AIM TO TOP TRAINING AND REVIEW 10.

Diastole is defined as:

A. A measure of contractility
CENTER B. The amount of blood ejected from the ventricles with
each contraction of the heart
C. The period when the heart contracts and the muscles
1. The nurse manager has requested that a nurse perform a fibers are tight and short
self-assessment prior to an annual performance evaluation. D. The period when the muscle fibers are stretched and
Using Maslow’s model of self-actualization, the nurse the heart’s cavities fill with blood
understands that self-actualization is at the top of the
pyramid and refers to: 11. What is a characteristic of the nursing process?
A. Becoming the person you would like to be by making A. Asystematic
the most of your physical, mental, and spiritual B. Goal-oriented
competencies C. Inflexible
B. Needing recognition, usefulness, independence, D. Stagnant
dignity and freedom
C. Needing safety, security, and protection 12. What is the order of the nursing process?
D. Needing to belong to a group A. Assessing, diagnosing, implementing, evaluating,
planning
2. The nurse is evaluating a patient complaining of shortness B. Assessing, diagnosing, planning, implementing,
of breath. The nurse assesses the patient’s respiratory rate evaluating
to be 26 breaths/minute and documents that the patient is C. Diagnosing, assessing, planning, implementing,
tachypneic. The nurse understands that tachypnea means: evaluating
A. Frequent bowel sounds D. Planning, diagnosing, implementing, assessing,
B. Heart rate greater than 100 beats/minute evaluating
C. Hyperventilation
D. Respiratory rate greater than 20 breaths/minute 13. During the planning phase of the nursing process, which of
the following is the “product’ developed?
3. The nurse assesses a patient complaining of frequent A. Nursing care plan
episode of epistaxis. The nurse knows the patient has: B. Nursing diagnosis
A. An enlarged spleen C. Nursing history
B. A tendency to bruise easily D. Nursing notes
C. Nosebleeds
D. Seizures 14. Objective data are also known as:
4. The doctor order intra-arterial monitoring to obtain A. Covert data
continuous blood pressure in a critically ill patient. Collateral B. Inferences
circulation should be assessed prior to selection of an C. Overt data
arterial site. The test used to assess the patency of the D. Symptoms
radial and ulnar arteries is the:
A. Allen’s test 15. The primary source of data collection in the assessment
B. Homans’ sign phase of the nursing process is the:
C. Trendelenburg’s test A. Chart
D. Weber’s test B. Patient
5. The four major concepts in nursing theory are the C. Doctor
A. Person, Environment, Nurse, Health D. Family
B. Nurse, Person, Environment, Cure
16. What is an example of subjective data?
C. Promotive, Preventive, Curative, Rehabilitative
A. Color of wound drainage
D. Person, Environment, Nursing, Health B. Odor of breath
6. The act of utilizing the environment of the patient to assist C. Respirations of 14 breaths/minute
him in his recovery is theorized by D. The patient’s statement of “I feel sick to my stomach”
A. Nightingale
17. This is the best patient care model when there are many
B. Benner
nurses but few patients.
C. Swanson
A. Functional nursing
D. King
B. Team nursing
7. The most unique characteristic of nursing as a profession is C. Primary nursing
A. Education D. Total patient care
B. Theory
18. This patient care model works best when there are plenty of
C. Caring
patient but few nurses
D. Autonomy
A. Functional nursing
B. Team nursing
8. To administer nitroglycerin sublingually, the nurse:
A. Insert it rectally C. Primary nursing
B. Places it in the buccal area D. Total patient care
C. Places it on the chest wall
D. Places it under the tongue 19. Who developed the first theory of nursing?
A. Hammurabi
SITUATION: Sheila Reyes has a history of hypertension and
complains of shortness of breath when she lies flat. The nurse B. Alexander
assesses her blood pressure to have a diastolic reading of 200 C. Fabiola
mmHg. (Questions 10 and 11 relate to this situation) D. Nightingale
9. The nurse documents that Mrs. Killian has:
20. She described the four conservation principle.
A. Dyspnea
B. Exertional dyspnea A. Levin
C. Orthopnea B. Leininger
D. Paroxysmal nocturnal dyspnea C. Orlando
 D. Parse C. Strategy
D. Theory
21. Established in 1906 by the Baptist foreign mission society of
31. An expected outcome on a patient’s nursing care plan
America. Miss rose Nicolet, was its first superintendent. reads. “patient will be able to transfer from the bed to a
A. St. Paul Hospital School of nursing wheelchair without assistance by the end of the week.”
B. Iloilo Mission Hospital School of nursing When the nurse evaluated the patient’s progress, the patient
C. Philippine General Hospital School of nursing was able to transfer from the bed to a wheelchair to go to
D. St. Luke’s Hospital School of nursing the physical therapy department without any help from the
nurse. Which of the following would be an appropriate
evaluative statement for the nurse to place on the patient’s
22. Anastacia Giron-Tupas was the first Filipino nurse to occupy nursing care plan?
the position of chief nurse in this hospital. A. “Patient was able to transfer from the bed to a
A. St. Paul Hospital wheelchair without assistance.”
B. Iloilo Mission Hospital B. “Goal impossible to measure.”
C. “Goal met; patient was able to transfer from the bed to
C. Philippine General Hospital a wheelchair without assistance.”
D. St. Luke’s Hospital D. “Goal not met.”

23. Period of nursing where religious Christian orders emerged 32. The goal or expected outcome “Patient will maintain current
to take care of the sick weight of 165 pounds” can best be evaluated by which of the
following measures?
A. Apprentice period
A. Determining the patient’s food preferences
B. Dark period B. Monitoring dietary intake for each meal
C. Contemporary period C. Restricting high-calorie food
D. Educative period D. Weighing the patient on the same scale
33. The nurse manager evaluates the quality of the nursing care
plans developed for the patients on the nursing unit. This is
24. This period marked the religious upheaval of Luther, Who an example of which type of evaluation?
questions the Christian faith. A. Outcome
A. Apprentice period B. Peer
B. Dark period C. Process
C. Contemporary period D. Structure
D. Educative period 34. In the implementing phase of the nursing process, the nurse
does which of the following tasks?
25. She conceptualized that man, as an Open system is in A. Determines the patient’s health status
constant interaction and transaction with a changing B. Identifies available resources
environment. C. Measures goal achievement
A. Roy D. Puts the nursing care plan into action
B. Levin 35. Collaborative nursing interventions:
C. Neuman A. Are based on the written instructions of another
D. Newman professional
26. Two-year-old Jason’s mother states, “Jason vomited 8 B. Are determined solely by the nurse and patient
ounces of his formula this morning.” This statement is an C. Reflect the overlapping responsibilities of health care
example of: personnel
A. Objective data from a primary source D. Require supervision by the doctor
B. Objective data from a secondary source
C. Subjective data from a primary source 36. When a assessing a patient’s level of pain, which type of
D. Subjective data from a secondary source nursing intervention is the nurse performing?
A. Collaborative
27. The nurse performs a neurologic exam on a patient. After B. Dependent
the exam, which of the following should be recorded as C. Independent
objective data? D. Professional
A. +4 patellar reflexes in both of the patient’s legs
B. Patient’s description of ringing in his ears 37. What should the nurse do after making a charting error in
C. Patient’s sensations of numbness in his right arm the nurses’ notes?
D. Patient’s statement, “The room is spinning” A. Draw a line through the error and write “Error” and her
initials above it
28. It is most important to identify the etiology (risk factors) of a B. Obliterate the mistaken with a black felt pen
nursing diagnosis because doing so: C. Recopy the page of nurses’ notes and start over
A. Assists in organizing nursing care of patients with a D. Report the incident immediately to the head nurse
similar diagnosis
B. Describes that patient’s health problem or response in 38. Independent nursing interventions:
a few words A. Are also known as standing orders
C. Gives direction to the required nursing interventions B. Are initiated based on the nurse’s own knowledge and
for the patient skill
D. Indicates the presence of a particular health problem C. Consist primarily of health education
in a patient D. Relate directly to the patient’s disease process
29. When should discharge planning commence?
A. 24 hours after discharge 39. The head nurse wants to determine how the size and
B. The day before discharge location of the nursing station influences the delivery of
C. Upon admission nursing care on the unit. This is an example of which type of
D. When the patient desires evaluation?
A. Outcome
30. The scientific reason for selecting a specific nursing B. Peer
intervention supported by clinical research is called a: C. Process
A. Criterion D. Structure
B. Rationale
40. Which of the following statements about the term nursing 4. Traumatic
process is true? 5. Congenital
A. It is used only in the United States 6. Degenerative
B. It originated with Florence Nightingale a. 5 and 2
C. It was first used by Lydia Hall in 1955
D. It was initiated by the national league for Nursing in b. 2 and 3
1983 c. 3 and 4
41. The nurse has organized an immunization clinic for healthy d. 3 and 5
babies and preschool children. This would be an example of
what level of preventative health care? 50. Term to describe the reactiviation and recurrence of
A. Curative pronounced symptoms of a disease
B. Primary
C. Secondary A. Remission
D. Tertiary B. Emission
C. Exacerbation
42. The nurse is caring for a patient in the hospital after the D. Sub-acute
surgical removal of his gallbladder. This would be an
example of what level of preventative health care?
A. Curative 51. A foley catheter operates by the principle of
B. Primary a. Inertia c. diffusion
C. Secondary b. Gravity d. osmosis
D. Tertiary
52. The client is receiving total parenteral nutrition (TPN). Which
43. A nurse is a lifelong learner. The most important reason for lab test should be taken daily?
this is: a. Hemoglobin
A. Accrediting agencies, such as the National League for b. Creatinine
Nursing, require it c. Blood glucose
B. Employers require it to stay employed d. White blood cell count
C. Doctors need to be ensured the nurse is competent in
nursing 53. Nurse Honeyboy is suctioning a client via a tracheostomy
D. Nurses must remain current in nursing research, skills, tube. When suctioning, he must limit the suctioning to a
and knowledge maximum of :
a. 5 seconds
44. Maslow’s hierarchy of basic needs is a common theory that b. 15 seconds
nursing education incorporates to explain the basic needs of c. 10 seconds
people. What need must be met before the person can focus d. 20 seconds
on safety and security?
A. Love and belonging 54. The client with Cirrhosis is scheduled for a parencentesis.
B. Physiological Which instruction should be given to the client before the
C. Self-actualization exam?
D. Self-esteem a. “You will need to lay flat during the exam.”
b. “You need to empty your bladder before the
45. The nurse performs many roles in the practice of nursing. procedure.”
Which role is defined as “the protection of human or legal c. “You will be asleep during the procedure.”
rights and the securing of quality care for each patient”? d. “The doctor will inject a medication to treat your illness
A. Advocator during the procedure.”
B. Communicator
C. Counselor 55. After undergoing a liver biopsy, the client would be placed in
D. Leader which position?
a. Semi- fowler
46. The nurse is teaching a diabetic patient how to inject insulin b. lateral on affected site
and the dosages necessary for optimal control. This would c. supine
be an example of what level of health care? d. prone
A. Curative 56. Which medication administration situations should be
B. Primary documented in a healthcare facility's incident reporting
C. Secondary system?
D. Tertiary
A. Medication errors and adverse drug reactions only
47. Founder of the PNA B. Medication errors that cause patient harm
C. Near misses and medication errors only
A. JulitaSotejo D. near misses, medication errors, and adverse drug
B. Anastacia GironTupas reactions
C. Eufemia Octaviano
D. Anesia Dionisio 57. A nurse is assessing his patients in the morning and finds
that a frail a 85 year-old female patient is soiled in bed. The
48. A woman undergoing radiation therapy developed redness patient reports that she has been asked to cleaned
and burning of the skin around the best. This is best numerous times and has been ignored. Of the following,
classified as what type of disease? which demonstrates appropriate documentation in the
A. Neoplastic patient's chart.
B. Traumatic
C. Nosocomial A. The patient was found soiled in bed by this RN. she
reports being left alone all night by the night shift RN, who
D. Iatrogenic
did not clean her before the change of shift. She was given a
bed bath and provided skin care. Her skin was reddened on
49. The classification of CANCER according to its etiology Is
her buttocks; emollient applied.
best described as
B. The patient was found soiled in bed by this RN. She was
1. Nosocomial
incontinent of urine and feces and she said she was
2. Idiopathic
"ignored for hours" by the night shift RN. She was given a
3. Neoplastic
 bed bath and provided skin care. Her skin was reddened on 62. A physician involved in the patient's care asks to see the
her buttocks; emollient applied. results of his HbA1c. How should the nurse respond?
C. The patient was found soiled; incontinent of urine and A. "Asked the clerk for that information."
feces. She was given a bed bath and provided skin care. B. "I can't give you that information."
Her skin was reddened on the buttocks; Emollient applied. C. "It is 8.5."
Incident report made. D. "You can look it up on the computer"
D. The patient was found soiled; incontinent of urine and
feces. She was given a bed bath and provided skin care. 63. A living will include which of the following?
Her skin was reddened on the buttocks; emollient applied. Select all that apply:
A. Documentation requirements
58. A home health nurse makes weekly visits to an 87-year-old B. How and when the Living will takes effect
client who lives with her son. When home alone, the client is C. How the patient's valuables are distributed among the
talkative and friendly, but when the son is home, the client is family
observed to be withdrawn and appears anxious. The client D. Immunity from liability for following the living will
has bruises, which she states is from "bumping into things" E. Which family member will inherit the patient's home
and a weight-loss of 10 pounds in the past month. With
these objective findings, the nurse is required to do which of 64. The circulating nurse in the OR notices a small laceration on
the following? the patient’s hip while positioning pre-op, but this was
select all that apply. missed and not reported during the pre-op assessment. Of
the following, which is the appropriate action for the nurse to
A. ask the client if she has any concerns about her living take?
situation, maintaining an objective, non-accusatory role. A. At the laceration to the pre-op nurse’s documentation so it
B. Confront the son about the abuse, demanding that he won't be confused with a surgical injury
turn himself in to seek help for the abusive pattern of B. Document the laceration along with the surgical sites in
behavior. the peri-op note
C. Question the client's son privately about the suspicions of C. Document the presence of a preexisting skin laceration in
his mother's condition and about possible abuse or neglect. the peri-op now.
D. Report suspected abuse to adult protective services so D. Report it to the receiving PACU nurse after the procedure
investigation into the clients welfare can be performed. so she can document it.

59. The nurse understands the following about informing and 65. Which of the following should the nurse delegate to the LPN.
obtaining consent for an eight-year-old patient who is Select all that apply:
undergoing a heart transplant: A. Administering a piggyback IV medication
Select all that apply. B. IM medication administration
A. Since the child is a minor, he does not need to be C. Initiating a primary IV medication
informed about the surgery D. Oral medication administration
B. The child must be informed about the surgery. E. Urinary catheterization
C. The child must sign the informed consent form along with
their parent 66. Which of the following tasks can be delegated to a nursing
D. The child only needs to know the risks of the surgery. assistant?
E. The parent/guardian must be informed of the risks and Select all that apply.
benefits of the procedure and sign the informed consent on A. Ambulating a stable patient
behalf of the child B. Emptying and measuring a foley catheter reservoir
C. Intake and output documentation
60. The patient refuses chemotherapy based on religious D. Irrigating a nasogastric tube
beliefs. The hospital staff must follow his decision based on E. nasotracheal suctioning of a stable patient
which patient right? F. Setting up patient-controlled analgesia
A. The right to counsel
B. The right to informed consent 67. The five-year-old is admitted to the hospital with pneumonia.
C. The right to refuse treatment The nurse observes bruises on the child's back and arms.
D. The right to suffer The Mother is present in the patient's room. What should the
nurse do next?
61. The patient was recently admitted to hospice care for lung A. Ask the mother if she is abusing her child
cancer. After filling out his advanced directive, the patient B. Call the police
says that he worries his physician will be uninterested in his C. Notify the physician of suspected child abuse
care. Which of the following statements made by the nurse D. When the mother leaves, ask the child if she feels scared
best addresses the patient's concerns? or unsafe at home
A. "After you fill out an advance directive, the physician
plays a limited role to allow you space and time to be with 68. A nurse on the medical surgical floor is caring for patient
your family." who is confused and combative after abdominal surgery.
B."Once you are admitted to hospice, the physician plays a The patient has pulled out the nasogastric tube required for
passive role." gastric rest. The nurse called the doctor to discuss these
C. "Your physician is required by law to help you, so don't issues. The doctor has ordered two point restraints , so the
worry." nurse creates a telephone order read back. The nurse
D. "Your physician will continue to take care of you. The knows that the restraint order will require which of the
advanced directive just states what type of care you want, following?
so we can provide that care even when you cannot tell us Select all that apply.
too." A. The doctor must perform an in-person assessment of the
patient's need for restraints within one hour
B. The doctor must sign a telephone order and assess the
 need for continued restraints every four hours B. Healthy food choices
C. The doctor must sign a telephone order and assess the C. Importance of getting enough sleep
need for continued restraints within 24 hours D. Use of seat belts and safety equipment
D. The nurse assesses the patient's need for restraints and
obtain another telephone order each hour 78. The nurse should encourage a group of teenagers to eat
plenty of _______________?
69. Which of the following contributions of Florence Nightingale A. Dairy products
had an immediate impact on improving patient's health? B. Fish
A. Providing a clean environment C. Nuts & Legumes
B. Improving nursing education D. High fiber products
C. Changing the delivery of care in hospitals
D. establishing nursing as a distinct profession 79. A patient tells the nurse, "I can't see well enough to read
anymore. I have new glasses but it is still hard." What should
70. Which of the following is the most important reason for the nurse advise the patient to do first?
nurses to be critical thinkers? A. Go back to the eye doctor and have the glasses checked.
A. Nurses need to follow policies and procedures B. Buy some audio books and listen to those.
B. Nurses work with other healthcare professionals C. Adapt to reading less.
C. Nurses care for patients with multiple health issues D. Install a bright, but glare-free light near where you read.
D. Nurses have to be flexible and work different schedules
80. When providing postmortem care, why would the nurse
71. Which of the following includes objective and subjective place dentures in the mouth and close the eyes and mouth
data? of the patient within 2 to 4 hours after death?
A. Patient's BP is 132/68 and HR is 88 A. To prevent blood from settling in the head, neck, and
B. Patient's cholesterol is elevated, and stated that he likes shoulders
fried food B. To perform these actions more easily before rigor mortis
C. Patient states she is having trouble sleeping and drinks develops
coffee at night C. To set mouth in natural position for viewing by the family
D. Patient states he gets frequent headaches and takes D. To prevent discoloration caused by blood settling in the
aspirin for it facial area.

72. Which of the following is an example of an active listening 81. A client who cannot manage a patient-controlled analgesia
behavior? pump is prescribed morphine 4mg IV q 1 hr PRN for pain.
A. Taking frequent notes When should the nurse administer the medication?
B. Asking for more details A. Every hour around the clock
C. Leaning in, facing the patient B. Immediately after taking off the order
D. Sitting with legs crossed C. As needed, but not more than once per hour
D. 1 hour after the last dose administered.
73. Which of the following explains why it is important to have
the correct etiology for a nursing diagnosis? The etiology: 82. Which of the following nursing activities is of highest priority
A. is the cause of the problem for maintaining medical asepsis?
B. cannot always be observed A Washing hands
C. directs nursing care B. Donning gloves
D. is an inference C. Wearing a gown
D. Wearing a face mask
74. Who is the primary decision maker when caring for healthy
adult clients? 83. Which of the following behaviors indicates the highest
A. Physician potential for spreading infectious among patients. The nurse
B. Family ___________________
C. Patient A. disinfects dirty hands with antibacterial soap.
D. Nurse B. allows alcohol-based rub to dry for 10 seconds
C. washes hands only after leaving patients room
75. Which of the following nursing interventions is an indirect- D. uses cold water for medical asepsis.
care intervention?
A. Emotional support 84. Alcohol-based solutions for hand hygiene can be used to
B. Teaching combat which types of organisms? Select all that apply.
C. Consulting A. Virus
D. Physical care B. Bacterial Spores
C. Yeast
76. A patient is having difficulty with feelings of self-loathing and D. Mold
disgust after being attacked and raped. According to
Maslow, which level is the patient struggling with? 85. A patient infected with a virus but who does not have any
A. Physiological outward signs of the disease is considered a:
B. Safety & Security A. pathogen
C. Love & Belonging B. fomite
D. Self-esteem C. vector
D. carrier
77. The nurse is talking to a class of children ages 9-12. For this
group, it would be most important for the nurse to 86. The nurse is instructing a client how to appropriately dress
discuss______. an infant in cold weather. Which of the following instructions
A. Safe sex practices would be most appropriate for the nurse to include?
 A. Be sure to put mittens on the baby for this patient?
B. Layer the infant's clothing A. transparent film dressing
C. Place a cap on the baby's head B. sheet hydrogel
D. Put warm booties on the baby C. frequent turn schedule
D. debridement
87. Bathing a patient with liver dysfunction, the nurse notes
yellow skin tone. The nurse should document this finding as: 96. Which electrolyte is the primary regulator of fluid volume?
A. Edema A. potassium
B. Jaundice B. calcium
C. Cyanosis C. sodium
D. Pallor D. magnesium

88. Where should the nurse assess skin color changes in the 97. Which of the following terms refers to the ethics questions
dark-skinned patient? that arise out of nursing practice?
A. Nailbeds A. nursing ethics
B. Any exposed area B. bioethics
C. Oral mucosa C. ethical dillema
D. Palm of hands D. moral distress

89. What is the body's first line of defense against bacteria? 98. Which form of communication is the nurse using when
A. intact skin interviewing the patient during the admission health history
B. hair and physical assessment?
C. immune system A. small group
D. lymph glands B. interpersonal
C. group
90. Before administering medication, the nurse must verify the D. intrapersonal
rights of medication administration which include:
A. right patient, right room, right drug, right route, right time 99. The patient refuses chemotherapy based on religious
B. right drug, right dose, right route, right physician, right beliefs. The hospital staff must follow his decision based on
time which patient right?
C. right patient, right drug, right route, right equipment, right
time A. The right to counsel
D. right patient, right drug, right dose, right route, right time, B. The right to informed consent
right documentation C. The right to refuse treatment
D. The right to suffer
91. Which action should the nurse take to relax the vastus
lateralis muscle before administering an IM injection into this 100. A nurse stops to help in an emergency at the scene of an
site? accident. The injured party files a suit and the nurse's
A. Apply a warm compress employing institution insurance does not cover the nurse.
B. Massage the site in a circular motion What would probably cover the nurse in this situation?
C. Apply a soothing lotion A. The nurse's auto insurance
D. Put the patient in a sitting position B. The nurse's homeowner's insurance
C. The Good Samaritan laws, which grant immunity from
92. When changing a diaper, the nurse observes that a 2 day suit if there is no gross negligence.
old infant has a green, black, tarry stool. What should the D. The Patient Care Partnership, which may grant immunity
nurse do? from suit if the injured party contends.
A. notify the physician
B. Do nothing, this is normal
C. Give the baby sterile water
D. Apply a skin barrier

93. A patient suddenly develops right lower quadrant pain,

nausea, vomiting. How should the nurse classify this
patient?
A. Acute
B. Chronic
C. Intralatable
D. neuropathic

94. A patient who underwent a left above the knee amputation

complains of pain in his left foot. What type of pain is he
experiencing?
A. psychogenic
B. phantom
C. reffered
D. radiating

95. A patient has an area of non-blancheable erythemia on his

coccyx. The nurse has determined this to be a stage I
pressure ulcer. What would be the most important treatment