Situation - Nurse Ceny assists in the care of several male patients with fluid volume deficit.

1. Nurse Ceny reads the medical diagnoses of the patients assigned to her. Which patient with the following
medical conditions is at risk for fluid volume deficit? A patient with________.
A. Congestive Heart Failure C. Cirrhosis
B. Chronic Obstructive Pulmonary Disease D. Colostomy

2. Nurse Ceny assesses the skin turgor on a 35 year old male patient. Which of the following is an indicator of fluid
volume deficit?
A. There is skin tenting.
B. The skin immediately flattens after release.
C. The skin is dry and pale.
D. The skin returns to a normal position within 1 or 2 seconds after pinching and lifting the skin.

3. The physician prescribes an intravenous infusion of 750 mL Normal Saline to a 78- year old male patient with
fluid volume deficit and urinary tract infection. After a rapid IV infusion, the patient begins to cough. The nurse
raises the head part of the bed to ease the patient's breathing. Nurse Ceny observes that the patient's jugular vein
is distended and respiratory rate is increased. Which of the following conditions is the patient experiencing?
A. Beginning hypotonic water intoxication C. Developing hypervolemia
B. Worsening of fluid volume deficit D. Respiratory compromise due to ascites

4. Nurse Ceny inspects the tongue and oral mucosa of a 40- year old patient and notes that they are dry. The
patient had cough, fever, nausea and vomiting which started three days before he was admitted to the medical
unit. The patient further complains of feeling weak and dizzy. Which vital sign measurement would provide the
BEST indicator of the patient's current fluid status?
A. Rate and depth of respiration
B. Body temperature.
C. Pulse oximetry reading at rest
D. Blood pressure and pulse taken in lying and standing positions

5. Nurse Ceny assesses a 50-year old male with liver failure due to cirrhosis. The patient complains of a distended
abdomen and dizziness upon standing. The patient looks pale, has weak radial pulse, and with delayed hand vein
filling. Based on the assessment data, Nurse Ceny writes a nursing diagnosis. Which of the following is the MOST
appropriate nursing diagnosis? Fluid volume________.
A. deficit related to hormonal disturbances C. excess related to hormonal disturbances
B. deficit related to third space fluid shifts D. excess related to third space fluid shifts

Situation - Ms. Simon is a newly registered nurse. She upgrades her nursing competencies by attending seminars
and workshops on advanced nursing procedures. A workshop she recently participated is on physical assessment.
She applies her skills in the female medical unit where she is assigned.

6. Ms. Simon inspects the abdomen of a patient. Which of the following sequences represent the order in assessing
a patient's abdomen?
A. Palpate, percuss, auscultate, observe C. Percuss, palpate, auscultate, observe
B. Observe, auscultate, percuss, palpate D. Auscultate, observe, percuss, palpate
WHEN YOU PERFORM a physical assessment, you'll use four
techniques: inspection, palpation, percussion, and auscultation. Use them in sequence—unless
you're performing an abdominal assessment. Palpation and percussion can alter bowel sounds, so
you'd inspect, auscultate, percuss, then palpate an abdomen.

7. Ms. Simon auscultates for breath sounds. What type of data should auscultation produce?
A. Secondary C. Primary
B. Subjective D. Objective
8. Ms. Simon proceeds to palpate a patient's body to detect warmth. What part of her hand should she use?
A. Finger tips C. Ulnar surface
B. Back or dorsal surface D. Finger pads

9. Ms. Simon assesses a patient for gag reflex. Which part of the tongue should she place the tongue blade?
A. On the middle of the tongue and ask the patient to cough
B. On the uvula
C. Lightly on the posterior aspect of the tongue
D. On the front of the tongue and ask the patient to say "ahh"

10. Ms. Simon takes and records the body temperature of a patient. The temperature registers a reading of 38˚C.
Which of the following conditions will the' patient MOST likely demonstrate?
A. Increased pulse rate C. Dyspnea
B. Precordial pain D. Elevated blood pressure

Situation 8 - You are a nurse manager of a female and male medical unit. You realize that being a manager entails a
great responsibility. One of your major responsibilities is to implement quality improvement initiatives in your unit.

11. You collaborate with the maintenance personnel to prepare a safety program. The program includes, periodic
inspection of electrical equipment, conduct of fire drills and proper disposal of hazardous waste materials. These
activities illustrate a component of which quality program?
A. Total quality management C. Risk management
B. Quality assurance D. Quality improvement

12. You call for a staff meeting. You remind the nurses to improve the quality of care to patients. Which of the
following activities is MOST important to safeguard nursing practice?
A. Know own strengths and limitations.
B. Provide nursing care competently and efficiently.
C. Document care accurately.
D. Understand professional, legal, ethical obligations and responsibilities.

13. You take time to review reports from your staff. One report records the incidence of patients falling off from
their beds and other falls. Which of the following approaches is NOT appropriate to manage the situation?
A. Implement quality assurance measures.
B. Apply risk management principles.
C. Apply total quality management principles in the unit.
D. Implement a systems approach to the situation.

14. A staff nurse in your unit administers a drug incorrectly to a diabetic patient who needs more than one type of
insulin. The staff nurse's action causes serious negative effects on the patient. What would be the MOST
appropriate action that you as the nurse manager should take?
A. Refer the staff nurse to the quality assurance committee.
 B. Refer the staff nurse to the risk management committee.
C. Refer the patient to the attending physician immediately,
D. Ask the staff nurse to write a detailed incident report.

15. A patient in the unit had episodes of seizures. Sometime during the night, the patient fell off from the bed. The
nurse on duty finds the patient on the floor. As a nurse manager, you ask the nurse involved in the incident to
write an incident report. Which of the following statements is NOT true about incident reports? The
report_______.
A. is a part of the patient's medical record
B. can be used in a court of law
C. identifies the people involved, the date, time and location of the incident
D. serves as a record of facts surrounding the incident

Situation - Nurse Gloria is assigned in the emergency department and takes care of patients with different cases.
16. A client with multiple injuries is rushed after head car collision. Which assessment Nurse Gloria takes priority?
A. Unequal pupils C. A deviated trachea
B. Irregular apical pulse D. Ecchymosis in the flank area

17. The ambulance has transported a male client with severe chest pain. As the client is being transferred to the
emergency stretcher Gloria noted that the client is unresponsive not breathing and no palpable pulse. Which of
the following emergency measures will Nurse Gloria anticipates to do?
A. Starting bag valve mask ventilation. C. Placing the defibrillator pads
B. Performing chest compressions D. Aiding with oral intubation

18. A child with fever has been admitted to the emergency department for several hours. Cooling measures are
ordered by the physician in order for the temperature to come down. Which task would be appropriate for Nurse
Gloria to do ?
A. Educate the need for giving cool fluids
B. Prepare and administer a tepid bath
C. Tell the parent to use acetaminophen instead of aspirin.
D. Assist the child in removing outer garments

19. When Gloria conducts primary assessment on a trauma patient. Which of the following is considered one of
the priority elements?
A. Complete vital signs C. Initiation of pulse oximetry
B. Brief neurologic assessment D. Client's allergy history

20. Triage is the process of determining the priority of patients Treatments based on the severity of their
condition. The purpose of reverse triage is to_______.
A. Save those persons who are in the most critical condition.
B. Save scarce resources for future use
C. Do the greatest good for the greatest number with limited resources
D. The first responders on the triage classification category
reverse triage, has been explored in the adult population.4 Reverse triage is a
utilitarian ethical concept (ie, greatest good for the greatest number) wherein
inpatients at low risk for untoward events would be discharged or transferred back
to the community, giving inpatients and individuals affected by the disaster equal
consideration for inpatient resources.

Situation - The nurse manager of the Oncology Unit invites an oncology nurse specialist to conduct an educational.
Session to the nursing staff on the topic Hodgkin's disease.
21. The nurse specialist explains the characteristics of Hodgkin's disease. Which of the following is NOT a
characteristic of Hodgkin's disease?
A. There is presence of Reed-Sternberg cells. C. The lymph nodes, spleen, and liver are involved.
B. The disease occurs most often in the older adult. D. The prognosis depends on the stage of the disease.

22. The nurse specialist describes the stages of Hodgkin's disease. Which of the following symptoms is MOST
commonly an EARLY indicator of Stage I?
A. Chest and back pains C. Unexplained fever, night sweats
B. Subnormal body temperature D. Swelling of extremities

23. The nurse specialist emphasizes the importance of preventing complications. Which of the following conditions
are complications of Hodgkin's disease?
1. Nausea 4. Infection
2. Myocardial infraction 5. Hypotension
3. Anemia
A. 1, 2, 3, 5 C. 1, 3, 4
B. 1, 2, 3, 4, 5 D. 2, 3, 4, 5

24. The nurse specialist sites a situation. If a patient experiences episodes of severe nausea and vomiting with
more than 1000 ml. of vomitus with in a period of four hours, which of the following is the' nurses' MOST
appropriate action?
A. Withhold fluids for four hours C. Observe the patient for another four hours
B. Notify the physician D. Place the patient for a liquid diet

25. The nurse specialist explains that Chemotherapy is extremely toxic to the bone marrow and the patient may
develop thrombocytopenia. What is the PRIORITY goal of the nurse? To take precautions to control _______.
A. Bleeding C. Infection
B. Hypotension D. Diarrhea

Situation - Nurse Clara assists in the care of a male patient who has developed acute respiratory acidosis.
26. Nurse Clara recalls the causes of respiratory acidosis- Which of the following are causes of acute respiratory
acidosis?
1.Chronic obstructive pulmonary disease (COPD) 4.Atelectasis
2.Pneumonia 5.Bronchitis
3.Pulmonary edema
A. 1,2,3,4,5 C. 1,3,4,5
B. 2,3,4,5 D. 1,2,3,4

27. Nurse Clara further recalls that respiratory acidosis nearly always results from which of the following
conditions?
A. Hyperventilation C. Decrease amount of acid in body fluids
B. Hypoventilation D. Low production of carbon dioxide

28. Nurse Clara reviews the results of the arterial blood gases. Which 'of the following would the nurse expect to
read in the report?
A. pH 7.25, PCO2 50 mm Hg C. pH 7.35, PCO2 40 mm Hg
B. pH 7.40, PCO2 52 mm Hg D. pH 7.50, PCO2 30 mm Hg

29. The patient is worried about his kidneys being affected because of his condition. The nurse explains that usually
kidneys ________.
A. can achieve optimal compensation in about 72 hours
B. can achieve optimal compensation immediately
C. will compensate within 24 hours
 D. are unable to compensate

30. Based on assessment data gathered Nurse Clara writes a nursing diagnosis. Which of the following is the MOST
appropriate nursing diagnosis?
A. Risk for injury C. Risk for respiratory infection
B. Ineffective breathing pattern D. Ineffective tissue perfusion

Situation 12 - Ms. E.D., 45-year old is admitted to the medical ward because of complaints of muscle weakness,
fatigue, ptosis and diplopia. The admitting diagnosis is myasthenia gravis.
31. Based on the complaints of the patient, the nurse formulates a nursing diagnosis. Which of the following is the
MOST appropriate?
A. Activity intolerance related to muscle weakness and fatigue
B. Imbalance nutrition: less than body requirements related to muscle weakness and dysphgia
C. Ineffective airway clearance related to chest muscle weakness and impaired cough and gag reflex.
D. Ineffective breathing patterns related to weakness of chest muscle and fatigue

32. The nurse administers anticholinesterase medication. When is the BEST time to give the medication?
A. 30 minutes before meals C. Early in the morning
B. Before the patient sleeps at night D. When the patient has eaten a full meal

33. The nurse observes that the client had not been compliant with her medication regimen of Pyridostigmine
(Mestinon). The patient missed several doses. Which of the following complications should the nurse watch for?
A. Gastrointestinal symptoms C. Bradycardia
B. Respiratory distress D. Vertigo

34. The nurse prepares Ms. E.D. for diagnostic tests. Which of the following is NOT a diagnostic test for myasthenia
gravis.
A. Tensilon test
B. Position Emission Tomography (PET)
C. Serum assay for circulating Ach receptor antibodies
D. Electromyography (EMG)

35. The nurse should always keep which of these drugs at the bedside of a client with myasthenia gravis.
A. Atropine C. Inderal
B. Tensilonn D. Neostigmine
Situation 13 - You are a new registered nurse in the surgical unit. You admit 30 year old male with head injury
sustained in a motor cycle accident. You understand that reporting information is a critical part of documentation.
36. You are aware that documentation should reflect objective data. Based on your assessment of the neurological
function of the patient's LOC, you chart the following observations. Which of the following is an objective data?
A. Client appears confused.
B. Client looks lethargic.
C. Vital signs are stable.
D. Patient has a score of 3-4-3 on the Glasgow Coma Scale.

37. You assess the pupils of the patient and record your observations. Which of the following is LEAST important to
record?
A. Symmetry C. Color
B. Size D. Reaction to light.

38. Based on the information you gathered from the patient, you write a nursing diagnosis. Which of the following
is NOT a well-written nursing diagnosis?
A. Disturbed sensory perception related to cerebral injury.
B. Fatigue related to cerebral injury.
 C. Acute confusion related to altered cerebral blood-flow.
D. Lethargy related to non-specific cause.

39. Based on the nursing diagnosis, you record an evaluation of the outcomes. Which outcome is NOT well-
written? The patient will _______.
A. rest as needed.
B. be conscious, oriented and will perform own self-care.
C. have functional sensory status.
D. feel lethargic.

40. You are aware that the primary purpose(s) of documentation are the following: EXCEPT: To________.
A. allow the nurse to express his or her opinion on patient care.
B. provide legal protection for the nurse in case of lawsuit.
C. collect data to improve quality of nursing care.
D. communicate patient information to other members of the health team.

Situation - Nurse Luisa is assigned in the coronary care unit of a tertiary' hospital. She reviews the cardiovascular
system before caring for patients with heart diseases.
41. Given a set of statements regarding the physiology of the cardiovascular system, which of the following
statements is TRUE?
A. When a person has heart muscle disease, the heart muscles stretches as far as is necessary in order to
maintain good function.
B. The heart rate increases when the parasympathetic system is stimulated.
C. The QRS interval on the electrocardiogram represents the electrical impulses passing through the
ventricles.
D. When there is a decrease in stroke volume, the heart rate decreases.

42. Nurse Luisa collects data from a patient with primary diagnosis of heart failure. The patient reports that he has
experienced the following disorders. Which disorder does NOT precipitate heart failure?
A. recent upper respiratory infections C. nutritional anemia
B. thyroid disorders D. peptic ulcer disease

43. Nurse Luisa has a patient admitted for palpitations and mild shortness of breath. An electrocardiogram (ECG)
was taken. The results revealed a normal P wave, P-R interval, and QRS complex with a regular rhythm and a rate
of 108 beats per minute. Nurse Luisa recognizes this cardiac dysrhythmia as_________.
A. Sinus dysrhythmia C. Sinus tachycardia
B. Supraventricular tachycardia D. Ventricular tachycardia

44. The electrical activity of the patient's heart is being continuously monitored. Suddenly the patient has a short
burst of ventricular tachycardia followed by ventricular fibrillation. Nurse Luisa should IMMEDIATELY_________:
A. Run to the nurse's station quickly and call a code.
B. Administer atropine as ordered.
C. Prepare the patient for surgical placement of a pacemaker.
D. Call for help and initiate Cardiopulmonary resuscitation.

45. Nurse Luisa attends to a patient who has continuous ECG monitoring. She observes that the monitor shows
that the rhythm has changed to ventricular tachycardia. Which of the following interventions is the FIRST action by
the nurse?
A. Quickly assess the level of consciousness, blood pressure, and pulse.
B. Administer a precordial thump.
C. Administer intravenous lidocaine following emergency protocol.
D. Quickly obtain a defibrillator and defibrillate the patient.
Situation - An alert 67-year-old woman with diabetes mellitus is discharge from the hospital. A referral is made to a
community agency. You are asked to reinforce the teaching program started in the hospital. The patient is using
sulfonylurea compound tolbutamide ( Orinase ).

46. When the patient turned 69 years old, Orinase was discontinued and NPH insulin is prescribed for her. After
several months, she is determined to be suffering from the Somogyi effect. Which of the following conditions
mostly likely result when the patient is receiving too much insulin.
A. Developing an elevation of the blood glucose level
B. Producing even more insulin
C. Becoming resistant to insulin
D. Conserving excessive amount of fluid

47. A few days later, a patient comes into the emergency department via ambulance stretcher and reveals a work-
up a blood sugar level at 800mg/ dl, ketones are absent in the urine, she is dehydrated, and has an altered mental
status. Based on the data, the patient is most likely suffering from what specific medical condition?
A. Hyperosmolar nonketotic coma ( HNKC )
B. Diabetic retinopathy
C. Acute renal failure
D. Diabetic ketoacidosis ( DKA )

48. Upon interview, the patient reported that she often felt nauseated, restless respired a lot, felt fatigued, and
was often hungry when she was younger, what do these signs indicate?
A. Diabetic nephropathy C. Hypoglycemia
B. Hyperglycemia D. Diabetic retinopathy

49. Upon further assessment, you noticed that she had many scratches on her right ankle, a resulting infection and
cellulitis. When you ask her about the scratches the patient states “Oh my cat must have been using my leg as a
scratching post again and I did not even feel it.” Which diabetic complications suspect the patient to have?
A. Neuropathy C. Retinopathy
B. Macroangiopathy D. Ephropathy

50. You should check the patient suspect disturbed through processes related to depressed metabolism and
altered cardiovascular and respiratory status. What is the rationale for orienting the patient to time, place, date,
and events?
A. Shows improve cognitive functioning.
B. Provides reality orientation to patient.
C. Permits evaluation of the effectiveness of treatment.
D. Lets the patient identify the time, place, date, and events correctly.

Situation – Mary, a hairstylist, is experiencing peri-umbilical pain, feeling feverish and nauseated while at work. She
was rushed to the hospital as the pain is becoming intense at the right lower quadrant of the abdomen. She
was advised by the ER physician to be admitted for further work – up.

51. Nurse Ella admitted the patient and started to do her assessment. What sign is elicited by the nurse when a
deep palpitation of the left iliac fossa is done and causes pain on the right iliac fossa of the patient?
A. Obturator sign C. Psoas sign
B. Blumberg sign D. Rovsing sign

52. After a thorough physical examination, laboratory and diagnostic tests, the physician ordered an emergency
open appendectomy due to a suspected ruptured appendicitis. This is done to prevent which of the following
MAJOR complication?
A. Thrombosis C. Perforation
B. Sepsis D. Bleeding
53. The nurse prepares the patient for surgery. The overall goals by the surgical team for the patient going for
operation include which of the following?
I. Relief of pain III. Reducing anxiety reaction
II. Preventing fluid volume deficit IV. Eliminating infection
A. I, II, III, & IV C. III & IV
B. I, II, & III D. I & II

54. As a safety alert, which of the following nursing measures should be AVOIDED by the nurse prior to
appendectomy?
A. Observe nothing by mouth C. Removal of nail polish
B. Administration enema D. Instruct to urinate

55. In wound care management, the nurse is aware NOT to perform which of the following intervention?
A. Allow the wound to drain freely. C. Application of cold pack solutions
B. Maintenance of an acidic or neutral PH D. Maintenance for moist wound environment

Situation 17 – Mr. Lam, a 44-year-old, male obese, married was rushed to the Emergency room because of feeling
nauseated, with shortness of breath and severe chest pain radiating to the back.
56. As a nurse, what is your PRIORITY step to be done in this situation?
A. Palpate the point of maximal impulse.
B. Inspect the nail bed if cyanotic.
C. Take the vital signs and report to the physician.
D. Auscultate the chest for murmurs.

57. A 12 lead EKG was ordered by the physician. Which finding in the EKG is suggestive evidence that the patient
has Myocardial infarction (MI)?
A. Prominent segment elevation C. Peaked P wave
B. ST segment elevation D. Minimal QRS wave

58. The physician confirmed that the patient is suffering from MI. She was advised to be hospitalized and was given
streptokinase. Which of the following is the DESIRED effect of the drug?
A. Dissolve clot formation C. Prevent dysrhythmia
B. Reduce tissue damage of the heart D. Reduce edema formation

59. As a nurse you are aware that the heart muscles damage after an attack without treatment becomes
permanent within ______ hours?
A. 7-9 C. 4-6
B. 10-12 D. 1-3

60. In designing a care plan, which modifiable risk factors have to be emphasized to the patient to prevent for
another heart attack to happen?
1. Smoking
2. High blood pressure
3. high cholesterol
4. over weight
A. 1, 2, & 3 C. 1 & 2
B. 3 & 4 D. 1, 2, 3, & 4