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Exam Nurses
Licensure Examination for Nurses
Version: 6.0

[ Total Questions: 150 ]

Question No : 1

When discovering a medication error, the nurse's FIRST action is to?

A. Call the nurse supervisor

B. Call the physician
C. Fill out a medication error reporting form
D. Assess the patient's condition

Answer: D

Question No : 2

While preparing for a kidney biopsy the nurse should position the patient:

A. Prone with a sandbag under the abdomen

B. Lateral opposite to biopsy site
C. Supine in bed with knee flexion
D. Lateral flexed knee-chest

Answer: A

Question No : 3

A patient with a central venous line develops sudden clinical manifestations that include a
decrease in blood pressure, an elevated heart rate, cyanosis, tachypnea, and changes in
mental status. Which of the following is the most likely cause of these symptoms?

A. An air embolism
B. Circulatory overload
C. Venous thrombosis
D. Developing bacteremia

Answer: A

Question No : 4

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Order: 1000 ml of D5W to run for 12 hours. Using a micro drip set calculate the drops per
minute (gtts/min):

A. 20 gtts/min
B. 45 gtts/min
C. 60 gtts/min
D. 83 gtts/min

Answer: D

Question No : 5

A patient voided a urine specimen at 9:00 AM. The specimen should be sent to the
laboratory before:

A. 9:30 AM
B. 10:00 AM
C. 10:30 AM
D. 11:00 AM

Answer: A

Question No : 6

An 84-year-old man has arthritis and is admitted for a severely edematous knee. The
physician orders heat packs every 2 hours and you feel this order may worsen the tissue
congestion. An appropriate nursing action would be:

A. Contact the physician and discuss your concerns about the order
B. To include the order in the nursing care plan and monitor outcome
C. Complete an incident report form and document concerns in the nursing notes
D. Involve the patient by asking what his treatment preference is

Answer: A

Question No : 7

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The minimal amount of urine that a post-operative patient weighing 60 kgs should pass is?

A. 120 ml/hr
B. 90 ml/hr
C. 60 ml/hr
D. 30 ml/hr

Answer: D

Question No : 8

When caring for a patient with impaired mobility that occurred as a result of a stroke (right
sided arm and leg weakness). The nurse would suggest that the patient use which of the
following assistive devices that would provide the best stability for ambulating?

A. Crutches
B. Single straight-legged cane
C. Quad cane
D. Walker

Answer: C

Question No : 9

While assessing a patient, the nurse learns that he has a history of allergic rhinitis, asthma,
and multiple food allergies. The nurse must:

A. Be alert to hypersensitivity response to the prescribed medications

B. Encourages the patient to carry an epinephrine kit in case of an allergic reaction
C. Advise the patient to use aspirin in case of febrile illnesses
D. Admit the patient to a single room with limited exposure to health care personnel

Answer: A

Question No : 10

A patient who has just had a miscarriage at 8 weeks of gestation is admitted to hospital. In

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caring for this patient, the nurse should be alert for signs of:

A. Dehydration
B. Subinvolution
C. Hemorrhage
D. Hypertension

Answer: C

Question No : 11

The nurse should observe for which of the following symptoms in a patient who has just
undergone a total thyroidectomy:

A. Weight gain
B. Depressed reflexes
C. Muscle spasm and twitching
D. Irritable behavior

Answer: C

Question No : 12

A patient is ordered 75mg of pethidine which comes in an ampoule of 100mg/2ml. What

would the nurse do with the remaining pethidine after drawing up the required dose?

A. Lock up the remaining dose in the medication cupboard to use later

B. Ask a fellow staff nurse to witness the disposal of the remaining drug
C. Use the remaining dose within 2 hours for another patient
D. Pour the remaining dose down the nearest sink

Answer: B

Question No : 13

A patient is to receive 50mL of fluid in 1/2 hour (30 min). The infusion pump should be set
to deliver how many milliters per hour?

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A. 25 ml/hr
B. 50 ml/hr
C. 75 ml/hr
D. 100 ml/hr

Answer: D

Question No : 14

A male patient with a right pleural effusion noted on a chest X-ray is being prepared for
thoracentesis. The patient experiences severe dizziness when sitting upright. To provide a
safe environment, the nurse assists the patient to which position for the procedure?

A. Prone with head turned toward the side supported by a pillow

B. Sims’ position with the head of the bed flat
C. Right side-lying with the head of the bed elevated 45 degrees
D. Left side-lying with the head of the bed elevated 45 degrees

Answer: D

Question No : 15

After application of a cast in the upper extremity, the patient complains of severe pain in the
affected site. Which of the following would the nurse initiate?

A. Administer analgesics as ordered

B. Assess neurovascular status
C. Notify his physician
D. Pad the edges of the cast

Answer: B

Question No : 16

The best dietary advice a nurse can give to a woman diagnosed with mild pregnancy-
induced hypertension is to:

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A. Follow a strict low salt diet
B. Restrict fluid intake
C. Increase protein intake
D. Maintain a well-balanced diet

Answer: D

Question No : 17

A nurse has been working in a general hospital on the same medical unit for 6 years. The
Behavioral Unit is desperately short staffed and the nurse is asked to work her shift in this
other unit. What would be the expected response of the nurse to this request?

A. "I will go to the unit and hopefully the behavioral health staff members will assist me with
my assignment."
B. "I cannot go. I have no previous behavioral health experience. I do not want to reduce
the quality of patient care."
C. "I have no previous behavioral health experience. I am willing to go and help with any
duties that are similar to those I perform on my unit."
D. "I should not be expected to float to another unit without a proper orientation. I will fill out
an incident report if I am sent there."

Answer: C

Question No : 18

A patient is to receive 25mg/hr of an aminophylline infusion. The solution prepared by the

pharmacy contains 500mg of aminophylline in 1000ml of D5W. How many milligrams are
available per ml?

A. 0.25 mg/ml
B. 0.5 mg/ml
C. 1 mg/ml
D. 2 mg/ml

Answer: B

Question No : 19

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A patient with pneumonia is coughing up purulent thick sputum. Which one of the following
nursing measures is most likely helpful to loosen the secretions?

A. Postural drainage
B. Breathing humidified air
C. Percussion over the affected lung
D. Coughing and deep breathing exercises

Answer: B

Question No : 20

A 21 year old woman is being treated for injuries sustained in a car accident. The patient
has a central venous pressure (CVP) line insitu. The nurse recognizes that CVP
measurements:

A. Estimate Cardiac output

B. Assess myocardial workload
C. Determine need for fluid replacement
D. Determine ventilation - perfusion mismatch

Answer: C

Question No : 21

A construction worker was brought to the emergency department and admitted with the
diagnosis of heat stroke due to strenuous physical activity during hot weather conditions.
Which action should the nurse take?

A. Immediately immerse the patient in cold water to reduce the patient's temperature
B. Administer an antipyretic such as aspirin or acetaminophen
C. Place ice packs to the neck, axillae, scalp and groin
D. Encourage foods and oral fluids that contain carbohydrates and electrolytes

Answer: C

Question No : 22

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Thirty minutes after starting a blood transfusion a patient develops tachycardia and
tachypnea and complains of chills and low back pain. The nurse recognizes these
symptoms as characteristic of:

A. Circulatory overload
B. Mild allergy
C. Febrile response
D. Hemolytic reaction

Answer: D

Question No : 23

As a part of the treatment given to a child with leukemia the child is placed on reverse
barrier isolation to:

A. Protect the child from injury

B. Protect the child from infectious agents
C. Provide the child with a quiet environment
D. Keep the child away from other children

Answer: B

Question No : 24

The rationale for having the patient void before an abdominal paracentesis procedure is to:

A. Minimize discomfort
B. Avoid abdominal distention
C. Prevent bladder puncture
D. Reduce infection rate

Answer: C

Question No : 25

The best time for the nurse to teach an anxious patient about the patient controlled

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analgesic (PCA) pump would be during which of the following stages of patient care?

A. Post-operative
B. Pre-operative
C. Intraoperative
D. Post anesthesia

Answer: B

Question No : 26

To maintain the airway and promote respiratory function, the best position for the nurse to
place the unconscious patient in the Post Anesthesia Care Unit (PACU) is:

A. Supine
B. Lateral
C. Trendelenberg
D. Fowler's

Answer: B

Question No : 27

When the post-operative patient returns to the surgical unit, the priority is to:

A. Assess the patient's pain

B. Measure the patient’s vital signs
C. Monitor the rate of the IV infusion
D. Check the physician’s post-operative orders

Answer: B

Question No : 28

When taking routine post-operative observations on a patient who underwent an

exploratory laparotomy, the nurse plans to monitor which important finding over the next
hour?

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A. Serosanguinous drainage on the surgical dressing
B. Blood pressure of 105/65 mmHg
C. Urinary output of 20 mls in the last hour
D. Temperature of 37.6 °C

Answer: C

Question No : 29

A patient has been taking Aluminum Hydroxide daily for 3 weeks. The nurse should be alert
for which of the following side effects?

A. Constipation
B. Flatulence
C. Nausea
D. Vomiting

Answer: A

Question No : 30

A patient with severe, protracted vomiting will often have what electrolyte abnormality?

A. Decreased potassium and decreased chloride

B. Increased sodium and decreased chloride
C. Increased potassium and increased sodium
D. Decreased sodium and increased chloride

Answer: A

Question No : 31

A 13 year old girl with manifestations of rheumatic heart disease is admitted to hospital.
Which of the following laboratory blood findings would confirm that she likely has had a
streptococcal infection within the past two weeks?

A. Decreased leukocyte count

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B. Elevated hemoglobin count
C. Elevated ASO titer
D. Decreased ESR

Answer: C

Question No : 32

To prevent post-operative thrombophlebitis, which one of the following measures is

effective?

A. Elevation of the leg on two pillows

B. Using of compression stocking at night
C. Massage the calf muscle frequently
D. Performing leg exercises

Answer: D

Question No : 33

The mother of a child with nephrotic syndrome asks why her child must be weighed each
morning. The nurse's response should be based on the fact that this is important to
determine the:

A. Nutritional status
B. Water retention
C. Medication doses
D. Blood volume

Answer: B

Question No : 34

A deficiency of which of the following vitamins can affect the absorption of calcium?

A. Vitamin C
B. Vitamin B6

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C. Vitamin D
D. Vitamin B12

Answer: C

Question No : 35

The nurse should place the automatic external defibrillator (AED) electrodes on the
patient's anterior chest with one electrode placed:

A. Below the left clavicle and one below the right nipple
B. On the right mid-axillary line and the other at mid-sternum
C. Below the right clavicle and one below the left nipple
D. On the mid-axillary line and one at the sternal notch

Answer: C

Question No : 36

When caring for a patient with hepatic encephalopathy the nurse may carry out the
following orders: give enemas, provide a low protein diet, and limit physical activities.
These measures are performed to:

A. Minimize edema
B. Decrease portal pressure
C. Reduce hyperkalemia
D. Decrease serum ammonia

Answer: D

Question No : 37

Collection urine bag should be emptied as necessary and at least every 8 - 9 hours to
prevent:

A. Pooling of urine in the tube

B. Reflux of urine into the bladder

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C. Pulling on catheter
D. Bacterial contamination

Answer: D

Question No : 38

The best example of documentation of patient teaching regarding wound care is:

A. "The patient was instructed about care of wound and dressing changes"
B. "The patient demonstrated correct technique of wound care following instruction"
C. "The patient and family verbalize that they understand the purposes of wound care"
D. "Written instructions regarding wound care and dressing changes were given to the
patient"

Answer: B

Question No : 39

The nurse teaches a patient recovering from a total hip replacement that it is important to
avoid:

A. Putting a pillow between the legs while sleeping

B. Sitting with the legs crossed
C. Abduction exercises of the affected leg
D. Bearing weight exercises on the affected leg for 6 weeks

Answer: B

Question No : 40

Which of the following actions is the most appropriate when the nurse is responding to a
patient during a tonic-clonic seizure?

A. Restrain the patient

B. Protect the patient from harm
C. Minimize noise and light stimulus

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D. Apply oxygen by mask or nasal cannula

Answer: B

Question No : 41

The patient did not sleep well last night and is anxious about having a bronchoscopy later
this morning. The priority nursing intervention would be to:

A. Reassure and encourage expression of feelings

B. Administer the premedication a little earlier
C. Keep the patient occupied until the procedure
D. Explain the purpose of the bronchoscopy

Answer: A

Question No : 42

The nurse should suspect that a patient has bleeding in the upper gastrointestinal tract
when the color of the patient's stool is:

A. Yellow
B. Black
C. Clay
D. Red

Answer: B

Question No : 43

The police bring a prisoner into the emergency department who is in severe pain. When the
nurse is assigned to this patient, the nurse should:

A. Ignore the prisoner because he deserves to be in pain

B. Give the prisoner the minimum amount of pain medication ordered
C. Tell the prisoner to be quiet, as he is disturbing the other patients
D. Implement nursing interventions to relieve the prisoner's pain

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Answer: D

Question No : 44

The nurse is preparing teaching plans for several patients. The nurse should recognize
which of the following patients is at greatest risk for fluid and electrolyte imbalance?

A. A 2-year-old patient who is receiving gastrostomy feedings

B. A 20-year-old patient with a sigmoid colostomy
C. A 40-year-old patient who is 3 days post-operative with an ileostomy
D. A 60-year-old patient who is 8 hours post-renal arteriography

Answer: C

Question No : 45

The patient with liver cirrhosis receives 100 ml of 25% serum albumin intravenously. Which
of the following findings would best indicate that the albumin is having its desired effect?

A. Decreased blood pressure

B. Increased serum albumin level
C. Increased urine output
D. Improved breathing pattern

Answer: C

Question No : 46

The apical pulse can be best auscultated at the:

A. Left 2nd intercostal space lateral to the mid clavicular line

B. Left 2nd intercostal space at the left sternal border
C. Left 5th intercostal space at the mid clavicular line
D. Left 5th intercostal space at the mid axillary line

Answer: C

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Question No : 47

Which of the following tasks requires specialized education and should be performed by
the nurse only after the training has been completed?

A. Administering a dose of promethazine (Phenergan) via intravenous push (IVP)

B. Applying a transdermal fentanyl (Duragesic)
C. Instilling tobramycin (Tobrex) ophthalmic solution
D. Beginning an intravenous infusion of cyclophosphamide (Cytoxan)

Answer: D

Question No : 48

An elderly patient is admitted to the hospital with swollen ankles. The best way to limit
edema of the feet is for the nurse to:

A. Restrict fluids
B. Apply bandages
C. Elevate the legs
D. Do passive range of motion exercises (ROM)

Answer: C

Question No : 49

A patient is diagnosed with diabetic ketoacidosis. The nurse would expect the physician to
prescribe:

A. Regular insulin IV
B. NPH insulin SC
C. Glucagon IM
D. Mixed insulin SC

Answer: A

Question No : 50

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A newborn infant is assessed using the Apgar assessment tool and scores 6. The infant
has a heart rate of 95, slow and irregular respiratory effort, and some flexion of extremities.
The infant is pink, but has a weak cry. The nurse should know that this Apgar score along
with the additional symptoms indicates the neonate is:

A. Functioning normally
B. Needing immediate life-sustaining measures
C. Needing special assistance
D. Needing to be warmed

Answer: C

Question No : 51

To promote accuracy of self-monitoring blood glucose by patients the nurse should:

A. Retrain patients periodically

B. Direct patients to rotate testing sites
C. Advise patients to buy new strips routinely
D. Compare results from patient's meter against lab results

Answer: A

Question No : 52

A nurse can ensure she maintains her competency to practice through:

A. Being involved in continuing education programs

B. Making sure that what was learnt at nursing school is strictly followed
C. Closely carrying out instructions given by the Charge Nurse
D. Working on the same ward for at least 2 years

Answer: A

Question No : 53

When checking the capillary refill time of a patient's extremity, the color returns in 7

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seconds. The nurse recognizes this finding as indicative of:

A. A normal response
B. Thrombus formation in the veins
C. Lymphatic obstruction of venous return
D. Impaired arterial flow to the extremities

Answer: D

Question No : 54

In caring for a woman and baby day 3 postnatally, she tells you that her baby has not had a
bowel action since delivery. Your appropriate response would be:

A. Reassure the mother that it is quite normal for a baby to not move their bowels until day
5 after a few days of milk feeding
B. Start a bowel chart, document all findings, and wait another 48 hours before reporting to
the physician
C. Encourage more frequent warm baths for the neonate with gentle abdomen massages
D. Tell the mother that you will let the physician know, so the baby can be checked for any
obstruction

Answer: D

Question No : 55

When caring for a patient with acute pancreatitis, the patient is most likely to complain of
pain which is:

A. Severe and located in the left lower quadrant and radiating to the groin
B. Burning and located in the epigastric area and radiating to the groin
C. Severe and located in the epigastric area and radiating to the back
D. Burning and located in the left lower quadrant and radiating to the back

Answer: C

Question No : 56

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The patient with iron deficiency anemia should be encouraged to eat which of the following
foods high in iron?

A. Eggs
B. Lettuce
C. Citrus fruits
D. Cheese

Answer: A

Question No : 57

A patient arrived to the Post Anesthesia Care Unit (PACU) complaining of pain after
undergoing a right total hip arthroplasty. Which of the following should the nurse do to
assess the patient's level of pain?

A. Determine the patient's position during surgery and how long the patient was in this
position
B. Inspect the dressing, note type and amount of drainage, and insure bandage adhesive is
not pulling on skin
C. Ask anesthesiologist what type of anesthesia patient received and last dose of pain
medication
D. Note location, intensity and duration of pain and last dose and time of pain medication

Answer: D

Question No : 58

An 85-year-old man is admitted with dementia. He continuously attempts to remove his

nasogastric tube. The nurse applies cloth wrist restraints as ordered. Which of the following
actions by the nurse is most appropriate?

A. Evaluate the need to restrain by observing patient's behavior once every 24 hrs
B. Perform circulation checks to the extremities every two hours
C. Remove the restraints when the patient is sleeping
D. Instruct family to limit physical contact with the patient

Answer: B

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Question No : 59

A patient with deep partial-thickness and full-thickness burns of the face and chest is
admitted to the emergency department. The nurse must be particularly alert for:

A. Paralytic ileus
B. Respiratory distress
C. Severity of pain
D. Strong burn odor

Answer: B

Question No : 60

A patient becomes angry and threatens to leave the hospital unless the physician reviews
the reason for the patient's delay in discharge. The patient has a medication order for
agitation available p.m.. but refuses the medication and requests a drink of orange juice
instead. What should the nurse do?

A. Secretly slip the p.r.n. medication into the orange juice and give it to the patient
B. Give the patient the orange juice and tell the patient that a staff member is attempting to
call the physician
C. Inform the patient that staff is unable to force anyone to stay in the hospital
D. Inform the patient that nothing can be done until the morning

Answer: B

Question No : 61

A patient requires tracheal suctioning through the nose. Which of the following nursing
action would be incorrect?

A. Lubricating the catheter with sterile water

B. Applying suction while withdrawing the catheter from the nose
C. Applying suction for a minimum of 30 seconds
D. Rotating the catheter while withdrawing it

Answer: C

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Question No : 62

Pain management for terminally ill patients is most effective when analgesics are given:

A. Around the clock

B. Only when clearly needed
C. After non-pharmacological methods fail
D. As the patient requests them

Answer: A

Question No : 63

A patient is admitted to a hospital with acute renal failure. The patient wakes up
complaining of abdominal pain. On assessment, the nurse observes edema to the patient's
ankles and distended neck veins. The patient is dyspneic with a blood pressure of 200/96
mmHg. The proper nursing diagnosis for this patient is:

A. Deficient fluid volume related to disease process

B. Excess fluid volume related to decreased glomerular filtration rate
C. Knowledge deficit related to proper medication regimen
D. Acute pain related to renal edema

Answer: B

Question No : 64

The nurse knows that the greatest risk for a patient with a ruptured ectopic pregnancy is:

A. Hemorrhage leading to hypovolemic shock

B. Strictures and scarring of the fallopian tube
C. Adhesions and scarring from blood in the abdomen
D. Infertility resulting from treatment with a salpingectomy

Answer: A

Question No : 65

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A trauma patient with open wounds arrives in the emergency department. The nurse would
know that a tetanus injection is needed if the patient has:

A. Only received 3 doses of tetanus toxoid

B. Received less than 3 doses of tetanus toxoid
C. Not had a dose of tetanus toxoid in the past 4 years
D. Not had a dose of tetanus toxoid in the past 10 years

Answer: D

Question No : 66

A 3-month-old infant is admitted with a diagnosis of ventricular septal defect. The physical
assessment for this infant would reveal:

A. High pitched cry

B. Harsh heart murmur
C. Bradycardia
D. Hypertension

Answer: B

Question No : 67

The administration of which of the following types of parenteral fluids would result in a
lowering of the osmotic pressure and cause the fluid to move into the cells?

A. Hypotonic
B. Isotonic
C. Hypertonic
D. Colloid

Answer: A

Question No : 68

Nursing management of the patient with external otitis includes:

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A. Irrigating the ear canal with warm saline several hours after instilling lubricating ear
drops
B. Inserting an ear wick into the external canal before instilling the ear drops to disperse
the medication
C. Teaching the patient how to instill antibiotic drops into the ear canal before swimming
D. Instilling ear drops without the dropper touching the auricle and positioning the ear
upward for 2 minutes afterwards

Answer: D

Question No : 69

The correct way to trim the toe nails of a patient with diabetes is to:

A. Cut the nails in a curve and then file

B. Cut the nails straight across and then file
C. File the nails straight across and square only
D. File the nails in a curved arch with low sides only

Answer: C

Question No : 70

Salem has Alzheimer’s disease. He is agitated and repeatedly asks to go home. The most
appropriate nursing intervention for him is to:

A. Isolate him in a single room

B. Find activities to keep him occupied
C. Ask the physician to discharge him
D. Administer a minor tranquillizer

Answer: B

Question No : 71

During the initial pain assessment process, the nurse should:

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A. Perform pain relief measures
B. Teach the patient about pain therapies
C. Conduct a comprehensive pain assessment
D. Provide appropriate treatment and evaluate its effect

Answer: C

Question No : 72

The immediate treatment for ventricular fibrillation is:

A. Precordial blow
B. Defibrillation
C. Bolus of lidocaine
D. Ventricular pacing

Answer: B

Question No : 73

The purpose of a cardiac pacemaker is to:

A. Initiate and maintain the heart rate when SA node is unable to do so

B. Stabilize the heart rate when it is above 100 beats per minute
C. Stabilize the heart when the patient has had a heart attack
D. Regulate the heart when the patient is going for open heart surgery

Answer: A

Question No : 74

When taking care of a patient who has undergone open reduction and internal fixation of a
fractured left tibia, the nurse should keep the leg:

A. Straight to reduce flexion deformities

B. Immobilized to enhance bone healing
C. Adducted to attain alignment

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D. Elevated to minimize venous stasis

Answer: D

Question No : 75

A nurse prepares to set up a secondary intravenous (IV) cannula. The primary IV infusing
is normal saline. In order for the secondary cannula to infuse correctly, the nurse should set
up the primary IV to:

A. Hang higher than the secondary IV

B. Hang at the same level as the secondary IV
C. Hang lower than the secondary IV
D. Discontinue before the secondary IV starts

Answer: C

Question No : 76

A young patient is extremely irritable due to meningitis. It would be most important for the
nurse to:

A. Use low-level lighting in the room

B. Ventilate the room
C. Eliminate strong odors
D. Allow frequent visitors

Answer: A

Question No : 77

Which of the following actions is the most effective measure to reduce hospital acquired
infections?

A. Double bagging of all contaminated laundry

B. Restricting visitors of infectious patients
C. Using disposable supplies

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D. Correct hand washing

Answer: D

Question No : 78

The coronary care nurse draws an Arterial Blood Gas (ABG) sample to assess a patient for
acidosis. A normal pH for arterial blood is:

A. 7.0 - 7.24
B. 7.25 - 7.34
C. 7.35 - 7.45
D. 7.5 - 7.6

Answer: C

Question No : 79

Order: Allopurinol 450 mg p.o. daily. Drug [Link] 300 mg scored tablets.
Which of the following will you administer?

A. 0.5 tablet
B. 1.5 tablets
C. 2 tablets
D. 2.5 tablets

Answer: B

Question No : 80

In preparing the patient for electroencephalogram (EEG), the nurse should:

A. Withhold breakfast
B. Give sleeping pills the night before
C. Shave the hair
D. Restrict intake of coffee

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Answer: D

Question No : 81

The patient's pre-operative blood pressure was 120/68 mmHg. On admission to the Post
Anesthesia Care Unit, the blood pressure was 124/70 mmHg. Thirty minutes after
admission, the patient's blood pressure falls to 112/60 mmHg, pulse to 72 BPM, and the
skin appears warm and dry. The most appropriate action by the nurse at this time is to:

A. Raise the head of the bed

B. Notify the anesthetist immediately
C. Increase the rate of IV fluid replacement
D. Continue to monitor the patient

Answer: D

Question No : 82

The nurse notes that there are no physician's orders regarding Fatima's post operative
daily insulin dose. The most appropriate action by the nurse is to:

A. Withhold any insulin dose since none is ordered and the patient is NPO
B. Call the physician to clarify whether insulin should be given and at what dose
C. Give half the usual daily insulin dose since she will not be eating in the morning
D. Give the patient her usual daily insulin dose since the stress of surgery will increase her
blood glucose

Answer: B

Question No : 83

Which of the following interventions should the nurse implement if a patient complains of
cramps while irrigating the colostomy?

A. Reduce the flow of solution

B. Have the patient sit up in bed
C. Remove the irrigation tube

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D. Insert the tube further into the colon

Answer: A

Question No : 84

A nurse is not familiar with a particular solution ordered to irrigate a patient's wound. The
appropriate action would be to:

A. Check if the solution is available on the ward, and if so, use it to clean the wound
B. Put a neat line through the order and re-write the solution more commonly used
C. Check with the Pharmacist about the uses of the solution ordered
D. Ask the patient what solution he would prefer to be used

Answer: C

Question No : 85

While assessing an 84-year-old post-operative patient, the nurse observes that the patient
suddenly becomes very anxious, appears cyanotic and has severe dyspnea. The nurse
recognizes these symptoms to be consistent with:

A. Congestive heart failure

B. Pulmonary embolism
C. COPD exacerbation
D. Myocardial infarction

Answer: B

Question No : 86

When preparing an eye medication, the nurse reads the order "OS". Medication is given
into:

A. Both eyes
B. Left eye
C. Right eye

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D. Infected eye

Answer: B

Question No : 87

A patient with allergic rhinitis reports severe nasal congestion, sneezing, and watery eyes
at various times of the year. To teach the patient to control these symptoms the nurse
advises the patient to:

A. Avoid all over the counter intranasal sprays

B. Limit the use of nasal decongestant sprays to 10 days
C. Use oral decongestants at bedtime to prevent symptoms during the night
D. Keep a diary of when an allergic reaction occurs and what precipitates it

Answer: D

Question No : 88

The urinary catheter is kept securely in the bladder by:

A. Taping the urinary catheter to the leg

B. Securing catheter and collection bag connections
C. Inflating the balloon of the catheter
D. Anchoring the catheter bag to the bed

Answer: C

Question No : 89

You have started work on a new ward. One of the patient's allocated to you has been on
the ward for the last 7 months since she had a cerebrovascular accident (CVA). You notice
that her nursing care plan says strict bed rest, but on assessment you can not see any
reason why this patient can not sit out of bed for short periods. Your nursing action would
be:

A. Check with the other nursing staff as to reasons behind the nursing care plan then

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update the plan based on your assessment
B. Follow the nursing care plan strictly as this would have been developed after a detailed
and collaborative assessment
C. Seek physician's orders so that you have permission to move the patient
D. Try and move the patient without consulting with anyone to see how she manages

Answer: A

Question No : 90

A patient is admitted to the emergency department with a possible allergic reaction to a bee
sting. What is the first action the nurse should take?

A. Quickly use tweezers to remove the stinger

B. Observe the patient for signs of anaphylaxis
C. Apply warm compresses to the site of local reaction
D. Squeeze the venom sac to remove additional venom

Answer: B

Question No : 91

The physician orders heparin 40 000 U in 1 liter of D5W IV to infuse at 1000 U/hr. What is
the flow rate in milliliters per hour?

A. 250 mls/hr
B. 25 mls/hr
C. 2.5 mls/hr
D. 0.25 mls/hr

Answer: B

Question No : 92

The nurse plans the care for a patient with increased intracranial pressure, she knows that
the best way to position the patient is to:

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A. Keep patient in a supine position until stable
B. Elevate the head of the bed to 30 degrees
C. Maintain patient on right side with head supported on a pillow
D. Keep patient in a semi-sitting position

Answer: B

Question No : 93

During balloon inflation of an indwelling urinary catheter, the patient complains of pain and
discomfort. The nurse should:

A. Continue the procedure and assure the patient

B. Aspirate the fluid and remove the catheter
C. Withdraw the fluid and reinsert the catheter
D. Decrease the amount of injected fluid and secure

Answer: C

Question No : 94

To remove soft contact lenses from the eyes of an unconscious patient the nurse should:

A. Uses a small suction cup placed on the lenses

B. Pinches the lens off the eye then slides it off the cornea
C. Lifts the lenses with a dry cotton ball that adheres to the lenses
D. Tenses the lateral canthus while stimulating a blink reflex by the patient

Answer: B

Question No : 95

After administration of penicillin, a patient develops respiratory distress and severe

bronchospasm. The nurse should:

A. Contact the physician

B. Apply ice packs to the axilla

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C. Assess the patient for orthostatic hypotension
D. Encourage the patient to take slow deep breaths

Answer: A

Question No : 96

Which of the following laboratory blood values is expected to be decreased in hepatic

dysfunction?

A. Albumin
B. Bilirubin
C. Ammonia
D. ALT and AST

Answer: A

Question No : 97

Whilst recovering from surgery a patient develops deep vein thrombosis. The sign that
would indicate this complication to the nurse would be:

A. Intermittent claudication
B. Pitting edema of the area
C. Severe pain when raising the legs
D. Localized warmth and tenderness of the site

Answer: D

Question No : 98

During the acute phase of a cerebrovascular accident (CVA) the nurse should maintain the
patient in which of the following positions?

A. Semi-prone with the head of the bed elevated 60-90 degrees

B. Lateral, with the head of the bed flat
C. Prone, with the head of the bed flat

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D. Supine, with the head of the bed elevated 30-45 degrees

Answer: D

Question No : 99

A patient who presents with acute weight loss, dry skin and mucous membranes and
decreased urine output is most likely be suffering from:

A. Fluid volume deficit

B. Acute renal failure
C. Acute heart failure
D. Urinary tract infection

Answer: A

Question No : 100

A patient with duodenal peptic ulcer would describe his pain as:

A. Generalized burning sensation

B. Intermittent colicky pain
C. Gnawing sensation relieved by food
D. Colicky pain intensified by food

Answer: C

Question No : 101

Which of the following techniques should the nurse implement to prevent the patient's
mucous membranes from drying when the oxygen flow rate is higher than 4 liters per
minute?

A. Use a non rebreather mask

B. Add humidity to the delivery system
C. Use a high flow oxygen delivery system
D. Ensure that the prongs are in the nares correctly

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Answer: B

Question No : 102

Extrapyramidal adverse effects and symptoms are most often associated with which of the
following drug classes?

A. Antidepressants
B. Antipsychotics
C. Antihypertensives
D. Antidysrhythmics

Answer: B

Question No : 103

While preparing the midday medications, the nurse finds difficulty reading the label on a
medicine bottle. The best action by the nurse is to:

A. Document that it could not be given due to difficulty in reading the label
B. Make out a new label with clear handwriting using adhesive tape to attach it
C. Ask the pharmacist to replace it with a clearly labeled bottle
D. Give the medication if it is similar to a bottle present on the trolley

Answer: C

Question No : 104

One factor affecting the pharmokinetics of older patients' drug absorption is:

A. Decreased gastrointestinal motility

B. A difficulty in swallowing
C. A prevalence of obesity
D. Numerous medications

Answer: A

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Question No : 105

Elevated levels of amylase and lipase in the blood are common in:

A. Diabetes mellitus
B. Esophagitis
C. Pancreatitis
D. Hepatitis

Answer: C

Question No : 106

Which of the following correctly describes wound packing in a wet to dry dressing?

A. Pack gauze into the wound tightly

B. Overlap the wound edges with wet packing
C. Pack the wound with slightly moistened gauze
D. Use gauze well saturated with saline for packing the wound

Answer: C

Question No : 107

A patient who sustained a chest injury has a chest tube inserted which is connected to an
under water seal drainage system. When caring for this patient the nurse will:

A. Instruct the patient to limit movement of the affected shoulder

B. Observe for fluctuation of the water level
C. Clamp the tube when needed
D. Administer hourly analgesia

Answer: B

Question No : 108

When preparing to administer a medication the nurse should first:

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A. Ensure that the medication is on the medication cart
B. Determine the expiry date of the medication
C. Check the patient's identification armband
D. Verify the physician order for accuracy

Answer: D

Question No : 109

Immediately after a craniotomy for head trauma, the nurse must monitor the drainage on
the dressing. Which of the following should be reported?

A. Blood tinged
B. Straw colored
C. Clotted
D. Foul-smelling

Answer: B

Question No : 110

The nurse is caring for a patient who is receiving dialysis. The patient has an arteriovenous
(AV) fistula. Appropriate care for this patient would include which one of the following
options?

A. Infusing medications through the AV fistula

B. Drawing blood samples from the AV fistula
C. Massaging the AV fistula
D. Palpating the AV fistula for a thrill

Answer: D

Question No : 111

The patient is receiving piperacillin (Pipril) I.V. Which of the following should the nurse
consider when administering the medication to the patient?

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A. Assess for Stevens-Johnson Syndrome
B. Be alert for the possibility of hypersensitivity
C. Watch for signs of increasing severity of infection
D. Instruct patient to increase the intake of protein-rich foods

Answer: B

Question No : 112

Which of the following indicates the nurse is engaging in a therapeutic nurse-patient

relationship?

A. The nurse establishes a relationship that is mutually beneficial

B. The nurse demonstrates sympathetic feelings toward the patient
C. The nurse commits to helping the patient find ways to help self
D. The nurse utilizes therapeutic touch to convey acceptance of the patient

Answer: C

Question No : 113

Order: Compazine 8 mg IM stat. Drug availablE.10 mg/ 2mL in vial.

How many mLs would you give?

A. 0.6 mL
B. 1.6 mL
C. 2.6 mL
D. 3.6 mL

Answer: B

Question No : 114

A newborn is diagnosed with ventricular septal defect. The baby is discharged with a
prescription for digoxin syrup 20 micrograms bid. The bottle of digoxin is labeled as 0.05
mg/ml. The nurse should teach the mother to administer on each dose:

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A. 0.1 ml
B. 0.2 ml
C. 0.4 ml
D. 0.8 ml

Answer: C

Question No : 115

When the nurse is caring for a patient placed on droplet precautions, the nurse should:

A. Have the patient wear a high-efficiency particulate air (HEPA) mask

B. Wear a surgical mask when standing within 3 feet (1 meter) of the patient
C. Assign the patient to a room with monitored negative air pressure
D. Apply a disposable gown when entering the patient's room

Answer: B

Question No : 116

A nursing measure that is helpful in communicating with a hearing impaired patient is to:

A. Use simple sentences

B. Talk while close to patient's ear
C. Raise the voice
D. Write out all questions and responses

Answer: A

Question No : 117

The patient has a nursing diagnosis of altered cerebral tissue perfusion related to cerebral
edema. An appropriate nursing intervention for this problem is to:

A. Elevate the head of the bed 30 degrees

B. Provide a position of comfort with knee flexion
C. Provide uninterrupted periods of rest

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D. Ensure adequate hydration with mannitol

Answer: A

Question No : 118

Nursing management of a patient with pulmonary embolism would focus on which of the
following actions?

A. Assessing oxygenation status

B. Assessing signs of DVT in legs
C. Monitoring for other sources of clots
D. Monitoring patient for cardiogenic shock

Answer: A

Question No : 119

The physician orders 20 u of U-100 regular insulin. The only syringe on hand is a 1 ml
tuberculin syringe. How many milliliters should be administered?

A. 0.02 ml
B. 0.2 ml
C. 1 ml
D. 2 ml

Answer: B

Question No : 120

The nurse should be aware that tetracycline is contraindicated in children under 12 years of
age because:

A. Minimal doses are needed to control infection

B. Immunosuppression is a common side effect
C. Staining of the teeth is an adverse effect
D. They are prone to develop renal failure

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Answer: C

Question No : 121

The nurse should administer nasogastric tube (NGT) feeding slowly to reduce the hazard
of:

A. Distention
B. Abdominal cramps
C. Diarrhea
D. Regurgitation

Answer: A

Question No : 122

To ensure safe practice during defibrillation, the nurse must:

A. Cover paddles with electrode gel

B. Avoid touching the patient's bed
C. Remove paddles after the shock
D. Synchronize prior to shock delivery

Answer: B

Question No : 123

Which of the following statements accurately describes the occurrence of dyspnea in

patients who are receiving end of life care?

A. Dyspnea is only experienced by patients who have primary diagnoses that involve the
lungs
B. Dyspnea occurs in less than 50% of the patients who are receiving end of life care
C. Dyspnea that is caused by increased fluid volume may be improved by diuretics
D. Dyspnea may be caused by antibiotic therapy used over a long period of time

Answer: C

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Question No : 124

A patient admitted to the hospital in hypertensive crisis is ordered to receive hydralazine

(Apresoline) 20mg IV stat for blood pressure greater than 190/100 mmHg. The best
response of the nurse to this order is to:

A. Give the dose immediately and once

B. Give medication if patient's blood pressure is > 190/100 mmHg
C. Call the physician because the order is not clear
D. Administer the dose and repeat as necessary

Answer: A

Question No : 125

The nurse manager has just prepared a medication for a patient and she asked you to give
the medication. Which of the following is the best response to the nurse manager's
request?

A. Give the patient his medication and record it on the chart

B. Ask another nursing colleague to give and record the medication
C. Explain that you cannot give a medication that you did not prepare
D. Give the medication and ask the nurse manager to record it on the chart

Answer: C

Question No : 126

A patient is to receive 2.5mg of morphine sulfate. The ampoule contains l000mcg/mL. How
much morphine should the nurse administer?

A. 0.25 ml
B. 1 ml
C. 1.5 ml
D. 2.5 ml

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Answer: D

Question No : 127

A patient has had a total hip joint replacement. Which of the following actions should the
nurse consider for the patient's daily recommended exercise program?

A. Administering an analgesic before exercising

B. Discontinuing the program if the patient dislikes it
C. Continuing exercises inspire of severe pain
D. Evaluating effectiveness of exercise based on pain scale

Answer: A

Question No : 128

A patient presents to the emergency department with diminished and thready pulses,
hypotension and an increased pulse rate. The patient reports weight loss, lethargy, and
decreased urine output. The lab work reveals increased urine specific gravity. The nurse
should suspect:

A. Renal failure
B. Sepsis
C. Pneumonia
D. Dehydration

Answer: D

Question No : 129

A registered nurse delegates care to a practical nurse. The person most responsible for the
safe performance of the care is the:

A. Head nurse who is in-charge of the unit

B. The practical nurse assigned to provide the care
C. The registered nurse who delegated the care to the practical nurse
D. The nursing care coordinator who is the supervisor of the unit

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Answer: C

Question No : 130

Symptoms of alcohol withdrawal include:

A. Euphoria, hyperactivity and insomnia

B. Depression, suicidal ideation and hypersomnia
C. Diaphoresis, nausea and vomiting and tremors
D. Unsteady gait, nystagmus and profound disorientation

Answer: C

Question No : 131

What two behaviors are important when documenting the depth of the patient’s
depression?

A. Orientation and appearance

B. Helplessness and hopelessness
C. Affect and thought processes
D. Mood and impulse control

Answer: B

Question No : 132

An 11 year old girl with a history of asthma arrives at the primary health clinic with
signs/symptoms of shortness of breath, audible wheezing, nasal flaring and mild lip
cyanosis. Your immediate nursing action is to:

A. Assess respiratory distress and peak expiratory flow rate

B. Take a blood sample to assess COlevels
C. Instruct the parents to take the child immediately to hospital
D. Sit the child comfortably and offer 2 puffs of ventolin stat

Answer: A

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Question No : 133

Which of the following interventions is most significant in the prevention of pressure sores?

A. Increasing fluid intake

B. Changing soiled linen
C. Regular changing of position
D. Use of a water mattress

Answer: C

Question No : 134

A patient complains of pain in his right arm. The physician orders codeine 45 mg and
aspirin 650 mgs every 4 hours PRN. Each codeine tablet contains 15mg of codeine and
each aspirin tablet contains 325mg of aspirin. What should the nurse administer?

A. 2 codeine tablets and 4 aspirin tablets

B. 4 codeine tablets and 3 ½ aspirin tablets
C. 3 codeine tablets and 2 aspirin tablets
D. 3 codeine tablets and 3 aspirin tablets

Answer: C

Question No : 135

A patient on diuretics has had vomiting and diarrhea for the past 3 days. Which of the
following is this patient most at risk for developing?

A. Hypokalemia and cardiac arrhythmias

B. Hypercalcemia and polyuria
C. Dehydration and hyperglycemia
D. Hyperalimentation and heart block

Answer: A

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Question No : 136

The patient is to receive 100 ml/hr of D5W through a micro drip. How many drops per
minute should the patient receive?

A. 25 gtts/min
B. 30 gtts/min
C. 100 gtts/min
D. 200 gtts/min

Answer: C

Question No : 137

Which of the following is the most appropriate first action for the nurse to take for a pre-
schooler who has fallen and has a hematoma formed on the temporal bone?

A. Encourage a nap
B. Give pain medication
C. Apply ice and monitor vital signs
D. Allow the child to continue activities

Answer: C

Question No : 138

A patient undergoes laminectomy. In the immediate post-operative period, the nurse

shoulD.

A. Monitor the patient’s vital signs and log roll him to prone position
B. Monitor the patient’s vital signs and encourage him to ambulate
C. Monitor the patient’s vital signs and auscultate his bowel sounds
D. Monitor the patient’s vital signs, check sensation and motor power of the feet

Answer: D

Question No : 139

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A nurse is making rounds taking vital signs. Which of the following vital signs is abnormal?

A. 11 year old male – 90 b.p.m, 22 resp/min. , 100/70 mm Hg

B. 13 year old female – 105 b.p.m., 22 resp/min., 105/60 mm Hg
C. 5 year old male- 102 b.p.m, 24 resp/min., 90/65 mm Hg
D. 6 year old female- 100 b.p.m., 26 resp/min., 90/70mm Hg

Answer: B

Question No : 140

An early sign of acute respiratory failure is:

A. Diaphoresis
B. Cyanosis
C. Restlessness
D. Orthopnea

Answer: C

Question No : 141

A medication was ordered by a physician. The nurse believes the medication dose is
incorrect. What should the nurse do next?

A. Clarify the order with another physician who is available on the unit
B. Ask the nurse in charge if the order is correct
C. Contact the pharmacy department
D. Call the physician who prescribed the medication

Answer: D

Question No : 142

The priority nursing diagnosis for a hospitalized patient with a Stage IV pressure ulcer on
the hip would be:

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A. Altered body image
B. Acute pain
C. Risk for infection
D. Altered nutrition

Answer: C

Question No : 143

You are the nurse providing post-operative care for a 9 year old boy who is 6 hours post-
tonsillectomy. He is sleeping, but on routine observation you notice that his pulse has
increased, he seems to be restless and trying to swallow frequently. Your immediate action
would be:

A. Apply an ice collar to reduce discomfort

B. Allow child to keep sleeping and record observations
C. Wake him and offer some ice chips to suck
D. Check inside his mouth for any signs of bleeding and notify the physician

Answer: D

Question No : 144

A 65-year-old patient is admitted with ischemic stroke. Which of the following would be
initially assessed by the nurse to determine the patient’s level of consciousness?

A. Visual fields
B. Deep tendon reflexes
C. Auditory acuity
D. Verbal response

Answer: D

Question No : 145

A nurse prepares a narcotic analgesic for administration, but the patient refuses to take it.
Which of the following actions by the nurse is most appropriate?

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A. Encourage the patient to reconsider taking the medication
B. Label the medication and replace it for use at a later time
C. Discard the medication in the presence of a witness and chart the action
D. Call the physician with the patient's refusal to take the prescribed medication

Answer: C

Question No : 146

Whenever a child with thalassemia comes for blood transfusion, he is administered

Desferoxamine (Desferal). The action of this drug is to:

A. Inhibit the inflammatory process

B. Enhance iron excretion
C. Antagonize the effect of vitamin C
D. Increase red blood cell production

Answer: B

Question No : 147

A patient arrives at the emergency department with slurred speech and a right facial droop.
The patient's relative states the patient "is not himself." Upon assessment, the nurse finds
paresthesia to the right side of the body, receptive aphasia, hemianopia and altered
cognitive abilities. The nurse should suspect:

A. A narcotic overdose
B. Parkinson's disease
C. Alcohol withdrawal
D. A cerebrovascular accident (CVA)

Answer: D

Question No : 148

An 8-month-old infant is diagnosed with communicating hydrocephalus. The nurse notices

that his intracranial pressure is increasing from the following changes in his vital signs:

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A. Bradycardia, hypotension and hypothermia
B. Bradycardia, hypertension and hyperthermia
C. Tachycardia, hypotension and hyperthermia
D. Tachycardia, hypertension and hypothermia

Answer: B

Question No : 149

When inserting a rectal suppository for a patient the nurse should?

A. Insert the suppository while the patient performs the 'valsava maneuver'
B. Place the patient in a supine position
C. Position the suppository beyond the muscle sphincter of the rectum
D. Insert the suppository 1/2 inch into the rectum

Answer: C

Question No : 150

A patient with a history of angina pectoris arrives in emergency complaining of headache,

visual disturbances and feeling dizzy. Your nursing assessment also notes he looks
flushed, is perspiring perfusely and is experiencing palpitations. You should suspect:

A. An overdose of sublingual nitroglycerin

B. The onset of a myocardial infarction
C. The patient has been over exercising
D. The beginning of a severe chest infection

Answer: A

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