1.

The nurse is teaching a mother whose daughter has

iron-deficiency anemia. The nurse determines the parent
understood the dietary modifications if she selects?

a)  Bread and coffee

b)  Fish and Pork meat
c)  Cookies and milk
d)  Oranges and green leafy vegetables

2. Which of the following is the most common clinical

manifestation of G6PD following ingestion of aspirin?

a) Kidney failure
b) Acute hemolytic anemia
c) Hemophilia A
d) Thalassemia
 
3. The nurse assesses a client with an ileostomy for
possible development of which of the following acid-base
imbalances?

a)  Respiratory acidosis
b)  Metabolic acidosis
c)  Metabolic alkalosis
d)  Respiratory alkalosis

4. The nurse anticipates which of the following responses

in a client who develops metabolic acidosis.

a)  Heart rate of 105 bpm

b)  Urinary output of 15 ml
c)  Respiratory rate of 30 cpm
d)  Temperature of 39 degree Celsius
 
 5. A client has a phosphorus level of 5.0mg/dL. The nurse
closely monitors the client for?

a)  Signs of tetany

b)  Elevated blood glucose
c)  Cardiac dysrhythmias
d)  Hypoglycemia

6. A nurse is caring for a child with pyloric stenosis. The

nurse would watch out for symptoms of?

a)  Vomiting large amounts

b)  Watery stool
c)   Projectile vomiting
d)  Dark-colored stool

7. The nurse responder finds a patient unresponsive in his

house. Arrange steps for adult CPR.
a)  Assess consciousness
b)  Give 2 breaths
c)  Perform chest compression
d)  Check for serious bleeding and shock
e)  Open patient’s airway
f)   Check breathing

___, ___, ___, ___, ___, ___

8. Which of the following has mostly likely occurred when

there is continuous bubbling in the water seal chamber of
the closed chest drainage system?

a)  The connection has been taped too tightly

b)  The connection tubes are kinked
c)  Lung expansion
d)  Air leak in the system
 
9. Which if the following young adolescent and adult male
clients are at most risk for testicular cancer?

a)  A basketball player who wears supportive gear during

basketball games
b)  Teenager who swims on a varsity swim team
c)  20-year-old with undescended testis
d)  Patient with a family history of colon cancer

10. The nurse plans to frequently assess a post-

thyroidectomy patient for?

a)   Polyuria
b)   Hypoactive deep tendon reflex
c)    Hypertension
d)   Laryngospasm

11. An 18-month-old baby appears to have a rounded

belly, bowlegs and a slightly large head. The nurse
concludes?

a)   The child appears to be a normal toddler

b)   The child is developmentally delayed
c)   The child is malnourished
d)   The child’s large head may have neurological
problems.
 
13. An appropriate instruction to be included in the
discharge teaching of a patient following a spinal fusion
is?

a)  Don’t use the stairs

b)  Don’t bend at the waist
c)   Don’t walk for long hours
d)   Swimming should be avoided
14. A nurse is preparing to give an IM injection of Iron
Dextran that is irritating to the subcutaneous tissue. To
prevent irritation to the tissue, what is the best action to be
taken?

a)   Apply ice over the injection site

b)  Administer drug at a 45-degree angle
c)  Use a 24-gauge-needle
d)  Use the z-track technique

15. What should a nurse do prior to taking the patient’s

history?

a)  Offer the patient a glass of water

b)  Establish rapport
c)   Ask the patient to disrobe and put on a gown
d)  Ask pertinent information for insurance purposes

16. A pregnant woman is admitted for pre-eclampsia. The

nurse would include in the health teaching that
magnesium will be part of the medical management to
accomplish the following?

a)     Control seizures

b)    promote renal perfusion
c)     To decrease sustained contractions
d)    Maintain intrauterine homeostasis

17. A nurse is going to administer ear drops to a 4-year-

old child. What is the correct way of instilling the medicine
after tilting the patient’s head sidewards?
 
a)  Pull the pinna back then downwards
b)  Pull the pinna back then upwards
c)  Pull the pinna up then backwards
d)  Pull the pinna down then backwards

18. A nursing student was intervened by the clinical

instructor if which of the following is observed?

a)  Inserting a nasogastric tube

b)  Positioning the infant in a “sniffing “position
c)  Suctioning first the mouth, then the nose
d)  Squeezing the bulb syringe to suction the mouth

19. Choose amongst the options illustrated below that

best describes the angle for an intradermal injection?
 
20. During a basic life support class, the instructor said
that blind finger sweeping is not advisable for infants.
Which among the following could be the reason?

a)  The mouth is still too small

b)  The object may be pushed deeper into the throat
c)  Sharp fingernails might injure the victim
d)  The infant might bite

21. A nurse enters a room and finds a patient lying on the

floor. Which of the following actions should the nurse
perform first?

a)   Call for help

b)   Establish responsiveness of the patient
c)   Ask the patient what happened
d)   Assess vital signs
 
22. A patient with complaints of chest pain was rushed to
the emergency department. Which priority action should
the nurse do first?

a)   Administer morphine sulfate intravenously

b)  Initiate venous access by performing venipuncture
c)   Administer oxygen via nasal cannula
d)  Complete physical assessment and patient history

23. A rehab nurse reviews a post-stroke patient’s

immunization history. Which immunization is a priority for a
72-year-old patient?

a)   Hepatitis A vaccine

b)  Hepatitis B vaccine
c)  Rotavirus Vaccine
d)  Pneumococcal Vaccine
 
24. Several patients from a reported condominium fire
incident were rushed to the emergency room. Which
should the nurse attend to first?

a)   A 15-year-old girl, with burns on the face and chest,

reports hoarseness of the voice
b)  A 28-year-old man with burns on all extremities
c)  A 4-year-old child who is crying inconsolably and
reports a severe headache
d)  A 40-year-old woman with complaints of severe pain
on the left thigh

25. The doctor ordered 1 pack of red blood cells (PRBC)

to be transfused to a patient.  The nurse prepares the
proper IV tubing. The IV tubing appropriate for blood
transfusion comes with?
a)   Air vent
b)   Microdrip chamber
c)   In-line filter
d)   Soluset

26. The expected yet negative (harmful ) result for post

hemodialysis is a decrease in?

a)   Creatinine
b)   BUN
c)   Phosphorus
d)   Red blood cell count
 
27. A patient was brought to the emergency room after
she fell down the stairs. Which of the following is the best
indicator for increased intracranial pressure in the head
and spinal injury?

a)  Inability to move extremities

b)  Decreased respiratory rate
c)  Increase in pulse and blood pressure
d)  Decrease level of consciousness

28. A new nurse is administering an enema to a patient.

The senior nurse should intervene if the new nurse?

a)  Hangs the enema bag 18 inches above the anus

b)  Positions the client on the right side
c)  Advances the catheter 4 inches into the anal canal
d)  Lubricates 4 inches of the catheter tip

29. The medication nurse is going to give a patient his

morning medications. What is the primary action a nurse
should do before administering the medications?

a)  Provide privacy
b)  Raise the head of the bed
c)  Give distilled water
d)  Check the client’s identification bracelet

30. A 30-year-old client is admitted with inflammatory

bowel syndrome (Crohn’s disease). Which of the following
instructions should the nurse include in the health
teaching? Select all that apply

a)  Corticosteroid medication is part of the treatment

b)  Include milk in the diet
c)  Aspirin should be administered
d)  Antidiarrheal medication can help
 
1. The nurse anticipates which of the following responses
in a client who develops metabolic acidosis.

A. Heart rate of 105 bpm

B. Urinary output of 15 ml
C. Respiratory rate of 30 cpm
D. Temperature of 39 degree Celsius

2. The nurse responder finds a patient unresponsive in his

house. Arrange steps for adult CPR.

A. Assess consciousness
B. Give 2 breaths
C. Perform chest compression
D. Check for serious bleeding and shock
E. Open patient’s airway
F. Check breathing

3. An appropriate instruction to be included in the

discharge teaching of a patient following a spinal fusion
is?

A. Don’t use the stairs

B. Don’t bend at the waist
C. Don’t walk for long hours
D. Swimming should be avoided

4. A nurse is preparing to give an IM injection of Iron

Dextran that is irritating to the subcutaneous tissue. To
prevent irritation to the tissue, what is the best action to be
taken?

A. Apply ice over the injection site

B. Administer drug at a 45-degree angle
C. Use a 24-gauge-needle
D. Use the z-track technique

5. During a basic life support class, the instructor said that

blind finger sweeping is not advisable for infants. Which
among the following could be the reason?

A. The mouth is still too small

B. The object may be pushed deeper into the throat
C. Sharp fingernails might injure the victim
D. The infant might bite

6. A patient with complaints of chest pain was rushed to

the emergency department. Which priority action should
the nurse do first?

A. Administer morphine sulfate intravenously
B. Initiate venous access by performing venipuncture
C. Administer oxygen via nasal cannula
D. Complete physical assessment and patient history

7. Several patients from a reported condominium fire

incident were rushed to the emergency room. Which
should the nurse attend to first?

A. A 15-year-old girl, with burns on the face and chest,

reports hoarseness of the voice
B. A 28-year-old man with burns on all extremities
C. A 4-year-old child who is crying inconsolably and
reports severe headache
D. A 40-year-old woman with complaints of severe pain on
the left thigh

8. A new nurse is administering an enema to a patient.

The senior nurse should intervene if the new nurse?

A. Hangs the enema bag 18 inches above the anus

B. Positions the client on the right side
C. Advances the catheter 4 inches into the anal canal
D. Lubricates 4 inches of the catheter tip

9. The 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

10. The 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 scores 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.

11, 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

12. The mother of a child with bronchial asthma tells the

nurse that the child wants a pet. Which of the following
pets is most appropriate?

A. Cat
B. Fish
C. Gerbil
D. Canary

13. A client with a fractured leg has been instructed to

ambulate without weight bearing on the affected leg. The
nurse evaluates that the client is ambulating correctly if
she uses which of the following crutch-walking gaits?

A. Two-point gait
B. Four-point gait
C. Three-point gait
D. Swing-to gait

14. Older adults with known cardiovascular disease must

balance which of the following measures for optimum
health?

A. Diet, exercise, and medication

B. Stress, hypertension, and pain
C. Mental health, diet, and stress
D. Social events, diet, and smoking

15. A client whose condition remains stable after a

myocardial infarction gradually increases his activity.
Which of the following conditions should the nurse assess
to determine whether the activity is appropriate for the
client?

A. Edema
B. Cyanosis
C. Dyspnea
D. Weight loss

16. Which of the following is an adverse effect of

vancomycin (Vancocin) and needs to be reported
promptly?

A. Vertigo
B. Tinnitus
C. Muscle stiffness
D. Ataxia
17. When performing an otoscopic examination of the
tympanic membrane of a 2-year-old child, the nurse
should pull the pinna in which of the following directions?

A. Down and back

B. Down and slightly forward
C. Up and back
D. Up and forward

18. A client has his leg immobilized in a long leg cast.

Which of the following assessments indicates the early
beginning of circulatory impairment?

A. Inability to move toes.

B. Cyanosis of toes.
C. Complaints of cast tightness.
D. Tingling of toes.

19. Which of the following baseline laboratory data should

be established before a client is started on tissue
plasminogen activator or alteplase recombinant
(Activase)?

A. Potassium level
B. Lee-White clotting time
C. Hemoglobin level, hematocrit, and platelet count
D. Blood glucose level

20. The antidote for heparin is:

A. Vitamin K
B. Warfarin (Coumadin)
C. Thrombin
D. Protamine sulfate

21. Which of the following sounds should the nurse expect

to hear when percussing a distended bladder?

A. Hyperresonance
B. Tympany
C. Dullness
D. Flatness

22. The nurse observes a darkish blue pigment on the

buttocks and back of an African American neonate. Which
of the following actions is most appropriate?

A. Ask the obstetrician to assess the child.

B. Assess the child for other areas of cyanosis.
C. Document this observation in the child’s record.
D. Advise the mother that laser therapy is needed.
23. The nurse is caring for a client who has severe burns
on the head, neck, trunk, and groin areas. Which position
would be most appropriate for preventing contractures?

A. High Fowler’s.
B. Semi-Fowler’s.
C. Prone.
D. Supine.

24. While assessing a 4-day-old neonate delivered at 28

weeks gestation, the nurse cannot elicit the neonate’s
Moro reflex, which was present 1 hour after birth. The
nurse notifies the physician because this may indicate
which of the following?

A. Postnatal asphyxia.
B. Skull fracture.
C. Intracranial hemorrhage.
D. Facial nerve paralysis

25. Which of the following factors can alter tissue

tolerance and lead to the development of a pressure
ulcer?

A. The client’s age.

B. Exposure to moisture.
C. Presence of hypertension.
D. Smoking.

26. Which of the following types of restraints is best for the

nurse to use for a child in the immediate postoperative
period after cleft palate repair?

A. Safety jacket.
B. Elbow restraints.
C. Wrist restraints.
D. Body restraints.

27. A client in severe respiratory distress is admitted to the

hospital. When assessing the client, the nurse should:

A. Conduct a complete health history.

B. Complete a comprehensive physical examination.
C. Delay assessment until the client’s respiratory distress
is resolved.
D. Focus assessment on the respiratory system and
distress.

28. A client has had a total hip replacement. Which of the

following signs most likely indicates that the hip has
dislocated?
A. Abduction of the affected leg.
B. Loosening of the prosthesis.
C. External rotation of the affected leg.
D. Shortening of the affected leg.

29. A 25-year-old has been diagnosed with hypertrophic

cardiomyopathy. The nurse should assess

the client for:

A. Angina.
B. Fatigue and shortness of breath.
C. Abdominal pain.
D. Hypertension.

30. What is the priority nursing intervention for a client

who is admitted to the emergency department with burns
over an estimated 27% of the body surface area?

A. Insert a large-caliber I.V. line.

B. Administer morphine intramuscularly.
C. Establish an airway.
D. Administer tetanus toxoid.
1. 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”.

2. The 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.

3. The 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

4. 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.

5. The 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

6. The 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.

7. The 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 the 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 the drainage system at the level of the client’s
chest

8. The client with DKA is receiving bicarbonate IV infusion

for the 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 levels.
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

9. The 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 a 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.

10. The nurse is providing home instructions to a client

with an 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

11. The 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

12. The 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. Amputation
f. Delayed healing

13. Nursing 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 the client’s stockings or socks.
d. Manually compress or tap the bladder to allow urine to
flow down the catheter.
e. Administer prescribed vasodilators.

14. Neurologic conditions can be manifested by changes

in breathing patterns. The client presents with symptoms
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

15. The 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.

16. The 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.

17. An 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

18. The 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.

19. The 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 the required immunizations.
d. Avoiding any throat examination or agitation of the
child.

20. The 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

21. The nurse is to administer Meperidine (Demerol) 35

mg through the intramuscular route. Available meperidine
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

22. The client presented with a 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 the electrolyte
level of the client
c. Switch the client to a loop diuretic
d. Give the client a non-steroidal anti-inflammatory drug
(NSAID)

23. The 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

24. The 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

25. The 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

26. Chemotherapy 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 the 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.

27. 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

28. The 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 a dry desquamation present.
d. The skin is reddened.

29. The nurse is assessing the muscle coordination and

mobility of the client with a 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

30. 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 the hip level.
c. Swivel the body when moving the client.
d. Move the client with a wide base and straight knees.
1. A patient who is in isolation needs a temperature taken
several times a day. Where is the appropriate place for the
thermometer to be kept?

A. At the nurses’ station.

B. On the isolation cart outside the patient’s room.
C. In the dirty utility room.
D. In the patient’s room.

2. Which of the following best describes how persons

affected by Parkinson’s disease typically walk?

A. Long, steady gaits

B. They shuffle their feet while taking small steps
C. Fast movement of the feet
D. Always needs support from assistive devices

3. A male patient with a right pleural effusion noted on a

chest X-ray is being prepared for thoracentesis. The
patient experiences severe dizziness when sitting upright.
To provide a
safe environment, the nurse assists the patient to which
position for the procedure?

A. Prone with head turned toward the side supported by a

pillow
B. Sims’ position with the head of the bed flat
C. Right side-lying with the head of the bed elevated 45
degrees
D. Left side-lying with the head of the bed elevated 45
degrees

4. A patient is experiencing pain during the first stage of

labor. What should the nurse instruct the patient to do to
manage her pain? Select all that apply

A. Walk in the hospital room.

B. Use slow chest breathing.
C. Request pain medication on a regular basis.
D. Lightly massage her abdomen.
E. Sip ice water.

5. The nurse is monitoring a child with burns during

treatment for burn shock. Which
assessment provides the most accurate guide to
determine the adequacy of fluid
resuscitation?

A. Skin turgor
B. Level of edema at burn site
C. Adequacy of capillary filling
D. Amount of fluid tolerated in 24 hours
 6. Which of the following structures should be closed by
the time the child is 2 months old?

1. A.       2. B.     3. C.      4. D.

7. The nurse is evaluating an infant who has an

intravenous infusion secured to a sandbag (see figure).
The nurse should:

A. Add tape to cover the toe.

B. Secure the right leg to a sandbag.
C. Check the infusion rate every hour.
D. Change the sandbag to an extremity restraint

8. The nurse is assessing a patient who has had a

myocardial infarction (MI). The nurse notes the cardiac
rhythm shown on the electrocardiogram strip below. The
nurse identifies this rhythm as which of the following?

A. Atrial fibrillation.
B. Ventricular tachycardia.
C. Premature ventricular contractions (PVCs).
D. Third-degree heart block.

9. The nurse is assessing a patient who has had a

myocardial infarction. The nurse notes the cardiac rhythm
shown on the electrocardiogram strip below. The nurse
identifies this rhythm as which of the following?

A. Atrial fibrillation.
B. Ventricular tachycardia.
C. Premature ventricular contractions.
D. Sinus tachycardia.

10. The patient admitted with peripheral vascular disease

(PVD) asks the nurse why her legs hurt when she walks.
The nurse bases a response on the knowledge that the
main characteristic of PVD is:

A. Decreased blood flow.

B. Increased blood flow.
C. Slow blood flow.
D. Thrombus formation.

11. A patient is scheduled to undergo right axillary-to-

axillary artery bypass surgery. Which of the following
interventions is most important for the nurse to implement
in the preoperative period?

A. Assess the temperature in the affected arm.

B. Monitor the radial pulse in the affected arm.
C. Protect the extremity from cold.
D. Avoid using the arm for a venipuncture.

12. When giving discharge instructions to the patient with

vasospastic disorder (Raynaud’s phenomenon), the nurse
should explain that the expected outcome of taking a beta
adrenergic blocking medication is to control the symptoms
by:

A. Decreasing the influence of the sympathetic nervous

system on the tissues in the hands and feet.
B. Decreasing the pain by producing analgesia.
C. Increasing the blood supply to the affected area.
D. Increasing monoamine oxidase.

13. The patient is admitted with left lower leg pain, a

positive Homans’ sign, and a temperature of 100.4° F (38°
C). The nurse should assess the patient further for signs
of:

A. Aortic aneurysm.
B. Deep vein thrombosis (DVT) in the left leg.
C. I.V. drug abuse.
D. Intermittent claudication.

14. A patient has sudden, severe pain in his back and

chest, accompanied by shortness of breath. The patient
describes the pain as a “tearing” sensation. The physician
suspects the patient is experiencing a dissecting aortic
aneurysm. The code cart is brought into the room because
one complication of a dissecting aneurysm is:

A. Cardiac tamponade.
B. Stroke.
C. Pulmonary edema.
D. Myocardial infarction.

15. A nurse is teaching a patient about taking

antihistamines. Which of the following instructions should
the nurse include in the teaching plan? Select all that
apply.

A. Operating machinery and driving may be dangerous

while taking antihistamines.
B. Continue taking antihistamines even if nasal infection
develops.
C. The effect of antihistamines is not felt until a day later.
D. Do not use alcohol with antihistamines.
E. Increase fluid intake to 2,000 mL/day.

16. A patient who has had a total laryngectomy appears

withdrawn and depressed. He keeps the curtain drawn,
refuses visitors, and indicates a desire to be left alone.
Which nursing intervention would most likely be
therapeutic for the patient?

A. Discussing his behavior with his wife to determine the

cause.
B. Exploring his future plans.
C. Respecting his need for privacy.
D. Encouraging him to express his feelings nonverbally
and in writing.

17. A 79-year-old female patient is admitted to the hospital

with a diagnosis of bacterial pneumonia. While obtaining
the patient’s health history, the nurse learns that the
patient has osteoarthritis, follows a vegetarian diet, and is
very concerned with cleanliness. Which of the following
would most likely be a predisposing factor for the
diagnosis of pneumonia?

A. Age.
B. Osteoarthritis.
C. Vegetarian diet.
D. Daily bathing

18. Which of the following symptoms is common in

patients with active tuberculosis?

A. Weight loss.
B. Increased appetite.
C. Dyspnea on exertion.
D. Mental status changes.

19. A patient experiencing a severe asthma attack has the

following arterial blood gas: pH 7.33; PCO2 48; PO2 58;
HCO3 26. Which of the following orders should the nurse
perform first?

A. Albuterol (Proventil) nebulizer.

B. Chest x-ray.
C. Ipratropium (Atrovent) inhaler.
D. Sputum culture.

20. A female patient diagnosed with lung cancer is to have

a left lower lobectomy. Which of the following increase the
patient’s risk of developing postoperative pulmonary
complications?

A. Height is 5 feet, 7 inches and weight is 110 lb.

B. The patient tends to keep her real feelings to herself.
C. She ambulates and can climb one flight of stairs
without dyspnea.
D. The patient is 58 years of age.
21. The nurse is assessing a patient who has a chest tube
connected to a water-seal chest tube drainage system.
According to the illustration shown, which should the
nurse do?

A. Clamp the chest tube near the insertion site to prevent

air from entering the pleural cavity.
B. Notify the physician of the amount of chest tube
drainage.
C. Add water to maintain the water seal.
D. Lower the drainage system to maintain gravity flow.

22. A patient has entered a smoking cessation program to

quit a two-pack-a-day cigarette habit. He tells the nurse
that he has not smoked a cigarette for 3 weeks, but is
afraid he is going to “slip up” and smoke because of
current job pressures. What would be the most
appropriate reply for the nurse to make in response to the
patient’s comments?

A. “Don’t worry about it. Everybody has difficulty quitting

smoking, and you should expect to as well.”
B. “If you increase your self-control, I am sure you will be
able to avoid smoking.”
C. “Try taking a couple of days of vacation to relieve the
stress of your job.”
D. “It is good that you can talk about your concerns. Try
calling a friend when you want to smoke.”

23. The nurse is developing standards of care for a patient

with gastroesophageal reflux disease and wants to review
current evidence for practice. Which one of the following
resources will provide the most helpful information?

A. A review in the Cochrane Library.

B. A literature search in a database, such as the
Cumulative Index to Nursing and Allied Health Literature
(CINHAL).
C. An online nursing textbook.
D. The online policy and procedure manual at the health
care agency.

24. TPN is ordered for a patient with Crohn’s disease.

Which of the following indicate the TPN solution is having
an intended outcome?

A. There is increased cell nutrition.

B. The patient does not have metabolic acidosis.
C. The patient is hydrated.
D. The patient is in a negative nitrogen balance.

25. The nurse notes that the sterile, occlusive dressing on

the central catheter insertion site of a patient receiving
total parenteral nutrition (TPN) is moist. The patient is
breathing easily with no abnormal breath sounds. The
nurse should do the following in order of what priority from
first to last?

A. Change dressing per institutional policy.

B. Culture drainage at insertion site.
C. Notify physician.
D. Position rolled towel under patient’s back, parallel to
the spine.

26. Serum concentrations of thyroid hormones and

thyroid-stimulating hormone (TSH) are tests ordered for
the patient with thyrotoxicosis. Which of the following
laboratory values are indicative of thyrotoxicosis?

A. Elevated thyroid hormone concentrations and normal

TSH.
B. Elevated TSH and normal thyroid hormone
concentrations.
C. Decreased thyroid hormone concentrations and
elevated TSH.
D. Elevated thyroid hormone concentrations and
decreased TSH.

27. The nurse is checking the laboratory results on a 52-

year-old patient with type 1 diabetes (see chart). What
laboratory result indicates a problem that should be
managed?
A. Blood glucose.
B. Total cholesterol.
C. Hemoglobin.
D. Low-density lipoprotein (LDL) cholesterol.

28. The patient with type 1 diabetes mellitus is taught to

take isophane insulin suspension NPH (Humulin N) at 5
p.m. each day. The patient should be instructed that the
greatest risk of hypoglycemia will occur at about what
time?

A. 11 a.m., shortly before lunch.

B. 1 p.m., shortly after lunch.
C. 6 p.m., shortly after dinner.
D. 1 a.m., while sleeping.

29. Four days after surgery for internal fixation of a C3 to

C4 fracture, a nurse is moving a patient from the bed to
the wheelchair. The nurse is checking the wheelchair for
correct features for this patient. Which of the following
features of the wheelchair are appropriate for the needs of
this patient? Select all that apply.

A. Back at the level of the patient’s scapula.

B. Back and head that are high.
C. Seat that is lower than normal.
D. Seat with firm cushions.
E. Chair controlled by the patient’s breath

30. A patient with multiple sclerosis (MS) is experiencing

bowel incontinence and is starting a bowel retraining
program. Which strategy is inappropriate?

A. Eating a diet high in fiber.

B. Setting a regular time for elimination.
C. Using an elevated toilet seat.
D. Limiting fluid intake to 1,000 mL/day.