FON Mcqs From Nurses Lab Web by Abdullah Danish, Educational Platform

FON mcqs from Nurseslab Web (By Abdullah Danish)
1. Question
The most important nursing intervention to correct skin dryness is:
 A. Consult the dietitian about increasing the patient‘s fat intake, and take
necessary measures to prevent infection.
 B. Ask the physician to refer the patient to a dermatologist, and suggest that
the patient wear home-laundered sleepwear.
 C. Encourage the patient to increase his fluid intake, use non-irritating

soap when bathing the patient, and apply lotion to the involved areas.
 D. Avoid bathing the patient until the condition is remedied, and notify the
physician.
Incorrect
Correct Answer: C. Encourage the patient to increase his fluid intake, use
non-irritating soap when bathing the patient, and apply lotion to the
involved areas.
Dry skin will eventually crack, ranking the patient more prone to infection. To
prevent this, the nurse should provide adequate hydration through fluid intake,
use non irritating soaps or no soap when bathing the patient, and lubricate the
patient‘s skin with lotion. In most cases, dry skin responds well to lifestyle
measures, such as using moisturizers and avoiding long, hot showers and baths.
Moisturizers provide a seal over the skin to keep water from escaping. Apply
moisturizer several times a day and after bathing.
 Option B: The attending physician and dietitian may be consulted for
treatment, but home-laundered items usually are not necessary. Natural
fibers, such as cotton and silk, allow the skin to breathe. But wool, although
natural, can irritate even normal skin. Wash clothes with detergents without
dyes or perfumes, both of which can irritate the skin.
 Option C: Increasing fat intake is unnecessary. Hot, dry, indoor air can
parch sensitive skin and worsen itching and flaking. A portable home
humidifier or one attached to the furnace adds moisture to the air inside
the home. Be sure to keep the humidifier clean. It‘s best to use cleansing
creams or gentle skin cleansers and bath or shower gels with added
Abdullah Danish Educational Platform Abdullah Danish

moisturizers. Choose mild soaps that have added oils and fats. Avoid
deodorant and antibacterial detergents, fragrance, and alcohol.
 Option D: Bathing may be limited but need not be avoided entirely. Long
showers or baths and hot water remove oils from the skin. Limit baths or
showers to five to 10 minutes and use warm, not hot, water.
2. Question
When bathing a patient‘s extremities, the nurse should use long, firm strokes
from the distal to the proximal areas. This technique:
 A. Provides an opportunity for skin assessment.
 B. Avoids undue strain on the nurse.
 C. Increases venous blood return.
 D. Causes vasoconstriction and increases circulation.

Incorrect
Correct Answer: C. Increases venous blood return.
Washing from distal to proximal areas stimulates venous blood flow, thereby
preventing venous stasis. Good personal hygiene is essential for skin health but it
also has an important role in maintaining self-esteem and quality of life.
Supporting patients to maintain personal hygiene is a fundamental aspect of
nursing care.
 Option A: The nurse can assess the patient‘s condition throughout the
bath. Helping patients to wash and dress is frequently delegated to junior
staff, but time spent attending to a patient‘s hygiene needs is a valuable
opportunity for nurses to carry out a holistic assessment (Dougherty and
Lister, 2015; Burns and Day, 2012). It also allows time to address any
concerns patients have and provides a valuable opportunity to assess the
condition of their skin.
 Option B: The nurse should feel no strain while bathing the patient. Nurses
should also discuss with patients any religious and cultural issues relating
to personal care (Dougherty and Lister, 2015). For example, ideally, Muslim
patients should be cared for by a nurse of the same gender (Rassool, 2015),
and Hindus may wish to wash before prayer (Dougherty and Lister, 2015).
 Option D: It improves circulation but does not result in vasoconstriction.
Bed bathing is not as effective as showering or bathing and should only be

undertaken when there is no alternative (Dougherty and Lister, 2015). If a
bed bath is required, it is important to offer patients the opportunity to
participate in their own care, which helps to maintain their independence,
self-esteem and dignity.
3. Question
Vivid dreaming occurs in which stage of sleep?
 A. Stage I non-REM
 B. Rapid eye movement (REM) stage
 C. Stage II non-REM
 D. Delta stage
Incorrect
Correct Answer: B. Rapid eye movement (REM) stage
Other characteristics of rapid eye movement (REM) sleep are deep sleep (the
patient cannot be awakened easily), depressed muscle tone, and possibly
irregular heart and respiratory rates. This is the stage associated with dreaming.
Interestingly, the EEG is similar to an awake individual, but the skeletal muscles
are atonic and without movement. The exception is the eye and diaphragmatic
breathing muscles, which remain active. The breathing rate is altered though,
being more erratic and irregular. This stage usually starts 90 minutes after falling
asleep, and each of the REM cycles gets longer throughout the night. The first
period typically lasts 10 minutes, and the final one can last up to an hour.
 Option A: Non-REM sleep is a deep, restful sleep without dreaming. This is
the lightest stage of sleep and starts when more than 50% of the alpha
waves are replaced with low-amplitude mixed-frequency (LAMF) activity.
There is muscle tone present in the skeletal muscle and breathing tends to
occur at a regular rate. This stage tends to last 1 to 5 minutes, consisting of
around 5% of the total cycle.
 Option C: This stage represents deeper sleep the heart rate and body
temperature drop. It is characterized by the presence of sleep spindles, K-
complexes, or both. These sleep spindles will activate the superior temporal
gyri, anterior cingulate, insular cortices, and the thalamus. The K-complexes
show a transition into a deeper sleep. Stage 2 sleep lasts around 25

minutes in the initial cycle and lengthens with each successive cycle,
eventually consisting of about 50% of total sleep.
 Option D: Delta stage, or slow-wave sleep, occurs during non-REM Stages
III and IV and is often equated with quiet sleep. This is considered the
deepest stage of sleep and is characterized by a much slower frequency
with high amplitude signals known as delta waves. This stage is the most
difficult to awaken from, and for some people, even loud noises (over 100
decibels) will not awaken them. As people get older, they tend to spend
less time in this slow, delta wave sleep and more time stage N2 sleep. This
is the stage when the body repairs and regrows its tissues, builds bone and
muscle, and strengthens the immune system.
4. Question
The natural sedative in meat and milk products (especially warm milk) that can
help induce sleep is:
 A. Flurazepam
 B. Temazepam
 C. Methotrimeprazine
 D. Tryptophan
Incorrect
Correct Answer: D. Tryptophan
Tryptophan is a natural sedative; flurazepam (Dalmane), temazepam (Restoril),
and methotrimeprazine (Levoprome) are hypnotic sedatives. Protein foods such
as milk and milk products contain the sleep-inducing amino acid tryptophan.
Having warm milk at bedtime is a good way to work towards reaching the
recommended number of servings of Milk and Alternatives each day, and can be
a comforting way to unwind. Tryptophan is an amino acid that promotes sleep
and is found in small amounts in all protein foods. It is a precursor to the sleep-
inducing compounds serotonin (a neurotransmitter), and melatonin (a hormone
which also acts as a neurotransmitter).
 Option A: Flurazepam (marketed under the brand names Dalmane and
Dalmadorm) is a drug which is a benzodiazepine derivative. It possesses
anxiolytic, anticonvulsant, hypnotic, sedative and skeletal muscle relaxant

properties. It produces a metabolite with a long half-life, which may stay in
the bloodstream for days.
 Option B: Temazepam is used on a short-term basis to treat insomnia
(difficulty falling asleep or staying asleep). Temazepam is in a class of
medications called benzodiazepines. It works by slowing activity in the
brain to allow sleep.
 Option C: Levomepromazine (also known as methotrimeprazine) is used to
treat severe mental/mood disorders (such as schizophrenia, bipolar
disorder). It works by helping to restore certain natural substances in the
brain. Levomepromazine belongs to a class of drugs known as
phenothiazines. It can help the client to think clearly and take part in
everyday life. It is also used to treat anxiety disorders, a certain sleep
problem (insomnia), nausea/vomiting, and pain. This medication has
calming, relaxing, and pain-relieving effects.
5. Question
Nursing interventions that can help the patient to relax and sleep restfully include
all of the following except:
 A. Have the patient take a 30- to 60-minute nap in the afternoon.
 B. Turn on the television in the patient‘s room.
 C. Provide quiet music and interesting reading material.
 D. Massage the patient‘s back with long strokes.

Incorrect
Correct Answer: A. Have the patient take a 30- to 60-minute nap in the
afternoon.
Napping in the afternoon is not conducive to nighttime sleeping. There are few
considerations about naps. For example, a short daytime nap of 15-30 minutes
can be restorative for elders and will not interfere with nighttime sleep. On the
other hand, insomniacs are cautioned to avoid naps. Quiet music, watching
television, reading, and massage usually will relax the patient, helping him to fall
asleep.
 Option B: For patients in the hospital, factors that can prevent sound sleep
include staff noise during a shift, telephones and call lights, doors, paging
systems, and even carts wheeled through corridors. Safety and comfort can

be promoted by raising side rails, placing the bed in a low position, and
using night-lights.
 Option C: For individuals who are unable to sleep, they must get out of
bed and spend some time in another room. There, they can start some
relaxing activities like reading and listening to soft music. They should
continue the activity till they feel drowsy.
 Option D: Rituals can be supported in institutionalized patients by
assisting them with a hand and face wash, massage, pillow plumping, and
even talking about today‘s accomplishments and enjoyable events. These
can promote relaxation and peace of mind.
6. Question
Restraints can be used for all of the following purposes except to:
 A. Prevent a confused patient from removing tubes, such as feeding tubes,

I.V. lines, and urinary catheters.
 B. Prevent a patient from falling out of bed or a chair.
 C. Discourage a patient from attempting to ambulate alone when he requires

assistance for his safety.
 D. Prevent a patient from becoming confused or disoriented.

Incorrect
Correct Answer: D. Prevent a patient from becoming confused or
disoriented.
By restricting a patient‘s movements, restraints may increase stress and lead to
confusion, rather than prevent it. Restraints in a medical setting are devices that
limit a patient‘s movement. Restraints can help keep a person from getting hurt
or doing harm to others, including their caregivers. They are used as a last resort.
The other choices are valid reasons for using restraints.
 Option A: Sometimes hospital patients who are confused need restraints
so that they do not remove catheters and tubes that give them medicine
and fluids. A nurse who has special training in using restraints can begin to
use them. A doctor or another provider must also be told restraints are
being used. The doctor or other provider must then sign a form to allow
the continued use of restraints.

 Option B: Restraints may be used to keep a person in proper position and
prevent movement or falling during surgery or while on a stretcher.
Patients who are restrained also need to have their blood flow checked to
make sure the restraints are not cutting off their blood flow. They also
need to be watched carefully so that the restraints can be removed as soon
as the situation is safe.
 Option C: Restraints can also be used to control or prevent harmful
behavior or get out of bed, fall, and hurt themselves. Restraints should not
cause harm or be used as punishment. Health care providers should first
try other methods to control a patient and ensure safety. Restraints should
be used only as a last choice.
7. Question
Which of the following is the nurse‘s legal responsibility when applying
restraints?
 A. Document the patient‘s behavior.
 B. Document the type of restraint used.
 C. Obtain a written order from the physician except in an emergency, when

the patient must be protected from injury to himself or others.
 D. All of the above.

Incorrect
Correct Answer: D. All of the above
When applying restraints, the nurse must document the type of behavior that
prompted her to use them, document the type of restraints used, and obtain a
physician‘s written order for the restraints. Nurses are accountable for providing,
facilitating, advocating and promoting the best possible patient care and to take
action when patient safety and well-being are compromised, including when
deciding to apply restraints.
 Option A: Restraint use should be continually assessed by the health care
team and reduced or discontinued as soon as possible. After the
discontinuing restraints, interprofessional teams should debrief with the
patient, patient‘s family, or substitute decision maker to discuss
intervention, previous interventions and alternatives to restraints.

 Option B: There are three types of restraints: physical, chemical and
environmental. Physical restraints limit a patient‘s movement. Chemical
restraints are any form of psychoactive medication used not to treat illness,
but to intentionally inhibit a particular behaviour or movement.
Environmental restraints control a patient‘s mobility.
 Option C: With any intervention, such as restraint use, nurses need to
ensure they actively involve the patient, patient‘s family, substitute
decision-makers and the broader health care team. Nurses are also
accountable for documenting nursing care provided, including assessment,
planning, intervention and evaluation. In emergency situations, nurses may
apply restraints without consent when a serious threat of harm to the
patient or others exists and only after all alternative interventions were
unsuccessful.
8. Question
Kubler-Ross‘s five successive stages of death and dying are:
 A. Anger, bargaining, denial, depression, acceptance
 B. Denial, anger, depression, bargaining, acceptance
 C. Denial, anger, bargaining, depression acceptance
 D. Bargaining, denial, anger, depression, acceptance

Incorrect
Correct Answer: C. Denial, anger, bargaining, depression acceptance
Kubler-Ross‘s five successive stages of death and dying are denial, anger,
bargaining, depression, and acceptance. The patient may move back and forth
through the different stages as he and his family members react to the process of
dying, but he usually goes through all of these stages to reach acceptance.
 Option A: Denial is a common defense mechanism used to protect oneself
from the hardship of considering an upsetting reality. Kubler-Ross noted
that after the initial shock of receiving a terminal diagnosis, patients would
often reject the reality of the new information. Patients may directly deny
the diagnosis, attribute it to faulty tests or an unqualified physician, or
simply avoid the topic in conversation.
 Option B: Anger, as Kubler-Ross pointed out, is commonly experienced
and expressed by patients as they concede the reality of a terminal illness.

It may be directed, as with blame of medical providers for inadequately
preventing the illness, of family members for contributing to risks of not
being sufficiently supportive, or of spiritual providers or higher powers for
the diagnosis‘ injustice.
 Option D: Bargaining typically manifests as patients seek some measure of
control over their illness. The negotiation could be verbalized or internal
and could be medical, social, or religious. The patients‘ proffered bargains
could be rational, such as a commitment to adhere to treatment
recommendations or accept help from their caregivers, or could represent
more magical thinking, such as with efforts to appease misattributed guilt
they may feel is responsible for their diagnosis. Depression is perhaps the
most immediately understandable of Kubler-Ross‘s stages and patients
experience it with unsurprising symptoms such as sadness, fatigue, and
anhedonia. Acceptance describes recognizing the reality of a difficult
diagnosis while no longer protesting or struggling against it. Patients may
choose to focus on enjoying the time they have left and reflecting on their
memories.
9. Question
A terminally ill patient usually experiences all of the following feelings during the
anger stage except:
 A. Rage
 B. Envy
 C. Numbness
 D. Resentment
Incorrect
Correct Answer: C. Numbness
Numbness is typical of the depression stage, when the patient feels a great sense
of loss. Depression is perhaps the most immediately understandable of Kubler-
Ross‘s stages and patients experience it with unsurprising symptoms such as
sadness, fatigue, and anhedonia. Spending time in the first three stages is
potentially an unconscious effort to protect oneself from this emotional pain,
and, while the patient‘s actions may potentially be easier to understand, they may
be more jarring in juxtaposition to behaviors arising from the first three stages.

 Option A: The anger stage includes such feelings as rage, envy,
resentment, and the patient‘s questioning ―Why me?‖ Anger, as Kubler-
Ross pointed out, is commonly experienced and expressed by patients as
they concede the reality of a terminal illness. It may be directed, as with
blame of medical providers for inadequately preventing the illness, of
family members for contributing to risks of not being sufficiently
supportive, or of spiritual providers or higher powers for the diagnosis‘
injustice.
 Option B: Patients may feel sadness, anger, or confusion. They are
experiencing the pain of loss. The task is completed as the patient begins
to feel ―normal‖ again.
 Option D: The anger may also be generalized and undirected, manifesting
as a shorter temper or a loss of patience. Recognizing anger as a natural
response can help health care providers and loved-ones to tolerate what
might otherwise feel like hurtful accusations, though they must take care
not to disregard criticism that may be warranted by attributing them solely
to an emotional stage.
10. Question
Nurses and other healthcare providers often have difficulty helping a terminally ill
patient through the necessary stages leading to acceptance of death. Which of
the following strategies is most helpful to the nurse in achieving this goal?
 A. Taking psychology courses related to gerontology.
 B. Reading books and other literature on the subject of thanatology.
 C. Reflecting on the significance of death.
 D. Reviewing varying cultural beliefs and practices related to death.

Incorrect
Correct Answer: C. Reflecting on the significance of death
According to thanatologists, reflecting on the significance of death helps to
reduce the fear of death and enables the health care provider to better
understand the terminally ill patient‘s feelings. It also helps to overcome the
belief that medical and nursing measures have failed, when a patient cannot be
cured. Thanatology is the science and study of death and dying from multiple
perspectives—medical, physical, psychological, spiritual, ethical, and more.

 Option A: Professionals in a wide range of disciplines use thanatology to
inform their work, from doctors and coroners to hospice workers and grief
counselors. There also are thanatology specialists who focus on a specific
aspect of the dying process or work directly with people facing their own
death or that of loved ones.
 Option B: A wide variety of professionals incorporate thanatology into
their work. How they do so depends on what they need to know about the
dying process. For example, a medical examiner, coroner, doctor, nurse, or
other medical practitioners might study thanatology to better understand
the physical process of death—what happens to the body during death as
well as immediately after.
 Option D: Thanatology also examines attitudes toward death, the meaning
and behaviors of bereavement and grief, and the moral and ethical
questions of euthanasia, organ transplants, and life support.
11. Question
Which of the following symptoms is the best indicator of imminent death?
 A. A weak, slow pulse
 B. Increased muscle tone
 C. Fixed, dilated pupils
 D. Slow, shallow respirations

Incorrect
Correct Answer: C. Fixed, dilated pupils
Fixed, dilated pupils are a sign of imminent death. Death is a part of natural life;
however, society is notorious for being uncomfortable with death and dying as a
topic on the whole. Many caregivers experience a level of burden from their
duties during end-of-life care. This burden is multi-faceted and may include
performing medical tasks, communicating with providers, decision-making and
possibly anticipating the grief of impending loss.
 Option A: Pulse becomes weak but rapid. It is important to identify how to
know death has occurred and to educate the family of a patient who may
be actively dying. This is especially important if the patient is choosing to
die at home.

 Option B: Muscles become weak and atonic. It is imperative that patients
and families have access to the care and support they require when
entering a terminal phase of life. This phase is different for each patient,
and the needs may differ for each patient and family, but it is vital for
healthcare providers to provide care and support in a way that respects the
patient‘s dignity and autonomous wishes.
 Option D: In the late stages, an altered respiratory pattern which can be
periods of apnea alternated with hyperpnea or irregular breathing can be
noticed.
12. Question
A nurse caring for a patient with an infectious disease who requires isolation
should refers to guidelines published by the:
 A. National League for Nursing (NLN)
 B. Centers for Disease Control (CDC)
 C. American Medical Association (AMA)
 D. American Nurses Association (ANA)

Incorrect
Correct Answer: B. Centers for Disease Control (CDC)
The Center of Disease Control (CDC) publishes and frequently updates guidelines
on caring for patients who require isolation. CDC is responsible for controlling the
introduction and spread of infectious diseases, and provides consultation and
assistance to other nations and international agencies to assist in improving their
disease prevention and control, environmental health, and health promotion
activities.
 Option A: The National League of Nursing‘s (NLN‘s) major function is
accrediting nursing education programs in the United States. The NLN, the
premier organization for nurse educators, offers professional development,
teaching resources, research grants, testing services, and public policy
initiatives to its 40,000 individual and 1,200 institutional members,
comprising nursing education programs across higher education and
health care.
 Option C: The American Medical Association (AMA) is a national
organization of physicians. American Medical Association (AMA),

organization of American physicians, the objective of which is ―to promote
the science and art of medicine and the betterment of public health.‖ It was
founded in Philadelphia in 1847 by 250 delegates representing more than
40 medical societies and 28 colleges.
 Option D: The American Nurses‘ Association (ANA) is a national
organization of registered nurses. ANA guides the profession on issues of
nursing practice, health policy, and social concerns that impact patient
wellbeing. Through their position statements, ANA amplifies the voice of
nurses and educates both consumers and policymakers.
13. Question
To institute appropriate isolation precautions, the nurse must first know the:
 A. Organism’s mode of transmission
 B. Organism‘s Gram-staining characteristics
 C. Organism‘s susceptibility to antibiotics
 D. Patient‘s susceptibility to the organism

Incorrect
Correct Answer: A. Organism’s mode of transmission
Before instituting isolation precaution, the nurse must first determine the
organism‘s mode of transmission. For example, an organism transmitted through
nasal secretions requires that the patient be kept in respiratory isolation, which
involves keeping the patient in a private room with the door closed and wearing
a mask, a gown, and gloves when coming in direct contact with the patient.
 Option B: The organism‘s Gram-staining characteristics reveal whether the
organism is gram-negative or gram-positive, an important criterion in the
physician‘s choice for drug therapy and the nurse‘s development of an
effective plan of care.
 Option C: The nurse also needs to know whether the organism is
susceptible to antibiotics, but this could take several days to determine; if
she waits for the results before instituting isolation precautions, the
organism could be transmitted in the meantime.
 Option D: The patient‘s susceptibility to the organism has already been
established. The nurse would not be instituting isolation precautions for a
non-infected patient.

14. Question
Which is the correct procedure for collecting a sputum specimen for culture and
sensitivity testing?
 A. Have the patient place the specimen in a container and enclose the
container in a plastic bag.
 B. Have the patient expectorate the sputum while the nurse holds the
container.
 C. Have the patient expectorate the sputum into a sterile container.
 D. Offer the patient an antiseptic mouthwash just before he expectorate the

sputum.
Incorrect
Correct Answer: C. Have the patient expectorate the sputum into a sterile
container
Placing the specimen in a sterile container ensures that it will not become
contaminated. A sputum specimen is obtained for culture to identify the
microorganism responsible for lung infections; identify cancer cells shed by lung
tumors; or aid in the diagnosis and management of occupational lung diseases.
The other answers are incorrect because they do not mention sterility and
because antiseptic mouthwash could destroy the organism to be cultured (before
sputum collection, the patient may use only tap water for nursing the mouth).
 Option A: Using the sterile collection container provided, instruct the
patient to take three deep breaths, then force a deep cough and
expectorate into a sterile screw-top container. To prevent contamination by
particles in the air, keep the container closed until the patient is ready to
spit into it.
 Option B: Ten to 15 ml of sputum is typically needed for laboratory
analysis. A specimen will be rejected by the laboratory if it contains
excessive numbers of epithelial cells from the mouth or throat or if it fails
to show adequate numbers of neutrophils on gram staining. If the patient
cannot cough up a specimen, the respiratory therapist can use sputum
induction techniques such as heated aerosol (nebulization), followed in
some instances by postural drainage and percussion.

 Option D: Don‘t allow the patient to brush his teeth or use mouthwash.
Doing so could kill bacteria in the sputum, rendering it useless. For best
results, obtain the sample first thing in the morning. If it can‘t be obtained
before the patient has breakfast, though, wait at least an hour after he‘s
eaten before trying. Before beginning, describe the procedure to him.
15. Question
An autoclave is used to sterilize hospital supplies because:
 A. More articles can be sterilized at a time.
 B. Steam causes less damage to the materials.
 C. A lower temperature can be obtained.
 D. Pressurized steam penetrates the supplies better.

Incorrect
Correct Answer: D. Pressurized steam penetrates the supplies better.
An autoclave, an apparatus that sterilizes equipment by means of high-
temperature pressurized steam, is used because it can destroy all forms of
microorganisms, including spores. Autoclaves operate at high temperature and
pressure in order to kill microorganisms and spores. They are used to
decontaminate certain biological waste and sterilize media, instruments, and
labware.
 Option A: Autoclaves provide a physical method for disinfection and
sterilization. They work with a combination of steam, pressure, and time.
Autoclaves operate at high temperature and pressure in order to kill
microorganisms and spores. They are used to decontaminate certain
biological waste and sterilize media, instruments and lab ware. Regulated
medical waste that might contain bacteria, viruses and other biological
material are recommended to be inactivated by autoclaving before
disposal.
 Option B: The rate of exhaust will depend upon the nature of the load. Dry
material can be treated in a fast exhaust cycle, while liquids and biological
waste require slow exhaust to prevent boiling over of superheated liquids.
 Option C: To be effective, the autoclave must reach and maintain a
temperature of 121° C for at least 30 minutes by using saturated steam

under at least 15 psi of pressure. Increased cycle time may be necessary
depending upon the make-up and volume of the load.
16. Question
The best way to decrease the risk of transferring pathogens to a patient when
removing contaminated gloves is to:
 A. Wash the gloves before removing them.
 B. Gently pull on the fingers of the gloves when removing them.
 C. Gently pull just below the cuff and invert the gloves when removing
them.
 D. Remove the gloves and then turn them inside out.

Incorrect
Correct Answer: C. Gently pull just below the cuff and invert the gloves
when removing them
Turning the gloves inside out while removing them keeps all contaminants inside
the gloves. They should then be placed in a plastic bag with soiled dressings and
discarded in a soiled utility room garbage pail (double bagged). The other
choices can spread pathogens within the environment.
 Option A: They should also only be worn once, being changed between
patients or between treatment areas on the same patient. For situations
where there is a high risk of contamination or infection, NHS Professionals
advise wearing two sets of gloves, known as ‗double gloving‘.
 Option B: Grasp the outside of one glove at the wrist. Do not touch the
bare skin. Peel the glove away from the body, pulling it inside out. Hold the
glove that was just removed in a gloved hand.
 Option D: Peel off the second glove by putting the fingers inside the glove
at the top of the wrist. Turn the second glove inside out while pulling it
away from the body, leaving the first glove inside the second.
17. Question

After having an I.V. line in place for 72 hours, a patient complains of tenderness,
burning, and swelling. Assessment of the I.V. site reveals that it is warm and
erythematous. This usually indicates:
 A. Infection
 B. Infiltration
 C. Phlebitis
 D. Bleeding
Incorrect
Correct Answer: C. Phlebitis
Tenderness, warmth, swelling, and, in some instances, a burning sensation are
signs and symptoms of phlebitis. Superficial phlebitis affects veins on the skin
surface. The condition is rarely serious and, with proper care, usually resolves
rapidly. Sometimes people with superficial phlebitis also get deep vein
thrombophlebitis, so a medical evaluation is necessary.
 Option A: Infection is less likely because no drainage or fever is present.
Call a health care provider if there are signs and symptoms of swelling,
pain, and inflamed superficial veins on the arms or legs. If the client is not
better in a week or two or if it gets any worse, he or she should get
reevaluated to make sure they don‘t have a more serious condition.
 Option B: Infiltration would result in swelling and pallor, not erythema,
near the insertion site. In phlebitis, there is usually a slow onset of a tender
red area along the superficial veins on the skin. A long, thin red area may
be seen as the inflammation follows a superficial vein. This area may feel
hard, warm, and tender. The skin around the vein may be itchy and swollen.
The area may begin to throb or burn.
 Option D: The patient has no evidence of bleeding. Injury to a vein
increases the risk of forming a blood clot. Sometimes clots occur without
an injury.
18. Question
To ensure homogenization when diluting powdered medication in a vial, the
nurse should:

 A. Shake the vial vigorously.
 B. Roll the vial gently between the palms.
 C. Invert the vial and let it stand for 1 minute.
 D. Do nothing after adding the solution to the vial.

Incorrect
Correct Answer: B. Roll the vial gently between the palms.
Gently rolling a sealed vial between the palms produces sufficient heat to
enhance dissolution of a powdered medication.
 Option A: Shaking the vial vigorously can break down the medication and
alter its pharmacologic action.
 Option C: Inverting the vial or leaving it alone does not ensure thorough
homogenization of the powder and the solvent.
 Option D: Use aseptic technique to draw up the specified amount of
diluent and inject it into the medication vial. Roll the vial in the hands to
dissolve all the powder (emphasize not to shake the vial).
19. Question
The nurse is teaching a patient to prepare a syringe with 40 units of U-100 NPH
insulin for self-injection. The patient‘s first priority concerning self-injection in
this situation is to:
 A. Assess the injection site.
 B. Select the appropriate injection site.
 C. Check the syringe to verify that the nurse has removed the prescribed
insulin dose.
 D. Clean the injection site in a circular manner with an alcohol sponge.

Incorrect
Correct Answer: C. Check the syringe to verify that the nurse has removed
the prescribed insulin dose
When the nurse teaches the patient to prepare an insulin injection, the patient‘s
first priority is to validate the dose accuracy. The next steps are to select the site,
assess the site, and clean the site with alcohol before injecting the insulin.

 Option A: The site the client chooses for the injection should be clean and
dry. If the skin is visibly dirty, clean it with soap and water. DO NOT use an
alcohol wipe on the injection site. Choose where to give the injection. Keep
a chart of places that have been used, so the client does not inject the
insulin in the same place all the time. Ask the doctor for a chart.
 Option B: The insulin needs to go into the fat layer under the skin. If the
skin tissues are thicker, the client may be able to inject straight up and
down (90º angle). Check with the provider before doing this.
 Option D: To give an insulin injection, the client needs to fill the right
syringe with the right amount of medicine, decide where to give the
injection, and know how to give the injection.
20. Question
The physician‘s order reads ―Administer 1 g cefazolin sodium (Ancef) in 150 ml of
normal saline solution in 60 minutes.‖ What is the flow rate if the drop factor is 10
gtt = 1 ml?
 A. 25 gtt/minute
 B. 37 gtt/minute
 C. 50 gtt/minute
 D. 60 gtt/minute
Incorrect
Correct Answer: A. 25 gtt/minute
When you have an order for an IV infusion, it is the nurse‘s responsibility to make
sure the fluid will infuse at the prescribed rate. IV fluids may be infused by gravity
using a manual roller clamp or dial-a-flow, or infused using an infusion pump.
Regardless of the method, it is important to know how to calculate the correct IV
flow rate.
 Option B: When calculating the flow rate, determine which IV tubing you
will be using, microdrip or macrodrip, so you can use the proper drop
factor in your calculations. The drop factor is the number of drops in one
mL of solution, and is printed on the IV tubing package.
 Option C: Macrodrip and microdrip refers to the diameter of the needle
where the drop enters the drip chamber. Macrodrip tubing delivers 10 to
20 gtts/mL and is used to infuse large volumes or to infuse fluids quickly.

Microdrip tubing delivers 60 gtts/mL and is used for small or very precise
amounts of fluid, as with neonates or pediatric patients.
 Option D: If you simply need to figure out the mL per hour to infuse, take
the total volume in mL, divided by the total time in hours, to equal the mL
per hour.
21. Question
A patient must receive 50 units of Humulin regular insulin. The label reads 100
units = 1 ml. How many milliliters should the nurse administer?
 A. 0.5 ml
 B. 0.75 ml
 C. 1 ml
 D. 2 ml
Incorrect
Correct Answer: A. 0.5 ml
There are 3 primary methods for calculation of medication dosages; Dimensional
Analysis, Ratio Proportion, and Formula or Desired Over Have Method. Desired
Over Have or Formula Method uses a formula or equation to solve for an
unknown quantity (x) much like ratio proportion.
 Option B: Drug calculations require the use of conversion factors, for
example, when converting from pounds to kilograms or liters to milliliters.
Simplistic in design, this method allows clinicians to work with various units
of measurement, converting factors to find the answer. These methods are
useful in checking the accuracy of the other methods of calculation, thus
acting as a double or triple check.
 Option C: The Ratio and Proportion Method has been around for years
and is one of the oldest methods utilized in drug calculations (as cited in
Boyer, 2002)[Lindow, 2004]. Addition principals is a problem-solving
technique that has no bearing on this relationship, only multiplication, and
division are used to navigate through a ratio and proportion problem, not
adding.
 Option D: High-risk medications such as heparin and insulin often require
a second check on dosage amounts by more than one provider before the
administration of the drug. Follow institutional policies and

recommendations on the double-checking of dose calculations by another
licensed provider.
22. Question
How should the nurse prepare an injection for a patient who takes both regular
and NPH insulin?
 A. Draw up the NPH insulin, then the regular insulin, in the same syringe.
 B. Draw up the regular insulin, then the NPH insulin, in the same
syringe.
 C. Use two separate syringes.
 D. Check with the physician.

Incorrect
Correct Answer: B. Draw up the regular insulin, then the NPH insulin, in the
same syringe.
Drugs that are compatible may be mixed together in one syringe. In the case of
insulin, the shorter-acting, clear insulin (regular) should be drawn up before the
longer-acting, cloudy insulin (NPH) to ensure accurate measurements.
 Option A: Insulin, regular when administered subcutaneously, it should be
injected 30 to 40 minutes before each meal. Avoid cold injections. The
injection is in the buttocks, thighs, arms, or abdomen; it is necessary to
rotate injection sites to avoid lipodystrophy. Do not inject if the solution is
viscous or cloudy; use only if clear and colorless.
 Option C: When administered intravenously, U-100 administration should
be with close monitoring of serum potassium and blood glucose. Do not
use if the solution is viscous or cloudy; administration should only take
place if it is colorless and clear.
 Option D: For intravenous infusions, to minimize insulin adsorption to
plastic IV tubing, flush the intravenous tube with priming infusion of 20 mL
from a 100 mL-polyvinyl chloride bag insulin, every time a new intravenous
tubing is added to the insulin infusion container.
23. Question

A patient has just received 30 mg of codeine by mouth for pain. Five minutes
later he vomits. What should the nurse do first?
 A. Call the physician
 B. Remedicate the patient
 C. Observe the emesis
 D. Explain to the patient that she can do nothing to help him.

Incorrect
Correct Answer: C. Observe the emesis.
After a patient has vomited, the nurse must inspect the emesis to document
color, consistency, and amount. Nausea or vomiting is another commonly seen
adverse effect that is expected to diminish the following days to weeks of
continued codeine exposure. Antiemetic therapies, in oral and rectal
formulations, are available for the treatment of nausea or vomiting.
 Option A: The nurse must then notify the physician, who will decide
whether to repeat the dose or prescribe an antiemetic. Monitoring should
include subjective as well as objective assessment via laboratory testing.
There must be documentation of pain intensity, level of functioning,
progress toward therapeutic goals, the presence of adverse effects, and
adherence to the therapy.
 Option B: In this situation, the patient recently ingested medication, so the
nurse needs to check for remnants of the medication to help determine
whether the patient retained enough of it to be effective.
 Option D: Codeine has a half-life of 3 hours. Initial dosing and titration can
be individualized depending on the patient‘s health status, previous opioid
exposure, attainment of therapeutic outcomes, and predicted or observed
adverse events.
24. Question
A patient is catheterized with a #16 indwelling urinary (Foley) catheter to
determine if:
 A. Trauma has occurred.
 B. His 24-hour output is adequate.

 C. He has a urinary tract infection.
 D. Residual urine remains in the bladder after voiding.

Incorrect
Correct Answer: B. His 24-hour output is adequate.
A 24-hour urine output of less than 500 ml in an adult is considered inadequate
and may indicate kidney failure. This must be corrected while the patient is in the
acute state so that appropriate fluids, electrolytes, and medications can be
administered and excreted. Indwelling catheterization is not needed to diagnose
trauma, urinary tract infection, or residual urine.
 Option A: Urinary bladder catheterization is performed for both
therapeutic and diagnostic purposes. Based on the dwell time, the urinary
catheter can be either intermittent (short-term) or indwelling (long-term).
 Option C: Cystitis, urethritis, prostatitis (common infectious etiology in
men), and vulvovaginitis in the woman can cause urinary retention.
 Option D: Brain or spinal cord injury, cerebrovascular accident, multiple
sclerosis, Parkinson disease, and dementia can lead to urinary retention.
25. Question
A staff nurse who is promoted to assistant nurse manager may feel
uncomfortable initially when supervising her former peers. She can best decrease
this discomfort by:
 A. Writing down all assignments.
 B. Making changes after evaluating the situation and having discussions

with the staff.
 C. Telling the staff nurses that she is making changes to benefit their
performance.
 D. Evaluating the clinical performance of each staff nurse in a private

conference.
Incorrect
Correct Answer: B. Making changes after evaluating the situation and
having discussions with the staff.

A new assistant nurse manager should not make changes until she has had a
chance to evaluate staff members, patients, and physicians. Changes must be
planned thoroughly and should be based on a need to improve conditions, not
just for the sake of change.
 Option A: Written assignments allow all staff members to know their own
and others‘ responsibilities and serve as a checklist for the manager,
enabling her to gauge whether the unit is being run effectively and
whether patients are receiving appropriate care.
 Option C: Telling the staff nurses that she is making changes to benefit
their performance should occur only after the nurse has made a thorough
evaluation.
 Option D: Evaluations are usually done on a yearly basis or as needed.
26. Question
Nurse Clarisse is teaching a patient about a newly prescribed drug. What could
cause a geriatric patient to have difficulty retaining knowledge about prescribed
medications?
 A. Decreased plasma drug levels
 B. Sensory deficits
 C. Lack of family support
 D. History of Tourette syndrome

Incorrect
Correct Answer: B. Sensory deficits
Sensory deficits could cause a geriatric patient to have difficulty retaining
knowledge about prescribed medications. Age-related decline of the five classical
senses (vision, smell, hearing, touch, and taste) poses significant burdens on older
adults. The co-occurrence of multiple sensory deficits in older adults is not well
characterized and may reflect a common mechanism resulting in global sensory
impairment.
 Option A: Decreased plasma drug levels do not alter the patient‘s
knowledge about the drug. Aging has long been associated with decline in
sensory function, a critical component of the health and quality of life of
older people

 Option C: A lack of family support may affect compliance, not knowledge
retention. Vision impairment is correlated with depression, poor quality of
life, cognitive decline, and mortality. Hearing loss is associated with slower
gait speed (a marker of physical decline), poor cognition, and mortality.
Like smell, taste has been associated with nutritional compromise and in-
patient mortality, suggesting that chemosensory function is critical. Tactile
discrimination declines with age due to the cumulative effects of decreased
nerve conduction velocity, decreased density of Meissner‘s and Pacinian
corpuscles, and gray matter changes within the central nervous system,
and is also associated with cognitive decline
 Option D: Tourette syndrome is unrelated to knowledge retention.
Tourette syndrome referred to as Tourette disorder in the recently updated
Diagnostic and Statistical Manual of Mental Disorders (DSM–5), is a
common neurodevelopmental disorder affecting up to 1% of the
population. It is characterized by multiple motor and vocal tics and starts in
childhood.
27. Question
When examining a patient with abdominal pain the nurse in charge should
assess:
 A. Any quadrant first
 B. The symptomatic quadrant first
 C. The symptomatic quadrant last
 D. The symptomatic quadrant either second or third

Incorrect
Correct Answer: C. The symptomatic quadrant last
The nurse should systematically assess all areas of the abdomen, if time and the
patient‘s condition permit, concluding with the symptomatic area. Otherwise, the
nurse may elicit pain in the symptomatic area, causing the muscles in other areas
to tighten. This would interfere with further assessment.
 Option A: When possible, the history should be obtained from a non
sedated patient. The initial differential diagnosis can be determined by a
delineation of the pain‘s location, radiation, and movement (e.g.,

appendicitis-associated pain usually moves from the periumbilical area to
the right lower quadrant of the abdomen).
 Option B: After the location is identified, the physician should obtain
general information about onset, duration, severity, and quality of pain and
about exacerbating and remitting factors.
 Option D: There are several specialized maneuvers that evaluate for signs
associated with causes of abdominal pain. When present, some signs are
highly predictive of certain diseases.
28. Question
The nurse is assessing a postoperative adult patient. Which of the following
should the nurse document as subjective data?
 A. Vital signs
 B. Laboratory test result
 C. Patient’s description of pain
 D. Electrocardiographic (ECG) waveforms

Incorrect
Correct Answer: C. Patient’s description of pain
Subjective data come directly from the patient and usually are recorded as direct
quotations that reflect the patient‘s opinions or feelings about a situation.
Subjective data provide clues to possible physiologic, psychological, and
sociologic problems. They also provide the nurse with information that may
reveal a client‘s risk for a problem as well as areas of strengths for the client. The
information is obtained through interviewing. Vital signs, laboratory test results,
and ECG waveforms are examples of objective data.
 Option A: Vital sign monitoring is a fundamental component of nursing
care. A patient‘s pulse, respirations, blood pressure, and body temperature
are essential in identifying clinical deterioration and that these parameters
must be measured consistently and recorded accurately.
 Option B: Many other tests are reported as numbers or values. Laboratory
test results reported as numbers are not meaningful by themselves. Their
meaning comes from comparison to reference values. Reference values are
the values expected for a healthy person. They are sometimes called
―normal‖ values.

 Option D: The standard 12-lead electrocardiogram (ECG) is one of the
most commonly used medical studies in the assessment of cardiovascular
disease. It is the most important test for interpretation of the cardiac
rhythm, detection of myocardial ischemia and infarction, conduction
system abnormalities, preexcitation, long QT syndromes, atrial
abnormalities, ventricular hypertrophy, pericarditis, and other conditions.
29. Question
A male patient has a soft wrist-safety device. Which assessment finding should
the nurse consider abnormal?
 A. A palpable radial pulse
 B. A palpable ulnar pulse
 C. Cool, pale fingers
 D. Pink nail beds

Incorrect
Correct Answer: C. Cool, pale fingers
A safety device on the wrist may impair circulation and restrict blood supply to
body tissues. Therefore, the nurse should assess the patient for signs of impaired
circulation, such as cool, pale fingers. A palpable radial or lunar pulse and pink
nail beds are normal findings.
 Option A: To palpate a radial pulse, place the tips of the first two or three
fingers over the groove along the radial (or thumb) side of the patient‘s
inner wrist. Slightly extended or flexed the patient‘s wrist with the palm
down until the pulse was strongest. Lightly compressed the artery against
the radius, obliterating the pulse initially.
 Option B: The pulse is felt just above a large, raised bony area called the
zygomatic arch. Like the radial pulse, the ulnar pulse is taken at the wrist.
 Option D: These old cells flatten and harden, thanks to keratin, a protein
made by these cells. The newly formed nail then slides along the nail bed,
the flat surface under the nails. The nail bed sits on top of tiny blood
vessels that feed it and give the nails their pink color.
30. Question

Which of the following planes divides the body longitudinally into anterior and
posterior regions?
 A. Frontal plane
 B. Sagittal plane
 C. Midsagittal plane
 D. Transverse plane
Incorrect
Correct Answer: A. Frontal plane
Frontal or coronal plane runs longitudinally at a right angle to a sagittal plane
dividing the body in anterior and posterior regions. The coronal plane or frontal
plane (vertical) divides the body into dorsal and ventral (back and front, or
posterior and anterior) portions. An anatomical plane is a hypothetical plane used
to transect the body, in order to describe the location of structures or the
direction of movements.
 Option B: A sagittal plane runs longitudinally dividing the body into right
and left regions. The sagittal plane or lateral plane (longitudinal,
anteroposterior) is a plane parallel to the sagittal suture. It divides the body
into left and right.
 Option C: If exactly midline, it is called a midsagittal plane. The midsagittal
or median plane is in the midline; i.e. it would pass through midline
structures such as the navel or spine, and all other sagittal planes (also
referred to as parasagittal planes) are parallel to it. Median can also refer to
the midsagittal plane of other structures, such as a digit.
 Option D: A transverse plane runs horizontally at a right angle to the
vertical axis, dividing the structure into superior and inferior regions. The
transverse plane or axial plane (horizontal) divides the body into cranial
and ca
31. Question
A female patient with a terminal illness is in denial. Indicators of denial include:
 A. Shock dismay
 B. Numbness

 C. Stoicism
 D. Preparatory grief
Incorrect
Correct Answer: A. Shock dismay
Shock and dismay are early signs of denial-the first stage of grief. Denial is a
common defense mechanism used to protect oneself from the hardship of
considering an upsetting reality. Kubler-Ross noted that after the initial shock of
receiving a terminal diagnosis, patients would often reject the reality of the new
information. The other options are associated with depression—a later stage of
grief.
 Option B: Depression is perhaps the most immediately understandable of
Kubler-Ross‘s stages and patients experience it with unsurprising
symptoms such as sadness, fatigue, and anhedonia.
 Option C: Spending time in the first three stages is potentially an
unconscious effort to protect oneself from this emotional pain, and, while
the patient‘s actions may potentially be easier to understand, they may be
more jarring in juxtaposition to behaviors arising from the first three
stages.
 Option D: Consequently, caregivers may need to make a conscious effort
to restore compassion that may have waned while caring for patients
progressing through the first three stages.
32. Question
The nurse in charge is transferring a patient from the bed to a chair. Which action
does the nurse take during this patient transfer?
 A. Position the head of the bed flat.
 B. Helps the patient dangle the legs.
 C. Stands behind the patient.
 D. Place the chair facing away from the bed.

Incorrect
Correct Answer: B. Helps the patient dangle the legs

After placing the patient in High Fowler‘s position and moving the patient to the
side of the bed, the nurse helps the patient sit on the edge of the bed and dangle
the legs; the nurse then faces the patient and places the chair next to and facing
the head of the bed.
 Option A: Allow the patient to sit for a few moments, in case the patient
feels dizzy when first sitting up. To get the patient into a seated position,
roll the patient onto the same side as the wheelchair.
 Option C: The nurse should put one arm under the patient‘s shoulders and
one behind the knees. Bend the knees. Swing the patient‘s feet off the
edge of the bed and use the momentum to help the patient into a sitting
position.
 Option D: Move the patient to the edge of the bed and lower the bed so
the patient‘s feet are touching the ground. Make sure any loose rugs are
out of the way to prevent slipping. You may want to put non-skid socks or
shoes on the patient‘s feet if the patient needs to step onto a slippery
surface.
1. 33. Question
A female patient who speaks a little English has emergency gallbladder surgery,
during discharge preparation, which nursing action would best help this patient
understand wound care instruction?
o A. Asking frequently if the patient understands the instruction.
o B. Asking an interpreter to replay the instructions to the patient.
o C. Writing out the instructions and having a family member read them to the
patient.
o D. Demonstrating the procedure and having the patient return the

demonstration.
Incorrect
Correct Answer: D. Demonstrating the procedure and having the patient
return the demonstration
Demonstrating by the nurse with a return demonstration by the patient ensures
that the patient can perform wound care correctly. One of the leading causes of
medical errors in the United States is miscommunication between patients and
providers. When patients with limited English proficiency (LEP) cannot adequately

communicate their needs, they are less likely to comply with medical instructions
and receive vital services.
 Option A: Patients may claim to understand discharge instruction when
they do not. In-person translation services are preferred when complex
medical information or end-of-life decisions are to be discussed. Studies
show in-person professional interpretation increases patient satisfaction
and outcomes of care. Interpreters use visual cues to enhance
communication. However, in-person interpreters can be costly and can
limit the number of languages that can be adequately staffed.
 Option B: An interpreter of family members may communicate verbal or
written instructions inaccurately. In some cases, patients prefer to use their
family and friends as medical interpreters, but experts recommend against
the practice because vital information may be lost.
 Option C: Internet-based apps for smartphones and tablets help medical
professionals interpret information quickly so they can be used in
emergency settings. Experts warn, however, that the one-sided nature of
such applications can lead to missed or misconstrued information.
ADV
1. Question 34 of 75
34. Question
Before administering the evening dose of a prescribed medication, the nurse on
the evening shift finds an unlabeled, filled syringe in the patient‘s medication
drawer. What should the nurse in charge do?
o A. Discard the syringe to avoid a medication error.
o B. Obtain a label for the syringe from the pharmacy.
o C. Use the syringe because it looks like it contains the same medication the
nurse was prepared to give.
o D. Call the day nurse to verify the contents of the syringe.

Incorrect
Correct Answer: A. Discard the syringe to avoid a medication error.

As a safety precaution, the nurse should discard an unlabeled syringe that
contains medication. The other options are considered unsafe because they
promote error.
 Option B: Since there are no labels on the syringe, obtaining a label from
the pharmacy does not guarantee that they would be able to identify the
medication inside the syringe.
 Option C: Giving an unidentified medication could cause unwanted effects
on the patient instead of desired effects.
 Option D: The day nurse would not be able to guarantee that she could
identify the medication without its label.
ADV
35. Question
When administering drug therapy to a male geriatric patient, the nurse must stay
especially alert for adverse effects. Which factor makes geriatric patients have
adverse drug effects?
o A. Faster drug clearance
o B. Aging-related physiological changes
o C. Increased amount of neurons
o D. Enhanced blood flow to the GI tract

Incorrect
Correct Answer: B. Aging-related physiological changes
Aging-related physiological changes account for the increased frequency of
adverse drug reactions in geriatric patients. ADEs are estimated to be indicated in
5% to 28% of acute geriatric medical admissions. Preventable ADEs are among
one of the serious consequences of inappropriate medication use in older adults.
 Option A: Renal and hepatic changes cause drugs to clear more slowly in
these patients. Aging leads to a reduced number of functional glomeruli
and an increased prevalence of sclerotic changes within the glomeruli or
renal vasculature. Additionally, there is a normal decrease in GFR observed
in advanced age, but this places the elderly at much higher risk for
complications in the event that they develop chronic or acute kidney

disease, as they have less functional glomeruli as a result of normal aging
physiology.
 Option C: With increasing age, neurons are lost. Abnormal compensatory
mechanisms predispose individuals to neurodegeneration and dementia,
Parkinson disease, and overall cerebral atrophy are observable in aging
individuals.
 Option D: Blood flow to the GI tract decreases. The weakening of smooth
muscle in the intestinal tract can promote the development of diverticular
disease and can play a role in bowel obstructions or constipation.
Decreased metabolic activity, specifically in the liver, can lead to alterations
in drug metabolism.
ADV
36. Question
A female patient is being discharged after cataract surgery. After providing
medication teaching, the nurse asks the patient to repeat the instructions. The
nurse is performing which professional role?
o A. Manager
o B. Educator
o C. Caregiver
o D. Patient advocate
Incorrect
Correct Answer: B. Educator
When teaching a patient about medications before discharge, the nurse is acting
as an educator. They provide educational leadership to patients and care
providers to enhance specialized patient care within established healthcare
settings. Assists patients and caregivers with educational needs, problem
resolution, and health management across the continuum of care.
 Option A: The nurse acts as a manager when performing such activities as
scheduling and making patient care assignments. Great nurse managers
are able to work in coordination with other departments. They must also
possess the ability to oversee an array of practice functions including staff

supervision, clinical tasks, and appointments. It is also part of their jobs to
liaise with pathology labs, suppliers, and other health facilities.
 Option C: The nurse performs the caregiving role when providing direct
care, including bathing patients and administering medications and
prescribed treatments. Healthcare should address a patient‘s cultural,
spiritual and mental needs. Increasing diversity in a growing patient
population requires nurses to demonstrate cultural awareness and
sensitivity. Patients may have specific needs and preferences due to their
religion or gender, for example. Nurses need to be respectful of, and
knowledgeable about, diverse backgrounds while remaining vigilant in
providing quality care.
 Option D: The nurse acts as a patient advocate when making the patient‘s
wishes known to the doctor. A nurse advocate is a nurse who works on
behalf of patients to maintain quality of care and protect patients‘ rights.
They intervene when there is a care concern, and following the proper
channels, work to resolve any patient care issues. Realistically, every nurse
is an advocate.
ADV
37. Question
A female patient exhibits signs of heightened anxiety. Which response by the
nurse is most likely to reduce the patient‘s anxiety?
o A. ―Everything will be fine. Don‘t worry.‖
o B. ―Read this manual and then ask me any questions you may have.‖
o C. ―Why don‘t you listen to the radio?‖
o D. “Let’s talk about what’s bothering you.”

Incorrect
Correct Answer: D. “Let’s talk about what’s bothering you.”
Anxiety may result from feelings of helplessness, isolation, or insecurity. This
response helps reduce anxiety by encouraging the patient to express feelings.
The nurse should be supportive and develop goals together with the patient to
give the patient some control over an anxiety-inducing situation. Because the

other options ignore the patient‘s feelings and block communication, they would
not reduce anxiety.
 Option A: Recognize awareness of the patient‘s anxiety. Since a cause of
anxiety cannot always be identified, the patient may feel as though the
feelings being experienced are counterfeit. Acknowledgment of the
patient‘s feelings validates the feelings and communicates acceptance of
those feelings.
 Option B: Converse using a simple language and brief statements. Allow
patients to talk about anxious feelings and examine anxiety-provoking
situations if they are identifiable. Talking about anxiety-producing
situations and anxious feelings can help the patient perceive the situation
realistically and recognize factors leading to the anxious feelings.
 Option C: Assist the patient in developing new anxiety-reducing skills (e.g.,
relaxation, deep breathing, positive visualization, and reassuring self-
statements). Discovering new coping methods provides the patient with a
variety of ways to manage anxiety.
ADV
38. Question
A scrub nurse in the operating room has which responsibility?
o A. Positioning the patient
o B. Assisting with gowning and gloving
o C. Handling surgical instruments to the surgeon
o D. Applying surgical drapes

Incorrect
Correct Answer: C. Handling surgical instruments to the surgeon
The scrub nurse assists the surgeon by providing appropriate surgical
instruments and supplies, maintaining strict surgical asepsis and, with the
circulating nurse, accounting for all gauze, sponges, needles, and instruments.
The circulating nurse assists the surgeon and scrub nurse, positions the patient,
applies appropriate equipment and surgical drapes, assists with gowning and
gloving, and provides the surgeon and scrub nurse with supplies.

 Option A: The circulating nurse is responsible for managing all nursing
care within the operating room, observing the surgical team from a broad
perspective, and assisting the team to create and maintain a safe,
comfortable environment for the patient‘s surgery.
 Option B: A circulating nurse is responsible for coordinating care,
obtaining supplies, and liaising with the patient‘s family.
 Option D: Assessing the patient right before surgery is critical to making
sure that all required prep was completed. Serving as a patient advocate
and safety monitor, the circulating nurse observes the surgery and ensures
that no aspect of patient care is missed.
ADV
39. Question
A patient is in the bathroom when the nurse enters to give a prescribed
medication. What should the nurse in charge do?
o A. Leave the medication at the patient‘s bedside.
o B. Tell the patient to be sure to take the medication. And then leave it at the
bedside.
o C. Return shortly to the patient’s room and remain there until the
patient takes the medication.
o D. Wait for the patient to return to bed, and then leave the medication at the
bedside.
Incorrect
Correct Answer: C. Return shortly to the patient’s room and remain there
until the patient takes the medication
The nurse should return shortly to the patient‘s room and remain there until the
patient takes the medication to verify that it was taken as directed. With the
growing reliance on medication therapy as the primary intervention for most
illnesses, patients receiving medication interventions are exposed to potential
harm as well as benefits. Benefits are effective management of the illness/disease,
slowed progression of the disease, and improved patient outcomes with few if

any errors. Harm from medications can arise from unintended consequences as
well as medication error (wrong medication, wrong time, wrong dose, etc.).
 Option A: The nurse should never leave medication at the patient‘s
bedside unless specifically requested to do so.
 Option B: With inadequate nursing education about patient safety and
quality, excessive workloads, staffing inadequacies, fatigue, illegible
provider handwriting, flawed dispensing systems, and problems with the
labeling of drugs, nurses are continually challenged to ensure that their
patients receive the right medication at the right time.
 Option D: Examples of errors that can be initiated at the transcribing,
dispensing, and delivering stages include failure to transcribe the order,
incorrectly filling the order, and failure to deliver the correct medication for
the correct patient.
ADV
40. Question
The physician orders heparin, 7,500 units, to be administered subcutaneously
every 6 hours. The vial reads 10,000 units per milliliter. The nurse should
anticipate giving how much heparin for each dose?
o A. ¼ ml
o B. ½ ml
o C. ¾ ml
o D. 1 ¼ ml
Incorrect
Correct Answer: C. ¾ ml
The nurse solves the problem as follows:
10,000 units/7,500 units = 1 ml/X
10,000 X = 7,500
X= 7,500/10,000 or ¾ ml
 Option A: There are 3 primary methods for the calculation of medication
dosages, as referenced above. These include Desired Over Have Method or
Formula, Dimensional Analysis and Ratio and Proportion.

 Option B: Desired over Have or Formula Method is a formula or equation
to solve for an unknown quantity (x) much like ratio proportion. Drug
calculations require the use of conversion factors, such as when converting
from pounds to kilograms or liters to milliliters. Simplistic in design, this
method allows us to work with various units of measurement, converting
factors to find our answer. Useful in checking the accuracy of the other
methods of calculation as above mentioned, thus acting as a double or
triple check.
 Option D: The Ratio and Proportion Method has been around for years
adding.
ADV
41. Question
The nurse in charge measures a patient‘s temperature at 102 degrees F. what is
the equivalent Centigrade temperature?
o A. 39 degrees C
o B. 47 degrees C
o C. 38.9 degrees C
o D. 40.1 degrees C
Incorrect
Correct Answer: C. 38.9 degrees C
To convert Fahrenheit degrees to centigrade, use this formula:
C degrees = (F degrees – 32) x 5/9
C degrees = (102 – 32) 5/9
+ 70 x 5/9
38.9 degrees C
 Option A: Fahrenheit and Celsius both use different temperatures for the
freezing and boiling points of water, and also use differently sized degrees.

Water freezes at 0 degrees Celsius, and boils at 100 degrees C, while in
Fahrenheit, water freezes at 32 degrees F and boils at 212 degrees F.
 Option B: Use the relationship in degree size to convert between Celsius
and Fahrenheit. Because Celsius degrees are larger than those in
Fahrenheit, to convert from Celsius to Fahrenheit, multiply the Celsius
temperature by 1.8, then add 32.
 Option D: The Fahrenheit and Celsius scales are the two most common
temperature scales. However, the two scales use different measurements
for the freezing and boiling points of water, and also use different sized
degrees.
ADV
42. Question
To evaluate a patient for hypoxia, the physician is most likely to order which
laboratory test?
o A. Red blood cell count
o B. Sputum culture
o C. Total hemoglobin
o D. Arterial blood gas (ABG) analysis

Incorrect
Correct Answer: D. Arterial blood gas (ABG) analysis
All of these tests help evaluate a patient with respiratory problems. However, ABG
analysis is the only test that evaluates gas exchange in the lungs, providing
information about a patient‘s oxygenation status. An acceptable normal range of
ABG values of ABG components are the following,[5][6] noting that the range of
normal values may vary among laboratories, and in different age groups from
neonates to geriatrics: pH (7.35-7.45) PaO2 (75-100 mmHg) PaCO2 (35-45
mmHg).
 Option A: A red blood cell count is a blood test that the doctor uses to
find out how many red blood cells (RBCs) a person has. It‘s also known as
an erythrocyte count. The test is important because RBCs contain
hemoglobin, which carries oxygen to the body‘s tissues. The number of

RBCs one has can affect how much oxygen the tissues receive. The tissues
need oxygen to function.
 Option B: A sputum culture is a test that checks for bacteria or another
type of organism that may be causing an infection in the lungs or the
airways leading to the lungs. Sputum, also known as phlegm, is a thick type
of mucus made in the lungs.
 Option C: The normal range for hemoglobin is: For men, 13.5 to 17.5
grams per deciliter. For women, 12.0 to 15.5 grams per deciliter.
ADV
43. Question
The nurse uses a stethoscope to auscultate a male patient‘s chest. Which
statement about a stethoscope with a bell and diaphragm is true?
o A. The bell detects high-pitched sounds best.
o B. The diaphragm detects high-pitched sounds best.
o C. The bell detects thrills best.
o D. The diaphragm detects low-pitched sounds best.

Incorrect
Correct Answer: B. The diaphragm detects high-pitched sounds best.
The diaphragm of a stethoscope detects high-pitched sound best; the bell
detects low pitched sounds best. Palpation detects thrills best. The bell is flat and
round and is covered by a thin layer of plastic known as the diaphragm. The
diaphragm vibrates as sound is produced within the body. These vibrations travel
from the bell, up the hollow tube which splits into two, and into hollow earpieces
to be heard as sound by the medical professional.
 Option A: The smaller or other part of the resonator is called a bell. It is
made up of hollow pieces of metal that help at picking up low-frequency
sounds.
 Option C: Whenever a medical practitioner places a stethoscope
diaphragm on a chest of a patient, vibration will occur at the flat surface of
the stethoscope which is a result of sound waves that is being generated
from the patient‘s body. The vibration picked by the diaphragm is being

protected externally in other to prevent sound loss and thereby channeled
through the tube to a specific direction.
 Option D: The diaphragm is the lower part of the chest piece. It is a flat
metallic disc surrounded by chill rings which enable it to pick a very high
pitch sound.
ADV
44. Question
A male patient is to be discharged with a prescription for an analgesic that is a
controlled substance. During discharge teaching, the nurse should explain that
the patient must fill this prescription how soon after the date on which it was
written?
o A. Within 1 month
o B. Within 3 months
o C. Within 6 months
o D. Within 12 months
Incorrect
Correct Answer: C. Within 6 months
In most cases, an outpatient must fill a prescription for a controlled substance
within 6 months of the date on which the prescription was written. A common
reason people seek the care of medical professionals is pain relief. While many
categories of pain medications are available, opioid analgesics are FDA-approved
for moderate to severe pain. As such, they are a common choice for patients with
acute, cancer-related, neurologic, and end-of-life pain. The prescribing of opioid
analgesics for chronic pain is controversial and fraught with inconclusive
standards.
 Option A: All health professionals engaged in pain management need an
understanding of the treatment recommendations and safety concerns in
prescribing opioid analgesics. Appropriate opioid prescribing requires a
thorough patient assessment, short and long-term treatment planning,
close follow-up, and continued monitoring.

 Option B: All providers need to be aware of not only appropriate patient
assessment and treatment planning but also the possibility of use disorder,
diversion, and potentially dangerous behavioral responses to controlled
substances, e.g., opioid analgesics differ from pseudo-addiction and
physical dependence.
 Option D: All providers should be familiar with the guidelines and laws for
each schedule, which have, as their basis, the purpose of the drug and the
risk of use disorder. In the United States, controlled substances are under
strict regulation by both federal and state laws that guide their
manufacture and distribution. Controlled substances have a high risk of
resulting in an addiction and substance use disorder.
ADV
45. Question
Which human element considered by the nurse in charge during assessment can
affect drug administration?
o A. The patient‘s ability to recover
o B. The patient‘s occupational hazards
o C. The patient‘s socioeconomic status
o D. The patient’s cognitive abilities

Incorrect
Correct Answer: D. The patient’s cognitive abilities
The nurse must consider the patient‘s cognitive abilities to understand drug
instructions. If not, the nurse must find a family member or significant other to
take on the responsibility of administering medications in the home setting. The
patient‘s ability to recover, occupational hazards, and socioeconomic status do
not affect drug administration.
 Option A: Many drugs can be administered orally as liquids, capsules,
tablets, or chewable tablets. Because the oral route is the most convenient
and usually the safest and least expensive, it is the one most often used.
However, it has limitations because of the way a drug typically moves
through the digestive tract.

 Option B: For drugs administered orally, absorption may begin in the
mouth and stomach. However, most drugs are usually absorbed from the
small intestine. The drug passes through the intestinal wall and travels to
the liver before being transported via the bloodstream to its target site.
The intestinal wall and liver chemically alter (metabolize) many drugs,
decreasing the amount of drug reaching the bloodstream. Consequently,
these drugs are often given in smaller doses when injected intravenously to
produce the same effect.
 Option C: When a drug is taken orally, food and other drugs in the
digestive tract may affect how much of and how fast the drug is absorbed.
Thus, some drugs should be taken on an empty stomach, others should be
taken with food, others should not be taken with certain other drugs, and
still others cannot be taken orally at all.
ADV
46. Question
An employer establishes a physical exercise area in the workplace and
encourages all employees to use it. This is an example of which level of health
promotion?
o A. Primary prevention
o B. Secondary prevention
o C. Tertiary prevention
o D. Passive prevention
Incorrect
Correct Answer: A. Primary prevention
Primary prevention precedes disease and applies to healthy patients. Primary
prevention includes those preventive measures that come before the onset of
illness or injury and before the disease process begins. Examples include
immunization and taking regular exercise to prevent health problems from
developing in the future.
 Option B: Secondary prevention focuses on patients who have health
problems and are at risk for developing complications. Secondary

prevention includes those preventive measures that lead to early diagnosis
and prompt treatment of a disease, illness, or injury. This should limit
disability, impairment or dependency and prevent more severe health
problems from developing in the future.
 Option C: Tertiary prevention enables patients to gain health from others‘
activities without doing anything themselves. Tertiary prevention includes
those preventive measures aimed at rehabilitation following a significant
illness. At this level, health educators work to retrain, re-educate and
rehabilitate the individual who has already had an impairment or disability.
 Option D: Prevention, as it relates to health, is really about avoiding
disease before it starts. It has been defined as the plans for, and the
measures taken, to prevent the onset of a disease or other health problem
before the occurrence of the undesirable health event.
ADV
47. Question
What does the nurse in charge do when making a surgical bed?
o A. Leaves the bed in the high position when finished.
o B. Place the pillow at the head of the bed.
o C. Rolls the patient to the far side of the bed.
o D. Tucks the top sheet and blanket under the bottom of the bed.
Incorrect
Correct Answer: A. Leaves the bed in the high position when finished.
When making a surgical bed, the nurse leaves the bed in a high position when
finished. After placing the top linens on the bed without pouching them, the
nurse fan folds these linens to the side opposite from where the patient will enter
and places the pillow on the bedside chair. All these actions promote transfer of
the postoperative patient from the stretcher to the bed.
 Option B: When making an occupied bed or unoccupied bed, the nurse
places the pillow at the head of the bed and tucks the top sheet and
blanket under the bottom of the bed.

 Option C: When making an occupied bed, the nurse rolls the patient to the
far side of the bed. Bed Making is a key nursing skill that is essential for the
promotion of patient comfort, hygiene, and wellbeing. Bed Making
requires technical and practical skills and consideration should be given to
issues of safety, moving and handling and infection control practices.
 Option D: The blanket is placed at the center of the bed with its top 20cms
approximately from the top of the mattress. The top sheet is folded back
over the blanket. The blanket is folded under the foot of the mattress.
Make a square corner & tuck in along sides.
ADV
48. Question
The physician prescribes 250 mg of a drug. The drug vial reads 500 mg/ml. How
much of the drug should the nurse give?
o A. 2 ml
o B. 1 ml
o C. ½ ml
o D. ¼ ml
Incorrect
Correct Answer: C. ½ ml
The nurse should give ½ ml of the drug. The dosage is calculated as follows:
250 mg/X=500 mg/1 ml
500x=250
X=1/2 ml
Formula, Dimensional Analysis and Ratio and Proportion

triple check.
adding.
ADV
49. Question
Nurse Mackey is monitoring a patient for adverse reactions during barbiturate
therapy. What is the major disadvantage of barbiturate use?
o A. Prolonged half-life
o B. Poor absorption
o C. Potential for drug dependence
o D. Potential for hepatotoxicity

Incorrect
Correct Answer: C. Potential for drug dependence
Patients can become dependent on barbiturates, especially with prolonged use.
Due to the abuse potential of barbiturates, restricted access started with the
passage of the Federal Comprehensive Drug Abuse and Control Act of 1970.
Barbiturates classify as Schedule II-IV based on their abuse potential.
 Option A: Because of the rapid distribution of some barbiturates, no
correlation exists between duration of action and half-life. The elimination
half-life for thiopental is about 5 hours. In children, a shorter elimination
half-time occurs due to greater hepatic clearance.
 Option B: Barbiturates are absorbed well. Age-related changes have been
demonstrated in pharmacokinetics due to slower intercompartmental
clearance in the elderly, resulting in higher serum concentrations with
smaller drug doses.

 Option D: They do not cause hepatotoxicity, although existing hepatic
damage does require cautious use of the drug because barbiturates are
metabolized in the liver.
ADV
50. Question
Which nursing action is essential when providing continuous enteral feeding?
o A. Elevating the head of the bed.
o B. Positioning the patient on the left side.
o C. Warming the formula before administering it.
o D. Hanging a full day‘s worth of formula at one time.

Incorrect
Correct Answer: A. Elevating the head of the bed.
Elevating the head of the bed during enteral feeding minimizes the risk of
aspiration and allows the formula to flow in the patient‘s intestines. Lying
prone/supine during feeding increases the risk of aspiration and therefore where
clinically possible the client should be placed in an upright position. If unable to
sit up for a bolus feed or if receiving continuous feeding, the head of the bed
should be elevated 30-45 degrees during feeding and for at least 30 minutes
after the feed to reduce the risk of aspiration.
 Option B: When such elevation is contraindicated, the patient should be
positioned on the right side. Turn the patient onto their side. This will allow
the tip of the tube to move to a position where fluid has accumulated.
 Option C: The nurse should give enteral feeding at room temperature to
minimize GI distress. Continuous feeds should NOT be warmed. They may
be removed from the fridge 15-20 minutes prior to administration to bring
it to room temperature. Feeds should NOT be warmed in a microwave or in
jugs of boiling water.
 Option D: To limit microbial growth, the nurse should hang only the
amount of formula that can be infused in 3 hours. It should not hang for
longer than 4 hours – use the dose limit function on the feed pump to
ensure this occurs.

ADV
51. Question
When teaching a female patient how to take a sublingual tablet, the nurse should
instruct the patient to place the table on the:
o A. Top of the tongue
o B. Roof of the mouth
o C. Floor of the mouth
o D. Inside of the cheek

Incorrect
Correct Answer: C. Floor of the mouth
The nurse should instruct the patient to touch the tip of the tongue to the roof of
the mouth and then place the sublingual tablet on the floor of the mouth.
Sublingual medications are absorbed directly into the bloodstream from the oral
mucosa, bypassing the GI and hepatic systems. No drug is administered on top of
the tongue or on the roof of the mouth.
 Option A: The cheek and area under the tongue have many capillaries, or
tiny blood vessels. There, drugs can be absorbed directly into the
bloodstream without going through the digestive system.
 Option B: These drugs do not go through the digestive system, so they
aren‘t metabolized through the liver. This means the client may be able to
take a lower dose and still get the same results.
 Option D: With the buccal route, the tablet is placed between the gum and
the cheek. Drugs that are absorbed under the tongue or between the
cheek and gum can be easier to take for people who have problems
swallowing pills.
ADV
52. Question
Which action by the nurse in charge is essential when cleaning the area around a
Jackson-Pratt wound drain?

o A. Cleaning from the center outward in a circular motion.
o B. Removing the drain before cleaning the skin.
o C. Cleaning briskly around the site with alcohol.
o D. Wearing sterile gloves and a mask.

Incorrect
Correct Answer: A. Cleaning from the center outward in a circular motion.
The nurse always should clean around a wound drain, moving from center
outward in ever-larger circles, because the skin near the drain site is more
contaminated than the site itself. A Jackson-Pratt (JP) drain is used to remove
fluids that build up in an area of the body after surgery. The JP drain is a bulb-
shaped device connected to a tube. One end of the tube is placed inside the
client during surgery. The other end comes out through a small cut in the skin.
The bulb is connected to this end. The client may have a stitch to hold the tube in
place.
 Option B: The nurse should never remove the drain before cleaning the
skin. The JP drain removes fluids by creating suction in the tube. The bulb
is squeezed flat and connected to the tube that sticks out of the body. The
bulb expands as it fills with fluid.
 Option C: Alcohol should never be used to clean around a drain; it may
irritate the skin and has no lasting effect on bacteria because it evaporates.
Use soap and water or saline (salt water) solution to clean a JP drain site.
Dip a cotton swab or gauze pad in the solution and gently clean the skin.
 Option D: The nurse should wear sterile gloves to prevent contamination,
but a mask is not necessary. Wash hands with soap and water after
discarding the gloves.
ADV
53. Question
The doctor orders dextrose 5% in water, 1,000 ml to be infused over 8 hours. The
I.V. tubing delivers 15 drops per milliliter. The nurse in charge should run the I.V.
infusion at a rate of:
o A. 15 drop per minute

o B. 21 drop per minute
o C. 32 drop per minute
o D. 125 drops per minute

Incorrect
Correct Answer: C. 32 drop per minute
Giving 1,000 ml over 8 hours is the same as giving 125 ml over 1 hour (60
minutes) to find the number of milliliters per minute:
125/60 min = X/1 minute
60X = 125X = 2.1 ml/minute
To find the number of drops/minute:
2.1 ml/X gtts = 1 ml/15 gtts
X = 32 gtts/minute, or 32 drops/minute
 Option A: When the nurse has an order for an IV infusion, it is her to make
sure the fluid will infuse at the prescribed rate. IV fluids may be infused by
gravity using a manual roller clamp or dial-a-flow, or infused using an
infusion pump. Regardless of the method, it is important to know how to
calculate the correct IV flow rate.
 Option B: When calculating the flow rate, determine which IV tubing will
be used, microdrip or macrodrip, so the nurse can use the proper drop
factor in her calculations. The drop factor is the number of drops in one mL
of solution, and is printed on the IV tubing package. Macrodrip and
microdrip refers to the diameter of the needle where the drop enters the
drip chamber. Macrodrip tubing delivers 10 to 20 gtts/mL and is used to
infuse large volumes or to infuse fluids quickly. Microdrip tubing delivers
60 gtts/mL and is used for small or very precise amounts of fluid, as with
neonates or pediatric patients.
 Option D: To calculate the drops per minute, the drop factor is needed.
The formula for calculating the IV flow rate (drip rate) is total volume (in
mL) divided by time (in min), multiplied by the drop factor (in gtts/mL),
which equals the IV flow rate in gtts/min.
ADV
54. Question

A female patient undergoes a total abdominal hysterectomy. When assessing the
patient 10 hours later, the nurse identifies which finding as an early sign of
shock?
o A. Restlessness
o B. Pale, warm, dry skin
o C. Heart rate of 110 beats/minute
o D. Urine output of 30 ml/hour

Incorrect
Correct Answer: A. Restlessness
Early in shock, hyperactivity of the sympathetic nervous system causes increased
epinephrine secretion, which typically makes the patient restless, anxious,
nervous, and irritable. It also decreases tissue perfusion to the skin, causing pale,
cool clammy skin. Shock is characterized by decreased oxygen delivery and/or
increased oxygen consumption or inadequate oxygen utilization leading to
cellular and tissue hypoxia. It is a life-threatening condition of circulatory failure
and most commonly manifested as hypotension (systolic blood pressure less than
90 mm Hg or MAP less than 65 mmHg).
 Option B: Hypoxia at the cellular level causes a series of physiologic and
biochemical changes, resulting in acidosis and a decrease in regional blood
flow, which further worsens the tissue hypoxia.
 Option C: An above-normal heart rate is a late sign of shock. The most
common clinical features/labs which are suggestive of shock include
hypotension, tachycardia, tachypnea, obtundation or abnormal mental
status, cold, clammy extremities, mottled skin, oliguria, metabolic acidosis,
and hyperlactatemia.
 Option D: A urine output of 30 ml/hour is within normal limits. During this
stage, most of the classic signs and symptoms of shock appear due to early
organ dysfunction, resulting from the progression of the pre-shock stage
as the compensatory mechanisms become insufficient.
ADV
55. Question

Which pulse should the nurse palpate during rapid assessment of an unconscious
male adult?
o A. Radial
o B. Brachial
o C. Femoral
o D. Carotid
Incorrect
Correct Answer: D. Carotid
During a rapid assessment, the nurse‘s first priority is to check the patient‘s vital
functions by assessing his airway, breathing, and circulation. To check a patient‘s
circulation, the nurse must assess his heart and vascular network function. This is
done by checking his skin color, temperature, mental status and, most
importantly, his pulse. The nurse should use the carotid artery to check a patient‘s
circulation.
 Option A: In a patient with circulatory problems or a history of
compromised circulation, the radial pulse may not be palpable. Examiners
frequently evaluate the radial artery during a routine examination of adults,
due to the unobtrusive position required to palpate it and its easy
accessibility in various types of clothing. Like other distal peripheral pulses
(such as those in the feet) it also may be quicker to show signs of
pathology.
 Option B: The brachial pulse is palpated during rapid assessment of an
infant. The brachial artery is often the site of evaluation during
cardiopulmonary resuscitation of infants. It is palpated proximal to the
elbow between the medial epicondyle of the humerus and the distal biceps
tendon.
 Option C: The femoral pulse may be the most sensitive in assessing for
septic shock and is routinely checked during resuscitation. It is palpated
distally to the inguinal ligament at a point less than halfway from the pubis
to the anterior superior iliac spine.
ADV

56. Question
Clients should be taught that repeatedly ignoring the sensation of needing to
defecate could result in which of the following?
o A. Constipation
o B. Diarrhea
o C. Incontinence
o D. Hemorrhoids
Incorrect
Correct Answer: A. Constipation
Habitually ignoring the urge to defecate can lead to constipation through loss of
the natural urge and the accumulation of feces. Functional constipation is a
prevalent condition in childhood, about 29.6% worldwide. In the United States, it
represents 3% to 5% of pediatric visits and a considerable annual health care
cost. Most children do not have an etiological factor, and one third continue to
have problems beyond adolescence.
 Option B: Diarrhea will not result-if anything, there is increased
opportunity for water reabsorption because the stool remains in the colon,
leading to firmer stool. Diarrhea is described as three or more loose or
watery stools a day. Infection commonly causes acute diarrhea.
Noninfectious etiologies are more common as the duration of diarrhea
becomes chronic. Treatment and management are based on the duration
and specific etiology.
 Option C: Ignoring the urge shows a strong voluntary sphincter, not a
weak one that could result in incontinence. Fecal incontinence (FI) is the
involuntary passage of fecal matter through anus or inability to control the
discharge of bowel contents. Its severity can range from an involuntary
passage of flatus to complete evacuation of fecal matter. Depending on
the severity of the disease, it has a significant impact on a patient‘s quality
of life
 Option D: Hemorrhoids would only occur only if severe drying out of the
stool occurs, and thus repeated need to strain to pass stool. Hemorrhoids
are rich in vascular supply and have a tendency to engorge and prolapse.
Symptoms can vary from mild itching, bleeding to severe pain.

Unfortunately, because of the location, many patients never seek treatment
for fear of embarrassment.
ADV
57. Question
Which statement provides evidence that an older adult who is prone to
constipation is in need of further teaching?
o A. "I need to drink one and a half to 2 quarts of liquid each day."
o B. "I need to take a laxative such as milk of magnesia or if I don't have a

BM every day."
o C. "If my bowel pattern changes on its own, I should call you."
o D. "Eating my meals at regular times is likely to result in regular bowel

movements."
Incorrect
Correct Answer: B. “I need to take a laxative such as milk of magnesium or if
I don’t have a BM every day”
Stimulant laxatives can be very irritating and are not the preferred treatment for
occasional constipation in older adults. In addition, a normal stool pattern for an
older adult may not be daily elimination. The cause of constipation is
multifactorial. The problem may arise in the colon or rectum or it may be due to
an external cause. In most people, slow colonic motility that occurs after years of
laxative abuse is the problem. In a few patients, the cause may be related to an
outlet obstruction like rectal prolapse or a rectocele. External causes of
constipation may include poor dietary habits, lack of fluid intake, overuse of
certain medications, an endocrine problem like hypothyroidism or some type of
an emotional issue.
 Option A: The standard of practice in assisting the older adults to maintain
normal function of the gastrointestinal tract is regular ingestion of a well-
balanced diet, adequate fluid intake, and regular exercise.
 Option C: If the bowel pattern is not regular with these activities, this
abnormality should be reported. Pathophysiology underlying functional
constipation is multifactorial and not well understood. Factors that may

contribute to functional constipation include pain, fever, dehydration,
dietary and fluid intake, psychological issues, toilet training, medicines, and
family history of constipation.
 Option D: A normal fiber intake, fluid intake, and physical activity level are
recommended, and the routine use of prebiotics or probiotics is not
recommended in the treatment of childhood constipation.
ADV
58. Question
A client is scheduled for a colonoscopy. The nurse will provide information to the
client about which type of enema?
o A. Oil retention
o B. Return flow
o C. High large volume
o D. Low, small volume

Incorrect
Correct Answer: D. Low, small volume
Small volume enemas along with other preparations are used to prepare the
client for this procedure. The small volume enema is used to clean the lower
portion of the colon or the sigmoid. This type of cleansing enema is often used
for the patient who is constipated but does not need cleansing of the higher
colon. The amount used is less than 500 ml and the bag is raised no higher than
12 inches.
 Option A: An oil retention enema is used to soften hard stool. A rectal
injection of mineral oil or vegetable Oil, introduced at low pressure and
retained for 30 minutes to 3 hours before being expelled. given to soften
feces in cases of constipation or impaction. The volume of oil is relatively
low, four to six ounces are commonly used, which allows the oil to be more
easily retained.
 Option B: Return flow enemas help expel flatus because of the risk of loss
of fluid and electrolytes A return-flow enema, or Harris flush, is used to
remove intestinal gas and stimulate peristalsis. A large volume fluid is used

but the fluid is instilled in 100-200 ml increments. Then, the fluid is drawn
out by lowering the container below the level of the bowel. This brings the
flatus out with the fluid.
 Option C: High, large volume enemas are seldom used. The purpose of a
large volume enema is to clean as much of the colon as possible of feces,
as an intervention for constipation as well as ―bowel prep‖ before a
diagnostic procedure. The amount used is 500-1000 ml and the bag is
raised as high as 18 inches above the anal opening. The patient is
instructed to retain and hold the fluid as long as possible to induce
peristalsis and cause evacuation of feces.
ADV
59. Question
The nurse is most likely to report which finding to the primary care provider for a
client who has an established colostomy?
o A. The stoma extends 1/2 inch above the abdomen.
o B. The skin under the appliance looks red briefly after removing the
appliance.
o C. The stoma color is a deep red purple.
o D. An ascending colostomy just delivers liquid feces.

Incorrect
Correct Answer: C. The stoma color is a deep red purple.
An established stoma should be dark pink like the color of the buccal mucosa
and is slightly raised above the abdomen. A stoma is the exteriorization of a loop
of bowel from the anterior abdominal wall, done during a surgical procedure. It is
done for diversion or decompression of the remaining bowel. It may be
temporary or permanent, depending on the indication for which it was
performed. Most stomas are incontinent, which means that there is no voluntary
control over the passage of flatus and feces from the stoma.
 Option A: The stoma should be assessed and must be moist, above skin
level, and pink to red in color, and the peristomal skin should be normal.
Any deviation from this should be notified to the surgeon. The stoma

should be measured, or the previous measurement remembered and size
should not be more than 1/16-1/8.
 Option B: The skin under the appliance may remain pink/red for a while
after the adhesive is pulled off. The peristomal skin should be dried
appropriately to allow good seal formation. Adhesive pastes or powders
may also be applied peristomally. The paper cover on the back of the
flange is then removed with the border tape in place. It is then placed
around the stoma and held in place for 1 to 2 minutes to create an
adequate seal.
 Option D: Feces from an ascending ostomy are very liquid, less so from a
transverse ostomy, and more solid from a descending or sigmoid stoma.
Colostomy diarrhea may be complained by the patient in case of ascending
or transverse colostomies in case they are not fully explained about the
nature of content expected, but stomal diarrhea may be the result of
extensive resection with failure of bowel adaptation or if associated with
short bowel syndrome.
ADV
60. Question
Which goal is the most appropriate for clients with diarrhea related to ingestion
of an antibiotic for an upper respiratory infection?
o A. The client will wear a medical alert bracelet for antibiotic allergy.
o B. The client will return to his or her previous fecal elimination pattern.
o C. The client verbalizes the need to take an antidiarrheal medication PRN.
o D. The client will increase intake of insoluble fiber such as grains, rice, and
cereals.
Incorrect
Correct Answer: B. The client will return to his or her previous fecal
elimination pattern.
Once the cause of diarrhea has been identified and corrected, the client returns
to his or her previous elimination pattern. Diarrhea is a common adverse effect of
antibiotic treatments. Antibiotic-associated diarrhea occurs in about 5-30% of

patients either early during antibiotic therapy or up to two months after the end
of the treatment. The frequency of antibiotic-associated diarrhea depends on the
definition of diarrhea, the inciting antimicrobial agents, and host factors.
 Option A: This is not an example of an allergy to the antibiotic but a
common consequence of overgrowth of bowel organisms not killed by the
drug. Antibiotic-associated diarrhea results from disruption of the normal
microflora of the gut by antibiotics. This microflora, composed of 1011
bacteria per gram of intestinal content, forms a stable ecosystem that
permits the elimination of exogenous organisms. Antibiotics disturb the
composition and the function of this flora and enable the overgrowth of
micro-organisms that induce diarrhea.
 Option C: Antidiarrheal medications are usually prescribed according to
the number of stools, not routinely around the clock. Managing diarrhea
depends on the clinical presentation and the inciting agent. In mild to
moderate diarrhea conventional measures include rehydration or
discontinuation of the inciting agent or its replacement by an antibiotic
with a lower risk of inducing diarrhea, such as quinolones, co-trimoxazole,
or aminoglycosides. In 22% of cases of diarrhea related to C difficile,
withdrawal of the inciting agent will lead to resolution of clinical signs in
three days.
 Option D: Increasing intake of soluble fiber such as oatmeal or potatoes
may help absorb excess liquid and decrease diarrhea, but insoluble fiber
will not. The key measure for preventing antibiotic-associated diarrhea,
however, is to limit antibiotic use. Probiotics have proved useful in
preventing diarrhea, but the number of clinical trials is limited, and further
controlled trials using different probiotics are needed.
ADV
61. Question
A client with a new stoma who has not had a bowel movement since surgery last
week reports feeling nauseous. What is the appropriate nursing action?
o A. Prepare to irrigate the colostomy.
o B. After assessing the stoma and surrounding skin, notify the surgeon.

o C. Assess bowel sounds and administer antiemetic.
o D. Administer a bulk forming laxative, and encourage increased fluids and

exercise.
Incorrect
Correct Answer: B. After assessing the stoma and surrounding skin, notify
the surgeon.
The client has assessment findings consistent with complications of surgery.
Providers and nurses should monitor stomas at regular intervals to look for the
multiple complications of colostomies as an integrated team approach. Some
complications are extremely troublesome to patients, and they come to the
hospital with these presentations, but others may be more occult and have to be
looked for.
 Option A: Irrigating the stoma is a dependent nursing action, and is also
intervention without appropriate assessment. Some procedures like
irrigation or enema should be avoided in case of stoma prolapse,
chemotherapy, pelvic or abdominal radiation treatments, diarrhea-
producing medication, or in case of an irregular functioning stoma and
may lead to dependence.
 Option C: Assessing the peristomal skin area is an independent action, but
administering an antiemetic is an intervention without appropriate
assessment. Antiemetics are generally ordered to treat immediate
postoperative nausea, not several days postoperative.
 Option D: Administering a bulk-forming laxative to a nauseated
postoperative client is contraindicated. The surgeon must call the patient
for regular follow up to assess the condition of the stoma and look for any
complications and also assess the disease process for which the colostomy
was made and also plan for colostomy closure in case of temporary
colostomies.
ADV
62. Question
The nurse assesses a client‘s abdomen several days after abdominal surgery. It is
firm, distended, and painful to palpate. The client reports feeling ―bloated‖ . The

nurse consults with the surgeon, who orders an enema. The nurse prepares to
give what kind of enema?
o A. Soapsuds
o B. Retention
o C. Return flow
o D. Oil retention
Incorrect
Correct Answer: C. Return flow
This provides relief of postoperative flatus, stimulating bowel motility. Options
one, two, and four manage constipation and do not provide flatus relief. A
return-flow enema, or Harris flush, is used to remove intestinal gas and stimulate
peristalsis. A large volume fluid is used but the fluid is instilled in 100-200 ml
increments. Then, the fluid is drawn out by lowering the container below the level
of the bowel. This brings the flatus out with the fluid.
 Option A: The soapsuds enema uses a mixture of a mild soap and warm
water injected into the colon in order to stimulate a bowel movement.
Normally given to relieve constipation or for bowel cleansing before a
medical examination or procedure.
 Option B: An enema that may be used to provide nourishment,
medication, or anesthetic. It should be made from fluids that will not
stimulate peristalsis. A small amount of solution (e.g., 100 to 250 mL) is
typically used in adults.
 Option D: If fecal material is hardened, an oil-retention enema may be
given to soften the feces. Commercially packaged enemas contain 90-120
ml solution. The patient should retain the solution to at least one hour for
the enema to be effective. This enema is usually followed by a cleansing
enema.
ADV
63. Question
Which of the following is most likely to validate that a client is experiencing
intestinal bleeding?

o A. Large quantities of fat mixed with pale yellow liquid stool
o B. Brown, formed stool
o C. Semi soft tar colored stools
o D. Narrow, pencil shaped stool

Incorrect
Correct Answer: C. Semi soft tar colored stools
Blood in the upper GI tract is black and tarry. Gastrointestinal (GI) bleeding is a
symptom of a disorder in the digestive tract. The blood often appears in stool or
vomit but isn‘t always visible, though it may cause the stool to look black or tarry.
The level of bleeding can range from mild to severe and can be life-threatening.
 Option A: This can be a sign of malabsorption in an infant. Malabsorption
syndromes encompass numerous clinical entities that result in chronic
diarrhea, abdominal distention, and failure to thrive. Clinical malabsorption
can be broken down into several distinct conditions, both congenital and
acquired, that affect one or more of the different steps in the intestinal
hydrolysis and subsequent transport of nutrients.
 Option B: Brown, formed stool is a normal stool. Anywhere between a firm
and soft consistency is pretty much normal. If it sways one way or another,
it could suggest some digestion or fiber issues.
 Option D: Narrow, pencil-shaped stool is a characteristic of an obstructive
condition of the rectum. Narrow stools that occur infrequently probably are
harmless. However in some cases, narrow stools — especially if pencil thin
— may be a sign of narrowing or obstruction of the colon due to colon
cancer.
Sources:
ADV
64. Question
Which nursing diagnosis is/are most applicable to a client with fecal
incontinence? Select all that apply.
o A. Bowel incontinence

o B. Risk for deficient fluid volume
o C. Disturbed body image
o D. Social isolation
o E. Risk for impaired skin integrity

Incorrect
Correct Answer: A, C, D, and E
Incontinence is the inability to control feces of normal consistency. Fecal
incontinence (FI) is the involuntary passage of fecal matter through anus or
inability to control the discharge of bowel contents. Its severity can range from an
involuntary passage of flatus to complete evacuation of fecal matter. Depending
on the severity of the disease, it has a significant impact on a patient‘s quality of
life
 Option A: This is the most appropriate. The client is unable to decide when
stool evacuation will occur. Patients with fecal incontinence have an
unintentional loss of liquid or solid stool. In true anal incontinence, there is
loss of control of the anal sphincter which leads to the untimely release of
feces.
 Option B: Risk for deficient fluid volume is more appropriate for a client
with diarrhea. Avoid perianal skin soiling with regular cleaning, zinc oxide
application, incontinence pads. Avoid food which can provoke diarrhea
(high lactose/ fructose diet).
 Option C: The client‘s thoughts about self may be altered if unable to
control stool evacuation. To maintain fecal continence, there is a complex
interplay of several organ systems and nerves. As the fecal mass presents
to the rectum, this causes distension. The sensation of rectal distension is
transmitted by the parasympathetic nerves (S2-S4), which induces
relaxation of the rectoanal inhibitory reflex and contraction of the rectoanal
contractile reflex. The rectal lining has a rich supply of nerve endings that
can sample if the mass is liquid or solid. It is believed that abnormal
sampling and lowered anorectal sensation most likely contribute to fecal
incontinence in many individuals.
 Option D: The prognosis for most patients with fecal incontinence is
guarded. Short term outcomes after sphincteroplasty vary from 30-60%.
Satisfactory results are seen in less than 50% of patients in the long term.
The quality of life is poor and mental anguish is common.

 Option E: Increased tissue contact with fecal material may result in
impairment. Fecal incontinence is a complex issue that is not easy to
manage. The vast number of methods used to manage the condition is an
indication that no method works reliably. Patients with fecal incontinence
have enormous mental anguish, depression, and anxiety.
ADV
65. Question
A nurse determines that a fracture bedpan should be used for the patient who:
o A. Has a spinal cord injury
o B. Is on bedrest
o C. Has dementia
o D. Is obese
Incorrect
Correct Answer: A. Has a spinal cord injury
A fracture bedpan has a low back that promotes function of the patient‘s lower
back while on the bedpan. The fracture pan has one flat end for ease of use with
specific patient populations: i.e. hip fractures, hip replacements, or lower
extremity fractures. Using the toilet may be a source of discomfort and
embarrassment among all genders. Semi-private rooms or shared wards and
hospital overcrowding are a challenge regarding patient privacy.
 Option B: Bedpans come in regular size or a smaller, fracture pan. Bedpans
are chosen based on diagnosis, patient comfort or preference and if any
contraindications exist for using the regular size such as a fracture. The
regular bedpan is larger than its fracture counterpart. Bariatric bedpans are
available up to a 1200-pound (544-kg) capacity.
 Option C: A patient that can assist with care by raising their hips is
approached differently than a patient that cannot lift their hips due to
surgical considerations, fractures, or other contraindications. In both cases,
ensure the patient is pulled up as high as they can be on the stretcher or
bed. If they can assist with raising their hips, then raise the head of the bed
at least thirty degrees.

 Option D: Positioning in this Semi-Fowler‘s position allows for anatomical
support and facilitates ease of defecation or urination by assuming a
natural position for these bodily functions. According to a 2003 study,
body positioning has a significant influence on intestinal gas propulsion
and transit times with gastric flow being faster in the upright position than
when supine [Dainese, Serra, Azpiroz & Malagelada, 2003].
ADV
66. Question
A patient with the diagnosis of diverticulosis is advised to eat a diet high in fiber.
What should the nurse recommend that the patient eat to best increase the bulk
and fecal material?
o A. Whole wheat bread
o B. White rice
o C. Pasta
o D. Kale
Incorrect
Correct Answer: D. Kale
Kale is an excellent source of dietary fiber. A serving of 3 1/2 ounces of kale
contains 6.6 g of dietary fiber. Fiber is a very important component of our diet
and comes from plant-based food sources (fruits, vegetables, legumes and whole
grains). Different food sources contain different types of fiber and resistant
starches and the side effects depend on the individual‘s microbiome (gut
bacteria). Instead of avoiding fiber altogether, you may want to identify the
certain types of food that cause the distress.
 Option A: One slice of whole wheat bread contains only 1.5 g of dietary
fiber. Whole wheat bread is made from flour that contains the entire wheat
kernel, including the bran and germ. It‘s here that wheat packs the most
nutrients, such as fiber, B vitamins, iron, folate, potassium, and magnesium.
Leaving the wheat kernel intact makes for a less processed, more nutritious
bread.

 Option B: A serving of a 1/2 cup of white rice contains only 0.8 g of dietary
fiber. White rice is mostly a source of ―empty‖ calories and carbs with very
few essential nutrients. 100 grams (3.5 ounces) of cooked brown rice
provide 1.8 grams of fiber, whereas 100 grams of white provide only 0.4
grams of fiber (1, 2). Bottom Line: Brown rice is much higher in nutrients
than white rice.
 Option C: A serving of 3 1/2 ounces of cooked pasta contains only 1.6 g of
dietary fiber. Whole-wheat pasta is usually made from whole-wheat durum
semolina, or flour made from the whole grain rather than the striped grain.
For about 175 calories, a 1-cup serving of cooked whole-wheat spaghetti
delivers 6.3 grams of fiber, or 25 percent of the daily value.
ADV
67. Question
Which statement by a patient with an ileostomy alerts the nurse to the need for
further education?
o A. "I don't expect to have much of a problem with fecal odor."
o B. "I will have to take special precaution to protect my skin around the
stoma."
o C. "I'm going to have to irrigate my stoma so I have a bowel movement

every morning."
o D. "I should avoid gas forming foods like beans to limit funny noises from the
stoma."
Incorrect
Correct Answer: C. “I’m going to have to irrigate my stoma so I have a bowel
movement every morning”
This statement is inaccurate in relation to an ileostomy and indicates that the
patient needs more teaching. An ileostomy produces liquid fecal drainage that is
constant and cannot be regulated. An ileostomy is when the lumen of the ileum
(small bowel) is brought through the abdominal wall via a surgical opening
(created by an operation). This can either be temporary or permanent, an end or

a loop. The purpose of an ileostomy is to evacuate stool from the body via the
ileum rather than the usual route of the anus.
 Option A: The odor from drainage is minimal because fewer bacteria are
present in the ileum compared with the large intestine. There are different
indications for forming an ileostomy but essentially arrive at the same
result of diverting stool out of the body without it ever entering the colon.
 Option B: An ileostomy is an opening into the ileum (distal small intestine
from the jejunum to the cecum). Cleansing the skin, skin barriers, and a
well fitted appliance are precautions to protect the skin around the
ileostomy stoma. The drainage from ileostomy contains enzymes that can
damage the skin.
 Option D: An ileostomy stoma does not have a sphincter that can control
the flow of flatus or drainage, resulting in noise. The output from an
ileostomy consists of loose or porridge-like stool consistent with that
expected to pass through the small bowel (as it is the large bowel that is
responsible for making the stool more solid dependent upon water
absorption). The output from an ileostomy can vary but typically ranges
from 200 to 700 ml per day, and an Ileostomy is typically formed on the
right side of the abdomen.
ADV
68. Question
A practitioner orders a return flow enema (Harris flush drip) for an adult patient
with flatulence. When preparing to administer this enema the nurse compares the
steps of a return flow enema with cleansing enemas. What should the nurse do
that is unique to a return flow enema?
o A. Lubricate the last 2 inches of the rectal tube.
o B. Insert the rectal tube about 4 inches into the anus.
o C. Raise the solution container about 12 inches above the anus.
o D. Lower the solution container after instilling about 150 mL of solution.

Incorrect

Correct Answer: D. Lower the solution container after instilling about 150
mL of solution.
Lowering the container of solution creates a siphon effect that pulls the instilled
fluid back out through the rectal tube into the solution container. The return flow
promotes the evacuation of gas from the intestines. This technique is used only
with a return flow enema. This action is appropriate for all types of enemas.
 Option A: All rectal tubes should be lubricated to facilitate entry of the
tube into the anus and rectum and prevent mucosal trauma. Use a solution
at a temperature of 105o to 110oF in adults and 100oF in children. Cool
solutions will increase the incidence of cramping.
 Option B: The anal canal is 1 to 2 inches long. Inserting the rectal tube 3 to
4 inches ensures that the tip of the tube is beyond the anal sphincter. The
recommended position for the patient during enema administration is
lying in the left lateral position with their right leg flexed as much as
possible.
 Option C: The solution container should be raised no higher than 12
inches for all enemas; this allows the solution to instill slowly, which limits
discomfort and intestinal spasms. Alternately, raise the enema container
12-18 inches above the rectum for an adult and administer approximately
200 ml of fluid, then lower the container 12-18 inches below the patient‘s
rectum until no further flatus is seen.
ADV
69. Question
A nurse discourages a patient from straining excessively when attempting to have
a bowel movement. What physiological response primarily may be prevented by
avoiding straining on defecation?
o A. Incontinence
o B. Dysrhythmias
o C. Fecal impaction
o D. Rectal hemorrhoids
Incorrect

Correct Answer: B. Dysrhythmias
Straining on defecation requires the person to hold the breath while bearing
down. This maneuver increases the intrathoracic and intracranial pressures, which
can precipitate dysrhythmias, brain attack, and respiratory difficulties; all of these
can be life threatening. Strain at stool causes blood pressure rise, which can
trigger cardiovascular events such as congestive heart failure, arrhythmia, acute
coronary disease, and aortic dissection.
 Option A: The loss of the voluntary ability to control the passage of fecal
or gaseous discharges through the anus is caused by impaired functioning
of the anal sphincter or its nerve supply, not straining on defecation. Fecal
incontinence is the inability to control bowel movements, causing stool
(feces) to leak unexpectedly from the rectum. Also called bowel
incontinence, fecal incontinence ranges from an occasional leakage of stool
while passing gas to a complete loss of bowel control.
 Option C: Fecal impaction is caused by prolonged retention and the
accumulation of fecal material in the large intestine, not straining on
defecation. Fecal impaction is a severe bowel condition in which a hard, dry
mass of stool becomes stuck in the colon or rectum. This immobile mass
will block the passage and cause a buildup of waste, which a person will be
unable to pass.
 Option D: Although straining on defecation can contribute to the
formation of hemorrhoids, this is not the primary reason straining on
defecation is discouraged. Hemorrhoids, although painful, are not life-
threatening. Hemorrhoids are rich in vascular supply and have a tendency
to engorge and prolapse. Symptoms can vary from mild itching, bleeding
to severe pain. Unfortunately, because of the location, many patients never
seek treatment for fear of embarrassment.
ADV
70. Question
A nurse is caring for a client who will perform fecal occult blood testing at home.
Which of the following information should the nurse include when explaining the
procedure to the client?
o A. Eating more protein is optimal prior to testing.

o B. One stool specimen is sufficient for testing.
o C. A red color changes indicates a positive test.
o D. The specimen cannot be contaminated with urine.

Incorrect
Correct Answer: D. The specimen cannot be contaminated with urine.
For fecal occult blood testing at home, the stool specimens cannot be
contaminated with water or urine. The fecal occult blood test (FOBT) is a
diagnostic test to assess for occult blood in the stool. This test has commonly
been used for colorectal cancer screening, especially in developed nations. When
used correctly for screening, this testing modality has established associations
with decreased morbidity and mortality. When performing at home, the stool
should be collected in a dry, clean container.
 Option A: Some proteins such as red meat, fish, and poultry can alter the
test results. Three days prior to fecal occult blood testing, avoidance of
certain foods should be to help prevent false test results. False-positive
results have been associated with red or rare meat as well as raw fruits and
vegetables, including but not limited to horseradish, raw turnips,
cantaloupe, broccoli, cauliflower, parsnips, and red radishes. False-negative
results are also known to occur in patients taking ascorbic acid (vitamin C)
in excess of 250mg/day.
 Option B: Three specimens from three different bowel movements are
required. One problem with FOBT is the need for medication and dietary
restrictions before testing. These restrictions are in order to decrease the
risk of false negative and false-positive results. Many studies assessing the
risk of these false results exist. One particular retrospective study evaluated
the medications that could create false-positive results and encouraged
patients to avoid these medications, if possible, for seven days before
testing. The listed medications include acetylsalicylic acid, unfractionated or
low-molecular-weight heparin, warfarin, clopidogrel, nonsteroidal anti-
inflammatory drugs, and selective serotonin reuptake inhibitors.
 Option C: A blue color indicates blood in the stool. If the patient‘s fecal
occult blood test does not turn blue, it is negative. If the card turns blue,
this is positive and requires further gastroenterological workup.
ADV

71. Question
A nurse is talking with a client who reports constipation. When the nurse
discusses dietary changes that can help prevent constipation, which of the
following foods should the nurse recommend?
o A. Macaroni and cheese
o B. Fresh food and whole-wheat toast
o C. Rice pudding and ripe bananas
o D. Roast chicken and white rice

Incorrect
Correct Answer: B. Fresh food and whole-wheat toast.
A high fiber diet promotes normal bowel elimination. The choice of fruit and
toast is the highest-fiber option. Most Americans consume only half the levels of
recommended fiber per day, which is almost 15 grams per day. All existing
definitions recognize fiber as ―carbohydrate or lignin which bypasses digestion in
the small intestine and is partially or completely fermented in the large intestine
or colon.‖
 Option A: Macaroni and cheese is a low residue option that could actually
worse and constipate. Insoluble fiber maintains bowel movements. They
absorb water and soften the stool. Soft stool is easier to pass, thus
preventing constipation. They also add bulk to the stools hence prevent
the formation of loose stools.
 Option C: Rice pudding and ripe bananas are low residue options that
could actually worsen constipation. High fiber diet prevents the formation
or worsening of hemorrhoids, and of diverticular disease, which presents as
outpouchings in the walls of the colon.
 Option D: Roast chicken and white rice or low residue options that could
actually worsen constipation. They are water-soluble and derived from the
inner flesh of plants such as pectin, gums, and mucilage. They form a
viscous gel and are usually fermented by bacteria in the colon into gases
and by-products such as short-chain fatty acids. They alter the blood
glucose and cholesterol concentrations.
ADV

72. Question
A nurse is caring for a client who has diarrhea for the past four days. When
assessing a client, the nurse should expect which of the following findings? Select
all that apply.
o A. Bradycardia
o B. Hypotension
o C. Fever
o D. Poor skin turgor
o E. Peripheral edema
Incorrect
Correct Answer: B, C, and D
Diarrhea is described as three or more loose or watery stools a day. Infection
commonly causes acute diarrhea. Noninfectious etiologies are more common as
the duration of diarrhea becomes chronic. Treatment and management are based
on the duration and specific etiology. Rehydration therapy is an important aspect
of the management of any patient with diarrhea. Prevention of infectious diarrhea
includes proper handwashing to prevent the spread of infection.
 Option A: Prolonged diarrhea is more likely to cause tachycardia than
bradycardia. Diarrhea is the result of reduced water absorption by the
bowel or increased water secretion. A majority of acute diarrheal cases are
due to infectious etiology. Chronic diarrhea is commonly categorized into
three groups; watery, fatty (malabsorption), or infectious.
 Option B: Prolonged diarrhea leads to dehydration, which causes a
decrease in blood pressure. In bacterial and viral diarrhea, the watery stool
is the result of injury to the gut epithelium. Epithelial cells line the intestinal
tract and facilitate the absorption of water, electrolytes, and other solutes.
Infectious etiologies cause damage to the epithelial cells which leads to
increased intestinal permeability. The damaged epithelial cells are unable
to absorb water from the intestinal lumen leading to loose stool.
 Option C: Prolonged diarrhea leads to dehydration, which causes fever.
History should include the duration of symptoms, accompanying
symptoms, travel history, and exposures to medications and food. It is
important to ask about the stool frequency, type, volume, and presence of

blood or mucus. Patients with diarrhea may also complain of abdominal
pain or cramping, vomit, bloating, flatulence, fever, and bloody or mucoid
stools.
Option D: Prolonged diarrhea is more likely to cause a fluid deficit. An
important aspect of diarrhea management is replenishing fluid and
electrolyte loss. Patients should be encouraged to drink diluted fruit juice,
Pedialyte or Gatorade. In more severe cases of diarrhea, IV fluid
rehydration may become necessary.
Option E: Peripheral edema results from a fluid overload. Important aspects
of the physical exam include the patient‘s vital signs, volume status, and
abdominal exam. Dry mucous membranes, poor skin turgor, and delayed
capillary refill are signs of dehydration. A thorough history and physical
exam are important to determine the proper diagnostic workup.
ADV
73. Question
A nurse is preparing to administer a cleansing enema to an adult client in
preparation for a diagnostic procedure. Which of the following are appropriate
steps for the nurse to take? Select all that apply.
o A. Warm the enema solution prior to installation.
o B. Position the client on the left side with the right leg flexed forward.
o C. Lubricate the rectal tube or nozzle.
o D. Slowly insert the rectal tube about 2 inches.
o E. Hang the enema container 24 inches above the clients anus.

Incorrect
Correct Answer: A, B, and C
Enemas are rectal injections of fluid intended to cleanse or stimulate the
emptying of the bowel. Enemas can be administered by a medical professional or
self-administered at home. Enemas may also be prescribed to flush out the colon
before certain diagnostic tests or surgeries. The bowel needs to be empty before
these procedures to reduce infection risk and prevent stool from getting in the
way.

 Option A: The nurse should warm the enema solution because cold fluid
can cause abdominal cramping and hot fluid can injure the intestinal
mucosa. Cleansing enemas are water-based and meant to be held in the
rectum for a short time to flush the colon. Once injected, they‘re retained
for a few minutes until the body rids itself of the fluid, along with loose
matter and impacted stool in the bowel.
 Option B: Option B allows a downward flow of solution by gravity along
the natural anatomical curve of the sigmoid colon. Some advocates claim
that enemas can support weight loss, remove toxins and heavy metals from
the body, and improve the skin, immunity, blood pressure, and energy
levels.
 Option C: Lubrication prevents trauma or irritation to the rectal mucosa.
The least irritating of all options, water or saline — salt water that mimics
the body‘s sodium concentration — are used primarily for their ability to
expand the colon and mechanically promote defecation.
 Option D: This is an appropriate length of insertion for a child. For an adult
client, the nurse should insert a tube 3 to 4 inches. Research shows that
enemas used in preparation for medical procedures significantly disrupt
gut bacteria, though the effect appears to be temporary. However, enemas
that are split and administered in two doses seem to have fewer effects on
the microbiome.
 Option E: The height of the fluid container affects the speed of installation.
The maximum recommended height is 18 inches. Hanging the container
higher than that could cause rapid installation and possibly painful
distention of the colon.
ADV
74. Question
While a nurse is administering a cleansing enema, the client reports abdominal
cramping. Which of the following is the appropriate intervention?
o A. Have a client hold his breath briefly.
o B. Discontinue the fluid installation.
o C. Remind the client that cramping is common at this time.

o D. Lower the enema fluid container.
Incorrect
Correct Answer: D. Lower the enema fluid container.
To relieve the client‘s discomfort, the nurse should slow the rate of installation by
reducing the height of the enema solution container. An enema may be helpful
when there is a problem forming or passing stool. The colon, also called the large
intestine or large bowel, is a long, hollow organ in the abdomen. It plays an
important role in digestion by removing water from digested material and
forming feces (stool). In some circumstances, due to diet, medical condition, or
medication, among other possible causes, the bowel may form stool that is hard
to pass easily resulting in constipation.
 Option A: Taking slow, deep breaths is more therapeutic for easing
discomfort than holding the breath. A cleansing enema can also lower the
amount of bacteria in the colon and reduce the risk of infection for certain
surgeries.
 Option B: The nurse should stop the installation if the client‘s abdomen
becomes rigid and distended or if the nurse notes bleeding from the
rectum. An enema should not be painful when administered properly. The
client may feel fullness, mild pressure, or brief, minimal cramping during
the procedure. The client may also feel like he needs to have a bowel
movement.
 Option C: This intervention is not therapeutic as it implies that the client
must tolerate the discomfort and that the nurse cannot or will not do
anything to ease it. The client may take a few long, deep breaths to help
himself relax. If he has pain or discomfort while self-inserting an enema,
stop and contact the doctor.
ADV
75. Question
A client with chronic pulmonary disease has a bluish tinge around the lips. The
nurse charts which term to most accurately describe the client‘s condition?
o A. Hypoxia
o B. Hypoxemia

o C. Dyspnea
o D. Cyanosis
Incorrect
Correct Answer: D. Cyanosis
A bluish tinge to mucous membranes is called cyanosis. This is most accurate
because it is what the nurse observes. Cyanosis refers to a bluish cast to the skin
and mucous membranes. Peripheral cyanosis is when there is a bluish
discoloration to the hands or feet. It‘s usually caused by low oxygen levels in the
red blood cells or problems getting oxygenated blood to the body.
 Option A: The nurse can only observe signs/symptoms of hypoxia. More
information is needed to validate this conclusion. Hypoxia is a condition in
which the body or a region of the body is deprived of adequate oxygen
supply at the tissue level. Hypoxia may be classified as either generalized,
affecting the whole body, or local, affecting a region of the body.
 Option B: Hypoxemia requires blood oxygenation saturation data to be
confirmed. Hypoxemia refers to the low level of oxygen in the blood, and
the more general term hypoxia is an abnormally low oxygen content in any
tissue or organ or the body as a whole. Hypoxemia can cause hypoxia
(hypoxemic hypoxia), but hypoxia can also occur via other mechanisms,
such as anemia.
 Option C: Dyspnea is difficult to breathe. Dyspnea is the medical term for
shortness of breath, sometimes described as ―air hunger.‖ It is an
uncomfortable feeling. Shortness of breath can range from mild and
temporary to serious and long-lasting. It is sometimes difficult to diagnose
and treat dyspnea because there can be many different causes.
ADV
1. Question
Which intervention is an example of primary prevention?
 A. Administering digoxin (Lanoxicaps) to a patient with heart failure.
 B. Administering measles, mumps, and rubella immunization to an

infant.
 C. Obtaining a Papanicolaou smear to screen for cervical cancer.

 D. Using occupational therapy to help a patient cope with arthritis.
Incorrect
Correct Answer: B. Administering measles, mumps, and rubella
immunization to an infant.
Immunizing an infant is an example of primary prevention, which aims to prevent
health problems. Primary prevention includes those preventive measures that
come before the onset of illness or injury and before the disease process begins.
Examples include immunization and taking regular exercise to prevent health
problems developing in the future.
 Option A: Administering digoxin to treat heart failure and obtaining a
smear for a screening test are examples for secondary prevention, which
promotes early detection and treatment of disease. Those preventive
measures that lead to early diagnosis and prompt treatment of a disease,
illness, or injury to prevent more severe problems developing. Here health
educators such as Health Extension Practitioners can help individuals
acquire the skills of detecting diseases in their early stages.
 Option C: Obtaining a Papanicolau smear is a secondary prevention.
Secondary prevention includes those preventive measures that lead to
early diagnosis and prompt treatment of a disease, illness, or injury. This
should limit disability, impairment, or dependency and prevent more
severe health problems developing in the future.
 Option D: Using occupational therapy to help a patient cope with arthritis
is an example of tertiary prevention, which aims to help a patient deal with
the residual consequences of a problem or to prevent the problem from
recurring. Tertiary prevention includes those preventive measures aimed at
rehabilitation following significant illness. At this level, health educators
work to retrain, re-educate and rehabilitate the individual who has already
had an impairment or disability.
Question 2 of 75
2. Question
The nurse in charge is assessing a patient‘s abdomen. Which examination
technique should the nurse use first?
 A. Auscultation

 B. Inspection
 C. Percussion
 D. Palpation
Incorrect
Correct Answer: B. Inspection
Inspection always comes first when performing a physical examination. It is
important to begin with the general examination of the abdomen with the
patient in a completely supine position. The presence of any of the following
signs may indicate specific disorders. Percussion and palpation of the abdomen
may affect bowel motility and therefore should follow auscultation.
 Option A: The last step of the abdominal examination is auscultation with
a stethoscope. The diaphragm of the stethoscope should be placed on the
right side of the umbilicus to listen to the bowel sounds, and their rate
should be calculated after listening for at least two minutes. Normal bowel
sounds are low-pitched and gurgling, and the rate is normally 2-5/min.
Absent bowel sounds may indicate paralytic ileus and hyperactive rushes
(borborygmi) are usually present in small bowel obstruction and
sometimes may be auscultated in lactose intolerance.
 Option C: A proper technique of percussion is necessary to gain maximum
information regarding the abdominal pathology. While percussing, it is
important to appreciate tympany over air-filled structures such as the
stomach and dullness to percussion which may be present due to an
underlying mass or organomegaly (for example, hepatomegaly or
splenomegaly).
 Option D: The ideal position for abdominal examination is to sit or kneel
on the right side of the patient with the hand and forearm in the same
horizontal plane as the patient‘s abdomen. There are three stages of
palpation that include the superficial or light palpation, deep palpation,
and organ palpation and should be performed in the same order.
Maneuvers specific to certain diseases are also a part of abdominal
palpation.
3. Question
Which statement regarding heart sounds is correct?

 A. S1 and S2 sound equally loud over the entire cardiac area.
 B. S1 and S2 sound fainter at the apex.
 C. S1 and S2 sound fainter at the base.
 D. S1 is loudest at the apex, and S2 is loudest at the base.

Incorrect
Correct Answer: D. S1 is loudest at the apex, and S2 is loudest at the base.
The S1 sound—the ―lub‖ sound—is loudest at the apex of the heart. It sounds
longer, lower, and louder there than the S2 sounds. The S2—the ―dub‖ sound—is
loudest at the base. It sounds shorter, sharper, higher, and louder there than S1.
Heart sounds are created from blood flowing through the heart chambers as the
cardiac valves open and close during the cardiac cycle. Vibrations of these
structures from the blood flow create audible sounds — the more turbulent the
blood flow, the more vibrations that get created.
 Option A: The S1 heart sound is produced as the mitral and tricuspid
valves close in systole. This structural and hemodynamic change creates
vibrations that are audible at the chest wall. The mitral valve closing is the
louder component of S1. It also occurs sooner because of the left ventricle
contracts earlier in systole.
 Option B: Changes in the intensity of S1 are more attributable to forces
acting on the mitral valve. Such causes include a change in left ventricular
contractility, mitral structure, or the PR interval. However, under normal
resting conditions, the mitral and tricuspid sounds occur close enough
together not to be discernible. The most common reasons for a split S1 are
things that delay right ventricular contraction, like a right bundle branch
block.
 Option C: The S2 heart sound is produced with the closing of the aortic
and pulmonic valves in diastole. The aortic valve closes sooner than the
pulmonic valve, and it is the louder component of S2; this occurs because
the pressures in the aorta are higher than the pulmonary artery.
4. Question
The nurse in charge identifies a patient‘s responses to actual or potential health
problems during which step of the nursing process?

 A. Assessment
 B. Nursing diagnosis
 C. Planning
 D. Evaluation
Incorrect
Correct Answer: B. Nursing diagnosis
The nurse identifies human responses to actual or potential health problems
during the nursing diagnosis step of the nursing process. The formulation of a
nursing diagnosis by employing clinical judgment assists in the planning and
implementation of patient care. The North American Nursing Diagnosis
Association (NANDA) provides nurses with an up to date list of nursing
diagnoses. A nursing diagnosis, according to NANDA, is defined as a clinical
judgment about responses to actual or potential health problems on the part of
the patient, family or community.
 Option A: During the assessment step, the nurse systematically collects
data about the patient or family. Assessment is the first step and involves
critical thinking skills and data collection; subjective and objective.
Subjective data involves verbal statements from the patient or caregiver.
Objective data is measurable, tangible data such as vital signs, intake and
output, and height and weight.
 Option C: During the planning step, the nurse develops strategies to
resolve or decrease the patient‘s problem. The planning stage is where
goals and outcomes are formulated that directly impact patient care based
on EDP guidelines. These patient-specific goals and the attainment of such
assist in ensuring a positive outcome.
 Option D: During the evaluation step, the nurse determines the
effectiveness of the plan of care. This final step of the nursing process is
vital to a positive patient outcome. Whenever a healthcare provider
intervenes or implements care, they must reassess or evaluate to ensure
the desired outcome has been met. Reassessment may frequently be
needed depending upon overall patient condition. The plan of care may be
adapted based on new assessment data.
5. Question

A female patient is receiving furosemide (Lasix), 40 mg P.O. b.i.D. in the plan of
care, the nurse should emphasize teaching the patient about the importance of
consuming:
 A. Fresh, green vegetables
 B. Bananas and oranges
 C. Lean red meat
 D. Creamed corn
Incorrect
Correct Answer: B. Bananas and oranges
Because furosemide is a potassium-wasting diuretic, the nurse should plan to
teach the patient to increase intake of potassium-rich foods, such as bananas and
oranges. Potassium is a mineral in the cells. It helps the nerves and muscles work
as they should. The right balance of potassium also keeps the heart beating at a
steady rate. Fresh, green vegetables; lean red meat; and creamed corn are not
good sources of potassium.
 Option A: GLVs are considered as natural caches of nutrients for human
beings as they are a rich source of vitamins, such as ascorbic acid, folic
acid, tocopherols, ?-carotene, and riboflavin, as well as minerals such as
iron, calcium, and phosphorous.
 Option C: Lean red meat is an excellent source of high biological value
protein, vitamin B12, niacin, vitamin B6, iron, zinc, and phosphorus. It is a
source of long?chain omega?3 polyunsaturated fats, riboflavin, pantothenic
acid, selenium, and, possibly, also vitamin D. It is also relatively low in fat
and sodium.
 Option D: Corn has several health benefits. Because of the high fiber
content, it can aid with digestion. It also contains valuable B vitamins,
which are important to your overall health. Corn also provides our bodies
with essential minerals such as zinc, magnesium, copper, iron, and
manganese.
6. Question
The nurse in charge must monitor a patient receiving chloramphenicol for
adverse drug reaction. What is the most toxic reaction to chloramphenicol?

 A. Lethal arrhythmias
 B. Malignant hypertension
 C. Status epilepticus
 D. Bone marrow suppression

Incorrect
Correct Answer: D. Bone marrow suppression
The most toxic reaction to chloramphenicol is bone marrow suppression.
Chloramphenicol is a synthetically manufactured broad-spectrum antibiotic. It
was initially isolated from the bacteria Streptomyces venezuelae in 1948 and was
the first bulk produced synthetic antibiotic. However, chloramphenicol is a rarely
used drug in the United States because of its known severe adverse effects, such
as bone marrow toxicity and grey baby syndrome. Chloramphenicol is not known
to cause lethal arrhythmias, malignant hypertension, or status epilepticus.
 Option A: Chloramphenicol is associated with severe hematological side
effects when administered systemically. Since 1982, chloramphenicol has
reportedly caused fatal aplastic anemia, with possible increased risk when
taken together with cimetidine. This adverse side effect can occur even
with the topical administration of the drug, which is most likely due to the
systemic absorption of the drug after topical application.
 Option B: Besides causing fatal aplastic anemia and bone marrow
suppression, other side effects of chloramphenicol include ototoxicity with
the use of topical ear drops, gastrointestinal reactions such as oesophagitis
with oral use, neurotoxicity, and severe metabolic acidosis.
 Option C: Optic neuritis is the most commonly associated neurotoxic
complication that can arise from chloramphenicol use. This adverse effect
usually takes more than six weeks to manifest, presenting with either acute
or subacute vision loss, with possible fundal changes. It may also present
with peripheral neuropathy, which may present as numbness or tingling. If
optic neuropathy occurs, the drug should be withdrawn immediately, which
will usually lead to partial or complete recovery of vision.
7. Question
A female patient is diagnosed with deep-vein thrombosis. Which nursing
diagnosis should receive highest priority at this time?

 A. Impaired gas exchanges related to increased blood flow.
 B. Fluid volume excess related to peripheral vascular disease.
 C. Risk for injury related to edema.
 D. Altered peripheral tissue perfusion related to venous congestion.

Incorrect
Correct Answer: D. Altered peripheral tissue perfusion related to venous
congestion.
Altered peripheral tissue perfusion related to venous congestion‖ takes highest
priority because venous inflammation and clot formation impede blood flow in a
patient with deep-vein thrombosis. A deep-vein thrombosis (DVT) is a blood clot
that forms within the deep veins, usually of the leg, but can occur in the veins of
the arms and the mesenteric and cerebral veins. Deep-vein thrombosis is a
common and important disease. It is part of the venous thromboembolism
disorders which represent the third most common cause of death from
cardiovascular disease after heart attacks and stroke.
 Option A: Option A is incorrect because impaired gas exchange is related
to decreased, not increased, blood flow. Depending on the relative balance
between the coagulation and thrombolytic pathways, thrombus
propagation occurs. DVT is commonest in the lower limb below the knee
and starts at low-flow sites, such as the soleal sinuses, behind venous valve
pockets.
 Option B: Option B is inappropriate because no evidence suggests that
this patient has a fluid volume excess. Nurses need to educate the patients
on the importance of ambulation, being compliant with compression
stockings, and taking the prescribed anticoagulation medications.
 Option C: Option C may be warranted but is secondary to altered tissue
perfusion. Thrombosis is a protective mechanism that prevents the loss of
blood and seals off damaged blood vessels. Fibrinolysis counteracts or
stabilizes the thrombosis. The triggers of venous thrombosis are frequently
multifactorial, with the different parts of the triad of Virchow contributing
in varying degrees in each patient, but all result in early thrombus
interaction with the endothelium. This then stimulates local cytokine
production and causes leukocyte adhesion to the endothelium, both of
which promote venous thrombosis.

8. Question
When positioned properly, the tip of a central venous catheter should lie in the:
 A. Superior vena cava
 B. Basilica vein
 C. Jugular vein
 D. Subclavian vein
Incorrect
Correct Answer: A. Superior vena cava
When the central venous catheter is positioned correctly, its tip lies in the
superior vena cava, inferior vena cava, or the right atrium—that is, in central
venous circulation. Blood flows unimpeded around the tip, allowing the rapid
infusion of large amounts of fluid directly into circulation. The basilica, jugular,
and subclavian veins are common insertion sites for central venous catheters.
 Option B: There are three main access sites for the placement of central
venous catheters. The internal jugular vein, common femoral vein, and
subclavian veins are the preferred sites for temporary central venous
catheter placement. Additionally, for mid-term and long-term central
venous access, the basilic and brachial veins are utilized for peripherally
inserted central catheters (PICCs).
 Option C: The internal jugular vein (IJ) is often chosen for its reliable
anatomy, accessibility, low complication rates, and the ability to employ
ultrasound guidance during the procedure. The individual clinical scenario
may dictate laterality in some cases (such as with trauma, head and neck
cancer, or the presence of other invasive devices or catheters), but all
things being equal, many physicians prefer the right IJ. As compared to the
left, the right IJ forms a more direct path to the superior vena cava (SVC)
and right atrium. It is also wider in diameter and more superficial, thus
presumably easier to cannulated.
 Option D: The subclavian vein site has the advantage of low rates of both
infectious and thrombotic complications. Additionally, the SC site is
accessible in trauma, when a cervical collar negates the choice of the IJ.
However, disadvantages include a higher relative risk of pneumothorax,

less accessibility to use ultrasound for CVC placement, and the non-
compressible location posterior to the clavicle.
9. Question
Nurse Nikki is revising a client‘s care plan. During which step of the nursing
process does such revision take place?
 A. Assessment
 B. Planning
 C. Implementation
 D. Evaluation
Incorrect
Correct Answer: D. Evaluation
During the evaluation step of the nursing process, the nurse determines whether
the goals established in the care plan have been achieved, and evaluates the
success of the plan. If a goal is unmet or partially met the nurse reexamines the
data and revises the plan. This final step of the nursing process is vital to a
positive patient outcome. Whenever a healthcare provider intervenes or
implements care, they must reassess or evaluate to ensure the desired outcome
has been met. Reassessment may frequently be needed depending upon overall
patient condition. The plan of care may be adapted based on new assessment
data. Assessment involves data collection. Planning involves setting priorities,
establishing goals, and selecting appropriate interventions.
 Option A: Assessment is the first step and involves critical thinking skills
and data collection; subjective and objective. Subjective data involves
verbal statements from the patient or caregiver. Objective data is
measurable, tangible data such as vital signs, intake and output, and height
and weight.
 Option B: The planning stage is where goals and outcomes are formulated
that directly impact patient care based on EDP guidelines. These patient-
specific goals and the attainment of such assist in ensuring a positive
outcome. Nursing care plans are essential in this phase of goal setting.
Care plans provide a course of direction for personalized care tailored to
an individual‘s unique needs. Overall condition and comorbid conditions
play a role in the construction of a care plan. Care plans enhance

communication, documentation, reimbursement, and continuity of care
across the healthcare continuum.
 Option C: Implementation is the step that involves action or doing and the
actual carrying out of nursing interventions outlined in the plan of care.
This phase requires nursing interventions such as applying a cardiac
monitor or oxygen, direct or indirect care, medication administration,
standard treatment protocols, and EDP standards.
10. Question
A 65-year-old female who has diabetes mellitus and has sustained a large
laceration on her left wrist asks the nurse, ―How long will it take for my scars to
disappear?‖ Which statement would be the nurse‘s best response?
 A. ―The contraction phase of wound healing can take 2 to 3 years.‖
 B. ―Wound healing is very individual but within 4 months the scar should
fade.
 C. “With your history and the type of location of the injury, it’s hard to
say.”
 D. ―If you don‘t develop an infection, the wound should heal any time
between 1 and 3 years from now.‖
Incorrect
Correct Answer: C. “With your history and the type of location of the injury,
it’s hard to say.”
Wound healing in a client with diabetes will be delayed. Providing the client with
a time frame could give the client false information. There is no doubt that
diabetes plays a detrimental role in wound healing. It does so by affecting the
wound healing process at multiple steps. Wound hypoxia, through a combination
of impaired angiogenesis, inadequate tissue perfusion, and pressure-related
ischemia, is a major driver of chronic diabetic wounds.
 Option A: Ischemia can lead to prolonged inflammation, which increases
the levels of oxygen radicals, leading to further tissue injury. Elevated levels
of matrix metalloproteases in chronic diabetic wounds, sometimes up to
50-100 times higher than acute wounds, cause tissue destruction and
prevent normal repair processes from taking place. Furthermore, diabetes
is associated with impaired immunity, with critical defects occurring at

multiple points within the immune system cascade of the wound healing
process.
 Option B: To further complicate matters, these wounds have defects in
angiogenesis and neovascularization. Normally, wound hypoxia stimulates
mobilization of endothelial progenitor cells via vascular endothelial growth
factor (VEGF). In diabetic wounds, there are aberrant levels of VEGF and
other angiogenic factors such as angiopoietin-1 and angiopoietin-2 that
lead to dysangiogenesis.
 Option D: Diabetic neuropathy may also play a role in poor wound
healing. Lower levels of neuropeptides, as well as reduced leukocyte
infiltration as a result of sensory denervation, have been shown to impair
wound healing. When combined, all these diverse factors play a role in the
formation and propagation of chronic, debilitating wounds in patients with
diabetes.
11. Question
One aspect of implementation related to drug therapy is:
 A. Developing a content outline.
 B. Documenting drugs given.
 C. Establishing outcome criteria.
 D. Setting realistic client goals.

Incorrect
Correct Answer: B. Documenting drugs given.
Although documentation isn‘t a step in the nursing process, the nurse is legally
required to document activities related to drug therapy, including the time of
administration, the quantity, and the client‘s reaction. Developing a content
outline, establishing outcome criteria, and setting realistic client goals are part of
planning rather than implementation.
 Option A: UE has a common goal with the pharmaceutical care it supports:
to improve an individual patient‘s quality of life through the achievement
of predefined, medication-related therapeutic outcomes. Through its focus
on the system of medication use, the MUE process helps to identify actual
and potential medication-related problems, resolve actual medication-
related problems, and prevent potential medication-related problems that

could interfere with achieving optimum outcomes from medication
therapy.
 Option C: Although distinctions historically have been made among the
terms drug-use evaluation, drug-use review, and medication use evaluation
(MUE), they all refer to the systematic evaluation of medication use
employing standard, observational quality-improvement methods. MUE is
a quality-improvement activity, but it also can be considered a formulary
system management technique. An MUE is a performance improvement
method that focuses on evaluating and improving medication-use
processes with the goal of optimal patient outcomes.
 Option D: MUE encompasses the goals and objectives of drug use
evaluation (DUE) in its broadest application, emphasizing improving patient
outcomes. The use of MUE, rather than DUE, emphasizes the need for a
more multifaceted approach to improving medication use.
12. Question
A female client is readmitted to the facility with a warm, tender, reddened area on
her right calf. Which contributing factor would the nurse recognize
as most important?
 A. A history of increased aspirin use.
 B. Recent pelvic surgery.
 C. An active daily walking program.
 D. A history of diabetes.
Incorrect
Correct Answer: B. Recent pelvic surgery
The client shows signs of deep vein thrombosis (DVT). The pelvic area is rich in
blood supply, and thrombophlebitis of the deep vein is associated with pelvic
surgery. Thrombosis is a protective mechanism that prevents the loss of blood
and seals off damaged blood vessels. Fibrinolysis counteracts or stabilizes the
thrombosis. The triggers of venous thrombosis are frequently multifactorial, with
the different parts of the triad of Virchow contributing in varying degrees in each
patient, but all result in early thrombus interaction with the endothelium. This
then stimulates local cytokine production and causes leukocyte adhesion to the
endothelium, both of which promote venous thrombosis.

 Option A: Aspirin, an antiplatelet agent, and an active walking program
help decrease the client‘s risk of DVT. The use of thrombolytic therapy can
result in an intracranial bleed, and hence, careful patient selection is vital.
Recently endovascular interventions like catheter-directed extraction,
stenting, or mechanical thrombectomy have been tried with moderate
success.
 Option C: Treatment of DVT aims to prevent pulmonary embolism, reduce
morbidity, and prevent or minimize the risk of developing post-thrombotic
syndrome. The cornerstone of treatment is anticoagulation. NICE
guidelines only recommend treating proximal DVT (not distal) and those
with pulmonary emboli. In each patient, the risks of anticoagulation need
to be weighed against the benefits.
 Option D: In general, diabetes is a contributing factor associated with
peripheral vascular disease. In the hospital, the most commonly associated
conditions are malignancy, congestive heart failure, obstructive airway
disease, and patients undergoing surgery. In the hospital, the most
commonly associated conditions are malignancy, congestive heart failure,
obstructive airway disease, and patients undergoing surgery.
13. Question
Which intervention should the nurse in charge try first for a client that exhibits
signs of sleep disturbance?
 A. Administer sleeping medication before bedtime.
 B. Ask the client each morning to describe the quantity of sleep during the
previous night.
 C. Teach the client relaxation techniques, such as guided imagery,

medication, and progressive muscle relaxation.
 D. Provide the client with normal sleep aids, such as pillows, back rubs,
and snacks.
Incorrect
Correct Answer: D. Provide the client with normal sleep aids, such as pillows,
back rubs, and snacks
The nurse should begin with the simplest interventions, such as pillows or snacks,
before interventions that require greater skill such as relaxation techniques. Sleep

is a complex biological process. It is a reversible state of unconsciousness in
which there are reduced metabolism and motor activity. Sleep disorders are a
group of conditions that disturb the normal sleep patterns of a person. Sleep
disorders are one of the most common clinical problems encountered.
Inadequate or non-restorative sleep can interfere with normal physical, mental,
social, and emotional functioning. Sleep disorders can affect overall health, safety,
and quality of life.
 Option A: Sleep medication should be avoided whenever possible.
Histamine type 1 receptor blockers: due to their sedative effects, these
drugs can be helpful in patients with sleep disorders. Benzodiazepines
(BZD) are the mainstay in the treatment of insomnia. Non-benzodiazepine
hypnotics are used for the treatment of acute and short term insomnia.
 Option B: At some point, the nurse should do a thorough sleep
assessment, especially if common sense interventions fail. The sleep diary,
or sleep log, is a subjective paper record of sleep and wakefulness over a
period of weeks to a month. Patients should record the detailed
description of sleep, such as bedtime, duration until sleep onset, the
number of awakenings, duration of awakenings, and nap times.
 Option C: Relaxation techniques may be implemented before sleep.
Meditation and breathing exercises are some of the relaxation techniques.
It begins with being in a comfortable position and closing eyes. The mind
and thoughts should be redirected towards a peaceful image, and
relaxation should be allowed to spread throughout the body.
14. Question
While examining a client‘s leg, the nurse notes an open ulceration with visible
granulation tissue in the wound. Until a wound specialist can be contacted, which
type of dressings is most appropriate for the nurse in charge to apply?
 A. Dry sterile dressing
 B. Sterile petroleum gauze
 C. Moist, sterile saline gauze
 D. Povidone-iodine-soaked gauze
Incorrect
Correct Answer: C. Moist, sterile saline gauze

Moist, sterile saline dressings support would heal and are cost-effective. If the
wound is infected and there are a lot of sloughs, which cannot be mechanically
debrided, then a chemical debridement can be done with collagenase-based
products. The goal is to help the wound heal as soon as possible by using an
appropriate dressing material to maintain the right amount of moisture. When
the wound bed is dry, use a dressing to increase moisture and if too wet and the
surrounding skin is macerated, use material that will absorb excess fluid and
protect the surrounding healthy skin.
 Option A: Dry sterile dressings adhere to the wound and debride the
tissue when removed. Tulle is a non-adherent dressing impregnated with
paraffin. It aids healing but doesn‘t absorb exudate. It also requires a
secondary dressing to hold it in place. It is ideal for burns as one can add
topical antibiotics to the dressing. It is known to cause allergies, and this
limits its wider use.
 Option B: Petroleum supports healing but is expensive. The
semipermeable dressing allows for moisture to evaporate and also reduces
pain. This dressing also acts as a barrier to prevent environmental
contamination. The semipermeable dressing does not absorb moisture and
requires regular inspection. It also requires a secondary dressing to hold
the semipermeable dressing in place.
 Option D: Povidone-iodine can irritate epithelial cells, so it shouldn‘t be
left on an open wound. Plastic film dressings are known to absorb exudate
and can be used for wounds with a moderate amount of exudate. They
should not be used on dry wounds. They often require a secondary
dressing to hold the plastic in place.
15. Question
A male client in a behavioral-health facility receives a 30-minute psychotherapy
session, and the provider uses a current procedure terminology (CPT) code that
bills for a 50-minute session. Under the False Claims Act, such illegal behavior is
known as:
 A. Unbundling
 B. Overbilling
 C. Upcoding

 D. Misrepresentation
Incorrect
Correct Answer: C. Upcoding
Upcoding is the practice of using a CPT code that‘s reimbursed at a higher rate
than the code for the service actually provided. Upcoding is fraudulent medical
billing in which a bill sent for a health service is more expensive than it should
have been based on the service that was performed. An upcoded bill can be sent
to any payer—whether a private health insurer, Medicaid, Medicare, or the
patient. Unbundling, overbilling, and misrepresentation aren‘t the terms used for
this illegal practice.
 Option A: Unbundling refers to using multiple CPT codes for those parts of
the procedure, either due to misunderstanding or in an effort to increase
payment.
 Option B: Overbilling (sometimes spelled as over-billing) is the practice of
charging more than is legally or ethically acceptable on an invoice or bill.
 Option D: A misrepresentation is a false statement of a material fact made
by one party which affects the other party‘s decision in agreeing to a
contract. If the misrepresentation is discovered, the contract can be
declared void, and depending on the situation, the adversely impacted
party may seek damages.
16. Question
A nurse assigned to care for a postoperative male client who has diabetes
mellitus. During the assessment interview, the client reports that he‘s impotent
and says that he‘s concerned about its effect on his marriage. In planning this
client‘s care, the most appropriate intervention would be to:
 A. Encourage the client to ask questions about personal sexuality.
 B. Provide time for privacy.
 C. Provide support for the spouse or significant other.
 D. Suggest referral to a sex counselor or other appropriate professional.

Incorrect
Correct Answer: D. Suggest referral to a sex counselor or other appropriate
professional

The nurse should refer this client to a sex counselor or other professional. Making
appropriate referrals is a valid part of planning the client‘s care. Therefore,
providing time for privacy and providing support for the spouse or significant
other are important, but not as important as referring the client to a sex
counselor.
 Option A: The nurse doesn‘t normally provide sex counseling. The nurse is
ideally placed in the primary care field to help ease the upset caused;
however, in order to offer care that is effective, insight and understanding
of the condition are required as well as the various treatment options
available to help men manage their health and wellbeing.
 Option B: The key goal of management is to diagnose and treat the cause
of ED when this is possible, enabling the man or couple to enjoy a
satisfactory sexual experience. This can occur when the nurse has identified
and treated any curable causes of ED, initiating lifestyle change and risk
factor modification, including drug-related factors, and offering education
and counselling to patients and their partners.
 Option C: The potential benefits of lifestyle changes (e.g. weight
management, smoking cessation) may be particularly important in
individuals with ED and specific comorbid cardiovascular or metabolic
diseases, such as diabetes or hypertension. As well as improving erectile
function, lifestyle changes may also benefit overall cardiovascular and
metabolic health. Further studies are needed to clarify the role of lifestyle
changes in the management of ED and related cardiovascular disease.
1. 17. Question
Using Abraham Maslow’s hierarchy of human needs, a nurse assigns highest priority to which
client need?
o A. Security
o B. Elimination
o C. Safety
o D. Belonging
Incorrect
Correct Answer: B. Elimination
According to Maslow, elimination is a first-level or physiological need and therefore takes
priority over all other needs. In 1943, Abraham Maslow developed a hierarchy based on basic

fundamental needs innate for all individuals. Maslow’s hierarchy of needs is a motivational
theory in psychology comprising a five-tier model of human needs, often depicted as hierarchical
levels within a pyramid. From the bottom of the hierarchy upwards, the needs are: physiological
(food and clothing), safety (job security), love and belonging needs (friendship), esteem, and
self-actualization. Security and safety are second-level needs; belonging is a third-level need.
Second- and third-level needs can be met only after a client’s first-level needs have been
satisfied.
 Option A: Once an individual’s physiological needs are satisfied, the needs for security
and safety become salient. People want to experience order, predictability, and control in
their lives. These needs can be fulfilled by the family and society (e.g. police, schools,
business, and medical care).
 Option C: Physiological and safety needs provide the basis for the implementation of
nursing care and nursing interventions. For example, emotional security, financial
security (e.g. employment, social welfare), law and order, freedom from fear, social
stability, property, health, and wellbeing (e.g. safety against accidents and injury).
 Option D: After physiological and safety needs have been fulfilled, the third level of
human needs is social and involves feelings of belongingness. The need for interpersonal
relationships motivates behavior. Examples include friendship, intimacy, trust, and
acceptance, receiving and giving affection and love. Affiliating, being part of a group
(family, friends, work)
18. Question
A male client on prolonged bed rest has developed a pressure ulcer. The wound shows no signs
of healing even though the client has received skin care and has been turned every 2 hours.
Which factor is most likely responsible for the failure to heal?
o A. Inadequate vitamin D intake.
o B. Inadequate protein intake.
o C. Inadequate massaging of the affected area.
o D. Low calcium level.

Incorrect
Correct Answer: B. Inadequate protein intake.
A client on bed rest suffers from a lack of movement and a negative nitrogen balance. Therefore,
inadequate protein intake impairs wound healing. Decubitus ulcers, also termed bedsores or
pressure ulcers, are skin and soft tissue injuries that form as a result of constant or prolonged
pressure exerted on the skin. These ulcers occur at bony areas of the body such as the ischium,
greater trochanter, sacrum, heel, malleolus (lateral than medial), and occiput. Inadequate vitamin
D intake and low calcium levels aren’t factors in poor healing for this client. A pressure ulcer
should never be massaged.

 Option A: Decubitus ulcer formation is multifactorial (external and internal factors), but
all these results in a common pathway leading to ischemia and necrosis. Tissues can
sustain an abnormal amount of external pressure, but constant pressure exerted over a
prolonged period is the main culprit.
 Option C: External pressure must exceed the arterial capillary pressure (32 mmHg) to
impede blood flow and must be greater than the venous capillary closing pressure (8 to
12 mmHg) to impair the return of venous blood. If the pressure above these values is
maintained, it causes tissue ischemia and further resulting in tissue necrosis. This
enormous pressure can be exerted due to compression by a hard mattress, railings of
hospital beds, or any hard surface with which the patient is in contact.
 Option D: Friction caused by skin rubbing against surfaces like clothing or bedding can
also lead to the development of ulcers by contributing to breaks in the superficial layers
of the skin. Moisture can cause ulcers and worsens existing ulcers via tissue breakdown
and maceration.
ADVERTISEMENTS
19. Question
A female client who received general anesthesia returns from surgery. Postoperatively, which
nursing diagnosis takes highest priority for this client?
o A. Acute pain related to surgery.
o B. Deficient fluid volume related to blood and fluid loss from surgery.
o C. Impaired physical mobility related to surgery.
o D. Risk for aspiration related to anesthesia.

Incorrect
Correct Answer: D. Risk for aspiration related to anesthesia.
Risk for aspiration related to anesthesia takes priority for this client because general anesthesia
may impair the gag and swallowing reflexes, possibly leading to aspiration. The gag reflex, also
known as the pharyngeal reflex, is a reflex contraction of the muscles of the posterior pharynx
after stimulation of the posterior pharyngeal wall, tonsillar area, or base of the tongue. The gag
reflex is believed to be an evolutionary reflex that developed as a method to prevent the
aspiration of solid food particles. It is an essential component of evaluating the medullary
brainstem and plays a role in the declaration of brain death.The other options, although
important, are secondary.
 Option A: Postoperative pain can additionally characterize as somatic or visceral. The
somatic division of pain is composed of a rich input of nociceptive myelinated, rapidly
conducting A-beta-fibers found in cutaneous and deep tissue, which contribute to a more
localized, sharp quality. The visceral division of pain is composed of a network of
unmyelinated C-fibers and thinly myelinated A-delta-fibers that span across multiple
viscera and converge together before entering the spinal cord. Also, visceral afferent

fibers run close to autonomic ganglia before their entrance into the dorsal root of the
spinal cord. These characteristic features of visceral nociceptive fibers are what
contribute to a more diffuse, poorly localized pattern of pain that may be accompanied by
autonomic reactions such as a change in heart rate or blood pressure.
 Option B: The acid-base and electrolyte changes observed in the perioperative period
could be secondary to the underlying illness or surgical procedure, for example,
hyponatremia occurring with transurethral resection of the prostate where glycine or
other hypotonic fluid is used for irrigation. Serum sodium concentration <120 mmol/L
will cause confusion and irritability, whereas <110 mmol/L may cause seizures and
coma.
 Option C: Complete physiologic recovery takes place by 40 min in 40% of the patients.
The functional quality of recovery in all domains occurs in only 11% of the patients by
day 3. Thus, the concept of awakening is involved with far greater dimensions than
judging the anesthetic effect as terminated and assessing a patient as being ―recovered‖ or
―awakened.‖ Patients cannot be considered fully recovered until they have returned to
their preoperative physiological state.
ADVERTISEMENTS
20. Question
The nurse inspects a client’s back and notices small hemorrhagic spots. The nurse documents
that the client has:
o A. Extravasation
o B. Osteomalacia
o C. Petechiae
o D. Uremia
Incorrect
Correct Answer: C. Petechiae
Petechiae are small hemorrhagic spots. Petechiae are tiny purple, red, or brown spots on the skin.
They usually appear on the arms, legs, stomach, and buttocks. They can also be found inside the
mouth or on the eyelids. These pinpoint spots can be a sign of many different conditions — some
minor, others serious. They can also appear as a reaction to certain medications.
 Option A: Extravasation is the leakage of fluid in the interstitial space. Extravasation is
the leakage of a fluid out of its container into the surrounding area, especially blood or
blood cells from vessels. In the case of inflammation, it refers to the movement of white
blood cells from the capillaries to the tissues surrounding them (leukocyte extravasation,
also known as diapedesis).
 Option B: Osteomalacia is the softening of bone tissue. Osteomalacia refers to a marked
softening of the bones, most often caused by severe vitamin D deficiency. The softened
bones of children and young adults with osteomalacia can lead to bowing during growth,

especially in weight-bearing bones of the legs. Osteomalacia in older adults can lead to
fractures.
 Option D: Uremia is an excess of urea and other nitrogen products in the blood. Uremia
is the condition of having high levels of urea in the blood. Urea is one of the primary
components of urine. It can be defined as an excess of amino acid and protein metabolism
end products, such as urea and creatinine, in the blood that would be normally excreted in
the urine.
ADVERTISEMENTS
21. Question
Which document addresses the client’s right to information, informed consent, and treatment
refusal?
o A. Standard of Nursing Practice
o B. Patient’s Bill of Rights
o C. Nurse Practice Act
o D. Code for Nurses

Incorrect
Correct Answer: B. Patient’s Bill of Rights
The Patient’s Bill of Rights addresses the client’s right to information, informed consent, timely
responses to requests for services, and treatment refusal. A legal document, it serves as a
guideline for the nurse’s decision making. Standards of Nursing Practice, the Nurse Practice Act,
and the Code for Nurses contain nursing practice parameters and primarily describe the use of
the nursing process in providing care.
 Option A: Standards of nursing practice developed by the American Nurses’ Association
(ANA) provide guidelines for nursing performance. They are the rules or definition of
what it means to provide competent care. The registered professional nurse is required by
law to carry out care in accordance with what other reasonably prudent nurses would do
in the same or similar circumstances. Thus, provision of high-quality care consistent with
established standards is critical.
 Option C: Every state and territory in the US set laws to govern the practice of nursing.
These laws are defined in the Nursing Practice Act (NPA). The NPA is then interpreted
into regulations by each state and territorial nursing board with the authority to regulate
the practice of nursing care and the power to enforce the laws.
 Option D: The ANA Code of Ethics for Nurses serves the following purposes: It is a
succinct statement of the ethical obligations and duties of every individual who enters the
nursing profession. It is the profession’s nonnegotiable ethical standard. It is an
expression of nursing’s own understanding of its commitment to society.
ADVERTISEMENTS

22. Question
If a blood pressure cuff is too small for a client, blood pressure readings taken with such a cuff
may do which of the following?
o A. Fail to show changes in blood pressure.
o B. Produce a false-high measurement.
o C. Cause sciatic nerve damage.
o D. Produce a false-low measurement.

Incorrect
Correct Answer: B. Produce a false-high measurement.
Using an undersized blood pressure cuff produces a falsely elevated blood pressure because the
cuff can’t record brachial artery measurements unless it’s excessively inflated.
 Option A: Using a blood pressure cuff that’s too large or too small can give inaccurate
blood pressure readings. The doctor’s office should have several sizes of cuffs to ensure
an accurate blood pressure reading. When one measures their blood pressure at home, it’s
important to use the proper size cuff.
 Option C: The sciatic nerve wouldn’t be damaged by hyperinflation of the blood
pressure cuff because the sciatic nerve is located in the lower extremity.
 Option D: The inflatable part of the blood pressure cuff should cover about 40% of the
distance around (circumference of) the upper arm. The cuff should cover 80% of the area
from the elbow to the shoulder.
ADVERTISEMENTS
23. Question
Nurse Elijah has been teaching a client about a high-protein diet. The teaching is successful if the
client identifies which meal as high in protein?
o A. Baked beans, hamburger, and milk
o B. Spaghetti with cream sauce, broccoli, and tea
o C. Bouillon, spinach, and soda
o D. Chicken cutlet, spinach, and soda

Incorrect
Correct Answer: A. Baked beans, hamburger, and milk

Baked beans, hamburger, and milk are all excellent sources of protein. Good choices include soy
protein, beans, nuts, fish, skinless poultry, lean beef, pork, and low-fat dairy products. Avoid
processed meats.
 Option B: The spaghetti-broccoli-tea choice is high in carbohydrates. The quality of the
carbohydrates (carbs) one eats is important too. Cut processed carbs from the diet, and
choose carbs that are high in fiber and nutrient-dense, such as whole grains and
vegetables and fruit.
 Option C: The bouillon-spinach-soda choice provides liquid and sodium as well as some
iron, vitamins, and carbohydrates.
 Option D: Chicken provides protein but the chicken-spinach-soda combination provides
less protein than the baked beans-hamburger-milk selection.
ADVERTISEMENTS
24. Question
A male client is admitted to the hospital with blunt chest trauma after a motor vehicle accident.
The first nursing priority for this client would be to:
o A. Assess the client’s airway.
o B. Provide pain relief.
o C. Encourage deep breathing and coughing.
o D. Splint the chest wall with a pillow.

Incorrect
Correct Answer: A. Assess the client’s airway.
The first priority is to evaluate airway patency before assessing for signs of obstruction, sternal
retraction, stridor, or wheezing. Airway management is always the nurse’s first priority. Blunt
trauma, on the whole, is a more common cause of traumatic injuries and can be equally life-
threatening. It is important to know the mechanism as management may be different. Most blunt
trauma is managed non-operatively, whereas penetrating chest trauma often requires operative
intervention. Pain management and splinting are important for the client’s comfort but would
come after airway assessment.
 Option B: Pain control greatly affects mortality and morbidity in patients with chest
trauma. Pain leads to splints which worsen or prevent healing. In many cases, it can lead
to pneumonia. Early analgesia should be considered to decrease splinting. In the acute
setting, push doses of short-acting narcotics should be used.
 Option C: Coughing and deep breathing may be contraindicated if the client has internal
bleeding and other injuries. Minor injuries may simply require close monitoring and pain
control. Care should be taken in the young and the elderly. Patients with 3 or more rib
fractures, a flail segment, and any number of rib fractures with pulmonary contusions,
hemopneumothorax, hypoxia, or pre-existing pulmonary disease should be monitored at
an advanced level of care.

 Option D: Immediate life-threatening injuries require prompt intervention, such as
emergent tube thoracostomy for large pneumothoraces, and initial management of
hemothorax. For cases of hemothorax, adequate drainage is imperative to prevent
retained hemothorax. Retained hemothorax can lead to empyema requiring video-assisted
thoracoscopic surgery.
ADVERTISEMENTS
25. Question
A newly hired charge nurse assesses the staff nurses as competent individually but ineffective
and unproductive as a team. In addressing her concern, the charge nurse should understand that
the usual reason for such a situation is:
o A. Unhappiness about the charge in leadership.
o B. Unexpected feelings and emotions among the staff.
o C. Fatigue from overwork and understaffing.
o D. Failure to incorporate staff in decision making.

Incorrect
Correct Answer: B. Unexpected feelings and emotions among the staff.
The usual or most prevalent reason for lack of productivity in a group of competent nurses is
inadequate communication or a situation in which the nurses have unexpected feelings and
emotions. Although the other options could be contributing to the problematic situation, they’re
less likely to be the cause.
 Option A: Providing employees with acknowledgment of the good work that they have
done is one of the easiest management tasks. However, it is also as easily neglected. For
instance, a study in the financial sector shows that only 20% of employees feel strongly
valued at work.
 Option C: Another big issue that causes low productivity is workplace stress. A study by
Health Advocate shows that there are about one million employees who are suffering
from low productivity due to stress, which costs companies $600 dollars per worker
every single year.
 Option D: An important reason for low employee productivity might be the fact that they
do not feel that they belong with the company that they are part of. It is important for
every manager to make sure that the environment in their business is welcoming to new
hires and does not make them feel underappreciated.
ADVERTISEMENTS
26. Question

A male client blood test results are as follows: white blood cell (WBC) count, 100ul; hemoglobin
(Hb) level, 14 g/dl; hematocrit (HCT), 40%. Which goal would be most important for this client?
o A. Promote fluid balance
o B. Prevent infection
o C. Promote rest
o D. Prevent injury
Incorrect
Correct Answer: B. Prevent infection
The client is at risk for infection because WBC count is dangerously low. Neutrophils play an
essential role in immune defenses because they ingest, kill, and digest invading microorganisms,
including fungi and bacteria. Failure to carry out this role leads to immunodeficiency, which is
mainly characterized by the presence of recurrent infections. Hb level and HCT are within
normal limits; therefore, fluid balance, rest, and prevention of injury are inappropriate.
 Option A: Neutrophils play a role in the immune defense against extracellular bacteria,
including Staphylococci, Streptococci, and Escherichia coli, among others. They also
protect against fungal infections, including those produced by Candida albicans. Once
their count is below 1 x 10/L recurrent infections start. As compensation, the monocyte
count may increase.
 Option C: Application of granulocyte-colony stimulating factor (G-CSF) can improve
neutrophil functions and number. Prophylactic use of antibiotics and antifungals is
reserved for some forms of alteration in neutrophil function such as chronic
granulomatous disease CGD).
 Option D: In primary neutropenia disorders such as chronic granulomatous disease
presents with recurrent infections affecting many organs since childhood. It is caused by
a failure to produce toxic reactive oxygen species so that the neutrophils can ingest the
microorganisms, but they are unable to kill them, as a significant consequence granuloma
can obstruct organs such as the stomach, esophagus, or bladder. Patients with this disease
are very susceptible to opportunistic infections by certain bacteria and fungi, especially
with Serratia and Burkholderia.
ADVERTISEMENTS
27. Question
Following a tonsillectomy, a female client returns to the medical-surgical unit. The client is
lethargic and reports having a sore throat. Which position would be most therapeutic for this
client?
o A. Semi-Fowler’s

o B. Supine
o C. High-Fowler’s
o D. Side-lying
Incorrect
Correct Answer: D. Side-lying
Because of lethargy, the post-tonsillectomy client is at risk for aspirating blood from the surgical
wound. Therefore, placing the client in the side-lying position until he awake is best. The semi-
Fowler’s, supine, and high-Fowler’s position don’t allow for adequate oral drainage in a
lethargic post-tonsillectomy client and increase the risk of blood aspiration.
 Option A: Semi-Fowler’s would not be able to facilitate effective drainage. Bleeding is
one of the most common and feared complications following tonsillectomy with or
without adenoidectomy. A study from 2009 to 2013 involving over one hundred thousand
children showed that 2.8% of children had unplanned revisits for bleeding following
tonsillectomy, 1.6% percent of patients came through the emergency department, and
0.8% required a procedure.
 Option B: Supine position predisposes the patient to aspiration. Frequency is higher at
night with 50% of bleeding occurring between 10pm-1am and 6am-9am; this is thought
to be from changes in circadian rhythm, vibratory effects of snoring on the oropharynx,
or drying of the oropharyngeal mucosa from mouth breathing. Risk of bleeding in
patients with known coagulopathies may be significantly higher.
 Option C: Tonsillectomy can be either extracapsular or intracapsular. The ―hot‖
extracapsular technique with monopolar cautery is the most popular technique in the
United States.
ADVERTISEMENTS
28. Question
The nurse inspects a client’s pupil size and determines that it’s 2 mm in the left eye and 3 mm in
the right eye. Unequal pupils are known as:
o A. Anisocoria
o B. Ataxia
o C. Cataract
o D. Diplopia
Incorrect
Correct Answer: A. Anisocoria

Unequal pupils are called anisocoria. Anisocoria, or unequal pupil sizes, is a common condition.
The varied causes have implications ranging from life-threatening to completely benign, and a
clinically guided history and examination is the first step in establishing a diagnosis.
 Option B: Ataxia is uncoordinated actions of involuntary muscle use. Ataxia is a
degenerative disease of the nervous system. Many symptoms of Ataxia mimic those of
being drunk, such as slurred speech, stumbling, falling, and incoordination. These
symptoms are caused by damage to the cerebellum, the part of the brain that is
responsible for coordinating movement.
 Option C: A cataract is an opacity of the eye’s lens. A cataract is a clouding of the
normally clear lens of the eye. For people who have cataracts, seeing through cloudy
lenses is a bit like looking through a frosty or fogged-up window. Clouded vision caused
by cataracts can make it more difficult to read, drive a car (especially at night) or see the
expression on a friend’s face.
 Option D: Diplopia is double vision. Diplopia is the perception of 2 images of a single
object. Diplopia may be monocular or binocular. Monocular diplopia is present when
only one eye is open. Binocular diplopia disappears when either eye is closed.
ADVERTISEMENTS
29. Question
The nurse in charge is caring for an Italian client. He’s complaining of pain, but he falls asleep
right after his complaint and before the nurse can assess his pain. The nurse concludes that:
o A. He may have a low threshold for pain.
o B. He was faking pain.
o C. Someone else gave him medication.
o D. The pain went away.

Incorrect
Correct Answer: A. He may have a low threshold for pain.
People of Italian heritage tend to verbalize discomfort and pain. The pain was real to the client,
and he may need medication when he wakes up. Italian females reported the highest sensitivity
to both mechanical and electrical stimulation, while Swedes reported the lowest sensitivity.
Mechanical pain thresholds differed more across cultures than did electrical pain thresholds.
Cultural factors may influence response to type of pain test.
 Option B: Our pain threshold is the minimum point at which something, such as pressure
or heat, causes us pain. For example, someone with a lower pain threshold might start
feeling pain when only minimal pressure is applied to part of their body. Pain tolerance
and threshold varies from person to person.
 Option C: When we feel pain, nearby nerves send signals to the brain through the spinal
cord. The brain interprets this signal as a sign of pain, which can set off protective
reflexes. For example, when one touches something very hot, the brain receives signals

indicating pain. This in turn can make one quickly pull the hand away without even
thinking.
 Option D: Biofeedback is a type of therapy that helps increase the awareness of how the
body responds to stressors and other stimuli. This includes pain. During a biofeedback
session, a therapist will teach the client how to use relaxation techniques, breathing
exercises, and mental exercises to override the body’s response to stress or pain.
ADVERTISEMENTS
30. Question
A female client is admitted to the emergency department with complaints of chest pain and
shortness of breath. The nurse’s assessment reveals jugular vein distention. The nurse knows that
when a client has jugular vein distension, it’s typically due to:
o A. A neck tumor
o B. An electrolyte imbalance
o C. Dehydration
o D. Fluid overload
Incorrect
Correct Answer: D. Fluid overload
Fluid overload causes the volume of blood within the vascular system to increase. This increase
causes the vein to distend, which can be seen most obviously in the neck veins. JVD is a sign of
increased central venous pressure (CVP). That’s a measurement of the pressure inside the vena
cava. CVP indicates how much blood is flowing back into the heart and how well the heart can
move that blood into the lungs and the rest of the body.
 Option A: A neck tumor doesn’t typically cause jugular vein distention. Right-sided
heart failure is a common cause. Right-sided heart failure usually develops after a left-
sided heart failure. The left ventricle pumps blood out through the aorta to most of the
body. The right ventricle pumps blood to the lungs. When the left ventricle’s pumping
power weakens, fluid can back up into the lungs. This eventually weakens the right
ventricle.
 Option B: An electrolyte imbalance may result in fluid overload, but it doesn’t directly
contribute to jugular vein distention. The pericardium is a thin, fluid-filled sac that
surrounds the heart. An infection of the pericardium, called constrictive pericarditis, can
restrict the volume of the heart. As a result, the chambers can’t fill with blood properly,
so blood can back up into veins, including the jugular veins.
 Option C: Dehydration does not cause JVD. Another common cause is pulmonary
hypertension. Pulmonary hypertension occurs when the pressure in your lungs increases,
sometimes as a result of changes to the lining of the artery walls. This can also lead to
right-sided heart failure.
ADVERTISEMENTS

31. Question
Critical thinking and the nursing process have which of the following in common? Both:
o A. Are important to use in nursing practice.
o B. Use an ordered series of steps.
o C. Are patient-specific processes.
o D. Were developed specifically for nursing.

Incorrect
Correct Answer: A. Are important to use in nursing practice.
Nurses make many decisions: some require using the nursing process, whereas others are not
client related but require critical thinking. Neither is linear. Critical thinking applies to any
discipline. n 1958, Ida Jean Orlando started the nursing process that still guides nursing care
today. Defined as a systematic approach to care using the fundamental principles of critical
thinking, client-centered approaches to treatment, goal-oriented tasks, evidence-based practice
(EDP) recommendations, and nursing intuition. Holistic and scientific postulates are integrated
to provide the basis for compassionate, quality-based care.
 Option B: The nursing process has specific steps; critical thinking does not. The nursing
process functions as a systematic guide to client-centered care with 5 sequential steps.
These are assessment, diagnosis, planning, implementation, and evaluation.
 Option C: The utilization of the nursing process to guide care is clinically significant
going forward in this dynamic, complex world of patient care. Aging populations carry
with them a multitude of health problems and inherent risks of missed opportunities to
spot a life-altering condition.
 Option D: Critical thinking skills will play a vital role as we develop plans of care for
these patient populations with multiple comorbidities and embrace this challenging
healthcare arena. Thus, the trend towards concept-based curriculum changes will assist us
in the navigation of these uncharted waters.
ADVERTISEMENTS
32. Question
In which step of the nursing process does the nurse analyze data and identify client problems?
o A. Assessment
o B. Diagnosis
o C. Planning outcomes

o D. Evaluation
Incorrect
Correct Answer: B. Diagnosis
In the diagnosis phase, the nurse identifies the client’s health status. The North American
Nursing Diagnosis Association (NANDA) provides nurses with an up to date list of nursing
diagnoses. A nursing diagnosis, according to NANDA, is defined as a clinical judgment about
responses to actual or potential health problems on the part of the patient, family, or community.
 Option A: In the assessment phase, the nurse gathers data from many sources for
analysis in the diagnosis phase. Assessment is the first step and involves critical thinking
skills and data collection; subjective and objective. Subjective data involves verbal
statements from the patient or caregiver. Objective data is measurable, tangible data such
as vital signs, intake and output, and height and weight.
 Option C: In the planning outcomes phase, the nurse formulates goals and outcomes.
The planning stage is where goals and outcomes are formulated that directly impact
patient care based on EDP guidelines. These patient-specific goals and the attainment of
such assist in ensuring a positive outcome. Nursing care plans are essential in this phase
of goal setting. Care plans provide a course of direction for personalized care tailored to
an individual’s unique needs. Overall condition and comorbid conditions play a role in
the construction of a care plan. Care plans enhance communication, documentation,
reimbursement, and continuity of care across the healthcare continuum.
 Option D: In the evaluation phase, which occurs after implementing interventions, the
nurse gathers data about the client’s responses to nursing care to determine whether client
outcomes were met. This final step of the nursing process is vital to a positive patient
outcome. Whenever a healthcare provider intervenes or implements care, they must
reassess or evaluate to ensure the desired outcome has been met. Reassessment may
frequently be needed depending upon overall patient condition. The plan of care may be
ADVERTISEMENTS
33. Question
In which phase of the nursing process does the nurse decide whether her actions have
successfully treated the client’s health problem?
o A. Assessment
o B. Diagnosis
o D. Evaluation
Incorrect

During the implementation phase, the nurse carries out the interventions or delegates them to
other health care team members. During the evaluation phase, the nurse judges whether her
actions have been successful in treating or preventing the identified client health problem. This
final step of the nursing process is vital to a positive patient outcome. Whenever a healthcare
provider intervenes or implements care, they must reassess or evaluate to ensure the desired
outcome has been met. Reassessment may frequently be needed depending upon overall patient
condition. The plan of care may be adapted based on new assessment data.
 Option B: In the diagnosis phase, the nurse identifies the client’s health status. The North
American Nursing Diagnosis Association (NANDA) provides nurses with an up to date
list of nursing diagnoses. A nursing diagnosis, according to NANDA, is defined as a
clinical judgment about responses to actual or potential health problems on the part of the
patient, family or community.
 Option C: In the planning outcomes phase, the nurse and client decide on goals they
want to achieve. In the intervention planning phase, the nurse identifies specific
interventions to help achieve the identified goal. The planning stage is where goals and
outcomes are formulated that directly impact patient care based on EDP guidelines.
These patient-specific goals and the attainment of such assist in ensuring a positive
outcome.
ADVERTISEMENTS
34. Question
What is the most basic reason that self-knowledge is important for nurses? Because it helps the
nurse to:
o A. Identify personal biases that may affect his thinking and actions.
o B. Identify the most effective interventions for a patient.
o C. Communicate more efficiently with colleagues, patients, and families.
o D. Learn and remember new procedures and techniques.

Incorrect
Correct Answer: A. Identify personal biases that may affect his thinking and actions.
The most basic reason is that self-knowledge directly affects the nurse’s thinking and the actions
he chooses. Indirectly, thinking is involved in identifying effective interventions,
communicating, and learning procedures. However, because identifying personal biases affect all
the other nursing actions, it is the most basic reason.

 Option B: In philosophy, ―self-knowledge‖ standardly refers to knowledge of one’s own
sensations, thoughts, beliefs, and other mental states. At least since Descartes, most
philosophers have believed that our knowledge of our own mental states differs markedly
from our knowledge of the external world (where this includes our knowledge of others’
thoughts).
 Option C: Perhaps the most widely accepted view along these lines is that self-
knowledge, even if not absolutely certain, is especially secure, in the following sense:
self-knowledge is immune from some types of error to which other kinds of empirical
knowledge—most obviously, perceptual knowledge—are vulnerable.
 Option D: Self-awareness is important because when we have a better understanding of
ourselves, we are able to experience ourselves as unique and separate individuals. We are
then empowered to make changes and to build on our areas of strength as well as identify
areas where we would like to make improvements.
ADVERTISEMENTS
35. Question
Arrange the steps of the nursing process in the sequence in which they generally occur.
View Answers:
o Planning interventions
o Planning outcomes
o Assessment
o Evaluation
o Diagnosis
Incorrect
The correct order is shown above.
Logically, the steps are assessment, diagnosis, planning outcomes, planning interventions, and
evaluation. Keep in mind that steps are not always performed in this order, depending on the
patient’s needs and that steps overlap.
 Assessment is the first step and involves critical thinking skills and data collection;
subjective and objective. Subjective data involves verbal statements from the patient or
caregiver. Objective data is measurable, tangible data such as vital signs, intake and
 The formulation of a nursing diagnosis by employing clinical judgment assists in the
planning and implementation of patient care. The North American Nursing Diagnosis
Association (NANDA) provides nurses with an up to date list of nursing diagnoses. A
nursing diagnosis, according to NANDA, is defined as a clinical judgment about
responses to actual or potential health problems on the part of the patient, family, or
community.

 The planning stage is where goals and outcomes are formulated that directly impact
 Implementation is the step which involves action or doing and the actual carrying out of
nursing interventions outlined in the plan of care. This phase requires nursing
interventions such as applying a cardiac monitor or oxygen, direct or indirect care,
medication administration, standard treatment protocols, and EDP standards.
 This final step of the nursing process is vital to a positive patient outcome. Whenever a
healthcare provider intervenes or implements care, they must reassess or evaluate to
ensure the desired outcome has been met. Reassessment may frequently be needed
depending upon overall patient condition. The plan of care may be adapted based on new
assessment data.
ADVERTISEMENTS
36. Question
How are critical thinking skills and critical thinking attitudes similar? Both are:
o A. Influences on the nurse's problem solving and decision making.
o B. Like feelings rather than cognitive activities.
o C. Cognitive activities rather than feelings.
o D. Applicable in all aspects of a person's life.

Incorrect
Correct Answer: A. Influences on the nurse’s problem solving and decision making.
Cognitive skills are used in complex thinking processes, such as problem-solving and decision
making. Critical thinking attitudes determine how a person uses her cognitive skills. Critical
thinking attitudes are traits of the mind, such as independent thinking, intellectual curiosity,
intellectual humility, and fair-mindedness, to name a few. Critical thinking skills refer to the
cognitive activities used in complex thinking processes. A few examples of these skills involve
recognizing the need for more information, recognizing gaps in one’s own knowledge, and
separating relevant information from irrelevant data. Critical thinking, which consists of
intellectual skills and attitudes, can be used in all aspects of life.
 Option B: Critical Thinking is, in short, self-directed, self-disciplined, self-monitored,
and self-corrective thinking. It presupposes assent to rigorous standards of excellence and
mindful command of their use. It entails effective communication and problem-solving
abilities and a commitment to overcome our native egocentrism and sociocentrism.

 Option C: Critical Thinking is a domain-general thinking skill. The ability to think
clearly and rationally is important whenever one chooses to do. But critical thinking skills
are not restricted to a particular subject area. Being able to think well and solve problems
systematically is an asset for any career.
 Option D: A critical thinking attitude is related to the motivation to try to reason well,
but it can also motivate an attempt to use various strategies to overcome personal
limitations. Additionally, a person with a critical thinking attitude should often rely on
the expertise of others rather than trying to assess all arguments on her own because
expertise is often required to properly evaluate an argument.
ADVERTISEMENTS
37. Question
The nurse is preparing to admit a patient from the emergency department. The transferring nurse
reports that the patient with chronic lung disease has a 30+ year history of tobacco use. The nurse
used to smoke a pack of cigarettes a day at one time and worked very hard to quit smoking. She
immediately thinks to herself, ―I know I tend to feel negative about people who use tobacco,
especially when they have a serious lung condition; I figure if I can stop smoking, they should be
able to. I must remember how physically and psychologically difficult that is, and be very careful
not to let it be judgmental of this patient.‖ This best illustrates:
o A. Theoretical knowledge
o B. Self-knowledge
o C. Using reliable resources
o D. Use of the nursing process

Incorrect
Correct Answer: B. Self-knowledge
Personal knowledge is self-understanding—awareness of one’s beliefs, values, biases, and so on.
That best describes the nurse’s awareness that her bias can affect her patient care. Self-
knowledge refers to knowledge of one’s own mental states, processes, and dispositions. Most
agree it involves a capacity for understanding the representational properties of mental states and
their role in shaping behavior.
 Option A: Theoretical knowledge consists of information, facts, principles, and theories
in nursing and related disciplines; it consists of research findings and rationally
constructed explanations of phenomena. Theoretical knowledge is a knowledge of why
something is true. A set of true affirmations (factual knowledge) does not necessarily
explain anything. In order to explain something, it is necessary to state why these truths
are true. An explanation is required.
 Option C: Using reliable resources is a critical thinking skill. Critical thinking is, in
short, self-directed, self-disciplined, self-monitored, and self-corrective thinking. It
presupposes assent to rigorous standards of excellence and mindful command of their

use. It entails effective communication and problem-solving abilities and a commitment
to overcome our native egocentrism and sociocentrism.
 Option D: The nursing process is a problem-solving process consisting of the steps of
assessing, diagnosing, planning outcomes, planning interventions, implementing, and
evaluating. The nurse has not yet met this patient, so she could not have begun the
nursing process.
ADVERTISEMENTS
38. Question
Which organization’s standards require that all patients be assessed specifically for pain?
o A. American Nurses Association (ANA)
o B. State nurse practice acts
o C. National Council of State Boards of Nursing (NCSBN)
o D. The Joint Commission

Incorrect
Correct Answer: D. The Joint Commission
The Joint Commission has developed assessment standards, including that all clients be assessed
for pain.
 Option A: The ANA has developed standards for clinical practice, including those for
assessment, but not specifically for pain. The American Nurses Association (ANA) is the
premier organization representing the interests of the nation’s 4 million registered nurses.
ANA is at the forefront of improving the quality of health care for all. Founded in 1896,
and with members in all 50 states and U.S. territories, ANA is the strongest voice for the
profession.
 Option B: State nurse practice acts regulate nursing practice in individual states. An
NPA is enacted by state legislation and its purpose is to govern and guide nursing
practice within that state. An NPA is actually a law and must be adhered to as law. Each
state has a Board of Nursing (BON) that interprets and enforces the rules of the NPA.
 Option C: The NCSBN asserts that the scope of nursing includes a comprehensive
assessment but does not specifically include pain. National Council of State Boards of
Nursing (NCSBN) is an independent, not-for-profit organization through which nursing
regulatory bodies act and counsel together on matters of common interest and concern
affecting public health, safety, and welfare, including the development of nursing
licensure examinations.
ADVERTISEMENTS
39. Question

Which of the following is an example of data that should be validated?
o A. The urinalysis report indicates there are white blood cells in the urine.
o B. The client states she feels feverish; you measure the oral temperature at 98°F.
o C. The client has clear breath sounds; you count a respiratory rate of 18.
o D. The chest x-ray report indicates the client has pneumonia in the right lower lobe.
Incorrect
Correct Answer: B. The client states she feels feverish; you measure the oral temperature
at 98°F.
Validation should be done when subjective and objective data do not make sense. For instance, it
is inconsistent data when the patient feels feverish and you obtain a normal temperature. The
other distractors do not offer conflicting data. Validation is not usually necessary for laboratory
test results.
 Option A: When this test is positive and/or the WBC count in urine is high, it may
indicate that there is inflammation in the urinary tract or kidneys. The most common
cause for WBCs in urine (leukocyturia) is a bacterial urinary tract infection (UTI), such
as a bladder or kidney infection.
 Option C: Breath sounds are the noises produced by the structures of the lungs during
breathing. Normal lung sounds occur in all parts of the chest area, including above the
collarbones and at the bottom of the rib cage. Using a stethoscope, the doctor may hear
normal breathing sounds, decreased or absent breath sounds, and abnormal breath sounds.
Normal respiration rates for an adult person at rest range from 12 to 16 breaths per
minute.
 Option D: The most common organisms which cause lobar pneumonia are Streptococcus
pneumoniae, also called pneumococcus, Haemophilus influenza, and Moraxella
catarrhalis. Mycobacterium tuberculosis, the tubercle bacillus, may also cause lobar
pneumonia if pulmonary tuberculosis is not treated promptly.
ADVERTISEMENTS
40. Question
Which of the following is an example of appropriate behavior when conducting a client
interview?
o A. Recording all the information on the agency-approved form during the interview.
o B. Asking the client, "Why did you think it was necessary to seek health care at this time?"
o C. Using precise medical terminology when asking the client questions.

o D. Sitting, facing the client in a chair at the client's bedside, using active listening.
Incorrect
Correct Answer: D. Sitting, facing the client in a chair at the client’s bedside, using active
listening.
Active listening should be used during an interview. The nurse should face the patient, have
relaxed posture, and keep eye contact. Nonjudgmental interest in the patient’s problems (active
listening), empathy (communicating to the patient an accurate assessment of emotional state),
and concern for the patient as a unique person are among the most important tools in the
physician’s interpersonal repertoire. The difference between interviewing a patient who is lying
flat in bed and one who is sitting in a chair can be striking. This simple act can emphasize patient
autonomy and active involvement in the interview.
 Option A: Note-taking interferes with eye contact. By recognizing the patient’s emotions
and responding to them in a supportive manner, the clinician can conduct an effective
patient-centered interview.
 Option B: Asking ―why‖ may make the client defensive. Frequently used opening
questions include, ―What problems brought you to the hospital (or office) today?‖ or
―What kind of problems have you been having recently?‖ or ―What kind of problems
would you like to share with me?‖ These open-ended, non-directive questions encourage
the patient to report any and all problems. At this point in the interview, it is important to
let the patient talk spontaneously rather than restricting and directing the flow of
information with multiple questions.
 Option C: The client may not understand medical terminology or health care jargon.
Questions should be worded so that the patient has no difficulty understanding what is
being asked. Avoid using technical terms and diagnostic labels. The interviewer’s
questions should indicate what type of information is requested, but not what answer is
expected.
ADVERTISEMENTS
41. Question
The nurse wishes to identify nursing diagnoses for a patient. She can best do this by using a data
collection form organized according to: Select all that apply.
o A. A body systems model
o B. A head-to-toe framework
o C. Maslow's hierarchy of needs
o D. Gordon's functional health patterns
o E. Adaptation Model of Nursing

Incorrect

Correct Answer: C & D
Nursing models produce a holistic database that is useful in identifying nursing rather than
medical diagnoses. Body systems and Maslow’s hierarchy is not a nursing model, but it is
holistic, so it is acceptable for identifying nursing diagnoses. Gordon’s functional health patterns
are a nursing model.
 Option A: A body system model is not a nursing model. It is a representation of all the
systems of the body in a figurine.
 Option B: Head-to-toe framework is not a nursing model, and they are not holistic; they
focus on identifying physiological needs or disease.
 Option C: Maslow’s hierarchy of needs is a motivational theory in psychology
comprising a five-tier model of human needs, often depicted as hierarchical levels within
a pyramid. From the bottom of the hierarchy upwards, the needs are: physiological (food
and clothing), safety (job security), love and belonging needs (friendship), esteem, and
self-actualization.
 Option D: Gordon’s functional health patterns is a method devised by Marjory Gordon
to be used by nurses in the nursing process to provide a more comprehensive nursing
assessment of the patient.
 Option E: The Adaptation Model of Nursing is a prominent nursing theory aiming to
explain or define the provision of nursing science. In her theory, Sister Callista Roy’s
model sees the individual as a set of interrelated systems that strives to maintain a
balance between various stimuli.
ADVERTISEMENTS
42. Question
The nurse is recording assessment data. She writes, ―The patient seems worried about his
surgery. Other than that, he had a good night.‖ Which errors did the nurse make? Select all that
apply.
o A. Used a vague generality.
o B. Did not use the patient's exact words.
o C. Used a "waffle" word (e.g., appears).
o D. Recorded an inference rather than a cue.
o E. Did not record the patient’s vital signs.

Incorrect
Correct Answer: A, C, D & E
The initial nursing assessment, the first step in the five steps of the nursing process, involves the
systematic and continuous collection of data; sorting, analyzing, and organizing that data; and
the documentation and communication of the data collected. Subjective and objective data
collection are an integral part of this process.

 Option A: The nurse recorded a vague generality: ―he has had a good night.‖ The
assessment identifies current and future care needs of the patient by allowing the
formation of a nursing diagnosis. The nurse recognizes normal and abnormal patient
physiology and helps prioritize interventions and care.
 Option B: The nurse did not use the patient’s exact words, but she did not quote the
patient at all, so that is not one of her errors.
 Option C: The nurse used the ―waffle‖ word, ―seems‖ worried instead of documenting
what the patient said or did to lead her to that conclusion. Asking about how the client
feels and their response to those feelings is part of a psychological assessment.
 Option D: The nurse recorded these inferences: worried and had a good night. The
psychological examination may include perceptions, whether justifiable or not, on the
part of the patient or client. Religion and cultural beliefs are critical areas to consider.
 Option E: Part of the assessment includes data collection by obtaining vital signs such as
temperature, respiratory rate, heart rate, blood pressure, and pain level using age or
condition appropriate pain scale.
ADVERTISEMENTS
43. Question
A patient is admitted with shortness of breath, so the nurse immediately listens to his breath
sounds. Which type of assessment is the nurse performing?
o A. Ongoing assessment
o B. Comprehensive physical assessment
o C. Focused physical assessment
o D. Psychosocial assessment
Incorrect
Correct Answer: C. Focused physical assessment
The nurse is performing a focused physical assessment, which is done to obtain data about an
identified problem, in this case shortness of breath. Detailed nursing assessment of specific body
system(s) relating to the presenting problem or current concern(s) of the patient. This may
involve one or more body systems.
 Option A: An ongoing assessment is performed as needed, after the initial data are
collected, preferably with each patient contact. Repeat of the focused or rapid emergency
department assessment of a prehospital patient to detect changes in condition and to
judge the effectiveness of treatment before or during transport. Repeated every 5 minutes
for an unstable patient and every 15 minutes for a stable patient.
 Option B: A comprehensive physical assessment includes an interview and a complete
examination of each body system. A comprehensive health assessment gives nurses
insight into a patient’s physical status through observation, the measurement of vital

signs, and self-reported symptoms. It includes a medical history, a general survey, and a
complete physical examination.
 Option D: A psychosocial assessment examines both psychological and social factors
affecting the patient. The nurse conducting a psychosocial assessment would gather
information about stressors, lifestyle, emotional health, social influences, coping patterns,
communication, and personal responses to health and illness, to name a few aspects.
ADVERTISEMENTS
44. Question
The nurse is assessing vital signs for a patient just admitted to the hospital. Ideally, and if there
are no contraindications, how should the nurse position the patient for this portion of the
admission assessment?
o A. Sitting upright.
o B. Lying flat on the back with knees flexed.
o C. Lying flat on the back with arms and legs fully extended.
o D. Side-lying with the knees flexed.

Incorrect
Correct Answer: A. Sitting upright.
If the patient is able, the nurse should have the patient sit upright to obtain vital signs in order to
allow the nurse to easily access the anterior and posterior chest for auscultation of heart and
breath sounds. It allows for full lung expansion and is the preferred position for measuring blood
pressure. Additionally, patients might be more comfortable and feel less vulnerable when sitting
upright (rather than lying down on the back) and can have direct eye contact with the examiner.
However, other positions can be suitable when the patient’s physical condition restricts the
comfort or ability of the patient to sit upright.
 Option B: Lying flat on the back with knees flexed or supine horizontal recumbent is
most commonly used during breast exam.
 Option C: Lying flat on the back with arms and legs fully extended can make the patient
feel uncomfortable.
 Option D: Sim’s position is usually used to obtain rectal temperature.
ADVERTISEMENTS
45. Question
For all body systems except the abdomen, what is the preferred order for the nurse to perform the
following examination techniques?

View Answers:
o Palpation
o Percussion
o Auscultation
o Inspection
Incorrect
Inspection begins immediately as the nurse meets the patient, as she observes the patient’s
appearance and behavior. Observational data are not intrusive to the patient. When performing
assessment techniques involving physical touch, the behavior, posture, demeanor, and responses
might be altered. Palpation, percussion, and auscultation should be performed in that order,
except when performing an abdominal assessment. During abdominal assessment, auscultation
should be performed before palpation and percussion to prevent altering bowel sounds.
 1. It is important to begin with the general examination of the abdomen with the patient
in a completely supine position. The presence of any of the following signs may indicate
specific disorders. Distension of the abdomen could be present due to small bowel
obstruction, masses, tumors, cancer, hepatomegaly, splenomegaly, constipation,
abdominal aortic aneurysm, and pregnancy.
 2. The ideal position for abdominal examination is to sit or kneel on the right side of the
patient with the hand and forearm in the same horizontal plane as the patient’s abdomen.
There are three stages of palpation that include the superficial or light palpation, deep
palpation, and organ palpation and should be performed in the same order. Maneuvers
specific to certain diseases are also a part of abdominal palpation.
 3. A proper technique of percussion is necessary to gain maximum information regarding
the abdominal pathology. While percussing, it is important to appreciate tympany over
air-filled structures such as the stomach and dullness to percussion which may be present
due to an underlying mass or organomegaly (for example, hepatomegaly or
splenomegaly).
 4. The last step of the abdominal examination is auscultation with a stethoscope. The
diaphragm of the stethoscope should be placed on the right side of the umbilicus to listen
to the bowel sounds, and their rate should be calculated after listening for at least two
minutes. Normal bowel sounds are low-pitched and gurgling, and the rate is normally 2-
5/min. Absent bowel sounds may indicate paralytic ileus and hyperactive rushes
(borborygmi) are usually present in small bowel obstruction and sometimes may be
auscultated in lactose intolerance.
ADVERTISEMENTS
46. Question
The nurse is assessing a patient admitted to the hospital with rectal bleeding. The patient had a
hip replacement 2 weeks ago. Which position should the nurse avoid when examining this
patient’s rectal area?

o A. Sims'
o B. Supine
o C. Dorsal recumbent
o D. Semi-Fowler's
Incorrect
Correct Answer: A. Sims’
Sims’ position is typically used to examine the rectal area. However, the position should be
avoided if the patient has undergone hip replacement surgery The patient with a hip replacement
can assume the supine, dorsal recumbent, or semi-Fowler’s positions without causing harm to the
joint.
 Option B: Supine position is lying on the back facing upward. The supine position
means lying horizontally with the face and torso facing up, as opposed to the prone
position, which is face down. When used in surgical procedures, it allows access to the
peritoneal, thoracic, and pericardial regions; as well as the head, neck, and extremities.
 Option C: The patient in dorsal recumbent is on his back with knees flexed and soles of
feet flat on the bed. A position in which the patient lies on the back with the lower
extremities moderately flexed and rotated outward. It is employed in the application of
obstetrical forceps, repair of lesions following parturition, vaginal examination, and
bimanual palpation.
 Option D: In semi-Fowler’s position, the patient is supine with the head of the bed
elevated and legs slightly elevated. The Semi-Fowler’s position is a position in which a
patient, typically in a hospital or nursing home is positioned on their back with the head
and trunk raised to between 15 and 45 degrees, although 30 degrees is the most
frequently used bed angle.
ADVERTISEMENTS
47. Question
How should the nurse modify the examination for a 7-year-old child?
o A. Ask the parents to leave the room before the examination.
o B. Demonstrate equipment before using it.
o C. Allow the child to help with the examination.
o D. Perform invasive procedures (e.g., otoscopic) last.

Incorrect
Correct Answer: B. Demonstrate equipment before using it.

The nurse should modify his examination by demonstrating equipment before using it to
examine a school-age child. The physical examination is often the first direct contact between
the nurse and the child. Establishing a trusting relationship between the child and the examiner is
important. Throughout the examination the nurse should be sensitive to the cultural needs of and
differences among children. Providing a quiet, private environment for the history and physical
examination is important. The classic systematic approach to the physical examination is to
begin at the head and proceed through the entire body to the toes. When examining a child,
however, the examiner tailors the physical assessment to the child’s age and developmental
level.
 Option A: The nurse should make sure parents are not present during the physical
examination of an adolescent, but they usually help younger children feel more secure.
To establish trust with the school-age child, the examiner asks the child questions the
child can answer. Children in elementary school will talk about school, favorite friends,
and activities. Older school-age children may have to be encouraged to talk about their
school performance and activities. The examiner encourages the parent to support and
reinforce the child’s participation in the examination.
 Option C: The nurse should allow a preschooler to help with the examination when
possible, but not usually a school-age child. The examination proceeds from head to toe.
Children of this age prefer a simple drape over their underpants or a colorful examination
gown, and the examiner should be sensitive to the child’s modesty. The examination is a
wonderful opportunity to teach the child about the body and personal care. The nurse
answers questions openly and in simple terms.
 Option D: It is best to perform invasive procedures last for all age groups; therefore, this
does not represent a modification. Toddlers are often fearful of invasive procedures, so
those should be performed last in this age group.
ADVERTISEMENTS
48. Question
The nurse must examine a patient who is weak and unable to sit unaided or to get out of bed.
How should she position the patient to begin and perform most of the physical examination?
o A. Dorsal recumbent
o B. Semi-Fowler's
o C. Lithotomy
o D. Sims'
Incorrect
Correct Answer: B. Semi-Fowler’s
If a patient is unable to sit up, the nurse should place him lying flat on his back, with the head of
the bed elevated. The Semi-Fowler’s position is a position in which a patient, typically in a

hospital or nursing home is positioned on their back with the head and trunk raised to between 15
and 45 degrees, although 30 degrees is the most frequently used bed angle.
 Option A: Dorsal recumbent position is used for abdominal assessment if the patient has
abdominal or pelvic pain. The patient in dorsal recumbent is on his back with knees
flexed and soles of feet flat on the bed.
 Option C: Lithotomy position is used for female pelvic examination. It is similar to
dorsal recumbent position, except that the patient’s legs are well separated and thighs are
acutely flexed. Feet are usually placed in stirrups. Fold sheet or bath blanket crosswise
over thighs and legs so that genital area is easily exposed. Keep the patient covered as
much as possible.
 Option D: The patient in Sim’s position is on the left side with right knee flexed against
abdomen and left knee slightly flexed. Left arm is behind the body; the right arm is
placed comfortably. Sims’ position is used to examine the rectal area. In semi-Fowler’s
position, the patient is supine with the head of the bed elevated and legs slightly elevated.
ADVERTISEMENTS
49. Question
The nurse should use the diaphragm of the stethoscope to auscultate which of the following?
o A. Heart murmurs
o B. Jugular venous hums
o C. Bowel sounds
o D. Carotid bruits
Incorrect
Correct Answer: C. Bowel sounds
The bell of the stethoscope should be used to hear low-pitched sounds, such as murmurs, bruits,
and jugular hums. The diaphragm should be used to hear high-pitched sounds that normally
occur in the heart, lungs, and abdomen. The diaphragm is best for higher-pitched sounds, like
breath sounds and normal heart sounds. The bell is best for detecting lower pitch sounds, like
some heart murmurs, and some bowel sounds.
 Option A: Earpieces should be angled forwards to match the direction of the
practitioner’s external auditory meatus. The bell is used to hear low-pitched sounds. Use
for mid-diastolic murmur of mitral stenosis or S3 in heart failure.
 Option B: The stethoscope bell is lightly applied in each supraclavicular fossa over the
subclavian artery. As usual, the examiner’s free hand palpates the contralateral carotid
pulse for timing purposes. If a bruit is appreciated, firmly compress the patient’s
ipsilateral radial artery, noting the effect on the murmur.
 Option D: If the intensity of sound is greater above the clavicle it is most likely a carotid
bruit. If it is louder below the clavicle it is most likely a heart murmur. Use either the bell

or the diaphragm when listening for the carotid bruit, at a point just lateral to Adam’s
apple.
ADVERTISEMENTS
50. Question
The nurse calculates a body mass index (BMI) of 18 for a young adult woman who comes to the
physician’s office for a college physical. This patient is considered:
o A. Obese
o B. Overweight
o C. Average
o D. Underweight
Incorrect
Correct Answer: D. Underweight
For adults, BMI should range between 20 and 25. Body mass index (BMI) is a person’s weight
in kilograms divided by the square of height in meters. BMI is an inexpensive and easy screening
method for the weight category—underweight, healthy weight, overweight, and obesity.
 Option A: BMI greater than 30 is considered obese For adults 20 years old and older,
BMI is interpreted using standard weight status categories. These categories are the same
for men and women of all body types and ages.
 Option B: BMI 25 to 29.9 is overweight. The prevalence of adult BMI greater than or
equal to 30 kg/m2 (obese status) has greatly increased since the 1970s. Recently,
however, this trend has leveled off, except for older women. Obesity has continued to
increase in adult women who are 60 years and older.
 Option C: BMI less than 20 is considered underweight. BMI can be a screening tool, but
it does not diagnose the body fatness or health of an individual. To determine if BMI is a
health risk, a healthcare provider performs further assessments. Such assessments include
skinfold thickness measurements, evaluations of diet, physical activity, and family
history.
ADVERTISEMENTS
51. Question
Using the principles of standard precautions, the nurse would wear gloves in what nursing
interventions?
o A. Providing a back massage.

o B. Feeding a client.
o C. Providing hair care.
o D. Providing oral hygiene.

Incorrect
Correct Answer: D. Providing oral hygiene
Doing oral care requires the nurse to wear gloves. Standard precautions apply to the care of all
patients, irrespective of their disease state. These precautions apply when there is a risk of
potential exposure to (1) blood; (2) all body fluids, secretions, and excretions, except sweat,
regardless of whether or not they contain visible blood; (3) non-intact skin, and (4) mucous
membranes. This includes the use of hand hygiene and personal protective equipment (PPE),
with hand hygiene being the single most important means to prevent transmission of disease.
 Option A: Must be worn when touching blood, body fluids, secretions, excretions,
mucous membranes, or non-intact skin. Change when there is contact with potentially
infected material in the same patient to avoid cross-contamination. Remove before
touching surfaces and clean items. Wearing gloves does not mitigate the need for proper
hand hygiene.
 Option B: Hand washing after feeding the client is sufficient. Handwashing with soap
and water for at least 40 to 60 seconds, making sure not to use clean hands to turn off the
faucet, must be performed if hands are visibly soiled, after using the restroom, or if
potential exposure to spore-forming organisms.
 Option C: Gloves are not needed in providing hair care. Hand rubbing with alcohol
applied generously to cover hands completely should be performed and hands rubbed
until dry.
ADVERTISEMENTS
52. Question
The nurse is preparing to take vital signs in an alert client admitted to the hospital with
dehydration secondary to vomiting and diarrhea. What is the best method used to assess the
client’s temperature?
o A. Oral
o B. Axillary
o C. Radial
o D. Heat sensitive tape

Incorrect
Correct Answer: B. Axillary

Axilla is the most accessible body part in this situation. Body temperature is a numerical
expression of the body’s heat and metabolic activity balance and can be a major indicator of a
person’s health status. Assessing a patient’s body temperature is a common procedure nurses
perform to monitor for signs of infection, environmental exposure, shock, ovulation, or
therapeutic response to medications or medical procedures. A normal body temperature can be a
potentially positive sign that the patient isn’t experiencing a disease process, infection, or trauma
and that the body’s cells, tissues, and organs aren’t under metabolic distress.
 Option A: The esophageal temperature probe (ETP) is an 18-in (45.7 cm) long, thin,
flexible catheter that has a rounded tip that should be lubricated with water-soluble
lubricant before being placed through the nares or mouth, extending into the esophagus at
least 2 to 3 in (5 to 7.6 cm). The external end portion of the catheter has a small, coated
wire with a plug that can be attached to a telemetry monitor for continuous temperature
monitoring.
 Option C: The ETP and RTP (rectal temperature probe) are the same device but can be
used in either orifice depending on the patient’s medical condition. Again, the tip should
be lubricated with water-soluble lubricant, and then placed approximately 3 in (7.6 cm)
inside the rectal vault. The RTP can also be attached to a telemetry monitor cable for
continuous temperature monitoring.
 Option D: This is a latex-free, disposable, adhesive strip that can be applied to the
forehead. These strips contain embedded liquid crystals and chemical compounds that
react to the temperature (heat) of the skin by changing colors. After it has been on the
forehead for approximately 2 minutes, the color will illuminate a line and correlate
numeric temperature. The strips measure temperatures ranging from 96.6[degrees] F to
104.6[degrees] F (35.8[degrees] C to 40.3[degrees] C). Consider use for infants, children,
and adults with cognitive deficits because they’re painless.
ADVERTISEMENTS
53. Question
A nurse obtained a client’s pulse and found the rate to be above normal. The nurse document
these findings as:
o A. Tachypnea
o B. Hyperpyrexia
o C. Arrhythmia
o D. Tachycardia
Incorrect
Correct Answer: D. Tachycardia
Tachycardia means rapid heart rate. Tachycardia refers to a heart rate that’s too fast. How that’s
defined may depend on age and physical condition. Generally speaking, for adults, a heart rate of
more than 100 beats per minute (BPM) is considered too fast.

 Option A: Tachypnea refers to rapid respiratory rate. Tachypnea is a respiration rate
greater than normal, resulting in abnormally rapid breathing. In adult humans at rest, any
respiratory rate between 12 and 20 breaths is normal and tachypnea is indicated by a rate
greater than 20 breaths per minute.
 Option B: Hyperpyrexia means increase in temperature. Hyperpyrexia is another term
for a very high fever. The medical criterion for hyperpyrexia is when someone is running
a body temperature of more than 106.7°F or 41.5°C. Hyperpyrexia is an emergency that
needs immediate attention from a medical professional.
 Option C: Arrhythmia means irregular heart rate. An arrhythmia is a problem with the
rate or rhythm of the heartbeat. During an arrhythmia, the heart can beat too fast, too
slowly, or with an irregular rhythm. When a heart beats too fast, the condition is called
tachycardia. When a heart beats too slowly, the condition is called bradycardia.
ADVERTISEMENTS
54. Question
Which of the following actions should the nurse take to use wide base support when assisting a
client to get up in a chair?
o A. Bend at the waist and place arms under the client’s arms and lift.
o B. Face the client, bend knees, and place hands-on client’s forearm and lift.
o C. Spread his or her feet apart.
o D. Tighten his or her pelvic muscles.

Incorrect
Correct Answer: B. Face the client, bend knees, and place hands-on client’s forearm and
lift.
This is the proper way of supporting the client to get up in a chair that conforms to safety and
proper body mechanics. It is important to use proper body mechanics as a health care
professional for many reasons, foremost of which is to prevent injuries to both patient and
provider. Health care professionals at the front line, especially those who deliver direct care to
patients, are often in situations where they have to assist with moving patients from one position
to another.
 Option A: Keep the back straight throughout the transfer to avoid bending or straining
the back. Get as close to the person as possible while still allowing him/her to lean
forward as needed to assist with the transfer.
 Option C: Allow the patient to help as much as possible. Estimate the patient’s weight
and mentally practice. Make sure that the floor is free of any obstacles or liquids. Keep
your feet shoulder-width apart. Keep the person (or object) as close to your body as
possible. Tighten your stomach muscles.
 Option D: Position patients appropriately for transfer. While standing in front of the
patient, maintain proper posture with the back straight and knees bent. Hold a strong

abdominal contraction. Position the body close to the patient to decrease strain on the
back. Before movement, contract the abdominal muscles to protect the back. Use the
knees and the lower body during transfer to decrease strain on the back.
ADVERTISEMENTS
55. Question
A client had oral surgery following a motor vehicle accident. The nurse assessing the client finds
the skin flushed and warm. Which of the following would be the best method to take the client’s
body temperature?
o A. Oral
o B. Axillary
o C. Arterial line
o D. Rectal
Incorrect
Taking the temperature via the axilla is the most appropriate route. Body temperature is a
numerical expression of the body’s heat and metabolic activity balance and can be a major
indicator of a person’s health status. Assessing a patient’s body temperature is a common
procedure nurses perform to monitor for signs of infection, environmental exposure, shock,
ovulation, or therapeutic response to medications or medical procedures. A normal body
temperature can be a potentially positive sign that the patient isn’t experiencing a disease
process, infection, or trauma and that the body’s cells, tissues, and organs aren’t under metabolic
distress.
 Option A: Taking the temperature via the oral route is incorrect since the client had oral
surgery. The esophageal temperature probe (ETP) is an 18-in (45.7 cm) long, thin,
monitoring.
 Option C: A PiCCO thermodilution catheter (Pulsion Medical Systems) containing a
temperature thermistor was inserted into the brachial artery at the antecubital fossa and
doubled as the arterial pressure monitoring line and arterial blood sampling portal. This
measured brachial artery temperature from the time of insertion to the time the patient left
the operating room.
 Option D: This is unnecessary. The ETP and RTP (rectal temperature probe) are the
same device but can be used in either orifice depending on the patient’s medical
condition. Again, the tip should be lubricated with water-soluble lubricant, and then

placed approximately 3 in (7.6 cm) inside the rectal vault. The RTP can also be attached
to a telemetry monitor cable for continuous temperature monitoring.
ADVERTISEMENTS
56. Question
A client who is unconscious needs frequent mouth care. When performing mouth care,
the best position of a client is:
o A. Fowler’s position
o B. Side-lying
o C. Supine
o D. Trendelenburg
Incorrect
Correct Answer: B. Side-lying
An unconscious client is best placed on his side when doing oral care to prevent aspiration. An
unconscious patient is placed in the side-lying position when mouth care is provided because this
position prevents pooling of secretions at the back of the oral cavity, thereby reducing the risk of
aspiration. Oral hygiene is especially important for patients receiving oxygen therapy, patients
who have nasogastric tubes, and patients who are NPO. Their oral mucosa dries out much faster
than normal due to their mouth-breathing.
 Option A: A soft toothbrush or gauze-padded tongue blade may be used to clean the
teeth and mouth. The patient should be positioned in the lateral position with the head
turned toward the side to provide for drainage and to prevent aspiration.
 Option C: This is the most common position for surgery with a patient lying on his or
her back with head, neck, and spine in neutral positioning and arms either adducted
alongside the patient or abducted to less than 90 degrees.
 Option D: A variation of supine in which the head of the bed is tilted down such that the
pubic symphysis is the highest point of the trunk facilitates venous return and improves
exposure during abdominal and laparoscopic surgeries.
ADVERTISEMENTS
57. Question
A client is hospitalized for the first time, which of the following actions ensure the safety of the
client?
o A. Keep unnecessary furniture out of the way.

o B. Keep the lights on at all times.
o C. Keep side rails up at all times.
o D. Keep all equipment out of view.

Incorrect
Correct Answer: C. Keep side rails up at all time
Keeping the side rails up at all times ensures the safety of the client. The risk of falling increases
with age and the number of times someone has been in hospital. During the client’s hospital stay,
he may be more unsteady on his feet because of illness or surgery, or because he is unfamiliar
with the hospital environment or is taking new medication.
 Option A: Home health care providers need to know the risk factors for falls and
demonstrate effective assessment and interventions for fall and injury prevention. Falls
are generally the result of a complex set of intrinsic patient and extrinsic environmental
factors. Use of a fall-prevention program, standardized tools, and an interdisciplinary
approach may be effective for reducing fall-related injuries.
 Option B: Make sure the client’s pajamas, dressing gown, and day clothes are the right
length so they don’t trip over them. Check that their slippers or other footwear fit
properly and are not slippery. If they have to wear pressure stockings, wear slippers over
them so they do not slip.
 Option D: Keep personal items and the call button within reach to avoid standing and
walking to get them. Ask for help when in need to get out of bed to use the toilet if not
feeling at all unsteady.
ADVERTISEMENTS
58. Question
A walk-in client enters the clinic with a chief complaint of abdominal pain and diarrhea. The
nurse takes the client’s vital sign hereafter. What phrase of the nursing process is being
implemented here by the nurse?
o A. Assessment
o B. Diagnosis
o C. Planning
o D. Implementation
Incorrect
Correct Answer: A. Assessment
Assessment is the first phase of the nursing process where a nurse collects information about the
client. Assessment is the first step and involves critical thinking skills and data collection;

caregiver. Objective data is measurable, tangible data such as vital signs, intake and output, and
height and weight.
 Option B: Diagnosis is the formulation of the nursing diagnosis from the information
collected during the assessment. The formulation of a nursing diagnosis by employing
clinical judgment assists in the planning and implementation of patient care. The North
patient, family, or community.
 Option C: In Planning, the nurse sets achievable and measurable short and long-term
goals. The planning stage is where goals and outcomes are formulated that directly
impact patient care based on EDP guidelines. These patient-specific goals and the
attainment of such assist in ensuring a positive outcome. Nursing care plans are essential
in this phase of goal setting. Care plans provide a course of direction for personalized
care tailored to an individual’s unique needs. Overall condition and comorbid conditions
play a role in the construction of a care plan. Care plans enhance communication,
documentation, reimbursement, and continuity of care across the healthcare continuum.
 Option D: Implementation is where nursing care is given. Implementation is the step
which involves action or doing and the actual carrying out of nursing interventions
outlined in the plan of care. This phase requires nursing interventions such as applying a
cardiac monitor or oxygen, direct or indirect care, medication administration, standard
treatment protocols, and EDP standards.
ADVERTISEMENTS
59. Question
It is best described as a systematic, rational method of planning and providing nursing care for
individual, families, group, and community
o A. Assessment
o B. Nursing Process
o C. Diagnosis
o D. Implementation
Incorrect
Correct Answer: B. Nursing Process
The statement describes the Nursing Process. The Nursing Process is the essential core of
practice for the registered nurse to deliver holistic, patient-focused care. Defined as a systematic
approach to care using the fundamental principles of critical thinking, client-centered approaches
to treatment, goal-oriented tasks, evidence-based practice (EDP) recommendations, and nursing
intuition. Holistic and scientific postulates are integrated to provide the basis for compassionate,
quality-based care.

 Option A: Assessment is the first step and involves critical thinking skills and data
collection; subjective and objective. Subjective data involves verbal statements from the
patient or caregiver. Objective data is measurable, tangible data such as vital signs, intake
and output, and height and weight.
 Option C: The formulation of a nursing diagnosis by employing clinical judgment assists
in the planning and implementation of patient care. The North American Nursing
Diagnosis Association (NANDA) provides nurses with an up to date list of nursing
diagnoses. A nursing diagnosis, according to NANDA, is defined as a clinical judgment
about responses to actual or potential health problems on the part of the patient, family,
or community.
 Option D: Implementation is the step which involves action or doing and the actual
carrying out of nursing interventions outlined in the plan of care. This phase requires
nursing interventions such as applying a cardiac monitor or oxygen, direct or indirect
care, medication administration, standard treatment protocols, and EDP standards.
ADVERTISEMENTS
60. Question
Exchange of gases takes place in which of the following organs?
o A. Kidney
o B. Lungs
o C. Liver
o D. Heart
Incorrect
Correct Answer: B. Lungs
Gas exchange is the transport of oxygen from the lungs to the bloodstream and the expulsion of
carbon dioxide from the bloodstream to the lungs. It transpires in the lungs between the alveoli
and a network of tiny blood vessels called capillaries, which are located in the walls of the
alveoli.
 Option A: The renal system consists of the kidney, ureters, and urethra. The overall
function of the system filters approximately 200 liters of fluid a day from renal blood
flow which allows for toxins, metabolic waste products, and excess ions to be excreted
while keeping essential substances in the blood. The kidney regulates plasma osmolarity
by modulating the amount of water, solutes, and electrolytes in the blood. It ensures long-
term acid-base balance and also produces erythropoietin which stimulates the production
of red blood cells.
 Option C: The liver is a critical organ in the human body that is responsible for an array
of functions that help support metabolism, immunity, digestion, detoxification, vitamin
storage among other functions. It comprises around 2% of an adult’s body weight. The

liver is a unique organ due to its dual blood supply from the portal vein (approximately
75%) and the hepatic artery (approximately 25%).
 Option D: The heart is a muscular organ situated in the center of the chest behind the
sternum. It consists of four chambers: the two upper chambers are called the right and left
atria, and the two lower chambers are called the right and left ventricles. The right atrium
and ventricle together are often called the right heart, and the left atrium and left ventricle
together functionally form the left heart.
ADVERTISEMENTS
61. Question
The chamber of the heart that receives oxygenated blood from the lungs is the:
o A. Left atrium
o B. Right atrium
o C. Left ventricle
o D. Right ventricle
Incorrect
Correct Answer: A. Left atrium
The left atrium receives oxygenated blood from the lungs and pumps it to the left ventricle. In
the lungs, the blood oxygenates as it passes through the capillaries where it is close enough to the
oxygen in the alveoli of the lungs. This oxygenated blood is collected by the four pulmonary
veins, two from each lung. All four of these veins open into the left atrium that acts as a
collection chamber for oxygenated blood. Just like the right atrium, the left atrium passes the
blood onto its ventricle both by passive flow and active pumping.
 Option B: The right atrium receives blood from the veins and pumps it to the right
ventricle. The right atrium receives deoxygenated blood from the entire body except for
the lungs (the systemic circulation) via the superior and inferior vena cavae. Also,
deoxygenated blood from the heart muscle itself drains into the right atrium via the
coronary sinus. The right atrium, therefore, acts as a reservoir to collect deoxygenated
blood.
 Option C: The left ventricle (the strongest chamber) pumps oxygen-rich blood to the rest
of the body, its vigorous contractions create the blood pressure. Oxygenated blood thus
fills the left ventricle, passing through the mitral valve. The left ventricle, which is the
main pumping chamber of the left heart, then pumps, sending freshly oxygenated blood
to the systemic circulation through the aortic valve
 Option D: The right ventricle receives blood from the right atrium and pumps it to the
lungs, where it is loaded with oxygen. The right ventricle pumps blood through the right
ventricular outflow tract, across the pulmonic valve, and into the pulmonary artery that
distributes it to the lungs for oxygenation.
ADVERTISEMENTS

62. Question
A muscular enlarged pouch or sac that lies slightly to the left which is used for temporary storage
of food…
o A. Gallbladder
o B. Urinary bladder
o C. Stomach
o D. Lungs
o E. Rugae of the stomach

Incorrect
Correct Answer: C. Stomach
The stomach is a muscular organ located on the left side of the upper abdomen. It is a saclike
expansion of the digestive tract of a vertebrate that is located between the esophagus and
duodenum. The major part of the digestion of food occurs in the stomach.
 Option A: The gallbladder is a small hollow organ about the size and shape of a pear. It
is a part of the biliary system, also known as the biliary tree or biliary tract. The biliary
system is a series of ducts within the liver, gallbladder, and pancreas that empty into the
small intestine. There are intrahepatic (within the liver) and extrahepatic (outside of the
liver) components. The gallbladder is a component of the extrahepatic biliary system
where bile is stored and concentrated.
 Option B: The bladder forms an integral part of the genitourinary system. Urine, created
by the kidneys, is drained into the bladder by the bilateral ureters. The bladder then acts
as the storage site for this waste product until higher-order centers within the central
nervous system initiate the micturition (i.e., urination) process, which permits the
expulsion of urine into the urethra, located on the inferior aspect of the bladder.
 Option D: The purpose of the lung is to provide oxygen to the blood. Anatomically, the
lung has an apex, three borders, and three surfaces. The apex lies above the first rib. The
function of the lung is to get oxygen from the air to the blood, performed by the alveoli.
The alveoli are a single cell membrane that allows for gas exchange to the pulmonary
vasculature. There are a couple of muscles that help with inspiration and expiration, such
as the diaphragm and intercostal muscles.
 Option E. The inner layer of the stomach is full of wrinkles known as rugae (or gastric
folds). Rugae both allow the stomach to stretch in order to accommodate large meals and
help to grip and move food during digestion
ADVERTISEMENTS
63. Question

The ability of the body to defend itself against scientific invading agent such as bacteria, toxin,
viruses, and foreign body:
o A. Hormones
o B. Secretion
o C. Immunity
o D. Glands
Incorrect
Correct Answer: C. Immunity
Immunity is the ability of an organism to resist a particular infection or toxin by the action of
specific antibodies or sensitized white blood cells. The Immune response is the body’s ability to
stay safe by affording protection against harmful agents and involves lines of defense against
most microbes as well as specialized and highly specific responses to a particular offender. This
immune response classifies as either innate which is non-specific and adaptive acquired which is
highly specific.
 Option A: The endocrine hormones are a wide array of molecules that traverse the
bloodstream to act on distant tissues, leading to alterations in metabolic functions within
the body. They can broadly divide into peptides, steroids, and tyrosine derivatives that
may work on either cell surface or intracellular receptors.
 Option B: Secretion, in biology, production and release of a useful substance by a gland
or cell; also, the substance produced. In addition to the enzymes and hormones that
facilitate and regulate complex biochemical processes, body tissues also secrete a variety
of substances that provide lubrication and moisture.
 Option D: A gland is an organ which produces and releases substances that perform a
specific function in the body. There are two types of gland. Endocrine glands are ductless
glands and release the substances that they make (hormones) directly into the
bloodstream.
ADVERTISEMENTS
64. Question
Hormones secreted by Islets of Langerhans
o A. Progesterone
o B. Testosterone
o C. Insulin
o D. Hemoglobin

Incorrect
Correct Answer: C. Insulin
The Islets of Langerhans are the regions of the pancreas that contain its endocrine cells. Insulin is
a peptide hormone secreted in the body by beta cells of islets of Langerhans of the pancreas and
regulates blood glucose levels. Medical treatment with insulin is indicated when there is
inadequate production or increased demands of insulin in the body.
 Option A: Progesterone (Choice A) is produced by the ovaries. Progesterone is an
endogenous steroid hormone that is commonly produced by the adrenal cortex as well as
the gonads, which consist of the ovaries and the testes. Progesterone is also secreted by
the ovarian corpus luteum during the first ten weeks of pregnancy, followed by the
placenta in the later phase of pregnancy.
 Option B: Testosterone (Choice B) is secreted by the testicles of males and ovaries of
females. Testosterone is the primary male hormone responsible for regulating sex
differentiation, producing male sex characteristics, spermatogenesis and fertility.
Testosterone is responsible for the development of primary sexual development, which
includes testicular descent, spermatogenesis, enlargement of the penis and testes, and
increasing libido.
 Option D: Hemoglobin (Choice D) is a protein molecule in the red blood cells that
carries oxygen from the lungs to the body’s tissues and returns carbon dioxide.
Hemoglobin is an oxygen-binding protein found in erythrocytes which transports oxygen
from the lungs to tissues. Each hemoglobin molecule is a tetramer made of four
polypeptide globin chains. Each globin subunit contains a heme moiety formed of an
organic protoporphyrin ring and a central iron ion in the ferrous state (Fe2+). The iron
molecule in each heme moiety can bind and unbind oxygen, allowing for oxygen
transport in the body.
ADVERTISEMENTS
65. Question
It is a transparent membrane that focuses the light that enters the eyes to the retina.
o A. Lens
o B. Sclera
o C. Cornea
o D. Pupils
Incorrect
Correct Answer: A. Lens
The lens is located in the eye. By changing its shape, the lens changes the focal distance of the
eye. In other words, it focuses the light rays that pass through it (and onto the retina) in order to
create clear images of objects that are positioned at various distances. It also works together with
the cornea to refract, or bend, light. The lens consists of the lens capsule, the lens epithelium, and

the lens fibers. The lens capsule is the smooth, transparent outermost layer of the lens, while the
lens fibers are long, thin, transparent cells that form the bulk of the lens. The lens epithelium lies
between these two and is responsible for the stable functioning of the lens. It also creates lens
fibers for the lifelong growth of the lens.
 Option B: The sclera is the white part of the eye that surrounds the cornea. In fact, the
sclera forms more than 80 percent of the surface area of the eyeball, extending from the
cornea all the way to the optic nerve, which exits the back of the eye. Only a small
portion of the anterior sclera is visible.
 Option C: The cornea is the eye’s clear, protective outer layer. Along with the sclera (the
white of your eye), it serves as a barrier against dirt, germs, and other things that can
cause damage. The cornea can also filter out some of the sun’s ultraviolet light. It also
plays a key role in vision. As light enters the eye, it gets refracted, or bent, by the
cornea’s curved edge. This helps determine how well the eye can focus on objects close-
up and far away.
 Option D: Pupils are the black center of the eye. Their function is to let in light and focus
it on the retina (the nerve cells at the back of the eye) so one can see. Muscles located in
the iris (the colored part of your eye) control each pupil.
ADVERTISEMENTS
66. Question
Which of the following is included in Orem’s theory?
o A. Maintenance of a sufficient intake of air.
o B. Self perception.
o C. Love and belongingness.
o D. Physiologic needs.
Incorrect
Correct Answer: A. Maintenance of a sufficient intake of air.
Dorothea Orem’s Self-Care Theory defined Nursing as ―The act of assisting others in the
provision and management of self-care to maintain or improve human functioning at home level
of effectiveness.‖ The Self-Care or Self-Care Deficit Theory of Nursing is composed of three
interrelated theories: (1) the theory of self-care, (2) the self-care deficit theory, and (3) the theory
of nursing systems, which is further classified into wholly compensatory, partial compensatory
and supportive-educative. Choices B, C, and D are from Abraham Maslow’s Hierarchy of Needs.
 Option B: At the fourth level in Maslow’s hierarchy is the need for appreciation and
respect. When the needs at the bottom three levels have been satisfied, the esteem needs
begin to play a more prominent role in motivating behavior. At this point, it becomes
increasingly important to gain the respect and appreciation of others. People have a need
to accomplish things and then have their efforts recognized. In addition to the need for

feelings of accomplishment and prestige, esteem needs include such things as self-esteem
and personal worth.
 Option C: The social needs in Maslow’s hierarchy include such things as love,
acceptance, and belonging. At this level, the need for emotional relationships drives
human behavior. In order to avoid problems such as loneliness, depression, and anxiety,
it is important for people to feel loved and accepted by other people. Personal
relationships with friends, family, and lovers play an important role, as does involvement
in other groups that might include religious groups, sports teams, book clubs, and other
group activities.
 Option D: The basic physiological needs are probably fairly apparent—these include the
things that are vital to our survival. In addition to the basic requirements of nutrition, air
and temperature regulation, the physiological needs also include such things as shelter
and clothing. Maslow also included sexual reproduction in this level of the hierarchy of
needs since it is essential to the survival and propagation of the species.
ADVERTISEMENTS
67. Question
Which of the following cluster of data belong to Maslow’s hierarchy of needs
o A. Love and belonging
o B. Physiological needs
o C. Self actualization
o D. All of the above

Incorrect
All of the choices are part of Maslow’s Hierarchy of Needs. Maslow first introduced his concept
of a hierarchy of needs in his 1943 paper ―A Theory of Human Motivation‖ and his subsequent
book Motivation and Personality. This hierarchy suggests that people are motivated to fulfill
basic needs before moving on to other, more advanced needs. As a humanist, Maslow believed
that people have an inborn desire to be self-actualized, that is, to be all they can be. In order to
achieve these ultimate goals, however, a number of more basic needs must be met such as the
need for food, safety, love, and self-esteem.
 Option A: The social needs in Maslow’s hierarchy include such things as love,
group activities.

 Option B: The basic physiological needs are probably fairly apparent—these include the
 Option C: At the very peak of Maslow’s hierarchy are the self-actualization needs.
―What a man can be, he must be,‖ Maslow explained, referring to the need people have to
achieve their full potential as human beings. According to Maslow’s definition of self-
actualization, ―It may be loosely described as the full use and exploitation of talents,
capabilities, potentialities, etc. Such people seem to be fulfilling themselves and to be
doing the best that they are capable of doing. They are people who have developed or are
developing to the full stature of which they are capable.‖
ADVERTISEMENTS
68. Question
This is characterized by severe symptoms relatively of short duration.
o A. Chronic Illness
o B. Acute Illness
o C. Pain
o D. Syndrome
Incorrect
Correct Answer: B. Acute Illness
Acute illnesses are different than chronic illnesses in that they usually develop quickly and they
only last a short time – usually a few days or weeks. Acute illnesses are often caused by viral or
bacterial infections.
 Option A: Chronic Illness (Choice A) are illnesses that are persistent or long-term. A
chronic illness is a condition that develops over time and is present for a long period of
time. Some people have chronic conditions for many years. Technically, a chronic
disease is defined as a health condition that lasts anywhere from three months to a
lifetime. Chronic conditions may get worse over time.
 Option C: Pain refers to the product of higher brain center processing; it entails the
actual unpleasant emotional and sensory experience generated from nervous signals.
 Option D: A syndrome is a set of medical signs and symptoms which are correlated with
each other and often associated with a particular disease or disorder. The word derives
from the Greek ?????????, meaning ―concurrence‖.
ADVERTISEMENTS

69. Question
Which of the following is the nurse’s role in health promotion?
o A. Health risk appraisal
o B. Teach client to be effective health consumer
o C. Worksite wellness
o D. None of the above

Incorrect
Correct Answer: B. Teach client to be effective health consumer
Nurses play a huge role in illness prevention and health promotion. Nurses assume the role of
ambassadors of wellness. The World Health Organization (WHO) defines health promotion as a
process of enabling people to increase control over and to improve their health (WHO, 1986).
Nurses are best qualified to take on the job of health promoter due to their expertise. There are
few health care occupations that have the high level of health education knowledge, skills,
theory, and research to be able to focus on prevention because it is considered part of their
professional development focus.
 Option A: An HRA may be a simple questionnaire eliciting self-reported information on
risk factors, behaviors, or diagnoses. Questionnaires may be supplemented with clinical
examinations to obtain data on variables such as height, weight, body mass index (BMI),
heart rate, or blood pressure. Some HRAs may include performance tests such as grip
strength, timed-up-and-go, chair rise, or four-meter walk test.
 Option C: Studies show that employees are more likely to be on the job and performing
well when they are in optimal health. Benefits of implementing a wellness program
include: improved disease management and prevention, and a healthier workforce in
general, both of which contribute to lower health care costs.
 Option D: One of the most critical roles that nurses have in health promotion and disease
preventions is that of an educator. Nurses spend the most time with the patients and
provide anticipatory guidance about immunizations, nutrition, dietary, medications, and
safety.
ADVERTISEMENTS
70. Question
It is described as a collection of people who share some attributes of their lives.
o A. Family
o B. Illness
o C. Community

o D. Nursing
Incorrect
Correct Answer: C. Community
A community is defined by the shared attributes of the people in it, and/or by the strength of the
connections among them. When an organization is identifying communities of interest, the
shared attribute is the most useful definition of a community.
 Option A: In human society, family is a group of people related either by consanguinity
(by recognized birth) or affinity (by marriage or other relationship). The purpose of
families is to maintain the well-being of its members and of society. Ideally, families
would offer predictability, structure, and safety as members mature and participate in the
community.
 Option B: Illness is a condition of being unhealthy in the body or mind; a specific
condition that prevents the body or mind from working normally; a sickness or disease.
 Option D: Nursing encompasses autonomous and collaborative care of individuals of all
ages, families, groups, and communities, sick or well, and in all settings. Nursing
includes the promotion of health, prevention of illness, and the care of ill, disabled, and
dying people.
ADVERTISEMENTS
71. Question
Five teaspoons is equivalent to how many milliliters (ml)?
o A. 30 ml
o B. 25 ml
o C. 12 ml
o D. 22 ml
Incorrect
Correct Answer: B. 25 ml
One teaspoon is equal to 5ml. Drug calculations require the use of conversion factors, for
example, when converting from pounds to kilograms or liters to milliliters. Simplistic in design,
this method allows clinicians to work with various units of measurement, converting factors to
find the answer. These methods are useful in checking the accuracy of the other methods of
calculation, thus acting as a double or triple check.
 Option A: 30 ml is equal to 6 teaspoons. When clinicians are prepared and know the key
conversion factors, they will be less anxious about the calculation involved. This is vital
to accuracy, regardless of which formula or method employed.
 Option C: 12 ml is equal to 2.4 teaspoons. Units of measurement must match, for
example, milliliters and milliliters, or one needs to convert to like units of measurement.

 Option D: 22 ml is equal to 4.4 teaspoons. Medication errors can be detrimental and
costly to patients. Drug calculation and basic mathematical skills play a role in the safe
administration of medications.
ADVERTISEMENTS
72. Question
1800 ml is equal to how many liters?
o A. 1.8
o B. 18000
o C. 180
o D. 2800
Incorrect
Correct Answer: A. 1.8
1,800 ml is equal to 1.8 liters.
 Option B: 18000 liters is equal to 18,000,000 ml.
 Option C: 180 liters is equal to 180,000 ml.
 Option D: 2800 liters is equal to 280,000 ml.
ADVERTISEMENTS
73. Question
Which of the following is the abbreviation of drops?
o A. Gtt.
o B. Gtts.
o C. Dp.
o D. Dr.
Incorrect
Correct Answer: B. Gtts.
Gtt (Choice A) is an abbreviation for drop. Dp and Dr are not recognized abbreviations for
measurement. Standardization and uniform use of codes, symbols, and abbreviations can
improve communication and understanding between health care practitioners, leading to safer
and more effective care for patients.

 Option A: Appropriate use of abbreviations is particularly important. Numerous studies
have focused on health care practitioners’ understanding and interpretation of
abbreviations in medical documents, such as medical records, discharge summaries, and
medication orders. Findings indicate that it is not uncommon for practitioners to have
difficulty understanding the abbreviations used in their hospitals.
 Option C: To prevent misunderstandings and potential risks to patient safety, MOI.4
requires hospitals to establish lists for approved and do-not-use abbreviations and
monitor for appropriate abbreviation use. There are resources for identifying
abbreviations for the do-not-use list, such as the Institute for Safe Medication Practices
(ISMP), which publishes a list of dangerous abbreviations not to be used due to frequent
misinterpretation and associated medication errors.
 Option D: When developing lists, hospitals need to ensure that abbreviations on the
approved list are not also on the do-not-use list, and vice versa. In addition, abbreviations
can have only one meaning within the entire organization—for example, the abbreviation
NKDA could mean ―no known drug allergies,‖ or it could mean ―nonketotic diabetic
acidosis,‖ but it cannot have both meanings in an organization.
ADVERTISEMENTS
74. Question
The abbreviation for microdrop is…
o A. µgtt
o B. gtt
o C. mdr
o D. mgts
Incorrect
Correct Answer: A. µgtt
The abbreviation for microdrop is µgtt. When abbreviations are used in documents given to the
patient, the potential for misunderstanding can increase. Information needs to be clear and
unambiguous to improve patients’ comprehension.
 Option B: When abbreviations are used in documents given to the patient, the potential
for misunderstanding can increase. Information needs to be clear and unambiguous to
improve patients’ comprehension.
 Option C: As stated in MOI.4, ME 5, ―Abbreviations are not used on informed consent
and patient rights documents, discharge instructions, discharge summaries, and other
documents patients and families receive from the hospital about the patient’s care.‖
 Option D: No abbreviations of any kind should appear in informed consent documents,
patient rights documents, and discharge instructions. These documents are meant for the
patient and every effort should be made to increase the readability and clarity of the
documents.

ADVERTISEMENTS
75. Question
Which of the following is the meaning of PRN?
o A. When advice
o B. Immediately
o C. When necessary
o D. Now.
Incorrect
Correct Answer: C. When necessary
PRN comes from the Latin ―pro re nata‖ meaning, ―for an occasion that has arisen or as
circumstances require‖. When an abbreviation is less known outside of the organization or
clinical specialty, it is necessary to spell out the abbreviation throughout the discharge summary
to prevent misunderstanding and confusion by the physician or health care organization that
receives the summary.
 Option A: The practice of spelling out an abbreviation when first mentioned, then using
the abbreviation thereafter in the document is acceptable only in discharge summaries.
Abbreviations are not to be used in the other types of documents listed in the measurable
element.
 Option B: Laboratory test results sometimes go to patients, but it is not the intent of the
standard for the abbreviations of the laboratory tests to be spelled out. When test results
are given to patients, they are shared with their physician who can help explain the
results.
 Option D: Hospitals may want to consider providing a separate form or resource to
patients for information about the tests — such as a handout or website that has the
names of common laboratory tests along with their definitions or descriptions. Results of
diagnostic imaging studies also go to a patient’s physician, after interpretation by a
radiologist.
ADVERTISEMENTS
1. Question
The charge nurse asks the nursing assistive personnel (NAP) to give a bag bath to
a patient with end-stage chronic obstructive pulmonary disease. How should the
NAP proceed?
 A. Bathe the patient's entire body using 8 to 10 washcloths.

 B. Assist the patient to a chair and provide bathing supplies.
 C. Saturate a towel and blanket in a plastic bag, and then bathe the patient.
 D. Assist the patient to the bathtub and provide a bath chair.

Incorrect
Correct Answer: A. Bathe the patient’s entire body using 8 to 10 washcloths.
A towel bath is a modification of the bed bath in which the NAP places a large
towel and a bath blanket into a plastic bag, saturates them with a commercially
prepared mixture of moisturizer, non rinse cleaning agent, and water; warms in
them in a microwave, and then uses them to bathe the patient. A bag bath is a
modification of the towel bath, in which the NAP uses 8 to 10 washcloths instead
of a towel or blanket. Each part of the patient‘s body is bathed with a fresh cloth.
 Option B: A bag bath is not given in a chair or in the tub. The bag bath is
one alternative to the traditional bed bath used in some nursing homes.
The bath is performed with a series of 10 washcloths and a no-rinse liquid
cleanser. Close the door and windows to prevent cold drafts and wash
hands with warm water before beginning.
 Option C: Moisten the washcloths with water and put in a plastic bag with
the cleanser. Warm the bag in the microwave for 60 to 90 seconds. Test the
temperature of the clothes before touching a resident with them and be
careful when you open the bag, as steam can burn.
 Option D: Take the bag to the resident‘s bedside. When you are not
cleaning a body part, keep it covered. Only expose as much of the
resident‘s body as necessary to adequately clean him or her. Be especially
sensitive to exposing genitals, buttocks, and breasts. Bathing can be an
extremely stressful experience for residents, so try to make it as easy as
possible.
2. Question
For a morbidly obese patient, which intervention should the nurse choose to
counteract the pressure created by the skin folds?
 A. Cover the mattress with a sheepskin.
 B. Keep the linens wrinkle free.
 C. Separate the skin folds with towels.

 D. Apply petrolatum barrier creams.
Incorrect
Correct Answer: C. Separate the skin folds with towels.
Separating the skin folds with towels relieves the pressure of skin rubbing on
skin. Skin folds, in particular, may be difficult for the patient to clean thoroughly;
the abdominal folds and groins may be ignored, leading to an increased risk of
skin breakdown in these areas.
 Option A: Sheepskins are not recommended for use at all. Skin folds
present a challenge in the management of patients who are morbidly
obese. The weight from excess adipose tissue in skinfold areas can have an
increased risk of skin injury such as friction, maceration, skin tears and
pressure ulcer development.
 Option B: Skin folds and areas vulnerable to skin injury should be cleaned
and dried several times a day. Alcohol-based lotions and harsh soaps, as
well as talcum powders, should be avoided in these areas. If necessary, dry
cloths to absorb moisture can be left in skin folds in between washing and
drying of the skin folds.
 Option D: Petrolatum barrier creams are used to minimize moisture
caused by incontinence. Patient hydration should also be considered in the
nutrition plan for the patients and the health of their skin.
1. 3. Question
A client exhibits all of the following during a physical assessment. Which of these
is considered a primary defense against infection?
o A. Fever
o B. Intact skin
o C. Inflammation
o D. Lethargy
Incorrect
Correct Answer: B. Intact skin
Intact skin is considered a primary defense against infection. Usually, the skin
prevents invasion by microorganisms unless it is damaged (for example, by an
injury, insect bite, or burn). Mucous membranes, such as the lining of the mouth,

nose, and eyelids, are also effective barriers. Typically, mucous membranes are
coated with secretions that fight microorganisms. For example, the mucous
membranes of the eyes are bathed in tears, which contain an enzyme called
lysozyme that attacks bacteria and helps protect the eyes from infection. Fever,
the inflammatory response, and phagocytosis (a process of killing pathogens) are
considered secondary defenses against infection.
 Option A: Body temperature increases as a protective response to
infection and injury. An elevated body temperature (fever) enhances the
body‘s defense mechanisms, although it can cause discomfort. A part of
the brain called the hypothalamus controls body temperature. Fever results
from an actual resetting of the hypothalamus‘s thermostat. The body raises
its temperature to a higher level by moving (shunting) blood from the skin
surface to the interior of the body, thus reducing heat loss.
 Option C: Any injury, including an invasion by microorganisms, causes
inflammation in the affected area. Inflammation, a complex reaction, results
from many different conditions. During inflammation, the blood supply
increases, helping carry immune cells to the affected area. Because of the
increased blood flow, an infected area near the surface of the body
becomes red and warm. The walls of blood vessels become more porous,
allowing fluid and white blood cells to pass into the affected tissue. The
increase in fluid causes the inflamed tissue to swell. The white blood cells
attack the invading microorganisms and release substances that continue
the process of inflammation.
 Option D: Lethargy refers to a state of lacking energy. People who are
experiencing fatigue or tiredness can also be said to be lethargic because
of low energy. The same medical conditions that can lead to tiredness or
fatigue can also lead to lethargy.
ADVERTISEMENTS
1. Question 4 of 75
4. Question
A client with a stage 2 pressure ulcer has methicillin-resistant Staphylococcus
aureus (MRSA) cultured from the wound. Contact precautions are initiated. Which
rule must be observed to follow contact precautions?

o A. A clean gown and gloves must be worn when in contact with the
client.
o B. Everyone who enters the room must wear a N-95 respirator mask.
o C. All linen and trash must be marked as contaminated and send to

biohazard waste.
o D. Place the client in a room with a client with an upper respiratory infection.
Incorrect
Correct Answer: A. A clean gown and gloves must be worn when in contact
with the client.
A clean gown and gloves must be worn when any contact is anticipated with the
client or with contaminated items in the room. Visitors might also be asked to
wear a gown and gloves. Patients are asked to stay in their hospital rooms as
much as possible. They should not go to common areas, such as the gift shop or
cafeteria. They may go to other areas of the hospital for treatments and tests.
 Option B: A respirator mask is required only with airborne precautions, not
contact precautions. Healthcare providers will put on gloves and wear a
gown over their clothing while taking care of patients with MRSA.
 Option C: All linen must be double-bagged and clearly marked as
contaminated. When leaving the room, healthcare providers and visitors
remove their gown and gloves and clean their hands.
 Option D: The client should be placed in a private room or in a room with
a client with an active infection caused by the same organism and no other
infections. Whenever possible, patients with MRSA will have a single room
or will share a room only with someone else who also has MRSA.
ADVERTISEMENTS
1. Question 5 of 75
5. Question
A client requires protective isolation. Which client can be safely paired with this
client in a client-care assignment? One:
o A. Admitted with unstable diabetes mellitus.
o B. Who underwent surgical repair of a perforated bowel.

o C. With a stage 3 sacral pressure ulcer.
o D. Admitted with a urinary tract infection.

Incorrect
Correct Answer: A. Admitted with unstable diabetes mellitus.
The client with unstable diabetes mellitus can safely be paired in a client-care
assignment because the client is free from infection. Protective Isolation aims to
protect an immunocompromised patient who is at high risk of acquiring micro-
organisms from either the environment or from other patients, staff, or visitors.
 Option B: Perforation of the bowel exposes the client to infection requiring
antibiotic therapy during the postoperative period. Therefore, this client
should not be paired with a client in protective isolation. Patients should
remain in isolation whilst they remain symptomatic; a risk assessment
should be undertaken to ascertain if and when isolation precautions can be
relaxed.
 Option C: A client in protective isolation should not be paired with a client
who has an open wound, such as a stage 3 pressure ulcer. Patient‘s
requiring protective isolation should be nursed in a single room. Where
possible this room should have an ante-room, positive pressure ventilation
and Hepa filtered air. The room should have an en-suite and hand washing
facilities and the doors(s) should be kept closed at all times.
 Option D: A client in protective isolation should not be paired with a client
who has a urinary tract infection. Many infections acquired by
immunocompromised patients are endogenous infections (An infection
caused by an infectious agent that is already present in the body but has
previously been inapparent or dormant), however, the transmission of
infection from other patients, staff, or the environment can be a risk and
therefore extra precautions are required.
ADVERTISEMENTS
1. Question 6 of 75
6. Question
A newly hired at Nurseslabs Medical Center is assigned to the OR Department.
Which action demonstrates a break in sterile technique?
o A. Remaining 1 foot away from non sterile areas.

o B. Placing sterile items on the sterile field.
o C. Avoiding the border of the sterile drape.
o D. Reaching 1 foot over the sterile field.

Incorrect
Correct Answer: D. Reaching 1 foot over the sterile field.
Reaching over the sterile field while wearing sterile garb breaks the sterile
technique. While observing sterile technique, healthcare workers should remain 1
foot away from non-sterile areas while wearing sterile garb, place sterile items
needed for the procedure on the sterile drape, and avoid coming in contact with
the 1-inch border of the sterile drape. The principles of the Sterile Technique are
applied in various ways. If the principle itself is understood, the applications of it
become obvious. A strict aseptic technique is needed at all times in the Operating
Room.
 Option A: Sterile persons avoid leaning over an unsterile area; non-sterile
persons avoid reaching over a sterile field. Unsterile persons do not get
closer than 12 inches from a sterile field.
 Option B: Persons who are sterile touch only sterile articles; persons who
are not sterile touch only unsterile articles. If in doubt about the sterility of
anything consider it not sterile. If a non-sterile person brushes close
consider yourself contaminated.
 Option C: Sterile persons keep contact with sterile areas to a minimum. Do
not lean on the sterile tables or on the draped patient. Do not lean on the
nurse‘s mayo tray.
ADVERTISEMENTS
1. Question 7 of 75
7. Question
Nurse Berta is facilitating a monthly mothers‘ class at a small village. As a
knowledgeable nurse, she must know that a mother who breastfeeds her child
passes on which antibody through breast milk?
o A. IgA
o B. IgE

o C. IgG
o D. IgM
Incorrect
Correct Answer: A. IgA
Antibodies, which are also called immunoglobulins, take five basic forms,
indicated as IgG, IgA, IgM, IgD and IgE. All have been detected in human milk,
but by far the most abundant type is IgA, particularly the form known as
secretory IgA, which is found in great amounts throughout the gut and
respiratory system of adults. The secretory IgA molecules passed to the suckling
child are helpful in ways that go beyond their ability to bind to microorganisms
and keep them away from the body‘s tissues.
 Option B: IgE is a monomer. It has a molecular weight of 188 Kd and a
serum concentration of 0.00005 mg/mL. It protects against parasites and
also binds to high-affinity receptors on mast cells and basophils causing
allergic reactions. IgE is regarded as the most important host defense
against different parasitic infections which include Strongyloides
stercoralis, Trichinella spiralis, Ascaris lumbricoides, and the hookworms
Necator americanus and Ancylostoma duodenal.
 Option C: IgG2 forms an important host defense against bacteria that are
encapsulated. IgG is the only immunoglobulin that crosses the placentae as
its Fc portion binds to the receptors present on the surface of the placenta,
protecting the neonate from infectious diseases. IgG is thus the most
abundant antibody present in newborns.
 Option D: IgM has a molecular weight of 970 Kd and an average serum
concentration of 1.5 mg/ml. It is mainly produced in the primary immune
response to infectious agents or antigens. It is a pentamer and activates
the classical pathway of the complement system. IgM is regarded as a
potent agglutinin (e.g., anti-A and anti-B isoagglutinin present in type B
and type A blood respectively) and a monomer of IgM is used as a B cell
receptor (BCR).
ADVERTISEMENTS
1. Question 8 of 75
8. Question

The clinical instructor asks her students the rationale for handwashing. The
students are correct if they answered that handwashing is expected to remove:
o A. Transient flora from the skin
o B. Resident flora from the skin
o C. All microorganisms from the skin
o D. Media for bacterial growth

Incorrect
Correct Answer: A. Transient flora from the skin
There are two types of normal flora: transient and resident. Transient flora are
normal flora that a person picks up by coming in contact with objects or another
person (e.g., when you touch a soiled dressing). You can remove these with hand
washing. Hand washing can prevent about 30% of diarrhea-related illnesses and
about 20% of respiratory infections (e.g., colds). Antibiotics often are prescribed
unnecessarily for these health issues
 Option B: Resident flora live deep in skin layers where they live and
multiply harmlessly. They are permanent inhabitants of the skin and cannot
usually be removed with routine hand washing.
 Option C: Removing all microorganisms from the skin (sterilization) is not
possible without damaging the skin tissues. To live and thrive in humans,
microbes must be able to use the body‘s precise balance of food, moisture,
nutrients, electrolytes, pH, temperature, and light.
 Option D: Food, water, and soil that provide these conditions may serve as
nonliving reservoirs. Hand washing does little to make the skin
uninhabitable for microorganisms, except perhaps briefly when an
antiseptic agent is used for cleansing. Handwashing with soap could
protect about 1 out of every 3 young children who get sick with diarrhea
and almost 1 out of 5 young children with respiratory infections like
pneumonia.
ADVERTISEMENTS
1. Question 9 of 75
9. Question

Which of the following incidents requires the nurse to complete an occurrence
report?
o A. Medication given 30 minutes after scheduled dose time.
o B. Patient's dentures lost after transfer.
o C. Worn electrical cord discovered on an IV infusion pump.
o D. Prescription without the route of administration.

Incorrect
Correct Answer: B. Patient’s dentures lost after transfer
You would need to complete an occurrence report if you suspect your patient‘s
personal items to be lost or stolen. An incident report also provides vital
information the facility needs to decide whether restitution should be made—if
personal belongings were lost or damaged, for example. Without proper
documentation of the incident, there‘s no way to make these important decisions
effectively.
 Option A: A medication can be administered within a half-hour of the
administration time without an error in administration; therefore, an
occurrence report is not necessary. An incident report invariably makes its
way to risk managers and other administrators, who review it rapidly and
act quickly to change any policy or procedure that appears to be a key
contributing factor to the incident.
 Option C: The worn electrical cord should be taken out of use and
reported to the biomedical department. An incident report should be filed
whenever an unexpected event occurs. The rule of thumb is that any time a
patient makes a complaint, a medication error occurs, a medical device
malfunctions, or anyone—patient, staff member, or visitor—is injured or
involved in a situation with the potential for injury, an incident report is
required.
 Option D: The nurse should seek clarification if the provider‘s order is
missing information; an occurrence report is not necessary. The medical
record is patient-focused, and facts pertinent to an unexpected incident
will likely be left out. So if a claim were filed and the case proceeded to
court, which sometimes occurs years after the event, you or anyone else
involved might be hard-pressed to recreate the scene—especially if you
consider it to be ―minor‖ at the time. You may not be able to rely on

memory alone, but you can count on the incident report to refresh your
memory.
ADVERTISEMENTS
10. Question
The nurse is orienting a new nurse to the unit and reviews source-oriented
charting. Which statement by the nurse best describes source-oriented charting?
Source-oriented charting:
o A. Separates the health record according to discipline.
o B. Organizes documentation around the patient's problems.
o C. Highlights the patient's concerns, problems, and strengths.
o D. Is designed to streamline documentation.

Incorrect
Correct Answer: A. Separates the health record according to discipline
In source-oriented charting, each discipline documents findings in a separately
labeled section of the chart. Source-oriented (SO) charting is a narrative
recording by each member (source) of the health care team charts on separate
records. SO charting is time-consuming and can lead to fragmented care.
Effective documentation requires the use of common vocabulary; legibility and
neatness; the use of only authorized abbreviations and symbols; factual and time-
sequenced organization; and accuracy, including any errors that occurred. All
documents related to client care are confidential and clients must sign a release
to have their information released, specifying what type of information may be
released and to whom it may be released.
 Option B: Problem-oriented charting organizes notes around the patient‘s
problems. POMR is a structured, logical format of narrative charting, using
―SOAP,‖ where S means ―subjective data,‖ O means ―objective data,‖ A
means assessment data, and P means ―plan.‖ Some institutions add,
intervention, E, evaluation, and R, revision, to the SOAP format. POMR is
sometimes altered to become a problem-oriented record (POR). The critical
components of POMR/POR are the database; the problem list; the initial

plan; and the progress notes, based on the SOAP, SOAPIE, or SOAPIER
format.
 Option C: Focus charting highlights the patient‘s concerns, problems, and
strengths. Focus Charting of F-DAR is intended to make the client and
client concerns and strengths the focus of care. It is a method of organizing
health information in an individual‘s record. Focus Charting is a systematic
approach to documentation.
 Option D: Charting by exception is a unique charting system designed to
streamline documentation. Charting by exception (CBE) is a shorthand
method of documenting normal findings, based on clearly defined
normals, standards of practice, and predetermined criteria for assessments
and interventions. Significant findings or exceptions to the predefined
norms are documented in detail.
ADVERTISEMENTS
1. 11. Question
When the nurse completes the patient‘s admission nursing database, the patient
reports that he does not have any allergies. Which acceptable medical
abbreviation can the nurse use to document this finding?
o A. NA
o B. NDA
o C. NKA
o D. NPO
Incorrect
Correct Answer: C. NKA
The nurse can use the medical abbreviation NKA, which means no known
allergies, to document this finding. NKA is the abbreviation for ―no known
allergies,‖ meaning no known allergies of any sort. By contrast, NKDA stands
exclusively for ―no known drug allergies.‖
 Option A: NA is an abbreviation for not applicable.
 Option B: NDA is an abbreviation for no known drug allergies.
 Option D: NPO is an abbreviation that means nothing by mouth.
ADVERTISEMENTS

12. Question
The nurse is working on a unit that uses nursing assessment flow sheets. Which
statement best describes this form of charting? Nursing assessment flow sheets:
o A. Are comprehensive charting forms that integrate assessments and

nursing actions.
o B. Contain only graphic information, such as I&O, vital signs, and medication
administration.
o C. Are used to record routine aspects of care; they do not contain assessment
data.
o D. Contain vital data collected upon admission, which can be compared with
newly collected data.
Incorrect
Correct Answer: A. Are comprehensive charting forms that integrate
assessments and nursing actions
Nursing assessment flow sheets are organized by body systems. The nurse checks
the box corresponding to the current assessment findings. Nursing actions, such
as wound care, treatments, or IV fluid administration, are also included. A flow
sheet is simply a one- or two-page form that gathers all the important data
regarding a patient‘s condition. The flow sheet is housed in the patient‘s chart
and serves as a reminder of care and a record of whether care expectations have
been met.
 Option B: Graphic information, such as vital signs, I&O, and routine care,
may be found on the graphic record. This where records of serial
measurements and observations, nursing interventions, and nursing care
plans are recorded.
 Option C: Nursing documentation covers a wide variety of issues, topics,
and systems. Researchers, practitioners, and hospital administrators view
recordkeeping as an important element leading to continuity of care,
safety, quality care, and compliance.
 Option D: The admission form contains baseline information. In health
care organizations, the EHR, oral reports, handoffs, conferences, and health
information technologies (HIT) are intended to facilitate information flow.

In particular, the JCAHO specifically conceptualizes the care planning
process as the structuring framework for coordinating communication that
will result in safe and effective care.
ADVERTISEMENTS
1. 13. Question
At the end of the shift, the nurse realizes that she forgot to document a dressing
change that she performed for a patient. Which action should the nurse take?
o A. Complete an occurrence report before leaving.
o B. Do nothing; the next nurse will document it was done.
o C. Write the note of the dressing change into an earlier note.
o D. Make a late entry as an addition to the narrative notes.

Incorrect
Correct Answer: D. Make a late entry as an addition to the narrative notes.
If the nurse fails to make an important entry while charting, she should make a
late entry as an addition to the narrative notes. The nurse can only document
care directly performed or observed. Therefore, the nurse on the incoming shift
would not record the wound change as performed. A primary purpose of
documentation and recordkeeping systems is to facilitate information flow that
supports the continuity, quality, and safety of care.
 Option A: An occurrence report is not necessary in this case. The issue of
completeness is important; Croke cites failure to document as one of the
six top reasons that nurses face malpractice suits. In terms of overall
completeness, Stokke and Kalfoss found many gaps in nursing
documentation in Norway. Care plans, goals, diagnoses, planned
interventions, and projected outcomes were absent between 18 percent
and 45 percent of the time.
 Option B: If documentation is omitted, there is no legal verification that
the procedure was performed. Completeness of a record may have an
impact on the quality of care, but only if it reflects completeness of the
right content. Echoed again here is that document focus, rather than the
patient-centric nature of the medical record, does little to support shared
understanding by clinicians of care and the communication needed to
ensure the continuity, quality, and safety of care.

 Option C: It is illegal to add to a chart entry that was previously
documented. The typical content and format of documentation—and its
lack of accessibility—have also resulted in document-centric rather than
patient-centric records.
ADVERTISEMENTS
14. Question
Patient Z asks Nurse Toni why an electronic health record (EHR) system is being
used. Which response by the nurse indicates an understanding of the rationale
for an EHR system?
o A. It includes organizational reports of unusual occurrences that are not part

of the client's record.
o B. This type of system consists of combined documentation and daily care

plans.
o C. It improves interdisciplinary collaboration that improves efficiency in

procedures.
o D. This type of system tracks medication administration and usage over 24

hours.
Incorrect
Correct Answer: C. It improves interdisciplinary collaboration that improves
efficiency in procedures.
The EHR has several benefits for users, including improving interdisciplinary
collaboration and making procedures more accurate and efficient. An Electronic
Health Record (EHR) is an electronic version of a patient‘s medical history, that is
maintained by the provider over time, and may include all of the key
administrative clinical data relevant to that persons care under a particular
provider, including demographics, progress notes, problems, medications, vital
signs, past medical history, immunizations, laboratory data, and radiology reports
The EHR automates access to information and has the potential to streamline the
clinician‘s workflow. The EHR also has the ability to support other care-related
activities directly or indirectly through various interfaces, including evidence-
based decision support, quality management, and outcomes reporting.

 Option A: An occurrence report is an organizational record of an unusual
occurrence or accident that is not a part of the client‘s record. The purpose
of the incident report is to document the exact details of the occurrence
while they are fresh in the minds of those who witnessed the event. This
information may be useful in the future when dealing with liability issues
stemming from the incident.
 Option B: Integrated plans of care (IPOC) are a combined charting and
care plan format. It is care that is planned with people who work together
to understand the service user and their carer(s), puts them in control, and
coordinates and delivers services to achieve the best outcomes
 Option D: A medication administration record (MAR) is used to document
medications administered and their usage. A Medication Administration
Record (MAR, or eMAR for electronic versions), commonly referred to as a
drug chart, is the report that serves as a legal record of the drugs
administered to a patient at a facility by a healthcare professional. The
MAR is a part of a patient‘s permanent record on their medical chart.
ADVERTISEMENTS
15. Question
In the United States, the first programs for training nurses were affiliated with:
o A. The military
o B. General hospitals
o C. Civil service
o D. Religious orders
Incorrect
Correct Answer: D. Religious orders
When the Civil War broke out, the Army used nurses who had already been
trained in religious orders. Nursing started with religious orders. The Hindu faith
was the first to write about nursing. In the United States, all training for nurses
was affiliated with religious orders until after the Civil War.
 Option A: Although the Army did provide some training, it occurred later
than in the religious orders. Most people think of the nursing profession as

beginning with the work of Florence Nightingale, an upper class British
woman who captured the public imagination when she led a group of
female nurses to the Crimea in October of 1854 to deliver nursing service
to British soldiers.
 Option B: Although nurses were trained in hospitals, the training and the
hospitals were affiliated with religious orders. Upon her return to England,
Nightingale successfully established nurse education programs in a
number of British hospitals. These schools were organized around a
specific set of ideas about how nurses should be educated, developed by
Nightingale often referred to as the ―Nightingale Principles.‖
 Option C: Civil service was not mentioned in Chapter 1 and was not a
factor in the early 1800s. While Nightingale‘s work was groundbreaking in
that she confirmed that a corps of educated women, informed about
health and the ways to promote it, could improve the care of patients
based on a set of particular principles, she was not the first to put these
principles into action.
ADVERTISEMENTS
16. Question
Which of the following is/are an example(s) of a health restoration
activity? Select all that apply.
o A. Administering an antibiotic every day.
o B. Teaching the importance of handwashing.
o C. Assessing a client's surgical incision.
o D. Advising a woman to get an annual mammogram after age 50 years.
o E. Attending rehabilitation of a fractured arm.

Incorrect
Correct Answer: A, C, E
Health restoration activities help an ill client return to health. This would include
taking an antibiotic every day and assessing a client‘s surgical incision. Hand
washing and mammograms both involve healthy people who are trying to
prevent illness.

 Option A: Rehabilitation or restoration is defined as ―a set of interventions
designed to optimize functioning and reduce disability in individuals with
health conditions in interaction with their environment‖.
 Option B: Disease prevention, understood as specific, population-based,
and individual-based interventions for primary and secondary (early
detection) prevention, aiming to minimize the burden of diseases and
associated risk factors.
 Option C: Rehabilitation helps a child, adult, or older person to be as
independent as possible in everyday activities and enables participation in
education, work, recreation, and meaningful life roles such as taking care of
a family. It does so by addressing underlying conditions (such as pain) and
improving the way an individual function in everyday life, supporting them
to overcome difficulties with thinking, seeing, hearing, communicating,
eating, or moving around.
 Option D: Secondary prevention deals with early detection when this
improves the chances for positive health outcomes (this comprises
activities such as evidence-based screening programs for early detection of
diseases or for prevention of congenital malformations; and preventive
drug therapies of proven effectiveness when administered at an early stage
of the disease).
 Option E: Rehabilitation is highly person-centered, meaning that the
interventions and approach selected for each individual depends on their
goals and preferences. Rehabilitation can be provided in many different
settings, from inpatient or outpatient hospital settings to private clinics, or
community settings such as an individual‘s home.
ADVERTISEMENTS
1. 17. Question
Which of the following aspects of nursing is essential to defining it as both a
profession and a discipline?
o A. Established standards of care
o B. Professional organizations
o C. Practice supported by scientific research
o D. Activities determined by a scope of practice

Incorrect
Correct Answer: C. Practice supported by scientific research
A profession must have knowledge that is based on technical and scientific
knowledge. The theoretical knowledge of a discipline must be based on research,
so both are scientifically based. The profession of nursing consists of persons
educated in the discipline according to nationally regulated, defined, and
monitored standards. The standards and regulations are to preserve healthcare
safety for members of society. Although the discipline and the profession of
nursing have different goals, the raison d‘être of nursing is the enhancement of
quality of life for humankind. The discipline provides the science lived in the art of
practice.
 Option A: The American Nurses Association (ANA) has developed
standards of care, but they are unrelated to defining nursing as a
profession or discipline. Nursing is a discipline and a profession. The goal
of the discipline is to expand knowledge about human experiences
through creative conceptualization and research. This knowledge is the
scientific guide to living the art of nursing. The discipline-specific
knowledge is given birth and fostered in academic settings where research
and education move the knowledge to new realms of understanding.
 Option B: Having professional organizations is not included in accepted
characteristics of either a profession or a discipline. The goal of the
profession is to provide service to humankind through living the art of
science. Members of the nursing profession are responsible for regulation
of standards of practice and education based on disciplinary knowledge
that reflects safe health service to society in all settings.
 Option D: Having a scope of practice is not included in accepted
characteristics of either a profession or a discipline. The discipline of
nursing encompasses the knowledge in the extant frameworks and
theories that are embedded in the totality and simultaneity paradigms
(Parse, 1987). These theories and frameworks explicate the nature of
nursing‘s major phenomenon of concern, the human-universe-health
process.
ADVERTISEMENTS
18. Question

The charge nurse on the medical-surgical floor assigns vital signs to the nursing
assistive personnel (NAP) and medication administration to the licensed
vocational nurse (LVN). Which nursing model of care is this floor following?
o A. Team nursing
o B. Case method nursing
o C. Functional nursing
o D. Primary nursing
Incorrect
Correct Answer: C. Functional nursing
This medical-surgical floor is following the functional nursing model of care, in
which care is partitioned and assigned to a staff member with the appropriate
skills. For example, the NAP is assigned vital signs, and the LVN is assigned
medication administration. Functional nursing is task-oriented in scope. Instead
of one nurse performing many functions, several nurses are given one or two
assignments. For example, there is a medicine nurse whose sole responsibility is
administering medications.
 Option A: With team nursing, an RN or LVN is paired with a NAP. The pair
is then assigned to render care for a group of patients. Team nursing is a
system that distributes the care of a patient amongst a team that is all
working together to provide for this person. This team consists of up to 4
to 6 members that has a team leader who gives jobs and instructions to
the group.
 Option B: In case method nursing, one nurse cares for one patient during
her entire shift. Private duty nursing is an example of this care model. The
case method is a participatory, discussion-based way of learning where
students gain skills in critical thinking, communication, and group
dynamics. It is a type of problem-based learning.
 Option D: When the primary nursing model is utilized, one nurse manages
care for a group of patients 24 hours a day, even though others provide
care during part of the day. A method of providing nursing services to
inpatients whereby one nurse plans the care of specific patients for a
period of 24 hours. The primary nurse provides direct care to those
patients when working and is responsible for directing and supervising
their care in collaboration with other health care team members.

ADVERTISEMENTS
19. Question
Paul Jake suffered a stroke and has difficulty swallowing. Which healthcare team
member should be consulted to assess the patient‘s risk for aspiration?
o A. Respiratory therapist
o B. Occupational therapist
o C. Dentist
o D. Speech therapist
Incorrect
Correct Answer: D. Speech therapist
Speech and language therapists provide assistance to clients experiencing
swallowing and speech disturbances. They assess the risk for aspiration and
recommend a treatment plan to reduce the risk. Speech-language pathologists
(SLPs) work to prevent, assess, diagnose, and treat speech, language, social
communication, cognitive-communication, and swallowing disorders in children
and adults.
 Option A: Respiratory therapists provide care for patients with respiratory
disorders. Respiratory therapists interview and examine patients with
breathing or cardiopulmonary disorders. Respiratory therapists care for
patients who have trouble breathing—for example, from a chronic
respiratory disease, such as asthma or emphysema.
 Option B: Occupational therapists help patients regain function and
independence. Occupational therapists treat injured, ill, or disabled
patients through the therapeutic use of everyday activities. They help these
patients develop, recover, improve, as well as maintain the skills needed for
daily living and working.
 Option C: Dentists diagnose and treat dental disorders. Dentists remove
tooth decay, fill cavities, and repair fractured teeth. Dentists diagnose and
treat problems with patients‘ teeth, gums, and related parts of the mouth.
They provide advice and instruction on taking care of the teeth and gums
and on diet choices that affect oral health.
ADVERTISEMENTS

20. Question
Which of the following is/are an example(s) of theoretical knowledge? Select all
that apply.
o A. Antibiotics are ineffective in treating viral infections.
o B. When you take a patient's blood pressure, the patient's arm should be at
heart level.
o C. In Maslow's framework, physical needs are most basic.
o D. When drawing medication out of a vial, inject air into the vial first.
o E. Let the patient dangle his feet first before assisting him to stand or
transfer.
Incorrect
Correct Answer: A, C
Theoretical knowledge consists of research findings, facts (e.g., ―Antibiotics are
ineffective . . .‖ is a fact), principles, and theories (e.g., ―In Maslow‘s framework . . .‖
is a statement from a theory). Instructions for taking blood pressure and
withdrawing medications are examples of practical knowledge—what to do and
how to do it. While practical knowledge is gained by doing things, theoretical
knowledge is gained, for example, by reading a manual.
 Option A: Theoretical knowledge teaches the reasoning, techniques and
theory of knowledge.
 Option B: Practical knowledge is the knowledge that is acquired by day-
to-day hands-on experiences. In other words, practical knowledge is
gained through doing things; it is very much based on real-life endeavors
and tasks.
 Option C: While theoretical knowledge may guarantee that you
understand the fundamental concepts and have know-how about how
something works and its mechanism, it will only get you so far, as, without
practice, one is not able to perform the activity as well as he could.
 Option D: Practical knowledge guarantees that you are able to actually do
something instead of simply knowing how to do it.

 Option E: Theoretical and practical knowledge are interconnected and
complement each other — if one knows exactly HOW to do something,
one must be able to apply these skills and therefore succeed in practical
knowledge.
ADVERTISEMENTS
21. Question
The nurse recognizes that urinary elimination changes may occur even in healthy
older adults because of which of the following?
o A. The bladder distends and its capacity increases.
o B. Older adults ignore the need to void.
o C. Urine becomes more concentrated.
o D. The amount of urine retained after voiding increases.

Incorrect
Correct Answer: D. The amount of urine retained after voiding increases
The capacity of the bladder may decrease with age but the muscle is weaker and
can cause urine to be retained. Muscle changes and changes in the reproductive
system can affect bladder control. As the volume of urine held by the bladder
increases, so too does the pressure therein. Wall pressure of 5 to 15 mm Hg
creates a sensation of bladder fullness while 30 mm Hg and beyond is painful.
The sensation of increasing bladder fullness is conveyed to the spinal cord via the
pudendal and hypogastric nerves on both A-delta and C nerve fibers.
 Option A: The bladder wall changes. The elastic tissue becomes tough and
the bladder becomes less stretchy. The bladder cannot hold as much urine
as before. The urethra can become blocked. In women, this can be due to
weakened muscles that cause the bladder or vagina to fall out of position
(prolapse). In men, the urethra can become blocked by an enlarged
prostate gland.
 Option B: Older adults don‘t ignore the urge to void and may have
difficulty getting to the toilet in time. Bladder capacity changes throughout
one‘s life. In children, an approximation of bladder volume can be
calculated with the formula: (years of age + 2) x 30 mL. By adulthood, the

average volume that a functional bladder can comfortably hold is between
300 and 400 mL.
 Option C: The kidney becomes less able to concentrate urine with age.
Urination or micturition primarily functions in the excretion of metabolic
products and toxic wastes. The urinary tract also serves as a storage vessel
of the waste filtered from the kidneys. Urine stored in the bladder is
released from the bladder through the urethra upon a complex network of
neurological function.
ADVERTISEMENTS
22. Question
During the assessment of the client with urinary incontinence, the nurse is most
likely to assess for which of the following? Select all that apply.
o A. Perineal skin irritation
o B. Fluid intake of less than 1,500 mL/d
o C. History of antihistamine intake
o D. Hx of UTI
o E. A fecal impaction
Incorrect
Correct Answer: A, B, D, and E
Urinary incontinence is the involuntary leakage of urine. This medical condition is
common in the elderly, especially in nursing homes, but it can affect younger
adult males and females as well. Urinary incontinence can impact both patient
health and quality of life. The prevalence may be underestimated as some
patients do not inform health care providers of having issues with urinary
incontinence for various reasons.
 Option A: The perineum may become irritated by the frequent contact
with urine. Approximately 13 million Americans experience urinary
incontinence. The prevalence is 50% or greater among residents of nursing
facilities. Caregivers report that 53% of the homebound elderly are
incontinent. A random sampling of hospitalized elderly patients reports

that 11% of patients have persistent urinary incontinence at admission, and
23% at discharge.
 Option B: Normal fluid intake is at least 1,500 mL/d and clients often
decrease their intake to try to minimize urine leakage. Functional urinary
incontinence is the involuntary leakage of urine due to environmental or
physical barriers to toileting. This type of incontinence is sometimes
referred to as toileting difficulty.
 Option C: Antihistamines can cause urinary retention rather than urinary
incontinence. The urethra is the tube that takes urine from the bladder out
of the body. The problem can also be caused by using drugs such as
antihistamines (like Benadryl®), antispasmodics (like Detrol®), and tricyclic
antidepressants (like Elavil®) that can change the way the bladder muscle
works.
 Option D: UTIs can contribute to incontinence. Patients should be asked
about medical conditions such as chronic obstructive pulmonary disease
and asthma (which can cause cough), heart failure (with related fluid
overload and diuresis), neurologic conditions (which may suggest
dysregulated bladder innervation), musculoskeletal conditions (which may
contribute to toileting barriers), etc.
 Option E: A fecal impaction can compress the urethra, which results in sm.
amts of urine leakage. Overflow urinary incontinence is the involuntary
leakage of urine from an overdistended bladder due to impaired detrusor
contractility and/or bladder outlet obstruction. Neurologic diseases such as
spinal cord injuries, multiple sclerosis, and diabetes can impair detrusor
function. Bladder outlet obstruction can be caused by external
compression by abdominal or pelvic masses and pelvic organ prolapse,
among other causes. A common cause in men is benign prostatic
hyperplasia.
ADVERTISEMENTS
23. Question
Which action represents the appropriate nursing management of a client wearing
a condom catheter?
o A. Ensure that the tip of the penis fits snugly against the end of the condom.

o B. Check the penis for adequate circulation 30 min after applying.
o C. Change the condom every 8 hours.
o D. Tape the collecting tube to the lower abdomen.

Incorrect
Correct Answer: B. Check the penis for adequate circulation 30 min after
applying
The penis and condom should be checked 1/2 hour after application to ensure
that it‘s not too tight. and the tubing is taped to the leg or attached to a leg bag.
Condom catheters are external urinary catheters that are worn like a condom.
They collect urine as it drains out of your bladder and send it to a collection bag
strapped to your leg. They‘re typically used by men who have urinary
incontinence (can‘t control their bladder).
 Option A: A 1 in. space should be left between the penis and the end of
the condom. Place the condom over the tip of the penis and slowly unroll it
until it gets to the base. Leave enough room at the tip (1 to 2 inches) so it
won‘t rub against the condom.
 Option C: The condom is changed every 24h. Condom catheters should be
replaced every 24 hours. Throw away the old one unless it‘s designed to be
reusable. The collection bag should be emptied when it‘s about half full or
at least every three to four hours for a small bag and every eight hours for
a large one.
 Option D: An indwelling catheter is taped to the lower abdomen or upper
thigh. Use a nonadhesive condom catheter to help prevent irritation from
adhesive. An inflatable ring holds it in place. Keep the bag lower than the
bladder to avoid backflow of urine from the bag. Securely attach the tube
to the leg (below the knee, such as the calf), but leave a little slack so it
doesn‘t pull on the catheter.
ADVERTISEMENTS
24. Question
The catheter slips into the vagina during a straight catheterization of a female
client. The nurse does which action?

o A. Leaves the catheter in place and gets a new sterile catheter.
o B. Leaves the catheter in place and asks another nurse to attempt the
procedure.
o C. Removes the catheter and redirects it to the urinary meatus.
o D. Removes the catheter, wipes it with a sterile gauze, and redirects it to the
urinary meatus.
Incorrect
Correct Answer: A. Leaves the catheter in place and gets a new sterile
catheter.
The catheter in the vagina is contaminated and can‘t be reused. If left in place, it
may help avoid mistaking the vaginal opening for the urinary meatus. A single
failure to catheterize the meatus doesn‘t indicate that another nurse is needed
although sometimes a second nurse can assist in visualization of the meatus.
Urinary bladder catheterization is performed for both therapeutic and diagnostic
purposes. Based on the dwell time, the urinary catheter can be either intermittent
(short-term) or indwelling (long-term).
 Option B: After exposing the urethral meatus, a lubricated catheter tip is
advanced in the meatus until there is a spontaneous return of urine. The
catheter balloon is then inflated as per the manufacturer‘s
recommendations.
 Option C: In the event a catheter is inserted in the vagina, it should be left
there until a new sterile catheter is successfully inserted into the meatus.
Analgesia is of no proven clinical use in women. Lubrication jelly should be
applied to the tip of the catheter. The application of lubricant to the
urethral meatus is associated with difficulty in catheter insertion.
 Option D: Urinary tract infection (UTI) is the most common complication
that occurs as a result of long-term catheterization. The normal urinary
flow prevents the ascension of microbes from the periurethral skin
avoiding the infection. Alteration of the defensive mechanism from the
catheter results in an increased risk of UTIs. Escherichia coli and Klebsiella
pneumonia are the most common organisms implicated in UTIs. Recurrent
UTIs are associated with increased antibiotic resistance.
ADVERTISEMENTS

25. Question
Which statement indicates a need for further teaching of a home care client with
a long term indwelling catheter?
o A. "I will keep the collecting bag below the level of the bladder at all times."
o B. "Intake of cranberry juice may help decrease the risk of infection."
o C. "Soaking in a warm tub bath may ease the irritation associated with
the catheter."
o D. "I should use clean tech. when emptying the collecting bag."
Incorrect
Correct Answer: C. “Soaking in a warm tub bath may ease the irritation
associated with the catheter”
Soaking in a bathtub can increase the risk of exposure to bacteria. Avoid taking
baths, but shower daily. For the first few days after getting a suprapubic catheter,
use a waterproof bandage when showering. Once the wound heals, the client can
shower as usual, but avoid scented soaps.
 Option A: The bag should be below the level of the bladder to promote
proper drainage. Always keep the bag below the waist. Check the tube
once in a while for bends or kinks that keep pee from flowing out. Don‘t
use any lotions or powders around where the catheter goes into the body.
 Option B: Intake of cranberry juice creates an environment nonconducive
to infection. ―Indwelling‖ means inside the body. This catheter drains urine
from the bladder into a bag outside the body. Common reasons to have an
indwelling catheter are urinary incontinence (leakage), urinary retention
(not being able to urinate), a surgery that made this catheter necessary, or
another health problem.
 Option D: Clean technique is appropriate for touching the exterior
portions of the system. Wash hands with soap and water. Empty urine from
the bag into the toilet. Pinch the catheter closed between the fingers.
Remove the bag. Wipe the end of the catheter with a fresh alcohol pad.
Wipe the tip of the new bag with the second alcohol pad. Connect the new
bag and stop pinching the catheter now. Make sure there are no bends or
kinks in the catheter tube. Wash hands again.
ADVERTISEMENTS

26. Question
During shift report, the nurse learns that an older female client is unable to
maintain continence after she senses the urge to void and becomes incontinent
on the way to the bathroom. Which nursing diagnosis is most appropriate?
o A. Stress urinary incontinence
o B. Reflex urinary incontinence
o C. Functional urinary incontinence
o D. Urge urinary incontinence

Incorrect
Correct Answer: D. Urge urinary incontinence
The key phrase is ―the urge to void‖ option one occurs when the client coughs,
sneezes, or jars the body, resulting in accidental loss of urine. If one feels a strong
urge to urinate even when the bladder isn‘t full, the incontinence might be
related to overactive bladder, sometimes called urge incontinence. This condition
occurs in both men and women and involves an overwhelming urge to urinate
immediately, frequently followed by loss of urine before the client can reach a
bathroom. Even if one never has an accident, urgency and urinary frequency can
interfere with work and a social life because of the need to keep running to the
bathroom.
 Option A: Stress Urinary Incontinence (SUI) is when urine leaks out with
sudden pressure on the bladder and urethra, causing the sphincter muscles
to open briefly. With mild SUI, pressure may be from sudden forceful
activities, like exercise, sneezing, laughing, or coughing.
 Option B: Reflex urinary incontinence occurs with involuntary loss of urine
at somewhat predictable intervals when a specific bladder volume is
reached. Reflex incontinence occurs when the bladder muscle contracts
and urine leaks (often in large amounts) without any warning or urge. This
can happen as a result of damage to the nerves that normally warn the
brain that the bladder is filling.
 Option C: Functional urinary continence is the involuntary loss of urine
related to impaired function. If the urinary tract is functioning properly but
other illnesses or disabilities are preventing one from staying dry, the client

might have what is known as functional incontinence. For example, if an
illness rendered the client unaware or unconcerned about the need to find
a toilet, the client would become incontinent. Medications, dementia, or
mental illness can decrease awareness of the need to find a toilet.
ADVERTISEMENTS
27. Question
A female client has a urinary tract infection. Which teaching points by the nurse
should be helpful to the client? Select all that apply.
o A. Limit fluids to avoid the burning sensation on urination.
o B. Review symptoms of UTI with the client.
o C. Wipe the perineal area from back to front.
o D. Wear cotton underclothes.
o E. Take baths rather than showers.

Incorrect
Correct Answer: B, D
Uncomplicated urinary tract infection (UTI) is a bacterial infection of the bladder
and associated structures. These are patients with no structural abnormality and
no comorbidities, such as diabetes, immunocompromised, or pregnant.
Uncomplicated UTI is also known as cystitis or lower UTI. Forty percent of women
in the United States will develop a UTI during their lifetime, making it one of the
most common infections in women. UTI is uncommon in circumcised males, and
by definition, any male UTI is considered complicated.
 Option A: Increased fluids decrease concentration and irritation. An
uncomplicated UTI usually only involves the bladder. When the bacteria
invade the bladder mucosal wall, cystitis is produced. The majority of
organisms causing a UTI are enteric coliforms that usually inhabit the
periurethral vaginal introitus. These organisms ascend into the bladder and
cause a UTI.
 Option B: Reviewing the symptoms of UTI with the client validates the
diagnosis. Symptoms of uncomplicated UTI are pain on urination (dysuria),
frequent urination (frequency), inability to start the urine stream

(hesitation), sudden onset of the need to urinate (urgency), and blood in
the urine (hematuria). Usually, patients with uncomplicated UTI do not have
fever, chills, nausea, vomiting, or back pain, which are signs of kidney
involvement or upper tract disease/pyelonephritis.
 Option C: The client should wipe the perineal area from front to back to
prevent the spread of bacteria from the rectal area to the urethra. Sexual
intercourse is a common cause of a UTI as it promotes the migration of
bacteria into the bladder. People who frequently void and empty the
bladder have a much lower risk of a UTI.
 Option D: Cotton underwear promotes appropriate exposure to air,
resulting in decreased bacterial growth. Urine is an ideal medium for
bacterial growth; factors that make it unfavorable for bacterial growth
include a pH of less than 5, presence of organic acids, and high levels of
urea. Frequent urination is also known to decrease the risk of UTI.
 Option E: Showers reduce exposure of the area to bacteria. Bacteria that
cause UTI have adhesins on their surface which allow the organism to
attach to the mucosal surface. In addition, a short urethra also makes it
easier for the uropathogen to invade the urinary tract.
ADVERTISEMENTS
28. Question
The nurse will need to assess the client‘s performance of clean intermittent self
catheterization (CISC) for a client with which urinary diversion?
o A. Ileal conduit
o B. Kock pouch
o C. Neobladder
o D. Vesicostomy
Incorrect
Correct Answer: B. Kock pouch
The ileal conduit and vesicostomy are incontinent urinary diversions, and clients
are required to use an external ostomy appliance to contain the urine. In this new
operation, a pouch or reservoir is fashioned out of the terminal ileum with a valve

mechanism at its exit to the skin surface. This allows storage of the liquid bowel
contents in an expandable container with no leakage of stool or gas and
therefore no skin problems. There is no need for appliances or bags, no
embarrassment from the involuntary noise and smell of flatus through the
ileostomy. The stoma is created flush and within the bikini line. The patient
catheterizes the pouch on an average of three times a day.
 Option A: An ileal conduit aims to divert urine produced from the upper
urinary tracts to a newly formed reservoir created from the terminal ileum.
The ureters are disconnected from the bladder and implanted into the
conduit.
 Option C: Clients with a neobladder can control their voiding. During
neobladder surgery, the surgeon takes out the existing bladder and forms
an internal pouch from part of the intestine. The pouch, called a
neobladder, stores the urine.
 Option D: A vesicostomy is a stoma (opening) created between the
bladder and the abdomen. This allows urine to drain freely, with low
pressure, to help protect and prevent harm to the kidneys. It is a surgical
procedure that typically involves an overnight stay in the hospital.
ADVERTISEMENTS
29. Question
Which focus is the nurse most likely to teach for a client with a flaccid bladder?
o A. Habit training: attempt voiding at specific time periods.
o B. Bladder training: delay voiding according to a pre-schedule timetable.
o C. Crede's maneuver: apply gentle manual pressure to the lower

abdomen.
o D. Kegel exercises: contract the pelvic muscles.

Incorrect
Correct Answer: C. Crede’s maneuver: apply gentle manual pressure to the
lower abdomen.
Because the bladder muscles will not contract to increase the intra-bladder
pressure to promote urination, the process is initiated manually. The Credé

maneuver is a technique used to void urine from the bladder of an individual
who, due to disease, cannot do so without aid. The Credé maneuver is executed
by exerting manual pressure on the abdomen at the location of the bladder, just
below the navel. Options one, two, and four: to promote continence bladder
contractions are required for habit training, bladder training, and increasing the
tone of the pelvic muscles.
 Option A: One type of toilet training is habit training. Habit training is the
process of teaching a child to eliminate on the toilet at routine times. Habit
training involves teaching children to eliminate on the toilet by developing
a toileting routine/habit.
 Option B: Bladder training is an important form of behavior therapy that
can be effective in treating urinary incontinence. The goals are to increase
the amount of time between emptying your bladder and the amount of
fluids your bladder can hold. It also can diminish leakage and the sense of
urgency associated with the problem.
 Option D: Kegel exercises can help make the muscles under the uterus,
bladder, and bowel (large intestine) stronger. They can help both men and
women who have problems with urine leakage or bowel control.
ADVERTISEMENTS
30. Question
Which of the following behaviors indicates that the client on a bladder training
program has met the expected outcomes? Select all that apply.
o A. Voids each time there is an urge.
o B. Practices slow, deep breathing until the urge decreases.
o C. Uses adult diapers, for "just in case".
o D. Drinks citrus juices and carbonated beverages.
o E. Performs pelvic muscle exercises.

Incorrect
Correct Answer: B, E
It is important for the client to inhibit the urge to void sensation when a
premature urge is experienced. Bladder training, a program of urinating on

schedule, enables the client to gradually increase the amount of urine the client
can comfortably hold. Bladder training is a mainstay of treatment for urinary
frequency and overactive bladder in both women and men, alone or in
conjunction with medications or other techniques.
 Option A: Choose an interval. Based on the typical interval between
urinations, select a starting interval for training that is 15 minutes longer. If
the typical interval is one hour, make a starting interval one hour and 15
minutes.
 Option B: When the client starts training, he should empty his bladder first
thing in the morning and not again until the interval he set. If the time
arrives before he can feel the urge, he should go anyway. If the urge hits
first, he should remind himself that his bladder isn‘t really full, and use
whatever techniques he can to delay going.
 Option C: Some clients may need diapers; this is not the best indicator of a
successful program.
 Option D: Citrus juices may irritate the bladder. Carbonated beverages
increase diuresis and the risk of incontinence.
 Option E: Try the pelvic floor exercises sometimes called Kegels, or simply
try to wait another five minutes before walking slowly to the bathroom.
Once comfortable with a set interval, increase it by 15 minutes. Over
several weeks or months, the client may find that they are able to wait
much longer and that they have experienced far fewer feelings of urgency
or episodes of urge incontinence.
ADVERTISEMENTS
31. Question
A nurse has identified that the patient has overflow incontinence. What is a major
factor that contributes to this clinical manifestation?
o A. Coughing
o B. Mobility deficits
o C. Prostate enlargement
o D. Urinary tract infection

Incorrect
Correct Answer: C. Prostate enlargement
An enlarged prostate compresses the urethra and interferes with the outflow of
urine, resulting in urinary retention. With urinary retention, the pressure within
the bladder builds until the external urethral sphincter temporarily opens to allow
a small volume (25-60mL) of urine to escape (overflow incontinence). Men who
are unable to completely empty their bladder and experience unexpected urine
leakage may have what is called overflow incontinence.
 Option A: Coughing, which raises the intra abdominal pressure, is related
to stress incontinence, not overflow incontinence. An enlarged prostate can
interfere with the passage of urine through the urethra, the tube connected
to the bladder.
 Option B: Mobility deficits, such as spinal cord injuries, are related to reflex
incontinence, not overflow incontinence. Damage to nerves near the
bladder causing under-activity. This can occur with neurological injury or
with diseases such as diabetes.
 Option D: Urinary tract infections are related to urge incontinence, not
overflow incontinence. Men with this type of urinary incontinence often do
not feel that their bladders are full, which then leads to leakage as the
bladder has reached its full capacity. In addition to leakage, urine left in the
bladder can lead to urinary tract infections due to the growth of bacteria as
well as bladder stones.
ADVERTISEMENTS
32. Question
A nurse must measure the intake and output (I&O) for a patient who has a
urinary retention catheter. Which equipment is most appropriate to use to
accurately measure urine output from a urinary retention catheter?
o A. Urinal
o B. Graduate
o C. Large syringe
o D. Urine collection bag

Incorrect
Correct Answer: B. Graduate
A graduate is a collection container with volume markings usually at 25 mL
increments that promote accurate measurements of urine volume. To measure
urine output in critical care units, a Foley catheter is introduced through the
patient‘s urethra until it reaches his/her bladder. The other end of the catheter is
connected to a graduated container that collects the urine.
 Option A: Although urinals have volume markings on the side, usually they
occur in 100 mL increments that do not promote accurate measurements.
Urine output is the best indicator of the state of the patient‘s kidneys. If the
kidneys are producing an adequate amount of urine it means that they are
well perfused and oxygenated. Otherwise, it is a sign that the patient is
suffering from some complications.
 Option C: Large syringe is impractical. A large syringe is used to obtain a
sterile specimen from a retention catheter (Foley catheter). Urine output is
required for calculating the patient‘s water balance, which is essential in the
treatment of burn patients. Finally, it is also used in multiple therapy
protocols to check whether the patient reacts properly to treatment
 Option D: A urine collection bag is flexible and balloons outward as urine
collects. In addition, the volume markings are at 100 mL increments that do
not promote accurate measurements. In critical care units of first world
countries, measurements of every patient‘s urine output are taken hourly,
24 times a day, 365 days a year. In the case of emerging countries, often
only burn patients—for whom urine output monitoring is of paramount
importance—have this parameter recorded every hour, while the remaining
critical patients have it recorded every 2 or 3 hours.
ADVERTISEMENTS
33. Question
A patient‘s urine is cloudy, is amber, and has an unpleasant odor. What problem
may this information indicate that requires the nurse to make a focused
assessment?
o A. Urinary retention
o B. Urinary tract infection

o C. Ketone bodies in the urine
o D. High urinary calcium level

Incorrect
Correct Answer: B. Urinary tract infection
The urine appears concentrated (amber)and cloudy because of the presence of
bacteria, white blood cells, and red blood cells. The unpleasant odor is caused by
pus in the urine (pyuria). Uncomplicated urinary tract infection (UTI) is a bacterial
infection of the bladder and associated structures. These are patients with no
structural abnormality and no comorbidities, such as diabetes,
immunocompromised, or pregnancy. Uncomplicated UTI is also known as cystitis
or lower UTI.
 Option A: These clinical manifestations do not reflect urinary retention.
Urinary retention is evidenced by supra pubic distention and lack of
voiding or small, frequent voiding (overflow incontinence). The
mechanisms of acute urinary retention can include outflow obstruction,
which can be mechanical such as from physical narrowing of the urethral
channel. The other dynamic is from an increase in the muscle tone within
and around the urethra as in benign prostatic hypertrophy and hyperplasia.
 Option C: These clinical manifestations do not reflect ketone bodies in the
urine. A reagent strip dipped in urine will measure the presence of Ketone
bodies. If the cells don‘t get enough glucose, the body burns fat for energy
instead. This produces a substance called ketones, which can show up in
the blood and urine.
 Option D: These clinical manifestations do not reflect excessive calcium in
the urine. Urine calcium levels are measured by assessing a 24-hour urine
specimen. If urine calcium levels are too high or too low, it may mean that
the client has a medical condition, such as kidney disease or kidney stones.
Kidney stones are hard, pebble-like substances that can form in one or
both kidneys when calcium or other minerals build up in the urine. Most
kidney stones are formed from calcium.
ADVERTISEMENTS
34. Question

A nurse is caring for a debilitated female patient with nocturia. Which nursing
intervention is the priority when planning to meet this patient‘s needs?
o A. Encouraging the use of bladder training exercises.
o B. Providing assistance with toileting every four hours.
o C. Positioning a bedside commode near the bed.
o D. Teaching the avoidance of fluid after 5 PM.

Incorrect
Correct Answer: C. Positioning a bedside commode near the bed.
The use of a commode requires less energy than using a bedpan and is safer than
walking to the bathroom. Sitting on the commode uses gravity to empty the
bladder fully and thus prevent urinary stasis. Nocturia is defined as the need for a
patient to get up at night on a regular basis to urinate. A period of sleep must
precede and follow the urinary episode to count as a nocturnal void. This means
the first-morning void is not considered when determining nocturia episodes.
Use of a bedside commode or urinal can minimize the bother, if not the
frequency, of nocturia and may reduce the risk of falls. Remove any obstacles,
loose rugs, or furniture between the bed and the nearest commode to reduce fall
risk further. Consider using nightlights to help illuminate the passage to the
bathroom.
 Option A: Although bladder training exercises should be done, it is not the
priority. Behavioral therapy, which includes pelvic floor muscle training,
urge-suppression techniques, delayed voiding, fluid management, sleep
hygiene, Kegel exercises, and peripheral edema management, has been
shown to be reasonably efficacious both when used alone or together with
pharmacological therapy in controlling nocturia.
 Option B: Assisting with toileting may be too often or not often enough
for the patient. Care should be individualized for the patient. In particular,
older adults with nocturia who make multiple nocturnal trips to the
bathroom are at a substantially increased risk of potentially serious falls. A
quarter of all the falls that occur in older individuals happen overnight. Of
these, 25% are directly related to nocturia. Patients who make at least 2 or
more nocturnal bathroom visits a night, have more than double the risk of
fractures and fall-related traumas.

 Option D: Fluids may be decreased during the last two hours before
bedtime, but they should not be avoided completely after 5 PM (opt4).
Some fluid intake is necessary for adequate renal perfusion. Drinking large
amounts of fluids shortly before going to bed and ingesting caffeine or
alcohol late in the day and before bed is likely to contribute to nocturia as
well. Be aware that some elderly patients may already be somewhat
dehydrated and might require extra fluid intake earlier in the day before
they can safely do any evening fluid restriction before bedtime.
ADVERTISEMENTS
35. Question
A practitioner uses a urine specimen for culture and sensitivity via a straight
catheter for a patient. What should the nurse do when collecting this urine
specimen?
o A. Use a sterile specimen container.
o B. Collect urine from the catheter port.
o C. Inflate the balloon with 10 mL of sterile water.
o D. Have the patient void before collecting the specimen.

Incorrect
Correct Answer: A. Use a sterile specimen container.
A culture attempts to identify the microorganisms present in the urine, and a
sensitivity study identifies the antibiotics that are effective against the isolated
microorganisms. A sterile specimen container is used to prevent contamination of
the specimen by microorganisms outside the body (exogenous).
 Option B: The urine from the straight catheter flows directly into the
specimen container. Collecting a urine specimen from a catheter port is
necessary when the patient has a urinary retention catheter. A straight
catheter has a single lumen for draining urine from the bladder.
 Option C: A straight catheter does not remain in the bladder and therefore
does not have a 2nd lumen for water to be inserted into a balloon. This
may result in no urine left in the bladder for the straight catheter to collect.

 Option D: A minimum of 3 mL of urine is necessary for a specimen for
urine culture and sensitivity. Do not urinate for at least 1 hour before the
test. If the client doesn‘t have the urge to urinate, he may be instructed to
drink a glass of water 15 to 20 minutes before the test. Otherwise, there is
no preparation for the test.
ADVERTISEMENTS
36. Question
A nurse in a provider‘s office is assessing a client who reports losing control of
urine whenever she coughs, laughs, or sneezes. The client relates a history of
three vaginal births, but no serious accidents or illnesses. Which of the following
interventions are appropriate for helping to control or eliminate the clients
o A. Limit total daily fluid intake
o B. Decrease or avoid caffeine
o C. Increase the intake of calcium supplements
o D. Avoid the intake of alcohol
o E. Use Crede maneuver

Incorrect
Correct Answer: B and D
Caffeine and alcohol are bladder irritants and can worsen stress incontinence.
Alcohol is a bladder irritant and can worsen stress incontinence. Quitting
smoking, losing excess weight, or treating a chronic cough will lessen the risk of
stress incontinence and improve the symptoms. Stress incontinence is different
from urgency incontinence and overactive bladder (OAB). If the client has
urgency incontinence or OAB, the bladder muscle contracts, causing a sudden
urge to urinate before he can get to the bathroom. Stress incontinence is much
more common in women than in men.
 Option A: Because stress incontinence results from weak pelvic muscles
and other structures, limiting fluid will not resolve the problem. The doctor
may recommend how much and when one should consume fluids during

the day and evening. However, don‘t limit what the client drinks so much
that he becomes dehydrated.
 Option B: Lifestyle changes should be made such as reducing caffeine
intake (including green tea), stopping smoking, and losing weight.
 Option C: Calcium has no effect on stress incontinence. Bladder training
involves learning techniques to increase the length of time between feeling
the need to urinate and passing urine. The course usually lasts for at least
six weeks and can be combined with the Kegel exercises. Some individuals
may find that timed toileting is helpful, particularly for people with a
learning disability or cognitive impairment.
 Option D: The doctor may also suggest that the client avoid caffeinated,
carbonated, and alcoholic beverages, which may irritate and affect bladder
function in some people. If he finds that using fluid schedules and avoiding
certain beverages significantly improves leakage, the client will have to
decide whether making these changes in the diet are worth it.
 Option E: The Crede maneuver helps manage reflex incontinence, not
stress incontinence. Pelvic floor muscle training is a technique that
strengthens the pelvic floor muscles and is an effective treatment for stress
incontinence, especially if the muscle has been damaged.
ADVERTISEMENTS
37. Question
A client who has an indwelling catheter reports the need to urinate. Which of the
following interventions should the nurse perform?
o A. Check to see whether the catheter is patent.
o B. Reassure the client that it is not possible for her to urinate.
o C. Re-catheterize the bladder with a larger gauge catheter.
o D. Collect a urine specimen for analysis.

Incorrect
Correct Answer: A. Check to see whether the catheter is patent.
A clogged or kinked catheter causes the bladder to fill and stimulates the need to
urinate. An indwelling urinary catheter (IUC), generally referred to as a ―Foley‖

catheter, is a closed sterile system with a catheter and retention balloon that is
inserted either through the urethra or suprapubically to allow for bladder
drainage. External collecting devices (e.g. drainage tubing and bag) are
connected to the catheter for urine collection.
 Option B: Reassuring the client that it is not possible to urinate is a non-
therapeutic response because it diminishes the client‘s concern. Check the
tube once in a while for bends or kinks that keep pee from flowing out.
Empty the leg bag twice a day or when it‘s half full. Keep the drainage bag
below your bladder so it drains well.
 Option C: There are less invasive approaches the nurse can take before
replacing the catheter. Indwelling urinary catheters are recommended only
for short-term use, defined as less than 30 days (EAUN recommends no
longer than 14 days.) The catheter is inserted for continuous drainage of
the bladder for two common bladder dysfunction: urinary incontinence (UI)
and urinary retention.
 Option D: Although it may become necessary to collect a urine specimen,
there is a simpler approach the nurse can take to assess and possibly
resolve the client‘s problem.
ADVERTISEMENTS
38. Question
A provider prescribes a 24-hour urine collection for a client. Which of the
following actions should the nurse take?
o A. Discard the first voiding.
o B. Keep all voidings in a container at room temperature.
o C. Ask the client to urinate and pour the urine into a specimen container.
o D. Ask the client to urinate into the toilet, stop midstream, and finish
urinating into the specimen container.
Incorrect
Correct Answer: A. Discard the first voiding.
The nurse should discard the first voiding of the 24 hour urine specimen, and
note the time. 24-hour urine protein measures the amount of protein released in

urine over a 24-hour period. The normal value is less than 100 milligrams per day
or less than 10 milligrams per deciliter of urine.
 Option B: The nurse should collect all voidings after that and keep them in
a refrigerated container. A 24-hour urine collection is done by collecting
the urine in a special container over a full 24-hour period. The container
must be kept cool until the urine is returned to the lab.
 Option C: For a urinalysis, the nurse should ask the client to urinate and
pour the urine into a specimen container. Urine is made up of water and
dissolved chemicals, such as sodium and potassium. It also contains urea.
This is made when protein breaks down. And it contains creatinine, which is
formed from muscle breakdown. Normally, urine contains certain amounts
of these waste products. It may be a sign of a certain disease or condition if
these amounts are not within a normal range. Or if other substances are
present.
 Option D: For a culture, the nurse should ask the client to urinate first into
the toilet, then stop midstream, and finish urinating in the specimen
container. A 24-hour urine collection helps diagnose kidney problems. It is
often done to see how much creatinine clears through the kidneys. It‘s also
done to measure protein, hormones, minerals, and other chemical
compounds.
ADVERTISEMENTS
39. Question
A nurse is preparing to initiate a bladder training program for a client who has a
voiding disorder. Which of the following actions should the nurse take? Select all
that apply.
o A. Establish a schedule of voiding prior to meal times.
o B. Have the client record voiding times.
o C. Gradually increase the voiding intervals.
o D. Reminded client to hold urine until next scheduled voiding time.
o E. Provide a sterile container for voiding.

Incorrect

Ask the client to keep track of voiding times is an appropriate nursing action.
Gradually increasing the voiding interval is an appropriate nursing action. The
client should be reminded to hold urine until the next scheduled voiding time.
Bladder training involves voiding at scheduled in frequent intervals and gradually
increasing these intervals to four hours.
 Option A: Mealtimes are not regular, and the intervals may be longer than
every four hours. Bladder training requires following a fixed voiding
schedule, whether or not one feels the urge to urinate. If one feels an urge
to urinate before the assigned interval, he should use urge suppression
techniques — such as relaxation and Kegel exercises.
 Option B: Keeping a diary of bladder activity is very important. This helps
the health care provider determine the correct place to start the training
and to monitor progress throughout the program.
 Option C: Bladder training is an important form of behavior therapy that
the amount of time between emptying the bladder and the amount of
fluids the bladder can hold. It also can diminish leakage and the sense of
 Option D: When the client feels the urge to urinate before the next
designated time, he should use ―urge suppression‖ techniques or try
relaxation techniques like deep breathing. Focus on relaxing all other
muscles. If possible, he must sit down until the sensation passes. If the urge
is suppressed, adhere to the schedule. If the client cannot suppress the
urge, wait five minutes then slowly make way to the bathroom. After
urinating, re-establish the schedule. Repeat this process every time an urge
is felt.
 Option E: A sterile container is not used in a bladder training program.
When the client has accomplished the initial goal, he should gradually
increase the time between emptying the bladder by 15-minute intervals.
He should try to increase the interval each week. However, he will be the
best judge of how quickly he can advance to the next step. Increase the
time between each urination until he reaches a three- to four-hour voiding
interval.
ADVERTISEMENTS

40. Question
A nurse educator on a medical unit is reviewing factors that increase the risk of
urinary tract infections with a group of assistive personnel. Which of the following
should be included in the review? Select all that apply.
o A. Having sexual intercourse on a frequent basis.
o B. Lowering of testosterone levels.
o C. Wiping from front to back.
o D. The location of the vagina in relation to the anus.
o E. Undergoing frequent catheterization.

Incorrect
Correct Answer: A, D, and E
no comorbidities, such as diabetes, immunocompromised, or pregnancy.
Uncomplicated UTI is also known as cystitis or lower UTI. E.coli causes the
majority of UTI but other organisms of importance include proteus, klebsiella,
and enterococcus. The diagnosis of UTI is made from the clinical history and
urinalysis, but the proper collection of the urine sample is important.
 Option A: Having sexual intercourse on a frequent basis is a factor that
increases the risk of UTI in both males and females. Sexual intercourse and
the use of spermicide and diaphragm are also risk factors for UTI. Sexual
 Option B: The decrease in estrogen levels during menopause increases a
woman‘s susceptibility to UTIs. An uncomplicated UTI usually only involves
the bladder. When the bacteria invade the bladder mucosal wall, cystitis is
produced. The majority of organisms causing a UTI are enteric coliforms
that usually inhabit the periurethral vaginal introitus. These organisms
ascend into the bladder and cause a UTI.
 Option C: Wiping from front to back decreases a woman‘s risk of UTIs.
After urination, women should wipe from front to back, not from the anal
area forward, which seems to drag pathogenic organisms nearer to the

urethra. Bacteria that cause UTI have adhesins on their surface which allow
the organism to attach to the mucosal surface. In addition, a short urethra
also makes it easier for the uropathogen to invade the urinary tract.
Premenopausal women have large concentrations of lactobacilli in the
vagina and prevent the colonization of uropathogens. However, the use of
antibiotics can erase this protective effect.
 Option D: The close proximity of the female urethra to the anus is a factor
that increases the risk of UTIs. Pathogenic bacteria ascend from the
perineum, causing UTI. Women have shorter urethras than men and
therefore are more susceptible to UTI. Very few uncomplicated UTIs are
caused by blood-borne bacteria. Escherichia coli is the most common
organism in uncomplicated UTI by a large margin.
 Option E: Undergoing frequent catheterization and the use of indwelling
catheters are risk factors for UTIs. A major risk factor for UTI is the use of a
catheter. In addition, manipulation of the urethra is also a risk factor. In-
and-out catheterization of the bladder will cause UTI in uninfected women
1% of the time. Men should start the urine stream to clean the urethra and
then obtain a midstream sample. Urine should be sent to the lab
immediately or refrigerated because bacteria grow rapidly when a sample
is left at room temperature, causing an overestimate of the infection‘s
severity.
ADVERTISEMENTS
41. Question
To prevent postoperative complications, Nurse Kim assists the client with
coughing and deep breathing exercises. This is best accomplished by
implementing which of the following?
o A. Coughing exercises one hour before meals and deep breathing one hour
after meals.
o B. Forceful coughing as many times as tolerated.
o C. Huff coughing every two hours or as needed.
o D. Diaphragmatic and pursed lip breathing 5 to 10 times, four times a day.

Incorrect
Correct Answer: C. Huff coughing every two hours or as needed.
Huff coughing helps keep the airways open and secretions mobilized. Huff
coughing is an alternative for clients who are unable to perform a normal forceful
cough (such as postoperatively) deep breathing and coughing should be
performed at the same time.
 Option A: Only at mealtimes is not sufficient. Deep breathing and
coughing exercises can decrease the risk of lung complications following
surgery. Not only can they prevent pneumonia, deep breathing helps to
get more oxygen to the body‘s cells. These exercises can also be beneficial
to individuals who are susceptible to pulmonary or respiratory problems.
Coughing and deep breathing work to clear mucus and allow moist air to
enter the airways.
 Option B: Extended forceful coughing fatigues the client, especially
postoperatively. If you are lying in bed and need to cough, it may be more
comfortable to bend your knees up. Lean forward when you cough, if you
are sitting in a chair. Place a pillow over your surgical incision and apply
pressure to the area while coughing. This can help to alleviate any
discomfort you feel. It‘s more comfortable to sit upright if you can when
doing coughing exercises.
 Option D: Diaphragmatic and pursed-lip breathing are techniques used for
clients with obstructive airway disease. You can perform breathing
exercises by relaxing your shoulders and upper chest. Take a deep breath
in through your nose. Hold the breath for three seconds. Breathe out
slowly through your mouth. Repeat three times. Taking too many breaths
can make you dizzy or light-headed. Perform breathing exercises every
hour.
ADVERTISEMENTS
42. Question
Nurse Trixie is preparing to perform tracheostomy care. Prior to the beginning of
the procedure, the nurse performs which action?
o A. Tells the client to raise two fingers to indicate pain or distress.
o B. Changes twill tape holding the tracheostomy and place.

o C. Cleans the incision site.
o D. Check the tightness of the ties and knot.

Incorrect
Correct Answer: A. Tells the client to raise two fingers to indicate pain or
distress.
Prior to starting the procedure, it is important to develop a means of
communication by which the client can express pain or discomfort. Tracheostomy
is a procedure where an artificial airway is established surgically or
percutaneously in the cervical trachea. The term ―tracheostomy‖ has evolved to
refer to both the procedure as well as the clinical condition of having a
tracheostomy tube. With the increasing number of patients with tracheostomy,
safe caring requires knowledge and competencies in dealing with routine care,
weaning, decannulation, as well as tracheostomy-related emergencies.
 Option B: The twill tape is not changed until after performing
tracheostomy care. Remove any sutures or ties attached to the
tracheostomy tube and patient. When doing this, the assistant must
stabilize the flange at all times to prevent premature removal.
 Option C: Cleaning the incision should be done after cleaning the inner
cannula. Inspect the stoma for signs of infection, presence of granulation
tissue, bleeding, wound breakdown, and adequacy of a tract. Clean the
area with moist gauze (with normal saline or hydrogen peroxide) followed
by dry gauze while ensuring no foreign body enters the airway. Stay
sutures, if present, may be used gently to pull up the trachea to provide
exposure.
 Option D: Checking the tightness of the ties and knot is done after
applying new twill tape. Make sure the trach ties are not too tight and
should be able to pass an index finger in between the trach ties and neck.
ADVERTISEMENTS
43. Question
Which action by the nurse represents proper nasopharyngeal/nasotracheal
suctioning technique?

o A. Lubricate the suction catheter with petroleum jelly before and between
insertion.
o B. Apply suction intermittently while inserting the suction catheter.
o C. Rotate the catheter while applying suction.
o D. Hyper oxygenate with 100% oxygen for 30 minutes before and after
suctioning.
Incorrect
Correct Answer: C. Rotate the catheter while applying suction.
Rotating the catheter prevents pulling of tissue into the opening on the catheter
tip and the side. Suction is used to clear retained or excessive lower respiratory
tract secretions in patients who are unable to do so effectively for themselves.
This could be due to the presence of an artificial airway, such as an endotracheal
or tracheostomy tube, or in patients who have a poor cough due to an array of
reasons such as excessive sedation or neurological involvement.
 Option A: Suction catheters may only be lubricated with water or water-
soluble lubricant and petroleum jelly such as Vaseline has an oil base.
Lubricate the outside of the airway with a water-soluble/aqueous gel (e.g.
KY Jelly). Initially, choose the larger nostril that is clear from other tubes
(e.g. nasogastric tube). Insert the tip of the NPA into the nostril, then
slightly lift the nares up and direct the airway to follow a path along the
floor of the nose, parallel to the hard palate.
 Option B: No suction should ever be applied while the catheters are being
inserted because this can traumatize tissues. Apply a gentle partial rotation
to the NPA if resistance is felt during insertion e.g. from opposition against
the turbinates. If this does not relieve the resistance/obstruction then
withdraw the airway and try the other nostril before selecting a smaller
size.
 Option D: The client should be hyper-oxygenated for only a few minutes
before and after suctioning and this is generally limited to clients who are
intubated or have a tracheostomy. Hyper-oxygenate the patient if able
(increase mask flow rate or FiO2) delivery of 100% oxygen for > 30 secs
prior to the suction event.
ADVERTISEMENTS

44. Question
Which client statement informs the nurse that his teaching about the proper use
of an incentive spirometer was effective?
o A. "I should breathe out as fast and as hard as possible into the device."
o B. "I should inhale slowly and steadily to keep the balls up."
o C. "I should use the device three times a day, after meals."
o D. "The entire device should be washed thoroughly in sudsy water once a

week."
Incorrect
Correct Answer: B. “I should inhale slowly and steadily to keep the balls up.”
Proper use of an SMI requires the client to take slow, steady inhalations, every
hour or two, 5 to 10 reps each time. Spirometry is one of the most readily
available and useful tests for pulmonary function. It measures the volume of air
exhaled at specific time points during complete exhalation by force, which is
preceded by a maximal inhalation. The most important variables reported include
total exhaled volume, known as the forced vital capacity (FVC), the volume
exhaled in the first second, known as the forced expiratory volume in one second
(FEV1), and their ratio (FEV1/FVC).
 Option A: The patient must breathe in as much air as they can with a
pause lasting for less than 1s at the total lung capacity. The mouthpiece is
placed just inside the mouth between the teeth, soon after the deep
inhalation. The lips should be sealed tightly around the mouthpiece to
prevent air leakage. Exhalation should last at least 6 seconds, or as long as
advised by the instructor. If only the forced expiratory volume is to be
measured, the patient must insert the mouthpiece after performing step 1
and must not breathe from the tube.
 Option C: The procedure is repeated in intervals separated by 1 minute
until two matching, and acceptable results are acquired. Spirometry has
proved to be a crucial tool in diagnosing lung disease, monitoring patients
for their pulmonary function, and assessing their fitness for various
procedures.
 Option D: Only the mouthpiece can be successfully rinsed or wiped clean.
The device should not be submerged in water. Spirometry is an apparatus

used to assess pulmonary function for diagnostic or monitoring purposes.
The procedure must be explained thoroughly to the subject patient by
competent personnel who underwent training under supervision by a
specialist mentor and will undergo periodic retraining in order to ensure
that the results obtained are as accurate as possible and the complications
are kept to a minimum.
ADVERTISEMENTS
45. Question
While a client with chest tubes is ambulating, the connection between the tube
and the water seal dislodges. Which action by Nurse Flora is most appropriate?
o A. Assist the client to ambulate back to bed.
o B. Reconnect the tube to the water seal.
o C. Assess the client's lung sounds with a stethoscope.
o D. Have the client cough forcibly several times.

Incorrect
Correct Answer: B. Reconnect the tube to the water seal.
The tube should be reconnected to the water seal as quickly as possible. Assisting
the client back to bed and assessing the client‘s lung are possible actions after
the system is reconnected. Or place the end of the tube in a bottle of sterile
water, creating a water seal. Instruct a colleague to prepare a new sterile chest-
drainage collection device, or retrieve a new sterile connector while safely
returning the patient to bed. Observe the patient for signs and symptoms of
respiratory decline. Then reconnect the chest tube to the new drain and unclamp
it.
 Option A: If walking with the patient and the chest tube becomes
dislodged where it connects to the drainage tubing, immediately close off
the tubing to air with a gloved hand by crimping it or using a clamp, if
readily available.
 Option C: Whether chest-tube removal was planned or unplanned,
monitor the patient closely for signs and symptoms of respiratory

compromise, using such techniques as pulse oximetry (Spo2), end-tidal
carbon dioxide (ETco2) monitoring, and breath sound auscultation.
 Option D: Monitor the patient‘s respiratory rate and effort. A repeat chest
X-ray (if indicated) may be done to compare to previous films and evaluate
for presence or return of a pneumothorax, an effusion, or other problem.
ADVERTISEMENTS
46. Question
Nurse Peter makes the assessment that which client has the greatest risk for a
problem with the transport of oxygen from the lungs to the tissues? A client who
has:
o A. Anemia
o B. An infection
o C. A fractured rib
o D. A tumor of the medulla

Incorrect
Correct Answer: A. Anemia
Anemia is a condition of decreased red blood cells and decreased hemoglobin.
Hemoglobin is how the oxygen molecules are transported to the tissues. Anemia
is described as a reduction in the proportion of red blood cells. Anemia is not a
diagnosis, but a presentation of an underlying condition. Whether or not a
patient becomes symptomatic depends on the etiology of anemia, the acuity of
onset, and the presence of other comorbidities, especially the presence of
cardiovascular disease.
 Option B: An infection would depend on its location. Infections can be
caused by a variety of different organisms, including viruses, bacteria,
fungi, and parasites. The different ways that you can get an infection can
be just as diverse as the organisms that cause them.
 Option C: A fractured rib would interrupt the transport of oxygen from the
atmosphere to the airways. Broken ribs are most commonly caused by
direct impacts — such as those from motor vehicle accidents, falls, child

abuse, or contact sports. Ribs also can be fractured by repetitive trauma
from sports like golf and rowing or from severe and prolonged coughing.
 Option D: Damage to the medulla would interfere with neural stimulation
of the respiratory system. Tumors of the medulla cause swallowing
problems and limb weakness.
ADVERTISEMENTS
47. Question
Which term does the nurse document to best describe a client experiencing
shortness of breath while lying down who must assume an upright or sitting
position to breathe more comfortably and effectively?
o A. Dyspnea
o B. Hyperpnea
o C. Orthopnea
o D. Apnea
Incorrect
Correct Answer: C. Orthopnea
Respiratory difficulty related to a reclining position without other physical
alterations is defined as orthopnea. Orthopnea is the sensation of breathlessness
in the recumbent position, relieved by sitting or standing. Orthopnea is caused by
pulmonary congestion during recumbency. In the horizontal position there is
redistribution of blood volume from the lower extremities and splanchnic beds to
the lungs.
 Option A: Dyspnea is the medical term for shortness of breath, sometimes
described as ―air hunger.‖ It is an uncomfortable feeling. Shortness of
breath can range from mild and temporary to serious and long-lasting. It is
sometimes difficult to diagnose and treat dyspnea because there can be
many different causes.
 Option B: Hyperpnea is breathing more deeply and sometimes faster than
usual. It‘s normal during exercise or exertion. Hyperpnea is breathing
deeply, a normal response to exertion requiring more oxygen. This is when
you‘re breathing in more air but not necessarily breathing faster. It can

happen during exercise or because of a medical condition that makes it
harder for your body to get oxygen, like heart failure or sepsis (a serious
overreaction by your immune system).
 Option D: Apnea is breathing that stops briefly during sleep. Oxygen to
the brain is decreased. It requires treatment. Apnea is the medical term
used to describe slowed or stopped breathing. Apnea can affect people of
all ages, and the cause depends on the type of apnea one has. Apnea
usually occurs while sleeping. For this reason, it‘s often called sleep apnea.
ADVERTISEMENTS
48. Question
A client with emphysema is prescribed corticosteroid therapy on a short-term
basis for acute bronchitis. The client asks the nurse how the steroids will help him.
The nurse responded by saying that the corticosteroids will do which of the
following?
o A. Promote bronchodilation
o B. Help the client to cough
o C. Prevent respiratory infection
o D. Decrease inflammation in the airways

Incorrect
Correct Answer: D. Decrease inflammation in the airways
Glucocorticoids are prescribed because of their anti-inflammatory effect. Options
1, 2, and 4 are not achieved with glucocorticoids. Corticosteroids produce their
effect through multiple pathways. In general, they produce anti-inflammatory and
immunosuppressive effects, protein and carbohydrate metabolic effects, water
and electrolyte effects, central nervous system effects, and blood cell effects.
 Option A: The glucocorticoid receptor is located intracellularly within the
cytoplasm and upon binding trans-locates rapidly into the nucleus where it
affects gene transcription and causes inhibition of gene expression and
translation for inflammatory leukocytes and structural cells such as
epithelium. This action leads to a reduction in proinflammatory cytokines,

chemokines, and cell adhesion molecules, as well as other enzymes
involved in the inflammatory response.
 Option B: The non-genomic mechanism occurs more rapidly and is
mediated through interactions between the intracellular glucocorticoid
receptor or a membrane-bound glucocorticoid receptor. Within seconds to
minutes of receptor activation, a cascade of effects is set off, including
inhibition of phospholipase A2, which is critical for the production of
inflammatory cytokines, impaired release of arachidonic acid, and
regulation of apoptosis in thymocytes.
 Option C: Their nonendocrine role regularly takes advantage of their
potent anti-inflammatory and immunosuppressive effects to treat patients
with a wide range of immunologic and inflammatory disorders.
Corticosteroids are used at physiologic doses as replacement therapy in
cases of adrenal insufficiency and supraphysiologic doses in treatments for
anti-inflammatory and immunosuppressive effects.
ADVERTISEMENTS
49. Question
Nurse Aleli is planning to perform percussion and postural drainage. Which is an
important aspect of planning the clients‘ care?
o A. Percussion and postural drainage should be done before lunch.
o B. The order should be coughing, percussion, positioning, and then

suctioning.
o C. A good time to perform percussion and postural drainage is in the

morning after breakfast when the client is well rested.
o D. Percussion and postural drainage should always be preceded by three

minutes of 100% oxygen.
Incorrect
Correct Answer: A. Percussion and postural drainage should be done before
lunch.
Postural drainage results in expectoration of large amounts of mucus. Clients
sometimes ingest part of the secretions. The secretions may also produce an

unpleasant taste in the oral cavity, which could result in nausea/vomiting. This
procedure should be done on an empty stomach to decrease client discomfort.
 Option B: PD & P involves a combination of techniques, including multiple
positions to drain the lungs, percussion, vibration, deep breathing and
coughing. When the person with CF is in one of the positions, the caregiver
can clap on the person‘s chest wall. This is usually done for three to five
minutes and is sometimes followed by vibration over the same area for
approximately 15 seconds (or during five exhalations). The person is then
encouraged to cough or huff forcefully to get the mucus out of the lungs.
 Option C: Generally, each treatment session can last for 20 to 40 minutes.
PD & P is best done before meals or one and a half to two hours after
eating, to decrease the chance of vomiting. Early morning and bedtimes
are usually recommended. The length of PD & P and the number of times
of day it is done may need to be increased if the person is more congested
or getting sick.
 Option D: When the person with CF is in one of the positions, the
caregiver can clap on the person‘s chest wall. This is usually done for three
to five minutes and is sometimes followed by vibration over the same area
for approximately 15 seconds (or during five exhalations). The person is
then encouraged to cough or huff forcefully to get the mucus out of the
lungs.
ADVERTISEMENTS
50. Question
Nurse Winona teaches a patient how to use an incentive spirometer. What
patient outcome will support the conclusion that the use of the incentives
spirometer was effective?
o A. Supplemental oxygen use will be reduced.
o B. Inspiratory volume will be increased.
o C. Sputum will be expectorated.
o D. Coughing will be stimulated.

Incorrect

Correct Answer: B. Inspiratory volume will be increased.
An incentive spirometry or provides a visual goal for and measurement of
inspiration. It encourages the patient to execute and maintain a sustained
inspiration. A sustained inspiration opens airways, increases the inspiratory
volume, and reduces the risk of atelectasis. Spirometry is one of the most readily
preceded by a maximal inhalation.
 Option A: Patients who use an incentive spirometer may or may not be
receiving oxygen. All patients must be informed that they must abstain
from smoking, physical exercise in the hours before the procedure. Any
bronchodilator therapy must also be stopped beforehand.
 Option C: Although sputum may be expectorated after the use of an
incentive spirometer, this is not the primary reason for its use. Recent
evidence also supports the use of spirometry in non thoracic surgeries. A
recent retrospective observational study found that lower preoperative
spirometry FVC may predict postoperative pulmonary complications in
high-risk patients undergoing abdominal surgery.
 Option D: Although the deep breathing associated with the use of an
incentive barometer may stimulate coughing, this is not the primary reason
for its use. Complete spirometry exams will identify FEV1, forced vital
capacity (FVC), vital capacity (VC), residual lung volume (RV), maximum
voluntary minute ventilation (MMV), and total lung capacity (TLC). One
parametric that is highly indicative of postoperative complications is
predicted postoperative FEV 1(ppo FEV 1). Predicted postoperative FEV1
<30% are at a higher risk of postoperative pulmonary complications after
thoracic surgery.
ADVERTISEMENTS
1. 51. Question
Nurse AJ is applying a warm compress. What should the nurse explain to the
patient is the primary reason why heat is used instead of cold?
o A. Minimizes muscle spasms
o B. Prevents hemorrhage

o C. Increases circulation
o D. Reduces discomfort
Incorrect
Correct Answer: C. Increases circulation
Heat increases the skin surface temperature, promoting vasodilation, which
increases blood flow to the area. Cold has the opposite effect: it promotes
vasoconstriction, which decreases blood flow to the area. In general, heat therapy
is also recommended prior to exercise for those who have chronic injuries. Heat
warms the muscles and helps increase flexibility. The only time one should ever
consider using cold to treat a chronic injury is after finishing exercising when
inflammation may reappear. Applying cold at this time helps reduce any residual
swelling.
 Option A: Both heat and cold relax muscles and thus minimize muscle
spasms. It reduces joint stiffness and muscle spasm, which makes it useful
when muscles are tight. There is no advantage to using heat over cold.
When muscles work, chemical byproducts are made that need to be
eliminated. When exercise is very intense, there may not be enough blood
flow to eliminate all the chemicals. It is the buildup of chemicals (for
example, lactic acid) that cause muscle ache. Because the blood supply
helps eliminate these chemicals, use heat to help sore muscles after
exercise.
 Option B: Heat does not prevent hemorrhage; heat causes vasodilation,
which promotes hemorrhage. Apply an ice compress to the injury as soon
as possible. This will cool down the tissues, lower their metabolic rate and
nerve conduction velocity, resulting in vasoconstriction of the surrounding
blood vessels and reduced inflammation.
 Option D: Both heat and cold can reduce discomfort. Cold reduces
discomfort by numbing the area, slowing the transmission of pain
impulses, and increasing the pain threshold. Heat reduces the discomfort
by relaxing the muscles. When an injury or inflammation, such as tendonitis
or bursitis occurs, tissues are damaged. Cold numbs the affected area,
which can reduce pain and tenderness. Cold can also reduce swelling and
inflammation.
ADVERTISEMENTS

52. Question
A practitioner orders chest physiotherapy with percussion and vibration for a
newly admitted patient. Which information obtained by the nurse during the
health history should alert the nurse to question the practitioner‘s order?
o A. Emphysema
o B. Osteoporosis
o C. Cystic fibrosis
o D. Chronic bronchitis
Incorrect
Correct Answer: B. Osteoporosis
Implementing the practitioner‘s order may compromise patient safety because
percussion and vibration in the presence of osteoporosis may cause fractures.
Osteoporosis is an abnormal loss of bone mass and strength. Chest
physiotherapy is a group of physical techniques that improve lung function and
help you breathe better. Chest PT, or CPT expands the lungs, strengthens
breathing muscles, and loosens and improves drainage of thick lung secretions.
 Option A: These are appropriate interventions for a patient with
emphysema. Emphysema is a chronic pulmonary disease characterized by
an abnormal increase in the size of air spaces distal to the terminal
bronchioles with destructive changes in their walls. Chest percussion and
vibration to help loosen lung secretions. Some patients wear a special CPT
vest hooked up to a machine. The machine makes the vest vibrate at a high
frequency to break up the secretions.
 Option C: These are appropriate interventions for a patient with cystic
fibrosis causes widespread dysfunction of the exocrine glands. It is
characterized by thick, tenacious secretions in the respiratory system that
block the bronchioles, creating breathing difficulties. Chest PT helps treat
such diseases as cystic fibrosis and COPD (chronic obstructive pulmonary
disease). It also keeps the lungs clear to prevent pneumonia after surgery
and during periods of immobility.
 Option D: These are appropriate interventions for a patient with chronic
bronchitis. Bronchitis is an inflammation of the mucous membranes of the
bronchial airways. The doctor may recommend chest PT to help loosen and

cough up thick or excessive lung secretions from such conditions as lung
infections, which include pneumonia, acute bronchitis, and lung abscess.
ADVERTISEMENTS
53. Question
Nurse Sue teaches a patient about pursed lip breathing. The nurse identifies that
the teaching is affected when the patient says its purpose is to:
o A. Precipitate coughing
o B. Help maintain open airways
o C. Decrease intrathoracic pressure
o D. Facilitate expectoration of mucus

Incorrect
Correct Answer: B. Help maintain open airways
Pursed-lip breathing involves deep inspiration and prolonged expiration against
slightly closed lips. The pursed lips create a resistance to the air flowing out of
the lungs, which prolongs exhalation and maintains positive airway pressure,
thereby maintaining an open airway and preventing airway collapse. Pursed lip
breathing is beneficial for people with chronic lung disease. It can help
strengthen the lungs and make them more efficient.
 Option A: Deep breathing and huff coughing, not pursed-lip breathing,
stimulate effective coughing. Deep breathing prevents air from getting
trapped in the lungs, which can cause the client to feel short of breath. As a
result, the client can breathe in a more fresh air.
 Option C: Pursed lip breathing increases, not decreased intrathoracic
pressure. Pursed lip breathing is a simple technique for slowing down a
person‘s breathing and getting more air into their lungs. With regular
practice, it can help strengthen the lungs and make them work more
efficiently. The technique involves breathing in through the nose and
breathing out slowly through the mouth.
 Option D: The huff coughing stimulates the natural cough reflex and is
effective for clearing the central airways of sputum. Saying the word huff
with short forceful exhalations keeps the glottis open, mobilizes sputum,

and stimulates a cough. When one has COPD, mucus can build up more
easily in the lungs. The huff cough is a breathing exercise designed to help
one cough up mucus effectively without making one feel too tired. A huff
cough should be less tiring than a traditional cough, and it can keep one
from feeling worn out when coughing up mucus.
ADVERTISEMENTS
54. Question
What should Nurse Mavie do first if a patient is choking on food?
o A. Apply sharp for thrusts over the patient's xiphoid process.
o B. Determine if the patient can make any verbal sounds.
o C. Hit the middle of the patients back firmly.
o D. Sweep the patient's mouth with a finger.

Incorrect
Correct Answer: B. Determine if the patient can make any verbal sounds.
When a person is choking on food, the first intervention is to determine if the
person can speak because the next intervention will depend on if it is partial or
total airway obstruction. With a partial airway obstruction, the person will be able
to make sounds because some air can pass from the lungs through the vocal
cords. In this situation the person‘s own efforts open parentheses gagging and
coughing) should be allowed to clear the airway. With a total airway obstruction,
the person will not be able to make a sound because the airway is blocked and
the nurse should immediately initiate the abdominal thrust maneuver (Heimlich
maneuver).
 Option A: Thrusts to the xiphoid process may cause a fracture that may
result in a pneumothorax. The foreign body lodged in the larynx or trachea
is most dangerous as this causes complete airway obstruction.
Alternatively, foreign bodies such as small beads or small pieces of food
may pass below the vocal cords and become lodged at the carina or within
a mainstem bronchus. In adults, due to differences in right versus left
pulmonary anatomy, foreign bodies are more commonly retrieved from the

right main bronchus. However, children will have equal likelihood in either
bronchus, due to equal growth until the age of 16.
 Option C: All adults can and should receive the Heimlich maneuver while
they are conscious. If the Heimlich cannot be performed due to body
habitus or pregnancy, the American Heart Association recommends a
supine patient with force again applied just above the umbilicus in a
cephalad posterior vector. If the adult loses consciousness, it is imperative
to check for a pulse and begin cardiopulmonary resuscitation if a pulse is
not detected. Advanced airway techniques are now indicated, and you may
be able to visualize the foreign body under direct laryngoscopy.
 Option D: Never sweep a choking patient‘s mouth with a finger. It might
further dislodge the food. The commonly known abdominal thrust
maneuver, known as the Heimlich maneuver, is performed by a bystander
on a person who appears to be choking. The bystander stands behind the
subject and wraps his/her arms around the upper abdominal region, about
two inches above the belly button. Making a fist with one hand and
wrapping the other hand tightly over the fist and delivering five sharp
midline thrusts inward and upward.
ADVERTISEMENTS
55. Question
Nurse Stephanie is assessing a client who has an acute respiratory infection that
puts her at risk for hypoxemia. Which of the following findings are early
indications that should alert the nurse that the client is developing
hypoxemia? Select all that apply.
o A. Restlessness
o B. Tachypnea
o C. Bradycardia
o D. Confusion
o E. Cyanosis
Incorrect
Correct Answer: A, B, & E

Restlessness, tachypnea, and pallor are early manifestations of hypoxemia, along
with tachycardia, elevated blood pressure, use of accessory muscles, nasal flaring,
tracheal tugging, and adventitious lung sounds. Bradycardia and confusion are
late manifestations of hypoxemia, along with stupor, cyanotic skin and mucous
membranes, bradypnea, hypotension, and cardiac dysrhythmias. Hypoxemia is
defined as a decrease in the partial pressure of oxygen in the blood whereas
hypoxia is defined by reduced level of tissue oxygenation. It can be due to either
defective delivery or defective utilization of oxygen by the tissues.
 Option A: When oxygen delivery is severely compromised, organ function
will start to deteriorate. Neurologic manifestations include restlessness,
headache, and confusion with moderate hypoxia. In severe cases, altered
mentation and coma can occur, and if not corrected quickly may lead to
death.
 Option B: The chronic presentation is usually less dramatic, with dyspnea
on exertion as the most common complaint. Symptoms of the underlying
condition that induced the hypoxia can help in narrowing the differential
diagnosis. The physical exam may show tachypnea and low oxygen
saturation. Fever may point to infection as the cause of hypoxia.
 Option C: Bradycardia is a late manifestation of hypoxemia. Increase in
cardiac output with exercise results in accelerated blood flow through
alveoli, reducing the time available for gas exchange. In case of the
abnormal pulmonary interstitium, gas exchange time becomes insufficient,
and hypoxemia ensues.
 Option D: Both confusion and somnolence may occur in respiratory failure.
Myoclonus and seizures may occur with severe hypoxemia. Polycythemia is
a complication of long-standing hypoxemia.
 Option E: Cyanosis, a bluish color of skin and mucous membranes,
indicates hypoxemia. Visible cyanosis typically is present when the
concentration of deoxygenated hemoglobin in the capillaries of tissues is
at least 5 g/dL.
ADVERTISEMENTS
56. Question

Nurse CJ is caring for a client who is having difficulty breathing. The client is lying
in bed and is already receiving oxygen therapy via nasal cannula. Which of the
following interventions is the nurse‘s priority?
o A. Increase the oxygen flow.
o B. Assist the client with Fowler's position.
o C. Promote removal of pulmonary secretions.
o D. Attain a specimen for arterial blood gases.

Incorrect
Correct Answer: B. Assist the client with Fowler’s position.
The priority action the nurse should take when using the airway, breathing,
circulation approach to care delivery is to relieve the clients‘ dyspnea. Fowler‘s
position facilitates maximal long expansion and thus optimizing breathing. With
the client in this position, the nurse can better assess and determine the cause of
the clients dyspnea.
 Option A: The client may need more oxygen, as hypoxemia may be the
cause of his difficulty breathing. However, administering oxygen and
adjusting the fraction of inspired oxygen requires the provider‘s
prescription after a careful assessment of the clients‘ oxygenation status,
there is a higher priority given the nature of the client‘s distress.
 Option C: The client may need suction or expectoration, as pulmonary
secretions may be the cause of his difficulty breathing. However, there is a
higher priority given the nature of the client‘s distress.
 Option D: It is important to check the client‘s oxygenation status, and in
many nursing situations, assessment precedes action, but there is a higher
priority given the nature of the clients‘ distress.
ADVERTISEMENTS
57. Question
Nurse Aldrin is preparing to perform endotracheal suctioning for a client. Which
of the following are appropriate guidelines for the nurse to follow? Select all
that apply.

o A. Apply suction while withdrawing the catheter.
o B. Perform suctioning on a routine basis, every 2 to 3 hours.
o C. Maintain medical asepsis during suctioning.
o D. Use a new catheter for each suctioning attempt.
o E. Limit suctioning to 2 to 3 attempts.

Incorrect
Correct Answer: A, D, & E
Within intensive care units (ICUs), one such common procedure is the suctioning
of respiratory secretions in patients who have been intubated or who have
undergone tracheostomy. The traditional goal of suctioning is to aid in
maintaining airway patency and prevent complications related to the retention of
secretions
 Option A: The nurse should apply suction pressure only while withdrawing
the catheter, not while inserting it. One interesting thing to note about ETS
is that negative pressure is created inside of the lungs only while air flows
out of the suction catheter. As soon as secretions are aspirated into the
catheter, the intrapulmonary pressure returns to that of the atmospheric
level, and lung volume loss stops.
 Option B: The nurse should not suction routinely because suctioning is not
without risk. It can cause mucosal damage, bleeding, and bronchospasm.
Although there has been a very limited number of studies regarding a
scheduled frequency of performing ETS every 1, 3, 4, 6, 8, or even 12 hours,
the overall recommendation is to suction only as indicated (as needed).
 Option C: Endotracheal suctioning requires surgical asepsis. The second
method of suctioning is the shallow (premeasured) technique, which is also
considered minimally invasive.1-3 With shallow ETS, the catheter is inserted
only to the tip of the ETT, thereby avoiding injury to the airway.
 Option D: The nurse should not reuse the suction catheter unless an in-
line suctioning system is in place. If a suction catheter is too large for the
ETT, and/or there is too much vacuum pressure, massive atelectasis may
occur. Therefore, the general recommendation is to use a suction catheter
that has an external diameter less than 50% of the size of the ETT inner
diameter.

 Option E: To prevent hypoxemia, the nurse should limit each section in
session to 2 to 3 attempts and allow at least one minute between passes
for ventilation and oxygenation. The reason for this is because there is
considerable risk with using ―routine‖ suctioning. It has been suggested by
Pedersen et al3 that ETS should be performed at least every 8 hours to
slow the formation of the secretion biofilm within the lumen of the
endotracheal tube (ETT). Clifton-Koeppel1 made a good general
recommendation that ETS should be performed as infrequently as
possible—yet as much as needed.
ADVERTISEMENTS
58. Question
A nurse is caring for a client who has a tracheostomy. Which of the following
actions should the nurse take each time he provides tracheostomy care? Select
all that apply.
o A. Apply the oxygen source loosely if the SPO2 increases during the
procedure.
o B. Use surgical asepsis to remove and clean the inner cannula.
o C. Clean the outer surfaces in a circular motion from the stoma site
outward.
o D. Replace the tracheostomy ties with new ties.
o E. Cut a slit in gauze squares to place beneath the tube holder.

Incorrect
Correct Answer: A, B, & C
A tracheostomy is an opening (made by an incision) through the neck into the
trachea (windpipe). A tracheostomy opens the airway and aids breathing. A
tracheostomy may be required in an emergent setting to bypass an obstructed
airway, or (more commonly) may be placed electively to facilitate mechanical
ventilation, to wean from a ventilator, or to allow more efficient management of
secretions (referred to as pulmonary toilet), among other reasons.
 Option A: The nurse must be prepared to provide supplemental oxygen in
response to any decline in oxygenation saturation while performing

tracheostomy care. Nurses need to understand all aspects of tracheostomy
care, including routine and emergency airway management, safe
decannulation, weaning and safe discharge into the community. The
patient‘s airway requires close monitoring 24 hours a day using a
tracheostomy care chart to record care.
 Option B: The nurse should use a sterile disposable tracheostomy cleaning
kit or sterile supplies and maintain surgical asepsis throughout this part of
the procedure. The NTSP (2013) recommends that all patients with a
tracheostomy have a bed-head label with information regarding their tube
and airway, including whether it is surgical or percutaneous, the tube type,
size and suction-catheter size, patency of the upper airway and whether
the tracheostomy is temporary, permanent or involves a laryngectomy
(removal of the larynx).
 Option C: This action helps move mucus and contaminated material away
from the stoma for easy removal. The stoma site should be checked at least
once a day, or more frequently if required, and this requires two nurses:
one to hold the tube and one to clean the stoma site. The site should be
cleaned using a tracheostomy wipe or with 0.9% sodium chloride solution,
and dried thoroughly.
 Option D: To help keep the skin clean and dry, the nurse should replace
the tracheostomy ties if they are wet or soiled. There is a risk of two
dislodgements replacing the ties, so he should not replace them routinely.
Leaving the old ties in place while securing the clean ties prevents
inadvertent dislodging of the tracheostomy tube. Securing tapes in this
manner avoids the use of knots, which can come untied or cause pressure
and irritation.
 Option E: The nurse should use a commercially prepared tracheostomy
dressing with a slit in it. Cutting gauze squares can loosen lint or cause
fibers the client could aspirate. Use a commercially prepared tracheostomy
dressing of non-raveling material or open and refold a 4-in. X 4-in. Gauze
dressing into a V shape. Avoid using cotton-filled gauze squares or cutting
the 4×4 gauze. Cotton lint or gauze fibers can be aspirated by the client,
potentially creating a tracheal abscess.
ADVERTISEMENTS
59. Question

An elderly nursing home resident has refused to eat or drink for several days and
is admitted to the hospital. The nurse should expect which assessment finding?
o A. Increase blood pressure
o B. Weak, rapid pulse
o C. Moist mucous membranes
o D. Jugular vein distention

Incorrect
Correct Answer: B. Week, rapid pulse
All other options are indicated by fluid volume excess. A client who has not eaten
or drunk anything for several days would be experiencing a fluid volume deficit.
The primary control of water homeostasis is through osmoreceptors in the brain.
Dehydration, as perceived by these osmoreceptors, stimulates the thirst center in
the hypothalamus, which leads to water consumption. These osmoreceptors can
also cause conservation of water by the kidney. When the hypothalamus detects
lower water concentration, it causes the posterior pituitary to release antidiuretic
hormone (ADH), which stimulates the kidneys to reabsorb more water.
 Option A: Decreased blood pressure, which often accompanies
dehydration triggers renin secretion from the kidney. Renin converts
angiotensin I to angiotensin II, which increases aldosterone release from
the adrenals. Aldosterone increases the absorption of sodium and water
from the kidney. Using these mechanisms, the body regulates body volume
and sodium and water concentration.
 Option C: Some of the most common presenting symptoms of
dehydration include but are not limited to fatigue, thirst, dry skin and lips,
dark urine or decreased urine output, headaches, muscle cramps,
lightheadedness, dizziness, syncope, orthostatic hypotension, and
palpitations. The physical examination could show dry mucosa, skin
tenting, delayed capillary refill, or cracked lips.
 Option D: A 2015 Cochrane review evaluated predictors of dehydration in
the elderly. Historical and physical findings tested were dry axilla, mucous
membranes, tongue, increased capillary refill time, poor skin turgor, sunken
eyes, orthostatic blood pressure drop, dizziness, thirst, urine color,
weakness, blue lips, altered mentation, tiredness, and appetite. Of all these

factors only fatigue and missed drinks between meals predicted the
diagnosis of dehydration.
ADVERTISEMENTS
60. Question
A man brings his elderly wife to the emergency department. He states that she
has been vomiting and has had diarrhea for the past two days. She appears
lethargic and is complaining of leg cramps. What should the nurse do first?
o A. Start an IV.
o B. Review the results of serum electrolytes.
o C. Offer the woman foods that are high in sodium and potassium content.
o D. Administer an antiemetic.
Incorrect
Correct Answer: B. Review the results of serum electrolytes.
Further assessment is needed to determine appropriate action. While the nurse
may perform some of the interventions in options one, three, and four,
assessment is needed initially. Electrolyte abnormalities may be addressed on an
individual level, although often these are caused by an overall fluid volume
depletion which, when corrected, will also cause electrolytes to normalize. Both
saline and lactated Ringer‘s solutions appear to be effective for the treatment of
dehydration due to viral gastroenteritis.
 Option A: The most important goal of treatment is to maintain hydration
status and effectively counter fluid and electrolyte losses. Fluid therapy is a
fundamental part of treatment. Intravenous fluids may be administered to
those individuals who appear dehydrated or to those unable to tolerate
oral fluids.
 Option C: No specific nutritional recommendations are universal for
patients with viral gastroenteritis. A diet of banana, rice, apples, tea, and
toast is often advised, but several studies have failed to show any
significant outcome difference when compared to regular diets.
 Option D: Antiemetic medications such as ondansetron or
metoclopramide may be used to assist with controlling nausea and

vomiting symptoms. Patients demonstrating severe dehydration or
intractable vomiting may require hospital admission for continued
intravenous fluids and careful monitoring of electrolyte status.
ADVERTISEMENTS
61. Question
Which of the following is the appropriate meaning of CBR?
o A. Cardiac Board Room
o B. Complete Bathroom
o C. Complete Bed Rest
o D. Complete Board Room

Incorrect
Correct Answer: C. Complete Bed Rest
CBR means complete bed rest. For more abbreviations, please see this post.
Standardization and uniform use of codes, symbols, and abbreviations can
improve communication and understanding between health care practitioners,
leading to safer and more effective care for patients.
 Option A: When developing lists, hospitals need to ensure that
abbreviations on the approved list are not also on the do-not-use list, and
vice versa. In addition, abbreviations can have only one meaning within the
entire organization—for example, the abbreviation NKDA could mean ―no
known drug allergies,‖ or it could mean ―nonketotic diabetic acidosis,‖ but
it cannot have both meanings in an organization.
 Option B: Appropriate use of abbreviations is particularly important.
Numerous studies have focused on health care practitioners‘
understanding and interpretation of abbreviations in medical documents,
such as medical records, discharge summaries, and medication orders.
Findings indicate that it is not uncommon for practitioners to have
 Option D: To prevent misunderstandings and potential risks to patient
safety, requires hospitals to establish lists for approved and do-not-use
abbreviations and monitor for appropriate abbreviation use. There are

resources for identifying abbreviations for the do-not-use list, such as the
Institute for Safe Medication Practices (ISMP), which publishes a list of
dangerous abbreviations not to be used due to frequent misinterpretation
and associated medication errors.
ADVERTISEMENTS
62. Question
One (1) tsp is equal to how many drops?
o A. 15
o B. 60
o C. 10
o D. 30
Incorrect
Correct Answer: B. 60
One teaspoon (tsp) is equal to 60 drops (gtts). When the nurse has an order for
an IV infusion, it is her responsibility to make sure the fluid will infuse at the
prescribed rate. IV fluids may be infused by gravity using a manual roller clamp or
dial-a-flow, or infused using an infusion pump. Regardless of the method, it is
important to know how to calculate the correct IV flow rate.
 Option A: When calculating the flow rate, determine which IV tubing will
drip chamber.
 Option C: Macrodrip tubing delivers 10 to 20 gtts/mL and is used to infuse
large volumes or to infuse fluids quickly. Microdrip tubing delivers 60
gtts/mL and is used for small or very precise amounts of fluid, as with
The formula for calculating the IV flow rate (drip rate) is… total volume (in

ADVERTISEMENTS
1. 63. Question
20 cc is equal to how many ml?
o A. 2
o B. 20
o C. 2000
o D. 20000
Incorrect
One cubic centimeter is equal to one milliliter. When clinicians are prepared and
know the key conversion factors, they will be less anxious about the calculation
involved. This is vital to accuracy, regardless of which formula or method
employed.
 Option A: Drug calculations require the use of conversion factors, for
 Option C: Units of measurement must match, for example, milliliters and
milliliters, or one needs to convert to like units of measurement. In the
example above, the ordered dose was in milligrams, and the have dose was
in milligrams, both of which cancel out leaving milliliters (answer called for
milliliters), so no further conversion is required.
 Option D: All members of the interprofessional team are responsible for
dose calculations. Physicians, nurses, and pharmacists all must be
conversant in the desired overall formula. This technique is invaluable in
properly treating patients.
ADVERTISEMENTS

64. Question
1 cup is equal to how many ounces?
o A. 8
o B. 80
o C. 800
o D. 8000
Incorrect
Correct Answer: A. 8
One cup is equal to 8 ounces. Weight conversion is also utilized daily in health
care. There are two systems calculating weight used in all healthcare settings for
health management, such as medication dosing per patient body weight. First,
the metric system is in common use in health care in the US. It is also the only
system universally used in many countries on all continents of the globe. It has
the advantage of a decimal system in increments or the power of tenths. Second,
the US weight system customarily uses the ounce or pound. It derives from the
British colonial era. This non-metric system is still being used nowadays among
laypersons in the US for products sold to the public.
 Option B: The metric system is essential in all health care settings. Patients
are weighed at each clinical encounter. Scales used in the US have double
marking indicators: metric and non-metric markings. Metric weight values
are used in medication calculation, radiation dosing, and weight
compliance in equipment use, such as the maximum weight of a CAT-
SCAN unit or a surgical table that may hold a person.
 Option C: Nowadays, all medications are based on weight for dose
calculations for all populations but very specifically in children and infants.
Adults have their weight recorded mainly by their doctors at each physical
patient-clinician encounter. Commonly, most adults monitor their weight
for weight management. Clinicians record it in the electronic health records
in both kilograms and pounds.
 Option D: Commonly in healthcare and medical practices, the metric
system is used for weighing mass. In the metric system, there are
increments at the power of the tenth for calculations. This weight
conversion is used daily among scientists and health care providers.

ADVERTISEMENTS
65. Question
The nurse must verify the client‘s identity before administration of medication.
Which of the following is the safest way to identify the client?
o A. Ask the client his name.
o B. Check the client’s identification band.
o C. State the client‘s name aloud and have the client repeat it.
o D. Check the room number.

Incorrect
Correct Answer: B. Check the client’s identification band
The identification band is the safest way to know the identity of a patient whether
he is conscious or unconscious. Nurses have a unique role and responsibility in
medication administration, in that they are frequently the final person to check to
see that the medication is correctly prescribed and dispensed before
administration.
 Option A: Ask the client his name only after you have checked his ID band.
Right patient‘ – ascertaining that a patient being treated is, in fact, the
correct recipient for whom medication was prescribed. This is best
practiced by nurses directly asking a patient to provide his or her full name
aloud, checking medical wristbands if appropriate for matching name and
ID number as on a chart.
 Option C: It is advisable not to address patients by first name or surname
alone, in the event, there are two or more patients with identical or similar
names in a unit. Depending on the unit that a patient may be in, some
patients, such as psychiatric patients, may not wear wristbands or may have
altered mentation to the point where they are unable to identify
themselves correctly. In these instances, nurses are advised to confirm a
patient‘s identity through alternative means with appropriate due
diligence.
 Option D: The medical literature states that the value of nurses‘ critical
thinking, the role of patient advocacy, and clinical judgment are not
accounted for by the five rights framework that is commonly observed in

modern practice to deliver patient-centered care. Research has shown a
clear benefit in the value of nursing experience as it relates to decision-
making capability; however, it states that further studies are necessary to
achieve an improved understanding of how nurses apply intuition, the
context of the situation, and interpretation.
ADVERTISEMENTS
66. Question
The nurse prepares to administer buccal medication. The medicine should be
placed in what area?
o A. On the client‘s skin.
o B. Between the client’s cheeks and gums.
o C. Under the client‘s tongue.
o D. On the client‘s conjunctiva.

Incorrect
Correct Answer: B. Between the client’s cheeks and gums
Buccal administration involves placing a drug between the gums and cheek,
where it also dissolves and is absorbed into the blood. Because the medication
absorbs quickly, these types of administration can be important during
emergencies when you need the drug to work right away, such as during a heart
attack.
 Option A: An advantage of a transdermal drug delivery route over other
types of medication delivery such as oral, topical, intravenous,
intramuscular, etc. is that the patch provides a controlled release of the
medication into the patient, usually through either a porous membrane
covering a reservoir of medication or through body heat melting thin
layers of medication embedded in the adhesive.
 Option C: Sublingual administration involves placing a drug under the
tongue to dissolve and absorb into the blood through the tissue there.
These drugs do not go through the digestive system, so they aren‘t
metabolized through the liver. This means you may be able to take a lower
dose and still get the same results.

 Option D: The three primary methods of delivery of ocular medications to
the eye are topical, local ocular (ie, subconjunctival, intravitreal, retrobulbar,
intracameral), and systemic. The most appropriate method of
administration depends on the area of the eye to be medicated. The
conjunctiva, cornea, anterior chamber, and iris usually respond well to
topical therapy. The eyelids can be treated with topical therapy but more
frequently require systemic therapy. The posterior segment always requires
systemic therapy, because most topical medications do not penetrate to
the posterior segment. Retrobulbar and orbital tissues are treated
systemically.
ADVERTISEMENTS
67. Question
The nurse administers a cleansing enema. The common position for this
procedure is?
o A. Sims left lateral
o B. Dorsal Recumbent
o C. Supine
o D. Prone
Incorrect
Correct Answer: A. Sims left lateral
This position provides comfort to the patient and easy access to the natural
curvature of the rectum. Enemas are rectal injections of fluid intended to cleanse
or stimulate the emptying of the bowel. Enemas may also be prescribed to flush
out the colon before certain diagnostic tests or surgeries. The bowel needs to be
empty before these procedures to reduce infection risk and prevent stool from
getting in the way.
 Option B: Position the patient on the left side, lying with the knees drawn
to the abdomen. This eases the passage and flow of fluid into the rectum.
Gravity and the anatomical structure of the sigmoid colon also suggest that
this will aid enema distribution and retention. Dorsal recumbent is a
position in which the patient lies on the back with the lower extremities

moderately flexed and rotated outward. It is employed in the application of
obstetrical forceps, repair of lesions following parturition, vaginal
examination, and bimanual palpation.
 Option C: The supine position means lying horizontally with the face and
torso facing up, as opposed to the prone position, which is face down.
When used in surgical procedures, it allows access to the peritoneal,
thoracic, and pericardial regions; as well as the head, neck, and extremities.
 Option D: Prone position is a body position in which the person lies flat
with the chest down and the backup. In anatomical terms of location, the
dorsal side is up, and the ventral side is down. The supine position is the
180° contrast.
ADVERTISEMENTS
68. Question
A client complains of difficulty swallowing when the nurse tries to administer
capsule medication. Which of the following measures should the nurse do?
o A. Dissolve the capsule in a glass of water.
o B. Break the capsule and give the content with applesauce.
o C. Check the availability of a liquid preparation.
o D. Crush the capsule and place it under the tongue.

Incorrect
Correct Answer: C. Check the availability of a liquid preparation.
The nurse should check first if the medication is available in liquid form before
doing Choice A. The swallowing of capsules can be particularly difficult. This is
because capsules are lighter than water and float due to air trapped inside the
gelatine shell. In comparison, tablets are heavier than water and do not float.
 Option A: The physical properties of capsules predispose them to floating
in the mouth when taken with water. As a result, the swallowing of capsules
can be problematic. In patients who experience such difficulty, it is
suggested that they try leaning forward when swallowing, as this has been
found to assist. It may be necessary to reassure patients about this
technique as they may initially find it unnatural to execute.

 Option B: Some tablets, pills and capsules don‘t work properly or may be
harmful if they‘re crushed or opened. Most capsules are intended to be
swallowed whole so patients should be encouraged to trial the ‗lean-
forward‘ technique. If swallowing difficulties remain other options, such as
a liquid or tablet form of the medicine, can be considered.
 Option D: Placing it under the tongue is not the intended way of
administering an oral medication. Crushing the medication may alter the
medicine‘s effects. You shouldn‘t chew, crush or break tablets or pills, or
open and empty powder out of capsules unless your GP or another
healthcare professional has told you to do so. Some tablets, pills, and
capsules don‘t work properly or may be harmful if they‘re crushed or
opened.
ADVERTISEMENTS
69. Question
Which of the following is the appropriate route of administration for insulin?
o A. Intramuscular
o B. Intradermal
o C. Subcutaneous
o D. Intravenous
Incorrect
Correct Answer: C. Subcutaneous
The subcutaneous tissue of the abdomen is preferred because the absorption of
the insulin is more consistent from this location than subcutaneous tissues in
other locations. Insulin may be injected into the subcutaneous tissue of the upper
arm and the anterior and lateral aspects of the thigh, buttocks, and abdomen
(with the exception of a circle with a 2-inch radius around the navel).
 Option A: Intramuscular injection is not recommended for routine
injections. Rotation of the injection site is important to prevent
lipohypertrophy or lipoatrophy. Rotating within one area is recommended
(e.g., rotating injections systematically within the abdomen) rather than

rotating to a different area with each injection. This practice may decrease
variability in absorption from day to day.
 Option B: Site selection should take into consideration the variable
absorption between sites. The abdomen has the fastest rate of absorption,
followed by the arms, thighs, and buttocks. Exercise increases the rate of
absorption from injection sites, probably by increasing blood flow to the
skin and perhaps also by local actions.
 Option D: Administration of mixtures of rapid- or short- and intermediate-
or long-acting insulins will produce a more normal glycemia in some
patients than the use of single insulin. The formulations and particle size
distributions of insulin products vary. On mixing, physicochemical changes
in the mixture may occur (either immediately or over time). As a result, the
physiological response to the insulin mixture may differ from that of the
injection of the insulins separately.
ADVERTISEMENTS
70. Question
The nurse is ordered to administer ampicillin capsule TID p.o. The nurse should
give the medication by which frequency?
o A. Three times a day orally
o B. Three times a day after meals
o C. Two times a day by mouth
o D. Two times a day before meals

Incorrect
Correct Answer: A. Three times a day orally
TID is the Latin for ―ter in die‖ which means three times a day. P.O. means per
orem or through mouth. The ―time‖ of administration of medication is valuable
information to consider during patient counselling and is a typical query by
patients especially when filling a prescription for the first time.
 Option B: The timing of doses isn‘t the only question people may have
when it comes to deciphering prescriptions or oral communication from
the doctor. Other abbreviations include the number of refills allowed and

whether one is receiving a brand name or generic drug. Medical errors are
a significant cause of death in the United States. Fortunately, most of these
errors are preventable when patients are active advocates for their health
and ask plenty of questions.
 Option C: Two times a day by mouth is BID P.O. Seen on a prescription,
b.i.d. means twice (two times) a day. It is an abbreviation for ―bis in die‖
which in Latin means twice a day. The abbreviation b.i.d. is sometimes
written without a period either in lower-case letters as ―bid‖ or in capital
letters as ―BID‖.
 Option D: However it is written, it is one of a number of hallowed
abbreviations of Latin terms that have been traditionally used in
prescriptions to specify the frequency with which medicines should be
taken.
ADVERTISEMENTS
71. Question
Back Care is best described as:
o A. Caring for the back by means of massage.
o B. Washing of the back.
o C. Application of cold compress at the back.
o D. Application of hot compress at the back.

Incorrect
Correct Answer: A. Caring for the back by means of massage
Back care or massage is usually given in conjunction with the activities of bathing
the client. It can also be done on other occasions when a client seems to have a
risk of developing skin irritation due to bed rest. The goal when performing this
procedure is to enhance relaxation, reduce muscle tension and stimulate
circulation.
 Option B: Help the patient to turn on his abdomen or on his side with his
back toward the nurse and his body near the edge of the bed so that he is
as near the operator as possible. If the supine position is used and the
patient is a woman, a pillow under the abdomen removes pressure from

the breasts and favors relaxation. Apply to back rubbing lotion or talcum
powder to reduce friction. In rubbing the back use firm long strokes and
kneading motions. The amount of pressure to exert depends upon the
patient‘s condition. Begin from the neck and shoulders then proceed over
the entire back.
 Option C: Massage with both hands working with a strong stroke. In
upward then in downward motions. Give particular attention to pressure
areas in rubbing (Alcohol 25%) to 50% is generally used for its refreshing
effect, but rubbing lotion may be used. Powder again the area at the
completion of the rubbing process which should consume from 3-5
minutes.
 Option D: Effleurage (stroking) is a long sweeping movement with the
palm of hand conforming to the contour of the surface-treated, over a
small surface (on the neck) the thumb and fingers are used. Strokes should
be slow, rhythmical, and gentle with pressure constant and in the direction
of the venous stream. Kneading is performed with the ulnar side palm
resting on the surface and the fingers, and thumb grasping the skin and
subcutaneous tissues which move with the hand of the operator.
ADVERTISEMENTS
72. Question
It refers to the preparation of the bed with a new set of linens
o A. Bed bath
o B. Bed making
o C. Bed shampoo
o D. Bed lining
Incorrect
Correct Answer: B. Bed making
Bed making is one of the important nursing techniques to prepare various types
of bed for patients or clients to guarantee comfort and beneficial position for a
specific condition. The bed is particularly important for patients who are sick. The
nurse plays an inevitable role to ensure comfort and cleanliness for ill patients. It

should be adaptable to various positions as per patient‘s needs because they
spend a varying amount of the day in bed.
 Option A: Bed bathing is not as effective as showering or bathing and
should only be undertaken when there is no alternative (Dougherty and
Lister, 2015). If a bed bath is required, it is important to offer patients the
opportunity to participate in their own care, which helps to maintain their
independence, self-esteem and dignity.
 Option C: The condition of their hair and how it is styled is an important
part of patients‘ identity and wellbeing, so assisting them with hair care is a
fundamental aspect of nursing care
 Option D: The purpose of a well-made hospital bed, as well as an
appropriately chosen mattress, is to provide a safe, comfortable place for
the patient, where repositioning is more easily achieved, and pressure
ulcers are prevented.
ADVERTISEMENTS
73. Question
Which of the following is the most important purpose of handwashing?
o A. To promote hand circulation.
o B. To prevent the transfer of microorganisms.
o C. To avoid touching the client with a dirty hand.
o D. To provide comfort.
Incorrect
Correct Answer: B. To prevent the transfer of microorganism
Hand washing is the single most effective infection control measure.
Handwashing practices in the patient care setting began in the early 19th century.
The practice evolved over the years with evidential proof of its vast importance
and coupled with other hand-hygienic practices, decreased pathogens
responsible for nosocomial or hospital-acquired infections (HAI).
 Option A: According to the Centers for Disease Control and Prevention
(CDC), hand hygiene is the single most important practice in the reduction
of the transmission of infection in the healthcare setting Transient

microorganisms are often acquired by healthcare workers through direct,
close contact with patients or contaminated inanimate objects or
environmental surfaces. Transient flora colonizes the superficial skin layers.
It can be removed by routine hand washing more easily than resident flora.
These organisms vary in number depending upon body location.
Healthcare-associated infections are a result of these transient organisms.
 Option C: Contaminated hands of healthcare providers are a primary
source of pathogenic spread. Proper hand hygiene decreases the
proliferation of microorganisms, thus reducing infection risk and overall
healthcare costs, length of stays, and ultimately, reimbursement. According
to the CDC, hand hygiene encompasses the cleansing of your hands with
soap and water, antiseptic hand washes, antiseptic hand rubs such as
alcohol-based hand sanitizers, foams or gels, or surgical hand antisepsis.
 Option D: Indications for handwashing include when hands are visibly
soiled, contaminated with blood or other bodily fluids, before eating, and
after restroom use. Hands should be washed if there was potential
exposure to Clostridium difficile, Norovirus, or Bacillus anthracis. Alcohol-
based hand sanitizers are the recommended product for hand hygiene
when hands are not visibly soiled. Apply alcohol-based products per
manufacturer guidelines on dispensing of the product. Typically, 3 mL to 5
mL in the palm, rubbing vigorously, ensuring all surfaces on both hands
get covered, about 20 seconds is required for all surfaces to dry
completely.
ADVERTISEMENTS
74. Question
What should be done in order to prevent contaminating the environment in bed
making?
o A. Avoid fanning soiled linens
o B. Strip all linens at the same time
o C. Finished both sides at the time
o D. Embrace soiled linen

Incorrect
Correct Answer: A. Avoid fanning soiled linens
Fanning soiled linens would scatter the lodged microorganisms and dead skin
cells on the linens. Healthcare linens are known to harbor a number of
microorganisms. Most notably, there is an increased concern that methicillin-
resistant Staphylococcus aureus (MRSA)and vancomycin-resistant Enterococcus
(VRE) can survive for days on linens. There is further concern that these
contaminated linens then become a potential source of cross-contamination.
 Option B: There is now a common understanding that linens, once in use,
are usually contaminated and could be harboring microorganisms such as
MRSA and VRE. Further, the Centers for Disease Control and Prevention
(CDC) cautions that healthcare professionals should handle contaminated
textiles and fabrics with minimum agitation to avoid contamination of air,
surfaces, and persons. Even one of the leading nursing textbooks,
Fundamentals of Nursing, Soiled linen is never shaken in the air because
shaking can disseminate secretions and excretions and the microorganisms
they contain. This text also states linens that have been soiled with
excretions and secretions harbor microorganisms that can be transmitted
to others.
 Option C: Healthcare laundry protocols have long relied on chlorine-based
sanitizers to kill bacteria in bed linens and other fabrics. While chlorine is
known as one of the best antimicrobial agents in the world, its power has
been limited because it evaporates from untreated fabric soon after
laundering. But with this new patented technology in HaloShield ® linens,
the chlorine keeps killing bacteria right up until the next laundering.
 Option D: The environment in which linens are used in healthcare is often
ideal for the proliferation and spread of bacteria and viruses. Often the
patient, in a weakened or compromised state, is lying on a sheet. That
sheet under the patient‘s body is warm, dark, and sometimes damp. Most
would agree that those conditions are considered ideal for bacteria and
viruses to thrive.
ADVERTISEMENTS
75. Question
The most important purpose of cleansing bed bath is:

 A. To cleanse, refresh and give comfort to the client who must remain in
bed.
 B. To expose the necessary parts of the body.
 C. To develop skills in bed bath.
 D. To check the body temperature of the client in bed.

Incorrect
Correct Answer: A. To cleanse, refresh and give comfort to the client who
must remain in bed.
The nurse provides a bed bath for patients who must remain in bed and depend
on someone else for their care. It is an important part of the patient‘s daily care.
Not only does it remove sweat, oil, and micro-organisms from the patient‘s skin,
but it also stimulates circulation and promotes a feeling of self-worth by
improving the patient‘s appearance. For patients who are on bedrest, bathing can
also be a time for socialization.
 Option B: During bed bath, the patient is always given privacy so as not to
expose their intimate parts of the body. Some patients cannot safely leave
their beds to bathe. For these people, daily bed baths can help keep their
skin healthy, control odor, and increase comfort. If moving the patient
causes pain, plan to give the patient a bed bath after the person has
received pain medicine and it has taken effect.
 Option C: The nurse may develop her skills in bed bath, but it is not the
main purpose. A bed bath is a good time to inspect a patient‘s skin for
redness and sores. Pay special attention to skin folds and bony areas when
checking. Encourage the patient to be involved as possible in bathing
themselves.
 Option D: A bed bath may give a relaxation effect on the patient. It may
also stimulate blood circulation to the skin, respiration, and elimination;
maintain joint mobility, and improve the patient‘s self-image and
emotional and mental well-being. It provides the nurse with an opportunity
for health teaching and assessment; gives the patient psychological
support, and the process of building rapport may begin during the initial
bath.
1. 1. Question
All of the following can cause tachycardia except:

o A. Fever
o B. Exercise
o C. Sympathetic nervous system stimulation
o D. Parasympathetic nervous system stimulation

Incorrect
Correct Answer: D. Parasympathetic nervous system stimulation
Parasympathetic nervous system stimulation of the heart decreases the heart rate
as well as the force of contraction, rate of impulse conduction and blood flow
through the coronary vessels. Fever, exercise, and sympathetic stimulation all
increase the heart rate. The parasympathetic nervous system (PNS) releases the
hormone acetylcholine to slow the heart rate. Such factors as stress, caffeine, and
excitement may temporarily accelerate your heart rate, while meditating or taking
slow, deep breaths may help to slow your heart rate.
 Option A: Tachypnea and tachycardia develop, and the patient becomes
dehydrated because of sweating and vapor losses from the increased
respiratory rate. Many manifestations of fever are related to the increased
metabolic rate, increased need for oxygen, and use of body proteins as an
energy source.
 Option B: Often, ventricular tachycardia will occur during the recovery
period post exercise due to increased levels of adrenaline. In a study
conducted in 1991, it was found that 70% of patients tested experienced
idiopathic ventricular tachycardia as a result of exercise. Exercising for any
duration will increase your heart rate and will remain elevated for as long
as the exercise is continued. At the beginning of exercise, your body
removes the parasympathetic stimulation, which enables the heart rate to
gradually increase. As you exercise more strenuously, the sympathetic
system ―kicks in‖ to accelerate your heart rate even more.
 Option C: Heart rate is controlled by the two branches of the autonomic
(involuntary) nervous system. The sympathetic nervous system (SNS) and
the parasympathetic nervous system (PNS). The sympathetic nervous
system (SNS) releases the hormones (catecholamines – epinephrine and
norepinephrine) to accelerate the heart rate.
ADVERTISEMENTS
1. Question 2 of 75

2. Question
Palpating the midclavicular line is the correct technique for assessing:
o A. Baseline vital signs
o B. Systolic blood pressure
o C. Respiratory rate
o D. Apical pulse
Incorrect
Correct Answer: D. Apical pulse
The apical pulse (the pulse at the apex of the heart) is located on the
midclavicular line at the fourth, fifth, or sixth intercostal space. Assessing whether
the rhythm of the pulse is regular or irregular is essential. The pulse could be
regular, irregular, or irregularly irregular. Changes in the rate of the pulse, along
with changes in respiration is called sinus arrhythmia. In sinus arrhythmia, the
pulse rate becomes faster during inspiration and slows down during expiration.
Irregularly irregular pattern is more commonly indicative of processes like atrial
flutter or atrial fibrillation.
 Option A: Baseline vital signs include pulse rate, temperature, respiratory
rate, and blood pressure. Vital signs are an objective measurement for the
essential physiological functions of a living organism. They have the name
―vital‖ as their measurement and assessment is the critical first step for any
clinic evaluation. The first set of clinical examinations is an evaluation of the
vital signs of the patient.
 Option B: Blood pressure is typically assessed at the antecubital fossa. The
arm should be supported at the heart level. Unsupported arm leads to 10
mmHg to the pressure readings. The patient‘s blood pressure should get
checked in each arm, and in younger patients, it should be tested in an
upper and lower extremity to rule out the coarctation of the aorta.
 Option C: Respiratory rate is assessed best by observing chest movement
with each inspiration and expiration. The respiratory rate is the number of
breaths per minute. The normal breathing rate is about 12 to 20 beats per
minute in an average adult. In the pediatric age group, it is defined by the
particular age group. Parameters important here again include its rate,
depth of breathing, and its pattern rate of breathing is a crucial parameter.

ADVERTISEMENTS
1. Question 3 of 75
3. Question
The absence of which pulse may not be a significant finding when a patient is
admitted to the hospital?
o A. Apical
o B. Radial
o C. Pedal
o D. Femoral
Incorrect
Correct Answer: C. Pedal
Because the pedal pulse cannot be detected in 10% to 20% of the population, its
absence is not necessarily a significant finding. However, the presence or absence
of the pedal pulse should be documented upon admission so that changes can
be identified during the hospital stay. Absent peripheral pulses may be indicative
of peripheral vascular disease (PVD). PVD may be caused by atherosclerosis,
which can be complicated by an occluding thrombus or embolus. This may be
life-threatening and may cause the loss of a limb.
 Option A: Apical pulse rate is indicated during some assessments, such as
when conducting a cardiovascular assessment and when a client is taking
certain cardiac medications (e.g., digoxin). Sometimes the apical pulse is
auscultated pre and post medication administration. It is also a best
practice to assess apical pulse in infants and children up to five years of
age because radial pulses are difficult to palpate and count in this
population.
 Option B: Examiners frequently evaluate the radial artery during a routine
examination of adults, due to the unobtrusive position required to palpate
it and it‘s easy accessibility in various types of clothing. Like other distal
peripheral pulses (such as those in the feet) it also may be quicker to show
signs of pathology. Palpation is at the anterior wrist just proximal to the
base of the thumb.
 Option D: The femoral pulse may be the most sensitive in assessing for

ADVERTISEMENTS
1. Question 4 of 75
4. Question
Which of the following patients is at greatest risk for developing pressure ulcers?
o A. An alert, chronic arthritic patient treated with steroids and aspirin.
o B. An 88-year old incontinent patient with gastric cancer who is

confined to his bed at home.
o C. An apathetic 63-year old COPD patient receiving nasal oxygen via cannula.
o D. A confused 78-year old patient with congestive heart failure (CHF) who
requires assistance to get out of bed.
Incorrect
Correct Answer: B. An 88-year old incontinent patient with gastric cancer
who is confined to his bed at home.
Pressure ulcers are most likely to develop in patients with impaired mental status,
mobility, activity level, nutrition, circulation and bladder or bowel control. Age is
also a factor. Thus, the 88-year old incontinent patient who has impaired nutrition
(from gastric cancer) and is confined to bed is at greater risk. Pressure injuries are
defined as localized damage to the skin as well as underlying soft tissue, usually
occurring over a bony prominence or related to medical devices. They are the
result of prolonged or severe pressure with contributions from shear and friction
forces.
 Option A: Risk factors for developing pressure injuries, in general, include
immobility, reduced perfusion, malnutrition, and sensory loss. Other
patients at increased risk for pressure injury development include those
with cerebrovascular or cardiovascular disease, recent fracture of a lower
extremity, diabetes, and incontinence. Older patients are also at increased
risk for the formation of pressure injuries due to skin changes associated
with aging, including thinning of the dermis and epidermis, resulting in
decreased resistance to shear forces.

 Option C: The pressure of an individual‘s body weight or pressure from a
medical device above a certain threshold for a prolonged period is thought
to be the cause of pressure injuries. In patients with sensory deficits, an
absent pressure feedback response may result in sustained pressure for a
prolonged period, leading to tissue injury. Many factors are identified in
contributing to pressure ulcer and injury formation, such as increased
arteriole pressure, shearing forces, friction, moisture, and nutrition status.
 Option D: Pressure injuries of the skin and soft tissues affect an estimated
1 to 3 million people in the United States each year. The incidence differs
based on the clinical setting. For example, the prevalence of pressure
injuries among hospitalized patients is 5% to 15%, with the percentage
considerably higher in some long-term care environments and intensive
care units.
ADVERTISEMENTS
1. Question 5 of 75
5. Question
The physician orders the administration of high-humidity oxygen by face mask
and placement of the patient in a high Fowler‘s position. After assessing Mrs.
Paul, the nurse writes the following nursing diagnosis: Impaired gas exchange
related to increased secretions. Which of the following nursing interventions has
the greatest potential for improving this situation?
o A. Encourage the patient to increase her fluid intake to 200 ml every 2

hours.
o B. Place a humidifier in the patient‘s room.
o C. Continue administering oxygen by a high humidity face mask.
o D. Perform chest physiotherapy on a regular schedule.

Incorrect
Correct Answer: A. Encourage the patient to increase her fluid intake to 200
ml every 2 hours
Adequate hydration thins and loosens pulmonary secretions and also helps to
replace fluids lost from elevated temperature, diaphoresis, dehydration, and
dyspnea. Encourage patients to increase fluid intake to 3 liters per day within the

limits of cardiac reserve and renal function. Fluids help minimize mucosal drying
and maximize ciliary action to move secretions.
 Option B: Consider the need for humidifiers in-home care settings. This
facilitates the liquefaction of secretions. Teach the patient the proper ways
of coughing and breathing. (e.g., take a deep breath, hold for 2 seconds,
and cough two or three times in succession). The most convenient way to
remove most secretions is coughing. So it is necessary to assist the patient
during this activity. Deep breathing, on the other hand, promotes
oxygenation before controlled coughing.
 Option C: Maintain humidified oxygen as prescribed. Increasing humidity
of inspired air will reduce the thickness of secretions and aid their removal.
Provide supplemental oxygen if the patient experiences bradycardia, an
increase in ventricular ectopy, and/or significant desaturation. Oxygen
therapy is recommended to improve oxygen saturation and reduce
possible complications.
 Option D: Coordinate with a respiratory therapist for chest physiotherapy
and nebulizer management as indicated. Chest physiotherapy includes the
techniques of postural drainage and chest percussion to mobilize
secretions from smaller airways that cannot be eliminated by means of
coughing or suctioning.
ADVERTISEMENTS
1. Question 6 of 75
6. Question
The most common deficiency seen in alcoholics is:
o A. Thiamine
o B. Riboflavin
o C. Pyridoxine
o D. Pantothenic acid
Incorrect
Correct Answer: A. Thiamine
Chronic alcoholism commonly results in thiamine deficiency and other symptoms
of malnutrition. Chronic alcohol consumption can cause thiamine deficiency and

thus reduced enzyme activity through several mechanisms, including inadequate
dietary intake, malabsorption of thiamine from the gastrointestinal tract, and
impaired utilization of thiamine in the cells.
 Option B: Riboflavin, vitamin B2, is a water-soluble and heat-stable vitamin
that the body uses to metabolize fats, protein, and carbohydrates into
glucose for energy. In addition to boosting energy, riboflavin functions as
an antioxidant for the proper function of the immune system, healthy skin,
and hair. Riboflavin deficiency can result from inadequate dietary intake or
by endocrine abnormalities. Riboflavin deficiency also correlates with other
vitamin B complexes.
 Option C: Vitamin B6 deficiency is usually caused by pyridoxine-
inactivating drugs (eg, isoniazid), protein-energy undernutrition,
malabsorption, alcoholism, or excessive loss. Deficiency can cause
peripheral neuropathy, seborrheic dermatitis, glossitis, and cheilosis, and, in
adults, depression, confusion, and seizures.
 Option D: Pantothenic acid deficiency is very rare in the United States.
Severe deficiency can cause numbness and burning of the hands and feet,
headache, extreme tiredness, irritability, restlessness, sleeping problems,
stomach pain, heartburn, diarrhea, nausea, vomiting, and loss of appetite.
ADVERTISEMENTS
1. Question 7 of 75
7. Question
Which of the following statements is incorrect about a patient with dysphagia?
o A. The patient will find pureed or soft foods, such as custards, easier to
swallow than water.
o B. Fowler‘s or semi Fowler‘s position reduces the risk of aspiration during

swallowing.
o C. The patient should always feed himself.
o D. The nurse should perform oral hygiene before assisting with feeding.
Incorrect
Correct Answer: C. The patient should always feed himself.

A patient with dysphagia (difficulty swallowing) requires assistance with feeding.
Feeding himself is a long-range expected outcome. Dysphagia is defined as
objective impairment or difficulty in swallowing, resulting in an abnormal delay in
the transit of a liquid or solid bolus. The delay may be during the oropharyngeal
or esophageal phase of swallowing.
 Option A: The Academy of Nutrition and Dietetics has created a diet plan
for people with dysphagia. The plan is called the National Dysphagia Diet.
The dysphagia diet has 4 levels of foods. Level 1 foods are foods that are
pureed or smooth, like pudding. They need no chewing. This includes
foods such as yogurt, mashed potatoes with gravy to moisten it, smooth
soups, and pureed vegetables and meats.
 Option B: While eating or drinking, it may help to sit upright, with the back
straight. The client may need support pillows to get into the best position.
It may also help to have few distractions while eating or drinking. Changing
between solid food and liquids may also help the swallowing. Stay upright
for at least 30 minutes after eating. This can help reduce the risk for
aspiration.
 Option D: After meals, it‘s important to do proper oral care. The SLP
(speech-language pathologist) can give the client instructions for the teeth
or dentures. Make sure to not swallow any water during the oral care
routine. While on a dysphagia diet, the client may have trouble taking in
enough fluid. This can cause dehydration, which can lead to serious health
problems. Talk with the healthcare team about how it can be prevented. In
some cases drinking thicker liquids may make some of the medicines work
less well. Because of this, the client may need some of the medicines
changed for a while.
ADVERTISEMENTS
1. Question 8 of 75
8. Question
To assess the kidney function of a patient with an indwelling urinary (Foley)
catheter, the nurse measures his hourly urine output. She should notify the
physician if the urine output is:
o A. Less than 30 ml/hour
o B. 64 ml in 2 hours

o C. 90 ml in 3 hours
o D. 125 ml in 4 hours
Incorrect
Correct Answer: A. Less than 30 ml/hour
A urine output of less than 30ml/hour indicates hypovolemia or oliguria, which is
related to kidney function and inadequate fluid intake. Urine output is a
noninvasive method to measure fluid balance once intravascular volume has
been restored. Normal urine output is defined as 1.5 to 2 mL/kg per hour
 Option B: Micturition process entails contraction of the detrusor muscle
and relaxation of the internal and external urethral sphincter. The process is
slightly different based on age. Children younger than three years old have
the micturition process coordinated by the spinal reflex.
 Option C: It starts with urine accumulation in the bladder that stretches the
detrusor muscle causing activation of stretch receptors. The stretch
sensation is carried by the visceral afferent to the sacral region of the spinal
cord where it synapses with the interneuron that excites the
parasympathetic neurons and inhibits the sympathetic neurons. The
visceral afferent impulse concurrently decreases the firing of the somatic
efferent that normally keeps the external urethral sphincter closed allowing
reflexive urine output.
 Option D: Low bladder volume activates the pontine storage center which
activates the sympathetic nervous system and inhibits the parasympathetic
nervous system cumulatively allowing the accumulation of urine in the
bladder. High bladder volume activates the pontine micturition center
which activates the parasympathetic nervous system and inhibits the
sympathetic nervous system as well as triggers awareness of a full bladder;
consequently leading to relaxation of the internal sphincter and a choice to
relax the external urethral sphincter once ready to void.
ADVERTISEMENTS
1. Question 9 of 75
9. Question
Certain substances increase the amount of urine produced. These include:
o A. Caffeine-containing drinks, such as coffee and cola

o B. Beets
o C. Urinary analgesics
o D. Kaolin with pectin (Kaopectate)

Incorrect
Correct Answer: A. Caffeine-containing drinks, such as coffee and cola.
Fluids containing caffeine have a diuretic effect. Drinking caffeine-containing
beverages as part of a normal lifestyle doesn‘t cause fluid loss in excess of the
volume ingested. While caffeinated drinks may have a mild diuretic effect —
meaning that they may cause the need to urinate — they don‘t appear to
increase the risk of dehydration.
 Option B: In some people, eating beets turn urine pink or red—which can
be alarming because it looks like blood in the urine. These odor and color
changes are harmless. But if urine smells sweet, that‘s a cause for concern
because it could mean diabetes.
 Option C: Pyridium will most likely darken the color of urine to an orange
or red color. This is a normal effect and is not cause for alarm unless there
are other symptoms such as pale or yellowed skin, fever, stomach pain,
nausea, and vomiting.
 Option D: Kaopectate is an antidiarrheal medication. This medication is
used to treat occasional upset stomach, heartburn, and nausea. It is also
used to treat diarrhea and help prevent travelers‘ diarrhea. It works by
helping to slow the growth of bacteria that might be causing diarrhea. This
product should not be used to self-treat diarrhea if there is also fever or
blood/mucus in the stools. These could be signs of a serious health
condition.
ADVERTISEMENTS
10. Question
A male patient who had surgery 2 days ago for head and neck cancer is about to
make his first attempt to ambulate outside his room. The nurse notes that he is
steady on his feet and that his vision was unaffected by the surgery. Which of the
following nursing interventions would be appropriate?

o A. Encourage the patient to walk in the hall alone.
o B. Discourage the patient from walking in the hall for a few more days.
o C. Accompany the patient for his walk.
o D. Consult a physical therapist before allowing the patient to ambulate.

Incorrect
Correct Answer: C. Accompany the patient for his walk.
Accompanying him will offer moral support, enabling him to face the rest of the
world. Ambulation stimulates circulation which can help stop the development of
stroke-causing blood clots. Walking improves blood flow which aids in quicker
wound healing. The gastrointestinal, genitourinary, pulmonary and urinary tract
functions are all improved by walking.
 Option A: A hospitalized surgical patient leaving his room for the first time
fears rejection and others staring at him, so he should not walk alone.
Refusal to ambulate correlated with those that eventually developed a
complication. Those that eventually developed a postoperative
complication were more likely to be in the higher refusal group. Thorn et
al. suggested that patient compliance may be a marker of underlying
complications. If patients are not engaged in their recovery, there may be a
physiologic reason for refusal (i.e., a developing abscess).
 Option B: Patients should begin ambulation as soon as possible after
surgery to decrease complications and to regain strength and confidence.
The multiple physiological benefits of patient ambulation have been
documented including the prevention of muscular and cardiovascular
deconditioning, reducing the risk of pulmonary and thromboembolic
events, and stimulating gastrointestinal recovery through prokinetic effects
 Option D: Waiting to consult a physical therapist is unnecessary. Daily
ambulation requires collaboration between hospital resources, patient
education and available personnel. Second, aggressive non-opioid pain
medication regimens are critical to maintain a low mLOS. The increasing
use of narcotics especially with a PCA prolonged the LOS. Third, refusal of
ambulation often predicted the development of a postoperative
complication.
ADVERTISEMENTS

11. Question
A patient has exacerbation of chronic obstructive pulmonary disease (COPD)
manifested by shortness of breath; orthopnea: thick, tenacious secretions; and a
dry hacking cough. An appropriate nursing diagnosis would be:
o A. Ineffective airway clearance related to thick, tenacious secretions
o B. Ineffective airway clearance related to dry, hacking cough
o C. Ineffective individual coping to COPD
o D. Pain related to immobilization of affected leg

Incorrect
Correct Answer: A. Ineffective airway clearance related to thick, tenacious
secretions.
Thick, tenacious secretions, a dry, hacking cough, orthopnea, and shortness of
breath are signs of ineffective airway clearance. Chronic obstructive pulmonary
disease (COPD) is a common and treatable disease characterized by progressive
airflow limitation and tissue destruction. It is associated with structural lung
changes due to chronic inflammation from prolonged exposure to noxious
particles or gases most commonly cigarette smoke. Chronic inflammation causes
airway narrowing and decreased lung recoil. The disease often presents with
symptoms of cough, dyspnea, and sputum production.
 Option B: Ineffective airway clearance related to dry, hacking cough is
incorrect because the cough is not the reason for the ineffective airway
clearance. COPD is an inflammatory condition involving the airways, lung
parenchyma, and pulmonary vasculature. The process is thought to involve
oxidative stress and protease-antiprotease imbalances. Emphysema
describes one of the structural changes seen in COPD where there is the
destruction of the alveolar air sacs (gas-exchanging surfaces of the lungs)
leading to obstructive physiology.
 Option C: Ineffective individual coping related to COPD is wrong because
the etiology for a nursing diagnosis should not be a medical diagnosis
(COPD) and because no data indicate that the patient is coping
ineffectively. In emphysema, an irritant (e.g., smoking) causes an
inflammatory response. Neutrophils and macrophages are recruited and
release multiple inflammatory mediators. Oxidants and excess proteases

leading to the destruction of the air sacs. The protease-mediated
destruction of elastin leads to a loss of elastic recoil and results in airway
collapse during exhalation.
 Option D: Pain related to immobilization of affected legs would be an
appropriate nursing diagnosis for a patient with a leg fracture. COPD will
typically present in adulthood and often during the winter months. Patients
usually present with complaints of chronic and progressive dyspnea,
cough, and sputum production. Patients may also have wheezing and chest
tightness. While a smoking history is present in most cases, there are many
without such history.
ADVERTISEMENTS
12. Question
Mrs. Lim begins to cry as the nurse discusses hair loss. The best response would
be:
o A. ―Don‘t worry. It‘s only temporary‖
o B. ―Why are you crying? I didn‘t get to the bad news yet‖
o C. ―Your hair is really pretty‖
o D. “I know this will be difficult for you, but your hair will grow back
after the completion of chemotherapy”
Incorrect
Correct Answer: D. “I know this will be difficult for you, but your hair will
grow back after the completion of chemotherapy”
―I know this will be difficult‖ acknowledges the problem and suggests a resolution
to it. The term alopecia means hair loss regardless of the cause. It is not exclusive
to the scalp; it can be anywhere on the body. As an individual grows older, they
will lose hair. The difference between male hair loss and female hair loss is the
pattern. Men generally lose hair in the front and the temporal region, while
women tend to lose hair from the central area of the scalp. Also, female hair loss
will not end up with complete baldness, whereas male hair loss can end up with
complete baldness.

 Option A: ―Don‘t worry..‖ offers some relief but doesn‘t recognize the
patient‘s feelings. The epidemiology is variable depending on the cause of
alopecia and the type. In alopecia areata, the prevalence is 0.2% with no
racial or sexual predilection, and it may affect any age group. Androgenetic
alopecia is a common disorder affecting 50% of men and 15% of women,
especially postmenopausal women.
 Option B: ―..I didn‘t get to the bad news yet‖ would be inappropriate at
any time. Pathophysiology is dependent on the type of alopecia. In
alopecia areata, it is unknown, but the most common hypothesis involves
autoimmunity in the form of a T-cell–mediated pathway. In androgenetic
alopecia, both genetic and hormonal androgens play a role in
pathogenesis. In telogen effluvium, the shedding of hair is under the
influence of hormone or stress, but sometimes the trigger is not very clear.
 Option C: ―Your hair is really pretty‖ offers no consolation or alternatives to
the patient. During the physical examination, it is essential to notice the
pattern of hair loss. In a patient with androgenetic alopecia, patients tend
to lose hair from the frontal and temporal area (male type) and the central
scalp area (female type). In alopecia areata, the patient may lose hair from
a single area (alopecia areata classical type), the whole scalp and eyebrows
(alopecia totalis), or from the entire body (alopecia universalis). In tinea
capitis, the classic presentation is black dots associated with broken hair,
while the inflammatory type (favus) correlates with the scarring type of
alopecia.
ADVERTISEMENTS
13. Question
An additional Vitamin C is required during all of the following periods except:
o A. Infancy
o B. Young adulthood
o C. Childhood
o D. Pregnancy
Incorrect

Correct Answer: B. Young adulthood
Additional Vitamin C is needed in growth periods, such as infancy and childhood,
and during pregnancy to supply demands for fetal growth and maternal tissues.
Other conditions requiring extra vitamin C include wound healing, fever, infection
and stress. Vitamin C is a water-soluble vitamin, antioxidant, and essential
cofactor for collagen biosynthesis, carnitine and catecholamine metabolism, and
dietary iron absorption. Humans are unable to synthesize vitamin C, so they can
only obtain it through dietary intake of fruits and vegetables.
 Option A: An infant requires Vitamin C. Although most vitamin C is
completely absorbed in the small intestine, the percentage of absorbed
vitamin C decreases as intraluminal concentrations increase. Proline
residues on procollagen require vitamin C for the hydroxylation, making it
necessary for the triple-helix formation of mature collagen. The lack of a
stable triple-helical structure compromises the integrity of the skin, mucous
membranes, blood vessels, and bone.
 Option C: Children need lots of Vitamin C. Usual dietary doses of up to 100
mg/day are almost completely absorbed. The highest concentrations of
ascorbic acid are in the pituitary gland, the adrenal gland, the brain,
leukocytes, and eyes. Ascorbic acid functions as a cofactor, enzyme
complement, co-substrate, and a powerful antioxidant in a variety of
reactions and metabolic processes. It also stabilizes vitamin E and folic acid
and enhances iron absorption. It neutralizes free radicals and toxins as well
as attenuates inflammatory response, including sepsis syndrome.
 Option D: A pregnant woman requires an abundant amount of Vitamin C.
The average protective adult dose of vitamin C is 70 to 150 mg daily.
Increase the dose to 300 mg to 1 g daily when scurvy is present. Daily need
increases in patients with conditions like gingivitis, asthma, glaucoma,
collagen disorders, heatstroke, arthritis, infections (pneumonia, sinusitis,
rheumatic fever), and chronic illnesses. Hemovascular disorders, burns, and
delayed wound healing are causes for an increase in daily intake.
ADVERTISEMENTS
14. Question
A prescribed amount of oxygen is needed for a patient with COPD to prevent:

o A. Cardiac arrest related to increased partial pressure of carbon dioxide in
arterial blood (PaCO2).
o B. Circulatory overload due to hypervolemia.
o C. Respiratory excitement.
o D. Inhibition of the respiratory hypoxic stimulus.

Incorrect
Correct Answer: D. Inhibition of the respiratory hypoxic stimulus.
Delivery of more than 2 liters of oxygen per minute to a patient with chronic
obstructive pulmonary disease (COPD), who is usually in a state of compensated
respiratory acidosis (retaining carbon dioxide (CO2)), can inhibit the hypoxic
stimulus for respiration. Long-term oxygen therapy is used for COPD if the client
has low levels of oxygen in the blood (hypoxia). It is used mostly to slow or
prevent right-sided heart failure. It can help the client live longer.
 Option A: An increased partial pressure of carbon dioxide in arterial blood
(PACO2) would not initially result in cardiac arrest. Long-term oxygen
therapy should be used for at least 15 hours a day with as few interruptions
as possible. Regular use can reduce the risk of death from low oxygen
levels.. To get the most benefit from oxygen, the client should use it 24
hours a day. Supplemental oxygen is a well-established therapy with clear
evidence for benefit in patients with COPD and severe resting hypoxemia,
which is defined as a room air Pao2 ? 55 mm Hg or ? 59 mm Hg with signs
of right-sided heart strain or polycythemia.
 Option B: Long-term use of supplemental oxygen improves survival in
patients with COPD and severe resting hypoxemia. However, the role of
oxygen in symptomatic patients with COPD and more moderate
hypoxemia at rest and desaturation with activity is unclear. The few long-
term reports of supplemental oxygen in this group have been of small size
and insufficient to demonstrate a survival benefit.
 Option C: Circulatory overload and respiratory excitement have no
relevance to the question. Short-term trials have suggested beneficial
effects other than survival in patients with COPD and moderate hypoxemia
at rest. In addition, supplemental oxygen appeared to improve exercise
performance in small short-term investigations of patients with COPD and
moderate hypoxemia at rest and desaturation with exercise, but long-term
trials evaluating patient-reported outcomes are lacking.

ADVERTISEMENTS
15. Question
After 1 week of hospitalization, Mr. Gray develops hypokalemia. Which of the
following is the most significant symptom of his disorder?
o A. Lethargy
o B. Increased pulse rate and blood pressure
o C. Muscle weakness
o D. Muscle irritability
Incorrect
Correct Answer: C. Muscle weakness
Presenting symptoms of hypokalemia ( a serum potassium level below 3.5
mEq/liter) include muscle weakness, chronic fatigue, and cardiac dysrhythmias.
The combined effects of inadequate food intake and prolonged diarrhea can
deplete the potassium stores of a patient with GI problems. Significant muscle
weakness occurs at serum potassium levels below 2.5 mmol/L but can occur at
higher levels if the onset is acute. Similar to the weakness associated with
hyperkalemia, the pattern is ascending in nature affecting the lower extremities,
progressing to involve the trunk and upper extremities, and potentially advancing
to paralysis.
 Option A: Periodic paralysis is a rare neuromuscular disorder, which is
inherited or acquired, that is caused by an acute transcellular shift of
potassium into the cells. It is characterized by potentially fatal episodes of
muscle weakness or paralysis that can affect the respiratory muscles.
Clinical manifestations mainly involve the musculoskeletal and
cardiovascular systems. Hence, the physical exam should focus on
identifying neurologic manifestations and cardiac dysrhythmias.
 Option B: Clinical symptoms of hypokalemia do not become evident until
the serum potassium level is less than 3 mmol/L unless there is a
precipitous fall or the patient has a process that is potentiated by
hypokalemia. The severity of symptoms also tends to be proportional to
the degree and duration of hypokalemia. Symptoms resolve with
correction of the hypokalemia.

 Option D: Affected muscles can include the muscles of respiration which
can lead to respiratory failure and death. Involvement of GI muscles can
cause an ileus with associated symptoms of nausea, vomiting, and
abdominal distension. Severe hypokalemia can also lead to muscle cramps,
rhabdomyolysis, and resultant myoglobinuria.
ADVERTISEMENTS
16. Question
Which of the following nursing interventions promotes patient safety?
o A. Assess the patient‘s ability to ambulate and transfer from a bed to a chair.
o B. Demonstrate the signal system to the patient.
o C. Check to see that the patient is wearing his identification band.
o D. All of the above.

Incorrect
Patient Safety is a healthcare discipline that emerged with the evolving
complexity in health care systems and the resulting rise of patient harm in health
care facilities. It aims to prevent and reduce risks, errors, and harm that occur to
patients during the provision of health care. A cornerstone of the discipline is a
continuous improvement based on learning from errors and adverse events.
 Option A: Assisting a patient with ambulation and transfer from a bed to a
chair allows the nurse to evaluate the patient‘s ability to carry out these
functions safely. Patient safety is fundamental to delivering quality essential
health services. Indeed, there is a clear consensus that quality health
services across the world should be effective, safe, and people-centered. In
addition, to realize the benefits of quality health care, health services must
be timely, equitable, integrated, and efficient.
 Option B: Demonstrating the signal system and providing an opportunity
for a return demonstration ensures that the patient knows how to operate
the equipment and encourages him to call for assistance when needed. To
ensure successful implementation of patient safety strategies; clear policies,
leadership capacity, data to drive safety improvements, skilled health care

professionals, and effective involvement of patients in their care, are all
needed.
 Option C: Checking the patient‘s identification band verifies the patient‘s
identity and prevents identification mistakes in drug administration. Safety
of patients during the provision of health services that are safe and of high
quality is a prerequisite for strengthening health care systems and making
progress towards effective universal health coverage (UHC) under
Sustainable Development Goal 3 (Ensure healthy lives and promote health
and well-being for all at all ages).
ADVERTISEMENTS
17. Question
Studies have shown that about 40% of patients fall out of bed despite the use of
side rails; this has led to which of the following conclusions?
o A. Side rails are ineffective.
o B. Side rails should not be used.
o C. Side rails are a deterrent that prevent a patient from falling out of bed.
o D. Side rails are a reminder to a patient not to get out of bed.

Incorrect
Correct Answer: D. Side rails are a reminder to a patient not to get out of
bed.
Since about 40% of patients fall out of bed despite the use of side rails, side rails
cannot be said to prevent falls; however, they do serve as a reminder that the
patient should not get out of bed. A process that requires ongoing patient
evaluation and monitoring will result in optimizing bed safety. Many patients go
through a period of adjustment to become comfortable with new options.
Patients and their families should talk to their health care planning team to find
out which options are best for them.
 Option A: Patients who have problems with memory, sleeping,
incontinence, pain, uncontrolled body movement, or who get out of bed
and walk unsafely without assistance, must be carefully assessed for the
best ways to keep them from harm, such as falling. Assessment by the

patient‘s health care team will help to determine how best to keep the
patient safe.
 Option B: Historically, physical restraints (such as vests, ankle or wrist
restraints) were used to try to keep patients safe in health care facilities. In
recent years, the health care community has recognized that physically
restraining patients can be dangerous. Although not indicated for this use,
bed rails are sometimes used as restraints. Regulatory agencies, health care
organizations, product manufacturers, and advocacy groups encourage
hospitals, nursing homes, and home care providers to assess patients‘
needs and to provide safe care without restraints.
 Option C: Anticipate the reasons patients get out of bed such as hunger,
thirst, going to the bathroom, restlessness, and pain; meet these needs by
offering food and fluids, scheduling ample toileting, and providing calming
interventions and pain relief. When bed rails are used, perform an on-
going assessment of the patient‘s physical and mental status; closely
monitor high-risk patients.
ADVERTISEMENTS
18. Question
Examples of patients suffering from impaired awareness include all of the
following except:
o A. A semiconscious or over fatigued patient.
o B. A disoriented or confused patient.
o C. A patient who cannot care for himself at home.
o D. A patient demonstrating symptoms of drugs or alcohol withdrawal.

Incorrect
Correct Answer: C. A patient who cannot care for himself at home
A patient who cannot care for himself at home does not necessarily have
impaired awareness; he may simply have some degree of immobility.
 Option A: Fatigue is the feeling of tiredness and decreased energy that
results from inadequate sleep time or poor quality of sleep. Fatigue can
also result from increased work intensity or long work hours. Sleep

deprivation has long been known to impair various cognitive functions,
including mood, motivation, response time, and initiative. In a classic
review of sleep deprivation and decision-making, investigators argued that
effective performance in health care environments requires naturalistic
decision-making and situation awareness.
 Option B: Impaired self-awareness of deficits is a common finding in
patients who have suffered a traumatic brain injury. Impaired awareness
can limit motivation for treatment and contribute to a poor outcomes.
Consequently, it is important for brain injury rehabilitation professionals to
understand this phenomenon and utilize treatment approaches that may
improve patient awareness.
 Option D: Most alcoholics exhibit mild-to-moderate deficiencies in
intellectual functioning, along with diminished brain size and regional
changes in brain-cell activity. The most prevalent alcohol-associated brain
impairments affect visuospatial abilities and higher cognitive functioning.
Visuospatial abilities include perceiving and remembering the relative
locations of objects in 2- and 3-dimensional space. Examples include
driving a car or assembling a piece of furniture based on instructions
contained in a line drawing. Higher cognitive functioning includes the
abstract-thinking capabilities needed to organize a plan, set it in motion,
and change it as needed.
ADVERTISEMENTS
19. Question
The most common injury among elderly persons is:
o A. Atherosclerotic changes in the blood vessels
o B. Increased incidence of gallbladder disease
o C. Urinary Tract Infection
o D. Hip fracture
Incorrect
Correct Answer: D. Hip fracture

Hip fracture, the most common injury among elderly persons, usually results from
osteoporosis. Hip fractures from falls are one of the leading causes of injuries for
seniors and result in the largest number of hospitalizations. Family members and
hourly caregivers can take steps to prevent falls, such as removing area rugs,
improving lighting throughout the home, and offering mobility support when
needed.
 Option A: Some changes in the heart and blood vessels normally occur
with age. However, many other changes that are common with aging are
due to modifiable factors. If not treated, these can lead to heart disease.
Arteriosclerosis (hardening of the arteries) is very common. Fatty plaque
deposits inside the blood vessels cause them to narrow and totally block
blood vessels. The capillary walls thicken slightly. This may cause a slightly
slower rate of exchange of nutrients and wastes.
 Option B: Increasing age is a major risk factor for their formation, with the
prevalence of gallstones being greatest at advanced age. While the
majority of gallstones remain asymptomatic, seniors have a high risk for
acute cholecystitis with atypical presentation, even when gangrene or
perforation has occurred.
 Option C: The main cause of UTIs, at any age, is usually bacteria.
Escherichia coli is the primary cause, but other organisms can also cause a
UTI. In older adults who use catheters or live in a nursing home or other
full-time care facility, bacteria such as Enterococci and Staphylococci are
more common causes.
ADVERTISEMENTS
20. Question
The most common psychogenic disorder among elderly person is:
o A. Depression
o B. Sleep disturbances (such as bizarre dreams)
o C. Inability to concentrate
o D. Decreased appetite
Incorrect

Correct Answer: A. Depression
Depression typically begins before the onset of old age and usually is caused by
psychosocial, genetic, or biochemical factors. Depression is a common problem
among older adults, but it is NOT a normal part of aging. In fact, studies show
that most older adults feel satisfied with their lives, despite having more illnesses
or physical problems. However, important life changes that happen as we get
older may cause feelings of uneasiness, stress, and sadness. Sometimes older
people who are depressed appear to feel tired, have trouble sleeping, or seem
grumpy and irritable. Confusion or attention problems caused by depression can
sometimes look like Alzheimer‘s disease or other brain disorders.
 Option B: Primary sleep disorders are more common in the elderly than in
younger persons. Restless legs syndrome and periodic limb movement
disorder can disrupt sleep and may respond to low doses of
antiparkinsonian agents as well as other drugs. Sleep apnea can lead to
excessive daytime sleepiness.
 Option C: A study finds that seniors‘ attention shortfall is associated with
the locus coeruleus, a tiny region of the brainstem that connects to many
other parts of the brain. The locus coeruleus helps focus brain activity
during periods of stress or excitement. Increased distractibility is a sign of
cognitive aging.
 Option D: 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.
ADVERTISEMENTS
21. Question
Which of the following vascular system changes results from aging?
o A. Increased peripheral resistance of the blood vessels
o B. Decreased blood flow
o C. Increased workload of the left ventricle

Incorrect
Aging decreases the elasticity of the blood vessels, which leads to increased
peripheral resistance and decreased blood flow. These changes, in turn, increase
the workload of the left ventricle. Some changes in the heart and blood vessels
normally occur with age. However, many other changes that are common with
aging are due to modifiable factors. If not treated, these can lead to heart
disease.
 Option A: Receptors called baroreceptors monitor the blood pressure and
make changes to help maintain a fairly constant blood pressure when a
person changes positions or is doing other activities. The baroreceptors
become less sensitive with aging. This may explain why many older people
have orthostatic hypotension, a condition in which the blood pressure falls
when a person goes from lying or sitting to standing. This causes dizziness
because there is less blood flow to the brain.
 Option B: The main artery from the heart (aorta) becomes thicker, stiffer,
and less flexible. This is probably related to changes in the connective
tissue of the blood vessel wall. This makes the blood pressure higher and
makes the heart work harder, which may lead to thickening of the heart
muscle (hypertrophy). The other arteries also thicken and stiffen. In general,
most older people have a moderate increase in blood pressure.
 Option C: The heart has a natural pacemaker system that controls the
heartbeat. Some of the pathways of this system may develop fibrous tissue
and fat deposits. The natural pacemaker (the SA node) loses some of its
cells. These changes may result in a slightly slower heart rate. A slight
increase in the size of the heart, especially the left ventricle occurs in some
people. The heart wall thickens, so the amount of blood that the chamber
can hold may actually decrease despite the increased overall heart size. The
heart may fill more slowly.
ADVERTISEMENTS
22. Question
Which of the following is the most common cause of dementia among elderly
persons?

o A. Parkinson‘s disease
o B. Multiple sclerosis
o C. Amyotrophic lateral sclerosis (Lou Gehrig‘s disease)
o D. Alzheimer’s disease
Incorrect
Correct Answer: D. Alzheimer’s disease
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. Alzheimer‘s is
the most common cause of dementia among older adults. Dementia is the loss of
cognitive functioning—thinking, remembering, and reasoning—and behavioral
abilities to such an extent that it interferes with a person‘s daily life and activities.
 Option A: Parkinson‘s disease is a neurologic disorder caused by lesions in
the extrapyramidal system and manifested by tremors, muscle rigidity,
hypokinesia, dysphagia, and dysphonia. Parkinson‘s disease is a
neurodegenerative disorder that mostly presents in later life with
generalized slowing of movements (bradykinesia) and at least one other
symptom of resting tremor or rigidity. Other associated features are a loss
of smell, sleep dysfunction, mood disorders, excess salivation, constipation,
and excessive periodic limb movements in sleep (REM behavior disorder).
 Option B: 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. Multiple sclerosis (MS) is
a chronic autoimmune disease of the central nervous system (CNS)
characterized by inflammation, demyelination, gliosis, and neuronal loss.
Pathologically, perivascular lymphocytic infiltrates, and macrophages
produce degradation of myelin sheaths that surround neurons.
 Option C: 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. Amyotrophic lateral
sclerosis (ALS), also known as ―Lou Gehrig‘s disease,‖ is a
neurodegenerative disease of the motor neurons. No single etiology has
been proven; rather, multiple pathways (both heritable and sporadic) have
been shown to result in unmistakably similar disease entities. ALS
necessarily affects both upper and lower motor neurons with variable

patterns of onset, most commonly beginning with signs of lower motor
neuron degeneration within proximal limbs.
ADVERTISEMENTS
23. Question
The nurse‘s most important legal responsibility after a patient‘s death in a
hospital is:
o A. Obtaining a consent of an autopsy.
o B. Notifying the coroner or medical examiner.
o C. Labeling the corpse appropriately.
o D. Ensuring that the attending physician issues the death certification.

Incorrect
Correct Answer: C. Labeling the corpse appropriately.
The nurse is legally responsible for labeling the corpse when death occurs in the
hospital. After a person dies it is important to give the family the time that they
need with the body. Some family members might like to lie in bed with their
loved one who has died, while others might like to be involved with washing the
body. Others may not want to be there at all. Washing the body is particularly
important in paediatric palliative care, as often parents feel it is a special ritual to
have washed their baby after they are born, and it is the same after they die. It is
important to discuss rigor mortis with families as people are often unaware of
this.
 Option A: She may be involved in obtaining consent for an autopsy. There
are considerations regarding care and preparation of the body after
someone dies. Traditionally this task was performed by families, but
nowadays much of the preparation of a body is done by nursing staff or
undertakers. The required procedures are often included in an
organizations‘ procedures manual or there may be local requirements
regarding the preparation of a body.
 Option B: The nurse may be responsible for notifying the coroner or
medical examiner of a patient‘s death; however, she is not legally
responsible for performing these functions. Depending on the location of

the death, the nurse would contact the medical examiner to notify them of
the death, as well as the physician and other clinicians who were involved
with the patient. The nurse can also contact the funeral home for the family
as requested.
 Option D: The attending physician may need information from the nurse
to complete the death certificate, but he is responsible for issuing it. A
doctor must certify the death. This involves completing a medical
certificate of the cause of death and stating what the cause of death was.
This should happen as soon as possible. If there are any unexpected or
suspicious circumstances, or if the cause of death is not known, the doctor
may not be able to issue a death certificate without talking to the coroner
(England, Wales, and Northern Ireland) or procurator fiscal (Scotland). The
doctor completing the certificate may wish to talk to you as part of their
standard checks.
ADVERTISEMENTS
24. Question
Before rigor mortis occurs, the nurse is responsible for:
o A. Providing a complete bath and dressing change.
o B. Placing one pillow under the body’s head and shoulders.
o C. Removing the body‘s clothing and wrapping the body in a shroud.
o D. Allowing the body to relax normally.

Incorrect
Correct Answer: B. Placing one pillow under the body’s head and shoulders.
The nurse must place a pillow under the deceased person‘s head and shoulders
to prevent blood from settling in the face and discoloring it. A body undergoes
complex and intricate changes after death. These post mortem changes depend
on a diverse range of variables. Factors such as the ambient temperature, season,
and geographical location at which the body is found, the fat content of the
body, sepsis/injuries, intoxication, presence of clothes/insulation over the body,
etc. determine the rate at which post-mortem changes occur in a cadaver.

 Option A: She is required to bathe only soiled areas of the body since the
mortician will wash the entire body. Changes that occur to a body after
death are a result of complex physicochemical and environmental
processes. They are affected by factors within the cadaver and outside it.
These factors affect the onset and either increase the rate of post-mortem
changes or retard it. Factors that hasten the rate of post mortem changes
include hot and humid climate, presence of body fat, open injuries on the
body, sepsis or infection, and the location of the cadaver in the open.
 Option C: Before wrapping the body in a shroud, the nurse places a clean
gown on the body and closes the eyes and mouth. Rigor Mortis appears in
1 to 2 hours after death, is completely formed 12 hours after death, is
sustained for the next 12 hours, and vanishes over the next 12 hours,
sometimes referred to as the ‗march of rigor.‘
 Option D: Rigor mortis appears rapidly in children and old aged
individuals, in cases of persons dying of diseases or conditions involving
great exhaustion such as cholera, or due to convulsions as in cases of
strychnine poisoning. In such cases, the rigor disappears early as well. The
effect of rigor on individual muscles can be of additional significance. The
rigor of erector pilae muscles may cause elevation of hair leading to the
pimpled appearance of the skin.
ADVERTISEMENTS
25. Question
When a patient in the terminal stages of lung cancer begins to exhibit loss of
consciousness, a major nursing priority is to:
o A. Protect the patient from injury.
o B. Insert an airway.
o C. Elevate the head of the bed.
o D. Withdraw all pain medications.

Incorrect
Correct Answer: A. Protect the patient from injury

Ensuring the patient‘s safety is the most essential action at this time. This phase is
different for each patient, and the needs may differ for each patient and family,
but it is vital for healthcare providers to provide care and support in a way that
respects the patient‘s dignity and autonomous wishes.
 Option B: The vast majority of patients who experience a natural death,
meaning no medical, life-saving interventions to counter the process,
follow a stereotypical pattern of signs and symptoms in the time leading
up to death. This time frame is often referred to as ―actively dying‖ or
―imminent death.‖ It is important for healthcare providers to be familiar
with this process, not only so they know what to expect when providing
direct care to patients during this time, but also so they can guide the
family in understanding what to expect during this process and providing
support as needed.
 Option C: The self-determination of the patient with capacity must be
respected. When the patient can make their own choices, their autonomy
must be upheld. It is not the role of the provider to impart their values and
beliefs onto patients. Patients‘ families may experience anticipatory grief
and have a hard time fully handling the current situation, and they may
want to push their personal choices for the situation instead of respecting
their loved one‘s wishes and choices.
 Option D: The primary goal in treatment for patients is alleviating
suffering. Hospice care and palliative care are often confused. Hospice care
is the term given to the care provided when a patient is given a prognosis
of death within 6 months, and they do not pursue curative treatments.
They focus on improving the quality of life which can mean many things.
Palliative care can be incorporated into the plan of care at any time for any
patient who is experiencing suffering and wants to ease that suffering
without directly treating the cause of that suffering.
ADVERTISEMENTS
26. Question
Which element in the circular chain of infection can be eliminated by preserving
skin integrity?
o A. Host

o B. Reservoir
o C. Mode of transmission
o D. Portal of entry
Incorrect
Correct Answer: D. Portal of entry
In the circular chain of infection, pathogens must be able to leave their reservoir
and be transmitted to a susceptible host through a portal of entry, such as
broken skin. The portal of entry refers to the manner in which a pathogen enters
a susceptible host. The portal of entry must provide access to tissues in which the
pathogen can multiply or a toxin can act. Often, infectious agents use the same
portal to enter a new host that they used to exit the source host.
 Option A: The final link in the chain of infection is a susceptible host.
Susceptibility of a host depends on genetic or constitutional factors,
specific immunity, and nonspecific factors that affect an individual‘s ability
to resist infection or to limit pathogenicity. An individual‘s genetic makeup
may either increase or decrease susceptibility.
 Option B: The reservoir of an infectious agent is the habitat in which the
agent normally lives, grows, and multiplies. Reservoirs include humans,
animals, and the environment. The reservoir may or may not be the source
from which an agent is transferred to a host.
 Option C: An infectious agent may be transmitted from its natural
reservoir to a susceptible host in different ways. There are different
classifications for modes of transmission. In direct transmission, an
infectious agent is transferred from a reservoir to a susceptible host by
direct contact or droplet spread. Indirect transmission refers to the transfer
of an infectious agent from a reservoir to a host by suspended air particles,
inanimate objects (vehicles), or animate intermediaries (vectors).
ADVERTISEMENTS
27. Question
Which of the following will probably result in a break in sterile technique for
respiratory isolation?

o A. Opening the patient‘s window to the outside environment.
o B. Turning on the patient‘s room ventilator.
o C. Opening the door of the patient’s room leading into the hospital
corridor.
o D. Failing to wear gloves when administering a bed bath.

Incorrect
Correct Answer: C. Opening the door of the patient’s room leading into the
hospital corridor.
Respiratory isolation, like strict isolation, requires that the door to the door
patient‘s room remain closed. Appropriate patient placement is a significant
component of isolation precautions. A private room is important to prevent
direct- or indirect-contact transmission when the source patient has poor
hygienic habits, contaminates the environment, or cannot be expected to assist in
maintaining infection control precautions to limit transmission of microorganisms
(ie, infants, children, and patients with altered mental status).
 Option A: Opening the patient‘s window is acceptable because the room
needs to be well-ventilated. A private room with appropriate air handling
and ventilation is particularly important for reducing the risk of
transmission of microorganisms from a source patient to susceptible
patients and other persons in hospitals when the microorganism is spread
by airborne transmission. Some hospitals use an isolation room with an
anteroom as an extra measure of precaution to prevent airborne
transmission.
 Option B: The patient‘s room should be well ventilated, so turning on the
ventilator is desirable.
 Option D: The nurse does not need to wear gloves for respiratory isolation,
but good handwashing is important for all types of isolation. Wearing
gloves does not replace the need for handwashing, because gloves may
have small, apparent defects or may be torn during use, and hands can
become contaminated during removal of gloves. Failure to change gloves
between patient contacts is an infection control hazard.
ADVERTISEMENTS
28. Question

Which of the following patients is at greater risk for contracting an infection?
o A. A postoperative patient who has undergone orthopedic surgery.
o B. A patient receiving broad-spectrum antibiotics.
o C. A patient with leukopenia.
o D. A newly diagnosed diabetic patient.

Incorrect
Correct Answer: C. A patient with leukopenia.
Leukopenia is a decreased number of leukocytes (white blood cells), which are
important in resisting infection. Leukopenia is a condition where a person has a
reduced number of white blood cells. This increases their risk of infections. A
person‘s blood is made up of many different types of blood cells. White blood
cells, also known as leukocytes, help to fight off infection. Leukocytes are a vital
part of the immune system.
 Option A: Surgical site infections (SSI) following total hip arthroplasty
(THA) have a significantly adverse impact on patient outcomes and pose a
great challenge to the treating surgeon. Therefore, timely recognition of
those patients at risk for this complication is very important, as it allows for
adopting measures to reduce this risk.
 Option B: Antibiotic-mediated cell death, however, is a complex process
that begins with the physical interaction between a drug molecule and its
bacterial-specific target, and involves alterations to the affected bacterium
at the biochemical, molecular and ultrastructural levels. Antibiotic-induced
cell death has been associated with the formation of double-stranded DNA
breaks following treatment with DNA gyrase inhibitors, with the arrest of
DNA-dependent RNA synthesis following treatment with rifamycins, with
cell envelope damage and loss of structural integrity following treatment
with cell-wall synthesis inhibitors, and with cellular energetics, ribosome
binding and protein mistranslation following treatment with protein
synthesis inhibitors.
 Option D: People who have had diabetes for a long time may have
peripheral nerve damage and reduced blood flow to their extremities,
which increases the chance for infection. The high sugar levels in your
blood and tissues allow bacteria to grow and allow infections to develop
more quickly.

ADVERTISEMENTS
29. Question
Effective handwashing requires the use of:
o A. Soap or detergent to promote emulsification.
o B. Hot water to destroy bacteria.
o C. A disinfectant to increase surface tension.

Incorrect
Correct Answer: A. Soap or detergent to promote emulsification.
Soaps and detergents are used to help remove bacteria because of their ability to
lower the surface tension of water and act as emulsifying agents. Handwashing is
the act of washing hands with soap, either antimicrobial or non antimicrobial, and
water for at least 15 to 20 seconds with a vigorous motion to cause friction
making sure to include all surfaces of the hands and fingers.
 Option B: Hot water may lead to skin irritation or burns. Warm water
would be enough for handwashing. Healthcare professionals caring for
high-risk patients that are immunocompromised must take great care in
performing proper hand hygiene as this patient population is at high risk
for opportunistic infections
 Option C: Handwashing with soap and water will remove nearly all
transient gram-negative bacilli in 10 seconds while chlorhexidine may be
more appropriate than soap and water for the removal of transient gram-
positive bacteria. According to the CDC, established guidelines recommend
that agents used for surgical hand scrubs should reduce microorganisms
on intact skin in a substantial manner, contain a nonirritating antimicrobial
preparation, have broad-spectrum activity, and be fast-acting and
persistent.
 Option D: Hand hygiene practices are paramount in reducing cross-
transmission of microorganisms, hospital-acquired infections and the risk
of occupational exposure to infectious diseases. According to the CDC,
understanding the importance of hand hygiene and its impact on the
pathogenic spread of microorganisms is best understood when one

understands the anatomy of the skin. The skin serves as a protective barrier
against water loss, heat loss, microorganisms, and other environmental
hazards.
ADVERTISEMENTS
30. Question
After routine patient contact, handwashing should last at least:
o A. 30 seconds
o B. 1 minute
o C. 2 minutes
o D. 3 minutes
Incorrect
Correct Answer: A. 30 seconds
Depending on the degree of exposure to pathogens, hand washing may last from
10 seconds to 4 minutes. After routine patient contact, hand washing for 30
seconds effectively minimizes the risk of pathogen transmission. According to the
Centers for Disease Control and Prevention (CDC), hand hygiene is the single
most important practice in the reduction of the transmission of infection in the
healthcare setting.
 Option B: According to the CDC, hand hygiene encompasses the cleansing
of your hands with soap and water, antiseptic hand washes, antiseptic hand
rubs such as alcohol-based hand sanitizers, foams or gels, or surgical hand
antisepsis. Indications for handwashing include when hands are visibly
after restroom use.
 Option C: Handwashing is the act of washing hands with soap, either
antimicrobial or non-antimicrobial, and water for at least 15 to 20 seconds
with a vigorous motion to cause friction making sure to include all surfaces
of the hands and fingers. Hand rubbing with an alcohol-based rub should
not be performed when the hands are visibly soiled. In this case, the CDC
and WHO guidelines recommend that handwashing with soap and water

 Option D: Alcohol-based hand sanitizers are the recommended product
for hand hygiene when hands are not visibly soiled. Apply alcohol-based
products per manufacturer guidelines on dispensing of the product.
Typically, 3 mL to 5 mL in the palm, rubbing vigorously, ensuring all
surfaces on both hands get covered, about 20 seconds is required for all
surfaces to dry completely.
ADVERTISEMENTS
31. Question
Which of the following procedures always requires surgical asepsis?
o A. Vaginal instillation of conjugated estrogen
o B. Urinary catheterization
o C. Nasogastric tube insertion
o D. Colostomy irrigation
Incorrect
Correct Answer: B. Urinary catheterization
The urinary system is normally free of microorganisms except at the urinary
meatus. Any procedure that involves entering this system must use surgically
aseptic measures to maintain a bacteria-free state. Guidelines from The Centers
for Disease Control and Prevention (CDC) and The European Association of
Urology Nurses (EAUN) recommend ‗sterile technique‘ when inserting an
indwelling urinary catheter. Insertion of indwelling urinary catheters should be
performed in a way that minimizes the risk of introducing bacteria to the urinary
bladder.
 Option A: Conjugated estrogens is a medicine that contains a mixture of
estrogen hormones. Conjugated estrogen vaginal cream is used to treat
changes in and around the vagina (such as vaginal dryness, itching, and
burning) caused by low estrogen levels or menopause. It is also used to
treat vaginal pain during sexual intercourse. This medicine is to be used
only in the vagina. Use at bedtime unless your doctor tells otherwise.
 Option C: Nasogastric (NG) intubation is a procedure in which a thin,
plastic tube is inserted into the nostril, toward the esophagus, and down

into the stomach. Once an NG tube is properly placed and secured,
healthcare providers such as the nurses can deliver food and medicine
directly to the stomach or obtain substances from it. Clean, not sterile,
technique is necessary because the gastrointestinal (GI) tract is not sterile.
 Option D: Sterile supplies are used in acute care with a fresh post-surgical
urostomy. A patient in the community may not use sterile supplies, but
strict adherence to proper hand hygiene is required to prevent infections
of the bladder, kidney, or urinary tract. Never place anything inside the
stoma.
ADVERTISEMENTS
32. Question
Sterile technique is used whenever:
o A. Strict isolation is required
o B. Terminal disinfection is performed
o C. Invasive procedures are performed
o D. Protective isolation is necessary

Incorrect
Correct Answer: C. Invasive procedures are performed
All invasive procedures, including surgery, catheter insertion, and administration
of parenteral therapy, require a sterile technique to maintain a sterile
environment. All equipment must be sterile, and the nurse and the physician
must wear sterile gloves and maintain surgical asepsis. In the operating room, the
nurse and physician are required to wear sterile gowns, gloves, masks, hair
covers, and shoe covers for all invasive procedures.
 Option A: Strict isolation requires the use of clean gloves, masks, gowns,
and equipment to prevent the transmission of highly communicable
diseases by contact or by airborne routes. Strict isolation is used for
diseases spread through the air and in some cases by contact. Patients
must be placed in isolation to prevent the spread of infectious diseases.

Those who are kept in strict isolation are often kept in a special room at
the facility designed for that purpose.
 Option B: Terminal disinfection is the disinfection of all contaminated
supplies and equipment after a patient has been discharged to prepare
them for reuse by another patient. Terminal disinfection has the objective
of preparing complete rooms or areas for subsequent patients or residents
for them to be treated or cared for without the risk of acquiring an
infection. This disinfection measure is applied in rooms and areas where an
infected or colonized patient/resident has been cared for or treated.
Depending on the existing disease or type of pathogen all near-patient
surfaces/objects or all accessible surfaces (e.g. also floors or walls) are to be
disinfected.
 Option D: The purpose of protective (reverse)isolation is to prevent a
person with seriously impaired resistance from coming into contact with
potentially pathogenic organisms. Protective Isolation aims to protect an
immunocompromised patient who is at high risk of acquiring micro-
organisms from either the environment or from other patients, staff, or
visitors.
ADVERTISEMENTS
33. Question
Which of the following constitutes a break in sterile technique while preparing a
sterile field for a dressing change?
o A. Using sterile forceps, rather than sterile gloves, to handle a sterile item.
o B. Touching the outside wrapper of sterilized material without sterile gloves.
o C. Placing a sterile object on the edge of the sterile field.
o D. Pouring out a small amount of solution (15 to 30 ml) before pouring the
solution into a sterile container.
Incorrect
Correct Answer: C. Placing a sterile object on the edge of the sterile field.
The edges of a sterile field are considered contaminated. When sterile items are
allowed to come in contact with the edges of the field, the sterile items also

become contaminated. The sterile field should be prepared as close as possible
to the time of use.2 The sterility of supplies used during a surgical procedure can
be affected by the events taking place within the operating room, and the length
of time the items have been exposed to the environment.
 Option A: Under no circumstances should sterile and nonsterile
items/areas be mixed since one contaminates the other.4 Sterilization
provides the highest level of assurance that all instruments, sutures, fluids,
supplies, and drapes are void of microorganisms.2 The sterility of a
package is determined by events, not by time. To ensure sterility, all sterile
items need to be inspected for package integrity and sterilization process
indicators, such as indicator tape and internal chemical indicators, prior to
introduction onto the sterile field. If a package has been compromised, it
should be considered contaminated and not be used.
 Option B: When opening wrapped supplies, the nonsterile person should
open the top wrapper flap away from them first, then open the flaps to
each side. The last wrapper flap is pulled toward the nonsterile person
opening the package. This technique of opening a wrapped package
ensures that the nonsterile person does not reach over the sterile item
inside. All wrapper edges should be secured to prevent flipping the
wrapper and contaminating the contents of the sterile package or field.
 Option D: Only the top rim of the bottle top and bottle contents are
considered sterile once the cap has been removed from the bottle.
Therefore, when sterile fluids are dispensed, the entire contents of the
bottle must be poured or the fluid remaining in the bottle discarded. When
solutions are poured onto the sterile field, they should be poured slowly to
prevent contamination and fluid strikethrough from splashing.
ADVERTISEMENTS
34. Question
A natural body defense that plays an active role in preventing infection is:
o A. Yawning
o B. Body hair
o C. Hiccupping

o D. Rapid eye movements
Incorrect
Correct Answer: B. Body hair
Hair on or within body areas, such as the nose, traps and holds particles that
contain microorganisms. One of the body‘s most important physical barriers is
the skin barrier, which is composed of three layers of closely packed cells. The
thin upper layer is called the epidermis. A second, thicker layer, called the dermis,
contains hair follicles, sweat glands, nerves, and blood vessels. A layer of fatty
tissue called the hypodermis lies beneath the dermis and contains blood and
lymph vessels
 Option A: Evidence suggests that drowsiness is the most common
stimulus of yawn. Boredom occurs when the main source of stimulation in
a person‘s environment is no longer able to sustain their attention. This
induces drowsiness by stimulating the sleep generating system. At this
moment, the mind has to make an effort to maintain contact with the
external environment.
 Option C: Hiccupping does not prevent microorganisms from entering or
leaving the body. As they breathe out, the diaphragm pushes up to expel
the air. When a person has hiccups, the diaphragm contracts and pulls
down, drawing in air between breaths. Immediately after this, the windpipe
closes for a moment to prevent more air from entering the lungs. Hiccups
often come after eating or drinking too much or too quickly.
 Option D: Rapid eye movement marks the stage of sleep during which
dreaming occurs. Rapid eye movement (REM) is the stage of sleep
characterized by rapid saccadic movements of the eyes. During this stage,
the activity of the brain‘s neurons is quite similar to that during waking
hours. Most of the vividly recalled dreams occur during REM sleep.
ADVERTISEMENTS
35. Question
All of the following statement are true about donning sterile gloves except:
o A. The first glove should be picked up by grasping the inside of the cuff.

o B. The second glove should be picked up by inserting the gloved fingers
under the cuff outside the glove.
o C. The gloves should be adjusted by sliding the gloved fingers under the
sterile cuff and pulling the glove over the wrist.
o D. The inside of the glove is considered sterile.

Incorrect
Correct Answer: D. The inside of the glove is considered sterile.
The inside of the glove is always considered to be clean, but not sterile. Sterile
gloves are gloves that are free from all microorganisms. They are required for any
invasive procedure and when contact with any sterile site, tissue, or body cavity is
expected (PIDAC, 2012).
 Option A: Pick up the glove for the dominant hand by touching the inside
cuff of the glove. Do not touch the outside of the glove. Pull the glove
completely over the dominant hand. Sterile gloves help prevent surgical
site infections and reduce the risk of exposure to blood and body fluid
pathogens for the health care worker. Studies have shown that 18% to 35%
of all sterile gloves have tiny holes after surgery, and up to 80% of the tiny
puncture sites go unnoticed by the surgeon (Kennedy, 2013).
 Option B: Insert gloved hand into the cuff of the remaining glove. Pull the
remaining glove on a non-dominant hand and insert fingers. Adjust gloves
if necessary. Double gloving is known to reduce the risk of exposure and
has become common practice, but does not reduce the risk of cross-
contamination after surgery (Kennedy, 2013).
 Option C: Once gloves are on, interlock gloved hands and keep at least six
inches away from clothing, keeping hands above waist level and below the
shoulders. To remove gloves, grasp the outside of the cuff or palm of the
glove and gently pull the glove off, turning it inside out and placing it into
a gloved hand.
ADVERTISEMENTS
36. Question
When removing a contaminated gown, the nurse should be careful that the first
thing she touches is the:

o A. Waist tie and necktie at the back of the gown
o B. Waist tie in front of the gown
o C. Cuffs of the gown
o D. Inside of the gown

Incorrect
Correct Answer: A. Waist tie and necktie at the back of the gown
The back of the gown is considered clean, the front is contaminated. So, after
removing gloves and washing hands, the nurse should untie the back of the
gown; slowly move backward away from the gown, holding the inside of the
gown and keeping the edges off the floor; turn and fold the gown inside out;
discard it in a contaminated linen container; then wash her hands again.
 Option B: First, release the tie, then grasp the gown at the hip area, and
pull the gown down and away from the sides of the body. Once the gown
is off the shoulders, pull one arm at a time from the sleeves of the gown so
that the gown arms are bunched at the wrists. Then, roll the exposed side
of the gown inward until it‘s a tight ball. Dispose of it.
 Option C: Following the doffing protocol will minimize the risk for disease
transmission, so it‘s very important that you understand all the steps. A
Trained Observer will help you with the process. Gown front and sleeves
are contaminated!
 Option D: Grasp the gown in the front and pull away from your body so
that the ties break, touching the outside of the gown only with gloved
hands. While removing the gown, fold or roll the gown inside-out into a
bundle
ADVERTISEMENTS
37. Question
Which of the following nursing interventions is considered the most effective
form for universal precautions?
o A. Cap all used needles before removing them from their syringes.

o B. Discard all used uncapped needles and syringes in an impenetrable
protective container.
o C. Wear gloves when administering IM injections.
o D. Follow enteric precautions.

Incorrect
Correct Answer: B. Discard all used uncapped needles and syringes in an
impenetrable protective container.
According to the Centers for Disease Control (CDC), blood-to-blood contact
occurs most commonly when a health care worker attempts to cap a used needle.
Universal precautions are a standard set of guidelines aimed at preventing the
transmission of bloodborne pathogens from exposure to blood and other
potentially infectious materials (OPIM).
 Option A: Therefore, used needles should never be recapped; instead they
should be inserted in a specially designed puncture resistant, labeled
container. In 1987, the CDC introduced another set of guidelines termed
Body Substance Isolation. These guidelines advocated the avoidance of
direct physical contact with ―all moist and potentially infectious body
substances,‖ even if blood is not visible. A limitation of this guideline was
that it emphasized handwashing after removal of gloves only if the hands
were visibly soiled.
 Option C: Wearing gloves is not always necessary when administering an
I.M. injection. Must be worn when touching blood, body fluids, secretions,
excretions, mucous membranes, or non-intact skin. Change when there is
contact with potentially infected material in the same patient to avoid
cross-contamination. Remove before touching surfaces and clean items.
Wearing gloves does not mitigate the need for proper hand hygiene.
 Option D: Enteric precautions prevent the transfer of pathogens via feces.
Universal precautions do not apply to sputum, feces, sweat, vomit, tears,
urine, or nasal secretions unless they are visibly contaminated with blood
because their transmission of Hepatitis B or HIV is extremely low or non-
existent.
ADVERTISEMENTS
38. Question

All of the following measures are recommended to prevent pressure
ulcers except:
o A. Massaging the reddened area with lotion.
o B. Using a water or air mattress.
o C. Adhering to a schedule for positioning and turning.
o D. Providing meticulous skin care.

Incorrect
Correct Answer: A. Massaging the reddened area with lotion
Nurses and other healthcare professionals previously believed that massaging a
reddened area with lotion would promote venous return and reduce edema to
the area. However, research has shown that massage only increases the likelihood
of cellular ischemia and necrosis to the area.
 Option B: In patients with a high risk of developing pressure injuries,
support surfaces to alleviate pressure can be used. This can include higher-
speciation foam mattresses, medical-grade sheepskins, continuous low-
pressure supports, alternating-pressure devices, low air loss therapy;
however, the effectiveness of these devices compared to other surfaces in
the treatment of existing pressure injuries has not been conclusively
established.
 Option C: General care for pressure injuries can include redistribution of
pressure with the use of support surfaces and changes in positioning.
Redistribution of pressure and appropriate patient positioning is required
to prevent the development and worsening of pressure injuries, as these
methods can reduce force from friction and shear.
 Option D: Wound care, including maintaining a clean environment,
debridement, application of dressings, monitoring, and various adjunctive
therapies, is generally advised to facilitate the healing of pressure injuries.
Options for treatment can be guided by the stage of the pressure injury.
Stage 1 pressure injuries can be covered with transparent film dressings as
needed.
ADVERTISEMENTS

39. Question
Which of the following blood tests should be performed before a blood
transfusion?
o A. Prothrombin and coagulation time
o B. Blood typing and cross-matching
o C. Bleeding and clotting time
o D. Complete blood count (CBC) and electrolyte levels

Incorrect
Correct Answer: B. Blood typing and cross-matching
Before a blood transfusion is performed, the blood of the donor and recipient
must be checked for compatibility. This is done by blood typing (a test that
determines a person‘s blood type) and cross-matching (a procedure that
determines the compatibility of the donor‘s and recipient‘s blood after the blood
types have been matched). If the blood specimens are incompatible, hemolysis
and antigen-antibody reactions will occur. If the donor is eligible to donate, the
donated blood is tested for blood type (ABO group) and Rh type (positive or
negative). This is to make sure that patients receive blood that matches their
blood type. Before transfusion, the donor and blood unit are also tested for
certain proteins (antibodies) that may cause adverse reactions in a person
receiving a blood transfusion.
 Option A: A prothrombin time (PT) is a test used to help detect and
diagnose a bleeding disorder or excessive clotting disorder. A PT measures
the number of seconds it takes for a clot to form in your sample of blood
after substances (reagents) are added. The PT is often performed along
with a partial thromboplastin time (PTT) and together they assess the
amount and function of proteins called coagulation factors that are an
important part of proper blood clot formation. The coagulation time is a
measurement of the intrinsic power of the blood to convert fibrinogen to
fibrin. It is an empirical test no matter how performed, and therefore in
order to be reliable requires that the test be done on venous blood under
strictly controlled conditions.
 Option C: Bleeding time is a laboratory test to assess platelet function and
the body‘s ability to form a clot. The test involves making a puncture

wound in a superficial area of the skin and monitoring the time needed for
bleeding to stop (ie, the bleeding site turns ―glassy‖). The expected range
for clotting time is 4-10 mins. This test measures the time taken for blood
vessel constriction and platelet plug formation to occur. No clot is allowed
to form, so that the arrest of bleeding depends exclusively on blood vessel
constriction and platelet action.
 Option D: The complete blood count (CBC) is a group of tests that
evaluate the cells that circulate in the blood, including red blood cells
(RBCs), white blood cells (WBCs), and platelets (PLTs). The CBC can evaluate
your overall health and detect a variety of diseases and conditions, such as
infections, anemia, and leukemia.
ADVERTISEMENTS
40. Question
The primary purpose of a platelet count is to evaluate the:
o A. Potential for clot formation
o B. Potential for bleeding
o C. Presence of an antigen-antibody response
o D. Presence of cardiac enzymes

Incorrect
Correct Answer: A. Potential for clot formation
Platelets are disk-shaped cells that are essential for blood coagulation. A platelet
count determines the number of thrombocytes in blood available for promoting
hemostasis and assisting with blood coagulation after injury. Platelets, also called
thrombocytes, are tiny fragments of cells that are essential for normal blood
clotting. They are formed from very large cells called megakaryocytes in the bone
marrow and are released into the blood to circulate. The platelet count is a test
that determines the number of platelets in your sample of blood.
 Option B: It also is used to evaluate the patient‘s potential for bleeding;
however, this is not its primary purpose. The normal count ranges from
150,000 to 350,000/mm3. A count of 100,000/mm3 or less indicates a

potential for bleeding; count of less than 20,000/mm3 is associated with
spontaneous bleeding.
 Option C: Platelets, the smallest of our blood cells, can only be seen under
a microscope. They‘re literally shaped like small plates in their inactive
form. A blood vessel will send out a signal when it becomes damaged.
When platelets receive that signal, they‘ll respond by traveling to the area
and transforming into their ―active‖ formation. To make contact with the
broken blood vessel, platelets grow long tentacles and then resemble a
spider or an octopus.
 Option D: If you have too many platelets, it can increase your risk for
clotting. But often your cardiovascular risk has more to do with platelet
function than platelet number. For example, you could have a healthy
number of platelets, but if they‘re sticking together too much it can
increase your chance of having a heart attack or stroke.
ADVERTISEMENTS
41. Question
Which of the following white blood cell (WBC) counts clearly indicates
leukocytosis?
o A. 4,500/mm³
o B. 7,000/mm³
o C. 10,000/mm³
o D. 25,000/mm³
Incorrect
Correct Answer: D. 25,000/mm³
Leukocytosis is any transient increase in the number of white blood cells
(leukocytes) in the blood. The normal number of WBCs in the blood is 4,500 to
11,000 WBCs per microliter (4.5 to 11.0 × 109/L). Normal value ranges may vary
slightly among different labs. Thus, a count of 25,000/mm3 indicates leukocytosis.
 Option A: A WBC count is a blood test to measure the number of white
blood cells (WBCs) in the blood. WBCs are also called leukocytes. They help
fight infections. A higher than normal WBC count is called leukocytosis.

Leukocytosis is the broad term for an elevated white blood cell (WBC)
count, typically above 11.0×10^9/L, on a peripheral blood smear
collection. The exact value of WBC elevation can vary slightly between
laboratories depending on their ‗upper limits of normal‘ as identified by
their reference ranges.
 Option B: The WBC value represents the sum-total of white blood cell
subtypes, including neutrophils, eosinophils, lymphocytes, monocytes,
atypical leukocytes that are not normally present on a peripheral blood
smear (e.g., lymphoblasts), or any combination of these. The clinician
should properly characterize the leukocytosis and determine if further
evaluation and workup are indicated.
 Option C: Leukocytosis can occur acutely and often transiently or
chronically, either in response to an inflammatory stressor/cytokine
cascade or as part of an autonomous myeloproliferative neoplasm.
Neutrophilia is the most common presentation, but clinicians should be
aware of the other cell lines that can be involved in acute and chronic
presentations. A detailed history, physical examination, medication
reconciliation, full evaluation of a CBC with differential, and comparison to
prior CBCs can help clinicians elucidate the underlying cause of
leukocytosis and guide appropriate treatment.
ADVERTISEMENTS
42. Question
After 5 days of diuretic therapy with 20mg of furosemide (Lasix) daily, a patient
begins to exhibit fatigue, muscle cramping, and muscle weakness. These
symptoms probably indicate that the patient is experiencing:
o A. Hypokalemia
o B. Hyperkalemia
o C. Anorexia
o D. Dysphagia
Incorrect
Correct Answer: A. Hypokalemia

Fatigue, muscle cramping, and muscle weaknesses are symptoms of hypokalemia
(an inadequate potassium level), which is a potential side effect of diuretic
therapy. The physician usually orders supplemental potassium to prevent
hypokalemia in patients receiving diuretics. Hypokalemia is more prevalent than
hyperkalemia; however, most cases are mild. Although there is a slight variation,
an acceptable lower limit for normal serum potassium is 3.5 mmol/L. Severity is
categorized as mild when the serum potassium level is 3 to 3.4 mmol/L, moderate
when the serum potassium level is 2.5 to 3 mmol/L, and severe when the serum
potassium level is less than 2.5 mmol/L.
 Option B: Hyperkalemia is defined as a serum or plasma potassium level
above the upper limits of normal, usually greater than 5.0 mEq/L to 5.5
mEq/L. While mild hyperkalemia is usually asymptomatic, high levels of
potassium may cause life-threatening cardiac arrhythmias, muscle
weakness or paralysis. Symptoms usually develop at levels higher levels, 6.5
mEq/L to 7 mEq/L, but the rate of change is more important than the
numerical value.
 Option C: Anorexia is another symptom of hypokalemia. The most
frequent electrolyte imbalances seen in anorexia are hyponatremia (a low
concentration of sodium ions in the bloodstream) and hypokalemia (a low
concentration of potassium ions). A low potassium level has many causes
but usually results from vomiting, diarrhea, adrenal gland disorders, or use
of diuretics. A low potassium level can make muscles feel weak, cramp,
twitch or even become paralyzed, and abnormal heart rhythms may
develop.
 Option D: Dysphagia means difficulty swallowing. Dysphagia is the medical
term for swallowing difficulties. Some people with dysphagia have
problems swallowing certain foods or liquids, while others can‘t swallow at
all. Other signs of dysphagia include: coughing or choking when eating or
drinking. bringing food back up, sometimes through the nose.
ADVERTISEMENTS
43. Question
Which of the following statements about chest X-rays is not true?
o A. No contradictions exist for this test.

o B. Before the procedure, the patient should remove all jewelry, metallic
objects, and buttons above the waist.
o C. A signed consent is not required.
o D. Eating, drinking, and medications are allowed before this test.

Incorrect
Correct Answer: A. No contradictions exist for this test
Pregnancy or suspected pregnancy is the only contraindication for a chest X-ray.
However, if a chest X-ray is necessary, the patient can wear a lead apron to
protect the pelvic region from radiation. X-rays during pregnancy don‘t increase
the risk of miscarriage or cause problems in the unborn baby, such as birth
defects and physical or mental development problems. However, if a pregnant
woman has an X-ray and is exposed to radiation there is a very small increased
risk that the baby may go on to develop cancer in childhood. This is why the dose
of radiation used in an X-ray is always as low as possible.
 Option B: Jewelry, metallic objects, and buttons would interfere with the X-
ray and thus should not be worn above the waist. Metal appears as a bright
area on an X-ray, blocking visibility of underlying structures. The reason
you‘re asked to remove metal is to give the radiologist an unobstructed
view of the area of interest. Basically, you remove metal because it blocks
anatomy.
 Option C: A signed consent is not required because a chest X-ray is not an
invasive examination. Consent is ensuring the patient is aware of the
purpose and nature of any procedure to be carried out. The radiographer
must ensure that the patient is fully aware of his/her options, including
alternatives, the right to refuse and the consequences of refusal.
 Option D: Eating, drinking, and medications are allowed because the X-ray
is of the chest, not the abdominal region. To create a radiograph, a patient
is positioned so that the part of the body being imaged is located between
an x-ray source and an x-ray detector. When the machine is turned on, x-
rays travel through the body and are absorbed in different amounts by
different tissues, depending on the radiological density of the tissues they
pass through.
ADVERTISEMENTS

44. Question
The most appropriate time for the nurse to obtain a sputum specimen for culture
is:
o A. Early in the morning
o B. After the patient eats a light breakfast
o C. After aerosol therapy
o D. After chest physiotherapy

Incorrect
Correct Answer: A. Early in the morning
Obtaining a sputum specimen early in this morning ensures an adequate supply
of bacteria for culturing and decreases the risk of contamination from food or
medication. A sputum culture is a test to detect and identify bacteria or fungi that
infect the lungs or breathing passages. Sputum is a thick fluid produced in the
lungs and in the adjacent airways. Normally, a fresh morning sample is preferred
for the bacteriological examination of sputum.
type of organism that may be causing an infection in your lungs or the
of mucus made in your lungs. If you have an infection or chronic illness
affecting the lungs or airways, it can make you cough up sputum.
 Option C: Sputum is not the same as spit or saliva. Sputum contains cells
from the immune system that help fight the bacteria, fungi, or other
foreign substances in your lungs or airways. The thickness of sputum helps
trap the foreign material. This allows cilia (tiny hairs) in the airways to push
it through the mouth and be coughed out.
 Option D: A sputum culture is often done with another test called a Gram
stain. A Gram stain is a test that checks for bacteria at the site of a
suspected infection or in body fluids such as blood or urine. It can help
identify the specific type of infection you may have.
ADVERTISEMENTS
45. Question

A patient with no known allergies is to receive penicillin every 6 hours. When
administering the medication, the nurse observes a fine rash on the patient‘s skin.
The most appropriate nursing action would be to:
o A. Withhold the moderation and notify the physician.
o B. Administer the medication and notify the physician.
o C. Administer the medication with an antihistamine.
o D. Apply cornstarch soaks to the rash.

Incorrect
Correct Answer: A. Withhold the moderation and notify the physician
Initial sensitivity to penicillin is commonly manifested by a skin rash, even in
individuals who have not been allergic to it previously. Because of the danger of
anaphylactic shock, the nurse should withhold the drug and notify the physician,
who may choose to substitute another drug.
 Option B: To determine if a patient has an IgE mediated penicillin allergy,
the only validated test currently available in the united states is penicillin
skin testing. A board-certified allergist should perform the test. It involves a
skin-prick with the application of the major and minor determinants as well
as a control. The area of skin is examined 15 minutes later. If a wheel of at
least 3 mm and concomitant erythema develop, the test is positive. The
test should not be performed if the reaction to penicillin was a severe non-
IgE mediated reaction.
 Option C: Administering an antihistamine is a dependent nursing
intervention that requires a written physician‘s order. Treatment for acute
IgE mediated reaction to penicillin depends on severity. Patients presenting
in acute anaphylaxis need to have immediate treatment with IM
epinephrine (1 mg/ml) 0.3 mg to 0.5 mg every 5 to 15 minutes until
resolution of symptoms. Adjunctive therapies include H1 and H2
antihistamines including diphenhydramine 25 mg to 50 mg intravenously
(IV) and ranitidine 50 mg IV, respectively.
 Option D: Although applying cornstarch to the rash may relieve
discomfort, it is not the nurse‘s top priority in such a potentially life-
threatening situation. Cutaneous symptoms are often the first and most
common finding of an allergic reaction, however, are absent in 10% to 20%

of patients experiencing an allergic reaction. Common cutaneous
symptoms are generalized urticaria, flushing, pruritus, and angioedema.
ADVERTISEMENTS
46. Question
All of the following nursing interventions are correct when using the Z-track
method of drug injection except:
o A. Prepare the injection site with alcohol.
o B. Use a needle that‘s at least 1‖ long.
o C. Aspirate for blood before injection.
o D. Rub the site vigorously after the injection to promote absorption.

Incorrect
Correct Answer: D. Rub the site vigorously after the injection to promote
absorption
The Z-track method is an I.M. injection technique in which the patient‘s skin is
pulled in such a way that the needle track is sealed off after the injection. This
procedure seals medication deep into the muscle, thereby minimizing skin
staining and irritation. Rubbing the injection site is contraindicated because it
may cause the medication to extravasate into the skin.
 Option A: Clean the injection site with an alcohol pad to minimize the
possibility of infection. Allow the area to air dry for a few minutes. The Z-
track method is not often recommended but can be particularly useful with
medication that must be absorbed by muscles to work. It also helps to
prevent the medication from seeping into the subcutaneous tissue and
ensures a full dosage.
 Option B: In an adult, the most commonly used needles are one inch or
one and a half inches long, and 22 to 25 gauge thick. Smaller needles are
typically used when injecting a child. Some medications are dark-colored
and can cause staining of the skin. If this is a side effect of the medication
you will be taking, the doctor may recommend using this technique to
prevent injection site discoloration or lesions.

 Option C: Use one hand to pull downward on your skin and fatty tissue.
Hold it firmly about an inch away (2.54 cm) from the muscle. On the other
hand, hold the needle at a 90-degree angle and insert it quickly and deeply
enough to penetrate your muscle. If there is no blood in the syringe, push
on the plunger to inject the medication slowly into the muscle.
ADVERTISEMENTS
47. Question
The correct method for determining the vastus lateralis site for I.M. injection is to:
o A. Locate the upper aspect of the upper outer quadrant of the buttock about
5 to 8 cm below the iliac crest.
o B. Palpate the lower edge of the acromion process and the midpoint lateral
aspect of the arm.
o C. Palpate a 1‖ circular area anterior to the umbilicus.
o D. Divide the area between the greater femoral trochanter and the
lateral femoral condyle into thirds, and select the middle third on the
anterior of the thigh.
Incorrect
Correct Answer: D. Divide the area between the greater femoral trochanter
and the lateral femoral condyle into thirds, and select the middle third on
the anterior of the thigh
The vastus lateralis, a long, thick muscle that extends the full length of the thigh,
is viewed by many clinicians as the site of choice for I.M. injections because it has
relatively few major nerves and blood vessels. The middle third of the muscle is
recommended as the injection site. The patient can be in a supine or sitting
position for an injection into this site.
 Option A: There are specific landmarks to be taken into consideration
while giving IM injections so as to avoid any neurovascular complications.
The heel of the opposing hand is placed in the greater trochanter, the
index finger in the anterior superior iliac spine, and the middle finger below
the iliac crest. The drug is injected in the triangle formed by the index,
middle finger, and the iliac crest

 Option B: The deltoid area is 2.5 to 5 cm below the acromion process.
Intramuscular injection is the method of installing medications into the
depth of the bulk of specifically selected muscles. The basis of this process
is that the bulky muscles have good vascularity, and therefore the injected
drug quickly reaches the systemic circulation and thereafter into the
specific region of action, bypassing the first-pass metabolism.
 Option C: The vastus lateralis is a common site for IM injection. The middle
third of the line joining the greater trochanter of the femur and the lateral
femoral condyle of the knee. It is one of the most common medical
procedures to be performed on an annual basis. However, there is still a
lack of uniform guidelines and an algorithm in giving IM among health
professionals across the world.
ADVERTISEMENTS
48. Question
The mid-deltoid injection site is seldom used for I.M. injections because it:
o A. Can accommodate only 1 ml or less of medication.
o B. Bruises too easily.
o C. Can be used only when the patient is lying down.
o D. Does not readily absorb parenteral medication.

Incorrect
Correct Answer: A. Can accommodate only 1 ml or less of medication
The mid-deltoid injection site can accommodate only 1 ml or less of medication
because of its size and location (on the deltoid muscle of the arm, close to the
brachial artery and radial nerve). It is becoming increasingly important for
clinicians to identify a safer intramuscular (IM) injection site in the deltoid muscle
because of possible complications following the vaccine administration of IM
injections.
 Option B: However, Cook reported that these 4 injection sites have the
potential to cause injury to the subdeltoid/subacromial bursa and/or
anterior branch of the axillary nerve with the arm in the anatomical
position. Additionally, we showed that the axillary nerve often runs near the

site 5 cm below the mid-acromion lateral border, and concluded that this
site is unsuitable for IM injection in terms of the high risk for the
complications related to this nerve.
 Option C: The deltoid muscle has been used in clinical settings because it
is easy for clinicians to administer injections at this site and for patients to
expose it, and it is the most commonly used site for vaccines worldwide.
Four injection sites have been recommended as safer and appropriate IM
injection sites in the deltoid muscle: the first site is 1 to 3 fingerbreadths (5
cm) below the mid-acromion, the second is a triangular injection site, the
third is the middle third of the deltoid muscle, and the fourth is a mid-
deltoid site.
 Option D: The following complications have been reported after the
administration of IM injections: injection site reactions such as pain,
erythema, and swelling due to over-or under penetration by the needle,
axillary or radial nerve palsies, musculoskeletal injuries, local sepsis, and
vascular complications. Therefore, it is becoming increasingly important to
establish a safer site for IM injections.
ADVERTISEMENTS
49. Question
The appropriate needle size for insulin injection is:
o A. 18G, 1 ½‖ long
o B. 22G, 1‖ long
o C. 22G, 1 ½‖ long
o D. 25G, 5/8” long

Incorrect
Correct Answer: D. 25G, 5/8” long
A 25G, 5/8‖ needle is the recommended size for insulin injection because insulin
is administered by the subcutaneous route. The board recommends 4-, 5-, and 6-
mm needles for all adult patients regardless of their BMI. It is also recommended
to insert 4-, 5-, and 6-mm needles at a 90-degree angle and that, if needed,

longer needles should be injected with either a skinfold or a 45-degree angle to
avoid intramuscular injection of insulin.
 Option A: An 18G, 1 ½‖ needle is usually used for I.M. injections in
children, typically in the vastus lateralis. Ensuring the correct delivery of
insulin is essential in the treatment of diabetes. Both proper injection
technique and needle length are important considerations for adequate
insulin delivery. There have been several studies demonstrating that BMI
does not affect efficacy or insulin leakage with shorter pen needles (e.g., 4
or 5 mm vs. 12.7 mm).
 Option B: Additionally, the International Scientific Advisory Board for the
Third Injection Technique Workshop released recommendations in 2010 on
best practices for injection technique for patients with diabetes, which, with
regard to needle length, concluded that 4-mm pen needles were
efficacious in all patients regardless of BMI.
 Option C: A 22G, 1 ½‖ needle is usually used for adult I.M. injections,
which are typically administered in the vastus lateralis or ventrogluteal site.
Needle lengths for subcutaneous injections started out as long as 16 mm
in 1985, and 12.7-mm needles were introduced in the early 1990s. Over
time, with growing evidence of longer needles increasing risks for
intramuscular injections and improved technology, shorter needles of 4, 5,
6, and 8 mm have been developed.
ADVERTISEMENTS
50. Question
The appropriate needle gauge for intradermal injection is:
o A. 20G
o B. 22G
o C. 25G
o D. 26G
Incorrect
Correct Answer: D. 26G

Because an intradermal injection does not penetrate deeply into the skin, a small-
bore 26G-27G needle is recommended. This type of injection is used primarily to
administer antigens to evaluate reactions for allergy or sensitivity studies.
Equipment used for ID injections is a tuberculin syringe calibrated in tenths and
hundredths of a millilitre, and a 1/4 to 1/2 in., 26 or 27 gauge needle. The dosage
of an ID injection is usually under 0.5 ml. The angle of administration for an ID
injection is 5 to 15 degrees.
 Option A: A 20G needle is usually used for I.M. injections of oil-based
medications. Intramuscular injections are administered at a 90-degree
angle to the skin, preferably into the anterolateral aspect of the thigh or
the deltoid muscle of the upper arm, depending on the age of the patient.
The needle gauge for intramuscular injection is 22-25 gauge.
 Option B: A 22G-25G needle for I.M. injections. A decision on needle
length and site of injection must be made for each person on the basis of
the size of the muscle, the thickness of adipose tissue at the injection site,
the volume of the material to be administered, injection technique, and the
depth below the muscle surface into which the material is to be injected
 Option C: A 25G needle, for subcutaneous insulin injections. Choosing the
right size needle and syringe is necessary to get the correct dose of
medicine, inject it properly, and minimize pain. To make it easier, these
items are sold separately and designed to attach securely. Subcutaneous
injections go into the fatty tissue just below the skin. Since these are
relatively shallow shots, the needle required is small and short—typically
one-half to five-eighths of an inch long with a gauge of 25 to 30.
ADVERTISEMENTS
51. Question
Parenteral penicillin can be administered as an:
o A. IM injection or an IV solution
o B. IV or an intradermal injection
o C. Intradermal or subcutaneous injection
o D. IM or a subcutaneous injection

Incorrect
Correct Answer: A. IM injection or an IV solution
Parenteral penicillin can be administered I.M. or added to a solution and given
I.V. It cannot be administered subcutaneously or intradermally. Penicillin G
administration can be either intravenously or intramuscularly. Penicillin G
benzathine administration ensures a continuous low dose of penicillin G over 2 to
4 weeks.
 Option B: Intradermal injection, often abbreviated ID, is a shallow or
superficial injection of a substance into the dermis, which is located
between the epidermis and the hypodermis. This route is relatively rare
compared to injections into the subcutaneous tissue or muscle.
 Option C: A subcutaneous injection is a method of administering
medication. Subcutaneous means under the skin. In this type of injection, a
short needle is used to inject a drug into the tissue layer between the skin
and the muscle. Medication given this way is usually absorbed more slowly
than if injected into a vein, sometimes over a period of 24 hours.
 Option D: An intramuscular injection is a technique used to deliver a
medication deep into the muscles. This allows the medication to be
absorbed into the bloodstream quickly. Intramuscular injections are a
common practice in modern medicine. They‘re used to deliver drugs and
vaccines. Several drugs and almost all injectable vaccines are delivered this
way.
ADVERTISEMENTS
52. Question
The physician orders gr 10 of aspirin for a patient. The equivalent dose in
milligrams is:
o A. 0.6 mg
o B. 10 mg
o C. 60 mg
o D. 600 mg
Incorrect

Correct Answer: D. 600 mg
gr 10 x 60 mg/gr 1 = 600 mg. There are 3 primary methods for the calculation of
medication dosages, as referenced above. These include Desired Over Have
Method or Formula, Dimensional Analysis and Ratio and Proportion (as cited in
Boyer, 2002)[Lindow, 2004].
 Option A: Desired over Have or Formula Method is a formula or equation
triple check.
 Option B: Units of measurement must match, for example, milliliters and
adding.
ADVERTISEMENTS
53. Question
The physician orders an IV solution of dextrose 5% in water at 100ml/hour. What
would the flow rate be if the drop factor is 15 gtt = 1 ml?
o A. 5 gtt/minute
o B. 13 gtt/minute
o C. 25 gtt/minute

o D. 50 gtt/minute
Incorrect
Correct Answer: C. 25 gtt/minute
100ml/60 min X 15 gtt/ 1 ml = 25 gtt/minute. When the nurse has an order for an
IV infusion, it is her responsibility to make sure the fluid will infuse at the
 Option A: When calculating the flow rate, determine which IV tubing you
 Option B: Macrodrip and microdrip refers to the diameter of the needle
 Option C: To calculate the drops per minute, the drop factor is needed.
The formula for calculating the IV flow rate (drip rate).. total volume (in mL)
divided by time (in min), multiplied by the drop factor (in gtts/mL), which
equals the IV flow rate in gtts/min.
ADVERTISEMENTS
54. Question
Which of the following is a sign or symptom of a hemolytic reaction to blood
transfusion?
o A. Hemoglobinuria
o B. Chest pain
o C. Urticaria
o D. Distended neck veins

Incorrect
Correct Answer: A. Hemoglobinuria

Hemoglobinuria, the abnormal presence of hemoglobin in the urine, indicates a
hemolytic reaction (incompatibility of the donor‘s and recipient‘s blood). In this
reaction, antibodies in the recipient‘s plasma combine rapidly with donor RBC‘s;
the cells are hemolyzed in either circulatory or reticuloendothelial systems.
Hemolysis occurs more rapidly in ABO incompatibilities than in Rh
incompatibilities.
 Option B: Flank pain is a common sign of hemolytic reaction. Symptoms of
a hemolytic transfusion reaction most often appear during or right after
the transfusion. Sometimes, they may develop after several days (delayed
reaction).
 Option C: Chest pain and urticaria may be symptoms of impending
anaphylaxis. A hemolytic transfusion reaction is a serious complication that
can occur after a blood transfusion. The reaction occurs when the red
blood cells that were given during the transfusion are destroyed by the
person‘s immune system. When red blood cells are destroyed, the process
is called hemolysis.
 Option D: Distended neck veins are an indication of hypervolemia. Most of
the time, a blood transfusion between compatible groups (such as O+ to
O+) does not cause a problem. Blood transfusions between incompatible
groups (such as A+ to O-) cause an immune response. This can lead to a
serious transfusion reaction. The immune system attacks the donated
blood cells, causing them to burst.
ADVERTISEMENTS
55. Question
Which of the following conditions may require fluid restriction?
o A. Fever
o B. Chronic Obstructive Pulmonary Disease
o C. Renal Failure
o D. Dehydration
Incorrect
Correct Answer: C. Renal Failure

In renal failure, the kidney loses their ability to effectively eliminate wastes and
fluids. Because of this, limiting the patient‘s intake of oral and I.V. fluids may be
necessary. The term renal failure denotes the inability of the kidneys to perform
excretory function leading to retention of nitrogenous waste products from the
blood.
 Option A: A fever draws moisture out of the body. Plus, you lose fluid as
your body makes mucus and it drains away. And that over-the-counter
cold medicine you‘re taking to dry up your head can dry the rest of you
out, too. So drink plenty of water, juice, or soup.
 Option B: Chronic obstructive pulmonary disease (COPD) is airflow
limitation caused by an inflammatory response to inhaled toxins, often
cigarette smoke. Alpha-1 antitrypsin deficiency and various occupational
exposures are less common causes in nonsmokers.
 Option D: Dehydration must be treated by replenishing the fluid level in
the body. This can be done by consuming clear fluids such as water, clear
broths, frozen water or ice pops, or sports drinks (such as Gatorade). Some
dehydration patients, however, will require intravenous fluids in order to
rehydrate.
ADVERTISEMENTS
56. Question
All of the following are common signs and symptoms of phlebitis except:
o A. Pain or discomfort at the IV insertion site
o B. Edema and warmth at the IV insertion site
o C. A red streak exiting the IV insertion site
o D. Frank bleeding at the insertion site

Incorrect
Correct Answer: D. Frank bleeding at the insertion site
Phlebitis, the inflammation of a vein, can be caused by chemical irritants (I.V.
solutions or medications), mechanical irritants (the needle or catheter used
during venipuncture or cannulation), or a localized allergic reaction to the needle
or catheter. It usually affects lower limbs, particularly the great saphenous vein

(60% to 80%) or the small/short saphenous vein (10% to 20%). However, it can
occur at other sites (10% to 20%) and may occur bilaterally (5% to 10%).
 Option A: When there is venous turbulence or stasis, vessel wall injuries,
abnormal coagulability, or vessel wall injuries, microthrombi could
propagate and then form macroscopic thrombi. Vascular endothelial injury
reliably results in thrombus formation by triggering an inflammatory
response that results in immediate platelet adhesion. Platelet aggregation
is mediated by thrombin and thromboxane A2.
 Option B: Patients with superficial thrombophlebitis typically present with
a reddened, warm, inflamed, tender area overlying the track of a superficial
vein. There is often a palpable cord. Some surrounding edema or
associated pruritus may occur. Significant swelling of the limb is more
commonly associated with DVT and should only be attributed to SVT after
DVT has been excluded.
 Option C: Signs and symptoms of phlebitis include pain or discomfort,
edema and heat at the I.V. insertion site, and a red streak going up the arm
or leg from the I.V. insertion site. Patients should be educated on the
likelihood and significance of the propagation of disease and recurrence
based on their risk factors. They should be advised of the need for further
evaluation in the presence of migratory thrombophlebitis or if they are
more than 40 years old at the time of their initial presentation and are
without other risk factors for venous thromboembolic disease.
ADVERTISEMENTS
57. Question
The best way of determining whether a patient has learned to instill ear
medication properly is for the nurse to:
o A. Ask the patient if he/she has used ear drops before.
o B. Have the patient repeat the nurse‘s instructions using her own words.
o C. Demonstrate the procedure to the patient and encourage to ask questions.
o D. Ask the patient to demonstrate the procedure.

Incorrect

Correct Answer: D. Ask the patient to demonstrate the procedure
Return demonstration provides the most certain evidence for evaluating the
effectiveness of patient teaching. No matter what kind of ear drops you use or
why you use them, it‘s important to administer them correctly. Using ear drops
properly allows the medication to enter your ear canal and treat your ear
problem.
 Option A: Merely asking the patient does not guarantee that he knows the
correct way of instilling the ear drops. Position the head so that the ear
faces upward. If you‘re giving the drops to yourself, it may be easiest to sit
or stand upright and tilt your head to the side. If you‘re giving the drops to
someone else, it may be easiest if the person tilts their head or lies down
on their side.
 Option B: It is better to repeat actions than only repeating words. or
adults, gently pull the upper ear up and back. For children, gently pull the
lower ear down and back. Squeeze the correct number of drops into the
ear. Your doctor‘s instructions or the bottle‘s label will tell you how many
drops to use.
 Option C: After demonstrating to the patient, allow him to demonstrate
the procedure too. You should also know how long you can use the ear
drops safely after opening the bottle. For prescription ear drops, ask your
pharmacist or doctor about the expiration date. For over-the-counter
drops, check the expiration date on the label. If the drops have expired,
throw them away. Don‘t use expired ear drops.
ADVERTISEMENTS
58. Question
Which of the following types of medications can be administered via gastrostomy
tube?
o A. Any oral medications.
o B. Capsules' whole contents are dissolved in water.
o C. Enteric-coated tablets that are thoroughly dissolved in water.

o D. Most tablets designed for oral use, except for extended-duration
compounds.
Incorrect
Correct Answer: D. Most tablets designed for oral use, except for extended-
duration compounds
Most tablets designed for oral use, except for extended-duration compounds can
be administered via gastrostomy tube. Drug therapy can be complicated in
hospitalized patients requiring an enteral feeding tube (EFT). Some medications
may be given via an EFT while others are unsuitable for this form of
administration.
 Option A: Inappropriate drug selection for EFT administration can cause
potential toxicity, reduced efficacy, and tube obstruction. Therefore, it is
important to know which drugs may be altered for EFT administration as
well as appropriate therapeutic alternatives that can temporarily be
substituted for those that may not be given via that route.
 Option B: It is preferable to utilize a liquid dosage form whenever possible
for EFT administration especially if the patient has a small-bore feeding
tube. If an appropriate liquid preparation is not available, the dilution of
crushed tablets or the contents of capsules may be necessary prior to EFT
administration.
 Option C: Capsules, enteric-coated tablets, and most extended duration or
sustained-release products should not be dissolved for use in a
gastrostomy tube. They are pharmaceutically manufactured in these forms
for valid reasons, and altering them destroys their purpose. The nurse
should seek an alternate physician‘s order when an ordered medication is
inappropriate for delivery by tube.
ADVERTISEMENTS
59. Question
A patient who develops hives after receiving an antibiotic is exhibiting drug:
o A. Tolerance
o B. Idiosyncrasy

o C. Synergism
o D. Allergy
Incorrect
Correct Answer: D. Allergy
A drug-allergy is an adverse reaction resulting from an immunologic response
following previous sensitizing exposure to the drug. The reaction can range from
a rash or hives to anaphylactic shock.
 Option A: Tolerance to a drug means that the patient experiences a
decreasing physiologic response to repeated administration of the drug in
the same dosage.
 Option B: Idiosyncrasy is an individual‘s unique hypersensitivity to a drug,
food, or other substance; it appears to be genetically determined.
 Option C: Synergism, is a drug interaction in which the sum of the drug‘s
combined effects is greater than that of their separate effects.
ADVERTISEMENTS
60. Question
A patient has returned to his room after femoral arteriography. All of the
following are appropriate nursing interventions except:
o A. Assess femoral, popliteal, and pedal pulses every 15 minutes for 2 hours.
o B. Check the pressure dressing for sanguineous drainage.
o C. Assess vital signs every 15 minutes for 2 hours.
o D. Order a hemoglobin and hematocrit count 1 hour after the

arteriography.
Incorrect
Correct Answer: D. Order a hemoglobin and hematocrit count 1 hour after
the arteriography
A hemoglobin and hematocrit count would be ordered by the physician if
bleeding were suspected. Arterial puncture occurs at the start of angiography
and interventional radiology, and is a very important factor determining the
success or failure of successive procedures. Recently, this procedure has been

performed by a range of approaches depending on the type of surgery, e.g,
through the radial artery.
 Option A: The methods of hemostasis for the femoral artery include
manual compression, which is the removal of the sheath and compression
with the hands, and methods that apply compression devices1). Of these,
manual compression requires absolute bed rest for a few hours. On the
other hand, the level of patient discomfort is increased due to lengthy bed
rest and the restriction of walking.
 Option B: Moreover, hematoma in the punctured area of blood vessels,
formation of a pseudoaneurysm, and vascular occlusions develop in
approximately 1–5% of cases). A variety of hemostasis devices have been
developed to treat these complications that allow for rapid recovery of
patients from bed rest. These include Angio-seal device (collagen sponge
and copolymer anchor) and percutaneous placement of a device (Prostar)
that utilizes two nonabsorbable sutures (Perclose, Redwood City, CA, USA).
 Option C: The other answers are appropriate nursing interventions for a
patient who has undergone femoral arteriography. The Angio-seal device
uses a method of adsorption with a collagen sponge placed within the
blood vessels. The Prostar device uses a method in which the blood vessels
are sutured. These hemostasis devices can reduce the discomfort and the
time to hemostasis (clotting time) in the puncture area when used in
patients, who cannot lie down in bed for a long time or in patients with low
platelet values who have received anticoagulation treatments.
ADVERTISEMENTS
61. Question
The nurse explains to a patient that a cough:
o A. Is a protective response to clear the respiratory tract of irritants.
o B. Is primarily a voluntary action.
o C. Is induced by the administration of an antitussive drug.
o D. Can be inhibited by ―splinting‖ the abdomen.

Incorrect

Correct Answer: A. Is a protective response to clear the respiratory tract of
irritants
Coughing, a protective response that clears the respiratory tract of irritants,
usually is involuntary. A cough is an innate primitive reflex and acts as part of the
body‘s immune system to protect against foreign materials. This reflex is
characterized with the closing of the glottis apparatus with subsequent increases
in the intrathoracic pressure which often exceeds 300 mm Hg. This is followed by
the forceful expulsion of the airway contents through the glottis into the
pharyngeal space and out of the body.
 Option B: However, it can be voluntary as when a patient is taught to
perform coughing exercises. Coughing is associated with a wide
assortment of clinical associations and etiologies. Furthermore, there are
no objective tools to measure or clinically quantify a cough. As such,
evaluation of a cough is initially a subjective and highly variable
assessment.
 Option C: An antitussive drug inhibits coughing. Cough suppressants may
be used to lessen the cough by blunting the cough reflex, and
expectorants may be used when excessive mucous secretions are
determined to be the primary issue to increase mucus clearance. The most
commonly used suppressant is dextromethorphan, and the most common
suppressant is guaifenesin.
 Option D: Splinting the abdomen supports the abdominal muscles when a
patient coughs. The reflex of coughing is initiated with a chemical irritation
at peripheral nerve receptors within the trachea, main carina, branching
points of large airways, and more distal smaller airways. They are also
present in the pharynx. Laryngeal and tracheobronchial receptors respond
to mechanical and chemical stimuli.
ADVERTISEMENTS
62. Question
An infected patient has chills and begins shivering. The best nursing intervention
is to:
o A. Apply iced alcohol sponges
o B. Provide increased cool liquids

o C. Provide additional bedclothes
o D. Provide increased ventilation

Incorrect
Correct Answer: C. Provide additional bedclothes
In an infected patient, shivering results from the body‘s attempt to increase heat
production and the production of neutrophils and phagocytic action through
increased skeletal muscle tension and contractions. Initial vasoconstriction may
cause skin to feel cold to the touch. Applying additional bed clothes helps to
equalize the body temperature and stop the chills. Attempts to cool the body
result in further shivering, increased metabolism, and thus increased heat
production.
 Option A: This intervention would further increase shivering. Therapeutic
temperature modulation, which incorporates mild hypothermia and
maintenance of normothermia, is being used to manage patients
resuscitated after cardiac arrest. During this therapy, the shiver response is
activated as a defense mechanism in response to an altered set-point
temperature and causes metabolic and hemodynamic stress for patients.
 Option B: Cool liquids may increase the shivering. Recognition of shivering
according to objective and subjective assessments is vital for early
detection of the condition. Once shivering is detected, treatment is
imperative to avoid deleterious effects. The Bedside Shivering Assessment
Scale can be used to determine the efficacy of interventions intended to
blunt thermoregulatory defenses and can provide continual evaluation of
patients‘ responses to the interventions.
 Option D: Increased ventilation may be done, but it could still increase
shivering. Nurses‘ knowledge and understanding of the harmful effects of
shivering are important to affect care and prevent injury associated with
uncontrolled shivering. Chills may also be a symptom of a serious or life-
threatening condition that should be immediately evaluated in an
emergency setting, such as hypothermia, which is an abnormally low body
temperature.
ADVERTISEMENTS
63. Question

A clinical nurse specialist is a nurse who has:
o A. Been certified by the National League for Nursing.
o B. Received credentials from the American Nurses‘ Association.
o C. Graduated from an associate degree program and is a registered

professional nurse.
o D. Completed a master’s degree in the prescribed clinical area and is a

registered professional nurse.
Incorrect
Correct Answer: D. Completed a master’s degree in the prescribed clinical
area and is a registered professional nurse.
A clinical nurse specialist must have completed a master‘s degree in a clinical
specialty and be a registered professional nurse. A clinical nurse specialist (CNS)
is a graduate-level registered nurse who is certified in a specialty of choice.
Obtaining specialty certification demonstrates an advanced level of knowledge as
well as advanced clinical skills in a niche area of nursing. There are differences
between a nurse practitioner (NP) and CNS.
 Option A: The National League of Nursing accredits educational programs
in nursing and provides a testing service to evaluate student nursing
competence but it does not certify nurses.
 Option B: The American Nurses Association identifies requirements for
certification and offers examinations for certification in many areas of
nursing, such as medical-surgical nursing. This certification (credentialing)
demonstrates that the nurse has the knowledge and the ability to provide
high-quality nursing care in the area of her certification.
 Option C: A graduate of an associate degree program is not a clinical
nurse specialist: however, she is prepared to provide bedside nursing with
a high degree of knowledge and skill. She must successfully complete the
licensing examination to become a registered professional nurse.
ADVERTISEMENTS
64. Question
The purpose of increasing urine acidity through dietary means is to:

o A. Decrease burning sensations
o B. Change the urine‘s color
o C. Change the urine‘s concentration
o D. Inhibit the growth of microorganisms

Incorrect
Correct Answer: D. Inhibit the growth of microorganisms
Microorganisms usually do not grow in an acidic environment. A diet high in
citrus fruits, vegetables, or dairy products can increase urine pH. A diet high in
meat products or cranberries can decrease urine pH. The acidity of urine — as
well as the presence of small molecules related to diet — may influence how well
bacteria can grow in the urinary tract, a new study shows. The research, at
Washington University School of Medicine in St. Louis, may have implications for
treating urinary tract infections, which are among the most common bacterial
infections worldwide.
 Option A: Henderson and his team, including first author Robin R. Shields-
Cutler, a graduate student in Henderson‘s lab, were interested in studying
how the body naturally fights bacterial infections. They cultured E. coli in
urine samples from healthy volunteers and noted major differences in how
well individual urine samples could harness a key immune protein to limit
bacterial growth. The urine samples that prevented bacterial growth
supported more activity of this key protein, which the body makes naturally
in response to infection, than the samples that permitted bacteria to grow
easily. The protein is called siderocalin, and past research has suggested
that it helps the body fight infection by depriving bacteria of iron, a mineral
necessary for bacterial growth.
 Option B: Importantly, the researchers also showed that they could
encourage or discourage bacterial growth in urine simply by adjusting the
pH, a finding that could have implications for how patients with UTIs are
treated.
 Option C: Indeed, their results implicate cranberries among other possible
dietary interventions. Shield-Cutler noted that many studies already have
investigated extracts or juices from cranberries as UTI treatments but the
results of such investigations have not been consistent. ―It‘s possible that
cranberries may be more effective when paired with a treatment to make

the urine less acidic,‖ Henderson said. ―And even then, maybe cranberries
only work in people who have the right gut microbes.‖
ADVERTISEMENTS
65. Question
Clay-colored stools indicate:
o A. Upper GI bleeding
o B. Impending constipation
o C. An effect of medication
o D. Bile obstruction
Incorrect
Correct Answer: D. Bile obstruction
Bile colors the stool brown. Any inflammation or obstruction that impairs bile
flow will affect the stool pigment, yielding light, clay-colored stool. The liver
releases bile salts into the stool, giving it a normal brown color. One may have
clay-colored stools if they have a liver infection that reduces bile production, or if
the flow of bile out of the liver is blocked. Yellow skin (jaundice) often occurs with
clay-colored stools.
 Option A: Upper GI bleeding results in black or tarry stool. Melena is a
black, tarry stool that is caused by GI bleeding. The black color is due to
the oxidation of blood hemoglobin during the bleeding in the ileum and
colon. Melena also refers to stools or vomit stained black by blood
pigment or dark blood products and may indicate upper GI bleeding.
 Option B: Constipation is characterized by small, hard masses. The
problem may arise in the colon or rectum or it may be due to an external
cause. In most people, slow colonic motility that occurs after years of
laxative abuse is the problem. In a few patients, the cause may be related
to an outlet obstruction like rectal prolapse or a rectocele. External causes
of constipation may include poor dietary habits, lack of fluid intake,
overuse of certain medications, an endocrine problem like hypothyroidism
or some type of an emotional issue.

 Option C: Many medications and foods will discolor stool – for example,
drugs containing iron turn stool black; beets turn stool red. Blue feces may
be caused by boric acid, chloramphenicol, or methylene blue. Causative
diseases for clay feces may include alcoholic hepatitis, biliary cirrhosis,
gallstones, sclerosing cholangitis, biliary strictures, or viral hepatitis.
Causative medications for gray feces may include cocoa or colchicines.
Potential causes for green stools may include spinach, Indomethacin, iron,
or medroxyprogesterone.
ADVERTISEMENTS
66. Question
In which step of the nursing process would the nurse ask a patient if the
medication she administered relieved his pain?
o A. Assessment
o B. Analysis
o C. Planning
o D. Evaluation
Incorrect
In the evaluation step of the nursing process, the nurse must decide whether the
patient has achieved the expected outcome that was identified in the planning
phase. This final step of the nursing process is vital to a positive patient outcome.
Whenever a healthcare provider intervenes or implements care, they must
reassess or evaluate to ensure the desired outcome has been met. Reassessment
may frequently be needed depending upon the overall patient‘s condition. The
plan of care may be adapted based on new assessment data.
and weight.

 Option B: Analysis can be a part of diagnosing. The formulation of a
nursing diagnosis by employing clinical judgment assists in the planning
and implementation of patient care. The North American Nursing
Diagnosis Association (NANDA) provides nurses with an up to date list of
nursing diagnoses. A nursing diagnosis, according to NANDA, is defined as
a clinical judgment about responses to actual or potential health problems
on the part of the patient, family, or community.
 Option C: The planning stage is where goals and outcomes are formulated
ADVERTISEMENTS
67. Question
All of the following are good sources of vitamin A except:
o A. White potatoes
o B. Carrots
o C. Apricots
o D. Egg yolks
Incorrect
Correct Answer: A. White potatoes
Potatoes contain a good amount of carbs and fiber, as well as vitamin C, vitamin
B6, potassium and manganese. Their nutrient contents can vary depending on
the type of potato and cooking method. The main sources of vitamin A are yellow
and green vegetables (such as carrots, sweet potatoes, squash, spinach, collard
greens, broccoli, and cabbage) and yellow fruits (such as apricots, and
cantaloupe). Animal sources include liver, kidneys, cream, butter, and egg yolks.

 Option B: They‘re rich in beta-carotene, a compound the body changes
into vitamin A, which helps keep the eyes healthy. And beta-carotene helps
protect the eyes from the sun and lowers the chances of cataracts and
other eye problems. Yellow carrots have lutein, which is also good for the
eyes.
 Option C: Apricots are a great source of many antioxidants, including beta
carotene and vitamins A, C, and E. What‘s more, they‘re high in a group of
polyphenol antioxidants called flavonoids, which have been shown to
protect against illnesses, including diabetes and heart disease.
 Option D: Egg yolks contain vitamins A, D, E, and K along with omega-3
fats. Compared to the whites, egg yolks are also rich in folate and vitamin
B12. The yolks are also packed with tryptophan and tyrosine, and amino
acids that help prevent heart diseases.
ADVERTISEMENTS
68. Question
Which of the following is a primary nursing intervention necessary for all patients
with a Foley Catheter in place?
o A. Maintain the drainage tubing and collection bag level with the patient‘s
bladder.
o B. Irrigate the patient with 1% Neosporin solution three times a day.
o C. Clamp the catheter for 1 hour every 4 hours to maintain the bladder‘s
elasticity.
o D. Maintain the drainage tubing and collection bag below bladder level
to facilitate drainage by gravity.
Incorrect
Correct Answer: D. Maintain the drainage tubing and collection bag below
bladder level to facilitate drainage by gravity
To prevent obstruction, the catheter and collecting tube should be kept free from
kinking, the collecting bag should be positioned below the level of the bladder at
all times and never placed on the floor. The collecting bag should be emptied

regularly using a clean collecting container (HICPAC, 2009). In ambulatory
patients, collecting bags may be disguised in bags and pouches.
 Option A: Maintaining the drainage tubing and collection bag level with
the patient‘s bladder could result in reflux of urine into the kidney. The
indwelling catheter should be secured to the thigh or abdomen after
insertion to prevent movement and the exertion of excessive force on the
bladder neck or urethra (Gray, 2008). Unsecured and displaced catheters
can also cause pressure ulcers on the perineum and buttock (Siegel, 2008).
 Option B: Irrigating the bladder with Neosporin must be indicated and
ordered by the physician. Nash (2003) conducted a recent review of the
literature on self-cleaning of catheter training bags. The study showed that
patients whose bags were irrigated with vinegar showed a significant
reduction of bacteriuria compared with patients whose bags were irrigated
with the hydrogen peroxide solutions (Washington, 2001). Authors
concluded that more research is needed on the self-cleaning of Foley bags.
 Option C: Clamping the catheter for 1 hour every 4 hours must be
prescribed by a physician. Patients practicing intermittent catheterization
should pay close attention to the catheterization schedule and avoid
bladder overdistension and unnecessary catheterizations. As CAUTIs are
more prevalent for intermittent catheterization in patients with high
residual urine volumes at the time of catheterization, urine volume should
determine the catheterization schedule.
ADVERTISEMENTS
69. Question
The ELISA test is used to:
o A. Screen blood donors for antibodies to human immunodeficiency virus

(HIV).
o B. Test blood to be used for transfusion for HIV antibodies.
o C. Aid in diagnosing a patient with AIDS.

Incorrect

Correct Answer: D. All of the above.
The ELISA test of venous blood is used to assess blood and potential blood
donors to human immunodeficiency virus (HIV). A positive ELISA test combined
with various signs and symptoms helps to diagnose acquired immunodeficiency
syndrome (AIDS). Enzyme-linked immunosorbent assay (ELISA) is a labeled
immunoassay that is considered the gold standard of immunoassays. This
immunological test is very sensitive and is used to detect and quantify
substances, including antibodies, antigens, proteins, glycoproteins, and
hormones. The detection of these products is accomplished by the complexing of
antibodies and antigens to produce a measurable result.
 Option A: ELISAs are performed in polystyrene plates, typically in 96-well
plates that are coated to bind protein very strongly. Depending on the
ELISA type, testing requires a primary and/or secondary detection
antibody, analyte/antigen, coating antibody/antigen, buffer, wash, and
substrate/chromogen. The primary detection antibody is a specific
antibody that only binds to the protein of interest, while a secondary
detection antibody is a second enzyme-conjugated antibody that binds a
primary antibody that is not enzyme-conjugated.
 Option B: In HIV testing, a blood or saliva specimen is collected for testing
typically by the use of indirect ELISA-based tests. The ELISA is a screening
tool for HIV detection, but not diagnostic. Diagnosis requires further
testing by Western blot due to potential false positives. Another virus,
Molluscum contagiosum virus (MCV) that commonly infects the skin of
children and young adults, can be detected by ELISA testing. ELISA testing
in this setting is currently being evaluated for the assessment of global
MCV seroprevalence.
 Option C: ELISA testing is used in the diagnosis of HIV infection,
pregnancy tests, and blood typing, among others. The first ELISA
methodology involved chromogenic reporter molecules and substrates to
generate observable color change that monitors the presence of antigen.
Further advancement in the ELISA technique leads to the development of
fluorogenic, quantitative PCR, and electrochemiluminescent reporters to
generate signals. However, some of these techniques do not rely on using
enzyme-linked substrates but non-enzymatic reporters that utilize the
principle of ELISA.
ADVERTISEMENTS

70. Question
The two blood vessels most commonly used for TPN infusion are the:
o A. Subclavian and jugular veins
o B. Brachial and subclavian veins
o C. Femoral and subclavian veins
o D. Brachial and femoral veins

Incorrect
Correct Answer: A. Subclavian and jugular veins
Total Parenteral Nutrition (TPN) requires the use of a large vessel, such as the
subclavian or jugular vein, to ensure the rapid dilution of the solution and
thereby prevent complications, such as hyperglycemia. TPN is a mixture of
separate components that contain lipid emulsions, dextrose, amino acids,
vitamins, electrolytes, minerals, and trace elements. TPN composition should be
adjusted to fulfill individual patients‘ needs. The main three macronutrients are
lipids, emulsions, proteins, and dextrose.
 Option B: Total parenteral nutrition is not administered through a
peripheral intravenous catheter (Peripheral Parenteral Nutrition, PPN)
because it has high osmolarity. PPN osmolarity needs to be less than 900
mOsm. The lower concentration necessitates larger volume feedings, and
high-fat content is necessary. High osmolarity irritates peripheral veins;
hence TPN is given through central venous access. PPN is used to provide
additional nutrition to patients with functional gut and enteral feedings.
 Option C: Historically, total parenteral nutrition (TPN) has been
administered by the central venous route because of the rapid
development of thrombophlebitis when TPN solutions are administered
into peripheral veins. The insertion and placement of central venous
catheters are, however, associated with morbidity and mortality and is the
main cause of TPN-related complications.
 Option D: The brachial and femoral veins usually are contraindicated
because they pose an increased risk of thrombophlebitis. By avoiding
central venous catheterization, TPN can be made safer. Current awareness
about the pathophysiology of peripheral vein thrombophlebitis and the

use of a number of techniques that prevent or delay the onset of
peripheral vein thrombophlebitis means it is now possible to administer
TPN via the peripheral route.
ADVERTISEMENTS
71. Question
Effective skin disinfection before a surgical procedure includes which of the
following methods?
o A. Shaving the site on the day before surgery.
o B. Applying a topical antiseptic to the skin in the evening before surgery.
o C. Having the patient take a tub bath on the morning of surgery.
o D. Having the patient shower with an antiseptic soap on the evening

before and the morning of surgery.
Incorrect
Correct Answer: D. Having the patient shower with an antiseptic soap on the
evening before and the morning of surgery
Studies have shown that showering with an antiseptic soap before surgery is the
most effective method of removing microorganisms from the skin. Procedural
and surgical site infections create difficult and complex clinical scenarios. A
source for pathogens is often thought to be the skin surface, making skin
preparation at the time of the procedure critical. The antiseptic used for bathing
should be approved using the testing criteria from the FDA‘s Tentative Final
Monograph (TFM) for Antiseptic Drug Products for preoperative skin preparation.
The goal for this recommendation would be to reduce the number of bacterial
flora at the patient‘s incision site.
 Option A: Shaving the site of the intended surgery might cause breaks in
the skin, thereby increasing the risk of infection; however, if indicated,
shaving, should be done immediately before surgery, not the day before.
The purpose of surgical skin preparation is to reduce the number of
microorganisms on the skin‘s surface. This is accomplished by removing
dirt and oil without causing damage to the skin‘s natural protective
function or interfering with postoperative wound healing. The CDC‘s 1999

guideline recommends that hair not be removed unless it interferes with
the surgical procedure and is a Category IA recommendation.12 Also,
according to AORN standards, ―Whenever possible, hair should be left at
the surgical site.‖13 Hair-removal methods discussed are depilatory; dry
clipped using an electric clipper and wet using a disposable razor.
 Option B: A topical antiseptic would not remove microorganisms and
would be beneficial only after proper cleaning and rinsing. The most
common skin preparation agents used today include products containing
iodophors or chlorhexidine gluconate (CHG). CHG has more sustained
antimicrobial activity and is more resistant to neutralization by blood
products than the iodophors. CHG is applied in a similar manner to PVP-I,
but should not be used in the genital region. This agent has gained
popularity as a hand-scrubbing and showering antiseptic prior to surgery,
but also continues to be used as a patient skin preparation agent.
 Option C: Tub bathing might transfer organisms to another body site
rather than rinse them away. The CDC‘s 1999 guideline states that the
incision site should be clean before surgical skin preparation and has
labeled this a Category IB.10 In the Standards, Recommended Practices,
and Guidelines of the Association of periOperative Registered Nurses
(AORN) it states, ―The surgical site and surrounding areas should be clean.‖
ADVERTISEMENTS
72. Question
When transferring a patient from a bed to a chair, the nurse should use which
muscles to avoid back injury?
o A. Abdominal muscles
o B. Back muscles
o C. Leg muscles
o D. Upper arm muscles

Incorrect
Correct Answer: C. Leg muscles

The leg muscles are the strongest muscles in the body and should bear the
greatest stress when lifting. Muscles of the abdomen, back, and upper arms may
be easily injured. Place the patient‘s outside leg (the one farthest from the
wheelchair) between the knees for support. Bend the knees and keep the back
straight. Patient safety is often the main concern when moving patients from bed.
But remember not to lift at the expense of your own back. This transfer often
requires the patient‘s help, so clear communication is essential. If the patient
can‘t help much, you‘ll need two people or a full body sling lift.
 Option A: Allow the patient to help as much as possible. Estimate the
patient‘s weight and mentally practice. Make sure that the floor is free of
any obstacles or liquids. Keep the feet shoulder width apart. Keep the
person (or object) as close to your body as possible. Tighten your stomach
muscles. Bend knees and hips, and keep your back straight throughout the
movement. Lift with your legs, NOT your back.
 Option B: Keep the back straight throughout the transfer to avoid bending
or straining the back. Get as close to the person as possible while still
allowing him/her to lean forward as needed to assist with the transfer. Do
not twist your back as you lift. To turn when lifting, pivot your feet. If you
have doubts, ASK FOR HELP!
 Option D: To get the patient into a seated position, roll the patient onto
the same side as the chair. Put one of the arms under the patient‘s
shoulders and one behind the knees. Bend the knees. Swing the patient‘s
feet off the edge of the bed and use the momentum to help the patient
into a sitting position. Move the patient to the edge of the bed and lower
the bed so the patient‘s feet are touching the ground.
ADVERTISEMENTS
73. Question
Thrombophlebitis typically develops in patients with which of the following
conditions?
o A. Increases partial thromboplastin time
o B. Acute pulsus paradoxus
o C. An impaired or traumatized blood vessel wall

o D. Chronic Obstructive Pulmonary Disease (COPD)
Incorrect
Correct Answer: C. An impaired or traumatized blood vessel wall
The factors, known as Virchow‘s triad, collectively predispose a patient to
thrombophlebitis; impaired venous return to the heart, blood hypercoagulability,
and injury to a blood vessel wall. The three factors of Virchow‘s triad include
intravascular vessel wall damage, stasis of flow, and the presence of a
hypercoagulable state. Understanding the factors involved in the thrombus
formation and subsequent thromboembolic events enables the clinician to
stratify risk, direct clinical decision making regarding treatment, and establish
preventative measures.
 Option A: Increased partial thromboplastin time indicates a prolonged
bleeding time during fibrin clot formation, commonly the result of
anticoagulant (heparin) therapy. A prolonged PTT may be due to:
underlying conditions that cause low levels of clotting factors, such as: liver
disease—most coagulation factors are produced by the liver, thus liver
disease may cause prolonged PT and PTT. However, PT is more likely to be
prolonged than PTT.
 Option B: Pulsus Paradoxus refers to an exaggerated fall in a patient‘s
blood pressure during inspiration by greater than 10 mm Hg. Pulsus
Paradoxus results from alterations in the mechanical forces imposed on the
chambers of the heart and pulmonary vasculature often due to pericardial
disease, particularly cardiac tamponade and to a lesser degree constrictive
pericarditis. However, it is important to understand that pulsus paradoxus
may be seen in non-pericardial cardiac diseases such as right ventricular
myocardial infarction and restrictive cardiomyopathy.
 Option D: Chronic obstructive pulmonary disease (COPD) is estimated to
affect 32 million persons in the United States and is the third leading cause
of death in this country. Patients typically have symptoms of chronic
bronchitis and emphysema, but the classic triad also includes asthma or a
combination of the above.
ADVERTISEMENTS
74. Question

In a recumbent, immobilized patient, lung ventilation can become altered,
leading to such respiratory complications as:
o A. Respiratory acidosis, atelectasis, and hypostatic pneumonia
o B. Apneustic breathing, atypical pneumonia and respiratory alkalosis
o C. Cheyne-Stokes respirations and spontaneous pneumothorax
o D. Kussmaul‘s respirations and hypoventilation

Incorrect
Correct Answer: A. Respiratory acidosis, atelectasis, and hypostatic
pneumonia
Because of restricted respiratory movement, a recumbent, immobilize patient is
at particular risk for respiratory acidosis from poor gas exchange; atelectasis from
reduced surfactant and accumulated mucus in the bronchioles, and hypostatic
pneumonia from bacterial growth caused by stasis of mucus secretions.
 Option B: Apneustic respiration (a.k.a. apneusis) is an abnormal pattern of
breathing characterized by deep, gasping inspiration with a pause at full
inspiration followed by a brief, insufficient release. Pneumonia is acquired
when a sufficient volume of a pathogenic organism bypasses the body‘s
cough and laryngeal reflexes and makes its way into the parenchyma. In
almost every scenario, respiratory alkalosis is induced by a process
involving hyperventilation. These include central causes, hypoxemic causes,
pulmonary causes, and iatrogenic causes. Central sources are a head injury,
stroke, hyperthyroidism, anxiety-hyperventilation, pain, fear, stress, drugs,
medications such as salicylates, and various toxins.
 Option C: Cheyne-Stokes respiration is a specific form of periodic
breathing (waxing and waning amplitude of flow or tidal volume)
characterized by a crescendo-decrescendo pattern of respiration between
central apneas or central hypopneas. Unlike obstructive sleep apnea (OSA),
which can be the cause of heart failure, Cheyne-Stokes respiration is
believed to be a result of heart failure. Spontaneous pneumothorax refers
to the abnormal collection of gas in the pleural space between the lungs
and the chest wall. Spontaneous pneumothorax occurs without an obvious
etiology such as trauma or iatrogenic causes.
 Option D: Kussmaul respirations were originally observed and described
by Dr. Adolf Kussmaul in 1874. He made his observation in diabetic

patients who were comatose and in the late stages of diabetic ketoacidosis.
As classically described, Kussmaul respirations are a deep, sighing
respiratory pattern. Dr. Kussmaul actually described it as ―air hunger.‖
Hypoventilation is breathing that is too shallow or too slow to meet the
needs of the body. If a person hypoventilates, the body‘s carbon dioxide
level rises. This causes a buildup of acid and too little oxygen in the blood.
A person with hypoventilation might feel sleepy.
Sources:
ADVERTISEMENTS
75. Question
Immobility impairs bladder elimination, resulting in such disorders as:
o A. Increased urine acidity and relaxation of the perineal muscles, causing

incontinence
o B. Urine retention, bladder distention, and infection
o C. Diuresis, natriuresis, and decreased urine specific gravity
o D. Decreased calcium and phosphate levels in the urine

Incorrect
Correct Answer: B. Urine retention, bladder distention, and infection
The immobilized patient commonly suffers from urine retention caused by
decreased muscle tone in the perineum. This leads to bladder distention and
urine stagnation, which provide an excellent medium for bacterial growth leading
to infection.
 Option A: Urea is the main nitrogenous waste product resulting from
protein breakdown (catabolism) and is rapidly eliminated in the urine by
the kidneys. During bed rest, the concentration of urea in the blood
increases, and the kidneys eliminate larger amounts of urea.
 Option C: As food intake usually decreases during bed rest, it is speculated
that these higher concentrations of urea in blood and urine can only come
from the catabolic breakdown of endogenous protein sources, such as
muscle and other lean tissues (Bilancio et al, 2014). This correlates with the

reduction in lean tissue mass and sarcopenia that are characteristic of
prolonged immobility.
 Option D: Immobility is independently associated with the development of
a series of complications, including pressure ulcer, deep vein thrombosis
(DVT), pneumonia, and urinary tract infection (UTI) Immobility also results
in more alkaline urine with excessive amounts of calcium, sodium, and
phosphate, a gradual decrease in urine production, and increased specific
gravity.
ADVERTISEMENTS
1. 1. Question
Once a nurse assesses a client‘s condition and identifies appropriate nursing
diagnoses, a:
o A. Plan is developed for nursing care.
o B. Physical assessment begins.
o C. List of priorities is determined.
o D. Review of the assessment is conducted with other team members.

Incorrect
Correct Answer: A. Plan is developed for nursing care.
The planning stage is where goals and outcomes are formulated that directly
attainment of such assist in ensuring a positive outcome. Nursing care plans are
essential in this phase of goal setting.
 Option B: Assessment is the first step and involves critical thinking skills
and weight.
 Option C: A nursing diagnosis encompasses Maslow‘s Hierarchy of Needs
and helps to prioritize and plan care based on patient-centered outcomes.
In 1943, Abraham Maslow developed a hierarchy based on basic
fundamental needs innate for all individuals.
 Option D: Data may come from the patient directly or from primary
caregivers who may or may not be direct relation family members. Friends

can play a role in data collection. Electronic health records may populate
data and assist in assessment.
ADVERTISEMENTS
1. Question 2 of 75
2. Question
Planning is a category of nursing behaviors in which:
o A. The nurse determines the health care needed for the client.
o B. The physician determines the plan of care for the client.
o C. Client-centered goals and expected outcomes are established.
o D. The client determines the care needed.

Incorrect
Correct Answer: C. Client-centered goals and expected outcomes are
established.
attainment of such assist in ensuring a positive outcome.
 Option A: Nursing care plans are essential in this phase of goal setting.
play a role in the construction of a care plan.
 Option B: As explored by Salmond and Echevarria, healthcare is changing,
and the traditional roles of nurses are transforming to meet the demands
of this new healthcare environment. Nurses are in a position to promote
change and impact patient delivery care models in the future.
 Option D: Care plans enhance communication, documentation,
Critical thinking skills will play a vital role as nurses develop plans of care
for these patient populations with multiple comorbidities and embrace this
challenging healthcare arena.
ADVERTISEMENTS
1. Question 3 of 75

3. Question
Priorities are established to help the nurse anticipate and sequence nursing
interventions when a client has multiple problems or alterations. Priorities are
determined by the client‘s:
o A. Physician
o B. Non-Emergent, non-life-threatening needs
o C. Future well-being.
o D. Urgency of problems
Incorrect
Correct Answer: D. Urgency of problems
Triage of patients involves looking for signs of serious illness or injury. These
emergency signs are connected to the Airway – Breathing –
Circulation/Consciousness – Dehydration and are easily remembered as ABCD. If
the client does not have any emergency signs, the health worker proceeds to
assess the client for priority conditions. This should not take more than a few
seconds. Some of these signs will have been noticed during the ABCD triage and
others need to be rechecked.
 Option A: All clinical staff involved in the care of the sick should be
prepared to carry out a rapid assessment to identify the few clients who are
severely ill and require emergency treatment.
 Option B: Triage is the process of rapidly examining sick children when
they first arrive in order to place them in one of the following categories:
those with EMERGENCY SIGNS who require immediate emergency
treatment; those with PRIORITY SIGNS who should be given priority in the
queue so they can be rapidly assessed and treated without delay; and
those who have no emergency or priority signs and are NON-URGENT
cases. These clients can wait their turn in the queue for assessment and
treatment. The majority of sick clients will be non-urgent and will not
require emergency treatment.
 Option C: Ideally, all clients should be checked on their arrival by a person
who is trained to assess how ill they are. This person decides whether the
client will be seen immediately and receive life-saving treatment, or will be
seen soon, or can safely wait for his or her turn to be examined.

ADVERTISEMENTS
1. Question 4 of 75
4. Question
A client-centered goal is a specific and measurable behavior or response that
reflects a client‘s:
o A. Desire for specific health care interventions.
o B. Highest possible level of wellness and independence in function.
o C. Physician‘s goal for the specific client.
o D. Response when compared to another client with a similar problem.

Incorrect
Correct Answer: B. Highest possible level of wellness and independence in
function.
Client-centered practices facilitate the development of strong therapeutic
relationships and enable care providers to understand how to maximize clients‘
strengths and minimize challenges in achieving treatment and recovery goals.
 Option A: Care providers negotiate between clients‘ decisions and
ongoing risk assessments. The care plan reflects safe practices and
promotes interventions that minimize or reduce potential harms to the
client.
 Option C: Client-centred care empowers clients, promoting autonomy,
rights, voice, and self-determination in the treatment planning and
recovery process and supports care plans that are developed in
collaboration with clients, and allows clients to express their self-identified
needs and choices.
 Option D: Client-centred care is about treating clients as they want to be
treated, with knowledge about and respect for their values and personal
priorities. Health care providers who take the time to get to know their
clients can provide care that better addresses the needs of clients and
improves their quality of care.
ADVERTISEMENTS
1. Question 5 of 75
5. Question

For clients to participate in goal setting, they should be:
o A. Alert and have some degree of independence.
o B. Ambulatory and mobile.
o C. Able to speak and write.
o D. Able to read and write.

Incorrect
Correct Answer: A. Alert and have some degree of independence.
Goal setting in nursing provides direction for planning nursing interventions and
evaluating patient progress. The purpose of goal setting in nursing is to enable
the patient and nurse to determine when the problem has been resolved and
help motivate the patient and the nurse by providing a sense of achievement.
 Option B: In light of the potential benefits of patient participation in goal
setting, a study by Baker, Rice, Zimmerman, Marshak, et. al. believes the
following are needed: (1) patient and therapist education regarding the
potential advantages of participation, (2) the enhancement of patient
readiness to assume greater responsibility in their care, and (3) the
development of models for use in achieving patient participation.
 Option C: Patient and therapist education is needed regarding methods
for patient participation during initial goal-setting activities. In a study by
Baker, Rice, Zimmerman, Marshak, et. al., the therapists stated that they
believed that it is important to include patients in goal-setting activities
and that outcomes will be improved if patients participate. Patients also
indicated that participation is important to them.
 Option D: Patient participation in goal setting is emphasized in order to
enhance patient management and the effectiveness of treatment.
Participation should improve outcomes and could be used to identify
benefits that may result from the treatment. These benefits include greater
goal attainment, increased patient satisfaction, gains in function, better
adherence to treatment regimens, decreased depression in patients, and
reduced burnout rates among physical therapists.
ADVERTISEMENTS
1. Question 6 of 75

6. Question
The nurse writes an expected outcome statement in measurable terms. An
example is:
o A. Client will have less pain.
o B. Client will be pain-free.
o C. Client will report pain acuity less than 4 on a scale of 0-10.
o D. Client will take pain medication every 4 hours around the clock.
Incorrect
Correct Answer: C. Client will report pain acuity less than 4 on a scale of 0-
10.
When developing goals for patients, the nurse needs to look at several factors.
Think back to the SMART goal criteria. In order to be specific, nurses focus on
questions like ‗What is the problem? What is the response desired?‘ To make it
measurable, ‗How will the client look or behave if the healthy response is
achieved? What can I see, hear, measure, observe?‘
 Option A: One way to help nurses remember how to write goals is to make
sure they are SMART. SMART goals are Specific, Measurable, Action-
Oriented, Realistic, and Timely. ‗Specific‘ refers to who, what, when, where,
and why. ‗Measurable‘ means that you can actually measure and evaluate
the progress of that goal in a concrete way. ‗Action-oriented‘ means there
are actions that can be taken to reach the goal. ‗Realistic‘ includes the
ability to work on the goal, having the resources, attitudes, abilities, and
skills to reach this goal, and how realistic it is to come to fruition. Finally,
‗Timely‘ means that there is an end time frame or date at which the goal is
going to be evaluated.
 Option B: Goal setting occurs in the third phase of the process, planning.
Is the goal for nursing care to heal patients? To help them get better? To
help them get well? While these are certainly at the forefront of nurses‘
minds, how do you evaluate these statements? What if the definition of
wellness is different from one person to another? This is why nursing goal
statements that are patient-centered and measurable are so important.
 Option D: Considering action-oriented, ‗Are there steps and nursing
interventions needed to reach that goal? Is this a realistic outcome for the

patient? Have we considered all of the factors involved, including the
client‘s capabilities and limitations? Does the patient have what he or she
needs to reach that goal?‘ And finally, ‗Is it timely? When do we expect the
goal to be reached?‘
ADVERTISEMENTS
1. Question 7 of 75
7. Question
As goals, outcomes, and interventions are developed, the nurse must:
o A. Be in charge of all care and planning for the client.
o B. Be aware of and committed to accepted standards of practice from

nursing and other disciples.
o C. Not change the plan of care for the client.
o D. Be in control of all interventions for the client.

Incorrect
Correct Answer: B. Be aware of and committed to accepted standards of
practice from nursing and other disciples.
may frequently be needed depending upon overall patient condition. The plan of
care may be adapted based on new assessment data.
 Option A: Patients‘ participation in decision-making in health care and
treatment is not a new area, but currently it has become a political
necessity in many countries and health care systems around the world.
Emphasizing the importance of participation in the decision-making
process motivates the service provider and the health care team to
promote participation of patients in treatment decision-making.
 Option C: A review of some literature reveals that participation of patients
in health care has been associated with improved treatment outcomes.
Moreover, this participation causes improved control of diabetes, better
physical functioning in rheumatic diseases, enhanced patients‘ compliance
with secondary preventive actions, and improvement in health of patients
with myocardial infarction.

 Option D: With enhanced patient participation, and considering patients
as equal partners in healthcare decision making patients are encouraged to
actively participate in their own treatment process and follow their
treatment plan and thus a better health maintenance service would be
provided.
ADVERTISEMENTS
1. Question 8 of 75
8. Question
When establishing realistic goals, the nurse:
o A. Bases the goals on the nurse‘s personal knowledge.
o B. Knows the resources of the health care facility, family, and the client.
o C. Must have a client who is physically and emotionally stable.
o D. Must have the client‘s cooperation.

Incorrect
Correct Answer: B. Knows the resources of the health care facility, family,
and the client.
attainment of such assist in ensuring a positive outcome. Data may come from
the patient directly or from primary caregivers who may or may not be direct
relation family members. Friends can play a role in data collection. Electronic
health records may populate data and assist in assessment.
 Option C: The utilization of the nursing process to guide care is clinically
significant going forward in this dynamic, complex world of patient care.
Aging populations carry with them a multitude of health problems and
inherent risks of missed opportunities to spot a life-altering condition.
 Option D: As explored by Salmond and Echevarria, healthcare is changing,

ADVERTISEMENTS
1. Question 9 of 75
9. Question
To initiate an intervention the nurse must be competent in three areas, which
include:
o A. Knowledge, function, and specific skills.
o B. Experience, advanced education, and skills.
o C. Skills, finances, and leadership.
o D. Leadership, autonomy, and skills.

Incorrect
Correct Answer: A. Knowledge, function, and specific skills
Critical thinking and reflection are essential skills because they can enhance
nurses‘ ability to solve problems and make sound decisions. Critical thinking skills
enable nurses to identify multiple possibilities in clinical situations and
alternatives to interventions; weigh the consequences of alternate actions; and
determine the right judgment and decisions. To provide safe and effective care to
the clients, nurses must integrate knowledge, skills, and attitudes to make sound
judgment and decisions.
 Option B: Due to the increasing internal and external expectations of
higher quality nursing, it is no longer acceptable for nurses to deliver
nursing care only on experience and textbook knowledge. Clinical nurses
are expected to systematically gather the best research evidence, draw
from nursing experience, and consider patient‘s preferences when they are
making professional decisions
 Option C: Some research findings showed that changing the attitude and
enhancing the knowledge of nurses are the first step in EBP. McCleary and
Brown conducted a study on 528 graduate nurses working in educational
pediatric hospitals of Canada and reported that the nurses‘ knowledge of
EBP and their positive attitude towards it will contribute to its
implementation in the healthcare system.

 Option D: Melnyk et al. stated that acquiring knowledge about research
methods and having the skill to evaluate research reports critically may
enable overcoming the obstacles hindering the application of research
findings and thus will lead to improvement of healthcare quality. Hence,
the EBP attitude, knowledge, and skills of nurses are so important.
ADVERTISEMENTS
10. Question
Collaborative interventions are therapies that require:
o A. Physician and nurse interventions.
o B. Nurse and client interventions.
o C. Client and Physician intervention.
o D. Multiple health care professionals.

Incorrect
Correct Answer: D. Multiple health care professionals.
Collaborative interventions are actions that the nurse carries out in collaboration
with other health team members, such as physicians, social workers, dietitians,
and therapists. These actions are developed in consultation with other health care
professionals to gain their professional viewpoint.
 Option A: Dependent nursing interventions are activities carried out under
the physician‘s orders or supervision. Includes orders to direct the nurse to
provide medications, intravenous therapy, diagnostic tests, treatments,
diet, and activity or rest.
 Option B: Independent nursing interventions are activities that nurses are
licensed to initiate based on their sound judgment and skills. Includes
ongoing assessment, emotional support, providing comfort, teaching,
physical care, and making referrals to other health care professionals.
 Option C: Nursing interventions are activities or actions that a nurse
performs to achieve client goals. Interventions chosen should focus on
eliminating or reducing the etiology of the nursing diagnosis. In this step,
nursing interventions are identified and written during the planning step of

the nursing process; however, they are actually performed during the
implementation step.
ADVERTISEMENTS
11. Question
Well formulated, client-centered goals should:
o A. Meet immediate client needs.
o B. Include preventative health care.
o C. Include rehabilitation needs.

Incorrect
The process of client-centered goal planning encourages members of the multi-
professional team to work in partnership with the client, his or her family, and
each other, united by the aim of helping the client to achieve his or her desired
outcome. Goals enable clients, their carers or partners, and the multidisciplinary
team to focus on strengths rather than problems. They also enable the team to
gauge where the client and family are in their ‗thinking‘ (Davis and O‘Connor,
1999).
 Option A: Once set, goals provide a central focus for all therapeutic
activity, enabling clients to move away from a period of dependency to a
level of achievement and/or adjustment to their situation.
 Option B: Goal planning is part of the overall care plan in which the client‘s
own values, beliefs, and aspirations are recognized and valued, and form
the central focus of the rehabilitation process.
 Option C: Goals for rehabilitation can be divided into two groups: short-
term and long-term. Short-term goals can act as stepping stones to
achieving longer-term targets. A short-term goal for this client might be to
be able to clean her teeth.
ADVERTISEMENTS

12. Question
The following statement appears on the nursing care plan for an
immunosuppressed client: The client will remain free from infection throughout
hospitalization. This statement is an example of a (an):
o A. Nursing diagnosis
o B. Short-term goal
o C. Long-term goal
o D. Expected outcome
Incorrect
Correct Answer: B. Short-term goal
Short-term goals can act as stepping stones to achieving longer-term targets. For
example, a client may have the long-term goal of being able to groom herself,
including cleaning her teeth, washing her face, combing her hair, and applying
her make-up on her own. A short-term goal for this client might be to be able to
clean her teeth.
 Option A: Actual or potential health problems that can be prevented or
resolved by independent nursing intervention are termed nursing
diagnoses. NANDA nursing diagnoses are a uniform way of identifying,
focusing on, and dealing with specific client needs and responses to actual
and high-risk problems.
 Option C: Long-term goals are often used for clients who have chronic
health problems or who live at home, in nursing homes, or extended-care
facilities. Long-term goal indicates an objective to be completed over a
longer period, usually over weeks or months.
 Option D: Goals or desired outcomes describe what the nurse hopes to
achieve by implementing the nursing interventions and are derived from
the client‘s nursing diagnoses. One overall goal is determined for each
nursing diagnosis. The terms goal, outcome, and expected outcome are
oftentimes used interchangeably.
ADVERTISEMENTS
13. Question

The following statements appear on a nursing care plan for a client after a
mastectomy: Incision site approximated; absence of drainage or prolonged
erythema at the incision site; and the client remains afebrile. These statements
are examples of:
o A. Nursing interventions
o B. Short-term goals
o C. Long-term goals
o D. Expected outcomes
Incorrect
Correct Answer: D. Expected outcomes
Goals or desired outcomes describe what the nurse hopes to achieve by
implementing the nursing interventions and are derived from the client‘s nursing
diagnoses. One overall goal is determined for each nursing diagnosis. The terms
goal, outcome, and expected outcome are oftentimes used interchangeably.
 Option A: Nursing interventions are activities or actions that a nurse
eliminating or reducing the etiology of the nursing diagnosis.
 Option B: Short-term goals can act as stepping stones to achieving
longer-term targets. For example, a client may have the long-term goal of
being able to groom herself, including cleaning her teeth, washing her face,
combing her hair, and applying her make-up on her own. A short-term
goal for this client might be to be able to clean her teeth.
ADVERTISEMENTS
14. Question
The planning step of the nursing process includes which of the following
activities?

o A. Assessing and diagnosing.
o B. Evaluating goal achievement.
o C. Performing nursing actions and documenting them.
o D. Setting goals and selecting interventions.

Incorrect
Correct Answer: D. Setting goals and selecting interventions.
essential in this phase of goal setting. Care plans provide a course of direction for
personalized care tailored to an individual‘s unique needs.
and data collection; subjective and objective. Data may come from the
patient directly or from primary caregivers who may or may not be direct
relation family members. Friends can play a role in data collection.
Electronic health records may populate data in and assist in assessment.
The formulation of a nursing diagnosis by employing clinical judgment
assists in the planning and implementation of patient care.
 Option B: This final step of the nursing process is vital to a positive patient
outcome. Whenever a healthcare provider intervenes or implements care,
they must reassess or evaluate to ensure the desired outcome has been
met. Reassessment may frequently be needed depending upon overall
patient condition. The plan of care may be adapted based on new
assessment data.
ADVERTISEMENTS
15. Question
The nursing care plan is:

o A. A written guideline for implementation and evaluation.
o B. A documentation of client care.
o C. A projection of potential alterations in client behaviors.
o D. A tool to set goals and project outcomes.

Incorrect
Correct Answer: A. A written guideline for implementation and evaluation.
Nursing care plans are essential in this phase of goal setting. Care plans provide a
course of direction for personalized care tailored to an individual‘s unique needs.
Overall condition and comorbid conditions play a role in the construction of a
care plan. Care plans enhance communication, documentation, reimbursement,
and continuity of care across the healthcare continuum.
 Option B: Documentation is any written or electronically generated
information about a client that describes the status, care or services
provided to that client. Through documentation, you communicate
observations, decisions, actions, and outcomes of these actions for clients,
demonstrating the nursing process.
 Option C: Behavioral tools are psychological instruments that are used for
understanding and interpreting human behavior. Such tools have found
many applications in corporate and educational sectors, considering their
exploratory and insightful nature.
 Option D: A SMART goal is one that is specific, measurable, attainable,
relevant and time-bound. The SMART criteria help to incorporate guidance
and realistic direction in goal setting, which increases motivation and leads
to better results in achieving lasting change.
ADVERTISEMENTS
16. Question
After determining a nursing diagnosis of acute pain, the nurse develops the
following appropriate client-centered goal:
o A. Encourage the client to implement guided imagery when pain begins.
o B. Determine the effect of pain intensity on client function.

o C. Administer analgesic 30 minutes before physical therapy treatment.
o D. Pain intensity reported as a 3 or less during hospital stay.

Incorrect
Correct Answer: D. Pain intensity reported as a 3 or less during hospital stay.
This is measurable and objective. Goals or desired outcomes describe what the
nurse hopes to achieve by implementing the nursing interventions and are
derived from the client‘s nursing diagnoses. Goals provide direction for planning
interventions, serve as criteria for evaluating client progress, enable the client and
nurse to determine which problems have been resolved, and help motivate the
client and nurse by providing a sense of achievement.
 Option A: This is an example of nursing intervention. Nursing interventions
are activities or actions that a nurse performs to achieve client goals.
Interventions chosen should focus on eliminating or reducing the etiology
of the nursing diagnosis.
 Option B: Evaluating is a planned, ongoing, purposeful activity in which
the client‘s progress towards the achievement of goals or desired
outcomes, and the effectiveness of the nursing care plan (NCP).
 Option C: This is an example of nursing intervention. Dependent nursing
interventions are activities carried out under the physician‘s orders or
supervision. Includes orders to direct the nurse to provide medications,
intravenous therapy, diagnostic tests, treatments, diet, and activity or rest.
ADVERTISEMENTS
17. Question
When developing a nursing care plan for a client with a fractured right tibia, the
nurse includes in the plan of care independent nursing interventions, including:
o A. Apply a cold pack to the tibia.
o B. Elevate the leg 5 inches above the heart.
o C. Perform a range of motion to right leg every 4 hours.
o D. Administer aspirin 325 mg every 4 hours as needed.

Incorrect

Correct Answer: B. Elevate the leg 5 inches above the heart.
This does not require a physician‘s order. Independent nursing interventions are
activities that nurses are licensed to initiate based on their sound judgment and
skills. Includes ongoing assessment, emotional support, providing comfort,
teaching, physical care, and making referrals to other health care professionals.
 Option A: This intervention requires a doctor‘s order. Assessment and
providing explanation while administering medical orders are also part of
the dependent nursing interventions.
 Option C: C is not appropriate for a fractured tibia. Isometrics contract
muscles without bending joints or moving limbs and help maintain muscle
strength and mass. Note: These exercises are contraindicated while acute
bleeding and edema are present.
 Option D: Dependent nursing interventions are activities carried out under
ADVERTISEMENTS
18. Question
Which of the following nursing interventions are written correctly?
o A. Apply continuous passive motion machines during the day.
o B. Perform neurovascular checks.
o C. Elevate head of bed 30 degrees before meals.
o D. Change dressing once a shift.

Incorrect
Correct Answer: C. Elevate head of bed 30 degrees before meals.
It is specific in what to do and when. Nursing interventions should be specific and
clearly stated, beginning with an action verb indicating what the nurse is
expected to do. Action verb starts the intervention and must be precise.
 Option A: This intervention does not specify the location of the
application. Nursing interventions are the actual treatments and actions
that are performed to help the patient to reach the goals that are set for

them. The nurse uses his or her knowledge, experience, and critical-
thinking skills to decide which interventions will help the patient the most.
 Option B: It was not stated in this intervention when the neurovascular
check should be performed. Nurses must use their knowledge, experience,
resources, research of evidence-based practice, the counsel of others, and
critical-thinking skills to decide which nursing interventions would best
benefit a specific patient.
 Option D: Qualifiers of how, when, where, time, frequency, and amount
provide the content of the planned activity. For example: ―Educate parents
on how to take temperature and notify of any changes,‖ or ―Assess urine
for color, amount, odor, and turbidity.‖
ADVERTISEMENTS
19. Question
A client‘s wound is not healing and appears to be worsening with the current
treatment. The nurse first considers:
o A. Notifying the physician.
o B. Calling the wound care nurse.
o C. Changing the wound care treatment.
o D. Consulting with another nurse.

Incorrect
Correct Answer: B. Calling the wound care nurse.
Calling the wound care nurse as a consultant is appropriate because he or she is
a specialist in the area of wound management. Professional and competent
nurses recognize limitations and seek appropriate consultation. As the largest
health care workforce, nurses apply their knowledge, skills, and experience to
care for the various and changing needs of patients. A large part of the demands
of patient care is centered on the work of nurses.
 Option A: Option A may be appropriate after deciding on a plan of action
with the wound care nurse specialist. The nurse may need to obtain orders
for special wound care products. Interprofessional and interprofessional
collaboration, through multidisciplinary teams, is important in the right

work environments. Skills for teamwork are considered nontechnical and
include leadership, mutual performance monitoring, adaptability, and
flexibility.
 Option C: Option C is possible unless the nurse is knowledgeable in
wound management, this could delay wound healing. Also, the current
wound management plan could have been ordered by the physician.
Clinicians working in teams will make fewer errors when they work well
together, use well-planned and standardized processes, know team
members and their own responsibilities, and constantly monitor team
members‘ performance to prevent errors before they could cause harm.
 Option D: Another nurse most likely will not be knowledgeable about
wounds, and the primary nurse would know the history of the wound
management plan. Understanding the complexity of the work environment
and engaging in strategies to improve its effects is paramount to higher-
quality, safer care.
ADVERTISEMENTS
20. Question
When calling the nurse consultant about a difficult client-centered problem, the
primary nurse is sure to report the following:
o A. Length of time the current treatment has been in place.
o B. The spouse‘s reaction to the client‘s dressing change.
o C. Client‘s concern about the current treatment.
o D. Physician‘s reluctance to change the current treatment plan.

Incorrect
Correct Answer: A. Length of time the current treatment has been in place.
This gives the consulting nurse facts that will influence a new plan. Other choices
are subjective and emotional issues and conclusions about the current treatment
plan may cause bias in the decision of a new treatment plan by the nurse
consultant. In general, it is important to create a supportive environment with
open and honest communication, focusing on the achievements and not on
negative aspects.

 Option B: Navigating the new system is very challenging and it is
important for the clients to have a person to whom they could always turn
with questions and concerns. It could not necessarily be a formal
caseworker, but rather any clinician who had a trusting relationship and
was helpful and willing to guide the client.
 Option C: Education and information for both the patient and the family
were mentioned by all the participants in a study as the main strategies to
help them develop a clear understanding of their condition and prognosis.
 Option D: Several successful strategies to improve client-centered care
have been introduced in different hospitals: writing a family note (a
summary that is given to the family) at the family meeting, appointing a
contact person/therapy leader for each client, improving continuity and
coordination of care through interdisciplinary collaborations, having the
same staff working with the client, and providing written materials.
ADVERTISEMENTS
21. Question
The primary nurse asked a clinical nurse specialist (CNS) to consult on a difficult
nursing problem. The primary nurse is obligated to:
o A. Implement the specialist‘s recommendations.
o B. Report the recommendations to the primary physician.
o C. Clarify the suggestions with the client and family members.
o D. Discuss and review advised strategies with CNS.

Incorrect
Correct Answer: D. Discuss and review advised strategies with CNS.
The primary nurse requested the consultation, it is important that they
communicate and discuss recommendations. The primary nurse can then accept
or reject the CNS recommendations. Effective clinical practice thus involves many
instances where critical information must be accurately communicated. Team
collaboration is essential.
 Option A: Some of the recommendations may not be appropriate for this
client. The primary nurse would know this information. A consultation

requires review of the recommendations, but not immediate
implementation. Collaboration in health care is defined as health care
professionals assuming complementary roles and cooperatively working
together, sharing responsibility for problem-solving, and making decisions
to formulate and carry out plans for patient care
 Option B: This would be appropriate after first talking with the CNS about
recommended changes in the plan of care and the rationale. Then the
primary nurse should call the physician. Collaboration between physicians,
nurses, and other health care professionals increases team members‘
awareness of each others‘ type of knowledge and skills, leading to
continued improvement in decision making.
 Option C: The client and family do not have the knowledge to determine
whether new strategies are appropriate or not. Better to wait until the new
plan of care is agreed upon by the primary nurse and physician before
talking with the client and/or family. A study determined that improved
teamwork and communication are described by health care workers as
among the most important factors in improving clinical effectiveness and
job satisfaction.
ADVERTISEMENTS
22. Question
After assessing the client, the nurse formulates the following diagnoses. Place
them in order of priority, with the most important (classified as high) listed first.
View Answers:
o Ineffective tissue perfusion.

o Constipation
o Ineffective airway clearance
o Anticipated grieving
Incorrect
Nurses should apply the concept of ABCs to each patient situation. Prioritization
begins with determining immediate threats to life as part of the initial assessment

and is based on the ABC pneumonic focusing on the airway as priority, moving to
breathing, and circulation (Ignatavicius et al., 2018).
 Ineffective airway clearance can be an acute (e.g., postoperative recovery)
or chronic (e.g., CVA or spinal cord injury) problem. High-risk for ineffective
airway clearance are the aged individuals who have an increased incidence
of emphysema and a higher prevalence of chronic cough or sputum
production.
 Decreased tissue perfusion can be temporary, with few or minimal
consequences to the health of the patient, or it can be more acute or
protracted, with potentially destructive effects on the patient. When
diminished tissue perfusion becomes chronic, it can result in tissue or
organ damage or death.
 Constipation occurs when bowel movements become less frequent than
normal. It is accompanied by a difficult or incomplete passage of stool.
Though common, constipation may also be a complex problem. Chronic
constipation can result in the development of hemorrhoids; diverticulosis;
straining at stool, and perforation of the colon.
 Grieving is an individual‘s normal response to a loss that may be perceived
or actual. Assessment is necessary in order to identify potential problems
that may have led to grief and also name any event that may happen
during nursing care.
ADVERTISEMENTS
23. Question
The nurse is reviewing the critical paths of the clients on the nursing unit. In
performing a variance analysis, which of the following would indicate the need
for further action and analysis?
o A. A client‘s family attending a diabetic teaching session.
o B. Canceling physical therapy sessions on the weekend.
o C. Normal VS and absence of wound infection in a post-op client.
o D. A client demonstrating accurate medication administration following

teaching.

Incorrect
Correct Answer: B. Canceling physical therapy sessions on the weekend.
Variance analysis is the identification of patient or family needs that are not
anticipated and the actions related to these needs in a system of managed care.
There are four kinds of origin for the variance: patient-family origin, system-
institutional origin; community origin, and clinician origin.
 Option A: Critical pathways are care plans that detail the essential steps
inpatient care with a view to describing the expected progress of the
patient. They also have a positive impact on outcomes, such as increased
quality of care and patient satisfaction, improved continuity of information,
and patient education.
 Option C: Clinical pathways are being increasingly used for daily patient
care. The pathways consist of a sequence of critical treatment events
matched to the patient‘s recovery. Variance analysis identifies deviations
from the pathway and can be used for quality improvement and clinical
audit.
 Option D: Clinical pathways can be used as a means of incorporating
evidence-based medicine into clinical practice. Variance analysis of the
pathways can be utilized as a process of quality control and to improve
patient outcomes.
ADVERTISEMENTS
24. Question
The RN has received her client assignment for the day shift. After making the
initial rounds and assessing the clients, which client would the RN need to
develop a care plan first?
o A. A client who is ambulatory.
o B. A client, who has a fever, is diaphoretic and restless.
o C. A client scheduled for OT at 1300.
o D. A client who just had an appendectomy and has just received pain
medication.
Incorrect

Correct Answer: B. A client, who has a fever, is diaphoretic and restless.
This client‘s needs are a priority. Clinical judgment and prioritization of patient
care is built on the nursing process. Nurses learn the steps of the nursing process
in their foundational nursing course and utilize it throughout their academic and
clinical careers to direct patient care and determine priorities.
 Option A: An ambulatory client would not be a priority. However, a
thorough assessment should still be done to make sure that the client does
not have any underlying diseases. In unfamiliar situations, patient
prioritization should be approached as a structured process, highlighting
risk factors that may contribute to a decline in the patient‘s condition and
potential interventions that can reduce the risk of adverse outcomes
(Jessee, 2019).
 Option C: The client does not have any emergent concerns based on the
stem. Seasoned nurses are able to pull from their depth of knowledge and
experience that allows them to act deductively and intuitively when
prioritizing patient care.
 Option D: The client has already received pain medication, therefore she is
not a priority. For expert nurses, the ability to prioritize based on these
processes is predominately intuitive, and tasks are completed in a
prioritized manner without much conscious thought.
ADVERTISEMENTS
25. Question
Which of the following statements about the nursing process is most accurate?
o A. The nursing process is a four-step procedure for identifying and resolving

patient problems.
o B. Beginning in Florence Nightingale‘s days, nursing students learned and

practiced the nursing process.
o C. Use of the nursing process is optional for nurses since there are many ways
to accomplish the work of nursing.

o D. The state board examinations for professional nursing practice now
use the nursing process rather than medical specialties as an organizing
concept.
Incorrect
Correct Answer: D. The state board examinations for professional nursing
practice now use the nursing process rather than medical specialties as an
organizing concept.
The nursing process is a systematic decision-making method focusing on
identifying and treating responses of individuals or groups to actual or potential
alterations in health it- is the essential core of nursing practice to deliver holistic,
patient-focused care. Nursing process provides an organizing framework for the
practice of nursing and the knowledge, judgments, and actions that nurses bring
to patient care.‖
 Option A: The nursing process is a five-step process. The nursing process
functions as a systematic guide to client-centered care with 5 sequential
steps. These are assessment, diagnosis, planning, implementation, and
evaluation. The utilization of the nursing process to guide care is clinically
 Option B: The term nursing process was first used by Hall in 1955. In 1958,
Ida Jean Orlando started the nursing process that still guides nursing care
today. Defined as a systematic approach to care using the fundamental
principles of critical thinking, client-centered approaches to treatment,
goal-oriented tasks, evidence-based practice (EDP) recommendations, and
nursing intuition.
 Option C: Nursing process is not optional since standards demand the use
of it. Holistic and scientific postulates are integrated to provide the basis
for compassionate, quality-based care. As explored by Salmond and
Echevarria, healthcare is changing, and the traditional roles of nurses are
transforming to meet the demands of this new healthcare environment.
Nurses are in a position to promote change and impact patient delivery
care models in the future.
ADVERTISEMENTS
26. Question

What equipment would be necessary to complete an evaluation of cranial nerves
9 and 10 during a physical assessment?
o A. A cotton ball
o B. A penlight
o C. An ophthalmoscope
o D. A tongue depressor and flashlight

Incorrect
Correct Answer: D. A tongue depressor and flashlight
Cranial nerves 9 and 10 are the glossopharyngeal and vagus nerves. The gag
reflex would be evaluated. The 9th (glossopharyngeal) and 10th (vagus) cranial
nerves are usually evaluated together. Whether the palate elevates symmetrically
when the patient says ―ah‖ is noted. If one side is paretic, the uvula is lifted away
from the paretic side. A tongue blade can be used to touch one side of the
posterior pharynx, then the other, and symmetry of the gag reflex is observed;
bilateral absence of the gag reflex is common among healthy people and may
not be significant.
 Option A: For the 5th (trigeminal) nerve, the 3 sensory divisions
(ophthalmic, maxillary, mandibular) are evaluated by using a pinprick to
test facial sensation and by brushing a wisp of cotton against the lower or
lateral cornea to evaluate the corneal reflex. If facial sensation is lost, the
angle of the jaw should be examined; sparing of this area (innervated by
spinal root C2) suggests a trigeminal deficit. A weak blink due to facial
weakness (eg, 7th cranial nerve paralysis) should be distinguished from
depressed or absent corneal sensation, which is common in contact lens
wearers. A patient with facial weakness feels the cotton wisp normally on
both sides, even though blink is decreased.
 Option B: A penlight provides a source of light and has become the most
common used tool to assess pupil diameter. Asymmetry of pupil
constriction in response to light means one pupil constricts and the other
remains dilated or constricts more slowly. It may indicate dynamic
anisocoria or a Marcus Gunn pupil, a relative afferent pupillary defect
(RAPD), or temporal lobe herniation in the brain.
 Option C: The eye can be examined with routine equipment, including a
standard ophthalmoscope; thorough examination requires special

equipment and evaluation by an ophthalmologist. Ophthalmoscopy
(examination of the posterior segment of the eye) can be done directly by
using a handheld ophthalmoscope or with a handheld lens in conjunction
with the slit lamp biomicroscope.
ADVERTISEMENTS
27. Question
Which technique would be best in caring for a client following receiving a
diagnosis of a stage IV tumor in the brain?
o A. Offering the client pamphlets on support groups for brain cancer.
o B. Asking the client if there is anything he or his family needs.
o C. Reminding the client that advances in technology are occurring every day.
o D. Providing accurate information about the disease and treatment

options.
Incorrect
Correct Answer: D. Providing accurate information about the disease and
treatment options.
Providing information for the client is the best technique for a new diagnosis.
Every clinician at one time or another faces these important questions. In the
treatment of terminally ill patients, the health professional needs many skills: the
ability to deliver bad news, the knowledge to provide appropriate optimal end-
of-life care, and the compassion to allow a person to retain his or her dignity.
 Option A: Cassem, in the Massachusetts General Hospital Handbook of
General Hospital Psychiatry, recommends relaying negative information to
patients through a brief, rehearsed initial statement that succinctly
communicates the news and clearly indicates that the treatment team is
committed to the ongoing care and support of the patient.
 Option B: In considering the emotional state of a person with terminal
illness, it is often helpful to consider the effects of the family members on
the patient and vice versa. By observing the interactions of a patient with
family, the consultant can become aware of long-standing grudges or new

difficulties in communication that can make the process of coming to
closure at the end of a life more difficult.
 Option C: In most cases, patients who are told their diagnosis in an up-
front, clear manner have better emotional adjustments to their situation
than those who are not told about their condition. By providing direct,
clear information in a compassionate manner, and by making clear to the
patient that everything possible will be done to provide medical and
emotional support, physicians can elicit trust and reduce anxiety.
ADVERTISEMENTS
28. Question
An 8.5 lb, 6 oz infant is delivered to a diabetic mother. Which nursing intervention
would be implemented when the neonate becomes jittery and lethargic?
o A. Administer insulin.
o B. Administer oxygen.
o C. Feed the infant glucose water (10%).
o D. Place the infant in a warmer.

Incorrect
Correct Answer: C. Feed the infant glucose water (10%)
After birth, the infant of a diabetic mother is often hypoglycemic. Treatment will
depend on the baby‘s gestational age and overall health. Treatment includes
giving the baby a fast-acting source of glucose. This may be as simple as a
glucose and water mixture or formula as an early feeding. Or the baby may need
glucose given through an IV. The baby‘s blood glucose levels are checked after
treatment to see if the hypoglycemia occurs again.
 Option A: Second-line therapies for the treatment of persistent
hypoglycemia include the use of corticosteroids or glucagon, not insulin.
Glucagon is a hormone that stimulates endogenous glucose production via
glycogenolysis and gluconeogenesis; thus its effectiveness depends on the
infant having adequate glycogen stores. It is most useful in term infants
and infants of diabetic mothers. Glucagon dosing is as a 30 mcg/kg bolus
or 300 mcg/kg per minute continuous infusion.

 Option B: Oxygen is not administered to hypoglycemic neonates. Early
initiation of breastfeeding is crucial for all infants. For asymptomatic infants
at risk of neonatal hypoglycemia, the AAP recommends initiating feeds
within the first hour of life and performing initial glucose screening 30
minutes after the first feed. The AAP recommends goal blood glucose
levels equal to or greater than 45 mg/dL prior to routine feedings, and
intervention for blood glucose <40 mg/dL in the first 4 hours of life and
<45 mg/dL at 4 to 24 hours of life.
 Option D: Placing the infant in a warmer does not manage the
hypoglycemia. In infants of diabetic mothers, lower glucose infusions rates
of 3 to 5 mg/kg/minute may be used to minimize pancreatic stimulation
and endogenous insulin secretion. Infants requiring higher rates of
intravenous dextrose (>12 to 16 mg/kg/minute) or for more than 5 days
are more likely to have a persistent cause of hypoglycemia.
ADVERTISEMENTS
29. Question
What question would be most important to ask a male client who is in for a
digital rectal examination?
o A. “Have you noticed a change in the force of the urinary system?”
o B. ―Have you noticed a change in tolerance of certain foods in your diet?‖
o C. ―Do you notice polyuria in the AM?‖
o D. ―Do you notice any burning with urination or any odor to the urine?‖
Incorrect
Correct Answer: A. “Have you noticed a change in the force of the urinary
system?”
This change would be most indicative of a potential complication with (BPH)
benign prostate hypertrophy. The goals of the evaluation of such men are to
identify the patient‘s voiding or, more appropriately, urinary tract problems, both
symptomatic and physiologic; to establish the etiologic role of BPH in these
problems.

 Option B: Food intolerances are more common in those with digestive
system disorders, such as irritable bowel syndrome (IBS). According to the
IBS network, most people with IBS have food intolerances. The symptoms
of food intolerances can also mimic the symptoms of chronic digestive
conditions, such as IBS. However, certain patterns in the symptoms can
help a doctor distinguish between the two.
 Option C: History can often distinguish polyuria from frequency, but rarely
a 24-hour urine collection may be needed. Polyuria caused by solute
diuresis is suggested by a history of diabetes mellitus. Abrupt onset of
polyuria at a precise time suggests central diabetes insipidus, as does
preference for extremely cold or iced water.
 Option D: Dysuria is a symptom of pain and/or burning, stinging, or
itching of the urethra or urethral meatus with urination. It is one of the
most common symptoms experienced by most people at least once over
their lifetimes. Primarily, causes of dysuria can be divided broadly into two
categories, infectious and non-infectious.
ADVERTISEMENTS
30. Question
The nurse assesses a prolonged late deceleration of the fetal heart rate while the
client is receiving oxytocin (Pitocin) IV to stimulate labor. The priority nursing
intervention would be to:
o A. Turn off the infusion.
o B. Turn the client to the left.
o C. Change the fluid to Ringer‘s Lactate.
o D. Increase mainline IV rate.

Incorrect
Correct Answer: A. Turn off the infusion
Stopping the infusion will decrease contractions and possibly remove uterine
pressure on the fetus, which is a possible cause of the deceleration. When late
decelerations are observed, the nurse should attempt to increase the oxygen

delivery to the fetus by turning the mother on her left side and/or administering
oxygen. If Oxytocin (Pitocin) is being administered, it should be stopped.
 Option B: Variable decelerations are marked by a sharp decrease (―V‖
shape) in FHR that does not correlate to contractions. Umbilical cord
compression is usually the cause of variable decelerations. Repositioning of
the mother can relieve this compression if it is minor.
 Option C: Late decelerations are shown by the FHR gradually decreasing
around the peak of the contraction and gradually increasing when the
contraction is over. These decelerations will also have a ―U‖ shape but will
not mirror the contractions. The most common cause of late decelerations
is uteroplacental insufficiency (insufficient oxygen exchange between the
placenta and the fetus).
 Option D: Increasing the main IV line would not manage the decelerations.
While caring for a patient in labor, one of the important nursing duties is
monitoring the variability of the fetal heart rate (FHR) and monitoring the
FHR response during contractions. Variability in the FHR during labor is a
sign of fetal well-being or fetal activity or both. The expected variability
usually includes slight accelerations and decelerations.
ADVERTISEMENTS
31. Question
Which nursing approach would be most appropriate to use while administering
an oral medication to a 4-month-old?
o A. Place medication in 45cc of formula.
o B. Place medication in an empty nipple.
o C. Place medication in a full bottle of formula.
o D. Place in supine position. Administer medication using a plastic syringe.

Incorrect
Correct Answer: B. Place medication in an empty nipple.
This is a convenient method for administering medications to an infant. Draw up
the correct amount of medicine into an oral syringe (a syringe without a needle)
or an empty nipple. Let the infant suck the medicine out of the syringe or empty

nipple. When giving medicine to an infant, use his natural reflexes (such as
sucking) whenever possible.
 Option A: Avoid mixing medicine with foods the child must have. The child
may begin to dislike the foods he needs. Mix the medicine with a small
amount (1 to 2 teaspoons) of applesauce or pears and give it with a spoon.
This is a good way to give pills that have been crushed well. (To crush a pill,
place it between two spoons and press the spoons together).
 Option C: Some medicines can be put in a small amount of juice or sugar
water. Follow the instructions from the doctor, nurse, or pharmacist. Do not
put medicine in a full bottle or cup in case the infant does not drink very
much.
 Option D: Option D is partially correct however, the infant is never placed
in a reclining position during a procedure due to a potential aspiration.
Hold the infant in a nearly upright position. If the infant struggles, gently
hold one arm and place his other arm around the waist. Hold the baby
close to the body.
ADVERTISEMENTS
32. Question
Which nursing intervention would be a priority during the care of a 2-month-old
after surgery?
o A. Minimize stimuli for the infant.
o B. Restrain all extremities.
o C. Encourage stroking of the infant.
o D. Demonstrate to the mother how she can assist with her infant‘s care.
Incorrect
Correct Answer: C. Encourage stroking of the infant.
Tactile stimulation is imperative for an infant‘s normal emotional development.
After the trauma of surgery, sensory deprivation can cause failure to thrive. Most
babies with FTT do not have a specific underlying disease or medical condition to
account for their growth failure. This is referred to as Non-organic FTT. Up to 80%
of all children with FTT have Non-organic type FTT. Non-organic FTT most

commonly occurs when there is inadequate food intake or there is a lack of
environmental stimuli.
 Option A: Provide sensory stimulation. Attempt to cuddle the child and
talk to him or her in a warm, soothing tone and allow for play activities
appropriate for the child‘s age. Feed the child slowly and carefully in a
quiet environment; during feeding, the child might be closely snuggled and
gently rocked; it may be necessary to feed the child every 2 to 3 hours
initially.
 Option B: Do not restrain the child. Burp the child frequently during and at
the end of each feeding, and then place him or her on the side with the
head slightly elevated or held in a chest-to-chest position.
 Option D: If a family caregiver is present, encourage him or her to become
involved in the child‘s feedings. While caring for the child, point out to the
caregiver the child‘s development and responsiveness, noting and praising
any positive parenting behaviors the caregiver displays.
ADVERTISEMENTS
33. Question
While performing a physical examination on a newborn, which assessment should
be reported to the physician?
o A. Head circumference of 40 cm.
o B. Chest circumference of 32 cm.
o C. Acrocyanosis and edema of the scalp.
o D. Heart rate of 160 and respirations of 40.

Incorrect
Correct Answer: A. Head circumference of 40 cm
Average circumference of the head for a neonate ranges between 32 to 36 cm.
An increase in size may indicate hydrocephalus or increased intracranial pressure.
A newborn‘s head is usually about 2 cm larger than the chest size. Between 6
months and 2 years, both measurements are about equal. After 2 years, the chest
size becomes larger than the head.

 Option B: The body of a normal newborn is essentially cylindrical; head
circumference slightly exceeds that of the chest. For a term baby, the
average circumference of the head is 33–35 cm (13–14 inches), and the
average circumference of the chest is 30–33 cm (12–13 inches).
 Option C: Peripheral cyanosis (acrocyanosis) involves the hands, feet, and
circumoral area. It is evident in most infants at birth and for a short time
thereafter. If limited to the extremities in an otherwise normal infant, it is
due to venous stasis and is innocuous. Localized cyanosis may occur in
presenting parts, particularly in association with abnormal presentations.
 Option D: Heart rates normally fluctuate between 120 and 160 beats per
minute. In agitated states, a rate of 200 beats per minute may occur
transiently. The heart rate of premature infants is usually between 130 and
170 beats per minute, and during occasional episodes of bradycardia, it
may slow to 70 beats per minute or less. Normal neonates breathe at rates
that vary between 40 and 60 respirations per minute. Rapid rates are likely
to be present for the first few hours after birth.
ADVERTISEMENTS
34. Question
Which action by the mother of a preschooler would indicate a disturbed family
interaction?
o A. Tells her child that if he does not sit down and shut up she will leave
him there.
o B. Explains that the injection will burn like a bee sting.
o C. Tells her child that the injection can be given while he‘s in her lap.
o D. Reassures the child that it is acceptable to cry.

Incorrect
Correct Answer: A. Tells her child that if he does not sit down and shut up
she will leave him there.
Threatening a child with abandonment will destroy the child‘s trust in his family.
Children growing up in such families are likely to develop low self-esteem and

feel that their needs are not important or perhaps should not be taken seriously
by others. As a result, they may form unsatisfying relationships as adults.
 Option B: It can help to describe the need for injections and blood testing
in kid terms. For example, the nurse might explain that the shots and blood
tests help keep the child feeling good throughout the day — and that not
getting them could mean having to stay home from school or miss fun
activities because of health problems.
 Option C: Having both parents (or one parent plus another caregiver)
involved in the management process will help keep treatment consistent
and also provide support as the nurse deals with struggles over shots and
blood tests.
 Option D: If the child argues or cries, the parents might be tempted to skip
an injection or test just this once. Nurses shouldn‘t negotiate blood tests or
shots. They‘re necessary and not optional. The first time you‘re talked out
of one, you‘ll set a precedent that that child won‘t forget.
ADVERTISEMENTS
35. Question
During the history, which information from a 21-year-old client would indicate a
risk for development of testicular cancer?
o A. Genital Herpes
o B. Hydrocele
o C. Measles
o D. Undescended testicle
Incorrect
Correct Answer: D. Undescended testicle
Undescended testicles make the client at high risk for testicular cancer. Mumps,
inguinal hernia in childhood, orchitis, and testicular cancer in the contralateral
testis are other predisposing factors. The risk of testicular cancer might be a little
higher for men whose testicles stayed in the abdomen as opposed to one that
has descended at least partway. If cancer does develop, it‘s usually in the

undescended testicle, but about 1 out of 4 cases occur in the normally descended
testicle.
 Option A: While HPV infections are very common, cancer caused by HPV is
not. Most people infected with HPV will not develop cancer-related to the
infection. However, some people with long-lasting infections of high-risk
types of HPV, are at risk of developing cancer.
 Option B: Hydroceles generally don‘t pose any threat to the testicles.
They‘re usually painless and disappear without treatment. However, if the
patient has scrotal swelling, he should see his doctor rule out other causes
that are more harmful such as testicular cancer.
 Option C: Measles has a low death rate in healthy children and adults, and
most people who contract the measles virus recover fully. The risk of
complications is higher in the following groups: children under 5 years old.
adults over 20 years old.
ADVERTISEMENTS
36. Question
While caring for a client, the nurse notes a pulsating mass in the client‘s
periumbilical area. Which of the following assessments is appropriate for the
nurse to perform?
o A. Measure the length of the mass.
o B. Auscultate the mass.
o C. Percuss the mass.
o D. Palpate the mass.

Incorrect
Correct Answer: B. Auscultate the mass.
Auscultate the mass. Auscultation of the abdomen and finding a bruit will confirm
the presence of an abdominal aneurysm and will form the basis of information
given to the provider. Occasionally, an overlying mass (pancreas or stomach) may
be mistaken for an AAA. An abdominal bruit is nonspecific for an unruptured
aneurysm, but the presence of an abdominal bruit or the lateral propagation of

the aortic pulse wave can offer subtle clues and maybe more frequently found
than a pulsatile mass.
 Option A: In one study, 38% of AAA cases were detected on the basis of
physical examination findings, whereas 62% were detected incidentally on
radiologic studies obtained for other reasons. Femoral/popliteal pulses and
pedal (dorsalis pedis or posterior tibial) pulses should be palpated to
determine if an associated aneurysm (femoral/popliteal) or occlusive
disease exists. Flank ecchymosis (Grey Turner sign) represents
retroperitoneal hemorrhage.
 Option C: Do not percuss the abdominal mass. The presence of a pulsatile
abdominal mass is virtually diagnostic of an AAA but is found in fewer than
50% of cases. It is more likely to be noted with a ruptured aneurysm.
 Option D: The mass should not be palpated because of the risk of rupture.
Most clinically significant AAAs are palpable upon routine physical
examination; however, the sensitivity of palpation depends on the
experience of the examiner, the size of the aneurysm, and the size of the
patient.
ADVERTISEMENTS
37. Question
When observing 4-year-old children playing in the hospital playroom, what
activity would the nurse expect to see the children participating in?
o A. Competitive board games with older children.
o B. Playing with their own toys alongside other children.
o C. Playing alone with handheld computer games.
o D. Playing cooperatively with other preschoolers.

Incorrect
Correct Answer: D. Playing cooperatively with other preschoolers.
Playing cooperatively with other preschoolers. Cooperative play is typical of the
late preschool period. Cooperative play is the final stage of play and represents
the child‘s ability to collaborate and cooperate with other children towards a

common goal. Children often reach the cooperative stage of play between 4 and
5 years of age after they have moved through the earlier five stages of play.
 Option A: Competitive play is when children learn to play organized
games with clear rules and clear guidelines on winning and losing. Ludo,
snake and ladders, and football are all forms of competitive play.
 Option B: After mastering onlooker play, a child will be ready to move into
parallel play. During parallel play, children will play beside and in proximity
to other children without actually playing with them. Children often enjoy
the buzz that comes with being around other kids, but they don‘t yet know
how to step into others‘ games or ask other kids to step into their games.
 Option C: Encourage the child to play with others and be active several
times a week instead of spending time in front of a screen. This can help to
build healthy, active bodies. (To be clear, learning can happen during
screen time, too — just not this specific type of learning.)
ADVERTISEMENTS
38. Question
The nurse is teaching the parents of a 3 month-old infant about nutrition. What is
the main source of fluids for an infant until about 12 months of age?
o A. Formula or breastmilk
o B. Dilute nonfat dry milk
o C. Warmed fruit juice
o D. Fluoridated tap water

Incorrect
Correct Answer: A. Formula or breastmilk
Formula or breast milk are the perfect food and source of nutrients and liquids
up to 1 year of age. Breastfeeding with appropriate supplementation is the
preferred method for feeding infants 0-12 months old. Iron-fortified formulas are
recommended if the child is not breastfed or requires supplemental formula in
addition to breast milk.
 Option B: The American Academy of Pediatrics Committee on Nutrition
updated their recommendations concerning infant feeding practices during

the second six months of life. The committee stated that breastfeeding is
the preferred method of feeding during the first year of life and that whole
cow‘s milk may be introduced after six months of age if adequate
supplementary feedings are given. Reduced fat content milk is not
recommended during infancy.
 Option C: When the infants are consuming one-third of their calories from
a balanced mixture of iron-fortified cereals, vegetables, fruits, and other
foods providing adequate sources of both iron and Vitamin C it is
considered adequate supplementary feeding.
 Option D: The World Health Organization (WHO) notes that babies that
are breastfed don‘t need additional water, as breast milk is over 80 percent
water and provides the fluids your baby needs. Children who are bottle-fed
will stay hydrated with the help of their formula. Water feedings tend to fill
up your baby, making them less interested in nursing. This could actually
contribute to weight loss and elevated bilirubin levels.
ADVERTISEMENTS
39. Question
While the nurse is administering medications to a client, the client states ―I do not
want to take that medicine today.‖ Which of the following responses by the nurse
would be best?
o A. ―That‘s OK, it's alright to skip your medication now and then.‖
o B. ―I will have to call your doctor and report this.‖
o C. “Is there a reason why you don’t want to take your medicine?”
o D. ―Do you understand the consequences of refusing your prescribed

treatment?‖
Incorrect
Correct Answer: C. “Is there a reason why you don’t want to take your
medicine?”
When a new problem is identified, it is important for the nurse to collect accurate
assessment data. This is crucial to ensure that client needs are adequately
identified in order to select the best nursing care approaches. The nurse should

try to discover the reason for the refusal which may be that the client has
developed untoward side effects.
 Option A: It is not alright to skip medication. Be very matter-of-fact in
communication style with the individual taking the medication. Do not beg,
threaten, bribe, or force the individual. Do not say ―I‘ll get in trouble ― or
―You‘ll get in trouble‖.
 Option B: If they continue to refuse, document the missed dose and state
the reason (individual refused), along with other relevant information if
known (i.e. they indicated nausea). In addition, contact the physician under
circumstances as agreed when medication was prescribed and/or
implement any steps in the ISP for missed doses.
 Option D: Find out if they understand what the medication is for. If they
do not understand, remind them of the purpose and ask them again to
take it. Find out if they understand the implications of not taking their
medication. If they do not understand, remind them of the implications
and ask them again to take it (In addition to physical symptoms,
implications may include the need to call the physician and report the
missed dose.)
ADVERTISEMENTS
40. Question
The nurse is assessing a 4 month-old infant. Which motor skill would the nurse
anticipate finding?
o A. Hold a rattle
o B. Bang two blocks
o C. Drink from a cup
o D. Wave ―bye-bye‖
Incorrect
Correct Answer: A. Hold a rattle
The age at which a baby will develop the skill of grasping a toy with help is 4 to 6
months. The baby is becoming more dexterous and doing more with their hands.
Their hands now work together to move a toy or shake a rattle. In fact, those

hands will grab for just about anything within reach, including a stuffed animal,
the mother‘s hair, and any colorful or shiny object hanging nearby
 Option B: At 9 months, babies repeat different actions with objects. They
mouth objects to explore the features. They bang objects with their hand
and bang two objects together to create sounds and actions. They drop
objects sometimes by chance and other times on purpose.
 Option C: Babies are learning functional actions with a purpose in mind.
They can put things in, such as put clothes in the dryer or a shape in a
puzzle. From ―put in‖ they learn a variety of functional actions. They can put
a sippy cup to their mouth to drink, a spoon in a bowl to scoop, and a
spoon in their mouth to eat.
 Option D: Learning how to wave bye-bye is an important milestone for an
infant that usually occurs between the age of 10 months and a year. A
study in Pediatrics International found premature infants mastered the
bye-bye gesture significantly later than full-term babies and used different
hand and wrist motions.
ADVERTISEMENTS
41. Question
The nurse should recognize that all of the following physical changes of the head
and face are associated with the aging client except:
o A. Pronounced wrinkles on the face.
o B. Decreased size of the nose and ears.
o C. Increased growth of facial hair.
o D. Neck wrinkles.
Incorrect
Correct Answer: B. Decreased size of the nose and ears.
The nose and ears of the aging client actually become longer and broader. The
chin line is also altered. Height doesn‘t change after puberty (well, if anything we
get shorter as we age) but ears and noses are always lengthening. That‘s due to
gravity, not actual growth. As people age, gravity causes the cartilage in the ears
and nose to break down and sag. This results in droopier, longer features.

 Option A: Wrinkles on the face become more pronounced and tend to
take on the general mood of the client over the years. For example laugh
or frown wrinkles above the eyebrows, lips, cheeks, and outer edges of the
eye orbit.
 Option C: The change in the androgen-estrogen ratio causes an increase in
growth of facial hair in most older adults. Women develop excessive body
or facial hair due to higher-than-normal levels of androgens, including
testosterone. All females produce androgens, but the levels typically
remain low.
 Option D: The aging process shortens the platysma muscle, which
contributes to neck wrinkles. Some amount of neck wrinkling is inevitable.
The extent of the necklines and other signs of aging skin are determined in
part by genetics. Necklines and wrinkles are a normal part of aging. They‘re
caused in part by skin losing elasticity and being exposed to UV light over
time.
ADVERTISEMENTS
42. Question
All of the following characteristics would indicate to the nurse that an elder client
might experience undesirable effects of medicines except:
o A. Increased oxidative enzyme levels.
o B. Alcohol taken with medication.
o C. Medications containing magnesium.
o D. Decreased serum albumin.

Incorrect
Correct Answer: A. Increased oxidative enzyme levels.
Oxidative enzyme levels decrease in the elderly, which affects the disposition of
medication and can alter the therapeutic effects of medication. Oxidative stress
causes cells and entire organisms to age. If reactive oxygen species accumulate,
this causes damage to the DNA as well as changes in the protein molecules and
lipids in the cell. The cell ultimately loses its functionality and dies. Over time, the
tissue suffers, and the body ages.

 Option B: Alcohol has a smaller water distribution level in the elderly,
resulting in higher blood alcohol levels. Alcohol also interacts with various
drugs to either potentiate or interfere with their effects. The older one gets,
the longer alcohol stays in the system. So it‘s more likely to be there when
the client takes medicine. And alcohol can affect the way the meds work. It
can also lead to serious side effects.
 Option C: Magnesium is contained in a lot of medications older clients
routinely obtain over the counter. Magnesium toxicity is a real concern.
Older adults have lower dietary intakes of magnesium than younger adults.
In addition, magnesium absorption from the gut decreases, and renal
magnesium excretion increases with age. Older adults are also more likely
to have chronic diseases or take medications that alter magnesium status,
which can increase their risk of magnesium depletion
 Option D: Albumin is the major drug-binding protein. Decreased levels of
serum albumin mean that higher levels of the drug remain free and that
there are fewer therapeutic effects and increased drug interactions.
ADVERTISEMENTS
43. Question
When assessing a newborn whose mother consumed alcohol during the
pregnancy, the nurse would assess for which of these clinical manifestations?
o A. Wide-spaced eyes, smooth philtrum, flattened nose
o B. Strong tongue thrust, short palpebral fissures, simian crease
o C. Negative Babinski sign, hyperreflexia, deafness
o D. Shortened limbs, increased jitteriness, constant sucking

Incorrect
Correct Answer: A. Wide-spaced eyes, smooth philtrum, flattened nose
The nurse should anticipate that the infant may have fetal alcohol syndrome and
should assess for signs and symptoms of it. These include the characteristics
listed in choice A. Fetal alcohol syndrome is a condition in a child that results
from alcohol exposure during the mother‘s pregnancy. Fetal alcohol syndrome
causes brain damage and growth problems. The problems caused by fetal alcohol

syndrome vary from child to child, but defects caused by fetal alcohol syndrome
are not reversible.
 Option B: A single palmar crease is a single line that runs across the palm
of the hand. People most often have 3 creases in their palms. A single
palmar crease appears in about 1 out of 30 people. Males are twice as
likely as females to have this condition. Some single palmar creases may
indicate problems with development and be linked with certain disorders.
 Option C: Hyperreflexia is a sign of upper motor neuron damage and is
associated with spasticity and a positive Babinski sign. In infants with at
CST which is not fully myelinated the presence of a Babinski sign in the
absence of other neurological deficits is considered normal up to 24
months of age.
 Option D: Achondroplasia is the most common form of short-limb
dwarfism. It is an autosomal dominant disorder caused by a mutation in
the gene that creates the cells (fibroblasts) which convert cartilage to bone.
This means, if the gene is passed on by one parent, the child will have
achondroplasia.
ADVERTISEMENTS
44. Question
Which of these statements, when made by the nurse, is most effective when
communicating with a 4-year-old?
o A. “Tell me where you hurt.”
o B. ―Other children like having their blood pressure taken.‖
o C. ―This will be like having a little stick in your arm.‖
o D. ―Anything you tell me is confidential.‖

Incorrect
Correct Answer: A. “Tell me where you hurt.”
Four-year-olds are egocentric and interested in having the focus on themselves.
As kids gain language skills, they also develop their conversational abilities. Kids 4
to 5 years old can follow more complex directions and enthusiastically talk about

things they do. They can make up stories, listen attentively to stories, and retell
stories.
 Option B: They will not be interested in what it feels like to other children.
By the time your child is in their later years of primary school, their
language and ability to convey ideas has improved a lot. They even alter
their speech to suit the circumstances. They may speak more formally in
front of a teacher than they do with family and friends.
 Option C: Preschoolers are concrete thinkers and would literally interpret
any analogies so they are not helpful in explaining procedures. Concrete
thinking is a kind of reasoning that relies heavily on what we observe in the
physical world around us. It‘s sometimes called literal thinking. Young
children think concretely, but as they mature, they usually develop the
ability to think more abstractly.
 Option D: Assurance of confidential communication is most appropriate
for the adolescent. In addition, confidentiality is not maintained if the child
plans to harm themselves, harm someone else, or discloses abuse.
ADVERTISEMENTS
45. Question
A 64-year-old client scheduled for surgery with a general anesthetic refuses to
remove a set of dentures prior to leaving the unit for the operating room. What
would be the most appropriate intervention by the nurse?
o A. Explain to the client that the dentures must come out as they may get lost
or broken in the operating room.
o B. Ask the client if there are second thoughts about having the procedure.
o C. Notify the anesthesia department and the surgeon of the client‘s refusal.
o D. Ask the client if the preference would be to remove the dentures in

the operating room receiving area.
Incorrect
Correct Answer: D. Ask the client if the preference would be to remove the
dentures in the operating room receiving area.

Clients anticipating surgery may experience a variety of fears. This choice allows
the client control over the situation and fosters the client‘s sense of self-esteem
and self-concept. Nurses need to allow patients the choice of what to do in
relation to their dentures when going to the theatre, although the anesthetist
must make the final decision of whether or not to remove them immediately
before the anesthetic if they feel patient safety could be compromised.
 Option A: According to a study, ―There are no set national guidelines on
how dentures should be managed during anesthesia, but it is known that
leaving dentures in during bag-mask ventilation allows for a better seal
during induction [when the anesthetic is being infused], and therefore
many hospitals allow dentures to be removed immediately before
intubation [when a tube is inserted into the airway to assist breathing]‖.
 Option B: The swallowing of dentures during general anesthesia is a
significant problem for anesthesiologists. It is seen more often in patients
with psychiatric disorders, mental retardation, alcoholism, or poor-quality
dentures. It has become an important issue for anesthesiologists
preoperatively due to the increase in the proportion of dentures associated
with the prolongation of life.
 Option C: The presence of any false teeth or dental plates should be
clearly documented before and after any surgical procedure, with all
members of the surgical team made aware of what is to be done with
them, they add.
ADVERTISEMENTS
46. Question
The nurse is assessing a client who states her last menstrual period was March 17,
and she has missed one period. She reports episodes of nausea and vomiting.
Pregnancy is confirmed by a urine test. What will the nurse calculate as the
estimated date of delivery (EDD)?
o A. November 8
o B. May 15
o C. February 21

o D. December 24
Incorrect
Correct Answer: D. December 24
Naegele‘s rule: add 7 days and subtract 3 months from the first day of the last
regular menstrual period to calculate the estimated date of delivery. Naegele‘s
rule, derived from a German obstetrician, subtracts 3 months and adds 7 days to
calculate the estimated due date (EDD). It is prudent for the obstetrician to get a
detailed menstrual history, including duration, flow, previous menstrual periods,
and hormonal contraceptives.
 Option A: Determining gestational age is one of the most critical aspects
of providing quality prenatal care. Knowing the gestational age allows the
obstetrician to provide care to the mother without compromising maternal
or fetal status. It allows for the correct timing of management, such as
administering steroids for fetal lung maturity, starting ASA therapy with a
history of pre-eclampsia in previous pregnancies, starting
hydroxyprogesterone caproate (Makena) for previous preterm deliveries.
 Option B: An average pregnancy lasts 280 days from the first day of the
last menstrual period (LMP) or 266 days after conception. Historically, an
accurate LMP is the best estimator to determine the due date.
 Option C: An official EDD is established after calculating the first-trimester
sonogram EDD date and then using the LMP. If the LMP and first trimester
EDD are within 7 days of each other, the LMP estimates the due date. The
margin of error is reduced depending on when (i.e., how early) the
sonogram occurred.
ADVERTISEMENTS
47. Question
The family of a 6-year-old with a fractured femur asks the nurse if the child‘s
height will be affected by the injury. Which statement is true concerning long
bone fractures in children?
o A. Growth problems will occur if the fracture involves the periosteum.
o B. Epiphyseal fractures often interrupt a child’s normal growth pattern.

o C. Children usually heal very quickly, so growth problems are rare.
o D. Adequate blood supply to the bone prevents growth delay after fractures.
Incorrect
Correct Answer: B. Epiphyseal fractures often interrupt a child’s normal
growth pattern.
Epiphyseal fractures often interrupt a child‘s normal growth pattern. Growth plate
fractures are classified based on which parts of the bone are damaged, in
addition to the growth plate. Areas of the bone immediately above and below
the growth plate may fracture. They are called the epiphysis (the tip of the bone)
and metaphysis (the ―neck‖ of the bone).
 Option A: The most serious complication is early closure (complete or
partial) of the growth plate. Complete closure means the entire growth
plate of the affected bone has stopped expanding. This results in the
affected bone not growing as long as the opposite side.
 Option C: The severity of and need for treatment of growth plate closures
depend on the location of the fracture and the age of the patient. Other
complications of growth plate fractures include delayed healing of the
bone, nonhealing, infection, and loss of blood flow to the area, causing
death of part of the bone.
 Option D: Growth plate fractures are generally treated with splints or casts.
Sometimes, the bone may need to be put back in place to allow it to heal
in the correct position. This may be done before or after the cast is placed
and is called a closed reduction. The length of time the child needs to be in
a cast or splint depends on the location and severity of the fracture. The
child‘s age also matters: younger patients heal faster than older patients.
ADVERTISEMENTS
48. Question
A client is admitted to the hospital with a history of confusion. The client has
difficulty remembering recent events and becomes disoriented when away from
home. Which statement would provide the best reality orientation for this client?
o A. ―Good morning. Do you remember where you are?‖

o B. ―Hello. My name is Elaine Jones and I am your nurse for today.‖
o C. ―How are you today? Remember, you‘re in the hospital.‖
o D. “Good morning. You’re in the hospital. I am your nurse Elaine Jones.”

Incorrect
Correct Answer: D. “Good morning. You’re in the hospital. I am your nurse
Elaine Jones.”
As cognitive ability declines, the nurse provides a calm, predictable environment
for the client. This response establishes time, location, and the caregiver‘s name.
Orient the patient to surroundings, staff, necessary activities as needed. Present
reality concisely and briefly. Avoid challenging illogical thinking—defensive
reactions may result.
 Option A: Modulate sensory exposure. Provide a calm environment;
eliminate extraneous noise and stimuli. Increased levels of visual and
auditory stimulation can be misinterpreted by the confused patient.
 Option B: Give simple directions. Allow sufficient time for the patient to
respond, to communicate, to make decisions. This communication method
can reduce anxiety experienced in a strange environment.
 Option C: Offer reassurance to the patient and use therapeutic
communication at frequent intervals. Patient reassurance and
communication are nursing skills that promote trust and orientation and
reduce anxiety.
ADVERTISEMENTS
49. Question
When a client wishes to improve the appearance of their eyes by removing excess
skin from the face and neck, the nurse should provide teaching regarding which
of the following procedures?
o A. Dermabrasion
o B. Rhinoplasty
o C. Blepharoplasty
o D. Rhytidectomy

Incorrect
Correct Answer: D. Rhytidectomy
Rhytidectomy is the procedure for removing excess skin from the face and neck.
It is commonly called a facelift. Rhytidectomy is a surgical procedure meant to
counteract the effects of time on the aging face. In the rhytidectomy procedure
(also known as a ―face-lift‖), the tissues under the skin are tightened and excess
facial and neck skin are excised. Rhytidectomy literally means wrinkle (rhytid-)
removal (-ectomy).
 Option A: Dermabrasion involves the spraying of a chemical to cause light
freezing of the skin, which is then abraded with sandpaper or a revolving
wire brush. It is used to remove facial scars, severe acne, and pigment from
tattoos. Dermabrasion is an exfoliating technique that uses a rotating
instrument to remove the outer layers of skin, usually on the face. This
treatment is popular with people who wish to improve the appearance of
their skin. Some of the conditions it can treat include fine lines, sun
damage, acne scars, and uneven texture.
 Option B: Rhinoplasty is done to improve the appearance of the nose and
involves reshaping the nasal skeleton and overlying skin. Rhinoplasty is
surgery that changes the shape of the nose. The motivation for rhinoplasty
may be to change the appearance of the nose, improve breathing, or both.
The upper portion of the structure of the nose is bone, and the lower
portion is cartilage.
 Option C: Blepharoplasty is the procedure that removes loose and
protruding fat from the upper and lower eyelids. Eyelid surgery, or
blepharoplasty, is a surgical procedure to improve the appearance of the
eyelids.
ADVERTISEMENTS
50. Question
A woman who is six months pregnant is seen in antepartal clinic. She states she is
having trouble with constipation. To minimize this condition, the nurse should
instruct her to
o A. Increase her fluid intake to three liters/day.
o B. Request a prescription for a laxative from her physician.

o C. Stop taking iron supplements.
o D. Take two tablespoons of mineral oil daily.

Incorrect
Correct Answer: A. increase her fluid intake to three liters/day.
In pregnancy, constipation results from decreased gastric motility and increased
water reabsorption in the colon caused by increased levels of progesterone.
Increasing fluid intake to three liters a day will help prevent constipation. The
client should increase fluid intake, increase roughage in the diet, and increase
exercise as tolerated.
 Option B: Laxatives are not recommended because of the possible
development of laxative dependence or abdominal cramping. The primary
medical treatment for constipation in pregnancy is a medication called a
laxative, which makes it easier and more comfortable to go to the
bathroom. It is generally safe to use gentle laxatives, but it is best to avoid
stimulant laxatives because they can induce uterine contractions.
 Option C: Iron supplements are necessary during pregnancy, as ordered,
and should not be discontinued. Daily oral iron and folic acid
supplementation with 30 mg to 60 mg of elemental iron and 400 µg (0.4
mg) folic acid is recommended for pregnant women to prevent maternal
anemia, puerperal sepsis, low birth weight, and preterm birth.
 Option D: Mineral oil is especially bad to use as a laxative because it
decreases the absorption of fat-soluble vitamins (A, D, E, K) if taken near
mealtimes. Mineral oil should always be prohibited during pregnancy, as its
use can cause hemorrhagic disease of the newborn due to impaired
absorption of vitamin K. Similarly, castor oil is absolutely prohibited during
pregnancy.
ADVERTISEMENTS
51. Question
A client with chronic pain reports to you, the charge nurse, that the nurse has not
been responding to requests for pain medication. What is your initial action?
o A. Check the MARs and nurses‘ notes for the past several days.

o B. Ask the nurse educator to give an in-service about pain management.
o C. Perform a complete pain assessment and history on the client.
o D. Have a conference with the nurses responsible for the care of this
client.
Incorrect
Correct Answer: D. Have a conference with the nurses responsible for the
care of this client.
As a charge nurse, you must assess the performance and attitude of the staff in
relation to this client. Handling conflicts in an efficient and effective manner
results in improved quality, patient safety, and staff morale, and limits work stress
for the caregiver. The nurse manager must approach this challenge thoughtfully
because it involves working relationships that are critical for the unit to function
effectively.
 Option A: After gathering data from the nurses, additional information
from the records and the client can be obtained as necessary. Effective
resolution and management of a conflict require clear communication and
a level of understanding of the perceived areas of disagreement. Conflict
resolution is an essential element of a healthy work environment because a
breakdown in communication and collaboration can lead to increased
patient errors.
 Option B: The educator may be of assistance if knowledge deficit or need
for performance improvement is the problem. The American Association of
Critical-Care Nurses standards for healthy work environments recognizes
the importance of proficiency in communication skills and The Joint
Commission‘s revised leadership standards place a mandate on healthcare
leadership to manage disruptive behavior that can impact patient safety.
 Option C: Nursing leaders need to assess how nurses deal with conflict in
the healthcare environment in an effort to develop and implement conflict
management training and processes that can assist them in dealing with
difficult situations.
ADVERTISEMENTS
52. Question

Family members are encouraging your client to ―tough it out‖ rather than run the
risk of becoming addicted to narcotics. The client is stoically abiding by the
family‘s wishes. Priority nursing interventions for this client should target which
dimension of pain?
o A. Sensory
o B. Sociocultural
o C. Behavioral
o D. Cognitive
Incorrect
Correct Answer: B. Sociocultural
The family is part of the socio-cultural dimension of pain. They are influencing the
client and should be included in the teaching sessions about the appropriate use
of narcotics and about the adverse effects of pain on the healing process. The
other dimensions should be included to help the client/family understand the
overall treatment plan and pain mechanism.
 Option A: The sensory dimension encompasses both the quality and
severity of pain. It includes the patient‘s report of the location, quality, and
intensity of pain. Assessing this dimension helps quantify the pain and
clarify the extent of poorly localized or radiating pain.
 Option C: The behavioral dimension of pain refers to the patient‘s verbal
or nonverbal behaviors exhibited in response to pain. To assess it, rely on
direct observation and continued patient interaction. Watch for common
behaviors associated with pain, such as guarding, splinting, tensing up,
crying, moaning, and massaging a specific body part.
 Option D: The cognitive dimension refers to thoughts, beliefs, attitudes,
intentions, and motivations related to pain and its management. Before
assessing this dimension, evaluate the patient‘s cognitive capacity and
functioning. Review the medical history for diseases or conditions that may
impair cognition; if any exists, assess its current level of progression. In
some patients, pain can temporarily worsen pre-existing cognitive
limitations.
ADVERTISEMENTS

53. Question
A client with diabetic neuropathy reports a burning, electrical type in the lower
extremities that is not responding to NSAIDs. You anticipate that the physician
will order which adjuvant medication for this type of pain?
o A. Amitriptyline (Elavil)
o B. Corticosteroids
o C. Methylphenidate (Ritalin)
o D. Lorazepam (Ativan)
Incorrect
Correct Answer: A. Amitriptyline (Elavil)
Antidepressants such as amitriptyline can be given for diabetic neuropathy. The
American Diabetes Association recommends amitriptyline, a tricyclic
antidepressant, as the first choice; however, titration to higher doses is limited by
its anticholinergic adverse effects.
 Option B: Corticosteroids are for pain associated with inflammation.
Corticosteroids produce their effect through multiple pathways. In general,
they produce anti-inflammatory and immunosuppressive effects, protein
and carbohydrate metabolic effects, water and electrolyte effects, central
nervous system effects, and blood cell effects.
 Option C: Methylphenidate is given to counteract sedation if the client is
on opioids. Methylphenidate is FDA-approved for the treatment of
attention deficit hyperactivity disorder (ADHD) in children and adults and
as a second-line treatment for narcolepsy in adults. Children with a
diagnosis of ADHD should be at least six years of age or older before being
started on this medication.
 Option D: Lorazepam is an anxiolytic. Lorazepam has common use as the
sedative and anxiolytic of choice in the inpatient setting owing to its fast (1
to 3 minute) onset of action when administered intravenously. Lorazepam
is also one of the few sedative-hypnotics with a relatively clean side effect
profile.
ADVERTISEMENTS

54. Question
Which client is most likely to receive opioids for extended periods of time?
o A. A client with fibromyalgia
o B. A client with phantom limb pain
o C. A client with progressive pancreatic cancer
o D. A client with trigeminal neuralgia

Incorrect
Correct Answer: C. A client with progressive pancreatic cancer
Cancer pain generally worsens with disease progression and the use of opioids is
more generous. Opioids (narcotics) are used with or without non-opioids to treat
moderate to severe pain. They are often a necessary part of a pain relief plan for
cancer patients. These medicines are much like natural substances (called
endorphins) made by the body to control pain. They were once made from the
opium poppy, but today many are man-made in a lab.
 Option A: Fibromyalgia is more likely to be treated with non-opioid and
adjuvant medications. It is recommended to continue nonpharmacologic
measures along with the use of medications for most patients with
fibromyalgia. Some patients may, however, respond adequately to
nonpharmacologic measures alone. The medications that have been well
studied and consistently effective are certain antidepressants and
anticonvulsants.
 Option B: Phantom limb pain usually subsides after ambulation begins.
Treatment, unfortunately, for PLP has not proven to be very effective. While
treatment for RLP tends to focus on an organic cause for the pain, PLP
focuses on symptomatic control.
 Option D: Trigeminal neuralgia is treated with anti-seizure medications
such as carbamazepine (Tegretol). The first-line treatment for patients with
classic TN and idiopathic TN is pharmacologic therapy. The most
commonly used medication is the anticonvulsant drug, carbamazepine. It is
usually started at a low dose, and the dose is gradually increased until it
controls the pain. It controls pain for most people in the early stages of the
disease.
ADVERTISEMENTS

55. Question
As the charge nurse, you are reviewing the charts of clients who were assigned to
a newly graduated RN. The RN has correctly chartered the dose and time of
medication, but there is no documentation regarding non-pharmaceutical
measures. What action should you take first?
o A. Make a note in the nurse‘s file and continue to observe clinical

performance.
o B. Refer the new nurse to the in-service education department.
o C. Quiz the nurse about knowledge of pain management.
o D. Give praise for the correct dose and time and discuss the deficits in
charting.
Incorrect
Correct Answer: D. Give praise for the correct dose and time and discuss the
deficits in charting.
In supervising the new RN, good performance should be reinforced first and then
areas of improvement can be addressed. Nursing activities are very important
within the hospital and must solve the problems that the patient needs. Every
nursing activity should produce documentation with critical thinking. If nursing
documents are not clear and accurate, inter-professional communication and an
evaluation of nursing care cannot be optimal.
 Option A: Making a note and watching do not help the nurse to correct
the immediate problem. Nursing activity that has been completed or that
will take place should be properly documented. Accurate documentation
and reports play a pivotal role in health services. This documentation is
necessary to identify nursing interventions that have been provided to
patients and to show patient progress during hospitalization.
 Option B: In-service might be considered if the problem persists. Nursing
documentation also serves as an effective tool of inter-professional
communication between nurses and other health professionals for
delivering ongoing nursing care, evaluating patient progress and
outcomes, and providing constant patient protection. High-quality nursing

documentation may improve the effectiveness of communication between
health professionals in first- and higher-level healthcare facilities.
 Option C: Asking the nurse about knowledge of pain management is also
an option; however, it would be a more indirect and time-consuming
approach. It is also an indicator of nurse performance and the nursing
service quality in a hospital. Documentation provides details of patient
condition, nursing interventions that have been provided, and patient
response to the intervention(s).
ADVERTISEMENTS
56. Question
In caring for a young child with pain, which assessment tool is the most useful?
o A. Simple descriptive pain intensity scale
o B. 0-10 numeric pain scale
o C. Faces pain-rating scale
o D. McGill-Melzack pain questionnaire

Incorrect
Correct Answer: C. Faces pain-rating scale
The Faces pain rating scale (depicting smiling, neutral, frowning, crying, etc.) is
appropriate for young children who may have difficulty describing pain or
understanding the correlation of pain to numerical or verbal descriptors. The
Faces Pain Scale-Revised (FPS-R) is a self-report measure of pain intensity
developed for children. It was adapted from the Faces Pain Scale to make it
possible to score the sensation of pain on the widely accepted 0-to-10 metric.
The scale shows a close linear relationship with visual analog pain scales across
the age range of 4-16 years. It is easy to administer and requires no equipment
except for the photocopied faces. The other tools require abstract reasoning
abilities to make analogies and use of advanced vocabulary.
 Option A: The Simple Descriptive Scale exhibits degrees of pain intensity
(no pain, mild pain, moderate pain, and severe pain). Risk factors for the
development of chronic pain have been a major topic in pain research in
the past two decades. Now, it has been realized that psychological and

psychosocial factors may substantially influence pain perception in patients
with chronic pain and thus may influence the surgical outcome.
 Option B: This pain scale is most commonly used. A person rates their pain
on a scale of 0 to 10 or 0 to 5. Zero means ―no pain,‖ and 5 or 10 means
―the worst possible pain.‖ These pain intensity levels may be assessed upon
initial treatment, or periodically after treatment.
 Option D: The McGill pain questionnaire, or MPQ, is one of the most
widely used multidimensional pain scales in the world. In the MPQ, the
evaluation of pain is divided into three categories: sensory, affective, and
evaluative. The questionnaire is self-reported and allows individuals to
describe the quality and intensity of their pain by using 78 adjectives in 20
different sections.
ADVERTISEMENTS
57. Question
In applying the principles of pain treatment, what is the first consideration?
o A. Treatment is based on client goals.
o B. A multidisciplinary approach is needed.
o C. The client must believe in perceptions of own pain.
o D. Drug side effects must be prevented and managed.

Incorrect
Correct Answer: C. The client must be believed about perceptions of own
pain.
The client must be believed and his or her experience of pain must be
acknowledged as valid. The data gathered via client reports can then be applied
to other options in developing the treatment plan. Assist patients to develop a
daily routine to support achievement and, where necessary, readjustment of
habits and roles according to individual capacity and life situation.
 Option A: Use a person-centered perspective to formulate collaborative
intervention strategies consistent with a physical therapy perspective.
Understand the need to involve family members and significant others
including employers where appropriate.

 Option B: Demonstrate an ability to integrate the patient assessment into
an appropriate management plan using the concepts and strategies of
clinical reasoning.
 Option D: Understand the principles of an effective therapeutic
patient/professional relationship to reduce pain, promote optimal function
and reduce disability through the use of active and where appropriate,
passive pain management approaches.
ADVERTISEMENTS
58. Question
Which route of administration is preferred if immediate analgesia and rapid
titration are necessary?
o A. Intraspinal
o B. Patient-controlled analgesia (PCA)
o C. Intravenous (IV)
o D. Sublingual
Incorrect
Correct Answer: C. Intravenous (IV)
The IV route is preferred as the fastest and most amenable to titration.
Medications may be given as repeated intermittent bolus doses or by continuous
infusion. Intravenous provides almost immediate analgesia; subcutaneous may
require up to 15 minutes for effect. Bolus IV dosing provides a shorter duration of
action than other routes.
 Option A: Intraspinal administration requires special catheter placement
and there are more potential complications with this route. Intraspinal and
intraventricular administration are options if maximal doses of opioids and
adjuvants administered through other routes are ineffective or produce
intolerable side effects {e.g., nausea/vomiting, excessive sedation,
confusion}. Opioids can be administered via indwelling percutaneous or
tunneled catheters into the epidural or intrathecal space.
 Option B: A PCA bolus can be delivered; however, the pump will limit the
dosage that can be delivered unless the parameters are changed. Patient-

controlled analgesia (PCA) devices can be used to combine continuous
infusion with intermittent bolus doses, allowing more flexible pain control.
It is recommended that the hourly SQ volume limit not exceed 5 cc.
Medications can be concentrated to maintain SQ volume limits; maximal
concentrations: fentanyl 50 ug/ml, morphine 50 mgs/ml, hydromorphone
50 mgs/ml.
 Option D: Sublingual is reasonably fast, but not a good route for titration,
medication variety in this form is limited. An alkaline pH microenvironment
that favors the unionized fraction of opioids increased sublingual drug
absorption. Although absorption was found to be independent of drug
concentration, it was contact time dependent for methadone and fentanyl
but not for buprenorphine. These results indicate that although the
sublingual absorption and apparent sublingual bioavailability of morphine
are poor, the sublingual absorption of methadone, fentanyl, and
buprenorphine under controlled conditions is relatively high.
ADVERTISEMENTS
59. Question
When titrating an analgesic to manage pain, what is the priority goal?
o A. Administer smallest dose that provides relief with the fewest side
effects.
o B. Titrate upward until the client is pain-free.
o C. Titrate downwards to prevent toxicity.
o D. Ensure that the drug is adequate to meet the client‘s subjective needs.
Incorrect
Correct Answer: A. Administer smallest dose that provides relief with the
fewest side effects.
The goal is to control pain while minimizing side effects. The World Health
Organization cancer pain ladder provides a helpful starting point for achieving
effective pain management. Clinicians should begin with nonopioid analgesics
(e.g., acetaminophen, nonsteroidal anti-inflammatory drugs [NSAIDs]), and
gradually progress to more potent analgesics until pain is relieved.

 Option B: For severe pain, the medication can be titrated upward until
pain is controlled. Many patients with terminal illnesses require immediate
opioid therapy or have contraindications to common non-opioid
analgesics, such as NSAIDs.
 Option C: Downward titration occurs when the pain begins to subside.
Acetaminophen is useful as a primary analgesic, or in combination with
other drugs, for treating mild to moderate pain. Dosages in healthy
persons should be limited to no more than 4,000 mg every 24 hours to
reduce the risk of hepatotoxicity.
 Option D: Adequate dosing is important; however, the concept of
controlled dosing applies more to potent vasoactive drugs. The World
Health Organization pain ladder offers a stepwise guideline for
approaching pain management. However, for many patients with terminal
illnesses, strong opioids are necessary for efficient and effective analgesia.
ADVERTISEMENTS
60. Question
In educating clients about non-pharmaceutical alternatives, which topic could
you delegate to an experienced LPN/LVN, who will function under your
continued support and supervision?
o A. Therapeutic touch
o B. Use of heat and cold applications
o C. Meditation
o D. Transcutaneous electrical nerve stimulation (TENS)

Incorrect
Correct Answer: B. Use of heat and cold applications
Use of heat and cold applications is a standard therapy with guidelines for safe
use and predictable outcomes, and an LPN/LVN will be implementing this
therapy in the hospital, under the supervision of an RN. Treating pain with hot
and cold can be extremely effective for a number of different conditions and
injuries, and easily affordable. The tricky part is knowing what situations call for

hot, and which calls for cold. Sometimes a single treatment will even include
both.
 Option A: Therapeutic touch requires additional training and practice. The
National Center for Complementary and Alternative Medicine places
therapeutic touch (TT) into the category of bio-field energy. In the TT
method, the therapist‘s hand is used to increase comfort and reduce pain
using the body‘s energy field correction mechanism
 Option C: Meditation is not acceptable to all clients and an assessment of
spiritual beliefs should be conducted. Mindfulness meditation is a fairly
loose term that applies to many meditation practices, which have been
found to improve a wide spectrum of clinically relevant cognitive and
health outcomes.
 Option D: Transcutaneous electrical stimulation is usually applied by a
physical therapist. Transcutaneous electrical nerve stimulation (TENS) is a
therapy that uses low voltage electrical current to provide pain relief. A
TENS unit consists of a battery-powered device that delivers electrical
impulses through electrodes placed on the surface of your skin. The
electrodes are placed at or near nerves where the pain is located or at
trigger points.
ADVERTISEMENTS
61. Question
Place the examples of drugs in the order of usage according to the World Health
Organization (WHO) analgesic ladder.
View Answers:
o Codeine, oxycodone, and diphenhydramine

o Morphine, hydromorphone, acetaminophen, and lorazepam
o NSAIDs and corticosteroids
Incorrect
The WHO analgesic ladder was a strategy proposed by the World Health
Organization (WHO), in 1986, to provide adequate pain relief for cancer patients.

The analgesic ladder was part of a vast health program termed the WHO Cancer
Pain and Palliative Care Program aimed at improving strategies for cancer pain
management through educational campaigns, the creation of shared strategies,
and the development of a global network of support.
 Step 1 includes non-opioids and adjuvant drugs. Mild pain: non-opioid
analgesics such as nonsteroidal anti-inflammatory drugs (NSAIDs) or
acetaminophen with or without adjuvants.
 Step 2 includes opioids for mild pain plus Step 1 drugs and adjuvant drugs
as needed. Moderate pain: weak opioids (hydrocodone, codeine, tramadol)
with or without non-opioid analgesics, and with or without adjuvants.
 Step 3 includes opioids for severe pain (replacing Step 2 opioids) and
continuing Step 1 drugs and adjuvant drugs as needed. Severe and
persistent pain: potent opioids (morphine, methadone, fentanyl,
oxycodone, buprenorphine, tapentadol, hydromorphone, oxymorphone)
ADVERTISEMENTS
62. Question
Which client is at greater risk for respiratory depression while receiving opioids
for analgesia?
o A. An elderly chronic pain client with a hip fracture.
o B. A client with heroin addiction and back pain.
o C. A young female client with advanced multiple myeloma.
o D. A child with an arm fracture and cystic fibrosis.

Incorrect
Correct Answer: D. A child with an arm fracture and cystic fibrosis.
At greatest risk are elderly clients, opiate naïve clients, and those with underlying
pulmonary disease. The child has two of the three risk factors. Many
complications can occur with multiple different opioids, such as non-cardiogenic
pulmonary edema, while many of the complications are unique to the opioid
used as well as the route of administration.

 Option A: Pain in the elderly population is especially difficult given the
myriad of physiological, pharmacological, and psychological aspects of
caring for geriatric patient. Opiates are the mainstay of pain treatment
throughout all age groups but special attention must be paid to the
efficacy and side effects of these powerful drugs when prescribing to a
population with impaired metabolism, excretion, and physical reserve.
 Option B: Prescription opioids and heroin are chemically similar and can
produce a similar high. In some places, heroin is cheaper and easier to get
than prescription opioids, so some people switch to using heroin instead.
More recent data suggest that heroin is frequently the first opioid people
use. In a study of those entering treatment for opioid use disorder,
approximately one-third reported heroin as the first opioid they used
regularly to get high.
 Option C: Bone pain is one of the most common presentations of multiple
myeloma and nearly all patients have skeletal involvement in the course of
the disease. Consequently, many patients require narcotics for symptom
management at the time of diagnosis but the long-term impact of MM
treatment on pain control remains uncertain.
ADVERTISEMENTS
63. Question
A client appears upset and tearful, but denies pain and refuses pain medication,
because ―my sibling is a drug addict and has ruined our lives.‖ What is
the priority intervention for this client?
o A. Encourage expression of fears on past experiences.
o B. Provide accurate information about the use of pain medication.
o C. Explain that addiction is unlikely among acute care clients.
o D. Seek family assistance in resolving this problem.

Incorrect
Correct Answer: A. Encourage expression of fears on past experiences.
This client has strong beliefs and emotions related to the issue of sibling
addiction. First, encourage expression. This indicated to the client that the

feelings are real and valid. It is also an opportunity to assess beliefs and fears.
Verbalization of feelings in a nonthreatening environment may help the client
come to terms with unresolved issues.
 Option B: Giving facts and information is appropriate at the right time.
Clients are often reluctant to share feelings for fear of ridicule and may
have repeatedly been told to ignore feelings. Once the client begins to
acknowledge and talk about these fears, it becomes apparent that the
feelings are manageable.
 Option C: Encourage the client to explore underlying feelings that may be
contributing to irrational fears. Help the client to understand how facing
these feelings, rather than suppressing them, can result in more adaptive
coping abilities.
 Option D: Family involvement is important, bearing in mind that their
beliefs about drug addiction may be similar to those of the client. Present
and discuss the reality of the situation with the client in order to recognize
aspects that can be changed and those that cannot. The client must accept
the reality of the situation before the work of reducing the fear can
progress.
ADVERTISEMENTS
64. Question
A client is being tapered off opioids and the nurse is watchful for signs of
withdrawal. What is one of the first signs of withdrawal?
o A. Fever
o B. Nausea
o C. Diaphoresis
o D. Abdominal cramps
Incorrect
Correct Answer: C. Diaphoresis
Diaphoresis is one of the early signs that occur between 6 and 12 hours. Fever,
nausea, and abdominal cramps are late signs that occur between 48 and 72
hours. According to Diagnostic and Statistical Manual of Mental Disorders (DSM–

5) criteria, signs, and symptoms of opioid withdrawal include lacrimation or
rhinorrhea, piloerection ―goose flesh,‖ myalgia, diarrhea, nausea/vomiting,
pupillary dilation and photophobia, insomnia, autonomic hyperactivity
(tachypnea, hyperreflexia, tachycardia, sweating, hypertension, hyperthermia),
and yawning.
 Option A: A fever can be a withdrawal symptom among people who have
been addicted to various substances, or even after a period of intense
substance use. Fever symptoms may range from mild to severe. Although
mild fevers can accompany a variety of substance withdrawal syndromes
and are usually self-limiting, fever can also be a component of a
particularly dangerous type of alcohol withdrawal.
 Option B: Prolonged use of these drugs changes the way nerve receptors
work in the brain, and these receptors become dependent upon the drug
to function. If the client becomes physically sick after he stops taking an
opioid medication, it may be an indication that he‘s physically dependent
on the substance.
 Option D: The symptoms the client is experiencing will depend on the
level of withdrawal he is experiencing. Also, multiple factors dictate how
long a person will experience the symptoms of withdrawal. Because of this,
everyone experiences opioid withdrawal differently. However, there‘s
typically a timeline for the progression of symptoms.
ADVERTISEMENTS
65. Question
In caring for clients with pain and discomfort, which task is most appropriate to
delegate to the nursing assistant?
o A. Assist the client with preparation of a sitz bath.
o B. Monitor the client for signs of discomfort while ambulating.
o C. Coach the client to deep breathe during painful procedures.
o D. Evaluate relief after applying a cold application.

Incorrect
Correct Answer: A. Assist the client with preparation of a sitz bath.

The nursing assistant is able to assist the client with hygiene issues and knows the
principles of safety and comfort for this procedure. Proper and appropriate
assignments facilitate quality care. Improper and inappropriate assignments can
lead to poor quality of care, disappointing outcomes of care, the jeopardization
of client safety, and even legal consequences. Monitoring the client, teaching
techniques, and evaluating outcomes are nursing responsibilities.
 Option B: Monitoring the client for signs of discomfort while ambulating is
a nursing responsibility. When a registered nurse delegates aspects of
patient care to a licensed practical nurse that are outside of the scope of
practice of the licensed practical nurse, the client is in potential physical
and/or psychological jeopardy because this delegated task, which is
outside of the scope of practice for this licensed practical nurse, is
something that this nurse was not prepared and educated to perform.
 Option C: Coaching the client to deep breathe during painful procedures is
a nursing responsibility. The nurse who delegates aspects of care to other
members of the nursing team must balance the needs of the client with the
abilities of those to which the nurse is delegating tasks and aspects of care,
among other things such as the scopes of practice and the policies and
procedures within the particular healthcare facility.
 Option D: Evaluation of relief after applying a cold application is a nursing
responsibility. The staff members‘ levels of education, knowledge, past
experiences, skills, abilities, and competencies are also evaluated and
matched with the needs of all of the patients in the group of patients that
will be cared for.
ADVERTISEMENTS
66. Question
The physician has ordered a placebo for a chronic pain client. You are a newly
hired nurse and you feel very uncomfortable administering the medication. What
is the first action that you should take?
o A. Prepare the medication and hand it to the physician.
o B. Check the hospital policy regarding the use of the placebo.
o C. Follow a personal code of ethics and refuse to give it.

o D. Contact the charge nurse for advice.
Incorrect
Correct Answer: D. Contact the charge nurse for advice.
A charge nurse is a resource person who can help locate and review the policy. If
the physician is insistent, he or she could give the placebo personally, but
delaying the administration does not endanger the health or safety of the client.
 Option A: In a treatment setting it is unethical to deliberately misinform
the patient. However, placebo effects can be an important factor in a
biopsychosocial context. Clinicians need to consider some ethical issues
relating to placebo effects. According to Pittrof and Rubenstein, the ethical
use of placebo effects should always benefit the patient and involve
disclosure.
 Option B: Placebo effects may thus be defined as psychological and/or
physiological responses that follow the administration of active and non-
active substances when coupled with an affirmation of the treatment
effects. The ethical use of placebo effects in a clinical setting should rely on
realistic expectations and be based on best practice. The use of a placebo
in clinical settings might still be seen as controversial by some.
 Option C: While following one‘s own ethical code is correct, you must
ensure that the client is not abandoned and that care continues. Placebo
effects, when considered as supplements to pharmacologically active
substances, should aim to increase patients‘ well-being. It is unethical to
deliberately misinform patients.
ADVERTISEMENTS
67. Question
For a cognitively impaired client who cannot accurately report pain, what is
the first action that you should take?
o A. Closely assess for nonverbal signs such as grimacing or rocking.
o B. Obtain baseline behavioral indicators from family members.
o C. Look at the MAR and chart, to note the time of the last dose and response.
o D. Give the maximum PRS dose within the minimum time frame for relief.

Incorrect
Correct Answer: B. Obtain baseline behavioral indicators from family
members.
Complete information from the family should be obtained during the initial
comprehensive history and assessment. If this information is not obtained, the
nursing staff will have to rely on observation of nonverbal behavior and careful
documentation to determine pain and relief patterns.
 Option A: Pain can be difficult to assess in cognitively impaired individuals
because their self-reports of pain can be inaccurate or difficult to obtain.
Thus, behavioral observation-based assessment is optimal in these
patients.
 Option C: Assess potential causes of pain. The clinician should consider
pathological causes of pain and any procedure known to cause pain.
Address any pain history from family, significant others, and caregivers.
 Option D: Use scheduled dosing when pain is chronic and/or when the
patient is unable to ask for medication. When administering the
medication, it is best to start with a lower dose and gradually increase the
dose to alleviate the pain.
ADVERTISEMENTS
68. Question
Which route of administration is preferable for administration of daily analgesics
(if all body systems are functional)?
o A. IV
o B. IM or subcutaneous
o C. Oral
o D. Transdermal
o E. PCA
Incorrect
Correct Answer: C. Oral
If the gastrointestinal system is functioning, the oral route is preferred for routine
analgesics because of lower cost and ease of administration. Oral route is also

less painful and less invasive than the IV, IM, subcutaneous, or PCA routes.
Although a few drugs taken orally are intended to be dissolved in the mouth,
nearly all drugs taken orally are swallowed. Of these, most are taken for the
systemic drug effects that result after absorption from the various surfaces along
the gastrointestinal tract.
 Option A: IV therapy allows a higher concentration of nutrients or
medication into the body — and that means the body gets what it needs
faster and more effectively without further damage to the GI system.
 Option B: Rapid and uniform absorption of the drug especially those of
the aqueous solutions. Rapid onset of the action compared to that of the
oral and the subcutaneous routes. IM injection bypasses the first-pass
metabolism. It also avoids the gastric factors governing drug absorption.
 Option D: Transdermal route is slower and medication availability is
limited compared to oral forms. Transdermal delivery systems provide
continuous administration of drugs through the skin, which maintains
constant plasma drug levels and avoids the peaks and troughs that are
seen with oral administration.
 Option E: Patient-controlled analgesia is used to treat acute, chronic,
postoperative, and labor pain. A variety of medications can be used for
patient-controlled analgesia and are administered intravenously (IV),
through an epidural or peripheral nerve catheter, and transdermally.
ADVERTISEMENTS
69. Question
A first-day postoperative client on a PCA pump reports that the pain control is
inadequate. What is the first action you should take?
o A. Deliver the bolus dose per standing order.
o B. Contact the physician to increase the dose.
o C. Try non-pharmacological comfort measures.
o D. Assess the pain for location, quality, and intensity.

Incorrect
Correct Answer: D. Assess the pain for location, quality, and intensity.

Assess the pain for changes in location, quality, and intensity, as well as changes
in response to medication. This assessment will guide the next steps. Patient-
controlled analgesia is used to treat acute, chronic, postoperative, and labor pain.
A variety of medications can be used for patient-controlled analgesia and are
administered intravenously (IV), through an epidural or peripheral nerve catheter,
and transdermally.
 Option A: The goal of PCA is to efficiently deliver pain relief at a patient‘s
preferred dose and schedule by allowing them to administer a
predetermined bolus dose of medication on-demand at the press of a
button. Each bolus can be administered alone or coupled with a
background infusion of medication.
 Option B: The initial loading dose can be titrated by a nurse to reach the
minimum effective concentration (MEC) of the desired medication. The
bolus or demand dose is the dose of medication delivered each time the
patient presses the button. A lockout interval is the time after a demand
dose in which a dose of medication will not get administered even if the
patient presses the button; this is done to prevent overdosing.
 Option C: The use of PCA has been proven to be more effective at pain
control than non-patient-controlled opioid injections and results in higher
patient satisfaction. PCA has also been found to be preferred by nurses
because it allows for a reduction in their workload. PCA will enable patients
to be in more control over their pain and helps them shift toward a more
internal locus of control over their care.
ADVERTISEMENTS
70. Question
Which non-pharmacological measure is particularly useful for a client with acute
pancreatitis?
o A. Diversional therapy, such as playing cards or board games.
o B. Massage the back and neck with warmed lotion.
o C. Side-lying position with knees to chest and pillow against the

abdomen.

o D. Transcutaneous electrical nerve stimulation (TENS).
Incorrect
Correct Answer: C. Side-lying position with knees to chest and pillow against
the abdomen.
The side-lying, knee-chest position opens retroperitoneal space and provides
relief. The pillow provides a splinting action. Reduces abdominal pressure and
tension, providing some measure of comfort and pain relief. Note: Supine
position often increases pain.
 Option A: Diversional therapy is not the best choice for acute pain,
especially if the activity requires concentration. Keep the environment free
of food odors. Sensory stimulation can activate pancreatic enzymes,
increasing pain.
 Option B: The additional stimulation of massage may be distressing to the
client. Provide alternative comfort measures (back rub), encourage
relaxation techniques (guided imagery, visualization), quiet diversional
activities (TV, radio).
 Option D: TENS is more appropriate for chronic muscular pain. Maintain
bed rest during an acute attack. Provide a quiet, restful environment.
Decreases metabolic rate and GI stimulation and secretions, thereby
reducing pancreatic activity.
ADVERTISEMENTS
71. Question
What is the best way to schedule medication for a client with constant pain?
o A. PRN at the client‘s request
o B. Prior to painful procedures
o C. IV bolus after pain assessment
o D. Around-the-clock
Incorrect
Correct Answer: D. Around-the-clock
If the pain is constant, the best schedule is around-the-clock, to provide steady
analgesia and pain control. The other options may actually require higher doses

to achieve control. Pain medication prescribed around-the-clock has the purpose
of managing a patient‘s baseline pain, which is the average pain intensity the
patient experiences. This is generally pain that is continuously experienced.
 Option A: The use of ―as needed‖ or ―pro re nata‖ (PRN) range opioid
analgesic orders is a common clinical practice in the management of acute
pain, designed to provide flexibility in dosing to meet an individual‘s
unique needs. Range orders enable necessary adjustments in doses based
on individual response to treatment.
 Option B: Of particular importance to nursing care, unrelieved pain
reduces patient mobility, resulting in complications such as deep vein
thrombosis, pulmonary embolism, and pneumonia. Postsurgical
complications related to inadequate pain management negatively affect
the patient‘s welfare and the hospital performance because of extended
lengths of stay and readmissions, both of which increase the cost of care.
 Option C: Assessment of pain is a critical step to providing good pain
management. In a sample of physicians and nurses, Anderson and
colleagues found lack of pain assessment was one of the most problematic
barriers to achieving good pain control. The most critical aspect of pain
assessment is that it is done on a regular basis (e.g., once a shift, every 2
hours) using a standard format. The assessment parameters should be
explicitly directed by hospital or unit policies and procedures.
ADVERTISEMENTS
72. Question
Which client(s) are appropriate to assign to the LPN/LVN, who will function
under the supervision of the RN or team leader? Select all that apply.
o A. A client who needs pre-op teaching for use of a PCA pump.
o B. A client with a leg cast who needs neurologic checks and PRN
hydrocodone.
o C. A client post-op toe amputation with diabetic neuropathic pain.
o D. A client with terminal cancer and severe pain who is refusing medication.
Incorrect

Correct Answer: B & C.
The clients with the cast and the toe amputation are stable clients and need
ongoing assessment and pain management that are within the scope of practice
for an LPN/LVN under the supervision of an RN. The RN should take
responsibility for preoperative teaching, and terminal cancer needs a
comprehensive assessment to determine the reason for refusal of medication.
 Option A: Preoperative teaching is a nursing responsibility. Proper and
appropriate assignments facilitate quality care. Improper and inappropriate
assignments can lead to poor quality of care, disappointing outcomes of
care, the jeopardization of client safety, and even legal consequences.
 Option B: The clients with the cast are within the scope of practice for an
LPN/LVN under the supervision of an RN. Delegation, simply defined, is the
transfer of the nurse‘s responsibility for the performance of a task to
another nursing staff member while retaining accountability for the
outcome. Responsibility can be delegated. Accountability cannot be
delegated. The delegating registered nurse remains accountable for all
client care despite the fact that some of these aspects of care can, and are,
delegated to others.
 Option C: The client with the toe amputation is a stable client and needs
ongoing assessment and pain management that are within the scope of
practice for an LPN/LVN under the supervision of an RN. The staff
members‘ levels of education, knowledge, past experiences, skills, abilities,
and competencies are also evaluated and matched with the needs of all of
the patients in the group of patients that will be cared for.
 Option D: A client with terminal cancer and severe pain who is refusing
medication is a nursing responsibility. Based on these characteristics and
the total client needs for the group of clients that the registered nurse is
responsible and accountable for, the registered nurse determines and
analyzes all of the health care needs for a group of clients; the registered
nurse delegates care that matches the skills of the person that the nurse is
delegating to.
ADVERTISEMENTS
73. Question

For a client who is taking aspirin, which laboratory value should be reported to
the physician?
o A. Potassium 3.6 mEq/L
o B. Hematocrit 41%
o C. PT 14 seconds
o D. BUN 20 mg/dL
Incorrect
Correct Answer: C. PT 14 seconds
When a client takes aspirin, monitor for increases in PT (normal range 11.0-12.5
seconds in 85%-100%). Also, monitor for possible decreases in potassium (normal
range 3.5-5.0 mEq/L). If bleeding signs are noted, hematocrit should be
monitored (normal range male 42%-52%, female 37%-47%). An elevated BUN
could be seen if the client is having chronic gastrointestinal bleeding (normal
range 10-20 mg/dL).
 Option A: Severity is categorized as mild when the serum potassium level
is 3 to 3.4 mmol/L, moderate when the serum potassium level is 2.5 to 3
mmol/L, and severe when the serum potassium level is less than 2.5
mmol/L. Values obtained from plasma and serum may differ.
 Option B: HCT calculation is by dividing the lengths of the packed RBC
layer by the length of total cells and plasma. As it is a ratio, it doesn‘t have
any unit. Multiplying the ratio by 100 gives the accurate value, which is the
accepted reporting style for HCT. A normal adult male shows an HCT of
40% to 54% and female shows 36% to 48%.
 Option D: BUN and creatinine levels that are within the ranges established
by the laboratory performing the test suggest that the kidneys are
functioning as they should. Increased BUN and creatinine levels may mean
that the kidneys are not working as they should. This healthcare
practitioner will consider other factors, such as the medical history and
physical exam, to determine what condition, if any, may be affecting the
kidneys.
ADVERTISEMENTS

74. Question
Which client would be appropriate to assign to a newly graduated RN, who has
recently completed orientation?.
o A. An anxious, chronic pain client who frequently uses the call button.
o B. A client second-day post-op who needs pain medication prior to

dressing changes.
o C. A client with HIV who reports headache and abdominal and pleuritic chest
pain.
o D. A client who is being discharged with a surgically implanted catheter.

Incorrect
Correct Answer: B. A client second-day post-op who needs pain medication
prior to dressing changes
A second-day postoperative client who needs medication prior to dressing
changes has predictable and routine care that a new nurse can manage. Some
staff members may possess greater expertise than others. Some, such as new
graduates, may not possess the same levels of knowledge, past experiences,
skills, abilities, and competencies that more experienced staff members possess.
 Option A: Although clients with chronic pain can be relatively stable, the
interaction with this client will be time-consuming and may cause the new
nurse to fall behind. Time is finite and often the needs of the client are
virtually infinite. Time management, organization, and priority setting skills,
therefore, are essential to the complete and effective provision of care to
an individual client and to a group of clients.
 Option C: The client with HIV has complex complaints that require expert
assessment skills. Staff members differ in terms of their knowledge, skills,
abilities, and competencies. A staff member who has just graduated as a
certified nursing assistant and a newly graduated registered nurse cannot
be expected to perform patient care tasks at the same level of proficiency,
skill, and competency as an experienced nursing assistant or registered
nurse. It takes time for new graduates to refine the skills that they learned
in school.
 Option D: The client pending discharge will need special and detailed
instructions. Validated and documented competencies must also be

considered prior to assignment of patient care. No aspect of care can be
assigned or delegated to another nursing staff member unless this staff
member has documented evidence that they are deemed competent by a
registered nurse to do so.
ADVERTISEMENTS
75. Question
A family member asks you, ―Why can‘t you give more medicine? He is still having
a lot of pain.‖ What is your best response?
o A. ―The doctor ordered the medicine to be given every 4 hours.‖
o B. ―If the medication is given too frequently he could suffer ill effects.‖
o C. “Please tell him that I will be right there to check on him.”
o D. ―Let‘s wait about 30-40 minutes. If there is no relief I‘ll call the doctor.‖
Incorrect
Correct Answer: C. “Please tell him that I will be right there to check on
him.”
Directly ask the client about the pain and do a complete pain assessment. This
information will determine which action to take next. Pain assessment is critical to
optimal pain management interventions. While pain is a highly subjective
experience, its management necessitates objective standards of care.
 Option A: Poorly managing pain may put clinicians at risk for legal action.
Current standards for pain management, such as the national standards
outlined by the Joint Commission (formerly known as the Joint Commission
on Accreditation of Healthcare Organizations, JCAHO), require that pain is
promptly addressed and managed.
 Option B: Continuous, unrelieved pain also affects the psychological state
of the patient and family members. Common psychological responses to
pain include anxiety and depression. The inability to escape from pain may
create a sense of helplessness and even hopelessness, which may
predispose the patient to more chronic depression.
 Option D: Inadequately managed pain can lead to adverse physical and
psychological patient outcomes for individual patients and their families.

Continuous, unrelieved pain activates the pituitary-adrenal axis, which can
suppress the immune system and result in postsurgical infection and poor
wound healing.
ADVERTISEMENTS
1. Question
The most important nursing intervention to correct skin dryness is:
 A. Consult the dietitian about increasing the patient‘s fat intake, and take
necessary measures to prevent infection.
 B. Ask the physician to refer the patient to a dermatologist, and suggest that
the patient wear home-laundered sleepwear.
 C. Encourage the patient to increase his fluid intake, use non-irritating

soap when bathing the patient, and apply lotion to the involved areas.
 D. Avoid bathing the patient until the condition is remedied, and notify the
physician.
Incorrect
Correct Answer: C. Encourage the patient to increase his fluid intake, use
non-irritating soap when bathing the patient, and apply lotion to the
involved areas.
Dry skin will eventually crack, ranking the patient more prone to infection. To
prevent this, the nurse should provide adequate hydration through fluid intake,
use non irritating soaps or no soap when bathing the patient, and lubricate the
patient‘s skin with lotion. In most cases, dry skin responds well to lifestyle
measures, such as using moisturizers and avoiding long, hot showers and baths.
Moisturizers provide a seal over the skin to keep water from escaping. Apply
moisturizer several times a day and after bathing.
 Option B: The attending physician and dietitian may be consulted for
treatment, but home-laundered items usually are not necessary. Natural
fibers, such as cotton and silk, allow the skin to breathe. But wool, although

natural, can irritate even normal skin. Wash clothes with detergents without
dyes or perfumes, both of which can irritate the skin.
 Option C: Increasing fat intake is unnecessary. Hot, dry, indoor air can
parch sensitive skin and worsen itching and flaking. A portable home
humidifier or one attached to the furnace adds moisture to the air inside
the home. Be sure to keep the humidifier clean. It‘s best to use cleansing
creams or gentle skin cleansers and bath or shower gels with added
moisturizers. Choose mild soaps that have added oils and fats. Avoid
deodorant and antibacterial detergents, fragrance, and alcohol.
 Option D: Bathing may be limited but need not be avoided entirely. Long
showers or baths and hot water remove oils from the skin. Limit baths or
showers to five to 10 minutes and use warm, not hot, water.
2. Question
When bathing a patient‘s extremities, the nurse should use long, firm strokes
from the distal to the proximal areas. This technique:
 A. Provides an opportunity for skin assessment.
 B. Avoids undue strain on the nurse.
 C. Increases venous blood return.
 D. Causes vasoconstriction and increases circulation.

Incorrect
Correct Answer: C. Increases venous blood return.
Washing from distal to proximal areas stimulates venous blood flow, thereby
preventing venous stasis. Good personal hygiene is essential for skin health but it
also has an important role in maintaining self-esteem and quality of life.
Supporting patients to maintain personal hygiene is a fundamental aspect of
nursing care.
 Option A: The nurse can assess the patient‘s condition throughout the
bath. Helping patients to wash and dress is frequently delegated to junior
staff, but time spent attending to a patient‘s hygiene needs is a valuable
opportunity for nurses to carry out a holistic assessment (Dougherty and
Lister, 2015; Burns and Day, 2012). It also allows time to address any

concerns patients have and provides a valuable opportunity to assess the
condition of their skin.
 Option B: The nurse should feel no strain while bathing the patient. Nurses
should also discuss with patients any religious and cultural issues relating
to personal care (Dougherty and Lister, 2015). For example, ideally, Muslim
patients should be cared for by a nurse of the same gender (Rassool, 2015),
and Hindus may wish to wash before prayer (Dougherty and Lister, 2015).
 Option D: It improves circulation but does not result in vasoconstriction.
Bed bathing is not as effective as showering or bathing and should only be
undertaken when there is no alternative (Dougherty and Lister, 2015). If a
bed bath is required, it is important to offer patients the opportunity to
participate in their own care, which helps to maintain their independence,
self-esteem and dignity.
3. Question
Vivid dreaming occurs in which stage of sleep?
 A. Stage I non-REM
 B. Rapid eye movement (REM) stage
 C. Stage II non-REM
 D. Delta stage
Incorrect
Correct Answer: B. Rapid eye movement (REM) stage
Other characteristics of rapid eye movement (REM) sleep are deep sleep (the
patient cannot be awakened easily), depressed muscle tone, and possibly
irregular heart and respiratory rates. This is the stage associated with dreaming.
Interestingly, the EEG is similar to an awake individual, but the skeletal muscles
are atonic and without movement. The exception is the eye and diaphragmatic
breathing muscles, which remain active. The breathing rate is altered though,
being more erratic and irregular. This stage usually starts 90 minutes after falling
asleep, and each of the REM cycles gets longer throughout the night. The first
period typically lasts 10 minutes, and the final one can last up to an hour.
 Option A: Non-REM sleep is a deep, restful sleep without dreaming. This is
the lightest stage of sleep and starts when more than 50% of the alpha

waves are replaced with low-amplitude mixed-frequency (LAMF) activity.
There is muscle tone present in the skeletal muscle and breathing tends to
occur at a regular rate. This stage tends to last 1 to 5 minutes, consisting of
around 5% of the total cycle.
 Option C: This stage represents deeper sleep the heart rate and body
temperature drop. It is characterized by the presence of sleep spindles, K-
complexes, or both. These sleep spindles will activate the superior temporal
gyri, anterior cingulate, insular cortices, and the thalamus. The K-complexes
show a transition into a deeper sleep. Stage 2 sleep lasts around 25
minutes in the initial cycle and lengthens with each successive cycle,
eventually consisting of about 50% of total sleep.
 Option D: Delta stage, or slow-wave sleep, occurs during non-REM Stages
III and IV and is often equated with quiet sleep. This is considered the
deepest stage of sleep and is characterized by a much slower frequency
with high amplitude signals known as delta waves. This stage is the most
difficult to awaken from, and for some people, even loud noises (over 100
decibels) will not awaken them. As people get older, they tend to spend
less time in this slow, delta wave sleep and more time stage N2 sleep. This
is the stage when the body repairs and regrows its tissues, builds bone and
muscle, and strengthens the immune system.
4. Question
The natural sedative in meat and milk products (especially warm milk) that can
help induce sleep is:
 A. Flurazepam
 B. Temazepam
 C. Methotrimeprazine
 D. Tryptophan
Incorrect
Correct Answer: D. Tryptophan
Tryptophan is a natural sedative; flurazepam (Dalmane), temazepam (Restoril),
and methotrimeprazine (Levoprome) are hypnotic sedatives. Protein foods such
as milk and milk products contain the sleep-inducing amino acid tryptophan.

Having warm milk at bedtime is a good way to work towards reaching the
recommended number of servings of Milk and Alternatives each day, and can be
a comforting way to unwind. Tryptophan is an amino acid that promotes sleep
and is found in small amounts in all protein foods. It is a precursor to the sleep-
inducing compounds serotonin (a neurotransmitter), and melatonin (a hormone
which also acts as a neurotransmitter).
 Option A: Flurazepam (marketed under the brand names Dalmane and
Dalmadorm) is a drug which is a benzodiazepine derivative. It possesses
anxiolytic, anticonvulsant, hypnotic, sedative and skeletal muscle relaxant
properties. It produces a metabolite with a long half-life, which may stay in
the bloodstream for days.
 Option B: Temazepam is used on a short-term basis to treat insomnia
(difficulty falling asleep or staying asleep). Temazepam is in a class of
medications called benzodiazepines. It works by slowing activity in the
brain to allow sleep.
 Option C: Levomepromazine (also known as methotrimeprazine) is used to
treat severe mental/mood disorders (such as schizophrenia, bipolar
disorder). It works by helping to restore certain natural substances in the
brain. Levomepromazine belongs to a class of drugs known as
phenothiazines. It can help the client to think clearly and take part in
everyday life. It is also used to treat anxiety disorders, a certain sleep
problem (insomnia), nausea/vomiting, and pain. This medication has
calming, relaxing, and pain-relieving effects.
5. Question
Nursing interventions that can help the patient to relax and sleep restfully include
all of the following except:
 A. Have the patient take a 30- to 60-minute nap in the afternoon.
 B. Turn on the television in the patient‘s room.
 C. Provide quiet music and interesting reading material.
 D. Massage the patient‘s back with long strokes.

Incorrect

Correct Answer: A. Have the patient take a 30- to 60-minute nap in the
afternoon.
Napping in the afternoon is not conducive to nighttime sleeping. There are few
considerations about naps. For example, a short daytime nap of 15-30 minutes
can be restorative for elders and will not interfere with nighttime sleep. On the
other hand, insomniacs are cautioned to avoid naps. Quiet music, watching
television, reading, and massage usually will relax the patient, helping him to fall
asleep.
 Option B: For patients in the hospital, factors that can prevent sound sleep
include staff noise during a shift, telephones and call lights, doors, paging
systems, and even carts wheeled through corridors. Safety and comfort can
be promoted by raising side rails, placing the bed in a low position, and
using night-lights.
 Option C: For individuals who are unable to sleep, they must get out of
bed and spend some time in another room. There, they can start some
relaxing activities like reading and listening to soft music. They should
continue the activity till they feel drowsy.
 Option D: Rituals can be supported in institutionalized patients by
assisting them with a hand and face wash, massage, pillow plumping, and
even talking about today‘s accomplishments and enjoyable events. These
can promote relaxation and peace of mind.
6. Question
Restraints can be used for all of the following purposes except to:
 A. Prevent a confused patient from removing tubes, such as feeding tubes,

I.V. lines, and urinary catheters.
 B. Prevent a patient from falling out of bed or a chair.
 C. Discourage a patient from attempting to ambulate alone when he requires

assistance for his safety.
 D. Prevent a patient from becoming confused or disoriented.

Incorrect
Correct Answer: D. Prevent a patient from becoming confused or
disoriented.

By restricting a patient‘s movements, restraints may increase stress and lead to
confusion, rather than prevent it. Restraints in a medical setting are devices that
limit a patient‘s movement. Restraints can help keep a person from getting hurt
or doing harm to others, including their caregivers. They are used as a last resort.
The other choices are valid reasons for using restraints.
 Option A: Sometimes hospital patients who are confused need restraints
so that they do not remove catheters and tubes that give them medicine
and fluids. A nurse who has special training in using restraints can begin to
use them. A doctor or another provider must also be told restraints are
being used. The doctor or other provider must then sign a form to allow
the continued use of restraints.
 Option B: Restraints may be used to keep a person in proper position and
prevent movement or falling during surgery or while on a stretcher.
Patients who are restrained also need to have their blood flow checked to
make sure the restraints are not cutting off their blood flow. They also
need to be watched carefully so that the restraints can be removed as soon
as the situation is safe.
 Option C: Restraints can also be used to control or prevent harmful
behavior or get out of bed, fall, and hurt themselves. Restraints should not
cause harm or be used as punishment. Health care providers should first
try other methods to control a patient and ensure safety. Restraints should
be used only as a last choice.
7. Question
Which of the following is the nurse‘s legal responsibility when applying
restraints?
 A. Document the patient‘s behavior.
 B. Document the type of restraint used.
 C. Obtain a written order from the physician except in an emergency, when

the patient must be protected from injury to himself or others.
 D. All of the above.

Incorrect

When applying restraints, the nurse must document the type of behavior that
prompted her to use them, document the type of restraints used, and obtain a
physician‘s written order for the restraints. Nurses are accountable for providing,
facilitating, advocating and promoting the best possible patient care and to take
action when patient safety and well-being are compromised, including when
deciding to apply restraints.
 Option A: Restraint use should be continually assessed by the health care
team and reduced or discontinued as soon as possible. After the
discontinuing restraints, interprofessional teams should debrief with the
patient, patient‘s family, or substitute decision maker to discuss
intervention, previous interventions and alternatives to restraints.
 Option B: There are three types of restraints: physical, chemical and
environmental. Physical restraints limit a patient‘s movement. Chemical
restraints are any form of psychoactive medication used not to treat illness,
but to intentionally inhibit a particular behaviour or movement.
Environmental restraints control a patient‘s mobility.
 Option C: With any intervention, such as restraint use, nurses need to
ensure they actively involve the patient, patient‘s family, substitute
decision-makers and the broader health care team. Nurses are also
accountable for documenting nursing care provided, including assessment,
planning, intervention and evaluation. In emergency situations, nurses may
apply restraints without consent when a serious threat of harm to the
patient or others exists and only after all alternative interventions were
unsuccessful.
8. Question
Kubler-Ross‘s five successive stages of death and dying are:
 A. Anger, bargaining, denial, depression, acceptance
 B. Denial, anger, depression, bargaining, acceptance
 C. Denial, anger, bargaining, depression acceptance
 D. Bargaining, denial, anger, depression, acceptance

Incorrect
Correct Answer: C. Denial, anger, bargaining, depression acceptance

Kubler-Ross‘s five successive stages of death and dying are denial, anger,
bargaining, depression, and acceptance. The patient may move back and forth
through the different stages as he and his family members react to the process of
dying, but he usually goes through all of these stages to reach acceptance.
 Option A: Denial is a common defense mechanism used to protect oneself
from the hardship of considering an upsetting reality. Kubler-Ross noted
that after the initial shock of receiving a terminal diagnosis, patients would
often reject the reality of the new information. Patients may directly deny
the diagnosis, attribute it to faulty tests or an unqualified physician, or
simply avoid the topic in conversation.
 Option B: Anger, as Kubler-Ross pointed out, is commonly experienced
and expressed by patients as they concede the reality of a terminal illness.
It may be directed, as with blame of medical providers for inadequately
preventing the illness, of family members for contributing to risks of not
being sufficiently supportive, or of spiritual providers or higher powers for
the diagnosis‘ injustice.
 Option D: Bargaining typically manifests as patients seek some measure of
control over their illness. The negotiation could be verbalized or internal
and could be medical, social, or religious. The patients‘ proffered bargains
could be rational, such as a commitment to adhere to treatment
recommendations or accept help from their caregivers, or could represent
more magical thinking, such as with efforts to appease misattributed guilt
they may feel is responsible for their diagnosis. Depression is perhaps the
most immediately understandable of Kubler-Ross‘s stages and patients
experience it with unsurprising symptoms such as sadness, fatigue, and
anhedonia. Acceptance describes recognizing the reality of a difficult
diagnosis while no longer protesting or struggling against it. Patients may
choose to focus on enjoying the time they have left and reflecting on their
memories.
9. Question
A terminally ill patient usually experiences all of the following feelings during the
anger stage except:
 A. Rage
 B. Envy

 C. Numbness
 D. Resentment
Incorrect
Correct Answer: C. Numbness
Numbness is typical of the depression stage, when the patient feels a great sense
of loss. Depression is perhaps the most immediately understandable of Kubler-
Ross‘s stages and patients experience it with unsurprising symptoms such as
sadness, fatigue, and anhedonia. Spending time in the first three stages is
potentially an unconscious effort to protect oneself from this emotional pain,
and, while the patient‘s actions may potentially be easier to understand, they may
be more jarring in juxtaposition to behaviors arising from the first three stages.
 Option A: The anger stage includes such feelings as rage, envy,
resentment, and the patient‘s questioning ―Why me?‖ Anger, as Kubler-
Ross pointed out, is commonly experienced and expressed by patients as
they concede the reality of a terminal illness. It may be directed, as with
blame of medical providers for inadequately preventing the illness, of
family members for contributing to risks of not being sufficiently
supportive, or of spiritual providers or higher powers for the diagnosis‘
injustice.
 Option B: Patients may feel sadness, anger, or confusion. They are
experiencing the pain of loss. The task is completed as the patient begins
to feel ―normal‖ again.
 Option D: The anger may also be generalized and undirected, manifesting
as a shorter temper or a loss of patience. Recognizing anger as a natural
response can help health care providers and loved-ones to tolerate what
might otherwise feel like hurtful accusations, though they must take care
not to disregard criticism that may be warranted by attributing them solely
to an emotional stage.
10. Question
Nurses and other healthcare providers often have difficulty helping a terminally ill
patient through the necessary stages leading to acceptance of death. Which of
the following strategies is most helpful to the nurse in achieving this goal?
 A. Taking psychology courses related to gerontology.

 B. Reading books and other literature on the subject of thanatology.
 C. Reflecting on the significance of death.
 D. Reviewing varying cultural beliefs and practices related to death.

Incorrect
Correct Answer: C. Reflecting on the significance of death
According to thanatologists, reflecting on the significance of death helps to
reduce the fear of death and enables the health care provider to better
understand the terminally ill patient‘s feelings. It also helps to overcome the
belief that medical and nursing measures have failed, when a patient cannot be
cured. Thanatology is the science and study of death and dying from multiple
perspectives—medical, physical, psychological, spiritual, ethical, and more.
 Option A: Professionals in a wide range of disciplines use thanatology to
inform their work, from doctors and coroners to hospice workers and grief
counselors. There also are thanatology specialists who focus on a specific
aspect of the dying process or work directly with people facing their own
death or that of loved ones.
 Option B: A wide variety of professionals incorporate thanatology into
their work. How they do so depends on what they need to know about the
dying process. For example, a medical examiner, coroner, doctor, nurse, or
other medical practitioners might study thanatology to better understand
the physical process of death—what happens to the body during death as
well as immediately after.
 Option D: Thanatology also examines attitudes toward death, the meaning
and behaviors of bereavement and grief, and the moral and ethical
questions of euthanasia, organ transplants, and life support.
11. Question
Which of the following symptoms is the best indicator of imminent death?
 A. A weak, slow pulse
 B. Increased muscle tone
 C. Fixed, dilated pupils
 D. Slow, shallow respirations

Incorrect
Correct Answer: C. Fixed, dilated pupils
Fixed, dilated pupils are a sign of imminent death. Death is a part of natural life;
however, society is notorious for being uncomfortable with death and dying as a
topic on the whole. Many caregivers experience a level of burden from their
duties during end-of-life care. This burden is multi-faceted and may include
performing medical tasks, communicating with providers, decision-making and
possibly anticipating the grief of impending loss.
 Option A: Pulse becomes weak but rapid. It is important to identify how to
know death has occurred and to educate the family of a patient who may
be actively dying. This is especially important if the patient is choosing to
die at home.
 Option B: Muscles become weak and atonic. It is imperative that patients
and families have access to the care and support they require when
entering a terminal phase of life. This phase is different for each patient,
and the needs may differ for each patient and family, but it is vital for
healthcare providers to provide care and support in a way that respects the
patient‘s dignity and autonomous wishes.
 Option D: In the late stages, an altered respiratory pattern which can be
periods of apnea alternated with hyperpnea or irregular breathing can be
noticed.
12. Question
A nurse caring for a patient with an infectious disease who requires isolation
should refers to guidelines published by the:
 A. National League for Nursing (NLN)
 B. Centers for Disease Control (CDC)
 C. American Medical Association (AMA)
 D. American Nurses Association (ANA)

Incorrect
Correct Answer: B. Centers for Disease Control (CDC)
The Center of Disease Control (CDC) publishes and frequently updates guidelines
on caring for patients who require isolation. CDC is responsible for controlling the

introduction and spread of infectious diseases, and provides consultation and
assistance to other nations and international agencies to assist in improving their
disease prevention and control, environmental health, and health promotion
activities.
 Option A: The National League of Nursing‘s (NLN‘s) major function is
accrediting nursing education programs in the United States. The NLN, the
premier organization for nurse educators, offers professional development,
teaching resources, research grants, testing services, and public policy
initiatives to its 40,000 individual and 1,200 institutional members,
comprising nursing education programs across higher education and
health care.
 Option C: The American Medical Association (AMA) is a national
organization of physicians. American Medical Association (AMA),
organization of American physicians, the objective of which is ―to promote
the science and art of medicine and the betterment of public health.‖ It was
founded in Philadelphia in 1847 by 250 delegates representing more than
40 medical societies and 28 colleges.
 Option D: The American Nurses‘ Association (ANA) is a national
organization of registered nurses. ANA guides the profession on issues of
nursing practice, health policy, and social concerns that impact patient
wellbeing. Through their position statements, ANA amplifies the voice of
nurses and educates both consumers and policymakers.
13. Question
To institute appropriate isolation precautions, the nurse must first know the:
 A. Organism’s mode of transmission
 B. Organism‘s Gram-staining characteristics
 C. Organism‘s susceptibility to antibiotics
 D. Patient‘s susceptibility to the organism

Incorrect
Correct Answer: A. Organism’s mode of transmission
Before instituting isolation precaution, the nurse must first determine the
organism‘s mode of transmission. For example, an organism transmitted through

nasal secretions requires that the patient be kept in respiratory isolation, which
involves keeping the patient in a private room with the door closed and wearing
a mask, a gown, and gloves when coming in direct contact with the patient.
 Option B: The organism‘s Gram-staining characteristics reveal whether the
organism is gram-negative or gram-positive, an important criterion in the
physician‘s choice for drug therapy and the nurse‘s development of an
effective plan of care.
 Option C: The nurse also needs to know whether the organism is
susceptible to antibiotics, but this could take several days to determine; if
she waits for the results before instituting isolation precautions, the
organism could be transmitted in the meantime.
 Option D: The patient‘s susceptibility to the organism has already been
established. The nurse would not be instituting isolation precautions for a
non-infected patient.
14. Question
Which is the correct procedure for collecting a sputum specimen for culture and
sensitivity testing?
 A. Have the patient place the specimen in a container and enclose the
container in a plastic bag.
 B. Have the patient expectorate the sputum while the nurse holds the
container.
 C. Have the patient expectorate the sputum into a sterile container.
 D. Offer the patient an antiseptic mouthwash just before he expectorate the

sputum.
Incorrect
Correct Answer: C. Have the patient expectorate the sputum into a sterile
container
Placing the specimen in a sterile container ensures that it will not become
contaminated. A sputum specimen is obtained for culture to identify the
microorganism responsible for lung infections; identify cancer cells shed by lung
tumors; or aid in the diagnosis and management of occupational lung diseases.
The other answers are incorrect because they do not mention sterility and

because antiseptic mouthwash could destroy the organism to be cultured (before
sputum collection, the patient may use only tap water for nursing the mouth).
 Option A: Using the sterile collection container provided, instruct the
patient to take three deep breaths, then force a deep cough and
expectorate into a sterile screw-top container. To prevent contamination by
particles in the air, keep the container closed until the patient is ready to
spit into it.
 Option B: Ten to 15 ml of sputum is typically needed for laboratory
analysis. A specimen will be rejected by the laboratory if it contains
excessive numbers of epithelial cells from the mouth or throat or if it fails
to show adequate numbers of neutrophils on gram staining. If the patient
cannot cough up a specimen, the respiratory therapist can use sputum
induction techniques such as heated aerosol (nebulization), followed in
some instances by postural drainage and percussion.
 Option D: Don‘t allow the patient to brush his teeth or use mouthwash.
Doing so could kill bacteria in the sputum, rendering it useless. For best
results, obtain the sample first thing in the morning. If it can‘t be obtained
before the patient has breakfast, though, wait at least an hour after he‘s
eaten before trying. Before beginning, describe the procedure to him.
15. Question
An autoclave is used to sterilize hospital supplies because:
 A. More articles can be sterilized at a time.
 B. Steam causes less damage to the materials.
 C. A lower temperature can be obtained.
 D. Pressurized steam penetrates the supplies better.

Incorrect
Correct Answer: D. Pressurized steam penetrates the supplies better.
An autoclave, an apparatus that sterilizes equipment by means of high-
temperature pressurized steam, is used because it can destroy all forms of
microorganisms, including spores. Autoclaves operate at high temperature and
pressure in order to kill microorganisms and spores. They are used to

decontaminate certain biological waste and sterilize media, instruments, and
labware.
 Option A: Autoclaves provide a physical method for disinfection and
sterilization. They work with a combination of steam, pressure, and time.
Autoclaves operate at high temperature and pressure in order to kill
microorganisms and spores. They are used to decontaminate certain
biological waste and sterilize media, instruments and lab ware. Regulated
medical waste that might contain bacteria, viruses and other biological
material are recommended to be inactivated by autoclaving before
disposal.
 Option B: The rate of exhaust will depend upon the nature of the load. Dry
material can be treated in a fast exhaust cycle, while liquids and biological
waste require slow exhaust to prevent boiling over of superheated liquids.
 Option C: To be effective, the autoclave must reach and maintain a
temperature of 121° C for at least 30 minutes by using saturated steam
under at least 15 psi of pressure. Increased cycle time may be necessary
depending upon the make-up and volume of the load.
16. Question
The best way to decrease the risk of transferring pathogens to a patient when
removing contaminated gloves is to:
 A. Wash the gloves before removing them.
 B. Gently pull on the fingers of the gloves when removing them.
 C. Gently pull just below the cuff and invert the gloves when removing
them.
 D. Remove the gloves and then turn them inside out.

Incorrect
Correct Answer: C. Gently pull just below the cuff and invert the gloves
when removing them
Turning the gloves inside out while removing them keeps all contaminants inside
the gloves. They should then be placed in a plastic bag with soiled dressings and
discarded in a soiled utility room garbage pail (double bagged). The other
choices can spread pathogens within the environment.

 Option A: They should also only be worn once, being changed between
patients or between treatment areas on the same patient. For situations
where there is a high risk of contamination or infection, NHS Professionals
advise wearing two sets of gloves, known as ‗double gloving‘.
 Option B: Grasp the outside of one glove at the wrist. Do not touch the
bare skin. Peel the glove away from the body, pulling it inside out. Hold the
glove that was just removed in a gloved hand.
 Option D: Peel off the second glove by putting the fingers inside the glove
at the top of the wrist. Turn the second glove inside out while pulling it
away from the body, leaving the first glove inside the second.
17. Question
After having an I.V. line in place for 72 hours, a patient complains of tenderness,
burning, and swelling. Assessment of the I.V. site reveals that it is warm and
erythematous. This usually indicates:
 A. Infection
 B. Infiltration
 C. Phlebitis
 D. Bleeding
Incorrect
Correct Answer: C. Phlebitis
Tenderness, warmth, swelling, and, in some instances, a burning sensation are
signs and symptoms of phlebitis. Superficial phlebitis affects veins on the skin
surface. The condition is rarely serious and, with proper care, usually resolves
rapidly. Sometimes people with superficial phlebitis also get deep vein
thrombophlebitis, so a medical evaluation is necessary.
 Option A: Infection is less likely because no drainage or fever is present.
Call a health care provider if there are signs and symptoms of swelling,
pain, and inflamed superficial veins on the arms or legs. If the client is not
better in a week or two or if it gets any worse, he or she should get
reevaluated to make sure they don‘t have a more serious condition.

 Option B: Infiltration would result in swelling and pallor, not erythema,
near the insertion site. In phlebitis, there is usually a slow onset of a tender
red area along the superficial veins on the skin. A long, thin red area may
be seen as the inflammation follows a superficial vein. This area may feel
hard, warm, and tender. The skin around the vein may be itchy and swollen.
The area may begin to throb or burn.
 Option D: The patient has no evidence of bleeding. Injury to a vein
increases the risk of forming a blood clot. Sometimes clots occur without
an injury.
18. Question
To ensure homogenization when diluting powdered medication in a vial, the
nurse should:
 A. Shake the vial vigorously.
 B. Roll the vial gently between the palms.
 C. Invert the vial and let it stand for 1 minute.
 D. Do nothing after adding the solution to the vial.

Incorrect
Correct Answer: B. Roll the vial gently between the palms.
Gently rolling a sealed vial between the palms produces sufficient heat to
enhance dissolution of a powdered medication.
 Option A: Shaking the vial vigorously can break down the medication and
alter its pharmacologic action.
 Option C: Inverting the vial or leaving it alone does not ensure thorough
homogenization of the powder and the solvent.
 Option D: Use aseptic technique to draw up the specified amount of
diluent and inject it into the medication vial. Roll the vial in the hands to
dissolve all the powder (emphasize not to shake the vial).
19. Question
The nurse is teaching a patient to prepare a syringe with 40 units of U-100 NPH
insulin for self-injection. The patient‘s first priority concerning self-injection in
this situation is to:

 A. Assess the injection site.
 B. Select the appropriate injection site.
 C. Check the syringe to verify that the nurse has removed the prescribed
insulin dose.
 D. Clean the injection site in a circular manner with an alcohol sponge.

Incorrect
Correct Answer: C. Check the syringe to verify that the nurse has removed
the prescribed insulin dose
When the nurse teaches the patient to prepare an insulin injection, the patient‘s
first priority is to validate the dose accuracy. The next steps are to select the site,
assess the site, and clean the site with alcohol before injecting the insulin.
 Option A: The site the client chooses for the injection should be clean and
dry. If the skin is visibly dirty, clean it with soap and water. DO NOT use an
alcohol wipe on the injection site. Choose where to give the injection. Keep
a chart of places that have been used, so the client does not inject the
insulin in the same place all the time. Ask the doctor for a chart.
 Option B: The insulin needs to go into the fat layer under the skin. If the
skin tissues are thicker, the client may be able to inject straight up and
down (90º angle). Check with the provider before doing this.
 Option D: To give an insulin injection, the client needs to fill the right
syringe with the right amount of medicine, decide where to give the
injection, and know how to give the injection.
20. Question
The physician‘s order reads ―Administer 1 g cefazolin sodium (Ancef) in 150 ml of
normal saline solution in 60 minutes.‖ What is the flow rate if the drop factor is 10
gtt = 1 ml?
 A. 25 gtt/minute
 B. 37 gtt/minute
 C. 50 gtt/minute
 D. 60 gtt/minute

Incorrect
Correct Answer: A. 25 gtt/minute
When you have an order for an IV infusion, it is the nurse‘s responsibility to make
sure the fluid will infuse at the prescribed rate. IV fluids may be infused by gravity
using a manual roller clamp or dial-a-flow, or infused using an infusion pump.
Regardless of the method, it is important to know how to calculate the correct IV
flow rate.
 Option B: When calculating the flow rate, determine which IV tubing you
 Option C: Macrodrip and microdrip refers to the diameter of the needle
 Option D: If you simply need to figure out the mL per hour to infuse, take
the total volume in mL, divided by the total time in hours, to equal the mL
per hour.
21. Question
A patient must receive 50 units of Humulin regular insulin. The label reads 100
units = 1 ml. How many milliliters should the nurse administer?
 A. 0.5 ml
 B. 0.75 ml
 C. 1 ml
 D. 2 ml
Incorrect
Correct Answer: A. 0.5 ml
There are 3 primary methods for calculation of medication dosages; Dimensional
Analysis, Ratio Proportion, and Formula or Desired Over Have Method. Desired
Over Have or Formula Method uses a formula or equation to solve for an
unknown quantity (x) much like ratio proportion.

 Option B: Drug calculations require the use of conversion factors, for
adding.
 Option D: High-risk medications such as heparin and insulin often require
a second check on dosage amounts by more than one provider before the
administration of the drug. Follow institutional policies and
recommendations on the double-checking of dose calculations by another
licensed provider.
22. Question
How should the nurse prepare an injection for a patient who takes both regular
and NPH insulin?
 A. Draw up the NPH insulin, then the regular insulin, in the same syringe.
 B. Draw up the regular insulin, then the NPH insulin, in the same
syringe.
 C. Use two separate syringes.
 D. Check with the physician.

Incorrect
Correct Answer: B. Draw up the regular insulin, then the NPH insulin, in the
same syringe.
Drugs that are compatible may be mixed together in one syringe. In the case of
insulin, the shorter-acting, clear insulin (regular) should be drawn up before the
longer-acting, cloudy insulin (NPH) to ensure accurate measurements.

 Option A: Insulin, regular when administered subcutaneously, it should be
injected 30 to 40 minutes before each meal. Avoid cold injections. The
injection is in the buttocks, thighs, arms, or abdomen; it is necessary to
rotate injection sites to avoid lipodystrophy. Do not inject if the solution is
viscous or cloudy; use only if clear and colorless.
 Option C: When administered intravenously, U-100 administration should
be with close monitoring of serum potassium and blood glucose. Do not
use if the solution is viscous or cloudy; administration should only take
place if it is colorless and clear.
 Option D: For intravenous infusions, to minimize insulin adsorption to
plastic IV tubing, flush the intravenous tube with priming infusion of 20 mL
from a 100 mL-polyvinyl chloride bag insulin, every time a new intravenous
tubing is added to the insulin infusion container.
23. Question
A patient has just received 30 mg of codeine by mouth for pain. Five minutes
later he vomits. What should the nurse do first?
 A. Call the physician
 B. Remedicate the patient
 C. Observe the emesis
 D. Explain to the patient that she can do nothing to help him.

Incorrect
Correct Answer: C. Observe the emesis.
After a patient has vomited, the nurse must inspect the emesis to document
color, consistency, and amount. Nausea or vomiting is another commonly seen
adverse effect that is expected to diminish the following days to weeks of
continued codeine exposure. Antiemetic therapies, in oral and rectal
formulations, are available for the treatment of nausea or vomiting.
 Option A: The nurse must then notify the physician, who will decide
whether to repeat the dose or prescribe an antiemetic. Monitoring should
include subjective as well as objective assessment via laboratory testing.
There must be documentation of pain intensity, level of functioning,

progress toward therapeutic goals, the presence of adverse effects, and
adherence to the therapy.
 Option B: In this situation, the patient recently ingested medication, so the
nurse needs to check for remnants of the medication to help determine
whether the patient retained enough of it to be effective.
 Option D: Codeine has a half-life of 3 hours. Initial dosing and titration can
be individualized depending on the patient‘s health status, previous opioid
exposure, attainment of therapeutic outcomes, and predicted or observed
adverse events.
24. Question
A patient is catheterized with a #16 indwelling urinary (Foley) catheter to
determine if:
 A. Trauma has occurred.
 B. His 24-hour output is adequate.
 C. He has a urinary tract infection.
 D. Residual urine remains in the bladder after voiding.

Incorrect
Correct Answer: B. His 24-hour output is adequate.
A 24-hour urine output of less than 500 ml in an adult is considered inadequate
and may indicate kidney failure. This must be corrected while the patient is in the
acute state so that appropriate fluids, electrolytes, and medications can be
administered and excreted. Indwelling catheterization is not needed to diagnose
trauma, urinary tract infection, or residual urine.
 Option A: Urinary bladder catheterization is performed for both
therapeutic and diagnostic purposes. Based on the dwell time, the urinary
catheter can be either intermittent (short-term) or indwelling (long-term).
 Option C: Cystitis, urethritis, prostatitis (common infectious etiology in
men), and vulvovaginitis in the woman can cause urinary retention.
 Option D: Brain or spinal cord injury, cerebrovascular accident, multiple
sclerosis, Parkinson disease, and dementia can lead to urinary retention.
25. Question

A staff nurse who is promoted to assistant nurse manager may feel
uncomfortable initially when supervising her former peers. She can best decrease
this discomfort by:
 A. Writing down all assignments.
 B. Making changes after evaluating the situation and having discussions

with the staff.
 C. Telling the staff nurses that she is making changes to benefit their
performance.
 D. Evaluating the clinical performance of each staff nurse in a private

conference.
Incorrect
Correct Answer: B. Making changes after evaluating the situation and
having discussions with the staff.
A new assistant nurse manager should not make changes until she has had a
chance to evaluate staff members, patients, and physicians. Changes must be
planned thoroughly and should be based on a need to improve conditions, not
just for the sake of change.
 Option A: Written assignments allow all staff members to know their own
and others‘ responsibilities and serve as a checklist for the manager,
enabling her to gauge whether the unit is being run effectively and
whether patients are receiving appropriate care.
 Option C: Telling the staff nurses that she is making changes to benefit
their performance should occur only after the nurse has made a thorough
evaluation.
 Option D: Evaluations are usually done on a yearly basis or as needed.
26. Question
Nurse Clarisse is teaching a patient about a newly prescribed drug. What could
cause a geriatric patient to have difficulty retaining knowledge about prescribed
medications?
 A. Decreased plasma drug levels
 B. Sensory deficits

 C. Lack of family support
 D. History of Tourette syndrome

Incorrect
Correct Answer: B. Sensory deficits
Sensory deficits could cause a geriatric patient to have difficulty retaining
knowledge about prescribed medications. Age-related decline of the five classical
senses (vision, smell, hearing, touch, and taste) poses significant burdens on older
adults. The co-occurrence of multiple sensory deficits in older adults is not well
characterized and may reflect a common mechanism resulting in global sensory
impairment.
 Option A: Decreased plasma drug levels do not alter the patient‘s
knowledge about the drug. Aging has long been associated with decline in
sensory function, a critical component of the health and quality of life of
older people
 Option C: A lack of family support may affect compliance, not knowledge
retention. Vision impairment is correlated with depression, poor quality of
life, cognitive decline, and mortality. Hearing loss is associated with slower
gait speed (a marker of physical decline), poor cognition, and mortality.
Like smell, taste has been associated with nutritional compromise and in-
patient mortality, suggesting that chemosensory function is critical. Tactile
discrimination declines with age due to the cumulative effects of decreased
nerve conduction velocity, decreased density of Meissner‘s and Pacinian
corpuscles, and gray matter changes within the central nervous system,
and is also associated with cognitive decline
 Option D: Tourette syndrome is unrelated to knowledge retention.
Tourette syndrome referred to as Tourette disorder in the recently updated
Diagnostic and Statistical Manual of Mental Disorders (DSM–5), is a
common neurodevelopmental disorder affecting up to 1% of the
population. It is characterized by multiple motor and vocal tics and starts in
childhood.
27. Question
When examining a patient with abdominal pain the nurse in charge should
assess:

 A. Any quadrant first
 B. The symptomatic quadrant first
 C. The symptomatic quadrant last
 D. The symptomatic quadrant either second or third

Incorrect
Correct Answer: C. The symptomatic quadrant last
The nurse should systematically assess all areas of the abdomen, if time and the
patient‘s condition permit, concluding with the symptomatic area. Otherwise, the
nurse may elicit pain in the symptomatic area, causing the muscles in other areas
to tighten. This would interfere with further assessment.
 Option A: When possible, the history should be obtained from a non
sedated patient. The initial differential diagnosis can be determined by a
delineation of the pain‘s location, radiation, and movement (e.g.,
appendicitis-associated pain usually moves from the periumbilical area to
the right lower quadrant of the abdomen).
 Option B: After the location is identified, the physician should obtain
general information about onset, duration, severity, and quality of pain and
about exacerbating and remitting factors.
 Option D: There are several specialized maneuvers that evaluate for signs
associated with causes of abdominal pain. When present, some signs are
highly predictive of certain diseases.
28. Question
The nurse is assessing a postoperative adult patient. Which of the following
should the nurse document as subjective data?
 A. Vital signs
 B. Laboratory test result
 C. Patient’s description of pain
 D. Electrocardiographic (ECG) waveforms

Incorrect
Correct Answer: C. Patient’s description of pain

Subjective data come directly from the patient and usually are recorded as direct
quotations that reflect the patient‘s opinions or feelings about a situation.
Subjective data provide clues to possible physiologic, psychological, and
sociologic problems. They also provide the nurse with information that may
reveal a client‘s risk for a problem as well as areas of strengths for the client. The
information is obtained through interviewing. Vital signs, laboratory test results,
and ECG waveforms are examples of objective data.
 Option A: Vital sign monitoring is a fundamental component of nursing
care. A patient‘s pulse, respirations, blood pressure, and body temperature
are essential in identifying clinical deterioration and that these parameters
must be measured consistently and recorded accurately.
 Option B: Many other tests are reported as numbers or values. Laboratory
test results reported as numbers are not meaningful by themselves. Their
meaning comes from comparison to reference values. Reference values are
the values expected for a healthy person. They are sometimes called
―normal‖ values.
 Option D: The standard 12-lead electrocardiogram (ECG) is one of the
most commonly used medical studies in the assessment of cardiovascular
disease. It is the most important test for interpretation of the cardiac
rhythm, detection of myocardial ischemia and infarction, conduction
system abnormalities, preexcitation, long QT syndromes, atrial
abnormalities, ventricular hypertrophy, pericarditis, and other conditions.
29. Question
A male patient has a soft wrist-safety device. Which assessment finding should
the nurse consider abnormal?
 A. A palpable radial pulse
 B. A palpable ulnar pulse
 C. Cool, pale fingers
 D. Pink nail beds

Incorrect
Correct Answer: C. Cool, pale fingers

A safety device on the wrist may impair circulation and restrict blood supply to
body tissues. Therefore, the nurse should assess the patient for signs of impaired
circulation, such as cool, pale fingers. A palpable radial or lunar pulse and pink
nail beds are normal findings.
 Option A: To palpate a radial pulse, place the tips of the first two or three
fingers over the groove along the radial (or thumb) side of the patient‘s
inner wrist. Slightly extended or flexed the patient‘s wrist with the palm
down until the pulse was strongest. Lightly compressed the artery against
the radius, obliterating the pulse initially.
 Option B: The pulse is felt just above a large, raised bony area called the
zygomatic arch. Like the radial pulse, the ulnar pulse is taken at the wrist.
 Option D: These old cells flatten and harden, thanks to keratin, a protein
made by these cells. The newly formed nail then slides along the nail bed,
the flat surface under the nails. The nail bed sits on top of tiny blood
vessels that feed it and give the nails their pink color.
30. Question
Which of the following planes divides the body longitudinally into anterior and
posterior regions?
 A. Frontal plane
 B. Sagittal plane
 C. Midsagittal plane
 D. Transverse plane
Incorrect
Correct Answer: A. Frontal plane
Frontal or coronal plane runs longitudinally at a right angle to a sagittal plane
dividing the body in anterior and posterior regions. The coronal plane or frontal
plane (vertical) divides the body into dorsal and ventral (back and front, or
posterior and anterior) portions. An anatomical plane is a hypothetical plane used
to transect the body, in order to describe the location of structures or the
direction of movements.
 Option B: A sagittal plane runs longitudinally dividing the body into right
and left regions. The sagittal plane or lateral plane (longitudinal,

anteroposterior) is a plane parallel to the sagittal suture. It divides the body
into left and right.
 Option C: If exactly midline, it is called a midsagittal plane. The midsagittal
or median plane is in the midline; i.e. it would pass through midline
structures such as the navel or spine, and all other sagittal planes (also
referred to as parasagittal planes) are parallel to it. Median can also refer to
the midsagittal plane of other structures, such as a digit.
 Option D: A transverse plane runs horizontally at a right angle to the
vertical axis, dividing the structure into superior and inferior regions. The
transverse plane or axial plane (horizontal) divides the body into cranial
and ca
31. Question
A female patient with a terminal illness is in denial. Indicators of denial include:
 A. Shock dismay
 B. Numbness
 C. Stoicism
 D. Preparatory grief
Incorrect
Correct Answer: A. Shock dismay
Shock and dismay are early signs of denial-the first stage of grief. Denial is a
common defense mechanism used to protect oneself from the hardship of
considering an upsetting reality. Kubler-Ross noted that after the initial shock of
receiving a terminal diagnosis, patients would often reject the reality of the new
information. The other options are associated with depression—a later stage of
grief.
 Option B: Depression is perhaps the most immediately understandable of
Kubler-Ross‘s stages and patients experience it with unsurprising
symptoms such as sadness, fatigue, and anhedonia.
 Option C: Spending time in the first three stages is potentially an
unconscious effort to protect oneself from this emotional pain, and, while
the patient‘s actions may potentially be easier to understand, they may be

more jarring in juxtaposition to behaviors arising from the first three
stages.
 Option D: Consequently, caregivers may need to make a conscious effort
to restore compassion that may have waned while caring for patients
progressing through the first three stages.
32. Question
The nurse in charge is transferring a patient from the bed to a chair. Which action
does the nurse take during this patient transfer?
 A. Position the head of the bed flat.
 B. Helps the patient dangle the legs.
 C. Stands behind the patient.
 D. Place the chair facing away from the bed.

Incorrect
Correct Answer: B. Helps the patient dangle the legs
After placing the patient in High Fowler‘s position and moving the patient to the
side of the bed, the nurse helps the patient sit on the edge of the bed and dangle
the legs; the nurse then faces the patient and places the chair next to and facing
the head of the bed.
 Option A: Allow the patient to sit for a few moments, in case the patient
feels dizzy when first sitting up. To get the patient into a seated position,
roll the patient onto the same side as the wheelchair.
 Option C: The nurse should put one arm under the patient‘s shoulders and
one behind the knees. Bend the knees. Swing the patient‘s feet off the
edge of the bed and use the momentum to help the patient into a sitting
position.
 Option D: Move the patient to the edge of the bed and lower the bed so
the patient‘s feet are touching the ground. Make sure any loose rugs are
out of the way to prevent slipping. You may want to put non-skid socks or
shoes on the patient‘s feet if the patient needs to step onto a slippery
surface.
2. 33. Question

A female patient who speaks a little English has emergency gallbladder surgery,
during discharge preparation, which nursing action would best help this patient
understand wound care instruction?
o A. Asking frequently if the patient understands the instruction.
o B. Asking an interpreter to replay the instructions to the patient.
o C. Writing out the instructions and having a family member read them to the
patient.
o D. Demonstrating the procedure and having the patient return the

demonstration.
Incorrect
Correct Answer: D. Demonstrating the procedure and having the patient
return the demonstration
Demonstrating by the nurse with a return demonstration by the patient ensures
that the patient can perform wound care correctly. One of the leading causes of
medical errors in the United States is miscommunication between patients and
providers. When patients with limited English proficiency (LEP) cannot adequately
communicate their needs, they are less likely to comply with medical instructions
and receive vital services.
 Option A: Patients may claim to understand discharge instruction when
they do not. In-person translation services are preferred when complex
medical information or end-of-life decisions are to be discussed. Studies
show in-person professional interpretation increases patient satisfaction
and outcomes of care. Interpreters use visual cues to enhance
communication. However, in-person interpreters can be costly and can
limit the number of languages that can be adequately staffed.
 Option B: An interpreter of family members may communicate verbal or
written instructions inaccurately. In some cases, patients prefer to use their
family and friends as medical interpreters, but experts recommend against
the practice because vital information may be lost.
 Option C: Internet-based apps for smartphones and tablets help medical
professionals interpret information quickly so they can be used in
emergency settings. Experts warn, however, that the one-sided nature of
such applications can lead to missed or misconstrued information.

ADV
34. Question
Before administering the evening dose of a prescribed medication, the nurse on
the evening shift finds an unlabeled, filled syringe in the patient‘s medication
drawer. What should the nurse in charge do?
o A. Discard the syringe to avoid a medication error.
o B. Obtain a label for the syringe from the pharmacy.
o C. Use the syringe because it looks like it contains the same medication the
nurse was prepared to give.
o D. Call the day nurse to verify the contents of the syringe.

Incorrect
Correct Answer: A. Discard the syringe to avoid a medication error.
As a safety precaution, the nurse should discard an unlabeled syringe that
contains medication. The other options are considered unsafe because they
promote error.
 Option B: Since there are no labels on the syringe, obtaining a label from
the pharmacy does not guarantee that they would be able to identify the
medication inside the syringe.
 Option C: Giving an unidentified medication could cause unwanted effects
on the patient instead of desired effects.
 Option D: The day nurse would not be able to guarantee that she could
identify the medication without its label.
ADV
35. Question
When administering drug therapy to a male geriatric patient, the nurse must stay
especially alert for adverse effects. Which factor makes geriatric patients have
adverse drug effects?
o A. Faster drug clearance

o B. Aging-related physiological changes
o C. Increased amount of neurons
o D. Enhanced blood flow to the GI tract

Incorrect
Correct Answer: B. Aging-related physiological changes
Aging-related physiological changes account for the increased frequency of
adverse drug reactions in geriatric patients. ADEs are estimated to be indicated in
5% to 28% of acute geriatric medical admissions. Preventable ADEs are among
one of the serious consequences of inappropriate medication use in older adults.
 Option A: Renal and hepatic changes cause drugs to clear more slowly in
these patients. Aging leads to a reduced number of functional glomeruli
and an increased prevalence of sclerotic changes within the glomeruli or
renal vasculature. Additionally, there is a normal decrease in GFR observed
in advanced age, but this places the elderly at much higher risk for
complications in the event that they develop chronic or acute kidney
disease, as they have less functional glomeruli as a result of normal aging
physiology.
 Option C: With increasing age, neurons are lost. Abnormal compensatory
mechanisms predispose individuals to neurodegeneration and dementia,
Parkinson disease, and overall cerebral atrophy are observable in aging
individuals.
 Option D: Blood flow to the GI tract decreases. The weakening of smooth
muscle in the intestinal tract can promote the development of diverticular
disease and can play a role in bowel obstructions or constipation.
Decreased metabolic activity, specifically in the liver, can lead to alterations
in drug metabolism.
ADV
36. Question
A female patient is being discharged after cataract surgery. After providing
medication teaching, the nurse asks the patient to repeat the instructions. The
nurse is performing which professional role?

o A. Manager
o B. Educator
o C. Caregiver
o D. Patient advocate
Incorrect
Correct Answer: B. Educator
When teaching a patient about medications before discharge, the nurse is acting
as an educator. They provide educational leadership to patients and care
providers to enhance specialized patient care within established healthcare
settings. Assists patients and caregivers with educational needs, problem
resolution, and health management across the continuum of care.
 Option A: The nurse acts as a manager when performing such activities as
scheduling and making patient care assignments. Great nurse managers
are able to work in coordination with other departments. They must also
possess the ability to oversee an array of practice functions including staff
supervision, clinical tasks, and appointments. It is also part of their jobs to
liaise with pathology labs, suppliers, and other health facilities.
 Option C: The nurse performs the caregiving role when providing direct
care, including bathing patients and administering medications and
prescribed treatments. Healthcare should address a patient‘s cultural,
spiritual and mental needs. Increasing diversity in a growing patient
population requires nurses to demonstrate cultural awareness and
sensitivity. Patients may have specific needs and preferences due to their
religion or gender, for example. Nurses need to be respectful of, and
knowledgeable about, diverse backgrounds while remaining vigilant in
providing quality care.
 Option D: The nurse acts as a patient advocate when making the patient‘s
wishes known to the doctor. A nurse advocate is a nurse who works on
behalf of patients to maintain quality of care and protect patients‘ rights.
They intervene when there is a care concern, and following the proper
channels, work to resolve any patient care issues. Realistically, every nurse
is an advocate.
ADV

37. Question
A female patient exhibits signs of heightened anxiety. Which response by the
nurse is most likely to reduce the patient‘s anxiety?
o A. ―Everything will be fine. Don‘t worry.‖
o B. ―Read this manual and then ask me any questions you may have.‖
o C. ―Why don‘t you listen to the radio?‖
o D. “Let’s talk about what’s bothering you.”

Incorrect
Correct Answer: D. “Let’s talk about what’s bothering you.”
Anxiety may result from feelings of helplessness, isolation, or insecurity. This
response helps reduce anxiety by encouraging the patient to express feelings.
The nurse should be supportive and develop goals together with the patient to
give the patient some control over an anxiety-inducing situation. Because the
other options ignore the patient‘s feelings and block communication, they would
not reduce anxiety.
 Option A: Recognize awareness of the patient‘s anxiety. Since a cause of
anxiety cannot always be identified, the patient may feel as though the
feelings being experienced are counterfeit. Acknowledgment of the
patient‘s feelings validates the feelings and communicates acceptance of
those feelings.
 Option B: Converse using a simple language and brief statements. Allow
patients to talk about anxious feelings and examine anxiety-provoking
situations if they are identifiable. Talking about anxiety-producing
situations and anxious feelings can help the patient perceive the situation
realistically and recognize factors leading to the anxious feelings.
 Option C: Assist the patient in developing new anxiety-reducing skills (e.g.,
relaxation, deep breathing, positive visualization, and reassuring self-
statements). Discovering new coping methods provides the patient with a
variety of ways to manage anxiety.
ADV
38. Question

A scrub nurse in the operating room has which responsibility?
o A. Positioning the patient
o B. Assisting with gowning and gloving
o C. Handling surgical instruments to the surgeon
o D. Applying surgical drapes

Incorrect
Correct Answer: C. Handling surgical instruments to the surgeon
The scrub nurse assists the surgeon by providing appropriate surgical
instruments and supplies, maintaining strict surgical asepsis and, with the
circulating nurse, accounting for all gauze, sponges, needles, and instruments.
The circulating nurse assists the surgeon and scrub nurse, positions the patient,
applies appropriate equipment and surgical drapes, assists with gowning and
gloving, and provides the surgeon and scrub nurse with supplies.
 Option A: The circulating nurse is responsible for managing all nursing
care within the operating room, observing the surgical team from a broad
perspective, and assisting the team to create and maintain a safe,
comfortable environment for the patient‘s surgery.
 Option B: A circulating nurse is responsible for coordinating care,
obtaining supplies, and liaising with the patient‘s family.
 Option D: Assessing the patient right before surgery is critical to making
sure that all required prep was completed. Serving as a patient advocate
and safety monitor, the circulating nurse observes the surgery and ensures
that no aspect of patient care is missed.
ADV
39. Question
A patient is in the bathroom when the nurse enters to give a prescribed
medication. What should the nurse in charge do?
o A. Leave the medication at the patient‘s bedside.

o B. Tell the patient to be sure to take the medication. And then leave it at the
bedside.
o C. Return shortly to the patient’s room and remain there until the
patient takes the medication.
o D. Wait for the patient to return to bed, and then leave the medication at the
bedside.
Incorrect
Correct Answer: C. Return shortly to the patient’s room and remain there
until the patient takes the medication
The nurse should return shortly to the patient‘s room and remain there until the
patient takes the medication to verify that it was taken as directed. With the
growing reliance on medication therapy as the primary intervention for most
illnesses, patients receiving medication interventions are exposed to potential
harm as well as benefits. Benefits are effective management of the illness/disease,
slowed progression of the disease, and improved patient outcomes with few if
any errors. Harm from medications can arise from unintended consequences as
well as medication error (wrong medication, wrong time, wrong dose, etc.).
 Option A: The nurse should never leave medication at the patient‘s
bedside unless specifically requested to do so.
 Option B: With inadequate nursing education about patient safety and
quality, excessive workloads, staffing inadequacies, fatigue, illegible
provider handwriting, flawed dispensing systems, and problems with the
labeling of drugs, nurses are continually challenged to ensure that their
patients receive the right medication at the right time.
 Option D: Examples of errors that can be initiated at the transcribing,
dispensing, and delivering stages include failure to transcribe the order,
incorrectly filling the order, and failure to deliver the correct medication for
the correct patient.
ADV
40. Question
The physician orders heparin, 7,500 units, to be administered subcutaneously
every 6 hours. The vial reads 10,000 units per milliliter. The nurse should
anticipate giving how much heparin for each dose?

o A. ¼ ml
o B. ½ ml
o C. ¾ ml
o D. 1 ¼ ml
Incorrect
Correct Answer: C. ¾ ml
The nurse solves the problem as follows:
10,000 units/7,500 units = 1 ml/X
10,000 X = 7,500
X= 7,500/10,000 or ¾ ml
Formula, Dimensional Analysis and Ratio and Proportion.
triple check.
adding.
ADV
41. Question
The nurse in charge measures a patient‘s temperature at 102 degrees F. what is
the equivalent Centigrade temperature?

o A. 39 degrees C
o B. 47 degrees C
o C. 38.9 degrees C
o D. 40.1 degrees C
Incorrect
Correct Answer: C. 38.9 degrees C
To convert Fahrenheit degrees to centigrade, use this formula:
C degrees = (F degrees – 32) x 5/9
C degrees = (102 – 32) 5/9
+ 70 x 5/9
38.9 degrees C
 Option A: Fahrenheit and Celsius both use different temperatures for the
freezing and boiling points of water, and also use differently sized degrees.
Water freezes at 0 degrees Celsius, and boils at 100 degrees C, while in
Fahrenheit, water freezes at 32 degrees F and boils at 212 degrees F.
 Option B: Use the relationship in degree size to convert between Celsius
and Fahrenheit. Because Celsius degrees are larger than those in
Fahrenheit, to convert from Celsius to Fahrenheit, multiply the Celsius
temperature by 1.8, then add 32.
 Option D: The Fahrenheit and Celsius scales are the two most common
temperature scales. However, the two scales use different measurements
for the freezing and boiling points of water, and also use different sized
degrees.
ADV
42. Question
To evaluate a patient for hypoxia, the physician is most likely to order which
laboratory test?
o A. Red blood cell count
o B. Sputum culture
o C. Total hemoglobin

o D. Arterial blood gas (ABG) analysis
Incorrect
Correct Answer: D. Arterial blood gas (ABG) analysis
All of these tests help evaluate a patient with respiratory problems. However, ABG
analysis is the only test that evaluates gas exchange in the lungs, providing
information about a patient‘s oxygenation status. An acceptable normal range of
ABG values of ABG components are the following,[5][6] noting that the range of
normal values may vary among laboratories, and in different age groups from
neonates to geriatrics: pH (7.35-7.45) PaO2 (75-100 mmHg) PaCO2 (35-45
mmHg).
 Option A: A red blood cell count is a blood test that the doctor uses to
find out how many red blood cells (RBCs) a person has. It‘s also known as
an erythrocyte count. The test is important because RBCs contain
hemoglobin, which carries oxygen to the body‘s tissues. The number of
RBCs one has can affect how much oxygen the tissues receive. The tissues
need oxygen to function.
type of organism that may be causing an infection in the lungs or the
of mucus made in the lungs.
 Option C: The normal range for hemoglobin is: For men, 13.5 to 17.5
grams per deciliter. For women, 12.0 to 15.5 grams per deciliter.
ADV
43. Question
The nurse uses a stethoscope to auscultate a male patient‘s chest. Which
statement about a stethoscope with a bell and diaphragm is true?
o A. The bell detects high-pitched sounds best.
o B. The diaphragm detects high-pitched sounds best.
o C. The bell detects thrills best.
o D. The diaphragm detects low-pitched sounds best.

Incorrect
Correct Answer: B. The diaphragm detects high-pitched sounds best.
The diaphragm of a stethoscope detects high-pitched sound best; the bell
detects low pitched sounds best. Palpation detects thrills best. The bell is flat and
round and is covered by a thin layer of plastic known as the diaphragm. The
diaphragm vibrates as sound is produced within the body. These vibrations travel
from the bell, up the hollow tube which splits into two, and into hollow earpieces
to be heard as sound by the medical professional.
 Option A: The smaller or other part of the resonator is called a bell. It is
made up of hollow pieces of metal that help at picking up low-frequency
sounds.
 Option C: Whenever a medical practitioner places a stethoscope
diaphragm on a chest of a patient, vibration will occur at the flat surface of
the stethoscope which is a result of sound waves that is being generated
from the patient‘s body. The vibration picked by the diaphragm is being
protected externally in other to prevent sound loss and thereby channeled
through the tube to a specific direction.
 Option D: The diaphragm is the lower part of the chest piece. It is a flat
metallic disc surrounded by chill rings which enable it to pick a very high
pitch sound.
ADV
44. Question
A male patient is to be discharged with a prescription for an analgesic that is a
controlled substance. During discharge teaching, the nurse should explain that
the patient must fill this prescription how soon after the date on which it was
written?
o A. Within 1 month
o B. Within 3 months
o C. Within 6 months
o D. Within 12 months
Incorrect

Correct Answer: C. Within 6 months
In most cases, an outpatient must fill a prescription for a controlled substance
within 6 months of the date on which the prescription was written. A common
reason people seek the care of medical professionals is pain relief. While many
categories of pain medications are available, opioid analgesics are FDA-approved
for moderate to severe pain. As such, they are a common choice for patients with
acute, cancer-related, neurologic, and end-of-life pain. The prescribing of opioid
analgesics for chronic pain is controversial and fraught with inconclusive
standards.
 Option A: All health professionals engaged in pain management need an
understanding of the treatment recommendations and safety concerns in
prescribing opioid analgesics. Appropriate opioid prescribing requires a
thorough patient assessment, short and long-term treatment planning,
close follow-up, and continued monitoring.
 Option B: All providers need to be aware of not only appropriate patient
assessment and treatment planning but also the possibility of use disorder,
diversion, and potentially dangerous behavioral responses to controlled
substances, e.g., opioid analgesics differ from pseudo-addiction and
physical dependence.
 Option D: All providers should be familiar with the guidelines and laws for
each schedule, which have, as their basis, the purpose of the drug and the
risk of use disorder. In the United States, controlled substances are under
strict regulation by both federal and state laws that guide their
manufacture and distribution. Controlled substances have a high risk of
resulting in an addiction and substance use disorder.
ADV
45. Question
Which human element considered by the nurse in charge during assessment can
affect drug administration?
o A. The patient‘s ability to recover
o B. The patient‘s occupational hazards
o C. The patient‘s socioeconomic status

o D. The patient’s cognitive abilities
Incorrect
Correct Answer: D. The patient’s cognitive abilities
The nurse must consider the patient‘s cognitive abilities to understand drug
instructions. If not, the nurse must find a family member or significant other to
take on the responsibility of administering medications in the home setting. The
patient‘s ability to recover, occupational hazards, and socioeconomic status do
not affect drug administration.
 Option A: Many drugs can be administered orally as liquids, capsules,
tablets, or chewable tablets. Because the oral route is the most convenient
and usually the safest and least expensive, it is the one most often used.
However, it has limitations because of the way a drug typically moves
through the digestive tract.
 Option B: For drugs administered orally, absorption may begin in the
mouth and stomach. However, most drugs are usually absorbed from the
small intestine. The drug passes through the intestinal wall and travels to
the liver before being transported via the bloodstream to its target site.
The intestinal wall and liver chemically alter (metabolize) many drugs,
decreasing the amount of drug reaching the bloodstream. Consequently,
these drugs are often given in smaller doses when injected intravenously to
produce the same effect.
 Option C: When a drug is taken orally, food and other drugs in the
digestive tract may affect how much of and how fast the drug is absorbed.
Thus, some drugs should be taken on an empty stomach, others should be
taken with food, others should not be taken with certain other drugs, and
still others cannot be taken orally at all.
ADV
46. Question
An employer establishes a physical exercise area in the workplace and
encourages all employees to use it. This is an example of which level of health
promotion?
o A. Primary prevention

o B. Secondary prevention
o C. Tertiary prevention
o D. Passive prevention
Incorrect
Correct Answer: A. Primary prevention
Primary prevention precedes disease and applies to healthy patients. Primary
prevention includes those preventive measures that come before the onset of
illness or injury and before the disease process begins. Examples include
immunization and taking regular exercise to prevent health problems from
developing in the future.
 Option B: Secondary prevention focuses on patients who have health
problems and are at risk for developing complications. Secondary
prevention includes those preventive measures that lead to early diagnosis
and prompt treatment of a disease, illness, or injury. This should limit
disability, impairment or dependency and prevent more severe health
problems from developing in the future.
 Option C: Tertiary prevention enables patients to gain health from others‘
activities without doing anything themselves. Tertiary prevention includes
those preventive measures aimed at rehabilitation following a significant
illness. At this level, health educators work to retrain, re-educate and
rehabilitate the individual who has already had an impairment or disability.
 Option D: Prevention, as it relates to health, is really about avoiding
disease before it starts. It has been defined as the plans for, and the
measures taken, to prevent the onset of a disease or other health problem
before the occurrence of the undesirable health event.
ADV
47. Question
What does the nurse in charge do when making a surgical bed?
o A. Leaves the bed in the high position when finished.
o B. Place the pillow at the head of the bed.

o C. Rolls the patient to the far side of the bed.
o D. Tucks the top sheet and blanket under the bottom of the bed.
Incorrect
Correct Answer: A. Leaves the bed in the high position when finished.
When making a surgical bed, the nurse leaves the bed in a high position when
finished. After placing the top linens on the bed without pouching them, the
nurse fan folds these linens to the side opposite from where the patient will enter
and places the pillow on the bedside chair. All these actions promote transfer of
the postoperative patient from the stretcher to the bed.
 Option B: When making an occupied bed or unoccupied bed, the nurse
places the pillow at the head of the bed and tucks the top sheet and
blanket under the bottom of the bed.
 Option C: When making an occupied bed, the nurse rolls the patient to the
far side of the bed. Bed Making is a key nursing skill that is essential for the
promotion of patient comfort, hygiene, and wellbeing. Bed Making
requires technical and practical skills and consideration should be given to
issues of safety, moving and handling and infection control practices.
 Option D: The blanket is placed at the center of the bed with its top 20cms
approximately from the top of the mattress. The top sheet is folded back
over the blanket. The blanket is folded under the foot of the mattress.
Make a square corner & tuck in along sides.
ADV
48. Question
The physician prescribes 250 mg of a drug. The drug vial reads 500 mg/ml. How
much of the drug should the nurse give?
o A. 2 ml
o B. 1 ml
o C. ½ ml
o D. ¼ ml
Incorrect

Correct Answer: C. ½ ml
The nurse should give ½ ml of the drug. The dosage is calculated as follows:
250 mg/X=500 mg/1 ml
500x=250
X=1/2 ml
Formula, Dimensional Analysis and Ratio and Proportion
triple check.
adding.
ADV
49. Question
Nurse Mackey is monitoring a patient for adverse reactions during barbiturate
therapy. What is the major disadvantage of barbiturate use?
o A. Prolonged half-life
o B. Poor absorption
o C. Potential for drug dependence
o D. Potential for hepatotoxicity

Incorrect

Correct Answer: C. Potential for drug dependence
Patients can become dependent on barbiturates, especially with prolonged use.
Due to the abuse potential of barbiturates, restricted access started with the
passage of the Federal Comprehensive Drug Abuse and Control Act of 1970.
Barbiturates classify as Schedule II-IV based on their abuse potential.
 Option A: Because of the rapid distribution of some barbiturates, no
correlation exists between duration of action and half-life. The elimination
half-life for thiopental is about 5 hours. In children, a shorter elimination
half-time occurs due to greater hepatic clearance.
 Option B: Barbiturates are absorbed well. Age-related changes have been
demonstrated in pharmacokinetics due to slower intercompartmental
clearance in the elderly, resulting in higher serum concentrations with
smaller drug doses.
 Option D: They do not cause hepatotoxicity, although existing hepatic
damage does require cautious use of the drug because barbiturates are
metabolized in the liver.
ADV
50. Question
Which nursing action is essential when providing continuous enteral feeding?
o A. Elevating the head of the bed.
o B. Positioning the patient on the left side.
o C. Warming the formula before administering it.
o D. Hanging a full day‘s worth of formula at one time.

Incorrect
Correct Answer: A. Elevating the head of the bed.
Elevating the head of the bed during enteral feeding minimizes the risk of
aspiration and allows the formula to flow in the patient‘s intestines. Lying
prone/supine during feeding increases the risk of aspiration and therefore where
clinically possible the client should be placed in an upright position. If unable to
sit up for a bolus feed or if receiving continuous feeding, the head of the bed

should be elevated 30-45 degrees during feeding and for at least 30 minutes
after the feed to reduce the risk of aspiration.
 Option B: When such elevation is contraindicated, the patient should be
positioned on the right side. Turn the patient onto their side. This will allow
the tip of the tube to move to a position where fluid has accumulated.
 Option C: The nurse should give enteral feeding at room temperature to
minimize GI distress. Continuous feeds should NOT be warmed. They may
be removed from the fridge 15-20 minutes prior to administration to bring
it to room temperature. Feeds should NOT be warmed in a microwave or in
jugs of boiling water.
 Option D: To limit microbial growth, the nurse should hang only the
amount of formula that can be infused in 3 hours. It should not hang for
longer than 4 hours – use the dose limit function on the feed pump to
ensure this occurs.
ADV
51. Question
When teaching a female patient how to take a sublingual tablet, the nurse should
instruct the patient to place the table on the:
o A. Top of the tongue
o B. Roof of the mouth
o C. Floor of the mouth
o D. Inside of the cheek

Incorrect
Correct Answer: C. Floor of the mouth
The nurse should instruct the patient to touch the tip of the tongue to the roof of
the mouth and then place the sublingual tablet on the floor of the mouth.
Sublingual medications are absorbed directly into the bloodstream from the oral
mucosa, bypassing the GI and hepatic systems. No drug is administered on top of
the tongue or on the roof of the mouth.

 Option A: The cheek and area under the tongue have many capillaries, or
tiny blood vessels. There, drugs can be absorbed directly into the
bloodstream without going through the digestive system.
 Option B: These drugs do not go through the digestive system, so they
aren‘t metabolized through the liver. This means the client may be able to
take a lower dose and still get the same results.
 Option D: With the buccal route, the tablet is placed between the gum and
the cheek. Drugs that are absorbed under the tongue or between the
cheek and gum can be easier to take for people who have problems
swallowing pills.
ADV
52. Question
Which action by the nurse in charge is essential when cleaning the area around a
Jackson-Pratt wound drain?
o A. Cleaning from the center outward in a circular motion.
o B. Removing the drain before cleaning the skin.
o C. Cleaning briskly around the site with alcohol.
o D. Wearing sterile gloves and a mask.

Incorrect
Correct Answer: A. Cleaning from the center outward in a circular motion.
The nurse always should clean around a wound drain, moving from center
outward in ever-larger circles, because the skin near the drain site is more
contaminated than the site itself. A Jackson-Pratt (JP) drain is used to remove
fluids that build up in an area of the body after surgery. The JP drain is a bulb-
shaped device connected to a tube. One end of the tube is placed inside the
client during surgery. The other end comes out through a small cut in the skin.
The bulb is connected to this end. The client may have a stitch to hold the tube in
place.
 Option B: The nurse should never remove the drain before cleaning the
skin. The JP drain removes fluids by creating suction in the tube. The bulb

is squeezed flat and connected to the tube that sticks out of the body. The
bulb expands as it fills with fluid.
 Option C: Alcohol should never be used to clean around a drain; it may
irritate the skin and has no lasting effect on bacteria because it evaporates.
Use soap and water or saline (salt water) solution to clean a JP drain site.
Dip a cotton swab or gauze pad in the solution and gently clean the skin.
 Option D: The nurse should wear sterile gloves to prevent contamination,
but a mask is not necessary. Wash hands with soap and water after
discarding the gloves.
ADV
53. Question
The doctor orders dextrose 5% in water, 1,000 ml to be infused over 8 hours. The
I.V. tubing delivers 15 drops per milliliter. The nurse in charge should run the I.V.
infusion at a rate of:
o A. 15 drop per minute
o B. 21 drop per minute
o C. 32 drop per minute
o D. 125 drops per minute

Incorrect
Correct Answer: C. 32 drop per minute
Giving 1,000 ml over 8 hours is the same as giving 125 ml over 1 hour (60
minutes) to find the number of milliliters per minute:
125/60 min = X/1 minute
60X = 125X = 2.1 ml/minute
To find the number of drops/minute:
2.1 ml/X gtts = 1 ml/15 gtts
X = 32 gtts/minute, or 32 drops/minute
 Option A: When the nurse has an order for an IV infusion, it is her to make
sure the fluid will infuse at the prescribed rate. IV fluids may be infused by
gravity using a manual roller clamp or dial-a-flow, or infused using an

infusion pump. Regardless of the method, it is important to know how to
calculate the correct IV flow rate.
 Option B: When calculating the flow rate, determine which IV tubing will
drip chamber. Macrodrip tubing delivers 10 to 20 gtts/mL and is used to
infuse large volumes or to infuse fluids quickly. Microdrip tubing delivers
60 gtts/mL and is used for small or very precise amounts of fluid, as with
The formula for calculating the IV flow rate (drip rate) is total volume (in
ADV
54. Question
A female patient undergoes a total abdominal hysterectomy. When assessing the
patient 10 hours later, the nurse identifies which finding as an early sign of
shock?
o A. Restlessness
o B. Pale, warm, dry skin
o C. Heart rate of 110 beats/minute
o D. Urine output of 30 ml/hour

Incorrect
Correct Answer: A. Restlessness
Early in shock, hyperactivity of the sympathetic nervous system causes increased
epinephrine secretion, which typically makes the patient restless, anxious,
nervous, and irritable. It also decreases tissue perfusion to the skin, causing pale,
cool clammy skin. Shock is characterized by decreased oxygen delivery and/or
increased oxygen consumption or inadequate oxygen utilization leading to

cellular and tissue hypoxia. It is a life-threatening condition of circulatory failure
and most commonly manifested as hypotension (systolic blood pressure less than
90 mm Hg or MAP less than 65 mmHg).
 Option B: Hypoxia at the cellular level causes a series of physiologic and
biochemical changes, resulting in acidosis and a decrease in regional blood
flow, which further worsens the tissue hypoxia.
 Option C: An above-normal heart rate is a late sign of shock. The most
common clinical features/labs which are suggestive of shock include
hypotension, tachycardia, tachypnea, obtundation or abnormal mental
status, cold, clammy extremities, mottled skin, oliguria, metabolic acidosis,
and hyperlactatemia.
 Option D: A urine output of 30 ml/hour is within normal limits. During this
stage, most of the classic signs and symptoms of shock appear due to early
organ dysfunction, resulting from the progression of the pre-shock stage
as the compensatory mechanisms become insufficient.
ADV
55. Question
Which pulse should the nurse palpate during rapid assessment of an unconscious
male adult?
o A. Radial
o B. Brachial
o C. Femoral
o D. Carotid
Incorrect
Correct Answer: D. Carotid
During a rapid assessment, the nurse‘s first priority is to check the patient‘s vital
functions by assessing his airway, breathing, and circulation. To check a patient‘s
circulation, the nurse must assess his heart and vascular network function. This is
done by checking his skin color, temperature, mental status and, most
importantly, his pulse. The nurse should use the carotid artery to check a patient‘s
circulation.

 Option A: In a patient with circulatory problems or a history of
compromised circulation, the radial pulse may not be palpable. Examiners
frequently evaluate the radial artery during a routine examination of adults,
due to the unobtrusive position required to palpate it and its easy
accessibility in various types of clothing. Like other distal peripheral pulses
(such as those in the feet) it also may be quicker to show signs of
pathology.
 Option B: The brachial pulse is palpated during rapid assessment of an
infant. The brachial artery is often the site of evaluation during
cardiopulmonary resuscitation of infants. It is palpated proximal to the
elbow between the medial epicondyle of the humerus and the distal biceps
tendon.
 Option C: The femoral pulse may be the most sensitive in assessing for
ADV
56. Question
Clients should be taught that repeatedly ignoring the sensation of needing to
defecate could result in which of the following?
o A. Constipation
o B. Diarrhea
o C. Incontinence
o D. Hemorrhoids
Incorrect
Correct Answer: A. Constipation
Habitually ignoring the urge to defecate can lead to constipation through loss of
the natural urge and the accumulation of feces. Functional constipation is a
prevalent condition in childhood, about 29.6% worldwide. In the United States, it
represents 3% to 5% of pediatric visits and a considerable annual health care

cost. Most children do not have an etiological factor, and one third continue to
have problems beyond adolescence.
 Option B: Diarrhea will not result-if anything, there is increased
opportunity for water reabsorption because the stool remains in the colon,
leading to firmer stool. Diarrhea is described as three or more loose or
watery stools a day. Infection commonly causes acute diarrhea.
Noninfectious etiologies are more common as the duration of diarrhea
becomes chronic. Treatment and management are based on the duration
and specific etiology.
 Option C: Ignoring the urge shows a strong voluntary sphincter, not a
weak one that could result in incontinence. Fecal incontinence (FI) is the
involuntary passage of fecal matter through anus or inability to control the
discharge of bowel contents. Its severity can range from an involuntary
passage of flatus to complete evacuation of fecal matter. Depending on
the severity of the disease, it has a significant impact on a patient‘s quality
of life
 Option D: Hemorrhoids would only occur only if severe drying out of the
stool occurs, and thus repeated need to strain to pass stool. Hemorrhoids
are rich in vascular supply and have a tendency to engorge and prolapse.
Symptoms can vary from mild itching, bleeding to severe pain.
Unfortunately, because of the location, many patients never seek treatment
for fear of embarrassment.
ADV
57. Question
Which statement provides evidence that an older adult who is prone to
constipation is in need of further teaching?
o A. "I need to drink one and a half to 2 quarts of liquid each day."
o B. "I need to take a laxative such as milk of magnesia or if I don't have a

BM every day."
o C. "If my bowel pattern changes on its own, I should call you."

o D. "Eating my meals at regular times is likely to result in regular bowel
movements."
Incorrect
Correct Answer: B. “I need to take a laxative such as milk of magnesium or if
I don’t have a BM every day”
Stimulant laxatives can be very irritating and are not the preferred treatment for
occasional constipation in older adults. In addition, a normal stool pattern for an
older adult may not be daily elimination. The cause of constipation is
multifactorial. The problem may arise in the colon or rectum or it may be due to
an external cause. In most people, slow colonic motility that occurs after years of
laxative abuse is the problem. In a few patients, the cause may be related to an
outlet obstruction like rectal prolapse or a rectocele. External causes of
constipation may include poor dietary habits, lack of fluid intake, overuse of
certain medications, an endocrine problem like hypothyroidism or some type of
an emotional issue.
 Option A: The standard of practice in assisting the older adults to maintain
normal function of the gastrointestinal tract is regular ingestion of a well-
balanced diet, adequate fluid intake, and regular exercise.
 Option C: If the bowel pattern is not regular with these activities, this
abnormality should be reported. Pathophysiology underlying functional
constipation is multifactorial and not well understood. Factors that may
contribute to functional constipation include pain, fever, dehydration,
dietary and fluid intake, psychological issues, toilet training, medicines, and
family history of constipation.
 Option D: A normal fiber intake, fluid intake, and physical activity level are
recommended, and the routine use of prebiotics or probiotics is not
recommended in the treatment of childhood constipation.
ADV
58. Question
A client is scheduled for a colonoscopy. The nurse will provide information to the
client about which type of enema?
o A. Oil retention

o B. Return flow
o C. High large volume
o D. Low, small volume

Incorrect
Correct Answer: D. Low, small volume
Small volume enemas along with other preparations are used to prepare the
client for this procedure. The small volume enema is used to clean the lower
portion of the colon or the sigmoid. This type of cleansing enema is often used
for the patient who is constipated but does not need cleansing of the higher
colon. The amount used is less than 500 ml and the bag is raised no higher than
12 inches.
 Option A: An oil retention enema is used to soften hard stool. A rectal
injection of mineral oil or vegetable Oil, introduced at low pressure and
retained for 30 minutes to 3 hours before being expelled. given to soften
feces in cases of constipation or impaction. The volume of oil is relatively
low, four to six ounces are commonly used, which allows the oil to be more
easily retained.
 Option B: Return flow enemas help expel flatus because of the risk of loss
of fluid and electrolytes A return-flow enema, or Harris flush, is used to
remove intestinal gas and stimulate peristalsis. A large volume fluid is used
but the fluid is instilled in 100-200 ml increments. Then, the fluid is drawn
out by lowering the container below the level of the bowel. This brings the
flatus out with the fluid.
 Option C: High, large volume enemas are seldom used. The purpose of a
large volume enema is to clean as much of the colon as possible of feces,
as an intervention for constipation as well as ―bowel prep‖ before a
diagnostic procedure. The amount used is 500-1000 ml and the bag is
raised as high as 18 inches above the anal opening. The patient is
instructed to retain and hold the fluid as long as possible to induce
peristalsis and cause evacuation of feces.
ADV
59. Question

The nurse is most likely to report which finding to the primary care provider for a
client who has an established colostomy?
o A. The stoma extends 1/2 inch above the abdomen.
o B. The skin under the appliance looks red briefly after removing the
appliance.
o C. The stoma color is a deep red purple.
o D. An ascending colostomy just delivers liquid feces.

Incorrect
Correct Answer: C. The stoma color is a deep red purple.
An established stoma should be dark pink like the color of the buccal mucosa
and is slightly raised above the abdomen. A stoma is the exteriorization of a loop
of bowel from the anterior abdominal wall, done during a surgical procedure. It is
done for diversion or decompression of the remaining bowel. It may be
temporary or permanent, depending on the indication for which it was
performed. Most stomas are incontinent, which means that there is no voluntary
control over the passage of flatus and feces from the stoma.
 Option A: The stoma should be assessed and must be moist, above skin
level, and pink to red in color, and the peristomal skin should be normal.
Any deviation from this should be notified to the surgeon. The stoma
should be measured, or the previous measurement remembered and size
should not be more than 1/16-1/8.
 Option B: The skin under the appliance may remain pink/red for a while
after the adhesive is pulled off. The peristomal skin should be dried
appropriately to allow good seal formation. Adhesive pastes or powders
may also be applied peristomally. The paper cover on the back of the
flange is then removed with the border tape in place. It is then placed
around the stoma and held in place for 1 to 2 minutes to create an
adequate seal.
 Option D: Feces from an ascending ostomy are very liquid, less so from a
transverse ostomy, and more solid from a descending or sigmoid stoma.
Colostomy diarrhea may be complained by the patient in case of ascending
or transverse colostomies in case they are not fully explained about the
nature of content expected, but stomal diarrhea may be the result of

extensive resection with failure of bowel adaptation or if associated with
short bowel syndrome.
ADV
60. Question
Which goal is the most appropriate for clients with diarrhea related to ingestion
of an antibiotic for an upper respiratory infection?
o A. The client will wear a medical alert bracelet for antibiotic allergy.
o B. The client will return to his or her previous fecal elimination pattern.
o C. The client verbalizes the need to take an antidiarrheal medication PRN.
o D. The client will increase intake of insoluble fiber such as grains, rice, and
cereals.
Incorrect
Correct Answer: B. The client will return to his or her previous fecal
elimination pattern.
Once the cause of diarrhea has been identified and corrected, the client returns
to his or her previous elimination pattern. Diarrhea is a common adverse effect of
antibiotic treatments. Antibiotic-associated diarrhea occurs in about 5-30% of
patients either early during antibiotic therapy or up to two months after the end
of the treatment. The frequency of antibiotic-associated diarrhea depends on the
definition of diarrhea, the inciting antimicrobial agents, and host factors.
 Option A: This is not an example of an allergy to the antibiotic but a
common consequence of overgrowth of bowel organisms not killed by the
drug. Antibiotic-associated diarrhea results from disruption of the normal
microflora of the gut by antibiotics. This microflora, composed of 1011
bacteria per gram of intestinal content, forms a stable ecosystem that
permits the elimination of exogenous organisms. Antibiotics disturb the
composition and the function of this flora and enable the overgrowth of
micro-organisms that induce diarrhea.
 Option C: Antidiarrheal medications are usually prescribed according to
the number of stools, not routinely around the clock. Managing diarrhea
depends on the clinical presentation and the inciting agent. In mild to

moderate diarrhea conventional measures include rehydration or
discontinuation of the inciting agent or its replacement by an antibiotic
with a lower risk of inducing diarrhea, such as quinolones, co-trimoxazole,
or aminoglycosides. In 22% of cases of diarrhea related to C difficile,
withdrawal of the inciting agent will lead to resolution of clinical signs in
three days.
 Option D: Increasing intake of soluble fiber such as oatmeal or potatoes
may help absorb excess liquid and decrease diarrhea, but insoluble fiber
will not. The key measure for preventing antibiotic-associated diarrhea,
however, is to limit antibiotic use. Probiotics have proved useful in
preventing diarrhea, but the number of clinical trials is limited, and further
controlled trials using different probiotics are needed.
ADV
61. Question
A client with a new stoma who has not had a bowel movement since surgery last
week reports feeling nauseous. What is the appropriate nursing action?
o A. Prepare to irrigate the colostomy.
o B. After assessing the stoma and surrounding skin, notify the surgeon.
o C. Assess bowel sounds and administer antiemetic.
o D. Administer a bulk forming laxative, and encourage increased fluids and

exercise.
Incorrect
Correct Answer: B. After assessing the stoma and surrounding skin, notify
the surgeon.
The client has assessment findings consistent with complications of surgery.
Providers and nurses should monitor stomas at regular intervals to look for the
multiple complications of colostomies as an integrated team approach. Some
complications are extremely troublesome to patients, and they come to the
hospital with these presentations, but others may be more occult and have to be
looked for.

 Option A: Irrigating the stoma is a dependent nursing action, and is also
intervention without appropriate assessment. Some procedures like
irrigation or enema should be avoided in case of stoma prolapse,
chemotherapy, pelvic or abdominal radiation treatments, diarrhea-
producing medication, or in case of an irregular functioning stoma and
may lead to dependence.
 Option C: Assessing the peristomal skin area is an independent action, but
administering an antiemetic is an intervention without appropriate
assessment. Antiemetics are generally ordered to treat immediate
postoperative nausea, not several days postoperative.
 Option D: Administering a bulk-forming laxative to a nauseated
postoperative client is contraindicated. The surgeon must call the patient
for regular follow up to assess the condition of the stoma and look for any
complications and also assess the disease process for which the colostomy
was made and also plan for colostomy closure in case of temporary
colostomies.
ADV
62. Question
The nurse assesses a client‘s abdomen several days after abdominal surgery. It is
firm, distended, and painful to palpate. The client reports feeling ―bloated‖ . The
nurse consults with the surgeon, who orders an enema. The nurse prepares to
give what kind of enema?
o A. Soapsuds
o B. Retention
o C. Return flow
o D. Oil retention
Incorrect
Correct Answer: C. Return flow
This provides relief of postoperative flatus, stimulating bowel motility. Options
one, two, and four manage constipation and do not provide flatus relief. A
return-flow enema, or Harris flush, is used to remove intestinal gas and stimulate

peristalsis. A large volume fluid is used but the fluid is instilled in 100-200 ml
increments. Then, the fluid is drawn out by lowering the container below the level
of the bowel. This brings the flatus out with the fluid.
 Option A: The soapsuds enema uses a mixture of a mild soap and warm
water injected into the colon in order to stimulate a bowel movement.
Normally given to relieve constipation or for bowel cleansing before a
medical examination or procedure.
 Option B: An enema that may be used to provide nourishment,
medication, or anesthetic. It should be made from fluids that will not
stimulate peristalsis. A small amount of solution (e.g., 100 to 250 mL) is
typically used in adults.
 Option D: If fecal material is hardened, an oil-retention enema may be
given to soften the feces. Commercially packaged enemas contain 90-120
ml solution. The patient should retain the solution to at least one hour for
the enema to be effective. This enema is usually followed by a cleansing
enema.
ADV
63. Question
Which of the following is most likely to validate that a client is experiencing
intestinal bleeding?
o A. Large quantities of fat mixed with pale yellow liquid stool
o B. Brown, formed stool
o C. Semi soft tar colored stools
o D. Narrow, pencil shaped stool

Incorrect
Correct Answer: C. Semi soft tar colored stools
Blood in the upper GI tract is black and tarry. Gastrointestinal (GI) bleeding is a
symptom of a disorder in the digestive tract. The blood often appears in stool or
vomit but isn‘t always visible, though it may cause the stool to look black or tarry.
The level of bleeding can range from mild to severe and can be life-threatening.

 Option A: This can be a sign of malabsorption in an infant. Malabsorption
syndromes encompass numerous clinical entities that result in chronic
diarrhea, abdominal distention, and failure to thrive. Clinical malabsorption
can be broken down into several distinct conditions, both congenital and
acquired, that affect one or more of the different steps in the intestinal
hydrolysis and subsequent transport of nutrients.
 Option B: Brown, formed stool is a normal stool. Anywhere between a firm
and soft consistency is pretty much normal. If it sways one way or another,
it could suggest some digestion or fiber issues.
 Option D: Narrow, pencil-shaped stool is a characteristic of an obstructive
condition of the rectum. Narrow stools that occur infrequently probably are
harmless. However in some cases, narrow stools — especially if pencil thin
— may be a sign of narrowing or obstruction of the colon due to colon
cancer.
Sources:
ADV
64. Question
Which nursing diagnosis is/are most applicable to a client with fecal
o A. Bowel incontinence
o B. Risk for deficient fluid volume
o C. Disturbed body image
o D. Social isolation
o E. Risk for impaired skin integrity

Incorrect
Correct Answer: A, C, D, and E
Incontinence is the inability to control feces of normal consistency. Fecal
incontinence (FI) is the involuntary passage of fecal matter through anus or
inability to control the discharge of bowel contents. Its severity can range from an
involuntary passage of flatus to complete evacuation of fecal matter. Depending

on the severity of the disease, it has a significant impact on a patient‘s quality of
life
 Option A: This is the most appropriate. The client is unable to decide when
stool evacuation will occur. Patients with fecal incontinence have an
unintentional loss of liquid or solid stool. In true anal incontinence, there is
loss of control of the anal sphincter which leads to the untimely release of
feces.
 Option B: Risk for deficient fluid volume is more appropriate for a client
with diarrhea. Avoid perianal skin soiling with regular cleaning, zinc oxide
application, incontinence pads. Avoid food which can provoke diarrhea
(high lactose/ fructose diet).
 Option C: The client‘s thoughts about self may be altered if unable to
control stool evacuation. To maintain fecal continence, there is a complex
interplay of several organ systems and nerves. As the fecal mass presents
to the rectum, this causes distension. The sensation of rectal distension is
transmitted by the parasympathetic nerves (S2-S4), which induces
relaxation of the rectoanal inhibitory reflex and contraction of the rectoanal
contractile reflex. The rectal lining has a rich supply of nerve endings that
can sample if the mass is liquid or solid. It is believed that abnormal
sampling and lowered anorectal sensation most likely contribute to fecal
incontinence in many individuals.
 Option D: The prognosis for most patients with fecal incontinence is
guarded. Short term outcomes after sphincteroplasty vary from 30-60%.
Satisfactory results are seen in less than 50% of patients in the long term.
The quality of life is poor and mental anguish is common.
 Option E: Increased tissue contact with fecal material may result in
impairment. Fecal incontinence is a complex issue that is not easy to
manage. The vast number of methods used to manage the condition is an
indication that no method works reliably. Patients with fecal incontinence
have enormous mental anguish, depression, and anxiety.
ADV
65. Question
A nurse determines that a fracture bedpan should be used for the patient who:

o A. Has a spinal cord injury
o B. Is on bedrest
o C. Has dementia
o D. Is obese
Incorrect
Correct Answer: A. Has a spinal cord injury
A fracture bedpan has a low back that promotes function of the patient‘s lower
back while on the bedpan. The fracture pan has one flat end for ease of use with
specific patient populations: i.e. hip fractures, hip replacements, or lower
extremity fractures. Using the toilet may be a source of discomfort and
embarrassment among all genders. Semi-private rooms or shared wards and
hospital overcrowding are a challenge regarding patient privacy.
 Option B: Bedpans come in regular size or a smaller, fracture pan. Bedpans
are chosen based on diagnosis, patient comfort or preference and if any
contraindications exist for using the regular size such as a fracture. The
regular bedpan is larger than its fracture counterpart. Bariatric bedpans are
available up to a 1200-pound (544-kg) capacity.
 Option C: A patient that can assist with care by raising their hips is
approached differently than a patient that cannot lift their hips due to
surgical considerations, fractures, or other contraindications. In both cases,
ensure the patient is pulled up as high as they can be on the stretcher or
bed. If they can assist with raising their hips, then raise the head of the bed
at least thirty degrees.
 Option D: Positioning in this Semi-Fowler‘s position allows for anatomical
support and facilitates ease of defecation or urination by assuming a
natural position for these bodily functions. According to a 2003 study,
body positioning has a significant influence on intestinal gas propulsion
and transit times with gastric flow being faster in the upright position than
when supine [Dainese, Serra, Azpiroz & Malagelada, 2003].
ADV
66. Question

A patient with the diagnosis of diverticulosis is advised to eat a diet high in fiber.
What should the nurse recommend that the patient eat to best increase the bulk
and fecal material?
o A. Whole wheat bread
o B. White rice
o C. Pasta
o D. Kale
Incorrect
Correct Answer: D. Kale
Kale is an excellent source of dietary fiber. A serving of 3 1/2 ounces of kale
contains 6.6 g of dietary fiber. Fiber is a very important component of our diet
and comes from plant-based food sources (fruits, vegetables, legumes and whole
grains). Different food sources contain different types of fiber and resistant
starches and the side effects depend on the individual‘s microbiome (gut
bacteria). Instead of avoiding fiber altogether, you may want to identify the
certain types of food that cause the distress.
 Option A: One slice of whole wheat bread contains only 1.5 g of dietary
fiber. Whole wheat bread is made from flour that contains the entire wheat
kernel, including the bran and germ. It‘s here that wheat packs the most
nutrients, such as fiber, B vitamins, iron, folate, potassium, and magnesium.
Leaving the wheat kernel intact makes for a less processed, more nutritious
bread.
 Option B: A serving of a 1/2 cup of white rice contains only 0.8 g of dietary
fiber. White rice is mostly a source of ―empty‖ calories and carbs with very
few essential nutrients. 100 grams (3.5 ounces) of cooked brown rice
provide 1.8 grams of fiber, whereas 100 grams of white provide only 0.4
grams of fiber (1, 2). Bottom Line: Brown rice is much higher in nutrients
than white rice.
 Option C: A serving of 3 1/2 ounces of cooked pasta contains only 1.6 g of
dietary fiber. Whole-wheat pasta is usually made from whole-wheat durum
semolina, or flour made from the whole grain rather than the striped grain.
For about 175 calories, a 1-cup serving of cooked whole-wheat spaghetti
delivers 6.3 grams of fiber, or 25 percent of the daily value.

ADV
67. Question
Which statement by a patient with an ileostomy alerts the nurse to the need for
further education?
o A. "I don't expect to have much of a problem with fecal odor."
o B. "I will have to take special precaution to protect my skin around the
stoma."
o C. "I'm going to have to irrigate my stoma so I have a bowel movement

every morning."
o D. "I should avoid gas forming foods like beans to limit funny noises from the
stoma."
Incorrect
Correct Answer: C. “I’m going to have to irrigate my stoma so I have a bowel
movement every morning”
This statement is inaccurate in relation to an ileostomy and indicates that the
patient needs more teaching. An ileostomy produces liquid fecal drainage that is
constant and cannot be regulated. An ileostomy is when the lumen of the ileum
(small bowel) is brought through the abdominal wall via a surgical opening
(created by an operation). This can either be temporary or permanent, an end or
a loop. The purpose of an ileostomy is to evacuate stool from the body via the
ileum rather than the usual route of the anus.
 Option A: The odor from drainage is minimal because fewer bacteria are
present in the ileum compared with the large intestine. There are different
indications for forming an ileostomy but essentially arrive at the same
result of diverting stool out of the body without it ever entering the colon.
 Option B: An ileostomy is an opening into the ileum (distal small intestine
from the jejunum to the cecum). Cleansing the skin, skin barriers, and a
well fitted appliance are precautions to protect the skin around the
ileostomy stoma. The drainage from ileostomy contains enzymes that can
damage the skin.
 Option D: An ileostomy stoma does not have a sphincter that can control
the flow of flatus or drainage, resulting in noise. The output from an

ileostomy consists of loose or porridge-like stool consistent with that
expected to pass through the small bowel (as it is the large bowel that is
responsible for making the stool more solid dependent upon water
absorption). The output from an ileostomy can vary but typically ranges
from 200 to 700 ml per day, and an Ileostomy is typically formed on the
right side of the abdomen.
ADV
68. Question
A practitioner orders a return flow enema (Harris flush drip) for an adult patient
with flatulence. When preparing to administer this enema the nurse compares the
steps of a return flow enema with cleansing enemas. What should the nurse do
that is unique to a return flow enema?
o A. Lubricate the last 2 inches of the rectal tube.
o B. Insert the rectal tube about 4 inches into the anus.
o C. Raise the solution container about 12 inches above the anus.
o D. Lower the solution container after instilling about 150 mL of solution.

Incorrect
Correct Answer: D. Lower the solution container after instilling about 150
mL of solution.
Lowering the container of solution creates a siphon effect that pulls the instilled
fluid back out through the rectal tube into the solution container. The return flow
promotes the evacuation of gas from the intestines. This technique is used only
with a return flow enema. This action is appropriate for all types of enemas.
 Option A: All rectal tubes should be lubricated to facilitate entry of the
tube into the anus and rectum and prevent mucosal trauma. Use a solution
at a temperature of 105o to 110oF in adults and 100oF in children. Cool
solutions will increase the incidence of cramping.
 Option B: The anal canal is 1 to 2 inches long. Inserting the rectal tube 3 to
4 inches ensures that the tip of the tube is beyond the anal sphincter. The
recommended position for the patient during enema administration is

lying in the left lateral position with their right leg flexed as much as
possible.
 Option C: The solution container should be raised no higher than 12
inches for all enemas; this allows the solution to instill slowly, which limits
discomfort and intestinal spasms. Alternately, raise the enema container
12-18 inches above the rectum for an adult and administer approximately
200 ml of fluid, then lower the container 12-18 inches below the patient‘s
rectum until no further flatus is seen.
ADV
69. Question
A nurse discourages a patient from straining excessively when attempting to have
a bowel movement. What physiological response primarily may be prevented by
avoiding straining on defecation?
o A. Incontinence
o B. Dysrhythmias
o C. Fecal impaction
o D. Rectal hemorrhoids
Incorrect
Correct Answer: B. Dysrhythmias
Straining on defecation requires the person to hold the breath while bearing
down. This maneuver increases the intrathoracic and intracranial pressures, which
can precipitate dysrhythmias, brain attack, and respiratory difficulties; all of these
can be life threatening. Strain at stool causes blood pressure rise, which can
trigger cardiovascular events such as congestive heart failure, arrhythmia, acute
coronary disease, and aortic dissection.
 Option A: The loss of the voluntary ability to control the passage of fecal
or gaseous discharges through the anus is caused by impaired functioning
of the anal sphincter or its nerve supply, not straining on defecation. Fecal
incontinence is the inability to control bowel movements, causing stool
(feces) to leak unexpectedly from the rectum. Also called bowel

incontinence, fecal incontinence ranges from an occasional leakage of stool
while passing gas to a complete loss of bowel control.
 Option C: Fecal impaction is caused by prolonged retention and the
accumulation of fecal material in the large intestine, not straining on
defecation. Fecal impaction is a severe bowel condition in which a hard, dry
mass of stool becomes stuck in the colon or rectum. This immobile mass
will block the passage and cause a buildup of waste, which a person will be
unable to pass.
 Option D: Although straining on defecation can contribute to the
formation of hemorrhoids, this is not the primary reason straining on
defecation is discouraged. Hemorrhoids, although painful, are not life-
threatening. Hemorrhoids are rich in vascular supply and have a tendency
to engorge and prolapse. Symptoms can vary from mild itching, bleeding
to severe pain. Unfortunately, because of the location, many patients never
seek treatment for fear of embarrassment.
ADV
70. Question
A nurse is caring for a client who will perform fecal occult blood testing at home.
Which of the following information should the nurse include when explaining the
procedure to the client?
o A. Eating more protein is optimal prior to testing.
o B. One stool specimen is sufficient for testing.
o C. A red color changes indicates a positive test.
o D. The specimen cannot be contaminated with urine.

Incorrect
Correct Answer: D. The specimen cannot be contaminated with urine.
For fecal occult blood testing at home, the stool specimens cannot be
contaminated with water or urine. The fecal occult blood test (FOBT) is a
diagnostic test to assess for occult blood in the stool. This test has commonly
been used for colorectal cancer screening, especially in developed nations. When
used correctly for screening, this testing modality has established associations

with decreased morbidity and mortality. When performing at home, the stool
should be collected in a dry, clean container.
 Option A: Some proteins such as red meat, fish, and poultry can alter the
test results. Three days prior to fecal occult blood testing, avoidance of
certain foods should be to help prevent false test results. False-positive
results have been associated with red or rare meat as well as raw fruits and
vegetables, including but not limited to horseradish, raw turnips,
cantaloupe, broccoli, cauliflower, parsnips, and red radishes. False-negative
results are also known to occur in patients taking ascorbic acid (vitamin C)
in excess of 250mg/day.
 Option B: Three specimens from three different bowel movements are
required. One problem with FOBT is the need for medication and dietary
restrictions before testing. These restrictions are in order to decrease the
risk of false negative and false-positive results. Many studies assessing the
risk of these false results exist. One particular retrospective study evaluated
the medications that could create false-positive results and encouraged
patients to avoid these medications, if possible, for seven days before
testing. The listed medications include acetylsalicylic acid, unfractionated or
low-molecular-weight heparin, warfarin, clopidogrel, nonsteroidal anti-
inflammatory drugs, and selective serotonin reuptake inhibitors.
 Option C: A blue color indicates blood in the stool. If the patient‘s fecal
occult blood test does not turn blue, it is negative. If the card turns blue,
this is positive and requires further gastroenterological workup.
ADV
71. Question
A nurse is talking with a client who reports constipation. When the nurse
discusses dietary changes that can help prevent constipation, which of the
following foods should the nurse recommend?
o A. Macaroni and cheese
o B. Fresh food and whole-wheat toast
o C. Rice pudding and ripe bananas

o D. Roast chicken and white rice
Incorrect
Correct Answer: B. Fresh food and whole-wheat toast.
A high fiber diet promotes normal bowel elimination. The choice of fruit and
toast is the highest-fiber option. Most Americans consume only half the levels of
recommended fiber per day, which is almost 15 grams per day. All existing
definitions recognize fiber as ―carbohydrate or lignin which bypasses digestion in
the small intestine and is partially or completely fermented in the large intestine
or colon.‖
 Option A: Macaroni and cheese is a low residue option that could actually
worse and constipate. Insoluble fiber maintains bowel movements. They
absorb water and soften the stool. Soft stool is easier to pass, thus
preventing constipation. They also add bulk to the stools hence prevent
the formation of loose stools.
 Option C: Rice pudding and ripe bananas are low residue options that
could actually worsen constipation. High fiber diet prevents the formation
or worsening of hemorrhoids, and of diverticular disease, which presents as
outpouchings in the walls of the colon.
 Option D: Roast chicken and white rice or low residue options that could
actually worsen constipation. They are water-soluble and derived from the
inner flesh of plants such as pectin, gums, and mucilage. They form a
viscous gel and are usually fermented by bacteria in the colon into gases
and by-products such as short-chain fatty acids. They alter the blood
glucose and cholesterol concentrations.
ADV
72. Question
A nurse is caring for a client who has diarrhea for the past four days. When
assessing a client, the nurse should expect which of the following findings? Select
all that apply.
o A. Bradycardia
o B. Hypotension

o C. Fever
o D. Poor skin turgor
o E. Peripheral edema
Incorrect
Diarrhea is described as three or more loose or watery stools a day. Infection
commonly causes acute diarrhea. Noninfectious etiologies are more common as
the duration of diarrhea becomes chronic. Treatment and management are based
on the duration and specific etiology. Rehydration therapy is an important aspect
of the management of any patient with diarrhea. Prevention of infectious diarrhea
includes proper handwashing to prevent the spread of infection.
 Option A: Prolonged diarrhea is more likely to cause tachycardia than
bradycardia. Diarrhea is the result of reduced water absorption by the
bowel or increased water secretion. A majority of acute diarrheal cases are
due to infectious etiology. Chronic diarrhea is commonly categorized into
three groups; watery, fatty (malabsorption), or infectious.
 Option B: Prolonged diarrhea leads to dehydration, which causes a
decrease in blood pressure. In bacterial and viral diarrhea, the watery stool
is the result of injury to the gut epithelium. Epithelial cells line the intestinal
tract and facilitate the absorption of water, electrolytes, and other solutes.
Infectious etiologies cause damage to the epithelial cells which leads to
increased intestinal permeability. The damaged epithelial cells are unable
to absorb water from the intestinal lumen leading to loose stool.
 Option C: Prolonged diarrhea leads to dehydration, which causes fever.
History should include the duration of symptoms, accompanying
symptoms, travel history, and exposures to medications and food. It is
important to ask about the stool frequency, type, volume, and presence of
blood or mucus. Patients with diarrhea may also complain of abdominal
pain or cramping, vomit, bloating, flatulence, fever, and bloody or mucoid
stools.
Option D: Prolonged diarrhea is more likely to cause a fluid deficit. An
important aspect of diarrhea management is replenishing fluid and
electrolyte loss. Patients should be encouraged to drink diluted fruit juice,
Pedialyte or Gatorade. In more severe cases of diarrhea, IV fluid
rehydration may become necessary.

Option E: Peripheral edema results from a fluid overload. Important aspects
of the physical exam include the patient‘s vital signs, volume status, and
abdominal exam. Dry mucous membranes, poor skin turgor, and delayed
capillary refill are signs of dehydration. A thorough history and physical
exam are important to determine the proper diagnostic workup.
ADV
73. Question
A nurse is preparing to administer a cleansing enema to an adult client in
preparation for a diagnostic procedure. Which of the following are appropriate
steps for the nurse to take? Select all that apply.
o A. Warm the enema solution prior to installation.
o B. Position the client on the left side with the right leg flexed forward.
o C. Lubricate the rectal tube or nozzle.
o D. Slowly insert the rectal tube about 2 inches.
o E. Hang the enema container 24 inches above the clients anus.

Incorrect
Correct Answer: A, B, and C
Enemas are rectal injections of fluid intended to cleanse or stimulate the
emptying of the bowel. Enemas can be administered by a medical professional or
self-administered at home. Enemas may also be prescribed to flush out the colon
before certain diagnostic tests or surgeries. The bowel needs to be empty before
these procedures to reduce infection risk and prevent stool from getting in the
way.
 Option A: The nurse should warm the enema solution because cold fluid
can cause abdominal cramping and hot fluid can injure the intestinal
mucosa. Cleansing enemas are water-based and meant to be held in the
rectum for a short time to flush the colon. Once injected, they‘re retained
for a few minutes until the body rids itself of the fluid, along with loose
matter and impacted stool in the bowel.

 Option B: Option B allows a downward flow of solution by gravity along
the natural anatomical curve of the sigmoid colon. Some advocates claim
that enemas can support weight loss, remove toxins and heavy metals from
the body, and improve the skin, immunity, blood pressure, and energy
levels.
 Option C: Lubrication prevents trauma or irritation to the rectal mucosa.
The least irritating of all options, water or saline — salt water that mimics
the body‘s sodium concentration — are used primarily for their ability to
expand the colon and mechanically promote defecation.
 Option D: This is an appropriate length of insertion for a child. For an adult
client, the nurse should insert a tube 3 to 4 inches. Research shows that
enemas used in preparation for medical procedures significantly disrupt
gut bacteria, though the effect appears to be temporary. However, enemas
that are split and administered in two doses seem to have fewer effects on
the microbiome.
 Option E: The height of the fluid container affects the speed of installation.
The maximum recommended height is 18 inches. Hanging the container
higher than that could cause rapid installation and possibly painful
distention of the colon.
ADV
74. Question
While a nurse is administering a cleansing enema, the client reports abdominal
cramping. Which of the following is the appropriate intervention?
o A. Have a client hold his breath briefly.
o B. Discontinue the fluid installation.
o C. Remind the client that cramping is common at this time.
o D. Lower the enema fluid container.

Incorrect
Correct Answer: D. Lower the enema fluid container.
To relieve the client‘s discomfort, the nurse should slow the rate of installation by
reducing the height of the enema solution container. An enema may be helpful

when there is a problem forming or passing stool. The colon, also called the large
intestine or large bowel, is a long, hollow organ in the abdomen. It plays an
important role in digestion by removing water from digested material and
forming feces (stool). In some circumstances, due to diet, medical condition, or
medication, among other possible causes, the bowel may form stool that is hard
to pass easily resulting in constipation.
 Option A: Taking slow, deep breaths is more therapeutic for easing
discomfort than holding the breath. A cleansing enema can also lower the
amount of bacteria in the colon and reduce the risk of infection for certain
surgeries.
 Option B: The nurse should stop the installation if the client‘s abdomen
becomes rigid and distended or if the nurse notes bleeding from the
rectum. An enema should not be painful when administered properly. The
client may feel fullness, mild pressure, or brief, minimal cramping during
the procedure. The client may also feel like he needs to have a bowel
movement.
 Option C: This intervention is not therapeutic as it implies that the client
must tolerate the discomfort and that the nurse cannot or will not do
anything to ease it. The client may take a few long, deep breaths to help
himself relax. If he has pain or discomfort while self-inserting an enema,
stop and contact the doctor.
ADV
75. Question
A client with chronic pulmonary disease has a bluish tinge around the lips. The
nurse charts which term to most accurately describe the client‘s condition?
o A. Hypoxia
o B. Hypoxemia
o C. Dyspnea
o D. Cyanosis
Incorrect
Correct Answer: D. Cyanosis

A bluish tinge to mucous membranes is called cyanosis. This is most accurate
because it is what the nurse observes. Cyanosis refers to a bluish cast to the skin
and mucous membranes. Peripheral cyanosis is when there is a bluish
discoloration to the hands or feet. It‘s usually caused by low oxygen levels in the
red blood cells or problems getting oxygenated blood to the body.
 Option A: The nurse can only observe signs/symptoms of hypoxia. More
information is needed to validate this conclusion. Hypoxia is a condition in
which the body or a region of the body is deprived of adequate oxygen
supply at the tissue level. Hypoxia may be classified as either generalized,
affecting the whole body, or local, affecting a region of the body.
 Option B: Hypoxemia requires blood oxygenation saturation data to be
confirmed. Hypoxemia refers to the low level of oxygen in the blood, and
the more general term hypoxia is an abnormally low oxygen content in any
tissue or organ or the body as a whole. Hypoxemia can cause hypoxia
(hypoxemic hypoxia), but hypoxia can also occur via other mechanisms,
such as anemia.
 Option C: Dyspnea is difficult to breathe. Dyspnea is the medical term for
shortness of breath, sometimes described as ―air hunger.‖ It is an
uncomfortable feeling. Shortness of breath can range from mild and
temporary to serious and long-lasting. It is sometimes difficult to diagnose
and treat dyspnea because there can be many different causes.
ADV
1. Question
Which intervention is an example of primary prevention?
 A. Administering digoxin (Lanoxicaps) to a patient with heart failure.
 B. Administering measles, mumps, and rubella immunization to an

infant.
 C. Obtaining a Papanicolaou smear to screen for cervical cancer.
 D. Using occupational therapy to help a patient cope with arthritis.

Incorrect
Correct Answer: B. Administering measles, mumps, and rubella
immunization to an infant.

Immunizing an infant is an example of primary prevention, which aims to prevent
health problems. Primary prevention includes those preventive measures that
come before the onset of illness or injury and before the disease process begins.
Examples include immunization and taking regular exercise to prevent health
problems developing in the future.
 Option A: Administering digoxin to treat heart failure and obtaining a
smear for a screening test are examples for secondary prevention, which
promotes early detection and treatment of disease. Those preventive
measures that lead to early diagnosis and prompt treatment of a disease,
illness, or injury to prevent more severe problems developing. Here health
educators such as Health Extension Practitioners can help individuals
acquire the skills of detecting diseases in their early stages.
 Option C: Obtaining a Papanicolau smear is a secondary prevention.
Secondary prevention includes those preventive measures that lead to
early diagnosis and prompt treatment of a disease, illness, or injury. This
should limit disability, impairment, or dependency and prevent more
severe health problems developing in the future.
 Option D: Using occupational therapy to help a patient cope with arthritis
is an example of tertiary prevention, which aims to help a patient deal with
the residual consequences of a problem or to prevent the problem from
recurring. Tertiary prevention includes those preventive measures aimed at
rehabilitation following significant illness. At this level, health educators
work to retrain, re-educate and rehabilitate the individual who has already
had an impairment or disability.
Question 2 of 75
2. Question
The nurse in charge is assessing a patient‘s abdomen. Which examination
technique should the nurse use first?
 A. Auscultation
 B. Inspection
 C. Percussion
 D. Palpation

Incorrect
Correct Answer: B. Inspection
Inspection always comes first when performing a physical examination. It is
important to begin with the general examination of the abdomen with the
patient in a completely supine position. The presence of any of the following
signs may indicate specific disorders. Percussion and palpation of the abdomen
may affect bowel motility and therefore should follow auscultation.
 Option A: The last step of the abdominal examination is auscultation with
a stethoscope. The diaphragm of the stethoscope should be placed on the
right side of the umbilicus to listen to the bowel sounds, and their rate
should be calculated after listening for at least two minutes. Normal bowel
sounds are low-pitched and gurgling, and the rate is normally 2-5/min.
Absent bowel sounds may indicate paralytic ileus and hyperactive rushes
(borborygmi) are usually present in small bowel obstruction and
sometimes may be auscultated in lactose intolerance.
 Option C: A proper technique of percussion is necessary to gain maximum
information regarding the abdominal pathology. While percussing, it is
important to appreciate tympany over air-filled structures such as the
stomach and dullness to percussion which may be present due to an
underlying mass or organomegaly (for example, hepatomegaly or
splenomegaly).
 Option D: The ideal position for abdominal examination is to sit or kneel
on the right side of the patient with the hand and forearm in the same
horizontal plane as the patient‘s abdomen. There are three stages of
palpation that include the superficial or light palpation, deep palpation,
and organ palpation and should be performed in the same order.
Maneuvers specific to certain diseases are also a part of abdominal
palpation.
3. Question
Which statement regarding heart sounds is correct?
 A. S1 and S2 sound equally loud over the entire cardiac area.
 B. S1 and S2 sound fainter at the apex.
 C. S1 and S2 sound fainter at the base.

 D. S1 is loudest at the apex, and S2 is loudest at the base.
Incorrect
Correct Answer: D. S1 is loudest at the apex, and S2 is loudest at the base.
The S1 sound—the ―lub‖ sound—is loudest at the apex of the heart. It sounds
longer, lower, and louder there than the S2 sounds. The S2—the ―dub‖ sound—is
loudest at the base. It sounds shorter, sharper, higher, and louder there than S1.
Heart sounds are created from blood flowing through the heart chambers as the
cardiac valves open and close during the cardiac cycle. Vibrations of these
structures from the blood flow create audible sounds — the more turbulent the
blood flow, the more vibrations that get created.
 Option A: The S1 heart sound is produced as the mitral and tricuspid
valves close in systole. This structural and hemodynamic change creates
vibrations that are audible at the chest wall. The mitral valve closing is the
louder component of S1. It also occurs sooner because of the left ventricle
contracts earlier in systole.
 Option B: Changes in the intensity of S1 are more attributable to forces
acting on the mitral valve. Such causes include a change in left ventricular
contractility, mitral structure, or the PR interval. However, under normal
resting conditions, the mitral and tricuspid sounds occur close enough
together not to be discernible. The most common reasons for a split S1 are
things that delay right ventricular contraction, like a right bundle branch
block.
 Option C: The S2 heart sound is produced with the closing of the aortic
and pulmonic valves in diastole. The aortic valve closes sooner than the
pulmonic valve, and it is the louder component of S2; this occurs because
the pressures in the aorta are higher than the pulmonary artery.
4. Question
The nurse in charge identifies a patient‘s responses to actual or potential health
problems during which step of the nursing process?
 A. Assessment
 B. Nursing diagnosis
 C. Planning

 D. Evaluation
Incorrect
Correct Answer: B. Nursing diagnosis
The nurse identifies human responses to actual or potential health problems
during the nursing diagnosis step of the nursing process. The formulation of a
nursing diagnosis by employing clinical judgment assists in the planning and
implementation of patient care. The North American Nursing Diagnosis
Association (NANDA) provides nurses with an up to date list of nursing
diagnoses. A nursing diagnosis, according to NANDA, is defined as a clinical
judgment about responses to actual or potential health problems on the part of
the patient, family or community.
 Option A: During the assessment step, the nurse systematically collects
data about the patient or family. Assessment is the first step and involves
critical thinking skills and data collection; subjective and objective.
Subjective data involves verbal statements from the patient or caregiver.
Objective data is measurable, tangible data such as vital signs, intake and
 Option C: During the planning step, the nurse develops strategies to
resolve or decrease the patient‘s problem. The planning stage is where
goals and outcomes are formulated that directly impact patient care based
on EDP guidelines. These patient-specific goals and the attainment of such
assist in ensuring a positive outcome.
 Option D: During the evaluation step, the nurse determines the
effectiveness of the plan of care. This final step of the nursing process is
vital to a positive patient outcome. Whenever a healthcare provider
intervenes or implements care, they must reassess or evaluate to ensure
the desired outcome has been met. Reassessment may frequently be
needed depending upon overall patient condition. The plan of care may be
5. Question
A female patient is receiving furosemide (Lasix), 40 mg P.O. b.i.D. in the plan of
care, the nurse should emphasize teaching the patient about the importance of
consuming:
 A. Fresh, green vegetables

 B. Bananas and oranges
 C. Lean red meat
 D. Creamed corn
Incorrect
Correct Answer: B. Bananas and oranges
Because furosemide is a potassium-wasting diuretic, the nurse should plan to
teach the patient to increase intake of potassium-rich foods, such as bananas and
oranges. Potassium is a mineral in the cells. It helps the nerves and muscles work
as they should. The right balance of potassium also keeps the heart beating at a
steady rate. Fresh, green vegetables; lean red meat; and creamed corn are not
good sources of potassium.
 Option A: GLVs are considered as natural caches of nutrients for human
beings as they are a rich source of vitamins, such as ascorbic acid, folic
acid, tocopherols, ?-carotene, and riboflavin, as well as minerals such as
iron, calcium, and phosphorous.
 Option C: Lean red meat is an excellent source of high biological value
protein, vitamin B12, niacin, vitamin B6, iron, zinc, and phosphorus. It is a
source of long?chain omega?3 polyunsaturated fats, riboflavin, pantothenic
acid, selenium, and, possibly, also vitamin D. It is also relatively low in fat
and sodium.
 Option D: Corn has several health benefits. Because of the high fiber
content, it can aid with digestion. It also contains valuable B vitamins,
which are important to your overall health. Corn also provides our bodies
with essential minerals such as zinc, magnesium, copper, iron, and
manganese.
6. Question
The nurse in charge must monitor a patient receiving chloramphenicol for
adverse drug reaction. What is the most toxic reaction to chloramphenicol?
 A. Lethal arrhythmias
 B. Malignant hypertension
 C. Status epilepticus

 D. Bone marrow suppression
Incorrect
Correct Answer: D. Bone marrow suppression
The most toxic reaction to chloramphenicol is bone marrow suppression.
Chloramphenicol is a synthetically manufactured broad-spectrum antibiotic. It
was initially isolated from the bacteria Streptomyces venezuelae in 1948 and was
the first bulk produced synthetic antibiotic. However, chloramphenicol is a rarely
used drug in the United States because of its known severe adverse effects, such
as bone marrow toxicity and grey baby syndrome. Chloramphenicol is not known
to cause lethal arrhythmias, malignant hypertension, or status epilepticus.
 Option A: Chloramphenicol is associated with severe hematological side
effects when administered systemically. Since 1982, chloramphenicol has
reportedly caused fatal aplastic anemia, with possible increased risk when
taken together with cimetidine. This adverse side effect can occur even
with the topical administration of the drug, which is most likely due to the
systemic absorption of the drug after topical application.
 Option B: Besides causing fatal aplastic anemia and bone marrow
suppression, other side effects of chloramphenicol include ototoxicity with
the use of topical ear drops, gastrointestinal reactions such as oesophagitis
with oral use, neurotoxicity, and severe metabolic acidosis.
 Option C: Optic neuritis is the most commonly associated neurotoxic
complication that can arise from chloramphenicol use. This adverse effect
usually takes more than six weeks to manifest, presenting with either acute
or subacute vision loss, with possible fundal changes. It may also present
with peripheral neuropathy, which may present as numbness or tingling. If
optic neuropathy occurs, the drug should be withdrawn immediately, which
will usually lead to partial or complete recovery of vision.
7. Question
A female patient is diagnosed with deep-vein thrombosis. Which nursing
diagnosis should receive highest priority at this time?
 A. Impaired gas exchanges related to increased blood flow.
 B. Fluid volume excess related to peripheral vascular disease.
 C. Risk for injury related to edema.

 D. Altered peripheral tissue perfusion related to venous congestion.
Incorrect
Correct Answer: D. Altered peripheral tissue perfusion related to venous
congestion.
Altered peripheral tissue perfusion related to venous congestion‖ takes highest
priority because venous inflammation and clot formation impede blood flow in a
patient with deep-vein thrombosis. A deep-vein thrombosis (DVT) is a blood clot
that forms within the deep veins, usually of the leg, but can occur in the veins of
the arms and the mesenteric and cerebral veins. Deep-vein thrombosis is a
common and important disease. It is part of the venous thromboembolism
disorders which represent the third most common cause of death from
cardiovascular disease after heart attacks and stroke.
 Option A: Option A is incorrect because impaired gas exchange is related
to decreased, not increased, blood flow. Depending on the relative balance
between the coagulation and thrombolytic pathways, thrombus
propagation occurs. DVT is commonest in the lower limb below the knee
and starts at low-flow sites, such as the soleal sinuses, behind venous valve
pockets.
 Option B: Option B is inappropriate because no evidence suggests that
this patient has a fluid volume excess. Nurses need to educate the patients
on the importance of ambulation, being compliant with compression
stockings, and taking the prescribed anticoagulation medications.
 Option C: Option C may be warranted but is secondary to altered tissue
perfusion. Thrombosis is a protective mechanism that prevents the loss of
blood and seals off damaged blood vessels. Fibrinolysis counteracts or
stabilizes the thrombosis. The triggers of venous thrombosis are frequently
multifactorial, with the different parts of the triad of Virchow contributing
in varying degrees in each patient, but all result in early thrombus
interaction with the endothelium. This then stimulates local cytokine
production and causes leukocyte adhesion to the endothelium, both of
which promote venous thrombosis.
8. Question
When positioned properly, the tip of a central venous catheter should lie in the:
 A. Superior vena cava

 B. Basilica vein
 C. Jugular vein
 D. Subclavian vein
Incorrect
Correct Answer: A. Superior vena cava
When the central venous catheter is positioned correctly, its tip lies in the
superior vena cava, inferior vena cava, or the right atrium—that is, in central
venous circulation. Blood flows unimpeded around the tip, allowing the rapid
infusion of large amounts of fluid directly into circulation. The basilica, jugular,
and subclavian veins are common insertion sites for central venous catheters.
 Option B: There are three main access sites for the placement of central
venous catheters. The internal jugular vein, common femoral vein, and
subclavian veins are the preferred sites for temporary central venous
catheter placement. Additionally, for mid-term and long-term central
venous access, the basilic and brachial veins are utilized for peripherally
inserted central catheters (PICCs).
 Option C: The internal jugular vein (IJ) is often chosen for its reliable
anatomy, accessibility, low complication rates, and the ability to employ
ultrasound guidance during the procedure. The individual clinical scenario
may dictate laterality in some cases (such as with trauma, head and neck
cancer, or the presence of other invasive devices or catheters), but all
things being equal, many physicians prefer the right IJ. As compared to the
left, the right IJ forms a more direct path to the superior vena cava (SVC)
and right atrium. It is also wider in diameter and more superficial, thus
presumably easier to cannulated.
 Option D: The subclavian vein site has the advantage of low rates of both
infectious and thrombotic complications. Additionally, the SC site is
accessible in trauma, when a cervical collar negates the choice of the IJ.
However, disadvantages include a higher relative risk of pneumothorax,
less accessibility to use ultrasound for CVC placement, and the non-
compressible location posterior to the clavicle.
9. Question
Nurse Nikki is revising a client‘s care plan. During which step of the nursing
process does such revision take place?

 A. Assessment
 B. Planning
 C. Implementation
 D. Evaluation
Incorrect
During the evaluation step of the nursing process, the nurse determines whether
the goals established in the care plan have been achieved, and evaluates the
success of the plan. If a goal is unmet or partially met the nurse reexamines the
data and revises the plan. This final step of the nursing process is vital to a
positive patient outcome. Whenever a healthcare provider intervenes or
implements care, they must reassess or evaluate to ensure the desired outcome
has been met. Reassessment may frequently be needed depending upon overall
patient condition. The plan of care may be adapted based on new assessment
data. Assessment involves data collection. Planning involves setting priorities,
establishing goals, and selecting appropriate interventions.
and weight.
 Option B: The planning stage is where goals and outcomes are formulated

10. Question
A 65-year-old female who has diabetes mellitus and has sustained a large
laceration on her left wrist asks the nurse, ―How long will it take for my scars to
disappear?‖ Which statement would be the nurse‘s best response?
 A. ―The contraction phase of wound healing can take 2 to 3 years.‖
 B. ―Wound healing is very individual but within 4 months the scar should
fade.
 C. “With your history and the type of location of the injury, it’s hard to
say.”
 D. ―If you don‘t develop an infection, the wound should heal any time
between 1 and 3 years from now.‖
Incorrect
Correct Answer: C. “With your history and the type of location of the injury,
it’s hard to say.”
Wound healing in a client with diabetes will be delayed. Providing the client with
a time frame could give the client false information. There is no doubt that
diabetes plays a detrimental role in wound healing. It does so by affecting the
wound healing process at multiple steps. Wound hypoxia, through a combination
of impaired angiogenesis, inadequate tissue perfusion, and pressure-related
ischemia, is a major driver of chronic diabetic wounds.
 Option A: Ischemia can lead to prolonged inflammation, which increases
the levels of oxygen radicals, leading to further tissue injury. Elevated levels
of matrix metalloproteases in chronic diabetic wounds, sometimes up to
50-100 times higher than acute wounds, cause tissue destruction and
prevent normal repair processes from taking place. Furthermore, diabetes
is associated with impaired immunity, with critical defects occurring at
multiple points within the immune system cascade of the wound healing
process.
 Option B: To further complicate matters, these wounds have defects in
angiogenesis and neovascularization. Normally, wound hypoxia stimulates
mobilization of endothelial progenitor cells via vascular endothelial growth
factor (VEGF). In diabetic wounds, there are aberrant levels of VEGF and

other angiogenic factors such as angiopoietin-1 and angiopoietin-2 that
lead to dysangiogenesis.
 Option D: Diabetic neuropathy may also play a role in poor wound
healing. Lower levels of neuropeptides, as well as reduced leukocyte
infiltration as a result of sensory denervation, have been shown to impair
wound healing. When combined, all these diverse factors play a role in the
formation and propagation of chronic, debilitating wounds in patients with
diabetes.
11. Question
One aspect of implementation related to drug therapy is:
 A. Developing a content outline.
 B. Documenting drugs given.
 C. Establishing outcome criteria.
 D. Setting realistic client goals.

Incorrect
Correct Answer: B. Documenting drugs given.
Although documentation isn‘t a step in the nursing process, the nurse is legally
required to document activities related to drug therapy, including the time of
administration, the quantity, and the client‘s reaction. Developing a content
outline, establishing outcome criteria, and setting realistic client goals are part of
planning rather than implementation.
 Option A: UE has a common goal with the pharmaceutical care it supports:
to improve an individual patient‘s quality of life through the achievement
of predefined, medication-related therapeutic outcomes. Through its focus
on the system of medication use, the MUE process helps to identify actual
and potential medication-related problems, resolve actual medication-
related problems, and prevent potential medication-related problems that
could interfere with achieving optimum outcomes from medication
therapy.
 Option C: Although distinctions historically have been made among the
terms drug-use evaluation, drug-use review, and medication use evaluation
(MUE), they all refer to the systematic evaluation of medication use

employing standard, observational quality-improvement methods. MUE is
a quality-improvement activity, but it also can be considered a formulary
system management technique. An MUE is a performance improvement
method that focuses on evaluating and improving medication-use
processes with the goal of optimal patient outcomes.
 Option D: MUE encompasses the goals and objectives of drug use
evaluation (DUE) in its broadest application, emphasizing improving patient
outcomes. The use of MUE, rather than DUE, emphasizes the need for a
more multifaceted approach to improving medication use.
12. Question
A female client is readmitted to the facility with a warm, tender, reddened area on
her right calf. Which contributing factor would the nurse recognize
as most important?
 A. A history of increased aspirin use.
 B. Recent pelvic surgery.
 C. An active daily walking program.
 D. A history of diabetes.
Incorrect
Correct Answer: B. Recent pelvic surgery
The client shows signs of deep vein thrombosis (DVT). The pelvic area is rich in
blood supply, and thrombophlebitis of the deep vein is associated with pelvic
surgery. Thrombosis is a protective mechanism that prevents the loss of blood
and seals off damaged blood vessels. Fibrinolysis counteracts or stabilizes the
thrombosis. The triggers of venous thrombosis are frequently multifactorial, with
the different parts of the triad of Virchow contributing in varying degrees in each
patient, but all result in early thrombus interaction with the endothelium. This
then stimulates local cytokine production and causes leukocyte adhesion to the
endothelium, both of which promote venous thrombosis.
 Option A: Aspirin, an antiplatelet agent, and an active walking program
help decrease the client‘s risk of DVT. The use of thrombolytic therapy can
result in an intracranial bleed, and hence, careful patient selection is vital.
Recently endovascular interventions like catheter-directed extraction,

stenting, or mechanical thrombectomy have been tried with moderate
success.
 Option C: Treatment of DVT aims to prevent pulmonary embolism, reduce
morbidity, and prevent or minimize the risk of developing post-thrombotic
syndrome. The cornerstone of treatment is anticoagulation. NICE
guidelines only recommend treating proximal DVT (not distal) and those
with pulmonary emboli. In each patient, the risks of anticoagulation need
to be weighed against the benefits.
 Option D: In general, diabetes is a contributing factor associated with
peripheral vascular disease. In the hospital, the most commonly associated
conditions are malignancy, congestive heart failure, obstructive airway
disease, and patients undergoing surgery. In the hospital, the most
commonly associated conditions are malignancy, congestive heart failure,
obstructive airway disease, and patients undergoing surgery.
13. Question
Which intervention should the nurse in charge try first for a client that exhibits
signs of sleep disturbance?
 A. Administer sleeping medication before bedtime.
 B. Ask the client each morning to describe the quantity of sleep during the
previous night.
 C. Teach the client relaxation techniques, such as guided imagery,

medication, and progressive muscle relaxation.
 D. Provide the client with normal sleep aids, such as pillows, back rubs,
and snacks.
Incorrect
Correct Answer: D. Provide the client with normal sleep aids, such as pillows,
back rubs, and snacks
The nurse should begin with the simplest interventions, such as pillows or snacks,
before interventions that require greater skill such as relaxation techniques. Sleep
is a complex biological process. It is a reversible state of unconsciousness in
which there are reduced metabolism and motor activity. Sleep disorders are a
group of conditions that disturb the normal sleep patterns of a person. Sleep

disorders are one of the most common clinical problems encountered.
Inadequate or non-restorative sleep can interfere with normal physical, mental,
social, and emotional functioning. Sleep disorders can affect overall health, safety,
and quality of life.
 Option A: Sleep medication should be avoided whenever possible.
Histamine type 1 receptor blockers: due to their sedative effects, these
drugs can be helpful in patients with sleep disorders. Benzodiazepines
(BZD) are the mainstay in the treatment of insomnia. Non-benzodiazepine
hypnotics are used for the treatment of acute and short term insomnia.
 Option B: At some point, the nurse should do a thorough sleep
assessment, especially if common sense interventions fail. The sleep diary,
or sleep log, is a subjective paper record of sleep and wakefulness over a
period of weeks to a month. Patients should record the detailed
description of sleep, such as bedtime, duration until sleep onset, the
number of awakenings, duration of awakenings, and nap times.
 Option C: Relaxation techniques may be implemented before sleep.
Meditation and breathing exercises are some of the relaxation techniques.
It begins with being in a comfortable position and closing eyes. The mind
and thoughts should be redirected towards a peaceful image, and
relaxation should be allowed to spread throughout the body.
14. Question
While examining a client‘s leg, the nurse notes an open ulceration with visible
granulation tissue in the wound. Until a wound specialist can be contacted, which
type of dressings is most appropriate for the nurse in charge to apply?
 A. Dry sterile dressing
 B. Sterile petroleum gauze
 C. Moist, sterile saline gauze
 D. Povidone-iodine-soaked gauze
Incorrect
Correct Answer: C. Moist, sterile saline gauze
Moist, sterile saline dressings support would heal and are cost-effective. If the
wound is infected and there are a lot of sloughs, which cannot be mechanically

debrided, then a chemical debridement can be done with collagenase-based
products. The goal is to help the wound heal as soon as possible by using an
appropriate dressing material to maintain the right amount of moisture. When
the wound bed is dry, use a dressing to increase moisture and if too wet and the
surrounding skin is macerated, use material that will absorb excess fluid and
protect the surrounding healthy skin.
 Option A: Dry sterile dressings adhere to the wound and debride the
tissue when removed. Tulle is a non-adherent dressing impregnated with
paraffin. It aids healing but doesn‘t absorb exudate. It also requires a
secondary dressing to hold it in place. It is ideal for burns as one can add
topical antibiotics to the dressing. It is known to cause allergies, and this
limits its wider use.
 Option B: Petroleum supports healing but is expensive. The
semipermeable dressing allows for moisture to evaporate and also reduces
pain. This dressing also acts as a barrier to prevent environmental
contamination. The semipermeable dressing does not absorb moisture and
requires regular inspection. It also requires a secondary dressing to hold
the semipermeable dressing in place.
 Option D: Povidone-iodine can irritate epithelial cells, so it shouldn‘t be
left on an open wound. Plastic film dressings are known to absorb exudate
and can be used for wounds with a moderate amount of exudate. They
should not be used on dry wounds. They often require a secondary
dressing to hold the plastic in place.
15. Question
A male client in a behavioral-health facility receives a 30-minute psychotherapy
session, and the provider uses a current procedure terminology (CPT) code that
bills for a 50-minute session. Under the False Claims Act, such illegal behavior is
known as:
 A. Unbundling
 B. Overbilling
 C. Upcoding
 D. Misrepresentation

Incorrect
Correct Answer: C. Upcoding
Upcoding is the practice of using a CPT code that‘s reimbursed at a higher rate
than the code for the service actually provided. Upcoding is fraudulent medical
billing in which a bill sent for a health service is more expensive than it should
have been based on the service that was performed. An upcoded bill can be sent
to any payer—whether a private health insurer, Medicaid, Medicare, or the
patient. Unbundling, overbilling, and misrepresentation aren‘t the terms used for
this illegal practice.
 Option A: Unbundling refers to using multiple CPT codes for those parts of
the procedure, either due to misunderstanding or in an effort to increase
payment.
 Option B: Overbilling (sometimes spelled as over-billing) is the practice of
charging more than is legally or ethically acceptable on an invoice or bill.
 Option D: A misrepresentation is a false statement of a material fact made
by one party which affects the other party‘s decision in agreeing to a
contract. If the misrepresentation is discovered, the contract can be
declared void, and depending on the situation, the adversely impacted
party may seek damages.
16. Question
A nurse assigned to care for a postoperative male client who has diabetes
mellitus. During the assessment interview, the client reports that he‘s impotent
and says that he‘s concerned about its effect on his marriage. In planning this
client‘s care, the most appropriate intervention would be to:
 A. Encourage the client to ask questions about personal sexuality.
 B. Provide time for privacy.
 C. Provide support for the spouse or significant other.
 D. Suggest referral to a sex counselor or other appropriate professional.

Incorrect
Correct Answer: D. Suggest referral to a sex counselor or other appropriate
professional

The nurse should refer this client to a sex counselor or other professional. Making
appropriate referrals is a valid part of planning the client‘s care. Therefore,
providing time for privacy and providing support for the spouse or significant
other are important, but not as important as referring the client to a sex
counselor.
 Option A: The nurse doesn‘t normally provide sex counseling. The nurse is
ideally placed in the primary care field to help ease the upset caused;
however, in order to offer care that is effective, insight and understanding
of the condition are required as well as the various treatment options
available to help men manage their health and wellbeing.
 Option B: The key goal of management is to diagnose and treat the cause
of ED when this is possible, enabling the man or couple to enjoy a
satisfactory sexual experience. This can occur when the nurse has identified
and treated any curable causes of ED, initiating lifestyle change and risk
factor modification, including drug-related factors, and offering education
and counselling to patients and their partners.
 Option C: The potential benefits of lifestyle changes (e.g. weight
management, smoking cessation) may be particularly important in
individuals with ED and specific comorbid cardiovascular or metabolic
diseases, such as diabetes or hypertension. As well as improving erectile
function, lifestyle changes may also benefit overall cardiovascular and
metabolic health. Further studies are needed to clarify the role of lifestyle
changes in the management of ED and related cardiovascular disease.
2. 17. Question
Using Abraham Maslow’s hierarchy of human needs, a nurse assigns highest priority to which
client need?
o A. Security
o B. Elimination
o C. Safety
o D. Belonging
Incorrect
Correct Answer: B. Elimination
According to Maslow, elimination is a first-level or physiological need and therefore takes
priority over all other needs. In 1943, Abraham Maslow developed a hierarchy based on basic

fundamental needs innate for all individuals. Maslow’s hierarchy of needs is a motivational
theory in psychology comprising a five-tier model of human needs, often depicted as hierarchical
levels within a pyramid. From the bottom of the hierarchy upwards, the needs are: physiological
(food and clothing), safety (job security), love and belonging needs (friendship), esteem, and
self-actualization. Security and safety are second-level needs; belonging is a third-level need.
Second- and third-level needs can be met only after a client’s first-level needs have been
satisfied.
 Option A: Once an individual’s physiological needs are satisfied, the needs for security
and safety become salient. People want to experience order, predictability, and control in
their lives. These needs can be fulfilled by the family and society (e.g. police, schools,
business, and medical care).
 Option C: Physiological and safety needs provide the basis for the implementation of
nursing care and nursing interventions. For example, emotional security, financial
security (e.g. employment, social welfare), law and order, freedom from fear, social
stability, property, health, and wellbeing (e.g. safety against accidents and injury).
 Option D: After physiological and safety needs have been fulfilled, the third level of
human needs is social and involves feelings of belongingness. The need for interpersonal
relationships motivates behavior. Examples include friendship, intimacy, trust, and
acceptance, receiving and giving affection and love. Affiliating, being part of a group
(family, friends, work)
18. Question
A male client on prolonged bed rest has developed a pressure ulcer. The wound shows no signs
of healing even though the client has received skin care and has been turned every 2 hours.
Which factor is most likely responsible for the failure to heal?
o A. Inadequate vitamin D intake.
o B. Inadequate protein intake.
o C. Inadequate massaging of the affected area.
o D. Low calcium level.

Incorrect
Correct Answer: B. Inadequate protein intake.
A client on bed rest suffers from a lack of movement and a negative nitrogen balance. Therefore,
inadequate protein intake impairs wound healing. Decubitus ulcers, also termed bedsores or
pressure ulcers, are skin and soft tissue injuries that form as a result of constant or prolonged
pressure exerted on the skin. These ulcers occur at bony areas of the body such as the ischium,
greater trochanter, sacrum, heel, malleolus (lateral than medial), and occiput. Inadequate vitamin
D intake and low calcium levels aren’t factors in poor healing for this client. A pressure ulcer
should never be massaged.

 Option A: Decubitus ulcer formation is multifactorial (external and internal factors), but
all these results in a common pathway leading to ischemia and necrosis. Tissues can
sustain an abnormal amount of external pressure, but constant pressure exerted over a
prolonged period is the main culprit.
 Option C: External pressure must exceed the arterial capillary pressure (32 mmHg) to
impede blood flow and must be greater than the venous capillary closing pressure (8 to
12 mmHg) to impair the return of venous blood. If the pressure above these values is
maintained, it causes tissue ischemia and further resulting in tissue necrosis. This
enormous pressure can be exerted due to compression by a hard mattress, railings of
hospital beds, or any hard surface with which the patient is in contact.
 Option D: Friction caused by skin rubbing against surfaces like clothing or bedding can
also lead to the development of ulcers by contributing to breaks in the superficial layers
of the skin. Moisture can cause ulcers and worsens existing ulcers via tissue breakdown
and maceration.
ADVERTISEMENTS
19. Question
A female client who received general anesthesia returns from surgery. Postoperatively, which
nursing diagnosis takes highest priority for this client?
o A. Acute pain related to surgery.
o B. Deficient fluid volume related to blood and fluid loss from surgery.
o C. Impaired physical mobility related to surgery.
o D. Risk for aspiration related to anesthesia.

Incorrect
Correct Answer: D. Risk for aspiration related to anesthesia.
Risk for aspiration related to anesthesia takes priority for this client because general anesthesia
may impair the gag and swallowing reflexes, possibly leading to aspiration. The gag reflex, also
known as the pharyngeal reflex, is a reflex contraction of the muscles of the posterior pharynx
after stimulation of the posterior pharyngeal wall, tonsillar area, or base of the tongue. The gag
reflex is believed to be an evolutionary reflex that developed as a method to prevent the
aspiration of solid food particles. It is an essential component of evaluating the medullary
brainstem and plays a role in the declaration of brain death.The other options, although
important, are secondary.
 Option A: Postoperative pain can additionally characterize as somatic or visceral. The
somatic division of pain is composed of a rich input of nociceptive myelinated, rapidly
conducting A-beta-fibers found in cutaneous and deep tissue, which contribute to a more
localized, sharp quality. The visceral division of pain is composed of a network of
unmyelinated C-fibers and thinly myelinated A-delta-fibers that span across multiple
viscera and converge together before entering the spinal cord. Also, visceral afferent

fibers run close to autonomic ganglia before their entrance into the dorsal root of the
spinal cord. These characteristic features of visceral nociceptive fibers are what
contribute to a more diffuse, poorly localized pattern of pain that may be accompanied by
autonomic reactions such as a change in heart rate or blood pressure.
 Option B: The acid-base and electrolyte changes observed in the perioperative period
could be secondary to the underlying illness or surgical procedure, for example,
hyponatremia occurring with transurethral resection of the prostate where glycine or
other hypotonic fluid is used for irrigation. Serum sodium concentration <120 mmol/L
will cause confusion and irritability, whereas <110 mmol/L may cause seizures and
coma.
 Option C: Complete physiologic recovery takes place by 40 min in 40% of the patients.
The functional quality of recovery in all domains occurs in only 11% of the patients by
day 3. Thus, the concept of awakening is involved with far greater dimensions than
judging the anesthetic effect as terminated and assessing a patient as being ―recovered‖ or
―awakened.‖ Patients cannot be considered fully recovered until they have returned to
their preoperative physiological state.
ADVERTISEMENTS
20. Question
The nurse inspects a client’s back and notices small hemorrhagic spots. The nurse documents
that the client has:
o A. Extravasation
o B. Osteomalacia
o C. Petechiae
o D. Uremia
Incorrect
Correct Answer: C. Petechiae
Petechiae are small hemorrhagic spots. Petechiae are tiny purple, red, or brown spots on the skin.
They usually appear on the arms, legs, stomach, and buttocks. They can also be found inside the
mouth or on the eyelids. These pinpoint spots can be a sign of many different conditions — some
minor, others serious. They can also appear as a reaction to certain medications.
 Option A: Extravasation is the leakage of fluid in the interstitial space. Extravasation is
the leakage of a fluid out of its container into the surrounding area, especially blood or
blood cells from vessels. In the case of inflammation, it refers to the movement of white
blood cells from the capillaries to the tissues surrounding them (leukocyte extravasation,
also known as diapedesis).
 Option B: Osteomalacia is the softening of bone tissue. Osteomalacia refers to a marked
softening of the bones, most often caused by severe vitamin D deficiency. The softened
bones of children and young adults with osteomalacia can lead to bowing during growth,

especially in weight-bearing bones of the legs. Osteomalacia in older adults can lead to
fractures.
 Option D: Uremia is an excess of urea and other nitrogen products in the blood. Uremia
is the condition of having high levels of urea in the blood. Urea is one of the primary
components of urine. It can be defined as an excess of amino acid and protein metabolism
end products, such as urea and creatinine, in the blood that would be normally excreted in
the urine.
ADVERTISEMENTS
21. Question
Which document addresses the client’s right to information, informed consent, and treatment
refusal?
o A. Standard of Nursing Practice
o B. Patient’s Bill of Rights
o C. Nurse Practice Act
o D. Code for Nurses

Incorrect
Correct Answer: B. Patient’s Bill of Rights
The Patient’s Bill of Rights addresses the client’s right to information, informed consent, timely
responses to requests for services, and treatment refusal. A legal document, it serves as a
guideline for the nurse’s decision making. Standards of Nursing Practice, the Nurse Practice Act,
and the Code for Nurses contain nursing practice parameters and primarily describe the use of
the nursing process in providing care.
 Option A: Standards of nursing practice developed by the American Nurses’ Association
(ANA) provide guidelines for nursing performance. They are the rules or definition of
what it means to provide competent care. The registered professional nurse is required by
law to carry out care in accordance with what other reasonably prudent nurses would do
in the same or similar circumstances. Thus, provision of high-quality care consistent with
established standards is critical.
 Option C: Every state and territory in the US set laws to govern the practice of nursing.
These laws are defined in the Nursing Practice Act (NPA). The NPA is then interpreted
into regulations by each state and territorial nursing board with the authority to regulate
the practice of nursing care and the power to enforce the laws.
 Option D: The ANA Code of Ethics for Nurses serves the following purposes: It is a
succinct statement of the ethical obligations and duties of every individual who enters the
nursing profession. It is the profession’s nonnegotiable ethical standard. It is an
expression of nursing’s own understanding of its commitment to society.
ADVERTISEMENTS

22. Question
If a blood pressure cuff is too small for a client, blood pressure readings taken with such a cuff
may do which of the following?
o A. Fail to show changes in blood pressure.
o B. Produce a false-high measurement.
o C. Cause sciatic nerve damage.
o D. Produce a false-low measurement.

Incorrect
Correct Answer: B. Produce a false-high measurement.
Using an undersized blood pressure cuff produces a falsely elevated blood pressure because the
cuff can’t record brachial artery measurements unless it’s excessively inflated.
 Option A: Using a blood pressure cuff that’s too large or too small can give inaccurate
blood pressure readings. The doctor’s office should have several sizes of cuffs to ensure
an accurate blood pressure reading. When one measures their blood pressure at home, it’s
important to use the proper size cuff.
 Option C: The sciatic nerve wouldn’t be damaged by hyperinflation of the blood
pressure cuff because the sciatic nerve is located in the lower extremity.
 Option D: The inflatable part of the blood pressure cuff should cover about 40% of the
distance around (circumference of) the upper arm. The cuff should cover 80% of the area
from the elbow to the shoulder.
ADVERTISEMENTS
23. Question
Nurse Elijah has been teaching a client about a high-protein diet. The teaching is successful if the
client identifies which meal as high in protein?
o A. Baked beans, hamburger, and milk
o B. Spaghetti with cream sauce, broccoli, and tea
o C. Bouillon, spinach, and soda
o D. Chicken cutlet, spinach, and soda

Incorrect
Correct Answer: A. Baked beans, hamburger, and milk

Baked beans, hamburger, and milk are all excellent sources of protein. Good choices include soy
protein, beans, nuts, fish, skinless poultry, lean beef, pork, and low-fat dairy products. Avoid
processed meats.
 Option B: The spaghetti-broccoli-tea choice is high in carbohydrates. The quality of the
carbohydrates (carbs) one eats is important too. Cut processed carbs from the diet, and
choose carbs that are high in fiber and nutrient-dense, such as whole grains and
vegetables and fruit.
 Option C: The bouillon-spinach-soda choice provides liquid and sodium as well as some
iron, vitamins, and carbohydrates.
 Option D: Chicken provides protein but the chicken-spinach-soda combination provides
less protein than the baked beans-hamburger-milk selection.
ADVERTISEMENTS
24. Question
A male client is admitted to the hospital with blunt chest trauma after a motor vehicle accident.
The first nursing priority for this client would be to:
o A. Assess the client’s airway.
o B. Provide pain relief.
o C. Encourage deep breathing and coughing.
o D. Splint the chest wall with a pillow.

Incorrect
Correct Answer: A. Assess the client’s airway.
The first priority is to evaluate airway patency before assessing for signs of obstruction, sternal
retraction, stridor, or wheezing. Airway management is always the nurse’s first priority. Blunt
trauma, on the whole, is a more common cause of traumatic injuries and can be equally life-
threatening. It is important to know the mechanism as management may be different. Most blunt
trauma is managed non-operatively, whereas penetrating chest trauma often requires operative
intervention. Pain management and splinting are important for the client’s comfort but would
come after airway assessment.
 Option B: Pain control greatly affects mortality and morbidity in patients with chest
trauma. Pain leads to splints which worsen or prevent healing. In many cases, it can lead
to pneumonia. Early analgesia should be considered to decrease splinting. In the acute
setting, push doses of short-acting narcotics should be used.
 Option C: Coughing and deep breathing may be contraindicated if the client has internal
bleeding and other injuries. Minor injuries may simply require close monitoring and pain
control. Care should be taken in the young and the elderly. Patients with 3 or more rib
fractures, a flail segment, and any number of rib fractures with pulmonary contusions,
hemopneumothorax, hypoxia, or pre-existing pulmonary disease should be monitored at
an advanced level of care.

 Option D: Immediate life-threatening injuries require prompt intervention, such as
emergent tube thoracostomy for large pneumothoraces, and initial management of
hemothorax. For cases of hemothorax, adequate drainage is imperative to prevent
retained hemothorax. Retained hemothorax can lead to empyema requiring video-assisted
thoracoscopic surgery.
ADVERTISEMENTS
25. Question
A newly hired charge nurse assesses the staff nurses as competent individually but ineffective
and unproductive as a team. In addressing her concern, the charge nurse should understand that
the usual reason for such a situation is:
o A. Unhappiness about the charge in leadership.
o B. Unexpected feelings and emotions among the staff.
o C. Fatigue from overwork and understaffing.
o D. Failure to incorporate staff in decision making.

Incorrect
Correct Answer: B. Unexpected feelings and emotions among the staff.
The usual or most prevalent reason for lack of productivity in a group of competent nurses is
inadequate communication or a situation in which the nurses have unexpected feelings and
emotions. Although the other options could be contributing to the problematic situation, they’re
less likely to be the cause.
 Option A: Providing employees with acknowledgment of the good work that they have
done is one of the easiest management tasks. However, it is also as easily neglected. For
instance, a study in the financial sector shows that only 20% of employees feel strongly
valued at work.
 Option C: Another big issue that causes low productivity is workplace stress. A study by
Health Advocate shows that there are about one million employees who are suffering
from low productivity due to stress, which costs companies $600 dollars per worker
every single year.
 Option D: An important reason for low employee productivity might be the fact that they
do not feel that they belong with the company that they are part of. It is important for
every manager to make sure that the environment in their business is welcoming to new
hires and does not make them feel underappreciated.
ADVERTISEMENTS
26. Question

A male client blood test results are as follows: white blood cell (WBC) count, 100ul; hemoglobin
(Hb) level, 14 g/dl; hematocrit (HCT), 40%. Which goal would be most important for this client?
o A. Promote fluid balance
o B. Prevent infection
o C. Promote rest
o D. Prevent injury
Incorrect
Correct Answer: B. Prevent infection
The client is at risk for infection because WBC count is dangerously low. Neutrophils play an
essential role in immune defenses because they ingest, kill, and digest invading microorganisms,
including fungi and bacteria. Failure to carry out this role leads to immunodeficiency, which is
mainly characterized by the presence of recurrent infections. Hb level and HCT are within
normal limits; therefore, fluid balance, rest, and prevention of injury are inappropriate.
 Option A: Neutrophils play a role in the immune defense against extracellular bacteria,
including Staphylococci, Streptococci, and Escherichia coli, among others. They also
protect against fungal infections, including those produced by Candida albicans. Once
their count is below 1 x 10/L recurrent infections start. As compensation, the monocyte
count may increase.
 Option C: Application of granulocyte-colony stimulating factor (G-CSF) can improve
neutrophil functions and number. Prophylactic use of antibiotics and antifungals is
reserved for some forms of alteration in neutrophil function such as chronic
granulomatous disease CGD).
 Option D: In primary neutropenia disorders such as chronic granulomatous disease
presents with recurrent infections affecting many organs since childhood. It is caused by
a failure to produce toxic reactive oxygen species so that the neutrophils can ingest the
microorganisms, but they are unable to kill them, as a significant consequence granuloma
can obstruct organs such as the stomach, esophagus, or bladder. Patients with this disease
are very susceptible to opportunistic infections by certain bacteria and fungi, especially
with Serratia and Burkholderia.
ADVERTISEMENTS
27. Question
Following a tonsillectomy, a female client returns to the medical-surgical unit. The client is
lethargic and reports having a sore throat. Which position would be most therapeutic for this
client?
o A. Semi-Fowler’s

o B. Supine
o C. High-Fowler’s
o D. Side-lying
Incorrect
Correct Answer: D. Side-lying
Because of lethargy, the post-tonsillectomy client is at risk for aspirating blood from the surgical
wound. Therefore, placing the client in the side-lying position until he awake is best. The semi-
Fowler’s, supine, and high-Fowler’s position don’t allow for adequate oral drainage in a
lethargic post-tonsillectomy client and increase the risk of blood aspiration.
 Option A: Semi-Fowler’s would not be able to facilitate effective drainage. Bleeding is
one of the most common and feared complications following tonsillectomy with or
without adenoidectomy. A study from 2009 to 2013 involving over one hundred thousand
children showed that 2.8% of children had unplanned revisits for bleeding following
tonsillectomy, 1.6% percent of patients came through the emergency department, and
0.8% required a procedure.
 Option B: Supine position predisposes the patient to aspiration. Frequency is higher at
night with 50% of bleeding occurring between 10pm-1am and 6am-9am; this is thought
to be from changes in circadian rhythm, vibratory effects of snoring on the oropharynx,
or drying of the oropharyngeal mucosa from mouth breathing. Risk of bleeding in
patients with known coagulopathies may be significantly higher.
 Option C: Tonsillectomy can be either extracapsular or intracapsular. The ―hot‖
extracapsular technique with monopolar cautery is the most popular technique in the
United States.
ADVERTISEMENTS
28. Question
The nurse inspects a client’s pupil size and determines that it’s 2 mm in the left eye and 3 mm in
the right eye. Unequal pupils are known as:
o A. Anisocoria
o B. Ataxia
o C. Cataract
o D. Diplopia
Incorrect
Correct Answer: A. Anisocoria

Unequal pupils are called anisocoria. Anisocoria, or unequal pupil sizes, is a common condition.
The varied causes have implications ranging from life-threatening to completely benign, and a
clinically guided history and examination is the first step in establishing a diagnosis.
 Option B: Ataxia is uncoordinated actions of involuntary muscle use. Ataxia is a
degenerative disease of the nervous system. Many symptoms of Ataxia mimic those of
being drunk, such as slurred speech, stumbling, falling, and incoordination. These
symptoms are caused by damage to the cerebellum, the part of the brain that is
responsible for coordinating movement.
 Option C: A cataract is an opacity of the eye’s lens. A cataract is a clouding of the
normally clear lens of the eye. For people who have cataracts, seeing through cloudy
lenses is a bit like looking through a frosty or fogged-up window. Clouded vision caused
by cataracts can make it more difficult to read, drive a car (especially at night) or see the
expression on a friend’s face.
 Option D: Diplopia is double vision. Diplopia is the perception of 2 images of a single
object. Diplopia may be monocular or binocular. Monocular diplopia is present when
only one eye is open. Binocular diplopia disappears when either eye is closed.
ADVERTISEMENTS
29. Question
The nurse in charge is caring for an Italian client. He’s complaining of pain, but he falls asleep
right after his complaint and before the nurse can assess his pain. The nurse concludes that:
o A. He may have a low threshold for pain.
o B. He was faking pain.
o C. Someone else gave him medication.
o D. The pain went away.

Incorrect
Correct Answer: A. He may have a low threshold for pain.
People of Italian heritage tend to verbalize discomfort and pain. The pain was real to the client,
and he may need medication when he wakes up. Italian females reported the highest sensitivity
to both mechanical and electrical stimulation, while Swedes reported the lowest sensitivity.
Mechanical pain thresholds differed more across cultures than did electrical pain thresholds.
Cultural factors may influence response to type of pain test.
 Option B: Our pain threshold is the minimum point at which something, such as pressure
or heat, causes us pain. For example, someone with a lower pain threshold might start
feeling pain when only minimal pressure is applied to part of their body. Pain tolerance
and threshold varies from person to person.
 Option C: When we feel pain, nearby nerves send signals to the brain through the spinal
cord. The brain interprets this signal as a sign of pain, which can set off protective
reflexes. For example, when one touches something very hot, the brain receives signals

indicating pain. This in turn can make one quickly pull the hand away without even
thinking.
 Option D: Biofeedback is a type of therapy that helps increase the awareness of how the
body responds to stressors and other stimuli. This includes pain. During a biofeedback
session, a therapist will teach the client how to use relaxation techniques, breathing
exercises, and mental exercises to override the body’s response to stress or pain.
ADVERTISEMENTS
30. Question
A female client is admitted to the emergency department with complaints of chest pain and
shortness of breath. The nurse’s assessment reveals jugular vein distention. The nurse knows that
when a client has jugular vein distension, it’s typically due to:
o A. A neck tumor
o B. An electrolyte imbalance
o C. Dehydration
o D. Fluid overload
Incorrect
Correct Answer: D. Fluid overload
Fluid overload causes the volume of blood within the vascular system to increase. This increase
causes the vein to distend, which can be seen most obviously in the neck veins. JVD is a sign of
increased central venous pressure (CVP). That’s a measurement of the pressure inside the vena
cava. CVP indicates how much blood is flowing back into the heart and how well the heart can
move that blood into the lungs and the rest of the body.
 Option A: A neck tumor doesn’t typically cause jugular vein distention. Right-sided
heart failure is a common cause. Right-sided heart failure usually develops after a left-
sided heart failure. The left ventricle pumps blood out through the aorta to most of the
body. The right ventricle pumps blood to the lungs. When the left ventricle’s pumping
power weakens, fluid can back up into the lungs. This eventually weakens the right
ventricle.
 Option B: An electrolyte imbalance may result in fluid overload, but it doesn’t directly
contribute to jugular vein distention. The pericardium is a thin, fluid-filled sac that
surrounds the heart. An infection of the pericardium, called constrictive pericarditis, can
restrict the volume of the heart. As a result, the chambers can’t fill with blood properly,
so blood can back up into veins, including the jugular veins.
 Option C: Dehydration does not cause JVD. Another common cause is pulmonary
hypertension. Pulmonary hypertension occurs when the pressure in your lungs increases,
sometimes as a result of changes to the lining of the artery walls. This can also lead to
right-sided heart failure.

ADVERTISEMENTS
31. Question
Critical thinking and the nursing process have which of the following in common? Both:
o A. Are important to use in nursing practice.
o B. Use an ordered series of steps.
o C. Are patient-specific processes.
o D. Were developed specifically for nursing.

Incorrect
Correct Answer: A. Are important to use in nursing practice.
Nurses make many decisions: some require using the nursing process, whereas others are not
client related but require critical thinking. Neither is linear. Critical thinking applies to any
discipline. n 1958, Ida Jean Orlando started the nursing process that still guides nursing care
today. Defined as a systematic approach to care using the fundamental principles of critical
thinking, client-centered approaches to treatment, goal-oriented tasks, evidence-based practice
(EDP) recommendations, and nursing intuition. Holistic and scientific postulates are integrated
to provide the basis for compassionate, quality-based care.
 Option B: The nursing process has specific steps; critical thinking does not. The nursing
process functions as a systematic guide to client-centered care with 5 sequential steps.
These are assessment, diagnosis, planning, implementation, and evaluation.
 Option C: The utilization of the nursing process to guide care is clinically significant
going forward in this dynamic, complex world of patient care. Aging populations carry
with them a multitude of health problems and inherent risks of missed opportunities to
spot a life-altering condition.
 Option D: Critical thinking skills will play a vital role as we develop plans of care for
these patient populations with multiple comorbidities and embrace this challenging
healthcare arena. Thus, the trend towards concept-based curriculum changes will assist us
in the navigation of these uncharted waters.
ADVERTISEMENTS
32. Question
In which step of the nursing process does the nurse analyze data and identify client problems?
o A. Assessment
o B. Diagnosis

o D. Evaluation
Incorrect
Correct Answer: B. Diagnosis
In the diagnosis phase, the nurse identifies the client’s health status. The North American
Nursing Diagnosis Association (NANDA) provides nurses with an up to date list of nursing
diagnoses. A nursing diagnosis, according to NANDA, is defined as a clinical judgment about
responses to actual or potential health problems on the part of the patient, family, or community.
 Option C: In the planning outcomes phase, the nurse formulates goals and outcomes.
The planning stage is where goals and outcomes are formulated that directly impact
 Option D: In the evaluation phase, which occurs after implementing interventions, the
nurse gathers data about the client’s responses to nursing care to determine whether client
outcomes were met. This final step of the nursing process is vital to a positive patient
outcome. Whenever a healthcare provider intervenes or implements care, they must
reassess or evaluate to ensure the desired outcome has been met. Reassessment may
frequently be needed depending upon overall patient condition. The plan of care may be
ADVERTISEMENTS
33. Question
In which phase of the nursing process does the nurse decide whether her actions have
successfully treated the client’s health problem?
o A. Assessment
o B. Diagnosis
o D. Evaluation

Incorrect
During the implementation phase, the nurse carries out the interventions or delegates them to
other health care team members. During the evaluation phase, the nurse judges whether her
actions have been successful in treating or preventing the identified client health problem. This
final step of the nursing process is vital to a positive patient outcome. Whenever a healthcare
provider intervenes or implements care, they must reassess or evaluate to ensure the desired
outcome has been met. Reassessment may frequently be needed depending upon overall patient
condition. The plan of care may be adapted based on new assessment data.
 Option B: In the diagnosis phase, the nurse identifies the client’s health status. The North
patient, family or community.
 Option C: In the planning outcomes phase, the nurse and client decide on goals they
want to achieve. In the intervention planning phase, the nurse identifies specific
interventions to help achieve the identified goal. The planning stage is where goals and
outcomes are formulated that directly impact patient care based on EDP guidelines.
These patient-specific goals and the attainment of such assist in ensuring a positive
outcome.
ADVERTISEMENTS
34. Question
What is the most basic reason that self-knowledge is important for nurses? Because it helps the
nurse to:
o A. Identify personal biases that may affect his thinking and actions.
o B. Identify the most effective interventions for a patient.
o C. Communicate more efficiently with colleagues, patients, and families.
o D. Learn and remember new procedures and techniques.

Incorrect
Correct Answer: A. Identify personal biases that may affect his thinking and actions.
The most basic reason is that self-knowledge directly affects the nurse’s thinking and the actions
he chooses. Indirectly, thinking is involved in identifying effective interventions,

communicating, and learning procedures. However, because identifying personal biases affect all
the other nursing actions, it is the most basic reason.
 Option B: In philosophy, ―self-knowledge‖ standardly refers to knowledge of one’s own
sensations, thoughts, beliefs, and other mental states. At least since Descartes, most
philosophers have believed that our knowledge of our own mental states differs markedly
from our knowledge of the external world (where this includes our knowledge of others’
thoughts).
 Option C: Perhaps the most widely accepted view along these lines is that self-
knowledge, even if not absolutely certain, is especially secure, in the following sense:
self-knowledge is immune from some types of error to which other kinds of empirical
knowledge—most obviously, perceptual knowledge—are vulnerable.
 Option D: Self-awareness is important because when we have a better understanding of
ourselves, we are able to experience ourselves as unique and separate individuals. We are
then empowered to make changes and to build on our areas of strength as well as identify
areas where we would like to make improvements.
ADVERTISEMENTS
35. Question
Arrange the steps of the nursing process in the sequence in which they generally occur.
View Answers:
o Planning interventions
o Planning outcomes
o Assessment
o Evaluation
o Diagnosis
Incorrect
Logically, the steps are assessment, diagnosis, planning outcomes, planning interventions, and
evaluation. Keep in mind that steps are not always performed in this order, depending on the
patient’s needs and that steps overlap.
 Assessment is the first step and involves critical thinking skills and data collection;
caregiver. Objective data is measurable, tangible data such as vital signs, intake and
 The formulation of a nursing diagnosis by employing clinical judgment assists in the
planning and implementation of patient care. The North American Nursing Diagnosis
Association (NANDA) provides nurses with an up to date list of nursing diagnoses. A
nursing diagnosis, according to NANDA, is defined as a clinical judgment about

responses to actual or potential health problems on the part of the patient, family, or
community.
 The planning stage is where goals and outcomes are formulated that directly impact
 Implementation is the step which involves action or doing and the actual carrying out of
nursing interventions outlined in the plan of care. This phase requires nursing
interventions such as applying a cardiac monitor or oxygen, direct or indirect care,
medication administration, standard treatment protocols, and EDP standards.
 This final step of the nursing process is vital to a positive patient outcome. Whenever a
healthcare provider intervenes or implements care, they must reassess or evaluate to
ensure the desired outcome has been met. Reassessment may frequently be needed
depending upon overall patient condition. The plan of care may be adapted based on new
assessment data.
ADVERTISEMENTS
36. Question
How are critical thinking skills and critical thinking attitudes similar? Both are:
o A. Influences on the nurse's problem solving and decision making.
o B. Like feelings rather than cognitive activities.
o C. Cognitive activities rather than feelings.
o D. Applicable in all aspects of a person's life.

Incorrect
Correct Answer: A. Influences on the nurse’s problem solving and decision making.
Cognitive skills are used in complex thinking processes, such as problem-solving and decision
making. Critical thinking attitudes determine how a person uses her cognitive skills. Critical
thinking attitudes are traits of the mind, such as independent thinking, intellectual curiosity,
intellectual humility, and fair-mindedness, to name a few. Critical thinking skills refer to the
cognitive activities used in complex thinking processes. A few examples of these skills involve
recognizing the need for more information, recognizing gaps in one’s own knowledge, and
separating relevant information from irrelevant data. Critical thinking, which consists of
intellectual skills and attitudes, can be used in all aspects of life.
 Option B: Critical Thinking is, in short, self-directed, self-disciplined, self-monitored,
and self-corrective thinking. It presupposes assent to rigorous standards of excellence and

mindful command of their use. It entails effective communication and problem-solving
abilities and a commitment to overcome our native egocentrism and sociocentrism.
 Option C: Critical Thinking is a domain-general thinking skill. The ability to think
clearly and rationally is important whenever one chooses to do. But critical thinking skills
are not restricted to a particular subject area. Being able to think well and solve problems
systematically is an asset for any career.
 Option D: A critical thinking attitude is related to the motivation to try to reason well,
but it can also motivate an attempt to use various strategies to overcome personal
limitations. Additionally, a person with a critical thinking attitude should often rely on
the expertise of others rather than trying to assess all arguments on her own because
expertise is often required to properly evaluate an argument.
ADVERTISEMENTS
37. Question
The nurse is preparing to admit a patient from the emergency department. The transferring nurse
reports that the patient with chronic lung disease has a 30+ year history of tobacco use. The nurse
used to smoke a pack of cigarettes a day at one time and worked very hard to quit smoking. She
immediately thinks to herself, ―I know I tend to feel negative about people who use tobacco,
especially when they have a serious lung condition; I figure if I can stop smoking, they should be
able to. I must remember how physically and psychologically difficult that is, and be very careful
not to let it be judgmental of this patient.‖ This best illustrates:
o A. Theoretical knowledge
o B. Self-knowledge
o C. Using reliable resources
o D. Use of the nursing process

Incorrect
Correct Answer: B. Self-knowledge
Personal knowledge is self-understanding—awareness of one’s beliefs, values, biases, and so on.
That best describes the nurse’s awareness that her bias can affect her patient care. Self-
knowledge refers to knowledge of one’s own mental states, processes, and dispositions. Most
agree it involves a capacity for understanding the representational properties of mental states and
their role in shaping behavior.
 Option A: Theoretical knowledge consists of information, facts, principles, and theories
in nursing and related disciplines; it consists of research findings and rationally
constructed explanations of phenomena. Theoretical knowledge is a knowledge of why
something is true. A set of true affirmations (factual knowledge) does not necessarily
explain anything. In order to explain something, it is necessary to state why these truths
are true. An explanation is required.

 Option C: Using reliable resources is a critical thinking skill. Critical thinking is, in
short, self-directed, self-disciplined, self-monitored, and self-corrective thinking. It
presupposes assent to rigorous standards of excellence and mindful command of their
use. It entails effective communication and problem-solving abilities and a commitment
to overcome our native egocentrism and sociocentrism.
 Option D: The nursing process is a problem-solving process consisting of the steps of
assessing, diagnosing, planning outcomes, planning interventions, implementing, and
evaluating. The nurse has not yet met this patient, so she could not have begun the
nursing process.
ADVERTISEMENTS
38. Question
Which organization’s standards require that all patients be assessed specifically for pain?
o A. American Nurses Association (ANA)
o B. State nurse practice acts
o C. National Council of State Boards of Nursing (NCSBN)
o D. The Joint Commission

Incorrect
Correct Answer: D. The Joint Commission
The Joint Commission has developed assessment standards, including that all clients be assessed
for pain.
 Option A: The ANA has developed standards for clinical practice, including those for
assessment, but not specifically for pain. The American Nurses Association (ANA) is the
premier organization representing the interests of the nation’s 4 million registered nurses.
ANA is at the forefront of improving the quality of health care for all. Founded in 1896,
and with members in all 50 states and U.S. territories, ANA is the strongest voice for the
profession.
 Option B: State nurse practice acts regulate nursing practice in individual states. An
NPA is enacted by state legislation and its purpose is to govern and guide nursing
practice within that state. An NPA is actually a law and must be adhered to as law. Each
state has a Board of Nursing (BON) that interprets and enforces the rules of the NPA.
 Option C: The NCSBN asserts that the scope of nursing includes a comprehensive
assessment but does not specifically include pain. National Council of State Boards of
Nursing (NCSBN) is an independent, not-for-profit organization through which nursing
regulatory bodies act and counsel together on matters of common interest and concern
affecting public health, safety, and welfare, including the development of nursing
licensure examinations.
ADVERTISEMENTS

39. Question
Which of the following is an example of data that should be validated?
o A. The urinalysis report indicates there are white blood cells in the urine.
o B. The client states she feels feverish; you measure the oral temperature at 98°F.
o C. The client has clear breath sounds; you count a respiratory rate of 18.
o D. The chest x-ray report indicates the client has pneumonia in the right lower lobe.
Incorrect
Correct Answer: B. The client states she feels feverish; you measure the oral temperature
at 98°F.
Validation should be done when subjective and objective data do not make sense. For instance, it
is inconsistent data when the patient feels feverish and you obtain a normal temperature. The
other distractors do not offer conflicting data. Validation is not usually necessary for laboratory
test results.
 Option A: When this test is positive and/or the WBC count in urine is high, it may
indicate that there is inflammation in the urinary tract or kidneys. The most common
cause for WBCs in urine (leukocyturia) is a bacterial urinary tract infection (UTI), such
as a bladder or kidney infection.
 Option C: Breath sounds are the noises produced by the structures of the lungs during
breathing. Normal lung sounds occur in all parts of the chest area, including above the
collarbones and at the bottom of the rib cage. Using a stethoscope, the doctor may hear
normal breathing sounds, decreased or absent breath sounds, and abnormal breath sounds.
Normal respiration rates for an adult person at rest range from 12 to 16 breaths per
minute.
 Option D: The most common organisms which cause lobar pneumonia are Streptococcus
pneumoniae, also called pneumococcus, Haemophilus influenza, and Moraxella
catarrhalis. Mycobacterium tuberculosis, the tubercle bacillus, may also cause lobar
pneumonia if pulmonary tuberculosis is not treated promptly.
ADVERTISEMENTS
40. Question
Which of the following is an example of appropriate behavior when conducting a client
interview?
o A. Recording all the information on the agency-approved form during the interview.
o B. Asking the client, "Why did you think it was necessary to seek health care at this time?"

o C. Using precise medical terminology when asking the client questions.
o D. Sitting, facing the client in a chair at the client's bedside, using active listening.
Incorrect
Correct Answer: D. Sitting, facing the client in a chair at the client’s bedside, using active
listening.
Active listening should be used during an interview. The nurse should face the patient, have
relaxed posture, and keep eye contact. Nonjudgmental interest in the patient’s problems (active
listening), empathy (communicating to the patient an accurate assessment of emotional state),
and concern for the patient as a unique person are among the most important tools in the
physician’s interpersonal repertoire. The difference between interviewing a patient who is lying
flat in bed and one who is sitting in a chair can be striking. This simple act can emphasize patient
autonomy and active involvement in the interview.
 Option A: Note-taking interferes with eye contact. By recognizing the patient’s emotions
and responding to them in a supportive manner, the clinician can conduct an effective
patient-centered interview.
 Option B: Asking ―why‖ may make the client defensive. Frequently used opening
questions include, ―What problems brought you to the hospital (or office) today?‖ or
―What kind of problems have you been having recently?‖ or ―What kind of problems
would you like to share with me?‖ These open-ended, non-directive questions encourage
the patient to report any and all problems. At this point in the interview, it is important to
let the patient talk spontaneously rather than restricting and directing the flow of
information with multiple questions.
 Option C: The client may not understand medical terminology or health care jargon.
Questions should be worded so that the patient has no difficulty understanding what is
being asked. Avoid using technical terms and diagnostic labels. The interviewer’s
questions should indicate what type of information is requested, but not what answer is
expected.
ADVERTISEMENTS
41. Question
The nurse wishes to identify nursing diagnoses for a patient. She can best do this by using a data
collection form organized according to: Select all that apply.
o A. A body systems model
o B. A head-to-toe framework
o C. Maslow's hierarchy of needs
o D. Gordon's functional health patterns

o E. Adaptation Model of Nursing
Incorrect
Correct Answer: C & D
Nursing models produce a holistic database that is useful in identifying nursing rather than
medical diagnoses. Body systems and Maslow’s hierarchy is not a nursing model, but it is
holistic, so it is acceptable for identifying nursing diagnoses. Gordon’s functional health patterns
are a nursing model.
 Option A: A body system model is not a nursing model. It is a representation of all the
systems of the body in a figurine.
 Option B: Head-to-toe framework is not a nursing model, and they are not holistic; they
focus on identifying physiological needs or disease.
 Option C: Maslow’s hierarchy of needs is a motivational theory in psychology
comprising a five-tier model of human needs, often depicted as hierarchical levels within
a pyramid. From the bottom of the hierarchy upwards, the needs are: physiological (food
and clothing), safety (job security), love and belonging needs (friendship), esteem, and
self-actualization.
 Option D: Gordon’s functional health patterns is a method devised by Marjory Gordon
to be used by nurses in the nursing process to provide a more comprehensive nursing
assessment of the patient.
 Option E: The Adaptation Model of Nursing is a prominent nursing theory aiming to
explain or define the provision of nursing science. In her theory, Sister Callista Roy’s
model sees the individual as a set of interrelated systems that strives to maintain a
balance between various stimuli.
ADVERTISEMENTS
42. Question
The nurse is recording assessment data. She writes, ―The patient seems worried about his
surgery. Other than that, he had a good night.‖ Which errors did the nurse make? Select all that
apply.
o A. Used a vague generality.
o B. Did not use the patient's exact words.
o C. Used a "waffle" word (e.g., appears).
o D. Recorded an inference rather than a cue.
o E. Did not record the patient’s vital signs.

Incorrect
Correct Answer: A, C, D & E

The initial nursing assessment, the first step in the five steps of the nursing process, involves the
systematic and continuous collection of data; sorting, analyzing, and organizing that data; and
the documentation and communication of the data collected. Subjective and objective data
 Option A: The nurse recorded a vague generality: ―he has had a good night.‖ The
assessment identifies current and future care needs of the patient by allowing the
formation of a nursing diagnosis. The nurse recognizes normal and abnormal patient
physiology and helps prioritize interventions and care.
 Option B: The nurse did not use the patient’s exact words, but she did not quote the
patient at all, so that is not one of her errors.
 Option C: The nurse used the ―waffle‖ word, ―seems‖ worried instead of documenting
what the patient said or did to lead her to that conclusion. Asking about how the client
feels and their response to those feelings is part of a psychological assessment.
 Option D: The nurse recorded these inferences: worried and had a good night. The
psychological examination may include perceptions, whether justifiable or not, on the
part of the patient or client. Religion and cultural beliefs are critical areas to consider.
 Option E: Part of the assessment includes data collection by obtaining vital signs such as
temperature, respiratory rate, heart rate, blood pressure, and pain level using age or
condition appropriate pain scale.
ADVERTISEMENTS
43. Question
A patient is admitted with shortness of breath, so the nurse immediately listens to his breath
sounds. Which type of assessment is the nurse performing?
o A. Ongoing assessment
o B. Comprehensive physical assessment
o C. Focused physical assessment
o D. Psychosocial assessment
Incorrect
Correct Answer: C. Focused physical assessment
The nurse is performing a focused physical assessment, which is done to obtain data about an
identified problem, in this case shortness of breath. Detailed nursing assessment of specific body
system(s) relating to the presenting problem or current concern(s) of the patient. This may
involve one or more body systems.
 Option A: An ongoing assessment is performed as needed, after the initial data are
collected, preferably with each patient contact. Repeat of the focused or rapid emergency
department assessment of a prehospital patient to detect changes in condition and to
judge the effectiveness of treatment before or during transport. Repeated every 5 minutes
for an unstable patient and every 15 minutes for a stable patient.

 Option B: A comprehensive physical assessment includes an interview and a complete
examination of each body system. A comprehensive health assessment gives nurses
insight into a patient’s physical status through observation, the measurement of vital
signs, and self-reported symptoms. It includes a medical history, a general survey, and a
complete physical examination.
 Option D: A psychosocial assessment examines both psychological and social factors
affecting the patient. The nurse conducting a psychosocial assessment would gather
information about stressors, lifestyle, emotional health, social influences, coping patterns,
communication, and personal responses to health and illness, to name a few aspects.
ADVERTISEMENTS
44. Question
The nurse is assessing vital signs for a patient just admitted to the hospital. Ideally, and if there
are no contraindications, how should the nurse position the patient for this portion of the
admission assessment?
o A. Sitting upright.
o B. Lying flat on the back with knees flexed.
o C. Lying flat on the back with arms and legs fully extended.
o D. Side-lying with the knees flexed.

Incorrect
Correct Answer: A. Sitting upright.
If the patient is able, the nurse should have the patient sit upright to obtain vital signs in order to
allow the nurse to easily access the anterior and posterior chest for auscultation of heart and
breath sounds. It allows for full lung expansion and is the preferred position for measuring blood
pressure. Additionally, patients might be more comfortable and feel less vulnerable when sitting
upright (rather than lying down on the back) and can have direct eye contact with the examiner.
However, other positions can be suitable when the patient’s physical condition restricts the
comfort or ability of the patient to sit upright.
 Option B: Lying flat on the back with knees flexed or supine horizontal recumbent is
most commonly used during breast exam.
 Option C: Lying flat on the back with arms and legs fully extended can make the patient
feel uncomfortable.
 Option D: Sim’s position is usually used to obtain rectal temperature.
ADVERTISEMENTS
45. Question

For all body systems except the abdomen, what is the preferred order for the nurse to perform the
following examination techniques?
View Answers:
o Palpation
o Percussion
o Auscultation
o Inspection
Incorrect
Inspection begins immediately as the nurse meets the patient, as she observes the patient’s
appearance and behavior. Observational data are not intrusive to the patient. When performing
assessment techniques involving physical touch, the behavior, posture, demeanor, and responses
might be altered. Palpation, percussion, and auscultation should be performed in that order,
except when performing an abdominal assessment. During abdominal assessment, auscultation
should be performed before palpation and percussion to prevent altering bowel sounds.
 1. It is important to begin with the general examination of the abdomen with the patient
in a completely supine position. The presence of any of the following signs may indicate
specific disorders. Distension of the abdomen could be present due to small bowel
obstruction, masses, tumors, cancer, hepatomegaly, splenomegaly, constipation,
abdominal aortic aneurysm, and pregnancy.
 2. The ideal position for abdominal examination is to sit or kneel on the right side of the
patient with the hand and forearm in the same horizontal plane as the patient’s abdomen.
There are three stages of palpation that include the superficial or light palpation, deep
palpation, and organ palpation and should be performed in the same order. Maneuvers
specific to certain diseases are also a part of abdominal palpation.
 3. A proper technique of percussion is necessary to gain maximum information regarding
the abdominal pathology. While percussing, it is important to appreciate tympany over
air-filled structures such as the stomach and dullness to percussion which may be present
due to an underlying mass or organomegaly (for example, hepatomegaly or
splenomegaly).
 4. The last step of the abdominal examination is auscultation with a stethoscope. The
diaphragm of the stethoscope should be placed on the right side of the umbilicus to listen
to the bowel sounds, and their rate should be calculated after listening for at least two
minutes. Normal bowel sounds are low-pitched and gurgling, and the rate is normally 2-
5/min. Absent bowel sounds may indicate paralytic ileus and hyperactive rushes
(borborygmi) are usually present in small bowel obstruction and sometimes may be
auscultated in lactose intolerance.
ADVERTISEMENTS
46. Question

The nurse is assessing a patient admitted to the hospital with rectal bleeding. The patient had a
hip replacement 2 weeks ago. Which position should the nurse avoid when examining this
patient’s rectal area?
o A. Sims'
o B. Supine
o C. Dorsal recumbent
o D. Semi-Fowler's
Incorrect
Correct Answer: A. Sims’
Sims’ position is typically used to examine the rectal area. However, the position should be
avoided if the patient has undergone hip replacement surgery The patient with a hip replacement
can assume the supine, dorsal recumbent, or semi-Fowler’s positions without causing harm to the
joint.
 Option B: Supine position is lying on the back facing upward. The supine position
means lying horizontally with the face and torso facing up, as opposed to the prone
position, which is face down. When used in surgical procedures, it allows access to the
peritoneal, thoracic, and pericardial regions; as well as the head, neck, and extremities.
 Option C: The patient in dorsal recumbent is on his back with knees flexed and soles of
feet flat on the bed. A position in which the patient lies on the back with the lower
extremities moderately flexed and rotated outward. It is employed in the application of
obstetrical forceps, repair of lesions following parturition, vaginal examination, and
bimanual palpation.
 Option D: In semi-Fowler’s position, the patient is supine with the head of the bed
elevated and legs slightly elevated. The Semi-Fowler’s position is a position in which a
patient, typically in a hospital or nursing home is positioned on their back with the head
and trunk raised to between 15 and 45 degrees, although 30 degrees is the most
frequently used bed angle.
ADVERTISEMENTS
47. Question
How should the nurse modify the examination for a 7-year-old child?
o A. Ask the parents to leave the room before the examination.
o B. Demonstrate equipment before using it.
o C. Allow the child to help with the examination.

o D. Perform invasive procedures (e.g., otoscopic) last.
Incorrect
Correct Answer: B. Demonstrate equipment before using it.
The nurse should modify his examination by demonstrating equipment before using it to
examine a school-age child. The physical examination is often the first direct contact between
the nurse and the child. Establishing a trusting relationship between the child and the examiner is
important. Throughout the examination the nurse should be sensitive to the cultural needs of and
differences among children. Providing a quiet, private environment for the history and physical
examination is important. The classic systematic approach to the physical examination is to
begin at the head and proceed through the entire body to the toes. When examining a child,
however, the examiner tailors the physical assessment to the child’s age and developmental
level.
 Option A: The nurse should make sure parents are not present during the physical
examination of an adolescent, but they usually help younger children feel more secure.
To establish trust with the school-age child, the examiner asks the child questions the
child can answer. Children in elementary school will talk about school, favorite friends,
and activities. Older school-age children may have to be encouraged to talk about their
school performance and activities. The examiner encourages the parent to support and
reinforce the child’s participation in the examination.
 Option C: The nurse should allow a preschooler to help with the examination when
possible, but not usually a school-age child. The examination proceeds from head to toe.
Children of this age prefer a simple drape over their underpants or a colorful examination
gown, and the examiner should be sensitive to the child’s modesty. The examination is a
wonderful opportunity to teach the child about the body and personal care. The nurse
answers questions openly and in simple terms.
 Option D: It is best to perform invasive procedures last for all age groups; therefore, this
does not represent a modification. Toddlers are often fearful of invasive procedures, so
those should be performed last in this age group.
ADVERTISEMENTS
48. Question
The nurse must examine a patient who is weak and unable to sit unaided or to get out of bed.
How should she position the patient to begin and perform most of the physical examination?
o A. Dorsal recumbent
o B. Semi-Fowler's
o C. Lithotomy
o D. Sims'
Incorrect

Correct Answer: B. Semi-Fowler’s
If a patient is unable to sit up, the nurse should place him lying flat on his back, with the head of
the bed elevated. The Semi-Fowler’s position is a position in which a patient, typically in a
hospital or nursing home is positioned on their back with the head and trunk raised to between 15
and 45 degrees, although 30 degrees is the most frequently used bed angle.
 Option A: Dorsal recumbent position is used for abdominal assessment if the patient has
abdominal or pelvic pain. The patient in dorsal recumbent is on his back with knees
flexed and soles of feet flat on the bed.
 Option C: Lithotomy position is used for female pelvic examination. It is similar to
dorsal recumbent position, except that the patient’s legs are well separated and thighs are
acutely flexed. Feet are usually placed in stirrups. Fold sheet or bath blanket crosswise
over thighs and legs so that genital area is easily exposed. Keep the patient covered as
much as possible.
 Option D: The patient in Sim’s position is on the left side with right knee flexed against
abdomen and left knee slightly flexed. Left arm is behind the body; the right arm is
placed comfortably. Sims’ position is used to examine the rectal area. In semi-Fowler’s
position, the patient is supine with the head of the bed elevated and legs slightly elevated.
ADVERTISEMENTS
49. Question
The nurse should use the diaphragm of the stethoscope to auscultate which of the following?
o A. Heart murmurs
o B. Jugular venous hums
o C. Bowel sounds
o D. Carotid bruits
Incorrect
Correct Answer: C. Bowel sounds
The bell of the stethoscope should be used to hear low-pitched sounds, such as murmurs, bruits,
and jugular hums. The diaphragm should be used to hear high-pitched sounds that normally
occur in the heart, lungs, and abdomen. The diaphragm is best for higher-pitched sounds, like
breath sounds and normal heart sounds. The bell is best for detecting lower pitch sounds, like
some heart murmurs, and some bowel sounds.
 Option A: Earpieces should be angled forwards to match the direction of the
practitioner’s external auditory meatus. The bell is used to hear low-pitched sounds. Use
for mid-diastolic murmur of mitral stenosis or S3 in heart failure.
 Option B: The stethoscope bell is lightly applied in each supraclavicular fossa over the
subclavian artery. As usual, the examiner’s free hand palpates the contralateral carotid
pulse for timing purposes. If a bruit is appreciated, firmly compress the patient’s
ipsilateral radial artery, noting the effect on the murmur.

 Option D: If the intensity of sound is greater above the clavicle it is most likely a carotid
bruit. If it is louder below the clavicle it is most likely a heart murmur. Use either the bell
or the diaphragm when listening for the carotid bruit, at a point just lateral to Adam’s
apple.
ADVERTISEMENTS
50. Question
The nurse calculates a body mass index (BMI) of 18 for a young adult woman who comes to the
physician’s office for a college physical. This patient is considered:
o A. Obese
o B. Overweight
o C. Average
o D. Underweight
Incorrect
Correct Answer: D. Underweight
For adults, BMI should range between 20 and 25. Body mass index (BMI) is a person’s weight
in kilograms divided by the square of height in meters. BMI is an inexpensive and easy screening
method for the weight category—underweight, healthy weight, overweight, and obesity.
 Option A: BMI greater than 30 is considered obese For adults 20 years old and older,
BMI is interpreted using standard weight status categories. These categories are the same
for men and women of all body types and ages.
 Option B: BMI 25 to 29.9 is overweight. The prevalence of adult BMI greater than or
equal to 30 kg/m2 (obese status) has greatly increased since the 1970s. Recently,
however, this trend has leveled off, except for older women. Obesity has continued to
increase in adult women who are 60 years and older.
 Option C: BMI less than 20 is considered underweight. BMI can be a screening tool, but
it does not diagnose the body fatness or health of an individual. To determine if BMI is a
health risk, a healthcare provider performs further assessments. Such assessments include
skinfold thickness measurements, evaluations of diet, physical activity, and family
history.
ADVERTISEMENTS
51. Question
Using the principles of standard precautions, the nurse would wear gloves in what nursing
interventions?

o A. Providing a back massage.
o B. Feeding a client.
o C. Providing hair care.
o D. Providing oral hygiene.

Incorrect
Correct Answer: D. Providing oral hygiene
Doing oral care requires the nurse to wear gloves. Standard precautions apply to the care of all
patients, irrespective of their disease state. These precautions apply when there is a risk of
potential exposure to (1) blood; (2) all body fluids, secretions, and excretions, except sweat,
regardless of whether or not they contain visible blood; (3) non-intact skin, and (4) mucous
membranes. This includes the use of hand hygiene and personal protective equipment (PPE),
with hand hygiene being the single most important means to prevent transmission of disease.
 Option A: Must be worn when touching blood, body fluids, secretions, excretions,
mucous membranes, or non-intact skin. Change when there is contact with potentially
infected material in the same patient to avoid cross-contamination. Remove before
touching surfaces and clean items. Wearing gloves does not mitigate the need for proper
hand hygiene.
 Option B: Hand washing after feeding the client is sufficient. Handwashing with soap
and water for at least 40 to 60 seconds, making sure not to use clean hands to turn off the
faucet, must be performed if hands are visibly soiled, after using the restroom, or if
potential exposure to spore-forming organisms.
 Option C: Gloves are not needed in providing hair care. Hand rubbing with alcohol
applied generously to cover hands completely should be performed and hands rubbed
until dry.
ADVERTISEMENTS
52. Question
The nurse is preparing to take vital signs in an alert client admitted to the hospital with
dehydration secondary to vomiting and diarrhea. What is the best method used to assess the
client’s temperature?
o A. Oral
o B. Axillary
o C. Radial
o D. Heat sensitive tape

Incorrect
Axilla is the most accessible body part in this situation. Body temperature is a numerical
expression of the body’s heat and metabolic activity balance and can be a major indicator of a
person’s health status. Assessing a patient’s body temperature is a common procedure nurses
perform to monitor for signs of infection, environmental exposure, shock, ovulation, or
therapeutic response to medications or medical procedures. A normal body temperature can be a
potentially positive sign that the patient isn’t experiencing a disease process, infection, or trauma
and that the body’s cells, tissues, and organs aren’t under metabolic distress.
 Option A: The esophageal temperature probe (ETP) is an 18-in (45.7 cm) long, thin,
monitoring.
 Option C: The ETP and RTP (rectal temperature probe) are the same device but can be
used in either orifice depending on the patient’s medical condition. Again, the tip should
be lubricated with water-soluble lubricant, and then placed approximately 3 in (7.6 cm)
inside the rectal vault. The RTP can also be attached to a telemetry monitor cable for
continuous temperature monitoring.
 Option D: This is a latex-free, disposable, adhesive strip that can be applied to the
forehead. These strips contain embedded liquid crystals and chemical compounds that
react to the temperature (heat) of the skin by changing colors. After it has been on the
forehead for approximately 2 minutes, the color will illuminate a line and correlate
numeric temperature. The strips measure temperatures ranging from 96.6[degrees] F to
104.6[degrees] F (35.8[degrees] C to 40.3[degrees] C). Consider use for infants, children,
and adults with cognitive deficits because they’re painless.
ADVERTISEMENTS
53. Question
A nurse obtained a client’s pulse and found the rate to be above normal. The nurse document
these findings as:
o A. Tachypnea
o B. Hyperpyrexia
o C. Arrhythmia
o D. Tachycardia
Incorrect
Correct Answer: D. Tachycardia

Tachycardia means rapid heart rate. Tachycardia refers to a heart rate that’s too fast. How that’s
defined may depend on age and physical condition. Generally speaking, for adults, a heart rate of
more than 100 beats per minute (BPM) is considered too fast.
 Option A: Tachypnea refers to rapid respiratory rate. Tachypnea is a respiration rate
greater than normal, resulting in abnormally rapid breathing. In adult humans at rest, any
respiratory rate between 12 and 20 breaths is normal and tachypnea is indicated by a rate
greater than 20 breaths per minute.
 Option B: Hyperpyrexia means increase in temperature. Hyperpyrexia is another term
for a very high fever. The medical criterion for hyperpyrexia is when someone is running
a body temperature of more than 106.7°F or 41.5°C. Hyperpyrexia is an emergency that
needs immediate attention from a medical professional.
 Option C: Arrhythmia means irregular heart rate. An arrhythmia is a problem with the
rate or rhythm of the heartbeat. During an arrhythmia, the heart can beat too fast, too
slowly, or with an irregular rhythm. When a heart beats too fast, the condition is called
tachycardia. When a heart beats too slowly, the condition is called bradycardia.
ADVERTISEMENTS
54. Question
Which of the following actions should the nurse take to use wide base support when assisting a
client to get up in a chair?
o A. Bend at the waist and place arms under the client’s arms and lift.
o B. Face the client, bend knees, and place hands-on client’s forearm and lift.
o C. Spread his or her feet apart.
o D. Tighten his or her pelvic muscles.

Incorrect
Correct Answer: B. Face the client, bend knees, and place hands-on client’s forearm and
lift.
This is the proper way of supporting the client to get up in a chair that conforms to safety and
proper body mechanics. It is important to use proper body mechanics as a health care
professional for many reasons, foremost of which is to prevent injuries to both patient and
provider. Health care professionals at the front line, especially those who deliver direct care to
patients, are often in situations where they have to assist with moving patients from one position
to another.
 Option A: Keep the back straight throughout the transfer to avoid bending or straining
the back. Get as close to the person as possible while still allowing him/her to lean
forward as needed to assist with the transfer.
 Option C: Allow the patient to help as much as possible. Estimate the patient’s weight
and mentally practice. Make sure that the floor is free of any obstacles or liquids. Keep

your feet shoulder-width apart. Keep the person (or object) as close to your body as
possible. Tighten your stomach muscles.
 Option D: Position patients appropriately for transfer. While standing in front of the
patient, maintain proper posture with the back straight and knees bent. Hold a strong
abdominal contraction. Position the body close to the patient to decrease strain on the
back. Before movement, contract the abdominal muscles to protect the back. Use the
knees and the lower body during transfer to decrease strain on the back.
ADVERTISEMENTS
55. Question
A client had oral surgery following a motor vehicle accident. The nurse assessing the client finds
the skin flushed and warm. Which of the following would be the best method to take the client’s
body temperature?
o A. Oral
o B. Axillary
o C. Arterial line
o D. Rectal
Incorrect
Taking the temperature via the axilla is the most appropriate route. Body temperature is a
numerical expression of the body’s heat and metabolic activity balance and can be a major
indicator of a person’s health status. Assessing a patient’s body temperature is a common
procedure nurses perform to monitor for signs of infection, environmental exposure, shock,
ovulation, or therapeutic response to medications or medical procedures. A normal body
temperature can be a potentially positive sign that the patient isn’t experiencing a disease
process, infection, or trauma and that the body’s cells, tissues, and organs aren’t under metabolic
distress.
 Option A: Taking the temperature via the oral route is incorrect since the client had oral
surgery. The esophageal temperature probe (ETP) is an 18-in (45.7 cm) long, thin,
monitoring.
 Option C: A PiCCO thermodilution catheter (Pulsion Medical Systems) containing a
temperature thermistor was inserted into the brachial artery at the antecubital fossa and
doubled as the arterial pressure monitoring line and arterial blood sampling portal. This
measured brachial artery temperature from the time of insertion to the time the patient left
the operating room.

 Option D: This is unnecessary. The ETP and RTP (rectal temperature probe) are the
same device but can be used in either orifice depending on the patient’s medical
condition. Again, the tip should be lubricated with water-soluble lubricant, and then
placed approximately 3 in (7.6 cm) inside the rectal vault. The RTP can also be attached
to a telemetry monitor cable for continuous temperature monitoring.
ADVERTISEMENTS
56. Question
A client who is unconscious needs frequent mouth care. When performing mouth care,
the best position of a client is:
o A. Fowler’s position
o B. Side-lying
o C. Supine
o D. Trendelenburg
Incorrect
Correct Answer: B. Side-lying
An unconscious client is best placed on his side when doing oral care to prevent aspiration. An
unconscious patient is placed in the side-lying position when mouth care is provided because this
position prevents pooling of secretions at the back of the oral cavity, thereby reducing the risk of
aspiration. Oral hygiene is especially important for patients receiving oxygen therapy, patients
who have nasogastric tubes, and patients who are NPO. Their oral mucosa dries out much faster
than normal due to their mouth-breathing.
 Option A: A soft toothbrush or gauze-padded tongue blade may be used to clean the
teeth and mouth. The patient should be positioned in the lateral position with the head
turned toward the side to provide for drainage and to prevent aspiration.
 Option C: This is the most common position for surgery with a patient lying on his or
her back with head, neck, and spine in neutral positioning and arms either adducted
alongside the patient or abducted to less than 90 degrees.
 Option D: A variation of supine in which the head of the bed is tilted down such that the
pubic symphysis is the highest point of the trunk facilitates venous return and improves
exposure during abdominal and laparoscopic surgeries.
ADVERTISEMENTS
57. Question
A client is hospitalized for the first time, which of the following actions ensure the safety of the
client?

o A. Keep unnecessary furniture out of the way.
o B. Keep the lights on at all times.
o C. Keep side rails up at all times.
o D. Keep all equipment out of view.

Incorrect
Correct Answer: C. Keep side rails up at all time
Keeping the side rails up at all times ensures the safety of the client. The risk of falling increases
with age and the number of times someone has been in hospital. During the client’s hospital stay,
he may be more unsteady on his feet because of illness or surgery, or because he is unfamiliar
with the hospital environment or is taking new medication.
 Option A: Home health care providers need to know the risk factors for falls and
demonstrate effective assessment and interventions for fall and injury prevention. Falls
are generally the result of a complex set of intrinsic patient and extrinsic environmental
factors. Use of a fall-prevention program, standardized tools, and an interdisciplinary
approach may be effective for reducing fall-related injuries.
 Option B: Make sure the client’s pajamas, dressing gown, and day clothes are the right
length so they don’t trip over them. Check that their slippers or other footwear fit
properly and are not slippery. If they have to wear pressure stockings, wear slippers over
them so they do not slip.
 Option D: Keep personal items and the call button within reach to avoid standing and
walking to get them. Ask for help when in need to get out of bed to use the toilet if not
feeling at all unsteady.
ADVERTISEMENTS
58. Question
A walk-in client enters the clinic with a chief complaint of abdominal pain and diarrhea. The
nurse takes the client’s vital sign hereafter. What phrase of the nursing process is being
implemented here by the nurse?
o A. Assessment
o B. Diagnosis
o C. Planning
o D. Implementation
Incorrect
Correct Answer: A. Assessment

Assessment is the first phase of the nursing process where a nurse collects information about the
client. Assessment is the first step and involves critical thinking skills and data collection;
caregiver. Objective data is measurable, tangible data such as vital signs, intake and output, and
height and weight.
 Option B: Diagnosis is the formulation of the nursing diagnosis from the information
collected during the assessment. The formulation of a nursing diagnosis by employing
clinical judgment assists in the planning and implementation of patient care. The North
patient, family, or community.
 Option C: In Planning, the nurse sets achievable and measurable short and long-term
goals. The planning stage is where goals and outcomes are formulated that directly
attainment of such assist in ensuring a positive outcome. Nursing care plans are essential
in this phase of goal setting. Care plans provide a course of direction for personalized
care tailored to an individual’s unique needs. Overall condition and comorbid conditions
play a role in the construction of a care plan. Care plans enhance communication,
documentation, reimbursement, and continuity of care across the healthcare continuum.
 Option D: Implementation is where nursing care is given. Implementation is the step
which involves action or doing and the actual carrying out of nursing interventions
outlined in the plan of care. This phase requires nursing interventions such as applying a
cardiac monitor or oxygen, direct or indirect care, medication administration, standard
treatment protocols, and EDP standards.
ADVERTISEMENTS
59. Question
It is best described as a systematic, rational method of planning and providing nursing care for
individual, families, group, and community
o A. Assessment
o B. Nursing Process
o C. Diagnosis
o D. Implementation
Incorrect
Correct Answer: B. Nursing Process
The statement describes the Nursing Process. The Nursing Process is the essential core of
practice for the registered nurse to deliver holistic, patient-focused care. Defined as a systematic
approach to care using the fundamental principles of critical thinking, client-centered approaches

to treatment, goal-oriented tasks, evidence-based practice (EDP) recommendations, and nursing
intuition. Holistic and scientific postulates are integrated to provide the basis for compassionate,
quality-based care.
 Option A: Assessment is the first step and involves critical thinking skills and data
collection; subjective and objective. Subjective data involves verbal statements from the
patient or caregiver. Objective data is measurable, tangible data such as vital signs, intake
and output, and height and weight.
 Option C: The formulation of a nursing diagnosis by employing clinical judgment assists
in the planning and implementation of patient care. The North American Nursing
Diagnosis Association (NANDA) provides nurses with an up to date list of nursing
diagnoses. A nursing diagnosis, according to NANDA, is defined as a clinical judgment
about responses to actual or potential health problems on the part of the patient, family,
or community.
 Option D: Implementation is the step which involves action or doing and the actual
carrying out of nursing interventions outlined in the plan of care. This phase requires
nursing interventions such as applying a cardiac monitor or oxygen, direct or indirect
care, medication administration, standard treatment protocols, and EDP standards.
ADVERTISEMENTS
60. Question
Exchange of gases takes place in which of the following organs?
o A. Kidney
o B. Lungs
o C. Liver
o D. Heart
Incorrect
Correct Answer: B. Lungs
Gas exchange is the transport of oxygen from the lungs to the bloodstream and the expulsion of
carbon dioxide from the bloodstream to the lungs. It transpires in the lungs between the alveoli
and a network of tiny blood vessels called capillaries, which are located in the walls of the
alveoli.
 Option A: The renal system consists of the kidney, ureters, and urethra. The overall
function of the system filters approximately 200 liters of fluid a day from renal blood
flow which allows for toxins, metabolic waste products, and excess ions to be excreted
while keeping essential substances in the blood. The kidney regulates plasma osmolarity
by modulating the amount of water, solutes, and electrolytes in the blood. It ensures long-
term acid-base balance and also produces erythropoietin which stimulates the production
of red blood cells.

 Option C: The liver is a critical organ in the human body that is responsible for an array
of functions that help support metabolism, immunity, digestion, detoxification, vitamin
storage among other functions. It comprises around 2% of an adult’s body weight. The
liver is a unique organ due to its dual blood supply from the portal vein (approximately
75%) and the hepatic artery (approximately 25%).
 Option D: The heart is a muscular organ situated in the center of the chest behind the
sternum. It consists of four chambers: the two upper chambers are called the right and left
atria, and the two lower chambers are called the right and left ventricles. The right atrium
and ventricle together are often called the right heart, and the left atrium and left ventricle
together functionally form the left heart.
ADVERTISEMENTS
61. Question
The chamber of the heart that receives oxygenated blood from the lungs is the:
o A. Left atrium
o B. Right atrium
o C. Left ventricle
o D. Right ventricle
Incorrect
Correct Answer: A. Left atrium
The left atrium receives oxygenated blood from the lungs and pumps it to the left ventricle. In
the lungs, the blood oxygenates as it passes through the capillaries where it is close enough to the
oxygen in the alveoli of the lungs. This oxygenated blood is collected by the four pulmonary
veins, two from each lung. All four of these veins open into the left atrium that acts as a
collection chamber for oxygenated blood. Just like the right atrium, the left atrium passes the
blood onto its ventricle both by passive flow and active pumping.
 Option B: The right atrium receives blood from the veins and pumps it to the right
ventricle. The right atrium receives deoxygenated blood from the entire body except for
the lungs (the systemic circulation) via the superior and inferior vena cavae. Also,
deoxygenated blood from the heart muscle itself drains into the right atrium via the
coronary sinus. The right atrium, therefore, acts as a reservoir to collect deoxygenated
blood.
 Option C: The left ventricle (the strongest chamber) pumps oxygen-rich blood to the rest
of the body, its vigorous contractions create the blood pressure. Oxygenated blood thus
fills the left ventricle, passing through the mitral valve. The left ventricle, which is the
main pumping chamber of the left heart, then pumps, sending freshly oxygenated blood
to the systemic circulation through the aortic valve
 Option D: The right ventricle receives blood from the right atrium and pumps it to the
lungs, where it is loaded with oxygen. The right ventricle pumps blood through the right

ventricular outflow tract, across the pulmonic valve, and into the pulmonary artery that
distributes it to the lungs for oxygenation.
ADVERTISEMENTS
62. Question
A muscular enlarged pouch or sac that lies slightly to the left which is used for temporary storage
of food…
o A. Gallbladder
o B. Urinary bladder
o C. Stomach
o D. Lungs
o E. Rugae of the stomach

Incorrect
Correct Answer: C. Stomach
The stomach is a muscular organ located on the left side of the upper abdomen. It is a saclike
expansion of the digestive tract of a vertebrate that is located between the esophagus and
duodenum. The major part of the digestion of food occurs in the stomach.
 Option A: The gallbladder is a small hollow organ about the size and shape of a pear. It
is a part of the biliary system, also known as the biliary tree or biliary tract. The biliary
system is a series of ducts within the liver, gallbladder, and pancreas that empty into the
small intestine. There are intrahepatic (within the liver) and extrahepatic (outside of the
liver) components. The gallbladder is a component of the extrahepatic biliary system
where bile is stored and concentrated.
 Option B: The bladder forms an integral part of the genitourinary system. Urine, created
by the kidneys, is drained into the bladder by the bilateral ureters. The bladder then acts
as the storage site for this waste product until higher-order centers within the central
nervous system initiate the micturition (i.e., urination) process, which permits the
expulsion of urine into the urethra, located on the inferior aspect of the bladder.
 Option D: The purpose of the lung is to provide oxygen to the blood. Anatomically, the
lung has an apex, three borders, and three surfaces. The apex lies above the first rib. The
function of the lung is to get oxygen from the air to the blood, performed by the alveoli.
The alveoli are a single cell membrane that allows for gas exchange to the pulmonary
vasculature. There are a couple of muscles that help with inspiration and expiration, such
as the diaphragm and intercostal muscles.
 Option E. The inner layer of the stomach is full of wrinkles known as rugae (or gastric
folds). Rugae both allow the stomach to stretch in order to accommodate large meals and
help to grip and move food during digestion
ADVERTISEMENTS

63. Question
The ability of the body to defend itself against scientific invading agent such as bacteria, toxin,
viruses, and foreign body:
o A. Hormones
o B. Secretion
o C. Immunity
o D. Glands
Incorrect
Correct Answer: C. Immunity
Immunity is the ability of an organism to resist a particular infection or toxin by the action of
specific antibodies or sensitized white blood cells. The Immune response is the body’s ability to
stay safe by affording protection against harmful agents and involves lines of defense against
most microbes as well as specialized and highly specific responses to a particular offender. This
immune response classifies as either innate which is non-specific and adaptive acquired which is
highly specific.
 Option A: The endocrine hormones are a wide array of molecules that traverse the
bloodstream to act on distant tissues, leading to alterations in metabolic functions within
the body. They can broadly divide into peptides, steroids, and tyrosine derivatives that
may work on either cell surface or intracellular receptors.
 Option B: Secretion, in biology, production and release of a useful substance by a gland
or cell; also, the substance produced. In addition to the enzymes and hormones that
facilitate and regulate complex biochemical processes, body tissues also secrete a variety
of substances that provide lubrication and moisture.
 Option D: A gland is an organ which produces and releases substances that perform a
specific function in the body. There are two types of gland. Endocrine glands are ductless
glands and release the substances that they make (hormones) directly into the
bloodstream.
ADVERTISEMENTS
64. Question
Hormones secreted by Islets of Langerhans
o A. Progesterone
o B. Testosterone

o C. Insulin
o D. Hemoglobin
Incorrect
Correct Answer: C. Insulin
The Islets of Langerhans are the regions of the pancreas that contain its endocrine cells. Insulin is
a peptide hormone secreted in the body by beta cells of islets of Langerhans of the pancreas and
regulates blood glucose levels. Medical treatment with insulin is indicated when there is
inadequate production or increased demands of insulin in the body.
 Option A: Progesterone (Choice A) is produced by the ovaries. Progesterone is an
endogenous steroid hormone that is commonly produced by the adrenal cortex as well as
the gonads, which consist of the ovaries and the testes. Progesterone is also secreted by
the ovarian corpus luteum during the first ten weeks of pregnancy, followed by the
placenta in the later phase of pregnancy.
 Option B: Testosterone (Choice B) is secreted by the testicles of males and ovaries of
females. Testosterone is the primary male hormone responsible for regulating sex
differentiation, producing male sex characteristics, spermatogenesis and fertility.
Testosterone is responsible for the development of primary sexual development, which
includes testicular descent, spermatogenesis, enlargement of the penis and testes, and
increasing libido.
 Option D: Hemoglobin (Choice D) is a protein molecule in the red blood cells that
carries oxygen from the lungs to the body’s tissues and returns carbon dioxide.
Hemoglobin is an oxygen-binding protein found in erythrocytes which transports oxygen
from the lungs to tissues. Each hemoglobin molecule is a tetramer made of four
polypeptide globin chains. Each globin subunit contains a heme moiety formed of an
organic protoporphyrin ring and a central iron ion in the ferrous state (Fe2+). The iron
molecule in each heme moiety can bind and unbind oxygen, allowing for oxygen
transport in the body.
ADVERTISEMENTS
65. Question
It is a transparent membrane that focuses the light that enters the eyes to the retina.
o A. Lens
o B. Sclera
o C. Cornea
o D. Pupils
Incorrect
Correct Answer: A. Lens

The lens is located in the eye. By changing its shape, the lens changes the focal distance of the
eye. In other words, it focuses the light rays that pass through it (and onto the retina) in order to
create clear images of objects that are positioned at various distances. It also works together with
the cornea to refract, or bend, light. The lens consists of the lens capsule, the lens epithelium, and
the lens fibers. The lens capsule is the smooth, transparent outermost layer of the lens, while the
lens fibers are long, thin, transparent cells that form the bulk of the lens. The lens epithelium lies
between these two and is responsible for the stable functioning of the lens. It also creates lens
fibers for the lifelong growth of the lens.
 Option B: The sclera is the white part of the eye that surrounds the cornea. In fact, the
sclera forms more than 80 percent of the surface area of the eyeball, extending from the
cornea all the way to the optic nerve, which exits the back of the eye. Only a small
portion of the anterior sclera is visible.
 Option C: The cornea is the eye’s clear, protective outer layer. Along with the sclera (the
white of your eye), it serves as a barrier against dirt, germs, and other things that can
cause damage. The cornea can also filter out some of the sun’s ultraviolet light. It also
plays a key role in vision. As light enters the eye, it gets refracted, or bent, by the
cornea’s curved edge. This helps determine how well the eye can focus on objects close-
up and far away.
 Option D: Pupils are the black center of the eye. Their function is to let in light and focus
it on the retina (the nerve cells at the back of the eye) so one can see. Muscles located in
the iris (the colored part of your eye) control each pupil.
ADVERTISEMENTS
66. Question
Which of the following is included in Orem’s theory?
o A. Maintenance of a sufficient intake of air.
o B. Self perception.
o C. Love and belongingness.
o D. Physiologic needs.
Incorrect
Correct Answer: A. Maintenance of a sufficient intake of air.
Dorothea Orem’s Self-Care Theory defined Nursing as ―The act of assisting others in the
provision and management of self-care to maintain or improve human functioning at home level
of effectiveness.‖ The Self-Care or Self-Care Deficit Theory of Nursing is composed of three
interrelated theories: (1) the theory of self-care, (2) the self-care deficit theory, and (3) the theory
of nursing systems, which is further classified into wholly compensatory, partial compensatory
and supportive-educative. Choices B, C, and D are from Abraham Maslow’s Hierarchy of Needs.
 Option B: At the fourth level in Maslow’s hierarchy is the need for appreciation and
respect. When the needs at the bottom three levels have been satisfied, the esteem needs

begin to play a more prominent role in motivating behavior. At this point, it becomes
increasingly important to gain the respect and appreciation of others. People have a need
to accomplish things and then have their efforts recognized. In addition to the need for
feelings of accomplishment and prestige, esteem needs include such things as self-esteem
and personal worth.
 Option C: The social needs in Maslow’s hierarchy include such things as love,
group activities.
 Option D: The basic physiological needs are probably fairly apparent—these include the
ADVERTISEMENTS
67. Question
Which of the following cluster of data belong to Maslow’s hierarchy of needs
o A. Love and belonging
o B. Physiological needs
o C. Self actualization

Incorrect
All of the choices are part of Maslow’s Hierarchy of Needs. Maslow first introduced his concept
of a hierarchy of needs in his 1943 paper ―A Theory of Human Motivation‖ and his subsequent
book Motivation and Personality. This hierarchy suggests that people are motivated to fulfill
basic needs before moving on to other, more advanced needs. As a humanist, Maslow believed
that people have an inborn desire to be self-actualized, that is, to be all they can be. In order to
achieve these ultimate goals, however, a number of more basic needs must be met such as the
need for food, safety, love, and self-esteem.
 Option A: The social needs in Maslow’s hierarchy include such things as love,

group activities.
 Option B: The basic physiological needs are probably fairly apparent—these include the
 Option C: At the very peak of Maslow’s hierarchy are the self-actualization needs.
―What a man can be, he must be,‖ Maslow explained, referring to the need people have to
achieve their full potential as human beings. According to Maslow’s definition of self-
actualization, ―It may be loosely described as the full use and exploitation of talents,
capabilities, potentialities, etc. Such people seem to be fulfilling themselves and to be
doing the best that they are capable of doing. They are people who have developed or are
developing to the full stature of which they are capable.‖
ADVERTISEMENTS
68. Question
This is characterized by severe symptoms relatively of short duration.
o A. Chronic Illness
o B. Acute Illness
o C. Pain
o D. Syndrome
Incorrect
Correct Answer: B. Acute Illness
Acute illnesses are different than chronic illnesses in that they usually develop quickly and they
only last a short time – usually a few days or weeks. Acute illnesses are often caused by viral or
bacterial infections.
 Option A: Chronic Illness (Choice A) are illnesses that are persistent or long-term. A
chronic illness is a condition that develops over time and is present for a long period of
time. Some people have chronic conditions for many years. Technically, a chronic
disease is defined as a health condition that lasts anywhere from three months to a
lifetime. Chronic conditions may get worse over time.
 Option C: Pain refers to the product of higher brain center processing; it entails the
actual unpleasant emotional and sensory experience generated from nervous signals.
 Option D: A syndrome is a set of medical signs and symptoms which are correlated with
each other and often associated with a particular disease or disorder. The word derives
from the Greek ?????????, meaning ―concurrence‖.
ADVERTISEMENTS

69. Question
Which of the following is the nurse’s role in health promotion?
o A. Health risk appraisal
o B. Teach client to be effective health consumer
o C. Worksite wellness
o D. None of the above

Incorrect
Correct Answer: B. Teach client to be effective health consumer
Nurses play a huge role in illness prevention and health promotion. Nurses assume the role of
ambassadors of wellness. The World Health Organization (WHO) defines health promotion as a
process of enabling people to increase control over and to improve their health (WHO, 1986).
Nurses are best qualified to take on the job of health promoter due to their expertise. There are
few health care occupations that have the high level of health education knowledge, skills,
theory, and research to be able to focus on prevention because it is considered part of their
professional development focus.
 Option A: An HRA may be a simple questionnaire eliciting self-reported information on
risk factors, behaviors, or diagnoses. Questionnaires may be supplemented with clinical
examinations to obtain data on variables such as height, weight, body mass index (BMI),
heart rate, or blood pressure. Some HRAs may include performance tests such as grip
strength, timed-up-and-go, chair rise, or four-meter walk test.
 Option C: Studies show that employees are more likely to be on the job and performing
well when they are in optimal health. Benefits of implementing a wellness program
include: improved disease management and prevention, and a healthier workforce in
general, both of which contribute to lower health care costs.
 Option D: One of the most critical roles that nurses have in health promotion and disease
preventions is that of an educator. Nurses spend the most time with the patients and
provide anticipatory guidance about immunizations, nutrition, dietary, medications, and
safety.
ADVERTISEMENTS
70. Question
It is described as a collection of people who share some attributes of their lives.
o A. Family
o B. Illness

o C. Community
o D. Nursing
Incorrect
Correct Answer: C. Community
A community is defined by the shared attributes of the people in it, and/or by the strength of the
connections among them. When an organization is identifying communities of interest, the
shared attribute is the most useful definition of a community.
 Option A: In human society, family is a group of people related either by consanguinity
(by recognized birth) or affinity (by marriage or other relationship). The purpose of
families is to maintain the well-being of its members and of society. Ideally, families
would offer predictability, structure, and safety as members mature and participate in the
community.
 Option B: Illness is a condition of being unhealthy in the body or mind; a specific
condition that prevents the body or mind from working normally; a sickness or disease.
 Option D: Nursing encompasses autonomous and collaborative care of individuals of all
ages, families, groups, and communities, sick or well, and in all settings. Nursing
includes the promotion of health, prevention of illness, and the care of ill, disabled, and
dying people.
ADVERTISEMENTS
71. Question
Five teaspoons is equivalent to how many milliliters (ml)?
o A. 30 ml
o B. 25 ml
o C. 12 ml
o D. 22 ml
Incorrect
Correct Answer: B. 25 ml
One teaspoon is equal to 5ml. Drug calculations require the use of conversion factors, for
example, when converting from pounds to kilograms or liters to milliliters. Simplistic in design,
this method allows clinicians to work with various units of measurement, converting factors to
find the answer. These methods are useful in checking the accuracy of the other methods of
calculation, thus acting as a double or triple check.
 Option A: 30 ml is equal to 6 teaspoons. When clinicians are prepared and know the key
conversion factors, they will be less anxious about the calculation involved. This is vital
to accuracy, regardless of which formula or method employed.

 Option C: 12 ml is equal to 2.4 teaspoons. Units of measurement must match, for
example, milliliters and milliliters, or one needs to convert to like units of measurement.
 Option D: 22 ml is equal to 4.4 teaspoons. Medication errors can be detrimental and
costly to patients. Drug calculation and basic mathematical skills play a role in the safe
administration of medications.
ADVERTISEMENTS
72. Question
1800 ml is equal to how many liters?
o A. 1.8
o B. 18000
o C. 180
o D. 2800
Incorrect
Correct Answer: A. 1.8
1,800 ml is equal to 1.8 liters.
 Option B: 18000 liters is equal to 18,000,000 ml.
 Option C: 180 liters is equal to 180,000 ml.
 Option D: 2800 liters is equal to 280,000 ml.
ADVERTISEMENTS
73. Question
Which of the following is the abbreviation of drops?
o A. Gtt.
o B. Gtts.
o C. Dp.
o D. Dr.
Incorrect
Correct Answer: B. Gtts.
Gtt (Choice A) is an abbreviation for drop. Dp and Dr are not recognized abbreviations for
measurement. Standardization and uniform use of codes, symbols, and abbreviations can

improve communication and understanding between health care practitioners, leading to safer
and more effective care for patients.
 Option A: Appropriate use of abbreviations is particularly important. Numerous studies
have focused on health care practitioners’ understanding and interpretation of
abbreviations in medical documents, such as medical records, discharge summaries, and
medication orders. Findings indicate that it is not uncommon for practitioners to have
 Option C: To prevent misunderstandings and potential risks to patient safety, MOI.4
requires hospitals to establish lists for approved and do-not-use abbreviations and
monitor for appropriate abbreviation use. There are resources for identifying
abbreviations for the do-not-use list, such as the Institute for Safe Medication Practices
(ISMP), which publishes a list of dangerous abbreviations not to be used due to frequent
misinterpretation and associated medication errors.
 Option D: When developing lists, hospitals need to ensure that abbreviations on the
approved list are not also on the do-not-use list, and vice versa. In addition, abbreviations
can have only one meaning within the entire organization—for example, the abbreviation
NKDA could mean ―no known drug allergies,‖ or it could mean ―nonketotic diabetic
acidosis,‖ but it cannot have both meanings in an organization.
ADVERTISEMENTS
74. Question
The abbreviation for microdrop is…
o A. µgtt
o B. gtt
o C. mdr
o D. mgts
Incorrect
Correct Answer: A. µgtt
The abbreviation for microdrop is µgtt. When abbreviations are used in documents given to the
patient, the potential for misunderstanding can increase. Information needs to be clear and
unambiguous to improve patients’ comprehension.
 Option B: When abbreviations are used in documents given to the patient, the potential
for misunderstanding can increase. Information needs to be clear and unambiguous to
improve patients’ comprehension.
 Option C: As stated in MOI.4, ME 5, ―Abbreviations are not used on informed consent
and patient rights documents, discharge instructions, discharge summaries, and other
documents patients and families receive from the hospital about the patient’s care.‖
 Option D: No abbreviations of any kind should appear in informed consent documents,
patient rights documents, and discharge instructions. These documents are meant for the

patient and every effort should be made to increase the readability and clarity of the
documents.
ADVERTISEMENTS
75. Question
Which of the following is the meaning of PRN?
o A. When advice
o B. Immediately
o C. When necessary
o D. Now.
Incorrect
Correct Answer: C. When necessary
PRN comes from the Latin ―pro re nata‖ meaning, ―for an occasion that has arisen or as
circumstances require‖. When an abbreviation is less known outside of the organization or
clinical specialty, it is necessary to spell out the abbreviation throughout the discharge summary
to prevent misunderstanding and confusion by the physician or health care organization that
receives the summary.
 Option A: The practice of spelling out an abbreviation when first mentioned, then using
the abbreviation thereafter in the document is acceptable only in discharge summaries.
Abbreviations are not to be used in the other types of documents listed in the measurable
element.
 Option B: Laboratory test results sometimes go to patients, but it is not the intent of the
standard for the abbreviations of the laboratory tests to be spelled out. When test results
are given to patients, they are shared with their physician who can help explain the
results.
 Option D: Hospitals may want to consider providing a separate form or resource to
patients for information about the tests — such as a handout or website that has the
names of common laboratory tests along with their definitions or descriptions. Results of
diagnostic imaging studies also go to a patient’s physician, after interpretation by a
radiologist.
ADVERTISEMENTS
1. Question
The charge nurse asks the nursing assistive personnel (NAP) to give a bag bath to
a patient with end-stage chronic obstructive pulmonary disease. How should the
NAP proceed?

 A. Bathe the patient's entire body using 8 to 10 washcloths.
 B. Assist the patient to a chair and provide bathing supplies.
 C. Saturate a towel and blanket in a plastic bag, and then bathe the patient.
 D. Assist the patient to the bathtub and provide a bath chair.

Incorrect
Correct Answer: A. Bathe the patient’s entire body using 8 to 10 washcloths.
A towel bath is a modification of the bed bath in which the NAP places a large
towel and a bath blanket into a plastic bag, saturates them with a commercially
prepared mixture of moisturizer, non rinse cleaning agent, and water; warms in
them in a microwave, and then uses them to bathe the patient. A bag bath is a
modification of the towel bath, in which the NAP uses 8 to 10 washcloths instead
of a towel or blanket. Each part of the patient‘s body is bathed with a fresh cloth.
 Option B: A bag bath is not given in a chair or in the tub. The bag bath is
one alternative to the traditional bed bath used in some nursing homes.
The bath is performed with a series of 10 washcloths and a no-rinse liquid
cleanser. Close the door and windows to prevent cold drafts and wash
hands with warm water before beginning.
 Option C: Moisten the washcloths with water and put in a plastic bag with
the cleanser. Warm the bag in the microwave for 60 to 90 seconds. Test the
temperature of the clothes before touching a resident with them and be
careful when you open the bag, as steam can burn.
 Option D: Take the bag to the resident‘s bedside. When you are not
cleaning a body part, keep it covered. Only expose as much of the
resident‘s body as necessary to adequately clean him or her. Be especially
sensitive to exposing genitals, buttocks, and breasts. Bathing can be an
extremely stressful experience for residents, so try to make it as easy as
possible.
2. Question
For a morbidly obese patient, which intervention should the nurse choose to
counteract the pressure created by the skin folds?
 A. Cover the mattress with a sheepskin.
 B. Keep the linens wrinkle free.

 C. Separate the skin folds with towels.
 D. Apply petrolatum barrier creams.

Incorrect
Correct Answer: C. Separate the skin folds with towels.
Separating the skin folds with towels relieves the pressure of skin rubbing on
skin. Skin folds, in particular, may be difficult for the patient to clean thoroughly;
the abdominal folds and groins may be ignored, leading to an increased risk of
skin breakdown in these areas.
 Option A: Sheepskins are not recommended for use at all. Skin folds
present a challenge in the management of patients who are morbidly
obese. The weight from excess adipose tissue in skinfold areas can have an
increased risk of skin injury such as friction, maceration, skin tears and
pressure ulcer development.
 Option B: Skin folds and areas vulnerable to skin injury should be cleaned
and dried several times a day. Alcohol-based lotions and harsh soaps, as
well as talcum powders, should be avoided in these areas. If necessary, dry
cloths to absorb moisture can be left in skin folds in between washing and
drying of the skin folds.
 Option D: Petrolatum barrier creams are used to minimize moisture
caused by incontinence. Patient hydration should also be considered in the
nutrition plan for the patients and the health of their skin.
2. 3. Question
A client exhibits all of the following during a physical assessment. Which of these
is considered a primary defense against infection?
o A. Fever
o B. Intact skin
o C. Inflammation
o D. Lethargy
Incorrect
Correct Answer: B. Intact skin

Intact skin is considered a primary defense against infection. Usually, the skin
prevents invasion by microorganisms unless it is damaged (for example, by an
injury, insect bite, or burn). Mucous membranes, such as the lining of the mouth,
nose, and eyelids, are also effective barriers. Typically, mucous membranes are
coated with secretions that fight microorganisms. For example, the mucous
membranes of the eyes are bathed in tears, which contain an enzyme called
lysozyme that attacks bacteria and helps protect the eyes from infection. Fever,
the inflammatory response, and phagocytosis (a process of killing pathogens) are
considered secondary defenses against infection.
 Option A: Body temperature increases as a protective response to
infection and injury. An elevated body temperature (fever) enhances the
body‘s defense mechanisms, although it can cause discomfort. A part of
the brain called the hypothalamus controls body temperature. Fever results
from an actual resetting of the hypothalamus‘s thermostat. The body raises
its temperature to a higher level by moving (shunting) blood from the skin
surface to the interior of the body, thus reducing heat loss.
 Option C: Any injury, including an invasion by microorganisms, causes
inflammation in the affected area. Inflammation, a complex reaction, results
from many different conditions. During inflammation, the blood supply
increases, helping carry immune cells to the affected area. Because of the
increased blood flow, an infected area near the surface of the body
becomes red and warm. The walls of blood vessels become more porous,
allowing fluid and white blood cells to pass into the affected tissue. The
increase in fluid causes the inflamed tissue to swell. The white blood cells
attack the invading microorganisms and release substances that continue
the process of inflammation.
 Option D: Lethargy refers to a state of lacking energy. People who are
experiencing fatigue or tiredness can also be said to be lethargic because
of low energy. The same medical conditions that can lead to tiredness or
fatigue can also lead to lethargy.
ADVERTISEMENTS
2. Question 4 of 75
4. Question

A client with a stage 2 pressure ulcer has methicillin-resistant Staphylococcus
aureus (MRSA) cultured from the wound. Contact precautions are initiated. Which
rule must be observed to follow contact precautions?
o A. A clean gown and gloves must be worn when in contact with the
client.
o B. Everyone who enters the room must wear a N-95 respirator mask.
o C. All linen and trash must be marked as contaminated and send to

biohazard waste.
o D. Place the client in a room with a client with an upper respiratory infection.
Incorrect
Correct Answer: A. A clean gown and gloves must be worn when in contact
with the client.
A clean gown and gloves must be worn when any contact is anticipated with the
client or with contaminated items in the room. Visitors might also be asked to
wear a gown and gloves. Patients are asked to stay in their hospital rooms as
much as possible. They should not go to common areas, such as the gift shop or
cafeteria. They may go to other areas of the hospital for treatments and tests.
 Option B: A respirator mask is required only with airborne precautions, not
contact precautions. Healthcare providers will put on gloves and wear a
gown over their clothing while taking care of patients with MRSA.
 Option C: All linen must be double-bagged and clearly marked as
contaminated. When leaving the room, healthcare providers and visitors
remove their gown and gloves and clean their hands.
 Option D: The client should be placed in a private room or in a room with
a client with an active infection caused by the same organism and no other
infections. Whenever possible, patients with MRSA will have a single room
or will share a room only with someone else who also has MRSA.
ADVERTISEMENTS
2. Question 5 of 75
5. Question
A client requires protective isolation. Which client can be safely paired with this
client in a client-care assignment? One:

o A. Admitted with unstable diabetes mellitus.
o B. Who underwent surgical repair of a perforated bowel.
o C. With a stage 3 sacral pressure ulcer.
o D. Admitted with a urinary tract infection.

Incorrect
Correct Answer: A. Admitted with unstable diabetes mellitus.
The client with unstable diabetes mellitus can safely be paired in a client-care
assignment because the client is free from infection. Protective Isolation aims to
protect an immunocompromised patient who is at high risk of acquiring micro-
organisms from either the environment or from other patients, staff, or visitors.
 Option B: Perforation of the bowel exposes the client to infection requiring
antibiotic therapy during the postoperative period. Therefore, this client
should not be paired with a client in protective isolation. Patients should
remain in isolation whilst they remain symptomatic; a risk assessment
should be undertaken to ascertain if and when isolation precautions can be
relaxed.
 Option C: A client in protective isolation should not be paired with a client
who has an open wound, such as a stage 3 pressure ulcer. Patient‘s
requiring protective isolation should be nursed in a single room. Where
possible this room should have an ante-room, positive pressure ventilation
and Hepa filtered air. The room should have an en-suite and hand washing
facilities and the doors(s) should be kept closed at all times.
 Option D: A client in protective isolation should not be paired with a client
who has a urinary tract infection. Many infections acquired by
immunocompromised patients are endogenous infections (An infection
caused by an infectious agent that is already present in the body but has
previously been inapparent or dormant), however, the transmission of
infection from other patients, staff, or the environment can be a risk and
therefore extra precautions are required.
ADVERTISEMENTS
2. Question 6 of 75
6. Question

A newly hired at Nurseslabs Medical Center is assigned to the OR Department.
Which action demonstrates a break in sterile technique?
o A. Remaining 1 foot away from non sterile areas.
o B. Placing sterile items on the sterile field.
o C. Avoiding the border of the sterile drape.
o D. Reaching 1 foot over the sterile field.

Incorrect
Correct Answer: D. Reaching 1 foot over the sterile field.
Reaching over the sterile field while wearing sterile garb breaks the sterile
technique. While observing sterile technique, healthcare workers should remain 1
foot away from non-sterile areas while wearing sterile garb, place sterile items
needed for the procedure on the sterile drape, and avoid coming in contact with
the 1-inch border of the sterile drape. The principles of the Sterile Technique are
applied in various ways. If the principle itself is understood, the applications of it
become obvious. A strict aseptic technique is needed at all times in the Operating
Room.
 Option A: Sterile persons avoid leaning over an unsterile area; non-sterile
persons avoid reaching over a sterile field. Unsterile persons do not get
closer than 12 inches from a sterile field.
 Option B: Persons who are sterile touch only sterile articles; persons who
are not sterile touch only unsterile articles. If in doubt about the sterility of
anything consider it not sterile. If a non-sterile person brushes close
consider yourself contaminated.
 Option C: Sterile persons keep contact with sterile areas to a minimum. Do
not lean on the sterile tables or on the draped patient. Do not lean on the
nurse‘s mayo tray.
ADVERTISEMENTS
2. Question 7 of 75
7. Question
Nurse Berta is facilitating a monthly mothers‘ class at a small village. As a
knowledgeable nurse, she must know that a mother who breastfeeds her child
passes on which antibody through breast milk?

o A. IgA
o B. IgE
o C. IgG
o D. IgM
Incorrect
Correct Answer: A. IgA
Antibodies, which are also called immunoglobulins, take five basic forms,
indicated as IgG, IgA, IgM, IgD and IgE. All have been detected in human milk,
but by far the most abundant type is IgA, particularly the form known as
secretory IgA, which is found in great amounts throughout the gut and
respiratory system of adults. The secretory IgA molecules passed to the suckling
child are helpful in ways that go beyond their ability to bind to microorganisms
and keep them away from the body‘s tissues.
 Option B: IgE is a monomer. It has a molecular weight of 188 Kd and a
serum concentration of 0.00005 mg/mL. It protects against parasites and
also binds to high-affinity receptors on mast cells and basophils causing
allergic reactions. IgE is regarded as the most important host defense
against different parasitic infections which include Strongyloides
stercoralis, Trichinella spiralis, Ascaris lumbricoides, and the hookworms
Necator americanus and Ancylostoma duodenal.
 Option C: IgG2 forms an important host defense against bacteria that are
encapsulated. IgG is the only immunoglobulin that crosses the placentae as
its Fc portion binds to the receptors present on the surface of the placenta,
protecting the neonate from infectious diseases. IgG is thus the most
abundant antibody present in newborns.
 Option D: IgM has a molecular weight of 970 Kd and an average serum
concentration of 1.5 mg/ml. It is mainly produced in the primary immune
response to infectious agents or antigens. It is a pentamer and activates
the classical pathway of the complement system. IgM is regarded as a
potent agglutinin (e.g., anti-A and anti-B isoagglutinin present in type B
and type A blood respectively) and a monomer of IgM is used as a B cell
receptor (BCR).
ADVERTISEMENTS
2. Question 8 of 75

8. Question
The clinical instructor asks her students the rationale for handwashing. The
students are correct if they answered that handwashing is expected to remove:
o A. Transient flora from the skin
o B. Resident flora from the skin
o C. All microorganisms from the skin
o D. Media for bacterial growth

Incorrect
Correct Answer: A. Transient flora from the skin
There are two types of normal flora: transient and resident. Transient flora are
normal flora that a person picks up by coming in contact with objects or another
person (e.g., when you touch a soiled dressing). You can remove these with hand
washing. Hand washing can prevent about 30% of diarrhea-related illnesses and
about 20% of respiratory infections (e.g., colds). Antibiotics often are prescribed
unnecessarily for these health issues
 Option B: Resident flora live deep in skin layers where they live and
multiply harmlessly. They are permanent inhabitants of the skin and cannot
usually be removed with routine hand washing.
 Option C: Removing all microorganisms from the skin (sterilization) is not
possible without damaging the skin tissues. To live and thrive in humans,
microbes must be able to use the body‘s precise balance of food, moisture,
nutrients, electrolytes, pH, temperature, and light.
 Option D: Food, water, and soil that provide these conditions may serve as
nonliving reservoirs. Hand washing does little to make the skin
uninhabitable for microorganisms, except perhaps briefly when an
antiseptic agent is used for cleansing. Handwashing with soap could
protect about 1 out of every 3 young children who get sick with diarrhea
and almost 1 out of 5 young children with respiratory infections like
pneumonia.
ADVERTISEMENTS
2. Question 9 of 75
9. Question

Which of the following incidents requires the nurse to complete an occurrence
report?
o A. Medication given 30 minutes after scheduled dose time.
o B. Patient's dentures lost after transfer.
o C. Worn electrical cord discovered on an IV infusion pump.
o D. Prescription without the route of administration.

Incorrect
Correct Answer: B. Patient’s dentures lost after transfer
You would need to complete an occurrence report if you suspect your patient‘s
personal items to be lost or stolen. An incident report also provides vital
information the facility needs to decide whether restitution should be made—if
personal belongings were lost or damaged, for example. Without proper
documentation of the incident, there‘s no way to make these important decisions
effectively.
 Option A: A medication can be administered within a half-hour of the
administration time without an error in administration; therefore, an
occurrence report is not necessary. An incident report invariably makes its
way to risk managers and other administrators, who review it rapidly and
act quickly to change any policy or procedure that appears to be a key
contributing factor to the incident.
 Option C: The worn electrical cord should be taken out of use and
reported to the biomedical department. An incident report should be filed
whenever an unexpected event occurs. The rule of thumb is that any time a
patient makes a complaint, a medication error occurs, a medical device
malfunctions, or anyone—patient, staff member, or visitor—is injured or
involved in a situation with the potential for injury, an incident report is
required.
 Option D: The nurse should seek clarification if the provider‘s order is
missing information; an occurrence report is not necessary. The medical
record is patient-focused, and facts pertinent to an unexpected incident
will likely be left out. So if a claim were filed and the case proceeded to
court, which sometimes occurs years after the event, you or anyone else
involved might be hard-pressed to recreate the scene—especially if you
consider it to be ―minor‖ at the time. You may not be able to rely on

memory alone, but you can count on the incident report to refresh your
memory.
ADVERTISEMENTS
10. Question
The nurse is orienting a new nurse to the unit and reviews source-oriented
charting. Which statement by the nurse best describes source-oriented charting?
Source-oriented charting:
o A. Separates the health record according to discipline.
o B. Organizes documentation around the patient's problems.
o C. Highlights the patient's concerns, problems, and strengths.
o D. Is designed to streamline documentation.

Incorrect
Correct Answer: A. Separates the health record according to discipline
In source-oriented charting, each discipline documents findings in a separately
labeled section of the chart. Source-oriented (SO) charting is a narrative
recording by each member (source) of the health care team charts on separate
records. SO charting is time-consuming and can lead to fragmented care.
Effective documentation requires the use of common vocabulary; legibility and
neatness; the use of only authorized abbreviations and symbols; factual and time-
sequenced organization; and accuracy, including any errors that occurred. All
documents related to client care are confidential and clients must sign a release
to have their information released, specifying what type of information may be
released and to whom it may be released.
 Option B: Problem-oriented charting organizes notes around the patient‘s
problems. POMR is a structured, logical format of narrative charting, using
―SOAP,‖ where S means ―subjective data,‖ O means ―objective data,‖ A
means assessment data, and P means ―plan.‖ Some institutions add,
intervention, E, evaluation, and R, revision, to the SOAP format. POMR is
sometimes altered to become a problem-oriented record (POR). The critical
components of POMR/POR are the database; the problem list; the initial

plan; and the progress notes, based on the SOAP, SOAPIE, or SOAPIER
format.
 Option C: Focus charting highlights the patient‘s concerns, problems, and
strengths. Focus Charting of F-DAR is intended to make the client and
client concerns and strengths the focus of care. It is a method of organizing
health information in an individual‘s record. Focus Charting is a systematic
approach to documentation.
 Option D: Charting by exception is a unique charting system designed to
streamline documentation. Charting by exception (CBE) is a shorthand
method of documenting normal findings, based on clearly defined
normals, standards of practice, and predetermined criteria for assessments
and interventions. Significant findings or exceptions to the predefined
norms are documented in detail.
ADVERTISEMENTS
2. 11. Question
When the nurse completes the patient‘s admission nursing database, the patient
reports that he does not have any allergies. Which acceptable medical
abbreviation can the nurse use to document this finding?
o A. NA
o B. NDA
o C. NKA
o D. NPO
Incorrect
Correct Answer: C. NKA
The nurse can use the medical abbreviation NKA, which means no known
allergies, to document this finding. NKA is the abbreviation for ―no known
allergies,‖ meaning no known allergies of any sort. By contrast, NKDA stands
exclusively for ―no known drug allergies.‖
 Option A: NA is an abbreviation for not applicable.
 Option B: NDA is an abbreviation for no known drug allergies.
 Option D: NPO is an abbreviation that means nothing by mouth.
ADVERTISEMENTS

12. Question
The nurse is working on a unit that uses nursing assessment flow sheets. Which
statement best describes this form of charting? Nursing assessment flow sheets:
o A. Are comprehensive charting forms that integrate assessments and

nursing actions.
o B. Contain only graphic information, such as I&O, vital signs, and medication
administration.
o C. Are used to record routine aspects of care; they do not contain assessment
data.
o D. Contain vital data collected upon admission, which can be compared with
newly collected data.
Incorrect
Correct Answer: A. Are comprehensive charting forms that integrate
assessments and nursing actions
Nursing assessment flow sheets are organized by body systems. The nurse checks
the box corresponding to the current assessment findings. Nursing actions, such
as wound care, treatments, or IV fluid administration, are also included. A flow
sheet is simply a one- or two-page form that gathers all the important data
regarding a patient‘s condition. The flow sheet is housed in the patient‘s chart
and serves as a reminder of care and a record of whether care expectations have
been met.
 Option B: Graphic information, such as vital signs, I&O, and routine care,
may be found on the graphic record. This where records of serial
measurements and observations, nursing interventions, and nursing care
plans are recorded.
 Option C: Nursing documentation covers a wide variety of issues, topics,
and systems. Researchers, practitioners, and hospital administrators view
recordkeeping as an important element leading to continuity of care,
safety, quality care, and compliance.
 Option D: The admission form contains baseline information. In health
care organizations, the EHR, oral reports, handoffs, conferences, and health
information technologies (HIT) are intended to facilitate information flow.

In particular, the JCAHO specifically conceptualizes the care planning
process as the structuring framework for coordinating communication that
will result in safe and effective care.
ADVERTISEMENTS
2. 13. Question
At the end of the shift, the nurse realizes that she forgot to document a dressing
change that she performed for a patient. Which action should the nurse take?
o A. Complete an occurrence report before leaving.
o B. Do nothing; the next nurse will document it was done.
o C. Write the note of the dressing change into an earlier note.
o D. Make a late entry as an addition to the narrative notes.

Incorrect
Correct Answer: D. Make a late entry as an addition to the narrative notes.
If the nurse fails to make an important entry while charting, she should make a
late entry as an addition to the narrative notes. The nurse can only document
care directly performed or observed. Therefore, the nurse on the incoming shift
would not record the wound change as performed. A primary purpose of
documentation and recordkeeping systems is to facilitate information flow that
supports the continuity, quality, and safety of care.
 Option A: An occurrence report is not necessary in this case. The issue of
completeness is important; Croke cites failure to document as one of the
six top reasons that nurses face malpractice suits. In terms of overall
completeness, Stokke and Kalfoss found many gaps in nursing
documentation in Norway. Care plans, goals, diagnoses, planned
interventions, and projected outcomes were absent between 18 percent
and 45 percent of the time.
 Option B: If documentation is omitted, there is no legal verification that
the procedure was performed. Completeness of a record may have an
impact on the quality of care, but only if it reflects completeness of the
right content. Echoed again here is that document focus, rather than the
patient-centric nature of the medical record, does little to support shared

understanding by clinicians of care and the communication needed to
ensure the continuity, quality, and safety of care.
 Option C: It is illegal to add to a chart entry that was previously
documented. The typical content and format of documentation—and its
lack of accessibility—have also resulted in document-centric rather than
patient-centric records.
ADVERTISEMENTS
14. Question
Patient Z asks Nurse Toni why an electronic health record (EHR) system is being
used. Which response by the nurse indicates an understanding of the rationale
for an EHR system?
o A. It includes organizational reports of unusual occurrences that are not part

of the client's record.
o B. This type of system consists of combined documentation and daily care

plans.
o C. It improves interdisciplinary collaboration that improves efficiency in

procedures.
o D. This type of system tracks medication administration and usage over 24

hours.
Incorrect
Correct Answer: C. It improves interdisciplinary collaboration that improves
efficiency in procedures.
The EHR has several benefits for users, including improving interdisciplinary
collaboration and making procedures more accurate and efficient. An Electronic
Health Record (EHR) is an electronic version of a patient‘s medical history, that is
maintained by the provider over time, and may include all of the key
administrative clinical data relevant to that persons care under a particular
provider, including demographics, progress notes, problems, medications, vital
signs, past medical history, immunizations, laboratory data, and radiology reports
The EHR automates access to information and has the potential to streamline the
clinician‘s workflow. The EHR also has the ability to support other care-related

activities directly or indirectly through various interfaces, including evidence-
based decision support, quality management, and outcomes reporting.
 Option A: An occurrence report is an organizational record of an unusual
occurrence or accident that is not a part of the client‘s record. The purpose
of the incident report is to document the exact details of the occurrence
while they are fresh in the minds of those who witnessed the event. This
information may be useful in the future when dealing with liability issues
stemming from the incident.
 Option B: Integrated plans of care (IPOC) are a combined charting and
care plan format. It is care that is planned with people who work together
to understand the service user and their carer(s), puts them in control, and
coordinates and delivers services to achieve the best outcomes
 Option D: A medication administration record (MAR) is used to document
medications administered and their usage. A Medication Administration
Record (MAR, or eMAR for electronic versions), commonly referred to as a
drug chart, is the report that serves as a legal record of the drugs
administered to a patient at a facility by a healthcare professional. The
MAR is a part of a patient‘s permanent record on their medical chart.
ADVERTISEMENTS
15. Question
In the United States, the first programs for training nurses were affiliated with:
o A. The military
o B. General hospitals
o C. Civil service
o D. Religious orders
Incorrect
Correct Answer: D. Religious orders
When the Civil War broke out, the Army used nurses who had already been
trained in religious orders. Nursing started with religious orders. The Hindu faith
was the first to write about nursing. In the United States, all training for nurses
was affiliated with religious orders until after the Civil War.

 Option A: Although the Army did provide some training, it occurred later
than in the religious orders. Most people think of the nursing profession as
beginning with the work of Florence Nightingale, an upper class British
woman who captured the public imagination when she led a group of
female nurses to the Crimea in October of 1854 to deliver nursing service
to British soldiers.
 Option B: Although nurses were trained in hospitals, the training and the
hospitals were affiliated with religious orders. Upon her return to England,
Nightingale successfully established nurse education programs in a
number of British hospitals. These schools were organized around a
specific set of ideas about how nurses should be educated, developed by
Nightingale often referred to as the ―Nightingale Principles.‖
 Option C: Civil service was not mentioned in Chapter 1 and was not a
factor in the early 1800s. While Nightingale‘s work was groundbreaking in
that she confirmed that a corps of educated women, informed about
health and the ways to promote it, could improve the care of patients
based on a set of particular principles, she was not the first to put these
principles into action.
ADVERTISEMENTS
16. Question
Which of the following is/are an example(s) of a health restoration
activity? Select all that apply.
o A. Administering an antibiotic every day.
o B. Teaching the importance of handwashing.
o C. Assessing a client's surgical incision.
o D. Advising a woman to get an annual mammogram after age 50 years.
o E. Attending rehabilitation of a fractured arm.

Incorrect
Correct Answer: A, C, E

Health restoration activities help an ill client return to health. This would include
taking an antibiotic every day and assessing a client‘s surgical incision. Hand
washing and mammograms both involve healthy people who are trying to
prevent illness.
 Option A: Rehabilitation or restoration is defined as ―a set of interventions
designed to optimize functioning and reduce disability in individuals with
health conditions in interaction with their environment‖.
 Option B: Disease prevention, understood as specific, population-based,
and individual-based interventions for primary and secondary (early
detection) prevention, aiming to minimize the burden of diseases and
associated risk factors.
 Option C: Rehabilitation helps a child, adult, or older person to be as
independent as possible in everyday activities and enables participation in
education, work, recreation, and meaningful life roles such as taking care of
a family. It does so by addressing underlying conditions (such as pain) and
improving the way an individual function in everyday life, supporting them
to overcome difficulties with thinking, seeing, hearing, communicating,
eating, or moving around.
 Option D: Secondary prevention deals with early detection when this
improves the chances for positive health outcomes (this comprises
activities such as evidence-based screening programs for early detection of
diseases or for prevention of congenital malformations; and preventive
drug therapies of proven effectiveness when administered at an early stage
of the disease).
 Option E: Rehabilitation is highly person-centered, meaning that the
interventions and approach selected for each individual depends on their
goals and preferences. Rehabilitation can be provided in many different
settings, from inpatient or outpatient hospital settings to private clinics, or
community settings such as an individual‘s home.
ADVERTISEMENTS
2. 17. Question
Which of the following aspects of nursing is essential to defining it as both a
profession and a discipline?
o A. Established standards of care

o B. Professional organizations
o C. Practice supported by scientific research
o D. Activities determined by a scope of practice

Incorrect
Correct Answer: C. Practice supported by scientific research
A profession must have knowledge that is based on technical and scientific
knowledge. The theoretical knowledge of a discipline must be based on research,
so both are scientifically based. The profession of nursing consists of persons
educated in the discipline according to nationally regulated, defined, and
monitored standards. The standards and regulations are to preserve healthcare
safety for members of society. Although the discipline and the profession of
nursing have different goals, the raison d‘être of nursing is the enhancement of
quality of life for humankind. The discipline provides the science lived in the art of
practice.
 Option A: The American Nurses Association (ANA) has developed
standards of care, but they are unrelated to defining nursing as a
profession or discipline. Nursing is a discipline and a profession. The goal
of the discipline is to expand knowledge about human experiences
through creative conceptualization and research. This knowledge is the
scientific guide to living the art of nursing. The discipline-specific
knowledge is given birth and fostered in academic settings where research
and education move the knowledge to new realms of understanding.
 Option B: Having professional organizations is not included in accepted
characteristics of either a profession or a discipline. The goal of the
profession is to provide service to humankind through living the art of
science. Members of the nursing profession are responsible for regulation
of standards of practice and education based on disciplinary knowledge
that reflects safe health service to society in all settings.
 Option D: Having a scope of practice is not included in accepted
characteristics of either a profession or a discipline. The discipline of
nursing encompasses the knowledge in the extant frameworks and
theories that are embedded in the totality and simultaneity paradigms
(Parse, 1987). These theories and frameworks explicate the nature of
nursing‘s major phenomenon of concern, the human-universe-health
process.

ADVERTISEMENTS
18. Question
The charge nurse on the medical-surgical floor assigns vital signs to the nursing
assistive personnel (NAP) and medication administration to the licensed
vocational nurse (LVN). Which nursing model of care is this floor following?
o A. Team nursing
o B. Case method nursing
o C. Functional nursing
o D. Primary nursing
Incorrect
Correct Answer: C. Functional nursing
This medical-surgical floor is following the functional nursing model of care, in
which care is partitioned and assigned to a staff member with the appropriate
skills. For example, the NAP is assigned vital signs, and the LVN is assigned
medication administration. Functional nursing is task-oriented in scope. Instead
of one nurse performing many functions, several nurses are given one or two
assignments. For example, there is a medicine nurse whose sole responsibility is
administering medications.
 Option A: With team nursing, an RN or LVN is paired with a NAP. The pair
is then assigned to render care for a group of patients. Team nursing is a
system that distributes the care of a patient amongst a team that is all
working together to provide for this person. This team consists of up to 4
to 6 members that has a team leader who gives jobs and instructions to
the group.
 Option B: In case method nursing, one nurse cares for one patient during
her entire shift. Private duty nursing is an example of this care model. The
case method is a participatory, discussion-based way of learning where
students gain skills in critical thinking, communication, and group
dynamics. It is a type of problem-based learning.
 Option D: When the primary nursing model is utilized, one nurse manages
care for a group of patients 24 hours a day, even though others provide
care during part of the day. A method of providing nursing services to

inpatients whereby one nurse plans the care of specific patients for a
period of 24 hours. The primary nurse provides direct care to those
patients when working and is responsible for directing and supervising
their care in collaboration with other health care team members.
ADVERTISEMENTS
19. Question
Paul Jake suffered a stroke and has difficulty swallowing. Which healthcare team
member should be consulted to assess the patient‘s risk for aspiration?
o A. Respiratory therapist
o B. Occupational therapist
o C. Dentist
o D. Speech therapist
Incorrect
Correct Answer: D. Speech therapist
Speech and language therapists provide assistance to clients experiencing
swallowing and speech disturbances. They assess the risk for aspiration and
recommend a treatment plan to reduce the risk. Speech-language pathologists
(SLPs) work to prevent, assess, diagnose, and treat speech, language, social
communication, cognitive-communication, and swallowing disorders in children
and adults.
 Option A: Respiratory therapists provide care for patients with respiratory
disorders. Respiratory therapists interview and examine patients with
breathing or cardiopulmonary disorders. Respiratory therapists care for
patients who have trouble breathing—for example, from a chronic
respiratory disease, such as asthma or emphysema.
 Option B: Occupational therapists help patients regain function and
independence. Occupational therapists treat injured, ill, or disabled
patients through the therapeutic use of everyday activities. They help these
patients develop, recover, improve, as well as maintain the skills needed for
daily living and working.

 Option C: Dentists diagnose and treat dental disorders. Dentists remove
tooth decay, fill cavities, and repair fractured teeth. Dentists diagnose and
treat problems with patients‘ teeth, gums, and related parts of the mouth.
They provide advice and instruction on taking care of the teeth and gums
and on diet choices that affect oral health.
ADVERTISEMENTS
20. Question
Which of the following is/are an example(s) of theoretical knowledge? Select all
that apply.
o A. Antibiotics are ineffective in treating viral infections.
o B. When you take a patient's blood pressure, the patient's arm should be at
heart level.
o C. In Maslow's framework, physical needs are most basic.
o D. When drawing medication out of a vial, inject air into the vial first.
o E. Let the patient dangle his feet first before assisting him to stand or
transfer.
Incorrect
Correct Answer: A, C
Theoretical knowledge consists of research findings, facts (e.g., ―Antibiotics are
ineffective . . .‖ is a fact), principles, and theories (e.g., ―In Maslow‘s framework . . .‖
is a statement from a theory). Instructions for taking blood pressure and
withdrawing medications are examples of practical knowledge—what to do and
how to do it. While practical knowledge is gained by doing things, theoretical
knowledge is gained, for example, by reading a manual.
 Option A: Theoretical knowledge teaches the reasoning, techniques and
theory of knowledge.
 Option B: Practical knowledge is the knowledge that is acquired by day-
to-day hands-on experiences. In other words, practical knowledge is
gained through doing things; it is very much based on real-life endeavors
and tasks.

 Option C: While theoretical knowledge may guarantee that you
understand the fundamental concepts and have know-how about how
something works and its mechanism, it will only get you so far, as, without
practice, one is not able to perform the activity as well as he could.
 Option D: Practical knowledge guarantees that you are able to actually do
something instead of simply knowing how to do it.
 Option E: Theoretical and practical knowledge are interconnected and
complement each other — if one knows exactly HOW to do something,
one must be able to apply these skills and therefore succeed in practical
knowledge.
ADVERTISEMENTS
21. Question
The nurse recognizes that urinary elimination changes may occur even in healthy
older adults because of which of the following?
o A. The bladder distends and its capacity increases.
o B. Older adults ignore the need to void.
o C. Urine becomes more concentrated.
o D. The amount of urine retained after voiding increases.

Incorrect
Correct Answer: D. The amount of urine retained after voiding increases
The capacity of the bladder may decrease with age but the muscle is weaker and
can cause urine to be retained. Muscle changes and changes in the reproductive
system can affect bladder control. As the volume of urine held by the bladder
increases, so too does the pressure therein. Wall pressure of 5 to 15 mm Hg
creates a sensation of bladder fullness while 30 mm Hg and beyond is painful.
The sensation of increasing bladder fullness is conveyed to the spinal cord via the
pudendal and hypogastric nerves on both A-delta and C nerve fibers.
 Option A: The bladder wall changes. The elastic tissue becomes tough and
the bladder becomes less stretchy. The bladder cannot hold as much urine
as before. The urethra can become blocked. In women, this can be due to
weakened muscles that cause the bladder or vagina to fall out of position

(prolapse). In men, the urethra can become blocked by an enlarged
prostate gland.
 Option B: Older adults don‘t ignore the urge to void and may have
difficulty getting to the toilet in time. Bladder capacity changes throughout
one‘s life. In children, an approximation of bladder volume can be
calculated with the formula: (years of age + 2) x 30 mL. By adulthood, the
average volume that a functional bladder can comfortably hold is between
300 and 400 mL.
 Option C: The kidney becomes less able to concentrate urine with age.
Urination or micturition primarily functions in the excretion of metabolic
products and toxic wastes. The urinary tract also serves as a storage vessel
of the waste filtered from the kidneys. Urine stored in the bladder is
released from the bladder through the urethra upon a complex network of
neurological function.
ADVERTISEMENTS
22. Question
During the assessment of the client with urinary incontinence, the nurse is most
likely to assess for which of the following? Select all that apply.
o A. Perineal skin irritation
o B. Fluid intake of less than 1,500 mL/d
o C. History of antihistamine intake
o D. Hx of UTI
o E. A fecal impaction
Incorrect
Correct Answer: A, B, D, and E
Urinary incontinence is the involuntary leakage of urine. This medical condition is
common in the elderly, especially in nursing homes, but it can affect younger
adult males and females as well. Urinary incontinence can impact both patient
health and quality of life. The prevalence may be underestimated as some

patients do not inform health care providers of having issues with urinary
incontinence for various reasons.
 Option A: The perineum may become irritated by the frequent contact
with urine. Approximately 13 million Americans experience urinary
incontinence. The prevalence is 50% or greater among residents of nursing
facilities. Caregivers report that 53% of the homebound elderly are
incontinent. A random sampling of hospitalized elderly patients reports
that 11% of patients have persistent urinary incontinence at admission, and
23% at discharge.
 Option B: Normal fluid intake is at least 1,500 mL/d and clients often
decrease their intake to try to minimize urine leakage. Functional urinary
incontinence is the involuntary leakage of urine due to environmental or
physical barriers to toileting. This type of incontinence is sometimes
referred to as toileting difficulty.
 Option C: Antihistamines can cause urinary retention rather than urinary
incontinence. The urethra is the tube that takes urine from the bladder out
of the body. The problem can also be caused by using drugs such as
antihistamines (like Benadryl®), antispasmodics (like Detrol®), and tricyclic
antidepressants (like Elavil®) that can change the way the bladder muscle
works.
 Option D: UTIs can contribute to incontinence. Patients should be asked
about medical conditions such as chronic obstructive pulmonary disease
and asthma (which can cause cough), heart failure (with related fluid
overload and diuresis), neurologic conditions (which may suggest
dysregulated bladder innervation), musculoskeletal conditions (which may
contribute to toileting barriers), etc.
 Option E: A fecal impaction can compress the urethra, which results in sm.
amts of urine leakage. Overflow urinary incontinence is the involuntary
leakage of urine from an overdistended bladder due to impaired detrusor
contractility and/or bladder outlet obstruction. Neurologic diseases such as
spinal cord injuries, multiple sclerosis, and diabetes can impair detrusor
function. Bladder outlet obstruction can be caused by external
compression by abdominal or pelvic masses and pelvic organ prolapse,
among other causes. A common cause in men is benign prostatic
hyperplasia.
ADVERTISEMENTS

23. Question
Which action represents the appropriate nursing management of a client wearing
a condom catheter?
o A. Ensure that the tip of the penis fits snugly against the end of the condom.
o B. Check the penis for adequate circulation 30 min after applying.
o C. Change the condom every 8 hours.
o D. Tape the collecting tube to the lower abdomen.

Incorrect
Correct Answer: B. Check the penis for adequate circulation 30 min after
applying
The penis and condom should be checked 1/2 hour after application to ensure
that it‘s not too tight. and the tubing is taped to the leg or attached to a leg bag.
Condom catheters are external urinary catheters that are worn like a condom.
They collect urine as it drains out of your bladder and send it to a collection bag
strapped to your leg. They‘re typically used by men who have urinary
incontinence (can‘t control their bladder).
 Option A: A 1 in. space should be left between the penis and the end of
the condom. Place the condom over the tip of the penis and slowly unroll it
until it gets to the base. Leave enough room at the tip (1 to 2 inches) so it
won‘t rub against the condom.
 Option C: The condom is changed every 24h. Condom catheters should be
replaced every 24 hours. Throw away the old one unless it‘s designed to be
reusable. The collection bag should be emptied when it‘s about half full or
at least every three to four hours for a small bag and every eight hours for
a large one.
 Option D: An indwelling catheter is taped to the lower abdomen or upper
thigh. Use a nonadhesive condom catheter to help prevent irritation from
adhesive. An inflatable ring holds it in place. Keep the bag lower than the
bladder to avoid backflow of urine from the bag. Securely attach the tube
to the leg (below the knee, such as the calf), but leave a little slack so it
doesn‘t pull on the catheter.
ADVERTISEMENTS

24. Question
The catheter slips into the vagina during a straight catheterization of a female
client. The nurse does which action?
o A. Leaves the catheter in place and gets a new sterile catheter.
o B. Leaves the catheter in place and asks another nurse to attempt the
procedure.
o C. Removes the catheter and redirects it to the urinary meatus.
o D. Removes the catheter, wipes it with a sterile gauze, and redirects it to the
urinary meatus.
Incorrect
Correct Answer: A. Leaves the catheter in place and gets a new sterile
catheter.
The catheter in the vagina is contaminated and can‘t be reused. If left in place, it
may help avoid mistaking the vaginal opening for the urinary meatus. A single
failure to catheterize the meatus doesn‘t indicate that another nurse is needed
although sometimes a second nurse can assist in visualization of the meatus.
Urinary bladder catheterization is performed for both therapeutic and diagnostic
purposes. Based on the dwell time, the urinary catheter can be either intermittent
(short-term) or indwelling (long-term).
 Option B: After exposing the urethral meatus, a lubricated catheter tip is
advanced in the meatus until there is a spontaneous return of urine. The
catheter balloon is then inflated as per the manufacturer‘s
recommendations.
 Option C: In the event a catheter is inserted in the vagina, it should be left
there until a new sterile catheter is successfully inserted into the meatus.
Analgesia is of no proven clinical use in women. Lubrication jelly should be
applied to the tip of the catheter. The application of lubricant to the
urethral meatus is associated with difficulty in catheter insertion.
 Option D: Urinary tract infection (UTI) is the most common complication
that occurs as a result of long-term catheterization. The normal urinary
flow prevents the ascension of microbes from the periurethral skin
avoiding the infection. Alteration of the defensive mechanism from the

catheter results in an increased risk of UTIs. Escherichia coli and Klebsiella
pneumonia are the most common organisms implicated in UTIs. Recurrent
UTIs are associated with increased antibiotic resistance.
ADVERTISEMENTS
25. Question
Which statement indicates a need for further teaching of a home care client with
a long term indwelling catheter?
o A. "I will keep the collecting bag below the level of the bladder at all times."
o B. "Intake of cranberry juice may help decrease the risk of infection."
o C. "Soaking in a warm tub bath may ease the irritation associated with
the catheter."
o D. "I should use clean tech. when emptying the collecting bag."
Incorrect
Correct Answer: C. “Soaking in a warm tub bath may ease the irritation
associated with the catheter”
Soaking in a bathtub can increase the risk of exposure to bacteria. Avoid taking
baths, but shower daily. For the first few days after getting a suprapubic catheter,
use a waterproof bandage when showering. Once the wound heals, the client can
shower as usual, but avoid scented soaps.
 Option A: The bag should be below the level of the bladder to promote
proper drainage. Always keep the bag below the waist. Check the tube
once in a while for bends or kinks that keep pee from flowing out. Don‘t
use any lotions or powders around where the catheter goes into the body.
 Option B: Intake of cranberry juice creates an environment nonconducive
to infection. ―Indwelling‖ means inside the body. This catheter drains urine
from the bladder into a bag outside the body. Common reasons to have an
indwelling catheter are urinary incontinence (leakage), urinary retention
(not being able to urinate), a surgery that made this catheter necessary, or
another health problem.
 Option D: Clean technique is appropriate for touching the exterior
portions of the system. Wash hands with soap and water. Empty urine from

the bag into the toilet. Pinch the catheter closed between the fingers.
Remove the bag. Wipe the end of the catheter with a fresh alcohol pad.
Wipe the tip of the new bag with the second alcohol pad. Connect the new
bag and stop pinching the catheter now. Make sure there are no bends or
kinks in the catheter tube. Wash hands again.
ADVERTISEMENTS
26. Question
During shift report, the nurse learns that an older female client is unable to
maintain continence after she senses the urge to void and becomes incontinent
on the way to the bathroom. Which nursing diagnosis is most appropriate?
o A. Stress urinary incontinence
o B. Reflex urinary incontinence
o C. Functional urinary incontinence
o D. Urge urinary incontinence

Incorrect
Correct Answer: D. Urge urinary incontinence
The key phrase is ―the urge to void‖ option one occurs when the client coughs,
sneezes, or jars the body, resulting in accidental loss of urine. If one feels a strong
urge to urinate even when the bladder isn‘t full, the incontinence might be
related to overactive bladder, sometimes called urge incontinence. This condition
occurs in both men and women and involves an overwhelming urge to urinate
immediately, frequently followed by loss of urine before the client can reach a
bathroom. Even if one never has an accident, urgency and urinary frequency can
interfere with work and a social life because of the need to keep running to the
bathroom.
 Option A: Stress Urinary Incontinence (SUI) is when urine leaks out with
sudden pressure on the bladder and urethra, causing the sphincter muscles
to open briefly. With mild SUI, pressure may be from sudden forceful
activities, like exercise, sneezing, laughing, or coughing.
 Option B: Reflex urinary incontinence occurs with involuntary loss of urine
at somewhat predictable intervals when a specific bladder volume is

reached. Reflex incontinence occurs when the bladder muscle contracts
and urine leaks (often in large amounts) without any warning or urge. This
can happen as a result of damage to the nerves that normally warn the
brain that the bladder is filling.
 Option C: Functional urinary continence is the involuntary loss of urine
related to impaired function. If the urinary tract is functioning properly but
other illnesses or disabilities are preventing one from staying dry, the client
might have what is known as functional incontinence. For example, if an
illness rendered the client unaware or unconcerned about the need to find
a toilet, the client would become incontinent. Medications, dementia, or
mental illness can decrease awareness of the need to find a toilet.
ADVERTISEMENTS
27. Question
A female client has a urinary tract infection. Which teaching points by the nurse
should be helpful to the client? Select all that apply.
o A. Limit fluids to avoid the burning sensation on urination.
o B. Review symptoms of UTI with the client.
o C. Wipe the perineal area from back to front.
o D. Wear cotton underclothes.
o E. Take baths rather than showers.

Incorrect
Correct Answer: B, D
no comorbidities, such as diabetes, immunocompromised, or pregnant.
Uncomplicated UTI is also known as cystitis or lower UTI. Forty percent of women
in the United States will develop a UTI during their lifetime, making it one of the
most common infections in women. UTI is uncommon in circumcised males, and
by definition, any male UTI is considered complicated.

 Option A: Increased fluids decrease concentration and irritation. An
uncomplicated UTI usually only involves the bladder. When the bacteria
invade the bladder mucosal wall, cystitis is produced. The majority of
organisms causing a UTI are enteric coliforms that usually inhabit the
periurethral vaginal introitus. These organisms ascend into the bladder and
cause a UTI.
 Option B: Reviewing the symptoms of UTI with the client validates the
diagnosis. Symptoms of uncomplicated UTI are pain on urination (dysuria),
frequent urination (frequency), inability to start the urine stream
(hesitation), sudden onset of the need to urinate (urgency), and blood in
the urine (hematuria). Usually, patients with uncomplicated UTI do not have
fever, chills, nausea, vomiting, or back pain, which are signs of kidney
involvement or upper tract disease/pyelonephritis.
 Option C: The client should wipe the perineal area from front to back to
prevent the spread of bacteria from the rectal area to the urethra. Sexual
 Option D: Cotton underwear promotes appropriate exposure to air,
resulting in decreased bacterial growth. Urine is an ideal medium for
bacterial growth; factors that make it unfavorable for bacterial growth
include a pH of less than 5, presence of organic acids, and high levels of
urea. Frequent urination is also known to decrease the risk of UTI.
 Option E: Showers reduce exposure of the area to bacteria. Bacteria that
cause UTI have adhesins on their surface which allow the organism to
attach to the mucosal surface. In addition, a short urethra also makes it
easier for the uropathogen to invade the urinary tract.
ADVERTISEMENTS
28. Question
The nurse will need to assess the client‘s performance of clean intermittent self
catheterization (CISC) for a client with which urinary diversion?
o A. Ileal conduit
o B. Kock pouch

o C. Neobladder
o D. Vesicostomy
Incorrect
Correct Answer: B. Kock pouch
The ileal conduit and vesicostomy are incontinent urinary diversions, and clients
are required to use an external ostomy appliance to contain the urine. In this new
operation, a pouch or reservoir is fashioned out of the terminal ileum with a valve
mechanism at its exit to the skin surface. This allows storage of the liquid bowel
contents in an expandable container with no leakage of stool or gas and
therefore no skin problems. There is no need for appliances or bags, no
embarrassment from the involuntary noise and smell of flatus through the
ileostomy. The stoma is created flush and within the bikini line. The patient
catheterizes the pouch on an average of three times a day.
 Option A: An ileal conduit aims to divert urine produced from the upper
urinary tracts to a newly formed reservoir created from the terminal ileum.
The ureters are disconnected from the bladder and implanted into the
conduit.
 Option C: Clients with a neobladder can control their voiding. During
neobladder surgery, the surgeon takes out the existing bladder and forms
an internal pouch from part of the intestine. The pouch, called a
neobladder, stores the urine.
 Option D: A vesicostomy is a stoma (opening) created between the
bladder and the abdomen. This allows urine to drain freely, with low
pressure, to help protect and prevent harm to the kidneys. It is a surgical
procedure that typically involves an overnight stay in the hospital.
ADVERTISEMENTS
29. Question
Which focus is the nurse most likely to teach for a client with a flaccid bladder?
o A. Habit training: attempt voiding at specific time periods.
o B. Bladder training: delay voiding according to a pre-schedule timetable.

o C. Crede's maneuver: apply gentle manual pressure to the lower
abdomen.
o D. Kegel exercises: contract the pelvic muscles.

Incorrect
Correct Answer: C. Crede’s maneuver: apply gentle manual pressure to the
lower abdomen.
Because the bladder muscles will not contract to increase the intra-bladder
pressure to promote urination, the process is initiated manually. The Credé
maneuver is a technique used to void urine from the bladder of an individual
who, due to disease, cannot do so without aid. The Credé maneuver is executed
by exerting manual pressure on the abdomen at the location of the bladder, just
below the navel. Options one, two, and four: to promote continence bladder
contractions are required for habit training, bladder training, and increasing the
tone of the pelvic muscles.
 Option A: One type of toilet training is habit training. Habit training is the
process of teaching a child to eliminate on the toilet at routine times. Habit
training involves teaching children to eliminate on the toilet by developing
a toileting routine/habit.
 Option B: Bladder training is an important form of behavior therapy that
the amount of time between emptying your bladder and the amount of
fluids your bladder can hold. It also can diminish leakage and the sense of
 Option D: Kegel exercises can help make the muscles under the uterus,
bladder, and bowel (large intestine) stronger. They can help both men and
women who have problems with urine leakage or bowel control.
ADVERTISEMENTS
30. Question
Which of the following behaviors indicates that the client on a bladder training
program has met the expected outcomes? Select all that apply.
o A. Voids each time there is an urge.

o B. Practices slow, deep breathing until the urge decreases.
o C. Uses adult diapers, for "just in case".
o D. Drinks citrus juices and carbonated beverages.
o E. Performs pelvic muscle exercises.

Incorrect
Correct Answer: B, E
It is important for the client to inhibit the urge to void sensation when a
premature urge is experienced. Bladder training, a program of urinating on
schedule, enables the client to gradually increase the amount of urine the client
can comfortably hold. Bladder training is a mainstay of treatment for urinary
frequency and overactive bladder in both women and men, alone or in
conjunction with medications or other techniques.
 Option A: Choose an interval. Based on the typical interval between
urinations, select a starting interval for training that is 15 minutes longer. If
the typical interval is one hour, make a starting interval one hour and 15
minutes.
 Option B: When the client starts training, he should empty his bladder first
thing in the morning and not again until the interval he set. If the time
arrives before he can feel the urge, he should go anyway. If the urge hits
first, he should remind himself that his bladder isn‘t really full, and use
whatever techniques he can to delay going.
 Option C: Some clients may need diapers; this is not the best indicator of a
successful program.
 Option D: Citrus juices may irritate the bladder. Carbonated beverages
increase diuresis and the risk of incontinence.
 Option E: Try the pelvic floor exercises sometimes called Kegels, or simply
try to wait another five minutes before walking slowly to the bathroom.
Once comfortable with a set interval, increase it by 15 minutes. Over
several weeks or months, the client may find that they are able to wait
much longer and that they have experienced far fewer feelings of urgency
or episodes of urge incontinence.
ADVERTISEMENTS

31. Question
A nurse has identified that the patient has overflow incontinence. What is a major
factor that contributes to this clinical manifestation?
o A. Coughing
o B. Mobility deficits
o C. Prostate enlargement
o D. Urinary tract infection

Incorrect
Correct Answer: C. Prostate enlargement
An enlarged prostate compresses the urethra and interferes with the outflow of
urine, resulting in urinary retention. With urinary retention, the pressure within
the bladder builds until the external urethral sphincter temporarily opens to allow
a small volume (25-60mL) of urine to escape (overflow incontinence). Men who
are unable to completely empty their bladder and experience unexpected urine
leakage may have what is called overflow incontinence.
 Option A: Coughing, which raises the intra abdominal pressure, is related
to stress incontinence, not overflow incontinence. An enlarged prostate can
interfere with the passage of urine through the urethra, the tube connected
to the bladder.
 Option B: Mobility deficits, such as spinal cord injuries, are related to reflex
incontinence, not overflow incontinence. Damage to nerves near the
bladder causing under-activity. This can occur with neurological injury or
with diseases such as diabetes.
 Option D: Urinary tract infections are related to urge incontinence, not
overflow incontinence. Men with this type of urinary incontinence often do
not feel that their bladders are full, which then leads to leakage as the
bladder has reached its full capacity. In addition to leakage, urine left in the
bladder can lead to urinary tract infections due to the growth of bacteria as
well as bladder stones.
ADVERTISEMENTS
32. Question

A nurse must measure the intake and output (I&O) for a patient who has a
urinary retention catheter. Which equipment is most appropriate to use to
accurately measure urine output from a urinary retention catheter?
o A. Urinal
o B. Graduate
o C. Large syringe
o D. Urine collection bag

Incorrect
Correct Answer: B. Graduate
A graduate is a collection container with volume markings usually at 25 mL
increments that promote accurate measurements of urine volume. To measure
urine output in critical care units, a Foley catheter is introduced through the
patient‘s urethra until it reaches his/her bladder. The other end of the catheter is
connected to a graduated container that collects the urine.
 Option A: Although urinals have volume markings on the side, usually they
occur in 100 mL increments that do not promote accurate measurements.
Urine output is the best indicator of the state of the patient‘s kidneys. If the
kidneys are producing an adequate amount of urine it means that they are
well perfused and oxygenated. Otherwise, it is a sign that the patient is
suffering from some complications.
 Option C: Large syringe is impractical. A large syringe is used to obtain a
sterile specimen from a retention catheter (Foley catheter). Urine output is
required for calculating the patient‘s water balance, which is essential in the
treatment of burn patients. Finally, it is also used in multiple therapy
protocols to check whether the patient reacts properly to treatment
 Option D: A urine collection bag is flexible and balloons outward as urine
collects. In addition, the volume markings are at 100 mL increments that do
not promote accurate measurements. In critical care units of first world
countries, measurements of every patient‘s urine output are taken hourly,
24 times a day, 365 days a year. In the case of emerging countries, often
only burn patients—for whom urine output monitoring is of paramount
importance—have this parameter recorded every hour, while the remaining
critical patients have it recorded every 2 or 3 hours.

ADVERTISEMENTS
33. Question
A patient‘s urine is cloudy, is amber, and has an unpleasant odor. What problem
may this information indicate that requires the nurse to make a focused
assessment?
o A. Urinary retention
o B. Urinary tract infection
o C. Ketone bodies in the urine
o D. High urinary calcium level

Incorrect
Correct Answer: B. Urinary tract infection
The urine appears concentrated (amber)and cloudy because of the presence of
bacteria, white blood cells, and red blood cells. The unpleasant odor is caused by
pus in the urine (pyuria). Uncomplicated urinary tract infection (UTI) is a bacterial
infection of the bladder and associated structures. These are patients with no
structural abnormality and no comorbidities, such as diabetes,
immunocompromised, or pregnancy. Uncomplicated UTI is also known as cystitis
or lower UTI.
 Option A: These clinical manifestations do not reflect urinary retention.
Urinary retention is evidenced by supra pubic distention and lack of
voiding or small, frequent voiding (overflow incontinence). The
mechanisms of acute urinary retention can include outflow obstruction,
which can be mechanical such as from physical narrowing of the urethral
channel. The other dynamic is from an increase in the muscle tone within
and around the urethra as in benign prostatic hypertrophy and hyperplasia.
 Option C: These clinical manifestations do not reflect ketone bodies in the
urine. A reagent strip dipped in urine will measure the presence of Ketone
bodies. If the cells don‘t get enough glucose, the body burns fat for energy
instead. This produces a substance called ketones, which can show up in
the blood and urine.
 Option D: These clinical manifestations do not reflect excessive calcium in
the urine. Urine calcium levels are measured by assessing a 24-hour urine

specimen. If urine calcium levels are too high or too low, it may mean that
the client has a medical condition, such as kidney disease or kidney stones.
Kidney stones are hard, pebble-like substances that can form in one or
both kidneys when calcium or other minerals build up in the urine. Most
kidney stones are formed from calcium.
ADVERTISEMENTS
34. Question
A nurse is caring for a debilitated female patient with nocturia. Which nursing
intervention is the priority when planning to meet this patient‘s needs?
o A. Encouraging the use of bladder training exercises.
o B. Providing assistance with toileting every four hours.
o C. Positioning a bedside commode near the bed.
o D. Teaching the avoidance of fluid after 5 PM.

Incorrect
Correct Answer: C. Positioning a bedside commode near the bed.
The use of a commode requires less energy than using a bedpan and is safer than
walking to the bathroom. Sitting on the commode uses gravity to empty the
bladder fully and thus prevent urinary stasis. Nocturia is defined as the need for a
patient to get up at night on a regular basis to urinate. A period of sleep must
precede and follow the urinary episode to count as a nocturnal void. This means
the first-morning void is not considered when determining nocturia episodes.
Use of a bedside commode or urinal can minimize the bother, if not the
frequency, of nocturia and may reduce the risk of falls. Remove any obstacles,
loose rugs, or furniture between the bed and the nearest commode to reduce fall
risk further. Consider using nightlights to help illuminate the passage to the
bathroom.
 Option A: Although bladder training exercises should be done, it is not the
priority. Behavioral therapy, which includes pelvic floor muscle training,
urge-suppression techniques, delayed voiding, fluid management, sleep
hygiene, Kegel exercises, and peripheral edema management, has been

shown to be reasonably efficacious both when used alone or together with
pharmacological therapy in controlling nocturia.
 Option B: Assisting with toileting may be too often or not often enough
for the patient. Care should be individualized for the patient. In particular,
older adults with nocturia who make multiple nocturnal trips to the
bathroom are at a substantially increased risk of potentially serious falls. A
quarter of all the falls that occur in older individuals happen overnight. Of
these, 25% are directly related to nocturia. Patients who make at least 2 or
more nocturnal bathroom visits a night, have more than double the risk of
fractures and fall-related traumas.
 Option D: Fluids may be decreased during the last two hours before
bedtime, but they should not be avoided completely after 5 PM (opt4).
Some fluid intake is necessary for adequate renal perfusion. Drinking large
amounts of fluids shortly before going to bed and ingesting caffeine or
alcohol late in the day and before bed is likely to contribute to nocturia as
well. Be aware that some elderly patients may already be somewhat
dehydrated and might require extra fluid intake earlier in the day before
they can safely do any evening fluid restriction before bedtime.
ADVERTISEMENTS
35. Question
A practitioner uses a urine specimen for culture and sensitivity via a straight
catheter for a patient. What should the nurse do when collecting this urine
specimen?
o A. Use a sterile specimen container.
o B. Collect urine from the catheter port.
o C. Inflate the balloon with 10 mL of sterile water.
o D. Have the patient void before collecting the specimen.

Incorrect
Correct Answer: A. Use a sterile specimen container.
A culture attempts to identify the microorganisms present in the urine, and a
sensitivity study identifies the antibiotics that are effective against the isolated

microorganisms. A sterile specimen container is used to prevent contamination of
the specimen by microorganisms outside the body (exogenous).
 Option B: The urine from the straight catheter flows directly into the
specimen container. Collecting a urine specimen from a catheter port is
necessary when the patient has a urinary retention catheter. A straight
catheter has a single lumen for draining urine from the bladder.
 Option C: A straight catheter does not remain in the bladder and therefore
does not have a 2nd lumen for water to be inserted into a balloon. This
may result in no urine left in the bladder for the straight catheter to collect.
 Option D: A minimum of 3 mL of urine is necessary for a specimen for
urine culture and sensitivity. Do not urinate for at least 1 hour before the
test. If the client doesn‘t have the urge to urinate, he may be instructed to
drink a glass of water 15 to 20 minutes before the test. Otherwise, there is
no preparation for the test.
ADVERTISEMENTS
36. Question
A nurse in a provider‘s office is assessing a client who reports losing control of
urine whenever she coughs, laughs, or sneezes. The client relates a history of
three vaginal births, but no serious accidents or illnesses. Which of the following
interventions are appropriate for helping to control or eliminate the clients
o A. Limit total daily fluid intake
o B. Decrease or avoid caffeine
o C. Increase the intake of calcium supplements
o D. Avoid the intake of alcohol
o E. Use Crede maneuver

Incorrect
Correct Answer: B and D
Caffeine and alcohol are bladder irritants and can worsen stress incontinence.
Alcohol is a bladder irritant and can worsen stress incontinence. Quitting

smoking, losing excess weight, or treating a chronic cough will lessen the risk of
stress incontinence and improve the symptoms. Stress incontinence is different
from urgency incontinence and overactive bladder (OAB). If the client has
urgency incontinence or OAB, the bladder muscle contracts, causing a sudden
urge to urinate before he can get to the bathroom. Stress incontinence is much
more common in women than in men.
 Option A: Because stress incontinence results from weak pelvic muscles
and other structures, limiting fluid will not resolve the problem. The doctor
may recommend how much and when one should consume fluids during
the day and evening. However, don‘t limit what the client drinks so much
that he becomes dehydrated.
 Option B: Lifestyle changes should be made such as reducing caffeine
intake (including green tea), stopping smoking, and losing weight.
 Option C: Calcium has no effect on stress incontinence. Bladder training
involves learning techniques to increase the length of time between feeling
the need to urinate and passing urine. The course usually lasts for at least
six weeks and can be combined with the Kegel exercises. Some individuals
may find that timed toileting is helpful, particularly for people with a
learning disability or cognitive impairment.
 Option D: The doctor may also suggest that the client avoid caffeinated,
carbonated, and alcoholic beverages, which may irritate and affect bladder
function in some people. If he finds that using fluid schedules and avoiding
certain beverages significantly improves leakage, the client will have to
decide whether making these changes in the diet are worth it.
 Option E: The Crede maneuver helps manage reflex incontinence, not
stress incontinence. Pelvic floor muscle training is a technique that
strengthens the pelvic floor muscles and is an effective treatment for stress
incontinence, especially if the muscle has been damaged.
ADVERTISEMENTS
37. Question
A client who has an indwelling catheter reports the need to urinate. Which of the
following interventions should the nurse perform?
o A. Check to see whether the catheter is patent.

o B. Reassure the client that it is not possible for her to urinate.
o C. Re-catheterize the bladder with a larger gauge catheter.
o D. Collect a urine specimen for analysis.

Incorrect
Correct Answer: A. Check to see whether the catheter is patent.
A clogged or kinked catheter causes the bladder to fill and stimulates the need to
urinate. An indwelling urinary catheter (IUC), generally referred to as a ―Foley‖
catheter, is a closed sterile system with a catheter and retention balloon that is
inserted either through the urethra or suprapubically to allow for bladder
drainage. External collecting devices (e.g. drainage tubing and bag) are
connected to the catheter for urine collection.
 Option B: Reassuring the client that it is not possible to urinate is a non-
therapeutic response because it diminishes the client‘s concern. Check the
tube once in a while for bends or kinks that keep pee from flowing out.
Empty the leg bag twice a day or when it‘s half full. Keep the drainage bag
below your bladder so it drains well.
 Option C: There are less invasive approaches the nurse can take before
replacing the catheter. Indwelling urinary catheters are recommended only
for short-term use, defined as less than 30 days (EAUN recommends no
longer than 14 days.) The catheter is inserted for continuous drainage of
the bladder for two common bladder dysfunction: urinary incontinence (UI)
and urinary retention.
 Option D: Although it may become necessary to collect a urine specimen,
there is a simpler approach the nurse can take to assess and possibly
resolve the client‘s problem.
ADVERTISEMENTS
38. Question
A provider prescribes a 24-hour urine collection for a client. Which of the
following actions should the nurse take?
o A. Discard the first voiding.
o B. Keep all voidings in a container at room temperature.

o C. Ask the client to urinate and pour the urine into a specimen container.
o D. Ask the client to urinate into the toilet, stop midstream, and finish
urinating into the specimen container.
Incorrect
Correct Answer: A. Discard the first voiding.
The nurse should discard the first voiding of the 24 hour urine specimen, and
note the time. 24-hour urine protein measures the amount of protein released in
urine over a 24-hour period. The normal value is less than 100 milligrams per day
or less than 10 milligrams per deciliter of urine.
 Option B: The nurse should collect all voidings after that and keep them in
a refrigerated container. A 24-hour urine collection is done by collecting
the urine in a special container over a full 24-hour period. The container
must be kept cool until the urine is returned to the lab.
 Option C: For a urinalysis, the nurse should ask the client to urinate and
pour the urine into a specimen container. Urine is made up of water and
dissolved chemicals, such as sodium and potassium. It also contains urea.
This is made when protein breaks down. And it contains creatinine, which is
formed from muscle breakdown. Normally, urine contains certain amounts
of these waste products. It may be a sign of a certain disease or condition if
these amounts are not within a normal range. Or if other substances are
present.
 Option D: For a culture, the nurse should ask the client to urinate first into
the toilet, then stop midstream, and finish urinating in the specimen
container. A 24-hour urine collection helps diagnose kidney problems. It is
often done to see how much creatinine clears through the kidneys. It‘s also
done to measure protein, hormones, minerals, and other chemical
compounds.
ADVERTISEMENTS
39. Question
A nurse is preparing to initiate a bladder training program for a client who has a
voiding disorder. Which of the following actions should the nurse take? Select all
that apply.

o A. Establish a schedule of voiding prior to meal times.
o B. Have the client record voiding times.
o C. Gradually increase the voiding intervals.
o D. Reminded client to hold urine until next scheduled voiding time.
o E. Provide a sterile container for voiding.

Incorrect
Ask the client to keep track of voiding times is an appropriate nursing action.
Gradually increasing the voiding interval is an appropriate nursing action. The
client should be reminded to hold urine until the next scheduled voiding time.
Bladder training involves voiding at scheduled in frequent intervals and gradually
increasing these intervals to four hours.
 Option A: Mealtimes are not regular, and the intervals may be longer than
every four hours. Bladder training requires following a fixed voiding
schedule, whether or not one feels the urge to urinate. If one feels an urge
to urinate before the assigned interval, he should use urge suppression
techniques — such as relaxation and Kegel exercises.
 Option B: Keeping a diary of bladder activity is very important. This helps
the health care provider determine the correct place to start the training
and to monitor progress throughout the program.
 Option C: Bladder training is an important form of behavior therapy that
the amount of time between emptying the bladder and the amount of
fluids the bladder can hold. It also can diminish leakage and the sense of
 Option D: When the client feels the urge to urinate before the next
designated time, he should use ―urge suppression‖ techniques or try
relaxation techniques like deep breathing. Focus on relaxing all other
muscles. If possible, he must sit down until the sensation passes. If the urge
is suppressed, adhere to the schedule. If the client cannot suppress the
urge, wait five minutes then slowly make way to the bathroom. After
urinating, re-establish the schedule. Repeat this process every time an urge
is felt.

 Option E: A sterile container is not used in a bladder training program.
When the client has accomplished the initial goal, he should gradually
increase the time between emptying the bladder by 15-minute intervals.
He should try to increase the interval each week. However, he will be the
best judge of how quickly he can advance to the next step. Increase the
time between each urination until he reaches a three- to four-hour voiding
interval.
ADVERTISEMENTS
40. Question
A nurse educator on a medical unit is reviewing factors that increase the risk of
urinary tract infections with a group of assistive personnel. Which of the following
should be included in the review? Select all that apply.
o A. Having sexual intercourse on a frequent basis.
o B. Lowering of testosterone levels.
o C. Wiping from front to back.
o D. The location of the vagina in relation to the anus.
o E. Undergoing frequent catheterization.

Incorrect
Correct Answer: A, D, and E
no comorbidities, such as diabetes, immunocompromised, or pregnancy.
Uncomplicated UTI is also known as cystitis or lower UTI. E.coli causes the
majority of UTI but other organisms of importance include proteus, klebsiella,
and enterococcus. The diagnosis of UTI is made from the clinical history and
urinalysis, but the proper collection of the urine sample is important.
 Option A: Having sexual intercourse on a frequent basis is a factor that
increases the risk of UTI in both males and females. Sexual intercourse and
the use of spermicide and diaphragm are also risk factors for UTI. Sexual

 Option B: The decrease in estrogen levels during menopause increases a
woman‘s susceptibility to UTIs. An uncomplicated UTI usually only involves
the bladder. When the bacteria invade the bladder mucosal wall, cystitis is
produced. The majority of organisms causing a UTI are enteric coliforms
that usually inhabit the periurethral vaginal introitus. These organisms
ascend into the bladder and cause a UTI.
 Option C: Wiping from front to back decreases a woman‘s risk of UTIs.
After urination, women should wipe from front to back, not from the anal
area forward, which seems to drag pathogenic organisms nearer to the
urethra. Bacteria that cause UTI have adhesins on their surface which allow
the organism to attach to the mucosal surface. In addition, a short urethra
also makes it easier for the uropathogen to invade the urinary tract.
Premenopausal women have large concentrations of lactobacilli in the
vagina and prevent the colonization of uropathogens. However, the use of
antibiotics can erase this protective effect.
 Option D: The close proximity of the female urethra to the anus is a factor
that increases the risk of UTIs. Pathogenic bacteria ascend from the
perineum, causing UTI. Women have shorter urethras than men and
therefore are more susceptible to UTI. Very few uncomplicated UTIs are
caused by blood-borne bacteria. Escherichia coli is the most common
organism in uncomplicated UTI by a large margin.
 Option E: Undergoing frequent catheterization and the use of indwelling
catheters are risk factors for UTIs. A major risk factor for UTI is the use of a
catheter. In addition, manipulation of the urethra is also a risk factor. In-
and-out catheterization of the bladder will cause UTI in uninfected women
1% of the time. Men should start the urine stream to clean the urethra and
then obtain a midstream sample. Urine should be sent to the lab
immediately or refrigerated because bacteria grow rapidly when a sample
is left at room temperature, causing an overestimate of the infection‘s
severity.
ADVERTISEMENTS
41. Question

To prevent postoperative complications, Nurse Kim assists the client with
coughing and deep breathing exercises. This is best accomplished by
implementing which of the following?
o A. Coughing exercises one hour before meals and deep breathing one hour
after meals.
o B. Forceful coughing as many times as tolerated.
o C. Huff coughing every two hours or as needed.
o D. Diaphragmatic and pursed lip breathing 5 to 10 times, four times a day.

Incorrect
Correct Answer: C. Huff coughing every two hours or as needed.
Huff coughing helps keep the airways open and secretions mobilized. Huff
coughing is an alternative for clients who are unable to perform a normal forceful
cough (such as postoperatively) deep breathing and coughing should be
performed at the same time.
 Option A: Only at mealtimes is not sufficient. Deep breathing and
coughing exercises can decrease the risk of lung complications following
surgery. Not only can they prevent pneumonia, deep breathing helps to
get more oxygen to the body‘s cells. These exercises can also be beneficial
to individuals who are susceptible to pulmonary or respiratory problems.
Coughing and deep breathing work to clear mucus and allow moist air to
enter the airways.
 Option B: Extended forceful coughing fatigues the client, especially
postoperatively. If you are lying in bed and need to cough, it may be more
comfortable to bend your knees up. Lean forward when you cough, if you
are sitting in a chair. Place a pillow over your surgical incision and apply
pressure to the area while coughing. This can help to alleviate any
discomfort you feel. It‘s more comfortable to sit upright if you can when
doing coughing exercises.
 Option D: Diaphragmatic and pursed-lip breathing are techniques used for
clients with obstructive airway disease. You can perform breathing
exercises by relaxing your shoulders and upper chest. Take a deep breath
in through your nose. Hold the breath for three seconds. Breathe out
slowly through your mouth. Repeat three times. Taking too many breaths

can make you dizzy or light-headed. Perform breathing exercises every
hour.
ADVERTISEMENTS
42. Question
Nurse Trixie is preparing to perform tracheostomy care. Prior to the beginning of
the procedure, the nurse performs which action?
o A. Tells the client to raise two fingers to indicate pain or distress.
o B. Changes twill tape holding the tracheostomy and place.
o C. Cleans the incision site.
o D. Check the tightness of the ties and knot.

Incorrect
Correct Answer: A. Tells the client to raise two fingers to indicate pain or
distress.
Prior to starting the procedure, it is important to develop a means of
communication by which the client can express pain or discomfort. Tracheostomy
is a procedure where an artificial airway is established surgically or
percutaneously in the cervical trachea. The term ―tracheostomy‖ has evolved to
refer to both the procedure as well as the clinical condition of having a
tracheostomy tube. With the increasing number of patients with tracheostomy,
safe caring requires knowledge and competencies in dealing with routine care,
weaning, decannulation, as well as tracheostomy-related emergencies.
 Option B: The twill tape is not changed until after performing
tracheostomy care. Remove any sutures or ties attached to the
tracheostomy tube and patient. When doing this, the assistant must
stabilize the flange at all times to prevent premature removal.
 Option C: Cleaning the incision should be done after cleaning the inner
cannula. Inspect the stoma for signs of infection, presence of granulation
tissue, bleeding, wound breakdown, and adequacy of a tract. Clean the
area with moist gauze (with normal saline or hydrogen peroxide) followed
by dry gauze while ensuring no foreign body enters the airway. Stay

sutures, if present, may be used gently to pull up the trachea to provide
exposure.
 Option D: Checking the tightness of the ties and knot is done after
applying new twill tape. Make sure the trach ties are not too tight and
should be able to pass an index finger in between the trach ties and neck.
ADVERTISEMENTS
43. Question
Which action by the nurse represents proper nasopharyngeal/nasotracheal
suctioning technique?
o A. Lubricate the suction catheter with petroleum jelly before and between
insertion.
o B. Apply suction intermittently while inserting the suction catheter.
o C. Rotate the catheter while applying suction.
o D. Hyper oxygenate with 100% oxygen for 30 minutes before and after
suctioning.
Incorrect
Correct Answer: C. Rotate the catheter while applying suction.
Rotating the catheter prevents pulling of tissue into the opening on the catheter
tip and the side. Suction is used to clear retained or excessive lower respiratory
tract secretions in patients who are unable to do so effectively for themselves.
This could be due to the presence of an artificial airway, such as an endotracheal
or tracheostomy tube, or in patients who have a poor cough due to an array of
reasons such as excessive sedation or neurological involvement.
 Option A: Suction catheters may only be lubricated with water or water-
soluble lubricant and petroleum jelly such as Vaseline has an oil base.
Lubricate the outside of the airway with a water-soluble/aqueous gel (e.g.
KY Jelly). Initially, choose the larger nostril that is clear from other tubes
(e.g. nasogastric tube). Insert the tip of the NPA into the nostril, then
slightly lift the nares up and direct the airway to follow a path along the
floor of the nose, parallel to the hard palate.

 Option B: No suction should ever be applied while the catheters are being
inserted because this can traumatize tissues. Apply a gentle partial rotation
to the NPA if resistance is felt during insertion e.g. from opposition against
the turbinates. If this does not relieve the resistance/obstruction then
withdraw the airway and try the other nostril before selecting a smaller
size.
 Option D: The client should be hyper-oxygenated for only a few minutes
before and after suctioning and this is generally limited to clients who are
intubated or have a tracheostomy. Hyper-oxygenate the patient if able
(increase mask flow rate or FiO2) delivery of 100% oxygen for > 30 secs
prior to the suction event.
ADVERTISEMENTS
44. Question
Which client statement informs the nurse that his teaching about the proper use
of an incentive spirometer was effective?
o A. "I should breathe out as fast and as hard as possible into the device."
o B. "I should inhale slowly and steadily to keep the balls up."
o C. "I should use the device three times a day, after meals."
o D. "The entire device should be washed thoroughly in sudsy water once a

week."
Incorrect
Correct Answer: B. “I should inhale slowly and steadily to keep the balls up.”
Proper use of an SMI requires the client to take slow, steady inhalations, every
hour or two, 5 to 10 reps each time. Spirometry is one of the most readily
preceded by a maximal inhalation. The most important variables reported include
total exhaled volume, known as the forced vital capacity (FVC), the volume
exhaled in the first second, known as the forced expiratory volume in one second
(FEV1), and their ratio (FEV1/FVC).

 Option A: The patient must breathe in as much air as they can with a
pause lasting for less than 1s at the total lung capacity. The mouthpiece is
placed just inside the mouth between the teeth, soon after the deep
inhalation. The lips should be sealed tightly around the mouthpiece to
prevent air leakage. Exhalation should last at least 6 seconds, or as long as
advised by the instructor. If only the forced expiratory volume is to be
measured, the patient must insert the mouthpiece after performing step 1
and must not breathe from the tube.
 Option C: The procedure is repeated in intervals separated by 1 minute
until two matching, and acceptable results are acquired. Spirometry has
proved to be a crucial tool in diagnosing lung disease, monitoring patients
for their pulmonary function, and assessing their fitness for various
procedures.
 Option D: Only the mouthpiece can be successfully rinsed or wiped clean.
The device should not be submerged in water. Spirometry is an apparatus
used to assess pulmonary function for diagnostic or monitoring purposes.
The procedure must be explained thoroughly to the subject patient by
competent personnel who underwent training under supervision by a
specialist mentor and will undergo periodic retraining in order to ensure
that the results obtained are as accurate as possible and the complications
are kept to a minimum.
ADVERTISEMENTS
45. Question
While a client with chest tubes is ambulating, the connection between the tube
and the water seal dislodges. Which action by Nurse Flora is most appropriate?
o A. Assist the client to ambulate back to bed.
o B. Reconnect the tube to the water seal.
o C. Assess the client's lung sounds with a stethoscope.
o D. Have the client cough forcibly several times.

Incorrect
Correct Answer: B. Reconnect the tube to the water seal.

The tube should be reconnected to the water seal as quickly as possible. Assisting
the client back to bed and assessing the client‘s lung are possible actions after
the system is reconnected. Or place the end of the tube in a bottle of sterile
water, creating a water seal. Instruct a colleague to prepare a new sterile chest-
drainage collection device, or retrieve a new sterile connector while safely
returning the patient to bed. Observe the patient for signs and symptoms of
respiratory decline. Then reconnect the chest tube to the new drain and unclamp
it.
 Option A: If walking with the patient and the chest tube becomes
dislodged where it connects to the drainage tubing, immediately close off
the tubing to air with a gloved hand by crimping it or using a clamp, if
readily available.
 Option C: Whether chest-tube removal was planned or unplanned,
monitor the patient closely for signs and symptoms of respiratory
compromise, using such techniques as pulse oximetry (Spo2), end-tidal
carbon dioxide (ETco2) monitoring, and breath sound auscultation.
 Option D: Monitor the patient‘s respiratory rate and effort. A repeat chest
X-ray (if indicated) may be done to compare to previous films and evaluate
for presence or return of a pneumothorax, an effusion, or other problem.
ADVERTISEMENTS
46. Question
Nurse Peter makes the assessment that which client has the greatest risk for a
problem with the transport of oxygen from the lungs to the tissues? A client who
has:
o A. Anemia
o B. An infection
o C. A fractured rib
o D. A tumor of the medulla

Incorrect
Correct Answer: A. Anemia

Anemia is a condition of decreased red blood cells and decreased hemoglobin.
Hemoglobin is how the oxygen molecules are transported to the tissues. Anemia
is described as a reduction in the proportion of red blood cells. Anemia is not a
diagnosis, but a presentation of an underlying condition. Whether or not a
patient becomes symptomatic depends on the etiology of anemia, the acuity of
onset, and the presence of other comorbidities, especially the presence of
cardiovascular disease.
 Option B: An infection would depend on its location. Infections can be
caused by a variety of different organisms, including viruses, bacteria,
fungi, and parasites. The different ways that you can get an infection can
be just as diverse as the organisms that cause them.
 Option C: A fractured rib would interrupt the transport of oxygen from the
atmosphere to the airways. Broken ribs are most commonly caused by
direct impacts — such as those from motor vehicle accidents, falls, child
abuse, or contact sports. Ribs also can be fractured by repetitive trauma
from sports like golf and rowing or from severe and prolonged coughing.
 Option D: Damage to the medulla would interfere with neural stimulation
of the respiratory system. Tumors of the medulla cause swallowing
problems and limb weakness.
ADVERTISEMENTS
47. Question
Which term does the nurse document to best describe a client experiencing
shortness of breath while lying down who must assume an upright or sitting
position to breathe more comfortably and effectively?
o A. Dyspnea
o B. Hyperpnea
o C. Orthopnea
o D. Apnea
Incorrect
Correct Answer: C. Orthopnea

Respiratory difficulty related to a reclining position without other physical
alterations is defined as orthopnea. Orthopnea is the sensation of breathlessness
in the recumbent position, relieved by sitting or standing. Orthopnea is caused by
pulmonary congestion during recumbency. In the horizontal position there is
redistribution of blood volume from the lower extremities and splanchnic beds to
the lungs.
 Option A: Dyspnea is the medical term for shortness of breath, sometimes
described as ―air hunger.‖ It is an uncomfortable feeling. Shortness of
breath can range from mild and temporary to serious and long-lasting. It is
sometimes difficult to diagnose and treat dyspnea because there can be
many different causes.
 Option B: Hyperpnea is breathing more deeply and sometimes faster than
usual. It‘s normal during exercise or exertion. Hyperpnea is breathing
deeply, a normal response to exertion requiring more oxygen. This is when
you‘re breathing in more air but not necessarily breathing faster. It can
happen during exercise or because of a medical condition that makes it
harder for your body to get oxygen, like heart failure or sepsis (a serious
overreaction by your immune system).
 Option D: Apnea is breathing that stops briefly during sleep. Oxygen to
the brain is decreased. It requires treatment. Apnea is the medical term
used to describe slowed or stopped breathing. Apnea can affect people of
all ages, and the cause depends on the type of apnea one has. Apnea
usually occurs while sleeping. For this reason, it‘s often called sleep apnea.
ADVERTISEMENTS
48. Question
A client with emphysema is prescribed corticosteroid therapy on a short-term
basis for acute bronchitis. The client asks the nurse how the steroids will help him.
The nurse responded by saying that the corticosteroids will do which of the
following?
o A. Promote bronchodilation
o B. Help the client to cough
o C. Prevent respiratory infection

o D. Decrease inflammation in the airways
Incorrect
Correct Answer: D. Decrease inflammation in the airways
Glucocorticoids are prescribed because of their anti-inflammatory effect. Options
1, 2, and 4 are not achieved with glucocorticoids. Corticosteroids produce their
effect through multiple pathways. In general, they produce anti-inflammatory and
immunosuppressive effects, protein and carbohydrate metabolic effects, water
and electrolyte effects, central nervous system effects, and blood cell effects.
 Option A: The glucocorticoid receptor is located intracellularly within the
cytoplasm and upon binding trans-locates rapidly into the nucleus where it
affects gene transcription and causes inhibition of gene expression and
translation for inflammatory leukocytes and structural cells such as
epithelium. This action leads to a reduction in proinflammatory cytokines,
chemokines, and cell adhesion molecules, as well as other enzymes
involved in the inflammatory response.
 Option B: The non-genomic mechanism occurs more rapidly and is
mediated through interactions between the intracellular glucocorticoid
receptor or a membrane-bound glucocorticoid receptor. Within seconds to
minutes of receptor activation, a cascade of effects is set off, including
inhibition of phospholipase A2, which is critical for the production of
inflammatory cytokines, impaired release of arachidonic acid, and
regulation of apoptosis in thymocytes.
 Option C: Their nonendocrine role regularly takes advantage of their
potent anti-inflammatory and immunosuppressive effects to treat patients
with a wide range of immunologic and inflammatory disorders.
Corticosteroids are used at physiologic doses as replacement therapy in
cases of adrenal insufficiency and supraphysiologic doses in treatments for
anti-inflammatory and immunosuppressive effects.
ADVERTISEMENTS
49. Question
Nurse Aleli is planning to perform percussion and postural drainage. Which is an
important aspect of planning the clients‘ care?
o A. Percussion and postural drainage should be done before lunch.

o B. The order should be coughing, percussion, positioning, and then
suctioning.
o C. A good time to perform percussion and postural drainage is in the

morning after breakfast when the client is well rested.
o D. Percussion and postural drainage should always be preceded by three

minutes of 100% oxygen.
Incorrect
Correct Answer: A. Percussion and postural drainage should be done before
lunch.
Postural drainage results in expectoration of large amounts of mucus. Clients
sometimes ingest part of the secretions. The secretions may also produce an
unpleasant taste in the oral cavity, which could result in nausea/vomiting. This
procedure should be done on an empty stomach to decrease client discomfort.
 Option B: PD & P involves a combination of techniques, including multiple
positions to drain the lungs, percussion, vibration, deep breathing and
coughing. When the person with CF is in one of the positions, the caregiver
can clap on the person‘s chest wall. This is usually done for three to five
minutes and is sometimes followed by vibration over the same area for
approximately 15 seconds (or during five exhalations). The person is then
encouraged to cough or huff forcefully to get the mucus out of the lungs.
 Option C: Generally, each treatment session can last for 20 to 40 minutes.
PD & P is best done before meals or one and a half to two hours after
eating, to decrease the chance of vomiting. Early morning and bedtimes
are usually recommended. The length of PD & P and the number of times
of day it is done may need to be increased if the person is more congested
or getting sick.
 Option D: When the person with CF is in one of the positions, the
caregiver can clap on the person‘s chest wall. This is usually done for three
to five minutes and is sometimes followed by vibration over the same area
for approximately 15 seconds (or during five exhalations). The person is
then encouraged to cough or huff forcefully to get the mucus out of the
lungs.
ADVERTISEMENTS

50. Question
Nurse Winona teaches a patient how to use an incentive spirometer. What
patient outcome will support the conclusion that the use of the incentives
spirometer was effective?
o A. Supplemental oxygen use will be reduced.
o B. Inspiratory volume will be increased.
o C. Sputum will be expectorated.
o D. Coughing will be stimulated.

Incorrect
Correct Answer: B. Inspiratory volume will be increased.
An incentive spirometry or provides a visual goal for and measurement of
inspiration. It encourages the patient to execute and maintain a sustained
inspiration. A sustained inspiration opens airways, increases the inspiratory
volume, and reduces the risk of atelectasis. Spirometry is one of the most readily
preceded by a maximal inhalation.
 Option A: Patients who use an incentive spirometer may or may not be
receiving oxygen. All patients must be informed that they must abstain
from smoking, physical exercise in the hours before the procedure. Any
bronchodilator therapy must also be stopped beforehand.
 Option C: Although sputum may be expectorated after the use of an
incentive spirometer, this is not the primary reason for its use. Recent
evidence also supports the use of spirometry in non thoracic surgeries. A
recent retrospective observational study found that lower preoperative
spirometry FVC may predict postoperative pulmonary complications in
high-risk patients undergoing abdominal surgery.
 Option D: Although the deep breathing associated with the use of an
incentive barometer may stimulate coughing, this is not the primary reason
for its use. Complete spirometry exams will identify FEV1, forced vital
capacity (FVC), vital capacity (VC), residual lung volume (RV), maximum
voluntary minute ventilation (MMV), and total lung capacity (TLC). One
parametric that is highly indicative of postoperative complications is

predicted postoperative FEV 1(ppo FEV 1). Predicted postoperative FEV1
<30% are at a higher risk of postoperative pulmonary complications after
thoracic surgery.
ADVERTISEMENTS
2. 51. Question
Nurse AJ is applying a warm compress. What should the nurse explain to the
patient is the primary reason why heat is used instead of cold?
o A. Minimizes muscle spasms
o B. Prevents hemorrhage
o C. Increases circulation
o D. Reduces discomfort
Incorrect
Correct Answer: C. Increases circulation
Heat increases the skin surface temperature, promoting vasodilation, which
increases blood flow to the area. Cold has the opposite effect: it promotes
vasoconstriction, which decreases blood flow to the area. In general, heat therapy
is also recommended prior to exercise for those who have chronic injuries. Heat
warms the muscles and helps increase flexibility. The only time one should ever
consider using cold to treat a chronic injury is after finishing exercising when
inflammation may reappear. Applying cold at this time helps reduce any residual
swelling.
 Option A: Both heat and cold relax muscles and thus minimize muscle
spasms. It reduces joint stiffness and muscle spasm, which makes it useful
when muscles are tight. There is no advantage to using heat over cold.
When muscles work, chemical byproducts are made that need to be
eliminated. When exercise is very intense, there may not be enough blood
flow to eliminate all the chemicals. It is the buildup of chemicals (for
example, lactic acid) that cause muscle ache. Because the blood supply
helps eliminate these chemicals, use heat to help sore muscles after
exercise.
 Option B: Heat does not prevent hemorrhage; heat causes vasodilation,
which promotes hemorrhage. Apply an ice compress to the injury as soon

as possible. This will cool down the tissues, lower their metabolic rate and
nerve conduction velocity, resulting in vasoconstriction of the surrounding
blood vessels and reduced inflammation.
 Option D: Both heat and cold can reduce discomfort. Cold reduces
discomfort by numbing the area, slowing the transmission of pain
impulses, and increasing the pain threshold. Heat reduces the discomfort
by relaxing the muscles. When an injury or inflammation, such as tendonitis
or bursitis occurs, tissues are damaged. Cold numbs the affected area,
which can reduce pain and tenderness. Cold can also reduce swelling and
inflammation.
ADVERTISEMENTS
52. Question
A practitioner orders chest physiotherapy with percussion and vibration for a
newly admitted patient. Which information obtained by the nurse during the
health history should alert the nurse to question the practitioner‘s order?
o A. Emphysema
o B. Osteoporosis
o C. Cystic fibrosis
o D. Chronic bronchitis
Incorrect
Correct Answer: B. Osteoporosis
Implementing the practitioner‘s order may compromise patient safety because
percussion and vibration in the presence of osteoporosis may cause fractures.
Osteoporosis is an abnormal loss of bone mass and strength. Chest
physiotherapy is a group of physical techniques that improve lung function and
help you breathe better. Chest PT, or CPT expands the lungs, strengthens
breathing muscles, and loosens and improves drainage of thick lung secretions.
 Option A: These are appropriate interventions for a patient with
emphysema. Emphysema is a chronic pulmonary disease characterized by
an abnormal increase in the size of air spaces distal to the terminal
bronchioles with destructive changes in their walls. Chest percussion and

vibration to help loosen lung secretions. Some patients wear a special CPT
vest hooked up to a machine. The machine makes the vest vibrate at a high
frequency to break up the secretions.
 Option C: These are appropriate interventions for a patient with cystic
fibrosis causes widespread dysfunction of the exocrine glands. It is
characterized by thick, tenacious secretions in the respiratory system that
block the bronchioles, creating breathing difficulties. Chest PT helps treat
such diseases as cystic fibrosis and COPD (chronic obstructive pulmonary
disease). It also keeps the lungs clear to prevent pneumonia after surgery
and during periods of immobility.
 Option D: These are appropriate interventions for a patient with chronic
bronchitis. Bronchitis is an inflammation of the mucous membranes of the
bronchial airways. The doctor may recommend chest PT to help loosen and
cough up thick or excessive lung secretions from such conditions as lung
infections, which include pneumonia, acute bronchitis, and lung abscess.
ADVERTISEMENTS
53. Question
Nurse Sue teaches a patient about pursed lip breathing. The nurse identifies that
the teaching is affected when the patient says its purpose is to:
o A. Precipitate coughing
o B. Help maintain open airways
o C. Decrease intrathoracic pressure
o D. Facilitate expectoration of mucus

Incorrect
Correct Answer: B. Help maintain open airways
Pursed-lip breathing involves deep inspiration and prolonged expiration against
slightly closed lips. The pursed lips create a resistance to the air flowing out of
the lungs, which prolongs exhalation and maintains positive airway pressure,
thereby maintaining an open airway and preventing airway collapse. Pursed lip
breathing is beneficial for people with chronic lung disease. It can help
strengthen the lungs and make them more efficient.

 Option A: Deep breathing and huff coughing, not pursed-lip breathing,
stimulate effective coughing. Deep breathing prevents air from getting
trapped in the lungs, which can cause the client to feel short of breath. As a
result, the client can breathe in a more fresh air.
 Option C: Pursed lip breathing increases, not decreased intrathoracic
pressure. Pursed lip breathing is a simple technique for slowing down a
person‘s breathing and getting more air into their lungs. With regular
practice, it can help strengthen the lungs and make them work more
efficiently. The technique involves breathing in through the nose and
breathing out slowly through the mouth.
 Option D: The huff coughing stimulates the natural cough reflex and is
effective for clearing the central airways of sputum. Saying the word huff
with short forceful exhalations keeps the glottis open, mobilizes sputum,
and stimulates a cough. When one has COPD, mucus can build up more
easily in the lungs. The huff cough is a breathing exercise designed to help
one cough up mucus effectively without making one feel too tired. A huff
cough should be less tiring than a traditional cough, and it can keep one
from feeling worn out when coughing up mucus.
ADVERTISEMENTS
54. Question
What should Nurse Mavie do first if a patient is choking on food?
o A. Apply sharp for thrusts over the patient's xiphoid process.
o B. Determine if the patient can make any verbal sounds.
o C. Hit the middle of the patients back firmly.
o D. Sweep the patient's mouth with a finger.

Incorrect
Correct Answer: B. Determine if the patient can make any verbal sounds.
When a person is choking on food, the first intervention is to determine if the
person can speak because the next intervention will depend on if it is partial or
total airway obstruction. With a partial airway obstruction, the person will be able
to make sounds because some air can pass from the lungs through the vocal

cords. In this situation the person‘s own efforts open parentheses gagging and
coughing) should be allowed to clear the airway. With a total airway obstruction,
the person will not be able to make a sound because the airway is blocked and
the nurse should immediately initiate the abdominal thrust maneuver (Heimlich
maneuver).
 Option A: Thrusts to the xiphoid process may cause a fracture that may
result in a pneumothorax. The foreign body lodged in the larynx or trachea
is most dangerous as this causes complete airway obstruction.
Alternatively, foreign bodies such as small beads or small pieces of food
may pass below the vocal cords and become lodged at the carina or within
a mainstem bronchus. In adults, due to differences in right versus left
pulmonary anatomy, foreign bodies are more commonly retrieved from the
right main bronchus. However, children will have equal likelihood in either
bronchus, due to equal growth until the age of 16.
 Option C: All adults can and should receive the Heimlich maneuver while
they are conscious. If the Heimlich cannot be performed due to body
habitus or pregnancy, the American Heart Association recommends a
supine patient with force again applied just above the umbilicus in a
cephalad posterior vector. If the adult loses consciousness, it is imperative
to check for a pulse and begin cardiopulmonary resuscitation if a pulse is
not detected. Advanced airway techniques are now indicated, and you may
be able to visualize the foreign body under direct laryngoscopy.
 Option D: Never sweep a choking patient‘s mouth with a finger. It might
further dislodge the food. The commonly known abdominal thrust
maneuver, known as the Heimlich maneuver, is performed by a bystander
on a person who appears to be choking. The bystander stands behind the
subject and wraps his/her arms around the upper abdominal region, about
two inches above the belly button. Making a fist with one hand and
wrapping the other hand tightly over the fist and delivering five sharp
midline thrusts inward and upward.
ADVERTISEMENTS
55. Question
Nurse Stephanie is assessing a client who has an acute respiratory infection that
puts her at risk for hypoxemia. Which of the following findings are early

indications that should alert the nurse that the client is developing
hypoxemia? Select all that apply.
o A. Restlessness
o B. Tachypnea
o C. Bradycardia
o D. Confusion
o E. Cyanosis
Incorrect
Correct Answer: A, B, & E
Restlessness, tachypnea, and pallor are early manifestations of hypoxemia, along
with tachycardia, elevated blood pressure, use of accessory muscles, nasal flaring,
tracheal tugging, and adventitious lung sounds. Bradycardia and confusion are
late manifestations of hypoxemia, along with stupor, cyanotic skin and mucous
membranes, bradypnea, hypotension, and cardiac dysrhythmias. Hypoxemia is
defined as a decrease in the partial pressure of oxygen in the blood whereas
hypoxia is defined by reduced level of tissue oxygenation. It can be due to either
defective delivery or defective utilization of oxygen by the tissues.
 Option A: When oxygen delivery is severely compromised, organ function
will start to deteriorate. Neurologic manifestations include restlessness,
headache, and confusion with moderate hypoxia. In severe cases, altered
mentation and coma can occur, and if not corrected quickly may lead to
death.
 Option B: The chronic presentation is usually less dramatic, with dyspnea
on exertion as the most common complaint. Symptoms of the underlying
condition that induced the hypoxia can help in narrowing the differential
diagnosis. The physical exam may show tachypnea and low oxygen
saturation. Fever may point to infection as the cause of hypoxia.
 Option C: Bradycardia is a late manifestation of hypoxemia. Increase in
cardiac output with exercise results in accelerated blood flow through
alveoli, reducing the time available for gas exchange. In case of the
abnormal pulmonary interstitium, gas exchange time becomes insufficient,
and hypoxemia ensues.

 Option D: Both confusion and somnolence may occur in respiratory failure.
Myoclonus and seizures may occur with severe hypoxemia. Polycythemia is
a complication of long-standing hypoxemia.
 Option E: Cyanosis, a bluish color of skin and mucous membranes,
indicates hypoxemia. Visible cyanosis typically is present when the
concentration of deoxygenated hemoglobin in the capillaries of tissues is
at least 5 g/dL.
ADVERTISEMENTS
56. Question
Nurse CJ is caring for a client who is having difficulty breathing. The client is lying
in bed and is already receiving oxygen therapy via nasal cannula. Which of the
following interventions is the nurse‘s priority?
o A. Increase the oxygen flow.
o B. Assist the client with Fowler's position.
o C. Promote removal of pulmonary secretions.
o D. Attain a specimen for arterial blood gases.

Incorrect
Correct Answer: B. Assist the client with Fowler’s position.
The priority action the nurse should take when using the airway, breathing,
circulation approach to care delivery is to relieve the clients‘ dyspnea. Fowler‘s
position facilitates maximal long expansion and thus optimizing breathing. With
the client in this position, the nurse can better assess and determine the cause of
the clients dyspnea.
 Option A: The client may need more oxygen, as hypoxemia may be the
cause of his difficulty breathing. However, administering oxygen and
adjusting the fraction of inspired oxygen requires the provider‘s
prescription after a careful assessment of the clients‘ oxygenation status,
there is a higher priority given the nature of the client‘s distress.
 Option C: The client may need suction or expectoration, as pulmonary
secretions may be the cause of his difficulty breathing. However, there is a
higher priority given the nature of the client‘s distress.

 Option D: It is important to check the client‘s oxygenation status, and in
many nursing situations, assessment precedes action, but there is a higher
priority given the nature of the clients‘ distress.
ADVERTISEMENTS
57. Question
Nurse Aldrin is preparing to perform endotracheal suctioning for a client. Which
of the following are appropriate guidelines for the nurse to follow? Select all
that apply.
o A. Apply suction while withdrawing the catheter.
o B. Perform suctioning on a routine basis, every 2 to 3 hours.
o C. Maintain medical asepsis during suctioning.
o D. Use a new catheter for each suctioning attempt.
o E. Limit suctioning to 2 to 3 attempts.

Incorrect
Correct Answer: A, D, & E
Within intensive care units (ICUs), one such common procedure is the suctioning
of respiratory secretions in patients who have been intubated or who have
undergone tracheostomy. The traditional goal of suctioning is to aid in
maintaining airway patency and prevent complications related to the retention of
secretions
 Option A: The nurse should apply suction pressure only while withdrawing
the catheter, not while inserting it. One interesting thing to note about ETS
is that negative pressure is created inside of the lungs only while air flows
out of the suction catheter. As soon as secretions are aspirated into the
catheter, the intrapulmonary pressure returns to that of the atmospheric
level, and lung volume loss stops.
 Option B: The nurse should not suction routinely because suctioning is not
without risk. It can cause mucosal damage, bleeding, and bronchospasm.
Although there has been a very limited number of studies regarding a

scheduled frequency of performing ETS every 1, 3, 4, 6, 8, or even 12 hours,
the overall recommendation is to suction only as indicated (as needed).
 Option C: Endotracheal suctioning requires surgical asepsis. The second
method of suctioning is the shallow (premeasured) technique, which is also
considered minimally invasive.1-3 With shallow ETS, the catheter is inserted
only to the tip of the ETT, thereby avoiding injury to the airway.
 Option D: The nurse should not reuse the suction catheter unless an in-
line suctioning system is in place. If a suction catheter is too large for the
ETT, and/or there is too much vacuum pressure, massive atelectasis may
occur. Therefore, the general recommendation is to use a suction catheter
that has an external diameter less than 50% of the size of the ETT inner
diameter.
 Option E: To prevent hypoxemia, the nurse should limit each section in
session to 2 to 3 attempts and allow at least one minute between passes
for ventilation and oxygenation. The reason for this is because there is
considerable risk with using ―routine‖ suctioning. It has been suggested by
Pedersen et al3 that ETS should be performed at least every 8 hours to
slow the formation of the secretion biofilm within the lumen of the
endotracheal tube (ETT). Clifton-Koeppel1 made a good general
recommendation that ETS should be performed as infrequently as
possible—yet as much as needed.
ADVERTISEMENTS
58. Question
A nurse is caring for a client who has a tracheostomy. Which of the following
actions should the nurse take each time he provides tracheostomy care? Select
all that apply.
o A. Apply the oxygen source loosely if the SPO2 increases during the
procedure.
o B. Use surgical asepsis to remove and clean the inner cannula.
o C. Clean the outer surfaces in a circular motion from the stoma site
outward.

o D. Replace the tracheostomy ties with new ties.
o E. Cut a slit in gauze squares to place beneath the tube holder.

Incorrect
Correct Answer: A, B, & C
A tracheostomy is an opening (made by an incision) through the neck into the
trachea (windpipe). A tracheostomy opens the airway and aids breathing. A
tracheostomy may be required in an emergent setting to bypass an obstructed
airway, or (more commonly) may be placed electively to facilitate mechanical
ventilation, to wean from a ventilator, or to allow more efficient management of
secretions (referred to as pulmonary toilet), among other reasons.
 Option A: The nurse must be prepared to provide supplemental oxygen in
response to any decline in oxygenation saturation while performing
tracheostomy care. Nurses need to understand all aspects of tracheostomy
care, including routine and emergency airway management, safe
decannulation, weaning and safe discharge into the community. The
patient‘s airway requires close monitoring 24 hours a day using a
tracheostomy care chart to record care.
 Option B: The nurse should use a sterile disposable tracheostomy cleaning
kit or sterile supplies and maintain surgical asepsis throughout this part of
the procedure. The NTSP (2013) recommends that all patients with a
tracheostomy have a bed-head label with information regarding their tube
and airway, including whether it is surgical or percutaneous, the tube type,
size and suction-catheter size, patency of the upper airway and whether
the tracheostomy is temporary, permanent or involves a laryngectomy
(removal of the larynx).
 Option C: This action helps move mucus and contaminated material away
from the stoma for easy removal. The stoma site should be checked at least
once a day, or more frequently if required, and this requires two nurses:
one to hold the tube and one to clean the stoma site. The site should be
cleaned using a tracheostomy wipe or with 0.9% sodium chloride solution,
and dried thoroughly.
 Option D: To help keep the skin clean and dry, the nurse should replace
the tracheostomy ties if they are wet or soiled. There is a risk of two
dislodgements replacing the ties, so he should not replace them routinely.
Leaving the old ties in place while securing the clean ties prevents
inadvertent dislodging of the tracheostomy tube. Securing tapes in this

manner avoids the use of knots, which can come untied or cause pressure
and irritation.
 Option E: The nurse should use a commercially prepared tracheostomy
dressing with a slit in it. Cutting gauze squares can loosen lint or cause
fibers the client could aspirate. Use a commercially prepared tracheostomy
dressing of non-raveling material or open and refold a 4-in. X 4-in. Gauze
dressing into a V shape. Avoid using cotton-filled gauze squares or cutting
the 4×4 gauze. Cotton lint or gauze fibers can be aspirated by the client,
potentially creating a tracheal abscess.
ADVERTISEMENTS
59. Question
An elderly nursing home resident has refused to eat or drink for several days and
is admitted to the hospital. The nurse should expect which assessment finding?
o A. Increase blood pressure
o B. Weak, rapid pulse
o C. Moist mucous membranes
o D. Jugular vein distention

Incorrect
Correct Answer: B. Week, rapid pulse
All other options are indicated by fluid volume excess. A client who has not eaten
or drunk anything for several days would be experiencing a fluid volume deficit.
The primary control of water homeostasis is through osmoreceptors in the brain.
Dehydration, as perceived by these osmoreceptors, stimulates the thirst center in
the hypothalamus, which leads to water consumption. These osmoreceptors can
also cause conservation of water by the kidney. When the hypothalamus detects
lower water concentration, it causes the posterior pituitary to release antidiuretic
hormone (ADH), which stimulates the kidneys to reabsorb more water.
 Option A: Decreased blood pressure, which often accompanies
dehydration triggers renin secretion from the kidney. Renin converts
angiotensin I to angiotensin II, which increases aldosterone release from
the adrenals. Aldosterone increases the absorption of sodium and water

from the kidney. Using these mechanisms, the body regulates body volume
and sodium and water concentration.
 Option C: Some of the most common presenting symptoms of
dehydration include but are not limited to fatigue, thirst, dry skin and lips,
dark urine or decreased urine output, headaches, muscle cramps,
lightheadedness, dizziness, syncope, orthostatic hypotension, and
palpitations. The physical examination could show dry mucosa, skin
tenting, delayed capillary refill, or cracked lips.
 Option D: A 2015 Cochrane review evaluated predictors of dehydration in
the elderly. Historical and physical findings tested were dry axilla, mucous
membranes, tongue, increased capillary refill time, poor skin turgor, sunken
eyes, orthostatic blood pressure drop, dizziness, thirst, urine color,
weakness, blue lips, altered mentation, tiredness, and appetite. Of all these
factors only fatigue and missed drinks between meals predicted the
diagnosis of dehydration.
ADVERTISEMENTS
60. Question
A man brings his elderly wife to the emergency department. He states that she
has been vomiting and has had diarrhea for the past two days. She appears
lethargic and is complaining of leg cramps. What should the nurse do first?
o A. Start an IV.
o B. Review the results of serum electrolytes.
o C. Offer the woman foods that are high in sodium and potassium content.
o D. Administer an antiemetic.
Incorrect
Correct Answer: B. Review the results of serum electrolytes.
Further assessment is needed to determine appropriate action. While the nurse
may perform some of the interventions in options one, three, and four,
assessment is needed initially. Electrolyte abnormalities may be addressed on an
individual level, although often these are caused by an overall fluid volume
depletion which, when corrected, will also cause electrolytes to normalize. Both

saline and lactated Ringer‘s solutions appear to be effective for the treatment of
dehydration due to viral gastroenteritis.
 Option A: The most important goal of treatment is to maintain hydration
status and effectively counter fluid and electrolyte losses. Fluid therapy is a
fundamental part of treatment. Intravenous fluids may be administered to
those individuals who appear dehydrated or to those unable to tolerate
oral fluids.
 Option C: No specific nutritional recommendations are universal for
patients with viral gastroenteritis. A diet of banana, rice, apples, tea, and
toast is often advised, but several studies have failed to show any
significant outcome difference when compared to regular diets.
 Option D: Antiemetic medications such as ondansetron or
metoclopramide may be used to assist with controlling nausea and
vomiting symptoms. Patients demonstrating severe dehydration or
intractable vomiting may require hospital admission for continued
intravenous fluids and careful monitoring of electrolyte status.
ADVERTISEMENTS
61. Question
Which of the following is the appropriate meaning of CBR?
o A. Cardiac Board Room
o B. Complete Bathroom
o C. Complete Bed Rest
o D. Complete Board Room

Incorrect
Correct Answer: C. Complete Bed Rest
CBR means complete bed rest. For more abbreviations, please see this post.
Standardization and uniform use of codes, symbols, and abbreviations can
improve communication and understanding between health care practitioners,
leading to safer and more effective care for patients.
 Option A: When developing lists, hospitals need to ensure that
abbreviations on the approved list are not also on the do-not-use list, and

vice versa. In addition, abbreviations can have only one meaning within the
entire organization—for example, the abbreviation NKDA could mean ―no
known drug allergies,‖ or it could mean ―nonketotic diabetic acidosis,‖ but
it cannot have both meanings in an organization.
 Option B: Appropriate use of abbreviations is particularly important.
Numerous studies have focused on health care practitioners‘
understanding and interpretation of abbreviations in medical documents,
such as medical records, discharge summaries, and medication orders.
Findings indicate that it is not uncommon for practitioners to have
 Option D: To prevent misunderstandings and potential risks to patient
safety, requires hospitals to establish lists for approved and do-not-use
abbreviations and monitor for appropriate abbreviation use. There are
resources for identifying abbreviations for the do-not-use list, such as the
Institute for Safe Medication Practices (ISMP), which publishes a list of
dangerous abbreviations not to be used due to frequent misinterpretation
and associated medication errors.
ADVERTISEMENTS
62. Question
One (1) tsp is equal to how many drops?
o A. 15
o B. 60
o C. 10
o D. 30
Incorrect
One teaspoon (tsp) is equal to 60 drops (gtts). When the nurse has an order for
an IV infusion, it is her responsibility to make sure the fluid will infuse at the

 Option A: When calculating the flow rate, determine which IV tubing will
drip chamber.
 Option C: Macrodrip tubing delivers 10 to 20 gtts/mL and is used to infuse
large volumes or to infuse fluids quickly. Microdrip tubing delivers 60
gtts/mL and is used for small or very precise amounts of fluid, as with
The formula for calculating the IV flow rate (drip rate) is… total volume (in
ADVERTISEMENTS
2. 63. Question
20 cc is equal to how many ml?
o A. 2
o B. 20
o C. 2000
o D. 20000
Incorrect
One cubic centimeter is equal to one milliliter. When clinicians are prepared and
know the key conversion factors, they will be less anxious about the calculation
involved. This is vital to accuracy, regardless of which formula or method
employed.
 Option A: Drug calculations require the use of conversion factors, for

 Option C: Units of measurement must match, for example, milliliters and
 Option D: All members of the interprofessional team are responsible for
dose calculations. Physicians, nurses, and pharmacists all must be
conversant in the desired overall formula. This technique is invaluable in
properly treating patients.
ADVERTISEMENTS
64. Question
1 cup is equal to how many ounces?
o A. 8
o B. 80
o C. 800
o D. 8000
Incorrect
Correct Answer: A. 8
One cup is equal to 8 ounces. Weight conversion is also utilized daily in health
care. There are two systems calculating weight used in all healthcare settings for
health management, such as medication dosing per patient body weight. First,
the metric system is in common use in health care in the US. It is also the only
system universally used in many countries on all continents of the globe. It has
the advantage of a decimal system in increments or the power of tenths. Second,
the US weight system customarily uses the ounce or pound. It derives from the
British colonial era. This non-metric system is still being used nowadays among
laypersons in the US for products sold to the public.
 Option B: The metric system is essential in all health care settings. Patients
are weighed at each clinical encounter. Scales used in the US have double

marking indicators: metric and non-metric markings. Metric weight values
are used in medication calculation, radiation dosing, and weight
compliance in equipment use, such as the maximum weight of a CAT-
SCAN unit or a surgical table that may hold a person.
 Option C: Nowadays, all medications are based on weight for dose
calculations for all populations but very specifically in children and infants.
Adults have their weight recorded mainly by their doctors at each physical
patient-clinician encounter. Commonly, most adults monitor their weight
for weight management. Clinicians record it in the electronic health records
in both kilograms and pounds.
 Option D: Commonly in healthcare and medical practices, the metric
system is used for weighing mass. In the metric system, there are
increments at the power of the tenth for calculations. This weight
conversion is used daily among scientists and health care providers.
ADVERTISEMENTS
65. Question
The nurse must verify the client‘s identity before administration of medication.
Which of the following is the safest way to identify the client?
o A. Ask the client his name.
o B. Check the client’s identification band.
o C. State the client‘s name aloud and have the client repeat it.
o D. Check the room number.

Incorrect
Correct Answer: B. Check the client’s identification band
The identification band is the safest way to know the identity of a patient whether
he is conscious or unconscious. Nurses have a unique role and responsibility in
medication administration, in that they are frequently the final person to check to
see that the medication is correctly prescribed and dispensed before
administration.
 Option A: Ask the client his name only after you have checked his ID band.
Right patient‘ – ascertaining that a patient being treated is, in fact, the

correct recipient for whom medication was prescribed. This is best
practiced by nurses directly asking a patient to provide his or her full name
aloud, checking medical wristbands if appropriate for matching name and
ID number as on a chart.
 Option C: It is advisable not to address patients by first name or surname
alone, in the event, there are two or more patients with identical or similar
names in a unit. Depending on the unit that a patient may be in, some
patients, such as psychiatric patients, may not wear wristbands or may have
altered mentation to the point where they are unable to identify
themselves correctly. In these instances, nurses are advised to confirm a
patient‘s identity through alternative means with appropriate due
diligence.
 Option D: The medical literature states that the value of nurses‘ critical
thinking, the role of patient advocacy, and clinical judgment are not
accounted for by the five rights framework that is commonly observed in
modern practice to deliver patient-centered care. Research has shown a
clear benefit in the value of nursing experience as it relates to decision-
making capability; however, it states that further studies are necessary to
achieve an improved understanding of how nurses apply intuition, the
context of the situation, and interpretation.
ADVERTISEMENTS
66. Question
The nurse prepares to administer buccal medication. The medicine should be
placed in what area?
o A. On the client‘s skin.
o B. Between the client’s cheeks and gums.
o C. Under the client‘s tongue.
o D. On the client‘s conjunctiva.

Incorrect
Correct Answer: B. Between the client’s cheeks and gums

Buccal administration involves placing a drug between the gums and cheek,
where it also dissolves and is absorbed into the blood. Because the medication
absorbs quickly, these types of administration can be important during
emergencies when you need the drug to work right away, such as during a heart
attack.
 Option A: An advantage of a transdermal drug delivery route over other
types of medication delivery such as oral, topical, intravenous,
intramuscular, etc. is that the patch provides a controlled release of the
medication into the patient, usually through either a porous membrane
covering a reservoir of medication or through body heat melting thin
layers of medication embedded in the adhesive.
 Option C: Sublingual administration involves placing a drug under the
tongue to dissolve and absorb into the blood through the tissue there.
These drugs do not go through the digestive system, so they aren‘t
metabolized through the liver. This means you may be able to take a lower
dose and still get the same results.
 Option D: The three primary methods of delivery of ocular medications to
the eye are topical, local ocular (ie, subconjunctival, intravitreal, retrobulbar,
intracameral), and systemic. The most appropriate method of
administration depends on the area of the eye to be medicated. The
conjunctiva, cornea, anterior chamber, and iris usually respond well to
topical therapy. The eyelids can be treated with topical therapy but more
frequently require systemic therapy. The posterior segment always requires
systemic therapy, because most topical medications do not penetrate to
the posterior segment. Retrobulbar and orbital tissues are treated
systemically.
ADVERTISEMENTS
67. Question
The nurse administers a cleansing enema. The common position for this
procedure is?
o A. Sims left lateral
o B. Dorsal Recumbent

o C. Supine
o D. Prone
Incorrect
Correct Answer: A. Sims left lateral
This position provides comfort to the patient and easy access to the natural
curvature of the rectum. Enemas are rectal injections of fluid intended to cleanse
or stimulate the emptying of the bowel. Enemas may also be prescribed to flush
out the colon before certain diagnostic tests or surgeries. The bowel needs to be
empty before these procedures to reduce infection risk and prevent stool from
getting in the way.
 Option B: Position the patient on the left side, lying with the knees drawn
to the abdomen. This eases the passage and flow of fluid into the rectum.
Gravity and the anatomical structure of the sigmoid colon also suggest that
this will aid enema distribution and retention. Dorsal recumbent is a
position in which the patient lies on the back with the lower extremities
moderately flexed and rotated outward. It is employed in the application of
obstetrical forceps, repair of lesions following parturition, vaginal
examination, and bimanual palpation.
 Option C: The supine position means lying horizontally with the face and
torso facing up, as opposed to the prone position, which is face down.
When used in surgical procedures, it allows access to the peritoneal,
thoracic, and pericardial regions; as well as the head, neck, and extremities.
 Option D: Prone position is a body position in which the person lies flat
with the chest down and the backup. In anatomical terms of location, the
dorsal side is up, and the ventral side is down. The supine position is the
180° contrast.
ADVERTISEMENTS
68. Question
A client complains of difficulty swallowing when the nurse tries to administer
capsule medication. Which of the following measures should the nurse do?
o A. Dissolve the capsule in a glass of water.

o B. Break the capsule and give the content with applesauce.
o C. Check the availability of a liquid preparation.
o D. Crush the capsule and place it under the tongue.

Incorrect
Correct Answer: C. Check the availability of a liquid preparation.
The nurse should check first if the medication is available in liquid form before
doing Choice A. The swallowing of capsules can be particularly difficult. This is
because capsules are lighter than water and float due to air trapped inside the
gelatine shell. In comparison, tablets are heavier than water and do not float.
 Option A: The physical properties of capsules predispose them to floating
in the mouth when taken with water. As a result, the swallowing of capsules
can be problematic. In patients who experience such difficulty, it is
suggested that they try leaning forward when swallowing, as this has been
found to assist. It may be necessary to reassure patients about this
technique as they may initially find it unnatural to execute.
 Option B: Some tablets, pills and capsules don‘t work properly or may be
harmful if they‘re crushed or opened. Most capsules are intended to be
swallowed whole so patients should be encouraged to trial the ‗lean-
forward‘ technique. If swallowing difficulties remain other options, such as
a liquid or tablet form of the medicine, can be considered.
 Option D: Placing it under the tongue is not the intended way of
administering an oral medication. Crushing the medication may alter the
medicine‘s effects. You shouldn‘t chew, crush or break tablets or pills, or
open and empty powder out of capsules unless your GP or another
healthcare professional has told you to do so. Some tablets, pills, and
capsules don‘t work properly or may be harmful if they‘re crushed or
opened.
ADVERTISEMENTS
69. Question
Which of the following is the appropriate route of administration for insulin?
o A. Intramuscular

o B. Intradermal
o C. Subcutaneous
o D. Intravenous
Incorrect
Correct Answer: C. Subcutaneous
The subcutaneous tissue of the abdomen is preferred because the absorption of
the insulin is more consistent from this location than subcutaneous tissues in
other locations. Insulin may be injected into the subcutaneous tissue of the upper
arm and the anterior and lateral aspects of the thigh, buttocks, and abdomen
(with the exception of a circle with a 2-inch radius around the navel).
 Option A: Intramuscular injection is not recommended for routine
injections. Rotation of the injection site is important to prevent
lipohypertrophy or lipoatrophy. Rotating within one area is recommended
(e.g., rotating injections systematically within the abdomen) rather than
rotating to a different area with each injection. This practice may decrease
variability in absorption from day to day.
 Option B: Site selection should take into consideration the variable
absorption between sites. The abdomen has the fastest rate of absorption,
followed by the arms, thighs, and buttocks. Exercise increases the rate of
absorption from injection sites, probably by increasing blood flow to the
skin and perhaps also by local actions.
 Option D: Administration of mixtures of rapid- or short- and intermediate-
or long-acting insulins will produce a more normal glycemia in some
patients than the use of single insulin. The formulations and particle size
distributions of insulin products vary. On mixing, physicochemical changes
in the mixture may occur (either immediately or over time). As a result, the
physiological response to the insulin mixture may differ from that of the
injection of the insulins separately.
ADVERTISEMENTS
70. Question
The nurse is ordered to administer ampicillin capsule TID p.o. The nurse should
give the medication by which frequency?

o A. Three times a day orally
o B. Three times a day after meals
o C. Two times a day by mouth
o D. Two times a day before meals

Incorrect
Correct Answer: A. Three times a day orally
TID is the Latin for ―ter in die‖ which means three times a day. P.O. means per
orem or through mouth. The ―time‖ of administration of medication is valuable
information to consider during patient counselling and is a typical query by
patients especially when filling a prescription for the first time.
 Option B: The timing of doses isn‘t the only question people may have
when it comes to deciphering prescriptions or oral communication from
the doctor. Other abbreviations include the number of refills allowed and
whether one is receiving a brand name or generic drug. Medical errors are
a significant cause of death in the United States. Fortunately, most of these
errors are preventable when patients are active advocates for their health
and ask plenty of questions.
 Option C: Two times a day by mouth is BID P.O. Seen on a prescription,
b.i.d. means twice (two times) a day. It is an abbreviation for ―bis in die‖
which in Latin means twice a day. The abbreviation b.i.d. is sometimes
written without a period either in lower-case letters as ―bid‖ or in capital
letters as ―BID‖.
 Option D: However it is written, it is one of a number of hallowed
abbreviations of Latin terms that have been traditionally used in
prescriptions to specify the frequency with which medicines should be
taken.
ADVERTISEMENTS
71. Question
Back Care is best described as:
o A. Caring for the back by means of massage.

o B. Washing of the back.
o C. Application of cold compress at the back.
o D. Application of hot compress at the back.

Incorrect
Correct Answer: A. Caring for the back by means of massage
Back care or massage is usually given in conjunction with the activities of bathing
the client. It can also be done on other occasions when a client seems to have a
risk of developing skin irritation due to bed rest. The goal when performing this
procedure is to enhance relaxation, reduce muscle tension and stimulate
circulation.
 Option B: Help the patient to turn on his abdomen or on his side with his
back toward the nurse and his body near the edge of the bed so that he is
as near the operator as possible. If the supine position is used and the
patient is a woman, a pillow under the abdomen removes pressure from
the breasts and favors relaxation. Apply to back rubbing lotion or talcum
powder to reduce friction. In rubbing the back use firm long strokes and
kneading motions. The amount of pressure to exert depends upon the
patient‘s condition. Begin from the neck and shoulders then proceed over
the entire back.
 Option C: Massage with both hands working with a strong stroke. In
upward then in downward motions. Give particular attention to pressure
areas in rubbing (Alcohol 25%) to 50% is generally used for its refreshing
effect, but rubbing lotion may be used. Powder again the area at the
completion of the rubbing process which should consume from 3-5
minutes.
 Option D: Effleurage (stroking) is a long sweeping movement with the
palm of hand conforming to the contour of the surface-treated, over a
small surface (on the neck) the thumb and fingers are used. Strokes should
be slow, rhythmical, and gentle with pressure constant and in the direction
of the venous stream. Kneading is performed with the ulnar side palm
resting on the surface and the fingers, and thumb grasping the skin and
subcutaneous tissues which move with the hand of the operator.
ADVERTISEMENTS

72. Question
It refers to the preparation of the bed with a new set of linens
o A. Bed bath
o B. Bed making
o C. Bed shampoo
o D. Bed lining
Incorrect
Correct Answer: B. Bed making
Bed making is one of the important nursing techniques to prepare various types
of bed for patients or clients to guarantee comfort and beneficial position for a
specific condition. The bed is particularly important for patients who are sick. The
nurse plays an inevitable role to ensure comfort and cleanliness for ill patients. It
should be adaptable to various positions as per patient‘s needs because they
spend a varying amount of the day in bed.
 Option A: Bed bathing is not as effective as showering or bathing and
should only be undertaken when there is no alternative (Dougherty and
Lister, 2015). If a bed bath is required, it is important to offer patients the
opportunity to participate in their own care, which helps to maintain their
independence, self-esteem and dignity.
 Option C: The condition of their hair and how it is styled is an important
part of patients‘ identity and wellbeing, so assisting them with hair care is a
fundamental aspect of nursing care
 Option D: The purpose of a well-made hospital bed, as well as an
appropriately chosen mattress, is to provide a safe, comfortable place for
the patient, where repositioning is more easily achieved, and pressure
ulcers are prevented.
ADVERTISEMENTS
73. Question
Which of the following is the most important purpose of handwashing?

o A. To promote hand circulation.
o B. To prevent the transfer of microorganisms.
o C. To avoid touching the client with a dirty hand.
o D. To provide comfort.
Incorrect
Correct Answer: B. To prevent the transfer of microorganism
Hand washing is the single most effective infection control measure.
Handwashing practices in the patient care setting began in the early 19th century.
The practice evolved over the years with evidential proof of its vast importance
and coupled with other hand-hygienic practices, decreased pathogens
responsible for nosocomial or hospital-acquired infections (HAI).
 Option A: According to the Centers for Disease Control and Prevention
(CDC), hand hygiene is the single most important practice in the reduction
of the transmission of infection in the healthcare setting Transient
microorganisms are often acquired by healthcare workers through direct,
close contact with patients or contaminated inanimate objects or
environmental surfaces. Transient flora colonizes the superficial skin layers.
It can be removed by routine hand washing more easily than resident flora.
These organisms vary in number depending upon body location.
Healthcare-associated infections are a result of these transient organisms.
 Option C: Contaminated hands of healthcare providers are a primary
source of pathogenic spread. Proper hand hygiene decreases the
proliferation of microorganisms, thus reducing infection risk and overall
healthcare costs, length of stays, and ultimately, reimbursement. According
to the CDC, hand hygiene encompasses the cleansing of your hands with
soap and water, antiseptic hand washes, antiseptic hand rubs such as
alcohol-based hand sanitizers, foams or gels, or surgical hand antisepsis.
 Option D: Indications for handwashing include when hands are visibly
after restroom use. Hands should be washed if there was potential
exposure to Clostridium difficile, Norovirus, or Bacillus anthracis. Alcohol-
based hand sanitizers are the recommended product for hand hygiene
when hands are not visibly soiled. Apply alcohol-based products per
manufacturer guidelines on dispensing of the product. Typically, 3 mL to 5
mL in the palm, rubbing vigorously, ensuring all surfaces on both hands

get covered, about 20 seconds is required for all surfaces to dry
completely.
ADVERTISEMENTS
74. Question
What should be done in order to prevent contaminating the environment in bed
making?
o A. Avoid fanning soiled linens
o B. Strip all linens at the same time
o C. Finished both sides at the time
o D. Embrace soiled linen

Incorrect
Correct Answer: A. Avoid fanning soiled linens
Fanning soiled linens would scatter the lodged microorganisms and dead skin
cells on the linens. Healthcare linens are known to harbor a number of
microorganisms. Most notably, there is an increased concern that methicillin-
resistant Staphylococcus aureus (MRSA)and vancomycin-resistant Enterococcus
(VRE) can survive for days on linens. There is further concern that these
contaminated linens then become a potential source of cross-contamination.
 Option B: There is now a common understanding that linens, once in use,
are usually contaminated and could be harboring microorganisms such as
MRSA and VRE. Further, the Centers for Disease Control and Prevention
(CDC) cautions that healthcare professionals should handle contaminated
textiles and fabrics with minimum agitation to avoid contamination of air,
surfaces, and persons. Even one of the leading nursing textbooks,
Fundamentals of Nursing, Soiled linen is never shaken in the air because
shaking can disseminate secretions and excretions and the microorganisms
they contain. This text also states linens that have been soiled with
excretions and secretions harbor microorganisms that can be transmitted
to others.
 Option C: Healthcare laundry protocols have long relied on chlorine-based
sanitizers to kill bacteria in bed linens and other fabrics. While chlorine is

known as one of the best antimicrobial agents in the world, its power has
been limited because it evaporates from untreated fabric soon after
laundering. But with this new patented technology in HaloShield ® linens,
the chlorine keeps killing bacteria right up until the next laundering.
 Option D: The environment in which linens are used in healthcare is often
ideal for the proliferation and spread of bacteria and viruses. Often the
patient, in a weakened or compromised state, is lying on a sheet. That
sheet under the patient‘s body is warm, dark, and sometimes damp. Most
would agree that those conditions are considered ideal for bacteria and
viruses to thrive.
ADVERTISEMENTS
75. Question
The most important purpose of cleansing bed bath is:
 A. To cleanse, refresh and give comfort to the client who must remain in
bed.
 B. To expose the necessary parts of the body.
 C. To develop skills in bed bath.
 D. To check the body temperature of the client in bed.

Incorrect
Correct Answer: A. To cleanse, refresh and give comfort to the client who
must remain in bed.
The nurse provides a bed bath for patients who must remain in bed and depend
on someone else for their care. It is an important part of the patient‘s daily care.
Not only does it remove sweat, oil, and micro-organisms from the patient‘s skin,
but it also stimulates circulation and promotes a feeling of self-worth by
improving the patient‘s appearance. For patients who are on bedrest, bathing can
also be a time for socialization.
 Option B: During bed bath, the patient is always given privacy so as not to
expose their intimate parts of the body. Some patients cannot safely leave
their beds to bathe. For these people, daily bed baths can help keep their
skin healthy, control odor, and increase comfort. If moving the patient

causes pain, plan to give the patient a bed bath after the person has
received pain medicine and it has taken effect.
 Option C: The nurse may develop her skills in bed bath, but it is not the
main purpose. A bed bath is a good time to inspect a patient‘s skin for
redness and sores. Pay special attention to skin folds and bony areas when
checking. Encourage the patient to be involved as possible in bathing
themselves.
 Option D: A bed bath may give a relaxation effect on the patient. It may
also stimulate blood circulation to the skin, respiration, and elimination;
maintain joint mobility, and improve the patient‘s self-image and
emotional and mental well-being. It provides the nurse with an opportunity
for health teaching and assessment; gives the patient psychological
support, and the process of building rapport may begin during the initial
bath.
2. 1. Question
All of the following can cause tachycardia except:
o A. Fever
o B. Exercise
o C. Sympathetic nervous system stimulation
o D. Parasympathetic nervous system stimulation

Incorrect
Correct Answer: D. Parasympathetic nervous system stimulation
Parasympathetic nervous system stimulation of the heart decreases the heart rate
as well as the force of contraction, rate of impulse conduction and blood flow
through the coronary vessels. Fever, exercise, and sympathetic stimulation all
increase the heart rate. The parasympathetic nervous system (PNS) releases the
hormone acetylcholine to slow the heart rate. Such factors as stress, caffeine, and
excitement may temporarily accelerate your heart rate, while meditating or taking
slow, deep breaths may help to slow your heart rate.
 Option A: Tachypnea and tachycardia develop, and the patient becomes
dehydrated because of sweating and vapor losses from the increased
respiratory rate. Many manifestations of fever are related to the increased

metabolic rate, increased need for oxygen, and use of body proteins as an
energy source.
 Option B: Often, ventricular tachycardia will occur during the recovery
period post exercise due to increased levels of adrenaline. In a study
conducted in 1991, it was found that 70% of patients tested experienced
idiopathic ventricular tachycardia as a result of exercise. Exercising for any
duration will increase your heart rate and will remain elevated for as long
as the exercise is continued. At the beginning of exercise, your body
removes the parasympathetic stimulation, which enables the heart rate to
gradually increase. As you exercise more strenuously, the sympathetic
system ―kicks in‖ to accelerate your heart rate even more.
 Option C: Heart rate is controlled by the two branches of the autonomic
(involuntary) nervous system. The sympathetic nervous system (SNS) and
the parasympathetic nervous system (PNS). The sympathetic nervous
system (SNS) releases the hormones (catecholamines – epinephrine and
norepinephrine) to accelerate the heart rate.
ADVERTISEMENTS
2. Question 2 of 75
2. Question
Palpating the midclavicular line is the correct technique for assessing:
o A. Baseline vital signs
o B. Systolic blood pressure
o C. Respiratory rate
o D. Apical pulse
Incorrect
Correct Answer: D. Apical pulse
The apical pulse (the pulse at the apex of the heart) is located on the
midclavicular line at the fourth, fifth, or sixth intercostal space. Assessing whether
the rhythm of the pulse is regular or irregular is essential. The pulse could be
regular, irregular, or irregularly irregular. Changes in the rate of the pulse, along
with changes in respiration is called sinus arrhythmia. In sinus arrhythmia, the
pulse rate becomes faster during inspiration and slows down during expiration.

Irregularly irregular pattern is more commonly indicative of processes like atrial
flutter or atrial fibrillation.
 Option A: Baseline vital signs include pulse rate, temperature, respiratory
rate, and blood pressure. Vital signs are an objective measurement for the
essential physiological functions of a living organism. They have the name
―vital‖ as their measurement and assessment is the critical first step for any
clinic evaluation. The first set of clinical examinations is an evaluation of the
vital signs of the patient.
 Option B: Blood pressure is typically assessed at the antecubital fossa. The
arm should be supported at the heart level. Unsupported arm leads to 10
mmHg to the pressure readings. The patient‘s blood pressure should get
checked in each arm, and in younger patients, it should be tested in an
upper and lower extremity to rule out the coarctation of the aorta.
 Option C: Respiratory rate is assessed best by observing chest movement
with each inspiration and expiration. The respiratory rate is the number of
breaths per minute. The normal breathing rate is about 12 to 20 beats per
minute in an average adult. In the pediatric age group, it is defined by the
particular age group. Parameters important here again include its rate,
depth of breathing, and its pattern rate of breathing is a crucial parameter.
ADVERTISEMENTS
2. Question 3 of 75
3. Question
The absence of which pulse may not be a significant finding when a patient is
admitted to the hospital?
o A. Apical
o B. Radial
o C. Pedal
o D. Femoral
Incorrect
Correct Answer: C. Pedal
Because the pedal pulse cannot be detected in 10% to 20% of the population, its
absence is not necessarily a significant finding. However, the presence or absence

of the pedal pulse should be documented upon admission so that changes can
be identified during the hospital stay. Absent peripheral pulses may be indicative
of peripheral vascular disease (PVD). PVD may be caused by atherosclerosis,
which can be complicated by an occluding thrombus or embolus. This may be
life-threatening and may cause the loss of a limb.
 Option A: Apical pulse rate is indicated during some assessments, such as
when conducting a cardiovascular assessment and when a client is taking
certain cardiac medications (e.g., digoxin). Sometimes the apical pulse is
auscultated pre and post medication administration. It is also a best
practice to assess apical pulse in infants and children up to five years of
age because radial pulses are difficult to palpate and count in this
population.
 Option B: Examiners frequently evaluate the radial artery during a routine
examination of adults, due to the unobtrusive position required to palpate
it and it‘s easy accessibility in various types of clothing. Like other distal
peripheral pulses (such as those in the feet) it also may be quicker to show
signs of pathology. Palpation is at the anterior wrist just proximal to the
base of the thumb.
 Option D: The femoral pulse may be the most sensitive in assessing for
ADVERTISEMENTS
2. Question 4 of 75
4. Question
Which of the following patients is at greatest risk for developing pressure ulcers?
o A. An alert, chronic arthritic patient treated with steroids and aspirin.
o B. An 88-year old incontinent patient with gastric cancer who is

confined to his bed at home.
o C. An apathetic 63-year old COPD patient receiving nasal oxygen via cannula.
o D. A confused 78-year old patient with congestive heart failure (CHF) who
requires assistance to get out of bed.

Incorrect
Correct Answer: B. An 88-year old incontinent patient with gastric cancer
who is confined to his bed at home.
Pressure ulcers are most likely to develop in patients with impaired mental status,
mobility, activity level, nutrition, circulation and bladder or bowel control. Age is
also a factor. Thus, the 88-year old incontinent patient who has impaired nutrition
(from gastric cancer) and is confined to bed is at greater risk. Pressure injuries are
defined as localized damage to the skin as well as underlying soft tissue, usually
occurring over a bony prominence or related to medical devices. They are the
result of prolonged or severe pressure with contributions from shear and friction
forces.
 Option A: Risk factors for developing pressure injuries, in general, include
immobility, reduced perfusion, malnutrition, and sensory loss. Other
patients at increased risk for pressure injury development include those
with cerebrovascular or cardiovascular disease, recent fracture of a lower
extremity, diabetes, and incontinence. Older patients are also at increased
risk for the formation of pressure injuries due to skin changes associated
with aging, including thinning of the dermis and epidermis, resulting in
decreased resistance to shear forces.
 Option C: The pressure of an individual‘s body weight or pressure from a
medical device above a certain threshold for a prolonged period is thought
to be the cause of pressure injuries. In patients with sensory deficits, an
absent pressure feedback response may result in sustained pressure for a
prolonged period, leading to tissue injury. Many factors are identified in
contributing to pressure ulcer and injury formation, such as increased
arteriole pressure, shearing forces, friction, moisture, and nutrition status.
 Option D: Pressure injuries of the skin and soft tissues affect an estimated
1 to 3 million people in the United States each year. The incidence differs
based on the clinical setting. For example, the prevalence of pressure
injuries among hospitalized patients is 5% to 15%, with the percentage
considerably higher in some long-term care environments and intensive
care units.
ADVERTISEMENTS
2. Question 5 of 75
5. Question

The physician orders the administration of high-humidity oxygen by face mask
and placement of the patient in a high Fowler‘s position. After assessing Mrs.
Paul, the nurse writes the following nursing diagnosis: Impaired gas exchange
related to increased secretions. Which of the following nursing interventions has
the greatest potential for improving this situation?
o A. Encourage the patient to increase her fluid intake to 200 ml every 2

hours.
o B. Place a humidifier in the patient‘s room.
o C. Continue administering oxygen by a high humidity face mask.
o D. Perform chest physiotherapy on a regular schedule.

Incorrect
Correct Answer: A. Encourage the patient to increase her fluid intake to 200
ml every 2 hours
Adequate hydration thins and loosens pulmonary secretions and also helps to
replace fluids lost from elevated temperature, diaphoresis, dehydration, and
dyspnea. Encourage patients to increase fluid intake to 3 liters per day within the
limits of cardiac reserve and renal function. Fluids help minimize mucosal drying
and maximize ciliary action to move secretions.
 Option B: Consider the need for humidifiers in-home care settings. This
facilitates the liquefaction of secretions. Teach the patient the proper ways
of coughing and breathing. (e.g., take a deep breath, hold for 2 seconds,
and cough two or three times in succession). The most convenient way to
remove most secretions is coughing. So it is necessary to assist the patient
during this activity. Deep breathing, on the other hand, promotes
oxygenation before controlled coughing.
 Option C: Maintain humidified oxygen as prescribed. Increasing humidity
of inspired air will reduce the thickness of secretions and aid their removal.
Provide supplemental oxygen if the patient experiences bradycardia, an
increase in ventricular ectopy, and/or significant desaturation. Oxygen
therapy is recommended to improve oxygen saturation and reduce
possible complications.
 Option D: Coordinate with a respiratory therapist for chest physiotherapy
and nebulizer management as indicated. Chest physiotherapy includes the
techniques of postural drainage and chest percussion to mobilize

secretions from smaller airways that cannot be eliminated by means of
coughing or suctioning.
ADVERTISEMENTS
2. Question 6 of 75
6. Question
The most common deficiency seen in alcoholics is:
o A. Thiamine
o B. Riboflavin
o C. Pyridoxine
o D. Pantothenic acid
Incorrect
Correct Answer: A. Thiamine
Chronic alcoholism commonly results in thiamine deficiency and other symptoms
of malnutrition. Chronic alcohol consumption can cause thiamine deficiency and
thus reduced enzyme activity through several mechanisms, including inadequate
dietary intake, malabsorption of thiamine from the gastrointestinal tract, and
impaired utilization of thiamine in the cells.
 Option B: Riboflavin, vitamin B2, is a water-soluble and heat-stable vitamin
that the body uses to metabolize fats, protein, and carbohydrates into
glucose for energy. In addition to boosting energy, riboflavin functions as
an antioxidant for the proper function of the immune system, healthy skin,
and hair. Riboflavin deficiency can result from inadequate dietary intake or
by endocrine abnormalities. Riboflavin deficiency also correlates with other
vitamin B complexes.
 Option C: Vitamin B6 deficiency is usually caused by pyridoxine-
inactivating drugs (eg, isoniazid), protein-energy undernutrition,
malabsorption, alcoholism, or excessive loss. Deficiency can cause
peripheral neuropathy, seborrheic dermatitis, glossitis, and cheilosis, and, in
adults, depression, confusion, and seizures.
 Option D: Pantothenic acid deficiency is very rare in the United States.
Severe deficiency can cause numbness and burning of the hands and feet,

headache, extreme tiredness, irritability, restlessness, sleeping problems,
stomach pain, heartburn, diarrhea, nausea, vomiting, and loss of appetite.
ADVERTISEMENTS
2. Question 7 of 75
7. Question
Which of the following statements is incorrect about a patient with dysphagia?
o A. The patient will find pureed or soft foods, such as custards, easier to
swallow than water.
o B. Fowler‘s or semi Fowler‘s position reduces the risk of aspiration during

swallowing.
o C. The patient should always feed himself.
o D. The nurse should perform oral hygiene before assisting with feeding.
Incorrect
Correct Answer: C. The patient should always feed himself.
A patient with dysphagia (difficulty swallowing) requires assistance with feeding.
Feeding himself is a long-range expected outcome. Dysphagia is defined as
objective impairment or difficulty in swallowing, resulting in an abnormal delay in
the transit of a liquid or solid bolus. The delay may be during the oropharyngeal
or esophageal phase of swallowing.
 Option A: The Academy of Nutrition and Dietetics has created a diet plan
for people with dysphagia. The plan is called the National Dysphagia Diet.
The dysphagia diet has 4 levels of foods. Level 1 foods are foods that are
pureed or smooth, like pudding. They need no chewing. This includes
foods such as yogurt, mashed potatoes with gravy to moisten it, smooth
soups, and pureed vegetables and meats.
 Option B: While eating or drinking, it may help to sit upright, with the back
straight. The client may need support pillows to get into the best position.
It may also help to have few distractions while eating or drinking. Changing
between solid food and liquids may also help the swallowing. Stay upright
for at least 30 minutes after eating. This can help reduce the risk for
aspiration.

 Option D: After meals, it‘s important to do proper oral care. The SLP
(speech-language pathologist) can give the client instructions for the teeth
or dentures. Make sure to not swallow any water during the oral care
routine. While on a dysphagia diet, the client may have trouble taking in
enough fluid. This can cause dehydration, which can lead to serious health
problems. Talk with the healthcare team about how it can be prevented. In
some cases drinking thicker liquids may make some of the medicines work
less well. Because of this, the client may need some of the medicines
changed for a while.
ADVERTISEMENTS
2. Question 8 of 75
8. Question
To assess the kidney function of a patient with an indwelling urinary (Foley)
catheter, the nurse measures his hourly urine output. She should notify the
physician if the urine output is:
o A. Less than 30 ml/hour
o B. 64 ml in 2 hours
o C. 90 ml in 3 hours
o D. 125 ml in 4 hours
Incorrect
Correct Answer: A. Less than 30 ml/hour
A urine output of less than 30ml/hour indicates hypovolemia or oliguria, which is
related to kidney function and inadequate fluid intake. Urine output is a
noninvasive method to measure fluid balance once intravascular volume has
been restored. Normal urine output is defined as 1.5 to 2 mL/kg per hour
 Option B: Micturition process entails contraction of the detrusor muscle
and relaxation of the internal and external urethral sphincter. The process is
slightly different based on age. Children younger than three years old have
the micturition process coordinated by the spinal reflex.
 Option C: It starts with urine accumulation in the bladder that stretches the
detrusor muscle causing activation of stretch receptors. The stretch
sensation is carried by the visceral afferent to the sacral region of the spinal

cord where it synapses with the interneuron that excites the
parasympathetic neurons and inhibits the sympathetic neurons. The
visceral afferent impulse concurrently decreases the firing of the somatic
efferent that normally keeps the external urethral sphincter closed allowing
reflexive urine output.
 Option D: Low bladder volume activates the pontine storage center which
activates the sympathetic nervous system and inhibits the parasympathetic
nervous system cumulatively allowing the accumulation of urine in the
bladder. High bladder volume activates the pontine micturition center
which activates the parasympathetic nervous system and inhibits the
sympathetic nervous system as well as triggers awareness of a full bladder;
consequently leading to relaxation of the internal sphincter and a choice to
relax the external urethral sphincter once ready to void.
ADVERTISEMENTS
2. Question 9 of 75
9. Question
Certain substances increase the amount of urine produced. These include:
o A. Caffeine-containing drinks, such as coffee and cola
o B. Beets
o C. Urinary analgesics
o D. Kaolin with pectin (Kaopectate)

Incorrect
Correct Answer: A. Caffeine-containing drinks, such as coffee and cola.
Fluids containing caffeine have a diuretic effect. Drinking caffeine-containing
beverages as part of a normal lifestyle doesn‘t cause fluid loss in excess of the
volume ingested. While caffeinated drinks may have a mild diuretic effect —
meaning that they may cause the need to urinate — they don‘t appear to
increase the risk of dehydration.
 Option B: In some people, eating beets turn urine pink or red—which can
be alarming because it looks like blood in the urine. These odor and color
changes are harmless. But if urine smells sweet, that‘s a cause for concern
because it could mean diabetes.

 Option C: Pyridium will most likely darken the color of urine to an orange
or red color. This is a normal effect and is not cause for alarm unless there
are other symptoms such as pale or yellowed skin, fever, stomach pain,
nausea, and vomiting.
 Option D: Kaopectate is an antidiarrheal medication. This medication is
used to treat occasional upset stomach, heartburn, and nausea. It is also
used to treat diarrhea and help prevent travelers‘ diarrhea. It works by
helping to slow the growth of bacteria that might be causing diarrhea. This
product should not be used to self-treat diarrhea if there is also fever or
blood/mucus in the stools. These could be signs of a serious health
condition.
ADVERTISEMENTS
10. Question
A male patient who had surgery 2 days ago for head and neck cancer is about to
make his first attempt to ambulate outside his room. The nurse notes that he is
steady on his feet and that his vision was unaffected by the surgery. Which of the
following nursing interventions would be appropriate?
o A. Encourage the patient to walk in the hall alone.
o B. Discourage the patient from walking in the hall for a few more days.
o C. Accompany the patient for his walk.
o D. Consult a physical therapist before allowing the patient to ambulate.

Incorrect
Correct Answer: C. Accompany the patient for his walk.
Accompanying him will offer moral support, enabling him to face the rest of the
world. Ambulation stimulates circulation which can help stop the development of
stroke-causing blood clots. Walking improves blood flow which aids in quicker
wound healing. The gastrointestinal, genitourinary, pulmonary and urinary tract
functions are all improved by walking.
 Option A: A hospitalized surgical patient leaving his room for the first time
fears rejection and others staring at him, so he should not walk alone.
Refusal to ambulate correlated with those that eventually developed a

complication. Those that eventually developed a postoperative
complication were more likely to be in the higher refusal group. Thorn et
al. suggested that patient compliance may be a marker of underlying
complications. If patients are not engaged in their recovery, there may be a
physiologic reason for refusal (i.e., a developing abscess).
 Option B: Patients should begin ambulation as soon as possible after
surgery to decrease complications and to regain strength and confidence.
The multiple physiological benefits of patient ambulation have been
documented including the prevention of muscular and cardiovascular
deconditioning, reducing the risk of pulmonary and thromboembolic
events, and stimulating gastrointestinal recovery through prokinetic effects
 Option D: Waiting to consult a physical therapist is unnecessary. Daily
ambulation requires collaboration between hospital resources, patient
education and available personnel. Second, aggressive non-opioid pain
medication regimens are critical to maintain a low mLOS. The increasing
use of narcotics especially with a PCA prolonged the LOS. Third, refusal of
ambulation often predicted the development of a postoperative
complication.
ADVERTISEMENTS
11. Question
A patient has exacerbation of chronic obstructive pulmonary disease (COPD)
manifested by shortness of breath; orthopnea: thick, tenacious secretions; and a
dry hacking cough. An appropriate nursing diagnosis would be:
o A. Ineffective airway clearance related to thick, tenacious secretions
o B. Ineffective airway clearance related to dry, hacking cough
o C. Ineffective individual coping to COPD
o D. Pain related to immobilization of affected leg

Incorrect
Correct Answer: A. Ineffective airway clearance related to thick, tenacious
secretions.

Thick, tenacious secretions, a dry, hacking cough, orthopnea, and shortness of
breath are signs of ineffective airway clearance. Chronic obstructive pulmonary
disease (COPD) is a common and treatable disease characterized by progressive
airflow limitation and tissue destruction. It is associated with structural lung
changes due to chronic inflammation from prolonged exposure to noxious
particles or gases most commonly cigarette smoke. Chronic inflammation causes
airway narrowing and decreased lung recoil. The disease often presents with
symptoms of cough, dyspnea, and sputum production.
 Option B: Ineffective airway clearance related to dry, hacking cough is
incorrect because the cough is not the reason for the ineffective airway
clearance. COPD is an inflammatory condition involving the airways, lung
parenchyma, and pulmonary vasculature. The process is thought to involve
oxidative stress and protease-antiprotease imbalances. Emphysema
describes one of the structural changes seen in COPD where there is the
destruction of the alveolar air sacs (gas-exchanging surfaces of the lungs)
leading to obstructive physiology.
 Option C: Ineffective individual coping related to COPD is wrong because
the etiology for a nursing diagnosis should not be a medical diagnosis
(COPD) and because no data indicate that the patient is coping
ineffectively. In emphysema, an irritant (e.g., smoking) causes an
inflammatory response. Neutrophils and macrophages are recruited and
release multiple inflammatory mediators. Oxidants and excess proteases
leading to the destruction of the air sacs. The protease-mediated
destruction of elastin leads to a loss of elastic recoil and results in airway
collapse during exhalation.
 Option D: Pain related to immobilization of affected legs would be an
appropriate nursing diagnosis for a patient with a leg fracture. COPD will
typically present in adulthood and often during the winter months. Patients
usually present with complaints of chronic and progressive dyspnea,
cough, and sputum production. Patients may also have wheezing and chest
tightness. While a smoking history is present in most cases, there are many
without such history.
ADVERTISEMENTS
12. Question

Mrs. Lim begins to cry as the nurse discusses hair loss. The best response would
be:
o A. ―Don‘t worry. It‘s only temporary‖
o B. ―Why are you crying? I didn‘t get to the bad news yet‖
o C. ―Your hair is really pretty‖
o D. “I know this will be difficult for you, but your hair will grow back
after the completion of chemotherapy”
Incorrect
Correct Answer: D. “I know this will be difficult for you, but your hair will
grow back after the completion of chemotherapy”
―I know this will be difficult‖ acknowledges the problem and suggests a resolution
to it. The term alopecia means hair loss regardless of the cause. It is not exclusive
to the scalp; it can be anywhere on the body. As an individual grows older, they
will lose hair. The difference between male hair loss and female hair loss is the
pattern. Men generally lose hair in the front and the temporal region, while
women tend to lose hair from the central area of the scalp. Also, female hair loss
will not end up with complete baldness, whereas male hair loss can end up with
complete baldness.
 Option A: ―Don‘t worry..‖ offers some relief but doesn‘t recognize the
patient‘s feelings. The epidemiology is variable depending on the cause of
alopecia and the type. In alopecia areata, the prevalence is 0.2% with no
racial or sexual predilection, and it may affect any age group. Androgenetic
alopecia is a common disorder affecting 50% of men and 15% of women,
especially postmenopausal women.
 Option B: ―..I didn‘t get to the bad news yet‖ would be inappropriate at
any time. Pathophysiology is dependent on the type of alopecia. In
alopecia areata, it is unknown, but the most common hypothesis involves
autoimmunity in the form of a T-cell–mediated pathway. In androgenetic
alopecia, both genetic and hormonal androgens play a role in
pathogenesis. In telogen effluvium, the shedding of hair is under the
influence of hormone or stress, but sometimes the trigger is not very clear.
 Option C: ―Your hair is really pretty‖ offers no consolation or alternatives to
the patient. During the physical examination, it is essential to notice the
pattern of hair loss. In a patient with androgenetic alopecia, patients tend

to lose hair from the frontal and temporal area (male type) and the central
scalp area (female type). In alopecia areata, the patient may lose hair from
a single area (alopecia areata classical type), the whole scalp and eyebrows
(alopecia totalis), or from the entire body (alopecia universalis). In tinea
capitis, the classic presentation is black dots associated with broken hair,
while the inflammatory type (favus) correlates with the scarring type of
alopecia.
ADVERTISEMENTS
13. Question
An additional Vitamin C is required during all of the following periods except:
o A. Infancy
o B. Young adulthood
o C. Childhood
o D. Pregnancy
Incorrect
Correct Answer: B. Young adulthood
Additional Vitamin C is needed in growth periods, such as infancy and childhood,
and during pregnancy to supply demands for fetal growth and maternal tissues.
Other conditions requiring extra vitamin C include wound healing, fever, infection
and stress. Vitamin C is a water-soluble vitamin, antioxidant, and essential
cofactor for collagen biosynthesis, carnitine and catecholamine metabolism, and
dietary iron absorption. Humans are unable to synthesize vitamin C, so they can
only obtain it through dietary intake of fruits and vegetables.
 Option A: An infant requires Vitamin C. Although most vitamin C is
completely absorbed in the small intestine, the percentage of absorbed
vitamin C decreases as intraluminal concentrations increase. Proline
residues on procollagen require vitamin C for the hydroxylation, making it
necessary for the triple-helix formation of mature collagen. The lack of a
stable triple-helical structure compromises the integrity of the skin, mucous
membranes, blood vessels, and bone.

 Option C: Children need lots of Vitamin C. Usual dietary doses of up to 100
mg/day are almost completely absorbed. The highest concentrations of
ascorbic acid are in the pituitary gland, the adrenal gland, the brain,
leukocytes, and eyes. Ascorbic acid functions as a cofactor, enzyme
complement, co-substrate, and a powerful antioxidant in a variety of
reactions and metabolic processes. It also stabilizes vitamin E and folic acid
and enhances iron absorption. It neutralizes free radicals and toxins as well
as attenuates inflammatory response, including sepsis syndrome.
 Option D: A pregnant woman requires an abundant amount of Vitamin C.
The average protective adult dose of vitamin C is 70 to 150 mg daily.
Increase the dose to 300 mg to 1 g daily when scurvy is present. Daily need
increases in patients with conditions like gingivitis, asthma, glaucoma,
collagen disorders, heatstroke, arthritis, infections (pneumonia, sinusitis,
rheumatic fever), and chronic illnesses. Hemovascular disorders, burns, and
delayed wound healing are causes for an increase in daily intake.
ADVERTISEMENTS
14. Question
A prescribed amount of oxygen is needed for a patient with COPD to prevent:
o A. Cardiac arrest related to increased partial pressure of carbon dioxide in

arterial blood (PaCO2).
o B. Circulatory overload due to hypervolemia.
o C. Respiratory excitement.
o D. Inhibition of the respiratory hypoxic stimulus.

Incorrect
Correct Answer: D. Inhibition of the respiratory hypoxic stimulus.
Delivery of more than 2 liters of oxygen per minute to a patient with chronic
obstructive pulmonary disease (COPD), who is usually in a state of compensated
respiratory acidosis (retaining carbon dioxide (CO2)), can inhibit the hypoxic
stimulus for respiration. Long-term oxygen therapy is used for COPD if the client
has low levels of oxygen in the blood (hypoxia). It is used mostly to slow or
prevent right-sided heart failure. It can help the client live longer.

 Option A: An increased partial pressure of carbon dioxide in arterial blood
(PACO2) would not initially result in cardiac arrest. Long-term oxygen
therapy should be used for at least 15 hours a day with as few interruptions
as possible. Regular use can reduce the risk of death from low oxygen
levels.. To get the most benefit from oxygen, the client should use it 24
hours a day. Supplemental oxygen is a well-established therapy with clear
evidence for benefit in patients with COPD and severe resting hypoxemia,
which is defined as a room air Pao2 ? 55 mm Hg or ? 59 mm Hg with signs
of right-sided heart strain or polycythemia.
 Option B: Long-term use of supplemental oxygen improves survival in
patients with COPD and severe resting hypoxemia. However, the role of
oxygen in symptomatic patients with COPD and more moderate
hypoxemia at rest and desaturation with activity is unclear. The few long-
term reports of supplemental oxygen in this group have been of small size
and insufficient to demonstrate a survival benefit.
 Option C: Circulatory overload and respiratory excitement have no
relevance to the question. Short-term trials have suggested beneficial
effects other than survival in patients with COPD and moderate hypoxemia
at rest. In addition, supplemental oxygen appeared to improve exercise
performance in small short-term investigations of patients with COPD and
moderate hypoxemia at rest and desaturation with exercise, but long-term
trials evaluating patient-reported outcomes are lacking.
ADVERTISEMENTS
15. Question
After 1 week of hospitalization, Mr. Gray develops hypokalemia. Which of the
following is the most significant symptom of his disorder?
o A. Lethargy
o B. Increased pulse rate and blood pressure
o C. Muscle weakness
o D. Muscle irritability
Incorrect

Correct Answer: C. Muscle weakness
Presenting symptoms of hypokalemia ( a serum potassium level below 3.5
mEq/liter) include muscle weakness, chronic fatigue, and cardiac dysrhythmias.
The combined effects of inadequate food intake and prolonged diarrhea can
deplete the potassium stores of a patient with GI problems. Significant muscle
weakness occurs at serum potassium levels below 2.5 mmol/L but can occur at
higher levels if the onset is acute. Similar to the weakness associated with
hyperkalemia, the pattern is ascending in nature affecting the lower extremities,
progressing to involve the trunk and upper extremities, and potentially advancing
to paralysis.
 Option A: Periodic paralysis is a rare neuromuscular disorder, which is
inherited or acquired, that is caused by an acute transcellular shift of
potassium into the cells. It is characterized by potentially fatal episodes of
muscle weakness or paralysis that can affect the respiratory muscles.
Clinical manifestations mainly involve the musculoskeletal and
cardiovascular systems. Hence, the physical exam should focus on
identifying neurologic manifestations and cardiac dysrhythmias.
 Option B: Clinical symptoms of hypokalemia do not become evident until
the serum potassium level is less than 3 mmol/L unless there is a
precipitous fall or the patient has a process that is potentiated by
hypokalemia. The severity of symptoms also tends to be proportional to
the degree and duration of hypokalemia. Symptoms resolve with
correction of the hypokalemia.
 Option D: Affected muscles can include the muscles of respiration which
can lead to respiratory failure and death. Involvement of GI muscles can
cause an ileus with associated symptoms of nausea, vomiting, and
abdominal distension. Severe hypokalemia can also lead to muscle cramps,
rhabdomyolysis, and resultant myoglobinuria.
ADVERTISEMENTS
16. Question
Which of the following nursing interventions promotes patient safety?
o A. Assess the patient‘s ability to ambulate and transfer from a bed to a chair.
o B. Demonstrate the signal system to the patient.

o C. Check to see that the patient is wearing his identification band.

Incorrect
Patient Safety is a healthcare discipline that emerged with the evolving
complexity in health care systems and the resulting rise of patient harm in health
care facilities. It aims to prevent and reduce risks, errors, and harm that occur to
patients during the provision of health care. A cornerstone of the discipline is a
continuous improvement based on learning from errors and adverse events.
 Option A: Assisting a patient with ambulation and transfer from a bed to a
chair allows the nurse to evaluate the patient‘s ability to carry out these
functions safely. Patient safety is fundamental to delivering quality essential
health services. Indeed, there is a clear consensus that quality health
services across the world should be effective, safe, and people-centered. In
addition, to realize the benefits of quality health care, health services must
be timely, equitable, integrated, and efficient.
 Option B: Demonstrating the signal system and providing an opportunity
for a return demonstration ensures that the patient knows how to operate
the equipment and encourages him to call for assistance when needed. To
ensure successful implementation of patient safety strategies; clear policies,
leadership capacity, data to drive safety improvements, skilled health care
professionals, and effective involvement of patients in their care, are all
needed.
 Option C: Checking the patient‘s identification band verifies the patient‘s
identity and prevents identification mistakes in drug administration. Safety
of patients during the provision of health services that are safe and of high
quality is a prerequisite for strengthening health care systems and making
progress towards effective universal health coverage (UHC) under
Sustainable Development Goal 3 (Ensure healthy lives and promote health
and well-being for all at all ages).
ADVERTISEMENTS
17. Question

Studies have shown that about 40% of patients fall out of bed despite the use of
side rails; this has led to which of the following conclusions?
o A. Side rails are ineffective.
o B. Side rails should not be used.
o C. Side rails are a deterrent that prevent a patient from falling out of bed.
o D. Side rails are a reminder to a patient not to get out of bed.

Incorrect
Correct Answer: D. Side rails are a reminder to a patient not to get out of
bed.
Since about 40% of patients fall out of bed despite the use of side rails, side rails
cannot be said to prevent falls; however, they do serve as a reminder that the
patient should not get out of bed. A process that requires ongoing patient
evaluation and monitoring will result in optimizing bed safety. Many patients go
through a period of adjustment to become comfortable with new options.
Patients and their families should talk to their health care planning team to find
out which options are best for them.
 Option A: Patients who have problems with memory, sleeping,
incontinence, pain, uncontrolled body movement, or who get out of bed
and walk unsafely without assistance, must be carefully assessed for the
best ways to keep them from harm, such as falling. Assessment by the
patient‘s health care team will help to determine how best to keep the
patient safe.
 Option B: Historically, physical restraints (such as vests, ankle or wrist
restraints) were used to try to keep patients safe in health care facilities. In
recent years, the health care community has recognized that physically
restraining patients can be dangerous. Although not indicated for this use,
bed rails are sometimes used as restraints. Regulatory agencies, health care
organizations, product manufacturers, and advocacy groups encourage
hospitals, nursing homes, and home care providers to assess patients‘
needs and to provide safe care without restraints.
 Option C: Anticipate the reasons patients get out of bed such as hunger,
thirst, going to the bathroom, restlessness, and pain; meet these needs by
offering food and fluids, scheduling ample toileting, and providing calming
interventions and pain relief. When bed rails are used, perform an on-

going assessment of the patient‘s physical and mental status; closely
monitor high-risk patients.
ADVERTISEMENTS
18. Question
Examples of patients suffering from impaired awareness include all of the
following except:
o A. A semiconscious or over fatigued patient.
o B. A disoriented or confused patient.
o C. A patient who cannot care for himself at home.
o D. A patient demonstrating symptoms of drugs or alcohol withdrawal.

Incorrect
Correct Answer: C. A patient who cannot care for himself at home
A patient who cannot care for himself at home does not necessarily have
impaired awareness; he may simply have some degree of immobility.
 Option A: Fatigue is the feeling of tiredness and decreased energy that
results from inadequate sleep time or poor quality of sleep. Fatigue can
also result from increased work intensity or long work hours. Sleep
deprivation has long been known to impair various cognitive functions,
including mood, motivation, response time, and initiative. In a classic
review of sleep deprivation and decision-making, investigators argued that
effective performance in health care environments requires naturalistic
decision-making and situation awareness.
 Option B: Impaired self-awareness of deficits is a common finding in
patients who have suffered a traumatic brain injury. Impaired awareness
can limit motivation for treatment and contribute to a poor outcomes.
Consequently, it is important for brain injury rehabilitation professionals to
understand this phenomenon and utilize treatment approaches that may
improve patient awareness.
 Option D: Most alcoholics exhibit mild-to-moderate deficiencies in
intellectual functioning, along with diminished brain size and regional
changes in brain-cell activity. The most prevalent alcohol-associated brain

impairments affect visuospatial abilities and higher cognitive functioning.
Visuospatial abilities include perceiving and remembering the relative
locations of objects in 2- and 3-dimensional space. Examples include
driving a car or assembling a piece of furniture based on instructions
contained in a line drawing. Higher cognitive functioning includes the
abstract-thinking capabilities needed to organize a plan, set it in motion,
and change it as needed.
ADVERTISEMENTS
19. Question
The most common injury among elderly persons is:
o A. Atherosclerotic changes in the blood vessels
o B. Increased incidence of gallbladder disease
o C. Urinary Tract Infection
o D. Hip fracture
Incorrect
Correct Answer: D. Hip fracture
Hip fracture, the most common injury among elderly persons, usually results from
osteoporosis. Hip fractures from falls are one of the leading causes of injuries for
seniors and result in the largest number of hospitalizations. Family members and
hourly caregivers can take steps to prevent falls, such as removing area rugs,
improving lighting throughout the home, and offering mobility support when
needed.
 Option A: Some changes in the heart and blood vessels normally occur
with age. However, many other changes that are common with aging are
due to modifiable factors. If not treated, these can lead to heart disease.
Arteriosclerosis (hardening of the arteries) is very common. Fatty plaque
deposits inside the blood vessels cause them to narrow and totally block
blood vessels. The capillary walls thicken slightly. This may cause a slightly
slower rate of exchange of nutrients and wastes.
 Option B: Increasing age is a major risk factor for their formation, with the
prevalence of gallstones being greatest at advanced age. While the

majority of gallstones remain asymptomatic, seniors have a high risk for
acute cholecystitis with atypical presentation, even when gangrene or
perforation has occurred.
 Option C: The main cause of UTIs, at any age, is usually bacteria.
Escherichia coli is the primary cause, but other organisms can also cause a
UTI. In older adults who use catheters or live in a nursing home or other
full-time care facility, bacteria such as Enterococci and Staphylococci are
more common causes.
ADVERTISEMENTS
20. Question
The most common psychogenic disorder among elderly person is:
o A. Depression
o B. Sleep disturbances (such as bizarre dreams)
o C. Inability to concentrate
o D. Decreased appetite
Incorrect
Correct Answer: A. Depression
Depression typically begins before the onset of old age and usually is caused by
psychosocial, genetic, or biochemical factors. Depression is a common problem
among older adults, but it is NOT a normal part of aging. In fact, studies show
that most older adults feel satisfied with their lives, despite having more illnesses
or physical problems. However, important life changes that happen as we get
older may cause feelings of uneasiness, stress, and sadness. Sometimes older
people who are depressed appear to feel tired, have trouble sleeping, or seem
grumpy and irritable. Confusion or attention problems caused by depression can
sometimes look like Alzheimer‘s disease or other brain disorders.
 Option B: Primary sleep disorders are more common in the elderly than in
younger persons. Restless legs syndrome and periodic limb movement
disorder can disrupt sleep and may respond to low doses of
antiparkinsonian agents as well as other drugs. Sleep apnea can lead to
excessive daytime sleepiness.

 Option C: A study finds that seniors‘ attention shortfall is associated with
the locus coeruleus, a tiny region of the brainstem that connects to many
other parts of the brain. The locus coeruleus helps focus brain activity
during periods of stress or excitement. Increased distractibility is a sign of
cognitive aging.
 Option D: 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.
ADVERTISEMENTS
21. Question
Which of the following vascular system changes results from aging?
o A. Increased peripheral resistance of the blood vessels
o B. Decreased blood flow
o C. Increased workload of the left ventricle

Incorrect
Aging decreases the elasticity of the blood vessels, which leads to increased
peripheral resistance and decreased blood flow. These changes, in turn, increase
the workload of the left ventricle. Some changes in the heart and blood vessels
normally occur with age. However, many other changes that are common with
aging are due to modifiable factors. If not treated, these can lead to heart
disease.
 Option A: Receptors called baroreceptors monitor the blood pressure and
make changes to help maintain a fairly constant blood pressure when a
person changes positions or is doing other activities. The baroreceptors
become less sensitive with aging. This may explain why many older people
have orthostatic hypotension, a condition in which the blood pressure falls
when a person goes from lying or sitting to standing. This causes dizziness
because there is less blood flow to the brain.

 Option B: The main artery from the heart (aorta) becomes thicker, stiffer,
and less flexible. This is probably related to changes in the connective
tissue of the blood vessel wall. This makes the blood pressure higher and
makes the heart work harder, which may lead to thickening of the heart
muscle (hypertrophy). The other arteries also thicken and stiffen. In general,
most older people have a moderate increase in blood pressure.
 Option C: The heart has a natural pacemaker system that controls the
heartbeat. Some of the pathways of this system may develop fibrous tissue
and fat deposits. The natural pacemaker (the SA node) loses some of its
cells. These changes may result in a slightly slower heart rate. A slight
increase in the size of the heart, especially the left ventricle occurs in some
people. The heart wall thickens, so the amount of blood that the chamber
can hold may actually decrease despite the increased overall heart size. The
heart may fill more slowly.
ADVERTISEMENTS
22. Question
Which of the following is the most common cause of dementia among elderly
persons?
o A. Parkinson‘s disease
o B. Multiple sclerosis
o C. Amyotrophic lateral sclerosis (Lou Gehrig‘s disease)
o D. Alzheimer’s disease
Incorrect
Correct Answer: D. Alzheimer’s disease
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. Alzheimer‘s is
the most common cause of dementia among older adults. Dementia is the loss of
cognitive functioning—thinking, remembering, and reasoning—and behavioral
abilities to such an extent that it interferes with a person‘s daily life and activities.

 Option A: Parkinson‘s disease is a neurologic disorder caused by lesions in
the extrapyramidal system and manifested by tremors, muscle rigidity,
hypokinesia, dysphagia, and dysphonia. Parkinson‘s disease is a
neurodegenerative disorder that mostly presents in later life with
generalized slowing of movements (bradykinesia) and at least one other
symptom of resting tremor or rigidity. Other associated features are a loss
of smell, sleep dysfunction, mood disorders, excess salivation, constipation,
and excessive periodic limb movements in sleep (REM behavior disorder).
 Option B: 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. Multiple sclerosis (MS) is
a chronic autoimmune disease of the central nervous system (CNS)
characterized by inflammation, demyelination, gliosis, and neuronal loss.
Pathologically, perivascular lymphocytic infiltrates, and macrophages
produce degradation of myelin sheaths that surround neurons.
 Option C: 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. Amyotrophic lateral
sclerosis (ALS), also known as ―Lou Gehrig‘s disease,‖ is a
neurodegenerative disease of the motor neurons. No single etiology has
been proven; rather, multiple pathways (both heritable and sporadic) have
been shown to result in unmistakably similar disease entities. ALS
necessarily affects both upper and lower motor neurons with variable
patterns of onset, most commonly beginning with signs of lower motor
neuron degeneration within proximal limbs.
ADVERTISEMENTS
23. Question
The nurse‘s most important legal responsibility after a patient‘s death in a
hospital is:
o A. Obtaining a consent of an autopsy.
o B. Notifying the coroner or medical examiner.
o C. Labeling the corpse appropriately.

o D. Ensuring that the attending physician issues the death certification.
Incorrect
Correct Answer: C. Labeling the corpse appropriately.
The nurse is legally responsible for labeling the corpse when death occurs in the
hospital. After a person dies it is important to give the family the time that they
need with the body. Some family members might like to lie in bed with their
loved one who has died, while others might like to be involved with washing the
body. Others may not want to be there at all. Washing the body is particularly
important in paediatric palliative care, as often parents feel it is a special ritual to
have washed their baby after they are born, and it is the same after they die. It is
important to discuss rigor mortis with families as people are often unaware of
this.
 Option A: She may be involved in obtaining consent for an autopsy. There
are considerations regarding care and preparation of the body after
someone dies. Traditionally this task was performed by families, but
nowadays much of the preparation of a body is done by nursing staff or
undertakers. The required procedures are often included in an
organizations‘ procedures manual or there may be local requirements
regarding the preparation of a body.
 Option B: The nurse may be responsible for notifying the coroner or
medical examiner of a patient‘s death; however, she is not legally
responsible for performing these functions. Depending on the location of
the death, the nurse would contact the medical examiner to notify them of
the death, as well as the physician and other clinicians who were involved
with the patient. The nurse can also contact the funeral home for the family
as requested.
 Option D: The attending physician may need information from the nurse
to complete the death certificate, but he is responsible for issuing it. A
doctor must certify the death. This involves completing a medical
certificate of the cause of death and stating what the cause of death was.
This should happen as soon as possible. If there are any unexpected or
suspicious circumstances, or if the cause of death is not known, the doctor
may not be able to issue a death certificate without talking to the coroner
(England, Wales, and Northern Ireland) or procurator fiscal (Scotland). The
doctor completing the certificate may wish to talk to you as part of their
standard checks.

ADVERTISEMENTS
24. Question
Before rigor mortis occurs, the nurse is responsible for:
o A. Providing a complete bath and dressing change.
o B. Placing one pillow under the body’s head and shoulders.
o C. Removing the body‘s clothing and wrapping the body in a shroud.
o D. Allowing the body to relax normally.

Incorrect
Correct Answer: B. Placing one pillow under the body’s head and shoulders.
The nurse must place a pillow under the deceased person‘s head and shoulders
to prevent blood from settling in the face and discoloring it. A body undergoes
complex and intricate changes after death. These post mortem changes depend
on a diverse range of variables. Factors such as the ambient temperature, season,
and geographical location at which the body is found, the fat content of the
body, sepsis/injuries, intoxication, presence of clothes/insulation over the body,
etc. determine the rate at which post-mortem changes occur in a cadaver.
 Option A: She is required to bathe only soiled areas of the body since the
mortician will wash the entire body. Changes that occur to a body after
death are a result of complex physicochemical and environmental
processes. They are affected by factors within the cadaver and outside it.
These factors affect the onset and either increase the rate of post-mortem
changes or retard it. Factors that hasten the rate of post mortem changes
include hot and humid climate, presence of body fat, open injuries on the
body, sepsis or infection, and the location of the cadaver in the open.
 Option C: Before wrapping the body in a shroud, the nurse places a clean
gown on the body and closes the eyes and mouth. Rigor Mortis appears in
1 to 2 hours after death, is completely formed 12 hours after death, is
sustained for the next 12 hours, and vanishes over the next 12 hours,
sometimes referred to as the ‗march of rigor.‘
 Option D: Rigor mortis appears rapidly in children and old aged
individuals, in cases of persons dying of diseases or conditions involving
great exhaustion such as cholera, or due to convulsions as in cases of

strychnine poisoning. In such cases, the rigor disappears early as well. The
effect of rigor on individual muscles can be of additional significance. The
rigor of erector pilae muscles may cause elevation of hair leading to the
pimpled appearance of the skin.
ADVERTISEMENTS
25. Question
When a patient in the terminal stages of lung cancer begins to exhibit loss of
consciousness, a major nursing priority is to:
o A. Protect the patient from injury.
o B. Insert an airway.
o C. Elevate the head of the bed.
o D. Withdraw all pain medications.

Incorrect
Correct Answer: A. Protect the patient from injury
Ensuring the patient‘s safety is the most essential action at this time. This phase is
different for each patient, and the needs may differ for each patient and family,
but it is vital for healthcare providers to provide care and support in a way that
respects the patient‘s dignity and autonomous wishes.
 Option B: The vast majority of patients who experience a natural death,
meaning no medical, life-saving interventions to counter the process,
follow a stereotypical pattern of signs and symptoms in the time leading
up to death. This time frame is often referred to as ―actively dying‖ or
―imminent death.‖ It is important for healthcare providers to be familiar
with this process, not only so they know what to expect when providing
direct care to patients during this time, but also so they can guide the
family in understanding what to expect during this process and providing
support as needed.
 Option C: The self-determination of the patient with capacity must be
respected. When the patient can make their own choices, their autonomy
must be upheld. It is not the role of the provider to impart their values and
beliefs onto patients. Patients‘ families may experience anticipatory grief

and have a hard time fully handling the current situation, and they may
want to push their personal choices for the situation instead of respecting
their loved one‘s wishes and choices.
 Option D: The primary goal in treatment for patients is alleviating
suffering. Hospice care and palliative care are often confused. Hospice care
is the term given to the care provided when a patient is given a prognosis
of death within 6 months, and they do not pursue curative treatments.
They focus on improving the quality of life which can mean many things.
Palliative care can be incorporated into the plan of care at any time for any
patient who is experiencing suffering and wants to ease that suffering
without directly treating the cause of that suffering.
ADVERTISEMENTS
26. Question
Which element in the circular chain of infection can be eliminated by preserving
skin integrity?
o A. Host
o B. Reservoir
o C. Mode of transmission
o D. Portal of entry
Incorrect
Correct Answer: D. Portal of entry
In the circular chain of infection, pathogens must be able to leave their reservoir
and be transmitted to a susceptible host through a portal of entry, such as
broken skin. The portal of entry refers to the manner in which a pathogen enters
a susceptible host. The portal of entry must provide access to tissues in which the
pathogen can multiply or a toxin can act. Often, infectious agents use the same
portal to enter a new host that they used to exit the source host.
 Option A: The final link in the chain of infection is a susceptible host.
Susceptibility of a host depends on genetic or constitutional factors,
specific immunity, and nonspecific factors that affect an individual‘s ability

to resist infection or to limit pathogenicity. An individual‘s genetic makeup
may either increase or decrease susceptibility.
 Option B: The reservoir of an infectious agent is the habitat in which the
agent normally lives, grows, and multiplies. Reservoirs include humans,
animals, and the environment. The reservoir may or may not be the source
from which an agent is transferred to a host.
 Option C: An infectious agent may be transmitted from its natural
reservoir to a susceptible host in different ways. There are different
classifications for modes of transmission. In direct transmission, an
infectious agent is transferred from a reservoir to a susceptible host by
direct contact or droplet spread. Indirect transmission refers to the transfer
of an infectious agent from a reservoir to a host by suspended air particles,
inanimate objects (vehicles), or animate intermediaries (vectors).
ADVERTISEMENTS
27. Question
Which of the following will probably result in a break in sterile technique for
respiratory isolation?
o A. Opening the patient‘s window to the outside environment.
o B. Turning on the patient‘s room ventilator.
o C. Opening the door of the patient’s room leading into the hospital
corridor.
o D. Failing to wear gloves when administering a bed bath.

Incorrect
Correct Answer: C. Opening the door of the patient’s room leading into the
hospital corridor.
Respiratory isolation, like strict isolation, requires that the door to the door
patient‘s room remain closed. Appropriate patient placement is a significant
component of isolation precautions. A private room is important to prevent
direct- or indirect-contact transmission when the source patient has poor
hygienic habits, contaminates the environment, or cannot be expected to assist in

maintaining infection control precautions to limit transmission of microorganisms
(ie, infants, children, and patients with altered mental status).
 Option A: Opening the patient‘s window is acceptable because the room
needs to be well-ventilated. A private room with appropriate air handling
and ventilation is particularly important for reducing the risk of
transmission of microorganisms from a source patient to susceptible
patients and other persons in hospitals when the microorganism is spread
by airborne transmission. Some hospitals use an isolation room with an
anteroom as an extra measure of precaution to prevent airborne
transmission.
 Option B: The patient‘s room should be well ventilated, so turning on the
ventilator is desirable.
 Option D: The nurse does not need to wear gloves for respiratory isolation,
but good handwashing is important for all types of isolation. Wearing
gloves does not replace the need for handwashing, because gloves may
have small, apparent defects or may be torn during use, and hands can
become contaminated during removal of gloves. Failure to change gloves
between patient contacts is an infection control hazard.
ADVERTISEMENTS
28. Question
Which of the following patients is at greater risk for contracting an infection?
o A. A postoperative patient who has undergone orthopedic surgery.
o B. A patient receiving broad-spectrum antibiotics.
o C. A patient with leukopenia.
o D. A newly diagnosed diabetic patient.

Incorrect
Correct Answer: C. A patient with leukopenia.
Leukopenia is a decreased number of leukocytes (white blood cells), which are
important in resisting infection. Leukopenia is a condition where a person has a
reduced number of white blood cells. This increases their risk of infections. A
person‘s blood is made up of many different types of blood cells. White blood

cells, also known as leukocytes, help to fight off infection. Leukocytes are a vital
part of the immune system.
 Option A: Surgical site infections (SSI) following total hip arthroplasty
(THA) have a significantly adverse impact on patient outcomes and pose a
great challenge to the treating surgeon. Therefore, timely recognition of
those patients at risk for this complication is very important, as it allows for
adopting measures to reduce this risk.
 Option B: Antibiotic-mediated cell death, however, is a complex process
that begins with the physical interaction between a drug molecule and its
bacterial-specific target, and involves alterations to the affected bacterium
at the biochemical, molecular and ultrastructural levels. Antibiotic-induced
cell death has been associated with the formation of double-stranded DNA
breaks following treatment with DNA gyrase inhibitors, with the arrest of
DNA-dependent RNA synthesis following treatment with rifamycins, with
cell envelope damage and loss of structural integrity following treatment
with cell-wall synthesis inhibitors, and with cellular energetics, ribosome
binding and protein mistranslation following treatment with protein
synthesis inhibitors.
 Option D: People who have had diabetes for a long time may have
peripheral nerve damage and reduced blood flow to their extremities,
which increases the chance for infection. The high sugar levels in your
blood and tissues allow bacteria to grow and allow infections to develop
more quickly.
ADVERTISEMENTS
29. Question
Effective handwashing requires the use of:
o A. Soap or detergent to promote emulsification.
o B. Hot water to destroy bacteria.
o C. A disinfectant to increase surface tension.

Incorrect

Correct Answer: A. Soap or detergent to promote emulsification.
Soaps and detergents are used to help remove bacteria because of their ability to
lower the surface tension of water and act as emulsifying agents. Handwashing is
the act of washing hands with soap, either antimicrobial or non antimicrobial, and
water for at least 15 to 20 seconds with a vigorous motion to cause friction
making sure to include all surfaces of the hands and fingers.
 Option B: Hot water may lead to skin irritation or burns. Warm water
would be enough for handwashing. Healthcare professionals caring for
high-risk patients that are immunocompromised must take great care in
performing proper hand hygiene as this patient population is at high risk
for opportunistic infections
 Option C: Handwashing with soap and water will remove nearly all
transient gram-negative bacilli in 10 seconds while chlorhexidine may be
more appropriate than soap and water for the removal of transient gram-
positive bacteria. According to the CDC, established guidelines recommend
that agents used for surgical hand scrubs should reduce microorganisms
on intact skin in a substantial manner, contain a nonirritating antimicrobial
preparation, have broad-spectrum activity, and be fast-acting and
persistent.
 Option D: Hand hygiene practices are paramount in reducing cross-
transmission of microorganisms, hospital-acquired infections and the risk
of occupational exposure to infectious diseases. According to the CDC,
understanding the importance of hand hygiene and its impact on the
pathogenic spread of microorganisms is best understood when one
understands the anatomy of the skin. The skin serves as a protective barrier
against water loss, heat loss, microorganisms, and other environmental
hazards.
ADVERTISEMENTS
30. Question
After routine patient contact, handwashing should last at least:
o A. 30 seconds
o B. 1 minute

o C. 2 minutes
o D. 3 minutes
Incorrect
Correct Answer: A. 30 seconds
Depending on the degree of exposure to pathogens, hand washing may last from
10 seconds to 4 minutes. After routine patient contact, hand washing for 30
seconds effectively minimizes the risk of pathogen transmission. According to the
Centers for Disease Control and Prevention (CDC), hand hygiene is the single
most important practice in the reduction of the transmission of infection in the
healthcare setting.
 Option B: According to the CDC, hand hygiene encompasses the cleansing
of your hands with soap and water, antiseptic hand washes, antiseptic hand
rubs such as alcohol-based hand sanitizers, foams or gels, or surgical hand
antisepsis. Indications for handwashing include when hands are visibly
after restroom use.
 Option C: Handwashing is the act of washing hands with soap, either
antimicrobial or non-antimicrobial, and water for at least 15 to 20 seconds
with a vigorous motion to cause friction making sure to include all surfaces
of the hands and fingers. Hand rubbing with an alcohol-based rub should
not be performed when the hands are visibly soiled. In this case, the CDC
and WHO guidelines recommend that handwashing with soap and water
 Option D: Alcohol-based hand sanitizers are the recommended product
for hand hygiene when hands are not visibly soiled. Apply alcohol-based
products per manufacturer guidelines on dispensing of the product.
Typically, 3 mL to 5 mL in the palm, rubbing vigorously, ensuring all
surfaces on both hands get covered, about 20 seconds is required for all
surfaces to dry completely.
ADVERTISEMENTS
31. Question
Which of the following procedures always requires surgical asepsis?
o A. Vaginal instillation of conjugated estrogen

o B. Urinary catheterization
o C. Nasogastric tube insertion
o D. Colostomy irrigation
Incorrect
Correct Answer: B. Urinary catheterization
The urinary system is normally free of microorganisms except at the urinary
meatus. Any procedure that involves entering this system must use surgically
aseptic measures to maintain a bacteria-free state. Guidelines from The Centers
for Disease Control and Prevention (CDC) and The European Association of
Urology Nurses (EAUN) recommend ‗sterile technique‘ when inserting an
indwelling urinary catheter. Insertion of indwelling urinary catheters should be
performed in a way that minimizes the risk of introducing bacteria to the urinary
bladder.
 Option A: Conjugated estrogens is a medicine that contains a mixture of
estrogen hormones. Conjugated estrogen vaginal cream is used to treat
changes in and around the vagina (such as vaginal dryness, itching, and
burning) caused by low estrogen levels or menopause. It is also used to
treat vaginal pain during sexual intercourse. This medicine is to be used
only in the vagina. Use at bedtime unless your doctor tells otherwise.
 Option C: Nasogastric (NG) intubation is a procedure in which a thin,
plastic tube is inserted into the nostril, toward the esophagus, and down
into the stomach. Once an NG tube is properly placed and secured,
healthcare providers such as the nurses can deliver food and medicine
directly to the stomach or obtain substances from it. Clean, not sterile,
technique is necessary because the gastrointestinal (GI) tract is not sterile.
 Option D: Sterile supplies are used in acute care with a fresh post-surgical
urostomy. A patient in the community may not use sterile supplies, but
strict adherence to proper hand hygiene is required to prevent infections
of the bladder, kidney, or urinary tract. Never place anything inside the
stoma.
ADVERTISEMENTS
32. Question

Sterile technique is used whenever:
o A. Strict isolation is required
o B. Terminal disinfection is performed
o C. Invasive procedures are performed
o D. Protective isolation is necessary

Incorrect
Correct Answer: C. Invasive procedures are performed
All invasive procedures, including surgery, catheter insertion, and administration
of parenteral therapy, require a sterile technique to maintain a sterile
environment. All equipment must be sterile, and the nurse and the physician
must wear sterile gloves and maintain surgical asepsis. In the operating room, the
nurse and physician are required to wear sterile gowns, gloves, masks, hair
covers, and shoe covers for all invasive procedures.
 Option A: Strict isolation requires the use of clean gloves, masks, gowns,
and equipment to prevent the transmission of highly communicable
diseases by contact or by airborne routes. Strict isolation is used for
diseases spread through the air and in some cases by contact. Patients
must be placed in isolation to prevent the spread of infectious diseases.
Those who are kept in strict isolation are often kept in a special room at
the facility designed for that purpose.
 Option B: Terminal disinfection is the disinfection of all contaminated
supplies and equipment after a patient has been discharged to prepare
them for reuse by another patient. Terminal disinfection has the objective
of preparing complete rooms or areas for subsequent patients or residents
for them to be treated or cared for without the risk of acquiring an
infection. This disinfection measure is applied in rooms and areas where an
infected or colonized patient/resident has been cared for or treated.
Depending on the existing disease or type of pathogen all near-patient
surfaces/objects or all accessible surfaces (e.g. also floors or walls) are to be
disinfected.
 Option D: The purpose of protective (reverse)isolation is to prevent a
person with seriously impaired resistance from coming into contact with
potentially pathogenic organisms. Protective Isolation aims to protect an
immunocompromised patient who is at high risk of acquiring micro-

organisms from either the environment or from other patients, staff, or
visitors.
ADVERTISEMENTS
33. Question
Which of the following constitutes a break in sterile technique while preparing a
sterile field for a dressing change?
o A. Using sterile forceps, rather than sterile gloves, to handle a sterile item.
o B. Touching the outside wrapper of sterilized material without sterile gloves.
o C. Placing a sterile object on the edge of the sterile field.
o D. Pouring out a small amount of solution (15 to 30 ml) before pouring the
solution into a sterile container.
Incorrect
Correct Answer: C. Placing a sterile object on the edge of the sterile field.
The edges of a sterile field are considered contaminated. When sterile items are
allowed to come in contact with the edges of the field, the sterile items also
become contaminated. The sterile field should be prepared as close as possible
to the time of use.2 The sterility of supplies used during a surgical procedure can
be affected by the events taking place within the operating room, and the length
of time the items have been exposed to the environment.
 Option A: Under no circumstances should sterile and nonsterile
items/areas be mixed since one contaminates the other.4 Sterilization
provides the highest level of assurance that all instruments, sutures, fluids,
supplies, and drapes are void of microorganisms.2 The sterility of a
package is determined by events, not by time. To ensure sterility, all sterile
items need to be inspected for package integrity and sterilization process
indicators, such as indicator tape and internal chemical indicators, prior to
introduction onto the sterile field. If a package has been compromised, it
should be considered contaminated and not be used.
 Option B: When opening wrapped supplies, the nonsterile person should
open the top wrapper flap away from them first, then open the flaps to
each side. The last wrapper flap is pulled toward the nonsterile person

opening the package. This technique of opening a wrapped package
ensures that the nonsterile person does not reach over the sterile item
inside. All wrapper edges should be secured to prevent flipping the
wrapper and contaminating the contents of the sterile package or field.
 Option D: Only the top rim of the bottle top and bottle contents are
considered sterile once the cap has been removed from the bottle.
Therefore, when sterile fluids are dispensed, the entire contents of the
bottle must be poured or the fluid remaining in the bottle discarded. When
solutions are poured onto the sterile field, they should be poured slowly to
prevent contamination and fluid strikethrough from splashing.
ADVERTISEMENTS
34. Question
A natural body defense that plays an active role in preventing infection is:
o A. Yawning
o B. Body hair
o C. Hiccupping
o D. Rapid eye movements

Incorrect
Correct Answer: B. Body hair
Hair on or within body areas, such as the nose, traps and holds particles that
contain microorganisms. One of the body‘s most important physical barriers is
the skin barrier, which is composed of three layers of closely packed cells. The
thin upper layer is called the epidermis. A second, thicker layer, called the dermis,
contains hair follicles, sweat glands, nerves, and blood vessels. A layer of fatty
tissue called the hypodermis lies beneath the dermis and contains blood and
lymph vessels
 Option A: Evidence suggests that drowsiness is the most common
stimulus of yawn. Boredom occurs when the main source of stimulation in
a person‘s environment is no longer able to sustain their attention. This
induces drowsiness by stimulating the sleep generating system. At this

moment, the mind has to make an effort to maintain contact with the
external environment.
 Option C: Hiccupping does not prevent microorganisms from entering or
leaving the body. As they breathe out, the diaphragm pushes up to expel
the air. When a person has hiccups, the diaphragm contracts and pulls
down, drawing in air between breaths. Immediately after this, the windpipe
closes for a moment to prevent more air from entering the lungs. Hiccups
often come after eating or drinking too much or too quickly.
 Option D: Rapid eye movement marks the stage of sleep during which
dreaming occurs. Rapid eye movement (REM) is the stage of sleep
characterized by rapid saccadic movements of the eyes. During this stage,
the activity of the brain‘s neurons is quite similar to that during waking
hours. Most of the vividly recalled dreams occur during REM sleep.
ADVERTISEMENTS
35. Question
All of the following statement are true about donning sterile gloves except:
o A. The first glove should be picked up by grasping the inside of the cuff.
o B. The second glove should be picked up by inserting the gloved fingers

under the cuff outside the glove.
o C. The gloves should be adjusted by sliding the gloved fingers under the
sterile cuff and pulling the glove over the wrist.
o D. The inside of the glove is considered sterile.

Incorrect
Correct Answer: D. The inside of the glove is considered sterile.
The inside of the glove is always considered to be clean, but not sterile. Sterile
gloves are gloves that are free from all microorganisms. They are required for any
invasive procedure and when contact with any sterile site, tissue, or body cavity is
expected (PIDAC, 2012).
 Option A: Pick up the glove for the dominant hand by touching the inside
cuff of the glove. Do not touch the outside of the glove. Pull the glove
completely over the dominant hand. Sterile gloves help prevent surgical

site infections and reduce the risk of exposure to blood and body fluid
pathogens for the health care worker. Studies have shown that 18% to 35%
of all sterile gloves have tiny holes after surgery, and up to 80% of the tiny
puncture sites go unnoticed by the surgeon (Kennedy, 2013).
 Option B: Insert gloved hand into the cuff of the remaining glove. Pull the
remaining glove on a non-dominant hand and insert fingers. Adjust gloves
if necessary. Double gloving is known to reduce the risk of exposure and
has become common practice, but does not reduce the risk of cross-
contamination after surgery (Kennedy, 2013).
 Option C: Once gloves are on, interlock gloved hands and keep at least six
inches away from clothing, keeping hands above waist level and below the
shoulders. To remove gloves, grasp the outside of the cuff or palm of the
glove and gently pull the glove off, turning it inside out and placing it into
a gloved hand.
ADVERTISEMENTS
36. Question
When removing a contaminated gown, the nurse should be careful that the first
thing she touches is the:
o A. Waist tie and necktie at the back of the gown
o B. Waist tie in front of the gown
o C. Cuffs of the gown
o D. Inside of the gown

Incorrect
Correct Answer: A. Waist tie and necktie at the back of the gown
The back of the gown is considered clean, the front is contaminated. So, after
removing gloves and washing hands, the nurse should untie the back of the
gown; slowly move backward away from the gown, holding the inside of the
gown and keeping the edges off the floor; turn and fold the gown inside out;
discard it in a contaminated linen container; then wash her hands again.
 Option B: First, release the tie, then grasp the gown at the hip area, and
pull the gown down and away from the sides of the body. Once the gown

is off the shoulders, pull one arm at a time from the sleeves of the gown so
that the gown arms are bunched at the wrists. Then, roll the exposed side
of the gown inward until it‘s a tight ball. Dispose of it.
 Option C: Following the doffing protocol will minimize the risk for disease
transmission, so it‘s very important that you understand all the steps. A
Trained Observer will help you with the process. Gown front and sleeves
are contaminated!
 Option D: Grasp the gown in the front and pull away from your body so
that the ties break, touching the outside of the gown only with gloved
hands. While removing the gown, fold or roll the gown inside-out into a
bundle
ADVERTISEMENTS
37. Question
Which of the following nursing interventions is considered the most effective
form for universal precautions?
o A. Cap all used needles before removing them from their syringes.
o B. Discard all used uncapped needles and syringes in an impenetrable

protective container.
o C. Wear gloves when administering IM injections.
o D. Follow enteric precautions.

Incorrect
Correct Answer: B. Discard all used uncapped needles and syringes in an
impenetrable protective container.
According to the Centers for Disease Control (CDC), blood-to-blood contact
occurs most commonly when a health care worker attempts to cap a used needle.
Universal precautions are a standard set of guidelines aimed at preventing the
transmission of bloodborne pathogens from exposure to blood and other
potentially infectious materials (OPIM).
 Option A: Therefore, used needles should never be recapped; instead they
should be inserted in a specially designed puncture resistant, labeled
container. In 1987, the CDC introduced another set of guidelines termed

Body Substance Isolation. These guidelines advocated the avoidance of
direct physical contact with ―all moist and potentially infectious body
substances,‖ even if blood is not visible. A limitation of this guideline was
that it emphasized handwashing after removal of gloves only if the hands
were visibly soiled.
 Option C: Wearing gloves is not always necessary when administering an
I.M. injection. Must be worn when touching blood, body fluids, secretions,
excretions, mucous membranes, or non-intact skin. Change when there is
contact with potentially infected material in the same patient to avoid
cross-contamination. Remove before touching surfaces and clean items.
Wearing gloves does not mitigate the need for proper hand hygiene.
 Option D: Enteric precautions prevent the transfer of pathogens via feces.
Universal precautions do not apply to sputum, feces, sweat, vomit, tears,
urine, or nasal secretions unless they are visibly contaminated with blood
because their transmission of Hepatitis B or HIV is extremely low or non-
existent.
ADVERTISEMENTS
38. Question
All of the following measures are recommended to prevent pressure
ulcers except:
o A. Massaging the reddened area with lotion.
o B. Using a water or air mattress.
o C. Adhering to a schedule for positioning and turning.
o D. Providing meticulous skin care.

Incorrect
Correct Answer: A. Massaging the reddened area with lotion
Nurses and other healthcare professionals previously believed that massaging a
reddened area with lotion would promote venous return and reduce edema to
the area. However, research has shown that massage only increases the likelihood
of cellular ischemia and necrosis to the area.

 Option B: In patients with a high risk of developing pressure injuries,
support surfaces to alleviate pressure can be used. This can include higher-
speciation foam mattresses, medical-grade sheepskins, continuous low-
pressure supports, alternating-pressure devices, low air loss therapy;
however, the effectiveness of these devices compared to other surfaces in
the treatment of existing pressure injuries has not been conclusively
established.
 Option C: General care for pressure injuries can include redistribution of
pressure with the use of support surfaces and changes in positioning.
Redistribution of pressure and appropriate patient positioning is required
to prevent the development and worsening of pressure injuries, as these
methods can reduce force from friction and shear.
 Option D: Wound care, including maintaining a clean environment,
debridement, application of dressings, monitoring, and various adjunctive
therapies, is generally advised to facilitate the healing of pressure injuries.
Options for treatment can be guided by the stage of the pressure injury.
Stage 1 pressure injuries can be covered with transparent film dressings as
needed.
ADVERTISEMENTS
39. Question
Which of the following blood tests should be performed before a blood
transfusion?
o A. Prothrombin and coagulation time
o B. Blood typing and cross-matching
o C. Bleeding and clotting time
o D. Complete blood count (CBC) and electrolyte levels

Incorrect
Correct Answer: B. Blood typing and cross-matching
Before a blood transfusion is performed, the blood of the donor and recipient
must be checked for compatibility. This is done by blood typing (a test that
determines a person‘s blood type) and cross-matching (a procedure that

determines the compatibility of the donor‘s and recipient‘s blood after the blood
types have been matched). If the blood specimens are incompatible, hemolysis
and antigen-antibody reactions will occur. If the donor is eligible to donate, the
donated blood is tested for blood type (ABO group) and Rh type (positive or
negative). This is to make sure that patients receive blood that matches their
blood type. Before transfusion, the donor and blood unit are also tested for
certain proteins (antibodies) that may cause adverse reactions in a person
receiving a blood transfusion.
 Option A: A prothrombin time (PT) is a test used to help detect and
diagnose a bleeding disorder or excessive clotting disorder. A PT measures
the number of seconds it takes for a clot to form in your sample of blood
after substances (reagents) are added. The PT is often performed along
with a partial thromboplastin time (PTT) and together they assess the
amount and function of proteins called coagulation factors that are an
important part of proper blood clot formation. The coagulation time is a
measurement of the intrinsic power of the blood to convert fibrinogen to
fibrin. It is an empirical test no matter how performed, and therefore in
order to be reliable requires that the test be done on venous blood under
strictly controlled conditions.
 Option C: Bleeding time is a laboratory test to assess platelet function and
the body‘s ability to form a clot. The test involves making a puncture
wound in a superficial area of the skin and monitoring the time needed for
bleeding to stop (ie, the bleeding site turns ―glassy‖). The expected range
for clotting time is 4-10 mins. This test measures the time taken for blood
vessel constriction and platelet plug formation to occur. No clot is allowed
to form, so that the arrest of bleeding depends exclusively on blood vessel
constriction and platelet action.
 Option D: The complete blood count (CBC) is a group of tests that
evaluate the cells that circulate in the blood, including red blood cells
(RBCs), white blood cells (WBCs), and platelets (PLTs). The CBC can evaluate
your overall health and detect a variety of diseases and conditions, such as
infections, anemia, and leukemia.
ADVERTISEMENTS
40. Question

The primary purpose of a platelet count is to evaluate the:
o A. Potential for clot formation
o B. Potential for bleeding
o C. Presence of an antigen-antibody response
o D. Presence of cardiac enzymes

Incorrect
Correct Answer: A. Potential for clot formation
Platelets are disk-shaped cells that are essential for blood coagulation. A platelet
count determines the number of thrombocytes in blood available for promoting
hemostasis and assisting with blood coagulation after injury. Platelets, also called
thrombocytes, are tiny fragments of cells that are essential for normal blood
clotting. They are formed from very large cells called megakaryocytes in the bone
marrow and are released into the blood to circulate. The platelet count is a test
that determines the number of platelets in your sample of blood.
 Option B: It also is used to evaluate the patient‘s potential for bleeding;
however, this is not its primary purpose. The normal count ranges from
150,000 to 350,000/mm3. A count of 100,000/mm3 or less indicates a
potential for bleeding; count of less than 20,000/mm3 is associated with
spontaneous bleeding.
 Option C: Platelets, the smallest of our blood cells, can only be seen under
a microscope. They‘re literally shaped like small plates in their inactive
form. A blood vessel will send out a signal when it becomes damaged.
When platelets receive that signal, they‘ll respond by traveling to the area
and transforming into their ―active‖ formation. To make contact with the
broken blood vessel, platelets grow long tentacles and then resemble a
spider or an octopus.
 Option D: If you have too many platelets, it can increase your risk for
clotting. But often your cardiovascular risk has more to do with platelet
function than platelet number. For example, you could have a healthy
number of platelets, but if they‘re sticking together too much it can
increase your chance of having a heart attack or stroke.
ADVERTISEMENTS

41. Question
Which of the following white blood cell (WBC) counts clearly indicates
leukocytosis?
o A. 4,500/mm³
o B. 7,000/mm³
o C. 10,000/mm³
o D. 25,000/mm³
Incorrect
Correct Answer: D. 25,000/mm³
Leukocytosis is any transient increase in the number of white blood cells
(leukocytes) in the blood. The normal number of WBCs in the blood is 4,500 to
11,000 WBCs per microliter (4.5 to 11.0 × 109/L). Normal value ranges may vary
slightly among different labs. Thus, a count of 25,000/mm3 indicates leukocytosis.
 Option A: A WBC count is a blood test to measure the number of white
blood cells (WBCs) in the blood. WBCs are also called leukocytes. They help
fight infections. A higher than normal WBC count is called leukocytosis.
Leukocytosis is the broad term for an elevated white blood cell (WBC)
count, typically above 11.0×10^9/L, on a peripheral blood smear
collection. The exact value of WBC elevation can vary slightly between
laboratories depending on their ‗upper limits of normal‘ as identified by
their reference ranges.
 Option B: The WBC value represents the sum-total of white blood cell
subtypes, including neutrophils, eosinophils, lymphocytes, monocytes,
atypical leukocytes that are not normally present on a peripheral blood
smear (e.g., lymphoblasts), or any combination of these. The clinician
should properly characterize the leukocytosis and determine if further
evaluation and workup are indicated.
 Option C: Leukocytosis can occur acutely and often transiently or
chronically, either in response to an inflammatory stressor/cytokine
cascade or as part of an autonomous myeloproliferative neoplasm.
Neutrophilia is the most common presentation, but clinicians should be
aware of the other cell lines that can be involved in acute and chronic
presentations. A detailed history, physical examination, medication

reconciliation, full evaluation of a CBC with differential, and comparison to
prior CBCs can help clinicians elucidate the underlying cause of
leukocytosis and guide appropriate treatment.
ADVERTISEMENTS
42. Question
After 5 days of diuretic therapy with 20mg of furosemide (Lasix) daily, a patient
begins to exhibit fatigue, muscle cramping, and muscle weakness. These
symptoms probably indicate that the patient is experiencing:
o A. Hypokalemia
o B. Hyperkalemia
o C. Anorexia
o D. Dysphagia
Incorrect
Correct Answer: A. Hypokalemia
Fatigue, muscle cramping, and muscle weaknesses are symptoms of hypokalemia
(an inadequate potassium level), which is a potential side effect of diuretic
therapy. The physician usually orders supplemental potassium to prevent
hypokalemia in patients receiving diuretics. Hypokalemia is more prevalent than
hyperkalemia; however, most cases are mild. Although there is a slight variation,
an acceptable lower limit for normal serum potassium is 3.5 mmol/L. Severity is
categorized as mild when the serum potassium level is 3 to 3.4 mmol/L, moderate
when the serum potassium level is 2.5 to 3 mmol/L, and severe when the serum
potassium level is less than 2.5 mmol/L.
 Option B: Hyperkalemia is defined as a serum or plasma potassium level
above the upper limits of normal, usually greater than 5.0 mEq/L to 5.5
mEq/L. While mild hyperkalemia is usually asymptomatic, high levels of
potassium may cause life-threatening cardiac arrhythmias, muscle
weakness or paralysis. Symptoms usually develop at levels higher levels, 6.5
mEq/L to 7 mEq/L, but the rate of change is more important than the
numerical value.

 Option C: Anorexia is another symptom of hypokalemia. The most
frequent electrolyte imbalances seen in anorexia are hyponatremia (a low
concentration of sodium ions in the bloodstream) and hypokalemia (a low
concentration of potassium ions). A low potassium level has many causes
but usually results from vomiting, diarrhea, adrenal gland disorders, or use
of diuretics. A low potassium level can make muscles feel weak, cramp,
twitch or even become paralyzed, and abnormal heart rhythms may
develop.
 Option D: Dysphagia means difficulty swallowing. Dysphagia is the medical
term for swallowing difficulties. Some people with dysphagia have
problems swallowing certain foods or liquids, while others can‘t swallow at
all. Other signs of dysphagia include: coughing or choking when eating or
drinking. bringing food back up, sometimes through the nose.
ADVERTISEMENTS
43. Question
Which of the following statements about chest X-rays is not true?
o A. No contradictions exist for this test.
o B. Before the procedure, the patient should remove all jewelry, metallic
objects, and buttons above the waist.
o C. A signed consent is not required.
o D. Eating, drinking, and medications are allowed before this test.

Incorrect
Correct Answer: A. No contradictions exist for this test
Pregnancy or suspected pregnancy is the only contraindication for a chest X-ray.
However, if a chest X-ray is necessary, the patient can wear a lead apron to
protect the pelvic region from radiation. X-rays during pregnancy don‘t increase
the risk of miscarriage or cause problems in the unborn baby, such as birth
defects and physical or mental development problems. However, if a pregnant
woman has an X-ray and is exposed to radiation there is a very small increased
risk that the baby may go on to develop cancer in childhood. This is why the dose
of radiation used in an X-ray is always as low as possible.

 Option B: Jewelry, metallic objects, and buttons would interfere with the X-
ray and thus should not be worn above the waist. Metal appears as a bright
area on an X-ray, blocking visibility of underlying structures. The reason
you‘re asked to remove metal is to give the radiologist an unobstructed
view of the area of interest. Basically, you remove metal because it blocks
anatomy.
 Option C: A signed consent is not required because a chest X-ray is not an
invasive examination. Consent is ensuring the patient is aware of the
purpose and nature of any procedure to be carried out. The radiographer
must ensure that the patient is fully aware of his/her options, including
alternatives, the right to refuse and the consequences of refusal.
 Option D: Eating, drinking, and medications are allowed because the X-ray
is of the chest, not the abdominal region. To create a radiograph, a patient
is positioned so that the part of the body being imaged is located between
an x-ray source and an x-ray detector. When the machine is turned on, x-
rays travel through the body and are absorbed in different amounts by
different tissues, depending on the radiological density of the tissues they
pass through.
ADVERTISEMENTS
44. Question
The most appropriate time for the nurse to obtain a sputum specimen for culture
is:
o A. Early in the morning
o B. After the patient eats a light breakfast
o C. After aerosol therapy
o D. After chest physiotherapy

Incorrect
Correct Answer: A. Early in the morning
Obtaining a sputum specimen early in this morning ensures an adequate supply
of bacteria for culturing and decreases the risk of contamination from food or
medication. A sputum culture is a test to detect and identify bacteria or fungi that

infect the lungs or breathing passages. Sputum is a thick fluid produced in the
lungs and in the adjacent airways. Normally, a fresh morning sample is preferred
for the bacteriological examination of sputum.
type of organism that may be causing an infection in your lungs or the
of mucus made in your lungs. If you have an infection or chronic illness
affecting the lungs or airways, it can make you cough up sputum.
 Option C: Sputum is not the same as spit or saliva. Sputum contains cells
from the immune system that help fight the bacteria, fungi, or other
foreign substances in your lungs or airways. The thickness of sputum helps
trap the foreign material. This allows cilia (tiny hairs) in the airways to push
it through the mouth and be coughed out.
 Option D: A sputum culture is often done with another test called a Gram
stain. A Gram stain is a test that checks for bacteria at the site of a
suspected infection or in body fluids such as blood or urine. It can help
identify the specific type of infection you may have.
ADVERTISEMENTS
45. Question
A patient with no known allergies is to receive penicillin every 6 hours. When
administering the medication, the nurse observes a fine rash on the patient‘s skin.
The most appropriate nursing action would be to:
o A. Withhold the moderation and notify the physician.
o B. Administer the medication and notify the physician.
o C. Administer the medication with an antihistamine.
o D. Apply cornstarch soaks to the rash.

Incorrect
Correct Answer: A. Withhold the moderation and notify the physician
Initial sensitivity to penicillin is commonly manifested by a skin rash, even in
individuals who have not been allergic to it previously. Because of the danger of

anaphylactic shock, the nurse should withhold the drug and notify the physician,
who may choose to substitute another drug.
 Option B: To determine if a patient has an IgE mediated penicillin allergy,
the only validated test currently available in the united states is penicillin
skin testing. A board-certified allergist should perform the test. It involves a
skin-prick with the application of the major and minor determinants as well
as a control. The area of skin is examined 15 minutes later. If a wheel of at
least 3 mm and concomitant erythema develop, the test is positive. The
test should not be performed if the reaction to penicillin was a severe non-
IgE mediated reaction.
 Option C: Administering an antihistamine is a dependent nursing
intervention that requires a written physician‘s order. Treatment for acute
IgE mediated reaction to penicillin depends on severity. Patients presenting
in acute anaphylaxis need to have immediate treatment with IM
epinephrine (1 mg/ml) 0.3 mg to 0.5 mg every 5 to 15 minutes until
resolution of symptoms. Adjunctive therapies include H1 and H2
antihistamines including diphenhydramine 25 mg to 50 mg intravenously
(IV) and ranitidine 50 mg IV, respectively.
 Option D: Although applying cornstarch to the rash may relieve
discomfort, it is not the nurse‘s top priority in such a potentially life-
threatening situation. Cutaneous symptoms are often the first and most
common finding of an allergic reaction, however, are absent in 10% to 20%
of patients experiencing an allergic reaction. Common cutaneous
symptoms are generalized urticaria, flushing, pruritus, and angioedema.
ADVERTISEMENTS
46. Question
All of the following nursing interventions are correct when using the Z-track
method of drug injection except:
o A. Prepare the injection site with alcohol.
o B. Use a needle that‘s at least 1‖ long.
o C. Aspirate for blood before injection.

o D. Rub the site vigorously after the injection to promote absorption.
Incorrect
Correct Answer: D. Rub the site vigorously after the injection to promote
absorption
The Z-track method is an I.M. injection technique in which the patient‘s skin is
pulled in such a way that the needle track is sealed off after the injection. This
procedure seals medication deep into the muscle, thereby minimizing skin
staining and irritation. Rubbing the injection site is contraindicated because it
may cause the medication to extravasate into the skin.
 Option A: Clean the injection site with an alcohol pad to minimize the
possibility of infection. Allow the area to air dry for a few minutes. The Z-
track method is not often recommended but can be particularly useful with
medication that must be absorbed by muscles to work. It also helps to
prevent the medication from seeping into the subcutaneous tissue and
ensures a full dosage.
 Option B: In an adult, the most commonly used needles are one inch or
one and a half inches long, and 22 to 25 gauge thick. Smaller needles are
typically used when injecting a child. Some medications are dark-colored
and can cause staining of the skin. If this is a side effect of the medication
you will be taking, the doctor may recommend using this technique to
prevent injection site discoloration or lesions.
 Option C: Use one hand to pull downward on your skin and fatty tissue.
Hold it firmly about an inch away (2.54 cm) from the muscle. On the other
hand, hold the needle at a 90-degree angle and insert it quickly and deeply
enough to penetrate your muscle. If there is no blood in the syringe, push
on the plunger to inject the medication slowly into the muscle.
ADVERTISEMENTS
47. Question
The correct method for determining the vastus lateralis site for I.M. injection is to:
o A. Locate the upper aspect of the upper outer quadrant of the buttock about
5 to 8 cm below the iliac crest.

o B. Palpate the lower edge of the acromion process and the midpoint lateral
aspect of the arm.
o C. Palpate a 1‖ circular area anterior to the umbilicus.
o D. Divide the area between the greater femoral trochanter and the
lateral femoral condyle into thirds, and select the middle third on the
anterior of the thigh.
Incorrect
Correct Answer: D. Divide the area between the greater femoral trochanter
and the lateral femoral condyle into thirds, and select the middle third on
the anterior of the thigh
The vastus lateralis, a long, thick muscle that extends the full length of the thigh,
is viewed by many clinicians as the site of choice for I.M. injections because it has
relatively few major nerves and blood vessels. The middle third of the muscle is
recommended as the injection site. The patient can be in a supine or sitting
position for an injection into this site.
 Option A: There are specific landmarks to be taken into consideration
while giving IM injections so as to avoid any neurovascular complications.
The heel of the opposing hand is placed in the greater trochanter, the
index finger in the anterior superior iliac spine, and the middle finger below
the iliac crest. The drug is injected in the triangle formed by the index,
middle finger, and the iliac crest
 Option B: The deltoid area is 2.5 to 5 cm below the acromion process.
Intramuscular injection is the method of installing medications into the
depth of the bulk of specifically selected muscles. The basis of this process
is that the bulky muscles have good vascularity, and therefore the injected
drug quickly reaches the systemic circulation and thereafter into the
specific region of action, bypassing the first-pass metabolism.
 Option C: The vastus lateralis is a common site for IM injection. The middle
third of the line joining the greater trochanter of the femur and the lateral
femoral condyle of the knee. It is one of the most common medical
procedures to be performed on an annual basis. However, there is still a
lack of uniform guidelines and an algorithm in giving IM among health
professionals across the world.
ADVERTISEMENTS

48. Question
The mid-deltoid injection site is seldom used for I.M. injections because it:
o A. Can accommodate only 1 ml or less of medication.
o B. Bruises too easily.
o C. Can be used only when the patient is lying down.
o D. Does not readily absorb parenteral medication.

Incorrect
Correct Answer: A. Can accommodate only 1 ml or less of medication
The mid-deltoid injection site can accommodate only 1 ml or less of medication
because of its size and location (on the deltoid muscle of the arm, close to the
brachial artery and radial nerve). It is becoming increasingly important for
clinicians to identify a safer intramuscular (IM) injection site in the deltoid muscle
because of possible complications following the vaccine administration of IM
injections.
 Option B: However, Cook reported that these 4 injection sites have the
potential to cause injury to the subdeltoid/subacromial bursa and/or
anterior branch of the axillary nerve with the arm in the anatomical
position. Additionally, we showed that the axillary nerve often runs near the
site 5 cm below the mid-acromion lateral border, and concluded that this
site is unsuitable for IM injection in terms of the high risk for the
complications related to this nerve.
 Option C: The deltoid muscle has been used in clinical settings because it
is easy for clinicians to administer injections at this site and for patients to
expose it, and it is the most commonly used site for vaccines worldwide.
Four injection sites have been recommended as safer and appropriate IM
injection sites in the deltoid muscle: the first site is 1 to 3 fingerbreadths (5
cm) below the mid-acromion, the second is a triangular injection site, the
third is the middle third of the deltoid muscle, and the fourth is a mid-
deltoid site.
 Option D: The following complications have been reported after the
administration of IM injections: injection site reactions such as pain,
erythema, and swelling due to over-or under penetration by the needle,

axillary or radial nerve palsies, musculoskeletal injuries, local sepsis, and
vascular complications. Therefore, it is becoming increasingly important to
establish a safer site for IM injections.
ADVERTISEMENTS
49. Question
The appropriate needle size for insulin injection is:
o A. 18G, 1 ½‖ long
o B. 22G, 1‖ long
o C. 22G, 1 ½‖ long
o D. 25G, 5/8” long

Incorrect
Correct Answer: D. 25G, 5/8” long
A 25G, 5/8‖ needle is the recommended size for insulin injection because insulin
is administered by the subcutaneous route. The board recommends 4-, 5-, and 6-
mm needles for all adult patients regardless of their BMI. It is also recommended
to insert 4-, 5-, and 6-mm needles at a 90-degree angle and that, if needed,
longer needles should be injected with either a skinfold or a 45-degree angle to
avoid intramuscular injection of insulin.
 Option A: An 18G, 1 ½‖ needle is usually used for I.M. injections in
children, typically in the vastus lateralis. Ensuring the correct delivery of
insulin is essential in the treatment of diabetes. Both proper injection
technique and needle length are important considerations for adequate
insulin delivery. There have been several studies demonstrating that BMI
does not affect efficacy or insulin leakage with shorter pen needles (e.g., 4
or 5 mm vs. 12.7 mm).
 Option B: Additionally, the International Scientific Advisory Board for the
Third Injection Technique Workshop released recommendations in 2010 on
best practices for injection technique for patients with diabetes, which, with
regard to needle length, concluded that 4-mm pen needles were
efficacious in all patients regardless of BMI.

 Option C: A 22G, 1 ½‖ needle is usually used for adult I.M. injections,
which are typically administered in the vastus lateralis or ventrogluteal site.
Needle lengths for subcutaneous injections started out as long as 16 mm
in 1985, and 12.7-mm needles were introduced in the early 1990s. Over
time, with growing evidence of longer needles increasing risks for
intramuscular injections and improved technology, shorter needles of 4, 5,
6, and 8 mm have been developed.
ADVERTISEMENTS
50. Question
The appropriate needle gauge for intradermal injection is:
o A. 20G
o B. 22G
o C. 25G
o D. 26G
Incorrect
Correct Answer: D. 26G
Because an intradermal injection does not penetrate deeply into the skin, a small-
bore 26G-27G needle is recommended. This type of injection is used primarily to
administer antigens to evaluate reactions for allergy or sensitivity studies.
Equipment used for ID injections is a tuberculin syringe calibrated in tenths and
hundredths of a millilitre, and a 1/4 to 1/2 in., 26 or 27 gauge needle. The dosage
of an ID injection is usually under 0.5 ml. The angle of administration for an ID
injection is 5 to 15 degrees.
 Option A: A 20G needle is usually used for I.M. injections of oil-based
medications. Intramuscular injections are administered at a 90-degree
angle to the skin, preferably into the anterolateral aspect of the thigh or
the deltoid muscle of the upper arm, depending on the age of the patient.
The needle gauge for intramuscular injection is 22-25 gauge.
 Option B: A 22G-25G needle for I.M. injections. A decision on needle
length and site of injection must be made for each person on the basis of
the size of the muscle, the thickness of adipose tissue at the injection site,

the volume of the material to be administered, injection technique, and the
depth below the muscle surface into which the material is to be injected
 Option C: A 25G needle, for subcutaneous insulin injections. Choosing the
right size needle and syringe is necessary to get the correct dose of
medicine, inject it properly, and minimize pain. To make it easier, these
items are sold separately and designed to attach securely. Subcutaneous
injections go into the fatty tissue just below the skin. Since these are
relatively shallow shots, the needle required is small and short—typically
one-half to five-eighths of an inch long with a gauge of 25 to 30.
ADVERTISEMENTS
51. Question
Parenteral penicillin can be administered as an:
o A. IM injection or an IV solution
o B. IV or an intradermal injection
o C. Intradermal or subcutaneous injection
o D. IM or a subcutaneous injection
Incorrect
Correct Answer: A. IM injection or an IV solution
Parenteral penicillin can be administered I.M. or added to a solution and given
I.V. It cannot be administered subcutaneously or intradermally. Penicillin G
administration can be either intravenously or intramuscularly. Penicillin G
benzathine administration ensures a continuous low dose of penicillin G over 2 to
4 weeks.
 Option B: Intradermal injection, often abbreviated ID, is a shallow or
superficial injection of a substance into the dermis, which is located
between the epidermis and the hypodermis. This route is relatively rare
compared to injections into the subcutaneous tissue or muscle.
 Option C: A subcutaneous injection is a method of administering
medication. Subcutaneous means under the skin. In this type of injection, a
short needle is used to inject a drug into the tissue layer between the skin

and the muscle. Medication given this way is usually absorbed more slowly
than if injected into a vein, sometimes over a period of 24 hours.
 Option D: An intramuscular injection is a technique used to deliver a
medication deep into the muscles. This allows the medication to be
absorbed into the bloodstream quickly. Intramuscular injections are a
common practice in modern medicine. They‘re used to deliver drugs and
vaccines. Several drugs and almost all injectable vaccines are delivered this
way.
ADVERTISEMENTS
52. Question
The physician orders gr 10 of aspirin for a patient. The equivalent dose in
milligrams is:
o A. 0.6 mg
o B. 10 mg
o C. 60 mg
o D. 600 mg
Incorrect
Correct Answer: D. 600 mg
gr 10 x 60 mg/gr 1 = 600 mg. There are 3 primary methods for the calculation of
medication dosages, as referenced above. These include Desired Over Have
Method or Formula, Dimensional Analysis and Ratio and Proportion (as cited in
Boyer, 2002)[Lindow, 2004].
 Option A: Desired over Have or Formula Method is a formula or equation
triple check.

 Option B: Units of measurement must match, for example, milliliters and
adding.
ADVERTISEMENTS
53. Question
The physician orders an IV solution of dextrose 5% in water at 100ml/hour. What
would the flow rate be if the drop factor is 15 gtt = 1 ml?
o A. 5 gtt/minute
o B. 13 gtt/minute
o C. 25 gtt/minute
o D. 50 gtt/minute
Incorrect
Correct Answer: C. 25 gtt/minute
100ml/60 min X 15 gtt/ 1 ml = 25 gtt/minute. When the nurse has an order for an
IV infusion, it is her responsibility to make sure the fluid will infuse at the
 Option A: When calculating the flow rate, determine which IV tubing you

 Option B: Macrodrip and microdrip refers to the diameter of the needle
 Option C: To calculate the drops per minute, the drop factor is needed.
The formula for calculating the IV flow rate (drip rate).. total volume (in mL)
divided by time (in min), multiplied by the drop factor (in gtts/mL), which
equals the IV flow rate in gtts/min.
ADVERTISEMENTS
54. Question
Which of the following is a sign or symptom of a hemolytic reaction to blood
transfusion?
o A. Hemoglobinuria
o B. Chest pain
o C. Urticaria
o D. Distended neck veins

Incorrect
Correct Answer: A. Hemoglobinuria
Hemoglobinuria, the abnormal presence of hemoglobin in the urine, indicates a
hemolytic reaction (incompatibility of the donor‘s and recipient‘s blood). In this
reaction, antibodies in the recipient‘s plasma combine rapidly with donor RBC‘s;
the cells are hemolyzed in either circulatory or reticuloendothelial systems.
Hemolysis occurs more rapidly in ABO incompatibilities than in Rh
incompatibilities.
 Option B: Flank pain is a common sign of hemolytic reaction. Symptoms of
a hemolytic transfusion reaction most often appear during or right after
the transfusion. Sometimes, they may develop after several days (delayed
reaction).
 Option C: Chest pain and urticaria may be symptoms of impending
anaphylaxis. A hemolytic transfusion reaction is a serious complication that

can occur after a blood transfusion. The reaction occurs when the red
blood cells that were given during the transfusion are destroyed by the
person‘s immune system. When red blood cells are destroyed, the process
is called hemolysis.
 Option D: Distended neck veins are an indication of hypervolemia. Most of
the time, a blood transfusion between compatible groups (such as O+ to
O+) does not cause a problem. Blood transfusions between incompatible
groups (such as A+ to O-) cause an immune response. This can lead to a
serious transfusion reaction. The immune system attacks the donated
blood cells, causing them to burst.
ADVERTISEMENTS
55. Question
Which of the following conditions may require fluid restriction?
o A. Fever
o B. Chronic Obstructive Pulmonary Disease
o C. Renal Failure
o D. Dehydration
Incorrect
Correct Answer: C. Renal Failure
In renal failure, the kidney loses their ability to effectively eliminate wastes and
fluids. Because of this, limiting the patient‘s intake of oral and I.V. fluids may be
necessary. The term renal failure denotes the inability of the kidneys to perform
excretory function leading to retention of nitrogenous waste products from the
blood.
 Option A: A fever draws moisture out of the body. Plus, you lose fluid as
your body makes mucus and it drains away. And that over-the-counter
cold medicine you‘re taking to dry up your head can dry the rest of you
out, too. So drink plenty of water, juice, or soup.
 Option B: Chronic obstructive pulmonary disease (COPD) is airflow
limitation caused by an inflammatory response to inhaled toxins, often

cigarette smoke. Alpha-1 antitrypsin deficiency and various occupational
exposures are less common causes in nonsmokers.
 Option D: Dehydration must be treated by replenishing the fluid level in
the body. This can be done by consuming clear fluids such as water, clear
broths, frozen water or ice pops, or sports drinks (such as Gatorade). Some
dehydration patients, however, will require intravenous fluids in order to
rehydrate.
ADVERTISEMENTS
56. Question
All of the following are common signs and symptoms of phlebitis except:
o A. Pain or discomfort at the IV insertion site
o B. Edema and warmth at the IV insertion site
o C. A red streak exiting the IV insertion site
o D. Frank bleeding at the insertion site

Incorrect
Correct Answer: D. Frank bleeding at the insertion site
Phlebitis, the inflammation of a vein, can be caused by chemical irritants (I.V.
solutions or medications), mechanical irritants (the needle or catheter used
during venipuncture or cannulation), or a localized allergic reaction to the needle
or catheter. It usually affects lower limbs, particularly the great saphenous vein
(60% to 80%) or the small/short saphenous vein (10% to 20%). However, it can
occur at other sites (10% to 20%) and may occur bilaterally (5% to 10%).
 Option A: When there is venous turbulence or stasis, vessel wall injuries,
abnormal coagulability, or vessel wall injuries, microthrombi could
propagate and then form macroscopic thrombi. Vascular endothelial injury
reliably results in thrombus formation by triggering an inflammatory
response that results in immediate platelet adhesion. Platelet aggregation
is mediated by thrombin and thromboxane A2.
 Option B: Patients with superficial thrombophlebitis typically present with
a reddened, warm, inflamed, tender area overlying the track of a superficial
vein. There is often a palpable cord. Some surrounding edema or

associated pruritus may occur. Significant swelling of the limb is more
commonly associated with DVT and should only be attributed to SVT after
DVT has been excluded.
 Option C: Signs and symptoms of phlebitis include pain or discomfort,
edema and heat at the I.V. insertion site, and a red streak going up the arm
or leg from the I.V. insertion site. Patients should be educated on the
likelihood and significance of the propagation of disease and recurrence
based on their risk factors. They should be advised of the need for further
evaluation in the presence of migratory thrombophlebitis or if they are
more than 40 years old at the time of their initial presentation and are
without other risk factors for venous thromboembolic disease.
ADVERTISEMENTS
57. Question
The best way of determining whether a patient has learned to instill ear
medication properly is for the nurse to:
o A. Ask the patient if he/she has used ear drops before.
o B. Have the patient repeat the nurse‘s instructions using her own words.
o C. Demonstrate the procedure to the patient and encourage to ask questions.
o D. Ask the patient to demonstrate the procedure.

Incorrect
Correct Answer: D. Ask the patient to demonstrate the procedure
Return demonstration provides the most certain evidence for evaluating the
effectiveness of patient teaching. No matter what kind of ear drops you use or
why you use them, it‘s important to administer them correctly. Using ear drops
properly allows the medication to enter your ear canal and treat your ear
problem.
 Option A: Merely asking the patient does not guarantee that he knows the
correct way of instilling the ear drops. Position the head so that the ear
faces upward. If you‘re giving the drops to yourself, it may be easiest to sit
or stand upright and tilt your head to the side. If you‘re giving the drops to

someone else, it may be easiest if the person tilts their head or lies down
on their side.
 Option B: It is better to repeat actions than only repeating words. or
adults, gently pull the upper ear up and back. For children, gently pull the
lower ear down and back. Squeeze the correct number of drops into the
ear. Your doctor‘s instructions or the bottle‘s label will tell you how many
drops to use.
 Option C: After demonstrating to the patient, allow him to demonstrate
the procedure too. You should also know how long you can use the ear
drops safely after opening the bottle. For prescription ear drops, ask your
pharmacist or doctor about the expiration date. For over-the-counter
drops, check the expiration date on the label. If the drops have expired,
throw them away. Don‘t use expired ear drops.
ADVERTISEMENTS
58. Question
Which of the following types of medications can be administered via gastrostomy
tube?
o A. Any oral medications.
o B. Capsules' whole contents are dissolved in water.
o C. Enteric-coated tablets that are thoroughly dissolved in water.
o D. Most tablets designed for oral use, except for extended-duration

compounds.
Incorrect
Correct Answer: D. Most tablets designed for oral use, except for extended-
duration compounds
Most tablets designed for oral use, except for extended-duration compounds can
be administered via gastrostomy tube. Drug therapy can be complicated in
hospitalized patients requiring an enteral feeding tube (EFT). Some medications
may be given via an EFT while others are unsuitable for this form of
administration.

 Option A: Inappropriate drug selection for EFT administration can cause
potential toxicity, reduced efficacy, and tube obstruction. Therefore, it is
important to know which drugs may be altered for EFT administration as
well as appropriate therapeutic alternatives that can temporarily be
substituted for those that may not be given via that route.
 Option B: It is preferable to utilize a liquid dosage form whenever possible
for EFT administration especially if the patient has a small-bore feeding
tube. If an appropriate liquid preparation is not available, the dilution of
crushed tablets or the contents of capsules may be necessary prior to EFT
administration.
 Option C: Capsules, enteric-coated tablets, and most extended duration or
sustained-release products should not be dissolved for use in a
gastrostomy tube. They are pharmaceutically manufactured in these forms
for valid reasons, and altering them destroys their purpose. The nurse
should seek an alternate physician‘s order when an ordered medication is
inappropriate for delivery by tube.
ADVERTISEMENTS
59. Question
A patient who develops hives after receiving an antibiotic is exhibiting drug:
o A. Tolerance
o B. Idiosyncrasy
o C. Synergism
o D. Allergy
Incorrect
Correct Answer: D. Allergy
A drug-allergy is an adverse reaction resulting from an immunologic response
following previous sensitizing exposure to the drug. The reaction can range from
a rash or hives to anaphylactic shock.
 Option A: Tolerance to a drug means that the patient experiences a
decreasing physiologic response to repeated administration of the drug in
the same dosage.

 Option B: Idiosyncrasy is an individual‘s unique hypersensitivity to a drug,
food, or other substance; it appears to be genetically determined.
 Option C: Synergism, is a drug interaction in which the sum of the drug‘s
combined effects is greater than that of their separate effects.
ADVERTISEMENTS
60. Question
A patient has returned to his room after femoral arteriography. All of the
following are appropriate nursing interventions except:
o A. Assess femoral, popliteal, and pedal pulses every 15 minutes for 2 hours.
o B. Check the pressure dressing for sanguineous drainage.
o C. Assess vital signs every 15 minutes for 2 hours.
o D. Order a hemoglobin and hematocrit count 1 hour after the

arteriography.
Incorrect
Correct Answer: D. Order a hemoglobin and hematocrit count 1 hour after
the arteriography
A hemoglobin and hematocrit count would be ordered by the physician if
bleeding were suspected. Arterial puncture occurs at the start of angiography
and interventional radiology, and is a very important factor determining the
success or failure of successive procedures. Recently, this procedure has been
performed by a range of approaches depending on the type of surgery, e.g,
through the radial artery.
 Option A: The methods of hemostasis for the femoral artery include
manual compression, which is the removal of the sheath and compression
with the hands, and methods that apply compression devices1). Of these,
manual compression requires absolute bed rest for a few hours. On the
other hand, the level of patient discomfort is increased due to lengthy bed
rest and the restriction of walking.
 Option B: Moreover, hematoma in the punctured area of blood vessels,
formation of a pseudoaneurysm, and vascular occlusions develop in
approximately 1–5% of cases). A variety of hemostasis devices have been

developed to treat these complications that allow for rapid recovery of
patients from bed rest. These include Angio-seal device (collagen sponge
and copolymer anchor) and percutaneous placement of a device (Prostar)
that utilizes two nonabsorbable sutures (Perclose, Redwood City, CA, USA).
 Option C: The other answers are appropriate nursing interventions for a
patient who has undergone femoral arteriography. The Angio-seal device
uses a method of adsorption with a collagen sponge placed within the
blood vessels. The Prostar device uses a method in which the blood vessels
are sutured. These hemostasis devices can reduce the discomfort and the
time to hemostasis (clotting time) in the puncture area when used in
patients, who cannot lie down in bed for a long time or in patients with low
platelet values who have received anticoagulation treatments.
ADVERTISEMENTS
61. Question
The nurse explains to a patient that a cough:
o A. Is a protective response to clear the respiratory tract of irritants.
o B. Is primarily a voluntary action.
o C. Is induced by the administration of an antitussive drug.
o D. Can be inhibited by ―splinting‖ the abdomen.

Incorrect
Correct Answer: A. Is a protective response to clear the respiratory tract of
irritants
Coughing, a protective response that clears the respiratory tract of irritants,
usually is involuntary. A cough is an innate primitive reflex and acts as part of the
body‘s immune system to protect against foreign materials. This reflex is
characterized with the closing of the glottis apparatus with subsequent increases
in the intrathoracic pressure which often exceeds 300 mm Hg. This is followed by
the forceful expulsion of the airway contents through the glottis into the
pharyngeal space and out of the body.
 Option B: However, it can be voluntary as when a patient is taught to
perform coughing exercises. Coughing is associated with a wide

assortment of clinical associations and etiologies. Furthermore, there are
no objective tools to measure or clinically quantify a cough. As such,
evaluation of a cough is initially a subjective and highly variable
assessment.
 Option C: An antitussive drug inhibits coughing. Cough suppressants may
be used to lessen the cough by blunting the cough reflex, and
expectorants may be used when excessive mucous secretions are
determined to be the primary issue to increase mucus clearance. The most
commonly used suppressant is dextromethorphan, and the most common
suppressant is guaifenesin.
 Option D: Splinting the abdomen supports the abdominal muscles when a
patient coughs. The reflex of coughing is initiated with a chemical irritation
at peripheral nerve receptors within the trachea, main carina, branching
points of large airways, and more distal smaller airways. They are also
present in the pharynx. Laryngeal and tracheobronchial receptors respond
to mechanical and chemical stimuli.
ADVERTISEMENTS
62. Question
An infected patient has chills and begins shivering. The best nursing intervention
is to:
o A. Apply iced alcohol sponges
o B. Provide increased cool liquids
o C. Provide additional bedclothes
o D. Provide increased ventilation

Incorrect
Correct Answer: C. Provide additional bedclothes
In an infected patient, shivering results from the body‘s attempt to increase heat
production and the production of neutrophils and phagocytic action through
increased skeletal muscle tension and contractions. Initial vasoconstriction may
cause skin to feel cold to the touch. Applying additional bed clothes helps to
equalize the body temperature and stop the chills. Attempts to cool the body

result in further shivering, increased metabolism, and thus increased heat
production.
 Option A: This intervention would further increase shivering. Therapeutic
temperature modulation, which incorporates mild hypothermia and
maintenance of normothermia, is being used to manage patients
resuscitated after cardiac arrest. During this therapy, the shiver response is
activated as a defense mechanism in response to an altered set-point
temperature and causes metabolic and hemodynamic stress for patients.
 Option B: Cool liquids may increase the shivering. Recognition of shivering
according to objective and subjective assessments is vital for early
detection of the condition. Once shivering is detected, treatment is
imperative to avoid deleterious effects. The Bedside Shivering Assessment
Scale can be used to determine the efficacy of interventions intended to
blunt thermoregulatory defenses and can provide continual evaluation of
patients‘ responses to the interventions.
 Option D: Increased ventilation may be done, but it could still increase
shivering. Nurses‘ knowledge and understanding of the harmful effects of
shivering are important to affect care and prevent injury associated with
uncontrolled shivering. Chills may also be a symptom of a serious or life-
threatening condition that should be immediately evaluated in an
emergency setting, such as hypothermia, which is an abnormally low body
temperature.
ADVERTISEMENTS
63. Question
A clinical nurse specialist is a nurse who has:
o A. Been certified by the National League for Nursing.
o B. Received credentials from the American Nurses‘ Association.
o C. Graduated from an associate degree program and is a registered

professional nurse.
o D. Completed a master’s degree in the prescribed clinical area and is a

registered professional nurse.

Incorrect
Correct Answer: D. Completed a master’s degree in the prescribed clinical
area and is a registered professional nurse.
A clinical nurse specialist must have completed a master‘s degree in a clinical
specialty and be a registered professional nurse. A clinical nurse specialist (CNS)
is a graduate-level registered nurse who is certified in a specialty of choice.
Obtaining specialty certification demonstrates an advanced level of knowledge as
well as advanced clinical skills in a niche area of nursing. There are differences
between a nurse practitioner (NP) and CNS.
 Option A: The National League of Nursing accredits educational programs
in nursing and provides a testing service to evaluate student nursing
competence but it does not certify nurses.
 Option B: The American Nurses Association identifies requirements for
certification and offers examinations for certification in many areas of
nursing, such as medical-surgical nursing. This certification (credentialing)
demonstrates that the nurse has the knowledge and the ability to provide
high-quality nursing care in the area of her certification.
 Option C: A graduate of an associate degree program is not a clinical
nurse specialist: however, she is prepared to provide bedside nursing with
a high degree of knowledge and skill. She must successfully complete the
licensing examination to become a registered professional nurse.
ADVERTISEMENTS
64. Question
The purpose of increasing urine acidity through dietary means is to:
o A. Decrease burning sensations
o B. Change the urine‘s color
o C. Change the urine‘s concentration
o D. Inhibit the growth of microorganisms

Incorrect
Correct Answer: D. Inhibit the growth of microorganisms

Microorganisms usually do not grow in an acidic environment. A diet high in
citrus fruits, vegetables, or dairy products can increase urine pH. A diet high in
meat products or cranberries can decrease urine pH. The acidity of urine — as
well as the presence of small molecules related to diet — may influence how well
bacteria can grow in the urinary tract, a new study shows. The research, at
Washington University School of Medicine in St. Louis, may have implications for
treating urinary tract infections, which are among the most common bacterial
infections worldwide.
 Option A: Henderson and his team, including first author Robin R. Shields-
Cutler, a graduate student in Henderson‘s lab, were interested in studying
how the body naturally fights bacterial infections. They cultured E. coli in
urine samples from healthy volunteers and noted major differences in how
well individual urine samples could harness a key immune protein to limit
bacterial growth. The urine samples that prevented bacterial growth
supported more activity of this key protein, which the body makes naturally
in response to infection, than the samples that permitted bacteria to grow
easily. The protein is called siderocalin, and past research has suggested
that it helps the body fight infection by depriving bacteria of iron, a mineral
necessary for bacterial growth.
 Option B: Importantly, the researchers also showed that they could
encourage or discourage bacterial growth in urine simply by adjusting the
pH, a finding that could have implications for how patients with UTIs are
treated.
 Option C: Indeed, their results implicate cranberries among other possible
dietary interventions. Shield-Cutler noted that many studies already have
investigated extracts or juices from cranberries as UTI treatments but the
results of such investigations have not been consistent. ―It‘s possible that
cranberries may be more effective when paired with a treatment to make
the urine less acidic,‖ Henderson said. ―And even then, maybe cranberries
only work in people who have the right gut microbes.‖
ADVERTISEMENTS
65. Question
Clay-colored stools indicate:

o A. Upper GI bleeding
o B. Impending constipation
o C. An effect of medication
o D. Bile obstruction
Incorrect
Correct Answer: D. Bile obstruction
Bile colors the stool brown. Any inflammation or obstruction that impairs bile
flow will affect the stool pigment, yielding light, clay-colored stool. The liver
releases bile salts into the stool, giving it a normal brown color. One may have
clay-colored stools if they have a liver infection that reduces bile production, or if
the flow of bile out of the liver is blocked. Yellow skin (jaundice) often occurs with
clay-colored stools.
 Option A: Upper GI bleeding results in black or tarry stool. Melena is a
black, tarry stool that is caused by GI bleeding. The black color is due to
the oxidation of blood hemoglobin during the bleeding in the ileum and
colon. Melena also refers to stools or vomit stained black by blood
pigment or dark blood products and may indicate upper GI bleeding.
 Option B: Constipation is characterized by small, hard masses. The
problem may arise in the colon or rectum or it may be due to an external
cause. In most people, slow colonic motility that occurs after years of
laxative abuse is the problem. In a few patients, the cause may be related
to an outlet obstruction like rectal prolapse or a rectocele. External causes
of constipation may include poor dietary habits, lack of fluid intake,
overuse of certain medications, an endocrine problem like hypothyroidism
or some type of an emotional issue.
 Option C: Many medications and foods will discolor stool – for example,
drugs containing iron turn stool black; beets turn stool red. Blue feces may
be caused by boric acid, chloramphenicol, or methylene blue. Causative
diseases for clay feces may include alcoholic hepatitis, biliary cirrhosis,
gallstones, sclerosing cholangitis, biliary strictures, or viral hepatitis.
Causative medications for gray feces may include cocoa or colchicines.
Potential causes for green stools may include spinach, Indomethacin, iron,
or medroxyprogesterone.
ADVERTISEMENTS

66. Question
In which step of the nursing process would the nurse ask a patient if the
medication she administered relieved his pain?
o A. Assessment
o B. Analysis
o C. Planning
o D. Evaluation
Incorrect
In the evaluation step of the nursing process, the nurse must decide whether the
patient has achieved the expected outcome that was identified in the planning
phase. This final step of the nursing process is vital to a positive patient outcome.
may frequently be needed depending upon the overall patient‘s condition. The
plan of care may be adapted based on new assessment data.
and weight.
 Option B: Analysis can be a part of diagnosing. The formulation of a
nursing diagnosis by employing clinical judgment assists in the planning
and implementation of patient care. The North American Nursing
Diagnosis Association (NANDA) provides nurses with an up to date list of
nursing diagnoses. A nursing diagnosis, according to NANDA, is defined as
a clinical judgment about responses to actual or potential health problems
on the part of the patient, family, or community.
 Option C: The planning stage is where goals and outcomes are formulated

ADVERTISEMENTS
67. Question
All of the following are good sources of vitamin A except:
o A. White potatoes
o B. Carrots
o C. Apricots
o D. Egg yolks
Incorrect
Correct Answer: A. White potatoes
Potatoes contain a good amount of carbs and fiber, as well as vitamin C, vitamin
B6, potassium and manganese. Their nutrient contents can vary depending on
the type of potato and cooking method. The main sources of vitamin A are yellow
and green vegetables (such as carrots, sweet potatoes, squash, spinach, collard
greens, broccoli, and cabbage) and yellow fruits (such as apricots, and
cantaloupe). Animal sources include liver, kidneys, cream, butter, and egg yolks.
 Option B: They‘re rich in beta-carotene, a compound the body changes
into vitamin A, which helps keep the eyes healthy. And beta-carotene helps
protect the eyes from the sun and lowers the chances of cataracts and
other eye problems. Yellow carrots have lutein, which is also good for the
eyes.
 Option C: Apricots are a great source of many antioxidants, including beta
carotene and vitamins A, C, and E. What‘s more, they‘re high in a group of
polyphenol antioxidants called flavonoids, which have been shown to
protect against illnesses, including diabetes and heart disease.
 Option D: Egg yolks contain vitamins A, D, E, and K along with omega-3
fats. Compared to the whites, egg yolks are also rich in folate and vitamin

B12. The yolks are also packed with tryptophan and tyrosine, and amino
acids that help prevent heart diseases.
ADVERTISEMENTS
68. Question
Which of the following is a primary nursing intervention necessary for all patients
with a Foley Catheter in place?
o A. Maintain the drainage tubing and collection bag level with the patient‘s
bladder.
o B. Irrigate the patient with 1% Neosporin solution three times a day.
o C. Clamp the catheter for 1 hour every 4 hours to maintain the bladder‘s
elasticity.
o D. Maintain the drainage tubing and collection bag below bladder level
to facilitate drainage by gravity.
Incorrect
Correct Answer: D. Maintain the drainage tubing and collection bag below
bladder level to facilitate drainage by gravity
To prevent obstruction, the catheter and collecting tube should be kept free from
kinking, the collecting bag should be positioned below the level of the bladder at
all times and never placed on the floor. The collecting bag should be emptied
regularly using a clean collecting container (HICPAC, 2009). In ambulatory
patients, collecting bags may be disguised in bags and pouches.
 Option A: Maintaining the drainage tubing and collection bag level with
the patient‘s bladder could result in reflux of urine into the kidney. The
indwelling catheter should be secured to the thigh or abdomen after
insertion to prevent movement and the exertion of excessive force on the
bladder neck or urethra (Gray, 2008). Unsecured and displaced catheters
can also cause pressure ulcers on the perineum and buttock (Siegel, 2008).
 Option B: Irrigating the bladder with Neosporin must be indicated and
ordered by the physician. Nash (2003) conducted a recent review of the
literature on self-cleaning of catheter training bags. The study showed that
patients whose bags were irrigated with vinegar showed a significant

reduction of bacteriuria compared with patients whose bags were irrigated
with the hydrogen peroxide solutions (Washington, 2001). Authors
concluded that more research is needed on the self-cleaning of Foley bags.
 Option C: Clamping the catheter for 1 hour every 4 hours must be
prescribed by a physician. Patients practicing intermittent catheterization
should pay close attention to the catheterization schedule and avoid
bladder overdistension and unnecessary catheterizations. As CAUTIs are
more prevalent for intermittent catheterization in patients with high
residual urine volumes at the time of catheterization, urine volume should
determine the catheterization schedule.
ADVERTISEMENTS
69. Question
The ELISA test is used to:
o A. Screen blood donors for antibodies to human immunodeficiency virus

(HIV).
o B. Test blood to be used for transfusion for HIV antibodies.
o C. Aid in diagnosing a patient with AIDS.

Incorrect
The ELISA test of venous blood is used to assess blood and potential blood
donors to human immunodeficiency virus (HIV). A positive ELISA test combined
with various signs and symptoms helps to diagnose acquired immunodeficiency
syndrome (AIDS). Enzyme-linked immunosorbent assay (ELISA) is a labeled
immunoassay that is considered the gold standard of immunoassays. This
immunological test is very sensitive and is used to detect and quantify
substances, including antibodies, antigens, proteins, glycoproteins, and
hormones. The detection of these products is accomplished by the complexing of
antibodies and antigens to produce a measurable result.
 Option A: ELISAs are performed in polystyrene plates, typically in 96-well
plates that are coated to bind protein very strongly. Depending on the

ELISA type, testing requires a primary and/or secondary detection
antibody, analyte/antigen, coating antibody/antigen, buffer, wash, and
substrate/chromogen. The primary detection antibody is a specific
antibody that only binds to the protein of interest, while a secondary
detection antibody is a second enzyme-conjugated antibody that binds a
primary antibody that is not enzyme-conjugated.
 Option B: In HIV testing, a blood or saliva specimen is collected for testing
typically by the use of indirect ELISA-based tests. The ELISA is a screening
tool for HIV detection, but not diagnostic. Diagnosis requires further
testing by Western blot due to potential false positives. Another virus,
Molluscum contagiosum virus (MCV) that commonly infects the skin of
children and young adults, can be detected by ELISA testing. ELISA testing
in this setting is currently being evaluated for the assessment of global
MCV seroprevalence.
 Option C: ELISA testing is used in the diagnosis of HIV infection,
pregnancy tests, and blood typing, among others. The first ELISA
methodology involved chromogenic reporter molecules and substrates to
generate observable color change that monitors the presence of antigen.
Further advancement in the ELISA technique leads to the development of
fluorogenic, quantitative PCR, and electrochemiluminescent reporters to
generate signals. However, some of these techniques do not rely on using
enzyme-linked substrates but non-enzymatic reporters that utilize the
principle of ELISA.
ADVERTISEMENTS
70. Question
The two blood vessels most commonly used for TPN infusion are the:
o A. Subclavian and jugular veins
o B. Brachial and subclavian veins
o C. Femoral and subclavian veins
o D. Brachial and femoral veins

Incorrect

Correct Answer: A. Subclavian and jugular veins
Total Parenteral Nutrition (TPN) requires the use of a large vessel, such as the
subclavian or jugular vein, to ensure the rapid dilution of the solution and
thereby prevent complications, such as hyperglycemia. TPN is a mixture of
separate components that contain lipid emulsions, dextrose, amino acids,
vitamins, electrolytes, minerals, and trace elements. TPN composition should be
adjusted to fulfill individual patients‘ needs. The main three macronutrients are
lipids, emulsions, proteins, and dextrose.
 Option B: Total parenteral nutrition is not administered through a
peripheral intravenous catheter (Peripheral Parenteral Nutrition, PPN)
because it has high osmolarity. PPN osmolarity needs to be less than 900
mOsm. The lower concentration necessitates larger volume feedings, and
high-fat content is necessary. High osmolarity irritates peripheral veins;
hence TPN is given through central venous access. PPN is used to provide
additional nutrition to patients with functional gut and enteral feedings.
 Option C: Historically, total parenteral nutrition (TPN) has been
administered by the central venous route because of the rapid
development of thrombophlebitis when TPN solutions are administered
into peripheral veins. The insertion and placement of central venous
catheters are, however, associated with morbidity and mortality and is the
main cause of TPN-related complications.
 Option D: The brachial and femoral veins usually are contraindicated
because they pose an increased risk of thrombophlebitis. By avoiding
central venous catheterization, TPN can be made safer. Current awareness
about the pathophysiology of peripheral vein thrombophlebitis and the
use of a number of techniques that prevent or delay the onset of
peripheral vein thrombophlebitis means it is now possible to administer
TPN via the peripheral route.
ADVERTISEMENTS
71. Question
Effective skin disinfection before a surgical procedure includes which of the
following methods?
o A. Shaving the site on the day before surgery.

o B. Applying a topical antiseptic to the skin in the evening before surgery.
o C. Having the patient take a tub bath on the morning of surgery.
o D. Having the patient shower with an antiseptic soap on the evening

before and the morning of surgery.
Incorrect
Correct Answer: D. Having the patient shower with an antiseptic soap on the
evening before and the morning of surgery
Studies have shown that showering with an antiseptic soap before surgery is the
most effective method of removing microorganisms from the skin. Procedural
and surgical site infections create difficult and complex clinical scenarios. A
source for pathogens is often thought to be the skin surface, making skin
preparation at the time of the procedure critical. The antiseptic used for bathing
should be approved using the testing criteria from the FDA‘s Tentative Final
Monograph (TFM) for Antiseptic Drug Products for preoperative skin preparation.
The goal for this recommendation would be to reduce the number of bacterial
flora at the patient‘s incision site.
 Option A: Shaving the site of the intended surgery might cause breaks in
the skin, thereby increasing the risk of infection; however, if indicated,
shaving, should be done immediately before surgery, not the day before.
The purpose of surgical skin preparation is to reduce the number of
microorganisms on the skin‘s surface. This is accomplished by removing
dirt and oil without causing damage to the skin‘s natural protective
function or interfering with postoperative wound healing. The CDC‘s 1999
guideline recommends that hair not be removed unless it interferes with
the surgical procedure and is a Category IA recommendation.12 Also,
according to AORN standards, ―Whenever possible, hair should be left at
the surgical site.‖13 Hair-removal methods discussed are depilatory; dry
clipped using an electric clipper and wet using a disposable razor.
 Option B: A topical antiseptic would not remove microorganisms and
would be beneficial only after proper cleaning and rinsing. The most
common skin preparation agents used today include products containing
iodophors or chlorhexidine gluconate (CHG). CHG has more sustained
antimicrobial activity and is more resistant to neutralization by blood
products than the iodophors. CHG is applied in a similar manner to PVP-I,
but should not be used in the genital region. This agent has gained

popularity as a hand-scrubbing and showering antiseptic prior to surgery,
but also continues to be used as a patient skin preparation agent.
 Option C: Tub bathing might transfer organisms to another body site
rather than rinse them away. The CDC‘s 1999 guideline states that the
incision site should be clean before surgical skin preparation and has
labeled this a Category IB.10 In the Standards, Recommended Practices,
and Guidelines of the Association of periOperative Registered Nurses
(AORN) it states, ―The surgical site and surrounding areas should be clean.‖
ADVERTISEMENTS
72. Question
When transferring a patient from a bed to a chair, the nurse should use which
muscles to avoid back injury?
o A. Abdominal muscles
o B. Back muscles
o C. Leg muscles
o D. Upper arm muscles

Incorrect
Correct Answer: C. Leg muscles
The leg muscles are the strongest muscles in the body and should bear the
greatest stress when lifting. Muscles of the abdomen, back, and upper arms may
be easily injured. Place the patient‘s outside leg (the one farthest from the
wheelchair) between the knees for support. Bend the knees and keep the back
straight. Patient safety is often the main concern when moving patients from bed.
But remember not to lift at the expense of your own back. This transfer often
requires the patient‘s help, so clear communication is essential. If the patient
can‘t help much, you‘ll need two people or a full body sling lift.
 Option A: Allow the patient to help as much as possible. Estimate the
patient‘s weight and mentally practice. Make sure that the floor is free of
any obstacles or liquids. Keep the feet shoulder width apart. Keep the
person (or object) as close to your body as possible. Tighten your stomach

muscles. Bend knees and hips, and keep your back straight throughout the
movement. Lift with your legs, NOT your back.
 Option B: Keep the back straight throughout the transfer to avoid bending
or straining the back. Get as close to the person as possible while still
allowing him/her to lean forward as needed to assist with the transfer. Do
not twist your back as you lift. To turn when lifting, pivot your feet. If you
have doubts, ASK FOR HELP!
 Option D: To get the patient into a seated position, roll the patient onto
the same side as the chair. Put one of the arms under the patient‘s
shoulders and one behind the knees. Bend the knees. Swing the patient‘s
feet off the edge of the bed and use the momentum to help the patient
into a sitting position. Move the patient to the edge of the bed and lower
the bed so the patient‘s feet are touching the ground.
ADVERTISEMENTS
73. Question
Thrombophlebitis typically develops in patients with which of the following
conditions?
o A. Increases partial thromboplastin time
o B. Acute pulsus paradoxus
o C. An impaired or traumatized blood vessel wall
o D. Chronic Obstructive Pulmonary Disease (COPD)

Incorrect
Correct Answer: C. An impaired or traumatized blood vessel wall
The factors, known as Virchow‘s triad, collectively predispose a patient to
thrombophlebitis; impaired venous return to the heart, blood hypercoagulability,
and injury to a blood vessel wall. The three factors of Virchow‘s triad include
intravascular vessel wall damage, stasis of flow, and the presence of a
hypercoagulable state. Understanding the factors involved in the thrombus
formation and subsequent thromboembolic events enables the clinician to
stratify risk, direct clinical decision making regarding treatment, and establish
preventative measures.

 Option A: Increased partial thromboplastin time indicates a prolonged
bleeding time during fibrin clot formation, commonly the result of
anticoagulant (heparin) therapy. A prolonged PTT may be due to:
underlying conditions that cause low levels of clotting factors, such as: liver
disease—most coagulation factors are produced by the liver, thus liver
disease may cause prolonged PT and PTT. However, PT is more likely to be
prolonged than PTT.
 Option B: Pulsus Paradoxus refers to an exaggerated fall in a patient‘s
blood pressure during inspiration by greater than 10 mm Hg. Pulsus
Paradoxus results from alterations in the mechanical forces imposed on the
chambers of the heart and pulmonary vasculature often due to pericardial
disease, particularly cardiac tamponade and to a lesser degree constrictive
pericarditis. However, it is important to understand that pulsus paradoxus
may be seen in non-pericardial cardiac diseases such as right ventricular
myocardial infarction and restrictive cardiomyopathy.
 Option D: Chronic obstructive pulmonary disease (COPD) is estimated to
affect 32 million persons in the United States and is the third leading cause
of death in this country. Patients typically have symptoms of chronic
bronchitis and emphysema, but the classic triad also includes asthma or a
combination of the above.
ADVERTISEMENTS
74. Question
In a recumbent, immobilized patient, lung ventilation can become altered,
leading to such respiratory complications as:
o A. Respiratory acidosis, atelectasis, and hypostatic pneumonia
o B. Apneustic breathing, atypical pneumonia and respiratory alkalosis
o C. Cheyne-Stokes respirations and spontaneous pneumothorax
o D. Kussmaul‘s respirations and hypoventilation

Incorrect
Correct Answer: A. Respiratory acidosis, atelectasis, and hypostatic
pneumonia

Because of restricted respiratory movement, a recumbent, immobilize patient is
at particular risk for respiratory acidosis from poor gas exchange; atelectasis from
reduced surfactant and accumulated mucus in the bronchioles, and hypostatic
pneumonia from bacterial growth caused by stasis of mucus secretions.
 Option B: Apneustic respiration (a.k.a. apneusis) is an abnormal pattern of
breathing characterized by deep, gasping inspiration with a pause at full
inspiration followed by a brief, insufficient release. Pneumonia is acquired
when a sufficient volume of a pathogenic organism bypasses the body‘s
cough and laryngeal reflexes and makes its way into the parenchyma. In
almost every scenario, respiratory alkalosis is induced by a process
involving hyperventilation. These include central causes, hypoxemic causes,
pulmonary causes, and iatrogenic causes. Central sources are a head injury,
stroke, hyperthyroidism, anxiety-hyperventilation, pain, fear, stress, drugs,
medications such as salicylates, and various toxins.
 Option C: Cheyne-Stokes respiration is a specific form of periodic
breathing (waxing and waning amplitude of flow or tidal volume)
characterized by a crescendo-decrescendo pattern of respiration between
central apneas or central hypopneas. Unlike obstructive sleep apnea (OSA),
which can be the cause of heart failure, Cheyne-Stokes respiration is
believed to be a result of heart failure. Spontaneous pneumothorax refers
to the abnormal collection of gas in the pleural space between the lungs
and the chest wall. Spontaneous pneumothorax occurs without an obvious
etiology such as trauma or iatrogenic causes.
 Option D: Kussmaul respirations were originally observed and described
by Dr. Adolf Kussmaul in 1874. He made his observation in diabetic
patients who were comatose and in the late stages of diabetic ketoacidosis.
As classically described, Kussmaul respirations are a deep, sighing
respiratory pattern. Dr. Kussmaul actually described it as ―air hunger.‖
Hypoventilation is breathing that is too shallow or too slow to meet the
needs of the body. If a person hypoventilates, the body‘s carbon dioxide
level rises. This causes a buildup of acid and too little oxygen in the blood.
A person with hypoventilation might feel sleepy.
Sources:
ADVERTISEMENTS
75. Question

Immobility impairs bladder elimination, resulting in such disorders as:
o A. Increased urine acidity and relaxation of the perineal muscles, causing

incontinence
o B. Urine retention, bladder distention, and infection
o C. Diuresis, natriuresis, and decreased urine specific gravity
o D. Decreased calcium and phosphate levels in the urine

Incorrect
Correct Answer: B. Urine retention, bladder distention, and infection
The immobilized patient commonly suffers from urine retention caused by
decreased muscle tone in the perineum. This leads to bladder distention and
urine stagnation, which provide an excellent medium for bacterial growth leading
to infection.
 Option A: Urea is the main nitrogenous waste product resulting from
protein breakdown (catabolism) and is rapidly eliminated in the urine by
the kidneys. During bed rest, the concentration of urea in the blood
increases, and the kidneys eliminate larger amounts of urea.
 Option C: As food intake usually decreases during bed rest, it is speculated
that these higher concentrations of urea in blood and urine can only come
from the catabolic breakdown of endogenous protein sources, such as
muscle and other lean tissues (Bilancio et al, 2014). This correlates with the
reduction in lean tissue mass and sarcopenia that are characteristic of
prolonged immobility.
 Option D: Immobility is independently associated with the development of
a series of complications, including pressure ulcer, deep vein thrombosis
(DVT), pneumonia, and urinary tract infection (UTI) Immobility also results
in more alkaline urine with excessive amounts of calcium, sodium, and
phosphate, a gradual decrease in urine production, and increased specific
gravity.
ADVERTISEMENTS
2. 1. Question
Once a nurse assesses a client‘s condition and identifies appropriate nursing
diagnoses, a:

o A. Plan is developed for nursing care.
o B. Physical assessment begins.
o C. List of priorities is determined.
o D. Review of the assessment is conducted with other team members.

Incorrect
Correct Answer: A. Plan is developed for nursing care.
essential in this phase of goal setting.
 Option B: Assessment is the first step and involves critical thinking skills
and weight.
 Option C: A nursing diagnosis encompasses Maslow‘s Hierarchy of Needs
and helps to prioritize and plan care based on patient-centered outcomes.
In 1943, Abraham Maslow developed a hierarchy based on basic
fundamental needs innate for all individuals.
 Option D: Data may come from the patient directly or from primary
caregivers who may or may not be direct relation family members. Friends
can play a role in data collection. Electronic health records may populate
data and assist in assessment.
ADVERTISEMENTS
2. Question 2 of 75
2. Question
Planning is a category of nursing behaviors in which:
o A. The nurse determines the health care needed for the client.
o B. The physician determines the plan of care for the client.
o C. Client-centered goals and expected outcomes are established.

o D. The client determines the care needed.
Incorrect
Correct Answer: C. Client-centered goals and expected outcomes are
established.
attainment of such assist in ensuring a positive outcome.
 Option B: As explored by Salmond and Echevarria, healthcare is changing,
 Option D: Care plans enhance communication, documentation,
Critical thinking skills will play a vital role as nurses develop plans of care
for these patient populations with multiple comorbidities and embrace this
challenging healthcare arena.
ADVERTISEMENTS
2. Question 3 of 75
3. Question
Priorities are established to help the nurse anticipate and sequence nursing
interventions when a client has multiple problems or alterations. Priorities are
determined by the client‘s:
o A. Physician
o B. Non-Emergent, non-life-threatening needs
o C. Future well-being.
o D. Urgency of problems
Incorrect

Correct Answer: D. Urgency of problems
Triage of patients involves looking for signs of serious illness or injury. These
emergency signs are connected to the Airway – Breathing –
Circulation/Consciousness – Dehydration and are easily remembered as ABCD. If
the client does not have any emergency signs, the health worker proceeds to
assess the client for priority conditions. This should not take more than a few
seconds. Some of these signs will have been noticed during the ABCD triage and
others need to be rechecked.
 Option A: All clinical staff involved in the care of the sick should be
prepared to carry out a rapid assessment to identify the few clients who are
severely ill and require emergency treatment.
 Option B: Triage is the process of rapidly examining sick children when
they first arrive in order to place them in one of the following categories:
those with EMERGENCY SIGNS who require immediate emergency
treatment; those with PRIORITY SIGNS who should be given priority in the
queue so they can be rapidly assessed and treated without delay; and
those who have no emergency or priority signs and are NON-URGENT
cases. These clients can wait their turn in the queue for assessment and
treatment. The majority of sick clients will be non-urgent and will not
require emergency treatment.
 Option C: Ideally, all clients should be checked on their arrival by a person
who is trained to assess how ill they are. This person decides whether the
client will be seen immediately and receive life-saving treatment, or will be
seen soon, or can safely wait for his or her turn to be examined.
ADVERTISEMENTS
2. Question 4 of 75
4. Question
A client-centered goal is a specific and measurable behavior or response that
reflects a client‘s:
o A. Desire for specific health care interventions.
o B. Highest possible level of wellness and independence in function.
o C. Physician‘s goal for the specific client.

o D. Response when compared to another client with a similar problem.
Incorrect
Correct Answer: B. Highest possible level of wellness and independence in
function.
Client-centered practices facilitate the development of strong therapeutic
relationships and enable care providers to understand how to maximize clients‘
strengths and minimize challenges in achieving treatment and recovery goals.
 Option A: Care providers negotiate between clients‘ decisions and
ongoing risk assessments. The care plan reflects safe practices and
promotes interventions that minimize or reduce potential harms to the
client.
 Option C: Client-centred care empowers clients, promoting autonomy,
rights, voice, and self-determination in the treatment planning and
recovery process and supports care plans that are developed in
collaboration with clients, and allows clients to express their self-identified
needs and choices.
 Option D: Client-centred care is about treating clients as they want to be
treated, with knowledge about and respect for their values and personal
priorities. Health care providers who take the time to get to know their
clients can provide care that better addresses the needs of clients and
improves their quality of care.
ADVERTISEMENTS
2. Question 5 of 75
5. Question
For clients to participate in goal setting, they should be:
o A. Alert and have some degree of independence.
o B. Ambulatory and mobile.
o C. Able to speak and write.
o D. Able to read and write.

Incorrect
Correct Answer: A. Alert and have some degree of independence.

Goal setting in nursing provides direction for planning nursing interventions and
evaluating patient progress. The purpose of goal setting in nursing is to enable
the patient and nurse to determine when the problem has been resolved and
help motivate the patient and the nurse by providing a sense of achievement.
 Option B: In light of the potential benefits of patient participation in goal
setting, a study by Baker, Rice, Zimmerman, Marshak, et. al. believes the
following are needed: (1) patient and therapist education regarding the
potential advantages of participation, (2) the enhancement of patient
readiness to assume greater responsibility in their care, and (3) the
development of models for use in achieving patient participation.
 Option C: Patient and therapist education is needed regarding methods
for patient participation during initial goal-setting activities. In a study by
Baker, Rice, Zimmerman, Marshak, et. al., the therapists stated that they
believed that it is important to include patients in goal-setting activities
and that outcomes will be improved if patients participate. Patients also
indicated that participation is important to them.
 Option D: Patient participation in goal setting is emphasized in order to
enhance patient management and the effectiveness of treatment.
Participation should improve outcomes and could be used to identify
benefits that may result from the treatment. These benefits include greater
goal attainment, increased patient satisfaction, gains in function, better
adherence to treatment regimens, decreased depression in patients, and
reduced burnout rates among physical therapists.
ADVERTISEMENTS
2. Question 6 of 75
6. Question
The nurse writes an expected outcome statement in measurable terms. An
example is:
o A. Client will have less pain.
o B. Client will be pain-free.
o C. Client will report pain acuity less than 4 on a scale of 0-10.
o D. Client will take pain medication every 4 hours around the clock.

Incorrect
Correct Answer: C. Client will report pain acuity less than 4 on a scale of 0-
10.
When developing goals for patients, the nurse needs to look at several factors.
Think back to the SMART goal criteria. In order to be specific, nurses focus on
questions like ‗What is the problem? What is the response desired?‘ To make it
measurable, ‗How will the client look or behave if the healthy response is
achieved? What can I see, hear, measure, observe?‘
 Option A: One way to help nurses remember how to write goals is to make
sure they are SMART. SMART goals are Specific, Measurable, Action-
Oriented, Realistic, and Timely. ‗Specific‘ refers to who, what, when, where,
and why. ‗Measurable‘ means that you can actually measure and evaluate
the progress of that goal in a concrete way. ‗Action-oriented‘ means there
are actions that can be taken to reach the goal. ‗Realistic‘ includes the
ability to work on the goal, having the resources, attitudes, abilities, and
skills to reach this goal, and how realistic it is to come to fruition. Finally,
‗Timely‘ means that there is an end time frame or date at which the goal is
going to be evaluated.
 Option B: Goal setting occurs in the third phase of the process, planning.
Is the goal for nursing care to heal patients? To help them get better? To
help them get well? While these are certainly at the forefront of nurses‘
minds, how do you evaluate these statements? What if the definition of
wellness is different from one person to another? This is why nursing goal
statements that are patient-centered and measurable are so important.
 Option D: Considering action-oriented, ‗Are there steps and nursing
interventions needed to reach that goal? Is this a realistic outcome for the
patient? Have we considered all of the factors involved, including the
client‘s capabilities and limitations? Does the patient have what he or she
needs to reach that goal?‘ And finally, ‗Is it timely? When do we expect the
goal to be reached?‘
ADVERTISEMENTS
2. Question 7 of 75
7. Question
As goals, outcomes, and interventions are developed, the nurse must:

o A. Be in charge of all care and planning for the client.
o B. Be aware of and committed to accepted standards of practice from

nursing and other disciples.
o C. Not change the plan of care for the client.
o D. Be in control of all interventions for the client.

Incorrect
Correct Answer: B. Be aware of and committed to accepted standards of
practice from nursing and other disciples.
may frequently be needed depending upon overall patient condition. The plan of
care may be adapted based on new assessment data.
 Option A: Patients‘ participation in decision-making in health care and
treatment is not a new area, but currently it has become a political
necessity in many countries and health care systems around the world.
Emphasizing the importance of participation in the decision-making
process motivates the service provider and the health care team to
promote participation of patients in treatment decision-making.
 Option C: A review of some literature reveals that participation of patients
in health care has been associated with improved treatment outcomes.
Moreover, this participation causes improved control of diabetes, better
physical functioning in rheumatic diseases, enhanced patients‘ compliance
with secondary preventive actions, and improvement in health of patients
with myocardial infarction.
 Option D: With enhanced patient participation, and considering patients
as equal partners in healthcare decision making patients are encouraged to
actively participate in their own treatment process and follow their
treatment plan and thus a better health maintenance service would be
provided.
ADVERTISEMENTS
2. Question 8 of 75
8. Question
When establishing realistic goals, the nurse:

o A. Bases the goals on the nurse‘s personal knowledge.
o B. Knows the resources of the health care facility, family, and the client.
o C. Must have a client who is physically and emotionally stable.
o D. Must have the client‘s cooperation.

Incorrect
Correct Answer: B. Knows the resources of the health care facility, family,
and the client.
attainment of such assist in ensuring a positive outcome. Data may come from
the patient directly or from primary caregivers who may or may not be direct
relation family members. Friends can play a role in data collection. Electronic
health records may populate data and assist in assessment.
 Option C: The utilization of the nursing process to guide care is clinically
Aging populations carry with them a multitude of health problems and
inherent risks of missed opportunities to spot a life-altering condition.
 Option D: As explored by Salmond and Echevarria, healthcare is changing,
ADVERTISEMENTS
2. Question 9 of 75
9. Question
To initiate an intervention the nurse must be competent in three areas, which
include:
o A. Knowledge, function, and specific skills.

o B. Experience, advanced education, and skills.
o C. Skills, finances, and leadership.
o D. Leadership, autonomy, and skills.

Incorrect
Correct Answer: A. Knowledge, function, and specific skills
Critical thinking and reflection are essential skills because they can enhance
nurses‘ ability to solve problems and make sound decisions. Critical thinking skills
enable nurses to identify multiple possibilities in clinical situations and
alternatives to interventions; weigh the consequences of alternate actions; and
determine the right judgment and decisions. To provide safe and effective care to
the clients, nurses must integrate knowledge, skills, and attitudes to make sound
judgment and decisions.
 Option B: Due to the increasing internal and external expectations of
higher quality nursing, it is no longer acceptable for nurses to deliver
nursing care only on experience and textbook knowledge. Clinical nurses
are expected to systematically gather the best research evidence, draw
from nursing experience, and consider patient‘s preferences when they are
making professional decisions
 Option C: Some research findings showed that changing the attitude and
enhancing the knowledge of nurses are the first step in EBP. McCleary and
Brown conducted a study on 528 graduate nurses working in educational
pediatric hospitals of Canada and reported that the nurses‘ knowledge of
EBP and their positive attitude towards it will contribute to its
implementation in the healthcare system.
 Option D: Melnyk et al. stated that acquiring knowledge about research
methods and having the skill to evaluate research reports critically may
enable overcoming the obstacles hindering the application of research
findings and thus will lead to improvement of healthcare quality. Hence,
the EBP attitude, knowledge, and skills of nurses are so important.
ADVERTISEMENTS
10. Question
Collaborative interventions are therapies that require:

o A. Physician and nurse interventions.
o B. Nurse and client interventions.
o C. Client and Physician intervention.
o D. Multiple health care professionals.

Incorrect
Correct Answer: D. Multiple health care professionals.
Collaborative interventions are actions that the nurse carries out in collaboration
with other health team members, such as physicians, social workers, dietitians,
and therapists. These actions are developed in consultation with other health care
professionals to gain their professional viewpoint.
 Option A: Dependent nursing interventions are activities carried out under
 Option B: Independent nursing interventions are activities that nurses are
licensed to initiate based on their sound judgment and skills. Includes
ongoing assessment, emotional support, providing comfort, teaching,
physical care, and making referrals to other health care professionals.
 Option C: Nursing interventions are activities or actions that a nurse
eliminating or reducing the etiology of the nursing diagnosis. In this step,
nursing interventions are identified and written during the planning step of
the nursing process; however, they are actually performed during the
implementation step.
ADVERTISEMENTS
11. Question
Well formulated, client-centered goals should:
o A. Meet immediate client needs.
o B. Include preventative health care.
o C. Include rehabilitation needs.

Incorrect
The process of client-centered goal planning encourages members of the multi-
professional team to work in partnership with the client, his or her family, and
each other, united by the aim of helping the client to achieve his or her desired
outcome. Goals enable clients, their carers or partners, and the multidisciplinary
team to focus on strengths rather than problems. They also enable the team to
gauge where the client and family are in their ‗thinking‘ (Davis and O‘Connor,
1999).
 Option A: Once set, goals provide a central focus for all therapeutic
activity, enabling clients to move away from a period of dependency to a
level of achievement and/or adjustment to their situation.
 Option B: Goal planning is part of the overall care plan in which the client‘s
own values, beliefs, and aspirations are recognized and valued, and form
the central focus of the rehabilitation process.
 Option C: Goals for rehabilitation can be divided into two groups: short-
term and long-term. Short-term goals can act as stepping stones to
achieving longer-term targets. A short-term goal for this client might be to
be able to clean her teeth.
ADVERTISEMENTS
12. Question
The following statement appears on the nursing care plan for an
immunosuppressed client: The client will remain free from infection throughout
hospitalization. This statement is an example of a (an):
o A. Nursing diagnosis
o B. Short-term goal
o C. Long-term goal
o D. Expected outcome
Incorrect

Correct Answer: B. Short-term goal
Short-term goals can act as stepping stones to achieving longer-term targets. For
example, a client may have the long-term goal of being able to groom herself,
including cleaning her teeth, washing her face, combing her hair, and applying
her make-up on her own. A short-term goal for this client might be to be able to
clean her teeth.
 Option A: Actual or potential health problems that can be prevented or
resolved by independent nursing intervention are termed nursing
diagnoses. NANDA nursing diagnoses are a uniform way of identifying,
focusing on, and dealing with specific client needs and responses to actual
and high-risk problems.
 Option D: Goals or desired outcomes describe what the nurse hopes to
achieve by implementing the nursing interventions and are derived from
the client‘s nursing diagnoses. One overall goal is determined for each
nursing diagnosis. The terms goal, outcome, and expected outcome are
oftentimes used interchangeably.
ADVERTISEMENTS
13. Question
The following statements appear on a nursing care plan for a client after a
mastectomy: Incision site approximated; absence of drainage or prolonged
erythema at the incision site; and the client remains afebrile. These statements
are examples of:
o A. Nursing interventions
o B. Short-term goals
o C. Long-term goals
o D. Expected outcomes
Incorrect

Correct Answer: D. Expected outcomes
Goals or desired outcomes describe what the nurse hopes to achieve by
implementing the nursing interventions and are derived from the client‘s nursing
diagnoses. One overall goal is determined for each nursing diagnosis. The terms
goal, outcome, and expected outcome are oftentimes used interchangeably.
 Option A: Nursing interventions are activities or actions that a nurse
eliminating or reducing the etiology of the nursing diagnosis.
 Option B: Short-term goals can act as stepping stones to achieving
longer-term targets. For example, a client may have the long-term goal of
being able to groom herself, including cleaning her teeth, washing her face,
combing her hair, and applying her make-up on her own. A short-term
goal for this client might be to be able to clean her teeth.
ADVERTISEMENTS
14. Question
The planning step of the nursing process includes which of the following
activities?
o A. Assessing and diagnosing.
o B. Evaluating goal achievement.
o C. Performing nursing actions and documenting them.
o D. Setting goals and selecting interventions.

Incorrect
Correct Answer: D. Setting goals and selecting interventions.

essential in this phase of goal setting. Care plans provide a course of direction for
personalized care tailored to an individual‘s unique needs.
and data collection; subjective and objective. Data may come from the
patient directly or from primary caregivers who may or may not be direct
relation family members. Friends can play a role in data collection.
Electronic health records may populate data in and assist in assessment.
The formulation of a nursing diagnosis by employing clinical judgment
assists in the planning and implementation of patient care.
 Option B: This final step of the nursing process is vital to a positive patient
outcome. Whenever a healthcare provider intervenes or implements care,
they must reassess or evaluate to ensure the desired outcome has been
met. Reassessment may frequently be needed depending upon overall
patient condition. The plan of care may be adapted based on new
assessment data.
ADVERTISEMENTS
15. Question
The nursing care plan is:
o A. A written guideline for implementation and evaluation.
o B. A documentation of client care.
o C. A projection of potential alterations in client behaviors.
o D. A tool to set goals and project outcomes.

Incorrect
Correct Answer: A. A written guideline for implementation and evaluation.
Nursing care plans are essential in this phase of goal setting. Care plans provide a
course of direction for personalized care tailored to an individual‘s unique needs.

Overall condition and comorbid conditions play a role in the construction of a
care plan. Care plans enhance communication, documentation, reimbursement,
and continuity of care across the healthcare continuum.
 Option B: Documentation is any written or electronically generated
information about a client that describes the status, care or services
provided to that client. Through documentation, you communicate
observations, decisions, actions, and outcomes of these actions for clients,
demonstrating the nursing process.
 Option C: Behavioral tools are psychological instruments that are used for
understanding and interpreting human behavior. Such tools have found
many applications in corporate and educational sectors, considering their
exploratory and insightful nature.
 Option D: A SMART goal is one that is specific, measurable, attainable,
relevant and time-bound. The SMART criteria help to incorporate guidance
and realistic direction in goal setting, which increases motivation and leads
to better results in achieving lasting change.
ADVERTISEMENTS
16. Question
After determining a nursing diagnosis of acute pain, the nurse develops the
following appropriate client-centered goal:
o A. Encourage the client to implement guided imagery when pain begins.
o B. Determine the effect of pain intensity on client function.
o C. Administer analgesic 30 minutes before physical therapy treatment.
o D. Pain intensity reported as a 3 or less during hospital stay.

Incorrect
Correct Answer: D. Pain intensity reported as a 3 or less during hospital stay.
This is measurable and objective. Goals or desired outcomes describe what the
nurse hopes to achieve by implementing the nursing interventions and are
derived from the client‘s nursing diagnoses. Goals provide direction for planning
interventions, serve as criteria for evaluating client progress, enable the client and

nurse to determine which problems have been resolved, and help motivate the
client and nurse by providing a sense of achievement.
 Option A: This is an example of nursing intervention. Nursing interventions
are activities or actions that a nurse performs to achieve client goals.
Interventions chosen should focus on eliminating or reducing the etiology
of the nursing diagnosis.
 Option B: Evaluating is a planned, ongoing, purposeful activity in which
the client‘s progress towards the achievement of goals or desired
outcomes, and the effectiveness of the nursing care plan (NCP).
 Option C: This is an example of nursing intervention. Dependent nursing
interventions are activities carried out under the physician‘s orders or
supervision. Includes orders to direct the nurse to provide medications,
intravenous therapy, diagnostic tests, treatments, diet, and activity or rest.
ADVERTISEMENTS
17. Question
When developing a nursing care plan for a client with a fractured right tibia, the
nurse includes in the plan of care independent nursing interventions, including:
o A. Apply a cold pack to the tibia.
o B. Elevate the leg 5 inches above the heart.
o C. Perform a range of motion to right leg every 4 hours.
o D. Administer aspirin 325 mg every 4 hours as needed.

Incorrect
Correct Answer: B. Elevate the leg 5 inches above the heart.
This does not require a physician‘s order. Independent nursing interventions are
activities that nurses are licensed to initiate based on their sound judgment and
skills. Includes ongoing assessment, emotional support, providing comfort,
teaching, physical care, and making referrals to other health care professionals.
 Option A: This intervention requires a doctor‘s order. Assessment and
providing explanation while administering medical orders are also part of
the dependent nursing interventions.

 Option C: C is not appropriate for a fractured tibia. Isometrics contract
muscles without bending joints or moving limbs and help maintain muscle
strength and mass. Note: These exercises are contraindicated while acute
bleeding and edema are present.
 Option D: Dependent nursing interventions are activities carried out under
ADVERTISEMENTS
18. Question
Which of the following nursing interventions are written correctly?
o A. Apply continuous passive motion machines during the day.
o B. Perform neurovascular checks.
o C. Elevate head of bed 30 degrees before meals.
o D. Change dressing once a shift.

Incorrect
Correct Answer: C. Elevate head of bed 30 degrees before meals.
It is specific in what to do and when. Nursing interventions should be specific and
clearly stated, beginning with an action verb indicating what the nurse is
expected to do. Action verb starts the intervention and must be precise.
 Option A: This intervention does not specify the location of the
application. Nursing interventions are the actual treatments and actions
that are performed to help the patient to reach the goals that are set for
them. The nurse uses his or her knowledge, experience, and critical-
thinking skills to decide which interventions will help the patient the most.
 Option B: It was not stated in this intervention when the neurovascular
check should be performed. Nurses must use their knowledge, experience,
resources, research of evidence-based practice, the counsel of others, and
critical-thinking skills to decide which nursing interventions would best
benefit a specific patient.

 Option D: Qualifiers of how, when, where, time, frequency, and amount
provide the content of the planned activity. For example: ―Educate parents
on how to take temperature and notify of any changes,‖ or ―Assess urine
for color, amount, odor, and turbidity.‖
ADVERTISEMENTS
19. Question
A client‘s wound is not healing and appears to be worsening with the current
treatment. The nurse first considers:
o A. Notifying the physician.
o B. Calling the wound care nurse.
o C. Changing the wound care treatment.
o D. Consulting with another nurse.

Incorrect
Correct Answer: B. Calling the wound care nurse.
Calling the wound care nurse as a consultant is appropriate because he or she is
a specialist in the area of wound management. Professional and competent
nurses recognize limitations and seek appropriate consultation. As the largest
health care workforce, nurses apply their knowledge, skills, and experience to
care for the various and changing needs of patients. A large part of the demands
of patient care is centered on the work of nurses.
 Option A: Option A may be appropriate after deciding on a plan of action
with the wound care nurse specialist. The nurse may need to obtain orders
for special wound care products. Interprofessional and interprofessional
collaboration, through multidisciplinary teams, is important in the right
work environments. Skills for teamwork are considered nontechnical and
include leadership, mutual performance monitoring, adaptability, and
flexibility.
 Option C: Option C is possible unless the nurse is knowledgeable in
wound management, this could delay wound healing. Also, the current
wound management plan could have been ordered by the physician.
Clinicians working in teams will make fewer errors when they work well

together, use well-planned and standardized processes, know team
members and their own responsibilities, and constantly monitor team
members‘ performance to prevent errors before they could cause harm.
 Option D: Another nurse most likely will not be knowledgeable about
wounds, and the primary nurse would know the history of the wound
management plan. Understanding the complexity of the work environment
and engaging in strategies to improve its effects is paramount to higher-
quality, safer care.
ADVERTISEMENTS
20. Question
When calling the nurse consultant about a difficult client-centered problem, the
primary nurse is sure to report the following:
o A. Length of time the current treatment has been in place.
o B. The spouse‘s reaction to the client‘s dressing change.
o C. Client‘s concern about the current treatment.
o D. Physician‘s reluctance to change the current treatment plan.

Incorrect
Correct Answer: A. Length of time the current treatment has been in place.
This gives the consulting nurse facts that will influence a new plan. Other choices
are subjective and emotional issues and conclusions about the current treatment
plan may cause bias in the decision of a new treatment plan by the nurse
consultant. In general, it is important to create a supportive environment with
open and honest communication, focusing on the achievements and not on
negative aspects.
 Option B: Navigating the new system is very challenging and it is
important for the clients to have a person to whom they could always turn
with questions and concerns. It could not necessarily be a formal
caseworker, but rather any clinician who had a trusting relationship and
was helpful and willing to guide the client.

 Option C: Education and information for both the patient and the family
were mentioned by all the participants in a study as the main strategies to
help them develop a clear understanding of their condition and prognosis.
 Option D: Several successful strategies to improve client-centered care
have been introduced in different hospitals: writing a family note (a
summary that is given to the family) at the family meeting, appointing a
contact person/therapy leader for each client, improving continuity and
coordination of care through interdisciplinary collaborations, having the
same staff working with the client, and providing written materials.
ADVERTISEMENTS
21. Question
The primary nurse asked a clinical nurse specialist (CNS) to consult on a difficult
nursing problem. The primary nurse is obligated to:
o A. Implement the specialist‘s recommendations.
o B. Report the recommendations to the primary physician.
o C. Clarify the suggestions with the client and family members.
o D. Discuss and review advised strategies with CNS.

Incorrect
Correct Answer: D. Discuss and review advised strategies with CNS.
The primary nurse requested the consultation, it is important that they
communicate and discuss recommendations. The primary nurse can then accept
or reject the CNS recommendations. Effective clinical practice thus involves many
instances where critical information must be accurately communicated. Team
collaboration is essential.
 Option A: Some of the recommendations may not be appropriate for this
client. The primary nurse would know this information. A consultation
requires review of the recommendations, but not immediate
implementation. Collaboration in health care is defined as health care
professionals assuming complementary roles and cooperatively working
together, sharing responsibility for problem-solving, and making decisions
to formulate and carry out plans for patient care

 Option B: This would be appropriate after first talking with the CNS about
recommended changes in the plan of care and the rationale. Then the
primary nurse should call the physician. Collaboration between physicians,
nurses, and other health care professionals increases team members‘
awareness of each others‘ type of knowledge and skills, leading to
continued improvement in decision making.
 Option C: The client and family do not have the knowledge to determine
whether new strategies are appropriate or not. Better to wait until the new
plan of care is agreed upon by the primary nurse and physician before
talking with the client and/or family. A study determined that improved
teamwork and communication are described by health care workers as
among the most important factors in improving clinical effectiveness and
job satisfaction.
ADVERTISEMENTS
22. Question
After assessing the client, the nurse formulates the following diagnoses. Place
them in order of priority, with the most important (classified as high) listed first.
View Answers:
o Ineffective tissue perfusion.

o Constipation
o Ineffective airway clearance
o Anticipated grieving
Incorrect
Nurses should apply the concept of ABCs to each patient situation. Prioritization
begins with determining immediate threats to life as part of the initial assessment
and is based on the ABC pneumonic focusing on the airway as priority, moving to
breathing, and circulation (Ignatavicius et al., 2018).
 Ineffective airway clearance can be an acute (e.g., postoperative recovery)
or chronic (e.g., CVA or spinal cord injury) problem. High-risk for ineffective
airway clearance are the aged individuals who have an increased incidence

of emphysema and a higher prevalence of chronic cough or sputum
production.
 Decreased tissue perfusion can be temporary, with few or minimal
consequences to the health of the patient, or it can be more acute or
protracted, with potentially destructive effects on the patient. When
diminished tissue perfusion becomes chronic, it can result in tissue or
organ damage or death.
 Constipation occurs when bowel movements become less frequent than
normal. It is accompanied by a difficult or incomplete passage of stool.
Though common, constipation may also be a complex problem. Chronic
constipation can result in the development of hemorrhoids; diverticulosis;
straining at stool, and perforation of the colon.
 Grieving is an individual‘s normal response to a loss that may be perceived
or actual. Assessment is necessary in order to identify potential problems
that may have led to grief and also name any event that may happen
during nursing care.
ADVERTISEMENTS
23. Question
The nurse is reviewing the critical paths of the clients on the nursing unit. In
performing a variance analysis, which of the following would indicate the need
for further action and analysis?
o A. A client‘s family attending a diabetic teaching session.
o B. Canceling physical therapy sessions on the weekend.
o C. Normal VS and absence of wound infection in a post-op client.
o D. A client demonstrating accurate medication administration following

teaching.
Incorrect
Correct Answer: B. Canceling physical therapy sessions on the weekend.
Variance analysis is the identification of patient or family needs that are not
anticipated and the actions related to these needs in a system of managed care.

There are four kinds of origin for the variance: patient-family origin, system-
institutional origin; community origin, and clinician origin.
 Option A: Critical pathways are care plans that detail the essential steps
inpatient care with a view to describing the expected progress of the
patient. They also have a positive impact on outcomes, such as increased
quality of care and patient satisfaction, improved continuity of information,
and patient education.
 Option C: Clinical pathways are being increasingly used for daily patient
care. The pathways consist of a sequence of critical treatment events
matched to the patient‘s recovery. Variance analysis identifies deviations
from the pathway and can be used for quality improvement and clinical
audit.
 Option D: Clinical pathways can be used as a means of incorporating
evidence-based medicine into clinical practice. Variance analysis of the
pathways can be utilized as a process of quality control and to improve
patient outcomes.
ADVERTISEMENTS
24. Question
The RN has received her client assignment for the day shift. After making the
initial rounds and assessing the clients, which client would the RN need to
develop a care plan first?
o A. A client who is ambulatory.
o B. A client, who has a fever, is diaphoretic and restless.
o C. A client scheduled for OT at 1300.
o D. A client who just had an appendectomy and has just received pain
medication.
Incorrect
Correct Answer: B. A client, who has a fever, is diaphoretic and restless.
This client‘s needs are a priority. Clinical judgment and prioritization of patient
care is built on the nursing process. Nurses learn the steps of the nursing process

in their foundational nursing course and utilize it throughout their academic and
clinical careers to direct patient care and determine priorities.
 Option A: An ambulatory client would not be a priority. However, a
thorough assessment should still be done to make sure that the client does
not have any underlying diseases. In unfamiliar situations, patient
prioritization should be approached as a structured process, highlighting
risk factors that may contribute to a decline in the patient‘s condition and
potential interventions that can reduce the risk of adverse outcomes
(Jessee, 2019).
 Option C: The client does not have any emergent concerns based on the
stem. Seasoned nurses are able to pull from their depth of knowledge and
experience that allows them to act deductively and intuitively when
prioritizing patient care.
 Option D: The client has already received pain medication, therefore she is
not a priority. For expert nurses, the ability to prioritize based on these
processes is predominately intuitive, and tasks are completed in a
prioritized manner without much conscious thought.
ADVERTISEMENTS
25. Question
Which of the following statements about the nursing process is most accurate?
o A. The nursing process is a four-step procedure for identifying and resolving

patient problems.
o B. Beginning in Florence Nightingale‘s days, nursing students learned and

practiced the nursing process.
o C. Use of the nursing process is optional for nurses since there are many ways
to accomplish the work of nursing.
o D. The state board examinations for professional nursing practice now

use the nursing process rather than medical specialties as an organizing
concept.
Incorrect

Correct Answer: D. The state board examinations for professional nursing
practice now use the nursing process rather than medical specialties as an
organizing concept.
The nursing process is a systematic decision-making method focusing on
identifying and treating responses of individuals or groups to actual or potential
alterations in health it- is the essential core of nursing practice to deliver holistic,
patient-focused care. Nursing process provides an organizing framework for the
practice of nursing and the knowledge, judgments, and actions that nurses bring
to patient care.‖
 Option A: The nursing process is a five-step process. The nursing process
functions as a systematic guide to client-centered care with 5 sequential
steps. These are assessment, diagnosis, planning, implementation, and
evaluation. The utilization of the nursing process to guide care is clinically
 Option B: The term nursing process was first used by Hall in 1955. In 1958,
Ida Jean Orlando started the nursing process that still guides nursing care
today. Defined as a systematic approach to care using the fundamental
principles of critical thinking, client-centered approaches to treatment,
goal-oriented tasks, evidence-based practice (EDP) recommendations, and
nursing intuition.
 Option C: Nursing process is not optional since standards demand the use
of it. Holistic and scientific postulates are integrated to provide the basis
for compassionate, quality-based care. As explored by Salmond and
Echevarria, healthcare is changing, and the traditional roles of nurses are
transforming to meet the demands of this new healthcare environment.
Nurses are in a position to promote change and impact patient delivery
care models in the future.
ADVERTISEMENTS
26. Question
What equipment would be necessary to complete an evaluation of cranial nerves
9 and 10 during a physical assessment?
o A. A cotton ball
o B. A penlight

o C. An ophthalmoscope
o D. A tongue depressor and flashlight

Incorrect
Correct Answer: D. A tongue depressor and flashlight
Cranial nerves 9 and 10 are the glossopharyngeal and vagus nerves. The gag
reflex would be evaluated. The 9th (glossopharyngeal) and 10th (vagus) cranial
nerves are usually evaluated together. Whether the palate elevates symmetrically
when the patient says ―ah‖ is noted. If one side is paretic, the uvula is lifted away
from the paretic side. A tongue blade can be used to touch one side of the
posterior pharynx, then the other, and symmetry of the gag reflex is observed;
bilateral absence of the gag reflex is common among healthy people and may
not be significant.
 Option A: For the 5th (trigeminal) nerve, the 3 sensory divisions
(ophthalmic, maxillary, mandibular) are evaluated by using a pinprick to
test facial sensation and by brushing a wisp of cotton against the lower or
lateral cornea to evaluate the corneal reflex. If facial sensation is lost, the
angle of the jaw should be examined; sparing of this area (innervated by
spinal root C2) suggests a trigeminal deficit. A weak blink due to facial
weakness (eg, 7th cranial nerve paralysis) should be distinguished from
depressed or absent corneal sensation, which is common in contact lens
wearers. A patient with facial weakness feels the cotton wisp normally on
both sides, even though blink is decreased.
 Option B: A penlight provides a source of light and has become the most
common used tool to assess pupil diameter. Asymmetry of pupil
constriction in response to light means one pupil constricts and the other
remains dilated or constricts more slowly. It may indicate dynamic
anisocoria or a Marcus Gunn pupil, a relative afferent pupillary defect
(RAPD), or temporal lobe herniation in the brain.
 Option C: The eye can be examined with routine equipment, including a
standard ophthalmoscope; thorough examination requires special
equipment and evaluation by an ophthalmologist. Ophthalmoscopy
(examination of the posterior segment of the eye) can be done directly by
using a handheld ophthalmoscope or with a handheld lens in conjunction
with the slit lamp biomicroscope.
ADVERTISEMENTS

27. Question
Which technique would be best in caring for a client following receiving a
diagnosis of a stage IV tumor in the brain?
o A. Offering the client pamphlets on support groups for brain cancer.
o B. Asking the client if there is anything he or his family needs.
o C. Reminding the client that advances in technology are occurring every day.
o D. Providing accurate information about the disease and treatment

options.
Incorrect
Correct Answer: D. Providing accurate information about the disease and
treatment options.
Providing information for the client is the best technique for a new diagnosis.
Every clinician at one time or another faces these important questions. In the
treatment of terminally ill patients, the health professional needs many skills: the
ability to deliver bad news, the knowledge to provide appropriate optimal end-
of-life care, and the compassion to allow a person to retain his or her dignity.
 Option A: Cassem, in the Massachusetts General Hospital Handbook of
General Hospital Psychiatry, recommends relaying negative information to
patients through a brief, rehearsed initial statement that succinctly
communicates the news and clearly indicates that the treatment team is
committed to the ongoing care and support of the patient.
 Option B: In considering the emotional state of a person with terminal
illness, it is often helpful to consider the effects of the family members on
the patient and vice versa. By observing the interactions of a patient with
family, the consultant can become aware of long-standing grudges or new
difficulties in communication that can make the process of coming to
closure at the end of a life more difficult.
 Option C: In most cases, patients who are told their diagnosis in an up-
front, clear manner have better emotional adjustments to their situation
than those who are not told about their condition. By providing direct,
clear information in a compassionate manner, and by making clear to the

patient that everything possible will be done to provide medical and
emotional support, physicians can elicit trust and reduce anxiety.
ADVERTISEMENTS
28. Question
An 8.5 lb, 6 oz infant is delivered to a diabetic mother. Which nursing intervention
would be implemented when the neonate becomes jittery and lethargic?
o A. Administer insulin.
o B. Administer oxygen.
o C. Feed the infant glucose water (10%).
o D. Place the infant in a warmer.

Incorrect
Correct Answer: C. Feed the infant glucose water (10%)
After birth, the infant of a diabetic mother is often hypoglycemic. Treatment will
depend on the baby‘s gestational age and overall health. Treatment includes
giving the baby a fast-acting source of glucose. This may be as simple as a
glucose and water mixture or formula as an early feeding. Or the baby may need
glucose given through an IV. The baby‘s blood glucose levels are checked after
treatment to see if the hypoglycemia occurs again.
 Option A: Second-line therapies for the treatment of persistent
hypoglycemia include the use of corticosteroids or glucagon, not insulin.
Glucagon is a hormone that stimulates endogenous glucose production via
glycogenolysis and gluconeogenesis; thus its effectiveness depends on the
infant having adequate glycogen stores. It is most useful in term infants
and infants of diabetic mothers. Glucagon dosing is as a 30 mcg/kg bolus
or 300 mcg/kg per minute continuous infusion.
 Option B: Oxygen is not administered to hypoglycemic neonates. Early
initiation of breastfeeding is crucial for all infants. For asymptomatic infants
at risk of neonatal hypoglycemia, the AAP recommends initiating feeds
within the first hour of life and performing initial glucose screening 30
minutes after the first feed. The AAP recommends goal blood glucose
levels equal to or greater than 45 mg/dL prior to routine feedings, and

intervention for blood glucose <40 mg/dL in the first 4 hours of life and
<45 mg/dL at 4 to 24 hours of life.
 Option D: Placing the infant in a warmer does not manage the
hypoglycemia. In infants of diabetic mothers, lower glucose infusions rates
of 3 to 5 mg/kg/minute may be used to minimize pancreatic stimulation
and endogenous insulin secretion. Infants requiring higher rates of
intravenous dextrose (>12 to 16 mg/kg/minute) or for more than 5 days
are more likely to have a persistent cause of hypoglycemia.
ADVERTISEMENTS
29. Question
What question would be most important to ask a male client who is in for a
digital rectal examination?
o A. “Have you noticed a change in the force of the urinary system?”
o B. ―Have you noticed a change in tolerance of certain foods in your diet?‖
o C. ―Do you notice polyuria in the AM?‖
o D. ―Do you notice any burning with urination or any odor to the urine?‖
Incorrect
Correct Answer: A. “Have you noticed a change in the force of the urinary
system?”
This change would be most indicative of a potential complication with (BPH)
benign prostate hypertrophy. The goals of the evaluation of such men are to
identify the patient‘s voiding or, more appropriately, urinary tract problems, both
symptomatic and physiologic; to establish the etiologic role of BPH in these
problems.
 Option B: Food intolerances are more common in those with digestive
system disorders, such as irritable bowel syndrome (IBS). According to the
IBS network, most people with IBS have food intolerances. The symptoms
of food intolerances can also mimic the symptoms of chronic digestive
conditions, such as IBS. However, certain patterns in the symptoms can
help a doctor distinguish between the two.

 Option C: History can often distinguish polyuria from frequency, but rarely
a 24-hour urine collection may be needed. Polyuria caused by solute
diuresis is suggested by a history of diabetes mellitus. Abrupt onset of
polyuria at a precise time suggests central diabetes insipidus, as does
preference for extremely cold or iced water.
 Option D: Dysuria is a symptom of pain and/or burning, stinging, or
itching of the urethra or urethral meatus with urination. It is one of the
most common symptoms experienced by most people at least once over
their lifetimes. Primarily, causes of dysuria can be divided broadly into two
categories, infectious and non-infectious.
ADVERTISEMENTS
30. Question
The nurse assesses a prolonged late deceleration of the fetal heart rate while the
client is receiving oxytocin (Pitocin) IV to stimulate labor. The priority nursing
intervention would be to:
o A. Turn off the infusion.
o B. Turn the client to the left.
o C. Change the fluid to Ringer‘s Lactate.
o D. Increase mainline IV rate.

Incorrect
Correct Answer: A. Turn off the infusion
Stopping the infusion will decrease contractions and possibly remove uterine
pressure on the fetus, which is a possible cause of the deceleration. When late
decelerations are observed, the nurse should attempt to increase the oxygen
delivery to the fetus by turning the mother on her left side and/or administering
oxygen. If Oxytocin (Pitocin) is being administered, it should be stopped.
 Option B: Variable decelerations are marked by a sharp decrease (―V‖
shape) in FHR that does not correlate to contractions. Umbilical cord
compression is usually the cause of variable decelerations. Repositioning of
the mother can relieve this compression if it is minor.

 Option C: Late decelerations are shown by the FHR gradually decreasing
around the peak of the contraction and gradually increasing when the
contraction is over. These decelerations will also have a ―U‖ shape but will
not mirror the contractions. The most common cause of late decelerations
is uteroplacental insufficiency (insufficient oxygen exchange between the
placenta and the fetus).
 Option D: Increasing the main IV line would not manage the decelerations.
While caring for a patient in labor, one of the important nursing duties is
monitoring the variability of the fetal heart rate (FHR) and monitoring the
FHR response during contractions. Variability in the FHR during labor is a
sign of fetal well-being or fetal activity or both. The expected variability
usually includes slight accelerations and decelerations.
ADVERTISEMENTS
31. Question
Which nursing approach would be most appropriate to use while administering
an oral medication to a 4-month-old?
o A. Place medication in 45cc of formula.
o B. Place medication in an empty nipple.
o C. Place medication in a full bottle of formula.
o D. Place in supine position. Administer medication using a plastic syringe.

Incorrect
Correct Answer: B. Place medication in an empty nipple.
This is a convenient method for administering medications to an infant. Draw up
the correct amount of medicine into an oral syringe (a syringe without a needle)
or an empty nipple. Let the infant suck the medicine out of the syringe or empty
nipple. When giving medicine to an infant, use his natural reflexes (such as
sucking) whenever possible.
 Option A: Avoid mixing medicine with foods the child must have. The child
may begin to dislike the foods he needs. Mix the medicine with a small
amount (1 to 2 teaspoons) of applesauce or pears and give it with a spoon.

This is a good way to give pills that have been crushed well. (To crush a pill,
place it between two spoons and press the spoons together).
 Option C: Some medicines can be put in a small amount of juice or sugar
water. Follow the instructions from the doctor, nurse, or pharmacist. Do not
put medicine in a full bottle or cup in case the infant does not drink very
much.
 Option D: Option D is partially correct however, the infant is never placed
in a reclining position during a procedure due to a potential aspiration.
Hold the infant in a nearly upright position. If the infant struggles, gently
hold one arm and place his other arm around the waist. Hold the baby
close to the body.
ADVERTISEMENTS
32. Question
Which nursing intervention would be a priority during the care of a 2-month-old
after surgery?
o A. Minimize stimuli for the infant.
o B. Restrain all extremities.
o C. Encourage stroking of the infant.
o D. Demonstrate to the mother how she can assist with her infant‘s care.
Incorrect
Correct Answer: C. Encourage stroking of the infant.
Tactile stimulation is imperative for an infant‘s normal emotional development.
After the trauma of surgery, sensory deprivation can cause failure to thrive. Most
babies with FTT do not have a specific underlying disease or medical condition to
account for their growth failure. This is referred to as Non-organic FTT. Up to 80%
of all children with FTT have Non-organic type FTT. Non-organic FTT most
commonly occurs when there is inadequate food intake or there is a lack of
environmental stimuli.
 Option A: Provide sensory stimulation. Attempt to cuddle the child and
talk to him or her in a warm, soothing tone and allow for play activities
appropriate for the child‘s age. Feed the child slowly and carefully in a

quiet environment; during feeding, the child might be closely snuggled and
gently rocked; it may be necessary to feed the child every 2 to 3 hours
initially.
 Option B: Do not restrain the child. Burp the child frequently during and at
the end of each feeding, and then place him or her on the side with the
head slightly elevated or held in a chest-to-chest position.
 Option D: If a family caregiver is present, encourage him or her to become
involved in the child‘s feedings. While caring for the child, point out to the
caregiver the child‘s development and responsiveness, noting and praising
any positive parenting behaviors the caregiver displays.
ADVERTISEMENTS
33. Question
While performing a physical examination on a newborn, which assessment should
be reported to the physician?
o A. Head circumference of 40 cm.
o B. Chest circumference of 32 cm.
o C. Acrocyanosis and edema of the scalp.
o D. Heart rate of 160 and respirations of 40.

Incorrect
Correct Answer: A. Head circumference of 40 cm
Average circumference of the head for a neonate ranges between 32 to 36 cm.
An increase in size may indicate hydrocephalus or increased intracranial pressure.
A newborn‘s head is usually about 2 cm larger than the chest size. Between 6
months and 2 years, both measurements are about equal. After 2 years, the chest
size becomes larger than the head.
 Option B: The body of a normal newborn is essentially cylindrical; head
circumference slightly exceeds that of the chest. For a term baby, the
average circumference of the head is 33–35 cm (13–14 inches), and the
average circumference of the chest is 30–33 cm (12–13 inches).
 Option C: Peripheral cyanosis (acrocyanosis) involves the hands, feet, and
circumoral area. It is evident in most infants at birth and for a short time

thereafter. If limited to the extremities in an otherwise normal infant, it is
due to venous stasis and is innocuous. Localized cyanosis may occur in
presenting parts, particularly in association with abnormal presentations.
 Option D: Heart rates normally fluctuate between 120 and 160 beats per
minute. In agitated states, a rate of 200 beats per minute may occur
transiently. The heart rate of premature infants is usually between 130 and
170 beats per minute, and during occasional episodes of bradycardia, it
may slow to 70 beats per minute or less. Normal neonates breathe at rates
that vary between 40 and 60 respirations per minute. Rapid rates are likely
to be present for the first few hours after birth.
ADVERTISEMENTS
34. Question
Which action by the mother of a preschooler would indicate a disturbed family
interaction?
o A. Tells her child that if he does not sit down and shut up she will leave
him there.
o B. Explains that the injection will burn like a bee sting.
o C. Tells her child that the injection can be given while he‘s in her lap.
o D. Reassures the child that it is acceptable to cry.

Incorrect
Correct Answer: A. Tells her child that if he does not sit down and shut up
she will leave him there.
Threatening a child with abandonment will destroy the child‘s trust in his family.
Children growing up in such families are likely to develop low self-esteem and
feel that their needs are not important or perhaps should not be taken seriously
by others. As a result, they may form unsatisfying relationships as adults.
 Option B: It can help to describe the need for injections and blood testing
in kid terms. For example, the nurse might explain that the shots and blood
tests help keep the child feeling good throughout the day — and that not
getting them could mean having to stay home from school or miss fun
activities because of health problems.

 Option C: Having both parents (or one parent plus another caregiver)
involved in the management process will help keep treatment consistent
and also provide support as the nurse deals with struggles over shots and
blood tests.
 Option D: If the child argues or cries, the parents might be tempted to skip
an injection or test just this once. Nurses shouldn‘t negotiate blood tests or
shots. They‘re necessary and not optional. The first time you‘re talked out
of one, you‘ll set a precedent that that child won‘t forget.
ADVERTISEMENTS
35. Question
During the history, which information from a 21-year-old client would indicate a
risk for development of testicular cancer?
o A. Genital Herpes
o B. Hydrocele
o C. Measles
o D. Undescended testicle
Incorrect
Correct Answer: D. Undescended testicle
Undescended testicles make the client at high risk for testicular cancer. Mumps,
inguinal hernia in childhood, orchitis, and testicular cancer in the contralateral
testis are other predisposing factors. The risk of testicular cancer might be a little
higher for men whose testicles stayed in the abdomen as opposed to one that
has descended at least partway. If cancer does develop, it‘s usually in the
undescended testicle, but about 1 out of 4 cases occur in the normally descended
testicle.
 Option A: While HPV infections are very common, cancer caused by HPV is
not. Most people infected with HPV will not develop cancer-related to the
infection. However, some people with long-lasting infections of high-risk
types of HPV, are at risk of developing cancer.
 Option B: Hydroceles generally don‘t pose any threat to the testicles.
They‘re usually painless and disappear without treatment. However, if the

patient has scrotal swelling, he should see his doctor rule out other causes
that are more harmful such as testicular cancer.
 Option C: Measles has a low death rate in healthy children and adults, and
most people who contract the measles virus recover fully. The risk of
complications is higher in the following groups: children under 5 years old.
adults over 20 years old.
ADVERTISEMENTS
36. Question
While caring for a client, the nurse notes a pulsating mass in the client‘s
periumbilical area. Which of the following assessments is appropriate for the
nurse to perform?
o A. Measure the length of the mass.
o B. Auscultate the mass.
o C. Percuss the mass.
o D. Palpate the mass.

Incorrect
Correct Answer: B. Auscultate the mass.
Auscultate the mass. Auscultation of the abdomen and finding a bruit will confirm
the presence of an abdominal aneurysm and will form the basis of information
given to the provider. Occasionally, an overlying mass (pancreas or stomach) may
be mistaken for an AAA. An abdominal bruit is nonspecific for an unruptured
aneurysm, but the presence of an abdominal bruit or the lateral propagation of
the aortic pulse wave can offer subtle clues and maybe more frequently found
than a pulsatile mass.
 Option A: In one study, 38% of AAA cases were detected on the basis of
physical examination findings, whereas 62% were detected incidentally on
radiologic studies obtained for other reasons. Femoral/popliteal pulses and
pedal (dorsalis pedis or posterior tibial) pulses should be palpated to
determine if an associated aneurysm (femoral/popliteal) or occlusive
disease exists. Flank ecchymosis (Grey Turner sign) represents
retroperitoneal hemorrhage.

 Option C: Do not percuss the abdominal mass. The presence of a pulsatile
abdominal mass is virtually diagnostic of an AAA but is found in fewer than
50% of cases. It is more likely to be noted with a ruptured aneurysm.
 Option D: The mass should not be palpated because of the risk of rupture.
Most clinically significant AAAs are palpable upon routine physical
examination; however, the sensitivity of palpation depends on the
experience of the examiner, the size of the aneurysm, and the size of the
patient.
ADVERTISEMENTS
37. Question
When observing 4-year-old children playing in the hospital playroom, what
activity would the nurse expect to see the children participating in?
o A. Competitive board games with older children.
o B. Playing with their own toys alongside other children.
o C. Playing alone with handheld computer games.
o D. Playing cooperatively with other preschoolers.

Incorrect
Correct Answer: D. Playing cooperatively with other preschoolers.
Playing cooperatively with other preschoolers. Cooperative play is typical of the
late preschool period. Cooperative play is the final stage of play and represents
the child‘s ability to collaborate and cooperate with other children towards a
common goal. Children often reach the cooperative stage of play between 4 and
5 years of age after they have moved through the earlier five stages of play.
 Option A: Competitive play is when children learn to play organized
games with clear rules and clear guidelines on winning and losing. Ludo,
snake and ladders, and football are all forms of competitive play.
 Option B: After mastering onlooker play, a child will be ready to move into
parallel play. During parallel play, children will play beside and in proximity
to other children without actually playing with them. Children often enjoy
the buzz that comes with being around other kids, but they don‘t yet know
how to step into others‘ games or ask other kids to step into their games.

 Option C: Encourage the child to play with others and be active several
times a week instead of spending time in front of a screen. This can help to
build healthy, active bodies. (To be clear, learning can happen during
screen time, too — just not this specific type of learning.)
ADVERTISEMENTS
38. Question
The nurse is teaching the parents of a 3 month-old infant about nutrition. What is
the main source of fluids for an infant until about 12 months of age?
o A. Formula or breastmilk
o B. Dilute nonfat dry milk
o C. Warmed fruit juice
o D. Fluoridated tap water

Incorrect
Correct Answer: A. Formula or breastmilk
Formula or breast milk are the perfect food and source of nutrients and liquids
up to 1 year of age. Breastfeeding with appropriate supplementation is the
preferred method for feeding infants 0-12 months old. Iron-fortified formulas are
recommended if the child is not breastfed or requires supplemental formula in
addition to breast milk.
 Option B: The American Academy of Pediatrics Committee on Nutrition
updated their recommendations concerning infant feeding practices during
the second six months of life. The committee stated that breastfeeding is
the preferred method of feeding during the first year of life and that whole
cow‘s milk may be introduced after six months of age if adequate
supplementary feedings are given. Reduced fat content milk is not
recommended during infancy.
 Option C: When the infants are consuming one-third of their calories from
a balanced mixture of iron-fortified cereals, vegetables, fruits, and other
foods providing adequate sources of both iron and Vitamin C it is
considered adequate supplementary feeding.

 Option D: The World Health Organization (WHO) notes that babies that
are breastfed don‘t need additional water, as breast milk is over 80 percent
water and provides the fluids your baby needs. Children who are bottle-fed
will stay hydrated with the help of their formula. Water feedings tend to fill
up your baby, making them less interested in nursing. This could actually
contribute to weight loss and elevated bilirubin levels.
ADVERTISEMENTS
39. Question
While the nurse is administering medications to a client, the client states ―I do not
want to take that medicine today.‖ Which of the following responses by the nurse
would be best?
o A. ―That‘s OK, it's alright to skip your medication now and then.‖
o B. ―I will have to call your doctor and report this.‖
o C. “Is there a reason why you don’t want to take your medicine?”
o D. ―Do you understand the consequences of refusing your prescribed

treatment?‖
Incorrect
Correct Answer: C. “Is there a reason why you don’t want to take your
medicine?”
When a new problem is identified, it is important for the nurse to collect accurate
assessment data. This is crucial to ensure that client needs are adequately
identified in order to select the best nursing care approaches. The nurse should
try to discover the reason for the refusal which may be that the client has
developed untoward side effects.
 Option A: It is not alright to skip medication. Be very matter-of-fact in
communication style with the individual taking the medication. Do not beg,
threaten, bribe, or force the individual. Do not say ―I‘ll get in trouble ― or
―You‘ll get in trouble‖.
 Option B: If they continue to refuse, document the missed dose and state
the reason (individual refused), along with other relevant information if
known (i.e. they indicated nausea). In addition, contact the physician under

circumstances as agreed when medication was prescribed and/or
implement any steps in the ISP for missed doses.
 Option D: Find out if they understand what the medication is for. If they
do not understand, remind them of the purpose and ask them again to
take it. Find out if they understand the implications of not taking their
medication. If they do not understand, remind them of the implications
and ask them again to take it (In addition to physical symptoms,
implications may include the need to call the physician and report the
missed dose.)
ADVERTISEMENTS
40. Question
The nurse is assessing a 4 month-old infant. Which motor skill would the nurse
anticipate finding?
o A. Hold a rattle
o B. Bang two blocks
o C. Drink from a cup
o D. Wave ―bye-bye‖
Incorrect
Correct Answer: A. Hold a rattle
The age at which a baby will develop the skill of grasping a toy with help is 4 to 6
months. The baby is becoming more dexterous and doing more with their hands.
Their hands now work together to move a toy or shake a rattle. In fact, those
hands will grab for just about anything within reach, including a stuffed animal,
the mother‘s hair, and any colorful or shiny object hanging nearby
 Option B: At 9 months, babies repeat different actions with objects. They
mouth objects to explore the features. They bang objects with their hand
and bang two objects together to create sounds and actions. They drop
objects sometimes by chance and other times on purpose.
 Option C: Babies are learning functional actions with a purpose in mind.
They can put things in, such as put clothes in the dryer or a shape in a
puzzle. From ―put in‖ they learn a variety of functional actions. They can put

a sippy cup to their mouth to drink, a spoon in a bowl to scoop, and a
spoon in their mouth to eat.
 Option D: Learning how to wave bye-bye is an important milestone for an
infant that usually occurs between the age of 10 months and a year. A
study in Pediatrics International found premature infants mastered the
bye-bye gesture significantly later than full-term babies and used different
hand and wrist motions.
ADVERTISEMENTS
41. Question
The nurse should recognize that all of the following physical changes of the head
and face are associated with the aging client except:
o A. Pronounced wrinkles on the face.
o B. Decreased size of the nose and ears.
o C. Increased growth of facial hair.
o D. Neck wrinkles.
Incorrect
Correct Answer: B. Decreased size of the nose and ears.
The nose and ears of the aging client actually become longer and broader. The
chin line is also altered. Height doesn‘t change after puberty (well, if anything we
get shorter as we age) but ears and noses are always lengthening. That‘s due to
gravity, not actual growth. As people age, gravity causes the cartilage in the ears
and nose to break down and sag. This results in droopier, longer features.
 Option A: Wrinkles on the face become more pronounced and tend to
take on the general mood of the client over the years. For example laugh
or frown wrinkles above the eyebrows, lips, cheeks, and outer edges of the
eye orbit.
 Option C: The change in the androgen-estrogen ratio causes an increase in
growth of facial hair in most older adults. Women develop excessive body
or facial hair due to higher-than-normal levels of androgens, including
testosterone. All females produce androgens, but the levels typically
remain low.

 Option D: The aging process shortens the platysma muscle, which
contributes to neck wrinkles. Some amount of neck wrinkling is inevitable.
The extent of the necklines and other signs of aging skin are determined in
part by genetics. Necklines and wrinkles are a normal part of aging. They‘re
caused in part by skin losing elasticity and being exposed to UV light over
time.
ADVERTISEMENTS
42. Question
All of the following characteristics would indicate to the nurse that an elder client
might experience undesirable effects of medicines except:
o A. Increased oxidative enzyme levels.
o B. Alcohol taken with medication.
o C. Medications containing magnesium.
o D. Decreased serum albumin.

Incorrect
Correct Answer: A. Increased oxidative enzyme levels.
Oxidative enzyme levels decrease in the elderly, which affects the disposition of
medication and can alter the therapeutic effects of medication. Oxidative stress
causes cells and entire organisms to age. If reactive oxygen species accumulate,
this causes damage to the DNA as well as changes in the protein molecules and
lipids in the cell. The cell ultimately loses its functionality and dies. Over time, the
tissue suffers, and the body ages.
 Option B: Alcohol has a smaller water distribution level in the elderly,
resulting in higher blood alcohol levels. Alcohol also interacts with various
drugs to either potentiate or interfere with their effects. The older one gets,
the longer alcohol stays in the system. So it‘s more likely to be there when
the client takes medicine. And alcohol can affect the way the meds work. It
can also lead to serious side effects.
 Option C: Magnesium is contained in a lot of medications older clients
routinely obtain over the counter. Magnesium toxicity is a real concern.
Older adults have lower dietary intakes of magnesium than younger adults.

In addition, magnesium absorption from the gut decreases, and renal
magnesium excretion increases with age. Older adults are also more likely
to have chronic diseases or take medications that alter magnesium status,
which can increase their risk of magnesium depletion
 Option D: Albumin is the major drug-binding protein. Decreased levels of
serum albumin mean that higher levels of the drug remain free and that
there are fewer therapeutic effects and increased drug interactions.
ADVERTISEMENTS
43. Question
When assessing a newborn whose mother consumed alcohol during the
pregnancy, the nurse would assess for which of these clinical manifestations?
o A. Wide-spaced eyes, smooth philtrum, flattened nose
o B. Strong tongue thrust, short palpebral fissures, simian crease
o C. Negative Babinski sign, hyperreflexia, deafness
o D. Shortened limbs, increased jitteriness, constant sucking

Incorrect
Correct Answer: A. Wide-spaced eyes, smooth philtrum, flattened nose
The nurse should anticipate that the infant may have fetal alcohol syndrome and
should assess for signs and symptoms of it. These include the characteristics
listed in choice A. Fetal alcohol syndrome is a condition in a child that results
from alcohol exposure during the mother‘s pregnancy. Fetal alcohol syndrome
causes brain damage and growth problems. The problems caused by fetal alcohol
syndrome vary from child to child, but defects caused by fetal alcohol syndrome
are not reversible.
 Option B: A single palmar crease is a single line that runs across the palm
of the hand. People most often have 3 creases in their palms. A single
palmar crease appears in about 1 out of 30 people. Males are twice as
likely as females to have this condition. Some single palmar creases may
indicate problems with development and be linked with certain disorders.
 Option C: Hyperreflexia is a sign of upper motor neuron damage and is
associated with spasticity and a positive Babinski sign. In infants with at

CST which is not fully myelinated the presence of a Babinski sign in the
absence of other neurological deficits is considered normal up to 24
months of age.
 Option D: Achondroplasia is the most common form of short-limb
dwarfism. It is an autosomal dominant disorder caused by a mutation in
the gene that creates the cells (fibroblasts) which convert cartilage to bone.
This means, if the gene is passed on by one parent, the child will have
achondroplasia.
ADVERTISEMENTS
44. Question
Which of these statements, when made by the nurse, is most effective when
communicating with a 4-year-old?
o A. “Tell me where you hurt.”
o B. ―Other children like having their blood pressure taken.‖
o C. ―This will be like having a little stick in your arm.‖
o D. ―Anything you tell me is confidential.‖

Incorrect
Correct Answer: A. “Tell me where you hurt.”
Four-year-olds are egocentric and interested in having the focus on themselves.
As kids gain language skills, they also develop their conversational abilities. Kids 4
to 5 years old can follow more complex directions and enthusiastically talk about
things they do. They can make up stories, listen attentively to stories, and retell
stories.
 Option B: They will not be interested in what it feels like to other children.
By the time your child is in their later years of primary school, their
language and ability to convey ideas has improved a lot. They even alter
their speech to suit the circumstances. They may speak more formally in
front of a teacher than they do with family and friends.
 Option C: Preschoolers are concrete thinkers and would literally interpret
any analogies so they are not helpful in explaining procedures. Concrete
thinking is a kind of reasoning that relies heavily on what we observe in the

physical world around us. It‘s sometimes called literal thinking. Young
children think concretely, but as they mature, they usually develop the
ability to think more abstractly.
 Option D: Assurance of confidential communication is most appropriate
for the adolescent. In addition, confidentiality is not maintained if the child
plans to harm themselves, harm someone else, or discloses abuse.
ADVERTISEMENTS
45. Question
A 64-year-old client scheduled for surgery with a general anesthetic refuses to
remove a set of dentures prior to leaving the unit for the operating room. What
would be the most appropriate intervention by the nurse?
o A. Explain to the client that the dentures must come out as they may get lost
or broken in the operating room.
o B. Ask the client if there are second thoughts about having the procedure.
o C. Notify the anesthesia department and the surgeon of the client‘s refusal.
o D. Ask the client if the preference would be to remove the dentures in

the operating room receiving area.
Incorrect
Correct Answer: D. Ask the client if the preference would be to remove the
dentures in the operating room receiving area.
Clients anticipating surgery may experience a variety of fears. This choice allows
the client control over the situation and fosters the client‘s sense of self-esteem
and self-concept. Nurses need to allow patients the choice of what to do in
relation to their dentures when going to the theatre, although the anesthetist
must make the final decision of whether or not to remove them immediately
before the anesthetic if they feel patient safety could be compromised.
 Option A: According to a study, ―There are no set national guidelines on
how dentures should be managed during anesthesia, but it is known that
leaving dentures in during bag-mask ventilation allows for a better seal
during induction [when the anesthetic is being infused], and therefore

many hospitals allow dentures to be removed immediately before
intubation [when a tube is inserted into the airway to assist breathing]‖.
 Option B: The swallowing of dentures during general anesthesia is a
significant problem for anesthesiologists. It is seen more often in patients
with psychiatric disorders, mental retardation, alcoholism, or poor-quality
dentures. It has become an important issue for anesthesiologists
preoperatively due to the increase in the proportion of dentures associated
with the prolongation of life.
 Option C: The presence of any false teeth or dental plates should be
clearly documented before and after any surgical procedure, with all
members of the surgical team made aware of what is to be done with
them, they add.
ADVERTISEMENTS
46. Question
The nurse is assessing a client who states her last menstrual period was March 17,
and she has missed one period. She reports episodes of nausea and vomiting.
Pregnancy is confirmed by a urine test. What will the nurse calculate as the
estimated date of delivery (EDD)?
o A. November 8
o B. May 15
o C. February 21
o D. December 24
Incorrect
Correct Answer: D. December 24
Naegele‘s rule: add 7 days and subtract 3 months from the first day of the last
regular menstrual period to calculate the estimated date of delivery. Naegele‘s
rule, derived from a German obstetrician, subtracts 3 months and adds 7 days to
calculate the estimated due date (EDD). It is prudent for the obstetrician to get a
detailed menstrual history, including duration, flow, previous menstrual periods,
and hormonal contraceptives.

 Option A: Determining gestational age is one of the most critical aspects
of providing quality prenatal care. Knowing the gestational age allows the
obstetrician to provide care to the mother without compromising maternal
or fetal status. It allows for the correct timing of management, such as
administering steroids for fetal lung maturity, starting ASA therapy with a
history of pre-eclampsia in previous pregnancies, starting
hydroxyprogesterone caproate (Makena) for previous preterm deliveries.
 Option B: An average pregnancy lasts 280 days from the first day of the
last menstrual period (LMP) or 266 days after conception. Historically, an
accurate LMP is the best estimator to determine the due date.
 Option C: An official EDD is established after calculating the first-trimester
sonogram EDD date and then using the LMP. If the LMP and first trimester
EDD are within 7 days of each other, the LMP estimates the due date. The
margin of error is reduced depending on when (i.e., how early) the
sonogram occurred.
ADVERTISEMENTS
47. Question
The family of a 6-year-old with a fractured femur asks the nurse if the child‘s
height will be affected by the injury. Which statement is true concerning long
bone fractures in children?
o A. Growth problems will occur if the fracture involves the periosteum.
o B. Epiphyseal fractures often interrupt a child’s normal growth pattern.
o C. Children usually heal very quickly, so growth problems are rare.
o D. Adequate blood supply to the bone prevents growth delay after fractures.
Incorrect
Correct Answer: B. Epiphyseal fractures often interrupt a child’s normal
growth pattern.
Epiphyseal fractures often interrupt a child‘s normal growth pattern. Growth plate
fractures are classified based on which parts of the bone are damaged, in
addition to the growth plate. Areas of the bone immediately above and below

the growth plate may fracture. They are called the epiphysis (the tip of the bone)
and metaphysis (the ―neck‖ of the bone).
 Option A: The most serious complication is early closure (complete or
partial) of the growth plate. Complete closure means the entire growth
plate of the affected bone has stopped expanding. This results in the
affected bone not growing as long as the opposite side.
 Option C: The severity of and need for treatment of growth plate closures
depend on the location of the fracture and the age of the patient. Other
complications of growth plate fractures include delayed healing of the
bone, nonhealing, infection, and loss of blood flow to the area, causing
death of part of the bone.
 Option D: Growth plate fractures are generally treated with splints or casts.
Sometimes, the bone may need to be put back in place to allow it to heal
in the correct position. This may be done before or after the cast is placed
and is called a closed reduction. The length of time the child needs to be in
a cast or splint depends on the location and severity of the fracture. The
child‘s age also matters: younger patients heal faster than older patients.
ADVERTISEMENTS
48. Question
A client is admitted to the hospital with a history of confusion. The client has
difficulty remembering recent events and becomes disoriented when away from
home. Which statement would provide the best reality orientation for this client?
o A. ―Good morning. Do you remember where you are?‖
o B. ―Hello. My name is Elaine Jones and I am your nurse for today.‖
o C. ―How are you today? Remember, you‘re in the hospital.‖
o D. “Good morning. You’re in the hospital. I am your nurse Elaine Jones.”

Incorrect
Correct Answer: D. “Good morning. You’re in the hospital. I am your nurse
Elaine Jones.”
As cognitive ability declines, the nurse provides a calm, predictable environment
for the client. This response establishes time, location, and the caregiver‘s name.

Orient the patient to surroundings, staff, necessary activities as needed. Present
reality concisely and briefly. Avoid challenging illogical thinking—defensive
reactions may result.
 Option A: Modulate sensory exposure. Provide a calm environment;
eliminate extraneous noise and stimuli. Increased levels of visual and
auditory stimulation can be misinterpreted by the confused patient.
 Option B: Give simple directions. Allow sufficient time for the patient to
respond, to communicate, to make decisions. This communication method
can reduce anxiety experienced in a strange environment.
 Option C: Offer reassurance to the patient and use therapeutic
communication at frequent intervals. Patient reassurance and
communication are nursing skills that promote trust and orientation and
reduce anxiety.
ADVERTISEMENTS
49. Question
When a client wishes to improve the appearance of their eyes by removing excess
skin from the face and neck, the nurse should provide teaching regarding which
of the following procedures?
o A. Dermabrasion
o B. Rhinoplasty
o C. Blepharoplasty
o D. Rhytidectomy
Incorrect
Correct Answer: D. Rhytidectomy
Rhytidectomy is the procedure for removing excess skin from the face and neck.
It is commonly called a facelift. Rhytidectomy is a surgical procedure meant to
counteract the effects of time on the aging face. In the rhytidectomy procedure
(also known as a ―face-lift‖), the tissues under the skin are tightened and excess
facial and neck skin are excised. Rhytidectomy literally means wrinkle (rhytid-)
removal (-ectomy).

 Option A: Dermabrasion involves the spraying of a chemical to cause light
freezing of the skin, which is then abraded with sandpaper or a revolving
wire brush. It is used to remove facial scars, severe acne, and pigment from
tattoos. Dermabrasion is an exfoliating technique that uses a rotating
instrument to remove the outer layers of skin, usually on the face. This
treatment is popular with people who wish to improve the appearance of
their skin. Some of the conditions it can treat include fine lines, sun
damage, acne scars, and uneven texture.
 Option B: Rhinoplasty is done to improve the appearance of the nose and
involves reshaping the nasal skeleton and overlying skin. Rhinoplasty is
surgery that changes the shape of the nose. The motivation for rhinoplasty
may be to change the appearance of the nose, improve breathing, or both.
The upper portion of the structure of the nose is bone, and the lower
portion is cartilage.
 Option C: Blepharoplasty is the procedure that removes loose and
protruding fat from the upper and lower eyelids. Eyelid surgery, or
blepharoplasty, is a surgical procedure to improve the appearance of the
eyelids.
ADVERTISEMENTS
50. Question
A woman who is six months pregnant is seen in antepartal clinic. She states she is
having trouble with constipation. To minimize this condition, the nurse should
instruct her to
o A. Increase her fluid intake to three liters/day.
o B. Request a prescription for a laxative from her physician.
o C. Stop taking iron supplements.
o D. Take two tablespoons of mineral oil daily.

Incorrect
Correct Answer: A. increase her fluid intake to three liters/day.
In pregnancy, constipation results from decreased gastric motility and increased
water reabsorption in the colon caused by increased levels of progesterone.

Increasing fluid intake to three liters a day will help prevent constipation. The
client should increase fluid intake, increase roughage in the diet, and increase
exercise as tolerated.
 Option B: Laxatives are not recommended because of the possible
development of laxative dependence or abdominal cramping. The primary
medical treatment for constipation in pregnancy is a medication called a
laxative, which makes it easier and more comfortable to go to the
bathroom. It is generally safe to use gentle laxatives, but it is best to avoid
stimulant laxatives because they can induce uterine contractions.
 Option C: Iron supplements are necessary during pregnancy, as ordered,
and should not be discontinued. Daily oral iron and folic acid
supplementation with 30 mg to 60 mg of elemental iron and 400 µg (0.4
mg) folic acid is recommended for pregnant women to prevent maternal
anemia, puerperal sepsis, low birth weight, and preterm birth.
 Option D: Mineral oil is especially bad to use as a laxative because it
decreases the absorption of fat-soluble vitamins (A, D, E, K) if taken near
mealtimes. Mineral oil should always be prohibited during pregnancy, as its
use can cause hemorrhagic disease of the newborn due to impaired
absorption of vitamin K. Similarly, castor oil is absolutely prohibited during
pregnancy.
ADVERTISEMENTS
51. Question
A client with chronic pain reports to you, the charge nurse, that the nurse has not
been responding to requests for pain medication. What is your initial action?
o A. Check the MARs and nurses‘ notes for the past several days.
o B. Ask the nurse educator to give an in-service about pain management.
o C. Perform a complete pain assessment and history on the client.
o D. Have a conference with the nurses responsible for the care of this
client.
Incorrect

Correct Answer: D. Have a conference with the nurses responsible for the
care of this client.
As a charge nurse, you must assess the performance and attitude of the staff in
relation to this client. Handling conflicts in an efficient and effective manner
results in improved quality, patient safety, and staff morale, and limits work stress
for the caregiver. The nurse manager must approach this challenge thoughtfully
because it involves working relationships that are critical for the unit to function
effectively.
 Option A: After gathering data from the nurses, additional information
from the records and the client can be obtained as necessary. Effective
resolution and management of a conflict require clear communication and
a level of understanding of the perceived areas of disagreement. Conflict
resolution is an essential element of a healthy work environment because a
breakdown in communication and collaboration can lead to increased
patient errors.
 Option B: The educator may be of assistance if knowledge deficit or need
for performance improvement is the problem. The American Association of
Critical-Care Nurses standards for healthy work environments recognizes
the importance of proficiency in communication skills and The Joint
Commission‘s revised leadership standards place a mandate on healthcare
leadership to manage disruptive behavior that can impact patient safety.
 Option C: Nursing leaders need to assess how nurses deal with conflict in
the healthcare environment in an effort to develop and implement conflict
management training and processes that can assist them in dealing with
difficult situations.
ADVERTISEMENTS
52. Question
Family members are encouraging your client to ―tough it out‖ rather than run the
risk of becoming addicted to narcotics. The client is stoically abiding by the
family‘s wishes. Priority nursing interventions for this client should target which
dimension of pain?
o A. Sensory
o B. Sociocultural

o C. Behavioral
o D. Cognitive
Incorrect
Correct Answer: B. Sociocultural
The family is part of the socio-cultural dimension of pain. They are influencing the
client and should be included in the teaching sessions about the appropriate use
of narcotics and about the adverse effects of pain on the healing process. The
other dimensions should be included to help the client/family understand the
overall treatment plan and pain mechanism.
 Option A: The sensory dimension encompasses both the quality and
severity of pain. It includes the patient‘s report of the location, quality, and
intensity of pain. Assessing this dimension helps quantify the pain and
clarify the extent of poorly localized or radiating pain.
 Option C: The behavioral dimension of pain refers to the patient‘s verbal
or nonverbal behaviors exhibited in response to pain. To assess it, rely on
direct observation and continued patient interaction. Watch for common
behaviors associated with pain, such as guarding, splinting, tensing up,
crying, moaning, and massaging a specific body part.
 Option D: The cognitive dimension refers to thoughts, beliefs, attitudes,
intentions, and motivations related to pain and its management. Before
assessing this dimension, evaluate the patient‘s cognitive capacity and
functioning. Review the medical history for diseases or conditions that may
impair cognition; if any exists, assess its current level of progression. In
some patients, pain can temporarily worsen pre-existing cognitive
limitations.
ADVERTISEMENTS
53. Question
A client with diabetic neuropathy reports a burning, electrical type in the lower
extremities that is not responding to NSAIDs. You anticipate that the physician
will order which adjuvant medication for this type of pain?
o A. Amitriptyline (Elavil)

o B. Corticosteroids
o C. Methylphenidate (Ritalin)
o D. Lorazepam (Ativan)
Incorrect
Correct Answer: A. Amitriptyline (Elavil)
Antidepressants such as amitriptyline can be given for diabetic neuropathy. The
American Diabetes Association recommends amitriptyline, a tricyclic
antidepressant, as the first choice; however, titration to higher doses is limited by
its anticholinergic adverse effects.
 Option B: Corticosteroids are for pain associated with inflammation.
Corticosteroids produce their effect through multiple pathways. In general,
they produce anti-inflammatory and immunosuppressive effects, protein
and carbohydrate metabolic effects, water and electrolyte effects, central
nervous system effects, and blood cell effects.
 Option C: Methylphenidate is given to counteract sedation if the client is
on opioids. Methylphenidate is FDA-approved for the treatment of
attention deficit hyperactivity disorder (ADHD) in children and adults and
as a second-line treatment for narcolepsy in adults. Children with a
diagnosis of ADHD should be at least six years of age or older before being
started on this medication.
 Option D: Lorazepam is an anxiolytic. Lorazepam has common use as the
sedative and anxiolytic of choice in the inpatient setting owing to its fast (1
to 3 minute) onset of action when administered intravenously. Lorazepam
is also one of the few sedative-hypnotics with a relatively clean side effect
profile.
ADVERTISEMENTS
54. Question
Which client is most likely to receive opioids for extended periods of time?
o A. A client with fibromyalgia
o B. A client with phantom limb pain

o C. A client with progressive pancreatic cancer
o D. A client with trigeminal neuralgia

Incorrect
Correct Answer: C. A client with progressive pancreatic cancer
Cancer pain generally worsens with disease progression and the use of opioids is
more generous. Opioids (narcotics) are used with or without non-opioids to treat
moderate to severe pain. They are often a necessary part of a pain relief plan for
cancer patients. These medicines are much like natural substances (called
endorphins) made by the body to control pain. They were once made from the
opium poppy, but today many are man-made in a lab.
 Option A: Fibromyalgia is more likely to be treated with non-opioid and
adjuvant medications. It is recommended to continue nonpharmacologic
measures along with the use of medications for most patients with
fibromyalgia. Some patients may, however, respond adequately to
nonpharmacologic measures alone. The medications that have been well
studied and consistently effective are certain antidepressants and
anticonvulsants.
 Option B: Phantom limb pain usually subsides after ambulation begins.
Treatment, unfortunately, for PLP has not proven to be very effective. While
treatment for RLP tends to focus on an organic cause for the pain, PLP
focuses on symptomatic control.
 Option D: Trigeminal neuralgia is treated with anti-seizure medications
such as carbamazepine (Tegretol). The first-line treatment for patients with
classic TN and idiopathic TN is pharmacologic therapy. The most
commonly used medication is the anticonvulsant drug, carbamazepine. It is
usually started at a low dose, and the dose is gradually increased until it
controls the pain. It controls pain for most people in the early stages of the
disease.
ADVERTISEMENTS
55. Question
As the charge nurse, you are reviewing the charts of clients who were assigned to
a newly graduated RN. The RN has correctly chartered the dose and time of

medication, but there is no documentation regarding non-pharmaceutical
measures. What action should you take first?
o A. Make a note in the nurse‘s file and continue to observe clinical

performance.
o B. Refer the new nurse to the in-service education department.
o C. Quiz the nurse about knowledge of pain management.
o D. Give praise for the correct dose and time and discuss the deficits in
charting.
Incorrect
Correct Answer: D. Give praise for the correct dose and time and discuss the
deficits in charting.
In supervising the new RN, good performance should be reinforced first and then
areas of improvement can be addressed. Nursing activities are very important
within the hospital and must solve the problems that the patient needs. Every
nursing activity should produce documentation with critical thinking. If nursing
documents are not clear and accurate, inter-professional communication and an
evaluation of nursing care cannot be optimal.
 Option A: Making a note and watching do not help the nurse to correct
the immediate problem. Nursing activity that has been completed or that
will take place should be properly documented. Accurate documentation
and reports play a pivotal role in health services. This documentation is
necessary to identify nursing interventions that have been provided to
patients and to show patient progress during hospitalization.
 Option B: In-service might be considered if the problem persists. Nursing
documentation also serves as an effective tool of inter-professional
communication between nurses and other health professionals for
delivering ongoing nursing care, evaluating patient progress and
outcomes, and providing constant patient protection. High-quality nursing
documentation may improve the effectiveness of communication between
health professionals in first- and higher-level healthcare facilities.
 Option C: Asking the nurse about knowledge of pain management is also
an option; however, it would be a more indirect and time-consuming
approach. It is also an indicator of nurse performance and the nursing
service quality in a hospital. Documentation provides details of patient

condition, nursing interventions that have been provided, and patient
response to the intervention(s).
ADVERTISEMENTS
56. Question
In caring for a young child with pain, which assessment tool is the most useful?
o A. Simple descriptive pain intensity scale
o B. 0-10 numeric pain scale
o C. Faces pain-rating scale
o D. McGill-Melzack pain questionnaire

Incorrect
Correct Answer: C. Faces pain-rating scale
The Faces pain rating scale (depicting smiling, neutral, frowning, crying, etc.) is
appropriate for young children who may have difficulty describing pain or
understanding the correlation of pain to numerical or verbal descriptors. The
Faces Pain Scale-Revised (FPS-R) is a self-report measure of pain intensity
developed for children. It was adapted from the Faces Pain Scale to make it
possible to score the sensation of pain on the widely accepted 0-to-10 metric.
The scale shows a close linear relationship with visual analog pain scales across
the age range of 4-16 years. It is easy to administer and requires no equipment
except for the photocopied faces. The other tools require abstract reasoning
abilities to make analogies and use of advanced vocabulary.
 Option A: The Simple Descriptive Scale exhibits degrees of pain intensity
(no pain, mild pain, moderate pain, and severe pain). Risk factors for the
development of chronic pain have been a major topic in pain research in
the past two decades. Now, it has been realized that psychological and
psychosocial factors may substantially influence pain perception in patients
with chronic pain and thus may influence the surgical outcome.
 Option B: This pain scale is most commonly used. A person rates their pain
on a scale of 0 to 10 or 0 to 5. Zero means ―no pain,‖ and 5 or 10 means
―the worst possible pain.‖ These pain intensity levels may be assessed upon
initial treatment, or periodically after treatment.

 Option D: The McGill pain questionnaire, or MPQ, is one of the most
widely used multidimensional pain scales in the world. In the MPQ, the
evaluation of pain is divided into three categories: sensory, affective, and
evaluative. The questionnaire is self-reported and allows individuals to
describe the quality and intensity of their pain by using 78 adjectives in 20
different sections.
ADVERTISEMENTS
57. Question
In applying the principles of pain treatment, what is the first consideration?
o A. Treatment is based on client goals.
o B. A multidisciplinary approach is needed.
o C. The client must believe in perceptions of own pain.
o D. Drug side effects must be prevented and managed.

Incorrect
Correct Answer: C. The client must be believed about perceptions of own
pain.
The client must be believed and his or her experience of pain must be
acknowledged as valid. The data gathered via client reports can then be applied
to other options in developing the treatment plan. Assist patients to develop a
daily routine to support achievement and, where necessary, readjustment of
habits and roles according to individual capacity and life situation.
 Option A: Use a person-centered perspective to formulate collaborative
intervention strategies consistent with a physical therapy perspective.
Understand the need to involve family members and significant others
including employers where appropriate.
 Option B: Demonstrate an ability to integrate the patient assessment into
an appropriate management plan using the concepts and strategies of
clinical reasoning.
 Option D: Understand the principles of an effective therapeutic
patient/professional relationship to reduce pain, promote optimal function

and reduce disability through the use of active and where appropriate,
passive pain management approaches.
ADVERTISEMENTS
58. Question
Which route of administration is preferred if immediate analgesia and rapid
titration are necessary?
o A. Intraspinal
o B. Patient-controlled analgesia (PCA)
o C. Intravenous (IV)
o D. Sublingual
Incorrect
Correct Answer: C. Intravenous (IV)
The IV route is preferred as the fastest and most amenable to titration.
Medications may be given as repeated intermittent bolus doses or by continuous
infusion. Intravenous provides almost immediate analgesia; subcutaneous may
require up to 15 minutes for effect. Bolus IV dosing provides a shorter duration of
action than other routes.
 Option A: Intraspinal administration requires special catheter placement
and there are more potential complications with this route. Intraspinal and
intraventricular administration are options if maximal doses of opioids and
adjuvants administered through other routes are ineffective or produce
intolerable side effects {e.g., nausea/vomiting, excessive sedation,
confusion}. Opioids can be administered via indwelling percutaneous or
tunneled catheters into the epidural or intrathecal space.
 Option B: A PCA bolus can be delivered; however, the pump will limit the
dosage that can be delivered unless the parameters are changed. Patient-
controlled analgesia (PCA) devices can be used to combine continuous
infusion with intermittent bolus doses, allowing more flexible pain control.
It is recommended that the hourly SQ volume limit not exceed 5 cc.
Medications can be concentrated to maintain SQ volume limits; maximal

concentrations: fentanyl 50 ug/ml, morphine 50 mgs/ml, hydromorphone
50 mgs/ml.
 Option D: Sublingual is reasonably fast, but not a good route for titration,
medication variety in this form is limited. An alkaline pH microenvironment
that favors the unionized fraction of opioids increased sublingual drug
absorption. Although absorption was found to be independent of drug
concentration, it was contact time dependent for methadone and fentanyl
but not for buprenorphine. These results indicate that although the
sublingual absorption and apparent sublingual bioavailability of morphine
are poor, the sublingual absorption of methadone, fentanyl, and
buprenorphine under controlled conditions is relatively high.
ADVERTISEMENTS
59. Question
When titrating an analgesic to manage pain, what is the priority goal?
o A. Administer smallest dose that provides relief with the fewest side
effects.
o B. Titrate upward until the client is pain-free.
o C. Titrate downwards to prevent toxicity.
o D. Ensure that the drug is adequate to meet the client‘s subjective needs.
Incorrect
Correct Answer: A. Administer smallest dose that provides relief with the
fewest side effects.
The goal is to control pain while minimizing side effects. The World Health
Organization cancer pain ladder provides a helpful starting point for achieving
effective pain management. Clinicians should begin with nonopioid analgesics
(e.g., acetaminophen, nonsteroidal anti-inflammatory drugs [NSAIDs]), and
gradually progress to more potent analgesics until pain is relieved.
 Option B: For severe pain, the medication can be titrated upward until
pain is controlled. Many patients with terminal illnesses require immediate
opioid therapy or have contraindications to common non-opioid
analgesics, such as NSAIDs.

 Option C: Downward titration occurs when the pain begins to subside.
Acetaminophen is useful as a primary analgesic, or in combination with
other drugs, for treating mild to moderate pain. Dosages in healthy
persons should be limited to no more than 4,000 mg every 24 hours to
reduce the risk of hepatotoxicity.
 Option D: Adequate dosing is important; however, the concept of
controlled dosing applies more to potent vasoactive drugs. The World
Health Organization pain ladder offers a stepwise guideline for
approaching pain management. However, for many patients with terminal
illnesses, strong opioids are necessary for efficient and effective analgesia.
ADVERTISEMENTS
60. Question
In educating clients about non-pharmaceutical alternatives, which topic could
you delegate to an experienced LPN/LVN, who will function under your
continued support and supervision?
o A. Therapeutic touch
o B. Use of heat and cold applications
o C. Meditation
o D. Transcutaneous electrical nerve stimulation (TENS)

Incorrect
Correct Answer: B. Use of heat and cold applications
Use of heat and cold applications is a standard therapy with guidelines for safe
use and predictable outcomes, and an LPN/LVN will be implementing this
therapy in the hospital, under the supervision of an RN. Treating pain with hot
and cold can be extremely effective for a number of different conditions and
injuries, and easily affordable. The tricky part is knowing what situations call for
hot, and which calls for cold. Sometimes a single treatment will even include
both.
 Option A: Therapeutic touch requires additional training and practice. The
National Center for Complementary and Alternative Medicine places
therapeutic touch (TT) into the category of bio-field energy. In the TT

method, the therapist‘s hand is used to increase comfort and reduce pain
using the body‘s energy field correction mechanism
 Option C: Meditation is not acceptable to all clients and an assessment of
spiritual beliefs should be conducted. Mindfulness meditation is a fairly
loose term that applies to many meditation practices, which have been
found to improve a wide spectrum of clinically relevant cognitive and
health outcomes.
 Option D: Transcutaneous electrical stimulation is usually applied by a
physical therapist. Transcutaneous electrical nerve stimulation (TENS) is a
therapy that uses low voltage electrical current to provide pain relief. A
TENS unit consists of a battery-powered device that delivers electrical
impulses through electrodes placed on the surface of your skin. The
electrodes are placed at or near nerves where the pain is located or at
trigger points.
ADVERTISEMENTS
61. Question
Place the examples of drugs in the order of usage according to the World Health
Organization (WHO) analgesic ladder.
View Answers:
o Codeine, oxycodone, and diphenhydramine

o Morphine, hydromorphone, acetaminophen, and lorazepam
o NSAIDs and corticosteroids
Incorrect
The WHO analgesic ladder was a strategy proposed by the World Health
Organization (WHO), in 1986, to provide adequate pain relief for cancer patients.
The analgesic ladder was part of a vast health program termed the WHO Cancer
Pain and Palliative Care Program aimed at improving strategies for cancer pain
management through educational campaigns, the creation of shared strategies,
and the development of a global network of support.

 Step 1 includes non-opioids and adjuvant drugs. Mild pain: non-opioid
analgesics such as nonsteroidal anti-inflammatory drugs (NSAIDs) or
acetaminophen with or without adjuvants.
 Step 2 includes opioids for mild pain plus Step 1 drugs and adjuvant drugs
as needed. Moderate pain: weak opioids (hydrocodone, codeine, tramadol)
 Step 3 includes opioids for severe pain (replacing Step 2 opioids) and
continuing Step 1 drugs and adjuvant drugs as needed. Severe and
persistent pain: potent opioids (morphine, methadone, fentanyl,
oxycodone, buprenorphine, tapentadol, hydromorphone, oxymorphone)
ADVERTISEMENTS
62. Question
Which client is at greater risk for respiratory depression while receiving opioids
for analgesia?
o A. An elderly chronic pain client with a hip fracture.
o B. A client with heroin addiction and back pain.
o C. A young female client with advanced multiple myeloma.
o D. A child with an arm fracture and cystic fibrosis.

Incorrect
Correct Answer: D. A child with an arm fracture and cystic fibrosis.
At greatest risk are elderly clients, opiate naïve clients, and those with underlying
pulmonary disease. The child has two of the three risk factors. Many
complications can occur with multiple different opioids, such as non-cardiogenic
pulmonary edema, while many of the complications are unique to the opioid
used as well as the route of administration.
 Option A: Pain in the elderly population is especially difficult given the
myriad of physiological, pharmacological, and psychological aspects of
caring for geriatric patient. Opiates are the mainstay of pain treatment
throughout all age groups but special attention must be paid to the

efficacy and side effects of these powerful drugs when prescribing to a
population with impaired metabolism, excretion, and physical reserve.
 Option B: Prescription opioids and heroin are chemically similar and can
produce a similar high. In some places, heroin is cheaper and easier to get
than prescription opioids, so some people switch to using heroin instead.
More recent data suggest that heroin is frequently the first opioid people
use. In a study of those entering treatment for opioid use disorder,
approximately one-third reported heroin as the first opioid they used
regularly to get high.
 Option C: Bone pain is one of the most common presentations of multiple
myeloma and nearly all patients have skeletal involvement in the course of
the disease. Consequently, many patients require narcotics for symptom
management at the time of diagnosis but the long-term impact of MM
treatment on pain control remains uncertain.
ADVERTISEMENTS
63. Question
A client appears upset and tearful, but denies pain and refuses pain medication,
because ―my sibling is a drug addict and has ruined our lives.‖ What is
the priority intervention for this client?
o A. Encourage expression of fears on past experiences.
o B. Provide accurate information about the use of pain medication.
o C. Explain that addiction is unlikely among acute care clients.
o D. Seek family assistance in resolving this problem.

Incorrect
Correct Answer: A. Encourage expression of fears on past experiences.
This client has strong beliefs and emotions related to the issue of sibling
addiction. First, encourage expression. This indicated to the client that the
feelings are real and valid. It is also an opportunity to assess beliefs and fears.
Verbalization of feelings in a nonthreatening environment may help the client
come to terms with unresolved issues.

 Option B: Giving facts and information is appropriate at the right time.
Clients are often reluctant to share feelings for fear of ridicule and may
have repeatedly been told to ignore feelings. Once the client begins to
acknowledge and talk about these fears, it becomes apparent that the
feelings are manageable.
 Option C: Encourage the client to explore underlying feelings that may be
contributing to irrational fears. Help the client to understand how facing
these feelings, rather than suppressing them, can result in more adaptive
coping abilities.
 Option D: Family involvement is important, bearing in mind that their
beliefs about drug addiction may be similar to those of the client. Present
and discuss the reality of the situation with the client in order to recognize
aspects that can be changed and those that cannot. The client must accept
the reality of the situation before the work of reducing the fear can
progress.
ADVERTISEMENTS
64. Question
A client is being tapered off opioids and the nurse is watchful for signs of
withdrawal. What is one of the first signs of withdrawal?
o A. Fever
o B. Nausea
o C. Diaphoresis
o D. Abdominal cramps
Incorrect
Correct Answer: C. Diaphoresis
Diaphoresis is one of the early signs that occur between 6 and 12 hours. Fever,
nausea, and abdominal cramps are late signs that occur between 48 and 72
hours. According to Diagnostic and Statistical Manual of Mental Disorders (DSM–
5) criteria, signs, and symptoms of opioid withdrawal include lacrimation or
rhinorrhea, piloerection ―goose flesh,‖ myalgia, diarrhea, nausea/vomiting,
pupillary dilation and photophobia, insomnia, autonomic hyperactivity

(tachypnea, hyperreflexia, tachycardia, sweating, hypertension, hyperthermia),
and yawning.
 Option A: A fever can be a withdrawal symptom among people who have
been addicted to various substances, or even after a period of intense
substance use. Fever symptoms may range from mild to severe. Although
mild fevers can accompany a variety of substance withdrawal syndromes
and are usually self-limiting, fever can also be a component of a
particularly dangerous type of alcohol withdrawal.
 Option B: Prolonged use of these drugs changes the way nerve receptors
work in the brain, and these receptors become dependent upon the drug
to function. If the client becomes physically sick after he stops taking an
opioid medication, it may be an indication that he‘s physically dependent
on the substance.
 Option D: The symptoms the client is experiencing will depend on the
level of withdrawal he is experiencing. Also, multiple factors dictate how
long a person will experience the symptoms of withdrawal. Because of this,
everyone experiences opioid withdrawal differently. However, there‘s
typically a timeline for the progression of symptoms.
ADVERTISEMENTS
65. Question
In caring for clients with pain and discomfort, which task is most appropriate to
delegate to the nursing assistant?
o A. Assist the client with preparation of a sitz bath.
o B. Monitor the client for signs of discomfort while ambulating.
o C. Coach the client to deep breathe during painful procedures.
o D. Evaluate relief after applying a cold application.

Incorrect
Correct Answer: A. Assist the client with preparation of a sitz bath.
The nursing assistant is able to assist the client with hygiene issues and knows the
principles of safety and comfort for this procedure. Proper and appropriate
assignments facilitate quality care. Improper and inappropriate assignments can

lead to poor quality of care, disappointing outcomes of care, the jeopardization
of client safety, and even legal consequences. Monitoring the client, teaching
techniques, and evaluating outcomes are nursing responsibilities.
 Option B: Monitoring the client for signs of discomfort while ambulating is
a nursing responsibility. When a registered nurse delegates aspects of
patient care to a licensed practical nurse that are outside of the scope of
practice of the licensed practical nurse, the client is in potential physical
and/or psychological jeopardy because this delegated task, which is
outside of the scope of practice for this licensed practical nurse, is
something that this nurse was not prepared and educated to perform.
 Option C: Coaching the client to deep breathe during painful procedures is
a nursing responsibility. The nurse who delegates aspects of care to other
members of the nursing team must balance the needs of the client with the
abilities of those to which the nurse is delegating tasks and aspects of care,
among other things such as the scopes of practice and the policies and
procedures within the particular healthcare facility.
 Option D: Evaluation of relief after applying a cold application is a nursing
responsibility. The staff members‘ levels of education, knowledge, past
experiences, skills, abilities, and competencies are also evaluated and
matched with the needs of all of the patients in the group of patients that
will be cared for.
ADVERTISEMENTS
66. Question
The physician has ordered a placebo for a chronic pain client. You are a newly
hired nurse and you feel very uncomfortable administering the medication. What
is the first action that you should take?
o A. Prepare the medication and hand it to the physician.
o B. Check the hospital policy regarding the use of the placebo.
o C. Follow a personal code of ethics and refuse to give it.
o D. Contact the charge nurse for advice.

Incorrect

Correct Answer: D. Contact the charge nurse for advice.
A charge nurse is a resource person who can help locate and review the policy. If
the physician is insistent, he or she could give the placebo personally, but
delaying the administration does not endanger the health or safety of the client.
 Option A: In a treatment setting it is unethical to deliberately misinform
the patient. However, placebo effects can be an important factor in a
biopsychosocial context. Clinicians need to consider some ethical issues
relating to placebo effects. According to Pittrof and Rubenstein, the ethical
use of placebo effects should always benefit the patient and involve
disclosure.
 Option B: Placebo effects may thus be defined as psychological and/or
physiological responses that follow the administration of active and non-
active substances when coupled with an affirmation of the treatment
effects. The ethical use of placebo effects in a clinical setting should rely on
realistic expectations and be based on best practice. The use of a placebo
in clinical settings might still be seen as controversial by some.
 Option C: While following one‘s own ethical code is correct, you must
ensure that the client is not abandoned and that care continues. Placebo
effects, when considered as supplements to pharmacologically active
substances, should aim to increase patients‘ well-being. It is unethical to
deliberately misinform patients.
ADVERTISEMENTS
67. Question
For a cognitively impaired client who cannot accurately report pain, what is
the first action that you should take?
o A. Closely assess for nonverbal signs such as grimacing or rocking.
o B. Obtain baseline behavioral indicators from family members.
o C. Look at the MAR and chart, to note the time of the last dose and response.
o D. Give the maximum PRS dose within the minimum time frame for relief.
Incorrect

Correct Answer: B. Obtain baseline behavioral indicators from family
members.
Complete information from the family should be obtained during the initial
comprehensive history and assessment. If this information is not obtained, the
nursing staff will have to rely on observation of nonverbal behavior and careful
documentation to determine pain and relief patterns.
 Option A: Pain can be difficult to assess in cognitively impaired individuals
because their self-reports of pain can be inaccurate or difficult to obtain.
Thus, behavioral observation-based assessment is optimal in these
patients.
 Option C: Assess potential causes of pain. The clinician should consider
pathological causes of pain and any procedure known to cause pain.
Address any pain history from family, significant others, and caregivers.
 Option D: Use scheduled dosing when pain is chronic and/or when the
patient is unable to ask for medication. When administering the
medication, it is best to start with a lower dose and gradually increase the
dose to alleviate the pain.
ADVERTISEMENTS
68. Question
Which route of administration is preferable for administration of daily analgesics
(if all body systems are functional)?
o A. IV
o B. IM or subcutaneous
o C. Oral
o D. Transdermal
o E. PCA
Incorrect
Correct Answer: C. Oral
If the gastrointestinal system is functioning, the oral route is preferred for routine
analgesics because of lower cost and ease of administration. Oral route is also

less painful and less invasive than the IV, IM, subcutaneous, or PCA routes.
Although a few drugs taken orally are intended to be dissolved in the mouth,
nearly all drugs taken orally are swallowed. Of these, most are taken for the
systemic drug effects that result after absorption from the various surfaces along
the gastrointestinal tract.
 Option A: IV therapy allows a higher concentration of nutrients or
medication into the body — and that means the body gets what it needs
faster and more effectively without further damage to the GI system.
 Option B: Rapid and uniform absorption of the drug especially those of
the aqueous solutions. Rapid onset of the action compared to that of the
oral and the subcutaneous routes. IM injection bypasses the first-pass
metabolism. It also avoids the gastric factors governing drug absorption.
 Option D: Transdermal route is slower and medication availability is
limited compared to oral forms. Transdermal delivery systems provide
continuous administration of drugs through the skin, which maintains
constant plasma drug levels and avoids the peaks and troughs that are
seen with oral administration.
 Option E: Patient-controlled analgesia is used to treat acute, chronic,
postoperative, and labor pain. A variety of medications can be used for
patient-controlled analgesia and are administered intravenously (IV),
through an epidural or peripheral nerve catheter, and transdermally.
ADVERTISEMENTS
69. Question
A first-day postoperative client on a PCA pump reports that the pain control is
inadequate. What is the first action you should take?
o A. Deliver the bolus dose per standing order.
o B. Contact the physician to increase the dose.
o C. Try non-pharmacological comfort measures.
o D. Assess the pain for location, quality, and intensity.

Incorrect
Correct Answer: D. Assess the pain for location, quality, and intensity.

Assess the pain for changes in location, quality, and intensity, as well as changes
in response to medication. This assessment will guide the next steps. Patient-
controlled analgesia is used to treat acute, chronic, postoperative, and labor pain.
A variety of medications can be used for patient-controlled analgesia and are
administered intravenously (IV), through an epidural or peripheral nerve catheter,
and transdermally.
 Option A: The goal of PCA is to efficiently deliver pain relief at a patient‘s
preferred dose and schedule by allowing them to administer a
predetermined bolus dose of medication on-demand at the press of a
button. Each bolus can be administered alone or coupled with a
background infusion of medication.
 Option B: The initial loading dose can be titrated by a nurse to reach the
minimum effective concentration (MEC) of the desired medication. The
bolus or demand dose is the dose of medication delivered each time the
patient presses the button. A lockout interval is the time after a demand
dose in which a dose of medication will not get administered even if the
patient presses the button; this is done to prevent overdosing.
 Option C: The use of PCA has been proven to be more effective at pain
control than non-patient-controlled opioid injections and results in higher
patient satisfaction. PCA has also been found to be preferred by nurses
because it allows for a reduction in their workload. PCA will enable patients
to be in more control over their pain and helps them shift toward a more
internal locus of control over their care.
ADVERTISEMENTS
70. Question
Which non-pharmacological measure is particularly useful for a client with acute
pancreatitis?
o A. Diversional therapy, such as playing cards or board games.
o B. Massage the back and neck with warmed lotion.
o C. Side-lying position with knees to chest and pillow against the

abdomen.

o D. Transcutaneous electrical nerve stimulation (TENS).
Incorrect
Correct Answer: C. Side-lying position with knees to chest and pillow against
the abdomen.
The side-lying, knee-chest position opens retroperitoneal space and provides
relief. The pillow provides a splinting action. Reduces abdominal pressure and
tension, providing some measure of comfort and pain relief. Note: Supine
position often increases pain.
 Option A: Diversional therapy is not the best choice for acute pain,
especially if the activity requires concentration. Keep the environment free
of food odors. Sensory stimulation can activate pancreatic enzymes,
increasing pain.
 Option B: The additional stimulation of massage may be distressing to the
client. Provide alternative comfort measures (back rub), encourage
relaxation techniques (guided imagery, visualization), quiet diversional
activities (TV, radio).
 Option D: TENS is more appropriate for chronic muscular pain. Maintain
bed rest during an acute attack. Provide a quiet, restful environment.
Decreases metabolic rate and GI stimulation and secretions, thereby
reducing pancreatic activity.
ADVERTISEMENTS
71. Question
What is the best way to schedule medication for a client with constant pain?
o A. PRN at the client‘s request
o B. Prior to painful procedures
o C. IV bolus after pain assessment
o D. Around-the-clock
Incorrect
Correct Answer: D. Around-the-clock

If the pain is constant, the best schedule is around-the-clock, to provide steady
analgesia and pain control. The other options may actually require higher doses
to achieve control. Pain medication prescribed around-the-clock has the purpose
of managing a patient‘s baseline pain, which is the average pain intensity the
patient experiences. This is generally pain that is continuously experienced.
 Option A: The use of ―as needed‖ or ―pro re nata‖ (PRN) range opioid
analgesic orders is a common clinical practice in the management of acute
pain, designed to provide flexibility in dosing to meet an individual‘s
unique needs. Range orders enable necessary adjustments in doses based
on individual response to treatment.
 Option B: Of particular importance to nursing care, unrelieved pain
reduces patient mobility, resulting in complications such as deep vein
thrombosis, pulmonary embolism, and pneumonia. Postsurgical
complications related to inadequate pain management negatively affect
the patient‘s welfare and the hospital performance because of extended
lengths of stay and readmissions, both of which increase the cost of care.
 Option C: Assessment of pain is a critical step to providing good pain
management. In a sample of physicians and nurses, Anderson and
colleagues found lack of pain assessment was one of the most problematic
barriers to achieving good pain control. The most critical aspect of pain
assessment is that it is done on a regular basis (e.g., once a shift, every 2
hours) using a standard format. The assessment parameters should be
explicitly directed by hospital or unit policies and procedures.
ADVERTISEMENTS
72. Question
Which client(s) are appropriate to assign to the LPN/LVN, who will function
under the supervision of the RN or team leader? Select all that apply.
o A. A client who needs pre-op teaching for use of a PCA pump.
o B. A client with a leg cast who needs neurologic checks and PRN
hydrocodone.
o C. A client post-op toe amputation with diabetic neuropathic pain.

o D. A client with terminal cancer and severe pain who is refusing medication.
Incorrect
Correct Answer: B & C.
The clients with the cast and the toe amputation are stable clients and need
ongoing assessment and pain management that are within the scope of practice
for an LPN/LVN under the supervision of an RN. The RN should take
responsibility for preoperative teaching, and terminal cancer needs a
comprehensive assessment to determine the reason for refusal of medication.
 Option A: Preoperative teaching is a nursing responsibility. Proper and
appropriate assignments facilitate quality care. Improper and inappropriate
assignments can lead to poor quality of care, disappointing outcomes of
care, the jeopardization of client safety, and even legal consequences.
 Option B: The clients with the cast are within the scope of practice for an
LPN/LVN under the supervision of an RN. Delegation, simply defined, is the
transfer of the nurse‘s responsibility for the performance of a task to
another nursing staff member while retaining accountability for the
outcome. Responsibility can be delegated. Accountability cannot be
delegated. The delegating registered nurse remains accountable for all
client care despite the fact that some of these aspects of care can, and are,
delegated to others.
 Option C: The client with the toe amputation is a stable client and needs
ongoing assessment and pain management that are within the scope of
practice for an LPN/LVN under the supervision of an RN. The staff
members‘ levels of education, knowledge, past experiences, skills, abilities,
and competencies are also evaluated and matched with the needs of all of
the patients in the group of patients that will be cared for.
 Option D: A client with terminal cancer and severe pain who is refusing
medication is a nursing responsibility. Based on these characteristics and
the total client needs for the group of clients that the registered nurse is
responsible and accountable for, the registered nurse determines and
analyzes all of the health care needs for a group of clients; the registered
nurse delegates care that matches the skills of the person that the nurse is
delegating to.
ADVERTISEMENTS

73. Question
For a client who is taking aspirin, which laboratory value should be reported to
the physician?
o A. Potassium 3.6 mEq/L
o B. Hematocrit 41%
o C. PT 14 seconds
o D. BUN 20 mg/dL
Incorrect
Correct Answer: C. PT 14 seconds
When a client takes aspirin, monitor for increases in PT (normal range 11.0-12.5
seconds in 85%-100%). Also, monitor for possible decreases in potassium (normal
range 3.5-5.0 mEq/L). If bleeding signs are noted, hematocrit should be
monitored (normal range male 42%-52%, female 37%-47%). An elevated BUN
could be seen if the client is having chronic gastrointestinal bleeding (normal
range 10-20 mg/dL).
 Option A: Severity is categorized as mild when the serum potassium level
is 3 to 3.4 mmol/L, moderate when the serum potassium level is 2.5 to 3
mmol/L, and severe when the serum potassium level is less than 2.5
mmol/L. Values obtained from plasma and serum may differ.
 Option B: HCT calculation is by dividing the lengths of the packed RBC
layer by the length of total cells and plasma. As it is a ratio, it doesn‘t have
any unit. Multiplying the ratio by 100 gives the accurate value, which is the
accepted reporting style for HCT. A normal adult male shows an HCT of
40% to 54% and female shows 36% to 48%.
 Option D: BUN and creatinine levels that are within the ranges established
by the laboratory performing the test suggest that the kidneys are
functioning as they should. Increased BUN and creatinine levels may mean
that the kidneys are not working as they should. This healthcare
practitioner will consider other factors, such as the medical history and
physical exam, to determine what condition, if any, may be affecting the
kidneys.
ADVERTISEMENTS

74. Question
Which client would be appropriate to assign to a newly graduated RN, who has
recently completed orientation?.
o A. An anxious, chronic pain client who frequently uses the call button.
o B. A client second-day post-op who needs pain medication prior to

dressing changes.
o C. A client with HIV who reports headache and abdominal and pleuritic chest
pain.
o D. A client who is being discharged with a surgically implanted catheter.

Incorrect
Correct Answer: B. A client second-day post-op who needs pain medication
prior to dressing changes
A second-day postoperative client who needs medication prior to dressing
changes has predictable and routine care that a new nurse can manage. Some
staff members may possess greater expertise than others. Some, such as new
graduates, may not possess the same levels of knowledge, past experiences,
skills, abilities, and competencies that more experienced staff members possess.
 Option A: Although clients with chronic pain can be relatively stable, the
interaction with this client will be time-consuming and may cause the new
nurse to fall behind. Time is finite and often the needs of the client are
virtually infinite. Time management, organization, and priority setting skills,
therefore, are essential to the complete and effective provision of care to
an individual client and to a group of clients.
 Option C: The client with HIV has complex complaints that require expert
assessment skills. Staff members differ in terms of their knowledge, skills,
abilities, and competencies. A staff member who has just graduated as a
certified nursing assistant and a newly graduated registered nurse cannot
be expected to perform patient care tasks at the same level of proficiency,
skill, and competency as an experienced nursing assistant or registered
nurse. It takes time for new graduates to refine the skills that they learned
in school.

 Option D: The client pending discharge will need special and detailed
instructions. Validated and documented competencies must also be
considered prior to assignment of patient care. No aspect of care can be
assigned or delegated to another nursing staff member unless this staff
member has documented evidence that they are deemed competent by a
registered nurse to do so.
ADVERTISEMENTS
75. Question
A family member asks you, ―Why can‘t you give more medicine? He is still having
a lot of pain.‖ What is your best response?
o A. ―The doctor ordered the medicine to be given every 4 hours.‖
o B. ―If the medication is given too frequently he could suffer ill effects.‖
o C. “Please tell him that I will be right there to check on him.”
o D. ―Let‘s wait about 30-40 minutes. If there is no relief I‘ll call the doctor.‖
Incorrect
Correct Answer: C. “Please tell him that I will be right there to check on
him.”
Directly ask the client about the pain and do a complete pain assessment. This
information will determine which action to take next. Pain assessment is critical to
optimal pain management interventions. While pain is a highly subjective
experience, its management necessitates objective standards of care.
 Option A: Poorly managing pain may put clinicians at risk for legal action.
Current standards for pain management, such as the national standards
outlined by the Joint Commission (formerly known as the Joint Commission
on Accreditation of Healthcare Organizations, JCAHO), require that pain is
promptly addressed and managed.
 Option B: Continuous, unrelieved pain also affects the psychological state
of the patient and family members. Common psychological responses to
pain include anxiety and depression. The inability to escape from pain may
create a sense of helplessness and even hopelessness, which may
predispose the patient to more chronic depression.

 Option D: Inadequately managed pain can lead to adverse physical and
psychological patient outcomes for individual patients and their families.
Continuous, unrelieved pain activates the pituitary-adrenal axis, which can
suppress the immune system and result in postsurgical infection and poor
wound healing.
ADVERTISEMENTS
1. 1. Question
The nurse is caring for an elderly woman who has had a fractured hip repaired. In
the first few days following the surgical repair, which of the following nursing
measures will best facilitate the resumption of activities for this client?
o A. Arranging for the wheelchair
o B. Asking her family to visit
o C. Assisting her to sit out of bed in a chair qid
o D. Encouraging the use of an overhead trapeze

Incorrect
Correct Answer: D. Encouraging the use of an overhead trapeze.
Exercise is important to keep the joints and muscles functioning and to prevent
secondary complications. Using the overhead trapeze prevents hazards of
immobility by permitting movement in bed and strengthening of the upper
extremities in preparation for ambulation. Facilitates movement during hygiene
or skincare and linen changes; reduces the discomfort of remaining flat in bed.
―Post position‖ involves placing the uninjured foot flat on the bed with the knee
bent while grasping the trapeze and lifting the body off the bed.
 Option A: Sitting in a wheelchair would require too great hip flexion
initially. Place in supine position periodically if possible, when traction is
used to stabilize lower limb fractures. Reduces the risk of flexion
contracture of the hip.
 Option B: Asking her family to visit would not facilitate the resumption of
activities. Provide footboard, wrist splints, trochanter, or hand rolls as
appropriate. Useful in maintaining a functional position of extremities,
hands, and feet, and preventing complications (contractures, foot drop).

 Option C: Sitting in a chair would cause too much hip flexion. The client
initially needs to be in a low Fowler‘s position or taking a few steps (as
ordered) with the aid of a walker. Encourage the use of isometric exercises
starting with the unaffected limb. Isometrics contract muscles without
bending joints or moving limbs and help maintain muscle strength and
mass. Note: These exercises are contraindicated while acute bleeding and
edema are present.
ADVERTISEMENTS
1. Question 2 of 75
2. Question
Which of the following is the most important nursing order in a client with major
head trauma who is about to receive bolus enteral feeding?
o A. Measure intake and output
o B. Check albumin level
o C. Monitor glucose levels
o D. Increase enteral feeding

Incorrect
Correct Answer: A. Measure intake and output
It is important to measure intake and output, which should be equal. Water given
before feeding will present a hyperosmotic diuresis. I and O measures assess fluid
balance. A urinary catheter is inserted to assess the adequacy of renal perfusion.
The kidney requires 20% to 25% of cardiac output; commonly, it‘s the first organ
to show the effects of impaired perfusion or intravascular volume.
 Option B: Osmotherapy aims to increase the osmolality of the
intravascular space, which in turn helps mobilize excess fluid from brain
tissue. If ICP increases, mannitol (an osmotic diuretic) may be given to
decrease cerebral edema, transiently increase intravascular volume, and
improve cerebral blood flow.
 Option C: Low peripheral oxygen saturation values or low arterial blood
oxygen values (as shown by arterial blood gas testing) should be avoided.
Maintaining adequate brain tissue oxygenation seems to improve patient
outcomes.

 Option D: Enteral feedings are hyperosmotic agents pulling fluid from cells
into the vascular bed. Initially, a nasogastric or orogastric tube is inserted
to decompress the stomach and reduce the aspiration risk. (Typically, the
nasal route is avoided as it can obstruct sinus drainage, leading to sinusitis
or VAP).
ADVERTISEMENTS
1. Question 3 of 75
3. Question
The pathological process causing esophageal varices is/are:
o A. Ascites and edema
o B. Systemic hypertension
o C. Portal hypertension
o D. Dilated veins and varicosities

Incorrect
Correct Answer: C. Portal hypertension
Esophageal varices result from increased portal hypertension. In portal
hypertension, the liver cannot accept all of the fluid from the portal vein. The
excess fluid will backflow to the vessels with lesser pressure, such as esophageal
veins or rectal veins causing esophageal varices or hemorrhoids.
 Option A: Portal hypertension causes portocaval anastomosis to develop
to decompress portal circulation. Normal portal pressure is between 5-10
mmHg but in the presence of portal obstruction, the pressure may be as
high as 15-20 mmHg. Since the portal venous system has no valves,
resistance at any level between the splanchnic vessels and the right side of
the heart results in retrograde flow and elevated pressure.
 Option B: Esophageal varices are dilated submucosal distal esophageal
veins connecting the portal and systemic circulations. They form due to
portal hypertension, which commonly is a result of cirrhosis, resistance to
portal blood flow, and increased portal venous blood inflow.
 Option D: Intrahepatic vasoconstriction due to decreased nitric oxide
production, and increased release of endothelin-1 (ET-1), angiotensinogen,
and eicosanoids. Increased portal flow is caused by hyperdynamic

circulation due to splanchnic arterial vasodilation through mediators such
as nitric oxide, prostacyclin, and TNF.
ADVERTISEMENTS
1. Question 4 of 75
4. Question
Which of the following interventions will help lessen the effect of GERD (acid
reflux)?
o A. Elevate the head of the bed on 4-6 inch blocks.
o B. Lie down after eating.
o C. Increase fluid intake just before bedtime.
o D. Wear a girdle.
Incorrect
Correct Answer: A. Elevate the head of the bed on 4-6 inch blocks.
Elevation of the head of the bed allows gravity to assist in decreasing the
backflow of acid into the esophagus. The fluid does not flow uphill. Instruct to
remain in an upright position at least 2 hours after meals; avoiding eating 3 hours
before bedtime. Helps control reflux and causes less irritation from reflux action
into the esophagus. The other three options all increase fluid backflow into the
esophagus through position or increasing abdominal pressure.
 Option B: Avoid placing the patient in a supine position, have the patient
sit upright after meals. Supine position after meals can increase
regurgitation of acid. Elevate HOB while in bed. To prevent aspiration by
preventing the gastric acid to flow back into the esophagus.
 Option C: Instruct patient regarding eating small amounts of bland food
followed by a small amount of water. Instruct to remain in an upright
position at least 1–2 hours after meals, and to avoid eating within 2–4
hours of bedtime. Gravity helps control reflux and causes less irritation
from reflux action into the esophagus.
 Option D: Instruct the patient to avoid bending over, coughing, straining
at defecations, and other activities that increase reflux. Promotes comfort
by the decrease in intra-abdominal pressure, which reduces the reflux of
gastric contents.

ADVERTISEMENTS
1. Question 5 of 75
5. Question
The main benefit of therapeutic massages is:
o A. To help a person with swollen legs to decrease fluid retention.
o B. To help a person with duodenal ulcers feel better.
o C. To help damaged tissue in a diabetic to heal.
o D. To improve circulation and muscle tone.

Incorrect
Correct Answer: D. To improve circulation and muscle tone.
Particularly in elderly adults, therapeutic massage will help improve circulation
and muscle tone as well as the personal attention and social interaction that a
good massage provides. Damaged or strained muscle fibers release inflammatory
chemicals to aid the healing process, but these chemicals cause significant pain
and discomfort in the process. At least one study, which looked at the effects of
massage on post-exercise tissue inflammation, suggests that even 10 minutes of
massage can reduce signs of inflammation and improve cell processes, thereby
promoting healing, with effects lasting several hours after the massage.
 Option A: Massage only the hands, feet, or scalp of patients with sepsis,
fever over 100[degrees]F, nausea or vomiting, sickle cell crisis, HIV crisis, a
complicated or high-risk pregnancy, crepitus, edema, thrombocytopenia,
or meningitis.
 Option B: When patients have fragile skin, or the potential for skin
breakdown, apply only light pressure, using enough lotion or oil to
minimize friction. For patients with a previous injury, chronic pain, or scar
tissue, frequently ask them how the massage feels, and adjust both
pressure and massage technique to the patients‘ preferences.
 Option C: A massage is contraindicated in any condition where massage to
damaged tissue can dislodge a blood clot. Although massage is associated
with few adverse effects, nurses should be careful to avoid areas near open
wounds, any stage of pressure ulcer, reddened or swollen areas, rashes,
incisions, thromboses, iv lines, drains, shunts, and tubes.
ADVERTISEMENTS

1. Question 6 of 75
6. Question
Which of the following foods should be avoided by clients who are prone to
develop heartburn as a result of gastroesophageal reflux disease (GERD)?
o A. Lettuce
o B. Eggs
o C. Chocolate
o D. Butterscotch
Incorrect
Correct Answer: C. Chocolate
Ingestion of chocolate can reduce lower esophageal sphincter (LES) pressure
leading to reflux and clinical symptoms of GERD. Ingesting cocoa can cause a
surge of serotonin. This surge can cause the esophageal sphincter to relax and
gastric contents to rise. Caffeine and theobromine in chocolate may also trigger
acid reflux. All of the other foods do not affect LES pressure.
 Option A: Vegetables are naturally low in fat and sugar, and they help
reduce stomach acid. Good options include green beans, broccoli,
asparagus, cauliflower, leafy greens, potatoes, and cucumbers.
 Option B: Egg whites are a good option. Stay away from egg yolks,
though, which are high in fat and may trigger reflux symptoms. Reflux
symptoms may result from stomach acid touching the esophagus and
causing irritation and pain.
 Option D: The foods the patient eats affect the amount of acid the
stomach produces. Eating the right kinds of food is key to controlling acid
reflux or GERD, a severe, chronic form of acid reflux. Sources of healthy fats
include avocados, walnuts, flaxseed, olive oil, sesame oil, and sunflower oil.
Reduce the intake of saturated fats and trans fats and replace them with
these healthier unsaturated fats.
ADVERTISEMENTS
1. Question 7 of 75
7. Question

Which of the following should be included in a plan of care for a client receiving
total parenteral nutrition (TPN)?
o A. Withhold medications while the TPN is infusing.
o B. Change TPN solution every 24 hours.
o C. Flush the TPN line with water prior to initiating nutritional support.
o D. Keep the client on complete bed rest during TPN therapy.

Incorrect
Correct Answer: B. Change TPN solution every 24 hours.
TPN solutions should be changed every 24 hours in order to prevent bacterial
overgrowth due to the hypertonicity of the solution. Because the central venous
catheter needs to remain in place for a long time, a strict sterile technique must
be used during the insertion and maintenance of the TPN line. The TPN line
should not be used for any other purpose. External tubing should be changed
every 24 hours with the first bag of the day. In-line filters have not been shown to
decrease complications. Dressings should be kept sterile and are usually changed
every 48 hours using strict sterile techniques.
 Option A: Medication therapy can continue during TPN therapy. Progress
of patients with a TPN line should be followed on a flowchart. An
interdisciplinary nutrition team, if available, should monitor patients.
Weight, complete blood count, electrolytes, and blood urea nitrogen
should be monitored often (eg, daily for inpatients). Plasma glucose should
be monitored every 6 hours until patients and glucose levels become
stable. Fluid intake and output should be monitored continuously. When
patients become stable, blood tests can be done much less often.
 Option C: Flushing is not required because the initiation of TPN does not
require a client to remain on bed rest during therapy. Catheter-related
sepsis rates have decreased since the introduction of guidelines that
emphasize sterile techniques for catheter insertion and skincare around the
insertion site. The increasing use of dedicated teams of physicians and
nurses who specialize in various procedures including catheter insertion
also has accounted for a decrease in catheter-related infection rates.
 Option D: However, other clinical conditions of the client may affect
mobility issues and warrant the client‘s being on bed rest. Place the client
in a semi-Fowler‘s or high-Fowler‘s position. Maintaining the head of the

bed elevated will promote ease in breathing. This position also allows the
pooling of fluid in the bases and for gas exchange to be more available to
the lung tissue.
ADVERTISEMENTS
1. Question 8 of 75
8. Question
Which of the following should be included in a plan of care for a client who is
lactose intolerant?
o A. Remove all dairy products from the diet.
o B. Frozen yogurt can be included in the diet.
o C. Drink small amounts of milk on an empty stomach.
o D. Spread out selection of dairy products throughout the day.

Incorrect
Correct Answer: B. Frozen yogurt can be included in the diet.
Clients who are lactose intolerant can digest frozen yogurt. Yogurt products are
formed by bacterial action, and this action assists in the digestion of lactose. The
freezing process further stops bacterial action so that limited lactase activity
remains. Some people who are lactose-intolerant can eat some kinds of yogurt
without problems, especially yogurt with live cultures.
 Option A: Elimination of all dairy products can lead to significant clinical
deficiencies of other nutrients. Be sure to get enough calcium in the diet,
especially if the client avoids milk products completely. To get enough
calcium, the client would need to eat calcium-rich foods as often as
someone would drink milk. Calcium is very important because it keeps
bones strong and reduces the risk of osteoporosis.
 Option C: Drinking milk on an empty stomach can exacerbate clinical
symptoms. Drinking milk with a meal may benefit the client because other
foods, (especially fat) may decrease transit time and allow for increased
lactase activity. Limit the amount of milk and milk products in the diet. Try
to drink 1 glass of milk each day. Drink small amounts several times a day.
All types of milk contain the same amount of lactose.
Option D: Although individual tolerance should be acknowledged,

spreading out the use of known dairy products will usually exacerbate
clinical symptoms. Eat or drink milk and milk products along with other
foods. For some people, combining solid food (like cereal) with a dairy
product (like milk) can reduce symptoms.
ADVERTISEMENTS
1. Question 9 of 75
9. Question
Pain tolerance in an elderly patient with cancer would:
o A. Stay the same.
o B. Be lowered.
o C. Be increased.
o D. No effect on pain tolerance.

Incorrect
Correct Answer: B. Be lowered.
There is potential for a lowered pain tolerance to exist with diminished adaptive
capacity. For older patients with cancer, unrelieved pain can affect functioning,
increase cognitive impairment, and depression, which in turn can influence the
severity of pain and make management more challenging. In sum, the literature
indicates that cancer pain in advanced disease is multifaceted and can adversely
affect the lives of patients and their caregivers. Changes associated with aging
have the potential to further impact this experience.
 Option A: Pain continues to be a common and distressing symptom,
despite pain management being a central focus of palliative care and
guidelines for the management of cancer pain. Estimates suggest that as
many as 60% to 80% of individuals with recurrent or metastatic cancer
experience pain. Among older patients, cancer pain, similar to other types
of pain, tends to go unrecognized and undertreated
 Option C: In older individuals, the higher incidence of comorbidities, age-
related declines in functioning, and associated symptoms can further
complicate cancer pain and its management. Adding to the complexity is
the recognition that the experience of pain is not merely a sensory event,

but is multifaceted, comprising sensory, affective, and evaluative
components.
 Option D: Indeed, the belief that pain can emanate from both physical
sources and nonphysical sources (psychological, spiritual, and
interpersonal) is central to the concept of total pain, put forth by Dame
Cicely Saunders, founder of the modern hospice. This nonphysical source
of pain derives from feelings of helplessness, being dependent on others,
and having difficulty in reshaping relationships, and has been described by
terminally ill older patients as creating the worst suffering.
ADVERTISEMENTS
10. Question
What is the main advantage of cutaneous stimulation in managing pain?
o A. Costs less.
o B. Restricts movement and decreases.
o C. Gives client control over pain syndrome.
o D. Allows the family to care for the patient at home.

Incorrect
Correct Answer: C. Gives client control over pain syndrome.
Cutaneous stimulation allows the patient to have control over his pain and allows
him to be in his own environment. Cutaneous stimulation increases movement
and decreases pain. Cutaneous stimulation involves stimulation of nerves via skin
contact in an effort to reduce pain impulses to the brain, based on the ―gate
control‖ theory of pain. A device used to provide electrocutaneous nerve
stimulation was studied for its effect on symptoms of peripheral neuropathy.
 Option A: The potential for TENS-associated improvement, combined with
reduced medication-related complications and costs, are important points
that clinicians should consider when constructing a treatment plan for
chronic pain patients. Finally, cost simulation techniques provide a useful
tool for assessing outcomes in pain treatment and research.

 Option B: CS effectively reduces pain, heart rate, and blood pressure in ED
patients. The intervention of CS has solid utilization potential and could be
easily incorporated into standard ED procedures.
 Option D: TENS devices can be purchased over the counter and without
medical prescription in the UK. However, a practitioner experienced in
TENS principles should supervise patients using TENS for the first time. A
point of contact to troubleshoot any problems should also be provided.
ADVERTISEMENTS
11. Question
The nurse is instructing a 65-year-old female client diagnosed with osteoporosis.
The most important instruction regarding exercise would be to
o A. Exercise doing weight-bearing activities.
o B. Exercise to reduce weight.
o C. Avoid exercise activities that increase the risk of fracture.
o D. Exercise to strengthen muscles and thereby protect bones.

Incorrect
Correct Answer: A. Exercise doing weight-bearing activities.
Weight-bearing exercises are beneficial in the treatment of osteoporosis.
Although the loss of bone cannot be substantially reversed, it can be greatly
reduced if the client includes weight-bearing exercises along with estrogen
replacement and calcium supplements in their treatment protocol. 45 minutes to
one hour of aerobic activity two to three times per week
 Option B: Resistance training two or three times per week. Each session
should include exercises to strengthen the lower limb, trunk, and arm
muscles, and each exercise should be performed eight to 10 times
 Option C: Balance exercises need to be at a level that is challenging to
balance and should be performed for a few minutes at least twice a week.
For safety reasons, always make sure to hold on to something if you
overbalance it. People with severe osteoporosis or kyphosis (hunching of
the upper back) who are at high risk of bone fractures may find that
swimming or water exercise is their preferred activity.

 Option D: Even though walking is a weight-bearing exercise, it does not
greatly improve bone health, muscle strength, fitness or balance, unless it
is carried out at high intensity such as at a faster pace, for long durations
(such as bushwalking), or incorporates challenging terrain such as hills.
ADVERTISEMENTS
12. Question
A client in a long-term care facility complains of pain. The nurse collects data
about the client‘s pain. The first step in pain assessment is for the nurse to
o A. Have the client identify coping methods.
o B. Get the description of the location and intensity of the pain.
o C. Accept the client’s report of pain.
o D. Determine the client‘s status of pain.

Incorrect
Correct Answer: C. Accept the client’s report of pain.
Although all of the options above are correct, the first and most important piece
of information in this client‘s pain assessment is what the client is telling you
about the pain –―the client‘s report.‖ Pain is the most common complaint seen in
a primary care office. There are over 50 million Americans, 20 percent of all
patients, that suffer from chronic pain in the United States.
 Option A: Effective treatment modalities for acute, chronic, centralized, or
neuropathic are often different. Ten percent of the United States
population complain of neuropathic pain. This population may benefit
from a serotonin-norepinephrine reuptake inhibitor (SNRI) such as
duloxetine, as compared to ibuprofen for an acute injury.
 Option B: To fully assess the location of a patient‘s pain, a body diagram
map can be completed. Ankle sprains are solitary, acute injuries. Body
diagrams may not be necessary in such a case. Localized pain is different
from whole-body pain. Yet, in a patient with multiple comorbid pain
disorders such as fibromyalgia, centralized pain disorder, and rheumatoid
arthritis, distinguishing between the numerous locations of a patient‘s pain,
as well as factoring in the radiation of their pain, is difficult.

 Option D: An essential first step in the pain assessment is distinguishing
nociceptive pain from neuropathic. Pain characterized as burning, shooting,
pins, and needles, or electric shock-like point the differential towards a
neuropathic origin of the patient‘s pain Sharp or throbbing pain is more
likely to be acute nociceptive pain.
ADVERTISEMENTS
13. Question
Which statement best describes the effects of immobility in children?
o A. Immobility prevents the progression of language and fine motor

development.
o B. Immobility in children has similar physical effects to those found in

adults.
o C. Children are more susceptible to the effects of immobility than are adults.
o D. Children are likely to have prolonged immobility with subsequent

complications.
Incorrect
Correct Answer: B. Immobility in children has similar physical effects to
those found in adults.
Care of the immobile child includes efforts to prevent complications of muscle
atrophy, contractures, skin breakdown, decreased metabolism and bone
demineralization. Secondary alterations also occur in the cardiovascular,
respiratory and renal systems. Similar effects and alterations occur in adults.
 Option A: The hazards or complications of immobility, such as skin
breakdown, pressure ulcers, contractures, muscular weakness, muscular
atrophy, disuse osteoporosis, renal calculi, urinary stasis, urinary retention,
urinary incontinence, urinary tract infections, atelectasis, pneumonia,
decreased respiratory vital capacity, venous stasis, venous insufficiency,
orthostatic hypotension, decreased cardiac reserve, edema, emboli,
thrombophlebitis, constipation and the loss of calcium from the bones, are
highly costly in terms of health care dollars and in terms of client suffering.

 Option C: Immobility and complete bed rest can lead to life-threatening
physical and psychological complications and consequences. Members of
the nursing care team and other health care professionals like physical
therapists must, therefore, promote client mobility and prevent immobility
whenever possible. Immobility can adversely affect all physiological bodily
systems.
 Option D: Children stayed in a cast for a long period, so that the effect of
postoperative immobility had negative effects on the physical and
psychological wellbeing of children with musculoskeletal injuries.
Emphasize the importance of implementing a nursing care program for
children in the postoperative period for minimizing the physical and
psychological effects of immobility on children with musculoskeletal
injuries.
ADVERTISEMENTS
14. Question
After a myocardial infarction, a client is placed on a sodium-restricted diet. When
the nurse is teaching the client about the diet, which meal plan would be
the most appropriate to suggest?
o A. 3 oz. broiled fish, 1 baked potato, ½ cup canned beets, 1 orange, and milk.
o B. 3 oz. canned salmon, fresh broccoli, 1 biscuit, tea, and 1 apple.
o C. A bologna sandwich, fresh eggplant, 2 oz fresh fruit, tea, and apple juice.
o D. 3 oz. turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk,
and 1 orange.
Incorrect
Correct Answer: D. 3 oz. turkey, 1 fresh sweet potato, 1/2 cup fresh green
beans, milk, and 1 orange
Canned fish and vegetables and cured meats are high in sodium. This meal does
not contain any canned fish and/or vegetables or cured meats. Eat a
Mediterranean?style diet—more bread, fruit, vegetables, and fish; less meat; and
replace butter and cheese with products based on vegetable and plant oils
(reduces total mortality and the risk of myocardial infarction).

 Option A: Consume at least 7?g of omega?3 fatty acids per week from 2–4
portions of oily fish per week. If within 3?months of myocardial infarction
and they are not achieving this, consider providing at least 1?g daily of
omega?3?acid ethyl esters treatment licensed for secondary prevention
after myocardial infarction for up to 4 years.
 Option B: Choose foods with less sodium and prepare foods with little or
no salt. To lower blood pressure, aim to eat no more than 2,300 milligrams
of sodium per day. Reducing daily intake to 1,500 mg is desirable because
it can lower blood pressure even further.
 Option C: Processed meats, like hot dogs, sausage, and lunch meat, are
loaded with sodium and nitrates. This can raise the blood pressure and the
risk of another heart attack. High blood pressure is particularly dangerous
because there usually aren‘t any symptoms.
ADVERTISEMENTS
15. Question
A nurse is assessing several clients in a long-term health care facility. Which client
is at highest risk for the development of decubitus ulcers?
o A. A 79-year-old malnourished client on bed rest.
o B. An obese client who uses a wheelchair.
o C. An incontinent client who has had 3 diarrhea stools.
o D. An 80-year-old ambulatory diabetic client.

Incorrect
Correct Answer: A. A 79-year-old malnourished client on bed rest.
Weighing significantly less than ideal body weight increases the number and
surface area of bony prominences which are susceptible to pressure ulcers. Thus,
malnutrition is a major risk factor for decubitus, due in part to poor hydration and
inadequate protein intake. Both external and internal factors work simultaneously,
forming these ulcers. External factors; pressure, friction, shear force, and moisture
and internal factors; fever, malnutrition, anemia, and endothelial dysfunction
speed up the process of these lesions.

 Option B: Immobility of as little as two hours in a bedridden patient or
patient undergoing surgery is sufficient to create the basis of a decubitus
ulcer. The dysfunction of nervous regulatory mechanisms responsible for
the regulation of local blood flow is somewhat culpable in the formation of
these ulcers. Prolonged pressure on tissues can cause capillary bed
occlusion and, thus, low oxygen levels in the area. Over time, the ischemic
tissue begins to accumulate toxic metabolites. Subsequently, tissue
ulceration and necrosis occur.
 Option C: The development of decubitus ulcers is complex and
multifactorial. Loss of sensory perception, locally and general impaired loss
of consciousness, along with decreased mobility, are the most important
causes that aid in the formation of these ulcers because patients are not
aware of discomfort hence do not relieve the pressure.
 Option D: Elderly patients are more prone to sacral decubitus ulcers; two-
thirds of ulcers occur in patients who are over 70 years old. There is data
that shows 83% of hospitalized patients with ulcers developed them within
five days of their hospitalization.
ADVERTISEMENTS
16. Question
Mrs. Kennedy had a CVA (cerebrovascular accident) and has a severe right-sided
weakness. She has been taught to walk with a cane. The nurse is evaluating her
use of the cane prior to discharge. Which of the following reflects the correct use
of the cane?
o A. Holding the cane in her left hand, Mrs. Kennedy moves the cane
forward first, then her right leg, and finally her left leg.
o her left leg. B. Holding the cane in her right hand, Mrs. Kennedy moves the
cane forward first, then her left leg, and finally her right leg.
o C. Holding the cane in her right hand, Mrs. Kennedy moves the cane and her
right leg forward then moves her left leg forward.
o D. Holding the cane in her left hand, Mrs. Kennedy moves the cane and her
left leg forward, then moves her right leg forward.

Incorrect
Correct Answer: A. Holding the cane in her left hand, Mrs. Kennedy moves
the cane forward first, then her right leg, and finally her left leg
When a person with weakness on one side uses a cane, there should always be
two points of contact with the floor. When Mrs. Kennedy. moves the cane
forward, she has both feet on the floor, providing stability. As she moves the
weak leg, the cane and the strong leg provide support. Finally, the cane, which is
even with the weak leg, provides stability while she moves the strong leg.
 Option B: She should not hold the cane with her weak arm. The use of the
cane requires arm strength to ensure that the cane provides adequate
stability when standing on the weak leg. To go upstairs, use the handrail
and step up with the unaffected leg first and follow with the cane and the
affected foot together.
 Option C: The cane should be held in the left hand, the hand opposite the
affected leg. Hold the cane in the hand of the unaffected side. Move the
cane and the affected leg forward at the same time, so that the cane helps
take the weight of the weak leg. Then step with the unaffected leg.
 Option D: If Mrs. Kennedy. moved the cane and her strong foot at the
same time, she would be left standing on her weak leg at one point. This
would be unstable at best; at worst, impossible. To go downstairs, use the
handrail and step down with the affected foot and cane together first and
follow with the unaffected foot.
ADVERTISEMENTS
17. Question
The nurse is instructing a woman on a low-fat, high-fiber diet. Which of the
following food choices, if selected by the client, indicate an understanding of a
low-fat, high-fiber diet?
o A. Tuna salad sandwich on whole-wheat bread.
o B. Vegetable soup made with vegetable stock, carrots, celery, and

legumes served with toasted oat bread.
o C. Chef‘s salad with hard-boiled eggs and fat-free dressing.

o D. Broiled chicken stuffed with chopped apples and walnuts.
Incorrect
Correct Answer: B. Vegetable soup made with vegetable stock, carrots,
celery, and legumes served with toasted oat bread.
This choice shows a low-fat soup (which would have been higher in fat if made
with chicken or beef stock) and high-fiber bread and soup contents (both the
vegetables and the legumes). Eating a high-fiber diet that is low in fat can help
maintain overall health. Fiber-rich foods are naturally low in fat and contain
cancer-fighting and heart-healthy properties. While a low-fat diet is good, it is
important that the client does not dismiss all fats, however. Eat some foods
containing unsaturated fats because they are necessary for an overall healthy
diet.
 Option A: Mayonnaise in tuna salad is high in fat. The whole-wheat bread
has some fiber. Fiber‘s presence in the digestive tract can help reduce the
body‘s cholesterol absorption. This is especially true if you take statins,
which are medications to lower cholesterol, and use fiber supplements like
psyllium fiber
 Option C: Salad is high in fiber, but hard-boiled eggs are high in fat. In
fact, a single egg contains 212 mg of cholesterol, which is 71% of the
recommended daily intake. Plus, 62% of the calories in whole eggs are
from fat.
 Option D: There is some fiber in the apples and walnuts. The walnuts are
high in fat, as is the chicken. Nuts have a high-fat content, so are high in
energy. In most nuts, this is mainly unsaturated fat: either polyunsaturated
fats in walnuts and pine nuts or monounsaturated fats in almonds,
pistachios, pecans, and hazelnuts, for example. Brazil nuts, cashews, and
macadamia nuts are higher in saturated fat.
ADVERTISEMENTS
18. Question
An 85-year-old male patient has been bedridden for two weeks. Which of the
following complaints by the patient indicates to the nurse that he is developing a
complication of immobility?
o A. Stiffness of the right ankle joint.

o B. Soreness of the gums.
o C. Short-term memory loss.
o D. Decreased appetite.
Incorrect
Correct Answer: A. Stiffness of the right ankle joint.
Stiffness of a joint may indicate the beginning of contracture and/or early muscle
atrophy. In the development of joint contractures that result from long-term
immobilization, shortening of the joint capsule, synovial adhesions and
arthrofibrosis play decisive roles and may present as a generalized joint stiffness
 Option B: Soreness of the gums is not related to immobility. Brushing too
hard, improper flossing techniques, infection, or gum disease can cause
sore and sensitive gums. Other causes unrelated to oral hygiene could
include Vitamin K deficiency, hormonal changes during pregnancy,
leukemia, or blood disorders.
 Option C: Short-term memory loss is not related to immobility. Short-term
memory loss is when one forgets things they heard, saw, or did recently.
It‘s a normal part of getting older for many people. But it can also be a sign
of a deeper problem, such as dementia, a brain injury, or a mental health
issue.
 Option D: Decreased appetite is unlikely to be related to immobility.
People can experience a loss of appetite for a wide range of reasons. Some
of these are short-term, including colds, food poisoning, other infections,
or the side effects of medication. Others are to do with long-term medical
conditions, such as diabetes, cancer, or life-limiting illnesses.
ADVERTISEMENTS
19. Question
An eleven-month-old infant is brought to the pediatric clinic. The nurse suspects
that the child has iron-deficiency anemia. Because iron deficiency anemia is
suspected, which of the following is the most important information to obtain
from the infant‘s parents?
o A. Normal dietary intake.

o B. Relevant socio-cultural, economic, and educational background of the
family.
o C. Any evidence of blood in the stools.
o D. A history of maternal anemia during pregnancy.

Incorrect
Correct Answer: A. Normal dietary intake.
Iron deficiency anemia occurs commonly in children 6 to 24 months of age. For
the first 4 to 5 months of infancy iron stores laid down for the baby during
pregnancy are adequate. When fetal iron stores are depleted, supplemental
dietary iron needs to be supplied to meet the infant‘s rapid growth needs. Iron
deficiency may occur in the infant who drinks mostly milk, which contains no iron,
and does not receive adequate dietary iron or supplemental iron.
 Option B: Daily dietary intake is much more related to the diagnosis of
iron deficiency anemia than is the socio-cultural, economic, and
educational background of the family. The cause of iron-deficiency anemia
varies based on age, gender, and socioeconomic status. Iron deficiency
may result from insufficient iron intake, decreased absorption, or blood
loss.
 Option C: Iron deficiency anemia in an infant is very unlikely to be related
to gastrointestinal bleeding. In developing countries, a parasitic infestation
is also a significant cause of iron deficiency anemia. Dietary sources of iron
are green vegetables, red meat, and iron-fortified milk formulas.
 Option D: Anemia during pregnancy is unlikely to be the cause of the
infant‘s iron deficiency anemia. Fetal iron stores are drawn from the mother
even if she is anemic. In neonates, breastfeeding is protective against iron
deficiency due to the higher bioavailability of iron in breast milk compared
to cow‘s milk; iron deficiency anemia is the most common form of anemia
in young children on cow‘s milk.
ADVERTISEMENTS
20. Question
A 46-year-old female with chronic constipation is assessed by the nurse for a
bowel training regimen. Which factor indicates further information is needed by
the nurse?

o A. The client‘s dietary habits include foods high in bulk.
o B. The client‘s fluid intake is between 2500-3000 ml per day.
o C. The client engages in moderate exercise each day.
o D. The client’s bowel habits were not discussed.

Incorrect
Correct Answer: D. The client’s bowel habits were not discussed.
To assess the client for a bowel training program the factors causing the bowel
alteration should be assessed. A routine for bowel elimination should be based
on the client‘s previous bowel habits and alterations in bowel habits that have
occurred because of illness or trauma.
 Option A: Foods high in bulk are appropriate. Assist the patient to take at
least 20 g of dietary fiber (e.g., raw fruits, fresh vegetables, whole grains)
per day. Fiber adds bulk to the stool and makes defecation easier because
it passes through the intestine essentially unchanged.
 Option B: The client and the family should assist in the planning of the
program which should include foods high in bulk, adequate exercise, and
fluid intake of 2500-3000 ml. Encourage the patient to take in fluid 2000 to
3000 mL/day, if not contraindicated medically. Sufficient fluid is needed to
keep the fecal mass soft. But take note of some patients or older patients
having cardiovascular limitations requiring less fluid intake.
 Option C: Exercise should be a part of a bowel training regimen. Urge the
patient for some physical activity and exercise. Consider isometric
abdominal and gluteal exercises. Movement promotes peristalsis.
Abdominal exercises strengthen abdominal muscles that facilitate
defecation.
ADVERTISEMENTS
21. Question
Mr. Teban is a 73-year old patient diagnosed with pneumonia. Which data would
be of greatest concern to the nurse when completing the nursing assessment of
the patient?
o A. Alert and oriented to date, time, and place.

o B. Buccal cyanosis and capillary refill greater than 3 seconds.
o C. Clear breath sounds and nonproductive cough.
o D. Hemoglobin concentration of 13 g/dl and leukocyte count 5,300/mm3.

Incorrect
Correct Answer: B. Buccal cyanosis and capillary refill greater than 3
seconds.
Buccal cyanosis and capillary refill greater than 3 seconds are indicative of
decreased oxygen to the tissues, which requires immediate intervention. As
oxygenation and perfusion become impaired, peripheral tissues become cyanotic.
Cyanosis of nail beds may represent vasoconstriction or the body‘s response to
fever/chills; however, cyanosis of earlobes, mucous membranes, and skin around
the mouth (―warm membranes‖) is indicative of systemic hypoxemia. Alert and
oriented, clear breath sounds, nonproductive cough, hemoglobin concentration
of 13 g/dl, and leukocyte count of 5,300/mm3 are normal data.
 Option A: Restlessness, irritation, confusion, and somnolence may reflect
hypoxemia and decreased cerebral oxygenation and may require further
intervention. Check pulse oximetry results with any mental status changes
in older adults.
 Option C: Decreased airflow occurs in areas with consolidated fluid.
Bronchial breath sounds can also occur in these consolidated areas.
Crackles, rhonchi, and wheezes are heard on inspiration and/or expiration
in response to fluid accumulation, thick secretions, and airway spasms and
obstruction.
 Option D: Monitor serial chest x-rays, ABGs, pulse oximetry readings.
Follows progress and effects and extent of pneumonia. Therapeutic
regimen, and may facilitate necessary alterations in therapy. Oxygen
saturation should be maintained at 90% or greater. Imbalances in PaCO2
and PaO2 may indicate respiratory fatigue.
ADVERTISEMENTS
22. Question
During the nursing assessment, which data represent information concerning
health beliefs?

o A. Family role and relationship patterns.
o B. Educational level and financial status.
o C. Promotive, preventive, and restorative health practices.
o D. Use of prescribed and over-the-counter medications.

Incorrect
Correct Answer: C. Promotive, preventive, and restorative health practices.
The health-beliefs assessment includes expectations of health care; promotive,
preventive, and restorative practices, such as breast self-examination, testicular
examination, and seat-belt use; and how the client perceives illness. The basic
premise of the health belief assessment is that patients have a right to their
cultural beliefs, values, and practices, and that these factors should be
understood, respected, and considered when giving culturally competent care.
 Option A: Educational level and financial status represent information
associated with role and relationship patterns. Critical thinking skills
applied during the nursing process provide a decision-making framework
to develop and guide a plan of care for the patient incorporating evidence-
based practice concepts. This concept of precision education to tailor care
based on an individual‘s unique cultural, spiritual, and physical needs,
rather than a trial by error, one size fits all approach results in a more
favorable outcome.
 Option B: Family role and relationship patterns represent information
associated with role and relationship patterns. The nursing assessment
includes gathering information concerning the patient‘s individual
physiological, psychological, sociological, and spiritual needs. It is the first
step in the successful evaluation of a patient. Subjective and objective data
 Option D: The use of medications provides information about the client‘s
personal habits. Part of the assessment includes data collection by
obtaining vital signs such as temperature, respiratory rate, heart rate, blood
pressure, and pain level using age or condition-appropriate pain scale. The
assessment identifies the current and future care needs of the patient by
allowing the formation of a nursing diagnosis. The nurse recognizes normal
and abnormal patient physiology and helps prioritize interventions and
care.
ADVERTISEMENTS

23. Question
Nurse Patrick is acquiring information from a client in the emergency
department. Which is an example of biographic information that may be
obtained during a health history?
o A. The chief complaint
o B. Past health status
o C. History immunizations
o D. Location of an advance directive

Incorrect
Correct Answer: D. Location of an advance directive
Biographic information may include name, address, gender, race, occupation, and
location of a living will or durable power of attorney for health care. Biographic
data usually include information that identifies the client, such as name, address,
phone number, gender, and who provided the information—the client or
significant others. The client‘s birth date, Social Security number, medical record
number, or similar identifying data may be included in the biographic data
section. The chief complaint, past health status, and history of immunizations are
part of assessing the client‘s health and illness patterns.
 Option A: Encourage the client to explain the health problem or symptom
in as much detail as possible by focusing on the onset, progression, and
duration of the problem; signs and symptoms and related problems; and
what the client perceives as causing the problem. The client‘s answers to
the questions provide the nurse with a great deal of information about the
client‘s problem and especially how it affects the lifestyle and activities of
daily living. This helps the nurse to evaluate the client‘s insight into the
problem and the client‘s plans for managing it.
 Option B: This portion of the health history focuses on questions related
to the client‘s past, from the earliest beginnings to the present. These
questions elicit data related to the client‘s strengths and weaknesses in her
health history. The client‘s strengths may be physical (e.g., optimal body
weight), social (e.g., active in community services), emotional (e.g.,
expresses feeling openly), or spiritual (often turns to faith for support).

 Option C: Information covered in the past health history includes
questions about birth, growth, development, childhood diseases,
immunizations, allergies, previous health problems, hospitalizations,
surgeries, pregnancies, births, previous accidents, injuries, painful
experiences, and emotional or psychiatric problems.
ADVERTISEMENTS
24. Question
John Joseph was scheduled for a physical assessment. When percussing the
client‘s chest, the nurse would expect to find which assessment data as a normal
sign over his lungs?
o A. Dullness
o B. Resonance
o C. Hyperresonance
o D. Tympany
Incorrect
Correct Answer: B. Resonance
Normally, when percussing a client‘s chest, percussion over the lungs reveals
resonance, a hollow or loud, low-pitched sound of long duration. Since lungs are
mostly filled with air that we breathe in, percussion performed over most of the
lung area produces a resonant sound, which is a low-pitched, hollow sound.
Therefore, any dullness or hyper-resonance is indicative of lung pathology, such
as pleural effusion or pneumothorax, respectively.
 Option A: Dullness is typically heard on percussion of solid organs, such as
the liver or areas of consolidation. Dullness to percussion indicates denser
tissue, such as zones of effusion or consolidation. Once an abnormality is
detected, percussion can be used around the area of interest to define the
extent of the abnormality. Normal areas of dullness are those overlying the
liver and spleen at the anterior bases of the lungs.
 Option C: Hyperresonance would be evidenced by percussion over areas
of overinflation such as an emphysematous lung. Hyperresonant sounds
may also be heard when percussing lungs hyperinflated with air, such as

may occur in patients with COPD, or patients having an acute asthmatic
attack. An area of hyper resonance on one side of the chest may indicate a
pneumothorax.
 Option D: Tympany is typically heard on percussion over such areas as a
gastric air bubble or the intestine. Tympanic sounds are hollow, high,
drumlike sounds. Tympany is normally heard over the stomach but is not a
normal chest sound. Tympanic sounds heard over the chest indicate
excessive air in the chest, such as may occur with pneumothorax.
ADVERTISEMENTS
25. Question
Matteo is diagnosed with dehydration and underwent a series of tests. Which
laboratory result would warrant immediate intervention by the nurse?
o A. Serum sodium level of 138 mEq/L
o B. Serum potassium level of 3.1 mEq/L
o C. Serum glucose level of 120 mg/dl
o D. Serum creatinine level of 0.6 mg/100 ml

Incorrect
Correct Answer: B. Serum potassium level of 3.1 mEq/L
A normal potassium level is 3.5 to 5.5 mEq/L. Hypokalemia is more prevalent than
hyperkalemia, and most cases are mild. Severity is categorized as mild when the
serum potassium level is 3 to 3.4 mmol/L, moderate when the serum potassium
level is 2.5 to 3 mmol/L, and severe when the serum potassium level is less than
2.5 mmol/L.
 Option A: A normal sodium level is 135 to 145 mEq/L. Among the
electrolyte disorders, hyponatremia is the most frequent. Diagnosis is when
the serum sodium level is less than 135 mmol/L. Hyponatremia has
neurological manifestations. Patients may present with headache,
confusion, nausea, delirium. Hypernatremia presents when the serum
sodium levels are greater than145 mmol/L.
 Option C: A normal non fasting glucose level is 85 to 140 mg/dl. Normal
plasma glucose levels are defined as under 100 mg/dL during fasting and

less than 140 mg/dL 2-hours postprandial. Additionally, glucose levels in
healthy individuals can vary with age. Fasting plasma glucose in adults
tends to increase with age starting in the third decade of life but does not
increase significantly beyond 60 years of age. Normal HbA1c is lower than
5.7%.
 Option D: A normal creatinine level is 0.2 to 0.8 mg/100 ml. Serum
creatinine level for men with normal kidney function is approximately 0.6 to
1.2mg/dL and between 0.5 to 1.1 mg/dL for women. Alteration of serum
creatinine values can occur as its generation is subject to influence by
muscle function, activity, diet, and health status of the patient. Increased
tubular secretion of creatinine in certain patients with dysfunctional
kidneys could provide a false negative value. Elevated serum creatinine
levels are also present in patients with muscular dystrophy paralysis,
anemia, leukemia, and hyperthyroidism.
ADVERTISEMENTS
26. Question
During an otoscopic examination, which action should be avoided to prevent the
client from discomfort and injury?
o A. Tipping the client's head away from the examiner and pulling the ear up
and back.
o B. Inserting the otoscope inferiorly into the distal portion of the external
canal.
o C. Inserting the otoscope superiorly into the proximal two-thirds of the

external canal.
o D. Bracing the examiner's hand against the client's head.

Incorrect
Correct Answer: C. Inserting the otoscope superiorly into the proximal two-
thirds of the external canal.
In the superior position, the speculum of the otoscope is nearest the tympanic
membrane, and the most sensitive portion of the external canal is the proximal
two-thirds. It is important to avoid these structures during the examination. The

provider should then slowly progress the speculum into the canal until the
tympanic membrane becomes visible. The provider should evaluate the health of
the tympanic membrane and observe factors such as color, presence of
perforation, and a bulging appearance.
 Option A: With the hand that is not holding the otoscope, the provider
should grasp and gently pull the patient‘s pinna to help straighten the
patient‘s external auditory canal. This step will facilitate visualization of the
tympanic membrane. In a child, the examiner should pull the pinna
posteriorly and inferiorly. In an adult, the examiner should pull the pinna
posteriorly and superiorly.
 Option B: During the otoscopic examination, the provider utilizes an
otoscope, also known as an auriscope, to visualize the ear anatomy. While
performing the otoscopic examination, the provider holds the handle of
the otoscope and inserts the cone of the otoscope into the patient‘s
external auditory canal.
 Option D: Providers may have their own preferences regarding how to
grasp the otoscope. However, it is generally advisable to hold the otoscope
like a pen in between the first and second fingers. The otoscope is usually
held in the right hand when evaluating the patient‘s right ear and the left
hand when assessing the patient‘s left ear. The provider should place their
free fifth finger of the hand, holding the otoscope against the patient‘s
cheek to support and brace the hand during the examination.
ADVERTISEMENTS
27. Question
When assessing the lower extremities for arterial function, which intervention
should the nurse perform?
o A. Assessing the medial malleoli for pitting edema.
o B. Performing Allen's test.
o C. Assessing the Homans' sign.
o D. Palpating the pedal pulses.

Incorrect

Correct Answer: D. Palpating the pedal pulses.
Palpating the client‘s pedal pulses assists in determining if arterial blood supply
to the lower extremities is sufficient. Finding a pedal pulse is part of the trauma
patient assessment and performed before and after lower extremity splint
application as well as long backboard immobilization. Assessing a pedal pulse is
part of the ongoing assessment for a patient on a backboard or a lower extremity
splint.
 Option A: Assessing the medial malleoli for pitting edema is appropriate
for assessing the venous function of the lower extremity. The lower
extremity examination should focus on the medial malleolus, the bony
portion of the tibia, and the dorsum of the foot. Pitting edema also occurs
in the early stages of lymphedema because of an influx of protein-rich fluid
into the interstitium, before fibrosis of the subcutaneous tissue; therefore,
its presence should not exclude the diagnosis of lymphedema.
 Option B: Allen‘s test is used to evaluate arterial blood flow before
inserting an arterial line in an upper extremity or obtaining arterial blood
gases. The Allen test is a first-line standard test used to assess the arterial
blood supply of the hand. This test is performed whenever intravascular
access to the radial artery is planned or for selecting patients for radial
artery harvesting, such as for coronary artery bypass grafting or for forearm
flap elevation.
 Option C: Homans‘ sign is used to evaluate the possibility of deep vein
thrombosis. Homan‘s sign test also called dorsiflexion sign test is a physical
examination procedure that is used to test for Deep Vein Thrombosis
(DVT). A positive Homan‘s A positive Homan‘s sign in the presence of other
clinical signs may be a quick indicator of DVT.
ADVERTISEMENTS
28. Question
Newly hired nurse Liza is excited to perform her very first physical assessment
with a 19-year-old client. Which assessment examination requires Liza to wear
gloves?
o A. Breast
o B. Integumentary

o C. Ophthalmic
o D. Oral
Incorrect
Correct Answer: D. Oral
Gloves should be worn anytime there is a risk of exposure to the client‘s blood or
body fluids. Oral, rectal, and genital examinations require gloves because they
involve contact with body fluids. Ophthalmic, breast, or integumentary
examinations normally do not involve contact with the client‘s body fluids and do
not require the nurse to wear gloves for protection.
 Option A: After completing the visual inspection, the patient should be
instructed to lay supine. If a site-specific breast complaint is being
evaluated, the examiner should begin his/her exam on the opposite, or
―normal‖ side. As one breast is examined, the other is covered for the
patient‘s comfort. The patient should place the ipsilateral hand above
and/or behind their head to flatten the breast tissue as much as possible.
The breast tissue itself is evaluated using a sequence of palpation that
allows serial progression from superficial to deeper tissues.
 Option B: A general assessment of the skin begins at the initial contact
with the patient and continues throughout the examination. Specific areas
of the skin are assessed during the examination of other body systems
unless the chief complaint is a dermatologic problem. However, if there are
areas of skin breakdown or drainage, gloves should be used.
 Option C: The Royal College of Ophthalmologists have updated their
advice on PPE to ophthalmologists and are now recommending that
clinicians should wear standard surgical masks when examining or treating
patients at the slit lamp. Gowns and gloves are not recommended. They
also recommend that plastic breath shields attached to slit lamps provide
some protection, but must be disinfected between patients as studies show
that the COVID-19 virus is viable for up to 72 hours on plastic surfaces.
ADVERTISEMENTS
29. Question
Nurse Renner is about to perform Romberg‘s test on Pierro. To ensure the latter‘s
safety, which intervention should nurse Renner implement?

o A. Allowing the client to keep his eyes open.
o B. Having the client hold on to furniture.
o C. Letting the client spread his feet apart.
o D. Standing close to provide support.

Incorrect
Correct Answer: D. Standing close to provide support.
During Romberg‘s test, the client is asked to stand with feet together and eyes
shut and still maintain balance with the minimum of sway. If the client loses his
balance, the nurse standing close to provide support, such as having an arm close
around his shoulder, can prevent a fall. Allowing the client to keep his eyes open,
spread his feet apart, or hang on to a piece of furniture interferes with the proper
execution of the test and yields invalid results.
 Option A: The clinician asks the patient to first stand quietly with eyes
open, and subsequently with eyes closed. The patient tries to maintain his
balance. For safety, it is essential that the observer stand close to the
patient to prevent potential injury if the patient were to fall. When the
patient closes his eyes, he should not orient himself by light, sense or
sound, as this could influence the test result and cause a false positive
outcome.
 Option B: In the Romberg test, the patient stands upright and asked to
close his eyes. A loss of balance is interpreted as a positive Romberg sign.
The Romberg test is positive when the patient is unable to maintain
balance with their eyes closed. Losing balance can be defined as increased
body sway, placing one foot in the direction of the fall, or even falling.
 Option C: The patient is asked to remove his shoes and stand with his two
feet together. The arms are held next to the body or crossed in front of the
body. If the clinician observes that the patient is able to stand for long
periods of time with the eyes closed, it is evident that the patient‘s balance
and proprioceptive deficits have decreased.
ADVERTISEMENTS
30. Question

A physical assessment is being performed on patient Geoff by Nurse Tine. During
the abdominal examination, Nurse Tine should perform the four physical
examination techniques in which sequence?
o A. Auscultation immediately after the inspection and then percussion

and palpation.
o B. Percussion, followed by inspection, auscultation, and palpation.
o C. Palpation of tender areas first and then inspection, percussion, and

auscultation.
o D. Inspection and then palpation, percussion, and auscultation.

Incorrect
Correct Answer: A. Auscultation immediately after the inspection and then
percussion and palpation
With an abdominal assessment, auscultation always is performed before
percussion and palpation because any abdominal manipulation, such as from
palpation or percussion, can alter bowel sounds. Assessing the patient‘s abdomen
can provide critical information about his internal organs. Always follow this
sequence: inspection, auscultation, percussion, and palpation. Changing the order
of these assessment techniques could alter the frequency of bowel sounds and
make the findings less accurate.
 Option B: Percussion should never precede inspection or auscultation, and
any tender or painful areas should be palpated last. Assess for any visible
mass, bulging, or asymmetry. Look for unusual coloring, scars, striae,
lesions, petechiae, ecchymoses, spider angiomas, and suspicious-looking
moles. Inspect the umbilicus and note any hernias. Look for pulsations. A
thin patient may have a pulsation of the aorta in his epigastric area and
possibly peristaltic waves.
 Option C: Lightly percuss all four quadrants of the patient‘s abdomen.
You‘ll hear dull sounds over solid structures (such as the liver) and fluid-
filled structures (such as a full bladder). Air-filled areas (such as the
stomach) produce tympany. Dullness is a normal finding over the liver, but
a large, dull area elsewhere may indicate a tumor or mass.
 Option D: Using a light, gentle, dipping motion, palpate for abnormalities,
such as muscle guarding, rigidity, or superficial masses. Palpate clockwise,
lifting fingers as you move from one location to another. After light

palpation of the entire abdomen, place a non-dominant hand on the
dominant hand to perform deeper palpation (1½ to 2 inches [3.8 to 5 cm]).
However, avoid deep palpation if the patient may have a problem such as
splenomegaly, appendicitis, or aneurysm or if palpation is painful for any
reason.
ADVERTISEMENTS
31. Question
Which assessment data should the nurse include when obtaining a review of
body systems?
o A. Brief statement about what brought the client to the health care provider.
o B. Client complaints of chest pain, dyspnea, or abdominal pain.
o C. Information about the client's sexual performance and preference.
o D. The client's name, address, age, and phone number.

Incorrect
Correct Answer: B. Client complaints of chest pain, dyspnea, or abdominal
pain.
Client complaints about chest pain, dyspnea, or abdominal pain are considered
part of the review of body systems. This portion of the assessment elicits
subjective information on the client‘s perceptions of major body system
functions, including cardiac, respiratory, and abdominal. Critical thinking skills
applied during the nursing process provide a decision-making framework to
develop and guide a plan of care for the patient incorporating evidence-based
practice concepts.
 Option A: A brief statement about what brought the client to the health
care provider is the chief complaint. The CC is the reason for the visit as
stated in the patient‘s own words. This must be present for each encounter,
and should reference a specific condition or complaint (e.g., patient
complains of abdominal pain).
 Option C: Information about the client‘s sexual performance and
preference addresses past health status. Understanding the client‘s current
and past health is important and may provide an explanation or rationale

for the client‘s current health status. Furthermore, these data can provide
insight into health promotion needs and co-morbidities. It is helpful to
understand the current and past health profiles before assessing other
aspects of health, as the information will inform subsequent questions.
 Option D: The client‘s name, address, age, and phone number are
biographical data. ―Introductory Information‖ refers to the demographic
and biographic data that you collect from the client. This data provides you
with basic characteristics about the client, such as their name, contact
information, birth date and age, gender and preferred pronouns, allergies,
languages spoken and preferred language, relationship status, occupation,
and resuscitation status.
ADVERTISEMENTS
32. Question
Tywin has come to the nursing clinic for a comprehensive health assessment.
Which statement would be the best way to end the history interview?
o A. "What brought you to the clinic today?"
o B. "Would you describe your overall health as good?"
o C. "Do you understand what is happening?"
o D. "Is there anything else you would like to tell me?"

Incorrect
Correct Answer: D. “Is there anything else you would like to tell me?”
By asking the client if there is anything else, the nurse allows the client to end the
interview by discussing feelings and concerns. The purpose of obtaining a health
history is to gather subjective data from the patient and/or the patient‘s family so
that the health care team and the patient can collaboratively create a plan that
will promote health, address acute health problems, and minimize chronic health
conditions.
 Option A: Asking about what brought the client to the clinic is an
ambiguous question to which the client may answer ―my car‖ or any
similarly disingenuous reply. The health history is typically done on
admission to the hospital, but a health history may be taken whenever

additional subjective information from the patient may be helpful to inform
care (Wilson & Giddens, 2013).
 Option B: Asking if the client describes his overall health as good is a
leading question that puts words in his mouth. Objective data is
information that the health care professional gathers during a physical
examination and consists of information that can be seen, felt, smelled, or
heard by the health care professional. Taken together, the data collected
provides a health history that gives the health care professional an
opportunity to assess health promotion practices and offer patient
education (Stephen et al., 2012).
 Option C: Asking if the client understands what is happening is a yes-or-
no question that can elicit little information. Data gathered may be
subjective or objective in nature. Subjective data is information reported by
the patient and may include signs and symptoms described by the patient
but not noticeable to others. Subjective data also includes demographic
information, patient and family information about past and current medical
conditions, and patient information about surgical procedures and social
history.
ADVERTISEMENTS
33. Question
For which time period would the nurse notify the health care provider that the
client had no bowel sounds?
o A. 2 minutes
o B. 3 minutes
o C. 4 minutes
o D. 5 minutes
Incorrect
Correct Answer: D. 5 minutes
To completely determine that bowel sounds are absent, the nurse must
auscultate each of the four quadrants for at least 5 minutes; 2, 3, or 4 minutes is
too short a period to arrive at this conclusion. The first item to listen for is the

presence of bowel sounds. To chart an assessment finding of no bowel sounds,
the nurse needs to listen over the quadrant for at least five minutes. The nurse
should also do the auscultation before palpation and percussion to avoid
influencing bowel sounds.
 Option A: In most cases, bowel sounds are present, but the nurse needs to
categorize them. She should listen for the intensity of the sound – whether
it is soft or strong. The nurse should also listen for frequency. Hypoactive
bowel sounds could indicate a problem, so if the nurse is having trouble
hearing them, this is significant.
 Option B: Auscultating bowel sounds can allow the nurse to pinpoint areas
where an obstruction may have occurred. Finding no bowel sounds can
mean an ileus or obstruction above that area of the intestine.
 Option C: Hypoactive bowel sounds are considered as one every three to
five minutes, and this can indicate diarrhea, anxiety, or gastroenteritis.
Hyperactive bowel sounds are often found before a blockage. It is quite
common to find one quadrant with hyperactive bowel sounds and one with
none or hypoactive ones.
ADVERTISEMENTS
34. Question
Evaluating the apical pulse is the most reliable noninvasive way to assess cardiac
function. Which is the best area for auscultating the apical pulse?
o A. Aortic arch
o B. Pulmonic area
o C. Tricuspid area
o D. Mitral area
Incorrect
Correct Answer: D. Mitral area
The mitral area (also known as the left ventricular area or the apical area), the fifth
intercostal space (ICS) at the left midclavicular line, is the best area for
auscultating the apical pulse. The apical pulse is auscultated with a stethoscope
over the chest where the heart‘s mitral valve is best heard. In infants and young

children, the apical pulse is located at the fourth intercostal space at the left
midclavicular line. In adults, the apical pulse is located at the fifth intercostal
space at the left midclavicular line.
 Option A: The aortic arch is the second ICS to the right of the sternum.
Apical pulse rate is indicated during some assessments, such as when
conducting a cardiovascular assessment and when a client is taking certain
cardiac medications (e.g., digoxin). Sometimes the apical pulse is
auscultated pre and post medication administration.
 Option B: The pulmonic area is the second intercostal space to the left of
the sternum. It is also a best practice to assess apical pulse in infants and
children up to five years of age because radial pulses are difficult to
palpate and count in this population. It is typical to assess apical pulses in
children younger than eighteen, particularly in hospital environments.
Apical pulses may also be taken in obese people because their peripheral
pulses are sometimes difficult to palpate.
 Option C: The tricuspid area is the fifth ICS to the left of the sternum.
Position the client in a supine (lying flat) or in a seated position. Physically
palpate the intercostal spaces to locate the landmark of the apical pulse.
Ask the female client to re-position her own breast tissue to auscultate the
apical pulse.
ADVERTISEMENTS
35. Question
Beginning in their 20s, women should be told about the benefits and limitations
of breast self-exam (BSE). Which scientific rationale should the nurse remember
when performing a breast examination on a female client?
o A. One-half of all breast cancer deaths occurs in women ages 35 to 45.
o B. The tail of Spence area must be included in the self-examination.
o C. The position of choice for the breast examination is supine.
o D. A pad should be placed under the opposite scapula of the breast being
palpated.
Incorrect

Correct Answer: B. The tail of Spence area must be included in the self-
examination.
The tail of Spence, an extension of the upper outer quadrant of breast tissue, can
develop breast tumors. This area must also be included in breast self-
examination. As the fingers traverse the breasts, they must remain in contact with
the skin to avoid missing any tissue plane. Assessment of the inner half of the
breasts requires changing to a supine position, removing the hand from the
forehead, and placing the inactive arm at a right angle on the examination
surface.
 Option A: One-half of all women who die of breast cancer are older than
age 65. Breast cancer is the most prevalent malignancy among female
populations and is responsible for the second-highest number of cancer-
related deaths in American women. The need for early detection has
manifested several screening initiatives intent on curtailing morbidity and
mortality associated with the disease.
 Option C: The correct position for breast self-examination is not limited to
the supine position; the sitting position with hands at sides, above head,
and on the hips is also recommended. A visual survey of the breast tissue
requires an inspection from three angles, with arms at the side, arms raised
above the head while bending forward, and hunched over with the hands
placed on the hips. Each of these positions should be observed in a mirror
from a direct view, right profile, and left profile.
 Option D: A pad is placed under the ipsilateral (e.g., same side) scapula of
the breast being palpated. The middle fingertip pad should be used to
perform small circles with light, medium, and deep pressure investigating
varying depths of breast tissue. To complete the examination of the
breast‘s outer half, up and down motions of palpation are performed
medially from the axilla to the nipple and vertically from the clavicle to just
below the bra line.
ADVERTISEMENTS
36. Question
Mr. Lim, who has chronic pain, loss of self-esteem, no job, and bodily
disfigurement from severe burns over the trunk and arms, is admitted to a pain

center. Which evaluation criteria would indicate the client‘s successful
rehabilitation?
o A. The client remains free of the aftermath phase of the pain experience.
o B. The client experiences decreased frequency of acute pain episodes.
o C. The client continues normal growth and development with intact

support systems.
o D. The client develops increased tolerance for severe pain in the future.
Incorrect
Correct Answer: C. The client continues normal growth and development
with intact support systems.
Even though the client may experience an aftermath phase, progress is still
possible, as is effective rehabilitation. Give positive reinforcement of progress and
encourage endeavors toward the attainment of rehabilitation goals. Words of
encouragement can support the development of positive coping behaviors.
 Option A: Aftermath reactions may occur but need not interfere with
rehabilitation. Encourage family interaction with each other and with the
rehabilitation team. To open lines of communication and provide ongoing
support for the patient and family.
 Option B: Acute pain is not expected at this stage of recovery. Pain is
nearly always present to some degree because of varying severity of tissue
involvement and destruction but is usually most severe during dressing
changes and debridement.
 Option D: Conditioning probably would produce less pain tolerance.
Exercise is generally considered to be a safe and efficacious approach to
restoring physiological function in patients with various chronic diseases.
However, the inclusion of exercise regimens in the outpatient rehabilitation
of patients who have undergone major trauma, such as a large burn, is not
common.
ADVERTISEMENTS
37. Question

Christine Ann is about to take her NCLEX examination next week and is currently
reviewing the concept of pain. Which scientific rationale would indicate that she
understands the topic?
o A. Pain is an objective sign of a more serious problem.
o B. Pain sensation is affected by a client's anticipation of pain.
o C. Intractable pain may be relieved by treatment.
o D. Psychological factors rarely contribute to a client's pain perception.

Incorrect
Correct Answer: B. Pain sensation is affected by a client’s anticipation of
pain.
Phases of pain experience include the anticipation of pain. Fear and anxiety affect
a person‘s response to sensation and typically intensify the pain. Similarly, other
factors such as cognitive appraisal of the meaning of the sensation, the emotional
and psychophysiological reactions, expectations, and coping skills can all serve as
feedback to influence pain perception.
 Option A: Pain is a subjective sensation that cannot be quantified by
anyone except the person experiencing it. Pain refers to the product of
higher brain center processing; it entails the actual unpleasant emotional
and sensory experience generated from nervous signals. Reports of pain
are thus not merely a direct output of nociception, they involve interaction
with numerous inputs (attention, affective dimensions, autonomic variables,
immune variables, and more), and may be considered more accurately
from the perspective of a neuromatrix.
 Option C: Intractable pain is moderate to severe pain that cannot be
relieved by any known treatment. Intractable pain refers to a type of pain
that can‘t be controlled with standard medical care. Intractable essentially
means difficult to treat or manage. This type of pain isn‘t curable, so the
focus of treatment is to reduce the discomfort.
 Option D: Psychological factors contribute to a client‘s pain perception. In
many cases, pain results from emotions, such as hostility, guilt, or
depression. There are a number of psychological processes behind pain
perception. Attentional orienting to the painful sensation and its source
can serve to heighten the painful experience. For instance, patients with

somatic preoccupation and hypochondriasis are found to over-attend to
bodily sensations, amplifying them as pain.
ADVERTISEMENTS
38. Question
Miggy, a 6-year-old boy, received a small paper cut on his finger, his mother let
him wash it and apply a small amount of antibacterial ointment and bandage.
Then she let him watch TV and eat an apple. This is an example of which type of
pain intervention?
o A. Pharmacologic therapy
o B. Environmental alteration
o C. Control and distraction
o D. Cutaneous stimulation
Incorrect
Correct Answer: C. Control and distraction
The mother‘s actions are an example of control and distraction. Involving the
child in care and providing distraction took his mind off the pain. The brain can
only focus its attention in so many areas at one time. Pain sensations compete for
attention with all of the other things going on around. Just how much attention
the brain gives each thing depends on a number of factors, including how long
you have been hurting and the current mood.
 Option A: Pharmacologic agents for pain analgesics — were not used. A
wide range of drugs are used to manage pain resulting from inflammation
in response to tissue damage, chemical agents/pathogens (nociceptive
pain) or nerve damage (neuropathic pain).
 Option B: The home environment was not changed. There has recently
been heightened recognition that environmental factors can influence pain.
Clinicians involved in delivering multidisciplinary pain programs often
structure the social environment of their treatment settings to help
promote adaptive responses to pain.
 Option D: Cutaneous stimulation, such as massage, vibration, or pressure,
was not used. Cutaneous stimulation involves stimulation of nerves via skin

contact in an effort to reduce pain impulses to the brain, based on the
―gate control‖ theory of pain. A device used to provide electrocutaneous
nerve stimulation was studied for its effect on symptoms of peripheral
neuropathy.
ADVERTISEMENTS
39. Question
Which statement represents the best rationale for using noninvasive and non-
pharmacologic pain-control measures in conjunction with other measures?
o A. These measures are more effective than analgesics.
o B. These measures decrease input to large fibers.
o C. These measures potentiate the effects of analgesics.
o D. These measures block transmission of type C fiber impulses.

Incorrect
Correct Answer: C. These measures potentiate the effects of analgesics.
Noninvasive measures may result in the release of endogenous molecular
neuropeptides with analgesic properties. They potentiate the effect of analgesics.
The role of non-pharmacological approaches to pain management is evolving,
and some non-pharmacological and complementary therapies have an
increasingly important contribution to make to holistic patient care alongside
analgesics.
 Option A: No evidence indicates that noninvasive and nonpharmacologic
measures are more effective than analgesics in relieving pain. Exercise,
multidisciplinary rehabilitation, acupuncture, CBT, mindfulness practices,
massage, and mind-body practices most consistently improve function
and/or pain beyond the course of therapy for specific chronic pain
conditions.
 Option B: Decreased input over large fibers allows more pain impulses to
reach the central nervous system. When deciding the most effective non-
pharmacological technique, take into consideration the patient‘s age,
developmental level, medical history and prior experiences, the current

degree of pain, and/or anticipated pain. The advantage of non-
pharmacological treatments is that they are relatively inexpensive and safe.
 Option D: There is no connection between type C fiber impulses and
noninvasive and nonpharmacologic pain-control measures. Non-
pharmacological pain therapy refers to interventions that do not involve
the use of medications to treat pain. The goals of non-pharmacological
interventions are to decrease fear, distress, and anxiety, and reduce pain
and provide patients with a sense of control.
ADVERTISEMENTS
40. Question
When evaluating a client‘s adaptation to pain, which behavior indicates
appropriate adaptation?
o A. The client distracts himself during pain episodes.
o B. The client denies the existence of any pain.
o C. The client reports no need for family support.
o D. The client reports pain reduction with decreased activity.

Incorrect
Correct Answer: A. The client distracts himself during pain episodes.
Distraction is an appropriate method of reducing pain. This technique involves
heightening one‘s concentration upon non-painful stimuli to decrease one‘s
awareness and experience of pain. Drawing the person away from the pain
lessens the perception of pain. Examples include reading, watching TV, playing
video games, and guided imagery.
 Option B: Denying the existence of any pain is inappropriate and not
indicative of coping. It is essential to assist patients to express as factually
as possible (i.e., without the effect of mood, emotion, or anxiety) the effect
of pain relief measures. Inconsistencies between behavior or appearance
and what the patient says about pain relief (or lack of it) may be more a
reflection of other methods the patient is using to cope with the pain
rather than pain relief itself.

 Option C: Exclusion of family members and other sources of support
represents a maladaptive response. Nurses have the duty to ask their
clients about their pain and believe their reports of pain. Challenging or
undermining their pain reports results in an unhealthy therapeutic
relationship that may hinder pain management and deteriorate rapport.
 Option D: Range-of-motion exercises and at least mild activity, not a
decreased activity, can help reduce pain and are important to prevent
complications of immobility. Nonpharmacologic methods in pain
management may include physical, cognitive-behavioral strategies, and
lifestyle pain management. These methods are used to provide comfort by
altering psychological responses to pain.
ADVERTISEMENTS
1. 41. Question
In planning pain reduction interventions, which pain theory provides
information most useful to nurses?
o A. Specificity theory
o B. Pattern theory
o C. Gate-control theory
o D. Central-control theory
Incorrect
Correct Answer: D. Central-control theory
No one theory explains all the factors underlying the pain experience, but the
central-control theory discusses brain opiates with analgesic properties and how
their release can be affected by actions initiated by the client and caregivers. In
central-control theory, the master control mechanism directs the muscle
movement based on linguistic goals. The gate-control, specificity, and patter
theories do not address pain control to the depth included in the central-control
theory.
 Option A: Specificity theory is one of the first modern theories for pain. It
holds that specific pain receptors transmit signals to a ―pain center‖ in the
brain that produces the perception of pain. Von Frey (1895) argued that
the body has a separate sensory system for perceiving pain—just as it does
for hearing and vision.

 Option B: This theory ignored findings of specialized nerve endings and
many of the observations supporting the specificity and/or intensive
theories of pain. The theory stated that any somesthetic sensation occurred
by a specific and particular pattern of neural firing and that the spatial and
temporal profile of firing of the peripheral nerves encoded the stimulus
type and intensity.
 Option C: According to his theory, pain stimulation is carried by small, slow
fibers that enter the dorsal horn of the spinal cord; then other cells transmit
the impulses from the spinal cord up to the brain. These fibers are called T-
cells. The T-cells can be located in a specific area of the spinal cord, known
as the substantia gelatinosa. These fibers can have an impact on the
smaller fibers that carry the pain stimulation.
ADVERTISEMENTS
42. Question
Ryan underwent an open reduction and internal fixation of the left hip. One day
after the operation, the client is complaining of pain. Which data would cause the
nurse to refrain from administering the pain medication and to notify the health
care provider instead?
o A. Left hip dressing dry and intact.
o B. Blood pressure of 114/78 mm Hg; pulse rate of 82 beats per minute.
o C. Left leg in functional anatomic position.
o D. Left foot cold to touch; no palpable pedal pulse.

Incorrect
Correct Answer: D. Left foot cold to touch; no palpable pedal pulse.
A left foot cold to touch without palpable pedal pulse represents an abnormal
finding on neurovascular assessment of the left leg. The client is most likely
experiencing some complication from surgery, which requires immediate medical
intervention. The nurse should notify the health care provider of these findings.
 Option A: A dry and intact hip dressing is a normal assessment of findings
that do not require medical intervention. A dressing is considered INTACT
if portions of the white dressing border have lifted from the skin as long as

the clear viewing window maintains full contact with the skin. The skin
under the viewing window does not appear visibly soiled with exudate or
blood. The skin under the viewing window does not appear dampened or
moist with sweat, exudate, fluid, or blood.
 Option B: A blood pressure of 114/78 mm Hg and pulse rate of 82 beats
per minute are normal assessment findings that do not require medical
intervention. The normal range used in an adult is between 60 to 100 beats
/minute with rates above 100 beats/minute and rates and below 60 beats
per minute, referred to as tachycardia and bradycardia, respectively. The
respiratory rate is the number of breaths per minute. The normal breathing
rate is about 12 to 20 beats per minute in an average adult.
 Option C: A left foot in functional anatomic position are all normal
assessment findings that do not require medical intervention. It functions
as a rigid structure for weight-bearing and it can also function as a flexible
structure to conform to uneven terrain.
ADVERTISEMENTS
43. Question
Which term would the nurse use to document pain at one site that is perceived in
another site?
o A. Referred pain
o B. Phantom pain
o C. Intractable pain
o D. Aftermath of pain
Incorrect
Correct Answer: A. Referred pain
Referred pain is pain occurring at one site that is perceived in another site.
Referred pain follows dermatome and nerve root patterns. Referred pain is pain
perceived at a location other than the site of the painful stimulus/ origin. It is the
result of a network of interconnecting sensory nerves that supply many different
tissues. When there is an injury at one site in the network it is possible that when

the signal is interpreted in the brain signals are experienced in the surrounding
nervous tissue.
 Option B: Phantom pain refers to pain in a part of the body that is no
longer there, such as in amputation. Phantom pain is pain that feels like it‘s
coming from a body part that‘s no longer there. Doctors once believed this
post-amputation phenomenon was a psychological problem, but experts
now recognize that these real sensations originate in the spinal cord and
brain.
 Option C: Intractable pain refers to moderate to severe pain that cannot
be relieved by any known treatment. Intractable pain refers to a type of
pain that can‘t be controlled with standard medical care. Intractable
essentially means difficult to treat or manage. This type of pain isn‘t
curable, so the focus of treatment is to reduce the discomfort.
 Option D: Aftermath of pain, a phase of the pain experience and the most
neglected phase address the client‘s response to the pain experience. The
complexity of pain physiology makes some pains more difficult to manage
than others. Acute postoperative pain normally responds well to analgesia,
but this should be complemented by strategies such as comfortable
positioning, distraction, TENS, and reassurance.
ADVERTISEMENTS
44. Question
Chuck, who is in the hospital, complains of abdominal pain that ranks 9 on a scale
of 1 (no pain) to 10 (worst pain). Which interventions should the nurse
implement? Select all that apply.
o A. Assessing the client's bowel sounds.
o B. Taking the client's blood pressure and apical pulse.
o C. Obtaining a pulse oximeter reading.
o D. Notifying the health care provider.
o E. Determining the last time the client received pain medication.
o F. Encouraging the client to turn, cough, and deep breathe.

Incorrect
Correct Answers: A, B, & E
The nurse must rule out complications prior to administering pain medication, so
her interventions would include assessing to make sure the client has bowel
sounds and determining if the client is hemorrhaging by checking the client‘s
blood pressure and pulse. The nurse must also make sure the pain medication is
due according to the health care provider‘s orders. Obtaining a pulse oximeter
reading and turning, coughing, and deep breathing will not help the client‘s pain.
 Option A: Additionally, the nurse should ask the following questions
during pain assessment to determine its history: (1) effectiveness of
previous pain treatment or management; (2) what medications were taken
and when; (3) other medications being taken; (4) allergies or known side
effects to medications.
 Option B: Pain should be screened every time vital signs are evaluated.
Many health facilities set pain assessment as the ―fifth vital sign‖ and
should be added to during routine vital signs assessment.
 Option C: Investigate signs and symptoms related to pain. Bringing
attention to associated signs and symptoms may help the nurse in
evaluating the pain. In some instances, the existence of pain is disregarded
by the patient.
 Option D: There is no need to notify the health care provider in this
situation. Some patients may be satisfied when pain is no longer intense;
others will demand complete elimination of pain. This influences the
perceptions of the effectiveness of the treatment modality and their
eagerness to engage in further treatments.
 Option E: Some patients may be hesitant to try the effectiveness of
nonpharmacological methods and may be willing to try traditional
pharmacological methods (i.e., use of analgesics). A combination of both
therapies may be more effective and the nurse has the duty to inform the
patient of the different methods to manage pain.
 Option F: Stress correlates to an increase in pain perception by increasing
muscle tension and activating the SNS. Eliciting a relaxation response
decreases the effects of stress on pain. Examples include directed
meditation, music therapy, deep breathing.
ADVERTISEMENTS

45. Question
Albert, who suffered severe burns 6 months ago, is expressing concern about the
possible loss of job-performance abilities and physical disfigurement. Which
intervention is the most appropriate for him?
o A. Referring the client for counseling and occupational therapy.
o B. Staying with the client as much as possible and building trust.
o C. Providing cutaneous stimulation and pharmacologic therapy.
o D. Providing distraction and guided imagery techniques.

Incorrect
Correct Answer: A. Referring the client for counseling and occupational
therapy
Because it has been 6 months, the client needs professional help to get on with
life and handle the limitations imposed by the current problems. Staying with the
client, building trust, and providing methods of pain relief, such as cutaneous
stimulation, medications, distraction, and guided imagery interventions, would
have been more appropriate in earlier stages of postburn injury when physical
pain was most severe and fewer psychological factors needed to be addressed.
 Option B: Explain to the patient what happened. Provide opportunities for
questions and give honest answers. Compassionate statements reflecting
the reality of the situation can help the patient and SO acknowledge that
reality and begin to deal with what has happened.
 Option C: The burned patient may require around-the-clock medication
and dose titration. IV method is often used initially to maximize drug effect.
Concerns of patient addiction or doubts regarding the degree of pain
experienced are not valid during the emergent/acute phase of care, but
narcotics should be decreased as soon as feasible and alternative methods
for pain relief initiated.
 Option D: Encourage use of stress management techniques: progressive
relaxation, deep breathing, guided imagery, and visualization. Refocuses
attention, promotes relaxation, and enhances the sense of control, which
may reduce pharmacological dependency.
ADVERTISEMENTS

46. Question
Mrs. Bagapayo who had abdominal surgery 3 days earlier complains of sharp,
throbbing abdominal pain that ranks 8 on a scale of 1 (no pain) to 10 (worst
pain). Which intervention should the nurse implement first?
o A. Assessing the client to rule out possible complications secondary to

surgery.
o B. Checking the client's chart to determine when pain medication was last
administered.
o C. Explaining to the client that the pain should not be this severe 3 days
postoperatively.
o D. Obtaining an order for a stronger pain medication because the client's

pain has increased.
Incorrect
Correct Answer: A. Assessing the client to rule out possible complications
secondary to surgery.
The nurse‘s immediate action should be to assess the client in an attempt to
exclude possible complications that may be causing the client‘s complaints. The
health care provider ordered the pain medication for routine postoperative pain
that is expected after abdominal surgery, not for such complications as
hemorrhage, infection, or dehiscence. The nurse should never administer pain
medication without assessing the client first.
 Option B: Checking the client‘s chart is appropriate after the nurse
determines that the client is not experiencing complications from surgery.
It is essential to assist patients to express as factually as possible (i.e.,
without the effect of mood, emotion, or anxiety) the effect of pain relief
measures. Inconsistencies between behavior or appearance and what the
patient says about pain relief (or lack of it) may be more a reflection of
other methods the patient is using to cope with the pain rather than pain
relief itself.
 Option C: Pain is subjective, and each person has his own level of pain
tolerance. The nurse must always believe the client‘s complaint of pain.
Nurses have the duty to ask their clients about their pain and believe their
reports of pain. Challenging or undermining their pain reports results in an

unhealthy therapeutic relationship that may hinder pain management and
deteriorate rapport.
 Option D: Obtaining an order for a strong medication may be appropriate
after the nurse assesses the client and checks the chart to see whether the
current analgesic is infective. The World Health Organization (WHO) in
1986 published guidelines in the logical usage of analgesics to treat cancer
using a three-step ladder approach – also known as the analgesic ladder.
The analgesic ladder focuses on aligning the proper analgesics with the
intensity of pain.
ADVERTISEMENTS
47. Question
Which term refers to the pain that has a slower onset, is diffuse, radiates, and is
marked by somatic pain from organs in any body activity?
o A. Acute pain
o B. Chronic pain
o C. Superficial pain
o D. Deep pain
Incorrect
Correct Answer: D. Deep pain
Deep pain has a slow onset, is diffuse, and radiates, and is marked by somatic
pain from organs in any body activity. Deep somatic pain originates from
structures deeper within the body, such as the joints, bones, tendons, and
muscles. Like visceral pain, deep somatic pain is usually dull and aching. Deep
somatic pain can either be experienced locally or more generally depending on
the degree of trauma.
 Option A: Acute pain is rapid in onset, usually temporary (less than 6
months), and subsides spontaneously. Acute pain is a type of pain that
typically lasts less than 3 to 6 months or pain that is directly related to soft
tissue damage such as a sprained ankle or a paper cut. Acute pain is of
short duration but it gradually resolves as the injured tissues heal.

 Option B: Chronic pain is marked by gradual onset and lengthy duration
(more than 6 months). Chronic pain is pain that is ongoing and usually lasts
longer than six months. This type of pain can continue even after the injury
or illness that caused it has healed or gone away. Pain signals remain active
in the nervous system for weeks, months, or years.
 Option C: Superficial pain has an abrupt onset with sharp, stinging quality.
Superficial pain arises from nociceptive receptors in the skin and mucous
membranes. Superficial somatic pain is the type of pain that happens with
common everyday injuries and is characterized as pricking, sharp, burning,
or throbbing pain.
ADVERTISEMENTS
48. Question
A 50-year-old widower has arthritis and remains in bed too long because it hurts
to get started. Which intervention should the nurse plan?
o A. Telling the client to strictly limit the amount of movement of his inflamed
joints.
o B. Teaching the client's family how to transfer the client into a wheelchair.
o C. Teaching the client the proper method for massaging inflamed, sore joints.
o D. Encouraging gentle range-of-motion exercises after administering

aspirin and before rising.
Incorrect
Correct Answer: D. Encouraging gentle range-of-motion exercises after
administering aspirin and before rising.
Aspirin raises the pain threshold and, although range-of-motion exercises hurt,
mild exercise can relieve pain on rising. A tailored program that includes a
balance of three types of exercises — range-of-motion, strengthening, and
endurance — can relieve the symptoms of arthritis and protect joints from further
damage.
 Option A: Strict limitation of motion only increases the client‘s pain. The
stiffness, pain, and swelling associated with arthritis can severely reduce the
range of motion of joints (the distance joints can move in certain

directions). Avoiding physical activity because of pain or discomfort also
can lead to significant muscle loss and excessive weight pain.
 Option B: Having others transfer the client into a wheelchair does not
increase his feelings of dependency. Range-of-motion exercises (also called
stretching or flexibility exercises) help maintain normal joint function by
increasing and preserving joint mobility and flexibility.
 Option C: Massage increases inflammation and should be avoided with
this client. During the course of a range-of-motion exercise program, the
joints are stretched progressively farther until the normal or near-normal
range is achieved and maintained.
ADVERTISEMENTS
1. 49. Question
Which intervention should the nurse include as a nonpharmacologic pain-relief
intervention for chronic pain?
o A. Referring the client for hypnosis.
o B. Administering pain medication as prescribed.
o C. Removing all glaring lights and excessive noise.
o D. Using transcutaneous electric nerve stimulation.

Incorrect
Correct Answer: D. Using transcutaneous electric nerve stimulation.
Nonpharmacologic pain relief interventions include cutaneous stimulation, back
rubs, biofeedback, acupuncture, transcutaneous electric nerve stimulation, and
more. Transcutaneous electrical nerve stimulation (TENS) is a therapy that uses
low voltage electrical current to provide pain relief. A TENS unit consists of a
battery-powered device that delivers electrical impulses through electrodes
placed on the surface of your skin. The electrodes are placed at or near nerves
where the pain is located or at trigger points.
 Option A: Hypnosis is considered an alternative therapy. Hypnosis is a set
of techniques designed to enhance concentration, minimize one‘s usual
distractions, and heighten responsiveness to suggestions to alter one‘s
thoughts, feelings, behavior, or physiological state.
 Option B: Medications are pharmacologic measures. A wide range of
drugs are used to manage pain resulting from inflammation in response to

tissue damage, chemical agents/pathogens (nociceptive pain), or nerve
damage (neuropathic pain).
 Option C: Although removing glaring lights and excessive noise help to
reduce or remove noxious stimuli, it is not specific to pain relief. A noxious
stimulus is actually, or potentially, damaging to tissue and liable to cause
pain, but does not invariably do so. Some noxious stimuli, particularly in
the viscera, do not cause nociceptive responses.
ADVERTISEMENTS
50. Question
A 12-year-old student falls off the stairs, grabs his wrist, and cries, ―Oh, my wrist!
Help! The pain is so sharp, I think I broke it.‖ Based on this data, the pain the
student is experiencing is caused by impulses traveling from receptors to the
spinal cord along which type of nerve fibers?
o A. Type A-delta fibers
o B. Autonomic nerve fibers
o C. Type C fibers
o D. Somatic efferent fibers

Incorrect
Correct Answer: A. Type A-delta fibers
Type A-delta fibers conduct impulses at a very rapid rate and are responsible for
transmitting acute sharp pain signals from the peripheral nerves to the spinal
cord. Only type A-delta fibers transmit sharp, piercing pain. They respond to
stimuli such as cold and pressure, and as nociceptors stimulation of them is
interpreted as fast/first pain information.
 Option B: The autonomic system regulates involuntary vital functions and
organ control such as breathing. An autonomic nerve pathway involves two
nerve cells. One cell is located in the brainstem or spinal cord. It is
connected by nerve fibers to the other cell, which is located in a cluster of
nerve cells (called an autonomic ganglion). Nerve fibers from these ganglia
connect with internal organs.

 Option C: Type C fibers transmit sensory input at a much slower rate and
produce a slow, chronic type of pain. The C group fibers are unmyelinated
and have a small diameter and low conduction velocity, whereas Groups A
and B are myelinated. Group C fibers include postganglionic fibers in the
autonomic nervous system (ANS), and nerve fibers at the dorsal roots (IV
fiber). These fibers carry sensory information.
 Option D: Somatic efferent fibers affect the voluntary movement of
skeletal muscles and joints. General somatic efferent fibers carry motor
impulses to somatic skeletal muscles. In the head, the tongue and
extraocular muscles are of this type. Cranial nerves III, IV, VI, and XII carry
these fibers.
ADVERTISEMENTS
51. Question
Which nursing intervention takes the highest priority when caring for a newly
admitted client who‘s receiving a blood transfusion?
o A. Warming the blood prior to transfusion.
o B. Informing the client that the transfusion usually takes 4 to 6 hours.
o C. Documenting blood administration in the client chart.
o D. Instructing the client to report any itching, chest pain, or dyspnea.

Incorrect
Correct Answer: D. Instructing the client to report any itching, headache, or
dyspnea.
This will help the nurse take immediate action in case a reaction happens during
a transfusion. There are multiple complications of blood transfusions, including
infections, hemolytic reactions, allergic reactions, transfusion-related lung injury
(TRALI), transfusion-associated circulatory overload, and electrolyte imbalance.
 Option A: There is no evidence that warming blood is beneficial to the
patient when transfusion is slow. At transfusion rates of greater than 100
mL/minute, cold blood may be a contributing factor in cardiac arrest.
However, keeping the patient warm is probably more important than
warming the blood.

 Option B: Transfusion of a unit of blood should be completed within a
maximum period of four hours after removal from the blood fridge: discard
the unit if this period is exceeded. If blood has been out of the blood bank
refrigerator for more than 30 minutes and is not transfused, then the unit
must be returned to the laboratory, where it will be disposed of.
 Option C: Documentation related to transfusion therapy should include
verification of the prescribed blood product and blood product
compatibility; verification of appropriate clinical indication for the
transfusion; the date and time of transfusion, type of blood product
administered, in addition to the volume, infusion rate, and time of initiation
and completion of transfusion; any medication administered, including
premedication (if I.V. drugs are required during transfusion, another I.V. site
is required); the patient‘s clinical status throughout the transfusion therapy,
including patient assessment data such as vital signs and lung sounds; the
patient‘s response to therapy including any complications or adverse
reactions, treatment required, and response to that treatment; and the
amount of blood transfused and the return of the unused portion to the
blood bank.
ADVERTISEMENTS
52. Question
Nurse Paulo has received a blood unit from the blood bank and has rechecked
the blood bag properly with nurse Edward. Prior to the facilitation of the blood
transfusion, nurse Paulo priority checks which of the following?
o A. Intake and output
o B. NPO standing order
o C. Vital signs
o D. Skin turgor
Incorrect
Correct Answer: C. Vital signs
The nurse must assess the vital signs before and 15 minutes after the procedure
so that any changes during the transfusion may indicate a transfusion reaction is

happening. The nurse remains with the client, observing signs and symptoms and
monitoring vital signs as often as every 5 minutes.
 Option A: Monitoring the intake and output during blood transfusion may
be done, but not as often as necessary. Monitoring of intake helps the
caregiver to ensure that the patient has a proper intake of fluid and other
nutrients. Monitoring of output helps determine whether there is an
adequate output of urine as well as normal defecation.
 Option B: A patient on blood transfusion is not placed in an NPO standing
order. Current nil per os (NPO) standards promote pre-operative fasting as
an approach to reduce the volume and acidity of a patient‘s stomach
contents to reduce the risks of regurgitation and subsequent pulmonary
aspiration. Pre-anesthesia fasting standards apply to any procedure where
sedative medications reduce the protective airway reflex that under normal
conditions prevent aspiration.
 Option D: Physical findings suggestive of volume depletion include dry
mucous membranes, decreased skin turgor, and low jugular venous
distention. While the incidence of hypovolemic shock from extracellular
fluid loss is difficult to quantify, it is known that hemorrhagic shock is most
commonly due to trauma. In one study, 62.2% of massive transfusions at a
level 1 trauma center were due to traumatic injury.
ADVERTISEMENTS
53. Question
A client is brought to the emergency department having experienced blood loss
due to a deep puncture wound. A 3 unit Fresh-frozen plasma (FFP) is ordered.
The nurse determines that the reason behind this order is to:
o A. Provide clotting factors and volume expansion.
o B. Increase hemoglobin, hematocrit, and neutrophil levels.
o C. Treat platelet dysfunction.
o D. Treat thrombocytopenia.
Incorrect
Correct Answer: A. Provide clotting factors and volume expansion.

Fresh-frozen plasma may be used to provide clotting factors or volume
expansion. It is rich in clotting factors and can be thawed quickly and transfused
right away. Fresh frozen plasma is the fluid portion of a unit of whole blood
frozen in a designated time frame, usually within 8 hours. FFP contains all
coagulation factors except platelets.
 Option B: Increasing hemoglobin, hematocrit, and neutrophil levels is not
an indication for FFP. FFP corrects coagulopathy by replacing or supplying
plasma proteins in patients who are deficient in or have defective plasma
proteins. A standard dose of 10 to 20 mL/kg (4 to 6 units in adults) will
raise factor levels by approximately 20%.
 Option C: FFP does not contain platelets. Other situations where the
administration of FFP cannot be recommended for or against based on
systematic review include FFP transfusion at a plasma-to-RBC ratio of 1:3 or
more in trauma patients with massive transfusion. Conditions that cause
the deficiency of multiple coagulation factors and may require the
administration of FFP include liver disease and disseminated intravascular
coagulation.
 Option D: Treating thrombocytopenia is incorrect since FFP does not
contain any platelet. FFP contains fibrinogen (400 to 900 mg/unit), albumin,
protein C, protein S, antithrombin, tissue factor pathway inhibitor. It is free
of erythrocytes and leukocytes. FFP provides some volume resuscitation, as
each unit contains approximately 250 ml.
ADVERTISEMENTS
54. Question
Nurse Amanda is caring for a client with severe blood loss who is prescribed
multiple transfusions of blood. Nurse Amanda obtains which most essential piece
of equipment to prevent the risk of cardiac dysrhythmias?
o A. Cardiac monitor
o B. Blood warmer
o C. ECG machine
o D. Infusion pump

Incorrect
Correct Answer: B. Blood warmer
Rapid transfusion of cool blood puts the client at risk for cardiac dysrhythmias.
Modern methods of very rapid transfusion in resuscitation would cause clinically
dangerous hypothermia if unmodified, ice-cold blood were to be so transfused.
These needs must be reconciled in the interest of adequate patient care–hence
the need for blood warming. Countercurrent in-line blood warmers and the
method of rapid warm saline admixture can both be used successfully for rapid,
massive transfusions.
 Option A: Cardiac monitor is used to assess for any blood transfusion-
related complication, but they do not prevent the occurrence of cardiac
dysrhythmia. During the blood transfusion process, patients‘ vital signs
(heart rate, blood pressure, temperature, and respiration rate) should be
monitored throughout the procedure and recorded. Follow the
organization‘s policy on how often the vital signs should be measured.
 Option C: ECG machine is used to assess for any blood transfusion-related
complication, but they do not prevent the occurrence of cardiac
dysrhythmia. Many severe reactions occur within the first 30 minutes of
commencing a transfusion of a blood component unit (SHOT 2008). Close
observation during this period is essential.
 Option D: Infusion pump is not beneficial in this case since the infusion
must be given rapidly. SHOT 2008 recommends that patients be observed
during the subsequent 24 hours because, on occasion, transfusion
reactions can occur many hours after transfusion is completed.
ADVERTISEMENTS
55. Question
A client is receiving a first-time blood transfusion of packed RBC. How long
should the nurse stay and monitor the client to ensure a transfusion reaction will
not happen?
o A. 15 minutes
o B. 30 minutes
o C. 45 minutes

o D. 60 minutes
Incorrect
Correct Answer: A. 15 minutes
Usually, a transfusion reaction occurs within 15 minutes of a transfusion. For each
unit of blood transfused, monitor the patient before starting the transfusion
(baseline observation; 15 minutes after starting the transfusion; at least every
hour during transfusion; and carry out a final set of observations 15 minutes after
each unit has been transfused.
 Option B: Staying with the patient for 30 minutes might be too long. Acute
reactions may occur in 1% to 2% of transfused patients. Rapid recognition
and management of the reaction may save the patient‘s life. Once
immediate action has been taken, careful and repeated clinical assessment
is essential to identify and treat the patient‘s problems.
 Option C: 45 minutes of staying and monitoring the patient for transfusion
reactions is too long. All suspected acute transfusion reactions should be
reported immediately to the blood transfusion center and to the doctor
responsible for the patient. With the exception of urticarial allergic
reactions and febrile non-hemolytic reactions, all are potentially fatal and
require urgent treatment.
 Option D: Most transfusion reactions occur during the first 15 minutes of
transfusion. 60 minutes is too long. However, transfusion-transmitted
infections are the serious delayed complications of transfusion. Since a
delayed transfusion reaction may occur days, weeks, or months after the
transfusion, the association with the transfusion may not be recognized.
ADVERTISEMENTS
56. Question
Nurse Rick is administering 2 unit-packed RBCs on a client with low hemoglobin.
The nurse will prepare which of the following in order to transfuse the blood?
o A. Microfusion set
o B. Polyvol Pro Burette Set
o C. Photofusion set

o D. Tubing with an in-line filter
Incorrect
Correct Answer: D. Tubing with an in-line filter
The in-line filter helps ensure that any particles larger than the size of the filter
are caught in the filter and are not infused with the client. Use a new, sterile
blood administration set containing an integral 170?200µ filter. Change the set to
at least 12?hourly during a blood transfusion. In a very warm climate, change the
set more frequently and usually after every four units of blood, if given within a
12?hour period.
 Option A: Microinfusion set is incorrect since the tubing that should be
used is a macro drip. Use a fresh blood administration set or special
platelet transfusion set, primed with saline. All blood components can be
slowly infused through small?bore cannulas or butterfly needles, e.g. 21 to
25 G. For rapid infusion, large?bore cannulas, e.g. 14 G, are needed.
 Option B: Polyvol Pro Burette set is used for administration of IV
medication infusion. The Polymed Polyvol Pro Latex Free Burette Set is a
transparent, soft, cylindrical, and calibrated measured volume chamber
with a bold marking scale. It has a micro dropper of 60 drops per ml. The
burette set comes with a 15 ?m fluid filter to reduce particulate matter.
 Option C: Photofusion set is incorrect since blood does not need any
protection from light. It protects light-sensitive drugs from UV exposure &
its harmful effects. It has a 15-micron fluid filter in the drip chamber
ADVERTISEMENTS
57. Question
To verify the age of blood cells in blood, the nurse will check which of the
following?
o A. Blood type
o B. Blood group
o C. Blood identification number
o D. Blood expiration date

Incorrect

Correct Answer: D. Blood expiration date
The safe storage of blood usually takes 35 days. Examining the expiration date is
an important responsibility of a nurse prior to hanging the blood. Once issued by
the blood centre, the transfusion of whole blood, red cells, platelet concentrate
and thawed fresh frozen plasma should be commenced within 30 minutes of
removal from the optimal storage conditions.
 Option A: A 5 mL blood sample should be collected into a dry test tube
and then correctly and clearly labeled with the patient‘s details, and
submitted to the blood center for testing. The taking of a blood sample
from the patient needs supervision. If the patient is conscious at the time
of taking the sample, ask him/her to identify himself/herself by given name
and all other appropriate information.
 Option B: When taking a blood sample for cross match, complete the
whole procedure before any other task is undertaken – it is important that
there are no interruptions during the process. When correctly performed,
compatibility tests will confirm ABO compatibility between component and
recipient and will detect the most clinically significant unexpected
antibodies.
 Option C: Always take a completed patient documentation label to the
issue room of the blood transfusion department when collecting the first
unit of blood. Match the details on the blood request form against the
blood compatibility label (tag), the bag unit number, and the patient
documentation label. When receiving the unit of blood in the clinical area,
check that it is the right unit for the right patient.
ADVERTISEMENTS
58. Question
A client has an order to receive one unit of packed RBCs. The nurse makes sure
which of the following intravenous solutions to hang with the blood product at
the client‘s bedside?
o A. 0.9% sodium chloride.
o B. 5% dextrose in 0.9% sodium chloride.
o C. Balanced Multiple Maintenance Solution with 5% Dextrose.

o D. 5% dextrose in 0.45% sodium chloride.
Incorrect
Correct Answer: A. 0.9% sodium chloride.
0.9% sodium chloride is a standard solution used to follow infusion of blood
products. Of the various intravenous solutions, only isotonic saline (0.9%) is
recommended for use with blood components. Other commonly used
intravenous solutions will cause varying degrees of difficulty when mixed with red
cells.
 Option B: 5% dextrose in water will hemolyze red cells. Intravenous
solutions containing calcium, such as Lactated Ringer‘s solution, can cause
clots to form in the blood. Prior to blood transfusion, completely flush
incompatible intravenous solutions and drugs from the blood
administration set with isotonic saline.
 Option C: Normal saline is the only compatible solution to use with the
blood or blood component. Crystalloid solutions and medications may
cause agglutination and/or hemolysis of the blood or blood components.
 Option D: IV solution containing dextrose in water will hemolyze red cells.
Only isotonic, calcium-free IV solutions should be added to, or come in
contact with blood products. Calcium may bind with the citrate
anticoagulant and promote clotting in the tubing. Excess glucose and/or
dextrose causes hemolysis and shortens red cell survival. Studies have
shown other IV solutions to be compatible with citrated blood
components. However, these solutions should only be considered
compatible in situations where the use of 0.9% NaCl would lead to
undesirable metabolic abnormalities.
ADVERTISEMENTS
59. Question
Nurse Jay is caring for a client with an ongoing transfusion of packed RBCs when
suddenly the client is having difficulty breathing, skin is flushed, and having chills.
Which action should nurse Jay take first?
o A. Administer oxygen.
o B. Place the client on a droplight.

o C. Check the client's temperature.
o D. Stop the transfusion.

Incorrect
Correct Answer: D. Stop the transfusion.
The client in this situation is experiencing a transfusion reaction so the priority
action of the nurse is to first stop the transfusion. Disconnect the transfusion set-
but keep the IV line open with 0.9% saline to provide access for possible IV drug
infusion. Send the blood bag and tubing to the blood bank for repeat typing and
culture.
 Option A: Place the client in Fowler‘s position with shortness of breath and
administer O2 therapy. The nurse remains with the client, observing signs
and symptoms and monitoring vital signs as often as every 5 minutes.
Obtain a urine specimen and send it to the laboratory to determine
presence of hemoglobin as a result of RBC hemolysis.
 Option B: Placing the client under a drop light would not manage his
difficulty in breathing. For circulatory overload, immediate treatment
includes positioning the patient upright with feet dependent; diuretics,
oxygen, and aminophylline may be prescribed. The nurse prepares to
administer emergency drugs such as antihistamines, vasopressor, fluids,
and steroids as per the physician‘s order or protocol.
 Option C: Febrile, nonhemolytic transfusion reactions are treated
symptomatically with antipyretics; leukocyte-poor blood products may be
recommended for subsequent transfusions. Blood container, tubing,
attached label, and transfusion record are saved and returned to the
laboratory for analysis.
ADVERTISEMENTS
59. Question


Incorrect
culture.
ADVERTISEMENTS
60. Question
After terminating the transfusion during a reaction, which action should the
nurse immediately be taken next?
o A. Run a solution of 5% dextrose in water.

o B. Run normal saline at a keep-vein-open rate.
o C. Remove the IV line.
o D. Fast drip 200ml normal saline.

Incorrect
Correct Answer: B. Run normal saline at a keep-vein-open rate.
The nurse will infuse normal saline at a KVO rate to keep the patency of the IV
line while waiting for further orders from the physician. A transfusion reaction
evaluation request form typically is used to document signs and symptoms of a
suspected reaction so that the blood bank can use this information, in
conjunction with laboratory testing, to arrive at a likely diagnosis. The blood bag,
along with the infusion set and anything else attached to the set, should be sent
with the transfusion reaction evaluation request.
 Option A: IV solution containing dextrose will hemolyze the red cells. IV
solution containing dextrose in water will hemolyze red cells.Only isotonic,
calcium-free IV solutions should be added to, or come in contact with
blood products. Calcium may bind with the citrate anticoagulant and
promote clotting in the tubing. Excess glucose and/or dextrose causes
hemolysis and shortens red cell survival.
 Option C: The nurse will not remove the IV line because then there would
be no IV access route. Transfusion reaction treatment varies with the
reaction. Diphenhydramine and acetaminophen are some of the most
commonly used drugs for treating mild allergic and febrile nonhemolytic
reactions. For other reactions, expert consultation should be considered. In
cases of acute hemolytic reaction, baseline laboratory tests should be
performed and urine should be kept flowing, possibly with alkalinization.
 Option D: Doing a fast drip will potentially lead to congestion and is not
done without the physician‘s order. Volume overload may require diuretics.
TRALI is treated with oxygen and supportive care, which may involve
intubation. Bacterial contamination may involve blood pressure support
and antibiotics. Because anaphylaxis is treated emergently according to
hospital protocol, usually with epinephrine and diphenhydramine, there
may not be time for consultation until after the patient is stabilized.
ADVERTISEMENTS

61. Question
A client is receiving a platelet transfusion. The nurse determines that the client is
gaining from this therapy if the client exhibits which of the following?
o A. Less frequent febrile episodes.
o B. Increased level of hematocrit.
o C. Less episodes of bleeding.
o D. Increased level of hemoglobin.

Incorrect
Correct Answer: C. Less episodes of bleeding.
Platelet transfusions may be given to prevent bleeding when the platelet count
falls down. In a study of bleeding risks in thrombocytopenic patients, Webert et
al. noted that the majority of severe bleeds were preceded by bleeds of lesser
severity. Even patients with petechiae (WHO grade 1 bleeding) were 2.5 times
more likely to experience clinically significant bleeding on the next day; patients
experiencing WHO grade 1 or 2 bleeding were three times more likely to have a
severe bleed the next day.
 Option A: A decline in the febrile episode will happen after the transfusion
of agranulocytes. Transfusions of granulocytes have a long history of usage
in clinical practice to support and treat severe infection in high?risk groups
of patients with neutropenia or neutrophil dysfunction.
 Option B: An increased level of hematocrit occurs after infusion of red
blood cells. Blood transfusion is used to treat acute anemia with the goal of
increasing blood oxygen-carrying capacity as determined by hematocrit
(Hct), and oxygen delivery (DO2).
 Option D: An increased level of hemoglobin will happen after the
transfusion of red blood cells. The transfusion of red cell concentrates
(RCC) is indicated in order to achieve a fast increase in the supply of
oxygen to the tissues, when the concentration of hemoglobin (Hb) is low
and/or the oxygen-carrying capacity is reduced, in the presence of
inadequate physiological mechanisms of compensation.
ADVERTISEMENTS

62. Question
Nurse Daniel is caring for a client receiving a transfusion of packed red blood
cells (PRBCs). The client started to vomit and to be nauseous. Client‘s blood
pressure is 95/40 mm Hg from a baseline of 110/70 mm Hg. The client‘s
temperature is 100.5°F orally from a baseline of 99.5°F orally. The nurse
understands that the client may be experiencing which of the following?
o A. Circulatory overload
o B. Delayed transfusion reaction
o C. Hypocalcemia
o D. Septicemia
Incorrect
Correct Answer: D. Septicemia
Septicemia happens with the transfusion of blood that is contaminated with
microorganisms. Assessment includes the rapid onset of high fever and chills,
hypotension, nausea, diarrhea, vomiting, and shock. Fever and/or chills are most
commonly associated with a febrile, non-hemolytic reaction, however; they can
also be the first sign of a more serious acute hemolytic reaction, TRALI, or septic
transfusion reaction. If the temperature rises 1 C or higher from the temperature
at the start of the transfusion, the transfusion should be stopped.
 Option A: Circulatory overload causes hypertension, cough, dyspnea, chest
pain, tachycardia, and wheezing upon auscultation. Dyspnea, or shortness
of breath, is a concerning sign that can often be seen with more severe
reactions including anaphylaxis, TRALI, and TACO. It can also be seen by
itself without accompanying symptoms.
 Option B: Delayed reaction can occur days to years after a transfusion. It
causes fever, rashes, mild jaundice, and oliguria or anuria. Typically caused
by an anamnestic response to a foreign antigen that the patient was
previously exposed to (generally by prior transfusion or pregnancy).
 Option C: Hypocalcemia causes paresthesias, tetany, muscle cramps,
hyperactive reflexes, positive Trousseau‘s sign, and positive Chovstek‘s sign.
Hypocalcemia is said to be present when the total serum calcium
concentration is less than 8.8 mg/dl. The disorder may be acquired or
inherited but its presentation can vary- from asymptomatic to life-

threatening. Hypocalcemia is commonly seen in hospitalized patients and
for the most part, is mild in nature and only requires supportive treatment.
ADVERTISEMENTS
63. Question
Packed red blood cells have been prescribed for a client with low hemoglobin
and hematocrit levels. The nurse takes the client‘s temperature before hanging
the blood transfusion and records 100.8 °F. Which action should the nurse take?
o A. Give an antipyretic and begin the transfusion.
o B. Proceed with the transfusion.
o C. Administer an antihistamine and begin the transfusion.
o D. Delay hanging the blood and inform the physician.

Incorrect
Correct Answer: D. Delay hanging the blood and inform the physician.
If the patient has a temperature higher than 100 ° F, the unit of blood should be
hung and delayed until the physician is notified and has the opportunity to give
further orders. Fever and/or chills are most commonly associated with a febrile,
non-hemolytic reaction, however; they can also be the first sign of a more serious
acute hemolytic reaction, TRALI, or septic transfusion reaction.
 Option A: Giving an antipyretic would require a physician‘s order. All cases
of suspected reactions should prompt immediate discontinuation of the
transfusion and notification of the blood bank and treating clinician. A
clerical check should be performed by examining the product bag and
confirming the patient‘s identification. The patient‘s vital signs should be
monitored and recorded at 15-minute intervals.
 Option C: Administering an antihistamine is incorrect since the
administration of the medicine will need the physician‘s prescription.
Treatment of specific transfusion reactions is most often supportive. For
example, antihistamines (such as diphenhydramine) can be given for a mild
allergic reaction, or an antipyretic can be given for a nonhemolytic febrile
transfusion reaction.

 Option B: The decision to administer the blood is not within the scope of
nurse practice. Currently, guidelines for transfusion of red blood cells (RBC),
generally follow a restrictive threshold. While there is some variation in the
number for the threshold, 7 g/dL is an agreed-upon value for
asymptomatic healthy patients.
ADVERTISEMENTS
64. Question
A nurse is caring for a client requiring surgery and is ordered to have a standby
blood secured if in case a blood transfusion is needed during or after the
procedure. The nurse suggests to the client to do which of the following to lessen
the risk of possible transfusion reaction?
o A. Request that any donated blood be screened twice by the blood bank.
o B. Take iron supplements prior to the surgery and eat green leafy vegetables.
o C. Do an autologous blood donation.
o D. Have a family member donate their own blood.

Incorrect
Correct Answer: C. Do an autologous blood donation.
A donation of your own blood is autologous. Doing this will prevent the risk of
transfusion reaction. Autologous blood transfusion is the collection of blood from
a single patient and retransfusion back to the same patient when required. This is
in contrast to allogeneic blood transfusion where blood from
unrelated/anonymous donors is transfused to the recipient. The primary driving
forces for the use of autologous blood transfusion are to reduce the risk of
transmission of infection and to protect an increasingly scarce resource.
 Option A: More recently, concerns have focussed on the blood-borne
transmission of variant Creutzfeldt–Jakob disease (vCJD). In 2004, case
reports emerged of presumed transmission of vCJD via allogeneic blood
transfusion. Unlike hepatitis and HIV, there is no effective screening test
and the disease has a variable and often prolonged asymptomatic
incubation period.

 Option B: As oral iron supplementation requires a significant amount of
time, when the interval before surgery is sufficient (at least 6–8 weeks) and
no contraindications are present, supplementation with oral iron and
nutritional advice may be appropriate for mild-to-moderate IDA and/or
nonanemic ID or insufficient iron stores.
 Option D: Allogeneic donor blood is becoming an increasingly costly and
scarce resource. As demand for blood is outstripping donation, there is a
real social and economic pressure to increase the proportion of blood
transfused by autologous transfusion.
ADVERTISEMENTS
65. Question
A client is receiving a transfusion of one unit of cryoprecipitate. The nurse will
review which of the following laboratory studies to assess the effectiveness of the
therapy?
o A. Serum electrolytes
o B. White blood cell count
o C. Coagulation studies
o D. Hematocrit count
Incorrect
Correct Answer: C. Coagulation studies
The evaluation of the effective response of a cryoprecipitate transfusion is
assessed by monitoring coagulation studies and fibrinogen levels. Cryoprecipitate
Antihemophilic Factor, also called cryo, is a portion of plasma, the liquid part of
the blood. Cryo is rich in clotting factors, which are proteins that can reduce
blood loss by helping to slow or stop bleeding.
 Option A: Crystalloids are the fluids of choice for most minor procedures.
They are sterile aqueous solutions that may contain glucose, various
electrolytes, organic salts, and nonionic compounds. Some examples of
these solutes are sodium chloride, potassium chloride, sodium bicarbonate,
calcium carbonate, sodium acetate, sodium lactate, and sodium gluconate.

 Option B: White blood cells are transfused to treat life-threatening
infections in people who have a greatly reduced number of white blood
cells or whose white blood cells are functioning abnormally. The use of
white blood cell transfusions is rare because improved antibiotics and the
use of cytokine growth factors that stimulate people to produce more of
their own white blood cells have greatly reduced the need for such
transfusions.
 Option D: The average increase in hematocrit per liter of packed red blood
cells transfused was 6.4% +/- 4.1%. If 1 ―unit‖ of packed red blood cells is
approximately 300 mL, this becomes a change of hematocrit of 1.9% +/-
1.2% per ―unit‖ of blood. The accepted correlation of about 1 ―unit‖ of
blood loss per 3% change in hematocrit would be valid for a 500-cc unit,
but a typical unit of packed red blood cells is typically 300 cc.
ADVERTISEMENTS
66. Question
A nurse is teaching a client with pancreatitis about following a low-fat diet. The
nurse develops a list of high-fat foods to avoid and includes which food on the
item list?
o A. Chocolate milk
o B. Broccoli
o C. Apple
o D. Salmon
Incorrect
Correct Answer: A. Chocolate milk
Chocolate milk is a high-fat food. The pancreas helps with fat digestion, so foods
with more fat make the pancreas work harder. Registered dietitian Deborah
Gerszberg recommends that people with chronic pancreatitis limit their intake of
refined carbohydrates, such as white bread and high sugar foods. Refined
carbohydrates can lead to the pancreas releasing large amounts of insulin. Foods
that are high in sugar can also raise triglycerides.

 Option B: Vegetables are low in fat because they do not come from animal
sources. Vegetables, beans, lentils, and whole grains are beneficial because
of their fiber content. Eating more fiber can lower the chances of having
gallstones or elevated levels of fats in the blood called triglycerides. Both
of those conditions are common causes of acute pancreatitis.
 Option C: Fruits are low in fat because they do not come from animal
sources. Fruits are recommended for people with pancreatitis because they
tend to be naturally low in fat, which eases the amount of work the
pancreas needs to do to aid digestion.
 Option D: Salmon is naturally lower in fat. Many types of fish, such as
salmon, lake trout, tuna, and herring, provide healthy omega-3 fat. But
avoid fish canned in oil, such as sardines in olive oil. Bake, broil, or grill
meats, poultry, or fish instead of frying them in butter or fat.
ADVERTISEMENTS
67. Question
The nurse is giving dietary instructions to a client who is on a vegan diet. The
nurse provides dietary teaching focus on foods high in which vitamin that may be
lacking in a vegan diet?
o A. Vitamin A
o B. Vitamin D
o C. Vitamin E
o D. Vitamin C
Incorrect
Correct Answer: B. Vitamin D
Deficiencies in vegetarian diets include vitamin B12 which is found in animal
products and vitamin D (if limited exposure to sunlight). Vegans and other
vegetarians who limit their intake of animal products may be at greater risk of
vitamin D deficiency than nonvegetarians because foods providing the highest
amount of vitamin D per gram naturally are all from animal sources, and
fortification with vitamin D currently occurs in few foods.

 Option A: Plant sources contain vitamin A in the form of carotenoids which
have to be converted during digestion into retinol before the body can use
it. Carotenoids are the pigments that give plants their green color and
some fruits and vegetables their red or orange color.
 Option C: The best way to get the daily requirement of vitamin E is by
eating food sources. Vitamin E is found in vegetable oils, nuts, seeds, green
leafy vegetables, and fortified breakfast cereals. It is an antioxidant. This
means it protects body tissue from damage caused by substances called
free radicals. Free radicals can harm cells, tissues, and organs. They are
believed to play a role in certain conditions related to aging.
 Option D: Vitamin C can be found in fruits and vegetables, which are eaten
by a vegetarian. Humans are unable to synthesize vitamin C, so it is strictly
obtained through the dietary intake of fruits and vegetables. Citrus fruits,
berries, tomatoes, potatoes, and green leafy vegetables are excellent
sources of vitamin C.
ADVERTISEMENTS
68. Question
A nurse is caring for a client with Wernicke-Korsakoff syndrome. The physician
asks the nurse to teach the client to consume thiamine-rich food. The nurse
instructs the client to increase the intake of which food items?
o A. Chicken
o B. Milk
o C. Beef
o D. Broccoli
Incorrect
Correct Answer: C. Beef
Food sources of thiamin include beef, liver, nuts, oats, oranges, pork, eggs, seeds,
legumes, peas, and yeast. In meat, the liver has the highest amount of thiamine.
Whereas three ounces of beefsteak gives 7% of the daily value of thiamine, one
serving of beef liver will give about 10%. One serving of cooked salmon gives
18% of the daily value of thiamine.

 Option A: Poultry contains niacin. Chicken meat, particularly chicken
breast, is an excellent source of protein as well as niacin. A three-ounce
serving of skinless breast meat provides 10.3 mg. Niacin is an essential
nutrient that we mainly need to get from foods. The body may also convert
some tryptophan, one of the body‘s amino acids, into a nutrient.
 Option B: Milk contains vitamins A, D, and B2. Milk contains the fat-soluble
vitamins A, D, E, and K. The content level of fat-soluble vitamins in dairy
products depends on the fat content of the product. Milk contains the
water-soluble vitamins thiamin (vitamin B1), riboflavin (vitamin B2), niacin
(vitamin B3), pantothenic acid (vitamin B5), vitamin B6 (pyridoxine), vitamin
B12 (cobalamin), vitamin C, and folate. Milk is a good source of thiamin,
riboflavin, and vitamin B12.
 Option D: Broccoli contains folic acid, vitamins C, E, and K. Broccoli is a
good source of fiber and protein and contains iron, potassium, calcium,
selenium, and magnesium as well as the vitamins A, C, E, K, and a good
array of B vitamins including folic acid.
ADVERTISEMENTS
69. Question
A client who is recovering from surgery has been ordered a change from a clear
liquid diet to a full liquid diet. The nurse would offer which full liquid item to the
client?
o A. Popsicle
o B. Carbonated beverages
o C. Gelatin
o D. Custard
Incorrect
Correct Answer: D. Custard
Full liquid food items include items such as plain ice cream, sherbet, breakfast
drinks, milk, pudding, and custard, soups that are strained, refined cooked
cereals, and strained vegetable juices. A full liquid diet is made up only of fluids

and foods that are normally liquid and foods that turn to liquid when they are at
room temperature, like ice cream.
 Option A: A clear liquid diet is a specific dietary plan that only includes
liquids that are fully transparent at room temperature. Some items that
may be allowed include water, ice, fruit juices without pulp, sports drinks,
carbonated drinks, gelatin, tea, coffee, clear broths, and clear ice pops.
 Option B: Carbonated beverages are part of a clear liquid diet. Items can
have color as long as they are transparent. Items such as milk and orange
juice are not considered clear liquids because they are not fully transparent
and may take more effort for the digestive system to break down, whereas
grape juice is allowed (it is pigmented, but fully transparent).
 Option C: Gelatin is a clear liquid diet. The clear liquid diet assists in
maintaining hydration, provides electrolytes and calories, and offers some
level of satiety when a full diet is not appropriate, but may struggle to
provide adequate caloric needs if employed for more than five days.
ADVERTISEMENTS
70. Question
A postoperative client has been placed on a clear liquid diet. The nurse provides
the client with which items are allowed to be consumed on this diet?
o A. Vegetable juices
o B. Custard
o C. Sherbet
o D. Bouillon
Incorrect
Correct Answer: D. Bouillon
A clear liquid diet consists of foods that are relatively transparent to light and
liquid at room and body temperature. Foods allowed on the clear liquid diet
(bouillon, popsicles, plain gelatin, ice chips, sweetened tea or coffee (no creamer),
carbonated beverages, and water). The clear liquid diet assists in maintaining
hydration, it provides electrolytes and calories, and offers some level of satiety

when a full diet is not appropriate, but may struggle to provide adequate caloric
needs if employed for more than five days
 Option A: Vegetable juices are part of a full liquid diet. A patient
prescribed a full liquid diet follows a specific diet type requiring all liquids
and semi-liquids but no forms of solid intake. Unlike a clear liquid diet,
which includes only liquids and semi-liquids that are non-opaque, a full
liquid diet is more inclusive, as it allows all types of liquids.
 Option B: Custard is a full liquid diet. Patients not ready for a regular diet
due to elective or emergent procedures or who experience irregularity in
gastrointestinal function, dysphagia, a transition from prolonged fasted
periods, etc., are typically placed on a restrictive diet.
 Option C: Sherbet is a full liquid diet. Dietary restrictions can be as
restrictive as no food or liquids allowed by mouth, which may increase in a
stepwise fashion until reaching regular nutrition. One step in that
progression is a full liquid diet.
ADVERTISEMENTS
71. Question
The nurse is teaching a client who has iron-deficiency anemia about foods she
should include in her diet. The nurse determines that the client understands the
dietary instructions if she selects which of the following from her menu?
o A. Nuts and fish.
o B. Oranges and dark green leafy vegetables.
o C. Butter and margarine.
o D. Sugar and candy.

Incorrect
Correct Answer: B. Oranges and dark green leafy vegetables.
Dark green leafy vegetables are rich in iron while oranges are a good source of
vitamin C, which enhances iron absorption. A diet plan for anemia needs to
include a healthful balance of iron-rich foods, such as leafy vegetables, lean meat,
nuts and seeds, and fortified breakfast cereals. It is also crucial to include foods

that can improve the body‘s absorption of iron and avoid foods that may
interfere with this process.
 Option A: Phytates also termed phytic acid is present in legumes, whole
grains, nuts, and brown rice. The phytic acid binds with the iron present in
the digestive tract and inhibits its absorption. Hence, anemic patients must
avoid foods containing phytates.
 Option C: The mineral hinders iron absorption and therefore consuming
calcium-containing food products in combination with other iron-rich
foods can affect how much iron is being absorbed by the body. Dairy foods
like milk, yoghurt, and cheese should be avoided for this reason. Therefore,
it is advisable to take calcium-containing foods at different time slots.
 Option D: The effect of the iron-chelating sugars, fructose, glucose, and
galactose, on iron absorption in rats has been examined. Fructose has an
effect on increasing iron absorption. Glucose and galactose have no effect
on iron absorption. These findings suggest that the metabolism of fructose
is responsible for changing iron absorption in the rat since it is metabolized
during its absorption, while glucose and galactose are not.
ADVERTISEMENTS
72. Question
The nurse instructs a client with renal failure who is receiving hemodialysis about
dietary modifications. The nurse determines that the client understands these
dietary modifications if the client selects which items from the dietary menu?
o A. Mushroom and blueberry.
o B. Beans and bananas.
o C. Fish and tomato juice.
o D. Potato and spinach.

Incorrect
Correct Answer: A. Mushroom and blueberry.
A renal diet is one that is low in sodium, phosphorus, potassium and protein. A
renal diet also emphasizes the importance of consuming high-quality protein and
usually limiting fluids. Some patients may also need to limit potassium and

calcium. Every person‘s body is different, and therefore, it is crucial that each
patient works with a renal dietitian to come up with a diet that is tailored to the
patient‘s needs.
 Option B: Bananas are rich in potassium. The kidneys help to keep the
right amount of potassium in the body and they expel excess amounts into
the urine. When the kidneys fail, they can no longer remove excess
potassium, so potassium levels build up in the body.
 Option C: Tomato juice is high in sodium. Too much sodium can be
harmful for people with kidney disease because their kidneys cannot
adequately eliminate excess sodium and fluid from the body. Processed
foods often contain higher levels of sodium due to added salt.
 Option D: Potatoes and spinach are high in potassium. Potassium plays a
role in keeping the heartbeat regular and the muscles working correctly.
Potassium is also necessary for maintaining fluid and electrolyte balance in
the bloodstream. When the kidneys fail, they can no longer remove excess
ADVERTISEMENTS
73. Question
A client with heart failure has been told to maintain a low sodium diet. A nurse
who is teaching this client about foods that are allowed includes which food item
in a list provided to the client?
o A. Pretzels
o B. Whole wheat bread
o C. Tomato juice canned
o D. Dried apricot
Incorrect
Correct Answer: D. Dried apricot
Foods that are lower in sodium include fruits and vegetables like dried apricot.
Dried apricots are sodium-free. Dried apricots, as part of a low sodium diet, may
reduce the risk of high blood pressure. Apricots contain numerous antioxidants,

most notably flavonoids. They help protect the body from oxidative stress, which
is linked to many chronic diseases.
 Option A: These classic snacks are high in sodium — almost 20 percent of
the recommended daily intake is in one serving of pretzels. Too much
sodium leads to increased water retention, which can lead to bloating and
puffiness, and too much sodium over time can lead to heart disease.
 Option B: Sodium is finding its way into a lot of whole wheat bread brands
in amounts that average 240 to 400 mg per slice. If your serving usually
contains two slices, the sodium can add up quickly.
 Option C: Many tomato juice products contain added salt — which bumps
up the sodium content. For example, a 1.4-cup (340-ml) serving of
Campbell‘s 100% tomato juice contains 980 mg of sodium — which is 43%
of the DV. Research shows that diets high in sodium may contribute to
high blood pressure.
ADVERTISEMENTS
74. Question
The nurse is instructing a client with hyperkalemia on the importance of choosing
foods low in potassium. The nurse should teach the client to limit which of the
following foods?
o A. Grapes
o B. Carrot
o C. Green beans
o D. Lettuce
Incorrect
Correct Answer: B. Carrot
Carrots have 320 mg of potassium per 100 mg serving; green beans give 209 mg
of potassium, 194 mg for lettuce, and 191 mg for grapes all in 100 mg serving.
Other foods that are low in potassium include applesauce, blueberries, pineapple,
and cabbage. To minimize potassium buildup, a person with chronic kidney
disease should stick to a low-potassium diet of between 1,500 and 2,000

milligrams (mg) per day. Limiting phosphorus, sodium, and fluids may also be
important for people with kidney dysfunction.
 Option A: Grapes are also rich in potassium, but not as much as in carrots.
They‘re also a good source of vitamin C, an essential nutrient and powerful
antioxidant necessary for connective tissue health. Grapes are high in a
number of powerful antioxidant compounds. In fact, over 1,600 beneficial
plant compounds have been identified in this fruit.
 Option C: Half a cup of freshly cooked green beans has only 90 milligrams
of potassium and 18 milligrams of phosphorus, making them a great
vegetable choice for the kidney diet.
 Option D: Lettuce is a popular vegetable and is usually eaten raw in salads.
Because CKD patients with hyperkalemia need to limit potassium intake
from meals, they are not able to eat large quantities of raw vegetables such
as lettuce.
ADVERTISEMENTS
75. Question
A client is recovering from debridement of the right leg. A nurse encourages the
client to eat which food item that is naturally high in vitamin C to promote
wound healing?
o A. Milk
o B. Chicken
o C. Banana
o D. Strawberries
Incorrect
Correct Answer: D. Strawberries
Citrus fruits and juices are especially high in vitamin C. Strawberries are an
excellent source of vitamin C and manganese and also contain decent amounts
of folate (vitamin B9) and potassium. Strawberries are very rich in antioxidants
and plant compounds, which may have benefits for heart health and blood sugar
control

 Option A: Dairy products such as milk are high in vitamin B. Milk and other
dairy products pack about a third of the daily riboflavin requirement in just
1 cup (240 ml). Milk is also a good source of well-absorbed B12. Like other
animal products, milk also is a good source of B12, supplying 18% of the
RDI per 1-cup (240-ml) serving.
 Option B: Meats such as chicken are high in vitamin B. Chicken and turkey,
especially the white meat portions, are high in B3 and B6. Poultry also
supplies smaller amounts of riboflavin, pantothenic acid, and cobalamin.
Most of the nutrients are in the meat, not the skin.
 Option C: Bananas are rich in potassium. Bananas are rich in the mineral
potassium. Potassium helps maintain fluid levels in the body and regulates
the movement of nutrients and waste products in and out of cells. One
medium-sized banana contains 422 milligrams (mg) of potassium.
ADVERTISEMENTS
1. 1. Question

Incorrect

edema are present.
ADVERTISEMENTS
1. 1. Question

Incorrect

edema are present.
ADVERTISEMENTS
1. Question 2 of 75
2. Question
Which of the following is the most important nursing order in a client with major
head trauma who is about to receive bolus enteral feeding?
o A. Measure intake and output
o B. Check albumin level
o C. Monitor glucose levels
o D. Increase enteral feeding

Incorrect
Correct Answer: A. Measure intake and output
It is important to measure intake and output, which should be equal. Water given
before feeding will present a hyperosmotic diuresis. I and O measures assess fluid
balance. A urinary catheter is inserted to assess the adequacy of renal perfusion.
The kidney requires 20% to 25% of cardiac output; commonly, it‘s the first organ
to show the effects of impaired perfusion or intravascular volume.
 Option B: Osmotherapy aims to increase the osmolality of the
intravascular space, which in turn helps mobilize excess fluid from brain
tissue. If ICP increases, mannitol (an osmotic diuretic) may be given to

decrease cerebral edema, transiently increase intravascular volume, and
improve cerebral blood flow.
 Option C: Low peripheral oxygen saturation values or low arterial blood
oxygen values (as shown by arterial blood gas testing) should be avoided.
Maintaining adequate brain tissue oxygenation seems to improve patient
outcomes.
 Option D: Enteral feedings are hyperosmotic agents pulling fluid from cells
into the vascular bed. Initially, a nasogastric or orogastric tube is inserted
to decompress the stomach and reduce the aspiration risk. (Typically, the
nasal route is avoided as it can obstruct sinus drainage, leading to sinusitis
or VAP).
ADVERTISEMENTS
1. Question 3 of 75
3. Question
The pathological process causing esophageal varices is/are:
o A. Ascites and edema
o B. Systemic hypertension
o C. Portal hypertension
o D. Dilated veins and varicosities

Incorrect
Correct Answer: C. Portal hypertension
Esophageal varices result from increased portal hypertension. In portal
hypertension, the liver cannot accept all of the fluid from the portal vein. The
excess fluid will backflow to the vessels with lesser pressure, such as esophageal
veins or rectal veins causing esophageal varices or hemorrhoids.
 Option A: Portal hypertension causes portocaval anastomosis to develop
to decompress portal circulation. Normal portal pressure is between 5-10
mmHg but in the presence of portal obstruction, the pressure may be as
high as 15-20 mmHg. Since the portal venous system has no valves,
resistance at any level between the splanchnic vessels and the right side of
the heart results in retrograde flow and elevated pressure.

 Option B: Esophageal varices are dilated submucosal distal esophageal
veins connecting the portal and systemic circulations. They form due to
portal hypertension, which commonly is a result of cirrhosis, resistance to
portal blood flow, and increased portal venous blood inflow.
 Option D: Intrahepatic vasoconstriction due to decreased nitric oxide
production, and increased release of endothelin-1 (ET-1), angiotensinogen,
and eicosanoids. Increased portal flow is caused by hyperdynamic
circulation due to splanchnic arterial vasodilation through mediators such
as nitric oxide, prostacyclin, and TNF.
ADVERTISEMENTS
1. Question 4 of 75
4. Question
Which of the following interventions will help lessen the effect of GERD (acid
reflux)?
o A. Elevate the head of the bed on 4-6 inch blocks.
o B. Lie down after eating.
o C. Increase fluid intake just before bedtime.
o D. Wear a girdle.
Incorrect
Correct Answer: A. Elevate the head of the bed on 4-6 inch blocks.
Elevation of the head of the bed allows gravity to assist in decreasing the
backflow of acid into the esophagus. The fluid does not flow uphill. Instruct to
remain in an upright position at least 2 hours after meals; avoiding eating 3 hours
before bedtime. Helps control reflux and causes less irritation from reflux action
into the esophagus. The other three options all increase fluid backflow into the
esophagus through position or increasing abdominal pressure.
 Option B: Avoid placing the patient in a supine position, have the patient
sit upright after meals. Supine position after meals can increase
regurgitation of acid. Elevate HOB while in bed. To prevent aspiration by
preventing the gastric acid to flow back into the esophagus.
 Option C: Instruct patient regarding eating small amounts of bland food
followed by a small amount of water. Instruct to remain in an upright

position at least 1–2 hours after meals, and to avoid eating within 2–4
hours of bedtime. Gravity helps control reflux and causes less irritation
from reflux action into the esophagus.
 Option D: Instruct the patient to avoid bending over, coughing, straining
at defecations, and other activities that increase reflux. Promotes comfort
by the decrease in intra-abdominal pressure, which reduces the reflux of
gastric contents.
ADVERTISEMENTS
1. Question 5 of 75
5. Question
The main benefit of therapeutic massages is:
o A. To help a person with swollen legs to decrease fluid retention.
o B. To help a person with duodenal ulcers feel better.
o C. To help damaged tissue in a diabetic to heal.
o D. To improve circulation and muscle tone.

Incorrect
Correct Answer: D. To improve circulation and muscle tone.
Particularly in elderly adults, therapeutic massage will help improve circulation
and muscle tone as well as the personal attention and social interaction that a
good massage provides. Damaged or strained muscle fibers release inflammatory
chemicals to aid the healing process, but these chemicals cause significant pain
and discomfort in the process. At least one study, which looked at the effects of
massage on post-exercise tissue inflammation, suggests that even 10 minutes of
massage can reduce signs of inflammation and improve cell processes, thereby
promoting healing, with effects lasting several hours after the massage.
 Option A: Massage only the hands, feet, or scalp of patients with sepsis,
fever over 100[degrees]F, nausea or vomiting, sickle cell crisis, HIV crisis, a
complicated or high-risk pregnancy, crepitus, edema, thrombocytopenia,
or meningitis.
 Option B: When patients have fragile skin, or the potential for skin
breakdown, apply only light pressure, using enough lotion or oil to
minimize friction. For patients with a previous injury, chronic pain, or scar

tissue, frequently ask them how the massage feels, and adjust both
pressure and massage technique to the patients‘ preferences.
 Option C: A massage is contraindicated in any condition where massage to
damaged tissue can dislodge a blood clot. Although massage is associated
with few adverse effects, nurses should be careful to avoid areas near open
wounds, any stage of pressure ulcer, reddened or swollen areas, rashes,
incisions, thromboses, iv lines, drains, shunts, and tubes.
ADVERTISEMENTS
1. Question 6 of 75
6. Question
Which of the following foods should be avoided by clients who are prone to
develop heartburn as a result of gastroesophageal reflux disease (GERD)?
o A. Lettuce
o B. Eggs
o C. Chocolate
o D. Butterscotch
Incorrect
Correct Answer: C. Chocolate
Ingestion of chocolate can reduce lower esophageal sphincter (LES) pressure
leading to reflux and clinical symptoms of GERD. Ingesting cocoa can cause a
surge of serotonin. This surge can cause the esophageal sphincter to relax and
gastric contents to rise. Caffeine and theobromine in chocolate may also trigger
acid reflux. All of the other foods do not affect LES pressure.
 Option A: Vegetables are naturally low in fat and sugar, and they help
reduce stomach acid. Good options include green beans, broccoli,
asparagus, cauliflower, leafy greens, potatoes, and cucumbers.
 Option B: Egg whites are a good option. Stay away from egg yolks,
though, which are high in fat and may trigger reflux symptoms. Reflux
symptoms may result from stomach acid touching the esophagus and
causing irritation and pain.
 Option D: The foods the patient eats affect the amount of acid the
stomach produces. Eating the right kinds of food is key to controlling acid

reflux or GERD, a severe, chronic form of acid reflux. Sources of healthy fats
include avocados, walnuts, flaxseed, olive oil, sesame oil, and sunflower oil.
Reduce the intake of saturated fats and trans fats and replace them with
these healthier unsaturated fats.
ADVERTISEMENTS
1. Question 7 of 75
7. Question
Which of the following should be included in a plan of care for a client receiving
total parenteral nutrition (TPN)?
o A. Withhold medications while the TPN is infusing.
o B. Change TPN solution every 24 hours.
o C. Flush the TPN line with water prior to initiating nutritional support.
o D. Keep the client on complete bed rest during TPN therapy.

Incorrect
Correct Answer: B. Change TPN solution every 24 hours.
TPN solutions should be changed every 24 hours in order to prevent bacterial
overgrowth due to the hypertonicity of the solution. Because the central venous
catheter needs to remain in place for a long time, a strict sterile technique must
be used during the insertion and maintenance of the TPN line. The TPN line
should not be used for any other purpose. External tubing should be changed
every 24 hours with the first bag of the day. In-line filters have not been shown to
decrease complications. Dressings should be kept sterile and are usually changed
every 48 hours using strict sterile techniques.
 Option A: Medication therapy can continue during TPN therapy. Progress
of patients with a TPN line should be followed on a flowchart. An
interdisciplinary nutrition team, if available, should monitor patients.
Weight, complete blood count, electrolytes, and blood urea nitrogen
should be monitored often (eg, daily for inpatients). Plasma glucose should
be monitored every 6 hours until patients and glucose levels become
stable. Fluid intake and output should be monitored continuously. When
patients become stable, blood tests can be done much less often.

 Option C: Flushing is not required because the initiation of TPN does not
require a client to remain on bed rest during therapy. Catheter-related
sepsis rates have decreased since the introduction of guidelines that
emphasize sterile techniques for catheter insertion and skincare around the
insertion site. The increasing use of dedicated teams of physicians and
nurses who specialize in various procedures including catheter insertion
also has accounted for a decrease in catheter-related infection rates.
 Option D: However, other clinical conditions of the client may affect
mobility issues and warrant the client‘s being on bed rest. Place the client
in a semi-Fowler‘s or high-Fowler‘s position. Maintaining the head of the
bed elevated will promote ease in breathing. This position also allows the
pooling of fluid in the bases and for gas exchange to be more available to
the lung tissue.
ADVERTISEMENTS
1. Question 8 of 75
8. Question
Which of the following should be included in a plan of care for a client who is
lactose intolerant?
o A. Remove all dairy products from the diet.
o B. Frozen yogurt can be included in the diet.
o C. Drink small amounts of milk on an empty stomach.
o D. Spread out selection of dairy products throughout the day.

Incorrect
Correct Answer: B. Frozen yogurt can be included in the diet.
Clients who are lactose intolerant can digest frozen yogurt. Yogurt products are
formed by bacterial action, and this action assists in the digestion of lactose. The
freezing process further stops bacterial action so that limited lactase activity
remains. Some people who are lactose-intolerant can eat some kinds of yogurt
without problems, especially yogurt with live cultures.
 Option A: Elimination of all dairy products can lead to significant clinical
deficiencies of other nutrients. Be sure to get enough calcium in the diet,
especially if the client avoids milk products completely. To get enough

calcium, the client would need to eat calcium-rich foods as often as
someone would drink milk. Calcium is very important because it keeps
bones strong and reduces the risk of osteoporosis.
 Option C: Drinking milk on an empty stomach can exacerbate clinical
symptoms. Drinking milk with a meal may benefit the client because other
foods, (especially fat) may decrease transit time and allow for increased
lactase activity. Limit the amount of milk and milk products in the diet. Try
to drink 1 glass of milk each day. Drink small amounts several times a day.
All types of milk contain the same amount of lactose.
Option D: Although individual tolerance should be acknowledged,
spreading out the use of known dairy products will usually exacerbate
clinical symptoms. Eat or drink milk and milk products along with other
foods. For some people, combining solid food (like cereal) with a dairy
product (like milk) can reduce symptoms.
ADVERTISEMENTS
1. Question 9 of 75
9. Question
Pain tolerance in an elderly patient with cancer would:
o A. Stay the same.
o B. Be lowered.
o C. Be increased.
o D. No effect on pain tolerance.

Incorrect
Correct Answer: B. Be lowered.
There is potential for a lowered pain tolerance to exist with diminished adaptive
capacity. For older patients with cancer, unrelieved pain can affect functioning,
increase cognitive impairment, and depression, which in turn can influence the
severity of pain and make management more challenging. In sum, the literature
indicates that cancer pain in advanced disease is multifaceted and can adversely
affect the lives of patients and their caregivers. Changes associated with aging
have the potential to further impact this experience.

 Option A: Pain continues to be a common and distressing symptom,
despite pain management being a central focus of palliative care and
guidelines for the management of cancer pain. Estimates suggest that as
many as 60% to 80% of individuals with recurrent or metastatic cancer
experience pain. Among older patients, cancer pain, similar to other types
of pain, tends to go unrecognized and undertreated
 Option C: In older individuals, the higher incidence of comorbidities, age-
related declines in functioning, and associated symptoms can further
complicate cancer pain and its management. Adding to the complexity is
the recognition that the experience of pain is not merely a sensory event,
but is multifaceted, comprising sensory, affective, and evaluative
components.
 Option D: Indeed, the belief that pain can emanate from both physical
sources and nonphysical sources (psychological, spiritual, and
interpersonal) is central to the concept of total pain, put forth by Dame
Cicely Saunders, founder of the modern hospice. This nonphysical source
of pain derives from feelings of helplessness, being dependent on others,
and having difficulty in reshaping relationships, and has been described by
terminally ill older patients as creating the worst suffering.
ADVERTISEMENTS
10. Question
What is the main advantage of cutaneous stimulation in managing pain?
o A. Costs less.
o B. Restricts movement and decreases.
o C. Gives client control over pain syndrome.
o D. Allows the family to care for the patient at home.

Incorrect
Correct Answer: C. Gives client control over pain syndrome.
Cutaneous stimulation allows the patient to have control over his pain and allows
him to be in his own environment. Cutaneous stimulation increases movement
and decreases pain. Cutaneous stimulation involves stimulation of nerves via skin

contact in an effort to reduce pain impulses to the brain, based on the ―gate
control‖ theory of pain. A device used to provide electrocutaneous nerve
stimulation was studied for its effect on symptoms of peripheral neuropathy.
 Option A: The potential for TENS-associated improvement, combined with
reduced medication-related complications and costs, are important points
that clinicians should consider when constructing a treatment plan for
chronic pain patients. Finally, cost simulation techniques provide a useful
tool for assessing outcomes in pain treatment and research.
 Option B: CS effectively reduces pain, heart rate, and blood pressure in ED
patients. The intervention of CS has solid utilization potential and could be
easily incorporated into standard ED procedures.
 Option D: TENS devices can be purchased over the counter and without
medical prescription in the UK. However, a practitioner experienced in
TENS principles should supervise patients using TENS for the first time. A
point of contact to troubleshoot any problems should also be provided.
ADVERTISEMENTS
11. Question
The nurse is instructing a 65-year-old female client diagnosed with osteoporosis.
The most important instruction regarding exercise would be to
o A. Exercise doing weight-bearing activities.
o B. Exercise to reduce weight.
o C. Avoid exercise activities that increase the risk of fracture.
o D. Exercise to strengthen muscles and thereby protect bones.

Incorrect
Correct Answer: A. Exercise doing weight-bearing activities.
Weight-bearing exercises are beneficial in the treatment of osteoporosis.
Although the loss of bone cannot be substantially reversed, it can be greatly
reduced if the client includes weight-bearing exercises along with estrogen
replacement and calcium supplements in their treatment protocol. 45 minutes to
one hour of aerobic activity two to three times per week

 Option B: Resistance training two or three times per week. Each session
should include exercises to strengthen the lower limb, trunk, and arm
muscles, and each exercise should be performed eight to 10 times
 Option C: Balance exercises need to be at a level that is challenging to
balance and should be performed for a few minutes at least twice a week.
For safety reasons, always make sure to hold on to something if you
overbalance it. People with severe osteoporosis or kyphosis (hunching of
the upper back) who are at high risk of bone fractures may find that
swimming or water exercise is their preferred activity.
 Option D: Even though walking is a weight-bearing exercise, it does not
greatly improve bone health, muscle strength, fitness or balance, unless it
is carried out at high intensity such as at a faster pace, for long durations
(such as bushwalking), or incorporates challenging terrain such as hills.
ADVERTISEMENTS
12. Question
A client in a long-term care facility complains of pain. The nurse collects data
about the client‘s pain. The first step in pain assessment is for the nurse to
o A. Have the client identify coping methods.
o B. Get the description of the location and intensity of the pain.
o C. Accept the client’s report of pain.
o D. Determine the client‘s status of pain.

Incorrect
Correct Answer: C. Accept the client’s report of pain.
Although all of the options above are correct, the first and most important piece
of information in this client‘s pain assessment is what the client is telling you
about the pain –―the client‘s report.‖ Pain is the most common complaint seen in
a primary care office. There are over 50 million Americans, 20 percent of all
patients, that suffer from chronic pain in the United States.
 Option A: Effective treatment modalities for acute, chronic, centralized, or
neuropathic are often different. Ten percent of the United States
population complain of neuropathic pain. This population may benefit

from a serotonin-norepinephrine reuptake inhibitor (SNRI) such as
duloxetine, as compared to ibuprofen for an acute injury.
 Option B: To fully assess the location of a patient‘s pain, a body diagram
map can be completed. Ankle sprains are solitary, acute injuries. Body
diagrams may not be necessary in such a case. Localized pain is different
from whole-body pain. Yet, in a patient with multiple comorbid pain
disorders such as fibromyalgia, centralized pain disorder, and rheumatoid
arthritis, distinguishing between the numerous locations of a patient‘s pain,
as well as factoring in the radiation of their pain, is difficult.
 Option D: An essential first step in the pain assessment is distinguishing
nociceptive pain from neuropathic. Pain characterized as burning, shooting,
pins, and needles, or electric shock-like point the differential towards a
neuropathic origin of the patient‘s pain Sharp or throbbing pain is more
likely to be acute nociceptive pain.
ADVERTISEMENTS
13. Question
Which statement best describes the effects of immobility in children?
o A. Immobility prevents the progression of language and fine motor

development.
o B. Immobility in children has similar physical effects to those found in

adults.
o C. Children are more susceptible to the effects of immobility than are adults.
o D. Children are likely to have prolonged immobility with subsequent

complications.
Incorrect
Correct Answer: B. Immobility in children has similar physical effects to
those found in adults.
Care of the immobile child includes efforts to prevent complications of muscle
atrophy, contractures, skin breakdown, decreased metabolism and bone
demineralization. Secondary alterations also occur in the cardiovascular,
respiratory and renal systems. Similar effects and alterations occur in adults.

 Option A: The hazards or complications of immobility, such as skin
breakdown, pressure ulcers, contractures, muscular weakness, muscular
atrophy, disuse osteoporosis, renal calculi, urinary stasis, urinary retention,
urinary incontinence, urinary tract infections, atelectasis, pneumonia,
decreased respiratory vital capacity, venous stasis, venous insufficiency,
orthostatic hypotension, decreased cardiac reserve, edema, emboli,
thrombophlebitis, constipation and the loss of calcium from the bones, are
highly costly in terms of health care dollars and in terms of client suffering.
 Option C: Immobility and complete bed rest can lead to life-threatening
physical and psychological complications and consequences. Members of
the nursing care team and other health care professionals like physical
therapists must, therefore, promote client mobility and prevent immobility
whenever possible. Immobility can adversely affect all physiological bodily
systems.
 Option D: Children stayed in a cast for a long period, so that the effect of
postoperative immobility had negative effects on the physical and
psychological wellbeing of children with musculoskeletal injuries.
Emphasize the importance of implementing a nursing care program for
children in the postoperative period for minimizing the physical and
psychological effects of immobility on children with musculoskeletal
injuries.
ADVERTISEMENTS
14. Question
After a myocardial infarction, a client is placed on a sodium-restricted diet. When
the nurse is teaching the client about the diet, which meal plan would be
the most appropriate to suggest?
o A. 3 oz. broiled fish, 1 baked potato, ½ cup canned beets, 1 orange, and milk.
o B. 3 oz. canned salmon, fresh broccoli, 1 biscuit, tea, and 1 apple.
o C. A bologna sandwich, fresh eggplant, 2 oz fresh fruit, tea, and apple juice.
o D. 3 oz. turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk,
and 1 orange.

Incorrect
Correct Answer: D. 3 oz. turkey, 1 fresh sweet potato, 1/2 cup fresh green
beans, milk, and 1 orange
Canned fish and vegetables and cured meats are high in sodium. This meal does
not contain any canned fish and/or vegetables or cured meats. Eat a
Mediterranean?style diet—more bread, fruit, vegetables, and fish; less meat; and
replace butter and cheese with products based on vegetable and plant oils
(reduces total mortality and the risk of myocardial infarction).
 Option A: Consume at least 7?g of omega?3 fatty acids per week from 2–4
portions of oily fish per week. If within 3?months of myocardial infarction
and they are not achieving this, consider providing at least 1?g daily of
omega?3?acid ethyl esters treatment licensed for secondary prevention
after myocardial infarction for up to 4 years.
 Option B: Choose foods with less sodium and prepare foods with little or
no salt. To lower blood pressure, aim to eat no more than 2,300 milligrams
of sodium per day. Reducing daily intake to 1,500 mg is desirable because
it can lower blood pressure even further.
 Option C: Processed meats, like hot dogs, sausage, and lunch meat, are
loaded with sodium and nitrates. This can raise the blood pressure and the
risk of another heart attack. High blood pressure is particularly dangerous
because there usually aren‘t any symptoms.
ADVERTISEMENTS
15. Question
A nurse is assessing several clients in a long-term health care facility. Which client
is at highest risk for the development of decubitus ulcers?
o A. A 79-year-old malnourished client on bed rest.
o B. An obese client who uses a wheelchair.
o C. An incontinent client who has had 3 diarrhea stools.
o D. An 80-year-old ambulatory diabetic client.

Incorrect
Correct Answer: A. A 79-year-old malnourished client on bed rest.

Weighing significantly less than ideal body weight increases the number and
surface area of bony prominences which are susceptible to pressure ulcers. Thus,
malnutrition is a major risk factor for decubitus, due in part to poor hydration and
inadequate protein intake. Both external and internal factors work simultaneously,
forming these ulcers. External factors; pressure, friction, shear force, and moisture
and internal factors; fever, malnutrition, anemia, and endothelial dysfunction
speed up the process of these lesions.
 Option B: Immobility of as little as two hours in a bedridden patient or
patient undergoing surgery is sufficient to create the basis of a decubitus
ulcer. The dysfunction of nervous regulatory mechanisms responsible for
the regulation of local blood flow is somewhat culpable in the formation of
these ulcers. Prolonged pressure on tissues can cause capillary bed
occlusion and, thus, low oxygen levels in the area. Over time, the ischemic
tissue begins to accumulate toxic metabolites. Subsequently, tissue
ulceration and necrosis occur.
 Option C: The development of decubitus ulcers is complex and
multifactorial. Loss of sensory perception, locally and general impaired loss
of consciousness, along with decreased mobility, are the most important
causes that aid in the formation of these ulcers because patients are not
aware of discomfort hence do not relieve the pressure.
 Option D: Elderly patients are more prone to sacral decubitus ulcers; two-
thirds of ulcers occur in patients who are over 70 years old. There is data
that shows 83% of hospitalized patients with ulcers developed them within
five days of their hospitalization.
ADVERTISEMENTS
16. Question
Mrs. Kennedy had a CVA (cerebrovascular accident) and has a severe right-sided
weakness. She has been taught to walk with a cane. The nurse is evaluating her
use of the cane prior to discharge. Which of the following reflects the correct use
of the cane?
o A. Holding the cane in her left hand, Mrs. Kennedy moves the cane
forward first, then her right leg, and finally her left leg.

o her left leg. B. Holding the cane in her right hand, Mrs. Kennedy moves the
cane forward first, then her left leg, and finally her right leg.
o C. Holding the cane in her right hand, Mrs. Kennedy moves the cane and her
right leg forward then moves her left leg forward.
o D. Holding the cane in her left hand, Mrs. Kennedy moves the cane and her
left leg forward, then moves her right leg forward.
Incorrect
Correct Answer: A. Holding the cane in her left hand, Mrs. Kennedy moves
the cane forward first, then her right leg, and finally her left leg
When a person with weakness on one side uses a cane, there should always be
two points of contact with the floor. When Mrs. Kennedy. moves the cane
forward, she has both feet on the floor, providing stability. As she moves the
weak leg, the cane and the strong leg provide support. Finally, the cane, which is
even with the weak leg, provides stability while she moves the strong leg.
 Option B: She should not hold the cane with her weak arm. The use of the
cane requires arm strength to ensure that the cane provides adequate
stability when standing on the weak leg. To go upstairs, use the handrail
and step up with the unaffected leg first and follow with the cane and the
affected foot together.
 Option C: The cane should be held in the left hand, the hand opposite the
affected leg. Hold the cane in the hand of the unaffected side. Move the
cane and the affected leg forward at the same time, so that the cane helps
take the weight of the weak leg. Then step with the unaffected leg.
 Option D: If Mrs. Kennedy. moved the cane and her strong foot at the
same time, she would be left standing on her weak leg at one point. This
would be unstable at best; at worst, impossible. To go downstairs, use the
handrail and step down with the affected foot and cane together first and
follow with the unaffected foot.
ADVERTISEMENTS
17. Question
The nurse is instructing a woman on a low-fat, high-fiber diet. Which of the
following food choices, if selected by the client, indicate an understanding of a
low-fat, high-fiber diet?

o A. Tuna salad sandwich on whole-wheat bread.
o B. Vegetable soup made with vegetable stock, carrots, celery, and

legumes served with toasted oat bread.
o C. Chef‘s salad with hard-boiled eggs and fat-free dressing.
o D. Broiled chicken stuffed with chopped apples and walnuts.

Incorrect
Correct Answer: B. Vegetable soup made with vegetable stock, carrots,
celery, and legumes served with toasted oat bread.
This choice shows a low-fat soup (which would have been higher in fat if made
with chicken or beef stock) and high-fiber bread and soup contents (both the
vegetables and the legumes). Eating a high-fiber diet that is low in fat can help
maintain overall health. Fiber-rich foods are naturally low in fat and contain
cancer-fighting and heart-healthy properties. While a low-fat diet is good, it is
important that the client does not dismiss all fats, however. Eat some foods
containing unsaturated fats because they are necessary for an overall healthy
diet.
 Option A: Mayonnaise in tuna salad is high in fat. The whole-wheat bread
has some fiber. Fiber‘s presence in the digestive tract can help reduce the
body‘s cholesterol absorption. This is especially true if you take statins,
which are medications to lower cholesterol, and use fiber supplements like
psyllium fiber
 Option C: Salad is high in fiber, but hard-boiled eggs are high in fat. In
fact, a single egg contains 212 mg of cholesterol, which is 71% of the
recommended daily intake. Plus, 62% of the calories in whole eggs are
from fat.
 Option D: There is some fiber in the apples and walnuts. The walnuts are
high in fat, as is the chicken. Nuts have a high-fat content, so are high in
energy. In most nuts, this is mainly unsaturated fat: either polyunsaturated
fats in walnuts and pine nuts or monounsaturated fats in almonds,
pistachios, pecans, and hazelnuts, for example. Brazil nuts, cashews, and
macadamia nuts are higher in saturated fat.
ADVERTISEMENTS
18. Question

An 85-year-old male patient has been bedridden for two weeks. Which of the
following complaints by the patient indicates to the nurse that he is developing a
complication of immobility?
o A. Stiffness of the right ankle joint.
o B. Soreness of the gums.
o C. Short-term memory loss.
o D. Decreased appetite.
Incorrect
Correct Answer: A. Stiffness of the right ankle joint.
Stiffness of a joint may indicate the beginning of contracture and/or early muscle
atrophy. In the development of joint contractures that result from long-term
immobilization, shortening of the joint capsule, synovial adhesions and
arthrofibrosis play decisive roles and may present as a generalized joint stiffness
 Option B: Soreness of the gums is not related to immobility. Brushing too
hard, improper flossing techniques, infection, or gum disease can cause
sore and sensitive gums. Other causes unrelated to oral hygiene could
include Vitamin K deficiency, hormonal changes during pregnancy,
leukemia, or blood disorders.
 Option C: Short-term memory loss is not related to immobility. Short-term
memory loss is when one forgets things they heard, saw, or did recently.
It‘s a normal part of getting older for many people. But it can also be a sign
of a deeper problem, such as dementia, a brain injury, or a mental health
issue.
 Option D: Decreased appetite is unlikely to be related to immobility.
People can experience a loss of appetite for a wide range of reasons. Some
of these are short-term, including colds, food poisoning, other infections,
or the side effects of medication. Others are to do with long-term medical
conditions, such as diabetes, cancer, or life-limiting illnesses.
ADVERTISEMENTS
19. Question

An eleven-month-old infant is brought to the pediatric clinic. The nurse suspects
that the child has iron-deficiency anemia. Because iron deficiency anemia is
suspected, which of the following is the most important information to obtain
from the infant‘s parents?
o A. Normal dietary intake.
o B. Relevant socio-cultural, economic, and educational background of the

family.
o C. Any evidence of blood in the stools.
o D. A history of maternal anemia during pregnancy.

Incorrect
Correct Answer: A. Normal dietary intake.
Iron deficiency anemia occurs commonly in children 6 to 24 months of age. For
the first 4 to 5 months of infancy iron stores laid down for the baby during
pregnancy are adequate. When fetal iron stores are depleted, supplemental
dietary iron needs to be supplied to meet the infant‘s rapid growth needs. Iron
deficiency may occur in the infant who drinks mostly milk, which contains no iron,
and does not receive adequate dietary iron or supplemental iron.
 Option B: Daily dietary intake is much more related to the diagnosis of
iron deficiency anemia than is the socio-cultural, economic, and
educational background of the family. The cause of iron-deficiency anemia
varies based on age, gender, and socioeconomic status. Iron deficiency
may result from insufficient iron intake, decreased absorption, or blood
loss.
 Option C: Iron deficiency anemia in an infant is very unlikely to be related
to gastrointestinal bleeding. In developing countries, a parasitic infestation
is also a significant cause of iron deficiency anemia. Dietary sources of iron
are green vegetables, red meat, and iron-fortified milk formulas.
 Option D: Anemia during pregnancy is unlikely to be the cause of the
infant‘s iron deficiency anemia. Fetal iron stores are drawn from the mother
even if she is anemic. In neonates, breastfeeding is protective against iron
deficiency due to the higher bioavailability of iron in breast milk compared
to cow‘s milk; iron deficiency anemia is the most common form of anemia
in young children on cow‘s milk.

ADVERTISEMENTS
20. Question
A 46-year-old female with chronic constipation is assessed by the nurse for a
bowel training regimen. Which factor indicates further information is needed by
the nurse?
o A. The client‘s dietary habits include foods high in bulk.
o B. The client‘s fluid intake is between 2500-3000 ml per day.
o C. The client engages in moderate exercise each day.
o D. The client’s bowel habits were not discussed.

Incorrect
Correct Answer: D. The client’s bowel habits were not discussed.
To assess the client for a bowel training program the factors causing the bowel
alteration should be assessed. A routine for bowel elimination should be based
on the client‘s previous bowel habits and alterations in bowel habits that have
occurred because of illness or trauma.
 Option A: Foods high in bulk are appropriate. Assist the patient to take at
least 20 g of dietary fiber (e.g., raw fruits, fresh vegetables, whole grains)
per day. Fiber adds bulk to the stool and makes defecation easier because
it passes through the intestine essentially unchanged.
 Option B: The client and the family should assist in the planning of the
program which should include foods high in bulk, adequate exercise, and
fluid intake of 2500-3000 ml. Encourage the patient to take in fluid 2000 to
3000 mL/day, if not contraindicated medically. Sufficient fluid is needed to
keep the fecal mass soft. But take note of some patients or older patients
having cardiovascular limitations requiring less fluid intake.
 Option C: Exercise should be a part of a bowel training regimen. Urge the
patient for some physical activity and exercise. Consider isometric
abdominal and gluteal exercises. Movement promotes peristalsis.
Abdominal exercises strengthen abdominal muscles that facilitate
defecation.
ADVERTISEMENTS

21. Question
Mr. Teban is a 73-year old patient diagnosed with pneumonia. Which data would
be of greatest concern to the nurse when completing the nursing assessment of
the patient?
o A. Alert and oriented to date, time, and place.
o B. Buccal cyanosis and capillary refill greater than 3 seconds.
o C. Clear breath sounds and nonproductive cough.
o D. Hemoglobin concentration of 13 g/dl and leukocyte count 5,300/mm3.

Incorrect
Correct Answer: B. Buccal cyanosis and capillary refill greater than 3
seconds.
Buccal cyanosis and capillary refill greater than 3 seconds are indicative of
decreased oxygen to the tissues, which requires immediate intervention. As
oxygenation and perfusion become impaired, peripheral tissues become cyanotic.
Cyanosis of nail beds may represent vasoconstriction or the body‘s response to
fever/chills; however, cyanosis of earlobes, mucous membranes, and skin around
the mouth (―warm membranes‖) is indicative of systemic hypoxemia. Alert and
oriented, clear breath sounds, nonproductive cough, hemoglobin concentration
of 13 g/dl, and leukocyte count of 5,300/mm3 are normal data.
 Option A: Restlessness, irritation, confusion, and somnolence may reflect
hypoxemia and decreased cerebral oxygenation and may require further
intervention. Check pulse oximetry results with any mental status changes
in older adults.
 Option C: Decreased airflow occurs in areas with consolidated fluid.
Bronchial breath sounds can also occur in these consolidated areas.
Crackles, rhonchi, and wheezes are heard on inspiration and/or expiration
in response to fluid accumulation, thick secretions, and airway spasms and
obstruction.
 Option D: Monitor serial chest x-rays, ABGs, pulse oximetry readings.
Follows progress and effects and extent of pneumonia. Therapeutic
regimen, and may facilitate necessary alterations in therapy. Oxygen

saturation should be maintained at 90% or greater. Imbalances in PaCO2
and PaO2 may indicate respiratory fatigue.
ADVERTISEMENTS
22. Question
During the nursing assessment, which data represent information concerning
health beliefs?
o A. Family role and relationship patterns.
o B. Educational level and financial status.
o C. Promotive, preventive, and restorative health practices.
o D. Use of prescribed and over-the-counter medications.

Incorrect
Correct Answer: C. Promotive, preventive, and restorative health practices.
The health-beliefs assessment includes expectations of health care; promotive,
preventive, and restorative practices, such as breast self-examination, testicular
examination, and seat-belt use; and how the client perceives illness. The basic
premise of the health belief assessment is that patients have a right to their
cultural beliefs, values, and practices, and that these factors should be
understood, respected, and considered when giving culturally competent care.
 Option A: Educational level and financial status represent information
associated with role and relationship patterns. Critical thinking skills
applied during the nursing process provide a decision-making framework
to develop and guide a plan of care for the patient incorporating evidence-
based practice concepts. This concept of precision education to tailor care
based on an individual‘s unique cultural, spiritual, and physical needs,
rather than a trial by error, one size fits all approach results in a more
favorable outcome.
 Option B: Family role and relationship patterns represent information
associated with role and relationship patterns. The nursing assessment
includes gathering information concerning the patient‘s individual
physiological, psychological, sociological, and spiritual needs. It is the first

step in the successful evaluation of a patient. Subjective and objective data
 Option D: The use of medications provides information about the client‘s
personal habits. Part of the assessment includes data collection by
obtaining vital signs such as temperature, respiratory rate, heart rate, blood
pressure, and pain level using age or condition-appropriate pain scale. The
assessment identifies the current and future care needs of the patient by
allowing the formation of a nursing diagnosis. The nurse recognizes normal
and abnormal patient physiology and helps prioritize interventions and
care.
ADVERTISEMENTS
23. Question
Nurse Patrick is acquiring information from a client in the emergency
department. Which is an example of biographic information that may be
obtained during a health history?
o A. The chief complaint
o B. Past health status
o C. History immunizations
o D. Location of an advance directive

Incorrect
Correct Answer: D. Location of an advance directive
Biographic information may include name, address, gender, race, occupation, and
location of a living will or durable power of attorney for health care. Biographic
data usually include information that identifies the client, such as name, address,
phone number, gender, and who provided the information—the client or
significant others. The client‘s birth date, Social Security number, medical record
number, or similar identifying data may be included in the biographic data
section. The chief complaint, past health status, and history of immunizations are
part of assessing the client‘s health and illness patterns.
 Option A: Encourage the client to explain the health problem or symptom
in as much detail as possible by focusing on the onset, progression, and

duration of the problem; signs and symptoms and related problems; and
what the client perceives as causing the problem. The client‘s answers to
the questions provide the nurse with a great deal of information about the
client‘s problem and especially how it affects the lifestyle and activities of
daily living. This helps the nurse to evaluate the client‘s insight into the
problem and the client‘s plans for managing it.
 Option B: This portion of the health history focuses on questions related
to the client‘s past, from the earliest beginnings to the present. These
questions elicit data related to the client‘s strengths and weaknesses in her
health history. The client‘s strengths may be physical (e.g., optimal body
weight), social (e.g., active in community services), emotional (e.g.,
expresses feeling openly), or spiritual (often turns to faith for support).
 Option C: Information covered in the past health history includes
questions about birth, growth, development, childhood diseases,
immunizations, allergies, previous health problems, hospitalizations,
surgeries, pregnancies, births, previous accidents, injuries, painful
experiences, and emotional or psychiatric problems.
ADVERTISEMENTS
24. Question
John Joseph was scheduled for a physical assessment. When percussing the
client‘s chest, the nurse would expect to find which assessment data as a normal
sign over his lungs?
o A. Dullness
o B. Resonance
o C. Hyperresonance
o D. Tympany
Incorrect
Correct Answer: B. Resonance
Normally, when percussing a client‘s chest, percussion over the lungs reveals
resonance, a hollow or loud, low-pitched sound of long duration. Since lungs are
mostly filled with air that we breathe in, percussion performed over most of the

lung area produces a resonant sound, which is a low-pitched, hollow sound.
Therefore, any dullness or hyper-resonance is indicative of lung pathology, such
as pleural effusion or pneumothorax, respectively.
 Option A: Dullness is typically heard on percussion of solid organs, such as
the liver or areas of consolidation. Dullness to percussion indicates denser
tissue, such as zones of effusion or consolidation. Once an abnormality is
detected, percussion can be used around the area of interest to define the
extent of the abnormality. Normal areas of dullness are those overlying the
liver and spleen at the anterior bases of the lungs.
 Option C: Hyperresonance would be evidenced by percussion over areas
of overinflation such as an emphysematous lung. Hyperresonant sounds
may also be heard when percussing lungs hyperinflated with air, such as
may occur in patients with COPD, or patients having an acute asthmatic
attack. An area of hyper resonance on one side of the chest may indicate a
pneumothorax.
 Option D: Tympany is typically heard on percussion over such areas as a
gastric air bubble or the intestine. Tympanic sounds are hollow, high,
drumlike sounds. Tympany is normally heard over the stomach but is not a
normal chest sound. Tympanic sounds heard over the chest indicate
excessive air in the chest, such as may occur with pneumothorax.
ADVERTISEMENTS
25. Question
Matteo is diagnosed with dehydration and underwent a series of tests. Which
laboratory result would warrant immediate intervention by the nurse?
o A. Serum sodium level of 138 mEq/L
o B. Serum potassium level of 3.1 mEq/L
o C. Serum glucose level of 120 mg/dl
o D. Serum creatinine level of 0.6 mg/100 ml

Incorrect
Correct Answer: B. Serum potassium level of 3.1 mEq/L

A normal potassium level is 3.5 to 5.5 mEq/L. Hypokalemia is more prevalent than
hyperkalemia, and most cases are mild. Severity is categorized as mild when the
serum potassium level is 3 to 3.4 mmol/L, moderate when the serum potassium
level is 2.5 to 3 mmol/L, and severe when the serum potassium level is less than
2.5 mmol/L.
 Option A: A normal sodium level is 135 to 145 mEq/L. Among the
electrolyte disorders, hyponatremia is the most frequent. Diagnosis is when
the serum sodium level is less than 135 mmol/L. Hyponatremia has
neurological manifestations. Patients may present with headache,
confusion, nausea, delirium. Hypernatremia presents when the serum
sodium levels are greater than145 mmol/L.
 Option C: A normal non fasting glucose level is 85 to 140 mg/dl. Normal
plasma glucose levels are defined as under 100 mg/dL during fasting and
less than 140 mg/dL 2-hours postprandial. Additionally, glucose levels in
healthy individuals can vary with age. Fasting plasma glucose in adults
tends to increase with age starting in the third decade of life but does not
increase significantly beyond 60 years of age. Normal HbA1c is lower than
5.7%.
 Option D: A normal creatinine level is 0.2 to 0.8 mg/100 ml. Serum
creatinine level for men with normal kidney function is approximately 0.6 to
1.2mg/dL and between 0.5 to 1.1 mg/dL for women. Alteration of serum
creatinine values can occur as its generation is subject to influence by
muscle function, activity, diet, and health status of the patient. Increased
tubular secretion of creatinine in certain patients with dysfunctional
kidneys could provide a false negative value. Elevated serum creatinine
levels are also present in patients with muscular dystrophy paralysis,
anemia, leukemia, and hyperthyroidism.
ADVERTISEMENTS
26. Question
During an otoscopic examination, which action should be avoided to prevent the
client from discomfort and injury?
o A. Tipping the client's head away from the examiner and pulling the ear up
and back.

o B. Inserting the otoscope inferiorly into the distal portion of the external
canal.
o C. Inserting the otoscope superiorly into the proximal two-thirds of the

external canal.
o D. Bracing the examiner's hand against the client's head.

Incorrect
Correct Answer: C. Inserting the otoscope superiorly into the proximal two-
thirds of the external canal.
In the superior position, the speculum of the otoscope is nearest the tympanic
membrane, and the most sensitive portion of the external canal is the proximal
two-thirds. It is important to avoid these structures during the examination. The
provider should then slowly progress the speculum into the canal until the
tympanic membrane becomes visible. The provider should evaluate the health of
the tympanic membrane and observe factors such as color, presence of
perforation, and a bulging appearance.
 Option A: With the hand that is not holding the otoscope, the provider
should grasp and gently pull the patient‘s pinna to help straighten the
patient‘s external auditory canal. This step will facilitate visualization of the
tympanic membrane. In a child, the examiner should pull the pinna
posteriorly and inferiorly. In an adult, the examiner should pull the pinna
posteriorly and superiorly.
 Option B: During the otoscopic examination, the provider utilizes an
otoscope, also known as an auriscope, to visualize the ear anatomy. While
performing the otoscopic examination, the provider holds the handle of
the otoscope and inserts the cone of the otoscope into the patient‘s
external auditory canal.
 Option D: Providers may have their own preferences regarding how to
grasp the otoscope. However, it is generally advisable to hold the otoscope
like a pen in between the first and second fingers. The otoscope is usually
held in the right hand when evaluating the patient‘s right ear and the left
hand when assessing the patient‘s left ear. The provider should place their
free fifth finger of the hand, holding the otoscope against the patient‘s
cheek to support and brace the hand during the examination.
ADVERTISEMENTS

27. Question
When assessing the lower extremities for arterial function, which intervention
should the nurse perform?
o A. Assessing the medial malleoli for pitting edema.
o B. Performing Allen's test.
o C. Assessing the Homans' sign.
o D. Palpating the pedal pulses.

Incorrect
Correct Answer: D. Palpating the pedal pulses.
Palpating the client‘s pedal pulses assists in determining if arterial blood supply
to the lower extremities is sufficient. Finding a pedal pulse is part of the trauma
patient assessment and performed before and after lower extremity splint
application as well as long backboard immobilization. Assessing a pedal pulse is
part of the ongoing assessment for a patient on a backboard or a lower extremity
splint.
 Option A: Assessing the medial malleoli for pitting edema is appropriate
for assessing the venous function of the lower extremity. The lower
extremity examination should focus on the medial malleolus, the bony
portion of the tibia, and the dorsum of the foot. Pitting edema also occurs
in the early stages of lymphedema because of an influx of protein-rich fluid
into the interstitium, before fibrosis of the subcutaneous tissue; therefore,
its presence should not exclude the diagnosis of lymphedema.
 Option B: Allen‘s test is used to evaluate arterial blood flow before
inserting an arterial line in an upper extremity or obtaining arterial blood
gases. The Allen test is a first-line standard test used to assess the arterial
blood supply of the hand. This test is performed whenever intravascular
access to the radial artery is planned or for selecting patients for radial
artery harvesting, such as for coronary artery bypass grafting or for forearm
flap elevation.
 Option C: Homans‘ sign is used to evaluate the possibility of deep vein
thrombosis. Homan‘s sign test also called dorsiflexion sign test is a physical
examination procedure that is used to test for Deep Vein Thrombosis

(DVT). A positive Homan‘s A positive Homan‘s sign in the presence of other
clinical signs may be a quick indicator of DVT.
ADVERTISEMENTS
28. Question
Newly hired nurse Liza is excited to perform her very first physical assessment
with a 19-year-old client. Which assessment examination requires Liza to wear
gloves?
o A. Breast
o B. Integumentary
o C. Ophthalmic
o D. Oral
Incorrect
Correct Answer: D. Oral
Gloves should be worn anytime there is a risk of exposure to the client‘s blood or
body fluids. Oral, rectal, and genital examinations require gloves because they
involve contact with body fluids. Ophthalmic, breast, or integumentary
examinations normally do not involve contact with the client‘s body fluids and do
not require the nurse to wear gloves for protection.
 Option A: After completing the visual inspection, the patient should be
instructed to lay supine. If a site-specific breast complaint is being
evaluated, the examiner should begin his/her exam on the opposite, or
―normal‖ side. As one breast is examined, the other is covered for the
patient‘s comfort. The patient should place the ipsilateral hand above
and/or behind their head to flatten the breast tissue as much as possible.
The breast tissue itself is evaluated using a sequence of palpation that
allows serial progression from superficial to deeper tissues.
 Option B: A general assessment of the skin begins at the initial contact
with the patient and continues throughout the examination. Specific areas
of the skin are assessed during the examination of other body systems
unless the chief complaint is a dermatologic problem. However, if there are
areas of skin breakdown or drainage, gloves should be used.

 Option C: The Royal College of Ophthalmologists have updated their
advice on PPE to ophthalmologists and are now recommending that
clinicians should wear standard surgical masks when examining or treating
patients at the slit lamp. Gowns and gloves are not recommended. They
also recommend that plastic breath shields attached to slit lamps provide
some protection, but must be disinfected between patients as studies show
that the COVID-19 virus is viable for up to 72 hours on plastic surfaces.
ADVERTISEMENTS
29. Question
Nurse Renner is about to perform Romberg‘s test on Pierro. To ensure the latter‘s
safety, which intervention should nurse Renner implement?
o A. Allowing the client to keep his eyes open.
o B. Having the client hold on to furniture.
o C. Letting the client spread his feet apart.
o D. Standing close to provide support.

Incorrect
Correct Answer: D. Standing close to provide support.
During Romberg‘s test, the client is asked to stand with feet together and eyes
shut and still maintain balance with the minimum of sway. If the client loses his
balance, the nurse standing close to provide support, such as having an arm close
around his shoulder, can prevent a fall. Allowing the client to keep his eyes open,
spread his feet apart, or hang on to a piece of furniture interferes with the proper
execution of the test and yields invalid results.
 Option A: The clinician asks the patient to first stand quietly with eyes
open, and subsequently with eyes closed. The patient tries to maintain his
balance. For safety, it is essential that the observer stand close to the
patient to prevent potential injury if the patient were to fall. When the
patient closes his eyes, he should not orient himself by light, sense or
sound, as this could influence the test result and cause a false positive
outcome.

 Option B: In the Romberg test, the patient stands upright and asked to
close his eyes. A loss of balance is interpreted as a positive Romberg sign.
The Romberg test is positive when the patient is unable to maintain
balance with their eyes closed. Losing balance can be defined as increased
body sway, placing one foot in the direction of the fall, or even falling.
 Option C: The patient is asked to remove his shoes and stand with his two
feet together. The arms are held next to the body or crossed in front of the
body. If the clinician observes that the patient is able to stand for long
periods of time with the eyes closed, it is evident that the patient‘s balance
and proprioceptive deficits have decreased.
ADVERTISEMENTS
30. Question
A physical assessment is being performed on patient Geoff by Nurse Tine. During
the abdominal examination, Nurse Tine should perform the four physical
examination techniques in which sequence?
o A. Auscultation immediately after the inspection and then percussion

and palpation.
o B. Percussion, followed by inspection, auscultation, and palpation.
o C. Palpation of tender areas first and then inspection, percussion, and

auscultation.
o D. Inspection and then palpation, percussion, and auscultation.

Incorrect
Correct Answer: A. Auscultation immediately after the inspection and then
percussion and palpation
With an abdominal assessment, auscultation always is performed before
percussion and palpation because any abdominal manipulation, such as from
palpation or percussion, can alter bowel sounds. Assessing the patient‘s abdomen
can provide critical information about his internal organs. Always follow this
sequence: inspection, auscultation, percussion, and palpation. Changing the order
of these assessment techniques could alter the frequency of bowel sounds and
make the findings less accurate.

 Option B: Percussion should never precede inspection or auscultation, and
any tender or painful areas should be palpated last. Assess for any visible
mass, bulging, or asymmetry. Look for unusual coloring, scars, striae,
lesions, petechiae, ecchymoses, spider angiomas, and suspicious-looking
moles. Inspect the umbilicus and note any hernias. Look for pulsations. A
thin patient may have a pulsation of the aorta in his epigastric area and
possibly peristaltic waves.
 Option C: Lightly percuss all four quadrants of the patient‘s abdomen.
You‘ll hear dull sounds over solid structures (such as the liver) and fluid-
filled structures (such as a full bladder). Air-filled areas (such as the
stomach) produce tympany. Dullness is a normal finding over the liver, but
a large, dull area elsewhere may indicate a tumor or mass.
 Option D: Using a light, gentle, dipping motion, palpate for abnormalities,
such as muscle guarding, rigidity, or superficial masses. Palpate clockwise,
lifting fingers as you move from one location to another. After light
palpation of the entire abdomen, place a non-dominant hand on the
dominant hand to perform deeper palpation (1½ to 2 inches [3.8 to 5 cm]).
However, avoid deep palpation if the patient may have a problem such as
splenomegaly, appendicitis, or aneurysm or if palpation is painful for any
reason.
ADVERTISEMENTS
31. Question
Which assessment data should the nurse include when obtaining a review of
body systems?
o A. Brief statement about what brought the client to the health care provider.
o B. Client complaints of chest pain, dyspnea, or abdominal pain.
o C. Information about the client's sexual performance and preference.
o D. The client's name, address, age, and phone number.

Incorrect
Correct Answer: B. Client complaints of chest pain, dyspnea, or abdominal
pain.

Client complaints about chest pain, dyspnea, or abdominal pain are considered
part of the review of body systems. This portion of the assessment elicits
subjective information on the client‘s perceptions of major body system
functions, including cardiac, respiratory, and abdominal. Critical thinking skills
applied during the nursing process provide a decision-making framework to
develop and guide a plan of care for the patient incorporating evidence-based
practice concepts.
 Option A: A brief statement about what brought the client to the health
care provider is the chief complaint. The CC is the reason for the visit as
stated in the patient‘s own words. This must be present for each encounter,
and should reference a specific condition or complaint (e.g., patient
complains of abdominal pain).
 Option C: Information about the client‘s sexual performance and
preference addresses past health status. Understanding the client‘s current
and past health is important and may provide an explanation or rationale
for the client‘s current health status. Furthermore, these data can provide
insight into health promotion needs and co-morbidities. It is helpful to
understand the current and past health profiles before assessing other
aspects of health, as the information will inform subsequent questions.
 Option D: The client‘s name, address, age, and phone number are
biographical data. ―Introductory Information‖ refers to the demographic
and biographic data that you collect from the client. This data provides you
with basic characteristics about the client, such as their name, contact
information, birth date and age, gender and preferred pronouns, allergies,
languages spoken and preferred language, relationship status, occupation,
and resuscitation status.
ADVERTISEMENTS
32. Question
Tywin has come to the nursing clinic for a comprehensive health assessment.
Which statement would be the best way to end the history interview?
o A. "What brought you to the clinic today?"
o B. "Would you describe your overall health as good?"

o C. "Do you understand what is happening?"
o D. "Is there anything else you would like to tell me?"

Incorrect
Correct Answer: D. “Is there anything else you would like to tell me?”
By asking the client if there is anything else, the nurse allows the client to end the
interview by discussing feelings and concerns. The purpose of obtaining a health
history is to gather subjective data from the patient and/or the patient‘s family so
that the health care team and the patient can collaboratively create a plan that
will promote health, address acute health problems, and minimize chronic health
conditions.
 Option A: Asking about what brought the client to the clinic is an
ambiguous question to which the client may answer ―my car‖ or any
similarly disingenuous reply. The health history is typically done on
admission to the hospital, but a health history may be taken whenever
additional subjective information from the patient may be helpful to inform
care (Wilson & Giddens, 2013).
 Option B: Asking if the client describes his overall health as good is a
leading question that puts words in his mouth. Objective data is
information that the health care professional gathers during a physical
examination and consists of information that can be seen, felt, smelled, or
heard by the health care professional. Taken together, the data collected
provides a health history that gives the health care professional an
opportunity to assess health promotion practices and offer patient
education (Stephen et al., 2012).
 Option C: Asking if the client understands what is happening is a yes-or-
no question that can elicit little information. Data gathered may be
subjective or objective in nature. Subjective data is information reported by
the patient and may include signs and symptoms described by the patient
but not noticeable to others. Subjective data also includes demographic
information, patient and family information about past and current medical
conditions, and patient information about surgical procedures and social
history.
ADVERTISEMENTS
33. Question

For which time period would the nurse notify the health care provider that the
client had no bowel sounds?
o A. 2 minutes
o B. 3 minutes
o C. 4 minutes
o D. 5 minutes
Incorrect
Correct Answer: D. 5 minutes
To completely determine that bowel sounds are absent, the nurse must
auscultate each of the four quadrants for at least 5 minutes; 2, 3, or 4 minutes is
too short a period to arrive at this conclusion. The first item to listen for is the
presence of bowel sounds. To chart an assessment finding of no bowel sounds,
the nurse needs to listen over the quadrant for at least five minutes. The nurse
should also do the auscultation before palpation and percussion to avoid
influencing bowel sounds.
 Option A: In most cases, bowel sounds are present, but the nurse needs to
categorize them. She should listen for the intensity of the sound – whether
it is soft or strong. The nurse should also listen for frequency. Hypoactive
bowel sounds could indicate a problem, so if the nurse is having trouble
hearing them, this is significant.
 Option B: Auscultating bowel sounds can allow the nurse to pinpoint areas
where an obstruction may have occurred. Finding no bowel sounds can
mean an ileus or obstruction above that area of the intestine.
 Option C: Hypoactive bowel sounds are considered as one every three to
five minutes, and this can indicate diarrhea, anxiety, or gastroenteritis.
Hyperactive bowel sounds are often found before a blockage. It is quite
common to find one quadrant with hyperactive bowel sounds and one with
none or hypoactive ones.
ADVERTISEMENTS
34. Question

Evaluating the apical pulse is the most reliable noninvasive way to assess cardiac
function. Which is the best area for auscultating the apical pulse?
o A. Aortic arch
o B. Pulmonic area
o C. Tricuspid area
o D. Mitral area
Incorrect
Correct Answer: D. Mitral area
The mitral area (also known as the left ventricular area or the apical area), the fifth
intercostal space (ICS) at the left midclavicular line, is the best area for
auscultating the apical pulse. The apical pulse is auscultated with a stethoscope
over the chest where the heart‘s mitral valve is best heard. In infants and young
children, the apical pulse is located at the fourth intercostal space at the left
midclavicular line. In adults, the apical pulse is located at the fifth intercostal
space at the left midclavicular line.
 Option A: The aortic arch is the second ICS to the right of the sternum.
Apical pulse rate is indicated during some assessments, such as when
conducting a cardiovascular assessment and when a client is taking certain
cardiac medications (e.g., digoxin). Sometimes the apical pulse is
auscultated pre and post medication administration.
 Option B: The pulmonic area is the second intercostal space to the left of
the sternum. It is also a best practice to assess apical pulse in infants and
children up to five years of age because radial pulses are difficult to
palpate and count in this population. It is typical to assess apical pulses in
children younger than eighteen, particularly in hospital environments.
Apical pulses may also be taken in obese people because their peripheral
pulses are sometimes difficult to palpate.
 Option C: The tricuspid area is the fifth ICS to the left of the sternum.
Position the client in a supine (lying flat) or in a seated position. Physically
palpate the intercostal spaces to locate the landmark of the apical pulse.
Ask the female client to re-position her own breast tissue to auscultate the
apical pulse.
ADVERTISEMENTS

35. Question
Beginning in their 20s, women should be told about the benefits and limitations
of breast self-exam (BSE). Which scientific rationale should the nurse remember
when performing a breast examination on a female client?
o A. One-half of all breast cancer deaths occurs in women ages 35 to 45.
o B. The tail of Spence area must be included in the self-examination.
o C. The position of choice for the breast examination is supine.
o D. A pad should be placed under the opposite scapula of the breast being
palpated.
Incorrect
Correct Answer: B. The tail of Spence area must be included in the self-
examination.
The tail of Spence, an extension of the upper outer quadrant of breast tissue, can
develop breast tumors. This area must also be included in breast self-
examination. As the fingers traverse the breasts, they must remain in contact with
the skin to avoid missing any tissue plane. Assessment of the inner half of the
breasts requires changing to a supine position, removing the hand from the
forehead, and placing the inactive arm at a right angle on the examination
surface.
 Option A: One-half of all women who die of breast cancer are older than
age 65. Breast cancer is the most prevalent malignancy among female
populations and is responsible for the second-highest number of cancer-
related deaths in American women. The need for early detection has
manifested several screening initiatives intent on curtailing morbidity and
mortality associated with the disease.
 Option C: The correct position for breast self-examination is not limited to
the supine position; the sitting position with hands at sides, above head,
and on the hips is also recommended. A visual survey of the breast tissue
requires an inspection from three angles, with arms at the side, arms raised
above the head while bending forward, and hunched over with the hands
placed on the hips. Each of these positions should be observed in a mirror
from a direct view, right profile, and left profile.

 Option D: A pad is placed under the ipsilateral (e.g., same side) scapula of
the breast being palpated. The middle fingertip pad should be used to
perform small circles with light, medium, and deep pressure investigating
varying depths of breast tissue. To complete the examination of the
breast‘s outer half, up and down motions of palpation are performed
medially from the axilla to the nipple and vertically from the clavicle to just
below the bra line.
ADVERTISEMENTS
36. Question
Mr. Lim, who has chronic pain, loss of self-esteem, no job, and bodily
disfigurement from severe burns over the trunk and arms, is admitted to a pain
center. Which evaluation criteria would indicate the client‘s successful
rehabilitation?
o A. The client remains free of the aftermath phase of the pain experience.
o B. The client experiences decreased frequency of acute pain episodes.
o C. The client continues normal growth and development with intact

support systems.
o D. The client develops increased tolerance for severe pain in the future.
Incorrect
Correct Answer: C. The client continues normal growth and development
with intact support systems.
Even though the client may experience an aftermath phase, progress is still
possible, as is effective rehabilitation. Give positive reinforcement of progress and
encourage endeavors toward the attainment of rehabilitation goals. Words of
encouragement can support the development of positive coping behaviors.
 Option A: Aftermath reactions may occur but need not interfere with
rehabilitation. Encourage family interaction with each other and with the
rehabilitation team. To open lines of communication and provide ongoing
support for the patient and family.
 Option B: Acute pain is not expected at this stage of recovery. Pain is
nearly always present to some degree because of varying severity of tissue

involvement and destruction but is usually most severe during dressing
changes and debridement.
 Option D: Conditioning probably would produce less pain tolerance.
Exercise is generally considered to be a safe and efficacious approach to
restoring physiological function in patients with various chronic diseases.
However, the inclusion of exercise regimens in the outpatient rehabilitation
of patients who have undergone major trauma, such as a large burn, is not
common.
ADVERTISEMENTS
37. Question
Christine Ann is about to take her NCLEX examination next week and is currently
reviewing the concept of pain. Which scientific rationale would indicate that she
understands the topic?
o A. Pain is an objective sign of a more serious problem.
o B. Pain sensation is affected by a client's anticipation of pain.
o C. Intractable pain may be relieved by treatment.
o D. Psychological factors rarely contribute to a client's pain perception.

Incorrect
Correct Answer: B. Pain sensation is affected by a client’s anticipation of
pain.
Phases of pain experience include the anticipation of pain. Fear and anxiety affect
a person‘s response to sensation and typically intensify the pain. Similarly, other
factors such as cognitive appraisal of the meaning of the sensation, the emotional
and psychophysiological reactions, expectations, and coping skills can all serve as
feedback to influence pain perception.
 Option A: Pain is a subjective sensation that cannot be quantified by
anyone except the person experiencing it. Pain refers to the product of
higher brain center processing; it entails the actual unpleasant emotional
and sensory experience generated from nervous signals. Reports of pain
are thus not merely a direct output of nociception, they involve interaction
with numerous inputs (attention, affective dimensions, autonomic variables,

immune variables, and more), and may be considered more accurately
from the perspective of a neuromatrix.
 Option C: Intractable pain is moderate to severe pain that cannot be
relieved by any known treatment. Intractable pain refers to a type of pain
that can‘t be controlled with standard medical care. Intractable essentially
means difficult to treat or manage. This type of pain isn‘t curable, so the
focus of treatment is to reduce the discomfort.
 Option D: Psychological factors contribute to a client‘s pain perception. In
many cases, pain results from emotions, such as hostility, guilt, or
depression. There are a number of psychological processes behind pain
perception. Attentional orienting to the painful sensation and its source
can serve to heighten the painful experience. For instance, patients with
somatic preoccupation and hypochondriasis are found to over-attend to
bodily sensations, amplifying them as pain.
ADVERTISEMENTS
38. Question
Miggy, a 6-year-old boy, received a small paper cut on his finger, his mother let
him wash it and apply a small amount of antibacterial ointment and bandage.
Then she let him watch TV and eat an apple. This is an example of which type of
pain intervention?
o A. Pharmacologic therapy
o B. Environmental alteration
o C. Control and distraction
o D. Cutaneous stimulation
Incorrect
Correct Answer: C. Control and distraction
The mother‘s actions are an example of control and distraction. Involving the
child in care and providing distraction took his mind off the pain. The brain can
only focus its attention in so many areas at one time. Pain sensations compete for
attention with all of the other things going on around. Just how much attention

the brain gives each thing depends on a number of factors, including how long
you have been hurting and the current mood.
 Option A: Pharmacologic agents for pain analgesics — were not used. A
wide range of drugs are used to manage pain resulting from inflammation
in response to tissue damage, chemical agents/pathogens (nociceptive
pain) or nerve damage (neuropathic pain).
 Option B: The home environment was not changed. There has recently
been heightened recognition that environmental factors can influence pain.
Clinicians involved in delivering multidisciplinary pain programs often
structure the social environment of their treatment settings to help
promote adaptive responses to pain.
 Option D: Cutaneous stimulation, such as massage, vibration, or pressure,
was not used. Cutaneous stimulation involves stimulation of nerves via skin
contact in an effort to reduce pain impulses to the brain, based on the
―gate control‖ theory of pain. A device used to provide electrocutaneous
nerve stimulation was studied for its effect on symptoms of peripheral
neuropathy.
ADVERTISEMENTS
39. Question
Which statement represents the best rationale for using noninvasive and non-
pharmacologic pain-control measures in conjunction with other measures?
o A. These measures are more effective than analgesics.
o B. These measures decrease input to large fibers.
o C. These measures potentiate the effects of analgesics.
o D. These measures block transmission of type C fiber impulses.

Incorrect
Correct Answer: C. These measures potentiate the effects of analgesics.
Noninvasive measures may result in the release of endogenous molecular
neuropeptides with analgesic properties. They potentiate the effect of analgesics.
The role of non-pharmacological approaches to pain management is evolving,
and some non-pharmacological and complementary therapies have an

increasingly important contribution to make to holistic patient care alongside
analgesics.
 Option A: No evidence indicates that noninvasive and nonpharmacologic
measures are more effective than analgesics in relieving pain. Exercise,
multidisciplinary rehabilitation, acupuncture, CBT, mindfulness practices,
massage, and mind-body practices most consistently improve function
and/or pain beyond the course of therapy for specific chronic pain
conditions.
 Option B: Decreased input over large fibers allows more pain impulses to
reach the central nervous system. When deciding the most effective non-
pharmacological technique, take into consideration the patient‘s age,
developmental level, medical history and prior experiences, the current
degree of pain, and/or anticipated pain. The advantage of non-
pharmacological treatments is that they are relatively inexpensive and safe.
 Option D: There is no connection between type C fiber impulses and
noninvasive and nonpharmacologic pain-control measures. Non-
pharmacological pain therapy refers to interventions that do not involve
the use of medications to treat pain. The goals of non-pharmacological
interventions are to decrease fear, distress, and anxiety, and reduce pain
and provide patients with a sense of control.
ADVERTISEMENTS
40. Question
When evaluating a client‘s adaptation to pain, which behavior indicates
appropriate adaptation?
o A. The client distracts himself during pain episodes.
o B. The client denies the existence of any pain.
o C. The client reports no need for family support.
o D. The client reports pain reduction with decreased activity.

Incorrect
Correct Answer: A. The client distracts himself during pain episodes.

Distraction is an appropriate method of reducing pain. This technique involves
heightening one‘s concentration upon non-painful stimuli to decrease one‘s
awareness and experience of pain. Drawing the person away from the pain
lessens the perception of pain. Examples include reading, watching TV, playing
video games, and guided imagery.
 Option B: Denying the existence of any pain is inappropriate and not
indicative of coping. It is essential to assist patients to express as factually
as possible (i.e., without the effect of mood, emotion, or anxiety) the effect
of pain relief measures. Inconsistencies between behavior or appearance
and what the patient says about pain relief (or lack of it) may be more a
reflection of other methods the patient is using to cope with the pain
rather than pain relief itself.
 Option C: Exclusion of family members and other sources of support
represents a maladaptive response. Nurses have the duty to ask their
clients about their pain and believe their reports of pain. Challenging or
undermining their pain reports results in an unhealthy therapeutic
relationship that may hinder pain management and deteriorate rapport.
 Option D: Range-of-motion exercises and at least mild activity, not a
decreased activity, can help reduce pain and are important to prevent
complications of immobility. Nonpharmacologic methods in pain
management may include physical, cognitive-behavioral strategies, and
lifestyle pain management. These methods are used to provide comfort by
altering psychological responses to pain.
ADVERTISEMENTS
41. Question
In planning pain reduction interventions, which pain theory provides
information most useful to nurses?
o A. Specificity theory
o B. Pattern theory
o C. Gate-control theory
o D. Central-control theory

Incorrect
Correct Answer: D. Central-control theory
No one theory explains all the factors underlying the pain experience, but the
central-control theory discusses brain opiates with analgesic properties and how
their release can be affected by actions initiated by the client and caregivers. In
central-control theory, the master control mechanism directs the muscle
movement based on linguistic goals. The gate-control, specificity, and patter
theories do not address pain control to the depth included in the central-control
theory.
 Option A: Specificity theory is one of the first modern theories for pain. It
holds that specific pain receptors transmit signals to a ―pain center‖ in the
brain that produces the perception of pain. Von Frey (1895) argued that
the body has a separate sensory system for perceiving pain—just as it does
for hearing and vision.
 Option B: This theory ignored findings of specialized nerve endings and
many of the observations supporting the specificity and/or intensive
theories of pain. The theory stated that any somesthetic sensation occurred
by a specific and particular pattern of neural firing and that the spatial and
temporal profile of firing of the peripheral nerves encoded the stimulus
type and intensity.
 Option C: According to his theory, pain stimulation is carried by small, slow
fibers that enter the dorsal horn of the spinal cord; then other cells transmit
the impulses from the spinal cord up to the brain. These fibers are called T-
cells. The T-cells can be located in a specific area of the spinal cord, known
as the substantia gelatinosa. These fibers can have an impact on the
smaller fibers that carry the pain stimulation.
ADVERTISEMENTS
42. Question
Ryan underwent an open reduction and internal fixation of the left hip. One day
after the operation, the client is complaining of pain. Which data would cause the
nurse to refrain from administering the pain medication and to notify the health
care provider instead?
o A. Left hip dressing dry and intact.

o B. Blood pressure of 114/78 mm Hg; pulse rate of 82 beats per minute.
o C. Left leg in functional anatomic position.
o D. Left foot cold to touch; no palpable pedal pulse.

Incorrect
Correct Answer: D. Left foot cold to touch; no palpable pedal pulse.
A left foot cold to touch without palpable pedal pulse represents an abnormal
finding on neurovascular assessment of the left leg. The client is most likely
experiencing some complication from surgery, which requires immediate medical
intervention. The nurse should notify the health care provider of these findings.
 Option A: A dry and intact hip dressing is a normal assessment of findings
that do not require medical intervention. A dressing is considered INTACT
if portions of the white dressing border have lifted from the skin as long as
the clear viewing window maintains full contact with the skin. The skin
under the viewing window does not appear visibly soiled with exudate or
blood. The skin under the viewing window does not appear dampened or
moist with sweat, exudate, fluid, or blood.
 Option B: A blood pressure of 114/78 mm Hg and pulse rate of 82 beats
per minute are normal assessment findings that do not require medical
intervention. The normal range used in an adult is between 60 to 100 beats
/minute with rates above 100 beats/minute and rates and below 60 beats
per minute, referred to as tachycardia and bradycardia, respectively. The
respiratory rate is the number of breaths per minute. The normal breathing
rate is about 12 to 20 beats per minute in an average adult.
 Option C: A left foot in functional anatomic position are all normal
assessment findings that do not require medical intervention. It functions
as a rigid structure for weight-bearing and it can also function as a flexible
structure to conform to uneven terrain.
ADVERTISEMENTS
43. Question
Which term would the nurse use to document pain at one site that is perceived in
another site?

o A. Referred pain
o B. Phantom pain
o C. Intractable pain
o D. Aftermath of pain
Incorrect
Correct Answer: A. Referred pain
Referred pain is pain occurring at one site that is perceived in another site.
Referred pain follows dermatome and nerve root patterns. Referred pain is pain
perceived at a location other than the site of the painful stimulus/ origin. It is the
result of a network of interconnecting sensory nerves that supply many different
tissues. When there is an injury at one site in the network it is possible that when
the signal is interpreted in the brain signals are experienced in the surrounding
nervous tissue.
 Option B: Phantom pain refers to pain in a part of the body that is no
longer there, such as in amputation. Phantom pain is pain that feels like it‘s
coming from a body part that‘s no longer there. Doctors once believed this
post-amputation phenomenon was a psychological problem, but experts
now recognize that these real sensations originate in the spinal cord and
brain.
 Option C: Intractable pain refers to moderate to severe pain that cannot
be relieved by any known treatment. Intractable pain refers to a type of
pain that can‘t be controlled with standard medical care. Intractable
essentially means difficult to treat or manage. This type of pain isn‘t
curable, so the focus of treatment is to reduce the discomfort.
 Option D: Aftermath of pain, a phase of the pain experience and the most
neglected phase address the client‘s response to the pain experience. The
complexity of pain physiology makes some pains more difficult to manage
than others. Acute postoperative pain normally responds well to analgesia,
but this should be complemented by strategies such as comfortable
positioning, distraction, TENS, and reassurance.
ADVERTISEMENTS
1. 44. Question

Chuck, who is in the hospital, complains of abdominal pain that ranks 9 on a scale
of 1 (no pain) to 10 (worst pain). Which interventions should the nurse
implement? Select all that apply.
o A. Assessing the client's bowel sounds.
o B. Taking the client's blood pressure and apical pulse.
o C. Obtaining a pulse oximeter reading.
o D. Notifying the health care provider.
o E. Determining the last time the client received pain medication.
o F. Encouraging the client to turn, cough, and deep breathe.

Incorrect
Correct Answers: A, B, & E
The nurse must rule out complications prior to administering pain medication, so
her interventions would include assessing to make sure the client has bowel
sounds and determining if the client is hemorrhaging by checking the client‘s
blood pressure and pulse. The nurse must also make sure the pain medication is
due according to the health care provider‘s orders. Obtaining a pulse oximeter
reading and turning, coughing, and deep breathing will not help the client‘s pain.
 Option A: Additionally, the nurse should ask the following questions
during pain assessment to determine its history: (1) effectiveness of
previous pain treatment or management; (2) what medications were taken
and when; (3) other medications being taken; (4) allergies or known side
effects to medications.
 Option B: Pain should be screened every time vital signs are evaluated.
Many health facilities set pain assessment as the ―fifth vital sign‖ and
should be added to during routine vital signs assessment.
 Option C: Investigate signs and symptoms related to pain. Bringing
attention to associated signs and symptoms may help the nurse in
evaluating the pain. In some instances, the existence of pain is disregarded
by the patient.
 Option D: There is no need to notify the health care provider in this
situation. Some patients may be satisfied when pain is no longer intense;
others will demand complete elimination of pain. This influences the

perceptions of the effectiveness of the treatment modality and their
eagerness to engage in further treatments.
 Option E: Some patients may be hesitant to try the effectiveness of
nonpharmacological methods and may be willing to try traditional
pharmacological methods (i.e., use of analgesics). A combination of both
therapies may be more effective and the nurse has the duty to inform the
patient of the different methods to manage pain.
 Option F: Stress correlates to an increase in pain perception by increasing
muscle tension and activating the SNS. Eliciting a relaxation response
decreases the effects of stress on pain. Examples include directed
meditation, music therapy, deep breathing.
ADVERTISEMENTS
45. Question
Albert, who suffered severe burns 6 months ago, is expressing concern about the
possible loss of job-performance abilities and physical disfigurement. Which
intervention is the most appropriate for him?
o A. Referring the client for counseling and occupational therapy.
o B. Staying with the client as much as possible and building trust.
o C. Providing cutaneous stimulation and pharmacologic therapy.
o D. Providing distraction and guided imagery techniques.

Incorrect
Correct Answer: A. Referring the client for counseling and occupational
therapy
Because it has been 6 months, the client needs professional help to get on with
life and handle the limitations imposed by the current problems. Staying with the
client, building trust, and providing methods of pain relief, such as cutaneous
stimulation, medications, distraction, and guided imagery interventions, would
have been more appropriate in earlier stages of postburn injury when physical
pain was most severe and fewer psychological factors needed to be addressed.
 Option B: Explain to the patient what happened. Provide opportunities for
questions and give honest answers. Compassionate statements reflecting

the reality of the situation can help the patient and SO acknowledge that
reality and begin to deal with what has happened.
 Option C: The burned patient may require around-the-clock medication
and dose titration. IV method is often used initially to maximize drug effect.
Concerns of patient addiction or doubts regarding the degree of pain
experienced are not valid during the emergent/acute phase of care, but
narcotics should be decreased as soon as feasible and alternative methods
for pain relief initiated.
 Option D: Encourage use of stress management techniques: progressive
relaxation, deep breathing, guided imagery, and visualization. Refocuses
attention, promotes relaxation, and enhances the sense of control, which
may reduce pharmacological dependency.
ADVERTISEMENTS
46. Question
Mrs. Bagapayo who had abdominal surgery 3 days earlier complains of sharp,
throbbing abdominal pain that ranks 8 on a scale of 1 (no pain) to 10 (worst
pain). Which intervention should the nurse implement first?
o A. Assessing the client to rule out possible complications secondary to

surgery.
o B. Checking the client's chart to determine when pain medication was last
administered.
o C. Explaining to the client that the pain should not be this severe 3 days
postoperatively.
o D. Obtaining an order for a stronger pain medication because the client's

pain has increased.
Incorrect
Correct Answer: A. Assessing the client to rule out possible complications
secondary to surgery.
The nurse‘s immediate action should be to assess the client in an attempt to
exclude possible complications that may be causing the client‘s complaints. The
health care provider ordered the pain medication for routine postoperative pain

that is expected after abdominal surgery, not for such complications as
hemorrhage, infection, or dehiscence. The nurse should never administer pain
medication without assessing the client first.
 Option B: Checking the client‘s chart is appropriate after the nurse
determines that the client is not experiencing complications from surgery.
It is essential to assist patients to express as factually as possible (i.e.,
without the effect of mood, emotion, or anxiety) the effect of pain relief
measures. Inconsistencies between behavior or appearance and what the
patient says about pain relief (or lack of it) may be more a reflection of
other methods the patient is using to cope with the pain rather than pain
relief itself.
 Option C: Pain is subjective, and each person has his own level of pain
tolerance. The nurse must always believe the client‘s complaint of pain.
Nurses have the duty to ask their clients about their pain and believe their
reports of pain. Challenging or undermining their pain reports results in an
unhealthy therapeutic relationship that may hinder pain management and
deteriorate rapport.
 Option D: Obtaining an order for a strong medication may be appropriate
after the nurse assesses the client and checks the chart to see whether the
current analgesic is infective. The World Health Organization (WHO) in
1986 published guidelines in the logical usage of analgesics to treat cancer
using a three-step ladder approach – also known as the analgesic ladder.
The analgesic ladder focuses on aligning the proper analgesics with the
intensity of pain.
ADVERTISEMENTS
47. Question
Which term refers to the pain that has a slower onset, is diffuse, radiates, and is
marked by somatic pain from organs in any body activity?
o A. Acute pain
o B. Chronic pain
o C. Superficial pain

o D. Deep pain
Incorrect
Correct Answer: D. Deep pain
Deep pain has a slow onset, is diffuse, and radiates, and is marked by somatic
pain from organs in any body activity. Deep somatic pain originates from
structures deeper within the body, such as the joints, bones, tendons, and
muscles. Like visceral pain, deep somatic pain is usually dull and aching. Deep
somatic pain can either be experienced locally or more generally depending on
the degree of trauma.
 Option A: Acute pain is rapid in onset, usually temporary (less than 6
months), and subsides spontaneously. Acute pain is a type of pain that
typically lasts less than 3 to 6 months or pain that is directly related to soft
tissue damage such as a sprained ankle or a paper cut. Acute pain is of
short duration but it gradually resolves as the injured tissues heal.
 Option B: Chronic pain is marked by gradual onset and lengthy duration
(more than 6 months). Chronic pain is pain that is ongoing and usually lasts
longer than six months. This type of pain can continue even after the injury
or illness that caused it has healed or gone away. Pain signals remain active
in the nervous system for weeks, months, or years.
 Option C: Superficial pain has an abrupt onset with sharp, stinging quality.
Superficial pain arises from nociceptive receptors in the skin and mucous
membranes. Superficial somatic pain is the type of pain that happens with
common everyday injuries and is characterized as pricking, sharp, burning,
or throbbing pain.
ADVERTISEMENTS
48. Question
A 50-year-old widower has arthritis and remains in bed too long because it hurts
to get started. Which intervention should the nurse plan?
o A. Telling the client to strictly limit the amount of movement of his inflamed
joints.
o B. Teaching the client's family how to transfer the client into a wheelchair.

o C. Teaching the client the proper method for massaging inflamed, sore joints.
o D. Encouraging gentle range-of-motion exercises after administering

aspirin and before rising.
Incorrect
Correct Answer: D. Encouraging gentle range-of-motion exercises after
administering aspirin and before rising.
Aspirin raises the pain threshold and, although range-of-motion exercises hurt,
mild exercise can relieve pain on rising. A tailored program that includes a
balance of three types of exercises — range-of-motion, strengthening, and
endurance — can relieve the symptoms of arthritis and protect joints from further
damage.
 Option A: Strict limitation of motion only increases the client‘s pain. The
stiffness, pain, and swelling associated with arthritis can severely reduce the
range of motion of joints (the distance joints can move in certain
directions). Avoiding physical activity because of pain or discomfort also
can lead to significant muscle loss and excessive weight pain.
 Option B: Having others transfer the client into a wheelchair does not
increase his feelings of dependency. Range-of-motion exercises (also called
stretching or flexibility exercises) help maintain normal joint function by
increasing and preserving joint mobility and flexibility.
 Option C: Massage increases inflammation and should be avoided with
this client. During the course of a range-of-motion exercise program, the
joints are stretched progressively farther until the normal or near-normal
range is achieved and maintained.
ADVERTISEMENTS
49. Question
Which intervention should the nurse include as a nonpharmacologic pain-relief
intervention for chronic pain?
o A. Referring the client for hypnosis.
o B. Administering pain medication as prescribed.
o C. Removing all glaring lights and excessive noise.

o D. Using transcutaneous electric nerve stimulation.
Incorrect
Correct Answer: D. Using transcutaneous electric nerve stimulation.
Nonpharmacologic pain relief interventions include cutaneous stimulation, back
rubs, biofeedback, acupuncture, transcutaneous electric nerve stimulation, and
more. Transcutaneous electrical nerve stimulation (TENS) is a therapy that uses
low voltage electrical current to provide pain relief. A TENS unit consists of a
battery-powered device that delivers electrical impulses through electrodes
placed on the surface of your skin. The electrodes are placed at or near nerves
where the pain is located or at trigger points.
 Option A: Hypnosis is considered an alternative therapy. Hypnosis is a set
of techniques designed to enhance concentration, minimize one‘s usual
distractions, and heighten responsiveness to suggestions to alter one‘s
thoughts, feelings, behavior, or physiological state.
 Option B: Medications are pharmacologic measures. A wide range of
drugs are used to manage pain resulting from inflammation in response to
tissue damage, chemical agents/pathogens (nociceptive pain), or nerve
damage (neuropathic pain).
 Option C: Although removing glaring lights and excessive noise help to
reduce or remove noxious stimuli, it is not specific to pain relief. A noxious
stimulus is actually, or potentially, damaging to tissue and liable to cause
pain, but does not invariably do so. Some noxious stimuli, particularly in
the viscera, do not cause nociceptive responses.
ADVERTISEMENTS
50. Question
A 12-year-old student falls off the stairs, grabs his wrist, and cries, ―Oh, my wrist!
Help! The pain is so sharp, I think I broke it.‖ Based on this data, the pain the
student is experiencing is caused by impulses traveling from receptors to the
spinal cord along which type of nerve fibers?
o A. Type A-delta fibers
o B. Autonomic nerve fibers

o C. Type C fibers
o D. Somatic efferent fibers

Incorrect
Correct Answer: A. Type A-delta fibers
Type A-delta fibers conduct impulses at a very rapid rate and are responsible for
transmitting acute sharp pain signals from the peripheral nerves to the spinal
cord. Only type A-delta fibers transmit sharp, piercing pain. They respond to
stimuli such as cold and pressure, and as nociceptors stimulation of them is
interpreted as fast/first pain information.
 Option B: The autonomic system regulates involuntary vital functions and
organ control such as breathing. An autonomic nerve pathway involves two
nerve cells. One cell is located in the brainstem or spinal cord. It is
connected by nerve fibers to the other cell, which is located in a cluster of
nerve cells (called an autonomic ganglion). Nerve fibers from these ganglia
connect with internal organs.
 Option C: Type C fibers transmit sensory input at a much slower rate and
produce a slow, chronic type of pain. The C group fibers are unmyelinated
and have a small diameter and low conduction velocity, whereas Groups A
and B are myelinated. Group C fibers include postganglionic fibers in the
autonomic nervous system (ANS), and nerve fibers at the dorsal roots (IV
fiber). These fibers carry sensory information.
 Option D: Somatic efferent fibers affect the voluntary movement of
skeletal muscles and joints. General somatic efferent fibers carry motor
impulses to somatic skeletal muscles. In the head, the tongue and
extraocular muscles are of this type. Cranial nerves III, IV, VI, and XII carry
these fibers.
ADVERTISEMENTS
51. Question
Which nursing intervention takes the highest priority when caring for a newly
admitted client who‘s receiving a blood transfusion?
o A. Warming the blood prior to transfusion.

o B. Informing the client that the transfusion usually takes 4 to 6 hours.
o C. Documenting blood administration in the client chart.
o D. Instructing the client to report any itching, chest pain, or dyspnea.

Incorrect
Correct Answer: D. Instructing the client to report any itching, headache, or
dyspnea.
This will help the nurse take immediate action in case a reaction happens during
a transfusion. There are multiple complications of blood transfusions, including
infections, hemolytic reactions, allergic reactions, transfusion-related lung injury
(TRALI), transfusion-associated circulatory overload, and electrolyte imbalance.
 Option A: There is no evidence that warming blood is beneficial to the
patient when transfusion is slow. At transfusion rates of greater than 100
mL/minute, cold blood may be a contributing factor in cardiac arrest.
However, keeping the patient warm is probably more important than
warming the blood.
 Option B: Transfusion of a unit of blood should be completed within a
maximum period of four hours after removal from the blood fridge: discard
the unit if this period is exceeded. If blood has been out of the blood bank
refrigerator for more than 30 minutes and is not transfused, then the unit
must be returned to the laboratory, where it will be disposed of.
 Option C: Documentation related to transfusion therapy should include
verification of the prescribed blood product and blood product
compatibility; verification of appropriate clinical indication for the
transfusion; the date and time of transfusion, type of blood product
administered, in addition to the volume, infusion rate, and time of initiation
and completion of transfusion; any medication administered, including
premedication (if I.V. drugs are required during transfusion, another I.V. site
is required); the patient‘s clinical status throughout the transfusion therapy,
including patient assessment data such as vital signs and lung sounds; the
patient‘s response to therapy including any complications or adverse
reactions, treatment required, and response to that treatment; and the
amount of blood transfused and the return of the unused portion to the
blood bank.
ADVERTISEMENTS

52. Question
Nurse Paulo has received a blood unit from the blood bank and has rechecked
the blood bag properly with nurse Edward. Prior to the facilitation of the blood
transfusion, nurse Paulo priority checks which of the following?
o A. Intake and output
o B. NPO standing order
o C. Vital signs
o D. Skin turgor
Incorrect
Correct Answer: C. Vital signs
The nurse must assess the vital signs before and 15 minutes after the procedure
so that any changes during the transfusion may indicate a transfusion reaction is
happening. The nurse remains with the client, observing signs and symptoms and
monitoring vital signs as often as every 5 minutes.
 Option A: Monitoring the intake and output during blood transfusion may
be done, but not as often as necessary. Monitoring of intake helps the
caregiver to ensure that the patient has a proper intake of fluid and other
nutrients. Monitoring of output helps determine whether there is an
adequate output of urine as well as normal defecation.
 Option B: A patient on blood transfusion is not placed in an NPO standing
order. Current nil per os (NPO) standards promote pre-operative fasting as
an approach to reduce the volume and acidity of a patient‘s stomach
contents to reduce the risks of regurgitation and subsequent pulmonary
aspiration. Pre-anesthesia fasting standards apply to any procedure where
sedative medications reduce the protective airway reflex that under normal
conditions prevent aspiration.
 Option D: Physical findings suggestive of volume depletion include dry
mucous membranes, decreased skin turgor, and low jugular venous
distention. While the incidence of hypovolemic shock from extracellular
fluid loss is difficult to quantify, it is known that hemorrhagic shock is most
commonly due to trauma. In one study, 62.2% of massive transfusions at a
level 1 trauma center were due to traumatic injury.
ADVERTISEMENTS

53. Question
A client is brought to the emergency department having experienced blood loss
due to a deep puncture wound. A 3 unit Fresh-frozen plasma (FFP) is ordered.
The nurse determines that the reason behind this order is to:
o A. Provide clotting factors and volume expansion.
o B. Increase hemoglobin, hematocrit, and neutrophil levels.
o C. Treat platelet dysfunction.
o D. Treat thrombocytopenia.
Incorrect
Correct Answer: A. Provide clotting factors and volume expansion.
Fresh-frozen plasma may be used to provide clotting factors or volume
expansion. It is rich in clotting factors and can be thawed quickly and transfused
right away. Fresh frozen plasma is the fluid portion of a unit of whole blood
frozen in a designated time frame, usually within 8 hours. FFP contains all
coagulation factors except platelets.
 Option B: Increasing hemoglobin, hematocrit, and neutrophil levels is not
an indication for FFP. FFP corrects coagulopathy by replacing or supplying
plasma proteins in patients who are deficient in or have defective plasma
proteins. A standard dose of 10 to 20 mL/kg (4 to 6 units in adults) will
raise factor levels by approximately 20%.
 Option C: FFP does not contain platelets. Other situations where the
administration of FFP cannot be recommended for or against based on
systematic review include FFP transfusion at a plasma-to-RBC ratio of 1:3 or
more in trauma patients with massive transfusion. Conditions that cause
the deficiency of multiple coagulation factors and may require the
administration of FFP include liver disease and disseminated intravascular
coagulation.
 Option D: Treating thrombocytopenia is incorrect since FFP does not
contain any platelet. FFP contains fibrinogen (400 to 900 mg/unit), albumin,
protein C, protein S, antithrombin, tissue factor pathway inhibitor. It is free
of erythrocytes and leukocytes. FFP provides some volume resuscitation, as
each unit contains approximately 250 ml.

ADVERTISEMENTS
54. Question
Nurse Amanda is caring for a client with severe blood loss who is prescribed
multiple transfusions of blood. Nurse Amanda obtains which most essential piece
of equipment to prevent the risk of cardiac dysrhythmias?
o A. Cardiac monitor
o B. Blood warmer
o C. ECG machine
o D. Infusion pump
Incorrect
Correct Answer: B. Blood warmer
Rapid transfusion of cool blood puts the client at risk for cardiac dysrhythmias.
Modern methods of very rapid transfusion in resuscitation would cause clinically
dangerous hypothermia if unmodified, ice-cold blood were to be so transfused.
These needs must be reconciled in the interest of adequate patient care–hence
the need for blood warming. Countercurrent in-line blood warmers and the
method of rapid warm saline admixture can both be used successfully for rapid,
massive transfusions.
 Option A: Cardiac monitor is used to assess for any blood transfusion-
related complication, but they do not prevent the occurrence of cardiac
dysrhythmia. During the blood transfusion process, patients‘ vital signs
(heart rate, blood pressure, temperature, and respiration rate) should be
monitored throughout the procedure and recorded. Follow the
organization‘s policy on how often the vital signs should be measured.
 Option C: ECG machine is used to assess for any blood transfusion-related
complication, but they do not prevent the occurrence of cardiac
dysrhythmia. Many severe reactions occur within the first 30 minutes of
commencing a transfusion of a blood component unit (SHOT 2008). Close
observation during this period is essential.
 Option D: Infusion pump is not beneficial in this case since the infusion
must be given rapidly. SHOT 2008 recommends that patients be observed

during the subsequent 24 hours because, on occasion, transfusion
reactions can occur many hours after transfusion is completed.
ADVERTISEMENTS
55. Question
A client is receiving a first-time blood transfusion of packed RBC. How long
should the nurse stay and monitor the client to ensure a transfusion reaction will
not happen?
o A. 15 minutes
o B. 30 minutes
o C. 45 minutes
o D. 60 minutes
Incorrect
Correct Answer: A. 15 minutes
Usually, a transfusion reaction occurs within 15 minutes of a transfusion. For each
unit of blood transfused, monitor the patient before starting the transfusion
(baseline observation; 15 minutes after starting the transfusion; at least every
hour during transfusion; and carry out a final set of observations 15 minutes after
each unit has been transfused.
 Option B: Staying with the patient for 30 minutes might be too long. Acute
reactions may occur in 1% to 2% of transfused patients. Rapid recognition
and management of the reaction may save the patient‘s life. Once
immediate action has been taken, careful and repeated clinical assessment
is essential to identify and treat the patient‘s problems.
 Option C: 45 minutes of staying and monitoring the patient for transfusion
reactions is too long. All suspected acute transfusion reactions should be
reported immediately to the blood transfusion center and to the doctor
responsible for the patient. With the exception of urticarial allergic
reactions and febrile non-hemolytic reactions, all are potentially fatal and
require urgent treatment.
 Option D: Most transfusion reactions occur during the first 15 minutes of
transfusion. 60 minutes is too long. However, transfusion-transmitted

infections are the serious delayed complications of transfusion. Since a
delayed transfusion reaction may occur days, weeks, or months after the
transfusion, the association with the transfusion may not be recognized.
ADVERTISEMENTS
56. Question
Nurse Rick is administering 2 unit-packed RBCs on a client with low hemoglobin.
The nurse will prepare which of the following in order to transfuse the blood?
o A. Microfusion set
o B. Polyvol Pro Burette Set
o C. Photofusion set
o D. Tubing with an in-line filter

Incorrect
Correct Answer: D. Tubing with an in-line filter
The in-line filter helps ensure that any particles larger than the size of the filter
are caught in the filter and are not infused with the client. Use a new, sterile
blood administration set containing an integral 170?200µ filter. Change the set to
at least 12?hourly during a blood transfusion. In a very warm climate, change the
set more frequently and usually after every four units of blood, if given within a
12?hour period.
 Option A: Microinfusion set is incorrect since the tubing that should be
used is a macro drip. Use a fresh blood administration set or special
platelet transfusion set, primed with saline. All blood components can be
slowly infused through small?bore cannulas or butterfly needles, e.g. 21 to
25 G. For rapid infusion, large?bore cannulas, e.g. 14 G, are needed.
 Option B: Polyvol Pro Burette set is used for administration of IV
medication infusion. The Polymed Polyvol Pro Latex Free Burette Set is a
transparent, soft, cylindrical, and calibrated measured volume chamber
with a bold marking scale. It has a micro dropper of 60 drops per ml. The
burette set comes with a 15 ?m fluid filter to reduce particulate matter.

 Option C: Photofusion set is incorrect since blood does not need any
protection from light. It protects light-sensitive drugs from UV exposure &
its harmful effects. It has a 15-micron fluid filter in the drip chamber
ADVERTISEMENTS
57. Question
To verify the age of blood cells in blood, the nurse will check which of the
following?
o A. Blood type
o B. Blood group
o C. Blood identification number
o D. Blood expiration date

Incorrect
Correct Answer: D. Blood expiration date
The safe storage of blood usually takes 35 days. Examining the expiration date is
an important responsibility of a nurse prior to hanging the blood. Once issued by
the blood centre, the transfusion of whole blood, red cells, platelet concentrate
and thawed fresh frozen plasma should be commenced within 30 minutes of
removal from the optimal storage conditions.
 Option A: A 5 mL blood sample should be collected into a dry test tube
and then correctly and clearly labeled with the patient‘s details, and
submitted to the blood center for testing. The taking of a blood sample
from the patient needs supervision. If the patient is conscious at the time
of taking the sample, ask him/her to identify himself/herself by given name
and all other appropriate information.
 Option B: When taking a blood sample for cross match, complete the
whole procedure before any other task is undertaken – it is important that
there are no interruptions during the process. When correctly performed,
compatibility tests will confirm ABO compatibility between component and
recipient and will detect the most clinically significant unexpected
antibodies.

 Option C: Always take a completed patient documentation label to the
issue room of the blood transfusion department when collecting the first
unit of blood. Match the details on the blood request form against the
blood compatibility label (tag), the bag unit number, and the patient
documentation label. When receiving the unit of blood in the clinical area,
check that it is the right unit for the right patient.
ADVERTISEMENTS
58. Question
A client has an order to receive one unit of packed RBCs. The nurse makes sure
which of the following intravenous solutions to hang with the blood product at
the client‘s bedside?
o A. 0.9% sodium chloride.
o B. 5% dextrose in 0.9% sodium chloride.
o C. Balanced Multiple Maintenance Solution with 5% Dextrose.
o D. 5% dextrose in 0.45% sodium chloride.

Incorrect
Correct Answer: A. 0.9% sodium chloride.
0.9% sodium chloride is a standard solution used to follow infusion of blood
products. Of the various intravenous solutions, only isotonic saline (0.9%) is
recommended for use with blood components. Other commonly used
intravenous solutions will cause varying degrees of difficulty when mixed with red
cells.
 Option B: 5% dextrose in water will hemolyze red cells. Intravenous
solutions containing calcium, such as Lactated Ringer‘s solution, can cause
clots to form in the blood. Prior to blood transfusion, completely flush
incompatible intravenous solutions and drugs from the blood
administration set with isotonic saline.
 Option C: Normal saline is the only compatible solution to use with the
blood or blood component. Crystalloid solutions and medications may
cause agglutination and/or hemolysis of the blood or blood components.

 Option D: IV solution containing dextrose in water will hemolyze red cells.
Only isotonic, calcium-free IV solutions should be added to, or come in
contact with blood products. Calcium may bind with the citrate
anticoagulant and promote clotting in the tubing. Excess glucose and/or
dextrose causes hemolysis and shortens red cell survival. Studies have
shown other IV solutions to be compatible with citrated blood
components. However, these solutions should only be considered
compatible in situations where the use of 0.9% NaCl would lead to
undesirable metabolic abnormalities.
ADVERTISEMENTS
59. Question

Incorrect
culture.

ADVERTISEMENTS
60. Question
After terminating the transfusion during a reaction, which action should the
nurse immediately be taken next?
o A. Run a solution of 5% dextrose in water.
o B. Run normal saline at a keep-vein-open rate.
o C. Remove the IV line.
o D. Fast drip 200ml normal saline.

Incorrect
Correct Answer: B. Run normal saline at a keep-vein-open rate.
The nurse will infuse normal saline at a KVO rate to keep the patency of the IV
line while waiting for further orders from the physician. A transfusion reaction
evaluation request form typically is used to document signs and symptoms of a
suspected reaction so that the blood bank can use this information, in
conjunction with laboratory testing, to arrive at a likely diagnosis. The blood bag,
along with the infusion set and anything else attached to the set, should be sent
with the transfusion reaction evaluation request.
 Option A: IV solution containing dextrose will hemolyze the red cells. IV
solution containing dextrose in water will hemolyze red cells.Only isotonic,
calcium-free IV solutions should be added to, or come in contact with

blood products. Calcium may bind with the citrate anticoagulant and
promote clotting in the tubing. Excess glucose and/or dextrose causes
hemolysis and shortens red cell survival.
 Option C: The nurse will not remove the IV line because then there would
be no IV access route. Transfusion reaction treatment varies with the
reaction. Diphenhydramine and acetaminophen are some of the most
commonly used drugs for treating mild allergic and febrile nonhemolytic
reactions. For other reactions, expert consultation should be considered. In
cases of acute hemolytic reaction, baseline laboratory tests should be
performed and urine should be kept flowing, possibly with alkalinization.
 Option D: Doing a fast drip will potentially lead to congestion and is not
done without the physician‘s order. Volume overload may require diuretics.
TRALI is treated with oxygen and supportive care, which may involve
intubation. Bacterial contamination may involve blood pressure support
and antibiotics. Because anaphylaxis is treated emergently according to
hospital protocol, usually with epinephrine and diphenhydramine, there
may not be time for consultation until after the patient is stabilized.
ADVERTISEMENTS
61. Question
A client is receiving a platelet transfusion. The nurse determines that the client is
gaining from this therapy if the client exhibits which of the following?
o A. Less frequent febrile episodes.
o B. Increased level of hematocrit.
o C. Less episodes of bleeding.
o D. Increased level of hemoglobin.

Incorrect
Correct Answer: C. Less episodes of bleeding.
Platelet transfusions may be given to prevent bleeding when the platelet count
falls down. In a study of bleeding risks in thrombocytopenic patients, Webert et
al. noted that the majority of severe bleeds were preceded by bleeds of lesser
severity. Even patients with petechiae (WHO grade 1 bleeding) were 2.5 times

more likely to experience clinically significant bleeding on the next day; patients
experiencing WHO grade 1 or 2 bleeding were three times more likely to have a
severe bleed the next day.
 Option A: A decline in the febrile episode will happen after the transfusion
of agranulocytes. Transfusions of granulocytes have a long history of usage
in clinical practice to support and treat severe infection in high?risk groups
of patients with neutropenia or neutrophil dysfunction.
 Option B: An increased level of hematocrit occurs after infusion of red
blood cells. Blood transfusion is used to treat acute anemia with the goal of
increasing blood oxygen-carrying capacity as determined by hematocrit
(Hct), and oxygen delivery (DO2).
 Option D: An increased level of hemoglobin will happen after the
transfusion of red blood cells. The transfusion of red cell concentrates
(RCC) is indicated in order to achieve a fast increase in the supply of
oxygen to the tissues, when the concentration of hemoglobin (Hb) is low
and/or the oxygen-carrying capacity is reduced, in the presence of
inadequate physiological mechanisms of compensation.
ADVERTISEMENTS
62. Question
Nurse Daniel is caring for a client receiving a transfusion of packed red blood
cells (PRBCs). The client started to vomit and to be nauseous. Client‘s blood
pressure is 95/40 mm Hg from a baseline of 110/70 mm Hg. The client‘s
temperature is 100.5°F orally from a baseline of 99.5°F orally. The nurse
understands that the client may be experiencing which of the following?
o A. Circulatory overload
o B. Delayed transfusion reaction
o C. Hypocalcemia
o D. Septicemia
Incorrect
Correct Answer: D. Septicemia

Septicemia happens with the transfusion of blood that is contaminated with
microorganisms. Assessment includes the rapid onset of high fever and chills,
hypotension, nausea, diarrhea, vomiting, and shock. Fever and/or chills are most
commonly associated with a febrile, non-hemolytic reaction, however; they can
also be the first sign of a more serious acute hemolytic reaction, TRALI, or septic
transfusion reaction. If the temperature rises 1 C or higher from the temperature
at the start of the transfusion, the transfusion should be stopped.
 Option A: Circulatory overload causes hypertension, cough, dyspnea, chest
pain, tachycardia, and wheezing upon auscultation. Dyspnea, or shortness
of breath, is a concerning sign that can often be seen with more severe
reactions including anaphylaxis, TRALI, and TACO. It can also be seen by
itself without accompanying symptoms.
 Option B: Delayed reaction can occur days to years after a transfusion. It
causes fever, rashes, mild jaundice, and oliguria or anuria. Typically caused
by an anamnestic response to a foreign antigen that the patient was
previously exposed to (generally by prior transfusion or pregnancy).
 Option C: Hypocalcemia causes paresthesias, tetany, muscle cramps,
hyperactive reflexes, positive Trousseau‘s sign, and positive Chovstek‘s sign.
Hypocalcemia is said to be present when the total serum calcium
concentration is less than 8.8 mg/dl. The disorder may be acquired or
inherited but its presentation can vary- from asymptomatic to life-
threatening. Hypocalcemia is commonly seen in hospitalized patients and
for the most part, is mild in nature and only requires supportive treatment.
ADVERTISEMENTS
63. Question
Packed red blood cells have been prescribed for a client with low hemoglobin
and hematocrit levels. The nurse takes the client‘s temperature before hanging
the blood transfusion and records 100.8 °F. Which action should the nurse take?
o A. Give an antipyretic and begin the transfusion.
o B. Proceed with the transfusion.
o C. Administer an antihistamine and begin the transfusion.

o D. Delay hanging the blood and inform the physician.
Incorrect
Correct Answer: D. Delay hanging the blood and inform the physician.
If the patient has a temperature higher than 100 ° F, the unit of blood should be
hung and delayed until the physician is notified and has the opportunity to give
further orders. Fever and/or chills are most commonly associated with a febrile,
non-hemolytic reaction, however; they can also be the first sign of a more serious
acute hemolytic reaction, TRALI, or septic transfusion reaction.
 Option A: Giving an antipyretic would require a physician‘s order. All cases
of suspected reactions should prompt immediate discontinuation of the
transfusion and notification of the blood bank and treating clinician. A
clerical check should be performed by examining the product bag and
confirming the patient‘s identification. The patient‘s vital signs should be
monitored and recorded at 15-minute intervals.
 Option C: Administering an antihistamine is incorrect since the
administration of the medicine will need the physician‘s prescription.
Treatment of specific transfusion reactions is most often supportive. For
example, antihistamines (such as diphenhydramine) can be given for a mild
allergic reaction, or an antipyretic can be given for a nonhemolytic febrile
transfusion reaction.
 Option B: The decision to administer the blood is not within the scope of
nurse practice. Currently, guidelines for transfusion of red blood cells (RBC),
generally follow a restrictive threshold. While there is some variation in the
number for the threshold, 7 g/dL is an agreed-upon value for
asymptomatic healthy patients.
ADVERTISEMENTS
64. Question
A nurse is caring for a client requiring surgery and is ordered to have a standby
blood secured if in case a blood transfusion is needed during or after the
procedure. The nurse suggests to the client to do which of the following to lessen
the risk of possible transfusion reaction?
o A. Request that any donated blood be screened twice by the blood bank.

o B. Take iron supplements prior to the surgery and eat green leafy vegetables.
o C. Do an autologous blood donation.
o D. Have a family member donate their own blood.

Incorrect
Correct Answer: C. Do an autologous blood donation.
A donation of your own blood is autologous. Doing this will prevent the risk of
transfusion reaction. Autologous blood transfusion is the collection of blood from
a single patient and retransfusion back to the same patient when required. This is
in contrast to allogeneic blood transfusion where blood from
unrelated/anonymous donors is transfused to the recipient. The primary driving
forces for the use of autologous blood transfusion are to reduce the risk of
transmission of infection and to protect an increasingly scarce resource.
 Option A: More recently, concerns have focussed on the blood-borne
transmission of variant Creutzfeldt–Jakob disease (vCJD). In 2004, case
reports emerged of presumed transmission of vCJD via allogeneic blood
transfusion. Unlike hepatitis and HIV, there is no effective screening test
and the disease has a variable and often prolonged asymptomatic
incubation period.
 Option B: As oral iron supplementation requires a significant amount of
time, when the interval before surgery is sufficient (at least 6–8 weeks) and
no contraindications are present, supplementation with oral iron and
nutritional advice may be appropriate for mild-to-moderate IDA and/or
nonanemic ID or insufficient iron stores.
 Option D: Allogeneic donor blood is becoming an increasingly costly and
scarce resource. As demand for blood is outstripping donation, there is a
real social and economic pressure to increase the proportion of blood
transfused by autologous transfusion.
ADVERTISEMENTS
65. Question
A client is receiving a transfusion of one unit of cryoprecipitate. The nurse will
review which of the following laboratory studies to assess the effectiveness of the
therapy?

o A. Serum electrolytes
o B. White blood cell count
o C. Coagulation studies
o D. Hematocrit count
Incorrect
Correct Answer: C. Coagulation studies
The evaluation of the effective response of a cryoprecipitate transfusion is
assessed by monitoring coagulation studies and fibrinogen levels. Cryoprecipitate
Antihemophilic Factor, also called cryo, is a portion of plasma, the liquid part of
the blood. Cryo is rich in clotting factors, which are proteins that can reduce
blood loss by helping to slow or stop bleeding.
 Option A: Crystalloids are the fluids of choice for most minor procedures.
They are sterile aqueous solutions that may contain glucose, various
electrolytes, organic salts, and nonionic compounds. Some examples of
these solutes are sodium chloride, potassium chloride, sodium bicarbonate,
calcium carbonate, sodium acetate, sodium lactate, and sodium gluconate.
 Option B: White blood cells are transfused to treat life-threatening
infections in people who have a greatly reduced number of white blood
cells or whose white blood cells are functioning abnormally. The use of
white blood cell transfusions is rare because improved antibiotics and the
use of cytokine growth factors that stimulate people to produce more of
their own white blood cells have greatly reduced the need for such
transfusions.
 Option D: The average increase in hematocrit per liter of packed red blood
cells transfused was 6.4% +/- 4.1%. If 1 ―unit‖ of packed red blood cells is
approximately 300 mL, this becomes a change of hematocrit of 1.9% +/-
1.2% per ―unit‖ of blood. The accepted correlation of about 1 ―unit‖ of
blood loss per 3% change in hematocrit would be valid for a 500-cc unit,
but a typical unit of packed red blood cells is typically 300 cc.
ADVERTISEMENTS
66. Question

A nurse is teaching a client with pancreatitis about following a low-fat diet. The
nurse develops a list of high-fat foods to avoid and includes which food on the
item list?
o A. Chocolate milk
o B. Broccoli
o C. Apple
o D. Salmon
Incorrect
Correct Answer: A. Chocolate milk
Chocolate milk is a high-fat food. The pancreas helps with fat digestion, so foods
with more fat make the pancreas work harder. Registered dietitian Deborah
Gerszberg recommends that people with chronic pancreatitis limit their intake of
refined carbohydrates, such as white bread and high sugar foods. Refined
carbohydrates can lead to the pancreas releasing large amounts of insulin. Foods
that are high in sugar can also raise triglycerides.
 Option B: Vegetables are low in fat because they do not come from animal
sources. Vegetables, beans, lentils, and whole grains are beneficial because
of their fiber content. Eating more fiber can lower the chances of having
gallstones or elevated levels of fats in the blood called triglycerides. Both
of those conditions are common causes of acute pancreatitis.
 Option C: Fruits are low in fat because they do not come from animal
sources. Fruits are recommended for people with pancreatitis because they
tend to be naturally low in fat, which eases the amount of work the
pancreas needs to do to aid digestion.
 Option D: Salmon is naturally lower in fat. Many types of fish, such as
salmon, lake trout, tuna, and herring, provide healthy omega-3 fat. But
avoid fish canned in oil, such as sardines in olive oil. Bake, broil, or grill
meats, poultry, or fish instead of frying them in butter or fat.
ADVERTISEMENTS
67. Question

The nurse is giving dietary instructions to a client who is on a vegan diet. The
nurse provides dietary teaching focus on foods high in which vitamin that may be
lacking in a vegan diet?
o A. Vitamin A
o B. Vitamin D
o C. Vitamin E
o D. Vitamin C
Incorrect
Correct Answer: B. Vitamin D
Deficiencies in vegetarian diets include vitamin B12 which is found in animal
products and vitamin D (if limited exposure to sunlight). Vegans and other
vegetarians who limit their intake of animal products may be at greater risk of
vitamin D deficiency than nonvegetarians because foods providing the highest
amount of vitamin D per gram naturally are all from animal sources, and
fortification with vitamin D currently occurs in few foods.
 Option A: Plant sources contain vitamin A in the form of carotenoids which
have to be converted during digestion into retinol before the body can use
it. Carotenoids are the pigments that give plants their green color and
some fruits and vegetables their red or orange color.
 Option C: The best way to get the daily requirement of vitamin E is by
eating food sources. Vitamin E is found in vegetable oils, nuts, seeds, green
leafy vegetables, and fortified breakfast cereals. It is an antioxidant. This
means it protects body tissue from damage caused by substances called
free radicals. Free radicals can harm cells, tissues, and organs. They are
believed to play a role in certain conditions related to aging.
 Option D: Vitamin C can be found in fruits and vegetables, which are eaten
by a vegetarian. Humans are unable to synthesize vitamin C, so it is strictly
obtained through the dietary intake of fruits and vegetables. Citrus fruits,
berries, tomatoes, potatoes, and green leafy vegetables are excellent
sources of vitamin C.
ADVERTISEMENTS

68. Question
A nurse is caring for a client with Wernicke-Korsakoff syndrome. The physician
asks the nurse to teach the client to consume thiamine-rich food. The nurse
instructs the client to increase the intake of which food items?
o A. Chicken
o B. Milk
o C. Beef
o D. Broccoli
Incorrect
Correct Answer: C. Beef
Food sources of thiamin include beef, liver, nuts, oats, oranges, pork, eggs, seeds,
legumes, peas, and yeast. In meat, the liver has the highest amount of thiamine.
Whereas three ounces of beefsteak gives 7% of the daily value of thiamine, one
serving of beef liver will give about 10%. One serving of cooked salmon gives
18% of the daily value of thiamine.
 Option A: Poultry contains niacin. Chicken meat, particularly chicken
breast, is an excellent source of protein as well as niacin. A three-ounce
serving of skinless breast meat provides 10.3 mg. Niacin is an essential
nutrient that we mainly need to get from foods. The body may also convert
some tryptophan, one of the body‘s amino acids, into a nutrient.
 Option B: Milk contains vitamins A, D, and B2. Milk contains the fat-soluble
vitamins A, D, E, and K. The content level of fat-soluble vitamins in dairy
products depends on the fat content of the product. Milk contains the
water-soluble vitamins thiamin (vitamin B1), riboflavin (vitamin B2), niacin
(vitamin B3), pantothenic acid (vitamin B5), vitamin B6 (pyridoxine), vitamin
B12 (cobalamin), vitamin C, and folate. Milk is a good source of thiamin,
riboflavin, and vitamin B12.
 Option D: Broccoli contains folic acid, vitamins C, E, and K. Broccoli is a
good source of fiber and protein and contains iron, potassium, calcium,
selenium, and magnesium as well as the vitamins A, C, E, K, and a good
array of B vitamins including folic acid.
ADVERTISEMENTS

69. Question
A client who is recovering from surgery has been ordered a change from a clear
liquid diet to a full liquid diet. The nurse would offer which full liquid item to the
client?
o A. Popsicle
o B. Carbonated beverages
o C. Gelatin
o D. Custard
Incorrect
Correct Answer: D. Custard
Full liquid food items include items such as plain ice cream, sherbet, breakfast
drinks, milk, pudding, and custard, soups that are strained, refined cooked
cereals, and strained vegetable juices. A full liquid diet is made up only of fluids
and foods that are normally liquid and foods that turn to liquid when they are at
room temperature, like ice cream.
 Option A: A clear liquid diet is a specific dietary plan that only includes
liquids that are fully transparent at room temperature. Some items that
may be allowed include water, ice, fruit juices without pulp, sports drinks,
carbonated drinks, gelatin, tea, coffee, clear broths, and clear ice pops.
 Option B: Carbonated beverages are part of a clear liquid diet. Items can
have color as long as they are transparent. Items such as milk and orange
juice are not considered clear liquids because they are not fully transparent
and may take more effort for the digestive system to break down, whereas
grape juice is allowed (it is pigmented, but fully transparent).
 Option C: Gelatin is a clear liquid diet. The clear liquid diet assists in
maintaining hydration, provides electrolytes and calories, and offers some
level of satiety when a full diet is not appropriate, but may struggle to
provide adequate caloric needs if employed for more than five days.
ADVERTISEMENTS
70. Question

A postoperative client has been placed on a clear liquid diet. The nurse provides
the client with which items are allowed to be consumed on this diet?
o A. Vegetable juices
o B. Custard
o C. Sherbet
o D. Bouillon
Incorrect
Correct Answer: D. Bouillon
A clear liquid diet consists of foods that are relatively transparent to light and
liquid at room and body temperature. Foods allowed on the clear liquid diet
(bouillon, popsicles, plain gelatin, ice chips, sweetened tea or coffee (no creamer),
carbonated beverages, and water). The clear liquid diet assists in maintaining
hydration, it provides electrolytes and calories, and offers some level of satiety
when a full diet is not appropriate, but may struggle to provide adequate caloric
needs if employed for more than five days
 Option A: Vegetable juices are part of a full liquid diet. A patient
prescribed a full liquid diet follows a specific diet type requiring all liquids
and semi-liquids but no forms of solid intake. Unlike a clear liquid diet,
which includes only liquids and semi-liquids that are non-opaque, a full
liquid diet is more inclusive, as it allows all types of liquids.
 Option B: Custard is a full liquid diet. Patients not ready for a regular diet
due to elective or emergent procedures or who experience irregularity in
gastrointestinal function, dysphagia, a transition from prolonged fasted
periods, etc., are typically placed on a restrictive diet.
 Option C: Sherbet is a full liquid diet. Dietary restrictions can be as
restrictive as no food or liquids allowed by mouth, which may increase in a
stepwise fashion until reaching regular nutrition. One step in that
progression is a full liquid diet.
ADVERTISEMENTS
71. Question

The nurse is teaching a client who has iron-deficiency anemia about foods she
should include in her diet. The nurse determines that the client understands the
dietary instructions if she selects which of the following from her menu?
o A. Nuts and fish.
o B. Oranges and dark green leafy vegetables.
o C. Butter and margarine.
o D. Sugar and candy.

Incorrect
Correct Answer: B. Oranges and dark green leafy vegetables.
Dark green leafy vegetables are rich in iron while oranges are a good source of
vitamin C, which enhances iron absorption. A diet plan for anemia needs to
include a healthful balance of iron-rich foods, such as leafy vegetables, lean meat,
nuts and seeds, and fortified breakfast cereals. It is also crucial to include foods
that can improve the body‘s absorption of iron and avoid foods that may
interfere with this process.
 Option A: Phytates also termed phytic acid is present in legumes, whole
grains, nuts, and brown rice. The phytic acid binds with the iron present in
the digestive tract and inhibits its absorption. Hence, anemic patients must
avoid foods containing phytates.
 Option C: The mineral hinders iron absorption and therefore consuming
calcium-containing food products in combination with other iron-rich
foods can affect how much iron is being absorbed by the body. Dairy foods
like milk, yoghurt, and cheese should be avoided for this reason. Therefore,
it is advisable to take calcium-containing foods at different time slots.
 Option D: The effect of the iron-chelating sugars, fructose, glucose, and
galactose, on iron absorption in rats has been examined. Fructose has an
effect on increasing iron absorption. Glucose and galactose have no effect
on iron absorption. These findings suggest that the metabolism of fructose
is responsible for changing iron absorption in the rat since it is metabolized
during its absorption, while glucose and galactose are not.
ADVERTISEMENTS

72. Question
The nurse instructs a client with renal failure who is receiving hemodialysis about
dietary modifications. The nurse determines that the client understands these
dietary modifications if the client selects which items from the dietary menu?
o A. Mushroom and blueberry.
o B. Beans and bananas.
o C. Fish and tomato juice.
o D. Potato and spinach.

Incorrect
Correct Answer: A. Mushroom and blueberry.
A renal diet is one that is low in sodium, phosphorus, potassium and protein. A
renal diet also emphasizes the importance of consuming high-quality protein and
usually limiting fluids. Some patients may also need to limit potassium and
calcium. Every person‘s body is different, and therefore, it is crucial that each
patient works with a renal dietitian to come up with a diet that is tailored to the
patient‘s needs.
 Option B: Bananas are rich in potassium. The kidneys help to keep the
right amount of potassium in the body and they expel excess amounts into
the urine. When the kidneys fail, they can no longer remove excess
 Option C: Tomato juice is high in sodium. Too much sodium can be
harmful for people with kidney disease because their kidneys cannot
adequately eliminate excess sodium and fluid from the body. Processed
foods often contain higher levels of sodium due to added salt.
 Option D: Potatoes and spinach are high in potassium. Potassium plays a
role in keeping the heartbeat regular and the muscles working correctly.
Potassium is also necessary for maintaining fluid and electrolyte balance in
the bloodstream. When the kidneys fail, they can no longer remove excess
ADVERTISEMENTS
73. Question

A client with heart failure has been told to maintain a low sodium diet. A nurse
who is teaching this client about foods that are allowed includes which food item
in a list provided to the client?
o A. Pretzels
o B. Whole wheat bread
o C. Tomato juice canned
o D. Dried apricot
Incorrect
Correct Answer: D. Dried apricot
Foods that are lower in sodium include fruits and vegetables like dried apricot.
Dried apricots are sodium-free. Dried apricots, as part of a low sodium diet, may
reduce the risk of high blood pressure. Apricots contain numerous antioxidants,
most notably flavonoids. They help protect the body from oxidative stress, which
is linked to many chronic diseases.
 Option A: These classic snacks are high in sodium — almost 20 percent of
the recommended daily intake is in one serving of pretzels. Too much
sodium leads to increased water retention, which can lead to bloating and
puffiness, and too much sodium over time can lead to heart disease.
 Option B: Sodium is finding its way into a lot of whole wheat bread brands
in amounts that average 240 to 400 mg per slice. If your serving usually
contains two slices, the sodium can add up quickly.
 Option C: Many tomato juice products contain added salt — which bumps
up the sodium content. For example, a 1.4-cup (340-ml) serving of
Campbell‘s 100% tomato juice contains 980 mg of sodium — which is 43%
of the DV. Research shows that diets high in sodium may contribute to
high blood pressure.
ADVERTISEMENTS
74. Question
The nurse is instructing a client with hyperkalemia on the importance of choosing
foods low in potassium. The nurse should teach the client to limit which of the
following foods?

o A. Grapes
o B. Carrot
o C. Green beans
o D. Lettuce
Incorrect
Correct Answer: B. Carrot
Carrots have 320 mg of potassium per 100 mg serving; green beans give 209 mg
of potassium, 194 mg for lettuce, and 191 mg for grapes all in 100 mg serving.
Other foods that are low in potassium include applesauce, blueberries, pineapple,
and cabbage. To minimize potassium buildup, a person with chronic kidney
disease should stick to a low-potassium diet of between 1,500 and 2,000
milligrams (mg) per day. Limiting phosphorus, sodium, and fluids may also be
important for people with kidney dysfunction.
 Option A: Grapes are also rich in potassium, but not as much as in carrots.
They‘re also a good source of vitamin C, an essential nutrient and powerful
antioxidant necessary for connective tissue health. Grapes are high in a
number of powerful antioxidant compounds. In fact, over 1,600 beneficial
plant compounds have been identified in this fruit.
 Option C: Half a cup of freshly cooked green beans has only 90 milligrams
of potassium and 18 milligrams of phosphorus, making them a great
vegetable choice for the kidney diet.
 Option D: Lettuce is a popular vegetable and is usually eaten raw in salads.
Because CKD patients with hyperkalemia need to limit potassium intake
from meals, they are not able to eat large quantities of raw vegetables such
as lettuce.
ADVERTISEMENTS
75. Question
A client is recovering from debridement of the right leg. A nurse encourages the
client to eat which food item that is naturally high in vitamin C to promote
wound healing?
o A. Milk

o B. Chicken
o C. Banana
o D. Strawberries
Incorrect
Correct Answer: D. Strawberries
Citrus fruits and juices are especially high in vitamin C. Strawberries are an
excellent source of vitamin C and manganese and also contain decent amounts
of folate (vitamin B9) and potassium. Strawberries are very rich in antioxidants
and plant compounds, which may have benefits for heart health and blood sugar
control
 Option A: Dairy products such as milk are high in vitamin B. Milk and other
dairy products pack about a third of the daily riboflavin requirement in just
1 cup (240 ml). Milk is also a good source of well-absorbed B12. Like other
animal products, milk also is a good source of B12, supplying 18% of the
RDI per 1-cup (240-ml) serving.
 Option B: Meats such as chicken are high in vitamin B. Chicken and turkey,
especially the white meat portions, are high in B3 and B6. Poultry also
supplies smaller amounts of riboflavin, pantothenic acid, and cobalamin.
Most of the nutrients are in the meat, not the skin.
 Option C: Bananas are rich in potassium. Bananas are rich in the mineral
potassium. Potassium helps maintain fluid levels in the body and regulates
the movement of nutrients and waste products in and out of cells. One
medium-sized banana contains 422 milligrams (mg) of potassium.
ADVERTISEMENTS
1. 1. Question
Which of the following is not true regarding the types of a nasogastric tube?
o A. Cantor tube is a single-lumen long tube with a small inflatable bag at the
distal end.
o B. Miller-Abbott tube is a long double-lumen used to drain and decompress

the small intestine.
o C. Levin tube is a double-lumen nasogastric tube with an air vent.

o D. Sengstaken-Blakemore tube is a three-lumen tube.
Incorrect
Correct Answer: C. Levin tube is a double-lumen nasogastric tube with an air
vent.
A Levin tube is a single lumen nasogastric tube while a Salem sump tube is a
double-lumen nasogastric tube with an air vent. The Levin tube is used primarily
for long-continued gastric drainage and for gavage feeding. It is also used for
diagnostic purposes. Its advantages are that it can be inserted either nasally or
orally and that it is firm enough to be passed into an unconscious patient but
flexible enough so there is little danger of producing injury.
 Option A: The Cantor Tub is a 10-foot long, single-lumen tube used for
intestinal decompression. The Cantor tube has a mercury-weighted rubber
tab attached to its perforated tip to help carry the tube through the
stomach and intestine. The mercury is placed in the bag with a syringe and
needle before the tube is inserted nasally by the doctor.
 Option B: The Miller-Abbott tube is a 10-foot long double-lumen tube
that is equipped with a small balloon near the metal tip at the distal end of
the tube. One lumen is used for aspiration and irrigation; the other is used
for inflating the balloon. Air, water, or mercury (4 to 5 ml) accomplishes
inflation. This intestinal tube is used for small bowel suction. The two
openings are independent of each other and are clearly marked.
 Option D: Also referred to as a Blakemore tube, this tube is a three-lumen,
esophageal-gastric balloon tube that is used in the treatment of bleeding
esophageal varices. One lumen is used to inflate the esophageal balloon,
one lumen is used to inflate the gastric balloon, and the third lumen is
used for decompression and irrigation of the stomach.
ADVERTISEMENTS
1. Question 2 of 75
2. Question
A new RN nurse is about to insert a nasogastric tube into a client with Guillain-
Barre Syndrome. To determine the accurate measurement of the length of the
tube to be inserted, the nurse should:
o A. Place the tube at the tip of the nose, and measure by extending the tube
to the earlobe and then down to the top of the sternum.

o B. Place the tube at the tip of the nose and measure by extending the
tube to the earlobe and then down to the xiphoid process.
o C. Place the tube at the tip of the nose, and measure by extending the tube
down to the chin and then down to the top of the xiphoid process.
o D. Place the tube at the base of the nose and measure by extending the tube
to the earlobe and then down to the top of the sternum.
Incorrect
Correct Answer: B. Place the tube at the tip of the nose, and measure by
extending the tube to the earlobe and then down to the xiphoid process.
Estimate the length of insertion by measuring the distance from the tip of the
nose, around the ear, and down to just below the left costal margin. This point
can be marked with a piece of tape on the tube. When using the Salem sump NG
tube (Kendall, Mansfield, MA) in adults, the estimated length usually falls
between the second and third preprinted black lines on the tube.
 Option A: Apart from the nose-to-ear-to-xiphisternum (NEX) method,
several other methods for determining the length of the tube have been
described. Among the various options, a formula based on gender, weight,
and nose-to-umbilicus measurement while lying flat was found to be safer
and more accurate in a study by Santos et al.
 Option C: While the stomach is a highly distensible structure and
therefore, can vary in length, the empty stomach is generally around 25 cm
long. Thus if one intended to place a tube through the nares and place it in
the middle of the stomach, then approximately 55 cm of the tube should
be inserted.
 Option D: There are several methods to estimate the depth that an NG
should be placed. All methods for estimation will have some margin of
error. A common pre-procedure maneuver is to loop the tube over one of
the patient‘s ears and place the tip at the patient‘s xiphoid process and use
this as an estimate for the length of the tube that should be inserted.
ADVERTISEMENTS
1. Question 3 of 75
3. Question

A stroke client who was initially on NGT feeding was able to tolerate a soft diet so
the physician ordered the removal of it. The nurse would instruct the client to do
which of the following before he removes the tube?
o A. Inhale and exhale simultaneously.
o B. Take a long breath and hold it.
o C. Do a Valsalva maneuver.
o D. Blow the nose.

Incorrect
Correct Answer: B. Take a long breath and hold it.
Holding the breath closes the glottis hence it will be easier to withdraw the tube
through the esophagus into the nose, and this method will also prevent
aspiration. An NG tube should be removed if it is no longer required. The process
of removal is usually very quick. Prior to removing an NG tube, verify physician
orders. If the NG tube was ordered to remove gastric content, the physician‘s
order may state to ―trial‖ clamping the tube for a number of hours to see if the
patient tolerates its removal. During the trial, the patient should not experience
any nausea, vomiting, or abdominal distension.
 Option A: Instruct the patient to take a deep breath and hold it. This
prevents aspiration; holding the breath closes the glottis. Kink the NG tube
near the naris and gently pull out the tube in a swift, steady motion,
wrapping it in your hand as it is being pulled out. Dispose of tube in
garbage bag.
 Option C: The Valsalva maneuver is a breathing technique that can be
used to unclog ears, restore heart rhythm or diagnose an autonomic
nervous system (ANS). To perform the Valsalva maneuver, the patient
should close his mouth, pinch the nose shut and press the air out like
blowing up a balloon.
 Option D: Blowing the nose is a way of clearing out mucus that has
collected debris and pollutants from the atmosphere. Most of the time,
people blow their nose because of excess mucus production – a cold, nasal
allergy, hay fever, or other conditions.
ADVERTISEMENTS
1. Question 4 of 75

4. Question
The nurse is preparing to give bolus enteral feedings via a nasogastric tube to a
comatose client. Which of the following actions is an inappropriate practice by
the nurse?
o A. If bowel sounds are absent, hold the feeding and notify the physician.
o B. Assess tube placement by aspirating gastric content and check the PH

level.
o C. Warm the feeding to room temperature to prevent the occurrence of

diarrhea and cramps.
o D. Elevate the head of the bed to 45 degrees and maintain for 30

minutes after installation of feeding.
Incorrect
Correct Answer: D. Elevate the head of the bed to 45 degrees and maintain
for 30 minutes after instillation of feeding.
If the client is comatose, place in a high-Fowler‘s which is at a 90-degree level.
Position client upright or in full Fowler‘s position if possible. Place a clean towel
over the client‘s chest. Full Fowler‘s position assists the client to swallow, for
optimal neck-stomach alignment and promotes peristalsis.
 Option A: Inject 30 mL of air into the stomach and listen with the
stethoscope for the ―whoosh‖ of air into the stomach. The small diameter
of some NG tubes may make it difficult to hear air entering the stomach. It
is very important to ensure that the NG tube is in its correct place within
the stomach because, if by accident the NG is within the trachea, serious
complications in relation to the lungs would appear.
 Option B: Stomach aspirate will appear cloudy, green, tan, off-white,
bloody, or brown. It is not always visually possible to distinguish between
the stomach and respiratory aspirates. Measuring the pH of stomach
aspirate is considered more accurate than visual inspection. Stomach
aspirate generally has a pH range of 0 to 4, commonly less than 4.
 Option C: For powdered formula, mix according to the instructions on the
package. Prepare just enough for the next 24 hours and refrigerate unused
formula. Allow the formula to reach room temperature before using.

Formula loses its nutritional value and can be contaminated if kept for
more than 24 hours. Cold formulas can cause abdominal discomfort.
ADVERTISEMENTS
1. Question 5 of 75
5. Question
A nurse is checking the nasogastric tube position of a client receiving a long-term
therapy of Omeprazole (Prilosec) by aspirating the stomach contents to check for
the PH level. The nurse proves the correct tube placement if the PH level is?
o A. 7.75.
o B. 7.5.
o C. 6.5.
o D. 5.5.
Incorrect
Correct Answer: D. 5.5.
Gastric placement is indicated by a pH of less than 4 but may increase to
between pH 4-6 if the patient is receiving acid-inhibiting drugs. Measuring the
pH of stomach aspirate is considered more accurate than visual inspection.
Stomach aspirate generally has a pH range of 0 to 4, commonly less than 4.
 Option A: The aspirate of respiratory contents is generally more alkaline,
with a pH of 7 or more. Testing the pH of gastric aspirate to show pH ?5.5
is recommended first-line test to confirm correct placement of nasogastric
tubes and reduce the risk of potentially fatal aspiration.
 Option B: The pH readings between 4.5 and 6.0 provided the greatest
overall accuracy, however, there was only moderate agreement between
observers at pH readings ?5.0. Compared with studies that have taken
aspirate directly from the nasogastric tube, patients undergoing scope
procedures had a lower sensitivity at the pH cut-off ?5.5 for identifying
gastric aspirates for the whole group and in the presence and absence of
antacid medications.
 Option C: Current healthcare guidelines recommend that the first-line test
to confirm correct NGT placement prior to giving food or medications
must be that the pH of an NGT aspirate is ?5.5 (acidic). Nevertheless, false-

positive readings might occur if the tube is misplaced in the esophagus or
false-negative readings (pH >5.5) may occur in patients who secrete less
gastric acid, because of antacid medications, achlorhydria, or buffering by
NGT feeds.
ADVERTISEMENTS
1. Question 6 of 75
6. Question
Before feeding a client via NGT, the nurse checks for residual and obtains a
residual amount of 90ml. What is the appropriate action for the nurse to take?
o A. Discard the residual amount.
o B. Hold the due feeding.
o C. Skip the feeding and administer the next feeding due in 4 hours.
o D. Reinstill the amount and continue with administering the feeding.

Incorrect
Correct Answer: D. Reinstill the amount and continue with administering the
feeding.
If the residual feeding is less than 100ml, feeding is administered. Fasting volume
of the normal stomach ranged from 0 to 98 mL in the study group. The
researchers defined high as 100 mL for nasogastric (NG) tubes and 200 mL for
gastrostomy (G) tubes and concluded that EN feedings should not be stopped for
a single high GRV if there are no other physical examination or radiography
findings to show actual gastrointestinal dysfunction.
 Option A: When interpreting Gastric Residual Volume (GRV), clinicians
must keep in mind that the stomach has reservoir function and that the
stomach fluid is a mixture of both the infused EN formula and normal
gastric secretions. Chang and colleagues explained this concept in the
article ―Monitoring Bolus Nasogastric Tube Feeding by the Brix Value
Determination and Residual Volume Measurement of Gastric Contents‖
published in the Journal of Parenteral and Enteral Nutrition (JPEN) in 2004.
 Option B: In a review article, ―Measurement of Gastric Residual Volume:
State of the Science,‖ published in 2000 in MEDSURG Nursing, Edwards
and Metheny reported that the literature contained a variety of

recommendations for what is considered a high GRV, ranging from 100 to
500 mL. Some sources have even (incorrectly) suggested holding tube
feedings for a GRV of greater than 30 mL, or 1.5 times the flow rate, or
even one-half of the hourly flow rate.
 Option C: Normal gastric emptying occurs within three hours and after a
lag time of approximately one hour for a meal of solid foods. The process
is slower for high-fat meals. Liquids empty more quickly (within one hour
for a glucose solution and two hours for a protein solution).3 During
fasting, the stomach secretes approximately 500 to 1,500 mL2; in the fed
state, it secretes approximately 2,500 mL per day.
ADVERTISEMENTS
1. Question 7 of 75
7. Question
Continuous type of feedings is administered over a __ hour period?
o A. 4.
o B. 12.
o C. 24.
o D. 36.
Incorrect
Correct Answer: C. 24.
Continuous feeding is administered for 24 hours. An infusion pump regulates the
flow. Continuous drip feeding is delivered by either gravity drip or infusion pump.
The infusion pump is a better method of delivery than gravity drip. The flow rate
of gravity drip may be inconsistent and, therefore, needs to be checked
frequently.
 Option A: When feedings are delivered continuously, stool output is
reduced, a consideration for the child with chronic diarrhea. Continuous
infusions of elemental formula have been successful in managing infants
with short bowel syndrome, intractable diarrhea, necrotizing enterocolitis,
and Crohn‘s disease.
 Option B: Commonly, it is used for 8 to 10 hours during the night for
volume-sensitive patients so that smaller bolus feedings or oral feeding

may be used during the day. Continuous feeding can be administered at
night, so it will not interfere with daytime activities. Continuous feeding
increases energy efficiency, allowing more calories to be used for growth.
This can be important for severely malnourished children.
 Option D: Continuous drip-feeding may be delivered without interruption
for an unlimited period of time each day. Feeding around the clock is not
recommended as this limits a child‘s mobility and may elevate insulin levels
contributing to hypoglycemia.
ADVERTISEMENTS
1. Question 8 of 75
8. Question
A client is subjected to undergo a chest x-ray to confirm the endotracheal tube
placement. The tube should be how many centimeters above the carina?
o A. 2-4 cm.
o B. 1.5-3 cm.
o C. 1-2 cm.
o D. 0.5-1 cm.
Incorrect
Correct Answer: C. 1-2 cm.
Placement of an endotracheal tube is confirmed by a chest x-ray and the correct
placement is 1 to 2 cm above the carina. Check patient‘s chest x-ray for tube
placement and presence of C02 per ET C02 detector after any new intubation;
auscultate chest for equal breath sounds bilaterally, and adjust E.T. tube for
proper placement.
 Option A: Check tube placement with each ventilator assessment. The
optimal placement for the endotracheal tube is 2-3cm above the carina in
adults. If repositioning of the endotracheal tube is warranted, suction the
tube and then suction the oropharynx.
 Option B: Positioning the ET tip 4 cm above carina as recommended will
result in placement of tube cuff inside cricoid ring with currently available
tubes. Optimal depth of ET placement can be estimated by the formula
―(Height in cm/7)-2.5.‖

 Option D: It is suggested that the tip of ET should be at least 4 cm from
the carina, or the proximal part of the cuff should be 1.5 to 2.5 cm from the
vocal cords. Considering that the length of trachea, as well as the distance
from teeth to vocal cords, is variable, securing ET at a fixed length will
result in endobronchial intubation or endolaryngeal placement of the ET
cuff in some patients.
ADVERTISEMENTS
1. Question 9 of 75
9. Question
After the client had tolerated the weaning process, the physician ordered the
removal of the endotracheal tube and it will be shifted into a nasal cannula.
Which of the following findings after the removal
requires immediate intervention by the physician?
o A. Sore throat.
o B. Hoarseness of the voice.
o C. Coughing out blood.
o D. Neck discomfort.
Incorrect
Correct Answer: C. Coughing out blood.
A sign of a tracheal or esophageal perforation that prevents oxygen from
reaching the lungs and can result in internal bleeding. This life-threatening side
effect of being intubated requires immediate medical intervention. When
hemoptysis begins after endotracheal intubation, upper airway trauma caused by
the intubation procedure, endotracheal tube, or endotracheal suction catheters
must be considered. If hemoptysis begins after a latent period of 1 or more
weeks after intubation, a tracheo-artery fistula may be the source of hemorrhage.
 Option A: Endotracheal tube (ETT) is often necessary to achieve airway
control during general anesthesia. However, postoperative sore throat
(POST) is considered as a common adverse event after general anesthesia
with ETTs. POST continues to be reported with a high frequency and can
sometimes persist for several days

 Option B: The incidence of hoarseness after endotracheal intubation varies
widely from 14% to 50% but is mostly temporary. In a retrospective study
of 3093 patients who had endotracheal intubation during anesthesia, the
incidence of hoarseness was 49% in the immediate postoperative period.
 Option D: Neck discomfort is normal and the client should limit talking if it
occurs. Many people will experience a sore throat and difficulty swallowing
immediately after intubation, but recovery is usually quick, taking several
hours to several days depending on the time spent intubated. In most
cases, a person will fully recover from intubation within a few hours to days
and will have no long-term complications
ADVERTISEMENTS
10. Question
The nurse is assessing a client with an endotracheal tube and observes that the
client can make verbal sounds. What is the most likely cause of this?
o A. This is a normal finding.
o B. There is a leak.
o C. There is an occlusion.
o D. The endotracheal tube is displaced.

Incorrect
Correct Answer: B. There is a leak.
When conducting the minimal leak technique the client should not be able to
make verbal sounds or no air should be felt coming out of the client‘s mouth.
Because the cuff blocks the flow of air around the tube, speech is not possible.
Once the tube is removed (called extubation), the patient will be able to speak.
The voice may sound hoarse and the patient may have some throat discomfort
for the first few days.
 Option A: Verbal sounds in an intubated patient is not a normal finding. As
long as the patient has an endotracheal tube in place, the cuff will need to
be inflated. An inflated cuff will prevent the patient from being able to
speak. Speech is produced when we exhale air through the vocal cords,
causing them to vibrate.

 Option C: Without a gag reflex, saliva would enter the windpipe. This is
called aspiration. It was hypothesized that the high minute volume of
patients contributes to the inspissation of secretions. It is also possible that
some characteristic of the Pneumocystis organism in secretions causes
altered adherence characteristics of the sputum, resulting in this problem.
 Option D: If the patient has complete obstruction of the upper airway, a
displaced tracheostomy tube will result in immediate respiratory distress
and can lead to respiratory arrest. If the patient has an intact or at least a
partially open upper airway, the displaced tube may not cause an
immediate problem. Therefore, displacement of the tracheostomy tube
may not be obvious in the patient with a partial airway.
ADVERTISEMENTS
11. Question
While changing the tapes on a tracheostomy tube, the client coughs, and the
tube is dislodged. Which is the initial nursing action?
o A. Call a respiratory therapist to reinsert the tracheotomy.
o B. Cover the tracheostomy site with a sterile dressing.
o C. Call the physician to reinsert the tracheotomy.
o D. Grasp the retention sutures to spread the opening.

Incorrect
Correct Answer: D. Grasp the retention sutures to spread the opening.
If the tube is dislodged accidentally, the initial nursing action is to grasp the
retention sutures and spread the opening. The stay suture (if present) or tracheal
dilator may be used to help keep the stoma open if necessary. Once replaced, tie
the tube securely, leaving one finger space between ties and the patient‘s neck.
 Option A: Ask the patient to breathe normally via their stoma while
waiting for the doctor. Check tube position by (a) asking the patient to
inhale deeply – they should be able to do so easily and comfortably, and
(b) hold a piece of tissue in front of the opening – it should be ―blown‖
during the patient‘s exhalation.

 Option B: Covering the tracheostomy site will block the airway. Use
tracheostomy covers to protect the airway from outside elements (such as
dust, cold air, etc.). All trach tubes have an outer cannula (main shaft) and a
neck plate (flange). The flange rests on the neck over the stoma (opening).
Holes on each side of the neck plate allow you to insert trach tube ties to
secure the trach tube in place.
 Option C: Calling a respiratory therapist or the physician will delay
treatment in this emergency situation. Accidental dislodgement of the
tracheostomy tube during the first several days is not uncommon and can
be life-threatening, particularly in patients with severe oxygenation
problems and/or high demands for pressure and volume from the
ventilator.
ADVERTISEMENTS
12. Question
The nurse caring for a client with a pneumothorax and who has had a chest tube
inserted notes continuous gentle bubbling in the suction control chamber. What
action is most appropriate for the nurse?
o A. Increase the suction pressure so that the bubbling becomes vigorous.
o B. Do nothing since this is an expected finding.
o C. Immediately clamp the chest tube and notify the physician.
o D. Check for an air leak because the bubbling should be intermittent.

Incorrect
Correct Answer: B. Do nothing since this is an expected finding.
Continuous gentle bubbling should be noted in the suction control chamber.
Bubbling should be continuous in the suction control chamber and not
intermittent. The water level in the suction chamber should be at the prescribed
level and gentle bubbling should be observed. The level may drop due to
evaporation or over-vigorous bubbling, if this occurs top fluid level up as per
manufacturer‘s instructions.
 Option A: Increasing the suction pressure only increases the rate of
evaporation of water in the drainage system. and this is not done without

any prescription of the physician. Suction is not always required and may
lead to tissue trauma and prolongation of an air leak in some patients.
 Option C: Clamping should be done if there is accidental disconnection of
the system. Clamp the drain tubing at the patient end. Clean ends of the
drain and reconnect. Ensure all connections are cable tied. If a new
drainage system is needed, cover the exposed patient end of the drain with
sterile dressing while a new drain is set up. Ensure clamp is removed when
the problem is resolved.
 Option D: Chest tubes should only be clamped to check for an air leak or
when changing drainage devices. An air leak will be characterized by
intermittent bubbling in the water seal chamber when the patient with a
pneumothorax exhales or coughs. Continuous bubbling of this chamber
indicates large air leak between the drain and the patient. Check drain for
disconnection, dislodgement, and loose connection, and assess patient
condition. Notify medical staff immediately if a problem cannot be
remedied.
ADVERTISEMENTS
13. Question
The nurse is assessing the functioning of a chest tube drainage system in a client
with hemothorax. Which of the following findings should prompt the nurse to
notify the physician?
o A. Fluctuation of water in the tube in the water seal chamber during

inhalation and exhalation.
o B. Drainage system maintained below the client‘s chest.
o C. Drainage amount of 100ml in the drainage collection chamber.
o D. Occlusive dressing in place over the chest tube insertion site.

Incorrect
Correct Answer: C. Drainage amount of 100ml in the drainage collection
chamber.
Drainage of more than 70 to 100 mL/hour is not normal and requires the
immediate notification of the physician. Measure date and time, and the amount

of drainage, and mark on the outside of the chamber. Record amount and
characteristics of the drainage on the fluid balance sheet and patient chart.
Drainage that is red and free-flowing indicates a hemorrhage. A large amount of
drainage, or drainage that changes in color, should be recorded and reported to
the primary health care provider.
 Option A: The water in the water seal chamber will rise and fall (swing)
with respirations. This will diminish as the pneumothorax resolves. Watch
for unexpected cessation of swing as this may indicate the tube is blocked
or kinked. Cardiac surgical patients may have some of their drains in the
mediastinum in which case there will be no swing in the water seal
chamber.
 Option B: Collection chamber (drainage system) is below the level of the
chest and secured to prevent it from being accidentally knocked over. The
drainage system must remain upright for the water-seal chamber to
function correctly. The chest drainage system must be lower than the chest
to facilitate drainage and prevent backflow.
 Option D: The classic dressing for chest thoracostomy tube (CTT) insertion
sites is petroleum gauze held in place by a secondary dressing of sterile, 4?
x 4? sponge gauze secured with tape. Studies suggest that petroleum
gauze macerates skin over time.
ADVERTISEMENTS
14. Question
A nurse is supervising a student nurse who is performing tracheostomy care for a
client. Which of the following actions by the student should the nurse intervene?
o A. Removing the inner cannula and cleaning using universal precaution.
o B. Suctioning the tracheostomy tube before performing tracheostomy care.
o C. Changing the old tracheostomy ties and securing the tube in place.
o D. Replacing the inner cannula and cleaning the site of the stoma.
Incorrect
Correct Answer: A. Removing the inner cannula and cleaning using universal
precaution.

When performing tracheostomy care, a sterile field is set up and sterile technique
is required. Standard precautions such as washing hands must also be maintained
but are not enough when performing tracheostomy care. The presence of the
tracheostomy tube provides direct access to the lungs for organisms, so sterile
technique is used to prevent infection.
 Option B: Suctioning of the tracheostomy tube is necessary to remove
mucus, maintain a patent airway, and avoid tracheostomy tube blockages.
The frequency of suctioning varies and is based on individual patient
assessment. The depth of insertion of the suction catheter needs to be
determined prior to suctioning. Using a spare tracheostomy tube of the
same type and size and a suction catheter insert the suction catheter to
measure the distance from the length of the tracheostomy tube 15mm
connector to the end of the tracheostomy tube. Ensure the tip of the
suction catheter remains within the tracheostomy tube.
 Option C: If tie changes are required before the first tube change – it is
imperative that the procedure must be undertaken with both medical and
nursing staff present who are able to reinsert the tracheostomy tube in
case of accidental decannulation and the appropriate equipment is
available at the bedside. Tracheostomy tie changes are performed daily in
conjunction with stoma care, or as required if they become wet or soiled to
maintain skin integrity.
 Option D: Care of the stoma is commenced in the immediate
postoperative period, and is ongoing. Inspect the stoma area at least daily
to ensure the skin is clean and dry to maintain skin integrity and avoid
breakdown. Daily cleaning of the stoma is recommended using 0.9% sterile
saline solution.
ADVERTISEMENTS
15. Question
The nurse is handling a client with a chest tube. Suddenly, the chest drainage
system is accidentally disconnected. What is the most appropriate action for the
nurse to take?
o A. Secure the chest tube using tape.
o B. Clamp the chest tube immediately.

o C. Place the end of the chest tube in a container of normal sterile saline.
o D. Apply an occlusive dressing and notify the physician.

Incorrect
Correct Answer: C. Place the end of the chest tube in a container of normal
sterile saline.
If a chest drainage system is disconnected, the nurse can place the end of the
chest tube in a container of normal sterile saline to prevent air from entering the
chest tube, thereby preventing negative respiratory pressure. A chest tube
drainage system disconnecting from the chest tube inside the patient is an
emergency. Immediately place the end of the chest tube in sterile water or NS.
The two ends will need to be swabbed with alcohol and reconnected. Bleeding
may occur after insertion of the chest tube.
 Option A: The nurse should tape the chest tube securely to prevent it from
being disconnected, rather than taping it after it has been disconnected.
Keep the system closed and below chest level. Make sure all connections
are taped and the chest tube is secured to the chest wall.
 Option B: The nurse should not clamp the chest tube because doing so
increases the risk of tension pneumothorax. Never clamp a chest tube
without a doctor‘s order or valid reason. The tube must remain unobscured
and unclamped to drain air or fluid from the pleural space. There are a few
exceptions where a chest tube may be clamped.
 Option D: The nurse should apply an occlusive dressing if the chest tube is
pulled out and not if the system is disconnected. Dress the site with a dry
occlusive dressing and discard the chest tube and drainage device in the
hazardous waste bag. Obtain a post-removal chest X-ray if the physician
has ordered it or facility protocol requires it.
ADVERTISEMENTS
16. Question
A client with Congestive heart failure is about to take a dose of furosemide
(Lasix). Which of the following potassium levels, if noted in the client‘s record,
should be reported before giving the due medication?
o A. 5.1 mEq/L.

o B. 4.9 mEq/L.
o C. 3.9 mEq/L.
o D. 3.3 mEq/L.
Incorrect
Correct Answer: D. 3.3 mEq/L.
The normal potassium level is 3.5 to 5.5 mEq/L. Low potassium levels can be
dangerous, especially for people with CHF. Low potassium can cause fatal heart
arrhythmias. An abnormal serum K+ level is associated with an increased risk of
ventricular arrhythmia and sudden cardiac death (SCD) and these patients are
generally prescribed furosemide and potassium chloride (KCl).
 Option A: Furosemide, a short-acting diuretic is commonly recommended
as an essential drug in patients with heart failure and fluid retention. A
recent study has shown that furosemide administration increases mortality
in heart failure rat models. The commonly used drugs, furosemide, and KCl
in the treatment of various diseases render the differential expression of
proteins in the LV tissue, which is involved in the cardiac conductivity.
 Option B: The risk of hypokalemia increases with the use of a high dose of
furosemide, decreased oral intake of potassium in patients with
hyperaldosteronism states (liver abnormalities or licorice ingestion), or
concomitant use of corticosteroid, ACTH, and laxatives.
 Option C: Careful monitoring of the patient‘s clinical condition, daily
weight, fluids intake, and urine output, electrolytes, i.e., potassium and
magnesium, kidney function monitoring with serum creatinine and serum
blood urea nitrogen level is vital to monitor the response to furosemide. If
indicated as diuresis with furosemide, replete electrolytes lead to
electrolyte depletion and adjust the dose or even hold off on furosemide if
laboratory work shows signs of kidney dysfunction.
ADVERTISEMENTS
16. Question
A client with Congestive heart failure is about to take a dose of furosemide
(Lasix). Which of the following potassium levels, if noted in the client‘s record,
should be reported before giving the due medication?

o A. 5.1 mEq/L.
o B. 4.9 mEq/L.
o C. 3.9 mEq/L.
o D. 3.3 mEq/L.
Incorrect
Correct Answer: D. 3.3 mEq/L.
The normal potassium level is 3.5 to 5.5 mEq/L. Low potassium levels can be
dangerous, especially for people with CHF. Low potassium can cause fatal heart
arrhythmias. An abnormal serum K+ level is associated with an increased risk of
ventricular arrhythmia and sudden cardiac death (SCD) and these patients are
generally prescribed furosemide and potassium chloride (KCl).
 Option A: Furosemide, a short-acting diuretic is commonly recommended
as an essential drug in patients with heart failure and fluid retention. A
recent study has shown that furosemide administration increases mortality
in heart failure rat models. The commonly used drugs, furosemide, and KCl
in the treatment of various diseases render the differential expression of
proteins in the LV tissue, which is involved in the cardiac conductivity.
 Option B: The risk of hypokalemia increases with the use of a high dose of
furosemide, decreased oral intake of potassium in patients with
hyperaldosteronism states (liver abnormalities or licorice ingestion), or
concomitant use of corticosteroid, ACTH, and laxatives.
 Option C: Careful monitoring of the patient‘s clinical condition, daily
weight, fluids intake, and urine output, electrolytes, i.e., potassium and
magnesium, kidney function monitoring with serum creatinine and serum
blood urea nitrogen level is vital to monitor the response to furosemide. If
indicated as diuresis with furosemide, replete electrolytes lead to
electrolyte depletion and adjust the dose or even hold off on furosemide if
laboratory work shows signs of kidney dysfunction.
ADVERTISEMENTS
17. Question

A client went to the emergency room with a sudden onset of high fever and
diaphoresis. Serum sodium was one of the laboratory tests taken. Which of the
following values would you expect to see?
o A. 130 mEq/L.
o B. 148 mEq/L.
o C. 143 mEq/L.
o D. 139 mEq/L.
Incorrect
Correct Answer: B. 148 mEq/L.
The normal sodium level is 135-145 mEq/L. Diaphoresis and a high fever can lead
to free water loss through the skin, resulting in increased sodium level
(hypernatremia). Hypernatremia is defined as a serum sodium concentration of
greater than 145 meq/l. The human body maintains sodium and water
homeostasis by concentrating the urine secondary to the action of antidiuretic
hormone (ADH) and increased fluid intake by a powerful thirst response.
 Option A: The basic mechanisms of hypernatremia are water deficit and
excess solute. Total body water loss relative to solute loss is the most
common reason for developing hypernatremia. Hypernatremia is usually
associated with hypovolemia, which can occur in conditions that cause
combined water and solute loss, where water loss is greater than sodium
loss, or free water loss.
 Option C: Excessive sweating can occur due to exercise, fever, or high heat
exposure. Renal losses can be seen in intrinsic renal disease, post-
obstructive diuresis, and with the use of osmotic or loop diuretics.
Hyperglycemia and mannitol are common causes of osmotic diuresis. Free
water loss is seen with central or nephrogenic diabetes insipidus (DI) and
also in conditions with increased insensible loss.
 Option D: Sodium excretion also involves regulatory mechanisms such as
the renin-angiotensin-aldosterone systems. When serum sodium increases,
the plasma osmolality increases which triggers the thirst response and ADH
secretion, leading to renal water conservation and concentrated urine.
ADVERTISEMENTS

18. Question
A client is brought to the emergency department and states that he has
accidentally been taking two times his prescribed dose of Warfarin (Coumadin).
After observing that the client has no evidence of any obvious bleeding, the
nurse should do which of the following?
o A. Draw a sample for activated partial thromboplastin time (aPTT) level.
o B. Draw a sample for prothrombin time (PT) level and international

normalized ratio (INR).
o C. Prepare to administer Vitamin K.
o D. Prepare to administer Protamine sulfate.

Incorrect
Correct Answer: B. Draw a sample for prothrombin time (PT) level and
international normalized ratio (INR).
The next action for the nurse to take is to draw a sample for INR and PT level to
check the client‘s anticoagulation status and risk for bleeding. These results will
provide information on how to manage the client by either giving an antidote
such as Vitamin K or administering a blood transfusion. Specific evaluation of
warfarin toxicity should involve evaluation of the patient‘s PT, INR, CBC, and BMP
with hepatic function, in addition to the standard co-ingestions and a focused
evaluation surrounding their symptoms.
 Option A: The aPTT determines the effects of heparin therapy. It is
recommended that patients undergo measurement of PT/INR and PTT
during the initial presentation. For acute exposures, patients should receive
serial INR assessments every 12-24 hours. If INR remains normalized at 36
hours and there are no signs of bleeding, no further testing is generally
necessary.
 Option C: The results of the INR and PT level will be needed first. For these
recommendations, coagulopathy is defined as INR > 1.4. Warfarin toxicity
is defined as INR > 3.0 or >3.5 in a patient with a mechanical heart valve.
Unintentional toxicity in patients who are treated with warfarin for an
underlying condition (most common presentation).
 Option D: Protamine sulfate is the antidote for heparin overdose. Patients
with elevated INR displaying evidence of coagulopathy during evaluation,

do not need to be started on vitamin K unless the INR is greater than 10 or
they have evidence of bleeding.
ADVERTISEMENTS
19. Question
A male client with atrial fibrillation who is receiving maintenance therapy of
warfarin (Coumadin) has a prothrombin time of 37 seconds. Based on the result,
the nurse will follow which of the following doctor‘s orders?
 A. Administering the next dose of warfarin.
 B. Increasing the next dose of warfarin.
 C. Decreasing the next dose of warfarin.
 D. Withholding the next dose of warfarin.

Incorrect
Correct Answer: D. Withholding the next dose of warfarin.
The normal prothrombin time is 9.6 to 11.8 seconds (male adult). A therapeutic
level PT level is 1.5 to 2 times higher than the normal level. Since the value of 37
seconds is high, the nurse should expect that the client‘s next dose of warfarin
will be withheld. Patients receiving treatment with warfarin should have close
monitoring to ensure the safety and efficacy of the medication. Periodic blood
testing is recommended to assess the patient‘s prothrombin time (PT) and the
international normalized ratio (INR).
 Option A: The laboratory parameter utilized to monitor warfarin therapy is
the PT/INR. The PT is the number of seconds it takes the blood to clot, and
the INR allows for the standardization of the PT measurement depending
on the thromboplastin reagent used by a laboratory. Therefore, monitoring
a patient‘s INR while on warfarin is strongly preferable over PT because it
allows for a standardized measurement without variations due to different
laboratory sites.
 Option B: Routine assessment of INR is essential in the management of
patients receiving warfarin therapy. The INR of a patient who is not on
anticoagulation therapy is approximately 1.0. If a patient has an INR of 2.0
or 3.0, that would indicate that it takes two or three times longer for that

individual‘s blood to clot than someone who does not take any
anticoagulants.
 Option C: The therapeutic INR goal for patients on warfarin therapy is
dependent on the indication but may vary based on the patient‘s clinical
presentation and provider preference. Most patients on warfarin have an
INR goal of 2 to 3. However, specific indications, such as a mechanical
mitral valve, require an INR goal of 2.5 to 3.5.
1. 20. Question
A client is receiving a continuous intravenous infusion of heparin sodium to treat
deep vein thrombosis. The client‘s activated partial thromboplastin time is 77
seconds. Based on this result, the nurse anticipated which of the following
prescriptions?
o A. Maintain the rate of the heparin infusion.
o B. Decrease the rate of the heparin infusion.
o C. Increase the rate of the heparin infusion.
o D. Discontinue the heparin infusion.

Incorrect
Correct Answer: A. Maintain the rate of the heparin infusion.
The normal activated partial thromboplastin time is between 20 to 36 seconds. In
the treatment of deep vein thrombosis, the therapeutic range is to maintain the
aPTT level between 1.5 and 2.5 times the normal. This means that the client‘s
aPTT level should not be less than 30 seconds or greater than 90 seconds. Thus
the client‘s aPTT of 77 seconds is within the normal therapeutic range, and the
dose/rate should not be changed.
 Option B: Therapeutic monitoring for heparin includes activated partial
thromboplastin time (aPTT) and activated clotting time (ACT). Both of these
are aspects of clotting time, which are prolonged by therapeutic heparin
doses. Activated partial thromboplastin time is performed at baseline and
every 6 hours until 2 or more therapeutic values are obtained, then aPTT
can be assessed every 24 hours.
 Option C: Dose titrations are made based on the results of the aPTT.
Hospitals have dosing nomograms specific to their target aPTT, which may
vary depending upon the laboratory reagent used for their test.

Therapeutic aPTT is considered therapeutic at 1.5 to 2 times control, which
also varies from facility to facility based on controls.
 Option D: ACT is less sensitive than aPTT. ACT will only detect
abnormalities when there is 95% abnormality rate in the factors, whereas
aPTT can detect when there is 70% abnormality. ACT may also be affected
when platelets are abnormal, which can result from the administration of
heparin.
ADVERTISEMENTS
21. Question
A nurse is handling a pregnant client who was prescribed to have an Alpha
Fetoprotein level. The nurse should explain to the client that this blood test:
o A. Can indicate lung disorders and neural tube defects.
o B. Abnormal levels are associated with an increased risk for chromosome

abnormality.
o C. Once the Alpha-Fetoprotein levels are abnormal, amniocentesis will

be ordered.
o D. An Alpha-Fetoprotein is a definitive test for neural tube defects.

Incorrect
Correct Answer: C. Once the Alpha-Fetoprotein levels are abnormal,
amniocentesis will be ordered.
If the Alpha-Fetoprotein levels are abnormal, the physician will prescribe
amniocentesis to confirm or eliminate the diagnosis of a neural tube defect.
Alpha-fetoprotein (AFP) is a plasma protein produced by the embryonic yolk sac
and the fetal liver. AFP levels in serum, amniotic fluid, and urine function as a
screening test for congenital disabilities, chromosomal abnormalities, as well as
some other adult occurring tumors and pathologies.
 Option A: Option A is incorrect since Alpha Fetoprotein does not indicate
lung disorders. It is pertinent to explain that this is a screening test.
Depending on the outcome, more tests may be ordered for the purpose of
establishing a diagnosis. A negative test does not necessarily indicate no

risk as very low maternal blood alpha-fetoprotein is associated with an
increased incidence of Down syndrome.
 Option B: Option B is incorrect because an increase of human chorionic
gonadotropin instead is associated with an increased risk for chromosome
abnormality. This tumor marker is a glycoprotein encoded by the AFP gene
on chromosome 4q25. Prenatal levels in developing human embryos rise
from the end of the first trimester and begin to fall after 32 weeks of
gestation. Maternal serum AFP forms part of the triple or quadruple
screening tests for fetal anomaly.
 Option D: Option D is incorrect because an Alpha Fetoprotein level is a
screening test and is not a definitive test. This tumor marker is a
glycoprotein encoded by the AFP gene on chromosome 4q25. Prenatal
levels in developing human embryos rise from the end of the first trimester
and begin to fall after 32 weeks of gestation. Maternal serum AFP forms
part of the triple or quadruple screening tests for fetal anomaly.
ADVERTISEMENTS
22. Question
Which of the following laboratory results indicates hypoparathyroidism?
o A. Serum potassium of 3.6 mEq/L.
o B. Serum calcium level of 4.3 mEq/L.
o C. Serum phosphorus level of 5.7 mg/dL.
o D. Serum magnesium level of 1.7 mg/dL.

Incorrect
Correct Answer: C. Serum phosphorus level of 5.7 mg/dL.
The parathyroid is responsible for the absorption of calcium and phosphorus.
When a client has hypoparathyroidism, the serum calcium levels are low and the
serum phosphorus levels are high. The normal phosphorus level is 2.7 to 4.5
mg/dL. Parathyroid hormone deficiency, also called hypoparathyroidism, results
in hypocalcemia, hyperphosphatemia, and increased neuromuscular irritability.
Patients may present with myalgias, muscle spasms, and in extreme cases tetany.

 Option A: Calcium is maintained within a fairly narrow range from 8.5 to
10.5 mg/dl (4.3 to 5.3 mEq/L or 2.2 to 2.7 mmol/L). Normal values and
reference ranges may vary among laboratories as much as 0.5 mg/dl.
Aldinger KA, et al., studied a large group of patients of normal renal
function with hypercalcemia to determine the prevalence of hypokalemia
and reported that 16.9% had hyperparathyroidism, and the degree and
frequency of hypokalemia were greatest at the higher serum calcium levels.
 Option B: Parathyroid hormone activates the PTH receptor, another G-
protein coupled receptor, increasing resorption of calcium and phosphorus
from bone, enhancing the distal tubular reabsorption of calcium, and
decreasing the renal tubular reabsorption of phosphorus. Deficient PTH
results in hypocalcemia, hyperphosphatemia, while alkaline phosphatase, a
marker of bone formation, is normal.
 Option D: The normal range for blood magnesium level is 1.7 to 2.2 mg/dL
(0.85 to 1.10 mmol/L). Another common cause of hypoparathyroidism is
abnormally low levels of magnesium (hypomagnesemia) in the blood. This
is often called functional hypoparathyroidism because it resolves when
magnesium is restored. Magnesium is a mineral that is very important in
the function of the parathyroid glands.
ADVERTISEMENTS
23. Question
An adult male client has a hemoglobin count of 12.5 g/dL. Based on the result,
the client is most likely having this due to which of the following notes in the
client‘s record?
o A. Emphysema.
o B. Client living at a high altitude.
o C. Dehydration.
o D. History of an enlarged spleen.

Incorrect
Correct Answer: D. History of splenomegaly.

The normal hemoglobin level for an adult male is 14-16.5 g/dL. An enlarged
spleen may cause anemia (low hemoglobin count) in clients. The spleen normally
removes old and/or damaged red blood cells from the bloodstream. However,
when the spleen enlarges, it traps and stores an excessive number of red blood
cells, causing anemia. Sometimes, the spleen also destroys white blood cells
and/or platelets causing a low white blood cell count (leukopenia) and a low
platelet count (thrombocytopenia).
 Option A: Anemia of chronic disease (ACD) is probably the most common
type of anemia associated with COPD. ACD is driven by COPD-mediated
systemic inflammation. Anemia in COPD is associated with greater
healthcare resource utilization, impaired quality of life, decreased survival,
and a greater likelihood of hospitalization.
 Option B: Living at higher altitudes causes red blood cell production to
naturally increase to compensate for the lower oxygen supply. The amount
of hemoglobin in blood increases at high altitude. This is one of the best-
known features of acclimatization (acclimation) to high altitude. Increasing
the amount of hemoglobin in the blood increases the amount of oxygen
that can be carried.
 Option C: Dehydration may increase the hemoglobin level by
hemoconcentration. Both the hemoglobin and the hematocrit are based on
whole blood and are therefore dependent on plasma volume. If a patient is
severely dehydrated, the hemoglobin and hematocrit will appear higher
than if the patient were normovolemic; if the patient is fluid overloaded,
they will be lower than their actual level.
ADVERTISEMENTS
24. Question
A screen test for the detection of human immunodeficiency virus (HIV) reveals a
positive ELISA exam. Which of the following tests will be used to confirm the
diagnosis of HIV?
o A. Indirect immunofluorescence assay (IFA).
o B. CD4-to-CD8 ratio.
o C. Radioimmunoprecipitation assay (RIPA) test.

o D. p24 antigen assay.
Incorrect
Correct Answer: A. Indirect immunofluorescence assay (IFA)
The indirect immunofluorescence assay (IFA) test and Western Blot test result are
considered as confirmatory for HIV. An initial HIV test usually will either be an
antigen/antibody test or an antibody test. If the initial HIV test is a rapid test or a
self-test and it is positive, the individual should go to a health care provider to
get follow-up testing. If the initial HIV test is a laboratory test and it is positive,
the laboratory will usually conduct follow-up testing on the same blood sample
as the initial test. Although HIV tests are generally very accurate, follow-up
testing allows the health care provider to be sure the diagnosis is right.
 Option B: CD4-to-CD8 ratio monitors the progression of HIV. A normal
CD4/CD8 ratio is greater than 1.0, with CD4 lymphocytes ranging from 500
to 1200/mm 3 and CD8 lymphocytes ranging from 150 to 1000/mm 3. If
the ratio is higher than 1, it means the immune system is strong and the
client may not have HIV. If the ratio is less than 1, the client may have HIV.
 Option C: Radioimmunoprecipitation assay (RIPA) test detects HIV protein
rather than showing antibodies. Radioimmunoprecipitation assay buffer
(RIPA buffer) is a lysis buffer used for rapid, efficient cell lysis and
solubilization of proteins from both adherent and suspension-cultured
mammalian cells.
 Option D: p24 antigen assay quantifies the amount of HIV viral core
protein. One distinctive HIV antigen is a viral protein called p24, a structural
protein that makes up most of the HIV viral core, or ‗capsid‘. High levels of
p24 are present in the blood serum of newly infected individuals during the
short period between infection and seroconversion, making p24 antigen
assays useful in diagnosing primary HIV infection.
ADVERTISEMENTS
25. Question
The client went to the emergency room with a sudden onset of chest pain and
difficulty of breathing. Which of the following results is indicative that the client is
experiencing a myocardial infarction?
o A. Myoglobin level of 98 mcg/L.

o B. Troponin T of 0.09 ng/mL.
o C. Troponin I 0.5 ng/mL.
o D. Creatine kinase (CK-MB) 155 units/L.

Incorrect
Correct Answer: A. Myoglobin level of 98 mcg/L.
The normal value of myoglobin is lower than 90 mcg/L; An elevation could
indicate a myocardial infarction. Myoglobin, an oxygen-carrying protein found in
cardiac muscle and striated skeletal muscle, presents an attractive alternative to
CPK and LDH in the emergency department setting for identification of acute
myocardial infarction. Myoglobin levels may be elevated in the serum within one
hour after myocardial cell death with peak levels reached within four to six hours.
 Option B: The troponin T level is normal. Cardiac troponin T is measured in
nanograms per milliliter (ng/mL). If the client‘s troponin T level is above the
99th percentile for the test being used, the doctor will likely diagnose a
heart attack. Levels that start high and fall suggest a recent injury to the
heart. It could be a mild heart attack.
 Option C: The troponin I level is normal. High levels of troponin are an
immediate red flag. The higher the number, the more troponin —
specifically troponin T and I — has been released into the bloodstream,
and the higher the likelihood of heart damage. Troponin levels can elevate
within 3-4 hours after the heart has been damaged and can remain high
for up to 14 days.
 Option D: Creatine kinase level has a normal value. The ECG and the
determination of serum enzymes creatine phosphokinase (CPK) and lactate
dehydrogenase (LDH) may be falsely normal early in acute myocardial
infarction.
ADVERTISEMENTS
26. Question
A nurse is caring for a client with diarrhea and dehydration. The nurse determines
that the client has received adequate fluid replacement if the blood urea nitrogen
decreases to:

o A. 36 mg/dL.
o B. 27 mg/dL.
o C. 18 mg/dL.
o D. 6 mg/dL.
Incorrect
Correct Answer: C. 18 mg/dL.
The normal value of blood urea nitrogen is 8 to 25 mg/dL. Fluid status absolutely
affects the levels of BUN and creatinine in the blood, but volume depletion or
dehydration tends to affect BUN more so that we see a BUN: creatinine ratio of
20:1 or more in people who are very dry.
 Option A: 36 mg/dl indicates a high level of BUN. Dehydration generally
causes BUN levels to rise more than creatinine levels. This causes a high
BUN-to-creatinine ratio. Kidney disease or blockage of the flow of urine
from the kidney causes both BUN and creatinine levels to go up.
 Option B: 27 mg/dl still indicates dehydration. A patient who is severely
dehydrated may also have a high BUN due to the lack of fluid volume to
excrete waste products. Because urea is an end product of protein
metabolism, a diet high in protein, such as high-protein tube feeding, may
also cause the BUN to increase.
 Option D: A low BUN occurs with conditions such as fluid volume
overload, malnutrition, etc. Because urea is synthesized by the liver, severe
liver failure causes a reduction of urea in the blood. Just as dehydration
may cause an elevated BUN, overhydration causes a decreased BUN. When
a person has a ―syndrome of inappropriate antidiuretic secretion‖ (SIADH),
the antidiuretic hormone responsible for stimulating the kidney to
conserve water causes excess water to be retained in the bloodstream
rather than being excreted into the urine.
ADVERTISEMENTS
27. Question
A client with liver cirrhosis has been advised to follow a high-protein diet. The
nurse evaluates the effectiveness of the diet if the total protein level is which of
the following values?

o A. 6.9 g/dL.
o B. 4.9 g/dL.
o C. 2.9 g/dL.
o D. 0.9 g/dL.
Incorrect
Correct Answer: A. 6.9 g/dL.
The normal value for total serum protein is 6 to 8 g/dL. The client with liver
cirrhosis has low total protein levels secondary to inadequate nutrition. Protein
deficiency is often associated with liver disease. The principal cause of protein
deficiency is decreased dietary intake. Deficiencies in digestion and absorption
that are common in alcoholics contribute to protein deficiency in alcoholic liver
disease.
 Option B: 4.9 mg/dl is a low value for total serum protein. The protein
requirements in most patients with compensated chronic liver disease are
not different from normal but increase during episodes of hepatocellular
deterioration. Increased demand for protein after liver injury drains
nitrogen from other organs such as muscle.
 Option C: 2.9 mg/dl is a very low total serum protein level. Circulating
proteins synthesized by the liver, such as albumin and clotting factors, are
frequently decreased in chronic liver disease. Vitamin deficiencies that are
common in liver disease contribute to abnormalities of protein metabolism.
Hepatic regeneration following hepatic resection or injury is adversely
affected by protein and vitamin deficiencies and by alcohol ingestion.
 Option D: 0.9 mg/dl is an abnormally low total serum protein value. This is
because some conditions affect the amounts of albumin or globulin in the
blood. A low A/G ratio may be due to an overproduction of globulin,
underproduction of albumin, or loss of albumin, which may indicate the
following: an autoimmune disease. cirrhosis, involving inflammation and
scarring of the liver.
ADVERTISEMENTS
28. Question

The nurse is handling a client with chronic pancreatitis. Upon reviewing the
client‘s record, which of the following serum amylase levels is to be expected?
o A. 50 units/L.
o B. 150 units/L.
o C. 350 units/L.
o D. 650 units/L.
Incorrect
Correct Answer: C. 350 units/L.
The normal serum amylase level is 25 to 151 unit/L. Clients with chronic
pancreatitis have an increased level of serum amylase which does not exceed
three times the normal value. Serum amylase and lipase levels may be slightly
elevated in chronic pancreatitis; high levels are found only during acute attacks of
pancreatitis.
 Option A: 50 units/L is a low serum amylase level. Low serum amylase
(hypoamylasemia) has been reported in certain common cardiometabolic
conditions such as obesity, diabetes (regardless of type), and metabolic
syndrome, all of which appear to have a common etiology of insufficient
insulin action due to insulin resistance and/or diminished insulin secretion.
 Option B: 150 units/L is within the normal values. However, in the later
stages of chronic pancreatitis, atrophy of the pancreatic parenchyma can
result in normal serum enzyme levels because of significant fibrosis of the
pancreas, resulting in decreased concentrations of these enzymes within
the pancreas.
 Option D: 650 units/L is seen with acute pancreatitis since the value may
exceed five times the normal value. The sensitivity and specificity of
amylase as a diagnostic test for acute pancreatitis depends on the chosen
threshold value. By raising the cut-off level to 1000 IU/l (more than three
times the upper limit of normal), amylase has a specificity approaching
95%, but sensitivity as low as 61% in some studies.
ADVERTISEMENTS
29. Question

A client with diabetes mellitus has a glycosylated hemoglobin A1c level of 10%.
Based on the result, the nurse plans to teach the client about the importance of:
o A. Maintaining the result.
o B. Preventing hypoglycemia.
o C. Preventing hyperglycemia.
o D. Avoiding infection.
Incorrect
Correct Answer: C. Preventing hyperglycemia.
Glycosylated hemoglobin A1c level of 8% higher indicates poor diabetic control.
Elevations indicate continued need for teaching related to the prevention of
hyperglycemic episodes. The test shows an average of the blood sugar level over
the past 90 days and represents a percentage. The test can also be used to
diagnose diabetes.
 Option A: For an A1c test to classify as normal, or in the non-diabetic
range the value must be below 5.7 %. Anyone with an A1c value of 5.7 % to
6.4 % is considered to be prediabetic, while diabetes can be diagnosed
with an A1c of 6.5% or higher. Hemoglobin A1c serves as an indicator of
overall glycemic control and a reflection of the average blood sugar over
the past three months.
 Option B: A falsely low A1c value can result from several conditions
including high altitude, pregnancy, hemorrhages, blood transfusions,
erythropoietin administration, iron supplementation, hemolytic anemia,
chronic kidney failure, liver cirrhosis, alcoholism, folic acid deficiency, sickle
cell anemia, and spherocytosis.
 Option D: A1c provides a measure of the glucose concentration over three
months. Hemoglobin A1c is often used as an outcome measure to
determine if an intervention in a population is successful by showing a
decrease in A1c by a certain percentage. Levels of A1c should be measured
twice a year in stable patients and at least four times in patients who have
glucose fluctuations or those who have had a change in their diabetic
treatment.
ADVERTISEMENTS

30. Question
The nurse is reviewing the laboratory result of a client receiving digoxin (Lanoxin)
and notes that the result is 2.5 ng/mL. The nurse plans to do which of the
following?
o A. Give the next dose.
o B. Notify the physician.
o C. Check the client's pulse rate.
o D. Increase the next dose as ordered.

Incorrect
Correct Answer: B. Notify the physician.
The normal value therapeutic range for digoxin is 0.5 to 2 ng/mL. A level of 2.5
ng/mL indicates toxicity. The nurse should immediately inform the physician, who
may give further instructions about holding the next doses of digoxin. Digoxin
toxicity can present acutely after an overdose or chronically, as is often seen in
patients on digoxin that develop acute kidney injury. Approximately 1% of CHF
patients treated with digoxin develop toxicity. Additionally, 1% of adverse drug
effects in patients greater than age 40 are due to digoxin toxicity; the incidence
rises to greater than 3% in patients over age 85.
 Option A: Clinical staff should monitor the plasma digoxin level at least 6
hours or 12 hours post-administration of the last loading dose as this is the
time to achieve steady-state levels. Recommended thresholds of
therapeutic serum digoxin levels are between 0.5 to 2 ng/dl.
 Option C: The physician must request regular electrocardiograms and
bloodwork to assess for renal function, and electrolytes require close
monitoring. No more than 2 ml of the drug should be injected at the same
site. The injection should be made deep into the muscle, and the overlying
area massaged post-injection. Intravenous injections are metabolized more
efficiently than intramuscular injections and are the preferred route, as only
about 80% of the drug is absorbed in intramuscular injections as compared
to intravenous dosing.
 Option D: Digoxin has a narrow therapeutic index. The recommended
serum levels stand between 0.8 to 2 ng/mL. When measuring a digoxin
serum level, it is essential to draw blood at least 6 to 8 hours after the last

dose. The toxicity increases as the serum drug levels increase above 2.0
ng/mL.
ADVERTISEMENTS
31. Question
The nurse caring for a client with a serum calcium of 6.8 mg/dL. What would the
nurse expect the change on the electrocardiogram (ECG)?
o A. None. This is a normal calcium level.
o B. Prolonged QT interval.
o C. Shortened ST segment.
o D. Widened T wave.
Incorrect
Correct Answer: B. Prolonged QT interval.
The normal serum calcium level is 8.6 to 10 mg/dL. A serum calcium level lower
than 8.6 mg/dL indicates hypocalcemia. Electrocardiographic changes that occur
in a client with hypocalcemia include a prolonged ST or QT interval. The ECG
hallmark of hypocalcemia remains the prolongation of the QTc interval because
of lengthening of the ST segment, which is directly proportional to the degree of
hypocalcemia or, as otherwise stated, inversely proportional to the serum calcium
level. The exact opposite holds true for hypercalcemia.
 Option A: High and low levels of ionized serum calcium concentration can
produce characteristic changes on the electrocardiogram. These changes
are almost entirely limited to the duration of the ST segment, with no
change in the QRS complexes or T waves.
 Option C: The ST segment on an electrocardiogram (ECG) normally
represents an electrically neutral area of the complex between ventricular
depolarization (QRS complex) and repolarization (T wave). However, it can
take on various waveform morphologies that may indicate benign or
clinically significant injury or insult to the myocardium.
 Option D: A widened T wave occurs with hypercalcemia. On
electrocardiography (ECG), characteristic changes in patients with
hypercalcemia include shortening of the QT interval. ECG changes in

patients with very high serum calcium levels include the following: slight
prolongation of the PR and QRS intervals; and T wave flattening or
inversion.
ADVERTISEMENTS
32. Question
When providing care for a female client with Addison disease, the nurse should
be alert for which of the following laboratory values?
o A. Potassium level of 3.2 mEq/L.
o B. Calcium level of 3.3 mEq/L.
o C. Sodium level of 150 mg/dL.
o D. Hematocrit level of 25%.

Incorrect
Correct Answer: D. Hematocrit level of 25%.
A client with Addison‘s disease is at risk for anemia. The normal hematocrit level
of a female adult is 35% to 45%. A client with anemia has a low hematocrit level.
Addison anemia, better known today as pernicious anemia (PA), is characterized
by the presence in the blood of large, immature, nucleated cells (megaloblasts)
that are forerunners of red blood cells. (Red blood cells, when mature, have no
nucleus). It is thus a type of megaloblastic anemia.
 Option A: The client with Addison‘s disease has increased potassium. A
deficiency of aldosterone, in particular, causes the body to excrete large
amounts of sodium and retain potassium, leading to low levels of sodium
and high levels of potassium in the blood.
 Option B: The client with Addison‘s disease has an increased calcium level.
As not all cases of adrenal insufficiency present with hypercalcemia, adrenal
insufficiency is not easily considered an etiology of hypercalcemia. The
prevalence of hypercalcemia at the time of diagnosis of Addison‘s disease
is reported to be ~5.5%–6.0%.
 Option C: The client with Addison‘s disease has a low sodium level. The
kidneys are not able to retain sodium easily, so when a person with
Addison disease loses too much sodium, the level of sodium in the blood

falls, and the person becomes dehydrated. Severe dehydration and a low
sodium level reduce blood volume and can lead to shock.
ADVERTISEMENTS
33. Question
A client has been undergoing radiotherapy for the treatment of mandibular
cancer. After a few sessions, the client is diagnosed with Tumor Lysis Syndrome
(TLS). Which of the following findings correlates with TLS?
o A. Phosphorus level of 6 mg/dL.
o B. Phosphorus level of 3 mg/dL.
o C. Phosphorus level of 4 mg/dL.
o D. Phosphorus level of 2 mg/dL.

Incorrect
Correct Answer: A. Phosphorus level of 6 mg/dL.
Tumor lysis syndrome (TLS) is a potentially life-threatening metabolic disorder
characterized by elevated phosphorus levels. The normal phosphorus is 2.5 to 4.5
mg/dL. When cancer cells break down quickly in the body, levels of uric acid,
potassium, and phosphorus rise faster than the kidneys can remove them. This
causes TLS. Excess phosphorus can ―sop up‖ calcium, leading to low levels of
calcium in the blood.
 Option B: 3 mg/dL is a normal phosphorus level. Changes in blood levels
of uric acid, potassium, phosphorus, and calcium can affect the functioning
of several organs, especially the kidneys, and also the heart, brain, muscles,
and gastrointestinal tract.
 Option C: 4 mg/dL is a normal phosphorus level. Not all cancer patients
are at equal risk of developing TLS. Patients with a large ―tumor burden‖ of
cancer cells and/or tumors that typically have rapidly dividing cells, such as
acute leukemia or high-grade lymphoma, as well as tumors that are highly
responsive to therapy, are at greatest risk of developing TLS.
 Option D: 2 mg/dL is a normal phosphorus level. TLS is not limited to
patients receiving traditional chemotherapy; it can also occur in patients
receiving steroids, hormonal therapy, targeted therapy, or radiation

therapy. Patients who are dehydrated and those with existing kidney
dysfunction are at higher risk of developing TLS.
ADVERTISEMENTS
34. Question
A female client went to the clinic with a creatinine clearance of 200 mL/min.
Which of the following conditions of the client can cause the increased level of
this test?
o A. Renal disease.
o B. Dehydration.
o C. Congestive heart failure.
o D. History of high dietary protein intake.

Incorrect
Correct Answer: D. History of high dietary protein intake.
The normal creatinine clearance for a female is 88 to 128 ml/min. An increased
creatinine clearance is often referred to as hyperfiltration and is most commonly
seen during pregnancy or in clients with a large dietary protein intake. Dietary
protein consumption increases serum creatinine level through protein catabolism
rather than decreased clearance. Hence, serum creatinine may be less reliable for
estimating GFR or estimating a glomerular hyperfiltration response in studies that
manipulate dietary protein.
 Option A: Creatinine clearance has been used for many decades to
estimate GFR. It involves a 24-hour urine collection to measure creatinine
excretion. As the same sample can be used to measure the protein
excretion rate, creatinine clearance is often used for the initial evaluation of
renal diseases, such as glomerulonephritis.
 Option B: Dehydration generally causes BUN levels to rise more than
creatinine levels. This causes a high BUN-to-creatinine ratio. Kidney disease
or blocked urine flow from the kidney causes both BUN and creatinine
levels to rise.
 Option C: Congestive heart failure is seen with a decreased creatinine
clearance. Low creatinine clearance levels can mean the client has chronic

kidney disease or serious kidney damage. Kidney damage can be from
conditions such as a life-threatening infection, shock, cancer, low blood
flow to the kidneys, or urinary tract blockage. Other conditions, such as
heart failure and dehydration, can also cause low clearance levels.
ADVERTISEMENTS
1. 35. Question
A nurse is reviewing the complete blood count (CBC) of a child who has been
diagnosed with idiopathic thrombocytopenic purpura. Which of the following
laboratory results should the nurse report immediately to the physician?
o A. Platelet count of 30,000/mm3.
o B. Hemoglobin level of 7.5 g/dL.
o C. Reticulocyte count of 6.5%.
o D. Eosinophil count of 700 cells/mm3.

Incorrect
Correct Answer: B. Hemoglobin level of 7.5 g/dL.
The low hemoglobin level indicates that the client has active bleeding, and
immediate actions such as additional diagnostic exams and blood transfusions
can be suggested. An initial impression of the severity of ITP is formed by
examining the skin and mucous membranes. Widespread petechiae and
ecchymoses, oozing from a venipuncture site, gingival bleeding, and hemorrhagic
bullae indicate that the patient is at risk for a serious bleeding complication.
 Option A: Decreased platelet count is expected in a child with idiopathic
thrombocytopenic purpura. Immune thrombocytopenia (ITP) is a syndrome
in which platelets become coated with autoantibodies to platelet
membrane antigens, resulting in splenic sequestration and phagocytosis by
mononuclear macrophages. The resulting shortened life span of platelets in
the circulation, together with incomplete compensation by increased
platelet production by bone marrow megakaryocytes, results in a
decreased number of circulating platelets.
 Option C: Increased reticulocyte is expected in a child with idiopathic
thrombocytopenic purpura. The measurement of the content of
hemoglobin of reticulocytes (CHr or Ret-He) reflects the synthesis of

hemoglobin in marrow precursors and allows the detection of early stages
of iron deficiency.
 Option D: An increased eosinophil count is expected in a child with
idiopathic thrombocytopenic purpura. Many authors have reported
associations between the increased numbers of eosinophils with platelet
dysfunctions, such as increased bleeding time, reduction in platelet
aggregation induced by various agonists, among other disorders.
ADVERTISEMENTS
36. Question
A patient receiving parenteral nutrition is administered via the following routes
except:
o A. Subclavian line.
o B. Central Venous Catheter.
o C. PICC (Peripherally inserted central catheter) line.
o D. PEG tube.
Incorrect
Correct Answer: D. PEG tube.
Percutaneous endoscopic gastrostomy (PEG tube) is inserted into a person‘s
stomach through the abdominal wall that is used to provide a means of feeding
when oral intake is not adequate. While parenteral nutrition bypasses the
digestive system by the administration to the bloodstream.
 Option A: TPN may be administered as peripheral parenteral nutrition
(PPN) or via a central line, depending on the components and osmolality.
Central veins are usually the veins of choice because there is less risk of
thrombophlebitis and vessel damage (Chowdary & Reddy, 2010).
 Option B: Parenteral nutrition may be delivered via femoral lines, internal
jugular lines, and subclavian vein catheters in the hospital setting. Central
access is required for infusions that are toxic to small veins due to
medication pH, osmolarity, and volume.
 Option C: PICC lines may be used in ambulatory settings or for long-term
therapy. It is inserted in the cephalic, basilic, median basilic, or median

cephalic veins and threaded into the superior vena cava. It can remain in
place for up to 1 year with proper maintenance and without complications.
ADVERTISEMENTS
37. Question
A nurse is monitoring the status of a client‘s fat emulsion (lipid) infusion and
notes that the infusion is 2 hours delay. The nurse should do which of the
following actions?
o A. Adjust the infusion rate to catch up over the next hour.
o B. Make sure the infusion rate is infusing at the ordered rate.
o C. Increase the infusion rate to catch up over the next few hours.
o D. Adjust the infusion rate to full blast until the solution is back on time.
Incorrect
Correct Answer: B. Make sure the infusion rate is infusing at the ordered
rate.
The nurse should maintain the prescribed rate of a fat emulsion even if the
infusion‘s time consumed is behind. The infusion of lipid emulsions allows a high
energy supply, facilitates the prevention of high glucose infusion rates, and is
indispensable for the supply with essential fatty acids. The administration of lipid
emulsions is recommended within ?7 days after starting PN (parenteral nutrition)
to avoid deficiency of essential fatty acids.
 Option A: This intervention may cause hyperglycemia. Low-fat PN with a
high glucose intake increases the risk of hyperglycemia. In parenterally fed
patients with a tendency to hyperglycemia, an increase in the lipid-glucose
ratio should be considered. In critically ill patients the glucose infusion
should not exceed 50% of energy intake.
 Option C: C is incorrect since increasing the rate will potentially cause a
fluid overload. The risk of PN complications (e.g. refeeding syndrome,
hyperglycemia, bone demineralization, catheter infections) can be
minimized by carefully monitoring patients and the use of nutrition
support teams particularly during long-term PN.

 Option D: If the infusion rate is adjusted to full blast, the patient might
undergo fluid overload and other complications. Occurring complications
are e.g. the refeeding syndrome in patients suffering from severe
malnutrition with the initiation of refeeding or metabolic,
hypertriglyceridemia, hyperglycemia, osteomalacia and osteoporosis, and
hepatic complications including fatty liver, non-alcoholic fatty liver disease,
cholestasis, cholecystitis, and cholelithiasis.
ADVERTISEMENTS
38. Question
A nurse is preparing to hang the initial bag of the parenteral nutrition (PN)
solution via the central line of a malnourished client. The nurse ensures the
availability of which medical equipment before hanging the solution?
o A. Glucometer.
o B. Dressing tray.
o C. Nebulizer.
o D. Infusion pump.
Incorrect
Correct Answer: D. Infusion pump.
The nurse should prepare an infusion pump prior to hanging a parenteral
solution. The use of an infusion pump is important to make sure that the solution
does not infuse too quickly or delayed since the parenteral nutrition has a high
glucose content. An infusion pump controls the rate at which the TPN solution is
given so that the concentrated food does not overload other digestive organs.
For many patients receiving TPN, the pump is portable.
 Option A: A glucometer is also needed since the client‘s glucose level is
monitored every 4 to 6 hours, but it is not an essential item needed.
Hyperglycemia is associated with increased hospital complications and
mortality in patients receiving TPN. TPN-induced hyperglycemia is
associated with increased length of hospital stay, increased risk of
complications, and higher mortality in hospitalized patients.

 Option B: A dressing tray is not used before hanging a PN solution. With
total parenteral nutrition, a solution of essential nutrients (including
proteins, fluids, electrolytes, and fat-soluble vitamins) is given into the
veins (intravenously). Because TPN solutions are highly concentrated and
thick, the solutions must be given through catheters that are placed in
large central veins in the neck, chest, or groin.
 Option C: A nebulizer is not used before hanging a PN solution. Total
parenteral nutrition (TPN) is the standard therapy for people who have this
problem. TPN can be used to treat a severe disorder that is expected to last
for a relatively short time, such as intractable vomiting during pregnancy. It
is also used as a long-term therapy.
ADVERTISEMENTS
39. Question
A nurse is conducting a follow-up home visit to a client who has been discharged
with parenteral nutrition(PN). Which of the following should the
nurse most closely monitor in this kind of therapy?
o A. Blood pressure and temperature.
o B. Blood pressure and pulse rate.
o C. Height and weight.
o D. Temperature and weight.

Incorrect
Correct Answer: D. Temperature and weight.
The client‘s temperature is monitored to identify signs of infection which is one of
the complications of this therapy. While the weight is monitored to detect
hypervolemia and to determine the effectiveness of this nutritional therapy.
Monitoring patients on parenteral nutrition (PN) requires a multidisciplinary
approach with effective communication throughout the team. This will help to
minimize potential complications and will aid safe, effective, and appropriate use
of PN.
 Option A: Temperature should be monitored to watch for infection,
however, blood pressure is not as important during total parenteral

nutrition. But blood pressure should still be monitored routinely. The risk of
infectious complications is increased due to venous access for PN. The
likelihood of hyperglycemia-induced complications may depend on
concomitant diseases, duration of PN, and life expectancy.
 Option B: Blood pressure and pulse rate may be checked routinely in a
patient with TPN. Efficient monitoring in all types of PN can result in
reduced PN-associated complications and reduced costs. Water and
electrolyte balance, blood sugar, and cardiovascular function should
regularly be monitored during PN.
 Option C: Monitoring the patient‘s height is not necessary during TPN
administration. Nutritional status is most effectively assessed and
monitored through a combination of anthropometric data, biochemical
and clinical measures. A stand-alone measure e.g. weight can rarely
provide adequate information.
ADVERTISEMENTS
40. Question
A nurse is preparing to hang a fat emulsion (lipids) and observes some visible fat
globules at the top of the solution. The nurse ensures to do which of the
following actions?
o A. Take another bottle of solution.
o B. Run the bottle solution under warm water.
o C. Roll the bottle solution gently.
o D. Shake the bottle solution vigorously.

Incorrect
Correct Answer: A. Take another bottle of solution.
Fat emulsions are used as dietary supplements for patients who are unable to get
enough fat in their diet, usually because of certain illnesses or recent surgery. The
nurse should examine the bottle of fat emulsion for separation of emulsion into
layers or fat globules or the accumulation of froth. The nurse should not hang a
fat emulsion if any of these are observed and should return the solution to the
pharmacy.

 Option B: Continuous fat infusion over 24 hours is the preferred method in
neonates. For this reason, commercial lipid emulsions are repacked to a
polypropylene syringe from original commercial bags and administered
intravenously to neonates at neonates wards with a higher temperature.
The higher temperature in neonatal wards could be an additional factor
negatively affecting the stability of lipid emulsion.
 Option C: Storage of lipid emulsion in plastic containers is controversial. It
was shown that patients who received lipids delivered in plastic bags are
more likely to have hypertriglyceridemia than those who received lipids
from glass bottles. This is possible because of a higher proportion of large-
diameter fat globules in plastic bags.
 Option D: An increase in the droplet size is the first indication of
formulation stability issues. Moreover, droplets greater than 5 ?m can be
trapped in the lungs and cause pulmonary embolism. Pulmonary embolism
may develop and is associated with a high risk of morbidity and mortality.
ADVERTISEMENTS
41. Question
A client is receiving nutrition via parenteral nutrition (PN). A nurse assesses the
client for complications of the therapy and assesses the client for which of the
following signs of hyperglycemia?
o A. High-grade fever, chills, and decreased urination.
o B. Fatigue, increased sweating, and heat intolerance.
o C. Coarse dry hair, weakness, and fatigue.
o D. Thirst, blurred vision, and diuresis.

Incorrect
Correct Answer: D. Thirst, blurred vision, and diuresis.
Signs of hyperglycemia include excessive thirst, fatigue, restlessness, blurred
vision, confusion, weakness, Kussmaul‘s respirations, diuresis, and coma when
hyperglycemia is severe. Hyperglycaemia is found in up to 50% of PN patients.
Important predictors are insulin resistance or diabetes mellitus, severity of the

underlying illness, concomitant steroid therapy, and the amount of glucose
provided.
 Option A: High-grade fever, chills, and decreased urination are signs of
infection. The risk of infectious complications is increased due to venous
access for PN. The likelihood of hyperglycemia-induced complications may
depend on concomitant diseases, duration of PN, and life expectancy.
 Option B: Fatigue, increased sweating, and heat intolerance are signs of
hyperthyroidism. Hyperthyroidism may manifest as weight loss despite an
increased appetite, palpitation, nervousness, tremors, dyspnea, fatigability,
diarrhea or increased GI motility, muscle weakness, heat intolerance, and
diaphoresis.
 Option C: Coarse dry hair, weakness, and fatigue are signs of
hypothyroidism. Inquire about dry skin, voice changes, hair loss,
constipation, fatigue, muscle cramps, cold intolerance, sleep disturbances,
menstrual cycle abnormalities, weight gain, and galactorrhea. Also obtain a
complete medical, surgical, medication, and family history.
ADVERTISEMENTS
42. Question
A nurse is caring for a client who disconnected the tubing of the parenteral
nutrition from the central line catheter. A nurse suspects an occurrence of an air
embolism. Which of the following is an appropriate position for the client in this
kind of situation?
o A. On the right side, with head higher than the feet.
o B. On the right side, with head lower than the feet.
o C. On the left side, with the head higher than the feet.
o D. On the left side, with head lower than the feet.

Incorrect
Correct Answer: D. On the left side, with head lower than the feet.
Air embolism happens because of the entry of air into the catheter system. If it
occurs, the client should be placed in a left-side-lying position with the head be
lower than the feet. This position will lessen the effect of the air traveling as a

bolus to the lungs by trapping it on the right side of the heart. It occurs as a
result of a pressure gradient that allows air to enter the bloodstream, which can
subsequently occlude blood flow.
 Option A: When removing catheters, it is also recommended to raise CVP
by keeping the patient in a supine position or with their head down or
Trendelenburg position. Ideally, the venotomy site should be below the
level of the heart to ensure adequate central venous pressure at the time of
removal.
 Option B: Patients should be instructed to perform a Valsalva maneuver
during catheter removal, if possible. If this is not possible, removing the
catheter during active expiration is recommended. It should be ensured
that the exit site is covered with impermeable dressing and that pressure is
applied afterward for 5–10 min, for hemostasis and prevention of bubble
entry. It is recommended that the patient remains supine for 30 min after
central venous access removal
 Option C: In cases of venous air embolism, Durant‘s maneuver is
performed, by placing the patient in the left lateral decubitus and
Trendelenburg position. This serves to encourage the air bubble to move
out of the right ventricular outflow tract (RVOT) and into the right atrium,
thereby relieving the ―air-lock‖ effect responsible for potentially
catastrophic cardiopulmonary collapse.
ADVERTISEMENTS
43. Question
A client is being weaned off from parenteral nutrition (PN) and is given a go-
signal to take a regular diet. The ongoing solution rate has been 120ml/hr. A
nurse expects that which of the following prescriptions regarding the PN solution
will accompany the diet order?
o A. Decrease the PN rate to 60ml/hr.
o B. Start 0.9% normal saline at 30 ml/hr.
o C. Maintain the present infusion rate.
o D. Discontinue the PN.

Incorrect
Correct Answer: A. Decrease the PN rate to 60ml/hr.
When a client begins eating a regular diet after a period of receiving PN, the PN
is decreased slowly. Gradually decreasing the infusion rate allows the client to
remain sufficiently nourished during the transition to a normal diet and prevents
an episode of hypoglycemia.
 Option B: Parenteral nutrition is the intravenous administration of nutrition
outside of the gastrointestinal tract. Total parenteral nutrition (TPN) is
when the IV administered nutrition is the only source of nutrition the
patient is receiving. Total parenteral nutrition is indicated when there is an
inadequate gastrointestinal function and contraindications to enteral
nutrition.
 Option C: Patients who recently received TPN should be monitored daily
until stable. They require more frequent monitoring if metabolic
abnormalities are detected or if the patient has a risk of refeeding
syndrome. Refeeding syndrome can occur in severely malnourished and
cachectic individuals when feeding is reintroduced and can lead to severe
electrolyte instabilities.
 Option D: PN that is terminated abruptly will cause hypoglycemia. Total
parenteral nutrition administration is through a central venous catheter. A
central venous catheter is an access device that terminates in the superior
vena cava or the right atrium and is used to administer nutrition,
medication, chemotherapy, etc. Establishing this access could be through a
peripherally inserted central catheter (PICC), central venous catheter, or an
implanted port.
ADVERTISEMENTS
44. Question
A client receiving parenteral nutrition (PN) in the home setting has a weight gain
of 5 lb in 1 week. The nurse next assesses the client to identify the presence of
which of the following?
o A. Hypotension.
o B. Crackles upon auscultation of the lungs.

o C. Thirst.
o D. Polyuria.
Incorrect
Correct Answer: B. Crackles upon auscultation of the lungs.
Normally, the weight gain of a client receiving PN is about 1-2 pounds a week. A
weight gain of five (5) pounds over a week indicates a client is experiencing fluid
retention that can result in hypervolemia. Signs of hypervolemia include weight
gain more than desired, headache, jugular vein distention, bounding pulse, and
crackles on lung auscultation.
 Option A: Hypertension, not hypotension is expected. Fluid overload can
occur for the same reasons that fluid overload can occur with a regular
peripheral intravenous flow. The rate is too fast and rapid for the client. The
signs and symptoms of fluid overload include hypertension, edema,
adventitious breath sounds like crackles and rales, shortness of breath, and
bulging neck veins.
 Option C: Thirst is associated with hyperglycemia. Hyperglycemia can
occur as the result of the high dextrose content of the total parenteral
nutrition solution as well as the lack of a sufficient amount of administered.
This total parenteral nutrition complication can be prevented with the
continuous monitoring of the client‘s blood glucose levels and the titration
of insulin administration based on these levels of insulin.
 Option D: Polyuria is associated with hyperglycemia. The signs and
symptoms of hyperglycemia secondary to total parenteral nutrition are the
same as those associated with poorly managed diabetes and they include a
high blood glucose level, thirst, excessive urinary output, headache, nausea,
and fatigue.
ADVERTISEMENTS
45. Question
A nurse is making initial rounds at the beginning of the shift and notices that the
parenteral nutrition (PN) bag of an assigned client is empty. Which of the
following solutions readily available on the nursing unit should the nurse hang
until another PN solution is mixed and delivered to the nursing unit?

o A. 10% dextrose in water.
o B. 5% dextrose in water.
o C. 5% dextrose in normal saline.
o D. 5% dextrose in lactated Ringer solution.

Incorrect
Correct Answer: A. 10% dextrose in water.
The client is at risk of hypoglycemia. Hence the nurse will hang a solution that
has the highest amount of glucose until the new parenteral nutrition solution
becomes readily available. Crystalloid fluids are a subset of intravenous solutions
that are frequently used in the clinical setting. Crystalloid fluids are the first
choice for fluid resuscitation in the presence of hypovolemia, hemorrhage, sepsis,
and dehydration.
 Option B: Option B is also a crystalloid fluid, but contains less glucose than
option A. Other clinical applications include acting as a solution for
intravenous medication delivery, to deliver maintenance fluid in patients
with limited or no enteral nutrition, blood pressure management, and to
increase diuresis to avoid nephrotoxic drug or toxin-mediated end-organ
damage.
 Option C: Dextrose 5 in .9 Sodium Chloride is a prescription medicine used
to treat the symptoms of hypoglycemia. Dextrose 5 in .9 Sodium Chloride
may be used alone or with other medications. Dextrose 5 in .9 Sodium
Chloride belongs to a class of drugs called Glucose-Elevating Agents;
Metabolic and Endocrine, Other.
 Option D: 5% Dextrose in Lactated Ringer‘s Injection provides electrolytes
and calories, and is a source of water for hydration. It is capable of
inducing diuresis depending on the clinical condition of the patient. This
solution also contains lactate which produces a metabolic alkalinizing
effect.
ADVERTISEMENTS
46. Question

A nurse is caring for a group of clients in a medical-surgical nursing unit. The
nurse recognizes that which of the following clients would be the least likely
candidate for parenteral nutrition?
o A. A 55-year-old with persistent nausea and vomiting from chemotherapy.
o B. A 44-year old client with ulcerative colitis.
o C. A 59-year old client who had an appendectomy.
o D. A 25-year old client with Hirschsprung's Disease.

Incorrect
Correct Answer: C. A 59-year old client who had an appendectomy.
The client with an appendectomy is not a candidate because this client would
resume a regular diet within a few days following the surgery. The principal
indication for TPN is a seriously ill patient where enteral feeding is not possible. It
may also be used to supplement inadequate oral intake. The successful use of
TPN requires proper selection of patients, adequate experience with the
technique, and awareness of its complications.
 Option A: An indication of TPN are patients with malignancies in whom
malnutrition may jeopardize successful delivery of a therapeutic option
(surgery, chemo- or radiotherapy). While the indication for TPN may be
self-evident in the majority of the patients, it is recommended to have
some form of assessment of the nutritional status of the patient prior to
institution of TPN in order to plan the treatment and to formulate clear-cut
therapeutic goals
 Option B: Malabsorption secondary to sprue, enzyme & pancreatic
deficiencies, regional enteritis, ulcerative colitis, granulomatous colitis, and
tuberculous enteritis are indications for parenteral nutrition. The indications
of TPN are now fairly well defined, as is the knowledge about its
limitations, side effects, and complications. Advances in technology have
now made it possible for TPN to be delivered at the patient‘s own
residence, thus reducing hospital costs.
 Option D: Option D is incorrect because parenteral nutrition is indicated in
this client since their gastrointestinal tracts are not functional or cannot
take in a diet enterally for extended periods. Newborns with
gastrointestinal anomalies such as tracheoesophageal fistula, massive
intestinal atresia, complicated meconium ileus, massive diaphragmatic

hernia, gastroschisis, omphalocele or cloacal exstrophy, and neglected
pyloric stenosis.
ADVERTISEMENTS
47. Question
A client is receiving parenteral nutrition (PN) and is suddenly having a fever. A
nurse notifies the physician and the physician initially prescribes that the solution
and tubing be changed. The nurse should do which of the following with the
discontinued materials?
o A. Send them to the laboratory for culture.
o B. Save them for a return to the manufacturer.
o C. Return them to the hospital pharmacy.
o D. Discard them in the unit trash.

Incorrect
Correct Answer: A. Send them to the laboratory for culture.
When the client who is receiving PN has a high temperature, a catheter-related
infection should be suspected. The solution and tubing should be changed, and
the discontinued materials should be cultured for an infectious organism. Septic
complications of central venous catheters (CVCs) remain a significant cause of
patient morbidity and mortality both in the intensive care unit (ICU) and in
general hospital wards. Approximately 25% of CVCs inserted have been reported
to become colonized, with rates of catheter-related bloodstream infection
(CRBSI) varying between 0% and 11%.
 Option B: The solution and tubing should be brought immediately to the
laboratory to avoid the growth of other organisms. It has been proposed
that TPN, being a potential culture medium, is an independent risk factor
for CRBSI. However, there is a paucity of studies related to CVC
colonization and CRBSI and in patients receiving TPN via short-term CVCs.
 Option C: Returning the solution to the pharmacy is not the appropriate
action. Patients receiving total parenteral nutrition (TPN) are at high risk for
bloodstream infections (BSI). The notion that intravenous calories and

glucose lead to hyperglycemia, which in turn contributes to BSI risk, is
widely held.
 Option D: Do not discard the solution and tubing immediately. Other
studies have shown an increased infection risk without a survival benefit in
patients receiving TPN. There is a reported sepsis incidence of between
20% and 30% in patients receiving parenteral nutrition. The high risk of
sepsis is a major factor leading to an overall preference for enteral nutrition
over parenteral nutrition.
ADVERTISEMENTS
48. Question
A nurse is changing the central line dressing of a client receiving parenteral
nutrition (PN) and notes that there is redness and drainage at the insertion site.
The nurse next assesses which of the following?
o A. Time of last dressing change.
o B. Allergy.
o C. Client's temperature.
o D. Expiration date.
Incorrect
Correct Answer: C. Client’s temperature.
Redness at the catheter insertion site is a possible sign of infection. The nurse
would next assess for other signs of infection. Of the options given, the
temperature is the next item to assess. TPN requires a chronic IV access for the
solution to run through, and the most common complication is an infection of
this catheter. Infection is a common cause of death in these patients, with a
mortality rate of approximately 15% per infection, and death usually results from
septic shock.
 Option A: Assess skin integrity and wound healing. Skin integrity changes
and wound healing are used as parameters in monitoring the effectiveness
of TPN feeding.
 Option B: TPN composition is based on the calculated nutritional needs of
the client. Before the therapy is started, a thorough baseline assessment

will be completed by health care members which include physicians,
nurses, dieticians, and pharmacists. Changes in fluid balance, weight, and
caloric intake are used to assess TPN effectiveness.
 Option D: Administer TPN at the ordered rate; if the infusion is
interrupted, infuse 10% dextrose in water until the TPN infusion is
restarted. This substitute infusion provides needed fluid in addition to
protecting the client from sudden hypoglycemia; hypoglycemia can result
when the high glucose concentration to which the client has metabolically
adjusted is suddenly withdrawn.
ADVERTISEMENTS
49. Question
A client receiving parenteral nutrition (PN) complains of a headache. A nurse
notes that the client has a bounding pulse, jugular distension, and weight gain
greater than desired. The nurse determines that the client is experiencing which
complication of PN therapy?
o A. Air embolism.
o B. Hypervolemia.
o C. Hyperglycemia.
o D. Sepsis.
Incorrect
Correct Answer: B. Hypervolemia.
The client‘s signs and symptoms are consistent with hypervolemia. This happens
when the client receives excessive fluid administration or administration of fluid
too rapidly. Increased central venous pressure is noticed first as distention of the
jugular veins. Maintaining the head of bed elevated will promote ease in
breathing. This position also allows pooling of fluid in the bases and for gas
exchange to be more available to the lung tissue.
 Option A: An air embolism may occur if IV tubing disconnects and is open
to air, or if part of the catheter system is open or removed without being
clamped. Symptoms include sudden respiratory distress, decreased oxygen

saturation levels, shortness of breath, coughing, chest pain, and decreased
blood pressure.
 Option C: Hyperglycemia related to sudden increase in glucose after a
recent malnourished state. After starvation, glucose intake suppresses
gluconeogenesis by leading to the release of insulin and the suppression of
glycogen. Excessive glucose may lead to hyperglycemia, with osmotic
diuresis, dehydration, metabolic acidosis, and ketoacidosis. Excess glucose
also leads to lipogenesis (again caused by insulin stimulation). This may
cause fatty liver, increased CO2 production, hypercapnia, and respiratory
failure.
 Option D: CR-BSI, which starts at the hub connection, is the spread of
bacteria through the bloodstream. There‘s an increased risk of CR-BSI with
TPN, due to the high dextrose concentration of TPN. Symptoms include
tachycardia, hypotension, elevated or decreased temperature, increased
breathing, decreased urine output, and disorientation.
ADVERTISEMENTS
50. Question
A nurse is preparing to change the parenteral nutrition (PN) solution bag and
tubing. The client‘s central venous line is located in the right subclavian vein. The
nurse asks the client to take which essential action during the tube change?
o A. Turn the head to the right.
o B. Inhale deeply, hold it, and bear down.
o C. Breathe normally.
o D. Exhale slowly and evenly.

Incorrect
Correct Answer: B. Inhale deeply, hold it, and bear down.
The client should be asked to perform the Valsalva maneuver during tubing
changes. This helps avoid air embolism during tube changes. The nurse asks the
client to take a deep breath, hold it, and bear down. Make sure all connections
are clamped and closed. Clamp catheter, position patient in left Trendelenburg
position, call health care provider, and administer oxygen as needed.

 Option A: Option A is incorrect because if the intravenous line is on the
right, the client turns his or head to the left. This position increases
intrathoracic pressure. Central line management is a crucial skill that is
necessary on a routine basis to help lessen or prevent catheter-based
infections and complications. Initial placement of central lines is typically by
trained physicians, physician assistants, and nurse practitioners in a sterile
fashion.
 Option C: An air embolism may occur if IV tubing disconnects and is open
blood pressure.
 Option D: Exhaling can cause the potential for an air embolism during the
tube change. Routine evaluation by every team member will ensure that
appropriate handling and care of the central line is being performed to
help reduce the risk of catheter-associated complications.
ADVERTISEMENTS
51. Question
A nurse observes the client receiving fat emulsions is having hives. A nurse
reviews the client‘s history and notes which of the following may be caused by
the complaint of the client?
o A. Allergy to an egg.
o B. Allergy to peanuts.
o C. Allergy to shellfish.
o D. Allergy to corn.
Incorrect
Correct Answer: A. Allergy to an egg.
Fat emulsions (lipids) contain egg yolk phospholipids and should not be given to
clients with egg allergies. Intravenous fat emulsions (IFEs) are a vital component
of total parenteral nutrition, because they provide essential fatty acids. IFE is a

sterile fat emulsion that contains egg-yolk phospholipids. Although egg allergy is
listed as a contraindication, adverse reactions are uncommon.
 Option B: Hypersensitivity reactions to TPN can be managed by
withholding the TPN and treating with antihistamines if needed until the
reaction resolves. Identification, possibly by epicutaneous allergy testing,
and removal of the offending agent(s) from the TPN is necessary if TPN
therapy must be restarted.
 Option C: Although ingestion of egg lecithin in cooked food is generally
tolerated by egg-allergic people, administration of intravenous egg-
containing lipid emulsions may cause significant adverse reactions.
 Option D: If the patient has an allergy to amino acids, dextrose, fat
emulsion, or any other part of total parenteral nutrition, he should be
referred to a doctor first. If the patient has an allergy to corn, corn
products, eggs, peanuts, or soybeans, he should talk with a doctor.
ADVERTISEMENTS
52. Question
A client receiving parenteral nutrition (PN) complains of shortness of breath and
shoulder pain. A nurse notes that the client has an increased pulse rate. The nurse
determines that the client is experiencing which complication of PN therapy?
o A. Air embolism.
o B. Hypervolemia.
o C. Hyperglycemia.
o D. Pneumothorax.
Incorrect
Correct Answer: D. Pneumothorax.
Pneumothorax might happen during parenteral therapy due to inexact catheter
placement. In order to prevent this, the nurse obtains a chest x-ray after insertion
of the catheter to ensure proper catheter placement. A pneumothorax occurs
when the tip of the catheter enters the pleural space during insertion, causing the
lung to collapse. Symptoms include sudden chest pain, difficulty breathing,

decreased breath sounds, cessation of normal chest movement on affected side,
and tachycardia.
 Option A: An air embolism may occur if IV tubing disconnects and is open
blood pressure.
 Option B: Signs and symptoms include fine crackles in lower lung fields or
throughout lung fields, hypoxia (decreased O2 sats). Notify primary health
care providers regarding change in condition. The patient may require IV
medication, such as Lasix to remove excess fluids. A decrease or
discontinuation of IV fluids may also occur. Raise head of bed to enhance
breathing and apply O2 for oxygen saturation less than 92% or as per
agency protocol. Monitor intake and output. Pulmonary edema may be
more common in the elderly, young, and patients with renal or cardiac
conditions.
 Option C: Hyperglycemia related to sudden increase in glucose after a
recent malnourished state. After starvation, glucose intake suppresses
gluconeogenesis by leading to the release of insulin and the suppression of
glycogen. Excessive glucose may lead to hyperglycemia, with osmotic
diuresis, dehydration, metabolic acidosis, and ketoacidosis. Excess glucose
also leads to lipogenesis (again caused by insulin stimulation). This may
cause fatty liver, increased CO2 production, hypercapnia, and respiratory
failure.
ADVERTISEMENTS
53. Question
A nurse is caring for a combative client who is ordered to have a nutritional
therapy using parenteral nutrition (PN). The nurse should plan which of the
following measures to prevent the client from injury?
o A. Monitor blood glucose twice a day.
o B. Instruct the relative to stay with the nurse.
o C. Measure 24-hour intake and output.

o D. Secure all connections in the parenteral system.
Incorrect
Correct Answer: D. Secure all connections in the parenteral system.
The nurse should plan to secure all connections in the tubing. This will prevent
the client from pulling the connections apart. An air embolism may occur if IV
tubing disconnects and is open to air, or if part of the catheter system is open or
removed without being clamped. Symptoms include sudden respiratory distress,
decreased oxygen saturation levels, shortness of breath, coughing, chest pain,
and decreased blood pressure.
 Option A: The nurse may monitor the blood glucose but it is unrelated to
the situation. Many fatal instances of air emboli in patients with central
venous catheters have been reported in the literature. They frequently
occur when the tubing becomes tangled while a patient is getting out of
bed, causing the catheter to disconnect. Although less common, cracks in
the catheter hub can also allow air to enter the venous system.
 Option B: The relative may stay with the patient when necessary. Central
venous catheters are also used in applications other than TPN. These
include central venous pressure monitoring, rapid infusion of fluids,
pulmonary arterial pressure monitoring using Swan-Ganz catheters, and
hemodialysis. Also, a central venous catheter is often placed in the right
atrium during surgery to remove air that might be introduced elsewhere in
the venous system. It is possible for an air embolism to develop during all
of these central venous applications.
 Option C: Measuring the I&O of the patient is not related to the situation.
An air embolism can develop when the right side of the heart is open to
outside air through a disconnected catheter and a negative intrathoracic
pressure is present, such as during inspiration. The right side of the heart is
open to outside air when the catheter is first inserted and during catheter
changes.
ADVERTISEMENTS
54. Question
Nurse Spencer is caring for an anorexic client who is having a total parenteral
nutrition solution for the first time. Which of the following assessments requires
the most immediate attention?

o A. Dry sticky mouth.
o B. Temperature of 100° Fahrenheit.
o C. Blood glucose of 210 mg/dl.
o D. Fasting blood sugar of 98 mg/dl.

Incorrect
Correct Answer: C. Blood glucose of 210 mg/dl.
Total parenteral nutrition formula containing dextrose ranges from 5% to 70%. A
blood glucose level of 210mg/dl is considered high. After starvation, glucose
intake suppresses gluconeogenesis by leading to the release of insulin and the
suppression of glycogen. Excessive glucose may lead to hyperglycemia, with
osmotic diuresis, dehydration, metabolic acidosis, and ketoacidosis. Excess
glucose also leads to lipogenesis (again caused by insulin stimulation). This may
cause fatty liver, increased CO2 production, hypercapnia, and respiratory failure.
 Option A: Refeeding syndrome is caused by rapid refeeding after a period
of malnutrition, which leads to metabolic and hormonal changes
characterized by electrolyte shifts (decreased phosphate, magnesium, and
potassium in serum levels) that may lead to widespread cellular
dysfunction. Phosphorus, potassium, magnesium, glucose, vitamin, sodium,
nitrogen, and fluid imbalances can be life-threatening. High-risk patients
include the chronically undernourished and those with little intake for more
than 10 days. Patients with dysphagia are at higher risk. The syndrome
usually occurs 24 to 48 hours after refeeding has started. The shift of water,
glucose, potassium, phosphate, and magnesium back into the cells may
lead to muscle weakness, respiratory failure, paralysis, coma, cranial nerve
palsies, and rebound hypoglycemia.
 Option B: CR-BSI, which starts at the hub connection, is the spread of
bacteria through the bloodstream. There‘s an increased risk of CR-BSI with
TPN, due to the high dextrose concentration of TPN. Symptoms include
tachycardia, hypotension, elevated or decreased temperature, increased
breathing, decreased urine output, and disorientation.
 Option D: Monitor blood sugar frequently QID (four times per day), then
less frequently when blood sugars are stable. Follow agency policy for
glucose monitoring with TPN. Be alert to changes in dextrose levels in
amino acids and the addition/removal of insulin to TPN solution.
ADVERTISEMENTS

55. Question
Nurse Russell is preparing to give total parenteral nutrition using a central line.
Place the following steps for administration in the correct order?
View Answers:
o Prime the IV tubing through an infusion pump.

o Connect the tubing to the central line.
o Maintain an aseptic technique when handling the injection cap.
o Check the solution for cloudiness, particles, or a change in color.
o Regulate the electric infusion pump at the ordered rate.
o Select and flush the correct tubing and filter.
Incorrect
 Total Parenteral Nutrition (TPN), also known as intravenous or IV nutrition
feeding, is a method of getting nutrition into the body through the veins.
In other words, it provides nutrients for patients who do not have a
functioning GI tract or who have disorders requiring complete bowel rest.
Review physician‘s orders and compare to MAR and content label on TPN
solution bag and for rate of infusion. Each component of the TPN solution
must be verified with the physician‘s orders. Complete all safety checks for
CVC as per agency policy.
ADVERTISEMENTS
1. 56. Question
Nurse Aaron is inserting a nasogastric tube to a stroke client. He understands
that the best position for the insertion is?
o A. Low Fowler‘s.
o B. Sims position.
o C. Trendelenburg.

o D. High Fowler’s.
Incorrect
Correct Answer: D. High Fowler’s.
The best position during a nasogastric tube insertion is sitting or High Fowler‘s
position in order to prevent the risk of aspiration. Position patient sitting up at 45
to 90 degrees (unless contraindicated by the patient‘s condition), with a pillow
under the head and shoulders. This allows the NG tube to pass more easily
through the nasopharynx and into the stomach.
 Option A: Low fowler‘s position is similar to the supine position, and is
considered the best position for rest. In a low-Fowler‘s position, the
patient‘s head is inclined at a 15- or 30-degree angle. Insertion of NGT
could be particularly difficult in this position. Low Fowler‘s position is
typically used to reduce lower back pain, during administration of drugs, or
during tube feeding.
 Option B: Insertion of NGT would be impossible in Sim‘s position. The
Sims position is a standard position in which the patient lies on their left
side, with right hip and knees bent. The lower arm is behind the back, the
thighs flexed. The left knee is slightly tilted. The right arm is positioned
comfortably in front of the body, the right arm is rested behind the body.
This is also known as ―lateral‖ position. Sim‘s position is often used for
rectal examination and treatments.
 Option C: Placing the patient in Trendelenburg position for NGT insertion
is highly inappropriate. In Trendelenburg position, the patient is supine on
the table with their head declined below their feet at an angle of roughly
16°. Trendelenburg position is typically used for lower abdominal surgeries
including colorectal, gynecological, and genitourinary procedures as well as
central venous catheter placement.
ADVERTISEMENTS
57. Question
Nurse Monica is handling a female client who had undergone a mastectomy.
Which is the best position in which she should place the client?
o A. Head of bed elevated at least 30° with the affected arm elevated on a
pillow.

o B. Forward side-lying position.
o C. Supine position with the affected arm remains flat.
o D. Head of bed elevated at least 30° with the unaffected arm elevated on a
pillow.
Incorrect
Correct Answer: A. Head of bed elevated at least 30°.
Position a post-mastectomy client with the head of the bed elevated at least 30
degrees, with the affected arm elevated on a pillow to promote lymphatic fluid
return after the removal of axillary lymph nodes. The patient is draped with the
arm free to allow for movements during the procedure. It is important not to
hyperextend the arm when positioning the patient; hyperextension may cause
significant postoperative neurapraxia.
 Option B: Patient positioning is in a supine position in the operating room,
and the breast, chest wall, axilla, and upper arm are exposed, after
induction of anesthesia. Many surgeons may include the contralateral
breast in the prepped operative field. There has been a growing trend
toward breast conservation, and numerous studies have looked at the
efficacy of breast-conserving surgery when compared to standard
mastectomy techniques.
 Option C: The patient is kept in a supine position with a thin sandbag
under the ipsilateral scapula to facilitate axillary dissection. The ipsilateral
arm is draped separately and kept free for adduction during axillary
dissection.
 Option D: The patient is placed supine with the ipsilateral arm stretched
out level with the shoulder. The head end of the operating table is raised to
30º. The side being operated on is raised by 30º. Lymphedema is less
commonly present since the advent of modified mastectomy techniques.
Axillary lymph node dissection is the most significant risk factor for the
development of lymphedema, with a reported incidence of greater than
20%.
ADVERTISEMENTS
58. Question

A nurse is caring for a client with severe burns of the face and head. The nurse
will place the client in which position?
o A. Trendelenburg.
o B. Head of bed elevated.
o C. Supine position.
o D. Prone position.
Incorrect
Correct Answer: B. Head of bed elevated.
For clients with burns on the face and head, the best position is to elevate the
head of the bed to reduce the occurence of facial edema. Elevation will
encourage drainage of fluid and allow it to be reabsorbed by the body. The
swollen part should be higher than the rest of the limb so that gravity can assist.
 Option A: Placing the patient in Trendelenburg position would aggravate
the facial edema. Physiochemical changes in the extracellular spaces cause
protein denaturation, increasing the oncotic pressures, increasing local
edema. It is also important to be aware of the requirement for fluid
resuscitation, which increases the hydrostatic gradient, ultimately pushing
more fluid into the extracellular space, compounding the tissue edema
from the initial insult.
 Option C: If the client has facial swelling it is extremely important to
maintain an upright position. The client should avoid lying flat as this
encourages fluid collection in the face and head which can lead to difficulty
opening the eyes and may also affect breathing.
 Option D: If the patient is placed in a prone position, fluid would
accumulate in the face. Burns cause a local cytokine-mediated
inflammatory response, creating hyperpermeability of the
microvasculature, leading to tissue swelling. For the patient who sustains
any facial burns or inhalation injuries, local swelling can occur rapidly and
immediately.
ADVERTISEMENTS
59. Question

Which of the following does not match with the appropriate position?
o A. Vaginal examination: Lithotomy position.
o B. Thyroidectomy: Fowler's position.
o C. Hemorrhoidectomy: Lateral position.
o D. Hypophysectomy: Prone position.

Incorrect
Correct Answer: D. Hypophysectomy: Prone position.
Hypophysectomy is the surgical removal of the hypophysis (pituitary gland). After
the surgery, the client‘s head is elevated to prevent increased intracranial
pressure. CSF fluid around the brain and spine leaks into the nervous system. This
requires treatment with a procedure called a lumbar puncture, which involves
inserting a needle into the spine to drain excess fluid.
 Option A: Lithotomy position is commonly used during gynecologic,
rectal, and urologic surgeries with a patient lying supine with legs
abducted 30 to 45 degrees from midline with knees flexed and legs held
supported with the foot of the bed lowered or removed to facilitate the
procedure.
 Option B: When a patient comes back from having their thyroidectomy
surgery, place them in a semi-Fowler‘s position. Sitting totally upright
would put the patient at a 90-degree angle, but in a semi-Fowler‘s position,
they are angled between 15 and 45 degrees.
 Option C: In lateral position, the lower extremities are carefully padded
between the knees and below the dependent knee to avoid excessive
external pressure over bony prominences. The dependent lower extremity
is somewhat flexed to avoid stretch or compression of the lower extremity
nerves.
ADVERTISEMENTS
60. Question
Nurse Ian is handling a client with gastroesophageal reflux disease. Which of the
following positions will best help the client in this case?

o A. Right Lateral Recumbent.
o B. Supine position.
o C. Reverse Trendelenburg position.
o D. Sims position.
Incorrect
Correct Answer: C. Reverse Trendelenburg position.
Reverse Trendelenburg position is advised to a client to promote gastric
emptying and prevent gastroesophageal reflux. Studies that monitored
esophageal acid exposure after elevation of the head of the bed showed a
decrease in reflux activity in adults. Placing blocks under the head of the bed or
placing a foam wedge under the patient‘s mattress can accomplish this.
 Option A: In the right lateral recumbent position, the individual is lying on
their right side. This position makes it easier to access a patient‘s left side.
The word ―lateral‖ means ―to the side,‖ while ―recumbent‖ means ―lying
down.‖
 Option B: Avoid placing the patient in supine position, have the patient sit
upright after meals. Supine position after meals can increase regurgitation
of acid. Elevate HOB while in bed to prevent aspiration by preventing the
gastric acid to flow back into the esophagus.
 Option D: The Sims position is a standard position in which the patient lies
on their left side, with right hip and knees bent. The lower arm is behind
the back, the thighs flexed. The left knee is slightly tilted. The right arm is
positioned comfortably in front of the body, the right arm is rested behind
the body. This is also known as ―lateral‖ position. This position is often used
for rectal or vaginal examination, and treatments.
ADVERTISEMENTS
61. Question
A client with pleural effusion is scheduled to have a thoracentesis. The nurse on
duty will assist the client to which position during the procedure?
o A. Lying in bed on the unaffected side with the head of the bed elevated
about 45°.

o B. Forward side-lying position with head of bed flat.
o C. Lying in bed on the affected side with the head of the bed elevated about
45°.
o D. Supine position with both arms extended.

Incorrect
Correct Answer: A. Lying in bed on the unaffected side with head of bed
elevated about 45°.
During thoracentesis, to facilitate removal of pleural fluid from the pleural space,
position the client sitting on the edge of the bed, leaning over a bedside table
with the feet supported on a stool, or lying in bed on the unaffected side with
head of bed elevated about 45°.
 Option B: Patient lies between supine and prone with legs flexed in front
of the patient. Arms should be comfortably placed beside the patient, not
underneath. However, the head of the bed should be elevated to facilitate
drainage of pleural fluid from the pleural space.
 Option C: The patient should lie on the unaffected side. The patient is
moved to the extreme side of the bed, the ipsilateral hand is placed behind
the head, and a towel roll is placed under the contralateral shoulder. This
measure facilitates dependent drainage and provides good access to the
posterior axillary space.
 Option D: Patients who are alert and cooperative are most comfortable in
a seated position, leaning slightly forward and resting the head on the
arms or hands or on a pillow, which is placed on an adjustable bedside
table. This position facilitates access to the posterior axillary space, which is
the most dependent part of the thorax. Unstable patients and those who
are unable to sit up may be supine for the procedure.
ADVERTISEMENTS
62. Question
Nurse Maria is administering a cleansing enema to a client with severe
constipation. She will place the client in which position?
o A. Low Fowler's position.

o B. High Fowler's position.
o C. Left Sim's position.
o D. Right Sim's position.

Incorrect
Correct Answer: C. Left Sim’s position.
During a cleansing enema, place the client in the left Sim‘s position to allow the
solution to flow by gravity in the natural direction of the colon. Position the
patient on the left side, lying with the knees drawn to the abdomen. This eases
the passage and flow of fluid into the rectum. Gravity and the anatomical
structure of the sigmoid colon also suggest that this will aid enema distribution
and retention.
 Option A: Position the patient on his left side in Sims‘ position or left
lateral position with the right knee flexed, which will adequately expose the
anus. This position allows the solution to flow downward by gravity along
the curve of the sigmoid colon and rectum, thus improving the
effectiveness of the enema.
 Option B: The ideal positions for enema administration are the left-side
position and the knee-chest position. It is advised that the patient remains
in one of these positions to receive the enema for one-third of the time.
 Option D: The left lateral position is the most appropriate position for
giving an enema because of the anatomical characteristics of the colon.
Although the length of the tube to be inserted is designated as
approximately 5-6 cm, do not try to force it but pull it back slightly if any
resistance is felt.
ADVERTISEMENTS
63. Question
What type of client would benefit the most from an elevated head of the bed
position?
o A. Patient who had a hemorrhoidectomy.
o B. Patient who had a laryngectomy.

o C. Patient who had a liver biopsy.
o D. Patient who had a lumbar puncture.

Incorrect
Correct Answer: B. Patient who had a laryngectomy.
Place a post-laryngectomy client with the head of bed elevated at 30-45 degrees
to maintain a patent airway and reduce edema. Maintain an upright or sitting
position during feedings (or place on the lap or in an infant seat); allow to remain
in position for 30 minutes afterward. Promotes the flow of fluids and foods
through gravity.
 Option A: Post-operative hemorrhoidectomy position is supine position.
Supine position, also known as Dorsal Decubitus, is the most frequently
used position for procedures. In this position, the patient is face-up. The
patient‘s arms should be tucked at the patient‘s sides with a bedsheet,
secured with arm guards to sleds.
 Option C: Liver biopsy patients should remain in a right side-lying position
after the procedure. After the biopsy, the doctor will place a bandage over
the cut on the abdomen. The client may be asked to lie on his right side
after the biopsy, and he will need to remain lying down for a few hours.
Health care professionals will typically check the vital signs regularly for 2
to 4 hours after the procedure.
 Option D: After lumbar puncture, place the client in a supine position for
at least 4 hours. As blood will distribute into the epidural space through
few spinal segments superiorly and inferiorly, it is not essential to introduce
it into the exact place at which the dural puncture was performed. After the
procedure, the patient is asked to lie still in a supine position and is then
mobilized.
ADVERTISEMENTS
64. Question
Nurse Justin is taking care of a client with deep vein thrombosis. Which position
should be provided to the client?
o A. Bed rest with the affected extremity remains flat at all times.

o B. Bed rest with the unaffected extremity on top of the affected extremity.
o C. Bed rest with the affected extremity in a dependent position.
o D. Bed rest with the affected extremity elevated.

Incorrect
Correct Answer: D. Bed rest with the affected extremity elevated.
Bed rest is indicated to prevent emboli while the elevation of the affected leg
facilitates blood flow by the force of gravity and reduces pain and edema.
Elevating the legs can help to instantly relieve pain. A doctor may also instruct a
patient to elevate the legs above the heart three or four times a day for about 15
minutes at a time. This can help to reduce swelling. If prolonged standing or
sitting is necessary, bending the legs several times will help promote blood
circulation.
 Option A: DVT develops as a result of being in a continuous seated prone
positioning for 6 hours. Deep vein thrombosis and its sequelae such as PE
can be severe or fatal. However, these consequences are preventable. Deep
vein thrombosis may arise spontaneously or may be caused by trauma,
surgery, or prolonged bed rest.
 Option B: Deep vein thrombosis is a clinical challenge for doctors because
it can develop in any section of the venous system; however, it arises most
frequently in the deep veins of the leg. There are reports of DVT
developing in a fiberglass mold maker after 6 weeks of working in a
kneeling position, and in a patient maintaining a prone position after spine
surgery with a central venous catheter in place.
 Option C: A surgical operation where the patient is asleep (under general
anesthetic) is the most common cause of a DVT. The legs are still when the
client is under anesthetic because the muscles in the body are temporarily
paralyzed. Blood flow in the leg veins can become very slow, making a clot
more likely to occur. Certain types of surgery (particularly operations on
the pelvis or legs) increase the risk of DVT even more.
ADVERTISEMENTS
65. Question
Nurse Sandra had just received a postoperative total hip replacement client from
the recovery unit. Which is the best position in which she should place the client?

o A. Side-lying with the affected leg externally rotated.
o B. Side-lying with the affected leg internally rotated.
o C. On the nonoperative side with the legs abducted.
o D. On the nonoperative side with the legs adducted.

Incorrect
Correct Answer: C. On the nonoperative side with the legs abducted.
Abduction is maintained when the client is in a supine position or positioned on
the non-operative side. The patient‘s leg should be positioned in abduction. This
is to prevent dislocation of the prosthesis. It is very crucial that the femoral head
component of the acetabular cap is maintained in the correct position. Abduction
splints, wedge pillows, and two or three pillows between the legs of the patient
will keep the hip in abduction.
 Option A: In cases where the patient needs to be turned, the operative hip
must be kept in abduction and the entire length of the leg supported by
pillows. The hip of the patient should NOT be flexed more than 45 to 60
degrees.
 Option B: To prevent acute hip flexion, the head of the bed should not be
elevated more than 45 degrees. Remind the patient not to sleep on the
operated side until this position is cleared with the surgeon.
 Option D: An abduction splint or pillows should be kept between the legs.
The patient is encouraged to keep the operative hip in extension when
transferring or sitting. The patient is instructed to pivot in the unoperated
leg while assisted by the nurse, who protects the operative leg from
adduction, flexion, and excessive weight-bearing.
ADVERTISEMENTS
66. Question
A client has just returned to a nursing unit after a cardiac catheterization
performed using the femoral artery. The nurse places the client in which position?
o A. Bed rest with head elevation at 30°.
o B. Bed rest with head elevation at 45°.

o C. Bed rest with head elevation at 60°.
o D. Bed rest with head elevation at 90°.

Incorrect
Correct Answer: A. Bed rest with head elevation at 30°.
During cardiac catheterization, if the femoral artery was accessed for the
procedure, the client is maintained on bed rest for 4 to 6 hours and the affected
extremity is maintained straight and the head is elevated to no more than 30°.
Frequent assessment of the extremity for adequate perfusion enables prompt
intervention as needed.
 Option B: Guidelines require patient puncture sites to be assessed every
thirty minutes for four hours minimum before the patient is allowed off of
bed rest. The patient is free to move side to side for their comfort. The
head of the bed should be at a maximum thirty-degree tilt. The patient
should be allowed to eat and drink right after the procedure if they wish to.
 Option C: Encourage bed rest and keep affected extremity straight or
slight bend in the knee (10 degrees) for 6 hours. Bed rest and slight, or no
flexion, provide improved circulation and minimizes the risk of further
trauma which could promote the formation of a clot.
 Option D: Patients should be kept lying flat for several hours after the
procedure so that any serious bleeding can be avoided and that the artery
can heal. It is advised that diagnostic catheterization patients are kept on
bed rest for four hours, and interventional catheterization patients stay on
bed rest for six hours.
ADVERTISEMENTS
67. Question
A nurse is preparing to care for a client who had undergone an above-knee
amputation of the right leg. The nurse plans to allow which position for the client
in the first 24 hours?
o A. Supine position, with the affected limb flat on the bed.
o B. Supine position, with the affected limb supported with pillows.
o C. Prone position, with the affected limb in a dependent position.

o D. Trendelenburg's position.
Incorrect
Correct Answer: B. Supine position, with the affected limb supported with
pillows.
The amputated limb is usually supported with pillows on the first post-op day to
promote venous return and reduce edema. Preventing contractures is very
important. A contracture occurs when a joint becomes stuck in one position. If
this happens, it may be hard or impossible to straighten the remaining limb and
use an artificial leg.
 Option A: Make sure the client puts equal weight on both hips when he
sits. Use firm chairs, and sit up straight. The client should keep the
remaining limb flat with both legs together while lying on the back. The
client should not sit for more than an hour or two. He must stand, or lie on
his stomach now and then.
 Option C: If the affected limb is put in a dependent position, edema might
occur. Edema in the residual limb is also a common complication after LLA
surgery. Controlling the amount of edema post-surgically is vital for
promoting wound-healing, pain control, protecting the incision during
rehabilitation, and assisting in shaping the stump for prosthetic fitting
 Option D: The main goal of good positioning at any time is to prevent
adjacent joint contractures. The patient should be advised on how to
position themselves while sitting and lying in the hospital bed or standing
to prevent contractures. Make sure you explain to the patient the dangers
of the dependent position (residual limb hanging down) in the early post-
op phase as this may increase edema, pain, and healing time.
ADVERTISEMENTS
68. Question
A client is to be on bed rest for 24 hours and the affected extremity is to be kept
straight during this time. Which of the following procedures would require a
client to do the above?
o A. Varicose vein surgery.
o B. Myelogram.

o C. Abdominal aneurysm resection.
o D. Arterial Vascular Grafting.

Incorrect
Correct Answer: D. Arterial Vascular Grafting.
To promote graft patency after the procedure, bedrest is maintained for the first
24 hours and the affected extremity is kept straight. The pathophysiology of vein
graft failure has been attributed to acute thrombosis within the first month,
intimal hyperplasia up to 1 year, and atherosclerosis beyond 1 year.
 Option A: After treatment of large varicose veins by any method, a 30- to
40-mm Hg gradient compression stocking is applied, and patients are
instructed to maintain or increase their normal activity levels. Most
practitioners also recommend the use of gradient compression stockings
even after treatment of spider veins and smaller tributary veins.
 Option B: The client may need to sit or lay down for several hours after the
procedure to reduce the risk of developing a CSF (cerebral spinal fluid)
leak. Most patients are asked to lie down for two hours after the
procedure. If the client needs to urinate, he may need to do so in a bedpan
or urinal during the time that he needs to stay flat.
 Option C: Avoid strenuous activities that may put stress on the incision,
such as bicycle riding, jogging, weight lifting, or aerobic exercise, for 6
weeks or until the doctor says it is okay. For 6 weeks, avoid lifting anything
that would make a strain. This may include a child, heavy grocery bags and
milk containers, a heavy briefcase or backpack, cat litter or dog food bags,
or a vacuum cleaner.
ADVERTISEMENTS
69. Question
Which is the best position for a client with autonomic dysreflexia?
o A. Sim's Position.
o B. Fowler's Position.
o C. Semi-Fowler's Position.

o D. High Fowler's Position.
Incorrect
Correct Answer: D. High Fowler’s Position.
Autonomic dysreflexia is a condition in which there is a sudden onset of
excessively high blood pressure. If it occurs, immediately place the client in a high
Fowler‘s position to promote adequate ventilation and assist in the prevention of
a hypertensive stroke.
 Option A: The Sims position is a standard position in which the patient lies
on their left side, with right hip and knees bent. The lower arm is behind
the back, the thighs flexed. The left knee is slightly tilted. The right arm is
positioned comfortably in front of the body, the right arm is rested behind
the body. This is also known as ―lateral‖ position. This position is often used
for rectal or vaginal examination, and treatments.
 Option B: In Fowler‘s position, the patient is at an increased risk for air
embolism, skin injury from shearing and sliding, and DVT forming in the
patient‘s lower extremities. In this position, a patient has an increased
pressure risk in their scapulae, sacrum, coccyx, ischium, back of knees, and
heels.
 Option C: When positioning a patient in Fowler‘s position, the surgical staff
should minimize the degree of the patient‘s head elevation as much as
possible and always maintain the head in a neutral position. The patient‘s
arms should be flexed and secured across the body, the buttocks should be
padded, and the knees flexed 30 degrees.
ADVERTISEMENTS
70. Question
A nurse is caring for a client who has returned to the recovery unit following a
craniotomy. The nurse can safely place the client in which position?
o A. Trendelenburg position.
o B. Fowler's position with the head leaning on the left side.
o C. Semi-fowler's position with the head in a midline position.
o D. Supine position with the neck flexed.

Incorrect
Correct Answer: C. Semi-Fowler’s position with the head in a midline
position.
Post-craniotomy clients should be placed in a semi-Fowler‘s position and the
head is in a midline position to facilitate venous drainage from the head. For
nearly all types of craniotomy, the patient is observed for at least the first 24
hours in a neurological intensive care unit (NICU) or general surgical ICU. Basic
laboratory tests are sent (complete blood cell count and basic metabolic panel).
Neurological examinations are performed by the nursing staff every 1-2 hours
and any changes in neurologic status.
 Option A: Placing the client in a Trendelenburg position may increase the
swelling of the brain. Frequent neurological checks will be done by the
nursing and medical staff to test the brain function and to make sure the
body systems are functioning properly after the surgery. The client will be
asked to follow a variety of basic commands, such as moving the arms and
legs, to assess brain function.
 Option B: The client‘s head must be placed in a midline position to
facilitate venous drainage from the head and reduce the swelling. The
recovery process will vary depending upon the type of procedure done and
the type of anesthesia given. Once the client‘s blood pressure, pulse, and
breathing are stable and he is alert, he may be taken to the ICU or the
hospital room.
 Option D: The head of the bed may be elevated to prevent swelling of the
face and head. Some swelling is normal. The client will be encouraged to
move around as tolerated while in bed and to get out of bed and walk
around, with assistance at first, as his strength improves. A physical
therapist (PT) may be asked to evaluate the client‘s strength, balance, and
mobility, and give him suggestions for exercises to do both in the hospital
and at home.
ADVERTISEMENTS
71. Question
A nurse is caring for a Native American client who experiences emotional distress
due to a family problem. In anticipating pharmacological treatment for the client,
the nurse understands that they would most likely:

o A. Establish the trust of the health care provider first before accepting the
treatment.
o B. Call a clergy to ask for the religious preference of the treatment.
o C. Manage the emotional distress on their own to avoid disgrace.
o D. Resort with the use of herbal medicines with healing properties.

Incorrect
Correct Answer: D. Resort with the use of herbal medicines with healing
properties.
Native American cultures often use a variety of herbs or other plant and root
remedies. Not only were American Indians the first to discover the healing
properties of many of the medicinal herbs native to North America that we‘ve
come to know so well. In an era before antibiotics and knowledge of the causes
of infectious diseases, Native American herbal wisdom provided a crucial
foundation for the building of a new nation.
 Option A: Usually Northern European American people value medicine
and primary health care hence already having an established health care
provider. Traditional Western medicine, favored by most European
Americans in Minnesota, is characterized by methods developed according
to medical and scientific traditions and rigorous safety protocols with
treatments and medications that must pass a strict review before they can
be used for patient care. Western medicine‘s greatest strength is in trauma
care and therapies for acute problems, such as surgery, medications,
chemotherapy, radiation, and physical therapy.
 Option B: Latin Americans offer to call clergy because of the significance
of religious preference related to any illness. Churches are central to the life
of the family and community, hence can be important resources in
planning and delivering services. Faith and church remain powerful sources
of hope and strength in the Hispanic community, especially in times of
sickness.
 Option C: Asian American culture views mental illness as shameful and will
keep the stress on their own to manage it. Saving face—the ability to
preserve the public appearance of the patient and family for the sake of
community propriety—is extremely important to most Asian groups.
Patients may not be willing to discuss their moods or psychological states
because of fears of social stigma and shame.

ADVERTISEMENTS
72. Question
A nurse is conducting an assessment of an American Indian woman who has
come to the clinic complaining of a headache. The patient tells the nurse that the
medicines prescribed by the tribal healer have done some good. What is the
appropriate response of the nurse at this time?
o A. Tell me about these medicines and how often you are using them.
o B. I advise you to refrain from taking those medicines from the tribal healer.
o C. Could these medicines cause your headaches?
o D. Maybe you should increase the frequency of the healer's medicines.

Incorrect
Correct Answer: A. Tell me about these medicines and how often you are
using them.
Asking the patient about the nature of these medicines and how often the client
uses them allows the nurse to collect data about the medicines and their uses, to
learn more about the practices used by this patient to improve her health, and to
check for a potential drug interaction before prescribing other medications or
treatment.
 Option B: Advising the client to stop taking any nonprescription medicines
is inappropriate until the nurse knows the details about all medicines used
by the client. Health, for the individual Native American and/or the tribe or
family, depends on proper actions and interactions with the spirit world.
Well-being or wholeness comes about through walking in harmony with
the forces of nature and the universe. Illness is a sign of having fallen out
of step with those forces thus causing disharmony in spirit, mind, and
body.
 Option C: Suggesting the client‘s headaches are caused by the healer‘s
medicines is inappropriate until the nurse knows details about the
medicines. Native Americans consider healing a sacred calling. If one is
called into the healing ministry one must use that gift to help others.
Native healers use healing places and natural means to cure people during

illness. Healing power comes from the natural forces of the earth, which
can be reached through the saying of prayers.
 Option D: Telling the patient to increase the frequency of the healer‘s
medicines is not within the practice of a nurse. During times of illness,
many Native Americans will call upon a medicine man or woman or
shaman. In most cases, the medicine person is also considered a holy
person because it is the belief that they do all of their healing with the
Creator‘s help and guidance. Many Native Americans today will call upon
both modern medicine and traditional healing ceremonies to achieve
wellness.
ADVERTISEMENTS
73. Question
A nurse is preparing a plan of care for a client who is a Jehovah‘s Witness. The
client has been told that surgery is necessary. The nurse considers the client‘s
religious preferences in developing the plan of care and documents that:
o A. Giving any medication is not allowed.
o B. Surgery is strictly prohibited.
o C. Blood products can not be administered.
o D. Alternative medicines can be advised.

Incorrect
Correct Answer: C. Blood products can not be administered.
Among Jehovah‘s Witnesses, the administration of blood and blood products is
prohibited. Jehovah‘s Witnesses believe that it is against God‘s will to receive
blood and, therefore, they refuse blood transfusions, often even if it is their own
blood. The willing acceptance of blood transfusions by Jehovah‘s Witnesses has
in some cases led to expulsion from and ostracisation by their religious
community.
 Option A: Jehovah‘s Witnesses accept medical and surgical treatment.
They do not adhere to so-called ―faith healing‖ and are not opposed to the
practice of medicine. They are deeply religious and believe that blood
transfusions are forbidden for them by such Biblical passages.

 Option B: In the case of elective treatment or surgery, a medical
practitioner who believes that a blood transfusion may be necessary may
refuse to treat or perform surgery on a Jehovah‘s Witness patient who has
refused to consent to a blood transfusion being administered, provided
that the practitioner is not already involved in the ongoing treatment of
such patient, in which case a unilateral refusal to continue with the
treatment could be viewed as a breach of contract.
 Option D: Witnesses do not observe special rituals that are to be
performed for the sick or those dying. Every reasonable effort should be
made to provide medical assistance, comfort, and spiritual care needed by
the patient. Each patient who is a Jehovah‘s Witness will decide what is
appropriate for him or her according to his or her circumstances and the
provisions of the law.
ADVERTISEMENTS
74. Question
A Chinese-American client experiencing cough with clear white phlegm, which is
believed to be a yin disorder, is likely to treat it with:
o A. Foods considered being yin.
o B. Foods considered being yang.
o C. Aromatherapy.
o D. Touch therapy.
Incorrect
Correct Answer: B. Foods considered to be yang.
In the yin and yang theory, health is believed to exist when all aspects of the
person are in perfect balance. Yin foods are cold and yang foods are hot. One
eats cold foods when hot has a hot illness and one eats hot foods when one has
a cold illness.
 Option A: Foods considered yin include dark leafy greens like spinach,
lotus root, radish, dandelion greens, cucumbers, bamboo shoots, seaweed,
watermelon, green tea, chamomile tea, mint tea, clams, crab, and tofu.

 Option C: Aromatherapy is a holistic healing treatment that uses natural
plant extracts to promote health and well-being. Sometimes it‘s called
essential oil therapy. Aromatherapy uses aromatic essential oils medicinally
to improve the health of the body, mind, and spirit. It enhances both
physical and emotional health.
 Option D: In touch therapy, practitioners use their hands to manipulate
and direct the flow of energy — known as the biofield — throughout the
body in order to promote healing and restore the body‘s ability to heal
itself.
ADVERTISEMENTS
75. Question
Which of the following food items would be appropriate for a Jewish client who
follows a kosher diet?
o A. Shrimp and mussels.
o B. Beef and pork.
o C. Tuna and salmon.
o D. Cheese and milk.

Incorrect
Correct Answer: C. Tuna and salmon.
In the Jewish religion, only fish that have scales and fins are allowed such as tuna
and salmon. Certain animals may not be eaten at all, including pigs, shellfish,
rabbits, and reptiles. Fish must have fins and removable scales to be considered
kosher. The Jewish dietary laws explain the rules for choosing kosher animal
products, including the prohibition of what is considered ―unclean‖ animals and
the mixing of meat and dairy.
 Option A: Shellfish such as shrimps, crabs, mussels, and lobsters are
forbidden. The laws of kashrut, also referred to as the Jewish dietary laws,
are the basis for kosher observance. These rules were set forth in the Torah
and elucidated in the Talmud. The Hebrew word ―kasher‖ literally means
―fit,‖ and the kosher laws concern themselves with which foods are
considered fit to eat. Those who keep kosher follow Jewish dietary laws.

 Option B: Meats that are allowed include animals that are vegetable
eaters, cloven-hoofed, and ritually slaughtered. Any meat (the flesh of birds
and mammals) cannot be eaten with dairy. Utensils that have come into
contact with meat (while hot) may not be used with dairy and vice versa. In
addition, utensils that have come into contact with non-kosher food (while
hot) may not be used with kosher food.
 Option D: Cheese and milk coming from animal fat are prohibited. Milk
and eggs from kosher animals are kosher. Eggs must generally be checked
to ensure they do not contain blood, which is not kosher.
ADVERTISEMENTS
1. 1. Question
The best explanation of what Title VI of the Civil Rights Act mandates is the
freedom to:
o A. Pick any physician and insurance company despite one‘s income.
o B. Receive free medical benefits as needed within the county of residence.
o C. Have equal access to all health care regardless of race and religion.
o D. Have basic care with a sliding scale payment plan from all healthcare
facilities.
Incorrect
Correct Answer: C. Have equal access to all health care regardless of race
and religion.
Title VI of the Civil Rights Act of 1964 states that ―No person in the United States
shall, on the ground of race, color, or national origin, be excluded from
participation in, be denied the benefits of, or be subjected to discrimination
under any program or activity receiving Federal financial assistance.‖
 Option A: The Affordable Care Act puts consumers back in charge of their
health care. Under the law, a new ―Patient‘s Bill of Rights‖ gives the
American people the stability and flexibility they need to make informed
choices about their health. Through this bill, the client may choose the
primary care physician he wants from his plan‘s network.
 Option B: Since the Patient‘s Bill of Rights was enacted, the Affordable
Care Act has provided additional rights and protections. The health care

law covers preventive care at no cost. Clients may be eligible for
recommended preventive health services without a copayment.
 Option D: Under the Patient‘s Bill of Rights, a client‘s premium dollars are
ensured to be spent on primary healthcare, not on administrative costs.
Also, the bill removes insurance company barriers to emergency services
that are outside of their health plan‘s network.
ADVERTISEMENTS
1. Question 2 of 75
2. Question
Which statement would best explain the role of the nurse when planning care for
a culturally diverse population? The nurse will plan care to:
o A. Include care that is culturally congruent with the staff from predetermined
criteria.
o B. Focus only on the needs of the client, ignoring the nurse‘s beliefs and
practices.
o C. Blend the values of the nurse that are for the good of the client and
minimize the client‘s individual values and beliefs during care.
o D. Provide care while aware of one’s own bias, focusing on the client’s
individual needs rather than the staff’s practices.
Incorrect
Correct Answer: D. Provide care while aware of one’s own bias, focusing on
the client’s individual needs rather than the staff’s practices
Without understanding one‘s own beliefs and values, a bias or preconceived
belief by the nurse could create an unexpected conflict or an area of neglect in
the plan of care for a client (who might be expecting something totally different
from the care). During assessment values, beliefs, practices should be identified
by the nurse and used as a guide to identify the choices by the nurse to meet
specific needs/outcomes of that client. Therefore identification of values, beliefs,
and practices allows for planning meaningful and beneficial care specific for this
client.
 Option A: As nurses strive to learn more about becoming culturally
sensitive nurses, they should also let others know what they are doing and

why. Encourage co-workers to provide more culturally competent care.
Approach sharing awareness with openness and positivity, rather than from
a critical point of view.
 Option B: Cultural competency in the health care sector supports positive
patient outcomes and improves medical research accuracy. Cultural
competence is learning about how cultural differences may impact
healthcare decisions and being able to modify care to align with that
patient‘s culture.
 Option C: Active listening in the healthcare community is imperative,
especially when individuals of different racial or cultural backgrounds are
involved. It‘s important that patients feel heard and validated, particularly
when they are in a vulnerable position.
ADVERTISEMENTS
1. Question 3 of 75
3. Question
Which factor is least significant during assessment when gathering information
about cultural practices?
o A. Language, timing
o B. Touch, eye contact
o C. Biocultural needs
o D. Pain perception, management expectations

Incorrect
Correct Answer: C. Biocultural needs
Cultural practices do not influence biocultural needs because they are inborn
risks that are related to a biological need and not a learned cultural belief or
practice. Culturally competent healthcare professionals learn about different
groups and the values that drive them. They develop nonjudgmental acceptance
of cultural and noncultural differences in patients and coworkers, using diversity
as a strength that empowers them to achieve mutually acceptable healthcare
goals.
 Option A: When a patient doesn‘t speak English and there is no
interpreter, spend more time visiting to allay patients‘ anxiety. Learn key

phrases from the family and use flashcards to enhance communication.
When all else fails, sign language does work. Remember that making the
effort shows the patient that you care. You are using the language of the
heart and building trust.
 Option B: Both the clinician and the interpreter must pay particular
attention to nonverbal feedback during communication with the patient to
ensure understanding of the patient‘s concerns and desires. During the
exchange, the clinician and the interpreter must be able to convey caring
and support to gain patients‘ confidence and trust, particularly when they
are revealing sensitive information.
 Option D: Culture influences patients‘ perceptions of illness, pain, and
healing. These perceptions may conflict with clinicians‘ views based on the
medical model. Keep an open mind and listen actively to what patients say
about their illness.
ADVERTISEMENTS
1. Question 4 of 75
4. Question
Transcultural nursing implies:
o A. Using a comparative study of cultures to understand similarities and

differences across human groups to provide specific individualized care that
is culturally appropriate.
o B. Working in another culture to practice nursing within their limitations.
o C. Combining all cultural beliefs into a practice that is a non-threatening

approach to minimize cultural barriers for all clients‘ equality of care.
o D. Ignoring all cultural differences to provide the best-generalized care to all

clients.
Incorrect
Correct Answer: A. Using a comparative study of cultures to understand
similarities and differences across human groups to provide specific
individualized care that is culturally appropriate
Transcultural care means that by understanding and learning about specific
cultural practices the nurse can integrate these practices into the plan of care for

a specific individual client who has the same beliefs or practices to meet the
client‘s needs in a holistic manner of care.
 Option B: Nurses should explore new ways of providing cultural care in
multicultural societies, understand how culture affects health-illness
definitions, and build a bridge for the gap between the caring process and
the individuals in different cultures.
 Option C: The individuals‘ beliefs about health, attitudes, and behaviors,
past experiences, treatment practices, in short, their culture, play a vital role
in improving health, preventing and treating diseases. Health workers must
collect cultural data to understand the attitudes of coping with illness,
health promotion, and protection.
 Option D: Nurses should offer acceptable and affordable care for the
individuals under the conditions of the day. Knowing what cultural
practices are done in the target communities and identifying the cultural
barriers to offering quality health care positively affects the caring process.
ADVERTISEMENTS
1. Question 5 of 75
5. Question
What should the nurse do when planning nursing care for a client with a different
cultural background? The nurse should:
o A. Allow the family to provide care during the hospital stay so no rituals or
customs are broken.
o B. Identify how these cultural variables affect the health problem.
o C. Speak slowly and show pictures to make sure the client always
understands.
o D. Explain how the client must adapt to hospital routines to be effectively

cared for while in the hospital.
Incorrect
Correct Answer: B. Identify how these cultural variables affect the health
problem.
Without assessment and identification of the cultural needs, the nurse cannot
begin to understand how these might influence the health problem or health

care management. Culture is influential at many levels in health, ranging from the
formation of new diagnostic groups to the diagnosis of disease to the
determination of what is called a disease or no symptoms and disease cues
 Option A: The transcultural approach should be considered in a wide
range of subjects, starting from asking if there are any religious practices to
be followed or done by the patient during the hospitalization, and writing
the signs in the hospital in two different languages.
 Option C: Health culture is concerned with every individual‘s or the
society‘s patterns of living, celebrating, being happy in life, suffering, and
dying. It is not enough for the individual to acquire only health-related
information, but basic skills such as comprehending health-related values,
developing a healthy lifestyle, and self-evaluation must be developed.
 Option D: The environment is an integral part of the culture. Individuals as
physical, ecological, sociopolitical, and cultural beings are continuously
interacting with each other. Nurses may have to intervene in the patient
and family relationship because of frequent bureaucratic arrangements and
procedures.
ADVERTISEMENTS
1. Question 6 of 75
6. Question
Which activity would not be expected by the nurse to meet the cultural needs of
the client?
o A. Promote and support attitudes, behaviors, knowledge, and skills to

respectfully meet the client‘s cultural needs despite the nurse‘s own beliefs and
practices.
o B. Ensure that the interpreter understands not only the language of the client
but feelings and attitudes behind cultural practices to make sure an ethical
balance can be achieved.
o C. Develop structure and process for meeting cultural needs on a regular

basis and means to avoid overlooking these needs with clients.
o D. Expect the family to keep an interpreter present at all times to assist

in meeting the communication needs all day and night while hospitalized.

Incorrect
Correct Answer: D. Expect the family to keep an interpreter present at all
times to assist in meeting the communication needs all day and night while
hospitalized
It is not the family‘s responsibility to assist in the communication process. Many
families will leave someone to help at times, but it is the hospital‘s legal
obligation to find an interpreter for continued understanding by the client to
make sure the client is fully informed and comprehends in his or her primary
language.
 Option A: When caring for a patient from a culture different from the
nurse‘s own, she needs to be aware of and respect his cultural preferences
and beliefs; otherwise, he may consider the nurse insensitive and
indifferent, possibly even incompetent. But beware of assuming that all
members of any one culture act and behave in the same way; in other
words, don‘t stereotype people.
 Option B: Establishing an environment where cultural differences are
respected begins with effective communication. This occurs not just from
speaking the same language, but also through body language and other
cues, such as voice, tone, and loudness. The Joint Commission on
Accreditation of Healthcare Organizations (JCAHO) requires facilities to
have interpreters available, so every facility should make a list available.
 Option C: Thinking about one‘s beliefs and recognizing one‘s own cultural
bias and worldview will help understand differences and resolve cultural
and ethical conflicts one may face. But while caring for this patient,
promote open dialogue and work with him, his family, and health care
providers to reach a culturally appropriate solution. For example, a patient
who refuses a routine blood transfusion might accept an autologous one.
ADVERTISEMENTS
1. Question 7 of 75
7. Question
Ethical principles for professional nursing practice in a clinical setting are guided
by the principles of conduct that are written as the:
o A. American Nurses Association’s (ANA’s) Code of Ethics
o B. Nurse Practice Act (NPA) written by state legislation

o C. Standards of care from experts in the practice field
o D. Good Samaritan laws for civil guidelines

Incorrect
Correct Answer: A. American Nurses Association’s (ANA’s) Code of Ethics
This set of ethical principles provides the professional guidelines established by
the ANA to maintain the highest standards for ideal conduct in practice. As a
profession, the ANA wanted to establish rules and then incorporate guidelines for
accountability and responsibility of each nurse within the practice setting.
 Option B: Every state and territory in the US sets laws to govern the
practice of nursing. These laws are defined in the Nursing Practice Act
(NPA). The NPA is then interpreted into regulations by each state and
territorial nursing board with the authority to regulate the practice of
nursing care and the power to enforce the laws. Fifty states, the District of
Columbia and 4 United States (US) territories, have state boards of nursing
(BON) that are responsible for regulating their individual NPA.
 Option C: Professional standards describe the competent level of care in
each phase of the nursing process. They reflect a desired and achievable
level of performance against which a nurse‘s actual performance can be
compared. The main purpose of professional standards is to direct and
maintain a safe and clinically competent nursing practice.
 Option D: Good Samaritan laws have their basis on the idea that
consensus agreement favors good ―public policy‖ to limit liability for those
who voluntarily perform care and rescue in emergency situations. It is well
known that medical emergencies outside of the umbrella ―medical setting‖
or ―clinical environment‖ are common.
ADVERTISEMENTS
1. Question 8 of 75
8. Question
A bioethical issue should be described as:
o A. The physician‘s making all decisions of client management without getting

input from the client.

o B. A research project that included treating all the white men and not
treating all the black men to compare the outcomes of specific drug
therapy.
o C. The withholding of food and treatment at the request of the client in a

written advance directive given before a client acquired permanent brain damage
from an accident.
o D. After the client gives permission, the physician‘s disclosing all information
to the family for their support in the management of the client.
Incorrect
Correct Answer: B. A research project that included treating all the white
men and not treating all the black men to compare the outcomes of specific
drug therapy.
The ethical issue was the inequality of treatment based strictly upon racial
differences. Secondly, the drug was deliberately withheld even after results
showed that the drug was working to cure the disease process in white men for
many years. So after many years, the black men were still not treated despite the
outcome of the research process that showed the drug to be effective in
controlling the disease early at the beginning of the research project. Therefore
harm was done. Nonmaleficence, veracity, and justice were not followed.
 Option A: Patients have a right to make their own decisions about their
healthcare, guided by the advice of health professionals. This guidance
means making sure one fully understands his medical treatment options so
one can weigh up options along with the benefits and risks before making
a decision. This is called shared decision-making. It ensures that the patient
and the doctor are making treatment and healthcare decisions together.
 Option C: Advance care planning can help the people close to the patient
and those caring for him know what is important to him about the level of
healthcare and quality of life he would want if, for some reason, the patient
is unable to participate in the discussions.
 Option D: Information about medical conditions and treatments is more
available than ever before, thanks largely to health websites on the
internet. But despite this easy access to health information, it is hard to
know what is relevant and appropriate for each patient. Everyone is
different and only health professionals can provide the right health
information that relates to an individual medical condition.

ADVERTISEMENTS
1. Question 9 of 75
9. Question
When the nurse described the client as ―that nasty old man in room 201,‖ the
nurse is exhibiting which ethical dilemma?
o A. Gender bias and ageism
o B. HIPAA violation
o C. Beneficence
o D. Code of ethics violation

Incorrect
Correct Answer: A. Gender bias and ageism
Stereotyping an ―old man‖ as ―nasty‖ is a gender bias and an ageism issue. The
nurse is verbalizing a negative descriptor about the client. Anyone who lives long
enough is at risk of experiencing ageism. In Western, industrialized countries,
older people are often perceived as unproductive and as using too much of
society‘s resources (Gullette 2004). As countries‘ demographics shift toward larger
percentages of older citizens (due to declines in birth rates and increases in
longevity), aging is often framed in public policy debates as a social problem, and
the hyperbolic language that is frequently used (e.g., ―the gray tsunami‖) to
describe shifting demographics contributes to ageism.
 Option B: The Health Insurance Portability and Accountability Act of 1996
is a landmark piece of legislation that was introduced to simplify the
administration of healthcare, eliminate wastage, prevent healthcare fraud,
and ensure that employees could maintain healthcare coverage when
between jobs. A HIPAA violation is a failure to comply with any aspect of
HIPAA standards and provisions detailed in 45 CFR Parts 160, 162, and 164.
 Option C: Beneficence is defined as an act of charity, mercy, and kindness
with a strong connotation of doing good to others including moral
obligation. All professionals have the foundational moral imperative of
doing right.
 Option D: Serious ethical violations are acts that not only disregard codes
of medical ethics, but also risk directly harming patients and subjecting the
wrongdoer to criminal, tort, or medical board actions.

ADVERTISEMENTS
10. Question
The distribution of nurses to areas of ―most need‖ in the time of a nursing
shortage is an example of:
o A. Utilitarianism theory
o B. Deontological theory
o C. Justice
o D. Beneficence
Incorrect
Correct Answer: C. Justice
Justice is defined as the fairness of the distribution of resources. However,
guidelines for a hierarchy of needs have been established, such as with organ
transplantation. Nurses are moved to areas of greatest need when shortages
occur on the floors. No floor is left without staff, and another floor that had five
staff will give up two to go help the floor that had no staff.
 Option A: Utilitarianism is a theory of morality, which advocates actions
that foster happiness or pleasure and opposes actions that cause
unhappiness or harm. When directed toward making social, economic, or
political decisions, a utilitarian philosophy would aim for the betterment of
society as a whole.
 Option B: In contemporary moral philosophy, deontology is one of those
kinds of normative theories regarding which choices are morally required,
forbidden, or permitted. In other words, deontology falls within the domain
of moral theories that guide and assess our choices of what we ought to
do (deontic theories), in contrast to those that guide and assess what kind
of person we are and should be (aretaic [virtue] theories).
 Option D: Beneficence is defined as an act of charity, mercy, and kindness
with a strong connotation of doing good to others including moral
obligation. All professionals have the foundational moral imperative of
doing right.
ADVERTISEMENTS

11. Question
Nurses are bound by a variety of laws. Which description of a type of law is
correct?
o A. Statutory law is created by an elected legislature, such as the state

legislature that defines the Nurse Practice Act (NPA).
o B. Regulatory law includes prevention of harm for the public and punishment
for those laws that are broken.
o C. Common law protects the rights of the individual within society for fair and
equal treatment.
o D. Criminal law creates boards that pass rules and regulations to control
society.
Incorrect
Correct Answer: A. Statutory law is created by an elected legislature, such as
the state legislature that defines the Nurse Practice Act (NPA).
Statutory law is created by the legislature. It creates statutes such as the NPA,
which defines the role of the nurse and expectations of the performance of one‘s
duties and explains what is contraindicated as guidelines for breach of those
regulations.
 Option B: Federal and state regulations influence everything from the air
we breathe to the fine print on credit card agreements. Regulatory law
involves creating and/or managing the rules and regulations created by
federal and state agencies.
 Option C: Common law is a body of unwritten laws based on legal
precedents established by the courts. Common law influences the decision-
making process in unusual cases where the outcome cannot be determined
based on existing statutes or written rules of law.
 Option D: Criminal law, as distinguished from civil law, is a system of laws
concerned with the punishment of individuals who commit crimes. Thus,
wherein a civil case of two individuals dispute their rights, a criminal
prosecution involves the government deciding whether to punish an
individual for either an act or an omission.
ADVERTISEMENTS

12. Question
Besides the Joint Commission on Accreditation of Healthcare Organizations
(JACHO), which governing agency regulates hospitals to allow continued safe
services to be provided, funding to be received from the government, and
penalties if guidelines are not followed?
o A. Board of Nursing Examiners (BNE)
o B. Nurse Practice Act (NPA)
o C. American Nurses Association (ANA)
o D. Americans With Disabilities Act (ADA)

Incorrect
Correct Answer: D. Americans With Disabilities Act (ADA)
If the hospital fails to follow ADA guidelines for meeting special needs, the facility
loses funding and status for receiving low-income loans or reimbursement of
expenses. ADA protects the civil rights of disabled people. It applies to both the
hospital clients and hospital staff. Privacy issues for persons who are positive for
human immunodeficiency virus (HIV) have been one issue in relation to getting
information when hospital staff has been exposed to unclean sticks. The ADA
allows the infected client the right to choose whether or not to disclose that
information.
 Option A: Boards of nursing are state governmental agencies that protect
the public‘s health by overseeing and ensuring safe nursing practice. They
establish standards for safe nursing care and issue licenses to practice
nursing, monitor licensees‘ compliance to state laws, and take action
against the licenses of nurses who have exhibited unsafe nursing practice.
Most boards also review and approve or accredit nursing education
programs to ensure that graduates are prepared for safe, effective practice.
 Option B: Every state and territory in the US sets laws to govern the
practice of nursing. These laws are defined in the Nursing Practice Act
(NPA). The NPA is then interpreted into regulations by each state and
nursing care and the power to enforce the laws. Fifty states, District of

 Option C: The American Nurses Association (ANA) is the premier
organization representing the interests of the nation‘s 4 million registered
nurses. ANA is at the forefront of improving the quality of health care for
all. Founded in 1896, and with members in all 50 states and U.S. territories,
ANA is the strongest voice for the profession.
ADVERTISEMENTS
13. Question
When a client is confused, left alone with the side rails down, and the bed in a
high position, the client falls and breaks a hip. What law has been broken?
o A. Assault
o B. Battery
o C. Negligence
o D. Civil tort
Incorrect
Correct Answer: C. Negligence
Knowing what to do to prevent injury is a part of the standards of care for nurses
to follow. Safety guidelines dictate raising the side rails, staying with the client,
lowering the bed, and observing the client until the environment is safe. As a
nurse, these activities are known as basic safety measures that prevent injuries,
and to not perform them is not acting in a safe manner. Negligence is conduct
that falls below the standard of care that protects others against unreasonable
risk of harm.
 Option A: Assault is the intentional act of making someone fear that the
nurse will cause them harm. One does not have to actually harm them to
commit assault. Threatening them verbally or pretending to hit them are
both examples of assault.
 Option B: Battery is the intentional act of causing physical harm to
someone. Unlike assault, one doesn‘t have to warn the victim or make him
fearful before they hurt them for it to count as a battery. If a nursing home

attendant surprises the patient and pushes the patient from behind, that
would qualify as a battery.
 Option D: Torts are civil laws that address the legal rights of patients and
the responsibilities of the nurse in the nurse-patient relationship. Some
torts specific to nursing and nursing practice include things like
malpractice, negligence, and violations relating to patient confidentiality.
ADVERTISEMENTS
14. Question
When signing a form as a witness, your signature shows that the client:
o A. Is fully informed and is aware of all consequences.
o B. Was awake and fully alert and not medicated with narcotics.
o C. Was free to sign without pressure.
o D. Has signed that form and the witness saw it being done.
Incorrect
Correct Answer: D. Has signed that form and the witness saw it being done
Your signature as a witness only states that the person signing the form was the
person who was listed in the procedure. A witness‘s signature can be useful for
evidentiary purposes. If a party to the agreement later says they did not sign, the
person who witnessed the party signing can be called to confirm it. The witness
can confirm that the specific person signed and that was the sign they made.
 Option A: In a legal contract, a witness is someone who watches the
document is signed by the person they are being a witness for and who
verifies its authenticity by singing their own name on the document as well.
 Option B: Having a witness helps to reinforce the validity and authenticity
of a document by adding another layer of security should the contract ever
be questioned in court.
 Option C: Though witnesses aren‘t always a requirement for executing a
legal document, they can help solidify and authenticate a contract by
providing proof that the signatures are legitimate and consensual.
ADVERTISEMENTS

15. Question
Which criterion is needed for someone to give consent to a procedure?
o A. An appointed guardianship
o B. Unemancipated minor
o C. Minimum of 21 years or older
o D. An advocate for a child

Incorrect
Correct Answer: A. An appointed guardianship
A guardian has been appointed by a court and has full legal rights to choose
management of care. A situation may arise in which a patient cannot make
decisions independently but has not designated a decision-maker. In this
instance, the hierarchy of decision-makers, which is determined by each state‘s
laws, must be sought to determine the next legal surrogate decision-maker. If
this is unsuccessful, a legal guardian may need to be appointed by the court.
 Option B: An exception to this rule is a legally emancipated child who may
provide informed consent for himself. Some, but not all, examples of an
emancipated minor include minors who are (1) under 18 and married, (2)
serving in the military, (3) able to prove financial independence, or (4)
mothers of children (married or not).
 Option C: Children (typically under 17) cannot provide informed consent.
As such, parents must permit treatments or interventions. In this case, it is
not termed ―informed consent‖ but ―informed permission.‖ Legislation
regarding minors and informed consent is state-based as well. It is
important to understand the state laws.
 Option D: An advocate for the child is not legally appointed by the court.
Several exceptions to the requirement for informed consent include (1) the
patient is incapacitated, (2) life-threatening emergencies with inadequate
time to obtain consent, and (3) voluntary waived consent. If the patient‘s
ability to make decisions is questioned or unclear, an evaluation by a
psychiatrist to determine competency may be requested.
ADVERTISEMENTS

16. Question
Which of the following statement is correct?
o A. “Consent for medical treatment can be given by a minor with a

sexually transmitted disease (STD)”.
o B. ―A second-trimester abortion can be given without state involvement.‖
o C. ―Student nurses cannot be sued for malpractice while in a nursing clinical

class.‖
o D. ―Nurses who get sick and leave during a shift are not abandoning clients if
they call their supervisor and leave a message about their emergency illness.‖
Incorrect
Correct Answer: A. “Consent for medical treatment can be given by a minor
with a sexually transmitted disease (STD).”
Anyone, at any age, can be treated without parental permission for an STD
infection. The client is ―advised‖ to contact sexual partners but is not ―required‖ to
give names. Permission from parents is not needed, based upon current privacy
laws. According to the CDC, as of 2020, all jurisdictions have laws that explicitly
allow a minor of a particular age (as defined by each state) to give informed
consent to receive STD diagnosis and treatment services. In some jurisdictions, a
minor might be legally allowed to give informed consent to receive specific STD
or HIV services, including PrEP, even if the law is silent on those disease-related
services.
 Option B: Abortion is legal throughout the United States and its territories,
although restrictions and accessibility vary from state to state. Abortion is a
controversial and divisive issue in the society, culture, and politics of the
U.S., and various anti-abortion laws have been in force in each state since
at least 1900.
 Option C: One very important point is that student nurses are personally
responsible for their own negligent acts. Student nurses are responsible for
providing care to their patients, and students are held to the same
standards as a licensed professional nurses when performing the duties of
a nurse (Pozgar, 2016).

 Option D: North Dakota Board of Nursing defines ―abandonment‖ as
accepting the client assignment and disengaging the nurse and client
relationship without giving notice to a qualified person. Behavior that
demonstrates professional misconduct includes abandoning a client who is
in need of or receiving nursing care and may be grounds for disciplinary
action.
ADVERTISEMENTS
17. Question
Most litigation in the hospital comes from the:
o A. Nurse abandoning the clients when going to lunch.
o B. Nurse following an order that is incomplete or incorrect.
o C. Nurse documenting blame on the physician when a mistake is made.
o D. Supervisor watching a new employee check his or her skills level.

Incorrect
Correct Answer: B. Nurse following an order that is incomplete or incorrect
The nurse is responsible for clarifying all orders that are illegible, unreasonable,
unsafe, or incorrect. The failure of the nurse to question the physician about an
order creates an area of liability on the nurse‘s part because this is perceived as a
medical action and not the role of the nurse to write orders. Some RNs do have
prescriptive privileges based upon advanced degrees and certification. Therefore
the nurse who cannot correct the order must document that the physician was
called and clarification or a new order was given to correct the unclear or illegible
one that was currently on the chart. Contact of the staff‘s chain of command
should also be specifically stated for the proof of the responsibilities being
followed according to hospital policy.
 Option A: North Dakota Board of Nursing defines ―abandonment‖ as
accepting the client assignment and disengaging the nurse and client
relationship without giving notice to a qualified person. Behavior that
demonstrates professional misconduct includes abandoning a client who is
in need of or receiving nursing care and may be grounds for disciplinary
action.

 Option C: Phone calls, follow-up, and lack of follow-up by the physician
should also be documented if there is a problem with getting the
information in a timely manner. The nurse must show the sequence of
events of a situation in a clear manner if there is any conflict or question
about any orders or procedures that were not appropriate. Assessments
and documentation of the client‘s status should also be included if there is
a potential risk for harm present.
 Option D: The competence of new RN graduates, both at the point of
joining the workforce on graduation and as they gain experience, is an
important dimension of quality and safety. Thus each nursing school and
prospective employer has a vested interest in ensuring that the initial skills
and competency of the new graduate and the conditions for the transition
and the ongoing development of the new graduate RN are optimized.
ADVERTISEMENTS
18. Question
The nurse places an aquathermia pad on a client with a muscle sprain. The nurse
informs the client the pad should be removed in 30 minutes. Why will the nurse
return in 30 minutes to remove the pad?
o A. Reflex vasoconstriction occurs.
o B. Reflex vasodilation occurs.
o C. Systemic response occurs.
o D. Local response occurs.

Incorrect
Correct Answer: A. Reflex vasoconstriction occurs.
If heat is applied for 1 hour or more, blood flow is reduced by reflex
vasoconstriction. Vasoconstriction is the opposite of the desired effect of heat
application. An aquathermia (Aqua-K) pad, which produces dry heat, is used to
treat muscle sprains and mild inflammations and for pain relief. Temperature-
controlled, distilled water flows through the waterproof pad.
 Option B: Aquathermia pad is used as a heating pad for various parts of
the body. This heating pad is used on the upper side of the body because

it cannot be placed on the underside of the body part. There is a specific
time period, beyond which blood vessels will start shrinking leading to
increased blood pressure.
 Option C: Hot aquathermia pad is applied for 20 to 40 minutes and then it
should be removed to avoid vasoconstriction. The human body cannot
tolerate this heating aquathermia pad for more than 40 minutes, if it
exceeds 40 minutes, the patient will start feeling a burning sensation and
the blood vessels will constrict leading to further complications.
 Option D: Increased temperature of aquathermia pad may burn the skin
and the blood vessels may constrict. Due to vasoconstriction, blood
pressure may rise. So there is a specific temperature that should be
maintained. The ideal temperature set for adults is 45°C. A thin cloth or
pillowcase should be placed between a hot aquathermia pad and skin, as it
prevents direct heat action on the skin. 20 to 40 minutes is the ideal time
for the application of these pads and they should not be placed for more
than 40 minutes.
ADVERTISEMENTS
19. Question
A client has recently been told he has terminal cancer. As the nurse enters the
room, he yells, ―My eggs are cold, and I‘m tired of having my sleep interrupted by
noisy nurses!‖ The nurse may interpret the client‘s behavior as:
o A. An expression of the anger stage of dying.
o B. An expression of disenfranchised grief.
o C. The result of a maturational loss.
o D. The result of previous losses.

Incorrect
Correct Answer: A. An expression of the anger stage of dying.
In the anger stage of Kubler-Ross‘s stages of dying, the individual resists the loss
and may strike out at everyone and everything, in this case, the nurse. Anger, as
Kubler-Ross pointed out, is commonly experienced and expressed by patients as
they concede the reality of a terminal illness. It may be directed, as with blame of

medical providers for inadequately preventing the illness, of family members for
contributing to risks of not being sufficiently supportive, or of spiritual providers
or higher powers for the diagnosis‘ injustice.
 Option B: Grief can be caused by situations, relationships, or even
substance abuse. Children may grieve a divorce, a wife may grieve the
death of her husband, a teenager might grieve the ending of a relationship,
or one might have received terminal medical news and are grieving
pending death.
 Option C: Maturational loss happens as a person develops and goes
through the cycle of life, where developmental changes can create a loss
specific to every stage of life. It‘s a form of anticipatory loss — a type of
loss that people anticipate happening at every stage.
 Option D: Losses will occur in everyone‘s life at different stages and under
different circumstances. The pain of loss is universally acknowledged by all
people. It‘s the loss itself that can be categorized in a couple of different
ways. Throughout lifetimes, people can be expected to experience two
types of losses, called maturational losses and situational losses.
ADVERTISEMENTS
20. Question
When helping a person through grief work, the nurse knows:
o A. Coping mechanisms that were effective in the past are often disregarded
in response to the pain of a loss.
o B. A person‘s perception of a loss has little to do with the grieving process.
o C. The sequencing of stages of grief may occur in order, they may be

skipped, or they may recur.
o D. Most clients want to be left alone.

Incorrect
Correct Answer: C. The sequencing of stages of grief may occur in order,
they may be skipped, or they may recur.
Grief is manifested in a variety of ways that are unique to an individual and based
on personal experiences, cultural expectations, and spiritual beliefs. The

sequencing of stages or behaviors of grief may occur in order, they may be
skipped, or they may recur. The amount of time to resolve grief also varies
among individuals.
 Option A: Coping mechanisms are the strategies people often use in the
face of stress and/or trauma to help manage painful or difficult emotions.
Coping mechanisms can help people adjust to stressful events while
helping them maintain their emotional well-being.
 Option B: When a person loses someone close to them, it is natural to
grieve. This process takes time and involves many different emotions and
behaviors. People with cancer and their families may also grieve other
cancer-related losses. These may include the loss of a breast, the loss of
fertility, or the loss of independence.
 Option D: There is no specific time period suggested for any of these
stages. Someone may experience the stages fairly quickly, such as in a
matter of weeks, where another person may take months or even years to
move through to a place of acceptance.
ADVERTISEMENTS
21. Question
A client is hospitalized in the end stage of terminal cancer. His family members
are sitting at his bedside. What can the nurse do to best aid the family at this
time?
o A. Limit the time visitors may stay so they do not become overwhelmed by
the situation.
o B. Avoid telling family members about the client‘s actual condition so they
will not lose hope.
o C. Discourage spiritual practices because this will have little connection to the
client at this time.
o D. Find simple and appropriate care activities for the family to perform.
Incorrect
Correct Answer: D. Find simple and appropriate care activities for the family
to perform.

It is helpful for the nurse to find simple care activities for the family to perform,
such as feeding the client, washing the client‘s face, combing hair, and filling out
the client‘s menu. This helps the family demonstrate their caring for the client and
enables the client to feel their closeness and concern. a. Older adults often
become particularly lonely at night and may feel more secure if a family member
stays at the bedside during the night.
 Option A: The nurse should allow visitors to remain with dying clients at
any time if the client wants them. It is up to the family to determine if they
are feeling overwhelmed, not the nurse. Provide family-focused
interventions that assist parents in connecting or reconnecting with their
existing families, friends, and networks of support as a means of re-
establishing coherence and meaning as they go forward.
 Option B: Truthful and open communication between the healthcare
provider and patient is essential for trust in the relationship and for respect
for autonomy. Withholding pertinent medical information from patients in
the belief that disclosure is medically contraindicated creates a conflict
between the healthcare provider‘s obligations to promote patient welfare
and to respect patient autonomy.
 Option C: It is important to keep in mind that there are numerous
individual, familial, and cultural differences that make responding
appropriately to another person‘s grief anything but a formula. The United
States, as most Western countries, has a variety of cultural, religious, and
ethnic variations that mediate and modulate the experience of grief and
mourning.
ADVERTISEMENTS
22. Question
When caring for a terminally ill client, it is important for the nurse to maintain the
client‘s dignity. This can be facilitated by:
o A. Spending time to let clients share their life experiences.
o B. Decreasing emphasis on attending to the client's appearance because it

only increases their fatigue.
o C. Making decisions for clients so they do not have to make them.

o D. Placing the client in a private room to provide privacy at all times.
Incorrect
Correct Answer: A. Spending time to let clients share their life experiences.
Spending time to let clients share their life experiences enables the nurse to know
clients better. Knowing clients then facilitates the choice of therapies that
promote client decision-making and autonomy, thus promoting a client‘s self-
esteem and dignity. Regarding emotional needs, a review found that important
actions for healthcare professionals providing end-of-life care include
communicating, listening, conveying empathy, and involving patients in decision-
making. Furthermore, good communication between the patient and their
partner about their feelings should be promoted.
 Option B: Regarding physical needs, when trying to enhance and preserve
dignity, a systematic review found that symptom control and being placed
in the correct environment are important in delivering dignified end-of-life
care 5. Good management of physical symptoms such as pain, dyspnoea,
constipation, nausea, and respiratory secretions may allow for
opportunities to work through unfinished emotional, psychological, and
spiritual issues, and promote a sense of closure towards the end of life.
 Option C: Dignity can be upheld by measures such as symptom control 5;
promoting independence, privacy, social support, and a positive tone of
care; listening, giving appropriate information, having a caring bedside
manner; and showing respect, empathy and companionship. Spiritual care
has been shown to be facilitated by having sufficient time, employing
effective communication, and reflecting on one‘s personal experiences.
 Option D: Other measures found to promote dignity include enabling the
management of finances, facilitating activities such as reading or watching
television, allowing the patient to spend time with their family, providing
choices regarding the place of death, remembering the dignity of the
family after the death of the individual, and offering emotional support.
ADVERTISEMENTS
23. Question
What are the stages of dying according to Elizabeth Kubler-Ross?

o A. Numbing; yearning and searching; disorganization and despair; and
reorganization.
o B. Accepting the reality of loss, working through the pain of grief, adjusting
to the environment without the deceased, and emotionally relocating the
deceased and moving on with life.
o C. Anticipatory grief, perceived loss, actual loss, and renewal.
o D. Denial, anger, bargaining, depression, and acceptance.

Incorrect
Correct Answer: D. Denial, anger, bargaining, depression, and acceptance.
The most commonly taught system for understanding the process of dying was
introduced by Dr. Elizabeth Kubler-Ross in her 1969 book, On Death and Dying.
The book explored the experience of dying through interviews with terminally ill
patients and described Five Stages of Dying: Denial, Anger, Bargaining,
Depression, and Acceptance (DABDA). The model, which was the result of a
qualitative and experiential study, was purposely personal and subjective and
should not be interpreted as natural law. Rather, the stages provide a heuristic for
patterns of thought and behavior, common in the setting of terminal illness,
which may otherwise seem atypical.
 Option A: Bowlby and Parkes proposed a reformulated theory of grief
based in the 1980s. Their work is based on Kubler-Ross‘ model. Their
model has 4 stages and emphasizes that the grieving process is not linear.
 Option B: Woden‘s model of grief does not rely on stages but instead
states that 4 tasks must be completed by the patient to complete
bereavement. These tasks do not occur in any specific order. The grieving
person may work on a task intermittently until it is complete. This model is
more applicable to the grief of a survivor but may also be applied to a
patient-facing death.
 Option C: Anticipatory grief is the name given to the tumultuous set of
feelings and reactions that occur when someone is expecting the death of
a loved one. These emotions can be just as intense as the grief felt after a
death. The most important thing to remember is that anticipatory grief is a
normal process, even if it‘s not discussed as often as regular grief.
ADVERTISEMENTS

24. Question
Bereavement may be defined as:
o A. The emotional response to loss.
o B. The outward, social expression of loss.
o C. Postponing the awareness of the reality of the loss.
o D. The inner feeling and outward reactions of the survivor.

Incorrect
Correct Answer: D. The inner feeling and outward reactions of the survivor.
Bereavement is the state of loss when someone close to an individual has died.
The death of a loved one is one of the greatest sorrows that can occur in one‘s
life. People‘s responses to grief will vary depending upon the circumstances of
the death, but grief is a normal, healthy response to loss. Feelings of
bereavement can also accompany other losses, such as the decline of one‘s
health or the health of a close other, or the end of an important relationship.
 Option A: Grief is the psychological, physical, and emotional experience
and reaction to loss. People may experience grief in various ways, but
several theories, such as Kübler-Ross stages of loss theory, attempt to
explain and understand the way people deal with grief.
 Option B: Physical expressions of grief may include poor sleep, aches and
pains, weakness and fatigue, loss of appetite, more crying, and other
stress-related symptoms. Emotional expressions of grief may include feels
of sadness, numbness, anger, fear, irritability, guilt, regret, and loneliness.
 Option C: Talk about death. This will help the surviving individuals
understand what happened and remember the deceased in a positive way.
When coping with death, it can be easy to get wrapped up in denial, which
can lead to isolation and a lack of a solid support system.
ADVERTISEMENTS
25. Question
A client who had a ―Do Not Resuscitate‖ order passed away. After verifying there
is no pulse or respirations, the nurse should next:

o A. Have family members say goodbye to the deceased.
o B. Call the transplant team to retrieve vital organs.
o C. Remove all tubes and equipment (unless organ donation is to take

place), clean the body, and position appropriately.
o D. Call the funeral director to come and get the body.

Incorrect
Correct Answer: C. Remove all tubes and equipment (unless organ donation
is to take place), clean the body, and position appropriately.
The body of the deceased should be prepared before the family comes into view
and says their goodbyes. This includes removing all equipment, tubes, supplies,
and dirty linens according to protocol, bathing the client, applying clean sheets,
and removing trash from the room. In a home care, the nurse would ask the
family if it was alright to remove any tubes or catheters from the patient, and if
they would like to assist in bathing/preparing the patient for transport to the
funeral home. The nurse would assist the family in removing any jewelry or other
items from the patient. Be sure to maintain the highest dignity and respect for
the deceased patient during this post-mortem care.
 Option A: When the death is imminent, the family must be informed that
death is near. As mentioned before, sometimes this is shocking to the
family, despite knowing that their loved one is dying. This has to be
communicated to the family in a sensitive and calm manner. Each nurse will
have their own way to exchange this information, but it is very important
that the family be told that death can occur at any time so that they can
prepare. There may be a family in the area or out of town that would like to
come and see the patient and who is waiting until the patient gets closer to
death.
 Option B: Correct information given to a family clearly, sensitively, and in a
professional manner can accommodate relatives‘ understanding of why
their loved one is in a critical condition, which can help them accept death
and therefore consider the option of organ donation. Nurses must acquire
through regular training specific skills and knowledge in order to practice
efficiently and adhere to the needs of a dying patient‘s family.
 Option D: Following the death of a patient, the nurse should offer their
condolences to the family and extend assistance with contacting any other
family members or individuals the family requests. Depending on the

location of the death, the nurse would contact the medical examiner to
notify them of the death, as well as the physician and other clinicians who
were involved with the patient. The nurse can also contact the funeral
home for the family as requested.
ADVERTISEMENTS
26. Question
A client‘s family member says to the nurse, ―The doctor said he will provide
palliative care. What does that mean?‖ The nurse‘s best response is:
o A. ―Palliative care is given to those who have less than 6 months to live.‖
o B. “Palliative care aims to relieve or reduce the symptoms of a disease.”
o C. ―The goal of palliative care is to affect a cure of a serious illness or

disease.‖
o D. ―Palliative care means the client and family take a more passive role and
the doctor focuses on the physiological needs of the client. The location of death
will most likely occur in the hospital setting.‖
Incorrect
Correct Answer: B. “Palliative care aims to relieve or reduce the symptoms
of a disease.”
The goal of palliative care is the prevention, relief, reduction, or soothing of
symptoms of disease or disorders without effecting a cure. Palliative care
improves the quality of life of patients and that of their families who are facing
challenges associated with life-threatening illness, whether physical,
psychological, social, or spiritual. The quality of life of caregivers improves as well.
 Option A: Palliative care is required for a wide range of diseases. The
majority of adults in need of palliative care have chronic diseases such as
cardiovascular diseases (38.5%), cancer (34%), chronic respiratory diseases
(10.3%), AIDS (5.7%), and diabetes (4.6%). Many other conditions may
require palliative care, including kidney failure, chronic liver disease,
multiple sclerosis, Parkinson‘s disease, rheumatoid arthritis, neurological
disease, dementia, congenital anomalies, and drug-resistant tuberculosis.

 Option C: Palliative care is an approach that improves the quality of life of
patients (adults and children) and their families who are facing problems
associated with life-threatening illnesses. It prevents and relieves suffering
through the early identification, correct assessment, and treatment of pain
and other problems, whether physical, psychosocial, or spiritual.
 Option D: Addressing suffering involves taking care of issues beyond
physical symptoms. Palliative care uses a team approach to support
patients and their caregivers. This includes addressing practical needs and
providing bereavement counseling. It offers a support system to help
patients live as actively as possible until death.
ADVERTISEMENTS
27. Question
Which of the following is not included in evaluating the degree of heritage
consistency in a client?
o A. Gender
o B. Culture
o C. Ethnicity
o D. Religion
Incorrect
Correct Answer: A. Gender
The term heritage consistency is used to describe how much or how little a
person‘s lifestyle reflects his or her traditional culture. If one is very ―consistent‖
with their heritage, then one maintains more of the core values, beliefs, attitudes,
and behaviors of one‘s cultural heritage.
 Option B: Acculturation is necessary to survival so it is involuntary. The
degree to which one becomes acculturated and the speed of the process is
affected by an individual‘s circumstances and choices. Children, who can
easily avail themselves of socialization via public schools, tend to
acculturate quickly in the U.S. They have an easier time learning a new
language.

 Option C: Many European Americans today – Irish Americans, Italian
Americans, French Americans, etc. – are disconnected from their cultural
heritage. Exploring the assimilation experience of one‘s forebears can be
very eye-opening. America‘s history is truly a history of immigration,
acculturation, and assimilation (with notable exceptions/variations).
 Option D: Along with the socio-economic factors of poverty, literacy, and
health literacy, culturally responsive care takes into account the heritage
consistency of individual patients within the context of family dynamics. In
an effort to avoid applying cultural generalizations too rigidly, providers
explore the indicators of cultural consistency with their patients from
different cultural backgrounds to understand how closely each individual
adheres to the traditional culture in which they were raised.
ADVERTISEMENTS
28. Question
When providing care to clients with varied cultural backgrounds, it is imperative
for the nurse to recognize that:
o A. Cultural considerations must be put aside if basic needs are in jeopardy.
o B. Generalizations about the behavior of a particular group may be

inaccurate.
o C. Current health standards should determine the acceptability of cultural

practices.
o D. Similar reactions to stress will occur when individuals have the same
cultural background.
Incorrect
Correct Answer: B. Generalizations about the behavior of a particular group
may be inaccurate.
Nurses can pay close attention to their own biases and how they react to people
whose backgrounds and cultural experiences differ from their own. For example,
a person who becomes conscious that they think of immigrants as illegal aliens
achieves cultural awareness of that particular bias.

 Option A: Often, individual beliefs and values do not correspond to their
behavior and actions. Nurses can work to acknowledge that this disconnect
exists and view knowledge as an important element of developing cultural
competence. Research has shown that people who score low on prejudice
tests may still use labels such as ―illegal alien.‖
 Option C: Nurses put their awareness, attitude, and knowledge into
practice by repeating culturally competent behaviors until they become
integrated into their daily interactions. These behaviors include effective
and respectful communication and body language. Among various
cultures, nonverbal communication methods, such as gestures, can mean
very different things.
 Option D: Once nurses tap into awareness, they can actively analyze their
increased awareness and internal belief systems. Using the above example,
the person can examine their background, beliefs, and values to
understand their cultural bias regarding immigrants.
ADVERTISEMENTS
29. Question
To respect a client‘s personal space and territoriality, the nurse:
o A. Avoids the use of touch.
o B. Explains nursing care and procedures.
o C. Keeps the curtains pulled around the client's bed.
o D. Stands 8 feet away from the bed, if possible.

Incorrect
Correct Answer: B. Explains nursing care and procedures
The respect of territory and personal space represents an ethical and respectful
approach to patients, which can permit them to maintain their dignity even under
vulnerable conditions, favoring their recovery, as most studies have highlighted.
The patients reported that requesting permission to manipulate their body, to
examine them, or to perform other care/procedures shows consideration and
attention on the part of the professional, which makes the patient feel valued and

in control of the situation. This approach may minimize the effects of the invasion
and the feeling of being seen as an object.
 Option A: The greater perception of territorial invasion is probably due to
the fact that patients are somehow prepared for personal invasion in the
hospital as they are aware that the approximation by unknown people to
perform procedures and to touch their body is part of the treatment.
However, territorial invasion is less tolerated since the instinctive drive is
stronger, directing the control to personal possessions.
 Option C: Touching the patient‘s possessions without permission,
changing the bedside table to a position that cannot be reached, and
raising or lowering the window blinds without consulting the patient are
attitudes of the nursing staff that cause much discomfort. Healthcare
providers need to be more attentive to the patient‘s space and respect the
territoriality established by them, often with their personal objects and
possessions.
 Option D: In the hospital setting, most procedures and interventions are
performed at this distance, the intimate zone, often without due affectivity
and permission. Within this context of the cultural and personal use of
space, healthcare providers need to know and respect the limits of the
physical distance that should be maintained in different situations of
interaction with the patient so that both feel comfortable.
ADVERTISEMENTS
30. Question
To be effective in meeting various ethnic needs, the nurse should:
o A. Treat all clients alike.
o B. Be aware of the client's cultural differences.
o C. Act as if he or she is comfortable with the client‘s behavior.
o D. Avoid asking questions about the client‘s cultural background.

Incorrect
Correct Answer: B. Be aware of the client’s cultural differences.

Nurses can pay close attention to their own biases and how they react to people
whose backgrounds and cultural experiences differ from their own. For example,
a person who becomes conscious that they think of immigrants as illegal aliens
achieves cultural awareness of that particular bias.
 Option A: Once nurses tap into awareness, they can actively analyze their
increased awareness and internal belief systems. Using the above example,
the person can examine their background, beliefs, and values to
understand their cultural bias regarding immigrants.
 Option C: Often, individual beliefs and values do not correspond to their
behavior and actions. Nurses can work to acknowledge that this disconnect
exists and view knowledge as an important element of developing cultural
competence. Research has shown that people who score low on prejudice
tests may still use labels such as ―illegal alien.‖
 Option D: Nurses put their awareness, attitude, and knowledge into
practice by repeating culturally competent behaviors until they become
integrated into their daily interactions. These behaviors include effective
and respectful communication and body language. Among various
cultures, nonverbal communication methods, such as gestures, can mean
very different things.
ADVERTISEMENTS
31. Question
The most important factor in providing nursing care to clients in a specific ethnic
group is:
o A. Communication
o B. Time orientation
o C. Biological variation
o D. Environmental control
Incorrect
Correct Answer: A. Communication
The ability to communicate effectively with patients and families is paramount for
good patient care. This practice point reviews the importance of communicating

effectively in cross-cultural encounters. The LEARN (Listen, Explain, Acknowledge,
Recommend, Negotiate) model is a framework for cross-cultural communication
that helps build mutual understanding and enhance patient care.
 Option B: One way of looking at cultural attitudes to time is in terms of
time orientation, a cultural or national preference toward past, present, or
future thinking. The time orientation of a culture affects how it values time,
and the extent to which it believes it can control time.
 Option C: Biological variations in transcultural nursing relate to the genetic
difference between cultures that may or may not predispose certain groups
to specific diseases. This dimension may also include variations of ―pain
tolerance and deficiencies and predilections in nutrition‖ (Albougami,
Pounds, & Alotaibi, 2016).
 Option D: Environmental control refers to how the patient ―perceives
society and its internal and external factors, such as beliefs and
understandings regarding how illness occurs, how it should be treated, and
how health is uplifted and maintained‖ (Albougami, Pounds, & Alotaibi,
2016).
ADVERTISEMENTS
32. Question
A health care issue often becomes an ethical dilemma because:
o A. A client's legal rights coexist with a health professional's obligation.
o B. Decisions must be made quickly, often under stressful conditions.
o C. Decisions must be made based on value systems.
o D. The choices involved do not appear to be clearly right or wrong.

Incorrect
Correct Answer: D. The choices involved do not appear to be clearly right or
wrong.
Advances in medicine, increasing economic stress, a rise of patient self-
determination, and differing values between healthcare workers and patients are
among the many factors contributing to the frequency and complexity of ethical
issues in healthcare.

 Option A: Nurses are required to administer prescribed medicine, but
patients, at the same time, can refuse them. Patient autonomy can go
against medical directives, despite clearly defined needs. Patients have a
right to refuse all medical care. ANA highlights that it is important for
nurses and nurse managers to understand patient backgrounds and
individual circumstances to inform the patient of the medical necessity.
 Option B: Nurses can also benefit by surrounding themselves with well-
seasoned nurses as well as experienced nurse managers. They can rely on
the guidance of nurse managers when it comes to situations they may not
know how to address. Nurse managers can cultivate educational
environments, in which they regularly discuss ethical issues with the nurses
in their units. By having open dialogues about ethical issues, nurses can
learn from the mistakes others have made and learn how to approach
ethical issues and challenges.
 Option C: Healthcare, which is science-based and results-driven, can
impede religious or personal beliefs. Some religions restrict medical
interventions and lifesaving techniques. Nurses focus on providing medical
care to reduce suffering and to allow patients to concentrate on self-care.
For patients or their families with strong religious or spiritual convictions,
the focus may be on adhering to a strict set of guidelines.
ADVERTISEMENTS
33. Question
A document that lists the medical treatment a person chooses to refuse if unable
to make decisions is the:
o A. Durable power of attorney
o B. Informed consent
o C. Living will
o D. Advance directives
Incorrect
Correct Answer: D. Advance directives

An advance directive is a legal document that explains how the patient wants
medical decisions about him to be made if he cannot make the decisions himself.
An advance directive lets the health care team and loved ones know what kind of
health care the patient wants, or who he wants to make decisions for him when
he can‘t. An advance directive can help the patient think ahead of time about
what kind of care he wants. It may help guide loved ones and the health care
team in making clear decisions about health care when the patient can‘t do it
himself.
 Option A: A power of attorney (POA) authorizes someone else to handle
certain matters, such as finances or health care, on the patient‘s behalf. If a
power of attorney is durable, it remains in effect if the patient becomes
incapacitated, such as due to illness or an accident.
 Option B: Informed consent is the process in which a health care provider
educates a patient about the risks, benefits, and alternatives of a given
procedure or intervention. The patient must be competent to make a
voluntary decision about whether to undergo the procedure or
intervention.
 Option C: A living will, also called a directive to physicians or advance
directive, is a document that lets people state their wishes for end-of-life
medical care, in case they become unable to communicate their decisions.
It has no power after death.
ADVERTISEMENTS
34. Question
Which statement about an institutional ethics committee is correct?
o A. The ethics committee is an additional resource for clients and

healthcare professionals.
o B. The ethics committee relieves health care professionals from dealing with
ethical issues.
o C. The ethics committee would be the first option in addressing an ethical

dilemma.

o D. The ethics committee replaces decision-making by the client and health
care providers.
Incorrect
Correct Answer: A. The ethics committee is an additional resource for clients
and healthcare professionals.
In hospitals throughout the United States, institutional ethics committees (IECs)
have become a standard vehicle for the education of health professionals about
biomedical ethics, for the drafting and review of hospital policy, and for clinical
ethics case consultation.
 Option B: Institutional ethics committees (IECs) initially was proposed to
review decisions to limit or withdraw life-sustaining treatment for
neurologically devastated or dying adult patients and were viewed as a
reasonable approach to the complex issues raised by decisions not to treat
seriously ill or disabled newborns.
 Option C: An IEC that is engaged in providing ethics consultations should
have a policy and procedure statement that includes the following: who
can request a consultation, how the IEC is contacted, who responds to the
request, how the consultation is conducted, who is to be included in the
consultation, proper notification of affected persons, protection of patient
confidentiality, how the consultation is documented, whether in some
circumstances an ethics consultation is required, and the advisory nature of
the consultant‘s recommendations.
 Option D: IECs help resolve conflicts about treatment decisions through
case consultation, provide a forum for discussion of policies relating to
institutional ethics, and educate their health care communities about
ethical concepts.
ADVERTISEMENTS
35. Question
The nurse is working with the parents of a seriously ill newborn. Surgery has been
proposed for the infant, but the chances of success are unclear. In helping the
parents resolve this ethical conflict, the nurse knows that the first step is:
o A. Exploring reasonable courses of action.

o B. Collecting all available information about the situation.
o C. Clarifying values related to the cause of the dilemma.
o D. Identifying people who can solve the difficulty.

Incorrect
Correct Answer: B. Collecting all available information about the situation.
Autonomy allows healthcare teams to respect and support a patient‘s decision to
accept or refuse life-sustaining treatments. As patient advocates, it‘s our duty to
ensure that our patients receive all of the necessary information, such as potential
risks, benefits, and complications, to make well-informed decisions. The
healthcare team can then formulate care in compliance with the patient‘s wishes.
 Option A: Nurses use nonmaleficence by selecting interventions that will
cause the least amount of harm to achieve a beneficial outcome. For
example, if a patient verbalizes homicidal ideations with a plan, we may be
torn between wanting to ensure patient privacy and our duty to escalate
the patient‘s care to safeguard the public. The principle of nonmaleficence
points us to place the safety of the patient and community first in all care
delivery.
 Option C: Family members should refrain from making decisions for the
patient or inflicting undue pressure to alter his or her decisions unless the
patient is incapacitated or found to be legally incompetent. Many factors
may influence a patient‘s acceptance or refusal of medical treatment, such
as culture, age, general health, social support system, and previous
exposure to individuals who received a similar treatment modality with
negative clinical outcomes.
 Option D: Paternalism provides the power for healthcare professionals to
make decisions to reveal or conceal a diagnosis, potential treatment
modalities, or expected prognosis. An example of paternalism is when we
admit an adolescent with multiple complete cervical spine fractures whose
family is stating that the teen needs to participate in a state basketball
championship in 3 months. The benefit of sharing the anticipated
prognosis of quadriplegia at this time is far outweighed by the potential
emotional trauma it may cause the family.
ADVERTISEMENTS

36. Question
Miss Mary, an 88-year old woman, believes that life should not be prolonged
when hope is gone. She has decided that she does not want extraordinary
measures taken when her life is at its end. Because she feels this way, she has
talked with her daughter about her desires, completing a living will, and left
directions with her physician. This is an example of:
o A. Affirming a value
o B. Choosing a value
o C. Prizing a value
o D. Reflecting a value
Incorrect
Correct Answer: C. Prizing a value.
The alternative goal of value awareness is enabling patients to achieve their
desired balance between rational and nonrational decision-making, allowing
them to be as rational as they can and want to be. That means doing everything
possible to make the critical issues clear, thereby expanding the envelope of
potentially rational decision-making.
 Option A: Nurses engaged with mortality through a process of recognition
and through the affirmation of their values. The affirmed values are aligned
with the palliative care approach and within the ethics of finitude lens in
that their enactment is partly premised on the recognition of patients‘
accumulated losses related to human facticities (social, temporal, mortal).
 Option B: Advance directives treat patients (and their surrogates) as
rational actors, who will choose the option with the highest expected utility
if provided needed information. The rational actor model assumes well-
formulated decisions, with each option (e.g., treatment) represented as a
vector of expected outcomes (e.g., pain, anxiety, life expectancy) that a
decision-maker can weigh by relative importance.
 Option D: Reflection brings learning to life. Reflective practice helps
learners find relevancy and meaning in a lesson and make connections
between educational experiences and real-life situations. It increases
insight and creates pathways to future learning. Reflection is called by

many different names in the education field including processing,
reviewing, and debriefing.
ADVERTISEMENTS
37. Question
The scope of nursing practice is legally defined by:
o A. State nurses practice acts
o B. Professional nursing organizations
o C. Hospital policy and procedure manuals
o D. Physicians in the employing institutions

Incorrect
Correct Answer: A. State nurses practice acts
Every state and territory in the US sets laws to govern the practice of nursing.
These laws are defined in the Nursing Practice Act (NPA). The NPA is then
interpreted into regulations by each state and territorial nursing board with the
authority to regulate the practice of nursing care and the power to enforce the
laws. Fifty states, District of Columbia and 4 United States (US) territories, have
state boards of nursing (BON) that are responsible for regulating their individual
NPA.
 Option B: Professional organizations and associations in nursing are
critical for generating the energy, flow of ideas, and proactive work needed
to maintain a healthy profession that advocates for the needs of its clients
and nurses, and the trust of society.
 Option C: From patient discharge procedures to maintaining the hygiene
of the staff workers, policies and procedures are comprehensive guidelines
to ensure the organization is complying with the rules and regulations. The
maintenance of policies also ensures reduced risk of accidents, improves
efficiency, and helps maintain a sound working environment for patients,
staff, and visitors.
 Option D: Collaboration, between physicians and nurses, means
cooperation in work, sharing responsibilities for solving problems, and
making decisions to formulate and carry out plans for patient care.

Although the provision of healthcare is becoming more complex,
collaboration among healthcare workers can be a path to improve the
quality of healthcare services especially in hospitals in which the
environment is characterized by ongoing interaction among professionals.
ADVERTISEMENTS
38. Question
A student nurse who is employed as a nursing assistant may perform any
functions that:
o A. Have been learned about in school.
o B. Are expected of a nurse at that level.
o C. Are identified in the position's job description.
o D. Require technical rather than professional skill.

Incorrect
Correct Answer: C. Are identified in the position’s job description.
A student nurse works to maintain, promote and restore the health of patients
while following the procedures of the hospital where she is gaining practical
experience. A student nurse must follow the instructions of her clinical instructor.
Working at a health care facility offers a chance for a student nurse to practice
what she has learned in school. It is a challenging experience that involves several
duties.
 Option A: Student nurses should research the basics of their patients‘
needs. Clinical instructors expect student nurses to read and understand
the diagnoses of their designated patients. Student nurses must
understand the medical conditions of their patients as well as any
medications they might require. In addition, student nurses need to be
versed in modern technologies, which are important for patient care.
 Option B: As part of their clinical rotations, student nurses should
administer medications after researching the effects of the medications on
patients. They should carry out this function only with the approval of the
physician or clinical instructor. Administering medications involves
preparing them in the appropriate doses, administering them at the

specified times and using the right procedures. Student nurses must also
ensure that they are administering medications to the right patients by
asking them their names. Additionally, student nurses should check patient
IDs to confirm their identities.
 Option D: Student nurses also provide nursing care for their patients by
assisting them to bathe and eat. Bathing patients may be laborious,
especially when they are bedridden. The student nurse has to cover the
patient with blankets or sheets to keep him warm. In addition, she should
keep the bed dry by placing a towel under the patient. Part of the nursing
care demands that student nurses should change bedding after bathing
their patients. Gaining a patient‘s consent to care for him is vital because
he may be uncomfortable with a student nurse.
ADVERTISEMENTS
39. Question
A confused client who fell out of bed because side rails were not used is an
example of which type of liability?
o A. Felony
o B. Assault
o C. Battery
o D. Negligence
Incorrect
Correct Answer: D. Negligence
Negligence is defined as doing something or failing to do something that a
prudent, careful, and reasonable nurse would do or not do in the same situation.
It is the failure to meet accepted standards of nursing competence and nursing
scope of practice.
 Option A: Some examples of felonies include murder, rape, burglary,
kidnapping, and arson. People who have been convicted of a felony are
called felons. Repeat felons are punished extra harshly because sentencing
laws take into consideration their criminal history. A more serious crime
than a misdemeanor with a punishment greater than that for

misdemeanors; can be grounds for license denial, revocation, suspension,
or probation of a healthcare provider. It is punishable by imprisonment or
death, depending on state law and the type of crime.
 Option B: Assault is the intentional act of making someone fear that you
will cause them harm. You do not have to actually harm them to commit
assault. Threatening them verbally or pretending to hit them are both
examples of assault that can occur in a nursing home.
 Option C: Battery comprises a direct and intentional [or reckless] act of the
defendant which causes some physical contact with the person of the
plaintiff without the plaintiff‘s consent.
ADVERTISEMENTS
40. Question
The nurse puts a restraint jacket on a client without the client‘s permission and
without the physician‘s order. The nurse may be guilty of:
o A. Assault
o B. Battery
o C. Invasion of privacy
o D. Neglect
Incorrect
Correct Answer: B. Battery
A battery comprises a direct and intentional [or reckless] act of the defendant
which causes some physical contact with the person of the plaintiff without the
plaintiff‘s consent. Touching a person that does not invite touching or blatantly
says to stop is a battery. For example, going by a coworker‘s desk and continually
pinching, slapping, or punching them, when the force is strong enough to hurt
them and your intent is to hurt them, would constitute battery.
 Option A: Assault is the intentional act of making someone fear that you
will cause them harm. You do not have to actually harm them to commit
assault. Threatening them verbally or pretending to hit them are both
examples of assault that can occur in a nursing home.

 Option C: Invasion of privacy is the unjustifiable intrusion into the personal
life of another without consent. However, invasion of privacy is not a tort
on its own; rather it generally consists of four distinct causes of action.
 Option D: Negligence is defined as doing something or failing to do
something that a prudent, careful, and reasonable nurse would do or not
do in the same situation. It is the failure to meet accepted standards of
nursing competence and nursing scope of practice.
ADVERTISEMENTS
41. Question
In a situation in which there is insufficient staff to implement competent care, a
nurse should:
o A. Organize a strike.
o B. Inform the clients of the situation.
o C. Refuse the assignment.
o D. Accept the assignment but make a protest in writing to the administration.

Incorrect
Correct Answer: A. Organize a strike
Insufficient staffing ratios are causing tension in the nursing field across the
United States, and hospital safety managers should prevent and prepare for
picketing or strikes. Staffing is an issue that is becoming increasingly contentious
in hospitals and healthcare facilities across the United States. In 2018, nurses in
hospitals run HCA, one of the country‘s largest healthcare providers, picketed and
threatened to strike in five states, according to the New York Times.
 Option B: Hospitals have a responsibility to supply patients with
uninterrupted healthcare, even should a strike occur. Transparency is key
during a nursing strike, so if changes in treatment are inevitable, this must
be communicated to patients. Make sure that parents are informed of
changes in staffing, whether this is care from nurses or doctors. Patients
will appreciate the autonomy to make informed decisions amid staffing
disruptions.

 Option C: According to the American Nurses Association, Nurses have the
―professional right to accept, reject or object in writing to any patient
assignment that puts patients or themselves at serious risk for harm.
 Option D: If a nursing union is calling for the health care system to hire
more nurses amid staffing shortages, it is a signal to the administration
that patient safety might be jeopardized. Walk-outs and strikes are often
the last resort for nurses – they don‘t want to disrupt patient care or
hospital operations as much as hospital administrations don‘t. These
situations occur when communication does not occur.
ADVERTISEMENTS
42. Question
Which statement about loss is accurate?
o A. Loss is only experienced when there is an actual absence of something

valued.
o B. The more the individual has invested in what is lost, the less the feeling of
loss.
o C. Loss may be maturational, situational, or both.
o D. The degree of stress experienced is unrelated to the type of loss.

Incorrect
Correct Answer: C. Loss may be maturational, situational, or both.
The loss may be actual or perceived and is the absence of something that was
valued. An actual loss is recognized and verified by others while others cannot
verify a perceived loss. Both are real to the individual who has experienced the
loss. Grief is the internal part of the loss; it is the emotional feelings related to the
loss.
 Option A: The feelings of loss are commonly associated with the death of
a loved one, but they can be experienced for a number of reasons. People
may experience grief and feelings of loss about a significant change such
as the loss of a job, loss of function, loss of a limb, loss of a pet, the feeling
of loss of control, and loss of loved ones.

 Option B: It is important for the nurse to assist the patient and loved ones
in their coping with their grief to include anticipatory grief. Educate them
on what is expected to include the stages of grief and what are some
normal feelings as well as what are some resources to help adjust to this
loss they are experiencing. Evaluate how they are handling this experience
and address any fears related to grief and loss.
 Option D: Grief may affect individuals differently but can be exhibited
through signs and symptoms such as altered immune responses, distress,
anger, sleep disturbances, withdrawal, pain, panic, and suffering. It may be
evident by one‘s lack of understanding of death and its severity and finality
of the loss. Encourage loved ones at the bedside to remember to take care
of their own health. Remind them or help them have access to food and
hydration. Encourage adequate sleep and hygiene.
ADVERTISEMENTS
43. Question
Trying questionable and experimental forms of therapy is a behavior that is
characterized by which stage of dying?
o A. Anger
o B. Depression
o C. Bargaining
o D. Acceptance
Incorrect
Correct Answer: C. Bargaining
This is the step in the grieving process where one may think ―If this __, then
this__.‖ For example: ―I will do anything if you take the hurt away‖ or ―I will never
sin again if my loved one will be spared.‖ Bargaining may come in the form of
―what if‖ statements. For example, ―What if we found the cancer sooner?‖ or
―What if this accident never happened?‖ These ―what ifs‖ are a way to negotiate
the fact that an individual wants life to go back to how it once was.
 Option A: Anger is a necessary stage of the healing process. Before the
anger stage, an individual who is experiencing grief may feel like they have

been abandoned or may feel no connection to anything. Experiencing
anger allows for a connection; it allows for something to hold on to. Anger
may be directed at the thing or person that was lost, the doctors, friends,
family, God, etc.
 Option B: After the thoughts of the past in bargaining, thoughts of the
present flood in. They realize that the situation is real. Empty feelings come
forward, and one‘s grief moves in on a deeper level than before. This type
of depression is not a sign of mental illness; although, reaching out for help
may be the right step. It is an appropriate response to a great loss.
 Option D: Acceptance does not have to mean one is ―alright with what has
happened.‖ An individual may never be the same as before after a loss.
They may never feel ―OK‖ about the loss. Acceptance, as a stage, is about
accepting that this is their new reality, and it is permanent. Life cannot go
on as it once did, but through acceptance, life can and will go on.
ADVERTISEMENTS
44. Question
All of the following are crucial needs of the dying client except:
o A. Control of pain
o B. Preservation of dignity and self-worth
o C. Love and belonging
o D. Freedom from decision making

Incorrect
Correct Answer: D. Freedom from decision making
Patients should be made aware that they can participate in their end-of-life care
in two distinct ways: by actively making decisions at the end of their life and by
making decisions about how they believe they would wish to be cared for based
on a hypothetical scenario of impairment. The patient should understand that
while his or her health care provider may strongly disagree with or object to the
patient‘s decision to refuse the plan of care, the patient‘s decision is
constitutionally protected.

 Option A: Health care professionals should understand that personal,
social, and cultural experiences influence a patient‘s definition of pain,
health, and illness, and responses to pain vary among individuals and
cultural groups.3 A patient‘s reaction to pain is influenced by his or her
individual perception of it, and the perception of pain reflects his or her
attitude toward pain and characteristic way of responding.
 Option B: Two key factors which influence the preservation of dignity at
the end of life are promoting self-respect and treating the patient with
respect; but how are these translated in practice into palliative care? Most
end-of-life interventions focus predominantly on symptom control, rather
than holistic care. Therefore it may be helpful to consider the physical,
emotional, and spiritual needs of patients in palliative care settings.
 Option C: Regarding emotional needs, a review found that important
actions for healthcare professionals providing end-of-life care include
communicating, listening, conveying empathy, and involving patients in
decision-making 8. Furthermore, good communication between the patient
and their partner about their feelings should be promoted.
ADVERTISEMENTS
45. Question
Cultural awareness is an in-depth self-examination of one‘s:
o A. Background, recognizing biases and prejudices.
o B. Social, cultural, and biophysical factors.
o C. Engagement in cross-cultural interactions.
o D. Motivation and commitment to caring.

Incorrect
Correct Answer: A. Background, recognizing biases and prejudices.
Cultural awareness is an in-depth examination of one‘s own background,
recognizing biases and prejudices, and assumptions about other people. Cultural
awareness is sensitivity to the similarities and differences that exist between two
different cultures and the use of this sensitivity in effective communication with
members of another cultural group.

 Option B: Cultural competence is necessary because it helps the nurse
offer the best services to every patient, leading to high satisfaction and
care on the side of the patient. Without cultural competence, the health
sector will suffer a great loss and ultimately limit the services that it can
offer.
 Option C: A strong background and knowledge of cultural competence
prevent professional health caregivers from possessing stereotypes and
being myopic in their thoughts. It also helps them offer the best service to
all, regardless of their social status or belief.
 Option D: Cultural competence prepares nurses to empathize, relate more
to patients, and attend more deeply to their needs. Hospital patients can
often be agitated or stressed. Having someone on their care team who
speaks their language or understands their unique background may help
them to relax, leading to greater therapy and overall care.
ADVERTISEMENTS
46. Question
Cultural competence is the process of:
o A. Learning about vast cultures.
o B. Acquiring specific knowledge, skills, and attitudes.
o C. Influencing treatment and care of clients.
o D. Motivation and commitment to caring.

Incorrect
Correct Answer: B. Acquiring specific knowledge, skills, and attitudes.
Cultural competence is the process of acquiring specific knowledge, skills, and
attitudes that ensure the delivery of culturally congruent care. Culturally
competent care includes knowledge, attitudes, and skills that support caring for
people across different languages and cultures. Culture influences not only health
practices but also how the healthcare provider and the patient perceive illness.
 Option A: Knowledge is being cognizant of the culture base of those in the
nurse‘s service area, such as the shared traditions and values of that group.

Being aware of the patients‘ ethnicity—common genetic elements shared
by people of the same ancestry—is also important.
 Option C: It‘s important to address attitudes to evolve into a culturally
competent caregiver. Becoming aware of how culture influences individual
behavior and thinking allows the nurse to plan the best care for the
patients. Awareness of the rules of interactions within a specific cultural
group, such as communication patterns and customs, division of roles in
the family unit, and spirituality, will help the nurse better understand the
attitudes of the patients.
 Option D: Becoming aware of the nurse‘s own attitudes and tendencies to
stereotype with regard to different cultural groups allows her to provide
genuine care and concern. Learn ways of communicating that best allow
the patient to understand the plan of care. For example, developing
cultural competency skills can involve assisting non–English-speaking
patients with a translator or changing the phrases and words the nurse
uses when explaining care. It also involves learning to adapt to new and
different situations in a flexible way.
ADVERTISEMENTS
47. Question
Ethnocentrism is the root of:
o A. Biases and prejudices.
o B. Meanings by which people make sense of their experiences.
o C. Cultural beliefs.
o D. Individualism and self-reliance in achieving and maintaining health.

Incorrect
Correct Answer: A. Biases and prejudices.
Ethnocentrism can be defined as the judgment of different cultures based on
standards of one‘s own culture. Therefore, whilst providing care, it is important
for nurses to avoid ethnocentrism as this approach can have negative
consequences for the patient, and quality of care is jeopardized.

 Option B: In the health profession, the diversity of people requires the
ability to carefully, respectfully, and effectively provide care. For this reason,
it is vital that the approach of care delivered to patients depends on each
individual. This approach ensures patients receive the best quality of care
possible and avoid situations that can potentially prevent the improvement
of health status.
 Option C: Generally, everyone has their own beliefs, practices, and values
thus it becomes an issue for someone to impose their own views upon
someone else. In terms of a nurse imposing their perspective on a patient,
the patient‘s reaction can differ from becoming passive, to being defiant to
receiving care. Refusal of care potentially leads to a situation that could be
harmful or detrimental to their health.
 Option D: Ethnocentrism leads to assumptions and stereotypes that can
cause nurses to fail in treating patients as an individual. Consequently,
patient-centered care is neglected meaning individual care requirements
are not met. Additionally, there would be negative feelings from patients
towards nurses thus the relationship build is one that lacks trust.
ADVERTISEMENTS
48. Question
When action is taken on one‘s prejudices:
o A. Discrimination occurs.
o B. Sufficient comparative knowledge of diverse groups is obtained.
o C. Delivery of culturally congruent care is ensured.
o D. People think/know you are a dumbass for being prejudiced.

Incorrect
Correct Answer: A. Discrimination occurs.
Discrimination is defined as a showing of partiality or prejudice in treatment;
action or policies directed against the welfare of minority groups. Discrimination
in the health sector is disturbing as it violates the basic principles articulated by
care providers. Discrimination can be direct or indirect. Given the impact of
unintentional discrimination based upon attitudes and stereotyping, all nurses

must examine their biases and prejudices for indications of discriminatory
actions.
 Option B: People in socially disadvantaged groups face a myriad of
challenges to their health. Discrimination, based on group status such as
gender, immigration generation, race/ethnicity, or religion, are a well-
documented health challenge. Nurses must seek out and support nursing
practice environments that embrace inclusive strategies and promote
civility and mutual respect regarding patients, coworkers, and members of
the community.
 Option C: Individuals who have experienced discrimination in the past may
be more reluctant to seek health care, as they may perceive it as a setting
of increased risk for discrimination (i.e., refusal of service or lower quality of
care). This may be especially true for those who have experienced
discrimination within the health care setting itself. Nurses must encourage
all health care agencies to adopt and aggressively maintain policies,
procedures, and practices that embrace inclusiveness, promote civility and
mutual respect, contain methods for reporting violations, and require
interventions to avoid recurrence.
 Option D: Nurses must engage in a period of self-reflection regarding
their personal and professional values regarding civility, mutual respect,
and inclusiveness, and resolve any potential conflicts in ways that ensure
patient safety and promote the best interests of the patient (ANA, 2015).
ADVERTISEMENTS
49. Question
The dominant value orientation in North American society is:
o A. Use of rituals symbolizing the supernatural.
o B. Group reliance and interdependence.
o C. Healing emphasizing naturalistic modalities.
o D. Individualism and self-reliance in achieving and maintaining health.

Incorrect

Correct Answer: D. Individualism and self-reliance in achieving and
maintaining health.
The most important thing to understand about US Americans is probably their
devotion to ―individualism.‖ They have been trained from early in their lives to
consider themselves separate individuals who are responsible for their own
situations in life and their own destinies. They have not been trained to see
themselves as members of a close-knit, tightly interdependent family, religious
group, tribe, nation, or other groups.
 Option A: US Americans are generally less concerned about history and
tradition than are people from older societies. They look ahead. They have
the idea that what happens in the future is within their control, or at least
subject to their influences. They believe that people, as individuals or
working cooperatively together, can change most aspects of the physical
and social environment if they decide things to do and a schedule for
doing them.
 Option B: Americans have not been trained to see themselves as members
of a close-knit, tightly interdependent family, religious group, tribe, nation,
or other groups. People who grow up in a particular culture share certain
values and assumptions. This means that most of them, most of the time,
agree with each others‘ ideas about what is right and wrong, desirable and
undesirable.
 Option C: Cultural, social, and family influences shape attitudes and beliefs
and therefore influence health literacy. Social determinants of health are
well documented regarding the conditions over which the individual has
little or no control but that affect his or her ability to participate fully in a
health-literate society.
ADVERTISEMENTS
50. Question
Disparities in health outcomes between the rich and the poor illustrates: a (an)
o A. Illness attributed to natural, impersonal, and biological forces.
o B. Creation of own interpretation and descriptions of biological and

psychological malfunctions.

o C. Influence of socioeconomic factors in morbidity and mortality.
o D. Combination of naturalistic, religious, and supernatural modalities.

Incorrect
Correct Answer: C. Influence of socioeconomic factors in morbidity and
mortality.
Disparities in health outcomes between the rich and the poor illustrate the
influence of socioeconomic factors in morbidity and mortality. Social factors such
as poverty and lack of universal medical insurance compromise the health status
of the poor and unemployed. Health and health care disparities refer to
differences in health and health care between groups that are closely linked with
social, economic, and/or environmental disadvantage. Disparities occur across
many dimensions, including race/ethnicity, socioeconomic status, age, location,
gender, disability status, and sexual orientation.
 Option A: A complex and interrelated set of individual, provider, health
system, societal, and environmental factors contribute to disparities in
health and health care. Individual factors include a variety of health
behaviors from maintaining a healthy weight to following medical advice.
Provider factors encompass issues such as provider bias and cultural and
linguistic barriers to patient-provider communication.
 Option B: Health and health care disparities are commonly viewed through
the lens of race and ethnicity, but they occur across a broad range of
dimensions. For example, disparities occur across socioeconomic status,
age, geography, language, gender, disability status, citizenship status, and
sexual identity and orientation.
 Option D: A ―health care disparity‖ typically refers to differences between
groups in health insurance coverage, access to and use of care, and quality
of care. Health and health care disparities often refer to differences that are
not explained by variations in health needs, patient preferences, or
treatment recommendations and are closely linked with social, economic,
and/or environmental disadvantage.
ADVERTISEMENTS
51. Question

Culture strongly influences pain expression and the need for pain medication.
However, cultural pain:
o A. May be suffered by a client whose valued way of life is disregarded

by practitioners.
o B. Is more intense, thus necessitating more medication.
o C. Is not expressed verbally or physically.
o D. Is expressed only to others of like culture.

Incorrect
Correct Answer: A. May be suffered by a client whose valued way of life is
disregarded by practitioners.
Nurses need not assume that pain relief is equally valued across groups. Cultural
pain may be suffered by a client whose valued way of life is disregarded by
practitioners. The relationship between pain and ethnicity is shaped by
experience, learning and culture. A cultural group‘s expectations and acceptance
of pain as a normal part of life will determine whether pain is seen as a clinical
problem that requires a clinical solution.
 Option B: Experience, learning and culture shape the relationship between
pain and ethnicity rather than any fundamental neurological differences.
The distinction between race and ethnicity is particularly important for pain
research based on the biopsychosocial model. This model suggests the
experience of pain is derived via the interaction of biological,
psychological, and social factors.
 Option C: Chronic pain affects approximately 1 in 5 adults in Europe
resulting in substantial healthcare costs. Evidence that cultural influences
have an impact on pain is readily available from the UK where the pain is
the most common symptom encountered by the medical profession.
 Option D: Mistaken beliefs about the nature of pain and disability,
resistance to treatment-seeking, reluctance to comply with treatment, and
failure to accept responsibility for the treatment outcome are not culturally
or sub-culturally specific obstacles to pain management.
ADVERTISEMENTS

52. Question
The dominant values in American society on individual autonomy and self-
determination:
o A. Rarely has an effect on other cultures.
o B. Do have an effect on health care.
o C. May hinder the ability to get into a hospice program.
o D. May be in direct conflict with diverse groups.

Incorrect
Correct Answer: D. May be in direct conflict with diverse groups.
The dominant value in American society of individual autonomy and self-
determination may be in direct conflict with diverse groups. Advance directives,
informed consent, and consent for hospice are examples of mandates that may
violate client‘s values. Culture influences health care at all levels, including
communications and interactions with doctors and nurses, health disparities,
health care outcomes, and even the illness experience itself. People in some
cultures believe illness is the will of a higher power, and may be more reluctant to
receive health care.
 Option A: Culture plays a huge role in medical interactions. It influences
how an individual might view an illness or treatment, for example, and
affects how a physician should address an older patient. Culture may also
affect the decision-making process. Cultural beliefs can affect how a
patient will seek care and from whom, how he or she will manage self-care,
how he will make health choices, and how she might respond to a specific
therapy.
 Option B: Literacy and language barriers may play a role in poor
communication between doctors and patients from different cultures. The
communication gap can prevent some seniors and families from getting
the health information they need to make informed decisions. They may
not know where to access information in another language, or they may
not know how to find a health care provider that speaks the language.
 Option C: While family caregiving is the norm in the Hispanic community
and in other cultures, it is not always a viable option. Some older

individuals may not have family living nearby, for example, or the family
may be overwhelmed with children or other responsibilities.
ADVERTISEMENTS
53. Question
In the United States, access to health care usually depends on a client‘s ability to
pay for health care, either through insurance or by paying cash. The client the
nurse is caring for needs a liver transplant to survive. This client has been out of
work for several months and does not have insurance or enough cash. A
discussion about the ethics of this situation would involve predominantly the
principle of:
o A. Accountability, because you as the nurse are accountable for the well
being of this client.
o B. Respect of autonomy, because this client‘s autonomy will be violated if he

does not receive the liver transplant.
o C. Ethics of care, because the caring thing that a nurse could provide this
patient is resources for a liver transplant.
o D. Justice, because the first and greatest question in this situation is how
to determine the just distribution of resources.
Incorrect
Correct Answer: D. Justice, because the first and greatest question in this
situation is how to determine the just distribution of resources
Justice refers to fairness. Health care providers agree to strive for justice in health
care. The term often is used during discussions about resources. Decisions about
who should receive available organs are always difficult. All patients have a right
to be treated fair and equally by others. Justice involves how people are treated
when their interest competes with others. A current hot topic that addresses this
is the lack of healthcare insurance for some. Another example is with patients in
rural settings who may not have access to the same healthcare services that are
offered in metropolitan areas.
 Option A: As a nurse, it‘s inherent that accountability for all aspects of care
aligns with responsible decision-making. The use of authority must be

professional and about all aspects of individualism and patient, ethical
concerns. Nursing decisions must be well thought, planned, and
purposefully implemented responsibly. Any delegation of nursing activities
or functions must be done with respect for the action and the ultimate
results to occur.
 Option B: Each patient has the right to make their own decisions based on
their own beliefs and values. This is known as autonomy. A patient‘s need
for autonomy may conflict with care guidelines or suggestions that nurses
or other healthcare workers believe is best. A person has a right to refuse
medications, treatment, surgery, or other medical interventions regardless
of what benefit may come from it.
 Option C: The patient should always be a first and primary concern. The
nurse must recognize the need for the patient to include their individual
thought into care practices. Any conflict of interest, whether belonging to
external organizations, or the nurse‘s habits or ideals that conflict with the
act of being a nurse, should be shared and addressed to not impact patient
care.
ADVERTISEMENTS
54. Question
The Code of Ethics for nurses is composed and published by:
o A. The National League for Nursing
o B. The American Nurses Association
o C. The Medical American Association
o D. The National Institutes of Health, Nursing Division

Incorrect
Correct Answer: B. The American Nurses Association
The ANA has established widely accepted codes that professional nurses attempt
to follow. The Code of Ethics for Nurses developed by the American Nurses
Association (ANA) makes explicit the primary goals, values, and obligations of the
profession. Ethics is an integral part of the foundation of nursing. Nursing has a
distinguished history of concern for the welfare of the sick, injured, and

vulnerable and for social justice. This concern is embodied in the provision of
nursing care to individuals and the community.
 Option A: Dedicated to excellence in nursing, the National League for
Nursing is the premier organization for nurse faculty and leaders in nursing
education. The NLN offers professional development, networking
opportunities, testing services, nursing research grants, and public policy
initiatives to its 40,000 individual and 1,200 institutional members.
 Option C: Founded in 1847, the American Medical Association (AMA) is the
largest and only national association that convenes 190+ state and
specialty medical societies and other critical stakeholders. Throughout
history, the AMA has always followed its mission: to promote the art and
science of medicine and the betterment of public health.
 Option D: The National Institutes of Health (NIH), a part of the U.S.
Department of Health and Human Services, is the nation‘s medical research
agency — making important discoveries that improve health and save lives.
Thanks in large part to NIH-funded medical research, Americans today are
living longer and healthier. Life expectancy in the United States has jumped
from 47 years in 1900 to 78 years as reported in 2009, and disability in
people over age 65 has dropped dramatically in the past 3 decades. In
recent years, nationwide rates of new diagnoses and deaths from all
cancers combined have fallen significantly.
ADVERTISEMENTS
55. Question
Nurses agree to be advocates for their patients. The practice of advocacy calls for
the nurse to:
o A. Seek out the nursing supervisor in conflicting situations.
o B. Work to understand the law as it applies to the client‘s clinical condition.
o C. Assess the client’s point of view and prepare to articulate this point of
view.
o D. Document all clinical changes in the medical record in a timely manner.

Incorrect

Correct Answer: C. Assess the client’s point of view and prepare to articulate
this point of view.
Nurses strengthen their ability to advocate for a client when nurses are able to
identify personal values and then accurately identify the values of the client and
articulate the client‘s point of view. Nurse advocates support the patient‘s best
interests while respecting the family‘s important role. They attend healthcare
team meetings with the patient and family to clarify any communication
problems and ensure information from the healthcare team is complete and
correct.
 Option A: Throughout the treatment process, the nurse follows the
progress of the patient and acts accordingly with the patient‘s best
interests in mind. The care provided by a nurse extends beyond the
administration of medications and other therapies. They are responsible for
the holistic care of patients, which encompasses the psychosocial,
developmental, cultural, and spiritual needs of the individual.
 Option B: Nurses are also responsible for ensuring that patients are able to
understand their health, illnesses, medications, and treatments to the best
of their ability. This is of the essence when patients are discharged from the
hospital and need to take control of their own treatments.
 Option D: A nurse is directly involved in the decision-making process for
the treatment of patients. It is important that they are able to think
critically when assessing patient signs and identifying potential problems
so that they can make the appropriate recommendations and actions.
ADVERTISEMENTS
56. Question
Successful ethical discussion depends on people who have a clear sense of
personal values. When many people share the same values it may be possible to
identify a philosophy of utilitarianism, with proposes that:
o A. The value of people is determined solely by leaders in the Unitarian

church.
o B. The decision to perform a liver transplant depends on a measure of the

moral life that the client has led so far.

o C. The best way to determine the solution to an ethical dilemma is to refer
the case to the attending physician.
o D. The value of something is determined by its usefulness to society.

Incorrect
Correct Answer: D. The value of something is determined by its usefulness
to society.
A utilitarian system of ethics proposes that the value of something is determined
by its usefulness. Utilitarianism is a theory of morality, which advocates actions
that foster happiness or pleasure and opposes actions that cause unhappiness or
harm. When directed toward making social, economic, or political decisions, a
utilitarian philosophy would aim for the betterment of society as a whole.
 Option A: Utilitarianism is a theory of morality, which advocates actions
that foster happiness and opposes actions that cause unhappiness.
Utilitarianism promotes ―the greatest amount of good for the greatest
number of people.‖
 Option B: As patient advocates, it‘s our duty to ensure that our patients
receive all of the necessary information, such as potential risks, benefits,
and complications, to make well-informed decisions. The healthcare team
can then formulate care in compliance with the patient‘s wishes. Family
members should refrain from making decisions for the patient or inflicting
undue pressure to alter his or her decisions unless the patient is
incapacitated or found to be legally incompetent.
 Option C: Paternalism provides the power for healthcare professionals to
make decisions to reveal or conceal a diagnosis, potential treatment
modalities, or expected prognosis. An example of paternalism is when we
admit an adolescent with multiple complete cervical spine fractures whose
family is stating that the teen needs to participate in a state basketball
championship in 3 months. The benefit of sharing the anticipated
prognosis of quadriplegia at this time is far outweighed by the potential
emotional trauma it may cause the family.
ADVERTISEMENTS
57. Question

The philosophy sometimes called the code of ethics of care suggests that ethical
dilemmas can best be solved by attention to:
o A. Relationships
o B. Ethical principles
o C. Clients
o D. Code of ethics for nurses

Incorrect
Correct Answer: A. Relationships.
The ethic of care explores the notion of care as a central activity of human
behavior. Those who write about the ethics of care advocate a more female-
biased theory that is based on understanding relationships, especially personal
narratives.
 Option B: Normatively, care ethics seeks to maintain relationships by
contextualizing and promoting the well-being of caregivers and care-
receivers in a network of social relations. Most often defined as a practice
or virtue rather than a theory as such, ―care‖ involves maintaining the world
of, and meeting the needs of, yourself and others.
 Option C: It builds on the motivation to care for those who are dependent
and vulnerable, and it is inspired by both memories of being cared for and
the idealizations of self. Following in the sentimentalist tradition of moral
theory, care ethics affirms the importance of caring motivation, emotion,
and the body in moral deliberation, as well as reasoning from particulars.
 Option D: The Code of Ethics for Nurses developed by the American
Nurses Association (ANA) makes explicit the primary goals, values, and
obligations of the profession. Nursing encompasses the prevention of
illness, the alleviation of suffering, and the protection, promotion, and
restoration of health in the care of individuals, families, groups, and
communities. Individuals who become nurses are expected not only to
adhere to the ideals and moral norms of the profession but also to
embrace them as a part of what it means to be a nurse.
ADVERTISEMENTS

58. Question
In most ethical dilemmas, the solution to the dilemma requires negotiation
among members of the health care team. The nurse‘s point of view is valuable
because:
o A. Nurses have a legal license that encourages their presence during ethical
discussions.
o B. The principle of autonomy guides all participants to respect their own self-
worth.
o C. Nurses develop a relationship with the client that is unique among all
professional health care providers.
o D. The nurse‘s code of ethics recommends that a nurse be present at any

ethical discussion about client care.
Incorrect
Correct Answer: C. Nurses develop a relationship to the client that is unique
among all professional health care providers
When ethical dilemmas arise, the nurse‘s point of view is unique and critical. The
nurse usually interacts with clients over longer time intervals than do other
disciples. It is important to advocate for patient care, patient rights, and ethical
consideration of practice. Ethics inclusion should begin in nursing school and
continue as long as the nurse is practicing.
 Option A: Nurses have a responsibility to themselves, their profession, and
their patients to maintain the highest ethical principles. Many organizations
have ethics boards in place to review ethical concerns. Nurses at all levels
of practice should be involved in ethics reviews in their targeted specialty
area.
 Option B: Each patient has the right to make their own decisions based on
their own beliefs and values. This is known as autonomy. A patient‘s need
for autonomy may conflict with care guidelines or suggestions that nurses
or other healthcare workers believe is best. A person has a right to refuse
medications, treatment, surgery, or other medical interventions regardless
of what benefit may come from it.
 Option D: Ethical dilemmas arise as nurses care for patients. These
dilemmas may, at times, conflict with the Code of Ethics or with the nurse‘s

ethical values. Nurses are advocates for patients and must find a balance
while delivering patient care.
ADVERTISEMENTS
59. Question
Ethical dilemmas often arise over a conflict of opinion. Once the nurse has
determined that the dilemma is ethical, a critical first step in negotiating the
difference of opinion would be to:
o A. Consult a professional ethicist to ensure that the steps of the process

occur in full.
o B. Gather all relevant information regarding the clinical, social, and

spiritual aspects of the dilemma.
o C. List the ethical principles that inform the dilemma so that negotiations
agree on the language of the discussion.
o D. Ensure that the attending physician has written an order for an ethics
consultation to support the ethics process.
Incorrect
Correct Answer: B. Gather all relevant information regarding the clinical,
social, and spiritual aspects of the dilemma
Each step in the processing of an ethical dilemma resembles steps in critical
thinking. The nurse begins by gathering information and moves through
assessment, identification of the problem, planning, implementation, and
evaluation.
 Option A: To address health inequity factors, nurses are encouraged to be
aware of health disparities that could impair treatment outcomes. They can
then refer patients to social workers, case managers, and other healthcare
team members for additional services. Nurses should be mindful of the
social and economic factors that affect patient and community health.
 Option C: Nurses make decisions based on the information available to
them in the current situation. The more relevant information they have, the
more likely their decision will have a positive outcome. When a nurse‘s
decision leads to a negative outcome, the question becomes: What critical

pieces of information were lacking at the time of the decision? Nurses must
take responsibility for their decisions and strive to understand why some
decisions have negative outcomes.
 Option D: Even the most extensive code of ethics can‘t account for all the
potential dilemmas that nurses may encounter in their work. That‘s the
reason that one of the duties stated in the nursing code of ethics is to seek
the advice and counsel of others whenever a nurse is uncertain about a
medical decision‘s ethical aspects.
ADVERTISEMENTS
60. Question
The Nurse Practice Acts are an example of:
o A. Statutory law
o B. Common law
o C. Civil law
o D. Criminal law
Incorrect
Correct Answer: A. Statutory law
The NPA is then interpreted into regulations by each state and territorial nursing
board with the authority to regulate the practice of nursing care and the power
to enforce the laws. Fifty states, the District of Columbia and 4 United States (US)
territories, have state boards of nursing (BON) that are responsible for regulating
their individual NPA.
 Option B: Common law results from judicial decisions made in courts
when individual legal cases are decided. Examples of common law include
informed consent, the patient‘s right to refuse treatment, negligence, and
malpractice.
 Option C: Civil laws protect the rights of individuals within our society and
provide for fair and equitable treatment when civil wrongs or violations
occur (Garner, 2006). The consequences of civil law violations are damages
in the form of fines or specific performance of good works such as public

service. An example of a civil law violation for a nurse is negligence or
malpractice.
 Option D: Criminal laws protect society as a whole and provide
punishment for crimes, which are defined by municipal, state, and federal
legislation (Garner, 2006). There are two classifications of crimes. A felony is
a crime of a serious nature that has a penalty of imprisonment for longer
than 1 year or even death. A misdemeanor is a less serious crime that has a
penalty of a fine or imprisonment for less than 1 year. An example of
criminal conduct for nurses is a misuse of a controlled substance.
ADVERTISEMENTS
61. Question
The scope of Nursing Practice, the established educational requirements for
nurses, and the distinction between nursing and medical practice is defined by:
o A. Statutory law
o B. Common law
o C. Civil law
o D. Nurse Practice Acts

Incorrect
Correct Answer: D. Nurse Practice Acts
The NPA is then interpreted into regulations by each state and territorial nursing
board with the authority to regulate the practice of nursing care and the power
to enforce the laws. Fifty states, the District of Columbia and 4 United States (US)
territories, have state boards of nursing (BON) that are responsible for regulating
their individual NPA.
 Option A: Statutory Law is the term used to define written laws, usually
enacted by a legislative body. Statutory laws vary from regulatory or
administrative laws that are passed by executive agencies, and common
law, or the law created by prior court decisions.
 Option B: Common law results from judicial decisions made in courts
when individual legal cases are decided. Examples of common law include

informed consent, the patient‘s right to refuse treatment, negligence, and
malpractice.
malpractice.
ADVERTISEMENTS
62. Question
The client‘s right to refuse treatment is an example of:
o A. Statutory law
o B. Common law
o C. Civil laws
o D. Nurse practice acts

Incorrect
Correct Answer: B. Common law
Common law results from judicial decisions made in courts when individual legal
cases are decided. Examples of common law include informed consent, the
patient‘s right to refuse treatment, negligence, and malpractice.
 Option A: Statutory Law is the term used to define written laws, usually
enacted by a legislative body. Statutory laws vary from regulatory or
administrative laws that are passed by executive agencies, and common
law, or the law created by prior court decisions.
malpractice.

 Option D: The NPA is then interpreted into regulations by each state and
nursing care and the power to enforce the laws. Fifty states, the District of
ADVERTISEMENTS
63. Question
Even though the nurse may obtain the client‘s signature on a form, obtaining
informed consent is the responsibility of the:
o A. Client
o B. Physician
o C. Student nurse
o D. Supervising nurse
Incorrect
Correct Answer: B. Physician
It is the obligation of the provider to make it clear that the patient is participating
in the decision-making process and avoid making the patient feel forced to agree
to the provider. The provider must make a recommendation and provide their
reasoning for said recommendation.
 Option A: Informed consent is the process in which a health care provider
educates a patient about the risks, benefits, and alternatives of a given
procedure or intervention. The patient must be competent to make a
voluntary decision about whether to undergo the procedure or
intervention.
 Option C: Members of the healthcare team, such as nurses and patient
care assistants, should also be educated about all potential adverse
reactions so that they are able to identify them and notify a provider so
that any immediate intervention that is needed can be performed in a
timely manner.
 Option D: Members of the healthcare team involved with the care of a
patient should also be informed about procedures and interventions as

they may be used as witnesses in obtaining informed consent. They would
be able to evaluate whether all necessary information was given to the
patient and provide any information the provider obtaining informed
consent may have forgotten.
ADVERTISEMENTS
64. Question
The nurse is obligated to follow a physician‘s order unless:
o A. The order is a verbal order.
o B. The physician's order is illegible.
o C. The order has not been transcribed.
o D. The order is an error, violates hospital policy, or would be

detrimental to the client.
Incorrect
Correct Answer: D. The order is an error, violates hospital policy, or would
be detrimental to the client.
The court held that nurses have a duty to question a physician‘s order if they
think it is in the patient‘s best interest to do so and to delay discharge if they
believe discharge deviates from acceptable standards of care.
 Option A: The term physician‘s orders has outlived its appropriateness.
Nurses have an ethical duty to be members of collaborative teams.
Communication, consultation, and interdisciplinary cooperation are the
benchmarks for quality outcomes. Other professionals communicate
without issuing orders to each other—by continuing to use this phrase,
nurses support a linguistic and symbolic discounting of their autonomous
and accountable practice.
 Option B: Begin with asking a physician for the prescriptions rather than
the orders when admitting a patient. At the next nursing meeting or
roundtable in the institution, ask for the replacement of ―physician orders‖
with ―prescriptions‖ on the admission screen or at the next printing of
forms. Acknowledge that these prescriptions aren‘t just from physicians,
but are also from NPs and physician assistants.

 Option C: Nurses take no such oath, and are legally and ethically bound to
question an inappropriate order from a physician. In fact, many actions
described in physician‘s orders are simply nursing practices that are
fundamental to health maintenance: turn and position every two hours,
oral hygiene, side rails up.
ADVERTISEMENTS
65. Question
The nursing theorist who developed transcultural nursing theory is
o A. Dorothea Orem
o B. Madeleine Leininger
o C. Betty Newman
o D. Sr. Callista Roy

Incorrect
Correct Answer: B. Madeleine Leininger
Madeleine Leininger developed the theory on transcultural theory based on her
observations on the behavior of selected people within a culture. In the
Transcultural Nursing theory, nurses have a responsibility to understand the role
of culture in the health of the patient. Not only can a cultural background
influence a patient‘s health, but the patient may be taking home remedies that
can affect his or her health, as well.
 Option A: Dorothea Orem‘s Self-Care Deficit Theory focuses on each
―individual‘s ability to perform self-care, defined as ‗the practice of
activities that individuals initiate and perform on their own behalf in
maintaining life, health, and well-being.‘‖ Her theory defined Nursing as
―The act of assisting others in the provision and management of self-care
to maintain or improve human functioning at the home level of
effectiveness.‖
 Option C: In Betty Neuman‘s nursing theory, patients are cared for from a
holistic perspective in order to ensure they are cared for as people and not
simply ailments. The Neuman Systems Model is based on the patient‘s
relationship to stress, reaction to it, and reconstitution factors that are

dynamic. The Neuman Systems Model is universal in nature, which allows it
to be adapted to a variety of situations, and to be interpreted in many
different ways.
 Option D: Sr. Callista Roy‘s Adaptation Model of Nursing was developed
by Sister Callista Roy in 1976. The prominent nursing theory aims to explain
or define the provision of nursing. In her theory, Roy‘s model sees the
individual as a set of interrelated systems that maintain a balance between
these various stimuli.
ADVERTISEMENTS
66. Question
An American nurse tries to speak with a Korean client who cannot understand the
English language. To effectively communicate to a client with a different
language, which of the following should the nurse implement?
o A. Have an interpreter to translate.
o B. Speak slowly.
o C. Speak loudly and closely to the client.
o D. Speak to the client and family together.

Incorrect
Correct Answer: A. Have an interpreter to translate.
Having an interpreter would be the best practice when communicating with a
client who speaks a different language. When nurses and their patients don‘t
speak the same language, providing quality medical care and making the patient
feel comfortable and cared for can be exponentially more challenging. It can be
difficult to inform a patient or be confident about consent given when the patient
primarily communicates in their mother tongue.
 Option B: Language barriers exacerbate all other challenges nurses face
when providing care for culturally diverse patients. To effectively
communicate with a patient to ask them about their health history or to
educate them about a procedure, the language barrier must be broken in
some way.

 Option C: Ask the facility if a translator is available. Most hospitals do have
translators on staff, but a smaller doctor‘s office may not. Explore
translation technology — while it may not be 100% accurate, it can help
the nurse better understand patients and the patients better understand
their nurse.
 Option D: Use pictures or hand gestures to communicate when necessary,
and remember to be patient. Language barriers are frustrating for both the
nurse and the patient, but the patient is at a distinct disadvantage. If
there‘s a language barrier, a translator can help. Essentially, this will help
the nurse determine how much of what she is saying has been understood
and how she might be able to change the way she communicates to
improve the patient‘s understanding.
ADVERTISEMENTS
67. Question
Which of the following clients has the lowest risk of diabetes mellitus and stroke?
o A. A 45-year-old African-American woman.
o B. A 35-year-old Native-American man.
o C. A 30-year-old Hispanic-American man.
o D. A 25-year-old Asian-American woman.

Incorrect
Correct Answer: D. A 25-year-old Asian-American woman.
Among the choices, Asian Americans have the lowest risk of diabetes mellitus
and stroke due to their health and dietary practices. But people of Asian descent
have less muscle and more fat than other groups and often develop diabetes at a
younger age and lower weight. That extra body fat tends to be in the belly
(visceral fat).
 Option A: T2DM varies among ethnic groups and is 2 to 6times more
prevalent in African Americans, Native Americans, Pima Indians, and
Hispanic Americans compared to Whites in the United States. While
ethnicity alone plays a vital role in T2DM, environmental factors also
greatly confer risk for the disease.

 Option B: Recent data from the Centers for Disease Control and
Prevention (CDC) and Indian Health Service (IHS) show that in some
American Indian and Alaska Native communities, diabetes prevalence
among adults is as high as 60%. One in six American Indian and Alaska
Native adults has diagnosed diabetes—more than double the prevalence
rate for the general U.S. population.
 Option C: In the United States, T1DM rates rose in most age and ethnic
groups by about 2% yearly, and rates are higher in Hispanic youth. The
exact reason for this pattern remains unknown. However, some metrics,
such as the United States Military Health System data repository, found
plateauing over 2007 to 2012 with a prevalence of 1.5 per 1000 and
incidence of 20.7 to 21.3 per 1000.
ADVERTISEMENTS
68. Question
The nurse is providing instructions to a Chinese-American client about the
frequency and dosages of the take-home medicines. When conducting the
teaching, the client continuously turns away from the nurse. The nurse should do
which of the following appropriate actions?
o A. Walk around the client so that the nurse can constantly face the client.
o B. Call the attention of the client by speaking loudly.
o C. Continue with the instructions, then confirming the client's

understanding.
o D. Hand over a written instruction and discuss only what the client doesn't
understand.
Incorrect
Correct Answer: C. Continue with the instructions, verifying client
understanding.
Most Chinese maintain a formal personal space with others, which is a form of
respect. Most Chinese are uncomfortable with face-to-face communications,
especially when eye contact is direct. If the client turns away from the nurse
during a conversation, the most appropriate action is to continue with the

instructions. Many cultures have very different ways of thinking about healthcare
and may have traditions that go against the grain of Western medicine.
 Option A: Walking around to the client so that the nurse faces the client is
in direct conflict with the cultural practice. Healthcare providers who are
unfamiliar with cultural traditions surrounding medical care may have
difficulty connecting with the patient or the patient may not feel safe and
recognized, which is key to treatment acceptance.
 Option B: Calling attention and speaking loudly is viewed as a rude
gesture. It‘s important that nurses avoid making assumptions about
cultures they aren‘t familiar with. This can lead to a breakdown of trust and
rapport between the nurse and their patient and reduce treatment
acceptance.
 Option D: Discussing only what the client cannot understand is not an
acceptable practice of a nurse. When communicating with a patient, ask
them to repeat back to you what you said, in their own words. If there‘s a
language barrier, a translator can help. Essentially, this will help you
determine how much of what you are saying has been understood and
how you might be able to change the way you communicate to improve
the patient‘s understanding.
ADVERTISEMENTS
69. Question
The ambulatory care nurse is discussing preoperative procedures with a Japanese
American client who is scheduled for surgery the following week. During the
discussion, the client continually smiles and nods his head. How should the nurse
interpret this nonverbal behavior?
o A. An acceptance of the treatment.
o B. Client understanding of the preoperative procedures.
o C. Reflecting a cultural value.
o D. Client agreement to the required procedures.

Incorrect
Correct Answer: C. Reflecting a cultural value.

Nodding or smiling by a Japanese American client may reflect only the cultural
value of interpersonal harmony. This nonverbal behavior may not be an
indication of acceptance of the treatment, agreement with the speaker, or
understanding of the procedure. It‘s important that nurses avoid making
assumptions about cultures they aren‘t familiar with. This can lead to a
breakdown of trust and rapport between the nurse and their patient and reduce
treatment acceptance.
 Option A: If unsure about something, simply ask. Most people of different
cultures will happily educate a healthcare provider who is willing to listen
and understand their cultural differences. When asking questions, make
sure the body language communicates openness and an intent to truly
hear the patient versus listening to respond.
 Option B: In reality, healthcare only reaches its full potential when the
whole patient is considered, including their family, their day-to-day life,
and their culture. Make an effort to learn about those cultures by
becoming immersed in them. Visit the area where that culture is dominant
and read about the culture from reputable books and online sources.
 Option D: It‘s essential for nurses to build trust with their patients,
regardless of ethnic or racial background. However, treating culturally
diverse patients requires a heightened level of trust to be established,
which can become even more difficult when there‘s a language barrier.
ADVERTISEMENTS
70. Question
The nurse identifies low-risk therapies to a client and should include which
therapy(s) in the discussion, except?
o A. Acupuncture
o B. Relaxation
o C. Touch
o D. Prayer
Incorrect
Correct Answer: A. Acupuncture

Low-risk therapies are therapies that have no adverse effects and when
implementing care, can be used by the nurse who has training and experiences in
their use. It includes meditation, relaxation techniques, imagery, music therapy,
massage, touch, laughter and humor, and spiritual measures, such as prayer.
Acupuncture is a form of treatment that involves inserting very thin needles
through a person‘s skin at specific points on the body, to various depths.
Research suggests that it can help relieve pain, and it is used for a wide range of
other complaints.
 Option B: For centuries cultures have incorporated strategies that
recognize the power of engaging the mind in the process of healing. In this
century, relaxation training (RT) is a skill that has been repeatedly validated
by nursing, medical and psychology researchers as a complementary
intervention that is effective for a wide range of clinical situations.
Relaxation can be employed by nurses and patients to offset the negative
effects of stress, illness, and surgery while promoting healing and self-
efficacy.
 Option C: Some researchers have found there is a significant increase in
the patient communication response when physical touch is used; they
suggest nurse-patient touch represents an important and effective
communication tool.
 Option D: Prayer may benefit both the nurse and the patient; both may
find comfort in prayer. Prayer may also help patients and their families
adjust emotionally to their illness or life events and support the patients‘
spiritual health. Unfortunately, nurses may not know the prayers of
different faiths.
ADVERTISEMENTS
71. Question
A clinic nurse is preparing to examine a Hispanic child who was brought by the
mother for his first physical check-up. While assessing the child, the nurse would
avoid doing which of the following?
o A. Weighing the client.
o B. Asking the mother questions about the child.

o C. Having an interpreter if necessary.
o D. Admiring the child.

Incorrect
Correct Answer: D. Admiring the child.
Admiring a Hispanic-American child during the first encounter with a stranger
should be avoided since this may give the child the ―evil eye‖ (the child will get
sick). If this is done, it can be avoided by touching the child afterward. Beliefs
about illnesses affecting the child and infants include mal de ojo (evil eye)/illness
affecting children caused by admiration of others.
 Option A: Latinos have disproportionately higher rates of obesity and
diabetes mellitus. Approximately 43 percent of Mexican Americans older
than 20 years are obese, compared with 33 percent of the non-Latino white
population. Diabetes and hypertension are closely linked with obesity; 11.8
percent of Latinos older than 20 years have type 2 diabetes (13.3 percent
of Mexican Americans), making it the foremost health issue in this
population.
 Option B: Spanish language handouts are a better option. However, the
most useful technique is ―teach back‖ or ―show me‖: having patients repeat
their care instructions until they do it correctly. The extra time necessary for
this technique is justified by the prospect of much better understanding
and adherence.
 Option C: There is ample evidence that Latinos, especially those of
Mexican and Central American origin, face significant obstacles to
obtaining health care, especially language barriers. Many hospitals and
offices lack trained interpreters and rely on ad hoc interpretation by
bilingual staff or even the children of patients.
ADVERTISEMENTS
72. Question
A nurse is preparing to deliver a food tray to a Jewish client. The nurse checks the
food on the tray and notes that the client has received a hamburger and whole
milk as a beverage. Which is the appropriate action for the nurse?
o A. Ask the dietary department to replace the hamburger with crabs.

o B. Replace the whole milk with fat-free milk.
o C. Call the dietary department and ask for a new meal tray.
o D. Deliver the designated food tray to the client.

Incorrect
Correct Answer: C. Call the dietary department and ask for a new meal tray.
―You may not cook a young animal in the milk of its mother‖ -Torah says
(Ex.23:19). From this, it is derived that milk and meat products may not be
combined together. Not only may they not be cooked together, but they may not
be served together on the same table and surely not eaten at the same time. This
rule is followed observantly by the Jewish people so the appropriate nursing
action is to call the dietary department to change the meal tray of the patient.
 Option A: Jewish dietary laws are known as kashrut and food that adheres
to these standards is called kosher. Many mandates of the kosher diet are
similar to those found in Islam. The only type of fish that may be eaten are
those that have fins and scales. Therefore, shellfish, such as lobster, shrimp,
oysters and crab, are prohibited.
 Option B: Certain parts of permitted animals may not be eaten. In the case
of forbidden animals, their eggs and milk also cannot be consumed. Eating
any pork or pork products, including animal shortening, is prohibited.
 Option D: Dairy products and meat products cannot be eaten together,
because this is considered unhealthy. Cooking equipment and eating
utensils that have come into contact with dairy products cannot be used
with meat, and vice versa.
ADVERTISEMENTS
73. Question
A clinic nurse is performing an admission assessment for an African-American
client scheduled for an emergency appendectomy. Which of the following
questions would be inappropriate for the nurse to ask for the initial evaluation?
o A. Do you have any allergies to medicines?
o B. When did the pain start?

o C. Do you have any difficulty breathing?
o D. How close is your family during these situations?

Incorrect
Correct Answer: D. How close is your family during these situations?
For African-Americans, asking personal questions during the initial encounter is
prohibited since it may be viewed as a way of interfering with them. Negative
encounters from healthcare professionals can greatly affect African Americans‘
decision to seek medical attention (McNeil, Campinha-Bacote, Tapscott, &
Vample, 2002). One study reported that 12% of African Americans, compared to
1% of Caucasians, felt that health care practitioners treated them unfairly or with
disrespect because of their race (Kaiser Family Foundation, 2001).
 Option A: When interacting with African Africans, it is important to know
that most prefer to be greeted formally, such as Doctor, Reverend, Pastor,
Mr., Mrs., Ms., or Miss. They prefer their surname because the ―family
name‖ is highly respected and connotes pride in their family heritage.
 Option B: African-American communication has been described as high
context (Cokley, Cooke, & Nobles, 2005). They tend to rely on fewer words
and use more non-verbal messages than what is actually spoken. The
volume of African Americans‘ voices is often louder than those in some
other cultures; therefore, nurses must not misunderstand this attribute and
automatically assume this increase in tone reflects anger.
 Option C: Cultural skill is the ability to collect relevant cultural data
regarding the patient‘s presenting problem, as well as accurately perform a
culturally based, physical assessment in a culturally sensitive manner
(Campinha-Bacote, 2007). African-American speech is dynamic and
expressive. They are also reported to be comfortable with a closer personal
space than other cultural groups.
ADVERTISEMENTS
74. Question
A nurse is caring for a Chinese client who is hospitalized due to pneumonia.
Based on their culture, which of the following is believed to be the cause of the
illness?

o A. An illness is cast by an enemy.
o B. An illness is a result of punishment for sins.
o C. An illness may be attributed to overexertion.
o D. An illness may be given by someone who did not want it.

Incorrect
Correct Answer: C. An illness may be attributed to overexertion.
Illness for Chinese people may be attributed to prolonged sitting or lying or to
overexertion. Health is maintained through a balance between ―yin‖ (cold) and
―yang‖ (hot) forces. A lack of ―chi‖ (energy) causes illness. The body is viewed as a
gift and must be valued through proper care.
 Option A: When there is disharmony and imbalance of the functional
entities, the cardinal functions cannot be not well-performed and as a
result, the body becomes ill. Illness then is ultimately viewed as arising
from an imbalance of qi and yin-yang, rather than a purely physical
phenomenon.
 Option B: When a person is ill, he or she will manifest different disease
symptoms. Given that everything has Wu Xing, a pattern of disharmony
can be identified by a trained doctor. Because all the functional entities are
interconnected, accurately pinpointing patterns of illness is considered to
be one of the most challenging aspects for aspiring acupuncturists.
 Option D: As such, illness can be identified as to how the functional
entities are imbalanced. At the most basic level, this is measured as there is
an excess (vacuity) or deficiency (stagnation) in one of the entities.
ADVERTISEMENTS
75. Question
A nurse is caring for a client who has symptoms of chills, fever, no sweating,
headache, nasal congestion, and stiffness and pain in the shoulders, upper back,
neck, and back of the head that are common in Chinese culture and are called as
syndromes of Wind. This is an example of which of the following?
o A. Culture shock

o B. Culture-bound syndrome
o C. Cultural awareness
o D. Culture biased
Incorrect
Correct Answer: B. Culture-bound syndrome
Culture-bound syndrome is a combination of psychiatric and somatic symptoms
that are common in one culture group or not another. A culture-bound syndrome
is a collection of signs and symptoms that is restricted to a limited number of
cultures by reason of certain psychosocial features. Culture-bound syndromes are
usually restricted to a specific setting, and they have a special relationship to that
setting.
 Option A: Culture shock is a sense of anxiety, depression, or confusion that
results from being cut off from a familiar culture, environment, and norms
when living in a foreign country or society. Those experiencing culture
shock go through distinct phases of euphoria, discomfort, adjustment, and
acceptance.
 Option C: Cultural awareness is sensitivity to the similarities and
differences that exist between two different cultures and the use of this
sensitivity in effective communication with members of another cultural
group.
 Option D: Cultural bias is the interpretation of situations, actions, or data
based on the standards of one‘s own culture. Cultural biases are grounded
in the assumptions one might have due to the culture in which they are
raised.
By Abdullah Danish
Fb Page: Educational Platform
Gmail: abdullahdani4200@gmail.com

FON Mcqs From Nurses Lab Web by Abdullah Danish, Educational Platform

Uploaded by

Copyright:

Available Formats

FON Mcqs From Nurses Lab Web by Abdullah Danish, Educational Platform

Uploaded by

Document Information

Original Description:

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

FON Mcqs From Nurses Lab Web by Abdullah Danish, Educational Platform

Uploaded by

Copyright:

Available Formats

FON mcqs from Nurseslab Web (By Abdullah Danish)

 C. Encourage the patient to increase his fluid intake, use non-irritating

Abdullah Danish Educational Platform Abdullah Danish

 A. Provides an opportunity for skin assessment.

 B. Avoids undue strain on the nurse.

 C. Increases venous blood return.

 D. Causes vasoconstriction and increases circulation.

Abdullah Danish Educational Platform Abdullah Danish

 B. Rapid eye movement (REM) stage

Abdullah Danish Educational Platform Abdullah Danish

Abdullah Danish Educational Platform Abdullah Danish

 A. Have the patient take a 30- to 60-minute nap in the afternoon.

 B. Turn on the television in the patient‘s room.

 C. Provide quiet music and interesting reading material.

 D. Massage the patient‘s back with long strokes.

Abdullah Danish Educational Platform Abdullah Danish

 A. Prevent a confused patient from removing tubes, such as feeding tubes,

 B. Prevent a patient from falling out of bed or a chair.

 C. Discourage a patient from attempting to ambulate alone when he requires

 D. Prevent a patient from becoming confused or disoriented.

Abdullah Danish Educational Platform Abdullah Danish

 A. Document the patient‘s behavior.

 B. Document the type of restraint used.

 C. Obtain a written order from the physician except in an emergency, when

 D. All of the above.

Abdullah Danish Educational Platform Abdullah Danish

 A. Anger, bargaining, denial, depression, acceptance

 B. Denial, anger, depression, bargaining, acceptance

 C. Denial, anger, bargaining, depression acceptance

 D. Bargaining, denial, anger, depression, acceptance

Abdullah Danish Educational Platform Abdullah Danish

Abdullah Danish Educational Platform Abdullah Danish

 A. Taking psychology courses related to gerontology.

 B. Reading books and other literature on the subject of thanatology.

 C. Reflecting on the significance of death.

 D. Reviewing varying cultural beliefs and practices related to death.

Abdullah Danish Educational Platform Abdullah Danish

 A. A weak, slow pulse

 B. Increased muscle tone

 C. Fixed, dilated pupils

 D. Slow, shallow respirations

Abdullah Danish Educational Platform Abdullah Danish

 A. National League for Nursing (NLN)

 B. Centers for Disease Control (CDC)

 C. American Medical Association (AMA)

 D. American Nurses Association (ANA)

Abdullah Danish Educational Platform Abdullah Danish

 A. Organism’s mode of transmission

 B. Organism‘s Gram-staining characteristics

 C. Organism‘s susceptibility to antibiotics

 D. Patient‘s susceptibility to the organism

Abdullah Danish Educational Platform Abdullah Danish

 C. Have the patient expectorate the sputum into a sterile container.

 D. Offer the patient an antiseptic mouthwash just before he expectorate the

Abdullah Danish Educational Platform Abdullah Danish

 A. More articles can be sterilized at a time.

 B. Steam causes less damage to the materials.

 C. A lower temperature can be obtained.

 D. Pressurized steam penetrates the supplies better.