1.

Apregnantwomanwhoisattermis
admittedtothebirthingunitinactivelabor.
Theclienthasonlyprogressedfrom2cmto
3cmin8hours.Sheisdiagnosedwith
hypotonicdystociaandthephysician
orderedOxytocin(Pitocin)toaugmenther
contractions.Whichofthefollowingisthe
mostimportantaspectofnursing
interventionatthistime?
A. Timingandrecordinglengthofcontractions.
B.Monitoring.
C.Preparingforanemergencycesarean
birth.
D.Checkingtheperineumforbulging.
1.A.TheoxytociceffectofPitocinincreases
theintensityanddurationsofcontractions;
prolongedcontractionswilljeopardizethe
safetyofthefetusandnecessitatediscontinuing
thedrug.
2.Aclientwhohallucinatesisnotintouchwith
reality.Itisimportantforthenurseto:
A.Isolatetheclientfromotherpatients.
B.Maintainasafeenvironment.
C.Orienttheclienttotime,place,andperson.
D.Establishatrustingrelationship.
2.B.Itisofparamountimportancetopreventthe
clientfromhurtinghimselforherselforothers.
3.Thenurseiscaringtoachildclientwhohashada
tonsillectomy.Thechildcomplainsofhaving
drynessofthethroat.Whichofthefollowingwould
thenursegivetothechild?A.Colawithice
B.YellownoncitrusJello
C.CoolcherryKoolAid
D.Aglassofmilk
3. B. After tonsillectomy, clear, cool
liquids should be given. Citrus,
carbonated, and hot or cold liquids
should be avoided because they may
irritate the throat. Red liquids should be
avoided because they give the
appearance of blood if the child vomits.
Milk and milk products including pudding
are avoided because they coat the
throat, cause the child to clear the throat,
and increase the risk of bleeding.

4.ThephysicianorderedPhenylephrine(Neo
Synephrine)nasalspraytoa13yearoldclient.The
nursecaringtotheclientprovidesinstructionsthat
thenasalspraymustbeusedexactlyasdirectedto
preventthedevelopmentof:
A.Increasednasalcongestion.
B.Nasalpolyps.
C.Bleedingtendencies.
D.Tinnitusanddiplopia.4. A. Phenylephrine,
with frequent and continued use, can
cause rebound congestion of mucous
membranes.
5.Aclientwithtuberculosisistobeadmittedinthe
hospital.Thenursewhowillbeassignedtocarefor
theclientmustinstituteappropriateprecautions.
Thenurseshould:
A.Placetheclientinaprivateroom.
B.WearanN95respiratorwhencaringforthe
client.
C.Putonagowneverytimewhenenteringthe
room.
D.Donasurgicalmaskwithafaceshieldwhen
enteringtheroom.
5. B. The N 95 respirator is a highparticulate filtration mask that meets the
CDC performance criteria for a
tuberculosis respirator.

6.Whichofthefollowingisthemostfrequentcause
ofnoncompliancetothemedicaltreatmentofopen
angleglaucoma?
A.Thefrequentnauseaandvomitingaccompanying
useofmioticdrug.
B.Lossofmobilityduetoseveredriving
restrictions.
C.Decreasedlightandnearvisionaccommodation
duetomioticeffectsofpilocarpine.
D.Thepainfulandinsidiousprogressionofthis
typeofglaucoma.
6. C. The most frequent cause of
noncompliance to the treatment of

chronic, or open-angle glaucoma is the

miotic effects of pilocarpine. Pupillary
constriction impedes normal
accommodation, making night driving
difficult and hazardous, reducing the
clients ability to read for extended
periods and making participation in
games with fast-moving objects
impossible.
7.Inthemorningshift,thenurseismakingrounds
inthenursingcareunits.Thenurseentersina
clientsroomandnotesthattheclientstubehas
becomedisconnectedfromthePleurovac.What
wouldbetheinitialnursingaction?
A.Applypressuredirectlyovertheincisionsite.
B.Clampthechesttubeneartheincisionsite.
C.Clampthechesttubeclosertothedrainage
system.
D.ReconnectthechesttubetothePleurovac.
8.Whichofthefollowingcomplicationsduringa
breechbirththenurseneedstobealarmed?
A.Abruptionplacenta.
B.Caputsuccedaneum.
C.Pathologicalhyperbilirubinemia.
D.Umbilicalcordprolapse.
9.Thenurseiscaringtoaclientdiagnosedwith
severedepression.Whichofthefollowingnursing
approachisimportantindepression?
A.Protecttheclientagainstharmtoothers.
B.Providetheclientwithmotoroutletsfor
aggressive,hostilefeelings.
C.Reduceinterpersonalcontacts.
D.Deemphasizingpreoccupationwithelimination,
nourishment,andsleep.
10.A3montholdclientisinthepediatricunit.
Duringassessment,thenurseissuspectingthatthe
babymayhavehypothyroidismwhenmotherstates
thatherbabydoesnot:
A.Situp.
B.Pickupandholdarattle.

C.Rollover.
D.Holdtheheadup.
11.Thephysiciancallsthenursingunittoleavean
order.Theseniornursehadconversationwiththe
otherstaff.Thenewlyhirednurseanswersthe
phonesothattheseniornursesmaycontinuetheir
conversation.Thenewnursedoesnotknowthe
physicianortheclienttowhomtheorderpertains.
Thenurseshould:
A.Askthephysiciantocallbackafterthenursehas
readthehospitalpolicymanual.
B.Takethetelephoneorder.
C.Refusetotakethetelephoneorder.
D.Askthechargenurseoroneoftheothersenior
staffnursestotakethetelephoneorder.
12.Thestaffnurseonthelaboranddeliveryunitis
assignedtocaretoaprimigravidaintransition
complicatedbyhypertension.Anewpregnant
womaninactivelaborisadmittedinthesameunit.
Thenursemanagerassignedthesamenursetothe
secondclient.Thenursefeelsthattheclientwith
hypertensionrequiresonetoonecare.Whatwould
betheinitialactionofthenurse?
A.Acceptthenewassignmentandcompletean
incidentreportdescribingashortageofnursing
staff.
B.Reporttheincidenttothenursingsupervisorand
requesttobefloated.
C.Reportthenursingassessmentoftheclientin
transitionallabortothenursemanageranddiscuss
misgivingsaboutthenewassignment.
D.Acceptthenewassignmentandprovidethebest
care.
13.AnewborninfantwithDownsyndromeistobe
dischargedtoday.Thenurseispreparingtogivethe
dischargeteachingregardingthepropercareat
home.Thenursewouldanticipatethatthemotheris
probablyatthe:
A.40yearsofage.
B.20yearsofage.
C.35yearsofage.
D.20yearsofage.

14.Theemergencydepartmenthasshortageofstaff.
Thenursemanagerinformsthestaffnurseinthe
criticalcareunitthatshehastofloattothe
emergencydepartment.Whatshouldthestaffnurse
expectundertheseconditions?

A.Vigorouslystripthetubetodislodgeaclot.
B.Raisetheapparatusabovethechesttomove
fluid.
C.Increasewallsuctionabove20cmH2Opressure.
D.Asktheclienttocoughandtakeadeepbreath.

A.Thefloatstaffnursewillbeinformedofthe
situationbeforetheshiftbegins.
B.Thestaffnursewillbeabletonegotiatethe
assignmentsintheemergencydepartment.
C.Crosstrainingwillbeavailableforthestaff
nurse.
D.Clientassignmentswillbeequallydivided
amongthenurses.

18.Thepediatricnurseintheneonatalunitwas
informedthatthebabythatisbroughttothemother
inthehospitalroomiswrong.Thenursedetermines
thattwobabieswereplacedinthewrongcribs.The
mostappropriatenursingactionwouldbeto:

15.Thenurseisassignedtocareforachildclient
admittedinthepediatricsunit.Theclientis
receivingdigoxin.Whichofthefollowingquestions
willbeaskedbythenursetotheparentsofthechild
inordertoassesstheclientsrisk
fordigoxintoxicity?
A.Hashebeenexposedtoanychildhood
communicablediseasesinthepast23weeks?
B.Hashebeentakingdiureticsathome?
C.Doanyofhisbrothersandsistershavehistory
ofcardiacproblems?
D.Hashebeengoingtoschoolregularly?
16.Thenursenoticedthatthesignedconsentform
hasanerror.Theformstates,Amputationofthe
rightleginsteadoftheleftlegthatistobe
amputated.Thenursehasadministeredalreadythe
preoperativemedications.Whatshouldthenurse
do?
A.Callthephysiciantoreschedulethesurgery.
B.Callthenearestrelativetocomeintosignanew
form.
C.Crossouttheerrorandinitialtheform.
D.Havetheclientsignanotherform.
17.Thenurseinthenursingcareunitchecksthe
fluctuationinthewatersealcompartmentofa
closedchestdrainagesystem.Thefluctuationhas
stopped,thenursewould:

A.Determinewhoisresponsibleforthemistake
andterminatehisorheremployment.
B.Recordtheeventinanincident/variancereport
andnotifythenursingsupervisor.
C.Reassurebothmothers,reporttothecharge
nurse,anddonotrecord.
D.Recorddetailednotesoftheeventonthe
mothersmedicalrecord.
19.Beforetheadministrationofdigoxin,thenurse
completesanassessmenttoatoddlerclientforsigns
andsymptomsofdigoxintoxicity.Whichofthe
followingistheearliestandmostsignificantsign
ofdigoxintoxicity?
A.Tinnitus
B.Nauseaandvomiting
C.Visionproblem
D.Slowingintheheartrate
20.Whichofthefollowingtreatmentmodalityis
appropriateforaclientwithparanoidtendency?
A.Activitytherapy.
B.Individualtherapy.
C.Grouptherapy.
D.Familytherapy.
21.Theclientwithrheumatoidarthritisisfor
discharge.Inpreparingtheclientfordischargeon
prednisonetherapy,thenurseshouldadvisethe
clientto:
A.Wearsunglassesifexposedtobrightlightforan
extendedperiodoftime.

B.Takeoralpreparationsofprednisonebefore
meals.
C.Haveperiodiccompletebloodcountswhileon
themedication.
D.Neverstoporchangetheamountofthe
medicationwithoutmedicaladvice.
22.Apregnantclienttellsthenursethatsheis
worriedabouthavingurinaryfrequency.Whatwill
bethemostappropriatenursingresponse?
A.TryusingKegel(perineal)exercisesand
limitingfluidsbeforebedtime.Ifyouhave
frequencyassociatedwithfever,painonvoiding,or
bloodintheurine,callyourdoctor/nursemidwife.
B.Placentalprogesteronecausesirritabilityofthe
bladdersphincter.Yoursymptomswillgoaway
afterthebabycomes.
C.Pregnantwomenurinatefrequentlytogetridof
fetalwastes.Limitfluidsto1L/daily.
D.Frequencyisduetobladderirritationfrom
concentrateurineandisnormalinpregnancy.
Increaseyourdailyfluidintaketo3L.
23.Whichofthefollowingwillhelpthenurse
determinethattheexpressionofhostilityisuseful?
A.Expressionofangerdissipatestheenergy.
B.Energyfromangerisusedtoaccomplishwhat
needstobedone.
C.Expressionintimidatesothers.
D.Degreeofhostilityislessthantheprovocation.
24.Thenurseisprovidinganorientationregarding
casemanagementtothenursingstudents.Which
characteristicsshouldthenurseincludeinthe
discussioninunderstandingcasemanagement?
A.Mainobjectiveisawrittenplanthatcombines
disciplinespecificprocessesusedtomeasure
outcomesofcare.
B.Mainpurposeistoidentifyexpectedclient,
familyandstaffperformanceagainstthetimeline
forclientswiththesamediagnosis.
C.Mainfocusiscomprehensivecoordinationof
clientcare,avoidunnecessaryduplicationof
services,improveresourceutilizationanddecrease
cost.

D.Primarygoalistounderstandwhypredicted
outcomeshavenotbeenmetandthecorrectionof
identifiedproblems.
25.ThephysicianordersadoseofIVphenytointoa
childclient.Inpreparingintheadministrationofthe
drug,whichnursingactionisnotcorrect?
A.Infusethephenytoinintoasmallerveinto
preventpurpleglovesyndrome.
B.Checkthephenytoinsolutiontobesureitisclear
orlightyellowincolor,nevercloudy.
C.Plantogivephenytoinover3060minutes,using
aninlinefilter.
D.FlushtheIVtubingwithnormalsalinebefore
startingphenytoin.
26.Thepregnantwomanvisitstheclinicforcheck
up.Whichassessmentfindingswillhelpthenurse
determinethattheclientisin8weekgestation?
A.Leopoldmaneuvers.
B.Fundalheight.
C.Positiveradioimmunoassaytest(RIAtest).
D.Auscultationoffetalhearttones.
27.Whichofthefollowingnursinginterventionis
essentialfortheclientwhohadpneumonectomy?
A.Medicateforpainonlywhenneeded.
B.Connectthechesttubetowatersealdrainage.
C.Notifythephysicianifthechestdrainage
exceeds100mL/hr.
D.Encouragedeepbreathingandcoughing.
28.Thenurseisprovidingahealthteachingtoa
groupofparentsregardingChlamydiatrachomatis.
Thenurseiscorrectinthestatement,Chlamydia
trachomatisisnotonlyanintracellularbacterium
thatcausesneonatalconjunctivitis,butitalsocan
cause:
A.Discolorationofbabyandadultteeth.
B.Pneumoniainthenewborn.
C.Snufflesandrhagadesinthenewborn.
D.Centralhearingdefectsininfancy.

29.Thenurseisassignedtocaretoa17yearold
maleclientwithahistoryofsubstanceabuse.The
clientasksthenurse,Haveyouevertriedorused
drugs?Themostcorrectresponseofthenurse
wouldbe:

33.Theambulanceteamcallstheemergency
departmentthattheyaregoingtobringaclientwho
sustainedburnsinahousefire.Whilewaitingfor
theambulance,thenursewillanticipateemergency
caretoincludeassessmentfor:

A.Yes,onceItriedgrass.
B.No,Idontthinkso.
C.Whydoyouwanttoknowthat?
D.Howwillmyanswerhelpyou?

A.Gasexchangeimpairment.
B.Hypoglycemia.
C.Hyperthermia.
D.Fluidvolumeexcess.

30.Whichofthefollowingdescribesahealthcare
teamwiththeprinciplesofparticipativeleadership?

34.Mostcouplesareusingnaturalfamily
planningmethods.Mostaccidentalpregnanciesin
couplespreferredtousethismethodhavebeen
relatedtounprotectedintercoursebeforeovulation.
Whichofthefollowingfactorexplainswhy
pregnancymaybeachievedbyunprotected
intercourseduringthepreovulatoryperiod?

A.Eachmemberoftheteamcanindependently
makedecisionsregardingtheclientscarewithout
necessarilyconsultingtheothermembers.
B.Thephysicianmakesmostofthedecisions
regardingtheclientscare.
C.Theteamusestheexpertiseofitsmembersto
influencethedecisionsregardingtheclientscare.
D.Nursesdecidenursingcare;physiciansdecide
medicalandothertreatmentfortheclient.
31.Anurseisgivingahealthteachingtoawoman
whowantstobreastfeedhernewbornbaby.Which
hormone,normallysecretedduring
thepostpartumperiod,influencesboththemilk
ejectionreflexanduterineinvolution?
A.Oxytocin.
B.Estrogen.
C.Progesterone.
D.Relaxin.
32.Onestaffnurseisassignedtoagroupof5
patientsforthe12hourshift.Thenurseis
responsiblefortheoverallplanning,givingand
evaluatingcareduringtheentireshift.Afterthe
shift,sameresponsibilitywillbeendorsedtothe
nextnurseincharge.Thisdescribesnursingcare
deliveredviathe:
A.Primarynursingmethod.
B.Casemethod.
C.Functionalmethod.
D.Teammethod.

A.Ovumviability.
B.Tubalmotility.
C.Spermatozoalviability.
D.Secretoryendometrium.
35.Anolderadultclientwakesupat2oclockin
themorningandcomestothenursesstationsaying,
Iamhavingdifficultyinsleeping.Whatisthe
bestnursingresponsetotheclient?
A.Illgiveyouasleepingpilltohelpyougetmore
sleepnow.
B.Perhapsyoudliketosithereatthenurses
stationforawhile.
C.Wouldyoulikemetoshowyouwherethe
bathroomis?
D.Whatwokeyouup?
36.Thenurseistakingcareofamultiparawhoisat
42weeksofgestationandinactivelabor,her
membranesrupturedspontaneously2hoursago.
Whileauscultatingforthepointofmaximum
intensityoffetalhearttonesbeforeapplyingan
externalfetalmonitor,thenursecounts100beats
perminute.Theimmediatenursingactionisto:
A.Startoxygenbymasktoreducefetaldistress.
B.Examinethewomanforsignsofaprolapsed
cord.

C.Turnthewomanonherleftsidetoincrease
placentalperfusion.
D.Takethewomansradialpulsewhilestill
auscultatingtheFHR.
37.Thenursemustinstructaclientwithglaucoma
toavoidtakingoverthecountermedicationslike:
A.Antihistamines.
B.NSAIDs.
C.Antacids.
D.Salicylates.
38.Amaleclientisbroughttotheemergency
departmentduetomotorvehicleaccident.While
monitoringtheclient,thenursesuspectsincreasing
intracranialpressurewhen:
A.Clientisorientedwhenarousedfromsleep,and
goesbacktosleepimmediately.
B.Bloodpressureisdecreasedfrom160/90to
110/70.
C.Clientrefusesdinnerbecauseofanorexia.
D.Pulseisincreasedfrom8896withoccasional
skippedbeat.
39.Thenurseisconductingalecturetoaclassof
nursingstudentsaboutadvancedirectivesto
preoperativeclients.Whichofthefollowing
statementbythenursejscorrect?
A.Thespouse,butnottherestofthefamily,may
overridetheadvancedirective.
B.Anadvancedirectiveisrequiredforadonot
resuscitateorder.
C.Adurablepowerofattorney,aformofadvance
directive,mayonlybeheldbyabloodrelative.
D.Theadvancedirectivemaybeenforcedevenin
thefaceofoppositionbythespouse.
40.Aclientdiagnosedwithschizophreniais
shoutingandbangingonthedoorleadingtothe
outside,saying,Ineedtogotoanappointment.
Whatistheappropriatenursingintervention?
A.Telltheclientthathecannotbangonthedoor.
B.Ignorethisbehavior.

C.Escorttheclientgoingbackintotheroom.
D.Asktheclienttomoveawayfromthedoor.
41.Whichofthefollowingactionisanaccurate
trachealsuctioningtechnique?
A.25secondsofcontinuoussuctionduringcatheter
insertion.
B.20secondsofcontinuoussuctionduringcatheter
insertion.
C.10secondsofintermittentsuctionduringcatheter
withdrawal.
D.15secondsofintermittentsuctionduring
catheterwithdrawal.
42.Theclientsjawandcheekboneissuturedand
wired.Thenurseanticipatesthatthemostimportant
thingthatmustbereadyatthebedsideis:
A.Sutureset.
B.Tracheostomyset.
C.Suctionequipment.
D.Wirecutters.
43.Amotherisinthethirdstageoflabor.Whichof
thefollowingsignswillhelpthenursedetermine
thesignsofplacentalseparation?
A.Theuterusbecomesglobular.
B.Theumbilicalcordisshortened.
C.Thefundusappearsattheintroitus.
D.Mucoiddischargeisincreased.
44.Aftertherapywiththethrombolyticalteplase(t
PA.,whatobservationwillthenursereporttothe
physician?
A.3+peripheralpulses.
B.Changeinlevelofconsciousnessandheadache.
C.Occasionaldysrhythmias.
D.Heartrateof100/bpm.
45.Aclientwhoundergoneleftnephrectomyhasa
largeflankincision.Whichofthefollowingnursing
actionwillfacilitatedeepbreathingandcoughing?

A.Pushfluidadministrationtoloosenrespiratory
secretions.
B.Havetheclientlieontheunaffectedside.
C.MaintaintheclientinhighFowlersposition.
D.Coordinatebreathingandcoughingexercisewith
administrationofanalgesics.
46.Thecommunitynurseisteachingthegroupof
mothersaboutthecervicalmucusmethodof
naturalfamilyplanning.Whichcharacteristicsare
typicalofthecervicalmucusduringthefertile
periodofthemenstrualcycle?
A.Absenceofferning.
B.Thin,clear,goodspinnbarkeit.
C.Thick,cloudy.
D.Yellowandsticky.
47.Aclientwithrupturedappendixhadsurgeryan
houragoandistransferredtothenursingcareunit.
ThenurseplacedtheclientinasemiFowlers
positionprimarilyto:
A.Facilitatemovementandreducecomplications
fromimmobility.
B.Fullyaeratethelungs.
C.Splintthewound.
D.Promotedrainageandpreventsubdiaphragmatic
abscesses.
48.Whichofthefollowingwillbestdescribea
managementfunction?
A.Writingalettertotheeditorofanursingjournal.
B.Negotiatinglaborcontracts.
C.Directingandevaluatingnursingstaffmembers.
D.Explainingmedicationsideeffectstoaclient.
49.Theparentsofaninfantclientaskthenurseto
teachthemhowtoadministerCortisporineyedrops.
Thenurseiscorrectinadvisingtheparentstoplace
thedrops:
A.Inthemiddleofthelowerconjunctivalsacofthe
infantseye.
B.Directlyontotheinfantssclera.

C.Intheoutercanthusoftheinfantseye.
D.Intheinnercanthusoftheinfantseye.
50.Thenurseisassessingontheclientwhois
admittedduetovehicleaccident.Whichofthe
followingfindingswillhelpthenursethatthereis
internalbleeding?
A.Frankbloodontheclothing.
B.Thirstandrestlessness.
C.Abdominalpain.
D.Confusionandalteredofconsciousness.
51.Thenurseiscompletinganassessmentto
anewbornbabyboy.Thenurseobservesthatthe
skinofthenewbornisdryandflakingandthereare
severalareasofanapparentmacularrash.Thenurse
chartsthisas:
A.Icterusneonatorum
B.Multiplehemangiomas
C.Erythematoxicum
D.Milia
52.Theclientisbroughttotheemergency
departmentbecauseofseriousvehicleaccident.
Afteranhour,theclienthasbeendeclaredbrain
dead.Thenursewhohasbeenwiththeclientmust
nowtalktothefamilyaboutorgandonation.Which
ofthefollowingconsiderationisnecessary?
A.Includeasmanyfamilymembersaspossible.
B.Takethefamilytothechapel.
C.Discusslifesupportsystems.
D.Clarifythefamilysunderstandingofbrain
death.
53.Thenurseisteachingexercisesthataregoodfor
pregnantwomenincreasingtoneandfitnessand
decreasinglowerbackache.Whichofthefollowing
shouldthenurseexcludeintheexerciseprogram?
A.Standwithlegsapartandtouchhandstofloor
threetimesperday.
B.Tenminutesofwalkingperdaywithan
emphasisongoodposture.
C.Tenminutesofswimmingorlegkickinginpool

perday.
D.Pelvicrockexerciseandsquatsthreetimesaday.
54.Aclientwithobsessivecompulsivebehavioris
admittedinthepsychiatricunit.Thenursetaking
careoftheclientknowsthattheprimarytreatment
goalisto:
A.Providedistraction.
B.Supportbutlimitthebehavior.
C.Prohibitthebehavior.
D.Pointoutthebehavior.
55.Afterileostomy,thenurseexpectsthatthe
drainageappliancewillbeappliedtothestoma:
A.Whentheclientisabletobeginselfcare
procedures.
B.24hourslater,whentheswellingsubsided.
C.Intheoperatingroomaftertheileostomy
procedure.
D.Aftertheileostomybeginstofunction.
56.Afemaleclientwhohasa28daymenstrual
cycleasksthecommunityhealthnursewhensheget
pregnantduringhercycle.Whatwillbethebest
nursingresponse?
A.Itisimpossibletodeterminethefertileperiod
reliably.Soitisbesttoassumethatawomanis
alwaysfertile.
B.Ina28daycycle,ovulationoccursatorabout
day14.Theegglivesforabout24hoursandthe
spermliveforabout72hours.Thefertileperiod
wouldbeapproximatelybetweenday11andday
15.
C.Ina28daycycle,ovulationoccursatorabout
day14.Theegglivesforabout72hoursandthe
spermliveforabout24hours.Thefertileperiod
wouldbeapproximatelybetweenday13and17.
D.Ina28daycycle,ovulationoccurs8daysbefore
thenextperiodorataboutday20.Thefertileperiod
isbetweenday20andthebeginningofthenext
period.
57.Whichofthefollowingstatementdescribesthe
roleofanurseasaclientadvocate?

A.Anursemayoverrideclientswishesfortheir
owngood.
B.Anursehasthemoralobligationtopreventharm
anddowellforclients.
C.Anursehelpsclientsgaingreaterindependence
andselfdetermination.
D.Anursemeasurestheriskandbenefitsofvarious
healthsituationswhilefactoringincost.
58.Acommunityhealthnurseisprovidingahealth
teachingtoawomaninfectedwithherpessimplex
2.Whichofthefollowinghealthteachingmustthe
nurseincludetoreducethechancesoftransmission
ofherpessimplex2?
A.Abstainfromintercourseuntillesionsheal.
B.Therapyiscurative.
C.Penicillinisthedrugofchoicefortreatment.
D.Theorganismisassociatedwithlater
developmentofhydatidiformmole.
59.Thenurseinthepsychiatricwardinformedthe
maleclientthathewillbeattendingthe9:00AM
grouptherapysessions.Theclienttellsthenurse
thathemustwashhishandsfrom9:00to9:30AM
eachdayandthereforehecannotattend.Which
conceptdoesthenursingstaffneedtokeepinmind
inplanningnursinginterventionforthisclient?
A.Depressionunderlinesritualisticbehavior.
B.Fearandtensionsareoftenexpressedin
disguisedformthroughsymbolicprocesses.
C.Ritualisticbehaviormakesothersuncomfortable.
D.Unmetneedsaredischargedthroughritualistic
behavior.
10.Thenurseassessesthehealthconditionofthe
femaleclient.Theclienttellsthenursethatshe
discoveredalumpinthebreastlastyearand
hesitatedtoseekmedicaladvice.Thenurse
understandsthat,womenwhotendtodelayseeking
medicaladviceafterdiscoveringthediseaseare
displayingwhatcommondefensemechanism?
A.Intellectualization.
B.Suppression.
C.Repression.
D.Denial.

61.Whichofthefollowingsituationscannotbe
delegatedbytheregisterednursetothenursing
assistant?
A.Apostoperativeclientwhoisstableneedsto
ambulate.
B.Clientinsoftrestraintwhoisveryagitatedand
crying.
C.Aconfusedelderlywomanwhoneedsassistance
witheating.
D.Routinetemperaturecheckthatmustbedonefor
aclientatendofshift.
62.Intheadmissioncareunit,whichofthe
followingclientwouldthenursegiveimmediate
attention?
A.Aclientwhois3dayspostoperativewithleft
calfpain.
B.Aclientwhoispostoperativehippinningwhois
complainingofpain.
C.Newadmittedclientwithchestpain.
D.Aclientwithdiabeteswhohasaglucoscan
readingof180.
63.Acoupleseeksmedicaladviceinthe
communityhealthcareunit.Acouplehasbeen
unabletoconceive;themanisbeingevaluatedfor
possibleproblems.Thephysicianorderedsemen
analysis.Whichofthefollowinginstructionsis
correctregardingcollectionofaspermspecimen?
A.Collectaspecimenattheclinic,placeiniced
container,andgivetolaboratorypersonnel
immediately.
B.Collectspecimenafter4872hours
ofabstinenceandbringtoclinicwithin2hours.
C.Collectspecimeninthemorningafter24hours
ofabstinenceandbringtoclinicimmediately.
D.Collectspecimenatnight,refrigerate,andbring
toclinicthenextmorning.
64.ThephysicianorderedBetamethasonetoa
pregnantwomanat34weeksofgestationwithsign
ofpretermlabor.Thenurseexpectsthatthedrug
will:

A.Treatinfection.
B.Suppresslaborcontraction.
C.Stimulatetheproductionofsurfactant.
D.Reducetheriskofhypertension.
65.Atracheostomycuffistobedeflated,whichof
thefollowingnursinginterventionshouldbe
implementedbeforestartingtheprocedures?
A.Suctionthetracheaandmouth.
B.Havetheobduratoravailable.
C.Encouragedeepbreathingandcoughing.
D.Doapulseoximetryreading.
66.AclientisdiagnosedwithTuberculosisand
respiratoryisolationisinitiated.Thismeansthat:
A.Glovesarewornwhenhandlingtheclients
tissue,excretions,andlinen.
B.Bothclientandattendingnursemustwearmasks
atalltimes.
C.Nurseandvisitorsmustwearmasksuntil
chemotherapyisbegun.Clientisinstructedin
coughandtissuetechniques.
D.Fullisolation;thatis,capsandgownsare
requiredduringtheperiodofcontagion.
67.Aclientwithlungcancerisadmittedinthe
nursingcareunit.Thehusbandwantstoknowthe
conditionofhiswife.Howshouldthenurserespond
tothehusband?
A.Findoutwhatinformationhealreadyhas.
B.Suggestthathediscussitwithhiswife.
C.Referhimtothedoctor.
D.Referhimtothenurseincharge.
68.Ahospitalizedclientcannotfindhis
handkerchiefandaccusesothercientintheroom
andthenurseofstealingthem.Whichisthemost
therapeuticapproachtothisclient?
A.Diverttheclientsattention.
B.Listenwithoutreinforcingtheclientsbelief.
C.Injecthumortodefusetheintensity.
D.Logicallypointoutthattheclientisjumpingto
conclusions.

69.Afteracystectomyandformationofanileal
conduit,thenurseprovidesinstructionregarding
preventionofleakageofthepouchandbackflowof
theurine.Thenurseiscorrecttoincludeinthe
instructiontoemptytheurinepouch:
A.Every34hours.
B.Everyhour.
C.Twiceaday.
D.Oncebeforebedtime.
70.Whichtelephonecallfromastudentsmother
shouldtheschoolnursetakecareofatonce?
A.Atelephonecallnotifyingtheschoolnursethat
thechildpediatricianhasinformedthemotherthat
thechildwillneedcardiacrepairsurgerywithinthe
nextfewweeks.
B.Atelephonecallnotifyingtheschoolnursethat
thechildspediatricianhasinformedthemotherthat
thechildhasheadlice.
C.Atelephonecallnotifyingtheschoolnursethata
childhasatemperatureof102Fandarash
coveringthetrunkandupperextremitiesofthe
body.
D.Atelephonecallnotifyingtheschoolnursethata
childunderwentanemergencyappendectomy
duringthepreviousnight.
71.Whichofthefollowingsignsandsymptomsthat
requireimmediateattentionandmayindicatemost
seriouscomplicationsduringpregnancy?
A.Severeabdominalpainorfluiddischargefrom
thevagina.
B.Excessivesaliva,bumpsaroundtheareolae,and
increasedvaginalmucus.
C.Fatigue,nausea,andurinaryfrequencyatany
timeduringpregnancy.
D.Ankleedema,enlargingvaricosities,and
heartburn.
72.Thenurseisassessingthenewbornboy.Apgar
scoresare7and9.Thenewbornbecomesslightly
cyanotic.Whatistheinitialnursingaction?
A.Elevatehisheadtopromotegravitydrainageof
secretions.

B.Wraphiminanotherblanket,toreduceheatloss.
C.Stimulatehimtocry,,toincreaseoxygenation.
D.Aspiratehismouthandnosewithbulbsyringe.
73.Thenurseisformulatingaplanofcaretoa
clientwithasomatoformdisorder.Thenurseneeds
tohaveknowledgeofwhichpsychodynamic
principle?
A.Thesymptomsofasomatoformdisorderarean
attempttoadjusttopainfullifesituationsortocope
withconflictingsexual,aggressive,ordependent
feelings.
B.Themajorfundamentalmechanismisregression.
C.Theclientssymptomsareimaginaryandthe
sufferingisfaked.
D.Anextensive,prolongedstudyofthesymptoms
willbereassuringtotheclient,whoseeks
sympathy,attentionandlove.
74.Aninfantisbroughttothehealthcareclinicfor
threeimmunizationsatthesametime.Thenurse
knowsthathepatitisB,DPT,andHaemophilus
influenzaetypeBimmunizationsshould:
A.Bedrawninthesamesyringeandgiveninone
injection.
B.Bemixedandinjectinthesamesites.
C.Notbemixedandthenursemustgivethree
injectionsinthreesites.
D.Bemixedandthenursemustgivetheinjection
inthreesites.
75.Afemaleclientwithcancerhasradium
implants.Thenursewantstomaintaintheimplants
inthecorrectposition.Thenurseshouldposition
theclient:
A.Flatinbed.
B.Onthesideonly.
C.Withthefootofthebedelevated.
D.Withtheheadelevated45degrees(semi
Fowlers).
76.Thenursewantstoknowifthemotherofa
toddlerunderstandstheinstructionsregardingthe
administrationofsyrupofipecac.Whichofthe
followingstatementwillhelpthenursetoknowthat
themotherneedsadditionalteaching?

A.Illgivethemedicineifmychildgetsintosome
toiletbowlcleaner.
B.Illgivethemedicineifmychildgetsintosome
aspirin.
C.Illgivethemedicineifmychildgetsintosome
plantbulbs.
D.Illgivethemedicineifmychildgetsintosome
vitaminpills.
77.ToassessifthecranialnerveVIIoftheclient
wasdamaged,whichchangeswouldnotbe
expected?
A.Droolinganddroopingofthemouth.
B.Inabilitytoopeneyelidsonoperativeside.
C.Saggingofthefaceontheoperativeside.
D.Inabilitytocloseeyelidonoperativeside.
78.Thecommunityhealthnursemakesahomevisit
toafamily.Duringthevisit,thenurseobservesthat
themotherisbeatingherchild.Whatisthepriority
nursinginterventioninthissituation?
A.Assessthechildsinjuries.
B.Reporttheincidenttoprotectiveagencies.
C.Referthefamilytoappropriatesupportgroup.
D.Assistthefamilytoidentifystressorsanduseof
othercopingmechanismstopreventfurther
incidents.
79.Thenurseintheneonatalcareunitis
supervisingtheactionsofacertifiednursing
assistantingivingcaretothenewborns.The
nursingassistantmistakenlygivesaformulafeeding
toanewbornthatisonwaterfeedingonly.The
nurseisresponsibleforthemistakeofthenursing
assistant:
A.Always,asarepresentativeoftheinstitution.
B.Always,becausenurseswhosuperviseless
trainedindividualsareresponsiblefortheir
mistakes.
C.Ifthenursefailedtodeterminewhetherthe
nursingassistantwascompetenttotakecareofthe
client.
D.Onlyifthenurseagreedthatthenewborncould
befedformula.

80.Thenurseisassignedtocareforaclientwith
urinarycalculi.Fluidintakeof2L/dayis
encouragedtotheclient.theprimaryreasonforthis
isto:
A.Reducethesizeofexistingstones.
B.Preventcrystallineirritationtotheureter.
C.Reducethesizeofexistingstones
D.Increasethehydrostaticpressureintheurinary
tract.
81.Thenurseiscounselingacoupleintheirmid
30swhohavebeenunabletoconceiveforabout6
months.Theyareconcernedthatoneorbothof
themmaybeinfertile.Whatisthebestadvicethe
nursecouldgivetothecouple?
A.itisnounusualtotake612monthstoget
pregnant,especiallywhenthepartnersareintheir
mid30s.Eatwell,exercise,andavoidstress.
B.Startplanningadoption.Manycouplesget
pregnantwhentheyaretryingtoadopt.
C.Consultafertilityspecialistandstarttesting
beforeyougetanyolder.
D.Havesexasoftenasyoucan,especiallyaround
thetimeofovulation,toincreaseyourchancesof
pregnancy.
82.ThenurseiscaringforacientwhoIsaretired
nurse.A24hoururinecollectionforCreatinine
clearanceistobedone.Theclienttellsthenurse,I
cantrememberwhatthistestisfor.Thebest
responsebythenurseis:
A.Itprovidesawaytoseeifyouarepassingany
proteininyoururine.
B.Ittellshowwellthekidneysfilterwastesfrom
theblood.
C.Ittellsifyourrenalinsufficiencyhasaffected
yourheart.
D.Thetestmeasuresthenumberofparticlesthe
kidneyfilters.
83.Thenurseobservesthefemaleclientinthe
psychiatricwardthatsheishavingahardtime
sleepingatnight.Thenurseaskstheclientaboutit
andtheclientsays,Icantsleepatnightbecauseof

fearofdying.Whatisthebestinitialnursing
response?
A.Itmustbefrighteningforyoutofeelthatway.
Tellmemoreaboutit.
B.Dontworry,youwontdie.Youarejusthere
forsometest.
C.Whyareyouafraidofdying?
D.Trytosleep.Youneedtherestbefore
tomorrowstest.
84.Inthehospitallobby,theregisterednurse
overhearsatwostaffmembersdiscussingaboutthe
healthconditionofherclient.Whatwouldbethe
appropriateactionfortheregisterednursetotake?
A.Joinintheconversation,givingherinputabout
thecase.
B.Ignorethem,becausetheyhavetherightto
discussanythingtheywantto.
C.Tellthemitisnotappropriatetodiscusssuch
things.
D.Reportthisincidenttothenursingsupervisor.
85.Theclienthashadarightsidedcerebrovascular
accident.Intransferringtheclientfromthe
wheelchairtobed,inwhatpositionshouldaclient
beplacedtofacilitatesafetransfer?
A.Weakened(L)sideofthecientnexttobed.
B.Weakened(R)sideoftheclientnexttobed.
C.Weakened(L)sideoftheclientawayfrombed.
D.Weakened(R)sideofthecientawayfrombed.
86.Thechildclienthasundergonehipsurgeryand
isinaspicacast.Whichofthefollowingtoyshould
beavoidedtobeinthechildsbed?
A.Atoygun.
B.Astuffedanimal.
C.Aball.
D.Legos.
87.TheLPN/LVNaskstheregisterednurse
whyoxytocin(Pitocin),10units(IVorIM)mustbe
giventoaclientafterbirthfothefetus.Thenurseis
correcttoexplainthatoxytocin:

A.Minimizesdiscomfortfromafterpains.
B.Suppresseslactation.
C.Promoteslactation.
D.Maintainsuterinetone.
88.Thenurseinthenursingcareunitisawarethat
oneofthemedicalstaffdisplaysunlikelybehaviors
likeconfusion,agitation,lethargyandunkempt
appearance.Thisbehaviorhasbeenreportedtothe
nursemanagerseveraltimes,butnochanges
observed.Thenurseshould:
A.Continuetoreportobservationsofunusual
behavioruntiltheproblemisresolved.
B.Considerthattheobligationtoprotectthepatient
fromharmhasbeenmetbythepriorreportsanddo
nothingfurther.
C.Discussthesituationwithfriendswhoarealso
nursestogetideas.
D.Approachthepartnerofthismedicalstaff
memberwiththeseconcerns.
89.ThephysicianorderedtetracyclinePOqidtoa
childclientwhoweights20kg.Therecommended
POtetracyclinedoseis2550mg/kg/day.Whatis
themaximumsingledosethatcanbesafely
administeredtothischild?
A.1g
B.500mg
C.250mg
D.125mg
90.Thenurseiscompletinganobstetrichistoryofa
womaninlabor.Whicheventintheobstetric
historywillhelpthenursesuspects
dysfunctionallaborinthecurrentpregnancy?
A.Totaltimeofrupturedmembraneswas24hours
withthesecondbirth.
B.Firstlaborlasting24hours.
C.Uterinefibroidnotedattimeof
cesareandelivery.
D.Secondbirthbycesareanforfacepresentation.
91.Thenurseisplanningtotalktotheclientwith
anantisocialpersonalitydisorder.Whatwouldbe
themosttherapeuticapproach?

A.Provideexternalcontrols.
B.Reinforcetheclientsselfconcept.
C.Givetheclientopportunitiestotestreality.
D.Gratifytheclientsinnerneeds.
92.Thenurseisteachingagroupofwomenabout
fertilityawareness,thenurseshouldemphasize
thatbasalbodytemperature:
A.Canbedonewithamercurythermometerbutno
adigitalone.
B.Theaveragetemperaturetakeneachmorning.
C.Shouldberecordedeachmorningbeforeany
activity.
D.Hasalowerdegreeofaccuracyinpredicting
ovulationthanthecervicalmucustest.
93.Thenursingapplicanthasgiventhechanceto
askquestionsduringajobinterviewatalocal
hospital.Whatshouldbethemostimportant
questiontoaskthatcanincreasechancesof
securingajoboffer?
A.Beginwithquestionsaboutclientcare
assignments,advancementopportunities,and
continuingeducation.
B.Declinetoaskquestions,becausethatisthe
responsibilityoftheinterviewer.
C.Askasmanyquestionsaboutthefacilityas
possible.
D.Clarifyinformationregardingsalary,benefits,
andworkinghoursfirst,becausethiswillhelpin
decidingwhetherornottotakethejob.
94.Thenurseadvisedthepregnantwomanthat
smokingandalcoholshouldbeavoidedduring
pregnancy.Thenursetakesintoaccountthatthe
developingfetusismostvulnerabletoenvironment
teratogensthatcausemalformationduring:
A.Theentirepregnancy.
B.Thethirdtrimester.
C.Thefirsttrimester.
D.Thesecondtrimester.
95.Amaleclienttellsthenursethatthereisabig
buginhisbed.Themosttherapeuticnursing
responsewouldbe:

A.Silence.
B.Wheresthebug?Illkillitforyou.
C.Idontseeabuginyourbed,butyouseem
afraid.
D.Youmustbeseeingthings.
96.Apregnantclientinlatepregnancyis
complainingofgroinpainthatseemsworseonthe
rightside.Whichofthefollowingisthemostlikely
causeofit?
A.Beginningoflabor.
B.Bladderinfection.
C.Constipation.
D.Tensionontheroundligament.
97.Thenurseisconductingalecturetoagroupof
volunteernurses.Thenurseiscorrectinimparting
theideathattheGoodSamaritanlawprotectsthe
nursefromasuitformalpracticewhen:
A.Thenursestopstorenderemergencyaidand
leavesbeforetheambulancearrives.
B.Thenurseactsinanemergencyathisorher
placeofemployment.
C.Thenurserefusestostopforanemergency
outsideofthescopeofemployment.
D.Thenurseisgrosslynegligentatthesceneofan
emergency.
98.Awomanishospitalizedwithmild
preeclampsia.Thenurseisformulatingaplanof
careforthisclient,whichnursingcareisleastlikely
tobedone?
A.Deeptendonreflexesoncepershift.
B.VitalsignsandFHRandrhythmq4hwhile
awake.
C.Absolutebedrest.
D.Dailyweight.
99.Whilefeedinganewbornwithanunrepaired
cardiacdefect,thenursekeepsonassessingthe
conditionoftheclient.Thenursenotesthat
thenewbornsrespirationis72breathsperminute.
Whatwouldbetheinitialnursingaction?

A.Burpthenewborn.
B.Stopthefeeding.
C.Continuethefeeding.
D.Notifythephysician.
100.Aclientwhoundergoneappendectomy3days
agoisscheduledfordischargetoday.Thenurse
notesthattheclientisrestless,pickingatbedclothes
andsaying,Iamlateonmyappointment,and

callingthenursebythewrongname.Thenurse
suspects:
A.Panicreaction.
B.Medicationoverdose.
C.Toxicreactiontoanantibiotic.
D.Deliriumtremens.