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2. To remove soft contact lenses from the eyes of an unconscious patient the nurse should:
A. Uses a small suction cup placed on the lenses
B. Pinches the lens off the eye then slides it off the cornea
C. Lifts the lenses with a dry cotton ball that adheres to the lenses
D. Tenses the lateral canthus while stimulating a blink reflex by the patient
Answer:B
3.A patient undergoes laminectomy. In the immediate post-operative period, the nurse
should
A. Monitor the patient's vital signs and log roll him to prone position
B. Monitor the patient's vital signs and encourage him to ambulate
C. Monitor the patient's vital signs and auscultate his bowel sounds
D. Monitor the patient's vital signs, check sensation and motor power of the feet
Answer:D
4. A patient with duodenal peptic ulcer would describe his pain as:
A. Generalized burning sensation
B. Intermittent colicky pain
C. Gnawing sensation relieved by food
D. Colicky pain intensified by food
Answer:D
5.A patient admitted to the hospital in hypertensive crisis is ordered to receive hydralazine
(Apresoline) 20mg IV stat for blood pressure greater than 190/100 mmHg. The best
response of the
nurse to this order is to:
A. Give the dose immediately and once
B. Give medication if patient's blood pressure is > 190/100 mmHg
C. Call the physician because the order is not clear
D. Administer the dose and repeat as necessary
Answer:A
6. Whilst recovering from surgery a patient develops deep vein thrombosis. The sign that
would indicate this complication to the nurse would be:
A. Intermittent claudication
B. Pitting edema of the area
C. Severe pain when raising the legs
D. Localized warmth and tenderness of the site
Answer:D
8.client with chronic renal failure has a serum potassium level of 6.8 mEq/L. What should
the nurse assess first?
A. Blood pressure
B. Respirations
C. Temperature
D. Cardiac rhythm
Answer: D
9.The nurse is planning care for a client with pneumococcal pneumonia. Which of the
following would be most effective in removing respiratory secretions?
A. Administration of cough suppressants
B. Increasing oral fluid intake to 3000 cc per day
C. Maintaining bed rest with bathroom privileges
D. Performing chest physiotherapy twice a day
Answer is B: Increasing oral fluid intake to 3000 cc per day. Secretion removal is enhanced
with adequate hydration which thins and liquefies secretions.
11.The primary goal of therapy for a client with pulmonary edema and heart failure?
A Enhance comfort
B Improve respiratory status
C Peripheral edema decreased
D Increase cardiac output
Answer: D
12.The nurse is preparing to administer an I.M. injection in a client with a spinal cord injury
that has resulted in paraplegia. Which of the following muscles is best site for the injection
in this case?
A. Deltoid.
B. Dorsal gluteal.
C. Vastus lateralis.
D. Ventral gluteal.
Answer: A
13. The nurse is to collect a sputum specimen from a client. The best time to collect this
specimen is:
A. early in the evening.
B. anytime during the day.
C. in the morning, as soon as the client awakens.
D. before bedtime.
Answer: C Because sputum accumulates in the lungs during sleep, the nurse should collect
a sputum specimen in the morning, as soon as the client awakens and before he eats or
drinks. This specimen will be concentrated, increasing the likelihood of an accurate culture
14. An obese client has returned to the unit after receiving sedation and electroconvulsive
therapy. The nurse requests assistance moving the client from the stretcher to the bed.
There are 2 people available to assist. Which of the following is the best method of transfer
for this patient?
A. Carry lift.
B. Sliding board.
C. Lift sheet transfer.
D. Hydraulic lift.
Answer:B
Which type of nursing intervention does the nurse perform when she administers oral care
to a client?
A. Psychomotor.
B. Educational.
C. Maintenance.
D. Supervisory.
Answer:c
On her 3rd postpartum day, a client complains of chills and aches. Her chart shows that she
has had a temperature of 100.6° F (38.1° C) for the past 2 days. The nurse assesses foul-
smelling, yellow lochia. What do these findings suggest?
A. Lochia alba
B. Lochia serosa
C. Localized infection
D. Cervical laceration
. What is the term used for normal respiratory rhythm and depth in a client?
A. Eupnea
B. Apnea
C. Bradypnea
D. Tachypnea
A client says to the nurse "I know that I'm going to die." Which of the following responses
by the nurse would be best?
A. "We have special equipment to monitor you and your problem."
B. "Don't worry. We know what we're doing and you aren't going to die."
C. "Why do you think you're going to die?"
D. "Oh no, you're doing quite well considering your condition."
The nurse is assessing the reflexes of a newborn. The nurse assesses which of the following
reflexes by placing a finger in the newborn’s mouth?
A. Moro reflex
B. Sucking reflex
C. Rooting reflex
D. Babinski reflex
Answer: B
When caring for a patient who has intermittent claudication, a cardiac/vascular nurse
advises the patient to:
A. apply graduated compression stockings before getting out of bed.
B. elevate the legs when sitting.
C. refrain from exercise.
D. walk as tolerated.
Answer: D
The client is brought to the emergency department due to drug poisoning. Which of the
following nursing interventions is most effective in the management of the client’s
condition?
a) Gastric lavage
b) Activated charcoal
c) Cathartic administration
d) Milk dilution
Answer:B Activated charcoal
The administration of activated charcoal is the most effective in the management of
poisoning because it absorbs chemicals in the gastrointestinal tract, thus reducing its
toxicity.
A nurse is assessing a group of clients. The nurse knows that which of the following clients
is at risk for fluid volume deficit?(DHA)
a) Client diagnosed with liver cirrhosis.
b) Client with diminished kidney function.
c) Client diagnosed with congestive heart failure.
d) Client attached to a colostomy bag.
Answer: D
The physician teaches a client about the need to increase her intake of calcium. At a follow-
up appointment, the nurse asks the client which foods she has been consuming to increase
her calcium intake. Which answer suggests that teaching about calcium-rich foods was
effective?
A. Broccoli and nuts
B. Yogurt and kale
C. Bread and shrimp
D. Beans and potatoes
Answer: B
The nurse is caring for a client diagnosed with a stroke. Because of the stroke, the client
has dysphagia (difficulty swallowing). Which intervention by the nurse is best for preventing
aspiration?
A. Placing the client in high Fowler's position to eat.
B. Offering liquids and solids together.
C. Keeping liquids thinned.
D. Placing food on the affected side of the mouth.
Answer: A
When administering an I.M. injection to an infant, the nurse in charge should use which
site?
a. Deltoid
b. Dorsogluteal
c. Ventrogluteal
d. Vastus lateralis
Answer: D
Which organ in the body always recieve the most percentage of blood(%cardiac
output)flow?.(AIIMS,ME,BPSC )
A. Kidney
B. Heart
C. Brain
D. Lung
Answer: D
Lung recieves 100% of cardiac output via both pulmonary & systemic circulation.
A resident is on a bladder retraining program. The nurse aide can expect the resident to
A . Have a fluid intake restriction to prevent sudden urges to urinate.
B . Wear an incontinent brief in case of an accident.
C . Have an indwelling urinary catheter.
D . Have aschedule for toileting.
In a client with chronic bronchitis, which sign would lead the nurse to suspect right-sided
heart failure?
A. Cyanosis of the lips
B. Bilateral crackles
C. Productive cough
D. Leg edema
When instructing the client diagnosed with hyperparathyroidism about diet, the nurse
should stress the importance of:
A. restricting fluids.
B. restricting sodium.
C. forcing fluids.
D. restricting potassium.
. When assessing a client with glaucoma, a nurse expects which of the following findings?
A. Complaints of double vision.
B. Complaints of halos around lights.
C. Intraocular pressure of 15 mm Hg.
D. Soft globe on palpation.
In the emergency department, the nurse is caring for a client with type 1 diabetes who was
brought in by ambulance after losing consciousness. Upon assessment, the client's breath
was noted to be fruity. Which of the following ABG results would the nurse expect?
A. pH: 7.49 PCO2: 50 HCO3: 18
B. pH 7.28: PCO2: 40 HCO3: 16
C. pH:7.38 PCO2: 45 HCO3: 26
D. pH: 7.31 PCO2: 60 HCO3: 29
Answer:B
Risk for metabolic acidosis in type1 DM
The nurse is taking the health history of a patient being treated for sickle cell disease. After
being told the patient has severe generalized pain, the nurse expects to note which
assessment finding?
A. Severe and persistent diarrhea
B. Intense pain in the toe
C. Yellow-tinged sclera
D. Headache
A client has hypoxemia of pulmonary origin. What portion of arterial blood gas results is
most useful in distinguishing acute respiratory distress syndrome from acute respiratory
failure?
A. Partial pressure of arterial oxygen (PaO2)
B. Partial pressure of arterial carbon dioxide (PaCO2)
C. pH
D. Bicarbonate (HCO3–)
Answer: A
The procedure involves removal of the "head" (wide part) of the pancreas, the duodenum, a
portion of the common bile duct, gallbladder, and sometimes part of the stomach.And
anastomosis to jejunum ?
A. Birloth 1procedures
B. Birloth 2 procedures
C. Wipple procedures
D. Subtotal cholecystectomy
Answer: C
A client with a fluid volume deficit is receiving an I.V. infusion of dextrose 5% in water and
lactated Ringer's solution at 125 ml/hour. Which data collection finding indicates the need
for additional I.V. fluids?
A. Serum sodium level of 135 mEq/L
B. Temperature of 99.6° F (37.6° C)
C. Neck vein distention
D. Dark amber urine
Answer: D
Normally, urine appears light yellow; dark amber urine is concentrated and suggests
decreased fluid intake.
Which of the following types of immunoglobulins does not cross the barrier between mother
and infant in the womb?
A. IgA
B. IgM
C. IgD
D. IgE
A 39-year-old forklift operator presents with shakiness, sweating, anxiety, and palpitations
and tells the nurse he has type 1 diabetes mellitus. Which of the follow actions should the
nurse do first?
A. Inject 1 mg of glucagon subcutaneously.
B. Administer 50 mL of 50% glucose I.V.
C. Give 4 to 6 oz (118 to 177 mL) of orange juice.
D. Give the client four to six glucose tablets
The nurse is collecting data on a male client diagnosed with gonorrhea. Which symptom
likely prompted the client to seek medical attention?
A. Rashes on the palms of the hands and soles of the feet
B. Cauliflower-like warts on the penis
C. Painful red papules on the shaft of the penis
D. Foul-smelling discharge from the penis
A client with B negative blood requires a blood transfusion during surgery. If no B negative
blood is available, the client should be transfused with:
❍ A. A positive blood
❍ B. B positive blood
❍ C. O negative blood
❍ D. AB negative blood
Answer: C
If the client’s own blood type and Rh are not available, the safest transfusion is O negative
blood. Answers A, B, and D are incorrect because they can cause reactions that can prove
fatal to the client
An woman is prescribed metformin for glucose control. The patient is on NPO status pending
a diagnostic test. The nurse is most concerned about which side effect of metformin?
A. Diarrhea and Vomiting
B. Dizziness and Drowsiness
C. Metallic taste
D. Hypoglycemia
A 30-year-old male from Haiti is brought to the emergency department in sickle cell crisis.
What is the best position for this client?
a. Side-lying with knees flexed
b. Knee-chest
c. High Fowler’s with knees flexed
d. Semi-Fowler’s with legs extended on the bed
The nurse administers furosemide (Lasix) to treat a client with heart failure. Which adverse
effect must the nurse watch for most carefully?
A. Increase in blood pressure
B. Increase in blood volume
C. Low serum potassium level
D. High serum sodium level
Answer: C
Furosemide is a potassium-wasting diuretic. The nurse must monitor the serum potassium
level and assess for signs of low potassium. As water and sodium are lost in the urine, blood
pressure decreases, blood volume decreases, and urine output increases.
A confirmational test for gestational diabetes ?
A. Fasting blood sugar
B. Urine sugar
C.glucose tolerance test
D. Fasting lipid profile with RBS
Answer: C
The nurse is caring for a client with pneumonia. The physician orders 600 mg of ceftriaxone
(Rocephin) oral suspension to be given once per day. The medication label indicates that the
strength is 150 mg/5ml. How many milliliters of medication should the nurse pour to
administer the correct dose?
A. 2.5 ml
B. 4 ml
C. 10 ml
D. 20 ml
Answer: D
The nurse is preparing to discharge a 70-year-old man on warfarin therapy for a pulmonary
embolism. The nurse’s dischargeteaching should include which of the following instructions?
A.Follow a healthy diet by increasing ingestion of green, leafy vegetables.
B. Take herbal remedies to manage cold symptoms.
C. Avoid alcohol due to enhanced anticoagulant effect.
D. Take Coumadin only on an empty stomach.
During the initial admission process, a geriatric client seems confused. What is the most
probable cause of this client's confusion?
A. Depression
B. Altered long-term memory
C. Decreased level of consciousness (LOC)
D. Stress related to an unfamiliar situation
Answer: D
The stress of being in an unfamiliar situation, such as admission to a hospital, can cause
confusion in geriatric clients. Depression doesn't produce confusion, but it can cause mood
changes, weight loss, anorexia, constipation, and early morning awakening. In geriatric
clients, long-term memory usually remains intact, although short-term memory may be
altered. Decreased LOC doesn't normally result from aging; therefore, it's a less likely cause
of confusion in this client.
The physician orders an I.M. injection for a client. Which factor may affect the drug
absorption rate from an I.M. injection site?
A. Muscle tone
B. Muscle strength
C. Blood flow to the injection site
D. Amount of body fat at the injection site
Answer: C
Blood flow to the I.M. injection site affects the drug absorption rate. Muscle tone and
strength have no effect on drug absorption. The amount of body fat at the injection site
may help determine the size of the needle and the technique used to localize the site;
however, it doesn't affect drug absorption (unless the nurse inadvertently injects the
medication into the subcutaneous tissue instead of the muscle).
The nursing care plan for a client with decreased adrenal function should include
A. Encouraging activity
B. Placing client in reverse isolation
C. Limiting visitors
D. Measures to prevent constipation
Answer is C: Limiting visitors
Any exertion, either physical or emotional, places additional stress on the adrenal glands
which could precipitate an addisonian crisis. The plan of care should protect this client from
the physical and emotional exertion of visitors.
The nurse is doing a physical assessment and electrocardiogram on an elderly client. Which
finding during the nurse's assessment of the cardiac system is of most concern and
warrants prompt further investigation?
A. S4 heart sound.
B. Increased PR interval.
C. Orthostatic hypotension.
D. Irregularly irregular heart rate.
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A client with pemphigus is being seen in the clinic regularly. The nurse plans care based on
which of the following descriptions of this condition?
A. The presence of tiny red vesicles
B. An autoimmune disease that causes blistering in the epidermis
C. The presence of skin vesicles found along the nerve caused by a virus
D. The presence of red, raised papules and large plaques covered by silvery scales
The nurse is caring for a client in the coronary care unit. The display on the cardiac monitor
indicates ventricular fibrillation. What should the nurse do first?
A. Perform defibrillation
B. Administer epinephrine as ordered
C. Assess for presence of pulse
D. Institute CPR
answer is C: Assess for presence of pulse .Artifact can mimic ventricular fibrillation on a
cardiac monitor. If the client is truly in ventricular fibrillation, no pulse will be present.
The nurse is assigned to a newly delivered woman with HIV/AIDS. The student asks the
nurse about how it is determined that a person has AIDS other than a positive HIV test. The
nurse responds
A. "The complaints of at least 3 common findings."
B. "The absence of any opportunistic infection."
C. "CD4 lymphocyte count is less than 200."
D. "Developmental delays in children."
A answer C: "CD4 lymphocyte count is less than 200." CD4 lymphocyte counts are normally
600 to 1000.
The home care nurse is performing an assessment on a client who has been diagnosed with
an allergy to latex. In determining the client’s risk factors associated with the allergy, the
nurse questions the client about an allergy to which food item?
A. Eggs
B. Milk
C. Yogurt
D. Bananas
Answer: D
While assessing a client in an outpatient facility with a panic disorder, the nurse completes a
thorough health history and physical exam. Which finding is most significant for this client?
A. Compulsive behavior
B. Sense of impending doom
C. Fear of flying
D. Predictable episodes
Answer is B: Sense of impending doom
The feeling of overwhelming and uncontrollable doom is characteristic of a panic attack.
Indications for fundoplication?
A. Hiatus hernia
B. Diaphragmatic hernia
C. GERD
D. All the above
Answer: D
United Nations decided to mark the importance of India’s former President and great
scientist APJ Abdul Kalam and declared his birthday as ‘World Students Day’. The world
students day is ....?
A. November 15
B. October 15
C. October 17
D. November 17
Answer: B
Dowager's hump is the forward curvature(kyphosis) of the spine resulting in a stoop, caused
by collapse of the front edges of the thoracic vertebrae commonly seen in....?
A. Osteoarthritis
B. Rheumatoid arthritis
C. Osteoporosis
D. Lumbar fracture
Answer; C
Koplik spots (also Koplik's sign) are a prodromic viral enanthem of ---- disease?
A. Chikun gunya
B. Diphtheria
C. Herpes zoster
D. Herpes simplex
E. Measles.
Answer: E
A reflex that is seen in normal newborn babies, who automatically turn the face toward the
stimulus and make sucking motions with the mouth when the cheek or lip is touched.
A. Moro
B. Rooting
C. Sucking
D. Swallowing
Answer: B
CA cervix caused by
A. HPV
B. H. Pylori
C. E coli
D. Treponema
E. Gardnerella vaginalis
Answer: A
Mr.Ashok orients his staff on the patterns of reporting relationship throughout the
organization. Which of the following principles refer to this?
A.Span of control
B. Hierarchy
C.Esprit d’ corps
D. Unity of direction
Answer: B
Centralized organizations have some advantages. Which of the following statements are
TRUE?
A. Highly cost-effective
B. Makes management easier
C. Reflects the interest of the worker
D. Allows quick decisions or actions.
E. Both A&B
F. Both C&D
Answer: E
Which of the following guidelines should be least considered in formulating objectives for
nursing care?
A. Written nursing care plan
B. Holistic approach
C. Prescribed standards
D. Staff preferences
Answer: D
Pelvic cellulitis
A. Parametritis
B. Vulvitis
C. Pelvic abscess
D. Perinitis
Answer: A
An opioid analgesic is administered to a client during surgery. The nurse assigned to care
for the client ensures that which medication is readily available if respiratory depression
occurs?
A. Betamethasone
B. Morphine sulfate
C.Naloxone (Narcan)
D. Meperidine hydrochloride (Demerol)
Answer: C
The nurse is preparing to teach a client how to use crutches. Before initiating the lesson, the
nurse performs an assessment on the client.The priority nursing assessment should include
which focus?
A. The client's feelings about the restricted mobility
B. The client's fear related to the use of the crutches
C. The client's muscle strength and previous activity level
D. The client's understanding of the need for increased mobility
Answer: C
After TURP, the client having continues bladder irrigation. Which of these statements explain
the reason for continuous bladder irrigation?
a. To remove clot from the bladder
b. To maintain the patency of the catheter
c. To maintain the patency of the bladder
d. To dilute urine
Answer: A
The nurse has developed a plan of care for a client diagnosed with anorexia nervosa. Which
client problem should the nurse select as the priority in the plan of care?
A. Malnutrition
B. Inability to cope
C. Concern about body appearance
D. Lack of knowledge about nutrition
Answer: A
Why should an infant be quiet and seated upright when the nurse checks his fontanels?
A. The mother will have less trouble holding a quiet, upright infant.
B. Lying down can cause the fontanels to recede, making assessment more difficult.
C. The infant can breathe more easily when sitting up.
D. Lying down and crying can cause the fontanels to bulge.
Answer: D
Which of the following is an appropriate nursing diagnosis for a client with renal calculi?
A. Ineffective tissue perfusion
B. Functional urinary incontinence
C. Risk for infection
D. Decreased cardiac output
Answer: C
Which trait is the most important for ensuring that a nurse-manager is effective?
A. Communication skills
B. Clinical abilities
C. Health care experience
D. Time management skills
Answer :A
Communication skills are a necessity for a successful nurse-manager. The manager must be
able to communicate with the staff, clients, and family members. Clinical abilities,
experience, and time management are also important to the manager's success, but without
communication skills the manager won't be effective.
In Gynace ward , the find out a client, she is on PPH . What the nurse should do first?
A.monitor vitals
B. Call physician
C. Eliminate the blood loss
D. Stay with the client & call for help.
Answer: D
Client may goes to shock. So stay with client
Call help and ask another to call doctor.eliminate blood loss. Then monitor & record vitals
A client complains of abdominal discomfort and nausea while receiving tube feedings. Which
intervention is most appropriate for this problem?
A. Giving the feedings at room temperature
B. Decreasing the rate of feedings and the concentration of the formula
C. Placing the client in semi-Fowler's position while feeding
D. Changing the tube feeding administration set every 24 hours
Answer: B
Decreasing the rate of feedings and the concentration of the formula. Its the higher priority.
which detail of a client's drug therapy is the nurse legally responsible for documenting?
A. Peak concentration time of the drug
B. Safe ranges of the drug
C. Client's socioeconomic data
D. Client's reaction to the drug
Answer: D
The nurse legally must document the client's reaction to the drug in addition to the time the
drug was administered and the dosage given. The nurse isn't legally responsible for
documenting the peak concentration time of the drug, safe drug ranges, or the client's
socioeconomic data.
The Ward nurse administering mannitol and the doctor advised slowly to be given. Why?
The risk for ---?
A. cerebral embolism
B. Pulmonary edema
C.hypertension
D. Fluid overload
Answer: B
Rapid fluid shift will results pulmonary edema
The nurse is collecting data on a client before surgery. Which statement by the client would
alert the nurse to the presence of risk factors for postoperative complications?
A "I haven't been able to eat anything solid for the past 2 days."
B. "I've never had surgery before."
C. "I had an operation 2 years ago, and I don't want to have another one."
D. "I've cut my smoking down from two packs to one pack per day."
Answer: D
The physician prescribes morphine 4 mg I.V. every 2 hours as needed for pain. The nurse
should be on the alert for which adverse reaction to morphine?
A. Tachycardia
B. Hypertension
C. Neutropenia
D. Respiratory depression
Answer: D
The nurse should be alert for respiratory depression after morphine administration. Other
adverse reactions include bradycardia (not tachycardia), thrombocytopenia (not
neutropenia), and hypotension (not hypertension).
The nurse is auscultating a client's chest. How can the nurse differentiate a pleural friction
rub from other abnormal breath sounds?
A. A rub occurs during expiration only and produces a light, popping, musical noise.
B. A rub occurs during inspiration only and may be heard anywhere.
C. A rub occurs during both inspiration and expiration and produces a squeaking or grating
sound.
D. A rub occurs during inspiration only and clears with coughing.
Answer: C
A male client has been complaining of chest pain and shortness of breath for the past 2
hours. He has a temperature of 99° F (37.2° C), a pulse of 96 beats/minute, respirations
that are irregular and 16 breaths/minute, and a blood pressure of 140/96 mm Hg. He's
placed on continuous cardiac monitoring to:
A. prevent cardiac ischemia.
B. assess for potentially dangerous arrhythmias.
C. determine the degree of damage to the heart muscle.
D. evaluate cardiovascular function.
Answer: B
A client with mitral stenosis is scheduled for mitral valve replacement. Which condition may
arise as a complication of mitral stenosis?
A. Left-sided heart failure
B. Myocardial ischemia
C. Pulmonary hypertension
D. Left ventricular hypertrophy
Answer: C
Mitral stenosis, or severe narrowing of the mitral valve, impedes blood flow through the
stenotic valve, increasing pressure in the left atrium and pulmonary circulation.
A client with chest pain doesn't respond to nitroglycerin (Nitrostat). On admission to the
emergency department, the health care team obtains an electrocardiogram and administers
I.V. morphine. The physician also considers administering alteplase (Activase). This
thrombolytic agent must be administered how soon after onset of myocardial infarction (MI)
symptoms?
A. Within 3 to 6 hours
B. Within 24 hours
C. Within 24 to 48 hours
D. Within 5 to 7 days
Answer: A
An unconscious infant received to the emergency department. Which pulse should the nurse
palpate during rapid data collection of an unconscious infant?
A. Radial
B. Brachial
C. Femoral
D. Carotid
Answer: B
The brachial pulse is palpated during rapid data collection of an infant.
During rapid data collection, the nurse's first priority is to check the client's vital functions
by checking his airway, breathing, and circulation.
The nurse places a neonate with hyperbilirubinemia under a phototherapy lamp, covering
the eyes and gonads for protection. The nurse knows that the goal of phototherapy is to:
A. prevent hypothermia.
B. promote respiratory stability.
C. decrease the serum conjugated bilirubin level.
D. decrease the serum unconjugated bilirubin level.
Answer: D
Phototherapy is the primary treatment in neonates with unconjugated hyperbilirubinemia.
Photoisomerism is the therapeutic principle working here.
This conjugated form of bilirubin is then excreted into the bile and removed from the body
via the gut/urine.
The physician orders an I.M. injection for a client. Which factor may affect the drug
absorption rate from an I.M. injection site?
A. Muscle tone
B. Muscle strength
C. Blood flow to the injection site
D. Amount of body fat at the injection site
Answer: C
Blood flow to the I.M. injection site affects the drug absorption rate. Muscle tone and
strength have no effect on drug absorption.
What is the most appropriate method to use when drawing blood from a child with
hemophilia?
A. Use finger punctures for lab draws.
B. Be prepared to administer platelets for prolonged bleeding.
C. Apply heat to the extremity before venipunctures.
D. Schedule all labs to be drawn at one time.
Answer: D
For a client with cirrhosis, deterioration of hepatic function is best indicated by:
A. fatigue and muscle weakness.
B. difficulty in arousal.
C. nausea and anorexia.
D. weight gain.
Answer: B
Hepatic encephalopathy, a major complication of advanced cirrhosis, occurs when the liver
no longer can convert ammonia (a by-product of protein breakdown) into glutamine. This
leads to an increased blood level of ammonia — a central nervous system toxin — which
causes a decrease in the level of consciousness. Fatigue, muscle weakness, nausea,
anorexia, and weight gain occur during the early stages of cirrhosis
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) 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.
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?
9.Which if the following young adolescent and adult male clients are at most risk for
testicular cancer?
11.An 18-month-old baby appears to have a rounded belly, bowlegs and slightly large
head. The nurse concludes?
12.A nurse is going to administer 500mg capsule to a patient. Which is the correct
route?
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?
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?
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?
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) 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
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?
28.A new nurse is administering an enema to a patient. The senior nurse should
intervene if the new nurse?
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
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
7.) Answer: A, E, F, C, B, D
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
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
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
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
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
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
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