FUNDAMENTALS OF NURSING

PRACTICE QUESTIONS

Multiple Choice/With Answers and Rationale 1000+

[Link] nurse should assess the activity tolerance of the patient with which of the following conditions?
A. Diabetes mellitus
B.) Diarrhea
C. Anemia
D. Kidney stones
Ans: C Activity intolerance is an appropriate nursing diagnosis for a client with anemia. IN anemia, there
is low oxygen-carrying capacity of the blood, so the client experiences weakness and fatigue

2. According to Maslow’s hierarchy of needs, which of the following is a basic physiologic need after
oxygen?
A. Water B.) Freedom from infection
C. Love and belongingness
D. Self-esteem
Ans: A Water is next to oxygen in the hierarchy of physiologic needs for survival8.) Mrs. Sy, diagnosed
with cancer of the breast, is scheduled to undergo chemotherapy.

[Link] should the nurse deal with the topic of hair loss with client?
A. Discuss about hair loss as it occurs
B. Provide reading material about chemotherapy
C. Acknowledge that hair loss may be a difficult side effect and explore the patient’s feeling
about this
D. Give the patient information about headscarf, hats or wigs
Ans: C Focusing on the feelings of the client regarding hair loss is therapeutic. Discussing about wigs,
headscarf, and hats will be dealt with later 

4. The following are characteristics of basic human needs EXCEPT:

A. Priorities are uniform to all individuals
B. Needs may be met in different ways
C.) Needs are interrelated
D.) Needs may be deferred

Ans: A Priorities vary from individual to individual, according to stage of growth and development, life
situations and other factors

5. Which of the following needs is considered by the nurse when she implements reverseisolation for the
client with leukemia?
A.) Physiologic need
B.) Safety and security
C.) Love and belongingness
D.) Self esteem

Ans: B The client with leukemia has low resistance to infections. Protecting him from infection by
implementing reverse or protective isolation technique meets his need for safety and security

6. Who among the following clients should be attended first by the nurse?
A. The client with cough and colds
B. The client with pain on the chest
C. The client with fever due to infection
D. The client who is for discharge
Ans: B

7. All of the following can cause tachycardia except:

A. Fever
B. Exercise
C. Sympathetic nervous system stimulation
D. Parasympathetic nervous system stimulation
Answer: D. Parasympathetic nervous system stimulation
 Option D: Parasympathetic nervous system stimulation of the heart decreases the heart rate as
well as the force of contraction, rate of impulse conduction and blood flow through the coronary
vessels. Fever, exercise, and sympathetic stimulation all increase the heart rate.

8. A nurse who uses critical thinking in the decision-making process providing effective quality care to
individuals is known as a(n):
A. Advanced care Nurse B. Clinical decision maker
C. Evidence-based practitioner D. Multidiscipline practice

9. The document that assures clients that they will receive quality care from a competent nurse is the:
A. Standards of care B. Nurse Practice Act
C. Accreditation certification D. National council licensure

10. The regulation of licensure and practice of nursing is accomplished by the:

A. NCLEX-RN B. Certification examination
C. Nurse Practice Act D. ANA Congress for Nursing

11. A nurse who has been in a position on the same unit for 2 years understands the organization and
care of the clients on that nursing unit. Benner defines this nurse as able to anticipate nursing care and to
formulate long-range goals; this nurse is given the title:
A. Expert B. Proficient C. Competent D. Advanced beginner

12. An advanced practice nurse (APN) is the nurse most independently functioning of all professional
nurses. All of the following are examples of clinically focused APNs except:
A. Nurse specialist B. Nurse practitioner
C. Case manager D. Care provider

13. An APN is pursuing a job change. Which of the following positions would the APN be unable to pursue
without meeting additional criteria?
A. Nurse educator B. Certified registered nurse anesthetist
C. Nurse Manager D. Case manager

14. Which of the following is the meaning of PRN?

A. when advice B. Immediately
C. When necessary D. Now

15. Using the principles of standard precautions, the nurse would wear gloves in what nursing
interventions?
A. Providing a back massage B. Feeding a client
C. Providing hair care D .Providing oral hygiene

16. The nurse is preparing to take vital sign in an alert client admitted to the hospital with dehydration
secondary to vomiting and diarrhea. What is the best method used to assess the client’s temperature?
A .Oral B. Axillary C. Radial D. Heat sensitive tape

17. Which of the following actions should the nurse take to use a wide base support when assisting a
client to get up in a chair?
A .Bend at the waist and place arms under the client’s arms and lift
B .Face the client, bend knees and place hands on client’s forearm and lift
C .Spread his or her feet apart
D .Tighten his or her pelvic muscles
18. A client had oral surgery following a motor vehicle accident. The nurse assessing the client finds the
skin flushed and warm. Which of the following would be the best method to take the client’s body
temperature?
A. Oral B. Axillary C. Arterial line D. Rectal

19. 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 C. Supine D. Trendelenburg

20. 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 the lights on at all time
C. Keep side rails up at all time
D. Keep all equipment out of view

21. 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

22. It is best describe as a systematic, rational method of planning and providing nursing care for
individual, families, group and community
A. Assessment B. Nursing Process
C. Diagnosis D. Implementation

23.. Exchange of gases takes place in which of the following organ?

A. Kidney B. Lungs C. Liver D. Heart

[Link] Chamber of the heart that receives oxygenated blood from the lungs is the?
A. Left atrium B. Right atrium
C. Left ventricle D. Right ventricle

25. . A muscular enlarge pouch or sac that lies slightly to the left which is used for temporary storage of
food…
A. Gallbladder B. Urinary bladder C .Stomach D. Lungs

26. The ability of the body to defend itself against scientific invading agent such as baceria, toxin, viruses
and foreign body
A. Hormones B. Secretion C. Immunity D. Glands

27. Hormones secreted by Islets of Langerhans

A .Progesterone B. Testosterone C. Insulin D. Hemoglobin

28. It is a transparent membrane that focuses the light that enters the eyes to the retina.
A .Lens B. Sclera C. Cornea D. Pupils

29. Which of the following is included in Orem’s theory?

A. Maintenance of a sufficient intake of air B. Self perception
C. Love and belonging D. Physiologic needs

30. Which of the following cluster of data belong to Maslow’s hierarchy of needs
A. Love and belonging B. Physiologic needs
C. Self actualization D. All of the above

31.. A nurse obtained a client’s pulse and found the rate to be above normal. The nurse documents these
findings as:
A .Hyper pyrexia B. Arrythmia C. Tachycardia D. Tachypnea
32. This is characterized by severe symptoms relatively of short duration.
A. Chronic Illness
B. Acute Illness
C. Pain
D. Syndrome

33 Which of the following is the nurse’s role in the health promotion

A. Health risk appraisal
B. Teach client to be effective health consumer
C. Worksite wellness
D. None of the above

34. It is described as a collection of people who share some attributes of their lives.
A. Family
B. Illness
C. Community
D. Nursing

35. Five teaspoon is equivalent to how many milliliters (ml)?

A. 30 ml
B. 25 ml
C. 12 ml
D. 22 ml

36. 1800 ml is equal to how many liters?

A. 1.8
B. 18000
C. 180
D. 2800

37. Which of the following is the abbreviation of drops?

A. Gtt.
B. Gtts.
C. Dp.
D. Dr.

38. The abbreviation for micro drop is…

A. µgtt
B. gtt
C. mdr
D. mgts

39. Which of the following is the meaning of PRN?

A. When advice
B. Immediately
C. When necessary
D. Now

40. Which of the following is the appropriate meaning of CBR?

A. Cardiac Board Room
B. Complete Bathroom
C. Complete Bed Rest
D. Complete Board Room

41. 1 tsp is equals to how many drops?

A. 15
B. 60
C. 10
D. 30
42. 20 cc is equal to how many ml?
A. 2
B. 20
C. 2000
D. 20000

43. 1 cup is equals to how many ounces?

A. 8
B. 80
C. 800
D. 8000

44. The nurse must verify the client’s identity before administration of medication. Which of the following
is the safest way to identify the client?
A. Ask the client his name
B. Check the client’s identification band
C. State the client’s name aloud and have the client repeat it
D. Check the room number

45. The nurse prepares to administer buccal medication. The medicine should be placed…
A. On the client’s skin
B. Between the client’s cheeks and gums
C. Under the client’s tongue
D. On the client’s conjunctiva

46. The nurse administers cleansing enema. The common position for this procedure is…
A. Sims left lateral
B. Dorsal Recumbent
C. Supine
D. Prone

47. A client complains of difficulty of swallowing, when the nurse try to administer capsule medication.
Which of the following measures the nurse should do?
A. Dissolve the capsule in a glass of water
B. Break the capsule and give the content with an applesauce
C. Check the availability of a liquid preparation
D. Crash the capsule and place it under the tongue

48. Which of the following is the appropriate route of administration for insulin?
A. Intramuscular
B. Intradermal
C. Subcutaneous
D. Intravenous

49. The nurse is ordered to administer ampicillin capsule TIP p.o. The nurse shoud give the medication…
A. Three times a day orally
B. Three times a day after meals
C. Two time a day by mouth
D. Two times a day before meals

50. Back Care is best described as:

A. Caring for the back by means of massage
B. Washing of the back
C. Application of cold compress at the back
D. Application of hot compress at the back

51. It refers to the preparation of the bed with a new set of linens
A. Bed bath
B. Bed making
C. Bed shampoo
D. Bed lining

52. Which of the following is the most important purpose of handwashing

A. To promote hand circulation
B. To prevent the transfer of microorganism
C. To avoid touching the client with a dirty hand
D. To provide comfort

53. What should be done in order to prevent contaminating of the environment in bed making?
A. Avoid funning soiled linens
B. Strip all linens at the same time
C. Finished both sides at the time
D. Embrace soiled linen

54 The most important purpose of cleansing bed bath is:

A. To cleanse, refresh and give comfort to the client who must remain in bed
B. To expose the necessary parts of the body
C. To develop skills in bed bath
D. To check the body temperature of the client in bed

55. Which of the following technique involves the sense of sight?

A. Inspection
B. Palpation
C. Percussion
D. Auscultation

56. The first techniques used examining the abdomen of a client is:
A. Palpation
B. Auscultation
C. Percussion
D. Inspection

57. A technique in physical examination that is use to assess the movement of air through the
tracheobronchial tree:
A. Palpation
B. Auscultation
C. Inspection
D. Percussion

58 An instrument used for auscultation is:

A. Percussion-hammer
B. Audiometer
C. Stethoscope
D. Sphygmomanometer

59. Resonance is best describe as:

A. Sounds created by air filled lungs
B. Short, high pitch and thudding
C. Moderately loud with musical quality
D. Drum-like

60. The best position for examining the rectum is:

A. Prone
B. Sim’s
C. Knee-chest
D. Lithotomy
61. It refers to the manner of walking
A. Gait
B. Range of motion
C. Flexion and extension
D. Hopping

62. The nurse asked the client to read the Snellen chart. Which of the following is tested:
A. Optic
B. Olfactory
C. Oculomotor
D. Trochlear

63. Another name for knee-chest position is:

A. Genu-dorsal
B. Genu-pectoral
C. Lithotomy
D. Sim’s
64. The nurse prepare IM injection that is irritating to the subcutaneous tissue. Which of the following is
the best action in order to prevent tracking of the medication
A. Use a small gauge needle
B. Apply ice on the injection site
C. Administer at a 45° angle
D. Use the Z-track technique

[Link] most appropriate nursing order for a patient who develops dyspnea and shortness of breath would
be…
A. Maintain the patient on strict bed rest at all times
B. Maintain the patient in an orthopneic position as needed
C. Administer oxygen by Venturi mask at 24%, as needed
D. Allow a 1 hour rest period between activities

66.. The nurse observes that Mr. Adams begins to have increased difficulty breathing. She elevates the
head of the bed to the high Fowler position, which decreases his respiratory distress. The nurse
documents this breathing as:
A. Tachypnea
B. Eupnca
C. Orthopnea
D. Hyperventilation

67. The physician orders a platelet count to be performed on Mrs. Smith after breakfast. The nurse is
responsible for:
A. Instructing the patient about this diagnostic test
B. Writing the order for this test
C. Giving the patient breakfast
D. All of the above

68.. Mrs. Mitchell has been given a copy of her diet. The nurse discusses the foods allowed on a 500-mg
low sodium diet. These include:
A. A ham and Swiss cheese sandwich on whole wheat bread
B. Mashed potatoes and broiled chicken
C. A tossed salad with oil and vinegar and olives
D. Chicken bouillon

69.. The physician orders a maintenance dose of 5,000 units of subcutaneous heparin (an anticoagulant)
daily. Nursing responsibilities for Mrs. Mitchell now include:
A. Reviewing daily activated partial thromboplastin time (APTT) and prothrombin time.
B. Reporting an APTT above 45 seconds to the physician
C. Assessing the patient for signs and symptoms of frank and occult bleeding
D. All of the above

[Link] four main concepts common to nursing that appear in each of the current conceptual models are:
A. Person, nursing, environment, medicine
B. Person, health, nursing, support systems
C. Person, health, psychology, nursing
D. Person, environment, health, nursing

71. In Maslow’s hierarchy of physiologic needs, the human need of greatest priority is:
A. Love
B. Elimination
C. Nutrition
D. Oxygen

72. The family of an accident victim who has been declared brain-dead seems amenable to organ
donation. What should the nurse do?

A .Discourage them from making a decision until their grief has eased
B .Listen to their concerns and answer their questions honestly
C .Encourage them to sign the consent form right away
D. Tell them the body will not be available for a wake or funeral

73. A new head nurse on a unit is distressed about the poor staffing on the 11 p.m. to 7 a.m. shift. What
should she do?
A. Complain to her fellow nurses
B. Wait until she knows more about the unit
C. Discuss the problem with her supervisor
D. Inform the staff that they must volunteer to rotate

74. Which of the following principles of primary nursing has proven the most satisfying to the patient and
nurse?
A. Continuity of patient care promotes efficient, cost-effective nursing care
B. Autonomy and authority for planning are best delegated to a nurse who knows the patient well
C. Accountability is clearest when one nurse is responsible for the overall plan and its implementation.
D. The holistic approach provides for a therapeutic relationship, continuity, and efficient
nursing care.

75. . If nurse administers an injection to a patient who refuses that injection, she has committed:
A. Assault and battery
B. Negligence
C. Malpractice
D. None of the above

76.. If patient asks the nurse her opinion about a particular physicians and the nurse replies that the
physician is incompetent, the nurse could be held liable for:
A. Slander
B. Libel
C. Assault
D. Respondent superior

77. A registered nurse reaches to answer the telephone on a busy pediatric unit, momentarily turning
away from a 3 month-old infant she has been weighing. The infant falls off the scale, suffering a skull
fracture. The nurse could be charged with:
A. Defamation
B. Assault
C. Battery
D. Malpractice

78.. Which of the following is an example of nursing malpractice?

A. The nurse administers penicillin to a patient with a documented history of allergy to the
drug. The patient experiences an allergic reaction and has cerebral damage resulting from
anoxia.
B. The nurse applies a hot water bottle or a heating pad to the abdomen of a patient with abdominal
cramping.
C. The nurse assists a patient out of bed with the bed locked in position; the patient slips and
fractures his right humerus.
D. The nurse administers the wrong medication to a patient and the patient vomits. This information
is documented and reported to the physician and the nursing supervisor.

79.. Which of the following signs and symptoms would the nurse expect to find when assessing an Asian
patient for postoperative pain following abdominal surgery?
A. Decreased blood pressure and heart rate and shallow respirations
B. Quiet crying
C. Immobility, diaphoresis, and avoidance of deep breathing or coughing
D. Changing position every 2 hours

80.. A patient is admitted to the hospital with complaints of nausea, vomiting, diarrhea, and severe
abdominal pain. Which of the following would immediately alert the nurse that the patient has bleeding
from the GI tract?
A. Complete blood count
B. Guaiac test
C. Vital signs
D. Abdominal girth

81. The correct sequence for assessing the abdomen is:

A. Tympanic percussion, measurement of abdominal girth, and inspection
B. Assessment for distention, tenderness, and discoloration around the umbilicus.
C. Percussions, palpation, and auscultation
D. Auscultation, percussion, and palpation

82. High-pitched gurgles head over the right lower quadrant are:
A. A sign of increased bowel motility
B. A sign of decreased bowel motility
C. Normal bowel sounds
D. A sign of abdominal cramping

83. A patient about to undergo abdominal inspection is best placed in which of the following positions?
A. Prone
B. Trendelenburg
C. Supine
D. Side-lying

84. . For a rectal examination, the patient can be directed to assume which of the following positions?
A. Genupecterol
B. Sims
C. Horizontal recumbent
D. All of the above

85. During a Romberg test, the nurse asks the patient to assume which position?
A. Sitting
B. Standing
C. Genupectoral
D. Trendelenburg

86. If a patient’s blood pressure is 150/96, his pulse pressure is:

A. 54
B. 96
C. 150
D. 246

87.. A patient is kept off food and fluids for 10 hours before surgery. His oral temperature at 8 a.m. is
99.8 F (37.7 C) This temperature reading probably indicates:
A. Infection
B. Hypothermia
C. Anxiety
D. Dehydration

88. Which of the following parameters should be checked when assessing respirations?
A. Rate
B. Rhythm
C. Symmetry
D. All of the above

89.. A 38-year old patient’s vital signs at 8 a.m. are axillary temperature 99.6 F (37.6 C); pulse rate, 88;
respiratory rate, 30. Which findings should be reported?
A. Respiratory rate only
B. Temperature only
C. Pulse rate and temperature
D. Temperature and respiratory rate

90.. All of the following can cause tachycardia except:

A. Fever
B. Exercise
C. Sympathetic nervous system stimulation
D. Parasympathetic nervous system stimulation

91. Palpating the midclavicular line is the correct technique for assessing
A. Baseline vital signs
B. Systolic blood pressure
C. Respiratory rate
D. Apical pulse

92. The absence of which pulse may not be a significant finding when a patient is admitted to the
hospital?
A. Apical
B. Radial
C. Pedal
D. Femoral

93.. Which of the following patients is at greatest risk for developing pressure ulcers?
A. An alert, chronic arthritic patient treated with steroids and aspirin
B. An 88-year old incontinent patient with gastric cancer who is confined to his bed at home
C. An apathetic 63-year old COPD patient receiving nasal oxygen via cannula
D. A confused 78-year old patient with congestive heart failure (CHF) who requires assistance to get
out of bed.

94. The physician orders the administration of high-humidity oxygen by face mask and placement of the
patient in a high Fowler’s position. After assessing Mrs. Paul, the nurse writes the following nursing
diagnosis: Impaired gas exchange related to increased secretions. Which of the following nursing
interventions has the greatest potential for improving this situation?
A. Encourage the patient to increase her fluid intake to 200 ml every 2 hours
B. Place a humidifier in the patient’s room.
C. Continue administering oxygen by high humidity face mask
D. Perform chest physiotherapy on a regular schedule

95. The most common deficiency seen in alcoholics is:

A. Thiamine
B. Riboflavin
C. Pyridoxine
D. Pantothenic acid

96. . Which of the following statement is incorrect about a patient with dysphagia?
A. The patient will find pureed or soft foods, such as custards, easier to swallow than water
B. Fowler’s or semi Fowler’s position reduces the risk of aspiration during swallowing
C. The patient should always feed himself
D. The nurse should perform oral hygiene before assisting with feeding.

97. . To assess the kidney function of a patient with an indwelling urinary (Foley) catheter, the nurse
measures his hourly urine output. She should notify the physician if the urine output is:
A. Less than 30 ml/hour
B. 64 ml in 2 hours
C. 90 ml in 3 hours
D. 125 ml in 4 hours

98.. Certain substances increase the amount of urine produced. These include:
A. Caffeine-containing drinks, such as coffee and cola.
B. Beets
C. Urinary analgesics
D. Kaolin with pectin (Kaopectate)

99. . A male patient who had surgery 2 days ago for head and neck cancer is about to make his first
attempt to ambulate outside his room. The nurse notes that he is steady on his feet and that his vision
was unaffected by the surgery. Which of the following nursing interventions would be appropriate?
A. Encourage the patient to walk in the hall alone
B. Discourage the patient from walking in the hall for a few more days
C. Accompany the patient for his walk.
D. Consuit a physical therapist before allowing the patient to ambulate

100. A patient has exacerbation of chronic obstructive pulmonary disease (COPD) manifested by
shortness of breath; orthopnea: thick, tenacious secretions; and a dry hacking cough. An appropriate
nursing diagnosis would be:
A. Ineffective airway clearance related to thick, tenacious secretions.
B. Ineffective airway clearance related to dry, hacking cough.
C. Ineffective individual coping to COPD.
D. Pain related to immobilization of affected leg.

101.. Mrs. Lim begins to cry as the nurse discusses hair loss. The best response would be:
A. “Don’t worry. It’s only temporary”
B. “Why are you crying? I didn’t get to the bad news yet”
C. “Your hair is really pretty”
D. “I know this will be difficult for you, but your hair will grow back after the completion of
chemotheraphy”

102. An additional Vitamin C is required during all of the following periods except:
A. Infancy
B. Young adulthood
C. Childhood
D. Pregnancy
103.. A prescribed amount of oxygen s needed for a patient with COPD to prevent:
A. Cardiac arrest related to increased partial pressure of carbon dioxide in arterial blood (PaCO2)
B. Circulatory overload due to hypervolemia
C. Respiratory excitement
D. Inhibition of the respiratory hypoxic stimulus

104.. After 1 week of hospitalization, Mr. Gray develops hypokalemia. Which of the following is the most
significant symptom of his disorder?
A. Lethargy
B. Increased pulse rate and blood pressure
C. Muscle weakness
D. Muscle irritability

105.. Which of the following nursing interventions promotes patient safety?

A. Asses the patient’s ability to ambulate and transfer from a bed to a chair
B. Demonstrate the signal system to the patient
C. Check to see that the patient is wearing his identification band
D. All of the above

106.. Studies have shown that about 40% of patients fall out of bed despite the use of side rails; this has
led to which of the following conclusions?
A. Side rails are ineffective
B. Side rails should not be used
C. Side rails are a deterrent that prevent a patient from falling out of bed.
D. Side rails are a reminder to a patient not to get out of bed

107. Examples of patients suffering from impaired awareness include all of the following except:
A. A semiconscious or over fatigued patient
B. A disoriented or confused patient
C. A patient who cannot care for himself at home
D. A patient demonstrating symptoms of drugs or alcohol withdrawal
108.. The most common injury among elderly persons is:
A. Atheroscleotic changes in the blood vessels
B. Increased incidence of gallbladder disease
C. Urinary Tract Infection
D. Hip fracture

109. The most common psychogenic disorder among elderly person is:
A. Depression
B. Sleep disturbances (such as bizarre dreams)
C. Inability to concentrate
D. Decreased appetite

110.. Which of the following vascular system changes results from aging?
A. Increased peripheral resistance of the blood vessels
B. Decreased blood flow
C. Increased work load of the left ventricle
D. All of the above

111. Which of the following is the most common cause of dementia among elderly persons?
A. Parkinson’s disease
B. Multiple sclerosis
C. Amyotrophic lateral sclerosis (Lou Gerhig’s disease)
D. Alzheimer’s disease

112.. The nurse’s most important legal responsibility after a patient’s death in a hospital is:
A. Obtaining a consent of an autopsy
B. Notifying the coroner or medical examiner
C. Labeling the corpse appropriately
D. Ensuring that the attending physician issues the death certification

113.. Before rigor mortis occurs, the nurse is responsible for:

A. Providing a complete bath and dressing change
B. Placing one pillow under the body’s head and shoulders
C. Removing the body’s clothing and wrapping the body in a shroud
D. Allowing the body to relax normally

114.. When a patient in the terminal stages of lung cancer begins to exhibit loss of consciousness, a major
nursing priority is to:
A. Protect the patient from injury
B. Insert an airway
C. Elevate the head of the bed
D. Withdraw all pain medications

115.. Which element in the circular chain of infection can be eliminated by preserving skin integrity?
A. Host
B. Reservoir
C. Mode of transmission
D. Portal of entry
D. In the circular chain of infection, pathogens must be able to leave their reservoir and be
transmitted to a susceptible host through a portal of entry, such as broken skin.

116. Which of the following procedures always requires surgical asepsis?

A. Vaginal instillation of conjugated estrogen
B. Urinary catheterization
C. Nasogastric tube insertion
D. Colostomy irrigation
B. The urinary system is normally free of microorganisms except at the urinary meatus. Any
procedure that involves entering this system must use surgically aseptic measures to maintain
a bacteria-free state.
117. Which of the following will probably result in a break in sterile technique for respiratory isolation?
A. Opening the patient’s window to the outside environment
B. Turning on the patient’s room ventilator
C. Opening the door of the patient’s room leading into the hospital corridor
D. Failing to wear gloves when administering a bed bath
C. Respiratory isolation, like strict isolation, requires that the door to the door patient’s room
remain closed. However, the patient’s room should be well ventilated, so opening the window
or turning on the ventricular is desirable. The nurse does not need to wear gloves for
respiratoryisolation, but good hand washing is important for all types of isolation.

118. Which of the following patients is at greater risk for contracting an infection?
A. A patient with leukopenia
B. A patient receiving broad-spectrum antibiotics
C. A postoperative patient who has undergone orthopedic surgery
D. A newly diagnosed diabetic patient
A. Leukopenia is a decreased number of leukocytes (white blood cells), which are important in
resisting infection. None of the other situations would put the patient at risk for contracting an
infection; taking broad-spectrum antibiotics might actually reduce the infection risk.

119.. Effective hand washing requires the use of:

A. Soap or detergent to promote emulsification
B. Hot water to destroy bacteria
C. A disinfectant to increase surface tension
D. All of the above
A. Soaps and detergents are used to help remove bacteria because of their ability to lower the
surface tension of water and act as emulsifying agents. Hot water may lead to skin irritation or
burns.

120. After routine patient contact, hand washing should last at least:
A. 30 seconds
B. 1 minute
C. 2 minute
D. 3 minutes
A. Depending on the degree of exposure to pathogens, hand washing may last from 10
seconds to 4 minutes. After routine patient contact, hand washing for 30 seconds effectively
minimizes the risk of pathogen transmission.

121.. Sterile technique is used whenever:

A. Strict isolation is required
B. Terminal disinfection is performed
C. Invasive procedures are performed
D. Protective isolation is necessary
C. All invasive procedures, including surgery, catheter insertion, and administration of
parenteral therapy, require sterile technique to maintain a sterile environment. All equipment
must be sterile, and the nurse and the physician must wear sterile gloves and maintain surgical
asepsis. In the operating room, the nurse and physician are required to wear sterile gowns,
gloves, masks, hair covers, and shoe covers for all invasive procedures. Strictisolation requires
the use of clean gloves, masks, gowns and equipment to prevent the transmission of highly
communicable diseases by contact or by airborne routes. Terminal disinfection is the
disinfection of all contaminated supplies and equipment after a patient has been discharged to
prepare them for reuse by another patient. The purpose of protective (reverse)isolation is to
prevent a person with seriously impaired resistance from coming into contact who potentially
pathogenic organisms.

122.. Which of the following constitutes a break in sterile technique while preparing a sterile field for a
dressing change?
A. Using sterile forceps, rather than sterile gloves, to handle a sterile item
B. Touching the outside wrapper of sterilized material without sterile gloves
C. Placing a sterile object on the edge of the sterile field
D. Pouring out a small amount of solution (15 to 30 ml) before pouring the solution into a sterile
container
C. The edges of a sterile field are considered contaminated. When sterile items are allowed to
come in contact with the edges of the field, the sterile items also become contaminated.

123. A natural body defense that plays an active role in preventing infection is:
A. Yawning
B. Body hair
C. Hiccupping
D. Rapid eye movements
.B. Hair on or within body areas, such as the nose, traps and holds particles that contain
microorganisms. Yawning and hiccupping do not prevent microorganisms from entering or
leaving the body. Rapid eye movement marks the stage of sleep during which dreaming occurs.

124.. All of the following statement are true about donning sterile gloves except:
A. The first glove should be picked up by grasping the inside of the cuff.
B. The second glove should be picked up by inserting the gloved fingers under the cuff outside the
glove.
C. The gloves should be adjusted by sliding the gloved fingers under the sterile cuff and pulling the
glove over the wrist
D. The inside of the glove is considered sterile
.D. The inside of the glove is always considered to be clean, but not sterile.
127.. All of the following measures are recommended to prevent pressure ulcers except:
A. Massaging the reddened are with lotion
B. Using a water or air mattress
C. Adhering to a schedule for positioning and turning
D. Providing meticulous skin care
.A. Nurses and other health care professionals previously believed that massaging a reddened
area with lotion would promote venous return and reduce edema to the area. However,
research has shown that massage only increases the likelihood of cellular ischemia and
necrosis to the area.

128. Which of the following blood tests should be performed before a blood transfusion?
A. Prothrombin and coagulation time
B. Blood typing and cross-matching
C. Bleeding and clotting time
D. Complete blood count (CBC) and electrolyte levels.

B. Before a blood transfusion is performed, the blood of the donor and recipient must be
checked for compatibility. This is done by blood typing (a test that determines a person’s blood
type) and cross-matching (a procedure that determines the compatibility of the donor’s and
recipient’s blood after the blood types has been matched). If the blood specimens are
incompatible, hemolysis and antigen-antibody reactions will occur.

129.. The primary purpose of a platelet count is to evaluate the:

A. Potential for clot formation
B. Potential for bleeding
C. Presence of an antigen-antibody response
D. Presence of cardiac enzymes
A. Platelets are disk-shaped cells that are essential for blood coagulation. A platelet count
determines the number of thrombocytes in blood available for promoting hemostasis and
assisting with blood coagulation after injury. It also is used to evaluate the patient’s potential
for bleeding; however, this is not its primary purpose. The normal count ranges from 150,000
to 350,000/mm3. A count of 100,000/mm3 or less indicates a potential for bleeding; count of
less than 20,000/mm3 is associated with spontaneous bleeding.

130.. Which of the following white blood cell (WBC) counts clearly indicates leukocytosis?
A. 4,500/mm³
B. 7,000/mm³
C. 10,000/mm³
D. 25,000/mm³
D. Leukocytosis is any transient increase in the number of white blood cells (leukocytes) in the
blood. Normal WBC counts range from 5,000 to 10,000/mm 3. Thus, a count of
25,000/mm3 indicates leukocytosis.

131.. After 5 days of diuretic therapy with 20mg of furosemide (Lasix) daily, a patient begins to exhibit
fatigue, muscle cramping and muscle weakness. These symptoms probably indicate that the patient is
experiencing:
A. Hypokalemia
B. Hyperkalemia
C. Anorexia
D. Dysphagia
A. Fatigue, muscle cramping, and muscle weaknesses are symptoms of hypokalemia (an
inadequate potassium level), which is a potential side effect of diuretic therapy. The physician
usually orders supplemental potassium to prevent hypokalemia in patients receiving diuretics.
Anorexia is another symptom of hypokalemia. Dysphagia means difficulty swallowing.

132.. Which of the following statements about chest X-ray is false?

A. No contradictions exist for this test
B. Before the procedure, the patient should remove all jewelry, metallic objects, and buttons above
the waist
 C. A signed consent is not required
D. Eating, drinking, and medications are allowed before this test
A. Pregnancy or suspected pregnancy is the only contraindication for a chest X-ray. However, if
a chest X-ray is necessary, the patient can wear a lead apron to protect the pelvic region from
radiation. Jewelry, metallic objects, and buttons would interfere with the X-ray and thus should
not be worn above the waist. A signed consent is not required because a chest X-ray is not an
invasive examination. Eating, drinking and medications are allowed because the X-ray is of the
chest, not the abdominal region.

133.. The most appropriate time for the nurse to obtain a sputum specimen for culture is:
A. Early in the morning
B. After the patient eats a light breakfast
C. After aerosol therapy
D. After chest physiotherapy
A. Obtaining a sputum specimen early in this morning ensures an adequate supply of bacteria
for culturing and decreases the risk of contamination from food or medication.

[Link] of the following nursing interventions are correct when using the Z-track method of drug injection
except:
A. Prepare the injection site with alcohol
B. Use a needle that’s a least 1” long
C. Aspirate for blood before injection
D. Rub the site vigorously after the injection to promote absorption
D. The Z-track method is an I.M. injection technique in which the patient’s skin is pulled in
such a way that the needle track is sealed off after the injection. This procedure seals
medication deep into the muscle, thereby minimizing skin staining and irritation. Rubbing the
injection site is contraindicated because it may cause the medication to extravasate into the
skin

135. A patient with no known allergies is to receive penicillin every 6 hours. When administering the
medication, the nurse observes a fine rash on the patient’s skin. The most appropriate nursing action
would be to:
A. Withhold the moderation and notify the physician
B. Administer the medication and notify the physician
C. Administer the medication with an antihistamine
D. Apply corn starch soaks to the rash
A. Initial sensitivity to penicillin is commonly manifested by a skin rash, even in individuals who
have not been allergic to it previously. Because of the danger of anaphylactic shock, he nurse
should withhold the drug and notify the physician, who may choose to substitute another drug.
Administering an antihistamine is a dependent nursing intervention that requires a written
physician’s order. Although applying corn starch to the rash may relieve discomfort, it is not
the nurse’s top priority in such a potentially life-threatening situation.

136.. The correct method for determining the vastus lateralis site for I.M. injection is to:
A. Locate the upper aspect of the upper outer quadrant of the buttock about 5 to 8 cm below the iliac
crest
B. Palpate the lower edge of the acromion process and the midpoint lateral aspect of the arm
C. Palpate a 1” circular area anterior to the umbilicus
D. Divide the area between the greater femoral trochanter and the lateral femoral condyle into thirds,
and select the middle third on the anterior of the thigh
D. The vastus lateralis, a long, thick muscle that extends the full length of the thigh, is viewed
by many clinicians as the site of choice for I.M. injections because it has relatively few major
nerves and blood vessels. The middle third of the muscle is recommended as the injection site.
The patient can be in a supine or sitting position for an injection into this site.

137.. The mid-deltoid injection site is seldom used for I.M. injections because it:
A. Can accommodate only 1 ml or less of medication
B. Bruises too easily
C. Can be used only when the patient is lying down
 D. Does not readily parenteral medication
A. The mid-deltoid injection site can accommodate only 1 ml or less of medication because of
its size and location (on the deltoid muscle of the arm, close to the brachial artery and radial
nerve).

138. The appropriate needle size for insulin injection is:

A. 18G, 1 ½” long
B. 22G, 1” long
C. 22G, 1 ½” long
D. 25G, 5/8” long
D. A 25G, 5/8” needle is the recommended size for insulin injection because insulin is
administered by the subcutaneous route. An 18G, 1 ½” needle is usually used for I.M.
injections in children, typically in the vastus lateralis. A 22G, 1 ½” needle is usually used for
adult I.M. injections, which are typically administered in the vastus lateralis or ventrogluteal
site.

139.. The appropriate needle gauge for intradermal injection is:

A. 20G
B. 22G
C. 25G
D. 26G
D. Because an intradermal injection does not penetrate deeply into the skin, a small-bore 25G
needle is recommended. This type of injection is used primarily to administer antigens to
evaluate reactions for allergy or sensitivity studies. A 20G needle is usually used for I.M.
injections of oil-based medications; a 22G needle for I.M. injections; and a 25G needle, for I.M.
injections; and a 25G needle, for subcutaneous insulin injections.

140. Parenteral penicillin can be administered as an:

A. IM injection or an IV solution
B. IV or an intradermal injection
C. Intradermal or subcutaneous injection
D. IM or a subcutaneous injection
A. Parenteral penicillin can be administered I.M. or added to a solution and given I.V. It cannot
be administered subcutaneously or intradermally.

141.. The physician orders gr 10 of aspirin for a patient. The equivalent dose in milligrams is:
A. 0.6 mg
B. 10 mg
C. 60 mg
D. 600 mg
D. gr 10 x 60mg/gr 1 = 600 mg

[Link] physician orders an IV solution of dextrose 5% in water at 100ml/hour. What would the flow rate
be if the drop factor is 15 gtt = 1 ml?
A. 5 gtt/minute
B. 13 gtt/minute
C. 25 gtt/minute
D. 50 gtt/minute
C. 100ml/60 min X 15 gtt/ 1 ml = 25 gtt/minute

143.. Which of the following is a sign or symptom of a hemolytic reaction to blood transfusion?
A. Hemoglobinuria
B. Chest pain
C. Urticaria
D. Distended neck veins
A. Hemoglobinuria, the abnormal presence of hemoglobin in the urine, indicates a hemolytic
reaction (incompatibility of the donor’s and recipient’s blood). In this reaction, antibodies in
the recipient’s plasma combine rapidly with donor RBC’s; the cells are hemolyzed in either
circulatory or reticuloendothelial system. Hemolysis occurs more rapidly in ABO
incompatibilities than in Rh incompatibilities. Chest pain and urticaria may be symptoms of
impending anaphylaxis. Distended neck veins are an indication of hypervolemia.

144. Which of the following conditions may require fluid restriction?

A. Fever
B. Chronic Obstructive Pulmonary Disease
C. Renal Failure
D. Dehydration
C. In real failure, the kidney loses their ability to effectively eliminate wastes and fluids.
Because of this, limiting the patient’s intake of oral and I.V. fluids may be necessary. Fever,
chronic obstructive pulmonary disease, and dehydration are conditions for which fluids should
be encouraged.

145. All of the following are common signs and symptoms of phlebitis except:
A. Pain or discomfort at the IV insertion site
B. Edema and warmth at the IV insertion site
C. A red streak exiting the IV insertion site
D. Frank bleeding at the insertion site
D. Phlebitis, the inflammation of a vein, can be caused by chemical irritants (I.V. solutions or
medications), mechanical irritants (the needle or catheter used during venipuncture or
cannulation), or a localized allergic reaction to the needle or catheter. Signs and symptoms of
phlebitis include pain or discomfort, edema and heat at the I.V. insertion site, and a red streak
going up the arm or leg from the I.V. insertion site.

146.. The best way of determining whether a patient has learned to instill ear medication properly is for
the nurse to:
A. Ask the patient if he/she has used ear drops before
B. Have the patient repeat the nurse’s instructions using her own words
C. Demonstrate the procedure to the patient and encourage to ask questions
D. Ask the patient to demonstrate the procedure
D. Return demonstration provides the most certain evidence for evaluating the effectiveness of
patient teaching.

147. Which of the following types of medications can be administered via gastrostomy tube?
A. Any oral medications
B. Capsules whole contents are dissolve in water
C. Enteric-coated tablets that are thoroughly dissolved in water
D. Most tablets designed for oral use, except for extended-duration compounds
D. Capsules, enteric-coated tablets, and most extended duration or sustained release products
should not be dissolved for use in a gastrostomy tube. They are pharmaceutically manufactured
in these forms for valid reasons, and altering them destroys their purpose. The nurse should
seek an alternate physician’s order when an ordered medication is inappropriate for delivery by
tube.

148.. A patient who develops hives after receiving an antibiotic is exhibiting drug:
A. Tolerance
B. Idiosyncrasy
C. Synergism
D. Allergy
.D. A drug-allergy is an adverse reaction resulting from an immunologic response following a
previous sensitizing exposure to the drug. The reaction can range from a rash or hives to
anaphylactic shock. Tolerance to a drug means that the patient experiences a decreasing
physiologic response to repeated administration of the drug in the same
dosage. Idiosyncrasy is an individual’s unique hypersensitivity to a drug, food, or other
substance; it appears to be genetically determined. Synergism, is a drug interaction in which
the sum of the drug’s combined effects is greater than that of their separate effects.

149.. A patient has returned to his room after femoral arteriography. All of the following are appropriate
nursing interventions except:
 A. Assess femoral, popliteal, and pedal pulses every 15 minutes for 2 hours
B. Check the pressure dressing for sanguineous drainage
C. Assess a vital signs every 15 minutes for 2 hours
D. Order a hemoglobin and hematocrit count 1 hour after the arteriography
D. A hemoglobin and hematocrit count would be ordered by the physician if bleeding were
suspected. The other answers are appropriate nursing interventions for a patient who has
undergone femoral arteriography.

150.. The nurse explains to a patient that a cough:

A. Is a protective response to clear the respiratory tract of irritants
B. Is primarily a voluntary action
C. Is induced by the administration of an antitussive drug
D. Can be inhibited by “splinting” the abdomen
A. Coughing, a protective response that clears the respiratory tract of irritants, usually is
involuntary; however it can be voluntary, as when a patient is taught to perform coughing
exercises. An antitussive drug inhibits coughing. Splinting the abdomen supports the
abdominal muscles when a patient coughs.

151.. An infected patient has chills and begins shivering. The best nursing intervention is to:
A. Apply iced alcohol sponges
B. Provide increased cool liquids
C. Provide additional bedclothes
D. Provide increased ventilation
.C. In an infected patient, shivering results from the body’s attempt to increase heat production
and the production of neutrophils and phagocytotic action through increased skeletal muscle
tension and contractions. Initial vasoconstriction may cause skin to feel cold to the touch.
Applying additional bed clothes helps to equalize the body temperature and stop the chills.
Attempts to cool the body result in further shivering, increased metabloism, and thus increased
heat production.

152.. A clinical nurse specialist is a nurse who has:

A. Been certified by the National League for Nursing
B. Received credentials from the Philippine Nurses’ Association
C. Graduated from an associate degree program and is a registered professional nurse
D. Completed a master’s degree in the prescribed clinical area and is a registered professional nurse.
D. A clinical nurse specialist must have completed a master’s degree in a clinical specialty and
be a registered professional nurse. The National League of Nursing accredits educational
programs in nursing and provides a testing service to evaluate student nursing competence
but it does not certify nurses. The American Nurses Association identifies requirements for
certification and offers examinations for certification in many areas of nursing., such as
medical surgical nursing. These certification (credentialing) demonstrates that the nurse has
the knowledge and the ability to provide high quality nursing care in the area of her
certification. A graduate of an associate degree program is not a clinical nurse specialist:
however, she is prepared to provide bed side nursing with a high degree of knowledge and
skill. She must successfully complete the licensing examination to become a registered
professional nurse.

153.. The purpose of increasing urine acidity through dietary means is to:
A. Decrease burning sensations
B. Change the urine’s color
C. Change the urine’s concentration
D. Inhibit the growth of microorganisms
D. Microorganisms usually do not grow in an acidic environment.

154.. Clay colored stools indicate:

A. Upper GI bleeding
B. Impending constipation
C. An effect of medication
 D. Bile obstruction
.D. Bile colors the stool brown. Any inflammation or obstruction that impairs bile flow will
affect the stool pigment, yielding light, clay-colored stool. Upper GI bleeding results in black or
tarry stool. Constipation is characterized by small, hard masses. Many medications and foods
will discolor stool – for example, drugs containing iron turn stool black.; beets turn stool red.

155.. In which step of the nursing process would the nurse ask a patient if the medication she
administered relieved his pain?
A. Assessment
B. Analysis
C. Planning
D. Evaluation
D. In the evaluation step of the nursing process, the nurse must decide whether the patient
has achieved the expected outcome that was identified in the planning phase.

156. All of the following are good sources of vitamin A except:

A. White potatoes
B. Carrots
C. Apricots
D. Egg yolks
A. The main sources of vitamin A are yellow and green vegetables (such as carrots, sweet
potatoes, squash, spinach, collard greens, broccoli, and cabbage) and yellow fruits (such as
apricots, and cantaloupe). Animal sources include liver, kidneys, cream, butter, and egg yolks.

157. Which of the following is a primary nursing intervention necessary for all patients with a Foley
Catheter in place?
A. Maintain the drainage tubing and collection bag level with the patient’s bladder
B. Irrigate the patient with 1% Neosporin solution three times a daily
C. Clamp the catheter for 1 hour every 4 hours to maintain the bladder’s elasticity
D. Maintain the drainage tubing and collection bag below bladder level to facilitate drainage by gravity
.D. Maintaing the drainage tubing and collection bag level with the patient’s bladder could
result in reflux of urine into the kidney. Irrigating the bladder with Neosporin and clamping the
catheter for 1 hour every 4 hours must be prescribed by a physician.

158.. The ELISA test is used to:

A. Screen blood donors for antibodies to human immunodeficiency virus (HIV)
B. Test blood to be used for transfusion for HIV antibodies
C. Aid in diagnosing a patient with AIDS
D. All of the above
D. The ELISA test of venous blood is used to assess blood and potential blood donors to human
immunodeficiency virus (HIV). A positive ELISA test combined with various signs and
symptoms helps to diagnose acquired immunodeficiency syndrome (AIDS)

[Link] two blood vessels most commonly used for TPN infusion are the:
A. Subclavian and jugular veins
B. Brachial and subclavian veins
C. Femoral and subclavian veins
D. Brachial and femoral veins
A. Total Parenteral Nutrition (TPN) requires the use of a large vessel, such as the subclavian
or jugular vein, to ensure rapid dilution of the solution and thereby prevent complications,
such as hyperglycemia. The brachial and femoral veins usually are contraindicated because
they pose an increased risk of thrombophlebitis.

160.. When transferring a patient from a bed to a chair, the nurse should use which muscles to avoid back
injury?
A. Abdominal muscles B. Back muscles
C. Leg muscles D. Upper arm muscles
C. The leg muscles are the strongest muscles in the body and should bear the greatest stress
when lifting. Muscles of the abdomen, back, and upper arms may be easily injured.
161.. Effective skin disinfection before a surgical procedure includes which of the following methods?
A. Shaving the site on the day before surgery
B. Applying a topical antiseptic to the skin on the evening before surgery
C. Having the patient take a tub bath on the morning of surgery
D. Having the patient shower with an antiseptic soap on the evening v=before and the morning of
surgery
.D. Studies have shown that showering with an antiseptic soap before surgery is the most
effective method of removing microorganisms from the skin. Shaving the site of the intended
surgery might cause breaks in the skin, thereby increasing the risk of infection; however, if
indicated, shaving, should be done immediately before surgery, not the day before. A topical
antiseptic would not remove microorganisms and would be beneficial only after proper
cleaning and rinsing. Tub bathing might transfer organisms to another body site rather than
rinse them away.

162.. Thrombophlebitis typically develops in patients with which of the following conditions?
A. Increases partial thromboplastin time
B. Acute pulsus paradoxus
C. An impaired or traumatized blood vessel wall
D. Chronic Obstructive Pulmonary Disease (COPD)
.C. The factors, known as Virchow’s triad, collectively predispose a patient to thromboplebitis;
impaired venous return to the heart, blood hypercoagulability, and injury to a blood vessel
wall. Increased partial thromboplastin time indicates a prolonged bleeding time during fibrin
clot formation, commonly the result of anticoagulant (heparin) therapy. Arterial blood
disorders (such as pulsus paradoxus) and lung diseases (such as COPD) do not necessarily
impede venous return of injure vessel walls.

163. In a recumbent, immobilized patient, lung ventilation can become altered, leading to such
respiratory complications as:
A. Respiratory acidosis, ateclectasis, and hypostatic pneumonia
B. Appneustic breathing, atypical pneumonia and respiratory alkalosis
C. Cheyne-Strokes respirations and spontaneous pneumothorax
D. Kussmail’s respirations and hypoventilation
A. Because of restricted respiratory movement, a recumbent, immobilize patient is at particular
risk for respiratory acidosis from poor gas exchange; atelectasis from reduced surfactant and
accumulated mucus in the bronchioles, and hypostatic pneumonia from bacterial growth
caused by stasis of mucus secretions.

164.. Immobility impairs bladder elimination, resulting in such disorders as

A. Increased urine acidity and relaxation of the perineal muscles, causing incontinence
B. Urine retention, bladder distention, and infection
C. Diuresis, natriuresis, and decreased urine specific gravity
D. Decreased calcium and phosphate levels in the urine
B. The immobilized patient commonly suffers from urine retention caused by decreased muscle
tone in the perineum. This leads to bladder distention and urine stagnation, which provide an
excellent medium for bacterial growth leading to infection. Immobility also results in more
alkaline urine with excessive amounts of calcium, sodium and phosphate, a gradual decrease in
urine production, and an increased specific gravity.

165. A sudden redness of the skin is known as:

A. Flush
B. Cyanosis
C. Jaundice
D. Pallor
(A) Flush. Flush is a sudden redness of the skin. Cyanosis is a slightly bluish, grayish skin
discoloration caused by abnormal amounts or reduced hemoglobin in the blood. Jaundice is a
yellow discoloration of the skin, mucous membranes and sclerae caused by excessive amounts
of bilirubin in the blood. Pallor is an unnatural paleness or absence of color in the skin
indicating insufficient oxygen and excessive carbon dioxide in the blood.

166.. The term gavage indicates:

A. Administration of a liquid feeding into the stomach
B. Visual examination of the stomach
C. Irrigation of the stomach with a solution
D. A surgical opening through the abdomen to the stomach
(A) Administration of a liquid feeding into the stomach. Gavage is the administration of a liquid
feeding into the stomach

167.. A patient states that he has difficulty sleeping in the hospital because of noise. Which of the
following would be an appropriate nursing action?
A. Administer a sedative at bedtime, as ordered by the physician
B. Ambulate the patient for 5 minutes before he retires
C. Give the patient a glass of warm milk before bedtime
D. Close the patient’s door from 9pm to 7am
C) Give the patient a glass of warm milk before bedtime. Warm milk will relax the patient
because it contains tryptophan, a natural sedative.

168. Which of the following nursing theorists dveloped a conceptual model based on the belief that all
persons strive to achieve self-care?
A. Martha Rogers
B. Dorothea Orem
C. Florence Nightingale
D. Cister Callista Roy
B) Dorothea Orem. Dorothea Orem’s conceptual model is based on the premise that all persons
need to achieve self-care. She also views the goal of nursing as helping the patient to develop
self-care practices to maintain maximum wellness.

169.. Which of the following nursing theorists is credited with developing a conceptual model specific to
nursing, with man as the central focus?
A. Martha Rogers
B. Dorothea Orem
C. Florence Nightingale
D. Sister Callista Roy
A) Martha Rogers. Martha Roger’s life process model views man as an evolving creature
interacting with the environment in an open, adaptive manner. According to this model, the
purpose of nursing is to help man achieve maximum health in his environment.

170. Which of the following questions is most appropriate to ask when interviewing a potential candidate
fo an RN position?
A. What was your last nursing experience?
B. Are you willing to do overtime on weekends?
C. How many children do you have?
D. Do you plan to get pregnant?
(A) What was your last nursing experience?. An interviewer’s question should center on the
applicant’s qualifications for the position. Questions about the applicant’s personal life are
inappropriate and may be illegal.

171. . If a patient is injured because a nurse acted in a wrongful manner, which party could be held liable
along with the nurse?
A. The private attending physician
B. The nursing supervisor
C. The hospital
D. All of the above
C) The hospital. Under the master servant rule (also known as the doctrine or respondeat
superior), when a person is injured by an employee as a result of negligence in the course of
the employee’s work, the employer is responsible to the injured person.
172. . Which of the following may be considered a patient’s right?
A. The right to euthanasia
B. The right to refuse treatment
C. The right to ignore hospital regulations
D. The right to refuse to pay for what the patient considers to be inferior service.
B) The right to refuse treatment. Under the bill of rights law, the patient has the right to refuse
treatment/life – giving measures, to the extent permitted by law, and to be informed of the
medical consequences of his action.

173. If a patient sues a nurse for malpractice, the patient must be able to prove:
A. Error, proximal cause, and lack of concern
B. Error, injury and proximal cause
C. Injury, error and assault
D. Proximal cause, negligence and nurse error
B) Error, injury and proximal cause. Three criteria must be met to establish malpractice: a
nursing error, a patient injury, and a connection between the two.

174.. Which communication skills is most effective in dealing with covert communication?
A. Validation
B. Listening
C. Evaluation
D. Clarification
(A) Validation. Covert communication reflects inner feelings that a person may be
uncomfortable talking about. Such communication may be revealed through body language,
silence, withdrawn behavior, or crying. Validation is an attempt to confirm the observer’s
perceptions through feedback, interpretation and clarification

175. Which of the following qualities are relevant in documenting patient care?
A. Accuracy and conciseness
B. Thoroughness and currentness
C. Organization
D. All of the above
D) All of the above. Documentation should leave no room for misinterpretation. Thus, the nurse
must ensure that all information pertinent to patient care is reworded accurately, concisely and
thoroughly. The information must be up-to-date and well organized.

176.. The usual sequence for assessing the bowel is:

A. Right lower quadrant, right upper quadrant, left upper quadrant. left lower quadrant
B. Right lower lobe, right upper lobe, left upper lobe, left lower lobe
C. Right hypochondriac, left hypochondriac and umbilical regions
D. Rectum, pancreas, stomach and liver
A) Right lower quadrant, right upper quadrant, left upper quadrant. left lower quadrant. This
sequence follows the anatomy of the bowel. The lobes are parts of the lung. the right and left
hypochondriac and the umbilical area are three of the nine regions of the abdomen.

177. The nurse should take a rectal temperature of a patient who has:
A. His arm in a cast
B. Nasal packing
C. External hemorrhoids
D. Gastrostomy feeding tubes
B) Nasal packing. A rectal temperature is usually recommended whenever an oral temperature
is contraindicated (e.g. the patient who have undergone oral or nasal surgery, infants and
those who have history of seizures, etc). However, a rectal temperature is contraindicated in
patients having rectal disease, rectal surgery or diarrhea)
178. Blood pressure measurement is an important part of the patient’s data base. It is considered to be:
A. The basis of the nursing diagnosis
B. Objective data
C. An indicator of the patient’s well being
D. Subjective data
B) Objective data. Objective data are those such as BP, which can be measured or perceived by
someone other than the patient. Subjective data are those such as pain, which only the patient
can perceive.

179. Postural drainage to relieve respiratory congestion should take place:

A. Before meals
B. After meals
C. At the nurse’s convenience
D. At the patient’s convenience
A) Before meals. Postural drainage is best performed before, rather after meals to avoid tiring
the patient or inducing vomiting. The patient’s safety supersedes the convenience in scheduling
this procedure.

180. . The correct site at which to verify a radial pulse measurement is the:
A. Brachial artery
B. Apex of the heart
C. Temporal artery
D. Inguinal site
B) Apex of the heart. The best site for verifying a pulse rate is the apex of the heart, where the
heartbeat is measured directly.

181.. The average daily amount of urine excreted by an adult is:

A. 500 to 600 ml B .800 to 1,400 ml
C 1,000 to 1,200 ml D.1,500 to 2,000 ml
D) 1,500 to 2,000 ml. An adult’s average urine output ranges between 1,500 and 2,000 ml/day.

182.. The nurse’s main priority when caring foar a patient with hemiplegia?
A. Educating the patient
B. Providing a safe environment
C. Promoting a positive self-image
D. Helping the patient accept the illness
B) Providing a safe environment. A patient with hemiplegia (paralysis of one side of the body)
has a high risk of injury because of his altered motor and sensory function, so safety is the
nurse’s main priority.

183.. Constipation is a common problem for immobilized patients because of:

A. Decreased peristalsis and positional discomfort
B. An increased defacation reflex
C. Decreased tightening of the anal sphincter
D. Increased colon motility
A) Decreased peristalsis and positional discomfort. Increased adrenalin production in the
immobile patient results in decrease peristalsis and colon motility and more tightly constricted
sphincters.

184. . Antiembolism stockings are used primarily to:

A. Promote venous circulation
B. Provide external warmth
C. Prevent dependent edema
D. Hold foot dressings
A) Promote venous circulation. Antiembolism stockings are elastic stockings designed to
maintain compression of small veins and capillaries in the legs.

[Link] promote correct anatomic alignment in a supine patient, the nurse should:
A. Place the patient’s feet in dorsiflexion
 B. Place a pillow under the patient’s knees
C. Hyperextend the patient’s neck
D. Adduct the patient’s shoulder
A) Place the patient’s feet in dorsiflexion. Anatomic alignment prevents strain on body parts,
maintains balance, and promotes physiologic functioning. To promote this position, the nurse
should place the feet in dorsiflexion (at right angles to the legs)

186.. An appropriate interdependent intervention to prevent thrombophebitis would be:

A. Elevate the knee gatch of the bed
B. Massage the legs vigorously
C. Apply antiembolism stockings to both legs.
D. Encourage the patient to sit with his knees crossed
C) Apply antiembolism stockings to both legs.. Antiembolism stockings increase venous return
to the heart, which helps prevent thromboplebitis.

187. S1 is heard best at the:

A. 5th left intercoastal space along the midclavicular line
B. 3rd intercoastal space to the left of the midclavicular line
C. Second right intercoastal space at the sternal border
D. Second left intercoastal space at the sternal border
A) 5th left intercoastal space along the midclavicular line. The S1 heart sound is best heard at
the apex of the heart, at the fifth

188.. According to Maslow’s hierarchy of needs, which of the following is a basic physiologic need after
oxygen?
A. Activity
B. Safety
C. Love
D. Self esteem
A) Activity. According to Maslow, activity is one of the man’s most basic physiologic needs,
along with oxygen, shelter, food, water, erst, sleep and temperature maintenance.

189. Mr. Jose is admitted to the hospitalwith a diagnosis of pneumonia and COPD. The physician orders an
oxygen therapy for him. The most comfortable method of delivering oxygen to Mr. Jose is by:
A. Croupette
B. Nasal Cannula
C. Nasal catheter
D. Partial rebreathing mask
B) Nasal Cannula. The nasal cannula is the most comfortable method of delivering oxygen
because it allows the patient to talk, eat and drink.

[Link] Brenda is teaching a patient about a newly prescribed drug. What could cause a geriatric
patient to have difficulty retaining knowledge about prescribed medications?
A. Decreased plasma drug levels
B. Sensory deficits
C. Lack of family support
D. History of Tourette syndrome
Answer B. Sensory deficits could cause a geriatric patient to have difficulty retaining
knowledge about prescribed medications. Decreased plasma drug levels do not alter the
patient’s knowledge about the drug. A lack of family support may affect compliance, not
knowledge retention. Toilette syndrome is unrelated to knowledge retention.

191.. When examining a patient with abdominal pain the nurse in charge should assess:
A. Any quadrant first
B. The symptomatic quadrant first
C. The symptomatic quadrant last
D. The symptomatic quadrant either second or third
Answer C. The nurse should systematically assess all areas of the abdomen, if time and the
patient’s condition permit, concluding with the symptomatic area. Otherwise, the nurse may
elicit pain in the symptomatic area, causing the muscles in other areas to tighten. This would
interfere with further assessment.

192.. The nurse is assessing a postoperative adult patient. Which of the following should the nurse
document as subjective data?
A. Vital signs
B. Laboratory test result
C. Patient’s description of pain
D. Electrocardiographic (ECG) waveforms
Answer C. Subjective data come directly from the patient and usually are recorded as direct
quotations that reflect the patient’s opinions or feelings about a situation. Vital signs,
laboratory test result, and ECG waveforms are examples of objective data.

193.. A male patient has a soft wrist-safety device. Which assessment finding should the nurse consider
abnormal?
A. A palpable radial pulse
B. A palpable ulnar pulse
C. Cool, pale fingers
D. Pink nail beds
Answer C. A safety device on the wrist may impair circulation and restrict blood supply to body
tissues. Therefore, the nurse should assess the patient for signs of impaired circulation, such
as cool, pale fingers. A palpable radial or lunar pulse and pink nail beds are normal findings.

194. Which of the following planes divides the body longitudinally into anterior and posterior regions?
A. Frontal plane
B. Sagittal plane
C. Midsagittal plane
D. Transverse plane

Answer A. Frontal or coronal plane runs longitudinally at a right angle to a sagittal plane
dividing the body in anterior and posterior regions. A sagittal plane runs longitudinally dividing
the body into right and left regions; if exactly midline, it is called a midsagittal plane. A
transverse plane runs horizontally at a right angle to the vertical axis, dividing the structure
into superior and inferior regions.

195.. A female patient with a terminal illness is in denial. Indicators of denial include:
A. Shock dismay
B. Numbness
C. Stoicism
D. Preparatory grief

Answer A. Shock and dismay are early signs of denial-the first stage of grief. The other options
are associated with depression—a later stage of grief.

196.. The nurse in charge is transferring a patient from the bed to a chair. Which action does the nurse
take during this patient transfer?
A. Position the head of the bed flat
B. Helps the patient dangle the legs
C. Stands behind the patient
D. Places the chair facing away from the bed
Answer B. After placing the patient in high Fowler’s position and moving the patient to the side
of the bed, the nurse helps the patient sit on the edge of the bed and dangle the legs; the nurse
then faces the patient and places the chair next to and facing the head of the bed.

197. A female patient who speaks a little English has emergency gallbladder surgery, during discharge
preparation, which nursing action would best help this patient understand wound care instruction?
A. Asking frequently if the patient understands the instruction
B. Asking an interpreter to replay the instructions to the patient.
C. Writing out the instructions and having a family member read them to the patient
 D. Demonstrating the procedure and having the patient return the demonstration
Answer D. Demonstrating by the nurse with a return demonstration by the patient ensures that
the patient can perform wound care correctly. Patients may claim to understand discharge
instruction when they do not. An interpreter of family member may communicate verbal or
written instructions inaccurately.

198.. Before administering the evening dose of a prescribed medication, the nurse on the evening shift
finds an unlabeled, filled syringe in the patient’s medication drawer. What should the nurse in charge do?
A. Discard the syringe to avoid a medication error
B. Obtain a label for the syringe from the pharmacy
C. Use the syringe because it looks like it contains the same medication the nurse was prepared to
give
D. Call the day nurse to verify the contents of the syringe
Answer A.  As a safety precaution, the nurse should discard an unlabeled syringe that contains
medication. The other options are considered unsafe because they promote error.

199.. When administering drug therapy to a male geriatric patient, the nurse must stay especially alert for
adverse effects. Which factor makes geriatric patients to adverse drug effects?
A. Faster drug clearance
B. Aging-related physiological changes
C. Increased amount of neurons
D. Enhanced blood flow to the GI tract
Answer B. Aging-related physiological changes account for the increased frequency of adverse
drug reactions in geriatric patients. Renal and hepatic changes cause drugs to clear more
slowly in these patients. With increasing age, neurons are lost and blood flow to the GI tract
decreases.

11. A female patient is being discharged after cataract surgery. After providing medication teaching, the
nurse asks the patient to repeat the instructions. The nurse is performing which professional role?
A. Manager
B. Educator
C. Caregiver
D. Patient advocate
Answer B. When teaching a patient about medications before discharge, the nurse is acting as
an educator. The nurse acts as a manager when performing such activities as scheduling and
making patient care assignments. The nurse performs the care giving role when providing
direct care, including bathing patients and administering medications and prescribed
treatments. The nurse acts as a patient advocate when making the patient’s wishes known to
the doctor.

200.. A female patient exhibits signs of heightened anxiety. Which response by the nurse is most likely to
reduce the patient’s anxiety?
A. “Everything will be fine. Don’t worry.”
B. “Read this manual and then ask me any questions you may have.”
C. “Why don’t you listen to the radio?”
D. “Let’s talk about what’s bothering you.”
Answer D. Anxiety may result from feeling of helplessness, isolation, or insecurity. This
response helps reduce anxiety by encouraging the patient to express feelings. The nurse
should be supportive and develop goals together with the patient to give the patient some
control over an anxiety-inducing situation. Because the other options ignore the patient’s
feeling and block communication, they would not reduce anxiety.

201.. A scrub nurse in the operating room has which responsibility?

A. Positioning the patient
B. Assisting with gowning and gloving
C. Handling surgical instruments to the surgeon
D. Applying surgical drapes
Answer C. The scrub nurse assist the surgeon by providing appropriate surgical instruments
and supplies, maintaining strict surgical asepsis and, with the circulating nurse, accounting for
all gauze, sponges, needles, and instruments. The circulating nurse assists the surgeon and
scrub nurse, positions the patient, applies appropriate equipment and surgical drapes, assists
with gowning and gloving, and provides the surgeon and scrub nurse with supplies.

202. A patient is in the bathroom when the nurse enters to give a prescribed medication. What should the
nurse in charge do?
A. Leave the medication at the patient’s bedside
B. Tell the patient to be sure to take the medication. And then leave it at the bedside
C. Return shortly to the patient’s room and remain there until the patient takes the medication
D. Wait for the patient to return to bed, and then leave the medication at the bedside
Answer C. The nurse should return shortly to the patient’s room and remain there until the
patient takes the medication to verify that it was taken as directed. The nurse should never
leave medication at the patient’s bedside unless specifically requested to do so.

203.. The physician orders heparin, 7,500 units, to be administered subcutaneously every 6 hours. The
vial reads 10,000 units per milliliter. The nurse should
anticipate giving how much heparin for each dose?
A. ¼ ml
B. ½ ml
C. ¾ ml
D. 1 ¼ ml
Answer C. The nurse solves the problem as follows:
A. 10,000 units/7,500 units = 1 ml/X
B. 10,000 X = 7,500
C. X= 7,500/10,000 or ¾ ml

204.. The nurse in charge measures a patient’s temperature at 102 degrees F. what is the equivalent
Centigrade temperature?
A. 39 degrees C
B. 47 degrees C
C. 38.9 degrees C
D. 40.1 degrees C
Answer C. To convert Fahrenheit degrees to centigrade, use this formula:
 C degrees = (F degrees – 32) x 5/9
 C degrees = (102 – 32) 5/9
 70 x 5/9 = 38.9 degrees C

[Link] evaluate a patient for hypoxia, the physician is most likely to order which laboratory test?
A. Red blood cell count
B. Sputum culture
C. Total hemoglobin
D. Arterial blood gas (ABG) analysis

Answer D. All of these test help evaluate a patient with respiratory problems. However, ABG
analysis is the only test evaluates gas exchange in the lungs, providing information about
patient’s oxygenation status.

[Link] nurse uses a stethoscope to auscultate a male patient’s chest. Which statement about a
stethoscope with a bell and diaphragm is true?
A. The bell detects high-pitched sounds best
B. The diaphragm detects high-pitched sounds best
C. The bell detects thrills best
D. The diaphragm detects low-pitched sounds best

Answer B. The diaphragm of a stethoscope detects high-pitched sound best; the bell detects
low pitched sounds best. Palpation detects thrills best
207. Which human element considered by the nurse in charge during assessment can affect drug
administration?
A. The patient’s ability to recover
B. The patient’s occupational hazards
C. The patient’s socioeconomic status
D. The patient’s cognitive abilities
Answer D. The nurse must consider the patient’s cognitive abilities to understand drug
instructions. If not, the nurse must find a family member or significant other to take on the
responsibility of administering medications in the home setting. The patient’s ability to recover,
occupational hazards, and socioeconomic status do not affect drug administration.

208.. An employer establishes a physical exercise area in the workplace and encourages all employees to
use it. This is an example of which level of health promotion?
A. Primary prevention
B. Secondary prevention
C. Tertiary prevention
D. Passive prevention
Answer A. Primary prevention precedes disease and applies to health patients. Secondary
prevention focuses on patients who have health problems and are at risk for developing
complications. Tertiary prevention enables patients to gain health from others’ activities
without doing anything themselves.

209. What does the nurse in charge do when making a surgical bed?
A. Leaves the bed in the high position when finished
B. Places the pillow at the head of the bed
C. Rolls the patient to the far side of the bed
D. Tucks the top sheet and blanket under the bottom of the bed
Answer A. When making a surgical bed, the nurse leaves the bed in the high position when
finished. After placing the top linens on the bed without pouching them, the nurse fanfolds
these linens to the side opposite from where the patient will enter and places the pillow on the
bedside chair. All these actions promote transfer of the postoperative patient from the
stretcher to the bed. When making an occupied bed or unoccupied bed, the nurse places the
pillow at the head of the bed and tucks the top sheet and blanket under the bottom of the bed.
When making an occupied bed, the nurse rolls the patient to the far side of the bed.

[Link] physician prescribes 250 mg of a drug. The drug vial reads 500 mg/ml. how much of the drug
should the nurse give?
A. 2 ml
B. 1 ml
C. ½ ml
D. ¼ ml
Answer C. The nurse should give ½ ml of the drug. The dosage is calculated as follows:
 250 mg/X=500 mg/1 ml
 500x=250
 X=1/2 ml

[Link] Mackey is monitoring a patient for adverse reactions during barbiturate therapy. What is the
major disadvantage of barbiturate use?
A. Prolonged half-life
B. Poor absorption
C. Potential for drug dependence
D. Potential for hepatotoxicity
Answer C. Patients can become dependent on barbiturates, especially with prolonged use.
Because of the rapid distribution of some barbiturates, no correlation exists between duration
of action and half-life. Barbiturates are absorbed well and do not cause hepatotoxicity,
although existing hepatic damage does require cautions use of the drug because barbiturates
are metabolized in the liver.

212.. Which nursing action is essential when providing continuous enteral feeding?
 A. Elevating the head of the bed
B. Positioning the patient on the left side
C. Warming the formula before administering it
D. Hanging a full day’s worth of formula at one time
Answer A. Elevating the head of the bed during enteral feeding minimizes the risk of aspiration
and allows the formula to flow in the patient’s intestines. When such elevation is
contraindicated, the patient should be positioned on the right side. The nurse should give
enteral feeding at room temperature to minimize GI distress. To limit microbial growth, the
nurse should hang only the amount of formula that can be infused in 3 hours.

213.. When teaching a female patient how to take a sublingual tablet, the nurse should instruct the
patient to place the table on the:
A. Top of the tongue
B. Roof of the mouth
C. Floor of the mouth
D. Inside of the cheek
Answer C. The nurse should instruct the patient to touch the tip of the tongue to the roof of the
mouth and then place the sublingual tablet on the floor of the mouth. Sublingual medications
are absorbed directly into the bloodstream form the oral mucosa, bypassing the GI and hepatic
systems. No drug is administered on top of the tongue or on the roof of the mouth. With the
buccal route, the tablet is placed between the gum and the cheek.

[Link] action by the nurse in charge is essential when cleaning the area around a Jackson-Pratt
wound drain?
A. Cleaning from the center outward in a circular motion
B. Removing the drain before cleaning the skin
C. Cleaning briskly around the site with alcohol
D. Wearing sterile gloves and a mask
Answer A. The nurse always should clean around a wound drain, moving from center outward
in ever-larger circles, because the skin near the drain site is more contaminated than the site
itself. The nurse should never remove the drain before cleaning the skin. Alcohol should never
be used to clean around a drain; it may irritate the skin and has no lasting effect on bacteria
because it evaporates. The nurse should wear sterile gloves to prevent contamination, but a
mask is not necessary.

215.. The doctor orders dextrose 5% in water, 1,000 ml to be infused over 8 hours. The I.V. tubing
delivers 15 drops per milliliter. The nurse in charge should run the I.V. infusion at a rate of:
A. 15 drop per minute
B. 21 drop per minute
C. 32 drop per minute
D. 125 drops per minute
Answer C. Giving 1,000 ml over 8 hours is the same as giving 125 ml over 1 hour (60 minutes)
to find the number of milliliters per minute:
A. 125/60 min = X/1 minute
B. 60X = 125X = 2.1 ml/minute
C. To find the number of drops/minute:
A. 2.1 ml/X gtts = 1 ml/15 gtts
B. X = 32 gtts/minute, or 32 drops/minute

216.. A male patient undergoes a total abdominal hysterectomy. When assessing the patient 10 hours
later, the nurse identifies which finding as an early sign of shock?
A. Restlessness
B. Pale, warm, dry skin
C. Heart rate of 110 beats/minute
D. Urine output of 30 ml/hour
Answer A. Early in shock, hyperactivity of the sympathetic nervous system causes increased
epinephrine secretion, which typically makes the patient restless, anxious, nervous, and
irritable. It also decreases tissue perfusion to the skin, causing pale, cool clammy skin. An
above-normal heart rate is a late sign of shock. A urine output of 30 ml/hour is within normal
limits.

217. Which pulse should the nurse palpate during rapid assessment of an unconscious male adult?
A. Radial
B. Brachial
C. Femoral
D. Carotid

Answer D. During a rapid assessment, the nurse’s first priority is to check the patient’s vital
functions by assessing his airway, breathing, and circulation. To check a patient’s circulation,
the nurse must assess his heart and vascular network function. This is done by checking his
skin color, temperature, mental status and, most importantly, his pulse. The nurse should use
the carotid artery to check a patient’s circulation. In a patient with a circulatory problems or a
history of compromised circulation, the radial pulse may not be palpable. The brachial pulse is
palpated during rapid assessment of an infant.

218. Which intervention is an example of primary prevention?

A. Administering digoxin (Lanoxicaps) to a patient with heart failure
B. Administering a measles, mumps, and rubella immunization to an infant
C. Obtaining a Papanicolaou smear to screen for cervical cancer
D. Using occupational therapy to help a patient cope with arthritis
Answer B. Immunizing an infant is an example of primary prevention, which aims to prevent
health problems. Administering digoxin to treat heart failure and obtaining a smear for a
screening test are examples for secondary prevention, which promotes early detection and
treatment of disease. Using occupational therapy to help a patient cope with arthritis is an
example of tertiary prevention, which aims to help a patient deal with the residual
consequences of a problem or to prevent the problem from recurring.

[Link] nurse in charge is assessing a patient’s abdomen. Which examination technique should the nurse
use first?
A. Auscultation
B. Inspection
C. Percussion
D. Palpation
Answer B. Inspection always comes first when performing a physical examination. Percussion
and palpation of the abdomen may affect bowel motility and therefore should follow
auscultation

220.. Which statement regarding heart sounds is correct?

A. S1 and S2 sound equally loud over the entire cardiac area.
B. S1 and S2 sound fainter at the apex
C. S1 and S2 sound fainter at the base
D. S1 is loudest at the apex, and S2 is loudest at the base
Answer D. The S1 sound—the “lub” sound—is loudest at the apex of the heart. It sounds longer,
lower, and louder there than the S2 sounds. The S2—the “dub” sound—is loudest at the base. It
sounds shorter, sharper, higher, and louder there than S1.

221.. The nurse in charge identifies a patient’s responses to actual or potential health problems during
which step of the nursing process?
A. Assessment
B. Nursing diagnosis
C. Planning
D. Evaluation
Answer B. The nurse identifies human responses to actual or potential health problems during
the nursing diagnosis step of the nursing process. During the assessment step, the nurse
systematically collects data about the patient or family. During the planning step, the nurse
develops strategies to resolve or decrease the patient’s problem. During the evaluation step,
the nurse determines the effectiveness of the plan of care.
 222.. A female patient is receiving furosemide (Lasix), 40 mg P.O. b.i.d. in the plan of care, the nurse
should emphasize teaching the patient about the importance of consuming:
A. Fresh, green vegetables B. Bananas and oranges
B. Lean red meat D. Creamed corn
Answer B. Because furosemide is a potassium-wasting diuretic, the nurse should plan to teach
the patient to increase intake of potassium-rich foods, such as bananas and oranges. Fresh,
green vegetables; lean red meat; and creamed corn are not good sources of potassium.

223.. The nurse in charge must monitor a patient receiving chloramphenicol for adverse drug reaction.
What is the most toxic reaction to chloramphenicol?
A. Lethal arrhythmias B. Malignant hypertension
C .Status epilepticus D. Bone marrow suppression
Answer D. The most toxic reaction to chloramphenicol is bone marrow suppression.
Chloramphenicol is not known to cause lethal arrhythmias, malignant hypertension, or status
epilepticus.

224.. A female patient is diagnosed with deep-vein thrombosis. Which nursing diagnosis should receive
highest priority at this time?
A. Impaired gas exchanges related to increased blood flow
B. Fluid volume excess related to peripheral vascular disease
C. Risk for injury related to edema
D. Altered peripheral tissue perfusion related to venous congestion
Answer D. Altered peripheral tissue perfusion related to venous congestion” takes highest
priority because venous inflammation and clot formation impede blood flow in a patient with
deep-vein thrombosis. Option A is incorrect because impaired gas exchange is related to
decreased, not increased, blood flow. Option B is inappropriate because no evidence suggest
that this patient has a fluid volume excess. Option C may be warranted but is secondary to
altered tissue perfusion.

225.. When positioned properly, the tip of a central venous catheter should lie in the:
A. Superior vena cava
B. Basilica vein
C. Jugular vein
D. Subclavian vein
Answer A. When the central venous catheter is positioned correctly, its tip lies in the superior
vena cava, inferior vena cava, or the right atrium—that is, in central venous circulation. Blood
flows unimpeded around the tip, allowing the rapid infusion of large amounts of fluid directly
into circulation. The basilica, jugular, and subclavian veins are common insertion sites for
central venous catheters.

[Link] Margareth is revising a client’s care plan. During which step of the nursing process does such
revision take place?
A. Assessment
B. Planning
C. Implementation
D. Evaluation
Answer D. During the evaluation step of the nursing process the nurse determines whether the
goals established in the care plan have been achieved, and evaluates the success of the plan. If
a goal is unmet or partially met the nurse reexamines the data and revises the plan.
Assessment involves data collection. Planning involves setting priorities, establishing goals,
and selecting appropriate interventions.

227.. A 65-year-old female who has diabetes mellitus and has sustained a large laceration on her left wrist
asks the nurse, “How long will it take for my scars to disappear?” which statement would be the nurse’s
best response?
A. “The contraction phase of wound healing can take 2 to 3 years.”
B. “Wound healing is very individual but within 4 months the scar should fade.”
C. “With your history and the type of location of the injury, it’s hard to say.”
D. “If you don’t develop an infection, the wound should heal any time between 1 and 3 years from
now.”
Answer C. Wound healing in a client with diabetes will be delayed. Providing the client with a
time frame could give the client false information

228.. One aspect of implementation related to drug therapy is:

A. Developing a content outline
B. Documenting drugs given
C. Establishing outcome criteria
D. Setting realistic client goals
Answer B. Although documentation isn’t a step in the nursing process, the nurse is legally
required to document activities related to drug therapy, including the time of administration,
the quantity, and the client’s reaction. Developing a content outline, establishing outcome
criteria, and setting realistic client goals are part of planning rather than implementation

229.. A female client is readmitted to the facility with a warm, tender, reddened area on her right calf.
Which contributing factor would the nurse recognize as most important?
A. A history of increased aspirin use
B. Recent pelvic surgery
C. An active daily walking program
D. A history of diabetes
Answer B. The client shows signs of deep vein thrombosis (DVT). The pelvic area is rich in
blood supply, and thrombophlebitis of the deep vein is associated with pelvic surgery. Aspirin,
an antiplatelet agent, and an active walking program help decrease the client’s risk of DVT. In
general, diabetes is a contributing factor associated with peripheral vascular disease.

230.. Which intervention should the nurse in charge try first for a client that exhibits signs of sleep
disturbance?
A. Administer sleeping medication before bedtime
B. Ask the client each morning to describe the quantity of sleep during the previous night
C. Teach the client relaxation techniques, such as guided imagery, medication, and progressive
muscle relaxation
D. Provide the client with normal sleep aids, such as pillows, back rubs, and snacks
Answer D. The nurse should begin with the simplest interventions, such as pillows or snacks,
before interventions that require greater skill such as relaxation techniques. Sleep medication
should be avoided whenever possible. At some point, the nurse should do a thorough sleep
assessment, especially if common sense interventions fail.

231.. While examining a client’s leg, the nurse notes an open ulceration with visible granulation tissue in
the wound. Until a wound specialist can be contacted, which type of dressings is most appropriate for the
nurse in charge to apply?
A. Dry sterile dressing
B. Sterile petroleum gauze
C. Moist, sterile saline gauze
D. Povidone-iodine-soaked gauze
Answer C. Moist, sterile saline dressings support would heal and are cost-effective. Dry sterile
dressings adhere to the wound and debride the tissue when removed. Petroleum supports
healing but is expensive. Povidone-iodine can irritate epithelial cells, so it shouldn’t be left on
an open wound.

232.. A male client in a behavioral-health facility receives a 30-minute psychotherapy session, and
provider uses a current procedure terminology (CPT) code that bills for a 50-minute session. Under the
False Claims Act, such illegal behavior is known as:
A. Unbundling
B. Overbilling
C. Upcoding
 D. Misrepresentation
Answer C. Upcoding is the practice of using a CPT code that’s reimbursed at a higher rate than
the code for the service actually provided. Unbundling, overbilling, and misrepresentation
aren’t the terms used for this illegal practice.

233.. A nurse assigned to care for a postoperative male client who has diabetes mellitus. During the
assessment interview, the client reports that he’s impotent and says that he’s concerned about its effect
on his marriage. In planning this client’s care, the most appropriate intervention would be to:
A. Encourage the client to ask questions about personal sexuality
B. Provide time for privacy
C. Provide support for the spouse or significant other
D. Suggest referral to a sex counselor or other appropriate professional
Answer D. The nurse should refer this client to a sex counselor or other professional. Making
appropriate referrals is a valid part of planning the client’s care. The nurse doesn’t normally
provide sex counseling. Therefore, providing time for privacy and providing support for the
spouse or significant other are important, but not as important as referring the client to a sex
counselor.

234.. Using Abraham Maslow’s hierarchy of human needs, a nurse assigns highest priority to which client
need?
A. Security
B. Elimination
C. Safety
D. Belonging
Answer B. According to Maslow, elimination is a first-level or physiological need, and therefore
takes priority over all other needs. Security and safety are second-level needs; belonging is a
third-level need. Second- and third-level needs can be met only after a client’s first-level needs
have been satisfied.

235.. A male client is on prolonged bed rest has developed a pressure ulcer. The wound shows no signs of
healing even though the client has received skin care and has been turned every 2 hours. Which factor is
most likely responsible for the failure to heal?
A. Inadequate vitamin D intake
B. Inadequate protein intake
C. Inadequate massaging of the affected area
D. Low calcium level
Answer B. A client on bed rest suffers from a lack of movement and a negative nitrogen
balance. Therefore, inadequate protein intake impairs wound healing. Inadequate vitamin D
intake and low calcium levels aren’t factors in poor healing for this client. A pressure ulcer
should never be massaged.

236.. A female client who received general anesthesia returns from surgery. Postoperatively, which
nursing diagnosis takes highest priority for this client?
A. Acute pain related to surgery
B. Deficient fluid volume related to blood and fluid loss from surgery
C. Impaired physical mobility related to surgery
D. Risk for aspiration related to anesthesia
Answer D. Risk for aspiration related to anesthesia takes priority for thins client because
general anesthesia may impair the gag and swallowing reflexes, possibly leading to aspiration.
The other options, although important, are secondary.
237.. Nurse Cay inspects a client’s back and notices small hemorrhagic spots. The nurse documents that
the client has:
A. Extravasation
B. Osteomalacia
C. Petechiae
D. Uremia
Answer C. Petechiae are small hemorrhagic spots. Extravasation is the leakage of fluid in the
interstitial space. Osteomalacia is the softening of bone tissue. Uremia is an excess of urea and
other nitrogen products in the blood.

238.. Which document addresses the client’s right to information, informed consent, and treatment
refusal?
A. Standard of Nursing Practice
B. Patient’s Bill of Rights
C. Nurse Practice Act
D. Code for Nurses
Answer B. The Patient’s Bill of Rights addresses the client’s right to information, informed
consent, timely responses to requests for services, and treatment refusal. A legal document, it
serves as a guideline for the nurse’s decision making. Standards of Nursing Practice, the Nurse
Practice Act, and the Code for Nurses contain nursing practice parameters and primarily
describe the use of the nursing process in providing care.

239.. If a blood pressure cuff is too small for a client, blood pressure readings taken with such a cuff may
do which of the following?
A. Fail to show changes in blood pressure
B. Produce a false-high measurement
C. Cause sciatic nerve damage
D. Produce a false-low measurement
Answer B. Using an undersized blood pressure cuff produces a falsely elevated blood pressure
because the cuff can’t record brachial artery measurements unless it’s excessively inflated. The
sciatic nerve wouldn’t be damaged by hyperinflation of the blood pressure cuff because the
sciatic nerve is located in the lower extremity.

240.. Nurse Danny has been teaching a client about a high-protein diet. The teaching is successful if the
client identifies which meal as high in protein?
A. Baked beans, hamburger, and milk
B. Spaghetti with cream sauce, broccoli, and tea
C. Bouillon, spinach, and soda
D. Chicken cutlet, spinach, and soda
Answer A. Baked beans, hamburger, and milk are all excellent sources of protein. The
spaghetti-broccoli-tea choice is high in carbohydrates. The bouillon-spinach-soda choice
provides liquid and sodium as well as some iron, vitamins, and carbohydrates. Chicken provides
protein but the chicken-spinach-soda combination provides less protein than the baked beans-
hamburger-milk selection.

241. A male client is admitted to the hospital with blunt chest trauma after a motor vehicle accident. The
first nursing priority for this client would be to:
A. Assess the client’s airway
 B. Provide pain relief
C. Encourage deep breathing and coughing
D. Splint the chest wall with a pillow
Answer A. The first priority is to evaluate airway patency before assessing for signs of
obstruction, sternal retraction, stridor, or wheezing. Airway management is always the nurse’s
first priority. Pain management and splinting are important for the client’s comfort, but would
come after airway assessment. Coughing and deep breathing may be contraindicated if the
client has internal bleeding and other injuries.

242. A newly hired charge nurse assesses the staff nurses as competent individually but ineffective and
nonproductive as a team. In addressing her concern, the charge nurse should understand that the usual
reason for such a situation is:
A. Unhappiness about the charge in leadership
B. Unexpected feeling and emotions among the staff
C. Fatigue from overwork and understaffing
D. Failure to incorporate staff in decision making
Answer B. The usual or most prevalent reason for lack of productivity in a group of competent
nurses is inadequate communication or a situation in which the nurses have unexpected feeling
and emotions. Although the other options could be contributing to the problematic situation,
they’re less likely to be the cause.

243. A male client blood test results are as follows: white blood cell (WBC) count, 100ul; hemoglobin (Hb)
level, 14 g/dl; hematocrit (HCT), 40%. Which goal would be most important for this client?
A. Promote fluid balance
B. Prevent infection
C. Promote rest
D. Prevent injury
Answer B. The client is at risk for infection because WBC count is dangerously low. Hb level and
HCT are within normal limits; therefore, fluid balance, rest, and prevention of injury are
inappropriate.

244. Following a tonsillectomy, a female client returns to the medical-surgical unit. The client is lethargic
and reports having a sore throat. Which position would be most therapeutic for this client?
A. Semi-Fowler’s
B. Supine
C. High-Fowler’s
D. Side-lying
Answer D. Because of lethargy, the post tonsillectomy client is at risk for aspirating blood from
the surgical wound. Therefore, placing the client in the side-lying position until he awake is
best. The semi-Fowler’s, supine, and high-Fowler’s position don’t allow for adequate oral
drainage in a lethargic post tonsillectomy client, and increase the risk of blood aspiration.

245. Nurse Berri inspects a client’s pupil size and determines that it’s 2 mm in the left eye and 3 mm in
the right eye. Unequal pupils are known as:
A. Anisocoria
B. Ataxia
C. Cataract
D. Diplopia
Answer A. Unequal pupils are called anisocoria. Ataxia is uncoordinated actions of involuntary
muscle use. A cataract is an opacity of the eye’s lens. Diplopia is double vision.

246. The nurse in charge is caring for an Italian client. He’s complaining of pain, but he falls asleep right
after his complaint and before the nurse can assess his pain. The nurse concludes that:
A. He may have a low threshold for pain
B. He was faking pain
C. Someone else gave him medication
D. The pain went away
Answer A. People of Italian heritage tend to verbalize discomfort and pain. The pain was real to
the client, and he may need medication when he wakes up

247. A female client is admitted to the emergency department with complaints of chest pain shortness of
breath. The nurse’s assessment reveals jugular vein
distention. The nurse knows that when a client has jugular vein distension, it’s typically due to:
A. A neck tumor
B. An electrolyte imbalance
C. Dehydration
D. Fluid overload
Answer D. Fluid overload causes the volume of blood within the vascular system to increase.
This increase causes the vein to distend, which can be seen most obviously in the neck veins. A
neck tumor doesn’t typically cause jugular vein distention. An electrolyte imbalance may result
in fluid overload, but it doesn’t directly contribute to jugular vein distention.

248. 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 fingernails to a short length.

249. The skin produces and absorbs which of the following vitamins in conjunction with the ultraviolet rays
of the Sun, which activate this particular vitamin's precursor present in the skin?
A. vitamin D
B. vitamin C
C. vitamin E
D. vitamin K

250. You are working with a client who has dentures but does not wear them. When questioned about the
reason for not wearing the dentures, the client says it makes him feel old. Which of the following
responses would be best?
A. "You are not really old."
B. "It is all right not to wear your dentures."
C. "You look better with dentures."
D. "Wearing dentures helps gums not to shrink."

251. When assessing the client's hair, you are especially looking for pediculosis capitis. If it is present,
which of the following signs will you most likely find?
A. Oval particles looking like dandruff on the hairs.
B. Crusts on the scalp, especially at the client's hairline.
C. Brown or black threadlike lesions.
D. Small insects with red legs.

252. You are preparing to bathe and wash the hair of an African American woman. Which of the following
questions would be most important to ask the client?
A. "Will you please unbraid your hair?"
B. "Do you have or want oil put on your hair and scalp?"
C. "Is it all right if I shampoo your hair twice?"
D. "Will you brush your hair before the shampoo?

253. You need to remove the artificial eye of a client, and you need to clean it. Which of the following
methods is recommended for removal?
A. Put pressure on either side of the eye and pop it out.
B. Apply pressure directly above the eye.
C. Apply pressure directly to the eye with a small rubber bulb.
D. Apply pressure with a rubber bulb to lower half of the eye.

254. It is most likely that an acutely ill client will need the room temperature set at which of the following
temperatures?
A. 64 degrees F
B. 68 degrees F
C. 74 degrees F
D. 78 degrees F

255. You are cleaning a client's partial dentures, which have a metal clasp. Which of the following actions
are best on your part?
A. Place a washcloth in the sink where you are cleaning.
B. Remove the partial dentures by the metal clasp.
C. Use hot water to rinse the dentures after cleaning.
D. Soak the partial plate with the metal clasp overnight.

256. A nurse getting report at the beginning of shift learns that an assigned client has hyperpyrexia. The
nurse realizes that this client is experiencing which of the following signs or symptoms?
A. extreme bleeding of the gums
B. a very high fever, such as 41\B0C or 105.8\B0F
C. waxy flexibility of the muscles
D. third-degree burns over much of the body

257. You are ready to take the client's oral temperature. You ask this client how long it has been
since drinking something hot or cold or smoking. The client admits having just drunk a cup of hot coffee.
You will wait how long before taking the temperature?
A. 5 minutes
B. 10 minutes
C. 20 minutes
D. 30 minutes

258. When a nurse is tried under criminal law, the nurse is being brought to trial by:
A. society as a whole.
B. the plaintiff's lawyer.
C. an organization.
D. an individual.

[Link] newly licensed practical/vocational nurse begins work on a hospital unit where LPNs/LVNs are
allowed to start intravenous fluids. The physician orders intravenous fluids to be started on one of this
nurse's assigned clients. Which of the following actions would be most necessary on the part of this newly
hired and newly licensed nurse before starting an intravenous on the client?
A. Check the hospital policy and check on any certification required.
B. Ask another nurse to do a supervised check on administering IVs.
C. Ask one of your nursing-school instructors to refresh your skills.
D. Take a continuing-education IV course to make sure you have the skills.
260. . When working as a licensed vocational nurse, you determine that your client scheduled for surgery
does not understand the physician's earlier explanation of the surgery. The client is asking many questions
about the risks and seems worried. Which of the following actions would be best on your part?
A. Quickly explain the surgery procedures and the risks to the client.
B. Cancel the surgery.
C. Ask your supervising RN to explain the surgery procedure and its risks.
D. Notify the physician.

261.. You are the nurse working with an elderly, competent client who refuses a vitamin B injection
ordered by the physician. The family insists that this injection be given, and you give it while the client is
objecting. Even though the client improves, the client contacts a lawyer. From your knowledge of nursing
and the law, you realize that you:
A. did the right thing because the client improved.
B. should have had the family put their request in writing.
C. have commited an assault against the client.
D. have committed an act of battery against the client.

[Link] an LVN/LPN is working for a health-care organization that has professional liability insurance,
the nurse needs to base a decision on whether to buy individual professional liability insurance on which of
the following things?
A. the possibility that the organization could countersue the nurse in a lawsuit
B. the cost of professional liability insurance to the nurse
C. the amount and type of coverage the health-care organization carries
D. the number of hours worked and the type of nursing work

[Link] documenting an assigned client's record during and at the end of the shift, the nurse must keep
in mind which of the following facts?
A. In order to get the care done for all assigned clients, the charting must be as brief as possible.
B. The proper format, such as SOAP or PIE, as chosen by the hospital, must be adhered to.
C. The chart is a legal document and may be all a nurse has to support care that was given if
called to court.
D. Clients need to be assessed and the care documented at least once every hour during the shift.

[Link] the licensed practical/vocational nurse is checking the physician's orders against the medication
record prior to setting up medications, the nurse discovers a medication error made on the previous shift.
The nurse reports this error to the supervising nurse. Which of the following persons will need to fill out an
incident report?
A. licensed practical/vocational nurse who discovered the error
B. licensed nurse who committed the medication error the previous shift
C. supervising nurse who is in charge of the nursing care unit
D. primary nurse assigned to this client the previous day

[Link] to the nursing code of ethics, when working as a nurse and a conflict comes up between
your client's needs and what the family and/or the physician wants, and/or the hospital policies, your first
loyalty is to the:
A. hospital.
B. client.
C. family.
D. physician.
266. You are a student nurse working as a part-time or temporary nursing assistant in a nursing home.
The nurse on duty asks you to insert a nasogastric tube in a patient. You have recently passed an
examination on putting in a nasogastric tube. Which of the following actions is best on your part?
A. Go ahead and insert the nasogastric tube.
B. Ask the nurse to supervise you while you insert the tube.
C. Call your school instructor for help with your decision.
D. Tell the nurse that you cannot legally insert this tube.

267.. Which of the following strategies can most help you as a nurse to enhance your ethical practice and
client advocacy?
A. reading a book on religions of the world
B. examining and clarifying your own values
C. talking with peers about their beliefs and values
D. buying a nursing book on ethical decisions

268.. Which of the following actions by a practical/vocational nursing student represents the best example
of deductive reasoning?
A. observing that a client is constipated then doing some data gathering on client's health practices
B. assessing a client using Maslow's Hierarchy, then defining client's problem in terms of
nutrition
C. suspecting that a client is not being truthful and checking other sources for information
D. identifying several alternative courses of action and deciding on the best course of action

269. In the daily practice of nursing, nurses use critical thinking in:
A. setting priorities for the day.
B. every decision that is made.
C. calling the pharmacy to obtain a medication.
D. checking supplies in the client's room.

[Link] the nurse problem solves and has implemented a solution from several solutions identified, the
nurse most needs to do which of the following things?
A. Discard the solutions that were not selected for implementation.
B. Implement a second solution, comparing its usefulness with the first solution.
C. Evaluate the effectiveness of the solution implemented.
D. Consider the problem solving completed in this case.

271.. Using Strader's seven-step decision-making process, the nurse needs to first identify the purpose.
What must the nurse do next?
A. Decide who will be involved in the decision.
B. Enlist the cooperation of the client.
C. Set the criteria.
D. Identify solutions.
272.. Nurses, as they progress in their education, will most likely do which of the following things?
A. Learn to develop a personal theory of nursing.
B. Become less interested in bedside nursing.
C. Lose their ability to think critically in clinical areas.
D. Have increased enjoyment when doing paperwork.

273. When nurses assist clients in exploring their lifestyle habits and health behaviors to identify health
risks, nurses are most likely to use which of the following models?
A. medical model B. wellness models
C. psychosocial model D. physiological model

274. The lowest level of needs in Maslow's Hierarchy of Needs is which of the following?
A. safety and security needs
B. love and belonging needs
C. physiologic needs
D. self-esteem needs

275 In Hildegard Peplau's Interpersonal Relations Model, the focus is on which of the following?
A. individual
B. community
C. larger society
D. Family

276. In Virginia Henderson's 1966 definition of nursing, a person/client has which of the following
numbers of fundamental needs ?
A. 7
B. 14
C. 18
D. 22

277. Which of the following therorists stressed energy fields in their nursing theory?
A. Dorothea Orem
B. Helen Neuman
C. Rosemarie Parse
D. Martha E. Rogers

278. Which of the following people have the largest percentage of water in their bodies?
A. fat men
B. lean men
C. lean women
D. fat women

279. When talking with a client about complete and incomplete proteins, which of the following would you
use as the best example of a complete protein?
A. olives
B. rice
C. eggs
D. Nuts

280. In instructing a client on cholesterol, the nurse will teach which of the following things?
A. The body does not need cholesterol.
B. Most cholesterol in the body is destroyed in the small intestine.
C. The majority of cholesterol in the body comes from eating fatty foods.
D. Most cholesterol is synthesized in the liver.

281. A client asks which of the vitamins can be stored in the body. Which of the following answers by
the nurse would be correct?
A. C
B. B1 thiamine
C. Biotin
D. D
282. The newborn infant's stomach capacity is approximately which of the following in milliliters?
A. 50
B. 90
C. 120
D. 160

283. You are feeding a newborn infant in the nursery, as the mother is having some procedure done at
this time. Before the infant finishes taking the contents of the bottle of formula, the infant slowly stops
sucking and falls asleep. Which of the following actions would be best on your part?
A. Wake the baby by tickling the bottoms of the feet and then try feeding.
B. Wait about 30 minutes, then try to get the infant to take the formula.
C. Report this feeding behavior to the supervisor immediately.
D. Discontinue the feeding and allow the infant to sleep at this time.

284. The nurse will teach clients to use which of the following groups from the food pyramid in the
greatest amounts?
A. carbohydrates such as grains, potatoes, and rice
B. vegetables and fruits
C. milk and milk products
D. proteins such as meat and meat products

285. You are working with a client who is on a full liquid diet. The client is demanding some ice cream.
Which of the following responses on your part would be best?
A. Tell the client that ice cream is not allowed on a full liquid diet.
B. Call the physician and report the client\92s demands.
C. Get the client some plain vanilla ice cream.
D. Ask the supervising nurse to talk with the client.

286. The phosphate level of a newborn is best described in which of the following ways when comparing
the newborn's phosphate level with that of an adult?
A. nearly half that of the adult
B. about one fourth that of an adult
C. nearly twice that of an adult
D. approximately the same as an adult

287. The nurse is checking the placement of a nasogastric tube prior to giving medication and a
feeding. Which of the following is the preferred and most accurate method of testing?
A. Insert 5 to 20 mm of air into the tube while listening over the stomach with a stethoscope.
B. Aspirate 20 to 30 ml of gastrointestinal secretions and test the pH.
C. Insert 15 to 20 cc of water into the stomach and listen with the stethoscope.
D. Place an open end of the tube into a glass of water and check for bubbles.

288. Which of the following reasons is the most important, as well as the most widely accepted, reason
for nurses using nursing process?
A. Increase the unique body of knowledge known as nursing.
B. Help clients meet their actual and potential health problems.
C. Communicate with other members of the team.
D. Standardize the care of clients with the same diagnoses.

289. The primary source of data for the client's database is which of the following sources?
A. nurse's recording of health history
B. recent clinic or hospital records
C. physician's history and physical
D. Client

300. Which of the following statements best describes a wellness nursing diagnosis for an individual,
family, or community?
A. clinical judgment of transition to a higher level of wellness
B. nursing judgment that in some area no pathology exists
C. a judgment that in some area there is more wellness than illness
D. statement of an area of family strength to use in interventions

301. When reading the nursing-care plan of a newly assigned client prior to caring for this client, the
LPN/LVN will notice that potential problems are stated using how many parts in the statement?
A. One B. Two
C. Three D. Four

302. The physician writes an order for "progressive ambulation, as tolerated." The RN writes an order for
"Dangle for 5 min. 12 h post op and stand at bedside 24 h post op." The LVN assigned to care for this
client should do which of the following?
A. Call the physician for clarification of the ambulation orders.
B. Check with the State Board of Nursing for an opinion.
C. Check client's vital signs before dangling or standing client.
D. Dangle or stand client only if they are agreeable to this.

303. When does the nurse chart an intervention that involves administering medication to a client?
A. before the end of shift
B. before the next dose of medication or treatment is due
C. within one hour
D. Immediately

304. When writing goals/outcomes for clients, the nurse should do which of the following?
A. Combine related diagnoses and write a goal or goals for this set.
B. Write goals that the treatment team believes are important.
C. Involve the client in determining the goals/desired outcomes.
D. Combine no more than two nursing diagnoses per goal.

[Link] client you are assigned to has four nursing diagnoses. Which of the following would you assign
the highest priority?
A. chest pain related to cough secondary to pneumonia
B. self-care deficit related to activity intolerance secondary to sleep-pattern disturbance
C. risk for altered family processes secondary to hospitalization
D. self-esteem deficit situational

306. Which of the following activities on the part of the nurse most demonstrates individualization of the
nursing-care plan for a client?
A. Include client's preferred times of care and methods used.
B. Write the care plan instead of taking it off the computer.
C. Use a care plan from a book but add some things to it.
D. Select nursing diagnoses that match the client's problems
307. You are doing the evaluation step of the nursing process and find that two of the goals for the client
have not been met. Which of the following actions would be best on your part?
A. Stop working on these goals, as evaluation is the last step.
B. Assess client's motivation for complying with the care plan.
C. Reassess problem and then review care plan and revise as needed.
D. Determine if the client has a knowledge deficit causing nonattainment.

308. When you discover an electrical fire and decide you need a fire extinguisher, you will need to find a
fire extinguisher that is rated for which class of fire?
A. Class A
B. Class B
C. Class C
D. Class E

309. Which of the following statements is an OBRA regulation that the nurse must keep in mind when
considering applying a restraint to a client?
A. Apply physical restraints as a first-choice intervention in fall prevention.
B. The physician's order for restraints must be time limited.
C. Verbal or telephone orders for restraints must be signed within 72 hours.
D. Restraints cannot be applied if a family member objects.

310. When restraining a client in bed with a sleeveless jacket (vest) with straps, you will do which
of the following things?
A. Tie the straps to the side rails.
B. Tie the straps to the movable part of the bed frame.
C. Tie the straps with a square knot.
D. Tie the straps with a quick-release knot.

311. When you encounter the victim of an electrical-current injury who is still holding an electrical
appliance, you would do which of the following things first?
A. Move the client to a safe place immediately.
B. Unplug the electrical cord before moving client.
C. Shut off the electrical current.
D. Check for a carotid pulse and for respirations.

312. When instructing the family of a client who has diabetes with neuropathy causing impaired skin
sensitivity, you would stress the importance of which one of the following things in regard to showering or
bathing?
A. cleaning the tub or shower with full-strength peroxide
B. drying well after the shower or bath
C. applying lotion after the shower or bath
D. a method for assuring the water temperature is not hot
313. The nurse finds that an assigned client is restless, agitated, and confused and is thinking of
restraining the client. Which of the following questions is most important for the nurse to ask?
A. "Which restraint is most appropriate?"
B. "Will I be able to get an order for a restraint?"
C. "What is the underlying cause of the restless, agitated, confused behavior?"
D. "Could I try some medication to relax the client prior to using restraints?"

314. The nurse giving discharge instructions advises the client to get out of bed slowly and to get up in
stages from lying to sitting to standing. The client understands that the reason for doing this is:
A. to prevent falls.
B. to improve circulation.
C. as a warm-up exercise.
D. to increase oxygenation.

315. Which of the following interventions on the part of the nurse would most help a confused ambulatory
client find their room?
A. having large room numbers on the door
B. placing a picture on the door
C. giving hourly reorientation to the correct room
D. pinning the client's room number on their attire

316. When assessing the noise level that clients are exposed to, the nurse is aware that levels below
which of the following number of decibels is usually safe in terms of hearing?
A. 85 B. 95
C. 110 D. 120

317. One of your assigned clients who is scheduled for radiation therapy asks you to stay with her during
radiation because she is scared. Your best response to this request would be which of the following
responses?
A. "Let's think of how to reduce your fear, as I must stay a distance away."
B. "I will be right there with you, and I will hold your hand so you won't be afraid."
C. "It is not necessary to be afraid, as nothing bad will happen to you."
D. "I will see if I can get permission from your doctor and the X-ray department."

318. A true pathogen will cause disease or infection:

A. in a healthy person.
B. only in an immuno-compromised person.
C. in persons with allergy to the pathogen.
D. in very few people.

319. A client asks you to explain viruses. Which of the following statements would be true and therefore
best to include in your answer?
A. "Viruses are the most common agent causing infection."
B. "Viruses are commonly found in the intestinal tract."
C. "Viruses must enter into living cells to reproduce."
D. Candida is one of the most common viruses."

320. The nursing supervisor has asked the staff to reduce the number of iatrogenic infections on the
unit. Which of the following actions on your part would contribute to reducing iatrogenic infections?
A. teaching correct hand washing to assigned clients
B. using correct procedures in starting and caring for an intravenous infusion
C. properly bagging soiled linens and disposed items used for a client in isolation
D. isolating a client who has just been diagnosed as having tuberculosis
321 Your assigned client has encephalitis, and there are other cases in the community. In a team meeting
regarding your client and prevention of other cases of encephalitis, the nurse supervisor talks about
breaking the chain of infection at the second link: the reservoir. You realize the nurse supervisor is talking
about which of the following things?
A. an area for the storage and filtering of water
B. a place where the microorganism enters the body
C. the place where the microorganism naturally lives
D. the microorganism itself
322. On a home visit, you notice some dust on a vent in your client's room and on the windowsill. Which
of the following methods would you teach the family to use for removing dust?
A. Use a damp cloth to remove the dust.
B. Use a feather duster to remove dust.
C. Vacuum up the dust.
D. Use a broom covered with a cloth.

323. A client asks you how to best prevent vaginal infections. Your best answer would include which of
the following statements?
A. "I would suggest a vinegar douche."
B. "The pH of the vaginal secretions stops many disease-producing bacteria."
C. "Drinking cranberry juice will prevent most all of the vaginal infections."
D. "Your doctor can prescribe a medication that will prevent vaginal infections."

324. You would refer to the early phase of scar tissue formation as which of the following kinds of tissue?
A. Keloid B. Cicatrix
C. granulation D. Fibrous

325. Which of the following situations represents the best example of passive immunity?
A. a child receiving a vaccination for measles
B. an infant receiving breast milk from the mother
C. production of antibodies by a person with infection
D. a person receiving antibiotics for an infection

[Link] are working with a client who has cancer and is undergoing treatment. The client complains of a
loss of appetite. You will most need to make certain that your client eats which one of the following foods?
A. fresh fruits B. raw vegetables
C. carbohydrates D. Protein

327. Your assigned client has a leg ulcer that has a dressing on it. During your assessment, you find that
the dressing is wet. The client admits to spilling water on the dressing. What action would be best on your
part?
A. Reinforce the dressing with a dry dressing.
B. Remove wet dressing and apply new dressing.
C. Dry the dressing with a hair dryer.
D. Let the room air dry the dressing.

328. A fellow nurse who is working on another unit asks to read the chart of your assigned client. Which
one of the following criteria would enable the nurse to have access to the chart?
A. Be unrelated to the client.
B. Have a current nursing license.
C. Have client's verbal permission.
D. Be directly involved in client's care.

[Link] charting in the client's record or chart, the nurse most needs to do which one of the following
things?
A. Date and sign each entry.
B. Chart every two hours.
C. Use ballpoint pen and not pencil.
D. Cross out errors so others can't read them.
330. While giving a shift report on your assigned client, you realize that you forgot to record a nursing
procedure done on your client. Which of the following methods of documentation would be best on your
part?
A. Write the procedure between the two lines of your shift documentation closest to the occurrence.
B. Find a blank space in your earlier charting, and chart the procedure in that space.
C. Tell the oncoming nurse to chart the procedure for you and to cite the time it was done.
D. Chart the current date and time and "Late entry," indicating when and what was done.

331. One of your assigned clients gets up to go to the bathroom without calling you. The client falls to the
floor and calls for help. You answer the call and alert your supervisor. After assuring that the vital signs
are normal and there does not appear to be any injuries, you are told to fill out an incident report. In
addition to noting that the client was found on the floor, which of the following statements would you most
need to record in the nursing notes for the client?
A. "Incident report completed."
B. the reason the client was unattended
C. the vital signs and assessment of the client
D. location of the incident report

332. When the physician telephones to order a therapy such as a medication for the client of a student
nurse, who is the best person to take this telephone order?
A. whoever is authorized by hospital policy
B. the student nurse giving the client's care
C. the student nurse's instructor
D. any licensed nurse on duty

333. The nurse is sending some lab results to the primary physician's office. The nurse most needs to do
which of the following things?
A. Make a note that the fax was sent and what time it was sent in the nurses notes.
B. Document a follow-up telephone call verifying the receipt of information and who received
it.
C. Leave a note to the physician in the client's record saying what information was faxed and when.
D. Check with the laboratory to see if they have already provided the physician with the results.

[Link] the Problem Oriented Medical Record documentation system (POMR), which of the following
answers best represents the person or persons who may contribute to the problem list representing the
client's physiologic, psychologic, social, cultural, spiritual, developmental, and environmental needs?
A. the primary nurse
B. the assigned social worker
C. registered nurses and the physician
D. all caregivers

335. When working in a facility that uses focus charting, the nurse will use which of the following as a
focus of care?
A. problems identified in the initial assessment
B. maximum level of functioning
C. client identified goals and objectives
D. client concerns and strengths

336. When the nurse's assigned client is being discharged to another institution or a home setting where a
visit by the community health nurse is required, which of the following information is most likely to be
included in the discharge and referral summaries?
A. unresolved health-care problems and continuing care needs
B. an assessment of the family's financial assets and deficits
C. a copy of the discharge order signed by the physician
D. a new plan of care for the client and the family

337. Which of the following words represents the basic unit of all life and is the simplest structure that
possesses all the characteristics of life: organization, metabolism, responsiveness, homeostasis, growth,
and reproduction?
A. the cell B. a gene
C. a chromosome D. the organelles

338. Which of the following cells of the body are in almost constant mitosis?
A. nerve cells
B. stomach cells
C. muscle cells
D. renal cells

339. Where is ribosomal RNA used in protein synthesis produced?

A. organelles
B. mitochondria
C. Golgi apparatus
D. Centrioles

340. Tissue in the urinary bladder called transitional epithelium is best described in which of the following
ways?
A. changes from cuboidal to columnar
B. are single layer and not stratified
C. contain a special elastic substance to aid in expansion
D. change shape depending on the bladder's fullness
Ans: D

[Link] teaching someone about endocrine glands, which of the following statements could you use?
A. "The endocrine glands include sweat and sebaceous glands."
B. "Endocrine glands all have at least one duct."
C. "Hormones are carried away from the endocrine gland by the blood.
D. "There is no epithelial tissue in endocrine glands."

[Link] vocal cords have and function with which of the following kinds of tissue?
A. liquid connective tissue
B. hard connective tissue
C. fibrous connective tissue
D. soft connective tissue

343. The thoracic and abdominopelvic cavities are divided by which of the following body structures?
A. rib cage B. diaphragm
C. sternum D. Stomach

344. The body's biggest organ is which of the following components of the body?
A. large intestine B. the skin
C. small intestine D. Kidneys
345. The skeletal system acts as a storehouse for calcium, which is a very important component in muscle
contractions, as well as which of the following activities in the body?
A. producing testosterone
B. preventing seizures
C. making lymph
D. blood clotting

[Link] reading an autopsy report, the nurse encounters the term "mid-sagittal plane." This nurse
understands that this means the body was viewed using a plane that matched which of the following
descriptions?
A. This plane cuts the body horizontally.
B. This plane divides the body into front and back portions.
C. The body is separated into left and right equal portions.
D. The body is divided using an X across the chest.

[Link] nurse receives a report at the beginning of the shift and learns that the client scores 7 on the
Glasgow Coma Scale. The nurse realizes that this client is at which of the following levels of
consciousness?
A. comatose
B. moderate disability
C. severe disability
D. fully alert
Ans: A,D

348. You partially darken a room and ask the client to look straight ahead. You use a penlight and,
approaching from the side you shine the light, it constricts. You remove the light and then shine it on the
same pupil again. You also observe the response of the other pupil. You would normally find the other
pupil doing which of the following things?
A. not make any change in size
B. dilate in an oppositional response to the light
C. first constrict, then dilate larger than the other pupil
D. constrict in consensual response

349. The nurse is preparing to do a focused assessment of the abdomen on an assigned client. Which of
the following is most important for the nurse to do prior to the examination?
A. Have client empty their bladder.
B. Gather equipment.
C. Place client in semi-Fowler's position.
D. Remove any dressings from abdomen.

350. The physician of your assigned client tells you that the client has a heart murmur that can be
detected by direct auscultation. You realize that the physician is telling you which of the following things?
A. Use of a stethoscope is necessary to hear the murmur.
B. The murmur can be heard by using only the ear.
C. An ultrasound is necessary to find this murmur.
D. A Doplar device will be needed to find the murmur.

351. When weighing a client daily, you will most need to weigh the client at which of the following times?
A. when most rested
B. at the same time each day
C. after the shower or bath
D. when higher priorities are completed

352. When counting the apical pulse during the physical assessment, it is the most accepted practice for
the nurse to count the apical pulse in which of the following ways?
A. for 15 seconds and multiply by four
B. for 30 seconds and multiply by two
C. for one minute, checking radial pulse at the same time
D. for one full minute

353. While listening to a client's lung sounds, you hear something that you believe is not normal, and you
note that it is a continuous sound. You will chart this as which of the following findings?
A. crackles
B. Rales
C. adventitious sounds
D. pleral friction rub

354. When examining the client's abdomen, the nurse will most facilitate the examination by positioning
the client in which of the following ways?
A. supine with small pillows beneath knees and head
B. semi-Fowler's position with knees extended
C. sitting in the chair with legs elevated
D. supine with arms extended and hands behind head

[Link] highly suspect that your assigned client has abdominal distention. You most need to do and chart
which of the following things?
A. Have another nurse verify your suspicions.
B. Measure the abdominal girth at the umbilicus.
C. Measure abdominal girth at the most distended level.
D. Ask the client if they are distended.

356. When a client's skin is dry, which of the following nursing interventions would be most helpful?
A. Limit bathing to once or twice a week.
B. Bathing is daily, but no soap is used.
C. Bathing daily with mineral oil added to the water.
D. Bathing with lotion instead of water.

[Link] which of the following clients is a rectal temperature most usually contraindicated?
A. client who has had a myocardial infarction
B. client with Parkinson's disease
C. client who is prone to seizures
D. client with neuropathology associated with diabetes

358. When taking a radial pulse for half a minute, the nurse finds it to be irregular. Which of the following
would be best for the nurse to do next?
A. Take the radial pulse for one minute.
B. Check the carotid pulse to see if it is irregular.
C. Assess the apical pulse.
D. Chart the radial pulse and the irregularities.
359. The nurse wants to check the popliteal pulse. This pulse can be better palpated if the nurse does
which of the following things?
A. Ask the client to extend the knee.
B. Have the client flex the knee.
C. Press lightly on the right side of the front of the knee.
D. Palpate more deeply than for other pulses.
Ans: B

360. The nurse positioning a client after surgery will take into account that the position, which most often
predisposes a client to physiologic processes that suppress respiration, is which of the following positions?
A. Fowler's position
B. Prone
C. Supine
D. left side lying down

361. The nurse is taking the client's blood pressure. The physician asks for the pulse pressure. To obtain
the pulse pressure, the nurse will have to do which of the following things?
A. Obtain a pulse-pressure machine.
B. Subtract the diastolic blood pressure from the systolic.
C. Subtract the systolic blood pressure from the diastolic.
D. Take client's apical pulse and subtract it from systolic.

362. The nurse notices that the client has a hematocrit of 70 percent. This level of hematocrit will most
likely affect the vital signs in which of the following ways?
A. The blood pressure will be elevated.
B. The pulse will be low.
C. Temperature will be elevated.
D. Blood pressure will be low.

363. The nurse finds that a newborn has a mean systolic pressure of 75 mmHg. How would this blood
pressure be best described?
A. Normal B. slightly low
C. very low D. slightly high

364. When working with clients experiencing pain, you will define their pain in regard to whether they
have pain or not and how intense it is based on which of the following things?
A. nursing experience and expertise
B. the underlying cause of the pain
C. whatever the experiencing person says it is.
D. current medical and pharmacological research

365 When pain impulses are transmitted via the A-delta fibers, which of the following types of pain will
your client have?
A. sharp, pricking pain
B. throbbing pain
C. burning pain
D. intermittent stabbing pain

[Link] assigned client, who has been talking with the doctor about pain control, later asks you what the
doctor meant by "pain threshold." Which of the following would be the best reply?
A. the point at which pain medication brings relief
B. the maximum amount of pain a person can tolerate
C. the amount of pain the average person can tolerate
D. the amount of pain stimulation that it takes to cause pain

367. Which one of the following four clients is most likely to tolerate pain best?
A. a client with rheumatoid arthritis
B. a client who has terminal cancer in stage 1 of grief
C. an athlete having a knee surgery to prolong his career
D. a client who has a migraine headache

368. You are caring for a client who has just returned from surgery and has received intravenous
morphine minutes before leaving the recovery room. You need to assess the client's pain now and again at
which of the following times?
A. in 20 to 30 minutes
B. in one hour
C. in two hours
D. in 3 to 4 hours

369. Your assigned client seems to be getting a lot of attention from his mother when he complains of
pain. The mother may be encouraging which of the following types of gains?
A. primary gains
B. secondary gains
C. narcissistic gains
D. egocentric gains

370. When giving a client a diagnosis of acute pain, the nurse "using NANDA diagnostic categories" will
use this diagnosis only when the pain last no longer than which of the following lengths of time?
A. 3 days
B. 2 weeks
C. 1 month
D. 6 months

[Link] nurse visiting a client and the client's family in the home teaches family members to massage the
client's back and enlists their aid in providing backrubs. Which of the following reasons most likely
represents the main reason the nurse has enlisted the aid of the family?
A. It may diminish feelings of helplessness in family members.
B. The client may need a backrub when the nurse is gone.
C. Backrubs reduce the need for addicting medications.
D. The client will be able to get more sleep and rest.

372.A 28-month-old child with severe diarrhea is admitted. Upon assessment the child is feverish, has dry
lips and irritable. What is your first nursing priority upon admission?
a. Asses the hydration status
b. Assess the skin turgor
c. Obtain the apical-radial cardiac rate
d. Weigh the child
Answer: A The most critical part upon admission is the hydration status of the patient. While all
the answers were correct and important, the first objective is the hydration status of the child.

373..You were assigned to a patient. Upon assessment, the patient elicited Homan’s sign. What is the
nursing priority using this assessment?
a. Encourage fluid and electrolyte balance
b. Encourage good venous circulation
c. Secure patent airway
d. Promote skin care
Answer: B Promoting venous return flow may prevent thrombophlebitis. A sign that a patient
may suffer from thrombophlebitis is called Homan’s sign. The other goals are not well indicated
in the assessment.

374..You were assigned to a patient with a nasogastric tube attached for almost three days. It is time to
irrigate it, what is the protocol that you will follow?
a. A 30 mL sterile saline must be forcefully instilled and provide a basin to catch the return flow.
b. A 20 mL sterile saline must be gently instilled and provide a basin to catch the return flow.
c. Instill 30 mL sterile water and then withdraw solution.
d. Gently instill 20 mL normal saline and then withdraw solution.

Answer: D The proper way to irrigate the nasogastric tube is to use gentle pressure during the
instillation of the normal saline solution. Withdrawing the solution afterwards can end the
procedure. Gentle pressure is needed in order to preserve the integrity of the stomach walls.

375..A nurse therapeutically responds to a patient with AIDS when he expressed feelings of depression
and facing death with the following phrase: “Are you afraid of dying?” What type of therapeutic technique
is she using?
a. Using open-ended question
b. Using a close-ended question
c. Using a leading question
d. Mirroring

Answer: A Open-ended questions can help the patient verbalize his feelings. It helps the nurse
explore the thoughts of the patient in order to provide a means of nursing care in terms of
psychological support and as an active listener.

[Link] role does a nurse exhibits if she stands to protect the needs and wishes of the patient?
a. Caregiver
b. Counselor
c. Teacher
d. Client advocate

Answer: D As a client advocate, the nurse protects the interests of the client. She represents
the patient when the patient is not able to voice out his or her needs. She may also relay
information to the physician when the patient is not able to represent himself.

377.A post appendectomy patient is assigned to you. You have assessed him that he needs more
knowledge about proper wound care. What role should you apply in this situation?
a. Role Model
b. Counselor
c. Caregiver
d. Teacher
Answer: D Being a teacher in this situation means that you must allow the patient to learn
proper wound care on his own. As a teacher, the nurse helps the client to learn about their
health and health care procedures.
[Link] on your night rounds, you have noticed two nursing aides placing bed sheets that they have
taken from the floor. What is the proper nursing action?
a. Confront the two nursing aides about their and actions and call them for private counseling
b. Continue your night rounds, they have their own liabilities on their actions.
c. Remind them the principle of medical asepsis
d. Provide a clothes basket for them
Answer: C As a part of the healthcare team, nurses should be able to know that they have
responsibility on the situation above. In order to correct the behavior of the two nursing aides,
they must understand the reason to change the beddings. Giving them information about the
germ transmission is the appropriate approach.

[Link] a burn patient, in order to promote adequate fluid within 24 hours, what intravenous fluid is
appropriate?
a. D5 Water
b. Lactated Ringer’s Solution
c. 0.9% NaCl Solution
d. D5NSS
Answer: B Lactated Ringer’s Solution must be used within the first 24 hours. Colloids such as
D5Water and D5 NSS increase capillary permeability which may increase the risk of pulmonary
edema.

[Link] assigned in a pediatric ward, what is the characteristic sign of a normal psychosocial
development of a toddler?
a. Erikson’s stage of initiative vs. guilt
b. Imaginary playmates.
c. Negative behavior
d. Demonstrations of sexual curiosity.
Answer: C Assertion of automony is seen in 2 to 21/2-year-old toddlers as they begin their
language and social development. The stage of initiative vs. guilt (2) is more common in the
preschool-age child, 3 to 6 years. At 3 to 4 years of age, children have imaginary playmates
(1).

[Link] stress, all of the following describes its characteristics except:

a. Stress response is natural, productive and adaptive
b. Stress is not always a result of damage to the body
c. Stress always results to a feeling of distress
d. Stress involves the entire body as a whole
Answer: C Stress does not always result in feelings of distress such as harmful or unpleasant
stress. The others options definitely describes stress.

382..A one-year-old child is admitted. Looking into the physical development of the child, what will be
affected or may have a delay?
a. Walking
b. Sitting
c. Running
d. Crawling
Answer: A A 1-year-old child normally learns to walk. Any interruption on this development
such as physical stress and hospitalization can affect the normal development. The child should
sit (4) by 6 months and should already be crawling (1) by 1 year of age
383..A mother is concerned about the diet of her child that has noncomplicated acute glomerulonephritis.
What is the appropriate diet regimen you must teach as a nurse?
a. Low-protein, low-potassium diet.
b. Regular diet, no added salt.
c. Low-sodium, low-protein diet.
d. Low-sodium, high-protein diet.
Answer: B)A regular diet with moderate sodium is suggested for children who are in acute
glomerulonephritis. If the client’s condition progresses to renal failure, sodium, potassium, and
protein are restricted

384..A patient is on Respiratory Isolation for Tuberculosis (TB). Which of the following would be an
indicator for removal of Isolation Precautions?
a. Sputum Culture is negative for AFB, following a course of INH and PAS
b. Patient has been on Anti-Tubercular Drug Therapy with INH for one month’s time
c. Patient has no infiltrates on chest x-ray
d. Absence of adventitious breath sounds
Answer: A)Clients who have been on anti-TB drug regimes for at least 2-3 weeks and have
absence of AFB in at least two successive sputum cultures, no longer need to be on Respiratory
Isolation. Taking medication alone, or the absence of adventitious breath sounds such as
rhonchi, rales, etc, or the absence of infiltrates on chest x-ray, usually seen with Pneumonia
would not be a reason to D/C Isolation, making choices (b), (c), and (d) incorrect.

385.A client is diagnosed to have Congestive Heart Failure. Upon auscultating the client’s lungs the nurse
hears crackling sounds bilaterally at the bases. What term should you use in documenting this finding?
a. Rhonchi
b. Wheezing
c. Rales
d. Atelectasis
. Answer: C) Rales are defined as abnormal lung sounds which is crackling in nature. Rhonchi is
characterized by dry coarse sounds which is present when the patient coughs. Wheezes is
common upon expiration and denotes narrowed passages.

[Link] of the following response of a 10-year-old patient with acute appendicitis is an alarming sign?
a. “My pain has gone away. b. “I am afraid to have surgery.”
c. I feel hot and thirsty. d.I feel better with my legs up towards my chest
Answer: A) The classic finding when an appendix ruptures is a sudden cessation of pain.
Options b, c and dare expected findings for a child of this age who is diagnosed with acute
appendicitis.

387..A nurse assigned to a child with Acute Glomerulonephritis is picking up doctor’s orders to put in the
Kardex. Which of the orders should the nurse question?
a. Bed rest b. Daily weights
c. Daily blood pressure d. Strict I & O
Answer: C.) Blood pressure elevation signals a frequent complication associated with Acute
Glomerulonephritis. The nurse should expect to assess blood pressure every 2 to 4 hours with
vital signs. Options a, b and d are appropriate orders for a child with Acute Glomerulonephritis

[Link] are assigned to speak to a group of High School students about HIV and AIDS. In discussing
transmission the nurse knows that the highest concentration of the HIV virus in infected patients is in the:
a. Saliva b. Cerebrospinal Fluid
c. Blood d. Semen
Answer: C) The HIV virus has been found and isolated in all of the above body fluids, as well as
in the stool and urine. However, the highest concentration is found in the blood of infected
individuals.

[Link] of the following is an INCORRECT statement regarding diet therapy for a patient in renal
failure?
a. Limit dietary protein
b. Provide a diet high in carbohydrates
c. Limit Sodium (NA) intake
d. Provide a diet high in Potassium rich food
Answer: D)Patients with renal failure should have a diet that provides (high biologic value)
proteins rich foods such as eggs, dairy products and meats. These are necessary to maintain a
positive nitrogen balance. Foods high in calories are also necessary, and sodium intake should
be limited. Foods high in Potassium should be AVOIDED due to decreased ability of the
kidney(s) to filter and excrete Potassium.

[Link] teaching HIV in high school students, what is the appropriate health practice that the nurse should
emphasize?
a. Wash with antibacterial soap immediately after intercourse.
b. Use a latex condom and water soluble during intercourse
c. After oral sex, use anti-bacterial mouth wash to destroy the HIV virus
d. Abstain from intercourse if the female partner is having her menstrual period.
. Answer: A) Although abstinence is still the best protection against spread of the HIV virus,
the use of a latex condom with a H20 soluble lubricant is the most effective means. Other
choices does not give assurance of preventing acquiring HIV virus.

[Link] of the following is appropriate in a depressed patient?

a. Using silence
b. Passive Friendliness
c. Using open-ended questions
d. Giving information
Answer: C.) Using open-ended questions can allow the patient with depression to voice out his
or her problems or what is bothering him or her. Using silence at this time is not appropriate as
well as with the other options.

392..In a geriatric unit, you have noticed that one patient seemed to change his behavior. Which of the
following symptoms DOES NOT indicate that the patient is going into depression?
a. Being talkative b. Sleeplessness
c. Complains of getting tired easily
d. Change in appetite
Answer: A) Being talkative indicates that the patient may be developing dementia.

393..In admitting elderly patient, it is a nurse’s goal to orient the patient. What is the effective nursing
action in order to prevent disorientation?
a. Secure the side rails up all the time
b. Do routine rounds c. Leave a night light
d. Orient the patient every night before he or she sleeps
Answer: D) Elderly patients, are at a higher risk for sustaining injuries, especially in unfamiliar
surroundings. While other choices are potential interventions that the nurse could implement,
choice (c.) would allow the patient to better visualize the surroundings, delimiting possible
accidents or falls. Orienting the patient, as well as checking the patient, and keeping side rails
up are also importan , each patient must be assessed individually to determine which
measure(s) should be employed

[Link] assessing the cranial nerve function, a nurse finds out that a patient has a difficulty in determining
the different scents when the eyes is closed. Which of the following cranial nerve had a problem?
a. CN III b. CN II
c. CN I d. CN V
Answer: C) The cranial nerve I or olfactory nerve is responsible to take in the scents and send
signals to the brain.

[Link] is the proper order in the physical assessment when it comes to examination of the abdomen?
a. Auscultation, Inspection, Percussion, Palpation
b. Inspection, Auscultation, Percussion, Palpation
c. Palpation, Percussion, Inspection, Auscultation
d. Inspection, Percussion, Palpation, Auscultation
Answer: B) Percussion is first done in order to assess all the quadrants and the next is
palpation which involves direct pressure. This step can also elicit pain or dullness.

[Link] examining a patient with asthma in exacerbation, what lung sound is predominant?
a. Crackles
b. Pleural rub
c. Gurgles
d. Wheezes
Answer: D) Wheezes is continuous, lengthy, musical heard during inspiration or expiration. It
is common to those with asthma since there is an active narrowing of the bronchioles.

397. The client presented with complaints of body weakness, dizziness and chest pain. Upon careful
assessment, the nurse suspects Angina Pectoris. Which of the following statements made by the client can
confirm this?
a. “I suddenly felt a pain on my chest which radiates to my back and arms”.
b. “I suddenly felt a sharp pain on my lower abdomen”.
c. “The pain does not subside even if I rest”.
d. “The pain goes all the way down to my stomach”.
Answer: A ) Angina pectoris is a substernal pain that radiates to the neck, jaw, back and arms
and is relieved by rest. Lower abdominal pain may indicate other gastrointestinal problems

[Link] client from the OR is transferred to the post-anesthesia care unit after surgical repair of
abdominal aortic aneurysm. Which of the following assessment findings would indicate that the repair was
successful?
a. Urine output of 50 mL/hr.
b. Presence of non-pitting, peripheral edema.
c. Clear sclera.
d. Presence of carotid bruit.
Answer: A) 50 mL/hr is the normal urine output. A normal urine output indicates that there is a
good renal perfusion, and also connotes that the client is hemodynamically stable, therefore,
the repair is successful.

[Link] client is scheduled for cardiac catheterization because the physician wants to view the right side
of the heart. Which of the following would the nurse expect to see in this procedure?
a. A dye is injected to facilitate the viewing of the heart
b. Thallium is injected to facilitate the scintillation camera
c. A probe with a transducer tip is swallowed by the client.
d. A tiny ultrasound probe is inserted into the coronary artery

Answer: A) In cardiac catheterization or coronary angiogram, a catheter is inserted into the

heart via a vein to measure the ventricular function. A dye is used to provide further
assessment of the structure and motion of the heart. Thallium is a radioactive isotope injected
parenterally so that the scintillation camera can count the radioactive uptake. This is observed
when a physician requests for a Nuclear Cardiology test. When performing a Transesophageal
Echocardiogram (TEE), a probe with a transducer tip is swallowed by the client to visualize for
valvular abnormalities, possible thrombus, bacterial endocarditis and any congenital heart
defects. When performing an Intracoronary Ultrasound, a tiny ultrasound probe is inserted into
the coronary artery to evaluate for plaque size and consistency, arterial walls and effectiveness
of the treatment.

400. The client is being treated for hypovolemia. To assess the effectiveness of the treatment, the Central
Venous Pressure (CVP) of the client is being monitored. Which of the following is TRUE about CVP?
a. The CVP is measured with a central venous line in the inferior vena cava.
b. The normal CVP is 7 to 9 mmHg.
c. The zero point on the transducer needs to be at the level of the left atrium.
d. The client needs to be supine, with the head of the bed elevated at 45 degrees.
Answer: D) The central venous pressure is within the superior vena cava. The Normal CVP is 2-
6 mmHg. A decrease in the CVP indicates a decrease in the circulating blood volume, which
may be a result of hemorrhage or fluid imbalances. The right atrium is located at the
midaxillary line at the fourth intercostal space, and the zero point on the transducer needs to
be at the level of the right atrium. The client needs to be supine, with the head of the bed
elevated at 45 degrees to correctly assess the CVP.

[Link] client’s ECG tracing shows ventricular tachycardia secondary to low magnesium level. Which of
the following electrocardiogram tracing results is consistent with this finding?
a. The appearance of a U wave
b. Shortened ST segment and a widened T wave.
c. Tall, peaked T waves
d. Tall T waves and depressed ST segment
Answer: D) In hypokalemia, the electrocardiogram may show flattening and inversion of the T
wave, the appearance of a U wave, and ST depression. Hypercalcemia can cause a shortened ST
and widened T wave. The electrocardiogram of a hyperkalemic client shows tall peak T waves,
widened QRS complexes, prolonged PR intervals or flat P waves.

[Link] nurse is teaching the client how to use a dry powder inhaler (DPI). Which of the following are
correct instructions given by the nurse? Select All That Apply.
a. Load the drug first by turning to the next dose of drug, or inserting the capsule into the device, or
inserting the disk or compartment into the device.
b. Never wash or place the inhaler in water.
c. Shake your inhaler prior to use.
d. The drug is a dry powder that is why you will taste the drug as you inhale.
e. Never exhale into the inhaler.
f. Do not remove the inhaler from your mouth as soon as you have breathe in.
Answer: A, B, E: Loading of drug depends on the type of dry powder inhaler. Take note that
some dry powder inhalers do not require loading. Dry powder inhalers are kept dry always and
are place at room temperature. Never shake a dry powder inhaler. It is not a pressurized
container. There is no propellant, only the client’s breath can pull the drug in. Because the drug
is a dry powder and there is no propellant, the client will not feel, smell, or taste the drug
during inhalation. The client’s breath will moisten the powder causing it to clump and not be
delivered accurately. Immediately after inhalation of drug, the inhaler must be removed from
the client’s mouth to prevent moisture.

[Link] nurse is assigned to render care for a client who has a chest tube drainage system. Which of the
following are appropriate nursing actions? Select All That Apply.
a. Strip the chest tube.
b. Empty collection chamber when the drainage makes contact to the bottom of the tube.
c. Keep chest tube as straight as possible.
d. Notify the physician of drainage is greater than 70mL/hr.
e. Assess bubbling in the water seal chamber.
f. Keep drainage system at the level of the client’s chest
Answer: C, D, E: Stripping is not allowed. Also when changing the drainage system or when
checking air leaks, clamp the chest tube for short periods only. Emptying of collection chamber
or changing the drainage system should be done before the drainage comes in contact with the
bottom of the tube. Avoid kinks and dependent loops to allow effective drainage and prevent
disrupting the system. Report excessive drainage that is cloudy or red. Drainage will often
increase with position changes or coughing.

[Link] client with DKA is receiving bicarbonate IV infusion for treatment of severe metabolic acidosis.
The nurse notes that the latest ABG shows a pH of 7.0. What should the nurse keep in mind in giving the
drug?
a. Check vital signs before giving the drug and monitor serum sodium level.
b. Perform a sensitivity test prior to drug administration.
c. Mix the drug with D10W 500 ml IV fluid and infuse for over 4 to 8 hours.
d. Administer the drug slowly and monitor the potassium level
. Answer: D) Rationale: Sodium Bicarbonate should be slowly administered because fast
infusion may result to abrupt reduction of serum potassium level which can eventually lead to
arrhythmias. Diluting or mixing the drug with hypotonic solution (i.e. D5W) or isotonic solution
(0.9% NaCl) can be ordered but not with hypertonic solution (I.e D10W).

[Link] client with a gunshot wound on the abdomen starts to get lethargic, is breathing heavily, and the
wound dressing is fully soaked with blood. The nurse is expected to immediately perform which of the
following actions?
a. Loosen tight clothing and administer oxygen supply.
b. Apply warm blanket to prevent heat loss.
c. Apply large gauze on the bleeding site to put direct pressure or place a tourniquet on the artery near
the bleeding site.
d. Initiate IV access.
Answer: D: Loosening tight clothing, applying warm blanket to prevent heat loss, and
administering oxygen supply might help but is not the priority this time. Direct pressure over
the bleeding site is a priority to prevent shock but placing a tourniquet on the artery is done by
a surgeon. Because the client is showing signs of altered mental status, there is likely less
perfusion in the brain, which calls for fluid resuscitation. At least two IV access allows
administration of fluids – crystalloid, blood or clotting factors as necessary which is vital in
correcting acidosis, hypothermia and coagulopathy, and to restore perfusion rapidly.

[Link] nurse is providing home instructions to a client with increased adrenocorticotrophic hormone. The
nurse is aware that the client with excessive corticosteroids is suffering from what condition?
a. Cushing’s syndrome b. Addison’s disease
c. Hypothyroidism d. SIADH
Answer: A: Cushing’s syndrome is clinically defined as the presence of excessive
corticosteroids. Addison’s disease is clinically defined as adrenocortical insufficiency.
Hypothyroidism is a condition wherein there is insufficient thyroid hormone produced by the
thyroid glands while SIADH is characterized by excessive release of anti-diuretic hormone.

[Link] nurse is assigned to a post-thyroidectomy client and is monitoring for signs of hypocalcemia. The
nurse gently tapped the area below the zygomatic bone just in front of the ear. This action will elicit:
a. Facial tremor b. Hyperreflexia
c. Chvostek sign d. Trousseau sign
Answer: C: Facial tremors will occur even without performing a specific maneuver. Exaggerated
reflexes such as hyperreflexia can be assessed by performing a different maneuver. Gentle
tapping of the area below the zygomatic bone just in front of the ear is used to elicit Chvostek
sign to assess the presence of hypocalcemia. Trousseau sign is characterized by spasm of the
muscles of the hand and forearm upon inflation of a BP cuff on it.

[Link] nurse is caring for a client with an antineoplastic IV hooked on the right hand. The nurse notices
that IV site is swelling and feels cool when touched. The nurse recognizes this as extravasation. This
predisposes the client to develop which among the following complications? Select all that apply.
a. Infection b. Tissue necrosis
c. Disfigurement d. Loss of function
e. Amputationf. Delayed healing
Answer: A, B, C, D, E and F: The leaking of vesicant drugs into surrounding tissue causes local
tissue damage like delayed healing, tissue necrosis, disfigurement, loss of function and even
amputation.

[Link] interventions commonly performed when the client is experiencing Autonomic Dysreflexia will
include the following. Select all that apply.
a. Use digital stimulation to empty the bowel.
b. Have the client sit up straight and raise his head so that he is looking ahead.
c. Remove client’s stockings or socks.
d. Manually compress or tap the bladder to allow urine to flow down the catheter.
e. Administer prescribed vasodilators.
Answer: B, C, E: Manual stimulation is recommended to evacuate impacted stool. Having the
client sit up straight and raise his head so that he is looking ahead helps reduce the blood
pressure as it allows gravitational pooling of blood in the lower extremities. Constrictive
clothing may trigger an autonomic reaction that would cause the blood pressure to go up so
this must be removed. Manual compression or tapping the bladder to allow urine to flow down
the catheter should be avoided because this would trigger an increase in blood pressure.
Administration of prescribed vasodilators is done to reduce high blood pressure.

410..Neurologic conditions can be manifested by changes in breathing patterns. The client presents with
symptom of Cheyne-Stokes respirations. The nurse knows that this kind of breathing pattern shows:
a. Completely irregular breathing pattern with random deep and shallow respirations
b. Prolonged inspirations with inspiratory and /or expiratory pauses
c. Sustained regular rapid respirations of increased depth
d. Rhythmic waxing and waning of both rate and depth of respiration with brief periods of interspersed
apnea
Answer: D: Option A is ataxic breathing. Option B is apneustic breathing. Option C is central
neurogenic hyperventilation. Cheyne-stokes breathing respirations are a pattern of breathing
in which phases of hyperpnea regularly alternate with apnea in a crescendo-decrescendo
pattern.

[Link] physician is assessing the client’s sensorium by using the Glasgow Coma Scale. Which of the
following is true about the Glasgow Coma Scale?
a. If the client does not respond to painful stimuli, the score is 0.
b. A score lower than 10 indicates that the client is in a coma.
c. A score of 8 indicates that the client is alert and oriented.
d. A score of 4 indicates that the client sustained severe head trauma.

Answer: D: The lowest possible score for any response is 1. If a client is unresponsive to
painful stimuli, the score is 1. A score lower than 8 indicates that the client is in a comatose
state. The highest score for the GCS is 15. A score of 15 indicates an alert and oriented person.
A score of 3-8 indicates severe head injury.

[Link] nurse on duty is caring for a client with Amyotrophic Lateral Sclerosis and is concerned with the
client’s impaired physical mobility. The following nursing interventions are geared towards maintaining
optimal physical mobility EXCEPT:
a. Maintain an exercise program.
b. Encourage participation in activities.
c. Instruct client related safety measures.
d. Schedule activities in the morning.

Answer: D: Helping the client maintain an exercise program is a therapeutic intervention to

maintain joint mobility and good body alignment. This will also prevent venous stasis due to
impaired mobility. Client encouragement will not only address the physical aspect of the
disease but the client’s emotions and self-esteem as well. The safety of the client with impaired
physical mobility should always be considered. Continuous physical activity is not
recommended. There should be an alternate period of activity and rest to prevent excessive
fatigue.

[Link] elderly client had a cerebrovascular accident or stroke. The left brain is affected and is at risk for
impaired verbal communication. The nurse asked a question and noted that the client has difficulty talking
and communicating his thoughts. Which of the following terms should the nurse use to document the
finding?
a. Receptive Aphasia
b. Expressive Aphasia
c. Global aphasia
d. Apraxia
Answer: B: Receptive Aphasia refers to the inability to understand spoken words but can freely
express and verbalize. Expressive Aphasia refers to the inability to speak and communicate
formulated thoughts and sentiments. Global aphasia affects both expressive ability and
auditory comprehension. Apraxia is characterized by loss of the ability to perform activities
that a person is physically able and willing to do.
[Link] client diagnosed with Alzheimer’s disease is starting to show signs and symptoms. The nurse
wants to assess for graphesthesia. This is performed by:
a. Testing for the client’s ability to identify an object that is placed on the hand with eyes closed.
b. Testing for the client’s ability to recognize the written letter or number in the client’s skin while the eyes
are closed.
c. Making the client stand, with the arms at the side, feet together, with the eyes open and then closed.
The client is then observed for any swaying.
d. Testing for the presence of pain once the leg is flexed at the hip, and then extended.
Answer: B: Graphesthesia is the ability to identify the writing on the skin even with the eyes
closed. The client provides a verbal response, identifying the figure that was drawn. Option A is
a test for stereognosis. Option C is a test used to assess the Romberg’s sign while option D is a
test for Kernig’s sign.

[Link] pediatric client presents with the following signs and symptoms: high fever, drooling, difficulty of
breathing and leaning forward in a tripod position. Immunization history shows that the client never
received any Hib vaccine. Which of the following is the priority of the healthcare provider?
a. Continuous oxygen therapy and constant monitoring of oxygen saturation rate.
b. A well regulated IV infusion and timely administration of antibiotics.
c. Vaccination of Hib and other remaining vaccines to complete required immunizations.
d. Avoiding any throat examination or agitation of the child.
Answer: D: Any deterioration of oxygen saturation may necessitate intubation. However, the
priority this time is to maintain a patent airway. Infusion of IV fluids and administration of
antibiotics are expected nursing actions but not the top priority this time. Completing
vaccination at this time will not suffice or treat the underlying respiratory problem. The
situation calls for a curative management and not preventive measures. Airway closure is the
top priority. Throat examination is avoided as this increases the risk of laryngeal obstruction.
Aggression or agitation can also compromise airway and breathing.

[Link] physician prescribed Clarithromycin (Biaxin) 250mg BID x 7 days for the client’s infection.
Incorrect drug frequency and duration would cause inaccurate transfer time of the drug to specific tissues
in the body. The nurse explains to the client that accumulation of the drug in specific tissues is the
concept of:
a. Absorption
b. Distribution
c. Metabolism
d. Excretion

417..The nurse is to administer Meperidine (Demerol) 35 mg through the intramuscular route. Available
meperedine is 50mg/mL. Which of the following is the least favorable injection site for intramuscular
medication?
a. Ventrogluteal
b. Vastus lateralis
c. Deltoid muscle
d. Dorsogluteal
Answer: D: The Ventrogluteal site is safe for most intramuscular injections because it only
involves the gluteus medius and gluteus minimus muscles. The Vastus lateralis muscle is also a
safe injection site for intramuscular medications because there are no adjacent large blood
vessels and nerves. The deltoid muscle is a smaller muscle and is safe for administration of
intramuscular medications less than 1 mL. The Dorsogluteal muscle is not recommended for
intramuscular medications because of the potential damage to the sciatic nerve. Large blood
vessels are also located near the dorsogluteal muscle and should be avoided.
418..The client presented with complaint of leg cramps. Upon checking the client’s chart, the nurse noted
that the client is hypertensive and is prescribed with a Thiazide diuretic. The appropriate nursing
intervention for this client is:
a. Stop the Thiazide diuretic
b. Refer to the physician for evaluation of electrolyte level of the client
c. Switch the client to a loop diuretic
d. Give the client a non-steroidal anti-inflammatory drug (NSAID)
Answer: B: Prescribing or stopping medications is the responsibility of the physician, thus the
nurse must refer this first. Thiazide diuretics cause loss of blood potassium while conserving
blood calcium, thus, the electrolyte level must be evaluated first.

[Link] client is wheeled into the delivery room and is ready for childbirth. While crowning occurs, the
labor nurse applies gentle pressure over the perineum and fetal head. The maneuver performed is called:
a. Brandt-Andrew’s maneuver
b. McRobert’s maneuver
c. Schultz mechanism
d. Ritgen’s maneuver
Answer: D: The brandt-andrew maneuver is the proper extraction of the umbilical cord and
placenta. McRobert’s maneuver is performed in case of shoulder dystocia during childbirth. The
Schultz mechanism is used to describe placental delivery. The Ritgen’s maneuver is performed
by applying pressure over the perineum and counter-pressure on the fetal head. The Ritgen’s
maneuver controls the exit of the fetal head and prevents severe damage to maternal tissues

[Link] nurse is monitoring the condition of the postpartum client. As a part of the postpartum
adaptations, the nurse monitors for descent of the uterus and expects the fundus to be:
a. On the same level after delivery
b. Decreased by 1 cm/day
c. Decreased by 1.5 cm/day
d. Decreased by 2 cm/day
Answer: B: The uterine fundus should start to descend after 24 hours of delivery. The normal
rate of uterine descent is 1 cm/day.

[Link] granddaughter of the client asked the nurse if it is normal for elderly people to feel sleepy despite
sleeping for long hours. Which of the following conditions would the nurse suspect?
a. Somatoform Disorder b. Malingering
c. Anxiety d. Amnesia
Answer: B :In Somatoform Disorder, there is no real organ damage, but the client verbalizes
symptoms of a disease in an unconscious manner. In Malingering, verbalization of symptoms of
a disease is conscious and is used by the client to achieve a secondary gain or benefit. Anxiety
comes in many forms panic attacks, phobia, and social anxiety and the distinction between a
disorder and “normal” anxiety isn’t always clear. Amnesia refers to the loss of memories, such
as facts, information and experiences.

[Link] is one of the treatments for uterine cancer. The client asked the nurse how
chemotherapeutic drugs work. Which of the following statements will be the best explanation?
a. Chemotherapeutic agents alter molecular structure of DNA.
b. Chemotherapeutic agents hasten cell division.
c. Cancer cells are sensitive only to chemotherapeutic agents.
d. Chemotherapeutic agents act on all rapidly dividing cells.
. Answer: D :Not all chemotherapeutic agents alter the molecular structure of DNA.
Chemotherapy should slow down cell division not hasten it. All cells are sensitive to drug
toxins. Chemotherapeutic agents act on all rapidly dividing cells – most action of
chemotherapeutic agents is that it affects all rapidly dividing cells including the normal and
cancer cells.

423..Vomiting is one of the most common side effects of chemotherapy. The nurse should be aware of
which acid-base imbalance?
a. Ketoacidosis
b. Metabolic acidosis
c. Metabolic alkalosis
d. Respiratory alkalosis
Answer: C: Ketoacidosis is associated with high levels of ketone bodies in the body brought by
breakdown of fatty acids and is not related to vomiting. Metabolic acidosis happens when the
body produces excessive quantity of acid. Severe vomiting will result to loss of HCL and acids
coming from extracellular fluids which in turn lead to metabolic alkalosis. Respiratory alkalosis
occurs when there is an increased respiration which elevates the blood pH beyond the normal
range of 7.35-7.45.

[Link] client develops a 2nd degree skin reaction from radiation therapy. The nurse should expect the
following symptoms EXCEPT:
a. The skin is scaly.
b. There is an itchy feeling.
c. There is dry desquamation present.
d. The skin is reddened.
. Answer: D: 2nd degree skin reactions are evident by scaly skin, an itchy feeling and dry
desquamation. Reddening of the skin is not seen in 2nd degree skin reaction.

[Link] nurse is assessing the muscle coordination and mobility of the client with musculoskeletal
disorder. The nurse noted impulsive and brief muscle twitching of the face and the limbs. This finding is
called:
a. Tremor
b. Chorea
c. Athetosis
d. Dystonia
Answer: B: Tremor is clinically defined as the rhythmic and repetitive muscle movement.
Chorea is clinically defined as brief and involuntary muscle twitching of the face or limbs which
hinders the client’s mobility. Athetosis is clinically defined as the presence of irregular and
slow twisting motions. Dystonia is similar to the definition of Athetosis but involves larger
muscle areas.

426. The nurse is assigned to render care to a client with altered mobility. Which of the following
statements is true regarding body mechanics when moving clients?
a. Stand at arm’s length from the working area.
b. Elevate adjustable beds to hip level.
c. Swivel the body when moving the client.
d. Move the client with wide base and straight knees.
Answer: C: Standing close to the working area is a proper body mechanic to prevent muscle
fatigue. The nurse should adjust the bed to waist level in order to prevent stretching and
muscle strain. Proper body mechanic includes turning the body as a whole unit when moving
the client to avoid twisting the back. The knees are bent to support the body’s center of gravity
and maintain body balance. Bending the knees will provide a wider base of support for effective
leverage and use of energy.
427.A patient is now in the recovery room after having vaginal surgery. Due to the positioning of the
procedure, you would want to assess for what while the patient is in recovery?
A. Bowel Sounds B. Dysrhythmia
C. Homan's Sign D. Hemoglobin Level
The answer is C. Vaginal surgeries require the patient to be in the lithotomy position. This
position can put the patient at risk for a deep vein thrombosis. Therefore, the nurse would
want to check for this by using Homan's Sign.

[Link] surgery your patient is semicomatose with vital signs within normal limits. As the nurse, what
position would be best for this patient?
A. Semi-Fowlers B. Prone
C. Low-Fowlers D. Side positioning preferably on the left side
The answer is D. A patient who are semicomatose are at risk for aspiration (due to secretions
pooling in the mouth or vomiting which is a common side effect of sedation). Placing the
patient onto their side preferably the left will help decrease the risk of aspiration and help
promote cardiovascular circulation.

429. After surgery your patient starts to shiver uncontrollably. What nursing intervention would you do
FIRST?
A. Apply warm blankets & continue oxygen as prescribed
B. Take the patient's rectal temperature
C. Page the doctor for further orders
D. Adjust the thermostat in the room
The answer is A. Shivering is an early sign that the patient is starting to experience
hypothermia. Immediately, the nurse would need to control the shivering by applying warm
blankets and continue oxygen. When the patient starts to experience hypothermia, vital organs
are not receiving as much oxygenated blood due to the vasoconstriction. Therefore, oxygen
would need to be continued. Then the nurse would take the patient's temperature.

[Link] nurse is monitoring the patient who is 24 hours post-opt from surgery. Which finding requires
intervention?
A. BP 100/80 B. 24-hour urine output of 300 ml
C. Pain rating of 4 on 1-10 scale D. Temperature of 99.3' F
The answer is B. The nurse needs to watch the patient's urinary output closely. Urinary output
within a 24-hour period should be at least 30 ml/hr. In this case, the patient is only urinating
12.5 ml/hr.

431. A patient is 6 days post-opt from abdominal surgery. The patient is to be discharged later today. The
patient uses the call light and asks you to come to his room and look at his surgical site. On arrival, you
see that approximately 2 inches of internal organs are protruding through the incision. What intervention
would you NOT do?
A. Put the patient in prone position with knees extended to put pressure on the site
B. Cover the wound with sterile normal saline dressing
C. Monitor for signs of shock
D. Notify the MD and administer as prescribed antiemetic to prevent vomiting
The answer is A. The patient is experiencing wound evisceration. This is an emergent situation.
The patient should be placed in low Fowler's position with the knees bent to prevent abdominal
tension.
432. A patient reports he hasn't had a bowel movement or passed gas since surgery. On assessment, you
note the abdomen is distended and no bowel sounds are noted in the four quadrants. You notify the MD.
What non-invasive nursing interventions can you perform without a MD order?
A. Insert a nasogastric attached to intermittent suction
B. Administer IV fluids
C. Encourage ambulation, maintain NPO status, and monitor intake & output
D. Encourage at least 3000 ml of fluids per day
The answer is C. This patient is most likely experiencing a paralytic ileus which is failure for the
bowels to move its contents. The only correct non-invasive option is to encourage ambulation,
maintain NPO status, and monitor intake & output. Inserting a NG tube or administering IV
fluids is invasive and requires a MD order. Patients with potential paralytic ileus are to be NPO
(nothing by mouth) so encouraging fluid intake is incorrect.

[Link] is a potential postoperative concern regarding a patient who has already resumed a solid diet?
A. Failure to pass stool within 12 hours of eating solid foods
B. Failure to pass stool within 48 hours of eating solid foods
C. Passage of excessive flatus
D. Patient reports a decreased appetite
The answer is B. After a patient resumes solid food, they should have a bowel movement within
48 hours. The patient may be experiencing constipation and appropriate interventions must be
followed.

434. A nurse is developing a care plan for a patient who is at risk for developing pneumonia after surgery.
Which of the following is not an appropriate nursing intervention?
A. Encourage patient intake of 3000 ml/day of fluids if not contraindicated
B. Encourage patient to use the incentive spirometer device 10 times every 1-2 hours while awake
C. Encourage early ambulation and patient to eat meals in beside chair
D. Repositioning every 3-4 hours
The answer is D. All options are correct expect for repositioning every 3-4 hours. If the patient
is unable to reposition themselves or ambulate, they must be repositioned every 1 to 2 hours
minimally.

[Link] assessing your patient who is post-opt, you notice that the patient's right calf vein feels hard,
cord-like, and is tender to the touch. The patient reports it is aching and painful. What would NOT be an
appropriate nursing intervention for this patient?
A. Allow the patient to dangle the legs to help increase circulation and alleviate pain
B. Instruct the patient to not sit in one position for a long period of time
C. Elevate the extremity 30 degrees without allowing any pressure on affected area
D. Administer anticoagulants as ordered by MD
The answer is A. All options are correct except for "Allow the patient to dangle the legs to help
increase circulation and alleviate pain". The patient should NOT dangle the legs because this
causes blood to pool in the lower extremities which will put the patient at risk for another
blood clot formation.

436. A patient is recovering from surgery. The patient is very restless, heart rate is 120 bpm and blood
pressure is 70/53, skin is cool/clammy. As the nurse you would?
A. Continue to monitor the patient B. Notify the MD
C. Obtain an EKG D. Check the patient's blood glucose
The answer is B. This is an emergency situation. The patient is more than likely experiencing a
hemorrhage of some type. Notifying the MD would be the first line of action and then you could
check the patient's blood glucose and obtain an EKG. This patient is probably going to need a
surgical intervention.
437.A patient is taking Aspirin 325 mg PO by mouth daily. The patient is scheduled for surgery in a week.
What education do you provide the patient with before surgery?
A. Educate the patient to take the scheduled dose of Aspirin the day of surgery to help prevent blood clots
B. To hold his morning dose of Aspirin because the nurse will give it to him before surgery
C. None of the above are correct
D. The medication should be discontinued for 48 hours prior to the scheduled surgery date
The answer is D. Aspirin alters the normal clotting factors and increases the patient's chances
of hemorrhaging. Therefore, it should be held for at least 48 hours prior to surgery as specified
by the surgeon.

[Link] are observing your patient use the incentive spirometry. What demonstration by the patient lets
you know the patient understands how to use the device properly?
A. The patient inhales slowly on the device and maintains the flow indicator between 600 to 900 level
B. The patient blows on the mouthpiece rapidly.
C. The patient uses the incentive spirometry once a day
D. The patient rapidly inhales on the devices and exhales

The answer is A. All of the options are wrong expect for "The patient inhales slowly on the
device and maintains the flow indicator between 600 to 900 level". The other options do not
demonstrate how to properly use the incentive spirometry.

[Link] the nurse you are getting the patient ready for surgery. You are completing the preoperative
checklist. Which of the following is not part of the preoperative checklist?
A. Assess for allergies
B. Conducting the Time Out
C. Informed consent is signed
D. Ensuring that the history and physical examination has been completed
The answer is B. The time out is conducted by the OR nurse prior to surgery. All of the other
options are conducted by the nurse getting the patient ready for surgery.

[Link] are completing the history on a patient who is scheduled to have surgery. What health history
increases the risk for surgery for the patient?
A. Urinary Tract infections
B. History of Premature Ventricle Beats
C. Abuse of street drugs
D. Hyperthyroidism
The answer is C. If a patient has a history of street drug abuse this puts them at risk in
surgery. This information is very important for the anesthesiologist due to the complications
that can arise from the anestheisa. All of the other options are important to note but not a risk
for surgery.

[Link] a nurse, which statement is incorrect regarding an informed consent signed by a patient?
A. The nurse is responsible for obtaining the consent for surgery
B. Patients under 18 years of age may need a parent or legal guardian to sign a consent form
C. The nurse can witness the client signing the consent form
D. It is the nurse's responsibility to ensure the patient has been educated by the physician about the
procedure before informed consent is obtained
The answer is A. All statements are correct except that it's the nurse's responsibility for
obtaining the consent for surgery. It is the surgeon's responsibility.

[Link] does the medical abbreviation AED mean?

a. Automated External Defibrillator
b. Anatomical Exhibit Device
c. Alexander Entropy Discussion
d. Automated Exhibiting Defibrillator
A: AED stands for Automated External Defibrillator. This is the machine used to revive the
heart after it has gone into full arrest.

[Link] does the medical abbreviation a.c. mean?

a. After Completion.
b. Before Meals.
c. After Meals.
d. Before Bed.
B: A.C. stands for before meals. This is used most often on prescriptions, telling the patient
when to take the medication.

[Link] does the medical abbreviation ASA mean?

a. After supper. b. Arthritis Medication.
c. Asthma Medication. d. Aspirin.
D: ASA stands for aspirin. The “A” is added at the end to distinguish from the many other
medical abbreviations starting with AS.

445. What does the medical abbreviation BP mean?

a. Blood Pressure. b. Bone Pressure.
c. Bone Fracture. d. Blood Disorder.
A: BP stands for blood pressure. You’ll most often see this on a patient report of vital signs.

[Link] does the medical abbreviation cc mean?

a. Chief Complaint.
b. Cubic Centimeter.
c. Cancer / Carcinoma.
d. Complaining Of.
B: cc stands for cubic centimeter. Medications are frequently measured and dispensed using
this unit. This is not to be confused with C

[Link] does the medical abbreviation CXR mean?

a. Chief Exit Wound.
b. Chest X-ray.
c. Cardiovascular Exhibiting Symptoms
d. Colon X-ray.
B: CXR stands for Chest X-ray. The term is falling out of use but still occasionally used.

[Link] does the medical abbreviation DOA mean?

a. Dead On Arrival. b. Dying On Arrival.
c. Departed On Arrival. d. Dead Of Anthrax
A: DOA stands for dead on arrival. This designation could be used if the person died on the
scene before being transported to the hospital or if death occurs immediately upon being seen
by the medical staff.

449. What does the medical abbreviation ECG mean?

a. Endoscopy Cancer Graph.
b. Electrocardiogram
c. Electro Colon Graph.
d. Initials of the most famous heart doctor.
B: ECG stands for Electrocardiogram. Actually, it’s more popularly known as an EKG, although
linguistically, ECG would be more correct.

450. What does the medical abbreviation ETA mean?

a. Expected Time To Area. b. Estimated Turn Of Activity.
c. Estimated Time Of Arrival. d. Expected Tour Of Action.
C: ETA stands for estimated time of arrival. The term is used, not just among medical
professionals, but also the military and police.

451. What does the medical abbreviation H/A mean?

a. Heat Activity. b. Headache.
c. Heart Action. d. Heavy Arms.
B: H/A stands for headache. Most doctors report that this is one of the most common
“presenting symptoms” causing people to seek medical help.
[Link] does the medical abbreviation h/o mean?
a. Heart Murmur. b. Over-Heated.
c. History Of d. Head Oriented.
C: H/O stands for history of . . . This is primarily a quick and short abbreviation used for intra-
house patient reports.

[Link] individual is at greatest risk for developing hypertension?

A.45 year-old African American attorney
B.60-year-old Asian American shop owner
C.40-year-old Caucasian nurse
D.55-year-old Hispanic teacher
[Link] incidence of hypertension is greater among African Americans than other groups in the
US. The incidence among the Hispanic population is rising.

454. A child who ingested 15 maximum strength acetaminophen tablets 45 minutes ago is seen in the
emergency department. Which of these orders should the nurse do first?
A. Gastric lavage PRN
B. Acetylcysteine (mucomyst) for age per pharmacy
C. Start an IV Dextrose 5% with 0.33% normal saline to keep vein open
D. Activated charcoal per pharmacy
A: Removing as much of the drug as possible is the first step in treatment for this drug
overdose. This is best done by gastric lavage. The next drug to give would be activated
charcoal, then mucomyst and lastly the IV fluids.

455. Drugs that are administered by injection

a. Enteral administration c. Percutaneous administration
b. Parenteral administration d. Intravenous injection
Answer: B. Parenteral Administration (KNOWLEDGE)
Rationale: Parenteral drug administration - means any non-oral means of administration,
but is generally interpreted as relating to injecting directly into the body, bypassing the
skin and mucous membranes.

456. Drugs applied to the skin

a. Transdermal c. Inhalations
b. Instillations d. Topical
Answer: D. Topical (KNOWLEDGE)
 Rationale: Topical administration - is a medication that is applied to a particular place on
or in the body. Most often topical administration means application to body surfaces such
as the skin or mucous membranes to treat ailments via a large range of classes including
creams, foams, gels, lotions, and ointments.

457. Which of the following is CORRECT regarding administration of rectal suppositories

a. Ask the client to lie on his right side, bend the upper most leg towards the waist (sims position)
and breathe through the mouth to relax the anal sphincter
b. Apply small amount of lubricant at the tip of the suppository; then gently insert using your
thumb
c. Instruct client to remain on his side for 5 to 10 minutes after administration to allow absorption
and remind not to expel
d. Rectal suppositories are solid but melts at room temperature
Answer: D. Rectal suppositories are solid but melts at room temperature (ANALYSIS)
Rationale: Suppositories are drugs that melt at body temperature when inserted into the
rectal or the vaginal orifice; are solid but softens and dissolves at room temperature;
they must be refrigerated to avoid softening

458. The following are parental routes of administration EXCEPT

a. Intramuscular
b. Subcutaneous
c. Intravenous
d. Transdermal
Answer: D. Transdermal (ANALYSIS)
Rationale: Transdermal - is a type of percutaneous administration where in drugs are
absorbed directly through the skin by the use of patches

459. After administering a drug through nasogastric tubes, what should you first do?
a. Close the nasogastric tube to avoid contamination
b. Flush with 50cc or prescribed amount of water after
c. Push some air inside the nasogastric tube to prevent clogging
d. Remove the nasogastric tube and replace upon next feeding
Answer: B. Flush with 50cc or prescribed amount of water after (APPLICATION)
Rationale: Administering drugs via NGT (after checking placement of tube). Clamp NGT,
attach a bulb syringe and pour medication into syringe then unclamp tube and allow
drug to flow by gravity after administration, flush with 50cc or prescribed amount of
water and lastly do not forget to clamp and secure the NGT after.

460. Drugs applied to skin

a. Instillations c. Transdermal
b. Topical d. Inhalations
Answer: B. Topical (KNOWLEDGE)
Rationale: Topical administration - is a medication that is applied to a particular place on
or in the body. Most often topical administration means application to body surfaces such
as the skin or mucous membranes to treat ailments via a large range of classes including
creams, foams, gels, lotions, and ointments

461. Drugs absorbed directly through the skin by the use of patches
a. Reservoir patch c. Salonpas patch
b. Matrix patch d. Transdermal patch
Answer: B. Matrix Patch
Rationale: Matrix patch - is a medicated adhesive patch that is placed on the skin to
deliver a specific dose of medication through the skin and into the bloodstream. Often,
this promotes healing to an injured area of the body. 

462. IP
a. Internet Protocol c. Intraperitoneal
b. Intermediate Pressure d. Immunoprecipitation
 Answer: C. Intraperitoneal (KNOWLEDGE)
Rationale: Intraperitoneal means within or administered through the peritoneum.
The peritoneum is a thin, transparent membrane that lines the walls of the abdominal
(peritoneal) cavity and contains/encloses the abdominal organs such as the stomach
and intestines.
463. IV
a. Intravascular c. In Vivo
b. In Vitro d. Intravenous
Answer: D. Intravenous (KNOWLEDGE)
Rationale: Intravenous means "within a vein." Most often it refers to giving medicines or
fluids through a needle or tube inserted into a vein. This allows the medicine or fluid to
enter your bloodstream right away. For example, your health care provider may
prescribe medicines to be given through a vein, or an intravenous (IV) line.

464. OD
a. Right ear c. Right eye
b. Left eye d. Left ear
Answer: C. Right eye (KNOWLEDGE)
Rationale: OD – abbreviation for oculus dexter Latin word which means right eye

465. NGT
a. Nasogastric tube c. Natural gas technology
b. Natural gamma ray tool d. Normal glucose tolerance
Answer: A. Nasogastric tube (KNOWLEDGE)
Rationale: Nasogastric tube (NG tube) is a special tube that carries food and medicine to
the stomach through the nose. It can be used for all feedings or for giving a person extra
calories. You'll learn to take good care of the tubing and the skin around the nostrils so
that the skin doesn't get irritated.

466. OS
a. Right ear c. Right eye
b. Left eye d. Left ear
Answer: B. Left eye (KNOWLEDGE)
Rationale: OS – abbreviation for oculus sinister Latin word which means left eye
467. OU
a. By mouth c. Both ears
b. Both eyes d. Of each
Answer: B. Both eyes (KNOWLEDGE)
Rationale: OU – abbreviation for oculus uterque Latin word which means both eyes

468. Loss of deep tendon reflex

a. Hypercalcemia c. Hypocalcemia
b. Hypermagnesemia d. Hypokalemia
Answer: B. Hypermagnesemia (KNOWLEDGE)
Rationale:  is an electrolyte disorder in which there is a high level of magnesium in the
blood. Symptoms include weakness, confusion, decreased breathing rate, and decreased
reflexes. Complications may include low blood pressure and cardiac arrest.
469. Types of IVF that is indicated if IV therapy > 5 days
a. Crystalloids c. Colloids
b. Lipids d. Blood and blood products
Answer: B. Lipids (KNOWLEDGE)
Rationale: Lipid emulsion or fat emulsions are solutions to balance the client’s nutritional
needs. They refer to an emulsion of lipid for human intravenous use.

470. It is one of the basic forms of enteral administration (through NGT) that melt at body temperature
when inserted into rectal or vaginal orifice?
a. Liquids c. Topical
b. Lozenge d. Suppositories
Answer: D. Suppositories (knowledge)
 Rationale: Suppositories are solid medications that enter the body through the rectum,
vagina, or urethra. Rectal suppositories are the most common type of suppository.
Insert the suppository, pointed end first, with your finger until it passes the muscular
sphincter of the rectum, about 1/2 to 1 inch in infants and 1 inch in adults. 

471. Percutaneous Administration (through skin and mucous membranes) has 4 basic forms. Which
form of drugs applied to the skin?
a. Liquids c. Topical
b. Lozenge d. Suppositories
Answer: C. Topical (Analysis)
Rationale: The purpose of using topical medicine is to deliver medication directly onto
areas of the skin that are irritated, inflamed, itching, or infected. Topical medicines are
often applied directly onto a rash or irritated area on the skin for rapid relief of
symptoms.

472. Intradermal route can be administered in the following anatomical sites EXCEPT
a. Clavicular area of the chest c. Scapular area
b. Dorsal midthighs d. Ventral mid forearm
Answer: B (Analysis)
Rationale: In human anatomy, the thigh is the area between the hip (pelvis) and the
knee. Anatomically, it is part of the lower limb. The single bone in the thigh is called the
femur. The route that can be administered to this body part is intramuscular injection
(IM).

473. Which of the following CORRECTLY describes parenteral administration?

a. Intradermal: Local effect c. Intravenous: For irritating drugs
b. Intramuscular: For non-irritating drugs d. Subcutaneous: Wheal/Bleb formation
Answer: A. Intradermal: Local effect (Analysis)
Rationale: However, lightly pigmented, thinly keratinized and hairless skin (Ventral mid
forearm, scapular area and clavicular area of the chest) are the sites generally only allow
the administration of small volumes of drugs and tend to be used mostly for local effects,
such as local anesthesia, or to deliberately limit the rate of drug absorption.

474. Which of the following form of enteral administration, where drugs melt at body temperature when
inserted in body orifice?
a. Liquids c. Topical
b. Suppositories d. Lozenge
Answer: B. Suppositories (knowledge)
Rationale: Suppositories are solid medications that enter the body through the rectum,
vagina, or urethra. Rectal suppositories are the most common type of suppository.
Insert the suppository, pointed end first, with your finger until it passes the muscular
sphincter of the rectum, about 1/2 to 1 inch in infants and 1 inch in adults.

475. It is elongated shaped tablets or a coated oral medicine tablet?

a. Capsules c. Caplets
b. Tablets d. none of the above
Answer: C. Caplets (Knowledge)
Rationale: Caplets are smaller versions of tablets that have a smoother surface, which
makes them easier to swallow. Both caplets and tablets can be broken up and crushed
into smaller doses. Tablets and caplets are very similar forms of medication. They are
less expensive to produce than other forms of medicines.

476. Which of the following drugs is flat or oval preparations that dissolve in the mouth?
a. Capsule c. Caplets
b. Tablets d. None of the above
Answer: B Tablets (Analysis)
Rationale: Tablet pills may then have more additives and non-active ingredients than
liquid capsules. Tablets can be either coated with a sugar or film coating, or uncoated.
 Uncoated tablets are rougher, may be more difficult to swallow, and often leave a bad
taste in the mouth when swallowed.

477. “Admov”. is a medical abbreviation which means _______.

a. Around the clock c. Shake or stir
b. Apply d. Water
Answer: B Apply (Knowledge)
Rationale: Admov. is a medical abbreviation which means apply.

478. “Agit” is a medical abbreviation meaning “shake or stir”. TRUE or FALSE?

a. True c. Both A and B are wrong
b. False d. None of these
Answer: A True (Analysis)
Rationale: The answer is true because medical abbreviation agit. means shake or stir.

479. “Bis” is a medical abbreviation which means________.

a. Twice c. Of each
b. Twice a day d. Apply
Answer: A Twice (knowledge)
Rationale: Bis is a medical abbreviation which means twice.

480. What do you mean in the medical abbreviation “Bol.”?

a. With c. Twice
b. Distance d. Bolus or as a large single dose
Answer: D Bolus or as a large single dose (Knowledge)
Rationale: The answer is letter D because the medical abbreviation Bol. is a medical term
used as bolus or as a large single dose.

481. “e.m.p” is a medical abbreviation which meaning “At bed time”. TRUE or FALSE?
a. True c. Both A and B are wrong
b. b. False d. None of these
Answer: B False (Analysis)
Rationale: The answer is false because the medical abbreviation e.m.p is a medical term
which means as directed.

482. What is a common electrolyte problem that is defined as a rise in serum sodium concentration to a
value exceeding 145 mmol/L?

a. Hypernatremia c. Hypermagnesemia
b. b. Hypercalcemia d. Hypokalemia
Answer: A Hypernatremia (knowledge)
Rationale: Hypernatremia is a common electrolyte problem that is defined as a rise in
serum sodium concentration to a value exceeding 145 mmol/L. It is strictly defined as a
hyperosmolar condition caused by a decrease in total body water (TBW) relative to
electrolyte content.

483. It is a type of IVF that contains NaCl, KCl or glucose; usually used for replacement and
maintenance of fluid therapy?
a. Colloids c. Lipids
b. Crystalloids d. Blood and blood products
Answer: B Crystalloids (Analysis)
Rationale: The most commonly used crystalloid fluid is normal saline, a solution of
sodium chloride at 0.9% concentration, which is close to the concentration in the blood
(isotonic). Ringer's lactate or Ringer's acetate is another isotonic solution often used for
large-volume fluid replacement

484. What drugs are administered through the skin or mucous membranes?
a. Enteral c Parenteral
b. Percutaneous d. Topical
 Answer: B Percutaneous (knowledge)
Rationale: The term percutaneous administration refers to the application of medications
to the skin or mucous membranes for absorption. The primary advantage of the
percutaneous route is that the action of the drug, in general, is localized to the site of
application, which reduces the incidence of systemic side effects.

485. Choose which one is under 4 common forms.

A. Inhalers C. Enteral
B. Subcutaneous D. Injectables
Answer: B Subcutaneous [Knowledge]
Rationale- because it is a common route for drug administration.

486. Choose which one is under 4 common forms.

A. Tablets C. Intramuscular
B. Layered tablets D. Epidural space
Answer: C, Intramuscular [Knowledge]
Rationale- also one of the common route for drug administration.

487. Choose which one is under 4 common forms.

A. Intravenous C. Inhalers
B. Intracebroventricular D. Cannula
Answer: A, Intravenous [Knowledge]
Rationale- one of the common route for drug administration

489. Which of the following is CORRECTLY matched?

A. Intracavernosal: into the space between the 1st and 2nd cervical vertebra
B. Intracisternal: into the cerebral ventricles
C. Intrathecal: into the spinal canal
D. Intravitreal: into the base of the penis
Answer: C, Intrathecal [Analysis]
Rationale- it is matched correctly because it is a route of administration for drugs via an
injection into the spinal canal.

490. Which of the following abbreviations is CORRECT?

A. ac: after meal C. OD: left eye
B. AU: right ear D. qd: once a day
Answer: D qd [Analysis],
Rationale- because it is once a day or everyday

491. Preferably used to administer medicines and feedings for clients who cannot swallow.
A. Caplets C. Liquid solutions
B. Capsules D. Nasogastric tube
Answer: D nasogastric tube [Knowledge]
Rationale- it is used for patients that are unable to use the oral route, or are unable to
take sufficient nutrients to maintain growth and development.

492. Type of parenteral administration where drugs are administered through butterflies.
A. Intravenous C. Topicals
B. Intradermal D. Transdermal
Answer: A intravenous [Analysis],
Rationale- is one of the preferred sites to accessible veins

493. Type of parenteral administration which have local effect.

A. Intradermal C. Transdermal
B. Percutaneous D. Inhalation
Answer: A, intradermal [Evaluation]
Rationale- because it is commonly used for tuberculin skin testing but can also be used
for allergy testing.
 494. Related to Drug administration: q.o.d
A. Immediately C. Sufficient quantity
B. Three times a day D. Every other day
Answer: A, immediately [Analysis]
Rationale- it means Every other day.

495. Related to Drug administration: q.s.

A. Immediately C. Sufficient quantity
B. Three times a day D. Every other day
Answer: C, sufficient quantity [Analysis]
Rationale- it means sufficient quantity

496. Related to Drug administration: stat.

A. Immediately C. Sufficient quantity
B. Three times a day D. Every other day
Answer: A, immediately [Analysis]
Rationale- it means immediately

497. Related to Drug administration: t.i.d.

A. Immediately C. Sufficient quantity
B. Three times a day D. Every other day
Answer: B three times a day, [Analysis]
Rationale- it means three times a day.

498. The drugs are administered through the gastrointestinal tract

A. Tablets C. Multiparticulate Drug
B. Enternal administration D. Enteric-coated tablets
Answer: B enteral administration [knowledge]
Rationale- because it is used in gastrointestinal tract.

499. All are CORRECT way of Administration of tablets and capsules through NGT, EXCEPT.
A. Clamp tube, the pour drug into syringe
B. Do not forget to clamp and secure the NGT after.
C. Clamp tube and allow drug to flow by gravity
D. Crush and dilute drug with 1oz (30ml) water
Answer: C, clamp tube and allow drug to flow by gravity [Evaluation]
Rationale- you need to Unclamp tube because the drug won't flow if it is clamped.

500. Type of preparation of liquids that dissolved drugs in water

A. Elixirs C. Syrups
B. Solutions D. Tinctures
Answer: B solutions [knowledge]
Rationale- because in solutions we use water.

501 Drugs that are administered through gastrointestinal tract.

A. Enteral C. NGT
B. Percutaneous D. Parenteral
Answer: A. Enteral (Knowledge)
Rationale: Enteral Administration drugs administered through the gastrointestinal

[Link] Skin and mucous membranes?

A. Enteral C. Percutaneous B. Parenteral D. NGT
Answer: C. Percutaneous (knowledge)
Rationale: Drugs are administered through the skin or mucous membrane

503. Injectables?
A. Enteral C. Parenteral
 B. Percutaneous D. NGT
Answer: C. Parenteral
Rationale: Drugs are administered by injection

[Link] do you call the special form of capsule that contains multiple microspheres, and each
microsphere is coated with rale- controlling polymers to deliver the drug over an extended period of
time?
A. CODAS C. SODAS
B. GITS D. Time - released capsules
Answer: C. SODAS (Comprehensive)
Rationale: Contains microspheres which can produce immediate release of the drug.

505. Which of the following liquid preparations incorrectly described?

A. Elixir: suspension of fat globules. C. Solution: drug dissolved in a liquid
B. Liniment: drug in oily, soapy or alcohol mixture applied to skin D. Suspension: drug in finely
dissolved state dispersed in liquid.
Answer: A. Elixir: suspension of fat globules
Rationale: Elixirs drug dissolved in alcohol and water; some add flavoring agents (ex.
Cough Syrup)

506. The following are medical uses of enema except?

A. Direct delivery of drugs into the rectum to bypass the entire GIT.
B. Introduction of contrast substance for X-ray imaging of the bowels.
C. Promotion of bowel movements to threat Diarrhea.
D. stimulation of peristalsis to cleanse rectum and colon prior to procedures.
Answer: C. Promotion of bowel movements to threat Diarrhea. (Comprehensive)
Rationale: Medical uses of enema is promotion of bowel movements to treat
constipation, stimulation of peristalsis to cleanse rectum and colon prior to procedures
like colonoscopy, Introduction of general aesthetics.

507. Pharmaceutical Abbreviations for "Right Ear"?

A. AD [Link]
C. AS D. ID
Answer: A. AD (Synthesis)
Rationale: The abbreviation for the right ear is AD

508. Pharmaceutical abbreviations for "Left ear"?

A. AU B. AS
C. AD D. IP
Answer: B. AS (knowledge)
Rationale: The abbreviation for Left ear is AS

509. Pharmaceutical abbreviations for "Both ear"?

A. AS [Link]
C. AD D. IM
Answer: B. AU (Synthesis)
Rationale: The abbreviation for the both ear is AU

510. Pharmaceutical abbreviation for the "BUCC" is?

A. between cheeks and gum. B. Right Ear
C. Both ear D. Left ear
Answer: A. between cheeks and gum (knowledge)
Rationale: BUCC is the abbreviation for between cheeks and Gum

511. The pharmaceutical abbreviation for "ID" is?

A. Intradermal B. Intramuscular
C. Left ear D. Both ear
Answer: A. Intradermal (knowledge)
 Rationale: Intradermal is the pharmaceutical abbreviation ID

512. What is the meaning of "IM" in pharmaceutical Abbreviations?

A. Intradermal B. Intravenous
C. Intramuscular D. Phlebitis
Answer: C. Intramuscular (knowledge)
Rationale: Intramuscular is the meaning of pharmaceutical abbreviations for "IM".

513. Solid or Air bubble that blocks the vessel?

A. embolism B. Infiltration
C. Extravasation D. Phlebitis
Answer: A. embolism (comprehensive)
Rationale: Embolism is a solid air bubble that blocks the vessel common in administering
intravenous fluid

514. Flaccid Paralysis

A. Hypokalemia B. Hypothermia
C. Hyperkalemia D. Hypernatremia
Answer: A. Hypokalemia (Knowledge)
Rationale: Hypokalemia is Flaccid paralysis and cardiac arrest, weakness, fatigue,
anorexia, vomiting and abdominal distention.

515. It is the administration of a medicine, generally liquid from either drop by drop or with a
catheter into a body space or cavity.
A. Intradermal C. Instillations
B. Topical D. Inhalations
Answer: C. Instillations (Comprehension)
Rationale: Drug instillation, also known as medication instillation, is the administration of
a medicine, generally liquid from either drop by drop or with a catheter into a body space
or cavity.

516. It is pressurized metered-dose aerosol unit for oral:

A. Topical C. Instillations
B. Intradermal D. Inhalation
Answer: D. Inhalation (Knowledge)
Rationale: It contains a microcrystalline suspension of albuterol sulfate in propellant
HFA-134a (1,1,1,2,-tetrafluoroethane),ethanol, and oleic acid.

517. This injection administered into the dermis, just below the hypodermis.
A. Intradermal C. Subcutaneous
B. Intramuscular D. Intravenous
Answer: A – Intradermal (Application)
Rationale: Intradermal injection, often abbreviated ID, is a shallow or superficial
injection of a substance into the dermis, which is located between the epidermis and the
hypodermis.

518. p. r. n. means
A. At bed time C. Everyday, once a day
B. As needed D. After meal
Answer: B as needed – (knowledge) p.r.n.: Abbreviation meaning "when necessary"
(from the Latin "pro re nata", for an occasion that has arisen, as circumstances require,
as needed).

519. What is the abbreviation of “everyday, once a day”?

A. qh C. qd
B. qid D. q. s.
 Answer: C qd – (knowledge) (on prescription): Seen on a prescription, q.d. (orqd) means
one a day (from the Latin quaque die). The abbreviation is sometimes written without a
period in capital letters as "QD".

520. It is an electrolyte imbalance and is indicated by a low level of calcium in the blood. 
A. Hypercalcemia C. Hypocalcemia
B. Hypokalemia D. Hyponatremia
Answer: B Hypocalcemia– (Application) The normal adult value for calcium is 4.5-5.5
mEq/L. Calcium is important for healthy bones and teeth, as well as for normal muscle
and nerve function.

521. Type of IVF that contains synthetic or semi-synthetic molecules usually in water or saline
media which attracts water into the vascular component; volume expanders
A. Crystalloids C. Colloids
B. Hypotonic D. Hypertonic
Answer: C. Colloids– (Evaluation) Pharmaceutical applications of colloids Definition.
Interface and colloid science – Interface and colloid science is a branch of chemistry
dealing with colloid s, heterogeneous systems consisting of a mechanical mixture of
particles between 1 nm and 1000 nm dispersed in a continuous medium.

522. A small, oval, round or oblong tablet containing a medicinal Agent incorporated in a
flavored, sweetened mucilage or fruit base that dissolves in the mouth?
a. Liquids         c. Troche
  b. Tablet       d. Capsules
Answer: c troche (Application)
Rationale: A troche is a small lozenge designed to dissolve between a person's cheek and
gum over a period of time; typically 30 minutes. As the troche dissolves in the patient's
mouth, the medication is absorbed through the oral mucosa and gradually absorbs into
the blood stream.

523. It is a type of Enteral administration and sometimes referred to as elixirs, syrups, solutions,
or mixtures. Good for clients/patients have difficulty in swallowing capsules or tablets (usually
children).
a. Liquids c. Troche
b. Tablet d. Capsules Answer: a liquids (Analysis)
Rationale: The active part of the medicine is combined with a liquid to make it easier to
take or better absorbed. A liquid may also be called a ‘mixture’, ‘solution’ or ‘syrup’.
Medicines that are in a liquid form can be prescribed by a doctor or purchased over- the
counter(OTC). They are commonly used in children or adults who have difficulty
swallowing.

524. A translucent semi-solid preparation that liquefies when applied to skin?

a. Foam c. Liniment
b. Gel d. Paste Answer: b. Gel
Rationale: Gels are thicker than liquids. Gels are often a semisolid emulsion sometimes
using alcohol as a solvent for the active ingredient. Some gels liquefy at body
temperature. Gel tends to be cellulose cut with alcohol or acetone. Gels tend to be self-
[Link] is useful for hairy areas and body folds. In applying gel one should avoid
fissures in the skin, due to the stinging effect of the alcohol base.

525. Nasal sprays and eye drops are examples of:

a. Inhalations c. Topicals
b. Instillations d. Vapors
Answer: b instillations ( Analysis)
Rationale: Instillation the administration of therapeutic agents drop by drop, as eye
drops, ear drops, or nose drops. It is also administered into a body space or cavity
through a catheter. It differs from THERAPEUTIC IRRIGATION in that the irrigate is
removed within minutes, but the instill-ate is left in place.
526. Which of the following does NOT correctly describes subcutaneous administration?
A. Administered in areas with adequate fat pads
B. Faster absorption compared to intramuscular position
C. Injected at an angle of 45°
D. Insulin and measles vaccines are subcutaneously administered
Answer: B Faster absorption compared to intramuscular position (Comprehension)
Rationale: A subcutaneous injection is administered as a bolus into the subcutis, the layer
of skin directly below the dermis and epidermis, collectively referred to as the cutis.
Subcutaneous injections are highly effective in administering medications such as insulin,
morphine, diacetylmorphine and goserelin.

527. Mantoux test for TB is an example of what type of parenteral administration?

A. Intradermal C. Intramuscular
B. Intravenous D. Subcutaneous
Answer: A Intradermal – (Application)
Rationale: Intradermal injection, often abbreviated ID, is a shallow or superficial
injection of a substance into the dermis, which is located between the epidermis and the
hypodermis. This route is relatively rare compared to injections into the subcutaneous
tissue or muscle.

528. Good for clients who are unable to swallow tablets or capsules (usually children)
A. Lozenges B. Nasogastric tube
C. Liquid Solutions D. Suppositories
Answer: C Liquid Solutions – (Application)
Rationale: Oral liquids are homogeneous liquid preparations, usually contains a solution,
an emulsion or a suspension of one or more active ingredients in a suitable liquid base.

529. Parenteral administration where needle is inserted at 45°

A. Subcutaneous C. Transdermal
B. Intradermal D. Intramuscular
Answer: A Subcutaneous– (Application)
Rationale: A subcutaneous injection is administered as a bolus into the subcutis, the layer
of skin directly below the dermis and epidermis, collectively referred to as the
cutis. Subcutaneous injections are highly effective in administering medications such as
insulin, morphine, diacetylmorphine and goserelin.
530. Parenteral administration where you can use the Z-track technique
A. Intradermal B. Subcutaneous
C. Intramuscular D. Intravenous
Answer: B Intramuscular – (Application) Intramuscular injections (IM injections) deliver
a substance deep into a muscle, where they are quickly absorbed by blood vessels.

531. h.s. means

A. Nothing by mouth C. Everyday, once a day
B. At bedtime D. After meal
Answer: B. At bed time – (knowledge) h. s. ,medical abbreviation for "hours of
sleep" h.s., medical abbreviation for the Latin phrase hora somni ("at bedtime")
Hereditary spherocytosis, a genetic disorder marked by hemolytic anemia. Hidradenitis
suppurativa, a skin condition affecting apocrine sweat glands and hair follicles.
532. n.p.o. abbreviated as
A. After meal C. As needed
B. Nothing by mouth D. At bed time
Answer: B nothing by mouth– (knowledge) Nothing by mouth is a medical instruction
meaning to withhold food and fluids. It is also known as nil per os (n. p. o. or NPO), a
Latin phrase that translates literally to English as "nothing through the mouth". Variants
include nil by mouth (NBM), nihil/non/nulla per os, or complete bowel rest.

533. p. c. means
A. As needed C. After meal
 B. Everyday, once a day D. At bed time
Answer: C after meal – (knowledge) Some of the common Latin prescription
abbreviations include: ac (ante cibum) means "before meals" ... pc (post cibum) means
"after meals" prn (pro re nata) means "as needed" q 3 h (quaque 3 hora) means "every 3
hours".

534. What is the most advisable site of intramuscular injection in infants less than 7 months?
a. Dorsogluteal c. Vastus lateralis
b. Lateral upper arms d. Ventrogluteal
Answer: c vastus lateralis (Evaluation)
Rationale: The anterolateral thigh is the preferred site for IM injection in infants under 7
months of age. Medications are injected into the bulkiest part of the vastus lateralis
thigh muscle, which is the junction of the upper and middle thirds of this muscle.

535. Drugs that are compressed into disk?

a. Caplets c. Capsules
b. Syrup d. Tablets
Answer: d tablets (Comprehension)
Rationale: Tablets may be defined as the solid unit dosage form of medicament or
medicaments with suitable excipients and prepared either by molding or by compression.
It comprises a mixture of active substances and excipients, usually in powder form,
pressed or compacted from a powder into a solid dose.

536. Drugs that are contained gelatinous cylinders?

a. Caplets c. Syrup
b. Capsules d. Tablets
Answer: b capsules (Comprehension)
Rationale: Capsules are easier to swallow and are used by manufacturers when the drug
cannot be compacted into a solid tablet. It is normally a shell or container made of
gelatin that contains the drug. There are two types of capsules, hard or soft.

537. What does the pharmaceutical abbreviation PO mean?

a. By mouth c. By ears
b. By tooth d. By tongue
Answer: a by mouth (Knowledge)
Rationale: Per os or by mouth is an adverbial phrase meaning literally from Latin "by
opening" or "by way of the opening." The expression is used in medicine to describe a
treatment that is taken orally. The abbreviated P.O. is often used on medical
prescriptions.
538. Which abbreviation refers to Parenteral administration of medication?
a. SL c. Susp
b. PO d. SC or SQ
Answer: d SC or SQ (Knowledge)
Rationale: A subcutaneous injection is a method of administering medication.
Subcutaneous means under the skin. In this type of injection, a short needle is used to
inject a drug into the tissue layer between the skin and the muscle. Subcutaneous
administration may be abbreviated as SC or SQ.

539. What does the pharmaceutical abbreviation PR mean?

a. Per orem c. Per rectum
b. Proline rich d. Perfusion rate
Answer: c per rectum (Knowledge)
Rationale: By or through the rectum, denoting a method of delivering medication. Uses
the rectum as a route of administration for medication and other fluids, which are
absorbed by the rectum's blood vessels, and flow into the body's circulatory system,
which distributes the drug to the body's organs and bodily systems.
 540. Nitroglycerin Sublingual tablets are used to treat episodes of angina (chest pain) in people
who have coronary artery disease (narrowing of the blood vessels that supply blood to the heart).
What is the pharmaceutical abbreviation of sublingual?
a. SB c. SG
b. SL d. SN
Answer: b SL (Knowledge)
Rationale: Sublingual (abbreviated SL), from the Latin for "under the tongue", refers to
the pharmacological route of administration by which substances diffuse into the blood
through tissues under the tongue.

541. Some medicines need to be taken "a.c.". This is because food and some drinks can affect
the way these medicines work. What does the a.c mean?
a. After meals c. As desired
b. Of each d. Before meals
Answer: d before meals (Knowledge)
Rationale: As a general rule, medicines that are supposed to be taken on an empty
stomach should be taken about an hour before a meal, or 2 hours after a meal.

542. During an overnight fast when the patient is not to eat any food but can have water, the
doctor's order might read: "Water [Link].". The [Link]. Mean?
a. As denied c. As desired
b. As denote d. As decline
Answer: c as desired (Knowledge)
Rationale: [Link].:Abbreviation for the Latin "ad libitum" meaning "at pleasure" and "at
one's pleasure, as much as one desires, to the full extent of one's wishes.".

543. IVF complication that leads to hypertension, heart failure and pulmonary edema?
a. Fluid overload c. Extravasation
b. Infiltration  d. Embolism
Answer: a fluid overload (Evaluation)
Rationale: Fluid overload or volume overload (hypervolemia), is a medical condition
where there is too much fluid in the blood. Excess fluid, primarily salt and water, builds
up throughout the body resulting in weight gain. You will see the following signs or
symptoms: Noticeable swelling in the legs and arms (peripheral edema).

544. ____________ is a condition in which the calcium level in your blood is above normal. Too
much calcium in your blood can weaken your bones, create kidney stones, and interfere with how
your heart and brain work. 
a. Hypocalcemia c. Hypernatremia
b. Hypercalcemia d. Hypermagnesemia
Answer: b hypercalcemia (Analysis)
Rationale: Hypercalcemia can result when too much calcium enters the extracellular fluid
or when there is insufficient calcium excretion from the kidneys. Approximately 90% of
cases of hypercalcemia are caused by malignancy or hyperparathyroidism. The severity
of symptoms is related not only to the absolute calcium level but also to how fast the rise
in serum calcium occurred.
545. The order. “Please start Cefalexin 500mg PO q8° for 1 week.” But the available preparation is
Cefalexin 250mg/5ml. How many ml must the nurse give?
a. 5ml c. 15ml
b. 10ml d. 20ml
Answer: B. 10ml (Application)
Rationale: In order to know how many ml the nurse should give to the patient, he/she
should divide 500mg from 250mg then multiply it by 5ml

546. The order, “Please administer Heparin 8,000 units SC every 8 hours.” The available preparation is
Heparin 10,000 units/2ml. How much Heparin (in ml) should the patient receive per dose?
a. 1.4ml c. 1.6ml
b. 1.5ml d. 1.7ml
Answer: C. 1.6ml (Application)
 Rationale: In order to know how many ml the patient should receive per dose, divide
8,000 by 10,000 then multiply it by 2ml

547. The order: “Administer Phenobarbital grain ¼ OD” The available preparation is Phenobarbital
30mg/tab. How many tablets must the nurse administer?
a. 1tab c. ¼ tab
b. ½ tab d. 2 tabs
Answer: B. ½ tab (Application)
Rationale: In order to know how many tablets the nurse must administer, divide ¼ by 30
mg/tab then multiply it by 1 tab

548. A client weighing 66lbs was started on Amoxicillin 50mg/kg/day in three divided doses.” The
available drug is Amoxicillin 500mg/5ml. How many ml should the client receive?
a. 5ml c. 15ml
b. 10ml d. 20ml
Answer: A. 5ml (Application)
Rationale: In order to know how many ml the client should receive, multiply the pounds
to 2.2lbs and the answer would again be multiplied to 50mg/kg/day and the next
product will be now divided into 3. The total answer will be divided to 500mg and then
multiplied by 5ml.

549. The order: “Start Cloxacillin 100mg/kg/day every 6hours for 1 week.” The client weighs 22 lbs. The
available preparation in 250mg/5ml. How many ml should the nurse give every dose?
a. 5ml c. 15ml
b. 10ml d. 20ml
Answer: A. 5ml (Application)
Rationale: In order to know how many ml should the nurse give every dose, the given
weight should be divided by 2.2lbs/kg and then 10kg will be multiplied to
100mg/kg/day and then 1000mg/day divided into 4. Lastly, divide 250mg to 250mg
multiply to 5ml.

550. The nurse is instructed to administer a drug at 60mg/m²/day in 2 divided doses. The client’s body
surface area is 1.5m². The available preparation is 45mg/500ml. How many ounces should the nurse
administer?
a. 1000 ounces c. 6000 ounces
b. 1500 ounces d. 15,000 ounces
Answer: B. 1500 ounces (Application)
Rationale: In order to know the ounces the nurse should administer, 60mg²/day
multiplied to 1.5m² then 90mg/day divided into 2 doses/day then 45mg divided by 45
mg multiplied to 500 ml would be 50ml x 30 ml/ounce

551. IV
c. Intravascular c. In Vivo
d. In Vitro d. Intravenous
Answer: D. Intravenous (Knowledge)
Rationale: Intravenous means "within a vein." Most often it refers to giving medicines or
fluids through a needle or tube inserted into a vein. This allows the medicine or fluid to
enter your bloodstream right away. For example, your health care provider may
prescribe medicines to be given through a vein, or an intravenous (IV) line.

552. n.p.o.
A. breakfast C. As needed
B. Nothing by mouth D. At bed time
Answer: B nothing by mouth (knowledge)
Rationale: Nothing by mouth is a medical instruction meaning to withhold food and fluids.
It is also known as nil per os (n. p. o. or NPO), a Latin phrase that translates literally to
English as "nothing through the mouth".
 553. p. r. n.
A. At bed time C. as needed
B. breakfast D. once a day
Answer: C as needed (knowledge)
Rationale: p.r.n.: Abbreviation meaning "when necessary" (from the Latin "pro re nata",
for an occasion that has arisen, as circumstances require, as needed).
554. OS
a. Right ear c. Right eye
b. Left ear d. Left eye
Answer: d. Left eye (knowledge)
Rationale: OS – abbreviation for oculus sinister Latin word which means left eye

555. Bol.
a. once c. Twice
b. bold d. Bolus or as a large single dose
Answer: D Bolus or as a large single dose (Knowledge)
Rationale: The answer is letter D because the medical abbreviation Bol. is a medical term
used as bolus or as a large single dose.
556. Admov
a. Apply twice c. apply thrice
b. Apply d. add then move
Answer: B Apply (Knowledge)
Rationale: Admov. is a medical abbreviation which means apply.

557. Drugs that are compressed into disk?

a. syrup c. caplets
b. capsules d. Tablets
Answer: d tablets (Comprehension)
Rationale: Tablets may be defined as the solid unit dosage form of medicament or
medicaments with suitable excipients and prepared either by molding or by compression.

558. Preferably used to administer medicines and feedings for clients who cannot swallow.
a. Syrup c. Liquid solutions
b. Capsules d. Nasogastric tube
Answer: D nasogastric tube (Knowledge)
Rationale: NGT is a special tube that carries food and medicine to the stomach through
the nose. It can be used for all feedings or for giving a person extra calories. You'll learn
to take good care of the tubing and the skin around the nostrils so that the skin doesn't
get irritated.

559. This injection administered into the dermis, just below the hypodermis.
a. Intramuscular c. Intravenous
b. Subcutaneous d. Intradermal
Answer: D. Intradermal (Application)
Rationale: Intradermal injection, often abbreviated ID, is a shallow or superficial
injection of a substance into the dermis, which is located between the epidermis and the
hypodermis. This route is relatively rare compared to injections into the subcutaneous
tissue or muscle.

560. Total body water is ____% of Body weight?

a. 40% c.60%
b.35% d. 50%
Answer C. 60% (EVALUATION)
Rationale: Total Body water in healthy adults is 60% of total Body weight.

561. TBW Intracellular Fluid is ___% of total body weight?

a.20% c. 75%
b. 40% d.10%
Answer B. 40% (EVALUATION)
Rationale: Intracellular Fluid represents about two thirds of the TBW which is equivalent to
40%.

562. . TBW Extracellular fluid is ____ % of total body weight?

a.25% c.20%
b.10% d. 50%
Answer C. 20% (EVALUATION)
Rationale: The Extracellular fluid is separated from the Intracellular fluid, and the 20% of the
TBW is in the Extracellular fluid compartment.

563. . Interstitial Fluid is ___ of total body weight %?

a.10% c. 15%
b. 90% d. 5%
Answer C. 15% (EVALUATION)
Rationale: The Extracellular fluid comprises approximately 20% of total body weight and
further subcategorizes as interstitial space which is approximately 15% of body weight and
Plasma at approximately 5% of body weight.

[Link] of Plasma fluid is___ of total body weight?

a.3% c. 8%
b. 5% d. 10% Answer B.)
Rationale: The Extracellular fluid comprises approximately 20% of total body weight and
further subcategorizes as interstitial space which is approximately 15% of body weight and
Plasma at approximately 5% of body weight.

565. Purposes of IV Therapy- Continuous infusion of IV fluid to replace lost fluid?

a. To maintain electrolytes balance c. To maintain water balance
b. To expand intravascular fluid d. To provide emergency access
Answer C. To maintain water balance (KNOWLEDGE)
Rationale: Continuous Infusion of IV fluid to maintain body water concentration and to replace
lost fluid.

566. Purposes of IV Therapy- IV fluids that contain electrolytes.

a. to maintain electrolytes balance c. to expand intravascular fluid
b. to maintain water balance d. to provide emergency access
Answer A. To maintain electrolytes balance (KNOWLEDGE)
Rationale: IV fluids that contain electrolytes like sodium and potassium can be infused to
maintain normal serum levels of Electrolytes Balance.

567. Purposes of IV Therapy- IV fluid can be infused or given for hypovolemia (as a result of blood loss) to
immediately increase?
a. to expand intravascular fluid volume c. to provide parental nutrition
b. to maintain water balance d. To provide emergency access
Answer A. To expand intravascular fluid volume (KNOWLEDGE)
Rationale: IV fluids can be infused to immediately increase or Expand intravascular fluid
volume.

568. Purposes of IV Therapy- IV fluids can keep veins open for multiple intravenous injections in order to
provide?
a. To provide Parental nutrition c. To provide sites for intravenous drug
administration
b. To provide emergency access administration d. To expand intravascular fluid volume
Answer C. to provide sites for intravenous drug administration (KNOWLEDGE)
Rationale: All Intravenous drugs of the client will be injected through the IV line

569. Purposes of IV Therapy- Blood and blood products also used the same IV line for transfusion.
a. To provide sites for intravenous c. To provide route for blood and blood products
b. To expand intravascular fluid volume d. To provide emergency access
Answer C. to provide route for blood and blood products (KNOWLEDGE)
Rationale: Transfusion can restore blood volume; restore oxygen-carrying capacity of blood.

570. Purposes of IV Therapy- Some intravenous fluids can deliver glucose and fat solution in order to
provide?
a. To provide emergency access c. to provide Parental nutrition
b. to expand intravascular fluid volume d. to maintain water balance
Answer C. to provide Parental nutrition (KNOWLEDGE)
Rationale: Some intravenous fluids can deliver glucose and fat solution to act as energy
sources among clients not receiving enough food.

571. What is the nurse’s primary concern regarding fluid and electrolytes when caring for and elderly
patient who is intermittently confused?
a. Risk of stroke c. risk of dehydration
b. risk of kidney damage d. risk of bleeding
Answer C. Risk of dehydration (KNOWLEDGE)
Rationale: As adult ages the thirst mechanism declines, adding this in the patient with an
altered level of consciousness, there is an increased in risk of dehydration and high serum
osmolality.

572. The nurse is planning care for a patient with severe burns. Which of the following is this patient at
risk for developing?
a. Extracellular fluid deficit c. Intracellular fluid deficit
b. Intracellular fluid over load d. Interstitial fluid deficit
Answer C. Intracellular fluid deficit (EVALUATION)
Rationale: Because this patient was severely burned, the fluid within the cells is diminished
leading to an intracellular fluid deficit.

573. A pregnant patient is admitted with excessive thirst, increased urination and has a medical diagnosis
of diabetes insipidus. The nurse chooses which of the following nursing diagnosis is most appropriate?
a. Imbalance Nutrition perfusion c. Risk of imbalance fluid volume
b. Excess fluid volume d. Ineffective tissue
Answer C. Risk of imbalance fluid volume (EVALUATION)
Rationale: The patient with excessive thirst, Increased urination and a medical diagnosis of
diabetes insipidus is at risk for imbalance fluid volume due to the patients and excess volume
loss that can increase the serum levels of sodium.

574. A patient is receiving intravenous fluids postoperatively following cardiac surgery; nursing
assessments should focus on which postoperative complication?
a. Seizure activity c. Fluid volume excess
b. Fluid volume deficit d. Liver failure
Answer C. Fluid volume excess (EVALUATION)
Rationale: Anti diuretic hormone and aldosterone level are commonly increased following the
stress response before, during and immediately after surgery. The increase leads to sodium
and water retention Adding more fluid intravenously can cause a fluid volume excess and
stress upon the heart and circulatory system.

575. Some intravenous fluids can deliver glucose and fat solutions to act as energy sources among clients
not receiving enough food. What Purpose of IV Therapy is referring by the sentence above?
a. To provide energy c. To provide route for blood or blood product
b. To provide emergency access d. To Provide parenteral nutrition
if a Client/Patient that is admitted cannot take some nutrients by oral intake it is the best
solution to have an intravenous fluid so that the Client/Patient will have that specific nutrients
he/she needed.

576. Clients are usually hooked to intravenous fluids for easy administration of emergency drugs anytime
as the needed arises. What Purpose of IV Therapy is referring by the sentence above?
a. To provide route for blood or blood product c. To provide energy
b. To provide emergency access d. To Provide parenteral nutrition
Answer: B. To provide emergency access (KNOWLEDGE)
Rationale: if a Client/Patient is already unconscious or cannot intake some drugs because
he/she cannot swallow the specific drugs the intravenous therapy is the fastest and safe way
to administered the drug to the Client/Patient.

577. Which patient is at most risk for fluid volume deficient?

a. A patient who has been vomiting and having diarrhea for 2 days.
b. A patient with continuous nasogastric suction.
c. A patient with an abdominal wound vac at intermittent suction.
d. All of the above are correct.
Answer: D. All of the above are correct (EVALUATION)
Rationale: As the nursing administering Magnesium sulfate IV, you must monitor for reduced
deep tendon reflexes because the patient could quickly develop hypermagnesemia. In addition,
seizure precautions should be initiated due to the patient’s low magnesium level.

578. A patient is admitted with exacerbation of congestive heart failure. What would you expect to find
during your admission assessment?
a. Flat neck and hand veins c. Increased blood pressure and crackles throughout the lungs
b. Furrowed dry tongue d. Bradycardia and pitting edema in lower extremities
Answer: C. Increased blood pressure and crackles throughout the lungs (COMPREHENSION)
Rationale:  Patients with CHF are in fluid volume overload and the heart cannot compensate for
the extra fluid volume; therefore, the fluid starts to “backup”. You would find an increased
blood pressure and crackles in the lungs. You would also see pitting edema in the lower
extremities but NOT bradycardia.

579. What is the Major Intracellular Cation?

a. Magnesium c. Potassium
b. Sodium d. Calcium
Answer: C. Potassium (KNOWLEDGE)
Rationale:  Necessary for nerve impulse transmission and muscle contraction.

580. In which part of the circulatory system is an IV placed?

a. Artery c. Potassium
b. Veins d. Calcium
Answer: B. Veins (KNOWLEDGE)
Rationale:  The vein is a rapid route for distribution of fluids and drugs.

581. A new IV site is required every few days to prevent infection and other major complications.
a. True c. Both A & B
b. False d. None of the above
Answer: A. True (EVALUATION)
Rationale:  Recommendations for IV site changes vary from 72-96 hours. However, most health
care settings have policies for every 72 hours. The site changing decreases the chance of
infection and other complications.

582. A Nurse has written a prescription to discontinue an intravenous (IV) line. The nurse should obtain
which item from the unit supply area for applying pressure to the site after removing the IV catheter?
a. Elastic wrap c. Adhesive bandage
b. Betadine swab d. Sterile 2 × 2 gauze
Answer: D. Sterile 2 × 2 gauze (EVALUATION)
Rationale:  A dry sterile dressing such as a sterile 2 × 2 is used to apply pressure to the
discontinued IV site. This material is absorbent, sterile, and nonirritating. A Betadine swab
would irritate the opened puncture site and would not stop the blood flow. An adhesive
bandage or elastic wrap may be used to cover the site once hemostasis has occurred.

583. What is the Major Extracellular Cation?

a. Magnesium c. Potassium
b. Sodium d. Calcium
Answer: B. Sodium (KNOWLEDGE)
Rationale:  Regulates Body Fluids; Attracts Water.

584. The nurse is preparing a continuous intravenous (IV) infusion at the medication cart. As the nurse
goes to insert the spike end of the IV tubing into the IV bag, the tubing drops and the spike end hits the
top of the medication cart. The nurse should take which action?
a. Obtain a new IV bag. c. Wipe the spike end of the tubing with Betadine.
b. Obtain new IV tubing. d. Scrub the spike end of the tubing with an alcohol swab.
Answer: B. Obtain new IV tubing (COMPREHENSION)
Rationale:  The nurse should obtain new IV tubing because contamination has occurred and
could cause systemic infection to the client. There is no need to obtain a new IV bag because
the bag was not contaminated. Wiping with Betadine or alcohol is insufficient and is
contraindicated because the spike will be inserted into the IV bag.

585. What might the medical staff call a capped off IV?
a. Hepwell c. PRN adapter
b. Heparin lock d. All of the Above
Answer: D. All of the Above (EVALUATION)
Rationale: These IV accesses are for intermittent drugs, such as narcotics and antibiotics, and
are kept patent with periodic flushes of saline and/or heparin. However, most health care
settings are decreasing the use of heparin for intermittent flushing. Recommendations for
patency are normally for 2-5ml of saline every eight hours.

586. The nurse is making initial rounds on the nursing unit to assess the condition of assigned clients. The
nurse notes that a client’s intravenous (IV) site is cool, pale, and swollen, and the solution is not infusing.
The nurse concludes that which complication has occurred?
a. Infection c. Infiltration
b. Phlebitis d. Thrombosis
Answer: C. Infiltration (KNOWLEDGE)
Rationale: An infiltrated IV is one that has dislodged from the vein and is lying in subcutaneous
tissue. Pallor, coolness, and swelling are the results of IV fluid being deposited in the
subcutaneous tissue. When the pressure in the tissues exceeds the pressure in the tubing, the
flow of the IV solution will stop. The corrective action is to remove the catheter and start a new
IV line at another site. Infection, phlebitis, and thrombosis are likely to be accompanied by
warmth at the site, not coolness.

587. The nurse is inserting an intravenous line into a client’s vein. After the initial stick, the nurse would
continue to advance the catheter in which situation?
a. The catheter advances easily. c. The client does not complain of discomfort.
b. The vein is distended under the needle. d. Blood return shows in the backflash chamber of the catheter.
Answer: D. Blood return shows in the backflash chamber of the catheter. (COMPREHENSION)
Rationale: The IV catheter has entered the lumen of the vein successfully when blood backflash
shows in the IV catheter. The vein should have been distended by the tourniquet before the
vein was cannulated. Client discomfort varies with the client, the site, and the nurse’s insertion
technique and is not a reliable measure of catheter placement. The nurse should not advance
the catheter until placement in the vein is verified by blood return.

588. A client has just undergone insertion of a central venous catheter at the bedside. The nurse would be
sure to check which results before initiating the flow rate of the client’s intravenous (IV) solution at 100
mL/hour?
a. Serum osmolality c. Portable chest x-ray film
b. Serum electrolyte levels d. Intake and output record
Answer: C. Portable chest x-ray film (COMPREHENSION)
Rationale: Before beginning administration of IV solution, the nurse should assess whether the
chest radiograph reveals that the central catheter is in the proper place. This is necessary to
prevent infusion of IV fluid into pulmonary or subcutaneous tissues. The other options
represent items that are useful for the nurse to be aware of in the general care of this client,
but they do not relate to this procedure.
589. What is the normal potassium serum level in mEq/L?
a. 3.5-5.4mEq/L c. 3.5-5.6mEq/L
b. 3.5-5.3mEq/L d. 3.5-5.5mEq/L
B- 3.5-5.3mEq/L (APPLICATION)
Rationale: potassium helps electrical signals to cells in your body.

590. The nurse has a prescription to hang a 1000-mL intravenous (IV) bag of 5% dextrose in water with
20 mEq of potassium chloride and needs to add the medication to the IV bag. The nurse should plan to
take which action immediately after injecting the potassium chloride into the port of the IV bag?
a. Rotate the bag gently. c. Prime the tubing with the IV solution.
b. Attach the tubing to the client. d. Check the solution for yellowish discoloration.
Answer: A. Rotate the bag gently. (EVALUATION)
Rationale: After adding a medication to a bag of IV solution, the nurse should agitate or rotate
the bag gently to mix the medication evenly in the solution. The nurse should then attach a
completed medication label. The nurse can then prime the tubing. The IV solution should have
been checked for discoloration before the medication was added to the solution. The tubing is
attached to the client last.

591. What is the normal sodium serum level in mEq/L?

a. 130-145mEq/L c. 135-145mEq/L
b. 135-155mEq/L d. 135-145mEq/L
C- 135-145mEq/L (APPLICATION)
Rationale: excess dietary sodium is largely excreted in the urine, but too much salt in the diet
tends to increase the blood pressure.

592. What is the normal calcium serum level in mEq/L?

a. 3.5-4.5mEq/L c. 3.6-4.6mEq/L
b. 4.5-5.5mEq/L d. 4.6-5.5mEq/L
B- 4.5-5.5mEq/L (APPLICATION)
Rationale: The Calcium blood test measures the level of calcium in the blood and attached to
proteins, mainly albumin and also be measure in the urine.

593. Inflammation of vien

a. thrombophlebitis c. superficial thrombophlebitis
b. embolism d. phlebitis
D- Phlebitis (SYNTHESIS)
Rationale: Phlebitis is the inflammation of the wall of a vein.

594. Escape of fluid into tissues

a. infiltration c. extravasation
b. occlusion d. phlebitis
A- Infiltration

595. Leakage of caustic substance into tissues.

a. infiltration c. extravasation
b. occlusion d. phlebitis
C- Extravasation (COMPREHENSION)
Rationale: Extravasation is the leakage of a fluid out of its container. In the case of
imflammation, it refers to movement of the white blood cells from the capillaries to the tissues
surrounding th, also known as diapedesis

596. Always read the drug label _______times.

a. 2 times c. 4 times
b. 3 times d. 5 times
B- 3 times

597. Always clarify unclear dosage,especially if written according to _________ units only,like tablets
(since drug have many preparation,250mg and 500mg tablets)
a. date c. package
b. expiration d. box
C- Package (KNOWLEDGE)
Rationale: because medicines will clearly state what they’re meant to do on the medecines.

598. Always practice __________ zeroes (ex. 0.1mg; because .1mg can be mistaken as 1mg) for drug
doses; but avoid _________zeroes (ex. 1.0mg; because 1.0mg can be mistaken as 10mg)
a. leading, drug c. trailing,drug
b. trailing, leading d. leading,trailing
D- leading,trailing (EVALUATION)
Rationale: leading is a most [Link] is a draw or be drawn along the grund or other
surface

599. Always practice __________ zeroes (ex. 0.1mg; because .1mg can be mistaken as 1mg) for drug
doses; but avoid _________zeroes (ex. 1.0mg; because 1.0mg can be mistaken as 10mg)
a. leading, drug c. trailing,drug
b. trailing, leading d. leading,trailing
D- leading,trailing (EVALUATION)
Rationale:leading is a most [Link] is a draw or be drawn along the grund or other
surface

600. Always gain first the _________ of your client before attempting to administer the medication.
a. cooperation c. clarify
b. on time d. all of the above
A- Cooperation (KNOWLEDGE)
Rationale: cooperation to act or work with another.

601. Always check drug inserts (especially look for recommended doses, proper administration,adverse
reaction and _________interactions)
a. drug-client c. drug-route
b. drug-drug d. drug-expiration
B- drug-drug (COMPREHENSION)
Rationale: Drug-drug interaction can make a drug less effective, increase the action of a drug,
or cause unwanted side effects.

602. A patient who is taking Lasix knows that he should increase intake of what food?
a. iceberg lettuce c. plums
b. apples d. cantaloupe
D- cantaloupe (KNOWLEDGE)
Rationale: Cantaloupe has high levels of potassium in it, which tends to be lower in a patient
taking lasix

603. The nurse is reviewing the client’s medication and she noticed a prescription of Versed. Which
medication is important to have available for clients who have received Versed?
a. florinef (Fludrocortisone) c. flumazenil(Romazicon)
b. diazepam(Valium) d. naloxone(Narcan)
C- flumazenil(Romazicon) (ANALYSIS)
Rationale: Romazicon is the antidote for Versed. Versed is used for conscious sedation and is
an antianxiety agent.

604. The nurse is administering an unpleasant-tasting liquid medication to a 2 year-old child. Which
intervention should the nurse implement?
a. use a dropper to place the medication between the gum and cheek.
b. put the medication in 4 ounces of apple juice
c. tell the child the medication will not taste bad
d. prepare the medication in the childs favorite food `
A- use a dropper to place the medication between the gum and cheek. 605. A graduate nurse
prepare a patient to undergo a liver biopsy. The graduate nurse administer what pre-op medication?
a. vitamin A c. coumadin
b. vitamin B-12 d. vitamin K
D- vitamin K (KNOWLEDGE)
Rationale: Vitamin K is administered before a liver biopsy to reduse the risk of bleeding.

606. Always observe ________ technique (especially during parenteral administration).

a. Aseptic c. Neat
b. Clean d. Sterile
A- Aseptic (KNOWLEDGE)
Rationale: To protect patients from harmful bacteria and other pathogens during medical procedures,
healthcare providers use aseptic technique. Aseptic technique means using practices and procedures to
prevent contamination from pathogens. It involves applying the strictest rules to minimize the risk of
infection.

607. Always ________ drugs in the medication chart immediately after administration.
a. Note c. Copy
b. Record d. Take
B- Record (KNOWLEDGE)
Rationale: important in preventing prescription errors and consequent risks to patients. Apart
from preventing prescription errors, accurate medication histories are also useful in detecting
drug-related pathology or changes in clinical signs that may be the result of drug therapy.

Rationale: this action promotes swallowing and prevents the medication from being aspirated
or spit out. Do not use a favorite food or essential dietry item when administering a medication
because the child may refuse the food in the future.

608. Always educate clients about the drugs that they are taking; teach also the ________ to be expected
and reported.
a. Secondary effect c Side effects
b. Primary effect d. Double effect
C- Side effects (KNOWLEDGE)
Rationale: Side effects are unwanted symptoms caused by medical treatment. They're also
called "adverse effects" or "adverse reactions". You should check the patient information
leaflet that comes with your medication to see if certain side effects could make it unsafe
for you.

609. Always report medication errors to physician and nurse administrator; complete also a ________
report.
a. Hospital incident c. Comparative
b. Medication incident d. Narrative
B- Medication incident (KNOWLEDGE)
Rationale: The aim of MIR is to collect incident information that can allow RACFs to identify and
address the safety risks associated with medication incidents by understanding the types of
the incidents, their possible or actual effects, and causes.

610. Always determine if client has a scheduled ________ that would contraindicate the drug
administration.
a. Diagnostic procedure c. OR procedure
b. Medical procedure d. Surgical procedure
A- Diagnostic procedure (KNOWLEDGE)
Rationale: A contraindication is a specific situation in which a drug, procedure, or surgery
should not be used because it may be harmful to the person. This means that the diagnostic
procedure may be a contraindication to the drug administration.

611. Always ________ the client’s refusal to take the medication.

a. Note c. Document
b. Listen to d. Answer
C- Document (KNOWLEDGE)
Rationale: Competent adults have the right to refuse treatment, including diagnostic tests and
medication. But to avoid legal and ethical ramifications, you must document such refusals
properly. If your patient refuses treatment or medication, your first responsibility is to make
sure that he's been informed about the possible consequences of his decision in terms he can
understand.

612. Always evaluate the effectiveness of the medication by determining the client’s ________ to the
drug.
a. Nod c. Answer
b. Look d. Response
D- Response (KNOWLEDGE)
Rationale: Evaluating the effectiveness means that you are also assessing if the drug is safe for
the patient and if there are some changes happening to the patient.

613. Avoid carrying out a/an ________ drug order; never assume anything on drug orders.
a. Complete c. Prescribed
b. Incomplete d. PRN
B- Incomplete (KNOWLEDGE)
Rationale: All the factors that lead to medication errors in general contribute towards
prescription errors. They include lack of knowledge, using the wrong drug name, dosage form,
or abbreviation, and incorrect dosage calculations

614. Avoid administering drugs that were prepared by others (except by the ________).
a. Doctor c. Pharmacist
b. Nurse d. Midwife
C- Pharmacist (KNOWLEDGE)
Rationale: Pharmacists in healthcare facilities dispense medications and advise the medical
staff on the selection and effects of drugs. Some pharmacists are involved in research for
pharmaceutical manufacturers, developing new drugs and testing their effects.

615. Avoid administering drugs into the hand but use the ________.
a. Bottle c. Plate
b. Other cup d. Container’s cap
D- Container’s cap (KNOWLEDGE)
Rationale: To avoid the transmission of bacteria, you should put it in the container’s cap
because the hands may be soiled with bacteria.

616. A client is advised to take Senna (Senokot) for the treatment of constipation asks the nurse how this
medication works. The nurse responds knowing that it:
a. Accumulates water in the stool and increases peristalsis c. Coats the bowel wall
b. Stimulates the vagus nerve d. Adds fiber and bulk to the stool
A- Accumulates water in the stool and increases peristalsis (EVALUATION)
Rationale: Senna works by changing the transport of water and electrolytes in the
largeintestine, which causes the accumulation of water in the mass of stool and increased
peristalsis

617. A client is receiving heparin sodium by continuous intravenous infusion. The nurse monitors the client
for which adverse effect of this therapy?
a. Decreased blood pressure c. Ecchymoses
b. Increased pulse rate d. Tinnitus
C- Ecchymoses (ANALYSIS)
Rationale: Heparin sodium is an anticoagulant. The client who receives heparin sodium is at
risk for bleeding. The nurse monitors for signs of bleeding, which includes bleeding from the
gums, ecchymoses on the skin, cloudy or pink-tinged urine, tarry stools, and body fluids that
test positive for occult blood.
618. Walter, teenage patient is admitted to the hospital because of acetaminophen (Tylenol) overdose.
Overdoses of acetaminophen can precipitate life-threatening abnormalities in which of the following
organs?
a. Lungs c. Kidney
b. Liver d. Adrenal glands
B- Liver (ANALYSIS)
Rationale: Acetaminophen is extensively metabolized by pathways in the liver. Toxic doses of
acetaminophen deplete hepatic glutathione, resulting in accumulation of the intermediate
agent, quinine, which leads to hepatic necrosis. Prolonged use of acetaminophen may result in
an increased risk of renal dysfunction, but a single overdose does not precipitate life-
threatening problems in the respiratory system, renal system, or adrenal glands.

619. When can a male patient with eczema not be given a topical corticosteroid?
a. Parasite infection. c. Bacterial infection
b. Viral infection. d. Spirochete infection
B- Viral infections (KNOWLEDGE)
Rationale: Topical agents produce a localized, rather than systemic effect. When treating atopic
dermatitis with a steroidal preparation, the site is vulnerable to invasion by organisms. Viruses,
such as herpes simplex or varicella-zoster, present a risk of disseminated infection. Educate
the patient using topical corticosteroids to avoid crowds or people known to have infections
and to report even minor signs of an infection. Topical corticosteroid usage results in little
danger of concurrent infection with these agents.

620. Which is the correct option here?

Reyes syndrome, a potentially fatal illness associated with liver failure and encephalopathy is associated
with the administration of _________ over-the-counter (OTC) medication?
A. Acetaminophen (Tylenol) C. Aspirin
B. Ibuprofen (Motrin) D. Brompheniramine/pseudoephedrine (Dimetapp)
C- Aspirin (KNOWLEDGE)
Rationale: Virus-infected children who are given aspirin to manage pain, fever, and
inflammation are at an increased risk of developing Reyes Syndrome. Use of acetaminophen
has not been associated with Reyes Syndrome and can be safely given to patients with fever
due to viral illnesses. Ibuprofen adverse effects include gi irritation and bleeding, and in toxic
doses, both renal and hepatic failure is reported. However, ibuprofen has not been associated
with the onset of Reyes Disease. Brompheniramine/Psudoephedrine contains a first generation
OTC antihistamine and a decongestant. neither agent has been associated with the
development of Reyes Syndrome.

620. Avoid starting a client on new medication by borrowing drugs from another patient to
avoid___________ of the drug regimen
a. discontinuation c. discomfort
b. discoloration d. none of the above
Answer: A. discontinuation (KNOWLEDGE)
Rationale: Borrowing a drug as a workaround to speed the process of administering
medications because of excessive wait times related to the pharmacy-dispensing process
increases the risk of an error, especially if a drug intended for one patient is given to another.

621. Avoid giving drugs beyond the_________ date or are already dissolved, cloudy or have precipitate
and sediments
a. exact c. whole
b. before d. expiration
Answer: D. expiration (KNOWLEDGE)
Rationale: Solid dosage forms, such as tablets and capsules, appear to be most stable past
their expiration date. Drugs that exist in solution or as a reconstituted suspension, and that
require refrigeration (such as amoxicillin suspension), may not have the required potency if used
when outdated. Loss of potency can be a major health concern, especially when treating an
infection with an antibiotic. Additionally, antibiotic resistance may occur with sub-potent
medications. Drugs that exist in solution, especially injectable drugs, should be discarded if the
product forms a precipitant or looks cloudy or discolored. Expired medications that contain
preservatives such as ophthalmic (eye) drops, may be unsafe past their expiration date.
Outdated preservative may allow bacterial growth in the solution.

622. Avoid leaving medication at beside or with visitor; remember not to leave the client until
the_________ is taken
a. linen c. chart
b. drug d. none of the above
Answer: B. drug (APPLICATION)
Rationale: to ensure that the patient take the medicine on time

623. Avoid administering drugs__________ minutes before or after the specified time
a.1 hour c. 30 minutes
b. 25 minutes d. 35 minutes
Answer: C. 30 minutes (ANALYSIS)
Rationale: 30 minutes before or after the scheduled dose may cause harm or result in
substantial sub-optimal therapy or pharmacological effect.

624. Avoid giving___________-tasting first before___________-tasting drugs.

a. good, bad c. bad, pleasant
b. yummy, sour d. all of the above
Answer: C. bad, pleasant (KNOWLEDGE)
Rationale: Better-tasting medications may enhance pediatric adherence to drug therapy.
Sugars, acids, salt, and other substances reduce perceived bitterness of several
pharmaceuticals, and although pleasant flavorings may help children consume some medicines,
they often are not effective in suppressing bitter tastes.

625. Avoid giving drugs that causes gastric irritation on__________ stomach.
a. an empty c. both a and b
b. an open d. none of the above
Answer: B. an empty (COMPREHENSION)
Rationale: One of the most common irritants to the lining of the stomach is that caused by
nonsteroidal anti-inflammatory drugs (NSAIDs). This includes medicines, such as ibuprofen
and other common pain relievers. These medicines weaken the ability of the lining to resist
acid made in the stomach and can sometimes lead to inflammation of the stomach lining
(gastritis), ulcers, bleeding, or perforation of the lining.
Older people are at greater risk for irritation from these medicines because they are more likely
to take these pain relievers for chronic conditions. People with a history of peptic ulcers and
gastritis are also at risk.

626. Avoid using____________ terms when teaching or explaining to the client; give simple explanation
a. mathematician c. sped
b. agriculturist d. medical
Answer: D. medical (COMPREHENSION)
Rationale: Learning to speak to your patients in layman’s terms will help keep your patients
comfortable with the treatment you are recommending and allow them to make informed
decisions based on their needs.

627. Avoid___________ used needles to prevent__________ infections

a. opening, skin c. un-sealed, eye
b. recapping, blood borne d. all of the above
Answer: B. recapping, blood borne (SYNTHESIS)
Rationale: to prevent occupational exposure to blood borne pathogens and to reduce the
chances of infection when exposure does occur.
628. An order is written to start an IV on a 74-year-old client who is getting ready to go to the
operating room for a total hip replacement. What gauge of catheter would best meet the needs
of this client?
a. 21 butterfly c. 18
b. 20 d. 25
Answer: C. 18 (ANALYSIS)
Rationale: Clients going to the operating room ideally should have an 18- gauge catheter. This
is large enough to handle blood products safely and to allow rapid administration of large
amounts of fluid if indicated during the perioperative period. An 18-gauge catheter is
recommended. A 20-gauge catheter is a second choice. A 21-gauge needle is too small and a
butterfly too unstable for a client going to surgery. A 25-gauge needle is too small.

629. A 2 year-old child is receiving temporary total parental nutrition (TPN) through a central
venous line. This is the first day of TPN therapy. Although all of the following nursing actions
must be included in the plan of care of this child, which one would be a priority at this time?
a. Monitor serum glucose levels c. Use aseptic technique during dressing change
b. Maintain central line catheter integrity d. Check results of liver function tests
Answer: A. Monitor serum glucose levels (SYNTHESIS)
Rationale: Monitor serum glucose levels. Hyperglycemia may occur during the first day or 2 as
the child adapts to the high-glucose load of the TPN solution. Thus, a chief nursing
responsibility is blood glucose testing.

630. The physician orders penicillin for a patient with streptococcal pharyngitis. The nurse
administers the drug as ordered, and the patient has an allergic reaction. The nurse checks
the medication order sheet and finds that the patient is allergic to penicillin. Legal responsibility
for the error is:
a. only the nurse’s—she should have checked the allergies before administering the medication.
b. only the physician’s—she gave the order, the nurse is obligated to follow it.
c. only the pharmacist’s—he should alert the floor to possible allergic reactions.
d. the pharmacist, physician, and nurse are all liable for the mistake
Answer: D. the pharmacist, physician, and nurse are all liable for the mistake
(COMPREHENSIVE)
Rationale: The physician, nurse, and pharmacist all are licensed professionals and share
responsibility for errors.

631. James Perez, a nurse on a geriatric floor, is administering a dose of digoxinto one of his
patients. The woman asks why she takes a different pill than her niece, who also has heart
trouble. James replies that as people get older, liver and kidney function decline, and if the dose
is as high as her niece’s, the drug will tend to:
a. have a shorter half-life. c. have decreased distribution.
b. accumulate. d. have increased absorption.
Answer: B. accumulate (ANALYSIS)
Rationale: The decreased circulation to the kidney and reduced liver function tend to allow
drugs to accumulate and have toxic effects.

[Link] nurse is administering augmentin to her patient with a sinus infection. Which is the best way for
her to insure that she is giving it to the right patient?
a. Call the patient by name
b. Read the name of the patient on the patient’s door
c. Check the patient’s wristband
d. Check the patient’s room number on the unit census list
Answer: C. Check the patient’s wristband (APPLICATION)
Rationale: The correct way to identify a patient before giving a medication is to check the name
on the medication administration record with the patient’s identification band. The nurse
should also ask the patient to state their name. The name on the door or the census list are not
sufficient proof of identification. Calling the patient by name is not as effective as having the
patient state their name; patients may not hear well or understand what the nurse is saying,
and may respond to a name which is not their own.
633. Mr. Jessie Ray, a newly admitted patient, has a seizure disorder which is being treated with
medication. Which of the following drugs would the nurse question if ordered for him?
a. Phenobarbitol, 150 mg hs c. Valproic acid (Depakote), 150 mg BID
b. Amitriptylene (Elavil), 10 mg QID. d. Phenytoin (Dilantin), 100 mg TID
Answer: B. Amitriptyline (Elavil), 10 mg QI (EVALUATION)
Rationale: Elavil is an antidepressant that lowers the seizure threshold, so would not be
appropriate for this patient. The other medications are anti-seizure drugs.

634. When counseling a patient who is starting to take MAO (monoamine oxidase) inhibitors
such as Nardil for depression, it is essential that they be warned not to eat foods containing
tyramine, such as:
a. Roquefort, cheddar, or Camembert cheese.c. onions, garlic, or scallions.
b. grape juice, orange juice, or raisins. d. ground beef, turkey, or pork.
Answer: A. Roquefort, cheddar, or Camembert cheese (APPLICATION)
Rationale: Monoamine oxidase inhibitors react with foods high in the amino acid tyramine to
cause dangerously high blood pressure. Aged cheeses are all high in this amino acid; the other
foods are not.

635. Drugs recommended for the relief of mild to moderate pain

a. Aspirin c. NSAIDs
b. Narcotics d. Paracetamol
Answer C-NSAID’s (Knowledge)
Rationale: treatment of mild to moderate pain caused by inflammatory conditions

636. Glucocorticoids are used to treat the following conditions EXCEPT

a. Allergic conditions c. Autoimmune disorders
b. Arthritic conditions d. Cushing's syndrome
Answer D-Cushing's syndrome (EVALUATION)
Rationale: Cushing syndrome is a hormonal disorder caused by prolonged exposure to
glucocorticoids not to treat Glucocorticoids

637. Drug of choice for gout Prophylaxia

a. Allopurinol c. Probenacid
b. Arthritic conditions d. All of the above
Answer A-Allopurinol (KNOWLEDGE)
Rationale: Allopurinol is used to prevent gout attacks

638. What is the most common side effect of the first generation NSAID's ?
a. Depression c. Edema
b. Dizziness d. Gastric Irritation
Answer D-Gastric Irritation (ANALYSIS)
Rationale: Gastrointestinal Irritation and ulceration, bleeding first generation side effect

639. NSAID's are effective anti-inflammatory drugs. this drugs reduce signs of inflammation by blocking
the synthesis of what chemical?
a. Acetylcholine c. Prostaglandin
b. Histamine d. Uric Acid
Answer C-Prostaglandin (KNOWLEDGE)
Rationale: blocking both the prostaglandin and leukotriene pathways

630. The following are nursing implications when administering Nonsteroidal anti-inflammatory drugs
EXCEPT
a. Do not administer with other anti-inflammatory drugs
b. First generation NSAID's produce less side effects
c. Take with food or artacid
d. Watch out for signs of gastrointestinal bleeding
Answer B- First generation NSAID's produce less side effect (EVALUATION)
Letters a, b and c are the following nursing implications when administering nonsteroidal
anti-inflammatory drug
631. NSAID's increase the risk of CNS adverse effect when taken with which group of antibiotics
a. Macrolides c. Aminoglycosides
b. Penicillins d. Quinolones
Answer D-Quinolones (EVALUATION)
Rationale: NSAID's taken with quinolones result in an increased risk of CNS adverse effects .

632. The nurse is teaching a client about taking aspirin. which are not important poit for the nurse to
include?
a. Advising the client to avoid alcohol while taking aspirin
b. Instructing client to take aspirin before meal on an empty stomach
c. Instructing client to inform dentist of aspirin dosage before any dental work
d. Instructing client to inform surgeon of aspirin dosage before any surgery
Answer B-Instructing client to take aspirin before meal on an empty stomach (EVALUATION)
Rationale: It’s not good to take medicine with empty stomach

633. Celecoxib is what class of drug?

a. Muscle relaxant c. Nonsteroidal anti-inflammatory drug (NSAID)
b. Corticosteroid d. Narcotic
Answer C-Nonsteroidal anti-inflammatory drug (NSAID) (KNOWLEDGE)
Rationale: Celecoxib is a nonsteroidal anti-inflammatory drug (NSAID). These drugs work by
inhibiting cyclooxygenase-1 (COX-1) and cyclooxygenase-2 (COX-2), which reduces the
synthesis of pro-inflammatory prostaglandins and thromboxane.

634. Allopurinol can produce Steven Johnson Syndrome. What is this syndrome?
a. CNS depression, leading to drowsiness, respiratory depression and hypotension
b. Headache, palpitation and vomiting
c. Multiple organ toxicity, especially the liver and the kidney
d. Severe allergic reaction with formation of skin blisters and ulcers
Answer D-Severe allergic reaction with formation of skin blisters and ulcers (KNOWLEDGE)
Rationale: Allopurinol can produce Steven Johnson Syndrome severe allergic reaction with
formation of skin blisters and ulcers.

635. Which of the following statement about NSAID's is TRUE?

a. Most NSAID's are weak acids
b. most NSAID's are metabolized by the liver into inactive metabolites
c. Oxicams tends to have the longest half-lives of all NSAID's
d. All of the above
Answer D- All of the above (EVALUATION)
Rationale: all three statements are true

636. Which of the following NSAID's has greater inhibitory selectively for COX-1 than COX-2?
a. Flurbiprofen c. Diclofenac
b. Indomethacin d. Celecoxib
Answer A-Flurbiprofen (KNOWLEDGE)
Rationale: Flurbiprofen has greatest inhibitory selectivity for COX-1 rather than COX-2

637. Paracetamol is an NSAID's with a comparatively low anti-inflammatory effect compared to the other
NSAID's
a. True c. Maybe
b. False d. I don't know
Answer B-False (ANALYSIS)
Rationale: Paracetamol is not NSAID's

638. Which of the following two cycloxygenase isoenzymes is contitutively expressed?

a. COX-1 c. both A &
b. COX-2 d. none of the above
Answer A-COX-1 (EVALUATION)
Rationale: An agent that inhibits the action of the enzyme cox-1

639. Piroxicam has a particularly long half-life (50 hours) as it undergoes enterohepatic recycling
a. True c. maybe
b. False d. Both A & B
Answer A- True (ANALYSIS)
Rationale: Piroxicam has a very long half-life-50 hours- when compared to other NSAID's

640. Which of the following statements is true regarding the responsibility of the Licensed Practical Nurse
when it comes to IV therapy? The LPN may:
a. monitor and just flow rates of an infusion of colloidal solutions such as TPN and hang a subsequent bag
of the exact same solution or component.
b. administer any medication by direct IV push.
c. administer an IV fluid bolus for plasma volume expansion.
d. discontinue or remove any central venous access device.
Answer: A. monitor and just flow rates of an infusion of colloidal solutions such as TPN and
hang a subsequent bag of the exact same solution or component. (KNOWLEDGE)
Rationale: The delegation of IV therapy to a Licensed Practical Nurse is still under the
responsibility and accountability of the Registered Nurse. Among the choices given this is the
only one that states the allowed activity for an LPN in relation to IV therapy.

641. Which one of the following is not a route of administration?

a. Intravenous (IV) c. Topical
b. Oral d. Dissolution
Answer: D. Dissolution (COMPREHENSION)
Rationale: Dissolution is not a route of administration in itself, but may occur as part of drug
delivery via a particular route. For example, an oral tablet that is swallowed may exert its
pharmacological effect only after dissolution in the gastrointestinal tract.

642. A rectal suppository is used to treat a fever. This would represent what type of drug delivery?
a. Parenteral and Local c. Enteral and local
b. Parenteral and Systemic d. Enteral and systemic
Answer: D. Enteral and systemic (COMPREHENSION)
Rationale: The drug is absorbed through the (terminal region of the) gastrointestinal tract so
this is enteral delivery. The API would then be carried in the bloodstream to the target
receptors and so exerts a systemic effect.

643. Which one of the following medicines does not rely on topical drug delivery?
a. Nasal Spray c. Insulin pen
b. Anti-dandruff shampoo d. Nicotine patch
Answer: C. Insulin pen (KNOWLEDGE)
Rationale: An insulin pen is a syringe designed to deliver the drug parenterally. Any drug that
exerts its effect after application to an external surface of the body, including the nasal
passages, scalp, and skin, is an example of topical delivery.

644. Father of pharmacology?

a. Rudolf aschein c. Atkinson
b. Oswald schmiedeberg d. Rudolf shneider
Answer: B. Oswald schmiedeberg (KNOWLEDGE)
Rationale: Oswald Schmiedeberg was born in 1838 in Kurland, a Baltic province of Russia (later
Latvia).Throughout his life Schmiedeberg published over 200 articles and books. He studied a
series of carbamic acid esters and the relationship between chemical structure and narcotic
effectiveness. 

645. If your patient has a Sodium imbalance, which would you expect?
a. Hypovolemia and hypervolemia c. Hypervolemia
b. Neither d. Hypovolemia
Answer: A. Hypovolemia and hypervolemia (KNOWLEDGE)
Rationale: Hypervolemia is an abnormal increase in the volume of fluid in the blood,
particularly the blood plasma and hypovolemia is a deficit of bodily fluids. Hypervolemia, which
is often referred to as fluid overload, can occur as the result of increased sodium in the body
which is hypernatremia, excessive fluid supplementation that cannot be managed effectively by
the body, and other disorders and diseases such as hepatic failure, renal failure and heart
failure.

646. Which of the following is NOT a cardiac complication from hyperkalemia?

a. Hypertension c. ventricular fibrillation
b. Bradycardia d. Tall peaked T waves
Answer: B. Bradycardia (KNOWLEDGE)
Rationale: Elevated potassium in the blood. Hyperkalemia can be caused by taking excessive
amounts of potassium, by medications, tissue trauma, and by diseases such as kidney failure.
Hyperkalemia may not produce any symptoms, but severe hyperkalemia can lead to potentially
fatal arrythmias of the heart.

647. Which of the following range is considered wnl for potassium?

a. 3.5-5.5 mEq/L c. 96-108 mEq/L
b. 8.4-10.2 mg/dL d. 135-145 mEq/L
Answer: A. 3.5-5.5 mEq/L (KNOWLEDGE)
Rationale: The normal potassium level in the blood is 3.5-5.0 milliEquivalents per liter
(mEq/L).Potassium levels between 5.1 mEq/L to 6.0 mEq/L are considered to be mild
hyperkalemia. Potassium levels of 6.1 mEq/L to 7.0 mEq/L are moderate hyperkalemia,
and levels above 7 mEq/L reflect severe hyperkalemia.

648. Hyperphosphatemia is tolerated well by the body, if a patient is having hyperphosphatemia, what
condition should you be worried about?
a. Hypercalcemia c. Hypermagnesemia
b. Hypophosphatemia d. Hypocalcemia
Answer: D. Hypocalcemia (COMPREHENSION)
Rationale: Hypocalcemia is a condition in which there are lower-than-average levels of calcium
in the liquid part of the blood, or the plasma. Calcium has many important roles in your body:
Calcium is key to the conduction of electricity in your body.

649. A client with hyperparathyroidism complains of numbness and tingling in his fingers and around the
mouth. The nurse would assess for what electrolyte imbalance?
a. hyponatremia c. hyperkalemia
b. hypoclcemia d. hypermagnesemia
Answer: B. hypoclcemia (SYNTHESIS)
Rationale: Hypoparathyroidism can cause low serum calcium levels. Numbness and tingling in
extremities and in the circumoral area around the mouth are the hallmark signs of
hypocalcemia. Normal calcium level is 9 to 11 mg/dl.

670. The nurse evaluates which of the following clients to be at risk for developing hypernatremia?
a. 50-year-old with pneumonia, diaphoresis, and high fevers
b. 62-year-old with congestive heart failure taking loop diuretic
c. 39-year-old with diarrhea and vomiting
d. 60-year-old with lung cancer and syndrome of inappropriate antidiuretic hormone (SIADH)
Answer: A. 50-year-old with pneumonia, diaphoresis, and high fevers (ANALYSIS)
Rationale: Diaphoresis and a high fever can lead to free water loss through the skin, resulting
in hypernatremia. Loop diuretics are more likely to result in a hypovolemic hyponatremia.
Diarrhea and vomiting cause both sodium and water losses. Clients with syndrome of
inappropriate antidiuretic hormone (SIADH) have hyponatremia, due to increased water
reabsorption in the renal

671. The most important nursing intervention to correct skin dryness is:
A. Avoid bathing the patient until the condition is remedied, and notify the physician
B. Ask the physician to refer the patient to a dermatologist, and suggest that the patient wear home-
laundered sleepwear
C. Consult the dietitian about increasing the patient’s fat intake, and take necessary measures to
prevent infection
D. Encourage the patient to increase his fluid intake, use non-irritating soap when bathing the patient, and
apply lotion to the involved areas
D. Encourage the patient to increase his fluid intake, use non-irritating soap when bathing the
patient, and apply lotion to the involved areas

672. When bathing a patient’s extremities, the nurse should use long, firm strokes from the
distal to the proximal areas. This technique:
A. Provides an opportunity for skin assessment
B. Avoids undue strain on the nurse
C. Increases venous blood return
D. Causes vasoconstriction and increases circulation
C. Increases venous blood return
Washing from distal to proximal areas stimulates venous blood flow, thereby preventing
venous stasis. It improves circulation but does not result in vasoconstriction. The nurse can
assess the patient’s condition throughout the bath, regardless of washing technique, and
should feel no strain while bathing the patient.

673. Vivid dreaming occurs in which stage of sleep?

A. Stage I non-REM
B. Rapid eye movement (REM) stage
C. Stage II non-REM
D. Delta stage
B. Rapid eye movement (REM) stage
Other characteristics of rapid eye movement (REM) sleep are deep sleep (the patient cannot be awakened
easily), depressed muscle tone, and possibly irregular heart and respiratory rates. Non-REM sleep is a
deep, restful sleep without dreaming. Delta stage, or slow-wave sleep, occurs during non-REM Stages III
and IV and is often equated with quiet sleep.

674. The natural sedative in meat and milk products (especially warm milk) that can help
induce sleep is:
A. Flurazepam
B. Temazepam
C. Tryptophan
D. Methotrimeprazine
C. Tryptophan
Tryptophan is a natural sedative; flurazepam (Dalmane), temazepam (Restoril), and methotrimeprazine
(Levoprome) are hypnotic sedatives.

675. Nursing interventions that can help the patient to relax and sleep restfully include all of
the following except:
A. Have the patient take a 30- to 60-minute nap in the afternoon
B. Turn on the television in the patient’s room
C. Provide quiet music and interesting reading material
D. Massage the patient’s back with long strokes
A. Have the patient take a 30- to 60-minute nap in the afternoon
Napping in the afternoon is not conductive to nighttime sleeping. Quiet music, watching television,
reading, and massage usually will relax the patient, helping him to fall asleep.

676. Restraints can be used for all of the following purposes except to:
A. Prevent a confused patient from removing tubes, such as feeding tubes, I.V. lines, and urinary
catheters
B. Prevent a patient from falling out of bed or a chair
C. Discourage a patient from attempting to ambulate alone when he requires assistance for his safety
D. Prevent a patient from becoming confused or disoriented
D. Prevent a patient from becoming confused or disoriented
By restricting a patient’s movements, restraints may increase stress and lead to confusion, rather than
prevent it. The other choices are valid reasons for using restraints.

677. Which of the following is the nurse’s legal responsibility when applying restraints?
A. Document the patient’s behavior
B. Document the type of restraint used
C. Obtain a written order from the physician except in an emergency, when the patient must be protected
from injury to himself or others
D. All of the above
D. All of the above
When applying restraints, the nurse must document the type of behavior that prompted her to use them,
document the type of restraints used, and obtain a physician’s written order for the restraints.

678. A terminally ill patient usually experiences all of the following feelings during the anger
stage except:
A. Rage B. Envy
C. Numbness D. Resentment
C. Numbness is typical of the depression stage, when the patient feels a great sense of loss.
The anger stage includes such feelings as rage, envy, resentment, and the patient’s
questioning “Why me?”

679. Kubler-Ross’s five successive stages of death and dying are:

A. Anger, bargaining, denial, depression, acceptance
B. Denial, anger, depression, bargaining, acceptance
C. Denial, anger, bargaining, depression acceptance
D. Bargaining, denial, anger, depression, acceptance
C. Denial, anger, bargaining, depression acceptance
Kubler-Ross’s five successive stages of death and dying are denial, anger, bargaining, depression, and
acceptance. The patient may move back and forth through the different stages as he and his family
members react to the process of dying, but he usually goes through all of these stages to reach
acceptance.

680. Nurses and other health care provides often have difficulty helping a terminally ill patient
through the necessary stages leading to acceptance of death. Which of the following strategies
is most helpful to the nurse in achieving this goal?
A. Taking psychology courses related to gerontology
B. Reading books and other literature on the subject of thanatology
C. Reflecting on the significance of death
D. Reviewing varying cultural beliefs and practices related to death
Reflecting on the significance of death
According to thanatologists, reflecting on the significance of death helps to reduce the fear of death and
enables the health care provider to better understand the terminally ill patient’s feelings. It also helps to
overcome the belief that medical and nursing measures have failed, when a patient cannot be cured.

681. Which of the following symptoms is the best indicator of imminent death?
A. A weak, slow pulse
B. Increased muscle tone
C. Fixed, dilated pupils
D. Slow, shallow respirations
C. Fixed, dilated pupils
Fixed, dilated pupils are sign of imminent death. Pulse becomes weak but rapid, muscles become weak
and atonic, and periods of apnea occur during respiration.

682. A nurse caring for a patient with an infectious disease who requires isolation should refers
to guidelines published by the:
A. National League for Nursing (NLN)
B. Centers for Disease Control (CDC)
C. American Medical Association (AMA)
D. American Nurses Association (ANA)
B. Centers for Disease Control (CDC)
The Center of Disease Control (CDC) publishes and frequently updates guidelines on caring for patients
who require isolation. The National League of Nursing’s (NLN’s) major function is accrediting nursing
education programs in the United States. The American Medical Association (AMA) is a national
organization of physicians. The American Nurses’ Association (ANA) is a national organization of registered
nurses.

683. The best way to decrease the risk of transferring pathogens to a patient when removing
contaminated gloves is to:
A. Wash the gloves before removing them
B. Gently pull on the fingers of the gloves when removing them
C. Gently pull just below the cuff and invert the gloves when removing them
D. Remove the gloves and then turn them inside out
C. Gently pull just below the cuff and invert the gloves when removing them
Turning the gloves inside out while removing them keeps all contaminants inside the gloves. They should
then be placed in a plastic bag with soiled dressings and discarded in a soiled utility room garbage pail
(double bagged). The other choices can spread pathogens within the environment.

684. To institute appropriate isolation precautions, the nurse must first know the:
A. Organism’s mode of transmission
B. Organism’s Gram-staining characteristics
C. Organism’s susceptibility to antibiotics
D. Patient’s susceptibility to the organism
A. Organism’s mode of transmission
Before instituting isolation precaution, the nurse must first determine the organism’s mode of
transmission. For example, an organism transmitted through nasal secretions requires that the patient be
kept in respiratory isolation, which involves keeping the patient in a private room with the door closed and
wearing a mask, a gown, and gloves when coming in direct contact with the patient. The organism’s
Gram-straining characteristics reveal whether the organism is gram-negative or gram-positive, an
important criterion in the physician’s choice for drug therapy and the nurse’s development of an effective
plan of care. The nurse also needs to know whether the organism is susceptible to antibiotics, but this
could take several days to determine; if she waits for the results before instituting isolation precautions,
the organism could be transmitted in the meantime patient’s susceptibility to the organism has already
been established. The nurse would not be instituting isolation precautions for a non-infected patient.

685. Which is the correct procedure for collecting a sputum specimen for culture and sensitivity
testing?
A. Have the patient place the specimen in a container and enclose the container in a plastic bag
B. Have the patient expectorate the sputum while the nurse holds the container
C. Have the patient expectorate the sputum into a sterile container
D. Offer the patient an antiseptic mouthwash just before he expectorate the sputum
C. Have the patient expectorate the sputum into a sterile container
Placing the specimen in a sterile container ensures that it will not become contaminated. The other
answers are incorrect because they do not mention sterility and because antiseptic mouthwash could
destroy the organism to be cultured (before sputum collection, the patient may use only tap water for
nursing the mouth).

686. An autoclave is used to sterilize hospital supplies because:

A. More articles can be sterilized at a time
B. Steam causes less damage to the materials
C. A lower temperature can be obtained
D. Pressurized steam penetrates the supplies better
D. Pressurized steam penetrates the supplies better
An autoclave, an apparatus that sterilizes equipment by means of high-temperature pressurized steam, is
used because it can destroy all forms of microorganisms, including spores.
687. After having an I.V. line in place for 72 hours, a patient complains of tenderness, burning,
and swelling. Assessment of the I.V. site reveals that it is warm and erythematous. This usually
indicates:
A. Infection
B. Infiltration
C. Phlebitis
D. Bleeding
C. Phlebitis
Tenderness, warmth, swelling, and, in some instances, a burning sensation are signs and symptoms of
phlebitis. Infection is less likely because no drainage or fever is present. Infiltration would result in
swelling and pallor, not erythema, near the insertion site. The patient has no evidence of bleeding.

688. To ensure homogenization when diluting powdered medication in a vial, the nurse should:
A. Shake the vial vigorously
B. Roll the vial gently between the palms
C. Invert the vial and let it stand for 1 minute
D. Do nothing after adding the solution to the vial
B. Roll the vial gently between the palms
Gently rolling a sealed vial between the palms produces sufficient heat to enhance dissolution of a
powdered medication. Shaking the vial vigorously can break down the medication and alter its
pharmacologic action. Inverting the vial or leaving it alone does not ensure thorough homogenization of
the powder and the solvent.

689. The nurse is teaching a patient to prepare a syringe with 40 units of U-100 NPH insulin for
self-injection. The patient’s first priority concerning self-injection in this situation is to:
A. Assess the injection site
B. Select the appropriate injection site
C. Check the syringe to verify that the nurse has removed the prescribed insulin dose
D. Clean the injection site in a circular manner with alcohol sponge
C. Check the syringe to verify that the nurse has removed the prescribed insulin dose
When the nurse teaches the patient to prepare an insulin injection, the patient’s first priority is to validate
the dose accuracy. The next steps are to select the site, assess the site, and clean the site with alcohol
before injecting the insulin.

690. The physician’s order reads “Administer 1 g cefazolin sodium (Ancef) in 150 ml of normal

saline solution in 60 minutes.” What is the flow rate if the drop factor is 10 gtt = 1 ml?
A. 25 gtt/minute
B. 37 gtt/minute
C. 50 gtt/minute
D. 60 gtt/minute
A. 25 gtt/minute

691. A patient must receive 50 units of Humulin regular insulin. The label reads 100 units = 1
ml. How many milliliters should the nurse administer?
A. 0.5 ml
B. 0.75 ml
C. 1 ml
D. 2 ml
 A. 0.5 ml

692. How should the nurse prepare an injection for a patient who takes both regular and NPH
insulin?
A. Draw up the NPH insulin, then the regular insulin, in the same syringe
B. Draw up the regular insulin, then the NPH insulin, in the same syringe
C. Use two separate syringe
D. Check with the physician
B. Draw up the regular insulin, then the NPH insulin, in the same syringe
Drugs that are compatible may be mixed together in one syringe. In the case of insulin, the shorter-
acting, clear insulin (regular) should be drawn up before the longer-acting, cloudy insulin (NPH) to ensure
accurate measurements.

693. A patient has just received 30 mg of codeine by mouth for pain. Five minutes later he

vomits. What should the nurse do first?
A. Call the physician
B. Remedicate the patient
C. Observe the emesis
D. Explain to the patient that she can do nothing to help him

C. Observe the emesis

After a patient has vomited, the nurse must inspect the emesis to document color, consistency, and
amount. In this situation, the patient recently ingested medication, so the nurse needs to check for
remnants of the medication to help determine whether the patient retained enough of it to be effective.
The nurse must then notify the physician, who will decide whether to repeat the dose or prescribe an
antiemetic.

694. A patient is characterized with a #16 indwelling urinary (Foley) catheter to determine if:
A. Trauma has occurred
B. His 24-hour output is adequate
C. He has a urinary tract infection
D. Residual urine remains in the bladder after voiding
B. His 24-hour output is adequate
A 24-hour urine output of less than 500 ml in an adult is considered inadequate and may
indicate kidney failure. This must be corrected while the patient is in the acute state so that appropriate
fluids, electrolytes, and medications can be administered and excreted. Indwelling catheterization is not
needed to diagnose trauma, urinary tract infection, or residual urine.

695. A staff nurse who is promoted to assistant nurse manager may feel uncomfortable initially
when supervising her former peers. She can best decrease this discomfort by:
A. Writing down all assignments
B. Making changes after evaluating the situation and having discussions with the staff.
C. Telling the staff nurses that she is making changes to benefit their performance
D. Evaluating the clinical performance of each staff nurse in a private conference
Answer: B. Making changes after evaluating the situation and having discussions with the
staff. 
A new assistant nurse manager should not make changes until she has had a chance to evaluate staff
members, patients, and physicians. Changes must be planned thoroughly and should be based on a need
to improve conditions, not just for the sake of change. Written assignments allow all staff members to
know their own and others responsibilities and serve as a checklist for the manager, enabling her to gauge
whether the unit is being run effectively and whether patients are receiving appropriate care. Telling the
staff nurses that she is making changes to benefit their performance should occur only after the nurse has
made a thorough evaluation. Evaluations are usually done on a yearly basis or as needed.

696. Nurse Clarisse is teaching a patient about a newly prescribed drug. What could cause a
geriatric patient to have difficulty retaining knowledge about prescribed medications?
A. Decreased plasma drug levels
B. Sensory deficits
C. Lack of family support
D. History of Tourette syndrome
B.  Sensory deficits
Sensory deficits could cause a geriatric patient to have difficulty retaining knowledge about prescribed
medications. Decreased plasma drug levels do not alter the patient’s knowledge about the drug. A lack of
family support may affect compliance, not knowledge retention. Toilette syndrome is unrelated to
knowledge retention.

697. When examining a patient with abdominal pain the nurse in charge should assess:
A. Any quadrant first
B. The symptomatic quadrant first
C. The symptomatic quadrant last
D. The symptomatic quadrant either second or third
C.  The symptomatic quadrant last
The nurse should systematically assess all areas of the abdomen, if time and the patient’s condition
permit, concluding with the symptomatic area. Otherwise, the nurse may elicit pain in the symptomatic
area, causing the muscles in other areas to tighten. This would interfere with further assessment.

698. The nurse is assessing a postoperative adult patient. Which of the following should the
nurse document as subjective data?
A. Vital signs
B. Laboratory test result
C. Patient’s description of pain
D. Electrocardiographic (ECG) waveforms
C. Patient’s description of pain
Subjective data come directly from the patient and usually are recorded as direct quotations that reflect
the patient’s opinions or feelings about a situation. Vital signs, laboratory test result, and ECG waveforms
are examples of objective data.

699. A male patient has a soft wrist-safety device. Which assessment finding should the nurse
consider abnormal?
A. A palpable radial pulse
B. A palpable ulnar pulse
C. Cool, pale fingers
D. Pink nail beds
C. Cool, pale fingers
A safety device on the wrist may impair circulation and restrict blood supply to body tissues. Therefore,
the nurse should assess the patient for signs of impaired circulation, such as cool, pale fingers. A palpable
radial or lunar pulse and pink nail beds are normal findings.

700. Which of the following planes divides the body longitudinally into anterior and posterior
regions?
A. Frontal plane
B. Sagittal plane
C. Midsagittal plane
D. Transverse plane
A. Frontal plane
Frontal or coronal plane runs longitudinally at a right angle to a sagittal plane dividing the body in anterior
and posterior regions. A sagittal plane runs longitudinally dividing the body into right and left regions; if
exactly midline, it is called a midsagittal plane. A transverse plane runs horizontally at a right angle to the
vertical axis, dividing the structure into superior and inferior regions.

701. A female patient with a terminal illness is in denial. Indicators of denial include:
A. Shock dismay
B. Numbness
C. Stoicism
D. Preparatory grief
A. Shock dismay
Shock and dismay are early signs of denial-the first stage of grief. The other options are associated
with depression—a later stage of grief.

702. The nurse in charge is transferring a patient from the bed to a chair. Which action does
the nurse take during this patient transfer?
A. Position the head of the bed flat
B. Helps the patient dangle the legs
C. Stands behind the patient
D. Places the chair facing away from the bed
B. Helps the patient dangle the legs
After placing the patient in high Fowler’s position and moving the patient to the side of the bed, the nurse
helps the patient sit on the edge of the bed and dangle the legs; the nurse then faces the patient and
places the chair next to and facing the head of the bed.

703. A female patient who speaks a little English has emergency gallbladder surgery, during
discharge preparation, which nursing action would best help this patient understand wound
care instruction?
A. Asking frequently if the patient understands the instruction
B. Asking an interpreter to replay the instructions to the patient.
C. Writing out the instructions and having a family member read them to the patient
D. Demonstrating the procedure and having the patient return the demonstration
D. Demonstrating the procedure and having the patient return the demonstration
Demonstrating by the nurse with a return demonstration by the patient ensures that the patient can
perform wound care correctly. Patients may claim to understand discharge instruction when they do not.
An interpreter of family member may communicate verbal or written instructions inaccurately.

704. Before administering the evening dose of a prescribed medication, the nurse on the
evening shift finds an unlabeled, filled syringe in the patient’s medication drawer. What should
the nurse in charge do?
A. Discard the syringe to avoid a medication error
B. Obtain a label for the syringe from the pharmacy
C. Use the syringe because it looks like it contains the same medication the nurse was prepared to give
D. Call the day nurse to verify the contents of the syringe
A. Discard the syringe to avoid a medication error
As a safety precaution, the nurse should discard an unlabeled syringe that contains medication. The other
options are considered unsafe because they promote error.

705. When administering drug therapy to a male geriatric patient, the nurse must stay
especially alert for adverse effects. Which factor makes geriatric patients to adverse drug
effects?
A. Faster drug clearance
B. Aging-related physiological changes
C. Increased amount of neurons
D. Enhanced blood flow to the GI tract
B. Aging-related physiological changes
Aging-related physiological changes account for the increased frequency of adverse drug reactions in
geriatric patients. Renal and hepatic changes cause drugs to clear more slowly in these patients. With
increasing age, neurons are lost and blood flow to the GI tract decreases.

706. A female patient is being discharged after cataract surgery. After providing medication

teaching, the nurse asks the patient to repeat the instructions. The nurse is performing which
professional role?
A. Manager
B. Educator
C. Caregiver
D. Patient advocate
B. Educator
When teaching a patient about medications before discharge, the nurse is acting as an educator. The
nurse acts as a manager when performing such activities as scheduling and making patient care
assignments. The nurse performs the care giving role when providing direct care, including bathing
patients and administering medications and prescribed treatments. The nurse acts as a patient advocate
when making the patient’s wishes known to the doctor.

707. A female patient exhibits signs of heightened anxiety. Which response by the nurse is
most likely to reduce the patient’s anxiety?
A. “Everything will be fine. Don’t worry.”
B. “Read this manual and then ask me any questions you may have.”
C. “Why don’t you listen to the radio?”
D. “Let’s talk about what’s bothering you.”
D. “Let’s talk about what’s bothering you.”
Anxiety may result from feeling of helplessness, isolation, or insecurity. This response helps reduce
anxiety by encouraging the patient to express feelings. The nurse should be supportive and develop goals
together with the patient to give the patient some control over an anxiety-inducing situation. Because the
other options ignore the patient’s feeling and block communication, they would not reduce anxiety.

708. A scrub nurse in the operating room has which responsibility?

A. Positioning the patient
B. Assisting with gowning and gloving
C. Handling surgical instruments to the surgeon
D. Applying surgical drapes
C. Handling surgical instruments to the surgeon
The scrub nurse assist the surgeon by providing appropriate surgical instruments and supplies,
maintaining strict surgical asepsis and, with the circulating nurse, accounting for all gauze, sponges,
needles, and instruments. The circulating nurse assists the surgeon and scrub nurse, positions the patient,
applies appropriate equipment and surgical drapes, assists with gowning and gloving, and provides the
surgeon and scrub nurse with supplies.

709. A patient is in the bathroom when the nurse enters to give a prescribed medication. What
should the nurse in charge do?
A. Leave the medication at the patient’s bedside
B. Tell the patient to be sure to take the medication. And then leave it at the bedside
C. Return shortly to the patient’s room and remain there until the patient takes the medication
D. Wait for the patient to return to bed, and then leave the medication at the bedside
 C. Return shortly to the patient’s room and remain there until the patient takes the medication
The nurse should return shortly to the patient’s room and remain there until the patient takes the
medication to verify that it was taken as directed. The nurse should never leave medication at the
patient’s bedside unless specifically requested to do so.

710. The physician orders heparin, 7,500 units, to be administered subcutaneously every 6
hours. The vial reads 10,000 units per milliliter. The nurse should anticipate giving how much
heparin for each dose?
A. ¼ ml
B. ½ ml
C. ¾ ml
D. 1 ¼ ml
C. ¾ ml
The nurse solves the problem as follows:
To convert Fahrenheit degrees to centigrade, use this formula:
C degrees = (F degrees – 32) x 5/9
C degrees = (102 – 32) 5/9
+ 70 x 5/9
38.9 degrees C

712. To evaluate a patient for hypoxia, the physician is most likely to order which laboratory
test?
A. Red blood cell count
B. Sputum culture
C. Total hemoglobin
D. Arterial blood gas (ABG) analysis
D. Arterial blood gas (ABG) analysis
All of these test help evaluate a patient with respiratory problems. However, ABG analysis is the only test
evaluates gas exchange in the lungs, providing information about patient’s oxygenation status.

713. The nurse uses a stethoscope to auscultate a male patient’s chest. Which statement about
a stethoscope with a bell and diaphragm is true?
A. The bell detects high-pitched sounds best
B. The diaphragm detects high-pitched sounds best
C. The bell detects thrills best
D. The diaphragm detects low-pitched sounds best
B. The diaphragm detects high-pitched sounds best
The diaphragm of a stethoscope detects high-pitched sound best; the bell detects low pitched sounds
best. Palpation detects thrills best.

714. A male patient is to be discharged with a prescription for an analgesic that is a controlled
substance. During discharge teaching, the nurse should explain that the patient must fill this
prescription how soon after the date on which it was written?
A. Within 1 month
B. Within 3 months
C. Within 6 months
D. Within 12 months
C. Within 6 months
In most cases, an outpatient must fill a prescription for a controlled substance within 6 months of the date
on which the prescription was written.

715. Which human element considered by the nurse in charge during assessment can
affect drug administration?
A. The patient’s ability to recover
B. The patient’s occupational hazards
C. The patient’s socioeconomic status
D. The patient’s cognitive abilities
D. The patient’s cognitive abilities
The nurse must consider the patient’s cognitive abilities to understand drug instructions. If not, the nurse
must find a family member or significant other to take on the responsibility of administering medications
in the home setting. The patient’s ability to recover, occupational hazards, and socioeconomic status do
not affect drug administration.

716. An employer establishes a physical exercise area in the workplace and encourages all
employees to use it. This is an example of which level of health promotion?
A. Primary prevention
B. Secondary prevention
C. Tertiary prevention
D. Passive prevention
A. Primary prevention
Primary prevention precedes disease and applies to health patients. Secondary prevention focuses on
patients who have health problems and are at risk for developing complications. Tertiary prevention
enables patients to gain health from others’ activities without doing anything themselves.

711. The nurse in charge measures a patient’s temperature at 102 degrees F. what is the
equivalent Centigrade temperature?
A. 39 degrees C
B. 47 degrees C
C. 38.9 degrees C
D. 40.1 degrees C
C. 38.9 degrees C

To convert Fahrenheit degrees to centigrade, use this formula:

C degrees = (F degrees – 32) x 5/9
C degrees = (102 – 32) 5/9
+ 70 x 5/9
38.9 degrees C

712. To evaluate a patient for hypoxia, the physician is most likely to order which laboratory
test?
A. Red blood cell count
B. Sputum culture
C. Total hemoglobin
D. Arterial blood gas (ABG) analysis
D. Arterial blood gas (ABG) analysis
All of these test help evaluate a patient with respiratory problems. However, ABG analysis is the only test
evaluates gas exchange in the lungs, providing information about patient’s oxygenation status.

713. The nurse uses a stethoscope to auscultate a male patient’s chest. Which statement about
a stethoscope with a bell and diaphragm is true?
A. The bell detects high-pitched sounds best
B. The diaphragm detects high-pitched sounds best
C. The bell detects thrills best
D. The diaphragm detects low-pitched sounds best
B. The diaphragm detects high-pitched sounds best
The diaphragm of a stethoscope detects high-pitched sound best; the bell detects low pitched sounds
best. Palpation detects thrills best.

714. A male patient is to be discharged with a prescription for an analgesic that is a controlled
substance. During discharge teaching, the nurse should explain that the patient must fill this
prescription how soon after the date on which it was written?
A. Within 1 month
B. Within 3 months
C. Within 6 months
D. Within 12 months
C. Within 6 months
In most cases, an outpatient must fill a prescription for a controlled substance within 6 months of the date
on which the prescription was written.

715. Which human element considered by the nurse in charge during assessment can
affect drug administration?
A. The patient’s ability to recover
B. The patient’s occupational hazards
C. The patient’s socioeconomic status
D. The patient’s cognitive abilities
D. The patient’s cognitive abilities
The nurse must consider the patient’s cognitive abilities to understand drug instructions. If not, the nurse
must find a family member or significant other to take on the responsibility of administering medications
in the home setting. The patient’s ability to recover, occupational hazards, and socioeconomic status do
not affect drug administration.

716. An employer establishes a physical exercise area in the workplace and encourages all
employees to use it. This is an example of which level of health promotion?
A. Primary prevention
B. Secondary prevention
C. Tertiary prevention
D. Passive prevention
A. Primary prevention
Primary prevention precedes disease and applies to health patients. Secondary prevention focuses on
patients who have health problems and are at risk for developing complications. Tertiary prevention
enables patients to gain health from others’ activities without doing anything themselves.

717. What does the nurse in charge do when making a surgical bed?
A. Leaves the bed in the high position when finished
B. Places the pillow at the head of the bed
C. Rolls the patient to the far side of the bed
D. Tucks the top sheet and blanket under the bottom of the bed
A. Leaves the bed in the high position when finished
When making a surgical bed, the nurse leaves the bed in the high position when finished. After placing the
top linens on the bed without pouching them, the nurse fanfolds these linens to the side opposite from
where the patient will enter and places the pillow on the bedside chair. All these actions promote transfer
of the postoperative patient from the stretcher to the bed. When making an occupied bed or unoccupied
bed, the nurse places the pillow at the head of the bed and tucks the top sheet and blanket under the
bottom of the bed. When making an occupied bed, the nurse rolls the patient to the far side of the bed.

718. The physician prescribes 250 mg of a drug. The drug vial reads 500 mg/ml. how much of
the drug should the nurse give?
A. 2 ml
B. 1 ml
C. ½ ml
D. ¼ ml
C. ½ ml
The nurse should give ½ ml of the drug. The dosage is calculated as follows:
250 mg/X=500 mg/1 ml
500x=250
X=1/2 ml

719. Nurse Mackey is monitoring a patient for adverse reactions during barbiturate therapy.
What is the major disadvantage of barbiturate use?
A. Prolonged half-life
B. Poor absorption
C. Potential for drug dependence
D. Potential for hepatotoxicity
C. Potential for drug dependence
Patients can become dependent on barbiturates, especially with prolonged use. Because of the rapid
distribution of some barbiturates, no correlation exists between duration of action and half-life.
Barbiturates are absorbed well and do not cause hepatotoxicity, although existing hepatic damage does
require cautions use of the drug because barbiturates are metabolized in the liver.

720. Which nursing action is essential when providing continuous enteral feeding?
A. Elevating the head of the bed
B. Positioning the patient on the left side
C. Warming the formula before administering it
D. Hanging a full day’s worth of formula at one time
A. Elevating the head of the bed
Elevating the head of the bed during enteral feeding minimizes the risk of aspiration and allows the
formula to flow in the patient’s intestines. When such elevation is contraindicated, the patient should be
positioned on the right side. The nurse should give enteral feeding at room temperature to minimize GI
distress. To limit microbial growth, the nurse should hang only the amount of formula that can be infused
in 3 hours.

721. When teaching a female patient how to take a sublingual tablet, the nurse should instruct
the patient to place the table on the:
A. Top of the tongue
B. Roof of the mouth
C. Floor of the mouth
D. Inside of the cheek

C. Floor of the mouth

The nurse should instruct the patient to touch the tip of the tongue to the roof of the mouth and then
place the sublingual tablet on the floor of the mouth. Sublingual medications are absorbed directly into the
bloodstream form the oral mucosa, bypassing the GI and hepatic systems. No drug is administered on top
of the tongue or on the roof of the mouth. With the buccal route, the tablet is placed between the gum
and the cheek.

722. Which action by the nurse in charge is essential when cleaning the area around a Jackson-
Pratt wound drain?
A. Cleaning from the center outward in a circular motion
B. Removing the drain before cleaning the skin
C. Cleaning briskly around the site with alcohol
D. Wearing sterile gloves and a mask
A. Cleaning from the center outward in a circular motion
The nurse always should clean around a wound drain, moving from center outward in ever-larger circles,
because the skin near the drain site is more contaminated than the site itself. The nurse should never
remove the drain before cleaning the skin. Alcohol should never be used to clean around a drain; it may
irritate the skin and has no lasting effect on bacteria because it evaporates. The nurse should wear sterile
gloves to prevent contamination, but a mask is not necessary.

723. The doctor orders dextrose 5% in water, 1,000 ml to be infused over 8 hours. The I.V.
tubing delivers 15 drops per milliliter. The nurse in charge should run the I.V. infusion at a rate
of:
A. 15 drop per minute B. 21 drop per minute
C. 32 drop per minute D. 125 drops per minute
C. 32 drop per minute
Giving 1,000 ml over 8 hours is the same as giving 125 ml over 1 hour (60 minutes) to find the number of
milliliters per minute:
125/60 min = X/1 minute
60X = 125X = 2.1 ml/minute
To find the number of drops/minute:
2.1 ml/X gtts = 1 ml/15 gtts
X = 32 gtts/minute, or 32 drops/minute

724. A female patient undergoes a total abdominal hysterectomy. When assessing the patient
10 hours later, the nurse identifies which finding as an early sign of shock?
A. Restlessness
B. Pale, warm, dry skin
C. Heart rate of 110 beats/minute
D. Urine output of 30 ml/hour
A. Restlessness
Early in shock, hyperactivity of the sympathetic nervous system causes increased epinephrine secretion,
which typically makes the patient restless, anxious, nervous, and irritable. It also decreases tissue
perfusion to the skin, causing pale, cool clammy skin. An above-normal heart rate is a late sign of shock.
A urine output of 30 ml/hour is within normal limits.

725. Which pulse should the nurse palpate during rapid assessment of an unconscious male
adult?
A. Radial B. Brachial
C. Femoral D. Carotid
D. Carotid
During a rapid assessment, the nurse’s first priority is to check the patient’s vital functions by assessing
his airway, breathing, and circulation. To check a patient’s circulation, the nurse must assess his heart and
vascular network function. This is done by checking his skin color, temperature, mental status and, most
importantly, his pulse. The nurse should use the carotid artery to check a patient’s circulation. In a patient
with a circulatory problems or a history of compromised circulation, the radial pulse may not be palpable.
The brachial pulse is palpated during rapid assessment of an infant.

726. The coronary vessels, unlike any other blood vessels in the body, respond to sympathetic stimulation
by
A. Vasoconstriction
B. Vasodilatation
C. Decreases force of contractility
D. Decreases cardiac output

727. What stress response can you expect from a patient with blood sugar of 50 mg / dl?
A. Body will try to decrease the glucose level
B. There will be a halt in release of sex hormones
C. Client will appear restless
D. Blood pressure will increase

728. All of the following are purpose of inflammation except

A. Increase heat, thereby produce abatement of phagocytosis
B. Localized tissue injury by increasing capillary permeability
C. Protect the issue from injury by producing pain
D. Prepare for tissue repair

729. The initial response of tissue after injury is

A. Immediate Vasodilation
B. Transient Vasoconstriction
C. Immediate Vasoconstriction
D. Transient Vasodilation5. The last expected process in the stages of inflammation is characterized by
  
730. When the General adaptation syndrome is activated, FLIGHT OR FIGHT response sets in.
Sympathetic nervous system releases norepinephrine while thead renal medulla secretes epinephrine.
Which of the following is true with regards to that statement?
A. Pupils will constrict
B. Client will be lethargic
C. Lungs will bronchodilate
D. Gastric motility will increase

731. Which of the following response is not expected to a person whose GAS is activated and the FIGHT
OR FLIGHT response sets in?
A. The client will not urinate due to relaxation of the detrusor muscle
B. The client will be restless and alert
C. Clients BP will increase, there will be vasodilation
D. There will be increase glycogenolysis, Pancreas will decrease insulin secretion

732. State in which a person’s physical, emotional, intellectual and social development or spiritual
functioning is diminished or impaired compared with aprevious experience.
A. Illness
B. Disease
C. Health
D. Wellnes

733. This is the first stage of illness wherein, the person starts to believe that something is wrong. Also
known as the transition phase from wellness to illness.
A. Symptom Experience
B. Assumption of sick role
C. Medical care contact
D. Dependent patient role

734. In this stage of illness, the person accepts or rejects a professional ssuggestion. The person also
becomes passive and may regress to an earlierstage.A. Symptom Experience
B. Assumption of sick role
C. Medical care contact
D. Dependent patient role

735. In this stage of illness, The person learns to accept the illness
.A. Symptom Experience
B. Assumption of sick role
C. Medical care contact
D. Dependent patient role
736. The last expected process in the stages of inflammation is characterized by
A. There will be sudden redness of the affected part
B. Heat will increase on the affected part
C. The affected part will loss its normal function
D. Exudates will flow from the injured site

737. What kind of exudates is expected when there is an antibody-antigen reaction as a result of
microorganism infection?
A. Serous
B. Serosanguinous
C. Purulent
D. Sanguinous

738. The client has a chronic tissue injury. Upon examining the client’s antibody for a particular cellular
response, Which of the following WBC component is responsible for phagocytosis in chronic tissue injury?
A. Neutrophils
B. Basophils
C. Eosinophils
D. Monocytes

739. Which of the following WBC component proliferates in cases of Anaphylaxis?

A. Neutrophils
B. Basophils
C. Eosinophil
D. Monocytes

740. Icheanne, ask you, her Nurse, about WBC Components. She got an injury yesterday after she twisted
her ankle accidentally at her gymnastic class. She asked you, which WBC Component is responsible for
proliferation at the injured site immediately following an injury. You answer:
A. Neutrophils
B. Basophils
C. Eosinophils
D. Monocytes

741. Icheanne then asked you, what is the first process that occurs in the inflammatory response after
injury, You tell her:
A. Phagocytosis
B. Emigration
C. Pavementation
D. Chemotaxis

742. Icheanne asked you again, What is that term that describes the magnetic attraction of injured tissue
to bring phagocytes to the site of injury?
A. Icheanne, you better sleep now, you asked a lot of questions
B. It is Diapedesis
C. We call that Emigration
D. I don’t know the answer, perhaps I can tell you after I find it out later

743. This type of healing occurs when there is a delayed surgical closure of infected wound
A. First intention
B. Second intention
C. Third intention
D. Fourth intention

744. Type of healing when scars are minimal due to careful surgical incision and good healing
A. First intention
B. Second intention
C. Third intention
D. Fourth intention
745. Imelda, was slashed and hacked by an unknown suspects. She suffered massive tissue loss and
laceration on her arms and elbow in an attempt to evade the criminal. As a nurse, you know that the type
of healing that will most likely occur to Miss Imelda is
A. First intention
B. Second intention
C. Third intention
D. Fourth intention

746. Imelda is in the recovery stage after the incident. As a nurse, you know that the diet that will be
prescribed to Miss Imelda is
A. Low calorie, High protein with Vitamin A and C rich foods
B. High protein, High calorie with Vitamin A and C rich foods
C. High calorie, Low protein with Vitamin A and C rich foods
D. Low calorie, Low protein with Vitamin A and C rich foods

747. Miss Imelda asked you, What is WET TO DRY Dressing method? Your best response is
A. It is a type of mechanical debridement using Wet dressing that is applied and left to dry to
remove dead tissues
B. It is a type of surgical debridement with the use of Wet dressing to remove the necrotic tissues
C. It is a type of dressing where in, The wound is covered with Wet or Dry dressing to prevent
contamination
D. It is a type of dressing where in, A cellophane or plastic is placed on the wound over a wet dressing to
stimulate healing of the wound in a wet medium

748. The primary cause of pain in inflammation is

A. Release of pain mediators
B. Injury to the nerve endings
C. Compression of the local nerve endings by the edema fluids
D. Circulation is lessen, Supply of oxygen is insufficient

749. The client is in stress because he was told by the physician he needs to undergo surgery for removal
of tumor in his bladder. Which of the following are effects of sympatho-adreno-medullary response by the
client?
1. Constipation
2. Urinary frequency
3. Hyperglycemia
4. Increased blood pressure
A. 3,4
B. 1,3,4
C.1,2,4
D.1,4

750. The client is on NPO post midnight. Which of the following, if done by the client, is sufficient to cancel
the operation in the morning?
A. Eat a full meal at 10:00 P.M
B. Drink fluids at 11:50 P.M
C. Brush his teeth the morning before operation
D. Smoke cigarette around 3:00 A.M

751. The client place on NPO for preparation of the blood test. Adreno-cortical response is activated and
which of the following below is an expected response?
A. Low BP
B. Decrease Urine output
C. Warm, flushed, dry skin
D. Low serum sodium levels

752. Which of the following is true about therapeutic relationship?

A. Directed towards helping an individual both physically and emotionally
B. Bases on friendship and mutual trust
C. Goals are set by the solely nurse
D. Maintained even after the client doesn’t need anymore of the Nurse’s help

753. According to her, A nurse patient relationship is composed of 4 stages : Orientation, Identification,
Exploitation and Resolution
A. Roy
B. Peplau
C. Rogers
D. Travelbee

754. In what phase of Nurse patient relationship does a nurse review the client’s medical records thereby
learning as much as possible about the client?
A. Pre Orientation
B. Orientation
C. Working
D. Termination

755. Nurse Aida has seen her patient, Roger for the first time. She establish a contract about the
frequency of meeting and introduce to Roger the expected termination. She started taking baseline
assessment and set interventions and outcomes. On what phase of NPR Does Nurse Aida and Roger
belong?
A. Pre Orientation
B. Orientation
C. Working
D. Termination

756. Roger has been seen agitated, shouting and running. As Nurse Aida approaches, he shouts and
swear, calling Aida names. Nurse Aida told Roger “That is an unacceptable behavior Roger, Stop and go to
your room now.” The situation is most likely in what phase of NPR?
A. Pre Orientation
B. Orientation
C. Working
D. Termination

757. Nurse Aida, in spite of the incident, still consider Roger as worthwhile simply because he is a human
being. What major ingredient of a therapeutic communication is Nurse Aida using?
A. Empathy
B. Positive regard
C. Comfortable sense of self
D. Self awareness

758. Nurse Irma saw Roger and told Nurse Aida “ Oh look at that psychotic patient “ Nurse Aida should
intervene and correct Nurse Irma because her statement shows that she is lacking?
A. Empathy
B. Positive regard
C. Comfortable sense of self
D. Self awareness

759. Which of the following statement is not true about stress?

A. It is a nervous energy
B. It is an essential aspect of existence
C. It has been always a part of human experience
D. It is something each person has to cope

760. Martina, a Tennis champ was devastated after many new competitors outpaced her in the Wimbledon
event.
She became depressed and always seen crying. Martina is clearly on what kind of situation?
A. Martina is just stressed out
B. Martina is Anxious
C. Martina is in the exhaustion stage of GAS
D. Martina is in Crisis

761. Which of the following statement is not true with regards to anxiety?
A. It has physiologic component
B. It has psychologic component
C. The source of dread or uneasiness is from an unrecognized entity
D. The source of dread or uneasiness is from a recognized entity

762. Lorraine, a 27 year old executive was brought to the ER for an unknown reason. She is starting to
speak but her speech is disorganized and cannot be understood. On what level of anxiety does this
features belongs?
A. Mild B. Moderate
C. Severe D. Panic

763. Elton, 21 year old nursing student is taking the board examination. She is sweating profusely, has
decreased awareness of his environment and is purely focused on the exam questions characterized by his
selective attentiveness. What anxiety level is Elton exemplifying?
A. Mild B. Moderate
C. Severe D. Panic

764. You noticed the patient chart : ANXIETY +3 What will you expect to see in this client?
A. An optimal time for learning, Hearing and perception is greatly increased
B. Dilated pupils
C. Unable to communicate
D. Palliative Coping Mechanism

765. When should the nurse starts giving XANAX?

A. When anxiety is +1
B. When the client starts to have a narrow perceptual field and selective inattentiveness
C. When problem solving is not possible
D. When the client is immobile and disorganized

766. Which of the following behavior is not a sign or a symptom of Anxiety?

A. Frequent hand movement
B. Somatization
C. The client asks a question
D. The client is acting out

767. Which of the following intervention is inappropriate for client’s with anxiety?
A. Offer choices
B. Provide a quiet and calm environment
C. Provide detailed explanation on each and every procedures and equipments
D. Bring anxiety down to a controllable level

768. Which of the following statement, if made by the nurse, is considered not therapeutic?
A. “How did you deal with your anxiety before?”
B. “It must be awful to feel anxious.”
C. “How does it feel to be anxious?”
D. “What makes you feel anxious?”

769. Marissa Salva, Uses Benson’s relaxation. How is it done?

A. Systematically tensing muscle groups from top to bottom for 5 seconds, and then releasing them
B. Concentrating on breathing without tensing the muscle, Letting go and repeating a word or
sound after each exhalation
C. Using a strong positive, feeling-rich statement about a desired change
D. Exercise combined with meditation to foster relaxation and mental alacrity

770. What type of relaxation technique does Lyza uses if a machine is showing her pulse rate,
temperature and muscle tension which she can visualize and assess?
A. Biofeedback
B. Massage
C. Autogenic training
D. Visualization and Imagery

771. This is also known as Self-suggestion or Self-hypnosis

A. Biofeedback
B. Meditation
C. Autogenic training
D. Visualization and Imagery

772. Which among these drugs is NOT an anxiolytic?

A. Valium
B. Ativan
C. Milltown
D. Luvox

773. Kenneth, 25 year old diagnosed with HIV felt that he had not lived up with God’s expectation. He
fears that in the course of his illness, God will be punitive and not be supportive. What kind of spiritual
crisis is Kenneth experiencing?
1. Spiritual Pain
2. Spiritual Anxiety
3. Spiritual Guilt
4. Spiritual Despair
A. 1,2
B. 2,3
C. 3,4
D. 1,4

774. Grace, believes that her relationship with God is broken. She tried to go to church to ask forgiveness
everyday to remedy her feelings. What kind of spiritual distress is Grace experiencing?
A. Spiritual Pan
B. Spiritual Alienation
C. Spiritual Guilt
D. Spiritual Despair

775. Remedios felt “EMPTY” She felt that she has already lost God’s favor and love because of her sins.
This is a type of what spiritual crisis?

A. Spiritual Anger
B. Spiritual Loss
C. Spiritual Despair
D. Spiritual Anxiety

776. Budek is working with a schizophrenic patient. He noticed that the client is agitated, pacing back and
forth, restless and experiencing Anxiety +3. Budek said “You appear restless” What therapeutic technique
did Budek used?
A. Offering general leads
B. Seeking clarification
C. Making observation
D. Encouraging description of perception

777. Rommel told Budek “ I SEE DEAD PEOPLE “ Budek responded “You see dead people?” This Is an
example of therapeutic communication technique?
A. Reflecting
B. Restating
C. Exploring
D. Seeking clarification

778. Rommel told Budek, “Do you think Im crazy?” Budek responded, “Do you think your crazy?” Budek
uses what example of therapeutic communication?
A. Reflecting
B. Restating
C. Exploring
D. Seeking clarification

779. Myra, 21 year old nursing student has difficulty sleeping. She told Nurse Budek “I really think a lot
about my x boyfriend recently” Budek told Myra “And that causes you difficulty sleeping?” Which
therapeutic technique is used in this situation?
A. Reflecting
B. Restating
C. Exploring
D. Seeking clarification

780. Myra told Budek “I cannot sleep, I stay away all night” Budek told her “You have difficulty sleeping”
This is what type of therapeutic communication technique?
A. Reflecting B. Restating
C. Exploring D. Seeking clarification

781. Myra said “I saw my dead grandmother here at my bedside a while ago” Budek responded “Really?
That is hard to believe, How do you feel about it?” What technique did Budek used?
A. Disproving B. Disagreeing
C. Voicing Doubt D. Presenting Reality

782. Which of the following is a therapeutic communication in response to “I am a GOD, bow before me Or
ill summon the dreaded thunder to burn you and purge you to pieces!”
A. “You are not a GOD, you are Professor Tadle and you are a PE Teacher, not a Nurse. I am Glen, Your
nurse.”
B. “Oh hail GOD Tadle, everyone bow or face his wrath!”
C. “Hello Mr. Tadle, You are here in the hospital, I am your nurse and you are a patient here”
D. “How can you be a GOD Mr. Tadle? Can you tell me more about it?”

783. Erik John Senna, Told Nurse Budek “ I don’t want to that, I don’t want that thing.. that’s too painful!”
Which of the following response is NON THERAPEUTIC
A. “ This must be difficult for you, But I need to inject you this for your own good”
B. “ You sound afraid”
C. “Are you telling me you don’t want this injection?”
D. “Why are you so anxious? Please tell me more about your feelings Erik”

784. Legrande De Salvaje Y Cobrador La Jueteng, was caught by the bacolod police because of his illegal
activities. When he got home after paying for the bail, He shouted at his son. What defense mechanism
did Mr. La Jueteng used?
A. Restitution
B. Projection
C. Displacement
D. Undoing

785. Later that day, he bought his son ice cream and food. What defense mechanism is Legrande
unconsciously doing?
A. Restitution
B. Conversion
C. Redoing
D. Reaction formation

786. Crisis is a sudden event in ones life that disturbs a person’s homeostasis. Which of the following is
NOT TRUE in crisis?
A. The person experiences heightened feeling of stress
B. Inability to function in the usual organized manner
C. Lasts for 4 months
D. Indicates unpleasant emotional feelings

787. Which of the following is a characteristic of crisis?

A. Lasts for an unlimited period of time
B. There is a triggering event
C. Situation is not dangerous to the person
D. Person totality is not involved

788. Levito Devin, The Italian prime minister, is due to retire next week. He feels depressed due to the
enormous loss of influence, power, fame and fortune. What type of crisis is Devin experiencing?
A. Situational
B. Maturational
C. Social
D. Phenomenal

789. Estrada, The Philippine president, has been unexpectedly impeached and was out of office before the
end of his term. He is in what type of crisis?
A. Situational
B. Maturational
C. Social
D. Phenomenal

790. The tsunami in Thailand and Indonesia took thousands of people and change million lives. The people
affected by the Tsunami are saddened and do not know how to start all over again. What type of crisis is
this?
A. Situational
B. Maturational
C. Social
D. Phenomenal

791. Which of the following is the BEST goal for crisis intervention?
A. Bring back the client in the pre crisis state
B. Make sure that the client becomes better
C. Achieve independence
D. Provide alternate coping mechanism

792. What is the best intervention when the client has just experienced the crisis and still at the first
phase of the crisis?
A. Behavior therapy
B. Gestalt therapy
C. Cognitive therapy
D. Milieu Therapy

793. Therapeutic nurse client relationship is describes as follows

1. Based on friendship and mutual interest

2. It is a professional relationship
3. It is focused on helping the patient solve problems and achieve health-related goals
4. Maintained only as long as the patient requires professional help
A. 1,2,3
B. 1,2,4
C. 2,3,4
D. 1,3,4

794. The client is scheduled to have surgical removal of the tumor on her left breast. Which of the
following manifestation indicates that she is experiencing Mild Anxiety?

A. She has increased awareness of her environmental details

B. She focused on selected aspect of her illness
C. She experiences incongruence of action, thoughts and feelings
D. She experiences random motor activities

795. Which of the following nursing intervention would least likely be effective when dealing with a client
with aggressive behavior?
A. Approach him in a calm manner
B. Provide opportunities to express feelings
C. Maintain eye contact with the client
D. Isolate the client from others

796. Whitney, a patient of nurse Budek, verbalizes… “I have nothing, nothing… nothing! Don't make me
close one more door, I don't wanna hurt anymore!” Which of the following is the most appropriate
response by Budek?
A. Why are you singing?
B. What makes you say that?
C. Ofcourse you are everything!
D. What is that you said?

797. Whitney verbalizes that she is anxious that the diagnostic test might reveal laryngeal cancer. Which
of the following is the most appropriate nursing intervention?
A. Tell the client not to worry until the results are in
B. Ask the client to express feelings and concern
C. Reassure the client everything will be alright
D. Advice the client to divert his attention by watching television and reading newspapers

798. Considered as the most accurate expression of person’s thought and feelings
A. Verbal communication
B. Non verbal communication
C. Written communication
D. Oral communication

799. Represents inner feeling that a person do not like talking about.
A. Overt communication
B. Covert communication
C. Verbal communication
D. Non verbal communication

800. Which of the following is NOT a characteristic of an effective Nurse-Client relationship?

A. Focused on the patient
B. Based on mutual trust
C. Conveys acceptance
D. Discourages emotional bond

801. A type of record wherein , each person or department makes notation in separate records. A nurse
will use the nursing notes, The doctor will use the Physician’s order sheet etc. Data is arranged according
to information source.
A. POMR
B. POR
C. Traditional
D. Resource oriented
802. Type of recording that integrates all data about the problem, gathered by members of the health
team.
A. POMR
B. Traditional
C. Resource oriented
D. Source oriented

803. These are data that are monitored by using graphic charts or graphs that indicated the progression
or fluctuation of client’s Temperature and Blood pressure.
A. Progress notes
B. Kardex
C. Flow chart
D. Flow sheet

804. Provides a concise method of organizing and recording data about the client. It is a series of flip
cards kept in portable file used in change of shift reports.
A. Kardex
B. Progress Notes
C. SOAPIE
D. Change of shift report

805. You are about to write an information on the Kardex. There are 4 available writing instruments to
use. Which of the following should you use?
A. Mongol #2
B. Permanent Ink
C. A felt or fountain pen
D. Pilot Pentel Pen marker

806. The client has an allergy to Iodine based dye. Where should you put this vital information in the
client’s chart?
A. In the first page of the client’s chart
B. At the last page of the client’s chart
C. At the front metal plate of the chart
D. In the Kardex

807. Which of the following is NOT TRUE about the Kardex

A. It provides readily available information
B. It is a tool of end of shift reports
C. The primary basis of endorsement
D. Where Allergies information are written

808. Which of the following, if seen on the Nurses notes, violates characteristic of good recording?
A. The client has a blood pressure of 120/80, Temperature of 36.6 C Pulse rate of 120 and
Respiratory rate of 22
B. Ate 50% of food served
C. Refused administration of betaxolol
D. Visited and seen By Dr. Santiago

809. The physician ordered : Mannerix a.c , what does a.c means?
A. As desired
B. Before meals
C. After meals
D. Before bed time

810. The physician ordered, Maalox, 2 hours p.c, what does p.c means?
A. As desired
B. Before meals
C. After meals
D. Before bed time

811. The physician ordered, Maxitrol, Od. What does Od means?

A. Left eye
B. Right eye
C. Both eye
D. Once a day

812. The physician orderd, Magnesium Hydroxide cc Aluminum Hydroxide. What does cc means?
A. without
B. with
C. one half
D. With one half dose

813. Physician ordered, Paracetamol tablet ss. What does ss means?

A. without
B. with
C. one half
D. With one half dose

814. Which of the following indicates that learning has been achieved?
A. Matuts starts exercising every morning and eating a balance diet after you taught her mag
HL tayo program
B. Donya Delilah has been able to repeat the steps of insulin administration after you taught it to her
C. Marsha said “ I understand “ after you a health teaching about family planning
D. John rated 100% on your given quiz about smoking and alcoholism

815. In his theory of learning as a BEHAVIORISM, he stated that transfer of knowledge occurs if a new
situation closely resembles an old one.
A. Bloom
B. Lewin
C. Thorndike
D. Skinner

816. Which of the following is TRUE with regards to learning?

A. Start from complex to simple
B. Goals should be hard to achieve so patient can strive to attain unrealistic goals
C. Visual learning is the best for every individual
D. Do not teach a client when he is in pain

817. According to Bloom, there are 3 domains in learning. Which of these domains is responsible for the
ability of Donya Delilah to inject insulin?
A. Cognitive
B. Affective
C. Psychomotor
D. Motivative

818. Which domains of learning is responsible for making John and Marsha understand the different kinds
of family planning methods?
A. Cognitive
B. Affective
C. Psychomotor
D. Motivative

819. Which of the following statement clearly defines therapeutic communication?

A. Therapeutic communication is an interaction process which is primarily directed by the nurse
B. It conveys feeling of warmth, acceptance and empathy from the nurse to a patient in relaxed
atmosphere
C. Therapeutic communication is a reciprocal interaction based on trust and aimed at
identifying patient needs and developing mutual goals
D. Therapeutic communication is an assessment component of the nursing process

820. Which of the following concept is most important in establishing a therapeutic nurse patient
relationship?
A. The nurse must fully understand the patient’s feelings, perception and reactions before goals can be
established
B. The nurse must be a role model for health fostering behavior
C. The nurse must recognize that the patient may manifest maladaptive behavior after illness
D. The nurse should understand that patients might test her before trust is established

821. Which of the following communication skill is most effective in dealing with covert communication?
A. Validation B. Listening
C. Evaluation D. Clarification

822. Which of the following are qualities of a good recording?

1. Brevity
2. Completeness and chronology
3. Appropriateness
4. Accuracy
A. 1,2 B. 3,4
C. 1,2,3 D. 1,2,3,4

823. All of the following chart entries are correct except

A. V/S 36.8 C,80,16,120/80
B. Complained of chest pain
C. Seems agitated
D. Able to ambulate without assistance

824. Which of the following teaching method is effective in client who needs to be educated about self
injection of insulin?
A. Detailed explanation
B. Demonstration
C. Use of pamphlets
D. Film showing

825. What is the most important characteristic of a nurse patient relationship?

A. It is growth facilitating
B. Based on mutual understanding
C. Fosters hope and confidence
D. Involves primarily emotional bond

826. Which of the following nursing intervention is needed before teaching a client post spleenectomy
deep breathing and coughing exercises?
A. Tell the patient that deep breathing and coughing exercises is needed to promote good
breathing, circulation and prevent complication
B. Tell the client that deep breathing and coughing exercises is needed to prevent Thrombophlebitis,
hydrostatic pneumonia and atelectasis
C. Medicate client for pain
D. Tell client that cooperation is vital to improve recovery

827. The client has an allergy with penicillin. What is the best way to communicate this information?
A. Place an allergy alert in the Kardex
B. Notify the attending physician
C. Write it on the patient’s chart
D. Take note when giving medications

828. An adult client is on extreme pain. He is moaning and grimacing. What is the best way to assess the
client’s pain?
A. Perform physical assessment
B. Have the client rate his pain on the smiley pain rating scale
C. Active listening on what the patient says
D. Observe the client’s behavior

829. Therapeutic communication begins with?

A. Knowing your client
B. Knowing yourself
C. Showing empathy
D. Encoding

830 The PCS gave new guidelines including leaflets to educate cancer patients. As a nurse, When using
materials like this, what is your responsibility?
A. Read it for the patient
B. Give it for the patient to read himself
C. Let the family member read the material for the patient
D. Read it yourself then, Have the client read the material

831. Which characteristic of nursing process addresses the INDIVIDUALIZED care a client must receive?
A. Organized and Systematic
B. Humanistic
C. Efficient
D. Effective

832. A characteristic of the nursing process that is essential to promote client satisfaction and progress.
The care should also be relevant with the client’s needs.
A. Organized and Systematic B. Humanistic
C. Efficient D. Effective

833. Rhina, who has Menieres disease, said that her environment is moving. Which of the following is a
valid assessment?
1. Rhina is giving an objective data
2. Rhina is giving a subjective data
3. The source of the data is primary
4. The source of the data is secondary
A. 1,3 B. 2,3
C. 2.4 D. 1,4

834. Nurse Angela, observe Joel who is very apprehensive over the impending operation. The client is
experiencing dyspnea, diaphoresis and asks lots of questions. Angela made a diagnosis of ANXIETY R/T
INTRUSIVE PROCEDURE. This is what type of Nursing Diagnosis?
A. Actual B. Probable
C. Possible D. Risk

835. Nurse Angela diagnosed Mrs. Delgado, who have undergone a BKA. Her diagnosis is SELF ESTEEM
DISTURBANCE R/T CHANGE IN BODY IMAGE. Although the client has not yet seen her lost leg, Angela
already anticipated the diagnosis. This is what type of Diagnosis?
A. Actual
B. Probable
C. Possible
D. Risk

836. Nurse Angela is about to make a diagnosis but very unsure because the S/S the client is experiencing
is not specific with her diagnosis of POWERLESSNESS R/T DIFFICULTY ACCEPTING LOSS OF LOVED ONE.
She then focus on gathering data to refute or prove her diagnosis but her plans and interventions are
already ongoing for the diagnosis. Which type of Diagnosis is this?
A. Actual
B. Probable
C. Possible
D. Risk

837. Nurse Angela knew that Stephen Lee Mu Chin, has just undergone an operation with an incision near
the diaphragm. She knew that this will contribute to some complications later on. She then should develop
what type of Nursing diagnosis?
A. Actual
B. Probable
C. Possible
D. Risk

838. Which of the following Nursing diagnosis is INCORRECT?

A. Fluid volume deficit R/T Diarrhea
B. High risk for injury R/T Absence of side rails
C. Possible ineffective coping R/T Loss of loved one
D. Self esteem disturbance R/T Effects of surgical removal of the leg

839. Among the following statements, which should be given the HIGHEST priority?
A. Client is in extreme pain
B. Client’s blood pressure is 60/40
C. Client’s temperature is 40 deg. Centigrade
D. Client is cyanotic

840. Which of the following need is given a higher priority among others?
A. The client has attempted suicide and safety precaution is needed
B. The client has disturbance in his body image because of the recent operation
C. The client is depressed because her boyfriend left her all alone
D. The client is thirsty and dehydrated

841. Which of the following is TRUE with regards to Client Goals?

A. They are specific, measurable, attainable and time bounded

B. They are general and broadly stated
C. They should answer for WHO, WHAT ACTIONS, WHAT CIRCUMSTANCES, HOW WELL and WHEN.
D. Example is : After discharge planning, Client demonstrated the proper psychomotor skills for insulin
injection.

842. Which of the following is a NOT a correct statement of an Outcome criteria?

A. Ambulates 30 feet with a cane before discharge

B. Discusses fears and concerns regarding the surgical procedure
C. Demonstrates proper coughing and breathing technique after a teaching session
D. Reestablishes a normal pattern of elimination

843. Which of the following is a OBJECTIVE data?

A. Dizziness
B. Chest pain
C. Anxiety
D. Blue nails

844. A patient’s chart is what type of data source?

A. Primary
B. Secondary
C. Tertiary
D. Can be A and B
845. All of the following are characteristic of the Nursing process except
A. Dynamic
B. Cyclical
C. Universal
D. Intrapersonal

846. Which of the following is true about the NURSING CARE PLAN?
A. It is nursing centered
B. Rationales are supported by interventions
C. Verbal
D. Atleast 2 goals are needed for every nursing diagnosis

847. A framework for health assessment that evaluates the effects of stressors to the mind, body and
environment in relation with the ability of the client to perform ADL.
A. Functional health framework
B. Head to toe framework
C. Body system framework
D. Cephalocaudal framework

848. Client has undergone Upper GI and Lower GI series. Which type of health assessment framework is
used in this situation?
A. Functional health framework
B. Head to toe framework
C. Body system framework
D. Cephalocaudal framework

849. Which of the following statement is true regarding temperature?

A. Oral temperature is more accurate than rectal temperature
B. The bulb used in Rectal temperature reading is pear shaped or round
C. The older the person, the higher his BMR
D. When the client is swimming, BMR Decreases

850. A type of heat loss that occurs when the heat is dissipated by air current
A. Convection
B. Conduction
C. Radiation
D. Evaporation

851. Which of the following is TRUE about temperature?

A. The highest temperature usually occurs later in a day, around 8 P.M to 12 M.N
B. The lowest temperature is usually in the Afternoon,Around 12 P.M
C. Thyroxin decreases body temperature
D. Elderly people are risk for hyperthermia due to the absence of fats, Decreased thermoregulatory
control and sedentary lifestyle.

852. Hyperpyrexia is a condition in which the temperature is greater than

A. 40 degree Celsius
B. 39 degree Celsius
C. 100 degree Fahrenheit
D. 105.8 degree Fahrenheit
853. Tympanic temperature is taken from John, A client who was brought recently into the ER due to
frequent barking cough. The temperature reads 37.9 Degrees Celsius. As a nurse, you conclude that this
temperature is
A. High
B. Low
C. At the low end of the normal range
D. At the high end of the normal range
854. John has a fever of 38.5 Deg. Celsius. It surges at around 40 Degrees and go back to 38.5 degrees 6
times today in a typical pattern. What kind of fever is John having?
A. Relapsing
B. Intermittent
C. Remittent
D. Constant

855. John has a fever of 39.5 degrees 2 days ago, But yesterday, he has a normal temperature of 36.5
degrees. Today, his temperature surges to 40 degrees. What type of fever is John having?
A. Relapsing
B. Intermittent
C. Remittent
D. Constant

856. John’s temperature 10 hours ago is a normal 36.5 degrees. 4 hours ago, He has a fever with a
temperature of 38.9 Degrees. Right now, his temperature is back to normal. Which of the following best
describe the fever john is having?
A. Relapsing
B. Intermittent
C. Remittent
D. Constant

857. The characteristic fever in Dengue Virus is characterized as:

A. Tricyclic
B. Bicyclic
C. Biphasic
D. Triphasic

858. When John has been given paracetamol, his fever was brought down dramatically from 40 degrees
Celsius to 36.7 degrees in a matter of 10 minutes. The nurse would assess this event as:
A. The goal of reducing john’s fever has been met with full satisfaction of the outcome criteria
B. The desired goal has been partially met
C. The goal is not completely met
D. The goal has been met but not with the desired outcome criteria

859. What can you expect from Marianne, who is currently at the ONSET stage of fever
A. Hot, flushed skin
B. Increase thirst
C. Convulsion
D. Pale,cold skin

860. Marianne is now at the Defervescence stage of the fever, which of the following is expected?

A. Delirium
B. Goose flesh
C. Cyanotic nail beds
D. Sweating

861. Considered as the most accessible and convenient method for temperature taking
A. Oral
B. Rectal
C. Tympanic
D. Axillary

862. Considered as Safest and most non invasive method of temperature taking
A. Oral
B. Rectal
C. Tympanic
D. Axillary

863. Which of the following is NOT a contraindication in taking ORAL temperature?

A. Quadriplegic
B. Presence of NGT
C. Dyspnea
D. Nausea and Vomitting

864. Which of the following is a contraindication in taking RECTAL temperature?

A. Unconscious
B. Neutropenic
C. NPO
D. Very young children

865. How long should the Rectal Thermometer be inserted to the clients anus?
A. 1 to 2 inches
B. .5 to 1.5 inches
C. 3 to 5 inches
D. 2 to 3 inches

866. In cleaning the thermometer after use, The direction of the cleaning to follow Medical Asepsis is :
A. From bulb to stem
B. From stem to bulb
C. From stem to stem
D. From bulb to bulb

867. How long should the thermometer stay in the Client’s Axilla?
A. 3 minutes
B. 4 minutes
C. 7 minutes
D. 10 minutes

868. Which of the following statement is TRUE about pulse?

A. Young person have higher pulse than older persons
B. Males have higher pulse rate than females after puberty
C. Digitalis has a positive chronotropic effect
D. In lying position, Pulse rate is higher

869. The following are correct actions when taking radial pulse except:
A. Put the palms downward
B. Use the thumb to palpate the artery
C. Use two or three fingers to palpate the pulse at the inner wrist
D. Assess the pulse rate, rhythm, volume and bilateral quality

870. The difference between the systolic and diastolic pressure is termed as
A. Apical rate
B. Cardiac rate
C. Pulse deficit
D. Pulse pressure

871. Which of the following completely describes PULSUS PARADOXICUS?

A. A greater-than-normal increase in systolic blood pressure with inspiration
B. A greater-than-normal decrease in systolic blood pressure with inspiration
C. Pulse is paradoxically low when client is in standing position and high when supine.
D. Pulse is paradoxically high when client is in standing position and low when supine.

872. Which of the following is TRUE about respiration?

A. I:E 2:1 B. I:E : 4:3
C I:E 1:1 D. I:E 1:2
873. Contains the pneumotaxic and the apneutic centers
A. Medulla oblongata
B. Pons
C. Carotid bodies
D. Aortic bodies

874. Which of the following is responsible for deep and prolonged inspiration
A. Medulla oblongata
B. Pons
C. Carotid bodies
D. Aortic bodies

875. Which of the following is responsible for the rhythm and quality of breathing?
A. Medulla oblongata
B. Pons
C. Carotid bodies
D. Aortic bodies

876. The primary respiratory center

A. Medulla oblongata
B. Pons
C. Carotid bodies
D. Aortic bodies

877. Which of the following is TRUE about the mechanism of action of the Aortic and Carotid bodies?
A. If the BP is elevated, the RR increases
B. If the BP is elevated, the RR decreases
C. Elevated BP leads to Metabolic alkalosis
D. Low BP leads to Metabolic acidosis

878. All of the following factors correctly influence respiration except one. Which of the following is
incorrect?
A. Hydrocodone decreases RR
B. Stress increases RR
C. Increase temperature of the environment, Increase RR
D. Increase altitude, Increase RR

879. When does the heart receives blood from the coronary artery?
A. Systole
B. Diastole
C. When the valves opens
D. When the valves closes

880. Which of the following is more life threatening?

A. BP = 180/100
B. BP = 160/120
C. BP = 90/60
D. BP = 80/50

881. Refers to the pressure when the ventricles are at rest

A. Diastole
B. Systole
C. Preload
D. Pulse pressure

882. Which of the following is TRUE about the blood pressure determinants?
A. Hypervolemia lowers BP
B. Hypervolemia increases GFR
C. HCT of 70% might decrease or increase BP
D. Epinephrine decreases BP

883. Which of the following do not correctly correlates the increase BP of Ms. Aida, a 70 year old diabetic?
A. Females, after the age 65 tends to have lower BP than males
B. Disease process like Diabetes increase BP
C. BP is highest in the morning, and lowest during the night
D. Africans, have a greater risk of hypertension than Caucasian and Asians.

884. How many minutes are allowed to pass if the client had engaged in strenuous activities, smoked or
ingested caffeine before taking his/her BP?
A. 5
B. 10
C. 15
D. 30

885. Too narrow cuff will cause what change in the Client’s BP?
A. True high reading
B. True low reading
C. False high reading
D. False low reading

886. Which is a preferable arm for BP taking?

A. An arm with the most contraptions
B. The left arm of the client with a CVA affecting the right brain
C. The right arm
D. The left arm

887. Which of the following is INCORRECT in assessing client’s BP?

A. Read the mercury at the upper meniscus, preferably at the eye level to prevent error of
parallax
B. Inflate and deflate slowly, 2-3 mmHg at a time
C. The sound heard during taking BP is known as KOROTKOFF sound
D. If the BP is taken on the left leg using the popliteal artery pressure, a BP of 160/80 is normal.

888. Which of the following is the correct interpretation of the ERROR OF PARALLAX
A. If the eye level is higher than the level of the meniscus, it will cause a false high reading
B. If the eye level is higher than the level of the meniscus, it will cause a false low reading
C. If the eye level is lower than the level of the meniscus, it will cause a false low reading
D. If the eye level is equal to that of the level of the upper meniscus, the reading is accurate

889. How many minute/s is/are allowed to pass before making a re-reading after the first one?
A. 1
B. 5
C. 15
D. 30

890. Which of the following is TRUE about the auscultation of blood pressure?
A. Pulse + 4 is considered as FULL
B. The bell of the stethoscope is use in auscultating BP
C. Sound produced by BP is considered as HIGH frequency sound
D. Pulse +1 is considered as NORMAL

891. In assessing the abdomen, Which of the following is the correct sequence of the physical
assessment?
A. Inspection, Auscultation, Percussion, Palpation
B. Palpation, Auscultation, Percussion, Inspection
C. Inspection, Palpation, Auscultation, Percussion
D. Inspection, Auscultation, Palpation, Percussion
892. The sequence in examining the quadrants of the abdomen is:
A. RUQ,RLQ,LUQ,LLQ
B. RLQ,RUQ,LLQ,LUQ
C. RUQ,RLQ,LLQ,LUQ
D. RLQ,RUQ,LUQ,LLQ

893. In inspecting the abdomen, which of the following is NOT DONE?

A. Ask the client to void first
B. Knees and legs are straighten to relax the abdomen
C. The best position in assessing the abdomen is Dorsal recumbent
D. The knees and legs are externally rotated

894. Dr. Fabian De Las Santas, is about to conduct an ophthalmoscope examination. Which of the
following, if done by a nurse, is a Correct preparation before the procedure?
A. Provide the necessary draping to ensure privacy
B. Open the windows, curtains and light to allow better illumination
C. Pour warm water over the ophthalmoscope to ensure comfort
D. Darken the room to provide better illumination

895. If the client is female, and the doctor is a male and the patient is about to undergo a vaginal and
cervical examination, why is it necessary to have a female nurse in attendance?
A. To ensure that the doctor performs the procedure safely
B. To assist the doctor
C. To assess the client’s response to examination
D. To ensure that the procedure is done in an ethical manner

896. In palpating the client’s breast, Which of the following position is necessary for the patient to assume
before the start of the procedure?
A. Supine
B. Dorsal recumbent
C. Sitting
D. Lithotomy

897. When is the best time to collect urine specimen for routine urinalysis and C/S?
A. Early morning
B. Later afternoon
C. Midnight
D. Before breakfast

898. Which of the following is among an ideal way of collecting a urine specimen for culture and
sensitivity?
A. Use a clean container
B. Discard the first flow of urine to ensure that the urine is not contaminated
C. Collect around 30-50 ml of urine
D. Add preservatives, refrigerate the specimen or add ice according to the agency’s protocol

899. In a 24 hour urine specimen started Friday, 9:00 A.M, which of the following if done by a Nurse
indicate a NEED for further procedural debriefing?
A. The nurse ask the client to urinate at 9:00 A.M, Friday and she included the urine in the 24
hour urine specimen
B. The nurse discards the Friday 9:00 A M urine of the client
C. The nurse included the Saturday 9:00 A.M urine of the client to the specimen collection
D. The nurse added preservatives as per protocol and refrigerates the specimen

900. This specimen is required to assess glucose levels and for the presence of albumin the the urine
A. Midstream clean catch urine
B. 24 hours urine collection
C. Postprandial urine collection
D. Second voided urine

901. When should the client test his blood sugar levels for greater accuracy?
A. During meals
B. In between meals
C. Before meals
D. 2 Hours after meals

902. In collecting a urine from a catheterized patient, Which of the following statement indicates an
accurate performance of the procedure?
A. Clamp above the port for 30 to 60 minutes before drawing the urine from the port
B. Clamp below the port for 30 to 60 minutes before drawing the urine from the port
C. Clamp above the port for 5 to 10 minutes before drawing the urine from the port
D. Clamp below the port for 5 to 10 minutes before drawing the urine from the port

903. A community health nurse should be resourceful and meet the needs of the client. A villager ask him,
Can you test my urine for glucose? Which of the following technique allows the nurse to test a client’s
urine for glucose without the need for intricate instruments.
A. Acetic Acid test
B. Nitrazine paper test
C. Benedict’s test
D. Litmus paper test

904. A community health nurse is assessing client’s urine using the Acetic Acid solution. Which of the
following, if done by a nurse, indicates lack of correct knowledge with the procedure?
A. The nurse added the Urine as the 2/3 part of the solution
B. The nurse heats the test tube after adding 1/3 part acetic acid
C. The nurse heats the test tube after adding 2/3 part of Urine
D. The nurse determines abnormal result if she noticed that the test tube becomes cloudy

905. Which of the following is incorrect with regards to proper urine testing using Benedict’s Solution?

A. Heat around 5ml of Benedict’s solution together with the urine in a test tube
B. Add 8 to 10 drops of urine
C. Heat the Benedict’s solution without the urine to check if the solution is contaminated
D. If the color remains BLUE, the result is POSITIVE

906. +++ Positive result after Benedicts test is depicted by what color?
A. Blue
B. Green
C. Yellow
D. Orange

906. Clinitest is used in testing the urine of a client for glucose. Which of the following, If committed by a
nurse indicates error?
A. Specimen is collected after meals
B. The nurse puts 1 clinitest tablet into a test tube
C. She added 5 drops of urine and 10 drops of water
D. If the color becomes orange or red, It is considered postitive

907. Which of the following nursing intervention is important for a client scheduled to have a Guaiac Test?
A. Avoid turnips, radish and horseradish 3 days before procedure
B. Continue iron preparation to prevent further loss of Iron
C. Do not eat read meat 12 hours before procedure
D. Encourage caffeine and dark colored foods to produce accurate results

908. In collecting a routine specimen for fecalysis, Which of the following, if done by a nurse, indicates
inadequate knowledge and skills about the procedure?
A. The nurse scoop the specimen specifically at the site with blood and mucus
B. She took around 1 inch of specimen or a teaspoonful
C. Ask the client to call her for the specimen after the client wiped off his anus with a tissue
D. Ask the client to defecate in a bedpan, Secure a sterile container

909. In a routine sputum analysis, Which of the following indicates proper nursing action before sputum
collection?
A. Secure a clean container
B. Discard the container if the outside becomes contaminated with the sputum
C. Rinse the client’s mouth with Listerine after collection
D. Tell the client that 4 tablespoon of sputum is needed for each specimen for a routine sputum analysis

910. Who collects Blood specimen?

A. The nurse
B. Medical technologist
C. Physician
D. Physical therapist

911. David, 68 year old male client is scheduled for Serum Lipid analysis. Which of the following health
teaching is important to ensure accurate reading?
A. Tell the patient to eat fatty meals 3 days prior to the procedure
B. NPO for 12 hours pre procedure
C. Ask the client to drink 1 glass of water 1 hour prior to the procedure
D. Tell the client that the normal serum lipase level is 50 to 140 U/L

912. The primary factor responsible for body heat production is the
A. Metabolism B. Release of thyroxin
C. Muscle activity D. Stress

913. The heat regulating center is found in the

A. Medulla oblongata
B. Thalamus
C. Hypothalamus
D. Pons

914. A process of heat loss which involves the transfer of heat from one surface to another is
A. Radiation
B. Conduction
C. Convection
D. Evaporation

915. Which of the following is a primary factor that affects the BP?
A. Obesity
B. Age
C. Stress
D. Gender

916. The following are social data about the client except
A. Patient’s lifestyle
B. Religious practices
C. Family home situation
D. Usual health status

917. The best position for any procedure that involves vaginal and cervical examination is
A. Dorsal recumbent
B. Side lying
C. Supine
D. Lithotomy
918. Measure the leg circumference of a client with bipedal edema is best done in what position?
A. Dorsal recumbent
B. Sitting
C. Standing
D. Supine

919. In palpating the client’s abdomen, Which of the following is the best position for the client to
assume?
A. Dorsal recumbent B. Side lying
C. Supine D. Lithotomy

920. Rectal examination is done with a client in what position?

A. Dorsal recumbent B. Sims position
C. Supine D. Lithotomy

921. Which of the following is a correct nursing action when collecting urine specimen from a client with
an Indwelling catheter?
A. Collect urine specimen from the drainage bag
B. Detach catheter from the connecting tube and draw the specimen from the port
C. Use sterile syringe to aspirate urine specimen from the drainage port
D. Insert the syringe straight to the port to allow self sealing of the port

922. Which of the following is inappropriate in collecting mid stream clean catch urine specimen for urine
analysis?
A. Collect early in the morning, First voided specimen
B. Do perineal care before specimen collection
C. Collect 5 to 10 ml for urine
D. Discard the first flow of the urine

923. When palpating the client’s neck for lymphadenopathy, where should the nurse position himself?
A. At the client’s back
B. At the client’s right side
C. At the client’s left side
D. In front of a sitting client

924. Which of the following is the best position for the client to assume if the back is to be examined by
the nurse?
A. Standing
B. Sitting
C. Side lying
D. Prone

925. In assessing the client’s chest, which position best show chest expansion as well as its movements?
A. Sitting B. Prone
C. Sidelying D. Supine

926. When the General adaptation syndrome is activated, FLIGHT OR FIGHT response sets in.
Sympathetic nervous system releases norepinephrine while the adrenal medulla secretes epinephrine.
Which of the following is true with regards to that statement?
A. Pupils will constrict
B. Client will be lethargic
C. Lungs will bronchodilate
D. Gastric motility will increase
* To better understand the concept : The autonomic nervous system is composed of SYMPATHETIC and
PARASYMPATHETIC Nervous system. It is called AUTONOMIC Because it is Involuntary and stimuli based.
You cannot tell your heart to kindly beat for 60 per minute, Nor, Tell your blood vessels, Please constrict,
because you need to wear skirt today and your varicosities are bulging. Sympathetic Nervous system is
the FIGHT or FLIGHT mechanism. When people FIGHT or RUN, we tend to stimulate the ANS and
dominate over SNS. Just Imagine a person FIGHTING and RUNNING to get the idea on the signs of SNS
Domination. Imagine a resting and digesting person to get a picture of PNS Domination. A person
RUNNING or FIGHTING Needs to bronchodilate, because the oxygen need is increased due to higher
demand of the body. Pupils will DILATE to be able to see the enemy clearly. Client will be fully alert to
dodge attacks and leap through obstacles during running. The client's gastric motility will DECREASE
Because you cannot afford to urinate or defecate during fighting nor running.

927. Which of the following response is not expected to a person whose GAS is activated and the FIGHT
OR FLIGHT response sets in?
A. The client will not urinate due to relaxation of the detrusor muscle
B. The client will be restless and alert
C. Clients BP will increase, there will be vasodilation
D. There will be increase glycogenolysis, Pancrease will decrease insulin secretion
* If vasodilation will occur, The BP will not increase but decrease. It is true that Blood pressure increases
during SNS Stimulation due to the fact that we need more BLOOD to circulate during the FIGHT or FLIGHT
Response because the oxygen demand has increased, but this is facilitated by vasoconstriction and not
vasodilation. A,B and D are all correct. The liver will increase glycogenolysis or glycogen store utilization
due to a heightened demand for energy. Pancrease will decrease insulin secretion because almost every
aspect of digestion that is controlled by Parasympathetic nervous system is inhibited when the SNS
dominates.

928. State in which a person’s physical, emotional, intellectual and social development or spiritual
functioning is diminished or impaired compared with a previous experience.
A. Illness B. Disease
C. Health D. Wellness
* Disease is a PROVEN FACT based on a medical theory, standards, diagnosis and clinical feature while
ILLNESS Is a subjective state of not feeling well based on subjective appraisal, previous experience, peer
advice etc.

929. This is the first stage of illness wherein, the person starts to believe that something is wrong. Also
known as the transition phase from wellness to illness.
A. Symptom Experience
B. Assumption of sick role
C. Medical care contact
D. Dependent patient role
* A favorite board question are Stages of Illness. When a person starts to believe something is wrong,
that person is experiencing signs and symptoms of an illness. The patient will then ASSUME that he is
sick. This is called assumption of the sick role where the patient accepts he is Ill and try to give up some
activities. Since the client only ASSUMES his illness, he will try to ask someone to validate if what he is
experiencing is a disease, This is now called as MEDICAL CARE CONTACT. The client seeks professional
advice for validation, reassurance, clarification and explanation of the symptoms he is experiencing. client
will then start his dependent patient role of receiving care from the health care providers. The last stage of
Illness is the RECOVERY stage where the patient gives up the sick role and assumes the previous normal
gunctions.

930. In this stage of illness, the person accepts or rejects a professionals suggestion. The person also
becomes passive and may regress to an earlier stage.
A. Symptom Experience
B. Assumption of sick role
C. Medical care contact
D. Dependent patient role
* In the dependent patient role stage, Client needs professionals for help. They have a choice either to
accept or reject the professional's decisions but patients are usually passive and accepting. Regression
tends to occur more in this period.

931. In this stage of illness, The person learns to accept the illness.
A. Symptom Experience
B. Assumption of sick role
C. Medical care contact
D. Dependent patient role
* Acceptance of illness occurs in the Assumption of sick role phase of illness.

932. In this stage, the person tries to find answers for his illness. He wants his illness to be validated, his
symptoms explained and the outcome reassured or predicted
A. Symptom Experience
B. Assumption of sick role
C. Medical care contact
D. Dependent patient role
* At this stage, The patient seeks for validation of his symptom experience. He wants to find out if what
he feels are normal or not normal. He wants someone to explain why is he feeling these signs and
symptoms and wants to know the probable outcome of this experience.

933. The following are true with regards to aspect of the sick role except?
A. One should be held responsible for his condition
B. One is excused from his societal role
C. One is obliged to get well as soon as possible
D. One is obliged to seek competent help

* The nurse should not judge the patient and not view the patient as the cause or someone responsible
for his illness. A sick client is excused from his societal roles, Oblige to get well as soon as possible and
Obliged to seek competent help.

934. Refers to conditions that increases vulnerability of individual or group to illness or accident
A. Predisposing factor
B. Etiology
C. Risk factor
D. Modifiable Risks

935. Refers to the degree of resistance the potential host has against a certain pathogen
A. Susceptibility
B. Immunity
C. Virulence
D. Etiology
* Immunity is the ABSOLUTE Resistance to a pathogen considering that person has an INTACT IMMUNITY
while susceptibility is the DEGREE of resistance. Degree of resistance means how well would the individual
combat the pathogens and repel infection or invasion of these disease causing organisms. A susceptible
person is someone who has a very low degree of resistance to combat pathogens. An Immune person is
someone that can easily repel specific pathogens. However, Remember that even if a person is IMMUNE
[ Vaccination ] Immunity can always be impaired in cases of chemotherapy, HIV, Burns, etc.

936. A group of symptoms that sums up or constitute a disease

A. Syndrome
B. Symptoms
C. Signs
D. Etiology
* Symptoms are individual manifestation of a certain disease. For example, In Tourette syndrome, patient
will manifest TICS, but this alone is not enough to diagnose the patient as other diseases has the same tic
manifestation. Syndrome means COLLECTION of these symptoms that occurs together to characterize a
certain disease. Tics with coprolalia, echolalia, palilalia, choreas or other movement disorders are
characteristics of TOURETTE SYNDROME.

937. A woman undergoing radiation therapy developed redness and burning of the skin around the best.
This is best classified as what type of disease?
A. Neoplastic
B. Traumatic
C. Nosocomial
D. Iatrogenic
* Iatrogenic diseases refers to those that resulted from treatment of a certain disease. For example, A
child frequently exposed to the X-RAY Machine develops redness and partial thickness burns over the
chest area. Neoplastic are malignant diseases cause by proliferation of abnormally growing cells.
Traumatic are brought about by injuries like Motor vehicular accidents. Nosocomial are infections that
acquired INSIDE the hospital. Example is UTI Because of catheterization, This is commonly caused by
[Link].

938. The classification of CANCER according to its etiology Is best described as

1. Nosocomial A. 5 and 2
2. Idiopathic B. 2 and 3
3. Neoplastic C. 3 and 4
4. Traumatic D. 3 and 5
5. Congenital
6. Degenrative

* Aside from being NEOPLASTIC, Cancer is considered as IDIOPATHIC because the cause is UNKNOWN.

934. Refers to conditions that increases vulnerability of individual or group to illness or accident
A. Predisposing factor
B. Etiology
C. Risk factor
D. Modifiable Risks

935. Refers to the degree of resistance the potential host has against a certain pathogen
A. Susceptibility
B. Immunity
C. Virulence
D. Etiology
* Immunity is the ABSOLUTE Resistance to a pathogen considering that person has an INTACT IMMUNITY
while susceptibility is the DEGREE of resistance. Degree of resistance means how well would the individual
combat the pathogens and repel infection or invasion of these disease causing organisms. A susceptible
person is someone who has a very low degree of resistance to combat pathogens. An Immune person is
someone that can easily repel specific pathogens. However, Remember that even if a person is IMMUNE
[ Vaccination ] Immunity can always be impaired in cases of chemotherapy, HIV, Burns, etc.

936. A group of symptoms that sums up or constitute a disease

A. Syndrome
B. Symptoms
C. Signs
D. Etiology
* Symptoms are individual manifestation of a certain disease. For example, In Tourette syndrome, patient
will manifest TICS, but this alone is not enough to diagnose the patient as other diseases has the same tic
manifestation. Syndrome means COLLECTION of these symptoms that occurs together to characterize a
certain disease. Tics with coprolalia, echolalia, palilalia, choreas or other movement disorders are
characteristics of TOURETTE SYNDROME.

937. A woman undergoing radiation therapy developed redness and burning of the skin around the best.
This is best classified as what type of disease?
A. Neoplastic
B. Traumatic
C. Nosocomial
D. Iatrogenic
* Iatrogenic diseases refers to those that resulted from treatment of a certain disease. For example, A
child frequently exposed to the X-RAY Machine develops redness and partial thickness burns over the
chest area. Neoplastic are malignant diseases cause by proliferation of abnormally growing cells.
Traumatic are brought about by injuries like Motor vehicular accidents. Nosocomial are infections that
acquired INSIDE the hospital. Example is UTI Because of catheterization, This is commonly caused by
[Link].
938. The classification of CANCER according to its etiology Is best described as
1. Nosocomial A. 5 and 2
2. Idiopathic B. 2 and 3
3. Neoplastic C. 3 and 4
4. Traumatic D. 3 and 5
5. Congenital
6. Degenrative

* Aside from being NEOPLASTIC, Cancer is considered as IDIOPATHIC because the cause is UNKNOWN.

944. Refers to diseases that produced no anatomic changes but as a result from abnormal response to a
stimuli.
A. Functional
B. Occupational
C. Inorganic
D. Organic
* Refer to number 941

945. In what level of prevention according to Leavell and Clark does the nurse support the client in
obtaining OPTIMAL HEALTH STATUS after a disease or injury?
A. Primary
B. Secondary
C. Tertiary
D. None of the above
* Perhaps one of the easiest concept but asked frequently in the NLE. Primary refers to preventions that
aims in preventing the disease. Examples are healthy lifestyle, good nutrition, knowledge seeking
behaviors etc. Secondary prevention are those that deals with early diagnostics, case finding and
treatments. Examples are monthly breast self exam, Chest X-RAY, Antibiotic treatment to cure infection,
Iron therapy to treat anemia etc. Tertiary prevention aims on maintaining optimum level of functioning
during or after the impact of a disease that threatens to alter the normal body functioning. Examples are
prosthetis fitting for an amputated leg after an accident, Self monitoring of glucose among diabetics, TPA
Therapy after stroke etc.

The confusing part is between the treatment in secondary and treatment in tertiary. To best differentiate
the two, A client with ANEMIA that is being treated with ferrous sulfate is considered being in the
SECONDARY PREVENTION because ANEMIA once treated, will move the client on PRE ILLNESS STATE
again. However, In cases of ASPIRING Therapy in cases of stroke, ASPIRING no longer cure the patient or
PUT HIM IN THE PRE ILLNESS STATE. ASA therapy is done in order to prevent coagulation of the blood
that can lead to thrombus formation and a another possible stroke. You might wonder why I spelled
ASPIRIN as ASPIRING, Its side effect is OTOTOXICITY [ CN VIII ] that leads to TINNITUS or ringing of the
ears.

946. In what level of prevention does the nurse encourage optimal health and increases person’s
susceptibility to illness?
A. Primary
B. Secondary
C. Tertiary
D. None of the above
* The nurse never increases the person's susceptibility to illness but rather, LESSEN the person's
susceptibility to illness.

947. Also known as HEALTH MAINTENANCE prevention.

A. Primary B. Secondary
C. Tertiary D. None of the above
* Secondary prevention is also known as HEALTH MAINTENANCE Prevention. Here, The person feels signs
and symptoms and seeks Diagnosis and treatment in order to prevent deblitating complications. Even if
the person feels healthy, We are required to MAINTAIN our health by monthly check ups, Physical
examinations, Diagnostics etc.
948. PPD In occupational health nursing is what type of prevention?
A. Primary B. Secondary
C. Tertiary D. None of the above
* PPD or PERSONAL PROTECTIVE DEVICES are worn by the workes in a hazardous environment to protect
them from injuries and hazards. This is considered as a PRIMARY prevention because the nurse prevents
occurence of diseases and injuries.

949. BCG in community health nursing is what type of prevention?

A. Primary
B. Secondary
C. Tertiary
D. None of the above

950. A regular pap smear for woman every 3 years after establishing normal pap smear for 3 consecutive
years Is advocated. What level of prevention does this belongs?
A. Primary
B. Secondary
C. Tertiary
D. None of the above

[Link] monitoring of blood glucose for diabetic clients is on what level of prevention?
A. Primary
B. Secondary
C. Tertiary
D. None of the above

952. Which is the best way to disseminate information to the public?

A. Newspaper
B. School bulletins
C. Community bill boards
D. Radio and Television
* An actual board question, The best way to disseminate information to the public is by TELEVISION
followed by RADIO. This is how the DOH establish its IEC Programs other than publising posters, leaflets
and brochures. An emerging new way to disseminate is through the internet.

953. Who conceptualized health as integration of parts and subparts of an individual?

A. Newman B. Neuman
C. Watson D. Rogers
* The supra and subsystems are theories of Martha Rogers but the parts and subparts are Betty
Neuman's. She stated that HEALTH is a state where in all parts and subparts of an individual are in
harmony with the whole system. Margarex Newman defined health as an EXPANDING CONSCIOUSNESS.
Her name is Margaret not Margarex, I just used that to help you remember her theory of health.

954. The following are concept of health:

1. Health is a state of complete physical, mental and social wellbeing and not merely an absence of
disease or infirmity.
2. Health is the ability to maintain balance
3. Health is the ability to maintain internal milieu
4. Health is integration of all parts and subparts of an individual
A. 1,2,3 B. 1,3,4
C. 2,3,4 D. 1,2,3,4
* All of the following are correct statement about health. The first one is the definition by WHO, The
second one is from Walter Cannon's homeostasis theory. Third one is from Claude Bernard's concept of
Health as Internal Milieu and the last one is Neuman's Theory.

955. The theorist the advocated that health is the ability to maintain dynamic equilibrium is
A. Bernard B. Selye
C. Cannon D. Rogers
* Walter Cannon advocated health as HOMEOSTASIS or the ability to maintain dynamic equilibrium. Hans
Selye postulated Concepts about Stress and Adaptation. Bernard defined health as the ability to maintain
internal milieu and Rogers defined Health as Wellness that is influenced by individual's culture.

956. Excssive alcohol intake is what type of risk factor?

A. Genetcs B. Age
C. Environment D. Lifestyle

957. Osteoporosis and degenerative diseases like Osteoarthritis belongs to what type of risk factor?
A. Genetics B. Age
C. Environment D. Lifestyle

958. Also known as STERILE TECHNIQUE

A. Surgical Asepsis B. Medical Asepsis
C. Sepsis D. Asepsis
* Surgical Asepsis is also known as STERILE TECHNIQUE while Medical Asepsis is synonymous with CLEAN
TECHNIQUE.

959. This is a person or animal, who is without signs of illness but harbors pathogen within his body and
can be transferred to another
A. Host B. Agent
C. Environment D. Carrier

960. Refers to a person or animal, known or believed to have been exposed to a disease.
A. Carrier B. Contact
C. Agent D. Host

961. A substance usually intended for use on inanimate objects, that destroys pathogens but not the
spores.
A. Sterilization B. Disinfectant
C. Antiseptic D. Autoclave
* Disinfectants are used on inanimate objects while Antiseptics are intended for use on persons and other
living things. Both can kill and inhibit growth of microorganism but cannot kill their spores. That is when
autoclaving or steam under pressure gets in, Autoclaving can kill almost ALL type of microoganism
including their spores.

962. This is a process of removing pathogens but not their spores

A. Sterilization B. Auto claving
C. Disinfection D. Medical asepsis
* Both A and B are capable on killing spores. Autoclaving is a form of Sterilization. Medical Asepsis is a
PRACTICE designed to minimize or reduce the transfer of pathogens, also known as your CLEAN
TECHNIQUE. Disinfection is the PROCESS of removing pathogens but not their spores.

963. The third period of infectious processes characterized by development of specific signs and symptoms
A. Incubation period D. Carrier
C. Illness period D. Convalescent period
* In incubation period, The disease has been introduced to the body but no sign and symptom appear
because the pathogen is not yet strong enough to cause it and may still need to multiply. The second
period is called prodromal period. This is when the appearance of non specific signs and symptoms sets in,
This is when the sign and symptoms starts to appear. Illness period is characterized by the appearance of
specific signs and symptoms or refer tp as time with the greatest symptom experience. Acme is the PEAK
of illness intensity while the convalescent period is characterized by the abatement of the disease process
or it's gradual disappearance.

964. A child with measles developed fever and general weakness after being exposed to another child with
rubella. In what stage of infectious process does this child belongs?
A. Incubation period
B. Prodromal period
C. Illness period
D. Convalescent period
* To be able to categorize MEASLES in the Illness period, the specific signs of Fever, Koplik's
Spot and Rashes must appear. In the situation above, Only general signs and symptoms
appeared and the Specific signs and symptoms is yet to appear, therefore, the illness is still in
the Prodromal period. Signs and symptoms of measles during the prodromal phase are Fever,
fatigue, runny nose, cough and conjunctivitis. Koplik's spot heralds the Illness period and
cough is the last symptom to disappear. All of this processes take place in 10 days that is why,
Measles is also known as 10 day measles.

965. A 50 year old mailman carried a mail with anthrax powder in it. A minute after exposure, he still
hasn’t developed any signs and symptoms of anthrax. In what stage of infectious process does this man
belongs?
A. Incubation period
B. Prodromal period
C. Illness period
D. Convalescent period
* Anthrax can have an incubation period of hours to 7 days with an average of 48 hours. Since the
question stated exposure, we can now assume that the mailman is in the incubation period.

966. Considered as the WEAKEST LINK in the chain of infection that nurses can manipulate to prevent
spread of infection and diseases
A. Etiologic/Infectious agent
B. Portal of Entry
C. Susceptible host
D. Mode of transmission
* Mode of transmission is the weakest link in the chain of infection. It is easily manipulated by the Nurses
using the tiers of prevention, either by instituting transmission based precautions, Universal precaution or
Isolation techniques.

967. Which of the following is the exact order of the infection chain?
1. Susceptible host
2. Portal of entry
3. Portal of exit
4. Etiologic agent
5. Reservoir
6. Mode of transmission
A. 1,2,3,4,5,6 B. 5,4,2,3,6,1
C. 4,5,3,6,2,1 D. 6,5,4,3,2,1
* Chain of infection starts with the SOURCE : The etiologic agent itself. It will first proliferate on a
RESERVOIR and will need a PORTAL OF EXIT to be able to TRANSMIT irslef using a PORTAL OF ENTRY to a
SUSCEPTIBLE HOST. A simple way to understand the process is by looking at the lives of a young queen
ant that is starting to build her colony. Imagine the QUEEN ANT as a SOURCE or the ETIOLOGIC AGENT.
She first need to build a COLONY, OR the RESERVOIR where she will start to lay the first eggs to be able
to produce her worker ants and soldier ants to be able to defend and sustain the new colony. They need to
EXIT [PORTAL OF EXIT] their colony and crawl [MODE OF TRANSMISSION] in search of foods by
ENTERING / INVADING [PORTAL OF ENTRY] our HOUSE [SUSCEPTIBLE HOST]. By imagining the Ant's life
cycle, we can easily arrange the chain of infection.

968. Markee, A 15 year old high school student asked you. What is the mode of transmission of Lyme
disease. You correctly answered him that Lyme disease is transmitted via
A. Direct contact transmission
B. Vehicle borne transmission
C. Air borne transmission
D. Vector borne transmission

* Lyme disease is caused by Borrelia Burdorferi and is transmitted by a TICK BITE.

969. The ability of the infectious agent to cause a disease primarily depends on all of the following except
A. Pathogenicity B. Virulence
C. Invasiveness D. Non Specificity
* To be able to cause a disease, A pathogen should have a TARGET ORGAN/S. The pathogen should be
specific to these organs to cause an infection. Mycobacterium Avium is NON SPECIFIC to human organs
and therefore, not infective to humans but deadly to birds. An immunocompromised individual, specially
AIDS Patient, could be infected with these NON SPECIFIC diseases due to impaired immune system.

970. Contact transmission of infectious organism in the hospital is usually cause by

A. Urinary catheterization
B. Spread from patient to patient
C. Spread by cross contamination via hands of caregiver
D. Cause by unclean instruments used by doctors and nurses
* The hands of the caregiver like nurses, is the main cause of cross contamination in hospital setting. That
is why HANDWASHING is the single most important procedure to prevent the occurence of cross
contamination and nosocomial infection. D refers to Nosocomial infection and UTI is the most common
noscomial infection in the hospital caused by urinary catheterization. [Link] seems to be the major cause
of this incident. B best fits Cross Contamination, It is the spread of microogranisms from patient o patient.

971. Transmission occurs when an infected person sneezes, coughs or laugh that is usually projected at a
distance of 3 feet.
A. Droplet transmission
B. Airborne transmission
C. Vehicle transmission
D. Vector borne transmission

972. Considered as the first line of defense of the body against infection
A. Skin B. WBC
C. Leukocytes D. Immunization
* Remember that intact skin and mucus membrane is our first line of defense against infection.

973. All of the following contributes to host susceptibility except

A. Creed B. Immunization
C. Current medication being taken D. Color of the skin

* Creed, Faith or religious belief do not affect person's susceptibility to illness. Medication like
corticosteroids could supress a person's immune system that will lead to increase susceptibility. Color of
the skin could affect person's susceptibility to certain skin diseases. A dark skinned person has lower risk
of skin cancer than a fair skinned person. Fair skinned person also has a higher risk for cholecystitis and
cholelithiasis.

974. Graciel has been injected TT5, her last dosed for tetanus toxoid immunization. Graciel asked you,
what type of immunity is TT Injections? You correctly answer her by saying Tetanus toxoid immunization
is a/an
A. Natural active immunity B. Natural passive immunity
C. Artificial active immunity D. Artificial passive immunity
* TT1 ti TT2 are considered the primary dose, while TT3 to TT5 are the booster dose. A woman with
completed immunization of DPT need not receive TT1 and TT2. Tetanus toxoid is the actual toxin produce
by clostridium tetani but on its WEAK and INACTIVATED form. It is Artificial because it did not occur in the
course of actual illness or infection, it is Active because what has been passed is an actual toxin and not a
ready made immunoglobulin.

975. Agatha, was hacked and slashed by a psychotic man while she was crossing the railway. She suffered
multiple injuries and was injected Tetanus toxoid Immunoglobulin. Agatha asked you, What immunity
does TTIg provides? You best answered her by saying TTIg provides
A. Natural active immunity
B. Natural passive immunity
C. Artificial active immunity
D. Artificial passive immunity
* In this scenario, Agatha was already wounded and has injuries. Giving the toxin [TT Vaccine] itself
would not help Agatha because it will take time before the immune system produce antitoxin. What
agatha needs now is a ready made anti toxin in the form of ATS or TTIg. This is artificial, because the
body of agatha did not produce it. It is passive because her immune system is not stimulated but rather, a
ready made Immune globulin is given to immediately supress the invasion.

976. This is the single most important procedure that prevents cross contamination and infection
A. Cleaning
B. Disinfecting
C. Sterilizing
D. Handwashing
* When you see the word HANDWASHING as one of the options, 90% Chance it is the correct answer in
the local board. Or should I say, 100% because I have yet to see question from 1988 to 2005 board
questions that has option HANDWASHING on it but is not the correct answer.

977. This is considered as the most important aspect of handwashing

A. Time
B. Friction
C. Water
D. Soap
* The most important aspect of handwashing is FRICTION. The rest, will just enhance friction. The use of
soap lowers the surface tension thereby increasing the effectiveness of friction. Water helps remove
transient bacteria by working with soap to create the lather that reduces surface tension. Time is of
essence but friction is the most essential aspect of handwashing.

978. In handwashing by medical asepsis, Hands are held ….

A. Above the elbow, The hands must always be above the waist
B. Above the elbow, The hands are cleaner than the elbow
C. Below the elbow, Medical asepsis do not require hands to be above the waist
D. Below the elbow, Hands are dirtier than the lower arms
* Hands are held BELOW the elbow in medical asepsis in contrast with surgical asepsis, wherein, nurses
are required to keep the hands above the waist. The rationale is because in medical asepsis, Hands are
considered dirtier than the elbow and therefore, to limit contamination of the lower arm, The hands should
always be below the elbow.

979. The suggested time per hand on handwashing using the time method is

A. 5 to 10 seconds each hand

B. 10 to 15 seconds each hand
C. 15 to 30 seconds each hand
D. 30 to 60 seconds each hand

* Each hands requires atleast 15 to 30 seconds of handwashing to effectively remove transient

microorganisms.

980. The minimum time in washing each hand should never be below
A. 5 seconds
B. 10 seconds
C. 15 seconds
D. 30 seconds
* According to Kozier, The minimum time required for watching each hands is 10 seconds and should not
be lower than that. The recommended time, again, is 15 to 30 seconds.

981. How many ml of liquid soap is recommended for handwashing procedure?

A. 1-2 ml B. 2-3 ml
C. 2-4 ml D. 5-10 ml
* If a liquid soap is to be used, 1 tsp [ 5ml ] of liquid soap is recommended for handwashing procedure.
982. Which of the following is not true about sterilization, cleaning and disinfection?
A. Equipment with small lumen are easier to clean
B. Sterilization is the complete destruction of all viable microorganism including spores
C. Some organism are easily destroyed, while other, with coagulated protein requires longer time
D. The number of organism is directly proportional to the length of time required for sterilization
* Equipments with LARGE LUMEN are easier to clean than those with small lumen. B C and D are all
correct.

983. Karlita asked you, How long should she boil her glass baby bottle in water? You correctly answered
her by saying.
A. The minimum time for boiling articles is 5 minutes
B. Boil the glass baby bottler and other articles for atleast 10 minutes
C. For boiling to be effective, a minimum of 15 minutes is required
D. It doesn’t matter how long you boil the articles, as long as the water reached 100 degree Celsius
* Boiling is the most common and least expensive method of sterilization used in home. For it to be
effective, you should boil articles for atleast 15 minutes.

984. This type of disinfection is best done in sterilizing drugs, foods and other things that are required to
be sterilized before taken in by the human body
A. Boiling Water B. Gas sterilization
C. Steam under pressure D. Radiation
* Imagine foods and drugs that are being sterilized by a boiling water, ethylene oxide gas and autoclave
or steam under pressure, They will be inactivated by these methods. Ethylene oxide gas used in gas
sterlization is TOXIC to humans. Boiling the food will alter its consistency and nutrients. Autoclaving the
food is never performed. Radiation using microwave oven or Ionizing radiation penetrates to foods and
drugs thus, sterilizing them.

985. A TB patient was discharged in the hospital. A UV Lamp was placed in the room where he stayed for
a week. What type of disinfection is this?
A. Concurrent disinfection B. Terminal disinfection
C. Regular disinfection D. Routine disinfection
* Terminal disinfection refers to practices to remove pathogens that stayed in the belongings or
immediate environemnt of an infected client who has been discharged. An example would be Killing
airborne TB Bacilli using UV Light. Concurrent disinfection refers to ongoing efforts implented during the
client's stay to remove or limit pathogens in his supplies, belongings, immediate environment in order to
control the spread of the disease. An example is cleaning the bedside commode of a client with radium
implant on her cervix with a bleach disinfectant after each voiding.

986. Which of the following is not true in implementing medical asepsis?

A. Wash hand before and after patient contact
B. Keep soiled linens from touching the clothings
C. Shake the linens to remove dust
D. Practice good hygiene
* NEVER shake the linens. Once soiled, fold it inwards clean surface out. Shaking the linen will further
spread pathogens that has been harbored by the fabric.

987. Which of the following is true about autoclaving or steam under pressure?
A. All kinds of microorganism and their spores are destroyed by autoclave machine
B. The autoclaved instruments can be used for 1 month considering the bags are still intact
C. The instruments are put into unlocked position, on their hinge, during the autoclave
D. Autoclaving different kinds of metals at one time is advisable

* Only C is correct. Metals with locks, like clamps and scissors should be UNLOCKED in order to minimize
stiffening caused by autoclave to the hinges of these metals. NOT ALL microorganism are destroyed by
autoclaving. There are recently discovered microorganism that is invulnarable to extreme heat. Autoclaved
instruments are to be used within 2 weeks. Only the same type of metals should be autoclaved as this will
alteration in plating of these metals.
988. Which of the following is true about masks?
A. Mask should only cover the nose
B. Mask functions better if they are wet with alcohol
C. Masks can provide durable protection even when worn for a long time and after each and every patient
care
D. N95 Mask or particulate masks can filter organism as mall as 1 micromillimeter
* only D is correct. Mask should cover both nose and mouth. Masks will not function optimally when wet.
Masks should be worn not greater than 4 hours, as it will lose effectiveness after 4 hours. N95 mask or
particulate mask can filter organism as small as 1 micromillimeter.

989. Where should you put a wet adult diaper?

A. Green trashcan B. Black trashcan
C. Orange trashcan D. Yellow trashcan
* Infectious waste like blood and blood products, wet diapers and dressings are thrown in yellow
trashcans.

990. Needles, scalpels, broken glass and lancets are considered as injurious wastes. As a nurse, it is
correct to put them at disposal via a/an.
A. Puncture proof container B. Reused PET Bottles
C. Black trashcan
D. Yellow trashcan with a tag “INJURIOUS WASTES”
* Needles, scalpels and other sharps are to be disposed in a puncture proof container.

991. Miranda Priestly, An executive of RAMP magazine, was diagnosed with cancer of the cervix. You
noticed that the radioactive internal implant protrudes to her vagina where supposedly, it should be in her
cervix. What should be your initial action?
A. Using a long forceps, Push it back towards the cervix then call the physician
B. Wear gloves, remove it gently and place it on a lead container
C. Using a long forceps, Remove it and place it on a lead container
D. Call the physician, You are not allowed to touch, re insert or remove it

* A dislodged radioactive cervical implant in brachytherapy are to be picked by a LONG FORCEP and
stored in a LEAD CONTAINER in order to prevent damage on the client's normal tissue. Calling the
physician is the second most appropriate action among the choices. A nurse should never attempt to put it
back nor, touch it with her bare hands.

992. After leech therapy, Where should you put the leeches?
A. In specially marked BIO HAZARD Containers
B. Yellow trashcan
C. Black trashcan
D. Leeches are brought back to the culture room, they are not thrown away for they are reusable
* Leeches, in leech therapy or LEECH PHLEBOTOMY are to be disposed on a BIO HAZARD container. They
are never re used as this could cause transfer of infection. These leeches are hospital grown and not the
usual leeches found in swamps.

993. Which of the following should the nurse AVOID doing in preventing spread of infection?
A. Recapping the needle before disposal to prevent injuries
B. Never pointing a needle towards a body part
C. Using only Standard precaution to AIDS Patients
D. Do not give fresh and uncooked fruits and vegetables to Mr. Gatchie, with Neutropenia

* Never recap needles. They are directly disposed in a puncture proof container after used. Recapping the
needles could cause injury to the nurse and spread of infection. B C and D are all appropriate. Standard
precaution is sufficient for an HIV patient. A client with neutropenia are not given fresh and uncooked
fruits and vegetables for even the non infective organisms found in these foods could cause severe
infection on an immunocompromised patients.

994. Where should you put Mr. Alejar, with Category II TB?
A. In a room with positive air pressure and atleast 3 air exchanges an hr
B. In a room with positive air pressure and atleast 6 air exchanges an hr
C. In a room with negative air pressure and atleast 3 air exchanges an hr
D. In a room with negative air pressure and atleast 6 air exchanges an hr

* TB patients should have a private room with negative air pressure and atleast 6 to 12 air exhanges per
hour. Negative pressure room will prevent air inside the room from escaping. Air exchanges are necessary
since the client's room do not allow air to get out of the room.

995. A client has been diagnosed with RUBELLA. What precaution is used for this patient?
A. Standard precaution
B. Airborne precaution
C. Droplet precaution
D. Contact precaution

* Droplet precaution is sufficient on client's with RUBELLA or german measles.

996. A client has been diagnosed with MEASLES. What precaution is used for this patient?
A. Standard precaution
B. Airborne precaution
C. Droplet precaution
D. Contact precaution

* Measles is highly communicable and more contagious than Rubella, It requires airborne precaution as it
is spread by small particle droplets that remains suspended in air and disperesed by air movements.

997. A client has been diagnosed with IMPETIGO. What precaution is used for this patient?
A. Standard precaution
B. Airborne precaution
C. Droplet precaution
D. Contact precaution

* Impetigo causes blisters or sores in the skin. It is generally caused by GABS or Staph Aureaus. It is
spread by skin to skin contact or by scratching the lesions and touching another person's skin.

998. The nurse is to insert an NG Tube when suddenly, she accidentally dip the end of the tube in the
client’s glass containing distilled drinking water which is definitely not sterile. As a nurse, what should you
do?
A. Don’t mind the incident, continue to insert the NG Tube
B. Obtain a new NG Tube for the client
C. Disinfect the NG Tube before reinserting it again
D. Ask your senior nurse what to do

* The digestive tract is not sterile, and therefore, simple errors like this would not cause harm to the
patient. NGT tube need not be sterile, and so is colostomy and rectal tubes. Clean technique is sufficient
during NGT and colostomy care.

999. All of the following are principle of SURGICAL ASEPSIS except

A. Microorganism travels to moist surfaces faster than with dry surfaces
B. When in doubt about the sterility of an object, consider it not sterile
C. Once the skin has been sterilized, considered it sterile
D. If you can reach the object by overreaching, just move around the sterile field to pick it rather than
reaching for it
* Human skin is impossible to be sterilized. It contains normal flora of microorganism. A B and D are all
correct.

1000. Which of the following is true in SURGICAL ASEPSIS?

A. Autoclaved linens and gowns are considered sterile for about 4 months as long as the bagging is intact
B. Surgical technique is a sole effort of each nurse
C. Sterile conscience, is the best method to enhance sterile technique
D. If a scrubbed person leaves the area of the sterile field, He/she must do handwashing and gloving
again, but the gown need not be changed.

* Sterile conscience, or the moral imperative of a nurse to be honest in practicing sterile technique, is the
best method to enhance sterile technique. Autoclaved linens are considered sterile only within 2 weeks
even if the bagging is intact. Surgical technique is a team effort of each nurse. If a scrubbed person leave
the sterile field and area, he must do the process all over again.

1001. In putting sterile gloves, Which should be gloved first?

A. The dominant hand
B. The non dominant hand
C. The left hand
D. No specific order, Its up to the nurse for her own convenience

* Gloves are put on the non dominant hands first and then, the dominant hand. The rationale is simply
because humans tend to use the dominant hand first before the non dominant hand. Out of 10 humans
that will put on their sterile gloves, 8 of them will put the gloves on their non dominant hands first.

1002. As the scrubbed nurse, when should you apply the goggles, shoe cap and mask prior to the
operation?

A. Immediately after entering the sterile field

B. After surgical hand scrub
C. Before surgical hand scrub
D. Before entering the sterile field

* The nurse should put his goggles, cap and mask prior to washing the hands. If he wash his hands prior
to putting all these equipments, he must wash his hands again as these equipments are said to be
UNSTERILE.

1003. Which of the following should the nurse do when applying gloves prior to a surgical procedure?
A. Slipping gloved hand with all fingers when picking up the second glove
B. Grasping the first glove by inserting four fingers, with thumbs up underneath the cuff
C. Putting the gloves into the dominant hand first
D. Adjust only the fitting of the gloves after both gloves are on

* The nurse should only adjust fitting of the gloves when they are both on the hands. Not doing so will
break the sterile technique. Only 4 gingers are slipped when picking up the second gloves. You cannot slip
all of your fingers as the cuff is limited and the thumb would not be able to enter the cuff. The first glove
is grasp by simply picking it up with the first 2 fingers and a thumb in a pinching motion. Gloves are put
on the non dominant hands first.

1004. Which gloves should you remove first?

A. The glove of the non dominant hand

B. The glove of the dominant hand
C. The glove of the left hand
D. Order in removing the gloves Is unnecessary

* Gloves are worn in the non dominant hand first, and is removed also from the non dominant hand first.
Rationale is simply because in 10 people removing gloves, 8 of them will use the dominant hand first and
remove the gloves of the non dominant hand.

1005. Before a surgical procedure, Give the sequence on applying the protective items listed below
1. Eye wear or goggles A. 3,2,1,5,4
2. Cap B. 3,2,1,4,5
3. Mask C. 2,3,1,5,4
4. Gloves D. 2,3,1,4,5
5. Gown

* The nurse should use CaMEy Hand and Body Lotion in moisturizing his hand before surgical
procedure and after handwashing. Ca stands for CAP, M stands for MASK, Ey stands for eye goggles. The
nurse will do handwashing and then [HAND], Don the gloves first and wear the Gown [BODY]. I created
this mnemonic and I advise you use it because you can never forget Camey hand and body lotion. [ Yes, I
know it is spelled as CAMAY ]]

1006. In removing protective devices, which should be the exact sequence?

1. Eye wear or goggles
2. Cap A. 4,3,5,1,2
3. Mask B. 2,3,1,5,4
4. Gloves C. 5,4,3,2,1
5. Gown D. 1,2,3,4,5
* When the nurse is about to remove his protective devices, The nurse will remove the GLOVES first
followed by the MASK and GOWN then, other devices like cap, shoe cover, etc. This is to prevent
contamination of hair, neck and face area.

1007. In pouring a plain NSS into a receptacle located in a sterile field, how high should the nurse hold the
bottle above the receptacle?

A. 1 inch
B. 3 inches
C. 6 inches
D. 10 inches

* Even if you do not know the answer to this question, you can answer it correctly by imagining. If you
pour the NSS into a receptacle 1 to 3 inch above it, Chances are, The mouth of the NSS bottle would dip
into the receptacle as you fill it, making it contaminated. If you pour the NSS bottle into a receptacle 10
inches above it, that is too high, chances are, as you pour the NSS, most will spill out because the force
will be too much for the buoyant force to handle. It will also be difficult to pour something precisely into a
receptacle as the height increases between the receptacle and the bottle. 6 inches is the correct answer. It
is not to low nor too high.

1008. The tip of the sterile forceps is considered sterile. It is used to manipulate the objects in the sterile
field using the non sterile hands. How should the nurse hold a sterile forceps?

A. The tip should always be lower than the handle

B. The tip should always be above the handle
C. The handle and the tip should be at the same level
D. The handle should point downward and the tip, always upward

* A sterile forcep is usually dipped into a disinfectant or germicidal solution. Imagine, if the tip is HIGHER
than the handle, the solution will go into the handle and into your hands and as you use the forcep, you
will eventually lower its tip making the solution in your hand go BACK into the tip thus contaminating the
sterile area of the forcep. To prevent this, the tip should always be lower than the handle. In situation
questions like this, IMAGINATION is very important.

1009. The nurse enters the room of the client on airborne precaution due to tuberculosis. Which of the
following are appropriate actions by the nurse?
1. She wears mask, covering the nose and mouth
2. She washes her hands before and after removing gloves, after suctioning the client’s secretion
3. She removes gloves and hands before leaving the client’s room
4. She discards contaminated suction catheter tip in trashcan found in the clients room
A. 1,2 B. 1,2,3
C. 1,2,3,4 D. 1,3
* All soiled equipments use in an infectious client are disposed INSIDE the client's room to prevent
contamination outside the client's room. The nurse is correct in using Mask the covers both nose and
mouth. Hands are washed before and after removing the gloves and before and after you enter the client's
room. Gloves and contaminated suction tip are thrown in trashcan found in the clients room.

1010. When performing surgical hand scrub, which of the following nursing action is required to prevent
contamination?
1. Keep fingernail short, clean and with nail polish
2. Open faucet with knee or foot control
3. Keep hands above the elbow when washing and rinsing
4. Wear cap, mask, shoe cover after you scrubbed
A. 1,2
B. 2,3
C. 1,2,3
D. 2,3,4
* Cap, mask and shoe cover are worn BEFORE scrubbing.

1011. When removing gloves, which of the following is an inappropriate nursing action?
A. Wash gloved hand first
B. Peel off gloves inside out
C. Use glove to glove skin to skin technique
D. Remove mask and gown before removing gloves
Gloves are the dirtiest protective item nurses are wearing and therefore, the first to be
removed to prevent spread of microorganism as you remove the mask and gown.

1012. Which of the following is TRUE in the concept of stress?

A. Stress is not always present in diseases and illnesses
B. Stress are only psychological and manifests psychological symptoms
C. All stressors evoke common adaptive response
D. Hemostasis refers to the dynamic state of equilibrium

All stressors evoke common adaptive response. A psychologic fear like nightmare and a real
fear or real perceive threat evokes common manifestation like tachycardia, tachypnea,
sweating, increase muscle tension etc. ALL diseases and illness causes stress. Stress can be
both REAL or IMAGINARY. Hemostasis refers to the ARREST of blood flowing abnormally
through a damage vessel. Homeostasis is the one that refers to dynamic state of equilibrium
according to Walter Cannon.

1013. According to this theorist, in his modern stress theory, Stress is the non specific response of the
body to any demand made upon it.
A. Hans Selye B. Walter Cannon
C. Claude Bernard D. Martha Rogers

Hans Selye is the only theorist who proposed an intriguing theory about stress that has been
widely used and accepted by professionals today. He conceptualized two types of human
response to stress, The GAS or general adaptation syndrome which is characterized by stages
of ALARM, RESISTANCE and EXHAUSTION. The Local adaptation syndrome controls stress
through a particular body part. Example is when you have been wounded in your finger, it will
produce PAIN to let you know that you should protect that particular damaged area, it will also
produce inflammation to limit and control the spread of injury and facilitate healing process.
Another example is when you are frequently lifting heavy objects, eventually, you arm, back
and leg muscles hypertorphies to adapt to the stress of heavy lifting.

1014. Which of the following is NOT TRUE with regards to the concept of Modern Stress Theory?
A. Stress is not a nervous energy
B. Man, whenever he encounters stresses, always adapts to it
C. Stress is not always something to be avoided
D. Stress does not always lead to distress

Man, do not always adapt to stress. Sometimes, stress can lead to exhaustion and eventually,
death. A,C and D are all correct.

1015. Which of the following is TRUE with regards to the concept of Modern Stress Theory?
A. Stress is essential
B. Man does not encounter stress if he is asleep
C. A single stress can cause a disease
D. Stress always leads to distress

Stress is ESSENTIAL. No man can live normally without stress. It is essential because it is
evoked by the body's normal pattern of response and leads to a favorable adaptive mechanism
that are utilized in the future when more stressors are encountered by the body. Man can
encounter stress even while asleep, example is nightmare. Disease are multifactorial, No
diseases are caused by a single stressors. Stress are sometimes favorable and are not always a
cause for distress. An example of favorable stress is when a carpenter meets the demand and
stress of everyday work. He then develops calluses on the hand to lessen the pressure of the
hammer against the tissues of his hand. He also develop larger muscle and more dense bones
in the arm, thus, a stress will lead to adaptations to decrease that particular stress.

1016. Which of the following is TRUE in the stage of alarm of general adaptation syndrome?
A. Results from the prolonged exposure to stress
B. Levels or resistance is increased
C. Characterized by adaptation
D. Death can ensue

Death can ensue as early as the stage of alarm. Exhaustion results to a prolonged exposure to
stress. Resistance is when the levels of resistance increases and characterized by being able to
adapt.

1017. The stage of GAS where the adaptation mechanism begins

A. Stage of Alarm
B. Stage of Resistance
C. Stage of Homeostasis
D. Stage of Exhaustion

Adaptation mechanisms begin in the stage of alarm. This is when the adaptive mechanism are
mobilized. When someone shouts SUNOG!!! your heart will begin to beat faster, you vessels
constricted and bp increased.

1018. Stage of GAS Characterized by adaptation

A. Stage of Alarm
B. Stage of Resistance
C. Stage of Homeostasis
D. Stage of Exhaustion

1019. Stage of GAS wherein, the Level of resistance are decreased

A. Stage of Alarm
B. Stage of Resistance
C. Stage of Homeostasis
D. Stage of Exhaustion
 Resistance are decreased in the stage of alarm. Resistance is absent in the stage of
exhaustion. Resistance is increased in the stage of resistance.

1020. Where in stages of GAS does a person moves back into HOMEOSTASIS?
A. Stage of Alarm
B. Stage of Resistance
C. Stage of Homeostasis
D. Stage of Exhaustion

1021. Stage of GAS that results from prolonged exposure to stress. Here, death will ensue unless extra
adaptive mechanisms are utilized
A. Stage of Alarm
B. Stage of Resistance
C. Stage of Homeostasis
D. Stage of Exhaustion

1022. All but one is a characteristic of adaptive response

A. This is an attempt to maintain homeostasis
B. There is a totality of response
C. Adaptive response is immediately mobilized, doesn’t require time
D. Response varies from person to person

Aside from having limits that leads to exhaustion. Adaptive response requires time for it to act.
It requires energy, physical and psychological taxes that needs time for our body to mobilize
and utilize.

1023. Andy, a newly hired nurse, starts to learn the new technology and electronic devices at the hospital.
Which of the following mode of adaptation is Andy experiencing?
A. Biologic/Physiologic adaptive mode
B. Psychologic adaptive mode
C. Sociocultural adaptive mode
D. Technological adaptive mode

1024. Andy is not yet fluent in French, but he works in Quebec where majority speaks French. He is
starting to learn the language of the people. What type of adaptation is Andy experiencing?
A. Biologic/Physiologic adaptive mode
B. Psychologic adaptive mode
C. Sociocultural adaptive mode
D. Technological adaptive mode

Sociocultural adaptive modes include language, communication, dressing, acting and

socializing in line with the social and cultural standard of the people around the adapting
individual.

1025. Andy made an error and his senior nurse issued a written warning. Andy arrived in his house mad
and kicked the door hard to shut it off. What adaptation mode is this?
A. Biologic/Physiologic adaptive mode
B. Psychologic adaptive mode
C. Sociocultural adaptive mode
D. Technological adaptive mode

* Andy uses a defense mechanism called DISPLACEMENT. All DMs are categorized as
PSYCHOLOGIC ADAPTIVE RESPONSE to stressors.

1026.A nurse is teaching a staff seminar on patient confidentiality. Which of the following statements
would be included in the presentation?
a. Verbal consent is sufficient to allow family members to see a patient's medical records.
b. If a family member is at the hospital, he or she would be entitled to an update on the patient's status.
c. All hospital staff may have access to a patient's medical records.
d. Consent to disclosure is implied when a patient is transferred from one health provider or
facility to another.

Consent to disclosure is implied in the transfer from one health provider to another for
Continuity of Care under HIPAA laws as long as the facility members receiving the Patient
Health Information, or PHI, are directly involved in the care of the patient. Consent must be in
writing from the patient to allow the family members to see the patient’s medical record or
receive information from care providers. Updates on the patient’s status should only be given
with consent from the patient. This includes all family members, even a spouse. Under HIPAA
laws, only staff operating in the direct care of the patient are allowed access to a patient’s
medical records.

1027. A patient is suffering from heart failure. Which of the following would be recommended by a nurse
as part of the patient's health care plan?
a. Discouraging a diet of fruit and vegetables
b. Checking for swelling of the lower limbs
c. Encourage the daily intake of fluids
d. Encouraging vigorous exercise

Swelling of the lower limbs, known as edema, is due to a buildup of fluid from an impaired
circulatory system and is a common side effect of Congestive Heart Failure. It would not be
appropriate to discourage fruits and vegetables, as they are part of a heart healthy diet and
should be encouraged. Patients with heart failure are usually put on a water regimen of around
1-2 L of fluid total per day. This is due to the increased pressure on the heart to process fluids
and may cause worsening edema. Patients with heart failure need to be careful with the
amount of vigorous exercise activities they undertake. Heart rate should be monitored closely
to prevent overexertion.

1028. A patient has had diarrhea for the past 72 hours. Which of the symptoms would support a diagnosis
of hypovolemia?
a. Light colored urine output
b. Decreased pulse rate
c. Wet mucous membranes
d. Dizzy Spells

Hypovolemia indicates low fluid volume within the body. Dizziness spells would be one
symptom of hypovolemia due to the decreased pressure in the brain. 
Urine would be dark colored, not light colored, as the urine contains more byproducts and the
kidneys process less fluid. An increased pulse rate would indicate hypovolemia as the heart
works harder to spread the limited amount of fluid volume throughout the body. A patient
would have dry mucus membranes as fluid is directed towards more vital body organs.

1029. The spouse of a patient in a long term treatment facility asks a nurse for information about the
patient's treatment plan. The nurse should respond as follows?
a. Ask the patient for the information.
b. I cannot give you information on any patient.
c. The doctor will speak to you about the treatment plan.
d. Can you give me the patient's Social Security Number?

Unless the patient has given consent for information to be given to the spouse, the nurse
should respond that no PHI, or Protected Health Information, can be given out. Treatment plan
information would be considered PHI under HIPAA.
It would not be appropriate to direct the spouse to the patient for the information. The nurse
should already be aware of the treatment plan information and can ask permission from the
patient to speak to the spouse. It is not appropriate for the nurse to pass the buck to the
provider. In this scenario, the nurse should tell the spouse that information cannot be given.
Even if the spouse knows the patient’s Social Security Number, the patient’s PHI is protected
under HIPAA.
1030. Which of the following infectious control methods should be used when caring for a patient with
bacterial pneumonia?
a. Wear a mask when taking vital signs
b. Do not allow flowers in the patient's room
c. Require the patient to use disposable eating utensils
d. Do not allow visitors

A patient with Bacterial Pneumonia may spread the disease through droplets from coughing or
sneezing. Droplet precautions would be appropriate. A mask is required to prevent inhalation
of droplets containing bacteria.

1031. A patient is brought to the emergency room by her spouse. The patient's injuries are indicative of
physical abuse. Which of the following actions should be taken by the nurse?
a. Question the couple about how their marriage is going.
b. Inform the spouse that the patient's injuries appear to be the result of abuse.
c. Inform the patient that she will have to speak to the police.
d. With the spouse out of the room, question the patient about the possibility of abuse.

Using therapeutic communication, the nurse should question the patient about the possibility
of abuse. It is appropriate to talk with the patient when the spouse is out of the room as the
patient may be fearful and not answer questions honestly if the spouse is in the room.

1032. A patient is not to eat or drink anything 24 hours before a colonoscopy?

False: A patient may be instructed to not eat any solid foods up to 24 hours prior to a colonoscopy,
however clear liquids are typically allowed until midnight prior to the procedure up to a couple hours prior
to the procedure. The nurse will need to verify the orders given by the physician.

1033. A patient is having a tonic-clonic seizure. A nurse should take which of the following steps?
a. Put a pillow under the patient's head
b. Put restraints on the patient
c. Use a tongue blade on the patient
d. Lay the patient on his back

Putting a pillow under the patient’s head is an acceptable way to prevent injury to the patient
until the seizure has completed.

1034. A patient with a history of schizophrenia says "The medical staff is secretly employed by the CIA to
take me out." The nurse should respond as follows:
a. The CIA protects us and is not out to hurt you.
b. No other patient thinks that.
c. I want to help you, not harm you. It must be frightening thinking people want to hurt you.
d. When did you first start having these thoughts?
The best therapeutic communication with a schizophrenic patient is to acknowledge their fears while also
developing rapport with the patient as a nurse. This statement best meets those needs.

1035. Which of the following patients should a nurse recognize as having an increased risk of breast
cancer while doing breast cancer screening?
a. A 44 year old who has had five children
b. A 28 year old who is breast feeding her first child
c. A 35 year old who started her menstrual cycle at age 12
d. A 61 year old who has not had children
The risk for breast cancer is increased in elderly patients who have not had children.

1036. While preparing for discharge, a patient makes the statement to the nurse, "I'm not sure I will be
able to take care of myself at home." Who is the most appropriate team member to report this statement?
a. Doctor b. Physical Therapist
c. Case Manager d. Director of Nursing
The case manager is the most appropriate healthcare team member to report this kind of
statement to, especially around discharge. An assessment may need to take place regarding
the living and financial situation of the patient. The doctor and director of nursing would most
likely refer the nurse back to the case manager, so it would be appropriate for the nurse to
report this statement to the case manager first.
1037. A nurse just started a blood transfusion for a patient with a Hemoglobin of 6. The patient says, "I
feel hot, my stomach hurts, and I am having difficulty breathing." What should be the nurses first action?
a. Notify the physician immediately
b. Stop the infusion
c. Take vital signs
d. Call a code

The first action should be to stop the transfusion immediately once the patient complains of
any unusual symptoms. The patient is reporting symptoms of a transfusion reaction therefore
the transfusion should be stopped to prevent the patient from worsening. The provider should
be notified immediately after stopping the transfusion. Vital signs should be taken as quickly as
possible or as instructed by the provider after the transfusion has been stopped and the
physician has been notified. A code should be called if the patient becomes unresponsive. A
rapid response could be called if the patient is at risk of destabilizing.

1038. Which of the following lab tests would be considered Point of Care testing?
a. Urinalysis
b. Sputum Culture
c. Complete Metabolic Panel
d. Blood Glucose

A Blood Glucose would be considered a Point of Care test as the test can be completed at the
bedside with the result given immediately. A Urinalysis, Sputum Culture, or Complete
Metabolic Panel would not be considered Point of Care tests because these tests need to be run
in a laboratory setting with specialized equipment not available at the bedside.

1039. The nurse enters the room of a patient complaining of lower back pain after a left hip replacement
surgery. What non-pharmacological intervention would not be appropriate?
a. Reposition the patient onto the left side
b. Massage the patient's back
c. Lower the head of the bed and elevate the patient's legs onto a pillow
d. Apply a warm pack to the patient's back

If possible, the patient should not be repositioned onto the side where the hip surgery took
place as this may cause decreased circulation or improper healing to the hip or cause more
pain to the patient. The patient can be repositioned from supine to the right side. Massage is an
appropriate method for nursing staff to use in decreasing pain for the patient. It is appropriate
to lower the head of the bed to elongate the patient's back. The patient's legs may be elevated
to prevent swelling and pressure ulcers. The application of heat to a painful area is appropriate.
It would be acceptable for the nurse to obtain a doctor's order prior to heat application.

1040. The nurse notices a CNA using an alcohol-based hand sanitizer after walking out of a room marked
as Enteric Contact Precautions. What should the nurse's response be?
a. Nothing as the CNA has appropriately washed their hands after leaving the room
b. Tell the CNA they need to wear a mask in the room
c. Tell the CNA they should dispose of their gloves outside of the room
d. Tell the CNA they need to wash their hands with soap and water

A room marked with Enteric Contact Precautions indicates that normal alcohol-based hand
sanitizer will not remove the bacteria present in the room. Handwashing with soap and water
should be used instead of hand sanitizer.
A mask is not indicated with Enteric Contact Precautions. The CNA should dispose of gloves
inside the room to contain the bacteria within the room, then hands should be washed with
water and soap.
1041. A nurse is making a Home Health visit at a home of an elderly couple. The wife states regarding her
husband, the patient, "He always sits in that chair all day long." Which of the following should the nurse
consider the patient at risk for?
a. Pressure Ulcer
b. Deep Vein Thrombosis
c. Constipation
d. All of the above

The patient is at risk for all the listed conditions related to decreased mobility. Pressure ulcers
form as the skin layers break down between the chair or bed surface and bone. This may
happen due to the patient remaining in one position too long. This patient may be at risk for
pressure ulcers to his sacrum or areas where his leg meets the foot rest. Patients have been
shown to be higher risk for Deep Vein Thrombosis with decreased mobility. The patient should ambulate
multiple times a day to lower his risk for DVT. Constipation is another common side effect of decreased
mobility as the GI system slows.

1042. Which of the following statements to the Type 2 Diabetic patient by the nurse is correct?
a. Eat less fruits and vegetables and more grains.
b. Try to wear closed toe shoes whenever ambulating.
c. Minimize physical activity to prevent fatigue.
d. Check your blood sugar only after meals.

The correct statement by the nurse is that the patient should wear closed toe shoes when
ambulating. Patients with Diabetes are at high risk for impaired sensation in their lower
extremities and may develop wounds that are difficult to heal.
Patients with Diabetes should be encouraged to eat more fruits and vegetables as part of a
healthy blood-sugar regulating diet. Increasing physical activity is another way the patient
with Diabetes can regulate blood sugar levels. If the Diabetic patient is checking blood sugars,
the levels would normally be checked prior to meals, typically to determine a dose of insulin.

1043. A patient is being discharged with a new diagnosis of Congestive Heart Failure. Which of the
following statements made by the patient indicate understanding of the diagnosis?
a. "I can drink as much fluid as I want.
b. "I should notify my doctor if my feet start to swell.
c. "Weight gain of 3-5 lbs in one day is to be expected.
d. "It is normally to have difficulty breathing at night.

The patient should notify the physician if edema starts developing in the lower extremities.
This indicates more pressure on the heart and can cause complications.
Patients with Congestive Heart Failure need to have a limited fluid intake, typically around 2 L
per day to prevent fluid overloading. The patient should be aware this includes all types of
fluids, not just water. Weight gain of 3-5 lbs in one day should be reported to the physician as
this is a significant weight increase and may indicate fluid retention. The patient's medications
may need to be adjusted. The patient complaining of difficulty breathing at night is
experiencing pulmonary edema, a condition in which fluid builds up into the lungs. This
symptom should be reported to the physician immediately.

1044.A patient has Incentive Spirometry ordered QID x 10 breaths after a cholecystectomy. The patient is
asking why they need to perform this action. Which of the following would Not be a reason the patient
should use the Incentive Spirometer?
a. To decrease lung capacity
b. To gently exercise the lungs
c. To improve recovery time
d. To prevent pneumonia

Using an Incentive Spirometer will increase lung capacity, opening the bronchioles, and
allowing for better oxygenation throughout the body.
Using an Incentive Spirometer gently exercises the lungs and will encourage the patient to
take long and deep breaths instead of short and shallow breaths which are common following
surgery. Maintaining adequately expanded lungs and allow better oxygenation through the
blood stream will improve recovery times, allowing for the patient to start ambulating sooner
as well as encourage proper healing to the surgical site. Incentive Spirometry use prevents
pneumonia be keeping bronchioles open and clear, minimizing the sustainable environment for
pneumonia to develop.

1045.A nurse is changing the dressing for a post-op Bilateral Knee Amputation patient. The nurse notes
the patient refuses to look at the limb while the dressing is being changed but asks the nurse about their
personal life instead. Which nursing care plan should the nurse implement for the patient related to this
action?
a. Disturbed Body Image
b. Altered Sleep Pattern
c. Impaired Memory
d. Impaired Social Interaction

A patient with loss of limb may be experiencing Disturbed Body Image. The nurse should be
sensitive to the patient's emotional and mental acceptance of the loss and incorporate
therapeutic communication as the patient allows. Acceptance may take time and the patient
should not be pressured into looking at the limb.
The patient may be experiencing Altered Sleep Patterns related to the surgery, however the
patient refusing to look at the limb indicates Disturbed Body Image. The patient remembers the
limb is there and is refusing to look at it, therefore Impaired Memory does not appear to be the
issue. The patient does not appear to have any issues communicating with the nurse, so the
patient is more likely experiencing Disturbed Body Image related to the loss of the limb rather
than Impaired Social Interaction.