SAMPLE QUESTIONS

SOURCE: INTERNET

1. Maureen, a primigravida client, age 20, has just completed a difficult, forceps-assisted
delivery of twins. Her labor was unusually long and required oxytocin (Pitocin)
augmentation. The nurse who's caring for her should stay alert for:
a. Uterine inversion
b. Uterine atony
c. Uterine involution
d. Uterine discomfort

2. The uterus returns to the pelvic cavity in which of the following time frames?
a. 7th to 9th day postpartum.
b. 2 weeks postpartum.
c. End of 6th week postpartum.
d. When the lochia changes to alba.

3. Celeste who used heroin during her pregnancy delivers a neonate. When assessing
the neonate,
the nurse Lhynnette expects to find:
a. Lethargy 2 days after birth.
b. Irritability and poor sucking.
c. A flattened nose, small eyes, and thin lips.
d. Congenital defects such as limb anomalies.

4. To promote comfort during labor, the nurse John advises a client to assume certain
positions and
avoid others. Which position may cause maternal hypotension and fetal hypoxia?
a. Lateral position
b. Squatting position
c. Supine position
d. Standing position

5. Rh isoimmunization in a pregnant client develops during which of the following

conditions?
a. Rh-positive maternal blood crosses into fetal blood, stimulating fetal antibodies.
b. Rh-positive fetal blood crosses into maternal blood, stimulating maternal antibodies.
c. Rh-negative fetal blood crosses into maternal blood, stimulating maternal antibodies.
d. Rh-negative maternal blood crosses into fetal blood, stimulating fetal antibodies.

6. Dianne, 24 year-old is 27 weeks’ pregnant arrives at her physician’s office with

complaints of fever, nausea, vomiting, malaise, unilateral flank pain, and costovertebral
angle tenderness. Which of the following diagnoses is most likely?
a. Asymptomatic bacteriuria
b. Bacterial vaginosis
c. Pyelonephritis
d. Urinary tract infection (UTI)

7. Which of the following drugs is the antidote for magnesium toxicity?

a. Calcium gluconate (Kalcinate)
b. Hydralazine (Apresoline)
c. Naloxone (Narcan)
d. Rho (D) immune globulin (RhoGAM)
8. Magnesium sulfate is given to Jemma with preeclampsia to prevent which of the
following condition?
a. Hemorrhage
b. Hypertension
c. Hypomagnesemia
d. Seizure
9. Emily has gestational diabetes and it is usually managed by which of the following
therapy?
a. Diet
b. Long-acting insulin
c. Oral hypoglycemic
d. Oral hypoglycemic drug and insulin

10. Tyra experienced painless vaginal bleeding has just been diagnosed as having a
placenta previa. Which of the following procedures is usually performed to diagnose
placenta previa?
a. Amniocentesis
b. Digital or speculum examination
c. External fetal monitoring
d. Ultrasound
11. Following a precipitous delivery, examination of the client's vagina reveals a fourth-
degree laceration. Which of the following would be contraindicated when caring for this
client?
a. Applying cold to limit edema during the first 12 to 24 hours.
b. Instructing the client to use two or more peripads to cushion the area.
c. Instructing the client on the use of sitz baths if ordered.
d. Instructing the client about the importance of perineal (kegel) exercises.

12. A baby girl is born 8 weeks premature. At birth, she has no spontaneous respirations
but is successfully resuscitated. Within several hours she develops respiratory grunting,
cyanosis, tachypnea, nasal flaring, and retractions. She's diagnosed with respiratory
distress syndrome, intubated, and placed on a ventilator. Which nursing action should be
included in the baby's plan of care to prevent retinopathy of prematurity?
a. Cover his eyes while receiving oxygen.
b. Keep her body temperature low.
c. Monitor partial pressure of oxygen (Pao2) levels.
d. Humidify the oxygen.
13. A neonate begins to gag and turns a dusky color. What should the nurse do first?
a. Calm the neonate.
b. Notify the physician.
c. Provide oxygen via face mask as ordered
d. Aspirate the neonate’s nose and mouth with a bulb syringe.

14. A pregnant woman accompanied by her husband, seeks admission to the labor and
delivery area. She states that she's in labor and says she attended the facility clinic for
prenatal
care. Which question should the nurse Oliver ask her first?
a. “Do you have any chronic illnesses?”
b. “Do you have any allergies?”
c. “What is your expected due date?”
d. “Who will be with you during labor?”

15. Dr. Esteves decides to artificially rupture the membranes of a mother who is on labor.
Following this procedure, the nurse Hazel checks the fetal heart tones for which the
following reasons?
a. To determine fetal well-being.
b. To assess for prolapsed cord
c. To assess fetal position
d. To prepare for an imminent delivery.
16. Which symptom would indicate the Baby Alexandra was adapting appropriately to
extrauterine life without difficulty?
a. Nasal flaring
b. Light audible grunting
c. Respiratory rate 40 to 60 breaths/minute
d. Respiratory rate 60 to 80 breaths/minute

17. After reviewing the Myrna’s maternal history of magnesium sulfate during labor,
which condition
would nurse Richard anticipate as a potential problem in the neonate?
a. Hypoglycemia
b. Jitteriness
c. Respiratory depression
d. Tachycardia

18. Marjorie has just given birth at 42 weeks’ gestation. When the nurse assessing the
neonate, which physical finding is expected?
a. A sleepy, lethargic baby
b. Lanugo covering the body
c. Desquamation of the epidermis
d. Vernix caseosa covering the body
19. Baby Jenny who is small-for-gestation is at increased risk during the transitional
period for which complication?
a. Anemia probably due to chronic fetal hyposia
b. Hyperthermia due to decreased glycogen stores
c. Hyperglycemia due to decreased glycogen stores
d. Polycythemia probably due to chronic fetal hypoxia

20. Which finding might be seen in baby James a neonate suspected of having an
infection?
a. Flushed cheeks
b. Increased temperature
c. Decreased temperature
d. Increased activity level

21. When teaching parents of a neonate the proper position for the neonate’s sleep, the
nurse Patricia stresses the importance of placing the neonate on his back to reduce the
risk of which of the following?
a. Aspiration
b. Sudden infant death syndrome (SIDS)
c. Suffocation
d. Gastroesophageal reflux (GER)

22. When assessing a newborn diagnosed with ductus arteriosus, Nurse Olivia should
expect that the child most likely would have an:
a. Loud, machinery-like murmur.
b. Bluish color to the lips.
c. Decreased BP reading in the upper extremities
d. Increased BP reading in the upper extremities.

23. Hypoxia is a common complication of laryngotracheobronchitis. Nurse Oliver should

frequently assess a child with laryngotracheobronchitis for:
a. Drooling
b. Muffled voice
c. Restlessness
d. Low-grade fever
24. In doing a child’s admission assessment, Nurse Betty should be alert to note which
signs or
symptoms of chronic lead poisoning?
a. Irritability and seizures
b. Dehydration and diarrhea
c. Bradycardia and hypotension
d. Petechiae and hematuria
25. Maureen in her third trimester arrives at the emergency room with painless vaginal
bleeding. Which of the following conditions is suspected?
a. Placenta previa
b. Abruptio placentae
c. Premature labor
d. Sexually transmitted disease
26. Nurse Lynette is working in the triage area of an emergency department. She sees
that several pediatric clients arrive simultaneously. The client who needs to be treated
first is:
a. A crying 5 year old child with a laceration on his scalp.
b. A 4 year old child with a barking coughs and flushed appearance.
c. A 3 year old child with Down syndrome who is pale and asleep in his mother’s arms.
d. A 2 year old infant with stridorous breath sounds, sitting up in his mother’s arms and
drooling.

27. Malou was diagnosed with severe preeclampsia is now receiving I.V. magnesium
sulfate. The
adverse effects associated with magnesium sulfate is:
a. Anemia
b. Decreased urine output
c. Hyperreflexia
d. Increased respiratory rate
28. Nurse Carla knows that the common cardiac anomalies in children with Down
Syndrome (trisomy 21) is:
a. Atrial septal defect
b. Pulmonic stenosis
c. Ventricular septal defect
d. Endocardial cushion defect
29. The skin in the diaper area of a 7 month old infant is excoriated and red. Nurse Hazel
should instruct the mother to:
a. Change the diaper more often.
b. Apply talc powder with diaper changes.
c. Wash the area vigorously with each diaper change.
d. Decrease the infant’s fluid intake to decrease saturating diapers

30. The nurse is caring for a primigravid client in the labor and delivery area. Which
condition would
place the client at risk for disseminated intravascular coagulation (DIC)?
a. Intrauterine fetal death.
b. Placenta accreta.
c. Dysfunctional labor.
d. Premature rupture of the membranes.
31. Which action should nurse Marian include in the care plan for a 2 month old with
heart failure?
a. Feed the infant when he cries.
b. Allow the infant to rest before feeding.
c. Bathe the infant and administer medications before feeding.
d. Weigh and bathe the infant before feeding.

32. Baby Tina a 3 month old infant just had a cleft lip and palate repair. What should the
nurse do to prevent trauma to operative site?
a. Avoid touching the suture line, even when cleaning.
b. Place the baby in prone position.
c. Give the baby a pacifier.
d. Place the infant’s arms in soft elbow restraints.

33. A trial for vaginal delivery after an earlier caesarean, would likely to be given to a
gravida,
who had:
a. First low transverse cesarean was for active herpes type 2 infections; vaginal culture
at 39 weeks pregnancy was positive.
b. First and second caesareans were for cephalopelvic disproportion.
c. First caesarean through a classic incision as a result of severe fetal distress.
d. First low transverse caesarean was for breech position. Fetus in this pregnancy is in a
vertex presentation.

34. Calcium gluconate is being administered to a client with pregnancy induced

hypertension (PIH). A nursing action that must be initiated as the plan of care throughout
injection of the drug is:
a. Ventilator assistance
b. CVP readings
c. EKG tracings
d. Continuous CPR

35. A pregnant client is receiving oxytocin (Pitocin) for induction of labor. A condition that
warrant the nurse in-charge to discontinue I.V. infusion of Pitocin is:
a. Contractions every 1 ½ minutes lasting 70-80 seconds.
b. Maternal temperature 101.2
c. Early decelerations in the fetal heart rate.
d. Fetal heart rate baseline 140-160 bpm.

36. A pregnant client is receiving magnesium sulfate for severe pregnancy induced
hypertension (PIH). The clinical findings that would warrant use of the antidote , calcium
gluconate is:
a. Urinary output 90 cc in 2 hours.
b. Absent patellar reflexes.
c. Rapid respiratory rate above 40/min.
d. Rapid rise in blood pressure.

37. Nurse Michelle is assessing a 24 year old client with a diagnosis of hydatidiform
mole. She is aware that one of the following is unassociated with this condition?
a. Excessive fetal activity.
b. Larger than normal uterus for gestational age.
c. Vaginal bleeding
d. Elevated levels of human chorionic gonadotropin.

38. Nurse Oliver is teaching a diabetic pregnant client about nutrition and insulin needs
during pregnancy. The nurse determines that the client understands dietary and insulin
needs if the client states that the second half of pregnancy requires:
a. Decreased caloric intake
b. Increased caloric intake
c. Decreased Insulin
d. Increase Insulin

39. Nurse Hazel is preparing to care for a client who is newly admitted to the hospital
with a possible diagnosis of ectopic pregnancy. Nurse Hazel develops a plan of care for
the client and determines that which of the following nursing actions is the priority?
a. Monitoring weight
b. Assessing for edema
c. Monitoring apical pulse
d. Monitoring temperature

40. Nurse Reese is reviewing the record of a pregnant client for her first prenatal visit.
Which of the following data, if noted on the client’s record, would alert the nurse that the
client is at risk for a spontaneous abortion?
a. Age 36 years
b. History of syphilis
c. History of genital herpes
d. History of diabetes mellitus

41. May arrives at the health care clinic and tells the nurse that her last menstrual period
was 9 weeks ago. She also tells the nurse that a home pregnancy test was positive but
she began to have mild cramps and is now having moderate vaginal bleeding. During the
physical examination of the client, the nurse notes that May has a dilated cervix. The
nurse determines that May is experiencing which type of abortion?
a. Inevitable
b. Incomplete
c. Threatened
d. Septic

42. The painful phenomenon known as “back labor” occurs in a client whose fetus in
what position?
A. Brow position
B. Breech position
C. Right Occipito-Anterior Position
D. Left Occipito-Posterior Position
43. 2. A nurse is caring for a post-partum client and monitoring signs of bleeding. Which
of the following signs, if noted in the mother, would be an early sign of excessive blood
loss?
a. A BP change from 130/88 to 124/80 mmHg
b. An increase in the respiratory rate from 18 to 22 breaths per minute
c. An increase in the pulse rate from 88 to 102 beats per minute
d. A temperature of 100.4 degree Fahrenheit

44. A nurse is caring for a 12 year old female client who is a victim of physical and sexual
abuse. The client is newly admitted in the hospital and the nurse performs assessment
about the case of the client. Following assessment, the nurse founds out that the child’s
father is the abuser. That time, the father arrives and angrily approaches the nurse and
says, “I’m taking my daughter home. She told me what you people are up to and we’re
out of here!” The nurse makes which therapeutic response to the child’s father?
a. “Over my dead body you will! She’s here and here she stays until the doctor says
different”
b. “Your doctor is sick and needs to be here.”
c. “Listen to me. If you attempt to take your daughter from this unit, the police will bring
her back”
d. “You seem very upset. Let’s talk at the nurse’s station. I want to help you. It would be
best if you agree to let your daughter stay here for now.”

45. The nurse is assigned to monitor the condition of a 1 day postpartum client in the
postpartum room. The nurse notes that the lochia discharge of the client is red and has
foul smelling odor. The nurse determines that this assessment finding is:
a. Normal
b. Indicates the presence of infection
c. Indicates the need for increasing ambulation
d. Indicates the need for increasing oral fluids

46. A nurse is caring for a client admitted in the labor room. The nurse is completing an
assessment on a pregnant client in labor. The nurse notes the presence of the umbilical
cord protruding from the vagina. Which of the following would be the initial nursing
action?
a. Find the closest telephone and stat page the physician
b. Gently push the cord into the vagina
c. Call the delivery room to notify the staff that the client will be transported immediately
d. Place the client in a Trendelenburg position
47. A mother brought her child to the emergency room after the ingestion of about one
half bottle of acetylsalicylic acid (aspirin). The nurse in charge in the mergency room
anticipates that the most likely first treatment will be:
a. Administration of vitamin K
b. Administration of sodium bicarbonate
c. Dialysis
d. Administration of ipecac

48. A nurse formulated a plan of care for a client experiencing dystocia and includes
several nursing intervention in the plan of care. The nurse emphasizes the plan of care
and selects which of the following nursing interventions as the highest priority?
a. Monitoring the fetal heart rate
b. Providing comfort measure
c. Changing the clients position frequently
d. Keeping the significant other informed about the progress of labor

49. The nurse planning to conduct a teaching session with the female client who is
diagnosed with urethritis caused by infection with Chlamydia. The nurse would plan to
include which of the following points in the teaching session?
a. The infection can be prevented by using spermicidal to alter the pH in the perineal
area.
b. Sexual partners during the last 12 months should be notified and treated.
c. Medication therapy should be continued for 3 weeks without interruption.
d. The most serious complication of this infection is sterility.

50. The nurse is planning an intervention to help a client with bipolar I disorder, manic
episode meet needs for rest and sleep, the nurse must remember that the manic client:
a. Needs to expend energy to be tired enough to sleep
b. Is easily stimulated by the environment
c. Experiences few sleep pattern disturbances
d. Requires less sleep than the average person

51. The home health nurse is conducting a home care instruction to the parents of the
child with congestive heart failure regarding the procedure for the administration of
digoxin (Lanoxin). Which statement if made by the parents indicates the need for further
instructions?
a. “I will take the child’s pulse before administering the medication”
b. “If the child vomits after medication administration, I will repeat the dose”
c. “I will not mix the medication with food”
d. “If more than 1 dose is missed, I will call the physician”
52. A nurse provides a home care instruction to the parents of a child diagnosed with
celiac disease. The nurse teaches the parents of the child to include which of the
following food items in the child’s diet?
a. Rice
b. Oatmeal
c. Wheat bread
d. Rye toast

53. A nurse is caring to a client admitted in the labor room. The nurse performs an
assessment and monitors the fetal heart rate patterns. The nurse notes the presence of
episodic accelerations on the electronic fetal monitor tracing. Which of the following
actions is most appropriate?
a. Reposition the mother and check the monitor for changes in the fetal tracing
b. Notify the physician or nurse-midwife of the findings
c. Document the findings and tell the mother that the monitor indicates fetal well-being
d. Take the mother’s vital signs and tell the mother that the bed rest is required to
conserve oxygen

54. Female client with schizophrenia has been prescribed Chlorpromazine (Thorazine).
The client was alarmed with the color of her urine that becomes dark. The client has no
other urinary symptoms. The nurse tells the client:
a. That this is an expected side effect of the medication
b. To seek treatment for urinary tract infection
c. That this medication indicates toxicity
d. To increase intake of acid-ash foods and liquids

55. A severely depressed client is admitted in the mental health unit for 8 weeks. The
nurse observes that the client has not responded to any of the antidepressant
medication. The physician decides to try electroconvulsive therapy (ECT). Before the
treatment the nurse should:
a. Give the client a detailed explanation of the entire procedure
b. Have the client speak with other clients receiving ECT
c. Provide a simple explanation of the procedure and continue to reassure the client
d. Limit the client’s intake to a light breakfast on the day of the treatment

56. The mother of the child who had a myringotomy with insertion of tympanostomy was
so worried when the tubes have fallen out. The mother calls the nurse and asks for
immediate action. Which of the following is the most appropriate response of the nurse to
the mother?
a. “This is not an emergency, I will speak to the physician and call you right back”
b. “Place the tubes in hydrogen peroxide for 1 hour before replacing them in the child’s
ears”
c. “Replace the tube immediately so that the created opening does not close”
d. “This is an emergency and requires immediate intervention. Bring the child to the
emergency room”

57. A postpartum client with a diagnosis of deep vein thrombosis is receiving a

continuous intravenous infusion of heparin sodium. The nurse reviews the laboratory
results and wants to know if the client is given an appropriate dose of heparin. Which of
the following laboratory results the nurse would check to determine if an effective dose of
the heparin is being delivered?
a. Prothrombin time
b. International normalized ratio
c. Activated partial thromboplastin time
d. Platelet count

58. A nurse caring for the child with Kawasaki disease who just admitted to the hospital is
reviewing the order of the physician. The nurse expects to note an order which of the
following as part of the treatment plan for the child?
a. Digoxin
b. Morphine sulfate
c. Heparin infusion
d. Immune globulin

59. A nurse is in charge to care for a young female client, a victim of sexual assault. The
nurse completed the physical assessment and important evidence was gathered. The
nurse notes that the client is withdrawn, confused, and at times physically immobile.
These behaviors are interpreted by the nurse as:
a. Indicative of the need for hospital admission
b. Evidence that the client is a high suicide risk
c. Signs of depression
d. Normal reaction to a devastating event

60. A nurse is completing the assessment of a client who is 4 hours postpartum.

Following assessment, the nurse notes that the client is cool, clammy skin and observed
that the client is also restless and excessively thirsty. The nurse prepares immediately to:
a. Begin hourly pad counts and prepare the client.
b. Begin fundal massage and start oxygen by mask.
c. Elevate the head of the bed and assess vital signs.
d. Assess for hypovolemia and notify health care provider.

61. The mother of a child with a diagnosis of esophageal atresia with tracheoesophageal
fistula brings her child to the clinic. A nurse reviews the record of the infant. The nurse
expects to note which most likely sign of this condition documented in the record?
a. Severe projectile vomiting.
b. Incessant crying.
c. Coughing at night time.
d. Choking with feedings.

62. The client displaying an aggressive behavior in the mental health unit. The nurse
visits the unit and observes the client’s aggressive behavior is escalating. Which nursing
intervention is least helpful to this client at this time?
a. Assist the client to an area that is quiet.
b. Maintain a safe distance with the client.
c. Initiate confinement measures.
d. Acknowledge the client’s behavior.

63. A client newly diagnosed as having type I diabetes. The nurse explains to the client
self-monitoring of blood glucose is preferred to urine testing because it is:
a. Easier to perform.
b. More accurate.
c. Done by the client.
d. Not influence by drainage.

64. The nurse is developing a plan of care to a child scheduled for tonsillectomy. A nurse
is aware which of the following would present the highest risk for aspiration during
surgery?
a. Exudate in the throat area.
b. The presence of loose teeth.
c. Difficulty in swallowing.
d. Bleeding during surgery.

65. A nurse is teaching a mother who has been diagnosed with mastitis. Which of the
following statements if made by the client indicates a need for further teaching?
a. “I need to wear a supportive bra to relived the discomfort”
b. “I need to take antibiotics, and I should begin to feel better in 24-48 hours”
c. “I need to stop breast feeding until this condition resolves”
d. “I can use analgesics to assess in alleviating some of the discomfort”

66. A nurse is assigned to a female client who is newly admitted to the mental health unit
for anorexia nervosa. The nurse visits the client in her room and found out that the client
is engaged in rigorous push-ups. Which nursing action is most appropriate?
a. Interrupt the client and offer to take her for a walk
b. Allow the client to complete her exercise program
c. Tell the client that she is not allowed to exercise rigorously
d. Interrupt the client and weigh her immediately

67. A nurse is making rounds; he enters a client’s room. The client is begging to the
nurse to be released from the hospital. The nurse checks the client records and found
out that the client was voluntarily admitted two days ago with a diagnosis of an anxiety
disorder. Which of the following will the nurse take?
a. Contact the physician
b. Call the client’s family
c. Persuade the client to stay a few more days
d. Tell the client that discharge is not possible at this time

68. A nurse was hired to be a home care nurse to assist the family in caring for a
newborn with congenital tracheoesophageal fistula who is receiving enteral feedings. The
nurse receives a telephone call and a woman introduced herself to the nurse as a family
friend and wishes to know the condition of the client and inquire if there is anything she
can do to assist the parents. The best nursing action is to:
a. Report the friend’s telephone call to the nurse manager for referral to the client’s social
worker
b. Inform the friend that the family has no need for assistance at this time because the
nurse is making daily visits
c. Request that the friend come to the client’s home, where she can be taught to
administer the feedings
d. Inform the friend to directly contact the family and offer her assistance to them

69. A nurse assigned a nursing student to perform a cardiovascular assessment on a

postpartum woman. The nurse asks the student about the procedure to elicit Homan’s
sign. Which response by the nursing student would indicate an understanding of this
assessment technique?
a. “I will ask the woman to extend her legs flat on the bed, and I will grasp the foot and
gently dorsiflex it forward”
b. “I will ask the woman to raise the legs up to the waist and then lower the legs slowly”
c. “I will ask the woman to extend the legs flat on the bed, and I will grasp the foot and
sharply extend it backward”
d. “I will ask the woman to raise the legs and to try to lower them against pressure from
my hand”

70. Following an abdominal surgery, the client develops internal hemorrhage, the nurse
performs further assessment, the nurse should expect the client to exhibit:
a. Tachycardia
b. Bradypnea
c. Polyuria
d. Hypertension

71. A client is admitted in the mental health unit complaining of loose, watery stool, and
difficulty walking. The nurse would expect the serum lithium level to be which of the
following?
a. 1.0 mEq/L
b. 0.7 mEq/L
c. 1.3 mEq/L
d. 1.8 mEq/L

72. The home health nurse is scheduled to visit a client at home and found out that the
client is dependent on drugs. Which of the following assessment questions would assist
the nurse to provide appropriate nursing care?
a. The nurse does not ask any questions in fear that the client is in denial and will throw
the nurse out of the home.
b. “Why did you get started on these drugs?”
c. “How long did you think you could take these drugs without someone finding out?”
d. “How much do you use and what effect does it have on you?”

73. A nurse receives a telephone call from a female client who states that she wants to
kill herself and holding a bottle of poisonous substance. The best nursing action is to:
a. Use therapeutic communication techniques, especially the reflection of feelings
b. Keep the client talking and signal another staff member to race the call so that
appropriate help can be sent
c. Insist that the client give you her name and address so that you can get the police
there immediately
d. Keep the client talking and allow the client to ventilate feelings

74. The admitting office calls the nursing unit and informs the nurse in charge that a child
with rheumatic fever will be arriving in the unit for admission. On admission, the nurse
prepares to ask the mother of the child, which question to elicit assessment information
specific to the development of rheumatic fever?
a. “Has the child complained of headache?”
b. “Has the child had nausea and vomiting?”
c. “Did the child have a sore throat or an unexplained fever within the last 2 months?”
d. “Has the child complained of back pain?”

SITUATION 1: Ana Locca is admitted to the emergency room with a stiff neck and
temperature of 102 degree (38.9 C). She has had an earache for 1 week, but has not
sought treatment for it.
75. Nuchal rigidity will NOT be seen in which of the following?
a. Meningitis
b. Intracranial mass with herniation
c. Intracranial hematoma
d. Cerebral concussion

76. Which of the following is a contraindication to lumbar puncture?

a. Unequal pupils
b. Lack of lateralization
c. Suspicion of meningitis
d. Nuchal rigidity
77. In addition to a brief explanation of the lumbar puncture procedure, which of the
following is also the responsibility of the nurse?
a. Administer Narcotic to the client
b. Position the client safely and properly in a lateral recumbent position with his knees
flexed
c. Administer procaine hydrochloride
d. Prepare a suture set so that it will be ready after procedure
ANSWER: B. Position the client safely and properly in a lateral recumbent position with
his knees flexed

78. Bacterial meningitis is confirmed by the cerebrospinal fluid culture. Ms. Locca has
been transferred to a dimly lit private room. Why?
a. Increased stimulation such as bright lights may precipitate in seizure
b. Inappropriate secretion of antidiuretic hormone (ADH) can be minimized
c. It is easier to check his pupils in a darkened room
d. Most clients with meningitis have photophobia

79. Ms. Locca is placed on a hypothermia blanket. Twenty minutes following the start of
hypothermia treatments, what response would the nurse most likely expect to find?
a. Lowered vital signs
b. Elevated vital signs
c. Unchanged vital sings
d. Complaints of hot and cold flashes

80. A young woman is brought to ER following a motor vehicle accident. Assessment

findings indicate minor cuts and bruises, sullen mood guarded response to questions.
The nurse notes multiple old scars on the patient’s forearms. Which of the following
patient statement would require the nurse to investigate as a priority?
a. “My parents are going to be so mad about the car. I don’t know what I will tell them”
b. “I’m glad no one was hurt. The next time I’ll have to think of a different way to take
care of things”
c. “I don’t want to go home. My parents are going to punish me for the car”
d. “I don’t like hospitals, when can I go home”
ANSWER: C. “I don’t want to go home. My parents are going to punish me for the car”
RATIONALE: This statement requires the nurse to investigate due to the statement of
punishment that would indicate a threat.

81. Which of the following symptoms of depression would a nurse most likely observe in
children and adolescents but not in adults?
a. Loss of interest in usual activities
b. Significant weight loss
c. Acting-out behavior
d. Feeling of worthlessness

82. Which of the following behaviors by an adolescent patient who is suspected of having
a major depression would be best support a nursing diagnosis of self-esteem
disturbance?
a. Protest that others do not understand him
b. Inconsistent performance in school
c. Poor impulse control
d. Frequent criticism of others

83. After a competition of an incident report, the nurse places the documents in the
patient’s chart. The nurse should understand the incident reports?
a. Are considered legal documents but rather risk management tool
b. Are maintained by the hospital and used as a staff evaluation tool
c. Will prevent legal action against the nurse
d. Should be reviewed by the patient prior to discharge

84. A nurse should recognize that cardiac arrest in a previously healthy infants is usually
preceded by:
a. Ventricular arrhythmias
b. Respiratory failure
c. Generalized seizures
d. Distributive shock

85. Which of the following clients would the nurse prepare for an emergency cesarean
delivery?
a. A woman who has a prolapsed cord
b. A woman with a twin gestation
c. A woman who has meconium-stained amniotic fluid
d. A woman has a nonreactive non-stress test

86. While a patient who has Hodgkin’s disease is receiving chemotherapy, it is important
to assess the patient for symptoms of
a. Thrombus formation
b. Ascites
c. Infection
d. Splenomegaly
87. The nurse caring for patient with jaundice should expect to see an elevation in which
of the following laboratory values?
a. Serum ammonia
b. Blood urea nitrogen
c. Serum bilirubin
d. Serum albumin

88. Patients with eating disorder should also be assessed for which other psychiatric
disorder?
a. Depression
b. Borderline personality
c. Conduct disorder
d. Schizophrenia

89. Which of the following nursing diagnoses would be a priority for patient who has just
been admitted with a diagnosis of bipolar disorder, mania?
a. Decisional conflict related to making health care choices
b. Self-care deficit, bathing/hygiene, related to lack of attention
c. Hopelessness related to impending depression
d. Fatigue related to hyperactivity

90. If a person has foreign object of unknown material that of not readily seen in one eye,
what would be the first action be?
a. Irrigate the eye with a boric acid solution
b. Examine the lower eyelid and then the upper eyelid
c. Irrigate the eye with copious amount of water (Normal Saline)
d. Shield the eye from pressure, and seek medical help

SITUATION: Luca Pastillas, a newlywed, comes to the mental health clinic because of
“nervousness”. She relates to the nurse that “my stomach has butterflies a lot of the time.
I haven’t missed any work, but it’s getting harder because I can’t concentrate very long
on anything.”

91. What level of anxiety is Mrs. Pastillas MOST likely experiencing?

a. Mild
b. Moderate
c. Severe
d. Panic

92. Which would be BEST way to begin talking to Mrs. Pastillas nursing history?
a. “Tell me about your husband”
b. “What are you feeling now”
c. “Have you ever felt this way before”
d. “Does anyone else in your family ever get these feelings?

93. Which of the following would be MOST appropriate goal for nursing diagnosis of
“Ineffective individual coping related to feelings of hopelessness and anger”?
a. The client will deny feelings of hopelessness and anger
b. The client will demonstrate cheerful affect
c. The client will voice no complaints
d. The client will share feelings with nurse and others

94. Which of the following actions would be LEAST effective in helping the client cope
with painful feelings?
a. Focus on the positive aspects of life
b. Encourage the client to share feelings
c. Help the client of identity feelings
d. Provide reality orientation, and encourage realistic expectations of self

95. Which of the following would NOT be appropriate questions for the nurse to ask when
assessing the depressed client?
a. “What are your expectations of yourself?”
b. “How do you cope with anger?”
c. “Don’t you know that it is morally wrong to think of suicide?”
d. “What kinds of things are pleasurable for you?”

96. According to the social-interactional perspective of child abuse and neglect, four
factors place the family members at risk for abuse. These risk factors are the family
members at risk for abuse. These risk factors are the family itself, the caregiver, the
child, and
A. The presence of a family crisis
B. The national emphasis on sex
C. Genetics
D. Chronic poverty
97. A parent calls you and frantically reports that her child has gotten into her famous
ferrous sulfate pills and ingested a number of these pills. Her child is now vomiting, has
bloody diarrhea, and is complaining of abdominal pain. You will tell the mother to:
A. Call emergency medical services (EMS)
and get the child to the emergency room
B. Relax because these symptoms will pass and the child will be fine
C. Administer syrup of ipecac
D. Call the poison control center
98. The nurse assessing newborn babies and infants during their hospital stay after birth
will notice which of the following symptoms as a primary manifestation of Hirschsprung’s
disease?
A. A fine rash over the trunk
B. Failure to pass meconium during the first 24 to 48 hours after birth
C. The skin turns yellow and then brown over the first 48 hours of life
D. High-grade fever

99. A client is 7 months pregnant and has just been diagnosed as having a partial
placenta previa. She is stable and has minimal spotting and is being sent home. Which of
these instructions to the client may indicate a need for further teaching?
A. Maintain bed rest with bathroom privileges
B. Avoid intercourse for three days.
C. Call if contractions occur.
D. Stay on left side as much as possible when lying down.

100. A woman has been rushed to the hospital with ruptured membrane. Which of the
following should the nurse check first?
A. Check for the presence of infection
B. Assess for Prolapse of the umbilical cord
C. Check the maternal heart rate
D. Assess the color of the amniotic fluid
101. You are the nurse assigned to work with a child with acute glomerulonephritis. By
following the prescribed treatment regimen, the child experiences a remission. You are
now checking to make sure the child does not have a relapse. Which finding would most
lead you to the conclusion that a relapse is happening?
A. Elevated temperature, cough, sore throat, changing complete blood count (CBC) with
diiferential
B. A urine dipstick measurement of 2+ proteinuria or more for 3 days, or the child found
to have 3-4+ proteinutria plus edema.
C. The urine dipstick showing glucose in the urine for 3 days, extreme thirst, increase
in urine output, and a moon face.
D. A temperature of 37.8 degrees (100 degrees F), flank pain, burning frequency,
urgency on voiding, and cloudy urine.

102. The nurse is working with an adolescent who complains of being lonely and having
a lack of fulfillment in her life. This adolescent shies away from intimate relationships at
times yet at other times she appears promiscuous. The nurse will likely work with this
adolescent in which of the following areas?
A. Isolation
B. Lack of fulfillment
C. Loneliness
D. Identity