EVALUATION EXAM-POST TEST A.

Anger
B. Delaying tactics
LEADERSHIP & MANAGEMENT C. Withdrawal and acceptance
D. Passive aggressive behavior
- Which of the following is not an
appropriate reason for change? - Which of the following
A. Change in order to solve some problem behaviors/attitudes make it likely that a
B. Change to make work procedures more planned change will be unsuccessful?
efficient so that time will not be wasted A. The suggested change is brought
on relatively unimportant tacks forward only after the plan has been
C. Change to eliminate boredom on the formalized
part of the change agent B. All individuals who may be affected by
D. Change to reduce unnecessary work load the change are involved in planning for
the change
- Which of the following actions may keep C. The change agent is sensitive to the
an organization from becoming ever internal and external environment of the
renewing? organization
A. Retired staff are replaced with new D. An assessment of resources to carry out
graduate nurses the plan is completed
B. State of the art cardiac monitoring
equipment is placed in the ICU - The successful change agent makes a
C. A set pay increase is mandated commitment to:
annually, regardless of merit A. Help followers arrive at a total consensus
D. A suggestion committee composed of regarding the change
staff and management meet monthly to B. Encourage subgroup opposition to
discuss problems and pos solutions change so that many viewpoints can be
heard
- Distributing flyers that charge arbitrary C. Utilize change by drift if the resistance to
action on the part of an employer in an change is too strong
effort to garner interest in employee D. Be available to support those affected
unionization would be part of what by a change until the change is
phase of planned change? complete
A. Unfreezing
B. Movement - Which of the following leadership styles
C. Refreezing maintains strong control over the work
D. Resistance group and uses coercion to motivate
others?
- Refusing to ride in the car with or be A. Authoritarian
around an individual who smokes B. Democratic
cigarettes most closely represents which C. Laissez-faire
change strategy? D. Contingency approach
A. Power-coercive
B. Normative-reeducative - Which of the following statements is not
C. Rational-empirical true regarding management?
D. Resistance withdrawal A. Management position is assigned
B. Management position has inherent in it
- Which of the following represents a a legitimate source of power
management function in planned C. Members of a group will only follow a
change? person in a management position by
A. Inspiring group members to be involved choice
in planned change D. Managers manipulate the environment,
B. Visionary forecasting money, time and other resources to
C. Role modeling high level interpersonal achieve organizational goals
communication skills in providing
support for individuals undergoing rapid - Which of the following is not depictedon
or difficult change the organization chart?
D. Recognizing the need for planned A. Grapevine lines of communication
change and identifying the options and B. Span of control
resources available to implement the C. Line and staff authority
change D. Scalar chains

- Which of the following would not be a - Max Weber contributed immensely to

normal and expected behavioral the development of organization theory.
response in the unfreezing phase?
 Which of the following statement not B. Occurs when there is a consonance of
representative of his beliefs? sub unit cultures in the organization
A. That bureaucracy could provide a C. Refers to a position on the organization
rational basis for administrative chart where frequent and various types
decisions of communication occur
B. That worker satisfaction was integral to D. Occurs only in line relationships
productivity
C. That organization charts could depict the - Which of the following is a symptom of
hierarchy of authority poor organization structure?
D. That impersonality of interpersonal A. Communication follows the chain of
relationships should exist in an command
organization B. The smallest possible number of
managers exists to keep units
- Organizational culture can be defined as: functioning smoothly
A. How employees “perceive” an C. The chain of command is fairly short
organization D. There is heavy reliance on committees
B. The use of power by the organization to to solve unit problems
direct the work of others
C. The predictable stages of group - Having official power to act is the
development definition of:
D. The system, beliefs, values, history, and A. Responsibility
communication patterns unique to each B. Authority
organization C. Accountability
D. Leadership
- Advisory or staff relationships on the
organizational chart: - Optimum span of control:
A. Are depicted as unbroken lines A. Is between 40-60
B. Denote the official chain of command B. Varies with the manager’s abilities, the
C. Denote a relationship of information employee’s maturity and task
and assistance but thot organizational complexity
authority C. Is less than 5
D. Generally, outnumber line relationships D. Cannot be achieved in an organization
with a line/staff organizational structure
- Unity of command is best described as:
A. The number of individuals directly - A constructive culture is based on all but
reporting to a manager one of the following characteristics: Cam
B. Having a limited number of top level A. Affiliative norms
managers B. Self-actualization
C. Each employee having only one boss C. Encouragement of humanism
D. A flexible line structure that encourages D. Perfectionistic norms
participative decision making
- Changing a unit culture that has been
- Which of the following is not an example firmly entrenched:
of a first level manager? A. Often requires new leadership and a
A. Primary care nurse new leadership team, and most
B. Team leader frequently, these leaders and teams
C. Charge nurse must come from the outside
D. Nursing supervisor B. Can be accomplished fairly easily if the
change agent has well developed
- In decentralized decision making: leadership and management skills
A. Many problems can be solved at the C. Is easier when there is great consonance
level they occur at the top of the between units regarding the current
organizational hierarchy culture
B. Decisions are made by a few individuals D. Is impossible
C. Communication is limited to managers at
different levels of the hierarchy - Which of the following would suggest
D. Decision making and responsibility are that cultural dissonance is occurring?
assigned to the highest practical A. There is a collective spirit
managerial level in the organization B. There are shared work goals across units
C. There is little staff representation on
- Centrality: committees
A. Refers to the decision making structure D. Formal & Informal systems are placed to
in an organization address conflicts
- Implementation of a shared governance A. Focus of nursing care is patient centered
model: B. Emphasis is “getting the work done”
A. Alters lines of authority but does not C. Nurse must be a licensed person
affect decision making and D. Also known as total patient care
communication channels
B. Results in the formation of joint practice - You are assigned to administer
committees to assume the power and medications to all patients throughout
accountability for decision making and your shift. This is an example of:
professional communication A. Primary care delivery
C. Is synonymous with participatory B. Functional nursing
management C. Team nursing
D. Does not alter roles or functions of first D. Case method nursing
and middle level managers
- To maintain adequate numbers of staff in
- Jon is the only registered nurse at their organization, the managers should:
Hospital B to be certified to insert A. Use knowledge of turnover rates on
percutaneous intravenous catheters. their units for planning and hiring
This certification gives Jon: B. Look at staff/patient ratios at other
A. Legitimate power health care organization in the area
B. Expert power C. Proactively plan to hire two registered
C. Charismatic power nurses for each unit each year
D. Self-power D. Hire outside consultants to study
national turnover rates so they can
- Which of the following would be the better determine their own recruitment
least appropriate power building needs
strategy for a new employee?
A. Expand personal resources by gaining - The relationship between an employee
additional certifications and training and a role model is:
B. Learn the organizational culture A. Active
C. Maintain a sense of humor and be able B. Non-verbal
to laugh at oneself C. Encouraged by the role model
D. Serve as change agent to reorganize the D. Passive
patient care delivery system to
resemble that which work well at a - Clarification of role expectations is
former place of employment primarily the responsibility of
A. The employee
- Which of the following strategies could B. It is a shared responsibility of the
be used to effectively empower staff? employee and managers
A. Serve as a role model of an empowered C. The preceptor
nurse D. The manager
B. Develop more rigidity in rule
enforcement so that staff understand - Which of the following statements about
what is expected of them patient classification systems is the most
C. Give all employees an annual cost of accurate?
living raise A. Classification systems are able to solve
D. Encourage staff to establish a strong unit staffing problems
culture by establishing turf boundaries B. Nursing care hours assigned to a
with other departments. classification system should remain
constant
- One of the most politically serious errors C. A good classification system is without
one can make is: fault
A. Lying to others within the organization D. Internal and external forces may affect
B. Withholding or refusing to divulge the classification systems
information
C. Delaying decision making until adequate - The most realistic and appropriate goal
and accurate information has been for a manager in regard to staffing and
gathered and reviewed scheduling is to:
D. Promoting the identification of A. Schedule staff so there is no overtime
subordinate, thus decreasing one’s own B. Ensure that there is adequate staff to
personal power meet all the needs of each patient
C. Develop trust in staff by seeing that
- Which of the following statements best staffing is carried out in a fair manner
describes functional nursing care D. Ensure that staff usually have days off
delivery? and special requests granted

- You are working in the Staff
Development Department and must
organize a class to prepare nurses to
function in the new neonatal ICU. Of the
following tasks which should you do
first?
A. Identify possible learning resources
B. Determine learning needs based on the
discrepancy between current skills and
needed skills
C. Identify present level of knowledge
D. Define desired knowledge or skills
nurses will need
- Which statement about education is the
most accurate?
A. Education generally has an immediate
use
B. Managers have a responsibility to see
that their staff are well educated
C. Recognizing educational needs and
encouraging the educational pursuits of
the staff is a role of the nursing leader
D. Education always results in increased
productivity
- Which of the following best illustrates
competence?
A. Competence is the ability to meet
requirements for a role
B. Competence is determined by the
Nursing Board licensure
C. Competence should be determined by
the employee’s supervisor
D. Having a national certification is
evidence of competence
- The best method for determining the
effectiveness of a staff development
program for managing IV puncture sites
would be:
A. Have the participants in the class
evaluate the instructor and the class
B. Give the participants an exam or test at
the conclusion of the course
C. Determine if incidence of IV site
infections was reduced by nursing audit
D. Observe at the unit level that staff are
implementing the changes
recommended by the class with care
documented in the patient record
- Which of the following statements about
situational or contingency leadership
theory is true?
A. High relationship behavior is much more
essential to a good manager (than high
task behavior
B. Contingency theory was proposed and
developed by behaviorally oriented
theorists named Kotter and Burns
C. The leadership style chosen by the
manager should be consistent in
indifferent situations so that workers
understand what is expected of them
D. The leadership style chosen by a
manager should reflect the
task/relationship behavior of those
being managed
- The Hawthorne effect implied that:
A. Human being under investigation will
respond to the fact that they are being
studied
B. Production will increase or decrease as
light in a factory is increased or
decreased
C. Membership in small groups form social
control
D. People are inherently good and will seek
out work
- Early leadership theory (early to mid 20th
century)
A. Leadership is a process of influencing
others within an organizational culture
B. The interactive relationship between the
leader and the follower was significant
C. Some men are born to lead while others
are born to be led
D. Vision and empowerment are two of the
most critical leadership skills
- A decision grid:
A. Allows the decision maker to visually
examine alternatives and compare each
against the same criteria
B. Allows the decision maker to quantify
information
C. Is used to plot a decision over time
D. Is used to predict when events must take
place to complete a project on time
- Knowledge about good decision making
leads one to believe that:
A. Good decision makers are right-brained
intuitive thinkers
B. Effective decision makers are sensitive
to the situation and to others
C. Good decisions are made by left brained
logical thinkers
D. Effective decision making requires an
analytical rather than a creative process
- Decision making is triggered by a
problem and ends with a
A. An alternative problem
B. Choosing a course of action that
guarantee success
C. A chosen course of action
D. A restatement of the solution
- The function and priorities of an
organization can be determined by:
A. The organization’s mission statement
B. Consumer satisfaction surveys
C. The organization’s budget
 D. The organization’s policy and procedure B. Female condom
statements C. Oral contraceptives
D. Rhythm method
- A leadership role in planning includes:
A. Articulating the unit philosophy in - For which of the following clients would
writing the nurse expect that an intrauterine
B. Assessing unit resources available for device would not be recommended?
planning A. Woman over age 35
C. Developing unit policies and procedures B. Nulliparous woman
which operationalize unit objectives C. Promiscuous young adult
D. Encouraging subordinates to be D. Postpartum client
involved in policy formation
- A client in her third trimester tells the
- Document entitled “Fourteen Steps to nurse, “I’m constipated all the time!
Successful Intravenous Catheterization Which of the following should the nurse
at Hospital XYZ” probably best represent recommend?
a: A. Daily enemas
A. Philosophy B. Laxatives
B. Mission statement C. Increased fiber intake
C. Policy D. Decreased fluid intake
D. Procedure
- Which of the following would the nurse
- Strategic planning: use as the basis for the teaching plan
A. Generally, reflects planning for more when caring for a pregnant teenager
than 25 years in the future concerned about gaining too much
B. Requires managerial expertise in health weight during pregnancy?
care economics, human resource A. 10 pounds per trimester
management, and political and B. 1 pound per week for 40 weeks
legislative issues affecting health care, C. ½ pound per week for 40 weeks
as well as planning theory D. A total gain of 25 to 30 pounds
C. Should not be integrated with short-
range planning - The client tells the nurse that her last
D. Is relatively simple to do if managers menstrual period started on January 14
have a good working relationship with and ended on January 20. Using Nagele’s
their staff. rule, the nurse determines her EDD to be
which of the following?
MCN (MATERNAL AND CHILD HEALTH NURSING) A. September 27
B. October 21
- For the client who is using oral C. November 7
contraceptives, the nurse informs the D. December 27
client about the need to take the pill at
the same time each day to accomplish - When taking an obstetrical history on a
which of the following? pregnant client who states, “I had a son
A. Decrease the incidence of nausea born at 38 weeks’ gestation, a daughter
B. Maintain hormonal levels born at 30 weeks’ gestation and I lost a
C. Reduce side effects baby at about 8 weeks,” the nurse
D. Prevent drug interactions should record her obstetrical history as
which of the following?
- When teaching a client about A. G2 T2 PO A0 L2
contraception. Which of the following B. G3 T1 P1 A0 L2
would the nurse include as the most C. G3 T2 PO AD 12
effective method for preventing sexually D. G4 T1 P1 A1 12
transmitted infections?
A. Spermicides - When preparing to listen to the fetal
B. Diaphragm heart rate at 12 weeks’ gestation, the
C. Condoms nurse would use which of the following?
D. Vasectomy A. Stethoscope placed midline at the
umbilicus
- When preparing a woman who is 2 days B. Doppler placed midline at the
postpartum for discharge, suprapubic region
recommendations for which of the C. Fetoscope placed midway between the
following contraceptive methods would umbilicus and the xiphoid process
be avoided? D. External electronic fetal monitor placed
A. Diaphragm at the umbilicus
 minute. Which of the following should
- When developing a plan of care, for a the nurse do first?
client newly diagnosed with gestational A. Report the temperature to the physician
diabetes, which of the following B. Recheck the blood pressure with
instructions would be the priority? another cuff
A. Dietary intake C. Assess the uterus for firmness and
B. Medication position
C. Exercise D. Determine the amount of lochia
D. Glucose monitoring
- The nurse assesses the postpartum
- A client at 24 weeks’ gestation has vaginal discharge (lochia) on four clients.
gained 6 pounds in 4 weeks. Which of Which of the following assessments
the following would be the priority when would warrant notification of the
assessing the client? physician?
A. Glucosuria A. A dark red discharge on a 2-day
B. Depression postpartum client
C. Hand/face edema B. A pink to brownish discharge on a client
D. Dietary intake who is 5 days postpartum
C. To creamy discharge on a client 2 weeks
- A client 12 weeks pregnant come to the after delivery Almost colorless
emergency department with abdominal D. A bright red discharge 5 days after
cramping and moderate vaginal delivery
bleeding. Speculum examination reveals
2 to 3 cm cervical dilation. The nurse - A postpartum client has a temperature
would document these findings as which of 101.4°F, with a uterus that is tender
of the following? when palpated, remains unusually large,
A. Threatened abortion and not descending as normally
B. Imminent abortion expected. Which of the following should
C. Complete abortion the nurse assess next?
D. Missed Abortion A. Lochia
B. Breasts
- Which of the following would be the C. Incision
priority nursing diagnosis for a client D. Urine
with an ectopic pregnancy?
A. Risk for infection - Which of the following is the priority
B. Pain focus of nursing practice with the current
C. Knowledge Deficit early postpartum discharge?
D. Anticipatory Grieving A. Promoting comfort and restoration of
health
- Before assessing the postpartum client’s B. Exploring the emotional status of the
uterus for firmness and position in family
relation to the umbilicus and midline, C. Facilitating safe and effective self-and
which of the following should the nurse newborn care
do first? D. Teaching about the importance of family
A. Assess the vital signs planning
B. Administer analgesia
C. Assist her to urinate - Which of the following actions would be
D. Ambulate her in the hall least effective in maintaining a neutral
thermal environment for the newborn?
- Which of the following should the nurse A. Placing infant under radiant warmer
do when a primipara who is lactating after bathing
tells the nurse that she has sore nipples? B. Covering the scale with a warmed
A. Tell her to breast feed more frequently blanket prior to weighing
B. Administer a narcotic before breast C. Placing crib close to nursery window for
feeding family viewing
C. Encourage her to wear a nursing D. Covering the infant’s head with a knit
brassiere stockinet
D. Use soap and water to clean the nipples
- A newborn who has an asymmetrical
- The nurse assesses the vital signs of a Moro reflex response should be further
client, 4 hours’ postpartum that are as assessed for which of the following?
follows: BP 90/60; temperature 100.4°F, A. Talipes equinovar
pulse 100 weak, thready, R 20 per B. Fractured clavicle
C. Congenital hypothyroidism
D. Increased intracranial pressure - The post term neonate with meconium-
stained amniotic fluid needs care
- During the first 4 hours after a male designed to especially monitor for which
circumcision, assessing for which of the of the following?
following is the priority? A. Respiratory problems
A. Infection B. Gastrointestinal problems
B. Hemorrhage C. Integumentary problems
C. Discomfort D. Elimination problems
D. Dehydration
- When measuring a client’s fundal height,
- The mother asks the nurse. “What’s which of the following techniques
wrong with my son’s breasts? Why are denotes the correct method of
they so enlarged?” Which of the measurement used by the nurse?
following would be the best response by A. From the xiphoid process to the
the nurse? umbilicus
A. “The breast tissue is inflamed from the B. From the symphysis pubis to the xiphoid
trauma experienced with birth” process
B. “A decrease in material hormones C. From the symphysis pubis to the fundus
present before birth causes D. From the fundus to the umbilicus
enlargement”
C. “You should discuss this with your - A client with severe preeclampsia is
doctor. It could be a malignancy“ admitted with of BP 160/110,
D. The tissue has hypertrophied while the proteinuria, and severe pitting edema.
baby was in the uterus” Which of the following would be most
important to include in the client’s plan
- Immediately after birth the nurse notes of care?
the following on a male newborn: A. Daily weights
respirations 78; apical hearth rate 160 B. Seizure precautions
bpm, nostril flaring; mild intercostal C. Right lateral positioning
retractions, and grunting at the end of D. Stress reduction
expiration. Which of the following
should the nurse do? - A postpartum primipara asks the nurse,
A. Call the assessment data to the “When can we have sexual intercourse
physician’s attention again?” Which of the following would be
B. Start oxygen per nasal cannula at 2 L/min the nurse’s best response?
C. Suction the infant’s mouth and nares A. “Anytime you both want to.”
D. Recognize this as normal first period of B. “As soon as choose a contraceptive
reactivity method.”
C. “After your 6 weeks’ examination.”
- The nurse hears a mother telling a friend D. “When the discharge has stopped and
on the telephone about umbilical cord the incision is healed.”
care. Which of the following statements
by the mother indicates effective - When preparing to administer the
teaching? vitamin K injection to a neonate, the
A. “Daily soap and water cleansing is best” nurse would select which of the
B. “Alcohol helps it dry and kills germs” following sites as appropriate for the
C. “An antibiotic ointment applied daily injection?
prevents infection” A. Deltoid muscle
D. “He can have a tub bath each day” B. Anterior femoris muscle
C. Vastus lateralis muscle
- A newborn weighing 3000 grams and D. Gluteus maximus muscle
feeding every 4 hours needs 120
calories/kg of body weight every 24 - When performing a pelvic examination,
hours for proper growth and the nurse observes a red swollen area on
development. How many ounces of 20 the right side of the vaginal orifice. The
cal/oz formula should this newborn nurse would document this as
receive at each feeding to meet enlargement of which of the following?
nutritional needs? A. Clitoris
A. 2 ounces B. Parotid gland
B. 3 ounces C. Skene’s gland
C. 4 ounces D. Bartholin’s gland
D. 6 ounces
- To differentiate as a female, the following would the nurse anticipate
hormonal stimulation of the embryo that doing?
must occur involves which of the A. Obtaining an order to begin IV oxytocin
following? infusion
A. Increase in maternal estrogen secretion B. Administering a light sedative to allow
B. Decrease in maternal androgen the patient to rest for several hour
secretion C. Preparing for a cesarean section for
C. Secretion of androgen by the fetal gonad failure to progress
D. Secretion of estrogen by the fetal gonad D. Increasing the encouragement to the
patient when pushing begins
- A client at 8 weeks’ gestation calls
complaining of slight nausea in the - A multigravida at 38 weeks’ gestation is
morning hours. Which of the following admitted with painless, bright red
client interventions should the nurse bleeding and mild contractions every 7
question? to 10 minutes. Which of the following
A. Taking 1 teaspoon of bicarbonate of assessments should be avoided?
soda in an 8-ounce glass of water A. Maternal vital sign
B. Eating a few low-sodium crackers before B. Fetal heart rate
getting out of bed C. Contraction monitoring
C. Avoiding the intake of liquids in the D. Cervical dilation
morning hours
D. Eating six small meals a day instead of - Which of the following would be the
thee large meals nurse’s most appropriate response to a
client who asks why she must have a
- The nurse documents positive cesarean delivery if she has a complete
ballottement in the client’s prenatal placenta previa?
record. The nurse understands that this A. “You will have to ask your physician
indicates which of the following? when he returns.”
A. Palpable contractions on the abdomen B. “You need a cesarean to prevent
B. Passive movement of the unengaged hemorrhage.”
fetus C. “The placenta is covering most of your
C. Fetal kicking felt by the client cervix.”
D. Enlargement and softening of the uterus D. “The placenta is covering the opening of
the uterus and blocking your baby.”
- During a pelvic exam the nurse notes a
purple-blue tinge of the cervix. The - The nurse understands that the fetal
nurse documents this as which of the head is in which of the following
following? positions with a face presentation?
A. Braxton-Hicks sign A. Completely flexed
B. Chadwick’s sign B. Completely extended
C. Goodell’s sign C. Partially extended
D. McDonald’s sign D. Partially flexed

- During a prenatal class, the nurse - With a fetus in the left-anterior breech
explains the rationale for breathing presentation, the nurse would expect
techniques during preparation for labor the fetal heart rate would be most
based on the understanding that audible in which of the following areas?
breathing techniques are most A. Above the maternal umbilicus and to the
important in achieving which of the right of midline
following? B. In the lower-left maternal abdominal
A. Eliminate pain and give the expectant quadrant
parents something to do C. In the lower-right maternal abdominal
B. Reduce the risk of fetal distress by quadrant
increasing uteroplacental perfusion D. Above the maternal umbilicus and to the
C. Facilitate relaxation, possibly reducing left of midline
the perception of pain
D. Eliminate pain so that less analgesia and - The amniotic fluid of a client has a
anesthesia are needed greenish tint. The nurse interprets this to
be the result of which of the following?
- After 4 hours of active labor, the nurse A. Lanugo
notes that the contractions of a B. Hydramnio
primigravida client are not strong C. Meconium
enough to dilate the cervix. Which of the D. Vernix
- A patient is in labor and has just been D. Gonadotropin releasing hormone
told she has a breech presentation. The
nurse should be particularly alert for
which of the following? MEDICAL SURGICAL (CARDIO)
A. Quickening
B. Ophthalmia neonatorum - A client is receiving capton (Capoten) for
C. Pica heart failure. The nurse should notify the
D. Prolapsed umbilical cord physician that the medication therapy is
ineffective if an assessment reveals:
- When describing dizygotic twins to a A. Skin rash
couple, on which of the following would B. Peripheral edema
the nurse base the explanation? C. Dry cough
A. Two ova fertilized by separate sperm D. Postural hypotension
B. Sharing of a common placenta
C. Each ova with the same genotype - The HCP prescribed a beta blocker for
D. Sharing of a common chorion the client diagnosed with arterial HTN.
Which statement is the scientific
- The following refers to o the single cell rationale for administering this
that reproduces itself after conception? medication?
A. Chromosome A. This medication decreases the
B. Blastocyst sympathetic stimulation to the heart,
C. Zygote thereby decreasing the client’s heart
D. Trophoblast rate and blood pressure
B. This medication prevents the calcium
- In the late 1950s, consumers and health from entering the cell, which helps
care professionals began challenging the decrease the client’s blood pressure
routine use of analgesics and anesthetics C. This medication prevents the release of
during childbirth. Which of the following aldosterone, which decreases
was an outgrowth of this concept? absorption of sodium and water, which,
A. Labor, delivery, recovery, postpartum in turn, decreases blood pressure
(LDRP) D. This medication will cause an increased
B. Nurse-midwifery excretion of water from the vascular
C. Clinical nurse specialist system, which will decrease the blood
D. Prepared childbirth pressure

- A client has a midpelvic contracture from - When starting a client on oral or IV

a previous pelvic injury due to a motor diltiazem, for which potential
vehicle accident as a teenager. The nurse complication should the nurse monitor?
is aware that this could prevent a fetus A. Flushing
from passing through or around which B. Atrioventricular block
structure during childbirth? C. Renal Failure
A. Symphysis pubis D. Hypertension
B. Sacral promontory
C. Ischial spines - Prior to administration, a client starting
D. Pubic arch an increased dose of clonidine
(Catapres) should be assessed for which
- When teaching a group of adolescents of the following:
about variations in the length of the A. Orthostatic hypotension
menstrual understands that the B. Tachycardia
underlying mechanism is due to C. Hyperglycemia
variations in which of the following D. Oliguria
phases?
A. Menstrual phase - Following a percutaneous transluminal
B. Proliferative phase coronary angioplasty, a client is
C. Secretory phase monitored in the post procedure unit.
D. Ischemic phase The client’s heparin infusion stopped 2
hours earlier. There into evidence of
- When teaching a group of adolescents bleeding or hematoma at the insertion
about male hormone production, which site, and the pressure device is removed.
of the following would the nurse include The nurse should plan to remove the
as being produced by the Leydig cells? femoral arterial sheath when the partial
A. Follicle-stimulating hormone. thromboplastin time (PTT) is:
B. Testosterone A. 50 seconds or less
C. Luteinizing hormone B. 75 seconds or less
C. 100 seconds or less medication does the nurse anticipate
D. 125 seconds or less administering to treat his bradycardia?
A. Atropine
- A physician orders several drugs for a B. Dobutamine
client with hemorrhagic stroke. Which C. Amiodarone
drug order should the nurse question? D. Lidocaine
A. Dexamethasone
B. Methyldopa - The nurse is caring for the clients on the
C. Phenytoin telemetry unit. Which medication should
D. Heparin sodium the nurse administer first?
A. Clopidogrel to the client with arterial
- A home care nurse visits a client occlusive disease
diagnosed with atrial fibrillation who is B. Digoxin to the client diagnosed with CHF
ordered warfarin (Coumadin). The nurse C. Iron dextran infusion to the client with
teaches the client about warfarin iron-deficiency anemia who has pale skin
therapy. Which statement by the client D. Amiodarone ventricular bigeminy on
indicates the need for further teaching? the telemetry monitor
A. "I'll watch my gums for bleeding when I
brush my teeth” - Administering oral verapamil (isoptin)
B. “I’ll use an electric razor to shave” 14. The nurse is check the client’s tos
C. I’ll eat four servings of fresh, dark green client. Before administering the
vegetables every day verapamil the nurse should check the
D. ”I’ll report unexplained or severe clients:
bruising to my doctor” A. Electrolytes
B. Urine output
- For which of the following medications C. Weight
should a client undergo therapeutic drug D. Heart rate
monitoring?
A. Penicillin (antibiotic) - A clinic nurse is taking a health history
B. Propranolol (beta-blocker) from a 34-year-old man newly diagnosed
C. Furosemide (diuretic) with Buerger’s disease. The nurse would
D. Digoxin (cardiac glycoside) expect the client’s complaints to include
A. Heart palpitations
- The nurse suspects that a client has B. Dizziness when walking
digoxin toxicity. The nurse should assess C. Blurred vision
for: D. Digital sensitivity to cold
A. Decrease urine output
B. Gait instability - The MOST appropriate nursing action
C. Hearing loss before administration of (Capoten)
D. Vision changes would be to check the client’s Curing
output.
- Which of the following classes of drugs A. Apical pulse for 60 seconds
would most likely predispose a client to B. Blood pressure
digitalis toxicity? C. Temperature
A. Salicylate analgesics D. Urine output
B. Tetracycline antibiotics
C. Diuretics - A patient is being treated in the
D. Barbiturates telemetry unit for cardiac disease. The
patient is to receive propranolol
- The client taking digoxin has a serum hydrochloride (Inderal) 20 mg PO at 9
digoxin level of 4.2 ng/ml. Which AM. When the nurse goes into the room
medication should the nurse anticipate to give the medication to the patient, the
the HCP prescribing? nurse-finds him wheezing with a
A. Digitalis binder Fab antibody fragments nonproductive cough and shortness of
B. Furosemide breath, INITIALLY, the nurse should:
C. The HCP will not prescribe any A. Hold the medication and count the
medications respirations
D. Digoxin B. Hold the medication and call the
physician
- A nurse is caring for a client who’s C. Take an apical pulse and then give the
experiencing sinus bradycardia with a medication
pulse rate of 40 beats/minute. His blood D. Give the medication as ordered
pressure is 80/50 mm Hg and he
complains of dizziness. Which
- The nurse is monitoring a client’s EKG
strip and notes coupled premature
ventricular contractions greater than 10
per minute. The nurse should expect to
administer which of the following?
A. Atropine sulfate (Atropine) IV
B. Isoproterenol (Isuprel) IV
C. Verapamil (Calan) IV
D. Lidocaine hydrochloride (Xylocaine) IV
- If a client develops cor pulmonale (right-
sided heart failure), the nurse would
expect to observe
A. Increasing respiratory difficulty seen
with exertion
B. Cough productive of a large amount of
thick, yellow mucus
C. Peripheral edema and anorexia
D. Twitching of extremities
- A client is in cardiogenic shock after a
myocardial infarction (MI). Which of the
following is a correctly stated nursing
diagnosis for this client?
A. Activity intolerance: related to impaired
oxygen transport
B. Altered tissue perfusion related to
decreased heart-pumping action
C. Altered cardiac output related to cardiac
ischemia
D. Potential fluid volume deficit related to
decreased intake
- The nurse is caring for a client with deep
vein thrombosis (thrombophlebitis) of
the left leg. Which of the following would
be an appropriate nursing goal for this
client?
A. Decrease Inflammatory response in the
affected extremity and prevent
embolus formation
B. Increase peripheral circulation and
oxygenation of the affected extremity
C. Prepare the client and family for
anticipated vascular surgery on the
affected extremity
D. Prevent hypoxia associated with the
development of a pulmonary embolus
- A client who is receiving hydralazine
(Apresoline) q6h has a blood pressure of
90/60. Which of the following nursing
actions would be MOST appropriate?
A. Withhold the medication
B. Check the urinary output
C. Administer the medication.
D. Increase the potassium intake
- A client with chronic heart failure
developed an intractable cough and an
incident of angioedema after starting
Enalapril. Which prescription does the
nurse anticipate for this client?
A. Alprazolam
B. Dextromethorphan
C. Lisinopril
D. Valsartan
- The client diagnosed with coronary
artery disease is prescribed atorvastatin.
Which statement by the client warrant
the nurse notifying the HCP?
A. I really haven’t changed my diet but I am
taking my medication every day
B. I am feeling pretty good, except I am
having muscle pain all over my body
C. I am taking this medication first thing in
the morning with a bowl of oatmeal
D. I am swimming at the local pool about
three times a week for 30 minutes.
- In a bustling emergency room, a group of
nurses are presented with four patients,
all exhibiting atrial fibrillation but
differing in the duration of their
symptoms and presenting with
haemodynamic instability. The medical
team mush determines who among
them can proceed with cardioversion
without first undergoing anticoagulation
therapy. Which patients can receive
cardioversion without a preliminary
round of anticoagulation?
A. Patient that has been in atrial fibrillation
for less than 72 hours
B. Patient that had atrial fibrillation for less
than a week
C. Patient that in atrial fibrillation that
lasted less than 96 hours
D. Patient that has experienced atrial
fibrillation for less than 48 hour
- Lucas, a seasoned nurse, preparing to
administer warfarin to his patient with
atrial fibrillation. What is the ideal
International Normalized Ratio (INR)
range he should aim for to ensure
effective anticoagulation while
minimizing bleeding risks?
A. Set within 2 and 3
B. Ranging from 2 to 4
C. Between the values of 1.5 and 3
D. Spanning from 1.5 up to 4.
- Sitting in the bustling emergency room
of a local hospital, nurse practitioner
Claire patiently studies an
electrocardiogram (ECG) printout of a
patient who just arrived, an elderly
gentleman complaining of an erratic,
fluttering sensation in his chest. The
tracing reveals a curious pattern. Claire
knows the rhythm of a normal heart,
including the presence and
characteristics of the “p” wave, but she’s
contemplating if what she’s seeing might
indicate a heart condition, specifically
atrial fibrillation. In this context, which of
 the following statements best describes - A nurse notes that a client with sinus
an electrocardiographic hallmark of rhythm has a premature ventricular
atrial fibrillation? contraction that falls on the T wave of
A. None of the statements above are the preceding beat. The client's rhythm
accurate suddenly changes to one with no P
B. The ECG reading shows a complete waves or definable QRS complexes.
absence of the “P” wave Instead there are coarse wavy lines of
C. The “P” wave on the ECG presents with a varying amplitude. The nurse assesses
fluctuating shape this rhythm to be:
D. The “P” wave is clearly visible on the ECG. A. Ventricular tachycardia.
B. Ventricular fibrillation
- When ventricular fibrillation occurs in a C. Atrial fibrillation
CCU, the first person reaching the client D. Asystole
should
A. Administer oxygen - The nurse is preparing for the admission
B. Defibrillate the client of a client with heart failure who is being
C. Initiate CPR sent directly to the hospital from the
D. Administer sodium bicarbonate physician’s office. The nurse would plan
intravenously on having which of the following
medications readily available for use? C.
- A nurse is viewing the cardiac monitor in Propranolol (Inderal)
a client’s room and notes that the client A. Diltiazem (Cardizem)
has just gone into ventricular tachycardia. B. Digoxin (Lanoxin)
The client is awake and alert and has C. Metoprolol (Lopressor)
good skin color. The nurse would prepare D. Propranolol (Inderal)
to do which of the following?
A. Immediately defibrillate - What is the first intervention for a client
B. Prepare for pacemaker insertion experiencing MI?
C. Administer amiodarone (Cordarone) A. Administer morphine
intravenously B. Administer oxygen
D. Administer epinephrine (Adrenaline) C. Administer sublingual nitroglycerin
Intravenously D. Obtain an ECG

- While caring for a client who has - Which of the following is the most
sustained an MI, the nurse notes eight common symptom of Myocardial
PVCs in one minute on the cardiac infarction?
monitor. The client is receiving an IV A. Chest pain
infusion of DSW and oxygen at 2 B. Dyspnea
L/minute. The nurse’s first course of C. Edema
action should be to: D. Palpitations
A. Increase the IV infusion rate
B. Notify the physician promptly - Which of the following classes of
C. Increase the oxygen concentration medications maximizes cardiac
D. Administer a prescribed analgesic performance in clients with heart failure
by increasing ventricular contractibility?
- A nurse is watching the cardiac monitor A. Beta-adrenergic blockers
and notices that the rhythm suddenly B. Calcium channel blockers
changes. There are no P waves, the QRS C. Diuretics
complexes are wide, and the ventricular D. Inotropic agents
rate is regular but over 100. The nurse
determines that the client is - An early finding in the EKG of a client
experiencing: with an infarcted mycardium would be:
A. Premature ventricular contractions A. Disappearance of Q waves
B. Ventricular tachycardia B. Elevated ST segments
C. Ventricular fibrillation C. Absence of P wave
D. Sinus tachycardia D. Flattened T waves

- A client has developed atrial fibrillation, - Which of the following positions would
which a ventricular rate of 150 beats per best aid breathing for a client with acute
minute. A nurse assesses the client for: pulmonary edema?
A. Hypotension and dizziness A. Lying flat in bed
B. Nausea and vomiting B. Left side-lying
C. Hypertension and headache C. In high Fowler’s position
D. Flat neck veins D. In semi-Fowler’s position
- A client with pulmonary edema has been - Dyspnea, cough, expectoration,
on diuretic therapy. The client has an weakness, and edema are classic signs
order for additional furosemide (Lasix) in and symptoms of which of the following
the amount of 40 mg IV push. Knowing conditions?
that the client also will be started on A. Pericarditis
Digoxin (Lanoxin), a nurse checks the B. Heart failure
client’s most recent: C. Hypertension
A. Digoxin level D. MI
B. Creatinine level
C. Sodium level - What is the most common complication
D. Potassium level of an MI?
A. Arrhythmias
- Tissue plasminogen activator (t-PA) is B. Cardiogenic shock
considered for treatment of a patient C. Pericarditis
who arrives in the emergency D. Heart failure
department following onset of
symptoms of myocardial infarction. - To prevent a valsalva maneuver in a
Which of the following is a client recovering from an acute
contraindication for treatment with t- myocardial infarction, the nurse would?
PA? A. Assist the client to use the bedside
A. Worsening chest pain that began earlier commode
in the evening B. Administer stool softeners every day as
B. History of cerebral hemorrhage ordered
C. History of prior myocardial infarction C. Administer antidysrhythmics prn as
D. Hypertension ordered
D. Maintain the client on strict bed rest
- Which of the following conditions is
associated with a predictable level of - With which of the following disorders is
pain that occurs as a result of physical or jugular vein distention most prominent?
emotional stress? A. Myocardial infarction
A. Anxiety B. Pneumothorax
B. Stable angina C. Heart failure
C. Unstable angina D. Abdominal aortic aneurysm
D. Variant angina
- A female client with a history of
- A home care nurse is making a routine pheochromocytoma is admitted to the
visit to a client receiving digoxin hospital in an acute hypertensive crisis.
(Lanoxin) in the treatment of heart To reverse hypertensive crisis caused by
failure. The nurse would particularly pheochromocytoma, nurse Lyka expects
assess the client for: to administer:
A. Thrombocytopenia and weight gain A. Phentolamine (Regitine)
B. Diarrhea and hypotension B. Methyldopa (Aldomet)
C. Anorexia, nausea, and visual C. Mannitol (Osmitrol)
disturbances D. Felodipine (Plendil).
D. Fatigue and muscle twitching

- Acute pulmonary edema caused by COMMUNICABLE DISEASE NURSING

heart failure is usually a result of damage
to which of the following areas of the - You are assigned to a patient in isolation.
heart? After your nursing care, what will you
A. Left atrium remove first in order to ensure your
B. Right atrium safety as care provider?
C. Left ventricle A. Mask
D. Right ventricle B. Gown
C. Gloves
- Which of the following blood tests is D. Bonnet
most indicative of cardiac damage?
A. Lactate dehydrogenase - You are caring for a patient with
B. Complete blood count (CBC) suspected Dengue. As an initial
C. Creatine kinase (CK) procedure, you plan to conduct your
D. Troponin I tourniquet test. On this test, The BP cuff
should be inflated for how long?
A. Until the upper arm will have a tingling
sensation
B. For 5 minutes leprosy should have treatment for how
C. For 7-10 minutes long?
D. Until the sphygmomanometer level A. 3-4 months
drops at 0 mmHg level B. 6-9 months
C. 20-22 months
- You are conducting a sitio class about D. 24-30 months
Tuberculosis. You are giving the right
information if you will say that which of - You are teaching a group of the clients
the following measures is considered to about DOTS when suddenly somebody
be the best preventive way for stood up and asked, “How can that help
Tuberculosis? us?” You planned to answer the patient’s
A. Vaccination of newborns and grade 1/ question by discussing the elements of
school entrants the program. You are correct if you will
B. Educate the public in the mode of inform them that all but one is the
transmission and methods of control elements of Direct Observed Treatment
C. Improve social condition, such as Short Course.
overcrowding A. Political will in terms of funds and
D. Provide outreach services for home manpower
supervision of patients B. Sputum microscopy services and X-ray
examinations
- You are conducting your physical C. Drug intake supervised by health worker
assessment to a patient suspected of or family member
having leprosy. As a nurse, you should D. Regular drug supply
know that the following are included in
the early signs and symptoms of Leprosy, - The best artificial contraceptive method
EXCEPT: that is used in the prevention of Sexually
A. Ulcers that do not heal Transmitted Diseases is which of the
B. Loss of eyebrow following:
C. Paralysis of extremities A. Abstinence
D. Loss of sensation on the skin lesion B. Health Education
C. Use of condom
- You are teaching a group of families with D. Use of pills
TB infected member. With this group of
participants, your priority topic should - The vaccine for the prevention of the
be: disease that causes pseudo membrane
A. Enumeration of drug of choices of the throat should be stored at which
B. Food choices for menu planning part of the refrigerator?
C. Mode of transmission and control of A. At the freezer
spread B. At the body of the ref
D. Demonstration of disinfection C. Anywhere in the refrigerator
D. No specific location, as long as it should
- You are teaching a group of mothers be given on time
about leprosy. As part of your discussion,
you should include that leprosy is caused - You are teaching a group of students
by what type of microorganism? about the treatment of leprosy. You are
A. Bacteria at the right tract if you will teach
B. Virus Lepromatous classification of leprosy
C. Parasite should have treatment for how long?
D. Fungi A. 3-4 months
B. 5-9 months
- You are teaching a group of mothers C. 20-22 months
whose children are having diarrhea. Your D. 24-30 months
priority at this time is to inform them
that the best way to prevent diarrheal - Part of your discussion during your class
diseases among infants is: to a group of nursing students about
A. Proper food preparation malaria is to discuss about the causative
B. Breastfeeding agent of the disease. The following are
C. Improved weaning practices the parasites of the genus Plasmodium
D. Handwashing that produces malaria in humans,
EXCEPT:
- You are teaching a group of students A. Plasmodium vivax
about the treatment of leprosy. You are B. Plasmodium concrum
at the right tract if you will teach them C. Plasmodium ovale
that. Paucibacillary classification of D. Plasmodium falciparum
- Chloroquine is the prophylactic drug B. A nurse should recap needles and
against malaria. If you are planning to dispose it in a puncture proof container
enter an endemic area, how should you after use
take the drug? C. A nurse should wear gloves when
A. Take it at weekly interval, starting from draining urine from the IFC bag
1-2 weeks before entering the endemic D. A nurse must wear mask when attending
area to a patient with excessive bleeding
B. Take it daily for 1 week before entering
an endemic area - As a nurse assigned in the
C. Take it daily for 3 days before entering an Communicable Disease Pavillion, you
endemic area, and continue for 7 days should know that which of the following
more is a requirement in observing droplet
D. Take it at weekly interval for 1 month precautions?
before entering the endemic area A. Particulate respirators
B. Mask
C. Gloves
- In doing the Rumpel Leade Test as an D. Dedicated patient care equipment
initial diagnostic procedure for DHF, you
have to inflate the BP cuff on the upper - During your ward class, you know that a
arm of a patient with a blood pressure of student learned from your discussion if
130/90 at what level? she will state which of the following?
A. 110 mmHg A. I should always use a disinfectant on my
B. 130 mmHg hand to lessen my chances of acquiring
C. 90 mmHg diseases
D. 40 mmHg B. Frequent handwashing is needed as it
completely destroys microorganisms
- You are teaching a group of mothers C. Cleaning will just lessen the number of
about leptospirosis. As part of your microorganisms but will not completely
discussion, you should include that destroy them
leptospirosis is caused by what type of D. Disinfectants should always be used by
microorganism? nurses every after an invasive procedure.
A. Bacteria
B. Virus - An anxious mother came to the clinic
C. Parasite and asked what she can do to prevent
D. Fungi the spread of tuberculosis from her
husband. Your most appropriate
- During case finding of TB infected response should be:
persons, which procedure is A. Maintain isolation of the respiratory
immediately done by the PHN? secretions until the antibiotic therapy
A. Collection of sputum will be completed
B. Distribution of isoniazid B. Isolate the patient for 2 months and
C. X-ray mobile unit instruct him to cover his nose and mouth
D. BCG injection C. Maintain respiratory isolation for 1
month after good compliance with the
- A patient came to the clinic with an STD. antibiotics
He came because of disturbing D. Maintain isolation of the respiratory
symptoms he has been feeling for secretions for 2 weeks after start of
several weeks now. The best advice you antibiotics.
should give the patient would be to:
A. Take the medicine religiously - A mother asked, “how did my son got
B. Tell the patient not to be promiscuous this influenza?” As a nurse, you will have
again based your reply to the knowledge that
C. Tell the sexual contacts to have the most important predisposing factor
treatment too for the disease is:
D. Use condoms A. Malnutrition
B. Exposure to extreme weathers
- You are reviewing the principles of C. Exposure to polluted air
standard precautions. You are at the D. Overcrowding
right tract if you will be able to identify
that all but one of the following are - An 8-month old child was brought into
included: the clinic with cough and a respiratory
A. A nurse inserting Intravenous Fluids rate of 49 breaths per minute. As a
must wear gloves nurse, you will conclude that this
respiratory rate is:
A. Above the expected normal range
B. Within the expected normal range
C. Below the expected normal range
D. not conclusive
- You are lecturing about Amoebiasis to a
group of mothers in the community. You
are correct if you will emphasize that the
most effective preventive measure for
any diarrheal diseases is:
A. Eat only foods prepared by someone you
know
B. Frequent handwashing
C. Proper food storage
D. Right source of food
- A 4-month old baby boy was brought in
the Emergency Room with sunken
eyeballs, dry skin and lips, and poor skin
turgor after 2 days of LBM and vomiting.
When the nurse tried to stimulate his
lips, the baby moved his lips and showed
some sucking action. Based on this
observation, you will conclude that:
A. The child shows no signs of dehydration
B. The child needs immediate IV therapy to
check the condition
C. The child shows moderate signs of
dehydration
D. The child shows severe signs of
dehydration
- In preventing the occurrence of
amoebiasis in a certain community, you
should know that the least measure that
must be implemented is which of the
following:
A. Control the presence of flies in the area
B. Observe proper hygiene after sexual
contact
C. Avoid ingestion of uncooked leafy
vegetables
D. Avoid talking with patients with the
same disease
- Nurse Letty is caring for a patient
diagnosed with cholera. In this patient,
she will expect all of the following,
except:
A. Decrease in the level of consciousness
B. In late stage, signs of metabolic
alkalosis may be seen
C. If not properly treated, temperature will
drop
D. Prolonged tenting of the skin when
pinched
- Nurse Joey is a newly assigned nurse at
the Leprosy Ward. He is reviewing the
expected manifestations of the disease.
He is correct if he will identify that one of
the latest manifestation of the disease is:
A. Ulcers that do not heal
B. Paralysis of extremities
C. Loss of eyebrow
D. Loss of sensation on the skin lesion
- Nurse Raki is caring for a 12-year-old
patient diagnosed with Dengue. As you
approach the patient, you noticed that
the mother seems to be very anxious
and restless. When asked why, she said,
“I don’t know where my son got the
disease. Can you tell me the probable
reason how my son got this?” You will
give the right response if you will
answer:
A. The disease can be transmitted by direct
contact with individuals known to have
the disease
B. Your son probably got this from
mosquito bites in school
C. The disease can be acquired through
mosquito bites, that’s why it is important
to have mosquito nets and pajamas
during night time
D. The disease can be taken from vomitus
and stool of patients who have the
disease
- All but one is correct interventions when
handling patients with increase ICP
A. Giving mannitol and prednisone
B. Avoiding activities that increased
intraabdominal pressure
C. Positioning patient in high fowlers
position
D. Preparing tongue blade at bedside
- A patient under treatment for leprosy
states, “I can feel that I’m getting darker.
What causes this?” A nurse
knowledgeable of the disease is
expected to answer which of the
following?
A. “That is an expected effect of the
interaction of Rifampicin, Dapsone, and
Clofazimine.”
B. "No need to worry. That will gradually be
resolved on its own.”
C. “That is an expected side effect of your
clofazimine medication.”
D. “That is an expected side effect of your
dapsone medication.”
- You are conducting your health teaching
to a group of mothers in your
community. You are correct if you will say
the in measles, Koplik Spots are expected
to appear:
A. 2 days after the appearance of the body
rash
B. 2 days before the appearance of fever
C. 2 days before the appearance of the
body rash
D. On the same day of the onset fever
- Increasing incidence of german measles
is primarily attributed to what mode of
transmission?
A. Direct skin-to-skin
B. Respiratory droplets
C. Trans placental transmission
D. Indirectly through contact with
contaminated
- You are assessing a patient in the
emergency room with complaints of mild
fever and lymphadenopathy. When you
check the oral mucosa of the patient,
you noticed a pinkish rash on his soft
palate. With these assessments findings,
you will suspect that the patient might
be suffering from what disease?
A. Rubeola
B. Rubella
C. Varicella
D. Herpes zoster
- A curious mother asked, “If my son will
suffer from chicken pox, at what part of
his body will I expect the rashes to
appear first?”. As a knowledgeable
nurse, your response should be:
A. For varicella infection, the first rash is
expected to appear on the lower
extremities of the patient
B. Frequently assess the trunk area of the
patient. That is where the rash will
appear after its eruption on the patient’s
face
C. The first rash of varicella infection is
expected to appear on the chest area
D. Assess the face of the patient for any
rashes before it will progress to the
upper extremities
- For the control and prevention of
Malaria, the most important nursing
responsibility to be included on the
health teachings is:
A. To maintain good personal hygiene
B. To maintain adequate nutrition
C. To maintain environmental sanitation
D. To strictly comply with antibiotic
managements
- A patient confined with a diagnosis of
malaria asked the nurse, “when is the
most probable time I acquired the
disease? The nurse is correct if he will
say:
A. “You probably got the disease during
your snack break at the school”
B. “You probably got the disease when you
attended a lunch party at your friend’s
house.”
C. “Are you fond of going out at night?”
D. “What are your usual activities before
sunset?”
- The vaccine for the close that causes
paralysis or weakness of the lower
extremities should be stored at which
part of the refrigerator?
A. At the freezer
B. At the body of the ref
C. Anywhere in the refrigerator
D. No specific location, as long as it should
be given on time
- Nurse Anna is teaching a group of
students about the Chen of Infection.
She is of best help to the nursing
students she will make which of the
following statement:
A. “The best way to break the chain of
infection is by removing the causative
agent.”
B. “The best way to break the chain of
infection is by preventing the portal of
entry
C. “The best way to break the chain of
section is by disrupting the mode of
transmission.”
D. “The best way to break the chain of
infection is by giving medicines.”
- Tubercle bacilli can remain suspended in
the air for a prolonged period of time
until it is inhaled by a susceptible host.
This mode of transmission is known as:
A. Airborne transmission
B. Droplets transmission
C. Direct Contact transmission
D. Vector-borne transmission
- Dengue hemorrhagic fever can be
transferred from one person to another
via mosquito bite. This mode of
transmission is generally called:
A. Vehicle-borne transmission
B. Mosquito-borne transmission
C. Vector-borne transmission
D. Direct contact transmission
- A patient in the community came to you
immediately after the tuberculin testing
and ask you about when should she be
back in the clinic for the reading of the
result. Your response should be basedon
the knowledge that this test is read:
A. After 30 minutes
B. After 2 days but not later than 3 days
C. After 3 days but not later than 4 days
D. After 24 hours
- You performed mantoux test on a four-
year-old child whose parents are not
compliant with immunizations. Upon
reading the result of the test, you will
conclude that it is positive if the
induration has the following
measurement:
A. more than or equal to 5mm
B. more than or equal to 10mm
C. more than or equal to 5cm
D. more than or equal to 10cm
- According to the Strengthened National
Tuberculosis Control Program, a patient
who is negative on sputum examination
for the first time but shows symptoms of
the disease should be submitted to
which of the following:
A. Have X-ray examination to confirm the
disease
B. Have another sputum examination to
confirm the disease
C. Consider the patient as a non-TB case
D. Assist the patient in availing medicines
(antibiotics) for early treatment of the
disease.
- Mang Renato was previously diagnosed
of Tuberculosis and hence, was
prescribed with antibiotics. He is
compliant on the first month of
treatment but failed to continue the
regimen because he thought that he
already improved. Recently, he again
consulted the clinic for TB-like
symptoms. As a nurse, you will anticipate
that. Mang Renato will be classified
under what category of treatment?
A. Category 2
B. Category 1
C. Category 3
D. Category 4
- You are assessing a 3 Vs year old child
suspected of pneumonia. His respiratory
rate is 43 cycles per minute. You will
arrive at the correct interpretation if you
know that the cut-off respiratory rate for
this group of children is which of the
following:
A. 60 breaths per minute
B. 50 breaths per minute
C. 40 breaths per minute
D. 70 breaths per minute
- A 45 days old child presents in the clinic
with a respiratory rate of 63 breaths per
minute and with subcostal retractions.
The mother further verbalized that the
baby is not anymore feeding because of
ineffective sucking reflex and is always
seen sleeping. As a nurse assessing that
patient, you will conclude that the child
is suffering from:
A. Very severe pneumonia
B. Pneumonia
C. Severe pneumonia
D. No pneumonia: Cough and Colds
- A young infant is diagnosed with severe
pneumonia. As our responsibility, we
should immediately advise the mother
of which of the following:
A. Urgent referral to the hospital
B. To keep the young infant warm but avoid
excessive sweating
C. Continue home antibiotics with close
follow-up
D. Continue breastfeeding and boost the
child’s immune system at home
- Assessment of a 3-year-old child reveals
the following: respiratory rate of 45
breaths per minute, no intercostal
retractions, and no subcostal retractions.
Based on these findings, you will classify
the child as:
A. Very severe pneumonia
B. Pneumonia
C. Severe Pneumonia
D. No pneumonia
MS- NEURO
A nurse who witnesses a motor vehicle accident
stops to provide emergency assistance to the
injured motorists.
- When the nurse assesses a victim who
has been thrown from the vehicle, which
assessment finding is most suggestive of
a serious head injury?
A. The victim has a bad headache
B. The victim asks the nurse, “What
happened?”
C. The victim is hesitant to move
D. The victim has clear fluid draining from
the ears
- Which nursing action is most important
to do next?
A. Maintain the victim’s present position
A. Assist in obtaining the victim’s insurance
card
B. Cover the victim with a light blanket
C. Give the victim some water to drink.
- To reduce the risk of liability, which is the
most appropriate action for the nurse to
take?
A. Avoid giving the accident victim any
personal identification
B. Remain with the accident victim until
paramedics arrive
C. Provide a report of who caused the
accident to law enforcement officials
D. Let others at the scene provide direct
care.
The accident victim is taken to the emergency
department for evaluation.
- While waiting for the physician to
examine the client, how should the
nurse position the client?
A. Dorsal recumbent with the legs elevated
B. Supine with the head slightly elevated
 C. Flat with a neck immobilizer in place
D. Right lateral with the neck flexed.
After X-rays are taken of the head, neck, and
spine, the client is diagnosed with a head injury
and admitted for inpatient care.
- When assessing the client with a head
injury, which of the following should
receive priority attention?
A. Lung sounds
B. Clarity of speech
C. Mobility of finger
D. Pupillary responses
- If the nurse obtains the following data,
which finding should be reported to the
physician immediately?
A. The client leaves most of the food on the
dietary tray
B. The client rates a headache as 5 on a
scale of 0 to 10
C. The client complains of feeling cold
D. The client is difficult to arouse with
stimulation
- When assessing the client’s head injury,
the nurse observes a change in the
client’s condition. Which finding is most
likely contributing to the change?
A. The client has been disturbed every hour
B. The client has had very little fluid intake
C. The client’s neck is flexed toward the
chest
D. The client’s bladder is becoming quite
full
The client is treated with mannitol (Osmitrol).
- Which of the following is most important
for the nurse to assess when the client
receives mannitol (Osmitrol)?
A. Urine output
B. Respiratory rate
C. Level of pain
D. Blood pressure
The nurse makes a home health visit to evaluate
a 79-year old client.
- The nurse notes that the client has had a
change in baseline neurologic
functioning. Which symptom suggests
that the client may be having transient
ischemic attacks (TIAS)?
A. Brief periods of unilateral weakness
B. Brief periods of respiratory distress
C. Brief periods of photosensitivity
D. Brief periods of stabbing head pain
- After the nurse gathers more data
concerning the client’s signs and
symptoms, which action is most
appropriate?
A. Explain the event in understandable
language.
B. Refer the client for immediate medical
evaluation
C. Recommend taking a low-dose aspirin
once daily
D. Advise the client to call 911 if symptoms
persist
Later in the day, the client is admitted to the
hospital after emergency medical personnel
respond to a call that the client has been found
unconscious. The physician orders frequent
neurologic checks.
- The nurse in the emergency department
assesses the client’s neurologic function.
When checking the client’s pupils, which
technique is correct?
A. Shine the penlight from the side of the
temple into each pupil
B. Cover one of the client’s eyes, then the
other eye
C. Brighten the lights in the examination
area
D. Observe for extraocular eye movement.
The physician orders a computed tomography
scan of the client’s brain with contrast dye.
- The nurse describes the purpose of the
computed tomography (CT) scan to the
client and spouse and asks about the
client’s allergy history. The client’s
spouse reports that the client has several
allergies. Which one must be reportedto
the physician before the CT scan?
A. Penicillin
B. Shellfish
C. Latex
D. Metal
The nursing team begins developing a core plan
for the stroke victim.
- When the nurse monitors the client’s
neurologic status, which finding is most
suggestive that the client’s intracranial
pressure is increasing?
A. Systolic pressure increases and diastolic
pressure decreases
B. Systolic pressure decreases and diastolic
pressure increases
C. Apical heart rate is greater than the
radial rate
D. Radial pulse rate is greater than the
apical rate
The charge nurse enters the nursing diagnosis
“Risk for ineffective airway clearance related to
an inability to swallow” on the client’s care plan.
- Which nursing intervention is most
appropriate for managing the identified
problem?
A. Keeping the client supine
B. Removing all head pillows
C. Performing oral suctioning
D. Providing frequent oral hygiene
 D. Ask the client if a gait belt is preferred
The neurologist determines that the stroke
victim has right-sided hemiplegia. Because of the client’s diagnosis of right-sided
- The nurse documents that the client is at hemiplegia, the nurse instructs the client’s
risk for falls. Which risk factors increase spouse how to perform passive range-of-motion
any client’s risk for falls? Select all that (ROM) exercises.
apply. - When teaching the client’s spouse about
1. The client is male. these exercises, which instructions are
2. The client is taking antibiotics. most accurate? Select all that apply.
3. The client is confused. 1. Move the paralyzed limbs in as many
4. The client has vertigo. directions as possible.
5. The client has impaired vision. 2. Perform the exercises every 3 hours
6. The client needs help with toileting. while awake.
3. Repeat each exercise three times.
A. 1,2,3,4,5,6 4. Take the pulse before exercising.
B. 1,3,4,5,6 5. Allow rest periods between exercises.
C. 3,4,5,6 6. Begin the exercises starting with the
D. 1,3,4,5 affected leg.

The nurse evaluates the stroke victim’s A. 1,2,3,4,5,6

medication profile because of the increased risk B. 2,3,4,5,6
for falls. C. 3,4,5,6
- Which classifications of drugs are most D. 1,3,5
likely to result in falls? Select all that
apply. - When positioning the client and
1. Antihyperlipidemic supporting her extremities, the nurse
2. Benzodiazepines must remember that when voluntary
3. Sedatives control of muscles is lost:
4. Opioids A. The feet will maintain a position of
5. Anticonvulsants eversion
6. Antihypertensives B. The upper extremities will rotate
externally
A. 1,2,3,4,5,6 C. The hip joint will rotate internally
B. 2,3,4,5,6 D. Flexor muscles will become stronger
C. 3,4,5,6 than extensors
D. 1,3,4,5
The nurse attaches a footboard to the client’s
- Based on the client’s fall risk assessment, bed.
which interventions should the nurse - Which statement best describes how the
implement? Select all that apply. nurse positions the client’s feet when a
1. Instruct the client to ask for help before footboard is used?
getting up. A. The soles are perpendicular to the board
2. Turn on the bed alarm. B. The soles are parallel to the board
3. Apply restraints to the upper C. The knees are flexed less than 90
extremities. degrees
4. Advise the client’s family to inform the D. The ankles are extended more than 90
staff when leaving. degrees.
5. Place the bed in the lowest position.
6. Obtain an order for a physical therapy The speech therapist reports to the nurse that
consult. the client has expressive aphasia.
- Which nursing intervention is best for
A. 1,2,3,4,5,6 communicating with the client at this
B. 1,3,4,5,6 time?
C. 3,4,5,6 A. Speak using a low tone of voice
D. 1,2,4,5 B. Have the client point to key phrases
printed on a clipboard
- When the client is stable enough to C. Complete the sentence if the client
transfer from the bed to a wheelchair, becomes frustrated
which nursing action is correct? D. Encourage the client to practice
A. Instruct the client about how to balance verbalizing key words.
with a walker
B. Position the wheelchair perpendicular to - Which nursing goal is most important to
the bed the client’s rehabilitation?
C. Brace the paralyzed foot and knee
 A. To regulate bowel and bladder
elimination
B. To prevent contractures and joint
deformities
C. To deal with problems of altered body
image
D. To foster positive outcomes from
depression
- The client’s spouse notices situations
during which the client laughs or cries
inappropriately. The spouse asks the
nurse, “Why are these mood swings
occurring?” Which is the best response
by the nurse?
A. Your spouse is trying to gain control over
the situation by these mood swings
B. Emotional fluctuations are common for
many after experiencing a stroke
C. The stroke has destroyed the part of the
brain dealing with emotions
D. It is common to be very emotional after
a major life event.
An adult man fell off a ladder and hit his head.
- His wife rushed to help him and found
him unconscious. After regaining
consciousness several minutes later, he
was drowsy and had trouble staying
awake. He states that he has headache
and blurring of vision. He is unable to
move his legs. How should he be
transported?
A. Position him in a prone position and
place on a backboard
B. Apply a neck collar and position supine
on a backboard
C. Log roll him to a rigid backboard
D. Position in an upright position with a
firm neck collar
- He is admitted to the hospital for
evaluation. The patient is diagnosed of
subarachnoid hemorrhage and spinal
cord injury is ruled out. When the nurse
enters the room, he is sleeping. While
caring for the client, the nurse finds that
his systolic blood pressure has increased,
his pulse has decreased, and his
temperature is slightly elevated. What
does this suggest?
A. Increased cerebral blood flow
B. Respiratory depression
C. Increased intracranial pressure
D. Hyper oxygenation of the cerebrum
- The nursing care plan will most likely
include which of the following?
A. Elevate head of bed 15 to 30 degrees
B. Encourage fluids to 1000 mL every eight
hours
C. Assist the client to cough and deep
D. Breathe every two hours
- The next day, the nurse goes into his
room and finds him lying on the floor
starting to have a seizure. What action
should the nurse take at this time?
A. Carefully observe the seizure and gently
restrain him
B. Attempt to put an airway in his mouth so
he does not swallow his tongue and
observe the type and duration of the
seizure
C. Place something soft under his head,
carefully observe the seizure, and
protect him from injury
D. Shout for help so that someone can help
you move him away from the furniture
The patient regains consciousness three days
after admission. He has right-sided hemiparesis
and hemiplegia and has expressive aphasia.
- He becomes upset when he is unable to
say simple words. The best approach for
the nurse is to do which of the following?
A. Stay with her and give her time and
encouragement in attempting to speak
B. Say, “I’m sure you want a glass of water.
I’ll get it for you.” Back later and try to
talk to you then.”
C. Say, “Don’t get upset. You rest now and
I’ll come
D. Encourage her attempts and say, “Don’t
worry, it will get easier every day.”
- The physician has ordered mannitol IV
for a client with SAH. What should the
nurse closely monitor while the client
receiving mannitol that will indicate that
the treatment is effective?
A. Diminished reflexes
B. Increased urine output
C. Improved level of consciousness
D. Increased blood pressure
- The nurse notes that he seems to be
unaware of objects on her right side.
Which nursing action is most important
in planning to assist him to compensate
for this loss?
A. Place frequently used items on the
affected side
B. Position her so that her affected side is
toward the activity in the room
C. Encourage her to turn her head from
side to side to scan the environment on
the affected side
D. Stand on the affected side while assisting
her in ambulating.
Nurse is teaching a wellness class and is covering
the warning signs of stroke.
- The nurse is teaching regarding risk
factors for stroke. A patient asks, “What
is the greatest risk factor of stroke?”
Which is an appropriate response by the
nurse?
 A. Diabetes
B. Heart disease
C. Renal insufficiency
D. Hypertension
- Another patient asks the nurse, “What is
the most important thing for me to
remember?” Which is an appropriate
response by the nurse?
A. “Know your family history.”
B. “Keep a list of your medications.”
C. “Be alert for sudden weakness or
numbness.”
D. “Call 911 if you notice a gradual onset of
paralysis or confusion.”
- Another patient asks the nurse, “Which
symptoms suggest that a person may be
having transient ischemic attack TIA)?”
Which is an appropriate response by the
nurse?
A. Permanent periods of unilateral
weakness, dizziness, speech
disturbances, visual loss, or double
vision
B. Temporary brief periods of unilateral
weakness, dizziness, speech
disturbances, visual loss, or double
vision
C. Brief periods of photosensitivity
D. A and C
E. B and C
During the wellness class, a patient is admitted
with signs of brain attack. On admission, vital
signs were blood pressure 128/70, pulse 68, and
respirations 20.
- Two hours later the patient is not awake,
has a blood pressure of 170/70, pulse 52,
and the left pupil is now slower than the
right pupil in reacting to light. These
findings suggest which of the following?
A. Impending brain death
B. Decreasing intracranial pressure
C. Stabilization of the patient’s condition
D. Increased intracranial pressure
- The hospitalized patient has become
unresponsive. The left side of the body is
flaccid. The attending physician believes
the patient may have worsening
condition. What is the nurse’s priority
intervention?
A. Move the patient to the critical care unit
B. Assess blood pressure
C. Assess the airway and breathing
D. Observe urinary output
- A patient whose status is post-stroke
(CVD) has severe right-sided weakness.
Physical therapy recommends a quad
cane. Which of the following is proper use of the
cane by the patient?
A. The patient holds the cane in the left
hand. The patient moves the cane
forward first, then the right leg, and
then the left leg
B. The cane is held in either hand and
moved forward at the same time as the
left leg. Then the patient drags the right
leg forward
C. The patient holds the cane in the right
hand for support. The patient moves the
cane forward first, then the left leg, and
then the right leg
D. The patient holds the cane in the left
hand. The patient moves the left leg
forward first, then moves the cane and
the right leg forward together.
- The family of a patient who has had a
brain attack (CVD) asks if the patient will
ever talk again. The nurse should do
which of the following?
A. Explain that the patient’s speech will
return to normal with time
B. Explain that it is difficult to know how
far the patient will progress
C. Tell the family that nurses cannot discuss
such issues. Tell them to ask the
physician
D. Tell the family what they see today is all
they can expect
- Which of the following statements is/are
true concerning Neglect Syndrome?
A. Unilateral neglect is the loss of
awareness of the side affected by the
stroke
B. The client cannot see, feel, or move the
affected side of his body, therefore, he
forgets that it exists
C. This lack of awareness poses a great risk
for injury to the neglected extremities
and creates a self-care deficit
D. All except B
E. All of the above
- Which of the following are appropriate
health teachings to patient experiencing
unilateral neglect?
A. Instruct the client to dress the affected
side first
B. Teach the client how to care for the
affected side
C. Use the unaffected hand to pull the
affected extremity to midline and out of
danger from the wheel of the wheelchair
or from hitting or smashing it against a
doorway
D. Teach the client to look over the affected
side periodically
E. All of the above
Strokes, also known as cerebrovascular accidents A. 1,2,3,4,5
(CVAs) or brain attacks, involve a disruption in the B. 1,2,3,5
cerebral blood flow secondary to ischemia, C. 1,2,5
hemorrhage, brain attack, or embolism. D. 1,3,5
- A nurse is caring for a client who has
experienced a right-hemispheric stroke. - A nurse is caring for a client who has
Which of the following are expected global aphasia (both receptive and
findings? Select all that apply expressive). Which of the following
1. Impulse control difficulty should the nurse include in the client’s
2. Left hemiplegia plan of care? Select all that apply.
3. Loss of depth perception. 1. Speak to the client at a slower rate.
4. Aphasia 2. Look directly at the client when speaking
5. Lack of awareness 3. Allow extra time for the client to answer.
4. Complete sentences that the client
A. 1,2,3,4,5 cannot finish.
B. 1,2,3,5 5. Give instructions one step at a time.
C. 1,2,5
D. 1,3,5 A. 1,3,5
B. 1,2,3,4,5
C. 1,2,3,5
- A nurse is caring for a client who has left D. 1,2,5
homonymous hemianopia. Which of the
following is an appropriate nursing - A nurse is assessing a client who has
intervention? experienced a left-hemispheric stroke.
A. Teach the client to scan to the right to Which of the following is an expected
see objects on the right side of her body. finding?
B. Place the client’s bedside table on the A. Impulse control difficulty
right side of the bed. B. Poor judgment
C. Orient the client to the food on her plate C. Inability to recognize familiar objects
using the clock method. D. Loss of depth perception
D. Place the client’s wheelchair on her left
side. A nurse is caring for a client who was recently
admitted to the emergency department
- A nurse is planning care for a client who following a head-on motor vehicle crash.
has dysphagia and has a new dietary - The client is unresponsive, has
prescription. Which of the following spontaneous respirations of 22/min, and
should the nurse include in the plan of a laceration on his forehead that is
care? Select all that apply. bleeding. Which of the following is the
1. Have suction equipment available for priority nursing action at this time?
use. A. Keep neck stabilized
2. Use thickened liquids. B. Monitor pulse and blood pressure
3. Place food on the client’s unaffected side frequently
of her mouth. C. Insert nasogastric tube
4. Assign assistive personnel to feed the D. Establish IV access and start fluid
client slowly. replacement
5. Teach the client to swallow with her neck
flexed.
 - The client had a surgical evacuation of a C. Hypervolemia
subdural hematoma. Which of the D. Hypoglycemia
following is the priority assessment? E. Hyperglycemia/hypoglycemia
A. Glasgow Coma Scale
B. Oxygen saturation MS-GI
C. Pupillary response - A client asks the nurse what caused the
D. Cranial nerve function development of a hiatal hernia? What is
the best response by the nurse?
While completing the physical assessment, the A. Increased intra thoracic pressure
nurse notes that the patient ICP readings range B. Weakness of the esophageal muscle
from 16 to 22 mm Hg. C. Increased esophageal muscle pressure
D. Increased abdominal pressure
- Which of the following actions should
the nurse take to decrease the potential - Risk factors for the development of
for raising the client’s ICP? Select all that hiatal hernias are those that lead to
apply. increased abdominal pressure. The
1. Suction the endotracheal tube. nurse understands that which of the
2. Hyperventilate the client. following complications is most likely to
3. Elevate the client’s head on two pillows. result in a hiatal hernia?
4. Administer a stool softener. A. Obesity
5. Keep the client well hydrated. B. Volvulus
C. Constipation
A. 1,2,4 D. Intestinal obstruction
B. 2,4,5
C. 1,3,5 - A client is admitted with a hiatal hernia.
D. 2,4 The nurse should assess the client for
which symptom?
- Which of the following assessment A. Left arm pain
findings are indicative of increased ICP? B. Lower back pain
Select all that apply. C. Esophageal reflux
1. Headache D. Abdominal cramping
2. Dilated pupils
3. Tachycardia - A nurse is preparing to teach a client with
4. Decorticate posturing a hiatal hernia. The nurse should provide
5. Hypotension instruction on which diagnostic test?
A. Colonoscopy
A. 2,4,5 B. Lower Gl series
B. 2,4 C. Barium swallow
C. 1,2,4 D. Abdominal X-ray series
D. 1,3,5
- A client is admitted with right lower
- A nurse is caring for a client who has quadrant pain, anorexia, nausea, low-
increased ICP and a new prescription for grade fever, and elevated white blood
mannitol (Osmitrol). For which of the cell count. Based on these assessments,
following adverse effects should the which of the following complications is
nurse monitor? the client most likely experiencing?
A. Hyperglycemia A. Fecalith
B. Hyponatremia B. Bowel kinking
C. Internal bowel occlusion C. Myocardial infarction (MI)
D. Abdominal wall swelling D. Lumbar strain

- The nurse is assessing a client with - Which nursing intervention should be

suspected appendicitis. The nurse would included in the immediate postoperative
expect the client to use which of the management of a client who has
following terms to describe their Pain undergone gastrectomy?
location? A. Monitoring gastric pH to detect
A. Right upper quadrant complications
B. Right lower quadrant B. Assessing for bowel sounds
C. Left upper quadrant C. Providing nutritional support
D. Left lower quadrant D. Monitoring for symptoms of
hemorrhage
- Which of the following positions would
the nurse assist a client to assume for the - A client is being admitted with acute
relief of pain experienced with gastric ulcer. The nurse knows the
appendicitis? immediate collaborative treatment plan
A. Prone will include which of the following?
B. Sitting A. Reducing work stress
C. Supine, stretched out B. Completing a gastric resection
D. Lying with legs drawn up C. Treating the underlying cause
D. Administering enteral tube feedings
- Which nursing intervention should be
the priority when caring for a client with - Upon reviewing the history of a client
appendicitis? with chronic gastric ulcer, which of the
A. Providing discharge teaching following may be a risk factor for the
B. Assessing for symptoms of murphy’s sign development of this condition?
C. Assessing for pain A. Adolescent client
D. Encouraging oral intake of clear fluids B. Antibiotic usage
C. Gallbladder disease
- The nurse is teaching the client about D. Helicobacter pylori infection
gastritis. Which of the following
statements by the nurse would be the - A client with chronic gastritis asks why
most accurate in describing gastritis? they need to have injections of vitamin
A. Erosion of the gastric mucosa B12. Which response by the nurse’s
B. Inflammation of a diverticulum appropriate?
C. Inflammation of the gastric mucosa A. “Your white blood cell count is low”
D. Reflux of stomach acid into the B. “It will give you more energy”
esophagus C. “Your condition does not allow vitamin
B12 to be absorbed.”
- A 30-year-old client is complaining of D. “It is necessary for people with this
reflux in his esophagus 1-2 hours after disorder”
eating or when lying down for the last 2
weeks. The nurse recognizes that this - In which developmental stage would the
symptom is related to which of the nurse note that a client is at risk of
following disorders? developing diverticulosis?
A. Hiatal hernia A. Infant
B. Intestinal infection B. School age
C. Young adult - The nurse has provided discharge
D. Older adult teaching for a client who was
hospitalized and treated for acute
- A client newly diagnosed with diverticulitis. Which statement by the
diverticulosis is being discharged. The client indicates understanding of the
client asks the nurse what type of diet discharge instructions?
may have contributed to the diagnosis. A. “I’ll reduce my fluid intake.”
What is the best response by the nurse? B. “I’ll decrease the fiber in my diet.”
A. Low-fiber diet C. “I’ll take all of my antibiotics.”
B. High-fiber diet D. “I’ll exercise to increase my intra-
C. High-protein diet abdominal
D. Low-carbohydrate diet
- Crohn’s disease can be described as a
- Which mechanism can facilitate the chronic relapsing disease. Which area of
development of diverticulosis into the Gl system may be involved with this
diverticulitis? disease?
A. Treating constipation with chronic A. The entire length of the large colon
laxative use, leading to dependence on B. Only the sigmoid area.
the laxatives C. The entire large colon through the layers
B. Chronic constipation causing an of mucosa and submucosa
obstruction, reducing forward flow of D. The small intestine and colon, affecting
intestinal contents the entire thickness of the bowel
C. Herniation of the intestinal mucosa,
rupturing the wall of the intestine - A client presents with a recurrence of
D. Undigested food blocking the Crohn’s disease. Which area of the
diverticulum, predisposing the area to alimentary canal does the nurse suspect
bacterial invasion is the starting point involved?
A. Ascending colon
- While reviewing the clinical presentation B. Descending colon
of clients with diverticular disease, the C. Sigmoid colon
nurse understands that which of the D. Terminal ileum
following symptoms indicates
diverticulosis? - A nurse is preparing the teaching plan for
A. No symptoms exist a client with Crohn’s disease. Which
B. Change in bowel habits factor should the nurse include as a
C. Anorexia and low-grade fever possible link to the development of this
D. Episodic, dull or steady midabdominal disease?
pain A. Constipation
B. Diet
- Which test should the nurse expect to be C. Heredity
ordered for a client suspected of having D. Lack of exercise
diverticulosis?
A. Abdominal ultrasound - A nurse is reviewing the causes of
B. Barium enema ulcerative colitis with a client. Which
C. Barium swallow factor is believed to cause ulcerative
D. Gastroscopy colitis?
A. Acidic diet
B. Autoimmunity
C. Chronic constipation - The nurse determines that which diet
D. Emotional stress would be most appropriate for a client
with ulcerative colitis?
- A client is admitted with an anorectal A. Low fat, low protein
fistula. The nurse is aware that the client B. High calorie, low fiber
most likely has which condition? C. Low fiber, high protein
A. Crohn’s disease D. High residue, high fiber
B. Diverticulitis
C. Diverticulosis - If a client had irritable bowel syndrome,
D. Ulcerative colitis which diagnostic test would determine if
the diagnosis is Crohn’s disease or
- A client with Crohn’s disease ulcerative colitis?
experiences 20 watery stools per day. A. Abdominal computed tomography (CT)
When assessing the client, the nurse scan
would anticipate which finding? B. Barium swallow
A. Tenting skin turgor C. Abdominal X-ray
B. Decreased heart rate D. Colonoscopy with biopsy
C. Dilute urine
D. Elevated blood pressure - Which intervention should be included
in the collaborative management ofa
- Which associated disorder might a client client with Crohn’s disease?
with ulcerative colitis exhibit? A. Increasing oral intake of fiber
A. Gallstone B. Using long-term steroid therapy as
B. Hydronephrosis prescribed
C. Nephrolithiasis C. Administering laxatives as ordered
D. Hemorrhage D. Increasing physical activity

- Which associated disorder might a client - A client with Crohn’s disease is

with Crohn’s disease exhibit most often? experiencing an exacerbation. Which
A. Liver cirrhosis instruction would be a priority in
B. Colon cancer planning his care?
C. Malabsorption A. Increasing current weight
D. Lactase deficiency B. Encouraging ambulation
C. Promoting bowel rest
- A client with Crohn’s disease is admitted D. Controlling rectal bleeding
with fever, weight loss, leg cramping,
diarrhea, frequent premature - A nurse would expect to prepare a client
ventricular contractions, and abdominal with ulcerative colitis for surgery if the
pain. The nurse reviews the client’s lab client develops which condition?
data and determines immediate A. Bowel out pouching
intervention is required when the results B. Bowel perforation
identify which of the following? C. Gastritis
A. Hypo albuminemia D. Bowel herniation
B. Increased erythrocyte sedimentation
rate - Which medication would the nurse
C. Leukocytosis expect to find on the electronic
D. Hypokalemia medication administration record (E-
 MAR) for treating the pain associated C. To prevent the stomach from sliding into
with irritable bowel disease? the chest
A. Acetaminophen D. To remove a potentially malignant lesion
B. Opiates in the stomach
C. Steroids
D. Stool softeners - The nurse should be aware that which
condition is most likely to directly cause
- The nurse is prioritizing care for a client peritonitis?
2 days after surgery for a stoma creation A. Cholelithiasis
that resulted from ulcerative colitis. B. Gastritis
What is the most important issue for the C. Perforated ulcer
nurse to address? D. Incarcerated hernia
A. Body image
B. Ostomy care - Which assessment finding would a client
C. Sexual concerns in the early stages of peritonitis exhibit?
D. Skin care A. Hyperactive bowel sounds
B. Abdominal distention
- The nursing assessment of a client with C. Abdominal pain and rigidity
colon cancer may also include a past D. Right upper quadrant pain
medical history of which condition?
A. Appendicitis - Which laboratory result would the nurse
B. Hiatal hernia anticipate in a client with peritonitis?
C. Hemorrhoids A. Partial thromboplastin time above 100
D. Ulcerative colitis seconds
B. Potassium level above 5.5 mEq/L
- Which factor is the priority C. Hemoglobin level below 10 mg/dl
postoperative care need of the client D. White blood cell (WBC) count above
after gastric resection? 15,000/μl
A. Skin care
B. Body image - Which factor is most commonly
C. Spiritual needs associated with the development of
D. Nutritional needs pancreatitis?
A. Alcohol abuse
- The nurse is providing discharge B. Hypercalcemia
instructions for a client who has C. Hyperlipidemia
undergone a gastric resection. The nurse D. Pancreatic duct obstruction
is aware that the client is at risk for:
A. Constipation - Which action of pancreatic enzymes can
B. Dumping syndrome cause pancreatic damage?
C. Gastric spasm A. Utilization by the intestine
D. Intestinal spasms. B. Auto digestion of the pancreas
C. Clogging of the pancreatic duct
- Which response should a nurse offer to a D. Reflux into the pancreas
client who asks why he’s having a
vagotomy to treat his ulcer? - Which laboratory test would the nurse
A. To repair a hole in the stomach expect to be ordered to diagnose
B. To reduce the ability of the stomach to pancreatitis?
produce A. Amylase level
B. Hemoglobin level
C. Blood glucose level
D. White blood cell (WBC) count

- A client with pancreatitis may exhibit

Cullen’s sign on physical examination.
Which assessment finding best describes
Cullen’s sign?
A. Jaundiced sclera
B. Pain that occurs with movement
C. Bluish discoloration of the left flank area
D. Bluish discoloration of the peri
umbilical area

- Which factor should be the initial focus

of nursing management in a client with
acute pancreatitis?
A. Dietary management
B. Prevention of skin breakdown
C. Pain control
D. Management of hypoglycemia

- When admitting a client to the hospital

with suspected acute pancreatitis, which
disorder would be expected?
A. Hypoglycemia
B. Hypovolemia
C. Hypernatremia
D. Hyperkalemia

- If a gastric ulcer perforates, which action

should be included in the management
of the client?
A. Removal of the nasogastric (NG) tube
B. Antacid administration
C. H2-receptor antagonist administration
D. Fluid and electrolyte replacement