TIP: Focus on prioritization, medical-surgical, and fundamentals of nursing.

1.The nurse is teaching a mother whose daughter has iron deficiency anemia. The

nurse determines the parent understood the dietary modifications, if she selects?

a) Bread and coffee

b) Fish and Pork meat

c) Cookies and milk

d) Oranges and green leafy vegetables

2.Which of the following is the most common clinical manifestation of G6PD following

ingestion of aspirin?

a) Kidney failure

b) Acute hemolytic anemia

c) Hemophilia A

d) Thalassemia

3.The nurse assesses a client with an ileostomy for possible development of which of

the following acid-base imbalances?

a) Respiratory acidosis

b) Metabolic acidosis

c) Metabolic alkalosis

d) Respiratory alkalosis
4.The nurse anticipates which of the following responses in a client who develops

metabolic acidosis.

a) Heart rate of 105 bpm

b) Urinary output of 15 ml

c) Respiratory rate of 30 cpm

d) Temperature of 39 degree Celsius

5. A client has a phosphorus level of 5.0mg/dL. The nurse closely monitors the

client for?

a) Signs of tetany

b) Elevated blood glucose

c) Cardiac dysrhythmias

d) Hypoglycemia

6. A nurse is caring for a child with pyloric stenosis. The nurse would watch out for

symptoms of?

a) Vomiting large amounts

b) Watery stool

c) Projectile vomiting

d) Dark-colored stool
7.The nurse responder finds a patient unresponsive in his house. Arrange steps for

adult CPR.

a) Assess consciousness

b) Give 2 breaths

c) Perform chest compression

d) Check for serious bleeding and shock

e) Open patient’s airway

f) Check breathing

___, ___, ___, ___, ___, ___

8.Which of the following has mostly likely occurred when there is continuous

bubbling in the water seal chamber of the closed chest drainage system?

a) The connection has been taped too tightly

b) The connection tubes are kinked

c) Lung expansion

d) Air leak in the system

9.Which if the following young adolescent and adult male clients are at most risk for

testicular cancer?

a) Basketball player who wears supportive gear during basketball games

b) Teenager who swims on a varsity swim team

c) 20-year-old with undescended testis

d) Patient with a family history of colon cancer

10.The nurse plans to frequently assess a post-thyroidectomy patient for?

a) Polyuria

b) Hypoactive deep tendon reflex

c) Hypertension

d) Laryngospasm

11.An 18-month-old baby appears to have a rounded belly, bowlegs and slightly

large head. The nurse concludes?

a) The child appears to be a normal toddler

b) The child is developmentally delayed

c) The child is malnourished

d) The child’s large head may have neurological problems.

12.A nurse is going to administer 500mg capsule to a patient. Which is the correct

route?
13.An appropriate instruction to be included in the discharge teaching of a patient

following a spinal fusion is?

a) Don’t use the stairs

b) Don’t bend at the waist

c) Don’t walk for long hours

d) Swimming should be avoided

14.A nurse is preparing to give an IM injection of Iron Dextran that is irritating to

the subcutaneous tissue. To prevent irritation to the tissue, what is the best action

to be taken?

a) Apply ice over the injection site

b) Administer drug at a 45 degree angle

c) Use a 24-gauge-needle

d) Use the z-track technique

15.What should a nurse do prior to taking the patient’s history?

a) Offer the patient a glass of water

b) Establish rapport

c) Ask the patient to disrobe and put on gown

d) Ask pertinent information for insurance purposes

16.A pregnant woman is admitted for pre-eclampsia. The nurse would include in the

health teaching that magnesium will be part of the medical management to

accomplish the following?

a) Control seizures

b) promote renal perfusion

c) To decrease sustained contractions

d) Maintain intrauterine homeostasis

17.A nurse is going to administer ear drops to a 4-year-old child. What is the correct

way of instilling the medicine after tilting the patient’s head sidewards?

a) Pull the pinna back then downwards

b) Pull the pinna back then upwards

c) Pull the pinna up then backwards

d) Pull the pinna down then backwards

18.A nursing student was intervened by the clinical instructor if which of the

following is observed?

a) Inserting a nasogastric tube

b) Positioning the infant in a “sniffing “position

c) Suctioning first the mouth, then the nose

d) Squeezing the bulb syringe to suction mouth

19.Choose amongst the options illustrated below that best describes the angle for an

intradermal injection?

20.During a basic life support class, the instructor said that blind finger sweeping is

not advisable for infants. Which among the following could be the reason?

a) The mouth is still too small

b) The object may be pushed deeper into the throat

c) Sharp fingernails might injure the victim

d) The infant might bite

21.A nurse enters a room and finds a patient lying on the floor. Which of the

following actions should the nurse perform first?

a) Call for help

b) Establish responsiveness of patient

c) Ask the patient what happened

d) Assess vital signs

22.A patient with complaints of chest pain was rushed to the emergency

department. Which priority action should the nurse do first?

a) Administer morphine sulfate intravenously

b) Initiate venous access by performing venipunture

c) Administer oxygen via nasal cannula

d) Complete physical assessment and patient history

23.A rehab nurse reviews a post-stroke patient’s immunization history. Which

immunization is a priority for a 72-year-old patient?

a) Hepatitis A vaccine

b) Hepatitis B vaccine

c) Rotavirus Vaccine

d) Pneumococcal Vaccine
24.Several patients from a reported condominium fire incident were rushed to the

emergency room. Which should the nurse attend to first?

a) A 15-year-old girl, with burns on the face and chest, reports hoarseness of the

voice

b) A 28-year-old man with burns on all extremities

c) A 4-year-old child who is crying inconsolably and reports severe headache

d) A 40-year-old woman with complaints of severe pain on the left thigh

25.The doctor ordered 1 pack of red blood cells (PRBC) to be transfused to a patient.

The nurse prepares the proper IV tubing. The IV tubing appropriate for blood

transfusion comes with?

a) Air vent

b) Microdrip chamber

c) In-line filter

d) Soluset

26.The expected yet negative (harmful ) result for posthemodialysis is a decrease

in?

a) Creatinine

b) BUN

c) Phosphorus

d) Red blood cell count

27.A patient was brought to the emergency room after she fell down the stairs.

Which of the following is the best indicator for increased intracranial pressure in

head and spinal injury?

a) Inability to move extremities

b) Decreased respiratory rate

c) Increase in pulse and blood pressure

d) Decrease level of consciousness

28.A new nurse is administering an enema to a patient. The senior nurse should

intervene if the new nurse?

a) Hangs the enema bag 18 inches above the anus

b) Positions the client on the right side

c) Advances the catheter 4 inches into the anal canal

d) Lubricates 4 inches of the catheter tip

29.The medication nurse is going to give a patient his morning medications. What is

the primary action a nurse should do before administering the medications?

a) Provide privacy

b) Raise head of the bed

c) Give distilled water

d) Check client’s identification bracelet

30.A 30-year-old client is admitted with inflammatory bowel syndrome (Crohn’s

disease). Which of the following instructions should the nurse include in the health

teaching? Select all that apply

a) Corticosteroid medication is part of the treatment

b) Include milk in the diet

c) Aspirin should be administered

d) Antidiarrheal medication can help

1.) Answer: D

Dark green leafy vegetables are good sources of iron. Oranges are good sources of

vitamin C that enhances iron absorption in the small intestines.

2.) Answer: B

Individuals with G6PD may exhibit hemolytic anemia when exposed to infection,

certain medications or chemicals. Salicylates such as Aspirin damages plasma

membranes of erythrocytes, leading to hemolytic anemia.

3.) Answer: B

Lower GI fluids are alkaline in nature and can be lost via ileostomy. Thus, loss of

HCO3, results to metabolic acidosis.

4.) Answer: C

Initially, respiratory system will try to compensate metabolic acidosis. Patients with

metabolic acidosis have high respiratory rate.

5.) Answer: A

Normal phosphorus level is 2.5 – 4.5 mg/dL .The level reflects hyperphosphatemia

which is inversely proportional to calcium. Client should be assessed for tetany

which is a prominent symptom of hypocalcemia.

6.) Answer: C

Clinical manifestations of pyloric stenosis include projectile vomiting, irritability,

constipation, and signs of dehydration, including a decrease in urine output.

7.) Answer: A, E, F, C, B, D

In accordance with the new guidelines, remember AB-CABS. A-airway B-breathing

normally? − C-chest compression A-airway open B-breathing for patient S-serious

bleeding, shock, spinal injury. The nurse should first assess consciousness of the

patient. Next, open patient’s airway to check for breathing. When there is no

breathing, immediately perform chest compression then give 2 breaths, do the cycle

of care over. Finally, check for serious bleeding, shock, and spinal injury.

8.) Answer: D

Continuous bubbling seen in water-seal bottle/ chamber indicates an air leak or

loose connection, and air is sucked continuously into the closed chest drainage

system.

9.) Answer: C

Testicular cancer is most likely to affect males in late adolescence. Undescended

testis is also one major risk for testicular cancer.

10.) Answer: D
Hypocalcemia occurs when there is accidental removal or destruction of parathyroid

tissue during surgical removal of the thyroid gland. Laryngospasm is one of the

clinical manifestations of tetany, an indicator of hypocalcemia.

11.) Answer: A

It’s normal for a toddler to have bowlegs and a protruding belly. The head still

appears somewhat large in proportion from the rest of the body.

12.) Answer: D

13.) Answer: B

There is 6-8 months activity restriction following a spinal fusion. Sitting, lying,

standing, normal stair climbing, walking, and gentle swimming is allowed. Bending

and twisting at the waist should be avoided, along with lifting more than 10 lbs.

14.) Answer: D

Z-track technique is used to administer drugs especially irritating to the

subcutaneous tissue. This method promotes absorption of the drug by preventing

drug leakage into the subcutaneous layer.

15.) Answer: B

Establishing rapport is a way to gain trust that will lead for a patient to relax. You

can get more insights and information from a patient when rapport is established.

16.) Answer: A

Low magnesium (hypomagnesemia) produces clinical manifestations like increased

reflexes, tremors, and seizures. Magnesium Sulfate is the drug of choice to prevent

seizures in pre-eclampsia and eclampsia.

17.) Answer: C

Ear canal of children ages 3years and above can be straightened by pulling the pinna

up then backwards. For children below 3 years of age, the ear canal can be

straightened by pulling the pinna down then backwards.

18.) Answer: A

Infants are nose breathers. A gastric tube may be inserted to facilitate lung

expansion and stomach decompression, but not a nasogastric tube as it can occlude

the nare, thus, making breathing difficult for the infant.

19.) Answer: B

20.) Answer: B

Blind finger sweeps are not recommended in all CPR cases especially for infants and

children because the foreign object may be pushed back into the airway.

21.) Answer: B

First step in cardiopulmonary resuscitation (CPR) is assessing responsiveness of the

patient.

22.) Answer: C

Priority nursing action is to administer oxygen to patients with chest pain. Chest

pain is caused by insufficient myocardial oxygenation.

23.) Answer: D

Pneumococcal Vaccine is a priority immunization for the elderly. Seniors, ages 65

years old and above, have higher risk for serious pneumococcal infection and likely

have low immunity. This is administered every 5 years.

24.) Answer: A

Burns on the face and neck can cause swelling of the respiratory mucosa that can

lead to airway obstruction manifested by hoarseness of voice and difficulty in

breathing. Maintaining an airway patency is the main concern.

25.) Answer: C

An in-line filter is required for blood transfusions.

26.) Answer: D

Negative outcome: Hemodialysis decreases red blood cell count which worsens

anemia, because RBCs are lost in dialysis from anticoagulation during the procedure,

and from residual blood that is left in the dialyzer.

27.) Answer: D

Decrease in level of consciousness and headache are early signs of increase in

intracranial pressure (ICP). Altered level of consciousness is the most common

symptom that indicates a deficit in brain function.

28.) Answer: B

Recall the anatomy of the colon. The appropriate position is left lateral to facilitate

flow of enema by gravity into the colon.

29.) Answer: D

Recall the 12 Rights of administration. Checking the patient’s name is critical for

client-safety.

30.) Answer: A , D
Crohn’s disease is a chronic inflammation of the colon with symptoms of diarrhea,

abdominal pain, and weight loss. Corticosteroid is a treatment for Crohn’s disease.

Antidiarrheal can give relief to diarrheal episodes. Aspirin should be avoided as it can

worsen inflammation. Those with Crohn’s disease are mostly lactose intolerant, so

choice no. (2) is incorrect