Professional Documents
Culture Documents
References of rationale:
Mosbys Medical, Nursing, and Allied Health Dictionary
Saunders Comprehensive Review NCLEX-RN® Examination 6 th edition published 2013
Disclaimer:
I consulted my Saunders 6th edition book along with reputable online sources in answering this
compilation but please verify my answers for yourself so that you will have the BEST answer. If I
committed errors, kindly edit this compilation accordingly. Salamat po. ^_^
1. You are providing a health teaching for a patient prescribed with medroxyprogesterone acetate
(Depo Provera). What is an appropriate health teaching for the patient?
2. You have the patients chart on hand. Which laboratory value is helpful in identifying heart failure as
the cause of dyspnea?
3. A client has a tracheostomy in place. Which statement would indicate a need for additional teaching?
a. I can suction no more than 10 seconds each time before removing the catheter.
b. I can reuse the catheter for oral secretions afer the tracheostomy suctioning, if needed.
c. I will reuse the catheters several times before discarding them, to save money.
Suction catheters should be inserted only during one suctioning period to minimize the risk of
contamination from allowing the catheter to lie out of the sterile packet, which would allow bacteria
to grow between suctioning periods.
4. What will be included in health teachings imparted to a patient taking chlorpromazine (Thorazine)?
Instruct patient to report signs of agranulocytosis which include sore throat, fever and malaise.
Alcohol and other CNS depressants are avoided. Instruct patient to report signs of liver dysfunction
including jaundice, malaise, fever and RUQ pain. Agranulocytosis is the most dangerous side effect of
antipsychotics and can lead to death if not detected and treated early. In addition to the requirement
that weekly analysis of WBCs must be completed before antipsychotics can be reordered, it is
important that the client, family, and nursing staff understand that changes in the WBC could occur
during the time period between two laboratory tests. Therefore, reporting any observations of
suspected infection is an urgent priority.
5. Patient is taking sildenafil (Viagra), further teaching is given to patient when he states?
The question is asking for a negative statement. Sildenafil (Viagra) enhances the vasodilating effect
of nitric oxide in the corpus cavernosum of the penis, thus sustaining an erection. Because of the
effect of the medication, it is contraindicated with concurrent use of organic nitrates and
nitroglycerin. Use of vitamins is not contraindicated. Insomnia is an expected side effect.
6. The male parent will take his wife and 6 months old infant home afer confinement, which statement
indicates that teaching was understood by the father who will drive the car?
a. The newborn will be placed in the backseat facing forward.
b. The newborn will be placed in the backseat rear facing.
c. The newborn will be placed in a booster seat beside the driver seat.
d. The newborn will be placed in a booster seat in the backseat.
The safest place for all children to ride, regardless of age, is in the back seat of the car. Infants should
ride in a semi-reclined, rear-facing position in an infant-only seat or a convertible seat until they
weigh at least 20 pounds and are at least 1 year of age. The transition point for switching to the
forward-facing position is defined by the manufacturer of the convertible car safety seat but is
generally at a body weight of 9 kg or 20 pounds and 1 year of age. All children whose weight or
height is above the forward-facing limit for their car safety seat should use a belt-positioning booster
seat until the vehicle seatbelt fits properly, typically when they have reached 4 feet 9 inches in height
and are between 8 and 12 years of age.
7. What are appropriate nursing interventions for patients with migraine? Select all that apply:
If the client understands the importance of finding the triggering factors, he/she will be more willing
to be involved in decreasing the triggers, including lifestyle changes that might be necessary. The
client should continue to exercise for general health and stress management. Driving is permitted.
Medication might not be needed every 4 hours.
a. Lidocaine (Xylocaine)
b. Atropine
c. Diltiazem (Cardizem)
d. Metoprolol (Lopressor)
9. You are conducting a health education session on factors for GERD. Which lifestyle modifications will
you include? Select all that apply:
a. Exercise regularly
b. Eat small frequent feedings.
c. Avoid peppermint on food.
d. use anticholinergics if prescribed.
e. use prokinetic medications if prescribed.
The client is instructed to avoid factors that ↓lower esophageal sphincter pressure or cause
esophageal irritation such as peppermint, chocolate, coffee, fried or fatty foods, carbonated
beverages, alcoholic beverages, cigarette smoking, nicotine, beta blockers, calcium channel blockers,
nitrates, theophylline, ↑ levels of estrogen and progesterone, and anticholinergic drugs. On the
other hand, Prokinetic medications are used for they accelerate gastric emptying.
10. What are the manifestations of Cushing’s disease? Select all that apply:
a. hypernatremia
b. hypokalemia
c. weight loss
d. petechiae
e. purpura
f. bruising
g. hypercalcemia
Assessment findings for Cushings disease include: generalized muscle wasting and weakness; moon
face, buffalo hump; truncal obesity with thin extremities, supraclavicular fat pads, weight gain;
hirsutism, hyperglycemia, hypernatremia, hypokalemia, hypocalcemia; hypertension; fragile skin that
easily bruises, reddish purple striae on the abdomen and upper thighs.
Bethanechol (Urecholine) is a direct acting cholinergic used to ↑bladder tone and function and to
treat non obstructive urinary retention. It is administered on an empty stomach, 1 hour before or 2
hours after meals to lessen nausea and vomiting.
In caring for clients diagnosed with antisocial personality disorder, it is important to maintain a
structured and consistent environment to ↓ their attempts to control the situation through
manipulation. It is unlikely that they will develop insight as the causes of the problems in living are
externalized. They are frequently quite sociable and take advantage of others for personal profit.
Suicidal ideation is not associated with this disorder.
13. A patient is prescribed fluticasone propionate (Flovent HFA). Which is a component of health
teachings in the use of this medication?
14. What are the adverse effects of fosinopril? Select all that apply:
a. dry cough
b. orthostatic hypotension
c. hypokalemia
d. ↑ RBCs
e. ↓ platelet count
A patient on ACE inhibitors should be instructed to report development of a cough especially one that
is resistant to cough suppressants. Other adverse effects include orthostatic hypotension,
hyperkalemia and blood dyscrasias (↓RBCs, ↓WBCs, ↓platelet count)
15. You are the staff nurse on duty. Which patient is a priority?
16. What are the manifestations of toxic shock syndrome? Select all that apply:
a. hypertension
b. ↑ cardiac rate
c. ↑ respiratory rate
d. constipation
e. ↓ cardiac output
f. myalgia
In an otherwise healthy person, the onset of TSS occurs with a sudden fever (temperature is always
at least 38.9°C / 102°F, chills, malaise, and muscle pain. Vomiting, diarrhea, hypotension, headache,
and signs suggesting early septic shock may develop. A red, macular rash similar to sunburn (diffuse,
macular erythroderma) is a classic sign of TSS. In some patients, this rash appears first on the torso;
in others, it is first seen on the hands (palms and fingers) and feet (soles and toes). Inflammation of
mucous membranes also may occur. In 7 to 10 days, it desquamates (becomes scaly or peels).
Myalgia and dizziness are common. Severe cases can result in acute respiratory distress syndrome
(ARDS), and cardiac dysfunction may occur.
17. You are tasked to conduct a nursing conference regarding health risk factors of various races. Native
Americans are at risk for?
a. Diabetes mellitus
b. Sickle cell anemia
c. Cancer
d. Thalassemia
African Americans are at risk for sickle cell anemia instead of Native Americans. White Americans are
at risk for cancer instead of Native Americans. Asian Americans are at risk for thalassemia instead of
Native Americans.
18. A patient has disseminated varicella zoster. What will be a component of nursing care?
a. keep stethoscope and BP in the room only for the client s use contact
b. wear gloves before entering the room contact
c. wear surgical mask when feeding the client droplet
d. keep the door closed at all times
Disseminated varicella zoster requires airborne precautions. Airborne precautions include the
following: Placing the client in a single room that is maintained under negative pressure; door
remains closed except upon entering and exiting. Negative airflow pressure is used in the room, with
a minimum of 6 12 air exchanges per hour depending on health agency protocol. Ultraviolet
germicide irradiation or high efficiency particulate air filter is used in the room. Health care workers
wear a mask or personal respiratory protection device. Mask is placed on the client when the client
needs to leave the room; client leaves the room only if necessary.
19. ORDERED RESPONSE: Use of crutches in going downstairs with a weak lef leg.
20. You are taking care of a patient with bipolar disorder. Which statement by the patient will you be
most concerned with?
a. I gave away all my money because I dont need it since I live in the White House.
b. Ill have you arrested because Im from the White House.
a. calcium gluconate
b. RotaTeq
c. Cefalexin
d. Glargine
Rotavirus is teratogenic to pregnant women upon exposure to it. RotaTeq is a form of rotavirus
vaccine.
This presents a potential risk for aspiration and ineffective airway clearance. When the muscles
involved in mastication, swallowing, as wells as the diaphragm, and intercostal muscles are weak,
the client may aspirate or experience poor gas exchange.
23. A patients laboratory findings include WBC = 1,000 mm 3 and platelet count = 50,000 cells/mm3.
What are your appropriate nursing interventions? Select all that apply:
The patients laboratory values indicate leukopenia and thrombocytopenia. Hence, the patient is
placed on neutropenic and bleeding precautions. Aspirin intake will lead to further bleeding.
Intramuscular and subcutaneous injections are avoided. The patient should stay in a private room
instead of a semi-private room.
Negligence is the unintentional failure of an individual to perform or not perform an act that a
reasonable person would or would not do in the same circumstance. Atropine sulfate is an
anticholinergic and mydriatic medication. Anticholinergics are contraindicated in clients with angle-
closure glaucoma because they can inhibit flow of aqueous humor and ↑intraocular pressure.
25. A nurse is about to administer alendronate sodium (Fosamax), which indicates correct
understanding? Select all that apply:
Alendronate sodium (Fosamax) is a bisphosphonate given for patients with osteoporosis and/or
Paget’s disease. Milk is taken together with alendronate sodium (Fosamax). This may lead to milk
alkali syndrome. It is taken before meals with distilled/plain water. The patient is instructed to avoid
taking with mineralized water, orange juice, tea or coffee. The patient is instructed to remain upright
after taking the drug.
If the PT value is longer than 30 seconds on a client on warfarin therapy, bleeding precautions are
instituted.
a. bicycle riding
b. gymnastics
c. ball throwing and catching
d. finger paints
At 4 years, the childs gross movements include catching and throwing balls. School age children are
more adept at bicycle riding specifically 6 year olds. School age children are more attuned to
gymnastics specifically 8 year olds. Finger paints are appropriate for toddlers.
28. Which diagnostic finding requires follow up for patient taking prolonged Simvastatin (Zocor)?
a. ↓ triglycerides
b. ↑ HDL
c. ↓ LDL
d. ↑ AST
Imitative behaviors teach the toddler new skills. Toddlers enjoy such toys as a play telephone.
Manipulation of toys develops both gross and fine motor abilities in this period. Paint-by-number sets
are recommended for school-aged children. Musical mobiles and a set of blocks are appropriate for
infants.
30. A patient develops hyperkalemia, which drug will you give first?
A patient with hyperkalemia is assessed for ECG changes. If ECG abnormalities are present, calcium
gluconate is administered. If ECG abnormalities are absent, insulin + 10% glucose is administered
intravenously. Polystyrene sulfonate (Kayexelate) is administered via enema. Hemodialysis is the last
resort if the patient has persistent hyperkalemia.
31. What is the drug of choice for premature ventricular contractions (PVCs)?
a. Lidocaine (Xylocaine)
b. Atropine sulfate
c. Isuprel
d. Dopamine
32. Which of the following are true regarding Trousseau s sign? Select all that apply:
a. For assessment, infate the BP cuf in the patients arm and observe for carpopedal spasm
b. it is the contraction of facial muscles in response to a light tap over the facial nerve in front of
the ear.
c. It indicates hypocalcemia.
d. It indicates hypercalcemia.
e. It refers to distal paresthesia elicited by tapping the median nerve on the wrist.
Trosseaus sign is a carpal spasm induced by inflating a BP cuff. The BP cuff is kept above the systolic
pressure for a few minutes.
33. A patient post thyroidectomy suddenly experiences tingling around his/her mouth. The nurse will
administer which medication?
Tingling or numbness around the mouth or circumoral paresthesia is a sign of impending tetany and
indicates hypocalcemia. Calcium is administered either orally or intravenously.
a. Jehovah s witnesses
b. Roman Catholicism
c. Judaism
d. Shintoism
Filgrastim (Neupogen) is a leukopoietic growth factor. It helps prevent infections in patients with
neutropenia. Members are not allowed to receive blood transfusion.
35. You see a fire in patient's room. What will you do first?
36. A client with Menieres disease would probably NOT complain of which of the following?
Menieres disease is associated with vertigo that may last for hours as well as fluctuating hearing
loss, nausea, and vomiting. The disorder is unilateral, but because hearing is bilateral, the client
often does not realize the extent of the hearing loss.
37. What are you going to observe in a patient with retinal detachment? Select all that apply:
a. Floaters
b. loss of peripheral vision
c. blurred vision
d. loss of central vision
e. diplopia
f. absence of red reflex
Assessment findings for retinal detachment include: flashes of light; floaters or black spots (signs of
bleeding); ↑blurred vision; a sense of curtain being drawn over the eye; loss of a portion of the
visual field, painless loss of central or peripheral vision.
38. While assessing airway and breathing, the client presenting with ↑ intracranial pressure, Cushing’s
triad presents with?
The brainstem’s final effort to maintain cerebral perfusion is seen with ↑systolic BP, bradycardia,
and an irregular respiratory pattern known as Cushing’s triad.
a. 2 – 3 months
b. 4 – 6 months
c. 7 – 10 months
c. 12 – 18 months
Superior fontanel also refers to anterior fontanel. It is soft, flat, diamond shaped, 3-4 cm wide x 2-3
cm long. It closes between 12 and 18 months of age. The posterior fontanel is triangular in shape,
0.5-1 cm wide, located between occipital and parietal bones. It closes between 2-3 months of age.
a. before meals
b. with meals
c. afer meals
d. bedtime
41. What are the correct components for preventing VRE spread? Select all that apply:
Vancomycin resistant enterococci infection requires contact precautions. Contact precautions include
the following: placing the client in a private room; cohorting with a client whose body cultures
contain the same organism; use of gloves and a gown when in contact with the client. Paraphernalia
and equipment are used for the patients private use only and is kept at the client s room.
a. face mask
b. private room with negative air pressure airborne
c. the door is kept closed at all times airborne
Meningitis requires droplet precautions. Droplet precautions include the following: placing the client
in a private room; cohorting with a client whose body cultures contain the same organism; use of a
surgical mask when within 3 feet of the client; placement of a mask on the client when he/she needs
to leave the room.
42. Which statement is true about manifestations usually found in patients with small pox?
Smallpox is transmitted in air droplets and by handling contaminated materials and is higly
contagious. Symptoms begin 7 to 17 days after exposure and include fever, back pain, vomiting,
malaise, and headache. Papules develop 2 days after symptoms develop and progress to pustular
vesicles that are abundant on the face and extremities initially.
43. Doctors order: Administer regular insulin 6 units/hr. The RN has an IV bag of 100 ml NS with 20 units
of regular insulin. How many ml/hr should be given to the pt.?
44. You are to administer gentamycin (Garamycin) intravenously, which manifestation will you watch out
for?
a. ringing in the ears
b. dry cough
c. nasal stuffiness
d. diplopia
Among the more serious adverse reactions are nephrotoxicity, auditory or vestibular ototoxicity,
impairment of neuromuscular transmission, and hypersensitivity reactions. Ototoxicity is manifested
by tinnitus or ringing in the ears.
45. Doctors order: Administer 0.5 mg of Petrisin. The RN has 0.8 mg Petrisin in 1 ml. How many
milliliters should be given to the patient?
46. You are to provide nursing education to discuss atrial fibrillation, which of the following will you
include?
47. ILLUSTRATION/PICTURE: A cluster of papulovesicular lesions which follow a linear pattern from the
side of the abdomen up to the flank. Which components of transmission precautions will you include?
a. droplet precautions
b. airborne precautions
c. contact precautions
d. standard precautions
The illustration stated above is seen in Herpes simplex. HSV infection requires contact precautions.
Contact precautions include the following: placing the client in a private room; cohorting with a
client whose body cultures contain the same organism; use of gloves and a gown when in contact
with the client. Paraphernalia and equipment are used for the patient s private use only and is kept
at the clients room.
48. The patient is diagnosed with beta Thalassemia and asks you about his condition. Which is the
correct statement?
Beta-Thalassemia is prevalent in people of Mediterranean descent but also occur in people from the
Middle East and Asia. Mild forms present with microcytosis and mild anemia. Severe beta
thalassemia (Thalassemia Major or Cooleys anemia) presents with marked hemolysis and ineffective
erythropoiesis. Patients with beta Thalassemia require frequent blood transfusion.
Risk factors for cervical cancer include: history of HPV infection, cigarette smoking, early intercourse,
and multiple sex partners. On the other hand, late menopause, use of estrogen replacement therapy
and nulliparity are some of the risk factors for endometrial cancer.
1. Use the pads of your second, third, and fourth fingers to press every part of the breast firmly.
2. Use your right hand to examine your lef breast, and use your lef hand to examine your right
breast.
3. Use circular motions in a spiral or up-and-down motion.
4. Repeat the pattern of palpation under the arm.
5. Check for any lump, hard knot or thickening if the tissue.
51. Which is the appropriate diet for a patient with chronic renal failure?
a. ↓ protein, ↓ carbohydrates
b. ↓ protein, ↑ carbohydrates
c. ↑ protein, ↑ carbohydrates
d. ↑ protein, ↓ carbohydrates
Restricting dietary protein early in chronic renal failure may slow the disease progression and also ↓
nausea and vomiting due to anorexia associated with uremia. Protein intake of 0.6 g/kg body weight
or approximately 40g/day is usually adequate. Carbohydrates should be ↑ to compensate for energy
needs.
52. You are to administer fluphenazine, which adverse effect will you look out for?
53. You are to administer cholestyramine (Questral). Which is an appropriate nursing intervention?
Cholestyramine is indicated for hyperlipoproteinemia and for pruritus resulting from partial biliary
obstruction. Among the more serious adverse reactions are fecal impaction, GI disturbances, and
depletion of vitamins A, D, and K. Constipation is common.
54. What are the manifestations of liver disorders? Select all that apply:
The liver synthesizes clotting factors I, II, VII, IX and X as well as prothrombin and fibrinogen. These
substances are needed for adequate clotting, so their ↓ leads to ↑risk of bleeding.
55. What are appropriate health teachings to a patient taking ciprofloxacin (Ciprobay)?
The patient is advised to drink plenty of fluids to ↓ risk of urine crystals. Tendon rupture is an
adverse effect from fluoroquinolone therapy. The client is instructed to report joint and tendon pain
to the health care providers. Rashes and other hypersensitivity reactions are adverse effects.
56. What is an appropriate diet for clients with iron deficiency anemia?
a. Tofu salad
b. blueberry cheesecake
c. oat meal cookie
Food sources rich in iron include: breads and cereals, dark green vegetables, dried fruits, egg yolk,
legumes, liver and meats.
57. Patient is taking trandolapril (Mavik), what are correct health teachings? Select all that apply:
The patient is advised to avoid driving because he/she may experience dizziness and orthostatic
hypotension. Soft bristled toothbrushes are used because occurrence of blood dyscrasias is a side
effect. The patient is instructed to weigh himself/herself daily and to report rapid weight gain and
significant pedal edema. The patient is monitored for development of cough that is resistant to
cough suppressants.
58. A patient with anemia is receiving iron dextran, what is the priority nursing assessment?
a. hemoglobin = 14 mg/dl
b. palmar itching
c. joint pain
d. nausea
Iron dextran is an injectable hematinic. It is prescribed in the treatment of iron deficiency anemia not
responsive to oral iron therapy. It is contraindicated in early pregnancy, anemia other than iron
deficiency anemia. Among the more serious adverse effects are severe hypersensitivity reactions,
including fatal anaphylaxis. Inflammation or phlebitis at the site of injection, arthralgia, headache, GI
distress, fever and lesser hypersensitivity reactions.
a. ascites
b. diarrhea
c. nausea and vomiting
d. oliguria
Fecal impaction is an accumulation of hardened or inspissated feces in the rectum or sigmoid colon
that the individual is unable to move. Diarrhea may be a sign of fecal impaction since only liquid
material is able to pass the obstruction. Occasionally, fecal impaction may cause urinary
incontinence because of pressure on the bladder.
a. Cohort patient with GBS together with one with rheumatic heart disease.
b. Negative pressure room for influenza
c. HEPA filter mask for RSV.
Influenza patients require droplet precautions not airborne. RSV requires contact precautions not
airborne.
61. A patient is on MRSA precautions. What should the nurse question?
The question is looking for a negative answer. MRSA colonization requires contact precautions.
Contact precautions include the following: placing the client in a private room; cohorting with a
client whose body cultures contain the same organism; use of gloves and a gown when in contact
with the client. Paraphernalia and equipment are used for the patient s private use only and is kept
at the clients room.
62. The nurse is teaching the client the technique of cognitive restructuring in a client who experienced
near drowning. What statement by the client indicates to the nurse that the client is making progress?
a. It was my friends fault why I wasnt swifly rescued from drowning.
b. “I will stop thinking about negative thoughts.”
c. I know how to work this program; Im too smart to fail.
d. My family hasnt yet realized that Im doing this for them.
63. You have the patients chart on hand. His serum calcium is 11 mg/dl. What are the expected
assessment findings in the patients condition? Select all that apply:
a. circumoral hyperesthesia
b. hypoactive deep tendon refexes
c. hypotension
d. tetany
e. lethargy
f. widened T wave
Assessment findings of hypercalcemia are the following: tachycardia in the early phase and
bradycardia that can lead to cardiac arrest in the late phases; hypertension; bounding, full peripheral
pulses; ineffective respiratory movement; profound muscle weakness; diminished or absent deep
tendon reflexes; disorientation, lethargy, coma; formation of renal calculi, flank pain; ↓GI motility,
hypoactive bowel sounds; anorexia, nausea, abdominal distention, constipation; shortened ST
segment, widened T wave
64. You have the patient’s chart on hand. His serum sodium is 148 mEq/L. What are the expected
assessment findings in the patients condition? Select all that apply:
a. oliguria
b. urine specific gravity of 1.010
c. urine specific gravity of 1.030
d. confusion
e. diarrhea
f. abdominal cramping
Assessment findings for hypernatremia are the following: spontaneous muscle twitches and irregular
muscle contractions in the early phase; skeletal muscle weakness and diminished or absent deep
tendon reflexes in the late phase of hypernatremia; altered cerebral function; if with normovolemia
or hypovolemia (agitation, confusion, seizures); hypervolemia (lethargy, stupor, coma); extreme
thirst; ↓ urine output; dry and flushed skin; dry and sticky tongue and mucous membranes; presence
or absence of edema depending on fluid volume changes; ↑urinary specific gravity
65. You are the staff nurse in the oncology ward. Which will you see first?
Cisplatin is an alkylating medication. It is a platinum compound that may cause ototoxicity, tinnitus,
hypokalemia, hypocalcemia, hypomagnesemia, and nephrotoxicity. The client is assessed for
dizziness, tinnitus, hearing loss, incoordination and numbness or tingling of extremities.
67. Nurse expects which blood values in a patient with celiac sprue?
a. ↑ serum amylase
b. ↑ serum IgM
c. ↑ WBC count
d. ↑ serum gliadin
Gliadin is a protein substance that is obtained from wheat and rye. Its solubility in diluted alcohol
distinguishes gliadin from another grain protein, glutenin.
68. You are going to conduct a nursing conference regarding thyroid disorders. What are the signs and
symptoms manifested in Graves disease? Select all that apply:
a. weight loss
b. diaphoresis
c. hypernatremia
d. constipation
e. cardiomegaly
f. atrial fibrillation
Assessment findings for Graves disease otherwise referred to as toxic diffuse goiter include the
following: personality changes such as irritability, agitation, and mood swings; nervousness and fine
hand tremors; heat intolerance; weight loss; smooth, soft skin and hair; palpitations, cardiac
dysrhythmias (tachycardia or atrial fibrillation); diarrhea; protruding eyeballs (exophthalmos)
diaphoresis; hypertension and enlarged thyroid (goiter). This hyperthyroid state is due to the
hypersecretion of thyroid hormones with ↑T3 and ↑T4
69. You are going to conduct a nursing conference on neuromuscular disorders. What are the signs and
symptoms manifested in myasthenia gravis? Select all that apply:
a. weight loss
b. ptosis
c. blank facial expression
d. akinesia
e. rigidity with jerky movements
f. weakness
Assessment findings for myasthenia gravis include: weakness and fatigue, difficulty chewing and
swallowing, dysphagia; ptosis, diplopia; weak, hoarse voice; difficulty breathing, diminished breath
sounds, respiratory paralysis and failure.
70. You are taking care of a patient with rheumatic endocarditis. How will you assess for mitral stenosis?
a. use bell of stethoscope, left side lying position at the apex of the heart.
b. use bell of stethoscope, lef side lying position at the 5 th midaxillary line.
c. use diaphragm of stethoscope, lef side lying position at the 4 th ICS lef sternal border.
d. use diaphragm of stethoscope, right side lying position at the 4 th ICS right sternal border.
1. Gloves
2. Eyewear/Goggles
3. Gown
4. Shoe/Hair Covers
5. Mask/Respirator
6. Hand Hygiene
Asterixis is otherwise known as liver flap or flapping tremor. It is a hand flapping tremor seen
frequently in hepatic encephalopathy. The tremor is usually induced by extending the arm and
dorsiflexing the wrist.
73. You are going to conduct a nursing conference on neuromuscular disorders, what are the signs and
symptoms manifested by people with multiple sclerosis? Select all that apply:
a. urinary retention
b. nystagmus
c. dorsifexion of the big toe and fanning of the other toes upon stroking the lateral aspect of
the sole of the foot
d. fasciculations of the face
e. focal neurological deficit
f. nuchal rigidity
Assessment findings for multiple sclerosis include: fatigue and weakness; ataxia, vertigo, tremors
and spasticity of the lower extremities, paresthesia; blurred vision, diplopia, transient blindness;
nystagmus; dysphasia; ↓perception to pain, touch, and T°; bladder and bowel disturbances
( urgency, frequency, retention and incontinence); abnormal reflexes (hyperreflexia, absent reflexes,
and positive Babinski reflex); emotional changes (apathy, euphoria, irritability, and depression);
memory changes and confusion
74. You are providing dietary instructions to a patient with renal failure. He is instructed to avoid which
of the following?
a. lettuce
b. soy sauce
c. potato
d. veal
Patients with renal failure observe a prescribed diet which is usually a ↓ to moderate protein and ↓
carbohydrate diet. Potassium and sodium intake is restricted based on serum electrolyte levels. Soy
sauce is ↑ in sodium. Foods that are ↓ in sodium include fruits and vegetables (lettuce and potato)
because they do not contain physiologic saline.
75. Your patients chart is on hand. His serum K + level is 3 mEq/L. What are the assessment findings will
you expect? Select all that apply:
Assessment findings of hypokalemia include the following: thread, weak, irregular pulse; weak
peripheral pulses; orthostatic hypotension; shallow, ineffective respirations that result from profound
weakness of the skeletal muscles of respiration; diminished breath sounds; anxiety, lethargy,
confusion, coma; skeletal muscle weakness, eventual flaccid paralysis; loss of tactile discrimination;
paresthesia; deep tendon hyporeflexia; ↓GI motility, hypoactive or absent bowel sounds; nausea,
vomiting, constipation, abdominal distention; paralytic ileus; ST depression; shallow, flat, or inverted
T wave, prominent U wave.
76. A patient has an IVF infusing at 125 ml/hr. The nurse auscultates the patient’s lungs and observes
crackles. What is the next action that the nurse will take?
The presence of crackles signifies fluid overload. The infusion rate should be slowed to as low as
possible to prevent worsening of the problem. The patient is then positioned appropriately. Then vital
signs are assessed.
77. You are taking care of a patient diagnosed with Diabetes Mellitus type 1. He becomes diaphoretic
and irritable. What will you do first?
Always abide by the nursing process. Assessment entails obtaining the patient s blood glucose level.
78. Post-TABHSO FOR 24 hours complains that the wound feels opened . Which will be your nursing
intervention?
Wound dehiscence is separation of the wound edges at the suture line; it usually occurs 6 8 days
after surgery. The nurse first assesses the site, calls for help, stays with the client, and asks another
nurse to contact the surgeon and obtain the needed supplies to care for the client. The nurse places
the client in a low-Fowlers position, and the client is kept quiet, and instructed not to cough.
79. A patient has unrelieved chest pain, which will be your priority nursing intervention?
a. administer oxygen
b. administer ACE inhibitors
c. administer diuretics
d. administer morphine
Pain relief ↑ oxygen supply to the myocardium. Morphine is administered as a priority in managing
pain the client having unrelieved chest pain.
80. You are conducting a health teaching for a patient regarding proper foot care. What are the
components of diabetic foot care? Select all that apply:
a. keep feet always dry
b. check shoes before wearing
c. soak in hot water
d. avoid smoking
e. treat corns and ingrown toenails on your own
f. apply moisturizing lotion in between toes
Diabetic foot care include: meticulous skin care and proper foot care; daily inspection of feet and
monitoring for redness, swelling, or break in skin integrity; prevention of thermal injuries from hot
water, heating pads, and baths; washing of feet with warm (not hot) water and drying thoroughly;
referring corns, blisters, or ingrown toenails to podiatrist; not crossing legs or wearing tight
garments that may constrict blood flow; application of moisturizing lotion to the feet but not
between the toes; wearing loose socks and well-fitting (not tight) shoes; wearing clean cotton socks
to keep the feet warm; avoiding wearing the same pair of shoes 2 days in a row; avoiding wearing
open-toed shoes; checking shoes for cracks or tears; breaking in shoes gradually; cutting toenails
straight across and smoothing of nails with an emery board; avoiding smoking.
81. A client receiving chemotherapy is experiencing neutropenia. The client can be cohorted with
whom?
The client with neutropenia is at ↑ risk for infection. The patient with HIV, unless currently infected
with another infection, does not pose a risk.
82. You are going to conduct a nursing conference on toxoplasmosis. What can lead to toxoplasmosis?
Toxoplasmosis is caused by an infection with the intracellular protozoan parasite Toxoplasma gondii
which produces a rash and symptoms of acute, flulike infection. Transmission is through ingestion of
raw meat or handing of cat litter of infected cats. Histoplasmosis is caused by the inhalation of
spores from contaminated soil and bird droppings. Diffuse interstitial fibrosis is due to sustained
exposure to asbestos, talc or beryllium.
83. ILLUSTRATION: How will you position a patient afer liver biopsy?
84. A student nurse inquires about the different signs and symptoms of hypermagnesemia. Which of the
following are included? Select all that apply:
a. cardiac dysrhythmias
b. absent deep tendon refexes
c. tachycardia
d. hypertension
e. positive Trosseaus sign
f. prolonged PR interval
85. The nurse suspects that hepatotoxicity is developing in an African American client who is on an
antibiotic. In what area of the body should the nurse assess for jaundice?
Jaundice in the dark-skinned client can best be observed by assessing the hard palate. Normally, fat
may be deposited in the layer beneath the conjunctivae that can reflect as a yellowish hue of the
conjunctivae and the adjacent sclera in contrast to the dark periorbital skin. In these clients, palms
and soles may appear jaundiced, but calluses on the surface of their skin can also make the skin
appear yellow.
86. A patient has latex allergy. Which items is the patient instructed to avoid? Select all that apply:
a. kiwi
b. papaya
c. spinach
d. hazelnut
e. lettuce
f. avocado
Individuals allergic to latex are instructed to avoid kiwis, bananas, pineapples, tropical fruits, grapes,
avocados, potatoes, hazelnuts and chestnuts. This is because there is a possible cross-reaction
between these and the latex allergen.
87. Which statement illustrates a correct understanding of positive and negative symptoms of
Schizophrenia?
a. Anhedonia is a positive symptom of schizophrenia.
b. Avolition is a negative symptom of schizophrenia.
c. Thought blocking is a positive symptom of schizophrenia.
d. Hallucinations are negative symptoms of schizophrenia.
88. You are the staff nurse, which manifestation of a patient s condition is your highest priority?
Spinal cord injury at or above the level of T6 can experience an exaggerated sympathetic response,
seen only after recovery from spinal shock. If untreated, autonomic dysreflexia is potentially fatal as
bradycardia and severe hypertension progresses. Autonomic dysreflexia is a neurological emergency
and must be treated promptly to prevent a hypertensive stroke.
89. Which of the following laboratory findings is helpful in diagnosing that a patient has Grave s disease?
a. ↑ T4
b. ↑ TSH
c. ↓T4
d. ↓T3
Assessment findings for Grave’s disease otherwise referred to as toxic diffuse goiter include the
following: personality changes such as irritability, agitation, and mood swings; nervousness and fine
hand tremors; heat intolerance; weight loss; smooth, soft skin and hair; palpitations, cardiac
dysrhythmias (tachycardia or atrial fibrillation); diarrhea; protruding eyeballs (exophthalmos)
diaphoresis; hypertension and enlarged thyroid (goiter). This hyperthyroid state is due to the
hypersecretion of thyroid hormones with ↑T3 and ↑T4
90. A patient is prescribed escitalopram (Lexapro), which of the following described correct
understanding?
Escitalopram (Lexapro) is a selective serotonin reuptake inhibitor (SSRI). ↓ libido is an expected side
effect of SSRIs. Antidepressants may take several weeks to produce the desired effect. Client response
may not occur until 2 – 4 weeks after the 1 st dose. SSRIs are not taken concomitantly with MAOIs
because of the potential for serotonin syndrome. OTC cold medications also ↑ the risk for selective
serotonin syndrome. Serotonin syndrome is characterized by ↑ T°, ↑ creatinine phosphokinase and
muscle rigidity.
91. Which of the following statements illustrate/s correct understanding about Hepatitis A? Select all
that apply:
Hepatitis A is transmitted through the fecal oral route via contaminated food/ water or infected
food handlers. Strict and frequent handwashing is essential in preventing the spread of all types of
hepatitis. Hepatitis D occurs with Hepatitis B and causes infection only in the presence of active HBV
infection and not Hepatitis A.
a. antiviral
b. antibiotic
c. antiprotozoal
d. antifungal
Cellulitis is an infection of the dermis and underlying hypodermis; the causative organism is usually
group A Streptococcus or Staphylococcus aureus. Cellulitis is treated with antibiotics, antibacterial
dressings, ointments, or gels as prescribed. A culture of the area is obtained prior to initiating
antibiotics.
94. Which of the following statements illustrate correct understanding about restraints?
It is important that circulation is checked regularly. The application of restraints requires a doctor s
order but there is no need to wait for the physician to release the restraints. Physical restraints
impede a clients freedom, and thus their use needs to be ordered every 24 hours. Because restraints
may also impede circulation, they should be removed according to agency policy, which is generally
every 1-2 hours to evaluate skin condition and circulation.
95. A patient is on restraints, which situation needs follow up?
a. make sure to check orders if HCP signed within the past 24 hrs.
b. wait for the physician to release the restraints.
c. remove the restraints every 1-2 hours.
It is important that circulation is checked regularly. The application of restraints requires a doctor s
order but there is no need to wait for the physician to release the restraints. Physical restraints
impede a clients freedom, and thus their use needs to be ordered every 24 hours. Because restraints
may also impede circulation, they should be removed according to agency policy, which is generally
every 1-2 hours to evaluate skin condition and circulation.
96. Methadone (Dolophine) is used in treating withdrawal symptoms from which addiction?
a. methamphetamine
b. cocaine
c. heroin
d. alcohol
Methadone (Dolophine) treats withdrawal symptoms of heroin and opioid addiction. Clients
undergoing withdrawal from heroin exhibit craving, lacrimation, yawning, and diaphoresis.
97. Which is the psychosocial developmental task for a 9 year old child?
Based on Erik Eriksons developmental theory, a 9 year old child must accomplish the developmental
task of inculcating industry in himself/herself.
98. What is the appropriate health teaching for a client who underwent cataract surgery?
Proper positioning is important after eye surgery to avoid complications. The client should avoid
bending, straining, and strenuous activity in order to ↓ intraocular pressure in the affected eye.
99. You are going to conduct a nursing conference regarding oncological disorders. What are the risk
factors for cervical cancer? Select all that apply:
a. exposure to HPV
b. multiple sex partners
c. early sexual intercourse
d. nulliparity
e. postmenopausal bleeding
f. history of polycystic ovary disease
Patients are at risk for cervical cancer if they have the following: Human papilloma virus (HPV)
infection; cigarette smoking; engaging in early sexual intercourse and with multiple sex partners.
100. ILLUSTRATION of an ECG strip: Atrial fibrillation: Which action by the co-staff RN will need your
intervention?
This question is looking for a negative answer. Instead of defibrillation, the client is prepared for
cardioversion as prescribed. The patient is administered oxygen. Anticoagulants are administered as
prescribed because of the risk of emboli. Cardiac medications are administered to control the
ventricular rhythm and assist in the maintenance of cardiac output.
101. A client with a total hip replacement is concerned about dislocation of the prosthesis. What can the
nurse say to reassure the client?
Extremes of internal rotation, adduction, and 90° flexion of the hip should be avoided 4-6 weeks after
surgery to prevent dislocation. Although use of elevated seats prevents excess flexion of the hip, it
alone does not suffice in preventing dislocation. Bending activities (such as putting on shoes) place
the client at risk for dislocation. Abduction pillows are used to prevent external rotation and must be
used postoperatively.
102. You are taking care of a postoperative patient with a fractured femur. Which are signs and
symptoms of fat embolism? Select all that apply:
a. acute chest pain
b. acute lumbar pain
c. petechiae on his/her chest and neck
d. sudden difficulty of breathing
e. diminished breath sounds
f. hypertension
Fat embolism is the sudden dislodgement of a fat globule that is freed into the circulation, where it
can lodge in a blood vessel and obstruct blood flow to tissue distal to the obstruction. Assessment
findings include restlessness, hypoxemia, mental status changes, dyspnea, tachypnea, tachycardia,
and hypotension. In addition, a petechial rash may present over the upper chest and neck
103. What are signs and symptoms of mild Alzheimer s disease? Select all that apply:
Clients with Alzheimers disease experience patterns of forgetulness and progressive confusion, and
cannot perform daily activities.
Infection of respiratory syncytial virus requires contact precautions. Contact precautions include the
following: placing the client in a private room; cohorting with a client whose body cultures contain
the same organism; use of gloves and a gown when in contact with the client. Paraphernalia and
equipment are used for the patients private use only and is kept at the client s room.
105. You are caring for a patient with a staphylococcal infection. Which is the appropriate transmission
precaution?
Staphylococcal infections require contact precautions. Contact precautions include the following:
placing the client in a private room; cohorting with a client whose body cultures contain the same
organism; use of gloves and a gown when in contact with the client. Paraphernalia and equipment
are used for the patients private use only and is kept at the client s room.
106. You are to administer a MMR vaccine. What does the nurse anticipate in the vaccine
administration?
a. allergy to shellfish
b. allergy to eggs
c. allergy to cephalosporins
d. aluminum hydroxide
Bucks (extension) skin traction is used to alleviate muscle spasms and immobilize a lower limb by
maintaining a straight pull on the limb with the use of weights. A boot appliance is applied to attach
to the traction. The weights are attached to a pulley; the weights are allowed to hang freely over the
edge of the bed; not more than 8 10 lb of weight is applied as prescribed. The foot of the bed is
elevated to provide the traction. Counter traction will prevent the client from sliding to the foot of
the bed. This can be achieved with Trendelenburg position of the bed or raising the foot of the bed
slightly if the clients body weight is not sufficient.
108. A patient with lef sided paresis uses a quadripod cane. Which of the following illustrates
appropriate use of quadripod canes?
Hemicanes or quadripod canes are used for clients who have the use of only one upper extremity.
They provide more security than a single-tipped cane. The cane is positioned at the client s
unaffected side, with the straight, non-angled side adjacent to the body. The cane is positioned 6
inches from the unaffected side, with the hand grip level with the greater trochanter.
109. Which illustrates negligence in taking care of a patient with angle-closure glaucoma?
Negligence is the unintentional failure of an individual to perform or not perform an act that a
reasonable person would or would not do in the same circumstance. Atropine sulfate is an
anticholinergic and mydriatic medication. Anticholinergics are contraindicated in clients with angle-
closure glaucoma because they can inhibit flow of aqueous humor and ↑intraocular pressure.
What will you anticipate with the patient’s care? Select all that apply:
Tuberculosis requires airborne precautions. Airborne precautions include the following: Placing the
client in a single room that is maintained under negative pressure; door remains closed except upon
entering and exiting. Negative airflow pressure is used in the room, with a minimum of 6 12 air
exchanges per hour depending on health agency protocol. Ultraviolet germicide irradiation or high
efficiency particulate air filter is used in the room. Health care workers wear a mask or personal
respiratory protection device. Mask is placed on the client when the client needs to leave the room;
client leaves the room only if necessary.
111. Which of the following statement illustrates proper use of a metered dose inhaler?
a. hold the metered dose inhaler about 4 fingerbreadths in front of the mouth.
b. slowly inhale for 3-5 seconds after puf
c. clean the mouthpiece with sodium chloride every afer use
d. wait from 30 minutes before giving steroids
The metered dose inhaler may be held about 2 fingerbreadths (1 ½ inches) in front of the mouth.
Alternatively, an inhaler with a spacer device can be used. Clients should breathe deeply once before
activating the inhaler and then continue breathing in for about 5 seconds. Clients then should hold
their breath for 10 15 seconds before breathing out slowly. If a second dose is needed, clients
should wait 1 2 minutes before taking another dose.
Montelukast (Singulair) is a leukotriene modifier. The client is instructed to take the medication 1
hour before or 2 hours after meals. The client is instructed to continue to take leukotriene modifiers
as prescribed, even during symptom free periods.
113. A patient has celiac disease, which of the following connotes a correct understanding of this
disease?
Clients with celiac disease must maintain a gluten-free diet, substituting corn, rice, and millet as
grain sources. The client is instructed about lifelong elimination of gluten sources such as wheat, rye,
oats, and barley. His/her diet is supplemented with vitamins and minerals. Celiac crisis is precipitated
by fasting, infection, or ingestion of gluten sources. Oral fluid intake is ↑ to avoid celiac crisis.
114. You are to provide health teachings on promoting a safe home environment for toddlers and
prevention of poisoning. What will be the components of this health teaching? Select all that apply:
Toddlers are at risk for poisoning due to their developmentally inquisitive behavior. Toddlers explore
things with their hands and mouths. Small objects should be kept out of reach. It is developmentally
inappropriate to attempt to teach a toddler to stop normal hand-to-mouth activity. They must be
supervised at all times. Toxic substances and medications should be stored in a locked cabinet.
Medications should be kept in childproof containers.
115. You are taking care of a patient post hip replacement surgery. Which statement by the patient
requires your intervention?
The client with hip surgery should avoid all activities that will cause hip adduction, internal rotation,
and flexion beyond 90°. Nursing interventions are instituted to prevent falls such as: keeping the bed
in the lowest position with bed rails up; elimination of obstacles and clutter; providing adequate
lighting; keeping the call light within reach; and reduction of other safety hazards.
116. A patient is on monoclonal antibodies, you will assess for which signs and symptoms? Select all that
apply:
a. nausea
b. diarrhea
c. headache
d. fever
e. hyperglycemia
f. rash
Side/adverse effects include: infection site reactions, viral infections, upper respiratory infections,
sinusitis, headache, pharyngitis, anaphylaxis and malignancies. The patient is assessed for
respiratory rate, rhythm, depth and lung sounds. The patient is also assessed for allergic reactions
such as urticaria and rash.
117. A patient undergoing blood transfusion suddenly exhibits fever, chills and lower back pain. The
nurse has stopped the infusion. What will be his/her next action? Select all that apply:
If the client exhibits signs of a transfusion reaction, the nurse immediately stops the transfusion and
changes the IV tubing down to the IV site to prevent the entrance of additional blood solution into
the client. Normal saline solution is hung and infused to keep the IV line open in the event that
emergency medications need to be administered. The HCP is notified and the nurse also notifies the
blood bank of the occurrence. The nurse stays with the client and monitors the client closely while
other personnel obtain needed supplies to treat the client. As prescribed by the HCP, the nurse
administers emergency medications such as antihistamines, vasopressors, fluids, and corticosteroids.
The nurse then obtains a urine specimen for laboratory studies and any other laboratory studies as
prescribed to check for free hemoglobin indicating that red blood cells were hemolyzed. The blood
bag tubing, attached labels, and transfusion record are returned to the blood bank can check the
items to determine the reason that the reaction occurred. Finally, the nurse documents the
occurrence, actions taken, and the clients response.
118. You are to administer varicella vaccine for a child. You will be alert for which finding?
The varicella vaccine is prepared with a live virus; therefore, it is not appropriate to administer to a
person who will be in contact with a pregnant woman.
Individuals at risk for Hepatitis B include: IV drug users, clients undergoing long term hemodialysis
and health care personnel.
120. A patient is prescribed hormonal therapy, which entry into the patient s medical history will warrant
questioning the doctors order?
a. History of deep vein thrombosis
b. History of pancreatitis
c. History of tuberculosis
d. History of tonsillitis
Use of hormonal therapy places the client at risk for thrombus and embolus formation. The client is
instructed to report thromboembolic complications while on hormonal therapy.
121. When triaging in the clinic, which client should be seen first? The client with:
The primary genital herpes infection involves systemic viremia, and encephalitisis a possible
complication. Headache and stiff neck may indicate encephalitis, and require further investigation.
122. The nurse notices the fire in the patient s room. He/she rescues the patient. What will be his/her
next action?
In the event of a fire, one should first rescue clients in immediate danger. Secondly, the fire alarm is
activated. Thirdly, the fire is confined by closing all doors. Lastly, the fire is extinguished.
123. You are taking care of pediatric patients, who is your priority?
a. 7 y/o child who starts a fire in trash cans and disposes of dismembered spiders
b. 8 y/o child who interrupts other children during play time
c. 12 y/o who steals valuables of other children
d. 13 y/o child who argues with her parents
Options A & C exemplify antisocial behavior. Stealing, cruelty, and arson are included in the antisocial
behaviors seen in children with CD. Between the two, option A exhibits arson and animal cruelty
which is more dangerous than stealing. On the other hand, Options B & D exemplify oppositional
behavior. Children with oppositional defiance disorder (ODD) are primarily disruptive, argumentative,
hostile, and irritable.
124. You have the patients chart on hand, what laboratory finding will support the diagnosis of
atherosclerosis?
The normal homocysteine level is less than 14 mmol/dL. ↑ homocysteine levels correlate with ↑risk
for the development of atherosclerotic heart disease. Homocysteine is an amino acid that is
produced by the breakdown of the amino acid methionine.
125. A client has an order for an iron preparation to be given by the parenteral route. The nurse plans to
give the medication by which of the following routes?
a. intermittent infusion
b. deep gluteal intramuscular (IM) injection, using the Z-track method
c. intramuscular in the deltoid to promote medication dissipation through muscle contraction
d. subcutaneous injection with weekly site rotation
126. A confined depressed client says, I feel I will have to stay here forever. What will be your
therapeutic response?
The communication technique of restating occurs by repeating back to clients the main points or
content of the conversation.
The TPN solution is changed every 12 24 hours as prescribed or according to agency protocol. The
IV tubing is changed every 24 hours. The dressing is changed every 48 hours.
128. What is the appropriate positioning for a patient who underwent radical neck dissection?
For patients who underwent laryngectomy (radical neck dissection), the patient is placed in a semi
Fowlers position or Fowlers position to maintain a patent airway and minimize edema.
129. Using the rule of nines, the nurse would expect burns in which area if it was computed at 41.5%?
a. anterior and posterior torso, anterior head and neck
b. anterior and posterior torso with perineum
c. anterior and posterior torso
c. anterior and posterior lower extremities
130. ILLUSTRATION: Erythema Migrans. How will you correctly document the figure?
131. You witness a patient who is standing, clenches his neck and cannot cough. What will you do first?
In providing abdominal thrust maneuvers, the rescuer should first stand behind the victim. The
rescuer places his/her arms around the victim s waist. The rescuer makes a fist. The rescuer places
the thumb side of his/her fist above the victim s umbilicus/belly button and well below the xiphoid
process. 5 quick abdominal thrusts are performed in and up (between the umbilicus and the xiphoid
process)
a. Supine
b. Low Fowlers position
c. Right Sims positon
d. Left Sims position
For patients undergoing enema administration, the patient is placed in the left Sims position to
allow the solution to flow by gravity in the natural direction of the colon.
133. You are caring for psychiatric patients, which patient will you see first?
Signs & symptoms of mild lithium toxicity include: apathy, lethargy, diminished concentration, mild
ataxia, coarse hand tremors and slight muscle weakness. Signs & symptoms of moderate lithium
toxicity include: nausea, vomiting, severe diarrhea, mild to moderate ataxia and incoordination,
slurred speech, tinnitus, blurred vision, muscle twitching, irregular tremor. Signs & symptoms include:
nystagmus, muscle fasciculations, deep tendon hyperreflexia, visual or tactile hallucinations, oliguria
or anuria, impaired level of consciousness, tonic clonic seizures or coma, leading to death.
134. The nurse would be most concerned with which post-operative patient?
a. T-tube drainage of 200 ml/hr post cholecystectomy
b. Coffee ground drainage 2 days post subtotal gastrectomy
c. During a 16 hour period on the 2nd day of a postop hip replacement surgery, 500 ml of
sanguineous fuid was noted.
d. Chest tube drainage of 100 ml/hr on the collection chamber
By the 2nd day, the drainage fluid should have slowed down considerably. A volume of 500 ml is
almost 2 units of blood, and if the drainage is still sanguineous on the 2 nd day, the nurse should
suspect that a problem is present. Frank bleeding should have stopped soon after surgery, and
secretions gradually should become more serosanguineous in nature within a few hours post op. The
normal drainage in the collection chamber connected to a chest tube is 70-100 ml/hr. The HCP is
notified if drainage exceeds 70-100 ml/hr.
Nursing assistants/unlicensed assistive personnel are assigned noninvasive interventions such as skin
care, range of motion exercises, ambulation, grooming and hygiene practices.
136. Proper positioning for a patient who will undergo central venous catheter insertion.
a. Semi-fowlers position
b. High fowlers position
c. Sitting position
d. Trendelenburg position
For central line insertion, tubing change, and line removal, place the client in the Trendelenburg’s
position if not contraindicated or in supine position, and instruct the client to perform the Valsalva
maneuver to ↑ pressure in the central veins when the IV system is open.
137. What is the appropriate needle gauge for a peripheral vascular device?
a. 14 gauge
b. 18 gauge
c. 20 gauge
d. 24 gauge
For rapid emergency fluid administration, blood products, or anesthetics, large-diameter lumen
needles or cannulas are used such as 14-, 16-, 18-, or 19- gauge. For peripheral fat emulsion/ lipid
infusions, a 20- or 21- gauge lumen or cannula is used. For standard IV fluid and clear liquid IV
medications, a 22- or 24- gauge lumen or cannula is used. If the client has very small veins, a 24- to
25- gauge lumen or cannula is used.
138. What are you going to monitor during continuous ambulatory peritonea dialysis (CAPD)?
a. Assess for bruit
b. Palpate for thrill
c. Maintain dwell time
d. Monitor functionality of the peritoneal cycling machine
In continuous ambulatory peritoneal dialysis (CAPD), renal function is closely resembled because it is
a continuous process. A machine is not required for the procedure. It promotes client independence.
The client performs self-dialysis 24 hours a day, 7 days a week. 4 dialysis cycles are usually
administered in a 24 hour period, including an overnight 8-hour dwell time. 1 ½ - 2 liters of dialysate
is instilled into the abdomen 4 times daily and allow to dwell as prescribed. After dwell, the bag is
placed lower than the insertion site so that fluid drains by gravity flow. After fluid is drained, the bag
is changed, new dialysate is instilled into the abdomen, and the process continues. Between
exchanges, the catheter is clamped.
1 infusion (fill), dwell, and drain is considered 1 exchange. Fill: 1-2 liters of dialysate as prescribed is
infused by gravity into the peritoneal space, which usually takes 10-20 minutes. Dwell time: the
amount of time that the dialysate solution remains in the peritoneal cavity is prescribed by the HCP
and can last 20-30 minutes to 8 or more hours, depending on the type of dialysis used. Drain
(outflow): fluid drains out of the body by gravity into the drainage bag. Nursing interventions
include: monitoring of vital signs, monitoring for respiratory distress, pain or discomfort, signs of
pulmonary edema, malaise, nausea and vomiting, hypotension and hypertension. The catheter site is
assessed for wetness or bleeding. Dwell time is not allowed to extend beyond the HCP s prescription
as this ↑risk for hyperglycemia. Outflow is initiated by turning the client side to side if the outflow is
slow to start. Outflow should be a continuous stream after the clamp is considered. Outflow is
monitored for color and clarity. Intake and output is monitored accurately; if outflow is less than
inflow, the difference is equal to the amount absorbed or retained by the client during dialysis and
should be counted as intake. An outflow greater than inflow should be reported to the HCP as well as
the appearance of frank blood or cloudiness in the outflow.
140. Which of the following is a correct health teaching for a patient with Meniere s disease?
Nonsurgical interventions for Meniere’s disease include: preventing injury during vertigo attacks;
providing bed rest in a quiet environment; providing assistance with walking; instructing the client to
move the head slowly to prevent worsening of the vertigo; sodium and fluid restriction; smoking
cessation; avoiding watching television because the flickering of lights may exacerbate symptoms;
administration of nicotinic acid (niacin), antihistamines, antiemetics, tranquilizers, sedatives, mild
diuretics; and vestibular rehabilitation.
The client is advised to consume a ↑ fiber and ↑ fluid intake to prevent diverticulitis. Nursing
interventions for diverticular disease include: constipation is prevented with dietary bran and bulk
laxatives as ordered; the client is kept on NPO and gastric decompression during acute episode; the
client is monitored for signs of peritonitis; administration of fluid and electrolyte replacement; and
administration of antibiotic therapy.
142. You are going to conduct a nursing conference on neurological disorders. What are the
pathophysiological factors regarding ↑intracranial pressure (ICP). Select all that apply:
↑ intracranial pressure is caused by: cerebral edema (contusion, tumor, water intoxication/hypo-
osmolality, alteration in the blood brain barrier where protein leaks into cerebral tissue); hypoxia (a
↓ in the PaO2 causes cerebral vasodilation); hypercapnia (causes vasodilation); impaired venous
return (↑cerebral blood volume); ↑ in intrathoracic/ intraabdominal pressure (↑in these pressures
cause a ↓ in venous return).
143. What is the appropriate nursing intervention when the high pressure alarm of the ventilator is
activated?
If a cause for an alarm cannot be determined, the client is ventilated manually with a bag valve mask
until the problem is addressed. For mechanical ventilators, high pressure alarms are due to:
obstruction of the ventilator tubing, secretions, kinks; patient coughing and gagging; patient trying
to fight the ventilator; endotracheal tube displacement; or bronchospasm. Low pressure alarms are
due to: air leaks, disconnection, or spontaneous breathing.
144. Which is an appropriate health teaching for patient taking methylphenidate (Ritalin)?
a. administer at bedtime.
b. change in appetite is expected.
c. insomnia is expected.
Methylphenidate hydrochloride (Ritalin) is a CNS stimulant. It is prescribed in the treatment of
hyperkinesis in children and in the treatment of narcolepsy in adults. It is contraindicated to patients
with glaucoma, severe anxiety, tension, mental depression, and is not given to children under 6 years
of age. Side/adverse effects include: tachycardia, anorexia and weight loss, ↑BP, dizziness and
agitation. Children and parents are instructed to avoid OTC medications. The last dose is taken at
least 6 hours before bedtime (14 hours for extended-release forms) to prevent insomnia. The child’s
weight and height are monitored. The client and parents are instructed that a drug free period may
be prescribed to allow growth of the child if the medication caused growth retardation.
Paclitaxel (Taxol) is an antineoplastic drug used for ovarian or metastatic breast cancer. Aripiprazole
(Abilify) is an atypical antipsychotic. Lorazepam (Ativan) is an anxiolytic. Lithium (Eskalith) is a mood
stabilizer for mania.
146. You are going to conduct a nursing conference about Lyme disease. Which of the following is a
component of nursing care for Lyme disease?
Health teachings for prevention of Lyme disease include: avoiding direct contact with ticks usually
found in wooded and busy areas; application of repellants. Upon exposure to tick bites, the tick is
promptly removed with tweezers. The person takes a bath immediately. Then drugs are administered
such as doxycycline, amoxicillin, and cefuroxime.
147. What can you delegate to a nursing assistant when caring for a patient with 2 nd degree pressure
ulcer?
Nursing assistants/unlicensed assistive personnel are assigned noninvasive interventions such as skin
care, range of motion exercises, ambulation, grooming, and hygiene practices. Licensed practical
nurses (LPN) can be delegated routine tasks such as dressing changes. RNs have the responsibility to
administer intravenous medications.
a. lotion
b. zinc oxide
c. warm water
d. topical cream
Teletherapy or external beam radiation is a form of radiation therapy. Nursing care include: leaving
radiology marks intact on skin, avoiding use of creams, lotions, deodorants, perfumes; use of
lukewarm water to cleanse the area or mild soap; assessment of skin for redness and cracking;
administration of antiemetics for nausea and analgesics for pain; avoiding exposure of area to cold
or sunlight; use of cotton, unrestrictive clothing
149. ILLUSTRATION of Erythema migrans, which doctors order will you question?
Erythema migrans is the hallmark sign of Lyme disease. Health teachings for prevention of Lyme
disease include: avoiding direct contact with ticks usually found in wooded and busy areas;
application of repellants. Upon exposure to tick bites, the tick is promptly removed with tweezers.
The person takes a bath immediately. Then drugs are administered such as doxycycline, amoxicillin,
and cefuroxime.
150. A patient post lumbar puncture, what is the essence of placing the patient flat on bed?
a. prevent headache
b. prevent hypotension
c. prevent dehydration
The patient is placed flat on bed to prevent spinal headache and to relax lumbar and abdominal
muscles.
151. A patient with UTI utters the following statements, which of these needs follow up?
Health teachings for prevention of UTIs include: good perineal care wiping from front to back;
avoiding bubble baths, tub baths, and use of vaginal deodorants or sprays; voiding regularly;
wearing of loose cotton pants; avoiding use of tight clothing; avoiding sitting with a wet bathing suit
for a prolonged span of time; use of water-soluble lubricants for intercourse; application of vaginal
creams to restore vaginal pH; and voiding after sexual intercourse.
1. Put on gloves.
2. Inspect wound for appearance, drains, exudate, and integrity. Measure wound size (length,
width, and depth. Avoid contact with contaminated material.
3. Cleanse wound.
4. Use separate swab for each cleansing stroke, or spray wound surface.
5. Clean wound from least contaminated area to most contaminated.
6. Apply loose woven gauze as contact layer.
7. Cut 4 x 4 gauze flat to fit around drain if present or use precut split drain flat.
8. Apply 2nd layer of gauze.
9. Apply thicker woven pad (surgi-pad).
10. Secure dressing with tape, Montgomery ties or straps (which are applied perpendicular to the
wound), or binder. Sometimes strips of a hydrocolloid dressing are placed on the skin under the
Montgomery ties to further protect the skin.
Dry dressings are most commonly used for abrasions and non draining postoperative (primary
intention healing) incisions. The dry dressing does not debride the wound and should not be selected
for wounds requiring debridement. It is not appropriate for an open wound that is healing by
secondary intention. If a dry dressing adheres to a wound, the nurse should moisten the dressing
with sterile normal saline or water before removing the woven gauze. Moistening the dressing in this
manner ↓ the adherence of the dressing to the wound and ↓ the risk of further trauma to the
wound.
1. If ambulatory, position the client sitting on the toilet. If on bed rest, position the client on
his/her side.
2. Hang the irrigation bag so that the bottom of the bag is at the level of the client s shoulder
or slightly higher.
3. Insert the irrigation tube carefully without force.
4. Begin the flow of irrigation.
5. Clamp the tubing if cramping occurs; release the tubing as cramping subsides.
6. Perform irrigation at about the same time each day. Perform irrigation preferably 1 hour
afer meal.
The purpose of colostomy irrigation is to cleanse the bowel of feces before tests or surgical
procedures, to relieve constipation or to establish a pattern of regular bowel elimination after
ostomy surgery. Irrigations for achieving regular bowel evacuation can be achieved only with
descending and sigmoid end colostomies.
154. What is the proper assessment of the facial nerve (CN VII)?
Option A assesses the trigeminal nerve (CN V). Option C assesses the hypoglossal nerve (CN XII).
Option D assesses the spinal accessory nerve (CN XI).
155. Which of the following is the proper assessment for trigeminal nerve (CN V)?
a. Tell client to clench teeth and palpate temples.
b. Tell client to identify different nonirritating aromas such as coffee and vanilla.
c. Tell the patient to identify salty or sweet taste on front of tongue.
d. Tell the patient to identify sour or sweet taste on the back of the tongue.
Option B assesses the olfactory nerve (CN I). Option C assesses the facial nerve (CN VII). Option D
assesses the glossopharyngeal nerve (CN IX).
Transfusion therapy is the intravenous administration of whole blood or blood components. It may
be used to restore intravascular volume with whole blood or albumin, to restore the oxygen-carrying
capacity of blood by replacing red blood cells, to replace clotting factors and/or platelets to reverse
coagulopathy, or to replace white blood cells in neutropenic clients.
157. You are on duty with a nursing attendant. A patient dies, in which situation will you intervene?
a. NA removes dentures
b. NA removes jewelry
c. NA removes indwelling catheter
If a person wore dentures, they are inserted. If mouth fails to close, a rolled up towel is placed under
the chin. It is difficult to insert dentures after rigor mortis occurs. Dentures maintain natural facial
expression.
158. Patient with pelvic and femoral fracture experiences sudden dyspnea and chest pain. Afer
repositioning, what will you do next?
The patient is possibly experiencing fat embolism, after repositioning, further assessment is
warranted.
159. ORDERED RESPONSE: Dressing change for central vascular access device
1. Carefully remove old dressing in the direction the catheter was inserted, noting drainage and
appearance of catheter or needle insertion site.
2. Apply sterile gloves.
3. Clean placement or exit site with alcohol swabs by starting from inside moving out in a circular
fashion creating concentric circles. Clean about a 3 cm area. Allow alcohol to remain on the skin
for at least 60 seconds.
4. Clean placement or exit site with povidone iodine swabs.
5. Redress site using sterile gauze and tape or transparent dressing as indicated.
6. Dispose of soiled supplies; remove gloves and wash hands.
160. What indicates correct understanding of use of distraction in pain management of patient with
chronic low back pain?
a. I will start to deeply breathe and exhale to a slow rhythmical pattern when pain begins.
b. I will lie down and think of a positive thought when I have low back pains.
c. I will watch a comedy movie when my back starts to hurt.
Distraction is a technique that diverts an individual’s attention away from the pain sensation. By
introducing meaningful stimuli, the nurse helps the client refocus attention. The client’s pain
tolerance ↑ as distraction ↓ awareness of pain. Typically, distraction is most effective for mild to
moderate pain, but with intense concentration even acute pain can be relieved. In most cases the
pain relief lasts only as long as the distraction; when the distraction is removed, the client may have
a heightened awareness of pain. Examples of distraction include music, visitors, television, breathing
exercises, or active listening.
161. Which doctors order will you question for a patient with COPD?
Clients with COPD are administered a ↓ concentration of oxygen at 1-2 lpm as prescribed; their
stimulus to breathe is a ↓ arterial PO2 instead of an ↑ PCO2
1. Place lower tips of staple extractor under 1 st staple. As you close handles, upper tip of extractor
depresses center of staple, causing both ends of staple to be bent upward and simultaneously
exit their insertion sites in the dermal layer.
2. Carefully control staple extractor.
3. As soon as both ends of staple are visible, move it away from skin surface and continue on until
staple is over refuse bag.
4. Release handles of staple extractor, allowing staple to drop into refuse bag.
Staples are made of stainless steel wire. Their use is restricted by the location of the incision, because
there must be adequate distance between the skin and structures that lie below the skin, including
bone and vascular structures. The cosmetic result may not be as desirable as that obtained with finer
suture material. Staples do provide ample strength. Removal requires a sterile staple extractor and
maintenance of aseptic technique.
163. You are taking care of a patient with COPD. Which is the correct instruction for pursed lip breathing?
Pursed lip breathing facilitates maximal expiration and promotes carbon dioxide elimination. This
type of breathing allows better expiration by ↑ airway pressure that keeps air passages open during
exhalation.
a. ↑ serum lipase
b. ↓ calcium
165. Which of the following is an appropriate health teaching for a patient with stomatitis?
For a client with stomatitis, he/she is advised to rinse his/her mouth before and after meals and at
bedtime using normal saline or solution of ½ to 1 teaspoon of salt or baking soda to one pint of tepid
water. Soft-bristled toothbrush is used. To loosen and remove thick mucus, use 1 part of hydrogen
peroxide to 4 parts of normal saline followed by warm water or saline rinse.
166. A patient who underwent abdominal surgery suddenly complains of chest pain and difficulty of
breathing. This is possibly caused by:
Pulmonary embolism is a complication of deep vein thrombosis. Sudden chest pain and dyspnea are
characteristic of pulmonary embolism. Option A indicates a normal value. During heparin therapy,
the therapeutic level of activated partial thromboplastin time equals 1.5-2 times the control value.
167. Which complication is a priority for a patient who underwent paracentesis 2 days ago?
The physician is promptly notified if a patient contracts a fever and chills which are indicative of
infection and possible perforation. Other complications of paracentesis include hypovolemic shock
and peritonitis.
168. On his 2nd day afer undergoing radical neck dissection, the patient expresses helplessness. What
will be your therapeutic response?
a. I will sit here for a while. Let us talk when youre ready to talk.
b. Do you want to go for a walk?
Silence is a therapeutic communication technique. It allows client time to think and gain insights,
slows the pace of the interaction, and encourages client to initiate conversation, while conveying
nurses support, understanding, and acceptance.
169. You approach a schizophrenic patient pacing. How will you communicate with him/her
therapeutically?
170. You are assigned to the psychiatric ward, what describes working phase in a therapeutic
relationship with a depressed client?
a. Infant
b. Toddler
c. Preschooler
d. School aged child
172. Which assessment findings support a ruptured suspected ectopic pregnancy? Select all that apply:
a. cold, clammy skin
b. severe vaginal bleeding
c. low abdominal pain that radiates to her shoulder
d. headache
e. blurred vision
f. pressure in perineal area
Assessment findings for ruptured ectopic pregnancy include: acute pain, referred shoulder pain and
signs of shock such as pallor, tachycardia, and hypotension.
a. to ↓ CAD risk
b. help promote bone maintenance and growth
Resistive isometric exercises help to promote muscular strength and provide the necessary stress for
bone maintenance and growth. Without sufficient stress against bone, osteoclastic activity ↑ over
osteoblastic activity. The result is demineralization of the bone and eventual osteoporosis. Examples
of resistive isometric exercises are performing push-ups, pushing against a footboard to move up in
bed, and hip lifting. Isotonic exercises ↑circulation and respiratory rate and have beneficial effects
on the entire body. Some individuals, however, are unable to tolerate such exercises in activity.
174. A patient has celiac disease and is visibly irritable. Her laboratory results include: WBC = 11,000
cells/mm3; Hgb = 8.8 mg/dl
Clients with celiac disease must maintain a gluten-free diet, substituting corn, rice, and millet as
grain sources. The client is instructed about lifelong elimination of gluten sources such as wheat, rye,
oats, and barley. His/her diet is supplemented with vitamins and minerals. Celiac crisis is precipitated
by fasting, infection, or ingestion of gluten sources. Oral fluid intake is ↑ to avoid celiac crisis.
a. hypertension
b. hypotension
c. bradypnea
d. bradycardia
176. You are taking care of a depressed client who is severely withdrawn. He does not speak and avoids
eating his meals. His weight has gone down to 52 kg. You expect the physician to order which
intervention?
a. Administration of SSRIs
b. Electroconvulsive therapy
c. Administration of thorazine
d. Prescription for St. Johns wort
Use of electroconvulsive therapy (ECT) is indicated when antidepressant medications have no effect;
when there is a need for rapid definitive response, such as when a client is suicidal or homicidal;
when the client is in extreme agitation or stupor; when the risks of other treatments outweigh the
risk of ECT; when the client has a history of poor medication response, a history of good ECT
response, or both; when the client prefers ECT as treatment.
177. What are the assessment findings for digoxin toxicity? Select all that apply:
a. Loss of appetite
b. Nausea
c. Constipation
d. Headaches
e. Xanthopsia
f. Rashes
Early signs of digoxin toxicity present as gastrointestinal manifestations (anorexia, nausea, vomiting,
diarrhea); then, visual disturbances (diplopia, blurred vision, yellow-green halos, photophobia) and
heart rate abnormalities occur
Lifestyle modifications for hypertension include: weight control and reduction to attain a normal
BMI; adherence to dietary approaches to stop hypertension (DASH) eating plan such as ↑ intake of
fruits, vegetables, and ↓ fat dairy products that are rich in calcium and potassium; sodium
restriction (less than 2.4 g daily); aerobic exercise at least 30 minutes on most days; alcohol
moderation; smoking cessation and stress management.
179. What is the priority finding for a patient with systemic lupus erythematosus (SLE)?
a. Low-grade fever
b. ↑ erythrocyte sedimentation rate (ESR)
c. Pericarditis
d. Proteinuria
Signs of organ involvement include: pleuritic, nephritis, pericarditis, coronary artery disease,
hypertension, neuritis, anemia, and peritonitis.
180. Which of the following are manifestations of Addison s disease? Select all that apply:
a. Lethargy
b. Truncal obesity
c. Hirsutism
d. Hypokalemia
e. Hyperkalemia
f. Hyponatremia
g. Hypernatremia
Assessment findings for Addisons disease include: lethargy, fatigue, muscle weakness;
gastrointestinal disturbances, weight loss; menstrual changes in women, impotence in men;
hypoglycemia, hyponatremia, hyperkalemia, hypercalcemia; hypertension, and bronze
hyperpigmentation of skin.
181. What are the side effects of nitroglycerin? Select all that apply:
a. Constipation
b. Dizziness
c. Flushing
d. Agranulocytosis
e. Dry mouth
f. Hyperglycemia
182. What is a priority nursing action for a patient with ascites who was ordered for IFC insertion?
Hypoalbuminemia and ↓ membrane permeability predisposes the patient for bladder perforation
during urinary catheterization.
183. You are assigned to the medical-surgical unit. Which is your priority?
Bleeding can manifest as a resistant nonproductive cough. The goal of treatment is to control
bleeding, prevent complications, and prevent the recurrence of bleeding. Rupture and resultant
hemorrhage of esophageal varices is the primary concern because it is a life-threatening situation.
184. You are taking care of a child diagnosed with ADHD, he displays inappropriate behavior. What will
be an appropriate nursing action?
Timed urine collection begins after a client urinates. The first specimen is discarded and then every
successive specimen is collected until the time period has ended. The specimen is transferred
immediately to a large collection bottle kept in the client s bathroom. Any missed specimens make
test results inaccurate. The client should always provide the last specimen as close as possible to the
end of the collection period.
1. Assist patient to dorsal recumbent position (supine with knees flexed). Ask client to relax thighs
so the hip joints can be externally rotated.
2. Lubricate 2.5 5 cm (1 2 inches) for women
3. With nondominant hand, carefully retract labia to fully expose urethral meatus.
4. Using forceps in sterile dominant hand pick up cotton ball saturated with antiseptic solution and
clean perineal area, wiping front to back from clitoris toward anus. Using a new cotton ball for
each area, wipe along the far labial fold, and directly over center of urethral meatus.
5. Advance catheter a total of 5 7.5 cm (2 3 inches) in adult or until urine flows out catheter s
end. When urine appears, advance catheter another 2.5 5 cm (1 2 inches). Do not force
against resistance. Place end of catheter in urine tray receptacle.
6. Remove straight, single-use catheter. Withdraw catheter slowly but smoothly until removed.
Catheterization of the bladder involves introducing a rubber or plastic tube through the urethra and
into the bladder. The catheter provides for a continuous flow of urine in clients unable to control
micturition or in those with obstruction to urine outflow.
187. What are manifestations of peripheral arterial disease? Select all that apply:
188. What is NOT an appropriate component of intermittent catheterization of an 87 year old client?
Straight catheters are used only once and disposed of properly. Sterile asepsis is used to ↓ the risk of
bladder infections. A client with a catheter is especially vulnerable to UTI. The frail order adult client
who is physically compromised runs the additional risk of developing septicemia. Therefore, the
client who is incontinent should not be routinely catheterized.
189. A nurse is to perform IFC insertion to a female patient. What should the nurse do to minimize Foley-
related infection?
a. clean perineum and urethral meatus with tap water before insertion.
b. with the nondominant hand, carefully retract labia to fully expose urethral meatus.
c. use petroleum jelly to lubricate catheter.
d. ask client to bear down gently as if to void and slowly insert catheter through urethral meatus.
Option B provides full visualization of urethral meatus is provided. Full retraction prevents
contamination of urethral meatus during cleansing. Instead of tap water, sterile antiseptic solution is
used in cleaning the perineum and urethral meatus. Option D provides for relaxation of external
sphincter aids in insertion of the catheter.
190. A client on continuous bladder irrigation complains of unrelieved bladder spasms. What is an
appropriate nursing intervention?
An ↑ in bladder spasms may indicate occlusion of catheter with blood clots. The physician is notified
if bladder spasms ↑ or are unrelieved. Sterile irrigating solution is kept in room temperature because
cold solution could cause bladder spasms.
191. Which of the following statements by a client with liver cirrhosis indicates correct understanding
about his diet?
a. “I should take multivitamin supplements.”
b. “I need to ↓ my protein intake.”
c. “I need to ↑ my sodium intake.”
Dietary modification for clients with liver cirrhosis include: intake of supplemental multivitamins
(vitamins A, B complex C, K, folic acid and thiamine) as prescribed; sodium and fluid restriction as
prescribed.
192. You are the staff nurse on duty, which patient will you see first?
193. You are to provide nursing education about the Good Samaritan law, which of the following will you
include?
a. A nurse pulls the victim of a vehicular accident out of the care and provides prompt care.
b. Neighbor asking you for referral to another health care provider because she is not satisfied with
the present health care provider.
c. The nurse accepts a reward from the victims family for the aid provided.
In the U.S., state legislatures pass Good Samaritan laws, which vary from state to state. These laws
encourage health care professionals to assist in emergency situations and limit liability and offer
legal immunity for persons helping in an emergency, provided that they give reasonable care.
Immunity from suit applies only when all conditions of the state law are met, such as the health care
provider receives no compensation for the care provided and the care given is not intentionally
negligent.
a. A 17 year old does not consult her parents in providing consent to undergo HIV testing.
b. A 17 year old asks her mother to give consent prior to undergoing caesarian section.
Parental or guardian consent should be obtained before treatment is initiated for a minor except in
the following cases: in an emergency; in situations in which the consent of the minor is sufficient,
including treatment related to substance abuse; treatment of STDs, HIV, and AIDS; birth control
services, pregnancy; or psychiatric services; the minor is an emancipated minor; or a court order or
other legal authorization has been obtained. An emancipated minor has established independence
from his/her parents through marriage, pregnancy, service in the armed forces, or by a court order.
An emancipated minor is considered legally capable of signing an informed consent.
An informed consent is a legal document, and the client must be informed by the health care
provider, in understandable terms, of the risks and benefits of surgery, treatments, procedures, and
plan of care. The client needs to be a participant in decisions regarding health care. A client may
withdraw consent at any time. An informed consent can be waived for urgent medical or surgical
intervention as long as institutional policy so indicates.
196. A patient is diagnosed with lactose intolerance and inquires about alternate calcium sources. Which
will you include in your teaching?
a. Yogurt
b. Skimmed milk
Clients with lactose intolerance need to incorporate sources of calcium other than dairy
products into their dietary patterns regularly. Milk may be tolerated in cooked form, such as in
custards or fermented dairy products. Cheese and yogurt sometimes are tolerated. Lactase, an
enzyme, may be prescribed and is taken before ingesting milk or milk products. Lactase
treated milk or lactose free products are also available commercially.
Nursing interventions for constipation include: teaching parents to provide foods with fiber; teach
parents to ↑ amount of fluid; bowel retraining; appropriate use of enema and laxatives.
199. What is an appropriate nursing intervention for a child who underwent clef lip repair?
200. What are the appropriate nursing interventions for a patient who underwent bone marrow
aspiration?
Bone marrow aspiration is the removal of a small amount of the liquid organic material in the
medullary canals of selected bones, in particular the sternum and the posterior superior iliac crests.
In children, the proximal tibia may be used. Tenderness, erythema, hypotension and tachycardia may
indicate infection at the site or shock
201. You are assigned to the psychiatric ward. Which psychiatric client is your priority?
Safety is the priority for all clients. Suicidal clients who are depressed are at highest risk for suicide
when they begin to demonstrate improvement and have sufficient energy to carry out a suicidal act.
196. A patient has xerostoma, what are your nursing interventions for mouth care?
a. hydrogen peroxide
b. commercial mouthwash
c. commercial saliva replacement
197. What are your nursing interventions for patient with aphasia? Select all that apply:
198. You are going to conduct a nursing conference regarding gastric surgeries. What is true regarding a
continent ileostomy?
a.
Continent ileostomy otherwise referred to as Kock ileostomy is an intraabdominal pouch that
stores the feces and is constructed from the terminal ileum. The pouch is connected to the
stoma with a nipple-like valve constructed from a portion of the ileum; the stoma is flush with
the skin. A catheter is used to empty the pouch, and a small dressing or adhesive bandage is
between emptying.
199. What are appropriate nursing interventions for a patient diagnosed with lef CVA? Select all that
apply:
a. Penetrating wound
b. Fixed, dilated pupil with apnea
c. Pain upon inspiration with fracture
201. You are the admitting nurses, who can be with the HIV patient in the same room?
a. Streptococcal infection
b. Patient who underwent appendectomy
202. A patient with Schizophrenia exhibits the following manifestations, which needs immediate action?
a. I need it to protect nurse since the institution is concerned on the act of the suit.
b. I dont need it because I am protected by the Good Samaritan law.
c. I need it to protect me if I was named in the suit involving negligence and malpractice.
206. You are taking care of an AIDS patient. How can you promote effective infection control?
207. Which comorbidity does a patient have that predisposes him/her for cholecystitis?
a. Hepatitis C
b. Diabetes mellitus
208. Which is an appropriate diet for a patient with end stage renal disease?
a. ↓ CHON intake
b. ↓ fluid intake only if no urine output
209. A patient is on amlodipine besylate (Norvasc), you as the nurse on duty will be most concerned if?
211. The nurse manager says, Congratulations! Because of your suggestions, there is improved work
efficiency for the past 3 months. This statement reflects which of the following?
212. A patient is taking sildenafil (Viagra). Which of these following statements indicate that he requires
further teaching?
214. You are the home health nurse, which patient are you to visit first?
a. visit first the least infective patient.
215. A nursing student is about to provide health teaching on substance abuse, you determine that
he/she needs further teaching when he/she states?
216. ILLUSTRATION: Which position will facilitate proper assessment of diastolic BP?
a. Supine
b. Side lying
c. Semi – fowler’s
d. Trendelenburg
217. A patient with CHF has abnormal potassium and ↑ cholesterol, which medications are
contraindicated?
a. Potassium durule
b. Digoxin (Lanoxin)
c. Furosemide (Lasix)
d. Atorvastatin (Lipitor)
e. Nesiritide (Natrecor)
f. Colace
218. Which of the following exemplifies the appropriate diet for cystic fibrosis?
a. ↑ calcium ↑ sodium
b. ↓ calcium ↓ sodium
A child with cystic fibrosis requires a ↑calorie, ↑protein, and well-balanced diet to meet energy
and growth needs; multivitamins and vitamins A, D, E, and K are also administered; for those
with severe lung disease, energy requirements may be as high as 20% to 50% or more of the
recommended daily allowance.
219. You are assigned to a visually impaired client, which exemplifies therapeutic communication?
221. A patient with Parkinsons disease is taking Levodopa. Which statement will you follow up?
a. This drug is not working for me. I want to stop taking.
222. You are the school nurse, which is an appropriate response by the parent?
a. Vancomycin (Vancocin)
b. Zyvox
c. Synercid
224. 80 year old complaints about his difficulty sleeping and asks you for advice. Which of the following
will you include? Select all that apply:
227. A patient has CVA with dysphagia, the nurse observes his co-staff nurse. You will intervene if you
see him/her?
228. How will you accurately take a patients intra-aortic blood pressure?
229. What are the appropriate nursing interventions for a patient who was administered with
radioisotopes?
a. ↑ hydration
230. A patient is taking captopril (Capoten) for primary hypertension. What assessment needs follow up?
232. Which are correct regarding surgical positioning? Select all that apply:
233. Elderly patient. What are expected findings? Select all that apply:
234. You are conducting an assessment of an elderly patient. Which needs follow up?
a. ↑ shallow respirations
b. rales at the base of the lungs
c. oral intake of at least 1500 ml per day
237. A patient is rushed to the ER for submersion injury. What sign would need priority intervention?
a. dyspnea
b. restlessness
c. frequent coughing
d. pulse oximetry = 90%
239. Which among the patients who came from the PACU will the nurse attend to first?
240. Patient disagrees to take medications and asks nurse to focus care on other patients. What is an
appropriate response?
241. A nurse observes a schizophrenic client shouting at other patients. Other patients and personnel
had many attempts trying to make the patient go back to his room. Which is the best intervention?
246. ORDERED RESPONSE: Changing from permanent infusion line into intermittent infusion line.
a. administer IV antibiotics
Nursing interventions for patients in shock include: elevation of the legs; notifying the HCP;
oxygen administration; monitoring of the patient’s LOC, vital signs, intake and output;
assessment of the color, temperature, turgor and moisture of the skin and mucous membranes;
and administration of IV fluids, blood and colloid solutions as prescribed.
a. advise to change contraceptive method from hormonal pills to a different birth control
method.
254. A patient with Alzheimers disease has bruises. Which will be an appropriate nursing intervention?
256. ILLUSTRATION: Proper site to administer DTaP for 2 month old child.
a. vastus lateralis
b. deltoid
c. ventrogluteal
d. dorsogluteal
a. MMR at 2 months.
b. Hepatitis B 2 doses.
c. TDaP 5 doses at different intervals.
a. akathisia
b. pseudoparkinsonism
c. dysphagia
d. urinary retention
260. According to hospital policy, only 2 visitors enter a client s room at a time. A terminally ill client s
family wishes to enter and be beside him. What will the nurse do?
262. Sites of edema in right sided heart failure. Select all that apply:
a. shoulder
b. girdle
c. thorax
264. A patient is prescribed with indomethacin (Indocin); which are the side effects of this drug? Select
all that apply:
a. headache
b. blurred vision
c. metallic taste
d. muscle ache
Indomethacin (Indocin) is a prostaglandin inhibitor.
265. A child is scheduled for surgery, her parents were divorced but they have joint custody of the child.
The mother has signed the consent. What will you do?
A minor is a client under legal age as defined by state statute (usually younger than 18 years). A
minor may not give legal consent must be obtained from a parent or the legal guardian; assent
by the minor is important because it allows for communication of the minor s thoughts and
feelings.
a. the nurse instructs the patient who is aggressive to move away from the group
b. the nurse talks to the patient in a calm, nonjudgmental manner
c. the nurse tells the patient that what she will share with her will be kept confidential and
will not be shared with the health care team.
267. Which of the following statements illustrate a correct understanding about renal transplantation?
Select all that apply:
268. Which is the appropriate diet for patients with pressure ulcers?
a. ↑ CHON, ↑ vitamin C
b. ↑ K+, ↑ Na-
c. ↓ CHON, ↓ vitamin C
269. Which is the appropriate diet for patients with renal calculi?
270. You are assigned to the medical-surgical unit. Which patient is your priority?
271. Which is the appropriate diet for a CVA patient with dysphagia?
a. vegetable soup and cranberry juice
b. tuna sandwich with mayonnaise
c. broiled pork chop with applesauce
273. A patient with CVA has right sided hemiparesis, which nursing intervention needs follow up?
274. Which indicates correct understanding for a patient taking raloxifene (Evista)?
a. oligohydramnios
b. breech presentation
c. folic acid deficiency
285. A patient is on warfarin therapy, you will question the doctor s order if the patient has a history of?
286. A 45 year old female patient states, I have prolonged menstruation, how would I know if this
would lead to malignancy? What will be your response?
287. A patient with osteomyelitis has a pressure ulcer; the nurse emphasizes which component of
nursing care?
288. An elderly patient states his dietary preferences. Which items will you suggest to complement this?
289. Which statement/s made by an elderly patient illustrates elderly abuse? Select all that apply:
290. The nurse overheard the elderly patient s son: I sold your care because I don t have money. Afer
the son leaves the room, the nurse will impart which instructions to the elderly patient? Select all that
apply:
291. An infant is on phototherapy to eliminate excess bilirubin. The mother states, My baby is having
frequent bowel movements. The nurse will?
292. How will you administer liquid medications to a 3 year old patient with URTI?
a. use syringe to aspirate the medication and put on the middle portion of his/her tongue.
b. use dropper and put on anterior part of his/her tongue.
c. use spoon and put on posterior part of his/her tongue.
293. The nurse asks which of the following questions that may delay administration of chemotherapy?
294. You are taking care of patients with STDs, who is your priority?
The primary genital herpes infection involves systemic viremia, and encephalitis is a possible
complication. Headache and stiff neck may indicate encephalitis, and require further investigation.
295. Which of the following statements by the patient indicate correct understanding of fluphenazine
decanoate regimen?
Besides this compilation, the following are helpful references for passing the NCLEX-RN Exam:
A. Textbook
1. Saunders Comprehensive Review NCLEX-RN Examination 6th Edition published 2013
In my opinion, the Best textbook for the international nursing licensure exams
Saunders publishes a brand new edition every 3 years so the 7 th edition will be published in
2016 I suppose. It would be best to acquire the latest edition of Saunders because of the
updated content which may be part of the NCSBN test pool.
B. Computer programs
1. Evolve Reach Test by HESI the most difficult NCLEX computer program I have ever
answered. I along with my friends who passed the actual NCLEX-RN Exam had failing scores
while answering this computer program so it really is a commendable computer program
2. Comprehensive Review for NCLEX-RN by Prentice Hall/Pearson Vue/Mary Ann Hogan
3. Silvestri: Saunders Strategies for Alternate Item Formats on the NCLEX-RN® Exam Alternate
item formats include: Ordered responses, Select all that apply questions, Audiovisual format
If this compilation helps you in passing the NCLEX-RN exam, kindly pay it forward by sharing it so that
other nurses can fulfill their dreams of being NCLEX-RNs as well. Please update, proofread, and edit this
compilation every time other NCLEX-RNs are kind and generous enough to supplement it.
Let us all strive to be a blessing to those around us.
For I know the plans I have for you, declares the Lord, plans to prosper you and not to harm you,
plans to give you hope and a future. Jeremiah 29:11