1. A nurse is preparing to acquire a specimen for an arterial blood gas.

He plans to perform the Allen’s

test on the client. Number in order of the priority the steps for obtaining the specimen for the Allen’s
test.
1. Document or record the findings
2. Explain and describe the procedure to the client
3. Release pressure from the ulnar artery
4. Apply pressure from the radial and ulnar arteries
5. Request the client to open and close the hand repeatedly.
6. Assess the color of the extremity distal to the pressure point.

CHOICES FOR MOODLE

1. 2, 5, 4, 3, 6, 1
2. 2, 4, 3, 6, 5, 1
3. 2, 6, 4, 3, 5, 1
4. 2, 4, 5, 3, 6, 1 ANSWER

ANSWER 2, 4, 5, 3, 6, 1
The Allen’s test is done before obtaining an arterial blood specimen. This site is located from the radial
artery to identify the presence of collateral circulation and the adequacy of the ulnar artery. Failure to
determine the presence of adequate collateral circulation could result in severe ischemic injury to the
hand if damage to the radial artery occurs with arterial puncture.
2-The nurse first would explain the procedure to the client.
4-To perform the test, the nurse applies direct pressure over the client’s ulnar and radial arteries
simultaneously.
5-While applying pressure, the nurse asks the client to open and close the hand repeatedly; the hand
should blanch.
3-The nurse then releases pressure from the ulnar artery while compressing the radial artery and
assesses the color of the extremity distal to the pressure point.
6-If pinkness fails to return within 6 seconds, the ulnar artery is insufficient, indicating that the radial
artery should not be used for obtaining a blood specimen.
1-Finally, the nurse documents the findings

2. The client who has acute renal failure requests the nurse for a snack. Which of the following snacks
is most appropriate to this client who has increased potassium level?
1. A gelatin dessert.
2. Yogurt.
3. An orange.
4. Peanuts.

ANSWER: 1
1. Gelatin desserts contain no or little potassium, thus it can be served to a client on a potassium
restricted diet.
Foods high in potassium include:
Fruits: avocado, apricot, banana, coconut, citrus fruits, watermelon, dried fruits, raisins (mostly dried,
raw and frozen)
>Vegetables: broccoli, cauliflower, potato
>Bran and whole grains;
>Most milk and milk products
<Chocolate & nuts
>Strong brewed coffee.

3. During a large-scale community disaster occurrence, the lack of hospital rooms emerges. Due to
the rapid influx of victims, patients must share hospital rooms. Which room assignments are
appropriate in this situation? Select all that apply.
1. 2 clients on contact isolation, one with methicillin-resistant Staphylococcus infection and the other
with vancomycin-resistant enterococci infection
2. 2 clients with infection related to Clostridium difficile, one in his wound drainage and the other on
his stool.
3. A client in sickle cell anemia having crisis and a client with streptococcal pneumonia
4. A client who had intestinal surgery today and a client with universal precautions
5. A young client in Russel’s traction with an elderly client with Parkinson's disease

ANSWER: 245
Cohorting can be used when those infected with the same causative pathogens can be placed
together. These clients must be housed together in less than ideal circumstances. However, an
infectious client should not be placed/housed with an immunosuppressed client:
>on steroids/chemotherapy
>HIV positive
>new post-operative
>multiple chronic comorbidities
>spleenectomy
>diabetes
>very young/elderly (except during disaster occurrence provided both are not infectious)
Option 1-Though both clients are on contact isolation, they are infected with different organisms and
this places them at risk for cross-infection.
Option 2- Cohorting can be used when those infected with the same causative pathogens can be
placed together.
Option 3-Clients with sickle cell disease have some level of immunosuppression due to their
dysfunctional spleens during sickling episodes. An infectious client should not be placed with an
immunocompromised one due to risk of cross-infection).
Option 4-Every client in the hospital is on universal precautions; therefore, there should be no concern
about placing a vulnerable post-operative client in the same room where standard precautions are
being taken for another client.
Option 5-In a disaster setting, clients of different age groups can be placed in the same room together
so long as both are stable and noninfectious (even if this is not socially acceptable).

4. The American Heart Association (AHA) guidelines recommend greater availability of automated
external defibrillators (AEDs) and people trained to use them. AEDs are used in cardiac arrest
situations for:
1. Defibrillation in cases of atrial fibrillation.
2. Cardioversion in cases of atrial fibrillation.
3. Pacemaker placement.
4. Early defibrillation in cases of ventricular fibrillation.

ANSWER: 4
AEDs are indicated for early defibrillation in cases of ventricular fibrillation. Moreover, this can also be
used for pulseless V-tachycardia. The AHA targets major emphasis on early defibrillation for
ventricular fibrillation and utilization of the AED as an instrument to increase sudden cardiac arrest
survival rates.

5. An apartment fire continues and spreads to seven apartment units. Several injuries were
experienced by the victims such as broken bones, burns and minor hurts from jumping from windows.
Which client should be transported first?
1. A woman who is 4 months pregnant with no apparent injuries.
2. A middle-aged man without injuries but has coughs and rapid respirations
3. A 12-year-old with a simple fracture of the humerus who is in severe pain.
4. A 20-year-old with first-degree burns on her hands and forearms.

ANSWER: 2
2. The man with respiratory distress as indicated by fast breathing (DOB) and coughing should be
transported first because he is most likely experiencing smoke inhalation.
Option 1-The pregnant woman is not in imminent danger or likely to have a precipitous delivery.
Option 3-The 12-year-old is not at risk for infection and could be treated in an outpatient facility.
Option 4-First-degree burns are considered less urgent.

6. Which of the following patients is a contraindication to magnetic resonance imaging (MRI)?

1. A patient who is allergic to shellfish.
2. A patient with a pacemaker.
3. A patient who suffers miscarriages.
4. A patient who takes anti-psychotic medication.
5. A patient with a total hip replacement 2 years ago.
6. A patient with implantable cardioverter-defibrillator (ICD)

ANSWER: 256
MRI is not indicated to patients having metals and implanted devices. These are some patients that
are contraindicated with MRI:
>Implanted pacemaker → will interfere with the magnetic fields of the MRI scanner and may be
deactivated by them
> ICD is a small battery-powered device placed in your chest to monitor your heart rhythm and detect
irregular heartbeats.
>History of past surgeries especially if the surgery involved implantation of any metallic devices
(implants, clips, pacemakers, hip prosthesis)
>assess for hearing aids, electronic devices, shrapnel, bra hooks, necklaces, jewelry, credit cards,
zippers, or any type of metal that the magnet of the MRI unit would attract
Option 1-Shellfish/iodine allergy is not a contraindication because the contrast used in MRI scanning is
not iodine-based.
Option 3-Miscarriages is not a contraindication to MRI
Option 4-Psychiatric medication is not a contraindication to MRI scanning.

If the client is claustrophobic, the procedure may need to be rescheduled after an open MRI unit is
located or made available. Open MRI scanners and anti-anxiety medications are available for patients
with claustrophobia.
7. A nurse monitors the client’s electrolyte laboratory report and notes that the potassium level is 3.2
mEq/L. Which of the following ECG tracings should the nurse note on the electrocardiogram as a result
of the laboratory value?
1. U waves
2. Absent P waves
3. Tall T waves
4. Elevated ST segment

ANSWER: 1
The presence of U-wave indicates hypokalemia. Other ECG results of hypokalemia include ST
depression and T wave inversion.
Option 2-indicates ventricular dysrhythmias
Option 3-indicates hyperkalemia and hypomagnesemia
Option 4- This indicates myocardial injury

8. Four vehicles were involved in an accident on a remote interstate. The nearest emergency
department is 15 minutes away. Which victim should be transported by helicopter to the nearest
hospital?
1. 12-year-old with a simple fracture of the femur who is crying and cannot find his parents.
2. 35-year-old woman with cold, clammy skin and a heart rate of 120 bpm who is unconscious.
3. Middle-aged man with asthma and a heart rate of 120 bpm.
4. 70-year-old man with a severe headache who is conscious.

ANSWER: 2
The middle-aged woman is likely in shock. She is classified as a triage level I, requiring immediate
care.
Option 1-The child with moderate trauma is classified as triage level III (urgent and should be treated
within 30 minutes).
Option 3 and 4-The man with asthma and the man with the severe headache are classified as triage
level II (emergent), and can be transported by ambulance and reach the hospital within 15 minutes.

9. A client with type 1 diabetes mellitus inquires the nurse whether he can take ginseng at home. The
nurse should tell and say to the client:
1. “No, there are no therapeutic benefits of ginseng.”
2. “Taking ginseng will enhance the risk of hypoglycemia.”
3. “You can take the ginseng to help develop your memory.”
4. “You can take ginseng if you take it with a carbohydrate”

ANSWER: 2
Taking ginseng when on insulin is not recommended because ginseng potentially increases
hypoglycemia.
Option 1 & 3-Ginseng can be therapeutic in specific situations, but is potentially harmful for clients
taking insulin.
Option 4-Taking ginseng with a carbohydrate will not offset the effect of the ginseng.

10. The nurse is educating a client about applying topical gentamicin sulfate (Garamycin). Which of
the following comments by the client indicates the need for additional teaching?
1. “I will avoid sun exposure for long periods.”
2. “I should stop applying it when the infected area heals.”
3. “I’ll call the physician if the condition worsens.”
4. “I should put it on to large open areas.”

ANSWER: 4
The aminoglycoside antibiotic gentamicin sulfate should not be applied to large denuded areas
because toxicity and systemic absorption are possible.
Option1-The nurse should instruct the client to avoid excessive sun exposure because the education
can cause photosensitivity.
Option 2-The client should be instructed to avoid overusing this medication because of the possibility
of superinfection. Thus, the nurse should educate the client to apply the cream or ointment for only
the length of time prescribed
Option 3-The client should contact the physician if the condition worsens after use.

11. A client with chronic renal failure is admitted to the hospital and is taken cared of by a nurse. The
laboratory results indicate hypocalcemia and hyperphosphatemia. When assessing the client, the
nurse should be alert for which of the following? Select all that apply.
1. Trousseau’s sign
2. Cardiac arrhythmias
3. Constipation
4. Decreased clotting time
5. Drowsiness and lethargy
6. Fractures
ANSWER: 126
Option 1-Trousseau’s Sign is elicited by a positive spasm during BP cuff inflation and indicates
hypocalcemia
Option 2-Hopocalcemia reveals prolonged ST interval and prolonged QT interval
Option 3-Constipation is common in hypercalcemia
Option 4-Hypocalcemia increases clotting time
Option 5-Common in hypercalcemia
Option 6-Fractures may happen both in hypocalcemia and hypercalcemia.

12. The child who has urinary tract infection has developed a red, blistery rash after receiving
sulfamethoxazole and trimethoprim (Bactrim). Which of the following instructions should be given by
the nurse to the child’s parents?
1. Apply lotion to the affected areas.
2. Stop the medication and come for immediate further evaluation.
3. Use sunblock while on the medication.
4. Increase the child’s fluid intake.

ANSWER: 2
Sulfonamides have been linked with severe adverse reactions. A blistering rash may indicate Stevens-
Johnson syndrome, a severe allergic reaction that reveals skin lesions. This reaction is life threatening
and requires immediate attention.
Option 1-Lotion should not be applied to skin with blisters.
Option 3-Bactrim may cause photosensitivity, but this usually appears as a mild red rash, not blisters.
Option 4-Increasing the child’s fluid intake may aid the urinary tract infection, but does not address
the rash.

13. A client with a history of hypertension and peripheral vascular disease is scheduled for an
aortobifemoral bypass graft. Preoperative medications included furosemide (Lasix), pentoxifylline
(Trental), and metoprolol (Toprol XL). On postoperative day 1, the 12 noon vital signs are: respiratory
rate 20; heart rate 132 beats per minute; Temperature 37.2 ° C; and blood pressure 126/78. Urine
output is 50 to 70 mL/ hour while the hemoglobin and hematocrit are stable. Using the SBAR
(Situation-Background-Assessment- Recommendation) technique for communication, the nurse vouch
for that the primary care provider:
1. Continues the pentoxifylline.
2. Increases the I.V. fluids.
3. Restarts the metoprolol.
4. Resumes the furosemide.

ANSWER: 3
The client is suffering a rebound tachycardia from abrupt withdrawal of the beta blocker (metoprolol).
The beta blocker (metoprolol) should be restarted due to fast heart rate, history of hypertension, and
the desire to reduce the risk of postoperative myocardial morbidity.
Option 1-The bypass surgery should correct the claudication and need for pentoxifylline.
Option 2 & 4-The furosemide and increase in fluids are not indicated since the client’s urine output and
blood pressure are satisfactory and there is no indication of bleeding. The potassium should also be
assessed prior to starting the furosemide.

14. A client is admitted with a diagnosis of vancomycin-resistan enterococcal bacteremia associated

with catheter. Which of the following interventions should the nurse implement? Select all that apply.
1. Keep dedicated equipment for the client.
2. Perform hand hygiene before exiting the room
3. Place a “No visitors” sign on the client’s door
4. Wear a face mask when in the room
5. Wear an isolation gown when providing direct care

ANSWER: 125
Aside from the standard precaution, the client infected with multidrug resistant microorganisms (VRE,
MRSA), scabies, clostridium difficile will require contact precautions which includes:
>Private room or Semi-private room (with another client with same infection
>Dedicated equipment for the client (should be kept in the client’s room, disinfected when removed
out) [Option 1]
>Wear gloves upon entering the client’s room
>Perform hand hygiene before exiting the client’s room (soap and water/alcohol-based handrub for
MRSA and VRE; soap and water for scabies and C. Difficile). (Option 2)
>Wear gown with client contact and remove before exiting the room (Option 5)
>Put door notice for visitors
>Make it sure that the client leaves the roo only for vital clinical reasons (Procedures or TestsI

15. The nurse sets up a teaching plan for a client about crutch walking using a two-point gait pattern.
Which of the following should the nurse include?
A. Advance a crutch on one side and then advance the opposite foot; repeat on the opposite side.
B. Advance a crutch on one side and simultaneously advance and bear weight on the opposite foot;
repeat on the opposite side.
C. Advance both crutches together and then follow by lifting both lower extremities to the level of the
crutches.
D. Advance both crutches together and then follow by lifting both lower extremities past the level of
the crutches.

ANSWER: B
A two-point gait involves partial weight bearing on each foot, with each crutch advancing
simultaneously with the opposing leg.
Option 1- 4-Point Gait
Option 3- Swing to Gait
Option 4- Swing through Gait

16. A 75-year-old client is learning to use a cane applying a 2-steps sequence. Which of the following
observations by the nurse would indicate that the client uses the cane safely?
1. The cane is held on the unaffected side: the cane and the affected leg are advanced forward, then
the unaffected leg comes forward
2. The cane is held on the affected side: the cane is advanced forward, then the affected leg, then the
affected leg
3. The cane is held on the unaffected side: the cane is advanced forward, then the unaffected leg,
then the affected leg
4. The cane is held on the affected side: the cane and the unaffected leg are advanced forward, then
the affected leg comes forward

ANSWER: 1
The hand opposite to the affected extremity holds the cane to widen the base of support and to reduce
stress on the affected limb
Option 3-The cane should be advanced forward, then the affected/bad leg (reciprocal motion), then
the unaffected (good) leg
Option 2 and 4- Cane should be held on the unaffected side.

17. During the first hour after birth, the nurse will draw blood sample for glucose testing from a term
neonate. Which of the following areas should the nurse obtain the blood sample from the neonate’s
foot?

ANSWER: 1
The most appropriate site for obtaining a blood specimen in a neonate is the lateral aspect of the heel.
This area avoids damaging the calcaneus bone, which is located in the middle of the heel (Option 2).
Option 2-The middle of the heel is to be avoided because of the increased risk for damaging the
calcaneus bone located there.
Option 3-The middle of the foot comprises the medial plantar nerve and the medial plantar artery,
which might be injured if this site is selected.
Option 4-The base of the big toe is not the preferred site for specimen collection since it may cause a
great deal of discomfort for the neonate.
18. The nurse uses the Z-track technique when administering an I.M. injection of iron. This is done in
order to prevent leakage of the medication to the subcutaneous tissue and staining of the skin.
Number in order of the steps on performing the Z-track method.
1. Stretch the skin laterally
2. Push the plunger to administer the medication
3. Aspirate by pulling back the plunger
4. Withdraw the needle slowly and release the displaced skin
5. Wait for 10 seconds before withdrawing
6. Draw the drug from the medication container and change the needle
7. Inject the needle 90°

ANSWER: 6173254
1. Draw a small amount of air into syringe → prevent drug from flowing back into the needle track
2. Draw the drug from the container and change needle → to prevent the needle that is in contact with
iron to directly contact to the skin
3. Stretch the skin: lateral 1 inch (2.5 cm)
4. Inject the needle: 90°
5. Aspirate → pulling back plunger
6. Push the plunger → inject med slowly (10 sec /ml) →promotes comfort
7. Before withdrawing: Wait for → 10 seconds
8. Withdraw the needle slowly} simultaneously done: step #8 and #9
9. Release the displaced skin
10. Do not massage or rub the site

19. Which of the following clients will fall under the expectant category?
1. A client with a sucking chest wound
2. An unresponsive client with penetrating head wound
3. A client with wound without airway compromise
4. A client with pneumothorax
5. A client with 70% TBSA full thickness burns
6. A client with fractures of tibia and fibula
7. A client with smoke inhalation injuries
8. A middle-aged person with deep abrasions that are over 90% of the body

ANSWER: 258
Expectant category includes intensive injuries with poor prognosis. The clients/victims are considered
to have a low or least chances of survival. Examples of black tag (expectant category) are:
>Absent VS (Pulselessness, Apnea)
>Severe neurological trauma (eg. Cervical Spinal Cord Injury, penetrating head injury)
>Full-thickness burns → more than 60%
>Deep Abrasions more than 90%

Emergent (Red Tag)-life threatening injuries with high probability of survival if immediate treatment is
received
>Shock
>Compromised Airway/Breathing: ARDS
>Chest trauma: Pneumothorax
>MI and Chest pain
>Facial Burns
>Unstable wounds with hemorrhage

Urgent (Yellow Tag) - Serious injuries requiring treatment within 30 minutes and 2 hours.
>Open fractures with palpable distal pulse
>Large wounds (without haemorrhage)

Non-urgent (Green Tag)-Injuries requiring treatment but can wait for 2 hours or longer
>Minor injuries: Sprain, Strain, Closed (Simple) Fractures
>Walking wounded
>Abrasions (small and minor)
>Minor Burns (first degree)
>Small lacerations
>Infections

Sucking Chest wound-Emergent

Wound without Airway compromise-Either Urgent or Non-urgent (depends on the wound)
Pneumothorax-Emergent
Fractures of tibia and fibula- if open: Urgent, if closed: Non-urgent
Smoke Inhalation Injury-Emergent
20. A triage nurse is attending 4 clients who arrive in the emergency department within 15 minutes.
Which client should the triage nurse prioritize?
1. A 3-month-old infant with a history of rolling off the bed and has bulging fontanels with crying.
2. A teenager who got a singed beard and nasal hair while camping.
3. An elderly client who complains of frequent liquid brown colored stools.
4. A middle aged client with intermittent pain behind the right scapula.

ANSWER: 2
Any client with singed facial and nasal hair has been exposed to heat or fire in close range that could
have caused serious damage to the interior of the lungs. These interior linings have no nerve fibers so
the client might not be aware of the swelling. This client is in the greatest danger with a potential of
respiratory distress. Airway is still the priority.

21. The nurse caring for a client admitted with Addison’s Disease. During the intake assessment,
which of the following findings should the nurse expect from the client? Select all that apply.
1. Obesity
2. Edema
3. Low blood pressure
4. Hirsutism
5. Cool and bronze skin
6. Low blood sugar

ANSWER: 3, 5, 6
The client with acute adrenal crisis has symptoms of hypovolemia and shock; therefore, the blood
pressure would be low. Addison’s disease causes decrease glucocorticoids (hypoglycaemia, weight
loss), decrease mineralocorticoids (hyponatremia, hypovolemia, hypotension, hyperkalemia, bronze
skin) and decrease androgen (decrease libido, body hair loss). Bronze hyperpigmentation is caused by
an increase in adrenocorticotropic hormone (ACTH) by the pituitary in response to low cortisol.
Option 1, 2 and 4- indicates Cushing’s Disease)

22. The nurse is administering magnesium sulfate as ordered via IV for a client at 34 weeks’ gestation
due to severe preeclampsia. Which of the following are medication’s desired outcomes? Select all that
apply.
1. T 98, P 72, R 14.
2. Urinary output <30 mL/hr.
3. HR 120 BPM.
4. Fetal heart rate with late decelerations.
5. BP of <140/90.
6. DTR’s 2+.
7. Magnesium level= 5.6 mg/dL.
8. Clonus = 2+.

ANSWER: 1, 3, 5, 6, 7
The use of magnesium sulfate as an anticonvulsant acts to depress the central nervous system by
blocking peripheral neuromuscular transmissions and decreasing the amount of acetylcholine
liberated.
Option 1-While being used, the temperature and pulse of the client should remain within normal
limits. The respiratory rate (RR) has to be greater than 12 respirations per minute (RPM) since lower
RR (lesser than 12RR) is related to respiratory depression and indicates magnesium toxicity.
Option 2-Renal compromise is identified with a urinary output of <30 mL per hour.
Option 3 and 4-A fetal heart rate that is maintained within the 112–160 range is anticipated and
without later or variable decelerations.
Option5-One of the desired outcome is blood pressure below 140/90.
Option 6-Deep tendon reflexes that are not diminished or exaggerated are a desired outcome.
Option 7-The therapeutic magnesium sulfate level should be maintained at 5–8 mg/dL.
Option 8-Clonus and hyper-reflexivity are not desired outcomes.

By convention the deep tendon reflexes (DTR) are graded as follows:

0 = no response; always abnormal
1+ = a slight but definitely present response; may or may not be normal
2+ = a brisk response; normal
3+ = a very brisk response; may or may not be normal
4+ = a tap elicits a repeating reflex (clonus); always abnormal

23. Which of the following compensatory mechanisms or actions by the body would happen if a client
were in respiratory acidosis?
1. Elimination of bicarbonate (HCO3−) by the kidneys.
2. Conservation of HCO3− by the kidneys.
3. Increase in respiratory rate by the lungs.
4. Reduction in respiratory rate by the lungs.

ANSWER: 2
The compensatory mechanism for respiratory acidosis is the renal system. In respiratory acidosis, the
kidneys will retain HCO3− in an effort to correct the acidosis.
Option 1-Excretion of HCO3− would exacerbate the body’s acidosis.
Option 3 and 4-The lungs cannot compensate for a problem that arises in the respiratory system.

24. A preschooler with meningitis scheduled to be discharged shows her anger when the discharge is
delayed. Which of the following play activities would be most appropriate at this time?
1. Reading the child a story.
2. Painting with watercolors.
3. Pounding on a pegboard.
4. Stacking a tower of blocks.

ANSWER: 3
The child is angry and requires a positive outlet for expression of feelings. A physical activity is needed
by an emotionally tense child to release energy and frustration. Pounding on a pegboard offers this
opportunity especially if the child has pent-up hostilities.
Option 1-Listening to a story does not allow the child to express emotions. It also places the child in a
passive role and does not allow the child to deal with feelings in a healthy and positive way.
Option 2 Activity such as painting requires concentration and fine movements which could add to
unreleased frustration.
Option 4-Stacking a tower of blocks requires fine motor and concentration which could add to
frustration. However, if the child then knocks the tower over may aid to disperse some of the anger.

25. In preparation for the admission of the client with meningococcal meningitis, which would the
nurse do first upon the child’s arrival?
1. Institute droplet precautions.
2. Take the child’s vital signs.
3. Inquire the parents about medication allergies.
4. Make inquiries about the siblings’ health at home.

ANSWER: 1
The child with meningococcal meningitis necessitates droplet precautions for at least the first 24
hours after effective therapy is initiated to reduce the risk of transmission to others on the unit.
Options 2, 3 and 4-After the child has been placed on droplet precautions, other actions, such as
taking the child’s vital signs, asking about medication allergies, and inquiring about the health of
siblings at home, can be performed.

26. An infant is returned to the room in stable condition after he underwent surgical correction of
pyloric stenosis. While standing near her child’s crib, the mother expresses, “The surgery could have
been avoided possibly if I had brought my baby to the hospital sooner.” Which of the following should
be the nurse’s best response?
1. “Surgery is the most helpful treatment for pyloric stenosis.”
2. “Your baby will be fine. Try not to worry”
3. “Do you feel that this problem indicates that you are not a good mother?”
4. “Do you think that earlier hospitalization could have avoided surgery?”

ANSWER: 4
Restating or rephrasing a mother’s response offers the opportunity for clarification and validation. It
also supports to focus on what the mother is saying and deals with her concerns and feelings.
Option 1-Although surgery is the most effective treatment for pyloric stenosis, stating this disregards
the mother’s feelings and does not provide her an opportunity to express them.
Option 2-Informing the mother not to worry also ignores the mother’s feelings. Additionally, this type
of statement gives the mother premature reassurance, which may turn out to be false.
Option 3-Asking the mother if she thinks the problem indicates that she is not a good mother implies
such an idea. It does give her opportunity to express her feelings and apprehensions and therefore is
not a therapeutic response.

27. A patient with a diagnosis of alcohol abuse is admitted to the detoxification unit. Which of the
following products or articles should be omitted from the patient’s admission package? Select all that
apply.
1. Mouthwash
2. Liquid soap
3. Toothpaste
4. Cough syrup
5. Fruit juice
6. Talcum powder
7. Colognes and perfumes
8. Lozenges

ANSWER: 1478
The client who drinks alcohol while taking disulfiram (Antabuse) for detoxification processes might
experience sweating, flushing of the neck and face, tachycardia, hypotension, a throbbing headache,
nausea and vomiting, palpitations, dyspnea, tremor, and weakness. Alcohol-containing products
should be avoided to prevent disulfiram-like reactions. These products include rubbing alcohol,
aftershave, certain mouthwashes, perfumes, colognes, hand sanitizers, some hair sprays, cough
syrups, lozenges.

28. A client with chronic renal failure who receives hemodialysis three times a week is experiencing
severe nausea. Which of the following instructions by the nurse to manage the nausea? Select all that
apply.
1. Drink fluids before eating solid foods.
2. Have limited amounts of fluids only when thirsty.
3. Reduce and control activity.
4. Keep all dialysis appointments.
5. Eat small, frequent meals.

ANSWER: 2, 4, 5
To manage nausea, the nurse can recommend the client to drink limited amounts of fluid only when
thirsty, eat food before drinking fluids to ease dry mouth, motivate strict follow-up for blood work,
dialysis, and health care provider visits. Option 4-The client should also maintain the dialysis schedule
because the dialysis will eliminate wastes that can contribute to nausea. Option 5-Smaller, more
frequent meals may aid to decrease nausea and facilitate medication taking.
Option 1-To manage nausea, eat food before drinking fluids to alleviate dry mouth.
Option 3-Although the patient with chronic renal failure needs rest, the client is encouraged to be
active as possible (like ambulation with assistance) avoid immobilization since it intensifies bone
demineralization.

29. The client inquires about his diet changes when having continuous ambulatory peritoneal dialysis
(CAPD). Which of the following would be the nurse’s best response?
1. “Diet restrictions are stiffer with CAPD because standard peritoneal dialysis is a more effective
technique.”
2. “Diet restrictions both CAPD and standard peritoneal dialysis are the same.”
3. “Diet restrictions with CAPD are fewer than with standard peritoneal dialysis because dialysis is
constant.”
4. “Diet restrictions with CAPD are fewer than with standard peritoneal dialysis because CAPD works
more quickly.”

ANSWER: 3
Dietary restrictions with CAPD are lesser than those with standard peritoneal dialysis because dialysis
is constant and continuous (not intermittent). The constant slow diffusion of CAPD helps prevent
accumulation of toxins and allows for a more liberal diet.
Option 1-Both types of peritoneal dialysis are effective.
Option 2-Their diet restriction may differ such as that CAPD has fewer restrictions than the standard
peritoneal dialysis.
Option 4-CAPD does not work more quickly, but more consistently.

30. A client with a history of chronic cystitis goes to the outpatient clinic manifesting its sign and
symptoms. The nurse instructed the client to maintain an acid-ash diet to acidify the urine, to
decrease the rate of bacterial multiplication, and to prevent the recurrence of cystitis. Which of the
following beverages does not belong to an acid ash-diet?
1. Cranberry juice
2. Coffee
3. Prune juice
4. Milk

ANSWER: 4
Foods that are allowed on an acid-ash diet include
-meat
-fish
-shellfish
-eggs
-poultry
-grains
-cranberries, prunes, plums
-corn
-lentils and foods with high amounts of chlorine, phosphorus, and sulfur
Coffee and tea are considered neutral because they don’t alter the urine pH.

Foods that are not included are

-all milk and milk products
-all other vegetables except corn and lentils
-all fruits except cranberries, plums, and prunes
-foods containing high amounts of sodium, potassium, calcium, and magnesium.
31. Which of the following instructions should a nurse teach to an adult client who has bacterial
conjunctivitis? Select all that apply.
1. Utilize warm saline soaks four times per day to remove crusting.
2. Put on topical antibiotic without contacting the tip of the tube to his eye.
3. Wash his hands after touching his eyes.
4. Avoid touching his eyes.
5. Observe isolation procedures and confine himself to his bedroom until the redness in the eye
disappears.

ANSWER: 1, 2, 3, 4.
Option 1-The client with conjunctivitis can use warm soaks to remove crusting. The nurse should
explain the client to dispose of the soaks by wrapping them in a separate bag to prevent spreading
bacteria.
Option 2-Topical antibiotics are used to treat the infection. The client should keep away from
contaminating the tip of the medication dispenser.
Option 3, 4-Bacterial conjunctivitis needs to contain the spread of the infection by washing the hands
after touching the eyes as well as to avoid touching the eyes if necessary.
Option 5-The client does not need to be isolated.

32. A nurse has supplied instructions regarding home care measures to a client with pyelonephritis.
Which of the following statements by the client indicates a need for further teaching?
1. “I must take my daily dose of ascorbic acid (vitamin C).”
2. “I should intensify my fluid intake to 3L daily.”
3. “I should try to maintain acid-ash diet.”
4. “I need to avoid highly spiced foods and alcohol but perhaps continue to drink my coffee every
day.”

ANSWER: 4
Caffeine, alcohol, chocolate, and highly spiced foods are avoided or discouraged to prevent potential
bladder irritation.
Option 1-Medications like vitamin C help acidify the urine.
Option 2-Clients should be instructed to increase fluid intake to 3 L per day to help relieve dysuria and
to flush bacteria out of the bladder.
Option 3-An acid ash diet such as cranberry, plum, and prune juice will leave an acid ash in the urine
and may be of some benefit.

33. A client with urinary tract infection and dehydration has been admitted to the hospital. Which of
the following BUN results will evaluate that the client has received adequate volume replacement?
1. 35 mg/dL
2. 28 mg/dL
3. 15 mg/dL
4. 3 mg/dL

ANSWER: 3
The normal blood urea nitrogen level is 8 to 25 (10-20 some books) mg/dL.
Options 1 and 2-these values reflect continued dehydration.
Option 4 reveals a lower than normal value, which may occur with fluid volume overload, among other
conditions.

34. A 4-year-old child is admitted for a scheduled cardiac catheterization. Which of the following is
most important to include by the nurse in teaching this child about cardiac catheterization?
1. A plastic model of the heart.
2. A catheter that will be introduced into the artery.
3. The parents.
4. Other children undergoing catheterization.

ANSWER: 3
The most important aspect of teaching a preschooler is to have the family members there for support.
Preschoolers are able to comprehend information that is customized to their level.
Option 1-Including a plastic model of the heart and a catheter as part of the preoperative preparation
may be helpful. The other family members will understand the heart model and catheter better than
the preschooler will.

35. The school nurse interprets the peak expiratory flow rate for a client with asthma. Which zone
signals a medical alert and points out that the client may need their inhaler?
1. Green
2. Red
3. Yellow
4. Blue

ANSWER: 2
The peak expiratory flow rate (PERF) measures the maximum flow rate that can be forcefully exhaled
in one second. Three zones of measurement are used to interpret (PERF).
>Green (80-100% personal best) signals good control of asthma.
>Yellow (50-79% of personal best) signals caution. Asthma is not well-controlled and may reveal an
acute exacerbation of asthma. Maintenance therapy may be needed to be increased. The nurse should
contact the practitioner if the client stays in this zone.
>Red (below 50% of personal best) indicates a life threatening condition.

36. A nurse is educating a group of mothers about first aid treatment for burns. Which instructions
should be given by the nurse appropriately?
1. “Cover the burned area with butter or toothpaste.”
2. “Apply an antibacterial ointment to the burned area.”
3. “Put an ice pack on the burned area.”
4. “Submerge the burned area in cool water.”

ANSWER: 4
The best instruction for the nurse to give to the group of mothers is to submerge or to run cool water
in the burned area in order to stop the burning process. Then, the area should be wrapped in a clean
cloth. Once these initial actions are completed, the mother can call the child’s physician.
Option 1-It is not advisable to rub butter or toothpaste to the burned area as butter may aggravate
the burning process.
Option 2-For most burns, it is not advised to apply ointment until the area has been evaluated or
unless prescribed by the doctor.
Option 3-Packing the arm in ice may cause more damage to the burned area because cold can cause
burns just as heat can.

37. The nurse is promoting health education for a client about coronary heart disease prevention.
Which of the following vitamins should the nurse commend the client to comprise in his diet to reduce
homocysteine levels? Select all that apply.
1. Vitamin K.
2. Vitamin B6.
3. Folate.
4. Vitamin B12.
5. Vitamin D.

ANSWER: 2, 3, 4.
Vitamin B6, folate, and vitamin B12 have been revealed to lessen homocysteine levels.
Option 1 and 5 -The effects of vitamins K and D have not been established with regard to
homocysteine.

38. The client’s renal stone was found to be composed of uric acid for that reason a diet such as low-
purine, alkaline-ash diet was ordered. Which of the following food items should be incorporated in the
client’s home diet would indicate that he understands the necessary diet modifications?
1. Milk, apples, tomatoes, and corn.
2. Eggs, spinach, dried peas, and gravy.
3. Salmon, chicken, caviar, and asparagus.
4. Grapes, corn, cereals, and liver.

ANSWER: 2
A low-purine diet is advocated to prevent the formation of uric acid thus, the client should avoid
internal organs/organ meats (gravy, dinuguan (Filipino Food), sisig (Filipino Food), chicharong
bulaklak (Filipino Food) , pig brain), caviar, sardines, anchovies, shrimp, shellfish, legumes (peas,
peanuts, monggo, beans), beer and alcohol.
An alkaline-ash diet is also advocated because uric acid crystals are more likely to develop in acid
urine. Foods that may be eaten as desired in a low-purine diet include milk, all fruits, tomatoes,
cereals, and corn. Foods allowed on an alkaline-ash diet include milk, fruits (except cranberries,
plums, and prunes), and vegetables (especially legumes and green vegetables).
Options 2, 3 and 4-Gravy, caviar, and liver are high in purine.

39. A nurse is caring for a patient who develops compartment syndrome from a fractured leg. The
client questions the nurse how this can happen. The nurse’s response is base on the understanding
that
1. an injured artery causes the impaired arterial perfusion through the compartment
2. the fascia expands with injury, causing pressure on the underlying nerves and muscles
3. a bone fragment has injured the nerve supply in the area
4. bleeding and swelling cause increased pressure in an area that cannot expand

ANSWER: 4
Compartment syndrome is caused by swelling and bleeding within a tissue compartment that is lined
by fascia and does not expand. The bleeding and swelling put pressure and compresses the nerves,
muscles, and blood vessels in the compartment, triggering the symptoms such as paresthesia, pain
(unrelieved by analgesics), pulselessness, pallor and poikilothermia.
40. A nurse employed in an emergency department is appointed to triage clients arriving to the
emergency room for treatment. The nurse should assign the highest priority to which of the following
clients?
1. A client complaining of headache and muscle weakness or aches
2. A client who twisted her ankle when she fell while skateboarding
3. A client who has a minor laceration on the thumb sustained while cutting a cucumber
4. A client with chest pain who states that he just ate hash brown and pizza mixed with very spicy
sauce

ANSWER: 4
In an emergency department, triage consists of brief client assessment to categorise clients according
to their need for care as well as establishing priorities of care. The type of illness or injury, the
severity of the problem, and the resources available govern the process.
Clients classified as emergent and are the number 1 priority.
>trauma
>chest pain
>severe respiratory distress
>cardiac arrest
>limb amputation
>acute neurological deficits
>chemical splashes to the eyes are

Clients have urgent needs and are classified as number 2 priority

>simple fracture
>asthma without respiratory distress
>fever
>hypertension
>abdominal pain
>renal stone

Clients are classified as nonurgent and are the number 3 priority

>minor laceration
>sprain
>cold symptoms

41. Which of the following should a nurse do when getting ready for extracting blood specimens to a
3-year-old child?
1. Describe the procedure in advance.
2. Explain why the blood needs to be drawn.
3. Apply distraction techniques during the procedure.
4. Provide explanations verbally regarding what will occur.

ANSWER: 3
A 3-year-old child reacts best to distraction throughout a procedure due to the typical level of
cognitive development of a 3-year-old and the fear of painful events.
Option 1-Preparation for the procedure should be done immediately beforehand, so that the child will
not become too frightened.
Option 2-A 3-year-old is not worried about the why of the procedure but about whether the procedure
is painful or not.
Option 4-This child is too young for verbal explanations alone for the reason that his verbal abilities
are limited for his age.

42. You are helping a client with a spinal cord injury (SCI) to start a bladder retraining program.
Which approaches may stimulate the client to void? Select all that apply.
1. Stroking the client’s inner thigh
2. Pulling on the client’s pubic hair
3. Introducing intermittent straight catheterization
4. Streaming warm water over the client’s perineum
5. Tapping the bladder to stimulate the detrusor muscle

ANSWER: 1, 2, 4, 5
All of the approaches or strategies except straight catheterization may stimulate voiding in clients with
an SCI.
Option 3-Intermittent bladder catheterization will not stimulate voiding however can be used to empty
the client’s bladder.

43. Which of the following clients should the nurse assess first after receiving the change of shift
report?
1. 6-month-old with respiratory syncytial virus and pulse oximetry of 90%
2. 1-year-old with otitis media and a temperature of 102.5 F (39.2 C) rectally
3. 3-year-old with suspected of inflammation of epiglottis
4. 4-year-old who has a barking-type cough

ANSWER: 3
Epiglottitis is considered a medical emergency caused by Haemophilus influenza. It causes severe
inflammatory obstruction above and around the glottis which will usually progress from having no
symptoms to having a complete occlusion of airway within hours. A classic manifestation of epiglottitis
includes sitting in a tripod position (upright and leaning forward with the chin and tongue sticking
out). The child will probably drool and be very restless secondary to airway obstruction and hypoxia.
Option 1-Oxygen saturation ≥90% is the treatment goal for bronchiolitis caused by respiratory
syncytial virus.
Option 2- This temperature is an anticipated finding in the setting of otitis media and does not convey
the urgency of airway impairment.
Option 4- A barking-type cough is seen in viral croup syndromes and the 2nd option to be assessed.
The resonant hoarse cough is secondary to narrowed airways. Croup is characteristically mild but can
become life-threatening if there excessive swelling of the airway.

44. The nurse is doing health education and screening clients related to cancer prevention. Which of
the following is screening protocol recommended for colon cancer in low-risk and asymptomatic client?
1. Guaiac testing of stools should be done yearly at the age of 50 years.
2. Digital rectal examinations are compulsory every 5 years after age 40 years.
2. Sigmoidoscopy is recommended if symptoms of colon problems are present.
3. A low-fat diet should be implemented by age 50 years.

ANSWER: 1
1. The screening protocol recommended by the American Cancer Society for initial or early detection
of cancer in asymptomatic people comprises all clients beginning at 50 years old should have:
>fecal occult blood testing every year
>flexible sigmoidoscopy every 5 years
>colonoscopy every 10 years
Option 4-A diet low in fat and high in fruit and fiber is not a screening protocol but is good dietary
advice for all clients.

45. What of the following is the nurse’s first priority in managing care for a client who has renal colic
due to renal stones?
1. Do not let the client ingest fluids.
2. Encourage the client to drink at least 500 ml of water each hour.
3. Ask the central supply department to deliver supplies for straining urine.
4. Administer an opioid analgesic as prescribed.

ANSWER: 4
If infection or obstruction caused by calculi is present, a client can experience sudden severe pain
(renal colic) in the flank area. Pain from a kidney stone is considered an emergency situation and
requires analgesic intervention.
Option 1-Withholding fluids will create a more concentrated urine and more difficult passage of stones.
Option 2-Forcing large quantities of fluid may cause hydronephrosis (dilation of kidney) if urine is
prevented from flowing past calculi.
Option 3-Straining urine for small stones is does not take priority over pain management although this
is also important.

46. A bone mineral analysis shows that a patient who is postmenopausal has severe osteoporosis.
Which instructions should the nurse give to the patient’s family to ensure a safe environment for the
patient?
1. “Disinfect the bathroom wisely”
2. “Carpet floor surfaces”
3. “Install handrails on stairways”
4. “Keep the lights dim”

ANSWER: 3
Home modifications to reduce the risk for falls include use of railings and handrails on all staircases,
ample lighting, removal of scatter rugs, and placement of handrails in the bathroom.
Option 1-not necessary
Option 2-Having wall-to-wall carpeting is not necessary.
Option 4-Have an adequate lighting instead of dim ones.

47. Nursing staff are trying to provide a safe environment for a client with moderate dementia. This
elderly client keeps on wandering at night and has trouble keeping her balance. She has fallen twice
however has had no ensuing injuries. The nurse should:
1. Transfer the client to a room close the nurse’s station and install a bed alarm.
2. Let the client sleep in a reclining chair across from the nurse’s station.
3. Assist the client to bed and raise all four bedrails.
4. Request a family member to stay with the client at night.
ANSWER: 1
Using a bed alarm facilitates the staff to respond immediately if the client tries to get out of bed.
Option 2-Sleeping in a chair at the nurse’s station interferes with the client’s restful sleep and privacy.
Option 3-Using all four bedrails is reflected a restraint and unsafe practice. The best management is to
put the bed in the lowest position.
Option 4-It is not appropriate to expect a family member to stay all night with the client.

48. The parent raises question to the nurse about causes of brain injury in children. Which of the
following should be included in the nurse response as the major causes? Select all that apply.
1. Falls.
2. Motor vehicle accidents.
3. Bicycle accidents.
4. Child abuse.
5. Tumors.

ANSWER: 1, 2, 3.
Head injuries are common in children related to their impulsivity. Moreover, the larger size of the
heads of infants and toddlers causes them to fall more easily than older children.
Option 1-Falls account for one-third (33%) of all head injuries.
Option 2-Motor vehicle accidents are responsible for about 80% of all severe head injuries in children.
Option 3-Children age 5 to 15 are most probably involved in bicycle accidents due to 50% not wearing
their helmets.
Option 4 & 5-Child abuse and tumors involve a much smaller number of children.

49. A ten year old patient with rheumatic fever has a history of long-term aspirin use. Which
statement by the client indicates that the nurse should report to the health care provider?
A. “I hear buzzing in my ears.”
B. “Is it okay to put lotion on my itchy skin?”
C. “My stomach aches after I take that medicine.”
D. “These pills make me cough.”

ANSWER: 1
Tinnitus is an adverse effect of extended aspirin therapy and the child should be examined by a health
care provider for hearing loss.
Option 2-Itchy skin is commonly associated with the rash related with rheumatic fever. The nurse can
encourage lotion use.
Option 3-The nurse teaches clients to take aspirin with meals (food or milk) to avoid gastric irritation
or discomfort.
Option 4-The nurse can also address the fact that coughing after ingesting aspirin can be caused by
inadequate fluid intake during administration.

50. The nurse is caring for a 4-year-old child and has recognized a priority nursing diagnosis of
Anxiety related to surgery (tonsillectomy). While the 4-year-old child is preparing for a tonsillectomy,
the nurse should tell the child:
1. “You won’t have so many sore throats after the removal of your tonsils.”
2. “The doctor will put you to sleep so you don’t feel anything.”
3. “Show me how to give the doll an I.V.”
4. “When it is finished, you will get to see your mommy and get a Popsicle.”

ANSWER: 4
When preparing or engaging a child for a procedure, the nurse should use neutral words, concentrate
on sensory experiences, and focus on the positive aspects at the end. Being reunited with parents and
consuming a nice pop would be a pleasurable even.
Option 1- The nurse should utilize the word “fixed” instead of “removed” to describe what is being
done to the tonsils to reduce the anxiety. With this age, children fear bodily harm.
Option 3-Using the terms “put to sleep” and “I.V.” might be threatening. Additionally, directing a play
experience to focus on I.V. insertion may be counterproductive as the child may have little recollection
of this aspect of the procedure.

51. Which of the following possible sources of infection of Salmonella-related diarrhea could the nurse
obtain from the patient’s history?
1. Nonrefrigerated custard.
2. A canary.
3. Undercooked eggs.
4. Unwashed fruit.

ANSWER: 3
Diarrhea related to Salmonella bacilli is frequently spread by raw or undercooked fowl and eggs, pet
turtles, and kittens.
Option 1-Food poisoning caused by Staphylococcus species is frequently spread by inadequately
cooked or refrigerated custards, cream fillings, or mayonnaise.
Option 2-Psittacosis, a respiratory illness, may be spread by canaries.
Option 4-Contaminated, unwashed fruit is associated with typhoid fever (caused by Salmonella typhi),
a disorder hardly seen in the United States.

52. While you are working in the clinic, a healthy 32-year-old woman approaches and asks you about
the most effective breast cancer screening since her sister is a carrier of the BRCA gene. Which
response is best?
1. “An annual mammogram is typically sufficient screening for women your age.”
2. “Monthly self-breast examination is suggested because of your higher risk.”
3. “A yearly breast examination by a health care provider should be scheduled.”
4. “In addition to annual mammography, magnetic resonance imaging is recommended.”

ANSWER: 4
The current national guidelines identify first-degree relatives of clients with the BRCA gene to be
screened with both mammography and magnetic resonance imaging (MRI) yearly.
Option 1, 2, 3-Although annual mammography, breast self-examination, and clinical breast
examination by a health care provider may help to detect cancer, the best option for this client is
annual mammography and MRI.

53. A client experiences incontinence after recovering from transurethral resection of the prostate
(TURP). He informs the nurse that he has reduced his fluid intake because of the incontinence. What
would be the nurse’s best response to the client?
1. “Yes, limiting your fluids can decrease your incontinence.”
2. “Limiting your fluids will cause kidney stones.”
3. “Drink eight glasses of water a day and urinate every 2 hours.”
4. “If your incontinence continues, we will reinsert your catheter.”

ANSWER: 3
Clients who have undergone TURP need to be taught to maintain an adequate fluid intake even though
he experiences urinary dribbling or incontinence. The client should be instructed to drink at least eight
(8) glasses of water daily to dilute the urine and help inhibit urinary tract infections. Additionally,
maintaining a voiding schedule of every 2 hours can aid decrease incidents of incontinence. Another
management is teaching the client about Kegel’s exercises for strengthening sphincter tone.
Option 1-The nurse should not encourage the client to limit fluids.
Option 2-It is not necessarily true that a decreased intake will cause renal calculi.
Option 4-It is not beneficial to threatening the client with a catheter and it is not the treatment of
choice for a client who is experiencing incontinence from TURP.

54. A nurse has provided home care methods to the client with diabetes mellitus as regards to
exercise and insulin administration. Which statement by the client indicates a need for further
instruction?
1. “I should do my exercise during the peak action of the insulin.”
2. “I should always carry a fast-acting carbohydrate when I exercise”
3. “I should always wear a medical identification bracelet.”
4. “I should avoid exercising during periods when hypoglycemic reaction is likely to occur.”

ANSWER: 1
The client should be educated to avoid exercise at peak insulin time because of the high risk of
hypoglycemic reaction. If exercises are done at this time, the client should be informed to eat an hour
before the exercise and drink a carbohydrate liquid.
Options 2, 3 and 4- These are correct statements regarding exercise, insulin, and diabetic control.

55. You understand that epinephrine will be effective for the patient with anaphylaxis because of
which of the following effects?
1. Bronchodilating effects
2. Antihistaminic effects
3. Anticholinergic effects
4. Vasodilating effects

ANSWER: 1
Epinephrine belongs to a class alpha- and beta-adrenergic agonists. It works by relaxing the muscles
around the airways so that they open up and you can breathe more easily (bronchodilator
effect). With regards to the blood vessels, epinephrine causes vasoconstriction.

56. The nurse is formulating a plan of care for a client with Crohn’s disease who is receiving total
parenteral nutrition (TPN). Which of the following nursing interventions should the nurse include?
Select all that apply.
1. Monitoring vital signs once a shift.
2. Weighing the client every day.
3. Replacing the central venous line dressing daily.
4. Checking the I.V. infusion rate hourly.
5. Taping all I.V. tubing connections securely.
ANSWER: 2, 4, 5.
When caring for a client who is receiving TPN, the nurse should intend to weigh the client every day,
monitor the I.V. fluid infusion rate hourly (even when using an I.V. fluid pump), and securely tape all
I.V. tubing connections to stop disconnections.
Option 1-Vital signs should be checked at least every 4 hours to aid in early detection of
complications.
Option 3-It is commended that the I.V. dressing will be changed once or twice per week or when it
happens to be soiled, loose, or wet.

57. While serving clients transported to a crisis center during a severe flood, the nurse interviews a
client whose pregnant wife is missing and whose home has been devastated. The client keeps talking
hurriedly about his experience and states, “I can’t see how I can ever rebuild my life.” Which of the
following responses by the nurse would be most appropriate?
1. “If you start establishing your life now, I’m sure all will be fine.”
2. “This has been an awful experience. Tell me more about how you feel.”
3. “Let me document a few of the things you said before you resume with your story.”
4. “Tonight, think some more of what happened, so that we can continue with this tomorrow.”

ANSWER: 2
At the time of a major crisis, the client enduring a great loss is best helped by being encouraged to
describe his feelings and talk about his experience. Crisis interventions emphasize on reestablishing
emotional equilibrium and inhibiting decompensation.
Option 1-Telling the client that everything will be fine is a cliché and inappropriate.
Option 3-Asking the client to stop talking in order to write down notes points more emphasis on the
nurse’s needs than on the client’s needs.
Option 4-Telling the client to think more about what happened for further conversation the next day is
not assisting him with the crisis.

58. A nurse is about to assess and conduct a sexual history for a 16-year-old female who is
accompanied by her mother. What is an appropriate question for the nurse to ask this client or her
mother?
1. “What’s your idea about having your mother leave the room now?”
2. “Mother, do you believe your daughter is sexually active?”
3. “Mother, I am going to request you to wait a few minutes in the waiting room now so I can
complete the health history with your daughter.”
4. “The two of you seem like you share everything. I am going to ask questions about sexual history
now.”

ANSWER: 3
Privacy and confidentiality are critical developmental needs for the adolescent. These needs are
significant to enable the nurse to set up a trusting relationship with the adolescent. A sexual history
should be engaged with a teen without parents. Therefore, the nurse should not ask the mother to
offer information or put the daughter in a position of having to make a decision while her mother
remains in the room. Inform the adolescent that this information will not be shared with the parent
and is confidential. Inform the adolescent that disclosure to the authorities on issues related to abuse
is required.

59. A nurse is counseling a depressed client. Which of the following nursing actions promote trust
between the client and the nurse? Select all that apply.
1. Indicating an understanding for the client’s feelings as well as for their cause.
2. Listening and facilitating the client to say more.
3. Acknowledging that the nurse heard what the client said.
4. Maintaining eye contact with the client at all times.
5. Standing very close to the client.

CHOICES IF USED IN MOODLE

A. 124
B. 123 -ANSWER
C. 235
D. 345

ANSWER: 123
Active listening enables trust. It means that the nurse acknowledges that she has heard the client and
indicates in her own words an understanding of what the client says and the emotions underlying what
is said. It also involves encouraging the client to say more.
Option 4. Although the nurse should maintain eye contact, constant eye contact can be intimidating
and can impede trust building.
Option 5- Standing very close to a client can be unnerving and can hinder trust building.

60. A client was prescribed lithium carbonate (Eskalith) and reveals a serum lithium level of 1.9mEq/L.
The nurse should:
1. administer the lithium with an antacid.
2. give the next dose of lithium at the prescribed time.
3. ask the physician for an order to increase the lithium dose.
4. withhold the lithium and report the lithium level to the physician.

ANSWER: 4
The nurse should hold the 5 p.m. dose of lithium because a level of 1.9 mEq/L can cause adverse
reactions related to lithium toxicity. The signs and symptoms include diarrhea, vomiting, drowsiness,
muscle weakness, and lack of coordination. The nurse should report the lithium level to the physician,
including any symptoms of toxicity.

61. A client who go through colonoscopy was cared by the nurse. Which of the following assessment
findings should most concern the nurse?
1. Abdominal cramping
2. Frequent, watery stools
3. Presence of rebound tenderness
4. Repetitive flatus

ANSWER: 3
Bowel perforation is one of the risk complications of colonoscopy (procedure in which a scope is
inserted into a "hollow tube" organ). Perforation is manifested by positive rebound tenderness,
boardlike (rigid) abdomen, abdominal pain (with shoulder tip pain), guarding behavior, abdominal
distension, and tenesmus. Another possible complication is rectal bleeding.
Option 1- Abdominal cramping post procedure is an expected finding due to the stimulation of
peristalsis as the bowel is continuously inflated with air throughout the procedure.
Option 2 -The preparation for the procedure includes clear liquids, cathartics, and/or enemas in order
to empty the bowel. The stool is watery and copious and may

62. The nurse is observing a client with increased intracranial pressure (ICP). What indicators are the
most critical for the nurse to monitor? Select all that apply.
1. Systolic blood pressure.
2. Urine output.
3. Breath sounds.
4. Cerebral perfusion pressure.
5. Level of pain.

ANSWER: 1, 4.
The nurse must monitor the systolic and diastolic blood pressure to obtain the mean arterial pressure
(MAP), which represents the pressure needed for each cardiac cycle to perfuse the brain. The nurse
must also monitor the cerebral perfusion pressure (CPP), which is obtained from the ICP and the MAP.
Other assessment includes decreased LOC (restlessness, drowsiness, confusion) headache, projectile
vomiting and Cushing’s Triad (widened pulse pressure, bradycardia, bradypnea).
Options 2, 3 and 5-The nurse should also monitor urine output, respirations, and pain; however,
crucial measurements needed to maintain CPP are ICP and MAP. When ICP equals MAP, there is no
CPP.

63. The nurse is doing health education to a client with chronic pancreatitis before discharge. To
monitor the effectiveness of pancreatic enzyme replacement therapy, which of the following should
the nurse teach the client?
1. Monitoring fluid intake.
2. Performing consistent glucose fingerstick tests.
3. Noting stools for steatorrhea.
4. Testing urine for ketones.

ANSWER: 3
3. If the dosage and administration of pancreatic enzymes are adequate, the client’s stool will be
relatively normal. A sign of effectiveness from Pancrease (pancreatic enzyme) includes absence of
steatorrhea (fat in the stool) which is an indication that the fat is properly absorbed into the GIT.
Stable body weight would be another indirect indicator. Any increase in odor or fat content would
designate the need for dosage adjustment.
Option 1-Fluid intake does not affect enzyme replacement therapy.
Option 2-If diabetes has developed, the client will need to monitor glucose levels.
Option 3-Glucose and ketone levels are not affected by pancreatic enzyme therapy and would not
indicate effectiveness of the therapy.

64. After a cholecystectomy, the client is to follow a low-fat diet. Which of the following foods would
be most appropriate to include in a low-fat diet?
1. Cheese omelet.
2. Pig brain gravy.
3. Ham salad sandwich.
4. Roast beef.
ANSWER: 4
4. Lean meats, such as beef, lamb, veal, and well-trimmed lean ham and pork, turkey, chicken are
low in fat. Other foods that are low in fat rice, pasta, fruits and vegetables. The amount of fat allowed
in a client’s diet after a cholecystectomy will depend on the client’s ability to tolerate fat. Typically, the
client does not necessitate a special diet but is encouraged to keep away from excessive fat intake.
Option 1 & 2-A cheese omelet and pig brain gravy have high fat content.
Option 3-Ham salad is high in fat from the fat in salad dressing.
Other high fat foods include:
>Internal Organs, Organ meats
>Foods served with butter, cream, or sauces
>Crab
>Eggyolk/Balut
>Shrimp
>Fried Foods

65. After the nurse presents dietary restrictions to the guardians of a child with celiac disease, which
statement by the guardians indicates effective teaching?
1. “We’ll keep track of these instructions until our child has completely grown and developed.”
2. “Well follow these guidelines until our child’s symptoms disappear.”
3. “Our child must maintain these dietary restrictions until adolescent.”
4. “Our child must maintain these lifelong dietary restrictions.”

ANSWER: 4
Celiac disease is an autoimmune reaction to a protein called gluten. A patient with celiac disease must
maintain dietary restrictions lifetime to avoid the relapse of clinical manifestations of the disease. A
gluten-free diet should be followed by avoiding barley, rye, oats and wheat.
Options 1, 2, and 3: These are incorrect because signs and symptoms will recur if the patient eats
prohibited foods.

66. The nurse is to administer a starting bolus dose of heparin to a child who is taking penicillin. Which
of the following should the nurse do? Select all that apply.
1. Verify that the dose is appropriate for the child’s weight.
2. Note that the onset of the medication will be immediate.
3. Follow the administration of the bolus of heparin with an I.V. infusion of heparin 10 units/kg/hour.
4. Check the result of partial thromboplastic time (PTT).
5. Discontinue the penicillin until the PTT is at a therapeutic level.

ANSWER: 1, 2, 4.
Option 1-The child’s weight is the basis for heparin dosage.
Option 2-The onset of action is immediate since a bolus of heparin is administered by the I.V. route
Option 4-The PTT is an indicator of the effectiveness of heparin.
Option 3-A life-threatening anticoagulation in this child may happen if a bolus IV of heparin is followed
by a continuous infusion of heparin.
Option 5-Penicillin and cephalosporin potentiate the effects of heparin. Therefore, heparin must be
carefully titrated to obtain maximum effect without causing an overdose. However, the antibiotic
should not be discontinued.

67. To check the function of cranial nerve XII (hypoglossal), the nurse should instruct the client to:
1. smell and identify a nonirritating aromatic odor
2. read an eye chart from a distance of 20’
3. elevate the shoulders, with or without resistance
4. stick out the tongue and move rapidly from side to side and in and out

ANSWER: 4
To assess the function of the twelfth cranial (hypoglossal) nerve, the nurse would assess the client’s
ability to extend the tongue since CN 12 is responsible for tongue movement.
Option 1-Cranial nerve I (Olfactory nerve)
Option 2-Cranial nerve II (Optic nerve)
Option 3- Cranial nerve XI (Accessory, Spinal)

68. A client needs to achieve stable clinical condition before pursuing the surgery involving his
subarachnoid hemorrhage. Which of the following medications should the nurse plan to administer in
order to prevent clot breakdown?
1. amino caproic acid (Amicar)
2. heparin sodium (Heparin)
2. warfarin (Coumadin)
3. alteplase (Activase)

ANSWER: 1
Aminocaproic acid is an antifibrinolytic agent that prevents clot breakdown or dissolution. It is usually
ordered after subarachnoid hemorrhage if surgery is postponed or contraindicated. This is given to
prevent further hemorrhage.
Option 2 & 3-Heparin sodium and warfarin are anticoagulants which interfere or prevent the
development of clots. These drugs will increase the patient’s risk to bleeding
Option 4. Alteplase is a fibrinolytic (thrombolytic) which actively dissolves or breaks down the clots.

69. A young adult is hospitalized with a seizure disorder. The client suffered tonic-clonic seizure while
on his bed with padded side rails. In what order should the nurse take the following actions?
1. Loosen clothing around the client’s neck.
2. Turn the client on his or her side.
3. Clear the area around the client.
4. Suction the airway.

ANSWER: 2
The goal of care for a client who is having a seizure is to promote safety, prevent respiratory arrest
and avoid seizure. In this scenario (with limited options), the nurse should first clear the area nearby
the client. Next, the nurse should loosen clothing around the client’s neck and turn the client on the
side. Then, the nurse can then suction the airway and administer oxygen as needed.

70. The nurse is preparing a care plan of a hemiplegic client to prevent joint deformities of the arm
and hand. Which of the following appropriate positions should be performed by the nurse?
1. Placing a pillow in the axilla so the arm is away from the body.
2. Putting a pillow beneath the slightly flexed arm so the hand is higher than the elbow.
3. Immobilizing the upper extremity in a sling.
4. Positioning a hand cone in the hand so the fingers are barely flexed.
5. Keeping the arm at the side using a pillow.

ANSWER: 1, 2, 4.
Option 1-Placing a pillow in the axilla so the arm is away from the body keeps the arm abducted and
prevents skin from touching skin to avoid skin breakdown.
Option 2-This is done to prevent dependent edema.
Option 4-Positioning a hand cone (not a rolled washcloth) in the hand prevents hand contractures.
Option 3(wrong)-Immobilization of the extremity may cause a painful shoulder-hand syndrome.
Option 5(wrong)-Flexion contractures of the hand, wrist, and elbow can result from immobility of the
weak or paralyzed extremity. It is better to extend the arms to prevent contractures.

71. A client with Buerger’s disease has started a goal to stop smoking. Which of the following
medications would be the most helpful in attaining this goal?
1. Zyban (Bupropion).
2. Nicotine (Nicotrol).
3. Nitroglycerin (Tridil).
4. Ibuprofen (Advil).

ANSWER: 1
Zyban, a non-nicotine medication, is used to promote smoking cessation. All types of nicotine should
be avoided to prevent vasoconstriction.
Option 3-Nitroglycerin, used for angina, and
Option 4-Ibuprofen is an NSAIDs which is an anti-inflammatory medication and has no role in smoking
cessation.

72. A client was instructed about instillation of eye drops on the affected eye upon returning home
after a cataract surgery.The client is instructed to apply slight pressure alongside the nose at the inner
canthus of the eye after instilling the eye drops. The rationale that supports applying pressure is that
it:
1. Prevents the medication from inflowing the tear duct.
2. Prevents the drug from running down the client’s face.
3. Allows the sensitive cornea to adjust to the medication.
4. Enables distribution of the medication over the eye surface.

ANSWER: 1
After administering eye drops, application of pressure against the nose at the inner canthus of the
closed eye prevents the medication from entering the lacrimal (tear) duct. If the medication enters the
tear duct, it can go into the nose and pharynx and may be absorbed and cause toxic symptoms.

73. When formulating a nursing care plan to teach a client about phenytoin sodium (Dilantin) therapy,
the nurse should instruct the client not to stop the drug abruptly because:
1. Physical dependency on the drug progresses over time.
2. Status epilepticus could develop.
3. A hypoglycemic reaction ay happen.
4. Heart block is likely to develop.

ANSWER: 2
2. Anticonvulsant drug therapy should never be stopped abruptly/suddenly since doing so can lead to
life-threatening condition known as status epilepticus (continuous, uninterrupted seizure).
Option 1 & 3-Phenytoin sodium does not carry a risk of physical dependency or lead to hypoglycemia.
Option 4-Phenytoin has antiarrhythmic properties, and discontinuation does not cause heart block.

74. The nurse caring for an infant in the neonatal intensive care unit administers adult-strength
digitalis to the 3-pound infant. As a result of her actions, the infant suffers permanent heart and brain
damage. The nurse can be charged with:
1. Negligence
2. Tort
3. Assault
4. Malpractice

ANSWER: 4
The nurse could be charged with malpractice, which is failing to perform, or performing an act that
causes harm to the client. Giving the infant an overdose falls into this category.
Options 1, 2 and 3 are incorrect because they apply to other wrongful acts.
Option 1-Negligence is failing to perform care for the client.
Option 2-A tort is a wrongful act committed on the client or their belongings.
Option 3-Assault is a violent physical or verbal attack.

75. A 19-year-old G1 P0 preparing for the patient’s discharge plan after being hospitalized for
hyperemesis gravidarum. The nurse should develop a discharge plan that includes which of the
following? Select all that apply.
1. Refer the client to a nutritionist for the following day.
2. Make sure that the client has an antiemetic prescription.
3. Request the health care provider (HCP) for an anxiolytic prescription.
4. Encourage return to normal routine when the client feels ready.
5. Manage follow-up appointment with provider in 6 weeks.
6. Talk over the plan of care and discharge instructions with client.

ANSWER: 1, 2, 4, 6
Option 1-The nurse case manager should refer the client to a nutritionist to make the client aware
about her food intake and to assure transition to a normal pregnancy diet with intake of adequate
nutrients to support growth and development of the fetus
Option 2-A prescription for an antiemetic (as needed) is beneficial to overcome intermittent episodes
of nausea and vomiting.
Option 4-Encouraging a return to normal activities when the client feels ready offers the client a goal
to look forward.
Option 6-Discussion of the plan of care and discharge instructions is a standard of care when
discharging a client from a health care facility.
Option 3-There is no indication for an anxiolytic and hyperemesis gravidarum usually is not associated
with anxiety.
Option 5-Six weeks is too long to wait for a follow-up appointment post hospitalization.

76. An infant is born with facial abnormalities, mental retardation, growth retardation, and vision
abnormalities. These abnormalities are most likely caused by maternal:
1. Alcohol consumption.
2. Vitamin B6 deficiency.
3. Vitamin A deficiency.
4. Folic acid deficiency.

ANSWER: 1
Fetal alcohol syndrome (cluster of symptoms) is indicated by these effects and other symptoms shown
after birth.
Option 2 and 3- Vitamin B6 and vitamin A deficiency can affect growth and development but not with
these specific effects.
Option 4-Folic acid deficiency contributes to neural tube defects.

77. A nurse has offered dietary teachings to a client with a diagnosis of hypoparathyroidism. Which of
the following food items should be included in the menu?
1. Spinach and collard greens
2. Meat and poultry
3. Fish
4. Cereals and Wheat
ANSWER: 1
The client with hypoparathyroidism is taught to follow a calcium-rich diet and to restrict the amount of
phosphorus in the diet. The problem with most calcium-riched foods is that they are also high in
phosphorus. Thus, the client should limit meat, poultry, fish, eggs, cheese, and cereals.
The safest food that will be allowed in hypoparathyroidism is (green leafy) vegetables.

78. A patient who experiences nighttime confusion wanders from his room into the room of another
client. Which of the following interventions can the nurse best help to decrease the client’s confusion?
1. Assigning a nursing assistant to sit with him until he falls asleep
2. Permitting the client to room with another elderly client
3. Administering a bedtime sedative
4. Leaving a nightlight on during the evening and night shifts

ANSWER: 4
A patient who experiences nighttime confusion and wandering is known as sundowning. Leaving a
nightlight on during the evening and night shifts aids the client to be oriented to the environment and
fosters independence.
Option 1, 2 -will not decrease the client’s confusion.
Option 3- will increase the likelihood of confusion in an elderly client.

79. The nurse is teaching a client with COPD how to do pursed-lip breathing. In which order should the
nurse explain the steps to the client?
1. “Breathe in ordinarily through your nose for two counts (while counting to yourself, one, two).”
2. “Relax your neck and shoulder muscles.”
3. “Pucker your lips like you are going to whistle.”
4. “Breathe out through pursed lips which is twice as long as the inhalation count(while counting to
yourself, one, two, three, four).”

ANSWER: 4 (2, 1, 3, 4)
The nurse should instruct the client to first relax the neck and shoulders and then take several normal
breaths. After taking a breath in, the client should pucker the lips, and finally breathe out through
pursed lips.

80. Which of the following tasks would be the most appropriate to delegate to the UAP while caring for
a patient who is experiencing side effects of radiation therapy?
1. Helping the patient to identify patterns of fatigue
2. Recommending participation in a walking program
3. Reporting the amount and type of food consumed from the tray
4. Checking the skin for redness and irritation after the treatment

ANSWER: 3
The UAP can observe the amount that the patient eats (or what is gone from the tray) and report to
the nurse.
Option 1 and 4-It is the responsibilities of the nurse to assess patterns of fatigue and skin
Option 2-The initial recommendation for exercise should come from the physician.

81. Which of the following statements indicates an adverse reaction to glipizide (Glucotrol)?
1. “I have my worst headache ever.”
2. “I excreted a hard stool during my bowel.”
3. “My blood pressure decreases.”
4. “I felt that my skin reacted when exposed to sunlight.”

ANSWER: 4
Photosensitivity is one of the adverse reactions to the drug glipizide (Glucotrol).
Option 1-Headache may be a side effect of Glucotrol (not necessarily worst headache)
Option 2-Constipation or diarrhea may be side effects of the drug

82. Which of the following is a priority nursing diagnosis for the patient having pelvic inflammatory
disease?
1. Imbalanced nutrition: Less than body requirements.
2. Self-care deficit.
3. Acute pain.
4. Impaired skin integrity.

ANSWER: 3
Pelvic inflammatory disease is associated with severe pain making Acute Pain as its priority nursing
diagnosis.
Option 1, 2 and 4 Imbalanced nutrition, Self-care deficit, and Impaired skin integrity are not priority
nursing diagnoses associated with pelvic inflammatory disease.
.
83. The nurse is providing health education to a client with a diagnosis of trichomoniasis vaginal
infection. She was prescribed a one-time dose of metronidazole (Flagyl) orally. Which statements by
the nurse are considered appropriate? Select all that apply.
1. “Refrain from sexual intercourse till the symptoms are cleared.”
2. “Avoid drinking alcohol for at least 3 days after taking the last dose.”
3. “Inform your sexual partners that they must be treated.”
4. “Metronidazole (Flagyl) may momentarily turn your urine a dark, brownish color.”
5. “Vaginal douching after intercourse may prevent recurrence of infection.”

ANSWER: 1234
Option 1-correct Abstain from sexual intercourse about 1 week after the treatment or until the
symptoms are cleared.
Option 2-Alcohol should not be combined with metronidazole since its mixture can cause
nausea/vomiting, flushing, and severe abdominal pain.
Option 3-Partners should be treated concurrently in order to prevent reinfection. Condom usage is also
instructed to avoid future reinfection
Option 4-Potential side effects of metronidazole include: GI upset, metallic taste, or dark colored
urine.
Option 5- It is not recommended to do vagina douching since it alters the pH of the vagina and it gets
rid of good bacteria and increases the risk of infection such as bacterial vaginosis. Teach the patient
that cleaning of exterior vulva by using unscented products, wear cotton and breathable
undergarments/underwear, and report foul or persisting odor to the doctor.

84. A client who has a brain tumor returned to the recovery room after undergoing left supratentorial
surgery. In order to facilitate venous drainage, which of the following positions should the nurse place
the patient in?
1. Lying flat with his head turned to the right.
2. Lying flat with his head elevated on three pillows.
3. Head of the bed elevated to 30 degrees with his head at the midline.
4. Side-lying on his left side.

ANSWER: 3
The head of the bed should be elevated 30 degrees to promote venous drainage and decrease
intracranial pressure. The client’s head should be in a midline, or neutral, position.
Option 1 &2- Client with infratentorial incision should be position flat (with head at midline) to prevent
tension on the suture line and prevent potential brain herniation
Option 4-Clients with supratentorial surgery should be placed on the unoperative side (good side) to
prevent displacement of the cranial contents by gravity.

85. A nurse is caring for a client who is undergoing chemotherapy with existing laboratory values
recorded on the chart.
Laboratory Results Test Result
Hemoglobin 12.0 mg/dL
Platelet count 108,000/mm3
White blood cell (WBC) count 1,600/mm3
Neutrophil count (ANC) 1,000/mm3
Which of the following actions would be most appropriate for the nurse to implement?
1. Wearing a particulate respiratory mask and protective gown when carrying out treatments.
2. Washing hands before and after entering the room.
3. Limiting visitors.
4. Calling the physician for an order for hematopoietic factors like erythropoietin (Epogen, Procrit).

ANSWER: 2
Chemotherapy produces myelosuppression with a decrease in RBCs, WBCs and platelets. The client
has decreased WBC and neutrophil count (ANC) which increases the client’s risk for infection. When
the WBC count is low and immature WBCs are present, normal phagocytosis is impaired. Normal
phagocytosis is impaired when the WBC count is low and immature WBCs are present. Among the
choices, hand washing is the single best way to avoid the spread of infection.
Option 1-It is not obligatory to wear a gown and mask to take care of this client.
Option 3-The client’s visitors should be screened to avoid exposing the client to possible infections and
not necessarily restrict them (This option might be correct but hand washing is still the best way to
prevent infection spread)
Option 4-Epogen or Procrit acts to stimulate RBCs production, not WBCs. Filgastrim (Neupogen) is
useful for treating neutropenia.

86. The nurse is reviewing the laboratory results of a client receiving chemotherapy. The client is
placed on neutropenic precautions because it was noted that the client’s white blood cell count is low.
Which of the following interventions is considered inappropriate when basing on neutropenic
precautions?
1. Allowing fresh fruits only in the client’s room.
2. Removing fresh-cut flowers from the client’s room.
3. Instructing family members to wear a mask when entering the client’s room.
4. Permitting the patient to eat raw foods such as fish and rootcrops
5. Instructing family members on the proper technique for hand washing.
6. Placing a water on a long-standing pitcher at the bedside
7. Change gloves immediately after use.

ANSWER: 146
Option 1-Fresh fruits and vegetables harbor molds and should be avoided until the white blood cell
count rises.
Option 2-Flowers or plants should not be kept in the room because standing water and damp soil
harbor microorganisms such as Aspergillus and Pseudomonas aeruginosa.
Option 3-Wearing of mask is an appropriate intervention to prevent the spread of infection to the
patient
Option 4-The patient should have low bacteria diet (which means avoiding raw foods, unpeeled fruits,
undercooked meat)
Option 5-this intervention is appropriate since is the single best way to avoid the spread of infection.
Option 6-Long standing water or pitcher with water may harbor dust and microorganisms,
Option 7-Changing gloves immediately after use protects patients from contamination with organisms
picked up on hospital surfaces.

87. The nurse should assess the client with diabetic ketoacidosis for which acid-base imbalance?
1. Respiratory acidosis.
2. Respiratory alkalosis.
3. Metabolic acidosis.
4. Metabolic alkalosis.

ANSWER: 3
A client with diabetic ketoacidosis results when glucose cannot be taken out of the bloodstream and
used for energy without insulin. The body starts to breakdown fats which produce ketones (acidic)
causing metabolic acidosis (low pH and low HCO3).
Option 2-Respiratory alkalosis might happen as a compensatory effect of Kausmaul’s breathing.
Option 3-not correct
Option 4-Metabolic alkalosis does not result in this situation.

88. The nurse reveals that a client has 20/40 vision. Which of the following statements about this
client’s vision is true?
1. The client can read the full and entire vision at 40’ (12 meter)
2. The client can read from at a distance 20’ (6m) what a person with normal vision can read at 40’
3. The client can read the vision chart from 20 with the right eye and from 40’ with the left eye
4. The client can read at 30’ what a person with normal vision can read at 40’

ANSWER: 2
Vision that is 20/20 is normal—that is, the client is able to read from 20 feet what a person with
normal vision can read from 20 feet. A client with a visual acuity of 20/40 can only read at a distance
of 20 feet what a person with normal vision can read at 40 feet.

89. When examining a client with abdominal pain, the nurse should assess and palpate:
1. any quadrant first
2. the symptomatic quadrant first
3. the symptomatic quadrant last
4. the symptomatic quadrant either 2nd or 3rd

ANSWER: 3
Prior to assessment and palpation, ask the patient whether they have abdominal pain or tenderness. If
so, begin palpation in the non-painful area and last on the painful (symptomatic) area.

90. The nurse validates that the consent was obtained in an appropriate manner when she witnessed
an adult client’s signature on a consent for a procedure. The nurse should verify which of the
following? Select all that apply.
1. That there was sufficient disclosure of information.
2. That the client fully understood the information.
3. That the client voluntarily signed the consent.
4. That the client has full awareness of the potential complications.
5. The client’s relative, spouse or legal guardian was present.

ANSWER: 1234
The role of the nurse in witnessing the signing of the consent is to witness that the client is informed
of the procedure, understands the information, is aware of potential complications, and is signing of
his or her own free will (not coerced).
Option 5-It is not compulsory for a spouse, relative, or guardian to be present
91. A female client is receiving treatment for trichomoniasis with metronidazole (Flagyl). The nurse
instructs the client that:
1. The medication should not change the color of the urine.
2. She should stop oral contraceptive use while on this treatment.
3. She should avoid alcohol during treatment.
4. Her partner does not need treatment.

ANSWER: 3
Metronidazole (Flagyl) can cause a disulfiram (Antabuse)-like reaction if it is taken with alcohol.
Tachycardia, flushing, nausea, vomiting, abdominal pain and other serious interaction effects can
occur.
Option 1-Flagyl will make the urine a darker color (brown).
Option 2-Oral contraceptives should never be discontinued/stop with trichomoniasis.
Option 3-The partner also needs treatment to prevent retransmission of infection.

92. The nurse is preparing to mix 20 units of NPH insulin with 8 units of Regular insulin into 1 syringe
for injection. Select the order of the steps the nurse should follow:
1. Wipe tops of both vials with alcohol
2. Inject 8 units of air into the regular insulin vial
3. Inject 20 units of air into the NPH insulin vial
4. Withdraw 20 units of NPH insulin into the syringe
5. Withdraw 8 units of regular insulin into the syringe

ANSWER: 13254
First step among the choices include wiping the tops of the vials with alcohol. Then, inject 20 U air into
the NPH vial; inject 8 U air into the regular insulin vial; withdraw 8 U regular insulin (to prevent
contamination since regular insulin is clear); withdraw 20 U NPH.
Injection of air: Cloudy first then Clear (NPH-Regular: N-R)
Withdrawing of drug: Clear first then cloudy (Regular-NPH: R-N)

93. A neonate is to receive an I.V. infusion of normal saline solution at 3 mL/hour. The nurse is
establishing the alarms on an I.V. infusion pump. How should the nurse set the alarms?
1. At 5% above and 5% below the keep-vein open rate.
2. Within a 15% range of the keep-vein-open rate
3. To sound when the infusion is infiltrating.
4. At the exact drip rate as prescribed.

ANSWER: 1
Alarms on infusion pumps should be established at 5% above and 5% below the prescribed infusion
rate.
Option 2-A wider range is not safe.
Option 3-The alarms must be set to indicate a change in the drip rate, not infiltration.
Option 4-Setting the alarms for the exact drip rate will cause the alarms to trigger when the client
moves, and this exact range is not needed to alert the nurse to an unsafe rate.

94. The nurse came across a client lying on the floor next to the bed. After returning the client to bed,
assessing for injury, and notifying the physician, the nurse fills out an incident report. Which of the
following is the nurse’s next action?
1. Give the incident report to the nurse-manager.
2. Place the incident report on the chart.
3. Phone the family to inform them.
4. Omit stating the fall in the chart documentation.

ANSWER: 1
The incident report should be given to the nurse-manager.
Option 2-The incident report should not be placed on the chart because it is considered a confidential
communication and cannot be subpoenaed by a client or used as evidence in lawsuits.
Option 3-Unless there is a change in the client’s condition exhibiting an injury from the fall, there is no
need to notify the family. If the family does need to be notified, the nurse-manager or the physician
should place the call.
Option 4-It is appropriate, ethical, and legally required that the fall be documented in the chart.

95. Metformin (Glucophage) was prescribed by the physician. Which of the following pre-existing
disorders if documented in the client’s record would indicate a need to collaborate with the physician
before instructing the client to take the medication?
1. Hypertension
2. Foot ulcer
3. Emphysema
4. Hypothyroidism
ANSWER: 3*
Metformin should be used with caution in clients with kidney or liver disease, heart failure, chronic
lung disease (emphysema), or a history of heavy alcohol consumption.

96. A client approaches the nurse and complains of muscles stiffness, muscle spasms in his neck, and
that his eyes are rolling upward. The client had two doses of haloperidol (Haldol) as needed in the last
6 hours. Of the following drugs being ordered by the doctor, the nurse should administer:
1. lorazepam (Ativan).
2. amantadine (Symmetrel).
3. diphenhydramine (Benadryl).
4. benztropine (Cogentin).

ANSWER: 4
Dystonic adverse effects of haloperidol, especially oculogyric crises, are painful and frightening.
Benztropine (Congentin) is the fastest and most effective drug for managing dystonia.
Option 1-Lorazepam is an antianxiety medication and is not useful for treatment of dystonia.
Option 2 and 3-Although amantadine and diphenhydramine can be used for extrapyramidal
symptoms, oral medications do not work as quickly, and amantadine may worsen psychotic
symptoms.

97. A client is prescribed heparin which was adjusted by the doctor according to a prescribed
anticoagulation blood level. Which laboratory value should be maintained at therapeutic level for
heparin therapy?
1. Partial thromboplastin time (PTT), 1.5 to 2.5 times the normal control.
2. Prothrombin time (PT), 1.5 to 2.5 times the normal control.
3. International Normalized Ratio (INR), 2 to 3 seconds.
4. Thrombin clotting time, 10 to 15 seconds.

ANSWER: 1
The nurse should regulate the heparin dose to maintain the client’s partial thromboplastin time
between 1.5 and 2.5 times the normal control.
Option 2 and 3-The PT and INR are used to maintain therapeutic levels of warfarin (Coumadin), oral
anticoagulation therapy.
Option 4-The thrombin clotting time is used to indicate disseminated intravascular coagulation.

98. The nurse is educating a client regarding prophylactic warfarin sodium (Coumadin) prescription.
Which statement implies that the client understands how to take the drug? Select all that apply.
1. “The drug’s action peaks in 2 hours.”
2. “Maximum dosage is not achieved until 3 to 4 days after starting the medication.”
3. “The drug’s effect continues for 4 to 5 day after ceasing the medication.”
4. “The antidote for warfarin is protamine sulfate.”
5. “I should have my blood levels tested and monitored periodically.”

ANSWER: 2, 3, 5.
Options 2, 3 and 5-The maximum dosage of warfarin sodium (Coumadin) is achieved on 3 to 4 days
after starting the medication, and its effects endure for 4 to 5 days after discontinuing the medication.
The client should have his blood levels tested periodically to monitor that the desired level is
maintained.
Option 1-Warfarin has a peak action of 9 hours.
Option 4-Vitamin K is the antidote for warfarin; protamine sulfate is the antidote for heparin.

99. The nurse is evaluating a neonate born to a diabetic mother. Which findings should the nurse
expect to see in the infant?
1. Hypertonia.
2. Hyperactivity.
3. Large size.
4. Scaly skin.

ANSWER: 3
Women with diabetes mellitus usually have neonates who are large but physically immature. Other
expected findings in these infants are hypoglycemia, hyperbilirubinemia (increase bilirubin in the
blood), hypocalcemia, polycythemia, renal thrombosis, and congestive anomalies.
Options 1, 2 and 4: The neonates do not exhibit hypertonia, hyperactivity, or scaly skin.

100. What nutritional instruction should you advise to a client when taking theophylline? He should
AVOID taking __________.
1. Milk and milk products
2. Fruit and vegetable juices
3. Soda and non-carbonated drinks
4. Hot tea or coffee
ANSWER: 4
A patient who is taking theophylline should avoid caffeinated products or drinks since they can
aggravate the common side effects of theophylline which is tachycardia and palpitations. Thus any
irregularities in heart rate should be reported to the doctor. Other Side effects that can occur from the
use of this medication include tremors, nausea, nervousness, and dryness of the mouth or throat.

101. After 4 days from internal fixation of a C3 to C4 fracture, a nurse is transferring a client from bed
to the wheelchair. The nurse is inspecting the wheelchair for precise features for this client. Which of
the following features of the wheelchair are appropriate for the needs of this client? Select all that
apply.
1. Back at the level of the client’s scapula.
2. Back and head that are high.
3. Seat that is lower than normal.
4. Seat with firm cushions.
5. Chair controlled by the client’s breath.

ANSWER: 2, 3, 5
The client with a C3 to C4 fracture has neck control however he may tire easily with sore muscles
around the incision area to hold up his head. Because of his condition, the head and neck of his
wheelchair should be high (Option 2). The seat of the wheelchair should be lower than normal to
facilitate and ease the transfer from the bed to the wheelchair (Option 3). This client will need an
electric chair with breath, chin, or voice control to manipulate movement of the chair since he cannot
use his arms (Option 5).
Option 1-the placement of the back to the client’s scapula is necessary if a client can use his hands
and arms to move the wheelchair.
Option 4-A firm or hard cushion increases pressure to bony prominences; the cushion should instead
be padded to lessen the risk of pressure ulcers.