1.

A 42-year-old patient is admitted to the hospital after sustaining

multiple burns. The patient's arm is white, leathery, and does not
blanch. Based on this description, what is the depth of injury?

A. Superficial
B. Superficial partial thickness
C. Deep partial thickness
D. Full thickness burn

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2. A 25-year-old patient was admitted with a complete C7 transection
of the spinal cord injury. What must the nurse include in the care plan
of this patient during the immediate post-injury period?

A. Diaphragmatic pacing
B. Prevention of complications of autonomic dysreflexia.
C. Ventilatory support.
D. Bladder and bowel training

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3. A client is scheduled for surgery later in the day. The provider is
very busy with another surgery and asks the nurse to obtain informed
consent. How should the nurse proceed?

A. Inform the provider that the provider must legally obtain informed
consent from the client.
B. Delegate the task to the charge nurse.
C. Ask the physician assistant to obtain the consent.
D. Explain the risks and alternatives of the surgery and obtain written
consent.

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4. A client has moderate-to-severe hypotonic extracellular fluid loss.
Which IV fluids can be administered to correct the fluid balance?

A. 10% dextrose in water.

B. Lactated Ringer's solution
C. 5% dextrose in 0.225% saline
D. 0.9% normal saline

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5. Based on the Maslow hierarchy of needs, which of the following
should be a nurse’s first priority?

A. Administering a scheduled beta blocker to a client.

B. Allowing a client’s spouse to visit the client.
C. Providing emotional support to a family member.
D. Starting tube feeding on an unconscious client.

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6. The nurse is assessing a client who has returned from surgery. After
reviewing the client’s lab results, the nurse should notify the provider
of which of the following?

A. Sodium 144 mEq/L

B. Potassium 3.1 mEq/L
C. Magnesium 1.4 mEq/L
D. Phosphorus 3.8 mg/dL

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7. The nurse is reviewing the metabolic panel of an adult client with
sepsis. With which of the following BUN and creatinine lab values
does the nurse suspect acute renal failure?

A. BUN 9 mg/dL and creatinine 0.8 mg/Dl

B. BUN 18 mg/dL and creatinine 1.1 mg/Dl
C. BUN 38 mg/dL and creatinine 1.2 mg/dL
D. BUN 42 mg/dL and creatinine 3.4 mg/dL

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8. A home health nurse is caring for an older adult client with
advanced dementia. The client has a bruised eye and abdomen and
seems withdrawn. The nurse suspects abuse, but the client is unable
to communicate due to the dementia. What should the nurse
do next?

A. Keep an eye on the situation until there is proof.

B. Notify the client’s family.
C. Ask the client to report the problem.
D. Report the suspected abuse to the local authorities.

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9. The nurse is caring for a teenage client recently diagnosed with
celiac disease. When providing discharge instructions, the nurse
should tell the client to avoid which of the following?

A. Rice
B. Milk
C. Wheat
D. Cheese

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10. The nurse is caring for a 35-year-old patient with a history of
fibrocystic disease of the breasts. Which of the following indicates
that the patient understands the nature of this disorder?

A. Symptoms are likely to occur in the winter season

B. Most women with the condition discover symptoms in spring time
C. Symptoms are more likely to occur after menses
D. Symptoms are more likely to occur before menses

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11. The nurse is caring for a client with thalassemia major. What body
appearance is associated with this condition?
A. Frontal bossing and upper teeth protrusion
B. Hypergonadism.
C. Marked reddened appearance of the skin
D. Sunken abdomen

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12. An 80-year-old patient with hemiplegia was transferred by the nurse
aide from a sitting position on the bed to the wheelchair. Which of the
following interventions needs correction by the home health nurse who
was observing the aide?

A. Pulling the patient to a standing position by grasping the patient's

arms.
B. Telling the patient to lean forward before standing
C. Assisting the patient to stand by bracing the affected knee and foot
D. Moving the patient toward his unaffected side

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13. A patient arrives at the clinic for her annual pelvic exam and a
refill on her oral contraceptives. The nurse understands the
importance of assessing which of the following for a patient on oral
contraceptives?

A. BUN and creatinine

B. Blood pressure
C. Blood glucose
D. Oxygen saturation

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14. A nurse is preparing to administer IV fluids that will not alter
serum osmolarity or pull fluid into or out of the intravascular space.
Which fluid should the nurse administer?

A. Hypotonic
B. Hypertonic
C. Isotonic
D. Supratonic

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15. Upon the delivery of a newborn, the APGAR score of the child
within the first minute was five, this means:

A. Guarded and may need clearing of airway.

B. Serious danger and needs resuscitation
C. Good and just needs suctioning
D. Strong and doesn't need any clearing of airways

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16. An elderly patient is prescribed ciprofloxacin for the treatment of
a urinary tract infection (UTI). The nurse should inform the patient of
which potentially serious adverse effect?

A. Ototoxicity
B. Atrial fibrillation
C. Constipation
D. Tendon rupture

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17. A toddler-age client is admitted to the emergency room after
accidentally ingesting a bottle of iron supplements five hours ago.
Which of the following medications can the nurse expect the
physician to order?

A. Activated charcoal
B. Naloxone
C. Deferoxamine
D. Ipecac

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18. A 72‑year-old hospital client is explaining to the nurse that, after a
long life of many accomplishments, she is ready to die. The nurse
understands that the client has met which developmental stage?

A. Autonomy
B. Integrity
C. Isolation
D. Despair

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19. A client has an elevated serum osmolality and a serum sodium
level of 159 mEq/L. Which of the following IV fluids is
the most beneficial?

A. Dextrose 5% in water
B. Dextrose 10% in water
C. Dextrose 5% in normal saline
D. Dextrose 5% in lactated Ringer solution

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20. There are four clients with infections in the ED and only one private
room is available. Which among the clients is the most appropriate to
occupy the private room?

A. A client with a cough who may have tuberculosis

B. B. A client with toxic shock syndrome and a temperature of 102.4°F
(39.1°C)
C. A client with diarrhea caused by C. difficile
D. A client with a wound infected with Vancomycin-resistant
enterococci (VRE)

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21. The nurse is assigned to a client who has been diagnosed with
disseminated herpes zoster. Which PPE will the nurse plan to use
when preparing to assess the client? Select all that apply.

A. Gloves
B. Goggles
C. Gown
D. N95 respirator
E. Surgical face mask
F. Shoe covers

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22. The charge nurse is delegating tasks to her subordinates in the
medical unit. Which infection control activity should she assign to an
experienced nursing assistant?

A. Asking clients about the use of immunosuppressant medications.

B. Demonstrating correct hand washing to client visitors.
C. Disinfecting blood pressure cuffs after clients are discharged.
D. Screening clients for upper respiratory tract symptoms.

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23. In acid-base balance, the normal plasma PCO2 and bicarbonate
levels are disturbed. Match the changes in this parameter with the
disorders in the given choices: Low plasma PaCO2

A. Metabolic Acidosis
B. Respiratory Alkalosis
C. Metabolic Alkalosis
D. Respiratory Acidosis

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24. The physician orders an IV with heparin at 700 units/hour. You
have a bag with 100 units/mL of solution. How many milliliters per
hour will you set on the IV infusion controller?

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25. A primary healthcare provider ordered ceftriaxone (Rocephin) for
a 4-year old child with lower respiratory tract infection. The dose
required is 20 mg/kg/day divided twice a day, administered per dose
via IV. The child’s weight is 29 lbs. The drug comes prediluted in a
concentration of 10mg/ml. How much of the medication will you
administer in mL?

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26. A female client is brought to the emergency department with
second-and third-degree burns on the left arm, left anterior leg, and
anterior trunk. Using the Rule of Nines, what is the total body surface
area that has been burned?

A. 18%
B. 27%
C. 30%
D. 36%

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27. A male client is diagnosed with herpes simplex. Which statement
about herpes simplex infection is true?

A. During early pregnancy, herpes simplex infection may cause

spontaneous abortion or premature delivery.
B. Genital herpes simplex lesions are painless, fluid-filled vesicles
that ulcerate and heal in 3 to 7 days.
C. Herpetic keratoconjunctivitis usually is bilateral and causes
systemic symptoms.
D. A client with genital herpes lesions can have sexual contact but
must use a condom.

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28. A female client with a severe staphylococcal infection is receiving
the aminoglycoside gentamicin sulfate (Garamycin) by the I.V. route.
The nurse should assess the client for which adverse reaction to this
drug?

A. Aplastic anemia
B. Ototoxicity
C. Cardiac arrhythmias
D. Seizures

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29. The clinic nurse is preparing to test the visual acuity of a client using
a Snellen chart. Which of the following identifies the accurate procedure
for this visual acuity test?

A. Both eyes are assessed together, followed by the assessment of the

right and then the left eye.
B. The right eye is tested followed by the left eye, and then both eyes
are tested.
C. The client is asked to stand at a distance of 40ft. from the chart and
is asked to read the largest line on the chart.
D. The client is asked to stand at a distance of 40ft from the chart and
to read the line that can be read 200 ft away by an individual with
unimpaired vision.
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30. Tonometry is performed on the client with a suspected diagnosis
of glaucoma. The nurse analyzes the test results as documented in the
client’s chart and understands that normal intraocular pressure is:

A. 2-7 mmHg
B. 10-21 mmHg
C. 22-30 mmHg
D. 31-35 mmHg

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31. While assessing a one-month-old infant, which of the findings
warrants further investigation by the nurse? Select all that apply.

A. Abdominal respirations
B. Irregular breathing rate
C. Inspiratory grunt
D. Increased heart rate with crying
E. Nasal flaring
F. Cyanosis
G. Asymmetric chest movement

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32. A 32-year-old pregnant woman comes to the clinic for her
prenatal visit. The nurse gathers data about her obstetric history,
which includes 3-year-old twins at home and a miscarriage 10 years
ago at 12 weeks gestation. How would the nurse accurately document
this information?

GTPAL - ?

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33. Which complication of cardiac catheterization should the nurse
monitor for in the initial 24 hours after the procedure?

A. Angina at rest
B. Thrombus formation
C. Dizziness
D. Falling blood pressure

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34. A client is admitted to the emergency room with renal calculi and
is complaining of moderate to severe flank pain and nausea. The
client’s temperature is 100.8 degrees Fahrenheit. The priority nursing
goal for this client is:

A. Maintain fluid and electrolyte balance

B. Control nausea
C. Manage pain
D. Prevent urinary tract infection

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35. The hospital has sounded the call for a disaster drill on the evening
shift. Which of these clients would the nurse put first on the list to be
discharged in order to make a room available for a new admission?

A. A middle-aged client with a history of being ventilator dependent for

over seven (7) years and admitted with bacterial pneumonia five days
ago.
B. A young adult with diabetes mellitus Type 2 for over ten (10) years
and admitted with antibiotic-induced diarrhea 24 hours ago.
C. An elderly client with a history of hypertension,
hypercholesterolemia, and lupus, and was admitted with Stevens-
Johnson syndrome that morning.
D. An adolescent with a positive HIV test and admitted for acute cellulitis
of the lower leg 48 hours ago.
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36. A 3-year-old child was brought to the pediatric clinic after the
sudden onset of findings that include irritability, thick muffled voice,
croaking on inspiration, hot to touch, sit leaning forward, tongue
protruding, drooling, and suprasternal retractions. What should the
nurse do first?

A. Prepare the child for X-ray of upper airways

B. Examine the child’s throat
C. Collect a sputum specimen
D. Notify the healthcare provider of the child’s status

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37. A registered nurse who usually works in a spinal rehabilitation unit is
floated to the emergency department. Which of these clients should the
charge nurse assign to this RN?

A. A middle-aged client who says “I took too many diet pills” and “my
heart feels like it is racing out of my chest.”
B. A young adult who says “I hear songs from heaven. I need money for
beer. I quit drinking two (2) days ago for my family. Why are my arms
and legs jerking?”
C. An adolescent who has been on pain medications terminal cancer with
an initial assessment finding pupils and a relaxed respiratory rate of 11
D. An elderly client who reports having taken a “large crack hit” 10
minutes prior to walking into the emergency room.
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38. The home health nurse visits a male client to provide wound care
and finds the client lethargic and confused. His wife states he fell
down the stairs two (2) hours ago. The nurse should

A. Place a call to the client’s health care provider for instructions

B. Send him to the emergency room for evaluation
C. Reassure the client’s wife that the symptoms are transient
D. Instruct the client’s wife to call the doctor if his symptoms become
worse

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39. A patient who is scheduled for a bone marrow transplant is
concerned about the cost of the procedure. How should the nurse
respond?

• A. Ask the physician to discuss the financial options

• B. Inform the patient that he/she will be responsible for the hospital
bill
• C. Inform the patient that the hospital will cover all the costs
• D. Notify the social worker and ask that he/she speak with the
patient

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40. A newly married client is experiencing amenorrhea, nausea, and
vomiting. Upon consulting a healthcare provider, the client finds out
she is pregnant. The client is very excited while also feeling afraid of
the impending situation of her pregnancy. Which psychological state
of pregnancy has the client achieved?

A. Preparing for the end of the pregnancy

B. Accepting the pregnancy
C. Accepting the baby
D. Preparing for parenthood

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41. A middle-age client in the surgical ward has a blood pressure of
128/72 mm Hg, a heart rate of 125 beats/min, a respiratory rate of
32 breaths/min, and a temperature of 99.1° F (37.28° C). The client
reports severe shortness of breath. What does the nurse assess first?

A. Pupil reactivity
B. Breath sounds
C. Heart sounds
D. Peripheral circulation

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42. A nurse is teaching the parents of a newborn proper post-
circumcision care. Which of the following should the nurse not
include?

A. Report any amount of blood found on the diaper

B. Lubricating ointment should be applied to the penis after each
diaper change
C. 2 to 5 days of site care is required after discharge
D. The patient cannot be discharged until after voiding

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43. A nurse is viewing the cardiac monitor in a client’s room and notes
that the client has just gone into ventricular tachycardia. The client is
awake and alert and has good skin color. The nurse would prepare to
do which of the following?

A. Immediately defibrillate
B. Prepare for pacemaker insertion
C. Administer amiodarone intravenously
D. Administer epinephrine (Adrenaline) intravenously

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44. A nurse is reviewing the lab report of a pediatric client suspected
of having chronic glomerulonephritis. Along with proteinuria, which
lab findings should the nurse expect?

A. Elevated blood urea nitrogen (BUN), creatinine and uric acid leves
B. Decreased BUN, creatinine, and uric acid levels
C. Elevated BUN and creatinine and decreased uric acid levels
D. Decreased BUN and elevated creatinine and uric acid levels.

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45. A client who is experiencing paranoid delusions asks a nurse to
turn off the television stating. “It controls my thoughts.” Which is the
most appropriate intervention by the nurse?

A. Refuse the request in order to show control over the client.

B. Comply with the request in order to lessen the client’s
concerns/fears.
C. Comply with the request in order to show an understanding of
client’s concerns/fears.
D. Refuse the request to avoid supporting the client’s delusions.

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46. A 4 years old girl has been hospitalized for moderate burns. A
nurse plans care based on knowing that the most developmentally
appropriate response to the injuries and resultant treatment for a
child this age is likely to be?
A. Anger and hostility while trying to not appear young.
B. Pushing boundaries to further autonomy
C. Wanting clear instructions regarding details of treatment
D. Believing that she is responsible for the bad things that are
happening to her

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