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4 . You are the nurse working with an elderly, competent client who refuses a
vitamin B injection ordered by the physician. The family insists that this
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injection be given, and you give it while the client is objecting. Even though the
client improves, the client contacts a lawyer. From your knowledge of nursing
and the law, you realize that you:
A. did the right thing because the client improved.
B. should have had the family put their request in writing.
C. have commited an assault against the client.
D. have committed an act of battery against the client.
Answer: D
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6 . When documenting an assigned client’s record during and at the end of the
shift, the nurse must keep in mind which of the following facts?
A. In order to get the care done for all assigned clients, the charting must be as brief as
possible.
B. The proper format, such as SOAP or PIE, as chosen by the hospital, must be adhered to.
C. The chart is a legal document and may be all a nurse has to support care that was given if
called to court.
D. Clients need to be assessed and the care documented at least once every hour during the
shift.
Answer: C
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B. licensed nurse who committed the medication error the previous shift
C. supervising nurse who is in charge of the nursing care unit
D. primary nurse assigned to this client the previous day
Answer: A
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physician wants, and/or the hospital policies, your first loyalty is to the:
A. hospital.
B. client.
C. family.
D. physician.
Answer: B
10 . Which of the following strategies can most help you as a nurse to enhance
your ethical practice and client advocacy?
A. reading a book on religions of the world
B. examining and clarifying your own values
C. talking with peers about their beliefs and values
D. buying a nursing book on ethical decisions
Answer: B
NURSING MCQs
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nutrition
C. suspecting that a client is not being truthful and checking other sources for information
D. identifying several alternative courses of action and deciding on the best course of action
Answer: B
13 . When the nurse problem solves and has implemented a solution from
several solutions identified, the nurse most needs to do which of the following
things?
A. Discard the solutions that were not selected for implementation.
B. Implement a second solution, comparing its usefulness with the first solution.
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15 . Nurses, as they progress in their education, will most likely do which of the
following things?
A. Learn to develop a personal theory of nursing.
B. Become less interested in bedside nursing.
C. Lose their ability to think critically in clinical areas.
D. Have increased enjoyment when doing paperwork.
Answer: A
16 . When nurses assist clients in exploring their lifestyle habits and health
behaviors to identify health risks, nurses are most likely to use which of the
following models?
A. medical model
B. wellness models
C. psychosocial model
D. physiological model
Answer: B
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21 . Which of the following reasons is the most important, as well as the most
widely accepted, reason for nurses using nursing process?
A. Increase the unique body of knowledge known as nursing.
B. Help clients meet their actual and potential health problems.
C. Communicate with other members of the team.
D. Standardize the care of clients with the same diagnoses.
Answer: C
22 . The primary source of data for the client’s database is which of the
following sources?
A. nurse’s recording of health history
B. recent clinic or hospital records
C. physician’s history and physical
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D. Client
Answer: B & D
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Answer: C
27. When writing goals/outcomes for clients, the nurse should do which of the
following?
A. Combine related diagnoses and write a goal or goals for this set.
B. Write goals that the treatment team believes are important.
C. Involve the client in determining the goals/desired outcomes.
D. Combine no more than two nursing diagnoses per goal.
Answer: C
28 . The client you are assigned to has four nursing diagnoses. Which of the
following would you assign the highest priority?
A. chest pain related to cough secondary to pneumonia
B. self-care deficit related to activity intolerance secondary to sleep-pattern disturbance
C. risk for altered family processes secondary to hospitalization
D. self-esteem deficit situational
Answer: A
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40 . You are doing the evaluation step of the nursing process and find that two
of the goals for the client have not been met. Which of the following actions
would be best on your part?
A. Stop working on these goals, as evaluation is the last step.
B. Assess client’s motivation for complying with the care plan.
C. Reassess problem and then review care plan and revise as needed.
D. Determine if the client has a knowledge deficit causing nonattainment.
Answer: C
41 . When you discover an electrical fire and decide you need a fire
extinguisher, you will need to find a fire extinguisher that is rated for which
class of fire?
A. Class A
B. Class B
C. Class C
D. Class E
Answer: C
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43 . When restraining a client in bed with a sleeveless jacket (vest) with straps,
you will do which of the following things?
A. Tie the straps to the side rails.
B. Tie the straps to the movable part of the bed frame.
C. Tie the straps with a square knot.
D. Tie the straps with a quick-release knot.
Answer: D
45 . When instructing the family of a client who has diabetes with neuropathy
causing impaired skin sensitivity, you would stress the importance of which
one of the following things in regard to showering or bathing?
A. cleaning the tub or shower with full-strength peroxide
B. drying well after the shower or bath
C. applying lotion after the shower or bath
D. a method for assuring the water temperature is not hot
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Answer: D
46 . The nurse finds that an assigned client is restless, agitated, and confused
and is thinking of restraining the client. Which of the following questions is
most important for the nurse to ask?
A. “Which restraint is most appropriate?”
B. “Will I be able to get an order for a restraint?”
C. “What is the underlying cause of the restless, agitated, confused behavior?”
D. “Could I try some medication to relax the client prior to using restraints?”
Answer: C
47 . The nurse giving discharge instructions advises the client to get out of bed
slowly and to get up in stages from lying to sitting to standing. The client
understands that the reason for doing this is:
A. to prevent falls.
B. to improve circulation.
C. as a warm-up exercise.
D. to increase oxygenation.
Answer: A
48 . Which of the following interventions on the part of the nurse would most
help a confused ambulatory client find their room?
A. having large room numbers on the door
B. placing a picture on the door
C. giving hourly reorientation to the correct room
D. pinning the client’s room number on their attire
Answer: B
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49 . When assessing the noise level that clients are exposed to, the nurse is
aware that levels below which of the following number of decibels is usually
safe in terms of hearing?
A. 85
B. 95
C. 110
D. 120
Answer: A
50 . One of your assigned clients who is scheduled for radiation therapy asks
you to stay with her during radiation because she is scared. Your best response
to this request would be which of the following responses?
A. “Let’s think of how to reduce your fear, as I must stay a distance away.”
B. “I will be right there with you, and I will hold your hand so you won’t be afraid.”
C. “It is not necessary to be afraid, as nothing bad will happen to you.”
D. “I will see if I can get permission from your doctor and the X-ray department.”
Answer: A
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53 . The nursing supervisor has asked the staff to reduce the number of
iatrogenic infections on the unit. Which of the following actions on your part
would contribute to reducing iatrogenic infections?
A. teaching correct hand washing to assigned clients
B. using correct procedures in starting and caring for an intravenous infusion
C. properly bagging soiled linens and disposed items used for a client in isolation
D. isolating a client who has just been diagnosed as having tuberculosis
Answer: B
54 . Your assigned client has encephalitis, and there are other cases in the
community. In a team meeting regarding your client and prevention of other
cases of encephalitis, the nurse supervisor talks about breaking the chain of
infection at the second link: the reservoir. You realize the nurse supervisor is
talking about which of the following things?
A. an area for the storage and filtering of water
B. a place where the microorganism enters the body
C. the place where the microorganism naturally lives
D. the microorganism itself
Answer: C
55 . On a home visit, you notice some dust on a vent in your client’s room and
on the windowsill. Which of the following methods would you teach the family
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56 . A client asks you how to best prevent vaginal infections. Your best answer
would include which of the following statements?
A. “I would suggest a vinegar douche.”
B. “The pH of the vaginal secretions stops many disease-producing bacteria.”
C. “Drinking cranberry juice will prevent most all of the vaginal infections.”
D. “Your doctor can prescribe a medication that will prevent vaginal
E. infections.”
Answer: B
57 . You would refer to the early phase of scar tissue formation as which of the
following kinds of tissue?
A. Keloid
B. Cicatrix
C. granulation
D. Fibrous
Answer: C
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59 . You are working with a client who has cancer and is undergoing treatment.
The client complains of a loss of appetite. You will most need to make certain
that your client eats which one of the following foods?
A. fresh fruits
B. raw vegetables
C. carbohydrates
D. Protein
Answer: D
60 . Your assigned client has a leg ulcer that has a dressing on it. During your
assessment, you find that the dressing is wet. The client admits to spilling
water on the dressing. What action would be best on your part?
A. Reinforce the dressing with a dry dressing.
B. Remove wet dressing and apply new dressing.
C. Dry the dressing with a hair dryer.
D. Let the room air dry the dressing.
Answer: B
61 . A fellow nurse who is working on another unit asks to read the chart of
your assigned client. Which one of the following criteria would enable the
nurse to have access to the chart?
A. Be unrelated to the client.
B. Have a current nursing license.
C. Have client’s verbal permission.
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62 . When charting in the client’s record or chart, the nurse most needs to do
which one of the following things?
A. Date and sign each entry.
B. Chart every two hours.
C. Use ballpoint pen and not pencil.
D. Cross out errors so others can’t read them.
Answer: A
63 . While giving a shift report on your assigned client, you realize that you
forgot to record a nursing procedure done on your client. Which of the
following methods of documentation would be best on your part?
A. Write the procedure between the two lines of your shift documentation closest to the
occurrence.
B. Find a blank space in your earlier charting, and chart the procedure in that space.
C. Tell the oncoming nurse to chart the procedure for you and to cite the time it was done.
D. Chart the current date and time and “Late entry,” indicating when and what was done.
Answer: D
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66 . The nurse is sending some lab results to the primary physician’s office. The
nurse most needs to do which of the following things?
A. Make a note that the fax was sent and what time it was sent in the nurses’ notes.
B. Document a follow-up telephone call verifying the receipt of information and who received
it.
C. Leave a note to the physician in the client’s record saying what information was faxed and
when.
D. Check with the laboratory to see if they have already provided the physician with the
results.
Answer: B
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69 . When working in a facility that uses focus charting, the nurse will use
which of the following as a focus of care?
A. problems identified in the initial assessment
B. maximum level of functioning
C. client identified goals and objectives
D. client concerns and strengths
Answer: D
71 . Which of the following words represents the basic unit of all life and is the
simplest structure that possesses all the characteristics of life: organization,
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72 . Which of the following cells of the body are in almost constant mitosis?
A. nerve cells
B. stomach cells
C. muscle cells
D. renal cells
Answer: B
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76 . The vocal cords have and function with which of the following kinds of
tissue?
A. liquid connective tissue
B. hard connective tissue
C. fibrous connective tissue
D. soft connective tissue
Answer: C
78 . The body’s biggest organ is which of the following components of the body?
A. large intestine
B. the skin
C. small intestine
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D. Kidneys
Answer: B
80 . When reading an autopsy report, the nurse encounters the term “mid-
sagittal plane.” This nurse understands that this means the body was viewed
using a plane that matched which of the following descriptions?
A. This plane cuts the body horizontally.
B. This plane divides the body into front and back portions.
C. The body is separated into left and right equal portions.
D. The body is divided using an X across the chest.
Answer: C
81 . The nurse receives a report at the beginning of the shift and learns that the
client scores 7 on the Glasgow Coma Scale. The nurse realizes that this client is
at which of the following levels of consciousness?
A. comatose
B. moderate disability
C. severe disability
D. fully alert
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Answer: A,D
82 . You partially darken a room and ask the client to look straight ahead. You
use a penlight and, approaching from the side you shine the light, it constricts.
You remove the light and then shine it on the same pupil again. You also
observe the response of the other pupil. You would normally find the other
pupil doing which of the following things?
A. not make any change in size
B. dilate in an oppositional response to the light
C. first constrict, then dilate larger than the other pupil
D. constrict in consensual response
Answer: D
84 . The physician of your assigned client tells you that the client has a heart
murmur that can be detected by direct auscultation. You realize that the
physician is telling you which of the following things?
A. Use of a stethoscope is necessary to hear the murmur.
B. The murmur can be heard by using only the ear.
C. An ultrasound is necessary to find this murmur.
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85 . When weighing a client daily, you will most need to weigh the client at
which of the following times?
A. when most rested
B. at the same time each day
C. after the shower or bath
D. when higher priorities are completed
Answer: B
86 . When counting the apical pulse during the physical assessment, it is the
most accepted practice for the nurse to count the apical pulse in which of the
following ways?
A. for 15 seconds and multiply by four
B. for 30 seconds and multiply by two
C. for one minute, checking radial pulse at the same time
D. for one full minute
Answer: D
87. While listening to a client’s lung sounds, you hear something that you
believe is not normal, and you note that it is a continuous sound. You will chart
this as which of the following findings?
A. crackles
B. Rales
C. adventitious sounds
D. pleral friction rub
Answer: C
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88 . When examining the client’s abdomen, the nurse will most facilitate the
examination by positioning the client in which of the following ways?
A. supine with small pillows beneath knees and head
B. semi-Fowler’s position with knees extended
C. sitting in the chair with legs elevated
D. supine with arms extended and hands behind head
Answer: A
89 . You highly suspect that your assigned client has abdominal distention. You
most need to do and chart which of the following things?
A. Have another nurse verify your suspicions.
B. Measure the abdominal girth at the umbilicus.
C. Measure abdominal girth at the most distended level.
D. Ask the client if they are distended.
Answer: C
91. To protect the client’s skin from injury during hygiene care, including
bathing or showering, application of lotion, and bed making, you most need to
do which of the following things?
A. Cover your rings and bracelets with gloves.
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92. The skin produces and absorbs which of the following vitamins in
conjunction with the ultraviolet rays of the Sun, which activate this particular
vitamin’s precursor present in the skin?
A. vitamin D
B. vitamin C
C. vitamin E
D. vitamin K
Answer: A
93. You are working with a client who has dentures but does not wear them.
When questioned about the reason for not wearing the dentures, the client
says it makes him feel old. Which of the following responses would be best?
A. “You are not really old.”
B. “It is all right not to wear your dentures.”
C. “You look better with dentures.”
D. “Wearing dentures helps gums not to shrink.”
Answer: D
94. When assessing the client’s hair, you are especially looking for pediculosis
capitis. If it is present, which of the following signs will you most likely find?
A. Oval particles looking like dandruff on the hairs.
B. Crusts on the scalp, especially at the client’s hairline.
C. Brown or black threadlike lesions.
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95. You are preparing to bathe and wash the hair of an African American
woman. Which of the following questions would be most important to ask the
client?
A. “Will you please unbraid your hair?”
B. “Do you have or want oil put on your hair and scalp?”
C. “Is it all right if I shampoo your hair twice?”
D. “Will you brush your hair before the shampoo?”
Answer: B
96. You need to remove the artificial eye of a client, and you need to clean it.
Which of the following methods is recommended for removal?
A. Put pressure on either side of the eye and pop it out.
B. Apply pressure directly above the eye.
C. Apply pressure directly to the eye with a small rubber bulb.
D. Apply pressure with a rubber bulb to lower half of the eye.
Answer: C
97. It is most likely that an acutely ill client will need the room temperature set
at which of the following temperatures?
A. 64 degrees F
B. 68 degrees F
C. 74 degrees F
D. 78 degrees F
Answer: D
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98. You are cleaning a client’s partial dentures, which have a metal clasp.
Which of the following actions are best on your part?
A. Place a washcloth in the sink where you are cleaning.
B. Remove the partial dentures by the metal clasp.
C. Use hot water to rinse the dentures after cleaning.
D. Soak the partial plate with the metal clasp overnight.
Answer: A
99. A nurse getting report at the beginning of shift learns that an assigned
client has hyperpyrexia. The nurse realizes that this client is experiencing
which of the following signs or symptoms?
A. extreme bleeding of the gums
B. a very high fever, such as 41°C or 105.8°F
C. waxy flexibility of the muscles
D. third-degree burns over much of the body
Answer: B
100. You are ready to take the client’s oral temperature. You ask this client
how long it has been since drinking something hot or cold or smoking. The
client admits having just drunk a cup of hot coffee. You will wait how long
before taking the temperature?
A. 5 minutes
B. 10 minutes
C. 20 minutes
D. 30 minutes
Answer: D
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contraindicated?
A. client who has had a myocardial infarction
B. client with Parkinson’s disease
C. client who is prone to seizures
D. client with neuropathology associated with diabetes
Answer: A
102. When taking a radial pulse for half a minute, the nurse finds it to be
irregular. Which of the following would be best for the nurse to do next?
A. Take the radial pulse for one minute.
B. Check the carotid pulse to see if it is irregular.
C. Assess the apical pulse.
D. Chart the radial pulse and the irregularities.
Answer: C
103. The nurse wants to check the popliteal pulse. This pulse can be better
palpated if the nurse does which of the following things?
A. Ask the client to extend the knee.
B. Have the client flex the knee.
C. Press lightly on the right side of the front of the knee.
D. Palpate more deeply than for other pulses.
Answer: B
104. The nurse positioning a client after surgery will take into account that the
position, which most often predisposes a client to physiologic processes that
suppress respiration, is which of the following positions?
A. Fowler’s position
B. Prone
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C. Supine
D. left side lying down
Answer: C
105. The nurse is taking the client’s blood pressure. The physician asks for the
pulse pressure. To obtain the pulse pressure, the nurse will have to do which of
the following things?
A. Obtain a pulse-pressure machine.
B. Subtract the diastolic blood pressure from the systolic.
C. Subtract the systolic blood pressure from the diastolic.
D. Take client’s apical pulse and subtract it from systolic.
Answer: B
106. The nurse notices that the client has a hematocrit of 70 percent. This level
of hematocrit will most likely affect the vital signs in which of the following
ways?
A. The blood pressure will be elevated.
B. The pulse will be low.
C. Temperature will be elevated.
D. Blood pressure will be low.
Answer: A
107. The nurse finds that a newborn has a mean systolic pressure of 75 mmHg.
How would this blood pressure be best described?
A. Normal
B. slightly low
C. very low
D. slightly high
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Answer: A
108. When working with clients experiencing pain, you will define their pain in
regard to whether they have pain or not and how intense it is based on which of
the following things?
A. nursing experience and expertise
B. the underlying cause of the pain
C. whatever the experiencing person says it is.
D. current medical and pharmacological research
Answer: C
109. When pain impulses are transmitted via the A-delta fibers, which of the
following types of pain will your client have?
A. sharp, pricking pain
B. throbbing pain
C. burning pain
D. intermittent stabbing pain
Answer: A
110. Your assigned client, who has been talking with the doctor about pain
control, later asks you what the doctor meant by “pain threshold.” Which of
the following would be the best reply?
A. the point at which pain medication brings relief
B. the maximum amount of pain a person can tolerate
C. the amount of pain the average person can tolerate
D. the amount of pain stimulation that it takes to cause pain
Answer: D
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111. Which one of the following four clients is most likely to tolerate pain best?
A. a client with rheumatoid arthritis
B. a client who has terminal cancer in stage 1 of grief
C. an athlete having a knee surgery to prolong his career
D. a client who has a migraine headache
Answer: C
112. You are caring for a client who has just returned from surgery and has
received intravenous morphine minutes before leaving the recovery room. You
need to assess the client’s pain now and again at which of the following times?
A. in 20 to 30 minutes
B. in one hour
C. in two hours
D. in 3 to 4 hours
Answer: A
113. Your assigned client seems to be getting a lot of attention from his mother
when he complains of pain. The mother may be encouraging which of the
following types of gains?
A. primary gains
B. secondary gains
C. narcissistic gains
D. egocentric gains
Answer: B
114. When giving a client a diagnosis of acute pain, the nurse “using NANDA
diagnostic categories” will use this diagnosis only when the pain last no longer
than which of the following lengths of time?
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A. 3 days
B. 2 weeks
C. 1 month
D. 6 months
Answer: D
115. The nurse visiting a client and the client’s family in the home teaches
family members to massage the client’s back and enlists their aid in providing
backrubs. Which of the following reasons most likely represents the main
reason the nurse has enlisted the aid of the family?
A. It may diminish feelings of helplessness in family members.
B. The client may need a backrub when the nurse is gone.
C. Backrubs reduce the need for addicting medications.
D. The client will be able to get more sleep and rest.
Answer: A
116. Which of the following people have the largest percentage of water in their
bodies?
A. fat men
B. lean men
C. lean women
D. fat women
Answer: B
117. When talking with a client about complete and incomplete proteins, which
of the following would you use as the best example of a complete protein?
A. olives
B. rice
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C. eggs
D. Nuts
Answer: C
118. In instructing a client on cholesterol, the nurse will teach which of the
following things?
A. The body does not need cholesterol.
B. Most cholesterol in the body is destroyed in the small intestine.
C. The majority of cholesterol in the body comes from eating fatty foods.
D. Most cholesterol is synthesized in the liver.
Answer: D
119. A client asks which of the vitamins can be stored in the body. Which of the
following answers by the nurse would be correct?
A. C
B. B1 thiamine
C. Biotin
D. D
Answer: D
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121. You are feeding a newborn infant in the nursery, as the mother is having
some procedure done at this time. Before the infant finishes taking the
contents of the bottle of formula, the infant slowly stops sucking and falls
asleep. Which of the following actions would be best on your part?
A. Wake the baby by tickling the bottoms of the feet and then try feeding.
B. Wait about 30 minutes, then try to get the infant to take the formula.
C. Report this feeding behavior to the supervisior immediately.
D. Discontinue the feeding and allow the infant to sleep at this time.
122. The nurse will teach clients to use which of the following groups from the
food pyramid in the greatest amounts?
A. carbohydrates such as grains, potatoes, and rice
B. vegetables and fruits
C. milk and milk products
D. proteins such as meat and meat products
123. You are working with a client who is on a full liquid diet. The client is
demanding some ice cream. Which of the following responses on your part
would be best?
A. Tell the client that ice cream is not allowed on a full liquid diet.
B. Call the physician and report the client’s demands.
C. Get the client some plain vanilla ice cream.
D. Ask the supervising nurse to talk with the client.
Answer: C
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125. The nurse is checking the placement of a nasogastric tube prior to giving
medication and a feeding. Which of the following is the preferred and most
accurate method of testing?
A. Insert 5 to 20 mm of air into the tube while listening over the stomach with a stethoscope.
B. Aspirate 20 to 30 ml of gastrointestinal secretions and test the pH.
C. Insert 15 to 20 cc of water into the stomach and listen with the stethoscope.
D. Place an open end of the tube into a glass of water and check for bubbles.
Answer: B
------>>[MOST IMPORTANT]<<------
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Birhanu Gibore
MAY 21, 2021 AT 1:11 PM
REPLY
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