1. Patient X is diagnosed with constipation.

As a knowledgeable nurse, which nursing intervention is

appropriate for maintaining normal bowel function?
a. Assessing dietary intake
b. Decreasing fluid intake
c. Providing limited physical activity
d. Turning, coughing, and deep breathing
2. A 12-year-old boy was admitted in the hospital two days ago due to hyperthermia. His attending nurse,
Dennis, is quite unsure about his plan of care. Which of the following nursing intervention should be
included in the care of plan for the client?
a. Room temperature reduction
b. Fluid restriction of 2,000 ml/day
c. Axillary temperature measurements every 4 hours
d. Antiemetic agent administration
3. Tom is ready to be discharged from the medical-surgical unit after 5 days of hospitalization. Which client
statement indicates to the nurse that Tom understands the discharge teaching about cellular injury?
a. “I do not have to see my doctor unless i have problems.”
b. “I can stop taking my antibiotics once I am feeling better.”
c. “If I have redness, drainage, or fever, I should call my healthcare provider.”
d. “I can return to my normal activities as soon as I go home.”
4. Nurse Katee is caring for Adam, a 22-year-old client, in a long-term facility. All of the following nursing
interventions would be appropriate in promoting and preventing contractures except:
a. Maintaining correct body alignment
b. Using a footboard for correct foot alignment
c. Performing active and passive range of motion
d. Weighing client at the same time everyday wearing the same clothes
5. A 36-year-old male client is about to be discharged from the the hospital after 5 days due to surgery. Which
intervention should be included in the home health care nurse’s instructions about measures to prevent
constipation?
a. Discouraging the client from eating large amounts of roughage-containing foods in the diet.
b. Encouraging the client to use laxatives routinely to ensure adequate bowel elimination.
c. Instructing the client to establish a bowel evacuation schedule that changes every day.
d. Instructing the client to fill a 2-L bottle with water every night and drink it the next day.
6. Mr. McPartlin suffered abrasions and lacerations after a vehicular accident. He was hospitalized and was
treated for a couple of weeks. When planning care for a client with cellular injury, the nurse should consider
which scientific rationale?
a. Nutritional needs remain unchanged for the well-nourished adult.
b. Age is an insignificant factor in cellular repair.
c. The presence of infection may slow the healing process.
d. Tissue with inadequate blood supply may heal faster.
7. A 22-year-old lady is displaying facial grimaces during her treatment in the hospital due to burn trauma.
Which nursing intervention should be included for reducing pain due to cellular injury?
a. Administering anti-inflammatory agents as prescribed
b. Elevating the injured area to decrease venous return to the heart
c. Keeping the skin clean and dry
 d. Applying warm packs initially to reduce edema
8. Lisa, a client with altered urinary function, is under the care of nurse Tine. Which intervention is appropriate
to include when developing a plan of care for Lisa who is experiencing urinary dribbling?
a. Inserting an indwelling Foley catheter
b. Having the client perform Kegel exercises
c. Keeping the skin clean and dry
d. Using pads or diapers on the client
9. Jeron is admitted in the hospital due to bacterial pneumonia. He is febrile, diaphoretic, and has shortness of
breath and asthma. WHich goal is the most important for the client?
a. Prevention of fluid volume excess
b. Maintenance of adequate oxygenation
c. Education about infection prevention
d. Pain reduction
10. Mang Rogelio, a 32-year-old patient, is about to be discharged from the acute care setting. Which nursing
intervention is the most important to include in the plan of care?
a. Stress-reduction techniques
b. Home environment evaluation
c. Skin-care measures
d. Participation in activities of daily living
11. Mrs. dela Riva is in her first trimester of pregnancy. She has been lying all day because her OB-GYN
requested her to have a complete bed rest. Which nursing intervention is appropriate when addressing the
client’s need to maintain skin integrity?
a. Monitoring intake and output accurately
b. Instructing the client to cough and deep-breathe every 2 hours
c. Keeping the linens dry and wrinkle free
d. Using a foot board to maintain correct anatomic position
12. Maya, who is admitted in a hospital, is scheduled to have her general checkup and physical assessment.
Nurse Timothy observed a reddened area over her left hip. Which should the nurse do first?
a. Massage the reddened are for a few minutes
b. Notify the physician immediately
c. Arrange for a pressure-relieving device
d. Turn the client to the right side for 2 hours
13. Pierro was noted to be displaying facial grimaces after nurse Kara assessed his complaints of pain rated as
8 on a scale of 1 (no pain) 10 10 (worst pain). Which intervention should the nurse do?
a. Administering the client’s ordered pain medication immediately
b. Using guided imagery instead of administering pain medication
c. Using therapeutic conversation to try to discourage pain medication
d. Attempting to rule out complications before administering pain medication
14. Nurse Marthia is teaching her students about bacterial control. Which intervention is the most important
factor in preventing the spread of microorganism?
a. Maintenance of asepsis with indwelling catheter insertion
b. Use of masks, gowns, and gloves when caring for clients with infection
c. Correct handwashing technique
d. Cleanup of blood spills with sodium hydrochloride
15. A patient with tented skin turgor, dry mucous membranes,and decreased urinary output is under nurse
Mark’s care. Which nursing intervention should be included the care plan of Mark for his patient?
a. Administering I.V. and oral fluids
b. Clustering necessary activities throughout the day
c. Assessing color, odor, and amount of sputum
d. Monitoring serum albumin and total protein levels
16. Khaleesi is admitted in the hospital due to having lower than normal potassium level in her bloodstream. Her
medical history reveals vomiting and diarrhea prior to hospitalization. Which foods should the nurse instruct
the client to increase?
a. Whole grains and nuts
b. Milk products and green, leafy vegetables
c. Pork products and canned vegetables
d. Orange juice and bananas
17. Mary Jean, a first year nursing student, was rushed to the clinic department due to hyperventilation. Which
nursing intervention is the most appropriate for the client who is subsequently developing respiratory
alkalosis?
a. Administering sodium chloride I.V.
b. Encouraging slow, deep breaths
c. Preparing to administer sodium bicarbonate
d. Administer low-flow oxygen therapy
18. Nurse John Joseph is totaling the intake and output for Elena Reyes, a client diagnosed with septicemia
who is on a clear liquid diet. The client intakes 8 oz of apple juice, 850 ml of water, 2 cups of beef broth, and
900 ml of half-normal saline solution and outputs 1,500 ml of urine during the shift. How many milliliters
should the nurse document as the client’s intake.
a. 2,230
b. 2,740
c. 2,470
d. 2,320
19. Marie Joy’s lab test revealed that her serum calcium is 2.5 mEq/L. Which assessment data does the nurse
document when a client diagnosed with hypocalcemia develops a carpopedal spasm after the blood-
pressure cuff is inflated?
a. Positive Trousseau’s sign
b. Positive Chvostek’s sign
c. Tetany
d. Paresthesia
20. Lab tests revealed that patient Z’s [Na+] is 170 mEq/L. Which clinical manifestation would nurse Natty
expect to assess?
a. Tented skin turgor and thirst
b. Muscle twitching and tetany
c. Fruity breath and Kussmaul’s respirations
d. Muscle weakness and paresthesia
21. Mang Teban has a history of chronic obstructive pulmonary disease and has the following arterial blood gas
results: partial pressure of oxygen (PO2), 55 mm Hg, and partial pressure of carbon dioxide (PCO2), 60 mm
 Hg. When attempting to improve the client’s blood gas values through improved ventilation and oxygen
therapy, which is the client’s primary stimulus for breathing?
a. High PCO2
b. Low PO2
c. Normal pH
d. Normal bicarbonate (HCO3)
22. A client with very dry mouth, skin and mucous membranes is diagnosed of having dehydration. Which
intervention should the nurse perform when caring for a client diagnosed with fluid volume deficit?
a. Assessing urinary intake and output
b. Obtaining the client’s weight weekly at different times of the day
c. Monitoring arterial blood gas (ABG) results
d. Maintaining I.V. therapy at the keep-vein-open rate
23. Which client situation requires the nurse to discuss the importance of avoiding foods high in potassium?
a. 14-year-old Elena who is taking diuretics
b. 16-year-old John Joseph with ileostomy
c. 16-year-old Gabriel with metabolic acidosis
d. 18-year-old Albert who has renal disease
24. Genevieve is diagnosed with hyperkalemia, which nursing intervention would be appropriate?
a. Instituting seizure precaution to prevent injury
b. Instructing the client on the importance of preventing infection
c. Checking that the blood to be administered is fresh
d. Teaching the client the importance of early ambulation
25. Which electrolyte would the nurse identify as the major electrolyte responsible for determining the
concentration of the extracellular fluid?
a. Potassium
b. Phosphate
c. Chloride
d. Sodium
26. Jon has a potassium level of 6.5 mEq/L, which medication would nurse Wilma anticipate?
a. Potassium supplements
b. Kayexalate
c. Calcium gluconate
d. Sodium tablets
27. Which clinical finding would be seen in a patient having fluid volume excess?
a. Decreased urine output
b. CVP reading of 15 cmH20
c. Specific gravity of 1.050
d. Dry skin
28. Joshua is receiving furosemide and Digoxin, which laboratory data would be the most important to assess in
planning the care for the client?
a. Sodium level
b. Magnesium level
c. Potassium level
d. Calcium level
29. Mr. Salcedo has the following arterial blood gas (ABG) values: pH of 7.34, partial pressure of arterial oxygen
of 80 mm Hg, partial pressure of arterial carbon dioxide of 49 mm Hg, and a bicarbonate level of 24 mEq/L.
Based on these results, which intervention should the nurse implement?
a. Instructing the client to breathe slowly into a paper bag
b. Administering low-flow oxygen
c. Encouraging the client to cough and deep breathe
d. Nothing, because these ABG values are within normal limits.
30. A client is diagnosed with metabolic acidosis, which would the nurse expect the health care provider to
order?
a. Potassium
b. Sodium bicarbonate
c. Serum sodium level
d. Bronchodilator
31. A nurse is reading a physician’s progress notes in the client’s record and reads that the physician has
documented “insensible fluid loss of approximately 800ml daily.” The nurse understands that this type of
fluid loss can occur through:
a. The skin
b. Urinary output
c. Wound drainage
d. The gastrointestinal tract
32. A nurse is assigned to care for a group of clients. On review of the client’s medical records, the nurse
determines that which client is at risk for deficient fluid volume?
a. A client with a colostomy
b. A client with congestive heart failure
c. A client with decreased kidney function
d. A client receiving frequent wound irrigation
33. A nurse caring for a client who has been receiving intravenous diuretics suspects that the client is
experiencing a deficient fluid volume. Which assessment finding would the nurse note in a client with this
condition?
a. Lung congestion
b. Decreased hematocrit
c. Increased blood pressure
d. Decreased central venous pressure
34. A nurse is assigned to care for a group of clients. On review of the clients medical records, the nurse
determines that which client is at risk for excess fluid volume?
a. The client taking diuretics
b. Client with renal failure
c. Client with ileostomy
d. The client requiring GIT suctioning
35. The nurse is caring for a client with congestive heart failure. On assessment, the nurse notes that the client
is dyspneic and crackles are audible on auscultation. The nurse suspects excess fluid volume. What
additional signs would the nurse expect to note in this client if excess fluid volume is present?
a. Weight loss
b. Flat neck and hand veins
 c. An increase in BP
d. A decrease CVP
36. A nurse is preparing to care for a client with Potassium deficit. The nurse reviews the clients record and
determines that the client was at risk for developing the potassium deficit because the client:
a. Has renal failure
b. Requires NG suction
c. History of addisons disease
d. Is taking a potassium sparing diuretic
37. A nurse reviews a client’s electrolyte laboratory report and notes that the potassium level is 3.2 meq/L.
Which of the following would the nurse note on the electrocardiogram as a result of the laboratory value?
a. U waves
b. Absent P waves
c. Elevated T waves
d. Elevated ST segment
38. A nursing student needs to administer potassium chloride intravenously as prescribed to a client with
hypokalemia. The nursing instructor determines that the student is unprepared for this procedure if the
student states that which of the following is part of the plan for preparation and administration of the
potassium?
a. Obtaining a controlled IV infusion pump
b. Monitoring urine output during administration
c. Diluting inappropriate amount of normal saline
d. Preparing the medication for bolus administration
39. A nurse instructs a client at risk for hypokalemia about the foods high in potassium that should be included
in the daily diet. The nurse determines that the client understands the food sources of potassium if the client
states that the food item lowest in potassium is:
a. Apples
b. Carrots
c. Spinach
d. Avocado
40. A nurse caring for a group of clients reviews the electrolyte laboratory results and notes a potassium level of
5.5 meq/L on 1 client’s laboratory report. The nurse understands that which client is at highest risk for the
development of a potassium value at this level?
a. The client with colitis
b. Client with Cushing’s syndrome
c. A client who has been overusing laxatives
d. A client who has sustained a traumatic burn
41. A nurse reviews the electrolyte results of an assigned client and notes that the potassium level is 5.4 meq/L.
Which of the following would the nurse expect to note on the ECG as a result of the laboratory value?
a. ST depression
b. Inverted T wave
c. Prominent U wave
d. Tall peak T waves
42. A nurse caring for a group of clients reviews the electrolyte laboratory results and notes a sodium level of
130 meq/L on one client’s lab report. The nurse understands that which client is at highest risk for the
development of a sodium value at this level?
a. The client with renal failure
b. The client who is taking diuretics
c. The client with hyperaldosteronism
d. The client taking corticosteroids
43. A nurse is caring for a client with acute congestive heart failure who is receiving high doses of diuretics. On
assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and
diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse
expect to note in this client if hyponatremia were present?
a. Dry skin
b. Decrease urinary output
c. Hyperactive bowel sounds
d. Increase urine specific gravity
44. A nurse is caring for a client with a nasogastric tube. Nasogastric tube irrigations are prescribed to be
performed once every shift. The client’s serum electrolyte results indicate a potassium level of 4.5 meq/L
and a sodium level of 132 meq/L. Based on these lab findings, the nurse selcects which solution to use for
the nasogastric tube irrigation?
a. Tap water
b. Sterile water
c. Sodium Chloride
d. Distilled water
45. A nurse is reviewing lab results and notes that the client’s serum sodium level is 150 meq/L. The nurse
reports the serum sodium level to the physician and the physician prescribes dietary instructions based on
the sodium level. Which food item does the nurse instruct the client to avoid
a. Peas
b. Cauliflower
c. Low fat yogurt
d. Processed oat cerials
46. The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which of the following clinical
manifestation would the nurse suspect to note in the client?
a. Twitching
b. (-) Trosseau’s sign
c. Hypoactive bowel sounds
d. Hypoactive deep tendon reflexes
47. A nurse reviews a client’s lab report and reports the client’s serum phosphorus level is 2.0 mg/dL. Which
condition most likely caused this phosphorus level?
a. Alcoholism
b. Renal insufficiency
c. Hypoparathyroidism
d. Tumor lysis syndrome
48. A nurse is reviewing an ABG result of a patient and notes the following values: pH – 7.36, PCO2 – 50,
HCO3 – 29. Which of the following interpretations is fit for the given values?
 a. Partially compensated respiratory acidosis
b. Fully compensated metabolic acidosis
c. Fully compensated respiratory acidosis
d. Partially compensated respiratory acidosis
49. Which of the following values is expected from a patient who is constantly vomiting?
a. HCO3 – 24
b. pH – 7.30
c. PCO2 – 49
d. HCO3 – 20
50. Which of the following should be assessed from a patient who has a pH of 7.29?
a. Anxiety
b. Diarrhea
c. Vomiting
d. Intermittent NGT suctioning
51. All of the following are known true about the kidneys except:
a. Kidneys will maintain homeostasis
b. Functional unit of kidney is the glomeruli
c. Afferent arteriole carries blood to the glomeruli
d. Kidneys will reabsorb water in case of dehydration
52. The kidneys are bilateral organs that produce urine. Which of the following are not supposed to
be in the urine?
a. Creatinine
b. Urea
c. Potassium
d. Protein
53. A part of the nephron that will reabsorb water and sodium is:
a. Collecting duct
b. Vasa recta
c. Loop of henle
d. Proximal convoluted tubules
54. The client with acute renal failure has a serum potassium level of 6.0meq/L. The nurse would
plan which of the following as a priority action?
a. Check the sodium level
b. Place the client on cardiac monitor
c. Encourage increase in vegetables
d. Allow an extra 500 ml of fluid intake to dilute the electrolyte
55. The client with chronic renal failure who is scheduled for hemodialysis this morning is due to
receive a daily dose of enalapril (Vasotec). The nurse should plan to administer this medication:
a. During dialysis
b. Just before dialysis
c. The day after dialysis
d. On return from dialysis
56. The client with chronic renal failure has an indwelling abdominal catheter for peritoneal dialysis.
The client spills water on the catheter dressing while bathing. The nurse should immediately:
a. Change the dressing
b. Reinforce the dressing
c. Flush the peritoneal dialysis catheter
d. Scrub the catheter with povidone iodine
57. The client being hmodialyzed suddenly becomes short of breath and complains of chest pain.
The client is tachycardic, pale, and anxious. The nurse suspects air embolism. The priority action
for the nurse is to:
a. Discontinue the dialysis and notify the physician
b. Monitor vital signs every 15 mins
c. Continue dialysis at a slower rate
d. Bolus the client with 500 ml of normal saline solution
58. The nurse completes client teaching with the hemodialysis client about self monitoring between
dialysis treatments. The nurse determines that the client best understands the information if
the client states to record daily the:
a. Amount of activity
b. Pulse and respiratory rate
c. Intake and output and weight
d. Blood urea nitrogen and creatinine levels
59. The client with external arteriovenous shunt in place for hemodialysis is at risk for bleeding. The
priority nurse action is:
a. Check the shunt for the presence of bruit and thrill
b. Observe the site once as time permits during the shift
c. Check the results of the prothrombin time as they are determined
d. Ensure that small clamps are attached to the arteriovenous shunt dressing
60. The client arrives to the emergency room with complaints of low abdominal pain and hematuria.
The client is afebrile. The nurse next assesses the client to determine a history of:
a. Pyelonephritis
b. Glumerulonephritis
c. Trauma to the bladder or abdomen
d. Renal cancer in the client’s family
61. The female nurse is admitted to the emergency department following a fall from a horse and
the physician orders insertion of a Foley catheter. While preparing for the procedure, the nurse
notes blood at the urinary meatus. The nurse should:
a. Notify the physician
b. Use a smaller sized catheter
c. Administer pain medication before insertion
d. Use extra povidone iodine solution in cleansing the meatus
62. A nurse is assessing the patency of a client’s left arm arteriovenous fistula prior to hemodialysis.
Which finding indicates that the fistula is patent?
a. Palpation of a thrill over the fistula
 b. Presence of a radial pulse in the left wrist
c. Absence of bruit on auscultation of the fistula
d. Capillary refill less than 3 seconds in the nail beds of the fingers on the left hand
63. The male client has a tentative diagnosis of urethritis. The nurse assesses the client for which of
the following manifestations of the disorder?
a. Hematuria and pyuria
b. Dysuria and proteinuria
c. Hematuria and urgency
d. Dysuria and penile discharge
64. The nurse is planning teaching for a female client diagnosed with urethritis caused by chlamydial
infection. The nurse would plan to include which of the following points in the teaching session?
a. Altering the perineal pH by using a spermicide with a condom
b. Keeping follow up appointments with repeat cultures in 4-7 days
c. Discontinuing antibiotics after 3 weeks of uninterrupted administration
d. Identifying sexual partners for the last 12 months so they can be treated
65. The client with chlamydial infection has received instructions on self-care and prevention of
further infection. The nurse determines that the client needs further reinforcement if the client
states that he or she will:
a. Use latex condoms to prevent transmission
b. Return to the clinic as requested for follow up culture
c. Use doxycycline prophylactically to prevent symptoms of chlamydia
d. Reduce chance of reinfection by limiting number of sexual partners
66. The nurse admits a patient with Urinary tract infection. Which of the following manifestations
will be seen in a patient with upper UTI?
a. Frequency
b. Urgency
c. Fever and chills
d. Pain in urination
67. A patient was admitted with acute renal failure. Which of the following manifestations would
suggest that the patient is in recovery phase?
a. Dryness of the skin
b. Urine output of 4 liters per day
c. Edema
d. GFR of 95cc per minute
68. Which of the following managements is appropriate for a client with acute renal failure who is in
an oliguric phase?
a. Administer IVF as ordered
b. Administer diuretics as ordered
c. Administer antibiotics as ordered
d. Administer antipyretics as ordered
69. Tom, a patient with nephrotic syndrome asks the nurse about the nature of the disease. All of
the following are seen in nephrotic syndrome except:
 a. Edema
b. Increase in albumin
c. Proteinuria
d. Increase in serum cholesterol
70. Which of the following treatments is best for a patient who has Nephrotic syndrome?
a. Administer plasma volume expanders as ordered
b. Administer diuretics as ordered
c. Administer Cryoprecipitate as ordered
d. Administer beta blockers as ordered