NURSING PRACTICE IV

Situation 1: A patient has just arrived in the Oncology Unit from the PACU following a left modified radical mastectomy because of
inflammatory breast cancer (IBC). She has a pressure dressing over the surgical site and two drains. Assessment shows her vital signs
are stable, fully awake and claims that pain is under control. Fortune is the nurse assigned to the patient.
1.

From the following data obtained from the chart, which is not a risk factor which could have predisposed the patient to
breast cancer?
A.
B.
C.
D.

2.

Fortune read a literature which says that by the time IBC is diagnosed, 50%-75% have palpable auxiliary lymph nodes, as
many as 30% have gross distant metastasis and as few as 30% of patients have an underlying breast mass. Which of the
following is the appropriate interpretation of the research findings?
A.
B.
C.
D.

3.

Monoclonal antibody
Proton inhibitors
Antibiotics
Anti-estrogen

Fortune understands that when the antineoplastic agent leaks through the peripheral vascular access during chemotherapy,
which of the following is expected to be done first?
A.
B.
C.
D.

5.

Auxiliary nodes were palpated on 20 out of 30 women positive for IBC

Out of the 20 women who were positive for IBC, only 5 have metastasis
If there were 10 women diagnosed with IBC, 3 have positive lymph nodes
Breast mass was identified on 8 out of 30 women positive for IBC

Fortune recognizes that adjuvant chemotherapy for breast cancer may include any of the following except
A.
B.
C.
D.

4.

Age 55 years old

Height 52; Weight 160 lbs.
Menarche at age 13
Mother died of colon cancer

Refer to the physician

Stop the chemotherapy infusion
Cleanse site with saline solution
Call another nurse to check the intravenous site.

A clinical trial is currently undertaken to test treatments for IBC. The research team leader wishes to include the patient as a
participant in the study. As a patient advocate, which of the following will Fortune do first?
A.
B.
C.
D.

Obtain informed consent from the patient

Explain to the patient the scope of the clinical trial
Inquire from the team leader benefits for the patient
Read more related literature

Situation 2: During a staff meeting at the Intensive care unit, the nurse manager reported a list of procedures that need to be
reviewed and updated. One of these procedures is the precautionary measure related to ventilator-associated pneumonia.
6.

While brainstorming, the group mentioned the use of evidence-based techniques. Which of the following statements given
by the members of the group reflect evidence-based methods?
A.
B.
C.
D.

7.

The nurse manager assigned a group to develop a project intended to improve the existing procedure related to the
prevention of ventilator-associated pneumonia among ICU patients. A team leader was selected by the group. Which of the
following will the team leader do first?
A.
B.
C.
D.

8.

Tell the group to state their objectives

Formulate a list of desired outcomes
Set a target
State actions to be done by each member of the group

The team leader organized the group. Which of the following actions of the team leader reflect organization? The team
leader:
A.
B.
C.
D.

9.

Let us ask the opinion of experts.

The experiences of the nurses must be obtained.
Review of related literature will be very helpful.
We must agree on a common procedure.

Assigned tasks to each member

Eliminated non-performing members of the group
Checked the assignments of each member of the group
Determined which actions will be done first

Which of the following data will be most helpful to the group to ensure continuous process improvement?
A.
B.
C.
D.

Non-conformances to suctioning procedure

Incidences of ventilator-associated pneumonia during the last month
Experiences of nurses when managing care of intubated patients
Documentation of observation of intubated patients

10. The group developed revisions to the existing procedure. Before the procedure could be implemented as a standard
procedure, which of the following will be done first?
A.
B.
C.
D.

Gather relevant data

Check if procedure is effective through feedback
Plan for the implementation of the procedure
Do the procedure on selected patients

Situation 3: Luther, a 50-year-old construction worker sustained multiple injuries due to a motorcycle accident.
11. In the Emergency Department, the physician orderd diagnostic tests, one of which is blood alcohol level. Which of the
following is the purpose of this test?
A.
B.
C.
D.

Determine level of alcohol dependence

Discover injuries in the brain
Rule out alcoholism
Assessment of clients level of consciousness

12. Blood transfusion must be administered immediately because of loss of blood volume due to trauma. Luthers blood type is
O, as his nurse, you recognize which of the following statements is true?
A.
B.
C.
D.

Type O blood has both types of antibodies

Persons with type O blood can also receive Type A blood
Type O blood has no antibodies
Persons with Type O blood are also called universal recipients

13. When assessing Luther for hypovolemic shock, which of the following data indicates that he is in the irreversible stage of
shock?
A.
B.
C.
D.

Restless, anxious and confused

Anuria
Skin moist, pale and moist
Pulse rapid and weak

14. The physician ordered colloid solution such as Dextran 40. During the infusion, Luther complained of dyspnea. Upon
auscultation, you noted wheezes. Which of the following will you do first?
A.
B.
C.
D.

Discontinue the infusion

Place Luther on a Fowlers position
Decrease the infusion rate
Call the attending physician

15. Luthers central venous pressure is monitored every hour. When you measure the CVP using a water manometer, you are
expected to observe which of the following to ensure accuracy of CVP measurement?
A.
B.
C.
D.

Maintain the client on a Fowlers position

Use a one-way stopcock to regulate flow of IV fluids to the water manometer
Immobilize the clients right arm
Keep the zero point of the manometer in level with the clients right atrium

Situation 4: You are caring for Warren, 58 years old, who is diagnosed with laryngeal cancer.
16. Warren is scheduled for a total laryngectomy and radical neck dissection for cancer of the larynx. He asks you, How will I
talk after surgery? As his nurse, your best response will be
A.
B.
C.
D.

You will breathe through a permanent opening in your neck, but you will not be able to communicate orally.
You wont be able to talk right after the surgery, but you will be able to speak again once the tracheostomy tube is
removed.
You will have a permanent opening into your neck, and you will need to have rehabilitation for some type of voice
restoration.
You wont be able to speak as you used to, but there are artificial voice devices that will give you the ability to speak
normally.

17. Warren returns from surgery with a tracheostomy tube after a total laryngectomy and radical neck dissection. In caring for
Warren during the first 24 hours after surgery, your priority nursing action is to
A.
B.
C.
D.

Avoid changing the tracheostomy ties

Monitor for bleeding around the stoma
Assess airway patency and breath sounds
Clean the inner cannula every 8 hours

18. After doing assessment, one of the nursing diagnosis you identified is Body image Disturbance related to loss of control of
personal care. To evaluate effectiveness of your interventions, the expected outcome for the problem that Warren should
demonstrate is that he
A.
B.
C.
D.

Lets his wife provide hygiene and stoma care

Wears clothing that minimizes the disfigurement caused by the surgery
Asks that only family members be allowed to visit
Learns to remove and clean the laryngectomy tube independently

19. Warren is scheduled to start radiation therapy. You have just taught Warren all about radiation therapy. Which of the
following statements by Warren would indicate that your teaching has been effective?

A.
B.
C.
D.

I
I
I
I

can use lotions to moisturize the skin on my throat.

will need to buy water bottle to carry with me.
need to use alcohol-based mouthwashes to help clean oral ulcers.
may experience diarrhea, I may have diarrhea until the radiation is complete.

20. After completing the discharge instructions for Warren, you determine that additional instruction is needed when he says
A.
B.
C.
D.

I
I
I
I

can participate in most of my prior fitness activities except swimming.

should wear a Medic Alert bracelet that identifies me as a neck breather.
must keep the stoma covered with a loose sterile dressing at all times.
need to eat nutritious meals even though I cant smell or taste very well.

Situation 5: Bobby, 11 years old, was admitted because of hematuria. Diagnosis is Dengue fever.
21. Which of the following is the most likely description of Bobbys fever prior to the onset of hematuria that supports the
physicians diagnosis of dengue fever?
A.
B.
C.
D.

Intermittent fever for 4 days

Onset of fever was abrupt and remained elevated for 4 days
Abrupt onset of fever and sudden drop on the 4th day
Gradual increase of body temperature and sudden drop on the 4 th day

22. The nurse understands that the cycle of transmission of dengue fever virus begins during which of the following?
A.
B.
C.
D.

Infected mosquito bites an uninfected human

Virus multiply in the midgut of the mosquito
Mosquito feeds on an infected human
Mosquitos saliva is invaded by the virus during subsequent biting of infected human

23. The nurse noted that Aspirin and NSAID are contraindicated for Bobby. Which of the following is the rationale behind this
order?
A.
B.
C.
D.

Patient may be allergic

Drug contains anticoagulant properties
Due to stomach upset effects of the drug
Drugs enhance production of maculopapular rashes

24. The condition of Bobby is closely watched for signs of hypovolemic shock. Which of the following should the nurse report as
early signs of hypovolemic shock?
1.
2.
3.
4.
5.
6.

Lethargy
Rapid pulse
Clammy skin
Cyanosis
Restlessness
Hematemesis
A. 2, 3, 4 and
B. 1, 2, 3 and
C. 1, 2, 5 and
D. 1, 3, 4 and

5
5
6
6

25. To prevent transmission of the virus to others, which of the following is the most appropriate isolation measure the nurse
should implement in the care of Bobby?
A. Screen the environment
B. Blood and body secretion isolation
C. Use gown, gloves and mask
D. Use strict universal isolation technique
Situation 6: Agua Bendita, 35 years old, was admitted to the hospital because of near drowning. In the ICU where she was admitted
for observation, her oxygen saturation dropped to 84% and subsequent blood gases showed PaO 2 of 55mmHg. Diagnosis is probably
Acute Respiratory Distress Syndrome (ARDS). Endotracheal intubation and mechanical ventilation were ordered.
26. The nurse is aware that in ARDS, the basic changes in the lungs result from the injury to the alveolar wall and capillary
membrane leading to the following pathological changes, except
A.
B.
C.
D.

Fluid and protein leaks into alveoli and interstitial tissue

Damaged surfactant producing cells
Increased surfactant production
Increased alveolar capillary permeability

27. Which of the following ventilator settings reflect the amount of air delivered within each ventilator breath?
A.
B.
C.
D.

Inspiration to expiration ratio

Pressure limit
Tidal volume
Oxygen concentration (FiO2)

28. Which of the following will the nurse closely monitor to ensure that the percentage of oxygen delivered with ventilator
breaths is adequate?
A.

Respiratory rate

B.
C.
D.

Central venous pressure

Pulse oximeters reading
Cardiac monitor

29. The nurse is expected to closely watch the client for complications related to mechanical ventilation. Which of the following
will the nurse do to assess subcutaneous emphysema?
A.
B.
C.
D.

Observe for signs of unequal chest expansion

Auscultate the lungs and observe for crackles
Palpate neck for air bubble-popping sensation
Percuss for hyperresonant percussion tone

30. The nurse observed air leaks from the endotracheal tube and decreased breath sounds. Which of the following will the nurse
do first?
A.
B.
C.
D.

Report to the physician

Call the respiratory therapist
Place patient on semi-fowlers position
Reposition the endotracheal tube

Situation 7: You admitted Englebert, 70 years old, because of pulmonary edema. He has a history of congestive heart failure, type 2
diabetes mellitus and hypertension.
31. Based on the history, you specifically noted that Englebert regularly took Lanoxin (Digoxin). Which of the following is the
specific action of this drug on the patient?
A.
B.
C.
D.

Improves myocardial contractility, decreases the heart rate, and reduces oxygen consumption
Causes vasoconstriction, increased resistance preload and dilation of the ventricles
Reduces peripheral vascular resistance and afterload, reducing myocardial workload
Interfered with the production of angiotensin II resulting in improved cardiac output and reducing pulmonary congestion

32. Which of the following specific positions would be most helpful for Englebert to facilitate and trap excess fluids in the lower
extremities?
A.
B.
C.
D.

Head bent forward on an overbed table supported with pillows

Upright sitting position with the legs dangling
Lateral position with the upper leg flexed and lower leg extended
Fowlers position with the patient lying on the left side

33. Furosemide (Lasix) 20 mg was administered by IV push at 10 am with urinary output from indwelling catheter at the level of
120 cc. At 10:15 AM, the nurse observed that the urinary output did not change. Which of the following will you check first?
A.
B.
C.
D.

Foley cathter connecting tube for kinks

Patients hypogastrium for urinary retention
Intravenous site for swelling
Foley catheter for leakage

34. While preparing the medication, you checked the medication which was dispensed by the pharmacist with the written order
of the physician. Which of the following actions will you do first if you found out that instead of Regular insulin, the
pharmacist dispensed NPH insulin?
A.
B.
C.
D.

Validate the order with the physician

Document the error
Ask the pharmacist to change the drug
Report the error to the unit manager

35. You administered morphine Sulfate 1 mg intravenously as ordered. The following are the intended actions of this drug except
A.
B.
C.
D.

Improved efficacy of breathing

Reduce preload
Decrease anxiety
Relieve pain

Situation 8: Helen, a Pediatric Intensive Care Unit staff nurse, is assigned to a 4-year-old female unconscious patient due to an acute
head injury sustained from a vehicular accident.
36. Helen identifies which of the following nursing diagnosis to be of highest priority?
A. Risk for injury related to increased intracranial pressure
B. Disturbed sensory perception relation to central nervous system impairment
C. Risk for aspiration related to impaired motor functions
D. Ineffective airway clearance related to depressed sensorium
37. When interpreting the patients degree of depressed coma, the pediatric Glasgow Coma Scale is used. Which of the following
is not included in the three-part assessment of the scale?
A.
B.
C.
D.

Motor responses
Response to auditory and verbal stimuli
Pupil size and reaction
Eye opening

38. When assessing the level of consciousness of the patient, which of the following should the nurse consider most appropriate
in eliciting a desired response?

A.
B.
C.
D.

Environment should be quiet, well-lighted and ventilated

Keep equipment at the bedside
Parent should be present
Have record readily available for accurate documentation.

39. During assessment, the nurse observes absence of dolls eye movement. Which of the following is the correct interpretation
of this observation?
A.
B.
C.
D.

Ruptures aneurysm
Meningeal inflammation
Brainstem injury
Subdural hematoma

40. Due to hypothalamic dysfunction, a syndrome of inappropriate antidiuretic hormone develops. Which of the following
manifestations should the nurse watch closely?
A.
B.
C.
D.

Increased urine output, decreased specific gravity, decreased serum sodium

Increased urine output, increased urine specific gravity, increased serum sodium
Decreased urine output, decreased urine specific gravity, decreased serum sodium
Decreased urine output, increased urine specific gravity, increased serum sodium

Situation 9: Teddy, 8 years old, was playing in the garden when all of a sudden he stopped playing and started scratching his legs.
Teddys mother washed his legs but Teddy complained of difficulty of breathing; was nauseated and had cold moist skin. In the
emergency department, anaphylaxis was suspected. Insect bites were noted on Teddys legs.
41. The health team suspects that Teddy experienced a sting at some previous time. Which of the following could be the
rationale for the itchy skin?
A.
B.
C.
D.

Irritation caused by digestive substance released by the insect

Infiltration of inflammatory cells into the epidermis
Sensory nerve endings irritated by histamine
Accumulation of histamine at the insect bite

42. Which of the following drugs will the nurse expect the physician to prescribe initially?
A.
B.
C.
D.

Corticosteroids
Aminophylline
Epinephrine
Dipenhydramine

43. The mother asked the nurse what could have caused her son to experience difficulty of breathing. Which of the following is
the most appropriate response of the nurse?
A.
B.
C.
D.

It was an early sympatetic response to the insect bite.

Chemical mediators due to hypersensitivity reactions caused by edema in the bronchioles.
Histamine released due to allergic reaction caused narrowing of the airway.
It was due to threatening laryngeal edema.

44. The mother claimed that this is the first time it happened. Which of the following should be given priority by the nurse?
A.
B.
C.
D.

Instruct the mother on emergency measures in care recurrence

Recommend desensitization
Identification of allergens
Identification of environmental hazards

45. Since Teddy is allergic to insect venom, which of the following is the most appropriate measure to ensure that Teddy gets
immediate treatment during recurrence?
A.
B.
C.
D.

Have Teddy carry an emergency kit all the time

Teach Teddy how to use an emergency kit
Use of a medical information such as bracelet or necklace
Teach Teddy to get help when symptoms develop

Situation 10: Radiation therapy is another modality of cancer management. With the emphasis on multi-disciplinary management,
you have important responsibilities when caring for patients receiving radiation therapy.
46. Thrombocytopenia often results from bone marrow depression. As a nurse, you should observe for the following symptoms
that include
A.
B.
C.
D.

Headache, dizziness, blurred vision

Severe sore throat, bacteremia, hepatomegaly
Petechiae, ecchymosis, epistaxis
Weakness, easy fatigability, pallor

47. When caring for a client who has thrombocytopenia, which of the following intervention should you include in the care plan?
A.
B.
C.
D.

Provide rest between activities

Place the patient on strict isolation precaution
Inspect the patients skin for petechiae, bruising, GI bleeding regularly
Administer antipyretics if the patients temperature 38C

48. A patient is receiving external radiation therapy and he complains of fatigue and malaise. Which of the following nursing
interventions would be most appropriate?
A.
B.
C.
D.

Refer the patient to the physician

Help the patient plan activities and rest periods
Reassure the patient that these feelings are normal
Tell the patient that sometimes these feelings can be psychogenic

49. External beam radiation is planned for a patient with endometrial cancer. You teach her that the important measure to
prevent complications from the effects of radiation is to
A.
B.
C.
D.

Maintain a high-residue and high-fat diet

Perform perineal care with sitz bath and meticulous cleaning
Test all stools for the presence of blood
Inspect the mouth and throat daily for the appearance of thrush

50. A post total hysterectomy bilateral salphyngo-oophorectomy patient had chemotherapy and radiation therapy. The nurse
oriented her on the rationale and the measures to be done to prevent movement of the radioactive source which include the
following, except:
A.
B.
C.
D.

Complete bed rest while source is implanted

Spinal anesthesia while source is implanted
Bowel cleansing prior to insertion of source
Placement of urinary Foley catheter while source is implanted

Situation 11: It is important and necessary that the nurse is well-educated about Severe Acute Respiratory Syndrome (SARS), an
emerging global threat.
51. If you were a nurse who works in a health clinic, and you suspect that a patient has SARS, which of the following will you do
first?
A. Contact the hospital
B. Protect self by putting on an N95 disposable mask
C. Refer the patient to the physician for medical diagnosis
D. Have your patient put on surgical face mask
52. Which of the following confirms the diagnosis of SARS?
A.
B.
C.
D.

Travel to an area with known SARS outbreak

Signs and symptoms
History of contact with someone suspected of SARS
Presence of antibody to SARS

53. The SARS virus is transmitted through

A.
B.
C.
D.

Airborne droplets
Contact with urine
Mosquito bites
Contaminated needle

54. If the nurse has an unprotected exposure to SARS during incubation, which of the following will be done?
A.
B.
C.
D.

Voluntary quarantine of 10 days

Nurse is placed on vacation from work
Nurse will be given a high dose of gamma globulin
Administer vaccine to the nurse

55. After exposure to a patient with SARS, it is expected that SARS can develop in
A.
B.
C.
D.

2-10 days
6 weeks 6 months
30 days
12-14 days

Situation 12: You are assigned at the medical ward caring for clients with fluid and electrolyte imbalances. You know that you have
very important collaboration responsibilities when you give your patients their medications to correct their illness.
56. Samson is taking Hydrochlorothiazide, a potassium-wasting diuretic, for treatment of hypertension. As a nurse, you will teach
him to report symptoms of adverse effects such as
A.
B.
C.
D.

Facial muscle spasms

Frequent loose stools
Mood changes
Generalized weakness

57. Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for Hermin as a diuretic. Which statement made by
Hermin indicated that the teaching about his medication has been effective?
A.
B.
C.
D.

I
I
I
I

can use a salt-substitute

can have apple juice instead of orange juice.
can have low-fat cheese
will drink at least 6 glasses of water every day.

58. Joseph has been receiving diuretic therapy and is admitted to the hospital with a serum potassium level of 3.1 mEq/L. Of the
following medications that he has been taking at home, which you be most concerned about?
A.
B.
C.
D.

Oral digoxin (Lanoxin) 0.25 mg daily

Lantus insulin 23 U subcutaneously every evening
Ibuprofen (Motrrin) 400 mg every 6 hours
Metoprolol (Lopressor) 12.5 mg orally daily

59. You administered 3% Saline to Wanda who has hyponatremia. As her nurse, which one of your assessment findings will
require your most rapid response?
A.
B.
C.
D.

Her blood pressure increased from 120/80 to 142/94 mmHg

There is sediment and blood in Wandas urine
Wandas radial pulse is 105 beats per minute
There are crackles audible throughout her both lung fields

60. When caring for Edna who has just been admitted with septic chock, which of these assessment data will be your greatest
concern?
A.
B.
C.
D.

Arterial oxygen saturation of 90%

BP of 88/56
Apical pulse of 110 beats per minute
Urine output of 15 mL for 2 hours

Situation 13: Timothy, 56 years old, was admitted because of aortic dissection type B.
61. The nurse recognizes which of the following as the correct description of the patients diagnosis?
A.
B.
C.
D.

Tear in the intima of the aorta with hemorrhage into the tunica media
Stretching of the walls of the aorta involving one layer of the aorta
One-sided protrusions of one distinct area of the aorta
Pulsating hematoma on three layers of the aorta

62. Of the following diagnostic tests prescribed by the physician, which of the following will the nurse expect to show precise
measurement of the aneurysm?
A.
B.
C.
D.

Angiography
Chest X-ray
Transesophageal echocardiography
Abdominal ultrasonography

63. The physician initially treated Timothy with Propanolol (Inderal). The nurse noted in her nursing care plan that this drug will
A.
B.
C.
D.

Increase contractility of the heart

Enhance electrical conduction of the heart
Decrease release of epinephrine
Reduce heart rate

64. Based on an understanding of Heparin therapy, the nurse administers it to Timothy who has undergone repair of aneurysm
fro which of the following reasons?
A.
B.
C.
D.

To
To
To
To

prevent recurrence of aneurysm

control hemorrhage
maintain arterial pressure
prevent clot formation

65. To counteract reactions to overdosage of intravenous infusion of Heparin, which of the following drugs will the nurse expect
the physician to prescribe?
A.
B.
C.
D.

Protamine sulfate
Epinephrine
Vitamin K
Atropine Sulfate

Situation 14: You are caring for Rolando, 58 years old, who was admitted because of difficulty of swallowing and stiffening of the neck.
He has a history of a wound laceration on his right hand sustained while gardening. The physician suspects tetanus infection.
66. While you were preparing to administer oxygen inhalation, Rolando had seizures assumed an opisthotonic position. Which of
the following correctly describes this position?
A.
B.
C.
D.

Head retracted, back arched, and feet extended

Neck, hip, knee and feet plantar flexed
Head flexed forward, jaw clenched, arms pronated and feet plantar flexed.
Head hyperextended hip flexed, and feet extended

67. Taking into consideration the incubation period, which of the following data in Rolandos health history will you consider
relevant?
A.
B.

Positive for type 2 diabetes mellitus

Immunization status unceratain; no booster dose administered

C.
D.

Wound laceration sustained a week ago was treated at home

Wound pain, unbearable and unrelieved by analgesic

68. To decrease stimuli that cause spasms and seizures, which of the following nursing interventions is least relevant for you to
do?
A.
B.
C.
D.

Maintain a quiet, well-ventilated and darkened room

Administer sedatives as prescribed
Monitor for hazards of immobility
Perform physical care during time of maximal sedation

69. The priority nursing diagnosis for Rolando is Risk for ineffective airway clearance related to which of the following?
A.
B.
C.
D.

Stiffness of the jaw

Back muscle spasms
Seizures
Infection

70. During a seizure, which of the following are you expected to do first?
A.
B.
C.
D.

Monitor vital signs especially the respiratory rate

Provide a padded tongue blade in the patients mouth
Provide mechanical ventilation
Turn patient to his side

Situation 15: In the medical unit, Connie was assigned to work with Sandy, a staff nurse with 2 years experience
71. Which of the following reports of Connie will Sandy attend to immediately?
A.
B.
C.
D.

A
A
A
A

65-year-old
55-year-old
75-year-old
45-year-old

unconscious due to be turned to prevent bed sores

diabetic, first day post-operative for below-the-knee amputation, complains of severe pain
with hepatic encephalopathy, intravenous infusion due in 4 hours consumed
scheduled for partial thyroidectomy wishes to go home

72. Connie observes Sandy perform peripheral catheter insertion for intravenous infusion. The patient insisted to sit on the edge
of the bed. After a second unsuccessful attempt on cannulation, the patient suddenly became anxious, diaphoretic,
nauseated and dizzy. Which of the following will Sandy do first?
A.
B.
C.
D.

Place the patient on a supine position

Instruct Connie to call the physician
Check vital signs
Discontinue the IV fluids

73. Sandy explained to Connie that the patient experiences a vasovagal reaction. Which of the following vital signs will the nurse
expect?
A.
B.
C.
D.

Normal blood pressure and increased pulse

Decreased blood pressure and decreased cardiac rate
Increased blood pressure and tachycardia
Normal pulse and increased blood pressure

74. One of Connies patients is Greg who just had bronchoscopy. Sandy asked Connie what she should be alert for in observing
Greg?
A.
B.
C.
D.

Sore throat and hoarseness

Blood tinged sputum and coughing
Nausea and vomiting
Shortness of breath and laryngeal stridor

75. At the end of the shift, Sandy told Connie to do self-evaluation of competencies developed during the week. Which of the
following indicators will Connie consider as an improvement of her ability to respond to the urgency of her patients
conditions?
A.
B.
C.
D.

Able to identify adverse reactions of drugs

Responds to inquiries promptly
Recognize abnormal laboratory results
Administer medications on time

Situation 16: Nurse have crucial legal responsibilities in the exercise of her profession
76. Mary Jane, a 3rd year nursing student assigned to the surgical unit asks your permission to photocopy the surgical record
from a patients chart for an assignment that she must write. Which of the following is your appropriate nursing action?
A.
B.
C.
D.

Allow Mary Jane to photocopy the pages without the clients name
Photocopy the pages for Mary Jane
Ask the physician for permission to photocopy the pages
Allow Mary Jane to write down pertinent information but not identifying

77. You are caring for Felisa who has dementia and is soiled with feces but you failed to clean and bathe her because it is
endorsement time already. You endorse her to the next shift nurse. The nurse reports that you are guilty of

A.
B.
C.
D.

Malpractice
Nonmaleficence
Assault
Negligence

78. You are invited to talk to new graduate nurses about negligence. Which of the following situations is a priority for you to
include as an example of negligence?
A.
B.
C.
D.

Talking about client outside of the health care facility

Not allowing a family member to awaken an adult client who is sleeping
Not giving a prescribed medication to an older patient
Not turning off the oxygen at the bedside when a client wants to smoke in bed

79. You call the physician of your patient Erlinda, 76 years old, to report a change in her condition and to request orders for a
pain medication. The physician is unable to take the call and the message is left with the office secretary who repeats a
verbal order from the physician. Which of the following is your most appropriate nursing action?
A.
B.
C.
D.

Refuse to accept the order from the office secretary and call back later
Accept the order form the office secretary and document it appropriately
Accept the order as it comes from the physician as interpreted by the office secretary
Insist on speaking to the physician personally

80. You observe bruises and skin tears on Agatha, an 80-year-old client. She does not make eye contact and appears fearful.
Which of the following is your priority nursing action?
A.
B.
C.
D.

Ask the client about the bruises and skin tears

Ask the family members what has happened
Document your findings
Call the physician

Situation 17: You are assigned in the Pediatric ICU and your critical decisions and proper documentation are important. You are caring
for Charlie, 5 years old, who was admitted following a vehicular accident. Clinical data obtained were; BP 80/58 mmHg, heart rate
120, respirations 32, peripheral pulse slightly diminished, hematocrit 30%, pulse oximeter 94%, serum electrolytes normal. CT scan is
positive for abnormal bleeding. Weight 20 kg.
81. Based on the above data, which of the following nursing diagnosis would you select as being appropriate in Charlies care?
A.
B.
C.
D.

Fluid volume deficit

Ineffective airway clearance
Impaired gas exchange
Altered cardiac output: decreased
Answer: A

82. Charlie is placed on a cardiac monitor and a urinary catheter is inserted. One peripheral IV line in the left arm is infiltrated
and discontinued. An indirect BP reading is 70/40 mmHg and a heart rate of 140 is noted. Which of the following orders
should be initiated first?
A.
B.
C.
D.

IV access
Serum hematocrit and hemoglobin
Arterial line set-up
Dopamine continuous infusion

83. What parenteral solution would you anticipate to prepare for Charlies volume replacement?
A.
B.
C.
D.

5% Dextrose in 0.25% normal saline

25% albumin
0.9% Normal Saline
5% Dextrose in water

84. Charlies mother verbalizes her concerns regarding Charlies condition. She informs you that Charlie is their only child and
that her husband is working overseas. What would be your best response?
A.
B.
C.
D.

Hold her hand, and have an eye contact with her and reassure her that you are doing your best.
Ask one of your con-staff to assist Charlies mother
Tell her you understand how she feels but your priority is to take care of Charlie
Tell her to pray and leave everything to God

85. Charlies condition worsens. He develops respiratory arrest. What nursing intervention should you perform first?
A.
B.
C.
D.

Assemble intubation kit

Administer oxygen
Do chest compression
Ventilate with a bag-valve mask device

Situation 18: Kevin, 22 years old, swerved his car and hit a tree head-on when he avoided a dog crossing the street. Kevil loss
consciousness, sustained several cuts on his forehead and was bleeding from his nose and mouth. He was diagnosed in the
Emergency Department with Traumatic Brain Injury (TBI)
86. Since volume resuscitation was necessary for Kevin, intravenous 0.9% normal saline solution was started. The nurse who
admitted the patient understands that the intravenous solution was considered by the physician because it
A.

Will reduce intracranial pressure

B.
C.
D.

Will easily maintain hydration

Will promote fluid shift into the vascular space
Wont aggravate cerebral edema

87. To determine level of consciousness, the Glasgow Coma Scale (GCS) is used. Which of the following is a correct interpretation
of the nurse of the GCS score of Kevin?
A.
B.
C.
D.

The
The
The
The

higher the score, the higher is the probability of permanent damage

lower the score is, the lower is the probability of delayed recovery
higher the score, the greater is the impairment in the brain
lower the score, the more serious is the brain injury

88. The nurse maintains the body temperature of Kevin within normal limits. This intervention is significant in preventing which
of the following?
A.
B.
C.
D.

Cerebral ischemia
Infection
Seizures
Dehydration

89. When intracranial pressure increases, which of the following nursing diagnosis is appropriate?
A.
B.
C.
D.

Risk for ineffective breathing pattern

Disturbed sensory perception
Risk for cardiac dysfunction
Ineffective airway clearance

90. Which of the following interventions can the nurse include in the plan of care for Kevin to control intracranial pressure?
1. Maintain his head and neck in neutral alignment
2. Initiate measures to enhance valsalva maneuver
3. Administer Oxygen to maintain PaO2 >90 mmHg
4. Elevate head of the bed as prescribed
A.
B.
C.
D.

1 and2
All except 2
3 and 4
All of the above

Situation 19: You are caring for Angelo, 68 years old, who was diagnosed with acute heart failure. Angelo has a history of acute
myocardial infarction and underwent coronary artery bypass surgery. He is complaining of severe shortness of breath and
hemoptysis.
91. You recognize that pulmonary edema may develop because of which of the following?
A.
B.
C.
D.

Low plasma protein levels decreasing plasma oncotic pressure

Increase capillary permeability due to lung inflammation
Increased hydrostatic pressure in the pulmonary capillaries
Increased surface tension in the alveoli

92. Which of the following assessment findings would you consider as priority for immediate nursing intervention?
A.
B.
C.
D.

Hemoptysis
BP 95/72, skin cool, and diaphoretic
Significant jugular vein distention
Severe orthopnea

93. Cardiac assessment reveals apical pulse is lateral to midclavicular line. You understand that this finding means
A.
B.
C.
D.

Mitral valve regurgitation

The heart is enlarged
That cardiac output is adequate]
Dilated heart

94. You observed for fibrillation on the cardiac monitor. Which of the following ECG characteristics did you observe on the cardiac
monitor?
A.
B.
C.
D.

sawtooth appearance of P waves

P waves observed before, during, and after QRS complex
P wave hidden in the QRS complex
P waves unidentifiable

95. The physician prescribed Furosemide to be administered intravenously. Which of the following nursing orders is least
appropriate to ensure that adverse effects of the drug are closely monitored on Angelo?
A.
B.
C.
D.

Report significant weight changes

Monitor laboratory results on electrolytes
Measure hourly urine output
Integrate foods rich in potassium in the diet

Situation 20: Lilette, 4-year-old girl with a recent history of nausea, vomiting and diarrhea is admitted to the Pediatric Unit with a
diagnosis of acute gastroenteritis. Your significant physical examination includes dry skin with turgor, sunken soft eyeballs, parched
lips, abdominal distention. She has tachycardia and fever (38C)

96. Based on your assessment findings, which of the following is your nursing diagnosis?
A.
B.
C.
D.

Ineffective peripheral tissue perfusion related to fluid volume deficit

Fluid volume deficit related to abnormal loss and decrease intake
Activity intolerance related to malaise
Impaired skin integrity related to frequent diarrhea

97. The following management goals for Lilette are most important for you to include in your plan except
A.
B.
C.
D.

Adequate rehydration and fluid maintenance

Nothing per orem at all times
Continue assessment of fluid and electrolyte imbalance
Reintroduction of adequate diet

98. To ensure adequate fluid and electrolyte pelacement, the doctor ordered 500 ml of balanced electrolyte solution for 10
hours. The IV set delivers 60 gtt/min to administer the 500 ml IV solution, you should set the IV drip rate at
A.
B.
C.
D.

35
62
50
41

gtt/min
gtt/min
gtt/min
gtt/min

99. Which of the following findings would best indicate that Lilettes hydration level has improved?
A.
B.
C.
D.

No further weight loss

Lower hematocrit
Lower creatinine
Lower WBC

100.Lilette cries whenever her Mommy and Grandma leave her. Which of the following interventions can reduce her anxiety?
A.
B.
C.
D.

Have the same nurse care for her

Provide her with some new toys and bring her favorite toys
Restrict visiting hours to decrease her crying
Encourage her playmates to visit her