1. A mother brings her
3-week old infant to a clinic for a phenylketonuria re-screening blood test.
The test indicates a serum phenylalanine level of 1mg/dL. The nurse interprets
this result as:
d) requiring re-screening at age 6 weeks
51. A client with
acquired immunodeficiency syndrome (AIDS) has been started on therapy with
zidovudine (AZT, Retrovir). A nurse carefully assesses which of the following
as toxic effect of the drug?
c) yellowish discoloration of the skin
52. A pregnant human immunodeficiency virus (HIV) positive woman
delivers a newborn infant. A nurse provides instructions to the mother
regarding the newborn infant care. Which statement by the mother indicates a
need for further instruction?
a) I will wash my hands frequently
b) I want my baby to be roomed-in with me
c) my infant will be on antiviral medications for the first six weeks after
d) I will breastfeed for six months
53.The client with acquired immunodeficiency syndrome (AIDS) has oral
candidiasis. Who among these clients can safely be roomed-in with the client?
a) the client with
chronic renal failure who is undergoing
b) the client with hepatitis B (HBV) infection
c) the client who is human immunodeficiency virus (HIV) positive with
d) the client with viral pneumonia
54. Who among the following clients has the highest risk to develop
a) the client who had multiple body piercing
b) the client who had kidney transplant one year ago
c) the client on chronic hemodialysis
d) the client with multiple gestation
55. A male patient is HIV positive and with hepatitis B. Who among
these patients may roomed-in with him?
a) the patient with hypertension
b) the patient who had undergone appendectomy
c) the patient with pancreatitis
d) the patient with
peptic ulcer disease
Situation: Miss Mila Ty, a victim of the Quezon City fire incident,
sustained 2nd and 3rd degree burn.
56. What is your method of assessing the degree of burn?
a) count the presence of papule observed
b) observe presence of redness
c) check location of burn
d) rate and extent of burned area
57. Using the rule of nines, which has the largest percent of
a) face and neck
b) right upper arm and penis
c) right thigh and penis
d) upper trunk
58. What would be your first aid measure?
a) place her in the tub filled with clean water
b) pour cool water over the burned area
c) apply topical antibiotics to prevent infection
d) run tomato juice around the affected area for cooling comfort
59. What is the minimum safe range for the hourly urine output from
the indwelling catheter?
a) 25-30 ml
b) 90-120 ml
c) 60-90 ml
d) 30-60 ml
60. What should you provide for her burn on the lower extremity?
b) striker frame
c) cradle bed
d) circulo-electric bed
41. A nurse is planning the
assignment for the day shift. The care team consists of an RN, an LPN/LVN, and
a nursing assistant. Which of the following clients is most appropriate to
assign to the nursing assistant?
a) a 50-year old obese client who needs assistance out of bed with a Hoyer lift
b) a 42-year old client who needs to be straight catheterized (in-and-out
c) a 45-year old woman admitted for mastectomy and who is upset and tearful
d) a 62-year old client with an abdominal dressing and Montgomery straps
42. The nurse has delegated care of a client requiring
nasopharyngeal suctioning to the LPN/LVN. Which of the following actions if
performed by the LPN/LVN would require intervention by the nurse?
a) suction is applied as the catheter is inserted in the nares
b) the suction catheter is coiled as it is picked up from the sterile field
c) sterile gloves are used
d) the catheter is rotated slightly as it is inserted
43. The nurse has delegated care of a client who needs wrapping of
an above the knee amputation stump to a LPN/LVN. Which of the following actions
by the LPN/LVN would not require intervention by the nurse?
a) the stump is unwrapped for the bath and left unwrapped for 1 hour after
b) the stump is wrapped from proximal to distal
c) a diagonal figure of eight bandaging technique is used
d) care is taken to not flatten the skin at the end of the incision during
44. The nurse has delegated administration of 10am medications to
an LPN/LVN. At 10:15am, the nurse notes none of the medications have been
administer yet. Which is the best action for the nurse to take?
a) ask another LPN/LVN assigned to the unit to help administer medications
b) begin administering the medications
c) report he situation to the head nurse
d) ask the LPN/LVN to give the nurse a status report
45. A nurse on a pediatric unit is preparing the assignment for the
evening shift. The unit employs unlicensed assistive personnel (UAP). Which
task is most appropriate for the nurse to delegate to the UAP?
a) setting up Bryant's traction
b) completing the FACES pain scale for a child with sickle cell crisis
c) obtaining post-operative vital signs on a client status post-tonsillectomy
d) setting up an intravenous therapy pump
46. A new staff nurse is discussing with a nurse preceptor some of
the ethical dilemmas related to delegation. Which resource is most appropriate
for the nurse preceptor to direct the staff nurse to?
a) the Nursing Department Philosophy Statement
b) the National Council of State Board of Nurses
c) the Hospital Policy and Procedure Manual
d) the American Nurses Association's Code for Nurses
47. A nurse on a surgical unit is working with a team consisting of
an LPN/LVN and a nursing assistant. Which of the following activities should be
performed by the RN rather than delegated to the LPN/LVN or nursing assistant?
Select all that apply
a) completing a pressure ulcer assessment form
b) setting up tracheal suctioning device
c) changing a dressing on an abdominal wound
d) documenting a client's level of pain on a pain scale
e) giving an oral pain medication to a client with prostate cancer
f) evaluating the response of a client to pain medication
48. A nurse is assigned to care for a group of clients. On review
of the client's medical records, the nurse determines that which client is at
risk for deficient fluid volume
a) a client with a colostomy
b) a client with congestive heart failure
c) a client with decreased kidney function
d) a client receiving frequent wound irrigation
49. A nurse caring for a client who has been receiving intravenous
diuretics suspects that the client is experiencing a deficient fluid volume.
Which assessment finding would the nurse note in a client with this condition?
a) lung congestion
b) decreased hematocrit
c) increased blood pressure
d) decreased central venous pressure (CVP)
50. A nurse is assigned to care for a group of clients. On review
of the client's medical records, the nurse determines that which client is at
risk for excess fluid volume?
a) the client taking diuretics
b) the client with renal failure
c) the client with ileostomy
d) the client who requires gastrointestinal suctioning
31. A nurse (RN) on a
medical-surgical unit receives a new client admitted with abdominal pain. Which
of the following activities should be performed by the RN rather than delegated
to the LPN/LVN or nursing assistant?
a) preparing the client's chart
b) administering bedtime medications to the clients on the unit
c) completing the admission assessment for the new client
d) obtaining a clean-catch urine specimen from the client
32. A nurse is working with an LPN/LVN and a nursing assistant on a
long-term care unit. The nurse observes the LPN/LVN and the nursing assistant
moving a client up in bed to. The nurse will intervene if which of the
following is observed?
a) the LPN/LVN and the nursing assistant grasp the client under the arms to
pull up the bed
b) the client is asked to flex his knees and dig his heels in to help push up
c) the bed is put in the high position prior to lifting the client
d) the side rails are lowered prior to lifting the client up in bed
33. A nurse working on a surgical unit is approached by a physician
who asks if a client's consent form for surgery has been signed yet. The most
appropriate response for the nurse is:
a) the LPN/LVN is caring for that client. I will check on whether the form is
b) I asked the other nurse on the floor to get that while I was at lunch.
Please see that nurse about this
c) I have not had time to do that yet. I have been so busy today
d) I asked another nurse to get consent. I will check on whether it was done
34. An enema is ordered for a client as part of a bowel preparation
for surgery. The nurse delegates the task to the LPN/LVN. Which of the
following actions by the nurse is best?
a) write the task on the assignment sheet
b) explain the task and expected results to the LPN/LVN
c) explain to the client why the LPN/LVN will administer enema
d) if the LPN/LVN is too busy to give the enema, the nurse should give it
35. A new nurse is interested in learning more about how to
appropriately delegate tasks to the LPN/LVNs and nursing assistants on the
unit. The best source of information the nurse can refer to regarding which
tasks are appropriate for which level of personnel is:
a) the American Nurses Association Code for Nurses
b) the hospital's Nursing Procedure Manual
c) The Nurse Practice Act in the State the nurse is practicing
d) a nursing management textbook
36. A nurse delegates medication administration for a group of
clients to a LPN/LVN prepares to administer a subcutaneous (SQ) injection of
heparin to a client. The nurse should intervene if the LPN/LVN:
a) rubs the injection site with alcohol before and after the injection
b) administer the heparin SQ injection in the left lower quadrant of the
c) does not aspirate after inserting the needle
d) gently withdraws the needle at the same angle it was inserted
37. A registered nurse on a medical surgical unit is preparing the
assignment for the day shift. The RN is working with a licensed practical
(vocational) nurse (LPN/LVN) and a nursing assistant. The RN most appropriately
assigns which client to the LPN/LVN?
a) a newly admitted client with syncope
b) a client with tracheostomy needing suctioning
c) a client with cerebral palsy who needs assistance with feeding
d) a client with a below the knee amputation
38. A nurse on telemetry unit receives a new client admitted with
atrial fibrillation. Which of the following activities should be performed by
the RN rather than delegated to the LPN/LVN or nursing assistant?
a) attaching the leads of the cardiac monitor
b) obtaining an infusion pump for the client
c) completing the admission assessment for the client
d) obtaining a urinalysis specimen from the client
39. A nurse is working with a team consisting of an LPN/LVN
and nursing assistant. The nurse delegates medication administration to
the LPN/LVN. According to the principles of delegation, the nurse knows that in
delegating this task to the LPN/LVN, the nurse retains:
40. A nurse delegates application of anti-embolism stockings to an
LPN/LVN. Which of the following actions, if observed by the nurse, would not
a) rubs lotion on legs before applying stockings
b) applies stockings after client is assisted out of bed to a chair
c) turns the stocking inside out before applying
d) folds top of stockings over
21.Prior to tonsillectomy in a child, which of the following laboratory
results should be reported to the physician immediately?
a) prothrombin time of 25 seconds
b) hemoglobin of 10 mg/Dl
c) WBC 0f 15,000/cu. mm
d) platelet count of 200,000/cu. mm
22. An emergency department has emergency drill. Which of the
following should be given highest priority?
a) a child with bloody face and with fixed, dilated pupils
b) a patient with Glascow coma scale of 13
c) a woman with fracture of legs and swelling
d) a patient with no breath sounds on the affected side of the chest
23. Which among the following patients needs follow-up care?
a) a patient who has status epilepticus with gingival hyperplasia
b) a patient taking rifampicin with red-orange urine
c) a patient taking iron supplement with dark stools
d) a patient taking digoxin whose apical rate decreased from 90 beats per
minutes to 80 beats per minute
24. A 76-year old man is to be discharged with his adult child and
will stay with him. What will be the nurse's advice?
a) inform the adult child on the nearest health service facility
b) tell the patient that elder abuse is common
c) advice for stay on a long-term healthcare facility
d) inform the patient on availability of hospice care
25. The client had head injury due to vehicular accident. He is
experiencing Cushing's reflex. Which of the following would be manifested by
the client? Select all that apply
a) increased body temperature
b) decreased respiratory rate
c) increased systolic pressure
d) decreased diastolic pressure
f) widening of pulse pressure
26. Which of the following is a characteristic lesion of Psoriasis?
a) silvery white scales
b) linear burrows
c) maculo-papular lesions
d) clusters of vesicles
27. Which of the following interventions should be included in the
care of the client with myasthenia gravis?
a) start the client's meals with hot soup
b) administer mestinon (pyridostigmine) before feeding
c) place the client in isolation
d) cover the eyes with eye patch
28. Which of the following is not a manifestation of SIADH
(Syndrome of Inappropriate ADH)?
b) high specific gravity of urine
29. Which of the following should be included in the nursing
interventions of the client after tonsillectomy?
a) assess for frequent swallowing
b) include ice cream in the diet
c) apply ice collar on the neck
d) provide non-citrus, non-red, cold beverages
e) encourage to do deep breathing and coughing exercises
30. A registered nurse (RN) on a medical-surgical unit is preparing
the assignment for the day shift. The RN is working with a licensed practical
(vocational) nurse (LPN/LVN). and a nursing assistant. The RN most
appropriately assigns which client to the LPN/LVN?
a) a client who needs preoperative teaching for colectomy
b) a client with a leg wound requiring a dressing change
c) an elderly client who needs assistance with ambulation
d) a client with a 24-hour urine collection process
11. The client has been diagnosed to have sickle cell
anemia. Which of the following is appropriate nursing action when the
client experiences joint pains?
a) apply cold compress to the area
b) apply warm compress to the area
c) immobilize the involved area
d) massage the involved area
12. Which of the following statements when made by the client with systemic
lupus erythematosus indicates that she has good understanding of her
a) I will avoid using lotion after bathing
b) I need to have adequate sunlight in the morning
c) I am allowed to go and watch basketball games
d) range of motion of my joints will be good to maintain joint and muscle
13. Which of the following is least likely be included when the
nurse is giving information about hepatitis A? Select all that apply
a) it is transmitted through oro-fecal route
b) it is associated with eating shellfish from contaminated water
c) it is common in places with poor sanitation
d) it may be associated with multiple blood transfusion
e) it is a co-infection with hepatitis B
f) it usually follows intake of certain drugs
g) it is transmitted through blood and body fluids
14. The patient had been diagnosed to have Addison's
disease. The nursing care plan of the client should include the
following appropriate interventions. Select all that apply
a) monitor the client's weight and vital signs
b) restrict potassium-rich foods in the diet
c) monitor serum glucose levels
d) check for hypertension and hyperglycemia
e) observe for masculinization in women
f) avoid exposure to infection
15. The Monitor Tech called the attention of the nurse in a loud
and urgent voice informing her that the patient is in asystole in her monitor.
In responding to the situation, what should the nurse do first?
a) call code blue immediately
b) call the physician for orders
c) go to the patient, check for presence of pulse and blood pressure
d) get the crash cart and defibrillate the patient
16. Which among the following patient has the highest priority for
a referral to an interdisciplinary team?
a) a post-CVA patient with hemiparesis for physical therapy evaluation and
b) a patient with chronic pancreatitis for dietary teaching by the nutritionist
c) a patient with 1-week old carpal tunnel syndrome who wants immediate session
with the occupational therapist
d) a patient with fracture of the femur who is in cast
17. The client has been complaining of severe discomfort during
menstrual period. She would not take any analgesic but considers herbal approach.
What would you suggest to her?
a) cranberry relieves spastic pain during menstrual period
b) echinacea should be taken because aside from enhancing the immune system, it
relieves spasm during menstruation
c) ginseng promote uterine circulation
d) black cohosh relieves spastic pain of menstruation
18. A client had undergone herniorrhaphy. Which of the following
measures should be included in the nursing interventions postop?
a) increase fluid intake
b) encourage to do deep breathing and coughing exercises
c) place the client in semi-fowler's position most of the time
d) provide liquid diet until wound heals
19. Which of the following problems should be given highest
priority by the nurse when caring for a client with Guillain-Barre
c) difficulty in speaking
d) ascending paralysis
20. The patient has positive (+) carpal spasm response.
The appropriate action by the nurse is
a) take BP on the other arm
b) wait for 15 minutes and reassess again by taking BP at the same arm
c) take the BP on both arms every hour
d) repeat taking BP on the same arm after 4 hours
1. Which of the following is inappropriate nursing action when
caring for a client with multiple myeloma?
a) give calcium supplement
b) increase client's fluid intake
c) prevent falls
d) protect the client from infection
2. A client has an AV-fistula on the right arm. The RN would
intervene if the CNA performs which of the following?
a) listens for bruits
b) palpates for thrill
c) takes the BP on the right arm
d) takes the BP on the left arm
3. Which of the following conditions is Hawthorn indicated?
c) urinary tract infection
4. Eschinacea is used to treat which of the following conditions?
a) urinary tract infections
c) migraine headache
5. The client is for Caloric testing. The test primarily involves
which of the following:
a) introducing hot water into the ear
b) introducing warm water into the ear
c) introducing cold water into the ear
d) introducing tap water into the ear
6. The client was pronounced dead by the physician. When the RN
performs post-mortem care to the client, which of the following is appropriate
a) place the client's arms across his chest
b) place the client's arms over his abdomen
c) place the client's arms on the side and wrap the client
d) remove the client's gown and change linen to cover the body
7. The client is 66 years old, and is having diarrhea and vomiting.
How would you evaluate dehydration on the patient?
a) assess for poor skin turgor
b) check for dry mucous membrane
c) note for dark, concentrated urine
d) monitor vital signs
8. The client has been diagnosed to have thrombocytopenia. The
R.N. will administer heparin subcutaneously to the client. Which of the
following is appropriate nursing action?
a) aspirate before injecting the medication
b) massage the site of injection after introduction of the medication
c) inspect the site for hematoma
d) use syringe with needle gauge 22
9. The client who went on a mountain climbing was bitten by a
rattle snake. While waiting for the emergency rescue team, what is the most
appropriate immediate action for the client?
a) suck the area bitten by the rattle snake
b) apply tourniquet above the bitten area
c) cover the area with clean clothing
d) elevate the area above the level of the heart
10. The client is diagnosed to have systemic lupus
erythematosus. Which of the following assessment should be given
highest priority by the nurse?
a) butterfly rash over the cheek and nose
b) elevated BP
d) pericardial friction rub
21. The patient is suffering from hypomagnesemia. Which of the
following foods is appropriate for this client?
d) green beans
22. Which of the following clients should the nurse assess first?
a) a post-thyroidectomy client with tremors in the fingers
b) a diabetic client with blood glucose of 204 mg/dl
c) a postoperative client complaining of pain on incision site
d) an elderly client with urinary incontinence
23. The client will undergo Schilling's test. Which of the
following statements when made by the client indicates an understanding of the
a) blood will be drawn from me in the morning
b) I will be given vitamin B12 preparation
c) A medication will be instilled into my eyes
d) I will not eat anything for 8 hours before the test
24. A client has been diagnosed to have multiple myeloma. Which of
the following should be included in the nursing care of the client?
a) give ASA for pain
b) remove all loose rugs on the floor
c) increase milk intake of the client
d) encourage walking a mile each morning
25. Which of these clients is highest risk for falls?
a) a 65-year old client who walks with a three-pointed cane
b) a 60-year old client who asks for sedative-hypnotic at bedtime
c) a 71-year old client who has glaucoma and is receiving a miotic
d) a 68-year old client using walker
26. Which of the following clients should the nurse attend to
a) a client with hyperthyroidism whose temperature is 39.4C
b) a diabetic client with blood glucose of 365 mg/dl
c) a client who is waiting for blood transfusion in which the blood arrived the
unit 10 minutes ago
d) a client with myocardial infarction who experiences 2 to 4 premature
ventricular contractions per minute
27. The client has a WBC level of 13,000/cumm. Which of the
following would the nurse give as health teachings? Select all that apply
a) eat raw fruits and vegetables
b) practice hand washing before and after using the bathroom
c) avoid crowded places like shopping malls
d) eat in a disposable plate and throw them after use
e) avoid people with cough and colds
f) avoid exposure to cold and dampness
28. Which of the following precautions should the nurse observe
when caring for a client withMRSA?
a) putting mask on the client when he is transported to another department
b) keeping the client's room closed at all times
c) wearing gloves when caring for the client
d) wearing mask and gloves when performing procedures to the client
29. Which of the following clients should be assigned to an expert
a) a client who needs enema
b) a client who needs enteral feeding
c) a client who needs dressing changes every 4 hours
d) a client who needs assistance in bathing and complained of an incompetent
nursing assistant the previous shift
30. Which of the following is the most important nursing
intervention in a client with platelet count of 90,000/cumm?
a) bleeding precaution
b) isolation precaution
c) reverse isolation
d) strict isolation
11. Which of the following
foods are rich in sodium?
a) salad and cheese
b) baked potato
c) orange slices
12. Which of the following clients should be given highest priority
by the Emergency Department nurse?
a) the client with diffuse abdominal pain
b) the client with burns in the face
c) the client with severe diarrhea
d) the client with fracture of the arm
13. The client with multiple sclerosis is experiencing dysphagia.
Which of the following foods is most important for the client?
a) vanilla pudding
c) sliced fruits
14. client is diagnosed to have Addison's crisis. Which
of the following assessment findings characterize the condition?
a) hyponatremia, hypotension, hyperglycemia, hyperkalemia
b) hyponatremia, hypotension, hyperglycemia, hypokalemia
c) hyponatremia, hypotension, hypoglycemia, hyperkalemia
d) hyponatremia, hypotension, hypoglycemia, hypokalemia
15. Which of the following statements when made by the client
with systemic lupus erythematosus (SLE) indicates the need for
a) I will wear long-sleeved clothings when I go walking in the morning
b) I will walk in shaded areas only
c) I will go sunbathing in summer
d) I will wear wide-breamed hat when I go to the beach
16. The client is on heparin therapy. Partial thromboplastin time
(PTT) is 2 times the baseline. What is the appropriate nursing action?
a) continue heparin at the same dose
b) notify the physician
c) discontinue heparin
d) reduce the dose of heparin
17. Which of the following are signs and symptoms of dumping
syndrome? Select all that apply
a) explosive diarrhea
d) warm, flushed, dry skin
18. Which of the following is a manifestation of Addison's
a) blood pressure drops upon awakening in the morning
b) arterial blood gas results reveal respiratory alkalosis
c) weight gain of 4 lbs in 2 weeks
d) blood glucose is constantly elevated
19. The nurse takes care of a client with MRSA. Which
of the following is the most appropriate action by the nurse to prevent
a) leave the stethoscope in the client's room
b) keep the client's room closed
c) wear mask when entering the client's room
d) require the client to wear when transporting him to another department
20. Which of the following is the most appropriate nursing action
when promoting effective management on safety of clients?
a) the nurse secures the restraints to the siderails in square knot
b) the nurse puts up both siderails on a patient who is disoriented to time and
c) the nurse gives prescribed valium PRN to a patient who climbs out of bed
d) the nurse applies restraints to the restless client PRN as ordered by the
1. Which of the following statements when made by the client who
had undergone vasectomy indicates understanding of the procedure?
a) it is safe to have unprotected sex a week after the procedure
b) I should have 3 negative semen analysis before being considered sterile
c) I am considered sterile immediately after the procedure
d) I should have protected sex for 6 months after the procedure
2. Septic shock is caused by
a) massive blood loss
b) compromised myocardial contractility
c) interruption of the sympathetic nervous system
d) release of bacterial toxin in the blood vessel
3. The client is unresponsive to being shaken and to loud voice.
What is the next nursing action?
a) initiate painful stimuli
b) initiate external chest compression
c) initiate mechanical ventilation
d) initiate rescue breathing
4. Which of the following is a sign of improvement in a client
a) decrease in blood pressure
b) decrease in body temperature
c) decrease in edema
d) decrease in pulse rate
5. The patient with carpal tunnel syndrome is
being fitted for splint. What should be the position of the hand?
a) flexed position
b) neutral position
c) hyperextended position
d) supinated position
6. Which of the following laboratory results should be reported to
the physician first?
a) serum potassium is 4.0 mEq/L
b) serum calcium is 9 mg/dL
c) serum magnesium is 2.1 mEq/L
d) serum sodium is 165 mEq/L
7. The client had been diagnosed to have systemic lupus
erythematosus (SLE). Which of the following assessment findings should
the nurse watch out for?
a) pericardial friction rub
b) elevated blood pressure
8. Which of the following information is true with sickle
a) it affects the sons only
b) it is inherited from both parents
c) daughters will not develop the disease, they will only be carriers
d) the trait carriers will develop the disease as they grow old
9. Which of the following is an example of breach of a patient's
constitutional right to privacy?
a) nurse A discusses a patient's history with other staff to plan for
continuity of care
b) nurse B releases information to a patient's employer regarding his condition
without the patient's consent
c) nurse C documents in detail a patient's daily behaviors during his
d) nurse D asks the patient's family members to share information about his
10. A client has arterial blood gas results of pH=7.30, pO2=58,
pCO2=34, HCO3=19. What acid-base imbalance would these results most likely
a) metabolic acidosis
b) metabolic alkalosis
c) respiratory acidosis
d) respiratory alkalosis
21. Which of the following laboratory tests may help diagnose
presence of spina bifida?
a) kleihaeur-betke test
b) ABO typing
c) HCG levels determination
22. Which of the following signs and symptoms indicate that a
client is on Addison's crisis?
c) severe hypokalemia
d) severe hyperglycemia
23. Which of the following statements made by a 50-year old male
indicates that he understands health teachings about disease prevention?
a) I will have an annual digital rectal examination
b) I will go jogging every weekend
c) I will need to minimize my cigarette smoking
d) I will need to drink 4 glasses of whole milk a day
24. The client had been diagnosed to have systemic lupus
erythematosus. Which of the following assessment data needs follow-up?
c) butterfly rash over the nose and face
d) pericardial friction rub
25. The client will undergo mammogram. Which of the following
information should be included by the nurse when preparing the client for the
a) the procedure is painless
b) you should not eat or drink anything 2 hours before the procedure
c) you should not apply cream, powder, or deodorant in the axillae before the
d) you will lie down on a special table during the procedure
26. Which of the following instructions should be included when caring
for a client with deep vein thrombosis (DVT)?
a) do not ambulate
b) massage your legs when painful
c) apply compression stockings while in sitting position
d) dangle your legs while sitting at the side of bed several times a day
27. The child with sickle cell anemia is
experiencing vaso-occlusive crisis. Which of the following should the nurse
include in the nursing care plan of the client?
a) allow active range-of-motion exercises of the legs
b) apply cold over the legs
c) administer IV fluids as ordered
d) place the client in protective isolation
28. A client is started on an IV antibiotic in the emergency
department. He calls the nurse and tells her that he is beginning to itch and
has a "scratchy throat". Which of the following interventions would
the nurse do first?
a) call the attending physician at once
b) call a code
c) stop the infusion
d) take his vital signs and report them immediately
29. After receiving endorsement, which client should the nurse see
a) a client who had cholecystectomy one day ago, and had received analgesic 2
b) a client with blood sugar of 380 mg/dL and have recieved 20 units of regular
insulin 2 hours ago
c) a client who has blood transfusion and whose vital signs are being monitored
by a CNA
d) the client with total parenteral nutrition whose urine is positive for
30. The nurse is giving health teachings on diet to several
adolescents. Which among these clients need further teachings regarding diet?
a) the adolescent who takes cereal with milks during breakfast, pizza for
lunch, vegetable salad and fruits for dinner
b) the adolescent who takes rice and chicken dish for breakfast, burger and
orange juice for lunch, green salad and fruits for dinner
c) the adolescent who skips breakfast, takes soda and burger for lunch, green
salad for dinner
d) the adolescent who takes mashed potato and sausage for breakfast, rice and
roasted beef for lunch, mixed vegetables and fruits for dinner
11. A 38-year old man
was brought to the emergency room due to profuse bleeding from chest stab
wound. Assessments of his vital signs are follows: BP is 80/40 mmHg, PR is 110
bpm, and RR is 28. The nurse expects which of the following potential problems?
a) cardiogenic shock
b) hypovolemic shock
c) neurogenic shock
d) septic shock
12. A 60-year old clients report to the nurse that he has rash on
his back and right flank. The nurse observes elevated round blister-like
lesions that are filled with clear fluid. When documenting the
findings, what medical term should the nurse use to describe these lesions?
13. When caring for a client in restraints, which of the following
is not appropriate nursing action?
a) ensure that written consent for restraint application has been secured from
b) apply soft restraints
c) secure restraints on the side rails
d) check client and area of restraints application every 15-20 minutes
14. Which of the following is incorrect statement about incident
a) it is a tool used as means of identifying and improving care
b) the report form should be placed in the client's record
c) it is not a substitute for complete entry in the client's record regarding
d) it should be complete, accurate and factual
15. In which of the following situations does the nurse practice
a) she reports child abuse to the local authority
b) she advocates for the client from the practitioner who practices drug abuse
c) she refers the abused woman to support group
d) she practices universal precaution when caring for clients
16. The nurse from obstetric department is floated to the emergency
department. Who among these clients will the charge nurse appropriately assign
to the nurse?
a) the client receiving blood transfusion
b) the client with acute asthmatic attack
c) the client who is confused and agitated
d) the client who has chest injury
17. The client has severe jaundice. Which of the following should
the nurse not include when giving health teachings?
a) keep the environment warm
b) cut fingernails short and smoothen them
c) wash skin with water and mild soap
d) change clothing as necessary
18. Which of the following herbal medicines is used to relieved
stress, boost energy, and provides digestive support?
b) aloe vera
19. An 88-year old client complains, "I frequently wake-up at
night." What advise would the nurse give to the client?
a) drink milk instead of coffee at bedtime
b) limit your fluid intake to 1 liter a day
c) avoid drinking too much fluid before bedtime
d) drink fluids only when you're thirsty
20. Who among these clients may be assigned by the RN to the CNA?
a) the client on blood transfusion started 2 hours ago, whose BP needs to be
b) the client who requires nasogastric tube feedings every 3 hours
c) the client whose bladder is distended and requires catheterization
d) the client with tracheostomy who requires suctioning as necessary
1. The client is
complaining of confusion, tachycardia, serum sodium level is 150 mEq/L, BUN is
30 mg/dl. Which of the following problems should the nurse watch for?
a) fluid volume excess
b) fluid volume deficit
c) ineffective tissue perfusion
d) risk for injury
2. The client has severe wound from a vehicular accident. His
tetanus immunization status is unknown. Which of the following is the most
appropriate nursing action?
a) do not give tetanus immunization
b) give tetanus immune globulin
c) give tetanus toxoid
d) give tetanus toxoid immediately, then etanus globulin after one week
3. Which of the following laboratory findings support the diagnosis
of disseminated intravascular coagulopathy (DIC)?
a) elevated factor assays (II, V, and VII)
b) increased platelet count
c) elevated RBC, WBC, platelets
d) prolonged prothrombin time and partial thromboplastin time
4. Which of the following drugs are contraindicated in a client
with multiple sclerosis?
a) tetracycline and neomycin
b) penicillins and cephalosporins
c) aminoglycerides and vancomycins
d) quinolones and cephalosphorins
5. Which of the following actions by the registered nurse needs
intervention by the charge nurse?
a) the nurse applies compression stockings to a client with leg edema
b) the nurse applies ice pack over the abdomen of the client with appendicitis
c) the nurse serves the bedside commode to the client with myocardial
d) the nurse is about to five IM injection to a client with hemophilia
6. Who among these patients should the nurse see first after
a) a depressed client curled in a fetal position at a corner in his room
b) a 16-year old girl with anorexia nervosa sitting quietly in her bed
c) a manic patient standing on the chair and threatening to beat or slap
another patient with post traumatic stress disorder
d) a 24-year old patient with obsessive-compulsive disorder who keeps on
putting on and off his socks
7. Who among these clients should be roomed-in with a 6-year old
boy for splenectomy?
a) the 5-year old boy who had gastric surgery
b) the 7-year old boy with asthma and streptococcal infection
c) the 6-year old boy with pneumonia
d) the 6-year old boy with amoebiasis
8. The nurse witnessed a vehicular accident on her way home from
work. Who among these victims should the nurse attend to first?
a) a 25-year old man with fracture on the leg and bleeding profusely
b) a 4-year old child with fixed and dilated pupil
c) an 80-year old client with fracture on his arm and had petechiae on his
d) a 40-year old client who is showing panic anxiety
9. Which of the following is a common potential complication
10. Which of the following diseases is a chronic, progressive,
hereditary disease of the nervous system that results in progressive involuntary
dancelike movement and dementia
a) multiple sclerosis
b) huntington's disease
c) parkinson's disease
d) creutzfeldt-jacob's disease
21. Which of the following would the nurse include in the discharge
teaching of a client diagnosed to have shigellosis?
a) instruct client on the oro-fecal route transmission of disease
b) instruct the client on proper disposal of tissue wipes
c) instruct client on covering the nose and mouth when coughing and sneezing
d) instruct client on importance of daily bath
22. What is a characteristic of Marfan Syndrome?
b) tall, thin skeleton
d) hypertrophy of muscles in the thighs and legs
23. A client with pheochromocytoma is scheduled for adrenalectomy.
Which of the following should be given highest priority after the surgery?
a) fluid and electrolyte replacement
b) monitoring of blood pressure
c) measurement of hourly urine output
d) assessment of blood gases
24. Which of the following clients should be assessed first by the
a) the client with ileostomy which has no drainage for the past 6 hours
b) the client who had undergone appendectomy 24 hours ago with temperature of
c) the client who had vaginal delivery 3 hours ago, with reddish vaginal
d) the client who had colostomy 3 days ago, passing malodorous flatus from the
25. A 60-year old client is for prostatectomy. He asks the nurse on
the safe time when he can resume his sexual activity. What is the appropriate
response by the nurse?
a) after 6 months, it is safe for you to resume sexual activity
b) after 1 month, you are allowed to resume sexual activity
c) it is necessary that you abstain from sexual activity for 1 year
d) most probably, your physician will allow you to resume sexual activity
within two weeks after discharge
26. Four clients made a call to the unit. Which among these clients
should you make a return call first?
a) a client who had been crying all day because her boyfriend died
b) a client with bipolar disorder because he is unable to go to the restaurant
c) an alcoholic who says, "My family doesn't care about me. They will be
d) a client who feels anxious because she had just been told by his physician
that she has breast tumor
27. Which of the following is most effective nursing action to
prevent thrombophlebitis in a bedridden client?
a) avoid raising knee-gatch
b) massage the legs
c) apply moist heat in the legs
d) limit fluid intake
28. What is the appropriate action by the charge nurse when an RN's
breath smells alcohol after her break?
a) assign her patients to the other nurses and send her home
b) take the nurse to the conference room and interview her
c) allow her to continue caring for her parents
d) call the security
29. The client had been diagnosed to have Bell's palsy. Which of
the following is not appropriate nursing intervention?
a) encourage active facial muscle exercises
b) protect involved eye
c) apply ice pack on the involved area
d) administer steroids as ordered
30. The client has the following laboratory results: serum
potassium is 5.9 mEq/L, serum sodium is 142 mEq/L. Which action is most
essential for the nurse to do?
a) administer normal saline/IV as ordered
b) do cardiac monitoring
c) administer oxygen per nasal cannula
d) administer potassium chloride per slow IV drip as ordered
11. Which of the following is a characteristic manifestation of rubeola?
a) koplik's spot in the mouth
b) clusters of vesicles in the trunk
c) desquamation of skin at the tips of the fingers and toes
d) linear burrows in the skin
12. Which of the following clients should be given highest priority
by the nurse?
a) the client in the manic phase of bipolar disorder
b) the client whose severe depression is now resolving
c) the client with severe anxiety
d) the client with compulsive behavior
13. In which of the following may the nurse be charged for
a) the client's nasogastric tube feeding has been delayed for one hour
b) a medication has been delayed because of incomplete physician's order
c) the client's abdominal binder loosened while he was ambulating along the
d) the nurse allowed the client to read his chart
14. The patient is on SaO2 monitor. The nurse should intervene in
which of the following situations?
a) if the finger is wiped with alcohol before placing the sensor
b) if the sensor is placed on the little finger
c) if an arm board is kept on the same hand of the client, where the sensor is
d) if the sensor is placed alternately in the second, third, and fourth fingers
15. The client is on total parenteral nutrition (TPN) therapy at
home. Which of the following statements indicates that the client understands
the health teachings?
a) I will check my capillary blood sugar daily
b) I will check my urine ketones
c) I will check my pulse daily
d) I will check my weight daily
16. The nurse should intervene when she observes the CNA (Certified
Nursing Assistant) doing which of the following actions?
a) the CNA is talking loudly to an elderly client
b) the CNA checks the temperature of water before bathing an elderly
c) the CNA assisting an elderly who is ambulating along the hallway
d) the CNA applies lotion to the skin of an elderly
17. The hospital is conducting a drill on triage for registered
nurses. Which of the following clients should the nurse attend first?
a) an 80-year old client whose trachea is deviated to the left
b) a 15-year old with multiple fractures of the right femur
c) a 45-year old client with active bleeding on the left wrist
d) a 55-year old client with a closed head injury with fixed and dilated pupils
18. A female nursing assistant tells the nurse that she is not
comfortable about a young adolescent's behavior and will not provide care for
him. The adolescent has poor impulse control, but has never "acted
out" or assaulted the nursing assistant. Which of these goals should have
a priority in the nurse's dealing with the nursing assistant?
a) to have the assistant care for the client
b) to have the assistant identify her feelings about aggressive behavior
c) to have the assistant confront the patient's about his behavior
d) to have the assistant admit the need for a referral for counseling services
19. A client with long-term debilitating illness shouts, "Get
out of here. You're always bothering me with something." Which response by
the nurse is most appropriate?
a) you don't have to yell. I'm sorry you feel like I've bothered you
b) Ill go but I'll be back in a little while to find out what is bugging you
c) I'm going to have to ask you to be quiet as there are other clients in this
d) something is bothering you. I'll be glad to listen if you would like to talk
20. The nursing assistant reports to the charge nurse that she saw
the RN putting opioid in his pocket. Which of the following action is essential
for the charge nurse to do?
a) review the charts of the RN's patients, to check if medications were given
b) ask more information from the nursing assistant (CNA) about the incident
c) call the security
d) ignore what the CNA has informed