NURSING PRACTICE IV

Situation 1: A patient has just arrived in the Oncology Unit from the D. State actions to be done by each member of the
PACU following a left modified radical mastectomy because of group
inflammatory breast cancer (IBC). She has a pressure dressing over the
surgical site and two drains. Assessment shows her vital signs are 8. The team leader organized the group. Which of the
stable, fully awake and claims that pain is under control. Fortune is the following actions of the team leader reflect organization?
nurse assigned to the patient. The team leader:

1. From the following data obtained from the chart, which is A. Assigned tasks to each member
not a risk factor which could have predisposed the patient to B. Eliminated non-performing members of the group
breast cancer? C. Checked the assignments of each member of the group
D. Determined which actions will be done first
A. Age – 55 years old
B. Height – 5’2; Weight – 160 lbs. 9. Which of the following data will be most helpful to the
C. Menarche at age 13 group to ensure continuous process improvement?
D. Mother died of colon cancer
A. Non-conformances to suctioning procedure
2. Fortune read a literature which says that by the time IBC is B. Incidences of ventilator-associated pneumonia during
diagnosed, 50%-75% have palpable auxiliary lymph nodes, the last month
as many as 30% have gross distant metastasis and as few as C. Experiences of nurses when managing care of intubated
30% of patients have an underlying breast mass. Which of patients
the following is the appropriate interpretation of the D. Documentation of observation of intubated patients
research findings?
10. The group developed revisions to the existing procedure.
A. Auxiliary nodes were palpated on 20 out of 30 Before the procedure could be implemented as a standard
women positive for IBC procedure, which of the following will be done first?
B. Out of the 20 women who were positive for IBC,
only 5 have metastasis A. Gather relevant data
C. If there were 10 women diagnosed with IBC, 3 B. Check if procedure is effective through feedback
have positive lymph nodes C. Plan for the implementation of the procedure
D. Breast mass was identified on 8 out of 30 women D. Do the procedure on selected patients
positive for IBC
Situation 3: Luther, a 50-year-old construction worker sustained
3. Fortune recognizes that adjuvant chemotherapy for breast multiple injuries due to a motorcycle accident.
cancer may include any of the following except
11. In the Emergency Department, the physician orderd
A. Monoclonal antibody diagnostic tests, one of which is blood alcohol level. Which
B. Proton inhibitors of the following is the purpose of this test?
C. Antibiotics
D. Anti-estrogen A. Determine level of alcohol dependence
B. Discover injuries in the brain
4. Fortune understands that when the antineoplastic agent C. Rule out alcoholism
leaks through the peripheral vascular access during D. Assessment of client’s level of consciousness
chemotherapy, which of the following is expected to be done
first? 12. Blood transfusion must be administered immediately
because of loss of blood volume due to trauma. Luther’s
A. Refer to the physician blood type is O, as his nurse, you recognize which of the
B. Stop the chemotherapy infusion following statements is true?
C. Cleanse site with saline solution
D. Call another nurse to check the intravenous site. A. Type O blood has both types of antibodies
B. Persons with type O blood can also receive Type A
5. A clinical trial is currently undertaken to test treatments for blood
IBC. The research team leader wishes to include the patient C. Type O blood has no antibodies
as a participant in the study. As a patient advocate, which of D. Persons with Type O blood are also called universal
the following will Fortune do first? recipients

A. Obtain informed consent from the patient 13. When assessing Luther for hypovolemic shock, which of the
B. Explain to the patient the scope of the clinical trial following data indicates that he is in the irreversible stage of
C. Inquire from the team leader benefits for the shock?
patient
A. Restless, anxious and confused
D. Read more related literature
B. Anuria
Situation 2: During a staff meeting at the Intensive care unit, the nurse C. Skin moist, pale and moist
manager reported a list of procedures that need to be reviewed and D. Pulse rapid and weak
updated. One of these procedures is the precautionary measure related
to ventilator-associated pneumonia. 14. The physician ordered colloid solution such as Dextran 40.
During the infusion, Luther complained of dyspnea. Upon
6. While brainstorming, the group mentioned the use of auscultation, you noted wheezes. Which of the following
evidence-based techniques. Which of the following will you do first?
statements given by the members of the group reflect
evidence-based methods? A. Discontinue the infusion
B. Place Luther on a Fowler’s position
A. “Let us ask the opinion of experts.” C. Decrease the infusion rate
B. “The experiences of the nurses must be obtained.” D. Call the attending physician
C. “Review of related literature will be very helpful.”
D. “We must agree on a common procedure.” 15. Luther’s central venous pressure is monitored every hour.
When you measure the CVP using a water manometer, you
7. The nurse manager assigned a group to develop a project are expected to observe which of the following to ensure
intended to improve the existing procedure related to the accuracy of CVP measurement?
prevention of ventilator-associated pneumonia among ICU
patients. A team leader was selected by the group. Which of A. Maintain the client on a Fowler’s position
the following will the team leader do first? B. Use a one-way stopcock to regulate flow of IV fluids to
the water manometer
A. Tell the group to state their objectives C. Immobilize the client’s right arm
B. Formulate a list of desired outcomes D. Keep the zero point of the manometer in level with the
C. Set a target client’s right atrium
 A. Infected mosquito bites an uninfected human
Situation 4: You are caring for Warren, 58 years old, who is diagnosed B. Virus multiply in the midgut of the mosquito
with laryngeal cancer. C. Mosquito feeds on an infected human
D. Mosquito’s saliva is invaded by the virus during
16. Warren is scheduled for a total laryngectomy and radical subsequent biting of infected human
neck dissection for cancer of the larynx. He asks you, “How
will I talk after surgery?” As his nurse, your best response 23. The nurse noted that Aspirin and NSAID are
will be contraindicated for Bobby. Which of the following is the
rationale behind this order?
A. “You will breathe through a permanent opening in
your neck, but you will not be able to communicate A. Patient may be allergic
orally.” B. Drug contains anticoagulant properties
B. “You won’t be able to talk right after the surgery, but C. Due to stomach upset effects of the drug
you will be able to speak again once the tracheostomy D. Drugs enhance production of maculopapular rashes
tube is removed.”
C. “You will have a permanent opening into your neck, 24. The condition of Bobby is closely watched for signs of
and you will need to have rehabilitation for some type hypovolemic shock. Which of the following should the nurse
of voice restoration.” report as early signs of hypovolemic shock?
D. “You won’t be able to speak as you used to, but there
1. Lethargy
are artificial voice devices that will give you the ability
2. Rapid pulse
to speak normally.”
3. Clammy skin
4. Cyanosis
17. Warren returns from surgery with a tracheostomy tube after
5. Restlessness
a total laryngectomy and radical neck dissection. In caring
6. Hematemesis
for Warren during the first 24 hours after surgery, your
priority nursing action is to A. 2, 3, 4 and 5
B. 1, 2, 3 and 5
A. Avoid changing the tracheostomy ties C. 1, 2, 5 and 6
B. Monitor for bleeding around the stoma D. 1, 3, 4 and 6
C. Assess airway patency and breath sounds
25. To prevent transmission of the virus to others, which of the
D. Clean the inner cannula every 8 hours
following is the most appropriate isolation measure the
nurse should implement in the care of Bobby?
18. After doing assessment, one of the nursing diagnosis you
identified is “Body image Disturbance related to loss of A. Screen the environment
control of personal care.” To evaluate effectiveness of your B. Blood and body secretion isolation
interventions, the expected outcome for the problem that C. Use gown, gloves and mask
Warren should demonstrate is that he D. Use strict universal isolation technique

A. Lets his wife provide hygiene and stoma care Situation 6: Agua Bendita, 35 years old, was admitted to the hospital
B. Wears clothing that minimizes the disfigurement because of near drowning. In the ICU where she was admitted for
caused by the surgery observation, her oxygen saturation dropped to 84% and subsequent
C. Asks that only family members be allowed to visit blood gases showed PaO2 of 55mmHg. Diagnosis is probably Acute
D. Learns to remove and clean the laryngectomy tube Respiratory Distress Syndrome (ARDS). Endotracheal intubation and
independently mechanical ventilation were ordered.

26. The nurse is aware that in ARDS, the basic changes in the
19. Warren is scheduled to start radiation therapy. You have just
lungs result from the injury to the alveolar wall and capillary
taught Warren all about radiation therapy. Which of the
membrane leading to the following pathological changes,
following statements by Warren would indicate that your
except
teaching has been effective?
A. Fluid and protein leaks into alveoli and interstitial
A. “I can use lotions to moisturize the skin on my throat.”
tissue
B. “I will need to buy water bottle to carry with me.”
B. Damaged surfactant producing cells
C. “I need to use alcohol-based mouthwashes to help
clean oral ulcers.” C. Increased surfactant production
D. “I may experience diarrhea, I may have diarrhea until D. Increased alveolar capillary permeability
the radiation is complete.”
27. Which of the following ventilator settings reflect the amount
20. After completing the discharge instructions for Warren, you of air delivered within each ventilator breath?
determine that additional instruction is needed when he
says A. Inspiration to expiration ratio
B. Pressure limit
A. “I can participate in most of my prior fitness activities C. Tidal volume
except swimming.” D. Oxygen concentration (FiO2)
B. “I should wear a Medic Alert bracelet that identifies me
as a neck breather.” 28. Which of the following will the nurse closely monitor to
C. “I must keep the stoma covered with a loose sterile ensure that the percentage of oxygen delivered with
dressing at all times.” ventilator breaths is adequate?
D. “I need to eat nutritious meals even though I can’t
smell or taste very well.” A. Respiratory rate
B. Central venous pressure
Situation 5: Bobby, 11 years old, was admitted because of hematuria. C. Pulse oximeter’s reading
Diagnosis is Dengue fever. D. Cardiac monitor

21. Which of the following is the most likely description of 29. The nurse is expected to closely watch the client for
Bobby’s fever prior to the onset of hematuria that supports complications related to mechanical ventilation. Which of
the physician’s diagnosis of dengue fever? the following will the nurse do to assess subcutaneous
emphysema?
A. Intermittent fever for 4 days
B. Onset of fever was abrupt and remained elevated for 4 A. Observe for signs of unequal chest expansion
days B. Auscultate the lungs and observe for crackles
C. Abrupt onset of fever and sudden drop on the 4th day C. Palpate neck for air bubble-popping sensation
D. Gradual increase of body temperature and sudden D. Percuss for hyperresonant percussion tone
drop on the 4th day
30. The nurse observed air leaks from the endotracheal tube and
22. The nurse understands that the cycle of transmission of decreased breath sounds. Which of the following will the
dengue fever virus begins during which of the following? nurse do first?
 A. Report to the physician
B. Call the respiratory therapist 38. When assessing the level of consciousness of the patient,
C. Place patient on semi-fowlers position which of the following should the nurse consider most
D. Reposition the endotracheal tube appropriate in eliciting a desired response?

Situation 7: You admitted Englebert, 70 years old, because of A. Environment should be quiet, well-lighted and
pulmonary edema. He has a history of congestive heart failure, type 2 ventilated
diabetes mellitus and hypertension. B. Keep equipment at the bedside
C. Parent should be present
31. Based on the history, you specifically noted that Englebert D. Have record readily available for accurate
regularly took Lanoxin (Digoxin). Which of the following is documentation.
the specific action of this drug on the patient?
39. During assessment, the nurse observes absence of doll’s eye
A. Improves myocardial contractility, decreases the heart movement. Which of the following is the correct
rate, and reduces oxygen consumption interpretation of this observation?
B. Causes vasoconstriction, increased resistance preload
and dilation of the ventricles A. Ruptures aneurysm
C. Reduces peripheral vascular resistance and afterload, B. Meningeal inflammation
reducing myocardial workload C. Brainstem injury
D. Interfered with the production of angiotensin II D. Subdural hematoma
resulting in improved cardiac output and reducing
pulmonary congestion 40. Due to hypothalamic dysfunction, a syndrome of
inappropriate antidiuretic hormone develops. Which of the
32. Which of the following specific positions would be most following manifestations should the nurse watch closely?
helpful for Englebert to facilitate and trap excess fluids in the
lower extremities? A. Increased urine output, decreased specific gravity,
decreased serum sodium
A. Head bent forward on an overbed table supported with
B. Increased urine output, increased urine specific gravity,
pillows
increased serum sodium
B. Upright sitting position with the legs dangling
C. Decreased urine output, decreased urine specific
C. Lateral position with the upper leg flexed and lower leg gravity, decreased serum sodium
extended
D. Decreased urine output, increased urine specific
D. Fowler’s position with the patient lying on the left side
gravity, increased serum sodium
33. Furosemide (Lasix) 20 mg was administered by IV push at
Situation 9: Teddy, 8 years old, was playing in the garden when all of a
10 am with urinary output from indwelling catheter at the
sudden he stopped playing and started scratching his legs. Teddy’s
level of 120 cc. At 10:15 AM, the nurse observed that the
mother washed his legs but Teddy complained of difficulty of
urinary output did not change. Which of the following will
breathing; was nauseated and had cold moist skin. In the emergency
you check first?
department, anaphylaxis was suspected. Insect bites were noted on
Teddy’s legs.
A. Foley cathter connecting tube for kinks
B. Patient’s hypogastrium for urinary retention 41. The health team suspects that Teddy experienced a sting at
C. Intravenous site for swelling some previous time. Which of the following could be the
D. Foley catheter for leakage rationale for the itchy skin?

34. While preparing the medication, you checked the A. Irritation caused by digestive substance released by the
medication which was dispensed by the pharmacist with the insect
written order of the physician. Which of the following B. Infiltration of inflammatory cells into the epidermis
actions will you do first if you found out that instead of C. Sensory nerve endings irritated by histamine
Regular insulin, the pharmacist dispensed NPH insulin? D. Accumulation of histamine at the insect bite

A. Validate the order with the physician

42. Which of the following drugs will the nurse expect the
B. Document the error
physician to prescribe initially?
C. Ask the pharmacist to change the drug
D. Report the error to the unit manager A. Corticosteroids
B. Aminophylline
35. You administered morphine Sulfate 1 mg intravenously as C. Epinephrine
ordered. The following are the intended actions of this drug
D. Dipenhydramine
except
43. The mother asked the nurse what could have caused her son
A. Improved efficacy of breathing
to experience difficulty of breathing. Which of the following
B. Reduce preload is the most appropriate response of the nurse?
C. Decrease anxiety
D. Relieve pain A. “It was an early sympatetic response to the insect bite.”
B. “Chemical mediators due to hypersensitivity reactions
Situation 8: Helen, a Pediatric Intensive Care Unit staff nurse, is caused by edema in the bronchioles.”
assigned to a 4-year-old female unconscious patient due to an acute C. “Histamine released due to allergic reaction caused
head injury sustained from a vehicular accident. narrowing of the airway.”
D. “It was due to threatening laryngeal edema.”
36. Helen identifies which of the following nursing diagnosis to
be of highest priority?
44. The mother claimed that this is the first time it happened.
A. Risk for injury related to increased intracranial pressure
Which of the following should be given priority by the
B. Disturbed sensory perception relation to central
nurse?
nervous system impairment
C. Risk for aspiration related to impaired motor functions
A. Instruct the mother on emergency measures in care
D. Ineffective airway clearance related to depressed recurrence
sensorium B. Recommend desensitization
C. Identification of allergens
37. When interpreting the patient’s degree of depressed coma,
the pediatric Glasgow Coma Scale is used. Which of the D. Identification of environmental hazards
following is not included in the three-part assessment of the
scale? 45. Since Teddy is allergic to insect venom, which of the
following is the most appropriate measure to ensure that
A. Motor responses Teddy gets immediate treatment during recurrence?
B. Response to auditory and verbal stimuli
C. Pupil size and reaction A. Have Teddy carry an emergency kit all the time
D. Eye opening B. Teach Teddy how to use an emergency kit
 C. Use of a medical information such as bracelet or D. Contaminated needle
necklace
D. Teach Teddy to get help when symptoms develop 54. If the nurse has an unprotected exposure to SARS during
incubation, which of the following will be done?
Situation 10: Radiation therapy is another modality of cancer
management. With the emphasis on multi-disciplinary management, A. Voluntary quarantine of 10 days
you have important responsibilities when caring for patients receiving B. Nurse is placed on vacation from work
radiation therapy. C. Nurse will be given a high dose of gamma globulin
D. Administer vaccine to the nurse
46. Thrombocytopenia often results from bone marrow
depression. As a nurse, you should observe for the following 55. After exposure to a patient with SARS, it is expected that
symptoms that include SARS can develop in

A. Headache, dizziness, blurred vision

A. 2-10 days
B. Severe sore throat, bacteremia, hepatomegaly
B. 6 weeks – 6 months
C. Petechiae, ecchymosis, epistaxis
C. 30 days
D. Weakness, easy fatigability, pallor D. 12-14 days

47. When caring for a client who has thrombocytopenia, which Situation 12: You are assigned at the medical ward caring for clients
of the following intervention should you include in the care with fluid and electrolyte imbalances. You know that you have very
plan? important collaboration responsibilities when you give your patients
their medications to correct their illness.
A. Provide rest between activities
B. Place the patient on strict isolation precaution 56. Samson is taking Hydrochlorothiazide, a potassium-wasting
C. Inspect the patient’s skin for petechiae, bruising, GI diuretic, for treatment of hypertension. As a nurse, you will
bleeding regularly teach him to report symptoms of adverse effects such as
D. Administer antipyretics if the patient’s temperature
38°C A. Facial muscle spasms
B. Frequent loose stools
48. A patient is receiving external radiation therapy and he C. Mood changes
complains of fatigue and malaise. Which of the following D. Generalized weakness
nursing interventions would be most appropriate?
57. Spironolactone (Aldactone), an aldosterone antagonist, is
A. Refer the patient to the physician prescribed for Hermin as a diuretic. Which statement made
B. Help the patient plan activities and rest periods by Hermin indicated that the teaching about his medication
C. Reassure the patient that these feelings are normal has been effective?
D. Tell the patient that sometimes these feelings can be
psychogenic A. “I can use a salt-substitute”
B. “I can have apple juice instead of orange juice.”
49. External beam radiation is planned for a patient with C. “I can have low-fat cheese”
endometrial cancer. You teach her that the important D. “I will drink at least 6 glasses of water every day.”
measure to prevent complications from the effects of
radiation is to 58. Joseph has been receiving diuretic therapy and is admitted
to the hospital with a serum potassium level of 3.1 mEq/L.
A. Maintain a high-residue and high-fat diet Of the following medications that he has been taking at
B. Perform perineal care with sitz bath and meticulous home, which you be most concerned about?
cleaning
C. Test all stools for the presence of blood A. Oral digoxin (Lanoxin) 0.25 mg daily
D. Inspect the mouth and throat daily for the appearance B. Lantus insulin 23 U subcutaneously every evening
of thrush C. Ibuprofen (Motrrin) 400 mg every 6 hours
D. Metoprolol (Lopressor) 12.5 mg orally daily
50. A post total hysterectomy bilateral salphyngo-oophorectomy
patient had chemotherapy and radiation therapy. The nurse 59. You administered 3% Saline to Wanda who has
oriented her on the rationale and the measures to be done to hyponatremia. As her nurse, which one of your assessment
prevent movement of the radioactive source which include findings will require your most rapid response?
the following, except:
A. Her blood pressure increased from 120/80 to 142/94
A. Complete bed rest while source is implanted mmHg
B. Spinal anesthesia while source is implanted B. There is sediment and blood in Wanda’s urine
C. Bowel cleansing prior to insertion of source C. Wanda’s radial pulse is 105 beats per minute
D. Placement of urinary Foley catheter while source is D. There are crackles audible throughout her both lung
implanted fields

Situation 11: It is important and necessary that the nurse is well- 60. When caring for Edna who has just been admitted with
educated about Severe Acute Respiratory Syndrome (SARS), an septic chock, which of these assessment data will be your
emerging global threat. greatest concern?

51. If you were a nurse who works in a health clinic, and you A. Arterial oxygen saturation of 90%
suspect that a patient has SARS, which of the following will
B. BP of 88/56
you do first?
A. Contact the hospital C. Apical pulse of 110 beats per minute
D. Urine output of 15 mL for 2 hours
B. Protect self by putting on an N95 disposable mask
C. Refer the patient to the physician for medical diagnosis Situation 13: Timothy, 56 years old, was admitted because of aortic
D. Have your patient put on surgical face mask dissection type B.

52. Which of the following confirms the diagnosis of SARS? 61. The nurse recognizes which of the following as the correct
description of the patient’s diagnosis?
A. Travel to an area with known SARS outbreak
B. Signs and symptoms
A. Tear in the intima of the aorta with hemorrhage into the
C. History of contact with someone suspected of SARS
tunica media
D. Presence of antibody to SARS
B. Stretching of the walls of the aorta involving one layer
of the aorta
53. The SARS virus is transmitted through C. One-sided protrusions of one distinct area of the aorta
D. Pulsating hematoma on three layers of the aorta
A. Airborne droplets
B. Contact with urine
C. Mosquito bites
 62. Of the following diagnostic tests prescribed by the D. Turn patient to his side
physician, which of the following will the nurse expect to
show precise measurement of the aneurysm? Situation 15: In the medical unit, Connie was assigned to work with
Sandy, a staff nurse with 2 years experience
A. Angiography
B. Chest X-ray 71. Which of the following reports of Connie will Sandy attend
C. Transesophageal echocardiography to immediately?
D. Abdominal ultrasonography
A. A 65-year-old unconscious due to be turned to prevent
63. The physician initially treated Timothy with Propanolol bed sores
(Inderal). The nurse noted in her nursing care plan that this B. A 55-year-old diabetic, first day post-operative for
drug will below-the-knee amputation, complains of severe pain
C. A 75-year-old with hepatic encephalopathy,
A. Increase contractility of the heart intravenous infusion due in 4 hours consumed
B. Enhance electrical conduction of the heart D. A 45-year-old scheduled for partial thyroidectomy
C. Decrease release of epinephrine wishes to go home
D. Reduce heart rate
72. Connie observes Sandy perform peripheral catheter
64. Based on an understanding of Heparin therapy, the nurse insertion for intravenous infusion. The patient insisted to sit
administers it to Timothy who has undergone repair of on the edge of the bed. After a second unsuccessful attempt
aneurysm fro which of the following reasons? on cannulation, the patient suddenly became anxious,
diaphoretic, nauseated and dizzy. Which of the following
A. To prevent recurrence of aneurysm will Sandy do first?
B. To control hemorrhage
C. To maintain arterial pressure A. Place the patient on a supine position
D. To prevent clot formation B. Instruct Connie to call the physician
C. Check vital signs
65. To counteract reactions to overdosage of intravenous D. Discontinue the IV fluids
infusion of Heparin, which of the following drugs will the
nurse expect the physician to prescribe? 73. Sandy explained to Connie that the patient experiences a
vasovagal reaction. Which of the following vital signs will
the nurse expect?
A. Protamine sulfate
B. Epinephrine A. Normal blood pressure and increased pulse
C. Vitamin K
B. Decreased blood pressure and decreased cardiac rate
D. Atropine Sulfate
C. Increased blood pressure and tachycardia
Situation 14: You are caring for Rolando, 58 years old, who was D. Normal pulse and increased blood pressure
admitted because of difficulty of swallowing and stiffening of the neck.
He has a history of a wound laceration on his right hand sustained 74. One of Connie’s patients is Greg who just had
while gardening. The physician suspects tetanus infection. bronchoscopy. Sandy asked Connie what she should be alert
for in observing Greg?
66. While you were preparing to administer oxygen inhalation,
Rolando had seizures assumed an opisthotonic position. A. Sore throat and hoarseness
Which of the following correctly describes this position? B. Blood tinged sputum and coughing
C. Nausea and vomiting
A. Head retracted, back arched, and feet extended D. Shortness of breath and laryngeal stridor
B. Neck, hip, knee and feet plantar flexed
C. Head flexed forward, jaw clenched, arms pronated and 75. At the end of the shift, Sandy told Connie to do self-
feet plantar flexed. evaluation of competencies developed during the week.
D. Head hyperextended hip flexed, and feet extended Which of the following indicators will Connie consider as an
improvement of her ability to respond to the urgency of her
67. Taking into consideration the incubation period, which of patient’s conditions?
the following data in Rolando’s health history will you
consider relevant? A. Able to identify adverse reactions of drugs
B. Responds to inquiries promptly
A. Positive for type 2 diabetes mellitus C. Recognize abnormal laboratory results
B. Immunization status unceratain; no booster dose D. Administer medications on time
administered
C. Wound laceration sustained a week ago was treated at Situation 16: Nurse have crucial legal responsibilities in the exercise of
home her profession
D. Wound pain, unbearable and unrelieved by analgesic
76. Mary Jane, a 3rd year nursing student assigned to the surgical
68. To decrease stimuli that cause spasms and seizures, which of unit asks your permission to photocopy the surgical record
the following nursing interventions is least relevant for you from a patient’s chart for an assignment that she must write.
to do? Which of the following is your appropriate nursing action?

A. Maintain a quiet, well-ventilated and darkened room A. Allow Mary Jane to photocopy the pages without the
B. Administer sedatives as prescribed client’s name
C. Monitor for hazards of immobility B. Photocopy the pages for Mary Jane
C. Ask the physician for permission to photocopy the
D. Perform physical care during time of maximal sedation
pages
D. Allow Mary Jane to write down pertinent information
69. The priority nursing diagnosis for Rolando is “Risk for
but not identifying
ineffective airway clearance related to which of the
following?
77. You are caring for Felisa who has dementia and is soiled
A. Stiffness of the jaw with feces but you failed to clean and bathe her because it is
B. Back muscle spasms endorsement time already. You endorse her to the next shift
nurse. The nurse reports that you are guilty of
C. Seizures
D. Infection A. Malpractice
B. Nonmaleficence
70. During a seizure, which of the following are you expected to C. Assault
do first?
D. Negligence
A. Monitor vital signs especially the respiratory rate
78. You are invited to talk to new graduate nurses about
B. Provide a padded tongue blade in the patient’s mouth
negligence. Which of the following situations is a priority for
C. Provide mechanical ventilation you to include as an example of negligence?
 C. Do chest compression
A. Talking about client outside of the health care facility D. Ventilate with a bag-valve mask device
B. Not allowing a family member to awaken an adult
client who is sleeping Situation 18: Kevin, 22 years old, swerved his car and hit a tree head-
C. Not giving a prescribed medication to an older patient on when he avoided a dog crossing the street. Kevil loss consciousness,
D. Not turning off the oxygen at the bedside when a client sustained several cuts on his forehead and was bleeding from his nose
wants to smoke in bed and mouth. He was diagnosed in the Emergency Department with
Traumatic Brain Injury (TBI)
79. You call the physician of your patient Erlinda, 76 years old,
to report a change in her condition and to request orders for 86. Since volume resuscitation was necessary for Kevin,
a pain medication. The physician is unable to take the call intravenous 0.9% normal saline solution was started. The
and the message is left with the office secretary who repeats nurse who admitted the patient understands that the
a verbal order from the physician. Which of the following is intravenous solution was considered by the physician
your most appropriate nursing action? because it

A. Refuse to accept the order from the office secretary and A. Will reduce intracranial pressure
call back later B. Will easily maintain hydration
B. Accept the order form the office secretary and C. Will promote fluid shift into the vascular space
document it appropriately D. Won’t aggravate cerebral edema
C. Accept the order as it comes from the physician as
interpreted by the office secretary 87. To determine level of consciousness, the Glasgow Coma
D. Insist on speaking to the physician personally Scale (GCS) is used. Which of the following is a correct
interpretation of the nurse of the GCS score of Kevin?
80. You observe bruises and skin tears on Agatha, an 80-year-
old client. She does not make eye contact and appears A. The higher the score, the higher is the probability of
fearful. Which of the following is your priority nursing permanent damage
action? B. The lower the score is, the lower is the probability of
delayed recovery
A. Ask the client about the bruises and skin tears C. The higher the score, the greater is the impairment in
B. Ask the family members what has happened the brain
C. Document your findings D. The lower the score, the more serious is the brain injury
D. Call the physician
88. The nurse maintains the body temperature of Kevin within
Situation 17: You are assigned in the Pediatric ICU and your critical normal limits. This intervention is significant in preventing
decisions and proper documentation are important. You are caring for which of the following?
Charlie, 5 years old, who was admitted following a vehicular accident.
Clinical data obtained were; BP 80/58 mmHg, heart rate 120, A. Cerebral ischemia
respirations 32, peripheral pulse slightly diminished, hematocrit 30%, B. Infection
pulse oximeter 94%, serum electrolytes normal. CT scan is positive for C. Seizures
abnormal bleeding. Weight 20 kg. D. Dehydration

81. Based on the above data, which of the following nursing 89. When intracranial pressure increases, which of the following
diagnosis would you select as being appropriate in Charlie’s nursing diagnosis is appropriate?
care?
A. Risk for ineffective breathing pattern
A. Fluid volume deficit
B. Disturbed sensory perception
B. Ineffective airway clearance C. Risk for cardiac dysfunction
C. Impaired gas exchange D. Ineffective airway clearance
D. Altered cardiac output: decreased
Answer: A 90. Which of the following interventions can the nurse include
in the plan of care for Kevin to control intracranial pressure?
82. Charlie is placed on a cardiac monitor and a urinary catheter 1. Maintain his head and neck in neutral alignment
is inserted. One peripheral IV line in the left arm is 2. Initiate measures to enhance valsalva maneuver
infiltrated and discontinued. An indirect BP reading is 70/40 3. Administer Oxygen to maintain PaO2 >90 mmHg
mmHg and a heart rate of 140 is noted. Which of the 4. Elevate head of the bed as prescribed
following orders should be initiated first?
A. 1 and2
A. IV access B. All except 2
B. Serum hematocrit and hemoglobin C. 3 and 4
C. Arterial line set-up D. All of the above
D. Dopamine continuous infusion
Situation 19: You are caring for Angelo, 68 years old, who was
83. What parenteral solution would you anticipate to prepare diagnosed with acute heart failure. Angelo has a history of acute
for Charlie’s volume replacement? myocardial infarction and underwent coronary artery bypass surgery.
He is complaining of severe shortness of breath and hemoptysis.
A. 5% Dextrose in 0.25% normal saline
B. 25% albumin 91. You recognize that pulmonary edema may develop because
C. 0.9% Normal Saline of which of the following?
D. 5% Dextrose in water
A. Low plasma protein levels decreasing plasma oncotic
84. Charlie’s mother verbalizes her concerns regarding Charlie’s pressure
condition. She informs you that Charlie is their only child B. Increase capillary permeability due to lung
and that her husband is working overseas. What would be inflammation
your best response? C. Increased hydrostatic pressure in the pulmonary
capillaries
A. Hold her hand, and have an eye contact with her and D. Increased surface tension in the alveoli
reassure her that you are doing your best.
B. Ask one of your con-staff to assist Charlie’s mother 92. Which of the following assessment findings would you
C. Tell her you understand how she feels but your priority consider as priority for immediate nursing intervention?
is to take care of Charlie
D. Tell her to pray and leave everything to God A. Hemoptysis
B. BP 95/72, skin cool, and diaphoretic
85. Charlie’s condition worsens. He develops respiratory arrest. C. Significant jugular vein distention
What nursing intervention should you perform first? D. Severe orthopnea

A. Assemble intubation kit 93. Cardiac assessment reveals apical pulse is lateral to
B. Administer oxygen midclavicular line. You understand that this finding means
 A. Mitral valve regurgitation
B. The heart is enlarged
C. That cardiac output is adequate]
D. Dilated heart

94. You observed for fibrillation on the cardiac monitor. Which

of the following ECG characteristics did you observe on the
cardiac monitor?

A. “sawtooth” appearance of P waves

B. P waves observed before, during, and after QRS
complex
C. P wave hidden in the QRS complex
D. P waves unidentifiable

95. The physician prescribed Furosemide to be administered

intravenously. Which of the following nursing orders is least
appropriate to ensure that adverse effects of the drug are
closely monitored on Angelo?

A. Report significant weight changes

B. Monitor laboratory results on electrolytes
C. Measure hourly urine output
D. Integrate foods rich in potassium in the diet

Situation 20: Lilette, 4-year-old girl with a recent history of nausea,

vomiting and diarrhea is admitted to the Pediatric Unit with a
diagnosis of acute gastroenteritis. Your significant physical
examination includes dry skin with turgor, sunken soft eyeballs,
parched lips, abdominal distention. She has tachycardia and fever
(38C)

96. Based on your assessment findings, which of the following is

your nursing diagnosis?

A. Ineffective peripheral tissue perfusion related to fluid

volume deficit
B. Fluid volume deficit related to abnormal loss and
decrease intake
C. Activity intolerance related to malaise
D. Impaired skin integrity related to frequent diarrhea

97. The following management goals for Lilette are most

important for you to include in your plan except

A. Adequate rehydration and fluid maintenance

B. Nothing per orem at all times
C. Continue assessment of fluid and electrolyte imbalance
D. Reintroduction of adequate diet

98. To ensure adequate fluid and electrolyte pelacement, the

doctor ordered 500 ml of balanced electrolyte solution for 10
hours. The IV set delivers 60 gtt/min to administer the 500
ml IV solution, you should set the IV drip rate at

A. 35 gtt/min
B. 62 gtt/min
C. 50 gtt/min
D. 41 gtt/min

99. Which of the following findings would best indicate that

Lilette’s hydration level has improved?

A. No further weight loss

B. Lower hematocrit
C. Lower creatinine
D. Lower WBC

100. Lilette cries whenever her Mommy and Grandma leave her.
Which of the following interventions can reduce her anxiety?

A. Have the same nurse care for her

B. Provide her with some new toys and bring her favorite
toys
C. Restrict visiting hours to decrease her crying
D. Encourage her playmates to visit her