1

EXCELLENCE REVIEW CENTER,

INC.

NURSE LICENSURE EXAMINATION

EXAM DRILL 3 (REFRESHER-NOV. 2021)
Situation 1: Karen, age 37, has a history of hypertension. Her laboratory tests reveal chronic
hypokalemia. She has been diagnosed with primary hyperaldosteronism.
1) The diagnosis of chronic hyperaldosteronism indicates that Karen’s hypertension is caused by excessive
hormone secretion by the:
A. Adrenal cortex B. Pancreas C. Adrenal medulla D. Parathyroid glands 2) The most common
cause of hyperaldosteronism is:
A. Excessive sodium intake C. Deficient potassium intake
B. A pituitary adenoma D. An adrenal adenoma
3) Karen was diagnosed with a unilateral aldosteronoma for which she is scheduled for a unilateral adrenalectomy.
The

nurse is performing preoperative teaching. The client asks the nurse, “What will I look like and behave like
after surgery?” The nurse’s best response is:
A. “Don’t worry about that now. You need to concentrate on the surgery.”
B. “You will only have a small incision.”
C. “I know you are worried, maybe we should resume the education session.”
D. “After surgery you may not respond to any stressors, so we will do our best to help decrease stimuli and
help you through it. Your appearance will not change immediately after the surgery.”
4) Post unilateral adrenalectomy, the nurse can identify hyperkalemia by assessing the patient for: A. Muscle
weakness B. Tremors C. Diaphoresis D. Constipation 5) After surgery, Karen is treated with spironolactone, a
potassium-sparing diuretic. The nurse should inform her that an adverse effect of this medication is:
A. Breast tenderness B. Menstrual irregularities C. Increased facial hair D. Hair loss

Situation 2: David, newly diagnosed with chronic renal failure, complains of muscle weakness and
numbness in his legs. His lab results are: Na 136 mEq/L, K 5.9 mEq/L, Cl 100 mEq/L, Ca 4.5
mEq/L. 6) The nurse knows that Davis is suffering from:
A. Hyperkalemia B. Hypernatremia C. Hypocalcemia D. Hypochloremia 7) The client has begun
hemodialysis. Knowing that the client is at risk for disequilibrium syndrome, the nurse assesses the client
during dialysis for:
 A. Hypertension, tachycardia, and fever
B. Hypotension, bradycardia, and hypothermia
C. Restlessness, irritability, and generalized weakness
D. Headache, deteriorating level of consciousness and twitching
8) The nurse is assessing a client following hemodialysis. Which of the following findings indicates the treatment
was effective?
A. Hypertension B. Hyperkalemia C. Fluid volume decrease D. Cardiac dysrhythmias 9) After hemodialysis, the
nurse would assess the client for bleeding because of which rationale? A. Excessive amounts of urea in the blood C.
Increased platelet activity during dialysis B. Heparin administration during dialysis D. Increased hematocrit
secondary to fluid removal 10) The hemodialysis client with a left arm fistula is at risk for arterial steal syndrome.
The nurse assesses this client for which of the following manifestations?
A. Warmth, redness, and pain in the left hand
B. Pallor, diminished pulse, and pain in the left hand
C. Edema and reddish discoloration of the left arm
D. Aching pain, pallor, and edema of the left arm

Situation 3: A community health nurse volunteers in rescuing and assisting the victims of
Bagyong Ondoy.
11) A guideline that is utilized in determining priorities is to assess the status of the following
EXCEPT: A. Perfusion B. Locomotion C. Respiration D. Mentation
12) A community health nurse is caring for a group of homeless people in a certain area of a city. In planning
for the potential needs of this group, what is the most immediate concern?
A. Peer support through unstructured groups
B. Setting up a 24-hour crisis center and hotline

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C. Meeting the basic needs
D. Finding affordable housing for the group
13) A community health nurse is working with older residents involved in a recent flood caused by Bagyong
Ondoy. Many of the residents were emotionally despondent and reused to leave their homes for days. In
planning for the rescue and relocation of these older residents, what is the first item the nurse needs to
consider? A. Attending to the emotional needs of the older residents
B. Attending to the nutritional status and basic needs of the older residents
C. Contacting the older residents' families
D. Arranging for ambulance transportation for the older residents
14) Which of the following correctly explains the pathophysiologic changes and pulmonary injury that occur in
a client who nearly-drowned in fresh water?
A. Fresh water aspiration leads to pulmonary edema
B. Fresh water moves passively into the airways
C. Fresh water aspiration results in a loss of surfactant
D. Fresh water aspiration causes reflex closure of the larynx
15) Immediately after rescue, the nurse notices that the victim's stomach is bulging. In which position should
the victim be appropriately placed?
A. Prone B. Supine with head midline C. Side-lying D. Semi-fowlers
Situation 4: Mang Edgardo, found lying unconscious in an enclosed parking space, is rushed to the
emergency room. Carbon monoxide poisoning is suspected.
16) The nurse expects the physician to prescribe which of the following to confirm the
diagnosis? A. Carboxyhemoglobin C. Pulse oximetry
B. Complete blood cell count D. CT scan of the head
17) Mang Edgardo suffering from carbon monoxide poisoning:
A. Appears intoxicated C. Appears hyperactive
B. Presents with severe hypertension D. Will always present with a cherry red skin coloring 18) A nurse is
setting up oxygen for Mang Edgardo. He is to receive oxygen at 10 L per non-rebreather mask. It is important
for the nurse to do the following EXCEPT:
A. Adjust the flow rate to keep the reservoir bag inflated greater than 2/3 full during inspiration
B. Monitor the patient carefully for risk of aspiration
C. Make sure the valves and rubber flaps are patent, functional, and not stuck
D. Remind the client and his wife of the smoking policy
19) the results of serial arterial blood gases of Mang Edgardo who is asking for the oxygen mask to be removed.
The nurse determines that the oxygen may be safely removed once the carboxyhemoglobin level decreases to
less than:
A. 5% B. 10% C. 15% D. 25%
20) A nurse evaluates Mang Edgardo following treatment for carbon monoxide poisoning. The nurse
would document that the treatment was effective when the:
A. Client is awake and talking C. Heart monitor shows sinus tachycardia B.
Carboxyhemoglobin levels are less than 5% D. Client is sleeping soundly

Situation 5: Mang Jose, a 30 year-old construction worker, is rushed by his co-worker to the
emergency department. His co-worker reports that they were finishing the roof deck of a 10-storey
building the entire afternoon, when he fainted, and unable to respond. Upon assessment, tachypnea;
dry mucous membranes; hot, dry reddened skin; and a temperature greater than 106oF (41.1oC) were
noted.
21) Which feature can help you determine whether a patient has heat exhaustion or
heatstroke? A. Temperature higher than 102oF C. Dehydration
B. Altered CNS function D. Elevated liver transaminase levels
22) The best cooling method for heatstroke is:
A. Water immersion B. Iced peritoneal lavage C. Evaporative cooling D. IV fluids 23) When treating a patient
with siriasis or heatstroke, you need to monitor temperature continuously to make sure that it doesn’t fall below:
A. 101oF (38.3oC) B. 98.6oF (37oC) C. 104oF (40oC) D. 99oF (37.2oC) 24) After cooling a patient with
heatstroke, he begins to shiver. You expect to administer: A. Aspirin B. Acetaminophen C. Diazepam D.
Chlorpromazine 25) Which mechanism accounts for most of the body’s heat loss under typical
environmental conditions? A. Convection B. Conduction C. Radiation D. Evaporation

Situation 6: Cynthia, age 33, was involved in a house fire in which she suffered a burn injury to her
left hand and arm. She was admitted to the hospital for wound care and fluid resuscitation. 26)
Cynthia's burn is described as white and leathery with no blisters. Which degree of severity is this burn? A.
First-degree B. Second-degree C. Third-degree D. Fourth-degree
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27) What is the most important, immediate goal of therapy for Cynthia?
A. Maintaining fluid, electrolyte, and acid-base balance
B. Planning for rehabilitation and discharge
C. Providing emotional support to the patient and family
D. Preserving full range of motion to all affected joints
28) Cynthia receives fluid resuscitation using the Parkland formula. Which type of fluid is
used? A. Normal saline solution C. Lactated Ringer's solution
B. Half-normal saline solution D. Dextrose 5% in Lactated Ringer's solution 29) Cynthia has been prescribed a
regular diet. Which dietary items should the nurse encourage the client to eat in order to promote wound healing?
A. Potatoes, Jell-O, orange juice C. Chicken breast, broccoli, milk
B. Peanut butter and jelly, tea D. Spaghetti, garlic bread, ginger ale
30) Cynthia asks the nurse for a recommendation about how to prevent fires and burn injury. The nurse tells the
client that the one single intervention that has been shown to decrease the risk of dying in a residential fire
is: A. The installation of a sprinkler system
B. Fire extinguishers placed in key areas such as the kitchen
C. The use of operable smoke detectors
D. Installation of fire-resistant drywall panels throughout the house

Situation 7: Jacob, 45 years old, presents to the emergency department with nausea, and steady
epigastric pain centered near the navel that radiates to the back. Blood studies reveal elevated
amylase, lipase, and while blood cell count levels. The client is diagnosed with acute pancreatitis.
31) The pancreas functions as both an exocrine and endocrine gland. Which of these is an example of its
exocrine function?
A. The pancreas produces hydrochloric acid
B. Amylase is produced in the acinar cells
C. Insulin is produced into islets of Langerhans
D. The pancreas secretes its enzymes into the stomach
32) The most common cause of acute pancreatitis is:
A. Alcohol B. Eating low-fat foods C. Gallstones D. Pregnancy 33) Which of these imbalances
typically occur in acute pancreatitis?
A. Hypovolemia B. Hypercalcemia C. Hypernatremia D. Hypermagnesemia 34) The patient with acute
pancreatitis may report that his pain decreases:
A. When he lies on his stomach C. After eating a large meal
B. After vomiting D. When he lies on his side with his knees drawn toward his chest 35) Patients recovering
from acute pancreatitis should eat foods that are:
A. Low in carbohydrates, and high in fats and proteins
B. Low in carbohydrates, proteins, and fats
C. High in carbohydrates and fats, and low in proteins
 D. High in carbohydrates, and low in fats and proteins

Situation 8: Nursing care is not confined to hospital settings. Nurses must also have a background on
animal bites and its emergency care.
36) The course and prognosis of snake bite injuries depend on the following EXCEPT:
A. Age and size of the victim C. Location of the bite
B. Gender of the victim D. When the bite occurred
37) Which of the following can be given during the acute stage of the snake bite?
A. Ice compress B. Corticosteroids C. Heparin D. Antihistamines 38) After a snake bite, the
following interventions should be done EXCEPT:
A. Apply a constricting band 2 to 4 inches above the bite
B. Immobilize the victim’s arm or leg in the elevated position
C. Suck the poison out with the mouth
D. Wash the wound with soap and water
39) When stung by a jellyfish, the area should be washed thoroughly with:
A. Alcohol B. Acetic acid C. Ammonia D. Urine
40) A child is brought to the emergency room, after being bitten in the arm by a neighborhood dog. The nurse
performs a focused assessment, cleanses the wound as prescribed and continues to perform a thorough
assessment in the child. Which of the following is the priority question for the nurse to ask the mother of the
child?
A. “Did the dog have rabies?'
B. “Are the child's immunizations up-to-date?”
C. “How old is the dog?”
D. “Did the dog have its recommended shots?

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Situation 9: A preschool child with leukemia is admitted to the hospital with complaints of fever,
chills, fatigue, and pallor.
41) Labs are drawn and the results reported. Which lab data will provide the most likely explanation for the
fatigue and pallor?
A. Magnesium 2.0 mEq/L C. WBC 12.6 x 103/L
B. Hemoglobin 6.5 g/Dl D. Creatinine 2.5 mg/dL
42) In writing a nursing care plan for a child with leukemia, the nurse should include all of the following
goals. Which goal is most important?
A. Maintain infection-free state C. Promote adequate nutrition
B. Prevent injury D. Meet developmental needs
43) The child is receiving chemotherapy with vincristine. The nurse should observe this child closely for the
side effect of:
A. Diarrhea B. Diplopia C. Hemorrhagic cystitis D. Peripheral neuropathy 44) The child develops oral
ulcer. Which of the following interventions is inappropriate?
A. Encourage the child to use viscous lidocaine before meals
B. Offer the child a bland, moist, soft diet
C. Use a soft toothbrush
D. Provide frequent normal saline mouth rinses
45) The parents of a preschool child with leukemia tell the nurse that their daughter frequently has nightmares,
and they wonder how to handle this. The nurse would be most correct in advising them to:
A.
 Comfort her, but leave her in her own bed
B. Comfort her, by bringing her into her bed
C. Consult a child psychologist to determine why she has recurring sleep disturbances
D. Encourage the child to draw a picture of her dreams and discuss them with her primary nurse during
hospitalization

Situation 10: Cancer of the prostate is the leading cancer in men other than skin cancer. The following
questions will assess your knowledge and theoretical foundation in dealing with clients with prostate
cancer.
46) Among the following population groups, who has a higher risk in the development of prostate
cancer? A. African-American B. Caucasian C. Asian D. Hispanics
47) Which among the following is NOT a risk factor for prostate cancer?
A. A family member with prostate cancer C. Diet high in fat and red meats
B. Advancing age D. Smoking
48) At the initial sign and symptoms of prostate cancer, before diagnosis, the physician can perform a screening
test to detect a characteristic “stony hard” prostate and nodules at the prostate area using:
A. Cystoscopy B. PSA C. DRE D. MRI
49) To diagnose the presence of prostate cancer, the physician will perform:
A. Transrectal needle biopsy of the prostate
B. Test to identify the PSA level
C. Transurethral ultrasound
D. Radiolabeled monocional antibody capromab pendetide with iridium-111
50) In testing for the PSA, the nurse will collect which specimen?
A. Blood B. Urine C. Feces D. Prostatic fluid

Situation 11: Care of the clients with tracheostomy is often a challenge to a beginning nurse. The
following questions will test your knowledge on Tracheostomy and its related care. 51) In cleaning
the inner cannula or other parts of the tracheostomy tube, the best cleansing mediums are: A. Hydrogen
peroxide and sterile NSS C. Alcohol and sterile NSS
B. Povidone iodine and sterile NSS D. Alcohol and hydrogen peroxide
52) In contrary to tracheostomy tubes, sizes of chest tubes are expressed in terms of:
A. French B. Gauge C. m2 D. Diameter
53) The nurse knows that in Tracheotomy creation, 1% Lidocaine and 1:100,000 Epinephrine is injected at the
incision site. The purpose of Lidocaine is mainly to provide anesthetic effect, while the Epinephrine is needed
to: A. Relax the bronchus and dilate the airway for easier insertion
B. Promote faster healing
C. Prevent the vasovagal reflex that might cause bradycardia
D. Promote hemostasis
54) For which of the following reasons will a surgeon select a cuffed tube over a non-cuffed tracheostomy
tube? A. For efficient securing C. For excellent attachment
B. To prevent coughing D. For mechanical ventilation
55) A client has impaired verbal communication as a result of temporary tracheostomy following a laryngectomy.
In planning for communication with this client, the nurse would avoid which of the following methods because
it would be least helpful for this particular client?
A. Use of hand or finger signals
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B. Nodding and shaking the head for yes or no
C. Use of a picture board
D. Use of a pencil and paper

Situation 12: Each member of the OR team performs his/her tasks in collaboration with the
other members of the team.
56) Who holds the packet flaps of sutures to open it and place it in the sterile table for
use? A. Scrub nurse B. Circulating nurse C. Assistant surgeon D. Surgeon
57) Nurses in the PACU perform vital signs monitoring every:
A. 5 minutes B. 10 minutes C. 15 minutes D. 30 minutes 58) Another worthy study is the compliance to
principles of aseptic technique among the sterile OR team. Who does NOT belong to the sterile OR team?
A. Scrub nurse B. Assistant surgeon C. X-ray technician D. Surgeon
59) The OR team collaborates from the first to the last surgical procedure. Who monitors the activities of the
OR suite during a surgical procedure?
A. Scrub nurse B. Anesthesiologist C. Circulating nurse D. Surgeon
60) Who is responsible in daily monitoring the standards of safe nursing practice in the operating
suite? A. Surgeon B. Perioperative nurse C. OR nurse supervisor D. Chief nurse
Situation 13: Though often overlooked, nurses must bear in mind that giving health teachings is
an important part of nursing care.
61) A nurse has conducted a stress-management seminar for clients in an ambulatory care setting. Which
statement by an attendee would indicate that further instruction is needed?
A. “Biofeedback might be nice, but I don't like the idea of having to use equipment.”
B. “I can use guided imagery anywhere and anytime.”
C. “The progressive muscle relaxation technique should ease my tension headaches.”
D. “Using confrontation with co-workers should solve my problems at work quickly.”
62) A nursing instructor assigns a student nurse to present a clinical conference to the student group about
brain tumors on children. The nursing student prepares for the conference and includes which of the
following information in the presentation?
A. Surgery is not normally performed because of the risk of functional deficits occurring as a result of the
surgery
B. Head shaving is not required before removal of the brain tumor
C. Chemotherapy is the treatment of choice
D. The most significant symptoms are headaches and vomiting
63) A nurse provides discharge instructions to a client with testicular cancer who had testicular surgery. The
nurse tells the client:
A. To report any elevation in temperature to the physician
B. To avoid driving a car for at least 8 weeks
C. Not to be fitted for prosthesis for at least 6 months
D. To avoid sitting for long periods for at least 6 weeks
64) A nurse has given instructions on site care to a hemodialysis client who had an implantation of an
arteriovenous fistula in the right arm. The nurse determines that the client needs further instructions if the
client states to: A. Avoid carrying heavy objects on the right arm
B. Sleep on the right side
C. Report an increased temperature, redness and drainage at the site
D. Perform range of motion exercises routinely on the right arm
65) A nurse provides home care instructions to a client hospitalized for transurethral resection of the
prostate. Which statement by the client indicates the need for further instructions?
A. “I need to avoid strenuous activity for 4 to 6 weeks.”
B. “I need to maintain a daily intake of 6 to 8 glasses of water daily.”
C. “I can lift and push objects up to 30 pounds in weight.”
D. “I need to include prune juice in my diet.”

Situation 14: Organ donation is a new form of treatment that provides multiple complications such as
rejection.
66) Organ donation to save life was initialized with the first transplant done by:
A. Dr. Christian Barnard of the Union of South Africa
B. Dr. Christian Barnard of the United States of America
C. Dr. Christian Barnard of the Soviet Union
D. Dr. Christian Barnard of the United Kingdom
67) In 1983, the FDA approved the anti-rejection drug by the name of:
 A. Cyclosporine B. Prednisone C. Imuran D. Azathioprine

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68) A client for organ transplant is expected to take immunosuppressant medications such as
cyclosporine, prednisone and azathioprine:
A. For 2 years C. Until the rejection is not anymore viable
B. Until the suture heals D. For the rest of the client's life
69) Which of the following is a sign that the transplanted kidney is being rejected?
A. Fever and weight gain C. Chills, fever, and polyuria
B. Fever and weight loss D. Anuria, fever, weight gain, and hematuria
70) Among the children candidates for organ transplant, when all selected children have appropriate tissue
matches for the same donated organ, the basis for decision as to which child gets the organ is given to the
child who: A. Will receive the most benefit from the new organ
B. Is most likely to die without the transplant
C. Is selected by the lottery system for available organs
D. Is at the top of the list and has waited the longest time

Situation 15: Mrs. Dianzon is assigned in the female surgical ward. While on duty, a 15-year-old
client is admitted for cesarean section. The informed consent for the operation has to be obtained.
71) The person legally responsible for taking the informed consent is:
A. The OR nurse who is going to assist with the operation
B. Any doctor assigned with team
C. The doctor who is going to perform the procedure
D.
The
ward
nurse
where
the

patient stayed before the operation

72) Mrs. Dianzon recalls that which of the following is true of informed consent?
A. Because the patient is a minor, the parents should be asked to sign the consent
B. The informed consent should be signed by the patient or her 20-year-old husband if patient is unconscious
C. Nurses have the responsibility to obtain the informed consent prior to surgery
D. Legal guardian should sign the consent since the client is 15 years old
73) The medical intern who assisted in the operation gave the post operative orders. In this case, Mrs.
Dianzon should:
A. Validate the order from the surgeon and request him to countersign
B. Follow the order as long as they are within the scope of nursing practice
C. Clarify from the medical intern those that are ambiguous
D. Refuse to follow the order because it is not legal
74) After one year, Mrs. Dianzon rotated to the delivery room. As the DR nurse, the Obstetrician ordered her
to administer spinal anesthesia because the anesthesiologist did not arrive at the scene. The nurse would:
A. Give the anesthesia if the supervising nurse approves it
B. Give the anesthesia if the OB supervises her
 C. Give the anesthesia if the doctor writes the order
D. Do not follow
75) Which of the following should the nurse remember when the doctor requests to administer
anesthesia? A. The nurse has the right to refuse it if the doctor's order is unlawful
B. Doctor's orders should always be written
C. The nurse may render medical procedure if the doctor supervises him
D. The staff nurse can be accused of insubordination if she does not follow the doctor's order

Situation 16: Anesthesia is used even during the Ancient times. In its evolution, modern marvels
in use of anesthesia enable nurses to develop a more competitive approach in patient care. 76) An
anesthesia delivered directly into the spinal canal is known as:
A. Epidural B. Intrathecal C. General D. Local
77) After spinal anesthesia, 30% of the patients develop spinal headache. This is due
to: A. Severe hypotension with vasodilation due to the anesthetics
B. Increased volume of the cerebrospinal fluid due to anesthesia induction
C. Cerebral edema due to rapid absorption of the anesthetics
D. CSF leakage due to puncture created by the spinal needle
78) Before the induction of spinal anesthesia, the client is placed in which of the following positions to
widen vertebral space?
A. Quasi fetal position C. Flat on bed, supine
B. Prone position D. Side-lying on the affected side
79) To prevent spinal headache after spinal anesthesia, the client is placed on which of the following
positions? A. Sitting position C. Flat on bed, supine
B. Side-lying on affected side D. Flat on bed, prone
80) Another way to prevent spinal headache is by the use of correct needle gauge. If the client is an adult client,
the anesthesiologist might order a pink spinal set. The nurse knows that the pink spinal set has a huge gauge
of:
A. 12 B. 16 C. 22 D. 26

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Situation 17: Incidental reports, living wills, and patients' charts are legal documents admissible in
court. In working with the client, the nurse must be knowledgeable of the legal use, implications, and
accompanying responsibilities of these documents.
81) A nurse is performing admission assessment on a client admitted newly diagnosed with Hodgkin's
disease. Which of the following would the nurse expect the client to report?
A. Night sweats C. Weight gain
B. Severe lymph node pain D. Headache with minor visual changes
82) A nurse enters a client's room and finds the client sitting on the floor. The nurse performs a thorough
assessment and assists the client back into bed. The nurse completes an incident report and notifies the
physician of the incident. Which of the following is the next appropriate nursing action regarding the
incident? A. Make a copy of the incident report for the physician
B. Place the incident report in the client's chart
C. Document a complete entry in the client's record concerning the incident
D. Document in the client's record that an incident report has been completed
83) A nurse is caring for a client with cancer. The client tells the nurse that a lawyer will be arriving today to
prepare a living will. The client asks the nurse to act as one of the witnesses for the will. The nurse takes
which action?
A. Agrees to act as a witness
B. Refuses to help the client
C. Informs the client that a nurse caring for a client cannot serve as a witness to a living will
 D. Calls the physician
84) A nurse enters the client's room and finds the client lying on the floor. Following assessment of the client, the
nurse calls the nursing supervisor and the physician to inform them of the occurrence. The nursing supervisor
instructs the nurse to complete an incident report. The nurse understands that an incident reports allow the
analysis of adverse client events by:
A. Evaluating quality care and the potential risks for injury to the client
B. Determining the effectiveness of nursing intervention in relation to outcomes
C. Providing a method of reporting injuries to local agencies
D. Providing clients with necessary stabilizing treatments
85) Who owns the patient's chart?
A. The patient B. The attending physician C. The hospital D. The government

Situation 18: The following questions are related to the Operating Room.
86) If the suture is removed too soon, the nurse knows that it could lead to failed healing of the wound as well
as infection. If the suture is removed too late, which of the following can occur?
A. Itching B. Swelling C. Scarring D. Pain
87) The nurse noticed that there are yellow and brown crusting around the area of the suture. Which of
the following is the best cleansing medium to remove such crusting?
A. Hydrogen peroxide B. Povidone iodine C. NSS D. Alcohol
88) When least amount of trauma is desired, or when the client is prone to keloid formation, the nurse
should prepare which type of needle?
A. Swaged B. Round C. Blunt D. Taper
89) Another alternative suture for skin closure is the use of:
A. Staple B. Therapeutic glue C. Absorbent dressing D. Invisible suture 90) One of the hidden dangers in
the OR is missing instruments. What is the appropriate intervention for this happening?
A. Correct labeling
B. “A place for everything, and everything in its place”
C. Install a flush sterilizer in the OR
D. Increase instrument inventory

Situation 19: A nurse is to insert an indwelling Foley catheter into the bladder of a postoperative
male client who has not voided for 6 hours and has a distended bladder.
91) The nurse understands that which of the following represents an unsafe action when performing
this procedure?
A. Inflating the balloon to test patency before catheter insertion
B. Advancing the catheter an additional 2.5 to 5 cm (1 to 2 inches) once urine appears in the catheter tubing
C. Inflating the balloon with 4 to 5 mL more than the balloon capacity
D. Placing the drainage bag lower than the bladder level, with no kinks in the tubing
92) As the catheter is inserted into the urethra, urine begins to flow into the tubing. At this point, the
nurse: A. Immediately inflates the balloon
B. Withdraws the catheter approximately 1 inch and inflates the balloon
C. Inserts the catheter until resistance is met and inflates the balloon
D. Inserts the catheter 2.5 to 5 cm and inflates the balloon

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93) As the nurse inflates the balloon with a syringe, the client complains of discomfort. The nurse: A.
Removes the syringe from the balloon because the discomfort is normal and temporary B. Aspirates
the fluid from the balloon, advances the catheter farther, then reinflates the balloon C. Aspirates the
fluid from the balloon, waits until the discomfort subsides, then reinflates the balloon D. Aspirates the
fluid from the balloon, removes the catheter, and reinserts a new catheter
94) After the tubing is secured and the collection bag is hung on the bed frame, the nurse notices that 800 ml
of urine has drained into the collection bag. The appropriate nursing action for the safety of the client is to:
A. Clamp the tubing for 30 minutes and then release
B. Provide suprapubic pressure to maintain steady flow of urine
C. Check the specific gravity of the urine
D. Raise the collection bag high enough to slow the rate of the drainage
95) A nurse has an order to obtain a urinalysis from a client with an indwelling catheter. The nurse avoids which of
the following, which could contaminate the specimen?
A. Obtaining specimen from the urinary drainage bag
B. Clamping the tubing of the drainage bag
C. Aspirating a sample from the port on the drainage bag
D. Wiping the port with an alcohol swab before inserting the syringe

Situation 20: During surgical operation, it is inevitable to utilize sutures. The nurse should know
the principles in suturing, and must be knowledgeable in selecting sutures and caring for clients
with sutures.
96) Steel has the highest tensile strength among sutures in the non-absorbable category. When you say
tensile strength, it refers to:
A. The amount of weight force necessary to break the suture
B. The cross sectional size of the suture
C. The ability of the suture to absorb fluid
D. The force necessary to cause the knot to slip
97) In suturing the internal organs, such as the kidneys, liver, pancreas and stomach, the nurse knows that the
type of suture material that the physician will most likely use is:
A. Steel B. Vicryl C. Cotton D. Silk
98) If the suture is performed on the client's face, the nurse will reinforce the teaching that the client should
return when for the suture removal?
A. After 7 days B. After 3 to 4 days C. After 10 days D. The next day 99) Sizes of sutures denote the
diameter. The physician will perform a corneal transplant and will suture the eye. The nurse will prepare which
of the following suture size?
A. 7 B. 5 C. 3 D. 9-0
100) Non-absorbable suture materials such as cotton, nylon, and silk are best used in suturing which of the
following abdominal layer?
A. Skin B. Peritoneum C. Fascia D. Muscle

***END OF NLE EXAM DRILL 3 (REFRESHER)***

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