1. A pregnant woman who is at term is admitted to the birthing unit in active labor. 6.

6. Which of the following is the most frequent cause of noncompliance to the medical
The client has only progressed from 2cm to 3 cm in 8 hours. She is diagnosed with treatment of open-angle glaucoma?
hypotonic dystocia and the physician ordered Oxytocin (Pitocin) to augment her
contractions. Which of the following is the most important aspect of nursing A. The frequent nausea and vomiting accompanying use of miotic drug.
intervention at this time? B. Loss of mobility due to severe driving restrictions.
C. Decreased light and near-vision accommodation due to miotic effects of pilocarpine.
A. Timing and recording length of contractions. D. The painful and insidious progression of this type of glaucoma.
B. Monitoring. 7. In the morning shift, the nurse is making rounds in the nursing care units. The
C. Preparing for an emergency cesarean birth. nurse enters in a client’s room and notes that the client’s tube has become
D. Checking the perineum for bulging. disconnected from the Pleurovac. What would be the initial nursing action?
2. A client who hallucinates is not in touch with reality. It is important for the nurse
to: A. Apply pressure directly over the incision site.
B. Clamp the chest tube near the incision site.
A. Isolate the client from other patients. C. Clamp the chest tube closer to the drainage system.
B. Maintain a safe environment. D. Reconnect the chest tube to the Pleurovac.
C. Orient the client to time, place, and person. 8. Which of the following complications during a breech birth the nurse needs to be
D. Establish a trusting relationship. alarmed?
3. The nurse is caring to a child client who has had a tonsillectomy. The child
complains of having dryness of the throat. Which of the following would the nurse A. Abruption placenta.
give to the child? B. Caput succedaneum.
C. Pathological hyperbilirubinemia.
A. Cola with ice D. Umbilical cord prolapse.
B. Yellow noncitrus Jello 9. The nurse is caring to a client diagnosed with severe depression. Which of the
C. Cool cherry Kool-Aid following nursing approach is important in depression?
D. A glass of milk
4. The physician ordered Phenylephrine (Neo-Synephrine) nasal spray to a 13-year- A. Protect the client against harm to others.
old client. The nurse caring to the client provides instructions that the nasal spray B. Provide the client with motor outlets for aggressive, hostile feelings.
must be used exactly as directed to prevent the development of: C. Reduce interpersonal contacts.
D. Deemphasizing preoccupation with elimination, nourishment, and sleep.
A. Increased nasal congestion. 10. A 3-month-old client is in the pediatric unit. During assessment, the nurse is
B. Nasal polyps. suspecting that the baby may have hypothyroidism when mother states that her baby
C. Bleeding tendencies. does not:
D. Tinnitus and diplopia.
5. A client with tuberculosis is to be admitted in the hospital. The nurse who will be A. Sit up.
assigned to care for the client must institute appropriate precautions. The nurse B. Pick up and hold a rattle.
should: C. Roll over.
D. Hold the head up.
A. Place the client in a private room. 11. The physician calls the nursing unit to leave an order. The senior nurse had
B. Wear an N 95 respirator when caring for the client. conversation with the other staff. The newly hired nurse answers the phone so that
C. Put on a gown every time when entering the room. the senior nurses may continue their conversation. The new nurse does not knowthe
D. Don a surgical mask with a face shield when entering the room. physician or the client to whom the order pertains. The nurse should:

A. Ask the physician to call back after the nurse has read the hospital policy manual.
B. Take the telephone order.
C. Refuse to take the telephone order.
D. Ask the charge nurse or one of the other senior staff nurses to take the telephone
order.
 12. The staff nurse on the labor and delivery unit is assigned to care to a primigravida 17. The nurse in the nursing care unit checks the fluctuation in the water-seal
in transition complicated by hypertension. A new pregnant woman in active labor is compartment of a closed chest drainage system. The fluctuation has stopped, the
admitted in the same unit. The nurse manager assigned the same nurse to the second nurse would:
client. The nurse feels that the client with hypertension requires one-to-one care.
What would be the initial actionof the nurse? A. Vigorously strip the tube to dislodge a clot.
B. Raise the apparatus above the chest to move fluid.
A. Accept the new assignment and complete an incident report describing a shortage of C. Increase wall suction above 20 cm H2O pressure.
nursing staff. D. Ask the client to cough and take a deep breath.
B. Report the incident to the nursing supervisor and request to be floated. 18. The pediatric nurse in the neonatal unit was informed that the baby that is
C. Report the nursing assessment of the client in transitional labor to the nurse manager brought to the mother in the hospital room is wrong. The nurse determines that two
and discuss misgivings about the new assignment. babies were placed in the wrong cribs. The most appropriate nursing action would be
D. Accept the new assignment and provide the best care. to:
13. A newborn infant with Down syndrome is to be discharged today. The nurse is
preparing to give the discharge teaching regarding the proper care at home. The A. Determine who is responsible for the mistake and terminate his or her employment.
nurse would anticipate that the mother is probably at the: B. Record the event in an incident/variance report and notify the nursing supervisor.
C. Reassure both mothers, report to the charge nurse, and do not record.
A. 40 years of age. D. Record detailed notes of the event on the mother’s medical record.
B. 20 years of age.
C. 35 years of age.
D. 20 years of age. 19. Before the administration of digoxin, the nurse completes an assessment to a
14. The emergency department has shortage of staff. The nurse manager informs the toddler client for signs and symptoms of digoxin toxicity. Which of the following is the
staff nurse in the critical care unit that she has to float to the emergency department. earliest and most significant sign of digoxin toxicity?
What should the staff nurse expect under these conditions?
A. Tinnitus
A. The float staff nurse will be informed of the situation before the shift begins. B. Nausea and vomiting
B. The staff nurse will be able to negotiate the assignments in the emergency C. Vision problem
department. D. Slowing in the heart rate
C. Cross training will be available for the staff nurse. 20. Which of the following treatment modality is appropriate for a client with paranoid
D. Client assignments will be equally divided among the nurses. tendency?
15. The nurse is assigned to care for a child client admitted in the pediatrics unit. The
client is receiving digoxin. Which of the following questions will be asked by the nurse A. Activity therapy.
to the parents of the child in order to assess the client’s risk for digoxin toxicity? B. Individual therapy.
C. Group therapy.
A. “Has he been exposed to any childhood communicable diseases in the past 2-3 D. Family therapy.
weeks?” 21. The client with rheumatoid arthritis is for discharge. In preparing the client for
B. “Has he been taking diuretics at home?” discharge on prednisone therapy, the nurse should advise the client to:
C. “Do any of his brothers and sisters have history of cardiac problems?”
D. “Has he been going to school regularly?” A. Wear sunglasses if exposed to bright light for an extended period of time.
16. The nurse noticed that the signed consent form has an error. The form states, B. Take oral preparations of prednisone before meals.
“Amputation of the right leg” instead of the left leg that is to be amputated. The nurse C. Have periodic complete blood counts while on the medication.
has administered already the preoperative medications. What should the nurse do? D. Never stop or change the amount of the medication without medical advice.

A. Call the physician to reschedule the surgery.

B. Call the nearest relative to come in to sign a new form.
C. Cross out the error and initial the form.
D. Have the client sign another form.
 22. A pregnant client tells the nurse that she is worried about having urinary 27. Which of the following nursing intervention is essential for the client who had
frequency. What will be the most appropriate nursing response? pneumonectomy?

A. “Try using Kegel (perineal) exercises and limiting fluids before bedtime. If you have A. Medicate for pain only when needed.
frequency associated with fever, pain on voiding, or blood in the urine, call your B. Connect the chest tube to water-seal drainage.
doctor/nurse-midwife. C. Notify the physician if the chest drainage exceeds 100mL/hr.
B. “Placental progesterone causes irritability of the bladder sphincter. Your symptoms will D. Encourage deep breathing and coughing.
go away after the baby comes.” 28. The nurse is providing a health teaching to a group of parents regarding
C. “Pregnant women urinate frequently to get rid of fetal wastes. Limit fluids to 1L/daily.” Chlamydia trachomatis. The nurse is correct in the statement, “Chlamydia trachomatis
D. “Frequency is due to bladder irritation from concentrate urine and is normal in is not only an intracellular bacterium that causes neonatal conjunctivitis, but it also
pregnancy. Increase your daily fluid intake to 3L.” can cause:
23. Which of the following will help the nurse determine that the expression of
hostility is useful? A. Discoloration of baby and adult teeth.
B. Pneumonia in the newborn.
A. Expression of anger dissipates the energy. C. Snuffles and rhagades in the newborn.
B. Energy from anger is used to accomplish what needs to be done. D. Central hearing defects in infancy.
C. Expression intimidates others. 29. The nurse is assigned to care to a 17-year-old male client with a history of
D. Degree of hostility is less than the provocation. substance abuse. The client asks the nurse, “Have you ever tried or used drugs?” The
24. The nurse is providing an orientation regarding case management to the nursing most correct response of the nurse would be:
students. Which characteristics should the nurse include in the discussion in
understanding case management? A. “Yes, once I tried grass.”
B. “No, I don’t think so.”
A. Main objective is a written plan that combines discipline-specific processes used to C. “Why do you want to know that?”
measure outcomes of care. D. “How will my answer help you?”
B. Main purpose is to identify expected client, family and staff performance against the 30. Which of the following describes a health care team with the principles of
timeline for clients with the same diagnosis. participative leadership?
C. Main focus is comprehensive coordination of client care, avoid unnecessary duplication
of services, improve resource utilization and decrease cost. A. Each member of the team can independently make decisions regarding the client’s
D. Primary goal is to understand why predicted outcomes have not been met and the care without necessarily consulting the other members.
correction of identified problems. B. The physician makes most of the decisions regarding the client’s care.
25. The physician orders a dose of IV phenytoin to a child client. In preparing in the C. The team uses the expertise of its members to influence the decisions regarding the
administration of the drug, which nursing action is not correct? client’s care.
D. Nurses decide nursing care; physicians decide medical and other treatment for the
A. Infuse the phenytoin into a smaller vein to prevent purple glove syndrome. client.
B. Check the phenytoin solution to be sure it is clear or light yellow in color, never 31. A nurse is giving a health teaching to a woman who wants to breastfeed her
cloudy. newborn baby. Which hormone, normally secreted during the postpartum period,
C. Plan to give phenytoin over 30-60 minutes, using an in-line filter. influences both the milk ejection reflex and uterine involution?
D. Flush the IV tubing with normal saline before starting phenytoin.
26. The pregnant woman visits the clinic for check –up. Which assessment findings A. Oxytocin.
will help the nurse determine that the client is in 8-week gestation? B. Estrogen.
C. Progesterone.
A. Leopold maneuvers. D. Relaxin.
B. Fundal height.
C. Positive radioimmunoassay test (RIA test).
D. Auscultation of fetal heart tones.
 32. One staff nurse is assigned to a group of 5 patients for the 12-hour shift. The 37. The nurse must instruct a client with glaucoma to avoid taking over-the-counter
nurse is responsible for the overall planning, giving and evaluating care during the medications like:
entire shift. After the shift, same responsibility will be endorsed to the next nurse in
charge. This describes nursing care delivered via the: A. Antihistamines.
B. NSAIDs.
A. Primary nursing method. C. Antacids.
B. Case method. D. Salicylates.
C. Functional method. 38. A male client is brought to the emergency department due to motor vehicle
D. Team method. accident. While monitoring the client, the nurse suspects increasing intracranial
33. The ambulance team calls the emergency department that they are going to bring pressure when:
a client who sustained burns in a house fire. While waiting for the ambulance, the
nurse will anticipate emergency care to include assessment for: A. Client is oriented when aroused from sleep, and goes back to sleep immediately.
B. Blood pressure is decreased from 160/90 to 110/70.
A. Gas exchange impairment. C. Client refuses dinner because of anorexia.
B. Hypoglycemia. D. Pulse is increased from 88-96 with occasional skipped beat.
C. Hyperthermia. 39. The nurse is conducting a lecture to a class of nursing students about advance
D. Fluid volume excess. directives to preoperative clients. Which of the following statement by the nurse js
34. Most couples are using “natural” family planning methods. Most accidental correct?
pregnancies in couples preferred to use this method have been related to unprotected
intercourse before ovulation. Which of the following factor explains why pregnancy A. “The spouse, but not the rest of the family, may override the advance directive.”
may be achieved by unprotected intercourse during the preovulatory period? B. “An advance directive is required for a “do not resuscitate” order.”
C. “A durable power of attorney, a form of advance directive, may only be held by a
A. Ovum viability. blood relative.”
B. Tubal motility. D. “The advance directive may be enforced even in the face of opposition by the
C. Spermatozoal viability. spouse.”
D. Secretory endometrium. 40. A client diagnosed with schizophrenia is shouting and banging on the door leading
35. An older adult client wakes up at 2 o’clock in the morning and comes to the to the outside, saying, “I need to go to an appointment.” What is the appropriate
nurse’s station saying, “I am having difficulty in sleeping.” What is the best nursing nursing intervention?
response to the client?
A. Tell the client that he cannot bang on the door.
A. “I’ll give you a sleeping pill to help you get more sleep now.” B. Ignore this behavior.
B. “Perhaps you’d like to sit here at the nurse’s station for a while.” C. Escort the client going back into the room.
C. “Would you like me to show you where the bathroom is?” D. Ask the client to move away from the door.
D. “What woke you up?” 41. Which of the following action is an accurate tracheal suctioning technique?
36. The nurse is taking care of a multipara who is at 42 weeks of gestation and in
active labor, her membranes ruptured spontaneously 2 hours ago. While auscultating A. 25 seconds of continuous suction during catheter insertion.
for the point of maximum intensity of fetal heart tones before applying an external B. 20 seconds of continuous suction during catheter insertion.
fetal monitor, the nurse counts 100 beats per minute. The immediate nursing action is C. 10 seconds of intermittent suction during catheter withdrawal.
to: D. 15 seconds of intermittent suction during catheter withdrawal.
42. The client’s jaw and cheekbone is sutured and wired. The nurse anticipates that
A. Start oxygen by mask to reduce fetal distress. the most important thing that must be ready at the bedside is:
B. Examine the woman for signs of a prolapsed cord.
C. Turn the woman on her left side to increase placental perfusion. A. Suture set.
D. Take the woman’s radial pulse while still auscultating the FHR. B. Tracheostomy set.
C. Suction equipment.
D. Wire cutters.
 43. A mother is in the third stage of labor. Which of the following signs will help the 49. The parents of an infant client ask the nurse to teach them how to administer
nurse determine the signs of placental separation? Cortisporin eye drops. The nurse is correct in advising the parents to place the drops:

A. The uterus becomes globular. A. In the middle of the lower conjunctival sac of the infant’s eye.
B. The umbilical cord is shortened. B. Directly onto the infant’s sclera.
C. The fundus appears at the introitus. C. In the outer canthus of the infant’s eye.
D. Mucoid discharge is increased. D. In the inner canthus of the infant’s eye.
44. After therapy with the thrombolytic alteplase (t-PA), what observation will the 50. The nurse is assessing on the client who is admitted due to vehicle accident.
nurse report to the physician? Which of the following findings will help the nurse that there is internal bleeding?

A. 3+ peripheral pulses. A. Frank blood on the clothing.

B. Change in level of consciousness and headache. B. Thirst and restlessness.
C. Occasional dysrhythmias. C. Abdominal pain.
D. Heart rate of 100/bpm. D. Confusion and altered of consciousness.
45. A client who undergone left nephrectomy has a large flank incision. Which of the 51. The nurse is completing an assessment to a newborn baby boy. The nurse
following nursing action will facilitate deep breathing and coughing? observes that the skin of the newborn is dry and flaking and there are several areas
of an apparent macular rash. The nurse charts this as:
A. Push fluid administration to loosen respiratory secretions.
B. Have the client lie on the unaffected side. A. Icterus neonatorum
C. Maintain the client in high Fowler’s position. B. Multiple hemangiomas
D. Coordinate breathing and coughing exercise with administration of analgesics. C. Erythema toxicum
46. The community nurse is teaching the group of mothers about the cervical mucus D. Milia
method of natural family planning. Which characteristics are typical of the cervical 52. The client is brought to the emergency department because of serious vehicle
mucus during the “fertile” period of the menstrual cycle? accident. After an hour, the client has been declared brain dead. The nurse who has
been with the client must now talk to the family about organ donation. Which of the
A. Absence of ferning. following consideration is necessary?
B. Thin, clear, good spinnbarkeit.
C. Thick, cloudy. A. Include as many family members as possible.
D. Yellow and sticky. B. Take the family to the chapel.
47. A client with ruptured appendix had surgery an hour ago and is transferred to the C. Discuss life support systems.
nursing care unit. The nurse placed the client in a semi-Fowler’s position primarily to: D. Clarify the family’s understanding of brain death.
53. The nurse is teaching exercises that are good for pregnant women increasing tone
A. Facilitate movement and reduce complications from immobility. and fitness and decreasing lower backache. Which of the following should the nurse
B. Fully aerate the lungs. exclude in the exercise program?
C. Splint the wound.
D. Promote drainage and prevent subdiaphragmatic abscesses. A. Stand with legs apart and touch hands to floor three times per day.
48. Which of the following will best describe a management function? B. Ten minutes of walking per day with an emphasis on good posture.
C. Ten minutes of swimming or leg kicking in pool per day.
A. Writing a letter to the editor of a nursing journal. D. Pelvic rock exercise and squats three times a day.
B. Negotiating labor contracts. 54. A client with obsessive-compulsive behavior is admitted in the psychiatric unit.
C. Directing and evaluating nursing staff members. The nurse taking care of the client knows that the primary treatment goal is to:
D. Explaining medication side effects to a client.
A. Provide distraction.
B. Support but limit the behavior.
C. Prohibit the behavior.
D. Point out the behavior.
 55. After ileostomy, the nurse expects that the drainage appliance will be applied to 60. The nurse assesses the health condition of the female client. The client tells the
the stoma: nurse that she discovered a lump in the breast last year and hesitated to seek medical
advice. The nurse understands that, women who tend to delay seeking medical advice
A. When the client is able to begin self-care procedures. after discovering the disease are displaying what common defense mechanism?
B. 24 hours later, when the swelling subsided.
C. In the operating room after the ileostomy procedure. A. Intellectualization.
D. After the ileostomy begins to function. B. Suppression.
56. A female client who has a 28-day menstrual cycle asks the community health C. Repression.
nurse when she get pregnant during her cycle. What will be the best nursing D. Denial.
response? 61. Which of the following situations cannot be delegated by the registered nurse to
the nursing assistant?
A. It is impossible to determine the fertile period reliably. So it is best to assume that a
woman is always fertile. A. A postoperative client who is stable needs to ambulate.
B. In a 28-day cycle, ovulation occurs at or about day 14. The egg lives for about 24 B. Client in soft restraint who is very agitated and crying.
hours and the sperm live for about 72 hours. The fertile period would be C. A confused elderly woman who needs assistance with eating.
approximately between day 11 and day 15. D. Routine temperature check that must be done for a client at end of shift.
C. In a 28- day cycle, ovulation occurs at or about day 14. The egg lives for about 72 62. In the admission care unit, which of the following client would the nurse give
hours and the sperm live for about 24 hours. The fertile period would be immediate attention?
approximately between day 13 and 17.
D. In a 28-day cycle, ovulation occurs 8 days before the next period or at about day 20. A. A client who is 3 days postoperative with left calf pain.
The fertile period is between day 20 and the beginning of the next period. B. A client who is postoperative hip pinning who is complaining of pain.
57. Which of the following statement describes the role of a nurse as a client C. New admitted client with chest pain.
advocate? D. A client with diabetes who has a glucoscan reading of 180.
63. A couple seeks medical advice in the community health care unit. A couple has
A. A nurse may override clients’ wishes for their own good. been unable to conceive; the man is being evaluated for possible problems. The
B. A nurse has the moral obligation to prevent harm and do well for clients. physician ordered semen analysis. Which of the following instructions is correct
C. A nurse helps clients gain greater independence and self-determination. regarding collection of a sperm specimen?
D. A nurse measures the risk and benefits of various health situations while factoring in
cost. A. Collect a specimen at the clinic, place in iced container, and give to laboratory
58. A community health nurse is providing a health teaching to a woman infected with personnel immediately.
herpes simplex 2. Which of the following health teaching must the nurse include to B. Collect specimen after 48-72 hours of abstinence and bring to clinic within 2 hours.
reduce the chances of transmission of herpes simplex 2? C. Collect specimen in the morning after 24 hours of abstinence and bring to clinic
immediately.
A. “Abstain from intercourse until lesions heal.” D. Collect specimen at night, refrigerate, and bring to clinic the next morning.
B. “Therapy is curative.” 64. The physician ordered Betamethasone to a pregnant woman at 34 weeks of
C. “Penicillin is the drug of choice for treatment.” gestation with sign of preterm labor. The nurse expects that the drug will:
D. “The organism is associated with later development of hydatidiform mole.
59. The nurse in the psychiatric ward informed the male client that he will be A. Treat infection.
attending the 9:00 AM group therapy sessions. The client tells the nurse that he must B. Suppress labor contraction.
wash his hands from 9:00 to 9:30 AM each day and therefore he cannot attend. C. Stimulate the production of surfactant.
Which concept does the nursing staff need to keep in mind in planning nursing D. Reduce the risk of hypertension.
intervention for this client?

A. Depression underlines ritualistic behavior.

B. Fear and tensions are often expressed in disguised form through symbolic processes.
C. Ritualistic behavior makes others uncomfortable.
D. Unmet needs are discharged through ritualistic behavior.
 65. A tracheostomy cuff is to be deflated, which of the following nursing intervention 70. Which telephone call from a student’s mother should the school nurse take care of
should be implemented before starting the procedures? at once?

A. Suction the trachea and mouth. A. A telephone call notifying the school nurse that the child’ pediatrician has informed
B. Have the obdurator available. the mother that the child will need cardiac repair surgery within the next few weeks.
C. Encourage deep breathing and coughing. B. A telephone call notifying the school nurse that the child’s pediatrician has informed
D. Do a pulse oximetry reading. the mother that the child has head lice.
66. A client is diagnosed with Tuberculosis and respiratory isolation is initiated. This C. A telephone call notifying the school nurse that a child has a temperature of 102ºF
means that: and a rash covering the trunk and upper extremities of the body.
D. A telephone call notifying the school nurse that a child underwent an emergency
A. Gloves are worn when handling the client’s tissue, excretions, and linen. appendectomy during the previous night.
B. Both client and attending nurse must wear masks at all times. 71. Which of the following signs and symptoms that require immediate attention and
C. Nurse and visitors must wear masks until chemotherapy is begun. Client is instructed may indicate most serious complications during pregnancy?
in cough and tissue techniques.
D. Full isolation; that is, caps and gowns are required during the period of contagion. A. Severe abdominal pain or fluid discharge from the vagina.
67. A client with lung cancer is admitted in the nursing care unit. The husband wants B. Excessive saliva, “bumps around the areolae, and increased vaginal mucus.
to know the condition of his wife. How should the nurse respond to the husband? C. Fatigue, nausea, and urinary frequency at any time during pregnancy.
D. Ankle edema, enlarging varicosities, and heartburn.
A. Find out what information he already has. 72. The nurse is assessing the newborn boy. Apgar scores are 7 and 9. The newborn
B. Suggest that he discuss it with his wife. becomes slightly cyanotic. What is the initial nursing action?
C. Refer him to the doctor.
D. Refer him to the nurse in charge. A. Elevate his head to promote gravity drainage of secretions.
68. A hospitalized client cannot find his handkerchief and accuses other cient in the B. Wrap him in another blanket, to reduce heat loss.
room and the nurse of stealing them. Which is the most therapeutic approach to this C. Stimulate him to cry,, to increase oxygenation.
client? D. Aspirate his mouth and nose with bulb syringe.
73. The nurse is formulating a plan of care to a client with a somatoform disorder.
A. Divert the client’s attention. The nurse needs to have knowledge of which psychodynamic principle?
B. Listen without reinforcing the client’s belief.
C. Inject humor to defuse the intensity. A. The symptoms of a somatoform disorder are an attempt to adjust to painful life
D. Logically point out that the client is jumping to conclusions. situations or to cope with conflicting sexual, aggressive, or dependent feelings.
69. After a cystectomy and formation of an ileal conduit, the nurse provides B. The major fundamental mechanism is regression.
instruction regarding prevention of leakage of the pouch and backflow of the urine. C. The client’s symptoms are imaginary and the suffering is faked.
The nurse is correct to include in the instruction to empty the urine pouch: D. An extensive, prolonged study of the symptoms will be reassuring to the client, who
seeks sympathy, attention and love.
A. Every 3-4 hours. 74. An infant is brought to the health care clinic for three immunizations at the same
B. Every hour. time. The nurse knows that hepatitis B, DPT, and Haemophilus influenzae type B
C. Twice a day. immunizations should:
D. Once before bedtime.
A. Be drawn in the same syringe and given in one injection.
B. Be mixed and inject in the same sites.
C. Not be mixed and the nurse must give three injections in three sites.
D. Be mixed and the nurse must give the injection in three sites.
 75. A female client with cancer has radium implants. The nurse wants to maintain the 80. The nurse is assigned to care for a client with urinary calculi. Fluid intake of
implants in the correct position. The nurse should position the client: 2L/day is encouraged to the client. the primary reason for this is to:

A. Flat in bed. A. Reduce the size of existing stones.

B. On the side only. B. Prevent crystalline irritation to the ureter.
C. With the foot of the bed elevated. C. Reduce the size of existing stones
D. With the head elevated 45-degrees (semi-Fowler’s). D. Increase the hydrostatic pressure in the urinary tract.
81. The nurse is counseling a couple in their mid 30’s who have been unable to
conceive for about 6 months. They are concerned that one or both of them may be
76. The nurse wants to know if the mother of a toddler understands the instructions infertile. What is the best advice the nurse could give to the couple?
regarding the administration of syrup of ipecac. Which of the following statement will
help the nurse to know that the mother needs additional teaching? A. “it is no unusual to take 6-12 months to get pregnant, especially when the partners
are in their mid-30s. Eat well, exercise, and avoid stress.”
A. “I’ll give the medicine if my child gets into some toilet bowl cleaner.” B. “Start planning adoption. Many couples get pregnant when they are trying to adopt.”
B. “I’ll give the medicine if my child gets into some aspirin.” C. “Consult a fertility specialist and start testing before you get any older.”
C. “I’ll give the medicine if my child gets into some plant bulbs.” D. “Have sex as often as you can, especially around the time of ovulation, to increase
D. “I’ll give the medicine if my child gets into some vitamin pills.” your chances of pregnancy.”
77. To assess if the cranial nerve VII of the client was damaged, which changes would 82. The nurse is caring for a cient who Is a retired nurse. A 24-hour urine collection
not be expected? for Creatinine clearance is to be done. The client tells the nurse, “I can’t remember
what this test is for.” The best response by the nurse is:
A. Drooling and drooping of the mouth.
B. Inability to open eyelids on operative side. A. “It provides a way to see if you are passing any protein in your urine.”
C. Sagging of the face on the operative side. B. “It tells how well the kidneys filter wastes from the blood.”
D. Inability to close eyelid on operative side. C. “It tells if your renal insufficiency has affected your heart.”
78. The community health nurse makes a home visit to a family. During the visit, the D. “The test measures the number of particles the kidney filters.”
nurse observes that the mother is beating her child. What is the priority nursing 83. The nurse observes the female client in the psychiatric ward that she is having a
intervention in this situation? hard time sleeping at night. The nurse asks the client about it and the client says, “I
can’t sleep at night because of fear of dying.” What is the best initial nursing
A. Assess the child’s injuries. response?
B. Report the incident to protective agencies.
C. Refer the family to appropriate support group. A. “It must be frightening for you to feel that way. Tell me more about it.”
D. Assist the family to identify stressors and use of other coping mechanisms to prevent B. “Don’t worry, you won’t die. You are just here for some test.”
further incidents. C. “Why are you afraid of dying?”
79. The nurse in the neonatal care unit is supervising the actions of a certified nursing D. “Try to sleep. You need the rest before tomorrow’s test.”
assistant in giving care to the newborns. The nursing assistant mistakenly gives a 84. In the hospital lobby, the registered nurse overhears a two staff members
formula feeding to a newborn that is on water feeding only. The nurse is responsible discussing about the health condition of her client. What would be the appropriate
for the mistake of the nursing assistant: action for the registered nurse to take?

A. Always, as a representative of the institution. A. Join in the conversation, giving her input about the case.
B. Always, because nurses who supervise less-trained individuals are responsible for B. Ignore them, because they have the right to discuss anything they want to.
their mistakes. C. Tell them it is not appropriate to discuss such things.
C. If the nurse failed to determine whether the nursing assistant was competent to take D. Report this incident to the nursing supervisor.
care of the client.
D. Only if the nurse agreed that the newborn could be fed formula.
 85. The client has had a right-sided cerebrovascular accident. In transferring the client 90. The nurse is completing an obstetric history of a woman in labor. Which event in
from the wheelchair to bed, in what position should a client be placed to facilitate safe the obstetric history will help the nurse suspects dysfunctional labor in the current
transfer? pregnancy?

A. Weakened (L) side of the cient next to bed. A. Total time of ruptured membranes was 24 hours with the second birth.
B. Weakened (R) side of the client next to bed. B. First labor lasting 24 hours.
C. Weakened (L) side of the client away from bed. C. Uterine fibroid noted at time of cesarean delivery.
D. Weakened (R) side of the cient away from bed. D. Second birth by cesarean for face presentation.
86. The child client has undergone hip surgery and is in a spica cast. Which of the 91. The nurse is planning to talk to the client with an antisocial personality disorder.
following toy should be avoided to be in the child’s bed? What would be the most therapeutic approach?

A. A toy gun. A. Provide external controls.

B. A stuffed animal. B. Reinforce the client’s self-concept.
C. A ball. C. Give the client opportunities to test reality.
D. Legos. D. Gratify the client’s inner needs.
87. The LPN/LVN asks the registered nurse why oxytocin (Pitocin), 10 units (IV or IM) 92. The nurse is teaching a group of women about fertility awareness, the nurse
must be given to a client after birth fo the fetus. The nurse is correct to explain that should emphasize that basal body temperature:
oxytocin:
A. Can be done with a mercury thermometer but no a digital one.
A. Minimizes discomfort from “after pains.” B. The average temperature taken each morning.
B. Suppresses lactation. C. Should be recorded each morning before any activity.
C. Promotes lactation. D. Has a lower degree of accuracy in predicting ovulation than the cervical mucus test.
D. Maintains uterine tone. 93. The nursing applicant has given the chance to ask questions during a job
88. The nurse in the nursing care unit is aware that one of the medical staff displays interview at a local hospital. What should be the most important question to ask that
unlikely behaviors like confusion, agitation, lethargy and unkempt appearance. This can increase chances of securing a job offer?
behavior has been reported to the nurse manager several times, but no changes
observed. The nurse should: A. Begin with questions about client care assignments, advancement opportunities, and
continuing education.
A. Continue to report observations of unusual behavior until the problem is resolved. B. Decline to ask questions, because that is the responsibility of the interviewer.
B. Consider that the obligation to protect the patient from harm has been met by the C. Ask as many questions about the facility as possible.
prior reports and do nothing further. D. Clarify information regarding salary, benefits, and working hours first, because this
C. Discuss the situation with friends who are also nurses to get ideas . will help in deciding whether or not to take the job.
D. Approach the partner of this medical staff member with these concerns. 94. The nurse advised the pregnant woman that smoking and alcohol should be
89. The physician ordered tetracycline PO qid to a child client who weights 20kg. The avoided during pregnancy. The nurse takes into account that the developing fetus is
recommended PO tetracycline dose is 25-50 mg/kg/day. What is the maximum single most vulnerable to environment teratogens that cause malformation during:
dose that can be safely administered to this child?
A. The entire pregnancy.
A. 1g B. The third trimester.
B. 500 mg C. The first trimester.
C. 250 mg D. The second trimester.
D. 125 mg 95. A male client tells the nurse that there is a big bug in his bed. The most
therapeutic nursing response would be:

A. Silence.
B. “Where’s the bug? I’ll kill it for you.”
C. “I don’t see a bug in your bed, but you seem afraid.”
D. “You must be seeing things.”
 96. A pregnant client in late pregnancy is complaining of groin pain that seems worse
on the right side. Which of the following is the most likely cause of it?

A. Beginning of labor.
B. Bladder infection.
C. Constipation.
D. Tension on the round ligament.
97. The nurse is conducting a lecture to a group of volunteer nurses. The nurse is
correct in imparting the idea that the Good Samaritan law protects the nurse from a
suit for malpractice when:

A. The nurse stops to render emergency aid and leaves before the ambulance arrives.
B. The nurse acts in an emergency at his or her place of employment.
C. The nurse refuses to stop for an emergency outside of the scope of employment.
D. The nurse is grossly negligent at the scene of an emergency.
98. A woman is hospitalized with mild preeclampsia. The nurse is formulating a plan
of care for this client, which nursing care is least likely to be done?

A. Deep-tendon reflexes once per shift.

B. Vital signs and FHR and rhythm q4h while awake.
C. Absolute bed rest.
D. Daily weight.
99. While feeding a newborn with an unrepaired cardiac defect, the nurse keeps on
assessing the condition of the client. The nurse notes that the newborn’s respiration is
72 breaths per minute. What would be the initial nursing action?

A. Burp the newborn.

B. Stop the feeding.
C. Continue the feeding.
D. Notify the physician.
100. A client who undergone appendectomy 3 days ago is scheduled for discharge
today. The nurse notes that the client is restless, picking at bedclothes and saying, “I
am late on my appointment,” and calling the nurse by the wrong name. The nurse
suspects:

A. Panic reaction.
B. Medication overdose.
C. Toxic reaction to an antibiotic.
D. Delirium tremens.
 Answers and Rationales
1. A. The oxytocic effect of Pitocin increases the intensity and durations of contractions;
prolonged contractions will jeopardize the safetyof the fetus and necessitate
discontinuing the drug.
2. B. It is of paramount importance to prevent the client from hurting himself or herself
or others.
3. B. After tonsillectomy, clear, cool liquids should be given. Citrus, carbonated, and hot
or cold liquids should be avoided because they may irritate the throat. Red liquids
should be avoided because they give the appearance of blood if the child vomits. Milk
and milk products including pudding are avoided because they coat the throat, cause
the child to clear the throat, and increase the risk of bleeding.
4. A. Phenylephrine, with frequent and continued use, can cause rebound congestion of
mucous membranes.
5. B. The N 95 respirator is a high-particulate filtration mask that meets the CDC
performance criteria for a tuberculosis respirator.
6. C. The most frequent cause of noncompliance to the treatment of chronic, or open-
angle glaucoma is the miotic effects of pilocarpine. Pupillary constriction impedes
normal accommodation, making night driving difficult and hazardous, reducing the
client’s ability to read for extended periods and making participation in games with
fast-moving objects impossible.
7. B. This stops the sucking of air through the tube and prevents the entry of
contaminants. In addition, clamping near the chest wall provides for some stability
and may prevent the clamp from pulling on the chest tube.
8. D. Because umbilical cord’s insertion site is born before the fetal head, the cord may
be compressed by the after-coming head in a breech birth.
9. B. It is important to externalize the anger away from self.
10. D. Development normally proceeds cephalocaudally; so the first major developmental
milestone that the infant achieves is the ability to hold the head up within the first 8-
12 weeks of life. In hypothyroidism, the infant’s muscle tone would be poor and the
infant would not be able to achieve this milestone.
11. D. Get a senior nurse who know s the policies, the client, and the doctor. Generally
speaking, a nurse should not accept telephone orders. However, if it is necessary to
take one, follow the hospital’s policy regarding telephone orders. Failure to
followhospital policy could be considered negligence. In this case, the nurse was new
and did not know the hospital’s policy concerning telephone orders. The nurse was
also unfamiliar with the doctor and the client. Therefore the nurse should not take the
order unless a) no one else is available and b) it is an emergency situation.
12. C. The nurse is obligated to inform the nurse manager about changes in the condition
of the client, which may change the decision made by the nurse manager.
13. A. Perinatal risk factors for the development of Down syndrome include advanced
maternal age, especially with the first pregnancy.
14. B. Assignments should be based on scope of practice and expertise.
15. B. The child who is concurrently taking digoxin and diuretics is at increased risk for
digoxin toxicity due to the loss of potassium. The child and parents should be taught
what foods are high in potassium, and the child should be encouraged to eat a high-
potassium diet. In addition, the child’s serum potassium level should be carefully
monitored.
16. A. The responsible for an accurate informed consent is the physician. An exception to
this answer would be a life-threatening emergency, but there are no data to support
another response.
17. D. Asking the client to cough and take a deep breath will help determine if the chest
tube is kinked or if the lungs has reexpanded.
18. B. Every event that exposes a client to harm should be recorded in an incident report,
as well as reported to the appropriate supervisors in order to resolve the current
problems and permit the institution to prevent the problem from happening again.
19. D. One of the earliest signs of digoxin toxicity is Bradycardia. For a toddler, any heart
rate that falls below the norm of about 100-120 bpm would indicate Bradycardia and
would necessitate holding the medication and notifying the physician.
20. B. This option is least threatening.
21. D. In preparing the client for discharge that is receiving prednisone, the nurse should
caution the client to (a) take oral preparations after meals; (b) remember that routine
checks of vital signs, weight, and lab studies are critical; (c) NEVER STOP OR CHANGE
THE AMOUNT OF MEDICATION WITHOUT MEDICAL ADVICE; (d) store the medication
in a light-resistant container.
22. A. Progesterone also reduces smooth muscle motility in the urinary tract and
predisposes the pregnant woman to urinary tract infections. Women should contact
their doctors if they exhibit signs of infection. Kegel exercise will help strengthen the
perineal muscles; limiting fluids at bedtime reduces the possibility of being awakened
by the necessity of voiding.
23. B. This is the proper use of anger.
24. C. There are several models of case management, but the commonality is
comprehensive coordination of care to better predict needs of high-risk clients,
decrease exacerbations and continually monitor progress overtime.
25. A. Phenytoin should be infused or injected into larger veins to avoid the discoloration
know as purple glove syndrome; infusing into a smaller vein is not appropriate.
26. C. Serum radioimmunoassay (RIA) is accurate within 7days of conception. This test is
specific for HCG, and accuracy is not compromised by confusion with LH.
27. D. Surgery and anesthesia can increase mucus production. Deep breathing and
coughing are essential to prevent atelectasis and pneumonia in the client’s only
remaining lung.
28. B. Newborns can get pneumonia (tachypnea, mild hypoxia, cough, eosinophilia) and
conjunctivitis from Chlamydia.
29. D. The client may perceive this as avoidance, but it is more important to redirect back
to the client, especially in light of the manipulative behavior of drug abusers and
adolescents.
30. C. It describes a democratic process in which all members have input in the client’s
care.
31. A. Contraction of the milk ducts and let-down reflex occur under the stimulation of
oxytocin released by the posterior pituitary gland.
32. B. In case management, the nurse assumes total responsibility for meeting the needs
of the client during the entire time on duty.
33. A. Smoke inhalation affects gas exchange.
34. C. Sperm deposited during intercourse may remain viable for about 3 days. If
ovulation occurs during this period, conception may result.
35. B. This option shows acceptance (key concept) of this age-typical sleep pattern (that
of waking in the early morning).
36. D. Taking the mother’s pulse while listening to the FHR will differentiate between the
maternal and fetal heart rates and rule out fetal Bradycardia.
37. A. Antihistamines cause pupil dilation and should be avoided with glaucoma.
38. A. This suggests that the level of consciousness is decreasing.
39. D. An advance directive is a form of informed consent, and only a competent adult or
the holder of a durable power of attorney has the right to consent or refuse
treatment. If the spouse does not hold the power of attorney, the decisions of the
holder, even if opposed by the spouse, are enforced.
40. C. Gentle but firm guidance and nonverbal direction is needed to intervene when a
client with schizophrenic symptoms is being disruptive.
41. C. Suctioning is only done for 10 seconds, intermittently, as the catheter is being
withdrawn.
42. D. The priority for this client is being able to establish an airway.
43. A. Signs of placental separation include a change in the shape of the uterus from
ovoid to globular.
44. B. This could indicate intracranial bleeding. Alteplase is a thrombolytic enzyme that
lyses thrombi and emboli. Bleeding is an adverse effect. Monitor clotting times and
signs of any gastrointestinal or internal bleeding.
45. D. Because flank incision in nephrectomy is directly below the diaphragm, deep
breathing is painful. Additionally, there is a greater incisional pull each time the
person moves than there is with abdominal surgery. Incisional pain following
nephrectomy generally requires analgesics administration every 3-4 hours for 24-48
hours after surgery. Therefore, turning, coughing and deep-breathing exercises
should be planned to maximize the analgesic effects.
46. B. Under high estrogen levels, during the period surrounding ovulation, the cervical
mucus becomes thin, clear, and elastic (spinnbarkeit), facilitating sperm passage.
47. D. After surgery for a ruptured appendix, the client should be placed in a semi-
Fowler’s position to promote drainage and to prevent possible complications.
48. C. Directing and evaluation of staff is a major responsibility of a nursing manager.
49. A. The recommended procedure for administering eyedrops to any client calls for the
drops to be placed in the middle of the lower conjunctival sac.
50. B. Thirst and restlessness indicate hypovolemia and hypoxemia. Internal bleeding is
difficult to recognized and evaluate because it is not apparent.
51. C. Erythema toxicum is the normal, nonpathological macular newborn rash.
52. D. The family needs to understand what brain death is before talking about organ
donation. They need time to accept the death of their family member. An
environment conducive to discussing an emotional issue is needed.
53. A. Bending from the waist in pregnancy tends to make backache worse.
54. B. Support and limit setting decrease anxiety and provide external control.
55. C. The stoma drainage bag is applied in the operating room. Drainage from the
ileostomy contains secretions that are rich in digestive enzymes and highly irritating to
the skin. Protection of the skin from the effects of these enzymes is begun at once.
Skin exposed to these enzymes even for a short time becomes reddened, painful and
excoriated.
56. B. It is the most accurate statement of physiological facts for a 28-day menstrual
cycle: ovulation at day 14, egg life span 24 hours, sperm life span of 72 hours.
Fertilization could occur from sperm deposited before ovulation.
57. C. An advocate role encourage freedom of choice, includes speaking out for the client,
and supports the client’s best interests.
58. A. Abstinence will eliminate any unnecessary pain during intercourse and will reduce
the possibility of transmitting infection to one’s sexual partner.
59. B. Anxiety is generated by group therapy at 9:00 AM. The ritualistic behavioral
defense of hand washing decreases anxiety by avoiding group therapy.
60. D. Denial is a very strong defense mechanism used to allay the emotional effects of
discovering a potential threat. Although denial has been found to be an effective
mechanism for survival in some instances, such as during natural disasters, it may in
greater pathology in a woman with potential breast carcinoma.
61. B. The registered nurse cannot delegate the responsibility for assessment and
evaluation of clients. The status of the client in restraint requires further assessment
to determine if there are additional causes for the behavior.
62. C. The client with chest pain may be having a myocardial infarction, and immediate
assessment and intervention is a priority.
63. B. Is correct because semen analysis requires that a freshly masturbated specimen be
obtained after a rest (abstinence) period of 48-72 hours.
64. C. Betamethasone, a form of cortisone, acts on the fetal lungs to produce surfactant.
65. A. Secretions may have pooled above the tracheostomy cuff. If these are not
suctioned before deflation, the secretions may be aspirated.
66. C. Proper handling of sputum is essential to allay droplet transference of bacilli in the
air. Clients need to be taught to cover their nose and mouth with tissues when
sneezing or coughing. Chemotherapy generally renders the client noninfectious within
days to a few weeks, usually before cultures for tubercle bacilli are negative. Until
chemical isolation is established, many institutions require the client to wear a mask
when visitors are in the room or when the nurse is in attendance. Client should be in
a well-ventilated room, without air recirculation, to prevent air contamination.
67. A. It is best to establish baseline information first.
68. B. Listening is probably the most effective response of the four choices.
69. A. Urine flow is continuous. The pouch has an outlet valve for easy drainage every 3-
4 hours. (the pouch should be changed every 3-5 days, or sooner if the adhesive is
loose).
70. C. A high fever accompanied by a body rash could indicate that the child has a
communicable disease and would have exposed other students to the infection. The
school nurse would want to investigate this telephone call immediately so that plans
could be instituted to control the spread of such infection.
71. A. Severe abdominal pain may indicate complications of pregnancy such as abortion,
ectopic pregnancy, or abruption placenta; fluid discharge from the vagina may
indicate premature rupture of the membrane.
72. D. Gentle aspiration of mucus helps maintain a patent airway, required for effective
gas exchange.
73. A. Somatoform disorders provide a way of coping with conflicts.
74. C. Immunization should never be mixed together in a syringe, thus necessitating
three separate injections in three sites. Note: some manufacturers make a premixed
combination of immunization that is safe and effective.
75. A. Clients with radioactive implants should be positioned flat in bed to prevent the time of ovulation, a slight drop in temperature may be seen, after ovulation in
dislodgement of the vaginal packing. The client may roll to the side for meals but the concert with the increasing progesterone levels of the early luteal phase, the BBT rises
upper body should not be raised more than 20 degrees. 0.2-0.4 ºC. This elevation remains until 2-3 days before menstruation, or if pregnancy
76. A. Syrup of ipecac is not administered when the ingested substances is corrosive in has occurred.
nature. Toilet bowl cleaners, as a collective whole, are highly corrosive substances. If 93. A. This choice implies concern for client care and self-improvement.
the ingested substance “burned” the esophagus going down, it will “burn” the 94. C. The first trimester is the period of organogenesis, that is, cell differentiation into
esophagus coming back up when the child begins to vomit after administration of the various organs, tissues, and structures.
syrup of ipecac. 95. C. This response does not contradict the client’s perception, is honest, and shows
77. B. Inability to open eyelids on operative side is seen with cranial nerve III damage. empathy.
78. A. Assessment of physical injuries (like bruises, lacerations, bleeding and fractures) is 96. D. Tension on round ligament occurs because of the erect human posture and
the first priority. pressure exerted by the growing fetus.
79. C. The nurse who is supervising others has a legal obligation to determine that they 97. D. The Good Samaritan Law does not impose a duty to stop at the scene of an
are competent to perform the assignment, as well as legal obligation to provide emergency outside of the scope of employment, therefore nurses who do not stop are
adequate supervision. not liable for suit.
80. D. Increasing hydrostatic pressure in the urinary tract will facilitate passage of the 98. C. Although reducing environment stimuli and activity is necessary for a woman with
calculi. mild preeclampsia, she will most probably have bathroom privileges.
81. A. Infertility is not diagnosed until atleast 12months of unprotected intercourse has 99. B. A normal respiratory rate for a newborn is 30-40 breaths per minute.
failed to produce a pregnancy. Older couples will experience a longer time to get 100. D. The behavior described is likely to be symptoms of delirium tremens, or alcohol
pregnant. withdrawal (often unsuspected on a surgical unit.)
82. B. Determining how well the kidneys filter wastes states the purpose of a Creatinine
clearance test.
83. A. Acknowledging a feeling tone is the most therapeutic response and provides a
broad opening for the client to elaborate feelings.
84. C. The behavior should be stopped. The first is to remind the staff that confidentiality
maybe violated.
85. C. With a right-sided cerebrovascular accident the client would have left-sided
hemiplegia or weakness. The client’s good side should be closest to the bed to
facilitate the transfer.
86. D. Legos are small plastic building blocks that could easily slip under the child’s cast
and lead to a break in skin integrity and even infection. Pencils, backscratchers, and
marbles are some other narrow or small items that could easily slip under the child’s
cast and lead to a break in skin integrity and infection.
87. D. Oxytocin (Pitocin) is used to maintain uterine tone.
88. B. The submission of reports about incidents that expose clients to harm does not
remove the obligation to report ongoing behavior as long as the risk to the client
continues.
89. C. The recommended dosage of tetracycline is 25-50mg/kg/day. If the child weighs
20kg and the maximum dose is 50mg/kg, this would indicate a total daily dose of
1000mg of tetracycline. In this case, the child is being given this medication four
times a day. Therefore the maximum single dose that can be given is 250mg (1000
mg of tetracycline divided by four doses.)
90. C. An abnormality in the uterine muscle could reduce the effectiveness of uterine
contractions and lengthen the duration of subsequent labors.
91. A. Personality disorders stem from a weak superego, implying a lack of adequate
controls.
92. C. The basal body temperature is the lowest body temperature of a healthy person
that is taken immediately after waking and before getting out of bed. The BBT usually
varies from 36.2 ºC to 36.3ºC during menses and for about 5-7 days afterward. About