1.

Question
Which intervention is an example of primary prevention?

A. Administering digoxin (Lanoxicaps) to a patient with heart failure.

B. Administering measles, mumps, and rubella immunization to an infant.
C. Obtaining a Papanicolaou smear to screen for cervical cancer.
D. Using occupational therapy to help a patient cope with arthritis.
Incorrect
Correct Answer: B. Administering measles, mumps, and rubella immunization to an
infant.

Immunizing an infant is an example of primary prevention, which aims to prevent

health problems. Primary prevention includes those preventive measures that come
before the onset of illness or injury and before the disease process begins.
Examples include immunization and taking regular exercise to prevent health
problems developing in the future.

Option A: Administering digoxin to treat heart failure and obtaining a smear for a
screening test are examples for secondary prevention, which promotes early
detection and treatment of disease. Those preventive measures that lead to early
diagnosis and prompt treatment of a disease, illness, or injury to prevent more
severe problems developing. Here health educators such as Health Extension
Practitioners can help individuals acquire the skills of detecting diseases in
their early stages.
Option C: Obtaining a Papanicolau smear is a secondary prevention. Secondary
prevention includes those preventive measures that lead to early diagnosis and
prompt treatment of a disease, illness, or injury. This should limit disability,
impairment, or dependency and prevent more severe health problems developing in the
future.
Option D: Using occupational therapy to help a patient cope with arthritis is an
example of tertiary prevention, which aims to help a patient deal with the residual
consequences of a problem or to prevent the problem from recurring. Tertiary
prevention includes those preventive measures aimed at rehabilitation following
significant illness. At this level, health educators work to retrain, re-educate
and rehabilitate the individual who has already had an impairment or disability.
2. Question
The nurse in charge is assessing a patient’s abdomen. Which examination technique
should the nurse use first?

A. Auscultation
B. Inspection
C. Percussion
D. Palpation
Incorrect
Correct Answer: B. Inspection

Inspection always comes first when performing a physical examination. It is

important to begin with the general examination of the abdomen with the patient in
a completely supine position. The presence of any of the following signs may
indicate specific disorders. Percussion and palpation of the abdomen may affect
bowel motility and therefore should follow auscultation.

Option A: The last step of the abdominal examination is auscultation with a

stethoscope. The diaphragm of the stethoscope should be placed on the right side of
the umbilicus to listen to the bowel sounds, and their rate should be calculated
after listening for at least two minutes. Normal bowel sounds are low-pitched and
gurgling, and the rate is normally 2-5/min. Absent bowel sounds may indicate
paralytic ileus and hyperactive rushes (borborygmi) are usually present in small
bowel obstruction and sometimes may be auscultated in lactose intolerance.
Option C: A proper technique of percussion is necessary to gain maximum information
regarding the abdominal pathology. While percussing, it is important to appreciate
tympany over air-filled structures such as the stomach and dullness to percussion
which may be present due to an underlying mass or organomegaly (for example,
hepatomegaly or splenomegaly).
Option D: The ideal position for abdominal examination is to sit or kneel on the
right side of the patient with the hand and forearm in the same horizontal plane as
the patient’s abdomen. There are three stages of palpation that include the
superficial or light palpation, deep palpation, and organ palpation and should be
performed in the same order. Maneuvers specific to certain diseases are also a part
of abdominal palpation.
3. Question
Which statement regarding heart sounds is correct?

A. S1 and S2 sound equally loud over the entire cardiac area.

B. S1 and S2 sound fainter at the apex.
C. S1 and S2 sound fainter at the base.
D. S1 is loudest at the apex, and S2 is loudest at the base.
Incorrect
Correct Answer: D. S1 is loudest at the apex, and S2 is loudest at the base.

The S1 sound—the “lub” sound—is loudest at the apex of the heart. It sounds longer,
lower, and louder there than the S2 sounds. The S2—the “dub” sound—is loudest at
the base. It sounds shorter, sharper, higher, and louder there than S1. Heart
sounds are created from blood flowing through the heart chambers as the cardiac
valves open and close during the cardiac cycle. Vibrations of these structures from
the blood flow create audible sounds — the more turbulent the blood flow, the more
vibrations that get created.

Option A: The S1 heart sound is produced as the mitral and tricuspid valves close
in systole. This structural and hemodynamic change creates vibrations that are
audible at the chest wall. The mitral valve closing is the louder component of S1.
It also occurs sooner because of the left ventricle contracts earlier in systole.
Option B: Changes in the intensity of S1 are more attributable to forces acting on
the mitral valve. Such causes include a change in left ventricular contractility,
mitral structure, or the PR interval. However, under normal resting conditions, the
mitral and tricuspid sounds occur close enough together not to be discernible. The
most common reasons for a split S1 are things that delay right ventricular
contraction, like a right bundle branch block.
Option C: The S2 heart sound is produced with the closing of the aortic and
pulmonic valves in diastole. The aortic valve closes sooner than the pulmonic
valve, and it is the louder component of S2; this occurs because the pressures in
the aorta are higher than the pulmonary artery.
4. Question
The nurse in charge identifies a patient’s responses to actual or potential health
problems during which step of the nursing process?

A. Assessment
B. Nursing diagnosis
C. Planning
D. Evaluation
Incorrect
Correct Answer: B. Nursing diagnosis

The nurse identifies human responses to actual or potential health problems during
the nursing diagnosis step of the nursing process. The formulation of a nursing
diagnosis by employing clinical judgment assists in the planning and implementation
of patient care. The North American Nursing Diagnosis Association (NANDA) provides
nurses with an up to date list of nursing diagnoses. A nursing diagnosis, according
to NANDA, is defined as a clinical judgment about responses to actual or potential
health problems on the part of the patient, family or community.

Option A: During the assessment step, the nurse systematically collects data about
the patient or family. Assessment is the first step and involves critical thinking
skills and data collection; subjective and objective. Subjective data involves
verbal statements from the patient or caregiver. Objective data is measurable,
tangible data such as vital signs, intake and output, and height and weight.
Option C: During the planning step, the nurse develops strategies to resolve or
decrease the patient’s problem. The planning stage is where goals and outcomes are
formulated that directly impact patient care based on EDP guidelines. These
patient-specific goals and the attainment of such assist in ensuring a positive
outcome.
Option D: During the evaluation step, the nurse determines the effectiveness of the
plan of care. This final step of the nursing process is vital to a positive patient
outcome. Whenever a healthcare provider intervenes or implements care, they must
reassess or evaluate to ensure the desired outcome has been met. Reassessment may
frequently be needed depending upon overall patient condition. The plan of care may
be adapted based on new assessment data.
5. Question
A female patient is receiving furosemide (Lasix), 40 mg P.O. b.i.D. in the plan of
care, the nurse should emphasize teaching the patient about the importance of
consuming:

A. Fresh, green vegetables

B. Bananas and oranges
C. Lean red meat
D. Creamed corn
Incorrect
Correct Answer: B. Bananas and oranges

Because furosemide is a potassium-wasting diuretic, the nurse should plan to teach

the patient to increase intake of potassium-rich foods, such as bananas and
oranges. Potassium is a mineral in the cells. It helps the nerves and muscles work
as they should. The right balance of potassium also keeps the heart beating at a
steady rate. Fresh, green vegetables; lean red meat; and creamed corn are not good
sources of potassium.

Option A: GLVs are considered as natural caches of nutrients for human beings as
they are a rich source of vitamins, such as ascorbic acid, folic acid, tocopherols,
?-carotene, and riboflavin, as well as minerals such as iron, calcium, and
phosphorous.
Option C: Lean red meat is an excellent source of high biological value protein,
vitamin B12, niacin, vitamin B6, iron, zinc, and phosphorus. It is a source of
long?chain omega?3 polyunsaturated fats, riboflavin, pantothenic acid, selenium,
and, possibly, also vitamin D. It is also relatively low in fat and sodium.
Option D: Corn has several health benefits. Because of the high fiber content, it
can aid with digestion. It also contains valuable B vitamins, which are important
to your overall health. Corn also provides our bodies with essential minerals such
as zinc, magnesium, copper, iron, and manganese.
6. Question
The nurse in charge must monitor a patient receiving chloramphenicol for adverse
drug reaction. What is the most toxic reaction to chloramphenicol?

A. Lethal arrhythmias
B. Malignant hypertension
C. Status epilepticus
D. Bone marrow suppression
Incorrect
Correct Answer: D. Bone marrow suppression

The most toxic reaction to chloramphenicol is bone marrow suppression.

Chloramphenicol is a synthetically manufactured broad-spectrum antibiotic. It was
initially isolated from the bacteria Streptomyces venezuelae in 1948 and was the
first bulk produced synthetic antibiotic. However, chloramphenicol is a rarely used
drug in the United States because of its known severe adverse effects, such as bone
marrow toxicity and grey baby syndrome. Chloramphenicol is not known to cause
lethal arrhythmias, malignant hypertension, or status epilepticus.

Option A: Chloramphenicol is associated with severe hematological side effects when

administered systemically. Since 1982, chloramphenicol has reportedly caused fatal
aplastic anemia, with possible increased risk when taken together with cimetidine.
This adverse side effect can occur even with the topical administration of the
drug, which is most likely due to the systemic absorption of the drug after topical
application.
Option B: Besides causing fatal aplastic anemia and bone marrow suppression, other
side effects of chloramphenicol include ototoxicity with the use of topical ear
drops, gastrointestinal reactions such as oesophagitis with oral use,
neurotoxicity, and severe metabolic acidosis.
Option C: Optic neuritis is the most commonly associated neurotoxic complication
that can arise from chloramphenicol use. This adverse effect usually takes more
than six weeks to manifest, presenting with either acute or subacute vision loss,
with possible fundal changes. It may also present with peripheral neuropathy, which
may present as numbness or tingling. If optic neuropathy occurs, the drug should be
withdrawn immediately, which will usually lead to partial or complete recovery of
vision.
7. Question
A female patient is diagnosed with deep-vein thrombosis. Which nursing diagnosis
should receive highest priority at this time?

A. Impaired gas exchanges related to increased blood flow.

B. Fluid volume excess related to peripheral vascular disease.
C. Risk for injury related to edema.
D. Altered peripheral tissue perfusion related to venous congestion.
Incorrect
Correct Answer: D. Altered peripheral tissue perfusion related to venous
congestion.

Altered peripheral tissue perfusion related to venous congestion” takes highest

priority because venous inflammation and clot formation impede blood flow in a
patient with deep-vein thrombosis. A deep-vein thrombosis (DVT) is a blood clot
that forms within the deep veins, usually of the leg, but can occur in the veins of
the arms and the mesenteric and cerebral veins. Deep-vein thrombosis is a common
and important disease. It is part of the venous thromboembolism disorders which
represent the third most common cause of death from cardiovascular disease after
heart attacks and stroke.

Option A: Option A is incorrect because impaired gas exchange is related to

decreased, not increased, blood flow. Depending on the relative balance between the
coagulation and thrombolytic pathways, thrombus propagation occurs. DVT is
commonest in the lower limb below the knee and starts at low-flow sites, such as
the soleal sinuses, behind venous valve pockets.
Option B: Option B is inappropriate because no evidence suggests that this patient
has a fluid volume excess. Nurses need to educate the patients on the importance of
ambulation, being compliant with compression stockings, and taking the prescribed
anticoagulation medications.
Option C: Option C may be warranted but is secondary to altered tissue perfusion.
Thrombosis is a protective mechanism that prevents the loss of blood and seals off
damaged blood vessels. Fibrinolysis counteracts or stabilizes the thrombosis. The
triggers of venous thrombosis are frequently multifactorial, with the different
parts of the triad of Virchow contributing in varying degrees in each patient, but
all result in early thrombus interaction with the endothelium. This then stimulates
local cytokine production and causes leukocyte adhesion to the endothelium, both of
which promote venous thrombosis.
8. Question
When positioned properly, the tip of a central venous catheter should lie in the:

A. Superior vena cava

B. Basilica vein
C. Jugular vein
D. Subclavian vein
Incorrect
Correct Answer: A. Superior vena cava

When the central venous catheter is positioned correctly, its tip lies in the
superior vena cava, inferior vena cava, or the right atrium—that is, in central
venous circulation. Blood flows unimpeded around the tip, allowing the rapid
infusion of large amounts of fluid directly into circulation. The basilica,
jugular, and subclavian veins are common insertion sites for central venous
catheters.

Option B: There are three main access sites for the placement of central venous
catheters. The internal jugular vein, common femoral vein, and subclavian veins are
the preferred sites for temporary central venous catheter placement. Additionally,
for mid-term and long-term central venous access, the basilic and brachial veins
are utilized for peripherally inserted central catheters (PICCs).
Option C: The internal jugular vein (IJ) is often chosen for its reliable anatomy,
accessibility, low complication rates, and the ability to employ ultrasound
guidance during the procedure. The individual clinical scenario may dictate
laterality in some cases (such as with trauma, head and neck cancer, or the
presence of other invasive devices or catheters), but all things being equal, many
physicians prefer the right IJ. As compared to the left, the right IJ forms a more
direct path to the superior vena cava (SVC) and right atrium. It is also wider in
diameter and more superficial, thus presumably easier to cannulated.
Option D: The subclavian vein site has the advantage of low rates of both
infectious and thrombotic complications. Additionally, the SC site is accessible in
trauma, when a cervical collar negates the choice of the IJ. However, disadvantages
include a higher relative risk of pneumothorax, less accessibility to use
ultrasound for CVC placement, and the non-compressible location posterior to the
clavicle.
9. Question
Nurse Nikki is revising a client’s care plan. During which step of the nursing
process does such revision take place?

A. Assessment
B. Planning
C. Implementation
D. Evaluation
Incorrect
Correct Answer: D. Evaluation

During the evaluation step of the nursing process, the nurse determines whether the
goals established in the care plan have been achieved, and evaluates the success of
the plan. If a goal is unmet or partially met the nurse reexamines the data and
revises the plan. This final step of the nursing process is vital to a positive
patient outcome. Whenever a healthcare provider intervenes or implements care, they
must reassess or evaluate to ensure the desired outcome has been met. Reassessment
may frequently be needed depending upon overall patient condition. The plan of care
may be adapted based on new assessment data. Assessment involves data collection.
Planning involves setting priorities, establishing goals, and selecting appropriate
interventions.

Option A: Assessment is the first step and involves critical thinking skills and
data collection; subjective and objective. Subjective data involves verbal
statements from the patient or caregiver. Objective data is measurable, tangible
data such as vital signs, intake and output, and height and weight.
Option B: The planning stage is where goals and outcomes are formulated that
directly impact patient care based on EDP guidelines. These patient-specific goals
and the attainment of such assist in ensuring a positive outcome. Nursing care
plans are essential in this phase of goal setting. Care plans provide a course of
direction for personalized care tailored to an individual’s unique needs. Overall
condition and comorbid conditions play a role in the construction of a care plan.
Care plans enhance communication, documentation, reimbursement, and continuity of
care across the healthcare continuum.
Option C: Implementation is the step that involves action or doing and the actual
carrying out of nursing interventions outlined in the plan of care. This phase
requires nursing interventions such as applying a cardiac monitor or oxygen, direct
or indirect care, medication administration, standard treatment protocols, and EDP
standards.
10. Question
A 65-year-old female who has diabetes mellitus and has sustained a large laceration
on her left wrist asks the nurse, “How long will it take for my scars to
disappear?” Which statement would be the nurse’s best response?

A. “The contraction phase of wound healing can take 2 to 3 years.”

B. “Wound healing is very individual but within 4 months the scar should fade.
C. “With your history and the type of location of the injury, it’s hard to say.”
D. “If you don’t develop an infection, the wound should heal any time between 1
and 3 years from now.”
Incorrect
Correct Answer: C. “With your history and the type of location of the injury, it’s
hard to say.”

Wound healing in a client with diabetes will be delayed. Providing the client with
a time frame could give the client false information. There is no doubt that
diabetes plays a detrimental role in wound healing. It does so by affecting the
wound healing process at multiple steps. Wound hypoxia, through a combination of
impaired angiogenesis, inadequate tissue perfusion, and pressure-related ischemia,
is a major driver of chronic diabetic wounds.

Option A: Ischemia can lead to prolonged inflammation, which increases the levels
of oxygen radicals, leading to further tissue injury. Elevated levels of matrix
metalloproteases in chronic diabetic wounds, sometimes up to 50-100 times higher
than acute wounds, cause tissue destruction and prevent normal repair processes
from taking place. Furthermore, diabetes is associated with impaired immunity, with
critical defects occurring at multiple points within the immune system cascade of
the wound healing process.
Option B: To further complicate matters, these wounds have defects in angiogenesis
and neovascularization. Normally, wound hypoxia stimulates mobilization of
endothelial progenitor cells via vascular endothelial growth factor (VEGF). In
diabetic wounds, there are aberrant levels of VEGF and other angiogenic factors
such as angiopoietin-1 and angiopoietin-2 that lead to dysangiogenesis.
Option D: Diabetic neuropathy may also play a role in poor wound healing. Lower
levels of neuropeptides, as well as reduced leukocyte infiltration as a result of
sensory denervation, have been shown to impair wound healing. When combined, all
these diverse factors play a role in the formation and propagation of chronic,
debilitating wounds in patients with diabetes.
11. Question
One aspect of implementation related to drug therapy is:

A. Developing a content outline.

B. Documenting drugs given.
C. Establishing outcome criteria.
D. Setting realistic client goals.
Incorrect
Correct Answer: B. Documenting drugs given.

Although documentation isn’t a step in the nursing process, the nurse is legally
required to document activities related to drug therapy, including the time of
administration, the quantity, and the client’s reaction. Developing a content
outline, establishing outcome criteria, and setting realistic client goals are part
of planning rather than implementation.

Option A: UE has a common goal with the pharmaceutical care it supports: to improve
an individual patient’s quality of life through the achievement of predefined,
medication-related therapeutic outcomes. Through its focus on the system of
medication use, the MUE process helps to identify actual and potential medication-
related problems, resolve actual medication-related problems, and prevent potential
medication-related problems that could interfere with achieving optimum outcomes
from medication therapy.
Option C: Although distinctions historically have been made among the terms drug-
use evaluation, drug-use review, and medication use evaluation (MUE), they all
refer to the systematic evaluation of medication use employing standard,
observational quality-improvement methods. MUE is a quality-improvement activity,
but it also can be considered a formulary system management technique. An MUE is a
performance improvement method that focuses on evaluating and improving medication-
use processes with the goal of optimal patient outcomes.
Option D: MUE encompasses the goals and objectives of drug use evaluation (DUE) in
its broadest application, emphasizing improving patient outcomes. The use of MUE,
rather than DUE, emphasizes the need for a more multifaceted approach to improving
medication use.
12. Question
A female client is readmitted to the facility with a warm, tender, reddened area on
her right calf. Which contributing factor would the nurse recognize as most
important?

A. A history of increased aspirin use.

B. Recent pelvic surgery.
C. An active daily walking program.
D. A history of diabetes.
Incorrect
Correct Answer: B. Recent pelvic surgery

The client shows signs of deep vein thrombosis (DVT). The pelvic area is rich in
blood supply, and thrombophlebitis of the deep vein is associated with pelvic
surgery. Thrombosis is a protective mechanism that prevents the loss of blood and
seals off damaged blood vessels. Fibrinolysis counteracts or stabilizes the
thrombosis. The triggers of venous thrombosis are frequently multifactorial, with
the different parts of the triad of Virchow contributing in varying degrees in each
patient, but all result in early thrombus interaction with the endothelium. This
then stimulates local cytokine production and causes leukocyte adhesion to the
endothelium, both of which promote venous thrombosis.

Option A: Aspirin, an antiplatelet agent, and an active walking program help

decrease the client’s risk of DVT. The use of thrombolytic therapy can result in an
intracranial bleed, and hence, careful patient selection is vital. Recently
endovascular interventions like catheter-directed extraction, stenting, or
mechanical thrombectomy have been tried with moderate success.
Option C: Treatment of DVT aims to prevent pulmonary embolism, reduce morbidity,
and prevent or minimize the risk of developing post-thrombotic syndrome. The
cornerstone of treatment is anticoagulation. NICE guidelines only recommend
treating proximal DVT (not distal) and those with pulmonary emboli. In each
patient, the risks of anticoagulation need to be weighed against the benefits.
Option D: In general, diabetes is a contributing factor associated with peripheral
vascular disease. In the hospital, the most commonly associated conditions are
malignancy, congestive heart failure, obstructive airway disease, and patients
undergoing surgery. In the hospital, the most commonly associated conditions are
malignancy, congestive heart failure, obstructive airway disease, and patients
undergoing surgery.
13. Question
Which intervention should the nurse in charge try first for a client that exhibits
signs of sleep disturbance?

A. Administer sleeping medication before bedtime.

B. Ask the client each morning to describe the quantity of sleep during the
previous night.
C. Teach the client relaxation techniques, such as guided imagery, medication, and
progressive muscle relaxation.
D. Provide the client with normal sleep aids, such as pillows, back rubs, and
snacks.
Incorrect
Correct Answer: D. Provide the client with normal sleep aids, such as pillows, back
rubs, and snacks

The nurse should begin with the simplest interventions, such as pillows or snacks,
before interventions that require greater skill such as relaxation techniques.
Sleep is a complex biological process. It is a reversible state of unconsciousness
in which there are reduced metabolism and motor activity. Sleep disorders are a
group of conditions that disturb the normal sleep patterns of a person. Sleep
disorders are one of the most common clinical problems encountered. Inadequate or
non-restorative sleep can interfere with normal physical, mental, social, and
emotional functioning. Sleep disorders can affect overall health, safety, and
quality of life.

Option A: Sleep medication should be avoided whenever possible. Histamine type 1

receptor blockers: due to their sedative effects, these drugs can be helpful in
patients with sleep disorders. Benzodiazepines (BZD) are the mainstay in the
treatment of insomnia. Non-benzodiazepine hypnotics are used for the treatment of
acute and short term insomnia.
Option B: At some point, the nurse should do a thorough sleep assessment,
especially if common sense interventions fail. The sleep diary, or sleep log, is a
subjective paper record of sleep and wakefulness over a period of weeks to a month.
Patients should record the detailed description of sleep, such as bedtime, duration
until sleep onset, the number of awakenings, duration of awakenings, and nap times.
Option C: Relaxation techniques may be implemented before sleep. Meditation and
breathing exercises are some of the relaxation techniques. It begins with being in
a comfortable position and closing eyes. The mind and thoughts should be redirected
towards a peaceful image, and relaxation should be allowed to spread throughout the
body.
14. Question
While examining a client’s leg, the nurse notes an open ulceration with visible
granulation tissue in the wound. Until a wound specialist can be contacted, which
type of dressings is most appropriate for the nurse in charge to apply?
 A. Dry sterile dressing
B. Sterile petroleum gauze
C. Moist, sterile saline gauze
D. Povidone-iodine-soaked gauze
Incorrect
Correct Answer: C. Moist, sterile saline gauze

Moist, sterile saline dressings support would heal and are cost-effective. If the
wound is infected and there are a lot of sloughs, which cannot be mechanically
debrided, then a chemical debridement can be done with collagenase-based products.
The goal is to help the wound heal as soon as possible by using an appropriate
dressing material to maintain the right amount of moisture. When the wound bed is
dry, use a dressing to increase moisture and if too wet and the surrounding skin is
macerated, use material that will absorb excess fluid and protect the surrounding
healthy skin.

Option A: Dry sterile dressings adhere to the wound and debride the tissue when
removed. Tulle is a non-adherent dressing impregnated with paraffin. It aids
healing but doesn’t absorb exudate. It also requires a secondary dressing to hold
it in place. It is ideal for burns as one can add topical antibiotics to the
dressing. It is known to cause allergies, and this limits its wider use.
Option B: Petroleum supports healing but is expensive. The semipermeable dressing
allows for moisture to evaporate and also reduces pain. This dressing also acts as
a barrier to prevent environmental contamination. The semipermeable dressing does
not absorb moisture and requires regular inspection. It also requires a secondary
dressing to hold the semipermeable dressing in place.
Option D: Povidone-iodine can irritate epithelial cells, so it shouldn’t be left on
an open wound. Plastic film dressings are known to absorb exudate and can be used
for wounds with a moderate amount of exudate. They should not be used on dry
wounds. They often require a secondary dressing to hold the plastic in place.
15. Question
A male client in a behavioral-health facility receives a 30-minute psychotherapy
session, and the provider uses a current procedure terminology (CPT) code that
bills for a 50-minute session. Under the False Claims Act, such illegal behavior is
known as:

A. Unbundling
B. Overbilling
C. Upcoding
D. Misrepresentation
Incorrect
Correct Answer: C. Upcoding

Upcoding is the practice of using a CPT code that’s reimbursed at a higher rate
than the code for the service actually provided. Upcoding is fraudulent medical
billing in which a bill sent for a health service is more expensive than it should
have been based on the service that was performed. An upcoded bill can be sent to
any payer—whether a private health insurer, Medicaid, Medicare, or the patient.
Unbundling, overbilling, and misrepresentation aren’t the terms used for this
illegal practice.

Option A: Unbundling refers to using multiple CPT codes for those parts of the
procedure, either due to misunderstanding or in an effort to increase payment.
Option B: Overbilling (sometimes spelled as over-billing) is the practice of
charging more than is legally or ethically acceptable on an invoice or bill.
Option D: A misrepresentation is a false statement of a material fact made by one
party which affects the other party’s decision in agreeing to a contract. If the
misrepresentation is discovered, the contract can be declared void, and depending
on the situation, the adversely impacted party may seek damages.
16. Question
A nurse assigned to care for a postoperative male client who has diabetes mellitus.
During the assessment interview, the client reports that he’s impotent and says
that he’s concerned about its effect on his marriage. In planning this client’s
care, the most appropriate intervention would be to:

A. Encourage the client to ask questions about personal sexuality.

B. Provide time for privacy.
C. Provide support for the spouse or significant other.
D. Suggest referral to a sex counselor or other appropriate professional.
Incorrect
Correct Answer: D. Suggest referral to a sex counselor or other appropriate
professional

The nurse should refer this client to a sex counselor or other professional. Making
appropriate referrals is a valid part of planning the client’s care. Therefore,
providing time for privacy and providing support for the spouse or significant
other are important, but not as important as referring the client to a sex
counselor.

Option A: The nurse doesn’t normally provide sex counseling. The nurse is ideally
placed in the primary care field to help ease the upset caused; however, in order
to offer care that is effective, insight and understanding of the condition are
required as well as the various treatment options available to help men manage
their health and wellbeing.
Option B: The key goal of management is to diagnose and treat the cause of ED when
this is possible, enabling the man or couple to enjoy a satisfactory sexual
experience. This can occur when the nurse has identified and treated any curable
causes of ED, initiating lifestyle change and risk factor modification, including
drug-related factors, and offering education and counselling to patients and their
partners.
Option C: The potential benefits of lifestyle changes (e.g. weight management,
smoking cessation) may be particularly important in individuals with ED and
specific comorbid cardiovascular or metabolic diseases, such as diabetes or
hypertension. As well as improving erectile function, lifestyle changes may also
benefit overall cardiovascular and metabolic health. Further studies are needed to
clarify the role of lifestyle changes in the management of ED and related
cardiovascular disease.
17. Question
Using Abraham Maslow’s hierarchy of human needs, a nurse assigns highest priority
to which client need?

A. Security
B. Elimination
C. Safety
D. Belonging
Incorrect
Correct Answer: B. Elimination

According to Maslow, elimination is a first-level or physiological need and

therefore takes priority over all other needs. In 1943, Abraham Maslow developed a
hierarchy based on basic fundamental needs innate for all individuals. Maslow’s
hierarchy of needs is a motivational theory in psychology comprising a five-tier
model of human needs, often depicted as hierarchical levels within a pyramid. From
the bottom of the hierarchy upwards, the needs are: physiological (food and
clothing), safety (job security), love and belonging needs (friendship), esteem,
and self-actualization. Security and safety are second-level needs; belonging is a
third-level need. Second- and third-level needs can be met only after a client’s
first-level needs have been satisfied.
Option A: Once an individual’s physiological needs are satisfied, the needs for
security and safety become salient. People want to experience order,
predictability, and control in their lives. These needs can be fulfilled by the
family and society (e.g. police, schools, business, and medical care).
Option C: Physiological and safety needs provide the basis for the implementation
of nursing care and nursing interventions. For example, emotional security,
financial security (e.g. employment, social welfare), law and order, freedom from
fear, social stability, property, health, and wellbeing (e.g. safety against
accidents and injury).
Option D: After physiological and safety needs have been fulfilled, the third level
of human needs is social and involves feelings of belongingness. The need for
interpersonal relationships motivates behavior. Examples include friendship,
intimacy, trust, and acceptance, receiving and giving affection and love.
Affiliating, being part of a group (family, friends, work)
18. Question
A male client on prolonged bed rest has developed a pressure ulcer. The wound shows
no signs of healing even though the client has received skin care and has been
turned every 2 hours. Which factor is most likely responsible for the failure to
heal?

A. Inadequate vitamin D intake.

B. Inadequate protein intake.
C. Inadequate massaging of the affected area.
D. Low calcium level.
Incorrect
Correct Answer: B. Inadequate protein intake.

A client on bed rest suffers from a lack of movement and a negative nitrogen
balance. Therefore, inadequate protein intake impairs wound healing. Decubitus
ulcers, also termed bedsores or pressure ulcers, are skin and soft tissue injuries
that form as a result of constant or prolonged pressure exerted on the skin. These
ulcers occur at bony areas of the body such as the ischium, greater trochanter,
sacrum, heel, malleolus (lateral than medial), and occiput. Inadequate vitamin D
intake and low calcium levels aren’t factors in poor healing for this client. A
pressure ulcer should never be massaged.

Option A: Decubitus ulcer formation is multifactorial (external and internal

factors), but all these results in a common pathway leading to ischemia and
necrosis. Tissues can sustain an abnormal amount of external pressure, but constant
pressure exerted over a prolonged period is the main culprit.
Option C: External pressure must exceed the arterial capillary pressure (32 mmHg)
to impede blood flow and must be greater than the venous capillary closing pressure
(8 to 12 mmHg) to impair the return of venous blood. If the pressure above these
values is maintained, it causes tissue ischemia and further resulting in tissue
necrosis. This enormous pressure can be exerted due to compression by a hard
mattress, railings of hospital beds, or any hard surface with which the patient is
in contact.
Option D: Friction caused by skin rubbing against surfaces like clothing or bedding
can also lead to the development of ulcers by contributing to breaks in the
superficial layers of the skin. Moisture can cause ulcers and worsens existing
ulcers via tissue breakdown and maceration.
19. Question
A female client who received general anesthesia returns from surgery.
Postoperatively, which nursing diagnosis takes highest priority for this client?

A. Acute pain related to surgery.

B. Deficient fluid volume related to blood and fluid loss from surgery.
C. Impaired physical mobility related to surgery.
 D. Risk for aspiration related to anesthesia.
Incorrect
Correct Answer: D. Risk for aspiration related to anesthesia.

Risk for aspiration related to anesthesia takes priority for this client because
general anesthesia may impair the gag and swallowing reflexes, possibly leading to
aspiration. The gag reflex, also known as the pharyngeal reflex, is a reflex
contraction of the muscles of the posterior pharynx after stimulation of the
posterior pharyngeal wall, tonsillar area, or base of the tongue. The gag reflex is
believed to be an evolutionary reflex that developed as a method to prevent the
aspiration of solid food particles. It is an essential component of evaluating the
medullary brainstem and plays a role in the declaration of brain death.The other
options, although important, are secondary.

Option A: Postoperative pain can additionally characterize as somatic or visceral.

The somatic division of pain is composed of a rich input of nociceptive myelinated,
rapidly conducting A-beta-fibers found in cutaneous and deep tissue, which
contribute to a more localized, sharp quality. The visceral division of pain is
composed of a network of unmyelinated C-fibers and thinly myelinated A-delta-fibers
that span across multiple viscera and converge together before entering the spinal
cord. Also, visceral afferent fibers run close to autonomic ganglia before their
entrance into the dorsal root of the spinal cord. These characteristic features of
visceral nociceptive fibers are what contribute to a more diffuse, poorly localized
pattern of pain that may be accompanied by autonomic reactions such as a change in
heart rate or blood pressure.
Option B: The acid-base and electrolyte changes observed in the perioperative
period could be secondary to the underlying illness or surgical procedure, for
example, hyponatremia occurring with transurethral resection of the prostate where
glycine or other hypotonic fluid is used for irrigation. Serum sodium concentration
<120 mmol/L will cause confusion and irritability, whereas <110 mmol/L may cause
seizures and coma.
Option C: Complete physiologic recovery takes place by 40 min in 40% of the
patients. The functional quality of recovery in all domains occurs in only 11% of
the patients by day 3. Thus, the concept of awakening is involved with far greater
dimensions than judging the anesthetic effect as terminated and assessing a patient
as being “recovered” or “awakened.” Patients cannot be considered fully recovered
until they have returned to their preoperative physiological state.
20. Question
The nurse inspects a client’s back and notices small hemorrhagic spots. The nurse
documents that the client has:

A. Extravasation
B. Osteomalacia
C. Petechiae
D. Uremia
Incorrect
Correct Answer: C. Petechiae

Petechiae are small hemorrhagic spots. Petechiae are tiny purple, red, or brown
spots on the skin. They usually appear on the arms, legs, stomach, and buttocks.
They can also be found inside the mouth or on the eyelids. These pinpoint spots can
be a sign of many different conditions — some minor, others serious. They can also
appear as a reaction to certain medications.

Option A: Extravasation is the leakage of fluid in the interstitial space.

Extravasation is the leakage of a fluid out of its container into the surrounding
area, especially blood or blood cells from vessels. In the case of inflammation, it
refers to the movement of white blood cells from the capillaries to the tissues
surrounding them (leukocyte extravasation, also known as diapedesis).
Option B: Osteomalacia is the softening of bone tissue. Osteomalacia refers to a
marked softening of the bones, most often caused by severe vitamin D deficiency.
The softened bones of children and young adults with osteomalacia can lead to
bowing during growth, especially in weight-bearing bones of the legs. Osteomalacia
in older adults can lead to fractures.
Option D: Uremia is an excess of urea and other nitrogen products in the blood.
Uremia is the condition of having high levels of urea in the blood. Urea is one of
the primary components of urine. It can be defined as an excess of amino acid and
protein metabolism end products, such as urea and creatinine, in the blood that
would be normally excreted in the urine.
21. Question
Which document addresses the client’s right to information, informed consent, and
treatment refusal?

A. Standard of Nursing Practice

B. Patient’s Bill of Rights
C. Nurse Practice Act
D. Code for Nurses
Incorrect
Correct Answer: B. Patient’s Bill of Rights

The Patient’s Bill of Rights addresses the client’s right to information, informed
consent, timely responses to requests for services, and treatment refusal. A legal
document, it serves as a guideline for the nurse’s decision making. Standards of
Nursing Practice, the Nurse Practice Act, and the Code for Nurses contain nursing
practice parameters and primarily describe the use of the nursing process in
providing care.

Option A: Standards of nursing practice developed by the American Nurses’

Association (ANA) provide guidelines for nursing performance. They are the rules or
definition of what it means to provide competent care. The registered professional
nurse is required by law to carry out care in accordance with what other reasonably
prudent nurses would do in the same or similar circumstances. Thus, provision of
high-quality care consistent with established standards is critical.
Option C: Every state and territory in the US set laws to govern the practice of
nursing. These laws are defined in the Nursing Practice Act (NPA). The NPA is then
interpreted into regulations by each state and territorial nursing board with the
authority to regulate the practice of nursing care and the power to enforce the
laws.
Option D: The ANA Code of Ethics for Nurses serves the following purposes: It is a
succinct statement of the ethical obligations and duties of every individual who
enters the nursing profession. It is the profession’s nonnegotiable ethical
standard. It is an expression of nursing’s own understanding of its commitment to
society.
22. Question
If a blood pressure cuff is too small for a client, blood pressure readings taken
with such a cuff may do which of the following?

A. Fail to show changes in blood pressure.

B. Produce a false-high measurement.
C. Cause sciatic nerve damage.
D. Produce a false-low measurement.
Incorrect
Correct Answer: B. Produce a false-high measurement.

Using an undersized blood pressure cuff produces a falsely elevated blood pressure
because the cuff can’t record brachial artery measurements unless it’s excessively
inflated.
Option A: Using a blood pressure cuff that’s too large or too small can give
inaccurate blood pressure readings. The doctor’s office should have several sizes
of cuffs to ensure an accurate blood pressure reading. When one measures their
blood pressure at home, it’s important to use the proper size cuff.
Option C: The sciatic nerve wouldn’t be damaged by hyperinflation of the blood
pressure cuff because the sciatic nerve is located in the lower extremity.
Option D: The inflatable part of the blood pressure cuff should cover about 40% of
the distance around (circumference of) the upper arm. The cuff should cover 80% of
the area from the elbow to the shoulder.
23. Question
Nurse Elijah has been teaching a client about a high-protein diet. The teaching is
successful if the client identifies which meal as high in protein?

A. Baked beans, hamburger, and milk

B. Spaghetti with cream sauce, broccoli, and tea
C. Bouillon, spinach, and soda
D. Chicken cutlet, spinach, and soda
Incorrect
Correct Answer: A. Baked beans, hamburger, and milk

Baked beans, hamburger, and milk are all excellent sources of protein. Good choices
include soy protein, beans, nuts, fish, skinless poultry, lean beef, pork, and low-
fat dairy products. Avoid processed meats.

Option B: The spaghetti-broccoli-tea choice is high in carbohydrates. The quality

of the carbohydrates (carbs) one eats is important too. Cut processed carbs from
the diet, and choose carbs that are high in fiber and nutrient-dense, such as whole
grains and vegetables and fruit.
Option C: The bouillon-spinach-soda choice provides liquid and sodium as well as
some iron, vitamins, and carbohydrates.
Option D: Chicken provides protein but the chicken-spinach-soda combination
provides less protein than the baked beans-hamburger-milk selection.
24. Question
A male client is admitted to the hospital with blunt chest trauma after a motor
vehicle accident. The first nursing priority for this client would be to:

A. Assess the client’s airway.

B. Provide pain relief.
C. Encourage deep breathing and coughing.
D. Splint the chest wall with a pillow.
Incorrect
Correct Answer: A. Assess the client’s airway.

The first priority is to evaluate airway patency before assessing for signs of
obstruction, sternal retraction, stridor, or wheezing. Airway management is always
the nurse’s first priority. Blunt trauma, on the whole, is a more common cause of
traumatic injuries and can be equally life-threatening. It is important to know the
mechanism as management may be different. Most blunt trauma is managed non-
operatively, whereas penetrating chest trauma often requires operative
intervention. Pain management and splinting are important for the client’s comfort
but would come after airway assessment.

Option B: Pain control greatly affects mortality and morbidity in patients with
chest trauma. Pain leads to splints which worsen or prevent healing. In many cases,
it can lead to pneumonia. Early analgesia should be considered to decrease
splinting. In the acute setting, push doses of short-acting narcotics should be
used.
Option C: Coughing and deep breathing may be contraindicated if the client has
internal bleeding and other injuries. Minor injuries may simply require close
monitoring and pain control. Care should be taken in the young and the elderly.
Patients with 3 or more rib fractures, a flail segment, and any number of rib
fractures with pulmonary contusions, hemopneumothorax, hypoxia, or pre-existing
pulmonary disease should be monitored at an advanced level of care.
Option D: Immediate life-threatening injuries require prompt intervention, such as
emergent tube thoracostomy for large pneumothoraces, and initial management of
hemothorax. For cases of hemothorax, adequate drainage is imperative to prevent
retained hemothorax. Retained hemothorax can lead to empyema requiring video-
assisted thoracoscopic surgery.
25. Question
A newly hired charge nurse assesses the staff nurses as competent individually but
ineffective and unproductive as a team. In addressing her concern, the charge nurse
should understand that the usual reason for such a situation is:

A. Unhappiness about the charge in leadership.

B. Unexpected feelings and emotions among the staff.
C. Fatigue from overwork and understaffing.
D. Failure to incorporate staff in decision making.
Incorrect
Correct Answer: B. Unexpected feelings and emotions among the staff.

The usual or most prevalent reason for lack of productivity in a group of competent
nurses is inadequate communication or a situation in which the nurses have
unexpected feelings and emotions. Although the other options could be contributing
to the problematic situation, they’re less likely to be the cause.

Option A: Providing employees with acknowledgment of the good work that they have
done is one of the easiest management tasks. However, it is also as easily
neglected. For instance, a study in the financial sector shows that only 20% of
employees feel strongly valued at work.
Option C: Another big issue that causes low productivity is workplace stress. A
study by Health Advocate shows that there are about one million employees who are
suffering from low productivity due to stress, which costs companies $600 dollars
per worker every single year.
Option D: An important reason for low employee productivity might be the fact that
they do not feel that they belong with the company that they are part of. It is
important for every manager to make sure that the environment in their business is
welcoming to new hires and does not make them feel underappreciated.
26. Question
A male client blood test results are as follows: white blood cell (WBC) count,
100ul; hemoglobin (Hb) level, 14 g/dl; hematocrit (HCT), 40%. Which goal would be
most important for this client?

A. Promote fluid balance

B. Prevent infection
C. Promote rest
D. Prevent injury
Incorrect
Correct Answer: B. Prevent infection

The client is at risk for infection because WBC count is dangerously low.
Neutrophils play an essential role in immune defenses because they ingest, kill,
and digest invading microorganisms, including fungi and bacteria. Failure to carry
out this role leads to immunodeficiency, which is mainly characterized by the
presence of recurrent infections. Hb level and HCT are within normal limits;
therefore, fluid balance, rest, and prevention of injury are inappropriate.

Option A: Neutrophils play a role in the immune defense against extracellular

bacteria, including Staphylococci, Streptococci, and Escherichia coli, among
others. They also protect against fungal infections, including those produced by
Candida albicans. Once their count is below 1 x 10/L recurrent infections start. As
compensation, the monocyte count may increase.
Option C: Application of granulocyte-colony stimulating factor (G-CSF) can improve
neutrophil functions and number. Prophylactic use of antibiotics and antifungals is
reserved for some forms of alteration in neutrophil function such as chronic
granulomatous disease CGD).
Option D: In primary neutropenia disorders such as chronic granulomatous disease
presents with recurrent infections affecting many organs since childhood. It is
caused by a failure to produce toxic reactive oxygen species so that the
neutrophils can ingest the microorganisms, but they are unable to kill them, as a
significant consequence granuloma can obstruct organs such as the stomach,
esophagus, or bladder. Patients with this disease are very susceptible to
opportunistic infections by certain bacteria and fungi, especially with Serratia
and Burkholderia.
27. Question
Following a tonsillectomy, a female client returns to the medical-surgical unit.
The client is lethargic and reports having a sore throat. Which position would be
most therapeutic for this client?

A. Semi-Fowler’s
B. Supine
C. High-Fowler’s
D. Side-lying
Incorrect
Correct Answer: D. Side-lying

Because of lethargy, the post-tonsillectomy client is at risk for aspirating blood

from the surgical wound. Therefore, placing the client in the side-lying position
until he awake is best. The semi-Fowler’s, supine, and high-Fowler’s position don’t
allow for adequate oral drainage in a lethargic post-tonsillectomy client and
increase the risk of blood aspiration.

Option A: Semi-Fowler’s would not be able to facilitate effective drainage.

Bleeding is one of the most common and feared complications following tonsillectomy
with or without adenoidectomy. A study from 2009 to 2013 involving over one hundred
thousand children showed that 2.8% of children had unplanned revisits for bleeding
following tonsillectomy, 1.6% percent of patients came through the emergency
department, and 0.8% required a procedure.
Option B: Supine position predisposes the patient to aspiration. Frequency is
higher at night with 50% of bleeding occurring between 10pm-1am and 6am-9am; this
is thought to be from changes in circadian rhythm, vibratory effects of snoring on
the oropharynx, or drying of the oropharyngeal mucosa from mouth breathing. Risk of
bleeding in patients with known coagulopathies may be significantly higher.
Option C: Tonsillectomy can be either extracapsular or intracapsular. The “hot”
extracapsular technique with monopolar cautery is the most popular technique in the
United States.
28. Question
The nurse inspects a client’s pupil size and determines that it’s 2 mm in the left
eye and 3 mm in the right eye. Unequal pupils are known as:

A. Anisocoria
B. Ataxia
C. Cataract
D. Diplopia
Incorrect
Correct Answer: A. Anisocoria

Unequal pupils are called anisocoria. Anisocoria, or unequal pupil sizes, is a

common condition. The varied causes have implications ranging from life-threatening
to completely benign, and a clinically guided history and examination is the first
step in establishing a diagnosis.

Option B: Ataxia is uncoordinated actions of involuntary muscle use. Ataxia is a

degenerative disease of the nervous system. Many symptoms of Ataxia mimic those of
being drunk, such as slurred speech, stumbling, falling, and incoordination. These
symptoms are caused by damage to the cerebellum, the part of the brain that is
responsible for coordinating movement.
Option C: A cataract is an opacity of the eye’s lens. A cataract is a clouding of
the normally clear lens of the eye. For people who have cataracts, seeing through
cloudy lenses is a bit like looking through a frosty or fogged-up window. Clouded
vision caused by cataracts can make it more difficult to read, drive a car
(especially at night) or see the expression on a friend’s face.
Option D: Diplopia is double vision. Diplopia is the perception of 2 images of a
single object. Diplopia may be monocular or binocular. Monocular diplopia is
present when only one eye is open. Binocular diplopia disappears when either eye is
closed.
29. Question
The nurse in charge is caring for an Italian client. He’s complaining of pain, but
he falls asleep right after his complaint and before the nurse can assess his pain.
The nurse concludes that:

A. He may have a low threshold for pain.

B. He was faking pain.
C. Someone else gave him medication.
D. The pain went away.
Incorrect
Correct Answer: A. He may have a low threshold for pain.

People of Italian heritage tend to verbalize discomfort and pain. The pain was real
to the client, and he may need medication when he wakes up. Italian females
reported the highest sensitivity to both mechanical and electrical stimulation,
while Swedes reported the lowest sensitivity. Mechanical pain thresholds differed
more across cultures than did electrical pain thresholds. Cultural factors may
influence response to type of pain test.

Option B: Our pain threshold is the minimum point at which something, such as
pressure or heat, causes us pain. For example, someone with a lower pain threshold
might start feeling pain when only minimal pressure is applied to part of their
body. Pain tolerance and threshold varies from person to person.
Option C: When we feel pain, nearby nerves send signals to the brain through the
spinal cord. The brain interprets this signal as a sign of pain, which can set off
protective reflexes. For example, when one touches something very hot, the brain
receives signals indicating pain. This in turn can make one quickly pull the hand
away without even thinking.
Option D: Biofeedback is a type of therapy that helps increase the awareness of how
the body responds to stressors and other stimuli. This includes pain. During a
biofeedback session, a therapist will teach the client how to use relaxation
techniques, breathing exercises, and mental exercises to override the body’s
response to stress or pain.
30. Question
A female client is admitted to the emergency department with complaints of chest
pain and shortness of breath. The nurse’s assessment reveals jugular vein
distention. The nurse knows that when a client has jugular vein distension, it’s
typically due to:

A. A neck tumor
B. An electrolyte imbalance
 C. Dehydration
D. Fluid overload
Incorrect
Correct Answer: D. Fluid overload

Fluid overload causes the volume of blood within the vascular system to increase.
This increase causes the vein to distend, which can be seen most obviously in the
neck veins. JVD is a sign of increased central venous pressure (CVP). That’s a
measurement of the pressure inside the vena cava. CVP indicates how much blood is
flowing back into the heart and how well the heart can move that blood into the
lungs and the rest of the body.

Option A: A neck tumor doesn’t typically cause jugular vein distention. Right-sided
heart failure is a common cause. Right-sided heart failure usually develops after a
left-sided heart failure. The left ventricle pumps blood out through the aorta to
most of the body. The right ventricle pumps blood to the lungs. When the left
ventricle’s pumping power weakens, fluid can back up into the lungs. This
eventually weakens the right ventricle.
Option B: An electrolyte imbalance may result in fluid overload, but it doesn’t
directly contribute to jugular vein distention. The pericardium is a thin, fluid-
filled sac that surrounds the heart. An infection of the pericardium, called
constrictive pericarditis, can restrict the volume of the heart. As a result, the
chambers can’t fill with blood properly, so blood can back up into veins, including
the jugular veins.
Option C: Dehydration does not cause JVD. Another common cause is pulmonary
hypertension. Pulmonary hypertension occurs when the pressure in your lungs
increases, sometimes as a result of changes to the lining of the artery walls. This
can also lead to right-sided heart failure.
31. Question
Critical thinking and the nursing process have which of the following in common?
Both:

A. Are important to use in nursing practice.

B. Use an ordered series of steps.
C. Are patient-specific processes.
D. Were developed specifically for nursing.
Incorrect
Correct Answer: A. Are important to use in nursing practice.

Nurses make many decisions: some require using the nursing process, whereas others
are not client related but require critical thinking. Neither is linear. Critical
thinking applies to any discipline. n 1958, Ida Jean Orlando started the nursing
process that still guides nursing care today. Defined as a systematic approach to
care using the fundamental principles of critical thinking, client-centered
approaches to treatment, goal-oriented tasks, evidence-based practice (EDP)
recommendations, and nursing intuition. Holistic and scientific postulates are
integrated to provide the basis for compassionate, quality-based care.

Option B: The nursing process has specific steps; critical thinking does not. The
nursing process functions as a systematic guide to client-centered care with 5
sequential steps. These are assessment, diagnosis, planning, implementation, and
evaluation.
Option C: The utilization of the nursing process to guide care is clinically
significant going forward in this dynamic, complex world of patient care. Aging
populations carry with them a multitude of health problems and inherent risks of
missed opportunities to spot a life-altering condition.
Option D: Critical thinking skills will play a vital role as we develop plans of
care for these patient populations with multiple comorbidities and embrace this
challenging healthcare arena. Thus, the trend towards concept-based curriculum
changes will assist us in the navigation of these uncharted waters.
32. Question
In which step of the nursing process does the nurse analyze data and identify
client problems?

A. Assessment
B. Diagnosis
C. Planning outcomes
D. Evaluation
Incorrect
Correct Answer: B. Diagnosis

In the diagnosis phase, the nurse identifies the client’s health status. The North
American Nursing Diagnosis Association (NANDA) provides nurses with an up to date
list of nursing diagnoses. A nursing diagnosis, according to NANDA, is defined as a
clinical judgment about responses to actual or potential health problems on the
part of the patient, family, or community.

Option A: In the assessment phase, the nurse gathers data from many sources for
analysis in the diagnosis phase. Assessment is the first step and involves critical
thinking skills and data collection; subjective and objective. Subjective data
involves verbal statements from the patient or caregiver. Objective data is
measurable, tangible data such as vital signs, intake and output, and height and
weight.
Option C: In the planning outcomes phase, the nurse formulates goals and outcomes.
The planning stage is where goals and outcomes are formulated that directly impact
patient care based on EDP guidelines. These patient-specific goals and the
attainment of such assist in ensuring a positive outcome. Nursing care plans are
essential in this phase of goal setting. Care plans provide a course of direction
for personalized care tailored to an individual’s unique needs. Overall condition
and comorbid conditions play a role in the construction of a care plan. Care plans
enhance communication, documentation, reimbursement, and continuity of care across
the healthcare continuum.
Option D: In the evaluation phase, which occurs after implementing interventions,
the nurse gathers data about the client’s responses to nursing care to determine
whether client outcomes were met. This final step of the nursing process is vital
to a positive patient outcome. Whenever a healthcare provider intervenes or
implements care, they must reassess or evaluate to ensure the desired outcome has
been met. Reassessment may frequently be needed depending upon overall patient
condition. The plan of care may be adapted based on new assessment data.
33. Question
In which phase of the nursing process does the nurse decide whether her actions
have successfully treated the client’s health problem?

A. Assessment
B. Diagnosis
C. Planning outcomes
D. Evaluation
Incorrect
Correct Answer: D. Evaluation

During the implementation phase, the nurse carries out the interventions or
delegates them to other health care team members. During the evaluation phase, the
nurse judges whether her actions have been successful in treating or preventing the
identified client health problem. This final step of the nursing process is vital
to a positive patient outcome. Whenever a healthcare provider intervenes or
implements care, they must reassess or evaluate to ensure the desired outcome has
been met. Reassessment may frequently be needed depending upon overall patient
condition. The plan of care may be adapted based on new assessment data.
Option A: In the assessment phase, the nurse gathers data from many sources for
analysis in the diagnosis phase. Assessment is the first step and involves critical
thinking skills and data collection; subjective and objective. Subjective data
involves verbal statements from the patient or caregiver. Objective data is
measurable, tangible data such as vital signs, intake and output, and height and
weight.
Option B: In the diagnosis phase, the nurse identifies the client’s health status.
The North American Nursing Diagnosis Association (NANDA) provides nurses with an up
to date list of nursing diagnoses. A nursing diagnosis, according to NANDA, is
defined as a clinical judgment about responses to actual or potential health
problems on the part of the patient, family or community.
Option C: In the planning outcomes phase, the nurse and client decide on goals they
want to achieve. In the intervention planning phase, the nurse identifies specific
interventions to help achieve the identified goal. The planning stage is where
goals and outcomes are formulated that directly impact patient care based on EDP
guidelines. These patient-specific goals and the attainment of such assist in
ensuring a positive outcome.
34. Question
What is the most basic reason that self-knowledge is important for nurses? Because
it helps the nurse to:

A. Identify personal biases that may affect his thinking and actions.
B. Identify the most effective interventions for a patient.
C. Communicate more efficiently with colleagues, patients, and families.
D. Learn and remember new procedures and techniques.
Incorrect
Correct Answer: A. Identify personal biases that may affect his thinking and
actions.

The most basic reason is that self-knowledge directly affects the nurse’s thinking
and the actions he chooses. Indirectly, thinking is involved in identifying
effective interventions, communicating, and learning procedures. However, because
identifying personal biases affect all the other nursing actions, it is the most
basic reason.

Option B: In philosophy, “self-knowledge” standardly refers to knowledge of one’s

own sensations, thoughts, beliefs, and other mental states. At least since
Descartes, most philosophers have believed that our knowledge of our own mental
states differs markedly from our knowledge of the external world (where this
includes our knowledge of others’ thoughts).
Option C: Perhaps the most widely accepted view along these lines is that self-
knowledge, even if not absolutely certain, is especially secure, in the following
sense: self-knowledge is immune from some types of error to which other kinds of
empirical knowledge—most obviously, perceptual knowledge—are vulnerable.
Option D: Self-awareness is important because when we have a better understanding
of ourselves, we are able to experience ourselves as unique and separate
individuals. We are then empowered to make changes and to build on our areas of
strength as well as identify areas where we would like to make improvements.
35. Question
Arrange the steps of the nursing process in the sequence in which they generally
occur.

Assessment
Diagnosis
Planning outcomes
Planning interventions
Evaluation
Incorrect
The correct order is shown above.

Logically, the steps are assessment, diagnosis, planning outcomes, planning

interventions, and evaluation. Keep in mind that steps are not always performed in
this order, depending on the patient’s needs and that steps overlap.

Option A: Assessment is the first step and involves critical thinking skills and
data collection; subjective and objective. Subjective data involves verbal
statements from the patient or caregiver. Objective data is measurable, tangible
data such as vital signs, intake and output, and height and weight.
Option B: This final step of the nursing process is vital to a positive patient
outcome. Whenever a healthcare provider intervenes or implements care, they must
reassess or evaluate to ensure the desired outcome has been met. Reassessment may
frequently be needed depending upon overall patient condition. The plan of care may
be adapted based on new assessment data.
Option C: The planning stage is where goals and outcomes are formulated that
directly impact patient care based on EDP guidelines. These patient-specific goals
and the attainment of such assist in ensuring a positive outcome. Nursing care
plans are essential in this phase of goal setting. Care plans provide a course of
direction for personalized care tailored to an individual’s unique needs. Overall
condition and comorbid conditions play a role in the construction of a care plan.
Care plans enhance communication, documentation, reimbursement, and continuity of
care across the healthcare continuum.
Option D: Implementation is the step which involves action or doing and the actual
carrying out of nursing interventions outlined in the plan of care. This phase
requires nursing interventions such as applying a cardiac monitor or oxygen, direct
or indirect care, medication administration, standard treatment protocols, and EDP
standards.
Option E: The formulation of a nursing diagnosis by employing clinical judgment
assists in the planning and implementation of patient care. The North American
Nursing Diagnosis Association (NANDA) provides nurses with an up to date list of
nursing diagnoses. A nursing diagnosis, according to NANDA, is defined as a
clinical judgment about responses to actual or potential health problems on the
part of the patient, family, or community.
36. Question
How are critical thinking skills and critical thinking attitudes similar? Both are:

A. Influences on the nurse's problem solving and decision making.

B. Like feelings rather than cognitive activities.
C. Cognitive activities rather than feelings.
D. Applicable in all aspects of a person's life.
Incorrect
Correct Answer: A. Influences on the nurse’s problem solving and decision making.

Cognitive skills are used in complex thinking processes, such as problem-solving

and decision making. Critical thinking attitudes determine how a person uses her
cognitive skills. Critical thinking attitudes are traits of the mind, such as
independent thinking, intellectual curiosity, intellectual humility, and fair-
mindedness, to name a few. Critical thinking skills refer to the cognitive
activities used in complex thinking processes. A few examples of these skills
involve recognizing the need for more information, recognizing gaps in one’s own
knowledge, and separating relevant information from irrelevant data. Critical
thinking, which consists of intellectual skills and attitudes, can be used in all
aspects of life.

Option B: Critical Thinking is, in short, self-directed, self-disciplined, self-

monitored, and self-corrective thinking. It presupposes assent to rigorous
standards of excellence and mindful command of their use. It entails effective
communication and problem-solving abilities and a commitment to overcome our native
egocentrism and sociocentrism.
Option C: Critical Thinking is a domain-general thinking skill. The ability to
think clearly and rationally is important whenever one chooses to do. But critical
thinking skills are not restricted to a particular subject area. Being able to
think well and solve problems systematically is an asset for any career.
Option D: A critical thinking attitude is related to the motivation to try to
reason well, but it can also motivate an attempt to use various strategies to
overcome personal limitations. Additionally, a person with a critical thinking
attitude should often rely on the expertise of others rather than trying to assess
all arguments on her own because expertise is often required to properly evaluate
an argument.
37. Question
The nurse is preparing to admit a patient from the emergency department. The
transferring nurse reports that the patient with chronic lung disease has a 30+
year history of tobacco use. The nurse used to smoke a pack of cigarettes a day at
one time and worked very hard to quit smoking. She immediately thinks to herself,
“I know I tend to feel negative about people who use tobacco, especially when they
have a serious lung condition; I figure if I can stop smoking, they should be able
to. I must remember how physically and psychologically difficult that is, and be
very careful not to let it be judgmental of this patient.” This best illustrates:

A. Theoretical knowledge
B. Self-knowledge
C. Using reliable resources
D. Use of the nursing process
Incorrect
Correct Answer: B. Self-knowledge

Personal knowledge is self-understanding—awareness of one’s beliefs, values,

biases, and so on. That best describes the nurse’s awareness that her bias can
affect her patient care. Self-knowledge refers to knowledge of one’s own mental
states, processes, and dispositions. Most agree it involves a capacity for
understanding the representational properties of mental states and their role in
shaping behavior.

Option A: Theoretical knowledge consists of information, facts, principles, and

theories in nursing and related disciplines; it consists of research findings and
rationally constructed explanations of phenomena. Theoretical knowledge is a
knowledge of why something is true. A set of true affirmations (factual knowledge)
does not necessarily explain anything. In order to explain something, it is
necessary to state why these truths are true. An explanation is required.
Option C: Using reliable resources is a critical thinking skill. Critical thinking
is, in short, self-directed, self-disciplined, self-monitored, and self-corrective
thinking. It presupposes assent to rigorous standards of excellence and mindful
command of their use. It entails effective communication and problem-solving
abilities and a commitment to overcome our native egocentrism and sociocentrism.
Option D: The nursing process is a problem-solving process consisting of the steps
of assessing, diagnosing, planning outcomes, planning interventions, implementing,
and evaluating. The nurse has not yet met this patient, so she could not have begun
the nursing process.
38. Question
Which organization’s standards require that all patients be assessed specifically
for pain?

A. American Nurses Association (ANA)

B. State nurse practice acts
C. National Council of State Boards of Nursing (NCSBN)
D. The Joint Commission
Incorrect
Correct Answer: D. The Joint Commission

The Joint Commission has developed assessment standards, including that all clients
be assessed for pain.

Option A: The ANA has developed standards for clinical practice, including those
for assessment, but not specifically for pain. The American Nurses Association
(ANA) is the premier organization representing the interests of the nation’s 4
million registered nurses. ANA is at the forefront of improving the quality of
health care for all. Founded in 1896, and with members in all 50 states and U.S.
territories, ANA is the strongest voice for the profession.
Option B: State nurse practice acts regulate nursing practice in individual states.
An NPA is enacted by state legislation and its purpose is to govern and guide
nursing practice within that state. An NPA is actually a law and must be adhered to
as law. Each state has a Board of Nursing (BON) that interprets and enforces the
rules of the NPA.
Option C: The NCSBN asserts that the scope of nursing includes a comprehensive
assessment but does not specifically include pain. National Council of State Boards
of Nursing (NCSBN) is an independent, not-for-profit organization through which
nursing regulatory bodies act and counsel together on matters of common interest
and concern affecting public health, safety, and welfare, including the development
of nursing licensure examinations.
39. Question
Which of the following is an example of data that should be validated?

A. The urinalysis report indicates there are white blood cells in the urine.
B. The client states she feels feverish; you measure the oral temperature at 98°F.
C. The client has clear breath sounds; you count a respiratory rate of 18.
D. The chest x-ray report indicates the client has pneumonia in the right lower
lobe.
Incorrect
Correct Answer: B. The client states she feels feverish; you measure the oral
temperature at 98°F.

Validation should be done when subjective and objective data do not make sense. For
instance, it is inconsistent data when the patient feels feverish and you obtain a
normal temperature. The other distractors do not offer conflicting data. Validation
is not usually necessary for laboratory test results.

Option A: When this test is positive and/or the WBC count in urine is high, it may
indicate that there is inflammation in the urinary tract or kidneys. The most
common cause for WBCs in urine (leukocyturia) is a bacterial urinary tract
infection (UTI), such as a bladder or kidney infection.
Option C: Breath sounds are the noises produced by the structures of the lungs
during breathing. Normal lung sounds occur in all parts of the chest area,
including above the collarbones and at the bottom of the rib cage. Using a
stethoscope, the doctor may hear normal breathing sounds, decreased or absent
breath sounds, and abnormal breath sounds. Normal respiration rates for an adult
person at rest range from 12 to 16 breaths per minute.
Option D: The most common organisms which cause lobar pneumonia are Streptococcus
pneumoniae, also called pneumococcus, Haemophilus influenza, and Moraxella
catarrhalis. Mycobacterium tuberculosis, the tubercle bacillus, may also cause
lobar pneumonia if pulmonary tuberculosis is not treated promptly.
40. Question
Which of the following is an example of appropriate behavior when conducting a
client interview?

A. Recording all the information on the agency-approved form during the interview.
B. Asking the client, "Why did you think it was necessary to seek health care at
this time?"
C. Using precise medical terminology when asking the client questions.
D. Sitting, facing the client in a chair at the client's bedside, using active
listening.
Incorrect
Correct Answer: D. Sitting, facing the client in a chair at the client’s bedside,
using active listening.

Active listening should be used during an interview. The nurse should face the
patient, have relaxed posture, and keep eye contact. Nonjudgmental interest in the
patient’s problems (active listening), empathy (communicating to the patient an
accurate assessment of emotional state), and concern for the patient as a unique
person are among the most important tools in the physician’s interpersonal
repertoire. The difference between interviewing a patient who is lying flat in bed
and one who is sitting in a chair can be striking. This simple act can emphasize
patient autonomy and active involvement in the interview.

Option A: Note-taking interferes with eye contact. By recognizing the patient’s

emotions and responding to them in a supportive manner, the clinician can conduct
an effective patient-centered interview.
Option B: Asking “why” may make the client defensive. Frequently used opening
questions include, “What problems brought you to the hospital (or office) today?”
or “What kind of problems have you been having recently?” or “What kind of problems
would you like to share with me?” These open-ended, non-directive questions
encourage the patient to report any and all problems. At this point in the
interview, it is important to let the patient talk spontaneously rather than
restricting and directing the flow of information with multiple questions.
Option C: The client may not understand medical terminology or health care jargon.
Questions should be worded so that the patient has no difficulty understanding what
is being asked. Avoid using technical terms and diagnostic labels. The
interviewer’s questions should indicate what type of information is requested, but
not what answer is expected.
41. Question
The nurse wishes to identify nursing diagnoses for a patient. She can best do this
by using a data collection form organized according to: Select all that apply.

A. A body systems model

B. A head-to-toe framework
C. Maslow's hierarchy of needs
D. Gordon's functional health patterns
E. Adaptation Model of Nursing
Incorrect
Correct Answer: C & D

Nursing models produce a holistic database that is useful in identifying nursing

rather than medical diagnoses. Body systems and Maslow’s hierarchy is not a nursing
model, but it is holistic, so it is acceptable for identifying nursing diagnoses.
Gordon’s functional health patterns are a nursing model.

Option A: A body system model is not a nursing model. It is a representation of all

the systems of the body in a figurine.
Option B: Head-to-toe framework is not a nursing model, and they are not holistic;
they focus on identifying physiological needs or disease.
Option C: Maslow’s hierarchy of needs is a motivational theory in psychology
comprising a five-tier model of human needs, often depicted as hierarchical levels
within a pyramid. From the bottom of the hierarchy upwards, the needs are:
physiological (food and clothing), safety (job security), love and belonging needs
(friendship), esteem, and self-actualization.
Option D: Gordon’s functional health patterns is a method devised by Marjory Gordon
to be used by nurses in the nursing process to provide a more comprehensive nursing
assessment of the patient.
Option E: The Adaptation Model of Nursing is a prominent nursing theory aiming to
explain or define the provision of nursing science. In her theory, Sister Callista
Roy’s model sees the individual as a set of interrelated systems that strives to
maintain a balance between various stimuli.
42. Question
The nurse is recording assessment data. She writes, “The patient seems worried
about his surgery. Other than that, he had a good night.” Which errors did the
nurse make? Select all that apply.

A. Used a vague generality.

B. Did not use the patient's exact words.
C. Used a "waffle" word (e.g., appears).
D. Recorded an inference rather than a cue.
E. Did not record the patient’s vital signs.
Incorrect
Correct Answer: A, C, D & E

The initial nursing assessment, the first step in the five steps of the nursing
process, involves the systematic and continuous collection of data; sorting,
analyzing, and organizing that data; and the documentation and communication of the
data collected. Subjective and objective data collection are an integral part of
this process.

Option A: The nurse recorded a vague generality: “he has had a good night.” The
assessment identifies current and future care needs of the patient by allowing the
formation of a nursing diagnosis. The nurse recognizes normal and abnormal patient
physiology and helps prioritize interventions and care.
Option B: The nurse did not use the patient’s exact words, but she did not quote
the patient at all, so that is not one of her errors.
Option C: The nurse used the “waffle” word, “seems” worried instead of documenting
what the patient said or did to lead her to that conclusion. Asking about how the
client feels and their response to those feelings is part of a psychological
assessment.
Option D: The nurse recorded these inferences: worried and had a good night. The
psychological examination may include perceptions, whether justifiable or not, on
the part of the patient or client. Religion and cultural beliefs are critical areas
to consider.
Option E: Part of the assessment includes data collection by obtaining vital signs
such as temperature, respiratory rate, heart rate, blood pressure, and pain level
using age or condition appropriate pain scale.
43. Question
A patient is admitted with shortness of breath, so the nurse immediately listens to
his breath sounds. Which type of assessment is the nurse performing?

A. Ongoing assessment
B. Comprehensive physical assessment
C. Focused physical assessment
D. Psychosocial assessment
Incorrect
Correct Answer: C. Focused physical assessment

The nurse is performing a focused physical assessment, which is done to obtain data
about an identified problem, in this case shortness of breath. Detailed nursing
assessment of specific body system(s) relating to the presenting problem or current
concern(s) of the patient. This may involve one or more body systems.

Option A: An ongoing assessment is performed as needed, after the initial data are
collected, preferably with each patient contact. Repeat of the focused or rapid
emergency department assessment of a prehospital patient to detect changes in
condition and to judge the effectiveness of treatment before or during transport.
Repeated every 5 minutes for an unstable patient and every 15 minutes for a stable
patient.
Option B: A comprehensive physical assessment includes an interview and a complete
examination of each body system. A comprehensive health assessment gives nurses
insight into a patient’s physical status through observation, the measurement of
vital signs, and self-reported symptoms. It includes a medical history, a general
survey, and a complete physical examination.
Option D: A psychosocial assessment examines both psychological and social factors
affecting the patient. The nurse conducting a psychosocial assessment would gather
information about stressors, lifestyle, emotional health, social influences, coping
patterns, communication, and personal responses to health and illness, to name a
few aspects.
44. Question
The nurse is assessing vital signs for a patient just admitted to the hospital.
Ideally, and if there are no contraindications, how should the nurse position the
patient for this portion of the admission assessment?

A. Sitting upright.
B. Lying flat on the back with knees flexed.
C. Lying flat on the back with arms and legs fully extended.
D. Side-lying with the knees flexed.
Incorrect
Correct Answer: A. Sitting upright.

If the patient is able, the nurse should have the patient sit upright to obtain
vital signs in order to allow the nurse to easily access the anterior and posterior
chest for auscultation of heart and breath sounds. It allows for full lung
expansion and is the preferred position for measuring blood pressure. Additionally,
patients might be more comfortable and feel less vulnerable when sitting upright
(rather than lying down on the back) and can have direct eye contact with the
examiner. However, other positions can be suitable when the patient’s physical
condition restricts the comfort or ability of the patient to sit upright.

Option B: Lying flat on the back with knees flexed or supine horizontal recumbent
is most commonly used during breast exam.
Option C: Lying flat on the back with arms and legs fully extended can make the
patient feel uncomfortable.
Option D: Sim’s position is usually used to obtain rectal temperature.
45. Question
For all body systems except the abdomen, what is the preferred order for the nurse
to perform the following examination techniques?

Inspection
Palpation
Percussion
Auscultation
Incorrect
The correct order is shown above.

Inspection begins immediately as the nurse meets the patient, as she observes the
patient’s appearance and behavior. Observational data are not intrusive to the
patient. When performing assessment techniques involving physical touch, the
behavior, posture, demeanor, and responses might be altered. Palpation, percussion,
and auscultation should be performed in that order, except when performing an
abdominal assessment. During abdominal assessment, auscultation should be performed
before palpation and percussion to prevent altering bowel sounds.
Option A: The ideal position for abdominal examination is to sit or kneel on the
right side of the patient with the hand and forearm in the same horizontal plane as
the patient’s abdomen. There are three stages of palpation that include the
superficial or light palpation, deep palpation, and organ palpation and should be
performed in the same order. Maneuvers specific to certain diseases are also a part
of abdominal palpation.
Option B: The last step of the abdominal examination is auscultation with a
stethoscope. The diaphragm of the stethoscope should be placed on the right side of
the umbilicus to listen to the bowel sounds, and their rate should be calculated
after listening for at least two minutes. Normal bowel sounds are low-pitched and
gurgling, and the rate is normally 2-5/min. Absent bowel sounds may indicate
paralytic ileus and hyperactive rushes (borborygmi) are usually present in small
bowel obstruction and sometimes may be auscultated in lactose intolerance.
Option C: It is important to begin with the general examination of the abdomen with
the patient in a completely supine position. The presence of any of the following
signs may indicate specific disorders. Distension of the abdomen could be present
due to small bowel obstruction, masses, tumors, cancer, hepatomegaly, splenomegaly,
constipation, abdominal aortic aneurysm, and pregnancy.
Option D: A proper technique of percussion is necessary to gain maximum information
regarding the abdominal pathology. While percussing, it is important to appreciate
tympany over air-filled structures such as the stomach and dullness to percussion
which may be present due to an underlying mass or organomegaly (for example,
hepatomegaly or splenomegaly)
46. Question
The nurse is assessing a patient admitted to the hospital with rectal bleeding. The
patient had a hip replacement 2 weeks ago. Which position should the nurse avoid
when examining this patient’s rectal area?

A. Sims'
B. Supine
C. Dorsal recumbent
D. Semi-Fowler's
Incorrect
Correct Answer: A. Sims’

Sims’ position is typically used to examine the rectal area. However, the position
should be avoided if the patient has undergone hip replacement surgery The patient
with a hip replacement can assume the supine, dorsal recumbent, or semi-Fowler’s
positions without causing harm to the joint.

Option B: Supine position is lying on the back facing upward. The supine position
means lying horizontally with the face and torso facing up, as opposed to the prone
position, which is face down. When used in surgical procedures, it allows access to
the peritoneal, thoracic, and pericardial regions; as well as the head, neck, and
extremities.
Option C: The patient in dorsal recumbent is on his back with knees flexed and
soles of feet flat on the bed. A position in which the patient lies on the back
with the lower extremities moderately flexed and rotated outward. It is employed in
the application of obstetrical forceps, repair of lesions following parturition,
vaginal examination, and bimanual palpation.
Option D: In semi-Fowler’s position, the patient is supine with the head of the bed
elevated and legs slightly elevated. The Semi-Fowler’s position is a position in
which a patient, typically in a hospital or nursing home is positioned on their
back with the head and trunk raised to between 15 and 45 degrees, although 30
degrees is the most frequently used bed angle.
47. Question
How should the nurse modify the examination for a 7-year-old child?
 A. Ask the parents to leave the room before the examination.
B. Demonstrate equipment before using it.
C. Allow the child to help with the examination.
D. Perform invasive procedures (e.g., otoscopic) last.
Incorrect
Correct Answer: B. Demonstrate equipment before using it.

The nurse should modify his examination by demonstrating equipment before using it
to examine a school-age child. The physical examination is often the first direct
contact between the nurse and the child. Establishing a trusting relationship
between the child and the examiner is important. Throughout the examination the
nurse should be sensitive to the cultural needs of and differences among children.
Providing a quiet, private environment for the history and physical examination is
important. The classic systematic approach to the physical examination is to begin
at the head and proceed through the entire body to the toes. When examining a
child, however, the examiner tailors the physical assessment to the child’s age and
developmental level.

Option A: The nurse should make sure parents are not present during the physical
examination of an adolescent, but they usually help younger children feel more
secure. To establish trust with the school-age child, the examiner asks the child
questions the child can answer. Children in elementary school will talk about
school, favorite friends, and activities. Older school-age children may have to be
encouraged to talk about their school performance and activities. The examiner
encourages the parent to support and reinforce the child’s participation in the
examination.
Option C: The nurse should allow a preschooler to help with the examination when
possible, but not usually a school-age child. The examination proceeds from head to
toe. Children of this age prefer a simple drape over their underpants or a colorful
examination gown, and the examiner should be sensitive to the child’s modesty. The
examination is a wonderful opportunity to teach the child about the body and
personal care. The nurse answers questions openly and in simple terms.
Option D: It is best to perform invasive procedures last for all age groups;
therefore, this does not represent a modification. Toddlers are often fearful of
invasive procedures, so those should be performed last in this age group.
48. Question
The nurse must examine a patient who is weak and unable to sit unaided or to get
out of bed. How should she position the patient to begin and perform most of the
physical examination?

A. Dorsal recumbent
B. Semi-Fowler's
C. Lithotomy
D. Sims'
Incorrect
Correct Answer: B. Semi-Fowler’s

If a patient is unable to sit up, the nurse should place him lying flat on his
back, with the head of the bed elevated. The Semi-Fowler’s position is a position
in which a patient, typically in a hospital or nursing home is positioned on their
back with the head and trunk raised to between 15 and 45 degrees, although 30
degrees is the most frequently used bed angle.

Option A: Dorsal recumbent position is used for abdominal assessment if the patient
has abdominal or pelvic pain. The patient in dorsal recumbent is on his back with
knees flexed and soles of feet flat on the bed.
Option C: Lithotomy position is used for female pelvic examination. It is similar
to dorsal recumbent position, except that the patient’s legs are well separated and
thighs are acutely flexed. Feet are usually placed in stirrups. Fold sheet or bath
blanket crosswise over thighs and legs so that genital area is easily exposed. Keep
the patient covered as much as possible.
Option D: The patient in Sim’s position is on the left side with right knee flexed
against abdomen and left knee slightly flexed. Left arm is behind the body; the
right arm is placed comfortably. Sims’ position is used to examine the rectal area.
In semi-Fowler’s position, the patient is supine with the head of the bed elevated
and legs slightly elevated.
49. Question
The nurse should use the diaphragm of the stethoscope to auscultate which of the
following?

A. Heart murmurs
B. Jugular venous hums
C. Bowel sounds
D. Carotid bruits
Incorrect
Correct Answer: C. Bowel sounds

The bell of the stethoscope should be used to hear low-pitched sounds, such as
murmurs, bruits, and jugular hums. The diaphragm should be used to hear high-
pitched sounds that normally occur in the heart, lungs, and abdomen. The diaphragm
is best for higher-pitched sounds, like breath sounds and normal heart sounds. The
bell is best for detecting lower pitch sounds, like some heart murmurs, and some
bowel sounds.

Option A: Earpieces should be angled forwards to match the direction of the

practitioner’s external auditory meatus. The bell is used to hear low-pitched
sounds. Use for mid-diastolic murmur of mitral stenosis or S3 in heart failure.
Option B: The stethoscope bell is lightly applied in each supraclavicular fossa
over the subclavian artery. As usual, the examiner’s free hand palpates the
contralateral carotid pulse for timing purposes. If a bruit is appreciated, firmly
compress the patient’s ipsilateral radial artery, noting the effect on the murmur.
Option D: If the intensity of sound is greater above the clavicle it is most likely
a carotid bruit. If it is louder below the clavicle it is most likely a heart
murmur. Use either the bell or the diaphragm when listening for the carotid bruit,
at a point just lateral to Adam’s apple.
50. Question
The nurse calculates a body mass index (BMI) of 18 for a young adult woman who
comes to the physician’s office for a college physical. This patient is considered:

A. Obese
B. Overweight
C. Average
D. Underweight
Incorrect
Correct Answer: D. Underweight

For adults, BMI should range between 20 and 25. Body mass index (BMI) is a person’s
weight in kilograms divided by the square of height in meters. BMI is an
inexpensive and easy screening method for the weight category—underweight, healthy
weight, overweight, and obesity.

Option A: BMI greater than 30 is considered obese For adults 20 years old and
older, BMI is interpreted using standard weight status categories. These categories
are the same for men and women of all body types and ages.
Option B: BMI 25 to 29.9 is overweight. The prevalence of adult BMI greater than or
equal to 30 kg/m2 (obese status) has greatly increased since the 1970s. Recently,
however, this trend has leveled off, except for older women. Obesity has continued
to increase in adult women who are 60 years and older.
Option C: BMI less than 20 is considered underweight. BMI can be a screening tool,
but it does not diagnose the body fatness or health of an individual. To determine
if BMI is a health risk, a healthcare provider performs further assessments. Such
assessments include skinfold thickness measurements, evaluations of diet, physical
activity, and family history.
51. Question
Using the principles of standard precautions, the nurse would wear gloves in what
nursing interventions?

A. Providing a back massage.

B. Feeding a client.
C. Providing hair care.
D. Providing oral hygiene.
Incorrect
Correct Answer: D. Providing oral hygiene

Doing oral care requires the nurse to wear gloves. Standard precautions apply to
the care of all patients, irrespective of their disease state. These precautions
apply when there is a risk of potential exposure to (1) blood; (2) all body fluids,
secretions, and excretions, except sweat, regardless of whether or not they contain
visible blood; (3) non-intact skin, and (4) mucous membranes. This includes the use
of hand hygiene and personal protective equipment (PPE), with hand hygiene being
the single most important means to prevent transmission of disease.

Option A: Must be worn when touching blood, body fluids, secretions, excretions,
mucous membranes, or non-intact skin. Change when there is contact with potentially
infected material in the same patient to avoid cross-contamination. Remove before
touching surfaces and clean items. Wearing gloves does not mitigate the need for
proper hand hygiene.
Option B: Hand washing after feeding the client is sufficient. Handwashing with
soap and water for at least 40 to 60 seconds, making sure not to use clean hands to
turn off the faucet, must be performed if hands are visibly soiled, after using the
restroom, or if potential exposure to spore-forming organisms.
Option C: Gloves are not needed in providing hair care. Hand rubbing with alcohol
applied generously to cover hands completely should be performed and hands rubbed
until dry.
52. Question
The nurse is preparing to take vital signs in an alert client admitted to the
hospital with dehydration secondary to vomiting and diarrhea. What is the best
method used to assess the client’s temperature?

A. Oral
B. Axillary
C. Radial
D. Heat sensitive tape
Incorrect
Correct Answer: B. Axillary

Axilla is the most accessible body part in this situation. Body temperature is a
numerical expression of the body’s heat and metabolic activity balance and can be a
major indicator of a person’s health status. Assessing a patient’s body temperature
is a common procedure nurses perform to monitor for signs of infection,
environmental exposure, shock, ovulation, or therapeutic response to medications or
medical procedures. A normal body temperature can be a potentially positive sign
that the patient isn’t experiencing a disease process, infection, or trauma and
that the body’s cells, tissues, and organs aren’t under metabolic distress.

Option A: The esophageal temperature probe (ETP) is an 18-in (45.7 cm) long, thin,
flexible catheter that has a rounded tip that should be lubricated with water-
soluble lubricant before being placed through the nares or mouth, extending into
the esophagus at least 2 to 3 in (5 to 7.6 cm). The external end portion of the
catheter has a small, coated wire with a plug that can be attached to a telemetry
monitor for continuous temperature monitoring.
Option C: The ETP and RTP (rectal temperature probe) are the same device but can be
used in either orifice depending on the patient’s medical condition. Again, the tip
should be lubricated with water-soluble lubricant, and then placed approximately 3
in (7.6 cm) inside the rectal vault. The RTP can also be attached to a telemetry
monitor cable for continuous temperature monitoring.
Option D: This is a latex-free, disposable, adhesive strip that can be applied to
the forehead. These strips contain embedded liquid crystals and chemical compounds
that react to the temperature (heat) of the skin by changing colors. After it has
been on the forehead for approximately 2 minutes, the color will illuminate a line
and correlate numeric temperature. The strips measure temperatures ranging from
96.6[degrees] F to 104.6[degrees] F (35.8[degrees] C to 40.3[degrees] C). Consider
use for infants, children, and adults with cognitive deficits because they’re
painless.
53. Question
A nurse obtained a client’s pulse and found the rate to be above normal. The nurse
document these findings as:

A. Tachypnea
B. Hyperpyrexia
C. Arrhythmia
D. Tachycardia
Incorrect
Correct Answer: D. Tachycardia

Tachycardia means rapid heart rate. Tachycardia refers to a heart rate that’s too
fast. How that’s defined may depend on age and physical condition. Generally
speaking, for adults, a heart rate of more than 100 beats per minute (BPM) is
considered too fast.

Option A: Tachypnea refers to rapid respiratory rate. Tachypnea is a respiration

rate greater than normal, resulting in abnormally rapid breathing. In adult humans
at rest, any respiratory rate between 12 and 20 breaths is normal and tachypnea is
indicated by a rate greater than 20 breaths per minute.
Option B: Hyperpyrexia means increase in temperature. Hyperpyrexia is another term
for a very high fever. The medical criterion for hyperpyrexia is when someone is
running a body temperature of more than 106.7°F or 41.5°C. Hyperpyrexia is an
emergency that needs immediate attention from a medical professional.
Option C: Arrhythmia means irregular heart rate. An arrhythmia is a problem with
the rate or rhythm of the heartbeat. During an arrhythmia, the heart can beat too
fast, too slowly, or with an irregular rhythm. When a heart beats too fast, the
condition is called tachycardia. When a heart beats too slowly, the condition is
called bradycardia.
54. Question
Which of the following actions should the nurse take to use wide base support when
assisting a client to get up in a chair?

A. Bend at the waist and place arms under the client’s arms and lift.
B. Face the client, bend knees, and place hands-on client’s forearm and lift.
C. Spread his or her feet apart.
D. Tighten his or her pelvic muscles.
Incorrect
Correct Answer: B. Face the client, bend knees, and place hands-on client’s forearm
and lift.

This is the proper way of supporting the client to get up in a chair that conforms
to safety and proper body mechanics. It is important to use proper body mechanics
as a health care professional for many reasons, foremost of which is to prevent
injuries to both patient and provider. Health care professionals at the front line,
especially those who deliver direct care to patients, are often in situations where
they have to assist with moving patients from one position to another.

Option A: Keep the back straight throughout the transfer to avoid bending or
straining the back. Get as close to the person as possible while still allowing
him/her to lean forward as needed to assist with the transfer.
Option C: Allow the patient to help as much as possible. Estimate the patient’s
weight and mentally practice. Make sure that the floor is free of any obstacles or
liquids. Keep your feet shoulder-width apart. Keep the person (or object) as close
to your body as possible. Tighten your stomach muscles.
Option D: Position patients appropriately for transfer. While standing in front of
the patient, maintain proper posture with the back straight and knees bent. Hold a
strong abdominal contraction. Position the body close to the patient to decrease
strain on the back. Before movement, contract the abdominal muscles to protect the
back. Use the knees and the lower body during transfer to decrease strain on the
back.
55. Question
A client had oral surgery following a motor vehicle accident. The nurse assessing
the client finds the skin flushed and warm. Which of the following would be the
best method to take the client’s body temperature?

A. Oral
B. Axillary
C. Arterial line
D. Rectal
Incorrect
Correct Answer: B. Axillary

Taking the temperature via the axilla is the most appropriate route. Body
temperature is a numerical expression of the body’s heat and metabolic activity
balance and can be a major indicator of a person’s health status. Assessing a
patient’s body temperature is a common procedure nurses perform to monitor for
signs of infection, environmental exposure, shock, ovulation, or therapeutic
response to medications or medical procedures. A normal body temperature can be a
potentially positive sign that the patient isn’t experiencing a disease process,
infection, or trauma and that the body’s cells, tissues, and organs aren’t under
metabolic distress.

Option A: Taking the temperature via the oral route is incorrect since the client
had oral surgery. The esophageal temperature probe (ETP) is an 18-in (45.7 cm)
long, thin, flexible catheter that has a rounded tip that should be lubricated with
water-soluble lubricant before being placed through the nares or mouth, extending
into the esophagus at least 2 to 3 in (5 to 7.6 cm). The external end portion of
the catheter has a small, coated wire with a plug that can be attached to a
telemetry monitor for continuous temperature monitoring.
Option C: A PiCCO thermodilution catheter (Pulsion Medical Systems) containing a
temperature thermistor was inserted into the brachial artery at the antecubital
fossa and doubled as the arterial pressure monitoring line and arterial blood
sampling portal. This measured brachial artery temperature from the time of
insertion to the time the patient left the operating room.
Option D: This is unnecessary. The ETP and RTP (rectal temperature probe) are the
same device but can be used in either orifice depending on the patient’s medical
condition. Again, the tip should be lubricated with water-soluble lubricant, and
then placed approximately 3 in (7.6 cm) inside the rectal vault. The RTP can also
be attached to a telemetry monitor cable for continuous temperature monitoring.
56. Question
A client who is unconscious needs frequent mouth care. When performing mouth care,
the best position of a client is:

A. Fowler’s position
B. Side-lying
C. Supine
D. Trendelenburg
Incorrect
Correct Answer: B. Side-lying

An unconscious client is best placed on his side when doing oral care to prevent
aspiration. An unconscious patient is placed in the side-lying position when mouth
care is provided because this position prevents pooling of secretions at the back
of the oral cavity, thereby reducing the risk of aspiration. Oral hygiene is
especially important for patients receiving oxygen therapy, patients who have
nasogastric tubes, and patients who are NPO. Their oral mucosa dries out much
faster than normal due to their mouth-breathing.

Option A: A soft toothbrush or gauze-padded tongue blade may be used to clean the
teeth and mouth. The patient should be positioned in the lateral position with the
head turned toward the side to provide for drainage and to prevent aspiration.
Option C: This is the most common position for surgery with a patient lying on his
or her back with head, neck, and spine in neutral positioning and arms either
adducted alongside the patient or abducted to less than 90 degrees.
Option D: A variation of supine in which the head of the bed is tilted down such
that the pubic symphysis is the highest point of the trunk facilitates venous
return and improves exposure during abdominal and laparoscopic surgeries.
57. Question
A client is hospitalized for the first time, which of the following actions ensure
the safety of the client?

A. Keep unnecessary furniture out of the way.

B. Keep the lights on at all times.
C. Keep side rails up at all times.
D. Keep all equipment out of view.
Incorrect
Correct Answer: C. Keep side rails up at all time

Keeping the side rails up at all times ensures the safety of the client. The risk
of falling increases with age and the number of times someone has been in hospital.
During the client’s hospital stay, he may be more unsteady on his feet because of
illness or surgery, or because he is unfamiliar with the hospital environment or is
taking new medication.

Option A: Home health care providers need to know the risk factors for falls and
demonstrate effective assessment and interventions for fall and injury prevention.
Falls are generally the result of a complex set of intrinsic patient and extrinsic
environmental factors. Use of a fall-prevention program, standardized tools, and an
interdisciplinary approach may be effective for reducing fall-related injuries.
Option B: Make sure the client’s pajamas, dressing gown, and day clothes are the
right length so they don’t trip over them. Check that their slippers or other
footwear fit properly and are not slippery. If they have to wear pressure
stockings, wear slippers over them so they do not slip.
Option D: Keep personal items and the call button within reach to avoid standing
and walking to get them. Ask for help when in need to get out of bed to use the
toilet if not feeling at all unsteady.
58. Question
A walk-in client enters the clinic with a chief complaint of abdominal pain and
diarrhea. The nurse takes the client’s vital sign hereafter. What phrase of the
nursing process is being implemented here by the nurse?

A. Assessment
B. Diagnosis
C. Planning
D. Implementation
Incorrect
Correct Answer: A. Assessment

Assessment is the first phase of the nursing process where a nurse collects
information about the client. Assessment is the first step and involves critical
thinking skills and data collection; subjective and objective. Subjective data
involves verbal statements from the patient or caregiver. Objective data is
measurable, tangible data such as vital signs, intake and output, and height and
weight.

Option B: Diagnosis is the formulation of the nursing diagnosis from the

information collected during the assessment. The formulation of a nursing diagnosis
by employing clinical judgment assists in the planning and implementation of
patient care. The North American Nursing Diagnosis Association (NANDA) provides
nurses with an up to date list of nursing diagnoses. A nursing diagnosis, according
to NANDA, is defined as a clinical judgment about responses to actual or potential
health problems on the part of the patient, family, or community.
Option C: In Planning, the nurse sets achievable and measurable short and long-term
goals. The planning stage is where goals and outcomes are formulated that directly
impact patient care based on EDP guidelines. These patient-specific goals and the
attainment of such assist in ensuring a positive outcome. Nursing care plans are
essential in this phase of goal setting. Care plans provide a course of direction
for personalized care tailored to an individual’s unique needs. Overall condition
and comorbid conditions play a role in the construction of a care plan. Care plans
enhance communication, documentation, reimbursement, and continuity of care across
the healthcare continuum.
Option D: Implementation is where nursing care is given. Implementation is the step
which involves action or doing and the actual carrying out of nursing interventions
outlined in the plan of care. This phase requires nursing interventions such as
applying a cardiac monitor or oxygen, direct or indirect care, medication
administration, standard treatment protocols, and EDP standards.
59. Question
It is best described as a systematic, rational method of planning and providing
nursing care for individual, families, group, and community

A. Assessment
B. Nursing Process
C. Diagnosis
D. Implementation
Incorrect
Correct Answer: B. Nursing Process

The statement describes the Nursing Process. The Nursing Process is the essential
core of practice for the registered nurse to deliver holistic, patient-focused
care. Defined as a systematic approach to care using the fundamental principles of
critical thinking, client-centered approaches to treatment, goal-oriented tasks,
evidence-based practice (EDP) recommendations, and nursing intuition. Holistic and
scientific postulates are integrated to provide the basis for compassionate,
quality-based care.

Option A: Assessment is the first step and involves critical thinking skills and
data collection; subjective and objective. Subjective data involves verbal
statements from the patient or caregiver. Objective data is measurable, tangible
data such as vital signs, intake and output, and height and weight.
Option C: The formulation of a nursing diagnosis by employing clinical judgment
assists in the planning and implementation of patient care. The North American
Nursing Diagnosis Association (NANDA) provides nurses with an up to date list of
nursing diagnoses. A nursing diagnosis, according to NANDA, is defined as a
clinical judgment about responses to actual or potential health problems on the
part of the patient, family, or community.
Option D: Implementation is the step which involves action or doing and the actual
carrying out of nursing interventions outlined in the plan of care. This phase
requires nursing interventions such as applying a cardiac monitor or oxygen, direct
or indirect care, medication administration, standard treatment protocols, and EDP
standards.
60. Question
Exchange of gases takes place in which of the following organs?

A. Kidney
B. Lungs
C. Liver
D. Heart
Incorrect
Correct Answer: B. Lungs

Gas exchange is the transport of oxygen from the lungs to the bloodstream and the
expulsion of carbon dioxide from the bloodstream to the lungs. It transpires in the
lungs between the alveoli and a network of tiny blood vessels called capillaries,
which are located in the walls of the alveoli.

Option A: The renal system consists of the kidney, ureters, and urethra. The
overall function of the system filters approximately 200 liters of fluid a day from
renal blood flow which allows for toxins, metabolic waste products, and excess ions
to be excreted while keeping essential substances in the blood. The kidney
regulates plasma osmolarity by modulating the amount of water, solutes, and
electrolytes in the blood. It ensures long-term acid-base balance and also produces
erythropoietin which stimulates the production of red blood cells.
Option C: The liver is a critical organ in the human body that is responsible for
an array of functions that help support metabolism, immunity, digestion,
detoxification, vitamin storage among other functions. It comprises around 2% of an
adult’s body weight. The liver is a unique organ due to its dual blood supply from
the portal vein (approximately 75%) and the hepatic artery (approximately 25%).
Option D: The heart is a muscular organ situated in the center of the chest behind
the sternum. It consists of four chambers: the two upper chambers are called the
right and left atria, and the two lower chambers are called the right and left
ventricles. The right atrium and ventricle together are often called the right
heart, and the left atrium and left ventricle together functionally form the left
heart.
61. Question
The chamber of the heart that receives oxygenated blood from the lungs is the:

A. Left atrium
B. Right atrium
C. Left ventricle
D. Right ventricle
Incorrect
Correct Answer: A. Left atrium

The left atrium receives oxygenated blood from the lungs and pumps it to the left
ventricle. In the lungs, the blood oxygenates as it passes through the capillaries
where it is close enough to the oxygen in the alveoli of the lungs. This oxygenated
blood is collected by the four pulmonary veins, two from each lung. All four of
these veins open into the left atrium that acts as a collection chamber for
oxygenated blood. Just like the right atrium, the left atrium passes the blood onto
its ventricle both by passive flow and active pumping.

Option B: The right atrium receives blood from the veins and pumps it to the right
ventricle. The right atrium receives deoxygenated blood from the entire body except
for the lungs (the systemic circulation) via the superior and inferior vena cavae.
Also, deoxygenated blood from the heart muscle itself drains into the right atrium
via the coronary sinus. The right atrium, therefore, acts as a reservoir to collect
deoxygenated blood.
Option C: The left ventricle (the strongest chamber) pumps oxygen-rich blood to the
rest of the body, its vigorous contractions create the blood pressure. Oxygenated
blood thus fills the left ventricle, passing through the mitral valve. The left
ventricle, which is the main pumping chamber of the left heart, then pumps, sending
freshly oxygenated blood to the systemic circulation through the aortic valve
Option D: The right ventricle receives blood from the right atrium and pumps it to
the lungs, where it is loaded with oxygen. The right ventricle pumps blood through
the right ventricular outflow tract, across the pulmonic valve, and into the
pulmonary artery that distributes it to the lungs for oxygenation.
62. Question
A muscular enlarged pouch or sac that lies slightly to the left which is used for
temporary storage of food…

A. Gallbladder
B. Urinary bladder
C. Stomach
D. Lungs
E. Rugae of the stomach
Incorrect
Correct Answer: C. Stomach

The stomach is a muscular organ located on the left side of the upper abdomen. It
is a saclike expansion of the digestive tract of a vertebrate that is located
between the esophagus and duodenum. The major part of the digestion of food occurs
in the stomach.

Option A: The gallbladder is a small hollow organ about the size and shape of a
pear. It is a part of the biliary system, also known as the biliary tree or biliary
tract. The biliary system is a series of ducts within the liver, gallbladder, and
pancreas that empty into the small intestine. There are intrahepatic (within the
liver) and extrahepatic (outside of the liver) components. The gallbladder is a
component of the extrahepatic biliary system where bile is stored and concentrated.
Option B: The bladder forms an integral part of the genitourinary system. Urine,
created by the kidneys, is drained into the bladder by the bilateral ureters. The
bladder then acts as the storage site for this waste product until higher-order
centers within the central nervous system initiate the micturition (i.e.,
urination) process, which permits the expulsion of urine into the urethra, located
on the inferior aspect of the bladder.
Option D: The purpose of the lung is to provide oxygen to the blood. Anatomically,
the lung has an apex, three borders, and three surfaces. The apex lies above the
first rib. The function of the lung is to get oxygen from the air to the blood,
performed by the alveoli. The alveoli are a single cell membrane that allows for
gas exchange to the pulmonary vasculature. There are a couple of muscles that help
with inspiration and expiration, such as the diaphragm and intercostal muscles.
Option E. The inner layer of the stomach is full of wrinkles known as rugae (or
gastric folds). Rugae both allow the stomach to stretch in order to accommodate
large meals and help to grip and move food during digestion
63. Question
The ability of the body to defend itself against scientific invading agent such as
bacteria, toxin, viruses, and foreign body:

A. Hormones
B. Secretion
C. Immunity
D. Glands
Incorrect
Correct Answer: C. Immunity

Immunity is the ability of an organism to resist a particular infection or toxin by

the action of specific antibodies or sensitized white blood cells. The Immune
response is the body’s ability to stay safe by affording protection against harmful
agents and involves lines of defense against most microbes as well as specialized
and highly specific responses to a particular offender. This immune response
classifies as either innate which is non-specific and adaptive acquired which is
highly specific.

Option A: The endocrine hormones are a wide array of molecules that traverse the
bloodstream to act on distant tissues, leading to alterations in metabolic
functions within the body. They can broadly divide into peptides, steroids, and
tyrosine derivatives that may work on either cell surface or intracellular
receptors.
Option B: Secretion, in biology, production and release of a useful substance by a
gland or cell; also, the substance produced. In addition to the enzymes and
hormones that facilitate and regulate complex biochemical processes, body tissues
also secrete a variety of substances that provide lubrication and moisture.
Option D: A gland is an organ which produces and releases substances that perform a
specific function in the body. There are two types of gland. Endocrine glands are
ductless glands and release the substances that they make (hormones) directly into
the bloodstream.
64. Question
Hormones secreted by Islets of Langerhans

A. Progesterone
B. Testosterone
C. Insulin
D. Hemoglobin
Incorrect
Correct Answer: C. Insulin

The Islets of Langerhans are the regions of the pancreas that contain its endocrine
cells. Insulin is a peptide hormone secreted in the body by beta cells of islets of
Langerhans of the pancreas and regulates blood glucose levels. Medical treatment
with insulin is indicated when there is inadequate production or increased demands
of insulin in the body.

Option A: Progesterone (Choice A) is produced by the ovaries. Progesterone is an

endogenous steroid hormone that is commonly produced by the adrenal cortex as well
as the gonads, which consist of the ovaries and the testes. Progesterone is also
secreted by the ovarian corpus luteum during the first ten weeks of pregnancy,
followed by the placenta in the later phase of pregnancy.
Option B: Testosterone (Choice B) is secreted by the testicles of males and ovaries
of females. Testosterone is the primary male hormone responsible for regulating sex
differentiation, producing male sex characteristics, spermatogenesis and fertility.
Testosterone is responsible for the development of primary sexual development,
which includes testicular descent, spermatogenesis, enlargement of the penis and
testes, and increasing libido.
Option D: Hemoglobin (Choice D) is a protein molecule in the red blood cells that
carries oxygen from the lungs to the body’s tissues and returns carbon dioxide.
Hemoglobin is an oxygen-binding protein found in erythrocytes which transports
oxygen from the lungs to tissues. Each hemoglobin molecule is a tetramer made of
four polypeptide globin chains. Each globin subunit contains a heme moiety formed
of an organic protoporphyrin ring and a central iron ion in the ferrous state
(Fe2+). The iron molecule in each heme moiety can bind and unbind oxygen, allowing
for oxygen transport in the body.
65. Question
It is a transparent membrane that focuses the light that enters the eyes to the
retina.

A. Lens
B. Sclera
C. Cornea
D. Pupils
Incorrect
Correct Answer: A. Lens

The lens is located in the eye. By changing its shape, the lens changes the focal
distance of the eye. In other words, it focuses the light rays that pass through it
(and onto the retina) in order to create clear images of objects that are
positioned at various distances. It also works together with the cornea to refract,
or bend, light. The lens consists of the lens capsule, the lens epithelium, and the
lens fibers. The lens capsule is the smooth, transparent outermost layer of the
lens, while the lens fibers are long, thin, transparent cells that form the bulk of
the lens. The lens epithelium lies between these two and is responsible for the
stable functioning of the lens. It also creates lens fibers for the lifelong growth
of the lens.

Option B: The sclera is the white part of the eye that surrounds the cornea. In
fact, the sclera forms more than 80 percent of the surface area of the eyeball,
extending from the cornea all the way to the optic nerve, which exits the back of
the eye. Only a small portion of the anterior sclera is visible.
Option C: The cornea is the eye’s clear, protective outer layer. Along with the
sclera (the white of your eye), it serves as a barrier against dirt, germs, and
other things that can cause damage. The cornea can also filter out some of the
sun’s ultraviolet light. It also plays a key role in vision. As light enters the
eye, it gets refracted, or bent, by the cornea’s curved edge. This helps determine
how well the eye can focus on objects close-up and far away.
Option D: Pupils are the black center of the eye. Their function is to let in light
and focus it on the retina (the nerve cells at the back of the eye) so one can see.
Muscles located in the iris (the colored part of your eye) control each pupil.
66. Question
Which of the following is included in Orem’s theory?

A. Maintenance of a sufficient intake of air.

B. Self perception.
C. Love and belongingness.
D. Physiologic needs.
Incorrect
Correct Answer: A. Maintenance of a sufficient intake of air.

Dorothea Orem’s Self-Care Theory defined Nursing as “The act of assisting others in
the provision and management of self-care to maintain or improve human functioning
at home level of effectiveness.” The Self-Care or Self-Care Deficit Theory of
Nursing is composed of three interrelated theories: (1) the theory of self-care,
(2) the self-care deficit theory, and (3) the theory of nursing systems, which is
further classified into wholly compensatory, partial compensatory and supportive-
educative. Choices B, C, and D are from Abraham Maslow’s Hierarchy of Needs.
Option B: At the fourth level in Maslow’s hierarchy is the need for appreciation
and respect. When the needs at the bottom three levels have been satisfied, the
esteem needs begin to play a more prominent role in motivating behavior. At this
point, it becomes increasingly important to gain the respect and appreciation of
others. People have a need to accomplish things and then have their efforts
recognized. In addition to the need for feelings of accomplishment and prestige,
esteem needs include such things as self-esteem and personal worth.
Option C: The social needs in Maslow’s hierarchy include such things as love,
acceptance, and belonging. At this level, the need for emotional relationships
drives human behavior. In order to avoid problems such as loneliness, depression,
and anxiety, it is important for people to feel loved and accepted by other people.
Personal relationships with friends, family, and lovers play an important role, as
does involvement in other groups that might include religious groups, sports teams,
book clubs, and other group activities.
Option D: The basic physiological needs are probably fairly apparent—these include
the things that are vital to our survival. In addition to the basic requirements of
nutrition, air and temperature regulation, the physiological needs also include
such things as shelter and clothing. Maslow also included sexual reproduction in
this level of the hierarchy of needs since it is essential to the survival and
propagation of the species.
67. Question
Which of the following cluster of data belong to Maslow’s hierarchy of needs

A. Love and belonging

B. Physiological needs
C. Self actualization
D. All of the above
Incorrect
Correct Answer: D. All of the above

All of the choices are part of Maslow’s Hierarchy of Needs. Maslow first introduced
his concept of a hierarchy of needs in his 1943 paper “A Theory of Human
Motivation” and his subsequent book Motivation and Personality. This hierarchy
suggests that people are motivated to fulfill basic needs before moving on to
other, more advanced needs. As a humanist, Maslow believed that people have an
inborn desire to be self-actualized, that is, to be all they can be. In order to
achieve these ultimate goals, however, a number of more basic needs must be met
such as the need for food, safety, love, and self-esteem.

Option A: The social needs in Maslow’s hierarchy include such things as love,
acceptance, and belonging. At this level, the need for emotional relationships
drives human behavior. In order to avoid problems such as loneliness, depression,
and anxiety, it is important for people to feel loved and accepted by other people.
Personal relationships with friends, family, and lovers play an important role, as
does involvement in other groups that might include religious groups, sports teams,
book clubs, and other group activities.
Option B: The basic physiological needs are probably fairly apparent—these include
the things that are vital to our survival. In addition to the basic requirements of
nutrition, air and temperature regulation, the physiological needs also include
such things as shelter and clothing. Maslow also included sexual reproduction in
this level of the hierarchy of needs since it is essential to the survival and
propagation of the species.
Option C: At the very peak of Maslow’s hierarchy are the self-actualization needs.
“What a man can be, he must be,” Maslow explained, referring to the need people
have to achieve their full potential as human beings. According to Maslow’s
definition of self-actualization, “It may be loosely described as the full use and
exploitation of talents, capabilities, potentialities, etc. Such people seem to be
fulfilling themselves and to be doing the best that they are capable of doing. They
are people who have developed or are developing to the full stature of which they
are capable.”
68. Question
This is characterized by severe symptoms relatively of short duration.

A. Chronic Illness
B. Acute Illness
C. Pain
D. Syndrome
Incorrect
Correct Answer: B. Acute Illness

Acute illnesses are different than chronic illnesses in that they usually develop
quickly and they only last a short time – usually a few days or weeks. Acute
illnesses are often caused by viral or bacterial infections.

Option A: Chronic Illness (Choice A) are illnesses that are persistent or long-
term. A chronic illness is a condition that develops over time and is present for a
long period of time. Some people have chronic conditions for many years.
Technically, a chronic disease is defined as a health condition that lasts anywhere
from three months to a lifetime. Chronic conditions may get worse over time.
Option C: Pain refers to the product of higher brain center processing; it entails
the actual unpleasant emotional and sensory experience generated from nervous
signals.
Option D: A syndrome is a set of medical signs and symptoms which are correlated
with each other and often associated with a particular disease or disorder. The
word derives from the Greek ?????????, meaning “concurrence”.
69. Question
Which of the following is the nurse’s role in health promotion?

A. Health risk appraisal

B. Teach client to be effective health consumer
C. Worksite wellness
D. None of the above
Incorrect
Correct Answer: B. Teach client to be effective health consumer

Nurses play a huge role in illness prevention and health promotion. Nurses assume
the role of ambassadors of wellness. The World Health Organization (WHO) defines
health promotion as a process of enabling people to increase control over and to
improve their health (WHO, 1986). Nurses are best qualified to take on the job of
health promoter due to their expertise. There are few health care occupations that
have the high level of health education knowledge, skills, theory, and research to
be able to focus on prevention because it is considered part of their professional
development focus.

Option A: An HRA may be a simple questionnaire eliciting self-reported information

on risk factors, behaviors, or diagnoses. Questionnaires may be supplemented with
clinical examinations to obtain data on variables such as height, weight, body mass
index (BMI), heart rate, or blood pressure. Some HRAs may include performance tests
such as grip strength, timed-up-and-go, chair rise, or four-meter walk test.
Option C: Studies show that employees are more likely to be on the job and
performing well when they are in optimal health. Benefits of implementing a
wellness program include: improved disease management and prevention, and a
healthier workforce in general, both of which contribute to lower health care
costs.
Option D: One of the most critical roles that nurses have in health promotion and
disease preventions is that of an educator. Nurses spend the most time with the
patients and provide anticipatory guidance about immunizations, nutrition, dietary,
medications, and safety.
70. Question
It is described as a collection of people who share some attributes of their lives.

A. Family
B. Illness
C. Community
D. Nursing
Incorrect
Correct Answer: C. Community

A community is defined by the shared attributes of the people in it, and/or by the
strength of the connections among them. When an organization is identifying
communities of interest, the shared attribute is the most useful definition of a
community.

Option A: In human society, family is a group of people related either by

consanguinity (by recognized birth) or affinity (by marriage or other
relationship). The purpose of families is to maintain the well-being of its members
and of society. Ideally, families would offer predictability, structure, and safety
as members mature and participate in the community.
Option B: Illness is a condition of being unhealthy in the body or mind; a specific
condition that prevents the body or mind from working normally; a sickness or
disease.
Option D: Nursing encompasses autonomous and collaborative care of individuals of
all ages, families, groups, and communities, sick or well, and in all settings.
Nursing includes the promotion of health, prevention of illness, and the care of
ill, disabled, and dying people.
71. Question
Five teaspoons is equivalent to how many milliliters (ml)?

A. 30 ml
B. 25 ml
C. 12 ml
D. 22 ml
Incorrect
Correct Answer: B. 25 ml

One teaspoon is equal to 5ml. Drug calculations require the use of conversion
factors, for example, when converting from pounds to kilograms or liters to
milliliters. Simplistic in design, this method allows clinicians to work with
various units of measurement, converting factors to find the answer. These methods
are useful in checking the accuracy of the other methods of calculation, thus
acting as a double or triple check.

Option A: 30 ml is equal to 6 teaspoons. When clinicians are prepared and know the
key conversion factors, they will be less anxious about the calculation involved.
This is vital to accuracy, regardless of which formula or method employed.
Option C: 12 ml is equal to 2.4 teaspoons. Units of measurement must match, for
example, milliliters and milliliters, or one needs to convert to like units of
measurement.
Option D: 22 ml is equal to 4.4 teaspoons. Medication errors can be detrimental and
costly to patients. Drug calculation and basic mathematical skills play a role in
the safe administration of medications.
72. Question
1800 ml is equal to how many liters?

A. 1.8
B. 18000
C. 180
 D. 2800
Incorrect
Correct Answer: A. 1.8

1,800 ml is equal to 1.8 liters.

Option B: 18000 liters is equal to 18,000,000 ml.

Option C: 180 liters is equal to 180,000 ml.
Option D: 2800 liters is equal to 280,000 ml.
73. Question
Which of the following is the abbreviation of drops?

A. Gtt.
B. Gtts.
C. Dp.
D. Dr.
Incorrect
Correct Answer: B. Gtts.

Gtt (Choice A) is an abbreviation for drop. Dp and Dr are not recognized

abbreviations for measurement. Standardization and uniform use of codes, symbols,
and abbreviations can improve communication and understanding between health care
practitioners, leading to safer and more effective care for patients.

Option A: Appropriate use of abbreviations is particularly important. Numerous

studies have focused on health care practitioners’ understanding and interpretation
of abbreviations in medical documents, such as medical records, discharge
summaries, and medication orders. Findings indicate that it is not uncommon for
practitioners to have difficulty understanding the abbreviations used in their
hospitals.
Option C: To prevent misunderstandings and potential risks to patient safety, MOI.4
requires hospitals to establish lists for approved and do-not-use abbreviations and
monitor for appropriate abbreviation use. There are resources for identifying
abbreviations for the do-not-use list, such as the Institute for Safe Medication
Practices (ISMP), which publishes a list of dangerous abbreviations not to be used
due to frequent misinterpretation and associated medication errors.
Option D: When developing lists, hospitals need to ensure that abbreviations on the
approved list are not also on the do-not-use list, and vice versa. In addition,
abbreviations can have only one meaning within the entire organization—for example,
the abbreviation NKDA could mean “no known drug allergies,” or it could mean
“nonketotic diabetic acidosis,” but it cannot have both meanings in an
organization.
74. Question
The abbreviation for microdrop is…

A. µgtt
B. gtt
C. mdr
D. mgts
Incorrect
Correct Answer: A. µgtt

The abbreviation for microdrop is µgtt. When abbreviations are used in documents
given to the patient, the potential for misunderstanding can increase. Information
needs to be clear and unambiguous to improve patients’ comprehension.

Option B: When abbreviations are used in documents given to the patient, the
potential for misunderstanding can increase. Information needs to be clear and
unambiguous to improve patients’ comprehension.
Option C: As stated in MOI.4, ME 5, “Abbreviations are not used on informed consent
and patient rights documents, discharge instructions, discharge summaries, and
other documents patients and families receive from the hospital about the patient’s
care.”
Option D: No abbreviations of any kind should appear in informed consent documents,
patient rights documents, and discharge instructions. These documents are meant for
the patient and every effort should be made to increase the readability and clarity
of the documents.
75. Question
Which of the following is the meaning of PRN?

A. When advice
B. Immediately
C. When necessary
D. Now.
Incorrect
Correct Answer: C. When necessary

PRN comes from the Latin “pro re nata” meaning, “for an occasion that has arisen or
as circumstances require”. When an abbreviation is less known outside of the
organization or clinical specialty, it is necessary to spell out the abbreviation
throughout the discharge summary to prevent misunderstanding and confusion by the
physician or health care organization that receives the summary.

Option A: The practice of spelling out an abbreviation when first mentioned, then
using the abbreviation thereafter in the document is acceptable only in discharge
summaries. Abbreviations are not to be used in the other types of documents listed
in the measurable element.
Option B: Laboratory test results sometimes go to patients, but it is not the
intent of the standard for the abbreviations of the laboratory tests to be spelled
out. When test results are given to patients, they are shared with their physician
who can help explain the results.
Option D: Hospitals may want to consider providing a separate form or resource to
patients for information about the tests — such as a handout or website that has
the names of common laboratory tests along with their definitions or descriptions.
Results of diagnostic imaging studies also go to a patient’s physician, after
interpretation by a radiologist.