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1. The registered nurse is planning to delegate tasks to unlicensed assistive personnel (UAP).

Which of
the following task could the registered nurse safely assigned to a UAP?
A. Monitor the I&O of a comatose toddler client with salicylate poisoning
B. Perform a complete bed bath on a 2-year-old with multiple injuries from a serious fall
C. Check the IV of a preschooler with Kawasaki disease
D. Give an outmeal bath to an infant with eczema

2. A nurse manager assigned a registered nurse from telemetry unit to the pediatrics unit. There were
three patients assigned to the RN. Which of the following patients should not be assigned to the floated
A. A 9-year-old child diagnosed with rheumatic fever
B. A young infant after pyloromyotomy
C. A 4-year-old with VSD following cardiac catheterization
D. A 5-month-old with Kawasaki disease

3. A nurse in charge in the pediatric unit is absent. The nurse manager decided to assign the nurse in
the obstetrics unit to the pediatrics unit. Which of the following patients could the nurse manager safely
assign to the float nurse?
A. A child who had multiple injuries from a serious vehicle accident
B. A child diagnosed with Kawasaki disease and with cardiac complications
C. A child who has had a nephrectomy for Wilm’s tumor
D. A child receiving an IV chelating therapy for lead poisoning

4. The registered nurse is planning to delegate task to a certified nursing assistant. Which of the
following clients should not be assigned to a CAN?
A. A client diagnosed with diabetes and who has an infected toe
B. A client who had a CVA in the past two months
C. A client with Chronic renal failure
D. A client with chronic venous insufficiency

5. The nurse in the medication unit passes the medications for all the clients on the nursing unit. The
head nurse is making rounds with the physician and coordinates clients’ activities with other
departments. The nurse assistant changes the bed lines and answers call lights. A second nurse is
assigned for changing wound dressings; a licensed practitioner nurse takes vital signs and bathes the
clients. This illustrates of what method of nursing care?
A. Case management method
B. Primary nursing method
C. Team method
D. Functional method
6. A registered nurse has been assigned to six clients on the 12-hour shift. The RN is responsible for
every aspect of care such as formulating the care of plan, intervention and evaluating the care during
her shift. At the end of her shift, the RN will pass this same task to the next RN in charge. This nursing
care illustrates of what kind of method?
A. Primary nursing method
B. Case method
C. Team method
D. Functional method

7. A newly hired nurse on an adult medicine unit with 3 months experience was asked to float to
pediatrics. The nurse hesitates to perform pediatric skills and receive an interesting assignment that
feels overwhelming. The nurse should:
A. Resign on the spot from the nursing position and apply for a position that does not require
B. Inform the nursing supervisor and the charge nurse on the pediatric floor about the nurse’s
lack of skill and feelings of hesitations and request assistance
C. Ask several other nurses how they feel about pediatrics and find someone else who is willing
to accept the assignment
D. Refuse the assignment and leave the unit requesting a vacation a day

8. An experienced nurse who voluntarily trained a less experienced nurse with the intention of
enhancing the skills and knowledge and promoting professional advancement to the nurse is called a:
A. Mentor
B. Team leader
C. Case manager
D. Change agent

9. The pediatrics unit is understaffed and the nurse manager informs the nurses in the obstetrics unit
that she is going to assign one nurse to float in the pediatric units. Which statement by the designated
float nurse may put her job at risk?
A. “I do not get along with one of the nurses on the pediatrics unit”
B. “I have a vacation day coming and would like to take that now”
C. “I do not feel competent to go and work on that area”
D. “ I am afraid I will get the most serious clients in the unit”

10. The newly hired staff nurse has been working on a medical unit for 3 weeks. The nurse manager
has posted the team leader assignments for the following week. The new staff knows that a major
responsibility of the team leader is to:
A. Provide care to the most acutely ill client on the team
B. Know the condition and needs of all the patients on the team
C. Document the assessments completed by the team members
D. Supervise direct care by nursing assistants
11. A 15-year-old girl just gave birth to a baby boy who needs emergency surgery. The nurse prepared
the consent form and it should be signed by:
A. The Physician
B. The Registered Nurse caring for the client
C. The 15-year-old mother of the baby boy
D. The mother of the girl

12. A nurse caring to a client with Alzheimer’s disease overheard a family member say to the client,
“if you pee one more time, I won’t give you any more food and drinks”. What initial action is best for
the nurse to take?
A. Take no action because it is the family member saying that to the client
B. Talk to the family member and explain that what she/he has said is not appropriate for the
C. Give the family member the number for an Elder Abuse Hot line
D. Document what the family member has said

13. Which is true about informed consent?

A. A nurse may accept responsibility signing a consent form if the client is unable
B. Obtaining consent is not the responsibility of the physician
C. A physician will not subject himself to liability if he withholds any facts that are necessary
to form the basis of an intelligent consent
D. If the nurse witnesses a consent for surgery, the nurse is, in effect, indicating that the
signature is that of the purported person and that the person’s condition is as indicated at the
time of signing

14. A mother in labor told the nurse that she was expecting that her baby has no chance to survive and
expects that the baby will be born dead. The mother accepts the fate of the baby and informs the nurse
that when the baby is born and requires resuscitation, the mother refuses any treatment to her baby and
expresses hostility toward the nurse while the pediatric team is taking care of the baby. The nurse is
legally obligated to:
A. Notify the pediatric team that the mother has refused resuscitation and any treatment for the
baby and take the baby to the mother
B. Get a court order making the baby a ward of the court
C. Record the statement of the mother, notify the pediatric team, and observe carefully for signs
of impaired bonding and neglect as a reasonable suspicion of child abuse
D. Do nothing except record the mother’s statement in the medical record
15. The hospitalized client with a chronic cough is scheduled for bronchoscopy. The nurse is tasks to
bring the informed consent document into the client’s room for a signature. The client asks the nurse
for details of the procedure and demands an explanation why the process of informed consent is
necessary. The nurse responds that informed consent means:
A. The patient releases the physician from all responsibility for the procedure.
B. The immediate family may make decision against the patient’s will.
C. The physician must give the client or surrogates enough information to make health care
judgments consistent with their values and goals.
D. The patient agrees to a procedure ordered by the physician even if the client does not
understand what the outcome will be.

16. A hospitalized client with severe necrotizing ulcer of the lower leg is schedule for an
amputation. The client tells the nurse that he will not sign the consent form and he does not want any
surgery or treatment because of religious beliefs about reincarnation. What is the role of the RN?
A. Call a family meeting
B. Discuss the religious beliefs with the physician
C. Encourage the client to have the surgery
D. Inform the client of other options

17. While in the hospital lobby, the RN overhears the three staff discussing the health condition of her
client. What would be the appropriate nursing action for the RN to take?
A. Tell them it is not appropriate to discuss the condition of the client
B. Ignore them, because it is their right to discuss anything they want to
C. Join in the conversation, giving them supportive input about the case of the client
D. Report this incident to the nursing supervisor

18. A staff nurse has had a serious issue with her colleague. In this situation, it is best to:
A. Discuss this with the supervisor
B. Not discuss the issue with anyone. It will probably resolve itself
C. Try to discuss with the colleague about the issue and resolve it when both are calmer
D. Tell other members of the network what the team member did

19. The nurse is caring to a client who just gave birth to a healthy baby boy. The nurse may not disclose
confidential information when:
A. The nurse discusses the condition of the client in a clinical conference with other nurses
B. The client asks the nurse to discuss the her condition with the family
C. The father of a woman who just delivered a baby is on the phone to find out the sex of the
D. A researcher from an institutionally approved research study reviews the medical record of
a patient
20. A 17-year-old married client is scheduled for surgery. The nurse taking care of the client realizes
that consent has not been signed after preoperative medications were given. What should the nurse do?
A. Call the surgeon
B. Ask the spouse to sign the consent
C. Obtain a consent from the client as soon as possible
D. Get a verbal consent from the parents of the client

21. A 12-year-old client is admitted to the hospital. The physician ordered Dilantin to the client. In
administering IV phenytoin (Dilantin) to a child, the nurse would be most correct in mixing it with:
A. Normal Saline
B. Heparinized normal saline
C. 5% dextrose in water
D. Lactated Ringer’s solution

22. The nurse is caring to a client who is hypotensive. Following a large hematemesis, how should the
nurse position the client?
A. Feet and legs elevated 20 degrees, trunk horizontal, head on small pillow
B. Low Fowler’s with knees gatched at 30 degrees
C. Supine with the head turned to the left
D. Bed sloped at a 45 degree angle with the head lowest and the legs highest

23. The client is brought to the emergency department after a serious accident. What would be the
initial nursing action of the nurse to the client?
A. Assess the level of consciousness and circulation
B. Check respirations, circulation, neurological response
C. Align the spine, check pupils, check for hemorrhage
D. Check respiration, stabilize spine, check circulation

24. A nurse is assigned to care to a client with Parkinson’s disease. What interventions are important
if the nurse wants to improve nutrition and promote effective swallowing of the client?
A. Eat solid food
B. Give liquids with meals
C. Feed the client
D. Sit in an upright position to eat

25. During tracheal suctioning, the nurse should implement safety measures. Which of the following
should the nurse implements?
A. Limit suction pressure to 150-180 mmHg
B. suction for 15-20 seconds
C. Wear eye goggles
D. Remove the inner cannula
26. The nurse is conducting a discharge instructions to a client diagnosed with diabetes. What sign of
hypoglycemia should be taught to a client?
A. Warm, flushed skin
B. Hunger and thirst
C. Increase urinary output
D. Palpitation and weakness

27. A client admitted to the hospital and diagnosed with Addison’s disease. What would be the
appropriate nursing action to the client?
A. Administering insulin-replacement therapy
B. Providing a low-sodium diet
C. Restricting fluids to 1500 ml/day
D. Reducing physical and emotional stress

28. The nurse is to perform tracheal suctioning. During tracheal suctioning, which nursing action is
essential to prevent hypoxemia?
A. Aucultating the lungs to determine the baseline data to assess the effectiveness of suctioning
B. Removing oral and nasal secretions
C. Encouraging the patient to deep breathe and cough to facilitate removal of upper-airway
D. Administering 100% oxygen to reduce the effects of airway obstruction during suctioning.

29. An infant is admitted and diagnosed with pneumonia and suspicious-looking red marks on the
swollen face resembling a handprint. The nurse does further assessment to the client. How would the
nurse document the finding?
A. Facial edema with ecchymosis and handprint mark: crackles and wheezes
B. Facial edema, with red marks; crackles in the lung
C. Facial edema with ecchymosis that looks like a handprint
D. Red bruise mark and ecchymosis on face

30. On the evening shift, the triage nurse evaluates several clients who were brought to the emergency
department. Which in the following clients should receive highest priority?
A. An elderly woman complaining of a loss of appetite and fatigue for the past week
B. A football player limping and complaining of pain and swelling in the right ankle
C. A 50-year-old man, diaphoretic and complaining of severe chest pain radiating to his jaw
D. A mother with a 5-year-old boy who says her son has been complaining of nausea and
vomited once since noon
31. A 80-year-old female client is brought to the emergency department by her caregiver, on the nurse’s
assessment; the following are the manifestations of the client: anorexia, cachexia and multiple
bruises. What would be the best nursing intervention?
A. Check the laboratory data for serum albumin, hematocrit, and hemoglobin
B. Talk to the client about the caregiver and support system
C. Complete a police report on elder abuse
D. Complete a gastrointestinal and neurological assessment

32. The night shift nurse is making rounds. When the nurse enters a client’s room, the client is on the
floor next to the bed. What would be the initial action of the nurse?
A. Chart that the patient fell
B. Call the physician
C. Chart that the client was found on the floor next to the bed
D. Fill out an incident report

33. The nurse on the night shift is about to administer medication to a preschooler client and notes that
the child has no ID bracelet. The best way for the nurse to identify the client is to ask:
A. The adult visiting, “The child’s name is ____________________?”
B. The child, “Is your name____________?”
C. Another staff nurse to identify this child
D. The other children in the room what the child’s name is

34. The nurse caring to a client has completed the assessment. Which of the following will be
considered to be the most accurate charting of a lump felt in the right breast?
A. “Abnormally felt area in the right breast, drainage noted”
B. “Hard nodular mass in right breast nipple”
C. “Firm mass at five ‘clock, outer quadrant, 1cm from right nipple’
D. “Mass in the right breast 4cmx1cm

35. The physician instructed the nurse that intravenous pyelogram will be done to the client. The client
asks the nurse what is the purpose of the procedure. The appropriate nursing response is to:
A. Outline the kidney vasculature
B. Determine the size, shape, and placement of the kidneys
C. Test renal tubular function and the patency of the urinary tract
D. Measure renal blood flow

36. A client visits the clinic for screening of scoliosis. The nurse should ask the client to:
A. Bend all the way over and touch the toes
B. Stand up as straight and tall as possible
C. Bend over at a 90-degree angle from the waist
D. Bend over at a 45-degree angle from the waist
37. A client with tuberculosis is admitted in the hospital for 2 weeks. When a client’s family members
come to visit, they would be adhering to respiratory isolation precautions when they:
A. Wash their hands when leaving
B. Put on gowns, gloves and masks
C. Avoid contact with the client’s roommate
D. Keep the client’s room door open

38. An infant is brought to the emergency department and diagnosed with pyloric stenosis. The parents
of the client ask the nurse, “Why does my baby continue to vomit?” Which of the following would be
the best nursing response of the nurse?
A. “Your baby eats too rapidly and overfills the stomach, which causes vomiting
B. “Your baby can’t empty the formula that is in the stomach into the bowel”
C. “The vomiting is due to the nausea that accompanies pyloric stenosis”
D. “Your baby needs to be burped more thoroughly after feeding”

39. A 70-year-old client with suspected tuberculosis is brought to the geriatric care facilities. An
intradermal tuberculosis test is schedule to be done. The client asks the nurse what is the purpose of
the test. Which of the following would be the best rationale for this?
A. Reactivation of an old tuberculosis infection
B. Increased incidence of new cases of tuberculosis in persons over 65 years old
C. Greater exposure to diverse health care workers
D. Respiratory problems are characteristic in this population

40. The nurse is making a health teaching to the parents of the client. In teaching parents how to
measure the area of induration in response to a PPD test, the nurse would be most accurate in advising
the parents to measure:
A. Both the areas that look red and feel raised
B. The entire area that feels itchy to the child
C. Only the area that looks reddened
D. Only the area that feels raised

41. A community health nurse is schedule to do home visit. She visits to an elderly person living alone.
Which of the following observation would be a concern?
A. Picture windows
B. Unwashed dishes in the sink
C. Clear and shiny floors
D. Brightly lit rooms

42. After a birth, the physician cut the cord of the baby, and before the baby is given to the mother,
what would be the initial nursing action of the nurse?
A. Examine the infant for any observable abnormalities
B. Confirm identification of the infant and apply bracelet to mother and infant
C. Instill prophylactic medication in the infant’s eyes
D. Wrap the infant in a prewarmed blanket and cover the head
43. A 2-year-old client is admitted to the hospital with severe eczema lesions on the scalp, face, neck
and arms. The client is scratching the affected areas. What would be the best nursing intervention to
prevent the client from scratching the affected areas?
A. Elbow restraints to the arms
B. Mittens to the hands
C. Clove-hitch restraints to the hands
D. A posey jacket to the torso

44. The parents of the hospitalized client ask the nurse how their baby might have gotten pyloric
stenosis. The appropriate nursing response would be:
A. There is no way to determine this preoperatively
B. Their baby was born with this condition
C. Their baby developed this condition during the first few weeks of life
D. Their baby acquired it due to a formula allergy

45. A male client comes to the clinic for check-up. In doing a physical assessment, the nurse should
report to the physician the most common symptom of gonorrhea, which is:
A. Pruritus
B. Pus in the urine
C. WBC in the urine
D. Dysuria

46. Which of the following would be the most important goal in the nursing care of an infant client with
A. Preventing infection
B. Maintaining the comfort level
C. Providing for adequate nutrition
D. Decreasing the itching

47. The nurse is making a discharge instruction to a client receiving chemotherapy. The client is at risk
for bone marrow depression. The nurse gives instructions to the client about how to prevent infection
at home. Which of the following health teaching would be included?
A. “Get a weekly WBC count”
B. “Do not share a bathroom with children or pregnant woman”
C. “Avoid contact with others while receiving chemotherapy”
D. “Do frequent hand washing and maintain good hygiene”

48. The nurse is assigned to care the client with infectious disease. The best antimicrobial agent for the
nurse to use in handwashing is:
A. Isopropyl alcohol
B. Hexachlorophene (Phisohex)
C. Soap and water
D. Chlorhexidine gluconate (CHG) (Hibiclens)
49. The mother of the client tells the nurse, “ I’m not going to have my baby get any
immunization”. What would be the best nursing response to the mother?
A. “You and I need to review your rationale for this decision”
B. “Your baby will not be able to attend day care without immunizations”
C. “Your decision can be viewed as a form of child abuse and neglect”
D. “You are needlessly placing other people at risk for communicable diseases”

50. The nurse is teaching the client about breast self-examination. Which observation should the client
be taught to recognize when doing the examination for detection of breast cancer?
A. Tender, movable lump
B. Pain on breast self-examination
C. Round, well-defined lump
D. Dimpling of the breast tissue

51. What is the normal range of carbon dioxide (CO2) in arterial blood?
A. 35-45
B. 22-26
C. 7.35-7.45
D. Not listed

52. What is the normal range of bicarbonate ion (HCO3-) in arterial blood?
A. 35-45
B. 22-26
C. 7.35-7.45
D. Not listed

53. What is the normal range of pH in the body?

A. 35-45
B. 22-26
C. 7.35-7.45
D. Not listed

54. If HCO3- caused the acidosis or the alkalosis, it is what?

A. Metabolic
B. Respiratory
C. Combined
D. None
55. If the CO2 and the HCO3- caused the imbalance, it is what?
A. Metabolic
B. Respiratory
C. Combined
D. None

56. If the CO2 caused the acidosis or alkalosis, it is what?

A. Metabolic
B. Respiratory
C. Combined
D. None

57. When there is an abnormal pH and change in one blood parameter. It is:
A. Uncompensated
B. Partially compensated
C. Fully compensated
D. Corrected

58. When all 3 values--- pH, HCO3-, CO2 are abnormal. It is:
A. Uncompensated
B. Partially compensated
C. Fully compensated
D. Corrected

59. When pH is normal, both HCO3 and CO2 are abnormal. It is:
A. Uncompensated
B. Partially compensated
C. Fully compensated
D. Corrected

60. When all parameters of pH, HCO3-, and CO2 are normal. It is:
A. Uncompensated
B. Partially compensated
C. Fully compensated
D. Corrected

61. PH 7.31, CO2 50mmHg, HCO3- 22mEq/L

A. Respiratory acidosis, Uncompensated
B. Respiratory alkalosis, Partially compensated
C. Metabolic acidosis, Fully compensated
D. Metabolic alkalosis, Uncompensated
62. PH 7.46, CO2 32mmHg, HCO3- 23mEq/L
A. Respiratory acidosis, Partially compensated
B. Combined, Uncompensated
C. Metabolic alkalosis, Uncompensated
D. Respiratory alkalosis, Uncompensated

63. PH 7.30, CO2 46 mmHg, HCO3 16 mEq/L

A. Respiratory alkalosis, Uncompensated
B. Combined, Partially compensated
C. Respiratory acidosis, Partially compensated
D. Metabolic acidosis, Partially compensated

64. PH 7.31, CO2 44 mmHg, HCO3 20 mEq/L

A. Metabolic alkalosis, Fully compensated
B. Metabolic acidosis, Uncompensated
C. Respiratory alkalosis, partially compensated
D. Respiratory acidosis, Uncompensated

65. PH 7.47, CO2 48 mmHg, HCO3 30 mEq/L

A. Metabolic alkalosis, partially compensated
B. Respiratory acidosis, uncompensated
C. Metabolic acidosis, fully compensated
D. Respiratory alkalosis, partially compensated

66. PH 7.30, CO2 46 mmHg, HCO3 16 mEq/L

A. Metabolic alkalosis, partially compensated
B. Respiratory acidosis, uncompensated
C. Combined, partially compensated
D. Metabolic acidosis, uncompensated

67. Ben has an anxiety attack. His ABGs results show he is in respiratory alkalosis. He has just had a
car accident. What is your next nursing intervention?
A. Have him breathe into a paper bag
B. Give him O2
C. Check his temperature
D. Ask him if he is alright

68. Jake is complaining of shortness of breath. The nurse assesses his respiratory rate to be 30 breaths
per minute and documents that Jake is tachypneic. The nurse understands that tachypnea means:
A. Pulse rate greater than 100 beats per minute
B. Blood pressure of 140/90
C. Respiratory rate greater than 20 breaths per minute
D. Frequent bowel sounds
69. The nurse listens to Mrs. Sullen’s lungs and notes a hissing sound or musical sound. The nurse
documents this as:
A. Wheezes
B. Rhonchi
C. Gurgles
D. Vesicular

70. The nurse in charge measures a patient’s temperature at 101 degrees F. What is the equivalent
centigrade temperature?
A. 36.3 degrees C
B. 37.95 degrees C
C. 40.03 degrees C
D. 38.01 degrees C

71. Which approach to problem-solving tests any number of solutions until one is found that works for
that particular problem?
A. Intuition
B. Routine
C. Scientific method
D. Trial and error

72. What is the order of the nursing process?

A. Assessing, diagnosing, implementing, evaluating, and planning
B. Diagnosing, assessing, planning, implementing, and evaluating
C. Assessing, diagnosing, planning, implementing, and evaluating
D. Planning, evaluating, diagnosing, assessing, and implementing

73. During the planning phase of the nursing process, which of the following is the outcome?
A. Nursing history
B. Nursing notes
C. Nursing care plan
D. Nursing diagnosis

74. What is an example of a subjective data?

A. Heart rate of 68 beats per minute
B. Yellowish sputum
C. Client verbalized, “I feel pain when urinating.”
D. Noisy breathing
74. Which expected outcome is correctly written?
A. “The patient will feel less nauseated in 24 hours.”
B. “The patient will eat the right amount of food daily.”
C. “The patient will identify all the high-salt food from a prepared list by discharge.”
D. “The patient will have enough sleep.”

75. Which of the following behaviors by Nurse Jane Robles demonstrates that she understands well the
elements of effective charting?
A. She writes in the chart using a no. 2 pencils.
B. She noted: appetite is good this afternoon.
C. She signs on the medication sheet after administering the medication.
D. She signs her charting as follow: J.R

76. What is the disadvantage of computerized documentation of the nursing process?

A. Accuracy
B. Legibility
C. Concern for privacy
D. Rapid communication

77. The theorist who believes that adaptation and manipulation of stressors are related to foster change
A. Dorothea Orem
B. Sister Callista Roy
C. Imogene King
D. Virginia Henderson

78. Formulating a nursing diagnosis is a joint function of:

A. Patient and relatives
B. Nurse and patient
C. Doctor and family
D. Nurse and doctor

79. Mrs. Caperlac has been diagnosed to have hypertension since 10 years ago. Since then, she had
maintained low sodium, low-fat diet, to control her blood pressure. This practice is viewed as:
A. Cultural belief
B. Personal belief
C. Health belief
D. Superstitious belief
80. Becky is on NPO since midnight as preparation for a blood test. The adreno-cortical response is
activated. Which of the following is an expected response?
A. Low blood pressure
B. Warm, dry skin
C. Decreased serum sodium levels
D. Decreased urine output

81. What nursing action is appropriate when obtaining a sterile urine specimen from an indwelling
catheter to prevent infection?
A. Use sterile gloves when obtaining urine.
B. Open the drainage bag and pour out the urine.
C. Disconnect the catheter from the tubing and get urine.
D. Aspirate urine from the tubing port using a sterile syringe.

82. A client is receiving 115 ml/hr of continuous IVF. The nurse notices that the venipuncture site is
red and swollen. Which of the following interventions would the nurse perform first?
A. Stop the infusion
B. Call the attending physician
C. Slow that infusion to 20 ml/hr
D. Place a clod towel on the site

83. The nurse enters the room to give a prescribed medication but the patient is inside the bathroom.
What should the nurse do?
A. Leave the medication at the bedside and leave the room.
B. After a few minutes, return to that patient’s room and do not leave until the patient takes the
C. Instruct the patient to take the medication and leave it at the bedside.
D. Wait for the patient to return to bed and just leave the medication at the bedside.

84. Which of the following is inappropriate nursing action when administering NGT feeding?
A. Place the feeding 20 inches above the pint if insertion of NGT.
B. Introduce the feeding slowly.
C. Instill 60ml of water into the NGT after feeding.
D. Assist the patient in fowler’s position.

85. A female patient is being discharged after thyroidectomy. After providing the medication teaching.
The nurse asks the patient to repeat the instructions. The nurse is performing which professional role?
A. Manager
B. Caregiver
C. Patient advocate
D. Educator
86. Which data would be of greatest concern to the nurse when completing the nursing assessment of
a 68-year-old woman hospitalized due to Pneumonia?
A. Oriented to date, time and place.
B. Clear breath sounds.
C. Capillary refill greater than 3 seconds and buccal cyanosis.
D. Hemoglobin of 13 g/dl.

87. During a change-of-shift report, it would be important for the nurse relinquishing responsibility for
the care of the patient to communicate. Which of the following facts to the nurse assuming
responsibility for the care of the patient?
A. That the patient verbalized, “My headache is gone.”
B. That the patient’s barium enema performed 3 days ago was negative
C. Patient’s NGT was removed 2 hours ago
D. Patient’s family came for a visit this morning.

88. Which statement is the most appropriate goal for a nursing diagnosis of diarrhea?
A. “The patient will experience a decreased frequency of bowel elimination.”
B. “The patient will take anti-diarrheal medication.”
C. “The patient will give a stool specimen for laboratory examinations.”
D. “The patient will save urine for inspection by the nurse.

89. Which of the following is the most important purpose of planning care with this patient?
A. Development of a standardized NCP.
B. Expansion of the current taxonomy of nursing diagnosis.
C. Making of individualized patient care.
D. Incorporation of both nursing and medical diagnoses in patient care.

90. Using Maslow’s hierarchy of basic human needs, which of the following nursing diagnoses has the
highest priority?
A. Ineffective breathing pattern related to pain, as evidenced by shortness of breath.
B. Anxiety related to impending surgery, as evidenced by insomnia.
C. Risk of injury related to autoimmune dysfunction.
D. Impaired verbal communication related to tracheostomy, as evidenced by the inability to

91. When performing an abdominal examination, the patient should be in a supine position with the
head of the bed at what position?
A. 30 degrees
B. 90 degrees
C. 45 degrees
D. 0 degree
92. During the planning phase of the nursing process, which of the following is the outcome?
A. Nursing history
B. Nursing notes
C. Nursing care plan
D. Nursing diagnosis

93. Which of the following is not an education tool required prior to an endoscopic procedure?
A. The purpose of the procedure
B. What to expect during the procedure
C. How long the procedure will take
D. Preparation required prior to the surgery

94. Which patient is most susceptible for acquiring secondary stomatitis?

A. An AIDs patient suffering from pneumonia
B. An 65 y/o obese female
C. A 45 y/o male suffering from colon cancer
D. A 50 y/o male with CHF

95. When assessing a client during a routine checkup, the nurse reviews the history and notes that the
client had aphthous stomatitis at the time of the last visit. Aphthous stomatitis is best described as:
A. A canker sore of the oral soft tissues
B. An acute stomach infection
C. Acid indigestion
D. An early sign of peptic ulcer disease

96. Which item is unneccessary when examing the oral cavity of a patient with candidiasis?
A. Gloves
B. Penlight
C. Gown
D. Tongue blade

97. Which of the following is an inappropriate nursing diagnosis for a client with malignant tumors of
the oral cavity?
A. Impaired oral mucous membranes
B. Deficient fluid volume
C. Acute pain
D. Risk for ineffective airway clearance
98. The graduate nurse and her preceptor are establishing priorities for their morning assessments.
Which client should they assess first?
A. The newly admitted client with acute abdominal pain
B. The client who needs an abdominal dressing changed (POD 3)
C. The client receiving continuous tube feedings who needs the tube-feeding residual checked
D. The sleeping client who received pain medication 1 hour ago

99. Which foods should a patient with GERD stay away from (multiple answers)?
A. Burger King double cheeseburger
B. Lettuce
C. Candy canes
D. Chocolate espresso
E. White bread

100. To prevent gastroesophageal reflux in a client with hiatal hernia, the nurse should provide which
discharge instruction?
A. Lie down after meals to promote digestion
B. Avoid coffee and alcoholic beverages
C. Take antacids with meals
D. Limit fluid intake with meals

101. Which of the following is not a common symptom of GERD?

A. Dyspepsia
B. Regurgitation
C. Dysphagia
D. Hyposalivation

102. Which drug class isn't used to treat GERD?

A. Antacids
B. Histamine receptor antagonists
C. Beta blockers
D. Proton pump inhibitors

103. Which of the following has the least important role in terms of peptic ulcer formation?
A. Acid
B. NSAID use
C. Prescence of H. pylori
D. Hypertension
104. A client is admitted to the health care facility with a diagnosis of a bleeding gastric ulcer. The
nurse expects this client's stools to be:
A. Coffee-ground-like
B. Clay-colored
C. Black and tarry
D. Bright red

105. Which diagnostic test would be used first to evaluate a client with upper GI bleeding?
A. Endoscopy
B. Upper GI series
C. Hemoglobin (Hb) levels and hematocrit (HCT
D. Arteriography

106. Which of the following isn't a complication of peptic ulcer disease?

A. Perforation
B. GI bleeding
C. Pyloric obstruction
D. Pain

107. Which of the following are goals of drug therapy in the treatment of PUD (multiple answers)?
A. Provide pain relief
B. Prevent recurrence
C. Heal ulcerations
D. Eradicate H. pylori infection

108. An elderly client with Alzheimer's disease begins supplemental tube feedings through a
gastrostomy tube to provide adequate calorie intake. The nurse should be concerned most with the
potential for:
A. Hyperglycemia
B. Fluid volume excess
C. Aspiration
D. Constipation

109. A client who underwent abdominal surgery who has a nasogastric (NG) tube in place begins to
complain of abdominal pain that he describes as "feeling full and uncomfortable." Which assessment
should the nurse perform first?
A. Measure abdominal girth
B. Auscultate bowel sounds
C. Assess patency of the NG tube
D. Assess vital signs
110. To verify the placement of a gastric feeding tube, the nurse should perform at least two tests. One
test requires instilling air into the tube with a syringe and listening with a stethoscope for air passing
into the stomach. Which is another test method?
A. Aspiration of gastric contents and testing for a pH less than 6
B. Instillation of 30 ml of water while listening with a stethoscope
C. Cessation of reflex gagging
D. Ensuring proper measurement of the tube before insertion

111. Which of the following would you NOT teach a patient recently diagnosed with irritable bowel
A. Identifying food intolerances and needed dietary modifications
B. Decreasing fiber intake
C. Avoiding coffee and and limiting alcohol intake
D. Stress management

112. Which of the following are appropriate nursing diagnoses for patients with colorectal cancer
(multiple answers)?
A. Altered level of consciousness
B. Disturbed body image
C. Deficient fluid volume
D. Acute/ chronic pain

113. Which foods should patients with colorectal cancer avoid (multiple answers)?
A. Fish and chips
B. Boiled carrots and broccoli
C. Beef and cabbage
D. Concentrated sweets
E. Whole-grain products

114. A client has undergone a colon resection. While turning him, wound dehiscence with evisceration
occurs. The nurse's first response is to:
A. Call the physician
B. Place saline-soaked sterile dressings on the wound
C. Take a blood pressure and pulse
D. Take a blood pressure and pulse

115. Which is the least likely to cause constipation?

A. High fiber intake
B. Being over 75
C. Overuse of laxatives
D. Immobilization
116. A 72-year-old client seeks help for chronic constipation. This is a common problem for elderly
clients due to several factors related to aging. Which is one such factor?
A. Increased intestinal motility
B. Decreased abdominal strength
C. Increased gastric aid production
D. Hyperactive bowel sounds

117. Which outcome indicates effective client teaching to prevent constipation?

A. The client verbalizes consumption of low-fiber foods
B. The client maintains a sedentary lifestyle
C. The client limits water intake to three glasses per day
D. The client reports engaging in a regular exercise regimen

118. In regards to appendicitis, the location of pain in the lower, right abdominal quadrant is called:
A. Kernig's sign
B. Mc Burney's point
C. Brudzinski's point
D. Schrute's point

119. When preparing a client, age 50, for surgery to treat appendicitis, the nurse formulates a nursing
diagnosis of Risk for infection related to inflammation, perforation, and surgery. What is the rationale
for choosing this nursing diagnosis?
A. The appendectomy surgery is very invasive and it puts the client at a risk for infection
B. Obstruction of the appendix reduces arterial flow, leading to ischemia, inflammation, and
rupture of the appendix.
C. Infection of the appendix diminishes necrotic arterial blood flow and increases venous
D. The appendix may develop gangrene and rupture, especially in a middle-aged client

120. Which of the following assessment findings suggests early appendicitis?

A. Nausea and vomiting
B. Periumbilical pain
C. Tense positioning
D. Abdominal rigdity

121. Which of the following is not an appropriate nursing diagnosis related to appendicitis?
A. Disturbed body image
B. Acute pain
C. Risk for infection r/t rupture
D. Deficient knowledge
122. While preparing a client for cholecystectomy, the nurse explains that incentive spirometry will be
used after surgery primarily to:
A. Increase respiratory effectiveness.
B. Eliminate the need for nasogastric intubation.
C. Improve nutritional status during recovery.
D. Decrease the amount of postoperative analgesia needed.

123. Which task can the nurse delegate to a nursing assistant?

A. Irrigating a nasogastric (NG) tube
B. Assisting a client who had surgery three days ago walk down the hallway
C. Helping a client who just returned from surgery to the bathroom
D. Administering an antacid to a client complaining of heartburn

124. How are ulcerative colitis and Chron's disease definitively diagnosed?
C. Stool sample
D. Colonoscopy

125. What is toxic megacolon (mulitple answers)?

A. A complication of ulcerative colitis
B. Dilation and paralysis of the colon
C. A fistula
D. A risk factor for pancreatitis

126. A 28-year-old client is admitted with inflammatory bowel syndrome (Crohn's disease). Which
therapies should the nurse expect to be part of the care plan? Check all that apply
A. Lactulose therapy
B. High-fiber diet
C. High-protein milkshakes
D. Corticosteroid therapy
E. Antidiarrheal medications

127. A client is diagnosed with Crohn's disease after undergoing two weeks of testing. The client's boss
calls the medical-surgical floor requesting to speak with the nurse manager. He expresses concern over
the client and explains that he must know the client's diagnosis for insurance purposes. Which response
by the nurse is best?
A. "Sure, I understand how demanding insurance companies can be."
B. "I appreciate your concern, but I can't give out any information."
C. "Why don't you come in, and we can further discuss this issue."
D. "He has been diagnosed with Crohn's Disease."
128. A client with a recent history of rectal bleeding is being prepared for a colonoscopy. How should
the nurse position the client for this test initially?
A. Lying on the right side with legs straight
B. Lying on the left side with knees bent
C. Prone with the torso elevated
D. Bent over with hands touching the floor

129. A client has a newly created colostomy. After participating in counseling with the nurse and
receiving support from the spouse, the client decides to change the colostomy pouch unaided. Which
behavior suggests that the client is beginning to accept the change in body image?
A. The client asks his wife to leave the room
B. The client closes the eyes when the abdomen is exposed
C. The client avoids talking about the recent surgery
D. The client touches the altered body part