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

A. B. C. D. Providing a back massage Feeding a client Providing hair care Providing oral hygiene

2. The nurse is preparing to take vital sign in an alert client admitted to the hospital with dehydration secondary to vomiting and diarrhea. What is the best method used to assess the clients temperature?
A. B. C. D. Oral Axillary Radial Heat sensitive tape

3. A nurse obtained a clients pulse and found the rate to be above normal. The nurse document this findings as:
A. B. C. D. Tachypnea Hyper pyrexia Arrythmia Tachycardia

4. Which of the following actions should the nurse take to use a wide base support when assisting a client to get up in a chair?
Bend at the waist and place arms under the clients arms and lift Face the client, bend knees and place hands on clients forearm and lift Spread his or her feet apart Tighten his or her pelvic muscles

5. A client had oral surgery following a motor vehicle accident. The nurse assessing the client finds the skin flushed and warm. Which of the following would be the best method to take the clients body temperature?
A. B. C. D. Oral Axillary Arterial line Rectal

6. A client who is unconscious needs frequent mouth care. When performing a mouth care, the best position of a client is:
A. B. C. D. Fowlers position Side lying Supine Trendelenburg

7. A client is hospitalized for the first time, which of the following actions ensure the safety of the client?
A. B. C. D. Keep unnecessary furniture out of the way Keep the lights on at all time Keep side rails up at all time Keep all equipment out of view

8. A walk-in client enters into the clinic with a chief complaint of abdominal pain and diarrhea. The nurse takes the clients vital sign hereafter. What phrase of nursing process is being implemented here by the nurse?
A. B. C. D. Assessment Diagnosis Planning Implementation

9. It is best describe as a systematic, rational method of planning and providing nursing care for individual, families, group and community
A. B. C. D. Assessment Nursing Process Diagnosis Implementation

10. Exchange of gases takes place in which of the following organ?

A. B. C. D. Kidney Lungs Liver Heart

11. The Chamber of the heart that receives oxygenated blood from the lungs is the?
A. B. C. D. Left atrium Right atrium Left ventricle Right ventricle

12. A muscular enlarge pouch or sac that lies slightly to the left which is used for temporary storage of food
A. B. C. D. Gallbladder Urinary bladder Stomach Lungs

13. The ability of the body to defend itself against scientific invading agent such as baceria, toxin, viruses and foreign body
A. B. C. D. Hormones Secretion Immunity Glands

14.Hormones secreted by Islets of Langerhans

A. B. C. D. Progesterone Testosterone Insulin Hemoglobin

15. It is a transparent membrane that focuses the light that enters the eyes to the retina.
A. B. C. D. Lens Sclera Cornea Pupils

16.Which of the following is included in Orems theory?

A. B. C. D. Maintenance of a sufficient intake of air Self perception Love and belonging Physiologic needs

17.Which of the following cluster of data belong to Maslows hierarchy of needs

A. B. C. D. Love and belonging Physiologic needs Self actualization All of the above

18. This is characterized by severe symptoms relatively of short duration.

A. B. C. D. Chronic Illness Acute Illness Pain Syndrome

19.Which of the following is the nurses role in the health promotion

A. B. C. D. Health risk appraisal Teach client to be effective health consumer Worksite wellness None of the above

20. It is describe as a collection of people who share some attributes of their lives.
A. B. C. D. Family Illness Community Nursing

21. Five teaspoon is equivalent to how many milliliters (ml)?

A. B. C. D. 30 ml 25 ml 12 ml 75 ml

22. 1800 ml is equal to how many liters?

A. B. C. D. 1.8 18000 180 2800

23.Which of the following is the abbreviation of drops?

A. B. C. D. Gtt. Gtts. Dp. Dr.

24. The abbreviation for micro drop is

A. B. C. D. gtt gtt mdr mgts

25. Which of the following is the meaning of PRN?

A. B. C. D. When advice Immediately When necessary Now

26. Which of the following is the appropriate meaning of CBR?

A. B. C. D. Cardiac Board Room Complete Bathroom Complete Bed Rest Complete Board Room

27. 1 tsp is equals to how many drops?

A. B. C. D. 15 60 10 30

28. 20 cc is equal to how many ml?

A. B. C. D. 2 20 2000 20000

29. 1 cup is equal to how many ounces?

A. B. C. D. 8 80 800 8000

30. The nurse must verify the clients identity before administration of medication. Which of the following is the safest way to identify the client?
A. Ask the client his name B. Check the clients identification band C. State the clients name aloud and have the client repeat it D. Check the room number

31.The nurse prepares to administer buccal medication. The medicine should be placed
A. B. C. D. On the clients skin Between the clients cheeks and gums Under the clients tongue On the clients conjuctiva

32. The nurse administers cleansing enema. The common position for this procedure is
A. B. C. D. Sims left lateral Dorsal Recumbent Supine Prone

33. A client complains of difficulty of swallowing, when the nurse try to administer capsule medication. Which of the following measures the nurse should do?
A. Dissolve the capsule in a glass of water B. Break the capsule and give the content with an applesauce C. Check the availability of a liquid preparation D. Crash the capsule and place it under the tongue

34. Which of the following is the appropriate route of administration for insulin?
A. B. C. D. Intramuscular Intradermal Subcutaneous Intravenous

35. The nurse is ordered to administer ampicillin capsule TIP p.o. The nurse should give the medication
A. B. C. D. Three times a day orally Three times a day after meals Two time a day by mouth Two times a day before meals

36. Back Care is best describe as:

A. B. C. D. Caring for the back by means of massage Washing of the back Application of cold compress at the back Application of hot compress at the back

37. It refers to the preparation of the bed with a new set of linens
A. B. C. D. Bed bath Bed making Bed shampoo Bed lining

38. Which of the following is the most important purpose of handwashing

A. B. C. D. To promote hand circulation To prevent the transfer of microorganism To avoid touching the client with a dirty hand To provide comfort

39. What should be done in order to prevent contaminating of the environment in bed making?
A. B. C. D. Avoid funning soiled linens Strip all linens at the same time Finished both sides at the time Embrace soiled linen

40. The most important purpose of cleansing bed bath is:

A. To cleanse, refresh and give comfort to the client who must remain in bed B. To expose the necessary parts of the body C. To develop skills in bed bath D. To check the body temperature of the client in bed

41. Which of the following technique involves the sense of sight?

A. B. C. D. Inspection Palpation Percussion Auscultation

42. The first techniques used examining the abdomen of a client is:
A. B. C. D. Palpation Auscultation Percussion Inspection

43. A technique in physical examination that is use to assess the movement of air through the tracheobronchial tree:
A. B. C. D. Palpation Auscultation Inspection Percussion

44. An instrument used for auscultation is:

A. B. C. D. Percussion-hammer Audiometer Stethoscope Sphygmomanometer

45. Resonance is best describe as:

A. B. C. D. Sounds created by air filled lungs Short, high pitch and thudding Moderately loud with musical quality Drum-like

46. The best position for examining the rectum is:

A. B. C. D. Prone Sims Knee-chest Lithotomy

47. It refers to the manner of walking

A. B. C. D. Gait Range of motion Flexion and extension Hopping

48. The nurse asked the client to read the Snellen chart. Which of the following is tested:
A. B. C. D. Optic Olfactory Oculomotor Troclear

49. Another name for knee-chest position is:

A. B. C. D. Genu-dorsal Genu-pectoral Lithotomy Sims

50. The nurse prepare IM injection that is irritating to the subcutaneous tissue. Which of the following is the best action in order to prevent tracking of the medication
A. B. C. D. Use a small gauge needle Apply ice on the injection site Administer at a 45 angle Use the Z-track technique

PART 2

1. The most appropriate nursing order for a patient who develops dyspnea and shortness of breath would be
A. Maintain the patient on strict bed rest at all times B. Maintain the patient in an orthopneic position as needed C. Administer oxygen by Venturi mask at 24%, as needed D. Allow a 1 hour rest period between activities

2. The nurse observes that Mr. Adams begins to have increased difficulty breathing. She elevates the head of the bed to the high Fowler position, which decreases his respiratory distress. The nurse documents this breathing as:
A. B. C. D. Tachypnea Eupnca Orthopnea Hyperventilation

3. The physician orders a platelet count to be performed on Mrs. Smith after breakfast. The nurse is responsible for:
A. B. C. D. Instructing the patient about this diagnostic test Writing the order for this test Giving the patient breakfast All of the above

4. Mrs. Mitchell has been given a copy of her diet. The nurse discusses the foods allowed on a 500-mg low sodium diet. These include:
A. A ham and Swiss cheese sandwich on whole wheat bread B. Mashed potatoes and broiled chicken C. A tossed salad with oil and vinegar and olives D. Chicken bouillon

5. The physician orders a maintenance dose of 5,000 units of subcutaneous heparin (an anticoagulant) daily. Nursing responsibilities for Mrs. Mitchell now include:
A. Reviewing daily activated partial thromboplastin time (APTT) and prothrombin time. B. Reporting an APTT above 45 seconds to the physician C. Assessing the patient for signs and symptoms of frank and occult bleeding D. All of the above

6. The four main concepts common to nursing that appear in each of the current conceptual models are:
A. B. C. D. Person, nursing, environment, medicine Person, health, nursing, support systems Person, health, psychology, nursing Person, environment, health, nursing

7. In Maslows hierarchy of physiologic needs, the human need of greatest priority is:
A. B. C. D. Love Elimination Nutrition Oxygen

8. The family of an accident victim who has been declared brain-dead seems amenable to organ donation. What should the nurse do?
A. Discourage them from making a decision until their grief has eased B. Listen to their concerns and answer their questions honestly C. Encourage them to sign the consent form right away D. Tell them the body will not be available for a wake or funeral

9. A new head nurse on a unit is distressed about the poor staffing on the 11 p.m. to 7 a.m. shift. What should she do?
A. B. C. D. Complain to her fellow nurses Wait until she knows more about the unit Discuss the problem with her supervisor Inform the staff that they must volunteer to rotate

10. Which of the following principles of primary nursing has proven the most satisfying to the patient and nurse?
A. Continuity of patient care promotes efficient, costeffective nursing care B. Autonomy and authority for planning are best delegated to a nurse who knows the patient well C. Accountability is clearest when one nurse is responsible for the overall plan and its implementation. D. The holistic approach provides for a therapeutic relationship, continuity, and efficient nursing care.

11. If nurse administers an injection to a patient who refuses that injection, she has committed:
A. B. C. D. Assault and battery Negligence Malpractice None of the above

12. If patient asks the nurse her opinion about a particular physicians and the nurse replies that the physician is incompetent, the nurse could be held liable for:
A. B. C. D. Slander Libel Assault Respondent superior

13. A registered nurse reaches to answer the telephone on a busy pediatric unit, momentarily turning away from a 3 month-old infant she has been weighing. The infant falls off the scale, suffering a skull fracture. The nurse could be charged with:
A. B. C. D. Defamation Assault Battery Malpractice

14. Which of the following is an example of nursing malpractice?

A. The nurse administers penicillin to a patient with a documented history of allergy to the drug. The patient experiences an allergic reaction and has cerebral damage resulting from anoxia. B. The nurse applies a hot water bottle or a heating pad to the abdomen of a patient with abdominal cramping. C. The nurse assists a patient out of bed with the bed locked in position; the patient slips and fractures his right humerus. D. The nurse administers the wrong medication to a patient and the patient vomits. This information is documented and reported to the physician and the nursing supervisor.

15. Which of the following signs and symptoms would the nurse expect to find when assessing an Asian patient for postoperative pain following abdominal surgery?
A. Decreased blood pressure and heart rate and shallow respirations B. Quiet crying C. Immobility, diaphoresis, and avoidance of deep breathing or coughing D. Changing position every 2 hours

16. A patient is admitted to the hospital with complaints of nausea, vomiting, diarrhea, and severe abdominal pain. Which of the following would immediately alert the nurse that the patient has bleeding from the GI tract?
A. B. C. D. Complete blood count Guaiac test Vital signs Abdominal girth

17. The correct sequence for assessing the abdomen is:

A. Tympanic percussion, measurement of abdominal girth, and inspection B. Assessment for distention, tenderness, and discoloration around the umbilicus. C. Percussions, palpation, and auscultation D. Auscultation, percussion, and palpation

18. High-pitched gurgles head over the right lower quadrant are:
A. B. C. D. A sign of increased bowel motility A sign of decreased bowel motility Normal bowel sounds A sign of abdominal cramping

19.A patient about to undergo abdominal inspection is best placed in which of the following positions?
A. B. C. D. Prone Trendelenburg Supine Side-lying

20. For a rectal examination, the patient can be directed to assume which of the following positions?
A. B. C. D. Genupecterol Sims Horizontal recumbent All of the above

21. During a Romberg test, the nurse asks the patient to assume which position?
A. B. C. D. Sitting Standing Genupectoral Trendelenburg

22. If a patients blood pressure is 150/96, his pulse pressure is:

A. B. C. D. 54 96 150 246

23. A patient is kept off food and fluids for 10 hours before surgery. His oral temperature at 8 a.m. is 99.8 F (37.7 C) This temperature reading probably indicates:
A. B. C. D. Infection Hypothermia Anxiety Dehydration

24. Which of the following parameters should be checked when assessing respirations?
A. B. C. D. Rate Rhythm Symmetry All of the above

25. A 38-year old patients vital signs at 8 a.m. are axillary temperature 99.6 F (37.6 C); pulse rate, 88; respiratory rate, 30. Which findings should be reported?
A. B. C. D. Respiratory rate only Temperature only Pulse rate and temperature Temperature and respiratory rate

26. All of the following can cause tachycardia except:

A. B. C. D. Fever Exercise Sympathetic nervous system stimulation Parasympathetic nervous system stimulation

27. Palpating the midclavicular line is the correct technique for assessing
A. B. C. D. Baseline vital signs Systolic blood pressure Respiratory rate Apical pulse

28. The absence of which pulse may not be a significant finding when a patient is admitted to the hospital?
A. B. C. D. Apical Radial Pedal Femoral

29. Which of the following patients is at greatest risk for developing pressure ulcers?
A. An alert, chronic arthritic patient treated with steroids and aspirin B. An 88-year old incontinent patient with gastric cancer who is confined to his bed at home C. An apathetic 63-year old COPD patient receiving nasal oxygen via cannula D. A confused 78-year old patient with congestive heart failure (CHF) who requires assistance to get out of bed.

30. The physician orders the administration of highhumidity oxygen by face mask and placement of the patient in a high Fowlers position. After assessing Mrs. Paul, the nurse writes the following nursing diagnosis: Impaired gas exchange related to increased secretions. Which of the following nursing interventions has the greatest potential for improving this situation?
A. Encourage the patient to increase her fluid intake to 200 ml every 2 hours B. Place a humidifier in the patients room. C. Continue administering oxygen by high humidity face mask D. Perform chest physiotherapy on a regular schedule