1. The four major concepts in nursing theory are the A.

Henderson
B. Abdellah
A. Person, Environment, Nurse, Health C. Levin
B. Nurse, Person, Environment, Cure D. Peplau
C. Promotive, Preventive, Curative,
Rehabilitative 7. Caring is the essence and central unifying, a
D. Person, Environment, Nursing, Health dominant domain that distinguishes nursing from
other health disciplines. Care is an essential human
2. The act of utilizing the environment of the patient need.
to assist him in his recovery is theorized by
A. Benner
A. Nightingale B. Watson
B. Benner C. Leininger
C. Swanson D. Swanson
D. King
8. Caring involves 5 processes, KNOWING,
3. For her, Nursing is a theoretical system of BEING WITH, DOING FOR, ENABLING and
knowledge that prescribes a process of analysis and MAINTAINING BELIEF.
action related to care of the ill person
A. Benner
A. King B. Watson
B. Henderson C. Leininger
C. Roy D. Swanson
D. Leininger
9. Caring is healing, it is communicated through the
4. According to her, Nursing is a helping or consciousness of the nurse to the individual being
assistive profession to persons who are wholly or cared for. It allows access to higher human spirit.
partly dependent or when those who are supposedly
caring for them are no longer able to give care. A. Benner
B. Watson
A. Henderson C. Leininger
B. Orem D. Swanson
C. Swanson
D. Neuman 10. Caring means that person, events, projects and
things matter to people. It reveals stress and coping
5. Nursing is a unique profession, Concerned with options. Caring creates responsibility. It is an
all the variables affecting an individual’s response inherent feature of nursing practice. It helps the
to stressors, which are intra, inter and extra personal nurse assist clients to recover in the face of the
in nature. illness.

A. Neuman A. Benner
B. Johnson B. Watson
C. Watson C. Leininger
D. Parse D. Swanson

6. The unique function of the nurse is to assist the 11. Which of the following is NOT TRUE about
individual, sick or well, in the performance of those profession according to Marie Jahoda?
activities contributing to health that he would
perform unaided if he has the necessary strength, A. A profession is an organization of an
will and knowledge, and do this in such a way as to occupational group based on the application
help him gain independence as rapidly as possible. of special knowledge
B. It serves specific interest of a group
 C. It is altruistic C. Help client recognize and cope with stressful
D. Quality of work is of greater importance psychological situation
than the rewards D. Works in combined effort with all those
involved in patient’s care
12. Which of the following is NOT an attribute of a
professional? 18. The nurse questions a doctors order of
Morphine sulfate 50 mg, IM for a client with
A. Concerned with quantity pancreatitis. Which role best fit that statement?
B. Self directed
C. Committed to spirit of inquiry A. Change agent
D. Independent B. Client advocate
C. Case manager
13. The most unique characteristic of nursing as a D. Collaborator
profession is
19. These are nursing intervention that requires
A. Education knowledge, skills and expertise of multiple health
B. Theory professionals.
C. Caring
D. Autonomy A. Dependent
B. Independent
14. This is the distinctive individual qualities that C. Interdependent
differentiate a person to another D. Intradependent

A. Philosophy 20. What type of patient care model is the most

B. Personality common for student nurses and private duty nurses?
C. Charm
D. Character A. Total patient care
B. Team nursing
15. Refers to the moral values and beliefs that are C. Primary Nursing
used as guides to personal behavior and actions D. Case management

A. Philosophy 21. This is the best patient care model when there
B. Personality are many nurses but few patients.
C. Charm
D. Character A. Functional nursing
B. Team nursing
16. As a nurse manager, which of the following best C. Primary nursing
describes this function? D. Total patient care

A. Initiate modification on client’s lifestyle 22. This patient care model works best when there
B. Protect client’s right are plenty of patient but few nurses
C. Coordinates the activities of other members
of the health team in managing patient care A. Functional nursing
D. Provide in service education programs, Use B. Team nursing
accurate nursing audit, formulate philosophy C. Primary nursing
and vision of the institution D. Total patient care

17. What best describes nurses as a care provider? 23. RN assumes 24 hour responsibility for the client
to maintain continuity of care across shifts, days or
A. Determine client’s need visits.
B. Provide direct nursing care
A. Functional nursing
 B. Team nursing 30. Developed the ROLE MODELING and
C. Primary nursing MODELING theory
D. Total patient care
A. Erickson,Tomlin,Swain
24. Who developed the first theory of nursing? B. Neuman
C. Newman
A. Hammurabi D. Benner and Wrubel
B. Alexander
C. Fabiola 31. Proposed the GRAND THEORY OF
D. Nightingale NURSING AS CARING

25. She introduces the NATURE OF NURSING A. Erickson, Tomlin, Swain

MODEL. B. Peterson,Zderad
C. Bnner,Wrubel
A. Henderson D. Boykin,Schoenhofer
B. Nightingale
C. Parse 32. Postulated the INTERPERSONAL ASPECT
D. Orlando OF NURSING

26. She described the four conservation principle. A. Travelbee

B. Swanson
A. Levin C. Zderad
B. Leininger D. Peplau
C. Orlando
D. Parse 33. He proposed the theory of morality that is based
on MUTUAL TRUST
27. Proposed the HEALTH CARE SYSTEM
MODEL. A. Freud
B. Erikson
A. Henderson C. Kohlberg
B. Orem D. Peters
C. Parse
D. Neuman 34. He proposed the theory of morality based on
PRINCIPLES
28. Conceptualized the BEHAVIORAL SYSTEM
MODEL A. Freud
B. Erikson
A. Orem C. Kohlberg
B. Johnson D. Peters
C. Henderson
D. Parse 35. Freud postulated that child adopts parental
standards and traits through
29. Developed the CLINICAL NURSING – A
HELPING ART MODEL A. Imitation
B. Introjection
A. Swanson C. Identification
B. Hall D. Regression
C. Weidenbach
D. Zderad 36. According to them, Morality is measured of
how people treat human being and that a moral
child strives to be kind and just
 A. Zderad and Peterson 42. She dies of yellow fever in her search for truth
B. Benner and Wrubel to prove that yellow fever is carried by a
C. Fowler and Westerhoff mosquitoes.
D. Schulman and Mekler
A. Clara louise Maas
37. Postulated that FAITH is the way of behaving. B. Pearl Tucker
He developed four theories of faith and C. Isabel Hampton Robb
development based on his experience. D. Caroline Hampton Robb

A. Giligan 43. He was called the father of sanitation.

B. Westerhoff
C. Fowler A. Abraham
D. Freud B. Hippocrates
C. Moses
38. He described the development of faith. He D. Willam Halstead
suggested that faith is a spiritual dimension that
gives meaning to a persons life. Faith according to 44. The country where SHUSHURUTU originated
him, is a relational phenomenon.
A. China
A. Giligan B. Egypt
B. Westerhoff C. India
C. Fowler D. Babylonia
D. Freud
45. They put girls clothes on male infants to drive
39. Established in 1906 by the Baptist foreign evil forces away
mission society of America. Miss rose nicolet, was
it’s first superintendent. A. Chinese
B. Egyptian
A. St. Paul Hospital School of nursing C. Indian
B. Iloilo Mission Hospital School of nursing D. Babylonian
C. Philippine General Hospital School of
nursing 46. In what period of nursing does people believe in
D. St. Luke’s Hospital School of nursing TREPHINING to drive evil forces away?

40. Anastacia Giron-Tupas was the first Filipino A. Dark period

nurse to occupy the position of chief nurse in this B. Intuitive period
hospital. C. Contemporary period
D. Educative period
A. St. Paul Hospital
B. Iloilo Mission Hospital 47. This period ended when Pastor Fliedner, build
C. Philippine General Hospital Kaiserwerth institute for the training of
D. St. Luke’s Hospital Deaconesses

41. She was the daughter of Hungarian kings, who A. Apprentice period
feed 300-900 people everyday in their gate, builds B. Dark period
hospitals, and care of the poor and sick herself. C. Contemporary period
D. Educative period
A. Elizabeth
B. Catherine 48. Period of nursing where religious Christian
C. Nightingale orders emerged to take care of the sick
D. Sairey Gamp
 A. Apprentice period B. Rogers
B. Dark period C. Henderson
C. Contemporary period D. Johnson
D. Educative period
55. She theorized that man is composed of sub and
49. Founded the second order of St. Francis of supra systems. Subsystems are cells, tissues, organs
Assisi and systems while the suprasystems are family,
society and community.
A. St. Catherine
B. St. Anne A. Roy
C. St. Clare B. Rogers
D. St. Elizabeth C. Henderson
D. Johnson
50. This period marked the religious upheaval of
Luther, Who questions the Christian faith. 56. Which of the following is not true about the
human needs?
A. Apprentice period
B. Dark period A. Certain needs are common to all people
C. Contemporary period B. Needs should be followed exactly in
D. Educative period accordance with their hierarchy
C. Needs are stimulated by internal factors
51. According to the Biopsychosocial and spiritual D. Needs are stimulated by external factors
theory of Sister Callista Roy, Man, As a SOCIAL
being is 57. Which of the following is TRUE about the
human needs?
A. Like all other men
B. Like some other men A. May not be deferred
C. Like no other men B. Are not interrelated
D. Like men C. Met in exact and rigid way
D. Priorities are alterable
52. She conceptualized that man, as an Open system
is in constant interaction and transaction with a 58. According to Maslow, which of the following is
changing environment. NOT TRUE about a self actualized person?

A. Roy A. Understands poetry, music, philosophy,

B. Levin science etc.
C. Neuman B. Desires privacy, autonomous
D. Newman C. Follows the decision of the majority, uphold
justice and truth
53. In a CLOSED system, which of the following is D. Problem centered
true?
59. According to Maslow, which of the following is
A. Affected by matter TRUE about a self actualized person?
B. A sole island in vast ocean
C. Allows input A. Makes decision contrary to public opinion
D. Constantly affected by matter, energy, B. Do not predict events
information C. Self centered
D. Maximum degree of self conflict
54. Who postulated the WHOLISTIC concept that
the totality is greater than sum of its parts? 60. This is the essence of mental health

A. Roy A. Self awareness

 B. Self actualization 67. Which of the following provides that nurses
C. Self esteem must be a member of a national nurse organization?
D. Self worth
A. R.A 877
61. Florence nightingale is born in B. 1981 Code of ethics approved by the house
of delegates and the PNA
A. Germany C. Board resolution No. 1955 Promulgated by
B. Britain the BON
C. France D. RA 7164
D. Italy
68. Which of the following best describes the action
62. Which is unlikely of Florence Nightingale? of a nurse who documents her nursing diagnosis?

A. Born May 12, 1840 A. She documents it and charts it whenever

B. Built St. Thomas school of nursing when she necessary
was 40 years old B. She can be accused of malpractice
C. Notes in nursing C. She does it regularly as an important
D. Notes in hospital responsibility
D. She charts it only when the patient is acutely
63. What country did Florence Nightingale train in ill
nursing?
69. Which of the following does not govern nursing
A. Belgium practice?
B. US
C. Germany A. RA 7164
D. England B. RA 9173
C. BON Res. Code Of Ethics
64. Which of the following is recognized for D. BON Res. Scope of Nursing Practice
developing the concept of HIGH LEVEL
WELLNESS? 70. A nurse who is maintaining a private clinic in
the community renders service on maternal and
A. Erikson child health among the neighborhood for a fee is:
B. Madaw
C. Peplau A. Primary care nurse
D. Dunn B. Independent nurse practitioner
C. Nurse-Midwife
65. One of the expectations is for nurses to join D. Nurse specialist
professional association primarily because of
71. When was the PNA founded?
A. Promotes advancement and professional
growth among its members A. September 22, 1922
B. Works for raising funds for nurse’s benefit B. September 02, 1920
C. Facilitate and establishes acquaintances C. October 21, 1922
D. Assist them and securing jobs abroad D. September 02, 1922

66. Founder of the PNA 72. Who was the first president of the PNA ?

A. Julita Sotejo A. Anastacia Giron-Tupas

B. Anastacia Giron Tupas B. Loreto Tupas
C. Eufemia Octaviano C. Rosario Montenegro
D. Anesia Dionisio D. Ricarda Mendoza
73. Defines health as the ability to maintain internal 79. According to her, Wellness is a condition in
milieu. Illness according to him/her/them is the which all parts and subparts of an individual are in
failure to maintain internal environment. harmony with the whole system.

A. Cannon A. Orem
B. Bernard B. Henderson
C. Leddy and Pepper C. Neuman
D. Roy D. Johnson

74. Postulated that health is a state and process of 80. Postulated that health is reflected by the
being and becoming an integrated and whole organization, interaction, interdependence and
person. integration of the subsystem of the behavioral
system.
A. Cannon
B. Bernard A. Orem
C. Dunn B. Henderson
D. Roy C. Neuman
D. Johnson
75. What regulates HOMEOSTASIS according to
the theory of Walter Cannon? 81. According to them, Well being is a subjective
perception of BALANCE, HARMONY and
A. Positive feedback VITALITY
B. Negative feedback
C. Buffer system A. Leavell and Clark
D. Various mechanisms B. Peterson and Zderad
C. Benner and Wruber
76. Stated that health is WELLNESS. A termed D. Leddy and Pepper
define by the culture or an individual.
82. He describes the WELLNESS-ILLNESS
A. Roy Continuum as interaction of the environment with
B. Henderson well being and illness.
C. Rogers
D. King A. Cannon
B. Bernard
77. Defined health as a dynamic state in the life C. Dunn
cycle, and Illness as interference in the life cycle. D. Clark

A. Roy 83. An integrated method of functioning that is

B. Henderson oriented towards maximizing one’s potential within
C. Rogers the limitation of the environment.
D. King
A. Well being
78. She defined health as the soundness and B. Health
wholness of developed human structure and bodily C. Low level Wellness
mental functioning. D. High level Wellness

A. Orem 84. What kind of illness precursor, according to

B. Henderson DUNN is cigarette smoking?
C. Neuman
D. Clark A. Heredity
B. Social
C. Behavioral
 D. Environmental 91. Knowledge about the disease and prior contact
with it is what type of VARIABLE according to the
85. According to DUNN, Overcrowding is what health belief model?
type of illness precursor?
A. Demographic
A. Heredity B. Sociopsychologic
B. Social C. Structural
C. Behavioral D. Cues to action
D. Environmental
92. It includes internal and external factors that
86. Health belief model was formulated in 1975 by leads the individual to seek help
who?
A. Demographic
A. Becker B. Sociopsychologic
B. Smith C. Structural
C. Dunn D. Cues to action
D. Leavell and Clark
93. Influence from peers and social pressure is
87. In health belief model, Individual perception included in what variable of HBM?
matters. Which of the following is highly
UNLIKELY to influence preventive behavior? A. Demographic
B. Sociopsychologic
A. Perceived susceptibility to an illness C. Structural
B. Perceived seriousness of an illness D. Cues to action
C. Perceived threat of an illness
D. Perceived curability of an illness 94. Age, Sex, Race etc. is included in what variable
of HBM?
88. Which of the following is not a PERCEIVED
BARRIER in preventive action? A. Demographic
B. Sociopsychologic
A. Difficulty adhering to the lifestyle C. Structural
B. Economic factors D. Cues to action
C. Accessibility of health care facilities
D. Increase adherence to medical therapies 95. According to Leavell and Clark’s ecologic
model, All of this are factors that affects health and
89. Conceptualizes that health is a condition of illness except
actualization or realization of person’s potential.
Avers that the highest aspiration of people is A. Reservoir
fulfillment and complete development actualization. B. Agent
C. Environment
A. Clinical Model D. Host
B. Role performance Model
C. Adaptive Model 96. Is a multi dimensional model developed by
D. Eudaemonistic Model PENDER that describes the nature of persons as
they interact within the environment to pursue
90. Views people as physiologic system and health
Absence of sign and symptoms equates health.
A. Ecologic Model
A. Clinical Model B. Health Belief Model
B. Role performance Model C. Health Promotion Model
C. Adaptive Model D. Health Prevention Model
D. Eudaemonistic Model
97. Defined by Pender as all activities directed would facilitate the person’s reparative
toward increasing the level of well being and self process and identified different factors like
actualization. sanitation, noise, etc. that affects a person’s
reparative state.
A. Health prevention 2.  A. Nightingale. Florence nightingale do not
B. Health promotion believe in the germ theory, and perhaps this
C. Health teaching was her biggest mistake. Yet, her theory was
D. Self actualization the first in nursing. She believed that
manipulation of environment that includes
98. Defined as an alteration in normal function appropriate noise, nutrition, hygiene, light,
resulting in reduction of capacities and shortening comfort, sanitation etc. could provide the
of life span. client’s body the nurturance it needs for
repair and recovery.
A. Illness 3.  C. Roy. Remember the word “
B. Disease THEOROYTICAL “ For Callista Roy,
C. Health Nursing is a theoretical body of knowledge
D. Wellness that prescribes analysis and action to care
for an ill person. She introduced the
99. Personal state in which a person feels unhealthy ADAPTATION MODEL and viewed person
as a BIOSPSYCHOSOCIAL BEING. She
A. Illness believed that by adaptation, Man can
B. Disease maintain homeostasis.
C. Health 4. B. Orem. In self care deficit theory, Nursing
D. Wellness is defined as A helping or assistive
profession to person who are wholly or
100. According to her, Caring is defined as a partly dependent or when people who are to
nurturant way of responding to a valued client give care to them are no longer available.
towards whom the nurse feels a sense of Self care, are the activities that a person do
commitment and responsibility. for himself to maintain health, life and well
being.
A. Benner 5. A. Neuman. Neuman divided stressors as
B. Watson either intra, inter and extra personal in
C. Leininger nature. She said that NURSING is
D. Swanson concerned with eliminating these stressors to
obtain a maximum level of wellness. The
Answers and Rationales nurse helps the client through PRIMARY,
SECONDARY AND TERTIARY
1. D. Person, Environment, Nursing, prevention modes. Please do not confuse
Health. This is an actual board exam this with LEAVELL and CLARK’S level of
question and is a common board question. prevention.
Theorist always describes The nursing 6. A. Henderson. This was an actual board
profession by first defining what is question. Remember this definition and
NURSING, followed by the PERSON, associate it with Virginia Henderson.
ENVIRONMENT and HEALTH Henderson also describes the NATURE OF
CONCEPT. The most popular theory was NURSING theory. She identified 14 basic
perhaps Nightingale’s. She defined nursing needs of the client. She describes nursing
as the utilization of the persons environment roles as SUBSTITUTIVE : Doing
to assist him towards recovery. She defined everything for the client,
the person as somebody who has a SUPPLEMENTARY : Helping the client
reparative capabilities mediated and and COMPLEMENTARY : Working with
enhanced by factors in his environment. She the client. Breathing normally, Eliminating
describes the environment as something that waste, Eating and drinking adquately,
 Worship and Play are some of the basic 13. C. Caring. Caring and caring alone, is the
needs according to her. most unique quality of the Nursing
7. C. Leininger. There are many theorist that Profession. It is the one the delineate
describes nursing as CARE. The most Nursing from other professions.
popular was JEAN WATSON’S Human 14. B. Personality. Personality are qualities that
Caring Model. But this question pertains to make us different from each other. These are
Leininger’s definition of caring. CUD I LIE impressions that we made, or the footprints
IN GER? [ Could I Lie In There ] Is the that we leave behind. This is the result of the
Mnemonics I am using not to get confused. integration of one’s talents, behavior,
C stands for CENTRAL , U stands for appearance, mood, character, morals and
UNIFYING, D stands for DOMINANT impulses into one harmonious whole.
DOMAIN. I emphasize on this matter due to Philosophy is the basic truth that fuel our
feedback on the last June 2006 batch about a soul and give our life a purpose, it shapes
question about CARING. the facets of a person’s character. Charm is
8. D. Swanson . Caring according to Swanson to attract other people to be a change agent.
involves 5 processes. Knowing means Character is our moral values and belief that
understanding the client. Being with guides our actions in life.
emphasizes the Physical presence of the 15. D. Character.Rationale: Refer to number
nurse for the patient. Doing for means doing 14
things for the patient when he is incapable of 16. D. Provide in service education programs,
doing it for himself. Enabling means helping Use accurate nursing audit, formulate
client transcend maturational and philosophy and vision of the
developmental stressors in life while institution .  A refers to being a change
Maintaining belief is the ability of the Nurse agent. B is a role of a patient advocate. C is
to inculcate meaning to these events. a case manager while D basically
9. B. Watson. The deepest and spiritual summarized functions of a nurse manager. If
definition of Caring came from Jean watson. you haven’t read Lydia Venzon’s Book :
For her, Caring expands the limits of NURSING MANAGEMENT TOWARDS
openess and allows access to higher human QUALITY CARE, I suggest reading it in
spirit. advance for your management subjects in
10. A. Benner.  I think of CARE BEAR to the graduate school. Formulating philosophy
facilitate retainment of BENNER. As in, and vision is in PLANNING. Nursing Audit
Care Benner. For her, Caring means being is in CONTROLLING, In service education
CONNECTED or making things matter to programs are included in DIRECTING.
people. Caring according to Benner give These are the processes of Nursing
meaning to illness and re establish Management, I just forgot to add
connection. ORGANIZING which includes formulating
11. B. It serves specific interest of a an organizational structure and plans,
group.Believe it or not, you should know Staffing and developing qualifications and
the definition of profession according to job descriptions.
Jahoda because it is asked in the Local 17. A. Determine client’s need.You can never
boards. A profession should serve the provide nursing care if you don’t know what
WHOLE COMMUNITY and not just a are the needs of the client. How can you
specific intrest of a group. Everything else, provide an effective postural drainage if you
are correct. do not know where is the bulk of the client’s
12. A. Concerned with quantity. A secretion. Therefore, the best description of
professional is concerned with QUALITY a care provider is the accurate and prompt
and not QUANTITY. In nursing, We have determination of the client’s need to be able
methods of quality assurance and control to to render an appropriate nursing care.
evaluate the effectiveness of nursing care. 18. B. Client advocate. As a client’s advocate,
Nurses, are never concerned with Nurses are to protect the client’s right and
QUANTITY of care provided. promotes what is best for the client.
 Knowing that Morphine causes spasm of the from macedonia but he ruled Greece
sphincter of Oddi and will lead to further including Persia and Egypt. He is known to
increase in the client’s pain, The nurse knew use a hammer to pierce a dying soldier’s
that the best treatment option for the client medulla towards speedy death when he
was not provided and intervene to provide thinks that the soldier will die anyway, just
the best possible care. to relieve their suffering. Fabiola was a
19. C. Interdependent. Interdependent beautiful roman matron who converted her
functions are those that needs expertise and house into a hospital.
skills of multiple health professionals. 25. A. Henderson. Refer to question # 6.
Example is when A child was diagnosed 26. A. Levin. Myra Levin described the 4
with nephrotic syndrome and the doctor Conservation principles which are
ordered a high protein diet, Budek then work concerned with the Unity and Integrity of an
together with the dietician about the age individual. These are ENERGY : Our output
appropriate high protein foods that can be to facilitate meeting of our needs.
given to the child, Including the preparation STRUCTURAL INTEGRITY : We mus
to entice the child into eating the food. maintain the integrity of our organs, tissues
NOTE : It is still debated if the diet in NS is and systems to be able to function and
low, moderate or high protein, In the U.S, prevent harmful agents entering our body.
Protein is never restricted and can be taken PERSONAL INTEGRITY : These refers to
in moderate amount. As far as the local our self esteem, self worth, self concept,
examination is concerned, answer LOW identify and personality. SOCIAL
PROTEIN HIGH CALORIC DIET. INTEGRITY : Reflects our societal roles to
20. A. Total patient care. This is also known as our society, community, family, friends and
case nursing. It is a method of nursing care fellow individuals.
wherein, one nurse is assigned to one patient 27. D. Neuman . Betty Neuman asserted that
for the delivery of total care. These are the nursing is a unique profession and is
method use by Nursing students, Private concerned with all the variables affecting the
duty nurses and those in critical or isolation individual’s response to stressors. These are
units. INTRA or within ourselves, EXTRA or
21. D. Total patient care .Total patient care outside the individual, INTER means
works best if there are many nurses but few between two or more people. She proposed
patients. the HEALTH CARE SYSTEM MODEL
22. A. Functional nursing. Functional nursing which states that by PRIMARY,
is task oriented, One nurse is assigned on a SECONDARY and TERTIARY prevention,
particular task leading to task expertise and The nurse can help the client maintain
efficiency. The nurse will work fast because stability against these stressors.
the procedures are repetitive leading to task 28. B. Johnson. According to Dorothy Johnson,
mastery. This care is not recommended as Each person is a behavioral system that is
this leads fragmented nursing care. composed of 7 subsystems. Man adjust or
23. C. Primary nursing. Your keyword in adapt to stressors by a using a LEARNED
Primary nursing is the 24 hours. This does PATTERN OF RESPONSE. Man uses his
not necessarily means the nurse is awake for behavior to meet the demands of the
24 hours, She can have a SECONDARY environment, and is able to modified his
NURSES that will take care of the patient in behavior to support these demands.
shifts where she is not arround. 29. C. Weidenbach.Just remember
24. D. Nightingale .  Refer to question # 2. ERNESTINE WEIDENBACHLINICAL.
Hammurabi is the king of babylon that 30. A. Erickson,Tomlin,Swain
introduces the LEX TALIONES law, If you 31. D. Boykin,Schoenhofer . This theory was
kill me, you should be killed… If you rob called GRAND THEORY because boykin
me, You should be robbed, An eye for an and schoenofer thinks that ALL MAN ARE
eye and a tooth for a tooth. Alexander the CARING, And that nursing is a response to
great was the son of King Philip II and is this unique call. According to them,
 CARING IS A MORAL IMPERATIVE, morality has 3 components : EMOTION or
meaning, ALL PEOPLE will tend to help a how one feels, JUDGEMENT or how one
man who fell down the stairs even if he is reason and BEHAVIOR or how one actuates
not trained to do so. his EMOTION and JUDGEMENT. He
32. A. Travelbee. Travelbee’s theory was believes that MORALITY evolves with the
referred to as INTERPERSONAL theory development of PRINCPLES or the person’s
because she postulated that NURSING is to vitrue and traits. He also believes in
assist the individual and all people that AUTOMATICITY of virtues or he calls
affects this individual to cope with illness, HABIT, like kindness, charity, honesty,
recover and FIND MEANING to this sincerity and thirft which are innate to a
experience. For her, Nursing is a HUMAN person and therfore, will be performed
TO HUMAN relationship that is formed automatically.
during illness. To her, an individual is a 35. C. Identification. A child, according to
UNIQUE and irreplaceable being in Freud adopts parental standards, traits,
continuous process of becoming, evolving habits and norms through identication. A
and changing. PLEASE do remember, that it good example is the corned beef commercial
is PARSE who postulated the theory of ” WALK LIKE A MAN, TALK LIKE A
HUMAN BECOMING and not MAN ” Where the child identifies with his
TRAVELBEE, for I read books that say it father by wearing the same clothes and
was TRAVELBEE and not PARSE. doing the same thing.
33. C. Kohlberg. Kohlber states that 36. D. Schulman and Mekler . According to
relationships are based on mutual trust. He Schulman and Mekler, there are 2
postulated the levels of morality components that makes an action MORAL :
development. At the first stage called the The intention should be good and the Act
PREMORAL or preconventional, A child do must be just. A good example is ROBIN
things and label them as BAD or GOOD HOOD, His intention is GOOD but the act is
depending on the PUNISHMENT or UNJUST, which makes his action
REWARD they get. They have no concept IMMORAL.
of justice, fairness and equity, for them, If I 37. B. Westerhoff. There are only 2 theorist of
punch this kid and mom gets mad, thats FAITH that might be asked in the board
WRONG. But if I dance and sing, mama examinations. Fowler and Westerhoff. What
smiles and give me a new toy, then I am differs them is that, FAITH of fowler is
doing something good. In the Conventional defined abstractly, Fowler defines faith as a
level, The individual actuates his act based FORCE that gives a meaning to a person’s
on the response of the people around him. life while Westerhoff defines faith as a
He will follow the rules, regulations, laws behavior that continuously develops through
and morality the society upholds. If the law time.
states that I should not resuscitate this man 38. C. Fowler. Rationale: Refer to # 37
with a DNR order, then I would not. 39. B. Iloilo Mission Hospital School of
However, in the Post conventional level or nursing
the AUTONOMOUS level, the individual 40. C. Philippine General Hospital
still follows the rules but can make a rule or 41. A. Elizabeth.Saint Elizabeth of Hungary
bend part of these rules according to his own was a daughter of a King and is the patron
MORALITY. He can change the rules if he saint of nurses. She build hospitals and feed
thinks that it is needed to be changed. hungry people everyday using the
Example is that, A nurse still continue kingdom’s money. She is a princess, but
resuscitating the client even if the client has devoted her life in feeding the hungry and
a DNR order because he believes that the serving the sick.
client can still recover and his mission is to 42. A. Clara louise Maas. Clara Louise Maas
save lives, not watch patients die. sacrificed her life in research of YELLOW
34. D. Peters . Remember PETERS for FEVER. People during her time do not
PRINCIPLES. P is to P. He believes that believe that yellow fever was brought by
 mosquitoes. To prove that they are wrong, being, No man thinks alike. This basically
She allowed herself to be bitten by the summarized her BIOPSYHOSOCIAL
vector and after days, She died. theory which is included in our licensure
43. C. Moses exam coverage.
44. C. India 52. A. Roy. OPEN system theory is ROY. As an
45. A. Chinese. Chinese believes that male open system, man continuously allows input
newborns are demon magnets. To fool those from the environment. Example is when you
demons, they put female clothes to their tell me Im good looking, I will be happy the
male newborn. entire day, Because I am an open system and
46. B. Intuitive period.Egyptians believe that a continuously interact and transact with my
sick person is someone with an evil force or environment. A close system is best
demon that is inside their heads. To release exemplified by a CANDLE. When you
these evil spirits, They would tend to drill cover the candle with a glass, it will die
holes on the patient’s skull and it is called because it will eventually use all the oxygen
TREPHINING. it needs inside the glass for combustion. A
47. A. Apprentice period.What dilineates closed system do not allow inputs and
apprentice period among others is that, it output in its environment.
ENDED when formal schools were 53. B. A sole island in vast ocean
established. During the apprentice period, 54. B. Rogers. The wholistic theory by Martha
There is no formal educational institution for Rogers states that MAN is greater than the
nurses. Most of them receive training inside sum of all its parts and that his dignity and
the convent or church. Some of them are worth will not be lessen even if one of this
trained just for the purpose of nursing the part is missing. A good example is ANNE
wounded soldiers. But almost all of them are BOLEYN, The mother of Queen Elizabeth
influenced by the christian faith to serve and and the wife of King Henry VIII. She was
nurse the sick. When Fliedner build the first beheaded because Henry wants to mary
formal school for nurses, It marked the end another wife and that his divorce was not
of the APPRENTICESHIP period. approved by the pope. Outraged, He insisted
48. A. Apprentice period. Apprentice period is on the separation of the Church and State
marked by the emergence of religious orders and divorce Anne himself by making
the are devoted to religious life and the everyone believe that Anne is having an
practice of nursing. affair to another man. Anne was beheaded
49. C. St. Clare. The poor clares, is the second while her lips is still saying a prayer. Even
order of St. Francis of assisi. The first order without her head, People still gave respect to
was founded by St. Francis himself. St. her diseased body and a separate head. She
Catherine of Siena was the first lady with was still remembered as Anne boleyn,
the lamp. St. Anne is the mother of mama Mother of Elizabeth who lead england to
mary. St. Elizabeth is the patron saint of their GOLDEN AGE.
Nursing. 55. B. Rogers. According to Martha Rogers,
50. B. Dark period. Protestantism emerged Man is composed of 2 systems : SUB which
with Martin Luther questions the Pope and includes cells, tissues, organs and system
Christianity. This started the Dark period of and SUPRA which includes our famly,
nursing when the christian faith was community and society. She stated that
smeared by controversies. These leads to when any of these systems are affected, it
closure of some hospital and schools run by will affect the entire individual.
the church. Nursing became the work of 56. B. Needs should be followed exactly in
prostitutes, slaves, mother and least accordance with their hierarchy.Needs
desirable of women. can be deferred. I can urinate later as not to
51. B. Like some other men.According to miss the part of the movie’s climax. I can
ROY, Man as a social being is like some save my money that are supposedly for my
other man. As a spiritual being and Biologic lunch to watch my idols in concert. The
being, Man are all alike. As a psychologic physiologic needs can be meet later for
 some other needs and need not be strictly and Illness is the failure to maintain the
followed according to their hierarchy. internal environment.
57. D. Priorities are alterable. Refer to 74. D. Roy. According to ROY, Health is a state
question # 56. and process of becoming a WHOLE AND
58. C. Follows the decision of the majority, INTEGRATED Person.
uphold justice and truth. A,B and D are all 75. B. Negative feedback. The theory of Health
qualities of a self actualized person. A self as the ability to maintain homeostasis was
actualized person do not follow the decision postulated by Walter Cannon. According to
of majority but is self directed and can make him, There are certain FEEDBACK
decisions contrary to a popular opinion. Mechanism that regulates our Homeostasis.
59. A. Makes decision contrary to public A good example is that when we overuse
opinion. Refer to question # 58. our arm, it will produce pain. PAIN is a
60. B. Self actualization. The peak of maslow’s negative feedback that signals us that our
hierarchy is the essence of mental health. arm needs a rest.
61. D. Italy. Florence Nightingale was born in 76. C. Rogers. Martha Rogers states that
Florence, Italy, May 12, 1820. Studied in HEALTH is synonymous with WELLNESS
Germany and Practiced in England. and that HEALTH and WELLNESS is
62. A. Born May 12, 1840 subjective depending on the definition of
63. C. Germany one’s culture.
64. D. Dunn. According to Dunn, High level 77. D. King .Emogene King states that health is
wellness is the ability of an individual to a state in the life cycle and Illness is any
maximize his full potential with the interference on this cycle. I enjoyed the
limitations imposed by his environment. Movie LION KING and like what Mufasa
According to him, An individual can be said that they are all part of the CIRCLE OF
healthy or ill in both favorable and LIFE, or the Life cycle.
unfavorable environment. 78. A. Orem. Orem defined health as the
65. A. Promotes advancement and SOUNDNESS and WHOLENESS of
professional growth among its members developed human structure and of bodily
66. B. Anastacia Giron Tupas and mental functioning.
67. C. Board resolution No. 1955 79. C. Neuman. Neuman believe that man is
Promulgated by the BON.  This is an old composed of subparts and when this
board resolution. The new Board resolution subparts are in harmony with the whole
is No. 220 series of 2004 also known as the system, Wellness results. Please do not
Nursing Code Of ethics which states that confuse this with the SUB and SUPRA
[ SECTION 17, A ] A nurse should be a systems of martha rogers.
member of an accredited professional 80. D. Johnson . Once you see the phrase
organization which is the PNA. BEHAVIORAL SYSTEM, answer Dorothy
68. C. She does it regularly as an important Johnson.
responsibility 81. D. Leddy and Pepper .According to Leddy
69. A. RA 7164. 7164 is an old law. This is the and Pepper, Wellness is subjective and
1991 Nursing Law which was repealed by depends on an individuals perception of
the newer 9173. balance, harmony and vitality. Leavell and
70. B. Independent nurse practitioner Clark postulared the ecologic model of
71. D. September 02, 1922.  According to the health and illness or the AGENT-HOST-
official PNA website, they are founded ENVIRONMENT model. Peterson and
September 02, 1922. Zderad developed the HUMANISTIC
72. C. Rosario Montenegro. Anastacia Giron NURSING PRACTICE theory while Benner
Tupas founded the FNA, the former name of and Wruber postulate the PRIMACY OF
the PNA but the first President was Rosario CARING MODEL.
Montenegro. 82. C. Dunn
73. B. Bernard. According to Bernard, Health 83. D. High level Wellness
is the ability to maintain and Internal Milieu
84. C. Behavioral. Behavioral precursors 90. A. Clinical Model. Rationale: Refer to
includes smoking, alcoholism, high fat question # 89.
intake and other lifestyle choices. 91. C. Structural. Modifying variables in
Environmental factors involved poor Becker’s health belief model includes
sanitation and over crowding. Heridity DEMOGRAPHIC : Age, sex, race etc.
includes congenital and diseases acquired SOCIOPSYCHOLOGIC : Social and Peer
through the genes. There are no social influence. STRUCTURAL : Knowledge
precursors according to DUNN. about the disease and prior contact with it
85. D. Environmental and CUES TO ACTION : Which are the
86. A. Becker. According to Becker, The belief sign and symptoms of the disease or advice
of an individual greatly affects his behavior. from friends, mass media and others that
If a man believes that he is susceptible to an forces or makes the individual seek help.
illness, He will alter his behavior in order to 92. D. Cues to action . Refer to question # 91.
prevent its occurence. For example, If a man 93. B. Sociopsychologic. Refer to question #
thinks that diabetes is acquired through high 91.
intake of sugar and simple carbohydrates, 94. A. Demographic. Refer to question # 91.
then he will limit the intake of foods rich in 95. A. Reservoir. According to L&C’s Ecologic
these components. model, there are 3 factors that affect health
87. D. Perceived curability of an illness . If a and illness. These are the AGENT or the
man think he is susceptibe to a certain factor the leads to illness, either a bacteria or
disease, thinks that the disease is serious and an event in life. HOST are persons that may
it is a threat to his life and functions, he will or may not be affected by these agents.
use preventive behaviors to avoid the ENVIRONMENT are factors external to the
occurence of this threat. host that may or may not predispose him to
88. A. Difficulty adhering to the lifestyle the AGENT.
and B. Economic factors. Perceived 96. C. Health Promotion Model. Pender
barriers are those factors that affects the developed the concept of HEALTH
individual’s health preventive actions. Both PROMOTION MODEL which postulated
A and B can affect the individual’s ability to that an individual engages in health
prevent the occurence of diseases. C and D promotion activities to increase well being
are called Preventive Health Behaviors and attain self actualization. These includes
which enhances the individual’s preventive exercise, immunization, healthy lifestyle,
capabilities. good food, self responsibility and all other
89. D. Eudaemonistic Model . Smith factors that minimize if not totally eradicate
formulated 5 models of health. Clinical risks and threats of health.
model simply states that when people 97. B. Health promotion. Refer to question #
experience sign and symptoms, they would 96.
think that they are unhealthy therefore, 98. B. Disease. Disease are alteration in body
Health is the absence of clinical sign and functions resulting in reduction of
symptoms of a disease. Role performance capabilities or shortening of life span.
model states that when a person does his 99. A. Illness. Illness is something
role and activities without deficits, he is PERSONAL. Unlike disease, Illness are
healthy and the inability to perform usual personal state in which person feels
roles means that the person is ill. Adaptive unhealthy. An old person might think he is
Model states that if a person adapts well ILL but in fact, he is not due, to diminishing
with his environment, he is healthy and functions and capabilities, people might
maladaptation equates illness. think they are ILL. Disease however, is
Eudaemonistic Model of health according to something with tangible basis like lab
smith is the actualization of a person’s results, X ray films or clinical sign and
fullest potential. If a person functions symptoms.
optimally and develop self actualization, 100. B. Watson. This is Jean Watson’s
then, no doubt that person is healthy. definition of Nursing as caring. This was
 asked word per word last June 06′ NLE. environment.
Benner defines caring as something that C. Nursing is the science and practice that expands
matters to people. She postulated the adaptive abilities and enhances person and
responsibility created by Caring in nursing. environment transformation
She was also responsible for the PRIMACY D. Nursing care becomes necessary when client is
OF CARING MODEL. Leininger defind the unable to fulfill biological, psychological,
4 conservation principle while Swanson developmental, or social needs.
introduced the 5 processes of caring.
B. The role of nursing is to facilitate "the body's
reparative processes" by manipulating client's
environment.
Self-care deficit theory was proposed by:
A. Virginia Henderson Which of the following is NOT a concept related to
B. Betty Neuman Roy's Adaptation Model?
C. Imogene King A. Focal Stimuli
D. Dorothea Orem B. Cognator Subsystem
C. Role function
D. Dorothea Orem D. Flexible line of defense

Which theory defines nursing as the science and D. Flexible line of defense
practice that expands adaptive abilities and
enhances person and environment transformation? According to Roy's adapatation theory, which
A. Goal attainment theory subsystem responds through four cognitive
B. Henderson's definition of nursing responds through four cognitive-emotive channels
C. Roy's adaptation model (perceptual and information processing, learning,
D. Faye Glen Abdelah's theory judgment, and emotion)?

C. Roy's adaptation model A. Regulator Subsystem

Typology of twenty one Nursing problems were B. Cognator Subsystem

explained by:
A. Imogene King C. Physiologic Mode
B. Virginia Henderson's
C. Faye G. Abedellah D. Self Concept-Group Identity Mode
D. Lydia E. Hall
C. Faye G. Abedellah B. Cognator Subsystem

"Nursing is therapeutic interpersonal process". This The "humanistic science of nursing" was explained
definition was stated by: by:

A. Hildegard Peplau A. Rogers (1970)

B. Jean watson
C. Faye Glen Abdelah B. Ida Orlando (1960)
D. M. Rogers
C. Nightingale (1860)
A. Hildegard Peplau
D. Neuman (1972)
Which of the following statements is related to
Florence Nightingale? A. Rogers (1970)
A. Nursing is therapeutic interpersonal process.
B. The role of nursing is to facilitate "the body's Imogene King's "goal attainment theory" is a type
reparative processes" by manipulating client's of:
 Which is NOT a concept explained in Dorothy
A. Need theories Johnson's Behavioral Systems Model?

B. Interaction theories A. Affiliation

C. Outcome theories B. Dependency

D. Humanistic theories C. Achievement

B. Interaction theories D. Energy fields

Which of the following theory has used "General D. Energy fields

Systems Theory" as a framework for its
development? According to Rogers' theory "continuous and
mutual interaction between man and environment' is
A. Florence Nightingale's Environment Theory termed as:

B. Hildegard E. Peplau's Psychodynamic Nursing A. Pattern

Theory
B. Integrality
C. Martha E.Roger's: Science of Unitary Human
Beings C. Resonancy

D. Neuman's model D. Helicy

D. Neuman's model
B. Integrality
Transcultural Model of Nursing was proposed by:
Watson's carative factors include all the following,
A. Joyce Travelbee EXCEPT:

B. Rosemarie Rizzo Parse A. Forming humanistic-altruistic value system

C. Madeleine Leininger B. Instilling faith-hope

D. Ida Jean Orlando C. Cultivating sensitivity to self and others

C. Madeleine Leininger D. Strengthening flexible lines of defense

According to Neuman Systems Model, the increase D. Strengthening flexible lines of defense
in energy that occurs in relation to the degree of
reaction to the stressor is termed as: Statements that explain the relationship between the
concepts in a theory:
A. Reconstitution
A. Propositions
B. Lines of resistance
B. Assumptions
C. Primary prevention
C. Predictions
D. Secondary Prevention
D. Process
A. Reconstitution
A. Propositions
"Social inclusion, intimacy and the formation and Meaning, Rhythmicity, Cotranscendence are the
attachment of a strong social bond" are explained in three major concepts of:
which subsystem of Jhonson's model -
A. Transcultural Nursing Theory
A. Dependency subsystem
B. Unitary Human Being Theory
B. Attachment or affiliative subsystem
C. Self-care Deficit Theory
C. Achievement subsystem
D. Human Becoming Theory
D. Aggressive subsystem
D. Human Becoming Theory
B. Attachment or affiliative subsystem
the major concepts of Health Belief Model includes Caring consists of carative factors that result in the
all, EXCEPT; satisfaction of certain human needs". This
explanation was stated by:
A. Perceived Susceptibility
A. Sister Calista Roy,
B. Perceived severity
B. Jean Watson
C. Perceived benefits
C. Dorothea Orem
D. Perceived interaction
D. Florence Nightingale
D. Perceived interaction
B. Jean Watson
The sequential phases of interpersonal relationship
in Peplau's theory includes all, EXCEPT: The term which refers the "irreducible, pan
dimensional energy field identified by pattern and
A. Orientation integral with the human field" is:

B. Identification A. Unitary Human Being

C. Restoration B. Environment

D. Exploitation C. Health

C. Restoration D. Nursing

Who explained about "Care, Cure and Core as three B. Environment

independent but interconnected circles of the
nursing model"? Who described about 5 levels of nursing experience
from novice to expert?
A. Patricia Benner
A. Patricia E. Benner
B. Rosemary Rizzo Parse
B. Ernestine Wiedenbach
C. Lydia Hall
C. Myra Estrine Levine
D. Jean Watson
D. Faye Glenn Abdellah
C. Lydia Hall
A. Patricia E. Benner D. Interdependence

When applying Roy's Adaptation Model in caring a E. Achievement

patient, the type of stimuli which needs to be
assessed as per are all the following, EXCEPT; E. Achievement

A. Focal Stimulus Concept related to Betty Neuman's System Model

of Nursing is:
B. Contextual Stimulus
A. Pattern
C. Perceptual Stimulua
B. Rhythmicity
D. Residual Stimulus
C. Dependency
C. Perceptual Stimulua
D. Open system
Which nursing theory states that 'nursing is the
interpersonal process of action, reaction, interaction D. Open system
and transaction"?
"Each human being perceives the world as a total
A. Roy's adaptation model person in making transactions with individuals and
things in environment".
B. Self-care deficit theory
This assumption is stated by:
C. Imogene King's theory
A. Neuman's system model
D. Roger's unitary human beings
B. Nightingale's theory
C. Imogene King's theory
C. Peplau's Interpersonal Relations model
Which of the following in NOT a concept related to
personal system in Imogene King's Theory? D. Imogene King's conceptual framework

A. Perception D. Imogene King's conceptual framework

B. Self Deliberative Nursing Process Theory was explained

by:
C. Body image
A. Hildegard Peplau
D. Organization
B. Dorothea Orem
D. Organization
C. Ida Jean Orlando
According to Roy's Adaptation Model, the adaptive
modes includes all the following, EXCEPT: D. Patricia Benner

A. Physiologic Needs C. Ida Jean Orlando

According to Peplau's interpersonal model, during
B. Self Concept which phase of nursing process, the patient
participates in goal setting and has a feeling of
C. Role Function belonging and selectively responds to those who
can meet his or her needs?
 Ethnonursing research method was developed by:
A. Orientation
A. Madeleine Leininger
B. Identification
B. Florence Nightingale
C. Exploitation
C. Hildegard Peplau
D. Resolution
D. Ida Jean Orlando
B. Identification
A. Madeleine Leininger
Metaphysics is a branch of philosophy which deals
with : Attachment theory was originally proposed by:
A. The study of valid argument forms
A. Hildegard Peplau
B. Theory of knowledge
B. John Bowlby
C. Moral philosophy
C. Sigmond Frued
D. The study of the nature of reality
D. Kurt Lewin
D. The study of the nature of reality
. B. John Bowlby

Which nursing theorist defines environment as "the Who described 5 levels of nursing experience in her
totality of the internal and external forces which theory on nursing?
surround a person and with which they interact at
any given time"? A. B. F. Skinner

A. Dorothy Johnson B. Patricia Benner

B. Martha Rogers C. Callista Roy

C. Dorothea Orem D. Leon Festinger

D. Imogene King B. Patricia Benner

E. Betty Neuman A paradigm refers to

E. Betty Neuman A. A model that explains the linkages of science,

philosophy, and theory accepted and applied by the
The Sunrise Model of nursing was developed by: discipline

A. Joyce Travelbee B. Ideas and mental images that help to describe

phenomena
B. Rosemarie Rizzo Parse
C. Statements that describe concepts
C. Madeleine Leininger
D. Aspect of reality that can be consciously sensed
D. Ida Jean Orlando or experienced

C. Madeleine Leininger
A. A model that explains the linkages of science, What is the normal findings in measuring the thorax in
philosophy, and theory accepted and applied by the anteroposterior to transverse diameter ratio?
discipline
a. 1:1
b. 1-2
According to Behavior System Model,
c. 2:1
"predisposition to act with reference to the goal, in d. 2.2
certain ways rather than the other ways" refers to
Rationale: Chest movement should be symmetrical on
A. Drive inspiration and expiration. Observe the
anterior-posterior diameter of the patient's chest and
B. Goal compare to the transverse diameter. The expected
anteroposterior-transverse ratio should be 1:2.
C. Set

D. Scope of action It is an inadequate circulatory blood volume either

caused by fluid deficit or hemorrhage
C. Set
a. Pulmonary embolism
B. Hypovolemia
The study of feedback and derived concepts such as c. Thrombus
communication and control in living organisms, d bleeding
machines and organisations is termed as:
Assessing the peripheral vascular system: In a capillary
A. Cybernetics refill test. The nurse should expect a normal peripheral
perfusion assessment if the color of the nail after
B. Ontology pressing returns in?

C. Epistemology a. 22 seconds
b. 3- 4 seconds
c. 2-3 seconds
D. Philosophy d. 35 seconds

A. Cybernetics What are the steps in assessing the thorax?

a. Inspection, Palpation, Percussion, Auscultation
Nursing is defined as "action which assist b. Inspection. Auscultation, Percussion. Palpation
individuals, families and groups to maintain a c. Inspection, Percussion, Palpation, Auscultation
maximum level of wellness, and the primary aim is d. Percussion, Auscultation, Percussion, Inspection
stability of the patient/client system, through
nursing interventions to reduce stressors.'' Rationale: Thorough evaluation of the thorax and lungs
is an essential component of a complete physical
examination. The traditional systematic approach
This definition is given by:
involves inspection, followed by palpation, percussion
and then auscultation of both the anterior, lateral, and
A. Orem posterior thorax.

B. Peplau 41. The nurse is performing health assessment of the

abdomen is the correct order to perform
C. Neuman the asseessment?

D. Rogers A.Auscultate, percuss, palpate, inspect

B. Palpate, percuss, auscultate, inspect
C. Neuman C Inspect, auscultate, palpate, percuss
D. Inspect, auscultate, percuss, palpate
42. The nurse is performing a health assessment and 48. The nurse is assessing a female's breasts. The nurse
notes a yellow tinge to the sclera of the finds both breasts rounded, slightly
eye. The nurse would document this as which of the unequal in size, skin smooth and intact, and nipples
following? without discharge. What is the nurse's next
action?
A. Cyanosis
B. Pallor A. Document the findings in the nurse's notes as
C. Jaundice abnormal.
D. Erythema B. Document the findings in the nurse's notes as normal.
C. Notify the physician.
43. While performing an assessment of the D. Notify the charge nurse
integumentary system, the nurse notes the client's
eyeballs are protruding and the upper eyelids are 49. The nurse is preparing a client for an abdominal
elevated. What term would the nurse use to examination. Which of the following should
document this finding? be performed before the examination?
A. Assess vital signs.
A. Erythema B. Ask client to urinate.
B. Cyanosis C. Ask client to drink 8 ounces of water.
C. Normocephalic D. Assess heart rate
D. Exophthalmos
50. The nurse is performing a musculoskeletal
44. The nurse is preparing for morning rounds. Which of assessment on a client admitted with a possible
the following may not be delegated to stroke. When testing for muscle grip strength, the nurse
the nursing assistant? should ask the client to:
A.Skull and face assessment
B. Ambulate surgical clients A.Grasp the nurse's index and middle fingers while the
C. Vital signs nurse tries to pull the fingers out.
D. Fill water pitcher B. Flex each arm and then try to extend it against the
nurse's attempt to keep the arm in flexion.
45. The nurse is performing a lung assessment on a C. Shrug the shoulders against the resistance of the
client with suspected pneumonia. Which of nurse's hands.
the following assessments should the nurse report to the D. Hold an arm up and resist while the nurse tries to
physician immediately? push it down.

A. Breath sounds equal bilaterally 51. Many Paner, Level 2 student is assigned to take the
B. Chest symmetrical vital signs of a patient in Floor of SHH.
C. Asymmetric chest expansion Which of the following statement by the student
D. Bilateral symmetric vocal fremitus nurse shows understanding about temperature?

46. While performing a health assessment, in which A. Body temperature never changes during a 24 hour
position should the nurse place the client period.
for inspection of the jugular veins? B. Body temperature is constantly high
C. The highest body temperature occurs between 1:00
A. 15-degree angle and 4:00 AM
B. 30- to 45-degree angle D. The highest body temperature occurs later in the day
C. 90-degree angle around 6:00 pm
D. 60-degree angle
52. Is considered as the safest and most non invasive
47. The nurse is assessing peripheral pulses on a client method of temperature taking.
with suspected peripheral vascular
disease. Which of the following should the nurse report A.Axillary
to the physician immediately? B. Rectal
A.Thready pulses C. Oral
B. Full pulsations D. Temporal
C. Pulses equal bilaterally 53.Jomar, a 15-year-old patient was admitted and
D. Pulses present bilaterally diagnosed with dengue fever. The student
took his vital signs and the temperature was elevated.
She knows that the normal range of 59. After auscultating the abdomen, the nurse should
temperature is which of these? report which of the following to the primary
care provider?
A. 37 C
B. 36 C A.Bruit over the aorta
C. 36 C-37.5 C B. Absence of bowel sounds for 60 seconds
D. 35 C--36 C C. Continuous bowel sounds over the ileocecal valve
D. A completely irregular pattern of bowel sounds
54. A 2 year old client came to OPD for consultation,
due to on and off fever. What vital signs must the nurse 60. If unable to locate the client's popliteal pulse during
take first a routine examination, the nurse should
perform which of the following next?
A. Temperature
C. Respiratory rate A.Check for a pedal pulse.
B. Pulse rate B. Check for a femoral pulse.
D. Blood pressure C. Take the client's blood pressure on that thigh.
D. Ask another nurse to try to locate the pulse
55. Physical assessment entails touching some body
parts of the child, therefore anxiety is likely 61. Which of the following is an expected finding during
expected. in order to prevent or minimize anxiety, which assessment of the older adult?
of the following is helpful?
A. Facial hair becomes finer and softer.
A. Give her favorite food B. Decreased peripheral, color, and night vision.
B. Ask the favor from the mother to do the task when it C. Increased sensitivity to odors.
needs touch D. Respiratory rate and rhythm are irregular at rest.
C.Let the child see and touch the equipment before you
begin to use it. 62. If the client reports loss of short-term memory, the
D. Discontinue the examination if uncooperative nurse would assess this using which one
of the following?
56. During the nursing rounds the patient verbalized that
he feels hot. Which of the following A. Have the client repeat a series of three numbers,
signifies febrile values of vital signs? increasing to eight if possible.
B. Have the client describe his or her childhood
A. Temperature =37.8 C illnesses.
B. Temperature =37.4 C c. Ask the client to describe how he or she arrived at this
C. Respiratory rate =16 cpm location.
D. Respiratory rate = 21cpm D. Ask the client to count backwards from 100
subtracting seven each time.
57. Jericho, a clinical instructor share to his students that
intervention to perform if the patient is 63. The nurse will take the oral temperature of her client
febrile. Which of the following is NOT included in his who had a rectal surgery, but the client
teaching? had just eaten and drank. Which of the following action
should be done by the nurse?
A. Encourage drinking adequate fluids
B. Perform tepid sponge bath A. Do not take the temperature at all.
C. Elevate of head of bed B. Take the temperature rectally
D. Give medications as ordered C. Wait 15-30 minutes before taking an oral temperature
D. Take the temperature at 12 noon
58. Which of the following indicates a normal finding on
auscultation of the lungs? 64. A type of heat loss that occurs when heat is
dissipated by air currents.
A. Tympany over the right upper lobe A. Convection
B. Resonance over the left upper lobe B. Radiation
C. Hyperresonance over the left lower lobe C. Conduction
D. Dullness above the left 10th intercostal space D. Evaporation
 76. You know that pulse rate is just easy to take because
65. A process of heat loss which involves the transfer of no devices are used for it, if peripheral
heat from one surface to another Is. pulses are to be taken. Which pulse site the should not be
A. Convection palpated together in taking the pulse
B. Radiation fate?
C. Conduction
D. Evaporation A. Carotid
B. Radial
71. John has fever of 38.5 degrees Celsius. It surges at C. Popliteal
around 40 degrees Celsius and go back D. Brachial
to 38. 5 degrees Celsius 6 times today in a typical
pattern. What kind of fever does John have? 77. During a nursing assessment an adult client is noted
to have shallow respirations at a rate of
A. Intermittent 8 cycles per minute. His heart rate is 46 beats per
B. Remittent minute. His vital signs would be described as;
C. Relapsing
D. Constant A. Bradycardia and apnea
B. Tachycardia and apnea
72. Andrew's temperature 8 hours ago was normal, 36.5 C. Bradycardia and bradypnea
degrees Celsius, 4 hours ago his fever D. Tachycardia and bradypnea
was 38.9 degrees Celsius. Right now, his temp is back to
normal. Which of the following best 78. The difference between the systolic and diastolic is
describe the fever Andrew is having? termed as:
A. Apical pressure
A. Intermittent B. Cardiac pressure
B. Remittent C. Pulse pressure
C. Relapsing D. Pulse deficit
D. Constant
79. The nurse will perform physical assessment to
73. Two days ago, Mr. X had fever of 39.5 degrees a client. A systematic approach is followed
Celsius. But yesterday, he had a normal using the four techniques. He followed the head to toe
temperature of 36.5 degrees Celsius. Today, his approach, which is referred to as:
temperature surge to 40 degrees Celsius. What A. Cephalocaudal
type of fever does Mr. X have? B. Proximodistal
C. Mediolateral
A. Intermittent D. External to internal
B. Remittent
C. Relapsing During which part of the client interview would it
D. Constant be best for the nurse to ask, "What's the weather
forecast for today?"
74. Which of the following statement is TRUE about
pulse
A. Introduction
A. Children have higher pulse rate than adults.
B. In lying position, pulse rate is higher
B. Body
C. Fever does not affect pulse rate C. Closing
D. Radial pulse is the most reliable for infants and small D. Orientation
children
A. Introduction
75. The following are correct actions when taking radial
pulse Except. Rationale: Asking about the weather initiates the
A. Put the palms downward social or introductory phase of the interview and
b. Use the thumb to palpate the artery allows the nurse to begin an assessment of the
C. Use 2 to 3 fingers to palpate the pulses client's mental status. The goal is to develop rapport
D. Assess the pulse rhythm, rate and amplitude.
with the client at the beginning of the interview. In
the body the client responds to the nurse's questions.
During the closing the nurse or the client terminates A. The client has a hard, raised, red lesion on his
the interview. right hand.
B. A weight of 185 lbs. is recorded in the chart
The nurse is most likely to collect timely, specific C. The client reported an infected toe
information by asking which of the following D. The client's blood pressure is 124/70. It was
questions? 118/68 yesterday.

A. "Would you describe what you are feeling?" C. The client reported an infected tow
B. "How are you today?"
C. "What would you like to talk about?" Rationale: Validation is the process of confirming
D. "Where does it hurt?" that data are actual and factual. Data that can be
measured can be accepted as factual, as in options
A. "Would you describe what you are feeling?" 1, 3 and 4. The nurse should assess the client's toe
to validate the statement.
Rationale: This is an open-ended question that will
elicit subjective data. The data collected will reflect Which of the following items of subjective client
the client's current health status and human data would be documented in the medical record by
response(s) and should generate specific the nurse?
information that can be used to identify actual
and/or potential health problems. Options 2 and 3 A. Client's face is pale
are more likely to elicit general, nonspecific B. Cervical lymph nodes are palpable
information. Option 4 may result in a brief, one- C. Nursing assistant reports client refused lunch
word response or nonverbal gesture indicating the D. Client feel nauseated
site of the client's pain. A better approach to collect
specific information might be, "Describe any pain D. Client feel nauseated
you are having."
Rationale: Subjective data includes the client's
The nurse should avoid asking the client which of sensations, feelings, and perception of health status.
the following leading questions during a client Subjective data can only be verified by the affected
interview? person. Options 1, 2, and 3 represent objective data
that can be detected by the nurse or measured
A. "What medication do you take at home?" against an accepted norm.
B. "You are really excited about the plastic surgery,
aren't you?" A nurse explains to a student that the nursing
C. "Were you aware I've has this same type of process is a dynamic process. Which of the
surgery?" following actions by the nurse best demonstrates
D. "What would you like to talk about?" this concept during the work shift?

B. "You are really excited about the plastic surgery, A. Nurse and client agree upon health care goals for
aren't you?" the client
B. Nurse reviews the client's history on the medical
Rationale: A leading question directs the client's record
answer. The phrasing of the question indicates an C. Nurse explains to the client the purpose of each
expected answer. The client may be influenced by administered medication
the nurse's expectations and may give inaccurate D. Nurse rapidly reset priorities for client care
responses. This process can result in an error in based on a change in the client's condition
diagnostic reasoning.
D. Nurse rapidly reset priorities for client care
based on a change in the client's condition
The nurse needs to validate which of the following
statements pertaining to an assigned client? Rationale: The nursing process is characterized by
unique properties that enable it to respond to the
changing health status of the client. Options 1, 2,
and 3 are appropriate nursing care measures, but do A. Hopelessness
not demonstrate the dynamic nature of the nursing B. Powerlessness
process. C. Interrupted sleep pattern
D. Disturbed self esteem
The client reports nausea and constipation. Which E. Self care deficit
of the following would be the priority nursing
action? A. Hopelessness
B. Powerlessness
A. Collect a stool sample
B. Complete an abnormal assessment Rationale: Rationale: A nursing diagnosis is a
C. Administer an anti-nausea medication clinical judgment about a response to an actual or
D. Notify the physician potential health problem. This client is manifesting
symptoms of both hopelessness and powerlessness.
B. Complete an Abdominal assessment Although the client does report symptoms
compatible with fatigue, there is no direct data is
Rationale: Assessment involves the systematic given that indicates the client has interrupted sleep
collection of data about an individual upon which patterns (option 3), disturbed self esteem (option 4),
all subsequent phases of the nursing process are or self care deficit (option 5).
built. In response to a client's complaint, a nurse
assesses a specific body system to obtain data that Which of the following descriptors is most
will help the nurse make a nursing diagnosis and appropriate to use when stating the "problem" part
plan the client's care. The other options reflect of a nursing diagnosis?
interventions, which are not timely unless there is
first a complete assessment. A. Grimacing
B. Anxiety
The nurse suspects that a client is withholding C. Oxygenation saturation 93%
health-related information out of fear of discovery D. Output 500 mL in 8 hours
and possible legal problems. The nurse formulates
nursing diagnoses for the client carefully, being B. Anxiety
concerned about a diagnostic error resulting from
which of the following? Rationale: The problem part of a nursing diagnosis
should state the client's response to a life process,
A. Incomplete data event, or stressor. These are categorized as nursing
B. Generalize from experience diagnoses. The incorrect options are cues the nurse
C. Identifying with the client would use to formulate the nursing diagnostic
D. Lack of clinical experience statement.

A. Incomplete data Which desired outcome written by the nurse is

correctly written and measurable?
Rationale: To collect data accurately, the client
must actively participate. Incomplete data can lead A. Client will have a normal bowel pattern by April
to inappropriate nursing diagnosis and planning. 2
The other options are not relevant to the question as B. The client will lose 4 lbs. within next 2 weeks
presented. C. The nurse will provide skin care at least 3 times
each day
The nurse notes that the client often sighs and says
in a monotone voice, "I'm never going to get over D. The client will breathe better after resting for 10
this." When encouraged to participate in care, the minutes
client says, "I don't have the energy." The nurse B. The client will lose 4 lbs. within next 2 weeks
believes these cues are suggestive of which nursing
diagnoses? Select all that apply. Rationale: An outcome statement must describe the
observable client behavior that should occur in the following desired outcomes should the nurse
response to the nursing interventions. It consists of include in the care plan?
a subject, action verb, conditions under which the
behavior is to be performed, and the level at which A. Client will be able to turn self by day 3
the client will perform the desired behavior. Each of B. Skin will remain intact and without redness
the incorrect options lacks one of these required during hospital stay
elements. Option 1 is not measurable. Option 3 is a C. Client will state pain relieved within 30 minutes
nursing goal rather than a client goal. Option 4 does after medication
not include the level at which the behavior should D. Pressure will be prevented by repositioning
be performed. client every 2 hours

The rehabilitation nurse wishes to make the B. Skin will remain intact and without redness
following entry into a client's plan of care: "Client during hospital stay
will reestablish a pattern of daily bowel movements
without straining within two months." The nurse Rationale: The human response/label is what needs
would write this statement under which section of to change (Risk for impaired skin integrity). The
the plan of care? label suggests the outcomes. In this case, "skin will
remain intact" is the desired outcome for a client at
A. Nursing diagnosis/problem list risk for impaired skin integrity. Option 1 addresses
B. Nursing orders immobility. Option 3 addresses pain. Option 4 is an
C. Short-term goals intervention.
D. Long-term goals
D. Long-term goals While assisting a client from bed to chair, the nurse
observes that the client looks pale and is beginning
Rationale: Long-term goals describe changes in to perspire heavily. The nurse would then do which
client behavior expected over a time frame greater of the following activities as a reassessment?
than one week. They are usually designed to restore
normal functioning in a problem area and are A. Help client into the chair but more quickly
helpful to other healthcare workers who care for the B. Document client's vital signs taken just prior to
client, often in a variety of settings. moving the client
C. Help client back to bed immediately
Which of these is a correctly stated outcome goal D. Observe client's skin color and take another set
written by the nurse? of vital signs

A. The client will walk 2 miles daily by March 19 D. Observe client's skin color and take another set
B. The client will understand how to give insulin by of vital signs
discharge
C. The client will regain their former state of health Rationale: Assessment is ongoing throughout the
by April 1 nurse-client relationship. During re-assessment, the
D. The client achieve desired mobility by May 7 nurse collects additional data to help evaluate the
status of problems or identify new problems.
A. The client will walk 2 miles daily by March 19 Options 1, 2, and 3 are interventions.

Rationale: Outcome goals should be SMART, i.e., After instructing the client on crutch walking
Specific, Measurable, Appropriate, Realistic, and technique, the nurse should evaluate the client's
Timely. Option 1 is the only outcome that has a understanding by using which of the following
specific behavior (walks daily), with measurable methods?
performance criteria (2 miles), and a time estimate
for goal attainment (by March 19). A. Return demonstration
The nursing diagnosis is Risk for impaired skin B. Explanation
integrity related to immobility and pressure C. Achievement of 90 on written test
secondary to pain and presence of a cast. Which of D. Have client explain produce to the family
 Rationale: Subjective data includes thoughts,
A. Return demonstration beliefs, feelings, perceptions, and sensations that are
apparent only to the person affected and cannot be
Rationale: Interpersonal skills are the sum of the measured, seen, or felt by the nurse. This
activities the nurse uses when communicating with information should be documented using the client's
others. Technical/psychomotor skills are "hands-on" exact words in quotes. The other options indicate
skills, which are often procedures and are evaluated that the nurse has drawn the conclusion that the
by return demonstration. Cognitive skills are the client no longer wishes to live. From the data
intellectual skills of analysis and problem-solving provided, the cues do not support this assumption.
and are evaluated by tests. A more complete assessment should be conducted
to determine if the client is suicidal.
The nurse would do which of the following during
the implementation phase of the nursing process The nurse evaluates the client's progress and
when working with a hospitalized adult? determines that one of the nursing diagnoses on the
client's care plan has been resolved. How should the
A. Formulate a nursing diagnosis of impaired gas nurse document this so that it is best communicated
exchange to the healthcare team?
B. Record in the medical record the distance a client
ambulate in the hall A. Use Liquid PaperTM to "white out" the resolve
C. Write individualized nursing orders in the care diagnosis on the care plan
plan B. Recopy the care plan without the resolve
D. Compare client responses to the desired diagnosis
outcomes for pain relief C. Write a nursing process not indicating that the
outcome goals have been achieved
B. Record in the medical record the distance a client D. Draw a single line through the diagnosis on the
ambulate in the hall care plan and write the nurse's initials and date

Rationale: The implementation phase of the nursing D. Draw a single line through the diagnosis on the
process involves carrying out or delegating the care plan and write the nurse's initials and date
nursing interventions and recording nursing
activities and client responses in the medical Rationale: To discontinue a diagnosis once it has
records. Option 1 represents diagnosing. Option 3 been resolved, cross it off with a single line or
represents planning. Option 4 represents evaluation. highlight it, then write initials and date. Some
A client on the nursing unit is terminally ill but agency forms may require the nurse to put date and
remains alert and oriented. Three days after initials in a "Date Resolved" column. Using Liquid
admission, the nurse observes signs of depression. PaperTM is not a legal way to amend client records.
Outcome goals that have been met and nursing
The client states, "I'm tired of being sick. I wish I diagnoses that have been resolved should be
could end it all." What is the most accurate and documented on the care plan. A progress note
informative way to record this data in a nursing should also be written, but a single note may not be
progress note? read by all health team members.

A. Client appears to be depressed, possibly suicidal The client is being discharged to a long-term care
B. Client reports being tired of being ill and wants (LTC) facility. The nurse is preparing a progress
to die note to communicate to the LTC staff the client's
C. Client does not want to live any longer and is outcome goals that were met and those that were
tired of being ill not. To do this effectively, the nurse should:
D. Client states, "I'm tired of being sick. I wish I
could end it all." A. Formulate post-discharge nursing diagnoses
D. Client states, "I'm tired of being sick. I wish I B. Draw conclusion about resolution of current
could end it all." client problems
C. Assess the client for baseline data to be used at
the LTC facility
D. Plan the care that is needed in the LTC facility A. Close-ended question
B. Open-ended question
B. Draw conclusion about resolution of current C. Leading question
client problems D. Neutral question

Rationale: Terminal evaluation is done to determine C. Leading question

the client's condition at the time of discharge. This
evaluation is best reflected in option 2 because it Rationale: A leading question is asked in a way that
focuses on which goals were achieved and which suggests the type of answer that is expected. This
were not. Ongoing evaluation is done while or can result in inaccurate data collection. A closed-
immediately after implementing a nursing ended question generally requires only a "yes" or
intervention. Intermittent evaluation is performed at "no" or short factual answer. Open-ended questions
specified intervals, such as twice a week. Items encourage clients to elaborate on their thoughts and
related to care post-discharge (options 2, 3, and 4) feelings. Neutral questions do not influence the
should be done on admission to the LTC facility. client's answer.

A client who complains of nausea and seems The nurse would do which of the following
anxious is admitted to the nursing unit. The nurse activities during the diagnosing phase of the nursing
should take which of the following actions process? Select all that apply.
regarding completion of the admission interview?
A. Collect and organize client information
A. Help the client to get settled and do the interview B. Analyze data
the next morning when the client is rested C. Identify problems, risk, and client strengths
B. Do the interview immediately, directing the D. Develop nursing diagnoses
majority of the questions to the client's spouse E. Develop client goals
C. Do the interview as soon as some uninterrupted
time is available in order to address the client's B. Analyze data
concerns C. Identify problems, risk, and client strengths
D. Ask the charge nurse to interview the client D. Develop nursing diagnoses
while the admitting nurse calls the doctor for anti-
nausea and anti-anxiety medication Rationale: The diagnosing phase of the nursing
process involves data analysis, which leads to
C. Do the interview as soon as some uninterrupted identification of problems, risks, and strengths and
time is available in order to address the client's the development of nursing diagnoses. Collecting
concerns and organizing client data is done in the assessment
phase of the nursing process. Goal setting occurs
Rationale: To collect data accurately, the client during the planning phase.
must participate. Attending to the client's immediate
personal needs before expecting the client to focus The functional health pattern assessment data states:
on the interview will maximize the accuracy of the "Eats three meals a day and is of normal weight for
data collected. Data should be collected shortly after height." The nurse should draw which of the
admission. The best source of data is the client. The following conclusions about this data? Select all
management of the client's anxiety is the that apply.
responsibility of the nurse conducting the interview
and initiating the relationship. A. Client has an actual health problem
B. Client has a wellness diagnosis
The nurse overhears an unlicensed assistive person C. Collaborative health problem needs to be written
(UAP) who has just been accepted to nursing school D. Possible nursing diagnosis exists
say to a client, "You must be so pleased with your E. Specific questions about the diet should be asked
progress." The nurse later explains to the UAP that next
this is an example of what type of question?
B. Client has a wellness diagnosis program?

E. Specific questions about the diet should be asked A. Client will walk quickly three times a day
next B. Client will be able to walk a mile
C. Client will have no alteration in breathing during
Rationale: The description indicates a healthy the walk
pattern of nutrition for the client. A wellness D. Client will progress to walking a 20-minute mile
diagnosis might be stated as: "Potential for in one month
enhanced nutrition." An actual health problem is a
client problem that is currently present. The nurse D. Client will progress to walking a 20-minute mile
should also do a diet assessment to determine the in one month
quality of the food eaten during meals. These
actions by the nurse are within the scope of Rationale: Outcome statements must be written in
independent nursing practice and are not behavioral terms and identify specific, measurable
collaborative in nature. client behaviors. They are stated in terms of the
client with an action verb that, under identified
For the nursing diagnostic statement, Self-care conditions, will achieve the desired behavior. They
deficit: feeding related to bilateral fractured wrists should also be realistic and achievable.
in casts, what is the major related factor or risk
factor identified by the nurse? The nurse decides it would be beneficial to the
client to allow the client's infant granddaughter to
A. Discomfort visit before the client's scheduled heart transplant.
B. Deficit Before implementing this intervention the nurse
C. Feeding should collaborate with which of the following?
D. Fractured wrists Select all that apply.
D. Fractured Wrists
A. Client and Family
Rationale: The etiology or related factors of a B. Other nursing staff on the unit
nursing diagnostic statement define one or more C. Security department
probable causes of the problem and allow the nurse D. Hospital administration
to individualize the client's care. In this case, the E. This is not a collaborative intervention so no
fracture is the cause of the client's feeding problem. collaboration will be needed prior to
implementation
The nurse would make which of the following
inferences after performing the appropriate client A. Client and Family
assessment? B. Other nursing staff on the unit

A. Client is hypotensive Rationale: Collaboration with the client and family

B. Respiratory rate of 20 breaths per minute will encourage a sense of autonomy and active
C. Oxygen saturation of 95% involvement in the healthcare process for the client.
D. Client relays anxiety about blood work In this case collaboration with other nursing staff
will ensure the successful implementation of the
A. Client is hypotensive planned intervention. There is no real need for
collaboration with hospital administration or the
Rationale: An inference is the nurse's judgment or security department in this situation although the
interpretation of cues such as judging a blood nurse should be aware of her responsibility to
pressure to be lower than normal. A cue is any piece collaborate at those levels when the situation
of data information that influences a decision. demands it.
Options 2, 3, and 4 are cues that could lead to
inferences. The nurse informs the physical therapy department
The nurse would write which of the following that the client is too weak to use a walker and needs
outcome statements for a client starting an exercise to be transported by wheelchair. Which step of the
nursing process is the nurse engaged in at this time? D. Review of the assessment is conducted with
other team members.
A. Assessment A. Plan is developed for nursing care.
B. Planning
C. Implementation Planning is a category of nursing behaviors in
D. Evaluation which:

C. Implementation A. The nurse determines the health care needed for

the client.
Rationale: The nurse is responsible for coordinating B. The Physician determines the plan of care for the
the plan of care with other disciplines to ensure the client.
client's safety. This action represents the C. Client-centered goals and expected outcomes are
implementation phase of the nursing process. Data established.
gathering occurs during assessment. Goal setting D. The client determines the care needed.
occurs during planning. Determining attainment of
client goals occurs as part of evaluation. C. Client-centered goals and expected outcomes are
established.
A desired outcome for a client immobilized in a
long leg cast reads; Client will state three signs of Priorities are established to help the nurse anticipate
impaired circulation prior to discharge. When the and sequence nursing interventions when a client
nurse evaluates the client's progress, the client is has multiple problems or alterations. Priorities are
able to state that numbness and tingling are signs of determined by the client's:
impaired circulation. What would be an appropriate
evaluation statement for the nurse to write? A. Physician
B. Non Emergent, non-life threatening needs
A. Client understands the signs of impaired C. Future well-being.
circulation D. Urgency of problems
B. Goal met: Client cited numbness and tingling as
sign of impaired circulation D. Urgency of problems
C. Goal not met: Client able to name only two signs
of impaired circulation A client centered goal is a specific and measurable
D. Goal not met: Client unable to describe signs of behavior or response that reflects a client's:
impaired circulation
A. Desire for specific health care interventions
C. Goal not met: Client able to name only two signs B. Highest possible level of wellness and
of impaired circulation independence in function.
C. Physician's goal for the specific client.
Rationale: The goal has not been met because the D. Response when compared to another client with
client states only two out of three signs of impaired a like problem.
circulation. By comparing the data with the
expected outcomes, the nurse judges that while B. Highest possible level of wellness and
there has been progress toward the goal, it has not independence in function
been completely met. The care plan may need to be For clients to participate in goal setting, they should
revised or more effective teaching strategies may be:
need to be implemented to achieve the goal.
A. Alert and have some degree of independence.
Once a nurse assesses a client's condition and B. Ambulatory and mobile.
identifies appropriate nursing diagnoses, a: C. Able to speak and write.

A. Plan is developed for nursing care. D. Able to read and write.

B. Physical assessment begins
C. List of priorities is determined. A. Alert and have some degree of independence.
 Collaborative interventions are therapies that
The nurse writes an expected outcome statement in require:
measurable terms. An example is:
A. Physician and nurse interventions.
A. Client will have less pain. B. Nurse and client interventions.
B. Client will be pain free. C. Client and Physician intervention.
C. Client will report pain acuity less than 4 on a D. Multiple health care professionals.
scale of 0-10.
D. Client will take pain medication every 4 hours D. Multiple health care professionals.
around the clock.
Well formulated, client-centered goals should:
C. Client will report pain acuity less than 4 on a
scale of 0-10. A. Meet immediate client needs.
B. Include preventative health care.
As goals, outcomes, and interventions are C. Include rehabilitation needs.
developed, the nurse must: D. All of the above.

A. Be in charge of all care and planning for the D. All of the above.
client.
B. Be aware of and committed to accepted The following statement appears on the nursing care
standards of practice from nursing and other plan for an immunosuppressed client: The client
disciplines. will remain free from infection throughout
C. Not change the plan of care for the client. hospitalization. This statement is an example of a
D. Be in control of all interventions for the client. (an):

B. Be aware of and committed to accepted A. Nursing diagnosis

standards of practice from nursing and other B. Short-term goal
disciplines. C. Long-term goal
D. Expected outcome
When establishing realistic goals, the nurse:
B. Short-term goal
A. Bases the goals on the nurse's personal
knowledge. The following statements appear on a nursing care
B. Knows the resources of the health care facility, plan for a client after a mastectomy: Incision site
family, and the client. approximated; absence of drainage or prolonged
C. Must have a client who is physically and erythema at incision site; and client remains
emotionally stable. afebrile. These statements are examples of:
D. Must have the client's cooperation.
A. Nursing interventions
B. Knows the resources of the health care facility, B. Short-term goals
family, and the client. C. Long-term goals
D. Expected outcomes.
To initiate an intervention the nurse must be
competent in three areas, which include: D. Expected outcomes.

A. Knowledge, function, and specific skills The planning step of the nursing process includes
B. Experience, advanced education, and skills. which of the following activities?
C. Skills, finances, and leadership.
D. Leadership, autonomy, and skills. A. Assessing and diagnosing
A. Knowledge, function, and specific skills B. Evaluating goal achievement.
C. Performing nursing actions and documenting
them. C. Elevate head of bed 30 degrees before meals.
D. Setting goals and selecting interventions. D. Change dressing once a shift.

D. Setting goals and selecting interventions. C. Elevate head of bed 30 degrees before meals.
The nursing care plan is:
A client's wound is not healing and appears to be
A. A written guideline for implementation and worsening with the current treatment. The nurse
evaluation. first considers:
B. A documentation of client care.
C. A projection of potential alterations in client A. Notifying the physician.
behaviors B. Calling the wound care nurse
D. A tool to set goals and project outcomes. C. Changing the wound care treatment.
D. Consulting with another nurse.
A. A written guideline for implementation and
evaluation. B. Calling the wound care nurse

After determining a nursing diagnosis of acute pain, When calling the nurse consultant about a difficult
the nurse develops the following appropriate client- client-centered problem, the primary nurse is sure to
centered goal: report the following:

A. Encourage client to implement guided imagery A. Length of time the current treatment has been in
when pain begins. place.
B. Determine effect of pain intensity on client B. The spouse's reaction to the client's dressing
function. change.
C. Administer analgesic 30 minutes before physical C. Client's concern about the current treatment.
therapy treatment. D. Physician's reluctance to change the current
D. Pain intensity reported as a 3 or less during treatment plan.
hospital stay.
A. Length of time the current treatment has been in
D. Pain intensity reported as a 3 or less during place.
hospital stay.
The primary nurse asked a clinical nurse specialist
When developing a nursing care plan for a client (CNS) to consult on a difficult nursing problem.
with a fractured right tibia, the nurse includes in the The primary nurse is obligated to:
plan of care independent nursing interventions,
including: A. Implement the specialist's recommendations.
B. Report the recommendations to the primary
A. Apply a cold pack to the tibia. physician.
B. Elevate the leg 5 inches above the heart. C. Clarify the suggestions with the client and family
C. Perform range of motion to right leg every 4 members.
hours. D. Discuss and review advised strategies with CNS.
D. Administer aspirin 325 mg every 4 hours as
needed. D. Discuss and review advised strategies with CNS.

B. Elevate the leg 5 inches above the heart After assessing the client, the nurse formulates the
following diagnoses. Place them in order of priority,
Which of the following nursing interventions are with the most important (classified as high) listed
written correctly? Select all that apply. first.

A. Apply continuous passive motion machine A. Constipation

during day. B. Anticipated grieving
B. Perform neurovascular checks.
C. Ineffective airway clearance D. The state board examinations for professional
D. Ineffective tissue perfusion. nursing practice now use the nursing process rather
than medical specialties as an organizing concept.
C, D, A, B.

The nurse is reviewing the critical paths of the

clients on the nursing unit. In performing a variance The nurse would do which of the following
analysis, which of the following would indicate the activities during the diagnosing phase of the nursing
need for further action and analysis? process? Select all that apply.

A. A client's family attending a diabetic teaching A. Collect and organize client information
session. B. Analyze data
B. Canceling physical therapy sessions on the C. Identify problems, risk, and client strengths
weekend. D. Develop nursing diagnoses
C. Normal VS and absence of wound infection in a E. Develop client goals
post-op client.
D. A client demonstrating accurate medication B. Analyze data
administration following teaching. C. Identify problems, risk, and client strengths
D. Develop nursing diagnoses
B. Canceling physical therapy sessions on the
weekend. Rationale: The diagnosing phase of the nursing
process involves data analysis, which leads to
The RN has received her client assignment for the identification of problems, risks, and strengths and
day-shift. After making the initial rounds and the development of nursing diagnoses. Collecting
assessing the clients, which client would the RN and organizing client data is done in the assessment
need to develop a care plan first? phase of the nursing process. Goal setting occurs
during the planning phase.
A. A client who is ambulatory.
B. A client, who has a fever, is diaphoretic and For the nursing diagnostic statement, Self-care
restless. deficit: feeding related to bilateral fractured wrists
C. A client scheduled for OT at 1300. in casts, what is the major related factor or risk
D. A client who just had an appendectomy and has factor identified by the nurse?
just received pain medication.
A. Discomfort
B. A client, who has a fever, is diaphoretic and B. Deficit
restless. C. Feeding
D. Fractured wrists
Which of the following statements about the
nursing process is most accurate? D. Fractured Wrists

A. The nursing process is a four-step procedure for Rationale: The etiology or related factors of a
identifying and resolving patient problems. nursing diagnostic statement define one or more
B. Beginning in Florence Nightingale's days, probable causes of the problem and allow the nurse
nursing students learned and practiced the nursing to individualize the client's care. In this case, the
process. fracture is the cause of the client's feeding problem.
C. Use of the nursing process is optional for nurses,
since there are many ways to accomplish the work The nurse would make which of the following
of nursing. inferences after performing the appropriate client
D. The state board examinations for professional assessment?
nursing practice now use the nursing process rather
than medical specialties as an organizing concept. A. Client is hypotensive
B. Respiratory rate of 20 breaths per minute
C. Oxygen saturation of 95% A desired outcome for a client immobilized in a
D. Client relays anxiety about blood work long leg cast reads; Client will state three signs of
impaired circulation prior to discharge. When the
A. Client is hypotensive nurse evaluates the client's progress, the client is
able to state that numbness and tingling are signs of
Rationale: An inference is the nurse's judgment or impaired circulation. What would be an appropriate
interpretation of cues such as judging a blood evaluation statement for the nurse to write?
pressure to be lower than normal. A cue is any piece
of data information that influences a decision. A. Client understands the signs of impaired
Options 2, 3, and 4 are cues that could lead to circulation
inferences. B. Goal met: Client cited numbness and tingling as
sign of impaired circulation
The nurse would write which of the following C. Goal not met: Client able to name only two signs
outcome statements for a client starting an exercise of impaired circulation
program? D. Goal not met: Client unable to describe signs of
impaired circulation
A. Client will walk quickly three times a day
B. Client will be able to walk a mile C. Goal not met: Client able to name only two signs
C. Client will have no alteration in breathing during of impaired circulation
the walk
D. Client will progress to walking a 20-minute mile Rationale: The goal has not been met because the
in one month client states only two out of three signs of impaired
circulation. By comparing the data with the
D. Client will progress to walking a 20-minute mile expected outcomes, the nurse judges that while
in one month there has been progress toward the goal, it has not
been completely met. The care plan may need to be
Rationale: Outcome statements must be written in revised or more effective teaching strategies may
behavioral terms and identify specific, measurable need to be implemented to achieve the goal.
client behaviors. They are stated in terms of the
client with an action verb that, under identified Which of the following items of subjective client
conditions, will achieve the desired behavior. They data would be documented in the medical record by
should also be realistic and achievable. the nurse?

The nurse informs the physical therapy department A. Client's face is pale
that the client is too weak to use a walker and needs B. Cervical lymph nodes are palpable
to be transported by wheelchair. Which step of the C. Nursing assistant reports client refused lunch
nursing process is the nurse engaged in at this time? D. Client feel nauseated

A. Assessment D. Client feel nauseated

B. Planning
C. Implementation Rationale: Subjective data includes the client's
D. Evaluation sensations, feelings, and perception of health status.
Subjective data can only be verified by the affected
C. Implementation person. Options 1, 2, and 3 represent objective data
that can be detected by the nurse or measured
Rationale: The nurse is responsible for coordinating against an accepted norm.
the plan of care with other disciplines to ensure the
client's safety. This action represents the The client reports nausea and constipation. Which
implementation phase of the nursing process. Data of the following would be the priority nursing
gathering occurs during assessment. Goal setting action?
occurs during planning. Determining attainment of
client goals occurs as part of evaluation. A. Collect a stool sample
B. Complete an abnormal assessment the client will perform the desired behavior. Each of
C. Administer an anti-nausea medication the incorrect options lacks one of these required
D. Notify the physician elements. Option 1 is not measurable. Option 3 is a
nursing goal rather than a client goal. Option 4 does
B. Complete an Abdominal assessment not include the level at which the behavior should
be performed.
Rationale: Assessment involves the systematic
collection of data about an individual upon which Which of these is a correctly stated outcome goal
all subsequent phases of the nursing process are written by the nurse?
built. In response to a client's complaint, a nurse
assesses a specific body system to obtain data that A. The client will walk 2 miles daily by March 19
will help the nurse make a nursing diagnosis and B. The client will understand how to give insulin by
plan the client's care. The other options reflect discharge
interventions, which are not timely unless there is C. The client will regain their former state of health
first a complete assessment. by April 1
D. The client achieve desired mobility by May 7
Which of the following descriptors is most
appropriate to use when stating the "problem" part A. The client will walk 2 miles daily by March 19
of a nursing diagnosis?
Rationale: Outcome goals should be SMART, i.e.,
A. Grimacing Specific, Measurable, Appropriate, Realistic, and
B. Anxiety Timely. Option 1 is the only outcome that has a
C. Oxygenation saturation 93% specific behavior (walks daily), with measurable
D. Output 500 mL in 8 hours performance criteria (2 miles), and a time estimate
for goal attainment (by March 19).
B. Anxiety
The nursing diagnosis is Risk for impaired skin
Rationale: The problem part of a nursing diagnosis integrity related to immobility and pressure
should state the client's response to a life process, secondary to pain and presence of a cast. Which of
event, or stressor. These are categorized as nursing the following desired outcomes should the nurse
diagnoses. The incorrect options are cues the nurse include in the care plan?
would use to formulate the nursing diagnostic
statement. A. Client will be able to turn self by day 3
B. Skin will remain intact and without redness
Which desired outcome written by the nurse is during hospital stay
correctly written and measurable? C. Client will state pain relieved within 30 minutes
after medication
A. Client will have a normal bowel pattern by April D. Pressure will be prevented by repositioning
2 client every 2 hours
B. The client will lose 4 lbs. within next 2 weeks
C. The nurse will provide skin care at least 3 times B. Skin will remain intact and without redness
each day during hospital stay
D. The client will breathe better after resting for 10
minutes Rationale: The human response/label is what needs
to change (Risk for impaired skin integrity). The
B. The client will lose 4 lbs. within next 2 weeks label suggests the outcomes. In this case, "skin will
remain intact" is the desired outcome for a client at
Rationale: An outcome statement must describe the risk for impaired skin integrity. Option 1 addresses
observable client behavior that should occur in immobility. Option 3 addresses pain. Option 4 is an
response to the nursing interventions. It consists of intervention.
a subject, action verb, conditions under which the
behavior is to be performed, and the level at which
While assisting a client from bed to chair, the nurse A. Client appears to be depressed, possibly suicidal
observes that the client looks pale and is beginning B. Client reports being tired of being ill and wants
to perspire heavily. The nurse would then do which to die
of the following activities as a reassessment? C. Client does not want to live any longer and is
tired of being ill
A. Help client into the chair but more quickly D. Client states, "I'm tired of being sick. I wish I
B. Document client's vital signs taken just prior to could end it all."
moving the client
C. Help client back to bed immediately D. Client states, "I'm tired of being sick. I wish I
D. Observe client's skin color and take another set could end it all."
of vital signs
Rationale: Subjective data includes thoughts,
D. Observe client's skin color and take another set beliefs, feelings, perceptions, and sensations that are
of vital signs apparent only to the person affected and cannot be
measured, seen, or felt by the nurse. This
Rationale: Assessment is ongoing throughout the information should be documented using the client's
nurse-client relationship. During re-assessment, the exact words in quotes. The other options indicate
nurse collects additional data to help evaluate the that the nurse has drawn the conclusion that the
status of problems or identify new problems. client no longer wishes to live. From the data
Options 1, 2, and 3 are interventions. provided, the cues do not support this assumption.
A more complete assessment should be conducted
The nurse would do which of the following during to determine if the client is suicidal
the implementation phase of the nursing process
when working with a hospitalized adult?
1. Once a nurse assesses a client’s condition and
A. Formulate a nursing diagnosis of impaired gas identifies appropriate nursing diagnoses, a:
exchange
B. Record in the medical record the distance a client A. Plan is developed for nursing care.
ambulate in the hall B. Physical assessment begins
C. Write individualized nursing orders in the care C. List of priorities is determined.
plan D. Review of the assessment is conducted with
D. Compare client responses to the desired other team members.
outcomes for pain relief
2. Planning is a category of nursing behaviors in
B. Record in the medical record the distance a client which:
ambulate in the hall
A. The nurse determines the health care needed
Rationale: The implementation phase of the nursing for the client.
process involves carrying out or delegating the B. The Physician determines the plan of care for
nursing interventions and recording nursing the client.
activities and client responses in the medical C. Client-centered goals and expected outcomes
records. Option 1 represents diagnosing. Option 3 are established.
represents planning. Option 4 represents evaluation. D. The client determines the care needed.
A client on the nursing unit is terminally ill but
remains alert and oriented. Three days after 3. Priorities are established to help the nurse
admission, the nurse observes signs of depression. anticipate and sequence nursing interventions when
a client has multiple problems or alterations.
The client states, "I'm tired of being sick. I wish I Priorities are determined by the client’s:
could end it all." What is the most accurate and
informative way to record this data in a nursing A. Physician
progress note? B. Non Emergent, non-life threatening needs
C. Future well-being.
 D. Urgency of problems 9. To initiate an intervention the nurse must be
competent in three areas, which include:
4. A client centered goal is a specific and
measurable behavior or response that reflects a A. Knowledge, function, and specific skills
client’s: B. Experience, advanced education, and skills.
C. Skills, finances, and leadership.
A. Desire for specific health care interventions D. Leadership, autonomy, and skills.
B. Highest possible level of wellness and
independence in function. 10. Collaborative interventions are therapies that
C. Physician’s goal for the specific client. require:
D. Response when compared to another client
with a like problem. A. Physician and nurse interventions.
B. Nurse and client interventions.
5. For clients to participate in goal setting, they C. Client and Physician intervention.
should be: D. Multiple health care professionals.

A. Alert and have some degree of independence. 11. Well formulated, client-centered goals should:
B. Ambulatory and mobile.
C. Able to speak and write. A. Meet immediate client needs.
D. Able to read and write. B. Include preventative health care.
C. Include rehabilitation needs.
6. The nurse writes an expected outcome statement D. All of the above.
in measurable terms. An example is:
12. The following statement appears on the nursing
A. Client will have less pain. care plan for an immunosuppressed client: The
B. Client will be pain free. client will remain free from infection throughout
C. Client will report pain acuity less than 4 on a hospitalization. This statement is an example of a
scale of 0-10. (an):
D. Client will take pain medication every 4 hours
around the clock. A. Nursing diagnosis
B. Short-term goal
7. As goals, outcomes, and interventions are C. Long-term goal
developed, the nurse must: D. Expected outcome

A. Be in charge of all care and planning for the 13. The following statements appear on a nursing
client. care plan for a client after a mastectomy: Incision
B. Be aware of and committed to accepted site approximated; absence of drainage or prolonged
standards of practice from nursing and other erythema at incision site; and client remains
disciples. afebrile. These statements are examples of:
C. Not change the plan of care for the client.
D. Be in control of all interventions for the client. A. Nursing interventions
B. Short-term goals
8. When establishing realistic goals, the nurse: C. Long-term goals
D. Expected outcomes.
A. Bases the goals on the nurse’s personal
knowledge. 14. The planning step of the nursing process
B. Knows the resources of the health care facility, includes which of the following activities?
family, and the client.
C. Must have a client who is physically and A. Assessing and diagnosing
emotionally stable. B. Evaluating goal achievement.
D. Must have the client’s cooperation. C. Performing nursing actions and documenting
them.
 D. Setting goals and selecting interventions. D. Consulting with another nurse.

15. The nursing care plan is: 20. When calling the nurse consultant about a
difficult client-centered problem, the primary nurse
A. A written guideline for implementation and is sure to report the following:
evaluation.
B. A documentation of client care. A. Length of time the current treatment has been
C. A projection of potential alterations in client in place.
behaviors B. The spouse’s reaction to the client’s dressing
D. A tool to set goals and project outcomes. change.
C. Client’s concern about the current treatment.
16. After determining a nursing diagnosis of acute D. Physician’s reluctance to change the current
pain, the nurse develops the following appropriate treatment plan.
client-centered goal:
21. The primary nurse asked a clinical nurse
A. Encourage client to implement guided imagery specialist (CNS) to consult on a difficult nursing
when pain begins. problem. The primary nurse is obligated to:
B. Determine effect of pain intensity on client
function. A. Implement the specialist’s recommendations.
C. Administer analgesic 30 minutes before physical B. Report the recommendations to the primary
therapy treatment. physician.
D. Pain intensity reported as a 3 or less during C. Clarify the suggestions with the client and
hospital stay. family members.
D. Discuss and review advised strategies with CNS.
17. When developing a nursing care plan for a client
with a fractured right tibia, the nurse includes in the 22. After assessing the client, the nurse formulates
plan of care independent nursing interventions, the following diagnoses. Place them in order of
including: priority, with the most important (classified as high)
listed first.
A. Apply a cold pack to the tibia.
B. Elevate the leg 5 inches above the heart. A. Constipation
C. Perform range of motion to right leg every 4 B. Anticipated grieving
hours. C. Ineffective airway clearance
D. Administer aspirin 325 mg every 4 hours as D. Ineffective tissue perfusion.
needed.
23. The nurse is reviewing the critical paths of the
18. Which of the following nursing interventions clients on the nursing unit. In performing a variance
are written correctly? (Select all that apply.) analysis, which of the following would indicate the
need for further action and analysis?
A. Apply continuous passive motion machine
during day. A. A client’s family attending a diabetic teaching
B. Perform neurovascular checks. session.
C. Elevate head of bed 30 degrees before meals. B. Canceling physical therapy sessions on the
D. Change dressing once a shift. weekend.
C. Normal VS and absence of wound infection in a
19. A client’s wound is not healing and appears to post-op client.
be worsening with the current treatment. The nurse D. A client demonstrating accurate medication
first considers: administration following teaching.

A. Notifying the physician.  24. The RN has received her client assignment for
B. Calling the wound care nurse the day-shift. After making the initial rounds and
C. Changing the wound care treatment.
assessing the clients, which client would the RN nurse is knowledgeable in wound management,
need to develop a care plan first? this could delay wound healing. Also, the
current wound management plan could have
A. A client who is ambulatory. been ordered by the physician. d. Another
B. A client, who has a fever, is diaphoretic and nurse most likely will not be knowledgeable
restless. about wounds, and the primary nurse would
C. A client scheduled for OT at 1300. know the history of the wound management
D. A client who just had an appendectomy and has plan.)
just received pain medication. 20. A. This gives the consulting nurse facts that will
influence a new plan.
25. She is the first one to coin the term “NURSING (b, c, and d. These are all subjective and
PROCESS” She introduced 3 steps of nursing emotional issues/conclusions about the current
process which are Observation, Ministration and treatment plan and may cause a bias in the
Validation. decision of a new treatment plan by the nurse
consultant.)
A. Nightingale 21. D. Because the primary nurse requested the
B. Johnson consultation, it is important that they
C. Rogers communicate and discuss recommendations.
D. Hall The primary nurse can then accept or reject the
CNS recommendations. (a. Some of the
  recommendations may not be appropriate for
this client. The primary nurse would know this
Answers and Rationales information. A consultation requires review of
the recommendations, but not immediate
implementation. b. This would be appropriate
1. A
after first talking with the CNS about
2. C
recommended changes in the plan of care and
3. D
the rationale. Then the primary nurse should
4. B
call the physician. c. The client and family do
5. A
not have the knowledge to determine whether
6. C
new strategies are appropriate or not. Better to
7. B
wait until the new plan of care is agreed upon
8. B
by the primary nurse and physician before
9. A
talking with the client and/or family.)
10. D
22. C, D, A, B.
11. D
23. B. 
12. B
24. B. This clients needs are a priority.
13. D
25. D.
14. D
15. A
1. Which intervention is an example of primary
16. D. This is measurable and objective. 
17. B. This does not require a physician’s order. (A
prevention?
& D require an order; C is not appropriate for a
fractured tibia) A. Administering digoxin (Lanoxicaps) to a patient
18. C. It is specific in what to do and when. with heart failure
19. B. Calling in the wound care nurse as a B. Administering a measles, mumps, and rubella
consultant is appropriate because he or she is a immunization to an infant
specialist in the area of wound management. C. Obtaining a Papanicolaou smear to screen for
Professional and competent nurses recognize cervical cancer
limitations and seek appropriate consultation. D. Using occupational therapy to help a patient
(a. This might be appropriate after deciding on a cope with arthritis
plan of action with the wound care nurse
specialist. The nurse may need to obtain orders
for special wound care products. c. Unless the
2. The nurse in charge is assessing a patient’s A. Impaired gas exchanges related to increased
abdomen. Which examination technique should the blood flow
nurse use first? B. Fluid volume excess related to peripheral
vascular disease
A. Auscultation C. Risk for injury related to edema
B. Inspection D. Altered peripheral tissue perfusion related to
C. Percussion venous congestion
D. Palpation
8. When positioned properly, the tip of a central
3. Which statement regarding heart sounds is venous catheter should lie in the:
correct?
A. Superior vena cava
A. S1 and S2 sound equally loud over the entire B. Basilica vein
cardiac area. C. Jugular vein
B. S1 and S2 sound fainter at the apex D. Subclavian vein
C. S1 and S2 sound fainter at the base
D. S1 is loudest at the apex, and S2 is loudest at 9. Nurse Margareth is revising a client’s care plan.
the base During which step of the nursing process does such
revision take place?
4. The nurse in charge identifies a patient’s
responses to actual or potential health problems A. Assessment
during which step of the nursing process? B. Planning
C. Implementation
A. Assessment D. Evaluation
B. Nursing diagnosis
C. Planning 10. A 65-year-old female who has diabetes mellitus
D. Evaluation and has sustained a large laceration on her left wrist
asks the nurse, “How long will it take for my scars
5. A female patient is receiving furosemide (Lasix), to disappear?” which statement would be the
40 mg P.O. b.i.d. in the plan of care, the nurse nurse’s best response?
should emphasize teaching the patient about the
importance of consuming: A. “The contraction phase of wound healing can
take 2 to 3 years.”
A. Fresh, green vegetables B. “Wound healing is very individual but within 4
B. Bananas and oranges months the scar should fade.”
C. Lean red meat C. “With your history and the type of location of
D. Creamed corn the injury, it’s hard to say.”
D. “If you don’t develop an infection, the wound
6. The nurse in charge must monitor a patient should heal any time between 1 and 3 years
receiving chloramphenicol for adverse drug from now.”
reaction. What is the most toxic reaction to
chloramphenicol? 11. One aspect of implementation related to drug
therapy is:
A. Lethal arrhythmias
B. Malignant hypertension A. Developing a content outline
C. Status epilepticus B. Documenting drugs given
D. Bone marrow suppression C. Establishing outcome criteria
D. Setting realistic client goals
7. A female patient is diagnosed with deep-vein
thrombosis. Which nursing diagnosis should receive 12. A female client is readmitted to the facility with
highest priority at this time? a warm, tender, reddened area on her right calf.
Which contributing factor would the nurse A. Encourage the client to ask questions about
recognize as most important? personal sexuality
B. Provide time for privacy
A. A history of increased aspirin use C. Provide support for the spouse or significant
B. Recent pelvic surgery other
C. An active daily walking program D. Suggest referral to a sex counselor or other
D. A history of diabetes appropriate professional

13. Which intervention should the nurse in charge 17. Using Abraham Maslow’s hierarchy of human
try first for a client that exhibits signs of sleep needs, a nurse assigns highest priority to which
disturbance? client need?

A. Administer sleeping medication before bedtime A. Security

B. Ask the client each morning to describe the B. Elimination
quantity of sleep during the previous night C. Safety
C. Teach the client relaxation techniques, such as D. Belonging
guided imagery, medication, and progressive
muscle relaxation 18. A male client is on prolonged bed rest has
D. Provide the client with normal sleep aids, such developed a pressure ulcer. The wound shows no
as pillows, back rubs, and snacks signs of healing even though the client has received
skin care and has been turned every 2 hours. Which
14. While examining a client’s leg, the nurse notes factor is most likely responsible for the failure to
an open ulceration with visible granulation tissue in heal?
the wound. Until a wound specialist can be
contacted, which type of dressings is most A. Inadequate vitamin D intake
appropriate for the nurse in charge to apply? B. Inadequate protein intake
C. Inadequate massaging of the affected area
A. Dry sterile dressing D. Low calcium level
B. Sterile petroleum gauze
C. Moist, sterile saline gauze 19. A female client who received general anesthesia
D. Povidone-iodine-soaked gauze returns from surgery. Postoperatively, which
nursing diagnosis takes highest priority for this
15. A male client in a behavioral-health facility client?
receives a 30-minute psychotherapy session, and
provider uses a current procedure terminology A. Acute pain related to surgery
(CPT) code that bills for a 50-minute session. Under B. Deficient fluid volume related to blood and fluid
the False Claims Act, such illegal behavior is loss from surgery
known as: C. Impaired physical mobility related to surgery
D. Risk for aspiration related to anesthesia
A. Unbundling
B. Overbilling 20. Nurse Cay inspects a client’s back and notices
C. Upcoding small hemorrhagic spots. The nurse documents that
D. Misrepresentation the client has:

16. A nurse assigned to care for a postoperative A. Extravasation

male client who has diabetes mellitus. During the B. Osteomalacia
assessment interview, the client reports that he’s C. Petechiae
impotent and says that he’s concerned about its D. Uremia
effect on his marriage. In planning this client’s care,
the most appropriate intervention would be to: 21. Which document addresses the client’s right to
information, informed consent, and treatment
refusal?
 A. Standard of Nursing Practice D. Prevent injury
B. Patient’s Bill of Rights
C. Nurse Practice Act 27. Following a tonsillectomy, a female client
D. Code for Nurses returns to the medical-surgical unit. The client is
lethargic and reports having a sore throat. Which
22. If a blood pressure cuff is too small for a client, position would be most therapeutic for this client?
blood pressure readings taken with such a cuff may
do which of the following? A. Semi-Fowler’s
B. Supine
A. Fail to show changes in blood pressure C. High-Fowler’s
B. Produce a false-high measurement D. Side-lying
C. Cause sciatic nerve damage
D. Produce a false-low measurement 28. Nurse Berri inspects a client’s pupil size and
determines that it’s 2 mm in the left eye and 3 mm
23. Nurse Danny has been teaching a client about a in the right eye. Unequal pupils are known as:
high-protein diet. The teaching is successful if the
client identifies which meal as high in protein? A. Anisocoria
B. Ataxia
A. Baked beans, hamburger, and milk C. Cataract
B. Spaghetti with cream sauce, broccoli, and tea D. Diplopia
C. Bouillon, spinach, and soda
D. Chicken cutlet, spinach, and soda 29. The nurse in charge is caring for an Italian
client. He’s complaining of pain, but he falls asleep
24. A male client is admitted to the hospital with right after his complaint and before the nurse can
blunt chest trauma after a motor vehicle accident. assess his pain. The nurse concludes that:
The first nursing priority for this client would be to:
A. He may have a low threshold for pain
A. Assess the client’s airway B. He was faking pain
B. Provide pain relief C. Someone else gave him medication
C. Encourage deep breathing and coughing D. The pain went away
D. Splint the chest wall with a pillow
30. A female client is admitted to the emergency
25. A newly hired charge nurse assesses the staff department with complaints of chest pain shortness
nurses as competent individually but ineffective and of breath. The nurse’s assessment reveals jugular
nonproductive as a team. In addressing her concern, vein
the charge nurse should understand that the usual distention. The nurse knows that when a client has
reason for such a situation is: jugular vein distension, it’s typically due to:

A. Unhappiness about the charge in leadership A. A neck tumor

B. Unexpected feeling and emotions among the B. An electrolyte imbalance
staff C. Dehydration
C. Fatigue from overwork and understaffing D. Fluid overload
D. Failure to incorporate staff in decision making
Answers and Rationales
26. A male client blood test results are as follows:
white blood cell (WBC) count, 100ul; hemoglobin 1. Answer B. Immunizing an infant is an example
(Hb) level, 14 g/dl; hematocrit (HCT), 40%. Which of primary prevention, which aims to prevent
goal would be most important for this client? health problems. Administering digoxin to treat
heart failure and obtaining a smear for a
A. Promote fluid balance screening test are examples for secondary
B. Prevent infection prevention, which promotes early detection and
C. Promote rest treatment of disease. Using occupational
 therapy to help a patient cope with arthritis is the rapid infusion of large amounts of fluid
an example of tertiary prevention, which aims directly into circulation. The basilica, jugular,
to help a patient deal with the residual and subclavian veins are common insertion sites
consequences of a problem or to prevent the for central venous catheters.
problem from recurring. 9. Answer D. During the evaluation step of the
2. Answer B. Inspection always comes first when nursing process the nurse determines whether
performing a physical examination. Percussion the goals established in the care plan have been
and palpation of the abdomen may affect bowel achieved, and evaluates the success of the plan.
motility and therefore should follow If a goal is unmet or partially met the nurse
auscultation. reexamines the data and revises the plan.
3. Answer D. The S1 sound—the “lub” sound—is Assessment involves data collection. Planning
loudest at the apex of the heart. It sounds involves setting priorities, establishing goals,
longer, lower, and louder there than the S2 and selecting appropriate interventions.
sounds. The S2—the “dub” sound—is loudest at 10. Answer C. Wound healing in a client with
the base. It sounds shorter, sharper, higher, and diabetes will be delayed. Providing the client
louder there than S1. with a time frame could give the client false
4. Answer B. The nurse identifies human information.
responses to actual or potential health 11. Answer B. Although documentation isn’t a step
problems during the nursing diagnosis step of in the nursing process, the nurse is legally
the nursing process. During the assessment required to document activities related to drug
step, the nurse systematically collects data therapy, including the time of administration,
about the patient or family. During the planning the quantity, and the client’s reaction.
step, the nurse develops strategies to resolve or Developing a content outline, establishing
decrease the patient’s problem. During the outcome criteria, and setting realistic client
evaluation step, the nurse determines the goals are part of planning rather than
effectiveness of the plan of care. implementation.
5. Answer B. Because furosemide is a potassium- 12. Answer B. The client shows signs of deep vein
wasting diuretic, the nurse should plan to teach thrombosis (DVT). The pelvic area is rich in
the patient to increase intake of potassium-rich blood supply, and thrombophlebitis of the deep
foods, such as bananas and oranges. Fresh, vein is associated with pelvic surgery. Aspirin,
green vegetables; lean red meat; and creamed an antiplatelet agent, and an active walking
corn are not good sources of potassium. program help decrease the client’s risk of DVT.
6. Answer D. The most toxic reaction to In general, diabetes is a contributing factor
chloramphenicol is bone marrow suppression. associated with peripheral vascular disease.
Chloramphenicol is not known to cause lethal 13. Answer D. The nurse should begin with the
arrhythmias, malignant hypertension, or status simplest interventions, such as pillows or
epilepticus. snacks, before interventions that require
7. Answer D. Altered peripheral tissue perfusion greater skill such as relaxation techniques. Sleep
related to venous congestion” takes highest medication should be avoided whenever
priority because venous inflammation and clot possible. At some point, the nurse should do a
formation impede blood flow in a patient with thorough sleep assessment, especially if
deep-vein thrombosis. Option A is incorrect common sense interventions fail.
because impaired gas exchange is related to 14. Answer C. Moist, sterile saline dressings
decreased, not increased, blood flow. Option B support would heal and are cost-effective. Dry
is inappropriate because no evidence suggest sterile dressings adhere to the wound and
that this patient has a fluid volume excess. debride the tissue when removed. Petroleum
Option C may be warranted but is secondary to supports healing but is expensive. Povidone-
altered tissue perfusion. iodine can irritate epithelial cells, so it shouldn’t
8. Answer A. When the central venous catheter is be left on an open wound.
positioned correctly, its tip lies in the superior 15. Answer C. Upcoding is the practice of using a
vena cava, inferior vena cava, or the right CPT code that’s reimbursed at a higher rate
atrium—that is, in central venous circulation. than the code for the service actually provided.
Blood flows unimpeded around the tip, allowing
 Unbundling, overbilling, and misrepresentation because the sciatic nerve is located in the lower
aren’t the terms used for this illegal practice. extremity.
16. Answer D. The nurse should refer this client to 23. Answer A. Baked beans, hamburger, and milk
a sex counselor or other professional. Making are all excellent sources of protein. The
appropriate referrals is a valid part of planning spaghetti-broccoli-tea choice is high in
the client’s care. The nurse doesn’t normally carbohydrates. The bouillon-spinach-soda
provide sex counseling. Therefore, providing choice provides liquid and sodium as well as
time for privacy and providing support for the some iron, vitamins, and carbohydrates.
spouse or significant other are important, but Chicken provides protein but the chicken-
not as important as referring the client to a sex spinach-soda combination provides less protein
counselor. than the baked beans-hamburger-milk
17. Answer B. According to Maslow, elimination is a selection.
first-level or physiological need, and therefore 24. Answer A. The first priority is to evaluate airway
takes priority over all other needs. Security and patency before assessing for signs of
safety are second-level needs; belonging is a obstruction, sternal retraction, stridor, or
third-level need. Second- and third-level needs wheezing. Airway management is always the
can be met only after a client’s first-level needs nurse’s first priority. Pain management and
have been satisfied. splinting are important for the client’s comfort,
18. Answer B. A client on bed rest suffers from a but would come after airway assessment.
lack of movement and a negative nitrogen Coughing and deep breathing may be
balance. Therefore, inadequate protein intake contraindicated if the client has internal
impairs wound healing. Inadequate vitamin D bleeding and other injuries.
intake and low calcium levels aren’t factors in 25. Answer B. The usual or most prevalent reason
poor healing for this client. A pressure ulcer for lack of productivity in a group of competent
should never be massaged. nurses is inadequate communication or a
19. Answer D. Risk for aspiration related to situation in which the nurses have unexpected
anesthesia takes priority for thins client because feeling and emotions. Although the other
general anesthesia may impair the gag and options could be contributing to the
swallowing reflexes, possibly leading to problematic situation, they’re less likely to be
aspiration. The other options, although the cause.
important, are secondary. 26. Answer B. The client is at risk for infection
20. Answer C. Petechiae are small hemorrhagic because WBC count is dangerously low. Hb level
spots. Extravasation is the leakage of fluid in the and HCT are within normal limits; therefore,
interstitial space. Osteomalacia is the softening fluid balance, rest, and prevention of injury are
of bone tissue. Uremia is an excess of urea and inappropriate.
other nitrogen products in the blood. 27. Answer D. Because of lethargy, the post
21. Answer B. The Patient’s Bill of Rights addresses tonsillectomy client is at risk for aspirating
the client’s right to information, informed blood from the surgical wound. Therefore,
consent, timely responses to requests for placing the client in the side-lying position until
services, and treatment refusal. A legal he awake is best. The semi-Fowler’s, supine,
document, it serves as a guideline for the and high-Fowler’s position don’t allow for
nurse’s decision making. Standards of Nursing adequate oral drainage in a lethargic post
Practice, the Nurse Practice Act, and the Code tonsillectomy client, and increase the risk of
for Nurses contain nursing practice parameters blood aspiration.
and primarily describe the use of the nursing 28. Answer A. Unequal pupils are called anisocoria.
process in providing care. Ataxia is uncoordinated actions of involuntary
22. Answer B. Using an undersized blood pressure muscle use. A cataract is an opacity of the eye’s
cuff produces a falsely elevated blood pressure lens. Diplopia is double vision.
because the cuff can’t record brachial artery 29. Answer A. People of Italian heritage tend to
measurements unless it’s excessively inflated. verbalize discomfort and pain. The pain was real
The sciatic nerve wouldn’t be damaged by to the client, and he may need medication
hyperinflation of the blood pressure cuff when he wakes up.
 30. Answer D. Fluid overload causes the volume of 5. Nursing interventions that can help the patient to
blood within the vascular system to increase. relax and sleep restfully include all of the following
This increase causes the vein to distend, which except:
can be seen most obviously in the neck veins. A
neck tumor doesn’t typically cause jugular vein A. Have the patient take a 30- to 60-minute nap in
distention. An electrolyte imbalance may result the afternoon
in fluid overload, but it doesn’t directly B. Turn on the television in the patient’s room
contribute to jugular vein distention. C. Provide quiet music and interesting reading
material
1. The most important nursing intervention to D. Massage the patient’s back with long strokes
correct skin dryness is:
6. Restraints can be used for all of the following
A. Avoid bathing the patient until the condition is purposes except to:
remedied, and notify the physician
B. Ask the physician to refer the patient to a A. Prevent a confused patient from removing
dermatologist, and suggest that the patient tubes, such as feeding tubes, I.V. lines, and
wear home-laundered sleepwear urinary catheters
C. Consult the dietitian about increasing the B. Prevent a patient from falling out of bed or a
patient’s fat intake, and take necessary chair
measures to prevent infection C. Discourage a patient from attempting to
D. Encourage the patient to increase his fluid ambulate alone when he requires assistance for
intake, use nonirritating soap when bathing the his safety
patient, and apply lotion to the involved areas D. Prevent a patient from becoming confused or
disoriented
2. When bathing a patient’s extremities, the nurse
should use long, firm strokes from the distal to the 7. Which of the following is the nurse’s legal
proximal areas. This technique: responsibility when applying restraints?

A. Provides an opportunity for skin assessment A. Document the patient’s behavior

B. Avoids undue strain on the nurse B. Document the type of restraint used
C. Increases venous blood return C. Obtain a written order from the physician
D. Causes vasoconstriction and increases except in an emergency, when the patient must
circulation be protected from injury to himself or others
D. All of the above
3. Vivid dreaming occurs in which stage of sleep?
8. Kubler-Ross’s five successive stages of death and
A. Stage I non-REM dying are:
B. Rapid eye movement (REM) stage
C. Stage II non-REM A. Anger, bargaining, denial, depression,
D. Delta stage acceptance
B. Denial, anger, depression, bargaining,
4. The natural sedative in meat and milk products acceptance
(especially warm milk) that can help induce sleep C. Denial, anger, bargaining, depression
is: acceptance
D. Bargaining, denial, anger, depression,
A. Flurazepam acceptance
B. Temazepam
C. Tryptophan 9. A terminally ill patient usually experiences all of
D. Methotrimeprazine the following feelings during the anger stage
except:

A. Rage
 B. Envy C. Have the patient expectorate the sputum into a
C. Numbness sterile container
D. Resentment D. Offer the patient an antiseptic mouthwash just
before he expectorate the sputum
10. Nurses and other health care provides often
have difficulty helping a terminally ill patient 15. An autoclave is used to sterilize hospital
through the necessary stages leading to acceptance supplies because:
of death. Which of the following strategies is most
helpful to the nurse in achieving this goal? A. More articles can be sterilized at a time
B. Steam causes less damage to the materials
A. Taking psychology courses related to C. A lower temperature can be obtained
gerontology D. Pressurized steam penetrates the supplies
B. Reading books and other literature on the better
subject of thanatology
C. Reflecting on the significance of death 16. The best way to decrease the risk of transferring
D. Reviewing varying cultural beliefs and practices pathogens to a patient when removing contaminated
related to death gloves is to:

11. Which of the following symptoms is the best A. Wash the gloves before removing them
indicator of imminent death? B. Gently pull on the fingers of the gloves when
removing them
A. A weak, slow pulse C. Gently pull just below the cuff and invert the
B. Increased muscle tone gloves when removing them
C. Fixed, dilated pupils D. Remove the gloves and then turn them inside
D. Slow, shallow respirations out

12. A nurse caring for a patient with an infectious 17. After having an I.V. line in place for 72 hours, a
disease who requires isolation should refers to patient complains of tenderness, burning, and
guidelines published by the: swelling. Assessment of the I.V. site reveals that it
is warm and erythematons. This usually indicates:
A. National League for Nursing (NLN)
B. Centers for Disease Control (CDC) A. Infection
C. American Medical Association (AMA) B. Infiltration
D. American Nurses Association (ANA) C. Phlebitis
D. Bleeding
13. To institute appropriate isolation precautions,
the nurse must first know the: 18. To ensure homogenization when diluting
powdered medication in a vial, the nurse should:
A. Organism’s mode of transmission
B. Organism’s Gram-staining characteristics A. Shake the vial vigorously
C. Organism’s susceptibility to antibiotics B. Roll the vial gently between the palms
D. Patient’s susceptibility to the organism C. Invert the vial and let it stand for 1 minute
D. Do nothing after adding the solution to the vial
14. Which is the correct procedure for collecting a
sputum specimen for culture and sensitivity testing? 19. The nurse is teaching a patient to prepare a
syringe with 40 units of U-100 NPH insulin for self-
A. Have the patient place the specimen in a injection. The patient’s first priority concerning
container and enclose the container in a plastic self-injection in this situation is to:
bag
B. Have the patient expectorate the sputum while A. Assess the injection site
the nurse holds the container B. Select the appropriate injection site
 C. Check the syringe to verify that the nurse has 25. A staff nurse who is promoted to assistant nurse
removed the prescribed insulin dose manager may feel uncomfortable initially when
D. Clean the injection site in a circular manner with supervising her former peers. She can best decrease
and alcohol sponge this discomfort by:

20. The physician’s order reads “Administer 1 g A. Writing down all assignments
cefazolin sodium (Ancef) in 150 ml of normal B. Making changes after evaluating the situation
saline solution in 60 minutes.” What is the flow rate and having discussions with the staff.
if the drop factor is 10 gtt = 1 ml? C. Telling the staff nurses that she is making
changes to benefit their performance
A. 25 gtt/minute D. Evaluating the clinical performance of each staff
B. 37 gtt/minute nurse in a private conference
C. 50 gtt/minute
D. 60 gtt/minute Answers and Rationales

21. A patient must receive 50 units of Humulin 1. Answer – D. Dry skin will eventually crack,
regular insulin. The label reads 100 units = 1 ml. ranking the patient more prone to infection. To
How many milliliters should the nurse administer? prevent this, the nurse should provide adequate
hydration through fluid intake, use nonirritating
A. 0.5 ml soaps or no soap when bathing the patient, and
B. 0.75 ml lubricate the patient’s skin with lotion. Bathing
C. 1 ml may be limited but need not be avoided
D. 2 ml entirely. The attending physician and dietitian
may be consulted for treatment, but home-
22. How should the nurse prepare an injection for a laundered items usually are not necessary.
patient who takes both regular and NPH insulin? 2. Answer – C. Washing from distal to proximal
areas stimulates venous blood flow, thereby
A. Draw up the NPH insulin, then the regular preventing venous stasis. It improves circulation
insulin, in the same syringe but does not result in vasoconstriction. The
B. Draw up the regular insulin, then the NPH nurse can assess the patient’s condition
insulin, in the same syringe throughout the bath, regardless of washing
C. Use two separate syringe technique, and should feel no strain while
D. Check with the physician bathing the patient.
3. Answer – B. Other characteristics of rapid eye
23. A patient has just received 30 mg of codeine by movement (REM) sleep are deep sleep (the
mouth for pain. Five minutes later he vomits. What patient cannot be awakened easily), depressed
should the nurse do first? muscle tone, and possibly irregular heart and
respiratory rates. Non-REM sleep is a deep,
A. Call the physician restful sleep without dreaming. Delta stage, or
B. Remedicate the patient slow-wave sleep, occurs during non-REM Stages
C. Observe the emesis III and IV and is often equated with quiet sleep.
D. Explain to the patient that she can do nothing 4. Answer – C. Tryptophan is a natural sedative;
to help him flurazepam (Dalmane), temazepam (Restoril),
and methotrimeprazine (Levoprome) are
24. A patient is characterized with a #16 indwelling hypnotic sedatives.
5. Answer – A. Napping in the afternoon is not
urinary (Foley) catheter to determine if:
conductive to nighttime sleeping. Quiet music,
watching television, reading, and massage
A. Trauma has occurred
usually will relax the patient, helping him to fall
B. His 24-hour output is adequate
asleep.
C. He has a urinary tract infection
6. Answer – D. By restricting a patient’s
D. Residual urine remains in the bladder after
movements, restraints may increase stress and
voiding
lead to confusion, rather than prevent it. The
 other choices are valid reasons for using whether the organism is gram-negative or
restraints. gram-positive, an important criterion in the
7. Answer – D. When applying restraints, the physician’s choice for drug therapy and the
nurse must document the type of behavior that nurse’s development of an effective plan of
prompted her to use them, document the type care. The nurse also needs to know whether the
of restraints used, and obtain a physician’s organism is susceptible to antibiotics, but this
written order for the restraints. could take several days to determine; if she
8. Answer – C. Kubler-Ross’s five successive stages waits for the results before instituting isolation
of death and dying are denial, anger, precautions, the organism could be transmitted
bargaining, depression, and acceptance. The in the meantime. The patient’s susceptibility to
patient may move back and forth through the the organism has already been established. The
different stages as he and his family members nurse would not be instituting isolation
react to the process of dying, but he usually precautions for a noninfected patient.
goes through all of these stages to reach 14. Answer – C. Placing the specimen in a sterile
acceptance. container ensures that it will not become
9. Answer – C. Numbness is typical of the contaminated. The other answers are incorrect
depression stage, when the patient feels a great because they do not mention sterility and
sense of loss. The anger stage includes such because antiseptic mouthwash could destroy
feelings as rage, envy, resentment, and the the organism to be cultured (before sputum
patient’s questioning “Why me?” collection, the patient may use only tap water
10. Answer – C. According to thanatologists, for nursing the mouth).
reflecting on the significance of death helps to 15. Answer – D. An autoclave, an apparatus that
reduce the fear of death and enables the health sterilizes equipment by means of high-
care provider to better understand the temperature pressured steam, is used because
terminally ill patient’s feelings. It also helps to it can destroy all forms of microorganisms,
overcome the belief that medical and nursing including spores.
measures have failed, when a patient cannot be 16. Answer – C. Turning the gloves inside out while
cured. removing them keeps all contaminants inside
11. Answer – C. Fixed, dilated pupils are sign of the gloves. They should than be placed in a
imminent death. Pulse becomes weak but rapid, plastic bag with soiled dressings and discarded
muscles become weak and atonic, and periods in a soiled utility room garbage pail (double
of apnea occur during respiration. bagged). The other choices can spread
12. Answer – B. The Center of Disease Control pathogens within the environment.
(CDC) publishes and frequently updates 17. Answer – C. Tenderness, warmth, swelling, and,
guidelines on caring for patients who require in some instances, a burning sensation are signs
isolation. The National League of Nursing’s and symptoms of phlebitis. Infection is less
(NLN’s) major function is accrediting nursing likely because no drainage or fever is present.
education programs in the Infiltration would result in swelling and pallor,
United States. The American Medical not erythema, near the insertion site. The
Association (AMA) is a national organization of patient has no evidence of bleeding.
physicians. The American Nurses’ Association 18. Answer – B. Gently rolling a sealed vial between
(ANA) is a national organization of registered the palms produces sufficient heat to enhance
nurses. dissolution of a powdered medication. Shaking
13. Answer – A. Before instituting isolation the vial vigorously can break down the
precaution, the nurse must first determine the medication and alter its pharmacologic action.
organism’s mode of transmission. For example, Inverting the vial or leaving it alone does not
an organism transmitted through nasal ensure thorough homogenization of the powder
secretions requires that the patient be kept in and the solvent.
respiratory isolation, which involves keeping the 19. Answer – C. When the nurse teaches the
patient in a private room with the door closed patient to prepare an insulin injection, the
and wearing a mask, a grown, and gloves when patient’s first priority is to validate the dose
coming in direct contact with the patient. The accuracy. The next steps are to select the site,
organism’s Gram-straining characteristics reveal
 assess the site, and clean the site with alcohol
before injecting the insulin.
20. Answer – A. 25 gtt/minute
21. Answer – A. 0.5 ml
22. Answer – B. Drugs that are compatible may be
mixed together in one syringe. In the case of
insulin, the shorter-acting, clear insulin (regular)
should be drawn up before the longer-acting,
cloudy insulin (NPH) to ensure accurate
measurements.
23. Answer – C. After a patient has vomited, the
nurse must inspect the emesis to document
color, consistency, and amount. In this
situation, the patient recently ingested
medication, so the nurse needs to check for
remnants of the medication to help determine
whether the patient retained enough of it to be
effective. The nurse must then notify the
physician, who will decide whether to repeat
the dose or prescribe an antiemetic.
24. Answer – B. A 24-hour urine output of less than
500 ml in an adult is considered inadequate and
may indicate kidney failure. This must be
corrected while the patient is in the acute state
so that appropriate fluids, electrolytes, and
medications can be administered and excreted.
Indwelling catheterization is not needed to
diagnose trauma, urinary tract infection, or
residual urine.
25. Answer – B. A new assistant nurse manger
should not make changes until she has had a
chance to evaluate staff members, patients, and
physicians. Changes must be planned
thoroughly and should be based on a need to
improve conditions, not just for the sake of
change. Written assignments allow all staff
members to know their own and others
responsibilities and serve as a checklist for the
manager, enabling her to gauge whether the
unit is being run effectively and whether
patients are receiving appropriate care. Telling
the staff nurses that she is making changes to
benefit their performance should occur only
after the nurse has made a thorough
evaluation. Evaluations are usually done on a
yearly basis or as needed.