1. The nurse is planning care for several children who were admitted during the shift.

shift. Daily weights should be the

plan of care for the child who is receiving:
a. Total parenteral nutrition(TPN)
b. Supplement oxygen
c. Intravenous anti-ineffective
d. Chest physiotherapy

• Answer : A

2. The nurse is caring for a 4-year-old patient with a diagnosis of cystic fibrosis and pneumonia. The child is feeling
better on the 3rd day of the hospitalization and “wants to play.” What would be the best choice of entertainment?
a. Blowing bubbles
b. Looking at picture books
c. Watching videos
d. Riding in a wagon

• Answer : A

3. 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?
a. Restrict sodium and fluid intake
b. Give antidiarrheal medications
c. Discourage coughing after postural drainage
d. Administer pancreatic enzymes with each meal

• Answer: D

4. A nurse is caring for a child with a diagnosis of cystic fibrosis and pneumonia. The plan of care includes nebulizer
treatment and chest physiotherapy. The nurse should perform chest physiotherapy:
a. Continuously during the nebulizer treatment
b. Prior to the nebulizer treatment
c. After the nebulizer treatment
d. Intermittently during the nebulizer treatment

• Answer: C

5. While caring for a patient with an ileostomy, the nurse would expect the ostomy to be located In Which
Quadrant of the abdomen?
a. Right lower
b. Left lower
c. Left upper
d. Right upper

• Answer : A

6. A patient has been assessed and found to have severe dysphagia and will need long-term nutritional support,
which one of the following types of feeding would MOST likely to be beneficial for this patient?
a. Gastrostomy

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b. Patenteral
c. Nasogastric
d. Nasoduodenal

• Answer : C

7. A nurse is caring for a patient receiving total parenteral nutrition (TPN). The patient reports the sudden onset of
feeling short of breath and anxious. The nurse hears crackles in bilateral lower
lobes of the lungs and the patient’s O2 saturation is 90%on room air. The nurse must IMMEDIATELY:
a. Turn off the TPN
b. Notify the physician
c. Asses the patient’s capillary blood glucose level
d. Attempt to suction the patient’s airway

• Answer : A

8. A nurse has just started total parenteral nutrition (TPN) as prescribed for a patient with severe dysphagia low
prealbumin levels. In one to two hours, the nurse should anticipate assessing the patient’s:
a. Blood glucose level
b. Weight
c. Liver
d. Spo 2

• Answer : D

9. 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?
a. Continue the care plan for 1more month
b. Refer the patient to psychiatric services
c. Collaborate with the patient and spouse to revise the care plan
d. Revise the care plan based on the spouse’s input

• Answer : C

10. A home care patient with chronic obstructive pulmonary disease (COPD) reports an upset stomach. The patient
is taking theophylline(Theo-Dur) and triamcinolone acetonide (Azmacort) The nurse should instruct the patient to take:
a. Theo-dur an empty stomach
b. Theo-dur and Azmacort at the same time
c. Theo-dur and azmacort12 hours apart
d. Theo-dur milk or crackers

• Answer : B

11. When giving post-operative discharge instructs a patient who had abdominal surgery, all of the following
regarding wound healing are true EXCEPT:
a. Bathing to soak abdomen is preferred
b. Avoid tight belts and cloths with seams that may rub the wound

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c. Pain medication may affect ability to drive.
d. Irregular bowel habits can be expected

• Answer: A

12. 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:
a. Wound may feel tightly or itchy as healing occurs
b. Scabs promote infection of the new skin underneath them
c. Numbness or a slight pulling sensation is normal
d. Wound should not have any drainage

• Answer : C

13. A 12-year-old child who has been diagnosed with insulin dependent mellitus (IDDM) since age3.Comes to the
clinic for a routine visit. The patient has begun to self-manage care with parental supervision. The patient injects 28 units
of NPH insulin every morning and 8units at bedtime. The patient checks blood sugar 4 times every day. The patient’s
weight is stable and diet is unchanged. However, the patient reports several hypoglycemic reactions every week. The
nurse knows the MOST likely cause is that:
a. The patient is not eating the adequate number of calories reported
b. The dosages of insulin may need to be decreased as the patient continues to grow
c. There may be changes in exercise or stress levels or the beginning of a growth Spurt
d. The patient may not be competent in techniques of drawing up and injecting insulin

• Answer : C

14. A nurse visits a patient at home who does not understand how to take a newly prescribed medication. The
prescription reads: 5 ml PO TID p.c. meals. The nurse explains to the patient that the correct way to take the medication
is:
a. 1 teaspoon by mouth, 3times a day, before meals
b. 1 teaspoon by mouth, 3times a day, after meals
c. 1 tablespoon by mouth, 3times a day, before meals
d. 1 tablespoon by mouth, 3times a day, after meals

• Answer : B

15. 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:
a. Having minimal fine crackles in the base of the lungs
b. Using the incentive spirometry every 4 hours
c. Expectorating minimal amount of secretions
d. Performing Coughing Exercises every hour while awake

• Answer : D

16. While caring for a child with aventriculoperitoneal shunt revision, the nurse find the patient lying with the head
and feet flexed back. The nurse should call for help and prepare for a(n):
a. Spinal tap
b. Shunt culture

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c. Electrocardiogram
d. Ventricular tap

• Answer : D

17. During surgery requiring general anesthesia, the patient heart’s stops and a carotid pulse is not palpated. How
many compressions per minute should be administered?
a. 50
b. 60
c. 80
d. 100

• Answer :D

18. When teaching a community class on cerebrovascular accidents (stroke), which of the following should
participants of the class know at the completion of the class?
a. Muscle and ligament damage is not reversible
b. Expressive aphasia is resolved by voice rest
c. There is a risk for mood disorders such as depression
d. Liquids should be consumed at the same times as solids food

• Answer : D

19. A community health care nurse visits a patient who had cerebrovascular accident. The patient is at risk for
deficient volume due to voluntary reduction intake fluid intake to avoid the use of the bathroom. The nurse educates
the patient on the importance of drinking fluids and maintaining hydration. Which of the following indicates the efficacy
of the nursing intervention?
a. Amber color urine
b. Respiration of 35
c. Tachycardia
d. Moist mucous membrane

• Answer : A

20. A home health nurse is visiting a patient following a cerebrovascular 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 the following would be the nurse’s MOST likely intervention?
a. Assess for changes in cognitive abilities
b. Complete a depression index
c. Strengthen family coping methods
d. Screen for pain

• Answer : B

21. A home health nurse is visiting a patient who recently suffered a Cerebrovascular accident (CVA). The nurse
would MOST likely implement which of the following interventions to prevent muscle and ligament deformities?
a. Daily moist heat and isometric exercises
b. Daily balance training and routine medications for pain
c. Instruct patient to use non-affected side to perform activities of daily living

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d. Daily range of motion exercises.

• Answer : C

22. A nurse is assigned to do a home visit for an 81-year-old patient. The patient lives 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:
a. How to select a nursing home for the patient
b. Performing passive range of motion exercises
c. The importance of avoiding viscous drinks
d. Forming a local chapter of a care giver support group

• Answer : D

23. A home care nurse makes a follow-up visit to a patient who recently suffered a cerebrovascular accident. The
patient is mobile and able to perform activities of daily living. However, the patient has not sleeping and has lost weight
due to lack of appetite. The
patient also feels overwhelmed with sadness. Which of the following is the most appropriate
evaluation?
a. Patient’s progress is as expected and no further intervention is necessary
b. Patient needs referral to a nutritionist
c. Patient needs intervention for depression
d. Patient needs sleeping medication

• Answer : C

24. A patient admitted with a cerebrovascular accident (CVA), is unable to chew or swallowed. The patient is a risk
for aspiration. The nurse would anticipate receiving which of the following orders for this patient?
a. Give no food by mouth and start intravenous hydration
b. Start a pureed diet with thickened liquids
c. Refer the patient to a psychiatrist for depression related to the CVA
d. Refer the patient to physical therapy for muscle strengthening

• Answer : A

25. While the nurse is administering a large volume enema, the patient complains of cramping. The nurse should:
a. Increase the flow rate
b. Lower the fluid container
c. Elevate the head of the bed
d. Gently massage the abdomen

• Answer : B

26. A home health nurse has entered a home to complete an admission assessment on a patient who has a
methicillin-resistant Staphylococcus aureus (MRSA) urinary tract infection. The patient will receive intravenous anti-
infective via a peripherally inserted central catheter (PICC) for 3 weeks. Which of the following actions should the nurse
take FIRST?
a. Shake the patient’s hand
b. Place the nursing supply bagon a clean, dry surface

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c. Obtain the patient’s written consent for home health care
d. Perform hand hygiene per the agency protocol

• Answer : D

27. A home health nurse is teaching a family member about the care of patient’s peripherally inserted central
catheter (PICC). Which of the following statements would be appropriate for the nurse to make?
a. Place the used intravenous tubing in a leak proof container and then place this sealed container inside a second
leak proof container.”
b. “You will need to put on a disposable face mask before you connect the intravenous tubing to the port of
thePICC. The port of the PIC catheter will need to be cleansed with povidone-iodine (BETADINE) after the infusion is
completed.”
c. “The empty medication container can be placed in the same container as your Household refuses.”

• Answer : A

28. 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 per orbital
edema. Which of the following actions would be appropriate for the nurse to take?
a. Apply cold compresses to the patient’s eyes
b. Apply warm compresses to the patient’s eyes
c. Elevate the head of the patient’s bed to 60 degrees
d. Elevate the head of the patient’s bed to 45 degrees

• Answer :D

29. To decrease the incidence of aspiration of gastric contents in a child hospitalization with severe burns, the nurse
should position the head:
a. Flat except during meals
b. Elevates 30-45 degrees during meals
c. Elevated 15-30 degrees for12-hours after meals
d. Elevated 45 degrees at all times

• Answer : B

30. 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 the following evaluations indicates that the patient is noncompliant with glaucoma management?
a. Patient has not been taking Glucophage
b. Patient has tearing of the eye
c. Patient has not refilled prescription for timolol in 3 months
d. Patient has yellow discharge from the eyes

• Answer : C

31. A patient is having difficulty with cognitive abilities after a stroke. What part of the brain was MOST likely
affected?
a. Midbrain
b. Cerebrum

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c. Medulla oblongata
d. Cerebellum

• Answer : B

32. 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:
a. Verbalizing understanding of safe sex practices and following safe sexual practices in all
encounters
b. Not engaging in sexual encounters until she is over18 years old and maintaining a healthy life style
c. Recognizing the sign of pregnancy and the symptoms of sexually transmitted diseases
d. Understanding safe sexual practices and use a condom to prevent pregnancy and sexually transmitted diseases

• Answer : D

33. A nurse plans to teach a group of 20to25-year-old women about oral contraceptives. The nurse should instruct
that oral contraceptives may:
a. Increase the risk of pelvic inflammatory disease
b. Cause acne to worsen
c. Decrease the risk of breast and cervical cancer
d. Decrease the risk of endometriosis

• Answer : A

34. 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?
a. Primary intention
b. Secondary intention
c. Tertiary intention
d. Superficial epidermal

• Answer : A

35. 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?
a. Cone
b. Oval
c. Mushroom
d. Cylinder with blunt end

• Answer : D

36. A surgeon instructs a nurse to serve as a witness to an elderly patient’s informed consent for surgery. During the
explanations to the patient, it becomes clear that the patient is confused and does not understand the procedure, but
reluctantly sign the consent form. The nurse should:
a. Sign the form as a witness, making a nation that the patient did not appear to understand
b. Not sign the form as a witness and notify the nurse supervisor
c. Not sign the form and answer the patient’s questions after the surgeon leaves he room
d. Sign the form and tell surgeon that the patient doesn’t understand the procedure.

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• Answer : B

37. 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:
a. Flumazenil (Romazicon)
b. Medazolum (versed)
c. Naloxone (Narcan)
d. Ondansetron (Zofran)

• Answer : C

38. 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 to relax this patient?
a. Meperidine Hydrochloride(Demerol)
b. Scopolamine (Transderm-Scop)
c. Pentobarbital sodium(Nembutal sodium)
d. Trazodone hydrochloride(Trazadone)

• Answer : A

39. A patient with poor wound healing and poor appetite has an order to begin total parental nutrition (TPN).
Waiting for the TPN solution to arrive from the pharmacy, the nurse should obtain:
a. A pair of sterile gloves
b. An infusion pump
c. IV tubing with a micro-drip chamber
d. Povidine-iodine (Beta dine)swabs

• Answer : B

40. When conducting discharge teaching for the parent of a child newly diagnosed with cystic fibrosis. Which of the
following statement by the parent indicates the need for further teaching?
a. Weekly weights help evaluate effectiveness of nutritional interventions
b. Weekly weights help the doctor know if may child is absorbing nutrients
c. Weekly weights reassure my child that recovery is progressing
d. Weekly weights help the doctor know if my child needs additional enzymes

• Answer : D

41. 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:
a. Perform an Allens test
b. Explain the procedure
c. Gather the equipment
d. Document the procedure

• Answer : A

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42. A patient is diagnosed with pulmonary hypertension. Which of the following nursing diagnoses should be the
PRIORITY?
a. Impaired gas exchanged related to altered blood flow secondary to pulmonary capillary
constriction
b. Fatigue related to hypoxia
c. Anxiety related to illness and loss of control
d. Activity intolerance related to imbalance between oxygen supply and demand due to right and left ventricular
failure

• Answer : D

43. A patient who had abdominal surgery is in the post anesthesia care unit (PACU).Which of the following nursing
diagnosis takes PRIORITY?
a. Disturbed sleep pattern
b. Acute pain
c. Risk for infection
d. Ineffective airway clearance

• Answer : D

44. 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:
a. Administer bolus glucose
b. Suction the airway
c. Turn the patient to the right side
d. Administer intra venous fluids

• Answer : B

45. While caring for a patient in the post-anesthesia care unit (PACU) Who has developed Hypovolemic shock, a
nurse should position the patient:
a. Flat with legs elevated
b. In Trendelenburg position
c. With the head of the bed elevated 45 degrees
d. Completely flat

• Answer : B

46. 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?
a. Semi-fowler’s
b. Prone
c. Dorsal recumbent
d. Sim’s

• Answer : B

47. While caring for a patient in the post-anesthesia care unit (PACU), a nurse plans to Keep the patient warm. What
is the MUST important reason for this action?

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a. To preserve nutritional stores
b. To prevent cutaneous vessel dilation
c. To decrease patient anxiety
d. To lower risk of infection resulting from chill

• Answer : C

48. 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?
a. Gently massage the patient’s leg
b. Assess the patient’s pain level
c. Assess the patient for Homan’s sign
d. Instruct the patient to reflex the left knee and hip

• Answer : C

49. The nurse is teaching the mother of a 3-months-old infant about bottle feeding. Which statement indicates the
mother understands of appropriate procedure?
a. “I should hold my baby in as lightly reclined position, close to my body”
b. “It is OK to prop the bottle on a pillow”.
c. “It can feed my baby whole milk”
d. “I should warm the bottles in the microwave if they come out of the Refrigerator”.

• Answer : A

50. 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?
a. I should never put my baby to bed with bottle
b. My child should not use a pacifier after age 6 months
c. My child should drink his bottle while lying flat in my lap
d. My child should not be around people who smoke

• Answer : B

51. 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?
a. Acetaminophen (Tylenol)
b. Strict bed rest
c. Heating pad to the back of neck
d. Ibuprofen (Motrin)

• Answer : D

52. During Pre-operative preparation of a patient for amputation of the left leg. The nurse has primary responsibility
for:
a. Witnessing the patient signature on the consent form
b. Explaining the procedure to the patient

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c. Explaining the risks of the surgery to the patient
d. Making appropriate incision lines on the leg.

• Answer : A

53. 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?
a. Remove any high-foods from the patient’s room
b. Notify the dietitian of the diet order
c. Obtain venous access and start Ringer’s lactate infusion
d. Obtain an emesis basin and clean linens for the be side

• Answer : C

54. 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?
a. Perform the Heimlich maneuver
b. Initiate cardio pulmonary resuscitation (CPR)
c. Administer 4 back blows
d. Administer 4 thrusts midline on the patient back

• Answer : D

55. An infant arrives in the emergency department not breathing and does have a pulse. When starting cardio
pulmonary resuscitation
(CPR), where is the correct place to assess for a pulse in this patient?
a. Carotid
b. Radial
c. Brachial
d. Temporal

• Answer : C

56. A 5 years old patient who underwent 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 the
treatment is effective?
a. Urinary output of 15ml/hr.
b. Respiration rate, 35
c. Heart rate 100
d. Good skin turgor

• Answer : D

57. 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:

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a. Fifth disease
b. Rotavirus
c. Roseolainfantum

• Answer : A

58. 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?
a. At menopause
b. At 65-years-old
c. At the cessation of breastfeeding
d. At 40-years-old

• Answer : A

59. A patient is taught how to perform a breast self-exam by a nurse. Which statement is BEST described as
understanding of the proper procedure for doing a breast self-exam?
a. Use of the palm of the hand to feel for lumps
b. Apply three different levels of pressure to feel breast tissue
c. Stand when performing breast self-exam
d. Perform self-exam annually

• Answer : A

60. While caring for a child with in effective airway clearance related to increased mucus production, the nurse
should encourage fluids to:
a. Maintain nutrition
b. Prevent boredom
c. Stimulate coughing
d. Thin secretions

• Answer : D

61. 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:
a. Show no objective signs of pain
b. Not complain of pain
c. State pain is at a tolerable level
d. State that all pain is relieved

• Answer : D

62. 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?
a. Place in Trendelenburg position
b. Position on the right side
c. Elevate the head of the bed
d. Elevate extremities

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• Answer : C

63. If a patient develops a complication during a blood transfusion, the nurse first should be to:
a. Stop the transfusion
b. Notify the practitioner
c. Administer an antihistamine
d. Administer an anti- inflammatory medication

• Answer : A

64. Which of the following types of health care services is an example of the primary level of care?
a. Diagnosis
b. Acute care
c. Restoration
d. Immunization

• Answer : D

65. 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?
a. Surgery
b. Medications
c. High-residue diet
d. Blood replacement

• Answer : B

66. A patient with acute crohn’s disease has been prescribed an elemental diet. The MOST likely rationale for this is
to:
a. Reset the bowel
b. Improve nutrition
c. Improve medication absorption
d. Prepare for surgery

• Answer : C

67. 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
a. Consuming only elemental foods
b. Stopping smoking
c. Using effective birth control
d. Avoiding over heating

• Answer : A

68. A home health nurse is setting up a medication administration schedule for an elderly patient. The patient is
talking Oscal (calcium corbonate), Feosol (ferrous sulfate), and Orazinc (Zinc sulfate). The patient eats meals at 8:00 AM,

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12 noon, and6:00 PM. Which of the following medication administration times would the nurse MOST likely implement
for this patient?
a. Oscal, Orazinc, and foesal at 8:00AM
b. Oscal at 6:00AM, Orzinc at 12:00 noon, Foesal At 4:00PM
c. Oscal and Foesal at 12:00 noon and Orazinc at 6:00PM
d. Orazinc at 6:00 AM, Oscal at 12:00 noon, and Foesal at 6:00PM

• Answer : C

69. 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?
a. In 12-24 hours
b. In 24-36 hours
c. In 36-48 hours
d. In 48-72 hours

• Answer : D

70. 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:
a. Immediately upon being notified to prepare the patient for transport
b. When the operation room staff arrive to transport the patient
c. Only if clearly needed after assessment
Upon the patient’s arrival in the operation room

• Answer : A

71. A patient recently underwent 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
a. Gets 4 hours of uninterrupted sleep during the right
b. Takes naps during the day
c. Is free of pain in the first hour post-surgery
d. Ambulates 3 hours post-surgery

• Answer : B

72. 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:
a. Determine how long it has since the patient’s last dose of aspirin
b. Obtain a chair for the patient so sit down
c. Assess the patient’s radial pulse
d. Ask the patient to take several slow, deep breaths

• Answer : A

73. A 35-years-old female has an inherited gene mutation for achondroplasia, an autosomal dominate genetic
disorder. Her husband does not have genemutation. In planning genetic counseling for this patient, the nurse would be

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MOST correct in including which of the following statements regarding the risk of their children inherited the genetic
mutation?
a. Each child has a 50% chance of inheriting the gene mutation
b. Female children have 50% chance of inheriting the gene mutation
c. Male children will not inherited the gene mutation
d. All female children will inherit the gene mutation.

• Answer : A

74. 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:
a. Medicate the patient for pain
b. Instruct the patient to cough hard
c. Have the patient perform the valsalvas maneuver
d. Cover the abdomen with a sterile soaked dressing

• Answer : D

75. 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?
a. 37.20 C (99.00 F)
b. Heart rate 145
c. Respiration rate 25
d. Blood pressure level 95/55

• Answer : B

76. 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?
a. “Place the used intravenous tubing in a leak proof container and then this in sealed container inside a second
leak proof container”.
b. “You will need to put on a disposable face mask before you connect the port of the PICC.”
c. “The port of the PICC catheter will need to be cleansed with providence-iodine Betadine) after the insulin is
completed.”
d. “The empty medication container can be placed in the same container as your house hold refuses.”

• Answer : A

77. While Obtaining the pre-operative history of a patient schedules for cosmetic surgery, the most valuable skill at
the nurse disposal is:
a. knowledge of the procedure
b. Time management skills
c. Listening skills
d. Empathy

• Answer : D

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78. 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 the ventral surface of the forearm?
a. 16 gauge needle
b. 20 gauge needle
c. 22 gauge needle
d. 26 gauge needle

• Answer : D

79. 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?
a. Reverse isolation
b. Standard isolation
c. Positive-pressure
d. Negative-pressure

• Answer : D

80. 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?
a. Ethambutol(Myambuton),
b. Acetaminophen,
c. Izoniazid (Izoniazid),
d. Pyrazinamide (Rifamate).

• Answer : C

81. A Patient with tuberculosis can transmit the disease to another individual Through:
a. Air droplets
b. Physical contact
c. Hand to mouth exchange
d. Blood and body fluids

• Answer : A

82. A patient recently underwent joint replacement surgery, which of the following nursing diagnosis takes
PRIORITY?
a. Risk for peripheral neurovascular dysfunction
b. Deficient knowledge on appropriate activity precaution
c. Impaired physical mobility
d. Sexual dysfunction related to pain

• Answer : C

83. 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
a. “Did you know that feeling anxious about your child’s surgery is normal?”
b. “Can you wait until after surgery to begin to cope with being anxious?”

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c. “How do you think feeling of anxiety will affect your child?”
d. “What has helped you when you felt anxious in the past?”

• Answer : A

84. A 4-year-old child brought to the community health clinic for scheduled immunizations. The child should receive:
a. Varicella, rotavirus, pneumococcal and hepatitis B
b. Measles, mumps, rubella and varicella
c. Rotavirus and inactivated polio virus
d. Varicella andhaemophilus influenza

• Answer : B

85. 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?
a. Lantus insulin can be mixed with other insulin
b. It is necessary to wipe off the top the insulin vial with alcohol to prevent infection
c. Insulin will changed color after opening
d. Needles can be placed in a hard plastic container with a tightly secure lid

• Answer : B

86. 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?
a. Altered nutrition
b. Impaired skin integrity
c. Risk for infection
d. Acute pain

• Answer : D

87. 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 a terminal illness. Which of the following types of care would the team MOST likely is
providing?
a. Palliative
b. Curative
c. Respite
d. Preventive

• Answer : A

88. 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?
a. Recognizing signs of impending respiratory infection
b. Limiting fluids intake minimize bronchial secretions
c. Correct technique to auscultate the lung fields
d. Importance of starting antibiotic therapy

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• Answer : A

89. A patient with chronic obstructive pulmonary disease (COPD) experiencing frequent dyspnea which of the
following exercise would teach the patient how to BETTER control breathing?
a. Lower side rib
b. Segmental
c. Pursed-lip
d. Diaphragmatic

• Answer : C

90. In evaluating the appropriateness of various exercises enjoyed by a patient with osteoporosis, the nurse would
recommend:
a. Walking
b. Bowling
c. GolfS
d. it-ups

• Answer : A

91. A patient presents to the clinic with “pins and needles” sensations of the left foot and complains that objects
appear “Shimmering”. The patient is diagnosed with optic neuritis and referred for further testing. The patient is MOST
likely to be tested for:
a. Glaucoma
b. Multiple sclerosis
c. Lesion of brain stem
d. Psychosis

• Answer : B

92. 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:
a. Grasping the skin over the abdomen with two fingers raising the skin with two fingers
b. Grasping the skin over the forehead with two fingers and raising the skin with two fingers
c. Holding the patient’s mouth open and assessing the tongue for deep creases or Furrows
d. Drawing two tubes of blood and running blood urea nitrogen (BUN) and creatinine (Cr).

• Answer : A

93. When administering albuterol to a child with asthma, the nurse should observe for sign of what major side
effect to this medication?
a. Tachycardia
b. Renal failure
c. Apnea Blurred vision

• Answer : A

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94. A child with asthma is experiencing thick respiratory secretions resulting in increased work of breathing. The
best nursing intervention is to:
a. Encourage fluids
b. Eliminate dairy products
c. Decrease relative humidity of the room
d. Have the child lay on the left side.

• Answer : C

95. What would be the long-term goal for a child with asthma?
a. Quickly reverse airflow obstruction
b. Correct hypoxemia
c. Deliver humidified oxygen via nasal cannula
d. Develop a home and school management plan

• Answer : D

96. A nurse administers an albuterol nebulizer on a child with asthma exacerbation. Which of following indicates
effectiveness of the treatment?
a. Adventitious breath sound with cough
b. O2 saturation 94%
c. Nasal flaring
d. Respiration rate 28

• Answer : B

97. A Child is diagnosed with asthma exacerbation. Which of the following nursing diagnoses should be the FIRST
priority?
a. In effective airway clearance related to broncho spasm and mucosal edema
b. Fatigue related to hypoxia
c. Anxiety related to illness and loss of control
d. Deficient knowledge related to potential side effect of the medication

• Answer : A

98. An asthmatic patient presents with wheezing and coughing. Oxygen saturation is 88% on room air. Which of the
following nursing diagnosis would take priority?
a. Imbalanced nutrition related to decreased food intake
b. Activity intolerance related to inefficient breathing
c. Anxiety-related dyspnea and concern of illness
d. Ineffective gas exchange related to broncho spasm

• Answer : D

99. 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:
a. Supervision and coordination
b. Discharge planning
c. Monitoring and surveillance Ans c

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100. 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:
a. Sudden infant death syndrome
b. Apparent life-threatening event
c. Apnea of infancy
d. Apnea of unknown origin

• Answer : A

101. 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. A healthy newborn
b. The need for supplement oxygen
c. A genetic defect
d. The infant is becoming stable

• Answer : A

102. 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?
a. Maintaining the infant in the supine position
b. Assessing the infant’s red reflex
c. Preventing heat loss from the infant
d. Administering humidified oxygen to the infant

• Answer : A

103. Which of the following can be used to determine if a prescribed pain management therapy is effective for a non-
verbal patient?
a. Papanicolaoutest
b. Faces rating scale
c. Braden’s scale
d. Apgar assessment tool

• Answer : B

104. While caring for a neonate with a meningocele, the nurse should AVOID positioning the child on the:
a. Abdomen
b. Left side
c. Right side
d. Back

• Answer : D

105. 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?

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a. The patient has pitting edema
b. The patient has shortness of breath
c. The patient has a decrease in weight
d. The patient has jugular vein distention

• Answer : C

106. A 62-year-old patient has been treated for congestive heart failure and a Nursing diagnosis of fluid volume
excess. After diuretic therapy and dietary Interventions, the patient has met all short-term goals. The nurse should:
a. Revise the care plan with a diagnosis of risk for alteration in fluid balance
b. Add a new diagnosed of risk of fluid volume deficit
c. Discontinue the care plan as the diagnosis is resolved
d. Continue the care plan as written

• Answer : D

107. 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?
a. Diuretic therapy and intake and output
b. Nutritional education and low-sodium diet
c. Daily weights and intake output
d. Low-sodium diet and elevate legs when in bed

• Answer : A

108. 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 furosemide (Lasix). Which of the following
indicates the efficacy of the nursing intervention?
a. The patient has leg edema
b. The patient has shortness of breath
c. The patient has decreased in weight
d. The patient has jugular vein distention

• Answer : C

109. 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):
a. Ileostomy
b. Ascending colostomy
c. Transverse colostomy
d. Sigmoid colostomy

• Answer : B

110. While evaluating the nutritional intake of a bedridden patient with multiple pressure sores, the nurse should
make sure the patient INCREASES the intake of:
a. Protein-rich foods
b. Water Foods
c. Rich in vitamin

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d. A Fiber rich foods

• Answer : A

111. In what position should a dyspnea patient be placed?

a. Prone
b. Recumbent
c. Semi-fowler’s
d. Trendelenburg

• Answer : C

112. A patient presents to the clinic for a routine visit and has the following vital signs: temperature 37.00C (98.60F),
heart rate 82,
respiration rate 18 and blood pressure level of 130/94 mmHg. Which vital sign is abnormal?
a. Temperature
b. Pulse
c. Respiration
d. Blood pressure

• Answer : D

113. 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:
a. Intestinal obstruction
b. Influenza
c. Appendicitis
d. Pyloric Stenosis

• Answer : C

114. 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?
a. Tetanus-diphtheria toxoid every 20 years
b. Pneumococcal vaccination every 2 years
c. Influenza vaccination every year
d. One time typhoid vaccine followed by boosters every5 years

• Answer : C

115. A 6-year-old patient has been diagnosed with acute rheumatic fever. Then nurse knows that the antibiotic of
choice for this illness is:
a. Bezathgine penicillin(Megacillin)
b. Amoxicillin (Amoxil)
c. Erythromycin (Eryhrocin)
d. Vancomycin (Vancocin)

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• Answer : A

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

• Answer : A

117. Prior to initiating therapy with unfractionated heparin for a patient hospitalized with a deep vein thrombosis,
the nurse should plan to:
a. Weigh the patient
b. Administer aspirin
c. Limit fluid intake
d. Undress the patient

• Answer : B

118. Prior to initiating therapy with unfractionated heparin for a patient hospitalized with a deep vein thrombosis,
this treatment requires:
a. Bed rest
b. Aspirin therapy
c. Fluid restrictions
d. A high protein diet

• Answer : B

119. 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:
a. Gain at least 10% of bodyweight
b. Attain and maintain ideal weight
c. Verbalize understanding nutritional needs
d. Include high quality protein in diet

Answer: B

120. 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?
a. Prone
b. Supine
c. Semi-fowler’s
d. Lateral

• Answer : D

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121. 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?
a. Absence (petit mal)
b. Generalized (tonic-clonic)
c. Partial Psychomotor(temporal lobe)
d. Status epilepticus

• Answer : B

122. A patient is scheduled for an abdominal aneurysm repair. This is what type of surgical intervention?
a. Diagnostic
b. Transplant
c. Curative
d. Palliative

• Answer : C

123. 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?
a. Viral
b. Protozoan
c. Fungal
d. Bacterial

• Answer : A,

124. 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?
a. Rain forced relaxation techniques
b. Continue chemotherapy without change
c. Continue with radiation therapy only
d. Pre-medicate the patient with an antihistamine

• Answer : D

125. 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?
a. Electrocardiogram
b. Jones test
c. Spinal tap
d. Heart biopsy

• Answer : B

126. A community is experiencing an outbreak of staphylococcal infections. The nurse instructs residents that the
MOST common mode of transmission is by:

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a. Respiratory droplets
b. Contaminated foods
c. Hands
d. Soil

• Answer :D

127. 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?
a. Call for help
b. Immobilize the left leg
c. Obtain blood pressure
d. Evaluate lung sounds

• Answer : B

128. 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?
a. Speech therapist
b. Dietician
c. Physician therapist
d. Neurologist

• Answer : A

129. 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
a. Balanced between oxygen supply and demand
b. Increase in blood flow to the heart
c. Reduction in oxygen demand and consumption
d. Vessel relaxation

• Answer : B

130. 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?
a. Perform all activities of daily living without complaints of chest pain or shortness of breath
b. Verbalize and employ strategies to decrease pain and increase coronary blood
flow
c. Take pain medications around the check and use supplement oxygen at all times
d. Understand the disease process and accept the limitation that it places on his lifestyle

• Answer : A

131. A patient has an order for a pneumatic compression device. Which of the following is an appropriate goal?

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a. Reduce the risk deep vein thrombosis
b. Reduce lower extremity edema
c. Reduce lower extremity pain
d. Reduce the risk of phlebitis

• Answer : A

132. 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?
a. Knowledge deficit, colostomy care
b. Distorted body image
c. Self-care deficit, toileting
d. Alteration in comfort

• Answer : B

133. A patient presents to the emergency department with complaints of head ache, dizziness and confusion. Clinical
symptoms include tachypnea 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?
a. Oxygen therapy
b. Chest physical therapy
c. Bronchodilators
d. Hydration fluids

• Answer : A

134. 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?
a. 25th
b. 5th
c. 10th
d. Below the 5th

• Answer : B

135. 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?
a. Put the patient in a private room
b. Wear gloves during the dressing change
c. Wear gloves gown, and mask during dressing change
d. Put the patient in reverse isolation

• Answer : C

136. When administering an enema to adult patient, how far should the nurse insert the tubing into the rectum?
a. 2.2 to 4.4cm (1 to 2 inches)
b. 4.4 to 6.6cm (1 to 3 inches)
c. 6.6 to 8.8cm (3 to 4 inches)

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d. 8.8 to 11cm (4 to 5 inches)

• Answer : C

137. 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?
a. Deep vein thrombosis
b. Hemorrhage
c. Nausea
d. Hemiparesis

• Answer : B

138. As per of a neurological assessment, which of the following is associated with the higher score on the Glasgow
coma scale?
a. Eye opening to pain, no verbalization
b. Confused, obey commands
c. Localized pain, abnormal extension
d. Eye opening to speech confused

• Answer : B

139. 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?
a. Control pain prior to the surgery
b. Make sure the patient understands the procedure
c. Elevate the limb on two pillows
d. Help the patient grieve for the limb

• Answer : D

140. If a patient develops a complication during a blood transfusion, the nurse’s first action should do to:
a. Stop the transfusion
b. Notify the practitioner
c. Administer an antihistamine
d. 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?
e. Rifampin
f. Vitamin K
g. Birth control pills
h. Phenytoin (Dilantin)

• Answer : C

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141. 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?
a. Take oxycodone as soon as possible
b. Take cephalexin as soon as possible
c. Wash the incision site and apply bacitracin cream
d. Wash the incision site and apply hydrocortisone

• Answer : C

142. 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:
a. 5ml
b. 10 ml
c. 15 ml
d. 20 ml

• Answer : B

143. 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?
a. Bursitis
b. Tendonitis
c. Plantar fasciitis
d. Joint dislocation

• Answer : C

144. A mastectomy patient has developed lymphedema of the left arm. The nurse should teach the patient that the
BEST position for the arm is:
a. Immobilized across the chest
b. Dependent
c. Elevated
d. In traction

• Answer : C

145. 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?
a. Intravenous
b. Regional
c. General
d. Local

• Answer : B

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146. 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:
a. At the age they are scheduled to be administered
b. One month prior to recommended immunization schedule
c. At every clinic visit
d. At monthly intervals

• Answer : C

147. 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?
a. Lethargic
b. Obtunded
c. Semi-comatose
d. Comatose

• Answer :B

148. 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?
a. Prostate specific antigen(PSA)
b. Blood glucose
c. Creatine phosphokinaseisoenzymes (CPK enzymes)
d. Prothrombin time

Answer: D

149. 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?
a. Palliative
b. Curative
c. Reconstructive
d. Diagnostic

• Answer : A

150. 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:
a. Be free of pain with in 4hours
b. Report decreased pain
c. Rest quietly
d. Sleep with few movements

• Answer : C

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151. 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?
a. Administer the next dose of LMWH before the scheduled time.
b. Apply dry heal to the site
c. Elevate the extremity
d. Reinforce the importance of ankle circling exercises

• Answer : C,

152. A physician orders Lactated Ringer Solution to infuse at 125 cc/hour. This is an example of which type of
solution?
a. Hypotonic
b. Isotonic
c. Hypertonic
d. Hyper alimentation

• Answer : B

153. A physician orders an intravenous fluid of D5NS at 100cc/hr. This is an example of which of the solution?
a. Hypotonic
b. Isotonic
c. Hypertonic
d. Hyper alimentation

• Answer : C

154. 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
a. Anesthesia provider
b. Surgeon
c. Scrub nurse
d. Charge nurse

155. The nurse is caring for a patient diagnosed with human immune deficiency virus. Which of the following nursing
diagnoses takes priority?
a. Diarrhea related to medication side effects
b. Risk for infection related to inadequate immune system
c. Imbalanced nutrition relate to decreased appetite
d. Impaired tissue integrity related to cachexia and malnourishment

• Answer : B

156. 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?
a. Intervention
b. Primary
c. Secondary
d. Tertiary

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157. The nurse is caring for a patient with a coronary thrombosis who is receiving prescribed streptokinase
(striptease). 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. A medication side effect
b. An allergic embolus
c. A Pulmonary embolus
d. Peripheral artery occlusion

• Answer : B

158. 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?
a. Taking brief naps
b. Participating in an exercise program
c. Eating large meals
d. Working in a cool environment

159. 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?
a. 2.5
b. 2
c. 1.5
d. 1

• Answer : C

160. The nurse is teaching the parent of a child with celiac disease.Which of following diets should be reviewed with
the parent?
a. Gluten-free
b. Dairy free
c. Vegetarian
d. Sodium-restricted

• Answer : A

161. A patient has peripheral vascular disease. The nursing diagnosis is ineffective tissue perfusion: peripheral.Which
of the following is an appropriate goal?
a. The patient will identify three factors to improve peripheral circulation
b. The patient will have palpable peripheral pulses in1week
c. The patient’s feet will be warm to touch
d. The patient will ambulate the length of the hall way

• Answer : B

162. 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:

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a. Peanuts
b. Strawberries
c. Eggs
d. Latex

• Answer : D

163. A patient with malignant cancer has decided to stop chemotherapy and receive hospice care. What is the
PRIORITY nursing diagnosis?

a. Alteration in comfort
b. Hopelessness
c. Powerlessness
d. Non-compliance

• Answer : B

164. 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:

a. Ensure the physical and emotional safety of the child

b. Remove the child from the parents
c. Admonish the parents of the child
d. Ensure that the child stays with the biological parents

• Answer : A

165. 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?
a. Reassure the patient that this normal after surgery
b. Refer the patient to the surgeon immediately
c. Encourage the patient to decrease activities involving the left hip and extremities
d. Refer the patient to a physical therapist immediately

• Answer : C

166. A nurse is evaluating a patient 5 days after a right total hip replacement. Which of the following goals is
appropriate for the patient?
a. Maintain hip abduction without dislocation
b. Rest with legs elevate while sitting
c. Tie shoes and put on undergarments without assistive devices
d. Perform scissors-like leg exercise daily

• Answer : A

167. Prior to providing care for a hospitalized infant, the nurse MUST:

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a. Introduce self to parent
b. Perform hand hygiene
c. Have a witness present
d. Assess the child’s developmental level

• Answer : B

168. 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:
a. One months
b. Two months
c. Six months
d. One year

• Answer : A

169. 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?
a. Hepato-spleenomegaly
b. A palpable pyloric mass
c. Lymphadenopathy
d. Bulging fontanelles

• Answer : B

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

• Answer : B

171. 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:
a. Left-sided heart failure
b. Pressure sores of the coccyx
c. Constipation and ileus
d. Wound dehiscence

• Answer : D

172. Which of the following takes place during the implementation phase of the nursing process?
a. Development of a goals and a nursing care plan
b. Identification of actual or potential health problems
c. Actualization of the care plan throughnursing interventions

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d. Determination of the patient’s responses to the nursing interventions

• Answer : C

173. 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?
a. Empty pouch when it is completely full
b. Remove the skin barrier inspect the skin monthly
c. Recaps Skin barrier opening to size of stoma with each change
d. Cut an opening in the skin barrier then the circumference of the stoma

• Answer : B

174. 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?
a. 4
b. 8
c. 10
d. 12

• Answer : B

175. A patient has pacemaker implanted. Which of the following interventions is appropriate for the nursing
diagnosis of risk for injury?
a. Have patient avoid exposure to magnetic resonance imaging(MRI)
b. Observe incision site for redness, purulent drainage,
c. Offer back rubs to promote relaxation
d. Instruct patient in dorsiflexion exercises of ankles

• Answer : A

176. 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?
a. Adjuvant radiation therapy
b. Palliative radiation therapy
c. Curative radiation therapy
d. Radio surgery (stereotactic)

• Answer : B

177. 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:
a. The goal will not be met
b. Progression is being made towards the goal
c. The goal is met

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d. The goal is inappropriate

• Answer : B

178. A nurse is assigned to care for a patient with an ileostomy. The nurse would expect the ostomy discharge to be:
a. Fluid mushy
b. Mushy
c. Liquid
d. Solid

• Answer : C

179. 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?
a. Blood glucose level is 90mg/dl
b. HbA1C (glycosylated hemoglobin)level is 9.0%
c. Total H DL level is 60mg/dl
d. Low density Lipoprotien is130 mg/dl

• Answer : B

180. A nurse schedules a patient for a surgical procedure to take place in 1week. When would the nurse MOST likely
implement surgical education?
a. After admission to the hospital
b. Start during this visit
c. Immediately prior to anesthesia
d. After the operation

• Answer : B

181. 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:
a. Hold the breath
b. Stare upwards with eyes towards the ceiling
c. Perform the valsalvas maneuver
d. Lower the chin towards the chest

• Answer : B

182. 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?
a. Refer patient to dermatologist for diabetic cellulites
b. Instruct the patient to rotate the sites of injection
c. Refer patient to an end for better control of glucose level
d. Instruct patient to inject in the muscular area instead of endo area

• Answer : A

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183. After cardiac surgery, a patient has been prescribed low-sodium, low cholesteroldiet. Which of the
following menus is BEST?
a. Salami, rye bread, sanerkrant
b. Baked chicken thigh, iceberg lettuce, sliced tomatoes
c. Pasta with canned tomato sauce, peas, wheat bread
d. Bacon, lettuce and tomato sandwich with mayonnaise dressing

• Answer : C

184. 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:
a. Increased activity tolerance
b. Suppress the hypoxic drive
c. Alleviate the shortness of breath
d. Prevent lung infection

• Answer : B

185. 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?
a. Vagus
b. Sciatic
c. Llioinguinal
d. Lumbar plexus

• Answer : B

186. 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?
a. Call the physician
b. Administer pain medication
c. Position the patient on the left side
d. Apply cool, wet cloths under the arm

• Answer : A

187. 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?
a. Hydrogel
b. Hydrocolloid
c. Polyurethane
d. Polyurethane foam

• Answer : B

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188. 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:
a. Continue the plan of care as written
b. Allow the patient to replace the walker with a cane
c. Allow the patient to ambulate short distance without the walker
d. Have the patient practice stepping over small objects

• Answer : A

189. 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?
a. Dissemination intravascular coagulopathy (DIC)
b. Atelectasis
c. Syndrome of inappropriate anti-diuretics hormone(SIADH)
d. Hypokalemia

• Answer : D

190. When doing community-based teaching for latex allergies, the nurse should plan to teach the patient that :
a. Food handled by people wearing latex gloves stimulates an allergies response
b. Food containing nuts may trigger an allergic cross-response in people with latex allergies
c. The patient should wear a face while in the hospital due to large amount of airborne latex
d. Hoses used on gases pumps contain latex and should be avoided.

• Answer : B

191. 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?
a. Avoid scaring the child by saying “No or setting limits
b. Challenge the information the parents give regarding the injury
c. Question the parents of the child regarding the abuse
d. Assign one nurse to care for the child over the course of hospital stay

• Answer : C

192. 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:
a. Upper respiratory infection
b. Decreased breath sounds
c. Deep vein thrombosis
d. Bleeding at the surgical site

• Answer : C

193. A patient presents with a productive cough with a moderate amount of while Frothy sputum and dispend. The
patient is

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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?
a. Digoxin (lanoxin) toimprovethe abilityof the heart topump effectively
b. Oxygen therapy to combathypoxemia
c. Furosemide (lasix) toreduce blood volume andpulmonary congestion
d. Morphine sulface(Duramorph) to reduceanxiety

• Answer : A

194. 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:
a. Curing the Alzheimer’sdisease
b. Maximizing the functional ability and improve quality of life
c. Having the Alzheimer’s patient placed in a safe controlled environment
d. Making all decisions for the patient and confirming to home

• Answer : B

195. 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:
a. Data verification
b. Analytical interpretation
c. Mental assessment
d. Subjective observation

• Answer : A

196. 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?
a. Genetic history and male gender
b. Ethnic group and dietary habits
c. Genetic history and female gender
d. Dietary habits and male gender

• Answer : C

197. 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?
a. Instruct the family how to provide skin integrity
b. Suggest to the family that if the stress is overwhelming
,placement in a skilled nursing facility may be needed
c. Suggest collecting the patient on a regular schedule and applying incontinence brief at all times
d. Assess for the cause of incontinence and add an appropriate nursing diagnosis post and interventions

• Answer : A

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198. 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:
a. Providing privacy to complete the task
b. Completing task
c. Providing hand-over-hand assistance with the task
d. Telling the patient to brush the teeth today

• Answer : C

199. A child with iron deficiency complains of feeling tired all the times. The nursing diagnosis of fatigue is related to:
a. A decreased ability of the blood to transparent oxygen to the tissues
b. An increased paroxysmal abdominal pain and distension to the stomach
c. A decreased anxiety level during hospitalization
d. A decreased nutritional intake with mal absorption of nutrition

• Answer : A

200. 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?
a. Radial
b. Carotid
c. femoral
d. Apical

• Answer : C

201. 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:
a. Powerlessness
b. Delusions
c. Suicidal ideation
d. Resignation

• Answer : D

202. 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?
a. Rest flat on back, especially during the third trimester
b. Exercise programs should focus on their training
c. Frequent 15 minute to 30minute rest periods are important
d. Six hours of sleep a night is adequate

• Answer : C

203. A nurse is caring for a postoperative patient who is on subcutaneous, low dose heparin. This medication is used
to prevent:
a. Deep vein thrombosis
b. Congestive heart failure

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c. Paralytic Ileus
d. Pneumonia

• Answer : A

204. 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?
a. Document the patient’s refusal and add non-compliance to the care plan
b. Tell the patient that this is vital information and may delay discharged
c. Plan a time convenient to both the patient and the nurse
d. Pull the curtain around be bed and speak, ensuring privacy

• Answer : C

205. Which of the following actions would be appropriate for the nurse to take when Caring for a patient on contact
precautions?
a. Serve the patient’s meals on the disposable with plastic eating utensils
b. Instruct visitors to talk to the nurse before entering the patient’s room
c. Rinse both hands with water after removing gloves
d. Place a surgical mask on the patient during transport

• Answer : B

206. 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?
a. Anxiety
b. Social Isolation
c. Peripheral neurovascular dysfunction
d. Acute pain

ANS D

207. 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?
a. Airborne
b. Contact
c. Droplets
d. Ventilatory

• Answer : C

208. 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?
a. Gloves
b. Gowns
c. Face shields
d. Masks

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• Answer : D

209. 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?
a. Discontinue the opioid that is being administered
b. Place an extra blanket on the patient
c. Release the weights on the patient’s skeletal traction
d. Administer diphenhydramine(Benadryl) prescribed p.r.n allergic reaction

• Answer : D

210. A physician has ordered gavage feeding every 4 hours for a 12- week-old infant with failure to thrive. In order to
know how far to insert the feeding tube. The nurse should measure the distance from:
a. The infant’s mouth to the xiphoid process of the sternum
b. 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
d. The tip of the infant’s nose to the ear and then to the xiphoid process of the sternum

• Answer : D

211. 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
a. Parent-to-child interaction
b. Number of sibling in the home
c. Current sleep patterns
d. Exposure to second hand smoke

• Answer : A

212. 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:
a. Redness of the eye
b. Episodes of seizures
c. Improved vision with glasses
d. Lazy eye

• Answer : C

213. A2-years-old child in the emergency department exhibits symptoms of bacterial meningitis. Which of the
following tests confirm or rule out this diagnosed?
a. Magnetic resonanceimaging (MRI)
b. Magneto encephalogram
c. Computed tomography scan(CT)
d. Lumbar puncture (LP)

• Answer : D

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214. 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?
a. Computer tomography scan(CT scan)
b. Magnetic resonance imaging (MRI)
c. Pulmonary angiography
d. Pulmonary function test

• Answer : C

215. 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?
a. Monitor O2 saturation and arterial blood gas (ABG)levels
b. Apply Petroleum Gauze to wound
c. Prepare the patient for emergency thoracentesis
d. Position the patient in an upright position.

• Answer : B

216. A patient has pulmonary embolism. Which of the following nursing diagnoses has
PRORITY?
a. Anxiety related to pain, dyspnea, and concern of illness
b. Risk for injury related to altered hemodynamic status
c. Acute pain related to congestion and possible lung infarction
d. Ineffective breathing pattern related to acute increase in alveolar dead air space

• Answer: D

217. Which test should be added to the yearly physical of a patient who has recently turned 50 years old?
a. Culture and sensitivity
b. Fecal occult blood
c. Routine urine analysis test
d. Angiography studies

• Answer : A

218. The normal range of pH in arterial blood is:

a. 7.15-7.20
b. 7.25-7.30
c. 7.35-7.45
d. 7.50-7.55

• Answer : C

219. To prevent pressure on the feet of a bed-bound patient with decreased tissue perfusion, the BEST intervention
the nurse should take is:
a. Place sheep skin under the heels
b. Place a foot cradle on the bed
c. Pad the side rails with foam tubing

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d. Use only natural fiber linens

• Answer : D

220. The nurse assists with a lumbar puncture on a child with suspect bacterial meningitis. If the diagnosis is correct,
the cerebrospinal fluid, should have which of the following qualities?
a. High glucose level
b. Low protein level
c. Cloudy or turbid appearance
d. Pink or blood-tinged appearance

• Answer : C

221. 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:
a. Drug addiction
b. Drug tolerance
c. An improvement in condition
d. Lack of efficacy of the current medication

• Answer : D

222. 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. A
b. C
c. E
d. D

• Answer : B

223. 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:
a. Supine position with legs flexed to chest
b. Right lateral position with left sharply flexed
c. Supine position with legs spread
d. Left lateral position with right leg sharply flexed

• Answer : D

224. Respiratory depression is a potentially life-threatening adverse effect of

a. Opioids
b. Anticoagulants
c. Immune modulators
d. Non-steroidal (NSAIDS)

• Answer : A

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225. A child in the postictal state of a seizure should show which of the following signs or symptoms?
a. Feeling sleepy or exhausted
b. Stiffness over entire body
c. Verbalizes having an aura
d. Eyes fixed in one position

• Answer : A

226. Standards of pain management dictate the nurses:

a. Administer analgesic via injection whenever possible
b. Avoid the use of the word “pain”
c. Screen for pain at each encounter
d. Discourage around-the clock dosage of analgesics

• Answer : C

227. 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:
a. Lay the patient flat before compressing the mediastinal area
b. Insert a finger into the patient’s mouth to feel for any food
c. Stand behind the patient while performing abdominal thrusts
d. Activate the emergency call light near the patient

• Answer : C

228. 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?
a. Blood return
b. X-ray
c. Catheter potency
d. Length of catheter

• Answer : B

229. 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?

a. Wash hands frequently each day

b. Wear masks while in public spaces
c. Wear supplement oxygen at night
d. Take a multiple vitamin tablet each night

• Answer : A

230. Which of the following is the MOST important discharge planning instruction for a patient with mononucleosis?

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a. Avoid activities that may increase injury to the spleen
b. Avoid crowded areas to prevent the spread of infection
c. Consume vitamin K rich food to decrease the risk of bleeding
d. Take an antibiotics a prescribed to treat infection

• Answer : B

231. 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 deficiencies in the extrinsic factor?
a. Thrombin time (TT)
b. Prothrombin time (PT)
c. Partial prothrombin time(PTT)
d. Activated partial thromboplastin time (aPTT)

• Answer : B

232. 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:
a. Are located mainly in the abdomen and groin
b. Have increasing intensity
c. Occur with decreasing intervals
d. Occur at regular intervals

• Answer : B

233. 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?
a. Assess further determine the reason the reason for the patient’s Actions
b. Add a new diagnosis of non-compliance
c. Re-educate the patient about the importance of following his medication plan
d. Reevaluate the need for daily medication since the blood pressure is acceptable

• Answer : C

234. 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?
a. Instruct caretaker to change the patient’s position every 2 hours
b. Apply hydrogel to the stage I pressure sore every 8 hours
c. Refer the patient to wound care specialist for debridement
d. Encourage the patient to consume an increased amount of calcium

• Answer : A

235. Following an open-cholecystectomy, the nurse would instruct the patient to expect to resume normal activities
in:
a. 1 to 2 weeks
b. 2 to 3 weeks

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c. 4 to 6 weeks
d. 6 to 8 weeks

• Answer : A

236. 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:
a. 3 days
b. 2 weeks
c. 2 months
d. 3 months

• Answer : B

237. 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?
a. Constipation related to use of opioids
b. Decreased appetite due to depression
c. Constipation due to acute pain
d. Decreased appetite due to use of opioid

• Answer : A

238. 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?
a. High altitudes can be beneficial
b. Blood transfusion may be necessary in the future
c. Strenuous physical activity should be avoided
d. Increased fluid intake minimize pain

239. 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?
a. Interview the parents about the child’s pain tolerance and usual medication requirements
b. Medicate the patient with the medication orderedfor breakthrough pain as soon as
possible, the resume the evaluation
c. Ask the child to describe the pain, it is located, and to rate it on the Wong/baker pain scale.
d. Tell the child to rest while and the nurse will return at another time for the evaluation

• Answer : B

240. The nurse is entering the room of a patient who is blind. The nurse should:
a. Speak before touching the patient
b. Talk to the patient using aloud tone of voice
c. Ask then patient questions that can be answered “yes “or “no”
d. Stand directly in front of the patient while talking

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241. 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?
a.
b. An enema two times a week
c. Increased fiber in the diet
d. Aroutinebisacodyl(Dulcolax) suppository
e. An enema three times a week

• Answer : B

242. 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?
a. Massage the right heel four times per day
b. Add a trapeze to the bed
c. Float heels off bed with a pillow
d. Add a bed cradle to the bed

• Answer : C

243. 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?
a. Elevate the head of the bed30 degrees
b. Keep the patient well hydrated
c. Limit intake of salty food
d. Lower the temperature of the room

• Answer : B

244. 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?
a. Administer antibiotics as prescribed
b. Breastfeed as long as possible
c. Administer influenza vaccination
d. Avoid smoking around the child

• Answer : A

245. Three weeks post amputation of the leg the patient is instructed to massage the residual limb. The MOST likely
rationale for this to:
a. Provide counter-irritation for pain control
b. Prepare for a prosthesis
c. Promote wound healing
d. Promote acceptance of the limb’s appearance

• Answer : B

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246. 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?
a. Give the patient an anti-pyretic medication and continue the transfusion as ordered
b. Discontinue the intravenous line and restart in another site
c. Stop the transfusion, keep the vein open with normal saline, and notify the doctor immediately
d. Use a blood cooling device to cool the blood as it infuses

• Answer : C

247. 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
a. Putting on clean gloves before cleansing the eye
b. Taking medication as prescribe
c. Wearing a gauze eye patch
d. Performing hand hygiene

• Answer : D

248. A nurse for a child with celiac disease (CD). The patient would have a permanent inability to tolerate:
a. Protein
b. Dairy
c. Glutens
d. Fruits

• Answer : C

249. 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?
a. Morphine sulfate
b. Potassium chloride
c. Warfarin sodium(coumadin)
d. Bisacodyl (dulcolax)

• Answer : A

250. When planning discharge teaching for the parent of an infant with respiratory problems , the nurse should
EMPHASIZE
a. Use of supplemental oxygen at night
b. Frequent hand washing
c. Sleeping in the supine position
d. Rice-thickened formula during night-time feedings

• Answer: C

251. A nurse is caring for a child who is post-tonsillectomy and adenoidectomy. The nurse should plan to assess
which of the following complications?
a. Pulmonary hypertension
b. Hemorrhage

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c. Hearing loss
d. Corpulmonale

• Answer :B

252. A patient has multiple sclerosis and complains of over whelming fatigue. The nurse would be MOST
correct in instruction the patient to:
a. Conserve energy during activities of daily living
b. Increase muscle strength through aerobic exercise
c. Ignore fatigue and keep working
d. Increase early afternoon intake of caffeine

• Answer : A

253. 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?
a. Steamed carrots, milks and applesauce
b. Tuna fish with mayonnaise, boiled eggs and yogurt
c. Grilled steak, baked potato and peach pie
d. Chicken noodle soup ,banana and cocoa

• Answer : A

254. When administering an oral medication to a toddler, which of the following interventions should the nurse plan
to use?
a. Depress the child’s chin with thumb to open the child’s mouth
b. Place the medication in a nipple for the child to suck
c. Give the child a small plastic medication cup for day
d. Tell the child that the medication tastes good

• Answer : A

255. The nurse is monitoring a patient’s urine to determine hydration status what urine color would indicate the BEST
hydration?
a. Clear
b. Amber
c. Tea
d. Pale gold

• Answer : B

256. 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
a. Leukocytes
b. Platelets
c. Erythrocytes
d. Thrombocytes

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• Answer : C

257. 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:
a. Assess the patient’s oral temperature
b. Determine what foods the patient ate
c. Place the patient in reverse Trendelenburg position
d. Obtain order and administer morphine sulfate

• Answer : D

258. 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:
a. “How much protein does you normally eats for dinner?”
b. “How much caffeine are you consuming each day?”
c. “Are you having trouble controlling your bladder at night?”
d. “Do you have enough money to buy liquids to drink?”

• Answer : C

259. A nurse is caring for a patient who had rhinoplasty 2-weeks ago. Which of the following is an expected outcome?
a. Oral mucus membranes dry ,but pink and intact
b. Face and nose free from swelling
c. Able to make needs know, speech therapy started
d. Demonstrate throat clearing while eating

• Answer : B

260. 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?
a. Sphygmomanometer
b. Thermometer
c. Ophthalmoscope
d. Otoscope

• Answer: C

261. 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?
a. “Try doing some type of exercise two hours before bedtime”
b. “Drink a cup of warm tea before you go to bed”
c. “ Make sure the bedroom is dark when you get in bed”
d. “ A nap in the middle of the day should help”

• Answer : D

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262. 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?
a. Provide for continual contact between parents and infant
b. Activity involve parents in caring for the infant
c. Keep the infant’s environment quiet, dim, and free of sensory stimulation
d. Foster infant-sibling relationship as appropriate

• Answer : C

263. 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?
a. WBC count
b. Hematocrit
c. Platelet level
d. Potassium level

• Answer : A

264. 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:
a. Readily available and economical
b. Keeps a baby full longer
c. Larger curds than cow’s milk and therefore is easier to digest
d. Encourage greater deposits of subcutaneous fat in an infant

• Answer : A

265. When implementing a feeding schedule for a full term 2-weeks old infant, the nurse should expect the infant to
be fed:
a. 2-4 times per day
b. 6-8 times per day
c. 10-12 times per day
d. 14-16 times per day

• Answer : B

266. 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:
a. Met the expected outcome
b. Partially met the expected outcome
c. Has not improved
d. Has worsened

Answer : A

267. 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?
a. Open the airway

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b. Determine unresponsiveness
c. Activate the emergency call system
d. Obtain the automatic electronic defibrillator(AED)

• Answer : B

268. When caring for a patient who is receiving anticoagulant medications, the nurse MUST monitor the patient, for
signs of:
a. Skin breakdown
b. Bleeding
c. Pain
d. Confusion

• Answer : B

269. 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?
a. Review the post operative risks with the patient
b. Notify surgeon about the patient’s questions
c. Complete the patient’s preoperative check list
d. Show the patient photos of breast surgical scars

• Answer : B

270. 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?
a. Organ meats
b. Whole grains
c. Egg yolks
d. Lean means

• Answer : C

271. A patient has just diagnosed with hypothyroidism. Which of the following instructions is correct?
a. You will need to take thyroid hormone replacement therapy your Entire life
b. You will need to take thyroid hormone replacement therapy until your laboratory result
c. You will need to take thyroid hormone replacement therapy for about 2 months.
d. You will need to take thyroid hormone replacement therapy for 1 year.

• Ans . A

272. The stages of dying, as identified by Dr. Elizbathkubbler-ross, occur in what order?
a. Anger, depression, bargaining, denial, acceptance
b. Bargaining ,denial, acceptance, depression
c. Denial, anger, bargaining, depression, acceptance
d. Depression, Denial, Anger, bargaining, acceptance

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• Ans.C

273. 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 ;
a. Make a list of unfinished tasks
b. complete complex mental task before physical tasks
c. Acknowledge daily accomplishments
d. Spend time with colleague away from work

• Ans . B

274. 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 :

a. Entering a larger body vessel

b. Causing increased pain
c. Precipitating hyper ventilation
d. umbilical infection

• Ans . A

275. A pt with conjunctivitis reports the presence of photophobia and moderate eye drainage. The nurse should
teach pt to
a. Avoid touching the eye
b. Use sterile gauze to remove the drainage
c. Darken the room
d. rest in the prone position

• ANS. C

276. 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
a. 650 cc
b. 700cc
c. 900 cc
d. 1050 cc

• Ans. D

277. 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?
a. Analytical
b. Derived
c. Objective
d. Subjective

• Answer : D

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278. 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?
a. Maturation
b. Inflammation
c. Proliferation
d. Finalization

• Answer : C

279. 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?
a. Administer analgesics when necessary
b. Assess pain once a shift
c. Anticipate pain and intervene early
d. Encourage the use of self-quieting techniques

Answer : A

280. Which statement by the patient with hyperlipidemia shows a basic understanding of the disease and it
treatment?
a. Exercise has no effect on cholesterol levels
b. Hyperlipidemia is usually symptomatic until significant target organ damage is done
c. HDL cholesterol level of greater the 60 mg/dl increases the chance of coronary artery disease
d. Cholestyramine (Quesram)should be taken in the morning with other medications

• Answer : D

281. 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
a. Improve oxygenation
b. Decrease anxiety
c. Improve tissue perfusion
d. Decrease risk for aspiration

• Answer : A

282. 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?
a. Grape fruit
b. Oranges
c. Bananas
d. Red grapes

• Answer : B

283. A 2-month-old child in the emergency department has projectile vomiting after feeding. The vomitus is
non-bilious containing milk and gastric juices. Immediately after vomiting the child tries to feed again. The nurse

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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?
a. Hypertrophic pyloric stenosis
b. Hirschsprung’s disease
c. Gastro esophageal reflux
d. Tracheoesophagel fistula

• Answer : A

284. 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?
a. Thiazide diuretic
b. Intravenous normal saline(0.9% NaCl)
c. A potassium supplement
d. Broad-spectrum antibiotic

• Answer : B

285. 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?
a. Adding positive end expiratory pressure (PEEP)
b. Placing the patient in Trendelenburg position
c. Increasing the FIO2
d. Suctioning the patient hourly

• Answer : A

286. Which of the following nursing diagnosis takes PRIORITY for a patient after gastrointestinal surgery?
a. Impaired skin integrity related to surgical incision
b. Constipation related to surgery
c. Risk for infection related to surgical incision
d. Acute pain related to surgical incision

• Answer : D

287. Marijuana is an example of a drug classified as schedule:

a. C-I
b. C-II
c. C-III
d. C-IV

• Answer : A

288. 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:
a. Continue the plan of care as written
b. Replace the supplement with a high calorie food that the patient likes
c. Encourage the patient drink supplements

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d. Offer smaller amounts of supplement more frequently

• Answer : B

289. The nurse is caring for a patient with magnesium toxicity. Which of the following clinical manifestation
should the nurse anticipate?
a. Paresthesia
b. Decreased deep-tendon reflexes
c. Cardiac palpitations
d. Decreased cardiac output

• Answer : B

290. A patient returning from a3-hour shoulder repair with general anesthesia 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
a. Airway Obstruction
b. Vomiting
c. Impaired Circulation
d. a. Fluid volume deficit

• Answer : B

291. For a patient scheduled for a total pancrectectomy, the nurse would be instruct the patient that the
procedure work MOST likely cause
a. Pancreatic ascites
b. Chronic pancreatitis
c. Diabetes mellitus
d. Diabetes insipidus

• Answer : C

292. 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?
a. Blinking
b. Vertical suspension
c. Moro
d. Perez

• Answer : C

293. 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:
a. Counting the number of the heart beats during exercise for 6 sections, then multiply this number by 10
b. Subtracting the chronological age from the number 220
c. Counting then number of heart beats during exercise for 10 seconds, then multiply by 6
d. Subtracting he chronological age from 240

• Answer : C

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294. 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?
a. Asses the patient from pain
b. Obtain an order from supplemental oxygen
c. Elevate the head of the bed
d. Place a warmed blanket on the patient

• Answer : C

295. 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?
a. 1,500 ml
b. 1 liter
c. 1.5 liters
d. 500 ml

• Answer : B

296. 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
a. Sleep with the head elevated on at least two three pillows
b. Apply firm pressure to the nostrils four times a day
c. Use a cotton-filled applicator to apply a water-soluble lubricant to the nasal
septum twice daily
d. Minimize the intake of caffeine while increasing the intake of fluids rich in vitamin K

• Answer : B

297. A nurse is caring for an infant with respiratory distress syndrome.

Which of the following nursing intervention is appropriate
a. Measure oxygen saturation level once a shift
b. Suction frequently for 30-45second each time
c. Monitor for symptoms of hyperglycemia
d. Maintain infant temperature between 36.70& 37.80C(970& 980 F)

• Answer : A

298. 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 following activities would be MOST
appropriate?
a. Walking fingers up the wall
b. Using five pound weights
c. Knitting with a large needle
d. Rhythmic clapping

• Answer : A

299. What occurs during cardiogenic shock and result in inadequate tissue perfusion?

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a. Increased resistance of arterial vessels
b. Decreased effectiveness of the heart as a pump
c. Increased shunting of critical blood flow to heart
d. Decreased capacity of the venous beds

• Answer : B

300. The nurse is caring for child admitted with viral pneumonia. Which of the following nursing diagnoses should
receive PRIORITY?
a. Nutrition altered: less than body requirements
b. Ineffective airway clearance
c. Fluid volume deficit
d. Risk for injury

• Answer : B

301. A child has ingested an entire bottle acetaminophen(Tylenol). Which of the following organs is affected?
a. Liver
b. Brain
c. Kidneys
d. Gallbladder

• Answer : A

302. A patient is seen in the emergency department with complaints of angina. Nitroglycerin (Nitrostat) is ordered by
the physician. This medication is to be administered via which of the following routes?
a. Intradermal
b. Buccal
c. Parental
d. Topical

• Answer : B

303. The nurse is teaching a group of patient about hepatitis A(HAV). The nurse should state that HAV is MAINLY
transmitted Via:
a. Blood contact
b. Food
c. Sexual activity
d. Saliva

• Answer : B

304. 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?
a. Full recovery is possible
b. This illness should not progress
c. Cerebral palsy is a hereditary disease
d. Surgery can sometimes improve walking

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• Answer : D

305. 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
a. Intestinal obstruction
b. Intestinal parasite infestation
c. Intestinal perforation
d. Ascites

• Answer : A

306. A child is admitted to the hospital with dehydration. The nurse should Give PRIORITYto which of the
followingnursing diagnoses?
a. Anxiety related to hospitalization
b. Fluid volume deficit related to vomiting
c. Imbalance nutrition less than body requirementsrelated diarrhea
d. Risk for infection relatedto presence of invasivelines

• Answer : B

307. 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?
a. Daily complete blood count (CBC)
b. Laboratory tests for partial thromboplastin time (PTT)
c. Strict bed rest
d. Wearing elasticized support stockings

• Answer : C

308. 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 to the abdomen press towards the symphysis pubis. This
method is known as:
a. Crede’s
b. Intermittent
c. Foley
d. Prophylactic

• Answer : A

309. A 50-year-old patient is being admitted to the hospital in a vegetative state of unknown etiology what is the
PRIORITY nursing diagnosis?
a. Risk for impaired skin integrity
b. Impaired swallowing
c. Altered cerebral tissue perfusion
d. Altered thought processes

• Answer : A

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310. Prior to administering an enema, the nurse will assist the patient to assume what position
a. Prone with pillow under knees
b. Left-side with right knee flexed
c. Right-side with left knee flexed
d. On back with head of bed flat

• Answer : B

311. A nurse interview 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?
a. Analytical
b. Focused
c. Closed
d. Open-ended

• Answer : D

312. When selecting activities to help develop a child’s fine motor skills, which of the following would BEST meet this
goal?
a. Sorting cardboard objects that are in different shapes
b. Singing while turning the pages of a book that plays music
c. Jumping rope
d. Riding a three-wheeled cycle

• Answer : C

313. 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:
a. 5% loss
b. 8% loss
c. 10% loss
d. 20% loss

• Answer : D

314. 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:
a. Supine
b. Side-lying
c. Prone
d. Knee-chest

• Answer : B

315. A child is treated for possible acetaminophen (Tylenol) overdose. The child is currently stable with normal vital
signs. Which of the following organ function system would be MOST affected?

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a. Liver
b. Stomach
c. Lungs
d. Heart

• Answer : A

316. 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
a. Healing
b. Need for debridement
c. Inadequate nutrition
d. Infection

• Answer : A

317. To limit drug interactions, the nurse should advise the parent of chronically ill child to:
a. Refer to the medications by the generic name
b. Teach the child the name of all medications prescribed
c. Give all medications one hour apart
d. Get all prescriptions filled at the same pharmacy

• Answer : A

318. 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?
a. Allen test
b. Partial pressure of arterial oxygen
c. Partial carbon dioxide
d. Prothrombin time

• Answer : A

319. For an infant with hydrocephalus, a nurse should plan to monitor for what sign or symptom of increased
intracranial pressure?
a. High-pitched, shrill cry
b. Decrease in systolic blood pressure
c. Depressed fontanelle
d. Increase in respirations

• Answer : A

320. During surgery requiring general anesthesia, the patient’s heart stops, Ventilations using the end tracheal tube
(ETT) are started with an ambubag. Which of the following compression to ventilation rates is correct?
a. 10 to 2
b. 15 to 2
c. 30 to 2
d. 50 to 2

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Answer :C

321. 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?
a. Administer oxygen as ordered
b. Maintain a comfortable position
c. Increase fluid intake
d. Administer prescribed analgesic

• Answer : A

322. 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:
a. Write all communication and avoid speech
b. Raise the volume and pitch of the voice
c. Obtain an interpreter
d. Smile and nod frequently

• Answer : C

323. 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?
a. Administer additional oxycodone 5 mg
b. Administer morphine 5 mg
c. Change the dressing quickly
d. Encourage deep breathing

• Answer : B

324. 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?
a. Inspection and auscultation
b. Inspection and palpation
c. Palpation and percussion
d. Percussion and auscultation

• Answer : B

325. 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

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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:
a. Congestive heart failure
b. Meningitis
c. Rotovirus
d. Acute rheumatic fever

• Answer : D

326. A nurse is caring for a hospitalized diabetic patient with advanced peripheral recovery. Which of the following
nursing action is MOST important?
a. Moisturizing the skin with lotion each day
b. Ensuring that foods are not too hot
c. Facing the patient when speaking
d. Assessing the heels for breakdown

• Answer : D

327. 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?
a. Develop no further contractures
b. Wear an arm and hand splint
c. Have no pain related to the contractures

• ANS C

328. To facilitate self-care for a 2-year-old child with spastic cerebral palsy, the nurse should recommend:
a. Placing straws into beverage containers
b. Obtaining eating utensils that have large handles
c. Replacing zippers on clothing with metal snaps
d. Purchasing shoes that have an open heels area

• Answer : D

329. 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?
a. “My sexual partner needs to be treated with antibiotics”
b. “It’s OK to resume sexual relation now”
c. “I need to inform any sexual partners I have had in the past 30 days that I had PID”
d. “In order to prevent getting PID I need to continue to take birth control pills"

• Answer : A

330. 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:
a. Rotavirus
b. Hepatitis B
c. None at this time
d. Varicella

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• Answer : C

331. 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?
a. Coronary artery disease
b. Smoking
c. Hemophilia
d. Hyperlipidemia

• Answer : C

332. 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)?
a. Hypertrophic
b. Dilated
c. Restrictive
d. Diastolic

• Answer : A

333. The responsibility for teaching patients how to take medications safely when they are discharged from the
hospital belongs to the:
a. Nurse
b. Physician
c. Dietitian
d. Therapist

• Answer : B

334. A nurse is discharging a patient after hospitalization due to myocarditis. Which of the following statements
should be included in discharge teaching?
a. There is usually some residual heart enlargement
b. May resume previous activities as before hospitalization
c. Avoid immunizations against infectious disease
d. Rapidly beating heart is a common side effect of the illness and is not dangerous

• Answer : A

335. 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?
a. Place the infant in an infant seat after eating
b. Give large frequent feedings
c. Position the child in a swing
d. Thin formula with water

• Answer : C

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336. 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?
a. Activate emergency call system
b. Open the patient’s airway
c. Check for a carotid pulse
d. Administer 2 rescue breaths

• Answer : C

337. 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?
a. Delayed surgical recovery
b. Impaired gas exchange system
c. Ineffective breathing pattern
d. Risk for perioperative-positioning injury

• Answer : C

338. 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:
a. Tooth decay
b. Oral candidiasis
c. Dehydration
d. Hypertrophy of the gums

• Answer : B

339. 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?
a. Reports pain in legs while sitting
b. Urinating every two hours while awake
c. Fatigue after performing activities of daily living
d. Ambulates outdoors without assistive devices

• Answer : D

340. When a child is brought to the emergency department with acute epiglottitis, which of the following nursing
diagnoses should receive PRIORITY?
a. Ineffective airway clearance
b. Activity intolerance
c. Fluid volume deficit
d. Impaired verbal communication

• Answer : A

341. 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?

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a. Digoxin (Lanoxin)
b. Furosemide (Lasix)
c. Propranolol hydrochloride(Inderal)
d. Warfarin sodium(Coumadin)

• Answer : D

342. 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?
a. Deliver oxygen with humidity
b. Encourage fluid intake
c. Assist patient into position ofcomfort
d. Inspect sputum for odor andcolor

• Answer : A

343. 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?
a. Esophageal astresia withtracheoesophageal fistula
b. Gastroesophageal reflux
c. Hirschsprung’s disease
d. Celiac disease

• Answer : B

344. 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?
a. Cheese and breads
b. Liver and rice
c. Fish and rice
d. Fruits and vegetables

• Answer : D

345. 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?
a. Salty foods may be eatenon occasion
b. My child does not need torestrict salt intake
c. Salt is lost more rapidlyin hot weather
d. Salt replacement shouldoccur every day

• Answer : D

346. 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:

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a. Pulmonary decompensation
b. Hemorrhage
c. Aspiration
d. Infection

• Answer : D

347. 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?
a. Report abnormal diagnostic results to the surgeon
b. Review the patientconsent for the surgicalprocedure
c. Educate the patient on therisk factors and side-effects of the surgery
d. Ensure that the patient hasa post-surgery physicaltherapy order

• Answer : A

348. Which of the following discharge planning instructions takes PRIORITY in patient with congestive heart failure?
a. Maintaining a low cholesterol, low sodium and low potassium diet
b. Recognizing signs andsymptoms that requireimmediate medicalattention
c. The importance ofremaining physicallyactive
d. The importance ofdrinking plenty of fluid

• Answer : B

349. 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?
a. Activity intolerance
b. Impaired environmental interpretation syndrome
c. Disturbed sensoryperception
d. Risk for autonomicdysreflexia

• Answer : B

350. During the immediate postoperative period, a patient reveals an oxygen saturation level of 91%. The nurse
should:
a. Position the patient on the left side
b. Administer supplemental oxygen
c. Continue to providesupportive care
d. Lower the temperature ofthe room

• Answer : c

351. Which of the following goal take PRIORITY when recovering from general anesthesia in post anesthesia care unit
(PACU)?
a. Thermoregulation
b. Plastic skin turgor

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c. Patent airway
d. Patient voids freely

• Answer : C

352. 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:
a. Infections
b. Atelectasis
c. Thrombosis formation
d. Positioning injuries

• Answer : C

353. When administering an intramuscular injection to an infant, which of the following sites appropriate for the
nurse to use?
a. Rectus femoris
b. Deltoid
c. Dorsogluteal
d. Ventrogluteal

• Answer : D

354. A patient is admitted to the medical unit with a diagnosis of fluid volume deficit would the nurse expect the
doctor to order?
a. 0.9% Sodium chloride
b. 0.45% Sodium chloride
c. Dextran in normal saline
d. 5% Sodium chloride

• Answer : A

355. 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?
a. Blood
b. Saliva
c. Breast milk
d. Vaginal secretions

• Answer : A

356. 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?
a. Chest X-ray
b. Complete blood count
c. Body fat analysis
d. Blood glucose level

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• Answer : D

357. 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:
a. Skin turgor
b. Cough reflex
c. Lung sounds
d. Bowel sounds

• Answer : B

358. 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):
a. Immediately with repeat testin 6 weeks
b. If the patient refuses HIVtesting
c. If the patient has symptomsof HIV infection
d. A month after takingprophylactic antiviral

• Answer : A

359. 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?
a. Anorexia nervosa
b. Bulimia
c. Morbid obesity
d. Impulsive behavior

• Answer: B

360. A urinalysis is best evaluated for accurate result if specimen is analyzed within:
a. 1 hour of collection or refrigerated until analyzed
b. 1 hour of collection or left at room temperature
c. 2 hours of collection
d. 4 hours of collection

• Answer: C

361. The nurse has started intravenous fluid therapy on a child. Which of the followingaction is appropriate?
a. Using a padded arm board only if the child is active
b. Checking the site at leastonce every two hours
c. Determining the total volumeinfused every four hours
d. Using an infusion pump toprovide controlled rate ofinfusion

• Answer : D

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362. 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?
a. Post-anesthesia care unit(PACU) nurse
b. Scrub nurse
c. Anesthesia team
d. Charge nurse

• Answer : C

363. 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:
a. Oral temperature
b. O2 saturation
c. Apical pulse
d. Level of comfort

• Answer : B

364. 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:
a. Enucleation
b. Radial keratotomy
c. Vitrectomy
d. Peripheral Iridectomy

• Answer : C

365. 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:
a. Give the medication asordered by the physician
b. Administer the ordered dose rectally
c. Put moist cool cloths on thepatient’s forehead and axillac
d. Notify the physician andrequest other orders

• Answer : A

366. A home health nurse is preparing to administer a subcutaneous injection of heparin.When site on the abdomen,
the nurse will choose a site:
a. More than 6 inches from the umbilicus
b. More than 2 inches from the umbilicus
c. As close as possible to the umbilicus
d. As close as possible to the umbilicus

• Answer : B

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367. A patient with pulmonary 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?
a. Administer oxygen as ordered
b. Administer pain medication as ordered
c. Observe closely for signs of pain and discomfort
d. Listen to the patient’s concerns

• Answer : D

368. A patient with bacterial meningitis is treated with intravenous antimicrobial agent. Which of the following BEST
indicates effectiveness of treatment?
a. Severe headache
b. Negative kernig’s sign
c. Nuchal rigidity
d. Photophobia

• Answer : B

369. While caring for a patient with potassium deficiency, the nurse should expect that the patient may exhibit:
a. Dysrhythmias
b. Oliguria
c. Diminished deep-tendon reflexes
d. Hypertension

• Answer : A

370. A patient who underwent hand surgery requiring general anesthesia presents to the post anesthesia care unit
(PACU) after extubation, The nurse should FIRST assess
a. Circulatory status
b. Wound status
c. Respiratory status
d. Hydration status

• Answer : C

371. Prior to administration of an albuterol nebulizer, the nurse should help the patient assume what position?
a. Sitting and leaning forward
b. Feet elevated above level of heart
c. High fowler’s
d. Standing

• Answer : C

372. A patient presents to the doctor’s office 2-weeks status post-right- sided mastectomy. The nurse needs to
measure the blood pressure. Which would be the BEST site?
a. Above the left brachial artery
b. Right popliteal artery
c. Above the right brachial artery
d. Left popliteal artery

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• Answer : A

373. A child with cystic fibrosis exacerbation presents to the emergency room. Which nursing diagnosis takes FIRST?
Priority in planning for intervention?
a. Imbalanced nutrition related to increased metabolic requirements because of mal absorption
b. Deficient knowledge regarding prevention of cystic fibrosis exacerbation
c. Impaired gas exchange related to airway obstruction due to mucous
d. Interrupted family processes related to hospitalization

• Answer : C

374. A nurse is evaluating the home of patient with left-sided paralysis. Which of the following observations would
indicate that the patient is complying with home-based safety?
a. The telephone is on a bedside table with is next to the head of the bed
b. The bedside commode is on the left-side of the bed with the back of the commode facing the foot of the bed
c. The walker has wheels on its back legs and has tennis balls on the front legs
d. The stairs leading from the bedroom to the living area a handrail on the right-side of the stairway

• Answer : A

375. 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?
a. Learn to speak clearly within30 days
b. Communicate effectively within one week
c. Have all needs anticipated by staff daily
d. Make basic needs known daily

• Answer : D

376. A Patient has a dissection aortic aneurysm. The patient’s surgery would be categorized as:
a. Elective
b. Urgent
c. Emergency
d. Diagnostic

• Answer : C

377. A patient presents to the emergency room due to an overdose of morphine sulfate. Which of the following
should the nurse has readily available?
a. Glucagon
b. Antibiotic
c. Acetyl cysteine (Mucomyst)
d. Naloxone (Narcan)

• Answer : D

378. 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 a plan of care and provide education on proper nutrition and

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good sources of iron. Besides educating the patient on a well-balanced diet the nurse would MOST likely teach the
patient that good source of iron include:
a. Seafood, cheese, soybean oil, and chocolate
b. Animal proteins, egg yolks, dried fruits, and nuts
c. Dairy products, citrus fruits, fish liver oils, and poultry
d. Seafood, fruit, poultry, and tomatoes

• Answer : C

379. 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:
a. Isometric exercises
b. Passive range of motion exercises
c. Active-assistive range of motion exercises
d. Resistive range of motion exercises

• Answer : C

380. 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 “whatever is put in front of me”. Which of the following actions would the nurse take?
a. Collaborate with the patient to set goals
b. Add a nursing diagnosis of non-compliance
c. Refer for Psychiatric screening for depression
d. Discuss nutritional interventions with the spouse

• Answer : A

381. 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:
a. Large number of lymphoblasts and lymphocytes
b. Low number of lymphoblasts and large number of lymphocytes
c. Low number of lymphoblasts and lymphocytes
d. Large number of lymphoblasts and low number of lymphocytes

• Answer : C

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

• Answer : A

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383. 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?
a. Slow the rate to prevent burning from the solution and continue to monitor
b. Discontinue the intravenous line and restart in another site
c. Monitor at least every half-hour for edema but continues the order state
d. Notify the doctor that the patient is having an adverse reaction to the medication

• Answer :A

384. 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?
a. Red blood cell count
b. Hematocrit
c. White blood cell count
d. Blood type

• Answer : D

385. 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?
a. Identify precipitating factors and underlying conditions
b. Administer morphine(Dura morph) to reduce anxiety
c. Assess oxygen saturation rate
d. Administer digoxin(Lanoxin) to decrease fluid backing up into the lungs

• Answer : C

386. 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?
a. 120cc
b. 200cc
c. 240cc
d. 440cc

• Answer : D

387. 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 the nurse expect to administer?
a. Flumazenil or (activated charcoal)
b. A tap water enema
c. Magnesium sulphate to reduce the risk of seizure
d. Nalaxazone Answer: A

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388. An asthmatic patient presents with wheezing and coughing. Oxygen saturation is 88% on room air. Which of the
following nursing diagnosis would take priority?
a. Imbalanced nutrition related to decreased food intake
b. Activity intolerance related to inefficient breathing.
c. Anxiety related dyspneaand concern of illness.
d. Ineffective gas exchange related to bronchospasm

Answer: D

389. 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

390. A patient scheduled for an abdominal aneurysm repair. This is what type of surgical intervention?
a. Diagnostic
b. Transplant
c. Curative
d. Palliative

• Ans: C

391. The patient present to the hospital voicing a concern about being exposed 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

392. 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
a. Position and length of the leg
b. Bilateral pulse
c. Bony prominence of ankles and feet
d. Rotation of patella

ANS – D

393. 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
a. Pre-operative weakness of the lower extremities

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b. Anxiety related to inherited risk factors of surgery
c. Fear related to body image disturbances
d. Allergy to aspirin based products

ANS- B

394. 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
a. Medicate the patient prior to ambulation
b. Add a nursing diagnosis of non-compliance
c. Let the patient rest now and then try to ambulate later
d. Assess to determine the course of the chest pain

ANS – D

395. 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 ..,
a. Place the cane and the affected extremities upon the step
b. Place the cane and the unaffected extremity upon the step
c. Step up on the affected extremity
d. Step up on the unaffected extremity

ANS – A

396. 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
a. Acceptance of altered body image
b. Avoid large crowd
c. Limit right arm movement
d. Perform range of motion for left arm

ANS – A

397. Which instruction take priority in reducing anxiety related to Surgical procedure and post-operative exercise
a. Risk of infection after surgery
b. Advanced directives and what it means
c. Pre-operative laboratory result and what to expect on it

ANS-b

398. 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 cannula is 84%. The nurse is awaiting the result of an ABG and anticipate that which of the following
elevated ?
a. Arterial O2 saturation (SaO2)
b. HYDROGEN ion concentration (PH)
c. Partial pressure of arterial CO2 (PaCO2)

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Ans – c

399. 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?
a. Behavioral training
b. Bladder training
c. Scheduled toileting
d. Prompted voiding

ANS – B

400. 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:
a. Blockage of large vessels as a result of atherosclerosis
b. Emboli produced from valvular heart disease
c. Decreased cerebral blood flow due to circulatory failure
d. A temporary disruption in oxygenation of the brain

Ans: A

401. 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?
a. Recap the needle, then place the needle and syringe into a waterproof container until safe disposal can be made
b. Bend the needle back towards the barrel of the syringe before putting the needle and syringe in a metal trash
container
c. Wrap the needle and syringe in disposable paper before putting the needle and syringe into the dirty section of
the nurse’s equipment bag
d. Put the needle and syringe directly into a puncture-resistant plastic container that has a lid

Ans: B

402. What is the most common characteristic of a stage IV pressure ulcer?

a. Pink skin
b. Presence of sinus tracts
c. Exposure of bone
d. Infection

Ans: C

403. 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?
a. Apply pectin, gelatin or synthetic skin barrier around the stoma
b. Apply triple antibiotic to the raw skin and leave it open to the air
c. Instruct to empty the pouch as soon as stool is present
d. Instruct to remove the bag and skin barrier after each stool

Ans: A

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404. 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?
a. Diagnosis
b. Assessment
c. Implementation
d. Evaluation

Ans: C

405. 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:
a. 6 hours
b. 24 hours
c. 48 hours
d. 72 hours

Ans: A

406. 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?
a. High protein foods
b. Soy- based foods
c. Foods high in vitamin K
d. Foods containing goat’s milk

Ans: C

407. 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?
a. Normal white blood cell count
b. Normal hematocrit count
c. Normal platelet level
d. Normal potassium level

Ans: A

408. 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:
a. Assessment
b. Diagnosis
c. Implementation
d. Evaluation

Ans: D

409. A plan of care for a child with cerebral palsy should include all the following except:
a. Physical therapy

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b. Play
c. Feeding
d. Bowel and bladder training

Ans: D

410. 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. A side effect
b. An indication of drug tolerance
c. A drug allergy
d. A toxic effect

Ans: A

411. A patient is diagnosed with peptic ulcer. What would be the long term goal for this patient?
a. Patient remainsfree of signs and symptoms of gastrointestinal bleeding
b. Patient maintains lifestyle alterations to prevent recurrence of ulcer
c. Patient expresses decreased pain level
d. Patient performs activities of daily living without difficulty

Ans: B

412. A patient visits the clinic for the first time. In order to perform an accurate and complete assessment, which of
the following would be the nurse first step?
a. Obtain a temperature, pulse and respiration
b. Obtain a complete history
c. Obtain a blood pressure
d. Perform a review of systems

Ans:B

413. The nurse is assigned to care for a patient who has recently been diagnosed with Crohn’s disease. The initial
treatment is usually:
a. Dietary changes
b. Reversible colostomy
c. Permanent colostomy
d. Watchful waiting

Ans: A

414. 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:
a. Stress
b. Urge
c. Overflow
d. Functional

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Ans: C

415. When caring for child with spina bifida, the nurse knows that the child has an increased risk of allergy to:
a. Peanuts
b. Strawberries
c. Eggs
d. Latex

Ans: D

416. When planning a class on pregnancy, the nurse should include symptoms of pregnancy that must be reported
immediately, such as:
a. Leg cramps
b. Vision disturbance
c. Swelling of the legs
d. Constipation

Ans: B

417. Which of the following reacts to viruses and bacteria by increasing in number?
a. Antigens
b. Antibodies
c. Rh factors
d. Platelets

Ans: B

418. A nurse is assessing a child with cystic fibrosis. After thoroughly assessing respiratory status, the nurse should
assess which of the following?
a. Level of pain
b. Skin turgor
c. Genitourinary status, clarity of urine
d. Nutritional status, characteristics of stool

Ans: A

419. 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?
a. 10
b. 25
c. 50
d. 100

Ans: C

420. 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?

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a. Pneumonia
b. Hypoxia
c. Postoperative bleeding
d. Bronchopleural fistula

Ans: B

421. 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?
a. Blood pressure
b. Pulse
c. Temperature
d. Respiration rate

Ans: B

422. 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?
a. Hemothorax
b. Perforation of the heart
c. Pneumothorax
d. Hemorrhage

Ans: C

423. 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:
a. Direct contact with contaminated soil
b. Direct contact with respiratory secretions
c. Sexual intercourse
d. Ingestion of contaminated food

Ans: d

424. 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?
a. Pulmonary embolism
b. Atelectasis
c. Pneumonia
d. Aspiration

• Answer A

425. 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 ?
a. Increased WBC

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b. Decreased hematocrit level
c. Increased hemoglobin
d. Decreased platelet

• Answer A

426. 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 :
• a. Sepsis
• Atelectasis
• Internal hemorrhaging
• Excess fluid volume

• Answer A

427. 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?
a. Pleural effusion
• Tension pneumothorax
• Pneumothorax
• Hemothorax

• Answer B

428. 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 outcome 24 hours postoperatively?
• Gag reflux present
• Cerebral perfusion pressure , 68mm Hg
• Intracranial pressure , 21 mm Hg
• Decreased lacrimation

• Answer C

429. 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 nurse should ask the patient to :
a. Write YES on the leg
b. Write OTHER ONE on the right leg
c. Draw an arrow on the left knee pointing upward
d. Draw an arrow on the left knee pointing downward

• Answer C

430. 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 suspects hemorrhage. The
patient’s vital signs remain 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

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• Answer A

431. 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

432. 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 discoloration 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

433. 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

434. A patient with chronic obstructive pulmonary disease complains of a frequent cough, bilateral wheezing is
auscultated in the lung fields. The nurse administers 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

435. 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 :
a. Assessment
• Diagnosis
• Implementation

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• Evaluation

• Answer D

436. 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?
a. Discharge planning
• Instruct
• Monitoring and surveillance
• Therapeutic interventions

• Answer D

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

• Answer B

438. To reduce the risk of treatment methicillin resistant staphylococcus aureus from an infectious wound which of
the following standard precautions should be implemented
a. Airborne
b. Contact
c. Droplet
d. Reverse isolation

Ans – B

439. A patient is experiencing intermittent claudication in the legs while at rest . Which of the following should
the nurse take ?
a. Vigorously massage the extremity
b. Place ice on the ankles every 20 mnts
c. Elevate the legs to heart level
d. Position the legs in dependent position

ANS – C

440. 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. A sterile towel
b. Petroleum gauze
c. Normal saline solution
d. Sterile gloves

ANS—C

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441. 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?
a. Indoor allergies
b. Intubation
c. Chest trauma
d. Co sack virus

ANS – A

442. 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?
a. Stays in bed
b. Verbalize constant pain
c. Avoids social gathering
d. Accepts altered body image

ANS: D

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

ANS –B

444. 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
a. Impetigo
b. Ringworm
c. Ascariasis
d. Amoebiasis

Answer: B

445. 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?
a. 100ml
b. 200ml
c. 300ml
d. 400ml

Answer: A

446. 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?
a. Feeling well rested each morning

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b. Not feeling tired each afternoon
c. Taking brief nap in the middle of the day
d. Using sleep aid on a nightly basis

Answer: A

447. 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?
a. It sounds like SLE is being well controlled
b. I need to get some nitroglycerine for your chest pain
c. There may be some inflammation surrounding your heart
d. Your symptoms may be due to a urinary tract infection

Answer: C

448. A patient has been hospitalized with a new diagnosis of crohn’s disease. The nurse best determine the patients
hydration level by monitoring the
a. Color of urine
b. Brightness of eyes
c. Capillary refill in nail beds
d. Temperature of lower extremities

Answer: C

449. 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
a. Over assertion the day before
b. Pulmonary edema
c. wound infection
d. deep vein thrombosis

Answer: C

450. 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 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?
a. Notify the doctor that there appears to be nerve damage of the right leg
b. Refer to pain management specialist for long term management
c. Refer to psychiatrist for evaluation since the patient has no right ankle
d. Explain the phenomena of phantom pain and phantom sensation to the patient

Answer: D

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451. 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;
a. To ask the child in simple terms about the comfort level of the past week
b. By direct observation of the child’s non-verbal behaviors during the visit
c. To teach the child how to use wong/baker faces pain rating scale
d. To interview the parent about behavior, moods, and sleep patterns over the past week

Answer: D

452. 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
a. Decreased phantom limb sensation
b. Increased range of motion after surgery
c. Decreased depression after surgery
d. Decreased likelihood of cancer recurrence

Answer: A

453. 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
a. Active range of motion exercise
b. Passive range of motion exercise
c. Active assistive range of motion exercise
d. Resistive range of motion exercise

Answer: B

454. 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?
a. Staphylococcal pneumonia
b. Pneumocystis carinii pneumonia
c. Bronchiolitis
d. Mycoplasma pneumonia

Answer: D

455. 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:
a. Structural factors (incompetent valves)
b. Impaired ventricular expansion
c. Impaired contractility
d. Fluid volume deficit

Answer: C

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456. 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?
a. Regain full hearing
b. Minimal facial nerve paralysis
c. Minimal urinary incontinence
d. Ambulate without difficulty

Answer A

457. When teaching a patient how to use a cane after a cerebral vascular accident (CVA), the nurse should make sure
the patient:
a. Uses the cane on the unaffected side
b. Advances the cane simultaneously with affected limb
c. Holds the cane away from the body
d. Moves the cane past the toes of the affected limb

Answer: A

458. 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. A dietician
b. An endocrinologist
c. An ophthalmologist
d. A physical therapist

Answer: C

459. Which nursing diagnosis takes priority for newly diagnosed patient with a left-sided stroke?
a. Risk for impaired swallowing related to absent gag reflex
b. Risk for impaired skin integrity related to immobility
c. Risk for infection related to invasive line placement
d. Risk for impaired speech related to left side stroke

Answer: A

460. 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?
a. Sepsis
b. Atelectasis
c. Congestive heart failure
d. Emphysema

Answer: B

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461. 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?
a. It is OK to use a straight edge razor when shaving
b. Blood pressure checks should be done in the left arm
c. Cuticle should not be cut
d. Avoid insect repellent on the left arm

Answer: C

462. 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:
a. Ineffective tissue perfusion
b. Fluid overload
c. Arterial occlusion
d. Deep vein thrombosis

Answer: D

463. 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
a. Coughing and deep breathing every 30 minutes
b. Positioning and turning every 2 hours
c. Range of motion exercise to all extremities every hour
d. Ambulates at least 20 steps every shift

Answer: B

464. A patient is 3 week postoperative left below the knee amputation. Which of the following is an expected
outcome for this patient?
a. Verbalize relief of incisional pain, has intense phantom sensation
b. Participates in care plan, express concern about independence
c. Full passive range of motion, requires assistance with transfers
d. Low grade temperature, dressing reinforced every hour Answer: B
465. During postoperative neuromuscular assessment of a patient who had a total knee replacement nurse assesses
the peroneal nerve by testing sensation:
a. On the bottom of the foot
b. In the space between great and second toe
c. In the anterior to the rectum
d. In the anterior portion of the calf Answer: B
466. 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

4‫ودالشمال‬
patients bowel sounds are absent and nasogastric tube is connected to low, intermittent suction. The nurse should
prepare to begin:
a. NG feeding

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b. Rapid weaning from the ventilator
c. Total parenteral nutrition
d. Chest physiotherapy Answer: C
467. 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?
a. Decrease the O2 to 1 L/minut and monitor O2 saturation
b. continue the O2 at 2 L/minut and monitor O2 saturation
c. Increase the O2 to 3 L/minut and monitor O2 saturation
d. continue to monitor O2 saturation and call the doctor for new orders
Answer: C
468. A child is treated for bacterial meningitis with an intravenous antimicrobial agent. Which of the following BEST
indicates effectiveness of the treatment?
a. Increased appetite
b. Temperature 37.2 C(99 F)
c. Episodes of apnoea
d. Increased intra cranial pressure

Answer: B

469. 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:
a. 30 to 60 minutes before meal
b. 90 to 120 minutes before meal
c. With apple sauce
d. With milk

Answer: A

470. 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?
a. Baclofen
b. Diazepam
c. Amantadine
d. Phenytoin

Answer B

471. 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:
a. resistive range of motion exercise
b. passive range of motion exercise
c. Active assistive range of motion exercise
d. Active range of motion exercise Answer: B

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472. 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?
a. heart rate
b. O2 saturation
c. Core temperature
d. Blood pressure

Answer: B

473. 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 a specific gravity of 1.001 to 1.005 the patient is MOST likely develop[ing
a. Diabetic mellitus
b. Diabetic insipidus
c. Hypothyroidism
d. Thyroid storm

Answer: B

474. 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, tachypnea and blood
pressure is rising. Which of the following complication is MOST likely?
a. Pneumonia
b. Hypoxia
c. Postoperative bleeding
d. Broncho pleural fistula

Answer: B

475. 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?
a. Health- seeking behavior
b. knowledge deficit , high risk behavior
c. Low self esteem
d. Altered thought process

Answer: B

476. 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?
a. Circulating nurse
b. Scrub Nurse
c. RN first assistance
d. Nurse anesthetist

Answer: A

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477. 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?
a. I need to gradually increase my activities
b. I will not need the influenza or pneumonia vaccine
c. I may experience fatigue and weakness for a prolonged time
d. I need to have another chest x-ray in 4-6 weeks

Answer: B

478. The nurse is assessing a patient recently diagnosed with acquired immune deficiency syndrome (AIDS). Which of
the following nursing diagnosis has PRIORITY?
a. Fear of disease progression, treatment effects, isolation and death related having aids
b. Risk for infection related immunodeficiency
c. Ineffective breathing pattern related to opportunistic infection
d. Disturbed body image related to rapid body changes from debilitating disease

Answer: C

479. A patient to have an elective surgical procedure to repair an umbilical hernia. The patient is 68 year old, weighs
136 kg( 300lb), and has diabetic mellitus. Which of the following approaches would be the MOST beneficial in order to
reduce the patient surgical risk?
a. Monitor blood glucose level monthly
b. Avoid fluid overload by restricting fluid
c. Discourage any changes in routine before surgery
d. Encourage weight reduction

Answer: D

480. A nurse caring for a patient following cardiac catheterization evaluates the patient post procedure, which of the
following signs and/or symptoms would MOST likely indicate the patient is having a vagal reaction?
a. diaphoresis
b. Chest pain
c. Tingling in extremities
d. Hematoma formation

Answer: B

481. 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 exercises 30 minutes a day 3 times a week. Which of the following educational intervention takes
PRIORITY?
a. Glucose monitoring
b. Medications
c. Dietary requirements
d. Exercise regimen

Answer: C

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482. Which of the following Best describes the assessment step of the nursing process?
a. Identifying nursing interventions as appropriate for short- term, intermediate, and long-term goal attainment
b. Assigning priorities to the nursing diagnosis
c. Establishing goals or expected outcomes
d. Obtaining a nursing history and complete a physical examination of the patient

Answer: D

483. 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:
a. Lift the dressing to assess the area
b. Ask if the patient is having any pain
c. Apply firm pressure for 10 to 15 minutes
d. Assess the apical pulse

Answer: C

484. 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:
a. Reposition the patient on the right side
b. Irrigate the nasal gastric tube to check patency
c. Medicate the patient for pain as ordered
d. Increase the suction on his nasal gastric tube to high intermittent suction

Answer: C

485. 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:
a. Inform the anesthesiologist immediately
b. Tell the patient the surgery must be rescheduled
c. Record the information on the form in red ink
d. Obtain blood sample and notify the attending physician

Answer: C

486. 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?
a. Prealbumin
b. Hemoglobin
c. Albumin
d. 24- urine creatinine

Answer: B

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487. 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?
a. Cough productive of serosanguineous fluid
b. 1+ pretibial edema
c. Nap after completing bed bath
d. Frequent premature ventricular contractions (PVC)

Answer: C

488. 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?
a. The patient will use a laxative every other day
b. The patient will have a soft bowel movement daily
c. The patient will report minimal pain with bowel movements
d. The patient will limit the intake of complex carbohydrates

Answer: B

489. 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:
a. Set consistent behavior limits
b. Be more lenient during times of illness
c. Cherish the limited time the child has to live
d. Avoid upsetting the child with limit setting

Answer: A

490. 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?
a. “You can use the stethoscope to listen to your heart and your doll’s, and then I will listen’
b. “You must not wiggle while listen to your heart. You can hold your doll’
c. The stethoscope will feel cold on your chest. You can tell your doll how cold it feels”
d. “ let go of your doll and place your hands on your tummy while I use the stethoscope”

Answer: A

491. A nursing process which involves the performance of the nursing plan care is:
a. Assessment
b. Nursing diagnosis
c. Implementation
d. Evaluation

Answer: C

492. 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?
a. Minimize invasive procedure
b. Crush oral medications

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c. Limit intake of vitamin K rich foods
d. Monitor the temperature every 4 hours

Answer: A

493. 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?
a. Risk for impaired skin integrity related to decreases sensation and circulation
b. Excess fluid volume related to disease process
c. Risk for injury to decrease gastric mobility and stress response
d. Deficient fluids volume related to diarrhea and loss of fluids and electrolytes

Answer: A

494. 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?
a. The child will recognize the urge to defecate daily
b. The parent will use praise when the child defecates in the toilet
c. Predictable, regular bowel habits will be restored and maintained
d. Toilet training will be delayed until the child is cognitively ready

Answer: A

495. The nurse is teaching a patient about spironolactone (aldactone). Which of the following instructions should the
nurse review with the patient?
a. Increasing intake of foods that are high in potassium
b. Taking the medication right before going to sleep
c. Avoiding seasoning that are labeled as salt substitutes
d. Scheduling the medication so that a multi vitamin is taken an hour later

Answer: A

496. Position maintained in self enema administration ANS - SIMS

497. Position maintained post vitrectomy

ANS – PRONE

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498. The nurse in preparing to insert RYLE’S tube (NGT) into an infant, the nurse knows that the length of the
tube should be taken as following:
a. From the nose down to the chin and then to the umbilicus
b. From the nose to the earlobe and then to the xiphoid process
c. From the nose to the mouth to the xiphoid process

499. A nurse is admitting a six month- old infant with pneumonia. Which of the following interventions
supports this infant’s emotional needs?
a. Allow the parents to leave the room during painful procedures
b. Encourage parents to distract the infant from crying
c. Interview the patents to learn the infant’s comforting habits
d. Enforce strict visiting schedule and routines

500. A patient visits the clinic for a 2- week checkup after a corneal transplantation (keratoplasty). The nurse
observes the patent’s sclera is red and the patient complains of the eye feeling irritated. The nurse suspects the patient
may have:
a. Infection
b. Hemorrhage
c. Graft rejection
d. Postoperative glaucoma

501. A patient has an order for 100 milliliters (ml) of intravenous (IV) fluid to infuse over eight hours. The available IV
tubing has a drip factor of 10 gtts/ml. Which of the following rates is correct?
a. 125 ml/hour
b. 125 drop/minute
c. 21 drops/minute
d. 21 ml/hour

502. When performing a newborn assessment, the nurse should measure the vital signs in the following sequence:
a. Pulse, respirations, temperature
b. Temperature, pulse, respirations
c. Respirations, temperature, pulse
d. Respirations, pulse, temperature

503. A patient is scheduled for a pneumonectomy in the morning. Which of the following diagnosis is the MOST likely
indication for this type of surgery?
a. Lung carcinoma
b. Pulmonary tuberculosis
c. Benign pulmonary nodule
d. Mediastinal shift

504. A 40 year- old woman presented with right hip pain. Palpation of the pelvic girdle is normal. An X- ray shows
bone deformities,with osteolytic lesions and bone enlargement. The patient has not suffered any trauma and has been
generally healthy. Which serum laboratory analysis would be most useful?
a. Prothrombin time
b. Alkaline phosphatase (if this high, calcium will be low and opposite)
c. Acid phosphatase
d. Parathyroid hormone

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505. What is the first intervention for a client experiencing MI?
a. Administer morphine
b. Administer oxygen (wasn’t from the list)
c. Administer sublingual nitroglycerin
d. Obtain an ECG

506. In planning home care for an immune-compromised child, the nurse instructs the parents to use cream or
emollients to prevent or manage dry and cracked skin. A parent will BEST demonstrate understanding of the rationale
for this be stating:
a. Creams will prevent breaks in the skin and decrease the chance of infection
b. Pleasantly scented creams will mask other less pleasant smells
c. Micronutrients in the creams will help prevent malnutrition
d. Creams will help prevent dehydration when my child does not drink enough

507. A 50 year-old male presents to the medical office 3 weeks after cardiac surgery with complaints of a feeling of
weakness, difficulty breathing, and joint pains. Upon examination the nurse finds a fever and a friction rub on
auscultation of the chest. The nurse recognizes that the MOST likely surgical complication is:
a. Neuropsychological dysfunction
B. Postpericardiotomy syndrome
c. Cardiac tamponade
d. Phrenic nerve damage

508. A 3-week-old infant is hospitalized with jaundice. When considering the fluid needs relative to body size of the
infant as compared to the fluid needs of an adult. The nurse knows this infant requires:
a. Less fluids
b. More fluids
c. Same amount of fluids
d. Much less fluid

509. Patient with diagnosis of Dilated cardiomyopathy. [700] The Medication order:
Glucophage 850mg po. qd Imdur 60mg. po .qd Lasix 80mg. po. qd Zocor 40mg. po. Qd
Past medical history: Heart failure, DM type 2, Peripheral vascular disease (pvd) & primary hyperlipidemia
Based on the patient's history which of the following medication orders should the nurse verify?
a. Glucophage
b. Zocor
c. Lasix
d. Imdur

510. The nurse is discussing the human immunodeficiency virus (HIV) with a group of high - risk patients. The nurse
should state that this virus is found MOST commonly in which of the following body fluids?
a. Blood
b. Saliva
c. Breast milk
d. vaginal secretions

511. The nurse assesses a patient who is 16-weeks pregnant. The patient states that she had taken isotretinoin
(Accutane) , a known teratogen for acne during her third, fourth, and fifth week of pregnancy According to the chart, the
nurse CAN expect fetal damage to the central nervous system as well as the:

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a. Palate and eare.
b. Heart, lower limbs, and palate.
c. Limbs, eyes, and teeth.
d. Heart, eyes, and limbs.

512. A community health nurse visits a patient who has suffered a stroke. The patient’s spouse explains to the nurse
that the patient chokes while eating some times. Which of the following referral orders would the nurse anticipate
needing for this patient?
a. Speech therapist
b. Dietician
c. Physical therapist
d. Neurologist

513. A patient who is 4 days postoperative after a total hip replacement surgery, is obese and has not been able to
ambulate since the surgery. The patient is now diaphoretic, has chills, and complains of pain in the thigh. There is
tenderness over the anteromedial surface of the thigh. The MOST likely cause is.
a. Wound infection
b. Deep vein thrombosis (DVT)
c. Pulmonary edema
d. Dehydration

514. You educate group of people about the prevention of Cerebro- Vascular Accident (CVA), this education about
CVA prevention consider as:
a. Primary
b. Secondary
c. Thread

Explanation: Primary stroke prevention refers to the treatment of individuals with no history of stroke.
Secondary stroke prevention refers to the treatment of individuals who have already had a stroke or transient ischemic
attack.

515. Question about Kubler theory…

e.g. As identified by Dr. Elizabeth Kubler-Ross, which stage of dying is characterized by the transition from, "NO, not me"
to "Yes, me, but ... "
a. Anger
b. Depression
c. Acceptance
d. Bargaining

516. Kubler-Ross’s five successive stages of death and dying are:

a. Anger, bargaining, denial, depression, acceptance
b. Denial, anger, depression, bargaining, acceptance
c. Denial, anger, bargaining, depression acceptance
d. Bargaining, denial, anger, depression, acceptance

517. A client undergoes right mastectomy for carcinoma. When teaching the client post-mastectomy exercises, it is
important for the nurse to:
a. Exercise both arms simultaneously
b. Exercise the right arm only

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c. Have the client wear a sling between exercise periods
d. Wait until the incision has healed

518. A patient with blood transfusion, the patient has reaction, what is the highest priority to do as intervention?
a. Stop the I.V

519. (similar question) Nurse caring for a patient receiving a transfusion assesses that the patient is wheezing
and is complaining of back pain. After the nurse stops the transfusion, the nurse should:
a. discontinue the IV.
b. notify the charge nurse.
c. administer heparin.
d. raise the patient’s head.

520. (similar question) Adult patient complains of diarrhea, vomiting, abdomen cramp and pain within the
past 2 weeks. The patient reported that the pain increases when he eats and relieves when he passes stool. Which of the
following may be the cause:
a. Appendicitis
b. Crohnâ€TMs disease
c. Ectopic pregnant
d. Cholecystitis

521. A surgery procedure that must be done within 24 hours is called:

a. Selective surgery
b. Elective surgery
c. Urgent surgery
d. Emergency surgery

522. Aortic anyrism operation what type of surgical intervention:

a. Elective
b. Urgent
c. Emergency
d. Diagnostic

523. A patient is scheduled for a bowel resection. The preoperative plan of care includes putting on antiembolism
stockings prior to the transferring the patient to the operating room. What these stockings will do‘?
a. Promote venous return
b. Minimize joint stillness
c. Encourage sustained maximum inspiration
d. Support intestinal peristalsis

524. The nurse performs a routine assessment of newborn boy who was born 30 minutes before. One testicle is
descended and the urinary meatus opens on the underside of the ventral shaft. Based on the findings, which additional
body part should be examined carefully?
a. Anus
b. Buttocks
c. Umbilicus

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d. Groin

525. A boy with skin disease, when you recommend the boy to go back to school?
a. When you see scaly over the skin
b. When he has temperature
c. When all symptom of skin disease are disappear

526. In the summer months, a five year old girl present with a sore throat and a dry cough that has slowly become
worse over the past three weeks, her body temperature is 38 c, on auscultation, there is a wheezing and shortness of
breath. She lives in an overcrowded house with three brothers, parents and grandparents in a low- income
neighborhood where she attend school. Which is the greatest risk favtor?
a. Resident in low-income neighborhood
b. Attending School
c. Exposure to pathogens in summer season
d. living crowded condition

527. A young girl that living with her parents and her grandfather going to bad hygienic school she affected with a
virus what the possible cause for her disease :
a. The virus transferred to her from the school
b. The summer wither is the cause
c. The virus transferred from the unclean city she lives in.
d. The crowded home.

528. Instrument which is used to examine the eye structure is called:

a. Ophthalmoscope
b. Laryngoscope
c. Otoscope
d. Bronchoscope

529. To examine the ear canal of the child, this is done by:
a. Pull the ear down and back
b. Pull the ear up and back
c. Pull the ear only back
d. Do not pull the ear, direct examine the ear by otoscope

530. To instill drops in the adult patient , the ear canal is opened by pulling the ear :-
a. up and back
b. down and back
c. up and forward
d. back and forward

531. A nurse is preparing to perform an otoscopic examination on an adult client. The nurse does which of the
following to perform this examination?
a. Pulls the pinna up and back before inserting the speculum
b. Pulls the earlobe down and back before inserting the speculum
c. Uses the smallest speculum available to decrease the discomfort of the exam
d. Tilts the client's head forward and down before inserting the speculum

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532. Patient came to emergency department with coughing and difficulty in breathing, you suspect patient has
asthma attack, the sound you expect to hear is:
a. Wheezing
b. Chronic
c. Crackle

533. Question about ECG, what is the most appropriate diagnosis?

a. Atrial Fibrillation
b. Atrial Flutter

534. A child came to the emergency complaining of diarrhea, abdominal pain and
vomiting. After the investigation it reveals that
he eats contaminated food and got germs, what kind of germs you suspect to find in the test result?
a. Streptococcus
b. typhoid

535. Patient came or diagnose with bradycardia, what is the appropriate treatment?
a. Atropine

536. Patient came to the clinic with pimples over all his body, the patient start to be alone and keep away from
people arround him. As well he starts to disappear due to how he looks?
a. Social isolation
b. anxiety
c. depression

537. A female patient pregnant 9 months, came to the emergency with bleeding and clot discharge with blood, what
is the diagnosis?
a. Placenta Pravia
b. Abrubito
c. Bleeding

538. A patient has received a unit of blood, after 1 hour the patient start to have chills and difficult breathing, there is
a high temperature, what might this indicate?
a. Septicemia

539. What of the following has propriety to check before start giving patient blood transfusion
a. Blood group
b. Name
c. Expiry date

540. Which of the following disease consider as an epidemic diseases? TB

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541. A new infant has just born, what is the most important and first priority to do for this infant?
Avoid heat loss

542. A child with the cast in a hand, how the nurse can assess the circulation, (capillary refill),?
Pulse

543. A patient post-operative of tonsillectomy, after few days he came to follow up and inform the doctor of strange
taste in this throat and ''Oder'' present< what is the best diagnosis for this patient? Infection

544. A child complain of abdominal pain, has bloody stool and greenish vomiting, what the appropriate nursing
intervention?
Give an enema

545. Which of the following is the most common yypes of leukemia that occur in the child period?
Lympho

546. A child diagnosis with bronchitis, what is the most appropriate instructions can be giving to the child parents
when discharge home?
Hand Washing

547. Which of the following patient with the heart diseases has fluid volume exceed?
Right heart failure

548. A patient with post-operative of a kidney surgery, what is the most complication that may happen for this
patient?
Hemorrhage

549. Patient with Alzheimer diseases, he looks confuse and often leave his room and went out. What i the first safety
take into account for this patient?
Raise side reel of the bed

550. A patient has allergy to fish, why this could be important data to obtain from the patient?
Because the patient will be affected due to Iodine

551. An infant he born 2 days ago, has difficulty in breathing and swelling over all his body and around the umbilical,
the body tend to yellow color, what is the best diagnosis for this case?
a. Hepatitis

552. Patient has complain of diarrhea, whcih look like ''rice diarrhea'', what is the most common causes for this kind
of diarrhra?
a. Cholera

553. A nurse do pevention procedure for cancer patient, this consider as?
a. primary prevention

554. A patient always feel she's full stomach, and feel lazy, what you recommend her?
a. eat less amount in a short time

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555. Which of the following consider as epdomic diseases?
a. TB

556. Scenario; patient pass stool look like clay, what may cause this problem?
a. clay stool – hepatitis

557. A pregant lady was taking food with - - calorie, how she supposed to take a calorie after delivery?
a. 1500 K.calorie

558. When the colostomy site look is red color that indicate?
a. normal

559. Patient feels cold even in the summer season, what the blood test you should do?
a. FSH

560. An old man with swelling in the tips of finger and has a fever, the patient expiernce what?
a. rheumetic arthritis

561. A child with bronchitis, what you should teach to his parents?
a. Hand hygiene

562. A child has tongue reflex, what might be the reason?

a. cerebral damage

563. A child is expeirencig difficulty in breathing due to bronchitis, what you should encourage this child to do?
a. encourage him to drink fluide

564. You have a patient with increasing in Ph; 7.50, and she has a vomiting as well, what you suspect her diagnosis
based on PH?
a. metabolic acidosis

565. A child has an operation and has lapoctomy, complicated to breathing difficulty and increase in heart rate, what
you suspected?
a. hypoxia

566. A child with burns injury, what make this patient not eating?
a. acute pain

567. You have a cancer patient, what priority you should do for this patient?
a. pain management

568. A diabetic patient schedule for operation, which of the following medication he can take while he is NPO
(nothing per oral)?
a. Glucophage

569. A patient has got insuline prescribed to him, what you suspect this patient has?
a. thrombosis

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570. A patient with CVA has plan for discharge, as a nurse what you should educate the patient?
a. using aspirin

571. On the auscultation, the physician heard the patient's heart with crackle sound and wheezing, where could the
problem is exist?
a. left ventricular

572. The pulse pressure is?

a. different between systolic and diastolic

573. A patient complains of pain the eye with high pressure on the eye as well, what is the right surgery for this
patient?
a. trabeculectomy

574. Patient who look confused, does not know his name and not orient to time, what the diagnosis for this patient/
a. Dementia

575. A child post-operative, how you can know and assess if he comfort or in pain?
a. Through observation, non-verbal (because he is a child)..

576. Patient has swelling on both legs, to assess and diagnosis this, which of the following i should do?
a. auscultation
b. palpitation
c. inspection

577. Patient with swalloing difficulty and has a fever, the appropriate diagnosis is?
a, pharyngitis

578. A mother came to the clinic and says that her baby does not feed well and lose weight as well he has a yellowish
color, what you expect the baby has?
a. problem in the liver

579. A patient with TB history, after the investigation he has the TB positive, what you should do next?
a. x-ray

580. A nurse educates a group of people about hyper-active, and said this how can be releaved?
a. x-ray
b. has no investigation or blood test
c. through blood

581. Patients sugar and sugar naturally what is the first step that you need to re-evaluate?
a. Glyccaylon

582. The patient has a surgical procedure what is the thing that is important to make sure of it?

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a. consent

583. After the surgery the patient was not conscious as side effect of?
a. Anesthetics

584. The patient has allergies and Dr. distract him medication allergenic what interventions
a. Call Dr. to change medicine

585. A [child / boy] in the emergency-department, oriented, crying and open his eyes spontaneously, the child move
as responding to pain, based on Glasgow Coma Scale, the child scores at:
a. 15
b. 13
c. 11
d. 9

586. The nurse is caring for a full-term new born who was delivered vaginally 5 minutes ago. The infant's APGAR
score was 8 at one minute and 10 at 5 minutes. Which of the following has the highest PRIORITY?
a. Maintaining the infant in the supine position
b. Assessing the infant's red reflex
c. Preventing heat loss from the infant- check !
d. Administering humidified oxygen to the infant

587. A child with deformity (broken) nose, the child went to the school and his friends find this funny, the child was
upset and went to the nurse in the school and told him, he will stop coming to school, the nurse toke a paper and draw
the child face and nose and tell him that ‘he will look like them after the procedure’. In which step the nurse perform:
a. Self-confidence
b. Self-deception

588. A child with burn injury, the burn covers 80 % of the child body, what is the appropriate diagnosis:
a. Liquid deficiency
b. Ineffective airways clearance

589. A boy has done tonsillectomy surgery, 2 hours later, the child complain of pain 7 from 10, what is the
appropriate diagnosis,
A. Acute pain
b. Swallowing difficulty

590. A newborn in 38 weeks, the infant was cyanotic, what is the best position for him:
a. Supine
b. Prone
c. Lateral

591. A nurse is administering IM injection to an infant, the nurse should use any area:
a. Left glottal
b. Right glottal
c. Rectus femoris

592. A 4 years old girl, was playing outside, she came to her mom crying and holding her right upper arm, she went to
the hospital with swelling over the upper arm, pain and itching, the appropriate management is:

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a. Maintain patent airway
b. Administer s/c epinephrine
c. Prepare for intubation

593. A woman she is on the18 week gestation her physicaian will insert a fine needle in her abdomen for anlaysis the
nurse is assistant in this procedure as nurse what is the color of liquid you expect to come out:
a. White
b. Yellow
c. Browen
d. Green browen

594. Patient with fecal ileostomy, in the lower left part of abdomen, the stool form will be:
a. Mushy
b. Solid
c. Watery

595. A child / boy in the emergency-department, oriented, crying and open his eyes spontaneously, the child move as
responding to pain, based on Glasgow Coma Scale, the child scores at:
a. 15
b. 13
c. 11
d. 9

596. A patient schedule for pneumonectomy, what is the name of this surgery, (what is the appropriate surgery) for
this patient;
a. Lung carcinoma

597. A patient got high dose of Morphine, what is the antidote of Morphine:
a. Nalaxone

598. A hand photo with opened fingers is this:

a. Abduction

599. Patient with pancreatectomy, what is the most cause of the surgery (this surgery to what may lead):
a. Diabetes mellitus

600. Patient came to emergency with lacenation in the left arm, what the first intervention for this patient:
a. Elevate the right arm and put ice
b. Give analgesic in the wound
c. Do pressure on the wound

601. To minimize a toddler from scratching and picking at healing skin graft, the nurse should utilize:
a. Mild sedatives
b. Hand mittens
c. Punishment for picking
d. Distractions

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602. 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 O2 saturation on 2L of
oxygen via nasal cannula is 86%. The nurse should IMMEDIETLY administer.
a. Flumazenil (Romazicon)
b. Midazolam (Versed)
c. Naloxone (Narcan)
d. Ondansetron (Zofran)

603. The nurse is caring for a full-term new born who was delivered vaginally 5 minutes ago. The infant's APGAR
score was 8 at one
minute and 10 at 5 minutes. Which of the following has the highest PRIORITY?
a. Maintaining the infant in the supine position
b. Assessing the infant's red reflex
c. Preventing heat loss from the infant
d. Administering humidified oxygen to the infant

604. A 23 year- old male comes to the Emergency Department in a sickle cell crisis. He reports that his pain level is a
10/10 in all extremities. During the assessment, he cannot lie still because of the pain. There is no cyanosis or clubbing in
the extremities and all examination findings are normal. The vital signs recorded were: Blood pressure 132/82 mmHg
Heart rate 110/min Respiratory rate 18/mm Temperature 38.4°C Oxygen Saturation 94 % an room air Which nursing
diagnosis is first priority?
a. Acute pain
b. Fluid volume deficit
c. Ineffective tissue perfusion
d. Ineffective airway clearance

605. A newborn was delivered pre-term weighing 2700 grams with. Apgar scores of 4 and 6, respectively. When the
mother had presented to the Obstetrical Triage Unit, she was already 7 centimeters dilated and fully effaced. Her due
date was unknown as she had no parental care. The infant showed signs of fetal distress and was finally delivered by
Cesarean section. At birth a large, thin, membranous sac was protruding from the umbilical base. What is the priority
nursing intervention at birth?
a. Maintain cardio respiratory stability
b. Protect the herniated viscera
c. Manage fluid intake and output
d. Establish vascular access

606. An 82 year-old woman with Alzheimer's disease had moved into a long-term care facility two weeks previously.
Since then, the staff has found her wondering in the hallways in middle of the night. When approached, she is confused
and frustrated, often forgetting where she is. Which intervention would most likely decrease the patient's confusion?
a. Administer a sleeping sedative
b. Provide full-time nursing care
c. Place a nightlight in the room
d. Provide a large meal before bed

607. A 16 year-old boy is in the Post-Operative Care Unit two hours after a tonsillectomy. He is alert and oriented but
complains of severe throat pain and difficulty swallowing. He rates the pain at a level 7, on a scale of 1-10. The urine
output from the folly catheter is 45 ml over the past two hours.
Blood pressure 130/74 mmHg Heart rate 64/min Respiratory rate 18/min Oxygen saturation 98 % on room air, Which
clinical finding is most important to report to the doctor?

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a. Oxygen saturation
b. Difficulty swallowing
c. Urinary output
d. Pain level

608. According to information provided in the accompanying graphic.

A descending colon would be expected to produce
a. Fluid feces
b. Mushy faces
c. Semi-solid faces
d. Solid faces

609. A 45 year-old patient has had difficulty sleeping and has lost ten kilograms despite having a large appetite on
examination there is a palpable thyroid gland.
Blood pressure 108/58 mmHg Heart rate 116/min Respiratory rate 22/min Body temperature 38.0 c oral Height 164
Weight 50 kilograms
Which additional symptom is most likely?
a. Heart palpitations.
b. Depression.
c. Anorexia.
d. Paresthesia.

610. Dyspnea is defined as:

a) Pallor
b) Absence of breathing
c) Cyanosis
d) Difficult respiration

611. Mrs Ahmed age 53, her pulse rate is found to be 52 per minute.
Her heart rate could be described as:
a) Tachypnea
b) Tachycardia
c) Bradypnea
d) Bradycardia

612. When you assess the respiratory rate for the patient, you should do all of the following EXCEPT:
a) Instruct the patient to breath in and out from his mouth.
b) Count each inspiration followed by expiration as one breath.
c) Make sure that the patient is not aware that you are counting his respiratory rate.
d) Count the respiratory rate for 30 seconds.

613. To examine the ear canal of the child, this is done by:
a) Pull the ear down and back
b) Pull the ear up and back
c) Pull the ear only back
d) Do not pull the ear, direct examine the ear by otoscope

614. The advantage of use head to toe approach when you assess the patient:
a) It increase the number of position changes

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b) It helps to prevent overlooking some aspect of data collection
c) It takes more time
d) It is difficult to detect the disease or problem

616. Discharge planning for hospitalized patient begins:

a) When the treating Dr. gives discharge order
b) When all of the specific needs of the patient have been identified
c) When the patient begins to ask about his discharge plans
d) From the first day of admission

617. Abnormal skin color which indicates yellowish color is called:

a) Erythema
b) Ecchymosis
c) Jaundice
d) Pallor

618. Which of the following is considered as subjective data?

a) Anxiety
b) Skin color
c) Height
d) Temperature

619. The physician has ordered an indwelling urinary catheter inserted in a hospitalized patient, the nurse is aware
that:
a) The procedure requires surgical asepsis
b) Lubricant not needed for catheter insertion
c) Smaller catheters are used for male catheter
d) Normally a clean technique is required for catheter insertion

620. Diarrhea is best described by its:

a) Amount
b) Consistency
c) Frequency
d) Odor

621. Medication is instilled between the skin & the muscle and used to administer Heparin.
a) Intravenous
b) Intramuscular
c) Intradermal
d) Subcutaneous

622. The angle of the syringe and needle for intramuscular injections is:
a) 90 degrees
b) 45 degrees
c) 15 degrees
d) 10 degrees

623. Is the term used to administered undiluted medication quickly into a vein:
a) Bolus

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b) Secondary infusion
c) Intermittent
d) Continuous

624. A primary concern when giving heparin subcutaneously to prevent bleeding is:
a) Don’t make massage on the injection site
b) To make massage on the injection site
c) Use the smallest gauge needle that is appropriate
d) Use Z technique

625. To ensure that medications are prepared and administered correctly, the nurse
should:
a) Give the medication without question
b) Use the patient's rights
c) Give the medication only when requested
d) Use the FIVE rights

626. The doctor order is 300 cc of normal saline solution, to be finished within 4 hours, how many drop/min you will
regulate this IV (drop factor is 20 drop/minute).
a) 10 drop/min
b) 15 drop/min
c) 25 drop/min
d) 35 drop/min

627. All of the following is used Central Venous Catheter, EXCEPT:

a) Clients require long term IV medication
b) IV medications are irritating to peripheral veins
c) Clients require short term IV medication
d) Difficult to insert peripheral catheter

628. A pre-operative check list form that should be completed before surgery, it should be including which of the
following?
a) The surgical consent form
b) All laboratory test
c) Vital Signs
d) All of above

629. The process of removing poisonous substance through gastric intubation is called:
a) Gastric Lavage
b) Gastric Gavage
c) Gastric Decompression
d) Gastric Tamponade

630. Of the following, which are the earliest signs of excessive pressure:
a) Pale appearance of the skin
b) Reddened appearance of the skin
c) Ulcer formation on the skin
d) Dark or cyanotic color to the skin

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631. To prevent the formation of thrombi in the postoperative patient, the nurse should
a) Teach foot and leg exercises
b) Have the patient lie still
c) Place pillows under the knee
d) Lie in lateral position

632. Which of the following is used to determine the activity of the brain:
a) Electrocardiography
b) Electromyography
c) Electroencephalography
d) Echocardiography

633. An infection that the patient acquires in the hospital is called:

a) A local infection
b) An endogenous infection
c) A nosocomial infection
d) A secondary infection

634. The nursing activity most likely to prevent the clogging of a nasogastric feeding tube is:
a) Attaching the tubing to suction after each feeding
b) Clamping the tubing after formula feeding
c) Flushing the tubing with water and clamping it after each feeding
d) Aspirate as much as possible from the tubing using a 50 ml syringe

635. When an order reads that a drug be administered t.i.d, how often should this drug be given?
a) Every three hours
b) Three times a day
c) Four times a day
d) Every other day

636. Dorsal recumbent position is used when performing the following procedures EXCEPT:
a) Suppository insertion
b) Cystoscopic examination
c) Urinary catheter insertion
d) Vaginal examination

637. Which action is believed to be the most useful in preventing wound infections?:
a) Using sterial dressing supplies
b) Performing careful hand hygiene
c) Suggesting dietary supplements
d) All of the above

638. The single most effective way to prevent nosocomial infections is to:
a) Isolate patients with infections
b) Cover the mouth and nose when coughing
c) Wash all equipment detergents
d) Practice continuous hand washing

639. Vitamin K. 10 mg given IM is ordered. Vitamin K is available as 5 mg/ml. How much would the nurse administer?

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a) 2 ml
b) 6 ml
c) 4 ml
d) 8 ml

640. Nonverbal communication includes all of the following EXCEPT?

a) Facial expression
b) Grooming and crying
c) Posture and mode of dress
d) Speaking in low voice

641. The condition in which a person is aware of his or her own heart contraction without having to feel the pulse is
called:
a) Arrhythmia
b) Dysrhythmia
c) Pulse rhythm
d) Palpitation

642. Cyanosis is blue color of skin, is caused by:

a) Fever
b) Hypertension
c) Low tissue oxygenation
d) Kidney disease

643. Instrument which is used to examine the eye structure is called:

a) Ophthalmoscope
b) Laryngoscope
c) Otoscope
d) Bronchoscope

644. A pattern in which the nursing personnel divide the patient into groups and complete their care together is
called:
a) Primary method
b) Team nursing
c) Nursing managed care case method
d) Case method

645. The term used to describe blood in the urine.

a) Glycosuria
b) Hematuria
c) Pyuria
d) Albuminuria

646. The normal color of urine is:

a) Dark amber
b) Reddish brown
c) Cloudy
d) Light yellow

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647. When a person has a fever or diaphoresis, the urine output will be which of the following:
a) Increased and diluted
b) Increased and concentrated
c) Decreased and highly diluted
d) Decreased and highly concentrated

648. When administering medication via nasogastric tubing, clamp the tube for at least:
a) One half hour prior to medication administration to prevent complication
b) One half hours after instilling medication to allow for absorption
c) One hour prior to medication administration to prevent complication
d) One and one half hours after instilling medication to allow for absorption

649. The nurse chooses to inject a prescribed intramuscular medication into the ventrogluteal site. If the nurse
selects the site correctly, the injection is administered into the.
a) Hip
b) Arm
c) Thigh
d) Buttock

650. 500 mg of a drug is order. It is supplied in tablets of 1 gm per tablet. How many tablets should be administered?
a) 0.5 tablet
b) 1 tablet
c) 1.5 tablet
d) 2 tablet

651. One of your patients complains of difficulty of breathing, all of the following measurement which help improve
breathing EXCEPT:
a) Put your patient in semi- fowler's position
b) Teach patient breathing techniques
c) Put the patient in prone position
d) Give oxygen therapy

652. The process of removing poisonous substance through gastric intubation is called:
a) Gastric Lavage
b) Gastric Gavage
c) Gastric Decompression
d) Gastric Tamponade

653. During the inflammation process, which of the following characteristics occur first:
a) Swelling
b) Pain
c) Redness
d) Decreased functioning

654. Paracentesis is best described as:

a) The removal of fluid from the lung
b) The removal of fluid or air from pleural cavity
c) The removal of body fluid from the abdominal cavity

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d) The removal of secretion from the stomach

655. Which of the following is used to determine the activity of the brain:
a) Electrocardiography

b) Electromyography
c) Electroencephalography
d) Echocardiography

656. When planning Mr. Asem care (50 years) who demonstrates difficulty in breathing. Which of the following
positions is most appropriate?
a) On either side
b) Flat on his back
c) On his abdomen
d) Mid-Flower's position

657. The following manifestations are commonly associated with a fever, EXCEPT:
a) Headache
b) Pinkish and red skin color
c) Bradycardia
d) Convulsions in infants and child

658. Dorsal recumbent position is used when performing the following procedures EXCEPT:
a) Suppository insertion
b) Cystoscopic examination
c) Urinary catheter insertion
d) Vaginal examination

659. If a vial of Gentamycin contains 80 mg in 2 ml, the physician order is 16 mg every 8 hr., the nurse should give
every time:
a) 0.1 ml
b) 0.2 ml
c) 0.3 ml
d) 0.4 ml

660. If a nasogastric tube has been misplaced in the trachea during preparation to obtain a gastric specimen, the
nurse should anticipate that the patient will:
a) Have difficulty in breathing
b) Swallow every few seconds
c) Gage without relief
d) Complain of feeling nauseated

661. Blood and urine analysis confirm a diagnosis of salicylate overdose. The client is treated with gastric lavage.
Which of the following positions would be most appropriate for the client during this procedure?
a) Lateral
b) Trednelenburg’s
c) Supine
d) Lithotomy

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662. All of the followings are signs of HYPOXIA Except:
a) Rapid pulse
b) Cyanosis
c) Rapid shallow respiration

d) Diarrhea.

663. Hypercabnia is:

a) Bluish discoloration of the skin nails beds and mucosal membrane.
b) Inadequate alveolar ventilation can lead to hypoxia.
c) Accumulation of carbon dioxide in the blood.
d) Slow respiration rate.

664. Which position allow maximum chest expansion to the client:

a) Prone.
b) Semi folwer.
c) Supine.
d) Lateral

665. Which one of the following its major function to supply energy:
a) Protein
b) Carbohydrates
c) Fats
d) Minerals

666. What number 18 indicate, regarding body mass index scale (BMI):
a) Underweight
b) Morbidly obese
c) Malnourished
d) Normal

667. Constipation is:

a) Fewer than 5 bowel movement per week.
b) Fewer than three bowel movement per week.
c) Passage of liquid feces and increased frequency of defecation.
d) air or gas in GI tract

668. All of the followings are normal characteristics of feces Except:

a) Brown color.
b) Very hard and solid.
c) Amount: varies with diet.
d) Odor: affected by digested food

669. Oliguria is:

a) Production of abnormally large amount of urine by kidneys.
b) Lack of urine production, with no effective urine production.
c) voiding that either painful or difficult.
d) Low urine output, usually less than 500 ml a day, or 30 ml an hour.

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670. All of the followings are normal characteristics of urine Except:
a) Volume: 1200- 1500 ml per day
b) Straw color.
c) Sterile, no microorganisms.
d) Cloudy.

671. Medical asepsis includes:

a) Hand washing.
b) Personal protective equipment (uniform, gown, gloves, face mask).
c) Cleaning, Disinfecting, Sterilizing.
d) All of the above.

672. Acute infection is:

a) Infection may occur slowly and takes long time.
b) is limited to the specific part of the body where micro- organisms remain.
c) Infection appears suddenly or in short time.
d) When microorganisms spread and damage different part of body.

673. Indirect transmission of infection includes:

a) Vehicle born transmission.
b) Vector borne transmission.
c) A only correct.
d) A and B are correct.

674. Incubation period of infection is:

a) Person is most infectious and nonspecific sign and symptom.
b) Organism growing and multiplying.
c) Recovery from infection.
d) Presence of specific sign and symptom.

675. All of the following laboratory data indicating infection EXCEPT:

a) Increased specific type of leukocyte.
b) Increased in body temp.
c) Decreased WBC.
d) Positive culture in blood, urine or sputum.

676. Health is defined as:

a) State of complete physical, social, mental, and spiritual wellbeing and not merely
absence of disease.
b) Felling of wellbeing.
c) Absence of disease.
d) State of complete physical and mental wellbeing only.

677. The patient should be fasts (NPO) before the surgery for:
a) 24 hours.
b) 16 hours.
c) 6 to 8 hours.
d) 12 hours.

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678. Complications of wound healing include:
a) Hematoma.
b) Nausea.
c) Hypertension.
d) All of the above

679. Which of the following vital signs are normal?

a) Temp: 37, RR: 22, HR: 90, BP: 135/85.
b) 75, BP: 125/80. Temp: 36.7, RR: 18, HR:
c) Temp: 38, RR: 12, HR: 110, BP: 155/90.
d) Temp: 37.2, RR: 16, HR: 50, BP: 115/65

680. Hyperthermia is:

a) Body temperature between 36.4 – 37.4
b) Body temperature between 39 – 41
c) Body temperature below 36.
d) Body temperature between 38 – 40.

681. All of the following are clinical sign of fever except:

a) Palled.
b) Shivering.
c) Decrease thirst.
d) Increase heart rate.

682. All of the following factors are increase respiratory rate except:
a) Decrease temp.
b) Stress.
c) Exercise.
d) Increase altitude.

683. The most safe and non-invasive site to measure the temperature is:
a) Oral site.
b) Auxiliary site.
c) Rectal site.
d) Tympanic site.

684. The difference between rectal and auxiliary temp is:

a) 0.5 c
b) 0.8 c
c) 2c
d) 1 c.

685. In which phase of nursing process the nurse collect data about the client:
a) Diagnosis.
b) Assessment.
c) Implementation.
d) Evaluation.

686. Chief complains includes:

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a) Immunization and childhood illness.
b) Hoppies and sleep pattern.
c) Risk factor for certain diseases.
d) The answer given to question “what brought you to the hospital”

687. The chief complain should be record using:

a) Nurse words.
b) Patient words.
c) Physician words.
d) None of the above.

688. Nursing diagnosis is:

a) A statement that describes actual health problem only.
b) A statement that describes potential health problem only.
c) A statement that describes actual and potential health problems.
d) Puts the nursing care plan into action.

689. The nursing diagnosis includes all the following except:

a) Problem.
b) Time.
c) Sign.
d) Etiology.

690. Pressure ulcer risk factors include:

a) Immobility and inactivity.
b) Fecal and urinary incontinence.
c) Decreased mental status.
d) All of the above.

691. All of the following are clinical manifestations of fluid volume excess except:
a) Edema
b) Oliguria
c) Distended neck veins
d) Increased CVP

692. Signs and symptoms of Hypovolemic shock are all of the following except:
a) Tachycardia
b) Hypertension
c) Pallor and cyanosis
d) Tachypnea

693. Normal Saline 0.9% solution is considered as which of the following:

a) Isotonic solution
b) Hypotonic solution
c) Hypertonic solution
d) None of the above

694. Apnea is medical term means:

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a) Rapid pulse
b) Increase body temperature
c) Stop breathing
d) Low blood pressure

695. When blood sugar level is above normal range, this means that patient has:
a) Hypotension
b) Hypoglycemia
c) Hyperglycemia
d) Bradycardia

696. The most important thing should be done after any nursing action is:
a) Documentation
b) Nursing diagnosis
c) Planning
d) All of the above

697. All of the following are assessment sites for body temperature except:
a) Oral Site.
b) Rectal Site.
c) Axillary Site.
d) Apical

698. Mr. Ashraf aged 35 years old, his pulse rate is found to be 120 bpm. His heart rate could be described as:
a) Tachypnea.
b) Tachycardia.
c) Bradypnea
d) Bradycardia.

699. Which of the following factors are affecting body temperature:

a) Food intake.
b) Age and Gender
c) Climate.
d) All of the above

700. The condition in which the body temperature is above the average normal is called:
a) Bradypnea
b) Fever.
c) Hypertension.
d) Hypothermia.

701. Which of the following best describes the technique of palpation:

a) The use of the sense of hearing to listen for sounds.
b) The use of tapping on a particular part of the body to produce sounds.
c) The use of the senses to evaluate general appearance of the patient.
d) The sense of touch to feel the body by slight or deep pressure.

702. Inhalation or inspiration means:

a) Stop breathing.

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b) Difficult breathing.
c) Breathing out.
d) Breathing in

703. Normal body temperature is ranging from:

a) 35.8 – 37.4 C
b) 34.5 – 36.5 C
c) 35.0 – 38.0 C
d) 36.5 – 38.5 C

704. Pulse pressure is defined as which of the following:

a) Difference between systolic and diastolic pressure.
b) Expansion of the artery as blood moves through it.
c) Difference between arterial and venous pressure.
d) Difference between venous and systolic pressure.

705. Unoccupied bed making means:

a) Changing linen when the patient remains in the bed.
b) Changing linen when the bed empty.
c) State in which a person is relieved of distress.
d) None of the above.

706. The most accurate time for measuring pulse rate is:
a) 30 seconds.
b) 15 seconds.
c) 60 seconds.
d) 45 seconds.

707. Practices that promote health throughpersonal cleanliness is called:

a) General appearance.
b) Self-image.
c) Insomnia.
d) Hygiene.

708. All of the following are therapeutic bathes except:

a) Shampooing bath.
b) Whirlpool bath,
c) Medicated bath.
d) Sitz bath.

709. Orthopnea is defined as:

a) Breathing facilitated by sitting or standing up.
b) Absence of breathing.
c) Rapid breathing.
d) Difficult breathing.

710. Which of the following is a form of radiography:

a) Fluoroscopy.

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b) Contrast medium.
c) C.T. Scan
d) All of the above

711. The examination that indicates physical inspection of the vagina and cervix with palpation of uterus and ovaries
is called:
a) A Pap test.
b) Electrocardiography.
c) Pelvic examination.
d) Paracentesis.

712. Procedure that involves the insertion of a needle between lumber vertebra in the spine but below the spinal
cord itself is called:
a) Lumber puncture.
b) Paracentesis.
c) Pelvic Examination.
d) Electromyography.

713. Which of the following is considered as a benefit of bathing:

a) Improving self-image.
b) Eliminating body odor.
c) Stimulating circulation.
d) All of the above.

714. Ventilation means:

a) Movement of air in and out of the chest.
b) Movement of air out of the chest.
c) Movement of air in the chest.
d) None of the above.

715. All of the following are common factors that invalidated examination or test
results except:
a) Inadequate specimen volume.
b) Failure to send the specimen in a timely manner.
c) Correct diet preparation.
d) Insufficient bowel cleansing.

716. All of the following are physical assessment techniques except:

a) Inspection.
b) Percussion.
c) Puncturing.
d) Palpation

717. All of the following are post procedural nursing responsibilities except:
a) The nurse has to attend the patient for comfort and rest.
b) Care of specimens.
c) Assist the examiner.
d) Record and report of information.

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718. A patient is prepared for hemodialysis. He receives heparin before therapy before primarily to help:
a) Relieve discomfort
b) Prevent blood clotting
c) Maintain blood pressure

d) Stimulate the production of urine

719. Another name for a stone in the urinary tract is:

a) Calix
b) Calculus
c) Calcemia
d) Calcitonin

720. Urine that remains in pt's bladder after he voids is called:

a) Reflux urine
b) Over flow urine
c) Retention urine
d) Residual urine

721. For a normal person the urine specific gravity is ranged between:
a) 1.000 and 1.010
b) 1.015 and 1.025
c) 1.025 and 1.050
d) 1.050 and 1.070

722. Which of the following is OBJECTIVE data:

a. Dizziness
b. Chest pain
c. Anxiety
d. Blue nails

723. Among the following statements, which should be given the HIGHEST priority?
a. Client is in extreme pain
b. Client’s blood pressure is 60/40
c. Client’s temperature is 40 degree Centigrade
d. Client is cyanotic.

724. Considered as the most accessible and convenient method for temperature taking is:
a. Oral
b. Rectal
c. Tympanic
d. Axillary

725. In cleaning the thermometer after use, The direction of the cleaning to
follow Medical Asepsis is :
a. From bulb to stem
b. From stem to bulb
c. From stem to stem

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d. From bulb to bulb.

726. Which is a preferable arm for BP taking?

a. An arm with the most contraptions
b. The left arm of the client with a CVA affecting the right brain

c. The right arm

d. The left arm.

727. In palpating the client’s breast, which of the following position is necessary for the patient to assume before the
start of the procedure?
a. Supine
b. Dorsal recumbent
c. Sitting
d. Lithotomy.

728. When is the best time to collect urine specimen for routine urinalysis and culture and sensitivity?
a. Early morning
b. Later afternoon
c. Midnight
d. Before breakfast.

729. This is a process of removing pathogens but not their spores:

a. Sterilization
b. Autoclaving
c. Disinfection
d. Medical asepsis

730. This is the single most important procedure that prevents cross contamination and infection
a. Cleaning
b. Disinfecting
c. Sterilizing
d. Hand washing.

731. The best example of the nursing order is:

a. Encourage fluids.
b. Change patient position every 2 hours on even hours.
c. Provide oral fluid.
d. All of the above.

732. The term holism refers to:

a. Reactions that occur when equilibrium is disturbed.
b. How an organism responds to change.
c. A relatively stable state of physiologic equilibrium.
d. The sum of physiological, emotional, social, and spiritual health, and determines how whole person feels.

733. When the nurse changes the client's dressing which nursing action is correct:
a. The nurse removes the solid dressing with sterile gloves.
b. The nurse frees the tape by pulling it away from the incision.

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c. The nurse encloses the solid dressing within a latex gloves.
d. The nurse cleans the wound in circles toward the incision.

734. Which of the following IS NOT true about preparing medication:

a. Prepare medication under well-lighted area.
b. Work alone without interruptions.

c. Do not use medication with a missing label.

d. Check the label of the drug two times.

735. How often should an inactive patient's positions be changed?

a. At least every 3 hours.
b. At least every 2 hours.
c. At least every 4 hours.
d. At least once a shift.

736. Hypertonic saline (fleet) enema works by:

a. Distending the rectum.
b. Irritating the rectum.
c. Lubricating and softening stool.
d. Moistening stool.

737. The physician orders dextrose 5% in water, 1,000 ml to be infused over 8 hours. The I.V. tubing delivers 15
drops/ml. The nurse should run the I.V. infusion at a rate of:
a) 15 drops/minute
b) 21 drops/minute.
c) 32 drops/minute.
d) 125 drops/minute

738. Hypertension is defined as persistent blood pressure levels in which the systolic and diastolic above
a) 110/60 mmHg
b) 130/80 mmHg
c) 120/70 mmHg
d) 140/90 mmHg

739. Of the following, which are the earliest signs of excessive pressure?
a) Pale appearance of the skin
b) Reddened appearance of the skin
c) Ulcer formation on the skin
d) Dark or cyanotic color to the skin

740. When an order reads that a drug be administered q.i.d, how often should this drug be given?
a) Every three hours
b) Three times a day
c) Four times a day
d) Every other day

741. Which action is believed to be the most useful in preventing wound infections?:
a) Using sterial dressing supplies

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b) Performing careful hand hygiene
c) Suggesting dietary supplements
d) All of the above

742. The single most effective way to prevent nosocomial infections is to:
a) Isolate patients with infections

b) Cover the mouth and nose when coughing

c) Wash all equipment detergents
d) Practice continuous hand washing

743. Vitamin K. 10 mg given IM is ordered. Vitamin K is available as 5 mg/ml. How much would the nurse administer?
a) 2 ml
b) 6 ml
c) 4 ml
d) 8 ml

744. Which one of the following diets include only water, tea, coffee, clear juice:
a) Clear liquid diet
b) Soft diet
c) Full liquid diet
d) Diabetic diet

745. The intentional wound is:

a) Occur during therapy.
b) Occur accidentally.
c) The mucous membrane or skin surface is broken.
d) The tissue is traumatized without a break in the skin.

746. The abrasion is:

a) Open wound involving skin only
b) It is due to surface scrape.
c) It is painful wound.
d) All of the above.

747. All of the followings are risk factors for nosocomial infections EXCEPT:
a) Poor hand washing.
b) Using sterile techniques.
c) Contamination of closed drainage system.
d) Improper procedure technique (dressing, suctioning, catherization).

748. Acute infection is:

a) Infection may occur slowly and takes long time.
b) is limited to the specific part of the body where microorganisms remain.
c) Infection appears suddenly or in short time.
d) When microorganisms spread and damage different part of body.

749. Indirect transmission of infection includes:

a) Vehicle born transmission.

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b) Vector borne transmission.
c) A only correct.
d) A and B are correct.

750. Incubation period of infection is:

a) Person is most infectious and non-specific sign and symptom.

b) Organism growing and multiplying.
c) Recovery from infection.
d) Presence of specific sign and symptom.

751. All of the followings are Signs of systematic infection EXCEPT:

a) Fever.
b) Vomiting.
c) Fatigue and loss of energy.
d) Enlargement and tenderness of lymph node.

752. All of the followings are etiologies of self-care deficit EXCEPT:

a) scar and abrasions.
b) Activity intolerance or weakness.
c) Mental impairment.
d) Visual impairment.

753. Skin turgor is:

a) Decrease sensation in extremities due to nerves system disease.
b) Collection of fluids inside the tissue.
c) Elasticity by lifting and pulling the skin on an extremity.
d) None of the above.

754. Pressure ulcer risk factors include:

a) Immobility and inactivity.
b) Fecal and urinary incontinence.
c) Decreased mental status.
d) All of the above.

755. Scrub nurse role includes:

a) Assist the surgeons.
b) Draping the client with sterile drapes.
c) Handling sterile equipment’s and supplies.
d) All of the above.

756. Example of health promotion:

a) Immunization.
b) Direct care (give medication).
c) Stop cigarette smoking.
d) All of the above is correct.

757. Immunization is an example of:

a) Health promotion.

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b) Prevent illness.
c) Restoring health.
d) Care of the dying.

758. The primary methods used to examine the skin, mucus membrane and hair are:
a) Inspection and palpation

b) Percussion and inspection

c) Palpation and auscultation
d) Auscultation and percussion

759. Hemoptysis is:

a) Cough with secretions.
b) Cough without secretions.
c) Difficult breathing.
d) Blood in the sputum.

760. Which of the following best define pulse deficit?

a) The difference between the apical and radial pulse rates.
b) The difference between the systole and diastole values.
c) The difference between the brachial and radial pulse rates.
d) The difference between the temporal and femoral pulse rates.

761. When the blood pressure is 140 / 100 mmHg, the pulse pressure is:
a) 40 mmHg
b) 142 mmHg
c) 100 mmHg
d) 242 mmHg

762. The relationship between the pulse and respiratory rate is represented by
Which of the following ratios:
a) One respiration to 2 or 3 heartbeat.
b) One respiration to 3 or 4 heartbeat.
c) One respiration to 4 or 5 heartbeat.
d) One respiration to 5 or 6 heartbeat.

763. All the following can cause hypertension except:

a) Excessive exercise and activity
b) Pain and emotions
c) Diseases such as atherosclerosis
d) Hemorrhage

764. The type of pulse that is strong and doesn’t disappear with moderate pressure is known as:
a) Absent pulse
b) Thready pulse
c) Weak pulse
d) Bounding pulse

765. A process of heat loss which involves the transfer of heat from one surface to Another without contact is:

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a) Radiation
b) Conduction
c) Convection
d) Evaporation

766. The geriatric client with a history of heart attack and hypertension presented with complaints of unusual
weakness and fatigue. Upon examination, the nurse noted diminished breath sounds throughout the lung fields and
crackles on both the lower lobes. Which of the following should be the next action of the nurse?
a. Notify the physician and document initial findings.
b. Facilitate chest x-ray
c. Start a thorough physical examination and history.
d. Recheck the client after five minutes and see if there are changes.

767. The client presented with complaints of rapid and shallow breathing. Upon lung auscultation, breath sound is
diminished on both lung bases and there’s audible course crackles on the upper lobes. If the condition worsens, which of
the following tests can be used to determine if intubation is necessary?
a. Peak flow meter
b. Partial Oxygen Saturation in Arterial Blood Gas
c. Oxygen Saturation in Pulse Oximeter
d. Lung Function test

768. The client with a genetic enzyme deficiency had an abnormal and different response to the drug administered
for the first time. This reaction is called as:
a. Allergic reaction
b. Cumulative effect
c. Idiosyncratic effect
d. Synergistic effect

769. The ICU nurse is preparing the instruments needed for endotracheal intubation. The nurse is knowledgeable
that clients in the ICU often need mechanical assistance to maintain a patent airway. Which of the following is NOT an
indication for endotracheal intubation?
a. Respiratory distress
b. Prolonged mechanical ventilation
c. High risk of aspiration
d. Ineffective clearance of secretions

770. The client with severe sensory alteration is transferred to the intensive care unit. Moments later, the client
became restless and agitated with complaints of hallucinations. The nurse noted the change in the level of
consciousness as:
a. Delirium
b. Dementia
c. Stupor
d. Confusion

771. The client complained of abdominal discomfort on the first postoperative day. Upon percussion of the lower
abdomen, the nurse expects to hear:
a. Dull
b. b. Flat
c. Tympanic

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d. Resonant

772. The nurse is performing a physical examination to the client with hearing difficulty. The nurse activated the
tuning fork and placed it on top of the client’s head. What test did the nurse perform?
a. Whisper test
b. Rinne test
c. Audiometer
d. Weber test

773. The nurse is in charge of the client with cardiac complaints. As a part of the cardiac assessment, the nurse
auscultates the mitral area which is located at:
a. 2nd ICS, Right sternal borde
b. 2nd ICS, Left sternal border
c. 5th ICS, Left sternal borde
d. 5th ICS, Medial to the midclavicular line

774. The nurse is caring for a client with abalanced suspension traction with a Thomas splint. The nurse observes that
the left leg of the client is externally rotated. Which of the following is the priority of the nurse?
a. Place a trochanter roll outside the thigh.
b. Perform resistive range of motion of the affected leg
c. Adduct and internally rotate the left leg.
d. Maintain the left leg in a neutral position.

775. The client is admitted and is on the fourth cycle of chemotherapy. During the night shift, the nurse noted signs
of extravasation. Which of the following is NOT a sign of extravasation?
a. Local infection
b. Tissue breakdown
c. Redness and heat on the site
d. Pain on the IV site

776. The nurse is instructing the client about early detection of cancer. The nurse should instruct the client to
perform breast self- examination during:
a. The first day of every month
b. B The first day of menstruation
c. Before menstruation
d. After menstruation

777. The geriatric client presented with complaints of difficulty in swallowing, fatigue, alternating constipation and
diarrhea, abdominal pain, and blood in the stools. Which of the following symptoms is NOT included in the warning signs
of cancer?
a. Irregular pattern of constipation and diarrhea
b. Blood in the stools
c. Difficulty in swallowing
d. Frequent vomiting

778. The client presented with complaints of body weakness, dizziness and chest pain. Upon careful assessment, the
nurse suspects Angina Pectoris. Which of the following statements made by the client can confirm this?
a. I suddenly felt a pain on my chest which radiates to my back and arms.
b. I suddenly felt a sharp pain on my lower abdomen.

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c. The pain does not subside even if I rest.
d. The pain goes all the way down to my stomach.

779. The client from the OR is transferred to the post-anesthesia care unit after surgical repair of abdominal aortic
aneurysm. Which of the following assessment findings would indicate that the repair was successful?
a. Urine output of 50 mL/hr.
b. Presence of non-pitting, peripheral edema
c. Clear sclera.
d. Presence of carotid bruit

780. The client is scheduled for cardiac catheterization because the physician wants to view the right side of the
heart. Which of the following would the nurse expect to see in this procedure?
a. A dye is injected to facilitate the viewing of the heart
b. Thallium is injected to facilitate the scintillation camera
c. A probe with a transducer tip is swallowed by the client.
d. A tiny ultrasound probe is inserted into the coronary artery

781. The nurse is caring for an adult patient with extensive burns on the front of the trunk, including the genitalia,
and the fronts of right legs. Using the rule of nines, the nurse would document that the burn size as:
a. 13%
b. 17%
c. 28%
d. 37%

782. Following abdominal surgery, a child has a nasogastric tube connected to suction. Several hours after surgery,
the child tells the nurse that he is nauseated and then vomits approximately 200 ml of fluid. Which of these actions
should the nurse take first?
a. Notify the physician
b. Check if the nasogastric tube can be irrigated
c. Discontinue the section attached to the nasogastric tube
d. Auscultate for bowel sounds

783. During the first 24 hours post burn, fluid replacement is the treatment priority. The assessment that would alert
the nurse that the fluid protocol is ineffective is:
a. Marked edema in the burn area.
b. Rectal temperature of 101º F
c. Crackles in the lower left lobe.
d. Urine output of 20 mL/hour.

784. A client who had a myocardial infarction has an order for digoxin (Lanoxin)0.25 mg po daily and furosemide
(Lasix) 40 mg intravenously, stat. Because the client is receiving these medications, the client should be assessed for
which of the following manifestations?
a. Tachycardia
b. Hypokalemia
c. Hypertension
d. Oliguria

785. During the nurse’s preoperative assessment, the nurse notices that the patient is extremely anxious. The
patient’s blood pressure is 142/92 mm Hg, heart rate is 104 per minute, and respirations are

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34. The nurse should:
a. Notify the anesthesiologist or surgeon
b. Call the operating room and cancel the surgery.
c. Go ahead and give the preoperative medicine early to help calm the patient.
d. Instruct the patient on possible postoperative complications.
786. A client who has Alzheimer’s disease is told by the nurse to brush his teeth. He shouts angrily, “Tomato soup!”
Which of these comments by the nurse would be appropriate?
a. Here is your toothbrush. First get your toothpaste, then wet your brush.”
b. “I don’t understand what you mean by “tomato soup.”
c. “You seem upset.”
d. “I’ll brush your teeth for you.”

787. An infant on the pediatric unit suddenly starts to have generalized seizure activity. Which of these actions should
the nurse take first?
a. Insert a padded tongue blade into the infant’s mouth.
b. Test the infant’s pupillary response to light at least twice during the seizure.
c. Suction the infant’s oropharynx several times during the seizure.
d. Note the duration of the infant’s seizure.

788. Because an infant has a meningomyelocele in the lumbosacral area, the infant should be observed for early
symptoms of hydrocephalus, which include
a. Overriding of cranial bones
b. A soft, flat anterior fontanel
c. An increase in head circumference
d. Prominent scalp veins

789. A nurse in a newborn nursery receives a phone call to prepare for the admission of a 43-week-gestation
newborn with Apgar scores of 1 and 4. In planning for the admission of this infant, the nurse’s highest priority should be
to:
a. Connect the resuscitation bag to the oxygen outlet
b. Turn on the apnea and cardiorespiratory monitors
c. Set the radiant warmer control temperature at 36.5* C (97.6*F)
d. Set up the intravenous line with 5% dextrose in water

790. A newly delivered infant has a pink trunk and blue hands and feet, pulse rate of 60 and does not respond to your
attempts to stimulate her. She also appears to be limp and taking slow, gasping breaths.
What is her Apgar score
a. 3
b. 6
c. 7
d. 9

791.(TB) has a productive cough and hemoptysis. Which of the following types of isolation room would be the BEST
choice for the patient?
a. Negative-pressure
b. Positive-pressure
c. Reverse isolation
d. D Standard isolation

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792. A hospitalized child develops exanthema (rash) that covers the trunk and extremities. The nurse reviews the
child’s health history and notes that the child was exposed to varicella 2 weeks ago. Which nursing intervention is most
appropriate to implement?
a. Immediately admit the client to any available bed.
b. Place the child in a private room on strict isolation.
c. Assess the progression of the exanthema and report it to the health care provider.
d. Allow the child to play in the playroom until the health care provider can be contacted

793. A nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a
pregnancy with placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which of the
following risks associated with placenta previa?
a. Infection
b. Hemorrhage
c. Chronic hypertension
d. Disseminated intravascular coagulation

794. A nurse is suctioning fluids from a client through an endotracheal tube. During the suctioning procedure, the
nurse notes on the monitor that the heart rate decreases. Which of the following is the most appropriate nursing
intervention?
a. Ensure that the suction is limited to 15 seconds
b. Continue to suction
c. Hold the procedure and re-oxygenate the client
d. Notify the physician immediately.

795. An intubated patient is receiving continuous enteral feedings through a Salem sump tube at a rate of 60ml/hr.
Gastric residuals have been 30-40ml when monitored Q4H. You check the gastric residual and aspirate 220ml. What is
your first response to this finding?
a. Notify the doctor immediately.
b. Discard the 220ml, and clamp the NG tube
c. Give a prescribed GI stimulant such as metoclopramide (Reglan).
d. Discontinue the feeding, and clamp the NG tube.

796. You’re performing an general assessment on patient who is 52 y.o. In which order do you proceed if the
abdomen is not included in this session of assessment?
a. Observation, percussion, palpation, auscultation
b. Inspection, palpation, auscultation, percussion
c. Percussion, palpation, auscultation, observation
d. Inspection, percussion, observation, auscultation

797. When teaching a client with a cardiac problem, who is on a a low saturated fat diet, the nurse should stress the
importance of decreasing the intake of:
a. Vegetables and whole grains
b. Fish and shrimp
c. Nuts and beans
d. Butter, lamb meats

798. A 68-year-old woman is scheduled to undergo mitral valve replacement for severe mitral stenosis and mitral
regurgitation. Although the diagnosis was made during childhood, she did not have any symptoms until 4 years ago.

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Recently, she noticed increased symptoms, despite daily doses of digoxin and furosemide. During the initial interview
with the nice lady, the nurse would most likely learn that the client’s childhood health history included:
a. Chicken pox
b. Rheumatic fever
c. Meningitis
d. Poliomyelitis
799. A client has driven himself to the ER. He is 50 years old, has a history of hypertension, and informs the nurse
that his father died of a heart attack at 60 years of age. The client is presently complaining of indigestion. The nurse
connects him to an ECG monitor. The nurse’s next action would be to:
a. Start intravenous line and draw blood for cardiac enzymes
b. Begin intravenous line then call doctor
c. Administering oxygen at 2 L/minute per NC then begin intravenous line
d. Administering oxygen 12 l/minute per oxygen face mask and obtain a portable chest radiograph

800. A nurse is assessing the blood pressure of a client diagnosed with primary hypertension. The nurse ensures
accurate measurement by considering which of the following?
a. Taking a blood pressure within 5 minutes after nicotine or caffeine ingestion.
b. Measuring the blood pressure after the client has been seated quietly for 5 minutes.
c. Using a cuff with a rubber bladder that encircles at least 30% of the limb.
d. Seating the client with arm bared, supported, lower than heart level.

801. A 35-year-old male was knifed in the street fight, admitted through the ER, and is now in the ICU. An assessment
of his condition reveals the following symptoms: respirations shallow and rapid, CVP 15 cm H2O, BP 90 mm Hg systolic,
skin cold and pale, urinary output 30 mL/hr for the last 2 hours. Analyzing these symptoms, the nurse will base a nursing
diagnosis on the conclusion that the client has which of the following conditions?
a. Hypovolemic shock
b. Cardiac tamponade
c. Wound dehiscence
d. Atelectasis

802. A nurse is assessing the neurovascular of a client who has returned to the surgical nursing unit 4 hours ago after
undergoing aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is
palpable and unchanged from admission. The nurse interprets that the neurovascular status is:
a. Slightly deteriorating and should be monitored for another hour
b. Moderately impaired, and the surgeon should be called
c. Normal because of increased blood flow through the leg
d. Adequate from an arterial approach, but venous complications are arising.

803. A client comes into the E.R. with acute shortness of breath and a cough that produces pink, frothy sputum.
Admission assessment reveals crackles and wheezes, a BP of 85/46, a HR of 122 BPM, and a respiratory rate of 38
breaths/minute. The client’s medical history included DM, HTN, and heart failure. Which of the following disorders
should the nurse suspect?
a. Pneumonia
b. Pneumothorax
c. Pulmonary edema
d. Pulmonary embolism

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804. 55-year-old client is admitted with an acute inferior-wall myocardial infarction. During the admission interview,
he says he stopped taking his metoprolol (Lopressor) 5 days ago because he was feeling better. Which of the following
nursing diagnoses takes priority for this client?
a. Ineffective tissue perfusion
b. ineffective airway clearance
c. Ineffective therapeutic regimen management
d. Ineffective communication pattern
805. Which of the following would the nurse identify as the priority nursing diagnosis during a toddler’s vasoocclusive
sickle cell crisis?
a. Pain related to tissue anoxia
b. Pain related to fear of unknown
c. Pain related to sever anxiety
d. Pain related to increased cardiac output

806. The client experiencing 7th cranial nerve (facial Nerve ) damage will most likely report which of the following
symptoms?
a. Bell's palsy
b. Vertigo
c. Impaired vision
d. Headache

807. A client with COPD has developed secondary polycythemia. Which nursing diagnosis would be included in the
plan of care because of the polycythemia?
a. Impaired tissue perfusion related to thrombosis
b. Activity intolerance related to dyspnea
c. Impaired tissue perfusion related to decrease cardiac output
d. Impaired tissue perfusion related to blood loss

808. A female client comes into the emergency room complaining of SOB and pain in the lung area. She states that
she started taking birth control pills 3 weeks ago and that she smokes. Her VS are:
BP :140/80, Pulse 110, R 40.
The physician orders ABG’s, results are as follows: pH: 7.50
PaCO2 29 mm Hg PaO2 60 mm Hg HCO3– 24 mEq/L
SaO2 86%.
Considering these results, the first intervention is to:
a. Place the client on oxygen
b. Give the client sodium bicarbonate
c. Begin mechanical ventilation
d. Monitor for pulmonary embolism

809. A nurse is preparing to obtain an arterial blood gas specimen from a client and plans to perform the Allen’s test
on the client. after explaining the procedure to patient, what is the next step nurse need to do for performing the Allen’s
test ?.
a. Ask the client to open and close the hand repeatedly.
b. Assess the color of the extremity distal to the pressure point
c. Release pressure from the ulnar artery
d. Apply pressure over the ulnar and radial arteries.

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810. A 34-year-old woman with a history of asthma is admitted to the emergency department. The nurse notes that
the client is dyspneic, with a respiratory rate of 35 breaths/minute, nasal flaring, and use of accessory muscles.
Auscultation of the lung fields reveals greatly diminished breath sounds. Based on these findings, what action should the
nurse take to initiate care of the client?
a. Administer bronchodilators
b. Initiate oxygen therapy and reassess the client in 10 minutes.

c. Draw blood for an ABG analysis and send the client for a chest x- ray.
d. Encourage the client to relax and breathe slowly through the mouth 811. A couple has brought in their Toddler
daughter for examination.
The parents tell the nurse that they are worried about all the safety risks for this age group. As the nurse plans to teach
the parents about these risks, the nurse remembers that toddler are at a greater risk for injury from:
a. Poisoning and child abduction
b. Home accidents
c. Physiological changes of aging
d. Automobile accidents, suicide, and substance abuse

812. When providing health maintenance teaching to new employees in the food-handling department, the nurse
emphasizes the need to perform hand hygiene after using the bathroom to prevent:
a. Spread of hepatitis A
b. Spread of hepatitis E
c. Salmonella contamination
d. Cholera contamination

813. As a member of the hospital's bioterrorism team, the nurse understands the importance of knowing how an
organism is transmitted. Smallpox has the potential to spread quickly because it is transmitted via which route?
a. Air-borne
b. Droplets
c. Contact
d. Absorption

814. A nurse plans to teach a group of 20 to 25 year-old women about oral contraceptives. The nurse should instruct
that side effects of intrauterine device may include contraceptive may cause:
a. Increase risk of pelvic inflammatory disease
b. Cause acne to worsen
c. Decrease the risk of breast and cervical cancer
d. Decrease the risk of endometriosis

815. A community health nurse assesses a68 year-old patient who lives in a group home. During physical assessment
nurse notice that patient skin and mucus membrane are dry and and pale. What type of data is the nurse collecting from
the above information?
a. Subjective
b. Objective
c. Medical History
d. Analytical

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816. The nurse 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:
A. Blockage of large vessels as a result of atherosclerosis
B. Emboli produce from valvular heart disease.
C. Decreased cerebral blood flow due to circulatory failure.
D. A temporary disruption in oxygenation of the brain.

817. A 68 year-old male patient has a chest tube and properly fixed following cardiac surgery. The chest tube is
patent and functioning. When the nurse removes the dressing the tube falls out of the chest. Which is the most
appropriate initial intervention the nurse should take?
A. Reinsert the chest tube and notify the surgeon
B. Apply an occlusive dressing to the insertion site.
C. Place the open end of the tube in 20 cm of water
D. Administer ð„‚2at 10L/min via non-rebreathe mask

818. 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

819. A child with asthma has an order for albuterol, before administration of the medication the nurse MUST.
A. Pre-oxygenate the patient
B. Assess the patient's heart rate
C. Obtain venous Access
D. Feed the patient a snack

820. A hospitalized patient eats 20% of the meal and states being too tired to eat more. What should the nurse do?
A. Offer to feed the patient after short rest period.
B. Encourage the patient to finish the fluids.
C. Remove the meal tray and allow the patient to rest.
D. Encourage the patient to finish the protein portion of the meal.

821. Patient who is scheduled for a tonsillectomy is in the preoperative unit. The nurse notes an order for
preanesthetic medication to be given “on call to operating room.” The nurse should give this medication.
A. Immediately upon being notified to prepare the patient for transport.
B. When the operating room staff.
C. arrives to transport the patient.
D. Only if clearly needed after.

822. A client with iron deficiency anemia is scheduled for discharge. Which Instruction about prescribed ferrous
gluconate therapy should the nurse Include in the teaching plan
A. Take the medication with an antacid.
B. Take the medication with a glass of milk.
C. Take the medication with cereal.
D. Take the medication on an empty stomach.

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823. A child with asthma has an order for albuterol, before administration of the
medication the nurse MUST.
A. Pre-oxygenate the patient
B. Assess the patient's heart rate
C. Obtain venous Access
D. Feed the patient a snack

824. The physician ordered a blood glucose test for the neonates the nurse knows the best site to puncture is usually:
A. The lateral heel.
B. Anterior sole
C. Finger tip
D. Anterior scalp

825. An old patient with history of risk to fall down use walker as assistant the pt use diuretic medicine and the pt use
to go to the bathroom more often in the night what the nurse should do for pt to ensure safety:
A. hold diuretic
B. keep bathroom light open
C. Commode a bathroom beside the patient.
D. keeps the way to the bathroom clear of any obstacles

826. A patient has a central line catheter and is receiving a three-in-one total parenteral nutrition that contains
glucose, proteins and lipids. The pump is set to deliver the infusion over a 12-hour period. After how many hours should
the intravenous administration set be changed?
A. 12
B. 24
C. 48
D. 72

827. A 1-year-old child is scheduled to receive an intravenous (IV) line. The most appropriate type of restraint to use
for this client to prevent removal of the IV line would be a(n):
A. Wrist restraint
B. Jacket restraint.
C. Elbow restraint
D. Mummy restraint.

828. Patient with nausea/aspiration what's the position of the patient ?

A. Lt lateral
B. Rt lateral
C. Sim fowler

829. TB exam confirmation with Patient has no S/S of TB?!

No sputum culture was in the options and X ray is not correct answer for the case the correct answer was PPD test.

830. Patient with Alzheimer's and want to prosh his teeth what's role of the nursing to build trust of the patient ?!
>>>Assisted him hand by hand to prosh his teeth

831. Why we need the patient to wear elastic stock pre op or post OP ?
>>> To prevent formulation of thrombosis.

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832. Which type of isolation category is indicated for patient with tuberculosis ‫؟‬
> Airborne isolation

833. A patient schedule for pneumonectomy, what is the name of this surgery, (what is the appropriate surgery) for
this patient?
> Lung carcinoma

834. What's the position of patient with chest pain?!

>>> sim fowler position

835. The nurse administered a dose of morphine sulfate, as prescribed to apatient who is in the post-anesthesia care
unit (PACU). The patient appears to be resting comfortably; the respiratory rate is 8 and the ðsaturation on 2L of oxygen
via nasal cannula is 86%. The nurse should IMMEDIETLY administer.
A. Flumazenil (Romazicon)
B. Midazolam (Versed)
C. Naloxone (Narcan)

836. What’s the instrument that be used to exam the eye?

>>.Ophthalmoscopy

837. What’s the require immunization at the birth ?

>>> Hep-B

838. What's the Nursing intervention with DVT patient who receiving heparin injection?
>>>>Best nursing intervention is To Keep the patient on bed rest

839. Drug of choice during Hypovolemic shock ?

>>> Dopamine

840. Baby with recurrent Fever and Abdominal upset and still use bottle
, As nurse What advice to you give the mother baby?
>>> Hand hygiene

841. Patient with Asthma and on Nebulization, as nurse when do you do the Chest physiotherapy?
A. During Nebulization
B. Before Nebulization
C. After Nebulization

842. What’s the action or purpose of protein?

>>> help to formulate or build new cells

843. One nursing intervention for patient with asthma is to facilitate removal of secretions. This can be done by:
A. Encourage the patient to perform slow and shallow breathing
B. Encourage the patient to increase fluid intake
C. Encourage the patient to hyperventilate
D. Encourage the patient to decrease

844. Hospitalized patient eats 20% of the meal and states being too tired to eat more what should the nurse do?

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A. Offer to feed the patient after short rest period.
B. Encourage the patient to finish the fluids.
C. Remove the meal tray and allow the patient to rest.
D. Encourage the patient to finish the protein portion of the meal

845. Patient is planning to have an elective surgical procedure to repair an umbilical hernia. The patient is 68 years
old. Weighs 136 kg (300 lbs.) Has diabetes mellitus. Which of the following approaches would be the MOST beneficial in
order to reduce the patients surgical risk?
A. Monitor blood glucose levels monthly
B. Avoid fluid overload by restricting fluids
C. Discourage any changes in routine before surgery
D. Encourage weight reduction

846. A 26 year-old woman is receiving an intravenous infusion of 5% dextrose in 0.45% sodium chloride. The
intravenous had been started one day prior and now the patient complains of tenderness at the site. On examination,
the site is pink-coloured, swollen and tender to the touch what is the most appropriate initial action?
A. Decrease the rate of infusion
B. Notify the doctor
C. Discontinue the infusion
D. Aspirate the injection port

847. A patient with measles (rubella) is on airborne precautions. Which of the following precaution techniques would
be essential to implement for non-immune persons entering the room ?‫؟‬
A. Gloves
B. Gowns
C. Face shields
D. Masks

848. A 60 year-old diabetic man maintains a simple daily insulin regimen. He injects a mixed dose of regular insulin
with intermediate-acting insulin before breakfast every morning at 07:00 hours and then goes for a walk. His lunch is at
12:00h and dinner at 18:30. He also eats a snack before he goes to bed at 21:30. He reports feeling confused, dizzy and
faint during for a short time every day. Which blood-glucose levels are most likely during the symptoms?
A. 𝗍 insulin, 𝗍glucose
B. 𝖸 insulin 𝖸glucose
C. 𝗍insulin 𝖸glucose
D. 𝖸insulin 𝗍glucose

849. What's the best time of nursing home care evaluation?

A. end of each Visit
B. end of the first months
C. after 2months
850. A client with a 3-day history of nausea and vomiting presents to the emergency department. The client is hypo
ventilating and has a respiratory rate of 10 breaths/min. The electrocardiogram (ECG) monitor displays tachycardia, with
a heart rate of 120 beats/min. Arterial blood gases are drawn and the nurse reviews the results, expecting to note which
of the following?
a. A decreased pH and an increased CO2
b. An increased pH and a decreased CO2
c. A decreased pH and a decreased HCO3
d. An increased pH with an increased HCO3

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