1. The nurse manager b. a brief loss of b.

a client who has fever

tells another nurse to consciousness and who is diaphoretic and
hold down a patient to c. severe head injury restless
insert a catheter. The d. death will occur c. a client scheduled for
patient says that he within minutes physical therapy at 1:00 pm
doesn’t want the 8.Pain from d. a post-operative
catheter inserted. The osteoarthritis is client who has received pain
nurse understands that described as mechanical medications
the patient isn’t pain, which means: 13. The charge nurse of
confused. If the nurse a. the pain responds to a psychiatric unit is
bodily restrains the mechanical device use
patient, she’s b. the pain is relived by planning the client
committing: rest and worsened by activity assignment for the day.
a. assault c. the pain is worse at The most appropriate
b. battery the beginning of the day and
improves with activity staff to be assigned to a
c. libel
d. negligence d. rest and activity have client with a potential for
2. A patient is no effect on the pain violence is which of the
complaining of blurred 9. A patient is
diagnosed with a following:
vision following a
motor vehicle accident. schizophrenic disorder a. A timid nurse
The nurse knows that is admitted to the in b. A mature
the lobe of the brain patient psychiatric
experienced nurse
responsible for vision unit. The patient
is the: refuses to eat, telling
the nurse that spies c. an
a.motor cortex
b.occipital have put poison in his inexperienced nurse
c. parietal food. The nurse
d. temporal assesses the patient d. a soft spoken
3.Mr. Del Rio is with the understanding nurse
diagnosed with gastric that a false belief to
ulcer, the nurse would which an individual
expect his pain to adheres is: 4. A 40 year old male
occur: a. ambivalence client is admitted in the
a. below the umbilicus b. anhedonia ward because of bizarre
b. at the umbilicus c. delusion behaviors. He is given a
c. in the epigastric area d. psychosis
d. after a high-fat meal 10. The model of diagnosis of
4.The most common cause care in which one nurse schizophrenia paranoid
of hyperaldosteronism is assigned the overall type. The client should
is: responsibility for a
a. excessive sodium patient throughout the have achieved the
intake patient’s entire developmental task of:
b. a pituitary adenoma hospitalization period
c. deficient potassium is known as: a. Trust vs.
intake a. case management mistrust
d. an adrenal adenoma nursing
5.Mrs. Reyes was b. functional nursing
diagnosed with a c. team nursing b. Industry vs.
unilateral d. total patient care inferiority
aldosteronoma for which nursing
she undergoes a 11. Dyan Villejo is c. Generativity vs.
unilateral diagnosed with retinal
stagnation
adrenalectomy. detachment. Which
Postoperatively, the intervention is the
nurse can identify most important for this d. Ego integrity vs.
hyperkalemia by patient? despair
assessing the patient a. admitting him to the
for: hospital on strict bed rest 15. Which is the priority
a. muscle weakness b. patching his both diagnosis for a patient
b. tremors eyes
c. referring him to an
experiencing angina?
c. diaphoresis
ophthalmologist a. decreased cardiac
d. constipation
6. Otorrhea and d. preparing him for output
rhinorrhea are most surgery
commonly seen in which 12. A registered b. pain
type of skull fracture? nurse has received the
a. basilar assignment for the day c. anxiety
b. temporal shift. After making
c. occipital initial rounds and
checking all the d. altered tissue
d. parietal
7. A Glasgow Coma Scale assigned clients, which perfusion
of 8 in a patient with will the RN plan to
a new head injury care for first? 6. Which of the following
indicates: a. a client who is statements refers to criteria?
a. a mild head injury ambulatory
a. Agreed on level of
nursing care
b. Characteristics used to
measure the level of
nursing care
c. Step-by-step guidelines
d. Statement which guide
the group in decision
making and problem
solving
17. Henson De Jesus is a 28
month old boy admitted to
the hospital with acute croup.
Which of the following
would be most threatening to
Henson’s autonomy?
a. complete bed rest
b. frequent visits by
friends and family
c. participation in
playroom activities with
other children
d. riding to the x-ray
department in a
wheelchair
18. The doctor orders
intra-arterial monitoring
to attain continuous
blood pressure in a
critically ill patient.
Collateral circulation
should be assessed prior
to selection of an arterial
site. The test used to
assess the patency of the
radial and ulnar arteries
is the:
a. Allen’s test
b. Homan’s test
c. Trendelenburg’s test
d. Weber’s test
9. Margaret Cruz is a 25
year old teacher admitted
to the hospital with acute
appendicitis. She’s now 1
day postoperative
appendectomy and has
an abdominal surgical
wound. Based on the
nurse’s knowledge of
surgical wounds, simple
surgical incisions heal by
________ intention.
a. primary
b. quartenary
c. secondary
d. tertiary
20. The subjective and
objective data that signal the
existence of an actual health
problem are which of parts of
an actual nursing diagnosis?
a. Etiology
b. Inferences
c. Problem statement
(diagnostic label)
d. Signs and symptoms
(defining characteristics)
21. A patient with history
of COPD presents with
dyspnea and an oxygen
saturation of 88%. What
amount of oxygen would the
nurse expect to be ordered for
this patient:
a. 2L via nasal cannula
b. 6L via nasal cannula
c. 50% by face mask
d. 100% by
nonrebreather mask
22. Which of the following
deformities is described as a
lateral curvature of the
thoracic spine?
a. kyphosis
b. scoliosis
c. lordosis
d. genu valgum
23. What is the most
common portal of entry
for microorganisms
associated with sepsis?
a. skin
b. GI tract
c. Respiratory tract
d. Urinary tract
24. Jess Villanes, who is
paraplegic due to a T6
spinal cord injury, is
admitted to the medical-
surgical floor with a stage
4 pressure ulcer on his
right hip. The doctor also
suspects osteomyelitis.
What are the
characteristics of a stage
4 pressure ulcer?
a. It is an area of
nonblanching erythema.
b. It is an area of skin loss
involving the dermis with
a shallow crater-like
appearance.
c. It is an area of full-
thickness skin loss with a
deep lesion that extends
down through the
subcutaneous tissue.
d. It is an area of full-
thickness skin loss with
exposure of muscle
tissue, the hip bone, and
surrounding support
structures.
25. Which of the
following statements
made by Mr. Villanes in
response to teaching
indicates he understands
how this episode of
osteomyelitis will be
treated?
a. “I will probably need to
have part of the bone- if
not the entire hip joint—
removed.”
b. “I will need I.V.
antibiotic therapy for 4 to
6 weeks.”
c. “After a week on I.V.
antibiotics, I will probably
go home on oral
antibiotics.”
d. “You will need to
irrigate my wound with
antibiotic solution, but I
won’t be on oral or
intravenous antibiotics.”
26. Mr. Gollez is a 49 year
old obese man who was seen
for a routine check-up. His
fasting blood glucose level is
135 mg/dl, so he’s scheduled
for a repeat test. Mr. Gollez
asks the nurse why he has to
return for another test. The
nurse’s best response would
be:
a. “Your fasting blood
glucose level was normal
but we need a conb.
“Fasting blood glucose
level tests are always
repeated.”firmation of
that result.”
c. “You have type 2
diabetes mellitus, so the
test must be repeated.”
d. “Your fasting blood
glucose level was
abnormal and needs to
be tested again.”
27. Mica Jaladoni, 27 years
old, comes in for an
appointment 6 months after
delivering her child. She
states she was unable to
breast-feed her baby and is
concerned that she hasn’t
menstruated. The best action
by the nurse would be to:
a. reassure her that this
is normal and her menses
should return soon
b. ask if she had any
hemorrhaging during or
after her delivery
c. refer her to a support
group
d. ask her if she had
gestational diabetes
mellitus
28. Which of the following
signs should the nurse
expect in a client with
known amphetamine
overdose?
a. Hypotension
b. Tachycardia
c. Hot, dry skin
d. Constricted pupils
29. In a horizontal chart,
the lowest level worker is
located at the:
a. Left most box
b. b. Middle
c. c. Right most box
d. d. Bottom
30. The nurse performs
many roles in the
practice of nursing.
Which role is defined as
“the protection of human
or legal rights and the
securing of quality care
for each patient”?
a. Advocator
b. Communicator
c. Counselor
d. Leader
31. The nurse is assessing a
newborn who had undergone
vaginal delivery. Which of
the following findings is least
likely to be observed in a
normal newborn?
a. uneven head shape
b. respirations are
irregular, abdominal, 30-
60 bpm
c. (+) moro reflex
d. heart rate is 80 bpm
32. The nurse is
assessing a 9-month-old
boy for a well-baby check
up. Which of the following
observations would be of
most concern?
a. The baby cannot say
“mama” when he wants
his mother.
b. The mother has not
given him finger foods.
c. The child does not sit
unsupported.
d. The baby cries
whenever the mother
goes out.
33. The twelve-year-old
boy has fractured his arm
because of a fall from his
bike. After the injury has
been casted, the nurse knows
it is most important to
perform all of the following
assessments on the area distal
to the injury except:
a. capillary refill.
b. radial and ulnar pulse.
c. finger movement
c. finger movement
34. At the community
center, the nurse leads an
adolescent health information
group, which often expands
into other areas of discussion.
She knows that these youths
are trying to find out “who
they are,” and discussion
often focuses on which
directions they want to take
in school and life, as well as
peer relationships. According
to Erikson, this stage is
known as:
a. identity vs. role
confusion.
b. adolescent rebellion.
c. career
experimentation.
d. relationship testing
35. An inborn error of
metabolism that causes
premature destruction of
RBC?
a. G6PD
b. Hemocystinuria
c. Phenylketonuria
d. Celiac Disease
36. A client who’s
admitted to labor and
delivery has the following
assessment findings:
gravida 2 para 1,
estimated 40 weeks’
gestation, contractions 2
minutes apart, lasting 45
seconds, vertex +4
station. Which of the
following would be the
priority at this time?
a. Placing the client in
bed to begin fetal
monitoring.
b. Preparing for
immediate delivery.
c. Checking for ruptured
membranes.
d. Providing comfort
measures.
37. After completing a
second vaginal
examination of a client in
labor, the nurse-midwife
determines that the fetus
is in the right occiput
anterior position and at –
1 station. Based on these
findings, the nurse-
midwife knows that the
fetal presenting part is:
a. 1 cm below the ischial
spines.
b. directly in line with the
ischial spines.
c. 1 cm above the ischial
spines.
d. in no relationship to
the ischial spines.
38. When assessing a
client during her first
prenatal visit, the nurse
discovers that the client
had a reduction
mammoplasty. The
mother indicates she
wants to breast-feed.
What information should
the nurse give to this
mother regarding breast-
feeding success?
a. “It’s contraindicated
for you to breast-feed
following this type of
surgery.”
b.”I support your
commitment; however,
you may have to
supplement each feeding
with formula.”
c. “You should check with
your surgeon to
determine whether
breast-feeding would be
possible.”
d. “You should be able to
breast-feed without
difficulty.”
39. The nurse uses a
stethoscope to auscultate a
male patient’s chest. Which
statement about a stethoscope
with a bell and diaphragm is
true?
1239
a. The bell
detects high-pitched sounds
best
b. The diaphragm detects
high-pitched sounds best
c. The bell detects thrills
best
d. The diaphragm detects
low-pitched sounds best
40. Which of the following
is the best method for
performing a physical
examination on a toddler
1240
a. From
head to toe
b. Distally to proximally
c. From abdomen to toes,
to the head
d. From least to most
intrusive
41. A mother tells the nurse
that she is very worried
because her 2-year old child
does not finish his meals.
What should the nurse advise
the mother?
1241
a. make
the child seat with the family
in the dining room until he
finishes his meal
b. provide quiet
environment for the child
before meals
c. do not give snacks to
the child before meals
d. put the child on a chair
and feed him
42. A patient is in last
trimester of pregnancy. Nurse
Jane should instruct her to
notify her primary health care
provider immediately if she
notices:
1242
a. Blurred
vision
b. Hemorrhoids
c. Increased vaginal
mucus
d. Shortness of breath on
exertion
43. A patient comes to the
hospital complaining of
severe pain in the right flank,
nausea, and vomiting. The
doctor tentatively diagnoses
right ureter-olithiasis (renal
calculi). When planning this
patient’s care, the nurse
should assign highest priority
to which nursing diagnosis?
1243
a. Pain
b. Risk of infection
c. Altered urinary
elimination
d. Altered nutrition: less
than body requirements
44. Buck’s traction with a
10 lb. weight is securing a
patient’s leg while she is
waiting for surgery to repair a
hip fracture. It is important to
check circulation- sensation-
movement:
1244
a. every
shift.

b. every day.
c. every 4 hours.
d. every 15 minutes.
45. Which of the following
would be inappropriate to
assess in a mother who’s
breast-feeding?
1245
a. The
attachment of the baby to the
breast.
b. The mother’s comfort
level with positioning the
baby.
c. Audible swallowing.
d. The baby’s lips
smacking
46. A nurse caring for a two
year old patient leaves the
bedside without raising the
side rails and the patient falls
to the floor. What type of
legal action could be used in
a lawsuit?
1246
a. Battery
b. Malpractice
c. Negligence
d. Slander
47. CHN is a community-
based practice. Which best
explains this statement?
1247
a. The
service is provided in the
natural environment of
people.
b. The nurse has to
conduct community diagnosis
to determine nursing needs
and problems.
c. The services are based
on the available resources
within the community.
d. Priority setting is
based on the magnitude of
the health problems d. “Who will be with you
identified. during labor?”
48. Which is true of
primary facilities?
1248
a. They
are usually government-run.
b. Their services are
provided on an out-patient
basis.
c. They are training
facilities for health
professionals.
d. A community hospital
is an example of this level of
health facilities.
49. Which of the following
situations increase risk of
lead poisoning in children?
1249
a. playing
in the park with heavy traffic
and with many vehicles
passing by
b. playing sand in the
park
c. playing plastic balls
with other children
d. playing with stuffed
toys at home
50. Accompanied by her
husband, a patient seeks
admission to the labor and
delivery area. The client
states that she is in labor, and
says she attended the hospital
clinic for prenatal care.
Which question should the
nurse ask her first?
1250
a. “Do
you have any chronic
illness?”
b. “Do you have any
allergies?”
c. “What is your
expected due date?”