PLT COLLEGE, INC.

Bayombong, Nueva Vizcaya

College of Nursing

Clinical Simulation Assessment (Exam Code 007)

Name: _________________________________________________ Score: ________________

Instructions: Kindly place the letter of the best answer or the best arrangement of letters
beside the number of each question. Take the exam quietly & honestly! Erasures and
superimpositions are STRICTLY not allowed. Godbless!

1. Safety of a drug is determined by the degree between:

A. Therapeutic and toxic doses C. Subtherapeutic and toxic levels
B. Potency and efficacy D. Side and adverse effects
2. When a drug binds to a receptor to produce a pharmacologic effect, the drug may
be called a(n):
A. Agonist B. Antagonist C. Blocker D. Accelerator
3. The extent to which drug is absorbed and transported to target tissue is known as:
A. Steady-state accumulation C. Bioavailability
B. Therapeutic drug levels D. Distribution
4. Distribution is affected by:
A. Biotransformation B. Excretion C. Protein binding D. Lipid binding
5. An unexpected effect of the drug is known as a(n):
A. Side effect B. Adverse effect C. Toxic reaction D. Allergic reaction
6. As a knowledgeable nurse, you know that the following are part of the five rights
except:
A. Right dose B. Right route C. Right drug D. Right room
7. When performing an assessment about medication, the drug history should include:
A. Complete vital signs C. Reason for medication
B. Client’s goal of therapy D. Administration of OTC medications
8. The volume of SC medication must be no more than:
A. 0.5 Ml B. 1.0 Ml C. 1.5 Ml D. 3.0 mL
9. Which of the following muscles is a possible site for IM injections?
A. Outer aspect of the hip B. Shoulder C. Vastus gluteus D. Vastus lateralis
10. When deciding on what time of day to give medications, the nurse pays closest
attention to the client’s habits regarding:
A. Eating B. Sleeping C. Elimination D. Activity
11. The client’s ability to take oral medications will be hindered by:
A. Age B. Dental caries C. Dysphagia D. Lifestyle
12. Which of the following will determine nursing interventions for a client on
medication?
A. Assessment B. Diagnoses C. Implementation D. Evaluation
13. When performing an assessment to determine which medications can be used,
which of the following elements is most important?
A. Physical examination B. Allergies C. Presence of illness D. Weight
14. Central venous access devices are beneficial in pediatric therapy because:
A. They are difficult to see.
B. They cannot be dislodged.
C. Use of the arms is not restricted.
D. They don’t frighten children.
15. When considering the pharmacotherapeutic effects of drugs administered to clients,
the nurse considers which property of most importance:
A. Efficacy
B. Interaction with other drugs
C. Potency
D. Toxicity
16. Doctor’s Order: Tylenol supp 1 g pr q 6 hr prn temp > 101; Available: Tylenol supp 325
mg (scored). How many supp will you administer?
A. 2 supp B. 1 supp C. 3 supp D. 5 supp
17. Doctor’s Order: Nafcillin 500 mg po pc; Available: Nafcillin 1 gm tab (scored). How
many tab will you administer per day?
A. 2.5 tabs B. 2 tabs C. 1.5 tabs D. 1 tab
18. Doctor’s Order: Synthroid 75 mcg po daily; Available: Synthroid 0.15 mg tab
(scored). How many tab will you administer?
A. 1 tab B. 0.5 tab C. 2 tabs D. 1.5 tabs
19. Doctor’s Order: Diuril 1.8 mg/kg po tid; Available: Diuril 12.5 mg caps. How many
cap will you administer for each dose to a 31 lb child?
A. 2 caps B. 2.5 caps C. 3 caps D. 1.5 caps
20. Doctor’s Order: Cleocin Oral Susp 600 mg po qid; Directions for mixing: Add 100 mL
of water and shake vigorously. Each 2.5 mL will contain 100 mg of Cleocin. How many
tsp of Cleocin will you administer?
A. 3 tsp B. 5 tsp C. 3.5 tsp D. 1 tsp
21. Doctor’s Order: Sulfasalazine Oral Susp 500 mg q 6 hr; Directions for mixing: Add 125
mL of water and shake well. Each tbsp will yield 1.5 g of Sulfasalazine. How many mL will
you give?
A. 5 ml B. 3 ml C. 4 ml D. 2 ml
22. Your patient has had the following intake: 2 ½ cups of coffee (240 mL/cup), 11.5 oz
of grape juice, ¾ qt of milk, 320 mL of diet coke, 1 ¼ L of D5W IV and 2 oz of grits. What
will you record as the total intake in mL for this patient?
A. 2,325 ml B. 3,265 ml C. 3,325 ml D. 2,235 ml
23. Your patient has had the following intake: 8 oz glasses of iced tea, 4 oz cartons
of grape juice, ¾ pt of ice cream, 32 oz of juice, 1 ½ L of D5W IV and 6 oz of
cottage cheese. What will you record as the total intake in mL for this patient?
A. 3,357 ml B. 3,375 ml C. 3,915 ml D. 3,195 ml
24. Doctor’s Order: Kantamycin 7.5 mg/kg IM q 12 hr; Available: Kantamycin 0.35
Gm/mL. How many mL will you administer for each dose to a 157 lb patient?
A. 2 ml B. 1 ml C. 2.5 ml D. 1.5 ml
25. Doctor’s Order: Heparin 7,855 units Sub Q bid; Available: Heparin 10,000 units per
ml. How many mL will you administer?
A. 0.79 ml B. 1.79 ml C. 0.17 ml D. 1.17 ml
26. Doctor’s Order: Demerol 50 mg IVP q 6 hr prn pain; Available: Demerol 75 mg/
1.3mL. How many mL will you administer?
A. 0.87 ml B. 1.87 ml C. 2 ml D. 2.87 ml
27. Doctor’s Order: Streptomycin 1.75 mg/ lb IM q 12 hr; Available: Streptomycin 0.35 g /
2.3 mL. How many mL will you administer a day to a 59 Kg patient?
A. 1.5 ml B. 2 ml C. 2.5 ml D. 3 ml
28. Doctor’s Order: Bumex 0.8 mg IV bolus bid; Reconstitution instructions: Constitute to
1000 micrograms/3.1 mL with 4.8mL of 5% Dextrose Water for Injection. How many mL
will you administer?
A. 2 ml B. 3.5 ml C. 3 ml D. 2.5 ml
29. Doctor’s Order: Tazidime 0.3 g IM tid; Reconstitution instructions: For IM solution add
1.5 mL of diluent. Shake to dissolve. Provides an approximate volume of 1.8 mL (280
mg/mL). How many mL will you give?
A. 1.9 ml B. 2 ml C. 3 ml D. 1.1 ml
30. Doctor’s Order: Infuse 50 mg of Amphotericin B in 250 mL NS over 4 hr 15 min; Drop
factor: 12gtt/mL. What flow rate (mL/hr) will you set on the IV infusion pump?
A. 11.8 ml/hr B. 58.8 ml/hr C. 14.1 ml/hr D. 60.2 ml/hr
31. Doctor’s Order: 1 ½ L of NS to be infused over 7 hours; Drop factor: 15 gtt/mL. What
flow rate (mL/hr) will you set on the IV infusion pump?
A. 53.6 ml/hr B. 214.3 ml/hr C. 35.7 ml/hr D. 142.9 ml/hr
32. Doctor’s Order: Mandol 300 mg in 50 mL of D5W to infuse IVPB 15 minutes; Drop
factor: 10 gtt/mL. How many mL/hr will you set on the IV infusion pump?
A. 200 ml/hr B. 87.5 ml/hr C. 3.3 ml/hr D. 50 ml/hr
33. Doctor’s Order: Infuse 1200 mL of 0.45% Normal Saline at 125 mL/hr; Drop Factor:
12gtt/min. How many gtt/min will you regulate the IV?
A. 2 gtt/min B. 12 gtt/min C. 25 gtt/min D. 27 gtt/min
34. Doctor’s Order: Rocephin 0.5 grams in 250 mL of D5W to infuse IVPB 45 minutes; Drop
Factor: 12gtt/min. How many gtt/ min will you regulate the IVPB?
A. 6 gtt/min B. 30 gtt/min C. 67 gtt/min D. 87 gtt/min
35. Doctor’s Order: ¼ L of D5W to infuse over 2 hr 45 min; Drop factor: 60 gtt/mL. How
many gtt/min will you regulate the IV?
A. 91 gtt/min B. 96 gtt/min C. 125 gtt/min D. 142 gtt/min
36. Doctor’s Order: Minipress 3000 mcg po ac; Available: Minipress tabs 2 mg
(scored). How many tab will you administer in 24 hr?
A. 1.5 tabs B. 3 tabs C. 4.5 tabs D. 5 tabs
37. Doctor’s Order: Dilantin 0.75 gm po stat; Available: Dilantin 250 mg cap. How many
cap will you administer?
A. 1 cap B. 2 caps C. 3 caps D. 4 caps
38. Doctor’s Order: Digoxin 0.25 mg po daily; Available: Digoxin 125 mcg tabs
(scored). How many tab will you administer for this dose?
A. 1 tabs B. 2 tabs C. 3 tabs D. 4 tabs
39. Doctor’s Order: Klotrix 0.35 mEq/ lb po dissolved in 6 oz of oj at 8 am; Available:
Klotrix 8 mEq/mL. How many mL of Klotrix will you add to the oj for a 20.5 Kg patient?
A. 0.5 ml B. 1 ml C. 2 ml D. 2.5 ml
40. Doctor’s Order: Megace Oral Suspension 160 mg po bid; Directions for mixing: Add
100 mL of water and shake vigorously. Each 0.5 mL will contain 10.7 mg of
Megace. How many tbsp of Megace will you administer?
A. 0.5 tbsp B. 2.5 tbsp C. 3.5 tbsp D. 5 tbsp
41. Doctor’s Order: Vistaril Oral Susp 10 mg q 4 hr prn for anxiety; Directions for mixing:
Add 125 mL of water and shake well. Each tsp will yield 15 mg of Vistaril. How many mL
will you give?
A. 1 ml B. 1.3 ml C. 3 ml D. 3.3 ml
42. Your patient had the following intake: 2 1/2 bowls of broth (180 mL/bowl), 1 can
of tomato juice (4.5 oz/can ), 4 oz of cottage cheese, 1 ¾ L of NS IV and ½ pt of ice
cream. What will you record as the total intake in mL for this patient?
A. 2,858 ml B. 2,585 ml C. 2,705 ml D. 2,505 ml
43. Your patient has had the following intake: ½ cup of hot tea (240 mL/cup), 3/4
container of grapefruit juice (4 oz/container), 3/4 qt of milk, 1 pt of water, 125 mL of D5W
IV x 8 hr and 2 oz of fruit cocktail. What will you record as the total intake in mL for this
patient?
A. 2,460 ml B. 2,640 ml C. 2,520 ml D. 2,250 ml
44. Doctor’s Order: Tobramycin 1.25mg/Kg IM q 12 hr; Available: Tobramycin 0.2
g/mL. How many mL will you administer to a 183 lb patient for each dose?
A. 0.52 ml B. 1.52 ml C. 2 ml D. 4 ml
45. Doctor’s Order: Heparin 4,390 units Sub Q bid; Available: Heparin 5,000 USP units per
ml in 10 ml. How many mL will you administer?
A. 8.8 ml B. 0.88 ml C. 1.88 ml D. 0.18 ml
46. Doctor’s Order: Penicillin G 223,500 units IM q 4 hr; Available: Penicillin G 500,000
units /2.5 mL. How many mL will you administer?
A. 0.4 ml B. 2 ml C. 1.1 ml D. 2.4 ml
47. Doctor’s Order: Amikacin 5 mg/ lb IM q 12 hr; Available: Amikacin 0.9 gm/ 2
mL. How many mL will you administer to a 72.7 Kg patient?
A. 0.9 ml B. 3 ml C. 5 ml D. 1.8 ml
48. Doctor’s Order: Fentanyl 0.05 mg IV bolus; Reconstitution instructions: Constitute to
Fentanyl 100 micrograms/2.3 mL with 2.4 mL of 5% Dextrose Water for Injection. How
many mL will you administer?
A. 0.01 ml B. 0.1 ml C. 1 ml D. 1.2
49. Doctor’s Order: Ancef 0.4253 Gm IM bid; Reconstitution instructions: For IM solution
add 1.25 mL of diluent. Shake to dissolve. Provides an approximate volume of 1.6 mL
(240 mg/mL). How many mL will you give?
A. 0.8 ml B. 1.8 ml C. 2.2 ml D. 3.2 ml
50. Doctor’s Order: Infuse 250 mL of platelets IV over 2 hr 30 min; Drop factor: 10
gtt/mL. What flow rate (mL/hr) will you set on the IV infusion pump?
A. 10 ml/hr B. 100 ml/hr C. 50 ml/hr D. 150 ml/hr
51. Doctor’s Order: 1 ¼ L of D5 with Ringer’s lactate to be infused over 18 hours; Drop
factor: 20 gtt/mL. What flow rate (mL/hr) will you set on the IV infusion pump?
A. 1.2 ml/hr B. 23.1 ml/hr C. 69.4 ml/hr D. 20 ml/hr
52. Doctor’s Order: Zantac 150 mg in 175 mL of D5W to infuse IVPB over 45 minutes; Drop
factor: 12 gtt/mL. How many mL/hr will you set on the IV infusion pump?
A. 7.2 ml/hr B. 233.3 ml/hr C. 86.7 ml/hr D. 433.3 ml/hr
53. Doctor’s Order: Infuse 2750 mL of 0.45% Normal Saline at 150 mL/hr; Drop Factor: 15
gtt/mL. How many gt/mL will you regulate the IV?
A. 46 gtt/min B. 38 gtt/min C. 48 gtt/min D. 36 gtt/min
54. Doctor’s Order: Cefoxin 0.5 Gm in 275 mL of D5W to infuse IVPB over 2 hours; Drop
Factor: 60 gtt/mL. How many gtt/min will you regulate the IV?
A. 200 gtt/min B. 150 gtt/min C. 257 gtt/min D. 138 gtt/min
55. Doctor’s Order: ¾ L of D5W to infuse over 5 hr 45 min; Drop factor: 60 gtt/mL. How
many gtt/min will you regulate the IV?
A. 12.5 gtt/min B. 75.5 gtt/min C. 375/ gtt/min D. 130 gtt/min
56. A nurse provides medication instructions to a first-time mother. Which statement
made by the mother indicates a need for further instructions?
A. “I should mix the medication in the baby food and give it when I feed the child”.
B. “I should administer the oral medication sitting in an upright position and with the
head elevated”.
C. “I will give my child a toy after giving the medication”.
D. “I will offer my child a juice drink after swallowing the medication”.
57. A nurse prepares to administer an intramuscular injection to a 6-month-old infant.
The nurse selects which site to administer the medication?
A. Rectus femoris. B. Dorsal gluteal. C. Ventrogluteal. D. Vastus lateralis.
58. A nurse prepares to administer a 3ml injection via intramuscular injection to a 5-
year-old child. The nurse selects which site to administer the medication?
A. Rectus femoris. B. Deltoid. C. Ventrogluteal. D. Vastus lateralis.
59. A nurse is providing instructions to a mother who has a child with congestive heart
failure regarding Digoxin (Lanoxin). Which statement made by the mother indicates
further teaching?
A. “I will administer the medication 1 hour before or 2 hours after meal”.
B. “I will use a special dose-measuring spoon or cup, not a regular table spoon for the
liquid preparation”.
C. “If my child vomits after administration, I will repeat the dose”.
D. “If more than one dose is missed, I will inform the physician”.
60. A physician prescribes an IV solution of 500 ml 0.45% Saline with an incorporation of
20mEq potassium chloride for a child with dehydration. The nurse should check which of
the following before administering this IV prescription?
A. Blood pressure. B. Height. C. Weight. D. Urine output.
61. A child was brought to the emergency department with complaints of nausea,
vomiting, fruity-scented breath. The resident on duty diagnosed the child
with diabetes ketoacidosis. Which of the following should the nurse expect to
administer?
A. Potassium chloride IV infusion.
B. Dextrose 5% IV infusion.
C. Ringer’s Lactate.
D. Normal saline IV infusion.
62. A 1-year-old child is diagnosed with scabies. Which of the following medicine is
expected to be prescribed?
A. Permethrin. B. Lindane. C. Both. D. None.
63. A nurse is monitoring the intake and output of an infant receiving furosemide (Lasix)
IV. Which of the following method is the most appropriate in measuring the urine
output?
A. Ask the mother regarding the number of diaper changes.
B. Compare intake with output.
C. Weighing the diaper.
D. Insert Foley catheter.
64. An infant with a patent ductus arteriosus is admitted to the pediatric unit ward. The
nurse anticipates which of the following medications will be given to the infant?
A. Prednisone. B. Ibuprofen. C. Penicillin. D. Albuterol.
65. Hydrocortisone cream 1% is given to a child with eczema. The nurse gives
instruction to the mother to apply the cream by?
A. Apply a thin layer of cream and spread it into the area thoroughly.
B. Avoid cleansing the area before the application.
C. Apply a thick layer of the cream to affected areas only.
D. Apply the cream to other areas to avoid occurrence.
66. The nurse is giving instructions to a mother with a child receiving a liquid oral iron
supplement. The nurse tells the mother to:
A. Take it with meals. C. Mix it with milk.
B. Mix it with food. D. Administer it using a straw.
67. A child with β-thalassemia is undergoing a blood transfusion. To prevent organ
damage from the excessive amount of iron, chelation therapy is prescribed. Which of
the following medications will be added to this therapy?
A. Dextromethorphan. B. Desirudin. C. Deferasirox. D. Desipramine.
68. A child with Kawasaki disease is admitted to the pediatric ward. Which of the
following medications will you expect to be a part of the treatment? Which among the
following medications should you not give.
A. Gamma Globulin. B. Warfarin. C. Acetaminophen D. Aspirin.
69. A child with known hemophilia A was brought to the emergency room with
complaints of nose bleeding and some bruises in the joints. Which of the following
should the nurse anticipate to be given to the child?
A. Oral iron supplement. C. Factor X.
B. Cyclosporine. D. Factor VIII
70. The nurse is reviewing the child’s record who is scheduled to receive inactivated
polio vaccine (IPV). Which of the following would prompt the nurse to withhold the
administration?
A. History of upper respiratory infections.
B. History of an anaphylactic reaction to streptomycin.
C. History of recent diarrheal episodes.
D. History of redness at the previous injection site.
71. A 4 month-year-old infant has just received diphtheria, tetanus, and acellular
pertussis (DtaP). Hours later, the mother report to the clinic because her child develops
redness and swelling at the injection site. The nurse instructs the mother to do which of
the following?
A. Application of cold compress.
B. Application of hot compress.
C. Monitor for signs of fever.
D. Report to the clinic for a repeat injection on the other site.
72. A 6-year-old child is scheduled to have measles, mumps, and rubella (MMR)
vaccine. Which of the following route will you expect the nurse to administer the
vaccine?
A. Intramuscularly in the vastus lateralis muscle.
B. Intramuscularly in the deltoid muscle.
C. Subcutaneously in the gluteal area.
D. Subcutaneously in the outer aspect of the upper arm.
73. Which of the following is not true regarding varicella vaccine?
A. It is administered subcutaneously.
B. Children 13 years and older (With no history of chickenpox or have not previously
vaccinated) need two doses given at least 28 days apart.
C. Give aspirin for any injection-related pain.
D. The most common mild side effects are pain, redness, or swelling at the injection site.
74. A nurse is handling a child who is on a Furosemide (Lasix) IV infusion. The nurse
instruct the mother to encourage the child to eat which of the following?
A. Apricot and baked potato skin.
B. Bread and butter.
C. Gelatin and Cauliflower.
D. Ginger ale and cereal.
75. An unconscious child is brought to the emergency room due to Tylenol poisoning.
Which of the following is the most appropriate nursing action?
A. Administer mucomyst P.O.
B. Gastric lavage with activated charcoal.
C. Gastric Lavage with activated charcoal and mucomyst.
D. Administer ethylenediaminetetraacetic acid (EDTA).
76. Once a nurse assesses a client’s condition and identifies appropriate nursing
diagnoses, a:
A. Plan is developed for nursing care.
B. Physical assessment begins
C. List of priorities is determined.
D. Review of the assessment is conducted with other team members.
77. Planning is a category of nursing behaviors in which:
A. The nurse determines the health care needed for the client.
B. The Physician determines the plan of care for the client.
C. Client-centered goals and expected outcomes are established.
D. The client determines the care needed.
78. Priorities are established to help the nurse anticipate and sequence nursing
interventions when a client has multiple problems or alterations. Priorities are
determined by the client’s:
A. Physician C. Future well-being.
B. Non Emergent, non-life threatening needs D. Urgency of problems
79. A client centered goal is a specific and measurable behavior or response that
reflects a client’s:
A. Desire for specific health care interventions
B. Highest possible level of wellness and independence in function.
C. Physician’s goal for the specific client.
D. Response when compared to another client with a like problem.
80. For clients to participate in goal setting, they should be:
A. Alert and have some degree of independence.
B. Ambulatory and mobile.
C. Able to speak and write.
D. Able to read and write.
81. The nurse writes an expected outcome statement in measurable terms. An example
is:
A. Client will have less pain.
B. Client will be pain free.
C. Client will report pain acuity less than 4 on a scale of 0-10.
D. Client will take pain medication every 4 hours around the clock.
82. As goals, outcomes, and interventions are developed, the nurse must:
A. Be in charge of all care and planning for the client.
B. Be aware of and committed to accepted standards of practice from nursing and
other disciples.
C. Not change the plan of care for the client.
D. Be in control of all interventions for the client.
83. When establishing realistic goals, the nurse:
A. Bases the goals on the nurse’s personal knowledge.
B. Knows the resources of the health care facility, family, and the client.
C. Must have a client who is physically and emotionally stable.
D. Must have the client’s cooperation.
84. To initiate an intervention the nurse must be competent in three areas, which
include:
A. Knowledge, function, and specific skills
B. Experience, advanced education, and skills.
C. Skills, finances, and leadership.
D. Leadership, autonomy, and skills.
85. Collaborative interventions are therapies that require:
A. Physician and nurse interventions.
B. Nurse and client interventions.
C. Client and Physician intervention.
D. Multiple health care professionals.
86. Well formulated, client-centered goals should:
A. Meet immediate client needs.
B. Include preventative health care.
C. Include rehabilitation needs.
D. All of the above.
87. The following statement appears on the nursing care plan for an immunosuppressed
client: The client will remain free from infection throughout hospitalization. This statement
is an example of a (an):
A. Nursing diagnosis B. Short-term goal C. Long-term goal D. Expected outcome
88. The following statements appear on a nursing care plan for a client after a
mastectomy: Incision site approximated; absence of drainage or prolonged erythema
at incision site; and client remains afebrile. These statements are examples of:
A. Nursing interventions C. Long-term goals
B. Short-term goals D. Expected outcomes.
89. The planning step of the nursing process includes which of the following activities?
A. Assessing and diagnosing
B. Evaluating goal achievement.
C. Performing nursing actions and documenting them.
D. Setting goals and selecting interventions.
90. The nursing care plan is:
A. A written guideline for implementation and evaluation.
B. A documentation of client care.
C. A projection of potential alterations in client behaviors
D. A tool to set goals and project outcomes.
91. After determining a nursing diagnosis of acute pain, the nurse develops the
following appropriate client-centered goal:
A. Encourage client to implement guided imagery when pain begins.
B. Determine effect of pain intensity on client function.
C. Administer analgesic 30 minutes before physical therapy treatment.
D. Pain intensity reported as a 3 or less during hospital stay.
92. When developing a nursing care plan for a client with a fractured right tibia, the
nurse includes in the plan of care independent nursing interventions, including:
A. Apply a cold pack to the tibia.
B. Elevate the leg 5 inches above the heart.
C. Perform range of motion to right leg every 4 hours.
D. Administer aspirin 325 mg every 4 hours as needed.
93. Which of the following nursing interventions are written correctly? Select all that
apply.
A. Apply continuous passive motion machine during day.
B. Perform neurovascular checks.
C. Elevate head of bed 30 degrees before meals.
D. Change dressing once a shift.
94. A client’s wound is not healing and appears to be worsening with the current
treatment. The nurse first considers:
A. Notifying the physician.
B. Calling the wound care nurse
C. Changing the wound care treatment.
D. Consulting with another nurse.
95. When calling the nurse consultant about a difficult client-centered problem, the
primary nurse is sure to report the following:
A. Length of time the current treatment has been in place.
B. The spouse’s reaction to the client’s dressing change.
C. Client’s concern about the current treatment.
D. Physician’s reluctance to change the current treatment plan.
96. The primary nurse asked a clinical nurse specialist (CNS) to consult on a difficult
nursing problem. The primary nurse is obligated to:
A. Implement the specialist’s recommendations.
B. Report the recommendations to the primary physician.
C. Clarify the suggestions with the client and family members.
D. Discuss and review advised strategies with CNS.
97. After assessing the client, the nurse formulates the following diagnoses. Place them
in order of priority, with the most important (classified as high) listed first.
A. Constipation
B. Anticipated grieving
C. Ineffective airway clearance
D. Ineffective tissue perfusion.
98. The nurse is reviewing the critical paths of the clients on the nursing unit. In
performing a variance analysis, which of the following would indicate the need for
further action and analysis?
A. A client’s family attending a diabetic teaching session.
B. Canceling physical therapy sessions on the weekend.
C. Normal VS and absence of wound infection in a post-op client.
D. A client demonstrating accurate medication administration following teaching.
99. The RN has received her client assignment for the day-shift. After making the initial
rounds and assessing the clients, which client would the RN need to develop a care
plan first?
A. A client who is ambulatory.
B. A client, who has a fever, is diaphoretic and restless.
C. A client scheduled for OT at 1300.
D. A client who just had an appendectomy and has just received pain medication.
100. Which of the following statements about the nursing process is most accurate?
A. The nursing process is a four-step procedure for identifying and resolving patient
problems.
B. Beginning in Florence Nightingale’s days, nursing students learned and practiced the
nursing process.
C. Use of the nursing process is optional for nurses, since there are many ways to
accomplish the work of nursing.
D. The state board examinations for professional nursing practice now use the nursing
process rather than medical specialties as an organizing concept.
RATIONALE (Exam Code 007)

1. Answer: A. Therapeutic and toxic doses

Safety is determined by the degree between therapeutic and toxic doses. Potency and
efficacy are not related to safety. Subtherapeutic levels are not part of safety
determinations because if a drug is subtherapeutic it does not exert any desired effect.
Side effects are expected, and adverse effects are often the result of toxicity.
2. Answer: A. Agonist
An agonist is the action described in the stem. B and C are synonymous. ELiminate
choice D because there is no such action described in drug nomenclature.
3. Answer: C. Bioavailability
Bioavailability is the extent to which a drug is absorbed and transported to target tissue.
Steady-state accumulation means that the amount of drug present is sufficient to exert
its therapeutic effect. Therapeutic drug levels are serum blood tests used to measure
the amount of circulating drug present. Distribution is the process by which drugs are
transported to tissues.
4. Answer: C. Protein binding
Distribution depends on protein binding as well as circulation. Biotransformation is the
act of metabolizing the drug. Excretion describes the act of eliminating the drug. There
is no such thing as lipid binding.
5. Answer: B. Adverse effect
An adverse reaction is a harmful and unexpected reaction. A side effect is expected
and predictable. C and D are incorrect because a toxic reaction is a type of adverse
reaction.
6. Answer: D. Right room
Right room is not one of the five rights.The five rights are right client, route, dose, drug,
and time.
7. Answer: D. Administration of OTC medications
The nurse should determine if the client is taking any other medications, especially OTC
medications because their effects are often minimized. Other choices are important
part of assessment, but choice D is the most accurate answer.
8. Answer: B. 1.0 mL
The maximum amount of fluid that can be injected into the SC space is 1.0 mL.
9. Answer: D. Vastus lateralis
Possible injection sites for IM administration include ventrogluteal, deltoid, dorsogluteal,
vastus lateralis, and rectus femoris.
10. Answer: A. Eating
Eating is the most important of these because food in the stomach must be a
consideration.
11. Answer: C. Dysphagia
Dysphagia is difficulty swallowing. This would make administration of oral medications
impossible. Other choices do not impair ingestion.
12. Answer: B. Diagnoses
The nursing diagnosis is the conclusion derived from the assessment, and it is the
component of the nursing process that drives the interventions.
13. Answer: B. Allergies
Allergies must be determined so that the nurse does not administer a drug that would
be dangerous to the client.
14. Answer: C. Use of the arms is not restricted.
The child can move his extremities and function in a normal fashion. This lessens stress
associated with position restriction and promotes normal activity. Fear may not be
eliminated. All lines can be dislodged. Even small catheters can be readily seen.
15. Answer: A. Efficacy
In pharmacology, efficacy is the maximum response achievable from a drug.
16. Answer: C. 3 supp

1 g = 1000 mg

17. Answer: C. 1.5 tabs

1 g = 1,000 mg
18. Answer: B. 0.5 tab
1 mg = 1,000 mcg

19. Answer: A. 2 caps

31 lbs = 14 kg
1.8 mg/kg x 14 kg = 25.2 mg or 25 mg (per dose)

20. Answer: A. 3 tsp

21. Answer: A. 5 ml
1 tbsp = 15 ml

22. Answer: B. 3,265 ml

1 qt = 1,000 ml
1 oz = 30 ml
600 ml + 345 ml + 750 ml + 320 ml + 1,250 ml = 3,265 ml (Grits is not liquid at room
temperature, so it is not included when calculating intake.)
23. Answer: D. 3,195 ml
1 pt = 500 ml
1 oz = 30 ml
240 ml + 120 ml + 375 ml + 960 ml + 1,500 ml = 3,195 ml (Cottage cheese is not liquid at
room temperature, so it is not included when calculating intake.)
24. Answer: D. 1.5 ml
157 lbs = 71.36 kg or 71 kg
7.5 mg/kg x 71 kg = 532.5 mg

25. Answer: A. 0.79 ml

26. Answer: A. 0.87 ml

27. Answer: D. 3 ml
59 kg = 130 lbs
1.75 mg/lbs x 130 lbs = 227.5 mg

1.5 ml x 2 = 3 ml
28. Answer: D 2.5 ml
1 mg = 1,000 mcg

l
29. Answer: D. 1.1 ml

30. Answer: B. 58.8 ml/hr

4 hr 15 min = 4.25 hrs [4 hrs + (15 mins÷60 mins)]

31. Answer: B. 214.3 ml/hr

32. Answer: A. 200 ml/hr

15 min = 0.25 hr

33. Answer: C. 25 gtt/min

34. Answer: C. 67 gtt/min

35. Answer: A. 91 gtt/min

36. Answer: C. 4.5 tabs

37. Answer: C. 3 caps

38. Answer: B. 2 tabs

39. Answer: C. 2 ml
20.5 kg x 2.2 lbs = 45.1 lbs
45.1 lbs x 0.35 0.35 mEq/lb = 15.8 mEq/lb

40. Answer: A. 0.5 tbsp

41. Answer: D. 3.3 ml

42. Answer: B. 2,585 ml

1 oz = 30 ml
1 pt = 500 ml
450 ml + 135 ml + 1,750 ml + 250 ml = 2,585 ml (Cottage cheese is not liquid at room
temperature, so it is not included when calculating intake.)
43. Answer: A. 2460
1 oz = 30 ml
1 qt = 1000 ml
120 ml + 90 ml + 750 ml + 500 ml + 1,000 ml = 2,460 ml (Fruit cocktail is not liquid at room
temperature, so it is not included when calculating intake.)
44. Answer: A. 0.52 ml
183 lb = 83.2 kg
83.2 kg x 1.25 mg/kg = 104 mg

45. Answer: B. 0.88 ml

46. Answer: C. 1.1 ml

47. Answer: D. 1.8 ml

72.7 x 2.2 = 160 lb
5 mg/lb x 160 lb = 800 mg (per dose)

48. Answer: D. 1.2

49. Answer: B. 1.8 ml

50. Answer: B. 100 ml/hr

51. Answer: C. 69.4 ml/hr

52. Answer: B. 233.3 ml/hr

53. Answer: B. 38 gtt/min

54. Answer: D. 138 gtt/min
2 hrs x 60 mins = 120 mins

55. Answer: D. 130 gtt/min

5 hrs x 60 = 300 mins + 45 mins = 345 mins

56. Answer: A. “I should mix the medication in the baby food and give it when I feed the
child”.
The nurse would teach the mother to avoid putting medications in foods because it
may cause an unpleasant taste to the food, and the child may refuse to accept the
same food in the future. Additionally, the child may not consume the entire serving and
would not receive require medication dosage.
Option B: Administering the medication in an upright position and head elevation will
prevent the risk of aspiration.
Option C: Offering a toy will provide comfort measures to the child.
Option D: The mother should offer drink such as juice or a soft drink to lessen the
aftertaste of the medication.
57. Answer: D. Vastus lateralis.
Intramuscular injection sites are selected based on the child’s age and muscle
development of the child. The vastus lateralis is the only safe muscle group to use for
intramuscular injection in a 6 month-old infant.
Options A, B, and D are unsafe for that age.
58. Answer: C. Ventrogluteal.
Intramuscular injection sites are chosen based on the child’s age and muscle
development of the child. The ventrogluteal muscle is the ideal choice to administer
0.5ml-3ml amount of injection on a 3-12-year-old child.
Options A and D only allows 2ml amount of injection.
Option B allows 0.5-1ml amount of injection.
59. Answer: C. “If my child vomits after administration, I will repeat the dose”.
Digoxin is a cardiac glycoside. The mother needs to be instructed not to repeat the
dose once the child vomits it.
Options A, B, and D are correct instructions regarding this medicine.
60. Answer: D. Urine output.
When it comes to hypotonic dehydration, electrolyte loss exceeds water loss. The
priority assessment for the nurse is to check the urinary output before the administration.
Potassium chloride is contraindicated for patients with oliguria or anuria.
Options A, B, and C are not related to the administration of this medicine.
61. Answer: D. Normal saline IV infusion.
The initial priority in the treatment of diabetic ketoacidosis is the restoration
of extracellular fluid volume through the intravenous administration of a normal
saline(0.9 percent sodium chloride) solution.
Option A is not part of the initial treatment.
Options B and C which are dextrose solutions will be used only when the
blood glucose level is decreased.
62. Answer: A. Permethrin.
Permethrin and Lindane are used against scabies, but lindane is contraindicated for
children below two years old because of the risk of seizures and neurotoxicity.
63. Answer: C. Weighing the diaper.
The most appropriate method for measuring urine output of an infant is by weighing the
diaper.
Options A and B will not provide the accurate measure of the urine output.
Option D: Inserting a foley catheter will provide the most accurate measurement but it
gives the infant the risk of urinary tract infection.
64. Answer: B. Ibuprofen.
When surgical ligation is not indicated, prostaglandin inhibitors (e.g., nonsteroid anti-
inflammatory drugs [NSAIDs]) are used to close the ductus arteriosus.
Options A, C, and D are not used for the management of patent ductus arteriosus.
65. Answer: A. Apply a thin layer of cream and spread it into the area thoroughly.
Topical corticosteroids are administered sparingly and rubbed into the area thoroughly.
Option B: The area should be cleaned first before administration.
Options C and D: Thickly application and rubbing it on other areas will likely lead to
systemic absorption.
66. Answer: D. Administer it using a straw.
An oral liquid iron supplement should be given with a straw because the medicine
will stain the teeth.
Option A: Taking it with meals will decrease the absorption.
Options B and C: Iron is not mixed with any food/drink.
67. Answer: C. Deferasirox.
Chelation therapy with deferasirox (Exjade) or deferoxamine (Desferal) is prescribed to
prevent organ damage from the presence of too much iron in the body as a result of
the transfusion.
Option A is a cough suppressant.
Option B is a thrombin inhibitor.
Option D is an antidepressant.
68. Answer: C. Acetaminophen
The principal goal of treatment for Kawasaki disease is to prevent coronary
artery disease and to relieve symptoms such as fever and joint pain so an antipyretic,
antiplatelet, and gamma globulin is used. Acetaminophen can be given but
researches would say that its not so effective
Option C is antipyretic but is not responsive to this disease.
Option D is a beta blocker.
69. Answer: D. Factor VIII
Hemophilia A, also called factor VIII (FVIII) deficiency or classic hemophilia, is a genetic
disorder caused by missing or defective factor VIII, a clotting protein. The initial
treatment is the administration of factor VIII to replace the missing factor and decreases
the bleeding episode.
Options A, B, and C are not used in this case.
70. Answer: B. History of an anaphylactic reaction to streptomycin.
Inactivated polio vaccine (IPV) contains a trace amount of streptomycin, neomycin,
and polymyxin.
Options A, C, and D are not contraindicated with this vaccine.
71. Answer: A. Application of cold compress.
Redness, tenderness or swelling may happen at the site of injection. This will be relieved
through cool application for the first 24 hours, followed by warm compress if
inflammation persists.
Options B, C, and D are inappropriate intervention.
72. Answer: D. Subcutaneously in the outer aspect of the upper arm.
(MMR) the vaccine is administered subcutaneously in the outer aspect of the upper
arm.
Options A and B: MMR is not administered intramuscularly.
Option C: Gluteal area is not used as a site.
73. Answer: C. Give aspirin for any injection-related pain.
Children receiving varicella vaccine should avoid aspirin or aspirin containing products
because of the risk of Reye’s syndrome.
74. Answer: A. Apricot and baked potato skin.
One of the side effects of taking furosemide is hypokalemia, so a supplemental food
rich in potassium is encouraged.
Options B, C, and D are low in potassium.
75. Answer: B. Gastric lavage with activated charcoal.
In an unconscious child with Tylenol poisoning, the priority intervention is to administer
gastric lavage with activated charcoal to decrease the absorption of Tylenol.
Option A is not correct due to the risk of aspiration.
Option C: Activated charcoal inactivates mucomyst.
Option D is the drug of choice for lead poisoning.
76. Answer: A. Plan is developed for nursing care.
77. Answer: C. Client-centered goals and expected outcomes are established.
78. Answer: D. Urgency of problems
79. Answer: B. Highest possible level of wellness and independence in function.
80. Answer: A. Alert and have some degree of independence.
81. Answer: C. Client will report pain acuity less than 4 on a scale of 0-10.
82. Answer: B. Be aware of and committed to accepted standards of practice from
nursing and other disciples.
83. Answer: B. Knows the resources of the health care facility, family, and the client.
84. Answer: A. Knowledge, function, and specific skills
85. Answer: D. Multiple health care professionals.
86. Answer: D. All of the above.
87. Answer: B. Short-term goal
88. Answer: D. Expected outcomes.
89. Answer: D. Setting goals and selecting interventions.
90. Answer: A. A written guideline for implementation and evaluation.
91. Answer: D. Pain intensity reported as a 3 or less during hospital stay.
This is measurable and objective.
92. Answer: B. Elevate the leg 5 inches above the heart.
This does not require a physician’s order. A and D require an order; C is not appropriate
for a fractured tibia.
93. Answer: C. Elevate head of bed 30 degrees before meals.
It is specific in what to do and when.
94. Answer: B. Calling the wound care nurse
Calling in the wound care nurse as a consultant is appropriate because he or she is a
specialist in the area of wound management. Professional and competent nurses
recognize limitations and seek appropriate consultation. Option A may be appropriate
after deciding on a plan of action with the wound care nurse specialist. The nurse may
need to obtain orders for special wound care products. Option C is possible unless the
nurse is knowledgeable in wound management, this could delay wound healing. Also,
the current wound management plan could have been ordered by the physician. As
for Option D, another nurse most likely will not be knowledgeable about wounds, and
the primary nurse would know the history of the wound management plan.
95. Answer: A. Length of time the current treatment has been in place.
This gives the consulting nurse facts that will influence a new plan. Other choices are
subjective and emotional issues and conclusions about the current treatment plan may
cause bias in the decision of a new treatment plan by the nurse consultant.
96. Answer: D. Discuss and review advised strategies with CNS.
The primary nurse requested the consultation, it is important that they communicate
and discuss recommendations. The primary nurse can then accept or reject the CNS
recommendations.
Option A: Some of the recommendations may not be appropriate for this client. The
primary nurse would know this information. A consultation requires review of the
recommendations, but not immediate implementation.
Option B: This would be appropriate after first talking with the CNS about
recommended changes in the plan of care and the rationale. Then the primary nurse
should call the physician.
Option C: The client and family do not have the knowledge to determine whether new
strategies are appropriate or not. Better to wait until the new plan of care is agreed
upon by the primary nurse and physician before talking with the client and/or family.
97. Answer: C, D, A, B.
98. Answer: B. Canceling physical therapy sessions on the weekend.
99. Answer: B. A client, who has a fever, is diaphoretic and restless.
This client’s needs are a priority.
100. Answer: D. The state board examinations for professional nursing practice now use
the nursing process rather than medical specialties as an organizing concept.
Option A: The nursing process is a five-step process. Option B: The term nursing process
was first used by Hall in 1955. Option C: Nursing process is not optional since standards
demand the use of it.