1.

The following statement appears on the nursing care plan for an immunosuppressed
client: The client will remain free from infection throughout hospitalization. This
statement is an example of a (an):

a. short-term goal

b. nursing diagnosis

c. long- term goal

d. expected outcome

2. Well formulated, client-centered goals should:

a. meet immediate client needs.

b. include preventive health care

c. include rehabilitation needs.

d. all of above.

3. Which of the following statements about the nursing process is most accurate?

a. Beginning in Florence Nightingale’s day, nursing students learned and practiced

the nursing process.

b. The state board examinations for professional nursing practice now use the

nursing process rather than medical specialties as an organizing concept.

c. The nursing process is a four-step procedure for identifying and resolving patient

problems.

d. Use of the nursing process is optional for nurses, since there are many ways to

accomplish the work for nursing.

4. Collaborative interventions are therapies that require:

a. Physician and nurse interventions.

b. Nurse and client interventions.

c. Client and physician interventions.

d. Multiple health care professionals.

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

a. Alert and have some degree of independence.

b. Ambulatory and mobile.

 c. able to speak and write.

d. able to read and write.

6. After assessing the client, the nurse formulates the following diagnoses. Place them

in order of priority, with the most

important (classified as high) listed first. 1. Constipation 2. Anticipated grieving 3.

Ineffective airway clearance 4. Ineffective tissue perfusion.

a. 3,4,2,1

b. 4,3,2,1

c. 1,3,2,4

d. 3,4,1,2

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

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

b. Be aware of and committed to accepted standards of practice from nursing and

other disciplines.

c. Not change the plan of care for the client.

d. Be in control of all interventions for the client.

8. When establishing realistic goals, the nurse:

a. Base the goals of on the nurse’s personal knowledge.

b. Knows the resources of the health care facility, family, and the client.

c. Must have a client who is physically and emotionally stable.

d. Must have the client’s cooperation.

9. The nursing care plan is:

a. A written guide line for implementation and evaluation.

b. A documentation of client care.

c. A projection of potential alterations in client behavior

d. A tool to set goals and project outcomes.

10. Once a nurse assesses a client’s condition and identifies appropriate nursing

diagnoses, a:

a. Plan is developed for nursing care.

b. Physical assessment begins.

c. List of priorities is determined.

d. Review of the assessment is conducted with other team members.

11. The planning step of the nursing process includes which of the following activities?

a. Assessing and diagnosing

b. Evaluating and achievement

c. Setting goals and selecting nursing interventions

d. Performing nursing and documenting them

12. To initiate an intervention the nurse must be competent in three areas, which include:

a. Knowledge, function, and specific skills.

b. Experience, advance education, and advance skills.

c. Skills, finances, and leadership.

d. Leadership, autonomy, and skills.

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

a. Client-centered goals and expected outcomes are established.

b. The physician determines the plan of care for the client.

c. The nurse determines the health care needed for the client.

d. The client determines the care needed.

14. Nurse Nikki is revising a client’s care plan. During which step of the nursing process

does such revision take place?

a. Assessment

b. Diagnosis

c. Planning

d. Evaluation

15. The nurse in charge identifies a patient’s responses to actual or potential health
problems during which step of the nursing process?

a. Assessment

b. Nursing Diagnosis

c. Implementation

d. Evaluation

16. A female patient is diagnosed with deep-vein thrombosis. Which nursing diagnosis
should receive highest priority at this time?

a. Impaired gas exchanges related to increased blood flow

b. Altered peripheral tissue perfusion related to venous congestion

c. Risk for injury related to edema

d. both b and c

17. The nurse in charge is assessing a patient’s abdomen. Which examination technique
should the nurse use first?

a. Inspection

b. Auscultation

c. Percussion

d. Palpation

18. . Understanding another’s feelings or perceptions, but not sharing the same feelings

a. Sympathetic b. empathetic
 b. Both a and b d. none of the above

19. Understanding and sharing the same feelings as another.

a. Sympathetic b. empathetic

c. Both a and b d. none of the above

20. In the diagnostic statement “Excess fluid volume related to decreased venous return as
manifested by lower extremity edema,” the etiology of the problem is which of the following?

a. excess fluid volume b. edema

c. decreased venous return d. unknown

21. How many components in Nursing Process?

a. 5 components b. 4 components

c. 3 components d. Both a and c

22. In which component we have collect, validate, organize, and record data.

a. assessment b. diagnosis
c. planning d. evaluation

23. Verbal information given by a patient.(eg, Pt states, “I have pain”)

a. objective data b. subjective data

c. none d. both a and b
24. A 18-year-old woman is in the emergency department with fever and cough. The nurse
obtains her vital signs, listen to her lung and heart sounds, determines her level of comfort, and
collects blood and sputum samples for analysis. Which standard of practice is formed?

a. Diagnosis b. Evaluation
b. Assessment d. Implementation

25. Hourly assessment if the patient’s fluid intake and urinary output is altered.

a. Ongoing assessment
b. Time-lapsed assessment
c. Emergency assessment
d. Initial assessment

26. In which the act of “double-checking” or verifying data to confirm that they are accurate and
factual

a. Organizing data b. Validating data

c. Recording data d. collecting data

27. A patient in the emergency department has developed wheezing and shortness of breath.
The nurse gives the ordered medicated nebulizer treatment now and in 4 hours. Which
standard of practice is performed?

a. Planning b. Evaluation

c. Assessment d. Diagnosis

28. In validating activity of the assessing phase of the nursing process, the nurse perform
which of the following?

a. Collects subjective data

 b. Applies a frame work to the collective data

c. Confirms data are complete and accurate

d. Record data in the client record

29. An element of quality improvement, rather than quality assurance, is which of the
following?

a. focus is on individual outcomes

b. evaluates organizational structure

c. aims to confirm that quality exists

d. plans corrective actions for problems

30. Events or changes that occur during one’s lifetime

a. Judgmental process b. life process

c. both a and b d. none of them

31. The client states:” I really don’t want anyone to visit me who has not been cleared by me
first” If utilizing the SOAP format this statement would be documented under which
category?

a. subjective data b. objective data

c. assessment d. planning

32. A client who has been wheelchair for several years is currently experiencing problems
with skin breakdown and urinary retention in addition to depression. When formulating a
nursing diagnosis, an appropriate selection would be which of the following?
 a. syndrome diagnosis

b. risk nursing diagnosis

c. actual diagnosis

d. wellness diagnosis

33. A state in which an individual

experiences and reports the presence of severe uncomfortable sensation is called……

a. Wellness

b. Illness

c. Pain

d. Health

34. The gate control theory was first proposed in 1965 by psychologist …………… and
anatomist ………………… .

a. melzack and Patrick Wsll

b. Florence nightingale and Dorothea Dix

c. Dorothea Dix and Clara Barton

d. Lillian Wald and Linda Richards

35. Short duration, goes away with healing, usually 6 months or less.
a. Chronic pain

b. Acute pain

c. Dull pain
 d. both a and b

36. ……….. pain is ongoing and usually lasts long than six months.

a. Acute pain

b. Chronic pain

c. both a and b

d. none of them

37. In pain assessment COLDERRA formula c stands for?

a. Chronic pain

b. Characteristics

c. Continuing pain

d. both a and b

38. Pain scale is from ..... to …… .

a. 01 to 08

b. 0 to 10

c. 0 to 5

d. 0 to 15

39. A pain stimulus is converted to electrical energy. This electrical energy is known as …….. .

a. Transduction

b. Modulation

c. Transmission

d. Perception
40. A client recovering from abdominal surgery refuses analgesia, nursing diagnosis should be
priority?

a. Deficient knowledge ( Pain control measure)

b. Ineffective Health Maintenance

c. Risk for Ineffective Airway Clearance

d. Impaired Physical Mobility

41. Which of the following objective assessment data will the nurse obtain before administering
a prescribed opioid medication to a client?

a. Pain level as standard by client

b. Any nausea the client may be feeling

c. Respiratory rate

d. Color of skin

42. A client is surprised to learn of the diagnosis of a heart attack when there was no chest pain
experienced but only some left shoulder pain. What should the nurse explain to the client about
the type of pain experienced?

a. Phantom pain

b. Referred pain

c. visceral pain

d. Chronic pain

43. The digestive system changes carbohydrates into ……….. .

a. lipid

b. protein

c. glucose

d. fats
44. ……… as rich energy molecules, maintain structure of cells.

a. Lipid

b. Glucose

c. Vitamins

d. minerals

45. Kwashiorkor develops in children whose diets are deficient of ……….. .

a. Protein

b. fat

c. calories and Proteins

d. both a and b

46. Marasmus develops in children whose diets are deficient of ……………. .

a. Protein

b. fat

c. calories and Proteins

d. both a and b

47. Kwashiorkor occurs in children between ….... months and ……… years of age.

a. 06 months and 03 years

b. 12 months and 05 years

c. 10 months and 06 years

d. 08 months and 05 years

48. Enlarged fatty liver only in ………. disease.

a. kwashiorkor

b. marasmus
 c. anemia

d. night blindness

49. To best assist a patient in the grieving process, which of the following is most helpful to
determine?
a. Previous experiences with grief and loss.
b. Religious affiliation and denomination.
c. Ethnic background and cultural practices
d. Current financial status

50. The uterus contains an inner lining called …………… .

a. Endometrium

b. Myometrium

c. Serosa

d. none of them

51. …………. stimulates the development of many follicles within the ovary.
a. Luteinizing hormone
b. Follicle stimulating hormone
c. Progesterone hormone
d. both b and c
52. Deficient or absent sexual fantasies and urges is in ……….. sexual disorder.
a. Hypoactive sexual desire disorder
b. Sexual aversion disorder
c. Female sexual arousal disorder
d. Female Orgasm disorder

53. The body is in a decreased state of activity without physical emotional stress and freedom
from anxiety called ………
a. Sleep
b. Rest
 c. Die
d. both a and b

54. During sleep the Pineal gland in the brain begins to actively secrete the natural hormone
called …………. .
a. Serotonin
b. Melatonin
c. Cortisol
d. both a and b
55. Absent eye ball movements is in …………. of Non Rapid Eye Movement(NREM).
a. stage 1

b. stage 2

c. stage 3

d. stage 4

56. Adults ….. to …… hours sleep per night.

a. 05 to 10 hours

b. 07 to 08 hours

c. 04 to 08 hours

d. 05 to 09 hours

57. Waking up frequently during the night time is in ………………. Sleep disorder.
a. Insomnia
b. Hypersomnia
c. Narcolepsy
d. Sleep apnea
58. Only in ………….. sleep disorder lake of chemical hypocretin in the area of CNS that
regulate sleep.
a. hypersomnia
b. narcolepsy
 c. sleep apnea
d. insomnia

59. Individuals obtains sufficient sleep at night but still cannot stay awake during the day
……………. Sleep disorder.
a. hypersomnia
b. narcolepsy
c. sleep apnea
d. insomnia
60. Dreaming occurs in ……. stage
a. Non Rapid Eye Movement stage
b. Rapid Eye Movement stage
c. Non Rapid Eye Movement stage 2
d. Non Rapid Eye Movement stage 3
61. The passage of small, and dry hard stool is called ……….. .
a. Fecal Impaction
b. Constipation
c. Diarrhea
d. Fecal incontinence
62. …………… is a mass of hard feces in the folds of rectum resulted by prolonged retention of
fecal material.
a. Fecal Impaction
b. Constipation
c. Diarrhea
d. Fecal incontinence
63. Kegel exercises to strengthen or retrain ................... and ...............
a. abdominal and heart muscles
b. pelvic and shoulder muscles
c. pelvic muscles and sphincter muscles
d. all of above
64. On entering the room the nurse sees the patient crying softly. What is the most therapeutic
response?
a. Using silence
b. Asking, ‘’why are you crying today?’’
c. Using therapeutic touch
d. Stating, ‘’I see that you’re crying.”
65. To best assist a patient in the grieving process, which of the following is most helpful to
determine?
a. Previous experiences with grief and loss.
b. Religious affiliation and denomination.
c. Ethnic background and cultural practices
d. Current financial status.
66. A patient is receiving total parental nutrition (TPN). What is the primary intervention the
nurse should follow to prevent a central line infection?
a. Institute isolation precautions.
b. Clean the central line port through which the TPN is infusing with antiseptic.
c. Change the TPN tubing every 24 hours
d. Monitor glucose level to watch and assess for glucose intolerance.
67. The nurse is performing an abdominal assessment on a patient. Which step will be first
performed by the nurse?
a. Inspection
b. Percussion
c. Auscultation
d. Palpation
68. The nurse is admitting a critically ill client to the intensive care unit. What question should
the nurse ask regarding this client’s sleep history?
a. No question should be asked.
b. when do you usually go to sleep?
 c. what are your bed time rituals?
d. Do you have any problems with sleeping?
69. In Non Rapid Eye Movement (NREM) stage1 which type of waves developed in brain EEG.
a. Theta waves
b. Delta waves
c. K-complex waves
d. none of them
70. How many stages in Non Rapid Eye Movement(NREM)?
a. 2 stages
b. 3 stages
c. 4 stages
d. 5 stages
71. Newborn sleeps ……. to ……… hours per day.
a. 12 to 18 hours
b. 13 to 15 hours
c. 15 to 20 hours
d. 10 to 15 hours
72. Which factors effecting sleep pattern?
a. Illness
b. Emotional stress
c. drugs and other substances
d. All of above
73. Individuals obtains sufficient sleep at night but still cannot stay awake during the day its
which type of sleep disorder?
a. Hypersomnia
b. Narcolepsy
c. insomnia
d. both a and b
74. Vital signs includes, blood pressure, Pulse, Temp. Resp. rate & Oxygen saturation.
a. True
b. False
75. Where is temperature is regulated?
a. Hypothalamus
b. Skin
c. Heat and cold
d. By what a person wear
76. What is the normal range of temperature?
a. 36.6-37.5c
b.34-36c
c. 35.6-38c
d.34.6-36c
77. What is normal pulse rate?
a. 12-20
b. 15-20
c. 60-100
d. 50-90
78. A weak pulse is rated as?
a. 0
b.1+
c. 2+
d. 3+
e. 4+
79. A patient have a pulse rate of 102, resp. rate of 25, a B/P of 139/90 and a temp. of 103 F. As
a nurse which will you assess first?
a. B/P of 139/90
b. Pulse rate of 102
c. Resp. rate of 25
d. Temp. pf 103F
80. Blood pressure is the force against the aterial wall.
a. True
b. False
82. A person that is dehydrated will experience a low B/P.
 a. True
b. False
c. Unknown
83. What factor does not influence Resp. rate?
a. Age
b. Gender
c. Smoking
d. Medication
e. Pain
84. It is best describe as a systematic, rational method of planning and providing nursing care
for individual, families, group and community
a. Assessment
b. Planning
c. Nursing process
d. Diagnosis
85. Which of the following cluster of data belong to Maslow’s hierarchy of needs
a. Love and belonging
b. Physiological needs
c. Self- actualization
d. All of above
86. A client is hospitalized for the first time, which of the following actions ensure the safety of
the client?
a. Keep unnecessary furniture out of the way
b. Keep side rails up at all time
c. Keep all equipment out of view
d. Keep the lights on at all the time
87. A nurse obtained a client’s pulse and found the rate to be above normal. The nurse
document these findings as:
a. Tachypnea
b. Hyperpyrexia
c. Arrhythmia
 d. Tachycardia
88. A client who is unconscious needs frequent mouth care. When performing a mouth care, the
best position of a client is:

a. Fowler’s position

b. Side lying position

c. Trendelenburg

d. Supine position

89. This is characterized by severe symptoms relatively of short duration.

a. Chronic illness

b. Acute illness

c. Syndrome

d. Pain

90. A walk-in client enters into the clinic with a chief complaint of abdominal pain and diarrhea.
The nurse takes the client’s vital sign hereafter. What phrase of nursing process is being
implemented here by the nurse?

a. Assessment

b. Diagnosis

c. Planning

d. Implementation

91. The nursing process is utilized to:

a) Provide a systemic, organized and comprehensive approach to meeting the needs of clients.

b) Encourage the family to make decisions regarding patient's care.

c) Increase involvement of allied healthcare professionals in decision-making

d) None of the above

92. Objective data might include:

a) Chest pain.

b) Complaint of dizziness.

C) An evaluation of blood pressure.

d) None of the above

93. According to Maslow’s hierarchy of human needs, the highest level is

a) Physiologic needs

b) Safety and security

c) Belongingness and affection and esteem and self-respect

d) Self-actualization

94. Which of the following is the appropriate route of administration for insulin?

a) Intramuscular

b) Intradermal

c) Subcutaneous

d) Intravenous

95. The following is the most important purpose of documentation?except

a) To Communication

b)To Reimbursement

b) To Quality assurance

d)To provide comfort

96. A patient asks you what vitamin is best for eye sight. Your response is:

a) Vitamin C

b)Vitamin A
c) Vitamin B6

d)Vitamin B12

97. Constipation is an accumulation of fecal material which forms a hard mass in the rectum.

a. True

b. False

98. Diarrhea is passage of unusually dry, hard stools produced by undue delay in the passage of
feces.

a. True

b. Unknown

c. False

99. The terminal stage of illness is one in which a person is approaching death.

a. True

b. False

c. Unknown

100. Chronic illness is caused by an irreversible alteration in normal anatomy and physiology.

a. True

b. False

c. Unknown

101. The nurses’ progress notes are used vertical or horizontal columns for recording dates and
times to show assessment and interventions.

a. True

b. False
 c. Unknown

102. Tachycardia is a pulse rate slower than 60 beat per minute.

a. True

b. False

c. Unknown

103. Changes that occur in musculoskeletal system due to immobility

a)decrease muscle endurance ,strength and mass

b) Change in calcium metabolism with hyper calcium result in renal calculi

c) Alteration in calcium,fluid and electrolyte d

) Non of the above

104. What are the four main vital signs?

a. BP, O2 Sat, Temp, Pulse

b. BP, Respiration, Temp, Pulse

c. BP, Respiration, Temp, Pain

d. BP, Respiration, O2Sat, Temp

105. To protect the client’s skin from injury during hygiene care, including bathing or
showering, application of lotion, and bed making, you most need to do which of the following
things?

a. Cover your rings and bracelets with gloves.

b. Briskly dry client’s skin after bath to ensure dryness.

c. Keep bottom sheets somewhat loose.

d. Cut your finger nails to a short length.