1.
The nurse is teaching a mother whose daughter has
iron-deficiency anemia. The nurse determines the
parent understood the dietary modifications if she
selects?
a)  Bread and coffee
b)  Fish and Pork meat
c)  Cookies and milk
d)  Oranges and green leafy vegetables
2. Which of the following is the most common clinical
manifestation of G6PD following ingestion of aspirin?
a) Kidney failure
b) Acute hemolytic anemia
c) Hemophilia A
d) Thalassemia
3. The nurse assesses a client with an ileostomy for
possible development of which of the following acid-
base imbalances?
a)  Respiratory acidosis
b)  Metabolic acidosis
c)  Metabolic alkalosis
d)  Respiratory alkalosis
4. The nurse anticipates which of the following
responses in a client who develops metabolic acidosis.
a)  Heart rate of 105 bpm
b)  Urinary output of 15 ml
c)  Respiratory rate of 30 cpm
d)  Temperature of 39 degree Celsius
5. A client has a phosphorus level of 5.0mg/dL. The
nurse closely monitors the client for?
a)  Signs of tetany
b)  Elevated blood glucose
c)  Cardiac dysrhythmias
d)  Hypoglycemia
6. A nurse is caring for a child with pyloric stenosis.
The nurse would watch out for symptoms of?
a)  Vomiting large amounts
b)  Watery stool
c)   Projectile vomiting
d)  Dark-colored stool
7. The nurse responder finds a patient unresponsive in
his house. Arrange steps for adult CPR.
a)  Assess consciousness
b)  Give 2 breaths
c)  Perform chest compression
d)  Check for serious bleeding and shock
e)  Open patient’s airway
f)   Check breathing
___, ___, ___, ___, ___, ___
8. Which of the following has mostly likely occurred
when there is continuous bubbling in the water seal
chamber of the closed chest drainage system?
a)  The connection has been taped too tightly
b)  The connection tubes are kinked
c)  Lung expansion
d)  Air leak in the system
9. Which if the following young adolescent and adult
male clients are at most risk for testicular cancer?
a)  A basketball player who wears supportive gear
during basketball games
b)  Teenager who swims on a varsity swim team
c)  20-year-old with undescended testis
d)  Patient with a family history of colon cancer
10. The nurse plans to frequently assess a post-
thyroidectomy patient for?
a)   Polyuria
b)   Hypoactive deep tendon reflex
c)    Hypertension
d)   Laryngospasm
11. An 18-month-old baby appears to have a rounded
belly, bowlegs and a slightly large head. The nurse
concludes?
a)   The child appears to be a normal toddler
b)   The child is developmentally delayed
c)   The child is malnourished
d)   The child’s large head may have neurological
problems.
12. A nurse is going to administer a 500mg capsule to
a patient. Which is the correct route?
13. An appropriate instruction to be included in the
discharge teaching of a patient following a spinal fusion
is?
a)  Don’t use the stairs
b)  Don’t bend at the waist
c)   Don’t walk for long hours
d)   Swimming should be avoided
14. A nurse is preparing to give an IM injection of Iron
Dextran that is irritating to the subcutaneous tissue. To
prevent irritation to the tissue, what is the best action
to be taken?
a)   Apply ice over the injection site
b)  Administer drug at a 45-degree angle
c)  Use a 24-gauge-needle
d)  Use the z-track technique
15. What should a nurse do prior to taking the
patient’s history?
a)  Offer the patient a glass of water
b)  Establish rapport
c)   Ask the patient to disrobe and put on a gown
d)  Ask pertinent information for insurance purposes
16. A pregnant woman is admitted for pre-eclampsia.
The nurse would include in the health teaching that
magnesium will be part of the medical management to
accomplish the following?
a)     Control seizures
b)    promote renal perfusion
c)     To decrease sustained contractions
d)    Maintain intrauterine homeostasis
17. A nurse is going to administer ear drops to a 4-
year-old child. What is the correct way of instilling the
medicine after tilting the patient’s head sidewards?
a)  Pull the pinna back then downwards
b)  Pull the pinna back then upwards
c)  Pull the pinna up then backwards
d)  Pull the pinna down then backwards
18. A nursing student was intervened by the clinical
instructor if which of the following is observed?
a)  Inserting a nasogastric tube
b)  Positioning the infant in a “sniffing “position
c)  Suctioning first the mouth, then the nose
d)  Squeezing the bulb syringe to suction the mouth
19. Choose amongst the options illustrated below that
best describes the angle for an intradermal injection?
 c)  Increase in pulse and blood pressure
d)  Decrease level of consciousness
28. A new nurse is administering an enema to a
patient. The senior nurse should intervene if the new
nurse?
a)  Hangs the enema bag 18 inches above the anus
b)  Positions the client on the right side
c)  Advances the catheter 4 inches into the anal canal
20. During a basic life support class, the instructor said
d)  Lubricates 4 inches of the catheter tip
that blind finger sweeping is not advisable for infants.
29. The medication nurse is going to give a patient his
Which among the following could be the reason?
morning medications. What is the primary action a
a)  The mouth is still too small
nurse should do before administering the medications?
b)  The object may be pushed deeper into the throat
a)  Provide privacy
c)  Sharp fingernails might injure the victim
b)  Raise the head of the bed
d)  The infant might bite
c)  Give distilled water
21. A nurse enters a room and finds a patient lying on
d)  Check the client’s identification bracelet
the floor. Which of the following actions should the
30. A 30-year-old client is admitted with inflammatory
nurse perform first?
bowel syndrome (Crohn’s disease). Which of the
a)   Call for help
following instructions should the nurse include in the
b)   Establish responsiveness of the patient
health teaching? Select all that apply
c)   Ask the patient what happened
a)  Corticosteroid medication is part of the treatment
d)   Assess vital signs
b)  Include milk in the diet
22. A patient with complaints of chest pain was rushed
c)  Aspirin should be administered
to the emergency department. Which priority action
d)  Antidiarrheal medication can help
should the nurse do first?
a)   Administer morphine sulfate intravenously
RATIONALE 1
b)  Initiate venous access by performing venipuncture
1.) Answer: D
c)   Administer oxygen via nasal cannula
Dark green leafy vegetables are good sources of iron.
d)  Complete physical assessment and patient history
Oranges are good sources of vitamin C that enhances
23. A rehab nurse reviews a post-stroke patient’s
iron absorption in the small intestines.
immunization history. Which immunization is a priority
2.) Answer: B
for a 72-year-old patient?
Individuals with G6PD may exhibit hemolytic
a)   Hepatitis A vaccine
anemia when exposed to infection, certain medications
b)  Hepatitis B vaccine
or chemicals. Salicylates such as Aspirin damages
c)  Rotavirus Vaccine
plasma membranes of erythrocytes, leading to
d)  Pneumococcal Vaccine
hemolytic anemia.
24. Several patients from a reported condominium fire
3.) Answer: B
incident were rushed to the emergency room. Which
Lower GI fluids are alkaline in nature and can be lost
should the nurse attend to first?
via ileostomy. Thus, loss of HCO3, results in metabolic
a)   A 15-year-old girl, with burns on the face and
acidosis.
chest, reports hoarseness of the voice
4.) Answer: C
b)  A 28-year-old man with burns on all extremities
Initially, the respiratory system will try to compensate
c)  A 4-year-old child who is crying inconsolably and
metabolic acidosis. Patients with metabolic acidosis
reports a severe headache
have a high respiratory rate.
d)  A 40-year-old woman with complaints of severe
5.) Answer: A
pain on the left thigh
Normal phosphorus level is 2.5 – 4.5 mg/dL .The level
25. The doctor ordered 1 pack of red blood cells
reflects hyperphosphatemia which is inversely
(PRBC) to be transfused to a patient.  The nurse
proportional to calcium. Client should be assessed for
prepares the proper IV tubing. The IV tubing
tetany which is a prominent symptom of hypocalcemia.
appropriate for blood transfusion comes with?
6.) Answer: C
a)   Air vent
Clinical manifestations of pyloric stenosis include
b)   Microdrip chamber
projectile vomiting, irritability, constipation, and signs
c)   In-line filter
of dehydration, including a decrease in urine output.
d)   Soluset
 7.) Answer: A, E, F, C, B, D
26. The expected yet negative  (harmful )  result for
In accordance with the new guidelines, remember AB-
post hemodialysis is a decrease in?
CABS. A-airway B-breathing normally? − C-chest
a)   Creatinine
compression A-airway open B-breathing for patient S-
b)   BUN
serious bleeding, shock, spinal injury. The nurse should
c)   Phosphorus
first assess the consciousness of the patient. Next,
d)   Red blood cell count
open the patient’s airway to check for breathing. When
27. A patient was brought to the emergency room
there is no breathing, immediately perform chest
after she fell down the stairs. Which of the following is
compression then give 2 breaths, do the cycle of care
the best indicator for increased intracranial pressure in
over. Finally, check for serious bleeding, shock, and
the head and spinal injury?
spinal injury.
a)  Inability to move extremities
8.) Answer: D
b)  Decreased respiratory rate
Continuous bubbling seen in the water-seal bottle/
chamber indicates an air leak or loose connection, and
the air is sucked continuously into the closed chest
drainage system.
9.) Answer: C
Testicular cancer is most likely to affect males in late
adolescence. Undescended testis is also one major risk
for testicular cancer.
10.) Answer: D
Hypocalcemia occurs when there is accidental removal
or destruction of parathyroid tissue during surgical
removal of the thyroid gland.  Laryngospasm is one of
the clinical manifestations of tetany, an indicator of
hypocalcemia.
11.) Answer: A
It’s normal for a toddler to have bowlegs and a
protruding belly. The head still appears somewhat
large in proportion from the rest of the body.
12.) Answer: D
13.) Answer: B
There is 6-8 months activity restriction following a
spinal fusion.  Sitting, lying, standing, normal stair
climbing, walking, and gentle swimming is allowed.
Bending and twisting at the waist should be avoided,
along with lifting more than 10 lbs.
14.) Answer: D
Z-track technique is used to administer drugs
especially irritating to the subcutaneous tissue. This
method promotes absorption of the drug by preventing
drug leakage into the subcutaneous layer.
15.) Answer: B
Establishing rapport is a way to gain trust that will lead
for a patient to relax. You can get more insights and
information from a patient when rapport is established.
16.) Answer: A
Low magnesium (hypomagnesemia) produces clinical
manifestations like increased reflexes, tremors, and
seizures. Magnesium Sulfate is the drug of choice to
prevent seizures in pre-eclampsia and eclampsia.
17.) Answer: C
The ear canal of children ages 3years and above can
be straightened by pulling the pinna up then
backwards. For children below 3 years of age, the ear
canal can be straightened by pulling the pinna down
then backwards.
18.) Answer: A
Infants are nose breathers. A gastric tube may be
inserted to facilitate lung expansion and stomach
decompression, but not a nasogastric tube as it can
occlude the nare, thus, making breathing difficult for
the infant.
19.) Answer: B
20.) Answer: B
Blind finger sweeps are not recommended in all CPR
cases especially for infants and children because the
foreign object may be pushed back into the airway.
21.) Answer: B
The first step in cardiopulmonary resuscitation (CPR) is
assessing the responsiveness of the patient.
22.) Answer: C
Priority nursing action is to administer oxygen to
patients with chest pain.  Chest pain is caused by
insufficient myocardial oxygenation.
23.) Answer: D
Pneumococcal Vaccine is a priority immunization for
the elderly. Seniors, ages 65 years old and above,
have a higher risk for serious pneumococcal infection
and likely have low immunity. This is administered
every 5 years.
24.) Answer: A
Burns on the face and neck can cause swelling of the
respiratory mucosa that can lead to airway obstruction
manifested by hoarseness of voice and difficulty in
breathing. Maintaining airway patency is the main
concern.
25.) Answer: C
An in-line filter is required for blood transfusions.
26.) Answer: D
Negative outcome: Hemodialysis decreases red blood
cell count which worsens anemia, because RBCs are
lost in dialysis from anticoagulation during the
procedure, and from residual blood that is left in the
dialyzer.
27.) Answer: D
A decrease in level of consciousness and headache are
early signs of increase in intracranial pressure (ICP).
Altered level of consciousness is the most common
symptom that indicates a deficit in brain function.
28.) Answer: B
Recall the anatomy of the colon. The appropriate
position is left lateral to facilitate the flow of enema by
gravity into the colon.
29.) Answer: D
Recall the 12 Rights of administration. Checking the
patient’s name is critical for client-safety.
30.) Answer: A , D
Crohn’s disease is a chronic inflammation of the colon
with symptoms of diarrhea, abdominal pain, and
weight loss. Corticosteroid is a treatment for Crohn’s
disease. Antidiarrheal can give relief to diarrheal
episodes. Aspirin should be avoided as it can worsen
inflammation. Those with Crohn’s disease are mostly
lactose intolerant, so choice no. (2) is incorrect.
TEST 2
1. The client presented with complaints of body
weakness, dizziness and chest pain. Upon careful
assessment, the nurse suspects Angina Pectoris. Which
of the following statements made by the client can
confirm this?
a. “I suddenly felt a pain on my chest which radiates to
my back and arms”.
b. “I suddenly felt a sharp pain on my lower abdomen”.
c. “The pain does not subside even if I rest”.
d. “The pain goes all the way down to my stomach”.
2. The client from the OR is transferred to the post-
anesthesia care unit after surgical repair of abdominal
aortic aneurysm. Which of the following assessment
findings would indicate that the repair was successful?
a. Urine output of 50 mL/hr.
b. Presence of non-pitting, peripheral edema.
c. Clear sclera.
d. Presence of carotid bruit.
3. The client is scheduled for cardiac catheterization
because the physician wants to view the right side of
the heart. Which of the following would the nurse
expect to see in this procedure?
a. A dye is injected to facilitate the viewing of the
heart
b. Thallium is injected to facilitate the scintillation
camera
c. A probe with a transducer tip is swallowed by the
client.
d. A tiny ultrasound probe is inserted into the coronary
artery
4. The client is being treated for hypovolemia. To
assess the effectiveness of the treatment, the Central
Venous Pressure (CVP) of the client is being monitored.
Which of the following is TRUE about CVP?
a. The CVP is measured with a central venous line in
the inferior vena cava.
b. The normal CVP is 7 to 9 mmHg.
c. The zero point on the transducer needs to be at the
level of the left atrium.
d. The client needs to be supine, with the head of the
bed elevated at 45 degrees.
5. The client’s ECG tracing shows ventricular
tachycardia secondary to low magnesium level. Which
of the following electrocardiogram tracing results is
consistent with this finding?
a. The appearance of a U wave
b. Shortened ST segment and a widened T wave.
c. Tall, peaked T waves
d. Tall T waves and depressed ST segment
6. The nurse is teaching the client how to use a dry
powder inhaler (DPI). Which of the following are
correct instructions given by the nurse? Select All
That Apply.
a. Load the drug first by turning to the next dose of
drug, or inserting the capsule into the device, or
inserting the disk or compartment into the device.
b. Never wash or place the inhaler in water.
c. Shake your inhaler prior to use.
d. The drug is a dry powder that is why you will taste
the drug as you inhale.
e. Never exhale into the inhaler.
f. Do not remove the inhaler from your mouth as soon
as you have breathe in.
7. The nurse is assigned to render care for a client who
has a chest tube drainage system. Which of the
following are appropriate nursing actions? Select All
That Apply.
a. Strip the chest tube.
b. Empty collection chamber when the drainage makes
contact to the bottom of the tube.
c. Keep the chest tube as straight as possible.
d. Notify the physician of drainage is greater than
70mL/hr.
e. Assess bubbling in the water seal chamber.
f. Keep the drainage system at the level of the client’s
chest
8. The client with DKA is receiving bicarbonate IV
infusion for the treatment of severe metabolic acidosis.
The nurse notes that the latest ABG shows a pH of 7.0.
What should the nurse keep in mind in giving the
drug?
a. Check vital signs before giving the drug and monitor
serum sodium levels.
b. Perform a sensitivity test prior to drug
administration.
c. Mix the drug with D10W 500 ml IV fluid and infuse
for over 4 to 8 hours.
d. Administer the drug slowly and monitor the
potassium level
9. The client with a gunshot wound on the abdomen
starts to get lethargic, is breathing heavily, and the
wound dressing is fully soaked with blood. The nurse is
expected to immediately perform which of the
following actions?
a. Loosen tight clothing and administer oxygen supply.
b. Apply a warm blanket to prevent heat loss.
c. Apply large gauze on the bleeding site to put direct
pressure or place a tourniquet on the artery near the
bleeding site.
d. Initiate IV access.
10. The nurse is providing home instructions to a client
with an increased adrenocorticotrophic hormone. The
nurse is aware that the client with excessive
corticosteroids is suffering from what condition?
a. Cushing’s syndrome
b. Addison’s disease
c. Hypothyroidism
d. SIADH
11. The nurse is assigned to a post-thyroidectomy
client and is monitoring for signs of hypocalcemia. The
nurse gently tapped the area below the zygomatic
bone just in front of the ear. This action will elicit:
a. Facial tremor
b. Hyperreflexia
c. Chvostek sign
d. Trousseau sign
12. The nurse is caring for a client with an
antineoplastic IV hooked on the right hand. The nurse
notices that IV site is swelling and feels cool when
touched. The nurse recognizes this as extravasation.
This predisposes the client to develop which among the
following complications? Select all that apply.
a. Infection
b. Tissue necrosis
c. Disfigurement
d. Loss of function
e. Amputation
f. Delayed healing
13. Nursing interventions commonly performed when
the client is experiencing Autonomic Dysreflexia will
include the following. Select all that apply.
a. Use digital stimulation to empty the bowel.
b. Have the client sit up straight and raise his head so
that he is looking ahead.
c. Remove the client’s stockings or socks.
d. Manually compress or tap the bladder to allow urine
to flow down the catheter.
e. Administer prescribed vasodilators.
14. Neurologic conditions can be manifested by
changes in breathing patterns. The client presents with
symptoms of Cheyne-Stokes respirations. The nurse
knows that this kind of breathing pattern shows:
a. Completely irregular breathing pattern with random
deep and shallow respirations
b. Prolonged inspirations with inspiratory and /or
expiratory pauses
c. Sustained regular rapid respirations of increased
depth
d. Rhythmic waxing and waning of both rate and depth
of respiration with brief periods of interspersed apnea
15. The physician is assessing the client’s sensorium
by using the Glasgow Coma Scale. Which of the
following is true about the Glasgow Coma Scale?
a. If the client does not respond to painful stimuli, the
score is 0.
b. A score lower than 10 indicates that the client is in a
coma.
c. A score of 8 indicates that the client is alert and
oriented.
d. A score of 4 indicates that the client sustained
severe head trauma.
16. The nurse on duty is caring for a client with
Amyotrophic Lateral Sclerosis and is concerned with
the client’s impaired physical mobility. The following
nursing interventions are geared towards maintaining
optimal physical mobility EXCEPT:
a. Maintain an exercise program.
b. Encourage participation in activities.
c. Instruct client-related safety measures.
d. Schedule activities in the morning.
17. An elderly client had a cerebrovascular accident
or stroke. The left brain is affected and is at risk for
impaired verbal communication. The nurse asked a
question and noted that the client has difficulty talking
and communicating his thoughts. Which of the
following terms should the nurse use to document the
finding?
a. Receptive Aphasia
b. Expressive Aphasia
c. Global aphasia
d. Apraxia
18. The client diagnosed with Alzheimer’s disease is
starting to show signs and symptoms. The nurse wants
to assess for graphesthesia. This is performed by:
a. Testing for the client’s ability to identify an object
that is placed on the hand with eyes closed.
b. Testing for the client’s ability to recognize the
written letter or number in the client’s skin while the
eyes are closed.
c. Making the client stand, with the arms at the side,
feet together, with the eyes open and then closed. The
client is then observed for any swaying.
d. Testing for the presence of pain once the leg is
flexed at the hip, and then extended.
19. The pediatric client presents with the following
signs and symptoms: high fever, drooling, difficulty of
breathing, and leaning forward in a tripod position.
Immunization history shows that the client never
received any Hib vaccine. Which of the following is the
priority of the healthcare provider?
a. Continuous oxygen therapy and constant monitoring
of oxygen saturation rate.
b. A well-regulated IV infusion and timely
administration of antibiotics.
c. Vaccination of Hib and other remaining vaccines to
complete the required immunizations.
d. Avoiding any throat examination or agitation of the
child.
20. The physician prescribed Clarithromycin (Biaxin)
250mg BID x 7 days for the client’s infection. Incorrect
drug frequency and duration would cause inaccurate
transfer time of the drug to specific tissues in the
body. The nurse explains to the client that
accumulation of the drug in specific tissues is the
concept of
a. Absorption
b. Distribution
c. Metabolism
d. Excretion
21. The nurse is to administer Meperidine (Demerol)
35 mg through the intramuscular route. Available
meperidine is 50mg/mL. Which of the following is the
least favorable injection site for intramuscular
medication?
a. Ventrogluteal
b. Vastus lateralis
c. Deltoid muscle
d. Dorsogluteal
22. The client presented with a complaint of leg
cramps. Upon checking the client’s chart, the nurse
noted that the client is hypertensive and is prescribed
with a Thiazide diuretic. The appropriate nursing
intervention for this client is:
a. Stop the Thiazide diuretic
b. Refer to the physician for evaluation of the
electrolyte level of the client
c. Switch the client to a loop diuretic
d. Give the client a non-steroidal anti-inflammatory
drug (NSAID)
23. The client is wheeled into the delivery room and is
ready for childbirth. While crowning occurs, the labor
nurse applies gentle pressure over the perineum and
fetal head. The maneuver performed is called:
a. Brandt-Andrew’s maneuver
b. McRobert’s maneuver
c. Schultz mechanism
d. Ritgen’s maneuver
24. The nurse is monitoring the condition of the
postpartum client. As a part of the postpartum
adaptations, the nurse monitors for descent of the
uterus and expects the fundus to be:
a. On the same level after delivery
b. Decreased by 1 cm/day
c. Decreased by 1.5 cm/day
d. Decreased by 2 cm/day
25. The granddaughter of the client asked the nurse if
it is normal for elderly people to feel sleepy despite
sleeping for long hours. Which of the following
conditions would the nurse suspect?
a. Somatoform Disorder
b. Malingering
c. Anxiety
d. Amnesia
26. Chemotherapy is one of the treatments for uterine
cancer. The client asked the nurse how
chemotherapeutic drugs work. Which of the following
statements will be the best explanation?
a. Chemotherapeutic agents alter the molecular
structure of DNA.
b. Chemotherapeutic agents hasten cell division.
c. Cancer cells are sensitive only to chemotherapeutic
agents.
d. Chemotherapeutic agents act on all rapidly dividing
cells.
27. Vomiting is one of the most common side effects of
chemotherapy. The nurse should be aware of which
acid-base imbalance?
a. Ketoacidosis
b. Metabolic acidosis
c. Metabolic alkalosis
d. Respiratory alkalosis
28. The client develops a 2nd-degree skin reaction
from radiation therapy. The nurse should expect the
following symptoms EXCEPT:
a. The skin is scaly.
b. There is an itchy feeling.
c. There is a dry desquamation present.
d. The skin is reddened.
29. The nurse is assessing the muscle coordination and
mobility of the client with a musculoskeletal disorder.
The nurse noted impulsive and brief muscle twitching
of the face and the limbs. This finding is called:
a. Tremor
b. Chorea
c. Athetosis
d. Dystonia
30. The nurse is assigned to render care to a client
with altered mobility. Which of the following
statements is true regarding body mechanics when
moving clients?
a. Stand at arm’s length from the working area.
b. Elevate adjustable beds to the hip level.
c. Swivel the body when moving the client.
d. Move the client with a wide base and straight knees.
RATIONALE 2
1. Answer:  A
Rationale:
Angina pectoris is a substernal pain that radiates to the
neck, jaw, back and arms and is relieved by rest.
Lower abdominal pain may indicate other
gastrointestinal problems.
2. Answer: A
Rationale:
50 mL/hr is the normal urine output. A normal urine
output indicates that there is a good renal perfusion,
and also connotes that the client is hemodynamically
stable, therefore, the repair is successful.
3. Answer: A
Rationale:
In cardiac catheterization or coronary angiogram, a
catheter is inserted into the heart via a vein to
measure the ventricular function. A dye is used to
provide further assessment of the structure and motion
of the heart. Thallium is a radioactive isotope injected
parenterally so that the scintillation camera can count
the radioactive uptake. This is observed when a
physician requests for a Nuclear Cardiology test. When
performing a Transesophageal Echocardiogram (TEE),
a probe with a transducer tip is swallowed by the client
to visualize for valvular abnormalities, possible
thrombus, bacterial endocarditis and any congenital
heart defects. When performing an Intracoronary
Ultrasound, a tiny ultrasound probe is inserted into the
coronary artery to evaluate for plaque size and
consistency, arterial walls and effectiveness of the
treatment.
4. Answer: D
Rationale:
The central venous pressure is within the superior vena
cava. The Normal CVP is 2-6 mmHg. A decrease in the
CVP indicates a decrease in the circulating blood
volume, which may be a result of hemorrhage or fluid
imbalances. The right atrium is located at the
midaxillary line at the fourth intercostal space, and the
zero points on the transducer needs to be at the level
of the right atrium. The client needs to be supine, with
the head of the bed elevated at 45 degrees to correctly
assess the CVP.
5. Answer: D
Rationale:
In hypokalemia, the electrocardiogram may show
flattening and inversion of the T wave, the appearance
of a U wave, and ST depression. Hypercalcemia can
cause a shortened ST and widened T wave. The
electrocardiogram of a hyperkalemic client shows tall
peak T waves, widened QRS complexes, prolonged PR
intervals or flat P waves.
6. Answer:  A, B, E
Rationale:
Loading of drugs depends on the type of dry powder
inhaler. Take note that some dry powder inhalers do
not require loading. Dry powder inhalers are kept dry
always and are place at room temperature. Never
shake a dry powder inhaler. It is not a pressurized
container. There is no propellant, only the client’s
breath can pull the drug in. Because the drug is a dry
powder and there is no propellant, the client will not
feel, smell, or taste the drug during inhalation. The
client’s breath will moisten the powder causing it to
clump and not be delivered accurately. Immediately
after inhalation of the drug, the inhaler must be
removed from the client’s mouth to prevent moisture.
7. Answer: C, D, E
Rationale:
Stripping is not allowed. Also when changing the
drainage system or when checking air leaks, clamp the
chest tube for short periods only. Emptying of the
collection chamber or changing the drainage system
should be done before the drainage comes in contact
with the bottom of the tube. Avoid kinks and
dependent loops to allow effective drainage and
prevent disrupting the system. Report excessive
drainage that is cloudy or red. Drainage will often
increase with position changes or coughing.
Bubbling is expected and indicates air drainage from
the client. Absence of bubbling may mean that the
chest tube is obstructed, the lungs have fully re-
expanded and no more air is leaking into the pleural
space. Keep the drainage system lower than the level
of the chest to allow effective drainage.
8. Answer: D
Rationale:
Sodium Bicarbonate should be slowly administered
because fast infusion may result in an abrupt reduction
of serum potassium level which can eventually lead to
arrhythmias. Diluting or mixing the drug with
hypotonic solution (i.e. D5W) or isotonic solution
(0.9% NaCl) can be ordered but not with the
hypertonic solution (I.e D10W).
9. Answer: D
Rationale:
Loosening tight clothing, applying a warm blanket to
prevent heat loss, and administering oxygen supply
might help but is not the priority this time. Direct
pressure over the bleeding site is a priority to prevent
shock but placing a tourniquet on the artery is done by
a surgeon. Because the client is showing signs of
altered mental status, there is likely less perfusion in
the brain, which calls for fluid resuscitation. At least
two IV access allows administration of fluids –
crystalloid, blood or clotting factors as necessary which
is vital in correcting acidosis, hypothermia, and
coagulopathy, and to restore perfusion rapidly.
10. Answer: A
Rationale:
Cushing’s syndrome is clinically defined as the
presence of excessive corticosteroids. Addison’s
disease is clinically defined as adrenocortical
insufficiency. Hypothyroidism is a condition wherein
there is insufficient thyroid hormone produced by the
thyroid glands while SIADH is characterized by
excessive release of anti-diuretic hormone.
11. Answer: C
Rationale:
Facial tremors will occur even without performing a
specific maneuver. Exaggerated reflexes such as
hyperreflexia can be assessed by performing a
different maneuver. Gentle tapping of the area below
the zygomatic bone just in front of the ear is used to
elicit Chvostek’s sign to assess the presence of
hypocalcemia. Trousseau sign is characterized by
spasm of the muscles of the hand and forearm upon
inflation of a BP cuff on it.
12. Answer: A, B, C, D, E and F
Rationale:
The leaking of vesicant drugs into surrounding tissue
causes local tissue damage like delayed healing, tissue
necrosis, disfigurement, loss of function and even
amputation.
13. Answer: B, C, E
Rationale:
Manual stimulation is recommended to evacuate
impacted stool. Having the client sit up straight and
raise his head so that he is looking ahead helps reduce
the blood pressure as it allows the gravitational pooling
of blood in the lower extremities. Constrictive clothing
may trigger an autonomic reaction that would cause
the blood pressure to go up so this must be removed.
Manual compression or tapping the bladder to allow
urine to flow down the catheter should be avoided
because this would trigger an increase in blood
pressure. Administration of prescribed vasodilators is
done to reduce high blood pressure.
14. Answer: D
Rationale:
Option A is ataxic breathing. Option B is apneustic
breathing. Option C is central neurogenic
hyperventilation. Cheyne-stokes breathing respirations
are a pattern of breathing in which phases of
hyperpnea regularly alternate with apnea in a
crescendo-decrescendo pattern.
15. Answer: D
Rationale:
The lowest possible score for any response is 1. If a
client is unresponsive to painful stimuli, the score is 1.
A score lower than 8 indicates that the client is in a
comatose state. The highest score for the GCS is 15. A
score of 15 indicates an alert and oriented person. A
score of 3-8 indicates severe head injury.
16. Answer: D
Rationale:
Helping the client maintain an exercise program is a
therapeutic intervention to maintain joint mobility and
good body alignment. This will also prevent venous
stasis due to impaired mobility. Client encouragement
will not only address the physical aspect of the disease
but the client’s emotions and self-esteem as well. The
safety of the client with impaired physical mobility
should always be considered. Continuous physical
activity is not recommended. There should be an
alternate period of activity and rest to prevent
excessive fatigue.
17. Answer: B
Rationale:
Receptive Aphasia refers to the inability to understand
spoken words but can freely express and verbalize.
Expressive Aphasia refers to the inability to speak and
communicate formulated thoughts and sentiments.
Global aphasia affects both expressive ability and
auditory comprehension. Apraxia is characterized by
loss of the ability to perform activities that a person is
physically able and willing to do.
18. Answer: B
Rationale:
Graphesthesia is the ability to identify the writing on
the skin even with the eyes closed. The client provides
a verbal response, identifying the figure that was
drawn. Option A is a test for stereognosis. Option C is
a test used to assess Romberg’s sign while option D is
a test for Kernig’s sign.
19. Answer: D
Rationale:
Any deterioration of oxygen saturation may necessitate
intubation. However, the priority this time is to
maintain a patent airway. Infusion of IV fluids and
administration of antibiotics are expected nursing
actions but not the top priority this time. Completing
vaccination at this time will not suffice or treat the
underlying respiratory problem. The situation calls for
a curative management and not preventive measures.
Airway closure is the top priority. Throat examination
is avoided as this increases the risk of laryngeal
obstruction. Aggression or agitation can also
compromise airway and breathing.
20. Answer: B
Rationale:
Absorption is the process when the drug is transferred
from the site of origin into the bloodstream.
Distribution occurs when the drug in the blood is
distributed to different parts of the body and
accumulates in specific tissues. Metabolism or
biotransformation is the process wherein the drug is
broken down into its inactive form. Excretion is the
body’s response to eliminate all the inactive form of
the drug.
21. Answer: D
Rationale:
The Ventrogluteal site is safe for most intramuscular
injections because it only involves the gluteus medius
and gluteus minimus muscles. The Vastus lateralis
muscle is also a safe injection site for intramuscular
medications because there are no adjacent large blood
vessels and nerves. The deltoid muscle is a smaller
muscle and is safe for administration of intramuscular
medications less than 1 mL. The Dorsogluteal muscle is
not recommended for intramuscular medications
because of the potential damage to the sciatic nerve.
Large blood vessels are also located near the
dorsogluteal muscle and should be avoided.
22. Answer: B
Rationale:
Prescribing or stopping medications is the responsibility
of the physician, thus the nurse must refer this first.
Thiazide diuretics cause loss of blood potassium while
conserving blood calcium, thus, the electrolyte level
must be evaluated first.
23. Answer: D
The Brandt-Andrew maneuver is the proper extraction
of the umbilical cord and placenta. McRobert’s
maneuver is performed in case of shoulder dystocia
during childbirth. The Schultz mechanism is used to
describe placental delivery. Ritgen’s maneuver is
performed by applying pressure over the perineum and
counter-pressure on the fetal head. The Ritgen’s
maneuver controls the exit of the fetal head and
prevents severe damage to maternal tissues.
24. Answer: B
Rationale:
The uterine fundus should start to descend after 24
hours of delivery. The normal rate of uterine descent is
1 cm/day.
25. Answer: B
Rationale:
In Somatoform Disorder, there is no real organ
damage, but the client verbalizes symptoms of a
disease in an unconscious manner. In Malingering,
verbalization of symptoms of a disease is conscious
and is used by the client to achieve a secondary gain
or benefit. Anxiety comes in many forms of panic
attacks, phobia, and social anxiety and the distinction
between a disorder and “normal” anxiety isn’t always
clear. Amnesia refers to the loss of memories, such as
facts, information and experiences.
26. Answer: D
Rationale:
Not all chemotherapeutic agents alter the molecular
structure of DNA. Chemotherapy should slow down cell
division not hasten it. All cells are sensitive to drug
toxins. Chemotherapeutic agents act on all rapidly
dividing cells – most action of chemotherapeutic
agents is that it affects all rapidly dividing cells
including the normal and cancer cells.
27. Answer: C
Rationale:
Ketoacidosis is associated with high levels of ketone
bodies in the body brought by the breakdown of fatty
acids and is not related to vomiting. Metabolic acidosis
happens when the body produces an excessive
quantity of acid. Severe vomiting will result in loss of
HCL and acids coming from extracellular fluids which in
turn leads to metabolic alkalosis. Respiratory alkalosis
occurs when there is an increased respiration which
elevates the blood pH beyond the normal range of
7.35-7.45.
28. Answer: D
Rationale:
2nd-degree skin reactions are evident by scaly skin, an
itchy feeling, and dry desquamation. Reddening of the
skin is not seen in 2nd-degree skin reactions.
29. Answer: B
Rationale:
Tremor is clinically defined as rhythmic and repetitive
muscle movement. Chorea is clinically defined as brief
and involuntary muscle twitching of the face or limbs
which hinders the client’s mobility. Athetosis is
clinically defined as the presence of irregular and slow
twisting motions. Dystonia is similar to the definition of
Athetosis but involves larger muscle areas.
30. Answer: C
Rationale:
Standing close to the working area is a proper body
mechanics to prevent muscle fatigue. The nurse should
adjust the bed to waist level in order to prevent
stretching and muscle strain. Proper body mechanic
includes turning the body as a whole unit when moving
the client to avoid twisting the back. The knees are
bent to support the body’s center of gravity and
maintain body balance. Bending the knees will provide
a wider base of support for effective leverage and use
of energy.
TEST 3
1. A patient who is in isolation needs a temperature
taken several times a day. Where is the appropriate
place for the thermometer to be kept?
A. At the nurses’ station.
B. On the isolation cart outside the patient’s room.
C. In the dirty utility room.
D. In the patient’s room.
2. Which of the following best describes how persons
affected by Parkinson’s disease typically walk?
A. Long, steady gaits
B. They shuffle their feet while taking small steps
C. Fast movement of the feet
D. Always needs support from assistive devices
3. A male patient with a right pleural effusion noted on
a chest X-ray is being prepared for thoracentesis. The
patient experiences severe dizziness when sitting
upright. To provide a
safe environment, the nurse assists the patient to
which position for the procedure?
A. Prone with head turned toward the side supported
by a pillow
B. Sims’ position with the head of the bed flat
C. Right side-lying with the head of the bed elevated
45 degrees
D. Left side-lying with the head of the bed elevated 45
degrees
4. A patient is experiencing pain during the first stage
of labor. What should the nurse instruct the patient to
do to manage her pain? Select all that apply
A. Walk in the hospital room.
B. Use slow chest breathing.
C. Request pain medication on a regular basis.
D. Lightly massage her abdomen.
E. Sip ice water.
5. The nurse is monitoring a child with burns during
treatment for burn shock. Which
assessment provides the most accurate guide to
determine the adequacy of fluid
resuscitation?
A. Skin turgor
B. Level of edema at burn site
C. Adequacy of capillary filling
D. Amount of fluid tolerated in 24 hours
 
6. Which of the following structures should be closed
by the time the child is 2 months old?

1. A.           2. B.                    3. C.                            10. The patient admitted with peripheral vascular
4. D.
7. The nurse is evaluating an infant who has an
intravenous infusion secured to a sandbag (see figure).
The nurse should:
A. Add tape to cover the toe.
B. Secure the right leg to a sandbag.
C. Check the infusion rate every hour.
D. Change the sandbag to an extremity restraint
8. The nurse is assessing a patient who has had a
myocardial infarction (MI). The nurse notes the cardiac
rhythm shown on the electrocardiogram strip below.
The nurse identifies this rhythm as which of the
following?
A. Atrial fibrillation.
B. Ventricular tachycardia.
C. Premature ventricular contractions (PVCs).
D. Third-degree heart block.
9. The nurse is assessing a patient who has had a
myocardial infarction. The nurse notes the cardiac
rhythm shown on the electrocardiogram strip below.
The nurse identifies this rhythm as which of the
following?
A. Atrial fibrillation.
B. Ventricular tachycardia.
C. Premature ventricular contractions.
D. Sinus tachycardia.
disease (PVD) asks the nurse why her legs hurt when
she walks. The nurse bases a response on the
knowledge that the main characteristic of PVD is:
A. Decreased blood flow.
B. Increased blood flow.
C. Slow blood flow.
D. Thrombus formation.
11. A patient is scheduled to undergo right axillary-to-
axillary artery bypass surgery. Which of the following
interventions is most important for the nurse to
implement in the preoperative period?
A. Assess the temperature in the affected arm.
B. Monitor the radial pulse in the affected arm.
C. Protect the extremity from cold.
D. Avoid using the arm for a venipuncture.
12. When giving discharge instructions to the patient
with vasospastic disorder (Raynaud’s phenomenon),
the nurse should explain that the expected outcome of
taking a beta adrenergic blocking medication is to
control the symptoms by:
A. Decreasing the influence of the sympathetic nervous
system on the tissues in the hands and feet.
B. Decreasing the pain by producing analgesia.
C. Increasing the blood supply to the affected area.
D. Increasing monoamine oxidase.
13. The patient is admitted with left lower leg pain, a
positive Homans’ sign, and a temperature of 100.4° F
(38° C). The nurse should assess the patient further
for signs of:
A. Aortic aneurysm.
B. Deep vein thrombosis (DVT) in the left leg.
C. I.V. drug abuse.
D. Intermittent claudication.
14. A patient has sudden, severe pain in his back and
chest, accompanied by shortness of breath. The
patient describes the pain as a “tearing” sensation. The
physician suspects the patient is experiencing a
dissecting aortic aneurysm. The code cart is brought
into the room because one complication of a dissecting
aneurysm is:
A. Cardiac tamponade.
B. Stroke.
C. Pulmonary edema.
D. Myocardial infarction.
15. A nurse is teaching a patient about taking
antihistamines. Which of the following instructions
should the nurse include in the teaching plan? Select
all that apply.
A. Operating machinery and driving may be dangerous
while taking antihistamines.
B. Continue taking antihistamines even if nasal
infection develops.
C. The effect of antihistamines is not felt until a day
later.
D. Do not use alcohol with antihistamines.
E. Increase fluid intake to 2,000 mL/day.
16. A patient who has had a total laryngectomy
appears withdrawn and depressed. He keeps the
curtain drawn, refuses visitors, and indicates a desire
to be left alone. Which nursing intervention would most
likely be therapeutic for the patient?
A. Discussing his behavior with his wife to determine
the cause.
B. Exploring his future plans.
C. Respecting his need for privacy.
D. Encouraging him to express his feelings nonverbally
and in writing.
17. A 79-year-old female patient is admitted to the
hospital with a diagnosis of bacterial pneumonia. While
obtaining the patient’s health history, the nurse learns
that the patient has osteoarthritis, follows a vegetarian
diet, and is very concerned with cleanliness. Which of
the following would most likely be a predisposing factor
for the diagnosis of pneumonia?
A. Age.
B. Osteoarthritis.
C. Vegetarian diet.
D. Daily bathing
18. Which of the following symptoms is common in
patients with active tuberculosis?
A. Weight loss.
B. Increased appetite.
C. Dyspnea on exertion.
D. Mental status changes.
19. A patient experiencing a severe asthma attack has
the following arterial blood gas: pH 7.33; PCO2 48;
PO2 58; HCO3 26. Which of the following orders should
the nurse perform first?
A. Albuterol (Proventil) nebulizer.
B. Chest x-ray.
C. Ipratropium (Atrovent) inhaler.
D. Sputum culture.
20. A female patient diagnosed with lung cancer is to
have a left lower lobectomy. Which of the following
increase the patient’s risk of developing postoperative
pulmonary complications?
A. Height is 5 feet, 7 inches and weight is 110 lb.
B. The patient tends to keep her real feelings to
herself.
C. She ambulates and can climb one flight of stairs
without dyspnea.
D. The patient is 58 years of age.
21. The nurse is assessing a patient who has a chest
tube connected to a water-seal chest tube drainage
system. According to the illustration shown, which
should the nurse do?
A. Clamp the chest tube near the insertion site to
prevent air from entering the pleural cavity.
B. Notify the physician of the amount of chest tube
drainage.
C. Add water to maintain the water seal.
D. Lower the drainage system to maintain gravity flow.
22. A patient has entered a smoking cessation
program to quit a two-pack-a-day cigarette habit. He
tells the nurse that he has not smoked a cigarette for 3
weeks, but is afraid he is going to “slip up” and smoke
because of current job pressures. What would be the
most appropriate reply for the nurse to make in
response to the patient’s comments?
A. “Don’t worry about it. Everybody has difficulty
quitting smoking, and you should expect to as well.”
B. “If you increase your self-control, I am sure you will
be able to avoid smoking.”
C. “Try taking a couple of days of vacation to relieve
the stress of your job.”
D. “It is good that you can talk about your concerns.
Try calling a friend when you want to smoke.”
23. The nurse is developing standards of care for a
patient with gastroesophageal reflux disease and wants
to review current evidence for practice. Which one of
the following resources will provide the most helpful
information?
A. A review in the Cochrane Library.
B. A literature search in a database, such as the
Cumulative Index to Nursing and Allied Health
Literature (CINHAL).
C. An online nursing textbook.
D. The online policy and procedure manual at the
health care agency.
See  also our latest Saudi Prometric Exam Question and
Answer
 Saudi Council for Health Specialty [Exam
for Nurses Set 1]
24. TPN is ordered for a patient with Crohn’s disease.
Which of the following indicate the TPN solution is
having an intended outcome?
A. There is increased cell nutrition.
B. The patient does not have metabolic acidosis.
C. The patient is hydrated.
D. The patient is in a negative nitrogen balance.
25. The nurse notes that the sterile, occlusive dressing
on the central catheter insertion site of a patient
receiving total parenteral nutrition (TPN) is moist. The
patient is breathing easily with no abnormal breath
sounds. The nurse should do the following in order of
what priority from first to last?
A. Change dressing per institutional policy.
B. Culture drainage at insertion site.
C. Notify physician.
D. Position rolled towel under patient’s back, parallel to
the spine.
26. Serum concentrations of thyroid hormones and
thyroid-stimulating hormone (TSH) are tests ordered
for the patient with thyrotoxicosis. Which of the
following laboratory values are indicative of
thyrotoxicosis?
A. Elevated thyroid hormone concentrations and
normal TSH.
B. Elevated TSH and normal thyroid hormone
concentrations.
C. Decreased thyroid hormone concentrations and
elevated TSH.
D. Elevated thyroid hormone concentrations and
decreased TSH.
27. The nurse is checking the laboratory results on a
52-year-old patient with type 1 diabetes (see chart).
What laboratory result indicates a problem that should
be managed?
A. Blood glucose.
B. Total cholesterol.
C. Hemoglobin.
D. Low-density lipoprotein (LDL) cholesterol.
28. The patient with type 1 diabetes mellitus is taught
to take isophane insulin suspension NPH (Humulin N)
at 5 p.m. each day. The patient should be instructed
that the greatest risk of hypoglycemia will occur at
about what time?
A. 11 a.m., shortly before lunch.
B. 1 p.m., shortly after lunch.
C. 6 p.m., shortly after dinner.
D. 1 a.m., while sleeping.
29. Four days after surgery for internal fixation of a C3
to C4 fracture, a nurse is moving a patient from the
bed to the wheelchair. The nurse is checking the
wheelchair for correct features for this patient. Which
of the following features of the wheelchair are
appropriate for the needs of this patient? Select all that
apply.
A. Back at the level of the patient’s scapula.
B. Back and head that are high.
C. Seat that is lower than normal.
D. Seat with fi rm cushions.
E. Chair controlled by the patient’s breath
30. A patient with multiple sclerosis (MS) is
experiencing bowel incontinence and is starting a
bowel retraining program. Which strategy is
inappropriate?
A. Eating a diet high in fiber.
B. Setting a regular time for elimination.
C. Using an elevated toilet seat.
D. Limiting fluid intake to 1,000 mL/day.
RATIONALE 3
1. D. In the patient’s room.
It is best to keep the equipment inside the room for
easy access to it when needed and also for infection
control measures. The patient in isolation may be
immunocompromised or have an infectious disease.
Making sure that the thermometer is only on him limits
the risk of infection.
2. B. They shuffle their feet while taking small
steps
Typical walk of patients with Parkinson’s disease is
usually described as shuffling gait, which is due to the
degeneration of the basal ganglia. This change in
movement is considered part of the extrapyramidal
symptoms observed among patients with Parkinson’s
disease.
3. D. Left side-lying with the head of the bed
elevated 45 degrees
This position helps ensure that the patient is protected
from accidental puncture of the surrounding structures
in the thoracic cavity. It also exposes the puncture site
while helping ensure that the patient has optimal
breathing for his condition
4. A, B, D.
Pain during the first stage of labor is primarily caused
by hypoxia of the uterine and cervical muscle cells
during contraction, stretching of the lower uterine
segment, dilatation of the cervix and perineum, and
pressure on adjacent structures. Ambulating will assist
in increasing circulation of blood to the area and
relaxing the muscles.
Slow chest breathing is appropriate during the first
stage of labor to promote increased oxygenation as
well as relaxation. The woman or her coach can lightly
massage the abdomen (effleurage) while using slow
chest breathing. Chest breathing and massaging
increase oxygenation and relaxation of uterine
muscles. Pain medication is not used during the first
stage of labor because most medications will slow
labor; anesthesia may be considered during the second
stage of labor. Sipping ice water, while helpful for
maintaining hydration, will not be useful as a pain
management strategy.
5. C.
Parameters such as vital signs (especially heart rate),
urinary output volume, adequacy of capillary filling,
and state of sensorium determine adequacy of fluid
resuscitation. Although options 1, 2, and 4 may
provide some information related to fluid
volume, in a burn injury, and from the options
provided, adequacy of capillary filling is most accurate.
6. 3.
The posterior fontanel should be closed by age 2
months. The anterior fontanel and sagittal and frontal
sutures should be closed by age 18 months.
7. C.
The intravenous infusion is secured appropriately; the
sandbag is used to limit movement of the leg. It is not
necessary to also secure the uninvolved extremity. The
intravenous site should be visible; the nurse should not
cover it with tape. The nurse should use an infusion
pump with monitoring alarms, and check the infusion
rate every hour.
8. C.
PVCs are characterized by a QRS of longer than 0.10
second and by a wide, notched, or slurred QRS
complex. There is no P wave related to the QRS
complex, and the T wave is usually inverted.
9. D.
Sinus tachycardia is characterized by normal
conduction and a regular rhythm, but with a rate
exceeding 100 bpm. A P wave precedes each QRS, and
the QRS is usually normal.
10. A.
Decreased blood flow is a common characteristic of all
PVD. When the demand for oxygen to the working
muscles becomes greater than the supply, pain is the
outcome. Slow blood flow throughout the circulatory
system may suggest pump failure. Thrombus
formation can result from stasis or damage to the
intima of the vessels.
11. D.
If surgery is scheduled, the nurse should avoid
venipunctures in the affected extremity. The goal
should be to prevent unnecessary trauma and possible
infection in the affected arm. Disruptions in skin
integrity and even minor skin irritations can cause the
surgery to be canceled. The nurse can continue to
monitor the temperature and radial pulse in the
affected arm; however, doing so is not the priority.
Keeping the patient warm is important but is not the
priority at this time.
12. A.
Beta-adrenergic medications block the beta-adrenergic
receptors. Therefore, the expected outcome of the
medication is to decrease the influence of the
sympathetic nervous system on the blood vessels in
the hands. Beta-adrenergic blockers have no analgesic
effects. Increasing blood supply to the affected area is
an indirect effect of beta adrenergic blockers. They do
not increase monoamine oxidase, which does not play
a role in Raynaud’s disease.
13. B.
The patient demonstrates classic symptoms of DVT,
and the nurse should continue to assess the patient.
Signs and symptoms of an aortic aneurysm include
abdominal pain and a pulsating abdominal mass.
Patients with drug abuse demonstrate confusion and
decreased levels of consciousness. Claudication is an
intermittent pain in the leg.
14. A.
Cardiac tamponade is a life-threatening complication of
a dissecting thoracic aneurysm. The sudden, painful
“tearing” sensation is typically associated with the
sudden release of blood, and the patient may
experience cardiac arrest. Stroke, pulmonary edema,
and myocardial infarction are not common
complications of a dissecting aneurysm.
15. A, D, E.
Antihistamines have an anticholinergic action and a
drying effect and reduce nasal, salivary, and lacrimal
gland hypersecretion (runny nose, tearing, and itching
eyes). An adverse effect is drowsiness, so operating
machinery and driving are not  recommended. There is
also an additive depressant effect when alcohol is
combined with antihistamines, so alcohol should be
avoided during antihistamine use. The patient should
ensure adequate fluid intake of at least 8 glasses per
day due to the drying effect of the drug.
Antihistamines have no antibacterial action. The effect
of antihistamines is prompt, not delayed.
16. D.
The patient has undergone body changes and
permanent loss of verbal communication. He may feel
isolated and insecure. The nurse can encourage him to
express his feelings and use this information to
develop an appropriate plan of care. Discussing the
patient’s behavior with his wife may not reveal his
feelings. Exploring future plans is not appropriate at
this time because more information about the patient’s
behavior is needed before proceeding to this level. The
nurse can respect the patient’s need for privacy while
also encouraging him to express his feelings.
17. A.
The patient’s age is a predisposing factor for
pneumonia; pneumonia is more common in elderly or
debilitated patients. Other predisposing factors include
smoking, upper respiratory tract infections,
malnutrition, immunosuppression, and the presence of
a chronic illness. Osteoarthritis, a nutritionally sound
vegetarian diet, and frequent bathing are not
predisposing factors for pneumonia.
18. A.
Tuberculosis typically produces anorexia and weight
loss. Other signs and symptoms may include fatigue,
low-grade fever, and night sweats. Increased appetite
is not a symptom of tuberculosis; dyspnea on exertion
and change in mental status are not common
symptoms of tuberculosis.
19. A.
The arterial blood gas reveals a respiratory acidosis
with hypoxia. A quick-acting bronchodilator, albuterol,
should be administered via nebulizer to improve gas
exchange. Ipratropium is a maintenance treatment for
bronchospasm that can be used with albuterol. A chest
x-ray and sputum sample can be obtained once the
patient is stable.
20. A.
Risk factors for postoperative pulmonary complications
include malnourishment, which is indicated by this
patient’s height and weight. It is thought that
emotional responses can affect overall health;
however, not verbalizing one’s feelings is not a
contributing factor in postoperative pulmonary
complications. The patient’s current activity level and
age do not place her at increased risk for
complications.
21. D.
To promote chest tube drainage the drainage system
must be lower than the patient’s lungs. The amount of
drainage is not abnormal; it is not necessary to notify
the physician. The nurse should chart the amount and eat a bedtime snack to help prevent hypoglycemia
color of drainage every 4 to 8 hours. The chest tube while sleeping.
does not need to be clamped; the tubing connection is 29. B, C, E.
intact. There is sufficient water to maintain a water The patient with a C3 to C4 fracture has neck control
seal. but may tire easily using sore muscles around the
22. D. incision area to hold up his head. Therefore, the head
It is important for individuals who are engaged in and neck of his wheelchair should be high. The seat of
smoking cessation efforts to feel comfortable with the wheelchair should be lower than normal to
sharing their fears of failure with others and seeking facilitate transfer from the bed to the wheelchair.
support. Although fewer than 5% of smokers When a patient can use his hands and arms to move
successfully quit on their first attempt, it is not helpful the wheelchair, the placement of the back to the
to tell a patient that he should anticipate failure. patient’s scapula is necessary. This patient cannot use
Telling the patient to exercise more self control his arms and will need an electric chair with breath,
does not provide him with support. Taking a vacation chin, or voice control to manipulate movement of the
to avoid job pressures does not address the issue of chair. A firm or hard cushion adds pressure to bony
fearing he will smoke a cigarette when in a stressful prominences; the cushion should instead be padded to
situation. reduce the risk of pressure ulcers.
23. A. 30. D.
The Cochrane Library provides systematic reviews of Limiting fluid intake is likely to aggravate rather than
health care interventions and will provide the best relieve symptoms when a bowel retraining program is
resource for evidence for nursing care. CINHAL offers being implemented. Furthermore, water imbalance, as
key word searches to published articles in nursing and well as electrolyte imbalance, tends to aggravate the
allied health literature, but not reviews. A nursing signs and symptoms of MS. A diet high in fiber helps
textbook has information about nursing care which keep bowel movements regular. Setting a regular time
may include evidence based practices, but textbooks each day for elimination helps train the body to
may not have the most up-to-date information. While maintain a schedule. Using an elevated toilet seat
the policy and procedure manual may be based on facilitates transfer of the patient from the wheelchair to
evidence-based practices, the most current practices the toilet or from a standing to a sitting position.
will be found in evidence-based reviews of literature.
24. A.
The goal of TPN is to meet the patient’s nutritional
needs. TPN is not used to treat metabolic acidosis;
ketoacidosis can actually develop as a result of
administering TPN. TPN is a hypertonic solution
containing carbohydrates, amino acids, electrolytes,
trace elements, and vitamins. It is not used to meet
the hydration needs of patients. TPN is administered to
provide a positive nitrogen balance.
25. C, D, B, A.
A potential complication of receiving TPN is leakage or
catheter puncture; notify the physician immediately
and prepare for changing of the catheter. If
pneumothorax is suspected, position a rolled towel
under the patient’s back. If there is drainage at the
insertion site, culture the drainage and change the
dressing using sterile technique.
26. D.
Elevated serum concentrations of thyroid hormones
and suppressed serum TSH are the features of
thyrotoxicosis. Decreased or absent serum TSH is a
very accurate indicator of thyrotoxicosis. Increased
levels of circulating thyroid hormones cause the
feedback mechanism to the brain to suppress TSH
secretion.
27. A.
The elevated blood glucose level indicates
hyperglycemia. The hemoglobin is normal. The
patient’s cholesterol and LDL levels are both normal.
The nurse should determine if there are standing
orders for the hyperglycemia or notify the physician.
28. D.
The patient with diabetes mellitus who is taking NPH
insulin (Humulin N) in the evening is most likely to
become hypoglycemic shortly after midnight because
this insulin peaks in 6 to 8 hours. The patient should