1. 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

2. 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

3. 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

4. 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

5. 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

6. A patient has an elevated prothrombin (PT) time. Which medication should the
Nurse consider as a possible cause of the elevated PT Time?
a. Rifampin
b. Vitamin k
c. Birth control pills
d. Phenytoin (Dilantin)

7. 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

8. 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

9. 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

10. 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

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

12. 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

13. 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

14. 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
15. 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

16. A patient has an order for a pneumatic compression device. Which of the
following is an appropriate goal?
a. Reduce the risk deep vein thrombosis
b. Reduce lower extremity edema
c. Reduce lower extremity pain
d. Reduce the risk of phlebitis

17. 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

18. 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 unstableb 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
19. 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

20. 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

21. A community is experiencing an outbreak of staphylococcal infections. The

nurse instructs residents that the MOST common mode of transmission is by:
a. Respiratory droplets
b. Contaminated foods
c. Hands
d. Soil

22. 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

23. 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

24. 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

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

26. 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

27. 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
28. 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

29. 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

30. 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

31. 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

32. 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. Bezathginepenicillin(Megacillin)
b. Amoxicillin (Amoxil)
c. Erythromycin (Eryhrocin)
d. Vancomycin (Vancocin)
33. 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 every 5 years

34. 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

35. 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

36. In what position should a dyspnea patie

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

37. 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
 d. A Fiber rich foods

38. 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

39. 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
40. 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

41. A 62-yearold 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

42. 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?
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

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

44. 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

45. 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

46. 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
47. 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

48. 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

49. 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

50. 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

51. 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

52. 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

53. A patient presents with a productive cough with a moderate amount

of while Frothy sputum and dispend. The patient is 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) toimprovetheabilityof the heart topump
effectively
b. Oxygen therapy to combathypoxemia
c. Furosemide (lasix) toreduce blood volume andpulmonary
congestion
d. Morphine sulface(Duramorph) to reduceanxiety
54. 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

55. 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

56. 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.

57. 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

58. 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

59. 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

60. 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

61. 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
62. 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

63. After cardiac surgery, a patient has been prescribed low-sodium, low
cholesterol diet. 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

64. 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

65. 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

66. 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

67. 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

68. 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

69. 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
100-1
a. The goal will not be met
b. Progression is being made towards the goal
c. The goal is met
d. The goal is inappropriate

70. 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)

71. 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

72. 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

73. 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

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

75. 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

76. 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

77. 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

78. 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 month
b. Two months
c. Six months
d. One year
79. Prior to providing care for a hospitalized infant, the nurse MUST:
a. Introduce self to parent
b. Perform hand hygiene
c. Have a witness present
d. Assess the child’s developmental level

80. 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

81. 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

82. 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

83. 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

84. 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:
a. Peanuts
b. Strawberries
c. Eggs
d. Latex

85. 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

86. 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

87. 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

88. 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

89. 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

90. 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

91. 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

92. 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

93. 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

94. 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

95. 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

96. 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
97. 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)

98. 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

99. 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

100. 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

101. 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

102. 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

103. 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

104. 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

105. 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

106. 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 ordered for
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

107. 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

108. 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

109. 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

110. 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
c. 4 to 6 weeks
d. 6 to 8 weeks

111. 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

112. 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

113. 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
114. 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)

115. Which of the following is the MOST important discharge planning

instruction for a patient with mononucleosis?
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

116. 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

117. 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

118. 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. Increase fluid intake
b. An enema two times a week
c. Increased fiber in the diet
d. Aroutinebisacodyl(Dulcolax) suppository

119. 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

120. 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

121. 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

122. Respiratory depression is a potentially life-threatening adverse

effect of
a. Opioids
b. Anticoagulants
c. Immune modulators
d. Non-steroidal (NSAIDS)
123. 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

124. 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

125. 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

126. 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

127. 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
d. Use only natural fiber linens

128. 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

129. 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
130. 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

131. 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.

132. 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

133. 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)

134. 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

135. 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

136. 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

137. 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

138. 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

139. 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

140. 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

141. 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

142. 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

143. 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
c. Paralytic Ileus
d. Pneumonia

144. 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

145. 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

146. 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