1. A sudden redness of the skin is known as: 10.

Which communication skills is most effective in

A. Flush dealing with covert communication?
B. Cyanosis A. Validation
C. Jaundice B. Listening
D. Pallor C. Evaluation
2. The term gavage indicates: D. Clarification
A. Administration of a liquid feeding into the 11. Which of the following qualities are relevant in
stomach documenting patient care?
B. Visual examination of the stomach A. Accuracy and conciseness
C. Irrigation of the stomach with a solution B. Thoroughness and currentness
D. A surgical opening through the abdomen to the C. Organization
stomach D. All of the above
3. A patient states that he has difficulty sleeping in the 12. The usual sequence for assessing the bowel is:
hospital because of noise. Which of the following would A. Right lower quadrant, right upper quadrant, left
be an appropriate nursing action? upper quadrant. left lower quadrant
A. Administer a sedative at bedtime, as ordered by B. Right lower lobe, right upper lobe, left upper
the physician lobe, left lower lobe
B. Ambulate the patient for 5 minutes before he C. Right hypochondriac, left hypochondriac and
retires umbilical regions
C. Give the patient a glass of warm milk before D. Rectum, pancreas, stomach and liver
bedtime 13. The nurse should take a rectal temperature of a
D. Close the patient’s door from 9pm to 7am patient who has:
4. Which of the following nursing theorists dveloped a A. His arm in a cast
conceptual model based on the belief that all persons B. Nasal packing
strive to achieve self-care? C. External hemorrhoids
A. Martha Rogers D. Gastrostomy feeding tubes
B. Dorothea Orem 14. Blood pressure measurement is an important part of
C. Florence Nightingale the patient’s data base. It is considered to be:
D. Cister Callista Roy A. The basis of the nursing diagnosis
5. Which of the following nursing theorists is credited B. Objective data
with developing a conceptual model specific to nursing, C. An indicator of the patient’s well being
with man as the central focus? D. Subjective data
A. Martha Rogers 15. Postural drainage to relieve respiratory congestion
B. Dorothea Orem should take place:
C. Florence Nightingale A. Before meals
D. Sister Callista Roy B. After meals
6. Which of the following questions is most appropriate C. At the nurse’s convenience
to ask when interviewing a potential candidate fo an RN D. At the patient’s convenience
position? 16. The correct site at which to verify a radial pulse
A. What was your last nursing experience? measurement is the:
B. Are you willing to do overtime on weekends? A. Brachial artery
C. How many children do you have? B. Apex of the heart
D. Do you plan to get pregnant? C. Temporal artery
7. If a patient is injured because a nurse acted in a D. Inguinal site
wrongful manner, which party could be held liable along 17. S1 is heard best at the:
with the nurse? A. 5th left intercoastal space along the
A. The private attending physician midclavicular line
B. The nursing supervisor B. 3rd intercoastal space to the left of the
C. The hospital midclavicular line
D. All of the above C. Second right intercoastal space at the sternal
8. Which of the following may be considered a patient’s border
right? D. Second left intercoastal space at the sternal
A. The right to euthanasia border
B. The right to refuse treatment 18. The nurse’s main priority when caring foar a patient
C. The right to ignore hospital regulations with hemiplegia?
D. The right to refuse to pay for what the patient A. Educating the patient
considers to be inferior service. B. Providing a safe environment
9. If a patient sues a nurse for malpractice, the patient C. Promoting a positive self-image
must be able to prove: D. Helping the patient accept the illness
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
19. Constipation is a common problem for immobilized 4. Answer :(B) Dorothea Orem. Dorothea Orem’s
patients because of: conceptual model is based on the premise that
A. Decreased peristalsis and positional discomfort all persons need to achieve self-care. She also
B. An increased defacation reflex views the goal of nursing as helping the patient
C. Decreased tightening of the anal sphincter to develop self-care practices to maintain
D. Increased colon motility maximum wellness.
20. Antiembolism stockings are used primarily to: 5.  Answer :(A) Martha Rogers. Martha Roger’s
A. Promote venous circulation life process model views man as an evolving
B. Provide external warmth creature interacting with the environment in an
C. Prevent dependent edema open, adaptive manner. According to this model,
D. Hold foot dressings the purpose of nursing is to help man achieve
21. To promote correct anatomic alignment in a supine maximum health in his environment.
patient, the nurse should: 6. Answer :(A) What was your last nursing
A. Place the patient’s feet in dorsiflexion experience?. An interviewer’s question should
B. Place a pillow under the patient’s knees center on the applicant’s qualifications for the
C. Hyperextend the patient’s neck position. Questions about the applicant’s
D. Adduct the patient’s shoulder personal life are inappropriate and may be
22. An appropriate interdependent intervention to illegal.
prevent thrombophebitis would be: 7. Answer :(C) The hospital. Under the master
A. Elevate the knee gatch of the bed servant rule (also known as the doctrine or
B. Massage the legs vigorously respondeat superior), when a person is injured
C. Apply antiembolism stockings to both legs. by an employee as a result of negligence in the
D. Encourage the patient to sit with his knees course of the employee’s work, the employer is
crossed responsible to the injured person.
23. The average daily amount of urine excreted by an 8. Answer :(B) The right to refuse
adult is: treatment. Under the bill of rights law, the
A. 500 to 600 ml patient has the right to refuse treatment/life –
B. 800 to 1,400 ml giving measures, to the extent permitted by law,
C. 1,000 to 1,200 ml and to be informed of the medical consequences
D. 1,500 to 2,000 ml of his action.
24. According to Maslow’s hierarchy of needs, which of 9. Answer :(B) Error, injury and proximal
the following is a basic physiologic need after oxygen? cause. Three criteria must be met to establish
A. Activity malpractice: a nursing error, a patient injury, and
B. Safety a connection between the two.
C. Love 10. Answer :(A) Validation. Covert communication
D. Self esteem reflects inner feelings that a person may be
25. Mr. Jose is admitted to the hospitalwith a diagnosis uncomfortable talking about. Such
of pneumonia and COPD. The physician orders an communication may be revealed through body
oxygen therapy for him. The most comfortable method language, silence, withdrawn behavior, or
of delivering oxygen to Mr. Jose is by: crying. Validation is an attempt to confirm the
A. Croupette observer’s perceptions through feedback,
B. Nasal Cannula interpretation and clarification.
C. Nasal catheter 11. Answer :(D) All of the above. Documentation
D. Partial rebreathing mask should leave no room for misinterpretation.
Answers and Rationales Thus, the nurse must ensure that all information
1. Answer : (A) Flush. Flush is a sudden redness of pertinent to patient care is reworded accurately,
the skin. Cyanosis is a slightly bluish, grayish concisely and thoroughly. The information must
skin discoloration caused by abnormal amounts be up-to-date and well organized.
or reduced hemoglobin in the blood. Jaundice is 12. Answer :(A) Right lower quadrant, right upper
a yellow discoloration of the skin, mucous quadrant, left upper quadrant. left lower
membranes and sclerae caused by excessive quadrant. This sequence follows the anatomy of
amounts of bilirubin in the blood. Pallor is an the bowel. The lobes are parts of the lung. the
unnatural paleness or absence of color in the right and left hypochondriac and the umbilical
skin indicating insufficient oxygen and area are three of the nine regions of the
excessive carbon dioxide in the blood. abdomen.
2. Answer :(A) Administration of a liquid feeding 13. Answer :(B) Nasal packing. A rectal temperature
into the stomach. Gavage is the administration is usually recommended whenever an oral
of a liquid feeding into the stomach temperature is contraindicated (e.g. the patient
3. Answer :(C) Give the patient a glass of warm who have undergone oral or nasal surgery,
milk before bedtime. Warm milk will relax the infants and those who have history of seizures,
patient because it contains tryptophan, a natural etc). However, a rectal temperature is
sedative. contraindicated in patients having rectal disease,
rectal surgery or diarrhea)
14. Answer :(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.
15. Answer :(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.
16. Answer :(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.
17. Answer :(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
intercoastal space along the midclavicular line.
(An infant’s apex is located at the third or fourth
intercoastal space just to the left of the
midclavicular line)
18. Answer :(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.
19. Answer :(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.
20. Answer :(A) Promote venous
circulation. Antiembolism stockings are elastic
stockings designed to maintain compression of
small veins and capillaries in the legs.
21. Answer :(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)
22. Answer :(C) Apply antiembolism stockings to
both legs.. Antiembolism stockings increase
venous return to the heart, which helps prevent
thromboplebitis.
23. Answer :(D) 1,500 to 2,000 ml. An adult’s
average urine output ranges between 1,500 and
2,000 ml/day.
24. Answer :(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.
25. Answer :(B) Nasal Cannula. The nasal cannula
is the most comfortable method of delivering
oxygen because it allows the patient to talk, eat
and drink.