SITUATION : Arthur, A registered nurse, witnessed an old woman hit by a motorcycle

while crossing a train railway. The old woman fell at the railway. Arthur rushed at the
scene.

1. As a registered nurse, Arthur knew that the first thing that he will do at the scene is

1. Stay with the person, Encourage her to remain still and Immobilize the leg
while While waiting for the ambulance.
2. Leave the person for a few moments to call for help.
3. Reduce the fracture manually.
4. Move the person to a safer place.

2. Arthur suspects a hip fracture when he noticed that the old woman’s leg is

1. A. Lengthened, Abducted and Internally Rotated.

2. Shortened, Abducted and Externally Rotated.
3. Shortened, Adducted and Internally Rotated.
4. Shortened, Adducted and Externally Rotated.

3. The old woman complains of pain. John noticed that the knee is reddened, warm to
touch and swollen. John interprets that this signs and symptoms are likely related to

1. Infection
2. Thrombophlebitis
3. Inflammation
4. Degenerative disease

4. The old woman told John that she has osteoporosis; Arthur knew that all of the
following factors would contribute to osteoporosis except

1. Hypothyroidism
2. End stage renal disease
 3. Cushing’s Disease
4. Taking Furosemide and Phenytoin.

5. Martha, The old woman was now Immobilized and brought to the emergency room.
The X-ray shows a fractured femur and pelvis. The ER Nurse would carefully monitor
Martha for which of the following sign and symptoms?

1. Tachycardia and Hypotension

2. Fever and Bradycardia
3. Bradycardia and Hypertension
4. Fever and Hypertension

SITUATION: Mr. D. Rojas, An obese 35 year old MS Professor of OLFU Lagro is admitted
due to pain in his weight bearing joint. The diagnosis was Osteoarthritis.

6. As a nurse, you instructed Mr. Rojas how to use a cane. Mr. Rojas has a weakness on
his right leg due to self immobilization and guarding. You plan to teach Mr. Rojas to hold
the cane

1. On his left hand, because his right side is weak.

2. On his left hand, because of reciprocal motion.
3. On his right hand, to support the right leg.
4. On his right hand, because only his right leg is weak.

7. You also told Mr. Rojas to hold the cane

1. 1 Inches in front of the foot.

2. 3 Inches at the lateral side of the foot.
3. 6 Inches at the lateral side of the foot.
4. 12 Inches at the lateral side of the foot.
8. Mr. Rojas was discharged and 6 months later, he came back to the emergency room
of the hospital because he suffered a mild stroke. The right side of the brain was
affected. At the rehabilitative phase of your nursing care, you observe Mr. Rojas use a
cane and you intervene if you see him

1. Moves the cane when the right leg is moved.

2. Leans on the cane when the right leg swings through.
3. keeps the cane 6 Inches out to the side of the right foot.
4. Holds the cane on the right side.

SITUATION: Alfred, a 40 year old construction worker developed cough, night sweats and
fever. He was brought to the nursing unit for diagnostic studies. He told the nurse he did
not receive a BCG vaccine during childhood

9. The nurse performs a Mantoux Test. The nurse knows that Mantoux Test is also
known as

1. PPD
2. PDP
3. PDD
4. DPP

10. The nurse would inject the solution in what route?

1. IM
2. IV
3. ID
4. SC

11. The nurse notes that a positive result for Alfred is

1. 5 mm wheal
 2. 5 mm Induration
3. 10 mm Wheal
4. 10 mm Induration

12. The nurse told Alfred to come back after

1. a week
2. 48 hours
3. 1 day
4. 4 days

13. Mang Alfred returns after the Mantoux Test. The test result read POSITIVE. What
should be the nurse’s next action?

1. Call the Physician

2. Notify the radiology dept. for CXR evaluation
3. Isolate the patient
4. Order for a sputum exam

14. Why is Mantoux test not routinely done in the Philippines?

1. It requires a highly skilled nurse to perform a Mantoux test

2. The sputum culture is the gold standard of PTB Diagnosis and it will
definitively determine the extent of the cavitary lesions
3. Chest X Ray Can diagnose the specific microorganism responsible for the
lesions
4. Almost all Filipinos will test positive for Mantoux Test

15. Mang Alfred is now a new TB patient with an active disease. What is his category
according to the DOH?
 1. I
2. II
3. III
4. IV

16. How long is the duration of the maintenance phase of his treatment?

1. 2 months
2. 3 months
3. 4 months
4. 5 months

17. Which of the following drugs is UNLIKELY given to Mang Alfred during the
maintenance phase?

1. Rifampicin
2. Isoniazid
3. Ethambutol
4. Pyridoxine

18. According to the DOH, the most hazardous period for development of clinical
disease is during the first

1. 6-12 months after

2. 3-6 months after
3. 1-2 months after
4. 2-4 weeks after

19. This is the name of the program of the DOH to control TB in the country
 1. DOTS
2. National Tuberculosis Control Program
3. Short Coursed Chemotherapy
4. Expanded Program for Immunization

20. Susceptibility for the disease [ TB ] is increased markedly in those with the following
condition except

1. 23 Year old athlete with diabetes insipidus

2. 23 Year old athlete taking long term Decadron therapy and anabolic steroids
3. 23 Year old athlete taking illegal drugs and abusing substances
4. Undernourished and Underweight individual who undergone gastrectomy

21. Direct sputum examination and Chest X ray of TB symptomatic is in what level of
prevention?

1. Primary
2. Secondary
3. Tertiary
4. Quarterly

SITUATION: Michiel, A male patient diagnosed with colon cancer was newly put in
colostomy.

22. Michiel shows the BEST adaptation with the new colostomy if he shows which of
the following?

1. Look at the ostomy site

2. Participate with the nurse in his daily ostomy care
3. Ask for leaflets and contact numbers of ostomy support groups
4. Talk about his ostomy openly to the nurse and friends
23. The nurse plans to teach Michiel about colostomy irrigation. As the nurse prepares
the materials needed, which of the following item indicates that the nurse needs further
instruction?

1. Plain NSS / Normal Saline

2. K-Y Jelly
3. Tap water
4. Irrigation sleeve

24. The nurse should insert the colostomy tube for irrigation at approximately

1. 1-2 inches
2. 3-4 inches
3. 6-8 inches
4. 12-18 inches

25. The maximum height of irrigation solution for colostomy is

1. 5 inches
2. 12 inches
3. 18 inches
4. 24 inches

26. Which of the following behavior of the client indicates the best initial step in learning
to care for his colostomy?

1. Ask to defer colostomy care to another individual

2. Promises he will begin to listen the next day
3. Agrees to look at the colostomy
4. States that colostomy care is the function of the nurse while he is in the
hospital
27. While irrigating the client’s colostomy, Michiel suddenly complains of severe
cramping. Initially, the nurse would

1. Stop the irrigation by clamping the tube

2. Slow down the irrigation
3. Tell the client that cramping will subside and is normal
4. Notify the physician

28. The next day, the nurse will assess Michiel’s stoma. The nurse noticed that a
prolapsed stoma is evident if she sees which of the following?

1. A sunken and hidden stoma

2. A dusky and bluish stoma
3. A narrow and flattened stoma
4. Protruding stoma with swollen appearance

29. Michiel asked the nurse, what foods will help lessen the odor of his colostomy. The
nurse best response would be

1. Eat eggs
2. Eat cucumbers
3. Eat beet greens and parsley
4. Eat broccoli and spinach

30. The nurse will start to teach Michiel about the techniques for colostomy irrigation.
Which of the following should be included in the nurse’s teaching plan?

1. Use 500 ml to 1,000 ml NSS

2. Suspend the irrigant 45 cm above the stoma
3. Insert the cone 4 cm in the stoma
4. If cramping occurs, slow the irrigation
31. The nurse knew that the normal color of Michiel’s stoma should be

1. Brick Red
2. Gray
3. Blue
4. Pale Pink

SITUATION: James, A 27 basketball player sustained inhalation burn that required him to
have tracheostomy due to massive upper airway edema.

32. Wilma, His sister and a nurse is suctioning the tracheostomy tube of James. Which
of the following, if made by Wilma indicates that she is committing an error?

1. Hyperventilating James with 100% oxygen before and after suctioning

2. Instilling 3 to 5 ml normal saline to loosen up secretion
3. Applying suction during catheter withdrawal
4. Suction the client every hour

33. What size of suction catheter would Wilma use for James, who is 6 feet 5 inches in
height and weighing approximately 145 lbs?

1. Fr. 5
2. Fr. 10
3. Fr. 12
4. Fr. 18

34. Wilma is using a portable suction unit at home, What is the amount of suction
required by James using this unit?

1. 2-5 mmHg
2. 5-10 mmHg
3. 10-15 mmHg
 4. 20-25 mmHg

35. If a Wall unit is used, What should be the suctioning pressure required by James?

1. 50-95 mmHg
2. 95-110 mmHg
3. 100-120 mmHg
4. 155-175 mmHg

36. Wilma was shocked to see that the Tracheostomy was dislodged. Both the inner
and outer cannulas was removed and left hanging on James’ neck. What are the 2
equipment’s at james’ bedside that could help Wilma deal with this situation?

1. New set of tracheostomy tubes and Oxygen tank

2. Theophylline and Epinephrine
3. Obturator and Kelly clamp
4. Sterile saline dressing

37. Which of the following method if used by Wilma will best assure that the
tracheostomy ties are not too tightly placed?

1. Wilma places 2 fingers between the tie and neck

2. The tracheotomy can be pulled slightly away from the neck
3. James’ neck veins are not engorged
4. Wilma measures the tie from the nose to the tip of the earlobe and to the
xiphoid process.

38. Wilma knew that James have an adequate respiratory condition if she notices that

1. James’ respiratory rate is 18

 2. James’ Oxygen saturation is 91%
3. There are frank blood suction from the tube
4. There are moderate amount of tracheobronchial secretions

39. Wilma knew that the maximum time when suctioning James is

1. 10 seconds
2. 20 seconds
3. 30 seconds
4. 45 seconds

SITUATION : Juan Miguel Lopez Zobel Ayala de Batumbakal was diagnosed with Acute
Close Angle Glaucoma. He is being seen by Nurse Jet.

40. What specific manifestation would nurse Jet see in Acute close angle glaucoma
that she would not see in an open angle glaucoma?

1. Loss of peripheral vision

2. Irreversible vision loss
3. There is an increase in IOP
4. Pain

41. Nurse jet knew that Acute close angle glaucoma is caused by

1. Sudden blockage of the anterior angle by the base of the iris

2. Obstruction in trabecular meshwork
3. Gradual increase of IOP
4. An abrupt rise in IOP from 8 to 15 mmHg

42. Nurse jet performed a TONOMETRY test to Mr. Batumbakal. What does this test
measures
 1. It measures the peripheral vision remaining on the client
2. Measures the Intra Ocular Pressure
3. Measures the Client’s Visual Acuity
4. Determines the Tone of the eye in response to the sudden increase in IOP.

43. The Nurse notices that Mr. Batumbakal cannot anymore determine RED from BLUE.
The nurse knew that which part of the eye is affected by this change?

1. IRIS
2. PUPIL
3. RODS [RETINA]
4. CONES [RETINA]

44. Nurse Jet knows that Aqueous Humor is produce where?

1. In the sub arachnoid space of the meninges

2. In the Lateral ventricles
3. In the Choroids
4. In the Ciliary Body

45. Nurse Jet knows that the normal IOP is

1. 8-21 mmHg
2. 2-7 mmHg
3. 31-35 mmHg
4. 15-30 mmHg

46. Nurse Jet wants to measure Mr. Batumbakal’s CN II Function. What test would
Nurse Jet implement to measure CN II’s Acuity?
 1. Slit lamp
2. Snellen’s Chart
3. Wood’s light
4. Gonioscopy

47. The Doctor orders pilocarpine. Nurse jet knows that the action of this drug is to

1. Contract the Ciliary muscle

2. Relax the Ciliary muscle
3. Dilate the pupils
4. Decrease production of Aqueous Humor

48. The doctor orders timolol [timoptic]. Nurse jet knows that the action of this drug is

1. Reduce production of CSF

2. Reduce production of Aquesous Humor
3. Constrict the pupil
4. Relaxes the Ciliary muscle

49. When caring for Mr. Batumbakal, Jet teaches the client to avoid

1. Watching large screen TVs

2. Bending at the waist
3. Reading books
4. Going out in the sun

50. Mr. Batumbakal has undergone eye angiography using an Intravenous dye and
fluoroscopy. What activity is contraindicated immediately after procedure?

1. Reading newsprint
 2. Lying down
3. Watching TV
4. Listening to the music

51. If Mr. Batumbakal is receiving pilocarpine, what drug should always be available in
any case systemic toxicity occurs?

1. Atropine Sulfate
2. Pindolol [Visken]
3. Naloxone Hydrochloride [Narcan]
4. Mesoridazine Besylate [Serentil]

SITUATION : Wide knowledge about the human ear, it’s parts and it’s functions will help a
nurse assess and analyze changes in the adult client’s health.

52. Nurse Anna is doing a caloric testing to his patient, Aida, a 55 year old university
professor who recently went into coma after being mauled by her disgruntled 3rd year
nursing students whom she gave a failing mark. After instilling a warm water in the ear,
Anna noticed a rotary nystagmus towards the irrigated ear. What does this means?

1. Indicates a CN VIII Dysfunction

2. Abnormal
3. Normal
4. Inconclusive

53. Ear drops are prescribed to an infant, The most appropriate method to administer
the ear drops is

1. Pull the pinna up and back and direct the solution towards the eardrum
2. Pull the pinna down and back and direct the solution onto the wall of the
canal
3. Pull the pinna down and back and direct the solution towards the eardrum
 4. Pull the pinna up and back and direct the solution onto the wall of the canal

54. Nurse Jenny is developing a plan of care for a patient with Menieres disease. What
is the priority nursing intervention in the plan of care for this particular patient?

1. Air, Breathing, Circulation

2. Love and Belongingness
3. Food, Diet and Nutrition
4. Safety

55. After mastoidectomy, Nurse John should be aware that the cranial nerve that is
usually damage after this procedure is

1. CN I
2. CN II
3. CN VII
4. CN VI

56. The physician orders the following for the client with Menieres disease. Which of the
following should the nurse question?

1. Dipenhydramine [Benadryl]
2. Atropine sulfate
3. Out of bed activities and ambulation
4. Diazepam [Valium]

57. Nurse Anna is giving dietary instruction to a client with Menieres disease. Which
statement if made by the client indicates that the teaching has been successful?

1. I will try to eat foods that are low in sodium and limit my fluid intake
 2. I must drink atleast 3,000 ml of fluids per day
3. I will try to follow a 50% carbohydrate, 30% fat and 20% protein diet
4. I will not eat turnips, red meat and raddish

58. Peachy was rushed by his father, Steven into the hospital admission. Peachy is
complaining of something buzzing into her ears. Nurse Joemar assessed peachy and
found out It was an insect. What should be the first thing that Nurse Joemar should try
to remove the insect out from peachy’s ear?

1. Use a flashlight to coax the insect out of peachy’s ear

2. Instill an antibiotic ear drops
3. Irrigate the ear
4. Pick out the insect using a sterile clean forceps

59. Following an ear surgery, which statement if heard by Nurse Oca from the patient
indicates a correct understanding of the post operative instructions?

1. Activities are resumed within 5 days

2. I will make sure that I will clean my hair and face to prevent infection
3. I will use straw for drinking
4. I should avoid air travel for a while

60. Nurse Oca will do a caloric testing to a client who sustained a blunt injury in the
head. He instilled a cold water in the client’s right ear and he noticed that nystagmus
occurred towards the left ear. What does this finding indicates?

1. Indicating a Cranial Nerve VIII Dysfunction

2. The test should be repeated again because the result is vague
3. This is Grossly abnormal and should be reported to the neurosurgeon
4. This indicates an intact and working vestibular branch of CN VIII
61. A client with Cataract is about to undergo surgery. Nurse Oca is preparing plan of
care. Which of the following nursing diagnosis is most appropriate to address the long
term need of this type of patient?

1. Anxiety R/T to the operation and its outcome

2. Sensory perceptual alteration R/T Lens extraction and replacement
3. Knowledge deficit R/T the pre operative and post operative self care
4. Body Image disturbance R/T the eye packing after surgery

62. Nurse Joseph is performing a WEBERS TEST. He placed the tuning fork in the
patients forehead after tapping it onto his knee. The client states that the fork is louder
in the LEFT EAR. Which of the following is a correct conclusion for nurse Josph to
make?

1. He might have a sensory hearing loss in the left ear

2. Conductive hearing loss is possible in the right ear
3. He might have a sensory hearing loss in the right hear, and/or a conductive
hearing loss in the left ear.
4. He might have a conductive hearing loss in the right ear, and/or a sensory
hearing loss in the left ear.

63. Aling myrna has Menieres disease. What typical dietary prescription would nurse
Oca expect the doctor to prescribe?

1. A low sodium , high fluid intake

2. A high calorie, high protein dietary intake
3. low fat, low sodium and high calorie intake
4. low sodium and restricted fluid intake

SITUATION : [ From DEC 1991 NLE ] A 45 year old male construction worker was
admitted to a tertiary hospital for incessant vomiting. Assessment disclosed: weak rapid
pulse, acute weight loss of .5kg, furrows in his tongue, slow flattening of the skin was
noted when the nurse released her pinch.
Temperature: 35.8 C , BUN Creatinine ratio : 10 : 1, He also complains for postural
hypotension. There was no infection.

64. Which of the following is the appropriate nursing diagnosis?

1. Fluid volume deficit R/T furrow tongue

2. Fluid volume deficit R/T uncontrolled vomiting
3. Dehydration R/T subnormal body temperature
4. Dehydration R/T incessant vomiting

65. Approximately how much fluid is lost in acute weight loss of .5kg?

1. 50 ml
2. 750 ml
3. 500 ml
4. 75 ml

66. Postural Hypotension is

1. A drop in systolic pressure less than 10 mmHg when patient changes

position from lying to sitting.
2. A drop in systolic pressure greater than 10 mmHg when patient changes
position from lying to sitting
3. A drop in diastolic pressure less than 10 mmHg when patient changes
position from lying to sitting
4. A drop in diastolic pressure greater than 10 mmHg when patient changes
position from lying to sitting

67. Which of the following measures will not help correct the patient’s condition
 1. Offer large amount of oral fluid intake to replace fluid lost
2. Give enteral or parenteral fluid
3. Frequent oral care
4. Give small volumes of fluid at frequent interval

68. After nursing intervention, you will expect the patient to have

1. Maintain body temperature at 36.5 C

2. Exhibit return of BP and Pulse to normal
3. Manifest normal skin turgor of skin and tongue
4. Drinks fluids as prescribed
1. 1,3
2. 2,4
3. 1,3,4
4. 2,3,4

SITUATION: A 65 year old woman was admitted for Parkinson’s Disease. The charge
nurse is going to make an initial assessment.

69. Which of the following is a characteristic of a patient with advanced Parkinson’s

disease?

1. Disturbed vision
2. Forgetfulness
3. Mask like facial expression
4. Muscle atrophy

70. The onset of Parkinson’s disease is between 50-60 years old. This disorder is
caused by

1. Injurious chemical substances

2. Hereditary factors
3. Death of brain cells due to old age
 4. Impairment of dopamine producing cells in the brain

71. The patient was prescribed with levodopa. What is the action of this drug?

1. Increase dopamine availability

2. Activates dopaminergic receptors in the basal ganglia
3. Decrease acetylcholine availability
4. Release dopamine and other catecholamine from neurological storage sites

72. You are discussing with the dietician what food to avoid with patients taking
levodopa?

1. Vitamin C rich food

2. Vitamin E rich food
3. Thiamine rich food
4. Vitamin B6 rich food

73. One day, the patient complained of difficulty in walking. Your response would be

1. You will need a cane for support

2. Walk erect with eyes on horizon
3. I’ll get you a wheelchair
4. Don’t force yourself to walk

SITUATION: Mr. Dela Isla, a client with early Dementia exhibits thought process
disturbances.

74. The nurse will assess a loss of ability in which of the following areas?

1. Balance
 2. Judgment
3. Speech
4. Endurance

75. Mr. Dela Isla said he cannot comprehend what the nurse was saying. He suffers
from:

1. Insomnia
2. Aphraxia
3. Agnosia
4. Aphasia

76. The nurse is aware that in communicating with an elderly client, the nurse will

1. Lean and shout at the ear of the client

2. Open mouth wide while talking to the client
3. Use a low-pitched voice
4. Use a medium-pitched voice

77. As the nurse talks to the daughter of Mr. Dela Isla, which of the following statement
of the daughter will require the nurse to give further teaching?

1. I know the hallucinations are parts of the disease

2. I told her she is wrong and I explained to her what is right
3. I help her do some tasks he cannot do for himself
4. Ill turn off the TV when we go to another room

78. Which of the following is most important discharge teaching for Mr. Dela Isla

1. Emergency Numbers
 2. Drug Compliance
3. Relaxation technique
4. Dietary prescription

SITUATION : Knowledge of the drug PROPANTHELINE BROMIDE [Probanthine] Is

necessary in treatment of various disorders.

79. What is the action of this drug?

1. Increases glandular secretion for clients affected with cystic fibrosis

2. Dissolve blockage of the urinary tract due to obstruction of cystine stones
3. Reduces secretion of the glandular organ of the body
4. Stimulate peristalsis for treatment of constipation and obstruction

80. What should the nurse caution the client when using this medication

1. Avoid hazardous activities like driving, operating machineries etc.

2. Take the drug on empty stomach
3. Take with a full glass of water in treatment of Ulcerative colitis
4. I must take double dose if I missed the previous dose

81. Which of the following drugs are not compatible when taking Probanthine?

1. Caffeine
2. NSAID
3. Acetaminophen
4. Alcohol

82. What should the nurse tell clients when taking Probanthine?
 1. Avoid hot weathers to prevent heat strokes
2. Never swim on a chlorinated pool
3. Make sure you limit your fluid intake to 1L a day
4. Avoid cold weathers to prevent hypothermia

83. Which of the following disease would Probanthine exert the much needed action for
control or treatment of the disorder?

1. Urinary retention
2. Peptic Ulcer Disease
3. Ulcerative Colitis
4. Glaucoma

SITUATION : Mr. Franco, 70 years old, suddenly could not lift his spoons nor speak at
breakfast. He was rushed to the hospital unconscious. His diagnosis was CVA.

84. Which of the following is the most important assessment during the acute stage of
an unconscious patient like Mr. Franco?

1. Level of awareness and response to pain

2. Papillary reflexes and response to sensory stimuli
3. Coherence and sense of hearing
4. Patency of airway and adequacy of respiration

85. Considering Mr. Franco’s conditions, which of the following is most important to
include in preparing Franco’s bedside equipment?

1. Hand bell and extra bed linen

2. Sandbag and trochanter rolls
3. Footboard and splint
4. Suction machine and gloves
86. What is the rationale for giving Mr. Franco frequent mouth care?

1. He will be thirsty considering that he is doesn’t drink enough fluids

2. To remove dried blood when tongue is bitten during a seizure
3. The tactile stimulation during mouth care will hasten return to consciousness
4. Mouth breathing is used by comatose patient and it’ll cause oral mucosa
dying and cracking.

87. One of the complications of prolonged bed rest is decubitus ulcer. Which of the
following can best prevent its occurrence?

1. Massage reddened areas with lotion or oils

2. Turn frequently every 2 hours
3. Use special water mattress
4. Keep skin clean and dry

88. If Mr. Franco’s Right side is weak, What should be the most accurate analysis by the
nurse?

1. Expressive aphasia is prominent on clients with right sided weakness

2. The affected lobe in the patient is the Right lobe
3. The client will have problems in judging distance and proprioception
4. Clients orientation to time and space will be much affected

SITUATION : a 20 year old college student was rushed to the ER of PGH after he fainted
during their ROTC drill. Complained of severe right iliac pain. Upon palpation of his
abdomen, Ernie jerks even on slight pressure. Blood test was ordered. Diagnosis is acute
appendicitis.

89. Which result of the lab test will be significant to the diagnosis?
 1. RBC : 4.5 TO 5 Million / cu. mm.
2. Hgb : 13 to 14 gm/dl.
3. Platelets : 250,000 to 500,000 cu.mm.
4. WBC : 12,000 to 13,000/cu.mm

90. Stat appendectomy was indicated. Pre op care would include all of the following
except?

1. Consent signed by the father

2. Enema STAT
3. Skin prep of the area including the pubis
4. Remove the jewelries

91. Pre-anesthetic med of Demerol and atrophine sulfate were ordered to :

1. Allay anxiety and apprehension

2. Reduce pain
3. Prevent vomiting
4. Relax abdominal muscle

92. Common anesthesia for appendectomy is

1. Spinal
2. General
3. Caudal
4. Hypnosis

93. Post op care for appendectomy include the following except

1. Early ambulation
 2. Diet as tolerated after fully conscious
3. Nasogastric tube connect to suction
4. Deep breathing and leg exercise

94. Peritonitis may occur in ruptured appendix and may cause serious problems which
are

1. Hypovolemia, electrolyte imbalance

2. Elevated temperature, weakness and diaphoresis
3. Nausea and vomiting, rigidity of the abdominal wall
4. Pallor and eventually shock
1. 1 and 2
2. 2 and 3
3. 1,2,3
4. All of the above

95. If after surgery the patient’s abdomen becomes distended and no bowel sounds
appreciated, what would be the most suspected complication?

1. Intussusception
2. Paralytic Ileus
3. Hemorrhage
4. Ruptured colon

96. NGT was connected to suction. In caring for the patient with NGT, the nurse must

1. Irrigate the tube with saline as ordered

2. Use sterile technique in irrigating the tube
3. advance the tube every hour to avoid kinks
4. Offer some ice chips to wet lips
97. When do you think the NGT tube be removed?

1. When patient requests for it

2. Abdomen is soft and patient asks for water
3. Abdomen is soft and flatus has been expelled
4. B and C only

Situation: Amanda is suffering from chronic arteriosclerosis Brain syndrome she fell
while getting out of the bed one morning and was brought to the hospital, and she was
diagnosed to have cerebrovascular thrombosis thus transferred to a nursing home.

98. What do you call a STROKE that manifests a bizarre behavior?

1. Inorganic Stroke
2. Inorganic Psychoses
3. Organic Stroke
4. Organic Psychoses

99. The main difference between chronic and organic brain syndrome is that the former

1. Occurs suddenly and reversible

2. Is progressive and reversible
3. tends to be progressive and irreversible
4. Occurs suddenly and irreversible

100. Which behavior results from organic psychoses?

1. Memory deficit
2. Disorientation
3. Impaired Judgement
4. Inappropriate affect
After a cerebrovascular accident, a 75 yr old client is admitted to the health care facility.
The client has left-sided weakness and an absent gag reflex. He’s incontinent and has a
tarry stool. His blood pressure is 90/50 mm Hg, and his hemoglobin is 10 g/dl. Which of
the following is a priority for this client?

1. checking stools for occult blood

2. performing range-of-motion exercises to the left side
3. keeping skin clean and dry
4. elevating the head of the bed to 30 degrees

2. The nurse is caring for a client with a colostomy. The client tells the nurse that he
makes small pin holes in the drainage bag to help relieve gas. The nurse should teach
him that this action:

1. destroys the odor-proof seal

2. wont affect the colostomy system
3. is appropriate for relieving the gas in a colostomy system
4. destroys the moisture barrier seal

3. When assessing the client with celiac disease, the nurse can expect to find which of
the following?

1. steatorrhea
2. jaundiced sclerae
3. clay-colored stools
4. widened pulse pressure

4. A client is hospitalized with a diagnosis of chronic glomerulonephritis. The client

mentions that she likes salty foods. The nurse should warn her to avoid foods
containing sodium because:

1. reducing sodium promotes urea nitrogen excretion

 2. reducing sodium improves her glomerular filtration rate
3. reducing sodium increases potassium absorption
4. reducing sodium decreases edema

5. The nurse is caring for a client with a cerebral injury that impaired his speech and
hearing. Most likely, the client has experienced damage to the:

1. frontal lobe
2. parietal lobe
3. occipital lobe
4. temporal lobe

6. The nurse is assessing a postcraniotomy client and finds the urine output from a
catheter is 1500 ml for the 1st hour and the same for the 2nd hour. The nurse should
suspect:

1. Cushing’s syndrome
2. Diabetes mellitus
3. Adrenal crisis
4. Diabetes insipidus

7. The nurse is providing postprocedure care for a client who underwent percutaneous
lithotripsy. In this procedure, an ultrasonic probe inserted through a nephrostomy tube
into the renal pelvis generates ultra-high-frequency sound waves to shatter renal calculi.
The nurse should instruct the client to:

1. limit oral fluid intake for 1 to 2 weeks

2. report the presence of fine, sandlike particles through the nephrostomy tube.
3. Notify the physician about cloudy or foul smelling urine
4. Report bright pink urine within 24 hours after the procedure
8. A client with a serum glucose level of 618 mg/dl is admitted to the facility. He’s
awake and oriented, has hot dry skin, and has the following vital signs: temperature of
100.6º F (38.1º C), heart rate of 116 beats/minute, and blood pressure of 108/70 mm
Hg. Based on these assessment findings, which nursing diagnosis takes the highest
priority?

1. deficient fluid volume related to osmotic diuresis

2. decreased cardiac output related to elevated heart rate
3. imbalanced nutrition: Less than body requirements related to insulin
deficiency
4. ineffective thermoregulation related to dehydration

9. Capillary glucose monitoring is being performed every 4 hours for a client diagnosed
with diabetic ketoacidosis. Insulin is administered using a scale of regular insulin
according to glucose results. At 2 p.m., the client has a capillary glucose level of 250
mg/dl for which he receives 8 U of regular insulin. The

nurse should expect the dose’s:

1. onset to be at 2 p.m. and its peak at 3 p.m.

2. onset to be at 2:15 p.m. and its peak at 3 p.m.
3. onset to be at 2:30 p.m. and its peak at 4 p.m.
4. onset to be at 4 p.m. and its peak at 6 p.m.

10. A client with a head injury is being monitored for increased intracranial pressure
(ICP). His blood pressure is 90/60 mmHG and the ICP is 18 mmHg; therefore his
cerebral perfusion pressure (CPP) is:

1. 52 mm Hg
2. 88 mm Hg
3. 48 mm Hg
4. 68 mm Hg
11. A 52 yr-old female tells the nurse that she has found a painless lump in her right
breast during her monthly self-examination. Which assessment finding would strongly
suggest that this client’s lump is cancerous?

1. eversion of the right nipple and a mobile mass

2. nonmobile mass with irregular edges
3. mobile mass that is oft and easily delineated
4. nonpalpable right axillary lymph nodes

12. A Client is scheduled to have a descending colostomy. He’s very anxious and has
many questions regarding the surgical procedure, care of stoma, and lifestyle changes.
It would be most appropriate for the nurse to make a referral to which member of the
health care team?

1. Social worker
2. registered dietician
3. occupational therapist
4. enterostomal nurse therapist

13. Ottorrhea and rhinorrhea are most commonly seen with which type of skull fracture?

1. basilar
2. temporal
3. occipital
4. parietal

14. A male client should be taught about testicular examinations:

1. when sexual activity starts

2. after age 60
3. after age 40
4. before age 20
15. Before weaning a client from a ventilator, which assessment parameter is most
important for the nurse to review?

1. fluid intake for the last 24 hours

2. baseline arterial blood gas (ABG) levels
3. prior outcomes of weaning
4. electrocardiogram (ECG) results

16. The nurse is speaking to a group of women about early detection of breast cancer.
The average age of the women in the group is 47. Following the American Cancer
Society (ACS) guidelines, the nurse should recommend that the women:

1. perform breast self-examination annually

2. have a mammogram annually
3. have a hormonal receptor assay annually
4. have a physician conduct a clinical evaluation every 2 years

17. When caring for a client with esophageal varices, the nurse knows that bleeding in
this disorder usually stems from:

1. esophageal perforation
2. pulmonary hypertension
3. portal hypertension
4. peptic ulcers

18. A 49-yer-old client was admitted for surgical repair of a Colles’ fracture. An external
fixator was placed during surgery. The surgeon explains that this method of repair:

1. has very low complication rate

2. maintains reduction and overall hand function
3. is less bothersome than a cast
4. is best for older people
19. A client is hospitalized with a diagnosis of chronic renal failure. An arteriovenous
fistula was created in his left arm for hemodialysis. When preparing the client for
discharge, the nurse should reinforce which dietary instruction?

1. “Be sure to eat meat at every meal.”

2. “Monitor your fruit intake and eat plenty of bananas.”
3. “Restrict your salt intake.”
4. “Drink plenty of fluids.”

20. The nurse is caring for a client who has just had a modified radical mastectomy with
immediate reconstruction. She’s in her 30s and has tow children. Although she’s
worried about her future, she seems to be adjusting well to her diagnosis. What should
the nurse do to support

her coping?

1. Tell the client’s spouse or partner to be supportive while she recovers.

2. Encourage the client to proceed with the next phase of treatment.
3. Recommend that the client remain cheerful for the sake of her children.
4. Refer the client to the American Cancer Society’s Reach for Recovery
program or another support program.

21. A 21 year-old male has been seen in the clinic for a thickening in his right testicle.
The physician ordered a human chorionic gonadotropin (HCG) level. The nurse’s
explanation to the client should include the fact that:

1. The test will evaluate prostatic function.

2. The test was ordered to identify the site of a possible infection.
3. The test was ordered because clients who have testicular cancer has
elevated levels of HCG.
4. The test was ordered to evaluate the testosterone level.

22. A client is receiving captopril (Capoten) for heart failure. The nurse should notify the
physician that the medication therapy is ineffective if an assessment reveals:
 1. A skin rash.
2. Peripheral edema.
3. A dry cough.
4. Postural hypotension.

23. Which assessment finding indicates dehydration?

1. Tenting of chest skin when pinched.

2. Rapid filling of hand veins.
3. A pulse that isn’t easily obliterated.
4. Neck vein distention

24. The nurse is teaching a client with a history of atherosclerosis. To decrease the risk
of atherosclerosis, the nurse should encourage the client to:

1. Avoid focusing on his weight.

2. Increase his activity level.
3. Follow a regular diet.
4. Continue leading a high-stress lifestyle.

25. For a client newly diagnosed with radiationinduced thrombocytopenia, the nurse
should include which intervention in the plan of care?

1. Administer aspirin if the temperature exceeds 38.8º C.

2. Inspect the skin for petechiae once every shift.
3. Provide for frequent periods of rest.
4. Place the client in strict isolation.

26. A client is chronically short of breath and yet has normal lung ventilation, clear
lungs, and an arterial oxygen saturation (SaO2) 96% or better. The client most likely has:
 1. poor peripheral perfusion
2. a possible Hematologic problem
3. a psychosomatic disorder
4. left-sided heart failure

27. For a client in addisonian crisis, it would be very risky for a nurse to administer:

1. potassium chloride
2. normal saline solution
3. hydrocortisone
4. fludrocortisone

28. The nurse is reviewing the laboratory report of a client who underwent a bone
marrow biopsy. The finding that would most strongly support a diagnosis of acute
leukemia is the existence of a large number of immature:

1. lymphocytes
2. thrombocytes
3. reticulocytes
4. leukocytes

29. The nurse is performing wound care on a foot ulcer in a client with type 1 diabetes
mellitus. Which technique demonstrates surgical asepsis?

1. Putting on sterile gloves then opening a container of sterile saline.

2. Cleaning the wound with a circular motion, moving from outer circles toward
the center.
3. Changing the sterile field after sterile water is spilled on it.
4. Placing a sterile dressing ½” (1.3 cm) from the edge of the sterile field.

30. A client with a forceful, pounding heartbeat is diagnosed with mitral valve prolapse.
This client should avoid which of the following?
 1. high volumes of fluid intake
2. aerobic exercise programs
3. caffeine-containing products
4. foods rich in protein

31. A client with a history of hypertension is diagnosed with primary

hyperaldosteronism. This diagnosis indicates that the client’s hypertension is caused by
excessive hormone secretion from which organ?

1. adrenal cortex
2. pancreas
3. adrenal medulla
4. parathyroid

32. A client has a medical history of rheumatic fever, type 1 (insulin dependent) diabetes
mellitus, hypertension, pernicious anemia, and appendectomy. She’s admitted to the
hospital and undergoes mitral valve replacement surgery. After discharge, the client is
scheduled for a tooth extraction. Which history finding is a major risk factor for infective
endocarditis?

1. appendectomy
2. pernicious anemia
3. diabetes mellitus
4. valve replacement

33. A 62 yr-old client diagnosed with pyelonephritis and possible septicemia has had
five urinary tract infections over the past two years. She’s fatigued from lack of sleep;
urinates frequently, even during the night; and has lost weight recently. Test reveal the
following: sodium level 152 mEq/L, osmolarity 340 mOsm/L, glucose level 125 mg/dl,
and potassium level 3.8 mEq/L. which of the following nursing diagnoses is most
appropriate for this client?

1. Deficient fluid volume related to inability to conserve water

 2. Imbalanced nutrition: less than body requirements related to hypermetabolic
state
3. Deficient fluid volume related to osmotic diuresis induced by hypernatremia
4. Imbalanced nutrition: less than body requirements related to catabolic
effects of insulin deficiency

34. A 20 yr-old woman has just been diagnosed with Crohn’s disease. She has lost 10 lb
(4.5 kg) and has cramps and occasional diarrhea. The nurse should include which of the
following when doing a nutritional assessment?

1. Let the client eat as desired during the hospitalization.

2. Weight the client daily.
3. Ask the client to list what she eats during a typical day.
4. Place the client on I & O status and draw blood for electrolyte levels.

35. When instructions should be included in the discharge teaching plan for a client
after thyroidectomy for Grave’s disease?

1. Keep an accurate record of intake and output.

2. Use nasal desmopressin acetate DDAVP).
3. Be sure to get regulate follow-up care.
4. Be sure to exercise to improve cardiovascular fitness.

36. A client comes to the emergency department with chest pain, dyspnea, and an
irregular heartbeat. An electrocardiogram shows a heart rate of 110 beats/minute
(sinus tachycardia) with frequent premature ventricular contractions. Shortly after
admission, the client has ventricular tachycardia and becomes unresponsive. After
successful resuscitation, the client is taken to the intensive care unit. Which nursing
diagnosis is appropriate at this time?

1. Deficient knowledge related to interventions used to treat acute illness

2. Impaired physical mobility related to complete bed rest
3. Social isolation related to restricted visiting hours in the intensive care unit
4. Anxiety related to the threat of death
37. A client is admitted to the health care facility with active tuberculosis. The nurse
should include which intervention in the plan of care?

1. Putting on a mask when entering the client’s room.

2. Instructing the client to wear a mask at all times
3. Wearing a gown and gloves when providing direct care
4. Keeping the door to the client’s room open to observe the client

38. The nurse is caring for a client who underwent a subtotal gastrectomy 24 hours
earlier. The client has a nasogastric (NG) tube. The nurse should:

1. Apply suction to the NG tube every hour.

2. Clamp the NG tube if the client complains of nausea.
3. Irrigate the NG tube gently with normal saline solution.
4. Reposition the NG tube if pulled out.

39. Which statement about fluid replacement is accurate for a client with hyperosmolar
hyperglycemic nonketotic syndrome (HHNS)?

1. administer 2 to 3 L of IV fluid rapidly

2. administer 6 L of IV fluid over the first 24 hours
3. administer a dextrose solution containing normal saline solution
4. administer IV fluid slowly to prevent circulatory overload and collapse

40. Which of the following is an adverse reaction to glipizide (Glucotrol)?

1. headache
2. constipation
3. hypotension
4. photosensitivity
41. The nurse is caring for four clients on a stepdown intensive care unit. The client at
the highest risk for developing nosocomial pneumonia is the one who:

1. has a respiratory infection

2. is intubated and on a ventilator
3. has pleural chest tubes
4. is receiving feedings through a jejunostomy tube

42. The nurse is teaching a client with chronic bronchitis about breathing exercises.
Which of the following should the nurse include in the teaching?

1. Make inhalation longer than exhalation.

2. Exhale through an open mouth.
3. Use diaphragmatic breathing.
4. Use chest breathing.

43. A client is admitted to the hospital with an exacerbation of her chronic systemic
lupus erythematosus (SLE). She gets angry when her call bell isn’t answered
immediately. The most appropriate response to her would be:

1. “You seem angry. Would you like to talk about it?”

2. “Calm down. You know that stress will make your symptoms worse.”
3. “Would you like to talk about the problem with the nursing supervisor?”
4. “I can see you’re angry. I’ll come back when you’ve calmed down.”

44. On a routine visit to the physician, a client with chronic arterial occlusive disease
reports stopping smoking after 34 years. To relive symptoms of intermittent
claudication, a condition associated with chronic arterial occlusive disease, the nurse
should recommend which additional measure?

1. Taking daily walks.

2. Engaging in anaerobic exercise.
 3. Reducing daily fat intake to less than 45% of total calories
4. Avoiding foods that increase levels of highdensity lipoproteins (HDLs)

45. A physician orders gastric decompression for a client with small bowel obstruction.
The nurse should plan for the suction to be:

1. low pressure and intermittent

2. low pressure and continuous
3. high pressure and continuous
4. high pressure and intermittent

46. Which nursing diagnosis is most appropriate for an elderly client with osteoarthritis?

1. Risk for injury

2. Impaired urinary elimination
3. Ineffective breathing pattern
4. Imbalanced nutrition: less than body requirements

47. Parathyroid hormone (PTH) has which effects on the kidney?

1. Stimulation of calcium reabsorption and phosphate excretion

2. Stimulation of phosphate reabsorption and calcium excretion
3. Increased absorption of vit D and excretion of vit E
4. Increased absorption of vit E and excretion of Vit D

48. A visiting nurse is performing home assessment for a 59-yr old man recently
discharged after hip replacement surgery. Which home assessment finding warrants
health promotion teaching from the nurse?

1. A bathroom with grab bars for the tub and toilet

 2. Items stored in the kitchen so that reaching up and bending down aren’t
necessary
3. Many small, unsecured area rugs
4. Sufficient stairwell lighting, with switches to the top and bottom of the stairs

49. A client with autoimmune thrombocytopenia and a platelet count of 800/uL

develops epistaxis and melena. Treatment with corticosteroids and immunoglobulins
has been unsuccessful, and the physician recommends a splenectomy. The client
states, “I don’t need surgery—this will go away on its own.” In considering her response
to the client, the nurse must depend on the ethical principle of:

1. beneficence
2. autonomy
3. advocacy
4. justice

50. Which of the following is t he most critical intervention needed for a client with
myxedema coma?

1. Administering and oral dose of levothyroxine (Synthroid)

2. Warming the client with a warming blanket
3. Measuring and recording accurate intake and output
4. Maintaining a patent airway

51. Because diet and exercise have failed to control a 63 yr-old client’s blood glucose
level, the client is prescribed glipizide (Glucotrol). After oral administration, the onset of
action is:

1. 15 to 30 minutes
2. 30 to 60 minutes
3. 1 to 1 ½ hours
4. 2 to 3 hours
52. A client with pneumonia is receiving supplemental oxygen, 2 L/min via nasal
cannula. The client’s history includes chronic obstructive pulmonary disease (COPD)
and coronary artery disease. Because of these findings, the nurse closely monitors the
oxygen flow and the client’s respiratory status. Which complication may arise if the
client receives a high oxygen concentration?

1. Apnea
2. Anginal pain
3. Respiratory alkalosis
4. Metabolic acidosis

53. A client with type 1 diabetes mellitus has been on a regimen of multiple daily
injection therapy. He’s being converted to continuous subcutaneous insulin therapy.
While teaching the client bout continuous subcutaneous insulin therapy, the nurse
would be accurate in telling him the regimen includes the use of:

1. intermediate and long-acting insulins

2. short and long-acting insulins
3. short-acting only
4. short and intermediate-acting insulins

54. a client who recently had a cerebrovascular accident requires a cane to ambulate.
When teaching about cane use, the rationale for holding a cane on the uninvolved side is
to:

1. prevent leaning
2. distribute weight away from the involved side
3. maintain stride length
4. prevent edema

55. A client with a history of an anterior wall myocardial infarction is being transferred
from the coronary care unit (CCU) to the cardiac stepdown unit (CSU). While giving
report to the CSU nurse, the CCU nurse says, “His pulmonary artery wedge pressures
have been in the high normal range.” The CSU nurse should be especially observant for:
 1. hypertension
2. high urine output
3. dry mucous membranes
4. pulmonary crackles

56. The nurse is caring for a client with a fractures hip. The client is combative,
confused, and trying to get out of bed. The nurse should:

1. leave the client and get help

2. obtain a physician’s order to restrain the client
3. read the facility’s policy on restraints
4. order soft restraints from the storeroom

57. For the first 72 hours after thyroidectomy surgery, the nurse would assess the client
for Chvostek’s sign and Trousseau’s sign because they indicate which of the following?

1. hypocalcemia
2. hypercalcemia
3. hypokalemia
4. Hyperkalemia

58. In a client with enteritis and frequent diarrhea, the nurse should anticipate an
acidbase imbalance of:

1. respiratory acidosis
2. respiratory alkalosis
3. metabolic acidosis
4. metabolic alkalosis

59. When caring for a client with the nursing diagnosis Impaired swallowing related to
neuromuscular impairment, the nurse should:
 1. position the client in a supine position
2. elevate the head of the bed 90 degrees during meals
3. encourage the client to remove dentures
4. encourage thin liquids for dietary intake

60. A nurse is caring for a client who has a tracheostomy and temperature of 39º C.
which intervention will most likely lower the client’s arterial blood oxygen saturation?

1. Endotracheal suctioning
2. Encouragement of coughing
3. Use of cooling blanket
4. Incentive spirometry

61. A client with a solar burn of the chest, back, face, and arms is seen in urgent care.
The nurse’s primary concern should be:

1. fluid resuscitation
2. infection
3. body image
4. pain management

62. Which statement is true about crackles?

1. They’re grating sounds.

2. They’re high-pitched, musical squeaks.
3. They’re low-pitched noises that sound like snoring.
4. They may be fine, medium, or course.

63. A woman whose husband was recently diagnosed with active pulmonary
tuberculosis (TB) is a tuberculin skin test converter. Management of her care would
include:
 1. scheduling her for annual tuberculin skin testing
2. placing her in quarantine until sputum cultures are negative
3. gathering a list of persons with whom she has had recent contact
4. advising her to begin prophylactic therapy with isoniazid (INH)

64. The nurse is caring for a client who ahs had an above the knee amputation. The
client refuses to look at the stump. When the nurse attempts to speak with the client
about his surgery, he tells the nurse that he doesn’t wish to discuss it. The client also
refuses to have his family visit. The nursing diagnosis that best describes the client’s
problem is:

1. Hopelessness
2. Powerlessness
3. Disturbed body image
4. Fear

65. A client with three children who is still I the child bearing years is admitted for
surgical repair of a prolapsed bladder. The nurse would find that the client understood
the surgeon’s preoperative teaching when the client states:

1. “If I should become pregnant again, the child would be delivered by cesarean
delivery.”
2. “If I have another child, the procedure may need to be repeated.”
3. “This surgery may render me incapable of conceiving another child.”
4. “This procedure is accomplished in two separate surgeries.”

66. A client experiences problems in body temperature regulation associated with a skin
impairment. Which gland is most likely involved?

1. Eccrine
2. Sebaceous
3. Apocrine
4. Endocrine
67. A school cafeteria worker comes to the physician’s office complaining of severe
scalp itching. On inspection, the nurse finds nail marks on the scalp and small light-
colored round specks attached to the hair shafts close to the scalp. These findings
suggest that the client suffers from:

1. scabies
2. head lice
3. tinea capitis
4. impetigo

68. Following a small-bowel resection, a client develops fever and anemia. The surface
surrounding the surgical wound is warm to touch and necrotizing fasciitis is suspected.
Another manifestation that would most suggest necrotizing fasciitis is:

1. erythema
2. leukocytosis
3. pressure-like pain
4. swelling

69. A 28 yr-old nurse has complaints of itching and a rash of both hands. Contact
dermatitis is initially suspected. The diagnosis is confirmed if the rash appears:

1. erythematous with raised papules

2. dry and scaly with flaking skin
3. inflamed with weeping and crusting lesions
4. excoriated with multiple fissures

70. When assessing a client with partial thickness burns over 60% of the body, which of
the following should the nurse report immediately?

1. Complaints of intense thirst

2. Moderate to severe pain
 3. Urine output of 70 ml the 1st hour
4. Hoarseness of the voice

71. A client is admitted to the hospital following a burn injury to the left hand and arm.
The client’s burn is described as white and leathery with no blisters. Which degree of
severity is this burn?

1. first-degree burn
2. second-degree burn
3. third-degree burn
4. fourth-degree burn

72. The nurse is caring for client with a new donor site that was harvested to treat a new
burn. The nurse position the client to:

1. allow ventilation of the site

2. make the site dependent
3. avoid pressure on the site
4. keep the site fully covered

73. a 45-yr-old auto mechanic comes to the physician’s office because an exacerbation
of his psoriasis is making it difficult to work. He tells the nurse that his finger joints are
stiff and sore in the morning. The nurse should respond by:

1. Inquiring further about this problem because psoriatic arthritis can

accompany psoriasis vulgaris
2. Suggesting he take aspirin for relief because it’s probably early rheumatoid
arthritis
3. Validating his complaint but assuming it’s an adverse effect of his vocation
4. Asking him if he has been diagnosed or treated for carpal tunnel syndrome
74. The nurse is providing home care instructions to a client who has recently had a skin
graft. Which instruction is most important for the client to remember?

1. Use cosmetic camouflage techniques.

2. Protect the graft from direct sunlight.
3. Continue physical therapy.
4. Apply lubricating lotion to the graft site.

75. a 28 yr-old female nurse is seen in the employee health department for mild itching
and rash of both hands. Which of the following could be causing this reaction?

1. possible medication allergies

2. current life stressors she may be experiencing
3. chemicals she may be using and use of latex gloves
4. recent changes made in laundry detergent or bath soap.

76. The nurse assesses a client with urticaria. The nurse understands that urticaria is
another name for:

1. hives
2. a toxin
3. a tubercle
4. a virus

77. A client with psoriasis visits the dermatology clinic. When inspecting the affected
areas, the nurse expects to see which type of secondary lesion?

1. scale
2. crust
3. ulcer
4. scar
78. The nurse is caring for a bedridden, elderly adult. To prevent pressure ulcers, which
intervention should the nurse include in the plan of care?

1. Turn and reposition the client a minimum of every 8 hours.

2. Vigorously massage lotion into bony prominences.
3. Post a turning schedule at the client’s bedside.
4. Slide the client, rather than lifting when turning.

79. Following a full-thickeness (3rd degree) burn of his left arm, a client is treated with
artificial skin. The client understands postoperative care of the artificial skin when he
states that during the first 7 days after the procedure, he’ll restrict:

1. range of motion
2. protein intake
3. going outdoors
4. fluid ingestion

80. A client received burns to his entire back and left arm. Using the Rule of Nines, the
nurse can calculate that he has sustained burns on what percentage of his body?

1. 9%
2. 18%
3. 27%
4. 36%

81. The nurse is providing care for a client who has a sacral pressure ulcer with wet-to-
dry dressing. Which guideline is appropriate for a wet-to-dry dressing?

1. The wound should remain moist form the dressing.

2. The wet-to-dry dressing should be tightly packed into the wound.
3. The dressing should be allowed to dry out before removal.
4. A plastic sheet-type dressing should cover the wet dressing.
82. While in skilled nursing facility, a client contracted scabies, which is diagnosed the
day after discharge. The client is living at her daughter’s home with six other persons.
During her visit to the clinic, she asks a staff nurse, “What should my family do?” the
most accurate response from the nurse is:

1. “All family members will need to be treated.”

2. “If someone develops symptoms, tell him to see a physician right away.”
3. “Just be careful not to share linens and towels with family members.”
4. “After you’re treated, family members won’t be at risk for contracting
scabies.”

83. In an industrial accident, client who weighs 155 lb (70.3 kg) sustained full-thickness
burns over 40% of his body. He’s in the burn unit receiving fluid resuscitation. Which
observation shows that the fluid resuscitation is benefiting the client?

1. A urine output consistently above 100 ml/hour.

2. A weight gain of 4 lb (1.8 kg) in 24 hours.
3. Body temperature readings all within normal limits
4. An electrocardiogram (ECG) showing no arrhythmias.

84. The nurse is reviewing the laboratory results of a client with rheumatoid arthritis.
Which of the following laboratory results should the nurse expect to find?

1. Increased platelet count

2. Elevated erythrocyte sedimentation rate (ESR)
3. Electrolyte imbalance
4. Altered blood urea nitrogen (BUN) and creatinine levels

85. Which nursing diagnosis takes the highest priority for a client with Parkinson’s
crisis?

1. Imbalanced nutrition: less than body requirements

 2. Ineffective airway clearance
3. Impaired urinary elimination
4. Risk for injury

86. A client with a spinal cord injury and subsequent urine retention receives
intermittent catheterization every 4 hours. The average catheterized urine volume has
been 550 ml. The nurse should plan to:

1. Increase the frequency of the catheterizations.

2. Insert an indwelling urinary catheter
3. Place the client on fluid restrictions
4. Use a condom catheter instead of an invasive one.

87.The nurse is caring for a client who is to undergo a lumbar puncture to assess for the
presence of blood in the cerebrospinal fluid (CSF) and to measure CSF pressure. Which
result would indicate n abnormality?

1. The presence of glucose in the CSF.

2. A pressure of 70 to 200 mm H2O
3. The presence of red blood cells (RBCs) in the first specimen tube
4. A pressure of 00 to 250 mmH2O

88. The nurse is administering eyedrops to a client with glaucoma. To achieve

maximum absorption, the nurse should instill the eyedrop into the:

1. conjunctival sac
2. pupil
3. sclera
4. vitreous humor
89. A 52 yr-old married man with two adolescent children is beginning rehabilitation
following a cerebrovascular accident. As the nurse is planning the client’s care, the
nurse should recognize that his condition will affect:

1. only himself
2. only his wife and children
3. him and his entire family
4. no one, if he has complete recovery

90. Which action should take the highest priority when caring for a client with
hemiparesis caused by a cerebrovascular accident (CVA)?

1. Perform passive range-of-motion (ROM) exercises.

2. Place the client on the affected side.
3. Use hand rolls or pillows for support.
4. Apply antiembolism stockings

91. The nurse is formulating a teaching plan for a client who has just experienced a
transient ischemic attack (TIA). Which fact should the nurse include in the teaching
plan?

1. TIA symptoms may last 24 to 48 hours.

2. Most clients have residual effects after having a TIA.
3. TIA may be a warning that the client may have cerebrovascular accident
(CVA)
4. The most common symptom of TIA is the inability to speak.

92. The nurse has just completed teaching about postoperative activity to a client who
is going to have a cataract surgery. The nurse knows the teaching has been effective if
the client:

1. coughs and deep breathes postoperatively

 2. ties his own shoes
3. asks his wife to pick up his shirt from the floor after he drops it.
4. States that he doesn’t need to wear an eyepatch or guard to bed

93. The least serious form of brain trauma, characterized by a brief loss of
consciousness and period of confusion, is called:

1. contusion
2. concussion
3. coup
4. contrecoup

94. When the nurse performs a neurologic assessment on Anne Jones, her pupils are
dilated and don’t respond to light.

1. glaucoma
2. damage to the third cranial nerve
3. damage to the lumbar spine
4. Bell’s palsy

95. A 70 yr-old client with a diagnosis of leftsided cerebrovascular accident is admitted

to the facility. To prevent the development of diffuse osteoporosis, which of the
following objectives is most appropriate?

1. Maintaining protein levels.

2. Maintaining vitamin levels.
3. Promoting weight-bearing exercises
4. Promoting range-of-motion (ROM) exercises

96. A client is admitted with a diagnosis of meningitis caused by Neisseria

meningitides. The nurse should institute which type of isolation precautions?
 1. Contact precautions
2. Droplet precautions
3. Airborne precautions
4. Standard precautions

97. A young man was running along an ocean pier, tripped on an elevated area of the
decking, and struck his head on the pier railing. According to his friends, “He was
unconscious briefly and then became alert and behaved as though nothing had
happened.” Shortly afterward, he began complaining of a headache and asked to be
taken to the emergency department. If the client’s intracranial pressure (ICP) is
increasing, the nurse would expect to observe which of the

following signs first?

1. pupillary asymmetry
2. irregular breathing pattern
3. involuntary posturing
4. declining level of consciousness

98. Emergency medical technicians transport a 28 yr-old iron worker to the emergency
department. They tell the nurse, “He fell from a two-story building. He has a large
contusion on his left chest and a hematoma in the left parietal area. He has compound
fracture of his left femur and he’s comatose. We intubated him and he’s maintaining an
arterial oxygen saturation of 92% by pulse oximeter with a manual-resuscitation bag.”
Which intervention by the nurse has the highest priority?

1. Assessing the left leg

2. Assessing the pupils
3. Placing the client in Trendelenburg’s position
4. Assessing the level of consciousness

99. Alzheimer’s disease is the secondary diagnosis of a client admitted with myocardial
infarction. Which nursing intervention should appear on this client’s plan of care?
 1. Perform activities of daily living for the client to decease frustration.
2. Provide a stimulating environment.
3. Establish and maintain a routine.
4. Try to reason with the client as much as possible.

100. For a client with a head injury whose neck has been stabilized, the preferred bed
position is:

1. Trendelenburg’s
2. 30-degree head elevation
3. flat
4. side-lying