: C
The nephron is the kidneys functioning unit. The glomerulus, Bowmans capsule, and
tubular system are components of the nephron.
44. Answer: A
As a response to shock, the renin-angiotensin-aldosterone system alters renal function by
decreasing urine output and increasing reabsorption of sodium and water. Reduced renal
perfusion stimulates the renin-angiotensin-aldosterone system in an effort to conserve
circulating volume.
45. Answer: D
The bladder isnt usually palpable unless it is distended. The feeling of pressure is usually
relieved with urination. Reduced bladder tone due to general anesthesia is a common
postoperative complication that causes difficulty in voiding. A urinary tract infection and
renal calculi arent palpable. The kidneys arent palpable above the symphysis pubis.
46. Answer: A
A pericardial friction rub may be present with the pericardial effusion of pericarditis. The
lungs are typically clear when auscultated. Sitting up and leaning forward often relieves
pericarditis pain. An S3 indicates left-sided heart failure and isnt usually present with
47. Answer: D
Assessing jugular vein distention should be done when the patient is in semi-Fowlers
position (head of the bed elevated 30 to 45 degrees). If the patient lies flat, the veins will
be more distended; if he sits upright, the veins will be flat.
48. Answer: C
Smoking should receive highest priority when trying to reduce risk factors for with
respiratory complications. Losing weight and decreasing salt and caffeine intake can help
to decrease risk factors for hypertension.
49. Answer: B
The correct ratio of compressions to ventilations when one rescuer performs CPR is 15:2

50. Answer: D
The lungs and kidneys are the bodys regulators of homeostasis. The lungs are
responsible for removing fluid and carbon dioxide; the kidneys maintain a balance of
fluid and electrolytes. The other organs play secondary roles in maintaining homeostasis.

1. Which of the following medications would the nurse in-charge expect the doctor to
order to reverse a dystonic reaction?
a. Procholorperazine (Compazine)
b. Diphenhydramine (Benadryl)
c. Haloperidol (Haldol)
d. Midazolam (Versed)
2. While pacing in the hall, a female patient with paranoid schizophrenia runs to the
nurse and says, Why are you poisoning me? I know you work for central thought
control! You can keep my thoughts. Give me back my soul! how should the nurse
a. Im a nurse, Im not poisoning you. Its against the nursing code of ethics.
b. Im a nurse, and youre a patient in the hospital. Im not going to harm you.
c. Im not poisoning you. And how could I possibly steal your soul?
d. I sense anger, Are you feeling angry today?
3. After completing chemical detoxification and a 12-step program to treat crack
addiction, a male patient is being prepared for discharge. Which remark by the patient
indicates a realistic view of the future?
a. Im never going to use crack again.
b. I know what I have to do. I have to limit my crack use.
c. Im going to take 1 day at a time. Im not making any promises.
d. I cant touch crack again, but I sure could use a drink. Ive earned it.

4. The nurse formulates a nursing diagnosis of impaired verbal communication fora

male patient with schizotypal personality disorder. Based on this nursing diagnosis,
which nursing intervention is most appropriate?
a. Helping the patient to participate in social interactions
b. Establishing a one-on-one relationship with the patient
c. Establishing alternative forms of communication
d. Allowing the patient to decide when he wants to participate in verbal
communication with you
5. A female patient with obsessive-compulsive disorder tells the nurse that he must
check the lock on his apartment door 25 times before leaving for an appointment. The
nurse knows that this behavior represents the patients attempt to:
a. Call attention to himself
b. Control his thoughts
c. Maintain the safety of his home
d. Reduce anxiety
6. A patient, age 42, is admitted for surgical biopsy of a suspicious lump in her left
breast. When the nurse comes to her surgery, she is tearfully finishing a letter to her
children. She tells the nurse, I want to leave this for my children in case anything
goes wrong today. Which response by the nurse would be most therapeutic?
a. In case anything goes wrong? What are your thoughts and feelings right now?
b. I cant understand that youre nervous, but this is really a minor procedure. Youll
be back in your room before you know it.
c. Try to take a few deep breaths and relax. I have some medication that will help.
d. Im sure your children know how much you love them. Youll be able to talk to
them on the phone in a few hours.
7. Which nursing intervention is most important when restraining a violent male
a. Reviewing hospital policy regarding how long the patient can be restrained
b. Preparing a p.r.n. dose of the patients psychotropic medication

c. Checking that the restraints have been applied correctly

d. Asking if the patient needs to use the bathroom or is thirsty
8. How soon after chlorpromazine administration should the nurse in charge expect to
see a patients delusion thoughts and hallucinations eliminated?
a. Several minutes
b. Several hours
c. Several days
d. Several weeks
9. Mental health laws in each state specify when restraints can be used and which
type of restraints are allowed. Most laws stipulate that restraints can be used:
a. For a maximum of 2 hours
b. As necessary to control the patient
c. If the patient poses a present danger to self or others
d. Only with the patients consent
10. A female patient has been severely depressed since her husband died 6 months
ago. Her doctor prescribes amitriptyline hydrochloride (Elavil), 50 mg P.O. daily.
Before administering amitriptyline, the nurse reviews the patients medical history.
Which preexisting condition would require cautions use of this drug?
a. Hiatal hernia
b. Hypernatremia
c. Hepatic disease
d. Hypokalemia
11. The physician orders a new medication for a male client with generalized anxiety
disorder. During medication teaching, which statement or question by the nurse
would be most appropriate?
a. Take this medication. It will reduce your anxiety.
b. Do you have any concern about taking the medication?

c. Trust us. This medication has helped many people. We wouldnt have you take it
if it were dangerous.
d. How can we help you if you wont cooperate?
12. The nurse is aware that the Hormonal effects of the antipsychotic medications
include which of the following?
a. Retrograde ejaculation and gynecomastia
b. Dysmenorrhea and increased vaginal bleeding
c. Polydipsia and dysmenorrheal
d. Akinesia and dysphasia
13. The nurse is caring for a female client in the manic phase of bipolar
disorderwhos ready for discharge from the psychiatric unit. As the nurse begins to
terminate the nurse-client relationship, which client response is most appropriate?
a. Expressing feeling of anxiety
b. Displaying anger, shouting, and banging the table
c. Withdrawing from the nurse in silence
d. Rationalizing the termination, saying that everything comes to an end
14. The nurse is caring for a male client with schizophrenia. Which outcome is the
least desirable?
a. The client spends more time by himself
b. The client doesnt engage in delusional thinking
c. The client doesnt harm himself or others
d. The client demonstrates the ability to meet his own self-care needs
15. The nurse is assigned to care for a recently admitted female client who has
attempted suicide. What should the nurse do?
a. Search the clients belongings and room carefully for items that could be used to
attempt suicide
b. Express trust that the client wont cause self-harm while in the facility

c. Respect the clients privacy by not searching any belongings

d. Remind all staff members to check on the client frequently
16. A male client becomes angry and belligerent toward the nurse after speaking on
the phone with his mother. The nurse recognizes this as what defense mechanism?
a. Rationalization
b. Repression
c. Displacement
d. Suppression
17. Nursing preparations for a client undergoing electroconvulsive therapy (ECT)
resembles those used for:
a. Physical therapy
b. Neurologic examination
c. General anesthesia
d. Cardiac stress testing
18. Nursing care for a male client with schizophrenia must be based on valid
psychiatric and nursing theories. The nurses interpersonal communication with the
client and specific nursing intervention must be:
a. Clearly identified with boundaries and specifically defined roles
b. Warn and non threatening
c. Centered on clearly defined limits and expression of empathy
d. Flexible enough for the nurse to adjust the care plan as the situation warrants
19. Before eating a meal, a female client with obsessive-compulsive disorder (OCD)
must wash his hands for 18 minutes, comb his hair 444 strokes, and switch the
bathroom lights 44 times. What is the most appropriate goal of care for this client?
a. Omit one unacceptable behavior each day
b. Increase the clients acceptance of therapeutic drug use

c. Allow ample time for the client to complete all rituals before each meal
d. Systematically decrease the number of repetitions of rituals and the amount of time
spent performing them.
20. A male client with a history of medication noncompliance is receiving outpatient
treatment for chronic undifferentiated schizophrenia. The physician is most likely to
prescribe which medication for this client?
a. Chlorpromazine (Thorazine)
b. Imipramine (Tofranil)
c. Lithium carbonate (Lithane)
d. Fluphenazine decanoate (Prolixin Decanoate)
21. A 23-year-old client is diagnosed with dependent personality disorder. Which
behavior is most likely to be evidence of ineffective individual coping?
a. In ability to make choices and decisions without advice
b. Showing interest only in solitary activities
c. Avoiding developing relationship
d. Recurrent self-destructive behavior with history of depression
22. During the mental status examination, a female client may be asked to explain
such proverbs as Dont cry over spilled milk. The purpose is to evaluate the clients
ability to think:
a. Rationally
b. Concretely
c. Abstractly
d. Tangentially
23. After an upsetting divorce, a male client threatens to commit suicide with a
handgun and is involuntarily admitted to the psychiatric unit with major depression.
Which nursing diagnosis takes highest priority for this client?
a. Hopelessness related to recent divorce

b. Ineffective coping related to inadequate stress management

c. Spiritual distress related to conflicting thoughts about suicide and sin
d. Risk for self-directed-violence related to planning to commit suicide with a
24. A 25-year-old man reports losing his sight in both eyes. Hes diagnosed as
havingconversion disorder and is admitted to the psychiatric unit. Which nursing
intervention would be most appropriate for this client?
a. Not focusing on his blindness
b. Providing self-care for him
c. Telling him that his blindness isnt real
d. Teaching eye exercises to strengthen his eyes
25. In group therapy, a male client angrily speaks up and responds to a peer, Youre
always whining and Im getting tired of listening to you! Here is the worlds smallest
violin playing for you. Which role is the client playing?
a. Blocker
b. Monopolizer
c. Recognition seeker
d. Aggressor
26. A nurse places a female client in full leather restraints. How often must the nurse
check the clients circulation?
a. Once per hour
b. Once per shift
c. Every 10 to 15 minutes
d. Every 2 hours
27. When interviewing the parents of an injured child, which sign is the strongest
indicator that child abuse may be a problem?
a. The injury isnt consistent with the history of the childs age

b. The mother and father tell different stories regarding what happened
c. The family is poor
d. The parents are argumentative and demanding with emergency department
28. Unhealthy personal boundaries are a product of dysfunctional families and a lack
of positive role models. Unhealthy boundaries may also be a result of:
a. Structured limit setting
b. Supportive environment
c. Abuse and neglect
d. Direction and attention
29. When monitoring a male client recently admitted for treatment of cocaine
addiction, the nurse notes sudden increase in the arterial blood pressure and heart rate.
To correct these problems, the nurse expects the physician to prescribe:
a. Norepinephrine (Levophed) and lidocaine (Xylocaine)
b. Nifedipine (Procardia) and lidocaine
c. Nitroglycerin (Nitro-Bid IV) and esmolol (Brevibloc)
d. Nifedipine and nitroglycerin
30. Conditions necessary for the development of a positive sense of self-esteem
a. Consistent limits
b. Critical environment
c. Inconsistent boundaries
d. Physical discipline

1. Answer B. Diphenhydramine, 25 to 50 mg I.M. or I.V., would quickly reverse this
condition. Prochlorperazine and haloperidol are both capable of causing dystonia, not
reversing it. Midazolam would make this patient drowsy.

2. Answer B. The nurse should directly orient a delusional patient to reality, especially to
place and person. Option A and C encourage further delusions by denying poisoning and
offering information related to the delusion. Validating the patients feeling, as in option
D, occurs during a later stage in the therapeutic process.
3. Answer C. Twelve-step programs focus on recovery 1 day at a time. Such programs
discourage people from claiming that they will never again use a substance, because
relapse is common. The belief that one may use a limit amount of an abused substance
indicates denial. Substituting one abused substance for another predisposes the patient to
4. Answer B. By establishing a one-to-one relationship, the nurse helps the patient learn
how to interact with other people in new situations. The other options are appropriate but
should take place only after the nurse-patient relationship is established.
5. Answer D. A compulsion is a repetitive act or impulse helps a person to reduce anxiety
unconsciously. An obsessive-compulsive patient does not want to call attention to self
and cannot control thoughts. This patients priority is to reduce anxiety, not maintain the
safety of the home.
6. Answer A. By acknowledging how the patient feels, this response encourages further
expression of thoughts and feelings. Minimizing feelings or offering empty reassurances
is not therapeutic or helpful. Deep breathing or preoperative medication would be
appropriate only after the patients fears have been expressed and dealt with.
7. Answer C. The nurse must determine whether the restraints have been applied correctly
to make sure that patients circulation and respiration are not restricted and that adequate
padding has been used. The nurse should document the patients response and status
carefully after the restraints are applied. All staff members involved in restraining
patients should be aware of hospital policy before using restraints. If p.r.n. medication is
ordered, it should be given before the restraints are in place and with the assistance of
other team members. The nurse should attend to the patients elimination and hydration
needs after the patient is properly restrained.
8. Answer D. Although most phenothiazine produce some effects within minutes to hours,
their antipsychotic effects may take several weeks to appear.
9. Answer C. Most states allow restraints to be used if the patient presents a danger to self
or others. This danger must be reevaluated every few hours. If the patient is still a danger,
restraints can be used until the violent behavior abates. No standing orders for restraints
are allowed, and restraints are permitted only until more humane methods, such as
sedatives, become more effective. Violent patients who are intoxicated with drugs or
alcohol present a problem because they rarely can be sedated until the drug or alcohol is
metabolized. In such cases, restraints may be needed for a longer period, but the patient
must be closely observed. Obtaining consent is not always possible, especially when the
patients violent behavior results from a psychosis, such as paranoid schizophrenia.
10. Answer C. Conditions requiring cautious use of amitriptyline include pregnancy,
lactation, suicidal tendencies, cardiovascular disease, and impaired hepatic function.
Hiatal hernia, hypernatremia, and hypokalemia do not affect amitriptyline therapy.
11. Answer B. Providing an opportunity for the client to express concern about a new
medication and to make a choice about taking it can help the client regain a sense of
control over his life. The client has the right to refuse the medication. Instead of simply
ordering the client to take it, as in option 1, the nurse should provide the information the

client needs to make an informed decision. Attempting to make the client feel guilty, as
in option 3, or threatening the client, as option 4, would increase anxiety.
12. Answer A. Decreased libido, retrograde ejaculation, and gynecomastia are all hormonal
effects that can occur with antipsychotic medications. Reassure the client that the effects
can be reversed or that changing medication may be possible. Polydipsia, akinesia, and
dysphasia arent hormonal effects.
13. Answer A. Anxiety is a normal reaction to the termination of the nurse-client
relationship. The nurse should help the client explore his feelings about the end of the
therapeutic relationship. While anger about the termination may be a healthy response,
banging the table, shouting, and other forms of acting out arent appropriate behavior.
Withdrawal isnt a healthy response to the termination of a relationship. By rationalizing
the termination, the client avoids expressing his feelings and emotions.
14. Answer A. The client with schizophrenia is commonly socially isolated and withdrawn;
therefore, having the client spend more time by himself wouldnt be a desirable outcome.
Rather, a desirable outcome would specify that the client spend more time with other
clients and staff on the unit. Delusions are false personal beliefs. Reducing or eliminating
delusional thinking using talking therapy and antipsychotic medications would be a
desirable outcome. Protecting the client and others from harm is a desirable client
outcome achieved by close observation, removing any dangerous objects, and
administering medications. Because the client with schizophrenia may have difficulty
meeting his or her own self-care needs, fostering the ability to perform self-care
independently is a desirable client outcome.
15. Answer A. Because a client who has attempted suicide could try again, the nurse should
search the clients belongings and room to remove any items that could be used in
another suicide attempt. Expressing trust that the client wont cause self-harm may
increase guilt and pain if the client cant live up to that trust. The nurse should search the
clients belonging because the need to maintain a safe environment supersedes the
clients right to privacy. Although frequent checks by staff members are helpful, they
arent enough because the client may attempt suicide between checks.
16. Answer C. Displacement is a defense mechanism in which the client transfers his feelings
for one person toward another person who is less threatening. Rationalization is a defense
mechanism in which the client makes excuses to justify unacceptable feeling or
behaviors. Repression is characterized by an involuntary blocking of unpleasant
experiences from ones consciousness. Suppression is the conscious blocking of
unpleasant experiences form ones awareness.
17. Answer C. The nurse should prepare a client for ECT in a manner similar to that for
general anesthesia. For example, the client should receive nothing by mouth for 8 hours
before ECT to reduce the risk of vomiting and aspiration. Also, the nurse should have the
client void before treatment to decrease the risk of involuntary voiding during the
procedure, remove any full denture, glasses, or jewelry to prevent breakage or loss; and
make sure the client is wearing a hospital gown or loose-fitting clothing to allow
unrestricted movement. Usually, these preparations arent indicated for a client
undergoing physical therapy, neurologic examination, or cardiac stress testing.
18. Answer D. A flexible care plan needed for any client who behaves in a suspicious,
withdrawn, or regressed manner or who has thought disorder. Because such a client
communicates at different levels and is in control of himself at various times, the nurse

must be able to adjust nursing care as the situation warrants. The nurses role should be
clear, however, the boundaries or limits of this role should be flexible enough to meet
client needs. Because a client with schizophrenia fears closeness and affection, a warm
approach may be too threatening. Expressing empathy is important, but centering
interventions on clear defined limits is impossible because the clients situation may
change without warning.
19. Answer D. When caring for a client with OCD, the goal is to systematically decrease the
undesirable behavior. (Therapy may not completely extinguish certain behaviors.)
Expecting to omit one behavior each day is unrealistic because the client may have used
ritualistic behavior would perpetuate the undesirable behavior.
20. Answer D. Fluphenazine decanoate is a long-acting antipsychotic agent given by
injection. Because it has a 4-week duration of action, its commonly prescribed for
outpatients with a history of medication noncompliance. Chlorpromazine, also an
antipsychotic agent, must be administered daily to maintain adequate plasma levels,
which necessitates compliance with the dosage schedule. Imipramine, a tricyclic
antidepressant, and lithium carbonate, a mood stabilizer, are rarely used to treat clients
with chronic schizophrenia.
21. Answer A. Individuals with dependent personality disorder typically shows
indecisiveness, submissiveness, and clinging behavior so that others will make decisions
for them. These clients feel helpless and uncomfortable when alone and dont show
interest in solitary activities. They also pursue relationships in order to have someone to
take care of them. Although clients with dependent personality disorder may become
depressed and suicidal if their needs arent met, this isnt a typical response.
22. Answer C. Abstract thinking is the ability to conceptualize and interpret meaning. Its
higher level of intellectual functioning than concrete thinking, in which the client
explains the proverb by its literal meaning. Rational thinking involves the ability to think
logically, make judgments, and be goal-directed. Tangential thinking is scattered, nongoal-directed, and hard to follow. Clients with such conditions as organic brain disease
and schizophrenia typically cant conceptualize and comprehend abstract meaning. They
interpret such statement as Dont cry over spilled milk in a literal sense, such as Even
if you spill your milk, you shouldnt cry about it.
23. Answer D. Although all these options may apply to this client, safety is the nurses first
priority in caring for any suicidal client. The nurse can address the clients hopelessness,
ineffective coping, and spiritual distress later in therapy.
24. Answer A. Focusing on the clients blindness can positively reinforce the blindness
and further promote the use of maladaptive behaviors to obtain secondary gains. The
client should be encouraged to participate in his own care as much as possible to avoid
fostering dependency. To promote self-esteem, give positive reinforcement for what the
client can do. Blindness and other physical symptoms in a conversion disorder arent
under the clients control and are real to him. Eye exercises wont resolve the clients
blindness because no organic pathology is causing the symptoms.
25. Answer D. The aggressor is negative and hostile and uses sarcasm to degrade others.
The role of the blocker is to resist group efforts. The monopolizer controls the group by
dominating conversations. The recognition seeker talks about accomplishments to gain

26. Answer C. Circulation as well as skin and nerve damage can occur within 15 minutes.
Checking every hour, 2 hours, or 8 hours isnt often enough and could result in
permanent damage to the clients extremities. Restraints should be removed every 2
hours, and range-of-motion exercises should be performed.
27. Answer A. When the childs injuries are inconsistent with the history given or
impossible because of the childs age and developmental stage, the emergency
department nurse should be suspicious that child abuse is occurring. The parents may tell
different stories because their perception may be different regarding what happened. If
they change their story when different health care workers ask the same question, this is a
clue that child abuse may be a problem. Child abuse occurs in all socioeconomic groups.
Parent may argue and be demanding because of the stress of having an injured child.
28. Answer C. Abuse and neglect lead to poor self-concept and confusion, the basis for
unhealthy personal boundaries. Healthy boundaries are established in childhood when
parent provide consistent, supportive limits and attention.
29. Answer D. This client requires a vasodilation such as nifedipine to treat hypertension,
and a beta-adrenergic blocker such as esmolol to reduce the heart rate. Lidocaine, an
antirrhythmic, isnt indicated because the client doesnt have an arrhythmia. Although
nitrolycerin may be used to treat coronary vasospasm, it isnt the drug of choice in
30. Answer A. A structured lifestyle demonstrates acceptance and caring provides a sense
of security. A critical environment erodes a persons esteem. Inconsistent boundaries lead
to feelings of insecurity and lack of concern. Physical discipline can decrease self-esteem.


1. Katherine is a young Unit Manager of the Pediatric Ward. Most of her staff
nurses are senior to her, very articulate, confident and sometimes aggressive.
Katherine feels uncomfortable believing that she is the scapegoat of everything
that goes wrong in her department. Which of the following is the best action that
she must take?

Identify the source of the conflict and understand the points of friction
Disregard what she feels and continue to work independently
Seek help from the Director of Nursing
Quit her job and look for another employment.

2. As a young manager, she knows that conflict occurs in any organization. Which
of the following statements regarding conflict is NOT true?
a. Can be destructive if the level is too high
b. Is not beneficial; hence it should be prevented at all times
c. May result in poor performance
d. May create leaders

3. Katherine tells one of the staff, I dont have time to discuss the matter with
you now. See me in my office later when the latter asks if they can talk about an
issue. Which of the following conflict resolution strategies did she use?


4. Kathleen knows that one of her staff is experiencing burnout. Which of the
following is the best thing for her to do?

Advise her staff to go on vacation.

Ignore her observations; it will be resolved even without intervention
Remind her to show loyalty to the institution.
Let the staff ventilate her feelings and ask how she can be of help.

5. She knows that performance appraisal consists of all the following activities

Setting specific standards and activities for individual performance.

Using agency standards as a guide.
Determine areas of strength and weaknesses
Focusing activity on the correction of identified behavior.

6. Which of the following statements is NOT true about performance appraisal?

a. Informing the staff about the specific impressions of their work help improve their
b. A verbal appraisal is an acceptable substitute for a written report
c. Patients are the best source of information regarding personnel appraisal.
d. The outcome of performance appraisal rests primarily with the staff.
7. There are times when Katherine evaluates her staff as she makes her daily
rounds. Which of the following is NOT a benefit of conducting an informal

The staff member is observed in natural setting.

Incidental confrontation and collaboration is allowed.
The evaluation is focused on objective data systematically.
The evaluation may provide valid information for compilation of a formal report.

8. She conducts a 6-month performance review session with a staff member.

Which of the following actions is appropriate?
a. She asks another nurse to attest the session as a witness.
b. She informs the staff that she may ask another nurse to read the appraisal before
the session is over.
c. She tells the staff that the session is manager-centered.
d. The session is private between the two members.

9. Alexandra is tasked to organize the new wing of the hospital. She was given the
authority to do as she deems fit. She is aware that the director of nursing has
substantial trust and confidence in her capabilities, communicates through
downward and upward channels and usually uses the ideas and opinions of her
staff. Which of the following is her style of management?

Benevolent authoritative

10. She decides to illustrate the organizational structure. Which of the following
elements is NOT included?

Level of authority
Lines of communication
Span of control
Unity of direction

11. She plans of assigning competent people to fill the roles designed in the
hierarchy. Which process refers to this?


12. She checks the documentary requirements for the applicants for staff nurse
position. Which one is NOT necessary?

Certificate of previous employment

Record of related learning experience (RLE)
Membership to accredited professional organization
Professional identification card

13. Which phase of the employment process includes getting on the payroll and
completing documentary requirements?


14. She tries to design an organizational structure that allows communication to

flow in all directions and involve workers in decision making. Which form of
organizational structure is this?


15. In a horizontal chart, the lowest level worker is located at the


Left most box

Right most box

16. She decides to have a decentralized staffing system. Which of the following is
an advantage of this system of staffing?

greater control of activities

Conserves time
Compatible with computerization
Promotes better interpersonal relationship

17. Aubrey thinks about primary nursing as a system to deliver care. Which of the
following activities is NOT done by a primary nurse?

Collaborates with the physician

Provides care to a group of patients together with a group of nurses
Provides care for 5-6 patients during their hospital stay.
Performs comprehensive initial assessment

18. Which pattern of nursing care involves the care given by a group of
paraprofessional workers led by a professional nurse who take care of patients
with the same disease conditions and are located geographically near each other?

Case method
Modular nursing
Nursing case management
Team nursing

19. St. Raphael Medical Center just opened its new Performance Improvement
Department. Ms. Valencia is appointed as the Quality Control Officer. She commits
herself to her new role and plans her strategies to realize the goals and objectives
of the department. Which of the following is a primary task that they should
perform to have an effective control system?

Make an interpretation about strengths and weaknesses

Identify the values of the department
Identify structure, process, outcome standards & criteria
Measure actual performances

20. Ms. Valencia develops the standards to be followed. Among the following
standards, which is considered as a structure standard?

The patients verbalized satisfaction of the nursing care received

Rotation of duty will be done every four weeks for all patient care personnel.
All patients shall have their weights taken recorded
Patients shall answer the evaluation form before discharge

21. When she presents the nursing procedures to be followed, she refers to what
type of standards?


22. The following are basic steps in the controlling process of the department.
Which of the following is NOT included?

Measure actual performance

Set nursing standards and criteria
Compare results of performance to standards and objectives
Identify possible courses of action

23. Which of the following statements refers to criteria?


Agreed on level of nursing care

Characteristics used to measure the level of nursing care
Step-by-step guidelines
Statement which guide the group in decision making and problem solving

24. She wants to ensure that every task is carried out as planned. Which of the
following tasks is NOT included in the controlling process?

Instructing the members of the standards committee to prepare policies

Reviewing the existing policies of the hospital
Evaluating the credentials of all nursing staff
Checking if activities conform to schedule

25. Ms. Valencia prepares the process standards. Which of the following is NOT a
process standard?
a. Initial assessment shall be done to all patients within twenty four hours upon
b. Informed consent shall be secured prior to any invasive procedure
c. Patients reports 95% satisfaction rate prior to discharge from the hospital.
d. Patient education about their illness and treatment shall be provided for all patients
and their families.
26. Which of the following is evidence that the controlling process is effective?

The things that were planned are done

Physicians do not complain.
Employees are contended
There is an increase in customer satisfaction rate.

27. Ms. Valencia is responsible to the number of personnel reporting to her. This
principle refers to:


Span of control
Unity of command
Carrot and stick principle
Esprit d corps

28. She notes that there is an increasing unrest of the staff due to fatigue brought
about by shortage of staff. Which action is a priority?

Evaluate the overall result of the unrest

Initiate a group interaction
Develop a plan and implement it
Identify external and internal forces.

29. Kevin is a member of the Nursing Research Council of the hospital. His first
assignment is to determine the level of patient satisfaction on the care they
received from the hospital. He plans to include all adult patients admitted from
April to May, with average length of stay of 3-4 days, first admission, and with no
complications. Which of the following is an extraneous variable of the study?

Date of admission
Length of stay
Age of patients
Absence of complications

30. He thinks of an appropriate theoretical framework. Whose theory addresses

the four modes of adaptation?

Martha Rogers
Sr. Callista Roy
Florence Nightingale
Jean Watson

31. He opts to use a self-report method. Which of the following is NOT TRUE about
this method?

Most direct means of gathering information

Versatile in terms of content coverage
Most accurate and valid method of data gathering
Yields information that would be difficult to gather by another method

32. Which of the following articles would Kevin least consider for his review of

Story-Telling and Anxiety Reduction Among Pediatric Patients

Turnaround Time in Emergency Rooms
Outcome Standards in Tertiary Health Care Institutions
Environmental Manipulation and Client Outcomes

33. Which of the following variables will he likely EXCLUDE in his study?
a. Competence of nurses

b. Caring attitude of nurses

c. Salary of nurses
d. Responsiveness of staff
34. He plans to use a Likert Scale to determine

degree of agreement and disagreement

compliance to expected standards
level of satisfaction
degree of acceptance

35. He checks if his instruments meet the criteria for evaluation. Which of the
following criteria refers to the consistency or the ability to yield the same
response upon its repeated administration?


36. Which criteria refer to the ability of the instrument to detect fine differences
among the subjects being studied?


37. Which of the following terms refer to the degree to which an instrument
measures what it is supposed to be measure?


38. He plans for his sampling method. Which sampling method gives equal chance
to all units in the population to get picked?


39. Raphael is interested to learn more about transcultural nursing because he is

assigned at the family suites where most patients come from different cultures
and countries. Which of the following designs is appropriate for this study?
a. Grounded theory
b. Ethnography
c. Case study

d. Phenomenology
40. The nursing theorist who developed transcultural nursing theory is
a. Dorothea Orem
b. Madeleine Leininger
c. Betty Newman
d. Sr. Callista Roy


1. Answer: (A) Identify the source of the conflict and understand the points of friction
This involves a problem solving approach, which addresses the root cause of the problem.
2. Answer: (B) Is not beneficial; hence it should be prevented at all times
Conflicts are beneficial because it surfaces out issues in the open and can be solved right away.
Likewise, members of the team become more conscientious with their work when they are aware
that other members of the team are watching them.
3. Answer: (C) Avoidance
This strategy shuns discussing the issue head-on and prefers to postpone it to a later time. In effect
the problem remains unsolved and both parties are in a lose-lose situation.
4. Answer: (D) Let the staff ventilate her feelings and ask how she can be of help.
Reaching out and helping the staff is the most effective strategy in dealing with burn out. Knowing
that someone is ready to help makes the staff feel important; hence her self-worth is enhanced.
5. Answer: (D) Focusing activity on the correction of identified behavior.
Performance appraisal deal with both positive and negative performance; is not meant to be a faultfinding activity
6. Answer: (C) Patients are the best source of information regarding personnel appraisal.
The patient can be a source of information about the performance of the staff but it is never the
best source. Directly observing the staff is the best source of information for personnel appraisal.
7. Answer: (C) The evaluation is focused on objective data systematically.
Collecting objective data systematically can not be achieved in an informal appraisal. It is focused
on what actually happens in the natural work setting.
8. Answer: (D) The session is private between the two members.
The session is private between the manager and the staff and remains to be so when the two
parties do not divulge the information to others.
9. Answer: (B) Consultative
A consultative manager is almost like a participative manager. The participative manager has
complete trust and confidence in the subordinate, always uses the opinions and ideas of
subordinates and communicates in all directions.
10. Answer: (D) Unity of direction
Unity of direction is a management principle, not an element of an organizational structure.
11. Answer: (A) Staffing
Staffing is a management function involving putting the best people to accomplish tasks and
activities to attain the goals of the organization.

12. Answer: (B) Record of related learning experience (RLE)

Record of RLE is not required for employment purposes but it is required for the nurses licensure
13. Answer: (B) Induction
This step in the recruitment process gives time for the staff to submit all the documentary
requirements for employment.
14. Answer: (B) Decentralized
Decentralized structures allow the staff to make decisions on matters pertaining to their practice
and communicate in downward, upward, lateral and diagonal flow.
15. Answer: (C) Rightmost box
The leftmost box is occupied by the highest authority while the lowest level worker occupies the
rightmost box.
16. Answer: (D) Promotes better interpersonal relationship
Decentralized structures allow the staff to solve decisions by themselves, involve them in decision
making; hence they are always given opportunities to interact with one another.
17. Answer: (B) Provides care to a group of patients together with a group of nurses
This function is done in team nursing where the nurse is a member of a team that provides care for
a group of patients.
18. Answer: (B) Modular nursing
Modular nursing is a variant of team nursing. The difference lies in the fact that the members in
modular nursing are paraprofessional workers.
19. Answer: (B) Identify the values of the department
Identify the values of the department will set the guiding principles within which the department will
operate its activities
20. Answer: (B) Rotation of duty will be done every four weeks for all patient care
Structure standards include management system, facilities, equipment, materials needed to deliver
care to patients. Rotation of duty is a management system.
21. Answer: (A) Process
Process standards include care plans, nursing procedure to be done to address the needs of the
22. Answer: (D) Identify possible courses of action
This is a step in a quality control process and not a basic step in the control process.
23. Answer: (B) Characteristics used to measure the level of nursing care
Criteria are specific characteristics used to measure the standard of care.
24. Answer: (A) Instructing the members of the standards committee to prepare policies
Instructing the members involves a directing function.
25. Answer: (C) Patients reports 95% satisfaction rate prior to discharge from the hospital.
This refers to an outcome standard, which is a result of the care that is rendered to the patient.
26. Answer: (A) The things that were planned are done
Controlling is defined as seeing to it that what is planned is done.

27. Answer: (A) Span of control

Span of control refers to the number of workers who report directly to a manager.
28. Answer: (B) Initiate a group interaction
Initiate a group interaction will be an opportunity to discuss the problem in the open.
29. Answer: (C) Age of patients
An extraneous variable is not the primary concern of the researcher but has an effect on the results
of the study. Adult patients may be young, middle or late adult.
30. Answer: (B) Sr. Callista Roy
Sr. Callista Roy developed the Adaptation Model which involves the physiologic mode, self-concept
mode, role function mode and dependence mode
31. Answer: (C) Most accurate and valid method of data gathering
The most serious disadvantage of this method is accuracy and validity of information gathered
32. Answer: (B) Turnaround Time in Emergency Rooms
The article is for pediatric patients and may not be relevant for adult patients.
33. Answer: (C) Salary of nurses
Salary of staff nurses is not an indicator of patient satisfaction, hence need not be included as a
variable in the study.
34. Answer: (A) degree of agreement and disagreement
Likert scale is a 5-point summated scale used to determine the degree of agreement or
disagreement of the respondents to a statement in a study.
35. Answer: (B) Reliability
Reliability is repeatability of the instrument; it can elicit the same responses even with varied
administration of the instrument
36. Answer: (A) Sensitivity
Sensitivity is an attribute of the instrument that allow the respondents to distinguish differences of
the options where to choose from
37. Answer: (A) Validity
Validity is ensuring that the instrument contains appropriate questions about the research topic
38. Answer: (A) Random
Random sampling gives equal chance for all the elements in the population to be picked as part of
the sample.
39. Answer: (B) Ethnography
Ethnography is focused on patterns of behavior of selected people within a culture
40. Answer: (B) Madeleine Leininger
Madeleine Leininger developed the theory on transcultural theory based on her observations on the
behavior of selected people within a culture

1. The following clients present to a walk-in clinic at the same time. Which should the nurse
schedule to be seen first?


25 year old with high fever, vomiting and diarrhea


38 year old with sore throat, fever, and swollen lymph glands


40 year old with severe headache, vomiting and stiff neck


44 year old limping on a very swollen bruised ankle

2. Of the four clients listed below, which responsibility should the nurse direct the technician to
carry out first?

89 year old with COPD resting quietly on 2 liters of o2 needs morning vitals with 02
77 year old with gastrointestinal bleeding needs bedside commode emptied
55 year old diabetic with fasting blood sugar of 75, at 80% of breakfast and needs
morning snack
49 year old with rheumatoid arthritis needs splints reapplied to both hands

3. The LPN is assigned to care for a client who had a total right hip two days ago. Which
observation should the LPN report immediately to the nurse?

incisional pain rated on 6 on a scale of 0-10


reddened incision line wiht a temperature of 99.6 F


pain and redness in the left lower leg


the client is not tolerating 20lbs of weight bearing on the right leg

Question 4 of 10
4. The nurse just received report on the following clients. Who should the nurse see first?

35 year old with suspected acute tubular necrosis, urine output totaled 25cc's for the
last two hours.
49 year old with cancer of the breast, 2 days post mastectomy, reported to be having
difficulty coping with the diagnosis.
54 year old with TB in respiratory isolation, requesting pain medication.
36 year old with chest tube insertion after a spontaneous pneumothorax, respirations

5. After receiving report on the following clients, who should the nurse assess first?

25 year old with the hemoglobin level of 15.9


36 year old on Coumadin with a prothrombin time of 35. 6 seconds


38 year old with a total calcium level of 9.4


45 year old with a BUN of 30 and creatinine of 1.1

6. After completing assessment rounds, which finding would the nurse report to the physician

a. client who has not had a bowel movement in 4 days abdomen is firm

client who had a pulse of 89 and regular now has pulse of 100 and irregular
client who is very depressed and has eaten 10% of meals for the last 2 days

client who has developed a rash around the neck and face who has been on iv
penicillin for 2 days
7. After receiving report on four clients at 7am, what should the nurse complete first?

call physician to report antiemetic for client who has been vomiting


notify family of a clients transfer to ICU for chest pain


call a potassium level of 5.9 to the attention of the physician


begin routine assessment rounds, starting with the sickest client

8. A 62 year old client has a history of coronary heart disease and is brought into the ER
complaining of chest pain. What initial action should be taken by the nurse?

give the client ntg gr 1/150 sl now


call the cardiologist about the admission


place the client in a high Fowlers position after loosening the shirt


check blood pressure and note the location and degree of chest pain

9. As a nurse working the ER, which cient needs the most immediate attention?

a 3 yr old with a barking cough, oxygen sat of 93 in room air, and occasional
inspiratory stridor
a 10 month old with a tympanic temperature of 102, green nasal drainage, and pulling
at the ears
an 8 month old with a harsh paroxysmal cough, audible expiratory wheeze and mild
a 3 year old with complaints of a sore throat, tongue slightly protruding out his
mouth, and drooling

10. As the office nurse, you are reviewing client messages for a return call. Which client should
the nurse call back first.

client 36 weeks gestation complaining of facial edema


a client 24 weeks gestation complaining of urinary frequency


a client 12 weeks gestation whose had five episodes of vomiting in 36 hours


a client 20 weeks gestation complaining of white, thick vaginal discharge