1. The four major concepts in nursing theory are the A.

Henderson
B. Abdellah
A. Person, Environment, Nurse, Health C. Levin
B. Nurse, Person, Environment, Cure D. Peplau
C. Promotive, Preventive, Curative,
Rehabilitative 7. Caring is the essence and central unifying, a
D. Person, Environment, Nursing, Health dominant domain that distinguishes nursing from
other health disciplines. Care is an essential human
2. The act of utilizing the environment of the patient need.
to assist him in his recovery is theorized by
A. Benner
A. Nightingale B. Watson
B. Benner C. Leininger
C. Swanson D. Swanson
D. King
8. Caring involves 5 processes, KNOWING,
3. For her, Nursing is a theoretical system of BEING WITH, DOING FOR, ENABLING and
knowledge that prescribes a process of analysis and MAINTAINING BELIEF.
action related to care of the ill person
A. Benner
A. King B. Watson
B. Henderson C. Leininger
C. Roy D. Swanson
D. Leininger
9. Caring is healing, it is communicated through the
4. According to her, Nursing is a helping or consciousness of the nurse to the individual being
assistive profession to persons who are wholly or cared for. It allows access to higher human spirit.
partly dependent or when those who are supposedly
caring for them are no longer able to give care. A. Benner
B. Watson
A. Henderson C. Leininger
B. Orem D. Swanson
C. Swanson
D. Neuman 10. Caring means that person, events, projects and
things matter to people. It reveals stress and coping
5. Nursing is a unique profession, Concerned with options. Caring creates responsibility. It is an
all the variables affecting an individual’s response inherent feature of nursing practice. It helps the
to stressors, which are intra, inter and extra personal nurse assist clients to recover in the face of the
in nature. illness.

A. Neuman A. Benner
B. Johnson B. Watson
C. Watson C. Leininger
D. Parse D. Swanson

6. The unique function of the nurse is to assist the
individual, sick or well, in the performance of those
activities contributing to health that he would
perform unaided if he has the necessary strength,
will and knowledge, and do this in such a way as to
help him gain independence as rapidly as possible.
11. Which of the following is NOT TRUE about
profession according to Marie Jahoda?
A. A profession is an organization of an
occupational group based on the application
of special knowledge
B. It serves specific interest of a group
 C. It is altruistic C. Help client recognize and cope with stressful
D. Quality of work is of greater importance psychological situation
than the rewards D. Works in combined effort with all those
involved in patient’s care
12. Which of the following is NOT an attribute of a
professional? 18. The nurse questions a doctors order of
Morphine sulfate 50 mg, IM for a client with
A. Concerned with quantity pancreatitis. Which role best fit that statement?
B. Self directed
C. Committed to spirit of inquiry A. Change agent
D. Independent B. Client advocate
C. Case manager
13. The most unique characteristic of nursing as a D. Collaborator
profession is
19. These are nursing intervention that requires
A. Education knowledge, skills and expertise of multiple health
B. Theory professionals.
C. Caring
D. Autonomy A. Dependent
B. Independent
14. This is the distinctive individual qualities that C. Interdependent
differentiate a person to another D. Intradependent

A. Philosophy 20. What type of patient care model is the most

B. Personality common for student nurses and private duty nurses?
C. Charm
D. Character A. Total patient care
B. Team nursing
15. Refers to the moral values and beliefs that are C. Primary Nursing
used as guides to personal behavior and actions D. Case management

A. Philosophy 21. This is the best patient care model when there
B. Personality are many nurses but few patients.
C. Charm
D. Character A. Functional nursing
B. Team nursing
16. As a nurse manager, which of the following best C. Primary nursing
describes this function? D. Total patient care

A. Initiate modification on client’s lifestyle 22. This patient care model works best when there
B. Protect client’s right are plenty of patient but few nurses
C. Coordinates the activities of other members
of the health team in managing patient care A. Functional nursing
D. Provide in service education programs, Use B. Team nursing
accurate nursing audit, formulate philosophy C. Primary nursing
and vision of the institution D. Total patient care

17. What best describes nurses as a care provider?
A. Determine client’s need
B. Provide direct nursing care
23. RN assumes 24 hour responsibility for the client
to maintain continuity of care across shifts, days or
visits.
A. Functional nursing
 B. Team nursing 30. Developed the ROLE MODELING and
C. Primary nursing MODELING theory
D. Total patient care
A. Erickson,Tomlin,Swain
24. Who developed the first theory of nursing? B. Neuman
C. Newman
A. Hammurabi D. Benner and Wrubel
B. Alexander
C. Fabiola 31. Proposed the GRAND THEORY OF
D. Nightingale NURSING AS CARING

25. She introduces the NATURE OF NURSING A. Erickson, Tomlin, Swain

MODEL. B. Peterson,Zderad
C. Bnner,Wrubel
A. Henderson D. Boykin,Schoenhofer
B. Nightingale
C. Parse 32. Postulated the INTERPERSONAL ASPECT
D. Orlando OF NURSING

26. She described the four conservation principle. A. Travelbee

B. Swanson
A. Levin C. Zderad
B. Leininger D. Peplau
C. Orlando
D. Parse 33. He proposed the theory of morality that is based
on MUTUAL TRUST
27. Proposed the HEALTH CARE SYSTEM
MODEL. A. Freud
B. Erikson
A. Henderson C. Kohlberg
B. Orem D. Peters
C. Parse
D. Neuman 34. He proposed the theory of morality based on
PRINCIPLES
28. Conceptualized the BEHAVIORAL SYSTEM
MODEL A. Freud
B. Erikson
A. Orem C. Kohlberg
B. Johnson D. Peters
C. Henderson
D. Parse 35. Freud postulated that child adopts parental
standards and traits through
29. Developed the CLINICAL NURSING – A
HELPING ART MODEL A. Imitation
B. Introjection
A. Swanson C. Identification
B. Hall D. Regression
C. Weidenbach
D. Zderad 36. According to them, Morality is measured of
how people treat human being and that a moral
child strives to be kind and just
 A. Zderad and Peterson 42. She dies of yellow fever in her search for truth
B. Benner and Wrubel to prove that yellow fever is carried by a
C. Fowler and Westerhoff mosquitoes.
D. Schulman and Mekler
A. Clara louise Maas
37. Postulated that FAITH is the way of behaving. B. Pearl Tucker
He developed four theories of faith and C. Isabel Hampton Robb
development based on his experience. D. Caroline Hampton Robb

A. Giligan 43. He was called the father of sanitation.

B. Westerhoff
C. Fowler A. Abraham
D. Freud B. Hippocrates
C. Moses
38. He described the development of faith. He D. Willam Halstead
suggested that faith is a spiritual dimension that
gives meaning to a persons life. Faith according to 44. The country where SHUSHURUTU originated
him, is a relational phenomenon.
A. China
A. Giligan B. Egypt
B. Westerhoff C. India
C. Fowler D. Babylonia
D. Freud
45. They put girls clothes on male infants to drive
39. Established in 1906 by the Baptist foreign evil forces away
mission society of America. Miss rose nicolet, was
it’s first superintendent. A. Chinese
B. Egyptian
A. St. Paul Hospital School of nursing C. Indian
B. Iloilo Mission Hospital School of nursing D. Babylonian
C. Philippine General Hospital School of
nursing 46. In what period of nursing does people believe in
D. St. Luke’s Hospital School of nursing TREPHINING to drive evil forces away?

40. Anastacia Giron-Tupas was the first Filipino A. Dark period

nurse to occupy the position of chief nurse in this B. Intuitive period
hospital. C. Contemporary period
D. Educative period
A. St. Paul Hospital
B. Iloilo Mission Hospital 47. This period ended when Pastor Fliedner, build
C. Philippine General Hospital Kaiserwerth institute for the training of
D. St. Luke’s Hospital Deaconesses

41. She was the daughter of Hungarian kings, who A. Apprentice period
feed 300-900 people everyday in their gate, builds B. Dark period
hospitals, and care of the poor and sick herself. C. Contemporary period
D. Educative period
A. Elizabeth
B. Catherine 48. Period of nursing where religious Christian
C. Nightingale orders emerged to take care of the sick
D. Sairey Gamp
 A. Apprentice period B. Rogers
B. Dark period C. Henderson
C. Contemporary period D. Johnson
D. Educative period
55. She theorized that man is composed of sub and
49. Founded the second order of St. Francis of supra systems. Subsystems are cells, tissues, organs
Assisi and systems while the suprasystems are family,
society and community.
A. St. Catherine
B. St. Anne A. Roy
C. St. Clare B. Rogers
D. St. Elizabeth C. Henderson
D. Johnson
50. This period marked the religious upheaval of
Luther, Who questions the Christian faith. 56. Which of the following is not true about the
human needs?
A. Apprentice period
B. Dark period A. Certain needs are common to all people
C. Contemporary period B. Needs should be followed exactly in
D. Educative period accordance with their hierarchy
C. Needs are stimulated by internal factors
51. According to the Biopsychosocial and spiritual D. Needs are stimulated by external factors
theory of Sister Callista Roy, Man, As a SOCIAL
being is 57. Which of the following is TRUE about the
human needs?
A. Like all other men
B. Like some other men A. May not be deferred
C. Like no other men B. Are not interrelated
D. Like men C. Met in exact and rigid way
D. Priorities are alterable
52. She conceptualized that man, as an Open system
is in constant interaction and transaction with a 58. According to Maslow, which of the following is
changing environment. NOT TRUE about a self actualized person?

A. Roy A. Understands poetry, music, philosophy,

B. Levin science etc.
C. Neuman B. Desires privacy, autonomous
D. Newman C. Follows the decision of the majority, uphold
justice and truth
53. In a CLOSED system, which of the following is D. Problem centered
true?
59. According to Maslow, which of the following is
A. Affected by matter TRUE about a self actualized person?
B. A sole island in vast ocean
C. Allows input A. Makes decision contrary to public opinion
D. Constantly affected by matter, energy, B. Do not predict events
information C. Self centered
D. Maximum degree of self conflict
54. Who postulated the WHOLISTIC concept that
the totality is greater than sum of its parts? 60. This is the essence of mental health

A. Roy A. Self awareness

 B. Self actualization 67. Which of the following provides that nurses
C. Self esteem must be a member of a national nurse organization?
D. Self worth
A. R.A 877
61. Florence nightingale is born in B. 1981 Code of ethics approved by the house
of delegates and the PNA
A. Germany C. Board resolution No. 1955 Promulgated by
B. Britain the BON
C. France D. RA 7164
D. Italy
68. Which of the following best describes the action
62. Which is unlikely of Florence Nightingale? of a nurse who documents her nursing diagnosis?

A. Born May 12, 1840 A. She documents it and charts it whenever

B. Built St. Thomas school of nursing when she necessary
was 40 years old B. She can be accused of malpractice
C. Notes in nursing C. She does it regularly as an important
D. Notes in hospital responsibility
D. She charts it only when the patient is acutely
63. What country did Florence Nightingale train in ill
nursing?
69. Which of the following does not govern nursing
A. Belgium practice?
B. US
C. Germany A. RA 7164
D. England B. RA 9173
C. BON Res. Code Of Ethics
64. Which of the following is recognized for D. BON Res. Scope of Nursing Practice
developing the concept of HIGH LEVEL
WELLNESS? 70. A nurse who is maintaining a private clinic in
the community renders service on maternal and
A. Erikson child health among the neighborhood for a fee is:
B. Madaw
C. Peplau A. Primary care nurse
D. Dunn B. Independent nurse practitioner
C. Nurse-Midwife
65. One of the expectations is for nurses to join D. Nurse specialist
professional association primarily because of
71. When was the PNA founded?
A. Promotes advancement and professional
growth among its members A. September 22, 1922
B. Works for raising funds for nurse’s benefit B. September 02, 1920
C. Facilitate and establishes acquaintances C. October 21, 1922
D. Assist them and securing jobs abroad D. September 02, 1922

66. Founder of the PNA 72. Who was the first president of the PNA ?

A. Julita Sotejo A. Anastacia Giron-Tupas

B. Anastacia Giron Tupas B. Loreto Tupas
C. Eufemia Octaviano C. Rosario Montenegro
D. Anesia Dionisio D. Ricarda Mendoza
73. Defines health as the ability to maintain internal 79. According to her, Wellness is a condition in
milieu. Illness according to him/her/them is the which all parts and subparts of an individual are in
failure to maintain internal environment. harmony with the whole system.

A. Cannon A. Orem
B. Bernard B. Henderson
C. Leddy and Pepper C. Neuman
D. Roy D. Johnson

74. Postulated that health is a state and process of 80. Postulated that health is reflected by the
being and becoming an integrated and whole organization, interaction, interdependence and
person. integration of the subsystem of the behavioral
system.
A. Cannon
B. Bernard A. Orem
C. Dunn B. Henderson
D. Roy C. Neuman
D. Johnson
75. What regulates HOMEOSTASIS according to
the theory of Walter Cannon? 81. According to them, Well being is a subjective
perception of BALANCE, HARMONY and
A. Positive feedback VITALITY
B. Negative feedback
C. Buffer system A. Leavell and Clark
D. Various mechanisms B. Peterson and Zderad
C. Benner and Wruber
76. Stated that health is WELLNESS. A termed D. Leddy and Pepper
define by the culture or an individual.
82. He describes the WELLNESS-ILLNESS
A. Roy Continuum as interaction of the environment with
B. Henderson well being and illness.
C. Rogers
D. King A. Cannon
B. Bernard
77. Defined health as a dynamic state in the life C. Dunn
cycle, and Illness as interference in the life cycle. D. Clark

A. Roy 83. An integrated method of functioning that is

B. Henderson oriented towards maximizing one’s potential within
C. Rogers the limitation of the environment.
D. King
A. Well being
78. She defined health as the soundness and B. Health
wholness of developed human structure and bodily C. Low level Wellness
mental functioning. D. High level Wellness

A. Orem 84. What kind of illness precursor, according to

B. Henderson DUNN is cigarette smoking?
C. Neuman
D. Clark A. Heredity
B. Social
C. Behavioral
 D. Environmental 91. Knowledge about the disease and prior contact
with it is what type of VARIABLE according to the
85. According to DUNN, Overcrowding is what health belief model?
type of illness precursor?
A. Demographic
A. Heredity B. Sociopsychologic
B. Social C. Structural
C. Behavioral D. Cues to action
D. Environmental
92. It includes internal and external factors that
86. Health belief model was formulated in 1975 by leads the individual to seek help
who?
A. Demographic
A. Becker B. Sociopsychologic
B. Smith C. Structural
C. Dunn D. Cues to action
D. Leavell and Clark
93. Influence from peers and social pressure is
87. In health belief model, Individual perception included in what variable of HBM?
matters. Which of the following is highly
UNLIKELY to influence preventive behavior? A. Demographic
B. Sociopsychologic
A. Perceived susceptibility to an illness C. Structural
B. Perceived seriousness of an illness D. Cues to action
C. Perceived threat of an illness
D. Perceived curability of an illness 94. Age, Sex, Race etc. is included in what variable
of HBM?
88. Which of the following is not a PERCEIVED
BARRIER in preventive action? A. Demographic
B. Sociopsychologic
A. Difficulty adhering to the lifestyle C. Structural
B. Economic factors D. Cues to action
C. Accessibility of health care facilities
D. Increase adherence to medical therapies 95. According to Leavell and Clark’s ecologic
model, All of this are factors that affects health and
89. Conceptualizes that health is a condition of illness except
actualization or realization of person’s potential.
Avers that the highest aspiration of people is A. Reservoir
fulfillment and complete development actualization. B. Agent
C. Environment
A. Clinical Model D. Host
B. Role performance Model
C. Adaptive Model 96. Is a multi dimensional model developed by
D. Eudaemonistic Model PENDER that describes the nature of persons as
they interact within the environment to pursue
90. Views people as physiologic system and health
Absence of sign and symptoms equates health.
A. Ecologic Model
A. Clinical Model B. Health Belief Model
B. Role performance Model C. Health Promotion Model
C. Adaptive Model D. Health Prevention Model
D. Eudaemonistic Model
97. Defined by Pender as all activities directed would facilitate the person’s reparative
toward increasing the level of well being and self process and identified different factors like
actualization. sanitation, noise, etc. that affects a person’s
reparative state.
A. Health prevention 2.  A. Nightingale. Florence nightingale do not
B. Health promotion believe in the germ theory, and perhaps this
C. Health teaching was her biggest mistake. Yet, her theory was
D. Self actualization the first in nursing. She believed that
manipulation of environment that includes
98. Defined as an alteration in normal function appropriate noise, nutrition, hygiene, light,
resulting in reduction of capacities and shortening comfort, sanitation etc. could provide the
of life span. client’s body the nurturance it needs for
repair and recovery.
A. Illness 3.  C. Roy. Remember the word “
B. Disease THEOROYTICAL “ For Callista Roy,
C. Health Nursing is a theoretical body of knowledge
D. Wellness that prescribes analysis and action to care
for an ill person. She introduced the
99. Personal state in which a person feels unhealthy ADAPTATION MODEL and viewed person
as a BIOSPSYCHOSOCIAL BEING. She
A. Illness believed that by adaptation, Man can
B. Disease maintain homeostasis.
C. Health 4. B. Orem. In self care deficit theory, Nursing
D. Wellness is defined as A helping or assistive
profession to person who are wholly or
100. According to her, Caring is defined as a partly dependent or when people who are to
nurturant way of responding to a valued client give care to them are no longer available.
towards whom the nurse feels a sense of Self care, are the activities that a person do
commitment and responsibility. for himself to maintain health, life and well
being.
A. Benner 5. A. Neuman. Neuman divided stressors as
B. Watson either intra, inter and extra personal in
C. Leininger nature. She said that NURSING is
D. Swanson concerned with eliminating these stressors to
obtain a maximum level of wellness. The
Answers and Rationales nurse helps the client through PRIMARY,
SECONDARY AND TERTIARY
1. D. Person, Environment, Nursing, prevention modes. Please do not confuse
Health. This is an actual board exam this with LEAVELL and CLARK’S level of
question and is a common board question. prevention.
Theorist always describes The nursing 6. A. Henderson. This was an actual board
profession by first defining what is question. Remember this definition and
NURSING, followed by the PERSON, associate it with Virginia Henderson.
ENVIRONMENT and HEALTH Henderson also describes the NATURE OF
CONCEPT. The most popular theory was NURSING theory. She identified 14 basic
perhaps Nightingale’s. She defined nursing needs of the client. She describes nursing
as the utilization of the persons environment roles as SUBSTITUTIVE : Doing
to assist him towards recovery. She defined everything for the client,
the person as somebody who has a SUPPLEMENTARY : Helping the client
reparative capabilities mediated and and COMPLEMENTARY : Working with
enhanced by factors in his environment. She the client. Breathing normally, Eliminating
describes the environment as something that waste, Eating and drinking adquately,
 Worship and Play are some of the basic
needs according to her.
7. C. Leininger. There are many theorist that
describes nursing as CARE. The most
popular was JEAN WATSON’S Human
Caring Model. But this question pertains to
Leininger’s definition of caring. CUD I LIE
IN GER? [ Could I Lie In There ] Is the
Mnemonics I am using not to get confused.
C stands for CENTRAL , U stands for
UNIFYING, D stands for DOMINANT
DOMAIN. I emphasize on this matter due to
feedback on the last June 2006 batch about a
question about CARING.
8. D. Swanson . Caring according to Swanson
involves 5 processes. Knowing means
understanding the client. Being with
emphasizes the Physical presence of the
nurse for the patient. Doing for means doing
things for the patient when he is incapable of
doing it for himself. Enabling means helping
client transcend maturational and
developmental stressors in life while
Maintaining belief is the ability of the Nurse
to inculcate meaning to these events.
9. B. Watson. The deepest and spiritual
definition of Caring came from Jean watson.
For her, Caring expands the limits of
openess and allows access to higher human
spirit.
10. A. Benner.  I think of CARE BEAR to
facilitate retainment of BENNER. As in,
Care Benner. For her, Caring means being
CONNECTED or making things matter to
people. Caring according to Benner give
meaning to illness and re establish
connection.
11. B. It serves specific interest of a
group.Believe it or not, you should know
the definition of profession according to
Jahoda because it is asked in the Local
boards. A profession should serve the
WHOLE COMMUNITY and not just a
specific intrest of a group. Everything else,
are correct.
12. A. Concerned with quantity. A
professional is concerned with QUALITY
and not QUANTITY. In nursing, We have
methods of quality assurance and control to
evaluate the effectiveness of nursing care.
Nurses, are never concerned with
QUANTITY of care provided.
13. C. Caring. Caring and caring alone, is the
most unique quality of the Nursing
Profession. It is the one the delineate
Nursing from other professions.
14. B. Personality. Personality are qualities that
make us different from each other. These are
impressions that we made, or the footprints
that we leave behind. This is the result of the
integration of one’s talents, behavior,
appearance, mood, character, morals and
impulses into one harmonious whole.
Philosophy is the basic truth that fuel our
soul and give our life a purpose, it shapes
the facets of a person’s character. Charm is
to attract other people to be a change agent.
Character is our moral values and belief that
guides our actions in life.
15. D. Character.Rationale: Refer to number
14
16. D. Provide in service education programs,
Use accurate nursing audit, formulate
philosophy and vision of the
institution .  A refers to being a change
agent. B is a role of a patient advocate. C is
a case manager while D basically
summarized functions of a nurse manager. If
you haven’t read Lydia Venzon’s Book :
NURSING MANAGEMENT TOWARDS
QUALITY CARE, I suggest reading it in
advance for your management subjects in
the graduate school. Formulating philosophy
and vision is in PLANNING. Nursing Audit
is in CONTROLLING, In service education
programs are included in DIRECTING.
These are the processes of Nursing
Management, I just forgot to add
ORGANIZING which includes formulating
an organizational structure and plans,
Staffing and developing qualifications and
job descriptions.
17. A. Determine client’s need.You can never
provide nursing care if you don’t know what
are the needs of the client. How can you
provide an effective postural drainage if you
do not know where is the bulk of the client’s
secretion. Therefore, the best description of
a care provider is the accurate and prompt
determination of the client’s need to be able
to render an appropriate nursing care.
18. B. Client advocate. As a client’s advocate,
Nurses are to protect the client’s right and
promotes what is best for the client.
 Knowing that Morphine causes spasm of the
sphincter of Oddi and will lead to further
increase in the client’s pain, The nurse knew
that the best treatment option for the client
was not provided and intervene to provide
the best possible care.
19. C. Interdependent. Interdependent
functions are those that needs expertise and
skills of multiple health professionals.
Example is when A child was diagnosed
with nephrotic syndrome and the doctor
ordered a high protein diet, Budek then work
together with the dietician about the age
appropriate high protein foods that can be
given to the child, Including the preparation
to entice the child into eating the food.
NOTE : It is still debated if the diet in NS is
low, moderate or high protein, In the U.S,
Protein is never restricted and can be taken
in moderate amount. As far as the local
examination is concerned, answer LOW
PROTEIN HIGH CALORIC DIET.
20. A. Total patient care. This is also known as
case nursing. It is a method of nursing care
wherein, one nurse is assigned to one patient
for the delivery of total care. These are the
method use by Nursing students, Private
duty nurses and those in critical or isolation
units.
21. D. Total patient care .Total patient care
works best if there are many nurses but few
patients.
22. A. Functional nursing. Functional nursing
is task oriented, One nurse is assigned on a
particular task leading to task expertise and
efficiency. The nurse will work fast because
the procedures are repetitive leading to task
mastery. This care is not recommended as
this leads fragmented nursing care.
23. C. Primary nursing. Your keyword in
Primary nursing is the 24 hours. This does
not necessarily means the nurse is awake for
24 hours, She can have a SECONDARY
NURSES that will take care of the patient in
shifts where she is not arround.
24. D. Nightingale .  Refer to question # 2.
Hammurabi is the king of babylon that
introduces the LEX TALIONES law, If you
kill me, you should be killed… If you rob
me, You should be robbed, An eye for an
eye and a tooth for a tooth. Alexander the
great was the son of King Philip II and is
from macedonia but he ruled Greece
including Persia and Egypt. He is known to
use a hammer to pierce a dying soldier’s
medulla towards speedy death when he
thinks that the soldier will die anyway, just
to relieve their suffering. Fabiola was a
beautiful roman matron who converted her
house into a hospital.
25. A. Henderson. Refer to question # 6.
26. A. Levin. Myra Levin described the 4
Conservation principles which are
concerned with the Unity and Integrity of an
individual. These are ENERGY : Our output
to facilitate meeting of our needs.
STRUCTURAL INTEGRITY : We mus
maintain the integrity of our organs, tissues
and systems to be able to function and
prevent harmful agents entering our body.
PERSONAL INTEGRITY : These refers to
our self esteem, self worth, self concept,
identify and personality. SOCIAL
INTEGRITY : Reflects our societal roles to
our society, community, family, friends and
fellow individuals.
27. D. Neuman . Betty Neuman asserted that
nursing is a unique profession and is
concerned with all the variables affecting the
individual’s response to stressors. These are
INTRA or within ourselves, EXTRA or
outside the individual, INTER means
between two or more people. She proposed
the HEALTH CARE SYSTEM MODEL
which states that by PRIMARY,
SECONDARY and TERTIARY prevention,
The nurse can help the client maintain
stability against these stressors.
28. B. Johnson. According to Dorothy Johnson,
Each person is a behavioral system that is
composed of 7 subsystems. Man adjust or
adapt to stressors by a using a LEARNED
PATTERN OF RESPONSE. Man uses his
behavior to meet the demands of the
environment, and is able to modified his
behavior to support these demands.
29. C. Weidenbach.Just remember
ERNESTINE WEIDENBACHLINICAL.
30. A. Erickson,Tomlin,Swain
31. D. Boykin,Schoenhofer . This theory was
called GRAND THEORY because boykin
and schoenofer thinks that ALL MAN ARE
CARING, And that nursing is a response to
this unique call. According to them,
 CARING IS A MORAL IMPERATIVE,
meaning, ALL PEOPLE will tend to help a
man who fell down the stairs even if he is
not trained to do so.
32. A. Travelbee. Travelbee’s theory was
referred to as INTERPERSONAL theory
because she postulated that NURSING is to
assist the individual and all people that
affects this individual to cope with illness,
recover and FIND MEANING to this
experience. For her, Nursing is a HUMAN
TO HUMAN relationship that is formed
during illness. To her, an individual is a
UNIQUE and irreplaceable being in
continuous process of becoming, evolving
and changing. PLEASE do remember, that it
is PARSE who postulated the theory of
HUMAN BECOMING and not
TRAVELBEE, for I read books that say it
was TRAVELBEE and not PARSE.
33. C. Kohlberg. Kohlber states that
relationships are based on mutual trust. He
postulated the levels of morality
development. At the first stage called the
PREMORAL or preconventional, A child do
things and label them as BAD or GOOD
depending on the PUNISHMENT or
REWARD they get. They have no concept
of justice, fairness and equity, for them, If I
punch this kid and mom gets mad, thats
WRONG. But if I dance and sing, mama
smiles and give me a new toy, then I am
doing something good. In the Conventional
level, The individual actuates his act based
on the response of the people around him.
He will follow the rules, regulations, laws
and morality the society upholds. If the law
states that I should not resuscitate this man
with a DNR order, then I would not.
However, in the Post conventional level or
the AUTONOMOUS level, the individual
still follows the rules but can make a rule or
bend part of these rules according to his own
MORALITY. He can change the rules if he
thinks that it is needed to be changed.
Example is that, A nurse still continue
resuscitating the client even if the client has
a DNR order because he believes that the
client can still recover and his mission is to
save lives, not watch patients die.
34. D. Peters . Remember PETERS for
PRINCIPLES. P is to P. He believes that
morality has 3 components : EMOTION or
how one feels, JUDGEMENT or how one
reason and BEHAVIOR or how one actuates
his EMOTION and JUDGEMENT. He
believes that MORALITY evolves with the
development of PRINCPLES or the person’s
vitrue and traits. He also believes in
AUTOMATICITY of virtues or he calls
HABIT, like kindness, charity, honesty,
sincerity and thirft which are innate to a
person and therfore, will be performed
automatically.
35. C. Identification. A child, according to
Freud adopts parental standards, traits,
habits and norms through identication. A
good example is the corned beef commercial
” WALK LIKE A MAN, TALK LIKE A
MAN ” Where the child identifies with his
father by wearing the same clothes and
doing the same thing.
36. D. Schulman and Mekler . According to
Schulman and Mekler, there are 2
components that makes an action MORAL :
The intention should be good and the Act
must be just. A good example is ROBIN
HOOD, His intention is GOOD but the act is
UNJUST, which makes his action
IMMORAL.
37. B. Westerhoff. There are only 2 theorist of
FAITH that might be asked in the board
examinations. Fowler and Westerhoff. What
differs them is that, FAITH of fowler is
defined abstractly, Fowler defines faith as a
FORCE that gives a meaning to a person’s
life while Westerhoff defines faith as a
behavior that continuously develops through
time.
38. C. Fowler. Rationale: Refer to # 37
39. B. Iloilo Mission Hospital School of
nursing
40. C. Philippine General Hospital
41. A. Elizabeth.Saint Elizabeth of Hungary
was a daughter of a King and is the patron
saint of nurses. She build hospitals and feed
hungry people everyday using the
kingdom’s money. She is a princess, but
devoted her life in feeding the hungry and
serving the sick.
42. A. Clara louise Maas. Clara Louise Maas
sacrificed her life in research of YELLOW
FEVER. People during her time do not
believe that yellow fever was brought by
 mosquitoes. To prove that they are wrong,
She allowed herself to be bitten by the
vector and after days, She died.
43. C. Moses
44. C. India
45. A. Chinese. Chinese believes that male
newborns are demon magnets. To fool those
demons, they put female clothes to their
male newborn.
46. B. Intuitive period.Egyptians believe that a
sick person is someone with an evil force or
demon that is inside their heads. To release
these evil spirits, They would tend to drill
holes on the patient’s skull and it is called
TREPHINING.
47. A. Apprentice period.What dilineates
apprentice period among others is that, it
ENDED when formal schools were
established. During the apprentice period,
There is no formal educational institution for
nurses. Most of them receive training inside
the convent or church. Some of them are
trained just for the purpose of nursing the
wounded soldiers. But almost all of them are
influenced by the christian faith to serve and
nurse the sick. When Fliedner build the first
formal school for nurses, It marked the end
of the APPRENTICESHIP period.
48. A. Apprentice period. Apprentice period is
marked by the emergence of religious orders
the are devoted to religious life and the
practice of nursing.
49. C. St. Clare. The poor clares, is the second
order of St. Francis of assisi. The first order
was founded by St. Francis himself. St.
Catherine of Siena was the first lady with
the lamp. St. Anne is the mother of mama
mary. St. Elizabeth is the patron saint of
Nursing.
50. B. Dark period. Protestantism emerged
with Martin Luther questions the Pope and
Christianity. This started the Dark period of
nursing when the christian faith was
smeared by controversies. These leads to
closure of some hospital and schools run by
the church. Nursing became the work of
prostitutes, slaves, mother and least
desirable of women.
51. B. Like some other men.According to
ROY, Man as a social being is like some
other man. As a spiritual being and Biologic
being, Man are all alike. As a psychologic
being, No man thinks alike. This basically
summarized her BIOPSYHOSOCIAL
theory which is included in our licensure
exam coverage.
52. A. Roy. OPEN system theory is ROY. As an
open system, man continuously allows input
from the environment. Example is when you
tell me Im good looking, I will be happy the
entire day, Because I am an open system and
continuously interact and transact with my
environment. A close system is best
exemplified by a CANDLE. When you
cover the candle with a glass, it will die
because it will eventually use all the oxygen
it needs inside the glass for combustion. A
closed system do not allow inputs and
output in its environment.
53. B. A sole island in vast ocean
54. B. Rogers. The wholistic theory by Martha
Rogers states that MAN is greater than the
sum of all its parts and that his dignity and
worth will not be lessen even if one of this
part is missing. A good example is ANNE
BOLEYN, The mother of Queen Elizabeth
and the wife of King Henry VIII. She was
beheaded because Henry wants to mary
another wife and that his divorce was not
approved by the pope. Outraged, He insisted
on the separation of the Church and State
and divorce Anne himself by making
everyone believe that Anne is having an
affair to another man. Anne was beheaded
while her lips is still saying a prayer. Even
without her head, People still gave respect to
her diseased body and a separate head. She
was still remembered as Anne boleyn,
Mother of Elizabeth who lead england to
their GOLDEN AGE.
55. B. Rogers. According to Martha Rogers,
Man is composed of 2 systems : SUB which
includes cells, tissues, organs and system
and SUPRA which includes our famly,
community and society. She stated that
when any of these systems are affected, it
will affect the entire individual.
56. B. Needs should be followed exactly in
accordance with their hierarchy.Needs
can be deferred. I can urinate later as not to
miss the part of the movie’s climax. I can
save my money that are supposedly for my
lunch to watch my idols in concert. The
physiologic needs can be meet later for
 some other needs and need not be strictly
followed according to their hierarchy.
57. D. Priorities are alterable. Refer to
question # 56.
58. C. Follows the decision of the majority,
uphold justice and truth. A,B and D are all
qualities of a self actualized person. A self
actualized person do not follow the decision
of majority but is self directed and can make
decisions contrary to a popular opinion.
59. A. Makes decision contrary to public
opinion. Refer to question # 58.
60. B. Self actualization. The peak of maslow’s
hierarchy is the essence of mental health.
61. D. Italy. Florence Nightingale was born in
Florence, Italy, May 12, 1820. Studied in
Germany and Practiced in England.
62. A. Born May 12, 1840
63. C. Germany
64. D. Dunn. According to Dunn, High level
wellness is the ability of an individual to
maximize his full potential with the
limitations imposed by his environment.
According to him, An individual can be
healthy or ill in both favorable and
unfavorable environment.
65. A. Promotes advancement and
professional growth among its members
66. B. Anastacia Giron Tupas
67. C. Board resolution No. 1955
Promulgated by the BON.  This is an old
board resolution. The new Board resolution
is No. 220 series of 2004 also known as the
Nursing Code Of ethics which states that
[ SECTION 17, A ] A nurse should be a
member of an accredited professional
organization which is the PNA.
68. C. She does it regularly as an important
responsibility
69. A. RA 7164. 7164 is an old law. This is the
1991 Nursing Law which was repealed by
the newer 9173.
70. B. Independent nurse practitioner
71. D. September 02, 1922.  According to the
official PNA website, they are founded
September 02, 1922.
72. C. Rosario Montenegro. Anastacia Giron
Tupas founded the FNA, the former name of
the PNA but the first President was Rosario
Montenegro.
73. B. Bernard. According to Bernard, Health
is the ability to maintain and Internal Milieu
and Illness is the failure to maintain the
internal environment.
74. D. Roy. According to ROY, Health is a state
and process of becoming a WHOLE AND
INTEGRATED Person.
75. B. Negative feedback. The theory of Health
as the ability to maintain homeostasis was
postulated by Walter Cannon. According to
him, There are certain FEEDBACK
Mechanism that regulates our Homeostasis.
A good example is that when we overuse
our arm, it will produce pain. PAIN is a
negative feedback that signals us that our
arm needs a rest.
76. C. Rogers. Martha Rogers states that
HEALTH is synonymous with WELLNESS
and that HEALTH and WELLNESS is
subjective depending on the definition of
one’s culture.
77. D. King .Emogene King states that health is
a state in the life cycle and Illness is any
interference on this cycle. I enjoyed the
Movie LION KING and like what Mufasa
said that they are all part of the CIRCLE OF
LIFE, or the Life cycle.
78. A. Orem. Orem defined health as the
SOUNDNESS and WHOLENESS of
developed human structure and of bodily
and mental functioning.
79. C. Neuman. Neuman believe that man is
composed of subparts and when this
subparts are in harmony with the whole
system, Wellness results. Please do not
confuse this with the SUB and SUPRA
systems of martha rogers.
80. D. Johnson . Once you see the phrase
BEHAVIORAL SYSTEM, answer Dorothy
Johnson.
81. D. Leddy and Pepper .According to Leddy
and Pepper, Wellness is subjective and
depends on an individuals perception of
balance, harmony and vitality. Leavell and
Clark postulared the ecologic model of
health and illness or the AGENT-HOST-
ENVIRONMENT model. Peterson and
Zderad developed the HUMANISTIC
NURSING PRACTICE theory while Benner
and Wruber postulate the PRIMACY OF
CARING MODEL.
82. C. Dunn
83. D. High level Wellness
84. C. Behavioral. Behavioral precursors
includes smoking, alcoholism, high fat
intake and other lifestyle choices.
Environmental factors involved poor
sanitation and over crowding. Heridity
includes congenital and diseases acquired
through the genes. There are no social
precursors according to DUNN.
85. D. Environmental
86. A. Becker. According to Becker, The belief
of an individual greatly affects his behavior.
If a man believes that he is susceptible to an
illness, He will alter his behavior in order to
prevent its occurence. For example, If a man
thinks that diabetes is acquired through high
intake of sugar and simple carbohydrates,
then he will limit the intake of foods rich in
these components.
87. D. Perceived curability of an illness . If a
man think he is susceptibe to a certain
disease, thinks that the disease is serious and
it is a threat to his life and functions, he will
use preventive behaviors to avoid the
occurence of this threat.
88. A. Difficulty adhering to the lifestyle
and B. Economic factors. Perceived
barriers are those factors that affects the
individual’s health preventive actions. Both
A and B can affect the individual’s ability to
prevent the occurence of diseases. C and D
are called Preventive Health Behaviors
which enhances the individual’s preventive
capabilities.
89. D. Eudaemonistic Model . Smith
formulated 5 models of health. Clinical
model simply states that when people
experience sign and symptoms, they would
think that they are unhealthy therefore,
Health is the absence of clinical sign and
symptoms of a disease. Role performance
model states that when a person does his
role and activities without deficits, he is
healthy and the inability to perform usual
roles means that the person is ill. Adaptive
Model states that if a person adapts well
with his environment, he is healthy and
maladaptation equates illness.
Eudaemonistic Model of health according to
smith is the actualization of a person’s
fullest potential. If a person functions
optimally and develop self actualization,
then, no doubt that person is healthy.
90. A. Clinical Model. Rationale: Refer to
question # 89.
91. C. Structural. Modifying variables in
Becker’s health belief model includes
DEMOGRAPHIC : Age, sex, race etc.
SOCIOPSYCHOLOGIC : Social and Peer
influence. STRUCTURAL : Knowledge
about the disease and prior contact with it
and CUES TO ACTION : Which are the
sign and symptoms of the disease or advice
from friends, mass media and others that
forces or makes the individual seek help.
92. D. Cues to action . Refer to question # 91.
93. B. Sociopsychologic. Refer to question #
91.
94. A. Demographic. Refer to question # 91.
95. A. Reservoir. According to L&C’s Ecologic
model, there are 3 factors that affect health
and illness. These are the AGENT or the
factor the leads to illness, either a bacteria or
an event in life. HOST are persons that may
or may not be affected by these agents.
ENVIRONMENT are factors external to the
host that may or may not predispose him to
the AGENT.
96. C. Health Promotion Model. Pender
developed the concept of HEALTH
PROMOTION MODEL which postulated
that an individual engages in health
promotion activities to increase well being
and attain self actualization. These includes
exercise, immunization, healthy lifestyle,
good food, self responsibility and all other
factors that minimize if not totally eradicate
risks and threats of health.
97. B. Health promotion. Refer to question #
96.
98. B. Disease. Disease are alteration in body
functions resulting in reduction of
capabilities or shortening of life span.
99. A. Illness. Illness is something
PERSONAL. Unlike disease, Illness are
personal state in which person feels
unhealthy. An old person might think he is
ILL but in fact, he is not due, to diminishing
functions and capabilities, people might
think they are ILL. Disease however, is
something with tangible basis like lab
results, X ray films or clinical sign and
symptoms.
100. B. Watson. This is Jean Watson’s
definition of Nursing as caring. This was
 asked word per word last June 06′ NLE.
Benner defines caring as something that
matters to people. She postulated the
responsibility created by Caring in nursing.
She was also responsible for the PRIMACY
OF CARING MODEL. Leininger defind the
4 conservation principle while Swanson
introduced the 5 processes of caring.
Self-care deficit theory was proposed by:
A. Virginia Henderson
B. Betty Neuman
C. Imogene King
D. Dorothea Orem
D. Dorothea Orem
environment.
C. Nursing is the science and practice that expands
adaptive abilities and enhances person and
environment transformation
D. Nursing care becomes necessary when client is
unable to fulfill biological, psychological,
developmental, or social needs.
B. The role of nursing is to facilitate "the body's
reparative processes" by manipulating client's
environment.
Which of the following is NOT a concept related to
Roy's Adaptation Model?
A. Focal Stimuli
B. Cognator Subsystem
C. Role function
D. Flexible line of defense

Which theory defines nursing as the science and
practice that expands adaptive abilities and
enhances person and environment transformation?
A. Goal attainment theory
B. Henderson's definition of nursing
C. Roy's adaptation model
D. Faye Glen Abdelah's theory
D. Flexible line of defense
According to Roy's adapatation theory, which
subsystem responds through four cognitive
responds through four cognitive-emotive channels
(perceptual and information processing, learning,
judgment, and emotion)?

C. Roy's adaptation model A. Regulator Subsystem

Typology of twenty one Nursing problems were B. Cognator Subsystem

explained by:
A. Imogene King C. Physiologic Mode
B. Virginia Henderson's
C. Faye G. Abedellah D. Self Concept-Group Identity Mode
D. Lydia E. Hall
C. Faye G. Abedellah B. Cognator Subsystem

"Nursing is therapeutic interpersonal process". This The "humanistic science of nursing" was explained
definition was stated by: by:

A. Hildegard Peplau A. Rogers (1970)

B. Jean watson
C. Faye Glen Abdelah B. Ida Orlando (1960)
D. M. Rogers
C. Nightingale (1860)
A. Hildegard Peplau
D. Neuman (1972)
Which of the following statements is related to
Florence Nightingale? A. Rogers (1970)
A. Nursing is therapeutic interpersonal process.
B. The role of nursing is to facilitate "the body's Imogene King's "goal attainment theory" is a type
reparative processes" by manipulating client's of:
 Which is NOT a concept explained in Dorothy
A. Need theories Johnson's Behavioral Systems Model?

B. Interaction theories A. Affiliation

C. Outcome theories B. Dependency

D. Humanistic theories C. Achievement

B. Interaction theories D. Energy fields

Which of the following theory has used "General D. Energy fields

Systems Theory" as a framework for its
development? According to Rogers' theory "continuous and
mutual interaction between man and environment' is
A. Florence Nightingale's Environment Theory termed as:

B. Hildegard E. Peplau's Psychodynamic Nursing A. Pattern

Theory
B. Integrality
C. Martha E.Roger's: Science of Unitary Human
Beings C. Resonancy

D. Neuman's model D. Helicy

D. Neuman's model
B. Integrality
Transcultural Model of Nursing was proposed by:
Watson's carative factors include all the following,
A. Joyce Travelbee EXCEPT:

B. Rosemarie Rizzo Parse A. Forming humanistic-altruistic value system

C. Madeleine Leininger B. Instilling faith-hope

D. Ida Jean Orlando C. Cultivating sensitivity to self and others

C. Madeleine Leininger D. Strengthening flexible lines of defense

According to Neuman Systems Model, the increase D. Strengthening flexible lines of defense
in energy that occurs in relation to the degree of
reaction to the stressor is termed as: Statements that explain the relationship between the
concepts in a theory:
A. Reconstitution
A. Propositions
B. Lines of resistance
B. Assumptions
C. Primary prevention
C. Predictions
D. Secondary Prevention
D. Process
A. Reconstitution
A. Propositions
"Social inclusion, intimacy and the formation and Meaning, Rhythmicity, Cotranscendence are the
attachment of a strong social bond" are explained in three major concepts of:
which subsystem of Jhonson's model -
A. Transcultural Nursing Theory
A. Dependency subsystem
B. Unitary Human Being Theory
B. Attachment or affiliative subsystem
C. Self-care Deficit Theory
C. Achievement subsystem
D. Human Becoming Theory
D. Aggressive subsystem
D. Human Becoming Theory
B. Attachment or affiliative subsystem
the major concepts of Health Belief Model includes Caring consists of carative factors that result in the
all, EXCEPT; satisfaction of certain human needs". This
explanation was stated by:
A. Perceived Susceptibility
A. Sister Calista Roy,
B. Perceived severity
B. Jean Watson
C. Perceived benefits
C. Dorothea Orem
D. Perceived interaction
D. Florence Nightingale
D. Perceived interaction
B. Jean Watson
The sequential phases of interpersonal relationship
in Peplau's theory includes all, EXCEPT: The term which refers the "irreducible, pan
dimensional energy field identified by pattern and
A. Orientation integral with the human field" is:

B. Identification A. Unitary Human Being

C. Restoration B. Environment

D. Exploitation C. Health

C. Restoration D. Nursing

Who explained about "Care, Cure and Core as three B. Environment

independent but interconnected circles of the
nursing model"? Who described about 5 levels of nursing experience
from novice to expert?
A. Patricia Benner
A. Patricia E. Benner
B. Rosemary Rizzo Parse
B. Ernestine Wiedenbach
C. Lydia Hall
C. Myra Estrine Levine
D. Jean Watson
D. Faye Glenn Abdellah
C. Lydia Hall
A. Patricia E. Benner D. Interdependence

When applying Roy's Adaptation Model in caring a E. Achievement

patient, the type of stimuli which needs to be
assessed as per are all the following, EXCEPT; E. Achievement

A. Focal Stimulus Concept related to Betty Neuman's System Model

of Nursing is:
B. Contextual Stimulus
A. Pattern
C. Perceptual Stimulua
B. Rhythmicity
D. Residual Stimulus
C. Dependency
C. Perceptual Stimulua
D. Open system
Which nursing theory states that 'nursing is the
interpersonal process of action, reaction, interaction D. Open system
and transaction"?
"Each human being perceives the world as a total
A. Roy's adaptation model person in making transactions with individuals and
things in environment".
B. Self-care deficit theory
This assumption is stated by:
C. Imogene King's theory
A. Neuman's system model
D. Roger's unitary human beings
B. Nightingale's theory
C. Imogene King's theory
C. Peplau's Interpersonal Relations model
Which of the following in NOT a concept related to
personal system in Imogene King's Theory? D. Imogene King's conceptual framework

A. Perception D. Imogene King's conceptual framework

B. Self Deliberative Nursing Process Theory was explained

by:
C. Body image
A. Hildegard Peplau
D. Organization
B. Dorothea Orem
D. Organization
C. Ida Jean Orlando
According to Roy's Adaptation Model, the adaptive
modes includes all the following, EXCEPT: D. Patricia Benner

A. Physiologic Needs C. Ida Jean Orlando

According to Peplau's interpersonal model, during
B. Self Concept which phase of nursing process, the patient
participates in goal setting and has a feeling of
C. Role Function belonging and selectively responds to those who
can meet his or her needs?
 Ethnonursing research method was developed by:
A. Orientation
A. Madeleine Leininger
B. Identification
B. Florence Nightingale
C. Exploitation
C. Hildegard Peplau
D. Resolution
D. Ida Jean Orlando
B. Identification
A. Madeleine Leininger
Metaphysics is a branch of philosophy which deals
with : Attachment theory was originally proposed by:
A. The study of valid argument forms
A. Hildegard Peplau
B. Theory of knowledge
B. John Bowlby
C. Moral philosophy
C. Sigmond Frued
D. The study of the nature of reality
D. Kurt Lewin
D. The study of the nature of reality
. B. John Bowlby

Which nursing theorist defines environment as "the Who described 5 levels of nursing experience in her
totality of the internal and external forces which theory on nursing?
surround a person and with which they interact at
any given time"? A. B. F. Skinner

A. Dorothy Johnson B. Patricia Benner

B. Martha Rogers C. Callista Roy

C. Dorothea Orem D. Leon Festinger

D. Imogene King B. Patricia Benner

E. Betty Neuman A paradigm refers to

E. Betty Neuman A. A model that explains the linkages of science,

philosophy, and theory accepted and applied by the
The Sunrise Model of nursing was developed by: discipline

A. Joyce Travelbee B. Ideas and mental images that help to describe

phenomena
B. Rosemarie Rizzo Parse
C. Statements that describe concepts
C. Madeleine Leininger
D. Aspect of reality that can be consciously sensed
D. Ida Jean Orlando or experienced

C. Madeleine Leininger
A. A model that explains the linkages of science,
philosophy, and theory accepted and applied by the
discipline
According to Behavior System Model,
"predisposition to act with reference to the goal, in
certain ways rather than the other ways" refers to
A. Drive
B. Goal
C. Set
What is the normal findings in measuring the thorax in
anteroposterior to transverse diameter ratio?
a. 1:1
b. 1-2
c. 2:1
d. 2.2
Rationale: Chest movement should be symmetrical on
inspiration and expiration. Observe the
anterior-posterior diameter of the patient's chest and
compare to the transverse diameter. The expected
anteroposterior-transverse ratio should be 1:2.

D. Scope of action It is an inadequate circulatory blood volume either

caused by fluid deficit or hemorrhage
C. Set
a. Pulmonary embolism
B. Hypovolemia
The study of feedback and derived concepts such as c. Thrombus
communication and control in living organisms, d bleeding
machines and organisations is termed as:
Assessing the peripheral vascular system: In a capillary
A. Cybernetics refill test. The nurse should expect a normal peripheral
perfusion assessment if the color of the nail after
B. Ontology pressing returns in?

C. Epistemology a. 22 seconds
b. 3- 4 seconds
c. 2-3 seconds
D. Philosophy d. 35 seconds

A. Cybernetics What are the steps in assessing the thorax?

Nursing is defined as "action which assist
individuals, families and groups to maintain a
maximum level of wellness, and the primary aim is
stability of the patient/client system, through
nursing interventions to reduce stressors.''
This definition is given by:
A. Orem
a. Inspection, Palpation, Percussion, Auscultation
b. Inspection. Auscultation, Percussion. Palpation
c. Inspection, Percussion, Palpation, Auscultation
d. Percussion, Auscultation, Percussion, Inspection
Rationale: Thorough evaluation of the thorax and lungs
is an essential component of a complete physical
examination. The traditional systematic approach
involves inspection, followed by palpation, percussion
and then auscultation of both the anterior, lateral, and
posterior thorax.

B. Peplau 41. The nurse is performing health assessment of the

abdomen is the correct order to perform
C. Neuman the asseessment?

D. Rogers A.Auscultate, percuss, palpate, inspect

B. Palpate, percuss, auscultate, inspect
C. Neuman C Inspect, auscultate, palpate, percuss
D. Inspect, auscultate, percuss, palpate
42. The nurse is performing a health assessment and 48. The nurse is assessing a female's breasts. The nurse
notes a yellow tinge to the sclera of the finds both breasts rounded, slightly
eye. The nurse would document this as which of the unequal in size, skin smooth and intact, and nipples
following? without discharge. What is the nurse's next
action?
A. Cyanosis
B. Pallor A. Document the findings in the nurse's notes as
C. Jaundice abnormal.
D. Erythema B. Document the findings in the nurse's notes as normal.
C. Notify the physician.
43. While performing an assessment of the D. Notify the charge nurse
integumentary system, the nurse notes the client's
eyeballs are protruding and the upper eyelids are 49. The nurse is preparing a client for an abdominal
elevated. What term would the nurse use to examination. Which of the following should
document this finding? be performed before the examination?
A. Assess vital signs.
A. Erythema B. Ask client to urinate.
B. Cyanosis C. Ask client to drink 8 ounces of water.
C. Normocephalic D. Assess heart rate
D. Exophthalmos
50. The nurse is performing a musculoskeletal
44. The nurse is preparing for morning rounds. Which of assessment on a client admitted with a possible
the following may not be delegated to stroke. When testing for muscle grip strength, the nurse
the nursing assistant? should ask the client to:
A.Skull and face assessment
B. Ambulate surgical clients A.Grasp the nurse's index and middle fingers while the
C. Vital signs nurse tries to pull the fingers out.
D. Fill water pitcher B. Flex each arm and then try to extend it against the
nurse's attempt to keep the arm in flexion.
45. The nurse is performing a lung assessment on a C. Shrug the shoulders against the resistance of the
client with suspected pneumonia. Which of nurse's hands.
the following assessments should the nurse report to the D. Hold an arm up and resist while the nurse tries to
physician immediately? push it down.

A. Breath sounds equal bilaterally 51. Many Paner, Level 2 student is assigned to take the
B. Chest symmetrical vital signs of a patient in Floor of SHH.
C. Asymmetric chest expansion Which of the following statement by the student
D. Bilateral symmetric vocal fremitus nurse shows understanding about temperature?

46. While performing a health assessment, in which A. Body temperature never changes during a 24 hour
position should the nurse place the client period.
for inspection of the jugular veins? B. Body temperature is constantly high
C. The highest body temperature occurs between 1:00
A. 15-degree angle and 4:00 AM
B. 30- to 45-degree angle D. The highest body temperature occurs later in the day
C. 90-degree angle around 6:00 pm
D. 60-degree angle
52. Is considered as the safest and most non invasive
47. The nurse is assessing peripheral pulses on a client method of temperature taking.
with suspected peripheral vascular
disease. Which of the following should the nurse report A.Axillary
to the physician immediately? B. Rectal
A.Thready pulses C. Oral
B. Full pulsations D. Temporal
C. Pulses equal bilaterally 53.Jomar, a 15-year-old patient was admitted and
D. Pulses present bilaterally diagnosed with dengue fever. The student
took his vital signs and the temperature was elevated.
She knows that the normal range of 59. After auscultating the abdomen, the nurse should
temperature is which of these? report which of the following to the primary
care provider?
A. 37 C
B. 36 C A.Bruit over the aorta
C. 36 C-37.5 C B. Absence of bowel sounds for 60 seconds
D. 35 C--36 C C. Continuous bowel sounds over the ileocecal valve
D. A completely irregular pattern of bowel sounds
54. A 2 year old client came to OPD for consultation,
due to on and off fever. What vital signs must the nurse 60. If unable to locate the client's popliteal pulse during
take first a routine examination, the nurse should
perform which of the following next?
A. Temperature
C. Respiratory rate A.Check for a pedal pulse.
B. Pulse rate B. Check for a femoral pulse.
D. Blood pressure C. Take the client's blood pressure on that thigh.
D. Ask another nurse to try to locate the pulse
55. Physical assessment entails touching some body
parts of the child, therefore anxiety is likely 61. Which of the following is an expected finding during
expected. in order to prevent or minimize anxiety, which assessment of the older adult?
of the following is helpful?
A. Facial hair becomes finer and softer.
A. Give her favorite food B. Decreased peripheral, color, and night vision.
B. Ask the favor from the mother to do the task when it C. Increased sensitivity to odors.
needs touch D. Respiratory rate and rhythm are irregular at rest.
C.Let the child see and touch the equipment before you
begin to use it. 62. If the client reports loss of short-term memory, the
D. Discontinue the examination if uncooperative nurse would assess this using which one
of the following?
56. During the nursing rounds the patient verbalized that
he feels hot. Which of the following A. Have the client repeat a series of three numbers,
signifies febrile values of vital signs? increasing to eight if possible.
B. Have the client describe his or her childhood
A. Temperature =37.8 C illnesses.
B. Temperature =37.4 C c. Ask the client to describe how he or she arrived at this
C. Respiratory rate =16 cpm location.
D. Respiratory rate = 21cpm D. Ask the client to count backwards from 100
subtracting seven each time.
57. Jericho, a clinical instructor share to his students that
intervention to perform if the patient is 63. The nurse will take the oral temperature of her client
febrile. Which of the following is NOT included in his who had a rectal surgery, but the client
teaching? had just eaten and drank. Which of the following action
should be done by the nurse?
A. Encourage drinking adequate fluids
B. Perform tepid sponge bath A. Do not take the temperature at all.
C. Elevate of head of bed B. Take the temperature rectally
D. Give medications as ordered C. Wait 15-30 minutes before taking an oral temperature
D. Take the temperature at 12 noon
58. Which of the following indicates a normal finding on
auscultation of the lungs? 64. A type of heat loss that occurs when heat is
dissipated by air currents.
A. Tympany over the right upper lobe A. Convection
B. Resonance over the left upper lobe B. Radiation
C. Hyperresonance over the left lower lobe C. Conduction
D. Dullness above the left 10th intercostal space D. Evaporation
 76. You know that pulse rate is just easy to take because
65. A process of heat loss which involves the transfer of no devices are used for it, if peripheral
heat from one surface to another Is. pulses are to be taken. Which pulse site the should not be
A. Convection palpated together in taking the pulse
B. Radiation fate?
C. Conduction
D. Evaporation A. Carotid
B. Radial
71. John has fever of 38.5 degrees Celsius. It surges at C. Popliteal
around 40 degrees Celsius and go back D. Brachial
to 38. 5 degrees Celsius 6 times today in a typical
pattern. What kind of fever does John have? 77. During a nursing assessment an adult client is noted
to have shallow respirations at a rate of
A. Intermittent 8 cycles per minute. His heart rate is 46 beats per
B. Remittent minute. His vital signs would be described as;
C. Relapsing
D. Constant A. Bradycardia and apnea
B. Tachycardia and apnea
72. Andrew's temperature 8 hours ago was normal, 36.5 C. Bradycardia and bradypnea
degrees Celsius, 4 hours ago his fever D. Tachycardia and bradypnea
was 38.9 degrees Celsius. Right now, his temp is back to
normal. Which of the following best 78. The difference between the systolic and diastolic is
describe the fever Andrew is having? termed as:
A. Apical pressure
A. Intermittent B. Cardiac pressure
B. Remittent C. Pulse pressure
C. Relapsing D. Pulse deficit
D. Constant
79. The nurse will perform physical assessment to
73. Two days ago, Mr. X had fever of 39.5 degrees a client. A systematic approach is followed
Celsius. But yesterday, he had a normal using the four techniques. He followed the head to toe
temperature of 36.5 degrees Celsius. Today, his approach, which is referred to as:
temperature surge to 40 degrees Celsius. What A. Cephalocaudal
type of fever does Mr. X have? B. Proximodistal
C. Mediolateral
A. Intermittent D. External to internal
B. Remittent
C. Relapsing During which part of the client interview would it
D. Constant be best for the nurse to ask, "What's the weather
forecast for today?"
74. Which of the following statement is TRUE about
pulse
A. Introduction
A. Children have higher pulse rate than adults.
B. In lying position, pulse rate is higher
B. Body
C. Fever does not affect pulse rate C. Closing
D. Radial pulse is the most reliable for infants and small D. Orientation
children
A. Introduction
75. The following are correct actions when taking radial
pulse Except. Rationale: Asking about the weather initiates the
A. Put the palms downward social or introductory phase of the interview and
b. Use the thumb to palpate the artery allows the nurse to begin an assessment of the
C. Use 2 to 3 fingers to palpate the pulses client's mental status. The goal is to develop rapport
D. Assess the pulse rhythm, rate and amplitude.
with the client at the beginning of the interview. In
the body the client responds to the nurse's questions.
During the closing the nurse or the client terminates
the interview.
The nurse is most likely to collect timely, specific
information by asking which of the following
questions?
A. "Would you describe what you are feeling?"
B. "How are you today?"
C. "What would you like to talk about?"
D. "Where does it hurt?"
A. "Would you describe what you are feeling?"
Rationale: This is an open-ended question that will
elicit subjective data. The data collected will reflect
the client's current health status and human
response(s) and should generate specific
information that can be used to identify actual
and/or potential health problems. Options 2 and 3
are more likely to elicit general, nonspecific
information. Option 4 may result in a brief, one-
word response or nonverbal gesture indicating the
site of the client's pain. A better approach to collect
specific information might be, "Describe any pain
you are having."
The nurse should avoid asking the client which of
the following leading questions during a client
interview?
A. "What medication do you take at home?"
B. "You are really excited about the plastic surgery,
aren't you?"
C. "Were you aware I've has this same type of
surgery?"
D. "What would you like to talk about?"
B. "You are really excited about the plastic surgery,
aren't you?"
Rationale: A leading question directs the client's
answer. The phrasing of the question indicates an
expected answer. The client may be influenced by
the nurse's expectations and may give inaccurate
responses. This process can result in an error in
diagnostic reasoning.
The nurse needs to validate which of the following
statements pertaining to an assigned client?
A. The client has a hard, raised, red lesion on his
right hand.
B. A weight of 185 lbs. is recorded in the chart
C. The client reported an infected toe
D. The client's blood pressure is 124/70. It was
118/68 yesterday.
C. The client reported an infected tow
Rationale: Validation is the process of confirming
that data are actual and factual. Data that can be
measured can be accepted as factual, as in options
1, 3 and 4. The nurse should assess the client's toe
to validate the statement.
Which of the following items of subjective client
data would be documented in the medical record by
the nurse?
A. Client's face is pale
B. Cervical lymph nodes are palpable
C. Nursing assistant reports client refused lunch
D. Client feel nauseated
D. Client feel nauseated
Rationale: Subjective data includes the client's
sensations, feelings, and perception of health status.
Subjective data can only be verified by the affected
person. Options 1, 2, and 3 represent objective data
that can be detected by the nurse or measured
against an accepted norm.
A nurse explains to a student that the nursing
process is a dynamic process. Which of the
following actions by the nurse best demonstrates
this concept during the work shift?
A. Nurse and client agree upon health care goals for
the client
B. Nurse reviews the client's history on the medical
record
C. Nurse explains to the client the purpose of each
administered medication
D. Nurse rapidly reset priorities for client care
based on a change in the client's condition
D. Nurse rapidly reset priorities for client care
based on a change in the client's condition
Rationale: The nursing process is characterized by
unique properties that enable it to respond to the
changing health status of the client. Options 1, 2,
and 3 are appropriate nursing care measures, but do
not demonstrate the dynamic nature of the nursing
process.
The client reports nausea and constipation. Which
of the following would be the priority nursing
action?
A. Collect a stool sample
B. Complete an abnormal assessment
C. Administer an anti-nausea medication
D. Notify the physician
B. Complete an Abdominal assessment
Rationale: Assessment involves the systematic
collection of data about an individual upon which
all subsequent phases of the nursing process are
built. In response to a client's complaint, a nurse
assesses a specific body system to obtain data that
will help the nurse make a nursing diagnosis and
plan the client's care. The other options reflect
interventions, which are not timely unless there is
first a complete assessment.
The nurse suspects that a client is withholding
health-related information out of fear of discovery
and possible legal problems. The nurse formulates
nursing diagnoses for the client carefully, being
concerned about a diagnostic error resulting from
which of the following?
A. Incomplete data
B. Generalize from experience
C. Identifying with the client
D. Lack of clinical experience
A. Incomplete data
Rationale: To collect data accurately, the client
must actively participate. Incomplete data can lead
to inappropriate nursing diagnosis and planning.
The other options are not relevant to the question as
presented.
The nurse notes that the client often sighs and says
in a monotone voice, "I'm never going to get over
this." When encouraged to participate in care, the
client says, "I don't have the energy." The nurse
believes these cues are suggestive of which nursing
diagnoses? Select all that apply.
A. Hopelessness
B. Powerlessness
C. Interrupted sleep pattern
D. Disturbed self esteem
E. Self care deficit
A. Hopelessness
B. Powerlessness
Rationale: Rationale: A nursing diagnosis is a
clinical judgment about a response to an actual or
potential health problem. This client is manifesting
symptoms of both hopelessness and powerlessness.
Although the client does report symptoms
compatible with fatigue, there is no direct data is
given that indicates the client has interrupted sleep
patterns (option 3), disturbed self esteem (option 4),
or self care deficit (option 5).
Which of the following descriptors is most
appropriate to use when stating the "problem" part
of a nursing diagnosis?
A. Grimacing
B. Anxiety
C. Oxygenation saturation 93%
D. Output 500 mL in 8 hours
B. Anxiety
Rationale: The problem part of a nursing diagnosis
should state the client's response to a life process,
event, or stressor. These are categorized as nursing
diagnoses. The incorrect options are cues the nurse
would use to formulate the nursing diagnostic
statement.
Which desired outcome written by the nurse is
correctly written and measurable?
A. Client will have a normal bowel pattern by April
2
B. The client will lose 4 lbs. within next 2 weeks
C. The nurse will provide skin care at least 3 times
each day
D. The client will breathe better after resting for 10
minutes
B. The client will lose 4 lbs. within next 2 weeks
Rationale: An outcome statement must describe the
observable client behavior that should occur in
response to the nursing interventions. It consists of
a subject, action verb, conditions under which the
behavior is to be performed, and the level at which
the client will perform the desired behavior. Each of
the incorrect options lacks one of these required
elements. Option 1 is not measurable. Option 3 is a
nursing goal rather than a client goal. Option 4 does
not include the level at which the behavior should
be performed.
The rehabilitation nurse wishes to make the
following entry into a client's plan of care: "Client
will reestablish a pattern of daily bowel movements
without straining within two months." The nurse
would write this statement under which section of
the plan of care?
A. Nursing diagnosis/problem list
B. Nursing orders
C. Short-term goals
D. Long-term goals
D. Long-term goals
Rationale: Long-term goals describe changes in
client behavior expected over a time frame greater
than one week. They are usually designed to restore
normal functioning in a problem area and are
helpful to other healthcare workers who care for the
client, often in a variety of settings.
Which of these is a correctly stated outcome goal
written by the nurse?
A. The client will walk 2 miles daily by March 19
B. The client will understand how to give insulin by
discharge
C. The client will regain their former state of health
by April 1
D. The client achieve desired mobility by May 7
A. The client will walk 2 miles daily by March 19
Rationale: Outcome goals should be SMART, i.e.,
Specific, Measurable, Appropriate, Realistic, and
Timely. Option 1 is the only outcome that has a
specific behavior (walks daily), with measurable
performance criteria (2 miles), and a time estimate
for goal attainment (by March 19).
The nursing diagnosis is Risk for impaired skin
integrity related to immobility and pressure
secondary to pain and presence of a cast. Which of
the following desired outcomes should the nurse
include in the care plan?
A. Client will be able to turn self by day 3
B. Skin will remain intact and without redness
during hospital stay
C. Client will state pain relieved within 30 minutes
after medication
D. Pressure will be prevented by repositioning
client every 2 hours
B. Skin will remain intact and without redness
during hospital stay
Rationale: The human response/label is what needs
to change (Risk for impaired skin integrity). The
label suggests the outcomes. In this case, "skin will
remain intact" is the desired outcome for a client at
risk for impaired skin integrity. Option 1 addresses
immobility. Option 3 addresses pain. Option 4 is an
intervention.
While assisting a client from bed to chair, the nurse
observes that the client looks pale and is beginning
to perspire heavily. The nurse would then do which
of the following activities as a reassessment?
A. Help client into the chair but more quickly
B. Document client's vital signs taken just prior to
moving the client
C. Help client back to bed immediately
D. Observe client's skin color and take another set
of vital signs
D. Observe client's skin color and take another set
of vital signs
Rationale: Assessment is ongoing throughout the
nurse-client relationship. During re-assessment, the
nurse collects additional data to help evaluate the
status of problems or identify new problems.
Options 1, 2, and 3 are interventions.
After instructing the client on crutch walking
technique, the nurse should evaluate the client's
understanding by using which of the following
methods?
A. Return demonstration
B. Explanation
C. Achievement of 90 on written test
D. Have client explain produce to the family

A. Return demonstration
Rationale: Interpersonal skills are the sum of the
activities the nurse uses when communicating with
others. Technical/psychomotor skills are "hands-on"
skills, which are often procedures and are evaluated
by return demonstration. Cognitive skills are the
intellectual skills of analysis and problem-solving
and are evaluated by tests.
The nurse would do which of the following during
the implementation phase of the nursing process
when working with a hospitalized adult?
A. Formulate a nursing diagnosis of impaired gas
exchange
B. Record in the medical record the distance a client
ambulate in the hall
C. Write individualized nursing orders in the care
plan
D. Compare client responses to the desired
outcomes for pain relief
B. Record in the medical record the distance a client
ambulate in the hall
Rationale: The implementation phase of the nursing
process involves carrying out or delegating the
nursing interventions and recording nursing
activities and client responses in the medical
records. Option 1 represents diagnosing. Option 3
represents planning. Option 4 represents evaluation.
A client on the nursing unit is terminally ill but
remains alert and oriented. Three days after
admission, the nurse observes signs of depression.
The client states, "I'm tired of being sick. I wish I
could end it all." What is the most accurate and
informative way to record this data in a nursing
progress note?
A. Client appears to be depressed, possibly suicidal
B. Client reports being tired of being ill and wants
to die
C. Client does not want to live any longer and is
tired of being ill
D. Client states, "I'm tired of being sick. I wish I
could end it all."
D. Client states, "I'm tired of being sick. I wish I
could end it all."
Rationale: Subjective data includes thoughts,
beliefs, feelings, perceptions, and sensations that are
apparent only to the person affected and cannot be
measured, seen, or felt by the nurse. This
information should be documented using the client's
exact words in quotes. The other options indicate
that the nurse has drawn the conclusion that the
client no longer wishes to live. From the data
provided, the cues do not support this assumption.
A more complete assessment should be conducted
to determine if the client is suicidal.
The nurse evaluates the client's progress and
determines that one of the nursing diagnoses on the
client's care plan has been resolved. How should the
nurse document this so that it is best communicated
to the healthcare team?
A. Use Liquid PaperTM to "white out" the resolve
diagnosis on the care plan
B. Recopy the care plan without the resolve
diagnosis
C. Write a nursing process not indicating that the
outcome goals have been achieved
D. Draw a single line through the diagnosis on the
care plan and write the nurse's initials and date
D. Draw a single line through the diagnosis on the
care plan and write the nurse's initials and date
Rationale: To discontinue a diagnosis once it has
been resolved, cross it off with a single line or
highlight it, then write initials and date. Some
agency forms may require the nurse to put date and
initials in a "Date Resolved" column. Using Liquid
PaperTM is not a legal way to amend client records.
Outcome goals that have been met and nursing
diagnoses that have been resolved should be
documented on the care plan. A progress note
should also be written, but a single note may not be
read by all health team members.
The client is being discharged to a long-term care
(LTC) facility. The nurse is preparing a progress
note to communicate to the LTC staff the client's
outcome goals that were met and those that were
not. To do this effectively, the nurse should:
A. Formulate post-discharge nursing diagnoses
B. Draw conclusion about resolution of current
client problems
C. Assess the client for baseline data to be used at
the LTC facility
D. Plan the care that is needed in the LTC facility
B. Draw conclusion about resolution of current
client problems
Rationale: Terminal evaluation is done to determine
the client's condition at the time of discharge. This
evaluation is best reflected in option 2 because it
focuses on which goals were achieved and which
were not. Ongoing evaluation is done while or
immediately after implementing a nursing
intervention. Intermittent evaluation is performed at
specified intervals, such as twice a week. Items
related to care post-discharge (options 2, 3, and 4)
should be done on admission to the LTC facility.
A client who complains of nausea and seems
anxious is admitted to the nursing unit. The nurse
should take which of the following actions
regarding completion of the admission interview?
A. Help the client to get settled and do the interview
the next morning when the client is rested
B. Do the interview immediately, directing the
majority of the questions to the client's spouse
C. Do the interview as soon as some uninterrupted
time is available in order to address the client's
concerns
D. Ask the charge nurse to interview the client
while the admitting nurse calls the doctor for anti-
nausea and anti-anxiety medication
C. Do the interview as soon as some uninterrupted
time is available in order to address the client's
concerns
Rationale: To collect data accurately, the client
must participate. Attending to the client's immediate
personal needs before expecting the client to focus
on the interview will maximize the accuracy of the
data collected. Data should be collected shortly after
admission. The best source of data is the client. The
management of the client's anxiety is the
responsibility of the nurse conducting the interview
and initiating the relationship.
The nurse overhears an unlicensed assistive person
(UAP) who has just been accepted to nursing school
say to a client, "You must be so pleased with your
progress." The nurse later explains to the UAP that
this is an example of what type of question?
A. Close-ended question
B. Open-ended question
C. Leading question
D. Neutral question
C. Leading question
Rationale: A leading question is asked in a way that
suggests the type of answer that is expected. This
can result in inaccurate data collection. A closed-
ended question generally requires only a "yes" or
"no" or short factual answer. Open-ended questions
encourage clients to elaborate on their thoughts and
feelings. Neutral questions do not influence the
client's answer.
The nurse would do which of the following
activities during the diagnosing phase of the nursing
process? Select all that apply.
A. Collect and organize client information
B. Analyze data
C. Identify problems, risk, and client strengths
D. Develop nursing diagnoses
E. Develop client goals
B. Analyze data
C. Identify problems, risk, and client strengths
D. Develop nursing diagnoses
Rationale: The diagnosing phase of the nursing
process involves data analysis, which leads to
identification of problems, risks, and strengths and
the development of nursing diagnoses. Collecting
and organizing client data is done in the assessment
phase of the nursing process. Goal setting occurs
during the planning phase.
The functional health pattern assessment data states:
"Eats three meals a day and is of normal weight for
height." The nurse should draw which of the
following conclusions about this data? Select all
that apply.
A. Client has an actual health problem
B. Client has a wellness diagnosis
C. Collaborative health problem needs to be written
D. Possible nursing diagnosis exists
E. Specific questions about the diet should be asked
next
B. Client has a wellness diagnosis
E. Specific questions about the diet should be asked
next
Rationale: The description indicates a healthy
pattern of nutrition for the client. A wellness
diagnosis might be stated as: "Potential for
enhanced nutrition." An actual health problem is a
client problem that is currently present. The nurse
should also do a diet assessment to determine the
quality of the food eaten during meals. These
actions by the nurse are within the scope of
independent nursing practice and are not
collaborative in nature.
For the nursing diagnostic statement, Self-care
deficit: feeding related to bilateral fractured wrists
in casts, what is the major related factor or risk
factor identified by the nurse?
A. Discomfort
B. Deficit
C. Feeding
D. Fractured wrists
D. Fractured Wrists
Rationale: The etiology or related factors of a
nursing diagnostic statement define one or more
probable causes of the problem and allow the nurse
to individualize the client's care. In this case, the
fracture is the cause of the client's feeding problem.
The nurse would make which of the following
inferences after performing the appropriate client
assessment?
A. Client is hypotensive
B. Respiratory rate of 20 breaths per minute
C. Oxygen saturation of 95%
D. Client relays anxiety about blood work
A. Client is hypotensive
Rationale: An inference is the nurse's judgment or
interpretation of cues such as judging a blood
pressure to be lower than normal. A cue is any piece
of data information that influences a decision.
Options 2, 3, and 4 are cues that could lead to
inferences.
The nurse would write which of the following
outcome statements for a client starting an exercise
program?
A. Client will walk quickly three times a day
B. Client will be able to walk a mile
C. Client will have no alteration in breathing during
the walk
D. Client will progress to walking a 20-minute mile
in one month
D. Client will progress to walking a 20-minute mile
in one month
Rationale: Outcome statements must be written in
behavioral terms and identify specific, measurable
client behaviors. They are stated in terms of the
client with an action verb that, under identified
conditions, will achieve the desired behavior. They
should also be realistic and achievable.
The nurse decides it would be beneficial to the
client to allow the client's infant granddaughter to
visit before the client's scheduled heart transplant.
Before implementing this intervention the nurse
should collaborate with which of the following?
Select all that apply.
A. Client and Family
B. Other nursing staff on the unit
C. Security department
D. Hospital administration
E. This is not a collaborative intervention so no
collaboration will be needed prior to
implementation
A. Client and Family
B. Other nursing staff on the unit
Rationale: Collaboration with the client and family
will encourage a sense of autonomy and active
involvement in the healthcare process for the client.
In this case collaboration with other nursing staff
will ensure the successful implementation of the
planned intervention. There is no real need for
collaboration with hospital administration or the
security department in this situation although the
nurse should be aware of her responsibility to
collaborate at those levels when the situation
demands it.
The nurse informs the physical therapy department
that the client is too weak to use a walker and needs
to be transported by wheelchair. Which step of the
nursing process is the nurse engaged in at this time?
A. Assessment
B. Planning
C. Implementation
D. Evaluation
C. Implementation
Rationale: The nurse is responsible for coordinating
the plan of care with other disciplines to ensure the
client's safety. This action represents the
implementation phase of the nursing process. Data
gathering occurs during assessment. Goal setting
occurs during planning. Determining attainment of
client goals occurs as part of evaluation.
A desired outcome for a client immobilized in a
long leg cast reads; Client will state three signs of
impaired circulation prior to discharge. When the
nurse evaluates the client's progress, the client is
able to state that numbness and tingling are signs of
impaired circulation. What would be an appropriate
evaluation statement for the nurse to write?
A. Client understands the signs of impaired
circulation
B. Goal met: Client cited numbness and tingling as
sign of impaired circulation
C. Goal not met: Client able to name only two signs
of impaired circulation
D. Goal not met: Client unable to describe signs of
impaired circulation
C. Goal not met: Client able to name only two signs
of impaired circulation
Rationale: The goal has not been met because the
client states only two out of three signs of impaired
circulation. By comparing the data with the
expected outcomes, the nurse judges that while
there has been progress toward the goal, it has not
been completely met. The care plan may need to be
revised or more effective teaching strategies may
need to be implemented to achieve the goal.
Once a nurse assesses a client's condition and
identifies appropriate nursing diagnoses, a:
A. Plan is developed for nursing care.
B. Physical assessment begins
C. List of priorities is determined.
D. Review of the assessment is conducted with
other team members.
A. Plan is developed for nursing care.
Planning is a category of nursing behaviors in
which:
A. The nurse determines the health care needed for
the client.
B. The Physician determines the plan of care for the
client.
C. Client-centered goals and expected outcomes are
established.
D. The client determines the care needed.
C. Client-centered goals and expected outcomes are
established.
Priorities are established to help the nurse anticipate
and sequence nursing interventions when a client
has multiple problems or alterations. Priorities are
determined by the client's:
A. Physician
B. Non Emergent, non-life threatening needs
C. Future well-being.
D. Urgency of problems
D. Urgency of problems
A client centered goal is a specific and measurable
behavior or response that reflects a client's:
A. Desire for specific health care interventions
B. Highest possible level of wellness and
independence in function.
C. Physician's goal for the specific client.
D. Response when compared to another client with
a like problem.
B. Highest possible level of wellness and
independence in function
For clients to participate in goal setting, they should
be:
A. Alert and have some degree of independence.
B. Ambulatory and mobile.
C. Able to speak and write.
D. Able to read and write.
A. Alert and have some degree of independence.

The nurse writes an expected outcome statement in
measurable terms. An example is:
A. Client will have less pain.
B. Client will be pain free.
C. Client will report pain acuity less than 4 on a
scale of 0-10.
D. Client will take pain medication every 4 hours
around the clock.
C. Client will report pain acuity less than 4 on a
scale of 0-10.
As goals, outcomes, and interventions are
developed, the nurse must:
A. Be in charge of all care and planning for the
client.
B. Be aware of and committed to accepted
standards of practice from nursing and other
disciplines.
C. Not change the plan of care for the client.
D. Be in control of all interventions for the client.
B. Be aware of and committed to accepted
standards of practice from nursing and other
disciplines.
When establishing realistic goals, the nurse:
A. Bases the goals on the nurse's personal
knowledge.
B. Knows the resources of the health care facility,
family, and the client.
C. Must have a client who is physically and
emotionally stable.
D. Must have the client's cooperation.
B. Knows the resources of the health care facility,
family, and the client.
To initiate an intervention the nurse must be
competent in three areas, which include:
A. Knowledge, function, and specific skills
B. Experience, advanced education, and skills.
C. Skills, finances, and leadership.
D. Leadership, autonomy, and skills.
A. Knowledge, function, and specific skills
Collaborative interventions are therapies that
require:
A. Physician and nurse interventions.
B. Nurse and client interventions.
C. Client and Physician intervention.
D. Multiple health care professionals.
D. Multiple health care professionals.
Well formulated, client-centered goals should:
A. Meet immediate client needs.
B. Include preventative health care.
C. Include rehabilitation needs.
D. All of the above.
D. All of the above.
The following statement appears on the nursing care
plan for an immunosuppressed client: The client
will remain free from infection throughout
hospitalization. This statement is an example of a
(an):
A. Nursing diagnosis
B. Short-term goal
C. Long-term goal
D. Expected outcome
B. Short-term goal
The following statements appear on a nursing care
plan for a client after a mastectomy: Incision site
approximated; absence of drainage or prolonged
erythema at incision site; and client remains
afebrile. These statements are examples of:
A. Nursing interventions
B. Short-term goals
C. Long-term goals
D. Expected outcomes.
D. Expected outcomes.
The planning step of the nursing process includes
which of the following activities?
A. Assessing and diagnosing
B. Evaluating goal achievement.
C. Performing nursing actions and documenting
them.
D. Setting goals and selecting interventions.
D. Setting goals and selecting interventions.
The nursing care plan is:
A. A written guideline for implementation and
evaluation.
B. A documentation of client care.
C. A projection of potential alterations in client
behaviors
D. A tool to set goals and project outcomes.
A. A written guideline for implementation and
evaluation.
After determining a nursing diagnosis of acute pain,
the nurse develops the following appropriate client-
centered goal:
A. Encourage client to implement guided imagery
when pain begins.
B. Determine effect of pain intensity on client
function.
C. Administer analgesic 30 minutes before physical
therapy treatment.
D. Pain intensity reported as a 3 or less during
hospital stay.
D. Pain intensity reported as a 3 or less during
hospital stay.
When developing a nursing care plan for a client
with a fractured right tibia, the nurse includes in the
plan of care independent nursing interventions,
including:
A. Apply a cold pack to the tibia.
B. Elevate the leg 5 inches above the heart.
C. Perform range of motion to right leg every 4
hours.
D. Administer aspirin 325 mg every 4 hours as
needed.
B. Elevate the leg 5 inches above the heart
Which of the following nursing interventions are
written correctly? Select all that apply.
A. Apply continuous passive motion machine
during day.
B. Perform neurovascular checks.
C. Elevate head of bed 30 degrees before meals.
D. Change dressing once a shift.
C. Elevate head of bed 30 degrees before meals.
A client's wound is not healing and appears to be
worsening with the current treatment. The nurse
first considers:
A. Notifying the physician.
B. Calling the wound care nurse
C. Changing the wound care treatment.
D. Consulting with another nurse.
B. Calling the wound care nurse
When calling the nurse consultant about a difficult
client-centered problem, the primary nurse is sure to
report the following:
A. Length of time the current treatment has been in
place.
B. The spouse's reaction to the client's dressing
change.
C. Client's concern about the current treatment.
D. Physician's reluctance to change the current
treatment plan.
A. Length of time the current treatment has been in
place.
The primary nurse asked a clinical nurse specialist
(CNS) to consult on a difficult nursing problem.
The primary nurse is obligated to:
A. Implement the specialist's recommendations.
B. Report the recommendations to the primary
physician.
C. Clarify the suggestions with the client and family
members.
D. Discuss and review advised strategies with CNS.
D. Discuss and review advised strategies with CNS.
After assessing the client, the nurse formulates the
following diagnoses. Place them in order of priority,
with the most important (classified as high) listed
first.
A. Constipation
B. Anticipated grieving
C. Ineffective airway clearance
D. Ineffective tissue perfusion.
C, D, A, B.
The nurse is reviewing the critical paths of the
clients on the nursing unit. In performing a variance
analysis, which of the following would indicate the
need for further action and analysis?
A. A client's family attending a diabetic teaching
session.
B. Canceling physical therapy sessions on the
weekend.
C. Normal VS and absence of wound infection in a
post-op client.
D. A client demonstrating accurate medication
administration following teaching.
B. Canceling physical therapy sessions on the
weekend.
The RN has received her client assignment for the
day-shift. After making the initial rounds and
assessing the clients, which client would the RN
need to develop a care plan first?
A. A client who is ambulatory.
B. A client, who has a fever, is diaphoretic and
restless.
C. A client scheduled for OT at 1300.
D. A client who just had an appendectomy and has
just received pain medication.
B. A client, who has a fever, is diaphoretic and
restless.
Which of the following statements about the
nursing process is most accurate?
A. The nursing process is a four-step procedure for
identifying and resolving patient problems.
B. Beginning in Florence Nightingale's days,
nursing students learned and practiced the nursing
process.
C. Use of the nursing process is optional for nurses,
since there are many ways to accomplish the work
of nursing.
D. The state board examinations for professional
nursing practice now use the nursing process rather
than medical specialties as an organizing concept.
D. The state board examinations for professional
nursing practice now use the nursing process rather
than medical specialties as an organizing concept.
The nurse would do which of the following
activities during the diagnosing phase of the nursing
process? Select all that apply.
A. Collect and organize client information
B. Analyze data
C. Identify problems, risk, and client strengths
D. Develop nursing diagnoses
E. Develop client goals
B. Analyze data
C. Identify problems, risk, and client strengths
D. Develop nursing diagnoses
Rationale: The diagnosing phase of the nursing
process involves data analysis, which leads to
identification of problems, risks, and strengths and
the development of nursing diagnoses. Collecting
and organizing client data is done in the assessment
phase of the nursing process. Goal setting occurs
during the planning phase.
For the nursing diagnostic statement, Self-care
deficit: feeding related to bilateral fractured wrists
in casts, what is the major related factor or risk
factor identified by the nurse?
A. Discomfort
B. Deficit
C. Feeding
D. Fractured wrists
D. Fractured Wrists
Rationale: The etiology or related factors of a
nursing diagnostic statement define one or more
probable causes of the problem and allow the nurse
to individualize the client's care. In this case, the
fracture is the cause of the client's feeding problem.
The nurse would make which of the following
inferences after performing the appropriate client
assessment?
A. Client is hypotensive
B. Respiratory rate of 20 breaths per minute
C. Oxygen saturation of 95%
D. Client relays anxiety about blood work
A. Client is hypotensive
Rationale: An inference is the nurse's judgment or
interpretation of cues such as judging a blood
pressure to be lower than normal. A cue is any piece
of data information that influences a decision.
Options 2, 3, and 4 are cues that could lead to
inferences.
The nurse would write which of the following
outcome statements for a client starting an exercise
program?
A. Client will walk quickly three times a day
B. Client will be able to walk a mile
C. Client will have no alteration in breathing during
the walk
D. Client will progress to walking a 20-minute mile
in one month
D. Client will progress to walking a 20-minute mile
in one month
Rationale: Outcome statements must be written in
behavioral terms and identify specific, measurable
client behaviors. They are stated in terms of the
client with an action verb that, under identified
conditions, will achieve the desired behavior. They
should also be realistic and achievable.
The nurse informs the physical therapy department
that the client is too weak to use a walker and needs
to be transported by wheelchair. Which step of the
nursing process is the nurse engaged in at this time?
A. Assessment
B. Planning
C. Implementation
D. Evaluation
C. Implementation
Rationale: The nurse is responsible for coordinating
the plan of care with other disciplines to ensure the
client's safety. This action represents the
implementation phase of the nursing process. Data
gathering occurs during assessment. Goal setting
occurs during planning. Determining attainment of
client goals occurs as part of evaluation.
A desired outcome for a client immobilized in a
long leg cast reads; Client will state three signs of
impaired circulation prior to discharge. When the
nurse evaluates the client's progress, the client is
able to state that numbness and tingling are signs of
impaired circulation. What would be an appropriate
evaluation statement for the nurse to write?
A. Client understands the signs of impaired
circulation
B. Goal met: Client cited numbness and tingling as
sign of impaired circulation
C. Goal not met: Client able to name only two signs
of impaired circulation
D. Goal not met: Client unable to describe signs of
impaired circulation
C. Goal not met: Client able to name only two signs
of impaired circulation
Rationale: The goal has not been met because the
client states only two out of three signs of impaired
circulation. By comparing the data with the
expected outcomes, the nurse judges that while
there has been progress toward the goal, it has not
been completely met. The care plan may need to be
revised or more effective teaching strategies may
need to be implemented to achieve the goal.
Which of the following items of subjective client
data would be documented in the medical record by
the nurse?
A. Client's face is pale
B. Cervical lymph nodes are palpable
C. Nursing assistant reports client refused lunch
D. Client feel nauseated
D. Client feel nauseated
Rationale: Subjective data includes the client's
sensations, feelings, and perception of health status.
Subjective data can only be verified by the affected
person. Options 1, 2, and 3 represent objective data
that can be detected by the nurse or measured
against an accepted norm.
The client reports nausea and constipation. Which
of the following would be the priority nursing
action?
A. Collect a stool sample
B. Complete an abnormal assessment
C. Administer an anti-nausea medication
D. Notify the physician
B. Complete an Abdominal assessment
Rationale: Assessment involves the systematic
collection of data about an individual upon which
all subsequent phases of the nursing process are
built. In response to a client's complaint, a nurse
assesses a specific body system to obtain data that
will help the nurse make a nursing diagnosis and
plan the client's care. The other options reflect
interventions, which are not timely unless there is
first a complete assessment.
Which of the following descriptors is most
appropriate to use when stating the "problem" part
of a nursing diagnosis?
A. Grimacing
B. Anxiety
C. Oxygenation saturation 93%
D. Output 500 mL in 8 hours
B. Anxiety
Rationale: The problem part of a nursing diagnosis
should state the client's response to a life process,
event, or stressor. These are categorized as nursing
diagnoses. The incorrect options are cues the nurse
would use to formulate the nursing diagnostic
statement.
Which desired outcome written by the nurse is
correctly written and measurable?
A. Client will have a normal bowel pattern by April
2 client every 2 hours
B. The client will lose 4 lbs. within next 2 weeks
C. The nurse will provide skin care at least 3 times
each day
D. The client will breathe better after resting for 10
minutes
B. The client will lose 4 lbs. within next 2 weeks
Rationale: An outcome statement must describe the
observable client behavior that should occur in
response to the nursing interventions. It consists of
a subject, action verb, conditions under which the
behavior is to be performed, and the level at which
the client will perform the desired behavior. Each of
the incorrect options lacks one of these required
elements. Option 1 is not measurable. Option 3 is a
nursing goal rather than a client goal. Option 4 does
not include the level at which the behavior should
be performed.
Which of these is a correctly stated outcome goal
written by the nurse?
A. The client will walk 2 miles daily by March 19
B. The client will understand how to give insulin by
discharge
C. The client will regain their former state of health
by April 1
D. The client achieve desired mobility by May 7
A. The client will walk 2 miles daily by March 19
Rationale: Outcome goals should be SMART, i.e.,
Specific, Measurable, Appropriate, Realistic, and
Timely. Option 1 is the only outcome that has a
specific behavior (walks daily), with measurable
performance criteria (2 miles), and a time estimate
for goal attainment (by March 19).
The nursing diagnosis is Risk for impaired skin
integrity related to immobility and pressure
secondary to pain and presence of a cast. Which of
the following desired outcomes should the nurse
include in the care plan?
A. Client will be able to turn self by day 3
B. Skin will remain intact and without redness
during hospital stay
C. Client will state pain relieved within 30 minutes
after medication
D. Pressure will be prevented by repositioning
B. Skin will remain intact and without redness
during hospital stay
Rationale: The human response/label is what needs
to change (Risk for impaired skin integrity). The
label suggests the outcomes. In this case, "skin will
remain intact" is the desired outcome for a client at
risk for impaired skin integrity. Option 1 addresses
immobility. Option 3 addresses pain. Option 4 is an
intervention.
While assisting a client from bed to chair, the nurse
observes that the client looks pale and is beginning
to perspire heavily. The nurse would then do which
of the following activities as a reassessment?
A. Help client into the chair but more quickly
B. Document client's vital signs taken just prior to
moving the client
C. Help client back to bed immediately
D. Observe client's skin color and take another set
of vital signs
D. Observe client's skin color and take another set
of vital signs
Rationale: Assessment is ongoing throughout the
nurse-client relationship. During re-assessment, the
nurse collects additional data to help evaluate the
status of problems or identify new problems.
Options 1, 2, and 3 are interventions.
The nurse would do which of the following during
the implementation phase of the nursing process
when working with a hospitalized adult?
A. Formulate a nursing diagnosis of impaired gas
exchange
B. Record in the medical record the distance a client
ambulate in the hall
C. Write individualized nursing orders in the care
plan
D. Compare client responses to the desired
outcomes for pain relief
B. Record in the medical record the distance a client
ambulate in the hall
Rationale: The implementation phase of the nursing
process involves carrying out or delegating the
nursing interventions and recording nursing
activities and client responses in the medical
records. Option 1 represents diagnosing. Option 3
represents planning. Option 4 represents evaluation.
A client on the nursing unit is terminally ill but
remains alert and oriented. Three days after
admission, the nurse observes signs of depression.
The client states, "I'm tired of being sick. I wish I
could end it all." What is the most accurate and
informative way to record this data in a nursing
progress note?
A. Client appears to be depressed, possibly suicidal
B. Client reports being tired of being ill and wants
to die
C. Client does not want to live any longer and is
tired of being ill
D. Client states, "I'm tired of being sick. I wish I
could end it all."
D. Client states, "I'm tired of being sick. I wish I
could end it all."
Rationale: Subjective data includes thoughts,
beliefs, feelings, perceptions, and sensations that are
apparent only to the person affected and cannot be
measured, seen, or felt by the nurse. This
information should be documented using the client's
exact words in quotes. The other options indicate
that the nurse has drawn the conclusion that the
client no longer wishes to live. From the data
provided, the cues do not support this assumption.
A more complete assessment should be conducted
to determine if the client is suicidal
1. Once a nurse assesses a client’s condition and
identifies appropriate nursing diagnoses, a:
A. Plan is developed for nursing care.
B. Physical assessment begins
C. List of priorities is determined.
D. Review of the assessment is conducted with
other team members.
2. Planning is a category of nursing behaviors in
which:
A. The nurse determines the health care needed
for the client.
B. The Physician determines the plan of care for
the client.
C. Client-centered goals and expected outcomes
are established.
D. The client determines the care needed.
3. Priorities are established to help the nurse
anticipate and sequence nursing interventions when
a client has multiple problems or alterations.
Priorities are determined by the client’s:
A. Physician
B. Non Emergent, non-life threatening needs
C. Future well-being.
 D. Urgency of problems
4. A client centered goal is a specific and
measurable behavior or response that reflects a
client’s:
A. Desire for specific health care interventions
B. Highest possible level of wellness and
independence in function.
C. Physician’s goal for the specific client.
D. Response when compared to another client
with a like problem.
5. For clients to participate in goal setting, they
should be:
9. To initiate an intervention the nurse must be
competent in three areas, which include:
A. Knowledge, function, and specific skills
B. Experience, advanced education, and skills.
C. Skills, finances, and leadership.
D. Leadership, autonomy, and skills.
10. Collaborative interventions are therapies that
require:
A. Physician and nurse interventions.
B. Nurse and client interventions.
C. Client and Physician intervention.
D. Multiple health care professionals.

A. Alert and have some degree of independence. 11. Well formulated, client-centered goals should:
B. Ambulatory and mobile.
C. Able to speak and write. A. Meet immediate client needs.
D. Able to read and write. B. Include preventative health care.
C. Include rehabilitation needs.
6. The nurse writes an expected outcome statement D. All of the above.
in measurable terms. An example is:
12. The following statement appears on the nursing
A. Client will have less pain. care plan for an immunosuppressed client: The
B. Client will be pain free. client will remain free from infection throughout
C. Client will report pain acuity less than 4 on a hospitalization. This statement is an example of a
scale of 0-10. (an):
D. Client will take pain medication every 4 hours
around the clock. A. Nursing diagnosis
B. Short-term goal
7. As goals, outcomes, and interventions are C. Long-term goal
developed, the nurse must: D. Expected outcome

A. Be in charge of all care and planning for the 13. The following statements appear on a nursing
client. care plan for a client after a mastectomy: Incision
B. Be aware of and committed to accepted site approximated; absence of drainage or prolonged
standards of practice from nursing and other erythema at incision site; and client remains
disciples. afebrile. These statements are examples of:
C. Not change the plan of care for the client.
D. Be in control of all interventions for the client. A. Nursing interventions
B. Short-term goals
8. When establishing realistic goals, the nurse: C. Long-term goals
D. Expected outcomes.
A. Bases the goals on the nurse’s personal
knowledge. 14. The planning step of the nursing process
B. Knows the resources of the health care facility, includes which of the following activities?
family, and the client.
C. Must have a client who is physically and A. Assessing and diagnosing
emotionally stable. B. Evaluating goal achievement.
D. Must have the client’s cooperation. C. Performing nursing actions and documenting
them.
 D. Setting goals and selecting interventions.
15. The nursing care plan is:
A. A written guideline for implementation and
evaluation.
B. A documentation of client care.
C. A projection of potential alterations in client
behaviors
D. A tool to set goals and project outcomes.
16. After determining a nursing diagnosis of acute
pain, the nurse develops the following appropriate
client-centered goal:
A. Encourage client to implement guided imagery
when pain begins.
B. Determine effect of pain intensity on client
function.
C. Administer analgesic 30 minutes before physical
therapy treatment.
D. Pain intensity reported as a 3 or less during
hospital stay.
17. When developing a nursing care plan for a client
with a fractured right tibia, the nurse includes in the
plan of care independent nursing interventions,
including:
A. Apply a cold pack to the tibia.
B. Elevate the leg 5 inches above the heart.
C. Perform range of motion to right leg every 4
hours.
D. Administer aspirin 325 mg every 4 hours as
needed.
18. Which of the following nursing interventions
are written correctly? (Select all that apply.)
A. Apply continuous passive motion machine
during day.
B. Perform neurovascular checks.
C. Elevate head of bed 30 degrees before meals.
D. Change dressing once a shift.
19. A client’s wound is not healing and appears to
be worsening with the current treatment. The nurse
first considers:
A. Notifying the physician.
B. Calling the wound care nurse
C. Changing the wound care treatment.
D. Consulting with another nurse.
20. When calling the nurse consultant about a
difficult client-centered problem, the primary nurse
is sure to report the following:
A. Length of time the current treatment has been
in place.
B. The spouse’s reaction to the client’s dressing
change.
C. Client’s concern about the current treatment.
D. Physician’s reluctance to change the current
treatment plan.
21. The primary nurse asked a clinical nurse
specialist (CNS) to consult on a difficult nursing
problem. The primary nurse is obligated to:
A. Implement the specialist’s recommendations.
B. Report the recommendations to the primary
physician.
C. Clarify the suggestions with the client and
family members.
D. Discuss and review advised strategies with CNS.
22. After assessing the client, the nurse formulates
the following diagnoses. Place them in order of
priority, with the most important (classified as high)
listed first.
A. Constipation
B. Anticipated grieving
C. Ineffective airway clearance
D. Ineffective tissue perfusion.
23. The nurse is reviewing the critical paths of the
clients on the nursing unit. In performing a variance
analysis, which of the following would indicate the
need for further action and analysis?
A. A client’s family attending a diabetic teaching
session.
B. Canceling physical therapy sessions on the
weekend.
C. Normal VS and absence of wound infection in a
post-op client.
D. A client demonstrating accurate medication
administration following teaching.
 24. The RN has received her client assignment for
the day-shift. After making the initial rounds and
assessing the clients, which client would the RN nurse is knowledgeable in wound management,
need to develop a care plan first? this could delay wound healing. Also, the
current wound management plan could have
A. A client who is ambulatory. been ordered by the physician. d. Another
B. A client, who has a fever, is diaphoretic and nurse most likely will not be knowledgeable
restless. about wounds, and the primary nurse would
C. A client scheduled for OT at 1300. know the history of the wound management
D. A client who just had an appendectomy and has plan.)
just received pain medication. 20. A. This gives the consulting nurse facts that will
influence a new plan.
25. She is the first one to coin the term “NURSING (b, c, and d. These are all subjective and
PROCESS” She introduced 3 steps of nursing emotional issues/conclusions about the current
process which are Observation, Ministration and treatment plan and may cause a bias in the
Validation. decision of a new treatment plan by the nurse
consultant.)
A. Nightingale 21. D. Because the primary nurse requested the
B. Johnson consultation, it is important that they
C. Rogers communicate and discuss recommendations.
D. Hall The primary nurse can then accept or reject the
CNS recommendations. (a. Some of the
  recommendations may not be appropriate for
this client. The primary nurse would know this
Answers and Rationales information. A consultation requires review of
the recommendations, but not immediate
implementation. b. This would be appropriate
1. A
after first talking with the CNS about
2. C
recommended changes in the plan of care and
3. D
the rationale. Then the primary nurse should
4. B
call the physician. c. The client and family do
5. A
not have the knowledge to determine whether
6. C
new strategies are appropriate or not. Better to
7. B
wait until the new plan of care is agreed upon
8. B
by the primary nurse and physician before
9. A
talking with the client and/or family.)
10. D
22. C, D, A, B.
11. D
23. B. 
12. B
24. B. This clients needs are a priority.
13. D
25. D.
14. D
15. A
1. Which intervention is an example of primary
16. D. This is measurable and objective. 
17. B. This does not require a physician’s order. (A
prevention?
& D require an order; C is not appropriate for a
fractured tibia) A. Administering digoxin (Lanoxicaps) to a patient
18. C. It is specific in what to do and when. with heart failure
19. B. Calling in the wound care nurse as a B. Administering a measles, mumps, and rubella
consultant is appropriate because he or she is a immunization to an infant
specialist in the area of wound management. C. Obtaining a Papanicolaou smear to screen for
Professional and competent nurses recognize cervical cancer
limitations and seek appropriate consultation. D. Using occupational therapy to help a patient
(a. This might be appropriate after deciding on a cope with arthritis
plan of action with the wound care nurse
specialist. The nurse may need to obtain orders
for special wound care products. c. Unless the
2. The nurse in charge is assessing a patient’s A. Impaired gas exchanges related to increased
abdomen. Which examination technique should the blood flow
nurse use first? B. Fluid volume excess related to peripheral
vascular disease
A. Auscultation C. Risk for injury related to edema
B. Inspection D. Altered peripheral tissue perfusion related to
C. Percussion venous congestion
D. Palpation
8. When positioned properly, the tip of a central
3. Which statement regarding heart sounds is venous catheter should lie in the:
correct?
A. Superior vena cava
A. S1 and S2 sound equally loud over the entire B. Basilica vein
cardiac area. C. Jugular vein
B. S1 and S2 sound fainter at the apex D. Subclavian vein
C. S1 and S2 sound fainter at the base
D. S1 is loudest at the apex, and S2 is loudest at 9. Nurse Margareth is revising a client’s care plan.
the base During which step of the nursing process does such
revision take place?
4. The nurse in charge identifies a patient’s
responses to actual or potential health problems A. Assessment
during which step of the nursing process? B. Planning
C. Implementation
A. Assessment D. Evaluation
B. Nursing diagnosis
C. Planning 10. A 65-year-old female who has diabetes mellitus
D. Evaluation and has sustained a large laceration on her left wrist
asks the nurse, “How long will it take for my scars
5. A female patient is receiving furosemide (Lasix), to disappear?” which statement would be the
40 mg P.O. b.i.d. in the plan of care, the nurse nurse’s best response?
should emphasize teaching the patient about the
importance of consuming: A. “The contraction phase of wound healing can
take 2 to 3 years.”
A. Fresh, green vegetables B. “Wound healing is very individual but within 4
B. Bananas and oranges months the scar should fade.”
C. Lean red meat C. “With your history and the type of location of
D. Creamed corn the injury, it’s hard to say.”
D. “If you don’t develop an infection, the wound
6. The nurse in charge must monitor a patient should heal any time between 1 and 3 years
receiving chloramphenicol for adverse drug from now.”
reaction. What is the most toxic reaction to
chloramphenicol? 11. One aspect of implementation related to drug
therapy is:
A. Lethal arrhythmias
B. Malignant hypertension A. Developing a content outline
C. Status epilepticus B. Documenting drugs given
D. Bone marrow suppression C. Establishing outcome criteria
D. Setting realistic client goals
7. A female patient is diagnosed with deep-vein
thrombosis. Which nursing diagnosis should receive 12. A female client is readmitted to the facility with
highest priority at this time? a warm, tender, reddened area on her right calf.
Which contributing factor would the nurse A. Encourage the client to ask questions about
recognize as most important? personal sexuality
B. Provide time for privacy
A. A history of increased aspirin use C. Provide support for the spouse or significant
B. Recent pelvic surgery other
C. An active daily walking program D. Suggest referral to a sex counselor or other
D. A history of diabetes appropriate professional

13. Which intervention should the nurse in charge 17. Using Abraham Maslow’s hierarchy of human
try first for a client that exhibits signs of sleep needs, a nurse assigns highest priority to which
disturbance? client need?

A. Administer sleeping medication before bedtime A. Security

B. Ask the client each morning to describe the B. Elimination
quantity of sleep during the previous night C. Safety
C. Teach the client relaxation techniques, such as D. Belonging
guided imagery, medication, and progressive
muscle relaxation 18. A male client is on prolonged bed rest has
D. Provide the client with normal sleep aids, such developed a pressure ulcer. The wound shows no
as pillows, back rubs, and snacks signs of healing even though the client has received
skin care and has been turned every 2 hours. Which
14. While examining a client’s leg, the nurse notes factor is most likely responsible for the failure to
an open ulceration with visible granulation tissue in heal?
the wound. Until a wound specialist can be
contacted, which type of dressings is most A. Inadequate vitamin D intake
appropriate for the nurse in charge to apply? B. Inadequate protein intake
C. Inadequate massaging of the affected area
A. Dry sterile dressing D. Low calcium level
B. Sterile petroleum gauze
C. Moist, sterile saline gauze 19. A female client who received general anesthesia
D. Povidone-iodine-soaked gauze returns from surgery. Postoperatively, which
nursing diagnosis takes highest priority for this
15. A male client in a behavioral-health facility client?
receives a 30-minute psychotherapy session, and
provider uses a current procedure terminology A. Acute pain related to surgery
(CPT) code that bills for a 50-minute session. Under B. Deficient fluid volume related to blood and fluid
the False Claims Act, such illegal behavior is loss from surgery
known as: C. Impaired physical mobility related to surgery
D. Risk for aspiration related to anesthesia
A. Unbundling
B. Overbilling 20. Nurse Cay inspects a client’s back and notices
C. Upcoding small hemorrhagic spots. The nurse documents that
D. Misrepresentation the client has:

16. A nurse assigned to care for a postoperative A. Extravasation

male client who has diabetes mellitus. During the B. Osteomalacia
assessment interview, the client reports that he’s C. Petechiae
impotent and says that he’s concerned about its D. Uremia
effect on his marriage. In planning this client’s care,
the most appropriate intervention would be to: 21. Which document addresses the client’s right to
information, informed consent, and treatment
refusal?
 A. Standard of Nursing Practice D. Prevent injury
B. Patient’s Bill of Rights
C. Nurse Practice Act 27. Following a tonsillectomy, a female client
D. Code for Nurses returns to the medical-surgical unit. The client is
lethargic and reports having a sore throat. Which
22. If a blood pressure cuff is too small for a client, position would be most therapeutic for this client?
blood pressure readings taken with such a cuff may
do which of the following? A. Semi-Fowler’s
B. Supine
A. Fail to show changes in blood pressure C. High-Fowler’s
B. Produce a false-high measurement D. Side-lying
C. Cause sciatic nerve damage
D. Produce a false-low measurement 28. Nurse Berri inspects a client’s pupil size and
determines that it’s 2 mm in the left eye and 3 mm
23. Nurse Danny has been teaching a client about a in the right eye. Unequal pupils are known as:
high-protein diet. The teaching is successful if the
client identifies which meal as high in protein? A. Anisocoria
B. Ataxia
A. Baked beans, hamburger, and milk C. Cataract
B. Spaghetti with cream sauce, broccoli, and tea D. Diplopia
C. Bouillon, spinach, and soda
D. Chicken cutlet, spinach, and soda 29. The nurse in charge is caring for an Italian
client. He’s complaining of pain, but he falls asleep
24. A male client is admitted to the hospital with right after his complaint and before the nurse can
blunt chest trauma after a motor vehicle accident. assess his pain. The nurse concludes that:
The first nursing priority for this client would be to:
A. He may have a low threshold for pain
A. Assess the client’s airway B. He was faking pain
B. Provide pain relief C. Someone else gave him medication
C. Encourage deep breathing and coughing D. The pain went away
D. Splint the chest wall with a pillow
30. A female client is admitted to the emergency
25. A newly hired charge nurse assesses the staff department with complaints of chest pain shortness
nurses as competent individually but ineffective and of breath. The nurse’s assessment reveals jugular
nonproductive as a team. In addressing her concern, vein
the charge nurse should understand that the usual distention. The nurse knows that when a client has
reason for such a situation is: jugular vein distension, it’s typically due to:

A. Unhappiness about the charge in leadership A. A neck tumor

B. Unexpected feeling and emotions among the
staff
C. Fatigue from overwork and understaffing
D. Failure to incorporate staff in decision making
Answers and Rationales
26. A male client blood test results are as follows:
white blood cell (WBC) count, 100ul; hemoglobin
(Hb) level, 14 g/dl; hematocrit (HCT), 40%. Which
goal would be most important for this client?
A. Promote fluid balance
B. Prevent infection
C. Promote rest
B. An electrolyte imbalance
C. Dehydration
D. Fluid overload
1. Answer B. Immunizing an infant is an example
of primary prevention, which aims to prevent
health problems. Administering digoxin to treat
heart failure and obtaining a smear for a
screening test are examples for secondary
prevention, which promotes early detection and
treatment of disease. Using occupational
 therapy to help a patient cope with arthritis is
an example of tertiary prevention, which aims
to help a patient deal with the residual
consequences of a problem or to prevent the
problem from recurring.
2. Answer B. Inspection always comes first when
performing a physical examination. Percussion
and palpation of the abdomen may affect bowel
motility and therefore should follow
auscultation.
3. Answer D. The S1 sound—the “lub” sound—is
loudest at the apex of the heart. It sounds
longer, lower, and louder there than the S2
sounds. The S2—the “dub” sound—is loudest at
the base. It sounds shorter, sharper, higher, and
louder there than S1.
4. Answer B. The nurse identifies human
responses to actual or potential health
problems during the nursing diagnosis step of
the nursing process. During the assessment
step, the nurse systematically collects data
about the patient or family. During the planning
step, the nurse develops strategies to resolve or
decrease the patient’s problem. During the
evaluation step, the nurse determines the
effectiveness of the plan of care.
5. Answer B. Because furosemide is a potassium-
wasting diuretic, the nurse should plan to teach
the patient to increase intake of potassium-rich
foods, such as bananas and oranges. Fresh,
green vegetables; lean red meat; and creamed
corn are not good sources of potassium.
6. Answer D. The most toxic reaction to
chloramphenicol is bone marrow suppression.
Chloramphenicol is not known to cause lethal
arrhythmias, malignant hypertension, or status
epilepticus.
7. Answer D. Altered peripheral tissue perfusion
related to venous congestion” takes highest
priority because venous inflammation and clot
formation impede blood flow in a patient with
deep-vein thrombosis. Option A is incorrect
because impaired gas exchange is related to
decreased, not increased, blood flow. Option B
is inappropriate because no evidence suggest
that this patient has a fluid volume excess.
Option C may be warranted but is secondary to
altered tissue perfusion.
8. Answer A. When the central venous catheter is
positioned correctly, its tip lies in the superior
vena cava, inferior vena cava, or the right
atrium—that is, in central venous circulation.
Blood flows unimpeded around the tip, allowing
the rapid infusion of large amounts of fluid
directly into circulation. The basilica, jugular,
and subclavian veins are common insertion sites
for central venous catheters.
9. Answer D. During the evaluation step of the
nursing process the nurse determines whether
the goals established in the care plan have been
achieved, and evaluates the success of the plan.
If a goal is unmet or partially met the nurse
reexamines the data and revises the plan.
Assessment involves data collection. Planning
involves setting priorities, establishing goals,
and selecting appropriate interventions.
10. Answer C. Wound healing in a client with
diabetes will be delayed. Providing the client
with a time frame could give the client false
information.
11. Answer B. Although documentation isn’t a step
in the nursing process, the nurse is legally
required to document activities related to drug
therapy, including the time of administration,
the quantity, and the client’s reaction.
Developing a content outline, establishing
outcome criteria, and setting realistic client
goals are part of planning rather than
implementation.
12. Answer B. The client shows signs of deep vein
thrombosis (DVT). The pelvic area is rich in
blood supply, and thrombophlebitis of the deep
vein is associated with pelvic surgery. Aspirin,
an antiplatelet agent, and an active walking
program help decrease the client’s risk of DVT.
In general, diabetes is a contributing factor
associated with peripheral vascular disease.
13. Answer D. The nurse should begin with the
simplest interventions, such as pillows or
snacks, before interventions that require
greater skill such as relaxation techniques. Sleep
medication should be avoided whenever
possible. At some point, the nurse should do a
thorough sleep assessment, especially if
common sense interventions fail.
14. Answer C. Moist, sterile saline dressings
support would heal and are cost-effective. Dry
sterile dressings adhere to the wound and
debride the tissue when removed. Petroleum
supports healing but is expensive. Povidone-
iodine can irritate epithelial cells, so it shouldn’t
be left on an open wound.
15. Answer C. Upcoding is the practice of using a
CPT code that’s reimbursed at a higher rate
than the code for the service actually provided.
 Unbundling, overbilling, and misrepresentation
aren’t the terms used for this illegal practice.
16. Answer D. The nurse should refer this client to
a sex counselor or other professional. Making
appropriate referrals is a valid part of planning
the client’s care. The nurse doesn’t normally
provide sex counseling. Therefore, providing
time for privacy and providing support for the
spouse or significant other are important, but
not as important as referring the client to a sex
counselor.
17. Answer B. According to Maslow, elimination is a
first-level or physiological need, and therefore
takes priority over all other needs. Security and
safety are second-level needs; belonging is a
third-level need. Second- and third-level needs
can be met only after a client’s first-level needs
have been satisfied.
18. Answer B. A client on bed rest suffers from a
lack of movement and a negative nitrogen
balance. Therefore, inadequate protein intake
impairs wound healing. Inadequate vitamin D
intake and low calcium levels aren’t factors in
poor healing for this client. A pressure ulcer
should never be massaged.
19. Answer D. Risk for aspiration related to
anesthesia takes priority for thins client because
general anesthesia may impair the gag and
swallowing reflexes, possibly leading to
aspiration. The other options, although
important, are secondary.
20. Answer C. Petechiae are small hemorrhagic
spots. Extravasation is the leakage of fluid in the
interstitial space. Osteomalacia is the softening
of bone tissue. Uremia is an excess of urea and
other nitrogen products in the blood.
21. Answer B. The Patient’s Bill of Rights addresses
the client’s right to information, informed
consent, timely responses to requests for
services, and treatment refusal. A legal
document, it serves as a guideline for the
nurse’s decision making. Standards of Nursing
Practice, the Nurse Practice Act, and the Code
for Nurses contain nursing practice parameters
and primarily describe the use of the nursing
process in providing care.
22. Answer B. Using an undersized blood pressure
cuff produces a falsely elevated blood pressure
because the cuff can’t record brachial artery
measurements unless it’s excessively inflated.
The sciatic nerve wouldn’t be damaged by
hyperinflation of the blood pressure cuff
because the sciatic nerve is located in the lower
extremity.
23. Answer A. Baked beans, hamburger, and milk
are all excellent sources of protein. The
spaghetti-broccoli-tea choice is high in
carbohydrates. The bouillon-spinach-soda
choice provides liquid and sodium as well as
some iron, vitamins, and carbohydrates.
Chicken provides protein but the chicken-
spinach-soda combination provides less protein
than the baked beans-hamburger-milk
selection.
24. Answer A. The first priority is to evaluate airway
patency before assessing for signs of
obstruction, sternal retraction, stridor, or
wheezing. Airway management is always the
nurse’s first priority. Pain management and
splinting are important for the client’s comfort,
but would come after airway assessment.
Coughing and deep breathing may be
contraindicated if the client has internal
bleeding and other injuries.
25. Answer B. The usual or most prevalent reason
for lack of productivity in a group of competent
nurses is inadequate communication or a
situation in which the nurses have unexpected
feeling and emotions. Although the other
options could be contributing to the
problematic situation, they’re less likely to be
the cause.
26. Answer B. The client is at risk for infection
because WBC count is dangerously low. Hb level
and HCT are within normal limits; therefore,
fluid balance, rest, and prevention of injury are
inappropriate.
27. Answer D. Because of lethargy, the post
tonsillectomy client is at risk for aspirating
blood from the surgical wound. Therefore,
placing the client in the side-lying position until
he awake is best. The semi-Fowler’s, supine,
and high-Fowler’s position don’t allow for
adequate oral drainage in a lethargic post
tonsillectomy client, and increase the risk of
blood aspiration.
28. Answer A. Unequal pupils are called anisocoria.
Ataxia is uncoordinated actions of involuntary
muscle use. A cataract is an opacity of the eye’s
lens. Diplopia is double vision.
29. Answer A. People of Italian heritage tend to
verbalize discomfort and pain. The pain was real
to the client, and he may need medication
when he wakes up.
 30. Answer D. Fluid overload causes the volume of
blood within the vascular system to increase.
This increase causes the vein to distend, which
can be seen most obviously in the neck veins. A
neck tumor doesn’t typically cause jugular vein
distention. An electrolyte imbalance may result
in fluid overload, but it doesn’t directly
contribute to jugular vein distention.
1. The most important nursing intervention to
correct skin dryness is:
A. Avoid bathing the patient until the condition is
remedied, and notify the physician
B. Ask the physician to refer the patient to a
dermatologist, and suggest that the patient
wear home-laundered sleepwear
C. Consult the dietitian about increasing the
patient’s fat intake, and take necessary
measures to prevent infection
D. Encourage the patient to increase his fluid
intake, use nonirritating soap when bathing the
patient, and apply lotion to the involved areas
2. When bathing a patient’s extremities, the nurse
should use long, firm strokes from the distal to the
proximal areas. This technique:
A. Provides an opportunity for skin assessment
B. Avoids undue strain on the nurse
C. Increases venous blood return
D. Causes vasoconstriction and increases
circulation
3. Vivid dreaming occurs in which stage of sleep?
A. Stage I non-REM
B. Rapid eye movement (REM) stage
C. Stage II non-REM
D. Delta stage
4. The natural sedative in meat and milk products
(especially warm milk) that can help induce sleep
is:
A. Flurazepam
B. Temazepam
C. Tryptophan
D. Methotrimeprazine
5. Nursing interventions that can help the patient to
relax and sleep restfully include all of the following
except:
A. Have the patient take a 30- to 60-minute nap in
the afternoon
B. Turn on the television in the patient’s room
C. Provide quiet music and interesting reading
material
D. Massage the patient’s back with long strokes
6. Restraints can be used for all of the following
purposes except to:
A. Prevent a confused patient from removing
tubes, such as feeding tubes, I.V. lines, and
urinary catheters
B. Prevent a patient from falling out of bed or a
chair
C. Discourage a patient from attempting to
ambulate alone when he requires assistance for
his safety
D. Prevent a patient from becoming confused or
disoriented
7. Which of the following is the nurse’s legal
responsibility when applying restraints?
A. Document the patient’s behavior
B. Document the type of restraint used
C. Obtain a written order from the physician
except in an emergency, when the patient must
be protected from injury to himself or others
D. All of the above
8. Kubler-Ross’s five successive stages of death and
dying are:
A. Anger, bargaining, denial, depression,
acceptance
B. Denial, anger, depression, bargaining,
acceptance
C. Denial, anger, bargaining, depression
acceptance
D. Bargaining, denial, anger, depression,
acceptance
9. A terminally ill patient usually experiences all of
the following feelings during the anger stage
except:
A. Rage
 B. Envy
C. Numbness
D. Resentment
10. Nurses and other health care provides often
have difficulty helping a terminally ill patient
through the necessary stages leading to acceptance
of death. Which of the following strategies is most
helpful to the nurse in achieving this goal?
A. Taking psychology courses related to
gerontology
B. Reading books and other literature on the
subject of thanatology
C. Reflecting on the significance of death
D. Reviewing varying cultural beliefs and practices
related to death
11. Which of the following symptoms is the best
indicator of imminent death?
A. A weak, slow pulse
B. Increased muscle tone
C. Fixed, dilated pupils
D. Slow, shallow respirations
12. A nurse caring for a patient with an infectious
disease who requires isolation should refers to
guidelines published by the:
A. National League for Nursing (NLN)
B. Centers for Disease Control (CDC)
C. American Medical Association (AMA)
D. American Nurses Association (ANA)
13. To institute appropriate isolation precautions,
the nurse must first know the:
A. Organism’s mode of transmission
B. Organism’s Gram-staining characteristics
C. Organism’s susceptibility to antibiotics
D. Patient’s susceptibility to the organism
14. Which is the correct procedure for collecting a
sputum specimen for culture and sensitivity testing?
A. Have the patient place the specimen in a
container and enclose the container in a plastic
bag
B. Have the patient expectorate the sputum while
the nurse holds the container
C. Have the patient expectorate the sputum into a
sterile container
D. Offer the patient an antiseptic mouthwash just
before he expectorate the sputum
15. An autoclave is used to sterilize hospital
supplies because:
A. More articles can be sterilized at a time
B. Steam causes less damage to the materials
C. A lower temperature can be obtained
D. Pressurized steam penetrates the supplies
better
16. The best way to decrease the risk of transferring
pathogens to a patient when removing contaminated
gloves is to:
A. Wash the gloves before removing them
B. Gently pull on the fingers of the gloves when
removing them
C. Gently pull just below the cuff and invert the
gloves when removing them
D. Remove the gloves and then turn them inside
out
17. After having an I.V. line in place for 72 hours, a
patient complains of tenderness, burning, and
swelling. Assessment of the I.V. site reveals that it
is warm and erythematons. This usually indicates:
A. Infection
B. Infiltration
C. Phlebitis
D. Bleeding
18. To ensure homogenization when diluting
powdered medication in a vial, the nurse should:
A. Shake the vial vigorously
B. Roll the vial gently between the palms
C. Invert the vial and let it stand for 1 minute
D. Do nothing after adding the solution to the vial
19. The nurse is teaching a patient to prepare a
syringe with 40 units of U-100 NPH insulin for self-
injection. The patient’s first priority concerning
self-injection in this situation is to:
A. Assess the injection site
B. Select the appropriate injection site
 C. Check the syringe to verify that the nurse has 25. A staff nurse who is promoted to assistant nurse
removed the prescribed insulin dose manager may feel uncomfortable initially when
D. Clean the injection site in a circular manner with supervising her former peers. She can best decrease
and alcohol sponge this discomfort by:

20. The physician’s order reads “Administer 1 g A. Writing down all assignments
cefazolin sodium (Ancef) in 150 ml of normal B. Making changes after evaluating the situation
saline solution in 60 minutes.” What is the flow rate and having discussions with the staff.
if the drop factor is 10 gtt = 1 ml? C. Telling the staff nurses that she is making
changes to benefit their performance
A. 25 gtt/minute D. Evaluating the clinical performance of each staff
B. 37 gtt/minute nurse in a private conference
C. 50 gtt/minute
D. 60 gtt/minute Answers and Rationales

21. A patient must receive 50 units of Humulin 1. Answer – D. Dry skin will eventually crack,
regular insulin. The label reads 100 units = 1 ml. ranking the patient more prone to infection. To
How many milliliters should the nurse administer? prevent this, the nurse should provide adequate
hydration through fluid intake, use nonirritating
A. 0.5 ml soaps or no soap when bathing the patient, and
B. 0.75 ml lubricate the patient’s skin with lotion. Bathing
C. 1 ml may be limited but need not be avoided
D. 2 ml entirely. The attending physician and dietitian
may be consulted for treatment, but home-
22. How should the nurse prepare an injection for a laundered items usually are not necessary.
patient who takes both regular and NPH insulin? 2. Answer – C. Washing from distal to proximal
areas stimulates venous blood flow, thereby
A. Draw up the NPH insulin, then the regular preventing venous stasis. It improves circulation
insulin, in the same syringe but does not result in vasoconstriction. The
B. Draw up the regular insulin, then the NPH nurse can assess the patient’s condition
insulin, in the same syringe throughout the bath, regardless of washing
C. Use two separate syringe technique, and should feel no strain while
D. Check with the physician bathing the patient.
3. Answer – B. Other characteristics of rapid eye
23. A patient has just received 30 mg of codeine by movement (REM) sleep are deep sleep (the
mouth for pain. Five minutes later he vomits. What patient cannot be awakened easily), depressed
should the nurse do first? muscle tone, and possibly irregular heart and
respiratory rates. Non-REM sleep is a deep,
A. Call the physician restful sleep without dreaming. Delta stage, or
B. Remedicate the patient slow-wave sleep, occurs during non-REM Stages
C. Observe the emesis III and IV and is often equated with quiet sleep.
D. Explain to the patient that she can do nothing 4. Answer – C. Tryptophan is a natural sedative;
to help him flurazepam (Dalmane), temazepam (Restoril),
and methotrimeprazine (Levoprome) are
24. A patient is characterized with a #16 indwelling hypnotic sedatives.
5. Answer – A. Napping in the afternoon is not
urinary (Foley) catheter to determine if:
conductive to nighttime sleeping. Quiet music,
watching television, reading, and massage
A. Trauma has occurred
usually will relax the patient, helping him to fall
B. His 24-hour output is adequate
asleep.
C. He has a urinary tract infection
6. Answer – D. By restricting a patient’s
D. Residual urine remains in the bladder after
movements, restraints may increase stress and
voiding
lead to confusion, rather than prevent it. The
 other choices are valid reasons for using
restraints.
7. Answer – D. When applying restraints, the
nurse must document the type of behavior that
prompted her to use them, document the type
of restraints used, and obtain a physician’s
written order for the restraints.
8. Answer – C. Kubler-Ross’s five successive stages
of death and dying are denial, anger,
bargaining, depression, and acceptance. The
patient may move back and forth through the
different stages as he and his family members
react to the process of dying, but he usually
goes through all of these stages to reach
acceptance.
9. Answer – C. Numbness is typical of the
depression stage, when the patient feels a great
sense of loss. The anger stage includes such
feelings as rage, envy, resentment, and the
patient’s questioning “Why me?”
10. Answer – C. According to thanatologists,
reflecting on the significance of death helps to
reduce the fear of death and enables the health
care provider to better understand the
terminally ill patient’s feelings. It also helps to
overcome the belief that medical and nursing
measures have failed, when a patient cannot be
cured.
11. Answer – C. Fixed, dilated pupils are sign of
imminent death. Pulse becomes weak but rapid,
muscles become weak and atonic, and periods
of apnea occur during respiration.
12. Answer – B. The Center of Disease Control
(CDC) publishes and frequently updates
guidelines on caring for patients who require
isolation. The National League of Nursing’s
(NLN’s) major function is accrediting nursing
education programs in the
United States. The American Medical
Association (AMA) is a national organization of
physicians. The American Nurses’ Association
(ANA) is a national organization of registered
nurses.
13. Answer – A. Before instituting isolation
precaution, the nurse must first determine the
organism’s mode of transmission. For example,
an organism transmitted through nasal
secretions requires that the patient be kept in
respiratory isolation, which involves keeping the
patient in a private room with the door closed
and wearing a mask, a grown, and gloves when
coming in direct contact with the patient. The
organism’s Gram-straining characteristics reveal
whether the organism is gram-negative or
gram-positive, an important criterion in the
physician’s choice for drug therapy and the
nurse’s development of an effective plan of
care. The nurse also needs to know whether the
organism is susceptible to antibiotics, but this
could take several days to determine; if she
waits for the results before instituting isolation
precautions, the organism could be transmitted
in the meantime. The patient’s susceptibility to
the organism has already been established. The
nurse would not be instituting isolation
precautions for a noninfected patient.
14. Answer – C. Placing the specimen in a sterile
container ensures that it will not become
contaminated. The other answers are incorrect
because they do not mention sterility and
because antiseptic mouthwash could destroy
the organism to be cultured (before sputum
collection, the patient may use only tap water
for nursing the mouth).
15. Answer – D. An autoclave, an apparatus that
sterilizes equipment by means of high-
temperature pressured steam, is used because
it can destroy all forms of microorganisms,
including spores.
16. Answer – C. Turning the gloves inside out while
removing them keeps all contaminants inside
the gloves. They should than be placed in a
plastic bag with soiled dressings and discarded
in a soiled utility room garbage pail (double
bagged). The other choices can spread
pathogens within the environment.
17. Answer – C. Tenderness, warmth, swelling, and,
in some instances, a burning sensation are signs
and symptoms of phlebitis. Infection is less
likely because no drainage or fever is present.
Infiltration would result in swelling and pallor,
not erythema, near the insertion site. The
patient has no evidence of bleeding.
18. Answer – B. Gently rolling a sealed vial between
the palms produces sufficient heat to enhance
dissolution of a powdered medication. Shaking
the vial vigorously can break down the
medication and alter its pharmacologic action.
Inverting the vial or leaving it alone does not
ensure thorough homogenization of the powder
and the solvent.
19. Answer – C. When the nurse teaches the
patient to prepare an insulin injection, the
patient’s first priority is to validate the dose
accuracy. The next steps are to select the site,
 assess the site, and clean the site with alcohol
before injecting the insulin.
20. Answer – A. 25 gtt/minute
21. Answer – A. 0.5 ml
22. Answer – B. Drugs that are compatible may be
mixed together in one syringe. In the case of
insulin, the shorter-acting, clear insulin (regular)
should be drawn up before the longer-acting,
cloudy insulin (NPH) to ensure accurate
measurements.
23. Answer – C. After a patient has vomited, the
nurse must inspect the emesis to document
color, consistency, and amount. In this
situation, the patient recently ingested
medication, so the nurse needs to check for
remnants of the medication to help determine
whether the patient retained enough of it to be
effective. The nurse must then notify the
physician, who will decide whether to repeat
the dose or prescribe an antiemetic.
24. Answer – B. A 24-hour urine output of less than
500 ml in an adult is considered inadequate and
may indicate kidney failure. This must be
corrected while the patient is in the acute state
so that appropriate fluids, electrolytes, and
medications can be administered and excreted.
Indwelling catheterization is not needed to
diagnose trauma, urinary tract infection, or
residual urine.
25. Answer – B. A new assistant nurse manger
should not make changes until she has had a
chance to evaluate staff members, patients, and
physicians. Changes must be planned
thoroughly and should be based on a need to
improve conditions, not just for the sake of
change. Written assignments allow all staff
members to know their own and others
responsibilities and serve as a checklist for the
manager, enabling her to gauge whether the
unit is being run effectively and whether
patients are receiving appropriate care. Telling
the staff nurses that she is making changes to
benefit their performance should occur only
after the nurse has made a thorough
evaluation. Evaluations are usually done on a
yearly basis or as needed.