FUNDAMENTALS OF NURSING keypoints 16.

A patient who can’t write his name to give consent for

treatment must make an X in the presence of two
PART 1
witnesses, such as a nurse, priest, or physician.
1. A blood pressure cuff that’s too narrow can cause a
17. The Z-track I.M. injection technique seals the drug
falsely elevated blood pressure reading.
deep into the muscle, thereby minimizing skin irritation
2. When preparing a single injection for a patient who
and staining. It requires a needle that’s 1″ (2.5 cm) or
takes regular and neutral protein Hagedorn insulin, the
longer.
nurse should draw the regular insulin into the syringe first
18. In the event of fire, the acronym most often used is
so that it does not contaminate the regular insulin.
RACE. (R) Remove the patient. (A) Activate the alarm.
3. Rhonchi are the rumbling sounds heard on lung
(C) Attempt to contain the fire by closing the door. (E)
auscultation. They are more pronounced during expiration
Extinguish the fire if it can be done safely.
than during inspiration.
19. A registered nurse should assign a licensed vocational
4. Gavage is forced feeding, usually through a gastric tube
nurse or licensed practical nurse to perform bedside care,
(a tube passed into the stomach through the mouth).
such as suctioning and drug administration.
5. According to Maslow’s hierarchy of needs, physiologic
20. If a patient can’t void, the first nursing action should
needs (air, water, food, shelter, sex, activity, and comfort)
be bladder palpation to assess for bladder distention.
have the highest priority.
21. The patient who uses a cane should carry it on the
6. The safest and surest way to verify a patient’s identity is
unaffected side and advance it at the same time as the
to check the identification band on his wrist.
affected extremity.
7. In the therapeutic environment, the patient’s safety is
22. To fit a supine patient for crutches, the nurse should
the primary concern.
measure from the axilla to the sole and add 2″ (5 cm) to
8. Fluid oscillation in the tubing of a chest drainage
that measurement.
system indicates that the system is working properly.
23. Assessment begins with the nurse’s first encounter
9. The nurse should place a patient who has a Sengstaken-
with the patient and continues throughout the patient’s
Blakemore tube in semi-Fowler position.
stay. The nurse obtains assessment data through the health
10. The nurse can elicit Trousseau’s sign by occluding the
history, physical examination, and review of diagnostic
brachial or radial artery. Hand and finger spasms that
studies.
occur during occlusion indicate Trousseau’s sign and
24. The appropriate needle size for insulin injection is 25G
suggest hypocalcemia.
and 5/8″ long.
11. For blood transfusion in an adult, the appropriate
25. Residual urine is urine that remains in the bladder after
needle size is 16 to 20G.
voiding. The amount of residual urine is normally 50 to
12. Intractable pain is pain that incapacitates a patient and
100 ml.
can’t be relieved by drugs.
26. The five stages of the nursing process are assessment,
13. In an emergency, consent for treatment can be
nursing diagnosis, planning, implementation, and
obtained by fax, telephone, or other telegraphic means.
evaluation.
14. Decibel is the unit of measurement of sound.
27. Assessment is the stage of the nursing process in
15. Informed consent is required for any invasive
which the nurse continuously collects data to identify a
procedure.
patient’s actual and potential health needs.
28. Nursing diagnosis is the stage of the nursing process in 41. A positive Homan”s sign may indicate
which the nurse makes a clinical judgment about thrombophlebitis.
individual, family, or community responses to actual or 42. Electrolytes in a solution are measured in
potential health problems or life processes. milliequivalents per liter (mEq/L). A milliequivalent is the
29. Planning is the stage of the nursing process in which number of milligrams per 100 milliliters of a solution.
the nurse assigns priorities to nursing diagnoses, defines 43. Metabolism occurs in two phases: anabolism (the
short-term and long-term goals and expected outcomes, constructive phase) and catabolism (the destructive phase).
and establishes the nursing care plan. 44. The basal metabolic rate is the amount of energy
30. Implementation is the stage of the nursing process in needed to maintain essential body functions. It’s measured
which the nurse puts the nursing care plan into action, when the patient is awake and resting, hasn’t eaten for 14
delegates specific nursing interventions to members of the to 18 hours, and is in a comfortable, warm environment.
nursing team, and charts patient responses to nursing 45. The basal metabolic rate is expressed in calories
interventions. consumed per hour per kilogram of body weight.
31. Evaluation is the stage of the nursing process in which 46. Dietary fiber (roughage), which is derived from
the nurse compares objective and subjective data with the cellulose, supplies bulk, maintains intestinal motility, and
outcome criteria and, if needed, modifies the nursing care helps to establish regular bowel habits.
plan. 47. Alcohol is metabolized primarily in the liver. Smaller
32. Before administering any “as needed” pain amounts are metabolized by the kidneys and lungs.
medication, the nurse should ask the patient to indicate the 48. Petechiae are tiny, round, purplish red spots that
location of the pain. appear on the skin and mucous membranes as a result of
33. Jehovah’s Witnesses believe that they shouldn’t intradermal or submucosal hemorrhage.
receive blood components donated by other people. 49. Purpura is a purple discoloration of the skin that’s
34. To test visual acuity, the nurse should ask the patient caused by blood extravasation.
to cover each eye separately and to read the eye chart with 50. According to the standard precautions recommended
glasses and without, as appropriate. by the Centers for Disease Control and Prevention, the
35. When providing oral care for an unconscious patient, nurse shouldn’t recap needles after use. Most needle sticks
to minimize the risk of aspiration, the nurse should result from missed needle recapping.
position the patient on the side.
36. During assessment of distance vision, the patient PART 2
should stand 20′ (6.1 m) from the chart. 1. The nurse administers a drug by I.V. push by using a
37. For a geriatric patient or one who is extremely ill, the needle and syringe to deliver the dose directly into a
ideal room temperature is 66°to 76°F (18.8°to 24.4° C). vein, I.V. tubing, or a catheter.
38. Normal room humidity is 30% to 60%. 2. When changing the ties on a tracheostomy tube, the
39. Hand washing is the single best method of limiting the nurse should leave the old ties in place until the new
spread of microorganisms. Once gloves are removed after ones are applied.
routine contact with a patient, hands should be washed for 3. A nurse should have assistance when changing the ties
10 to 15 seconds. on a tracheostomy tube.
40. To perform catheterization, the nurse should place a 4. A filter is always used for blood transfusions.
woman in the dorsal recumbent position.
5. A four-point (quad) cane is indicated when a patient pulse (difficult to detect); and 0, absent pulse (not
needs more stability than a regular cane can provide. detectable).
6. A good way to begin a patient interview is to ask, 18. The intraoperative period begins when a patient is
“What made you seek medical help?” transferred to the operating room bed and ends when
7. When caring for any patient, the nurse should follow the patient is admitted to the postanesthesia care unit.
standard precautions for handling blood and body 19. On the morning of surgery, the nurse should ensure
fluids. that the informed consent form has been signed; that
8. Potassium (K+) is the most abundant cation in the patient hasn’t taken anything by mouth since
intracellular fluid. midnight, has taken a shower with antimicrobial soap,
9. In the four-point, or alternating, gait, the patient first has had mouth care (without swallowing the water),
moves the right crutch followed by the left foot and has removed common jewelry, and has received
then the left crutch followed by the right foot. preoperative medication as prescribed; and that vital
10. In the three-point gait, the patient moves two crutches signs have been taken and recorded. Artificial limbs
and the affected leg simultaneously and then moves and other prostheses are usually removed.
the unaffected leg. 20. Comfort measures, such as positioning the patient,
11. In the two-point gait, the patient moves the right leg rubbing the patient’s back, and providing a restful
and the left crutch simultaneously and then moves the environment, may decrease the patient’s need for
left leg and the right crutch simultaneously. analgesics or may enhance their effectiveness.
12. The vitamin B complex, the water-soluble vitamins 21. A drug has three names: generic name, which is used
that are essential for metabolism, include thiamine in official publications; trade, or brand, name (such as
(B1), riboflavin (B2), niacin (B3), pyridoxine (B6), Tylenol), which is selected by the drug company; and
and cyanocobalamin (B12). chemical name, which describes the drug’s chemical
13. When being weighed, an adult patient should be composition.
lightly dressed and shoeless. 22. To avoid staining the teeth, the patient should take a
14. Before taking an adult’s temperature orally, the nurse liquid iron preparation through a straw.
should ensure that the patient hasn’t smoked or 23. The nurse should use the Z-track method to administer
consumed hot or cold substances in the previous 15 an I.M. injection of iron dextran (Imferon).
minutes. 24. An organism may enter the body through the nose,
15. The nurse shouldn’t take an adult’s temperature mouth, rectum, urinary or reproductive tract, or skin.
rectally if the patient has a cardiac disorder, anal 25. In descending order, the levels of consciousness are
lesions, or bleeding hemorrhoids or has recently alertness, lethargy, stupor, light coma, and deep coma.
undergone rectal surgery. 26. To turn a patient by logrolling, the nurse folds the
16. In a patient who has a cardiac disorder, measuring patient’s arms across the chest; extends the patient’s
temperature rectally may stimulate a vagal response legs and inserts a pillow between them, if needed;
and lead to vasodilation and decreased cardiac output. places a draw sheet under the patient; and turns the
17. When recording pulse amplitude and rhythm, the patient by slowly and gently pulling on the draw sheet.
nurse should use these descriptive measures: +3, 27. The diaphragm of the stethoscope is used to hear high-
bounding pulse (readily palpable and forceful); +2, pitched sounds, such as breath sounds.
normal pulse (easily palpable); +1, thready or weak
28. A slight difference in blood pressure (5 to 10 mm Hg) site with alcohol. Stretch the skin taut or pick up a
between the right and the left arms is normal. well-defined skin fold. Hold the shaft of the needle in
29. The nurse should place the blood pressure cuff 1″ (2.5 a dart position. Insert the needle into the skin at a right
cm) above the antecubital fossa. (90-degree) angle. Firmly depress the plunger, but
30. When instilling ophthalmic ointments, the nurse don’t aspirate. Leave the needle in place for 10
should waste the first bead of ointment and then apply seconds. Withdraw the needle gently at the angle of
the ointment from the inner canthus to the outer insertion. Apply pressure to the injection site with an
canthus. alcohol pad.
31. The nurse should use a leg cuff to measure blood 41. For a sigmoidoscopy, the nurse should place the
pressure in an obese patient. patient in the knee-chest position or Sims’ position,
32. If a blood pressure cuff is applied too loosely, the depending on the physician’s preference.
reading will be falsely elevated. 42. Maslow’s hierarchy of needs must be met in the
33. Ptosis is drooping of the eyelid. following order: physiologic (oxygen, food, water,
34. A tilt table is useful for a patient with a spinal cord sex, rest, and comfort), safety and security, love and
injury, orthostatic hypotension, or brain damage belonging, self-esteem and recognition, and self-
because it can move the patient gradually from a actualization.
horizontal to a vertical (upright) position. 43. When caring for a patient who has a nasogastric tube,
35. To perform venipuncture with the least injury to the the nurse should apply a water-soluble lubricant to the
vessel, the nurse should turn the bevel upward when nostril to prevent soreness.
the vessel’s lumen is larger than the needle and turn it 44. During gastric lavage, a nasogastric tube is inserted,
downward when the lumen is only slightly larger than the stomach is flushed, and ingested substances are
the needle. removed through the tube.
36. To move a patient to the edge of the bed for transfer, 45. In documenting drainage on a surgical dressing, the
the nurse should follow these steps: Move the nurse should include the size, color, and consistency
patient’s head and shoulders toward the edge of the of the drainage (for example, “10 mm of brown
bed. Move the patient’s feet and legs to the edge of the mucoid drainage noted on dressing”).
bed (crescent position). Place both arms well under 46. To elicit Babinski’s reflex, the nurse strokes the sole
the patient’s hips, and straighten the back while of the patient’s foot with a moderately sharp object,
moving the patient toward the edge of the bed. such as a thumbnail.
37. When being measured for crutches, a patient should 47. A positive Babinski’s reflex is shown by dorsiflexion
wear shoes. of the great toe and fanning out of the other toes.
38. The nurse should attach a restraint to the part of the 48. When assessing a patient for bladder distention, the
bed frame that moves with the head, not to the nurse should check the contour of the lower abdomen
mattress or side rails. for a rounded mass above the symphysis pubis.
39. The mist in a mist tent should never become so dense 49. The best way to prevent pressure ulcers is to
that it obscures clear visualization of the patient’s reposition the bedridden patient at least every 2 hours.
respiratory pattern. 50. Antiembolism stockings decompress the superficial
40. To administer heparin subcutaneously, the nurse blood vessels, reducing the risk of thrombus
should follow these steps: Clean, but don’t rub, the formation.
 16. When caring for a comatose patient, the nurse should
PART 3 explain each action to the patient in a normal voice.
1. In adults, the most convenient veins for venipuncture
17. Dentures should be cleaned in a sink that’s lined with
are the basilic and median cubital veins in the
a washcloth.
antecubital space.
18. A patient should void within 8 hours after surgery.
2. Two to three hours before beginning a tube feeding,
19. An EEG identifies normal and abnormal brain waves.
the nurse should aspirate the patient’s stomach
20. Samples of feces for ova and parasite tests should be
contents to verify that gastric emptying is adequate.
delivered to the laboratory without delay and without
3. People with type O blood are considered universal
refrigeration.
donors.
21. The autonomic nervous system regulates the
4. People with type AB blood are considered universal
cardiovascular and respiratory systems.
recipients.
22. When providing tracheostomy care, the nurse should
5. Hertz (Hz) is the unit of measurement of sound
insert the catheter gently into the tracheostomy tube.
frequency.
When withdrawing the catheter, the nurse should
6. Hearing protection is required when the sound
apply intermittent suction for no more than 15 seconds
intensity exceeds 84 dB. Double hearing protection is
and use a slight twisting motion.
required if it exceeds 104 dB.
23. A low-residue diet includes such foods as roasted
7. Prothrombin, a clotting factor, is produced in the liver.
chicken, rice, and pasta.
8. If a patient is menstruating when a urine sample is
24. A rectal tube shouldn’t be inserted for longer than 20
collected, the nurse should note this on the laboratory
minutes because it can irritate the rectal mucosa and
request.
cause loss of sphincter control.
9. During lumbar puncture, the nurse must note the
25. A patient’s bed bath should proceed in this order: face,
initial intracranial pressure and the color of the
neck, arms, hands, chest, abdomen, back, legs,
cerebrospinal fluid.
perineum.
10. If a patient can’t cough to provide a sputum sample
26. To prevent injury when lifting and moving a patient,
for culture, a heated aerosol treatment can be used to
the nurse should primarily use the upper leg muscles.
help to obtain a sample.
27. Patient preparation for cholecystography includes
11. If eye ointment and eyedrops must be instilled in the
ingestion of a contrast medium and a low-fat evening
same eye, the eyedrops should be instilled first.
meal.
12. When leaving an isolation room, the nurse should
28. While an occupied bed is being changed, the patient
remove her gloves before her mask because fewer
should be covered with a bath blanket to promote
pathogens are on the mask.
warmth and prevent exposure.
13. Skeletal traction, which is applied to a bone with wire
29. Anticipatory grief is mourning that occurs for an
pins or tongs, is the most effective means of traction.
extended time when the patient realizes that death is
14. The total parenteral nutrition solution should be stored
inevitable.
in a refrigerator and removed 30 to 60 minutes before
30. The following foods can alter the color of the feces:
use. Delivery of a chilled solution can cause pain,
beets (red), cocoa (dark red or brown), licorice
hypothermia, venous spasm, and venous constriction.
(black), spinach (green), and meat protein (dark
15. Drugs aren’t routinely injected intramuscularly into
brown).
edematous tissue because they may not be absorbed.
31. When preparing for a skull X-ray, the patient should 46. The nurse should flush a peripheral heparin lock every
remove all jewelry and dentures. 8 hours (if it wasn’t used during the previous 8 hours)
32. The fight-or-flight response is a sympathetic nervous and as needed with normal saline solution to maintain
system response. patency.
33. Bronchovesicular breath sounds in peripheral lung 47. Quality assurance is a method of determining whether
fields are abnormal and suggest pneumonia. nursing actions and practices meet established
34. Wheezing is an abnormal, high-pitched breath sound standards.
that’s accentuated on expiration. 48. The five rights of medication administration are the
35. Wax or a foreign body in the ear should be flushed out right patient, right drug, right dose, right route of
gently by irrigation with warm saline solution. administration, and right time.
36. If a patient complains that his hearing aid is “not 49. The evaluation phase of the nursing process is to
working,” the nurse should check the switch first to determine whether nursing interventions have enabled
see if it’s turned on and then check the batteries. the patient to meet the desired goals.
37. The nurse should grade hyperactive biceps and triceps 50. Outside of the hospital setting, only the sublingual and
reflexes as +4. translingual forms of nitroglycerin should be used to
38. If two eye medications are prescribed for twice-daily relieve acute anginal attacks.
instillation, they should be administered 5 minutes
apart.
PART 4
39. In a postoperative patient, forcing fluids helps prevent
1. The implementation phase of the nursing process
constipation.
involves recording the patient’s response to the
40. A nurse must provide care in accordance with
nursing plan, putting the nursing plan into action,
standards of care established by the American Nurses
delegating specific nursing interventions, and
Association, state regulations, and facility policy.
coordinating the patient’s activities.
41. The kilocalorie (kcal) is a unit of energy measurement
2. The Patient’s Bill of Rights offers patients guidance
that represents the amount of heat needed to raise the
and protection by stating the responsibilities of the
temperature of 1 kilogram of water 1° C.
hospital and its staff toward patients and their families
42. As nutrients move through the body, they undergo
during hospitalization.
ingestion, digestion, absorption, transport, cell
3. To minimize omission and distortion of facts, the
metabolism, and excretion.
nurse should record information as soon as it’s
43. The body metabolizes alcohol at a fixed rate,
gathered.
regardless of serum concentration.
4. When assessing a patient’s health history, the nurse
44. In an alcoholic beverage, proof reflects the percentage
should record the current illness chronologically,
of alcohol multiplied by 2. For example, a 100-proof
beginning with the onset of the problem and
beverage contains 50% alcohol.
continuing to the present.
45. A living will is a witnessed document that states a
5. When assessing a patient’s health history, the nurse
patient’s desire for certain types of care and treatment.
should record the current illness chronologically,
These decisions are based on the patient’s wishes and
beginning with the onset of the problem and
views on quality of life.
continuing to the present.
6. A nurse shouldn’t give false assurance to a patient.
7. After receiving preoperative medication, a patient 21. Signs of accessory muscle use include shoulder
isn’t competent to sign an informed consent form. elevation, intercostal muscle retraction, and scalene
8. When lifting a patient, a nurse uses the weight of her and sternocleidomastoid muscle use during
body instead of the strength in her arms. respiration.
9. A nurse may clarify a physician’s explanation about 22. When patients use axillary crutches, their palms
an operation or a procedure to a patient, but must refer should bear the brunt of the weight.
questions about informed consent to the physician. 23. Activities of daily living include eating, bathing,
10. When obtaining a health history from an acutely ill or dressing, grooming, toileting, and interacting socially.
agitated patient, the nurse should limit questions to 24. Normal gait has two phases: the stance phase, in
those that provide necessary information. which the patient’s foot rests on the ground, and the
11. If a chest drainage system line is broken or swing phase, in which the patient’s foot moves
interrupted, the nurse should clamp the tube forward.
immediately. 25. The phases of mitosis are prophase, metaphase,
12. The nurse shouldn’t use her thumb to take a patient’s anaphase, and telophase.
pulse rate because the thumb has a pulse that may be 26. The nurse should follow standard precautions in the
confused with the patient’s pulse. routine care of all patients.
13. An inspiration and an expiration count as one 27. The nurse should use the bell of the stethoscope to
respiration. listen for venous hums and cardiac murmurs.
14. Eupnea is normal respiration. 28. The nurse can assess a patient’s general knowledge by
15. During blood pressure measurement, the patient asking questions such as “Who is the president of the
should rest the arm against a surface. Using muscle United States?”
strength to hold up the arm may raise the blood 29. Cold packs are applied for the first 20 to 48 hours
pressure. after an injury; then heat is applied. During cold
16. Major, unalterable risk factors for coronary artery application, the pack is applied for 20 minutes and
disease include heredity, sex, race, and age. then removed for 10 to 15 minutes to prevent reflex
17. Inspection is the most frequently used assessment dilation (rebound phenomenon) and frostbite injury.
technique. 30. The pons is located above the medulla and consists of
18. Family members of an elderly person in a long-term white matter (sensory and motor tracts) and gray
care facility should transfer some personal items (such matter (reflex centers).
as photographs, a favorite chair, and knickknacks) to 31. The autonomic nervous system controls the smooth
the person’s room to provide a comfortable muscles.
atmosphere. 32. A correctly written patient goal expresses the desired
19. Pulsus alternans is a regular pulse rhythm with patient behavior, criteria for measurement, time frame
alternating weak and strong beats. It occurs in for achievement, and conditions under which the
ventricular enlargement because the stroke volume behavior will occur. It’s developed in collaboration
varies with each heartbeat. with the patient.
20. The upper respiratory tract warms and humidifies 33. Percussion causes five basic notes: tympany (loud
inspired air and plays a role in taste, smell, and intensity, as heard over a gastric air bubble or puffed
mastication. out cheek), hyperresonance (very loud, as heard over
 an emphysematous lung), resonance (loud, as heard attempt to obliterate documentation or leave vacant
over a normal lung), dullness (medium intensity, as lines.
heard over the liver or other solid organ), and flatness 46. Factors that affect body temperature include time of
(soft, as heard over the thigh). day, age, physical activity, phase of menstrual cycle,
34. The optic disk is yellowish pink and circular, with a and pregnancy.
distinct border. 47. The most accessible & commonly used artery for
35. A primary disability is caused by a pathologic process. measuring a patient’s PR is the radial artery. To take
A secondary disability is caused by inactivity. the pulse rate, the artery is compressed against the
36. Nurses are commonly held liable for failing to keep an radius.
accurate count of sponges and other devices during 48. In a resting adult, the normal pulse rate is 60 to 100
surgery. beats/minute. The rate is slightly faster in women than
37. The best dietary sources of vitamin B6 are liver, in men and much faster in children than in adults.
kidney, pork, soybeans, corn, and whole-grain cereals. 49. Laboratory test results are an objective form of
38. Iron-rich foods, such as organ meats, nuts, legumes, assessment data.
dried fruit, green leafy vegetables, eggs, and whole 50. The measurement systems most commonly used in
grains, commonly have a low water content. clinical practice are the metric system, apothecaries’
39. Collaboration is joint communication and decision system, and household system.
making between nurses and physicians. It’s designed 51. Before signing an informed consent form, the patient
to meet patients’ needs by integrating the care should know whether other treatment options are
regimens of both professions into one comprehensive available and should understand what will occur
approach. during the preoperative, intraoperative, and
40. Bradycardia is a heart rate of fewer than 60 postoperative phases; the risks involved; and the
beats/minute. possible complications. The patient should also have a
41. A nursing diagnosis is a statement of a patient’s actual general idea of the time required from surgery to
or potential health problem that can be resolved, recovery. In addition, he should have an opportunity
diminished, or otherwise changed by nursing to ask questions.
interventions. 52. A patient must sign a separate informed consent form
42. During the assessment phase of the nursing process, for each procedure.
the nurse collects and analyzes three types of data: 53. During percussion, the nurse uses quick, sharp tapping
health history, physical examination, and laboratory of the fingers or hands against body surfaces to
and diagnostic test data. produce sounds. This procedure is done to determine
43. The patient’s health history consists primarily of the size, shape, position, and density of underlying
subjective data, information that’s supplied by the pt. organs and tissues; elicit tenderness; or assess
44. The physical examination includes objective data reflexes.
obtained by inspection, palpation, percussion, & 54. Ballottement is a form of light palpation involving
auscultation. gentle, repetitive bouncing of tissues against the hand
45. When documenting patient care, the nurse should and feeling their rebound.
write legibly, use only standard abbreviations, and 55. A foot cradle keeps bed linen off the patient’s feet to
sign each entry. The nurse should never destroy or prevent skin irritation and breakdown, especially in a
 patient who has peripheral vascular disease or c. Administer oxygen by Venturi mask at 24%,
neuropathy. as needed
d. Allow a 1 hour rest period between activities
56. Gastric lavage is flushing of the stomach and removal
of ingested substances through a nasogastric tube. It’s 2. The nurse observes that Mr. Adams begins to have
used to treat poisoning or drug overdose. increased difficulty breathing. She elevates the head of
the bed to the high Fowler position, which decreases
57. During the evaluation step of the nursing process, the
his respiratory distress. The nurse documents this
nurse assesses the patient’s response to therapy. breathing as:
58. Bruits commonly indicate life- or limb-threatening a. Tachypnea
b. Eupnca
vascular disease.
c. Orthopnea
59. O.U. means each eye. O.D. is the right eye, and O.S. d. Hyperventilation
is the left eye.
60. To remove a patient’s artificial eye, the nurse 3. The physician orders a platelet count to be performed
on Mrs. Smith after breakfast. The nurse is responsible
depresses the lower lid. for:
61. The nurse should use a warm saline solution to clean a. Instructing the patient about this diagnostic
an artificial eye. test
b. Writing the order for this test
62. A thready pulse is very fine and scarcely perceptible.
c. Giving the patient breakfast
63. Axillary temperature is usually 1° F lower than oral d. All of the above
temperature.
4. Mrs. Mitchell has been given a copy of her diet. The
64. After suctioning a tracheostomy tube, the nurse must
nurse discusses the foods allowed on a 500-mg low
document the color, amount, consistency, and odor of sodium diet. These include:
secretions. a. A ham and Swiss cheese sandwich on whole
wheat bread
65. On a drug prescription, the abbreviation p.c. means
b. Mashed potatoes and broiled chicken
that the drug should be administered after meals. c. A tossed salad with oil and vinegar and olives
66. After bladder irrigation, the nurse should document d. Chicken bouillon
the amount, color, and clarity of the urine and the
5. The physician orders a maintenance dose of 5,000
presence of clots or sediment. units of subcutaneous heparin (an anticoagulant) daily.
67. After bladder irrigation, the nurse should document Nursing responsibilities for Mrs. Mitchell now
the amount, color, and clarity of the urine and the include:
a. Reviewing daily activated partial
presence of clots or sediment.
thromboplastin time (APTT) and prothrombin
68. Gauge is the inside diameter of a needle: the smaller time.
the gauge, the larger the diameter. b. Reporting an APTT above 45 seconds to the
physician
69. An adult normally has 32 permanent teeth.
c. Assessing the patient for signs and symptoms
of frank and occult bleeding
FUNDAMENTALS OF NURSING ASSESSMENT d. All of the above
PART 1
1. The most appropriate nursing order for a patient who 6. The four main concepts common to nursing that
develops dyspnea and shortness of breath would be appear in each of the current conceptual models are:
a. Maintain the patient on strict bed rest at all a. Person, nursing, environment, medicine
times b. Person, health, nursing, support systems
b. Maintain the patient in an orthopneic position c. Person, health, psychology, nursing
as needed d. Person, environment, health, nursing
 12. If patient asks the nurse her opinion about a particular
7. In Maslow’s hierarchy of physiologic needs, the physicians and the nurse replies that the physician is
human need of greatest priority is: incompetent, the nurse could be held liable for:
a. Love a. Slander
b. Elimination b. Libel
c. Nutrition c. Assault
d. Oxygen d. Respondent superior

8. The family of an accident victim who has been 13. A registered nurse reaches to answer the telephone on
declared brain-dead seems amenable to organ a busy pediatric unit, momentarily turning away from
donation. What should the nurse do? a 3 month-old infant she has been weighing. The
a. Discourage them from making a decision until infant falls off the scale, suffering a skull fracture. The
their grief has eased nurse could be charged with:
b. Listen to their concerns and answer their a. Defamation
questions honestly b. Assault
c. Encourage them to sign the consent form right c. Battery
away d. Malpractice
d. Tell them the body will not be available for a
wake or funeral 14. Which of the following is an example of nursing
malpractice?
9. A new head nurse on a unit is distressed about the a. The nurse administers penicillin to a patient
poor staffing on the 11 p.m. to 7 a.m. shift. What with a documented history of allergy to the
should she do? drug. The patient experiences an allergic
a. Complain to her fellow nurses reaction and has cerebral damage resulting
b. Wait until she knows more about the unit from anoxia.
c. Discuss the problem with her supervisor b. The nurse applies a hot water bottle or a
d. Inform the staff that they must volunteer to heating pad to the abdomen of a patient with
rotate abdominal cramping.
c. The nurse assists a patient out of bed with the
10. Which of the following principles of primary nursing bed locked in position; the patient slips and
has proven the most satisfying to the patient and fractures his right humerus.
nurse? d. The nurse administers the wrong medication
a. Continuity of patient care promotes efficient, to a patient and the patient vomits. This
cost-effective nursing care information is documented and reported to the
b. Autonomy and authority for planning are best physician and the nursing supervisor.
delegated to a nurse who knows the patient
well 15. Which of the following signs and symptoms would the
c. Accountability is clearest when one nurse is nurse expect to find when assessing an Asian patient
responsible for the overall plan and its for postoperative pain following abdominal surgery?
implementation. a. Decreased blood pressure and heart rate and
d. The holistic approach provides for a shallow respirations
therapeutic relationship, continuity, and b. Quiet crying
efficient nursing care. c. Immobility, diaphoresis, and avoidance of
deep breathing or coughing
11. If nurse administers an injection to a patient who d. Changing position every 2 hours
refuses that injection, she has committed:
a. Assault and battery 16. A patient is admitted to the hospital with complaints
b. Negligence of nausea, vomiting, diarrhea, and severe abdominal
c. Malpractice pain. Which of the following would immediately alert
d. None of the above the nurse that the patient has bleeding from the GI
tract?
 a. Complete blood count a. Infection
b. Guaiac test b. Hypothermia
c. Vital signs c. Anxiety
d. Abdominal girth d. Dehydration

17. The correct sequence for assessing the abdomen is: 24. Which of the following parameters should be checked
a. Tympanic percussion, measurement of when assessing respirations?
abdominal girth, and inspection a. Rate
b. Assessment for distention, tenderness, and b. Rhythm
discoloration around the umbilicus. c. Symmetry
c. Percussions, palpation, and auscultation d. All of the above
d. Auscultation, percussion, and palpation
25. A 38-year old patient’s vital signs at 8 a.m. are
18. High-pitched gurgles head over the right lower axillary temperature 99.6 F (37.6 C); pulse rate, 88;
quadrant are: respiratory rate, 30. Which findings should be
a. A sign of increased bowel motility reported?
b. A sign of decreased bowel motility a. Respiratory rate only
c. Normal bowel sounds b. Temperature only
d. A sign of abdominal cramping c. Pulse rate and temperature
d. Temperature and respiratory rate
19. A patient about to undergo abdominal inspection is
best placed in which of the following positions? 26. All of the following can cause tachycardia except:
a. Prone a. Fever
b. Trendelenburg b. Exercise
c. Supine c. Sympathetic nervous system stimulation
d. Side-lying d. Parasympathetic nervous system stimulation

20. For a rectal examination, the patient can be directed to 27. Palpating the midclavicular line is the correct
assume which of the following positions? technique for assessing
a. Genupecterol a. Baseline vital signs
b. Sims b. Systolic blood pressure
c. Horizontal recumbent c. Respiratory rate
d. All of the above d. Apical pulse

21. During a Romberg test, the nurse asks the patient to 28. The absence of which pulse may not be a significant
assume which position? finding when a patient is admitted to the hospital?
a. Sitting a. Apical
b. Standing b. Radial
c. Genupectoral c. Pedal
d. Trendelenburg d. Femoral

22. If a patient’s blood pressure is 150/96, his pulse 29. Which of the following patients is at greatest risk for
pressure is: developing pressure ulcers?
a. 54 a. An 88-year old incontinent patient with
b. 96 gastric cancer who is confined to his bed at
c. 150 home
d. 246 b. An apathetic 63-year old COPD patient
receiving nasal oxygen via cannula
23. A patient is kept off food and fluids for 10 hours c. A confused 78-year old patient with
before surgery. His oral temperature at 8 a.m. is 99.8 F congestive heart failure (CHF) who requires
(37.7 C) This temperature reading probably indicates: assistance to get out of bed.
 d. A basketball player 35. A male patient who had surgery 2 days ago for head
and neck cancer is about to make his first attempt to
30. The physician orders the administration of high- ambulate outside his room. The nurse notes that he is
humidity oxygen by face mask and placement of the steady on his feet and that his vision was unaffected
patient in a high Fowler’s position. After assessing by the surgery. Which of the following nursing
Mrs. Paul, the nurse writes the following nursing interventions would be appropriate?
diagnosis: Impaired gas exchange related to increased a. Encourage the patient to walk in the hall alone
secretions. Which of the following nursing b. Discourage the patient from walking in the
interventions has the greatest potential for improving hall for a few more days
this situation? c. Accompany the patient for his walk.
a. Encourage the patient to increase her fluid d. Consuit a physical therapist before allowing
intake to 200 ml every 2 hours the patient to ambulate
b. Place a humidifier in the patient’s room.
c. Continue administering oxygen by high 36. A patient has exacerbation of chronic obstructive
humidity face mask pulmonary disease (COPD) manifested by shortness
d. Perform chest physiotheraphy on a regular of breath; orthopnea: thick, tenacious secretions; and a
schedule dry hacking cough. An appropriate nursing diagnosis
would be:
31. The most common deficiency seen in alcoholics is: a. Ineffective airway clearance related to thick,
a. Thiamine tenacious secretions.
b. Riboflavin b. Ineffective airway clearance related to dry,
c. Pyridoxine hacking cough.
d. Pantothenic acid c. Ineffective individual coping to COPD.
d. Pain related to immobilization of affected leg.
32. Which of the following statement is incorrect about a
patient with dysphagia? 37. Mrs. Lim begins to cry as the nurse discusses hair
a. The patient will find pureed or soft foods, loss. The best response would be:
such as custards, easier to swallow than water a. “Don’t worry. It’s only temporary”
b. Fowler’s or semi Fowler’s position reduces b. “Why are you crying? I didn’t get to the bad
the risk of aspiration during swallowing news yet”
c. The patient should always feed himself c. “Your hair is really pretty”
d. The nurse should perform oral hygiene before d. “I know this will be difficult for you, but your
assisting with feeding. hair will grow back after the completion of
chemotheraphy”
33. To assess the kidney function of a patient with an
indwelling urinary (Foley) catheter, the nurse 38. An additional Vitamin C is required during all of the
measures his hourly urine output. She should notify following periods except:
the physician if the urine output is: a. Infancy
a. Less than 30 ml/hour b. Young adulthood
b. 64 ml in 2 hours c. Childhood
c. 90 ml in 3 hours d. Pregnancy
d. 125 ml in 4 hours
39. A prescribed amount of oxygen s needed for a patient
34. Certain substances increase the amount of urine with COPD to prevent:
produced. These include: a. Cardiac arrest related to increased partial
a. Caffeine-containing drinks, such as coffee and pressure of carbon dioxide in arterial blood
cola. (PaCO2)
b. Beets b. Circulatory overload due to hypervolemia
c. Urinary analgesics c. Respiratory excitement
d. Kaolin with pectin (Kaopectate) d. Inhibition of the respiratory hypoxic stimulus
40. After 1 week of hospitalization, Mr. Gray develops vessels
hypokalemia. Which of the following is the most b. Decreased blood flow
significant symptom of his disorder? c. Increased work load of the left ventricle
a. Lethargy d. All of the above
b. Increased pulse rate and blood pressure
c. Muscle weakness 47. Which of the following is the most common cause of
d. Muscle irritability dementia among elderly persons?
a. Parkinson’s disease
41. Which of the following nursing interventions b. Multiple sclerosis
promotes patient safety? c. Amyotrophic lateral sclerosis (Lou Gerhig’s
a. Asses the patient’s ability to ambulate and disease)
transfer from a bed to a chair d. Alzheimer’s disease
b. Demonstrate the signal system to the patient
c. Check to see that the patient is wearing his 48. The nurse’s most important legal responsibility after a
identification band patient’s death in a hospital is:
d. All of the above a. Obtaining a consent of an autopsy
b. Notifying the coroner or medical examiner
42. Studies have shown that about 40% of patients fall out c. Labeling the corpse appropriately
of bed despite the use of side rails; this has led to d. Ensuring that the attending physician issues
which of the following conclusions? the death certification
a. Side rails are ineffective
b. Side rails should not be used 49. Before rigor mortis occurs, the nurse is responsible
c. Side rails are a deterrent that prevent a patient for:
from falling out of bed. a. Providing a complete bath and dressing
d. Side rails are a reminder to a patient not to get change
out of bed b. Placing one pillow under the body’s head and
shoulders
43. Examples of patients suffering from impaired c. Removing the body’s clothing and wrapping
awareness include all of the following except: the body in a shroud
a. A semiconscious or over fatigued patient d. Allowing the body to relax normally
b. A disoriented or confused patient
c. A patient who cannot care for himself at home 50. When a patient in the terminal stages of lung cancer
d. A patient demonstrating symptoms of drugs or begins to exhibit loss of consciousness, a major
alcohol withdrawal nursing priority is to:
a. Protect the patient from injury
44. The most common injury among elderly persons is: b. Insert an airway
a. Atheroscleotic changes in the blood vessels c. Elevate the head of the bed
b. Increased incidence of gallbladder disease d. Withdraw all pain medications
c. Urinary Tract Infection
d. Hip fracture

45. The most common psychogenic disorder among *** END ***
elderly person is:
a. Depression ANSWERS and RATIONALES:
b. Sleep disturbances (such as bizarre dreams)
c. Inability to concentrate 1. B. When a patient develops dyspnea and shortness
d. Decreased appetite of breath, the orthopneic position encourages
maximum chest expansion and keeps the
46. Which of the following vascular system changes abdominal organs from pressing against the
results from aging? diaphragm, thus improving ventilation. Bed rest
a. Increased peripheral resistance of the blood and oxygen by Venturi mask at 24% would
 improve oxygenation of the tissues and cells but donation. Because transplants are done within
must be ordered by a physician. Allowing for rest hours of death, decisions about organ donation
periods decreases the possibility of hypoxia. must be made as soon as possible. However, the
2. C. Orthopnea is difficulty of breathing except in family’s concerns must be addressed before
the upright position. Tachypnea is rapid respiration members are asked to sign a consent form. The
characterized by quick, shallow breaths. Eupnea is body of an organ donor is available for burial.
normal respiration – quiet, rhythmic, and without 9. C. Although a new head nurse should initially
effort. spend time observing the unit for its strengths and
3. C. A platelet count evaluates the number of weakness, she should take action if a problem
platelets in the circulating blood volume. The nurse threatens patient safety. In this case, the supervisor
is responsible for giving the patient breakfast at the is the resource person to approach.
scheduled time. The physician is responsible for 10. D. Studies have shown that patients and nurses
instructing the patient about the test and for writing both respond well to primary nursing care units.
the order for the test. Patients feel less anxious and isolated and more
4. B. Mashed potatoes and broiled chicken are low in secure because they are allowed to participate in
natural sodium chloride. Ham, olives, and chicken planning their own care. Nurses feel personal
bouillon contain large amounts of sodium and are satisfaction, much of it related to positive feedback
contraindicated on a low sodium diet. from the patients. They also seem to gain a greater
5. D. All of the identified nursing responsibilities are sense of achievement and esprit de corps.
pertinent when a patient is receiving heparin. The 11. A. Assault is the unjustifiable attempt or threat to
normal activated partial thromboplastin time is 16 touch or injure another person. Battery is the
to 25 seconds and the normal prothrombin time is unlawful touching of another person or the carrying
12 to 15 seconds; these levels must remain within out of threatened physical harm. Thus, any act that
two to two and one half the normal levels. All a nurse performs on the patient against his will is
patients receiving anticoagulant therapy must be considered assault and battery.
observed for signs and symptoms of frank and 12. A. Oral communication that injures an individual’s
occult bleeding (including hemorrhage, reputation is considered slander. Written
hypotension, tachycardia, tachypnea, restlessness, communication that does the same is considered
pallor, cold and clammy skin, thirst and confusion); libel.
blood pressure should be measured every 4 hours 13. D. Malpractice is defined as injurious or
and the patient should be instructed to report unprofessional actions that harm another. It
promptly any bleeding that occurs with tooth involves professional misconduct, such as
brushing, bowel movements, urination or heavy omission or commission of an act that a reasonable
prolonged menstruation. and prudent nurse would or would not do. In this
6. D. The focus concepts that have been accepted by example, the standard of care was breached; a 3-
all theorists as the focus of nursing practice from month-old infant should never be left unattended
the time of Florence Nightingale include the person on a scale.
receiving nursing care, his environment, his health 14. D. The three elements necessary to establish a
on the health illness continuum, and the nursing nursing malpractice are nursing error
actions necessary to meet his needs. (administering penicillin to a patient with a
7. D. Maslow, who defined a need as a satisfaction documented allergy to the drug), injury (cerebral
whose absence causes illness, considered oxygen to damage), and proximal cause (administering the
be the most important physiologic need; without it, penicillin caused the cerebral damage). Applying a
human life could not exist. According to this hot water bottle or heating pad to a patient without
theory, other physiologic needs (including food, a physician’s order does not include the three
water, elimination, shelter, rest and sleep, activity required components. Assisting a patient out of bed
and temperature regulation) must be met before with the bed locked in position is the correct
proceeding to the next hierarchical levels on nursing practice; therefore, the fracture was not the
psychosocial needs. result of malpractice. Administering an incorrect
8. B. The brain-dead patient’s family needs support medication is a nursing error; however, if such
and reassurance in making a decision about organ action resulted in a serious illness or chronic
 problem, the nurse could be sued for malpractice. with legs extended and hips rotated outward.
15. A. An Asian patient is likely to hide his pain. 21. B. During a Romberg test, which evaluates for
Consequently, the nurse must observe for objective sensory or cerebellar ataxia, the patient must stand
signs. In an abdominal surgery patient, these might with feet together and arms resting at the sides—
include immobility, diaphoresis, and avoidance of first with eyes open, then with eyes closed. The
deep breathing or coughing, as well as increased need to move the feet apart to maintain this stance
heart rate, shallow respirations (stemming from is an abnormal finding.
pain upon moving the diaphragm and respiratory 22. A. The pulse pressure is the difference between the
muscles), and guarding or rigidity of the abdominal systolic and diastolic blood pressure readings – in
wall. Such a patient is unlikely to display emotion, this case, 54.
such as crying. 23. A slightly elevated temperature in the immediate
16. B. To assess for GI tract bleeding when frank blood preoperative or post operative period may result
is absent, the nurse has two options: She can test from the lack of fluids before surgery rather than
for occult blood in vomitus, if present, or in stool – from infection. Anxiety will not cause an elevated
through guaiac (Hemoccult) test. A complete blood temperature. Hypothermia is an abnormally low
count does not provide immediate results and does body temperature.
not always immediately reflect blood loss. Changes 24. D. The quality and efficiency of the respiratory
in vital signs may be cause by factors other than process can be determined by appraising the rate,
blood loss. Abdominal girth is unrelated to blood rhythm, depth, ease, sound, and symmetry of
loss. respirations.
17. A. Because percussion and palpation can affect 25. D. Under normal conditions, a healthy adult
bowel motility and thus bowel sounds, they should breathes in a smooth uninterrupted pattern 12 to 20
follow auscultation in abdominal assessment. times a minute. Thus, a respiratory rate of 30
Tympanic percussion, measurement of abdominal would be abnormal. A normal adult body
girth, and inspection are methods of assessing the temperature, as measured on an oral thermometer,
abdomen. Assessing for distention, tenderness and ranges between 97° and 100°F (36.1° and 37.8°C);
discoloration around the umbilicus can indicate an axillary temperature is approximately one
various bowel-related conditions, such as degree lower and a rectal temperature, one degree
cholecystitis, appendicitis and peritonitis. higher. Thus, an axillary temperature of 99.6°F
18. A. Hyperactive sounds indicate increased bowel (37.6°C) would be considered abnormal. The
motility; two or three sounds per minute indicate resting pulse rate in an adult ranges from 60 to 100
decreased bowel motility. Abdominal cramping beats/minute, so a rate of 88 is normal.
with hyperactive, high pitched tinkling bowel 26. D. Parasympathetic nervous system stimulation of
sounds can indicate a bowel obstruction. the heart decreases the heart rate as well as the
19. D. The supine position (also called the dorsal force of contraction, rate of impulse conduction
position), in which the patient lies on his back with and blood flow through the coronary vessels.
his face upward, allows for easy access to the Fever, exercise, and sympathetic stimulation all
abdomen. In the prone position, the patient lies on increase the heart rate.
his abdomen with his face turned to the side. In the 27. D. The apical pulse (the pulse at the apex of the
Trendelenburg position, the head of the bed is tilted heart) is located on the midclavicular line at the
downward to 30 to 40 degrees so that the upper fourth, fifth, or sixth intercostal space. Base line
body is lower than the legs. In the lateral position, vital signs include pulse rate, temperature,
the patient lies on his side. respiratory rate, and blood pressure. Blood pressure
20. C. All of these positions are appropriate for a rectal is typically assessed at the antecubital fossa, and
examination. In the genupectoral (knee-chest) respiratory rate is assessed best by observing chest
position, the patient kneels and rests his chest on movement with each inspiration and expiration.
the table, forming a 90 degree angle between the 28. C. Because the pedal pulse cannot be detected in
torso and upper legs. In Sims’ position, the patient 10% to 20% of the population, its absence is not
lies on his left side with the left arm behind the necessarily a significant finding. However, the
body and his right leg flexed. In the horizontal presence or absence of the pedal pulse should be
recumbent position, the patient lies on his back documented upon admission so that changes can be
 identified during the hospital stay. Absence of the would be an appropriate nursing diagnosis for a
apical, radial, or femoral pulse is abnormal and patient with a leg fracture.
should be investigated. 37. D. “I know this will be difficult” acknowledges the
29. B. Pressure ulcers are most likely to develop in problem and suggests a resolution to it. “Don’t
patients with impaired mental status, mobility, worry..” offers some relief but doesn’t recognize
activity level, nutrition, circulation and bladder or the patient’s feelings. “..I didn’t get to the bad news
bowel control. Age is also a factor. Thus, the 88- yet” would be inappropriate at any time. “Your hair
year old incontinent patient who has impaired is really pretty” offers no consolation or
nutrition (from gastric cancer) and is confined to alternatives to the patient.
bed is at greater risk. 38. B. Additional Vitamin C is needed in growth
30. A. Adequate hydration thins and loosens periods, such as infancy and childhood, and during
pulmonary secretions and also helps to replace pregnancy to supply demands for fetal growth and
fluids lost from elevated temperature, diaphoresis, maternal tissues. Other conditions requiring extra
dehydration and dyspnea. High- humidity air and vitamin C include wound healing, fever, infection
chest physiotherapy help liquefy and mobilize and stress.
secretions. 39. D. Delivery of more than 2 liters of oxygen per
31. A. Chronic alcoholism commonly results in minute to a patient with chronic obstructive
thiamine deficiency and other symptoms of pulmonary disease (COPD), who is usually in a
malnutrition. state of compensated respiratory acidosis (retaining
32. A patient with dysphagia (difficulty swallowing) carbon dioxide (CO2)), can inhibit the hypoxic
requires assistance with feeding. Feeding himself is stimulus for respiration. An increased partial
a long-rage expected outcome. Soft foods, Fowler’s pressure of carbon dioxide in arterial blood
or semi-Fowler’s position, and oral hygiene before (PACO2) would not initially result in cardiac
eating should be part of the feeding regimen. arrest. Circulatory overload and respiratory
33. A. A urine output of less than 30ml/hour indicates excitement have no relevance to the question.
hypovolemia or oliguria, which is related to kidney 40. C. Presenting symptoms of hypokalemia ( a serum
function and inadequate fluid intake. potassium level below 3.5 mEq/liter) include
34. [Link] containing caffeine have a diuretic effect. muscle weakness, chronic fatigue, and cardiac
Beets and urinary analgesics, such as pyridium, can dysrhythmias. The combined effects of inadequate
color urine red. Kaopectate is an anti diarrheal food intake and prolonged diarrhea can deplete the
medications. potassium stores of a patient with GI problems.
35. C. A hospitalized surgical patient leaving his room 41. D. Assisting a patient with ambulation and transfer
for the first time fears rejection and others staring from a bed to a chair allows the nurse to evaluate
at him, so he should not walk alone. the patient’s ability to carry out these functions
Accompanying him will offer moral support, safely. Demonstrating the signal system and
enabling him to face the rest of the world. Patients providing an opportunity for a return demonstration
should begin ambulation as soon as possible after ensures that the patient knows how to operate the
surgery to decrease complications and to regain equipment and encourages him to call for
strength and confidence. Waiting to consult a assistance when needed. Checking the patient’s
physical therapist is unnecessary. identification band verifies the patient’s identity
36. A. Thick, tenacious secretions, a dry, hacking and prevents identification mistakes in drug
cough, orthopnea, and shortness of breath are signs administration.
of ineffective airway clearance. Ineffective airway 42. D. Since about 40% of patients fall out of bed
clearance related to dry, hacking cough is incorrect despite the use of side rails, side rails cannot be
because the cough is not the reason for the said to prevent falls; however, they do serve as a
ineffective airway clearance. Ineffective individual reminder that the patient should not get out of bed.
coping related to COPD is wrong because the The other answers are incorrect interpretations of
etiology for a nursing diagnosis should not be a the statistical data.
medical diagnosis (COPD) and because no data 43. C. A patient who cannot care for himself at home
indicate that the patient is coping ineffectively. does not necessarily have impaired awareness; he
Pain related to immobilization of affected leg may simply have some degree of immobility.
44. D. Hip fracture, the most common injury among essential action at this time. The other nursing
elderly persons, usually results from osteoporosis. actions may be necessary but are not a major
The other answers are diseases that can occur in the priority.
elderly from physiologic changes.
45. A. Sleep disturbances, inability to concentrate and
decreased appetite are symptoms of depression, the
most common psychogenic disorder among elderly
persons. Other symptoms include diminished
memory, apathy, disinterest in appearance,
withdrawal, and irritability. Depression typically
begins before the onset of old age and usually is
caused by psychosocial, genetic, or biochemical
factors
46. D. Aging decreases elasticity of the blood vessels,
which leads to increased peripheral resistance and
decreased blood flow. These changes, in turn,
increase the work load of the left ventricle.
47. D. Alzheimer;s disease, sometimes known as
senile dementia of the Alzheimer’s type or primary
degenerative dementia, is an insidious; progressive,
irreversible, and degenerative disease of the brain
whose etiology is still unknown. Parkinson’s
disease is a neurologic disorder caused by lesions
in the extrapyramidial system and manifested by
tremors, muscle rigidity, hypokinesis, dysphagia,
and dysphonia. Multiple sclerosis, a progressive,
degenerative disease involving demyelination of
the nerve fibers, usually begins in young adulthood
and is marked by periods of remission and
exacerbation. Amyotrophic lateral sclerosis, a
disease marked by progressive degeneration of the
neurons, eventually results in atrophy of all the
muscles; including those necessary for respiration.
48. C. The nurse is legally responsible for labeling the
corpse when death occurs in the hospital. She may
be involved in obtaining consent for an autopsy or
notifying the coroner or medical examiner of a
patient’s death; however, she is not legally
responsible for performing these functions. The
attending physician may need information from the
nurse to complete the death certificate, but he is
responsible for issuing it.
49. B. The nurse must place a pillow under the
decreased person’s head and shoulders to prevent
blood from settling in the face and discoloring it.
She is required to bathe only soiled areas of the
body since the mortician will wash the entire body.
Before wrapping the body in a shroud, the nurse
places a clean gown on the body and closes the
eyes and mouth.
50. A. Ensuring the patient’s safety is the most
PART 2 8. When describing disease development, which disease
1. The way you practice your profession of nursing should stage is described as producing generally mild, nonspecific
be guided by standards of nursing are and which of the signs and symptoms?
following? a. Latent
a. Nurse practice acts b. Acute
b. Facility policy c. Secondary latency
c. Joint Commission on Accreditation of Healthcare d. Prodromal
Organization
d. American Medical Association 9. The Code of Ethics for Nurses provides information that’s
necessary for the practicing nurse to:
2. Nurse practice acts are administered by your a. Document her nursing care appropriately
a. Health care facility b. Make ethical decisions about patient care
b. School of nursing c. Use of professional skills in providing the most effective
c. Licensing bureau holistic care possible
d. Individual state d. Strengthen and protect patient privacy

3. A nurse who can obtain histories, conduct physical 10. Which of the following is a type of unintentional tort?
examinations, order laboratory and diagnostic tests, interpret a. Invasion of privacy
results, diagnose disorders and treat patients has what b. Malpractice
nursing credentials? c. Assault and battery
a. Clinical nurse specialist d. Defamation of character
b. Case manager
c. Nurse practitioner 11. Which part of the medical record can be used as
d. Nurse manager evidence in court?
a. Entire record
4. The easiest way to participate in research is to: b. Medical orders
[Link] a good consumer of research c. Care plan
[Link] a meta analysis of related studies d. Nursing notes
[Link] a research study
[Link] on your institution’s internal review board 12. When obtaining a health history from a patient, ask first
about:
5. The purpose of evidence based practice is to: a. His chief complaint
a. Validate traditional nursing practices b. Biographic data
b. Improve patient outcomes c. Family history
c. Dispute traditional nursing practices d. Health insurance coverage
d. Establish a body of knowledge unique to nursing
13. Expected outcomes are defined as:
6. Which of the following is an example of health a. Goals the patient should reach as a result of planned
promotion? nursing intervention
a. Administering antibiotics to a patient b. Goal set by the medical team for each patient
b. Assisting a patient in stopping smoking c. Goals a little higher than what the patient can realistically
c. Splinting a patient’s fractured bone reach to help motivate him
d. Inserting an IV catheter d. What a patient and family ask you to accomplish

7. The effect of illness on a family unit depends on several 14. The nursing health history is most accurately described
factors including: as:
a. When the illness occurs a. A tool to guide diagnosis and treatment of the illness
b. Whether the illness is due to poor health habits b. A follow up to the medical history
c. Which family member is affected c. An interview that focuses holistically on the human
d. At what point the patient sought care response to illness
d. A care plan
 22. Silence is a communication technique used during an
15. The primary source of assessment information interview to:
a. The patient’s friends a. Show respect
b. The patient’s family members b. Change the topic
c. The patient c. Encourage the patient to continue talking
d. Medical records d. Clarify information

16. When developing a therapeutic nurse-patient- 23. Data are considered subjective if you obtain them from:
relationship, during what phase do you review the patient’s a. The patient’s verbal account
surgical history? b. The patient’s records
a. Orientation c. Your observations of the patient’s action
b. Working d. X-ray reports
c. Pre-interaction
d. Termination 24. Which heart rate in a neonate would be considered
normal?
17. What’s a good way to communicate with a very young a. 60 to 80 beats/minute
child? b. 100 to 120 beats/minute
a. Role playing c. 120 to 140 beats/minute
b. Explaining procedures d. 160 to 200 beats/minute
c. Showing him pictures
d. Showing him a movie 25. The highest temperature reading would be expected to
occur during what time of day?
18. What type of behavior provides encouragement during a. 4 and 5 am
communication without indicating agreement or b. 8 to 9 am
disagreement? c. 4 to 8 pm
a. Clapping d. 9 to 11 pm
b. Sighing
c. Looking away 26. Which breath sounds is referred to as snoring sound that
d. Nodding results from secretions in the trachea?
a. Stertor
19. What’s the main source of information and b. Stridor
communication among nurses, doctors, physical therapists, c. Wheezing
social workers and other caregivers? d. Expiratory grunting
a. Computer
b. Medical record 27. Which method for assessing temperature is the least
c. Telephone accurate?
d. Word of mouth a. Oral
b. Rectal
20. Leading questions may initiate untrue or inaccurate c. Tympanic
responses because such questions: d. Axillary
a. Encourage short or vague answers
b. Require an educational level the patient may not possess 28. What’s the most effective method of infection control?
c. Prompt the pt to try to give the answer you’re looking for a. Isolation precautions
d. Confuse the patient b. Hand washing
c. Neutroprenic precautions
21. When obtaining a health hx from a pt, ask first about: d. Wearing sterile gloves
a. Biographic data
b. His chief complaint 29. Which type of bacteria depends on host cells for
c. Health insurance coverage replication?
d. Family history a. Rickettsiae
b. Spirochetes
c. Fungi that’s richly supplied with blood
d. Chlamydiae b. Its method of injecting a small amount of liquid drug
(usually 0.5 to 2 mL) into the subcutaneous tissue beneath
30. What type of transmission occurs when an intermediate the patient’s skin
carrier, such as flea or mosquito, transfers an organism? c. Its method of displacing the tissues before you insert the
a. Vector borne transmission needle for an IM injection
b. Contact transmission d. Its method of aligning t-he tissues before you insert the
c. Vehicle borne transmission needle for a subcutaneous injection
d. Airborne transmission

31. What’s the name for a laboratory verified infection that 37. When suctioning a patient, you should:
causes no signs or symptoms? a. Apply suction intermittently as you insert the catheter
a. Colonized b. Suction the patient for longer than 10 seconds at a time
b. Subclinical c. Oxygenate the patient’s lungs before and after suctioning
c. Latent d. Apply suction continuously as you insert the catheter
d. Dormant
38. To help the patient achieve maximal ventilation, use:
32. When administering tablets or capsules by the oral route, a. An incentive spirometer
you would: b. An MDI
a. Assess the patient’s ability to swallow before c. A diskus
administering the drug d. A turbo inhaler
b. Give a drug that had been poured by someone else to save
time 39. Which tube permits speech through the upper airway?
c. Return any unused opened or unwrapped drug to the a. Uncuffed tube
patient’s medication drawer to avoid unnecessary waste b. Cuffed tube
d. Give a drug from a poorly labeled or an unlabeled bottle c. Fenestrated tube
d. Two piece tube
33. When instilling eyedrops, instruct your patient to:
a. Look down and away 40. When performing chest physiotherapy, which of the
b. Look straight ahead following uses gravity to promote drainage of secretions?
c. Look up and away a. Percussion
d. Look up and directly at the dropper b. Postural drainage
c. Vibration
34. When choosing supplies for a nonretention enema, what d. Deep breathing exercises
size rectal tube would you select for a child younger than
age 2? 41. When giving a back massage, which stroke uses
a. 12 French alternating kneading and stroking of the patient’s back and
b. 14 French upper arms?
c. 18 French a. Petrissage
d. 26 French b. Massage
c. Effleurage
35. Which route of administration would you use if you d. Tapotement
wanted to inject a small amount of liquid drug (usually 0.5
mL or less) into the outer layers of a patient’s skin? 42. When performing personal hygiene on a female patient,
a. ID it’s important to wash the genital area in what direction?
b. SQ a. Back to front
c. IM b. Side to side
d. IV c. In a circular motion
d. Front to back
36. Which statement best describes a Z tract injection?
a. Its method of depositing a drug deep into muscle tissue 43. Which of the following is the correct position to perform
mouth care on a comatose patient? c. Traumatic injury
a. Semi fowlers d. Surgical incision
b. Side lying
c. Prone 51. Which wound bed color indicates normal, healthy
d. Supine granulation tissue?
a. Red
44. When providing morning care to a patient, which of the b. Yellow
following is the correct direction for washing the patient’s c. Tan
eye? d. Black
a. Outer canthus to inner canthus
b. Lower canthus to upper canthus 52. Which intervention is most appropriate for preventing
c. Inner canthus to outer canthus excessive heel pressure?
d. Upper canthus to lower canthus a. Flexing the knees
b. Placing a donut-shaped cushion under the feet
45. Exercises performed without any effort by the patient are c. Suspending the heels by placing a pillow under the calves
called: [Link] a pressure reducing foam mattress under the heels
a. Strengthening exercises
b. Easy exerciseS 53. Which condition is characteristic of REM sleep?
c. Active ROM exercises a. Light sleep
d. Passive ROM exercises b. Paralysis of the muscles
c. Restricted eye movements
46. Your patient can’t move his right arm toward the d. Nonvivid dreams
midline, so you document this as impaired:
a. Supination 54. Which part of the brain regulates NREM sleep?
b. Abduction a. Pons
c. Adduction b. Hypothalamus
d. Eversion c. Basal forebrain
d. Amygdale
47. Which patient position requires that the head of the bed
be elevated to 45 degrees? 55. Which treatment is used to treat circadian rhythm sleep
a. Fowler’s disorders?
b. Sims’ a. Midafinil (Prodigil)
c. Prone b. Short acting sedative hypnotics
d. Semi-Fowler’s c. Relaxation techniques
d. Fluoxetine (Prozac)
48. Which gait should you teach a patient who ca bear
weight on both legs? 56. Which treatment is most commonly used to treat delayed
a. Three point sleep phase sleep disorder?
b. Four point a. Chronopharmacotherapy
c. Two point b. Luminotherapy
d. Five point c. Melatonin
d. Chronotherapy
49. The main functions of the skin include:
a. Support, nourishment and sensation 57. Which pain medication is an opioid agonist?
b. Protection, sensory perception and temperature regulation a. Carbamepine
c. Fluid transport, sensory perception and aging regulation b. Butorphanol
d. Support, protection and communication c. Fentanyl
d. Buprenorphine
50. Which type of wound closes by primary intention?
a. Second degree burn [Link] causes which effect?
b. Pressure ulcer a. Vasodilation
b. Paresthesia d. Urethra
c. Vasoconstriction
d. Vasocompression 66. In a healthy adult, what’s the normal range of bladder
capacity?
59. Massage promotes increased circulation and softening of a. 50 to 100 mL
connective tissues. It also has which effect? b. 200 to 300 mL
a. Narrows blood vessels c. 500 to 600 mL
b. Eases muscle spasms d. 700 to 900 mL
c. Causes hyperventilation
d. Widens blood vessels 67. The left ureter is slightly longer than the right Ureter
because the:
60. Through metabolism, energy is extracted from which a. Left kidney is higher than the right
nutrients? b. Right kidney is higher than the left
a. Carbohydrates, proteins, fats c. Left kidney performs more functions
b. Carbohydrates, fats, and sodium d. Left Ureter has a three layered wall
c. Fats, adenosine triphosphate and minerals
d. Vitamins, mineral and electrolytes 68. What role does the epiglottis play in swallowing?
a. Opens to allow air to enter
61. Essential nutrients are supplied to the body by: b. Closes to prevent aspiration
a. Vitamin or mineral supplements c. Opens or closes depending on the food type
b. Certain food combinations d. Rotates to aid in swallowing
c. Body functions
d. Food in many different combination 69. An adhesive backed ostomy opening should be how
much larger than the stoma?
62. Which GI hormone stimulates gastric secretion and a. ¼
motility? b. ½
a. Gastric inhibitory peptides c. 1/3
b. Gastrin d. 1/8
c. Secretin
d. Pepsinogen 70. Which GI hormone stimulates gastric secretion and
motility?
63. In which phase of digestion does the stomach secrete the a. Gastrin
digestive juices HCl and pepsin? b. Gastric inhibitory peptides
a. Cephalic c. Secretin
b. Gastric d. Cholecystokinin
c. Intestinal
d. Mastication 71. A nurse is considering working in a hospice setting. The
nurse should understand that the primary function of the
64. A patient complains of lower abdominal pressure and nurse in a hospice setting is which of the following?
you note a firm mass extending above the symphysis pubis. a. Performing ongoing assessments
You suspect: b. Acting as a case manager
a. Distended bladder c. Assisting in finding client resources
b. Enlarged kidney d. Providing client care in a home setting
c. UTI
d. Inflamed ovary 72. Which fact should take priority when projecting future
care for the frail elderly, people over age 85?
65. Although the male and female urinary systems function a. Ninety-five percent will live in their own homes.
in the same way, there’s difference in the length of the: b. They want to feel part of the community.
a. Bladder neck c. They are the fastest-growing population.
b. Ureter d. They want to feel productive.
c. Epididymis
73. Which statement regarding the women's movement is c. "I will share in any surplus money in the HMO at
most accurate? the end of the year."
a. It has been instrumental in changing health care practices. d. "I will pay a set fee for services."
b. It has directed research examining women equally to men
in health issues. 80. What is most important for the nurse to keep in mind
c. It has decreased the emphasis on psychosocial aspects of when deciding on a home care referral for a 68-year-old
women's health. client recovering from a stroke who requires a wheelchair at
d. It has inc. the focus on reproductive aspects of health. home?
a. The client must meet specific Medicare criteria for home
74. As demographic changes take place in North America, care.
what are agencies doing to try to meet the challenges of b. A brief written report will be required for the home care
these changes? agency.
a. They are implementing managed care programs. c. The nurse can write a nursing order for the home care.
b. Increased access to health care is a priority for the d. Medicare pays for all home care services.
homeless and poor.
c. They have a greater emphasis on the childcare needs of 81. What is the most appropriate nursing diagnosis for a
their employees. client who walks with crutches, has several animals, and has
d. Agencies are employing bilingual nurses. a second-floor bedroom?
a. Knowledge deficit c. Risk for infection
75. Which medical condition would best be suited to use of a b. Risk for injury d. Impaired home-maintenance mngt
nursing critical pathway?
a. Foreign object in ear 82. When evaluating the operational definition of
b. Fever of unknown origin collaboration, the nurse should focus primarily on which
c. Hip replacement surgery statement?
d. Viral infection acquired in a foreign country a. Providers work together in the provision of care.
b. All providers should be present when discussions take
76. What type of unit would the nurse be working on if the place.
unit were self-contained, with multi-skilled workers? c. The physician is usually the manager of client care.
a. Case-managed unit d. A nurse practitioner provides this type of care.
b. Differentiated-practice unit
c. Functional-method unit 83. A nurse who is planning a program on lifestyle and
d. Patient-focused unit behavior change should include which topic in the program?
a. Alcohol and drug abuse
77. Which statement best describes the federal Medicaid b. Health risk appraisal
program? c. Toxic and nuclear waste emissions
a. It is public assistance paid for out of general taxes. d. Smoking cessation
b. It is divided into two parts.
c. It now includes "catastrophic care" coverage. 84. Which intervention would be least effective when
d. The client pays a deductible for services rendered. assisting a client in making behavior changes that would
reduce his health risk factors?
78. Which would be an example of tertiary health care? a. Ask the client to follow a plan you wrote for him.
a. Promoting worker safety b. Have the client identify two or three goals for change.
b. Care of the dying c. Help the client to develop a plan for change.
c. Immunization d. Allow the client to set a reasonable time frame for change.
d. Acute care
85. A client has failed to follow the plan that was developed
79. A client belongs to a health maintenance organization. for health promotion. What would be the most effective
Which statement by the client indicates a misunderstanding response by the nurse?
about this system? a. Inform the physician of the client's lack of motivation.
a. "I will have more than one health care provider." b. Discard the idea that the client must change.
b. "I will pay for each individual part of my care." c. Discharge the client due to noncompliance.
d. Start over at the beginning of the process. 91. A client states that her cancer is the result of punishment
from God for her sins. This client will most likely be:
86. The two major goals of Healthy People 2010 reflect the a. A passive recipient of health care
nation's changing demographics. These goals include which b. Rigidly compliant to all aspects of the treatment regimen
of the following? c. Interested in alternative therapies for her cancer
a. Increase community health centers d. Highly motivated to seek health care
b. Implement programs that modify the environment and
behaviors 92. Which of the following descriptions best fits the
c. Increase quality and years of healthy life and eliminate eudaemonistic model of health?
health disparities a. Health is defined in terms of the individual's ability to
d. Increase illness-prevention strategies in the general fulfill societal roles.
population b. Health is a process of adaptation.
c. Health is identified by the absence of disease or injury.
87. According to Prochaska, Norcross, and DiClemente d. Health is the realization of a person's potential.
(1994), which stage in health behavior change would include
the client's acknowledging a problem? 93. An otherwise healthy 59-year-old client is hospitalized
a. Precontemplation stage with multiple fractures of the lower extremities after an
b. Contemplation stage automobile accident. Where would this client be placed on
c. Preparation stage Dunn's high-level wellness grid?
d. Action stage a. Protected poor health in a favorable environment
b. Poor health in an unfavorable environment
88. The majority of individuals who relapse during a health c. Emergent high-level wellness in an unfavorable
behavior change return to which stage for reevaluation? environment
a. Precontemplation stage d. High-level wellness in a favorable environment
b. Contemplation stage
c. Preparation stage 94. A 63-year-old client with diabetes depends on her
d. Action stage husband and daughter to bring her to the clinic. She refuses
to give herself insulin, and complains to the nurse, "I don't
89. A client is noncompliant about adhering to dietary understand why my blood sugar is always so high." What
restrictions designed to manage his diabetes. Which should the nurse consider when providing diabetic teaching
statement by the nurse would be most likely to motivate the for this client?
client to comply with treatment? a. The client is probably externally controlled, and may need
a. "I don't understand why you don't follow your diet." help to assume responsibility for her own health.
b. "I understand that following this diet is hard for you. Can b. The client is probably externally controlled, and therefore
you share with me why this has been difficult?" will be able to take responsibility for her own health.
c. "Not following your diet may shorten your life." c. The client's husband will need to take control of her health
d. "Let me review your diet with you again, because you care.
don't seem to understand it." d. The client is probably internally controlled, and therefore
will be able to take the initiative for her own health care.
90. Based on the concept that health is a highly individual
perception, which of the following individuals would 95. A client at a cardiology clinic is having difficulty
consider himself/herself healthy? following his low-fat diet. Which of the following actions by
a. A senior citizen who has high blood pressure and refuses the nurse would be least likely to foster compliance from
to leave home this client?
b. An honors college student who has multiple sclerosis and a. Using teaching aids, such as pamphlets
uses a wheelchair for mobility b. Motivating the client by telling him that he'll be dropped
c. A college student who is seen in the student clinic for from the clinic if he doesn't follow the diet
minor complaints at least once a week c. Demonstrating caring by asking about the client's home
d. A homeless person who walks several miles each day situation.
looking for food d. Establishing a therapeutic relationship by using her
knowledge and skills.
 ANSWERS AND RATIONALES:
96. A 76-year-old client with diabetes has had an above-the-
knee amputation and is almost ready to return home from the 1. A. the way you practice your profession of nursing should
hospital. The client lives alone. What is the best way to help be guided by two sets of care documents: standards of
the client adjust to the change in his health status? nursing care and nurse practice acts
a. Talk with the client about self-care measures and adaptive 2. D. The nurse practice acts are administered by your
equipment for home use individual state
b. Advise the client he should not live alone, because of his 3. C. The nurse practitioner may obtain histories, conduct
disability physical examinations, order laboratory and diagnostic tests,
c. Tell the client's family he should be in a nursing home interpret results, diagnose disorders and treat patients
d. Tell the client he will be fine at home 4. A. Nurses should start by reading research articles and
judging whether or not they’re applicable to their practice.
97. A 45-year-old executive insists on conducting business Research findings aren’t useful if they aren’t incorporated
in his hospital room after suffering an acute myocardial into actual practice
infarction. What other behavior might the nurse expect from 5. B. Although evidence based practices may validate or
this client? dispute traditional practice, the purpose is to improve patient
a. The client may become dependent on the hospital staff outcomes.
and have difficulty returning home. 6. B. Health promotion involves teaching good health
b. The client will not require extensive information practices as well as helping people correct their poor health
concerning his health care. practices. Helping a patient stop smoking helps him to
c. The client will not ask many questions. correct a poor health practice
d. The client will have difficulty giving up role obligations. 7. C. the effect of illness on a family unit depends on which
family member is affected, the seriousness and duration of
[Link] illness is characterized by: the illness, and the family’s social and cultural customs
a. Severe symptoms of relatively short duration 8. D. The prodromal period is described as producing
b. Physical limitations & discomfort that gradually increase generally mild, nonspecific signs and symptoms.
over time 9. C. the Code of Ethics for Nurses provides information
c. Occasional remissions that’s necessary for the practicing nurse to use her
d. An extended duration professional skills in providing the most effective holistic
care possible.
99. The nurse is assessing a new client for possible 10. B. Unintentional tort include negligence and malpractice.
impairment of verbal communication. What components Intentional torts include invasion of privacy, fraud, assault
need to be in the assessment? and battery. False imprisonment and defamation of character
a. Educational background and socioeconomic status 11. A. The entire record is a legal document that’s
b. Level of education and past personal experiences admissible in court
c. Hearing, vision, and cognitive functioning 12. B. Take care of the biographic data first; otherwise, you
d. Ability to read and write might get involved in the patient history and forget to ask
basic questions
100. A client asks about a procedure with which the nurse is 13. A. Expected outcomes are realistic; measureable goals
unfamiliar. What is the best nursing response? and their target dates
a. "I don't know much about that procedure, but I will find 14. C. A nursing health history focuses on responses,
out and bring you information about it." whereas a medical health history focuses on diagnosis and
b. "I don't have time to explain that now, but I'll get back to treatment
you later." 15. C. The patient should be your primary source of
c. "It is your doctor's responsibility to explain that procedure assessment information. However, if the patient is sedated,
to you." confused, hostile angry, dyspneic or in pain, you may have
d. "The technicians in special care will explain the procedure to rely initially on family members or close friends to supply
to you when you go for the test." information.
16. C. During the pre-interaction phase, you can review the
patient data that you might already have, such as the medical
or surgical history
17. A. Role playing is an excellent way to communicate with reduce the risk of hypoxemia, avoid suctioning for longer
a very young child than 10 seconds and apply it intermittently as you withdraw
18. D. Nonverbal behaviors, such as nodding and making the catheter
momentary eye contact, provide encouragement without 38. A. An incentive spirometer helps achieve maximal
indicating agreement or disagreement ventilation by inducing the patient to take a deep breath and
19. B. The medical record is the main source of information hold it
and communication among nurses, doctors, physical 39. C. a fenestrated tube permits speech through the upper
therapists, social workers and other caregivers airway when you cap the external opening and deflate the
20. C. Because of how they’re phrased. Leading questions cuff
may prompt the patient to give the answer you’re looking for 40. B. postural drainage uses gravity to promote drainage of
21. A. take care of the biographic data first; otherwise, you secretions from the lungs and bronchi into the trachea
might get involved in the patient history and forget to ask 41. A. Petrissage involves using alternating kneading and
basic questions stroking maneuvers on the patient’s back and upper arms
22. C. Silence allows the patient to collect his thoughts and 42. D. It’s best to wash the female genital area from the front
continue to answer your questions to back to avoid contaminated the urethral orifice with fecal
23. A. Data from the patient’s own words are subjective material from the anal area
24. C. A heart rate of 120 to 140 beats per minute is 43. B. the side lying position with the head of the bed
considered normal lowered will help water and debris drain from the patient’s
25. C. Temperature normally fluctuates with rest and mouth and prevent aspiration
activity. Lowest readings typically occur between 4 to 5 am, 44. C. The eye should be cleaned from the inner canthus to
the highest reading between 4 to 8 pm the outer canthus
26. A. stertor is snoring sound that results from secretions in 45. D. Passive ROM exercises are performed to test muscle
the trachea and large bronchi tone and of the patient can’t do active ROM exercises
27. D. axillary temperature, the least accurate reading is 46. C. Adduction is the ability to move a limb toward the
usually 1 degree to 2 degrees lower. midline
28. B. Handwashing with soap and water or an alcohol based 47. A. in Fowler’s position the head of the bed is elevated to
hand sanitizer is the most effective infection control method 45 degrees and the bed section under the patient’s knees is
29. D. unlike other bacteria, chlamydiae depends on host also raised to flex the knees slightly
cells for replication 48. B. Teach the four point gait to the patient who can bear
30. A. vector borne transmission occurs when an weight on both legs
intermediate carrier (vector) such as flea or mosquito 49. B. the skin’s main functions involve protection from
transfers an organism injury, noxious chemicals and bacterial invasion; sensory
31. B. A laboratory verified infection that causes no signs perception of touch, temperature and pain and regulation of
and symptoms is called subclinical, silent or asymptomatic body heat
infection 50. D. a surgical incision is an example of a wound that
32. A. before administering tablets or capsules by the oral closes by primary intention, in which there’s no deep tissue
route, assess the patient’s ability to swallow to prevent loss and the wound edges are well approximated
aspiration 51. A. red tissue indicates healthy granulation tissue
33. C. when instilling eyedrops, ask your patient to look up 52. C. suspending the heels using a pillow under the calves
and away. Doping so moves the cornea away from the lower is the best way to protect heels from pressure ulceration
lid and minimizes the risk of touching the cornea with the 53. B. During REM sleep, many muscles are effectively
dropper paralyzed so the sleeper won’t act out dreams. Eye
34. A. for a child youger than 2, select a #12 French rectal movements are rapid
tube 54. C. the basal forebrain controls NREM sleep. The pons
35. A. An ID injection allows of a small amount of liquid and midbrain control REM sleep
drug into the outer layers of a patient’s skin 55. B. Short acting sedative hypnotics are used to treat
36. C. A Z tract injection is a method of displacing the circadian rhythm sleep disorders
tissues before you insert the needle for an IM injection. 56. D. Chronotherapy is most commonly used to treat
Afterward, restoring the tissues to their normal positions delayed sleep phase sleep disorder.
traps the drug inside the muscle. 57. C. Fentanyl is an opioid agonist; all the other
37. C. oxygenate the patient before and after suctioning to medications are mixed opioid agonist antagonists
58. A. thermotherapy causes vasodilation, which enhances services provided. The other answers represent other types
blood flow to the affected area of group plans.
59. B. Massage decreases muscle tension, thereby easing 76. A. The client must meet specific Medicare criteria for
muscle spasms home care. Clients must meet specific criteria to have
60. A. energy is produced through the metabolism of Medicare or other third-party payers reimburse for home
carbohydrates, proteins and fats care services. A detailed report will be required, along with a
61. D. essential nutrients are supplied by the many specific written order by the physician
combinations of food consumed 77. B. Risk for injury. This client has a safety risk because
62. B. Gastrin is produced in the pyloric antrum and of the crutches, animals, and stairs. The other diagnoses may
duodenal end mucosa and stimulates gastric secretion and apply, but are not most appropriate
motility 78. A. Providers work together in the provision of care.
63. A. by the time the food is traveling toward the stomach, Collaboration means a collegial working relationship with
the cephalic phase-during which the stomach secretes other health care providers. All providers need not be
digestive juices- has begun. present when discussions take place,but must be consulted
64. A. the bladder is usually nonpalpable unless it’s someway. A physician is not the only one who can be the
distended. The feeling of pressure is usually relieved with manager of client care, nor is a nurse practitioner the only
urination one providing care.
65. D. because a man’s urethra passes through the erectile 79. D. Smoking cessation. Smoking cessation is a
tissue of the penis, its about 6 inches longer than a woman’s lifestyle/behavior change. Alcohol and drug abuse programs
urethra are classified as information dissemination. Health risk
66. C. in a healthy adult, bladder capacity ranges from 500 appraisal is a wellness program. Toxic and nuclear waste
to 600 mL emissions are environmental programs problems.
67. A. the left kidney is slighter higher than the right kidney. 80. A. Ask the client to follow a plan you wrote for him. In
Therefore, the left Ureter needs to be longer to reach the planning these changes, the client should develop a plan,
bladder. two or three goals, and a time frame for implementing the
68. B. the epiglottis, a thin flap of tissue over the pharynx, changes. Writing a plan for the client would be least
closes during swallowing to prevent aspiration effective, as it does not allow the client a say in the plan.
69. D. in general, the opening should be 1/8 larger than the Client decision making is a critical element in success.
stoma itself. An opening that fits too tightly can injure the 81. B. Discard the idea that the client must change.
stoma. If the opening is too large, skin surrounding the Understanding that the client may not change is a key for the
stoma may come in contact with feces, causing skin nurse. Forced changed will not work. Assuming lack of
breakdown. motivation, noncompliance, and starting over may be
70. A. gastrin is produced in the pyloric antrum and detrimental. The client needs to decide with the nurse if the
duodenal end mucosa and stimulates gastric secretion and change is possible, and reevaluate the plan.
motility. 82. C. Increase quality and years of healthy life and
71. B. Hospice nurses serve primarily as case managers, eliminate health disparities. The changing demographics
supervising direct care provided by other members of the reflect the aging population and the diversity of the
team. The other choices are some of the functions of the population. These are both reflected in the goals, which
hospice nurse, but are not the primary function. include increasing quality and years of healthy life and
72. D. A patient-focused unit is self-contained, with its own eliminating health disparities. The other answers could be
admitting, pharmacy, lab, and radiology areas. Workers are ways to implement these goals, but are not goals themselves.
crossed-trained, and perform multiple tasks. The other types 83. B, Contemplation stage. The client acknowledges a
of units are not self-contained. problem in the contemplation stage. The client denies a
73. A. Medicaid is a public assistance program of the federal problem in the precontemplation stage, prepares for a change
government that is paid for out of general taxes. The other in the preparation stage, and implements the change in the
answers are specific to Medicare action stage.
74. B. Tertiary health care involves rehabilitation and health 84. B. Contemplation stage. The majority of individuals will
restoration. The others are examples of primary and return to the contemplation stage to think about what they
secondary health care. learned and plan for the next action attempt.
75. D. Members of an HMO choose one primary care 85. B. "I understand that following this diet is hard for you.
provider that directs their care, and they pay a set fee for the Can you share with me why this has been difficult?" Answer
B is correct because it demonstrates caring and may provide her own health. A client who is probably externally
the nurse with an opportunity to address the cause of controlled and therefore will be able to take responsibility
noncompliance. Answer A could be construed as being for her own health is not indicative of someone with an
judgmental, and may make the client feel defensive. Answer external locus of control. The client's husband's taking
C may be true for some diabetics, but this answer may cause control of her health care is not the best option for the client.
some clients to be reluctant to seek further care, or make A client who is probably internally controlled and, therefore,
them feel doomed to failure regardless of their attempts to will be able to take the initiative for her own health care is
follow their treatment regimen. Answer Dassumes that the not indicative of someone with an internal locus of control.
client is incompetent, when they may instead be unwilling or 91. B. Motivating the client by telling him that he'll be
unable to adhere to the diet. dropped from the clinic if he doesn't follow the diet.
86. B. An honors college student who has multiple sclerosis Threatening the client is unlikely to increase the client's
and uses a wheelchair for mobility. An honors college compliance. Using teaching aids, such as pamphlets, is an
student who has multiple sclerosis and uses a wheelchair for appropriate way to increase the client's compliance.
mobility reflects a person who adapts to disability and Demonstrating caring by asking about the client's home
chronic illness, and still functions in a productive manner. A situation and establishing a therapeutic relationship by using
senior citizen who has high blood pressure and refuses to one's knowledge and skills would be an appropriate way to
leave home may indicate an emotional disorder. A college foster compliance and a therapeutic nurse-client relationship
student who is seen in the student clinic for minor 92. A. Talk with the client about self-care measures and
complaints at least once a week would probably not consider adaptive equipment for home use. The best way to help the
himself/herself to be healthy. A homeless person who walks client adjust is to talk with the client about self-care
several miles each day looking for food may be physically measures and adaptive equipment for home use. With
healthy, but his/her emotional and physical well-being are appropriate safety precautions and assistive devices,
questionable. amputees may function independently. Telling the client's
87. A. A passive recipient of health care. Individuals with an family that he should be in a nursing home does not support
external locus of control are less likely to exercise initiative the client's right to autonomy and self-determination. False
about their own health care. Rigidly compliant to all aspects reassurance does not help the client deal with problems he
of the treatment regimen would be more consistent with a may encounter at home.
client with an internal locus of control. Clients with an 93. D. The client will have difficulty giving up role
external locus of control tend not to seek health treatment, obligations. The nurse may expect the client will have
regardless of the type. Highly motivated to seek health care difficulty giving up role obligations. The client has shown a
would not be characteristic of an individual with an external need to retain control and independence, and is not likely to
locus of control. become dependent on the hospital staff. The client will
88. D. Health is the realization of a person's potential. Health probably request extensive information regarding his status.
is a process of adaptation. Health defined in terms of the The client will also be likely to ask many questions and to
individual's ability to fulfill societal roles take an active role in his own care.
89. A. Protected poor health in a favorable environment. 94. A. Severe symptoms of relatively short duration. Acute
This client would be placed in protected poor health in a illness is characterized by severe symptoms of relatively
favorable environment. Poor health in an unfavorable short duration. Physical limitations and discomfort that
environment does not fit this classification. This describes a gradually increase over time are more characteristic of
person in poor health who has no resources or access to care, chronic illnesses, which often have a slow onset. Occasional
such as a child in a famine situation. Emergent high-level remissions are characteristic of chronic illnesses, which
wellness in an unfavorable environment does not fit this often have periods of remission. An extended duration is
classification. This describes a person who has the characteristic of a chronic illness.
knowledge to implement a healthy lifestyle, but is hampered 95. C. Impairments to communication include language
by other factors. High-level wellness in a favorable deficits, sensory deficits, cognitive impairments, structural
environment describes a person who implements healthy deficits, and paralysis. Ability to read and write would not
behaviors and has the resources to support this lifestyle. affect ability to communicate verbally. Level of education,
90. B. The client is probably externally controlled, and may personal experience, and socioeconomic status may affect
need help to assume responsibility for her own health. The the nurse's choice of words to use when communicating, but
nurse should consider that the client is probably externally are not part of the assessment data for impaired
controlled and may need help to assume responsibility for communication.
96. A. An important component of a helping relationship is 6. During the planning phase of the nursing process, which
honesty. If the nurse does not know something, that should of the following is the outcome?
be acknowledged. The client however, does have the right to A. Nursing history
information, and the nurse should strive to provide it. B. Nursing notes
“Passing the buck” to others is not appropriate to fostering a C. Nursing care plan
helping relationship between the nurse and client. D. Nursing diagnosis

Fundamentals in Nursing Set A 7. What is an example of a subjective data?

1. Jake is complaining of shortness of breath. The nurse A. Heart rate of 68 beats per minute
assesses his respiratory rate to be 30 breaths per minute and B. Yellowish sputum
documents that Jake is tachypneic. The nurse understands C. Client verbalized, “I feel pain when urinating.”
that tachypnea means: D. Noisy breathing
A. Pulse rate greater than 100 beats per minute
B. Blood pressure of 140/90 8. Which expected outcome is correctly written?
C. Respiratory rate greater than 20 breaths per minute A. “The patient will feel less nauseated in 24 hours.”
D. Frequent bowel sounds B. “The patient will eat the right amount of food daily.”
C. “The patient will identify all the high-salt food from a
2. The nurse listens to Mrs. Sullen’s lungs and notes a prepared list by discharge.”
hissing sound or musical sound. The nurse documents this D. “The patient will have enough sleep.”
as:
A. Wheezes 9. Which of the following behaviors by Nurse Jane Robles
B. Rhonchi demonstrates that she understands well th elements of
C. Gurgles effecting charting?
D. Vesicular A. She writes in the chart using a no. 2 pencil.
B. She noted: appetite is good this afternoon.
3. The nurse in charge measures a patient’s temperature at C. She signs on the medication sheet after adm the med.
101 degrees F. What is the equivalent centigrade D. She signs her charting as follow: J.R
temperature?
A. 36.3 degrees C 10. What is the disadvantage of computerized
B. 37.95 degrees C documentation of the nursing process?
C. 40.03 degrees C A. Accuracy
D. 38.01 degrees C B. Legibility
C. Concern for privacy
4. Which approach to problem solving tests any number of D. Rapid communication
solutions until one is found that works for that particular
problem? 11. The theorist who believes that adaptation and
A. Intuition manipulation of stressors are related to foster change is:
B. Routine A. Dorothea Orem
C. Scientific method B. Sister Callista Roy
D. Trial and error C. Imogene King
D. Virginia Henderson
5. What is the order of the nursing process?
A. Assessing, diagnosing, implementing, evaluating, 12. Formulating a nursing diagnosis is a joint function of:
planning A. Patient and relatives
B. Diagnosing, assessing, planning, implementing, B. Nurse and patient
evaluat1ing C. Doctor and family
C. Assessing, diagnosing, planning, implementing, D. Nurse and doctor
evaluating
D. Planning, evaluating, diagnosing, assessing, 13. Mrs. Caperlac has been diagnosed to have hypertension
implementing since 10 years ago. Since then, she had maintained low
sodium, low fat diet, to control her blood pressure. This
practice is viewed as: thyroidectomy. After providing the medication teaching. The
A. Cultural belief nurse asks the patient to repeat the instructions. The nurse is
B. Personal belief performing which professional role?
C. Health belief A. Manager
D. Superstitious belief B. Caregiver
C. Patient advocate
14. Becky is on NPO since midnight as preparation for D. Educator
blood test. Adreno-cortical response is activated. Which of
the following is an expected response? 20. Which data would be of greatest concern to the nurse
A. Low blood pressure when completing the nursing assessment of a 68-year-old
B. Warm, dry skin woman hospitalized due to Pneumonia?
C. Decreased serum sodium levels A. Oriented to date, time and place
D. Decreased urine output B. Clear breath sounds
C. Capillary refill greater than 3 seconds & buccal cyanosis
15. What nursing action is appropriate when obtaining a D. Hemoglobin of 13 g/dl
sterile urine specimen from an indwelling catheter to prevent
infection? 21. During a change-of-shift report, it would be important
A. Use sterile gloves when obtaining urine. for the nurse relinquishing responsibility for care of the
B. Open the drainage bag and pour out the urine. patient to communicate. Which of the following facts to the
C. Disconnect the catheter from the tubing and get urine. nurse assuming responsibility for care of the patient?
D. Aspirate urine from the tubing port using a sterile A. That the patient verbalized, “My headache is gone.”
syringe. B. That the patient’s barium enema performed 3 days ago
was negative
16. A client is receiving 115 ml/hr of continuous IVF. The C. Patient’s NGT was removed 2 hours ago
nurse notices that the venipuncture site is red and swollen. D. Patient’s family came for a visit this morning.
Which of the following interventions would the nurse
perform first? 22. Which statement is the most appropriate goal for a
A. Stop the infusion nursing diagnosis of diarrhea?
B. Call the attending physician A.“The patient will experience decreased frequency of
C. Slow that infusion to 20 ml/hr bowel elimination.”
D. Place a clod towel on the site B.“The patient will take anti-diarrheal medication.”
C. “The patient will give a stool specimen for laboratory
17. The nurse enters the room to give a prescribed examinations.”
medication but the patient is inside the bathroom. What D. “The patient will save urine for inspection by the nurse.
should the nurse do?
A. Leave the medication at the bedside and leave the room. 23. Which of the following is the most important purpose of
B. After few minutes, return to that patient’s room and do planning care with this patient?
not leave until the patient takes the medication. A. Development of a standardized NCP.
C. Instruct the patient to take the medication and leave it at B. Expansion of the current taxonomy of nursing diagnosis
the bedside. C. Making of individualized patient care
D. Wait for the patient to return to bed and just leave the D. Incorporation of both nursing & medical dx in pt care
medication at the bedside.
24. Using Maslow’s hierarchy of basic human needs, which
18. Which of the following is inappropriate nursing action of the following nursing diagnoses has the highest priority?
when administering NGT feeding? A. Ineffective breathing pattern r/t pain, aeb sob.
A. Place the feeding 20” above the pint if insertion of NGT. B. Anxiety related to impending surgery, aeb insomnia.
B. Introduce the feeding slowly. C. Risk of injury related to autoimmune dysfunction
C. Instill 60ml of water into the NGT after feeding. D. Impaired verbal communication r/t tracheostomy, aeb
D. Assist the patient in fowler’s position. inability to speak.

19. A female patient is being discharged after 25. When performing an abdominal examination, the patient
should be in a supine position with the head of the bed at purpose.
what position? 11. (B) Sister Callista Roy. Sister Roy’s theory is called the
A. 30 degrees adaptation theory and she viewed each person as a unified
B. 90 degrees biophysical system in constant interaction with a changing
C. 45 degrees environment. Orem’s theory is called self-care deficit theory
D. 0 degree and is based on the belief that individual has a need for self-
care actions. King’s theory is the Goal attainment theory and
Answers and Rationales described nursing as a helping profession that assists
1. (C) Respiratory rate greater than 20 breaths per minute. individuals and groups in society to attain, maintain, and
A respiratory rate of greater than 20 breaths per minute restore health. Henderson introduced the nature of nursing
is tachypnea. A blood pressure of 140/90 is considered model and identified the 14 basic needs.
hypertension. Pulse greater than 100 beats per minute is 12. (B) Nurse and patient. Although diagnosing is basically
tachycardia. Frequent bowel sounds refer to hyper-active the nurse’s responsibility, input from the patient is essential
bowel sounds. to formulate the correct nursing diagnosis.
2. (A) Wheezes. Wheezes are indicated by continuous, 13. (C) Health belief. Health belief of an individual
lengthy, musical; heard during inspiration or expiration. influences his/her preventive health behavior.
Rhonchi are usually coarse breath sounds. Gurgles are loud 14. (D) Decreased urine output. Adreno-cortical response
gurgling, bubbling sound. Vesicular breath sounds are low involves release of aldosterone that leads to retention of
pitch, soft intensity on expiration. sodium and water. This results to decreased urine output.
3. (B) 37.95 degrees C. To convert °F to °C use this formula, 15. (D) Aspirate urine from the tubing port using a sterile
( °F – 32 ) (0.55). While when converting °C to °F use this syringe. The nurse should aspirate the urine from the port
formula, ( °C x 1.8) + 32. Note that 0.55 is 5/9 and 1.8 is using a sterile syringe to obtain a urine specimen. Opening a
9/5. closed drainage system increase the risk of urinary tract
4. (D) Trial and error. The trial and error method of problem infection.
solving isn’t systematic (as in the scientific method of 16. (A) Stop the infusion. The sign and symptoms indicate
problem solving) routine, or based on inner prompting (as in extravasation so the IVF should be stopped immediately and
the intuitive method of problem solving). put warm not cold towel on the affected site.
5. (C) Assessing, diagnosing, planning, implementing, 17. (B) After few minutes, return to that patient’s room and
evaluating. The correct order of the nursing process is do not leave until the patient takes the medication. This is to
assessing, diagnosing, planning, implementing, evaluating. verify or to make sure that the medication was taken by the
6. (C) Nursing care plan. The outcome, or the product of the patient as directed.
planning phase of the nursing process is a Nursing care plan. 18. (A) Place the feeding 20 inches above the pint if
7. (C) Client verbalized, “I feel pain when urinating.”. insertion of NGT. The height of the feeding is above 12
Subjective data are those that can be described only by the inches above the point of insertion, bot 20 inches. If the
person experiencing it. Therefore, only the patient can height of feeding is too high, this results to very rapid
describe or verify whether he is experiencing pain or not. introduction of feeding. This may trigger nausea and
8. (C) “The patient will identify all the high-salt food from a vomiting.
prepared list by discharge.”. Expected outcomes are specific, 19. (D) Educator. When teaching a patient about
measurable, realistic statements of goal attainment. The medications before discharge, the nurse is acting as an
phrases “right amount”, “less nauseated” and “enough sleep” educator. A caregiver provides direct care to the patient. The
are vague and not measurable. nurse acts as s patient advocate when making the patient’s
9. (C) She signs on the medication sheet after administering wishes known to the doctor.
the medication.A nurse should record a nursing intervention 20. (C) Capillary refill greater than 3 seconds and buccal
(ex. Giving medications) after performing the nursing cyanosis. Capillary refill greater than 3 seconds and buccal
intervention (not before). Recording should also be done cyanosis indicate decreased oxygen to the tissues which
using a pen, be complete, and signed with the nurse’s full requires immediate attention/intervention. Oriented to date,
name and title. time and place, hemoglobin of 13 g/dl are normal data.
10. (C) Concern for privacy. A patient’s privacy may be 21. (C) Patient’s NGT was removed 2 hours ago. The
violated if security measures aren’t used properly or if change-of-shift report should indicate significant recent
policies and procedures aren’t in place that determines what changes in the patient’s condition that the nurse assuming
type of information can be retrieved, by whom, and for what responsibility for care of the patient will need to monitor.
The other options are not critical enough to include in the
report. 5. What is the characteristic of the nursing process?
22. (A) “The patient will experience decreased frequency of A. stagnant
bowel elimination.” The goal is the opposite, healthy B. inflexible
response of the problem statement of the nursing diagnosis. C. asystematic
In this situation, the problem statement is diarrhea. D. goal-oriented
23. (C) Making of individualized patient care. To be
effective, the nursing care plan developed in the planning 6. A skin lesion which is fluid-filled, less than 1 cm in size is
phase of the nursing process must reflect the individualized called:
needs of the patient. A. papule
24. (A) Ineffective breathing pattern related to pain, as B. vesicle
evidenced by shortness of breath.. Physiologic needs (ex. C. bulla
Oxygen, fluids, nutrition) must be met before lower needs D. macule
(such as safety and security, love and belongingness, self-
esteem and self-actualization) can be met. Therefore, 7. During application of medication into the ear, which of
physiologic needs have the highest priority. the following is inappropriate nursing action?
25. (D) 0 degree. The patient should be positioned with the A. In an adult, pull the pinna upward.
head of the bed completely flattened to perform an B. Instill the med directly into the tympanic membrane.
abdominal examination. If the head of the bed is elevated, C. Warm the medication at room or body temperature.
the abdominal muscles and organs can be bunched up, D. Press the tragus of the ear a few times to assist flow of
altering the findings medication into the ear canal.

Fundamentals in Nursing Set B 8. Which of the following is appropriate nursing intervention

for a client who is grieving over the death of her child?
1. A patient is wearing a soft wrist-safety device. Which of A. Tell her not to cry and it will be better.
the following nursing assessment is considered abnormal? B. Provide opportunity to the client to tell their story.
A. Palpable radial pulse C. Encourage her to accept or to replace the lost person.
B. Palpable ulnar pulse D. Discourage the client in expressing her emotions.
C. Capillary refill within 3 seconds
D. Bluish fingernails, cool and pale fingers 9. It is the gradual decrease of the body’s temperature after
death.
2. Pia’s serum sodium level is 150 mEq/L. Which of the A. livor mortis
following food items does the nurse instruct Pia to avoid? B. rigor mortis
A. broccoli C. algor mortis
B. sardines D. none of the above
C. cabbage
D. tomatoes 10. When performing an admission assessment on a newly
admitted patient, the nurse percusses resonance. The nurse
3. Jason, 3 years old vomited. His mom stated, “He vomited knows that resonance heard on percussion is most
6 ounces of his formula this morning.” This statement is an commonly heard over which organ?
example of: A. thigh
A. objective data from a secondary source B. liver
B. objective data from a primary source C. intestine
C. subjective data from a primary source D. lung
D. subjective data from a secondary source
11. The nurse is aware that Bell’s palsy affects which cranial
4. Which of the following is a nursing diagnosis? nerve?
A. Hypethermia A. 2nd CN (Optic)
B. Diabetes Mellitus B. 3rd CN (Occulomotor)
C. Angina C. 4th CN (Trochlear)
D. Chronic Renal Failure D. 7th CN (Facial)
 C. 3-day diet recall
12. Prolonged deficiency of Vitamin B9 leads to: D. eating style and habits
A. scurvy
B. pellagra 19. Van Fajardo is a 55 year old who was admitted to the
C. megaloblastic anemia hospital with newly diagnosed hepatitis. The nurse is doing a
D. pernicious anemia patient teaching with Mr. Fajardo. What kind of role does
the nurse assume?
13. Nurse Cherry is teaching a 72 year old patient about a A. talker
newly prescribed medication. What could cause a geriatric B. teacher
patient to have difficulty retaining knowledge about the C. thinker
newly prescribed medication? D. doer
A. Absence of family support
B. Decreased sensory functions 20. When providing a continuous enteral feeding, which of
C. Patient has no interest on learning the following action is essential for the nurse to do?
D. Decreased plasma drug levels A. Place the client on the left side of the bed.
B. Attach the feeding bag to the current tubing.
14. When assessing a patient’s level of consciousness, which C. Elevate the head of the bed.
type of nursing intervention is the nurse performing? D. Cold the formula before administering it.
A. Independent
B. Dependent 21. Kussmaul’s breathing is;
C. Collaborative A. Shallow breaths interrupted by apnea.
D. Professional B. Prolonged gasping inspiration followed by a very short,
usually inefficient expiration.
15. Claire is admitted with a diagnosis of chronic shoulder C. Marked rhythmic waxing and waning of respirations from
pain. By definition, the nurse understands that the patient very deep to very shallow breathing and temporary apnea.
has had pain for more than: D. Increased rate and depth of respiration.
A. 3 months
B. 6 months 22. Presty has terminal cancer and she refuses to believe that
C. 9 months loss is happening ans she assumes artificial cheerfulness.
D. 1 year What stage of grieving is she in?
A. depression
16. Which of the following statements regarding the nursing B. bargaining
process is true? C. denial
A. It is useful on outpatient settings. D. acceptance
B. It progresses in separate, unrelated steps.
C. It focuses on the patient, not the nurse. 23. Immunization for healthy babies and preschool children
D. It provides the solution to all patient health problems. is an example of what level of preventive health care?
A. Primary
17. Which of the following is considered significant enough B. Secondary
to require immediate communication to another member of C. Tertiary
the health care team? D. Curative
A. Weight loss of 3 lbs in a 120 lb female patient.
B. Diminished breath sounds in pt w/ previously normal 24. Which is an example of a subjective data?
breath sounds A. Temperature of 38 0C
C. Patient stated, “I feel less nauseated.” B. Vomiting for 3 days
D. Change of heart rate from 70 to 83 beats per minute. C. Productive cough
D. Patient stated, “My arms still hurt.”
18. To assess the adequacy of food intake, which of the
following assessment parameters is best used? 25. The nurse is assessing the endocrine system. Which
A. food preferences organ is part of the endocrine system?
B. regularity of meal times A. Heart
B. Sinus tissue such as a normal lung.
C. Thyroid 11. (D) 7th CN (Facial). Bells’ palsy is the paralysis of the
D. Thymus motor component of the 7th caranial nerve, resulting in
facial sag, inability to close the eyelid or the mouth,
drooling, flat nasolabial fold and loss of taste on the affected
side of the face.
12. (C) megaloblastic anemia. Prolonged Vitamin B9
deficiency will lead to megaloblastic anemia while
pernicious anemia results in deficiency in Vitamin B12.
Prolonged deficiency of Vitamin C leads to scurvy and
Pellagra results in deficiency in Vitamin B3.
Answers and Rationales 13. (B) Decreased sensory functions. Decreased in sensory
1. (D) Bluish fingernails, cool and pale fingers. A safety functions could cause a geriatric patient to have difficulty
device on the wrist may impair blood circulation. Therefore, retaining knowledge about the newly prescribed
the nurse should assess the patient for signs of impaired medications. Absence of family support and no interest on
circulation such as bluish fingernails, cool and pale fingers. learning may affect compliance, not knowledge retention.
Palpable radial and ulnar pulses, capillary refill within 3 Decreased plasma levels do not alter patient’s knowledge
seconds are all normal findings. about the drug.
2. (B) sardines. The normal serum sodium level is 135 to 14. (A) Independent. Independent nursing interventions
145 mEq/L, the client is having hypernatremia. Pia should involve actions that nurses initiate based on their own
avoid food high in sodium like processed food. Broccoli, knowledge and skills without the direction or supervision of
cabbage and tomatoes are good source of Vitamin C. another member of the health care team.
3.(A) objective data from a secondary source. Jason is the 15. (B) 6 months. Chronic pain s usually defined as pain
primary source; his mother is a secondary source. The data lasting longer than 6 months.
is objective because it can be perceived by the senses, 16. (C) It focuses on the patient, not the nurse. The nursing
verified by another person observing the same patient, and process is patient-centered, not nurse-centered. It can be use
tested against accepted standards or norms. in any setting, and the steps are related. The nursing process
4. (A) Hypethermia. Hyperthermia is a NANDA-approved can’t solve all patient health problems.
nursing diagnosis. Diabetes Mellitus, Angina and Chronic 17. (B) Diminished breath sounds in patient with previously
Renal Failure are medical diagnoses. normal breath sounds. Diminished breath sound is a life
5. (D) goal-oriented. The nursing process is goal-oriented. It threatening problem therefore it is highly priority because
is also systematic, patient-centered, and dynamic. they pose the greatest threat to the patient’s well-being.
6. (B) vesicle. Vesicle is a circumscribed circulation 18. (C) 3-day diet recall. 3-day diet recall is an example of
containing serous fluid or blood and less than 1 cm (ex. dietary history. This is used to indicate the adequacy of food
Blister, chicken pox). intake of the client.
7. (B) Instill the medication directly into the tympanic 19. (B) teacher. The nurse will assume the role of a teacher
membrane. During the application of medication it is in this therapeutic relationship. The other roles are
inappropriate to instill the medication directly into the inappropriate in this situation.
tympanic membrane. The right thing to do is instill the 20. (C) Elevate the head of the bed. Elevating the head of the
medication along the lateral wall of the auditory canal. bed during an enteral feeding prevents aspiration. The
8. (B) Provide opportunity to the client to tell their story. patient may be placed on the right side to prevent aspiration.
Providing a grieving person an opportunity to tell their story Enteral feedings are given at room temperature to lessen GI
allows the person to express feelings. This is therapeutic in distress. The enteral tubing should be changed every 24
assisting the client resolve grief. hours to limit microbial growth.
9. (C) algor mortis. Algor mortis is the decrease of the 21. (D) Increased rate and depth of respiration. Kussmaul
body’s temperature after death. Livor mortis is the breathing is also called as hyperventilation. Seen in
discoloration of the skin after death. Rigor mortis is the metabolic acidosis and renal failure. Option A refers to
stiffening of the body that occurs about 2-4 hours after Biot’s breathing. Option B is apneustic breathing and option
death. C is the Cheyne-stokes breathing.
10. (D) lung. Resonance is loud, low-pitched and long 22. (C) denial. The client is in denial stage because she is
duration that’s heard most commonly over an air-filled unready to face the reality that loss is happening and she
assumes artificial cheerfulness.
23. (A) Primary. The primary level focuses on health
promotion. Secondary level focuses on health maintenance.
Tertiary focuses on rehabilitation. There is n Curative level
of preventive health care problems.
24. (D) Patient stated, “My arms still hurt.”. Subjective data
are apparent only to the person affected and can or verified
only by that person.
25. (C) Thyroid. The thyroid is part of the endocrine system.
Heart, sinus and thymus are not.