Ateneo de Zamboanga University

College of Nursing
NURCO 1
Fundamentals of Nursing Examination
Be Honest
Even If Others Are Not
Even If Others Will Not
Even if Others Can Not

1. What question would be most important to ask a male client who is in for a digital rectal examination?
a. “Have you noticed a change in the force of the urinary system?”
b. “Have you noticed a change in tolerance of certain foods in your diet?”
c. “Do you notice polyuria in the AM?”
d. “Do you notice any burning with urination or any odor to the urine?”
Rationale: This change would be most indicative of a potential complication with (BPH) benign prostate
hypertrophy. The goals of the evaluation of such men are to identify the patient’s voiding or, more
appropriately, urinary tract problems, both symptomatic and physiologic; to establish the etiologic role of
BPH in these problems.

2. Nurse Shaina assesses a prolonged late deceleration of the fetal heart rate while the client is receiving
oxytocin (Pitocin) IV to stimulate labor. The priority nursing intervention would be to:

a. Turn off the infusion.

b. Turn the client to the left.
c. Change the fluid to Ringer’s Lactate.
d. Increase mainline IV rate.
Answer:
Rationale: Stopping the infusion will decrease contractions and possibly remove uterine pressure on the
fetus, which is a possible cause of the deceleration. When late decelerations are observed, the nurse should
attempt to increase the oxygen delivery to the fetus by turning the mother on her left side and/or
administering oxygen. If Oxytocin (Pitocin) is being administered, it should be stopped.

3. A 64-year-old client scheduled for surgery with a general anesthetic refuse to remove a set of dentures
prior to leaving the unit for the operating room. What would be the most appropriate intervention by Nurse
Amandoron?
a. Explain to the client that the dentures must come out as they may get lost or broken in the operating
room.
b. Ask the client if there are second thoughts about having the procedure.
c. Notify the anesthesia department and the surgeon of the client’s refusal.
d. Ask the client if the preference would be to remove the dentures in the operating room receiving
area.
Answer: A
Rationale: Clients anticipating surgery may experience a variety of fears. This choice allows the client
control over the situation and fosters the client’s sense of self-esteem and self-concept. Nurses need to
allow patients the choice of what to do in relation to their dentures when going to the theater, although the
anesthetist must make the final decision of whether or not to remove them immediately before the
anesthetic if they feel patient safety could be compromised.

4. The family of a 6-year-old with a fractured femur asks the nurse if the child’s height will be affected by the
injury. Which statement is true concerning long bone fractures in children?
a. Growth problems will occur if the fracture involves the periosteum.
b. Epiphyseal fractures often interrupt a child’s normal growth pattern.
c. Children usually heal very quickly, so growth problems are rare.
d. Adequate blood supply to the bone prevents growth delay after fractures.
Answer:
Rationale: Epiphyseal fractures often interrupt a child’s normal growth pattern. Growth plate fractures are
classified based on which parts of the bone are damaged, in addition to the growth plate. Areas of the
bone immediately above and below the growth plate may fracture. They are called the epiphysis (the tip of
the bone) and metaphysis (the “neck” of the bone).

5. A client with diabetic neuropathy reports a burning, electrical type in the lower extremities that is not
responding to NSAIDs. You anticipate that the physician will order which adjuvant medication for this type of
pain?
a. Amitriptyline (Elavil)
b. Corticosteroids
c. Methylphenidate (Ritalin)
d. Lorazepam (Ativan)

Answer: A
Rationale: Antidepressants such as amitriptyline can be given for diabetic neuropathy. The American
Diabetes Association recommends amitriptyline, a tricyclic antidepressant, as the first choice; however,
titration to higher doses is limited by its anticholinergic adverse effects.

6. Nurse Amandoron was tasked to take the arterial blood gas of a 30-year- old patient who was
admitted due to an asthma attack. After extracting the specimen what nursing action is expected to
be done?
a. Allow for the puncture site to naturally heal and provide health teaching to
the patient
b. Apply pressure to the puncture site for 5-10 minutes after removing the
needle.
c. Monitor for infection on the site 10 minutes after the procedure
d. Instruct the patient to lightly tap on the site from time to time to numb the
pain.
Answer: B.
Rationale: Because of the relatively great pressure of the blood in these arteries, it is
important to prevent bleeding by applying pressure for 5-10 minutes.

7. A 45-year-old patient with Liver cirrhosis was due for an Abdominal Paracentesis. You have prepared
everything the doctor ordered and is assisting during the procedure. What should Nurse Biel watch out for
during this time?
a. Observe the client’s color, respiration, and pulse during the procedure.
b. Instruct the client to report headaches or persistent paint at the incision site.
c. Observe signs of hypovolemic shock.
d. Support the client verbally & describe the steps of the procedure
Answer: C
Rationale: An abdominal paracentesis is carried out to obtain a fluid specimen for laboratory study & to
relieve pressure on the abdominal organs due to the presence of excess fluid. Removal can cause
Hypovolemic shock induced by the loss of fluid which can result to pallor, dyspnea, diaphoresis, drop in BP
& restlessness or increased anxiety.

8. Nurse Go was assigned to provide Wellness care focusing on Safety measure throughout their lifespan
on a middle-aged client who is now retired. What should she include in her teaching plan?
a. “You should remove handles from unused equipment such as refrigerators or the pantry to avoid
access”
b. “After discharge its important for you to evaluate the potential workplace for death or hazards when
making career options
c. “You should just do whatever you want, as long as you make sure you have someone with you to
keep an eye on you”
d. “Since you have a two-story house, you should make sure your stairways are well lighted.”
Answer: D
Rationale: D is for Middle-aged adults typically between 45-65 years old. A is for Preschoolers

9. During a graveyard shift, Nurse Patega was instructed to assist a patient who was
significantly bigger compared to her petite size to the bathroom. In this situation what
should she do?
a. Contact the orderly to help her in moving the patient.
b. Contact the physician
c. Help the patient move from the bed using proper body mechanics.
d. Avoid going against gravity and lightly roll the patient to the side of the bed and hope
for the best
Answer: A.
Rationale: The heavier an object, the greater the force needed to move the object.
Guidelines: Obtain the assistance of other people or use mechanical devices to move objects that
are too heavy. Encourage clients to assist as much as possible by pushing or pulling themselves
to reduce your muscular effort. Use arms as levers whenever possible to increase lifting power.
10. Student nurse Sojor is reviewing a chapter regarding Diagnostic Testing and goes through
the phases of the procedure. Which is not part of the concept?

a. Providing nursing care of the client and follow-up activities and observations
are the role of the nurse during the post-test phase
b. Client preparation is the focus during the pretest phase
c. The nurse performs or assists with the diagnostic tests & collects the specimen
d. Administering medication during the intratestphase if the client request it.

Answer: D
Rationale: Unless it was ordered by the doctor do not administer any medication.
A,B & C are part of the Phases of Diagnostic Testing.

11. The difference in Mr. Hayes’ level of consciousness (LOC) may reflect:

a. early morning hunger.

b. beginning infection from the indwelling urinary catheter or arm wound.
c. an increase in intracranial pressure (ICP).
d. a normal variant in some individuals.
Answer: C
Rationale: A change in LOC is an early indicator of increased ICP. Hunger and early
infection don’t produce this sign. A subtle change in LOC is suspicious and may be the
only early sign of increased ICP in a patient with a head injury. Pupillary changes are a
later sign of increased ICP.

12. Your first action after seeing the change in Mr. Hayes is to:
a. Call the IV team to obtain a blood sample to send for a chemistry profile and complete
blood count, while you obtain a urine sample for urinalysis with culture and sensitivity.
b. Take his vital signs; measure his pupils; check the remainder of his
neurologic signs; and assist him into bed with the rails up.
c. Put up the bed rails, give him his call light, tell him to stay in bed, and then
leave to find his primary nurse or your instructor to ask for assistance.
d. Apply oxygen and then call the practitioner immediately and request a repeat
CT of the brain or magnetic resonance imaging of the brain because of a
probable subdural hematoma.
Answer: B
Rationale: Because Mr. Hayes isn’t in acute distress, your first action would be to assist
him to a safer position in case of further deterioration; then you would complete your
neurologic check and vital signs assessment so you can give objective, useful
information to the primary nurse or your instructor. Ordering laboratory work is out of
the scope of
practice of the nurse. Making the patient safe is only a portion of your responsibility when
a patient’s status changes; a focused assessment of the new findings must also be
completed unless the change is severe and beyond your skill level. There’s no indication
in the data given that the patient is in respiratory distress and may need immediate
oxygen therapy. Independently calling a practitioner for orders is outside the scope of
practice for a student.
13. Upon entering a room, a client and spouse are found crying. The nurse decides to sit with both of them,
offering presence and listening to their fears instead of providing the planned education. What action did the
nurse perform?
a. Implementing nursing intervention
b. Determining the nurses need for assistance
c. Supervising delegated care
d. Reassessing the client
Answer: D.
Rationale: Just before implementing an intervention, the nurse must reassess the client to make sure the
intervention is still needed or to discover if there are new data that indicate a need to change the priorities of
care. In this case, the client and the spouse are not in a good frame of mind to listen to or retain any kind of
teaching/learning experience. Instead, the nurse reassesses the situation and implements a more
appropriate intervention.

14. The nurse identifies for a client the nursing diagnosis Fluid volume deficit, related to active fluid loss,
secondary to diarrhea. What would be and appropriate goal statement for this diagnosis?
a. Client will drink more fluids by tomorrow.
b. Client will have good skin turgor.
c. Client will have moist mucous membranes.
d. Client will have an intake of at least 1000 mL within 24 hours.
Answer: D.
Rationale: The goal statement must be specific with observable outcomes in order for the nurse to evaluate
client progress, and all options must have a time frame for evaluating the desired performance. This option
includes all necessary components.
15. After an assessment, the nurse reviews the list of client problems. For which problems should the nurse
create nursing diagnoses?
a. The ones that the nurse is licensed to treat
b. The ones that address other health professionals interventions
c. The ones that focus on the clients primary illness
d. The ones that have standardized care available
Answer: A.
Rationale: The domain of nursing diagnoses includes only those health states that nurses are educated on
and licensed to treat. A nursing diagnosis is a judgment made only after data collection. Nursing diagnoses
describe a continuum of health states: deviations from health, presence of risk factors, and areas of
enhanced personal growth.

16.The nurse is preparing to care for a client who has returned to the nursing unit following cardiac
catheterization performed through the femoral vessel. The nurse checks the health care provider’s (HCP’s)
prescription and plans to allow which client position or activity following the procedure?
a. Bed rest in high Fowler’s position
b. Bed rest with bathroom privileges only
c. Bed rest with head elevation at 60 degrees
d. Bed rest with head elevation no greater than 30 degrees
Answer: D
Rationale: After cardiac catheterization, the extremity into which the catheter was inserted is kept straight for
4 to 6 hours (time for bed rest may vary depending on the HCP’s preference and on whether a vascular
closure device was used) and the client may turn from side to side. The head is elevated no more than 30
degrees (although some HCPs prefer a lower position or the flat position) until hemostasis is adequately
achieved.

17. The nurse is caring for a client with meningitis and implements which transmission-based precaution for
this client?
a. Private room or cohort client.
b. Personal respiratory protection device.
c. Private room with negative airflow pressure.
d. Mask worn by staff when the client needs to leave the room.
Answer: A
Rationale: Meningitis is transmitted by droplet infection. Precautions for the disease include a private room
or cohort client and use of a standard precaution mask. Private negative airflow pressure rooms and
personal respiratory protection devices are required for clients with airborne diseases such as tuberculosis.
When appropriate, a mask must be worn by the client and not the staff when the client leaves the room.

18. The nurse is reviewing a plan of care for a client with an internal radiation implant. Which intervention, if
noted in the plan, indicates the need for revision of the plan?
a. Wearing gloves when emptying the client’s bedpan.
b. Keeping all linens in the room until the implant is removed.
c. Wearing a lead apron when providing direct care to the client.
d. Placing the client in a semiprivate room at the end of the hallway.
Answer: D
Rationale: A private room with a private bath is essential if a client has an internal radiation implant. This is
necessary to prevent accidental exposure of other clients to radiation. The remaining options identify
accurate interventions for a client with an internal radiation implant and protect the nurse from exposure.

19. A mother calls a neighbor who is a nurse and tells the nurse that her 3- year-old child has just ingested
liquid furniture polish. The nurse would direct the mother to take which immediate action?
a. Induce vomiting.
b. Call an ambulance.
c. Call the Poison Control Center.
d. Bring the child to the emergency department.
Answer: C
Rationale: If a poisoning occurs, the Poison Control Center should be contacted immediately. Vomiting
should not be induced if the victim is unconscious or if the substance ingested is a strong corrosive or
petroleum product. Bringing the child to the emergency department or calling an ambulance would not be
the initial action because this would delay treatment. The Poison Control Center may advise the mother to
bring the child to the emergency department, if this is the case, the mother should call an ambulance.

20. The emergency department (ED) nurse receives a telephone call and is informed that a tornado has hit
a local residential area and that numerous casualties have occurred. The victims will be brought to the ED.
The nurse should take which initial action?
a. Prepare the triage rooms.
b. Activate the emergency response plans.
c. Obtain additional supplies from the central supply department.
d. Obtain additional nursing staff to assist in treating the casualties.
Answer: B
Rationale: In an external disaster (a disaster that occurs outside of the institution or agency), many victims
may be brought to the ED for treatment. The initial nursing action must be to activate the emergency
response plan. Once the emergency response plan is activated, the actions in the other options occur.

21. Nurse Shaina is facilitating a monthly mothers’ class at a small village. As a knowledgeable nurse, she
must know that a mother who breastfeeds her child passes on which antibody through breast milk?
a. IgA
b. IgE
c. IgG
d. IgM
Answer: A
Rationale: Antibodies, which are also called immunoglobulins, take five basic forms, indicated as IgG, IgA,
IgM, IgD and IgE. All have been detected in human milk, but by far the most abundant type is IgA,
particularly the form known as secretory IgA, which is found in great amounts throughout the gut and
respiratory system of adults. The secretory IgA molecules passed to the suckling child are helpful in ways
that go beyond their ability to bind to microorganisms and keep them away from the body’s tissues.

22. Patient Z asks Nurse Toni why an electronic health record (EHR) system is being used. Which response
by the nurse indicates an understanding of the rationale for an EHR system?
a. It includes organizational reports of unusual occurrences that are not part of the client's record.
b. This type of system consists of combined documentation and daily care plans.
c. It improves interdisciplinary collaboration that improves efficiency in procedures.
d. This type of system tracks medication administration and usage over 24 hours.
Answer: C
Rationale: The EHR has several benefits for users, including improving interdisciplinary collaboration and
making procedures more accurate and efficient. An Electronic Health Record (EHR) is an electronic version
of a patient’s medical history, that is maintained by the provider over time, and may include all of the key
administrative clinical data relevant to that persons care under a particular provider, including demographics,
progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data, and
radiology reports The EHR automates access to information and has the potential to streamline the
clinician’s workflow. The EHR also has the ability to support other care-related activities directly or indirectly
through various interfaces, including evidence-based decision support, quality management, and outcomes
reporting.

23. Paul Jake suffered a stroke and has difficulty swallowing. Which healthcare team member should be
consulted to assess the patient’s risk for aspiration?
a. Respiratory therapist
b. Occupational therapist
c. Dentist
d. Speech therapist
Answer: C
Rationale: Speech and language therapists provide assistance to clients experiencing swallowing and
speech disturbances. They assess the risk for aspiration and recommend a treatment plan to reduce the
risk. Speech-language pathologists (SLPs) work to prevent, assess, diagnose, and treat speech, language,
social communication, cognitive- communication, and swallowing disorders in children and adults.

24. A nurse must measure the intake and output (I&O) for a patient who has a urinary retention catheter.
Which equipment is most appropriate to use to accurately measure urine output from a urinary retention
catheter?
a. Urinal
b. Graduate
c. Large syringe
d. Urine collection bag
Answer: B
Rationale: A graduate is a collection container with volume markings usually at 25 mL increments that
promote accurate measurements of urine volume. To measure urine output in critical care units, a Foley
catheter is introduced through the patient’s urethra until it reaches his/her bladder. The other end of the
catheter is connected to a graduated container that collects the urine.

25. To prevent postoperative complications, Nurse Kim assists the client with coughing and deep breathing
exercises. This is best accomplished by implementing which of the following?
a. Coughing exercises one hour before meals and deep breathing one hour after meals.
b. Forceful coughing as many times as tolerated.
c. Huff coughing every two hours or as needed.
d. Diaphragmatic and pursed lip breathing 5 to 10 times, four times a day.
Answer: C
Rationale:Huff coughing helps keep the airways open and secretions
mobilized. Huff coughing is an alternative for clients who are unable to perform a normal forceful cough
(such as postoperatively) deep breathing and coughing should be performed at the same time.

26. The physician orders gr 10 of aspirin for a patient. The equivalent dose in milligrams is:
a. 0.6 mg
b. 10 mg
c. 60 mg
d. 600 mg
Answer: D
Rationale: gr 10 x 60 mg/gr 1 = 600 mg. There are 3 primary methods for the calculation of medication
dosages, as referenced above. These include Desired Over Have Method or Formula, Dimensional Analysis
and Ratio and Proportion

27. Which of the following is a sign or symptom of a hemolytic reaction to blood transfusion?
a. Hemoglobinuria
b. Chest pain
c. Urticaria
d. Distended neck veins
Answer: A
Rationale: Hemoglobinuria, the abnormal presence of hemoglobin in the urine, indicates a hemolytic
reaction (incompatibility of the donor’s and recipient’s blood). In this reaction, antibodies in the recipient’s
plasma combine rapidly with donor RBC’s; the cells are hemolyzed in either circulatory or reticuloendothelial
systems. Hemolysis occurs more rapidly in ABO incompatibilities than in Rh incompatibilities.

28. Clay-colored stools indicate:

a. Upper GI bleeding
b. Impending constipation
c. An effect of medication
d. Bile obstruction
Answer: D
Rationale: Bile colors the stool brown. Any inflammation or obstruction that impairs bile flow will affect the
stool pigment, yielding light, clay- colored stool. The liver releases bile salts into the stool, giving it a normal
brown color. One may have clay-colored stools if they have a liver infection that reduces bile production, or if
the flow of bile out of the liver is blocked. Yellow skin (jaundice) often occurs with clay-colored stools.

29. All of the following are good sources of vitamin A except:

a. White potatoes
b. Carrots
c. Apricots
d. Egg yolks
Answer: A
Rationale: Potatoes contain a good amount of carbs and fiber, as well as vitamin C, vitamin B6, potassium
and manganese. Their nutrient contents can vary depending on the type of potato and cooking method. The
main sources of vitamin A are yellow and green vegetables (such as carrots, sweet potatoes, squash,
spinach, collard greens, broccoli, and cabbage) and yellow fruits (such as apricots, and cantaloupe). Animal
sources include liver, kidneys, cream, butter, and egg yolks.

30. Thrombophlebitis typically develops in patients with which of the following conditions?
a. Increases partial thromboplastin time
b. Acute pulsus paradoxus
c. An impaired or traumatized blood vessel wall
d. Chronic Obstructive Pulmonary Disease (COPD)
Answer: C
Rationale: The factors, known as Virchow’s triad, collectively predispose a patient to thrombophlebitis;
impaired venous return to the heart, blood hypercoagulability, and injury to a blood vessel wall. The three
factors of Virchow’s triad include intravascular vessel wall damage, stasis of flow, and the presence of a
hypercoagulable state. Understanding the factors involved in the thrombus formation and subsequent
thromboembolic events enables the clinician to stratify risk, direct clinical decision-making regarding
treatment, and establish preventative measures

31. 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 similar problem.
Rationale: Client-centered practices facilitate the development of strong therapeutic relationships and
enable care providers to understand how to maximize clients’ strengths and minimize challenges in
achieving treatment and recovery goals.
32. The natural sedative in meat and milk products (especially warm milk) that can help induce sleep is:
a. Flurazepam
b. Temazepam
c. Methotrimeprazine
d. Tryptophan
Rationale: Tryptophan is a natural sedative; flurazepam (Dalmane), temazepam (Restoril), and
methotrimeprazine (Levoprome) are hypnotic sedatives. Protein foods such as milk and milk products
contain the sleep-inducing amino acid tryptophan. Tryptophan is an amino acid that promotes sleep and is
found in small amounts in all protein foods. It is a precursor to the sleep-inducing compounds serotonin (a
neurotransmitter), and melatonin (a hormone which also acts as a neurotransmitter)

33. 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.
Rationale: Napping in the afternoon is not conducive to nighttime sleeping. There are few considerations
about naps. For example, a short daytime nap of 15-30 minutes can be restorative for elders and will not
interfere with nighttime sleep. On the other hand, insomniacs are cautioned to avoid naps. Quiet music,
watching television, reading, and massage usually will relax the patient, helping him to fall asleep.

34. A client exhibits all of the following during a physical assessment. Which of these is considered a
primary defense against infection?
a. Fever
b. Intact skin
c. Inflammation
d. Lethargy
Rationale: Intact skin is considered a primary defense against infection. Usually, the skin prevents invasion
by microorganisms unless it is damaged (for example, by an injury, insect bite, or burn). Mucous
membranes, such as the lining of the mouth, nose, and eyelids, are also effective barriers. Typically,
mucous membranes are coated with secretions that fight microorganisms. For example, the mucous
membranes of the eyes are bathed in tears, which contain an enzyme called lysozyme that attacks bacteria
and helps protect the eyes from infection. Fever, the inflammatory response, and phagocytosis (a process of
killing pathogens) are considered secondary defenses against infection.

35. Which of the following incidents requires the nurse to complete an occurrence report?
a. Medication given 30 minutes after scheduled dose time.
b. Patient's dentures lost after transfer.
c. Worn electrical cord discovered on an IV infusion pump.
d. Prescription without the route of administration.
You would need to complete an occurrence report if you suspect your patient’s personal items to be lost or
stolen. An incident report also provides vital information the facility needs to decide whether restitution
should be made—if personal belongings were lost or damaged, for example. Without proper documentation
of the incident, there’s no way to make these important decisions effectively.

36. At the end of the shift, the nurse realizes that she forgot to document a dressing change that she
performed for a patient. Which action should the nurse take?
a. Complete an occurrence report before leaving.
b. Do nothing; the next nurse will document it was done.
c. Write the note of the dressing change into an earlier note.
d. Make a late entry as an addition to the narrative notes.
Rationale: If the nurse fails to make an important entry while charting, she should make a late entry as an
addition to the narrative notes. The nurse can only document care directly performed or observed.
Therefore, the nurse on the incoming shift would not record the wound change as performed. A primary
purpose of documentation and recordkeeping systems is to facilitate information flow that supports the
continuity, quality, and safety of care.

37. A prescribed amount of oxygen is needed for a patient with COPD to prevent:
a. Cardiac arrest related to increased partial pressure of carbon dioxide in arterial blood (PaCO2).
b. Circulatory overload due to hypervolemia.
c. Respiratory excitement.
d. Inhibition of the respiratory hypoxic stimulus.
Rationale: Delivery of more than 2 liters of oxygen per minute to a patient with chronic obstructive
pulmonary disease (COPD), who is usually in a state of compensated respiratory acidosis (retaining carbon
dioxide (CO2)), can inhibit the hypoxic stimulus for respiration. Long-term oxygen therapy is used for COPD
if the client has low levels of oxygen in the blood (hypoxia). It is used mostly to slow or prevent right-sided
heart failure. It can help the client live longer.

38. After 1 week of hospitalization, Mr. Gray develops hypokalemia. Which of the following is the most
significant symptom of his disorder?
a. Lethargy
b. Increased pulse rate and blood pressure
c. Muscle weakness
d. Muscle irritability
Rationale: Presenting symptoms of hypokalemia ( a serum potassium level below 3.5 mEq/liter) include
muscle weakness, chronic fatigue, and cardiac dysrhythmias. The combined effects of inadequate food
intake and prolonged diarrhea can deplete the potassium stores of a patient with GI problems. Significant
muscle weakness occurs at serum potassium levels below 2.5 mmol/L but can occur at higher levels if the
onset is acute. Similar to the weakness associated with hyperkalemia, the pattern is ascending in nature
affecting the lower extremities, progressing to involve the trunk and upper extremities, and potentially
advancing to paralysis.

39. The ELISA test is used to:

a. Screen blood donors for antibodies to human immunodeficiency virus (HIV).
b. Test blood to be used for transfusion for HIV antibodies.
c. Aid in diagnosing a patient with AIDS.
d. All of the above.
Rationale: The ELISA test of venous blood is used to assess blood and potential blood donors to human
immunodeficiency virus (HIV). A positive ELISA test combined with various signs and symptoms helps to
diagnose acquired immunodeficiency syndrome (AIDS). Enzyme-linked immunosorbent assay (ELISA) is a
labeled immunoassay that is considered the gold standard of immunoassays. This immunological test is
very sensitive and is used to detect and quantify substances, including antibodies, antigens, proteins,
glycoproteins, and hormones. The detection of these products is accomplished by the complexing of
antibodies and antigens to produce a measurable result.

40. Which of the following constitutes a break in sterile technique while preparing a sterile field for a
dressing change?
a. Using sterile forceps, rather than sterile gloves, to handle a sterile item.
b. Touching the outside wrapper of sterilized material without sterile gloves.
c. Placing a sterile object on the edge of the sterile field.
d. Pouring out a small amount of solution (15 to 30 ml) before pouring the solution into a sterile
container.
Rationale: The edges of a sterile field are considered contaminated. When sterile items are allowed to come
in contact with the edges of the field, the sterile items also become contaminated. The sterile field should be
prepared as close as possible to the time of use.2 The sterility of supplies used during a surgical procedure
can be affected by the events taking place within the operating room, and the length of time the items have
been exposed to the environment.

41. Which of the following patients is at greater risk for contracting an infection?
a. A newly diagnosed diabetic patient
b. A postoperative patient who has undergone orthopedic surgery
c. A patient with leukopenia
d. patient receiving broad-spectrum antibiotics
Rationale: Leukopenia is a decreased number of leukocytes (white blood cells), which are important in
resisting infection. None of the other situations would put the patient at risk for contracting an infection;
taking broad-spectrum antibiotics might actually reduce the infection risk.

42. The best way of determining whether a patient has learned to instill ear medication properly is for the
nurse to:
a. Have the patient repeat the nurse’s instructions using her own words
b. Ask the patient to demonstrate the procedure
c. Demonstrate the procedure to the patient and encourage to ask questions
d. Ask the patient if he/she has used ear drops before
Rationale: Return demonstration provides the most certain evidence for evaluating the effectiveness of
patient teaching.

43. The correct method for determining the vastus lateralis site for I.M. injection is to:
a. Palpate the lower edge of the acromion process and the midpoint lateral aspect of the arm
b. Palpate a 1” circular area anterior to the umbilicus
c. Locate the upper aspect of the upper outer quadrant of the buttock about 5 to 8 cm below the iliac
crest
d. Divide the area between the greater femoral trochanter and the lateral femoral condyle into thirds,
and select the middle third on the anterior of the thigh
Rationale: The vastus lateralis, a long, thick muscle that extends the full length of the thigh, is viewed by
many clinicians as the site of choice for I.M. injections because it has relatively few major nerves and blood
vessels. The middle third of the muscle is recommended as the injection site. The patient can be in a supine
or sitting position for an injection into this site.

44. Which of the following nursing interventions is considered the most effective form or universal
precautions?
a. Follow enteric precautions
b. Cap all used needles before removing them from their syringes
c. Wear gloves when administering IM injections
d. Discard all used uncapped needles and syringes in an impenetrable protective container

Rationale: According to the Centers for Disease Control (CDC), blood-to-blood contact occurs most
commonly when a health care worker attempts to cap a used needle. Therefore, used needles should never
be recapped; instead, they should be inserted in a specially designed puncture resistant, labeled container.
Wearing gloves is not always necessary when administering an I.M. injection. Enteric precautions prevent
the transfer of pathogens via feces.

45. Which of the following statements about chest X-ray is false?

a. A signed consent is not required
b. Eating, drinking, and medications are allowed before this test
c. Before the procedure, the patient should remove all jewelry, metallic objects, and buttons above the waist
d. No contradictions exist for this test
Rationale: Pregnancy or suspected pregnancy is the only contraindication for a chest X-ray. However, if a
chest X-ray is necessary, the patient can wear a lead apron to protect the pelvic region from radiation.
Jewelry, metallic objects, and buttons would interfere with the X-ray and thus should not be worn above the
waist. A signed consent is not required because a chest X-ray is not an invasive examination. Eating,
drinking and medications are allowed because the X-ray is of the chest, not the abdominal region.

46. In which step of the nursing process would the nurse ask a patient if the medication she administered
relieved his pain?
a. Assessment
b. Analysis
c. Evaluation
d. Planning
Rationale: In the evaluation step of the nursing process, the nurse must decide whether the patient has
achieved the expected outcome that was identified in the planning phase.

47. When removing a contaminated gown, the nurse should be careful that the first thing she touches is the:
a. Waist tie in front of the gown
b. Waist tie and neck tie at the back of the gown
c. Inside of the gown
d. Cuffs of the gown
Rationale: The back of the gown is considered clean; the front is contaminated. So, after removing gloves
and washing hands, the nurse should untie the back of the gown; slowly move backward away from the
gown, holding the inside of the gown and keeping the edges off the floor; turn and fold the gown inside out;
discard it in a contaminated linen container; then wash her hands again.

48. After routine patient contact, hand washing should last at least:
a. 3 minutes
b. 30 seconds
c. 2 minutes
d. 1 minute
Rationale: Depending on the degree of exposure to pathogens, hand washing may last from 10 seconds to
4 minutes. After routine patient contact, hand washing for 30 seconds effectively minimizes the risk of
pathogen transmission.

49. Which of the following blood tests should be performed before a blood transfusion?
a. Blood typing and cross-matching
b. Complete blood count (CBC) and electrolyte levels.
c. Bleeding and clotting time
d. Prothrombin and coagulation time
Rationale: Before a blood transfusion is performed, the blood of the donor and recipient must be checked for
compatibility. This is done by blood typing (a test that determines a person’s blood type) and cross-matching
(a procedure that determines the compatibility of the donor’s and recipient’s blood after the blood types has
been matched). If the blood specimens are incompatible, hemolysis and antigen-antibody reactions will
occur.
50. All of the following are common signs and symptoms of phlebitis except:
a. Frank bleeding at the insertion site
b. A red streak exiting the IV insertion site
c. Edema and warmth at the IV insertion site
d. Pain or discomfort at the IV insertion site
Rationale: Phlebitis, the inflammation of a vein, can be caused by chemical irritants (I.V. solutions or
medications), mechanical irritants (the needle or catheter used during venipuncture or cannulation), or a
localized allergic reaction to the needle or catheter. Signs and symptoms of phlebitis include pain or
discomfort, edema and heat at the
I.V. insertion site, and a red streak going up the arm or leg from the I.V. insertion site.

51.During a physical assessment, the nurse closes the door and provides drapes to promote privacy. The
nurse is performing her role as a/an:
a. Advocate
b. Communicator
c. Change agent
d. Caregiver
Rationale: The role of a nurse as caregiver helps clients promote, restore and maintain dignity, health and
wellness by viewing a person holistically. As an advocate the nurse intercedes or works on behalf of the
client. Identifying the need and problems of the client and communicating it to other members of the health
team is doing the role of a communicator. As a change agent, the nurse assists the client to MODIFY their
BEHAVIOR.

52.During the nursing rounds Nurse Cathy is instructing the patient to avoid smoking to prevent the
worsening of respiratory problems. The patient asked about the things that he can do when feelings of
wanting to smoke arises. The
nurse enumerates ways of dealing with the situation. This is an example of a nurse's role as a/an:
a. Advocate
b. Clinician
c. Change agent
d. Caregiver
Rationale: As a change agent, the nurse assists the client to MODIFY their BEHAVIOR. As an advocate the
nurse intercedes or works on behalf of the client. As a clinician, the nurse would use technical expertise to
administer nursing care.
The role of a nurse as caregiver helps client promote, restore and maintain dignity, health and wellness by
viewing a person holistically.

53.Nurse Cathy on the other hand, knows the case immediately even before a diagnosis is done. Based on
Benner's
theory she is a/an:
a. Novice
b. Expert
c. Competent
d. Advanced beginner
Rationale: The ability to perceive something without further evidence is the development of intuition and is
seen in Expert nurses. A novice nurse is governed by rules and usually inflexible. Competent nurses are
planning nursing care consciously. Advanced beginners demonstrate acceptable performance.

54.Newborn screening is done to every newborn in the Philippines. This is an example of:
a. Primary prevention
b. Secondary prevention
c. Tertiary prevention
d. Rehabilitation
Rationale: Promotion of early detection and early treatment of the disease is under secondary prevention.
Example, breast self-exam, TB screening, genetic counseling.

55. One of Nurse Cathy's co-workers is Annie who is flexible in any given situation. Annie is performing her
duties well without supervision but still needs more experience and practice to develop a consciously
planned nursing care. According to Patricia Benner's category in specialization in nursing, Annie is a/an:
a. Novice
b. Expert
c. Competent
d. Advanced beginner
Rationale: A- Novice is governed by rules and usually inflexible. B- Expert nurses have intuitive grasp on the
situation dealt. C- Competent nurses are planning nursing care consciously. D- Advanced beginners
demonstrate acceptable performance.
56. When a client is confused, left alone with the side rails down, and the bed in a high position, the client
falls and breaks a hip. What law has been broken?
a. Assault
b. Battery
c. Negligence
d. Civil tort
Rationale: Knowing what to do to prevent injury is a part of the standards of care for nurses to follow. Safety
guidelines dictate raising the side rails, staying with the client, lowering the bed, and observing the client
until the environment is safe. As a nurse, these activities are known as basic safety measures that prevent
injuries, and to not perform them is not acting in a safe manner. Negligence is conduct that falls below the
standard of care that protects others against unreasonable risk of harm.

57. The philosophy sometimes called the code of ethics of care suggests that ethical dilemmas can best be
solved by attention to:
a. Relationships
b. Ethical principles
c. Clients
d. Code of ethics for nurses.
Rationale: The ethic of care explores the notion of care as a central activity of human behavior. Those who
write about the ethics of care advocate a more female biased theory that is based on understanding
relationships, especially personal narratives

58. Nurses are bound by a variety of laws. Which description of a type of law is correct?
a. Statutory law is created by an elected legislature, such as the state legislature that defines the
Nurse Practice Act (NPA).
b. Regulatory law includes prevention of harm for the public and punishment for those laws that are
broken.
c. Common law protects the rights of the individual within society for fair and equal treatment.
d. Criminal law creates boards that pass rules and regulations to control society.
Rationale: Statutory law is created by legislature. It creates statues such as the NPA, which defines the role
of the nurse and expectations of the performance of one’s duties and explains what is contraindicated as
guidelines for breach of those regulations.

59. Which of the following should be included in a plan of care for a client receiving total parenteral nutrition
(TPN)?
a. Withhold medications while the TPN is infusing.
b. Change TPN solution every 24 hours.
c. Flush the TPN line with water prior to initiating nutritional support.
d. Keep client on complete bed rest during TPN therapy.
Rationale: TPN solutions should be changed every 24 hours in order to prevent bacterial overgrowth due to
hypertonicity of the solution. Option 1 is incorrect; medication therapy can continue during TPN therapy.
Option 3 is incorrect; flushing is not required because the initiation of TPN does not require a client to
remain on bed rest during therapy. However, other clinical conditions of the client may affect mobility issues
and warrant the client’s being on bed rest.

60. After a myocardial infarction, a client is placed on a sodium restricted diet. When the nurse is teaching
the client about the diet, which meal plan would be the most appropriate to suggest?
a. 3 oz. broiled fish, 1 baked potato, ½ cup canned beets, 1 orange, and milk
b. 3 oz. canned salmon, fresh broccoli, 1 biscuit, tea, and 1 apple
c. A bologna sandwich, fresh eggplant, 2 oz fresh fruit, tea, and apple juice
d. 3 oz. turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange
Rationale: Canned fish and vegetables and cured meats are high in sodium. This meal does not contain any
canned fish and/or vegetables or cured meats.