After a cerebrovascular accident, a 75 yr
old client is admitted to the health care
facility. The client has left-sided weakness
and an absent gag reflex. He's incontinent
and has a tarry stool. His blood pressure
is 90/50 mm Hg, and his hemoglobin is 10
g/dl. Which of the following is a priority for
this client?
A. Checking stools for occult blood
B. Performing range-of-motion
exercises to the left side
C. Keeping skin clean and dry
D. Elevating the head of the bed to 30
degrees
The nurse is caring for a client with a
colostomy. The client tells the nurse that
he makes small pin holes in the drainage
bag to help relieve gas. The nurse should
teach him that this action:
A. destroys the odor-proof seal
B. won't affect the colostomy system
C. is appropriate for relieving the gas
in a colostomy system
D. destroys the moisture barrier seal
When assessing the client with celiac
disease, the nurse can expect to find
which of the following?
A. Steatorrhea
B. jaundiced sclera
C. clay-colored stools
D. widened pulse pressure
A client is hospitalized with a diagnosis of
chronic glomerulonephritis. The client
mentions that she likes salty foods. The
nurse should warn her to avoid foods
containing sodium because:
A. reducing sodium promotes urea
nitrogen excretion
B. reducing sodium improves her
glomerular filtration rate
C. reducing sodium increases
potassium absorption
D. reducing sodium decreases edema
The nurse is caring for a client with a
cerebral injury that impaired his speech
and hearing. Most likely, the client has
experienced damage to the:
A. frontal lobe
B. Parietal lobe
C. occipital lobe
D. temporal lobe
The nurse is assessing a postcraniotomy
client and finds the urine output from a
catheter is 1500 ml for the 1st hour and
the same for the 2nd hour. The nurse
should suspect:
A. Cushing's syndrome
B. Diabetes mellitus
C. Adrenal crisis
D. Diabetes insipidus
The nurse is providing postprocedure care
for a client who underwent percutaneous
lithotripsy. In this procedure, an ultrasonic
probe inserted through a nephrostomy
tube into the renal pelvis generates
ultra-high-frequency sound waves to
shatter renal calculi. The nurse should
instruct the client to:
A. limit oral fluid intake for 1 to 2
weeks
B. report the presence of fine, sand
like particles through the
nephrostomy tube.
C. Notify the physician about cloudy
or foul smelling urine
D. Report bright pink urine within 24
hours after the procedure
A client with a serum glucose level of 618
mg/dl is admitted to the facility. He's
awake and oriented, has hot dry skin, and
has the following vital signs: temperature
of 100.6° F (38.1° C), heart rate of 116
beats/minute, and blood pressure of
108/70 mm Hg. Based on these
assessment findings, which nursing
diagnosis takes the highest priority?
A. Deficient fluid volume related to
osmotic diuresis
 B. decreased cardiac output related
to elevated heart rate
C. imbalanced nutrition: Less than
body requirements related to
insulin deficiency
D. ineffective thermoregulation related
to dehydration
Capillary glucose monitoring is being
performed every 4 hours for a client
diagnosed with diabetic ketoacidosis.
Insulin is administered using a scale of
regular insulin according to glucose
results. At 2 p.m., the client has a capillary
glucose level of 250 mg/dl for which he
receives 8 U of regular insulin. The nurse
should expect the dose's:
A. onset to be at 2 p.m. and its peak
at 3 p.m.
B. onset to be at 2:15 p.m. and its
peak at 3 p.m.
C. onset to be at 2:30 p.m. and its
peak at 4 p.m.
D. onset to be at 4 p.m. and its peak
at 6 p.m.
A client with a head injury is being
monitored for increased intracranial
pressure (ICP). His blood pressure is
90/60 mmHG and the ICP is 18 mmHg;
therefore his cerebral perfusion pressure
(CPP) is:
A. 52 mm Hg
B. 88 mm Hg
C. 48 mm Hg
D. 68 mm Hg
52 yr-old female tells the nurse that she
has found a painless lump in her right
breast during her monthly
self-examination. Which assessment
finding would strongly suggest that this
client's lump is cancerous?
A. eversion of the right nipple and a
mobile mass
B. nonmobile mass with irregular
edges
C. mobile mass that is soft and easily
delineated
D. nonpalpable right axillary lymph
nodes
A Client is scheduled to have a
descending colostomy. He's very anxious
and has many questions regarding the
surgical procedure, care of stoma, and
lifestyle changes. It would be most
appropriate for the nurse to make a
referral to which member of the health
care team?
A. Social worker
B. registered dietician
C. occupational therapist
D. enterostomal nurse therapist
Ottorrhea and rhinorrhea are most
commonly seen with which type of skull
fracture?
A. basilar
B. temporal
C. occipital
D. parietal
A male client should be taught about
testicular examinations:
A. when sexual activity starts
B. after age 60
C. after age 40
D. before age 20
Before weaning a client from a ventilator,
which assessment parameter is most
important for the nurse to review?
A. fluid intake for the last 24 hours
B. baseline arterial blood gas (ABG)
levels
C. prior outcomes of weaning
D. electrocardiogram (ECG) results
The nurse is speaking to a group of
women about early detection of breast
cancer. The average age of the women in
the group is 47. Following the American
Cancer Society (ACS) guidelines, the
nurse should recommend that the women:
 A. perform breast self-examination
annually
B. have a mammogram annually
C. have a hormonal receptor assay
annually
D. have a physician conduct a clinical
evaluation every 2 years
When caring for a client with esophageal
varices, the nurse knows that bleeding in
this disorder usually stems from:
A. esophageal perforation
B. pulmonary hypertension
C. portal hypertension
D. peptic ulcers
A 49-year-old client was admitted for
surgical repair of a Colles' fracture. An
external fixator was placed during surgery.
The surgeon explains that this method of
repair:
A. has very low complication rate
B. maintains reduction and overall
hand function
C. is less bothersome than a cast
D. is best for older people
A client is hospitalized with a diagnosis of
chronic renal failure. An arteriovenous
fistula was created in his left arm for
hemodialysis. When preparing the client
for discharge, the nurse should reinforce
which dietary instruction?
A. "Be sure to eat meat at every
meal."
B. "Monitor your fruit intake and eat
plenty of bananas."
C. "Restrict your salt intake."
D. “Drink plenty of fluids."
The nurse is caring for a client who has
just had a modified radical mastectomy
with immediate reconstruction. She's in
her 30s and has two children. Although
she's worried about her future, she seems
to be adjusting well to her diagnosis. What
should the nurse do to support her
coping?
A. Tell the client's spouse or partner
to be supportive while she
recovers.
B. Encourage the client to proceed
with the next phase of treatment.
C. Recommend that the client remain
cheerful for the sake of her
children.
D. Refer the client to the American
Cancer Society's Reach for
Recovery program or another
support program.
A 21 year-old male has been seen in the
clinic for a thickening in his right testicle.
The physician ordered a human chorionic
gonadotropin (HCG) level. The nurse's
explanation to the client should include the
fact that:
A. The test will evaluate prostatic
function.
B. The test was ordered to identify the
site of a possible infection.
C. The test was ordered because
clients who have testicular cancer
have elevated levels of HCG.
D. The test was ordered to evaluate
the testosterone level.
A client is receiving captopril (Capoten) for
heart failure. The nurse should notify the
physician that the medication therapy is
ineffective if an assessment reveals:
A. A skin rash.
B. Peripheral edema.
C. A dry cough.
D. Postural hypotension.
Which assessment finding indicates
dehydration?
A. Tenting of chest skin when
pinched.
B. Rapid filling of hand veins.
C. A pulse that isn't easily obliterated.
D. Neck vein distention
The nurse is teaching a client with a
history of atherosclerosis. To decrease the
risk of atherosclerosis, the nurse should
encourage the client to:
A. Avoid focusing on his weight.
B. Increase his activity level.
C. Follow a regular diet.
D. Continue leading a high-stress
lifestyle.
For a client newly diagnosed with radiation
induced thrombocytopenia, the nurse
should include which intervention in the
plan of care?
A. Administer aspirin if the
temperature exceeds 38.8° C.
B. Inspect the skin for petechiae once
every shift.
C. Provide for frequent periods of
rest.
D. Place the client in strict isolation.
A client is chronically short of breath and
yet has normal lung ventilation, clear
lungs, and an arterial oxygen saturation
(SaO2) 96% or better. The client most
likely has:
A. poor peripheral perfusion
B. a possible Hematologic problem
C. a psychosomatic disorder
D. left-sided heart failure
For a client in addisonian crisis, it would
be very risky for a nurse to administer:
A. potassium chloride
B. normal saline solution
C. hydrocortisone
D. fludrocortisone
The nurse is reviewing the laboratory
report of a client who underwent a bone
marrow biopsy. The finding that would
most strongly support a diagnosis of acute
leukemia is the existence of a large
number of immature:
A. lymphocytes
B. thrombocytes
C. reticulocytes
D. leukocytes
The nurse is performing wound care on a
foot ulcer in a client with type 1 diabetes
mellitus. Which technique demonstrates
surgical asepsis?
A. Putting on sterile gloves then
opening a container of sterile
saline.
B. Cleaning the wound with a circular
motion, moving from outer circles
toward the center.
C. Changing the sterile field after
sterile water is spilled on it.
D. Placing a sterile dressing ½* (1.3
cm) from the edge of the sterile
field.
A client with a forceful, pounding
heartbeat is diagnosed with mitral valve
prolapse. This client should avoid which of
the following?
A. high volumes of fluid intake
B. aerobic exercise programs
C. caffeine-containing products
D. foods rich in protein
A client with a history of hypertension is
diagnosed with primary
hyperaldosteronism. This diagnosis
indicates that the client's hypertension is
caused by excessive hormone secretion
from which organ?
A. adrenal cortex
B. pancreas
C. adrenal medulla
D. parathyroid
A client has a medical history of rheumatic
fever, type 1 (insulin dependent) diabetes
mellitus, hypertension, pernicious anemia,
and appendectomy. She's admitted to the
hospital and undergoes mitral valve
replacement surgery. After discharge, the
client is scheduled for a tooth extraction.
Which history finding is a major risk factor
for infective endocarditis?
A. appendectomy
B. pernicious anemia
C. diabetes mellitus
 D. valve replacement
A 62 yr-old client diagnosed with
pyelonephritis and possible septicemia
has had five urinary tract infections over
the past two years. She's fatigued from
lack of sleep; urinates frequently, even
during the night; and has lost weight
recently. Test reveal the following: sodium
level 152 mEq/L, osmolarity 340 mOsm/L,
glucose level 125 mg/dl, and potassium
level 3.8 mEq/L. which of the following
nursing diagnoses is most appropriate for
this client?
A. Deficient fluid volume related to
inability to conserve water
B. Imbalanced nutrition: less than
body requirements related to
hypermetabolic state
C. Deficient fluid volume related to
osmotic diuresis induced by
hypernatremia
D. Imbalanced nutrition: less than
body requirements related to
catabolic effects of insulin
deficiency
A 20 yr-old woman has just been
diagnosed with Crohn's disease. She has
lost 10 lb (4.5 kg) and has cramps and
occasional diarrhea. The nurse should
include which of the following when doing
a nutritional assessment?
A. Let the client eat as desired during
the hospitalization.
B. Weight the client daily.
C. Ask the client to list what she eats
during a typical day.
D. Place the client on I & O status and
draw blood for electrolyte levels.
When instructions should be included in
the discharge teaching plan for a client
after thyroidectomy for Grave's disease?
A. Keep an accurate record of intake
and output.
B. Use nasal desmopressin acetate
DDAVP).
C. Be sure to get regular follow-up
care.
D. Be sure to exercise to improve
cardiovascular fitness.
A client comes to the emergency
department with chest pain, dyspnea, and
an irregular heartbeat. An
electrocardiogram shows a heart rate of
110 beats/minute (sinus tachycardia) with
frequent premature ventricular
contractions. Shortly after admission, the
client has ventricular tachycardia and
becomes unresponsive. After successful
resuscitation, the client is taken to the
intensive care unit. Which nursing
diagnosis is appropriate at this time?
A. Deficient knowledge related to
interventions used to treat acute
illness
B. Impaired physical mobility related
to complete bed rest
C. Social isolation related to restricted
visiting hours in the intensive care
unit
D. Anxiety related to the threat of
death
A client is admitted to the health care
facility with active tuberculosis. The nurse
should include which intervention in the
plan of care?
A. Putting on a mask when entering
the client's room.
B. Instructing the client to wear a
mask at all times
C. Wearing a gown and gloves when
providing direct care
D. Keeping the door to the client's
room open to observe the client
The nurse is caring for a client who
underwent a subtotal gastrectomy 24
hours earlier. The client has a nasogastric
(NG) tube. The nurse should:
A. Apply suction to the NG tube every
hour.
 B. Clamp the NG tube if the client
complains of nausea.
C. Irrigate the NG tube gently with
normal saline solution.
D. Reposition the NG tube if pulled
out.
Which statement about fluid replacement
is accurate for a client with hyperosmolar
hyperglycemic nonketotic syndrome
(HHNS)?
A. administer 2 to 3 L of IV fluid
rapidly
B. administer 6 L of IV fluid over the
first 24 hours
C. administer a dextrose solution
containing normal saline solution
D. administer IV fluid slowly to
prevent circulatory overload and
collapse
Which of the following is an adverse
reaction to glipizide (Glucotrol)?
A. headache
B. constipation
C. hypotension
D. photosensitivity
The nurse is caring for four clients on a
step down intensive care unit. The client at
the highest risk for developing nosocomial
pneumonia is the one who:
A. has a respiratory infection
B. is intubated and on a ventilator
C. has pleural chest tubes
D. is receiving feedings through a
jejunostomy tube
The nurse is teaching a client with chronic
bronchitis about breathing exercises.
Which of the following should the nurse
include in the teaching?
A. Make inhalation longer than
exhalation.
B. Exhale through an open mouth.
C. Use diaphragmatic breathing.
D. Use chest breathing.
A client is admitted to the hospital with an
exacerbation of her chronic systemic lupus
erythematosus (SLE). She gets angry
when her call bell isn't answered
immediately. The most appropriate
response to her would be:
A. "You seem angry. Would you like to
talk about it?"
B. "Calm down. You know that stress
will make your symptoms worse."
C. "Would you like to talk about the
problem with the nursing
supervisor?"
D. "I can see you're angry. I'll come
back when you've calmed down."
On a routine visit to the physician, a client
with chronic arterial occlusive disease
reports stopping smoking after 34 years.
To relieve symptoms of intermittent
claudication, a condition associated with
chronic arterial occlusive disease, the
nurse should recommend which additional
measure?
A. Taking daily walks.
B. Engaging in anaerobic exercise.
C. Reducing daily fat intake to less
than 45% of total calories
D. Avoiding foods that increase levels
of high density lipoproteins (HDLs)
A physician orders gastric decompression
for a client with small bowel obstruction.
The nurse should plan for the suction to
be:
A. low pressure and intermittent
B. low pressure and continuous
C. high pressure and continuous
D. high pressure and intermittent
Which nursing diagnosis is most
appropriate for an elderly client with
osteoarthritis?
A. Risk for injury
B. Impaired urinary elimination
C. Ineffective breathing pattern
D. Imbalanced nutrition: less than
body requirements

Parathyroid hormone (PTH) has which
effects on the kidney?
A. Stimulation of calcium reabsorption
and phosphate excretion
B. Stimulation of phosphate
reabsorption and calcium excretion
C. Increased absorption of vit D and
excretion of vit E
D. Increased. Absorption of Vit E and
excretion of Vit D
A visiting nurse is performing home
assessment for a 59-yr old man recently
discharged after hip replacement surgery.
Which home assessment finding warrants
health promotion teaching from the nurse?
A. A bathroom with grab bars for the
tub and toilet
B. Items stored in the kitchen so that
reaching up and bending down
aren't necessary
C. Many small, unsecured area rugs
D. Sufficient stairwell lighting, with
switches to the top and bottom of
the stairs
A client with autoimmune
thrombocytopenia and a platelet count of
800/uL develops epistaxis and melena.
Treatment with corticosteroids and
immunoglobulins has been unsuccessful,
and the physician recommends a
splenectomy. The client states, "I don't
need surgery-this will go away on its own."
In considering her response to the client,
the nurse must depend on the ethical
principle of:
A. beneficence
B. autonomy
C. advocacy
D. justice
Which of the following is the most critical
intervention needed for a client with
myxedema coma?
A. Administering and oral dose of
levothyroxine (Synthroid)
B. Warming the client with a warming
blanket
C. Measuring and recording accurate
intake and output
D. Maintaining a patent airway
Because diet and exercise have failed to
control a 63 yr-old client's blood glucose
level, the client is prescribed glipizide
(Glucotrol) After oral administration, the
onset of action is:
A. 15 to 30 minutes
B. 30 to 60 minutes
C. 1 to 1½ hours
D. 2 to 3 hours
A client with pneumonia is receiving
supplemental oxygen, 2 L/min via nasal
cannula. The client's history includes
chronic obstructive pulmonary disease
(COPD) and coronary artery disease.
Because of these findings, the nurse
closely monitors the oxygen flow and the
client's respiratory status. Which
complication may arise if the client
receives a high oxygen concentration?
A. Apnea
B. Anginal pain
C. Respiratory alkalosis
D. Metabolic acidosis
A client with type 1 diabetes mellitus has
been on a regimen of multiple daily
injection therapy. He's being converted to
continuous subcutaneous insulin therapy.
While teaching the client bout continuous
subcutaneous insulin therapy, the nurse
would be accurate in telling him the
regimen includes the use of:
A. intermediate and long-acting
insulins
B. short and long-acting insulins
C. short-acting only
D. short and intermediate-acting
insulins
A client who recently had a
cerebrovascular accident requires a cane
to ambulate. When teaching about cane A. respiratory acidosis
use, the rationale for holding a cane on B. respiratory alkalosis
the uninvolved side is to: C. metabolic acidosis
A. prevent leaning D. metabolic alkalosis
B. distribute weight away from the
involved side When caring for a client with the nursing
C. maintain stride length diagnosis Impaired swallowing related to
D. prevent edema neuromuscular impairment, the nurse
should:
A client with a history of an anterior wall A. position the client in a supine
myocardial infarction is being transferred position
from the coronary care unit (CCU) to the B. elevate the head of the bed 90
cardiac stepdown unit (SU). While giving a degrees during meals
report to the CSU nurse, the CCU nurse C. encourage the client to remove
says, "His pulmonary artery wedge dentures
pressures have been in the high normal D. encourage thin liquids for dietary
range." The CSU nurse should be intake
especially observant for:
A. hypertension A nurse is caring for a client who has a
B. high urine output tracheostomy and temperature of 39° C.
C. dry mucous membranes which intervention will most likely lower
D. pulmonary crackles the client's arterial blood oxygen
saturation?
The nurse is caring for a client with a A. Endotracheal suctioning
fractures hip. The client is combative, B. Encouragement of coughing
confused, and trying to get out of bed. The C. Use of cooling blanket
nurse should: D. Incentive spirometry
A. leave the client and get help
B. obtain a physician's order to A client with a solar burn of the chest,
restrain the client back, face, and arms is seen in urgent
C. read the facility's policy on care. The nurse's primary concern should
restraints be:
D. order soft restraints from the A. fluid resuscitation
storeroom B. infection
C. body image
For the first 72 hours after thyroidectomy D. pain management
surgery, the nurse would assess the client
for Chostek's sign and Trousseau's sign Which statement is true about crackles?
because they indicate which of the A. They're grating sounds.
following? B. They're high-pitched, musical
A. hypocalcemia squeaks.
B. hypercalcemia C. They're low-pitched noises that
C. hypokalemia sound like snoring.
D. Hyperkalemia D. They may be fine, medium, or
coarse.
In a client with enteritis and frequent A woman whose husband was recently
diarrhea, the nurse should anticipate an diagnosed with active pulmonary
acid base imbalance of: tuberculosis (TB) is a tuberculin skin test
converter. Management of her care would
include:
A. scheduling her for annual
tuberculin skin testing
B. placing her in quarantine until
sputum cultures are negative
C. gathering a list of persons with
whom she has had recent contact
D. advising her to begin prophylactic
therapy with isoniazid (INH)
The nurse is caring for a client who ahs
had an above the knee amputation. The
client refuses to look at the stump. When
the nurse attempts to speak with the client
about his surgery, he tells the nurse that
he doesn't wish to discuss it. The client
also refuses to have his family visit. The
nursing diagnosis that best describes the
client's problem is:
A. Hopelessness
B. Powerlessness
C. Disturbed body image
D. Fear
A client with three children who is still in
the child bearing years is admitted for
surgical repair of a prolapsed bladder. The
nurse would find that the client understood
the surgeon's preoperative teaching when
the client states:
A. "If I should become pregnant
again, the child would be delivered
by cesarean delivery."
B. "If I have another child, the
procedure may need to be
repeated."
C. "This surgery may render me
incapable of conceiving another
child."
D. "This procedure is accomplished in
two separate surgeries."
A client experiences problems in body
temperature regulation associated with a
skin impairment. Which gland is most
likely involved?
A. Eccrine
B. Sebaceous
C. Apocrine
D. Endocrine
A school cafeteria worker comes to the
physician's office complaining of severe
scalp itching. On inspection, the nurse
finds nail marks on the scalp and small
light-colored round specks attached to the
hair shafts close to the scalp. These
findings suggest that the client suffers
from:
A. scabies
B. head lice
C. tinea capitis
D. impetigo
Following a small-bowel resection, a client
develops fever and anemia. The surface
surrounding the surgical wound is warm to
touch and necrotizing fasciitis is
suspected. Another manifestation that
would most suggest necrotizing fasciitis is:
A. erythema
B. leukocytosis
C. pressure-like pain
D. swelling
A 28 yr-old nurse has complaints of itching
and a rash of both hands. Contact
dermatitis is initially suspected. The
diagnosis is confirmed if the rash appears:
A. erythematous with raised papules
B. dry and scaly with flaking skin
C. inflamed with weeping and crusting
lesions
D. excoriated with multiple fissures
When assessing a client with partial
thickness burns over 60% of the body,
which of the following should the nurse
report immediately?
A. Complaints of intense thirst
B. Moderate to severe pain
C. Urine output of 70 ml the 1st hour
D. Hoarseness of the voice
A client is admitted to the hospital
following a burn injury to the left hand and
arm. The client's burn is described as
white and leathery with no blisters. Which
degree of severity is this burn?
A. first-degree burn
B. second-degree burn
C. third-degree burn
D. fourth-degree burn
The nurse is caring for client with a new
donor site that was harvested to treat a
new burn. The nurse position the client to:
A. allow ventilation of the site
B. make the site dependent
C. avoid pressure on the site
D. keep the site fully covered
A 45-yr-old auto mechanic comes to the
physician's office because an
exacerbation of his psoriasis is making it
difficult to work. He tells the nurse that his
finger joints are stiff and sore in the
morning. The nurse should respond by:
A. Inquiring further about this problem
because psoriatic arthritis can
accompany psoriasis vulgaris
B. Suggesting he take aspirin for
relief because it's probably early
rheumatoid arthritis
C. Validating his complaint but
assuming it's an adverse effect of
his vocation
D. Asking him if he has been
diagnosed or treated for carpal
tunnel syndrome
The nurse is providing home care
instructions to a client who has recently
had a skin graft. Which instruction is most
important for the client to remember?
A. Use cosmetic camouflage
techniques.
B. Protect the graft from direct
sunlight.
C. Continue physical therapy.
D. Apply lubricating lotion to the graft
site.
A 28 yr-old female nurse is seen in the
employee health department for mild
itching and rash of both hands. Which of
the following could be causing this
reaction?
A. possible medication allergies
B. current life stressors she may be
experiencing
C. chemicals she may be using and
use of latex gloves
D. recent changes made in laundry
detergent or bath soap.
The nurse assesses a client with urticaria.
The nurse understands that urticaria is
another name for:
A. hives
B. a toxin
C. a tubercle
D. a virus
A client with psoriasis visits the
dermatology clinic. When inspecting the
affected areas, the nurse expects to see
which type of secondary lesion?
A. scale
B. crust
C. ulcer
D. scar
The nurse is caring for a bedridden,
elderly adult. To prevent pressure ulcers,
which intervention should the nurse
include in the plan of care?
A. Turn and reposition the client a
minimum of every 8 hours.
B. Vigorously massage lotion into
bony prominences.
C. Post a turning schedule at the
client's bedside.
D. Slide the client, rather than lifting
when turning.
Following a full-thickness (3rd degree)
burn of his left arm, a client is treated with
artificial skin. The client understands
postoperative care of the artificial skin
when he states that during the first 7 days
after the procedure, he'll restrict:
A. range of motion
B. protein intake
C. going outdoors
D. fluid ingestion
A client received burns to his entire back
and left arm. Using the Rule of Nines, the
nurse can calculate that he has sustained
burns on what percentage of his body?
A. 9%
B. 18%
C. 27%
D. 36%
The nurse is providing care for a client
who has a sacral pressure ulcer with
wet-to-dry dressing. Which guideline is
appropriate for a wet-to-dry dressing?
A. The wound should remain moist
from the dressing.
B. The wet-to-dry dressing should be
tightly packed into the wound.
C. The dressing should be allowed to
dry out before removal.
D. A plastic sheet-type dressing
should cover the wet dressing.
While in a skilled nursing facility, a client
contracted scabies, which is diagnosed
the day after discharge. The client is living
at her daughter's home with six other
persons. During her visit to the clinic, she
asks a staff nurse, "What should my family
do?" the most accurate response from the
nurse is:
A. "All family members will need to be
treated."
B. “If someone develops symptoms,
tell him to see a physician right
away”
C. “Just be careful not to share linens
and towels with family members”
D. "After you're treated, family
members won't be at risk for
contracting scabies."
In an industrial accident, a client who
weighs 155 lb (70.3 kg) sustained
full-thickness burns over 40% of his body.
He's in the burn unit receiving fluid
resuscitation. Which observation shows
that the fluid resuscitation is benefiting the
client?
A. A urine output consistently above
100 ml/hour.
B. A weight gain of 4 lb (1.8 kg) in 24
hours.
C. Body temperature readings all
within normal limits
D. An electrocardiogram (ECG)
showing no arrhythmias.
The nurse is reviewing the laboratory
results of a client with rheumatoid arthritis.
Which of the following laboratory results
should the nurse expect to find?
A. Increased platelet count
B. Elevated erythrocyte sedimentation
rate (ESR)
C. Electrolyte imbalance
D. Altered blood urea nitrogen (BUN)
and creatinine levels
Which nursing diagnosis takes the highest
priority for a client with Parkinson's crisis?
A. Imbalanced nutrition: less than
body requirements
B. Ineffective airway clearance
C. Impaired urinary elimination
D. Risk for injury
A client with a spinal cord injury and
subsequent urine retention receives
intermittent catheterization every 4 hours.
The average catheterized urine volume
has been 550 ml. The nurse should plan
to:
A. Increase the frequency of the
catheterizations.
B. Insert an indwelling urinary
catheter
C. Place the client on fluid restrictions
D. Use a condom catheter instead of
an invasive one.

The nurse is caring for a client who is to
undergo a lumbar puncture to assess for
the presence of blood in the cerebrospinal
fluid (CSF) and to measure CSF pressure.
Which result would indicate an
abnormality?
A. The presence of glucose in the
CSF.
B. A pressure of 70 to 200 mm H2O
C. The presence of red blood cells
(RBCs) in the first specimen tube
D. A pressure of 00 to 250 mmH20
The nurse is administering eyedrops to a
client with glaucoma. To achieve
maximum absorption, the nurse should
instill the eyedrop into the:
A. conjunctival sac
B. pupil
C. sclera
D. vitreous humor
A 52 yr-old married man with two
adolescent children is beginning
rehabilitation following a cerebrovascular
accident. As the nurse is planning the
client's care, the nurse should recognize
that his condition will affect:
A. only himself
B. only his wife and children
C. him and his entire family
D. no one, if he has complete
recovery
Which action should take the highest
priority when caring for a client with
hemiparesis caused by a cerebrovascular
accident
A. Perform passive range-of-motion
(ROM) exercises.
B. Place the client on the affected
side.
C. Use hand rolls or pillows for
support.
D. Apply anti embolism stockings
The nurse is formulating a teaching plan
for a client who has just experienced a
transient ischemic attack (TIA). Which fact
should the nurse include in the teaching
plan?
A. TIA symptoms may last 24 to 48
hours.
B. Most clients have residual effects
after having a TIA.
C. TIA may be a warning that the
client may have cerebrovascular
accident (CVA)
D. The most common symptom of TIA
is the inability to speak.
The nurse has just completed teaching
about postoperative activity to a client who
is going to have cataract surgery. The
nurse knows the teaching has been
effective if the client:
A. coughs and deep breathes
postoperatively
B. ties his own shoes
C. asks his wife to pick up his shirt
from the floor after he drops it.
D. States that he doesn't need to
wear an eyepatch or guard to bed
The least serious form of brain trauma,
characterized by a brief loss of
consciousness and period of confusion, is
called:
A. contusion
B. concussion
C. coup
D. contrecoup
When the nurse performs a neurologic
assessment on Anne Jones, her pupils
are dilated and don't respond to light.
A. glaucoma
B. damage to the third cranial nerve
C. damage to the lumbar spine
D. Bell's palsy
A 70 yr-old client with a diagnosis of left
sided cerebrovascular accident is admitted
to the facility. To prevent the development
of diffuse osteoporosis, which of the
following objectives is most appropriate?
A. Maintaining protein levels
B. Maintaining vitamin levels.
C. Promoting weight-bearing
exercises
D. Promoting range-of-motion (ROM)
exercises
A client is admitted with a diagnosis of
meningitis caused by Neisseria
meningitidis. The nurse should institute
which type of isolation precautions?
A. Contact precautions
B. Droplet precautions
C. Airborne precautions
D. Standard precautions
A young man was running along an ocean
pier, tripped on an elevated area of the
decking, and struck his head on the pier
railing. According to his friends, "He was
unconscious briefly and then became alert
and behaved as though nothing had
happened." Shortly afterward, he began
complaining of a headache and asked to
be taken to the emergency department. If
the client's intracranial pressure (ICP) is
increasing, the nurse would expect to
observe which of the following signs first?
A. pupillary asymmetry
B. irregular breathing pattern
C. involuntary posturing
D. declining level of consciousness
Emergency medical technicians transport
a 28 yr-old iron worker to the emergency
department. They tell the nurse, "He fell
from a two-story building. He has a large
contusion on his left chest and a
hematoma in the left parietal area. He has
a compound fracture of his left femur and
he's comatose. We intubated him and he's
maintaining an arterial oxygen saturation
of 92% by pulse oximeter with a
manual-resuscitation bag." Which
intervention by the nurse has the highest
priority?
A. Assessing the left leg
B. Assessing the pupils
C. Placing the client in
Trendelenburg's position
D. Assessing the level of
consciousness
Alzheimer's disease is the secondary
diagnosis of a client admitted with
myocardial infarction. Which nursing
intervention should appear on this client's
plan of care?
A. Perform activities of daily living for
the client to decrease frustration.
B. Provide a stimulating environment.
C. Establish and maintain a routine.
D. Try to reason with the client as
much as possible.
For a client with a head injury whose neck
has been stabilized, the preferred bed
position is:
A. Trendelenburg's
B. 30-degree head elevation
C. flat
D. Side-lying
Lisa is newly diagnosed with asthma and
is being discharged from the hospital after
an episode of status asthmaticus.
Discharge teaching should include which
of the following:
A. Limitations in sports that will be
imposed by the illness
B. Specific instructions on staying cal
during an attack
C. The relationship of symptoms and
a specific trigger such as physical
exercise
D. Incidence of status asthmaticus in
children and teens
Which of the following symptoms is most
characteristic of a client with lung cancer
of the lung?
A. air hunger
B. exertional dyspnea
C. cough with night sweats
 D. persistent changing cough
The client has ST segment depression on
his 12-lead ECG. The nurse determines
that this would indicate the following:
A. necrosis
B. injury
C. ischemia
D. nothing significant
Red has just returned from the
postanesthesia care unit (PACU) from a
hemorrhoidectomy. His postoperative
orders include sitz baths every morning.
The nurse understands that sitz bath is
use for:
A. promote healing
B. relieve tension
C. lower body temperature
D. cause swelling
Trousseau's sign is associated with which
electrolyte imbalance?
A. hyponatremia
B. hypocalcemia
C. hypernatremia
D. hypercalcemia
A 36 year old female complains of
headache and neck pain. The nurse's
assessments reveal painful flexion of the
neck to the chest. The nurse understands
that nuchal rigidity is associated with:
A. brain tumor
B. CVA
C. meningitis
D. subdural hematoma
The nurse teaching the client about
behavioral changes, which can affect
development of atherosclerosis, should
discuss which of the following as a
non-modifiable risk factor for
atherosclerosis?
A. cigarette smoking
B. hyperlipidemia
C. female over 55 years of age
D. sedentary lifestyle
A 76 year old man enters the ER with
complaints of back pain and feeling
fatigued. Upon examination, his blood
pressure is 190/100, pulse is 118, and
hematocrit and hemoglobin are both low.
The nurse palpates the abdomen which is
soft, non-tender and auscultates an
abdominal pulse. The most likely
diagnosis is:
A. Buerger's disease
B. CHF
C. Secondary hypertension
D. Aneurysm
Nurse Fiona is caring for a patient with
Raynaud's disease. Which of the following
outcomes concerning medication regimen
is of highest priority
A. Controlling the pain once
vasospasm occur
B. Relaxing smooth muscle to avoid
vasospasms
C. Preventing major disabilities that
may occur
D. Avoiding lesions on the feet
Mr. Roberto Robles complains of a severe
headache and is extremely anxious. The
nurse checks his vital signs and finds him
to have a heart rate of 57 bpm and a
blood pressure of 230/110 mmg. The
nurse should also assess for?
A. presence of bowel sounds
B. presence of babinski reflex
C. fecal incontinence
D. urinary catheter patency
A 40 year old male patient complaining of
chronic progressive and mental
deterioration is admitted to the unit. The
nurse recognizes that these
characteristics indicate a disease that
results in degeneration of the basal
ganglia and cerebral cortex. The disease
is called:
A. multiple sclerosis
B. myasthenia gravis
 C. Huntington's disease
D. Guillain-Barre syndrome
Dianne Hizon is a 27 year old woman who
has been admitted to the ER due to
severe vomiting. Her ABG values are pH=
7.50, PaC02= 85, HCO3= 31, and Sa02=
93%. The nurse interpretation of this ABG
analysis is:
A. respiratory acidosis
B. respiratory alkalosis
C. metabolic acidosis
D. metabolic alkalosis
Mr. Perkson has a parkinson's disease
and he finds the resting tremor he is
experiencing in his right hand very
frustrating. The nurse advises him to:
A. take a warm bath
B. hold an object
C. practice deep breathing
D. take diazepam as needed
A shuffling gait is typically associated with
the patient who has:
A. Parkinson's disease
B. Multiple sclerosis
C. Raynaud's disease
D. Myasthenia gravis
The priority in preparing the room for a
client with a C7 spinal cord injury is
having:
A. the halo brace device
B. A catheterization tray
C. a ventilator on stand by
D. the spinal kinetic bed
A 47 year old man with liver failure who
has developed ascites. The nurse
understands that ascites is due to:
A. dehydration
B. protein deficiency
C. bleeding disorders
D. vitamin deficiency
A client with rheumatoid arthritis may
reveal which of the following assessment
data:
A. Heberden's nodes
B. Morning stiffness no longer than 30
minutes
C. Asymmetric joint swelling
D. Swan neck deformities
Elsa Santos is a 18 year old student
admitted to the ward with a diagnosis of
epilepsy. She tells the nurse that she is
experiencing a generalized tingling
sensation and is "smelling roses". The
nurse understands that Esla is probably
experiencing:
A. an acute alcohol withdrawal
B. an acute CVA
C. an aura
D. an olfactory hallucination
Mr. Lucas, a 63 year old, went to the clinic
complaining of hoarseness of voice and a
cough. His wife states that his voice has
changed in the last few months. The nurse
interprets that Mr. Lucas's symptoms are
consistent with which of the following
disorders:
A. chronic sinusitis
B. laryngeal cancer
C. gastroesophageal reflux disease
D. coronary artery disease
Sarah complains of a nursing sensation,
cramping pain in the top part of her
abdomen that becomes worse in the
afternoon and sometimes awakes her at
night. She reports that when she eats, it
helps the pain go away but that pain is
now becoming more intense. Which of the
following is the best condition for the
nurse to draw:
A. these symptoms are consistent
with an ulcer
B. The client probably has indigestion
C. A snack before going to bed
should be advised
 D. The client probably developing
cholelithiasis
Nurse Cynthia is providing discharge
teaching to a client with chronic cirrhosis.
His wife asks her to explain why there is
so much emphasis on bleeding
precautions. Which of the following
provides the most appropriate response?
A. "The low protein diet will result in
reduced clotting."
B. "The increased production of bile
decreases clotting factors."
C. "The liver affected by cirrhosis is
unable to produce clotting factors."
D. "The required medications reduce
clotting factors."
Betty Lee is a 58 year old woman who is
being admitted to the medical ward with
trigeminal neuralgia. The nurse anticipates
that Mr. Lee will demonstrate which of the
following major complaints?
A. excruciating, intermittent,
paroxysmal facial pain
B. unilateral facial droop
C. painless eye spasm
D. mildly painful unilateral eye
twitching
A 38 year old woman returns from a
subtotal thyroidectomy for the treatment of
hyperthyroidism. Upon assessment, the
immediate priority that the nurse would
include is:
A. Assess for pain
B. Assess for neurological status
C. Assess fluid volume status
D. Assess for respiratory distress
Nurse Shiela is teaching self-care to a
client with psoriasis. The nurse should
encourage which of the following for his
scaled lesion?
A. Importance of follow-up
appointments
B. Emollients and moisturizers to
soften scales
C. Keep occlusive dressings on the
lesions 24 hours a day
D. Use of a clean razor blade each
time he shaves
A 48 year old woman presents to the
hospital complaining of chest pain,
tachycardia and dyspnea. On exam, heart
sounds are muffled. Which of the following
assessment findings would support a
diagnosis of cardiac tamponade?
A. A deviated trachea
B. Absent breath sounds to the lower
lobes
C. Pulse 40 with inspiration
D. Blood pressure 140/80
Situation 1 – Because of the serious
consequences of severe burns,
management requires a multidisciplinary
approach. You have important
responsibilities as a nurse.
While Sergio was lighting a barbecue grill
with a lighter fluid, his shirt burned into
flames. The most effective way to extinguish
the flames with as little further damage as
possible is to:
A. log roll on the grass/ground
B. slap the flames with his hands
C. remove the burning clothes
D. pour cold liquid over the flames
Once the flames are extinguished, it is most
important to:
A. cover Sergio with a warm blanket
B. give him sips of water
C. calculate the extent of his burns
D. assess the Sergio’s breathing
Sergio is brought to the Emergency Room
after the barbecue grill accident. Based on
the assessment of the physician, Sergio
sustained superficial partial thickness burns
on his trunk, right upper extremities and
right lower extremities. His wife asks what
that means? Your most accurate response
would be:
 A. Structures beneath the skin are
damage
B. Dermis is partially damaged
C. Epidermis and dermis are both
damaged
D. Epidermis is damaged
During the first 24 hours after the thermal
injury, you should asses Sergio for
A. hypokalemia and hypernatremia
B. hypokalemia and hyponatremia
C. hyperkalemia and hyponatremia
D. hyperkalemia and hypernatremia
Teddy, who sustained deep partial
thickness and full thickness burns of the
face, whole anterior chest and both upper
extremities two days ago begins to exhibit
extreme restlessness. You recognize that
this most likely indicates that Teddy is
developing:
A. Cerebral hypoxia
B. Hypervolemia
C. metabolic acidosis
D. Renal failure
Situation 2 – You are now working as a
staff nurse in a general hospital. You have
to be prepared to handle situations with
ethico-legal and moral implications.
You are in night duty in surgical ward. One
of your patients Martin is a prisoner who
sustained an abdominal gunshot wound.
He is being guarded by policeman from
the local police unit. During your rounds
you heard a commotion. You saw the
policeman trying to hit Martin. You asked
why he was trying to hit Martin. He denied
the matter. Which among the following
activities will you do first?
A. Write an accident report
B. Call security officer and report the
incident
C. Call your nurse supervisor and
report the incident
D. Call the physician on duty
You are on morning duty in the medical
ward. You have 10 patients assigned to
you. During your endorsement rounds,
you found out that one of your patients
was not in bed. The patient next to him
informed you that he went home without
notifying the nurses. Which among the
following will you do first?
A. Make an incident report
B. Call security to report the incident
C. Wait for 2 hours before reporting
D. Report the incident to your
supervisor
You are on duty in the medical ward. You
were asked to check the narcotics cabinet.
You found out that what is on record does
not tally with the drugs used. Which
among the following will you do first?
A. Write an incident report and refer
the matter to the nursing director
B. Keep your findings to yourself
C. Report the matter to your
supervisor
D. Find out from the endorsement any
patient who might have been given
narcotics
You are on duty in the medical ward. The
mother of your patient who is also a nurse,
came running to the nurses station and
informed you that Fiolo went into
cardiopulmonary arrest.
A. Start basic life support measures
B. Call for the Code
C. Bring the crush cart to the room
D. Go to see Fiolo and assess for
airway patency and breathing
problems
You are admitting Jorge to the ward and
you found out that he is positive for HIV.
Which among the following will you do
first?
A. Take note of it and plan to endorse
this to next shift
B. Keep this matter to yourself
C. Write an incident report
 D. Report the matter to your head
nurse
Situation 3 - Colorectal cancer can affect
old and younger people. Surgical
procedures and other modes of treatment
are done to ensure quality of life. You are
assigned to the cancer institute to care for
patients with this type of cancer.
Larry, 55 years old, who is suspected of
having colorectal cancer, is admitted to the
CI. After taking the history and vital signs
the physician does which test as a
screening test for colorectal cancer.
A. Barium enema
B. Carcinoembryonic antigen
C. Annual digital rectal examination
D. Proctosigmoidoscopy
To confirm his impression of colorectal
cancer, Larry will require which diagnostic
study?
A. Carcinoembryonic antigen
B. Proctosigmoidoscopy
C. Stool hematologic test
D. Abdominal computed tomography
(CT) test
The following are risk factors for colorectal
cancer, EXCEPT:
A. Inflammatory bowels
B. High fat, high fiber diet
C. Smoking
D. Genetic factors-familial
adenomatous polyposis
Symptoms associated with cancer of the
colon include:
A. constipation, ascites and mucus in
the stool
B. diarrhea, heart burn and eructation
C. blood in the stools, anemia, and
"pencil shaped" stools
D. anorexia, hematemesis, and
increased peristalasis
Several days prior to bowel surgery, Larry
may be given sulfasuxidine and neomycin
primarily to:
A. promote rest of the bowel by
minimizing peristalsis
B. reduce the bacterial content of the
colon
C. Empty the bowel of solid waste
D. Soften the stool by retaining water
in the colon
Situation 4 - ENTEROSTOMAL
THERAPY is now considered a specialty
in nursing. You are participating in the
OSTOMY CARE CLASS.
You plan to teach Fermin how to irrigate
the colostomy when:
A. The perineal wound heals And
Fermin can sit comfortably on the
commode
B. Fermin can lie on the side
comfortably, about the 3rd
postoperative day
C. The abdominal incision is closed
and contamination is no longer a
danger
D. The stools starts to become
formed, around the 7th
postoperative day
When preparing to teach Fermin how to
irrigate colostomy, you should plan to do
the procedure:
A. When Fermin would have normal
bowel movement
B. At least 2 hours before visiting
hours
C. Prior to breakfast and morning
care
D. After Fermin accepts alteration in
body image
When observing a return demonstration of
a colostomy irrigation, you know that more
teaching is required if Fermin:
A. Lubricates the tip of the catheter
prior to inserting into the stoma
 B. Hangs the irrigating bag on the
bathroom door cloth hook during
fluid insertion
C. Discontinues the insertion of fluid
after only 500 ml of fluid has been
instilled
D. Clamps of the flow of fluid when
felling uncomfortable
You are aware that teaching about
colostomy care is understood when
Fermin states, "I will contact my physician
and report:
A. “If I have any difficulty inserting the
irrigating tub into the stoma."
B. “If I noticed a loss of sensation to
touch in the stoma tissue."
C. “The expulsion of flatus while the
irrigating fluid is running out."
D. “When mucus is passed from the
stoma between the irrigations."
You would know after teaching Fermin that
dietary instruction for him is effective when
he states, "It is important that I eat:
A. “Soft food that are easily digested
and absorbed by my large
intestines.”
B. “Bland food so that my intestines
do not become irritated.”
C. “Food low in fiber so that there is
less stool.”
D. “Everything that I ate before the
operation, while avoiding foods
that cause gas.”
Situation 5 – Ensuring safety is one of
your most important responsibilities. You
will need to provide instructions and
information to your clients to
prevent complications.
Randy has chest tubes attached to a
pleural drainage system. When caring for
him you should:
A. empty the drainage system at the
end of the shift
B. clamp the chest tube when
suctioning
C. palpate the surrounding areas for
crepitus
D. change the dressing daily using
aseptic techniques
Fanny, came in from PACU after pelvic
surgery. As Fanny’s nurse you know that
the sign that would be indicative of a
developing thrombophlebitis would be:
A. a tender, painful area on the leg
B. a pitting edema of the ankle
C. a reddened area at the ankle
D. pruritus on the calf and ankle
To prevent recurrent attacks on Terry who
has acute glomerulonephritis, you should
instruct her to:
A. seek early treatment for respiratory
infections
B. take showers instead of tub bath
C. continue to take the same
restrictions on fluid intake
D. avoid situations that involve
physical activity
Herbert had a laryngectomy and he is now
for discharge. He verbalized his concern
regarding his laryngectomy tube being
dislodged. What should you teach him
first?
A. Recognize that prompt closure of
the tracheal opening may occur
B. Keep calm because there is no
immediate emergency
C. Reinsert another tubing
immediately
D. Notify the physician at once
When caring for Larry after an exploratory
chest surgery and pneumonectomy, your
priority would be to maintain:
A. supplementary oxygen
B. ventilation exchange
C. chest tube drainage
D. blood replacement
Situation 6 – Infection can cause
debilitating consequences when host
resistance is compromised and virulence
of microorganisms and environmental
factors are favorable. Infection control is
one important responsibility of the nurse to
ensure quality of care.
Honrad, who has been complaining of
anorexia and feeling tired, develops
jaundice, after a workup he is diagnosed
of having Hepatitis A. his wife asks you
about gamma globulin for herself and her
household help. Your most appropriate
response would be:
A. “Don’t worry your husband’s type
of hepatitis is no longer
communicable”
B. “Gamma globulin provides passive
immunity for hepatitis B”
C. “You should contact your physician
immediately about getting
gammaglobulin.”
D. “A vaccine has been developed for
this type of hepatitis”
Voltaire develops a nosocomial respiratory
tract infection. He asks you what that
means? Your best response would be:
A. “You acquired the infection after
you have been admitted to the
hospital.”
B. “This is a highly contagious
infection requiring complete
isolation.”
C. “The infection you had prior to
hospitalization flared up.”
D. “As a result of medical treatment,
you have acquired a secondary
infection.’
As a nurse you know that one of the
complications that you have to watch out
for when caring for Omar who is receiving
total parenteral nutrition is:
A. stomatitis
B. hepatitis
C. dysrhythmia
D. infection
A solution used to treat Pseudomonas
wound infection is:
A. Dakin’s solution
B. Half-strength hydrogen peroxide
C. Acetic acid
D. Betadine
Which of the following is the most reliable
in diagnosing a wound infection?
A. Culture and sensitivity
B. Purulent drainage from a wound
C. WBC count of 20,000/μL
D. Gram stain testing
Situation 7 – As a nurse you need to
anticipate the occurrence of complications
of stroke so that life threatening situations
can be prevented.
Wendy is admitted to the hospital with
signs and symptoms of stroke. Her
Glasgow Coma Scale is 6 on admission. A
central venous catheter was inserted and
an infusion was started. As a nurse
assigned to Wendy, what will be your
priority goal?
A. Prevent skin breakdown
B. Preserve muscle function
C. Promote urinary elimination
D. Maintain a patent airway
Knowing that for a comatose patient
hearing is the last sense to be lost, as
Judy’s nurse, what should you do?
A. Tell her family that probably she
can’t hear them
B. Talk loudly so that Wendy can hear
you
C. Tell her family who are in the room
not to talk
D. Speak softly then hold her hands
gently
Which among the following interventions
should you consider as the highest priority
when caring for June who has
hemiparesis secondary to stroke?
A. Place June on an upright lateral
position
B. Perform range of motion exercises
C. Apply antiembolic stockings
D. Use hand rolls or pillows for
support
Ivy, age 40, was admitted to the hospital
with a severe headache, stiff neck and
photophobia. She was diagnosed with a
subarachnoid hemorrhage secondary to
ruptured aneurysm. While waiting for
surgery, you can provide a therapeutic
environment by doing which of the
following?
A. honoring her request for a
television
B. placing her bed near the window
C. dimming the light in her room
D. allowing the family unrestricted
visiting privileges
When performing a neurologic
assessment on Walter, you find that his
pupils are fixed and dilated. This indicated
that he:
A. probably has meningitis
B. is going to be blind because of
trauma
C. is permanently paralyzed
D. has received a significant brain
injury
Situation 8 - With the improvement in life
expectancies and the emphasis in the
quality of life it is important to provide
quality care to our older patients. There
are frequently encountered situations and
issues relevant to the older patients.
Hypoxia may occur in the older patients
because of the following physiologic
changes associated with aging.
A. Ineffective airway clearance
B. Decreased alveolar surface area
C. Decreased anterior-posterior chest
diameter
D. Hyperventilation
The older patient is at higher risk for
incontinence because of:
A. dilated urethra
B. increased glomerular filtration rate
C. diuretic use
D. decreased bladder capacity
Merle, age 86, is complaining of dizziness
when she stands up. This may indicate:
A. dementia
B. a visual problem
C. functional decline
D. drug toxicity
Cardiac ischemia in an older patient
usually produces:
A. ST-T wave changes
B. Very high creatinine kinase level
C. Chest pain radiating to the left arm
D. Acute confusion
The most dependable sign of infection in
the older patient is:
A. change in mental status
B. fever
C. pain
D. Decreased breath sounds
Situation 9 - A "disaster" is a large-scale
emergency-even a small emergency left
unmanaged may turn into a disaster.
Disaster preparedness is crucial and is
everybody's business. There are agencies
that are in charge of ensuring prompt
response. Comprehensive Emergency
Management (CEM) is an integrated
approach to the management of
emergency programs and activities for all
four emergency phases (mitigation,
preparedness, response, and recovery),
for all types of emergencies and disasters
(natural, man-made, and attack) and for all
levels of government and the private
sector.
Which of the four phases of emergency D. Urgent
management is defined as “sustained
action that reduces or eliminates long-term Which of the following terms refer to a
risk to people and property from natural process by which the individual receives
hazards and their effects.”? education about recognition of stress
A. Recovery reaction and management
B. Mitigation strategies for handling stress which may
C. Response be instituted after a disaster?
D. Preparedness A. Clinical incident stress
management
You are a community health nurse B. Follow-up
collaborating with the Red Cross and C. Debfriefing
working with disaster relief following a D. Defusion
typhoon which flooded and devastated the
whole province. Finding safe housing for Situation 10 – As a member of the health
survivors, organizing support for the and nursing team you have a crucial role
family, organizing counseling debriefing to play in ensuring that all the members
sessions and securing physical care are participate actively in the various tasks
the services you are involved with. To agreed upon.
which type of prevention are these
activities included: While eating his meal, Matthew
A. Tertiary prevention accidentally dislodges his IV lines and
B. Primary prevention bleeds. Blood oozes on the surface of the
C. Aggregate care prevention overbed table. It is most appropriate that
D. Secondary prevention you instruct the housekeeper to clean the
table with:
During the disaster you see a victim with a A. Acetone
green tag, you know that the person: B. Alcohol
A. has injuries that are significant and C. Ammonia
require medical care but can wait D. Bleach
hours with threat to life or limb
B. has injuries that are life threatening You are a member of the infection control
but survival is good with minimal team of the hospital. Based on a feedback
intervention during the meeting of the committee there
C. indicates injuries that are extensive is an increased incidence of
and chances of survival are pseudomonas infection in the Burn Unit (3
unlikely even with definitive care out of 10 patients had positive blood and
D. has injuries that are minor and wound culture). What is your priority
treatment can be delayed from activity?
hours to days A. Establish policies for surveillance
and monitoring
The term given to a category of triage that B. Do data gathering about the
refers to life threatening or potentially life possible sources of infection
threatening injury or illness requiring (observation, chart review,
immediate treatment: interview).
A. Immediate C. Assign point persons who can
B. Emergent implement policies.
C. Non-acute
 D. Meet with the nursing group
working in the burn unit and
discuss problems with them.
Part of your responsibility as a member of
the diabetes core group is to get referrals
from the various wards regarding diabetic
patients needing diabetes education. Prior
to discharge today, 4 patients are referred
to you. How would you start prioritizing
your activities?
A. Bring your diabetes teaching kit
and start your session taking into
consideration their distance from
your office.
B. Contact the nurse in-charge and
find out from her the reason for the
referral
C. Determine their learning needs
then prioritize
D. Involve the whole family in the
teaching class
You have been designated as a member
of the task force to plan activities for the
Cancer Consciousness Week. Your
committee has 4 months to plan and
implement the plan. You are assigned to
contact the various cancer support groups
in your hospital. What will be
your priority activity?
A. Find out if there is a budget for this
activity
B. Clarify objectives of the activity
with the task force before
contacting the support groups
C. Determine the VIPs and Celebrities
who will be invited
D. Find out how many support groups
there are in the hospital and get
the contact number of their
president
You are invited to participate in the
medical mission activity of your alumni
association. In the planning stage
everybody is expected to identify what
they can do during the medical mission
and what resources are needed. You
thought it is also your chance to share
what you can do for others. What will be
your most important role where you can
demonstrate the impact of nursing in
health?
A. Conduct health education on
healthy lifestyle
B. Be a triage nurse
C. Take the initial history and
document findings
D. Act as a coordinator
Situation 11 – One of the realities that we
are confronted with is our mortality. It is
important for us nurses to be aware of
how we view suffering, pain, illness, and
even our death as well as its meaning.
That way we can help our patients cope
with death and dying.
Irma is terminally ill, she speaks to you in
confidence. You now feel that Irma’s family
could be helpful if they knew what Irma
has told you. What should you do first?
A. Tell the physician who in turn could
tell the family
B. Obtain Irma’s permission to share
the information in the family
C. Tell Irma that she has to tell her
family what she told you
D. Make an appointment to discuss
the situation with the family
Ruby who has been told she has terminal
cancer, turns away and refuses to respond
to you. You can best help her by:
A. Coming back periodically and
indicating your availability if she
would like you to sit with her
B. Insisting that Ruby should talk with
you because it is not good to keep
everything inside
C. Leaving her alone because she is
uncooperative and unpleasant to
be with
D. Encouraging her to be physically
active as possible

Leo, who is terminally ill and recognizes
that he is in the process of losing
everything and everybody he loves, is
depressed. Which of the following would
best help him during his depression?
A. Arrange for visitors who might
cheer him
B. Sit down and talk with him for a
while
C. Encourage him to look at the
brighter side of things
D. Sit silently with him
Which of the following statements would
best indicate that Ruffy, who is dying, has
accepted his impending death?
A. "I'm ready to go."
B. "I have resigned myself to dying."
C. "What's the use”
D. "I'm giving up"
Marla, 90 years old has planned ahead for
her death-philosophically, socially,
financially and emotionally. This is
recognized as:
A. Acceptance that death is inevitable
B. Avoidance of the true situation
C. Denial with planning for continued
life
D. Awareness that death will soon
occur
Situation 12 - Brain tumor, whether
malignant or benign, has serious
management implications. As a nurse, you
should be able to understand the
consequences of the disease and the
treatment.
You are caring for Conrad who has a brain
tumor and increased Intracranial Pressure
(ICP). Which intervention should you
include in your plan to reduce ICP?
A. Administer bowel softener
B. Position Conrad with his head
turned toward the side of the tumor
C. Provide sensory stimulation
D. Encourage coughing and deep
breathing
Keeping Conrad's head and neck
alignment results in:
A. increased intrathoracic pressure
B. increased venous outflow
C. decreased venous outflow
D. increased intraabdominal pressure
Which of the following activities may
increase intracranial pressure (ICP)?
A. Raising the head of the bed
B. Manual hyperventilation
C. Use of osmotic diuretics
D. Valsalva's maneuver
After you assess Conrad, you suspected
increased ICP. Your most appropriate
respiratory goal is to:
A. maintain partial pressure of arterial
02 (Pa02) above 80 mmHg
B. lower arterial pH
C. prevent respiratory alkalosis
D. promote CO2 elimination
Conrad underwent craniotomy. As his
nurse, you know that drainage on a
craniotomy dressing must be measured
and marked. Which findings should you
report immediately to the surgeon?
A. Foul-smelling drainage
B. Yellowish drainage
C. Greenish drainage
D. Bloody drainage
Situation 13 – As a Nurse, you have
specific responsibilities as a professional.
You have to demonstrate specific
competencies.
The essential components of professional
nursing practice are all the following
EXCEPT:
A. Culture
B. Care
C. Cure
D. Coordination
 C. Allow Vincent uninterrupted period
You are assigned to care for four (4) of time
patients. Which of the following patients D. Limit Vincent’s visitors to coincide
Should you give first priority? with CCU policies
A. Grace, who is terminally ill with
breast cancer. Situation 14 – As a nurse in the Oncology
B. Emy, who was previously lucid but Unit, you have to be prepared to provide
is now unarousable. safe, efficient and effective care to your
C. Aris, who is newly admitted and is patients.
scheduled for an executive
check-up. Which one of the following nursing
D. Claire, who has cholelithiasis and interventions would be most helpful in
is for operation on call. preparing the patient for radiation
therapy?
Brenda, the Nursing Supervisor of the A. Offer tranquilizers and antiemetics
intensive care unit (ICU) is not on duty B. Instruct the patient of the possibility
when a staff nurse committed a serious of radiation burn
medication error. Which statement C. Emphasis on the therapeutic value
accurately reflects the accountability of the of the treatment
nursing supervisor? D. Map out the precise course of
A. Brenda should be informed when treatment
she goes back on duty
B. Although Brenda is not on duty, the What side effects are most apt to occur
nursing supervisor on duty decides the patient during radiation therapy to the
to call her if time permits pelvis?
C. The nursing supervisor on duty will A. Urinary retention
notify Brenda at home B. Abnormal vaginal or perineal
D. Brenda is not duty therefore it is discharge
not necessary to inform her. C. Paresthesia of the lower
extremities
Which barrier should you avoid, to D. Nausea and vomiting and diarrhea
manage time wisely?
A. Practical planning Which of the following can be used on the
B. Procrastination irradiated skin during a course of radiation
C. Setting limits therapy?
D. Realistic personal expectation A. Adhesive tape
B. Mineral oil
You are caring for Vincent who has just C. Talcum powder
been transferred to the private room. He is D. Zinc oxide ointment
anxious because he fears he won’t be
monitored as closely as he was in the Earliest sign of skin reaction to radiation
Coronary Care Unit. How can you allay his therapy is:
fear? A. desquamation
A. Move his bed to a room far from B. erythema
nurse’s station to reduce C. atrophy
B. Assign the same nurse to him D. pigmentation
when possible What is the purpose of wearing a film
badge while caring for the patient who is
radioactive?
A. Identify the nurse who is assigned
to care for such a patient
B. Prevent radiation-induced sterility
C. Protect the nurse from radiation
effects
D. Measure the amount of exposure
to radiation
Situation 15 – In a disaster there must be
a chain of command in place that defines
the roles of each member of the response
team. Within the health care group there
are pre-assigned roles based on
education, experience and training on
disaster.
As a nurse, which of the following groups
are you best prepared to join?
A. Treatment group
B. Triage group
C. Morgue management
D. Transport group
There are important principles that should
guide the triage team in disaster
management that you have to know if you
were to volunteer as part of the triage
team. The following principles should be
observed in disaster triage, EXCEPT:
A. any disaster plan should have
resources available to triage at
each facility and at the disaster site
if possible
B. make the most efficient use of
available resources
C. training on the disaster is not
important to the response in the
event of a real disaster because
each disaster is unique in itself
D. do the greatest good for the
greatest number of casualties
Which of the following categories of
conditions should be considered first
priority in a disaster?
A. Intracranial pressure and mental
status
B. Lower gastrointestinal problems
C. Respiratory infections
D. Trauma
A guideline that is utilized in determining
priorities is to assess the status of the
following, EXCEPT:
A. perfusion
B. locomotion
C. respiration
D. mentation
The most important component of
neurologic assessment is:
A. pupil reactivity
B. vital sign assessment
C. cranial nerve assessment
D. level of
consciousness/responsiveness
Situation 16 - You are going to participate
in Cancer Consciousness Week. You are
assigned to take charge of the women to
make them aware of cervical cancer. You
reviewed its manifestations and
management,
The following are risk factors for cervical
cancer EXCEPT:
A. immunosuppressive therapy
B. sex at an early age, multiple
partners, exposure to socially
transmitted disease, male partner's
sexual habits
C. viral agents like the Human
Papillomavirus
D. smoking
Late signs and symptoms of cervical
cancer include the following EXCEPT:
A. urinary/bowel changes
B. pain in pelvis, leg or flank
C. uterine bleeding
D. lymph edema of lower extremities
When a panhysterectomy is performed
due to cancer of the cervix, which of the
following organs are removed?
 A. the uterus, cervix, and one ovary following thyroidectomy. You should
B. the uterus, cervix, and two-thirds of include:
the vagina A. An airway and rebreathing tube
C. the uterus, cervix, tubes and B. A tracheostomy set and oxygen
ovaries C. A crush cart with bed board
D. the uterus and cervix D. Two ampules of sodium
bicarbonate
The primary modalities of treatment for
Stage 1 and IIA cervical cancer include Which of the following nursing
the following: interventions is appropriate after a total
A. surgery, radiation therapy and thyroidectomy?
hormone therapy A. Place pillows under your patient’s
B. surgery shoulders.
C. radiation therapy B. Raise the knee-gatch to 30
D. surgery and radiation therapy degrees
C. Keep you patient in a high-fowler’s
A common complication of hysterectomy position.
is D. Support the patient’s head and
A. thrombophlebitis of the pelvic and neck with pillows and sandbags.
thigh vessels
B. diarrhea due to overstimulation If there is an accidental injury to the
C. atelectasis parathyroid gland during a thyroidectomy
D. wound dehiscence which of the following might Leda develop
postoperatively?
Situation 17 – The body has regulatory A. Cardiac arrest
mechanism to maintain the needed B. Dyspnea
electrolytes. However there are C. Respiratory failure
conditions/surgical interventions that could D. Tetany
compromise life. You have to understand
how management of these conditions are After surgery Leda develops peripheral
done. numbness, tingling and muscle twitching
and spasm. What would you anticipate to
You are caring for Leda who is scheduled administer?
to undergo total thyroidectomy because of A. Magnesium sulfate
a diagnosis of thyroid cancer. Prior to total B. Calcium gluconate
thyroidectomy, you should instruct Leda C. Potassium iodide
to: D. Potassium chloride
A. Perform range and motion exercise
on the head and neck Situation 18 – NURSES are involved in
B. Apply gentle pressure against the maintaining a safe and healthy
incision when swallowing environment. This is part of quality care
C. Cough and deep breath every 2 management.
hours
D. Support head with the hands when The first step in decontamination is:
changing position A. to immediately apply a chemical
As Leda’s nurse, you plan to set up decontamination foam to the area
emergency equipment at her beside of contamination
 B. a through soap and water wash
and rinse of the patient
C. to immediately apply personal
protective equipment
D. removal of the patients clothing
and jewelry and then rinsing the
patient with water
For a patient experiencing pruritus, you
recommend which type of bath.
A. water
B. colloidal (oatmeal)
C. saline
D. sodium bicarbonate
Induction of vomiting is indicated for the
accidental poisoning patient who has
ingested.
A. rust remover
B. gasoline
C. toilet bowl cleaner
D. aspirin
Which of the following terms most
precisely refer to an infection acquired in
the hospital that was not present or
incubating at the same time of hospital
admission?
A. Secondary bloodstream infections
B. Nosocomial infection
C. Emerging infectious disease
D. Primary bloodstream infection
Which of the following guidelines is not
appropriate to helping family members
cope with sudden death?
A. Obtain orders for sedation of family
members
B. Provide details of the factors
attendant to the sudden death
C. Show acceptance of the body by
touching it and giving the family
permission to touch
D. Inform the family that the patient
has passed on
Situation 19 – As a nurse you are
expected to participate in initiating or
participating in the conduct of research
studies to improve nursing practice. You
have to be updated on the latest trends
and issues affecting the profession and
the best practices arrived at by the
profession.
You are interested in studying the effects
of meditation and relaxation on the pain
experienced by cancer patients. What type
of variable is pain?
A. Dependent
B. Correlational
C. Independent
D. Demographic
You would like to compare the support
system of patients with chronic illness to
those with acute illness. How will you best
state your problem?
A. A Descriptive Study To Compare
The Support System Of Patients
With Chronic Illness And Those
With Acute Illness In Terms Of
Demographic Data And Knowledge
About Interventions.
B. The Effect Of The Type Of Support
System of Patients With Chronic
Illness And Those With Acute
Illness.
C. A Comparative Analysis Of The
Support System Of Patients With
Chronic Illness And Those With
Acute Illness.
D. A Study To Compare The Support
System Of Patients With Chronic
Illness And Those With Acute
Illness.
You would like to compare the support
system of patients with chronic illness to
those with acute illness. What type of
research is this?
A. Correlational
B. Descriptive
C. Experimental
D. Quasi-experimental
You are shown a Likert Scale that will be C. Silver sulfadiazine
used in evaluating your performance in D. Sulfamylon
the clinical area. Which of the following
questions will you not use in critiquing the Hypertrophic burn scars are caused by:
Likert Scale? A. exaggerated contraction
A. Are the techniques to complete B. random layering of collagen
and score the scale provided? C. wound ischemia
B. Are the reliability and validity D. delayed epithelialization
information on the scale
described? The major disadvantage of whirlpool
C. If the Likert scale is to be used for cleansing of burn wound is:
a study, was the development A. patient hypothermia
process described? B. cross contamination of wound
D. Is the instrument clearly C. Patient discomfort
described? D. Excessive manpower requirement

In any research study where individual Oral analgesics are most frequently used
persons are involved, it is important that to control burn injury pain:
an informed consent for the study is A. upon patient request
obtained. The following are essential B. during the emergent phase
information about the consent that you C. after hospital discharge
should disclose to the prospective D. during the acute phase
subjects
A. Consent to incomplete disclosure
B. Descriptions of benefits, risks and
discomforts
C. Explanation of procedure
D. Assurance of anonymity and
confidentiality

Situation 20 - Because severe burn can

affect the person's totality it is important
that-you apply interventions focusing on
the various dimensions of man. You also
have to understand the rationale of the
treatment.

What type of debridement involves

proteolytic enzymes?
A. Interventional
B. Mechanical
C. Surgical
D. Chemical

Which topical antimicrobial is most

frequently used in burn wound care?
A. Neosporin
B. Silver nitrate