MOCK 4

1. A patient’s ECG shows ST segment elevation. Which of the following the nurse expect to do to
confirm the diagnosis of Ml?

A. Troponin level

B. Cardiac catheterization

C. Lipid profile

D. Echocardiogram
2. Nurse Vivian is reviewing immunizations with the caregiver of a 72 year old client with a
history of cerebrovascular disease. The caregiver learns that which immunization is a priority for
the client?
A. Hepatitis A vaccine
B. Lyme’s disease vaccine
C. Hepatitis B vaccine
D. Pneumococcal vaccine
3. The nurse is assessing a client with an endotracheal tube and observes that the client can
make verbal sounds. What is the most likely cause of this?
A. This is a normal finding
B. There is a leak
C. There is an occlusion
D. The endotracheal tube is displaced
4. The nurse expects that a client with mitral stenosis would demonstrate symptoms associated
with congestion in the:
A. Aorta
B. Right atrium
C. Superior vena cava
D. Pulmonary circulation
5. Which of the following is the initial intervention for a male client with external bleeding?
A. Elevation of the extremity
B. Pressure point control
C. Direct pressure
D. Application of a tourniquet
6. Which of these signs suggests that a male client with the syndrome of inappropriate
antidiuretic hormone(SIADH) secretion is experiencing complications?
A. Tetanic contractions
B. Neck vein distension
C. Weight loss
D. Polyuria
7. A 45-year-old distressed and restless patient in the Psychiatric Ward was unable to sleep
during the nights for the last two days. He was ordered sleep medication which was to be
administered at 10 pm. At the time medicine administration, the patient was found asleep in bed
Which of the following action should the nurse take regarding the dication?
A. Discard medicine and cancel the order
B. Leave it at the bed side for the patient
C. Wake him up and administer
D. Hold, record and report

8. A 12- year- old boy was brought to the Emergency respiratory arrest due to drowning. Cardiac
resuscitation
what is the major complication that might happen if treated after drowning quickly?
A. Sepsis
B. Alkalosis
C. Acidosis
D. Hypothermia

9. An ICU nurse reviews the chart of a 47-year-old man patient mechanical ventilator for a long
time. Arterial blood gas result see lab results).
Test Result Normal Values
ABG HCO3 24 22-28 mmd/L
ABG PCO3 10.66 4.7-6.0 KPa
PH 7.16 7.36-7.45
ABG PO2 6.13 10.6-14.2 KPa
SA O2 81 95-100 %
What condition the patient is experiencing presently?
A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis

10. Gastric suction can cause :

A. Metabolic acidosis
B. Respiratory acidosis
C. Metabolic alkalosis
D. Respiratory alkalosis

11. The nurse is assigned to care for the a patient with Cushing syndrome on adrenal corticoid
hormones syndrome on adrenal corticoid hormones Ph 7.2 Which of the following condition
should nurse expect to patient
A. Respiratory alkalosis
B. Respiratory acidosis
C. Metabolic alkalosis
D. Metabolic acidosis

12. A nurse reviewed a chart of a 42 year-old man whose ABG analysis report is shown PH 7.20
PCO2 35 HCO3 20. Which of the following I the most likely interpretation of the findings in the
report?
A. Respiratory alkalosis
B. Metabolic acidosis
C. Respiratory acidosis
D. Metabolic acidosis

13. The nurse is assigned to care for the a patient with Cushing syndrome on adrenal corticoid
hormones syndrome on adrenal corticoid hormones Ph 7.2 Which of the following condition
should nurse expect to patient
A. Respiratory alkalosis
B. Respiratory acidosis
C. Metabolic alkalosis
D. Metabolic acidosis

14. Ringer Lactate consider as which type of IV solution?

A. Hypotonic
B. Hypertonic
C. Isotonic
D. Hyper alimentation

15. physician orders an intravenous fluid of D5NS at 100cc/hr. This is an example of which of the
solution?
A. hyper alimentation
B. hypertonic
C. hypotonic
D. isotonic

16. 13-year-old patient is admitted for diarrhoea and vomiting. He looks pale and lethargic. A
nurse is preparing to give IV hypotonic solution.
Blood pressure 110/70 mmHg
Heart rate 76 /min
Respiratory rate 18 /min
Temperature 36.1°C
Which IV solution is most appropriate?
A. 0.9% saline
B. Lactated ringers
C. 10% dextrose in water
D. 0.45% sodium chloride

17. You are performing CPR on an infant when a second rescuer appears. What is the next step in
management?
A. Immediately transport the patient
B. Wait until exhausted, then switch
C. Have the second rescuer help with CPR, to minimize fatigue
D. Have the second rescuer begin ventilations; ratio 30:2
18. After activating the emergency call system, what should be the next immediate action?
A. Initiate ventricular pacing
B. Administer a bolus of lidocaine as prescribed
C. Defibrillate the patient
D. Open the patient's airway

19. A nursing instructor teaches a group of students about basic life support. The instructor asks
a student to identify the most appropriate location to assess the pulse of an infant under 1 year
of age. Which of the following if stated by the student, would indicate that the student
understands the appropriate procedure:
A. Carotid
B. Popliteal
C. Radial
D. Brachial

20. A nurse working in medical unit is preparing to with droplet precaution measures in place.
The following personal protective equipment; eyewear. What is the correct sequence foe putting
the equipment on?
A. Face Mask, Gown, Eyewear, and Gloves
B. Gown, Face Mask, Eyewear, and Gloves
C. Eyewear, Cloves, Face Mask, and Gown
D. Gloves, Gown, Face Mask, and Eyewear

21. A nurse working in medical unit is going out (removing) with droplet precaution measures in
place. The following personal protective equipment; eyewear. What is the correct sequence foe
putting the equipment off?
A. Face Mask, Gown, Eyewear, and Gloves
B. Gown, Face Mask, Eyewear, and Gloves
C. Eyewear, Cloves, Face Mask, and Gown
D. Gloves, Eyewear , Gown, , and Face Mask

22. Mr X attended in outpatient clinic with symptoms of shortness of breath, diarrhea and
severe respiratory distress Which of the following is the best diagnosis of Mrs. A case?
A. Corona virus
B. Swine Flue
C. Zika virus
D. Hepatitis

23. A nurse receives a telephone call from the admission office of the hospital and is told that a
patient with streptococcal meningitis will be admitted to the Medical Unit. The nurse is planning
to apply infection control measures for the patient. Which type of isolation precaution the nurse
must observe?
A. Droplet precautions
B. Contact precautions
C. Airborne precautions
D. Standard precautions

24. A nurse receives a telephone call from the admission office of the hospital and is told that a
patient with streptococcal meningitis will be admitted to the Medical Unit. The nurse is planning
to apply infection control measures for the patient. Which type of isolation precaution the nurse
must observe?
A. Droplet precautions
B. Contact precautions
C. Airborne precautions
D. Standard precautions

25. A 35 year old patient was admitted to a medical ward with confirmed agnosies f
meningococcal infection. Which of the following infection control preventions the nurse should
implement?
A. Droplet precaution
B. Contact precaution
C. Airborne precaution
D. Standard precaution

26. When planning discharge teaching for a patient hospitalized for treatment of the 3rd burns
over 30% of the body, a nurse knows it is most important to include instructions regarding the
loss of large amounts of serum occurring with burns and the resulting loss of immune function.
Which of the following instructions should be include?
A. Wash hands frequently each day
B. Wear supplemental oxygen at night
C. Wear masks while in public spaces
D. Take a multiple vitamin tablet night

27. A nurse is caring for patient who is being admitted with respiratory tract infection. The
patient feels cold and
shivering
Blood pressure 110/70 mmHg Heart rate 110 /min Respiratory rate
22 /min Temperature 39.7 C
Which of the following is the best nursing action?
A. Provide a hot drink
B. Cover the patient with light blanket
C. Start the air conditioning system
D. Turn off lights and close curtains

28. A nurse is assigned to care for a 32-year-old glomerulonephritis. The nurse is transcribing
patient file.
Which of the following orders should the nurse clarify?
A. Bed rest
B. Daily weights
C. Strict intake and output check
D. Frequent blood pressure check

29. A 22-year-old patient is admitted in the male Medical diagnosis of tonsillar abscess. He has
high fever and
sever along with dysphagia, difficulty in talking and in opening patient is planned for needle
aspiration of the
abscess intravenous antibiotics including penicillin.
What expected outcome of nursing care should be prioritized?
A. Patient is comfortable and has minimum pain
B. Patient is able to communicate appropriately
C. Able to swallow fluids and soft diet more easily
D. Normal body temperature and stable vital signs

30. Normal systolic Bp for new born:-

A. 40-60
B. 60-80
C. 80-100
D. 100-120

31. A conscious victim of a motor vehicle accident arrives at the emergency department. The
patient isGasping for air, is extremely anxious, and has a deviated trachea. What diagnosis
should the nurse
Anticipate?
A. pleural effusion.
B. tension pneumothorax
C. pneumothorax
D. cardiac tamponed

32. 27 years old female brought to the Emergency Room accompanied by her husband. He
described that she
had marked Weight loss with episodes of emesis in the past three months. She is diagnosed as
having anorexia.
She reported feeling Febrile, but had not measured her temperature. Her White Blood Count
was 11,000/mm3.
Which of the following most Likely describe her diagnostic criteria for her anorexia?
A. Restricting food intake
B. Fear of gaining weight
C. Problems with body image
D. Binge eating disorder

33. Diarrhoea, dementia and dermatitis(3 Ds) are due to deficiency of:
A. Thiamine
 B. Pantothenic acid
C. Riboflavin
D. Niacin
34. A 45 year-old man who is hospitalized feels tge constant need to keep things in order ,
particularly whilst
eating m the nurse observe him arranging the food on his plate into symmetrical and equal bite
sized pieces , he
constantly worries that the food served could be outdate and potentially causes illness
Which nursing diagnosis is most important
A. Ineffective verbal communication
B. Self-esteem disturbance
C. Impaired social interaction
D. Anxiety

35. What do the standards of pain management dictate nurse do?

A. Avoid the use of the word "pain"
B. Screen for pain at each encounter
C. Discourage around-the-clock dosage of analgesics
D. Administer analgesics via injection whenever possible

36. 50year-old male was diagnosed with subdural underwent burr hole craniotomy for subdural
hernatoma days
ago. In order to detect the sign of meningitis as one of which of the following indicates the
patient has
meningitis ?
A. Negative Kernig's signs
B. Positive Brudzinski's sign
C. Absence of nuchal rigidity
D. Glasgow comma scale of 14 points

37. A patient diagnosed with septic shock had an upward-trending glucose level (180-225
mg/dL) requiring
control with insulin. the patient's spouse asks why is insulin needed as the patient does not have
dia Which of
the following is the most appropriate nursing response to educate the patient's spouse?
A. "It is common for critically clients to develop type diabetes. We give insulin to keep
glucose level under control (less than140 mg/dL)"
B. " Patient had diabetes before, you just didn't know it. we give insulin to keep glucose level
in the normal range (70-110 mg/dL)
C. " Increase in glucose is a normal response to stress by the body. We give insulin to keep
the level 1t 140-180-mg/dL"
D. " Increase is common in critically ill clients and effects their ability to fight off infection.
We give insulin to keep the glucose level in the normal range (70-110 mg/dL)
38. 33-year old man presents to the emergency department with high grade fever, tachycardia,
and tachypnea.
What is an appropriate nursing intervention for the patient’s fever?
A. provide dry clothing
B. keep limbs close to the body
C. cover the patient’s scalp with a cap
D. measure the patient’s fluid intake and output

39. A 62 year-old male patient , admitted in the surgical Ward is scheduled for the surgical
removal of polyps
from his descending colon under general anaesthesia . he is experiencing fatigue , abdominal
pain and blood
streaked stools for a couple of months . he is worried whether the bleeding in his stools is going
to stop after
surgery .
What is most appropriate response by the nurse for the patient concern ?
A. Surgery often relieves the symptoms
B. Let us have a detail discussion with your physician
C. Your condition may or may not resolve , it depends
D. In fact surgery is the only treatment for the problem

40. A client with a diagnosis of HPV is at risk for which of the following?
A. Hodgkin’s lymphoma
B. Cervical cancer
C. Multiple myeloma
D. Ovarian cancer
41. Position given for patients after renal biopsy is:
A. Supine
B. Sitting
C. Side lying
D. Prone
42. Partial or total rupture of sutured wound is:
A. Dehiscence
B. Evisceration
C. Laceration
D. Concussion
43. A male client is admitted to the substance abuse unit for alcohol detoxification.
Which of the following medications is Nurse Alice most likely to administer to reduce
the symptoms of alcohol withdrawal?
A. Naloxone (Narcan)
B. Haloperidol (Haldol)
C. Magnesium sulfate
D. Chlordiazepoxide (Librium)
 44. PTT tests should be monitored while the clients is taking:
a-cumadine.
b-heparin.
c-warfarin
d-non.

45. A client who received heparin begins to bleed, and the physician calls for the
antidote. The nurse knows that which is the antidote for heparin?
a. protamine sulfate
b. vitamin K
c. aminocaproic acid
d. vitamin C

46. The nurse is assessing a client who is taking furosemide (Lasix). The client's
potassium level is 3.4 mEq/L, chloride is 90 mmol/L, and sodium is 140 mEq/L. What
is the nurse's primary intervention?
a. Mix 40 mEq of potassium in 250 mL D5W and infuse rapidly.
b. Administer Kayexalate.
c. Administer 2 mEq potassium chloride per kilogram per day IV.
d. Administer PhosLo, two tablets three times per day.

47. A patient came to emergency department ,complaints of angina. Nitroglycerin

(Nitrate) ordered the physician. This medication is to be administered via which of the
following routes?
A- Intradermal .
B-Buccal.
C- Parental.
D-Topical.

48. After receiving the initial treatment of TB , a 27 years

instruction on dietary management , medication, regimen, hygiene care and follow up visits.
What is the instructions need to be emphasized the most?
A. Increase protein diet to promote healing
B. More rest and relaxation to restore therapy
C. Maintain daily exercise schedule to improve health
D. Dispose sputum as guided to avoid spread of disease

49. Which common pregnancy condition can occur during the 3rd trimester?
a. Physiologic anemia
b. Unilateral mastitis
c. Acne vulgaris
d. Respiratory acidosis
50. How long is the first phase of the transitional period of the newborn?
 a.0-10 minutes
b.0-30 minutes
c.0-5 minutes
d.0-20 minutes
51. A nurse is assessing a client 8 hours after the creation of a colostomy. Which assessment
finding should the nurse expect?
A. Presence of hyperactive bowel sounds
B. Absence of drainage from the colostomy
C. Dusky-colored, edematous-appearing stoma
D. Red bloody drainage from the nasogastric tube
52. When admitting a client who is in labor to the birthing unit, a nurse asks the client about her
marital status. The client refuses to answer and becomes very agitated, telling the nurse to
leave. How should the nurse respond?
A. Question the family about the client’s marital status.
B. Try to obtain this information to complete the client’s history.
C. Refer the client to the social service department for counseling.
D. Ask questions that are restricted to the client’s present clinical situation.
53. A 5-week-old infant is admitted to the hospital with a tentative diagnosis of a congenital
heart defect. The infant tires easily and has difficulty breathing and feeding. In what position
should the nurse place this infant?
A. Supine with the knees flexed
B. Orthopneic with pillows for support
C. Side-lying with the upper body elevated
D. Prone with the head supported by pillows
54. Three weeks after a kidney transplant, a client develops leukopenia. Which factor should
the nurse conclude is the most probable cause of the leukopenia?
A. Bacterial infection
B. High creatinine levels
C. Rejection of the kidney
D. Antirejection medications
55. A nurse in the prenatal clinic is providing nutritional counseling for a pregnant woman with
a cardiac problem. What should the nurse advise the client to do?
A. Limit the intake of fat.
B. Increase sodium in the diet.
C. Eat a moderate amount of protein.
D. Control the number of calories consumed.
56. Control the number of calories consumed.
A. Encourage the father’s participation in a parenting class.
B. Provide time for the father to be alone with and get to know the infant.
 C. Offer the father a demonstration on newborn diapering, feeding, and bathing.
D. Allow time for the father to ask questions after viewing a film about a new infant.
57. On a 6-week postpartum visit, a new mother tells a nurse she wants to feed her baby whole
milk after 2 months because she will be returning to work and can no longer breastfeed. The
nurse plans to teach her that she should switch to formula feeding because whole milk does not
meet the infant’s nutritional requirements for which constituents?
A. Fat and calcium
B. Vitamin C and iron
C. Thiamine and sodium
D. Protein and carbohydrates
58. A client develops kidney damage as a result of a transfusion reaction. What is the most
significant clinical response that the nurse should assess when determining kidney damage?
A. Glycosuria
B. Blood in the urine
C. Decreased urinary output
D. Acute pain over the kidney
59. A nurse is caring for a client with chronic kidney failure. What should the nurse teach the
client to limit the intake of to help control uremia associated with end-stage renal disease
(ESRD)?
A. Fluid
B. Protein
C. Sodium
D. Potassium
60. What should the nurse do when caring for a client who is receiving peritoneal dialysis?
A. Maintain the client in the supine position during the procedure.
B. Position the client from side to side if fluid is not draining adequately.
C. Remove the cannula at the end of the procedure and apply a dry, sterile dressing.
D. Notify the health care provider if there is a deficit of 200 mL in the drainage return.
61. Children with special needs have the same needs as those without special needs, although
their means of satisfying these needs may be limited. What effect should the nurse expect that
these limitations will frequently cause in the child?
A. Frustration
B. Overcompensation
C. Feelings of rejection
D. Emotional dysfunction
62. A nurse assesses a client recently admitted to an alcoholdetoxification unit. What common
clinical manifestation should the nurse expect during the initial stage of alcohol detoxification?
A. Nausea
B. Euphoria
C. Bradycardia
 D. Hypotension
63. After an abdominal cholecystectomy, a client has a T-tube attached to a collection device.
On the day of surgery, at 10:30 PM, 300 mL of bile is emptied from the collection bag. At 6:30
AM the next day, the bag contains 60 mL of bile. What should the nurse consider in response to
this information?
A. The T-tube may have to be irrigated.
B. The bile is now draining into the duodenum.
C. Mechanical problems may have developed with the T-tube.
D. Suction must be reestablished in the portable drainage system.
64. A nurse in the emergency department is assessing a client who was beaten and sexually
assaulted. Which is the nurse’s priority assessment?
A. The family’s feelings about the attack
B. The client’s feelings of social isolation
C. Disturbance in the client’s thought processes
D. The client’s ability to cope with the situation
65. A health care provider orders oxygen therapy via nasal cannula at 2 L/min for an older,
confused client with heart failure. Which nursing action is the priority?
A. Maintaining the client on bed rest
B. Determining whether the client is agitated
C. Obtaining a cannula of appropriate size for the client
D. Investigating whether the client has chronic obstructive pulmonary disease
66. A health care provider orders oropharyngeal suctioning as needed for a client in a coma.
Which assessment made by the nurse indicates the need for suctioning?
A. Gurgling sounds with each breath
B. Fine crackles at the base of the lungs
C. Cyanosis in the nail beds of the fingers
D. Dry cough at increasingly frequent intervals
67. A parent of three young children has contracted tuberculosis. Which should the nurse
expect the health care provider to prescribe for members of the family who have a positive
reaction to the tuberculin skin test and are candidates for treatment?
A. Isoniazid (INH)
B. Multiple puncture tests (MPTs)
C. Bacille Calmette-Guérin (BCG)
D. Purified protein derivative (PPD)
68. A client is diagnosed with varicose veins, and the nurse teaches the client about the
pathophysiology associated with this disorder. The client asks, “What can I do to help myself?”
What should the nurse respond?
A. “Limit walking to as little as possible.”
B. “Reduce fluid intake to one liter of liquid a day.”
C. “Apply moisturizing lotion on your legs several times a day.”
 D. “Put on compression hose before getting out of bed in the morning.”
69. A nurse is caring for a newly admitted client with anorexia nervosa. What is the priority
treatment for the client at this time?
A. Medications to reduce anxiety
B. Family psychotherapy sessions
C. Separation from family members
D. Correction of electrolyte imbalances
70. A client with acquired immunodeficiency syndrome (AIDS) is receiving a treatment protocol
that includes a protease inhibitor. When assessing the client’s response to this drug, which
common side effect should the nurse expect?
A. Diarrhea
B. Hypoglycemia
C. Paresthesias of the extremities
D. Seeing yellow halos around lights
71. A nurse teaches a client about warfarin (Coumadin). Which juice to avoid identified by the
client indicates that the teaching is effective?
A. Apple juice
B. Grape juice
C. Orange juice
D. Cranberry juice
72. Medication is prescribed for a 7-year-old child with attention deficit hyperactivity disorder
(ADHD). What information should the school nurse emphasize when discussing this child’s
treatment with the parents?
A. Tutor their child in the subjects that are troublesome.
B. Monitor the effects of the drug on their child’s behavior.
C. Explain to their child that the behavior can be controlled if desired.
D. Avoid imposing too many rules because these will frustrate the child.
73. A nurse performs preoperative teaching for a client who is to have cataract surgery. Which
is most important for the nurse to include concerning what the client should do after surgery?
A. Remain flat for 3 hours.
B. Eat a soft diet for 2 days.
C. Breathe and cough deeply.
D. Avoid bending from the waist.
74. A nurse is supervising a recently hired nursing assistant who is caring for a debilitated,
bedbound client. What intervention being implemented necessitates the nurse to intervene?
A. Draining the client’s urinary collection bag into a measuring container
B. Taking the client’s blood pressure with an electronic sphygmomanometer
C. Removing boots that kept the client’s feet in dorsiflexion before giving a bath
D. Replacing a dressing on the client’s buttocks that was contaminated with fecal material
75. A client is receiving epoetin (Epogen) for the treatment of anemia associated with chronic
renal failure. Which client statement indicates to the nurse that further teaching about this
medication is necessary?
A. “I realize it is important to take this medication because it will cure my anemia.”
B. “I know many ways to protect myself from injury because I am at risk for seizures.”
C. “I recognize that I may still need blood transfusions if my blood values are very low.”
D. “I understand that I will still have to take supplemental iron therapy with this medication.”
76. Which of the following is the appropriate position for a patient who is suffering from acute
asthma attack is:
Right lateral
Supine
High fowler
Prone
77. A patient with COPD is admitted to the admitted to the hospital. How can the nurse best
position the patient to improve gas exchange:
A. Sitting up at the bedside in a chair and leaning slightly forward
B. Resting in bed with the head elevated to 45 to 60 degrees
C. In the Trendelenburg's position with several pillows behind the head
D. Resting in bed in a high-Fowler's position with the knees flexed
78. Following a tympanoplasty, the nurse should maintain the client in which position:
A. Fowler’s with the operative ear facing down
B. Low Trendelenburg’s with the head in neutral position+
C. Flat with the head turned to the side with the operative ear facing up
D. Supine with a small neck roll to allow for drainage
79. Which of the following is the proper position for a patient undergoing a cardiac surgery:
A. Supine
B. Prone
C. Lateral
D. Fowler’s
80. Which of the following is the proper position for a patient undergoing a cardiac surgery:
A. Supine
B. Prone
C. Lateral
D. Fowler’s
81. A nurse is caring for a toddler after surgical repair of a cleft palate. The nurse should
position the child:
A. On his back
B. On his stomach
C. On his back with his head slightly elevated
D. For comfort
82. The nurse observes that the infant's anterior fontanelle is bulging after placement of a
ventriculoperitoneal shunt. The nurse positions this infant:
A. Prone, with the head of the bed elevated
B. Supine, with the head flat
C. Side-lying on the operative side
D. In a semi-fowler's position
83. A nurse is providing care for a client following surgery to remove a cataract from the right
eye. In which position should the nurse place the client?
A. Right-side lying
B. Prone
C. Supine
D. Trendelenburg’s
84. An adult is admitted for a neurological workup and is scheduled for a spinal tap. When
preparing the client for the procedure, the nurse should position the client in which position:
A. Prone
B. On the side with knees drawn up to chest
C. Lithotomy
D. Semi-sitting
85. When suctioning the oropharynx, which of the following is the proper position of the
patient:
A. Prone
B. Supine
C. Semi-Fowler’s
D. Trendelenburg’s
86. To prevent headache after spinal anesthesia the patient should be positioned:
A. Semi- fowler’s
B. Flat on bed for 6 to 8 hours
C. Prone position
D. Modified Trendelenburg
87. If a patient develops autonomic hyperreflexia the first action his caring nurse should take is
to:
A. Elevate head of bed 90 degree (move from supine to sitting)
B. Make the bed in flat position
C. Apply ice on the axillary and groin
D. But the patient in trendelenburg position
88. To protect susceptible patients in the hospital from aspiration pneumonia, the nurse will
plan to:
A. Turn and reposition immobile patients at least every 2 hours.
B. Position patients with altered consciousness in lateral positions.
 C. Monitor frequently for respiratory symptoms in patients who are immunosuppressed.
D. Provide for continuous subglottic aspiration in patients receiving enteral feedings.
89. 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 administrating it
D. Hanging a full day’s worth formula at one time
90. Which of the following positions is appropriate for the patient who has hypovolemic shock:
A. Prone
B. Supine
C. Semi-fowler’s
D. Flat with elevating the feet
91. When caring for a patient admitted post-stroke (CVA) who has altered consciousness, the
nurse should place the patient in which position:
A. Side-lying
B. Supine
C. Supine
D. Prone
92. A nurse is providing instructions to a client and the family regarding home care after right
eye cataract removal. Which statement by the client would indicate an understanding of the
instructions:
A. “I should not sleep on my left side.”
B. “I should not sleep on my right side.”
C. “I should not sleep with my head elevated.”
D. “I should not wear my glasses at any time.”
93. The day after an amputation, the client begins to haemorrhage from his stump. What action
should the nurse take first:
A. Apply a pressure dressing to the stump
B. Place a tourniquet above the stump
C. Notify the physician
D. Apply an ice pack to the stump
94. A 72-year-old male client has a total hip replacement for long-standing degenerative bone
disease of the hip. When assessing this client postoperatively, the nurse considers that the most
common complication of hip surgery is:
A. Pneumonia
B. Wound infection
C. Hemorrhage
D. Pulmonary embolism
95. The nurse is caring for a client who had a right below-the-knee amputation three days ago.
The client complains of pain in the right foot and asks for pain medication. What nursing action
is appropriate initially?
A. Elevate the stump
B. Administer a placebo
C. Administer ordered medications
D. Encourage the client to discuss his feelings
96. During the assessment of an injury for a possible fracture, which of the following
manifestations would make you suspicious that a fracture has occurred:
A. Impaired sensation
B. Loss of function
C. Hotness
D. Pointed tenderness
97. A client who has had an above-the-knee amputation develops a dime-sized bright red spot
on the dressing after 45 minutes in the postanesthesia recovery unit. The nurse should:
A. Elevate the stump
B. Reinforce the dressing
C. Call the surgeon
D. Draw a mark around the site
98. How you will interfere to relieve swelling of the lower extremity in a cast for 3 days now:
A. Change the cast
B. Call the doctor
C. Elevate the extremity
D. Call the doctor
99. The nurse is developing a bowel-retraining plan for a client with multiple sclerosis. Which
measure is likely to be least helpful to the client:
A. Limiting fluid intake to 1000mL per day
B. Providing a high-roughage diet
C. Elevating the toilet seat for easy access
D. Establishing a regular schedule for toileting
100. A diabetic patient with foot gangrene undergone above knee amputation, while the nurse
changing the dressing he complains of pain on the same knee which was amputated. What
should the nurse do:
A. Inform physician about it
B. Re-do dressing to Assessment the wound
C. Psychiatry consultation to the patient because he wound above knee
D. Give analgesic as needed
101. A diabetic patient with foot gangrene undergone above knee amputation he complain of
pain and swelling at the wound site which is oozing bus and has a bad odor, the physician
ordered cephalexin and metronidazole. Which of the following you should do immediately:
A. Give cephalexin direct first action
 B. Give metronidazole direct first action
C. Do wash on wound with N/Sand put bacitracin
D. Do wash on wound with N/Sand put hydrocortisone
102. The physician has prescribed a cleansing enema to a client scheduled for colon surgery.
The nurse would place the client:
A. Prone
B. Supine
C. Leftsim’s ( left lateral )
D. Dorsal recumbent
103. At which side of the patient will the nurse stand when inserting a rectal enema:
A. Right side
B. Left side
C. Any side
D. Both sides
104. While undergoing a soapsuds enema, the client complains of abdominal cramping. The
nurse should:
A. Immediately stop the infusion
B. Lower the height of the enema container
C. Advance the enema tubing 2 to 3 inches
D. Clamp the tubing
105. The nurse must administer an enema to an adult patient with constipation. Which of the
following would be a safe and effective distance for the nurse to insert the tubing into the
patient's rectum:
A. 1:2 cm
B. 3:4 cm
C. 5.5:6.5 cm
D. 6.5:8 cm
106. The nurse is caring for a patient receiving IV furosemide (Lasix) 40 mg and Enalapril
(Vasotec) 5 mg PO bid for ADHF with severe orthopnea. When evaluating the patient response
to the medications, the best indicator that the treatment has been effective is:
A. Weight loss of 2 pounds overnight.
B. Improvement in hourly urinary output.
C. Reduction in systolic bp.
D. Decreased dyspnea with the head of the bed at 30 degrees.
107. The nurse in preparing to insert RYLE’S tube (NGT) into an infant, the nurse knows that the
length of the tube should be taken as following:
A. From the nose down to the chin and then to the umbilicus
B. From the nose to the earlobe and then to the xiphoid process
C. From the nose to the mouth to the xiphoid process
 D. From the nose to the earlobe to the umbilicus
108. The nurse is caring for a client who has had a chest tube inserted and connected to water
seal drainage. The nurse determines the drainage system is functioning correctly when which of
the following is observed:
A. Continuous bubbling in the water seal chamber
B. Fluctuation in the water seal chamber
C. Suction tubing attached to a wall unit
D. Vesicular breath sounds throughout the lung fields
109. The nurse is caring for a client who has just had a chest tube attached to a water seal
drainage system. To ensure that the system is functioning effectively the nurse should:
A. Observe for intermittent bubbling in the water seal chamber
B. Flush the chest tubes with 30-60 ml of NSS every 4-6 hours
C. Maintain the client in an extreme lateral position
D. Strip the chest tubes in the direction of the client
110. The nurse enters the room of a client who has a chest tube attached to a water seal
drainage system and notices the chest tube is dislodged from the chest. The most appropriate
nursing intervention is to:
A. Notify the physician
B. Insert a new chest tube
C. Cover the insertion site with petroleum gauze
D. Instruct the client to breathe deeply until help arrives
111. which type of isolation category is indicated for patient with tuberculosis:
A. Airborne isolation
B. Strict isolation
C. Reverse isolation
D. Contact isolation
112. While attempting to get out of bed, a patient accidentally disconnects the chest tube from
the Pleur-evac drainage system. Which of the following actions should the nurse take first?
A. Insert the end of the chest tube in a container of sterile solution
B. Clamp the chest tube near the Pleur-evac drainage system
C. Raise the end of the chest tube above the level of the insertion of the chest tube
D. Apply pressure dressing to the chest tube insertion site
113. which type of isolation category is indicated for a burn patient:
A. Airborne isolation
B. Strict isolation
C. Reverse isolation
D. No isolation required
114. which type of isolation category is indicated for patient with diphtheria:
A. Airborne
 B. Droplet
C. Blood
D. Contact
115. A 68-years-old woman diagnosed with thrombocytopenia due to acute lymphocytic
leukemia is admitted to the hospital. The nurse should assign the patient to a:
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A. To a private room so she will not infect other patients and health care workers.
B. To a private room so she will not be infected by other patients and health care workers.
C. To a semiprivate room so she will have stimulation during her hospitalization.
D. To a semiprivate room so she will have the opportunity to express her feelings about her
illness.
116. A nurse who begins to administer medications to a client via a nasogastric feeding tube
suspects that the tube has become clogged. The nurse should take which safe action first:
A. Aspirate the tube
B. Flush the tube with warm water
C. Prepare to remove and replace the tube
D. Flush with a carbonated liquid such as cola
117. Which of the following instructions is appropriate for the nurse to give to a female client a
who complains of abdominal upset after cholecystectomy operation:
A. Increase fluid intake
B. Avoid fatty meals
C. Increase protein intake
D. Daily exercise
118. Which of the following pulses should be checked before administrating Digoxin:
A. Apical pulse
B. Radial pulse
C. Femoral pulse
D. Dorsalispedis pulse
119. Which of the following pulses should be checked before administrating Digoxin:
A. Apical pulse
B. Radial pulse
C. Femoral pulse
D. Dorsalispedis pulse
120. which of the following interventions must the nurse take when administrating digoxin to
the patient:
A. Give him the medication with a glass of orange juice
B. Check him for signs of hypokalemia before giving the medication
C. Instruct him to place the medication under the tongue
 D. Withhold the medication if his pulse is less than 60 beats/ minute
121. The nurse must withhold Digoxin from a patient if his pulse rate is:
A. Less than 45/m
B. More than 60/m
C. Less than 60/m
D. More than 100/m
122. The nurse is assessing the client for possible evidence of digitalis toxicity. The nurse
acknowledges that which is included in the signs and symptoms for digitalis toxicity:
A. Pulse (heart) rate of 100 beats/min
B. Pulse of 72 with an irregular rate
C. Pulse greater than 60 beats/min and irregular rate
D. Pulse below 60 beats/min and irregular rate
123. A newly admitted client takes digoxin 0.25 mg/day. The nurse knows that the serum
therapeutic range for digoxin is:
0.1 to 1.5 ng/mL
0.5 to 2.0 ng/mL
1.0 to 2.5 ng/mL
2.0 to 4.0 ng/mL
124. A patient complains of severe pain which he stated to be 9/10, the physician ordered
morphine 50 mg IV every 4 hours, the last dose was given 2 hours ago, what is the best action
his caring nurse would take:
A. Give another dose of morphine
B. Inform the doctor to change the order
C. Distract the patient by TV, radio or games for 2 hour
D. Ignore the patient completely
125. The nurse is caring for a patient admitted 1 week agowith an acute spinal cord injury.
Which of the following assessment findings would alert the nurse to the presence of autonomic
dysreflexia (hyperreflexia)?
A. Tachycardia
B. Hypotension
C. Hot, dry skin
D. Throbbing headache
126. Which of the following is the best way for long term feeding for a patient experiencing
severe dysphagia:
A. NGT
B. Naso-dudenal tube
C. Gastrostomy
D. Parenteral
127. Patient records are as following, he had 650cc of IV fluid (n/s), 50 ml of orange Juice in the
NG tube, 100 water with the medications, and urinate 500 cc, and 100 cc collected in the NG
bag. What is the total intake for this patient?
A. 800 cc
B. 650 cc
C. 200 cc
D. 600 cc
128. The physician ordered to give the patient 10,000 unit of heparin, the preparation available
is 40,000/ml. how much would the nurse give this patient:
A. 4 ml
B. 2.5 ml
C. 0.25 ml
D. 25 ml
129. The nurse is caring for a client with a fracture. The client develops a deep vein thrombosis
in the opposite extremity. Physician orders include a heparin drip of D5W 250 mL with heparin
12,500 units at 16 mL/hr. How many units of heparin is this client receiving per hour:
200 unit/h
400 unit/h
600 unit/h
800 unit/h
130. A patient suffers from diarrhea and muscle weakness, the nurse would assess this patient
for which of the following abnormal laboratory blood tests:
A. Blood calcium
B. Blood magnesium
C. Blood potassium
D. Blood sodium
131. When assessing for therapeutic effects of mannitol, the nurse would expect to see:
A. Decreased intracranial pressure
B. Decreased excretion of therapeutic medications
C. Increased urine osmolality
D. Decreased serum osmolality
132. Which drug would be used to treat a patient who has increased intracranial pressure (ICP)
resulting from head trauma after an accident:
A. Mannitol
B. Atropine sulfate
C. Epinephrine hydrochloride
D. Sodium bicarbonate
133. Which of the following is the drug of choice for treatment of cerebral edema:
A. Mannitol
B. Atropine sulfate
C. Epinephrine hydrochloride
 D. Sodium bicarbonate
134. The nurse would assess which laboratory value to determine the effectiveness of
intravenous heparin:
A. Complete blood count (CBC)
B. Activated partial thromboplastin time (aPTT)
C. Prothrombin time (PT)
BUN
135. The antidote to heparin is:
A. Aspirin
B. Vitamin k
C. Warfarin
D. Protamine sulfate
136. How do we monitor the effectiveness of Coumadin (Warfarin):
A. Monitor vital signs
B. PT/INR
C. Weight
D. Ask the patient how they feel
137. Which medication is used to treat a patient suffering from severe adverse effects of a
narcotic analgesic:
A. Naloxone (Narcan)
B. Acetylcysteine (Mucomyst)
C. Methylprednisolone (Solu-Medrol)
D. Protamine sulfate
138. A patient who has been anticoagulated with warfarin (Coumadin) is admitted with
gastrointestinal bleeding. The nurse will anticipate administering which substance
A. Vitamin E
B. Vitamin K
C. Protamine sulfate
D. Calcium gluconate
139. While admitting a patient for treatment of an acetaminophen overdose, the nurse
prepares to administer which of the following medications to prevent toxicity:
A. Naloxone (Narcan)
B. Acetylcysteine (Mucomyst)
C. Methylprednisolone (Solu-Medrol)
D. Vitamin K
140. If the nurse gave a patient antihypertensive drug that is prescribed for another patient,
what should she do:
A. Ignore what she has done
B. Call urgent CPR
 C. Document that in nursing report
D. Inform doctor after 2 days
141. When a physician orders an arterial blood gas, which artery is the appropriate one to use
to obtain the specimen:
A. Cerebral artery
B. Radial artery
C. Carotid artery
D. Ulnar artery
142. A client has an order to have a set of arterial blood gases (ABG's) drawn. The intended site
is the radial artery. The nurse ensures that which of the following is positive before the ABGs are
drawn
A. Homan’s sign
B. Brudzinski's sign
C. Babinski reflex
D. Allen's test
143. A client is scheduled for blood to be drawn from the radial artery for an ABG
determination. A nurse assists with performing Allen's test before drawing the blood to
determine the adequacy of the:
A. Ulnar circulation
B. Carotid circulation
C. Femoral circulation
D. Brachial circulation
144. A nurse has administered approximately half of an enema solution to a preoperative client
when the client complains of pain and cramping. Which nursing action is the most appropriate:
A. Raise the enema bag so that the solution can be instilled quickly.
B. Clamp the tubing for 30 seconds and restart the flow at a slower rate.
C. Reassure the client and continue the flow.
D. Discontinue the enema and notify the physician
145. When caring for a client who is receiving total parenteral nutrition (TPN), which of the
following complications would be most important for the nurse to assess:
A. Chest pain
B. Hemorrhage and air embolus
C. Pneumonia and hyperglycemia
D. Electrolyte imbalance and sepsis
146. A client has a nasogastric tube after a gastric resection. The nurse should expect to
observe:
A. Vomiting
B. Gastric distention
C. Intermittent periods of diarrhea
D. Bloody drainage for the first 12 hours
147. While assessing a client with hypoparathyroidism, the nurse taps the client's facial nerve
and observes twitching of the mouth and tightening of the jaw. The nurse would document this
finding as which of the following:
A. Positive Trousseau's sign
B. Positive Chvostek's sign
C. Tetany
D. Hyperactive deep tendon reflex
148. Which of the following clinical manifestations of type 2 diabetes occurs if glucose levels
are very high:
A. Hyperactivity
B. Blurred vision
C. Oliguria
D. Increased energy
149. Which of the following would the nurse expect to find in a client with severe
hyperthyroidism:
A. Tetany
B. Buffalo hump
C. Exophthalmos
D. Striae
150. A client is receiving long-term treatment with high-dose corticosteroids. Which of the
following would the nurse expect the client to exhibit:
A. Weight loss
B. Pale thick skin
C. Hypotension
D. Moon face