FUNDA EVALUATIVE EXAM

1. This theorist believes that adaptation and manipulation of stressors are essential for
change.
A. Betty Newman
B. Dorothea Orem
C. Martha Rogers
D. Sister Calista Roy

2. Her theory can be defined as the development of science of humankind. She applied
in her theory the concept of energy fields, openness, pattern and organization.
A. Martha Rogers
B. Dorothea Orem
C. Virginia Henderson
D. Jean Watson

3.  Smith conceptualizes this health model as a condition of actualization or realization

of person’s potential. It claims that the highest aspiration of people is fulfillment and
complete developmental actualization. Which of the following models refer to this?
A. Clinical model
B. Eudemonistic model
C. Adaptive model
D. Role performance model

4.  Who among the following is considered as the first nursing theorist
A. Phoebe
B. Clara Barton
C. Florence Nightingale
D. Sister Calista Roy
5. The most commonly used model that assists in the understanding of the patient’s
place on the wellness/illness continuum is:
A. Abraham Maslow
B. Dorothea Dix
C. Clara Barton
D. Theodor Fliedner

6. All of the following statements related to the early nursing practice are true except;
A. Religion has significantly played a role in the development of nursing
B. The role of caring and nurturing family members has traditionally been delegated to the
males in the family
C. From the beginning of time, women have always cared for infants and children in the home
D. The traditional nursing role entailed physical maintenance and comfort, nurturing, comforting
and supporting
7. Which among the following statements is not true about the prominent nursing
leaders in the history of the early nursing?
A. Mary Breckinridge was the founder of the Planned Parenthood in America
B. Lilian Wald was the founder of public health nursing
C. Clara Barton was a schoolteacher turned nurse, who later established the America Red Cross
D. Linda Richards was the first trained nurse and was known for introducing nurse’s note and
doctor’s order in the patient’s chart

Situation: Admission, transfer and discharge are common events in any health
care settings therefore the nurse must be knowledgeable in the process of
admission, transfer and discharge.
8. A 50 year old male client who undergone an extensive surgery due to the trauma he
sustained from a vehicular accident is being transferred to the surgical unit from the
post anesthesia care unit. Which among the following is the most vital principle that the
assigned nurse to him should remember when admitting, transferring, or discharging a
client?
A. The patient is a human being deserving dignity, courtesy, and respect
B. The patient is ill and unable to make decisions or give accurate information
C. The nurse knows best and should tell the patient what to do
D. Families get in the way and should be encouraged not to get involved in the patient’s care

9. A 40 year old female client who has been diagnosed with type 1 DM is being
prepared for her dismissal from the hospital. Which among the following pertains to the
purpose of discharge planning?
A. Make certain she takes her medication as prescribed
B. Provide medical treatment
C. Provide ongoing patient education
D. Ensure continuity of care

10. A 85 year old male client has been diagnosed with cerebrovascular accident has
been admitted to the hospital for 6 days. The nurse is aware that discharge planning
should be initiated during which of the following?
A. When his condition has stabilized
B. On his admission to the hospital
C. When he begins to ask questions
D. When his family asks for information
11. Which of the following is the appropriate action of the nurse when the client insisted
on leaving the hospital despite his condition and without the doctor’s knowledge?
A. Call the family so they can expect the patient at home
B. Allow the patient to leave because no one can be held against his or her will
C. Call security because there must be a physician’s order before a patient may leave
D. Explain the risk of leaving and request that the patient sign a paper accepting responsibility
for problems that may occur

12. Which among the following is the most appropriate action of the nurse during the
client’s discharge?
A. Tell the patient everything will be all right
B. Encourage the patient not to worry
C. Wish the patient well
D. Introduce the patient to the office staff

Situation: Hygiene is the science of health and its preservation. Hygiene is

personal matter established by individual’s values and practices. The nurse must
be knowledgeable in the proper ways of rendering hygienic care to clients.
13. A nurse is bathing a 10year old client with a cast on the left leg. Which of the
following actions is appropriate for the nurse do when providing eye care?
A. To wash from the outer canthus to inner canthus
B. To cleanse dried exudate with hot water
C. To avoid drying circumorbital area after washing
D. To use a different section of washcloth for each eye

14. A nurse is to render perineal care to an 80 year old male client 1 day post TURP.
Which among the following is most appropriate action of the nurse?14. A nurse is to
render perineal care to an 80 year old male client 1 day post TURP. Which among the
following is most appropriate action of the nurse?
A. Retract the foreskin, cleanse the penis, and allow the foreskin to return to former position
B. Sprinkle powder under the foreskin to facilitate retraction of the foreskin
C. Leave the foreskin slightly damp to allow retraction to its former state
D. Retract the foreskin, cleanse the penis, and return the foreskin with a gentle forward motion

15. Which among the following clients has the highest risk for complication of the feet?
A. A young man in a career that requires standing
B. A disoriented, elderly man
C. A 60-year-old person with diabetes mellitus
D. A 62-year-old patient with total hip replacement
Situation: Pressure ulcer is any lesions brought by unrelieved pressure leading
to the damage of the underlying tissue. It is most common among clients who are
confined in bed.
16. When the nurse is placing the client on a 30 degrees lateral position, she is
preventing the client to develop pressure ulcer over which of the  following areas?
A. Spinous processes
B. Ischial tuberosities
C. Greater tronchanters
D. Occipital prominence

17. Which among the following pertains to stage III pressure ulcers?
A. Nonblanchable reddened areas where the skin is intact
B. Full-thickness skin loss extending to but not through the fascia
C. Extensive destruction of skin and muscle with possible sinus tracts
D. Areas of full-thickness skin loss with possible extension to the bone

Situation: Conduction of surgical procedures may vary in every health care

institution but providing quality care and ensuring client’s safety is a mutual aim
among every health care facilities.
18. A nurse is caring for a female client with Penrose drain in the left lower quadrant,
who has been returned to the medical-surgical unit from the post anesthesia care unit.
The nurse knows that the Penrose drain was placed to
A. instill solution for wound irrigation
B. prevent blockage of a passageway
C. drain the wound area by suction
D. drain the wound area by gravity

19. While doing an assessment to the client, the nurse noticed that the client’s
abdominal wound eviscerated, the nurse should;
A. Place her in high Fowler’s position
B. Give her fluids to prevent shock
C. Replace dressings with sterile fluffy pads
D. Apply warm, moist sterile dressings

20. A client was prescribed to wear an antiembolic stocking. The nurse should initially;
A. Measure the legs before applying stockings to assure proper fit
B. Apply the stockings while the client is sitting in a chair
C. Massage the legs when removing the stockings
D. Leave the stockings in place for one week intervals

21. The OR nurse must be aware of the surgical environment and the proper attire in
each area.  Which of the following constitute a break in infection control which may
cause contamination in the OR?
A. The spouse of the client enters the unrestricted area in street clothes.
B. The OR nurse wear surgical attire when going to the storage areas.
C. The OR nurse is wearing scrub attire in the restricted area.
D. The OR nurse wear surgical attire in the OR room when preparing for the instruments.

Situation: Infection control is one of the most important parts of health care. It is
concerned on preventing nosocomial or health care related infection 
22. To be able to protect the client’s first line of defense against infection, the nurse
should do which of the following?
A. Turn the client who is immobilized every 2 hours so the skin does not break down.
B. Collect an immunization history on the client.
C. Apply heat immediately after an injury.
D. Desensitize the client by providing small doses of allergen.

23. A client was admitted to the hospital after sustaining a traumatic abdominal injury.
Prior to undergoing a surgery to remove the spleen, the nurse should instruct the client
to avoid which of the following?
A. Carcinogens such as smoking
B. Animal dander causing allergies
C. Cuts leading to bloodstream infections
D. Irritants causing dermatitis

24. Which of the following actions of the nurse demonstrates surgical asepsis?
A. Wearing clean gloves to change linen.
B. Cleaning the client’s skin with povidone/iodine and alcohol before inserting an intravenous
catheter.
C. Putting on a HEPA mask when entering the room of a client with tuberculosis.
D. Placing a used syringe in a sharps container.

25. Which element of the chain of infection is being broken when the nurse uses sterile
technique in changing soiled surgical dressing?
A. Transmission
B. Infectious agent
C. Host
D. Reservoir
26. Which of the following actions would be helpful in preventing the development of
hospital acquired infection among clients?
A. Wearing a mask when changing the dressing on the client’s central line
B. Rising the suction catheter with normal saline after suctioning the client’s tracheostomy tube
C. Wearing clean gloves to remove the lunch tray of a client with hepatitis A.
D. Wearing clean gloves to empty a would drain

27. Older clients are at a higher risk of acquiring infection because of which of the
following characteristics?
A. Increased production of saliva
B. Increased cough effort
C. Increased cell-mediated immunity
D. Thinning of the skin

SITUATION: Basic nursing skills are essential for they are vital in many nursing
procedures. Such skills are needed in order to promote health, prevent illness,
cure a disease and rehabilitate infirmities.
28. A client with anemia is prescribed to receive iron injection. The nurse is aware that
this medication should be administered in the:
A. Gluteal muscle using Z-Track technique
B. Deltoid muscle using an air lock
C. Subcutaneous tissue of the abdomen
D. Anterolateral thigh using 5/8-inch needle

29. A 28 year old female client is to undergo cerebral angiogram. Prior to the procedure
the nurse should assess the client for:
A. Claustrophobia
B. Excessive weight
C. Allergy to eggs
D. Allergy to iodine or shellfish

30. The physician ordered for a client to have a wound culture to be obtained during the
next wound irrigation and dressing change. Which of the following is the most
appropriate solution to be use for  the wound irrigation  prior to the procedure?
A. Povidone-iodine (Betadine)
B. One-half-strength hydrogen peroxide
C. Normal saline
D. Acetic acid
31. To determine the necessity to perform an airway suctioning, the nurse should check
the client’s;
A. Oxygen saturation measurement
B. Respiratory rate
C. Breath sounds
D. Arterial blood gas results

32. A nurse is caring for  a diabetic client. She is assisting the client in performing self
monitoring of blood glucose level. The nurse should teach the client to do which of the
following to obtain an adequate capillary sample?
A. Cleanse the hands beforehand using cool water
B. Let the arm hang dependently and milk the digit
C. Puncture the center of the finger pad
D. Puncture the finger as deeply as possible
Situation: A 45 year old male client has been admitted to the medical surgical unit
with a diagnosis of acute pancreatitis. The nurse assigned to him took the initial
vital sign and obtained a blood pressure of 136/76 mmHg, pulse rate of 96 beats
per minute and temperature of 101°F (38.3°C). During the interview the nurse
noted that the client has a history of hyperlipidemia and alcohol abuse. 
33. The client is prescribed to have a nasogastric tube insertion. Prior to the procedure
the nurse explains its purpose to the client. Which among the following is the most
appropriate statement the nurse should make?
A. “It empties the stomach of fluids and gas.”
B. “It prevents spasm of the sphincter of Oddi.”
C. “It prevents air from forming in the small and large intestine.”
D. “It removes bile from the gall bladder.”

34. Which among the following is the most reliable method of checking the placement of
the nasogastric tube?
A. Assessing the patient’s respiration and skin color.
B. Inserting the end of the tube in water and checking for bubbling.
C. Aspirating gastric contents with a syringe and checking ph.
D. Injecting air into the tube with a syringe and listening for rush of air.

35. Which of the following is the most appropriate initial action of the nurse when the
client vomits 200 ml after the nasogastric tube insertion?
A. Change the suction applied to the nasogastric tube from intermittent to continuous.
B. Advance the nasogastric tube 2”(5cm).
C. Replace a nasogastric contents with a large one.
D. Irrigate the tube with saline solution.

36. After caring for a client with extensive body burns, the nurse perform which of the
following actions when removing protective wear? 
A. Remove mask, gown, gloves, cap and shoe cover
B. Remove gloves, mask, down, cap and shoe cover
C. Remove gown, mask, gloves, cap and shoe cover
D. Remove cap and shoe cover, mask, gloves, gown

37. The pain that is perceived at an area other than the site injury is: 
A. Radiating pain
B. Phantom pain
C. Referred pain
D. Psychogenic pain

38. Which of the following chemical agents may not cause pain? 
A. P-substance
B. Histamine
C . Endorphins
D .bradykinin

39. A client has an order for an injection to be administered intradermally. The nurse
avoids which of the following actions when administering this medication? 
A. Inserting the needle at a 10- to 15-degree angle
B. Injecting the medication slowly
C. Massaging the area after removing needle
D. Making a circular mark around the injection site

40. Which of the following personal protective equipment may be reused by the same
nurse during a single shift caring for a single client? 
A. Goggles.
B. Gown.
C. Surgical mask.
D. Clean gloves.

41. A nurse reviews a clients’ electrolyte laboratory report and notes that the potassium
level is 3.2 meq/l. Which of the following would the nurse note on the ecg as a result of
the laboratory value? 
A. Elevated t waves
B. Absent p waves
C. Elevated st segment
D. U waves

42. A nurse is reviewing a laboratory results and notes that a client’s serum sodium
level is 150 meq/l. The nurse reports the serum sodium level to the physician, and the
physician prescribes dietary instructions based on the sodium level. Which food item
does the nurse instruct the client to avoid? 
A. Low-fat yogurt
B. Cauliflower
C. Processed oat cereals
D. Peas

43. A nurse is preparing to remove a nasogastric tube from a client. The nurse would
instruct the client to do which of the following just before the nurse removes the tube? 
A. To perform valsalva’s maneuver
B. To take and hold a deep breath
C. To exhale
D. To inhale and exhale quickly

44. A nurse is inserting an indwelling urinary catheter into a male client. As the catheter
is inserted into the urethra, urine begins to flow into the tubing. At this point, the nurse 
A. Immediately inflates the balloon.
B. Withdraws the catheter about 1 inch and inflates the balloon.
C. Inserts the catheter until resistance is met and inflates the balloon.
D. Inserts the catheter 2.5 to 5 cm and inflates the balloon.

45. A nurse is reviewing a client’s laboratory reports and notes that the serum calcium
level is 4.0 mg/dl. The nurse understands that which condition most likely caused this
serum calcium level? 
A. Prolonged bed rest
B. Excessive administration of vitamin d
C. Renal insufficiency
D. Hyperparathyroidism

46. A nurse is assigned to care for a group of clients. On review of the clients’ medical
records, the nurse determines that which client is at risk for a fluid volume excess? 
A. The client with renal failure
B. The client with an ileostomy
C. The client taking diuretics
D. The client who requires gastrointestinal suctioning

47. A nurse is reviewing a laboratory results and notes that a client’s serum sodium
level is 150 meq/l. The nurse reports the serum sodium level to the physician, and the
physician prescribes dietary instructions based on the sodium level. Which food item
does the nurse instruct the client to avoid? 
A. Low-fat yogurt
B. Cauliflower
C. Processed oat cereals
D. Peas

48. To adequately inspect the external ear canal of an adult client, the nurse should do
which of the following prior to inserting the otoscope? 
A. Require that all earrings be removed for safety purposes
B. Pull the pinna up and back
C. Use an applicator to remove cerumen
D. Have the client lie down to promote comfort

49.  A nurse is preparing to remove a nasogastric tube from a client. The nurse would
instruct the client to do which of the following just before the nurse removes the tube? 
A. To perform valsalva’s maneuver
B. To take and hold a deep breath
C. To exhale
D. To inhale and exhale quickly
50. The client with fever had been observed to experience elevated temperature for few
day, followed by 1 to 2 day of normal range of temperature. The type of fever hi is
experiencing is; 
A. Intermittent fever
B. Relapsing fever
C. Remittent fever

RESPI HEMA EVALUATIVE EXAM

1. An emergency department nurse is assessing a client who has sustained a blunt

injury to the chest wall. Which of these signs would indicate the presence of a
pneumothorax in this client?
A. A low respiratory rate
B. Diminished breath sounds
C. The presence of a barrel chest
D. A sucking sound at the site of injury

2. A nurse is caring for a client hospitalized with acute exacerbation of chronic

obstructive pulmonary disease. Which of the following would the nurse expect to note
on assessment of this client?
A. Hypocapnia
B. A hyperinflated chest noted on the chest x-ray
C. Increased oxygen saturation with exercise
D. A widened diaphragmnoted on the chest x-ray

3. A nurse instructs a client to use the pursed-lip method of breathing and the client
asks the nurse about the purpose of this type of breathing. The nurse responds,
knowing that the primary purpose of pursed-lip breathing is to:
A. Promote oxygen intake.
B. Strengthen the diaphragm.
C. Strengthen the intercostal muscles.
D. Promote carbon dioxide elimination.

4. The low-pressure alarm sounds on a ventilator. A nurse assesses the client and then
attempts to determine the cause of the alarm. The nurse is unsuccessful in determining
the cause of the alarm and takes what initial action?
A. Administers oxygen
B. Checks the client’s vital signs
C. Ventilates the client manually
D. Starts cardiopulmonary resuscitation

5. A nurse is caring for a client after a bronchoscopy and biopsy. Which of the following
signs, if noted in the client, should be reported immediately to the physician?
A. Dry cough
B. Hematuria
C. Bronchospasm
D. Blood-streaked sputum

6. A nurse is suctioning fluids from a client via a tracheostomy tube. When suctioning,
the nurse must limit the suctioning time to a maximum of:
A. 1 minute
B. 5 seconds
C. 10 seconds
D. 30 seconds

7. A nurse is suctioning fluids from a client through an endotracheal tube. During the
suctioning procedure, the nurse notes on the monitor that the heart rate is decreasing.
Which of the following is the appropriate nursing intervention?
A. Continue to suction.
B. Notify the physician immediately.
C. Stop the procedure and reoxygenate the client.
D. Ensure that the suction is limited to 15 seconds.

8. A nurse is assessing the respiratory status of a client who has suffered a fractured

rib. The nurse would expect to note which of the following?
A. Slow deep respirations
B. Rapid deep respirations
C. Paradoxical respirations
D. Pain, especially with inspiration

9. A client with a chest injury has suffered flail chest. A nurse assesses the client for
which most distinctive sign of flail chest?
A. Cyanosis
B. Hypotension
C. Paradoxical chest movement
D. Dyspnea, especially on exhalation

10. A client has been admitted with chest trauma after a motor vehicle accident and has
undergone subsequent intubation. A nurse checks the client when the high-pressure
alarm on the ventilator sounds, and notes that the client has absence of breath sounds
in the right upper lobe of the lung.

The nurse immediately assesses for other signs of:

A. Right pneumothorax
B. Pulmonary embolism
C. Displaced endotracheal tube
D. Acute respiratory distress syndrome
11. A nurse is assessing a client with multiple trauma who is at risk for developing acute
respiratory distress syndrome. The nurse assesses for which earliest sign of acute
respiratory distress syndrome?
A. Bilateral wheezing
B. Inspiratory crackles
C. Intercostal retractions
D. Increased respiratory rate

12. A nurse is assessing a client with chronic airflow limitation and notes that the client
has a “barrel chest.” The nurse interprets that this client has which of the following forms
of chronic airflow limitation?
A. Emphysema
B. Bronchial asthma
C. Chronic obstructive bronchitis
D. Bronchial asthma and bronchitis

13. A nurse has conducted discharge teaching with a client diagnosed with tuberculosis.
The client has been taking medication for 1½ weeks. The nurse evaluates that the client
has understood the information if the client makes which of the following statements?
A. “I need to continue drug therapy for 2 months.”
B. “I can’t shop at the mall for the next 6 months.”
C. “I can return to work if a sputum culture comes back negative.”
D. “I should not be contagious after 2 to 3 weeks of medication therapy.”

14. A nurse is preparing to give a bed bath to an immobilized client with tuberculosis.
The nurse should wear which of the following items when performing this care?
A. Surgical mask and gloves
B. Particulate respirator, gown, and gloves
C. Particulate respirator and protective eyewear
D. Surgical mask, gown, and protective eyewear
15. A client has experienced pulmonary embolism. A nurse assesses for which
symptom, which is most commonly reported?
A. Hot, flushed feeling
B. Sudden chills and fever
C. Chest pain that occurs suddenly
D. Dyspnea when deep breaths are taken
16. A client who is human immunodeficiency virus– positive has had a Mantoux skin
test. The nurse notes a 7-mm area of induration at the site of the skin test. The nurse
interprets the results as:
A. Positive
B. Negative
C. Inconclusive
D. Indicating the need for repeat testing

17. A client with acquired immunodeficiency syndrome has histoplasmosis. A nurse

assesses the client for which of the following signs and symptoms?
A. Dyspnea
B. Headache
C. Weight gain
D. Hypothermia

18. A nurse is giving discharge instructions to a client with pulmonary sarcoidosis. The
nurse concludes that the client understands the information if the client reports which of
the following early signs of exacerbation?
A. Fever
B. Fatigue
C. Weight loss
D. Shortness of breath

19. A nurse is taking the history of a client with silicosis. The nurse assesses whether
the client wears which of the following items during periods of exposure to silica
particles?
A. Mask
B. Gown
C. Gloves
D. Eye protection

20. An oxygen delivery system is prescribed for a client with chronic obstructive
pulmonary disease to deliver a precise oxygen concentration. Which oxygen delivery
system would the nurse anticipate to be prescribed?
A. Face tent
B. Venturi mask
C. Aerosol mask
D. Tracheostomy collar
21. The nurse is reviewing the results of serum laboratory studies drawn on a client with
acquired immunodeficiency syndrome who is receiving didanosine (Videx). The nurse
interprets that the client may have the medication discontinued by the physician if which
of the following significantly elevated results is noted?
A. Serum protein level
B. Blood glucose level
C. Serum amylase level
D. Serum creatinine level

22. The nurse is caring for a post–renal transplantation client taking cyclosporine
(Sandimmune, Gengraf, Neoral). The nurse notes an increase in one of the client’s vital
signs and the client is complaining of a headache. What is the vital sign that is most
likely increased?
A. Pulse
B. Respirations
C. Blood pressure
D. Pulse oximetry

23. Amikacin (Amikin) is prescribed for a client with a bacterial infection. The nurse
instructs the client to contact the physician immediately if which of the following occurs?
A. Nausea
B. Lethargy
C. Hearing loss
D. Muscle aches

24. The nurse is assigned to care for a client with cytomegalovirus retinitis and acquired
immunodeficiency syndrome who is receiving foscarnet (Foscavir), an antiviral. The
nurse checks the latest results of which of the following laboratory studies while the
client is taking this medication?
A. CD4 cell count
B. Serum albumin level
C. Serum creatinine level
D. Lymphocyte count
25. A patient with Sickle cell disease is assigned to the nurse. The nurse is to give
analgesic to the patient and she knows that she must avoid giving Demerol because
this may induce:
A. Respiratory depression
B. Seizures
C. Sickle cell crisis
D. Hypotension

26. The patient is closely monitored for acute exacerbations of the Sickle cell disease.
Which of the ff. phases of this disease poses a life-threatening crisis which may lead to
hypovolemia and shock?
A. Vasoocclusive crisis
B. Splenic sequestration
C. Aplastic Crisis
D. Hematologic crisis

27. Which is the most common type of crisis in Sickle cell disease?
A. Vasoocclusive crisis
B. Splenic sequestration
C. Aplastic Crisis
D. Hematologic crisis

28. The nurse is to perform a Trendelenburg’s test to a patient with Varicose veins. A
positive result is:
A. Veins fill from distal end when the client sits.
B. Veins fill from proximal end when the client sits.
C. Veins engorge when the client sits.
D. No veins are seen when the client sits.

29. The nurse and CNA plans their interventions for the day for the client with Peripheral
Arterial disease. Which of the ff. should not be done to the client?
A. Elevate feet at rest to decrease swelling.
B. Provide ROM.
C. Apply warm packs to dilate vessels.
D. Encourage walking

30. The nurse should ask which of the following questions to assess for latex allergy?
A. “Have you experienced working in a health care facility?”
B. “Do you have allergy to citrus fruits?”
C. “What kind of work do you have?”
D. “Are you taking any herbal medicines?”

31. The nurse is caring for a patient with peripheral arterial disease experiencing
intermittent claudication. What is the appropriate intervention to relieve pain?
A. Elevate leg at the level of the heart when sleeping
B. Massage and warm compress every 2- 3 minutes
C. Elevate feet above the heart level
D. Encourage exercise.

32. What will be the correct teaching for patient with SLE?
A. Avoid exposure to sunlight
B. Increase protein in the diet
C. Encourage vigorous exercises
D. Cold treatments for chronic pain in arthritis

33. Within 20 minutes of the start of transfusion, the client develops a sudden fever. The
most appropriate initial response by the nurse is to
A. Force fluids.
B. Continue to monitor the vital signs.
C. Increase the flow rate of IV fluids.
D. Stop the transfusion.

34. The nurse has been teaching an adult who has iron deficiency anemia about those
foods that she needs to include in her meal plans. Which of the following, if selected,
would indicate to the nurse that the client understands the dietary instructions?
A. Coffee and tea.
B. Bananas and nuts.
C. Dairy products.
D. Citrus fruits and green leafy vegetables.

35. In assessing clients for pernicious anemia, the nurse should be alert for which of the
following risk factors?
A. Positive family history.
B. Infectious agents or toxins.
C. Acute or chronic blood loss.
D. Inadequate dietary intake.
36. A client has been scheduled for a Schilling’s test. The nurse should instruct the
client to
A. Administer a fleets enema the evening before the test.
B. Empty his bladder immediately before the test.
C. Take nothing by mouth for 12 hours prior to the test.
D. Collect his urine for 12 hours.

37. A 40-year-old woman with aplastic anemia is prescribed estrogen with

progesterone. The nurse can expect that these medications arte given for which of the
following reasons?
A. To enhance sodium and potassium absorption.
B. To promote utilization and storage of fluids.
C. To regulate fluid balance.
D. To stimulate bone growth.

38. Which of the following lab value profiles should the nurse know to be consistent with
hemolytic anemia?
A. Decreased RBC, increased bilirubin, decreased hemoglobin and hematocrit,
increased reticulocytes.
B. Increased RBC, decreased bilirubin, decreased hemoglobin and hematocrit, increased
reticulocytes.
C. Decreased RBC, decreased biliribin, increased hemoglobin and hematocrit, decreased
reticulocytes.
D. Increased RBC, increased bilirubin, increased hemoglobin and hematocrit, decreased
reticulocytes.

39. In planning care for a client who has had a splenectomy, the nurse should be aware
that this client is most prone to developing 
A. Urinary retention.
B. Congestive heart failure.
C. Infection.
D. Viral hepatitis

40. In examining a child with suspected anemia the nurse would recognize which of the
following as a significant objective finding?
A. History of pica
B. Daily aspirin therapy
C. Chelosis and glossitis
D. Tonsillectomy three days ago

41. After assessing four clients is the anemia, which of the following clients is the priority
for the nurse to administer care to first?
A. A client whose speech is slurred and has hemiparesis
B. A client complaining of painful swelling of the hands or feet
C. A client who is experiencing pallor, icteric sclera, and fatigue
D. After client complaining of abdominal pain after eating a high-fat meal.

42. During thoracentesis, which of the following nursing intervention will be the most
crucial?
A. Place patient in a quiet and cool room
B. Maintain strict aseptic technique
C. Advice patient to sit perfectly still during needle insertion until it has been
withdrawn from the chest
D. Apply pressure over the puncture site as soon as the needle is withdrawn

43. Nurse Even is caring for four clients on a stepdown intensive care unit. The client at
the highest risk for developing nosocomial pneumonia is the one who:
A. has a respiratory infection
B. is intubated and on a ventilator
C. has pleural chest tubes
D. is receiving feedings through a jejunostomy tube

44. Mr. Aram 56-year-old client with a 40-year history of smoking one to two packs of
cigarettes per day has a chronic cough producing thick sputum, peripheral edema and
cyanotic nail beds. Based on this information, he most likely has which of the following
conditions?
A. Adult respiratory distress syndrome (ARDS)
B. Asthma
C. Chronic obstructive bronchitis
D. Emphysema

45. Which of the following laboratory test result indicate presence of an infectious
process?
A. Erythrocyte sedimentation rate (ESR) 12 mm/hr
B. White blood cells (WBC) 18,000/mm3
C. Iron 90 g/100ml
D. Neutrophils 67%

46. Which of the following physical assessment findings would the nurse expect to find
in a client with advanced COPD?
A. Increased anteroposterior chest diameter.
B. Underdevelped neck muscles.
C. Collapsed neck veins.
D. Increased chest excursions with respiration.

47. The nurse who is reviewing laboratory data for an 86-year-old patient will be most
concerned about 
A. a white blood cell (WBC) count of 3500/mL.
B. a hematocrit of 37%.
C. a platelet count of 400,000/mL.
D. a hemoglobin of 11.8 g/dL.

48.  After the nurse has finished teaching a patient about pursed lip breathing, which
patient action indicates that more teaching is needed? 
A. The patient inhales slowly through the nose.
B. The patient puffs up the cheeks while exhaling.
C. The patient practices by blowing through a straw.
D. The patient’s ratio of inhalation to exhalation is 1:3.

49. A confused patient with pancytopenia of unknown origin is scheduled for the
following diagnostic tests. The nurse should contact the patient’s family member to sign
a consent form before the 
A. ABO blood typing.
B. bone marrow biopsy.
C. abdominal ultrasound.
D. complete blood count (CBC).

50. When the nurse is interviewing a patient with a new diagnosis of chronic obstructive
pulmonary disease (COPD), which information will help most in confirming a diagnosis
of chronic bronchitis? 
a. The patient tells the nurse about a family history of bronchitis.
b. The patient’s history indicates a 40-pack year cigarette history.
c. The patient denies having any respiratory problems until the last 6 months.
D. The patient complains about a productive cough every winter for 3 months.