نماذج امتحانات اساسيات تمريض

1 ‫شبكة ومنتديات بيث التمريض‬
Fundamentals of Nursing
Nursing Process
1. Once a nurse assesses a client’s condition and identifies appropriate nursing diagnoses, a:
1. Plan is developed for nursing care.

2. Physical assessment begins
3. List of priorities is determined.
4. Review of the assessment is conducted with other team members.
2. Planning is a category of nursing behaviors in which:
1. The nurse determines the health care needed for the client.
2. The Physician determines the plan of care for the client.
3. Client-centered goals and expected outcomes are established.
4. The client determines the care needed.
3. Priorities are established to help the nurse anticipate and sequence nursing interventions when a
client has multiple problems or alterations. Priorities are determined by the client’s:
1. Physician
2. Non Emergent, non-life threatening needs
3. Future well-being.
4. Urgency of problems
4. A client centered goal is a specific and measurable behavior or response that reflects a client’s:
1. Desire for specific health care interventions

2. Highest possible level of wellness and independence in function.
3. Physician’s goal for the specific client.
4. Response when compared to another client with a like problem.
5. For clients to participate in goal setting, they should be:
‫ أبو أمحد‬- ‫ حسن عصغور‬/‫اعداد‬

1. Alert and have some degree of independence.

2. Ambulatory and mobile.
3. Able to speak and write.
4. Able to read and write.
6. The nurse writes an expected outcome statement in measurable terms. An example is:
1. Client will have less pain.

2. Client will be pain free.
3. Client will report pain acuity less than 4 on a scale of 0-10.
4. Client will take pain medication every 4 hours around the clock.
7. As goals, outcomes, and interventions are developed, the nurse must:
1. Be in charge of all care and planning for the client.

2. Be aware of and committed to accepted standards of practice from nursing and other disciples.
3. Not change the plan of care for the client.
4. Be in control of all interventions for the client.
8. When establishing realistic goals, the nurse:
1. Bases the goals on the nurse’s personal knowledge.

2. Knows the resources of the health care facility, family, and the client.
3. Must have a client who is physically and emotionally stable.
4. Must have the client’s cooperation.
9. To initiate an intervention the nurse must be competent in three areas, which include:
1. Knowledge, function, and specific skills

2. Experience, advanced education, and skills.
3. Skills, finances, and leadership.
4. Leadership, autonomy, and skills.
10. Collaborative interventions are therapies that require:
1. Physician and nurse interventions.

2. Nurse and client interventions.
3. Client and Physician intervention.
4. Multiple health care professionals.
11. Well formulated, client-centered goals should:
1. Meet immediate client needs.

2. Include preventative health care.

3. Include rehabilitation needs.

4. All of the above.
12. The following statement appears on the nursing care plan for an immunosuppressed client: The
client will remain free from infection throughout hospitalization. This statement is an example of a
(an):
1. Nursing diagnosis
2. Short-term goal
3. Long-term goal
4. Expected outcome
13. The following statements appear on a nursing care plan for a client after a mastectomy: Incision
site approximated; absence of drainage or prolonged erythema at incision site; and client remains
afebrile. These statements are examples of:
1. Nursing interventions
2. Short-term goals
3. Long-term goals
4. Expected outcomes.
14. The planning step of the nursing process includes which of the following activities?
1. Assessing and diagnosing

2. Evaluating goal achievement.
3. Performing nursing actions and documenting them.
4. Setting goals and selecting interventions.
15. The nursing care plan is:
1. A written guideline for implementation and evaluation.

2. A documentation of client care.
3. A projection of potential alterations in client behaviors
4. A tool to set goals and project outcomes.
16. After determining a nursing diagnosis of acute pain, the nurse develops the following appropriate
client-centered goal:
1. Encourage client to implement guided imagery when pain begins.

2. Determine effect of pain intensity on client function.
3. Administer analgesic 30 minutes before physical therapy treatment.
4. Pain intensity reported as a 3 or less during hospital stay.

17. When developing a nursing care plan for a client with a fractured right tibia, the nurse includes in
the plan of care independent nursing interventions, including:
1. Apply a cold pack to the tibia.

2. Elevate the leg 5 inches above the heart.
3. Perform range of motion to right leg every 4 hours.
4. Administer aspirin 325 mg every 4 hours as needed.
18. Which of the following nursing interventions are written correctly? (Select all that apply.)
1. Apply continuous passive motion machine during day.

2. Perform neurovascular checks.
3. Elevate head of bed 30 degrees before meals.
4. Change dressing once a shift.
19. A client’s wound is not healing and appears to be worsening with the current treatment. The nurse
first considers:
1. Notifying the physician.

2. Calling the wound care nurse
3. Changing the wound care treatment.
4. Consulting with another nurse.
20. When calling the nurse consultant about a difficult client-centered problem, the primary nurse is
sure to report the following:
1. Length of time the current treatment has been in place.

2. The spouse’s reaction to the client’s dressing change.
3. Client’s concern about the current treatment.
4. Physician’s reluctance to change the current treatment plan.
21. The primary nurse asked a clinical nurse specialist (CNS) to consult on a difficult nursing problem.
The primary nurse is obligated to:
1. Implement the specialist’s recommendations.

2. Report the recommendations to the primary physician.
3. Clarify the suggestions with the client and family members.
4. Discuss and review advised strategies with CNS.
22. After assessing the client, the nurse formulates the following diagnoses. Place them in order of
priority, with the most important (classified as high) listed first.
1. Constipation
2. Anticipated grieving

3. Ineffective airway clearance

4. Ineffective tissue perfusion.
23. The nurse is reviewing the critical paths of the clients on the nursing unit. In performing a variance
analysis, which of the following would indicate the need for further action and analysis?
1. A client’s family attending a diabetic teaching session.

2. Canceling physical therapy sessions on the weekend.
3. Normal VS and absence of wound infection in a post-op client.
4. A client demonstrating accurate medication administration following teaching.
24. The RN has received her client assignment for the day-shift. After making the initial rounds and
assessing the clients, which client would the RN need to develop a care plan first?
1. A client who is ambulatory.

2. A client, who has a fever, is diaphoretic and restless.
3. A client scheduled for OT at 1300.
4. A client who just had an appendectomy and has just received pain medication.
Answers and Rationale

1. A
2. C
3. D
4. B
5. A
6. C
7. B
8. B
9. A
10. D
11. D

12. B
13. D
14. D
15. A
16. D. This is measurable and objective.
17. B. This does not require a physician’s order. (A & D require an order; C is not appropriate for a
fractured tibia)
18. C. It is specific in what to do and when.
19. B. Calling in the wound care nurse as a consultant is appropriate because he or she is a specialist in
the area of wound management. Professional and competent nurses recognize limitations and seek
appropriate consultation. (a. This might be appropriate after deciding on a plan of action with the
wound care nurse specialist. The nurse may need to obtain orders for special wound care products.
c. Unless the nurse is knowledgeable in wound management, this could delay wound healing. Also, the
current wound management plan could have been ordered by the physician. d. Another nurse most
likely will not be knowledgeable about wounds, and the primary nurse would know the history of the
wound management plan.)
20. A. This gives the consulting nurse facts that will influence a new plan.
(b, c, and d. These are all subjective and emotional issues/conclusions about the current treatment plan
and may cause a bias in the decision of a new treatment plan by the nurse consultant.)
21. D. Because the primary nurse requested the consultation, it is important that they communicate and
discuss recommendations. The primary nurse can then accept or reject the CNS recommendations. (a.
Some of the recommendations may not be appropriate for this client. The primary nurse would know
this information. A consultation requires review of the recommendations, but not immediate
implementation. b. This would be appropriate after first talking with the CNS about recommended
changes in the plan of care and the rationale. Then the primary nurse should call the physician. c. The
client and family do not have the knowledge to determine whether new strategies are appropriate or
not. Better to wait until the new plan of care is agreed upon by the primary nurse and physician before
talking with the client and/or family.)
22. C, D, A, B.
23. B.
24. B. This clients needs are a priority.

Legal and Ethical Considerations

1. The best explanation of what Title VI of the Civil Rights Act mandates is the freedom to:
1. Pick any physician and insurance company despite one’s income

2. Receive free medical benefits as needed within the county of residence
3. Have equal access to all health care regardless of race and religion
4. Have basic care with a sliding scale payment plan from all health care facilities
2. Which statement would best explain the role of the nurse when planning care for a culturally
diverse population? The nurse will plan care to:
1. Include care that is culturally congruent with the staff from predetermined criteria
2. Focus only on the needs of the client, ignoring the nurse’s beliefs and practices
3. Blend the values of the nurse that are for the good of the client and minimize the client’s individual
values and beliefs during care
4. Provide care while aware of one’s own bias, focusing on the client’s individual needs rather than the
staff’s practices
3. Which factor is least significant during assessment when gathering information about cultural
practices?
1. Language, timing
2. Touch, eye contact
3. Biocultural needs
4. Pain perception, management expectations

4. Transcultural nursing implies:
1. Using a comparative study of cultures to understand similarities and differences across human groups
to provide specific individualized care that is culturally appropriate
2. Working in another culture to practice nursing within their limitations
3. Combining all cultural beliefs into a practice that is a nonthreatening approach to minimize cultural
barriers for all clients’ equality of care
4. Ignoring all cultural differences to provide the best generalized care to all clients.
5. What should the nurse do when planning nursing care for a client with a different cultural
background? The nurse should:
1. Allow the family to provide care during the hospital stay so no rituals or customs are broken
2. Identify how these cultural variables affect the health problem
3. Speak slowly and show pictures to make sure the client always understands
4. Explain how the client must adapt to hospital routines to be effectively cared for while in the hospital
6. Which activity would not be expected by the nurse to meet the cultural needs of the client?
1. Promote and support attitudes, behaviors, knowledge, and skills to respectfully meet client’s cultural
needs despite the nurse’s own beliefs and practices
2. Ensure that the interpreter understands not only the language of the client but feelings and attitudes
behind cultural practices to make sure an ethical balance can be achieved
3. Develop structure and process for meeting cultural needs on a regular basis and means to avoid
overlooking these needs with clients
4. Expect the family to keep an interpreter present at all times to assist in meeting the communication
needs all day and night while hospitalized
7. Ethical principles for professional nursing practice in a clinical setting are guided by the principles of
conduct that are written as the:
1. American Nurses Association’s (ANA’s) Code of Ethics

2. Nurse Practice Act (NPA) written by state legislation
3. Standards of care from experts in the practice field
4. Good Samaritan laws for civil guidelines
8. A bioethical issue should be described as:
1. The physician’s making all decisions of client management without getting input from the client
2. A research project that included treating all the white men and not treating all the black men to
compare the outcomes of a specific drug therapy.
3. The withholding of food and treatment at the request of the client in a written advance directive
given before a client acquired permanent brain damage from an accident.
4. After the client gives permission, the physician’s disclosing all information to the family for their
support in the management of the client.

9. When the nurse described the client as “that nasty old man in 354,” the nurse is exhibiting which
ethical dilemma?
1. Gender bias and ageism

2. HIPPA violation
3. Beneficence
4. Code of ethics violation
10. The distribution of nurses to areas of “most need” in the time of a nursing shortage is an example
of:
1. Utilitarianism theory
2. Deontological theory
3. Justice
4. Beneficence
11. Nurses are bound by a variety of laws. Which description of a type of law is correct?
1. Statutory law is created by elected legislature, such as the state legislature that defines the Nurse
Practice Act (NPA).
2. Regulatory law includes prevention of harm for the public and punishment for those laws that are
broken.
3. Common law protects the rights of the individual within society for fair and equal treatment.
4. Criminal law creates boards that pass rules and regulations to control society.
12. Besides the Joint Commission on Accreditation of Healthcare Organizations (JACHO), which
governing agency regulates hospitals to allow continued safe services to be provided, funding to be
received from the government and penalties if guidelines are not followed?
1. Board of Nursing Examiners (BNE)

2. Nurse Practice Act (NPA)
3. American Nurses Association (ANA)
4. Americans With Disabilities Act (ADA)
13. 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?
1. Assault
2. Battery
3. Negligence
4. Civil tort
14. When signing a form as a witness, your signature shows that the client:

1. Is fully informed and is aware of all consequences.

2. Was awake and fully alert and not medicated with narcotics.
3. Was free to sign without pressure
4. Has signed that form and the witness saw it being done
15. Which criterion is needed for someone to give consent to a procedure?
1. An appointed guardianship
2. Unemancipated minor
3. Minimum of 21 years or older
4. An advocate for a child
16. Which statement is correct?
1. Consent for medical treatment can be given by a minor with a sexually transmitted disease (STD).
2. A second trimester abortion can be given without state involvement.
3. Student nurses cannot be sued for malpractice while in a nursing clinical class.
4. Nurses who get sick and leave during a shift are not abandoning clients if they call their supervisor
and leave a message about their emergency illness.
17. Most litigation in the hospital comes from the:
1. Nurse abandoning the clients when going to lunch

2. Nurse following an order that is incomplete or incorrect
3. Nurse documenting blame on the physician when a mistake is made
4. Supervisor watching a new employee check his or her skills level
18. The nurse places an aquathermia pad on a client with a muscle sprain. The nurse informs the client
the pad should be removed in 30 minutes. Why will the nurse return in 30 minutes to remove the
pad?
1. Reflex vasoconstriction occurs.

2. Reflex vasodilation occurs.
3. Systemic response occurs.
4. Local response occurs.
19. A client has recently been told he has terminal cancer. As the nurse enters the room, he yells, “My
eggs are cold, and I’m tired of having my sleep interrupted by noisy nurses!” The nurse may interpret
the client’s behavior as:
1. An expression of the anger stage of dying

2. An expression of disenfranchised grief
3. The result of maturational loss
4. The result of previous losses

20. When helping a person through grief work, the nurse knows:
1. Coping mechanisms that were effective in the past are often disregarded in response to the pain of a
loss
2. A person’s perception of a loss has little to do with the grieving process.
3. The sequencing of stages of grief may occur in order, they may be skipped, or they may recur.
4. Most clients want to be left alone.
21. A client is hospitalized in the end stage of terminal cancer. His family members are sitting at his
bedside. What can the nurse do to best aid the family at this time?
1. Limit the time visitors may stay so they do not become overwhelmed by the situation.
2. Avoid telling family members about the client’s actual condition so they will not lose hope.
3. Discourage spiritual practices because this will have little connection to the client at this time.
4. Find simple and appropriate care activities for the family to perform.
22. When caring for a terminally ill client, it is important for the nurse maintain the client’s dignity.
This can be facilitated by:
1. Spending time to let clients share their life experiences

2. Decreasing emphasis on attending to the clients’ appearance because it only increases their fatigue
3. Making decisions for clients so they do not have to make them
4. Placing the client in a private room to provide privacy at all times
23. What are the stages of dying according to Elizabeth Kubler-Ross?
1. Numbing; yearning and searching; disorganization and despair; and reorganization.

2. Accepting the reality of loss, working through the pain of grief, adjusting to the environment without
the deceased, and emotionally relocating the deceased and moving on with life.
3. Anticipatory grief, perceived loss, actual loss, and renewal.
4. Denial, anger, bargaining, depression, and acceptance.
24. Bereavement may be defined as:
1. The emotional response to loss.

2. The outward, social expression of loss.
3. Postponing the awareness of the reality of the loss.
4. The inner feeling and outward reactions of the survivor.
25. A client who had a “Do Not Resuscitate” order passed away. After verifying there is no pulse or
respirations, the nurse should next:
1. Have family members say goodbye to the deceased.

2. Call the transplant team to retrieve vital organs.

3. Remove all tubes and equipment (unless organ donation is to take place), clean the body, and
position appropriately.
4. Call the funeral director to come and get the body.
26. A client’s family member says to the nurse, “The doctor said he will provide palliative care. What
does that mean?” The nurse’s best response is:
1. “Palliative care is given to those who have less than 6 months to live.”
2. “Palliative care aims to relieve or reduce the symptoms of a disease.”
3. “The goal of palliative care is to affect a cure of a serious illness or disease.”
4. “Palliative care means the client and family take a more passive role and the doctor focuses on the
physiological needs of the client. The location of death will most likely occur in the hospital setting.”
27. Which of the following is not included in evaluating the degree of heritage consistency in a client?
1. Gender
2. Culture
3. Ethnicity
4. Religion
28. When providing care to clients with varied cultural backgrounds, it is imperative for the nurse to
recognize that:
1. Cultural considerations must be put aside if basic needs are in jeopardy.

2. Generalizations about the behavior of a particular group may be inaccurate.
3. Current health standards should determine the acceptability of cultural practices.
4. Similar reactions to stress will occur when individuals have the same cultural background.
29. To respect a client’s personal space and territoriality, the nurse:
1. Avoids the use of touch

2. Explains nursing care and procedures
3. Keeps the curtains pulled around the clients bed
4. Stands 8 feet away from the bed, if possible.
30. To be effective in meeting various ethnic needs, the nurse should:
1. Treat all clients alike.

2. Be aware of clients’ cultural differences.
3. Act as if he or she is comfortable with the client’s behavior.
4. Avoid asking questions about the client’s cultural background.
31. The most important factor in providing nursing care to clients in a specific ethnic group is:

1. Communication
2. Time orientation
3. Biological variation
4. Environmental control
32. A health care issue often becomes an ethical dilemma because:
1. A clients legal rights coexist with a health professionals obligation.

2. Decisions must be made quickly, often under stressful conditions.
3. Decisions must be made based on value systems.
4. The choices involved do not appear to be clearly right or wrong.
33. A document that lists the medical treatment a person chooses to refuse if unable to make
decisions is the:
1. Durable power of attorney

2. Informed consent
3. Living will
4. Advance directives
34. Which statement about an institutional ethics committee is correct?
1. The ethics committee is an additional resource for clients and health care professionals.
2. The ethics committee relieves health care professionals from dealing with ethical issues.
3. The ethics committee would be the first option in addressing an ethical dilemma.
4. The ethics committee replaces decision making by the client and health care providers.
35. The nurse is working with parents of a seriously ill newborn. Surgery has been proposed for the
infant, but the chances of success are unclear. In helping the parents resolve this ethical conflict, the
nurse knows that the first step is:
1. Exploring reasonable courses of action

2. Collecting all available information about the situation
3. Clarifying values related to the cause of the dilemma.
4. Identifying people who can solve the difficulty.
36. Miss Mary, an 88-year old woman, believes that life should not be prolonged when hope is gone.
She has decided that she does not want extraordinary measures taken when her life is at its end.
Because she feels this way, she has talked with her daughter about her desires, completing a living
will and left directions with her physician. This is an example of:
1. Affirming a value
2. Choosing a value

3. Prizing a value
4. Reflecting a value
37. The scope of Nursing practice is legally defined by:
1. State nurses practice acts

2. Professional nursing organizations
3. Hospital policy and procedure manuals
4. Physicians in the employing institutions
38. A student nurse who is employed as a nursing assistant may perform any functions that:
1. Have been learned about in school

2. Are expected of a nurse at that level
3. Are identified in the positions job description
4. Require technical rather than professional skill.
39. A confused client who fell out of bed because side rails were not used is an example of which type
of liability?
1. Felony
2. Assault
3. Battery
4. Negligence
40. The nurse puts a restraint jacket on a client without the client’s permission and without the
physicians order. The nurse may be guilty of:
1. Assault
2. Battery
3. Invasion of privacy
4. Neglect
41. In a situation in which there is insufficient staff to implement competent care, a nurse should:
1. Organize a strike
2. Inform the clients of the situation
3. Refuse the assignment
4. Accept the assignment but make a protest in writing to the administration.
42. Which statement about loss is accurate?
1. Loss is only experienced when there is an actual absence of something valued.

2. The more the individual has invested in what is lost, the less the feeling of loss.

3. Loss may be maturational, situational, or both.

4. The degree of stress experienced is unrelated to the type of loss.
43. Trying questionable and experimental forms of therapy is a behavior that is characterized of which
stage of dying?
1. Anger
2. Depression
3. Bargaining
4. Acceptance
44. All of the following are crucial needs of the dying client except:
1. Control of pain
2. Preservation of dignity and self-worth
3. Love and belonging
4. Freedom from decision making
45. Cultural awareness is an in-depth self-examination of one’s:
1. Background, recognizing biases and prejudices.

2. Social, cultural, and biophysical factors
3. Engagement in cross-cultural interactions
4. Motivation and commitment to caring.
46. Cultural competence is the process of:
1. Learning about vast cultures

2. Acquiring specific knowledge, skills, and attitudes
3. Influencing treatment and care of clients
4. Motivation and commitment to caring.
47. Ethnocentrism is the root of:
1. Biases and prejudices

2. Meanings by which people make sense of their experiences.
3. Cultural beliefs
4. Individualism and self-reliance in achieving and maintaining health.
48. When action is taken on one’s prejudices:
1. Discrimination occurs
2. Sufficient comparative knowledge of diverse groups is obtained.

3. Delivery of culturally congruent care is ensured.

4. People think/know you are a dumbass for being prejudiced.
49. The dominant value orientation in North American society is:
1. Use of rituals symbolizing the supernatural.

2. Group reliance and interdependence
3. Healing emphasizing naturalistic modalities
4. Individualism and self-reliance in achieving and maintaining health.
50. Disparities in health outcomes between the rich and the poor illustrates: a (an)
1. Illness attributed to natural, impersonal, and biological forces.

2. Creation of own interpretation and descriptions of biological and psychological malfunctions.
3. Influence of socioeconomic factors in morbidity and mortality.
4. Combination of naturalistic, religious, ad supernatural modalities.
51. Culture strongly influences pain expression and need for pain medication. However, cultural pain:
1. May be suffered by a client whose valued way of life is disregarded by practitioners.

2. Is more intense, thus necessitating more medication.
3. Is not expressed verbally or physically
4. Is expressed only to others of like culture.
52. The dominant values in American society on individual autonomy and self-determination:
1. Rarely have an effect on other cultures

2. Do have an effect on health care
3. May hinder ability to get into a hospice program
4. May be in direct conflict with diverse groups.
53. In the United States, access to health care usually depends on a client’s ability to pay for health
care, either through insurance or by paying cash. The client the nurse is caring for needs a liver
transplant to survive. This client has been out of work for several months and does not have insurance
or enough cash. A discussion about the ethics of this situation would involve predominantly the
principle of:
1. Accountability, because you as the nurse are accountable for the well being of this client.
2. Respect of autonomy, because this client’s autonomy will be violated if he does not receive the liver
transplant.
3. Ethics of care, because the caring thing that a nurse could provide this patient is resources for a liver
transplant.
4. Justice, because the first and greatest question in this situation is how to determine the just
distribution of resources.

54. The code of ethics for nurses is composed and published by:
1. The national league for Nursing

2. The American Nurses Association
3. The Medical American Association
4. The National Institutes of Health, Nursing division.
55. Nurses agree to be advocates for their patients. Practice of advocacy calls for the nurse to:
1. Seek out the nursing supervisor in conflicting situations

2. Work to understand the law as it applies to the client’s clinical condition.
3. Assess the client’s point of view and prepare to articulate this point of view.
4. Document all clinical changes in the medical record in a timely manner.
56. Successful ethical discussion depends on people who have a clear sense of personal values. When
many people share the same values it may be possible to identify a philosophy of utilitarianism, with
proposes that:
1. The value of people is determined solely by leaders in the Unitarian church.

2. The decision to perform a lover transplant depends on a measure of the moral life that the client has
led so far.
3. The best way to determine the solution to an ethical dilemma is to refer the case to the attending
physician.
4. The value of something is determined by its usefulness to society.
57. The philosophy sometimes called the code of ethics of care suggests that ethical dilemmas can
best be solved by attention to:
1. Relationships
2. Ethical principles
3. Clients
4. Code of ethics for nurses.
58. In most ethical dilemmas, the solution to the dilemma requires negotiation among members of
the health care team. The nurse’s point of view is valuable because:
1. Nurses have a legal license that encourages their presence during ethical discussions.
2. The principle of autonomy guides all participants to respect their own self-worth.
3. Nurses develop a relationship to the client that is unique among all professional health care providers.
4. The nurse’s code of ethics recommends that a nurse be present at any ethical discussion about client
care.
59. Ethical dilemmas often arise over a conflict of opinion. Once the nurse has determined that the
dilemma is ethical, a critical first step in negotiating the difference of opinion would be to:

1. Consult a professional ethicist to ensure that the steps of the process occur in full.
2. Gather all relevant information regarding the clinical, social, and spiritual aspects of the dilemma.
3. List the ethical principles that inform the dilemma so that negotiations agree on the language of the
discussion.
4. Ensure that the attending physician has written an order for an ethics consultation to support the
ethics process.
60. The nurse practice acts are an example of:
1. Statutory law
2. Common law
3. Civil law
4. Criminal law
61. The scope of Nursing Practice, the established educational requirements for nurses, and the
distinction between nursing and medical practice is defined by:
1. Statutory law
2. Common law
3. Civil law
4. Nurse practice acts
62. The client’s right to refuse treatment is an example of:
1. Statutory law
2. Common law
3. Civil laws
4. Nurse practice acts
63. Even though the nurse may obtain the clients signature on a form, obtaining informed consent is
the responsibility of the:
1. Client
2. Physician
3. Student nurse
4. Supervising nurse.
64. The nurse is obligated to follow a physician’s order unless:
1. The order is a verbal order

2. The physicians order is illegible
3. The order has not been transcribed
4. The order is an error, violates hospital policy, or would be detrimental to the client.

65. The nursing theorist who developed transcultural nursing theory is
1. Dorothea Orem
2. Madeleine Leininger
3. Betty Newman
4. Sr. Callista Roy

1. C.
2. D. Without understanding one’s own beliefs and values, a bias or preconceived belief by the nurse
could create an unexpected conflict or an area of neglect in the plan of care for a client (who might be
expecting something totally different from the care). During assessment values, beliefs, practices should
be identified by the nurse and used as a guide to identify the choices by the nurse to meet specific
needs/outcomes of that client. Therefore identification of values, beliefs, and practices allows for
planning meaningful and beneficial care specific for this client.
3. C. Cultural practices do not influence biocultural needs because they are inborn risks that are related
to a biological need and not a learned cultural belief or practice.
4. A. Transcultural care means that by understanding and learning about specific cultural practices the
nurse can integrate these practices into the plan of care for a specific individual client who has the same
beliefs or practices to meet the client’s needs in a holistic manner of care.
5. B. Without assessment and identification of the cultural needs, the nurse cannot begin to understand
how these might influence the health problem or health care management.
6. D. It is not the family’s responsibility to assist in the communication process. Many families will leave
someone to help at times, but it is the hospital’s legal obligation to find an interpreter for continued
understanding by the client to make sure the client is fully informed and comprehends in his or her
primary language.
7. A. This set of ethical principles provides the professional guidelines established by the ANA to
maintain the highest standards for ideal conduct in practice. As a profession, the ANA wanted to
establish rules and then incorporate guidelines for accountability and responsibility of each nurse within
the practice setting.
8. B. The ethical issue was the inequality of treatment based strictly upon racial differences. Secondly,
the drug was deliberately withheld even after results showed that the drug was working to cure the
disease process in the white men for many years. So after many years, the black men were still not
treated despite the outcome of the research process that showed the drug to be effective in controlling
the disease early in the beginning of the research project. Therefore harm was done. Nonmaleficence,
veracity, and justice were not followed.

9. A. Stereotyping an “old man” as “nasty”is a gender bias and an ageism issue. The nurse is verbalizing a
negative descriptor about the client.
10. C. Justice is defined as the fairness of distribution of resources. However, guidelines for a hierarchy
of needs have been established, such as with organ transplantation. Nurses are moved to areas of
greatest need when shortages occur on the floors. No floor is left without staff, and another floor that
had five staff will give up two to go help the floor that had no staff.
11. A. 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 breech of those regulations.
12. D. If the hospital fails to follow ADA guidelines for meeting special needs, the facility loses funding
and status for receiving low-income loans or reimbursement of expenses. ADA protects the civil rights of
disabled people. It applies to both the hospital clients and hospital staff. Privacy issues for persons who
are positive for human immunodeficiency virus (HIV) have been one issue in relationship to getting
information when hospital staff have been exposed to unclean sticks. The ADA allows the infected client
the right to choose whether or not to disclose that information.
13. C. 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.
14. D. Your signature as a witness only states that the person signing the form was the person who was
listed in the procedure.
15. A. A guardian has been appointed by a court and has full legal rights to choose management of care.
16. A. Anyone, at any age, can be treated without parental permission for an STD infection. The client is
“advised” to contact sexual partners but is not “required” to give names. Permission from parents is not
needed, based upon current privacy laws.
17. B. The nurse is responsible for clarifying all orders that are illegible, unreasonable, unsafe, or
incorrect. The failure of the nurse to question the physician about an order creates an area of liability on
the nurse’s part because this is perceived as a medical action and not the role of the nurse to write
orders. Some RNs do have prescriptive privileges based upon advanced degrees and certification.
Therefore the nurse who cannot correct the order must document that the physician was called and
clarification or a new order was given to correct the unclear or illegible one that was currently on the
chart. Phone calls, follow-up, and lack of follow-up by the physician should also be documented if there
is a problem with getting the information in a timely manner. The nurse must show the sequence of
events of a situation in a clear manner if there is any conflict or question about any orders or procedures
that were not appropriate. Assessments and documentation of the client’s status should also be

included if there is a potential risk for harm present. Contact of the staff’s chain of command should also
be specifically stated for the proof of the responsibilities being followed according to hospital policy.
18. A. If heat is applied for 1 hour or more, blood flow is reduced by reflex vasoconstriction.
Vasoconstriction is the opposite of the desired effect of heat application
19. a. In the anger stage of Kubler-Ross’s stages of dying, the individual resists the loss and may strike
out at everyone and everything, in this case, the nurse.
20. C. Grief is manifested in a variety of ways that are unique to an individual and based on personal
experiences, cultural expectations, and spiritual beliefs. The sequencing of stages or behaviors of grief
may occur in order, they may be skipped, or they may reoccur. The amount of time to resolve grief also
varies among individuals.
21. D. It is helpful for the nurse to find simple care activities for the family to perform, such as feeding
the client, washing the client’s face, combing hair, and filling out the client’s menu. This helps the family
demonstrate their caring for the client and enables the client to feel their closeness and concern. a.
Older adults often become particularly lonely at night and may feel more secure if a family member
stays at the bedside during the night. The nurse should allow visitors to remain with dying clients at any
time if the client wants them. It is up to the family to determine if they are feeling overwhelmed, not the
nurse.
22. A. Spending time to let clients share their life experiences enables the nurse to know clients better.
Knowing clients then facilitates choice of therapies that promote client decision making and autonomy,
thus promoting a client’s self-esteem and dignity.
23. D.
24. D.
25. C. The body of the deceased should be prepared before the family comes in to view and say their
goodbyes. This includes removing all equipment, tubes, supplies, and dirty linens according to protocol,
bathing the client, applying clean sheets, and removing trash from the room.
26. B. The goal of palliative care is the prevention, relief, reduction, or soothing of symptoms of disease
or disorders without effecting a cure.
27. A.
28. B.
29. B.

30. B.
31. A.
32. D.
33. D.
34. A.
35. B.
36. C.
37. A.
38. C.
39. D.
40. B.
41. D.
42. C.
43. C.
44. D.
45. A. Cultural awareness is an in-depth examination of one’s own background, recognizing biases and
prejudices and assumptions about other people.
46. B. Cultural competence is the process of acquiring specific knowledge, skills, and attitudes that
ensure delivery of culturally congruent care.
47. A.
48. A.
49. D.

50. C. Disparities in health outcomes between the rich and the poor illustrate the influence of
socioeconomic factors in morbidity and mortality. Social factors such as poverty and lack of universal
medical insurance compromise the health status of the poor and unemployed.
51. A. Nurses need not assume that pain relief is equally valued across groups. Cultural pain may be
suffered by a client whose valued way of life is disregarded by practitioners.
52. D. The dominant value in American society of individual autonomy and self-determination may be in
direct conflict with diverse groups. Advance directives, informed consent, and consent for hospice are
examples of mandates that my violate client’s values.
53. D. Justice refers to fairness. Health care providers agree to strive for justice in health care. The term
often is used during discussions about resources. Decisions about who should receive available organs
are always difficult.
54. B. the ANA has established widely accepted codes that professional nurses attempt to follow.
55. C. Nurses strengthen their ability to advocate for a client when nurses are able to identify personal
values and then accurately identify the values of the client and articulate the client’s point of view.
56. D. A utilitarian system of ethics proposes that the value of something is determined by its
usefulness.
57. A. 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. C. When ethical dilemmas arise, the nurses point of view unique and critical. The nurse usually
interacts with clients over longer time intervals than do other disciples.
59. B. Each step in the processing of an ethical dilemma resembles steps in critical thinking. The nurse
begins by gathering information and moves through assessment, identification of the problem, planning,
implementation, and evaluation.
60. A.
61. D.
62. B.
63. B.
64. D.

65. (B) Madeleine Leininger. Madeleine Leininger developed the theory on transcultural theory based
on her observations on the behavior of selected people within a culture.

Safety and Infection

Control
1. The parents of a child, age 6, who will begin school in the fall ask the nurse for anticipatory
guidance. The nurse should explain that a child of this age:
a. Still depends on the parents

b. Rebels against scheduled activities
c. Is highly sensitive to criticism
d. Loves to tattle
2. While preparing to discharge an 8-month-old infant who is recovering from gastroenteritis and
dehydration, the nurse teaches the parents about their infant’s dietary and fluid requirements. The
nurse should include which other topic in the teaching session?
a. Nursery schools
b. Toilet Training
c. Safety guidelines
d. Preparation for surgery
3. Nurse Betina should begin screening for lead poisoning when a child reaches which age?
a. 6 months
b. 12 months
c. 18 months
d. 24 months
4. When caring for an 11-month-old infant with dehydration and metabolic acidosis, the nurse expects
to see which of the following?
a. A reduced white blood cell count

b. A decreased platelet count
c. Shallow respirations
d. Tachypnea
5. After the nurse provides dietary restrictions to the parents of a child with celiac disease, which
statement by the parents indicates effective teaching?

a. “Well follow these instructions until our child’s symptoms disappear.”

b. “Our child must maintain these dietary restrictions until adulthood.”
c. “Our child must maintain these dietary restrictions lifelong.”
d. “We’ll follow these instructions until our child has completely grown and developed.”
6. A parent brings a toddler, age 19 months, to the clinic for a regular check-up. When palpating the
toddler’s fontanels, what should the nurse expects to find?
a. Closed anterior fontanel and open posterior fontanel

b. Open anterior and fontanel and closed posterior fontanel
c. Closed anterior and posterior fontanels
d. Open anterior and posterior fontanels
7. Patrick, a healthy adolescent has meningitis and is receiving I.V. and oral fluids. The nurse should
monitor this client’s fluid intake because fluid overload may cause:
a. Cerebral edema
b. Dehydration
c. Heart failure
d. Hypovolemic shock
8. An infant is hospitalized for treatment of nonorganic failure to thrive. Which nursing action is most
appropriate for this infant?
a. Encouraging the infant to hold a bottle

b. Keeping the infant on bed rest to conserve energy
c. Rotating caregivers to provide more stimulation
d. Maintaining a consistent, structured environment
9. The mother of Gian, a preschooler with spina bifida tells the nurse that her daughter sneezes and
gets a rash when playing with brightly colored balloons, and that she recently had an allergic reaction
after eating kiwifruit and bananas. The nurse would suspect that the child may have an allergy to:
a. Bananas
b. Latex
c. Kiwifruit
d. Color dyes
10. Cristina, a mother of a 4-year-old child tells the nurse that her child is a very poor eater. What’s
the nurse’s best recommendation for helping the mother increase her child’s nutritional intake?
a. Allow the child to feed herself

b. Use specially designed dishes for children – for example, a plate with the child’s favorite cartoon
character

c. Only serve the child’s favorite foods

d. Allow the child to eat at a small table and chair by herself
11. Nurse Roy is administering total parental nutrition (TPN) through a peripheral I.V. line to a school-
age child. What’s the smallest amount of glucose that’s considered safe and not caustic to small veins,
while also providing adequate TPN?
a. 5% glucose
b. 10% glucose
c. 15% glucose
d. 17% glucose
12. David, age 15 months, is recovering from surgery to remove Wilms’ tumor. Which findings best
indicates that the child is free from pain?
a. Decreased appetite
b. Increased heart rate
c. Decreased urine output
d. Increased interest in play
13. When planning care for a 8-year-old boy with Down syndrome, the nurse should:
a. Plan interventions according to the developmental level of a 7-year-old child because that’s the child’s
age
b. Plan interventions according to the developmental levels of a 5-year-old because the child will have
developmental delays
c. Assess the child’s current developmental level and plan care accordingly
d. Direct all teaching to the parents because the child can’t understand
14. Nurse Vincent is teaching the parents of a school-age child. Which teaching topic should take
priority?
a. Prevent accidents
b. Keeping a night light on to allay fears
c. Explaining normalcy of fears about body integrity
d. Encouraging the child to dress without help
15. The nurse is finishing her shift on the pediatric unit. Because her shift is ending, which intervention
takes top priority?
a. Changing the linens on the clients’ beds

b. Restocking the bedside supplies needed for a dressing change on the upcoming shift
c. Documenting the care provided during her shift
d. Emptying the trash cans in the assigned client room

16. Nurse Harry is providing cardiopulmonary resuscitation (CPR) to a child, age 4. the nurse should:
a. Compress the sternum with both hands at a depth of 1½ to 2” (4 to 5 cm)

b. Deliver 12 breaths/minute
c. Perform only two-person CPR
d. Use the heel of one hand for sternal compressions
17. A 4-month-old with meningococcal meningitis has just been admitted to the pediatric unit. Which
nursing intervention has the highest priority?
a. Instituting droplet precautions

b. Administering acetaminophen (Tylenol)
c. Obtaining history information from the parents
d. Orienting the parents to the pediatric unit
18. Shane tells the nurse that she wants to begin toilet training her 22-month-old child. The most
important factor for the nurse to stress to the mother is:
a. Developmental readiness of the child

b. Consistency in approach
c. The mother’s positive attitude
d. Developmental level of the child’s peers
19. An infant who has been in foster care since birth requires a blood transfusion. Who is authorized
to give written, informed consent for the procedure?
a. The foster mother

b. The social worker who placed the infant in the foster home
c. The registered nurse caring for the infant
d. The nurse-manager
20. A child is undergoing remission induction therapy to treat leukemia. Allopurinol is included in the
regimen. The main reason for administering allopurinol as part of the client’s chemotherapy regimen
is to:
a. Prevent metabolic breakdown of xanthine to uric acid

b. Prevent uric acid from precipitating in the ureters
c. Enhance the production of uric acid to ensure adequate excretion of urine
d. Ensure that the chemotherapy doesn’t adversely affect the bone marrow
21. A 10-year-old client contracted severe acute respiratory syndrome (SARS) when traveling abroad
with her parents. The nurse knows she must put on personal protective equipment to protect herself
while providing care. Based on the mode of SARS transmission, which personal protective should the
nurse wear?

a. Gloves
b. Gown and gloves
c. Gown, gloves, and mask
d. Gown, gloves, mask, and eye goggles or eye shield
22. A tuberculosis intradermal skin test to detect tuberculosis infection is given to a high-risk
adolescent. How long after the test is administered should the result be evaluated?
a. Immediately
b. Within 24 hours
c. In 48 to 72 hours
d. After 5 days
23. Nurse Oliver s teaching a mother who plans to discontinue breast-feeding after 5 months. The
nurse should advise her to include which foods in her infant’s diet?
a. Iron-rich formula and baby food

b. Whole milk and baby food
c. Skim milk and baby food
d. Iron-rich formula only
24. Gracie, the mother of a 3-month-old infant calls the clinic and states that her child has a diaper
rash. What should the nurse advice?
a. “Switch to cloth diapers until the rash is gone”

b. “Use baby wipes with each diaper change.”
c. “Leave the diaper off while the infant sleeps.”
d. “Offer extra fluids to the infant until the rash improves.”
25. Nurse Kelly is teaching the parents of a young child how to handle poisoning. If the child ingests
poison, what should the parents do first?
a. Administer ipecac syrup

b. Call an ambulance immediately
c. Call the poison control center
d. Punish the child for being bad
26. A child has third-degree burns of the hands, face, and chest. Which nursing diagnosis takes
priority?
a. Ineffective airway clearance related to edema

b. Disturbed body image related to physical appearance
c. Impaired urinary elimination related to fluid loss
d. Risk for infection related to epidermal disruption

27. A 3-year-old child is receiving dextrose 5% in water and half-normal saline solution at 100
ml/hour. Which sign or symptom suggests excessive I.V. fluid intake?
a. Worsening dyspnea
b. Gastric distension
c. Nausea and vomiting
d. Temperature of 102°F (38.9° C)
28. Which finding would alert a nurse that a hospitalized 6-year-old child is at risk for a severe asthma
exacerbation?
a. Oxygen saturation of 95%

b. Mild work of breathing
c. Absence of intercostals or substernal retractions
d. History of steroid-dependent asthma
29. Nurse Mariane is caring for an infant with spina bifida. Which technique is most important in
recognizing possible hydrocephalus?
a. Measuring head circumference

b. Obtaining skull X-ray
c. Performing a lumbar puncture
d. Magnetic resonance imaging (MRI)
30. An adolescent who sustained a tibia fracture in a motor vehicle accident has a cast. What should
the nurse do to help relieve the itching?
a. Apply cool air under the cast with a blow-dryer

b. Use sterile applicators to scratch the itch
c. Apply cool water under the cast
d. Apply hydrocortisone cream under the cast using sterile applicator.

1. Answer C.
In a 6-year-old child, a precarious sense of self causes overreaction to criticism and a sense of inferiority.
By age 6, most children no longer depend on the parents for daily tasks and love the routine of a
schedule. Tattling is more common at age 4 to 5, by age 6, the child wants to make friends and be a
friend.
2. Answer C.
The nurse always should reinforce safety guidelines when teaching parents how to care for their child.
By giving anticipatory guidance the nurse can help prevent many accidental injuries. For parents of a 9-

month-old infant, it is too early to discuss nursery schools or toilet training. Because surgery is not used
gastroenteritis, this topic is inappropriate.
3. Answer C.
The nurse should start screening a child for lead poisoning at age 18 months and perform repeat
screening at age 24, 30, and 36 months. High-risk infants, such as premature infants and formula-fed
infants not receiving iron supplementation, should be screened for iron-deficiency anemia at 6 months.
Regular dental visits should begin at age 24 months.
4. Answer D.
The body compensates for metabolic acidosis via the respiratory system, which tries to eliminate the
buffered acids by increasing alveolar ventilation through deep, rapid respirations, altered white blood
cell or platelet counts are not specific signs of metabolic imbalance.
5. Answer C.
A patient with celiac disease must maintain dietary restrictions lifelong to avoid recurrence of clinical
manifestations of the disease. The other options are incorrect because signs and symptoms will
reappear if the patient eats prohibited foods.
6. Answer C.
By age 18 months, the anterior and posterior fontanels should be closed. The diamond-shaped anterior
fontanel normally closes between ages 9 and 18 months. The triangular posterior fontanel normally
closes between ages 2 and 3 months.
7. Answer A.
Because of the inflammation of the meninges, the client is vulnerable to developing cerebral edema and
increase intracranial pressure. Fluid overload won’t cause dehydration. It would be unusual for an
adolescent to develop heart failure unless the overhydration is extreme. Hypovolemic shock would
occur with an extreme loss of fluid of blood.
8. Answer D.
The nurse caring for an infant with nonorganic failure to thrive should maintain a consistent, structured
environment that provides interaction with the infant to promote growth and development.
Encouraging the infant to hold a bottle would reinforce an uncaring feeding environment. The infant
should receive social stimulation rather than be confined to bed rest. The number of caregivers should
be minimized to promote consistency of care.
9. Answer B.
Children with spina bifida often develop an allergy to latex and shouldn’t be exposed to it. If a child is
sensitive to bananas, kiwifruit, and chestnuts, then she’s likely to be allergic to latex. Some children are
allergic to dyes in foods and other products but dyes aren’t a factor in a latex allergy.
10. Answer A.
The best recommendation is to allow the child to feed herself because the child’s stage of development
is the preschool period of initiative. Special dishes would enhance the primary recommendation. The

child should be offered new foods and choices, not just served her favorite foods. Using a small table
and chair would also enhance the primary recommendation.
11. Answer B.
The amount of glucose that’s considered safe for peripheral veins while still providing adequate
parenteral nutrition is 10%. Five percent glucose isn’t sufficient nutritional replacement, although it’s
sake for peripheral veins. Any amount above 10% must be administered via central venous access.
12. Answer D.
One of the most valuable clues to pain is a behavior change: A child who’s pain-free likes to play. A child
in pain is less likely to consume food or fluids. An increased heart rate may indicate increased pain;
decreased urine output may signify dehydration.
13. Answer C.
Nursing care plan should be planned according to the developmental age of a child with Down
syndrome, not the chronological age. Because children with Down syndrome can vary from mildly to
severely mentally challenged, each child should be individually assessed. A child with Down syndrome is
capable of learning, especially a child with mild limitations.
14. Answer A.
Accidents are the major cause of death and disability during the school-age years. Therefore, accident
prevention should take priority when teaching parents of school-age children. Preschool (not school-
age) children are afraid of the dark, have fears concerning body integrity, and should be encouraged to
dress without help (with the exception of tying shoes).
15. Answer C.
Documentation should take top priority. Documentation is the only way the nurse can legally claim that
interventions were performed. The other three options would be appreciated by the nurses on the
oncoming shift but aren’t mandatory and don’t take priority over documentation.
16. Answer D.
The nurse should use the heel of one hand and compress 1” to 1½ “. The nurse should use the heels of
both hands clasped together and compress the sternum 1½ “to 2” for an adult. For a small child, two-
person rescue may be inappropriate. For a child, the nurse should deliver 20 breaths/minute instead of
12.
17. Answer A.
Instituting droplet precautions is a priority for a newly admitted infant with meningococcal meningitis.
Acetaminophen may be prescribed but administering it doesn’t take priority over instituting droplet
precautions. Obtaining history information and orienting the parents to the unit don’t take priority.
18. Answer A.
If the child isn’t developmentally ready, child and parent will become frustrated. Consistency is
important once toilet training has already started. The mother’s positive attitude is important when the
child is ready. Developmental levels of children are individualized and comparison to peers isn’t useful.

19. Answer A.
When children are minors and aren’t emancipated, their parents or designated legal guardians are
responsible for providing consent for medical procedures. Therefore, the foster mother is authorized to
give consent for the blood transfusion. The social workers, the nurse, and the nurse-manager have no
legal rights to give consent in this scenario.
20. Answer A.
The massive cell destruction resulting from chemotherapy may place the client at risk for developing
renal calculi; adding allopurinol decreases this risk by preventing the breakdown of xanthine to uric acid.
Allopurinol doesn’t act in the manner described in the other options.
21. Answer D.
The transmission of SARS isn’t fully understood. Therefore, all modes of transmission must be
considered possible, including airborne, droplet, and direct contact with the virus. For protection from
contracting SARS, any health care worker providing care for a client with SARS should wear a gown,
gloves, mask, and eye goggles or an eye shield.
22. Answer C.
Tuberculin skin tests of delayed hypersensitivity. If the test results are positive, a reaction should appear
in 48 to 72 hours. Immediately after the test and within 24 hours are both too soon to observe a
reaction. Waiting more than 5 days to evaluate the test is too long because any reaction may no longer
be visible.
23. Answer D.
The American Academy of Pediatrics recommends that infants at age 5 months receive iron-rich formula
and that they shouldn’t receive solid food – even baby food – until age 6 months. The Academy doesn’t
recommend whole milk until age 12 months, and skim milk until after age 2 years.
24. Answer C.
Leaving the diaper off while the infant sleeps helps to promote air circulation to the area, improving the
condition. Switching to cloth diapers isn’t necessary; in fact, that may make the rash worse. Baby wipes
contain alcohol, which may worsen the condition. Extra fluids won’t make the rash better.
25. Answer C.
Before interviewing in any way, the parents should call the poison control center for specific directions.
Ipecac syrup is no longer recommended. The parents may have to call an ambulance after calling the
poison control center. Punishment for being bad isn’t appropriate because the parents are responsible
for making the environment safe.
26. Answer A.
Initially, when a preschool client is admitted to the hospital for burns, the primary focus is on assessing
and managing an effective airway. Body image disturbance, impaired urinary elimination, and infection
are all integral parts of burn management but aren’t the first priority.

27. Answer A.
Dyspnea and other signs of respiratory distress signify fluid volume excess (overload), which can occur
quickly in a child as fluid shifts rapidly between the intracellular and extracellular compartments. Gastric
distention may suggest excessive oral fluid intake or infection. Nausea and vomiting or an elevated
temperature may indicate a fluid volume deficit.
28. Answer D.
A history of steroid-dependent asthma, a contributing factor to this client’s high-risk status, requires the
nurse to treat the situation as a severe exacerbation regardless of the severity of the current episode.
An oxygen saturation of 95%, mild work of breathing, and absence of intercostals or substernal
retractions are all normal findings.
29. Answer A.
Measuring head circumference is the most important assessment technique for recognizing possible
hydrocephalus, and is a key part of routine infant screening. Skull X-rays and MRI may be used to
confirm the diagnosis. A lumbar puncture isn’t appropriate.
30. Answer A.
Itching underneath a cast can be relieved by directing blow-dryer, set, on the cool setting, toward the
itchy area. Skin breakdown can occur if anything is placed under the cast. Therefore, the client should be
cautioned not to put any object down the cast in an attempt to scratch.
1. A child is admitted to the pediatric unit with a diagnosis of suspected meningococcal meningitis.
Which of the following nursing measures should the nurse do FIRST?
a. Institute seizure precautions

b. Assess neurologic status
c. Place in respiratory isolation
d. Assess vital signs
2. A client is diagnosed with methicillin resistant staphylococcus aureus pneumonia. What type of
isolation is MOST appropriate for this client?
a. Reverse isolation
b. Respiratory isolation
c. Standard precautions
d. Contact isolation
3. Several clients are admitted to an adult medical unit. The nurse would ensure airborne precautions
for a client with which of the following medical conditions?
a. A diagnosis of AIDS and cytomegalovirus

b. A positive PPD with an abnormal chest x-ray
c. A tentative diagnosis of viral pneumonia
d. Advanced carcinoma of the lung

4. Which of the following is the FIRST priority in preventing infections when providing care for a
client?
a. Handwashing
b. Wearing gloves
c. Using a barrier between client’s furniture and nurse’s bag
d. Wearing gowns and goggles
5. An adult woman is admitted to an isolation unit in the hospital after tuberculosis was detected
during a pre-employment physical. Although frightened about her diagnosis, she is anxious to
cooperate with the therapeutic regimen. The teaching plan includes information regarding the most
common means of transmitting the tubercle bacillus from one individual to another. Which
contamination is usually responsible?
a. Hands.
b. Droplet nuclei.
c. Milk products.
d. Eating utensils.
6. A 2-year-old is to be admitted in the pediatric unit. He is diagnosed with febrile seizures. In

preparing for his admission, which of the following is the most important nursing action?
a. Order a stat admission CBC.

b. Place a urine collection bag and specimen cup at the bedside.
c. Place a cooling mattress on his bed.
d. Pad the side rails of his bed.
7. A young adult is being treated for second and third degree burns over 25% of his body and is now
ready for discharge. The nurse evaluates his understanding of discharge instructions relating to wound
care and is satisfied that he is prepared for home care when he makes which statement?
a. “I will need to take sponge baths at home to avoid exposing the wounds to unsterile bath water.”
b. “If any healed areas break open I should first cover them with a sterile dressing and then report it.”
c. “I must wear my Jobst elastic garment all day and can only remove it when I’m going to bed.”
d. “I can expect occasional periods of low-grade fever and can take Tylenol every 4 hours.”
8. An eighty five year old man was admitted for surgery for benign prostatic hypertrophy.
Preoperatively he was alert, oriented, cooperative, and knowledgeable about his surgery. Several
hours after surgery, the evening nurse found him acutely confused, agitated, and trying to climb over
the protective side rails on his bed. The most appropriate nursing intervention that will calm an
agitated client is:
a. limit visits by staff.

b. encourage family phone calls.

c. position in a bright, busy area.

d. speak soothingly and provide quiet music.
9. Ms. Smith is admitted for internal radiation for cancer of the cervix. The nurse knows the client
understands the procedure when she makes which of the following remarks the night before the
procedure?
a. She says to her husband, “Please bring me a hamburger and french fries tomorrow when you come. I
hate hospital food.”
b. “I told my daughter who is pregnant to either come to see me tonight or wait until I go home from the
hospital.”
c. “I understand it will be several weeks before all the radiation leaves my body.”
d. “I brought several craft projects to do while the radium is inserted.”
10. The nurse in charge is evaluating the infection control procedures on the unit. Which finding
indicates a break in technique and the need for education of staff?
a. The nurse aide is not wearing gloves when feeding an elderly client.
b. A client with active tuberculosis is asked to wear a mask when he leaves his room to go to another
department for testing.
c. A nurse with open, weeping lesions of the hands puts on gloves before giving direct client care.
d. The nurse puts on a mask, a gown, and gloves before entering the room of a client on strict isolation.
11. The charge nurse observes a new staff nurse who is changing a dressing on a surgical wound. After
carefully washing her hands the nurse dons sterile gloves to remove the old dressing. After removing
the dirty dressing, the nurse removes the gloves and dons a new pair of sterile gloves in preparation
for cleaning and redressing the wound. The most appropriate action for the charge nurse is to:
a. interrupt the procedure to inform the staff nurse that sterile gloves are not needed to remove the old
dressing.
b. congratulate the nurse on the use of good technique.
c. discuss dressing change technique with the nurse at a later date.
d. interrupt the procedure to inform the nurse of the need to wash her hands after removal of the dirty
dressing and gloves.
12. Nurse Jane is visiting a client at home and is assessing him for risk of a fall. The most important
factor to consider in this assessment is:
a. Correct illumination of the environment.

b. amount of regular exercise.
c. the resting pulse rate.
d. status of salt intake.

13. Mrs. Jones will have to change the dressing on her injured right leg twice a day. The dressing will
be a sterile dressing, using 4 X 4s, normal saline irrigant, and abdominal pads. Which statement best
indicates that Mrs. Jones understands the importance of maintaining asepsis?
a. “If I drop the 4 X 4s on the floor, I can use them as long as they are not soiled.”
b. “If I drop the 4 X 4s on the floor, I can use them if I rinse them with sterile normal saline.”
c. “If I question the sterility of any dressing material, I should not use it.”
d. “I should put on my sterile gloves, then open the bottle of saline to soak the 4 X 4s.”
14. A client has been placed in blood and body fluid isolation. The nurse is instructing auxiliary
personnel in the correct procedures. Which statement by the nursing assistant indicates the best
understanding of the correct protocol for blood and body fluid isolation?
a. Masks should be worn with all client contact.

b. Gloves should be worn for contact with nonintact skin, mucous membranes, or soiled items.
c. Isolation gowns are not needed.
d. A private room is always indicated.
15. The nurse is evaluating whether nonprofessional staff understand how to prevent transmission of
HIV. Which of the following behaviors indicates correct application of universal precautions?
a. A lab technician rests his hand on the desk to steady it while recapping the needle after drawing
blood.
b. An aide wears gloves to feed a helpless client.
c. An assistant puts on a mask and protective eye wear before assisting the nurse to suction a
tracheostomy.
d. A pregnant worker refuses to care for a client known to have AIDS.
16. Jayson, 1 year old child has a staph skin infection. Her brother has also developed the same
infection. Which behavior by the children is most likely to have caused the transmission of the
organism?
a. Bathing together.
b. Coughing on each other.
c. Sharing pacifiers.
d. Eating off the same plate.
17. Jessie, a young man with newly diagnosed acquired immune deficiency syndrome (AIDS) is being
discharged from the hospital. The nurse knows that teaching regarding prevention of AIDS
transmission has been effective when the client:
a. verbalizes the role of sexual activity in spread of the disorder.

b. states he will make arrangements to drop his college classes.
c. acknowledges the need to avoid all contact sports.
d. says he will avoid close contact with his three-year-old niece.

18. Which question is least useful in the assessment of a client with AIDS?
a. Are you a drug user?

b. Do you have many sex partners?
c. What is your method of birth control?
d. How old were you when you became sexually active?
19. Mrs. Parker, a 70-year-old woman with severe macular degeneration, is admitted to the hospital
the day before scheduled surgery. The nurse’s preoperative goals for Mrs. M. would include:
a. independently ambulating around the unit.

b. reading the routine preoperative education materials.
c. maneuvering safely after orientation to the room.
d. using a bedpan for elimination needs.
20. A child is undergoing remission induction therapy to treat leukemia. Allopurinol is included in the
regimen. The main reason for administering allopurinol as part of the client’s chemotherapy regimen
is to:
a. Prevent metabolic breakdown of xanthine to uric acid

b. Prevent uric acid from precipitating in the ureters
c. Enhance the production of uric acid to ensure adequate excretion of urine
d. Ensure that the chemotherapy doesn’t adversely affect the bone marrow

1. Answer C.
The initial therapeutic management of acute bacterial meningitis includes isolation precautions,
initiation of antimicrobial therapy and maintenance of optimum hydration. Nurses should take
necessary precautions to protect themselves and others from possible infection.
2. Answer D.
Contact or Body Substance Isolation (BSI) involves the use of barrier protection (e.g. gloves, mask, gown,
or protective eyewear as appropriate) whenever direct contact with any body fluid is expected. When
determining the type of isolation to use, one must consider the mode of transmission. The hands of
personnel continues to be the principal mode of transmission for methicillin resistant staphylococcus
aureus (MRSA). Because the organism is limited to the sputum in this example, precautions are taken if
contact with the patient”s sputum is expected. A private room and BSI, along with good hand washing
techniques, are the best defense against the spread of MRSA pneumonia.
3. Answer B.
The client who must be placed in airborne precautions is the client with a positive PPD (purified protein
derivative) who has a positive x-ray for a suspicious tuberculin lesion.

4. Answer A.
Handwashing remains the most effective way to avoid spreading infection. However, too often nurses
do not practice good handwashing techniques and do not teach families to do so. Nurses need to wash
their hands before and after touching the client and before entering the nursing bag.
5. Answer B.
Hands are the primary method of transmission of the common cold. The most frequent means of
transmission of the tubercle bacillus is by droplet nuclei. The bacillus is present in the air as a result of
coughing, sneezing, and expectoration of sputum by an infected person. The tubercle bacillus is not
transmitted by means of contaminated food. Contact with contaminated food or water could cause
outbreaks of salmonella, infectious hepatitis, typhoid, or cholera. The tubercle bacillus is not transmitted
by eating utensils. Some exogenous microbes can be transmitted via reservoirs such as linens or eating
utensils.
6. Answer D.
Preparing for routine laboratory studies is not as high a priority as preventing injury and promoting
safety. Preparing for routine laboratory studies is not as high a priority as preventing injury and
promoting safety. A cooling blanket must be ordered by the physician and is usually not used unless
other methods for the reduction of fever have not been successful. The child has a diagnosis of febrile
seizures. Precautions to prevent injury and promote safety should take precedence.
7. Answer B.
Bathing or showering in the usual manner is permitted, using a mild detergent soap such as Ivory Snow.
This cleanses the wounds, especially those that are still open, and removes dead tissue. The client is
taught to report changes in wound healing such as blister formation, signs of infection, and opening of a
previously healed area. Sterile dressings are applied until the wound is assessed and a plan of care
developed. The Jobs garment is designed to place constant pressure on the new healthy tissue that is
forming to promote adherence to the underlying structure in order to prevent hypertrophic scarring. In
order to be effective, the garment must be worn for 23 hours daily. It is removed for wound assessment
and wound care and to permit bathing. The client must be aware that infection of the wound may occur;
signs of infection, including fever, redness, pain, warmth in and around the wound and increased or foul
smelling drainage must be reported immediately.
8. Answer D.
The client needs frequent visits by the staff to orient him and to assess his safety. Phone calls from his
family will not help a client who is trying to climb over the side rails and may even add to his danger.
Putting the client in a bright, busy area would probably add to his confusion. The environment is an
important factor in the prevention of injuries. Talking softly and providing quiet music have a calming
effect on the agitated client.
9. Answer B.
The client will be on a clear liquid or very low residue diet. Hamburgers and french fries are not allowed.
People who are pregnant should not come in close contact with someone who has internal radiation
therapy. The radioactivity could possibly damage the fetus. This statement is not true. As soon as the
radiation source is removed (probably 36 to 72 hours after insertion), the client is no longer

contaminated with radioactivity. Craft projects usually require the client to sit. The client must remain
flat with very little head elevation during the time the rods are in place.
10. Answer C.
There is no need to wear gloves when feeding a client. However, universal precautions (treating all
blood and body fluids as if they are infectious) should be observed in all situations. A client with active
tuberculosis should be on respiratory precautions. Having the client wear a mask when leaving his
private room is appropriate. Persons with exudative lesions or weeping dermatitis should not give direct
client care or handle client-care equipment until the condition resolves. Strict isolation requires the use
of mask, gown, and gloves.
11. Answer D.
Nonsterile gloves are adequate to remove the old dressing. However, the use of sterile gloves does not
put the client in danger so discussion of this can wait until later. The staff nurse is doing two things
incorrectly. Nonsterile gloves are adequate to remove the old dressing. The nurse should wash her
hands after removing the soiled dressing and before donning sterile gloves to clean and dress the
wound. The nurse should wash her hands after removing the soiled dressing and before donning the
sterile gloves to clean and dress the wound. Not doing this compromises client safety and should be
brought to the immediate attention of the nurse. The staff nurse is doing two things incorrectly.
Nonsterile gloves are adequate to remove the old dressing. However, the use of sterile gloves does not
put the client in danger so discussion of this can wait until later. However, the nurse should wash her
hands after removing the soiled dressing and before donning sterile gloves to clean and dress the
wound. Not doing this compromises client safety and should be brought to the immediate attention of
the nurse.
12. Answer A.
To prevent falls, the environment should be well lighted. Night lights should be used if necessary. Other
factors to assess include removing loose scatter rugs, removing spills, and installing handrails and grab
bars as appropriate. The amount of regular exercise is not the most important factor to assess. It is only
indirectly related. The resting pulse rate is not related to preventing falls. The salt intake is not directly
related to preventing falls.
13. Answer C.
Anything dropped on the floor is no longer sterile and should not be used. The statement indicates lack
of understanding. Anything dropped on the floor is no longer sterile and should not be used. The
statement indicates lack of understanding. If there is ever any doubt about the sterility of an instrument
or dressing, it should not be used. The 4 X 4s should be soaked prior to donning the sterile gloves. Once
the sterile gloves touch the bottle of normal saline they are no longer sterile. This statement indicates a
need for further instruction.
14. Answer B.
Masks should only be worn during procedures that are likely to cause splashes of blood or body fluid.
Gloves should be worn for all contact with blood and body fluids, nonintact skin and mucous
membranes; for handling soiled items; and for performing venipuncture. Gowns should be worn during
procedures that are likely to cause splashes of blood or body fluids. A private room is only indicated if
the client’s hygiene is poor.

15. Answer C.
Needles that have been used to draw blood should not be recapped. If it is necessary to recap them, an
instrument such as a hemostat should be used to recap. The hand should never be used. Gloves are not
necessary when feeding, since there is no contact with mucous membranes. Although saliva may have
small amounts of HIV in it, the virus does not invade through unbroken skin. There is no evidence in the
question to indicate broken skin. Masks and protective eye wear are indicated anytime there is great
potential for splashing of body fluids that may be contaminated with blood. Suctioning of a
tracheostomy almost always stimulates coughing, which is likely to generate droplets that may splash
the health care worker. Clients who are suctioned frequently or have had an invasive procedure like a
tracheostomy are likely to have blood in the sputum. There is no reason to restrict pregnant workers
from caring for persons with AIDS as long as they utilize universal precautions.
16. Answer A.
Direct contact is the mode of transmission for staphylococcus. Staph is not spread by coughing. Staph is
not spread through oral secretions. Direct contact is required. Staph is not spread through oral
secretions.
17. Answer A.
HIV is spread through direct contact with body fluids such as blood and through sexual intercourse.
Casual contact with other people does not pose a risk of transmission of HIV. Unless the client is feeling
very ill, there is no need for him to drop his college classes. Contact sports are not contraindicated
unless there is a significant chance of bleeding and direct contact with others. Casual contact with other
people does not pose a risk of transmission of HIV . There is no need to limit casual contact with
children.
18. Answer D.
Drug use is a risk factor for AIDS. Multiple sex partners is a risk factor for AIDS. Birth control methods are
important to prevent a baby from being born with the AIDS virus. The age at which sexual activity began
it not relevant as it does not usually provide information that identifies the presence of risk factors for
AIDS.
19. Answer C.
Independently ambulating around the unit is not appropriate because the unit environment can change
and injury could result. Assistance is necessary because of the client’s visual deficit. It is unlikely the
client can see well enough to read the materials. Maneuvering safely after orientation to the room is a
realistic goal for a person with impaired vision. Orienting the client to the room should help the client to
move safely. Using the bedpan is an unnecessary restriction on the client as she can be oriented to the
bathroom or to call for assistance.
20. Answer A.
The massive cell destruction resulting from chemotherapy may place the client at risk for developing
renal calculi; adding allopurinol decreases this risk by preventing the breakdown of xanthine to uric acid.
Allopurinol doesn’t act in the manner described in the other options.

Health Promotion and

Maintenance
1. What equipment would be necessary to complete an evaluation of cranial nerves 9 and 10 during a
physical assessment?
a. A cotton ball
b. A penlight
c. An ophthalmoscope
d. A tongue depressor and flashlight
2. Which technique would be best in caring for a client following receiving a diagnosis of a state IV
tumor in the brain?

a. Offering the client pamphlets on support groups for brain cancer

b. Asking the client if there is anything he or his family needs
c. Reminding the client that advances in technology are occurring everyday
d. Providing accurate information about the disease and treatment options
3. An 8.5 lb, 6 oz infant is delivered to a diabetic mother. Which nursing intervention would be
implemented when the neonate becomes jittery and lethargic?
a. Administer insulin
b. Administer oxygen
c. Feed the infant glucose water (10%)
d. Place infant in a warmer
4. 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?”
5. The nurse 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
6. Which nursing approach would be most appropriate to use while administering an oral medication
to a 4 month old?
a. Place medication in 45cc of formula

b. Place medication in an empty nipple
c. Place medication in a full bottle of formula
d. Place in supine position. Administer medication using a plastic syringe
7. Which nursing intervention would be a priority during the care of a 2 month old after surgery?
a. Minimize stimuli for the infant

b. Restrain all extremities
c. Encourage stroking of the infant
d. Demonstrate to the mother how she can assist with her infant’s care.

8. While performing a physical examination on a newborn, which assessment should be reported to

the physician?
a. Head circumference of 40 cm
b. Chest circumference of 32 cm
c. Acrocyanosis and edema of the scalp
d. Heart rate of 160 and respirations of 40
9. Which action by the mother of a preschooler would indicate a disturbed family interaction?
a. Tells her child that if he does not sit down and shut up she will leave him there.
b. Explains that the injection will burn like a bee sting.
c. Tells her child that the injection can be given while he’s in her lap
d. Reassures child that it is acceptable to cry.
10. During the history, which information from a 21 year old client would indicate a risk for
development of testicular cancer?
a. Genital Herpes
b. Hydrocele
c. Measles
d. Undescended testicle
11. While caring for a client, the nurse notes a pulsating mass in the client’s periumbilical area. Which
of the following assessments is appropriate for the nurse to perform?
a. Measure the length of the mass

b. Auscultate the mass
c. Percuss the mass
d. Palpate the mass
12. When observing 4 year-old children playing in the hospital playroom, what activity would the
nurse expect to see the children participating in?
a. Competitive board games with older children

b. Playing with their own toys along side with other children
c. Playing alone with hand held computer games
d. Playing cooperatively with other preschoolers
13. The nurse is teaching the parents of a 3 month-old infant about nutrition. What is the main source
of fluids for an infant until about 12 months of age?
a. Formula or breastmilk
b. Dilute nonfat dry milk

c. Warmed fruit juice

d. Fluoridated tap water
14. While the nurse is administering medications to a client, the client states “I do not want to take
that medicine today.” Which of the following responses by the nurse would be best?
a. “That’s OK, its alright to skip your medication now and then.”
b. “I will have to call your doctor and report this.”
c. “Is there a reason why you don’t want to take your medicine?”
d. “Do you understand the consequences of refusing your prescribed treatment?”
15. The nurse is assessing a 4 month-old infant. Which motor skill would the nurse anticipate finding?
a. Hold a rattle
b. Bang two blocks
c. Drink from a cup
d. Wave “bye-bye”
16. The nurse should recognize that all of the following physical changes of the head and face are
associated with the aging client except:
a. pronounced wrinkles on the face.

b. decreased size of the nose and ears.
c. increased growth of facial hair.
d. neck wrinkles.
17. All of the following characteristics would indicate to the nurse that an elder client might
experience undesirable effects of medicines except:
a. increased oxidative enzyme levels.

b. alcohol taken with medication.
c. medications containing magnesium.
d. decreased serum albumin.
18. When assessing a newborn whose mother consumed alcohol during the pregnancy, the nurse
would assess for which of these clinical manifestations?
a. wide-spaced eyes, smooth philtrum, flattened nose

b. strong tongue thrust, short palpebral fissures, simian crease
c. negative Babinski sign, hyperreflexia, deafness
d. shortened limbs, increased jitteriness, constant sucking
19. Which of these statements, when made by the nurse, is most effective when communicating with
a 4-year-old?

a. “Tell me where you hurt.”

b. “Other children like having their blood pressure taken.”
c. “This will be like having a little stick in your arm.”
d. “Anything you tell me is confidential.”
20. A 64-year-old client scheduled for surgery with a general anesthetic refuses to remove a set of
dentures prior to leaving the unit for the operating room. What would be the most appropriate
intervention by the nurse?
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
21. The nurse is assessing a client who states her last menstrual period was March 17, and she has
missed one period. She reports episodes of nausea and vomiting. Pregnancy is confirmed by a urine
test. What will the nurse calculate as the estimated date of delivery (EDD)?
a. November 8
b. May 15
c. February 21
d. December 24
22. 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
23. A client is admitted to the hospital with a history of confusion. The client has difficulty
remembering recent events and becomes disoriented when away from home. Which statement
would provide the best reality orientation for this client?
a. “Good morning. Do you remember where you are?”

b. “Hello. My name is Elaine Jones and I am your nurse for today.”
c. “How are you today? Remember, you’re in the hospital.”
d. “Good morning. You’re in the hospital. I am your nurse Elaine Jones.”
24. When a client wishes to improve the appearance of their eyes by removing excess skin from the
face and neck, the nurse should provide teaching regarding which of the following procedures?

a. Dermabrasion
b. Rhinoplasty
c. Blepharoplasty
d. Rhytidectomy
25. A woman who is six months pregnant is seen in antepartal clinic. She states she is having trouble
with constipation. To minimize this condition, the nurse should instruct her to
a. increase her fluid intake to three liters/day.

b. request a prescription for a laxative from her physician.
c. stop taking iron supplements.
d. take two tablespoons of mineral oil daily.

1. Answer D.
Cranial nerves 9 and 10 are the glossopharyngeal and vagus nerves. The gag reflex would be evaluated.
2. Answer D.
Providing information for the client is the best technique for a new diagnosis.
3. Answer C.
After birth, the infant of a diabetic mother is often hypoglycemic.
4. Answer A.
This change would be most indicative of a potential complication with (BPH) benign prostate
hypertrophy.
5. Answer A.
Stopping the infusion will decrease contractions and possibly remove uterine pressure on the fetus,
which is a possible cause of the deceleration.
6. Answer B.
This is a convenient method for administering medications to an infant. Option D is partially correct
however, the infant is never placed in a reclining position during a procedure due to a potential
aspiration.
7. Answer C.
Tactile stimulation is imperative for an infant’s normal emotional development. After the trauma of
surgery, sensory deprivation can cause failure to thrive.
8. Answer A.
Average circumference of the head for a neonate ranges between 32 to 36 cm. An increase in size may
indicate hydrocephaly or increased intracranial pressure.
9. Answer A.
Threatening a child with abandonment will destroy the child’s trust in his family.
10. Answer D.
Undescended testicles make the client high risk for testicular cancer. Mumps, inguinal hernia in
childhood, orchitis, and testicular cancer in the contralateral testis are other predisposing factors.
11. Answer B.
Auscultate the mass. Auscultation of the abdomen and finding a bruit will confirm the presence of an
abdominal aneurysm and will form the basis of information given to the provider. The mass should not
be palpated because of the risk of rupture.
12. Answer D.
Playing cooperatively with other preschoolers. Cooperative play is typical of the late preschool period.
13. Answer A.
Formula or breast milk are the perfect food and source of nutrients and liquids up to 1 year of age.
14. Answer C.
When a new problem is identified, it is important for the nurse to collect accurate assessment data. This
is crucial to ensure that client needs are adequately identified in order to select the best nursing care
approaches. The nurse should try to discover the reason for the refusal which may be that the client has
developed untoward side effects.
15. Answer A.
The age at which a baby will develop the skill of grasping a toy with help is 4 to 6 months.
16. Answer B.
The nose and ears of the aging client actually become longer and broader. The chin line is also altered.
Wrinkles on the face become more pronounced and tend to take on the general mood of the client over
the years. For example laugh or frown wrinkles about the eyebrows, lips, cheeks, and outer edges of the
eye orbit. The change in the androgen-estrogen ratio causes an increase in growth of facial hair in most
older adults. The aging process shortens the platysma muscle, which contributes to neck wrinkles.
17. Answer A.
Oxidative enzyme levels decrease in the elderly, which affects the disposition of medication and can
alter the therapeutic effects of medication. Alcohol has a smaller water distribution level in the elderly,
resulting in higher blood alcohol levels. Alcohol also interacts with various drugs to either potentate or
interfere with their effects. Magnesium is contained in a lot of medications elder clients routinely obtain
over the counter. Magnesium toxicity is a real concern. Albumin is the major drug-binding protein.
Decreased levels of serum albumin mean that higher levels of the drug remain free and that there are
less therapeutic effects and increased drug interactions.

18. Answer A.
The nurse should anticipate that the infant may have fetal alcohol syndrome and should assess for signs
and symptoms of it. These include the characteristics listed in choice A.
19. Answer A.
Four-year-olds are egocentric and interested in having the focus on themselves. They will not be
interested in what it feels like to other children. Preschoolers are concrete thinkers and would literally
interpret any analogies so they are not helpful in explaining procedures. Assurance of confidential
communication is most appropriate for the adolescent. In addition, confidentiality is not maintained if
the child plans to harm themselves, harm someone else, or discloses abuse.
20. Answer D.
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.
21. Answer D.
Naegele’s rule: add 7 days and subtract 3 months from the first day of the last regular menstrual period
to calculate the estimated date of delivery.
22. Answer B.
Epiphyseal fractures often interrupt a child’s normal growth pattern
23. Answer is D.
As cognitive ability declines, the nurse provides a calm, predictable environment for the client. This
response establishes time, location and the caregivers name.
24. Answer D.
Rhytidectomy is the procedure for removing excess skin from the face and neck. It is commonly called a
face lift. Dermabrasion involves the spraying of a chemical to cause light freezing of the skin, which is
then abraded with sandpaper or a revolving wire brush. It is used to remove facial scars, severe acne,
and pigment from tattoos. Rhinoplasty is done to improve the appearance of the nose and involves
reshaping the nasal skeleton and overlying skin. Blepharoplasty is the procedure that removes loose and
protruding fat from the upper and lower eyelids.
25. Answer A.
In pregnancy, constipation results from decreased gastric motility and increased water reabsorption in
the colon caused by increased levels of progesterone. Increasing fluid intake to three liters a day will
help prevent constipation. The client should increase fluid intake, increase roughage in the diet, and
increase exercise as tolerated. Laxatives are not recommended because of the possible development of
laxative dependence or abdominal cramping. Iron supplements are necessary during pregnancy, as
ordered, and should not be discontinued. The client should increase fluid intake, increase roughage in
the diet, and increase exercise as tolerated. Laxatives are not recommended because of the possible
development of laxative dependence or abdominal cramping. Mineral oil is especially bad to use as a
laxative because it decreases the absorption of fat-soluble vitamins (A, D, E, K) if taken near mealtimes.

Basic Care and Comfort

1. The nurse is caring for an elderly woman who has had a fractured hip repaired. In the first few days
following the surgical repair, which of the following nursing measures will best facilitate the
resumption of activities for this client?
a. arranging for the wheelchair

b. asking her family to visit
c. assisting her to sit out of bed in a chair qid
d. encouraging the use of an overhead trapeze
2. What do you think is the most important nursing order in a client with major head trauma who is
about to receive bolus enteral feeding?
a. measure intake and output.

b. check albumin level.
c. monitor glucose levels.
d. increase enteral feeding.
3. The pathological process causing esophageal varices is:
a. ascites and edema.

b. systemic hypertension.
c. portal hypertension.
d. dilated veins and varicesitis.
4. Which of the following interventions will help lessen the effect of GERD (acid reflux)?
a. Elevate the head of the bed on 4-6 inch blocks.

b. Lie down after eating.
c. Increase fluid intake just before bedtime.
d. Wear a girdle.
5. What is the main benefit of therapeutic massages is:
a. to help a person with swollen legs to decrease the fluid retention.

b. to help a person with duodenal ulcers feel better.
c. to help damaged tissue in a diabetic to heal.

d. to improve circulation and muscles tone.
6. Which of the following foods should be avoided by clients who are prone to develop heartburn as a
result of gastroesophageal reflux disease (GERD)?
a. Lettuce
b. Eggs
c. Chocolate
d. Butterscotch
7. 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.
8. Which of the following should be included in a plan of care for a client who is lactose intolerant?
a. Remove all dairy products from the diet.

b. Frozen yogurt can be included in the diet.
c. Drink small amounts of milk on an empty stomach.
d. Spread out selection of dairy products throughout the day.
9. Pain tolerance in an elderly patient with cancer would:
a. stay the same.

b. be lowered.
c. be increased.
d. no effect on pain tolerance.
10. What is the main advantage of cutaneous stimulation in managing pain:
a. costs less.
b. restricts movement and decreases.
c. gives client control over pain syndrome.
d. allows the family to care for the patient at home.
11. The nurse is instructing a 65-year-old female client diagnosed with osteoporosis. The most
important instruction regarding exercise would be to

a. exercise doing weight bearing activities

b. exercise to reduce weight
c. avoid exercise activities that increase the risk of fracture
d. exercise to strengthen muscles and thereby protect bones
12. A client in a long term care facility complains of pain. The nurse collects data about the client’s
pain. The first step in pain assessment is for the nurse to
a. have the client identify coping methods

b. get the description of the location and intensity of the pain
c. accept the client’s report of pain
d. determine the client’s status of pain
13. Which statement best describes the effects of immobility in children?
a. Immobility prevents the progression of language and fine motor development

b. Immobility in children has similar physical effects to those found in adults
c. Children are more susceptible to the effects of immobility than are adults
d. Children are likely to have prolonged immobility with subsequent complications
14. 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
15. A nurse is assessing several clients in a long term health care facility. Which client is at highest risk
for development of decubitus ulcers?
a. A 79 year-old malnourished client on bed rest

b. An obese client who uses a wheelchair
c. An incontinent client who has had 3 diarrhea stools
d. An 80 year-old ambulatory diabetic client
16. Mrs. Kennedy had a CVA (cerebrovascular accident) and has severe right-sided weakness. She has
been taught to walk with a cane. The nurse is evaluating her use of the cane prior to discharge. Which
of the following reflects correct use of the cane?
a. Holding the cane in her left hand, Mrs. Kennedy moves the cane forward first, then her right leg, and
finally her left leg
b. Holding the cane in her right hand, Mrs. Kennedy moves the cane forward first, then her left leg, and
finally her right leg

c. Holding the cane in her right hand, Mrs. Kennedy moves the cane and her right leg forward, then
moves her left leg forward.
d. Holding the cane in her left hand, Mrs. Kennedy moves the cane and her left leg forward, then moves
her right leg forward
17. The nurse is instructing a woman in a low-fat, high-fiber diet. Which of the following food choices,
if selected by the client, indicate an understanding of a low-fat, high-fiber diet?
a. Tuna salad sandwich on whole wheat bread.

b. Vegetable soup made with vegetable stock, carrots, celery, and legumes served with toasted oat
bread
c. Chef’s salad with hard boiled eggs and fat-free dressing
d. Broiled chicken stuffed with chopped apples and walnuts
18. An 85-year-old male patient has been bedridden for two weeks. Which of the following complaints
by the patient indicates to the nurse that he is developing a complication of immobility?
a. Stiffness of the right ankle joint

b. Soreness of the gums
c. Short-term memory loss.
d. Decreased appetite.
19. An eleven-month-old infant is brought to the pediatric clinic. The nurse suspects that the child has
iron deficiency anemia. Because iron deficiency anemia is suspected, which of the following is the
most important information to obtain from the infant’s parents?
a. Normal dietary intake.

b. Relevant socio cultural, economic, and educational background of the family.
c. Any evidence of blood in the stools
d. A history of maternal anemia during pregnancy
20. A 46-year-old female with chronic constipation is assessed by the nurse for a bowel training
regimen. Which factor indicates further information is needed by the nurse?
a. The client’s dietary habits include foods high in bulk.

b. The client’s fluid intake is between 2500-3000 ml per day
c. The client engages in moderate exercise each day
d. The client’s bowel habits were not discussed.

1. Answer D.
Exercise is important to keep the joints and muscles functioning and to prevent secondary
complications. Using the overhead trapeze prevents hazards of immobility by permitting movement in

bed and strengthening of the upper extremities in preparation for ambulation. Sitting in a wheelchair
would require too great hip flexion initially. Asking her family to visit would not facilitate the resumption
of activities. Sitting in a chair would cause too much hip flexion. The client initially needs to be in a low
Fowler’s position or taking a few steps (as ordered) with the aid of a walker.
2. Answer A.
It is important to measure intake and output, which should equal. Enteral feeding are hyperosmotic
agents pulling fluid from cells into vascular bed. Water given before feeding will present a hyperosmotic
diuresis. I and O measures assess fluid balance.
3. Answer C.
Esophageal varices results from increased portal hypertension. In portal hypertension, the liver cannot
accept all of the fluid from the portal vein. The excess fluid will back flow to the vessels with lesser
pressure, such as esophageal veins or rectal veins causing esophageal varices or hemorrhoids.
4. Answer A.
Elevation of the head of the bed allows gravity to assist in decreasing the backflow of acid into the
esophagus. Fluid does not flow uphill. The other three options all increase fluid backflow into the
esophagus through position or increasing abdominal pressure.
5. Answer D.
Particularly in the elderly adults, therapeutic massage will help improve circulation and muscle tone as
well as the personal attention and social interaction that a good massage provides. A massage is
contraindicated in any condition where massage to damaged tissue can dislodge a blood clot.
6. Answer C.
Ingestion of chocolate can reduce lower esophageal sphincter (LES) pressure leading to reflux and
clinical symptoms of GERD. All of the other foods do not affect LES pressure.
7. Answer B.
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.
8. Answer B.
Clients who are lactose intolerant can digest frozen yogurt. Yogurt products are formed by bacterial
action, and this action assists in the digestion of lactose. The freezing process further stops bacterial
action so that limited lactase activity remains. Option 1 is incorrect; elimination of all dairy products can
lead to significant clinical deficiencies of other nutrients. Option 3 is incorrect because drinking milk on
an empty stomach can exacerbate clinical symptoms. Drinking milk with a meal may benefit the client
because other foods, (especially fat) may decrease transit time and allow for increased lactase activity.
Option 4 is incorrect because although individual tolerance should be acknowledged, spreading out the
use of known dairy products will usually exacerbate clinical symptoms.

9. Answer B.
There is potential for a lowered pain tolerance to exist with diminished adaptative capacity.
10. Answer C.
Cutaneous stimulation allows the patient to have control over his pain and allows him to be in his own
environment. Cutaneous stimulation increases movement and decreases pain.
11. Answer A.
Weight bearing exercises are beneficial in the treatment of osteoporosis. Although loss of bone cannot
be substantially reversed, further loss can be greatly reduced if the client includes weight bearing
exercises along with estrogen replacement and calcium supplements in their treatment protocol.
12. Answer C.
Although all of the options above are correct, the first and most important piece of information in this
client’s pain assessment is what the client is telling you about the pain –“the client’s report.”
13. Answer B.
Care of the immobile child includes efforts to prevent complications of muscle atrophy, contractures,
skin breakdown, decreased metabolism and bone demineralization. Secondary alterations also occur in
the cardiovascular, respiratory and renal systems. Similar effects and alterations occur in adults.
14. Answer D.
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
15. Answer A.
Weighing significantly less than ideal body weight increases the number and surface area of bony
prominences which are susceptible to pressure ulcers. Thus, malnutrition is a major risk factor for
decubitus, due in part to poor hydration and inadequate protein intake.
16. Answer A.
When a person with weakness on one side uses a cane, there should always be two points of contact
with the floor. When Mrs. Kennedy. moves the cane forward, she has both feet on the floor, providing
stability. As she moves the weak leg, the cane and the strong leg provide support. Finally, the cane,
which is even with the weak leg, provides stability while she moves the strong leg. She should not hold
the cane with her weak arm. The use of the cane requires arm strength to ensure that the cane provides
adequate stability when standing on the weak leg. The cane should be held in the left hand, the hand
opposite the affected leg. If Mrs. Kennedy. moved the cane and her strong foot at the same time, she
would be left standing on her weak leg at one point. This would be unstable at best; at worst, impossible
17. Answer B.
Mayonnaise in tuna salad is high in fat. The whole wheat bread has some fiber. This choice shows a low-
fat soup (which would have been higher in fat if made with chicken or beef stock) and high-fiber bread
and soup contents (both the vegetables and the legumes). Salad is high in fiber, but hard boiled eggs are
high in fat. There is some fiber in the apples and walnuts. The walnuts are high in fat, as is the chicken.

18. Answer A.
Stiffness of a joint may indicate the beginning of a contracture and/or early muscle atrophy. Soreness of
the gums is not related to immobility. Short-term memory loss is not related to immobility. Decreased
appetite is unlikely to be related to immobility.
19. Answer A.
Iron deficiency anemia occurs commonly in children 6 to 24 months of age. For the first 4 to 5 months of
infancy iron stores laid down for the baby during pregnancy are adequate. When fetal iron stores are
depleted, supplemental dietary iron needs to be supplied to meet the infant’s rapid growth needs. Iron
deficiency may occur in the infant who drinks mostly milk, which contains no iron, and does not receive
adequate dietary iron or supplemental iron. Daily dietary intake is much more related to the diagnosis of
iron deficiency anemia than is sociocultural, economic, and educational background of the family. Iron
deficiency anemia in an infant is very unlikely to be related to gastrointestinal bleeding. Anemia during
pregnancy is unlikely to be the cause of the infant’s iron deficiency anemia. Fetal iron stores are drawn
from the mother even if she is anemic.
20. Answer D.
Foods high in bulk are appropriate. Exercise should be a part of a bowel training regimen. To assess the
client for a bowel training program the factors causing the bowel alteration should be assessed. A
routine for bowel elimination should be based on the client’s previous bowel habits and alterations in
bowel habits that have occurred because of illness or trauma. The client and the family should assist in
the planning of the program which should include foods high in bulk, adequate exercise, and fluid intake
of 2500-3000 ml.
Fundamentals of
Nursing
1. The most important nursing intervention to correct skin dryness is:
a. Avoid bathing the patient until the condition is remedied, and notify the physician
b. Ask the physician to refer the patient to a dermatologist, and suggest that the patient wear home-

laundered sleepwear
c. Consult the dietitian about increasing the patient’s fat intake, and take necessary measures to prevent
infection
d. Encourage the patient to increase his fluid intake, use non-irritating soap when bathing the patient,
and apply lotion to the involved areas
2. When bathing a patient’s extremities, the nurse should use long, firm strokes from the distal to the
proximal areas. This technique:
a. Provides an opportunity for skin assessment

b. Avoids undue strain on the nurse
c. Increases venous blood return
d. Causes vasoconstriction and increases circulation
3. Vivid dreaming occurs in which stage of sleep?
a. Stage I non-REM
b. Rapid eye movement (REM) stage
c. Stage II non-REM
d. Delta stage
4. The natural sedative in meat and milk products (especially warm milk) that can help induce sleep is:
a. Flurazepam
b. Temazepam
c. Tryptophan
d. Methotrimeprazine
5. Nursing interventions that can help the patient to relax and sleep restfully include all of the
following except:
a. Have the patient take a 30- to 60-minute nap in the afternoon

b. Turn on the television in the patient’s room
c. Provide quiet music and interesting reading material
d. Massage the patient’s back with long strokes
6. Restraints can be used for all of the following purposes except to:
a. Prevent a confused patient from removing tubes, such as feeding tubes, I.V. lines, and urinary
catheters
b. Prevent a patient from falling out of bed or a chair
c. Discourage a patient from attempting to ambulate alone when he requires assistance for his safety
d. Prevent a patient from becoming confused or disoriented

7. Which of the following is the nurse’s legal responsibility when applying restraints?
a. Document the patient’s behavior

b. Document the type of restraint used
c. Obtain a written order from the physician except in an emergency, when the patient must be
protected from injury to himself or others
d. All of the above
8. Kubler-Ross’s five successive stages of death and dying are:
a. Anger, bargaining, denial, depression, acceptance

b. Denial, anger, depression, bargaining, acceptance
c. Denial, anger, bargaining, depression acceptance
d. Bargaining, denial, anger, depression, acceptance
9. A terminally ill patient usually experiences all of the following feelings during the anger stage
except:
a. Rage
b. Envy
c. Numbness
d. Resentment
10. Nurses and other health care provides often have difficulty helping a terminally ill patient through
the necessary stages leading to acceptance of death. Which of the following strategies is most helpful
to the nurse in achieving this goal?
a. Taking psychology courses related to gerontology

b. Reading books and other literature on the subject of thanatology
c. Reflecting on the significance of death
d. Reviewing varying cultural beliefs and practices related to death
11. Which of the following symptoms is the best indicator of imminent death?
a. A weak, slow pulse

b. Increased muscle tone
c. Fixed, dilated pupils
d. Slow, shallow respirations
12. A nurse caring for a patient with an infectious disease who requires isolation should refers to
guidelines published by the:
a. National League for Nursing (NLN)

b. Centers for Disease Control (CDC)

c. American Medical Association (AMA)

d. American Nurses Association (ANA)
13. To institute appropriate isolation precautions, the nurse must first know the:
a. Organism’s mode of transmission

b. Organism’s Gram-staining characteristics
c. Organism’s susceptibility to antibiotics
d. Patient’s susceptibility to the organism
14. Which is the correct procedure for collecting a sputum specimen for culture and sensitivity
testing?
a. Have the patient place the specimen in a container and enclose the container in a plastic bag
b. Have the patient expectorate the sputum while the nurse holds the container
c. Have the patient expectorate the sputum into a sterile container
d. Offer the patient an antiseptic mouthwash just before he expectorate the sputum
15. An autoclave is used to sterilize hospital supplies because:
a. More articles can be sterilized at a time

b. Steam causes less damage to the materials
c. A lower temperature can be obtained
d. Pressurized steam penetrates the supplies better
16. The best way to decrease the risk of transferring pathogens to a patient when removing
contaminated gloves is to:
a. Wash the gloves before removing them

b. Gently pull on the fingers of the gloves when removing them
c. Gently pull just below the cuff and invert the gloves when removing them
d. Remove the gloves and then turn them inside out
17. After having an I.V. line in place for 72 hours, a patient complains of tenderness, burning, and
swelling. Assessment of the I.V. site reveals that it is warm and erythematous. This usually indicates:
a. Infection
b. Infiltration
c. Phlebitis
d. Bleeding
18. To ensure homogenization when diluting powdered medication in a vial, the nurse should:

a. Shake the vial vigorously

b. Roll the vial gently between the palms
c. Invert the vial and let it stand for 1 minute
d. Do nothing after adding the solution to the vial
19. The nurse is teaching a patient to prepare a syringe with 40 units of U-100 NPH insulin for self-
injection. The patient’s first priority concerning self-injection in this situation is to:
a. Assess the injection site

b. Select the appropriate injection site
c. Check the syringe to verify that the nurse has removed the prescribed insulin dose
d. Clean the injection site in a circular manner with alcohol sponge
20. The physician’s order reads “Administer 1 g cefazolin sodium (Ancef) in 150 ml of normal saline
solution in 60 minutes.” What is the flow rate if the drop factor is 10 gtt = 1 ml?
a. 25 gtt/minute
b. 37 gtt/minute
c. 50 gtt/minute
d. 60 gtt/minute
21. A patient must receive 50 units of Humulin regular insulin. The label reads 100 units = 1 ml. How
many milliliters should the nurse administer?
a. 0.5 ml
b. 0.75 ml
c. 1 ml
d. 2 ml
22. How should the nurse prepare an injection for a patient who takes both regular and NPH insulin?
a. Draw up the NPH insulin, then the regular insulin, in the same syringe
b. Draw up the regular insulin, then the NPH insulin, in the same syringe
c. Use two separate syringe
d. Check with the physician
23. A patient has just received 30 mg of codeine by mouth for pain. Five minutes later he vomits.
What should the nurse do first?
a. Call the physician

b. Remedicate the patient
c. Observe the emesis
d. Explain to the patient that she can do nothing to help him

24. A patient is characterized with a #16 indwelling urinary (Foley) catheter to determine if:
a. Trauma has occurred

b. His 24-hour output is adequate
c. He has a urinary tract infection
d. Residual urine remains in the bladder after voiding
25. A staff nurse who is promoted to assistant nurse manager may feel uncomfortable initially when
supervising her former peers. She can best decrease this discomfort by:
a. Writing down all assignments

b. Making changes after evaluating the situation and having discussions with the staff.
c. Telling the staff nurses that she is making changes to benefit their performance
d. Evaluating the clinical performance of each staff nurse in a private conference

1. Answer – D.
Dry skin will eventually crack, ranking the patient more prone to infection. To prevent this, the nurse
should provide adequate hydration through fluid intake, use nonirritating soaps or no soap when
bathing the patient, and lubricate the patient’s skin with lotion. Bathing may be limited but need not be
avoided entirely. The attending physician and dietitian may be consulted for treatment, but home-
laundered items usually are not necessary.
2. Answer – C.
Washing from distal to proximal areas stimulates venous blood flow, thereby preventing venous stasis. It
improves circulation but does not result in vasoconstriction. The nurse can assess the patient’s condition
throughout the bath, regardless of washing technique, and should feel no strain while bathing the
patient.
3. Answer – B.
Other characteristics of rapid eye movement (REM) sleep are deep sleep (the patient cannot be
awakened easily), depressed muscle tone, and possibly irregular heart and respiratory rates. Non-REM
sleep is a deep, restful sleep without dreaming. Delta stage, or slow-wave sleep, occurs during non-REM
Stages III and IV and is often equated with quiet sleep.
4. Answer – C.
Tryptophan is a natural sedative; flurazepam (Dalmane), temazepam (Restoril), and methotrimeprazine
(Levoprome) are hypnotic sedatives.
5. Answer – A.
Napping in the afternoon is not conductive to nighttime sleeping. Quiet music, watching television,
reading, and massage usually will relax the patient, helping him to fall asleep.

6. Answer – D.
By restricting a patient’s movements, restraints may increase stress and lead to confusion, rather than
prevent it. The other choices are valid reasons for using restraints.
7. Answer – D.
When applying restraints, the nurse must document the type of behavior that prompted her to use
them, document the type of restraints used, and obtain a physician’s written order for the restraints.
8. Answer – C.
Kubler-Ross’s five successive stages of death and dying are denial, anger, bargaining, depression, and
acceptance. The patient may move back and forth through the different stages as he and his family
members react to the process of dying, but he usually goes through all of these stages to reach
acceptance.
9. Answer – C.
Numbness is typical of the depression stage, when the patient feels a great sense of loss. The anger
stage includes such feelings as rage, envy, resentment, and the patient’s questioning “Why me?”
10. Answer – C.
According to thanatologists, reflecting on the significance of death helps to reduce the fear of death and
enables the health care provider to better understand the terminally ill patient’s feelings. It also helps to
overcome the belief that medical and nursing measures have failed, when a patient cannot be cured.
11. Answer – C.
Fixed, dilated pupils are sign of imminent death. Pulse becomes weak but rapid, muscles become weak
and atonic, and periods of apnea occur during respiration.
12. Answer – B.
The Center of Disease Control (CDC) publishes and frequently updates guidelines on caring for patients
who require isolation. The National League of Nursing’s (NLN’s) major function is accrediting nursing
education programs in the
United States. The American Medical Association (AMA) is a national organization of physicians. The
American Nurses’ Association (ANA) is a national organization of registered nurses.
13. Answer – A.
Before instituting isolation precaution, the nurse must first determine the organism’s mode of
transmission. For example, an organism transmitted through nasal secretions requires that the patient
be kept in respiratory isolation, which involves keeping the patient in a private room with the door
closed and wearing a mask, a grown, and gloves when coming in direct contact with the patient. The
organism’s Gram-straining characteristics reveal whether the organism is gram-negative or gram-
positive, an important criterion in the physician’s choice for drug therapy and the nurse’s development
of an effective plan of care. The nurse also needs to know whether the organism is susceptible to
antibiotics, but this could take several days to determine; if she waits for the results before instituting
isolation precautions, the organism could be transmitted in the meantime. The patient’s susceptibility to

the organism has already been established. The nurse would not be instituting isolation precautions for
a non infected patient.
14. Answer – C.
Placing the specimen in a sterile container ensures that it will not become contaminated. The other
answers are incorrect because they do not mention sterility and because antiseptic mouthwash could
destroy the organism to be cultured (before sputum collection, the patient may use only tap water for
nursing the mouth).
15. Answer – D.
An autoclave, an apparatus that sterilizes equipment by means of high-temperature pressured steam, is
used because it can destroy all forms of microorganisms, including spores.
16. Answer – C.
Turning the gloves inside out while removing them keeps all contaminants inside the gloves. They
should than be placed in a plastic bag with soiled dressings and discarded in a soiled utility room
garbage pail (double bagged). The other choices can spread pathogens within the environment.
17. Answer – C.
Tenderness, warmth, swelling, and, in some instances, a burning sensation are signs and symptoms of
phlebitis. Infection is less likely because no drainage or fever is present. Infiltration would result in
swelling and pallor, not erythema, near the insertion site. The patient has no evidence of bleeding.
18. Answer – B.
Gently rolling a sealed vial between the palms produces sufficient heat to enhance dissolution of a
powdered medication. Shaking the vial vigorously can break down the medication and alter its
pharmacologic action. Inverting the vial or leaving it alone does not ensure thorough homogenization of
the powder and the solvent.
19. Answer – C.
When the nurse teaches the patient to prepare an insulin injection, the patient’s first priority is to
validate the dose accuracy. The next steps are to select the site, assess the site, and clean the site with
alcohol before injecting the insulin.
20. Answer – A. 25 gtt/minute
21. Answer – A. 0.5 ml
22. Answer – B.
Drugs that are compatible may be mixed together in one syringe. In the case of insulin, the shorter-
acting, clear insulin (regular) should be drawn up before the longer-acting, cloudy insulin (NPH) to
ensure accurate measurements.

23. Answer – C.
After a patient has vomited, the nurse must inspect the emesis to document color, consistency, and
amount. In this situation, the patient recently ingested medication, so the nurse needs to check for
remnants of the medication to help determine whether the patient retained enough of it to be effective.
The nurse must then notify the physician, who will decide whether to repeat the dose or prescribe an
antiemetic.
24. Answer – B.
A 24-hour urine output of less than 500 ml in an adult is considered inadequate and may indicate kidney
failure. This must be corrected while the patient is in the acute state so that appropriate fluids,
electrolytes, and medications can be administered and excreted. Indwelling catheterization is not
needed to diagnose trauma, urinary tract infection, or residual urine.
25. Answer – B.
A new assistant nurse manager should not make changes until she has had a chance to evaluate staff
members, patients, and physicians. Changes must be planned thoroughly and should be based on a
need to improve conditions, not just for the sake of change. Written assignments allow all staff
members to know their own and others responsibilities and serve as a checklist for the manager,
enabling her to gauge whether the unit is being run effectively and whether patients are receiving
appropriate care. Telling the staff nurses that she is making changes to benefit their performance should
occur only after the nurse has made a thorough evaluation. Evaluations are usually done on a yearly
basis or as needed.
Fundamentals of Nursing 2 – Dosage

Calculations
1. Nurse Clarisse is teaching a patient about a newly prescribed drug. What could cause a geriatric
patient to have difficulty retaining knowledge about prescribed medications?
a. Decreased plasma drug levels

b. Sensory deficits
c. Lack of family support
d. History of Tourette syndrome
2. When examining a patient with abdominal pain the nurse in charge should assess:
a. Any quadrant first

b. The symptomatic quadrant first
c. The symptomatic quadrant last
d. The symptomatic quadrant either second or third

3. The nurse is assessing a postoperative adult patient. Which of the following should the nurse
document as subjective data?
a. Vital signs
b. Laboratory test result
c. Patient’s description of pain
d. Electrocardiographic (ECG) waveforms
4. A male patient has a soft wrist-safety device. Which assessment finding should the nurse consider
abnormal?
a. A palpable radial pulse

b. A palpable ulnar pulse
c. Cool, pale fingers
d. Pink nail beds
5. Which of the following planes divides the body longitudinally into anterior and posterior regions?
a. Frontal plane
b. Sagittal plane
c. Midsagittal plane
d. Transverse plane
6. A female patient with a terminal illness is in denial. Indicators of denial include:
a. Shock dismay
b. Numbness
c. Stoicism
d. Preparatory grief
7. The nurse in charge is transferring a patient from the bed to a chair. Which action does the nurse
take during this patient transfer?
a. Position the head of the bed flat

b. Helps the patient dangle the legs
c. Stands behind the patient
d. Places the chair facing away from the bed
8. A female patient who speaks a little English has emergency gallbladder surgery, during discharge
preparation, which nursing action would best help this patient understand wound care instruction?
a. Asking frequently if the patient understands the instruction

b. Asking an interpreter to replay the instructions to the patient.

c. Writing out the instructions and having a family member read them to the patient
d. Demonstrating the procedure and having the patient return the demonstration
9. Before administering the evening dose of a prescribed medication, the nurse on the evening shift
finds an unlabeled, filled syringe in the patient’s medication drawer. What should the nurse in charge
do?
a. Discard the syringe to avoid a medication error

b. Obtain a label for the syringe from the pharmacy
c. Use the syringe because it looks like it contains the same medication the nurse was prepared to give
d. Call the day nurse to verify the contents of the syringe
10. When administering drug therapy to a male geriatric patient, the nurse must stay especially alert
for adverse effects. Which factor makes geriatric patients to adverse drug effects?
a. Faster drug clearance

b. Aging-related physiological changes
c. Increased amount of neurons
d. Enhanced blood flow to the GI tract
11. A female patient is being discharged after cataract surgery. After providing medication teaching,
the nurse asks the patient to repeat the instructions. The nurse is performing which professional role?
a. Manager
b. Educator
c. Caregiver
d. Patient advocate
12. A female patient exhibits signs of heightened anxiety. Which response by the nurse is most likely
to reduce the patient’s anxiety?
a. “Everything will be fine. Don’t worry.”

b. “Read this manual and then ask me any questions you may have.”
c. “Why don’t you listen to the radio?”
d. “Let’s talk about what’s bothering you.”
13. A scrub nurse in the operating room has which responsibility?
a. Positioning the patient

b. Assisting with gowning and gloving
c. Handling surgical instruments to the surgeon
d. Applying surgical drapes

14. A patient is in the bathroom when the nurse enters to give a prescribed medication. What should
the nurse in charge do?
a. Leave the medication at the patient’s bedside

b. Tell the patient to be sure to take the medication. And then leave it at the bedside
c. Return shortly to the patient’s room and remain there until the patient takes the medication
d. Wait for the patient to return to bed, and then leave the medication at the bedside
15. The physician orders heparin, 7,500 units, to be administered subcutaneously every 6 hours. The
vial reads 10,000 units per milliliter. The nurse should anticipate giving how much heparin for each
dose?
a. ¼ ml
b. ½ ml
c. ¾ ml
d. 1 ¼ ml
16. The nurse in charge measures a patient’s temperature at 102 degrees F. what is the equivalent
Centigrade temperature?
a. 39 degrees C
b. 47 degrees C
c. 38.9 degrees C
d. 40.1 degrees C
17. To evaluate a patient for hypoxia, the physician is most likely to order which laboratory test?
a. Red blood cell count

b. Sputum culture
c. Total hemoglobin
d. Arterial blood gas (ABG) analysis
18. The nurse uses a stethoscope to auscultate a male patient’s chest. Which statement about a
stethoscope with a bell and diaphragm is true?
a. The bell detects high-pitched sounds best

b. The diaphragm detects high-pitched sounds best
c. The bell detects thrills best
d. The diaphragm detects low-pitched sounds best
19. A male patient is to be discharged with a prescription for an analgesic that is a controlled
substance. During discharge teaching, the nurse should explain that the patient must fill this
prescription how soon after the date on which it was written?

a. Within 1 month
b. Within 3 months
c. Within 6 months
d. Within 12 months
20. Which human element considered by the nurse in charge during assessment can affect drug
administration?
a. The patient’s ability to recover

b. The patient’s occupational hazards
c. The patient’s socioeconomic status
d. The patient’s cognitive abilities
21. An employer establishes a physical exercise area in the workplace and encourages all employees
to use it. This is an example of which level of health promotion?
a. Primary prevention
b. Secondary prevention
c. Tertiary prevention
d. Passive prevention
22. What does the nurse in charge do when making a surgical bed?
a. Leaves the bed in the high position when finished

b. Places the pillow at the head of the bed
c. Rolls the patient to the far side of the bed
d. Tucks the top sheet and blanket under the bottom of the bed
23. The physician prescribes 250 mg of a drug. The drug vial reads 500 mg/ml. how much of the drug
should the nurse give?
a. 2 ml
b. 1 ml
c. ½ ml
d. ¼ ml
24. Nurse Mackey is monitoring a patient for adverse reactions during barbiturate therapy. What is
the major disadvantage of barbiturate use?
a. Prolonged half-life
b. Poor absorption
c. Potential for drug dependence
d. Potential for hepatotoxicity

25. Which nursing action is essential when providing continuous enteral feeding?
a. Elevating the head of the bed

b. Positioning the patient on the left side
c. Warming the formula before administering it
d. Hanging a full day’s worth of formula at one time
26. When teaching a female patient how to take a sublingual tablet, the nurse should instruct the
patient to place the table on the:
a. Top of the tongue

b. Roof of the mouth
c. Floor of the mouth
d. Inside of the cheek
27. Which action by the nurse in charge is essential when cleaning the area around a Jackson-Pratt
wound drain?
a. Cleaning from the center outward in a circular motion

b. Removing the drain before cleaning the skin
c. Cleaning briskly around the site with alcohol
d. Wearing sterile gloves and a mask
28. The doctor orders dextrose 5% in water, 1,000 ml to be infused over 8 hours. The I.V. tubing
delivers 15 drops per milliliter. The nurse in charge should run the I.V. infusion at a rate of:
a. 15 drop per minute

b. 21 drop per minute
c. 32 drop per minute
d. 125 drops per minute
29. A female patient undergoes a total abdominal hysterectomy. When assessing the patient 10 hours
later, the nurse identifies which finding as an early sign of shock?
a. Restlessness
b. Pale, warm, dry skin
c. Heart rate of 110 beats/minute
d. Urine output of 30 ml/hour
30. Which pulse should the nurse palpate during rapid assessment of an unconscious male adult?
a. Radial
b. Brachial

c. Femoral
d. Carotid

1. Answer B.
Sensory deficits could cause a geriatric patient to have difficulty retaining knowledge about prescribed
medications. Decreased plasma drug levels do not alter the patient’s knowledge about the drug. A lack
of family support may affect compliance, not knowledge retention. Toilette syndrome is unrelated to
knowledge retention.
2. Answer C.
The nurse should systematically assess all areas of the abdomen, if time and the patient’s condition
permit, concluding with the symptomatic area. Otherwise, the nurse may elicit pain in the symptomatic
area, causing the muscles in other areas to tighten. This would interfere with further assessment.
3. Answer C.
Subjective data come directly from the patient and usually are recorded as direct quotations that reflect
the patient’s opinions or feelings about a situation. Vital signs, laboratory test result, and ECG
waveforms are examples of objective data.
4. Answer C.
A safety device on the wrist may impair circulation and restrict blood supply to body tissues. Therefore,
the nurse should assess the patient for signs of impaired circulation, such as cool, pale fingers. A
palpable radial or lunar pulse and pink nail beds are normal findings.
5. Answer A.
Frontal or coronal plane runs longitudinally at a right angle to a sagittal plane dividing the body in
anterior and posterior regions. A sagittal plane runs longitudinally dividing the body into right and left
regions; if exactly midline, it is called a midsagittal plane. A transverse plane runs horizontally at a right
angle to the vertical axis, dividing the structure into superior and inferior regions.
6. Answer A.
Shock and dismay are early signs of denial-the first stage of grief. The other options are associated with
depression—a later stage of grief.
7. Answer B.
After placing the patient in high Fowler’s position and moving the patient to the side of the bed, the
nurse helps the patient sit on the edge of the bed and dangle the legs; the nurse then faces the patient
and places the chair next to and facing the head of the bed.
8. Answer D.
Demonstrating by the nurse with a return demonstration by the patient ensures that the patient can

perform wound care correctly. Patients may claim to understand discharge instruction when they do
not. An interpreter of family member may communicate verbal or written instructions inaccurately.
9. Answer A.
As a safety precaution, the nurse should discard an unlabeled syringe that contains medication. The
other options are considered unsafe because they promote error.
10. Answer B.
Aging-related physiological changes account for the increased frequency of adverse drug reactions in
geriatric patients. Renal and hepatic changes cause drugs to clear more slowly in these patients. With
increasing age, neurons are lost and blood flow to the GI tract decreases.
11. Answer B.
When teaching a patient about medications before discharge, the nurse is acting as an educator. The
nurse acts as a manager when performing such activities as scheduling and making patient care
assignments. The nurse performs the care giving role when providing direct care, including bathing
patients and administering medications and prescribed treatments. The nurse acts as a patient advocate
when making the patient’s wishes known to the doctor.
12. Answer D.
Anxiety may result from feeling of helplessness, isolation, or insecurity. This response helps reduce
anxiety by encouraging the patient to express feelings. The nurse should be supportive and develop
goals together with the patient to give the patient some control over an anxiety-inducing situation.
Because the other options ignore the patient’s feeling and block communication, they would not reduce
anxiety.
13. Answer C.
The scrub nurse assist the surgeon by providing appropriate surgical instruments and supplies,
maintaining strict surgical asepsis and, with the circulating nurse, accounting for all gauze, sponges,
needles, and instruments. The circulating nurse assists the surgeon and scrub nurse, positions the
patient, applies appropriate equipment and surgical drapes, assists with gowning and gloving, and
provides the surgeon and scrub nurse with supplies.
14. Answer C.
The nurse should return shortly to the patient’s room and remain there until the patient takes the
medication to verify that it was taken as directed. The nurse should never leave medication at the
patient’s bedside unless specifically requested to do so.
15. Answer C.
The nurse solves the problem as follows:
10,000 units/7,500 units = 1 ml/X

10,000 X = 7,500
X= 7,500/10,000 or ¾ ml

16. Answer C.
To convert Fahrenheit degrees to centigrade, use this formula:
C degrees = (F degrees – 32) x 5/9

C degrees = (102 – 32) 5/9
+ 70 x 5/9
38.9 degrees C
17. Answer D.
All of these test help evaluate a patient with respiratory problems. However, ABG analysis is the only
test evaluates gas exchange in the lungs, providing information about patient’s oxygenation status.
18. Answer B.
The diaphragm of a stethoscope detects high-pitched sound best; the bell detects low pitched sounds
best. Palpation detects thrills best.
19. Answer C.
In most cases, an outpatient must fill a prescription for a controlled substance within 6 months of the
date on which the prescription was written.
20. Answer D.
The nurse must consider the patient’s cognitive abilities to understand drug instructions. If not, the
nurse must find a family member or significant other to take on the responsibility of administering
medications in the home setting. The patient’s ability to recover, occupational hazards, and
socioeconomic status do not affect drug administration.
21. Answer A.
Primary prevention precedes disease and applies to health patients. Secondary prevention focuses on
patients who have health problems and are at risk for developing complications. Tertiary prevention
enables patients to gain health from others’ activities without doing anything themselves.
22. Answer A.
When making a surgical bed, the nurse leaves the bed in the high position when finished. After placing
the top linens on the bed without pouching them, the nurse fanfolds these linens to the side opposite
from where the patient will enter and places the pillow on the bedside chair. All these actions promote
transfer of the postoperative patient from the stretcher to the bed. When making an occupied bed or
unoccupied bed, the nurse places the pillow at the head of the bed and tucks the top sheet and blanket
under the bottom of the bed. When making an occupied bed, the nurse rolls the patient to the far side
of the bed.
23. Answer C.
The nurse should give ½ ml of the drug. The dosage is calculated as follows:

250 mg/X=500 mg/1 ml

500x=250
X=1/2 ml
24. Answer C.
Patients can become dependent on barbiturates, especially with prolonged use. Because of the rapid
distribution of some barbiturates, no correlation exists between duration of action and half-life.
Barbiturates are absorbed well and do not cause hepatotoxicity, although existing hepatic damage does
require cautions use of the drug because barbiturates are metabolized in the liver.
25/ Answer A.
Elevating the head of the bed during enteral feeding minimizes the risk of aspiration and allows the
formula to flow in the patient’s intestines. When such elevation is contraindicated, the patient should be
positioned on the right side. The nurse should give enteral feeding at room temperature to minimize GI
distress. To limit microbial growth, the nurse should hang only the amount of formula that can be
infused in 3 hours.
26. Answer C.
The nurse should instruct the patient to touch the tip of the tongue to the roof of the mouth and then
place the sublingual tablet on the floor of the mouth. Sublingual medications are absorbed directly into
the bloodstream form the oral mucosa, bypassing the GI and hepatic systems. No drug is administered
on top of the tongue or on the roof of the mouth. With the buccal route, the tablet is placed between
the gum and the cheek.
27. Answer A.
The nurse always should clean around a wound drain, moving from center outward in ever-larger circles,
because the skin near the drain site is more contaminated than the site itself. The nurse should never
remove the drain before cleaning the skin. Alcohol should never be used to clean around a drain; it may
irritate the skin and has no lasting effect on bacteria because it evaporates. The nurse should wear
sterile gloves to prevent contamination, but a mask is not necessary.
28. Answer C.
Giving 1,000 ml over 8 hours is the same as giving 125 ml over 1 hour (60 minutes) to find the number of
milliliters per minute:
125/60 min = X/1 minute

60X = 125X = 2.1 ml/minuteTo find the number of drops/minute:
2.1 ml/X gtts = 1 ml/15 gtts

X = 32 gtts/minute, or 32 drops/minute
29. Answer A.
Early in shock, hyperactivity of the sympathetic nervous system causes increased epinephrine secretion,
which typically makes the patient restless, anxious, nervous, and irritable. It also decreases tissue

perfusion to the skin, causing pale, cool clammy skin. An above-normal heart rate is a late sign of shock.
A urine output of 30 ml/hour is within normal limits.
30. Answer D.
During a rapid assessment, the nurse’s first priority is to check the patient’s vital functions by assessing
his airway, breathing, and circulation. To check a patient’s circulation, the nurse must assess his heart
and vascular network function. This is done by checking his skin color, temperature, mental status and,
most importantly, his pulse. The nurse should use the carotid artery to check a patient’s circulation. In a
patient with a circulatory problems or a history of compromised circulation, the radial pulse may not be
palpable. The brachial pulse is palpated during rapid assessment of an infant.

Fundamentals of
Nursing
1. Which intervention is an example of primary prevention?
a. Administering digoxin (Lanoxicaps) to a patient with heart failure

b. Administering a measles, mumps, and rubella immunization to an infant
c. Obtaining a Papanicolaou smear to screen for cervical cancer
d. Using occupational therapy to help a patient cope with arthritis
2. The nurse in charge is assessing a patient’s abdomen. Which examination technique should the
nurse use first?
a. Auscultation
b. Inspection
c. Percussion
d. Palpation
3. Which statement regarding heart sounds is correct?
a. S1 and S2 sound equally loud over the entire cardiac area.

b. S1 and S2 sound fainter at the apex
c. S1 and S2 sound fainter at the base
d. S1 is loudest at the apex, and S2 is loudest at the base
4. The nurse in charge identifies a patient’s responses to actual or potential health problems during
which step of the nursing process?
a. Assessment
b. Nursing diagnosis
c. Planning
d. Evaluation

5. A female patient is receiving furosemide (Lasix), 40 mg P.O. b.i.d. in the plan of care, the nurse
should emphasize teaching the patient about the importance of consuming:
a. Fresh, green vegetables

b. Bananas and oranges
c. Lean red meat
d. Creamed corn
6. The nurse in charge must monitor a patient receiving chloramphenicol for adverse drug reaction.
What is the most toxic reaction to chloramphenicol?
a. Lethal arrhythmias
b. Malignant hypertension
c. Status epilepticus
d. Bone marrow suppression
7. A female patient is diagnosed with deep-vein thrombosis. Which nursing diagnosis should receive
highest priority at this time?
a. Impaired gas exchanges related to increased blood flow

b. Fluid volume excess related to peripheral vascular disease
c. Risk for injury related to edema
d. Altered peripheral tissue perfusion related to venous congestion
8. When positioned properly, the tip of a central venous catheter should lie in the:
a. Superior vena cava

b. Basilica vein
c. Jugular vein
d. Subclavian vein
9. Nurse Nikki is revising a client’s care plan. During which step of the nursing process does such
revision take place?
a. Assessment
b. Planning
c. Implementation
d. Evaluation
10. A 65-year-old female who has diabetes mellitus and has sustained a large laceration on her left
wrist asks the nurse, “How long will it take for my scars to disappear?” which statement would be the
nurse’s best response?

a. “The contraction phase of wound healing can take 2 to 3 years.”

b. “Wound healing is very individual but within 4 months the scar should fade.”
c. “With your history and the type of location of the injury, it’s hard to say.”
d. “If you don’t develop an infection, the wound should heal any time between 1 and 3 years from now.”
11. One aspect of implementation related to drug therapy is:
a. Developing a content outline

b. Documenting drugs given
c. Establishing outcome criteria
d. Setting realistic client goals
12. A female client is readmitted to the facility with a warm, tender, reddened area on her right calf.
Which contributing factor would the nurse recognize as most important?
a. A history of increased aspirin use

b. Recent pelvic surgery
c. An active daily walking program
d. A history of diabetes
13. Which intervention should the nurse in charge try first for a client that exhibits signs of sleep
disturbance?
a. Administer sleeping medication before bedtime

b. Ask the client each morning to describe the quantity of sleep during the previous night
c. Teach the client relaxation techniques, such as guided imagery, medication, and progressive muscle
relaxation
d. Provide the client with normal sleep aids, such as pillows, back rubs, and snacks
14. While examining a client’s leg, the nurse notes an open ulceration with visible granulation tissue in
the wound. Until a wound specialist can be contacted, which type of dressings is most appropriate for
the nurse in charge to apply?
a. Dry sterile dressing

b. Sterile petroleum gauze
c. Moist, sterile saline gauze
d. Povidone-iodine-soaked gauze
15. A male client in a behavioral-health facility receives a 30-minute psychotherapy session, and
provider uses a current procedure terminology (CPT) code that bills for a 50-minute session. Under the
False Claims Act, such illegal behavior is known as:
a. Unbundling
b. Overbilling

c. Upcoding
d. Misrepresentation
16. A nurse assigned to care for a postoperative male client who has diabetes mellitus. During the
assessment interview, the client reports that he’s impotent and says that he’s concerned about its
effect on his marriage. In planning this client’s care, the most appropriate intervention would be to:
a. Encourage the client to ask questions about personal sexuality

b. Provide time for privacy
c. Provide support for the spouse or significant other
d. Suggest referral to a sex counselor or other appropriate professional
17. Using Abraham Maslow’s hierarchy of human needs, a nurse assigns highest priority to which
client need?
a. Security
b. Elimination
c. Safety
d. Belonging
18. A male client is on prolonged bed rest has developed a pressure ulcer. The wound shows no signs
of healing even though the client has received skin care and has been turned every 2 hours. Which
factor is most likely responsible for the failure to heal?
a. Inadequate vitamin D intake

b. Inadequate protein intake
c. Inadequate massaging of the affected area
d. Low calcium level
19. A female client who received general anesthesia returns from surgery. Postoperatively, which
nursing diagnosis takes highest priority for this client?
a. Acute pain related to surgery

b. Deficient fluid volume related to blood and fluid loss from surgery
c. Impaired physical mobility related to surgery
d. Risk for aspiration related to anesthesia
20. The nurse inspects a client’s back and notices small hemorrhagic spots. The nurse documents that
the client has:
a. Extravasation
b. Osteomalacia
c. Petechiae
d. Uremia

21. Which document addresses the client’s right to information, informed consent, and treatment
refusal?
a. Standard of Nursing Practice

b. Patient’s Bill of Rights
c. Nurse Practice Act
d. Code for Nurses
22. If a blood pressure cuff is too small for a client, blood pressure readings taken with such a cuff may
do which of the following?
a. Fail to show changes in blood pressure

b. Produce a false-high measurement
c. Cause sciatic nerve damage
d. Produce a false-low measurement
23. Nurse Elijah has been teaching a client about a high-protein diet. The teaching is successful if the
client identifies which meal as high in protein?
a. Baked beans, hamburger, and milk

b. Spaghetti with cream sauce, broccoli, and tea
c. Bouillon, spinach, and soda
d. Chicken cutlet, spinach, and soda
24. A male client is admitted to the hospital with blunt chest trauma after a motor vehicle accident.
The first nursing priority for this client would be to:
a. Assess the client’s airway

b. Provide pain relief
c. Encourage deep breathing and coughing
d. Splint the chest wall with a pillow
25. A newly hired charge nurse assesses the staff nurses as competent individually but ineffective and
nonproductive as a team. In addressing her concern, the charge nurse should understand that the
usual reason for such a situation is:
a. Unhappiness about the charge in leadership

b. Unexpected feeling and emotions among the staff
c. Fatigue from overwork and understaffing
d. Failure to incorporate staff in decision making
26. A male client blood test results are as follows: white blood cell (WBC) count, 100ul; hemoglobin
(Hb) level, 14 g/dl; hematocrit (HCT), 40%. Which goal would be most important for this client?

a. Promote fluid balance

b. Prevent infection
c. Promote rest
d. Prevent injury
27. Following a tonsillectomy, a female client returns to the medical-surgical unit. The client is
lethargic and reports having a sore throat. Which position would be most therapeutic for this client?
a. Semi-Fowler’s
b. Supine
c. High-Fowler’s
d. Side-lying
28. The nurse inspects a client’s pupil size and determines that it’s 2 mm in the left eye and 3 mm in
the right eye. Unequal pupils are known as:
a. Anisocoria
b. Ataxia
c. Cataract
d. Diplopia
29. The nurse in charge is caring for an Italian client. He’s complaining of pain, but he falls asleep right
after his complaint and before the nurse can assess his pain. The nurse concludes that:
a. He may have a low threshold for pain

b. He was faking pain
c. Someone else gave him medication
d. The pain went away
30. A female client is admitted to the emergency department with complaints of chest pain shortness
of breath. The nurse’s assessment reveals jugular vein distention. The nurse knows that when a client
has jugular vein distension, it’s typically due to:
a. A neck tumor
b. An electrolyte imbalance
c. Dehydration
d. Fluid overload

1. Answer B.
Immunizing an infant is an example of primary prevention, which aims to prevent health problems.
Administering digoxin to treat heart failure and obtaining a smear for a screening test are examples for
secondary prevention, which promotes early detection and treatment of disease. Using occupational

therapy to help a patient cope with arthritis is an example of tertiary prevention, which aims to help a
patient deal with the residual consequences of a problem or to prevent the problem from recurring.
2. Answer B.
Inspection always comes first when performing a physical examination. Percussion and palpation of the
abdomen may affect bowel motility and therefore should follow auscultation.
3. Answer D.
The S1 sound—the “lub” sound—is loudest at the apex of the heart. It sounds longer, lower, and louder
there than the S2 sounds. The S2—the “dub” sound—is loudest at the base. It sounds shorter, sharper,
higher, and louder there than S1.
4. Answer B.
The nurse identifies human responses to actual or potential health problems during the nursing
diagnosis step of the nursing process. During the assessment step, the nurse systematically collects data
about the patient or family. During the planning step, the nurse develops strategies to resolve or
decrease the patient’s problem. During the evaluation step, the nurse determines the effectiveness of
the plan of care.
5. Answer B.
Because furosemide is a potassium-wasting diuretic, the nurse should plan to teach the patient to
increase intake of potassium-rich foods, such as bananas and oranges. Fresh, green vegetables; lean red
meat; and creamed corn are not good sources of potassium.
6. Answer D.
The most toxic reaction to chloramphenicol is bone marrow suppression. Chloramphenicol is not known
to cause lethal arrhythmias, malignant hypertension, or status epilepticus.
7. Answer D.
Altered peripheral tissue perfusion related to venous congestion” takes highest priority because venous
inflammation and clot formation impede blood flow in a patient with deep-vein thrombosis. Option A is
incorrect because impaired gas exchange is related to decreased, not increased, blood flow. Option B is
inappropriate because no evidence suggest that this patient has a fluid volume excess. Option C may be
warranted but is secondary to altered tissue perfusion.
8. Answer A.
When the central venous catheter is positioned correctly, its tip lies in the superior vena cava, inferior
vena cava, or the right atrium—that is, in central venous circulation. Blood flows unimpeded around the
tip, allowing the rapid infusion of large amounts of fluid directly into circulation. The basilica, jugular,
and subclavian veins are common insertion sites for central venous catheters.
9. Answer D.
During the evaluation step of the nursing process the nurse determines whether the goals established in
the care plan have been achieved, and evaluates the success of the plan. If a goal is unmet or partially

met the nurse reexamines the data and revises the plan. Assessment involves data collection. Planning
involves setting priorities, establishing goals, and selecting appropriate interventions.
10. Answer C.
Wound healing in a client with diabetes will be delayed. Providing the client with a time frame could give
the client false information.
11. Answer B.
Although documentation isn’t a step in the nursing process, the nurse is legally required to document
activities related to drug therapy, including the time of administration, the quantity, and the client’s
reaction. Developing a content outline, establishing outcome criteria, and setting realistic client goals
are part of planning rather than implementation.
12. Answer B.
The client shows signs of deep vein thrombosis (DVT). The pelvic area is rich in blood supply, and
thrombophlebitis of the deep vein is associated with pelvic surgery. Aspirin, an antiplatelet agent, and
an active walking program help decrease the client’s risk of DVT. In general, diabetes is a contributing
factor associated with peripheral vascular disease.
13. Answer D.
The nurse should begin with the simplest interventions, such as pillows or snacks, before interventions
that require greater skill such as relaxation techniques. Sleep medication should be avoided whenever
possible. At some point, the nurse should do a thorough sleep assessment, especially if common sense
interventions fail.
14. Answer C.
Moist, sterile saline dressings support would heal and are cost-effective. Dry sterile dressings adhere to
the wound and debride the tissue when removed. Petroleum supports healing but is expensive.
Povidone-iodine can irritate epithelial cells, so it shouldn’t be left on an open wound.
15. Answer C.
Upcoding is the practice of using a CPT code that’s reimbursed at a higher rate than the code for the
service actually provided. Unbundling, overbilling, and misrepresentation aren’t the terms used for this
illegal practice.
16. Answer D.
The nurse should refer this client to a sex counselor or other professional. Making appropriate referrals
is a valid part of planning the client’s care. The nurse doesn’t normally provide sex counseling.
Therefore, providing time for privacy and providing support for the spouse or significant other are
important, but not as important as referring the client to a sex counselor.
17. Answer B.
According to Maslow, elimination is a first-level or physiological need, and therefore takes priority over
all other needs. Security and safety are second-level needs; belonging is a third-level need. Second- and
third-level needs can be met only after a client’s first-level needs have been satisfied.

18. Answer B.
A client on bed rest suffers from a lack of movement and a negative nitrogen balance. Therefore,
inadequate protein intake impairs wound healing. Inadequate vitamin D intake and low calcium levels
aren’t factors in poor healing for this client. A pressure ulcer should never be massaged.
19. Answer D.
Risk for aspiration related to anesthesia takes priority for thins client because general anesthesia may
impair the gag and swallowing reflexes, possibly leading to aspiration. The other options, although
important, are secondary.
20. Answer C.
Petechiae are small hemorrhagic spots. Extravasation is the leakage of fluid in the interstitial space.
Osteomalacia is the softening of bone tissue. Uremia is an excess of urea and other nitrogen products in
the blood.
21. Answer B.
The Patient’s Bill of Rights addresses the client’s right to information, informed consent, timely
responses to requests for services, and treatment refusal. A legal document, it serves as a guideline for
the nurse’s decision making. Standards of Nursing Practice, the Nurse Practice Act, and the Code for
Nurses contain nursing practice parameters and primarily describe the use of the nursing process in
providing care.
22. Answer B.
Using an undersized blood pressure cuff produces a falsely elevated blood pressure because the cuff
can’t record brachial artery measurements unless it’s excessively inflated. The sciatic nerve wouldn’t be
damaged by hyperinflation of the blood pressure cuff because the sciatic nerve is located in the lower
extremity.
23. Answer A.
Baked beans, hamburger, and milk are all excellent sources of protein. The spaghetti-broccoli-tea choice
is high in carbohydrates. The bouillon-spinach-soda choice provides liquid and sodium as well as some
iron, vitamins, and carbohydrates. Chicken provides protein but the chicken-spinach-soda combination
provides less protein than the baked beans-hamburger-milk selection.
24. Answer A.
The first priority is to evaluate airway patency before assessing for signs of obstruction, sternal
retraction, stridor, or wheezing. Airway management is always the nurse’s first priority. Pain
management and splinting are important for the client’s comfort, but would come after airway
assessment. Coughing and deep breathing may be contraindicated if the client has internal bleeding and
other injuries.
25. Answer B.
The usual or most prevalent reason for lack of productivity in a group of competent nurses is inadequate
communication or a situation in which the nurses have unexpected feeling and emotions. Although the
other options could be contributing to the problematic situation, they’re less likely to be the cause.

26. Answer B.
The client is at risk for infection because WBC count is dangerously low. Hb level and HCT are within
normal limits; therefore, fluid balance, rest, and prevention of injury are inappropriate.
27. Answer D.
Because of lethargy, the post tonsillectomy client is at risk for aspirating blood from the surgical wound.
Therefore, placing the client in the side-lying position until he awake is best. The semi-Fowler’s, supine,
and high-Fowler’s position don’t allow for adequate oral drainage in a lethargic post tonsillectomy client,
and increase the risk of blood aspiration.
28. Answer A.
Unequal pupils are called anisocoria. Ataxia is uncoordinated actions of involuntary muscle use. A
cataract is an opacity of the eye’s lens. Diplopia is double vision.
29. Answer A.
People of Italian heritage tend to verbalize discomfort and pain. The pain was real to the client, and he
may need medication when he wakes up.
30. Answer D.
Fluid overload causes the volume of blood within the vascular system to increase. This increase causes
the vein to distend, which can be seen most obviously in the neck veins. A neck tumor doesn’t typically
cause jugular vein distention. An electrolyte imbalance may result in fluid overload, but it doesn’t
directly contribute to jugular vein distention.

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1 ‫شبكة ومنتديات بيث التمريض‬

1. Plan is developed for nursing care.

2. Planning is a category of nursing behaviors in which:

1. Desire for specific health care interventions

5. For clients to participate in goal setting, they should be:

‫ أبو أمحد‬- ‫ حسن عصغور‬/‫اعداد‬

1. Alert and have some degree of independence.

1. Client will have less pain.

7. As goals, outcomes, and interventions are developed, the nurse must:

1. Be in charge of all care and planning for the client.

8. When establishing realistic goals, the nurse:

1. Bases the goals on the nurse’s personal knowledge.

1. Knowledge, function, and specific skills

10. Collaborative interventions are therapies that require:

1. Physician and nurse interventions.

11. Well formulated, client-centered goals should:

1. Meet immediate client needs.

‫ أبو أمحد‬- ‫ حسن عصغور‬/‫اعداد‬

3. Include rehabilitation needs.

1. Assessing and diagnosing

15. The nursing care plan is:

1. A written guideline for implementation and evaluation.

1. Encourage client to implement guided imagery when pain begins.

‫ أبو أمحد‬- ‫ حسن عصغور‬/‫اعداد‬

1. Apply a cold pack to the tibia.

1. Apply continuous passive motion machine during day.

1. Notifying the physician.

1. Length of time the current treatment has been in place.

1. Implement the specialist’s recommendations.

‫ أبو أمحد‬- ‫ حسن عصغور‬/‫اعداد‬

3. Ineffective airway clearance

1. A client’s family attending a diabetic teaching session.

1. A client who is ambulatory.

Answers and Rationale

‫ أبو أمحد‬- ‫ حسن عصغور‬/‫اعداد‬

16. D. This is measurable and objective.

18. C. It is specific in what to do and when.

24. B. This clients needs are a priority.

‫ أبو أمحد‬- ‫ حسن عصغور‬/‫اعداد‬

Legal and Ethical Considerations

1. Pick any physician and insurance company despite one’s income

‫ أبو أمحد‬- ‫ حسن عصغور‬/‫اعداد‬

4. Transcultural nursing implies:

1. American Nurses Association’s (ANA’s) Code of Ethics

8. A bioethical issue should be described as:

‫ أبو أمحد‬- ‫ حسن عصغور‬/‫اعداد‬

1. Gender bias and ageism

1. Board of Nursing Examiners (BNE)

‫ أبو أمحد‬- ‫ حسن عصغور‬/‫اعداد‬

1. Is fully informed and is aware of all consequences.

15. Which criterion is needed for someone to give consent to a procedure?

16. Which statement is correct?

17. Most litigation in the hospital comes from the:

1. Nurse abandoning the clients when going to lunch

1. Reflex vasoconstriction occurs.

1. An expression of the anger stage of dying

‫ أبو أمحد‬- ‫ حسن عصغور‬/‫اعداد‬

1. Spending time to let clients share their life experiences

23. What are the stages of dying according to Elizabeth Kubler-Ross?

1. Numbing; yearning and searching; disorganization and despair; and reorganization.

24. Bereavement may be defined as:

1. The emotional response to loss.

1. Have family members say goodbye to the deceased.

‫ أبو أمحد‬- ‫ حسن عصغور‬/‫اعداد‬