• Prometric Questionnaire

• The nurse administered a dose of

morphine sulfate as prescribed to a
patient who is in the post anesthesia
care unit (PACU). The patient
appears to be resting comfortably,
the respiratory rate is 8 and the
O2saturation is 21 oxygen via
cannula is 86%. The nurse should
IMMEDIATELY administer:

• Flumazenil (Romazicon)
• Medazolum (versed)
• Naloxone (Narcan)

• Ondansetron (Zofran)
• Answer : C

• A patient schedule for a major

surgery in one hour is very nervous
and upset. Which of the following
order medications would the nurse
administer torelax this patient?

• Meperidine Hydrochloride(Demerol)
• Scopolamine (Transderm-Scop)
• Pentobarbital sodium(Nembutal
sodium)
• Trazodone hydrochloride(Trazadone)

• Answer : A

• A patient with poor wound healing

and poor appetite has an order to
begin total parentalnutrition (TPN).
Waiting for the TPN solution to
arrivefrom the
pharmacy, the nurse shouldobtain:

• A pair of sterile gloves

• An infusion pump
• IV tubing with a micro-dripchamber
• Povidine-iodine (Beta dine)swabs

• Answer : B

• A nurse is caring for a

patientreceivingtotal parenteral
nutrition(TPN). The patient
reportsthesudden onset of feeling
short ofbreath and anxious. The
nursehears crackles inbilateral
lowerlobes of the lungs and the
patient’s O2 saturation is 90%on
 room air.The nurse must
IMMEDIATELY:

• Turn off the TPN

• Notify the physician
• Asses the patient’s capillary blood
glucose level
• Attempt to suction the patient’s
airway

• Answer : A

• A nurse has just started

totalparenteral nutrition (TPN)
asprescribed for a patientwithsevere
 dysphagia lowprealbumin levels.In
one totwo hours, the nurse
shouldanticipate assessing
thepatient’s:

• Blood glucose level

• Weight
• Liver
• Spo 2

• Answer : D

• The nurse is planning care for several

children who were admitted during
the shift. Daily weights should be the
plan of care for the child who is
receiving:

• Total parenteral nutrition(TPN)

• Supplement oxygen
• Intravenous anti-ineffective
• Chest physiotherapy

• Answer : A

• The nurse is caring for a 4-year-old

patient with adiagnosis of cystic
fibrosis andpneumonia. The child
isfeeling better on the 3rd day ofthe
hospitalization and “wantsto play.”
What would be thebest choice of
entertainment?

• Blowing bubbles
• Looking at picture books
• Watching videos
• Riding in a wagon

• Answer : A

• A nurse is caring for an 8-year-old

male with cystic fibrosis. Based on
the nurse’s understanding of the
disease.What nursing intervention
should the nurse expect to perform?

• Restrict sodium and fluidintake

• Give antidiarrhealmedications
• Discourage coughing afterpostural
 drainage
• Administer pancreatic enzymes with
each meal

• Answer: D

• A nurse is caring for a childwith a

diagnosis of cysticfibrosis and
pneumonia. Theplan of care includes
nebulizer treatment and
chestphysiotherapy. The
nurseshouldperform chest
 physiotherapy:

• Continuously during thenebulizer

treatment
• Prior to the nebulizer treatment
• After the nebulizer treatment
• Intermittently during the nebulizer
treatment

• Answer: C

• When conducting discharge teaching

 for the parent of achild newly
diagnosed with cystic fibrosis. Which
of the following statement by the
parent indicates the need for further
teaching?

• Weekly weights help evaluate

effectiveness ofnutritional
interventions
• Weekly weights help thedoctor know
if may child isabsorbing nutrients
• Weekly weights reassure mychild
that recovery isprogressing
• Weekly weights help the doctor know
if my child needs additional enzymes
 • Answer : D

• While caring for a patientwith an

ileostomy, the nursewould expect the
ostomy tobe located In Which
Quadrant of the abdomen?

• Right lower
• Left lower
• Left upper
• Right upper
 • Answer : A

• A patient has been assessedand

found to have severe dysphagia and
will need longterm nutritional
support,which one of the following
types of feeding would MOST likely
to be beneficial for this patient?

• Gastrostomy
• Patenteral
• Nasogastric
• Nasoduodenal

• Answer : C
• A surgeon instructs a nurse to serve
as a witness to anelderly patient’s
informedconsent for surgery.
Duringthe explanations to the
patient,it becomes clear that the
patient is confused and does not
understand the procedure,but
reluctantly sign theconsent form. The
nurseshould:

• Sign the form as a witness,making a

nation that the patient did not appear
tounderstand
• Not sign the form as a witness and
notify the nurse supervisor
• Not sign the form and answerthe
patient’s questions afterthe
surgeonleaves he room
• Sign the form and tellsurgeon that
 the patientdoesn’t understand
theprocedure

• Answer : B

• The nurse is evaluating the patient

with end stage chronic obstructive
pulmonary disease (COPD).The
patient has not achieved any of the
goals in the plan of care.The spouse
reports concerns about the patient’s
mood and increased dependency
.What action should the nurse take
FIRST?
• Continue the care plan for 1more
month
• Refer the patient to psychiatric
services
• Collaborate with the patient and
spouse to revise the care plan
• Revise the care plan based on the
spouse’s input

• Answer : C
• A home care patient withchronic
obstructivepulmonary disease
(COPD)reports anupset stomach.
Thepatient is taking
theophylline(Theo-Dur) and
triamcinoloneacetonide (Azmacort)
Thenurse should instruct thepatient
to take:

• Theo-dur an emptystomach
• Theo-dur and azmacortat the
same time
• Theo-dur and azmacort12 hours
apart
• Theo-dur milk or crackers
• Answer : B

• When giving post operative discharge

instructs a patient who had
abdominal surgery,all of the following
regarding wound healing are true
EXCEPT:

• Bathing to soak abdomen ispreferred

• Avoid tight belts and clothswith
seams that may rub thewound
• Pain medication may effectability to
drive.
• Irregular bowel habits can
beexpected
 • Answer: A

• A nurse giving post operative

discharge instructs a patient who
had abdominal surgery, when
teaching the patient about wound
healing all of the following are the
true EXCEPT:

• Wound may feel tightly oritchy as

 healing occurs
• Scabs promote infection ofthe new
skin underneaththem
• Numbness or a slight pulling
sensation is normal
• Wound should not have anydrainage

• Answer : C
• A 12-year-old child who hasbeen
diagnosed with insulin dependant
mellitus (IDDM)since age3.Comes to
the clinicfor a routine visit. The
patienthas begun to self
managecarewith parental
supervision. Thepatient injects 28
units of NPHinsulin everymorning
and 8units at bedtime. The
patientchecks blood sugar 4
timesevery day.The patient’sweightis
stable and diet isunchanged.
However, thepatient reports
severalhypoglycemicreactions
everyweek. The nurse knows
theMOST likely cause is that:

• The patient is not eating the

adequate number of calories
 reported
• The dosages of insulin may need to
be decreased as the patient
continues to grow
• There may be changes in exercise or
stress levels or the beginning of a
growth Spurt
• The patient may not becompetent in
techniques ofdrawing up and
injectinginsulin

• Answer : C

• A nurse visits a patient at home who

does not understand how to take
 anewlyprescribed medication.The
prescription reads: 5 ml PO TID p.c.
meals. The nurseexplains to the
patient that thecorrect way to take
themedication is:
• 1 teaspoon by mouth, 3times a day,
before meals
• 1 teaspoon by mouth, 3times a day,
after meals
• 1 tablespoon by mouth, 3times a day,
before meals
• 1 tablespoon by mouth, 3times a day,
after meals

• Answer : B
• The nurse is caring for a patient who
had major abdominal surgery under
general anesthetic 4 hours ago. An
appropriate goal for the patient
includes:

• Having minimal fine cracklesin the

base of the lungs
• Using the incentivespirometry every 4
hours
• Expectorating minimalamount of
secretions
• Performing Coughing Exercises every
hour whileawake
• Answer : D

• While caring for a child with

aventriculoperitoneal shuntrevision,
the nurse find the patient lying with
the head and feet flexed back. The
nurse should call for help and
prepare for a(n):

• Spinal tap
• Shunt culture
• Electrocardiogram
• Ventricular tap

• Answer : D
• A patient under goingtreatment for
cancer with bone metastasis is
experiencing Severe pain.Which of
the following treatment would the
nurse MOST likely expect to improve
the patient’s pain control?

• Adjuvant radiation therapy

•
• Curative radiation therapy
• Radiosurgery (stereotactic)

• Answer : B

• During surgery requiring general

anesthesia, the patient heart’s stops
and acarotid pulse is not
palpated.How many
compressionsper minute should
 beadministered?

• 50
• 60
• 80
• 100

• Answer :D

• When teaching a community class on

cerebro vascular accidents (stroke),
which of the following should
participants of the class know at the
completion of the class?

• Muscle and ligament damageis not

reversible
• Expressive aphasia isresolved by
 voice rest
• There is a risk for mood disorders
such as depression
• Liquids should be consumed at the
same times as solids food

• Answer : D

• A community health carenurse visits

a patient who hada cerebrovascular
accident.The patient is at risk
fordeficient volume due tovoluntary
reductionintakefluid intake to avoid
the useof the bathroom. The
 nurseeducates thepatient on
theimportance of drinking fluidsand
maintaining hydration.Whichof the
followingindicates the efficacy of
thenursing intervention?

• Amber color urine

• Respiration of 35
• Tachycardia
• Moist mucous membrane

• Answer : A
• A home health nurse isvisiting a
patient following acerebrovascular
accident(CVA). The patient is having
trouble sleeping and is feeling sad.
The patient’s spouse tells the nurse
that the patient is not eating much
and often cries when nooneis
watching. Which of thefollowing
would be thenurse’s MOST
likelyintervention?

• Assess for changes in cognitive

abilities
• Complete a depression index
• Strengthen family coping methods
• Screen for pain

• Answer : B
• A home health nurse is visiting a
patient who recently suffered a
Cerebro vascular accident(CVA). The
nurse would MOST likely implement
which of the following interventions
to prevent muscle and ligament
deformities?

• Daily moist heat and isometric

 exercises
• Daily balance training and routine
medications for pain
• Instruct patient to use non-affected
side to perform activities of daily
living
• Daily range of motion exercises.

• Answer : C
• A nurse is assigned to do a home
visit for an 81-year-old patient. The
patientlives at home with an adult
caretaker and is completely
bed-bound following a
Cerebrovascular accident (CVA) 2
weeks ago. In planning caregiver
education, The nurse should be
prepared to instruct the caretaker in:

• How to select a nursing home for the

patient
• Performing passive range of motion
exercises
• The importance of avoiding viscous
drinks
• Forming a local chapter of a care
giver support group
 • Answer : D
• A home care nurse makes a
follow-up visit to a patient who
recently suffered acerebrovascular
accident. The patient is mobile and
able to perform activities ofdaily
living. However, the patient has not
sleeping and has lost weight due
tolack of appetite. The patient also
feels overwhelmed with sadness.
Which of thefollowing is the most
appropriate evaluation?

• Patient’s progress is as expected and

no furtherintervention is necessary
• Patient needs referral to anutritionist
• Patient needs intervention
 fordepression
• Patient needs sleeping medication

• Answer : C

• A patient admitted with a

cerebrovascular accident (CVA), is
unable to chew orswallowed. The
patient is a risk for aspiration. The
nurse would anticipate
receivingwhich of the following
orders for this patient?

• Give no food by mouth andstart

 intravenous hydration
• Start a pureed diet withthickened
liquids
• Refer the patient to apsychiatrist for
depressionrelated to the CVA
• Refer the patient to physicaltherapy
for musclestrengthening

• Answer : A

• While the nurse is administering a

 large volume enema, the patient
complains ofcramping. The nurse
should:

• Increase the flow rate

• Lower the fluid container
• Elevate the head of the bed
• Gently massage the abdomen

• Answer : B
• A home health nurse has entered a
home to complete an admission
assessment on apatient who has a
methicillin-resistant Staphylococcus
aureus (MRSA) urinary tractinfection.
The patient will receive intravenous
anti-infective via a
peripherallyinserted central catheter
 (PICC) for 3 weeks. Which of the
following actions shouldthe nurse
take FIRST?

• Shake the patient’s hand

• Place the nursing supply bagon a
clean, dry surface
• Obtain the patient’s writtenconsent
for home health care
• Perform hand hygiene perthe agency
protocol

• Answer : D

• A home health nurse is teaching a

family member about the care of
 patient’speripherally inserted central
catheter (PICC). Which of the
following statementswould be
appropriate for the nurse to make?

• Place the used intravenoustubing in a

leak proofcontainer and then place
thissealed container inside asecond
leak proof container.”
• “You will need to put on adisposable
face mask beforeyou connect
theintravenoustubing to the port of
thePICC.”“The port of the PICcatheter
will need to becleansed with
povidone-iodine(BETADINE) afterthe
infusion is completed.”
• “The empty medicationcontainer can
be placed inthe same container as
 yourHousehold refuses.”

• Answer : A

• A patient had a craniotomy with

resection of a nonmalignant
neoplasm for the temporal lobe. The
patient’s vital signs are within the
base line normal range. The nurse
observes that the patient has
developed bilateral periorbital
edema. Which of the following
actions would be appropriate for the
nurse to take?

• Apply cold compresses to the

 patient’s eyes
• Apply warm compresses to the
patient’s eyes
• Elevate the head of the patient’s bed
to 60 degrees
• Elevate the head of the patient’s bed
to 45 degrees

• Answer :D

• To decrease the incidence of

aspiration of gastric contents in a
child hospitalization with severe
burns, the nurse should position the
head:

• Flat except during meals

• Elevates 30-45 degrees during meals
• Elevated 15-30 degrees for12-hours
after meals
• Elevated 45 degrees at all times

• Answer : B

• A home health nurse visits a patient

with diabetes and primary open-angle
glaucoma.The patient takes
metformin (Glucophage) 500 mg
once a day for diabetes and timolol
ophthalmic solution twice a day in
each eye for glaucoma. Which of
thefollowing evaluations indicates
that the patient is noncompliant with
glaucomamanagement?

• Patient has not been taking

 glucophage
• Patient has tearing of the eye
• Patient has not refilled prescription
for timolol in 3 months
• Patient has yellow discharge from
the eyes

• Answer : C

• A patient is having difficulty with

cognitive abilities after a stroke.
What part of the brain was MOST
likely affected?

• Midbrain
• Cerebrum
• Medulla oblongata
• Cerebellum

• Answer : B

• A 16-years old patient present to the

clinic requesting birth control. With
the diagnosis of health seeking
behaviors, the BEST goals have the
patient:

• Verbalizing understanding of safe

sex practices and following safe
sexual practices in all encounters
• Not engaging in sexual encounters
 until she is over18 years old and
maintaining a healthy life style
• Recognizing the sign of pregnancy
and the symptoms of sexually
transmitted diseases
• Understanding safe sexual practices
and use a condomto prevent
pregnancy andsexually transmitted
diseases

• Answer : D

• A nurse plans to teach a group of

20to25-year-old women about oral
contraceptives.The nurse should
instruct that oral contraceptives may:
• Increase the risk of pelvic
inflammatory disease
• Cause acne to worsen
• Decrease the risk of breastand
cervical cancer
• Decrease the risk of endometriosis

• Answer : A

• Following lumbar surgery a patient

has a 4 millimeter (mm) surgical
incision. The incision is clean and the
edges are well appropriate. This type
of tissue healing is classified as
which of the following?
• Primary intention
• Secondary intention
• Tertiary intention
• Superficial epidermal

• Answer : A

• Shrinkage device is applied after

surgery for amputation of the leg.
The goal of the shrinkage device is to
from the residual limb into what
shape?

• Cone
• Oval
• Mushroom
• Cylinder with blunt end
 • Answer : D

• A patient with a pulmonary embolus

and a nursing diagnosis of impaired
gas exchange has an order to obtain
arterial blood gases. The FIRST
intervention by the nurse is to:

• Perform an Allens test

• Explain the procedure
• Gather the equipment
• Document the procedure

• Answer : A
 • .A patient is diagnosed with
pulmonary hypertension. Which
of the following nursing
diagnoses should be the
PRIORITY?

• Impaired gas exchanged related to

altered blood flow secondary to
pulmonarycapillary constriction
• Fatigue related to hypoxia
• Anxiety related to illness and loss of
control
• Activity intolerance related to
imbalance between oxygen supply
and demand due to right and left
ventricular failure
 • Answer : D
• A patient who had abdominal surgery
is in the post anesthesia care unit
(PACU).Which of the following
nursing diagnosis takes PRIORITY?

• Disturbed sleep pattern

• Acute pain
• Risk for infection
• Ineffective airway clearance

• Answer : D

• While caring for a patient in the

post-anesthesia care unit (PACU), a
nurse observes the onset of rapid
breathing cyanosis, and narrowing
 blood pressure. The nurse should
plan to:

• Administer bolus glucose

• Suction the airway
• Turn the patient to the right side
• Administer intra venous fluids

• Answer : B

• While caring for a patient in the

post-anesthesia care unit (PACU)
Who has developed Hypovolemic
shock, a nurse should position the
patient:

• Flat with legs elevated

• In Trendelenburg position
• With the head of the bed elevated 45
degrees
• Completely flat

• Answer : B

• A patient had a vitrectomy and is

about to be transported to the post
anesthesia care unit (PACU). The
patient should be placed in which of
the following positions before
transport to the PACU?

• Semi-fowler’s
• Prone
• Dorsal recumbent
• Sim’s
 • Answer : B
• While caring for a patient in the
post-anesthesia care unit (PACU), a
nurse plans toKeep the patient warm.
What is the MUST important reason
for this action?

• To preserve nutritional stores

• To prevent cutaneous vessel dilation
• To decrease patient anxiety
• To lower risk of infection resulting
from chill

• Answer : C
• A patient had a total abdominal
hysterectomy 2days-ago and has not
been out of the bed yet. The patient
is complaining left leg pain and
swelling. What should the nurse do
FIRST?

• Gently massage the patient’sleg

• Assess the patient’s pain level
• Assess the patient for Homan’s sign
• Instruct the patient to reflex the left
knee and hip

• Answer : C
• To minimize a toddler from
scratching and picking at a healing
skin graft site, the nurse should
utilize?

• Hand mittens
• Mild sedatives
• Punishment for picking
• Distraction

• Answer : D

• The nurse is teaching the mother of a

3-months-old infant about bottle
feeding.Which statement indicates
the mother understands of
 appropriate procedure?

• “I should hold my baby in aslightly

reclined position,close to my body”
• “It is OK to prop the bottle on a pillo
w”.
• “It can feed my baby wholemilk”
• “I should warm the bottlesin the
microwave if theycome out of
theRefrigerator”.

• Answer : C

• A 9-month-old child who has had four

ear infections in the past 6 months is
being discharged. Which statement
by the parent indicates the need for
 further discharge teaching?

• I should never put my baby to bed

with bottle
• My child should not use a pacifier
after age 6 months
• My child should drink his bottle while
laying flat in my lap
• My child should not be around people
who smoke

• Answer : B

• A Patient complains of severe

menstrual cramping. Bleeding is not
un usually heavy and the patient has
no uterine disorders. Which of the
 following interventions should the
nurse anticipate the doctor will order
promote comfort?

• Acetaminophen (Tylenol)
• Strict bed rest
• Heating pad to the back of neck
• Ibuprofen (Motrin)

• Answer : D

• During Pre operative preparation of a

patient for amputation of the left leg.
The nurse has primary responsibility
for:

• Witnessing the patient signature

 on the consent form
• Explaining the procedure to the
patient
• Explaining the risks of the surgery
to the patient
• Making appropriate incision lines
on the leg.

• Answer : A

• A 52-years-old is admitted to the

nursing unit from the physician’s
office with a diagnosis of acute
cholecystitis. Physician orders on
admission include: monitor vital sign
every 4 hours; IV of ringer’s lactate
125ml per hour; 1500 calorie, low-fat
liquid diet, morphine sulfate 2mg IV
every 2 hours as needed for pain,
notify physician for sudden increase
in frequency or intensity of pain,
promethazine12.5 mg IV every 4
hours as needed for nausea or
vomiting. Which of the following
should the nurse plan to do FIRST?

• Remove any high-foods from the

patient’s room
• Notify the dietitian of the diet
order
• Obtain venous access and start
Ringer’s lactate infusion
• Obtain an emesis basin and clean
linens for the be side
• Answer : C

• A parent brings a 10-month-old infant

into the department saying, “my baby
put a button in her mouth and now
she is not breathing!” After the nurse
determines the infant is not
breathing. What should the nurse do
NEXT?

• Perform the Heimlichmaneuver

• Initiate cardio pulmonary
resuscitation (CPR)
• Administer 4 back blows
• Administer 4 thrusts midline on
 the patient back

• Answer : D

• An infant arrives in the emergency

department not breathing and does
have a pulse. When starting cardio
pulmonary resuscitation (CPR),
where is the correctplace to assess
for a pulse in this patient?

• Carotid
• Radial
• Brachial
• Temporal
• Answer : C

• A 5 years old patient who under went

abdominal surgery suffers from
deficient fluid volume related to
nothing by mouth (NPO) status;
intravenous fluid therapy is given for
hydration. Which of the following
indicates that thetreatment is
effective?

• Urinary output of 15ml/hr

• Respiration rate, 35
• Heart rate 100
• Good skin turgor

• Answer : D
• A 7-years-old child is brought to the
physician office due to sudden onset
of bright redness on the cheeks. The
nurse observes that the child has a
temperature of 380 C (100.40 F) With
chills the nurse suspects that the
MOST like diagnosis would be:

• Fifth disease
• Rotavirus
• Roseolainfantum
• Answer : A

• A nurse instructs a community

education class on breast health.
Which statement BEST described
understanding of the appropriate age
to start screening mammograms is a
woman of average risk?

• At menopause
• At 65-years-old
• At the cessation of breastfeeding
• At 40-years-old

• Answer : A
• A patient is taught how to perform a
breast self-exam by a nurse.
Whichstatement is BEST described
as understanding of the proper
procedure fordoing a breast
self-exam?

• Use of the palm of the hand to

feel for lumps
• Apply three differentlevels of
pressure to feelbreast tissue
• Stand when performingbreast
self-exam
• Perform self-examannually
• Answer : A

• While caring for a child with in

effective airway clearance related to
increased mucus production, the
nurse should encourage fluids to:

• Maintain nutrition
• Prevent boredom
• Stimulate coughing
• Thin secretions
• Answer : D

• A 59-years old patient with lung

cancer and metastases to the bone
is in the hospital for pain
management. The patient rates the
pain 10 on a scale of 0(no pain) to 10
(severe pain). The BEST goal for the
nurse diagnosis of alteration is
comfort is that the patient will:

• Show no objective signs of pain

• Not complain of pain
• State pain is at a tolerable level
• State that all pain is relieved

• Answer : D

• A patient with advanced lung cancer

 is exhibiting cyanosis and edema of
the head and upper extremities.
Which of the following intervention
would MOST likely provide an
immediate benefit for this patient?
• Place in Trendelenburg position
• Position on the right side
• Elevate the head of the bed
• Elevate extremities

• Answer : C

• If a patient develops a complication

during a blood transfusion, the nurse
first should be to:

• Stop the transfusion

• Notify the practitioner
 • Administer anantihistamine
• Administer an anti- inflammatory
medication

• Answer : A

• Which of the following types of

health care services is an example of
the primary level of care?

• Diagnosis
• Acute care
• Restoration
• Immunization
• Answer : D

• In planning for the care of a patient

with Crohn’s disease, the nurse and
patient discuss the interventions.
Which of the following treatment
modalities
would MOST likely be considered a
primary intervention for this disease?

• Surgery
• Medications
• High-residue diet
• Blood replacement

• Answer : B
• A patient with acute crohn’s disease
has been prescribed an elemental
diet. The MOST likely rationale for
this is to:

• Reset the bowel

• Improve nutrition
• Improve medication absorption
• Prepare for surgery

• Answer : C

• A patient has a6-year history of

inflammatory bowel disease that is
resistant to medical therapy. The
patient can BEST decreased the like
 hood of the disease progressing to

• Consuming only elemental foods

• Stopping smoking
• Using effective birth control
• Avoiding over heating

• Answer : A

• A home health nurse is setting up a

medication administration schedule
for an elderly patient. The patient is
talking Oscal (calcium corbonate),
Feosol (ferroussulfate), and Orazinc
(Zinc sulfate). The patient eat meals
at 8:00 AM, 12 noon, and6:00 PM.
Which of the following medication
 administration times would the
nurseMOST likely implement for this
patient?

• Oscal, Orazinc, and foesal at 8:00AM

• Oscal at 6:00AM, Orzinc at 12:00
noon, Foesal At 4:00PM
• Oscal and Foesal at 12:00 noon and
Orazinc at 6:00PM
• Orazinc at 6:00 AM, Oscal at 12:00
noon, and Foesal at 6:00PM

• Answer : C

• A Community Health nurse is

administering tuberculin skin tests
purified protein derivative (PPD),
 which of the following time frames
should the nurse tell the patient to
return to the clinic for the test to be
read?
• In 12-24 hours
• In 24-36 hours
• In 36-48 hours
• In 48-72 hours

• Answer : D

• A patient who is scheduled for a

tonsillectomy is in pre operative unit.
The nurse notes an order for pre
anesthetic medication to be given
“on call to operation room”.The nurse
should give this medication:
• Immediately upon being notified to
prepare the patient for transport
• When the operation room staff arrive
to transport the patient
• Only if clearly needed after
assessment
• Upon the patient’s arrival in the
operation room

• Answer : A

• A patient recently under went

coronary artery bypass graft surgery
(CABG). The Nursing diagnosis
includes sleep deprivation related to
intensive care environment. The goal
for this diagnosis would be that the
 patient:

• Gets 4 hours of uninterrupted sleep

during the right
• Takes naps during the day
• Is free of pain in the first hour post
surgery
• Ambulates 3 hours post surgery

• Answer : B

• The nurse is assisting a patient to

ambulate in the hall. The patient a
history of coronary artery
disease(CAD), and had coronary
 artery bypass graft surgery(CABG) 3
days ago, the patient reports chest
pain rated 3 on a scale of 0 (no
pain)to 10 (severe pain) the nurse
should FIRST:

• Determine how long it has since the

patient’s last dose of aspirin
• Obtain a chair for the patient so sit
down
• Assess the patient’s radial pulse
• Ask the patient to take several slow,
deep breaths

• Answer : A

• A 35-years-old female has an

inherited gene mutation for
 achondroplasia, anautosomal
dominate genetic disorder. Her
husband does not have
genemutation. In planning genetic
counseling for this patient, the nurse
would beMOST correct in including
which of the following statements
regarding the risk of their children
inherited the genetic mutation?

• Each child has a 50% chance of

inheriting the gene mutation
• Female children have 50% chance of
inheriting the gene mutation
• Male children will not inherited the
gene mutation
• All female children will inherit the
gene mutation.
 • Answer : A

• A patient is one day post operative

repair of a large umbilical hernia. The
patient complains of abdominal pain
and described feeling the sutures
give way. Upon assessment of the
abdomen the nurse observes an
evisceration. The nurse’s
IMMEDIATE response should be to:

• Medicate the patient for pain

• Instruct the patient to cough hard
• Have the patient perform the
 valsalvas maneuver
• Cover the abdomen with asterile
soaked dressing

• Answer : D

• A 3-years old child is seen at the

pediatrician’s office. The parents the
child has had vomiting and diarrhea
for the past 15 hours. The child’s is
lethargic with the following vital
signs: temperature 37.20 C (99.0 F),
heart rate 145,respiration rate 25,
and blood pressure level 95/55
mmHg. Which of the vital sign is
 abnormal?

• 37.20 C (99.00 F)
• Heart rate 145
• Respiration rate 25
• Blood pressure level 95/55

• Answer : B

• A home health nurse is teaching a

family member about the care of a
patient’s peripherally inserted central
catheter (PICC). Which of the
following would be appropriate for
 the nurse to make?
• “Place the used intravenous tubing in
a leak proof container and then this
in sealed container inside a second
leak proof container”.
• “You will need to put on adisposable
face maskbefore you connect thethe
port of the PICC.”
• “The port of the PICCcatheter will
need to becleansed with
providence-iodine Betadine) after
theinsulin is completed.”
• “The empty medicationcontainer can
be placed inthe same container as
your house hold refuses.”

• Answer : A
• While Obtaining the pre operative
history of a patient schedules for
cosmetic surgery, the most valuable
skill at the nurse disposal is:

• knowledge of the procedure

• Time management skills
• Listening skills
• Empathy

• Answer : D

• A community health nurse screens a

group of high risk adults for
tuberculosis. Which gauage needle
 should the nurse use for an
intradermal injection on theventral
surface of the forearm?

• 16 gauge needle
• 20 gauge needle
• 22 gauge needle
• 26 gauge needle

• Answer : D

• A patient hospitalized with

tuberculosis (TB) has a productive
cough and hemoptysis. Which of the
following types of isolation room
would be the best choice for the
patient?
 • Reverse isolation
• Standard isolation
• Positive-pressure
• Negative-pressure

• Answer : D
• A patient diagnosed with
tuberculosis is prescribed isoniazid
(Isoniazid), Rifampin (Rifadin),
pyrazinamide (Rifamate), ethambutol
HCL (Myambuton), one month later
the patient comes to the physician
office with hepatitis. Which drug is
the MOST likely cause?

• Ethambutol(Myambuton),
• Acetaminophen,
 • Izoniazid (Izoniazid),
• Pyrazinamide (Rifamate).

• Answer : C

• A Patient with tuberculosis can

transmit the disease to another
individualThrough:

• Air droplets
• Physical contact
• Hand to mouth exchange
 • Blood and body fluids

• Answer : A

• A patient recently under went joint

replacement surgery, which of the
following nursing diagnosis takes
PRIORITY?

• Risk for peripheral neurovascular

dysfunction
• Deficient knowledge on
appropriate activity precaution
• Impaired physical mobility
• Sexual dysfunction related to pain
• Answer : C

• The parents are anxious after the

doctor tells that their child needs
surgery.The assess parents’ ability to
cope with this anxiety, which of the
following questions should the nurse
ask

• “Did you know that feeling anxious

about your child’s surgery is normal?”
• “Can you wait until after surgery to
begin to cope with being anxious?”
• “How do you think feeling of anxiety
will affect your child?”
• “What has helped you when you felt
 anxious in the past?”

• Answer : A

• A 4-year-old child brought to the

community health clinic for
scheduled immunizations. The child
should receive:

• Varicella, rotavirus,pneumococcal
and hepatitis B
 • Measles, mumps, rubella and
varicella
• Rotavirus and inactivatedpolio
virus
• Varicella andhaemophilus
influenza

• Answer : B

• The nurse is conducted a

community-based educational
program about Diabetes mellitus.
Which of the following statements by
 a participant would indicate correct
understanding of the teaching?

• Lantus insulin can be mixed with

other insulin
• It is necessary to wipe off the top
the insulin vial with alcohol to
prevent infection
• Insulin will changedcolor after
opening
• Needles can be placedin a hard
plasticcontainer with atightly
secure lid

• Answer : B
• A child is treated for superficial
(first-degree) thermal burns to the
thigh. The child is in great discomfort
and does not eat. Which of the
following diagnosis should receive
PRIORITY?

• Altered nutrition
• Impaired skin integrity
• Risk for infection
• Acute pain

• Answer : D

• The nurse calls together an inter

disciplinary team with members from
medicine, social services, the clergy,
 and nutritional services to care for a
patient with aterminal illness. Which
of the following types of care would
the team MOST likely is providing?

• Palliative
• Curative
• Respite
• Preventive

• Answer : A
• A nurse makes a home visit to a
patient recently diagnosed with
chronic obstructive pulmonary
disease (COPD), which of the
following should the nurse teach the
patient about managing COPD?

• Recognizing signs of impending

respiratory infection
• Limiting fluids intake minimize
bronchial secretions
• Correct technique to auscultate the
lung fields
• Importance of starting antibiotic
therapy

• Answer : A
• A patient with chronic obstructive
pulmonary disease (COPD)
experiencing frequent dyspnoea
which of the following exercise
would teach the patient how to
BETTER control breathing?

• Lower side rib

• Segmental
• Pursed-lip
• Diaphragmatic

• Answer : C
• In evaluating the appropriateness of
various exercises enjoyed by a
 patient with osteoporosis, the nurse
would recommend:

• Walking
• Bowling
• Sit-ups
• Golf

• Answer : A

• A patient present to the clinic

with“pins and needles” sensations of
the left foot and complains that
objects appear “ Shimmering”.The
patient is diagnosed with
 opticneuritis and referred for further
testing. The patient is MOST likely to
be tested for:

• Glaucoma
• Multiple sclerosis
• Lesion of brain stem
• Psychosis

• Answer : B

• A 3-years-old has returned to the

clinic 4 days after being diagnosed
with gastroenteritis and dehydration.
A parent reports that the vomiting
has stopped, and the child is
tolerating liquids, rice, apple sauce,
and bananas. The diarrhea
persists,but seems to be decreasing
 in volume. When evaluating for signs
of dehydration,the nurse will assess
the patient’s skin turgor by:

• Grasping the skin over the abdomen

with two fingers raising the skin with
twofingers
• Grasping the skin over the forehead
with two fingers and raising the skin
withtwo fingers
• Holding the patient’s mouth open
and assessing the tongue for deep
creases orFurrows
• Drawing two tubes of blood and
running blood urea nitrogen (BUN)
andCreatinine (Cr).

• Answer : A
• When administering albuterol to a
child with asthma, the nurse should
observe for sign of what major side
effect to this medication?

• Tachycardia
• Renal failure
• Apnea Blurred vision

• Answer : A

• A child with asthma is experiencing

thick respiratory secretions resulting
in increased work of breathing. The
best nursing intervention is to:

• Encourage fluids
• Eliminate dairy products
• Decrease relative humidity of the
room
• Have the child lay on the left side.

• Answer : C

• What would be the long-term goal for

a child with asthma?

• Quickly reverse airflow obstruction

• Correct hypoxemia
• Deliver humidified oxygen via nasal
cannula
• Develop a home and school
management plan
• Answer : D

• A nurse administers an albuterol

nebulizer on a child with asthma
exacerbation. Which of following
indicates effectiveness of the
treatment?

• Adventitious breath sound with

cough
• O2 saturation 94%
• Nasal flaring
• Respiration rate 28

• Answer : B
• A Child is diagnosed with asthma
exacerbation. Which of the following
nursing diagnoses should be the
FIRST priority?

• In effective airway clearance related

to broncho spasm and mucosal
edema
• Fatigue related to hypoxia
• Anxiety related to illness andloss of
control
• Deficient knowledge relatedto
potential side effect of
themedication

• Answer : A
• An asthmatic patient presents with
wheezing and coughing. Oxygen
saturation is 88% on room air. Which
of the following nursing diagnosis
would take priority?

• Imbalanced nutrition related to

decreased food intake
• Activity intolerance related to
inefficient breathing
• Anxiety-related dyspnea and concern
of illness
• Ineffective gas exchange related to
broncho spasm
 • Answer : D

• The nurse is visiting the asthmatic

patient at home to reinforce the
importance of eliminating
environmental allergens and to
assess the patient’s response to the
environmental changes. This type of
implementation is called:

• Supervision and coordination

• Discharge planning
• Monitoring and surveillance
 Ans c
• A patient finds their 2-weeks-old
infant unresponsive. The infant is
limp, cyanotic and pale. There is no
respiration, while the skin is cold to
the touch. The parent begins
resuscitation, and the infant is
transferred to the hospital where the
infant expires. The MOST likely
diagnosis is:

• Sudden infant death syndrome

• Apparent life-threatening event
• Apnea of infancy
• Apnea of unknown origin

• Answer : A
• A neonatal nurse performs Apgar
assessment at 1 minute of birth to
evaluate the physical condition of the
newborn and immediate need for
resuscitation. At 1 minute, Apgar
score is 7. At 5 minutes Apgar score
is to the progression of scores
suggests:

• A healthy newborn
• The need for supplement oxygen
• A genetic defect
• The infant is becoming stable
 • Answer : A

• The nurse is caring for full-term

newborn who was delivered vaginally
5minutes ago. The infant’s APGAR
Score was 8 at one minute and 10 at
5minutes. Which of the following has
the highest priority?

• Maintaining the infant in the supine

position
• Assessing the infant’s red reflex
• Preventing heat loss from the infant
• Administering humidified oxygen to
 the infant

• Answer : A

• Which of the following can be use to

determine if a prescribed pain
management therapy is effective for
a non verbal patient?

• Papanicolaoutest
• Faces rating scale
• Braden’s scale
• Apgar assessment tool
 • Answer : B

• While caring for a neonate with a

meningocele, the nurse should
AVOID positioning the child on the:

• Abdomen
• Left side
• Right side
• Back

• Answer : D

• A patient with exacerbation of

congestive heart failure has a
 nursing diagnosis of excess fluid
volume. The nurse monitors fluids
intake and output and administers
furosemide, as ordered. Which of the
following indicates the efficacy of the
intervention?

• The patient has pitting edema

• The patient has shortness of breath
• The patient has a decrease in weight
• The patient has jugular vein
distention

• Answer : C

• A 62-year-old patient has been

 treated for congestive heart failure
and aNursing diagnosis of fluid
volume excess. After diuretic therapy
and dietary Interventions, the patient
has met all short-term goals. The
nurse should:

• Revise the care plan with a diagnosis

of risk for alteration in fluid balance
• Add a new diagnosed of risk of fluid
volume deficit
• Discontinue the care plan as the
diagnosis is resolved
• Continue the care plan as written

• Answer : D
• A patient with congestive heart
failure and severe peripheral edema
has a nursing diagnosis of fluid
volume excess. What are the two
MOST important interventions for the
nurse to initiate?

• Diuretic therapy and intake and

output
• Nutritional education and low-sodium
diet
• C. Daily weights and intake output
• D.Low-sodium diet and elevate legs
when in bed

• Answer : A
• A patient has exacerbation of
congestive heart failure, with one of
the nursing diagnosis being excess
fluid (lasix). The nurse closely
monitors fluid intake and output and
administers furesemide (lasix).
Which of the following indicates
theefficacy of the nursing
intervention?

• The patient has leg edema

• The patient has shortness of
breath
• The patient has decreased in
 weight
• The patient has jugular vein
distention

• Answer : C

• When caring for a patient with an

ostomy, the nurse knows that extra
skin protection for the peristomal
skin is MOST important for those
with a(n):

• Ileostomy
• Ascending colostomy
• Transverse colostomy
• Sigmoid colostomy
• Answer : B

• While evaluating the nutritional intake

of a bedridden patient with multiple
pressuresores, the nurse should
make sure the patient INCREASES
the intake of:

• Protein-rich foods
• Water
• Foods rich in vitamin A
• Fiber rich foods
• Answer : A

• In what position should a dyspneic

patient be placed?

• Prone
• Recumbent
• Semi-fowler’s
• Trendelenburg

• Answer : C
• . A patient presents to the clinic for a
routine visit and has the following
0
vital signs: temperature 37.0 C
(98.60F), heart rate 82, respiration
rate 18 and blood pressure level of
130/94 mmHg. Which vital sign is
abnormal?
• Temperature
• Pulse
• Respiration
• Blood pressure

• Answer : D

• . A female patient admitted for

abdominal pain complains of
generalized pain, nausea vomiting
and constipation. Nursing
assessment finds:
temperature,38.60C (101.50F), heart
rate-92; respiration rate-18; blood
pressure level, 130/68mmHg. The
patient has rebound tenderness and
abdominal rigidity. In the past hour,
her pain has localized on the right
 side. The nurse suspects:

• Intestinal obstruction
• Influenza
• Appendicitis
• Pyloric Stenosis

• Answer : C

• . A community health nurse is

implementing an adult immunization
program in the neighborhood. Which
of the following would MOST likely
be a universally recommended adult
vaccination and dose frequency
general population?
• Tetanus-diphtheria toxoid every 20
years
• Pneumococcal vaccination every 2
years
• Influenza vaccination every year
• One time typhoid vaccine followed by
boosters every5 years

• Answer : C
• . A 6-year-old patient has been
diagnosed with acute rheumatic
fever. Then nurse knows that the
antibiotic of choice for this illness is:

• Bezathgine penicillin(Megacillin)
• Amoxicillin (Amoxil)
• Erythromycin (Eryhrocin)
• Vancomycin (Vancocin)

• Answer : A

• . A child is admitted to the

hospital with congenital heart
disease. Which of the following
nursing diagnoses should receive
PRIORITY?
• Decreased cardiac output related to
decreased myocardial function
• Activity intolerance related to
cachexia
• Impaired gas exchanged related to
altered pulmonary blood flow
• Imbalanced nutrition: less than body
requirements related to excessive
energy demands

• Answer : A

• . Prior to initiating therapy with

unfractionated heparin for a patient
hospitalized with a deep vein
thrombosis, the nurse should plan to:
• Weigh the patient
• Administer aspirin
• Limit fluid intake
• Undress the patient

• Answer : B

• . Prior to initiating therapy with

unfractionated heparin for a patient
hospitalized with a deep vein
thrombosis, this treatment requires:

• Bed rest
• Aspirin therapy
• Fluid restrictions
• A high protein diet
• Answer : B

• . A patient with chronic liver disease

secondary to hepatitis C has been
admitted with malnutrition. With a
nursing diagnosis of alteration in
nutrition, less than body
requirements, the BEST long-term
goal is the patient will:
• Gain atleast 10% of bodyweight
• Attain and maintain ideal weight
• Verbalize understandingnutritional
needs
• Include high quality protein in diet
• Answer : B
• . The nurse is assessing a patient
 with a history of a seizure disorder.
While checking the patient’s vital
signs, the patient develops rhythmic,
jerking movements of the arms and
legs. The nurse should
IMMEDIATELY place the patient in
which of the following positions?

• Prone
• Supine
• Semi-fowler’s
• Lateral

• Answer : D
• . A nurse is assessing to care for a
child with a seizure disorder. The
nurse observes the child becomes
stiff and lose consciousness,
following by jerking movements for 1
minute after which the child
becomes very sleepy, which of the
following types of seizures occurred?

• Absence (petit mal)

• Generalized (tonic-clonic)
• Partial Psychomotor(temporal lobe)
• Status epilepticus

• Answer : B
• . A patient is scheduled for an
abdominal aneurysm repair. This is
what type of surgical intervention?

• Diagnostic
• Transplant
• Curative
• Palliative

• Answer : C

• . A Community health nurse is

teaching a health class about
infectious disease processes. The
 nurse instructs the class that rabies
would be considered which of the
following types of infection?

• Viral
• Protozoan
• Fungal
• Bacterial

• Answer : A,

• . A patient receiving chemotherapy

developed some raised; red
edematous wheals on the skin, which
of the following care plan alter
natives MOST likely need to occur
before the treatment?
• Rein forced relaxation techniques
• Continue chemotherapy without
change
• Continue with radiation therapy only
• Pre-medicate the patient with an
antihistamine

• Answer : D

• A 6-year-old patient has presented to

the clinic with fever, malaise and
anorexia.The patient was treated 2
weeks ago for a streptococcal
infection of the throat. The nurse
should expect the physician to order
what test?

• Electrocardiogram
• Jones test
• Spinal tap
• Heart biopsy

• Answer : B

• . A community is experiencing an out

break of staphylococcal infections.
The nurse instructs residents that the
MOST common mode of
transmission is by:

• Respiratory droplets
• Contaminated foods
• Hands
• Soil

• Answer :D

• . A hospitalized patient has fallen

from bed. The nurse notes
shortening of the left leg.Pain upon
movement of the left leg, and rapid,
swallow respirations. What action
should the nurse take FIRST?

• Call for help

• Immobilize the left leg
• Obtain blood pressure
• Evaluate lung sounds
• Answer : B

• . A community health nurse visits a

patient who has suffered a stroke.
The patient’s spouse explains to the
nurse that the patient chokes on
foods at times. Which of the
following referral ordered would the
nurse anticipate needing for this
patient?

• Speech therapist
• Dietician
• Physician therapist
• Neurologist

• Answer : A
• . A 59-year-old patient arrives in the
emergency department diaphoretic
and complains of chest pain and
shortness of breath. The patient’s
sibling states that this has happened
before and it is just anxiety. Upon
evaluation the physician diagnosis
unstable angina and prescribes
anti-anginal medications. What is the
expected results of this drug therapy

• Balanced between oxygen supply and

demand
• Increase in blood flow to the heart
• Reduction in oxygen demand and
consumption
• Vessel relaxation
 • Answer : B
• . A patient with end-stage
cardiomyopathy and angina pectoris
to the office complaining of frequent
chest pain and severe dyspnea. With
a nursing diagnosed of alteration in
comfort, what is the BEST long term
goal for this patients?

• Perform all activities of daily living

without complaints of chest pain or
shortness of breath
• Verbalize and employ strategies to
decrease pain and increase coronary
blood flow
• Take pain medications around the
check and use supplement oxygen at
all times
• Understand the disease process and
accept the limitation that it places on
his lifestyle

• Answer : A

• . A patient has an order for a

pneumatic compression device.
Which of the following is an
appropriate goal?

• Reduce the risk deep vein

thrombosis
• Reduce lower extremity edema
• Reduce lower extremity pain
• Reduce the risk of phlebitis
 • Answer : A
• . A patient with severe diverticulitis
had surgery for placement of
colostomy. The patient is upset,
crying and will not look at the
colostomy. Which of the following
would be the HIGHEST priority
nursing diagnosis at this time?

• Knowledge deficit,colostomy care

• Distorted body image
• Self-care deficit, toileting
• Alteration in comfort

• Answer : B
• . A patient presents to the emergency
department with complaints of head
ache,dizziness and confusion.
Clinical symptoms include
tachypnoea and dyspnea with the
use of accessory muscles to
facilitate breathing. Which of the
following orders would the nurse
MOST likely implement to reduce the
patient’s confusion and
disorientation?

• Oxygen therapy
• Chest physical therapy
• Bronchodilators
• Hydration fluids
 • Answer : A
• 138. A 6-month-old boy is admitted
with a diagnosis of failure to thrive.
According to the growth chart at 3
months of age the infant’s weight is
in which percentile?

• 25th
• 5th
• 10th
• Below the 5th

• Answer : B

• . A patient is 2-days post operative

hernia repair and has an order for a
 dressing change patients has been
diagnosed with auto immune
deficiency disease syndrome(AIDS).
While performing the dressing
change the nurse should take which
of the following actions?

• Put the patient in a private room

• Wear gloves during the dressing
change
• Wear gloves gown, and mask during
dressing change
• Put the patient in reverse isolation

• Answer : C
• . When administering an enema to
adult patient, how far should the
 nurse insert the tubing into the
rectum?

• 2.2 to 4.4cm (1 to 2 inches)

• 4.4 to 6.6cm (1 to 3 inches)
• 6.6 to 8.8cm (3 to 4 inches)
• 8.8 to 11cm (4 to 5 inches)

• Answer : C

• . A nurse is implementing nursing

interventions to monitor a patient
following kidney surgery. Which of
the following complications would be
the MOST likely post operative risk
after renal surgery?
• Deep vein thrombosis
• Hemorrhage
• Nausea
• Hemiparesis

• Answer : B
• . As per of a neurological
assessment, which of the following
is associated with the higher score
on the Glasgow coma scale?

• Eye opening to pain, no verbalization

• Confused, obey commands
• Localized pain, abnormal extension
• Eye opening to speech confused
• Answer : B

• . While caring for a patient prior to

surgery to amputate the leg. What is
the MOST affective measure to
prevent phantom limb sensation
after the amputation?

• Control pain prior to the surgery

• Make sure the patient understands
the procedure
• Elevate the limb on two pillows
• Help the patient grieve for the limb

• Answer : D
• If a patient develops a complication
during a blood transfusion, the
nurse’s first action should do to:

• Stop the transfusion

• Notify the practitioner
• Administer anantihistamine
• Administer an anti-inflammatory
medication

• Answer : A

• . A patient has an elevated

prothrombin (PT) time. Which
medication should the Nurse
 consider as a possible cause of the
elevated PT Time?

• Rifampin
• Vitamin K
• Birth control pills
• Phenytoin (Dilantin)

• Answer : C

• . A home care nurse visits a patient

with a new-below-the knee
amputation. The site of the incision
is red, warm and tender with purulent
yellow drainage. The patient has a
new prescription for cephalexin
(Keflex) and oxycodone(oxycontin).
 What would the nurse instruct the
patient to do FIRST?

• Take oxycodone as soon as possible

• Take cephalexin as soon as possible
• Wash the incision site and apply
bacitracin cream
• Wash the incision site and apply
hydrocortisone

• Answer : C

• . A patient has the following order:

cephalexin (keflex) 500 milligrams
(mg) by mouth 4 times a day. The
pharmacy has the following dose:
250mg per 5milliliters (ml). The
 nurse should administer:

• 5ml
• 10 ml
• 15 ml
• 20 ml

• Answer : B

• A marathon runner experiences a

sudden onset of sharp pain in calf
immediately after a workout. The
nurse in the clinic notes mild swelling
of the calf and tenderness to touch.
Which of the following would the
nurse suspect the patient is
experiencing?
• Bursitis
• Tendonitis
• Plantar fascitis
• Joint dislocation

• Answer : C

• . A mastectomy patient has

developed lymphedema of the left
arm. The nurse should teach the
patient that the BEST position for the
arm is:
• Immobilized across the chest
• Dependent
• Elevated
• In traction

• Answer : C

• . A patient is seen in the emergency

room for a 20cm (7.8 inch) laceration
to the right fore arm. The course
prepares for which type of
anesthesia to be administered before
the laceration is repaired by the
physician?

• Intravenous
• Regional
• General
• Local

• Answer : B
• . A nurse in a community health
clinic is in charges of
immunizations. When patients
visits the clinic the nurse knows
that immunizations should be
reviewed:

• At the age they are scheduled to be

administered
• One month prior to recommended
immunization schedule
• At every clinic visit
• At monthly intervals
 • Answer : C

• . A child was admitted to the hospital

three hours ago with a closed head
injury. The child responds
appropriately but sluggishly to
stimuli, and drift in and out of sleep.
Which of the following best
describes this patient’s level of
consciousness?

• Lethargic
• Obtunded
• Semi comatose
• Comatose

• Answer :B
• . A healthy patient is in doctor’s
office for a pre operative visit before
a total replacement. The nurse
interviewing the patient charts the
following medications: aspirin 81 mg
once a day, vitamin E 260
international units once a day, and
unknown amount of a herbal
supplement once a day, based on the
patient’s medication list which of the
following labs would be important
pre operatively?

• Prostate specific antigen(PSA)

• Blood glucose
• Creatine phosphokinaseisoenzymes
(CPK enzymes)
• Prothrombin time
•
• Answer : D
• A patient with long-standing diabetes
mellitus (type I) is scheduled for
surgical amputation of 4 gangrenous
toes on the right foot. Which surgical
intervention would this be classified
as?

• Palliative
• Curative
• Reconstructive
• Diagnostic

• Answer : A

• . The nurse is caring for a patient

who just had a chest tube inserted
due to spontaneous pneumothorax.
 An appropriate goal is that the
patient will:

• Be free of pain with in 4hours

• Report decreased pain
• Rest quietly
• Sleep with few movements

• Answer : C
• . A patient with the deep vein
thrombosis (DVT) is being treated
with a low-molecular weight
heparin.(LMWH). The patient reports
increased pain in the affected
extremely. The nurse observe the
affected extremity has increased in
size by 0.2 cm (0.8 inches) during the
 past 24 hours. Which of the following
actions should the nurse take?

• Administer the next dose of LMWH

before the scheduled time.
• Apply dry heal to the site
• Elevate the extremity
• Reinforce the importance of ankle
circling exercises

• Answer : C,

• . A physician orders Lactated Ringer

Solution to infuse at 125 cc/hour.
This is an example of which type of
solution?
• Hypotonic
• Isotonic
• Hypertonic
• Hyper alimentation

• Answer : B

• A physician orders an intravenous

fluid of D5NS at 100cc/hr. This is an
example of which of the solution?

• Hypotonic
• Isotonic
• Hypertonic
• Hyper alimentation
• Answer : C

• . A patient is in the preoperative area

to lumbar surgery. The patient
reports anxiety about being intubated
and expresses concern about waking
up during the surgery. The nurse
MUST discuss the patient’s concern
with the

• Anesthesia provider
• Surgeon
• Scrub nurse
• Charge nurse

• Answer : B
• The nurse is caring for a patient
diagnosed with human immune
deficiency virus. Which of the
following nursing diagnoses takes
priority?

• Diarrhea related to medication side

effects
• Risk for infection related to
inadequate immune system
• Imbalanced nutrition relate to
decreased appetite
• Impaired tissue integrity related to
cachexia and malnourishment

• Answer : B
• . A nurse assesses a 3-month-old
infant. The patient expresses anxiety
and feeling over whelmed. The nurse
offer information on available
parenting support. This level of child
abuse prevention is classified as
which of the following?

• Intervention
• Primary
• Secondary
• Tertiary

• Answer : B
• The nurse is caring for a patient with
a coronary thrombosis who is
receiving prescribed streptokinase
(streptase). The patient reports the
onset of a rash as well as feeling hot
while experiencing chills. The nurse
should IMMEDIATELY implemented
the plan of care for:

• A medication side effect

• An allergic embolus
• A Pulmonary embolus
• Peripheral artery occlusion

• Answer : B
• . The nurse is teaching a patient who
was just diagnosed with narcolepsy.
The nurse should teach the patient
that which of the following typically
INCREASES the level of fatigue?

• Taking brief naps

• Participating in anexercise program
• Eating large meals
• Working in a coolenvironment

• Answer : B
• . The physician has prescribed
 quinidine polygalacturonate
(Apo-Quinidine), 8.25 mg/kg every 4
hours for a patient who weighs
50kgs. The drug is available as a 275
mg tablet. The nurse should
administer how many tablets for
each dose?

• 2.5
• 2
• 1.5
• 1

• Answer : C

• The nurse is teaching the parent of a

child with celiac disease.Which of
following diets should be reviewed
with the parent?
• Gluten-free
• Dairy free
• Vegetarian
• Sodium-restricted

• Answer : A

• A patient has peripheral vascular

disease.The nursing diagnosis is
ineffective tissue perfusion:
peripheral.Which of the following
is an appropriate goal?

• The patient will identify three factors

to improve peripheral circulation
• The patient will have palpable
 peripheral pulses in1week
• The patient’s feet will be warm to
touch
• The patient will ambulate the length
of the hall way

• Answer : B

• On the second day of

hospitalization for
ventriculoperitoneal shunt
revision, a child with spina bifida
developed hives, itching and
wheezing. The nurse should
determine if the patient has been
exposed to:
• Peanuts
• Strawberries
• Eggs
• Latex

• Answer : D

• A patient with malignant cancer has

decided to stop chemotherapy and
receive hospice care. What is the
 PRIORITY nursing diagnosis?

• Alteration in comfort
• Hopelessness
• Powerlessness
• Non-compliance

• Answer : B

• A nurse assessing a 16-month-old

child observes bruises scattered over
the body that are at different stage of
healing. The child also has poor and
diaper rash. The goal of treatment for
this child is to:

• Ensure the physical and emotional

 safety of the child
• Remove the child from the parents
• Admonish the parents of the child
• Ensure that the child stays with the
biological parents

• Answer : A

• While visiting a patient who had a

left hip replacement surgery one
week ago, the Patient complains
to the home care nurse of
episodic numbness and tingling
of the lower left extremities.
 Assessment of the patient shows
that the lower left extremities are
slightly cool to touch when
compared to the lower right
extremities. There is no swelling
or redness on assessment. What
would be the NEXT nursing
intervention?

• Reassure the patient that this normal

after surgery
• Refer the patient to the surgeon
immediately
• Encourage the patient to decrease
activities involving the left hip and
extremities
• Refer the patient to a physical the
rapist immediately
 • Answer : C

• . A nurse is evaluating a patient 5

days after a right total hip
replacement. Which of the following
goals is appropriate for the patient?

• Maintain hip abduction without

dislocation
• Rest with legs elevate while sitting
• Tie shoes and put on undergarments
without assistive devices
• Perform scissors-like leg exercise
daily

• Answer : A
• . Prior to providing care for a
hospitalized infant, the nurse MUST:

• Introduce self to parent

• Perform hand hygiene
• Have a witness present
• Assess the child’sdevelopmental
level

• Answer : B

• When caring for a patient with new

sigmoid colostomy, the nurse knows
that the stoma may be expected to
decrease in size from up to:

• One months
• Two months
• Six months
• One year

• Answer : A

• A 7-week-old infant boy is admitted

with projectile vomiting decreased
urine output, decreased bowel
movements and weight loss. He has
poor turgor and appears hungry. The
nurse observes left-to right peristaltic
waves after he vomits. The nurse
would expect to find which of the
following during the physical
assessment?
• Hepato-spleenomegaly
• A palpable pyloric mass
• Lymphadenopathy
• Bulging fontanelles

• Answer : B

• A nurse will need to change the

dressing on a patient’s central
venous catheter during the shift. The
nurse should plan to:
• Limit the patient’s activity for an hour
dressing change
• Position the patient on to the left
side before removing the old
dressing
• Put on sterile gloves after explaining
the procedure to the patient
• Cleanse the insertion site using a
circular motion

• Answer : B

• During the postoperative period, a

nurse is assigned to care for a
morbidly obese patient with an
abdominal incision. The nurse knows
that this patient’s weight increases
 the risk of:

• Left-sided heart failure

• Pressure sores of the coccyx
• Constipation and ileus
• Wound dehiscence

• Answer : D

• Which of the following takes place

during the implementation phase of
the nursing process?
• Development of a goals and a
nursing care plan
• Identification of actual or potential
health problems
• Actualization of the care plan
through nursing interventions
• Determination of the patient’s
responses to the nursing
interventions

• Answer : C

• For a patient with a colostomy,

which of the following-intervention is
appropriate for preventing the risk of
the impaired skin related to exposure
excretions?
• Empty pouch when it is completely
full
• Remove the skin barrier inspect the
skin monthly
• Recaps Skin barrier opening to size
of stoma with each change
• Cut an opening in the skin barrier
then the circumference of the stoma

• Answer : B

• An infant who weighs 9 kg (19.8 lbs)

requires 900ml of fluids per day for
maintenance fluids. The infant
typically consumes 120ml during
each feeding. The infant must have
how many feedings per day to meet
 the fluid maintenance needs?

• 4
• 8
• 10
• 12

• Answer : B

• A patient has pacemaker implanted.

Which of the following interventions
is appropriate for the nursing
 diagnosis of risk for injury?

• Have patient avoid exposure to

magnetic resonance imaging(MRI)
• Observe incision site for redness,
purulent drainage,
• Offer back rubs to promote
relaxation
• Instruct patient in dorsiflexion
exercises of ankles

• Answer : A

• A patient undergoing treatment for

cancer with bone metastasis is
experiencing severe pain. Which of
the following treatment would the
 nurse MOST likely expect to improve
the patient’s pain control?

• Adjuvant radiation therapy

• Palliative radiation therapy
• Curative radiation therapy
• Radio surgery (stereotactic)

• Answer : B

• A home care nurse visits a patient

with diabetes. The patient cast three
well balanced meals sweet dessert
and exercises 30 minutes a day twice
a week. Also, the patient is complaint
with taking hypoglycemia
medications Blood glucose level
ranges from 150-200 mg/dl. The
 nurse sets a goal of eliminating
sweet desserts and increasing the
frequency of exercises to 3 times a
week. This week, the patient
exercised 3 times for 30 minutes and
ate dessert only after dinner. The
glucose ranges from 100-150 mg/dl.
The nurse evaluate that:

• The goal will not be met

• Progression is being made towards
the goal
• The goal is met
• The goal is inappropriate

• Answer : B

• A nurse is assigned to care for a

 patient with an ileostomy. The nurse
would expect the ostomy discharge
to be:

• Fluid mushy
• Mushy
• Liquid
• Solid

• Answer : C

• A nurse educates a patient

diagnosed with diabetes, on the
importance of exercise and a
well-balanced, low-carbohydrate diet.
The patient takes
metforin(glucophage) 500 mg once a
day. Which following indicates the
 patient’s plan of Care needs to be
re-evaluated?

• Blood glucose level is 90mg/dl

• HbA1C (glycosylated
hemoglobin)level is 9.0%
• Total H DL level is 60mg/dl
• Low density Lipoprotien is130 mg/dl

• Answer : B
• A nurse schedules a patient for a
surgical procedure to take place in
1week. When would the nurse MOST
likely implement surgical education?

• After admission to the hospital

• Start during this visit
• Immediately prior to anesthesia
• After the operation

• Answer : B

• The nurse is inserting a nasogastric

(NG) tube into a patient as
prescribed. The nurse has advanced
the tube into patient’s posterior
pharynx. The nurse should ask the
patient to:

• Hold the breath

• Stare upwards with eyes towards the
ceiling
• Perform the valsalvas maneuver
• Lower the chin towards the chest
• Answer : B

• A home care nurse visits a diabetic

patient who was started on insulin
injections. Upon examination, the
nurse observes small lumps and
dents on the right upper arm where
the patient has injected insulin. What
is the BEST nursing intervention?

• Refer patient to dermatologist for

diabetic cellulites
• Instruct the patient to rotate the sites
of injection
• Refer patient to an endo forbetter
control of glucoselevel
• Instruct patient to inject inthe
muscular area instead ofa endoarea
• Answer : A

• After cardiac surgery, a patient has

been prescribed low-sodium, low
cholesterol diet. Which of the
following menus is BEST?

• Salami, rye bread, sanerkrant

• Baked chicken thigh, iceberg lettuce,
sliced tomatoes
• Pasta with canned tomato sauce,
peas, wheat bread
• Bacon, lettuce and tomato sandwich
with mayonnaise dressing

• Answer : C

• A home health nurse visits a patient

with chronic obstructive pulmonary
disease (COPD) using home oxygen
at 2 liters per minute. The patient
reports periods of shortness of
breath and inquires about increasing
the oxygen to 4 liters/minute. The
nurse explains that increasing the
supplemental oxygen will:

• Increased activity tolerance

• Suppress the hypoxic drive
• Alleviate the shortness ofbreath
• Prevent lung infection

• Answer : B

• The nurse should avoid the use of

the dorsogluteal site for an
intramuscular injection in children
because of the risk of injury to which
of the following nerves?

• Vagus
• Sciatic
• Llioinguinal
• Lumbar plexus

• Answer : B

• Twelve hours after removal of a

benign liver tumor, the nurse
observed that the patient has
decreasing blood pressure,
decreasing pulse pressure,
increasing heart rate and increasing
respiratory rate. The patient’s skin is
cool and pale after lowering the head
of the bed, what should the nurse do
next?

• Call the physician

• Administer pain medication
• Position the patient on the left side
• Apply cool, wet cloths under the arm

• Answer : A

• . The nurse is assigned to care for an

elderly patient with a low-exudates
stage III pressure ulcer, which of the
following types of dressings would
the nurse MOST likely plan to use?

• Hydrogel
• Hydrocolloid
• Polyurethane
• Polyurethane foam
• Answer : B

• A patient with an unnecessary gait

and a history of falls has a care plan
intervention that includes keeping the
walker in reach and pathway free of
obstacle. On evaluation after 1 week,
the patient has had no falls, but the
gait remains unsteady. The nurse
should:

• Continue the plan of care as written

• Allow the patient to replace the
walker with a cane
• Allow the patient to ambulate short
distance without the walker
• Have the patient practice stepping
over small objects
• Answer : A

• The nurse is caring for a patient who

had a total proctocolectomy 24
hours ago due to a malignant
neoplasm in the rectum. The patient
continues to receive intravenous
fluids and has started a clear liquid
diet. The nurse understands that the
patient is at INCREASED risk for
which of the following postoperative
complications?
• Dissemination intravascular
coagulopathy (DIC)
• Atelectasis
• Syndrome of inappropriate
anti-diuretics hormone(SIADH)
• Hypokalemia

• Answer : D

• . When doing community-based

teaching for latex allergies, the nurse
should plan to teach the patient that :

• Food handled by people wearing

latex gloves stimulates an allergies
response
• Food containing nuts may trigger an
allergic cross-response in people
with latex allergies
• The patient should wear a face while
in the hospital due to large amount of
airborne latex
• Hoses used on gases pumps contain
latex and should be avoided.

• Answer : B

• The nurse is assessing 16-month old

girl. The nurse observes poor
hygiene, diaper rash and bruises over
the child’s body that is at different
stages of healing. Which of the
following interventions would reduce
fear and promotes the trust of the
child?

• Avoid scaring the child by saying “No

or setting limits
• Challenge the information the
parents give regarding the injury
• Question the parents of the child
regarding the abuse
• Assign one nurse to care for the child
over the course of hospital stay

• Answer : C

• A patient is who is prepared for hip

surgery has an order for external
pneumatic compression devices. The
nurse teaches the patient that
pneumatic compression can help
prevent:

• Upper respiratory infection

• Decreased breath sounds
• Deep vein thrombosis
• Bleeding at the surgical site

• Answer : C

• A patient presents with a productive

cough with a moderate amount of
while Frothy sputum and dispend.
The patient is anxious and the nurse
notices on assessment that the
patient is using accessory muscle
including intercostals spaces to
breathe and has jugular vein
distention. The patient has a history
of hypertension and heart failure.
What should the nurse administer
FIRST?
• Digoxin (lanoxin) toimprovethe
abilityof the heart topump effectively
• Oxygen therapy to combathypoxemia
• Furosemide (lasix) toreduce blood
volume andpulmonary congestion
• Morphine sulface(Duramorph) to
reduceanxiety

• Answer : A

• A nurse is preparing to meet with an

individual whose spouse recently
diagnosed with Alzheimer’s disease.
The nurse should know that the
primary goals of treatment are:
• Curing the Alzheimer’sdisease
• Maximizing the functional ability and
improve quality of life
• Having the Alzheimer’s patient
placed in a safe controlled
environment
• Making all decisions for the patient
and confirming to home

• Answer : B

• A Community nurse interviews an

87-year-old patient diagnosed with
early Alzheimer’s disease. Because
 the patient provides conflicts
information, the nurse compares
subjective and objectives data to find
a possible reason for the conflicting
data. This process of assessment is
called:

• Data verification
• Analytical interpretation
• Mental assessment
• Subjective observation

• Answer : A

• The nurse assesses an elderly

patient for health problem. The
 family reports that the patient has
trouble remembering and they are
concerned about Alzheimer’s. Which
of the following are risk factors for
Alzheimer’s disease?

• Genetic history and male gender

• Ethnic group and dietary habits
• Genetic history and female gender
• Dietary habits and male gender

• Answer : C
• A patient with Alzheimer’s disease
has a fall, which results to a fracture
of the right leg, after repair of the
fracture the patient is discharged
home with family with instructions of
wound care, the family verbalizes
that the patient has been doing well
,which of the following instructions
would the nurse give to the family?

• Instruct the family how to provide

skin integrity
• Suggest to the family that if the
stress is overwhelming ,placement in
a skilled nursing facility may be
needed
• Suggest collecting the patient on a
regular schedule and applying
incontinence brief at all times
• Assess for the cause of incontinence
and add an appropriate nursing
diagnosis post and interventions

• Answer : A

• . A nurse assists a patient with

Alzheimer’s disease in teeth
brushing. The patient indicates
warning to complete the task alone,
but is unable to get the toothpaste on
the toothbrush. The nurse can MUST
effectively help the patient by:

• Providing privacy to complete the

task
• Completing task
• Providing hand-over-hand assistance
with the task
• Telling the patient to brush the teeth
today

• Answer : C

• A child with iron deficiency

complains of feeling tired all the
times. The nursing diagnosis of
fatigue is related to:

• A decreased ability of the blood to

transparent oxygen to the tissues
• An increased paroxysmal abdominal
 pain and distension to the stomach
• A decreased anxiety level during
hospitalization
• A decreased nutritional intake with
malabsorptionofnutrition

• Answer : A

• A patient arrives in the emergency

room with burns over the upper trunk
and arms. The nurse should obtain
the patient’s pulse at which of the
following arterial location?

• Radial
• Carotid
• femoral
• Apical

• Answer : C

• A patient with a spinal cord injury

states, “I have no control over my
situation, I can’t do anything for
myself”. This patient is exhibiting:
• Powerlessness
• Delusions
• Suicidal ideation
• Resignation

• Answer : D

• A nurse is teaching a prenatal class

 to a group of the first time mothers,
each at different points in their
gestation, which of the statement is
TRUE regarding the management of
fatigue?

• Rest flat on back, especially during

the third trimester
• Exercise programs should focus on
their training
• Frequent 15 minute to 30minute rest
periods are important
• Six hours of sleep a night is adequate

• Answer : C
• A nurse is caring for a postoperative
patient who is on subcutaneous, low
dose heparin. This medication is
used to prevent:

• Deep vein thrombosis

• Congestive heart failure
• Paralytic Ileus
• Pneumonia

• Answer : A
• A Patient is recovering following
surgery for placement of a
colostomy. The nurse goes to the
patient’s room to instruct the patient
 how to care for the colostomy. The
patient’s roommate has visitors and
the patient does not want to
participate at this time. What should
the nurse do?

• Document the patient’s refusal and

add non-compliance to the care plan
• Tell the patient that this is vital
information and may delay
discharged
• Plan a time convenient to both the
patient and the nurse
• Pull the curtain around be bed and
speak, ensuring privacy

• Answer : C
• Which of the following actions would
be appropriate for the nurse to take
when Caring for a patient on contact
precautions?

• Serve the patient’s meals on the

disposable with plastic eating
utensils
• Instruct visitors to talk to the nurse
before entering the patient’s room
• Rinse both hands with water after
removing gloves
• Place a surgical mask on the patient
during transport
 • Answer : B

• . A patient is recently diagnosed with

Herpes Zoster. The nurse
establishing the care plan would
MOST likely assign the highest
priority to which of the following
nursing diagnosis?

• Anxiety
• Social Isolation
• Peripheral neurovascular dysfunction
• Acute pain

ANS D
• In order to reduce the risk of disease
transmission from a patient with
diphtheria, which of the following
standard precautions would be the
nurse implemented?

• Airborne
• Contact
• Droplets
• Ventilatory

• Answer : C

• A patient with measles (rubella) is

on airborne precautions, which of the
 following Precautions techniques
would be ESSENTIAL to implement
for non-immune person entering the
room?

• Gloves
• Gowns
• Face shields
• Masks

• Answer : D

• A patient sustained multiple

musculoskeletal trauma after a
motor vehicle collision and is now in
skeletal traction awaiting surgery.
The nurse observes that the patient
has developed a large area of flat,
 Pin point purple-colored areas on the
thorax. Which of the following
actions would be appropriate for the
nurse to take?

• Discontinue the opioid that is being

administered
• Place an extra blanket on the patient
• Release the weights on the patient’s
skeletal traction
• Administer
diphenhydramine(Benadryl)
prescribed p.r.n allergic reaction

• Answer : D

• A physician has ordered gavage

feeding every 4 hours for a
 12-week-old infantwith failure to
thrive. In order to know how far to
insert the feeding tube. The
nurseshould measure the distance
from:

• The infant’s mouth to the xiphoid

process of the sternum
• The tip of the infant’s nose to the ear
and then to the umbilicus
• C.The infant’s mouth to the ear and
then to the umbilicus
• The tip of the infant’s nose to the ear
and then to the xiphoid process of
the sternum

• Answer : D
• . A nurse is assessing an infant
diagnosed with failure to thrive. In
addition to accurate anthropometric
measurements, complete nutritional
history, infant feeding ability, and
head-to-toe assessment the nurse
should asses which of the following

• Parent-to-child interaction
• Number of sibling in the home
• Current sleep patterns
• Exposure to second hand smoke

• Answer : A
• A school nurse refers a child who
failed the school vision screening for
eye doctor. The child returns with
glasses to be worn at all times. The
nurse should monitor this child for:

• Redness of the eye

• Episodes of seizures
• Improved vision with glasses
• Lazy eye

• Answer : C

• A2-years-old child in the emergency

department exhibits symptoms of
bacterial meningitis. Which of the
following tests confirm or rule out
 this diagnosed?

• Magnetic resonanceimaging (MRI)

• Magneto encephalogram
• Computed tomography scan(CT)
• Lumbar puncture (LP)

• Answer : D

• A patient exhibits clinical

manifestation of a pulmonary
embolism. Arterial blood gas
(ABG)levels and a chest x-ray are
ordered. Which of the following test
is used to diagnose this condition?

• Computer tomography scan(CT

scan)
• Magnetic resonanceimaging (MRI)
• Pulmonary angiography
• Pulmonary function test

• Answer : C

• A patient is admitted to the

emergency department with a
sucking, chest wound has diminished
breath sounds or auscultation. Which
of the following interventions would
the nurse perform FIRST?

• Monitor O2 saturation and arterial

 blood gas (ABG)levels
• Apply Petroleum Gauze to wound
• Prepare the patient for emergency
thoracentesis
• Position the patient in anupright
position.

• Answer : B

• A patient has pulmonary embolism.

Which of the following nursing
diagnoses has PRORITY?

• Anxiety related to pain,dyspnea, and

concern of illness
• Risk for injury related to altered
hemodynamic status
• Acute pain related to congestion and
possible lung infarction
• Ineffective breathing pattern related
to acute increase in alveolar dead air
space
• Answer : D

• Which test should be added to the

yearly physical of a patient who has
recently turned 50 years old?

• Culture and sensitivity

• Fecal occult blood
• Routine urine analysis test
• Angiography studies
• Answer : A

• The normal range of pH in arterial

blood is:

• 7.15-7.20
• 7.25-7.30
• 7.35-7.45
• 7.50-7.55

• Answer : C

• To prevent pressure on the feet of a

bed-bound patient with decreased
tissue perfusion, the BEST
intervention the nurse should take is:

• Place sheep skin under the heels

• Place a foot cradle on the bed
• Pad the side rails with foamtubing
• Use only natural fiber linens

• Answer : D

• The nurse assists with a lumbar

puncture on a child with suspect
bacterial meningitis. If the diagnosis
is correct, the cerebrospinalfluid,
should have which of the following
qualities?

• High glucose level

• Low protein level
• Cloudy or turbid appearance
• Pink or blood-tinged appearance

• Answer : C
• An elderly patient with severe
degenerative joint disease comes to
the clinic for routine follow up of pain
management. The patient reports
that over the past month, the pain
has begun to increase in severity.
The patient requests an increase in
dosage of the pain medication. The
nurse recognize that this is MOST
likely due to:

• Drug addiction
• Drug tolerance
• An improvement in condition
• Lack of efficacy of the current
medication
 • Answer : D

•
• A patient has hepatitis B (HBV) and
is now a chronic carrier. In planning
care, the nurse would explain an HBV
carrier would MOST likely be at risk
for developing a super infection with
which other type of hepatitis?

• A
• C
• E
• D

• Answer : B

• . A preoperative patient has a large

 volume cleansing enema ordered. In
order to facilitate the flow of the
solution into the rectum and colon,
the nurse should position the patient
in the:

• Supine position with legs flexed to

chest
• Right lateral position with left sharply
flexed
• Supine position with legs spread
• Left lateral position with right leg
sharply flexed

• Answer : D
• Respiratory depression is a
potentially life-threatening adverse
effect of

• Opioids
• Anticoagulants
• Immuno modulators
• Non-steriodials (NSAIDS)

• Answer : A

• A child in the postictal state of a

seizure should show which of the
following signs or symptoms?
• Feeling sleepy or exhausted
• Stiffness over entire body
• Verbalizes having an aura
• Eyes fixed in one position

• Answer : A

• Standards of pain management

dictate the nurses:

• Administer analgesic via injection

whenever possible
• Avoid the use of the word “pain”
• Screen for pain at each encounter
• Discourage around-the clock dosage
of analgesics
 • Answer : C

• The nurse observes a patient who is

eating. The patient suddenly stands
up, places both hands onto the neck
and is unable to speak when the
nurse asks if the patient can speak.
The nurse observes that the patient
is neither coughing not cyanotic. The
nurse should IMMEDIATELY:

• Lay the patient flat before

compressing the mediastinal area
• Insert a finger into the patient’s
mouth to feel for any food
• Stand behind the patient while
 performing abdominal thrusts
• Activate the emergency call light near
the patient

• Answer : C

• A patient required long-term

antibiotic has a central line catheter
inserted into the right subclavian vein
by the physician .Which of the
following must be verified prior to the
first use of the catheter?

• Blood return
• X-ray
• Catheter potency
• Length of catheter
 • Answer : B

• . When planning discharge teaching

for a patient hospitalized for
treatment of third-degree burns over
30% of the body, the nurse knows it
is MOST important to include which
of the following instruction regarding
the loss of large amounts of serum
occurring with burns and the
resulting loss of immune function?

• Wash hands frequently each day

• Wear masks while in public spaces
• Wear supplement oxygen at night
• Take a multiple vitamin tablet each
night
 • Answer : A

• . Which of the following is the MOST

important discharge planning
instruction for a patient with
mononucleosis?

• Avoid activities that may increase

injury to the spleen
• Avoid crowded areas to prevent the
spread of infection
• Consume vitamin K rich food to
decrease the risk of bleeding
• Take an antibiotics a prescribed to
 treat infection

• Answer : B

• . Which of the following tests

measures the total quantity of
prothrombin. In the blood and
monitors the effectiveness of
warfarin sodium (coumadin) therapy
and prolonged defficiencies in the
extrinsic factor?

• Thrombin time (TT)

• Prothrombin time (PT)
• Partial prothrombin time(PTT)
• Activated partialthromboplastin time
(aPTT)
 • Answer : B

• While conducting a class for

expected mothers, the nurse explains
the difference between true labor
construction and false labor
contraction by indicating that the
labor contractions:

• Are located mainly in the abdomen

and groin
• Have increasing intensity
• Occur with decreasing intervals
• Occur at regular intervals
 • Answer : B

• One month after starting new

medications for hypertension, a
patient returns to the clinic with
blood pressure in the range. The
patient admits to taking the
medications only when “feeling bad”
Which of the following actions would
the nurse take?
• Assess further determine the reason
the reason for the patient’s Actions
• Add a new diagnosis of
non-compliance
• Re-educate the patient about the
importance of following his
medication plan
• Reevaluate the need for daily
medication since the blood pressure
is acceptable

• Answer : C

• A home care nurse visits a patient

who is wheelchair bound due to
recent motor vehicle accident. The
patient has been sitting in the wheel
chair for extended periods of time
which resulted in the development of
a stage pressure sore on the right
buttocks. What is the BEST nursing
intervention?
• Instruct caretaker to change the
patient’s position every 2 hours
• Apply hydrogel to the stage I
pressure sore every 8 hours
• Refer the patient to wound care
specialist for debridement
• Encourage the patient to consume an
increased amount of calcium

• Answer : A

• . Following an open-cholecystectomy,
the nurse would instruct the patient
to expect to resume normal activities
in:
• 1 to 2 weeks
• 2 to 3 weeks
• 4 to 6 weeks
• 6 to 8 weeks

• Answer : A

• A patient had a retinal detachment

surgically repaired. The nurse
identified that the detachment would
MOST likely be correct and unlikely to
reoccur if the retina remains
attached at LEAST:

• 3 days
• 2 weeks
• 2 months
• 3 months
 • Answer : B

• . A home care nurse visits an elderly

patient who had a surgical repair for
fracture. The patient is taking opioid
analgesics. Today, the patient
complaints of decreased appetite
and absence of a bowel movement
for four days. Which of the following
can be inferred?

• Constipation related to use of

opioids
• Decreased appetite due to
depression
• Constipation due to acute pain
• Decreased appetite due to use of
 opioid

• Answer : A

• . A child recently diagnosed with

sickle cell anemia is being prepared
for discharge. Which of the following
statement by one of the parents
would require ADDITIONAL teaching
by the nurse?

• High altitudes can be beneficial

• Blood transfusion may be necessary
in the future
• Strenuous physical activity should be
 avoided
• Increased fluid intake minimize pain

• Answer : A

• A 13-year-old child is hospitalized for

treatment of sickle cell crisis. The
nurse finds the child is crying and
does not answer the nurse when
addressed. What should nurse do
FIRST?

• Interview the parents about the

child’s pain tolerance and usual
medication requirements
• Medicate the patient with the
medication ordered for breakthrough
 pain as soon as possible, the resume
the evaluation
• Ask the child to describe the pain, it
is located, and to rate it on the
wong/baker pain scale.
• Tell the child to rest while and the
nurse will return at another time for
the evaluation

• Answer : B

• . The nurse is entering the room of a

patient who is blind. The nurse
should:

• Speak before touching the patient

• Talk to the patient using aloud tone
of voice
• Ask then patient questions that can
be answered “yes”or “no”
• Stand directly in front of the patient
while talking

• Answer : A

• A nurse has been visiting a

bed-bound patient with decreased
bowel mobility in the home for one
month. The family tells the nurse that
the patient is becoming incontinent
of feces. The nurse evaluates the
plan of care and notes which of the
following intervention would MOST
likely beneficial?

• An enema two times a week

• Increased fiber in the diet
• Aroutinebisacodyl(Dulcolax)
suppository
• An enema three times aweek

• Answer : B

• A bed-bound patient has a care plan

with interventions to include re
positioning every 2 hours. The
patient develops a stage I pressure
sore on the right heel. What
intervention should be added to the
care plan?

• Massage the right heel four times per

day
• Add a trapeze to the bed
• Float heels off bed with a pillow
• Add a bed cradle to the bed

• Answer : C
• A patient is receiving from surgery
using spinal anesthesia. The patient
develops a spinal headache. Which
of the following nursing actions
would be MOST appropriate?

• Elevate the head of the bed30

degrees
• Keep the patient well hydrated
• Limit intake of salty food
• Lower the temperature of the room

• Answer : B
• A nurse is giving discharge planning
instruction to the parents of a
1-years old child with acute otitis
media. Which of the following
discharge instruction take FIRST
priority?

• Administer antibiotics as prescribed

• Breastfeed as long as possible
• Administer influenza vaccination
• Avoid smoking around the child

• Answer : A
• Three weeks post amputation of the
leg the patient is instructed to
massage the residual limb. The
MOST likely rationale for this to:

• Provide counter-irritation for pain

 control
• Prepare for a prosthesis
• Promote wound healing
• Promote acceptance of the limb’s
appearance

• Answer : B

• A patient receives a blood

transfusion for severe anemia after
surgery. While evaluating the patient
the nurse finds that the patient’s oral
temperature has began to rise from
98.20F (36.80F) to 101.00F(38.30C).
What should the nurse do?

• Give the patient an anti-pyretic

medication and continue the
transfusion as ordered
• Discontinue the intravenousline and
restart in anothersite
• Stop the transfusion, keep the vein
open with normalsaline,and notify the
doctor immediately
• Use a blood cooling deviceto cool the
blood as itinfuses

• Answer : C

• The nurse is teaching a patient who

has just diagnosed with bacterial
conjunctivitis, The nurse should that
the MOST effective way to
transmission of this to other people
is by
• Putting on clean gloves before
cleansing the eye
• Taking medication as prescribe
• Wearing a gauze eye patch
• Performing hand hygiene

• Answer : D

• A nurse for a child with celiac

disease (CD). The patient would have
a permanent inability to tolerate:
• Protein
• Dairy
• Glutens
• Fruits
• Answer : C

• The nurse is caring for a patient who

had an acute pulmonary edema.
The nurse should understand that
which of the following prescribed
medications will help to reduce the
increased pressure?

• Morphine sulfate
• Potassium chloride
• Warfarin sodium(coumadin)
• Bisacodyl (dulcolax)
• Answer : A

• When planning discharge teaching

for the parent of an infant with
respiratory problems , the nurse
should EMPHASIZE

• Use of supplemental oxygen at night

• Frequent hand washing
• Sleeping in the supine position
• Rice-thickened formula during
night-time feedings

• Answer: C

• A nurse is caring for a child who is

post-tonsillectomy and
adenoidectomy. The nurse should
 plan to assess which of the following
complications?

• Pulmonary hypertension
• Hemorrhage
• Hearing loss
• Corpulmonale

• Answer :B

• A patient has multiple sclerosis and

complains of overwhelming fatigue.
The nurse would be MOST correct in
instruction the patient to:

• Conserve energy during activities of

daily living
• Increase muscle strength through
aerobic exercise
• Ignore fatigue and keep working
• Increase early afternoon intake of
caffeine

• Answer : A

• While caring for an edentulous

patient with multiple pressure sores,
the nurse asked by the patient’s
spouse to evaluate several menus,
Which of the following menus would
be MOST therapeutic?

• Steamed carrots, milks and

applesauce
• Tuna fish with mayonnaise, boiled
 eggs and yogurt
• Grilled steak, baked potato and
peach pie
• Chicken noodle soup ,banana and
cocoa

• Answer : A

• When administering an oral

medication to a toddler, which of the
following interventions should the
nurse plan to use?

• Depress the child’s chin with thumb

to open the child’s mouth
• Place the medication in a nipple for
 the child to suck
• Give the child a small plastic
medication cup for day
• Tell the child that the medication
tastes good

• Answer : A

• The nurse is monitoring a patient’s

urine to determine hydration status
what urine color would indicate the
BEST hydration?

• Clear
• Amber
• Tea
• Pale gold
•

• Answer : B

• A patient is being evaluating due to

onset of paleness, shortness of
breath and sensations of heart
palpitations. Which of the following
component of complete blood count
(CBC) should the nurse review to
determine if the patient has anemia

• Leukocytes
• Platelets
• Erythrocytes
• Thrombocytes
• Answer : C

• While a nurse is assessing a patient

who reports indigestion that radiates
into the jaw. The jaw pain is rated 8
scale of 0 (no pain) to 10 (severe
pain). The patient reports the pain
started an hour ago. The nurse
should IMMEDIATELY:

• Assess the patient’s oral

temperature
• Determine what foods the patient ate
• Place the patient in reverse
Trendelenburg position
• Obtain order and administer
morphine sulfate
• Answer : D

• An elderly home-bound patient is

visited by the community health
nurse. During evaluation, decreased
skin turgor is noted. When asked
about fluids intake, the patient states
that she does not drink any fluids
after lunch each day, and wake sup
very thirsty. The MOST appropriate
question for the nurse to ask is:

• “How much protein does you

normally eats for dinner?”
• “How much caffeine are you
consuming each day?”
• “Are you having trouble controlling
your bladder at night?”
• “Do you have enough money to buy
liquids to drink?”

• Answer : C
• A nurse is caring for a patient who
had rhinoplasty 2-weeks ago. Which
of the following is an expected
outcome?

• Oral mucus membranes dry ,but pink

and intact
• Face and nose free from swelling
• Able to make needs know, speech
therapy started
• Demonstrate throat clearing while
eating
 • Answer : B

• A patient presents to the emergency

room with complaints of eye and
drainage. In planning for the
examination of the patients
complaints, which of the following
instruction would the nurse MOST
likely select?

• Sphygmomanometer
• Thermometer
• Ophthalmoscope
• Otoscope

• Answer: C
• A home health nurse has completed
the assessment of a 72-year-old
patient with & gait disturbance that
will begin home physical therapy.
During the interview, the patient
reported significant difficulty
sleeping more than 4 hours at night.
Which of the following responses
would be appropriate for the nurse to
make?

• “Try doing some type of exercise two

hours before bedtime”
• “Drink a cup of warm tea before you
go to bed”
• “ Make sure the bedroom is dark
 when you get in bed”
• “ A nap in the middle of the day
should help”

• Answer : D

• A nursing is caring for a 3-weeks-old

infant who was just admitted to the
hospital. Which of the following
nursing interventions does NOT
support this infant’s basic emotional
and social needs?

• Provide for continual contact

between parents and infant
• Activity involve parents in caring for
the infant
• Keep the infant’s environment quiet,
 dim, and free of sensory stimulation
• Foster infant-sibling relationship as
appropriate

• Answer : C
• . A home care nurse visits a patient
who is discharged from a hospital
after a treatment of urosepsis. Which
of the following post discharge
normal laboratory result BEST
indicates desired outcome?

• WBC count
• Hematocrit
• Platelet level
• Potassium level
 • Answer : A

• A nurse visits a patient who is

37-weeks pregnant and asking for
information about breast feeding
versus feeding prepared infant
formula. A beneficial reason to
breast feed includes:

• Readily available and economical

• Keeps a baby full longer
• Larger curds than cow’s milk and
therefore is easier to digest
• Encourage greater deposits of
subcutaneous fat in an infant

• Answer : A
• When implementing a feeding
schedule for a full term 2-weeks old
infant, the nurse should expect the
infant to be fed:

• 2-4 times per day

• 6-8 times per day
• 10-12 times per day
• 14-16 times per day

• Answer : B
• A home care nurse makes a
follow-up visit to a patient who had
shingles. A month since the onset,
the patient pain level is 6 on a scale
of 1 to 10 where 1 is no pain and 10
is greater pain. Two weeks ago, the
pain
Level decreases without any caring.
The patient’s condition has:

• Met the expected outcome

• Partially met the expected outcome
• Has not improved
• Has worsened
•
• Answer : A

• The nurse is in public area of the

 health care facility when an adult
falls to the floor. Which of the
following actions should the nurse
take NEXT?

• Open the airway

• Determine unresponsiveness
• Activate the emergency call system
• Obtain the automatic electronic
defibrillator(AED)

• Answer : B

• When caring for a patient who is

receiving anticoagulant medications,
the nurse MUST monitor the patient,
for signs of:
• Skin breakdown
• Bleeding
• Pain
• Confusion

• Answer : B

• A patient is being prepared for a right

breast biopsy under general
anesthesia. The patient asks the
nurse about the surgical scar and
possible postoperative
complications. Which of the
following actions would be
appropriate for the nurse to take?

• Review the post operative risks with

the patient
• Notify surgeon about the patient’s
questions
• Complete the patient’s preoperative
check list
• Show the patient photos of breast
surgical scars

• Answer : B

• A patient with bowlegs due to

abnormal bone formations and
deformities has a calcium level of
7.5mg/100ml. Which of the following
foods would the nurse MOST likely
instruct the patients to add to a diet?

• Organ meats
• Whole grains
• Egg yolks
• Lean means

• Answer : C

• A patient has just diagnosed with

hypothyroidism. Which of the
following instructions is correct?

• You will need to take thyroid

hormone replacement therapy your
Entire life
• You will need to take thyroid
hormone replacement therapy until
your laboratory result
• You will need to take thyroid
hormone replacement therapy for
 about 2 months.
• You will need to take thyroid
hormone replacement therapy for 1
year.

• Ans . A

• The stages of dying, as identified by

Dr.Elizbathkubbler-ross, occur in
what order?
• Anger, depression, bargaining, denial,
acceptance
• Bargaining ,denial, acceptance,
depression
• Denial, anger, bargaining, depression,
acceptance
• Depression, Denial, Anger,
bargaining, acceptance
• Ans.C

• A co-worker informs that the nurse

about experiencing increased level of
stress associated with daily
responsibilities to help cope with
professional stress, the nurse should
encourage the co-worker to ;
• Make a list of unfinished tasks
• complete complex mental task
before physical tasks
• Acknowledge daily accomplishments
• Spend time with colleague away from
work

• Ans . B
• A nurse is caring for a post operative
patient who is on subcutaneous, low
dose of heparin. When administering
injection on the abdomen, the nurse
avoids the umbilicus area because of
the possibility of :

• Entering a larger body vessel

• Causing increased pain
• Precipitating hyper ventilation
• umbilical infection

• Ans . A
• A pt with conjunctivitis reports the
 presence of photophobia and
moderate eye drainage. The nurse
should teach pt to

• Avoid touching the eye

• use sterile gauze to remove the
drainage
• Darken the room
• rest in the prone position

• ANS. C
• During surgery the pt has the
following intake and output: IV
fluid 650 cc ,IV antibiotic 50 cc , 1
unit of packed red blood cells 350
cc,nasogastric output 120
cc,estimated blood loss 80
cc,and urine in the folyes catheter
 240 cc.wat is the patient’s total
intake

• 650 cc
• 700cc
• 900 cc
• 1050 cc

• Ans. D
• A community health nurse assesses
a 68-year-old patient who lives in a
group home. The patient reports
decreased appetite after transferring
to the group home because the food
tastes too bland. What type of data is
the nurse collecting from the above
information?
• Analytical
• Derived
• Objective
• Subjective

• Answer : D

• The home care nurse is providing

wound care for a patient. The nurse
evaluates the wound and notes the
presence of granulation tissue in the
wound bed. This observation
represents which phase of wound
healing?

• Maturation
• Inflammation
• Proliferation
• Finalization
 • Answer : C

• A nurse is caring for a 3-year-old

child with a fractured arm. Which of
the following interventions is the
MOST appropriate for pain
management?

• Administer analgesics when

necessary
• Assess pain once a shift
• Anticipate pain and intervene early
• Encourage the use of self-quieting
techniques
• Answer : A

• Which statement by the patient with

hyperlipidemia shows a basic
 understanding of the disease and it
treatment?

• Exercise has no effect on cholesterol

levels
• Hyperlipidemia is usually
symptomatic until significant target
organ damage is done
• HDL cholesterol level of greater the
60 mg/dl increases the chance of
coronary artery disease
• Cholestyramine (Quesram)should be
taken in the morning with other
medications

• Answer : D
• A doctor has ordered an
intramuscular injection (IM) for a 6
month-old infant after her IV
infiltrated. Because infant have under
developed muscles, the nurse should
not administer the injection into
which muscle?

• Vastuslaterlis
• Rectus femoris
• Ventrogluteal
• Gluteus maximus

• Answer : B

• A nurse caring for a patient with

acute pulmonary edema observes
that the patient’s cough produces
 white, frothy and that the patient is
extremely dyspneic. The patient has
inspiratory and expiratory wheezing
on auscultation of the lungs. The
immediate objective of treatment is
to

• Improve oxygenation
• Decrease anxiety
• Improve tissue perfusion
• Decrease risk for aspiration
•

• Answer : A

• When discussing dietary choices

with a patient who is on heparin
 therapy, the nurse should teach the
patient that which of the following
foods may increase clotting time?

• Grape fruit
• Oranges
• Bananas
• Red grapes

• Answer : B

• A 2-month-old child in the

emergency department has projectile
vomiting after feeding. The vomitus
is nonbilious containing milk and
gastric juices. Immediately after
vomiting the child tries to feed again.
The nurse palpates the child’s
 abdomen during feeding and notes a
firm area to the right of the umbilicus
at the upper right quadrant. Which of
the following is consistent with this
history?

• Hypertrophic pyloric stenosis

• Hirschsprung’s disease
• Gastro esophageal reflux
• Tracheoesophagel fistula

• Answer : A

• A patient undergoing cancer

treatment has developed acute
hypocalcaemia with sign of
 weakness, nausea and vomiting.
Which of the following would the
nurse anticipate to be the initial
treatment?

• Thiazide diuretic
• Intravenous normal saline(0.9%
NaCl)
• A potassium supplement
• Broad-spectrum antibiotic

• Answer : B
•
• The patient is receiving mechanical
ventilation set at fraction of inspired
oxygen (FIO2) 100%. The nurse
should understand that which of the
following can improve this patient’s
 oxygenation?

• Adding positive end expiratory

pressure (PEEP)
• Placing the patient in Trendelenburg
position
• Increasing the FIO2
• Suctioning the patient hourly

• Answer : A

• Which of the following nursing

diagnosis takes PRIORITY for a
patient after gastrointestinal
surgery?
• Impaired skin integrity related to
surgical incision
• Constipation related to surgery
• Risk for infection related to surgical
incision
• Acute pain related to surgical
incision

• Answer : D

• Marijuana is an example of a drug

classified as schedule:

• C-I
• C-II
• C-III
• C-IV
 • Answer : A
• A patient with a weight loss of 12 in
60 days has a nursing care plan
written interventions including
offering a dietary supplement three
times per day. After 2 weeks, the
patient has had another 1% weight
loss. The patient indicates no likely
the supplements. The nurse should:

• Continue the plan of care as written

• Replace the supplement with a high
calorie food that the patient likes
• Encourage the patient drink
supplements
• Offer smaller amounts of
supplement more frequently
 • Answer : B

• The nurse is caring for a patient with

magnesium toxicity. Which of the
following clinical manifestation
should the nurse anticipate?

• Paresthesia
• Decreased deep-tendon reflexes
• Cardiac palpitations
• Decreased cardiac output
 • Answer : B
• A patient returning from a3-hour
shoulder repair with
generalanesthesia is being
transported from the operating room
(OR) to the post-anesthesia care unit
(PACU). The nurse knows that the
patient is at high risk for injury
related to residual anesthesia. During
this time period the patient is at
LOWEST risk for

• Airway Obstruction
• Vomiting
• Impaired Circulation
• Fluid volume deficit
• Answer : B

• For a patient scheduled for a total

pancrectectomy, the nurse would be
instruct the patient that the
procedure work MOST likely cause

• Pancreatic ascites
• Chronic pancreatitis
• Diabetes mellitus
• Diabetes insipidus

• Answer : C
• . A nurse is assessing an infant for
possible deafness. Which of the
following automatic reflexes would
the nurse MOST likely check to best
determine whether the child has a
serious hearing problem?

• Blinking
• Vertical suspension
• Moro
• Perez

• Answer : C

• . The nurse is teaching a group about

aerobics exercises. When discussing
the target heart rate for exercise, the
 nurse should state that this is
calculated by:

• Counting the number of the heart

beats during exercise for 6 sections,
then multiply this number by 10
• Subtracting the chronological age
from the number 220
• Counting then number of heart beats
during exercise for 10 seconds, then
multiply by 6
• Subtracting he chronological age
from 240

• Answer : C
• . While performing an assessment on
a post-surgical patient 2 days after
surgery, the nurse notes shallow and
rapid respirations. What should the
nurse do NEXT?

• Asses the patient from pain

• Obtain an order from supplemental
oxygen
• Elevate the head of the bed
• Place a warmed blanket on the
patient

• Answer : C

• A patient is receiving intravenous

fluids at a rate of 125 milliliters/hour
(ml/hr). What volume fluids will the
 patient receive during an 8-hour
shift?
• 1,500 ml
• 1 liter
• 1.5 liters
• 500 ml

• Answer : B

• A patient has a history of severe,

uncontrolled epistaxis. The patient’s
blood pressure and patient count are
normal. The nurse should teach the
patient to

• Sleep with the head elevated on at

least two three pillows
• Apply firm pressure to the nostrils
 four times a day
• Use a cotton-filled applicator to apply
a water-soluble lubricant to the nasal
septum twice daily
• Minimize the intake of caffeine while
increasing theintake of fluids rich
invitamin K

• Answer : B

• A nurse is caring for an infant with

respiratory distress syndrome. Which
of the following nursing intervention
is appropriate

• Measure oxygen saturation level

once a shift
• Suction frequently for 30-45second
 each time
• Monitor for symptoms of
hyperglycemia
• Maintain infant temperature between
36.70& 37.80C(970& 980 F)

• Answer : A

• A nurse is caring a patient who had a

left mastectomy with lymph node
removal seven days ago. The patient
asks about exercises to regain
function of the left arm. Which of the
followingactivities would be
MOSTappropriate?

• Walking fingers up the wall

• Using five pound weights
• Knitting with a large needle
• Rhythmic clapping

• Answer : A

• . What occurs during cardiogenic

shock and resultin inadequate
tissueperfusion?

• Increased resistance of arterial

vessels
• Decreased effectiveness of the heart
as a pump
• Increased shunting of critical blood
flow to heart
• Decreased capacity of the venous
beds

• Answer : B
• The nurse is caring for child admitted
with viralpneumonia. Which of the
following nursingdiagnoses should
receivePRIORITY?

• Nutrition altered: less thanbody

requirements
• Ineffective airway clearance
• Fluid volume deficit
• Risk for injury
 • Answer : B

• A child has ingested an entirebottle

acetaminophen(Tylenol). Which
ofthe following organs isaffected?

• Liver
• Brain
• Kidneys
• Gallbladder

• Answer : A

• A patient is seen in the emergency

department with complaints of
 angina.Nitroglycerin (Nitrostat)
isordered by the physician.This
medication is to beadministered via
which of thefollowing routes?

• Intradermal
• Buccal
• Parental
• Topical
•

• Answer : B

• The nurse is teaching a groupof

patient about hepatitis A(HAV). The
nurse shouldstate that HAV is
MAINLYtransmitted Via:
• Blood contact
• Food
• Sexual activity
• Saliva

• Answer : B

• A child was recently diagnosed with

spastic cerebral palsy. Which of the
following statement by the parent
would indicate to the nurse that
parent understands teaching about
illness?
• Full recovery is possible
• This illness should not progress
• Cerebral palsy is a hereditary disease
• Surgery can sometimes improve
walking
 • Answer : D

• . A patient hospitalized with Crohn’s

disease has developed fever
Increased respiratory rate, increased
heart rate, chills, diaphoreses, and
increased abdominal discomfort. The
nurse knows that patient has MOST
likely developed

• Intestinal obstruction
• Intestinal parasite infestation
• Intestinal perforation
• Ascites
 • Answer : A

• A child is admitted to the hospital

with dehydration. The nurse should
Give PRIORITYto which of the
followingnursing diagnoses?

• Anxiety related to hospitalization

• Fluid volume deficit related to
vomiting
• Imbalance nutrition less than body
requirementsrelated diarrhea
• Risk for infection relatedto presence
of invasivelines
• Answer : B

• The nurse is caring for patient with

deep vein thrombosis(DVT). The
patient’s heparin sodium infusion has
been discontinued and the patient is
receiving prescribed warfarin sodium
(Coumadin). The nurse should advise
the patient that which of the
following needs to be continued?

• Daily complete blood count (CBC)

• Laboratory tests for

partialthromboplastin time (PTT)
• Strict bedrest
• Wearing elasticized support
stockings

• Answer : C

• When teaching the parents of

neonate with spina bifida techniques
to promote bladder emptying, the
nurse reviews a technique in which
firm,gentle pressure is applied tothe
abdomen, presstowardsthe
symphysis pubis. Thismethod is
known as:

• Crede’s
• Intermittent
• Foley
• Prophylactic
• Answer : A

• A 50-year-old patient is being

admitted to the hospital in a
vegetative state of unknown etiology
what is the PRIORITY nursing
diagnosis?

• Risk for impaired skin integrity

• Impaired swallowing
• Altered cerebral tissue perfusion
• Altered thought processes

• Answer : A
• Prior to administering an enema, the
nurse will assist the patient to
assume what position
• Prone with pillow under knees
• Left-side with right knee flexed
• Right-side with left knee flexed
• On back with head of bed flat

• Answer : B

• A nurse interviews a patient, recently

admitted to long term care facility, to
obtain information on the patient’s
health perception. The nurse
encourages the patient to elaborate
about this change. Which type of
questioning would be MOST effective
in this situation?

• Analytical
• Focused
• Closed
• Open-ended

• Answer : D

• When selecting activities to help

develop a child’s fine motor
skills,which of the following would
BEST meet this goal?

• Sorting cardboard objects that are in

different shapes
• Singing while turning the pages of a
book that plays music
• Jumping rope
• Riding a three-wheeled cycle

• Answer : C
• 60 years age a patient weighed 73
kilograms (161 pounds). During the
current clinic visit the nurse note the
patient has an unintended weight
loss. This weight loss over 6 months
would be considered clinically
significant as soon as it reaches the
point of being more than a:

• 5% loss
• 8% loss
• 10% loss
• 20% loss

• Answer : D

• A child with a diagnosis of tetralogy

of fallot is scheduled to be
discharged from the hospital the
nurse planning discharge education
should instruct the caregivers that
during a hyper cyanotic spell the
position MOST likely to benefit the
child is:
• Supine
• Side-lying
• Prone
• Knee-chest

• Answer : B

• A child is treated for possible

acetaminophen (Tylenol) overdose.
Thechild is currently stable with
normal vital signs. Which of the
following organ function system
would be MOST affected?

• Liver
• Stomach
• Lungs
• Heart
 • Answer : A

• The nurse is caring for a patient with

stage III pressure ulcer to the coccyx.
Three days after initiating the plan of
care, the nurse observes that the
ulcer has hard black crust covering
the center of the ulcer. The nurse
should understand that this indicates

• Healing
• Need for debridement
• Inadequate nutrition
• Infection

• Answer : A
• To limit drug interactions, the nurse
should advise the parent of
chronically ill child to:

• Refer to the medications by the

generic name
• Teach the child the name of all
medications prescribed
• Give all medications one hour apart
• Get all prescriptions filled at the
same pharmacy
 • Answer : A

• The nurse receives an order to obtain

an arterial blood gas (ABG) specimen
on a patient. The nurse will use the
radial artery to obtain the specimen.
Which of the following will the nurse
assess before puncturing the radial
artery?

• Allen test
• Partial pressure of arterial oxygen
• Partial carbon dioxide
• Prothrombin time

• Answer : A
• For an infant with hydrocephalus, a
nurse should plan to monitor for
what sign or symptom of increased
intracranial pressure?

• High-pitched, shrill cry

• Decrease in systolic blood pressure
• Depressed fontanelle
• Increase in respirations

• Answer : A

• During surgery requiring general

anesthesia, the patient’s heart
 stops,Ventilations using the end
tracheal tube (ETT) are started with
an ambu bag. Which of the following
compression to ventilation rates is
correct?

• 10 to 2
• 15 to 2
• 30 to 2
• 50 to 2
•
• Answer :C

• A patient with pneumonia has a

temperature, 40 C (104 F); heart rate
20;respiratory rate 32 and dyspnea
patient has an ineffective airway
clearance related to excessive
tracheobronchial secretions. Which
 of the following interventions would
the nurse implement to enhance the
patient’s airway clearance?
• Administer oxygen as ordered
• Maintain a comfortable position
• Increase fluid intake
• Administer prescribed analgesic

• Answer : A

• A 57-year-old patient in a hospital

clinic is scheduled for a colon biopsy.
The patient speaks a different
language than the hospital staff, but
does understand simple
 communication in the language of
the staff. When conduction patient
education prior to the procedure, the
nurse should plan to:

• Write all communication and avoid

speech
• Raise the volume and pitch of the
voice
• Obtain an interpreter
• Smile and nod frequently

• Answer : C

• . The following pain medications are

ordered for a patient who had a right
leg debridement.Oxycodone 5 mg
 every 4 hours as needed and
morphine 5 mg every 4 hours as
needed. The nurse administered
oxycodone 2 hours ago, but the
patient report pain Rated 8 on a scale
of 0 (no pain) to 10 (Severe pain) as
the dressing change begins.Vital
signs are: blood pressure level,
169/98 mmHg; heat rate, 112;
Respiration rate 22; temperature 36.7
C (98.1 F).After evaluating the
effectiveness of the pain Medication,
what action should the nurse take?

• Administer additional oxycodone 5

mg
• Administer morphine 5 mg
• Change the dressing quickly
• Encourage deep breathing
 • Answer : B

• A nurse is assessing the peripheral

circulation of patient’s extremities.
The chart indicates the patient has
edema in both lower extremities.
Which of the following assessment
techniques would the nurse MOST
likely use to assess for this?

• Inspection and auscultation

• Inspection and palpation
• Palpation and percussion
• Percussion and auscultation
 • Answer : B

• A child is admitted with temperature

of 38.5 C (101.3 F), loss of appetite
and vomiting The nurse observes
several joints are red, swollen, warm
and tender to touch. A non pruritic
rash is on the child’s trunk.
Laboratory test results include an
elevate erythrocyte sedimentation
rate (ESR), a positive c- reactive
protein, and an elevated white blood
cell count (WBC). The nurse should
initiate the plan of care for:

• Congestive heart failure

• Meningitis
• Rotovirus
• Acute rheumatic fever

• Answer : D

• A nurse is caring for a hospitalized

diabetic patient with advanced
peripheral recovery. Which of the
following nursing action is MOST
important?

• Moisturizing the skin with lotion each

day
• Ensuring that foods are not too hot
• Facing the patient when speaking
• Assessing the heels for breakdown

• Answer : D

• . A patient in a long-term care facility

is in persistent vegetative state with
a right contracture of the right arm
and hand. What is the BEST goal over
the next 90days for this patient
related to the nursing diagnosis of
impaired mobility?

• Develop no further contractures

• Wear an arm and hand splint
• Have no pain related to the
contractures

• ANS C
•
• To facilitate self-care for a 2-year-old
child with spastic cerebral palsy, the
nurse should recommend:

• Placing straws into beverage

containers
• Obtaining eating utensils that have
large handles
• Replacing zippers on clothing with
metal snaps
• Purchasing shoes that have an open
heels area

• Answer : D
•
• . A 21-year-old female is being
discharged after a 2-day admission
for pelvic inflammatory disease
(PID). Which statement BEST
identifies the patients understanding
of follow-up care for PID?

• “My sexual partner needs to be

treated with antibiotics”
• “It’s OK to resume sexual relation
now”
• “I need to inform any sexual partners
I have had in the past 30 days that I
had PID”
• “In order to prevent getting PID I need
to continue to take birth control pills"

• Answer : A
• A healthy 2-years-old child is brought
to the community health clinic for a
routine checkup. At this visit the
nurse should administer the
following vaccine:

• Rotavirus
• Hepatitis B
• None at this time
• Varicella

• Answer : C
• . During an evaluation at a
community clinic, the patient
completes the medical history.
Which of the follow is NOT a risk
 factor for an acute myocardial
infarction?

• Coronary artery disease

• Smoking
• Hemophilia
• Hyperlipidemia

• Answer : C

• Which of the following is the MOST

common type of cardiomyopathy in
children and is treated with
medications such as digoxin
(Lanoxin) and warfarin (Coumadin)?

• Hypertrophic
• Dilated
• Restrictive
• Diastolic

• Answer : A

• The responsibility for teaching

patients how to take medications
safely when they are discharged
from the hospital belongs to the:

• Nurse
• Physician
• Dietitian
• Therapist
 • Answer : B

• A nurse is discharging a patient after

hospitalization due to myocarditis.
Which of the following statements
should be included in discharge
teaching?

• There is usually some residual heart

enlargement
• May resume previous activities as
before hospitalization
• Avoid immunizations against
infectious disease
• Rapidly beating heart is a common
side effect of the illness and is not
dangerous
 • Answer : A

• A nurse is assessing a 4-month-old

formula-fed infant. The parent
reports the infant has been irritable,
crying excessively, not sleeping well,
and vomiting. Gastro-esophageal
reflux is expected. What nursing
intervention should the nurse expect
to teach the parent?

• Place the infant in an infant seat

after eating
• Give large frequent feedings
• Position the child in a swing
• Thin formula with water

• Answer : C

• An adult arrived at the outpatient

facility due to the onset of chest
pain. The patient suddenly falls to the
floor and is unresponsive. What
action should the nurse take NEXT?

• Activate emergency call system

• Open the patient’s airway
• Check for a carotid pulse
• Administer 2 rescue breaths

• Answer : C

• A patient suffered a head trauma

which resulted in a nasal fracture
requiringsurgical intervention. Which
of the following nursing diagnoses
would MOST likely be a problem this
patient?

• Delayed surgical recovery

• Impaired gas exchange system
• Ineffective breathing pattern
• Risk for perioperative-positioning
 injury

• Answer : C

• After administering inhaled

corticosteroids to hospitalized child
with asthama, the nurse plans to
have the child rinse the mouth and
gargle with water. The nurse knows
the rationale for this action is
 prevention of:

• Tooth decay
• Oral candidiasis
• Dehydration
• Hypertrophy of the gums

• Answer : B

• The nurse is assessing a patient who

is 2-weeks postoperative a
kyphoplasty ofL2 and L3.The patient
has been participating in physical
therapy and has been doing daily
stretching and strengthening. Which
of the following would indicate that
the patient has met discharge goals?
• Reports pain in legs while sitting
• Urinating every two hours while
awake
• Fatigue after performing activities of
daily living
• Ambulates outdoors without
assistive devices

• Answer : D

• When a child is brought to the

emergency department with acute
epiglottitis, which of the following
nursing diagnoses should receive
PRIORITY?

• Ineffective airway clearance

• Activity intolerance
• Fluid volume deficit
• Impaired verbal communication

• Answer : A

• The nurse is reviewing the

medication of a patient who is
scheduled for a coronary artery
bypass graft (CABG) in three days.
Which of the following medications
MUST be discontinued at least a
week prior to surgery?

• Digoxin (Lanoxin)
• Furosemide (Lasix)
• Propranolol hydrochloride(Inderal)
• Warfarin sodium(Coumadin)
 • Answer : D

• A patient with pneumonia

experiences ineffective airway
clearance related to the presence of
thick secretions secondary to
infection. Oxygen saturation is 89%
on room air. Which of the following
nursing interventions takes priority?

• Deliver oxygen with humidity

• Encourage fluid intake
• Assist patient into position ofcomfort
• Inspect sputum for odor andcolor

• Answer : A

• A nurse is assessing a 5-month-old

infant. The parents’ state that the
infant is irritable, crying excessively,
vomiting formula (not projectile),
arching, and stiffening. Based on this
assessment, what diagnosis should
the nurse anticipate?

• Esophageal astresia
withtracheoesophageal fistula
• Gastroesophageal reflux
• Hirschsprung’s disease
• Celiac disease

• Answer : B

• A Patient presents at the clinic with

weight loss and complains of trouble
seeing at night. The nurse also
observes numerous teeth with decay.
Upon Learning that the patient has
avitamin deficiency, which of
thefollowing foods would the nurse
MOST likely instruct the patient to
 add to diet?

• Cheese and breads

• Liver and rice
• Fish and rice
• Fruits and vegetables

• Answer : D

• While providing discharge teaching

for the parents of a child newly
diagnosed with cystic fibrosis, the
nurse includes teaching regarding
 the role of salt in the disease. Which
of the following statements by the
patient indicates the need for further
teaching?

• Salty foods may be eatenon occasion

• My child does not need torestrict salt
intake
• Salt is lost more rapidlyin hot
weather
• Salt replacement shouldoccur every
day

• Answer : D
• A patient visiting the clinic 10 days
after sinus surgery for checkup
complains of having a bad taste in
the mouth. When the nurse smells a
foul odor while examining the
patients mouth, the nurse suspects
the patient have an:

• Pulmonarydecompensation
• Hemorrhage
• Aspiration
• Infection
• Answer : D

• A patient is scheduled for a total hip

arthroplasty. The preoperative nurse
reviews the chest and notes the
following: serum potassium level of
2.8 mEq/l, AB positive blood type,
and elevated ST Segments on the
electrocardiogram (ECG). Which of
the following would be the MOST
appropriate action for the nurse to do
next?
• Report abnormaldiagnostic results to
thesurgeon
• Review the patientconsent for the
surgicalprocedure
• Educate the patient on therisk
factors and side-effects of the
surgery
• Ensure that the patient hasa
post-surgery physicaltherapy order

• Answer : A
• Which of the following discharge
planning instructions takes PRIORITY
in patient with congestive heart
failure?

• Maintaining a lowcholesterol, low

sodiumand low potassium diet
• Recognizing signs andsymptoms
that requireimmediate
medicalattention
• The importance ofremaining
physicallyactive
• The importance ofdrinking plenty of
fluid

• Answer : B
• Following ocular surgery the nurse
establishes care interventions to
include orienting the patients to new
changes in environment and
supervising the Patients ability to
feed themselves and perform
self-care activities. Which of the
following nursing diagnosis do these
activities support?

• Activity intolerance
• Impaired environmental
interpretation syndrome
• Disturbed sensoryperception
• Risk for autonomicdysreflexia
• Answer : B

• During the immediate postoperative

period, a patient reveals an oxygen
saturation level of 91%. The nurse
should:

• Position the patient onthe left side

• Administer supplemental oxygen
• Continue to providesupportive care
• Lower the temperature ofthe room

• Answer : c
• Which of the following goal take
PRIORITY when recovering from
general anesthesia in post
anesthesia care unit (PACU)?

• Thermoregulation
• Plastic skin turgor
• Patent airway
• Patient voids freely

• Answer : C

• A patient is to receive heparin

sodium, 5,000 U, subcutaneous on
call to the operating room.Prior to
administering this medication, the
 nurse should advise patient that this
will help to prevent:

• Infections
• Atelectasis
• Thrombosis formation
• Positioning injuries

• Answer : C

• When administering an intramuscular

injection to an infant, which of the
 following sites appropriate for the
nurse to use?

• Rectus femoris
• Deltoid
• Dorsogluteal
• Ventrogluteal

• Answer : D

• A patient is admitted to the medical

unit with a diagnosis of fluid volume
deficit would the nurse expect the
doctor to order?
• 0.9% Sodium chloride
• 0.45% Sodium chloride
• Dextran in normal saline
• 5% Sodium chloride

• Answer : A

• The nurse is discussing the human

immunodeficiency virus (HIV) with a
group of high-risk patient. The nurse
should state that this virus is found
MOSTcommonly in which of the
following body fluids?

• Blood
• Saliva
• Breast milk
• Vaginal secretions

• Answer : A

• A parent is concerned their 8-year-old

child has 23kg (5lb) over the past 2
weeks and has been urination up to
30 times per day. The child also
seems to be eating and drinking
constantly. Which test would be
MOST helpful in evaluating the child’s
condition?

• Chest X-ray
• Complete blood count
• Body fat analysis
• Blood glucose level
 • Answer : D

• A patient has been transferred to the

medical unit following a
parathyroidectomy.Surgery was
performed under general anesthesia
and the patients diet my advanceas
tolerated. The patient requests a sip
of apple juice. The nurse should
FIRST assessthe patient’s:

• Skin turgor
• Cough reflex
• Lung sounds
• Bowel sounds

• Answer : B

• The nurse sustains a needle-stick

injury after administrating an
intramuscularinjection to a patient.It
is recommended that the nurse be
tested for humanimmunodeficiency
virus (HIV):
• Immediately with repeat testin 6
weeks
• If the patient refuses HIVtesting
• If the patient has symptomsof HIV
infection
• A month after takingprophylactic
antiviral

• Answer : A

• A parent brings their teenage child

the pediatrician’s office. The parent
reports that the patient frequently
complains of abdominal bloating and
 stomach pain after eating and also
has a chronic sore throat. The
patient’s labs show
hypokalemia.Which of the following
diagnosis should the nurse
anticipate?

• Anorexia nervosa
• Bulimia
• Morbid obesity
• Impulsive behavior

• Answer: B

• A urinalysis is best evaluated for

accurate result if specimen is
analyzed within:
• 1 hour of collection or refrigerated
until analyzed
• 1 hour of collection or left at room
temperature
• 2 hours of collection
• 4 hours of collection

• Answer: C

• The nurse has started intravenous

fluid therapy on a child. Which of the
followingaction is appropriate?
• Using a padded arm board only if the
child is active
• Checking the site at leastonce every
two hours
• Determining the total volumeinfused
every four hours
• Using an infusion pump toprovide
controlled rate ofinfusion

• Answer : D
• During the assessment phase of a
preoperative interview, the patient
reports feeling nervous. The patient
conveys to the nurse that a parent
died in surgery due to malignant
hyperthermia. To whom would this
information be MOST pertinent?

• Post-anesthesia care unit(PACU)

nurse
• Scrub nurse
• Anesthesia team
• Charge nurse
 • Answer : C

• A child presents to the emergency

department with difficulty breathing.
The child’sParents report that child
has a history of bronchial asthma
and has recently had an Upper
respiratory tract infection (URI). Upon
auscultation, the nurse decreased
Breath sounds in the left-lower lung
field. The nurse should NEXT assess
the child’s:
• Oral temperature
• O2 saturation
• Apical pulse
• Level of comfort
 • Answer : B

• A patient with diabetic retinopathy is

experiencing an episode of
unresolved hemorrhage in the eye.
The nurse identifies the MOST likely
procedure to benefitthis patient
would be:

• Enucleation
• Radial keratotomy
• Vitrectomy
• Peripheral Iridectomy
 • Answer : C
• . A patient admitted to the hospital
with acute cholecystitis, is scheduled
for surgery in the morning and is
NPO. At 8amthe patient develops a
fever of 102.4 F (39.1 C).medication
orders include acetaminophen 650
mg orally every four hours asneeded.
The nurse should:

• Give the medication asordered by the

physician
• Administer the ordered dose rectally
• Put moist cool cloths on thepatient’s
forehead and axillac
• Notify the physician andrequest other
orders
 • Answer : A
• A home health nurse is preparing
to administer a subcutaneous
injection of heparin.When site on
the abdomen, the nurse will
choose a site:

• More than 6 inches from

theumbilicus
• More than 2 inches from
theumbilicus
• As close as possible to theumbilicus
• As close as possible to theumbilicus

• Answer : B
• . A patient withpulmonary emboli
complains of pain, dyspnea, and a
fear of dying.Which of the following
interventions would MOST likely help
to reduce the patient’s anxiety level?

• Administer oxygen asordered

• Administer pain medicationas
ordered
• Observe closely for signs ofpain and
discomfort
• Listen to the patient’sconcerns

• Answer : D

• A patient with bacterial meningitis is

 treated with intravenous
antimicrobial agent.Which of the
following BEST indicates
effectiveness of treatment?
• Severe headache
• Negative kernig’s sign
• Nuchal rigidity
• Photophobia

• Answer : B

• While caring for a patient with

potassium deficiency, the nurse
should expect that the patient may
exhibit:
• Dysrhythmias
• Oliguria
• Diminished deep-tendonreflexes
• Hypertension

• Answer : A

• A patient who underwent hand

surgery requiring general anesthesia
presents to the post anesthesia care
unit (PACU) after extubation, The
nurse should FIRST assess

• Circulatory status
• Wound status
• Respiratory status
• Hydration status
 • Answer : C

• Prior to administration of an albuterol

nebulizer, the nurse should help the
patient assume what position?

• Sitting and leaning forward

• Feet elevated above level ofheart
• High fowler’s
• Standing

• Answer : C
• A patient presents to the doctor’s
office 2-weeks status
post-right-sidedmastectomy.The
nurse needs to measure the blood
pressure. Which would be the BEST
site?

• Above the left brachial artery

• Right popliteal artery
• Above the right brachialartery
• Left popliteal artery

• Answer : A

• A child with cystic fibrosis

exacerbation presents to the
emergency room. Which nursing
 diagnosis takes FIRST? Priority in
planning for intervention?

• Imbalanced nutrition relatedto

increased metabolicrequirements
because ofmalabsorption
• Deficient knowledgeregarding
prevention ofcystic fibrosis
exacerbation
• Impaired gas exchangerelated to
airwayobstruction due to mucous
• Interrupted familyn processes related
to hospitalization

• Answer : C

• A nurse is evaluating the home of

 patient with left-sided paralysis.
Which of thefollowing observations
would indicate that the patient is
complying with home-based safety?

• The telephone is on a bedsidetable

with is next to the headof the bed
• The bedside commode is onthe
left-side of the bed withthe back of
the commodefacing the foot of the
bed
• The walker has wheels on itsback
legs and has tennis ballson the front
legs
• The stairs leading from thebedroom
to the living area ahandrail on the
right-side ofthe stairway
 • Answer : A

• A patient is admitted to the hospital

with a cerebrovascular accident,
accident, right hemiplegia, and
expressive aphasia. With a nursing
diagnosis of impaired verbal
communication, what is the BEST
term goal for this patient?

• Learn to speak clearly within30 days

• Communicate effectivelywithin one
week
• Have all needs anticipated bystaff
daily
• Make basic needs knowndaily

• Answer : D

• A Patient has a dissection aortic

aneurysm. The patient’s surgery
would be categorized as:

• Elective
• Urgent
• Emergency
• Diagnostic

• Answer : C
• A patient presents to the emergency
room due to an overdose of
morphine sulfate.Which of the
following should the nurse has
readily available?

• Glucagon
• Antibiotic
• Acetylcysteine (Mucomyst)
• Naloxone (Narcan)

• Answer : D

• A patient with iron deficiency anemia

due to an insufficient iron intake
needs to learn to select better food
 choices. The nurse works with this
patient to establish aplan of care and
provide education on proper nutrition
and good sources of iron. Besides
educating the patient on a
well-balanced diet the nurse would
MOST likelyteach the patient that
good source of iron include:

• Seafood, cheese, soybean oil,and

chocolate
• Animal proteins, egg yolks,dried
fruits, and nuts
• Dairy products, citrus fruits,fish liver
oils, and poultry
• Seafood, fruit, poultry, andtomatoes

• Answer : C
• A 45-year-old patient is in a lower
body cast following a motor vehicle
accident. In order to minimize
muscle strength loss while in the
cast, the nurse will instruct the
patient in the performance of:

• Isometric exercises
• Passive range of motion exercises
• Active-assistive range of motion
exercises
• Resistive range of motion exercises

• Answer : C
• A patient is being followed in the
clinic for hypertension, adult onset
diabetes, and obesity. The patient is
apathetic about learning nutritional
guide lines to reach the goals of
weight loss and consumption of a
healthy diet. The patient admitted to
eating “what ever is put in front of m
e”. Which of the following actions
would the nurse take?

• Collaborate with the patient to set

goals
• Add a nursing diagnosis of
non-compliance
• Refer for Psychiatric screening for
 depression
• Discuss nutritional interventions with
the spouse

• Answer : A

• A child is admitted to the pediatric

ward with fever, lethargy, joint pain
and abdominal pain for several
weeks. The patient has a history of
recurrent respiratory and ear
infections. Physical findings include
wide spread ecchymosis, generalized
lymph adenopathy, hepato
splenomegaly, and pallor. Lab work
show a low hemoglobin level, low
 RBC count, low hematocrit, and low
platelets. The nurse should expect
the bone marrow stain to show a:
• Large number oflymphoblasts and
lymphocytes
• Low number of lymphoblasts and
large number oflymphocytes
• Low number of lymphoblasts and
lymphocytes
• Large number oflymphoblasts and
low number of lymphocytes

• Answer : C
• Immediately following the birth of a
full term newborn, which of the
following nursing diagnoses should
take PRIORITY?
• Ineffective airway clearance related
to nasal and oral secretions
• Ineffective thermoregulation related
to environmental factors
• Risk for imbalanced fluid volume
related to weak sucking reflex
• Risk for injury related to immature
defense mechanisms

• Answer : A

• A patient receives intravenous

therapy of 1000 cc normal saline
with 20mEq potassium chloride at a
rate of 75cc per hour. Upon
evaluation of the site, there is no
 edema, the vein appears slightly red,
and the patient complains of pain.
What should the nurse do?

• Slow the rate to prevent burning from

the solution and continue to monitor
• Discontinue the intravenousline and
restart in another site
• Monitor at least every half-hour for
edema but continueas the order
state
• Notify the doctor that thepatient is
having an adversereaction to the
medication

• Answer :A
• A healthy 26-year-old patient is at
39-weeks-gestation. The patient is
not considered high risk at the time
of admission to the labor and
delivery unit.Which of the following
pending laboratory test results
should receive PRIORITY?

• Red blood cell count

• Hematocrit
• White blood cell count
• Blood type
 • Answer : D

• A patient comes to the emergency

department with extreme dyspnea,
orthopnea,anxiety and complains of
feeling panicky. The patient is
coughing up white frothy sputum and
is cyanotic with profuse perspiration.
Inspiratory and expiratory wheezing
and bubbling sounds are
auscultated. The patient is
diagnosed with acute pulmonary
edema. What should the nurse do
FIRST?

• Identify precipitating factorsand

underlying conditions
• Administer morphine(Duramorph) to
reduceanxiety
• Assess oxygen saturation rate
•
• Administer digoxin(Lanoxin) to
decrease fluidbacking up into the
lungs

• Answer : C

• . During surgery, the patient has the

following intake and output:
intravenous fluid 650cc, intravenous
antibiotic 50cc, I unit of packed red
blood cells (PRBC)
 350cc,nasogastric output 120cc,
estimated blood loss 80cc, and urine
in the Foley catheter 240cc. What is
the patient’s total output?

• 120cc
• 200cc
• 240cc
• 440cc

• Answer : D

• A 25-year-old female presents to the

 emergency room with lethargy,
decreased reflexes, hypoventilation,
hypotension, and fixed and dilated
pupils. A family member who is
accompanying the patient has an
empty bottle of diazepam(Valium)
which the label states was recently
refilled.The family member also
indicates that the patient has a
history of depression what
intervention should thenurse expect
to administer?

• Flumazenil or (activated charcoal)

• A tap water enema
• Magnesium sulphate to reduce the
risk of seizure
• Nalaxazone
 A

• An asthmatic patient presents with

wheezing and coughing. Oxygen
saturation is 88% on room air. Which
of the following nursing diagnosis
would take priority?
• Imbalanced nutrition related to
decreased food intake
• Activity intolerance related to
inefficient breathing.
• Anxiety related dyspnea and
concern of illness.
• Ineffective gas exchange related to
bronchospam
 D

• A child is admitted to the hospital

with congenital heart disease. Which
of the following nursing diagnoses
should receive Priority?
• Decreased cardiac output related to
decreased myocardial functions.
• Activity intolerance related to
cachexia
• Impaired gas exchange related to
altered pulmonary blood flow
• Imbalanced nutrition : less than body
requirement related to excessive
 energy demands

• Ans: A
• A patient scheduled for an abdominal
aneurysm repair. This is what type of
surgical intervention?
• Diagnostic
• Transplant
• Curative
• Palliative

• Ans: C
• The patient present to the hospital
 voicing a concern about being
eposed to HEP A (HAV) 1 week upon
questioning the nurse finds the
patient purchased food from a
person recently diagnosed with HEP
A . Nurse would be most correct
when instruct the patient
• The incubation period is 3-5 wks
• HAV is spread by seual contact
• HAV is spread by blood contact
• The incubation period is 2-6wks

ANS –d

• While performing a pre operative

assessment on a pt having
arthroscopy of the right knee , a
 nurse examine the right leg for
baseline assessment . The nurse
should include all the following
EXCEPT
• Position and length of the leg
• Bilateral pulse
• Bony prominence of ankles and feet
• Rotation of patella

ANS – D

• A patient had right knee surgery and

is being transferred to the post
anesthesia care unit. which of the
following information is ESSENTIAL
to discuss
• Pre operative weakness of the lower
 extremities
• Anxiety related to inherited risk
factors of surgery
• Fear related to body image
disturbances
• Allergy to aspirin based products

ANS- B

• A patient who underwent a right knee

arthroplasty 2 days ago has a nursing
diagnosis of impaired mobility. The
patient refuses to get out of bed and
ambulate due to chest pain. which of
the following action would the nurse
MOST LIKELY implemented
• Medicate the patient prior to
 ambulation
• Add a nursing diagnosis of non
compliance
• Let the patient rest now and then try
to ambulate later
• Assess to determine the course of
the chest pain

ANS – D

• After total knee replacement a

patient being discharged to have
after which he will ambulate with
for-prong cane. When providing
patient teaching regarding giving up
and down stairs with the cane, the
 first step in going up stairs is to ..,
• Place the cane and the affected
extremities upon the step
• Place the cane and the unaffected
extremity upon the step
• Step up on the affected extremity
• Step up on the unaffected extremity

ANS – A

• A nurse is caring a patient who had

right mastectomy 2 days ago. Which
of the following is the appropriate
nursing goal for this type of surgery
• Acceptance of altered body image
• Avoid large crowd
• Limit right arm movement
• Perform range of motion for left arm

ANS – A

• Which instruction take priority in

reducing anxiety related to Surgical
 procedure and post operative
exercise

• Risk of infection after surgery

• Advanced directives and what it
means
• Pre operative laboratory result and
what to expect on it

ANS-b
• The nurse is assigned a patient who
had surgery under GA. The patient
respiratory rate is 4/mnt and the O2
saturation on 3mL/mnt of O2 via
nasal canula is 84%. The nurse is
awaiting the result of an ABG and
anticipate that which of the following
elevated ?
• Arterial O2 saturation (SaO2)
• HYDROGEN ion concentration (PH)
• Partial pressure of arterial CO2
(PaCO2)

Ans – c

• The traction and urinary catheter

have been discontinued for a
patient who was immobilized in
traction for 6 weeks . The pt is now
having a problem with urinary
incontinence .which of the
following interventions would the
nurse most likely implement ?
• Behavioural training
• Bladder training
• Scheduled toileting
 • Prompted voiding

ANS - B

• A nurse is assigned to care for a

patient with a diagnosis of
thrombotic stroke. The nurse knows
that this type of stroke is most likely
caused by:
• Blockage of large vessels
as a result of
atherosclerosis
• Emboli produced from
valvular heart disease
 • Decreased cerebral blood
flow due to circulatory
failure
• A temporary disruption in
oxygenation of the brain

Ans: A
• The nurse administered a prescribed
intramuscular medication to a
patient during a home health visit.
How should the nurse dispose of the
used needle and syringe?
• Recap the needle, then
place the needle and
syringe into a waterproof
 container until safe
disposal can be made
• Bend the needle back
towards the barrel of the
syringe before putting the
needle and syringe in a
metal trash container
• Wrap the needle and
syringe in disposable paper
before putting the needle
and syringe into the dirty
section of the nurse’s
equipment bag
• Put the needle and syringe
directly into a
 puncture-resistant plastic
container that has a lid

Ans: B
• What is the most common
characteristic of a stage IV pressure
ulcer?
• Pink skin
• Presence of sinus tracts
• Exposure of bone
• Infection

Ans: C
• While visiting a patient with a new
colostomy, the home care nurse
observes that the skin around the
stoma site is red. Which intervention
should the nurse do next?
• Apply pectin, gelatin or
synthetic skin barrier around
the stoma
• Apply triple antibiotic to the
raw skin and leave it open to
the air
• Instruct to empty the pouch as
soon as stool is present
 • Instruct to remove the bag and
skin barrier after each stool

Ans: A
• A nurse educates a patient about the
use of incentive spirometry to
prevent atlectasis after a surgery.
The nurse is performing what step of
the nursing process?
• Diagnosis
• Assessment
• Implementation
• Evaluation
 Ans: C
• A nurse evaluates a patient for signs
of rebleeding from ruptured
intracranial aneurysm that required
surgical ligation. The highest risk for
aneurysm rebleed is within:
• 6 hours
• 24 hours
• 48 hours
• 72 hours

Ans: A
• When discussing dietary choice with
a patient who is receiving heparin
therapy, the nurse should state that
which of the following foods affect
the clotting time?
• High protein foods
• Soy- based foods
• Foods high in vitamin K
• Foods containing goat’s milk

Ans: C
• A patient admitted to the hospital for
 pneumonia finishes a course of
levofloxacin, lungs are clear and the
patient is no longer coughing. Which
of the following post-discharge
laboratory results best indicates
desired outcome?
• Normal white blood cell count
• Normal hematocrit count
• Normal platelet level
• Normal potassium level

Ans: A
• A home health care nurse visits a
patient diagnosed with rheumatoid
arthritis. The nurse gathers
 information about the pain level after
the use of prescribed pain
medication to check on the
effectiveness of the intervention.
This phase of nursing process is
called:
• Assessment
• Diagnosis
• Implementation
• Evaluation
Ans: D
• A plan of care for a child with
cerebral palsy should include all the
following except:
• Physical therapy
 • Play
• Feeding
• Bowel and bladder training

Ans: D
• A patient is admitted to the hospital
with klebsiellapneumoniae. During
the initial intravenous dose of Amikin
(amikacin sulfate), the patient
develops severe respiratory distress.
This is most likely:
• A side effect
• An indication of drug tolerance
 • A drug allergy
• A toxic effect
Ans: A
• A patient is diagnosed with peptic
ulcer. What would be the long term
goal for this patient?
• Patient remains free of signs
and symptoms of
gastrointestinal bleeding
• Patient maintains lifestyle
alterations to prevent
recurrence of ulcer
• Patient expresses decreased
pain level
• Patient performs activities of
 daily living without difficulty

Ans: B
• A patient visits the clinic for the first
time. Inorder to perform an accurate
and complete assessment, which of
the following would be the nurse first
step?
• Obtain a temperature, pulse
and respiration
• Obtain a complete history
• Obtain a blood pressure
• Perform a review of systems
 Ans:B
• The nurse is assigned to care for a
patient who has recently been
diagnosed with Crohn’s disease. The
initial treatment is usually:
• Dietary changes
• Reversible colostomy
• Permanent colostomy
• Watchful waiting

Ans: A
• A patient comes to the medical
 office with complaints of some
urinary incontinence. The nurse
discovers the incontinence occurs
because of an inability to delay
voiding long enough to reach a toilet
after the patient feels a sensation of
bladder fullness. This type of
incontinence is:
• Stress
• Urge
• Overflow
• Functional

Ans: C
• When caring for child with spina
 bifida, the nurse knows that the child
has an increased risk of allergy to:
• Peanuts
• Strawberries
• Eggs
• Latex

Ans: D
• When planning a class on pregnancy,
the nurse should include symptoms
of pregnancy that must be reported
immediately, such as:
• Leg cramps
 • Vision disturbance
• Swelling of the legs
• Constipation

Ans: B
• Which of the following reacts to
viruses and bacteria by increasing in
number?
• Antigens
• Antibodies
• Rh factors
• Platelets
 Ans: B
• A nurse is assessing a child with
cystic fibrosis. After thoroughly
assessing respiratory status, the
nurse should assess which of the
following?
• Level of pain
• Skin turgor
• Genitourinary status, clarity of
urine
• Nutritional status,
characteristics of stool
 Ans: A
• The nurse is preparing to administer
100 ml potassium chloride solution.
The prescriptions indicate that this
should be infuse for 2 hours. The
nurse should administer how many
ml per hour?
• 10
• 25
• 50
• 100
 Ans: C
• A nurse is caring for a patient who is
6-hours post-left lobectomy. On
assessment the nurse observes that
the patient has become very restless
and the nail beds are blue. The vital
signs reveal tachycardia, tachypnoea
and the blood pressure is rising.
Which of the following complications
is most likely?
• Pneumonia
• Hypoxia
• Postoperative bleeding
• Bronchopleural fistula
 Ans: B

• A patient with heart failure has the

following vital signs: blood pressure
level, 136/84 mmHg, heart rate 48,
temperature 37.1 C (98.8 F); and
respiration rate 20 per minute. Which
of these vital signs should be
reported to the physician prior to
administering the next dose of
digoxin?
• Blood pressure
• Pulse
 • Temperature
• Respiration rate

Ans: B
• The nurse is caring for a patient two
hours after a pacemaker placement.
The patient suddenly starts
complaining of chest pain. The nurse
observes dyspnoea, cyanosis and
absent breath sounds on the right
side. The nurse should anticipate
what complications?
 • Hemothorax
• Perforation of the heart
• Pneumothorax
• Hemorrhage

Ans: C
• A community health nurse is
instructing a neighborhood class
about botulism. The nurse teaches
the group that the most likely mode
of infection would be by:
• Direct contact with
contaminated soil
• Direct contact with respiratory
 secretions
• Sexual intercourse
• Ingestion of contaminated
food

Ans: d

• A 32 year old female comes in for

evaluation 14 days after an
uncomplicated caesarean section .
The patient is very anxious and
complaining of sharp stabling pain in
her chest .The patient has dyspnea ,
 tachypnea , and hypoxemia .Which of
the following postoperative
complications is likely?
• Pulmonary embolism
• Atelectasis
• Pneumonia
• Aspiration

• Answer A

• A home care nurse reviews the

laboratory results for a postpartum
patient who had a caesarean section
 . Which of the following indicates
possible wound infection ?
• Increased WBC
• Decreased haematocrit level
• Increased haemoglobin
• Decreased platelet

• Answer A
• Three days ago a patient underwent
an invasive surgery with an open
wound . The patient is febrile with
drop in blood pressure . Laboratory
test results shows elevated WBC
 count . This could be possible
presentation of :
• Sepsis
• Atelectasis
• Internal haemorrhaging
• Excess fluid volume

• Answer A
• A conscious victim of motor vehicle
accident arrives at the emergency
department . The patient gasping of
air , is extremely anxious , and has a
deviated trachea . What diagnosis
 should the nurse anticipate ?
• Pleural effusion
• Tension pneumothorax
• Pneumothorax
• Hemothorax

• Answer B
• A patient is brought to emergency
room with a severe head injury . A
craniotomy is performed to evacuate
a blood clot . Which of the following
is a desired expected outcomes 24
hours postoperatively ?
• Gag reflux present
• Cerebral perfusion pressure , 68mm
Hg
• Intracranial pressure , 21 mm Hg
• Decreased lacrimation

• Answer C

• A nurse is assigned to a patient who

is scheduled for an above the knee
amputation of the left leg . During the
preoperative procedure the
nurseshould ask the patient to :
• Write YES on the leg
• Write OTHER ONE on the right leg
• Draw an arrow on the left knee
pointing upward
• Draw an arrow on the left knee
pointing downward

• Answer C
• A patient who is 18-hour
postoperative after an above-the
knee amputation complaints of
feeling like something is crawling
under the dressing as well as
increased pressure of the dressing .
The nurse suspect haemorrhage .
The patients vital signs remains
 within the normal range . What
should the nurse do FIRST?
• Call the physician
• Place ice around the dressing
• Encourage patient to discuss fears
• Lower the temperature of the room

• Answer A
• A patient is admitted for pain
management due to lung cancer with
metastasis of the bone . With a
nursing diagnosis of alteration in
comfort , the nurse would anticipate
the best shot-term goal for this
patient would be to :
• Not complain of pain
• Appear comfortable and sleep well
• Verbalize that pain is relived
• Verbalize that pain is tolerated

• Answer A
•
• A nurse is assessing a patient who
just arrived in the emergency
department (ED) after a motor
vehicle collision . The patient has a
strong smell of alcohol on the breath
, is restless , and has a bluish
discolouration on the abdomen by
 the umbilicus . The patients vital
signs are temperature 37.20C
(98.90F) , heart rate 120/min ,
respiration rate 24/min , and blood
pressure level 100/62 mmHg . While
other members of the team are
evaluating the patient , the nurse
should obtain :
• A pair of elastic support stockings
• A chest tube insertion tray
• Supplies for peritoneal lavage
• A vial of hydralazine
 • Answer D

• While caring for a terminally ill

preschool-aged child whose death is
eminent , the child asks the nurse “
Am I going to die”? The best nursing
response is :
• I’m not sure what is wrong with you,
but I hope not
• Don’t worry, when you die, you will be
the angels
• We all die someday , but you are not
going to die today or tomorrow
• I can’t talk to you about that , you will
have to ask your doctor
 • Answer A
• A patient with chronic obstructive
pulmonary disease complains of a
frequent cough , bilateral wheezing is
auscultated in the lung fields . The
nurse administer albuterol nebulizer
treatment , as ordered and educates
the patient on way to decrease
exacerbation . Which of the following
actions indicate that the patient
understands the instruction?
• The patient reduces number of
 cigarettes smoked per day
• The patient requested a
pneumococcal vaccination
• The patient increases sodium and
potassium intake
• The patent exercises whenever
experiencing shortness of breath

• Answer A
•
• A nurse administers albuterol
nebulizer to a child with asthma
exacerbation. The nurse measures
pulse oximetry and auscultates the
lungs to determine whether the goal
 of clear respiratory status has been
met. The step of nursing is called :
• Assessment
• Diagnosis
• Implementation
• Evaluation

• Answer D
• The home care nurse observe that
the asthmatic patient has a cough
wheezing . The nurse administers an
albuterol (Proventil) nebulizer
 treatment as ordered. Which type of
implementation is this?
• Discharge planning
• Instruct
• Monitoring and surveillance
• Therapeutic interventions

• Answer D
• A child with asthma has an order for
albuterol . Prior to administration of
medication the nurse must:
• Pre-oxygenate the patient
• Assess the patient’s heart rate
• Obtain venous access
• Feed the patient a snack

• Answer B

• To reduce the risk of treatment

methicillin resistant staphylococcus
aureus from an infectious wound
which of the following standard
precautions should be implemented
• Airborne
• Contact
• Droplet
 • Reverse isolation

Ans – B

• A patient is experiencing intermittent

claudication in the legs while at rest .
Which of the following should the
nurse take ?
• Vigorously massage the extremity
• Place ice on the ankles every 20
mnts
• Elevate the legs to heart level
• Position the legs in dependent
position

ANS – C
 • The nurse is caring for a patient with
chest tubes connected to close
suction .the nurse should make sure
that which of the following remains
readily available at the patients bed
side?
• A sterile towel
• Petroleum gauze
• Normal saline solution
• Sterile gloves

ANS—C

• The nursing a 15 year old patient who

is being admitted due to an
exacerbation of bronchial asthma.
 The nurse should give PRIORITY to
asking if the patient has history of?
• Indoor allergies
• Intubation
• Chest trauma
• Co sack virus

ANS – A

A community health nurse visits a

patient who had right foot amputation.
Which of the following would suggest
that the patient is meeting expected
outcome for this type surgery?
• Stays in bed
• Verbalize constant pain
 • Avoids social gathering
• Accepts altered body image

D
While reviewing stress management
techniques with a patient diagnosed
with multiple sclerosis, what would the
nurse identify as most appropriate?
• Relaxing in a warm bubble bath
• Yoga in a cool room
• Sunbathing
• Cross-country running

ANS –B
 • A child comes in the clinic with
several lesions to scalp .the round
lesions have dandruff like scaling
with hair loss . what is the most likely
diagnosis
• Impetigo
• Ringworm
• Ascariasis
• Amoebiasis

B
The nurse is measuring the chest tube
drainage of a patient who had open
heart surgery 4 hours ago. Which of the
following is the MAXIMUM hourly
amount of chest tube drainage that is
expected in this time frame?
• 100ml
• 200ml
• 300ml
• 400ml
A
A patient report difficulty sleeping
through the night since the death of
spouse 6 months ago which of the
following is an appropriate LONG term
goal?
• Feeling well rested each morning
• Not feeling tired each afternoon
• Taking brief nap in the middle of the
day
• Using sleep aid on a nightly basis
A
A patient with SLE( systemic lupus
erythematous ) report decreased urinary
output during the past 2-4 days and
chest pain that is aggravated by
breathing and coughing. The patient
vital signs remain within the baseline
normal range s1 and s2 are present with
audible friction rub. Which of the
following statement would be
appropriate for the nurse to make?
• It sounds like SLE is being well
controlled
• I need to get some nitroglycerine for
your chest pain
• There may be some inflammation
surrounding your heart
• Your symptoms may be due to a
urinary tract infection
C
A patient has been hospitalized with a
new diagnosis of crohn’s disease. The
nurse best determine the patients
hydration level by monitoring the
• Color of urine
• Brightness of eyes
• Capillary refill in nail beds
• Temperature of lower extremities
C
A patient who had abdominal surgery 6
days ago , has been ambulating the halls
without much difficulty. However, on day
7 postoperative the patient complains of
increased pain at incisional site and is
walking hunched over the MOST likely
cause of the change is
• Over assertion the day before
 • Pulmonary edema
• wound infection
• deep vein thrombosis
C
A diabetic patient comes to the office
for follow-up six weeks undergoing
below the knee amputation of the right
leg for gangrene. The nurse observes
that the patient is progressing well with
the use of a prosthesis and that the skin
is intact. The patient reports being
generally pain free but occasionally
feels severe pain and itching of the right
ankle. What should the nurse do?
• Notify the doctor that there appears
 to be nerve damage of the right leg
• Refer to pain management specialist
for long term management
• Refer to psychiatrist for evaluation
since the patient has no right ankle
• Explain the phenomena of phantom
pain and phantom sensation to the
patient
D
A 1 year old child presents at the clinic
one week after hospitalization for
surgical repair of a fractured right
femur. The patient is receiving pain
medications every morning and evening.
The best way to evaluate the
effectiveness of the pain management
plan is;
• To ask the child in simple terms
about the comfort level of the past
week
• By direct observation of the child’s
non-verbal behaviors during the visit
• To teach the child how to use
wong/baker faces pain rating scale
• To interview the parent about
behavior, moods, and sleep patterns
over the past week
D
The nurse is caring for a patient
scheduled for left arm amputation due
to bone carcinoma. Adequate
assessment and management of
preoperative pain will result in
• Decreased phantom limb sensation
• Increased range of motion after
surgery
• Decreased depression after surgery
• Decreased likelihood of cancer
recurrence
A
A 34 year old quadriplegia patient
resides at home with his wife. In order
to prevent contractures of all
extremities, the community care nurse
will instruct the patient’s wife in the
performance of
• Active range of motion exercise
• Passive range of motion exercise
• Active assistive range of motion
exercise
• Resistive range of motion exercise
B
A 7 year old child is brought to the
emergency room with complaints of
feeling sick for 3 weeks with sore throat,
cough, and muscle pain. Upon
examination, the nurse notes a low
grade fever, shortness of breath, and a
wheeze on auscultation. The child lives
with parents, 6 siblings, and grandfather
in a 3 bedroom house. Based on these
findings, which of the following
diagnosis MOST likely?
• Staphylococcal pneumonia
• Pneumocystis carinii pneumonia
• Bronchiolitis
• Mycoplasma pneumonia
D
A patient comes to the emergency
department complaining of severe
crushing substernal pain that radiates to
the left arm and jaw. The patient is
diaphoretic and pale with cool clammy
skin. The patient is diagnosed with
acute myocardial infarction. The nursing
diagnosis would be decreases cardiac
output related t:
• Structural factors (incompetent
valves)
• Impaired ventricular expansion
• Impaired contractility
• Fluid volume deficit
C
After a hearing restoration operation, a
patient has no signs of complications
and soon recovers which of the
following is an expected outcome 5
days after the hearing restoration
surgery?
 • Regain full hearing
• Minimal facial nerve paralysis
• Minimal urinary incontinence
• Ambulate without difficulty
A
When teaching a patient how to use a
cane after a cerebral vascular accident
(CVA), the nurse should make sure the
patient:
• Uses the cane on the unaffected side
• Advances the cane simultaneously
with affected limb
• Holds the cane away from the body
• Moves the cane past the toes of the
 affected limb
A
A home care nurse visits a patient
diagnose with diabetes mellitus whose
current glucose level ranges from
150mg/dl to 200mg/dl. The patient has
not been able to self-administer
prescribed insulin and complains of
blurred vision and an inability to read the
marking on the syringe for proper insulin
dosage. Which of the following referrals
would be MOST beneficial to the
patient?
• A dietician
• An endocrinologist
 • An ophthalmologist
• A physical therapist
C
Which nursing diagnosis takes priority
for newly diagnosed patient with a
left-sided stroke?
• Risk for impaired swallowing related
to absent gag reflex
• Risk for impaired skin integrity
related to immobility
• Risk for infection related to invasive
line placement
• Risk for impaired speech related to
left side stroke
 A
A nurse is taking care of a patient who
underwent abdominal surgery 3 years
ago. The patient has not been breaths
deeply and refuses to get out of bed
since the surgery due to pain. Also the
patient complains of shortness of
breath and the lung sounds are
diminished upon auscultation. Vital
signs are. Blood pressure level
120/70mm Hg, heart rate 22,
temperature 36.4C(97.6 F), o2
saturation 89%. Which of the following
condition should the nurse suspect?
• Sepsis
 • Atelectasis
• Congestive heart failure
• Emphysema
B
A nurse visits the home of a patient who
is 1 week post-left-breast mastectomy.
Which of the following should be
including in patient education?
• It is OK to use a straight edge razor
when shaving
• Blood pressure checks should be
done in the left arm
• Cuticle should not be cut
• Avoid insect repellent on the left arm
 C
A patient is 24 hours post-operative
after having a right total hip arthroplasty,
the patient complains of pain in the right
calf rated 6 on a scale of 0 no pain10
severe pain. The nurse observes that the
right calf is warm and tender to touch,
while the right foot is pale and cool.
There is edema from the toes up the
knee. The nurse recognizes that these
are the classic signs of:
• Ineffective tissue perfusion
• Fluid overload
• Arterial occlusion
• Deep vein thrombosis
 D
A patient with dementia is being treated
for dehydration. The patient is confused
and has been immobile for the past
month. Currently, the patient is
incontinent and unable to feed self. The
nursing care plan should include
• Coughing and deep breathing every
30 minutes
• Positioning and turning every 2 hours
• Range of motion exercise to all
extremities every hour
• Ambulates at least 20 steps every
shift
B
A patient is 3 week postoperative left
below the knee amputation. Which of
the following is an expected outcome
for this patient?
• Verbalize relief of incisional pain, has
intense phantom sensation
• Participates in care plan, express
concern about independence
• Full passive range of motion,
requires assistance with transfers
• Low grade temperature, dressing
reinforced every hour
B
During postoperative neuromuscular
assessment of a patient who had a total
knee replacement nurse assesses the
peroneal nerve by testing sensation:
• On the bottom of the foot
• In the space between great and
second toe
• In the anterior to the rectum
• In the anterior portion of the calf
B
The nurse is caring for a patient who
sustained a traumatic brain injury 4 days
ago. The patient remains in a
pharmacologic induced coma while
receiving mechanical ventilation. The
patient is on NPO status and the vital
signs are within the normal range. The
patients bowel sounds are absent and
nasogastric tube is connected to low,
intermittent suction. The nurse should
prepare to begin:
• NG feeding
• Rapid weaning from the ventilator
• Total parenteral nutrition
• Chest physiotherapy
C
The doctor has ordered the patient to
be on 1 to 3 litters of oxygen using a
nasal cannula
at all times. the home care nurse notes
the oxygen is currently at 2 L/minut. the
oxygen saturation( SaO2) reading is
currently 85% and the partial pressure of
CO2 is within normal limits. Based on an
evaluation of this information, which of
the following actions would the nurse
MOST likely perform?
• Decrease the O2 to 1 L/minut and
monitor O2 saturation
• continue the O2 at 2 L/minut and
monitor O2 saturation
• Increase the O2 to 3 L/minut and
monitor O2 saturation
• continue to monitor O2 saturation
and call the doctor for new orders
C
A child is treated for bacterial meningitis
with an intravenous antimicrobial agent.
Which of the following BEST indicates
effectiveness of the treatment?
• Increased appetite
• Temperature 37.2 C(99 F)
• Episodes of apnoea
• Increased intra cranial pressure
B
A patient with gastro esophageal reflux
disease (GERD) is to start taking
prescribed omeprazole (prilosec). The
nurse would istruct the patient to take
the medication:
 • 30 to 60 minutes before meal
• 90 to 120 minutes before meal
• With apple sauce
• With milk
A
A patient recently diagnosed with
multiple sclerosis has been taking the
following prescribed medications:
baclofen(lioresal), diazepam(valium),
Amantadine(symmetrel), and phenytoin(
dilantin). When the patient presents with
complaints of fatigue, the nurse should
address the dosage and frequency of
which medication?
• Baclofen
 • Diazepam
• Amantadine
• Phenytoin
B
A 12 year old patient had a cast
removed from the left leg after wearing
it for 8 weeks. The patients wants to
resume sports as soon as possible. In
order to regain muscle strength lost
while wearing the cast, the nurse will
instruct the patient in the performance
of:
• resistive range of motion eercise
• passive range of motion exercise
 • Active assistive range of motion
exercise
• Active range of motion exercise
B
During the intra operative period of
surgical procedure a 39 year old male
has the following vital signs: core
temperature 37 C(98.6F)( heart rate 62,
blood pressure126/78 mm Hg,and an
O2 saturation level of 89%. The patient
has received two units of packed cell
volume(PRBs) and is intubated. Which
of the vital signs is considered out of
normal range?
• heart rate
 • O2 saturation
• Core temperature
• Blood pressure
B
A 28 year old male is recovering from a
moderate concussion following a motor
vehicle accident 2 weeks ago, when he
suddenly develops an increased thirst,
craving coldwater. The patient urinates
very large amount of dilute, water like
urine with aspecific gravity of 1.001 to
1.005 the patient is MOST likely
develop[ing
• Diabetic mellitus
• Diabetic insipidus
 • Hypothyroidism
• THyroid storm
B
• A nurse is caring for a patient who is
6 hours post left lobectomy.On
assessment the nurse observes
thatthe patient has become very
restless and the nail beds are blue.
the vital signs reveal tachycardia,
tachypnea and blood pressure is
rising.Which of the following
complication is MOST likely?
• Pneumonia
• Hypoxia
• Postoperative bleeding
 • Broncho pleural fistula
B
A patient presents to the office for a
physical assessment. The patient is
found to be healthy and fit but
occasionally drinks alcohol and has
unprotected sex. What is the BEST
nursing diagnosis?
• Health- seeking behavior
• knowledge deficit , high risk behavior
• Low self esteem
• Altered thought process
B
During surgery, the nurse is assigned the
following duties: setting up the sterile
field, preparing sutures and ligatures
assisting the surgeon during the
procedure by anticipating the
instruments and supplies that will be
required and labeling tissue specimen
obtained during surgery. The nurse
MOST likely performing in what role?
• Circulating nurse
• Scrub Nurse
• RN first assistance
• Nurse anaesthetist
A
A nurse completes discharge instruction
for patient who was admitted 5 days
ago with pneumonia. Which statement
by the patient would alert the nurse that
more discharge teaching is needed?
• I need to gradually increase my
activities
• I will not need the influenza or
pneumonia vaccine
• I may experience fatigue and
weakness for a prolonged time
• I need to have another chest x-ray in
4-6 weeks
B
The nurse is assessing a patient
recently diagnosed with acquired
immuno deficiency syndrome(AIDS).
Which of the following nursing
diagnosis has PRIORITY?
• Fear of disease progression,
treatment effects, isolation and
death related having aids
• Risk for infection related
immunodeficiency
• Ineffective breathing pattern related
to opportunistic infection
• Disturbed body image related to
rapid body changes from debilitating
disease
C
A patient to hav an elective surgical
procedure to repaire an umbilical hernia.
The patient is 68 year old, weighs 136
kg( 300lb), and has diabetis mellitus.
Which of the following approaches
would be the MOST beneficial inorder to
reduce the patient surgical risk?
• Monitor blood glucose level monthly
• Avoid fluid overload by restricting
fluid
• Discourage any changes in routine
before surgery
• Encourage weight reduction
D
A nurse caring for a patient following
cardiac catheterization evaluates the
patient post procedure, Which of the
following signs and/or syptoms would
MOST likely indicate the patient is
having a vagal reaction?
• diaphoresis
• Chest pain
• Tingling in extremities
• Hematoma formation
B
A home health nurse visits a patient who
is newly diagnosed with diabetes . The
glucose level ranges from 120mg/dl to
150mg/dl while current glycosylated
hemoglobin (hbA1C)level is 6.9 %. The
patient is complaint with taking
prescribed hypoglycemic medications
and eats 3 meals a day followed by
desserts sweetened with granulated
sugar. The patient also exrcises 30
minutes a day 3 times a week. Which of
the following educational intervention
takes PRIORITY?
• Glucose monitoring
• Medications
• Dietary requirements
• Exercise regimen
C
Which of the following BESt describes
the assessment step of the nursing
process?
 • Identifying nursing interventions as
appropriate for short- term,
intermidiate, and long-term goal
attainment
• Assigning priorities to the nursing
diagnosis
• Establishing goals or epected
outcomes
• Obtaining a nursing history and
complete a physical examination of
the patient
D
A nurse is providing care to a patient
with a new skin graft on left leg. The
patient is upset and the nurse notes
copious red drainage oozing around the
dressing. The nurse should immediately:
∙ Lift the dressing to assess the area
∙ Ask if the patient is having any pain
∙ Apply firm pressure for 10 to 15
minutes
∙ Assess the apical pulse
C
An elderly patient had surgery two days
for an intestinal obstruction. Vital signs
at 10 am are temperature 37.5c (99.5 f),
heart rate 86, respiratory rate 16 blood
pressure level 132/72 mm Hg, pain level
of 4 on a scale of 0 to 10. The
abdominal dressing is dry and intact.
The nasal gastric tube to low
intermittent suction. The patient is on
strict input and output every two hours.
At 12.20 pm, the patient complains
abdominal pain, upon assessment the
vital signs are temperature 37.5 C, heart
rate 98, respiration rate 24, blood
pressure level 146/ 88 mm Hg, pain
level is 8 out of 10. The patient
abdomen is distended and rigid, the
dressing remains dry and intact. The
nurse should first:
∙ Reposition the patient on the right
side
∙ Irrigate the nasal gastric tube to
check patency
 ∙ Medicate the patient for pain as
ordered
∙ Increase the suction on his nasal
gastric tube to high intermittent
suction
C
While preparing post operative paper
work for a patient scheduled for
neurosurgery, the nurse asks about the
patient’s use of medications, the patient
reports taking an aspirin tablet every
day, but has not taken it today. The
patient has had nothing by mouth since
midnight of the day before, the nurse
should:
 ∙ Inform the anesthesiologist
immediately
∙ Tell the patient the surgery must be
rescheduled
∙ Record the information on the form
in red ink
∙ Obtain blood sample and notify the
attending physician
C
A nurse is preparing an assessment of a
patient’s nutritional status. Which of the
following diagnostic test would be the
best measure of the patient’s recent
nutritional status with a half- life of 2-3
days?
 ∙ Prealbumin
∙ Hemoglobin
∙ Albumin
∙ 24- urine creatinine
B
A nurse is caring for a patient who had a
pneumonectomy 2 days ago for lung
cancer. Which observation would
indicate that the patient is progressing
towards discharge goal?
∙ Cough productive of
serosanguineous fluid
∙ 1+ pretibial edema
∙ Nap after completing bed bath
 ∙ Frequent premature ventricular
contractions (PVC)
C
The nurse is caring for a patient with
parkinson’s disease. Which of the
following is an expected outcome
related to the nursing diagnosis of
constipation related to diminished
motor function, inactivity and
medications?
∙ The patient will use a laxative every
other day
∙ The patient will have a soft bowel
movement daily
∙ The patient will report minimal pain
 with bowel movements
∙ The patient will limit the intake of
complex carbohydrates
B
The parent of a child with chronic
asthma is hesitant to discipline because
the child often doesn’t feel well. The
nurse should encourage the patient to:
∙ Set consistent behavior limits
∙ Be more lenient during times of
illness
∙ Cherish the limited time the child has
to live
∙ Avoid upsetting the child with limit
 setting
A
In developing care plan for a
hospitalized 3 year old child with
asthma, the nurse plans to talk calmly in
an appropriate language and explains all
procedures. Which of the following
statements by the BEST demonstrates
implementation of the approach?
∙ “You can use the stethoscope to
listen to your heart and your doll’s,
and then I will listen’
∙ “you must not wiggle while listen to
your heart. You can hold your doll’
∙ The stethoscope will feel cold on
 your chest. You can tell your doll how
cold it feels”
∙ “ let go of your doll and place your
hands on your tummy while I use the
stethoscope”
A
A nursing process which involves the
performance of the nursing plan care
is:
∙ Assessment
∙ Nursing diagnosis
∙ Implementation
∙ Evaluation
C
A patient who is receiving chemotherapy
has a platelet count of 49,000/mm3
(normal value 150,000 to 400,000/ mm3
). Which of the following nursing action
is necessary?
∙ Minimize invasive procedure
∙ Crush oral medications
∙ Limit intake of vitamin K rich foods
∙ Monitor the temperature every 4
hours
A
An elderly patient with a long history of
diabetes mellitus comes in for a routine
check-up. Which of the following nursing
diagnosis would the nurse anticipate?
 ∙ Risk for impaired skin integrity
related to decreases sensation and
circulation
∙ Excess fluid volume related to
disease process
∙ Risk for injury to decrease gastric
mobility and stress response
∙ Deficient fluids volume related to
diarrhea and loss of fluids and
electrolytes
A
A 3 year old child is brought to the office
by the parents who have been toilet
training the child for the past 5 months,
with little success. The parent has been
using rewards for the keeping the parent
clean and dry. Today the parent realizes
that the child abdomen was very firm,
the appetite was poor, and there had not
been bowel movement for 6 days. With
a nursing diagnosis of alteration in
bowel elimination, what is BEST goal?
∙ The child will recognize the urge to
defecate daily
∙ The parent will use praise when the
child defecates in the toilet
∙ Predictable, regular bowel habits will
be restored and maintained
∙ Toilet training will be delayed until
the child is cognitively ready
 A
The nurse is teaching a patient about
spironolactone (aldactone). Which of
the following instructions should the
nurse review with the patient?
∙ Increasing intake of foods that are
high in potassium
∙ Taking the medication right before
going to sleep
∙ Avoiding seasoning that are labeled
as salt substitutes
∙ Scheduling the medication so that a
multi vitamin is taken an hour later
A
• Position maintained in self enema
administration

ANS - SIMS

• Position maintained post vitrectomy

ANS – PRONE

• respiratory distress exercises

. GCS
APGAR SCORE
ECG
PLAYS
WEIGHTS OF CHILD