Practice Questions NLE

8/18/2019 Practice Questions NLE

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FUNDA

1. Using the principles of standard precautions, the n urse would wear gloves in what nursing interventions?

A. Providing a back massage

B. Feeding a client

C. Providing hair careD. Providing oral hygiene

2. The nurse is p reparing to take vital sign in an alert client admitted to the hospital with dehydration

secondary t o vomiting and diarrhea. What is t he b est method used to a ssess t he cl ient’s t emperature?

A. Oral

B. Axillary

C. Radial

D. Heat sensitive tape

3. A nurse obtained a c lient’s p ulse and found the r ate t o be a bove normal. The n urse document this

ndings as:

A. Tachypnea

B. Hyperpyrexia

C. Arrhythmia

D. Tachycardia

4. Which of the following actions s hould the n urse t ake to use a wide b ase su pport when assisting a cl ient

to get up in a c hair?

A. Bend at the waist and place arms u nder t he client’s a rms a nd lift

B. Face the c lient, bend k nees a nd p lace hands o n client’s forearm and lift

C. Spread his o r her feet apart

D. Tighten his o r her pelvic m uscles

5. A client had oral surgery f ollowing a m otor vehicle a ccident. The n urse assessing the c lient nds t he s kin

ushed and warm. Which of the following would be the b est method to take t he client’s b ody temperature?

A. Oral

B. Axillary

C. Arterial line

D. Rectal


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6. A client who is u nconscious n eeds f requent mouth care. When performing a m outh care, the best

position of a client is:

A. Fowler’s p osition

B. Side lying

C. Supine

D. Trendelenburg

7. A client is hospitalized for t he rst t ime, which of the following actions ensure the safety of the client?

A. Keep u nnecessary furniture o ut of the w ay

B. Keep the lights on at all time

C. Keep side rails up at all time

D. Keep all equipment out of view

8. A walk-in client enters i nto the clinic with a c hief complaint of abdominal pain and diarrhea. The nurse

takes the c lient’s v italsignhereafterWhat phrase o f nursing process is b eing implemented here b y the

nurse?

A. Assessment

B. Diagnosis

C. Planning

D. Implementation

9. It is b est describe a s a systematic, rational method of planning and providing nursing care for individual,

families, group and community

A. Assessment

B. Nursing Process

C. Diagnosis

D. Implementation

10. Exchange o f gases t akes place in which of the following organ?

A. Kidney

B. Lungs

C. Liver

D. Heart

11. The ch amber of the h eart that receives oxygenated blood from the lungs is t he:


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A. Left atrium

B. Right atrium

C. Left ventricle

D. Right ventricle

12. A muscular en large pouch or sac t hat lies slightly to the left which is u sed for temporary st orage o f

food…

A. Gallbladder

B. Urinary b ladder

C. Stomach

D. Lungs

13. The a bility o f the b ody to defend itself against scientic i nvading agent such as baceria, toxin, viruses

and foreign body

A. Hormones

B. Secretion

C. Immunity

D. Glands

14. Hormones se creted by Islets o f Langerhans

A. Progesterone

B. Testosterone

C. Insulin

D. Hemoglobin

15. It is a transparent membrane that focuses the light that enters t he eyes to the retina.

A. Lens

B. ScleraC. Cornea

D. Pupils

16. Which of the following is i ncluded in Orem’s theory?

A. Maintenance of a sufficient intake of air

B. Self perception


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C. Love and belongingness

D. Physiologic needs

17. Which of the following cluster of data belong to Maslow’s h ierarchy o f needs

A. Love a nd belonging

B. Physiologic n eedsC. Self actualization

D. All of the above

18. This i s c haracterized by s evere s ymptoms rel atively o f short duration.

A. Chronic Illness

B. Acute Illness

C. Pain

D. Syndrome

19. Which of the following is t he nurse’s role in the health promotion

A. Health risk appraisal

B. Teach client to b e e ffective h ealth c onsumer

C. Worksite w ellness

D. None o f the above

20. It is d escribe a s a collection of people w ho share s ome a ttributes o f their lives.

A. Family

B. Illness

C. Community

D. Nursing

21. Five teaspoon is e quivalent to how many m illiliters ( ml)?

A. 30 ml

B. 25 ml

C. 12 ml

D. 22 ml

22. 1800 ml is e qual to how many liters?


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A. 1.8

B. 18000

C. 180

D. 2800

23. Which of the following is t he a bbreviation of drops?

A. Gtt.

B. Gtts.

C. Dp.

D. Dr.

24. The a bbreviation for micro d rop is…

A. µgtt

B. gtt

C. mdr

D. mgts

25. Which of the following is t he m eaning of PRN?

A. When advice

B. Immediately

C. When necessary

D. Now

26. Which of the following is t he a ppropriate m eaning of CBR?

A. Cardiac Board Room

B. Complete Bathroom

C. Complete Bed Rest

D. Complete Board Room

27. One (1) tsp is eq uals t o how many drops?

A. 15

B. 60

C. 10

D. 30


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28. 20 cc i s eq ual to how many ml?

A. 2

B. 20

C. 2000

D. 20000

29. 1 cup is equ als to how many ounces?

A. 8

B. 80

C. 800

D. 8000

30. The n urse must verify the c lient’s i dentity b efore a dministration of medication. Which of the following is

the safest way to identify the client?

A. Ask t he client his n ame

B. Check the client’s i dentication band

C. State the client’s n ame aloud and have the client repeat it

D. Check the room number

31. The n urse p repares t o administer buccal medication. The m edicine sh ould be p laced…

A. On the client’s skin

B. Between the client’s ch eeks a nd gums

C. Under the client’s tongue

D. On the client’s conjunctiva

32. The n urse a dministers cl eansing enema. The co mmon position for this p rocedure is…

A. Sims left lateralB. Dorsal Recumbent

C. Supine

D. Prone

33. A client complains of difficulty of swallowing, when the n urse try to administer cap sule medication.

Which of the following measures t he n urse sh ould do?


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A. Dissolve the capsule in a glass o f water

B. Break the capsule and give the content with an applesauce

C. Check the availability o f a liquid preparation

D. Crash the capsule and place it under the tongue

34. Which of the following is t he appropriate ro ute of administration for insulin?

A. Intramuscular

B. Intradermal

C. Subcutaneous

D. Intravenous

35. The n urse is o rdered to administer ampicillin capsule TID p.o. The n urse should give the m edication…

A. Three times a day orally

B. Three times a day a fter meals

C. Two time a d ay by m outh

D. Two times a day b efore meals

36. Back Care is b est describe as :

A. Caring for the back by m eans of massage

B. Washing of the back

C. Application of cold compress a t the back

D. Application of hot compress a t the back

37. It refers o the p reparation of the b ed with a n ew set of linens

A. Bed bath

B. Bed making

C. Bed shampoo

D. Bed lining

38. Which of the following is t he m ost important purpose o f handwashing

A. To promote hand circulation

B. To prevent the transfer of microorganism

C. To avoid touching the client with a dirty h and

D. To provide comfort


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39. What should be done in order to p revent contaminating of the en vironment in bed making?

A. Avoid fanning soiled linens

B. Strip all linens at the same time

C. Finished both sides a t the time

D. Embrace soiled linen

40. The m ost important purpose o f cleansing bed bath is:

A. To cleanse, refresh and give comfort to the client who must remain in bed

B. To expose t he necessary pa rts of the body

C. To develop skills i n bed bath

D. To check t he body temperature of the client in bed

41. Which of the following technique involves t he s ense of sight?

A. Inspection

B. Palpation

C. Percussion

D. Auscultation

42. The rst techniques u sed examining the a bdomen of a cl ient is:

A. Palpation

B. Auscultation

C. Percussion

D. Inspection

43. A technique in physical examination that is u se to assess t he m ovement of air through the

tracheobronchial t ree:

A. PalpationB. Auscultation

C. Inspection

D. Percussion

44. An instrument used for auscultation is:

A. Percussion-hammer

B. Audiometer


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C. Stethoscope

D. Sphygmomanometer

45. Resonance i s b est describe as :

A. Sounds c reated by air lled lungs

B. Short, high pitch and thuddingC. Moderately loud with musical quality

D. Drum-like

46. The b est position for examining the rectum is:

A. Prone

B. Sim’s

C. Knee-chest

D. Lithotomy

47. It refers o the m anner o f walking

A. Gait

B. Range of motion

C. Flexion and extension

D. Hopping

48. The n urse asked the c lient to read the S nellen chart. Which of the following is t ested:

A. Optic

B. Olfactory

C. Oculomotor

D. Trochlear

49. Another nam e for knee-chest position is:

A. Genu-dorsal

B. Genu-pectoral

C. Lithotomy

D. Sim’s

50. The n urse prepare I M injection that is i rritating to the s ubcutaneous t issue. Which of the following is t he

best action in order t o prevent tracking of the medication


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A. Use a small gauge n eedle

B. Apply ice on the injection site

C. Administer at a 45° an gle

D. Use the Z-track t echnique

Answers a nd Rationale

1. Answer: D. Providing oral hygiene

Doing oral care requires t he nurse to wear gloves.

2. Answer: B. Axillary

Axilla is t he most accessible body p art in this s ituation.

3. Answer: D. Tachycardia

Tachycardia means r apid heart rate. Tachypnea (Option A) refers t o rapid respiratory rate. Hyperpyrexia (Option B)

means i ncrease in temperature. Arrhythmia (Option C) means i rregular heart rate.

4. Answer: B. Face t he c lient, bend knees a nd place h ands o n client’s f orearm and lift

This i s t he p roper way o n s upporting the client to get up in a c hair that conforms t o safety a nd proper body

mechanics.

5. Answer: B. Axillary

Taking the temperature via the oral route is i ncorrect since the client had oral surgery. Choice C and D are

unnecessary. Taking the temperature via the axilla is t he most appropriate route.

6. Answer: B. Side lying

An unconscious cl ient is b est placed on h is si de w hen d oing oral care to prevent aspiration.

7. Answer: C. Keep side rai ls u p at all time

Although the other choices se em correct, they a re not the best answer.

8. Answer: A. Assessment


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Assessment is t he rst phase of the nursing process where a nurse collects i nformation about the client. Diagnosis

is the formulation of the nursing diagnosis from the information collected during the assessment. In Planning, the

nurse sets a chievable a nd m easurable s hort and long term goals. Implementation is w here n ursing c are is g iven.

9. Answer: B. Nursing Process

The statement describes t he Nursing Process. The Nursing Process i s t he essential core of practice for theregistered nurse to deliver holistic, patient-focused care.

10. Answer: B. Lungs

11. Answer: A. Left atrium

The left atrium receives oxygenated blood from the lungs and pumps it to the left v entricle . The right atrium

receives b lood from the veins a nd pumps i t to the right ventricle. The right ventricle receives b lood from the right

atrium and pumps i t to the lungs, where it is l oaded with oxygen. The left v entricle (the strongest chamber) pumps

oxygen-rich blood to the rest of the body, its v igorous c ontractions c reate the blood pressure.

12. Answer: C. Stomach

13. Answer: C. Immunity

14. Answer: C. Insulin

The Islets o f Langerhans a re the regions o f the pancreas t hat contain its e ndocrine cells. Progesterone (Choice A) is

produced b y the ovaries. Testosterone (C hoice B) is se creted by the testicles o f males a nd o varies o f females.

Hemoglobin (Choice D) is a protein molecule in the red blood cells t hat carries o xygen from the lungs t o the body’s

tissues a nd ret urns ca rbon dioxide.

15. Answer: C. Cornea

The cornea is t he transparent front part of the eye that covers t he iris, pupil, and anterior chamber. The cornea is l ikethe crystal of a watch.

16. Answer: A. Maintenance o f a su fficient intake of air

Dorothea O rem’s S elf-Care Theory de ned Nursing as “ The act of assisting others in the provision and m anagement

of self-care to maintain or improve human functioning at home level of effectiveness.” Choices B , C, and D are from

Abraham Maslow’s Hierarchy of Needs.

http://nurseslabs.com/dorothea-orems-self-care-theory/http://nurseslabs.com/dorothea-orems-self-care-theory/


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17. Answer: D. All of the a bove

All of the choices a re part of Maslow’s H ierarchy o f Needs.

18. Answer: B. Acute Illness

Chronic I llness (Choice A) are illnesses t hat are persistent or long-term.

19. Answer: B. Teach client to be effective health consumer

20. Answer: C. Community

Family is d ened as a group consisting typically o f parents a nd children living together in a household.

21. Answer: B. 25 ml

One teaspoon is eq ual to 5 ml.

22. Answer: A. 1.8

23. Answer: B. Gtts.

Gtt (Choice A) is a n abbreviation for drop. Dp a nd Dr are n ot recognized a bbreviation for measurement.

24. Answer: A. µgtt

25. Answer: C. When necessary

PRN comes from the Latin “pro re nata” m eaning, for an occasion that has a risen or as ci rcumstances require.

26. Answer: C. Complete Bed Rest

CBR means co mplete b ed rest. For more a bbreviations, please s ee this post .

27. Answer: B. 60

One t easpoon (tsp) is e qual to 60 d rops ( gtts).

28. Answer: B. 20

http://nurseslabs.com/big-fat-list-of-medical-abbreviations-acronymns/http://nurseslabs.com/big-fat-list-of-medical-abbreviations-acronymns/http://nurseslabs.com/big-fat-list-of-medical-abbreviations-acronymns/


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One cubic c entimeter is e qual to one milliliter.

29. Answer: A. 8

One cup is eq ual to 8 ounces.

30. Answer: B. Check the c lient’s i dentication band

The i dentication b and is t he safest way to know the identity o f a p atient whether he is co nscious o r unconscious.

Ask t he client his n ame only a fter you have c hecked his I D band.

31. Answer: B. Between the client’s ch eeks and gums

32. Answer: A. Sims l eft lateral

This p osition provides c omfort to the patient and an easy access to the natural curvature of the rectum.

33. Answer: C. Check the availability of a liquid preparation

The nurse should check rst if the medication is a vailable in liquid form before doing Choice A. Placing it under the

tongue is not the intended way of administering an oral medication.

34. Answer: C. Subcutaneous

The subcutaneous t issue of the abdomen is p referred because absorption of the insulin is m ore consistent from this

location than subcutaneous tissues in other locations.

35. Answer: A. Three times a d ay orally

TID is t he Latin for “terinie”whichmeans three t imes a d ay. P.O. means per orem or through m outh.

36. Answer: A. Caring for the back by m eans of massage

37. Answer: B. Bed making

38. Answer: B. To prevent the transfer of microorganism

Hand washing is t he single most effective infection control measure.

38. Answer: A. Avoid fanning soiled linens


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Fanning soiled linens would scatter t he lodged microorganisms a nd dead skin cells o n the linens.

40. Answer: A. To cleanse, refresh and give c omfort to the cl ient who m ust remain in bed

41. Answer: A. Inspection

Palpation is a method of feeling with the ngers o r hands d uring a physical examination. Percussion is a m ethod oftapping on a surface to determine the underlying structure, and is u sed in clinical examinations t o assess the

condition of the thorax or ab domen. Auscultation (based on the Latin verb auscultare “to listen”) is listening to the

internal sounds o f the body, usually u sing a stethoscope.

42. Answer: D. Inspection

For abdominal exam, auscultation is p erformed b efore palpation b ecause t he act of palpation c ould c hange w hat

was auscultated. Remember the mnemonic “I-A-Per-Pal”.

43. Answer: B. Auscultation

44. Answer: C. Stethoscope

45. Answer: A. Sounds cr eated by air lled lungs

46. Answer: C. Knee-chest

To assume the genupectoral position the person kneels so that the weight of the body is su pported by the knees and

chest, with the buttocks raised. The head is t urned to one side and the arms a re exed so that the upper pa rt of the

body ca n be su pported in part by the elbows.

47. Answer: A. Gait

48. Answer: A. Optic

Cranial Nerve II or the optic nerve is tested through the use of the Snellen chart.

49. Answer: B. Genu-pectoral

50. Answer: D. Use the Z-track technique

During the procedure, skin and tissue are pulled and held rmly while a long needle is i nserted into the muscle. After

the medication is i njected, the skin and tissue are released. The needle track that forms d uring this p rocedure takes


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the shape of the letter “Z,” which gives t he procedure its n ame. This z igzag track line is w hat prevents m edication

from leaking from the m uscle into s urrounding t issue.

1. The m ost appropriate n ursing order for a patient who develops d yspnea a nd s hortness o f breath would

be…

A. Maintain the patient on strict bed rest at all timesB. Maintain the patient in an orthopneic p osition as n eeded

C. Administer oxygen by V enturi mask a t 24%, as n eeded

D. Allow a 1 hour rest period between activities

2. The n urse observes t hat Mr. Adams b egins t o have increased difficulty b reathing. She e levates the h ead

of the b ed to the h igh Fowler position, which decrease s h is resp iratory d istress. The n urse documents t his

breathing as:

A. TachypneaB. Eupnea

C. Orthopnea

D. Hyperventilation

3. The physician orders a platelet count to be p erformed on Mrs. Smith after br eakfast. The n urse is

responsible for:

A. Instructing the patient about this diagnostic t est

B. Writing the order for this testC. Giving the patient breakfast

D. All of the above

4. Mrs. Mitchell has been given a c opy of her diet. The n urse d iscusses t he foods al lowed on a 50 0-mg low

sodium diet. These include:

A. A ham and S wiss cheese sandw ich on w hole wheat bread

B. Mashed p otatoes a nd broiled chicken

C. A tossed salad with oil and vinegar an d olivesD. Chicken b ouillon

5. The p hysician orders a m aintenance d ose o f 5,000 units o f subcutaneous h eparin (an anticoagulant)

daily. Nursing responsibilities for M rs. Mitchell now include:

A. Reviewing d aily a ctivated p artial thromboplastin t ime (A PTT) and p rothrombin t ime.

B. Reporting an APTT above 4 5 se conds t o the physician


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C. Assessing the patient for signs a nd symptoms o f frank and occult bleeding

D. All of the above

6. The four main concepts co mmon to nursing that appear in each of the cu rrent conceptual models ar e:

A. Person, nursing, environment, medicine

B. Person, health, nursing, support systemsC. Person, health, psychology, nursing

D. Person, environment, health, nursing

7. In Maslow’s h ierarchy o f physiologic n eeds, the h uman need of greatest priority is:

A. Love

B. Elimination

C. Nutrition

D. Oxygen

8. The family of an accident victim who has b een declared brain-dead seems am enable to organ donation.

What should the nurse do ?

A. Discourage them from making a decision until their grief has e ased

B. Listen to their concerns a nd answer their questions h onestly

C. Encourage t hem to s ign the consent form right away

D. Tell them the body w ill not be available for a wake or funeral

9. A new head nurse o n a u nit is d istressed about the p oor staffing on the 11 p.m. to 7 a.m. shift. What

should she do?

A. Complain to her fellow nurses

B. Wait until she knows m ore about the unit

C. Discuss t he problem with her supervisor

D. Inform the staff that they m ust volunteer to rotate

10. Which of the following principles of primary n ursing has proven the m ost satisfying to the p atient and

nurse?

A. Continuity of patient care promotes efficient, cost-effective nursing care

B. Autonomy a nd authority for pl anning are best delegated to a nurse who knows t he patient well

C. Accountability i s c learest when one nurse is r esponsible for the overall plan and its implementation.

D. The holistic a pproach provides f or a therapeutic r elationship, continuity, and efficient nursing care.

11. If nurse administers an injection to a patient who refuses t hat injection, she h as committed:


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A. Assault and battery

B. Negligence

C. Malpractice

D. None o f the above

12. If patient asks the nurse her op inion about a particular p hysicians and the nurse replies that the

physician is incompetent, the n urse could be h eld liable f or:

A. Slander

B. Libel

C. Assault

D. Respondent superior

13. A registered nurse reaches to answer the telephone o n a b usy p ediatric u nit, momentarily turning away

from a 3 month-old infant she h as been weighing. The infant falls o ff the s cale, suffering a s kull fracture.

The nurse co uld be charged with:

A. Defamation

B. Assault

C. Battery

D. Malpractice

14. Which of the following is a n example o f nursing malpractice?

A. The nurse administers p enicillin to a patient with a documented history of allergy t o the drug. The patientexperiences a n allergic r eaction and has ce rebral damage resulting from anoxia.

B. The nurse applies a hot water bot tle or a h eating pad to the abdomen of a patient with abdominal cramping.

C. The nurse assists a patient out of bed with the bed locked in position; the patient slips a nd fractures h is ri ght

humerus.

D. The nurse administers t he wrong medication to a patient and the patient vomits. This i nformation is d ocumented

and reported to the p hysician a nd the n ursing s upervisor.

15. Which of the following signs an d symptoms would the nurse exp ect to nd when as sessing an Asian

patient for postoperative pain following abdominal surgery?

A. Decreased blood p ressure and h eart rate and s hallow respirations

B. Quiet crying

C. Immobility, diaphoresis, and avoidance of deep breathing or co ughing

D. Changing position every 2 hours


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16. A patient is admitted to the hospital with complaints of nausea, vomiting, diarrhea, and severe

abdominal pain. Which of the following would immediately alert the n urse t hat the p atient has bleeding from

the GI tract?

A. Complete b lood cou nt

B. Guaiac test

C. Vital signsC. Abdominal girth

17. The co rrect sequence for assessing the ab domen is:

A. Tympanic p ercussion, measurement of abdominal girth, and inspection

B. Assessment for distention, tenderness, and discoloration a round the u mbilicus.

C. Percussions, palpation, and auscultation

D. Auscultation, percussion, and palpation

18. High-pitched gurgles head over t he right lower qu adrant are:

A. A sign of increased bowel motility

B. A sign of decreased b owel motility

C. Normal bowel sounds

D. A sign of abdominal cramping

19. A patient about to undergo abdominal inspection is best placed in which of the following positions?

A. Prone

B. Trendelenburg

C. Supine

D. Side-lying

20. For a rect al examination, the p atient can be d irected to assume w hich of the following positions?

A. Genupectoral

B. SimsC. Horizontal recumbent

D. All of the above

21. During a R omberg test, the n urse asks the p atient to assume w hich position?

A. S itting

B. Standing


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C. Genupectoral

D. Trendelenburg

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

A. 54

B. 96C. 150

D. 246

23. A patient is ke pt off food and uids for 10 hours b efore s urgery. His o ral temperature a t 8 a .m. is 9 9.8 F

(37.7 C) This t emperature r eading probably indicates:

A. Infection

B. Hypothermia

C. AnxietyD. Dehydration

24. Which of the following parameters sh ould be ch ecked when assessing respirations?

A. Rate

B. Rhythm

C. Symmetry

D. All of the above

25. A 38-year old patient’s vital signs a t 8 a.m. are axillary t emperature 99.6 F (37.6 C ); pulse rate, 88;

respiratory rate, 30. Which ndings s hould be reported?

A. Respiratory r ate only

B. Temperature o nly

C. Pulse rate and temperature

D. Temperature and respiratory rate

26. All of the following can cause tachycardia e xcept:

A. Fever

B. Exercise

C. Sympathetic ne rvous syst em stimulation

D. Parasympathetic ne rvous s ystem stimulation

27. Palpating the m idclavicular l ine is the c orrect technique f or assessing


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A. Baseline vital signs

B. Systolic blood pressure

C. Respiratory rat e

D. Apical pulse

28. The ab sence of which pulse may n ot be a signicant nding when a p atient is ad mitted to the h ospital?

A. Apical

B. Radial

C. Pedal

D. Femoral

29. Which of the following patients i s a t greatest risk for developing pressure u lcers?

A. An alert, chronic a rthritic p atient treated with steroids a nd aspirin

B. An 88-year ol d incontinent patient with gastric ca ncer who is co nned to his b ed at homeC. An apathetic 6 3-year old COPD patient receiving nasal oxygen via cannula

D. A confused 78-year old patient with congestive heart failure (CHF) who requires assistance to get out of bed.

30. The p hysician orders t he a dministration of high-humidity o xygen by face mask and placement of the

patient in a h igh Fowler’s p osition. After assessing Mrs. Paul, the n urse writes the following nursing

diagnosis: Impaired gas exchange related to increased secretions. Which of the following nursing

interventions has the greatest potential for i mproving this situation?

A. Encourage the patient to increase her uid intake to 200 ml every 2 hoursB. Place a humidier in the patient’s r oom.

C. Continue a dministering oxygen b y h igh humidity face m ask

D. Perform chest physiotherapy o n a regular schedule

31. The most common deciency seen in alcoholics is:

A. Thiamine

B. Riboavin

C. PyridoxineD. Pantothenic a cid

32. Which of the following statement is i ncorrect about a p atient with dysphagia?

A. The p atient will nd p ureed o r soft foods, such as cu stards, easier to swallow than water

B. Fowler’s o r semi Fowler’s p osition reduces t he risk of aspiration during swallowing

C. The p atient should a lways f eed himself

D. The nurse should perform oral hygiene before assisting with feeding.


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33. To assess the k idney function of a p atient with an indwelling urinary ( Foley) catheter, the n urse

measures his h ourly u rine o utput. She s hould notify the p hysician if the u rine o utput is:

A. Less t han 30 ml/hour

B. 64 ml in 2 hours

C. 90 ml in 3 hours

D. 125 m l in 4 hours

34. Certain substances increase t he a mount of urine p roduced. These include:

A. Caffeine-containing drinks, such as coffee and cola.

B. Beets

C. Urinary a nalgesics

D. Kaolin with pectin (Kaopectate)

35. A male p atient who had surgery 2 days ag o for head and neck c ancer is ab out to make h is rst attemptto ambulate o utside h is r oom. The n urse notes that he is st eady on his feet and that his vi sion was

unaffected by the s urgery. Which of the following nursing interventions w ould be a ppropriate?

A. Encourage the patient to walk in the hall alone

B. Discourage the patient from walking in the hall for a few more days

C. Accompany the p atient for his w alk.

D. Consult a p hysical therapist before allowing t he patient to a mbulate

36. A patient has exacerbation of chronic o bstructive pulmonary d isease (COPD) manifested by shortnessof breath; orthopnea: thick, tenacious s ecretions; and a d ry hacking cough. An appropriate n ursing

diagnosis would be:

A. Ineffective airway c learance related to thick, tenacious s ecretions.

B. Ineffective airway clearance related to dry, hacking cough.

C. Ineffective i ndividual coping to COPD.

D. Pain related to immobilization of affected leg.

37. Mrs. Lim begins t o cry as the n urse d iscusses h air loss. The b est response would be:

A. “Don’t worry. It’s only temporary”

B. “Why are you crying? I didn’t get to the bad news ye t”

C. “Your ha ir is really pretty”

D. “I know this w ill be difficult for you, but your hair will grow back after the completion of chemotheraphy”

38. An additional Vitamin C is required during all of the following periods except:


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A. Infancy

B. Young adulthood

C. Childhood

D. Pregnancy

39. A prescribed amount of oxygen s n eeded for a pat ient with COPD to prevent:

A. Cardiac arrest related to increased partial pressure of carbon dioxide in arterial blood (PaCO2)

B. Circulatory overload d ue t o h ypervolemia

C. Respiratory exc itement

D. Inhibition of the respiratory hypoxic stimulus

40. After 1 week o f hospitalization, Mr. Gray d evelops h ypokalemia. Which of the following is t he m ost

signicant symptom of his d isorder?

A. LethargyB. Increased pulse rate a nd blood p ressure

C. Muscle weakness

D. Muscle irritability

41. Which of the following nursing interventions p romotes patient safety?

A. Asses t he patient’s a bility t o ambulate and transfer from a bed to a chair

B. Demonstrate t he signal system to the p atient

C. Check to see that the patient is w earing his i dentication bandD. All of the above

42. Studies have shown that about 40% of patients f all out of bed despite t he u se of side rai ls; this h as led

to which of the following conclusions?

A. Side rails are ineffective

B. Side rails s hould not be used

C. Side rails are a deterrent that prevent a patient from falling out of bed.

D. Side rails are a reminder to a patient not to get out of bed

43. Examples of patients suffering from impaired awareness include all of the following except:

A. A semiconscious o r over fatigued patient

B. A disoriented o r confused p atient

C. A patient who cannot care for himself at home

D. A patient demonstrating symptoms o f drugs or alcohol withdrawal


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44. The m ost common injury among elderly persons is:

A. Atheroscleotic ch anges in the b lood ve ssels

B. Increased incidence of gallbladder disease

C. Urinary Tract Infection

D. Hip fracture

45. The most common psychogenic d isorder among elderly person is:

A. Depression

B. Sleep disturbances (such as bizarre dreams)

C. Inability t o concentrate

D. Decreased appetite

46. Which of the following vascular system changes r esults from aging?

A. Increased peripheral resistance of the blood vessels

B. Decreased blood ow

C. Increased workload of the left ventricle

D. All of the above

47. Which of the following is the most common cause o f dementia am ong elderly persons?

A. Parkinson’s d isease

B. Multiple sclerosis

C. Amyotrophic l ateral sclerosis ( Lou Gehrig’s d isease)

D. Alzheimer’s d isease

48. The nurse’s most important legal responsibility after a p atient’s death in a hospital is:

A. Obtaining a c onsent of an autopsy

B. Notifying the coroner or m edical examiner

C. Labeling the corpse appropriately

D. Ensuring that the a ttending p hysician issues t he d eath certication

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

A. Providing a c omplete b ath a nd dressing change

B. Placing one pillow under the body’s h ead and shoulders

C. Removing the body’s cl othing and wrapping the body in a shroud

D. Allowing the body to relax n ormally


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50. When a p atient in the t erminal stages of lung cancer begins t o exhibit loss of consciousness, a m ajor

nursing priority is to:

A. Protect the patient from injury

B. Insert an airway

C. Elevate the head of the bed

D. Withdraw all pain medications


The a nswers an d rationale b elow will give yo u a better understanding o f the e xam. Counter-check yo ur answers to

those below. If you have any d isputes o r objects, please direct them to the comments se ction.

1. Answer: B. Maintain the patient in an orthopneic p osition as needed

When a patient develops d yspnea and shortness o f breath, the orthopneic p osition encourages maximum chestexpansion and keeps t he abdominal organs from pressing a gainst the d iaphragm, thus improving ventilation. Bed

rest and oxygen by Venturi mask at 24% would improve oxygenation of the tissues a nd ce lls bu t must be ordered by

a physician. Allowing for rest periods d ecreases t he possibility o f hypoxia.

2. Answer: C. Orthopnea

Orthopnea i s d ifficulty o f breathing except in t he upright position. Tachypnea is r apid respiration characterized b y

quick, shallow breaths. Eupnea is n ormal respiration – quiet, rhythmic, and without effort.

3. Answer: C. Giving the p atient breakfast

A platelet count evaluates t he number of platelets i n the circulating blood volume. The nurse is r esponsible for giving

the patient breakfast at the scheduled time. The physician is r esponsible for instructing the patient about the test

and for writing the order for the test.

4. Answer: B. Mashed potatoes an d broiled chicken

Mashed potatoes and broiled chicken are low in natural sodium chloride. Ham, olives, and chicken bouillon contain

large amounts o f sodium and a re contraindicated on a low sodium diet.


All of the identied nursing responsibilities are pertinent when a patient is rec eiving heparin. The normal activated

partial thromboplastin time is 1 6 to 25 seconds a nd the normal prothrombin time is 1 2 to 15 seconds; these levels

must remain within two to two and one half the normal levels. All patients r eceiving anticoagulant therapy must be

observed for signs a nd symptoms o f frank a nd occult bleeding (including hemorrhage, hypotension, tachycardia,


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tachypnea, restlessness, pallor, cold and clammy skin, thirst and confusion); blood pressure should be measured

every 4 hours a nd the patient should be instructed to report promptly a ny bleeding that occurs w ith tooth brushing,

bowel movements, urination or heavy p rolonged m enstruation.

6. Answer: D. Person, environment, health, nursing

The focus c oncepts t hat have been accepted by all theorists a s t he focus o f nursing practice from the time ofFlorence Nightingale include the person receiving nursing care, his environment, his health on the health illness

continuum, and the nursing a ctions n ecessary to meet his n eeds.

7. Answer: D. Oxygen

Maslow, who dened a need as a satisfaction whose absence causes illness, considered oxygen to be the most

important physiologic n eed; without it, human life could not exist. According to this t heory, other physiologic n eeds

(including food, water, elimination, shelter, rest and sleep, activityand temperature regulation) must be met before

proceeding to the next hierarchical levels o n psychosocial needs.

8. Answer: B. Listen to their concerns a nd answer t heir questions h onestly

The b rain-dead p atient’s family needs su pport and reassurance in m aking a decision a bout organ d onation.

Because t ransplants ar e d one within hours of death, decisions ab out organ donation must be made a s soo n a s

possible. However, the family’s co ncerns m ust be addressed before m embers ar e a sked to si gn a consent form. The

body o f an organ donor is a vailable for burial.

9. Answer: C. Discuss t he p roblem with her supervisor

Although a new head nurse should initially s pend time observing the unit for its st rengths a nd weakness, she should

take action if a problem threatens p atient safety. In this c ase, the supervisor is t he resource person to approach.

10. Answer: D. The holistic approach provides for a therapeutic relationship, continuity, and efficient

nursing care.

Studies h ave shown that patients a nd nurses b oth respond w ell to primary n ursing care u nits. Patients feel less

anxious a nd isolated and more secure because they are allowed to participate in planning their own care. Nurses

feel personal satisfaction, much of it related to positive feedback from the patients. They a lso seem to gain a greater

sense of achievement and esprit de corps.

11. Answer: A. Assault and battery

Assault is t he unjustiable attempt or threat to touch or injure another person. Battery i s t he unlawful touching of

another pe rson or t he carrying out of threatened physical harm. Thus, any act that a nurse performs o n the patient

against his will is considered assault and battery.


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12. Answer: A. Slander

Oral communication that injures a n individual’s reputation is c onsidered slander. Written communication that does

the same is co nsidered libel.

13. Answer: D. Malpractice

Malpractice is dened as injurious or un professional actions that harm another. It involves professional misconduct,

such as omission or com mission of an act that a reasonable and prudent nurse would or w ould not do. In this

example, the s tandard o f care w as b reached; a 3 -month-old infant should n ever be left unattended o n a scale.

14. Answer: A. The n urse administers p enicillin to a p atient with a d ocumented history o f allergy to the

drug. The patient experiences an allergic react ion and has cerebral damage resu lting from anoxia.

The three elements necessary to establish a nursing malpractice are nursing error (administering penicillin to a

patient with a documented allergy to the drug), injury (cerebral damage), and proximal cause (administering the

penicillin caused the cerebral damage). Applying a hot water bottle or heating pad to a patient without a physician’s

order does n ot include the three required components. Assisting a patient out of bed with the bed locked in position

is t he correct nursing practice; therefore, the fracture was n ot the result of malpractice. Administering an incorrect

medication is a nursing error; however, if such action resulted in a serious i llness or chronic p roblem, the nurse could

be sued for malpractice.

15. Answer: C. Immobility, diaphoresis, and avoidance o f deep breathing or coughing

An Asian patient is l ikely to hide his p ain. Consequently, the nurse must observe for objective signs. In an abdominal

surgery p atient, these might include immobility, diaphoresis, and avoidance of deep breathing or coughing, as w ell

as increased heart rate, shallow respirations stemming from pain upon moving the d iaphragm and respiratory

muscles), and g uarding o r rigidity o f the abdominal wall. Such a p atient is u nlikely to d isplay e motion, such as

crying.

16. Answer: B. Guaiac t est

To assess for GI tract bleeding when frank b lood is a bsent, the nurse has t wo options: She can test for occult blood

in vomitus, if present, or in stool – through guaiac ( Hemoccult) test. A complete blood count does n ot provideimmediate results a nd does not always immediately reect blood loss. Changes i n vital signs m ay be cause by

factors o ther than blood loss. Abdominal girth is u nrelated to blood loss.

17. Answer: D. Auscultation, percussion, and palpation

Because percussion and palpation can affect bowel motility a nd thus b owel sounds, they should follow auscultation

in a bdominal assessment. Tympanic pe rcussion, measurement of abdominal girth, and inspection a re methods o f


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assessing the abdomen. Assessing for distention, tenderness and discoloration around the umbilicus can indicate

various b owel-related conditions, such as c holecystitis, appendicitis a nd peritonitis.

18. Answer: C. Normal bowel sounds

Hyperactive sounds i ndicate increased bowel motility; two or t hree sounds per minute indicate decreased bowel

motility. Abdominal cramping with hyperactive, high pitched tinkling bowel sounds c an indicate a bowel obstruction.

19. Answer: C. Supine

The supine position (also called the dorsal position), in which the patient lies o n his b ack with his f ace upward,

allows for easy a ccess t o the abdomen. In the p rone p osition, the p atient lies o n his a bdomen w ith his f ace turned to

the side. In the Trendelenburg position, the head of the bed is t ilteddownward to 30 to 40 degrees s o that the upper

body is l ower than the legs. In the lateral position, the patient lies on his side.


All of these positions are appropriate for a rectal examination. In the genupectoral (knee-chest) position, the patient

kneels a nd rests h is ch est on the table, forming a 9 0 d egree angle b etween the t orso and upper legs. In S ims’

position, the patient lies o n his l eft side with the left arm behind the body a nd his ri ght leg exed. In the horizontal

recumbent position, the patient lies o n his b ack w ith legs e xtended a nd h ips r otated outward.

21. Answer: B. Standing

During a Romberg test, which evaluates f or sensory o r cerebellar ataxia, the patient must stand with feet together

and a rms r esting a t the s ides—rst with e yes open, then with e yes cl osed. The n eed to m ove the feet apart to

maintain this st ance is a n abnormal nding.

22. Answer: A. 54

The p ulse pressure is t he difference between the systolic a nd diastolic b lood pressure r eadings – in this ca se, 54.

23. Answer: D. Dehydration

A slightly e levated temperature in the immediate preoperative or post operative period may result from the lack ofuids b efore surgery r ather than from infection. Anxiety w ill not cause an elevated temperature. Hypothermia is a n

abnormally low body temperature.

24 Answer D. All of the ab ove

The quality a nd efficiency of the respiratory p rocess c an be determined by appraising the rate, rhythm, depth, ease,

sound, and sy mmetry of respirations.


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25. Answer: D. Temperature a nd respiratory rate

Under normal conditions, a healthy adult breathes in a smooth uninterrupted pattern 12 to 20 times a minute. Thus,

a respiratory rate of 30 would be abnormal. A normal adult body temperature, as measured on an oral thermometer,

ranges b etween 97° and 100°F (36.1° an d 37.8°C); an axillary temperature is a pproximately o ne degree lower and a

rectal temperature, one degree higher. Thus, an axillary t emperature of 99.6°F (37.6°C) would be considered

abnormal. The resting pulse rate in an adult ranges f rom 60 to 100 beats/minute, so a rate of 88 is n ormal.

26. Answer: D. Parasympathetic n ervous s ystem stimulation

Parasympathetic n ervous s ystem stimulation of the heart decreases t he heart rate as w ell as t he force of

contraction, rate o f impulse conduction a nd b lood ow through the c oronary ve ssels. Fever, exercise, and

sympathetic stimulation all increase the heart rate.

27. Answer: D. Apical pulse

The apical pulse (the pulse at the apex of the heart) is located on the midclavicular line at the fourth, fth, or sixth

intercostal space. Base line vital signs i nclude pulse rate, temperature, respiratory rat e, and blood pressure. Blood

pressure is typically assessed at the antecubital fossa, and respiratory rate is assessed best by observing chest

movement with each inspiration and expiration.

28. Answer: C. Pedal

Because the p edal pulse cannot be d etected in 1 0% to 2 0% of the p opulation, its a bsence is n ot necessarily a

signicant nding. However, the presence o r absence o f the pedal pulse sh ould be d ocumented upon a dmission so

that changes c an be identied during the hospital stay. Absence of the apical, radial, or femoral pulse is a bnormal

and should be investigated.

29. Answer: B. An 88-year ol d incontinent patient with gastric c ancer w ho is c onned to his b ed at home

Pressure ulcers are most likely to develop in patients with impaired mental status, mobility, activity level, nutrition,

circulation and bladder or bowel control. Age is also a factor. Thus, the 88-year old incontinent patient who has

impaired nutrition (from gastric c ancer) and is c onned to bed is a t greater risk.

30. Answer: A. Encourage the p atient to increase h er uid intake to 200 m l every 2 h ours

Adequate hydration thins and loosens pulmonary s ecretions and also helps t o replace uids l ost from elevated

temperature, diaphoresis, dehydration and dyspnea. High- humidity a ir and chest physiotherapy help liquefy and

mobilize secretions.

31. Answer: A. Thiamine


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Chronic al coholism commonly results in thiamine d eciency a nd o ther symptoms of malnutrition.

32. Answer: C. The p atient should always feed himself

A patient with dysphagia (difficulty s wallowing) requires a ssistance with feeding. Feeding himself is a long-range

expected outcome. Soft foods, Fowler’s o r semi-Fowler’s p osition, and o ral hygiene before e ating should be part of

the feeding regimen.

33. Answer: A. Less t han 30 ml/hour

A urine output of less than 30ml/hour indicates hypovolemia or oliguria, which is related to kidney function and

inadequate uid intake.

34. Answer: A. Caffeine-containing drinks, such as c offee and cola.

Fluids co ntaining c affeine h ave a diuretic e ffect. Beets a nd u rinary a nalgesics, such as P yridium (Phenazopyridine),

can color urine red. Kaopectate is a n antidiarrheal medication.

35. Answer: C. Accompany the p atient for his w alk.

A hospitalized surgical patient leaving his roo m for the rst time fears rej ection and others s taring at him, so he

should not walk a lone. Accompanying him will offer moral support, enabling him to face the rest of the world.

Patients sh ould begin ambulation as soon as possible after surgery to decrease complications and to regain

strength and c ondence. Waiting to consult a physical therapist is u nnecessary.

36. Answer: A. Ineffective airway clearance related to thick, tenacious secretions.

Thick, tenacious se cretions, a dry, hacking cough, orthopnea, and shortness o f breath are signs o f ineffective airway

clearance. Ineffective airway clearance related to dry, hacking cough is i ncorrect because the cough is n ot the

reason for the ineffective airway clearance. Ineffective individual coping relatedtoCOPD is w rong because the

etiology for a nursing diagnosis sh ould n ot be a medical diagnosis ( COPD) and because n o data indicate that the

patient is c oping ineffectively. Pain related to immobilization of affected leg w ould be an appropriate n ursing

diagnosis f or a patient with a leg fracture.

37. Answer: D. “I know this w ill be d ifficult for you, but your hair will grow back a fter t he c ompletion

of chemotherapy”

“I know this w ill be difficult” acknowledges t he problem and suggests a resolution to it. “Don’t worry..” offers s ome

relief but doesn’t recognize the patient’s f eelings. “..I didn’tgettothebadn ews ye t” would be inappropriate at any

time. “Your hair is really pretty” o ffers no consolation or alternatives to the patient.

38. Answer: B. Young adulthood


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Additional Vitamin C is n eeded in g rowth periods, such as infancy a nd childhood, and d uring p regnancy t o supply

demands for fetal growth a nd maternal tissues. Other conditions r equiring extra v itamin C include wound healing,

fever, infection and stress.

39. Answer: D. Inhibition of the res piratory h ypoxic s timulus

Delivery o f more than 2 liters o f oxygen per m inute to a patient with chronic o bstructive pulmonary d isease (COPD),who is u sually in a s tate of compensated res piratory a cidosis ( retaining c arbon d ioxide (CO2)), can inhibit the

hypoxic s timulus f or respiration. An increased partial pressure of carbon dioxide in arterial blood (PACO2) would not

initially esultincardiacrrest.Circulatoryverloadand respiratoryxcitement have no relevance to the question.

40. Answer: C. Muscle weakness

Presenting s ymptoms o f hypokalemia ( a s erum potassium level below 3.5 mEq/liter) include muscle weakness,

chronic fatigue, and cardiac d ysrhythmias. The c ombined effects o f inadequate food intake and p rolonged d iarrhea

can deplete the potassium stores o f a patient with GI problems.


Assisting a patient with ambulation and transfer from a bed to a chair allows the nurse to evaluate the patient’s

ability to carry o ut these functions s afely.Demonstrating the signal system and providing an opportunity for a return

demonstration ensures that the patient knows h ow to operate the equipment and encourages him to call for

assistance when needed. Checking the patient’s i dentication band veries t he patient’s i dentity a nd prevents

identication mistakes in drug administration.

42. Answer: D. Side rai ls a re a reminder t o a p atient not to get out of bed

Since about 40% of patients f all out of bed despite the use of side rails, side rails c annot be said to prevent falls;

however, they do serve as a reminder that the patient should not get out of bed. The other an swers a re incorrect

interpre tations o f the statistical data.

43. Answer: C. A patient who cannot care for himself at home

A patient who cannot care for himself at home d oes no t necessarily ha ve impaired awareness; he may si mply ha ve

some degree of immobility.

44. Answer: D. Hip fracture

Hip fracture, the most common injury a mong elderly p ersons, usually results f rom osteoporosis. The other an swers

are d iseases t hat can o ccur in the e lderly from physiologic ch anges.

45. Answer: A. Depression


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Sleep disturbances, inabilityoconcentraanddecreased appetitearesymptoms o f depression, the most common

psychogenic d isorder among elderly persons. Other symptoms include d iminished m emory, apathy, disinterest in

appearance, withdrawal, and irritability. Depression typically b egins b efore the onset of old age and usually is

caused by p sychosocial, genetic, or biochemical factors


Aging decreases e lasticity o f the b lood vessels, which leads t o increased peripheral resistance and decreased blood

ow. These changes, in turn, increase the workload of the left ventricle.

47. Answer: D. Alzheimer’s d isease

Alzheimer;s disease, sometimes kn own a s senile d ementia o f the Alzheimer’s t ype o r primary degenerative

dementia , is a n insidious; progressive, irreversible, and degenerative disease of the brain whose etiology i s s till

unknown. Parkinson’s d isease is a neurologic d isorder caused by lesions i n the extrapyramidal system and

manifested by t remors, muscle rigidity, hypokinesia, dysphagia, and dysphonia. Multiple s clerosis, a progressive,degenerative disease involving demyelination of the nerve bers, usually b egins in young adulthood and is m arked

by periods o f remission and exacerbation. Amyotrophic lateral sclerosis , a d isease m arked by p rogressive

degeneration of the n eurons, eventually results i n a trophy o f all the m uscles; including t hose necessary for

respiration.

48. ANswer: C. Labeling the corpse appropriately

The n urse is l egally responsible for labeling the c orpse when death o ccurs i n t he h ospital. She m ay be involved in

obtaining consent for an autopsy or notifying the coroner or medical examiner of a patient’s d eath; however, she isnot legally responsible for performing these functions. The a ttending physician may need information from the n urse

to complete the death certicate, but he is responsible for issuing it.

49. Answer: B. Placing o ne p illow under the b ody’s h ead and shoulders

The n urse must place a pillow under the decreased p erson’s h ead a nd shoulders t o prevent blood from settling in

the face and discoloring it. She is required to bathe only s oiled areas of the body s ince the mortician will wash the

entire body. Before wrapping the body in a shroud, the nurse places a clean gown on the body a nd closes t he eyes

and mouth.

50. Answer: A. Protect the patient from injury

Ensuring the patient’s s afety is t he most essential action at this t ime. The other nursing actions m ay be necessary

but are not a major priority.

1. Which element in the circular ch ain of infection can be eliminated by preserving skin integrity?


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A. Host

B. Reservoir

C. Mode o f transmission

D. Portal of entry

2. Which of the f ollowing will probably res ult in a b reak in sterile t echnique f or respiratory i solation?

A. Opening the patient’s w indow to the outside environment

B. Turning on the patient’s r oom ventilator

C. Opening the door of the patient’s roo m leading into the hospital corridor

D. Failing to wear gloves w hen a dministering a bed b ath

3. Which of the following patients i s a t greater risk for contracting an infection?

A. A patient with leukopenia

B. A patient receiving broad-spectrum antibioticsC. A postoperative p atient who has u ndergone orthopedic su rgery

D. A newly diagnosed d iabetic p atient

4. Effective h and washing requires the u se of:

A. Soap o r detergent to p romote e mulsication

B. Hot water to destroy bacteria

C. A disinfectant to increase surface tension

D. All of the above

5. After r outine p atient contact, hand washing should last at least:

A. 30 secon ds

B. 1 m inute

C. 2 minute

D. 3 m inutes

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

A. Vaginal instillation of conjugated estrogen

B. Urinary c atheterization

C. Nasogastric t ube insertion

D. Colostomy irrigation

7. Sterile technique is u sed whenever:


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A. Strict isolation is required

B. Terminal disinfection is p erformed

C. Invasive procedures are performed

D. Protective isolation is necessary

8. Which of the f ollowing constitutes a break in sterile technique w hile preparing a sterile eld for a

dressing change?

A. Using sterile forceps, rather than sterile gloves, to handle a sterile item

B. Touching the outside wrapper of sterilized material without sterile gloves

C. Placing a sterile object on the edge of the sterile eld

D. Pouring out a small amount of solution (15 to 30 ml) before pouring the solution into a sterile container

9. A natural body d efense that plays a n active role in preventing infection is:

A. YawningB. Body ha ir

C. Hiccupping

D. Rapid eye m ovements

10. All of the following statement are t rue about donning sterile gloves except:

A. The rst glove should be picked up by grasping the inside of the cuff.

B. The second glove should be picked up by inserting the gloved ngers u nder the cuff outside the glove.

C. The g loves sh ould be adjusted b y sl iding the g loved ngers u nder the s terile cuff and p ulling t he glove o ver thewrist

D. The inside of the glove is c onsidered sterile

11. When removing a co ntaminated gown, the n urse s hould be ca reful that the rst thing she touches i s t he:

A. Waist tie and neck t ie at the back o f the gown

B. Waist tie in front of the gown

C. Cuffs of the g own

D. Inside o f the g own

12. Which of the following nursing interventions is co nsidered t he m ost effective form or universal

precautions?

A. Cap all used needles before removing them from their syringes

B. Discard all used uncapped needles and syringes i n a n impenetrable p rotective container

C. Wear gloves w hen a dministering IM injections

D. Follow enteric precautions


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13. All of the following measures are r ecommended to prevent pressure u lcers ex cept:

A. Massaging the reddened area w ith lotion

B. Using a water or air mattress

C. Adhering to a schedule for positioning and turning

D. Providing meticulous sk in care

14. Which of the following blood tests sh ould be p erformed before a b lood transfusion?

A. Prothrombin a nd c oagulation time

B. Blood typing a nd cr oss-matching

C. Bleeding and clotting time

D. Complete b lood count (CBC) and e lectrolyte levels.

15. The p rimary p urpose of a p latelet count is t o evaluate t he:

A. Potential for clot formation

B. Potential for bl eeding

C. Presence of an antigen-antibody response

D. Presence o f cardiac en zymes

16. Which of the following white b lood cell (WBC) counts c learly indicates leukocytosis?

A. 4,500/mm³

B. 7,000/mm³

C. 10,000/mm³

D. 25,000/mm³

17. After 5 d ays o f diuretic therapy with 20mg of furosemide (Lasix) daily, a patient begins to exhibit fatigue,

muscle cr amping and muscle weakness. These s ymptoms p robably indicate that the patient is

experiencing:

A. Hypokalemia

B. HyperkalemiaC. Anorexia

D. Dysphagia

18. Which of the following statements a bout chest X-ray is f alse?

A. No contradictions exist for this test

B. Before the procedure, the patient should remove all jewelry, metallic o bjects, and buttons a bove the waist


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C. A signed consent is n ot required

D. Eating, drinking, and medications a re allowed before this test

19. The m ost appropriate t ime for the n urse to obtain a s putum specimen for culture is:

A. Early in the morning

B. After the patient eats a light breakfastC. After aerosol therapy

D. After chest physiotherapy

20. A patient with no known allergies is t o receive penicillin every 6 hours. When administering the

medication, the n urse observes a ne rash on the p atient’s s kin. The m ost appropriate n ursing action would

be to:

A. Withhold t he moderation and n otify the physician

B. Administer the medication and notify t he physicianC. Administer the medication with an antihistamine

D. Apply co rn starch soaks t o the rash

21. All of the following nursing interventions a re c orrect when using the Z -track m ethod of drug injection

except:

A. Prepare the injection site with alcohol

B. Use a needle that’s a least 1” long

C. Aspirate for blood before injectionD. Rub the site vigorously a fter the injection to promote absorption

22. The c orrect method for determining the v astus l ateralis s ite f or I.M. injection is t o:

A. Locate the upper asp ect of the upper outer quadrant of the buttock a bout 5 to 8 cm below the iliac cr est

B. Palpate the lower edge of the acromion process a nd the midpoint lateral aspect of the arm

C. Palpate a 1” circular area anterior to the umbilicus

D. Divide the area between the greater femoral trochanter and the lateral femoral condyle into thirds, and select the

middle third on the anterior of the thigh

23. The mid-deltoid injection site is seldom used for I.M. injections because it:

A. Can accommodate o nly 1 m l or less o f medication

B. Bruises t oo easily

C. Can b e u sed o nly when the p atient is lying d own

D. Does n ot readily p arenteral medication


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24. The a ppropriate n eedle s ize for insulin injection is:

A. 18G, 1 ½ ” long

B. 22G, 1” long

C. 22G, 1 ½” long

D. 25G, 5/8” long

25. The appropriate needle gauge for intradermal injection is:

A. 20G

B. 22G

C. 25G

D. 26G

26. Parenteral penicillin can be administered as an:

A. IM injection or an IV solution

B. IV or an intradermal injection

C. Intradermal or subcutaneous i njection

D. IM or a su bcutaneous i njection

27. The physician orders g r 10 of aspirin for a patient. The equivalent dose in milligrams is:

A. 0.6 mg

B. 10 mg

C. 60 mg

D. 600 mg

28. The p hysician orders an IV solution o f dextrose 5 % in water at 100ml/hour. What would the ow rate b e if

the drop factor is 1 5 gtt = 1 m l?

A. 5 gtt/minute

B. 13 gtt/minute

C. 25 gtt/minuteD. 50 gtt/minute

29. Which of the following is a sign or symptom of a h emolytic r eaction to blood transfusion?

A. Hemoglobinuria

B. Chest pain

C. Urticaria

D. Distended neck ve ins


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30. Which of the following conditions may require uid restriction?

A. Fever

B. Chronic O bstructive P ulmonary Disease

C. Renal Failure

D. Dehydration

31. All of the following are c ommon signs an d symptoms o f phlebitis exc ept:

A. Pain or discomfort at the IV insertion site

B. Edema a nd warmth a t the IV insertion s ite

C. A red streak exiting the IV insertion site

D. Frank bleeding at the insertion site

32. The b est way of determining whether a p atient has learned to instill ear medication properly is f or the

nurse t o:

A. Ask t he patient if he/she has u sed ear drops before

B. Have t he p atient repeat the n urse’s instructions u sing h er own words

C. Demonstrate the procedure to the patient and encourage to ask questions

D. Ask t he p atient to demonstrate the p rocedure

33. Which of the following types o f medications ca n be ad ministered via g astrostomy tube?

A. Any o ral medications

B. Capsules w hole co ntents ar e d issolve in water

C. Enteric-coated tablets t hat are thoroughly d issolved in water

D. Most tablets d esigned for oral use, except for extended-duration compounds

34. A patient who develops h ives a fter r eceiving an antibiotic i s e xhibiting drug:

A. Tolerance

B. Idiosyncrasy

C. SynergismD. Allergy

35. A patient has returned to his roo m after f emoral arteriography. All of the following are ap propriate

nursing interventions except:

A. Assess femoral, popliteal, and pedal pulses e very 1 5 minutes f or 2 hours

B. Check t he pressure dressing for sanguineous d rainage


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A. Assessment

B. Analysis

C. Planning

D. Evaluation

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

A. White potatoes

B. Carrots

C. Apricots

D. Egg yolks

43. Which of the following is a primary n ursing intervention necessary for all patients with a Foley Catheter

in place?

A. Maintain t he drainage t ubing a nd collection b ag level with t he patient’s b ladderB. Irrigate the patient with 1% Neosporin solution three times a daily

C. Clamp the catheter for 1 hour every 4 hours t o maintain the bladder’s e lasticity

D. Maintain the drainage tubing and collection bag below bladder level to facilitate drainage by g ravity

44. The ELISA test is u sed to:

A. Screen blood donors for antibodies t o human immunodeciency vi rus ( HIV)

B. Test blood to be used for transfusion for HIV antibodies

C. Aid in d iagnosing a p atient with AIDSD. All of the above

45. The two blood ves sels m ost commonly used for TPN infusion are the:

A. Subclavian and jugular vei ns

B. Brachial and s ubclavian veins

C. Femoral and s ubclavian ve ins

D. Brachial and femoral veins

46. Effective s kin disinfection before a s urgical procedure includes which of the following m ethods?

A. Shaving the site on the day before surgery

B. Applying a topical antiseptic to the skin on the evening before surgery

C. Having the patient take a tub bath o n the m orning of surgery

D. Having the p atient shower with a n a ntiseptic so ap o n the evening b efore a nd the m orning o f surgery


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47. When transferring a p atient from a b ed to a c hair, the n urse should use which muscles to avoid back

injury?

A. Abdominal muscles

B. Back muscles

C. Leg muscles

D. Upper arm muscles

48. Thrombophlebitis typically develops in patients with which of the following conditions?

A. Increases p artial thromboplastin time

B. Acute pulsus paradoxus

C. An impaired or t raumatized blood vessel wall

D. Chronic O bstructive P ulmonary Disease (COPD)

49. In a recumbent, immobilized patient, lung ventilation can become altered, leading to such respiratorycomplications as:

A. Respiratory acidosis, atelectasis, and hypostatic p neumonia

B. Apneustic b reathing, atypical pneumonia and respiratory a lkalosis

C. Cheyne-Stokes r espirations an d sp ontaneous p neumothorax

D. Kussmaul’s respirations and hypoventilation

50. Immobility impairs b ladder el imination, resulting in such disorders a s

A. Increased urine acidity and relaxation of the perineal muscles, causing incontinence

B. Urine retention, bladder distention, and infection

C. Diuresis, natriuresis, and decreased urine specic gravity

D. Decreased calcium and phosphate levels i n the urine


Gauge your performance b y co unter checking your answers t o the answers be low. Learn m ore about the question

by reading the r ationale. If you h ave a ny d isputes o r questions, please direct them to the c omments se ction.

1. Answer: D. Portal of entry

In the circular chain of infection, pathogens m ust be able to leave their reservoir and be transmitted to a susceptible

host through a portal of entry, such as b roken skin.

2. Answer: C. Opening the d oor of the p atient’s r oom leading into the h ospital corridor


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Respiratory isolation, like strictisolation,requireshathedoortothedoor patient’sm remain closed. However,

the patient’s room should be well ventilated, so opening the window or turning on the ventricular is d esirable. The

nurse does n ot need to wear gloves f or respiratory isolation, but good hand washing is i mportant for all types o f

isolation.

3. Answer: A. A patient with leukopenia

Leukopenia is a decreased number of leukocytes ( white blood cells), which are important in resisting infection. None

of the other situations w ould put the patient at risk for contracting an infection; taking broad-spectrum antibiotics

might actually r educe the infection risk.

4. Answer: A. Soap or detergent to promote e mulsication

Soaps a nd d etergents a re u sed to h elp remove b acteria b ecause of their ability to lower the s urface tension o f water

and act as e mulsifying agents. Hot water may lead to skin irritation or burns.

5. Answer: A. 30 seco nds

Depending on the degree of exposure to pathogens, hand washing may last from 10 seconds t o 4 minutes. After

routine p atient contact, hand washing for 30 s econds e ffectively m inimizes t he ri sk o f pathogen t ransmission.

6. Answer: B. Urinary c atheterization

The urinary syst em is n ormally free of microorganisms e xcept at the urinary m eatus. Any procedure that involves

entering this s ystem must use surgically a septic m easures t o maintain a bacteria-free state.

7. Answer: C. Invasive p rocedures a re performed

All invasive procedures, including surgery, catheter insertion, and administration of parenteral therapy, require sterile

technique t o m aintain a sterile e nvironment. All equipment must be s terile, and the n urse and the p hysician m ust

wear sterile gloves a nd maintain surgical asepsis. In the operating room, the nurse and physician are required to

wear sterile gowns, gloves, masks, hair covers, and shoe covers f or all invasive procedures. Strict isolation requires

the use o f clean g loves, masks, gowns and e quipment to prevent the t ransmission o f highly co mmunicable d iseases

by c ontact or by a irborne routes. Terminal disinfection is t he disinfection of all contaminated supplies a nd equipment

after a patient has been discharged to prepare them for r euse by another patient. The purpose of protective

(reverse)isolation is t o prevent a person with seriously impaired resistance from coming into contact who potentially

pathogenic organisms.

8. Answer: C. Placing a s terile o bject on the e dge o f the s terile eld

The edges of a sterile eld are considered contaminated. When sterile items a re allowed to come in contact with the

edges o f the eld, the sterile items a lso become contaminated.


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9. Answer: B. Body hair

Hair on or within body a reas, such as t he nose, traps a nd holds p articles t hat contain microorganisms. Yawning and

hiccupping do not prevent microorganisms from entering or leaving the body. Rapid e ye m ovement marks t he stage

of sleep during which dreaming occurs.

10. Answer: D. The inside o f the glove is considered sterile

The inside of the glove is always considered to be clean, but not sterile.

11. Answer: A. Waist tie an d neck tie at the b ack o f the g own

The b ack of the g own is co nsidered c lean, the front is co ntaminated. So, after removing g loves a nd washing h ands,

the nurse should untie the back of the gown; slowly m ove backward away from the gown, holding the inside of the

gown and keeping the edges o ff the oor; turn and fold the gown inside out; discard it in a contaminated linen

container; then wash her hands a gain.

12. Answer: B. Discard all used uncapped needles a nd syringes i n an impenetrable p rotective c ontainer

According to the Centers for Disease C ontrol (CDC), blood-to-blood c ontact occurs m ost commonly when a h ealth

care worker attempts t o cap a used needle. Therefore, used needles should never be recapped; instead they sh ould

be inserted in a specially d esigned puncture resistant, labeled container. Wearing gloves i s n ot always n ecessary

when administering an I.M. injection. Enteric precautions prevent the transfer of pathogens via feces.

13. Answer: A. Massaging the r eddened area with lotion

Nurses a nd other health care professionals p reviously b elieved that massaging a reddened area with lotion would

promote venous r eturn a nd reduce edema to the area. However, research h as sh own that massage only increases

the likelihood of cellular ischemia and necrosis t o the area.

14. Answer: B. Blood typing and cross-matching

Before a blood transfusion is p erformed, the blood of the donor and recipient must be checked for compatibility. This

is d one by blood typing (a test that determines a person’s b lood type) an d cross-matching (a procedure that

determines the compatibility o f the donor’s a nd recipient’s blood after the blood types h as b een matched). If the

blood specimens are incompatible, hemolysis and antigen-antibody reactions will occur.

15. Answer: A. Potential for clot formation

Platelets are disk-shaped cells that are essential for blood coagulation. A plateletnt determines the number of

thrombocytes i n blood available for promoting hemostasis a nd assisting with blood coagulation after injury. It also is

used to evaluate the patient’s p otential for bleeding; however, this i s n ot itsrimary p urpose. The normal count


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ranges from 150,000 to 3 50,000/mm3. A count of 100,000/mm3 o r less i ndicates a p otential for bleeding; count of

less than 2 0,000/mm3 is a ssociated with s pontaneous bleeding.

16. Answer: D. 25,000/mm³

Leukocytosis i s a ny transient increase in the number of white blood cells ( leukocytes) in the blood. Normal WBC

counts r ange from 5,000 to 1 00,000/mm3. Thus, a c ount of 25,000/mm3 indicates l eukocytosis.

17. Answer: A. Hypokalemia

Fatigue, muscle cramping, and muscle weaknesses are symptoms o f hypokalemia (an inadequate potassium level),

which is a potential side effect of diuretic t herapy. The physician usually o rders s upplemental potassium to prevent

hypokalemia in p atients r eceiving d iuretics.Anorexia snother symptom of hypokalemia. Dysphagia m eans

difficulty sw allowing.

18. Answer: A. No contradictions e xist for this t est

Pregnancy o r suspected pregnancy is t he only c ontraindication for a chest X-ray. However, if a chest X-ray is

necessary, the patient can wear a lead apron to protect the pelvic r egion from radiation. Jewelry, metallic o bjects,

and buttons w ould interfere with the X-ray and thus sh ould not be worn above the waist. A signed consent is n ot

required because a chest X-ray is n ot an invasive examination. Eating, drinking and medications a re allowed

because the X-ray is o f the chest, not the abdominal region.

19. Answer: A. Early in the m orning

Obtaining a sputum specimen early in this m orning ensures a n a dequate s upply o f bacteria for culturing and

decreases t he risk o f contamination from food or medication.

20. Answer: A. Withhold the m oderation and notify the p hysician

Initial sensitivitytopenicmonly manifested by a skin rash, even in individuals who have not been allergic

to it previously. Because of the danger of anaphylactic sh ock, he nurse should withhold the drug and notify the

physician, who may choose to substitute another drug. Administering an antihistamine is a dependent nursing

intervention that requires a written physician’s o rder. Although applying corn starch to the rash may r elieve

discomfort, it is not the nurse’s top priority in such a potentially life-threatening situation.

21. Answer: D. Rub the s ite v igorously a fter t he injection to promote a bsorption

The Z-track method is a n I.M. injection technique in which the patient’s s kin is p ulled in such a way that the needle

track is s ealed off after the injection. This p rocedure seals m edication deep into the muscle, thereby minimizing skin

staining and irritation. Rubbing the injection site isontraindicatedbecause it may cause the medication to

extravasate into the skin.


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22. Answer: D. Divide the a rea between the g reater femoral trochanter and the lateral femoral condyle into

thirds, and select the middle third on the anterior of t he thigh

The vastus l ateralis, a long, thick muscle that extends t he full length of the thigh, is v iewed by m any c linicians a s t he

site of choice for I.M. injections b ecause it has r elatively few major nerves a nd blood vessels. The middle third of the

muscle is r ecommended as t he injection site. The patient can be in a supine or sitting position for an injection into

this site.

23. Answer: A. Can accommodate on ly 1 m l or less o f medication

The mid-deltoid injection site can accommodate only 1 ml or less of medication because of its s ize and location (on

the deltoid muscle of the arm, close to the brachial artery a nd radial nerve).

24. Answer: D. 25G, 5/8” long

A 25G, 5/8” needle is t he r ecommended size for insulin injection because insulin is a dministered by the

subcutaneous r oute. An 18G, 1 ½” needle is u sually u sed for I.M. injections i n children, typically in the vastus

lateralis. A 22G, 1 ½” needle is usually used for adult I.M. injections, which are typically administered in the vastus

lateralis or ve ntrogluteal site.

25. Answer: C. 25G

Because an intradermal injection does not penetrate deeply into the skin, a small-bore 25G needle is r ecommended.

This type of injection is used primarily to administer antigens to evaluate reactions for allergy or sensitivity studies. A

20G needle is u sually u sed for I.M. injections o f oil-based medications; a 22G needle for I.M. injections; and a 25G

needle, for I.M. injections; and a 25G needle, for subcutaneous i nsulin injections.

26. Answer: A. IM injection or an IV solution

Parenteral penicillin can be administered I.M. or added to a solution and given I.V. It cannot be administered

subcutaneously o r intradermally.

27. Answer: D. 600 mg

gr 10 x 60 m g/gr 1 = 6 00 mg

28. Answer: C. 25 gtt/minute

100ml/60 m in X 15 gtt/ 1 m l = 25 g tt/minute

29. Answer: A. Hemoglobinuria


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Hemoglobinuria, the abnormal presence of hemoglobin in the urine, indicates a hemolytic r eaction (incompatibility o f

the donor’s a nd recipient’s blood). In this reaction, antibodies in the recipient’splasma combine rapidly with donor

RBC’s; the cells are hemolyzed in either circulatory or reticuloendothelial system. Hemolysis occurs more rapidly in

ABO incompatibilities t han in Rh incompatibilities. Chest pain and urticaria may be symptoms o f impending

anaphylaxis. Distended neck veins a re an indication of hypervolemia.

30. Answer: C. Renal Failure

In real failure, the kidney loses their ability to effectively eliminate wastes and uids. Because of this, limiting the

patient’s i ntake of oral and I.V. uids m ay be necessary. Fever, chronic o bstructive pulmonary d isease, and

dehydration a re c onditions for which uids sh ould b e e ncouraged.

31. Answer: D. Frank bleeding at the insertion site

Phlebitis, the inammation of a vein, can be caused by chemical irritants (I.V. solutions or medications), mechanical

irritants (he needle or catheter used during venipuncture or cannulation), or a localized allergic r eaction to theneedle or catheter. Signs a nd symptoms o f phlebitis i nclude pain or discomfort, edema and heat at the I.V. insertion

site, and a red streak g oing up the arm or leg from the I.V. insertion site.

32. Answer: D. Ask the p atient to demonstrate t he p rocedure

Return demonstration p rovides t he most certain evidence for evaluating the e ffectiveness o f patient teaching.

33. Answer: D. Most tablets d esigned for oral use, except for extended-duration compounds

Capsules, enteric-coated tablets, and most extended duration or sustained release products s hould not be dissolved

for use in a gastrostomy tube. They are pharmaceutically m anufactured in these forms for valid reasons, and altering

them destroys their purpose. The nurse should seek a n a lternate physician’s o rder when a n ordered m edication is

inappropriate for de livery by tube.

34. Answer: D. Allergy

A drug-allergy is a n adverse reaction resulting from an immunologic r esponse following a previous s ensitizing

exposure to the drug. The reaction can range from a rash or hi ves to anaphylactic sh ock. Tolerance to a drug means

that the patient experiences a decreasing p hysiologic r esponse to repeated administration o f the drug in t he same

dosage. Idiosyncrasy is a n individual’s u nique hypersensitivity t o a drug, food, or other substance; it appears t o be

genetically d etermined. Synergism, is a drug interaction in which the sum of the drug’s c ombined effects i s g reater

than that of their separate effects.

35. Answer: D. Order a h emoglobin and hematocrit count 1 h our after the arteriography


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A hemoglobin and hematocrit count would be ordered by the physician if bleeding were suspected. The other

answers are appropriate nursing interventions f or a patient who has undergone femoral arteriography.

36. Answer: A. Is a protective response to clear the res piratory t ract of irritants

Coughing, a protective response that clears t he respiratory t ract of irritants, usually is i nvoluntary; however it can be

voluntary, as w hen a patient is t aught to perform coughing exercises. An antitussive drug inhibits c oughing. Splintingthe abdomen supports t he abdominal muscles w hen a p atient coughs.

37. Answer: C. Provide ad ditional bedclothes

In an infected patient, shivering results f rom the b ody’s a ttempt to increase heat production and t he production o f

neutrophils a nd p hagocytic a ction through increased skeletal muscle t ension and contractions. Initial

vasoconstriction may cause skin to feel cold to the touch. Applying additional bed clothes h elps t o equalize the body

temperature and stop the chills. Attempts t o cool the body result in further shivering, increased metabolism, and thus

increased heat production.

38. Answer: D. Completed a m aster’s d egree in the p rescribed clinical area a nd is a reg istered p rofessional

nurse.

A clinical nurse specialist must have completed a master’s d egree in a clinical specialty a nd be a registered

professional nurse. The National League of Nursing accredits e ducational programs i n nursing and provides a

testing service to evaluate student nursing competence but it does n ot certify n urses. The American Nurses

Association identies r equirements for certication and offers e xaminations f or certication in many areas of

nursing., such as m edical surgical nursing. These certication (credentialing) demonstrates that the nurse has t heknowledge and the ability t o provide high quality nursing care in the area of her certication. A graduate of an

associate degree program is n ot a clinical nurse specialist: however, she is p repared to provide bed side nursing

with a high d egree o f knowledge and s kill. She m ust successfully co mplete t he licensing e xamination to b ecome a

registered professional nurse.

39. Answer: D. Inhibit the g rowth of microorganisms

Microorganisms us ually do not grow in a n a cidic en vironment.

40. Answer: D. Bile obstruction

Bile colors t he stool brown. Any inammation or obstruction that impairs bile ow will affect the stool pigment,

yielding light, clay-colored stool. Upper GI bleeding results i n black or tarry s tool. Constipation is c haracterized by

small, hard masses. Many medications a nd foods w ill discolor stool – for example, drugs co ntaining iron turn stool

black.; beets t urn stool red.

41. Answer: D. Evaluation


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In the evaluation step of the nursing process, the nurse must decide whether the patient has a chieved the expected

outcome that was identied in the planning phase.

42. Answer: A. White p otatoes

The m ain s ources o f vitamin A are ye llow and g reen ve getables ( such as carrots, sweet potatoes, squash, spinach,

collard greens, broccoli, and cabbage) and yellow fruits ( such as a pricots, and cantaloupe). Animal sources i ncludeliver, kidneys, cream, butter, and egg yolks.

43. Answer: D. Maintain the d rainage tubing and collection bag below bladder l evel to facilitate drainage b y

gravity

Maintaining the drainage tubing and collection bag level with the patient’s bladder could result in reux of urine into

the kidney. Irrigatingthebladderwith Neosporin and clamping the catheter for 1 hour every 4 hours m ust be

prescribed by a physician.


The ELISA test of venous bl ood is use d to assess bl ood a nd potential blood d onors t o h uman immunodeciency

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