9/ January / 2020 Educational department

Universal Hospital
Department of Nursing
Kindly, choose the letter of the best single answer and wright it in the answer sheet given.

1) A patient is attached to EKG monitor and the nurse notes the rhythm observed on the
electrocardiogram (EKG) does not produce a pulse. Which actions should the healthcare provider
initiate to resolve this patient’s problem?

A. Administration of IV crystalloid.
B. Cardiopulmonary resuscitation (CPR).
C. Synchronized cardioversion.
D. Defibrillation.
2) A nurse is assessing an electrocardiogram rhythm strip. The P waves and QRS complexes are
regular. The PR interval is 0.16 second. And QRS complexes measure 0.06 second. The overall heart
rate is 64 beats per minute. The nurse assesses the cardiac rhythm as:
A. Normal sinus rhythm

B. Sinus bradycardia

C. Sick sinus syndrome

D. First-degree heart block.

3) A nurse notices frequent artifact on the ECG monitor for a client whose leads are connected by
cable to a console at the bedside. The nurse examines the client to determine the cause. Which of the
following items is unlikely to be responsible for the artifact?
A. Frequent movement of the client

B. Tightly secured cable connections

C. Leads applied over hairy areas

D. Leads applied to the limbs

4) A 38-year-old female is brought to the Emergency Department with complaints of her "heart
beating out of her chest" (palpitations) . She is diaphoretic, tachypneic and her BP is 70/40. The
cardiac monitor shows supraventricular tachycardia. Valsalva maneuvers and three doses of
Adenosine have not been successful. The nurse should immediately:

A.) prepare the patient for synchronized cardioversion.

B.) give Epinephrine 1 mg IV and repeat in 3 minutes.

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C.) give Adenosine 6 mg IV per protocol.

D.) perform unilateral carotid massage.
5) P wave represents:

A. Depolarization of right ventricle

B. Depolarization of both atria

C. Depolarization of left ventricle

D. Atria to ventricular conduction time

6) Identify the rhythm

A. Bradycardia

B. Normal ECG

C. Tachycardia

D. First degree heart block

7) Identify the rhythm.

A. Ventricular tachycardia.
B. Atrial fibrillation.
C. Ventricular fibrillation.
D. Supraventricular tachycardia.

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8) Identify the rhythm bellow:

A. Second degree AV block mobitz II

B. Complete heart block. 3th degree

C. First degree heart block

D. Normal sinus rhythm.

9) Which of the following does not refer to the process of adding written information to a health care
record?

A. Recording

B. Charting

C. Data entry

D. Documenting

10) Which of the following is considered a traditional charting?

A. Narrative

B. Problem Oriented Medical Record

C. SOAP

D. DARE

11) What is the difference between Traditional and Problem Oriented medical Record charting?

A . Traditional uses an abbreviated story form. POMR uses an outline form

B. Traditional uses SOAPE charting. Problems oriented medical record uses narrative charting

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C. Traditional uses blocks. POMR uses sections.

D. Traditional focuses on interventions. POMR focuses on interventions.

12) The SBAR document is useful for:

A. Hand-off communication

B. Admission and transfer communication

C. Change of shift report

D. All of the above

13) Which is the most appropriate notation for a use to use according to the guidelines that should be
followed when documenting client care?

A. 1230—Client's vital signs taken.

B. 0700—Client drank adequate amount of fluids.
C. 0900—Demerol given for lower abdominal pain.
D. 0830—Increased IV fluid rate to 100 mL/hr according to protocol.

14) The nurse has made an error and is documenting such on the client's record and notes. The action
that the nurse should take is to:

A. Draw a straight line through the error and initial it.

B. Erase the error and write over the material in the same spot.
C. Use a dark color marker to cover the error and continue immediately after that point.
D. Footnote the error at the bottom of the page.

15) What is the correct response for the registered nurse that answers the phone to respond within
the following scenario? The physician calls to leave orders late at night for one of his clients.

A. "I will not take the orders, come and wright it down."
B. "I am unable to take the order at this time. Please call in the morning."
C. "Please repeat the order for me so I can make sure it is written correctly."
D. "Let me have your phone number and I will have the supervisor call you back."

16) The nurse is about to administer a new medication to a patient. Which action best demonstrates
awareness of safe, proficient nursing practice?

A .Identify the patient by compare name and birth date to the medication administration record
(MAR).
B. Determine whether the medication and dose are appropriate for the patient.
C. Make sure the medication is in the medication cart.
D. Check the accuracy of the dose with another nurse.

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9/ January / 2020 Educational department

17) What should the nurse do first when preparing to administer medications to a patient?

A. Check the medication expiration date.

B. Check the medication administration record (MAR).
C. Call the pharmacy for administration instructions.
D. Check the patient's name band.

18) The nurse reviews a physician's order and finds that the medication amount is greater than the
standard dose. What should the nurse do?

A. Give the standard dose rather than the one that is ordered.
B. Inform the nursing supervisor.
C. Call the physician to discuss the order.
D. Give the drug as ordered by the physician.

19) A nurse is performing the three accuracy checks before administering an oral liquid medication to
a patient. When will the nurse perform the second accuracy check?

A. At the patient's bedside

B. Before going into the patient's room
C. When checking the medication order
D. When selecting medication from the unit-dose drawer

20) What is the best way for the nurse to make sure that the right patient is receiving a prescribed
drug when the patient is alert and oriented?

A. ask the patient to state his or her name

B. check the patient's wrist band
C. look at the patients chart
D. have the patient state his or her name and birth date.

21) The nurse attempts to give a patient medication and the patient states, "I am allergic to that". The
nurse should do which of the following

A. Notify the physician

B. Document the error
C. Tell the patient
D. Notify the nursing supervisor

22) When is it acceptable for the nurse to take a verbal order from the prescriber before giving a drug
to a patient?

A .during the night shift when the prescriber is not at the hospital
B. in an emergency situation such as a cardiac arrest

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9/ January / 2020 Educational department

C. when a patient is experiencing severe pain

D. at any time it is necessary

23) What is NOT an appropriate action when a patient, who is legally responsible for their care,
refuses a medication?
A. Notify the ordering physician of patient's refusal to take medication.
B. Document the patient's refusal to take medication and the education that you provided.
C. Explain the consequences for not taking the medication
D. Force the patient to take it anyway
24) John Joseph was scheduled for a physical assessment. When percussing the client’s chest, the
nurse would expect to find which assessment data as a normal sign over his lungs?
A. Dullness.
B. Resonance.
C. Hyper resonance
D. Tympany.

25) Physical assessment is being performed to Geoff by Nurse Tine. During the abdominal
examination, Tine should perform the four physical examination techniques in which sequence?
A. Auscultation immediately after inspection and then percussion and palpation

B. Percussion, followed by inspection, auscultation, and palpation

C. Palpation of tender areas first and then inspection, percussion, and
auscultation
D. Inspection and then palpation, percussion, and auscultation

26) For which time period would the nurse notify the health care provider that the client had no
bowel sounds?
A. 2 minutes.
B. 3 minutes.
C. 4 minutes.
D. 5 minutes.
27) Evaluating the apical pulse is the most reliable noninvasive way to assess cardiac function. Which
is the best area for auscultating the apical pulse?
A. Pulmonic area.
B. Aortic area.
C. Tricuspid area.
D. Mitral area.
28) The nurse tells a 75 year old patient that she will have to do a "head to toe" assessment on him.
The patient asks, "What is that"? Her best answer would be...
A. I will need to determine the etiology of any pathologic symptoms you might have.

B. Oh nothing, it is just something that we do.

C. It is a way for us to know how we are going to take care of you later

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9/ January / 2020 Educational department

D. Maybe you can tell me how you got here.

29) Regarding the head to toe assessment, a nurse is wrought the term ‘’PERRLA’’ in her
documentation, you understand that the term refers to …

A. Motor function

B. Order of assessment

C. Level of consciousness

D. Pupillary response

30) A patient has just been admitted. During physical assessment, it was observed that patient had
decreased skin turgor  and dried  outer lips. What would be the most appropriate thing to offer this
patient while the physical assessment is going on?

A. A chair to sit on

B. Medication

C. Water

D. Some snacks

31) When auscultating for lung sounds, which part of the stethoscope is designed to transmit the
higher pitch of abnormal sounds 

A. Ear piece

B. Bell

C. Diaphragm

D. Tubes

32) In person with good cardiac function and distal perfusion, how long should a capillary refill take
place?   

A. Less than 3 seconds

B. More than 3 seconds

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C. More than 5 seconds

D. Around 5 seconds

33) Which of the following is not a symptom? 

A. Pain.
B. Abdominal discomfort.
C. Soreness
D. Edema

34) What nerve is responsible for the function of smelling?

A. VESTIBULOCOCHLEAR
B. OLFACTORY
C. HYPOGLOSAL
D. FACIAL

35) You’re performing a head-to-toe assessment on a patient. While palpating the lymph nodes of the
neck, the patient reports tenderness at the following location.

When you document the findings of the head-to-toe assessment, you will note that the patient felt
tenderness at which lymph node site?

A. Preauricular

B. Submandibular

C. Superficial cervical

D. Tonsilar

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36) A nurse is doing general examination on her patient, she discovered that the patient’s heart
sounds has very high S1, and documented as abnormal findings. What is the sound of S1 represent on
cardiac examination?

A. The closure of mitral and tricuspid valves.

B. The closure of tricuspid and pulmonary valves
C. The opening of mitral and tricuspid valves.
D. The opening of tricuspid and pulmonary valves

37) A patient is admitted with severe lobar pneumonia. Which of the following assessment findings
would indicate that the patient needs airway suctioning?

A: Coughing up thick sputum only occasionally

B: Coughing up thin, watery sputum easily after nebulization
C: Decreased independent ability to cough
D: Lung sounds clear only after coughing

38) The nurse goes to assess a new patient and finds him lying supine in bed. The patient tells the
nurse that he feels short of breath. Which nursing action should the nurse perform first?

A: Raise the head of the bed to 45 degrees.

B: Take his oxygen saturation with a pulse oximeter.
C: Take his blood pressure and respiratory rate.
D: Notify the health care provider of his shortness of breath

39) A patient is sent to your unit from the emergency. The pt's history includes COPD, heart failure.
They begin complaining of shortness of breath, and chest pain. After assessing the patient at what
rate should this patient's SpO2 be maintained

A. 92% and above

B. Between 88-90%
C. 95% and above
D. 100%

40) Which patient should be the nurse's first priority?

A.) A patient whose airway is obstructed by mucous

B.) A patient expressing difficulty with breathing
C.) A patient whose extremities are cyanotic
D.) A patient who is hyperventilating

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41) Which value indicates clinical hypoxemia and the need to increase oxygen delivery?

A. Hemoglobin of 22 g/dL
B. PaCO2 of 30 mm Hg
C. PaO2 of 65 mm Hg
D. Oxygen saturation of 88%

42) A nurse is inserting an oropharyngeal airway for a patient who vomits when it is inserted. Which
action would be the first that should be taken by the nurse related to this occurrence?

A) Quickly position the patient on his or her side.

B) Put on disposable gloves and remove the oral airway.
C) Check that the airway is the appropriate size for the patient.
D) Put on sterile gloves and suction the airway.

43) An emergency department nurse is using a manual resuscitation bag (Ambu bag) to assist
ventilation in a patient with lung cancer who has stopped breathing on his own. What is an
appropriate step in this procedure?

A.Tilt the patient's head forward.

B. Hold the mask tightly over the patient's nose and mouth.
C. Pull the patient's jaw backward.
D. Compress the bag twice the normal respiratory rate for the patient.

44) When using the non- rebreathing mask on a patient, the flow rate of should be

A. 2-5L/MIN
B. 1-5L/MIN
C. 5-10L/MIN
D. 12-15L/MIN

45) A patient is coming with severer shortness of breath which oxygen delivering devices should the
nurse use on the patient..

A. Nasal cannula
B. Non- rebreather mask
C. Simple face mask
D. Venture mask

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