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1. Jake is complaining of shortness of breath. A.
Assessing, diagnosing, implementing,

The nurse assesses his respiratory rate to be 30 evaluating, planning
breaths per minute and documents that Jake is
B. Diagnosing, assessing, planning,
tachypneic. The nurse understands that
implementing, evaluating
tachypnea means:
C. Assessing, diagnosing, planning,
A. Pulse rate greater than 100 beats per
implementing, evaluating
minute
D. Planning, evaluating, diagnosing,
B. Blood pressure of 140/90
assessing, implementing
C. Respiratory rate greater than 20 breaths
6. During the planning
per minute
phase of the nursing process, which of the
D. Frequent bowel sounds following is the outcome?
2. The nurse listens to Mrs. Sullen’s lungs and A. Nursing history

notes a hissing sound or musical sound. The
B. Nursing notes
nurse documents this as:
C. Nursing care plan
A. Wheezes
D. Nursing diagnosis
B. Rhonchi
7. What is an example of a subjective data?
C. Gurgles
A. Heart rate of 68 beats per minute
D. Vesicular
B. Yellowish sputum
3. The nurse in charge measures a patient’s
temperature at 101 degrees F. What is the C. Client verbalized, “I feel pain when
equivalent centigrade temperature? urinating.”
A. 36.3 degrees C D. Noisy breathing
B. 37.95 degrees C 8. Which expected outcome is correctly written?
C. 40.03 degrees C A. “The patient will feel less nauseated in
24 hours.”
D. 38.01 degrees C
B. “The patient will eat the right
4. Which approach to problem solving tests any
amount of food daily.”
number of solutions until one is found that
works for that particular problem? C. “The patient will identify all the high-
salt food from a prepared list by
A. Intuition
discharge.”
B. Routine
D. “The patient will have enough sleep.”
C. Scientific method
9. Which of the following behaviors by Nurse
D. Trial and error Jane Robles demonstrates that she understands
well th elements of effecting charting?
5. What is the order of the nursing process?
A. She writes in the chart using a no. 2 C. Health belief
pencil.
D. Superstitious belief
B. She noted: appetite is good this
14. Becky is on NPO since midnight as
afternoon.
preparation for blood test. Adreno-cortical
C. She signs on the medication sheet after response is activated. Which of the following is
administering the medication. an expected response?
D. She signs her charting as follow: J.R A. Low blood pressure
10. What is the disadvantage of computerized B. Warm, dry skin

documentation of the nursing process?
C. Decreased serum sodium levels
A. Accuracy
D. Decreased urine output
B. Legibility
15. What nursing action is appropriate when
C. Concern for privacy obtaining a sterile urine specimen from an
indwelling catheter to prevent infection?
D. Rapid communication
A. Use sterile gloves when obtaining urine.
11. The theorist who believes that adaptation
and manipulation of stressors are related to B. Open the drainage bag and pour out the
foster change is: urine.
A. Dorothea Orem C. Disconnect the catheter from the tubing

and get urine.
B. Sister Callista Roy
D. Aspirate urine from the tubing port
C. Imogene King
using a sterile syringe.
D. Virginia Henderson
16. A client is receiving 115 ml/hr of continuous
12. Formulating a nursing diagnosis is a joint IVF. The nurse notices that the venipuncture site
function of: is red and swollen. Which of the following
interventions would the nurse perform first?
A. Patient and relatives
A. Stop the infusion
B. Nurse and patient
B. Call the attending physician
C. Doctor and family
C. Slow that infusion to 20 ml/hr
D. Nurse and doctor
D. Place a clod towel on the site
13. Mrs. Caperlac has been diagnosed to have
hypertension since 10 years ago. Since then, she 17. The nurse enters the room to give a
had maintained low sodium, low fat diet, to prescribed medication but the patient is inside
control her blood pressure. This practice is the bathroom. What should the nurse do?
viewed as:
A. Leave the medication at the bedside
A. Cultural belief and leave the room.
B. Personal belief
B. After few minutes, return to that 21. During a change-of-shift report, it would be
patient’s room and do not leave until important for the nurse relinquishing
the patient takes the medication. responsibility for care of the patient to
communicate. Which of the following facts to
C. Instruct the patient to take the
the nurse assuming responsibility for care of the
medication and leave it at the bedside.
patient?
D. Wait for the patient to return to bed
A. That the patient verbalized, “My
and just leave the medication at the
headache is gone.”
bedside.
B. That the patient’s barium enema
18. Which of the following is
performed 3 days ago was negative
inappropriate nursing action when
administering NGT feeding? C. Patient’s NGT was removed 2 hours ago
A. Place the feeding 20 inches above the D. Patient’s family came for a visit this
pint if insertion of NGT. morning.
B. Introduce the feeding slowly. 22. Which statement is the most appropriate
goal for a nursing diagnosis of diarrhea?
C. Instill 60ml of water into the NGT after
feeding. A. “The patient will experience decreased
frequency of bowel elimination.”
D. Assist the patient in fowler’s position.
B. “The patient will take anti-diarrheal
19. A female patient is being discharged after
medication.”
thyroidectomy. After providing the medication
teaching. The nurse asks the patient to repeat C. “The patient will give a stool specimen
the instructions. The nurse is performing which for laboratory examinations.”
professional role?
D. “The patient will save urine for
A. Manager inspection by the nurse.
B. Caregiver 23. Which of the following is the most

important purpose of planning care with this
C. Patient advocate
patient?
D. Educator
A. Development of a standardized NCP.
20. Which data would be of greatest concern to
B. Expansion of the current
the nurse when completing
taxonomy of nursing diagnosis
the nursing assessment of a 68-year-old woman
hospitalized due to Pneumonia? C. Making of individualized patient care
A. Oriented to date, time and place D. Incorporation of both nursing and

medical diagnoses in patient care
B. Clear breath sounds
24. Using Maslow’s hierarchy of basic human
C. Capillary refill greater than 3 seconds
needs, which of the following nursing diagnoses
and buccal cyanosis
has the highest priority?
D. Hemoglobin of 13 g/dl
A. Ineffective breathing pattern related to
pain, as evidenced by
shortness of breath.
B. Anxiety related to impending surgery, as

evidenced by insomnia.
C. Risk of injury related to autoimmune

dysfunction
D. Impaired verbal communication related

to tracheostomy, as evidenced by
inability to speak.
25. When performing an abdominal

examination, the patient should be in a supine
position with the head of the bed at what
position?
A. 30 degrees
B. 90 degrees
C. 45 degrees
D. 0 degree
Answers and Rationales 7. (C) Client verbalized, “I feel pain when
urinating.”. Subjective data are those
1. 1. (C) Respiratory rate greater than 20
that can be described only by the
breaths per minute. A respiratory
person experiencing it. Therefore, only
rate of greater than 20 breaths per
the patient can describe or verify
minute is tachypnea. A blood
whether he is experiencing pain or not.
pressure of 140/90 is considered
hypertension. Pulse greater than 100 8. (C) “The patient will identify all the
beats per minute is tachycardia. high-salt food from a prepared list by
Frequent bowel sounds refer to hyper- discharge.”. Expected outcomes are
active bowel sounds. specific, measurable, realistic
statements of goal attainment. The
2. (A) Wheezes. Wheezes are indicated by
phrases “right amount”, “less
continuous, lengthy, musical; heard
nauseated” and “enough sleep” are
during inspiration or expiration. Rhonchi
vague and not measurable.
are usually coarse breath sounds.
Gurgles are loud gurgling, bubbling 9. (C) She signs on the medication sheet
sound. Vesicular breath sounds are low after administering the medication.A
pitch, soft intensity on expiration. nurse should record
a nursing intervention (ex. Giving
medications) after performing
3. (B) 37.95 degrees C. To convert °F to °C
the nursing intervention (not before).
use this formula, ( °F – 32 ) (0.55). While
Recording should also be done using a
when converting °C to °F use this
pen, be complete, and signed with the
formula, ( °C x 1.8) + 32. Note that 0.55
nurse’s full name and title.
is 5/9 and 1.8 is 9/5.
10. (C) Concern for privacy. A patient’s
privacy may be violated if security
4. (D) Trial and error. The trial and error
measures aren’t used properly or if
method of problem solving isn’t
policies and procedures aren’t in place
systematic (as in the scientific
that determines what
method of problem solving) routine, or
type of information can be retrieved, by
based on inner prompting (as in the
whom, and for what purpose.
intuitive method of problem solving).
11. (B) Sister Callista Roy. Sister Roy’s theory
5. (C) Assessing, diagnosing, planning,
is called the adaptation theory and she
implementing, evaluating. The correct
viewed each person as a unified
order of the nursing process is
biophysical system in constant
assessing, diagnosing, planning,
interaction with a changing
implementing, evaluating.
environment. Orem’s theory is called
6. (C) Nursing care plan. The outcome, or self-care deficit theory and is based on
the product of the planning the belief that individual has a need for
phase of the nursing process is self-care actions. King’s theory is the
a Nursing care plan. Goal attainment theory and
described nursing as a helping
profession that assists individuals and
groups in society to attain, maintain, high, this results to very rapid
and restore health. Henderson introduction of feeding. This may trigger
introduced the nature of nursing model nausea and vomiting.
and identified the 14 basic needs.
19. (D) Educator. When teaching a patient
12. (B) Nurse and patient. Although about medications before discharge,
diagnosing is basically the nurse’s the nurse is acting as an educator. A
responsibility, input from the patient is caregiver provides direct care to the
essential to formulate the patient. The nurse acts as s patient
correct nursing diagnosis. advocate when making the patient’s
wishes known to the doctor.
13. (C) Health belief. Health belief of an
individual influences his/her preventive 20. (C) Capillary refill greater than 3
health behavior. seconds and buccal cyanosis. Capillary
refill greater than 3 seconds and buccal
14. (D) Decreased urine output. Adreno-
cyanosis indicate decreased oxygen to
cortical response involves
the tissues which requires immediate
release of aldosterone that leads to
attention/intervention. Oriented to
retention of sodium and water. This
date, time and place, hemoglobin of 13
results to decreased urine output.
g/dl are normal data.
15. (D) Aspirate urine from the tubing port
21. (C) Patient’s NGT was removed 2 hours
using a sterile syringe. The nurse should
ago. The change-of-shift report should
aspirate the urine from the port using a
indicate significant recent changes in
sterile syringe to obtain a urine
the patient’s condition that the nurse
specimen. Opening a closed drainage
assuming responsibility for care of the
system increase the risk of urinary tract
patient will need to monitor. The other
infection.
options are not critical enough to
16. (A) Stop the infusion. The sign and include in the report.
symptoms indicate extravasation so the
22. (A) “The patient will experience
IVF should be stopped immediately and
decreased frequency of bowel
put warm not cold towel on the
elimination.” The goal is the opposite,
affected site.
healthy response of the problem
17. (B) After few minutes, return to that statement of the nursing diagnosis. In
patient’s room and do not leave until this situation, the problem statement is
the patient takes the medication. This is diarrhea.
to verify or to make sure that the
23. (C) Making of individualized patient
medication was taken by the patient as
care. To be effective, the nursing care
directed.
plan developed in the planning
18. (A) Place the feeding 20 inches above phase of the nursing process must
the pint if insertion of NGT. The reflect the individualized needs of the
height of the feeding is above 12 inches patient.
above the point of insertion, bot 20
24. (A) Ineffective breathing pattern related
inches. If the height of feeding is too
to pain, as evidenced by
shortness of breath.. Physiologic needs
(ex. Oxygen, fluids, nutrition) must be
met before lower needs (such as safety
and security, love and belongingness,
self-esteem and self-actualization) can
be met. Therefore, physiologic needs
have the highest priority.
25. (D) 0 degree. The patient should be

positioned with the head of the bed
completely flattened to perform an
abdominal examination. If the
head of the bed is elevated, the
abdominal muscles and organs can be
bunched up, altering the findings.
1. A patient is wearing a soft wrist-safety device. D. goal-oriented
Which of the following nursing assessment is
6. A skin lesion which is fluid-filled, less than 1
considered abnormal?
cm in size is called:
A. Palpable radial pulse
A. papule
B. Palpable ulnar pulse
B. vesicle
C. Capillary refill within 3 seconds
C. bulla
D. Bluish fingernails, cool and pale fingers
D. macule
2. Pia’s serum sodium level is 150 mEq/L.
7. During application of medication into the ear,
Which of the following food items does the
which of the following is
nurse instruct Pia to avoid?
inappropriate nursing action?
A. broccoli
A. In an adult, pull the pinna upward.
B. sardines
B. Instill the medication directly into the
C. cabbage tympanic membrane.
D. tomatoes C. Warm the medication at room or body

temperature.
3. Jason, 3 years old vomited. His mom stated,
“He vomited 6 ounces of his formula this D. Press the tragus of the ear a few times
morning.” This statement is an example of: to assist flow of medication into the ear
canal.
A. objective data from a secondary source
8. Which of the following is
B. objective data from a primary source
appropriate nursing intervention for a client
C. subjective data from a primary source who is grieving over the death of her child?
D. subjective data from a secondary source A. Tell her not to cry and it will be better.
4. Which of the following is a nursing diagnosis? B. Provide opportunity to the client to tell
their story.
A. Hypethermia
C. Encourage her to accept or to replace
B. Diabetes Mellitus the lost person.
C. Angina D. Discourage the client in expressing her
D. Chronic Renal Failure emotions.
5. What is the 9. It is the gradual decrease of the body’s

characteristic of the nursing process? temperature after death.
A. stagnant A. livor mortis
B. inflexible B. rigor mortis
C. asystematic C. algor mortis

D. none of the above type of nursing intervention is the nurse
performing?
10. When performing an admission assessment
on a newly admitted patient, the nurse A. Independent
percusses resonance. The nurse knows that
B. Dependent
resonance heard on percussion is most
commonly heard over which organ? C. Collaborative
A. thigh D. Professional
B. liver 15. Claire is admitted with a diagnosis of chronic
shoulder pain. By definition, the nurse
C. intestine
understands that the patient has had pain for
D. lung more than:
11. The nurse is aware that Bell’s palsy affects A. 3 months

which cranial nerve?
B. 6 months
A. 2nd CN (Optic)
C. 9 months
B. 3rd CN (Occulomotor)
D. 1 year
C. 4th CN (Trochlear)
16. Which of the following statements regarding
D. 7th CN (Facial) the nursing process is true?
12. Prolonged deficiency of Vitamin B9 leads to: A. It is useful on outpatient settings.
A. scurvy B. It progresses in separate, unrelated

steps.
B. pellagra
C. It focuses on the patient, not the nurse.
C. megaloblastic anemia
D. It provides the solution to all patient
D. pernicious anemia
health problems.
13. Nurse Cherry is teaching a 72 year old
17. Which of the following is considered
patient about a newly prescribed medication.
significant enough to require immediate
What could cause a geriatric patient to have
communication to another member of the
difficulty retaining knowledge about the newly
health care team?
prescribed medication?
A. Weight loss of 3 lbs in a 120 lb female
A. Absence of family support
patient.
B. Decreased sensory functions
B. Diminished breath sounds in patient
C. Patient has no interest on learning with previously normal breath sounds
D. Decreased plasma drug levels C. Patient stated, “I feel less nauseated.”
14. When assessing a patient’s D. Change of heart rate from 70 to 83

level of consciousness, which beats per minute.
18. To assess the adequacy of food intake, to very shallow breathing and
which of the following assessment parameters temporary apnea.
is best used?
D. Increased rate and depth of respiration.
A. food preferences
22. Presty has terminal cancer and she refuses
B. regularity of meal times to believe that loss is happening ans she
assumes artificial cheerfulness. What
C. 3-day diet recall
stage of grieving is she in?
D. eating style and habits
A. depression
19. Van Fajardo is a 55 year old who was
B. bargaining
admitted to the hospital with newly diagnosed
hepatitis. The nurse is doing a patient teaching C. denial
with Mr. Fajardo. What kind of role does the
D. acceptance
nurse assume?
23. Immunization for healthy babies and
A. talker
preschool children is an example of what
B. teacher level of preventive health care?
C. thinker A. Primary
D. doer B. Secondary
20. When providing a continuous enteral C. Tertiary

feeding, which of the following action is
D. Curative
essential for the nurse to do?
24. Which is an example of a subjective data?
A. Place the client on the left side of the
bed. A. Temperature of 38 0C
B. Attach the feeding bag to the current B. Vomiting for 3 days
tubing.
C. Productive cough
C. Elevate the head of the bed.
D. Patient stated, “My arms still hurt.”
D. Cold the formula before administering
it. 25. The nurse is assessing the endocrine system.
Which organ is part of the endocrine system?
21. Kussmaul’s breathing is;
A. Heart
A. Shallow breaths interrupted by apnea.
B. Sinus
B. Prolonged gasping inspiration followed
by a very short, usually inefficient C. Thyroid
expiration. D. Thymus
C. Marked rhythmic waxing and
waning of respirations from very deep
nswers and Rationales The right thing to do is instill the
medication along the lateral wall of the
1. (D) Bluish fingernails, cool and pale
auditory canal.
fingers. A safety device on the wrist may
impair blood circulation. Therefore, the 8. (B) Provide opportunity to the client to
nurse should assess the patient for tell their story. Providing a grieving
signs of impaired circulation such as person an opportunity to tell their story
bluish fingernails, cool and pale fingers. allows the person to express feelings.
Palpable radial and ulnar pulses, This is therapeutic in assisting the client
capillary refill within 3 seconds are all resolve grief.
normal findings.
9. (C) algor mortis. Algor mortis is the
2. (B) sardines. The normal serum sodium decrease of the body’s temperature
level is 135 to 145 mEq/L, the client is after death. Livor mortis is the
having hypernatremia. Pia should avoid discoloration of the skin after death.
food high in sodium like processed food. Rigor mortis is the stiffening of the body
Broccoli, cabbage and tomatoes are that occurs about 2-4 hours after death.
good source of Vitamin C.
10. (D) lung. Resonance is loud, low-pitched
3. (A) objective data from a secondary and long duration that’s heard most
source. Jason is the primary source; his commonly over an air-filled tissue such
mother is a secondary source. The data as a normal lung.
is objective because it can be perceived
11. (D) 7th CN (Facial). Bells’ palsy is the
by the senses, verified by another
paralysis of the motor
person observing the same patient, and
component of the 7th caranial nerve,
tested against accepted standards or
resulting in facial sag, inability to close
norms.
the eyelid or the mouth, drooling, flat
4. (A) Hypethermia. Hyperthermia is a nasolabial fold and loss of taste on the
NANDA-approved nursing diagnosis. affected side of the face.
Diabetes Mellitus, Angina and Chronic
12. (C) megaloblastic anemia. Prolonged
Renal Failure are medical diagnoses.
Vitamin B9 deficiency will lead to
5. (D) goal-oriented. The nursing process is megaloblastic anemia while pernicious
goal-oriented. It is also systematic, anemia results in deficiency in Vitamin
patient-centered, and dynamic. B12. Prolonged deficiency of Vitamin C
leads to scurvy and Pellagra results in
6. (B) vesicle. Vesicle is a circumscribed
deficiency in Vitamin B3.
circulation containing serous fluid or
blood and less than 1 cm (ex. Blister, 13. (B) Decreased sensory
chicken pox). functions. Decreased in sensory
functions could cause a geriatric patient
7. (B) Instill the medication directly into
to have difficulty retaining knowledge
the tympanic membrane. During the
about the newly prescribed
application of medication it is
medications. Absence of family support
inappropriate to instill the medication
and no interest on learning may affect
directly into the tympanic membrane.
compliance, not knowledge retention.
Decreased plasma levels do not alter enteral tubing should be changed every
patient’s knowledge about the drug. 24 hours to limit microbial growth.
14. (A) 21. (D) Increased rate and

Independent. Independent nursing inter depth of respiration. Kussmaul
ventions involve actions that nurses breathing is also called as
initiate based on their own knowledge hyperventilation. Seen in metabolic
and skills without the direction or acidosis and renal failure. Option A
supervision of another member of the refers to Biot’s breathing. Option B is
health care team. apneustic breathing and option C is the
Cheyne-stokes breathing.
15. (B) 6 months. Chronic pain s usually
defined as pain lasting longer than 6 22. (C) denial. The client is in denial stage
months. because she is unready to face the
reality that loss is happening and she
16. (C) It focuses on the patient, not the
assumes artificial cheerfulness.
nurse. The nursing process is patient-
centered, not nurse-centered. It can be 23. (A) Primary. The primary level focuses
use in any setting, and the steps are on health promotion. Secondary level
related. The nursing process can’t solve focuses on health maintenance. Tertiary
all patient health problems. focuses on rehabilitation. There is n
Curative level of preventive health care
17. (B) Diminished breath sounds in patient
problems.
with previously normal breath
sounds. Diminished breath sound is a 24. (D) Patient stated, “My arms still
life threatening problem therefore it is hurt.”. Subjective data are apparent only
highly priority because they pose the to the person affected and can or
greatest threat to the patient’s well- verified only by that person.
being.
25. (C) Thyroid. The thyroid is part of the
18. (C) 3-day diet recall. 3-day diet recall is endocrine system. Heart, sinus and
an example of dietary history. This is thymus are not.
used to indicate the adequacy of food
intake of the client.
19. (B) teacher. The nurse will assume the

role of a teacher in this therapeutic
relationship. The other roles are
inappropriate in this situation.
20. (C) Elevate the head of the

bed. Elevating the head of the bed
during an enteral feeding prevents
aspiration. The patient may be placed
on the right side to prevent aspiration.
Enteral feedings are given at room
temperature to lessen GI distress. The
1. In accordance with standard precaution A. Oral method
guidelines, when should a nurse wear gloves B. Axillary method
during nursing interventions? C. Arterial line method
D. Rectal method
A. Taking a patient’s blood pressure
B. Assisting a patient with eating 6. When providing mouth care for an
C. Taking care of a patient’s hair unconscious patient, the most appropriate
D. Performing oral hygiene tasks position for the patient is:
2. When a nurse is preparing to measure the A. Fowler’s position

temperature of an alert patient admitted to the B. Side-lying position
hospital due to dehydration caused by vomiting C. Supine position
and diarrhea, which method is most D. Semi-Fowler’s position
appropriate?
7. To ensure the safety of a patient who is
A. Oral method hospitalized for the first time, which of the
B. Axillary method following actions should be taken?
C. Radial method
A. Remove unnecessary furniture to prevent
D. Rectal method
obstacles
3. A nurse measures a patient’s pulse rate and B. Maintain appropriate lighting at all times
discovers that it is higher than normal. The C. Keep side rails raised when necessary
nurse should document this finding as: D. Ensure the floor is clean and free of hazards
A. Tachypnea 8. A walk-in patient visits the clinic,

B. Hypotension complaining of abdominal pain and diarrhea.
C. Arrhythmia After taking the patient’s vital signs, which
D. Tachycardia phase of the nursing process is the nurse
implementing?
4. When a nurse is assisting a patient in getting
up from a chair, which of the following actions A. Assessment
should be taken to establish a wide B. Diagnosis
base of support? C. Planning
D. Implementation
A. Bend at the waist, position arms beneath the
patient’s arms, and lift 9. The following term is best described as a
B. Face the patient, bend knees, place hands on systematic, rational method of planning and
patient’s forearms, and lift providing nursing care for individuals, families,
C. Position their feet apart to maintain balance groups, and communities:
D. Maintain firm contact with the patient during
A. Assessment
the transfer
B. Nursing Process
5. A patient has undergone oral surgery after a C. Diagnosis
motor vehicle accident. The nurse assessing the D. Evaluation
patient notices flushed and warm skin.
10. In which organ does the exchange of gasses
Which of the following methods would be the
primarily occur?
most appropriate to measure the patient’s body
temperature?
A. Kidneys 16. Which of the following is a
B. Lungs component of Orem’s self-care
C. Intestines deficit nursing theory?
D. Heart
A. Maintenance of a sufficient intake of air
11. Which chamber of the heart receives B. Self-actualization
oxygen-rich blood from the lungs? C. Love and belonging
D. Physiologic needs
A. Left atrium
B. Right atrium 17. Which of the following clusters of data are
C. Left ventricle part of Maslow’s hierarchy of needs?
D. Right ventricle
A. Love and belonging
12. Which muscular, enlarged pouch or sac, B. Physiological needs
located slightly to the left, temporarily stores C. Safety and security
food? D. All of the above
A. Gallbladder 18. Which term is characterized by severe

B. Large intestine symptoms of relatively short duration?
C. Stomach
A. Chronic Illness
D. Small intestine
B. Acute Illness
13. What is the body’s ability to protect itself C. Pain
against harmful invading agents such as D. Infection
bacteria, toxins, viruses, and foreign bodies
19. Which of the following represents a nurse’s
called?
role in health promotion?
A. Hormones
A. Health risk appraisal
B. Inflammation
B. Teach client to be an effective health
C. Immunity
consumer
D. Glands
C. Worksite wellness
14. Which hormones are secreted by the D. None of the above
Islets of Langerhans?
20. Which term is used to describe a
A. Progesterone group of people who share certain
B. Testosterone aspects of their lives?
C. Insulin
A. Family
D. Hemoglobin
B. Illness
15. Which part of the eye is a transparent C. Community
membrane responsible for focusing incoming D. Population
light onto the retina?
21. Five teaspoons are equivalent to how many
A. Lens milliliters (ml)?
B. Iris
A. 30 ml
C. Cornea
B. 25 ml
D. Pupils
C. 15 ml A. 2
D. 22 ml B. 20
C. 2000
22. How many liters are equivalent to 1800
D. 200
milliliters (ml)?
29. One cup is equivalent to how many ounces?
A. 1.8
B. 18,000 A. 8
C. 180 B. 80
D. 18 C. 16
D. 4
23. Which abbreviation represents drops?
E. 7
A. Gtd.
30. What is the safest method for a nurse to
B. Gtts.
verify a client’s identity before administering
C. Dp.
medication?
D. Dr.
A. Ask the client their name
24. What is the abbreviation for micro drop?
B. Check the client’s identification band
A. µgtt C. State the client’s name aloud and have the
B. gtt client repeat it
C. mdr D. Verify the client’s social security number
D. µdrop
31. The nurse prepares to administer buccal
25. What does the abbreviation PRN stand for? medication. The medicine should be placed…
A. When advised A. On the client’s skin

B. Immediately B. Between the client’s cheeks and gums
C. When necessary C. Under the client’s tongue
D. Before meals D. In the client’s ear canal
26. What is the correct meaning of the 32. Which of the following positions is
abbreviation CBR? commonly used by a nurse for administering a
cleansing enema?
A. Cardiac Board Room
B. Complete Bathroom A. Left lateral Sims
C. Complete Bed Rest B. Dorsal recumbent
D. Comprehensive Bed Rest C. Trendelenburg
D. Prone
27. One teaspoon (tsp) is equivalent to how
many drops? 33. A patient experiences difficulty swallowing a
capsule medication. What should the nurse do
A. 15 to address this issue?
B. 60
C. 45 A. Dissolve the capsule in water
D. 30 B. Administer the capsule with a thickened
beverage
28. 20 cubic centimeters (cc) is equivalent to C. Inquire about the availability of a liquid
how many milliliters (ml)? formulation
D. Crush the capsule and place it under the C. Complete both sides of the bed at once
patient’s tongue D. Use disposable gloves while handling linens
34. Which of the following routes is suitable for 40. What is the primary
administering insulin? objective of administering a cleansing bed bath?
A. Intramuscular (IM) A. Provide hygiene, comfort, and refreshment

B. Intradermal (ID) for bedridden patients
C. Subcutaneous (SC) B. Expose essential body parts for examination
D. Transdermal (TD) C. Stimulate circulation in immobile patients
D. Assess the body temperature of a client in
35. The nurse receives an order to administer
bed
ampicillin capsules TID p.o. The medication
should be given… 41. Which medical examination technique
primarily utilizes the sense of vision?
A. Three times a day, taken orally
B. Four times a day, taken orally A. Inspection
C. Twice a day, taken by mouth B. Palpation
D. Twice a day, before meals C. Percussion
D. Auscultation
36. Back care can best be defined as:
42. Which technique is typically utilized first
A. Caring for the back by means of massage
when examining a patient’s abdomen?
B. Cleansing the back area
C. Applying a cold compress to the back A. Palpation
D. Applying a hot compress to the back B. Auscultation
C. Percussion
37. Which term describes the
D. Inspection
process of arranging a bed with fresh linens?
43. Which physical examination technique is
A. Bed bath
employed to evaluate airflow within the
B. Bed making
tracheobronchial tree?
C. Bed styling
D. Bed lining A. Palpation
B. Auscultation
38. What is the primary reason for
C. Inspection
handwashing?
D. Percussion
A. Enhancing hand circulation
44. Which tool is commonly utilized for the
B. Inhibiting the transmission of microorganisms
auscultation technique during a physical
C. Refraining from touching others with unclean
examination?
hands
D. Improving skin appearance A. Reflex hammer
B. Otoscope
39. How can one prevent contamination of the
C. Stethoscope
surroundings while making a bed?
D. Sphygmomanometer
A. Refrain from shaking soiled linens
45. How can resonance, a term related to
B. Remove all linens simultaneously
medical percussion, be best characterized?
A. Sounds generated by air-filled lungs C. Inject the medication at a 45-degree angle
B. Brief, high-pitched, and dull in nature D. Employ the Z-track technique
C. Of moderate volume and possessing a
musical quality
D. Resembling the sound of a drum
46. Which of the following positions is most

suitable for performing a rectal examination?
A. Prone (Face-down position)

B. Fowler’s position
C. Knee-chest position
D. Lithotomy position
47. What term is used to describe a person’s

style of walking?
A. Gait
B. Locomotion
C. Ambulation
D. Hopping
48. When a nurse requests a patient to read the

Snellen chart, which of the following senses is
being assessed?
A. Optic
B. Olfactory
C. Oculomotor
D. Gustatory
49. In nursing terminology, an alternative term

for the knee-chest position can be referred to
as:
A. Genu-dorsal
B. Genu-pectoral
C. Lithotomy
D. Trendelenburg
50. The nurse is preparing an intramuscular (IM)

injection containing an irritant to subcutaneous
tissue. To prevent tracking of the medication,
the most suitable action would be to:
A. Massage the injection site after

administration
B. Apply ice to the injection site prior to
administration
Answers and Rationales Incorrect answer options:
1. Correct answer: A. Oral method. The oral method is not the

most appropriate choice in this situation, as the
D. Performing oral hygiene tasks. Standard
patient may have difficulty keeping the
precautions are designed to protect healthcare
thermometer in place due to vomiting.
workers and patients from the
Additionally, there is a risk of aspiration if the
spread of infection. In accordance with these
patient vomits during the temperature
guidelines, a nurse should wear gloves when
measurement.
performing oral hygiene tasks. This is because
oral hygiene tasks may involve contact with the C. Radial method. There is no standard radial
patient’s saliva, blood, or mucous membranes, method for measuring a patient’s temperature.
which could potentially transmit pathogens. The radial pulse is used to assess circulation, not
temperature.
Incorrect answer options:
D. Rectal method. While the rectal method is
A. Taking a patient’s blood pressure. Wearing
considered to be accurate, it is invasive and can
gloves is not typically required when taking a
cause discomfort. It is also contraindicated in
patient’s blood pressure, as there is minimal
patients with diarrhea due to the increased
risk of contact with bodily fluids. However, if the
risk of infection and tissue damage.
nurse anticipates contact with blood or other
bodily fluids, gloves should be worn. 3. Correct answer:
B. Assisting a patient with eating. Gloves are not D. Tachycardia. When a patient’s pulse rate is
usually necessary when assisting a patient with higher than normal, the nurse should document
eating, as there is a low risk of exposure to this finding as tachycardia. Tachycardia refers to
bodily fluids. If the nurse has cuts or open a rapid heartbeat, typically defined as a heart
wounds on their hands, they should wear gloves rate greater than 100 beats per minute in
to protect themselves and the patient. adults.
C. Taking care of a patient’s hair. Gloves are not Incorrect answer options:
typically required for hair care tasks, as the
A. Tachypnea refers to rapid breathing, not an
risk of contact with blood or other bodily fluids
increased pulse rate. It is typically defined as a
is low. However, if the nurse anticipates contact
respiratory rate greater than 20 breaths per
with blood or other bodily fluids, gloves should
minute in adults.
be worn.
B. Hypotension refers to low blood pressure,
2. Correct answer:
not an increased pulse rate. It is generally
B. Axillary method. When a patient is admitted defined as a systolic blood pressure of less than
to the hospital due to dehydration caused by 90 mm Hg and/or a diastolic blood
vomiting and diarrhea, the most appropriate pressure of less than 60 mm Hg.
method to measure their temperature is the
C. Arrhythmia refers to an irregular or abnormal
axillary method. The axillary method is non-
heartbeat, which can include a rapid, slow, or
invasive and reduces the risk of further
irregular rhythm. While tachycardia is a
discomfort or infection in a patient who is
type of arrhythmia, it specifically refers to a
already experiencing gastrointestinal symptoms.
rapid heartbeat.
4. Correct answer: invasive and avoids any potential complications
or discomfort related to the patient’s oral
B. Face the patient, bend knees, place hands on
surgery.
the patient’s forearms, and lift. When a nurse is
assisting a patient in getting up from a chair, the Incorrect answer options:
appropriate action to establish a wide
A. Oral method. The oral method is not
base of support and ensure proper body
appropriate for a patient who has undergone
mechanics is to face the patient, bend their
oral surgery, as it may cause discomfort or
knees, place their hands on the patient’s
exacerbate the patient’s existing oral issues.
forearms, and lift. This technique helps maintain
stability and balance while preventing injuries to C. Arterial line method. The arterial line
both the patient and the nurse. method, while accurate, is invasive and typically
reserved for critically ill patients who require
continuous blood pressure and blood gas
A. Bend at the waist, position arms beneath the monitoring. It is not necessary for measuring
patient’s arms, and lift. This technique does not the body temperature of a patient who has
provide a wide base of support, and bending at undergone oral surgery and is not critically ill.
the waist can put unnecessary strain on the
D. Rectal method. The rectal method is accurate
nurse’s back, increasing the risk of injury.
but invasive, which makes it less appropriate for
C. Position their feet apart to maintain balance. a patient who has undergone oral surgery and is
While positioning feet apart does provide a not critically ill. The axillary method is a more
wider base of support, it is not the complete suitable choice for this patient, as it is non-
action required for safely assisting a patient in invasive and avoids potential complications or
getting up from a chair. Facing the patient, discomfort related to the oral surgery.
bending knees, placing hands on the patient’s
6. Correct answer:
forearms, and lifting provides a more
comprehensive technique to ensure safety and B. Side-lying position. When providing mouth
proper body mechanics. care for an unconscious patient, the most
appropriate position is the side-lying position.
D. Maintain firm contact with the patient during
This position allows for better drainage of oral
the transfer. While maintaining contact with the
secretions and helps prevent aspiration of fluids
patient during the transfer is important, it is not
into the lungs.
the primary action for establishing a wide
base of support. Facing the patient, bending Incorrect answer options:
knees, placing hands on the patient’s forearms,
and lifting better addresses the proper A. Fowler’s position. Although this position may
technique for assisting a patient in getting up be helpful for some procedures, it is not ideal
from a chair. for providing mouth care for an unconscious
patient, as it does not provide adequate
5. Correct answer: protection against aspiration.
B. Axillary method. For a patient who has C. Supine position. This position is not
undergone oral surgery, the most appropriate appropriate for mouth care in an unconscious
method to measure body temperature is the patient, as it increases the risk of aspiration due
axillary method. The axillary method is non-
to pooling of secretions in the back of the A. Assessment. When a nurse takes the patient’s
throat. vital signs, they are implementing the
assessment phase of the nursing process.
D. Semi-Fowler’s position. While the semi-
Assessment is the first step and involves
Fowler’s position may be more comfortable for
collecting data about the patient’s health status,
some patients, it is not the best choice for
including physiological, psychological, and
providing mouth care for an unconscious
sociocultural factors.
patient, as it does not offer optimal protection
against aspiration. Incorrect answer options:
7. Correct answer: B. Diagnosis. The diagnosis phase involves

analyzing the collected data from the
C. Keep side rails raised when necessary. To
assessment phase, identifying actual or
ensure the safety of a patient who is
potential health problems, and
hospitalized for the first time, it is important to
formulating nursing diagnoses.
keep side rails raised when necessary. This
provides additional support, prevents falls, and C. Planning. During the planning phase, the
helps the patient feel more secure in an nurse sets measurable and achievable short-
unfamiliar environment. term and long-term goals based on the
identified nursing diagnoses, prioritizes these
goals, and develops a nursing care plan.
A. Remove unnecessary furniture to prevent
D. Implementation. In the implementation
obstacles. While removing unnecessary
phase, the nurse carries out the interventions
furniture can help minimize potential hazards, it
outlined in the nursing care plan to help the
is not the primary action to ensure the
patient achieve their goals and address their
safety of a patient who is hospitalized for the
health problems.
first time. Keeping side rails raised when
necessary provides a more direct and 9. Correct answer:
immediate safety measure.
B. Nursing Process. The nursing process is best
B. Maintain appropriate lighting at all times. described as a systematic, rational
Appropriate lighting is important, but it is not method of planning and providing nursing care
the most crucial action to ensure the safety of a for individuals, families, groups, and
patient who is hospitalized for the first time. communities. It is a framework that
Raising side rails when necessary is a more guides nursing practice and consists of five
specific action that directly addresses patient interrelated steps: assessment, diagnosis,
safety. planning, implementation, and evaluation.
D. Ensure the floor is clean and free of hazards. Incorrect answer options:
Keeping the floor clean and free of hazards is
A. Assessment. Assessment is the first
important, but it is not the primary action for
step of the nursing process, which involves
ensuring the safety of a patient who is
collecting data about a patient’s health status. It
hospitalized for the first time. Keeping side rails
is not the overall method for planning and
raised when necessary offers more immediate
providing nursing care.
protection and support for the patient.
8. Correct answer:
C. Diagnosis. Diagnosis is the second A. Left atrium. The left atrium is the
step of the nursing process, which involves chamber of the heart that receives oxygen-rich
identifying and prioritizing actual or potential blood from the lungs. This oxygen-rich blood
health problems based on the assessment data. returns to the heart via the pulmonary veins,
It is not the overall method for planning and which empty into the left atrium. From there,
providing nursing care. the blood is pumped into the left ventricle and
then circulated throughout the body via the
D. Evaluation. Evaluation is the final
aorta.
step of the nursing process, which involves
determining the Incorrect answer options:
effectiveness of the nursing care plan and the
B. Right atrium. The right atrium receives
patient’s progress toward achieving their goals.
oxygen-poor blood from the body through the
It is not the overall method for planning and
superior and inferior vena cava. This blood is
providing nursing care.
then pumped into the right ventricle and sent to
10. Correct answer: the lungs for oxygenation.
B. Lungs. The exchange of gasses primarily C. Left ventricle. The left ventricle pumps
occurs in the lungs. This process, known as oxygen-rich blood received from the left atrium
respiration, involves the inhalation of oxygen out to the body through the aorta. It does not
(O2) and the exhalation of carbon dioxide (CO2). directly receive blood from the lungs.
The lungs facilitate this gas exchange between
D. Right ventricle. The right ventricle pumps
the air and the bloodstream through the
oxygen-poor blood received from the right
respiratory system’s complex
atrium to the lungs through the pulmonary
network of bronchi, bronchioles, and alveoli.
arteries for oxygenation. It does not receive
Incorrect answer options: oxygen-rich blood from the lungs.
A. Kidneys. The primary function of the kidneys 12. Correct answer:

is to filter waste products and excess substances
C. Stomach. The stomach is a muscular,
(such as water, salts, and electrolytes) from the
enlarged pouch or sac located slightly to the
blood to form urine, which is then excreted
left, which temporarily stores food. The
from the body.
stomach is responsible for breaking down food
C. Intestines. The primary function of the through a combination of mechanical and
intestines is to absorb nutrients from digested chemical digestion, using stomach muscles to
food and transport them into the bloodstream. mix and churn the food and gastric juices to
Gas exchange does not primarily occur in the break it down further.
intestines.
D. Heart. The heart is responsible for pumping
A. Gallbladder. The gallbladder is a small, pear-
blood throughout the body, which carries
shaped organ that stores and concentrates bile
oxygen and nutrients to cells and removes
produced by the liver. It is not responsible for
waste products. While the heart plays a crucial
temporarily storing food.
role in circulating blood, it is not the primary
site of gas exchange. B. Large intestine. The large intestine, also
known as the colon, is responsible for absorbing
11. Correct answer:
water and electrolytes from the remaining 14. Correct answers:
indigestible food matter and forming solid waste
C. Insulin. The Islets of Langerhans are
(feces) for elimination. It does not temporarily
specialized groups of cells within the pancreas.
store food.
They secrete two important hormones, insulin
D. Small intestine. The small intestine is the and glucagon, which play crucial roles in
primary site of nutrient absorption. Here, food regulating blood glucose levels. Insulin lowers
is broken down further by enzymes and blood glucose levels by promoting the uptake
absorbed into the bloodstream. The small and storage of glucose in cells, while glucagon
intestine does not temporarily store food. raises blood glucose levels by stimulating the
breakdown of glycogen in the liver.
13. Correct answer:
C. Immunity. Immunity is the body’s ability to
protect itself against harmful invading agents A. Progesterone. Progesterone is a hormone
such as bacteria, toxins, viruses, and foreign primarily involved in the menstrual cycle,
bodies. The immune system is a complex pregnancy, and embryogenesis. It is not
network of cells, tissues, and organs that work secreted by the Islets of Langerhans but is
together to defend the body against these produced by the ovaries, placenta, and adrenal
threats. Immunity can be innate (natural or non- glands.
specific) or adaptive (acquired or specific), with
B. Testosterone. Testosterone is the primary
the latter involving the
male sex hormone, responsible for the
development of antibodies or immune cells in
development of male reproductive tissues and
response to specific pathogens.
secondary sexual characteristics. It is not
Incorrect answer options: secreted by the Islets of Langerhans but is
produced by the testes in males and the ovaries
A. Hormones. Hormones are chemical
and adrenal glands in females.
messengers produced by glands in the
endocrine system. They regulate various D. Hemoglobin. Hemoglobin is not a hormone
physiological processes in the body, such as but a protein found in red blood cells that
growth, metabolism, and reproduction, but are carries oxygen from the lungs to the body’s
not directly responsible for the body’s defense tissues and returns carbon dioxide from the
against harmful agents. tissues back to the lungs. It is not secreted by
the Islets of Langerhans.
B. Inflammation. Inflammation is a protective
response of the body’s tissues to injury or 15. Correct answer:
infection. While it plays a crucial role in the
A. Lens. The lens is the part of the eye
immune response, it is not the overall term for
responsible for focusing incoming light onto the
the body’s ability to protect itself against
retina. It is a transparent, biconvex structure
harmful agents.
situated behind the iris and the pupil. The lens
D. Glands. Glands are organs that produce and changes shape (accommodation) to adjust its
secrete substances, such as hormones, refractive power, allowing the eye to focus on
enzymes, and sweat. They do not directly objects at varying distances.
provide the body’s protection against harmful
invading agents.
B. Iris. The iris is the colored, ring-shaped C. Love and belonging. Love and belonging are
muscular structure surrounding the pupil. It also concepts from Maslow’s
controls the amount of light entering the eye by hierarchy of needs, representing the third
adjusting the size of the pupil, but it is not level of psychological needs. These needs
responsible for focusing incoming light onto the include friendship, intimacy, and family.
retina. Although essential for overall well-being, they
are not components of Orem’s self-care
C. Retina. The retina is the light-sensitive
deficit nursing theory.
layer of cells at the back of the eye that detects
light and converts it into electrical signals that D. Physiologic needs. Physiologic needs are the
are sent to the brain through the optic nerve. It most basic needs in Maslow’s hierarchy,
is not responsible for focusing incoming light. including air, water, food, shelter, sleep, and
clothing. While these needs overlap with
D. Pupils. The pupils are the black, circular
some of Orem’s universal self-care requisites,
openings in the center of the iris. They control
the term “physiologic needs” is associated with
the amount of light entering the eye by
Maslow’s theory rather than Orem’s theory.
constricting (narrowing) or dilating (widening) in
response to light conditions. The pupils 17. Correct answer:
themselves do not focus incoming light onto the
D. All of the above. Maslow’s hierarchy of needs
retina.
is a motivational theory that outlines five
16. Correct answer: levels of human needs, which are often
depicted as a pyramid. From the base to the
A. Maintenance of a sufficient intake of air.
top of the pyramid, the levels are:
Dorothea Orem’s self-care deficit nursing theory
emphasizes the importance of self-care and the 1. Physiological needs – These are the most
nurse’s role in helping patients maintain or basic needs required for survival, such as air,
regain their ability to care for themselves. water, food, shelter, sleep, and clothing.
According to Orem, there are universal self-care 2. Safety and security – These needs include
requisites (basic needs) that apply to all personal safety, financial security, health, and
individuals, including the maintenance of a protection from harm.
sufficient intake of air. This need is crucial for 3. Love and belonging – These needs involve
overall health, as oxygen is essential for cellular friendship, intimacy, family, and a
respiration and energy production. sense of connection with others.
4. Esteem – This level includes self-esteem,
respect from others, achievement, and
B. Self-actualization. Self-actualization is a confidence.
concept from Abraham Maslow’s 5. Self-actualization – This is the highest
hierarchy of needs, which is a motivational level of psychological development, where a
theory. It represents the highest person realizes their full potential, creativity,
level of psychological development and the and self-fulfillment.
realization of one’s full potential. While self-
All of the clusters of data mentioned in the
actualization is important, it is not a
answer options are part of Maslow’s
component of Orem’s self-care
hierarchy of needs.
deficit nursing theory.
18. Correct answer:
B. Acute Illness. Acute illness is characterized by appraisals to gather information and guide their
severe symptoms that have a relatively short health promotion efforts, the
duration, usually lasting for a few days to a few primary nursing role is to educate and empower
weeks. Acute illnesses often have a sudden clients.
onset and may require immediate medical
C. Worksite wellness. Worksite wellness
attention. Examples of acute illnesses include
programs focus on promoting health and
appendicitis, the flu, and pneumonia.
preventing disease in the workplace. While
Incorrect answer options: nurses may participate in or develop worksite
wellness programs, it is not a
A. Chronic Illness. Chronic illnesses are long-
specific nursing role in health promotion. The
lasting health conditions that typically last for at
nurse’s primary role is to teach clients to be
least three months and may persist for years.
effective health consumers, which can occur in
Examples of chronic illnesses include diabetes,
various settings, including worksite wellness
hypertension, and arthritis.
programs.
C. Pain. Pain is an unpleasant sensory and
D. None of the above. This answer option is
emotional experience associated with actual or
incorrect because teaching clients to be
potential tissue damage. Pain can be acute or
effective health consumers is a nurse’s role in
chronic, depending on its duration and cause,
health promotion.
but it is not a specific type of illness.
20. Correct answer:
D. Infection. Infection refers to the invasion and
multiplication of microorganisms, such as C. Community. A community is a
bacteria, viruses, and fungi, in the body. group of people who share certain
Infections can cause acute or chronic illnesses, aspects of their lives, such as geographical
but the term “infection” does not specifically location, interests, beliefs, or cultural practices.
describe a severe, short-duration illness. Communities can be small, like neighborhoods,
or large, such as cities or countries. In public
19. Correct answer:
health and nursing, understanding the dynamics
B. Teach clients to be an effective health and needs of a community is essential for
consumer. A nurse’s role in health promotion promoting health, preventing disease, and
involves educating and empowering clients to providing healthcare services.
take control of their health, make informed
decisions, and adopt healthy lifestyle habits. By
teaching clients to be effective health A. Family. A family is a group of individuals who
consumers, nurses help them understand their are related by blood, marriage, or adoption, or
health needs, access appropriate resources, and who consider themselves family through
make choices that promote overall well-being. emotional bonds and support. Although families
can be part of a community, the term “family”
does not describe a broader group of people
A. Health risk appraisal. Health risk appraisal is who share aspects of their lives.
an assessment tool used to evaluate an
B. Illness. Illness refers to the subjective
individual’s risk factors and health behaviors,
experience of a person’s health condition or
but it is not a specific nursing role in health
promotion. While nurses may use health risk
disease. It does not describe a group of people A. Gtd. This abbreviation is not used to
who share certain aspects of their lives. represent drops in medical terms.
D. Population. A population is a C. Dp. This abbreviation is not used to represent

group of individuals who share a common drops in medical terms.
characteristic, such as age, gender, or health
D. Dr. This abbreviation is not used to represent
condition. While populations can be part of a
drops in medical terms. “Dr.” is commonly used
community, the term “population” does not
as an abbreviation for “doctor.”
specifically describe a group of people who
share aspects of their lives in the same way that 24. Correct answer:
“community” does.
A. µgtt. The abbreviation for micro drop is
21. Correct answer: “µgtt.” The symbol “µ” represents “micro” in the
metric system, and “gtt” represents “drop.”
B. 25 ml. In the metric system, 1 teaspoon is
Micro drop is used to describe very small drops,
equivalent to 5 milliliters (ml). Therefore, 5
typically in the context of intravenous (IV) fluid
teaspoons would be equivalent to 25 milliliters:
administration, where the drop size is much
5 teaspoons x 5 ml/teaspoon = 25 ml smaller than standard drop sizes.
22. Correct answer: Incorrect answer options:
A. 1.8 B. gtt. This abbreviation represents “drop” or

“drops” in medical terms but does not include
To convert milliliters (ml) to liters (L), divide the
the “micro” component.
number of milliliters by 1,000:
C. mdr. This abbreviation is not used to
1800 ml ÷ 1,000 = 1.8 L
represent micro drop in medical terms.
So, 1800 milliliters are equivalent to 1.8 liters.
D. µdrop. This abbreviation is not used to
Incorrect answer options: represent micro drop in medical terms.
B. 18,000. This option is incorrect because the 25. Correct answer:

conversion from milliliters to liters requires
C. When necessary. The abbreviation “PRN”
dividing by 1,000, not multiplying by 1,000.
stands for the Latin term “pro re nata,” which
C. 180. This option is incorrect because 1800 ml means “when necessary” or “as needed” in
is equivalent to 1.8 L, not 180 L. English. It is commonly used in healthcare to
indicate that a medication or treatment should
D. 18. This option is incorrect because 1800 ml be administered only when required by the
is equivalent to 1.8 L, not 18 L. patient’s condition.
23. Correct answer: Incorrect answer options:
B. Gtts. The abbreviation “gtts.” represents A. When advised. This option is incorrect
drops in medical terms. It is used to indicate the because PRN stands for “when necessary”
number of drops of a liquid medication or rather than “when advised.”
solution to be administered.

B. Immediately. This option is incorrect because A. 2: This option is incorrect because 20 cubic
PRN stands for “when necessary” rather than centimeters (cc) is not equivalent to 2 milliliters
“immediately.” (ml). The conversion is 1:1, so 20 cc equals 20
ml.
D. Before meals. This option is incorrect because
PRN stands for “when necessary” rather than C. 2000: This option is incorrect because 20
“before meals.” The abbreviation for “before cubic centimeters (cc) is not equivalent to 2000
meals” is “ac” (from the Latin “ante cibum”). milliliters (ml). The conversion is 1:1, so 20 cc
equals 20 ml.
26. Correct answer:
D. 200: This option is incorrect because 20 cubic
C. Complete Bed Rest. The abbreviation “CBR”
centimeters (cc) is not equivalent to 200
stands for “Complete Bed Rest.” It is used in
milliliters (ml). The conversion is 1:1, so 20 cc
healthcare to indicate that a patient should
equals 20 ml.
remain in bed and minimize physical activity,
often due to illness or injury that requires rest 29. Correct answer:
for proper healing and recovery.
A. 8. One cup is equivalent to 8 ounces. This
27. Correct answer: conversion is crucial in various fields, including
healthcare, where accurate measurements are
B. 60. One teaspoon (tsp) is equivalent to
necessary for medication administration, meal
approximately 60 drops. This conversion is
planning, and fluid intake monitoring.
especially important in the medical field, where
precise measurements are necessary for Incorrect answer options:
medication administration.
B. 80: This option is incorrect because one cup is
Incorrect answer options: not equivalent to 80 ounces. A cup contains 8
ounces, a much smaller volume than 80 ounces.
A. 15: This option is incorrect because 1
teaspoon (tsp) is equivalent to approximately 5 C. 16: This option is incorrect because one cup is
milliliters (mL) or 5 cubic centimeters (cc), not not equivalent to 16 ounces. A cup contains 8
15 drops. ounces, while 16 ounces is equivalent to 2 cups
or 1 pint.
C. 45: This option is incorrect because 45 drops
are less than the 60 drops equivalent to 1 D. 4: This option is incorrect because one cup is
teaspoon (tsp). not equivalent to 4 ounces. A cup contains 8
ounces, which is twice the volume of 4 ounces.
D. 30: This option is incorrect because 30 drops
are only half the amount of drops equivalent to 30. Correct answer:
1 teaspoon (tsp).
B. Check the client’s identification band.
28. Correct answer: Checking the client’s identification band is the
safest method for a nurse to verify a client’s
B. 20. 20 cubic centimeters (cc) is equivalent to
identity before administering medication. The
20 milliliters (ml). Both measurements
identification band provides a reliable and
represent volume and are interchangeable in
accurate source of information to confirm the
the medical field.
client’s identity, ensuring that the right
Incorrect answer options: medication is given to the right person.
Incorrect answer options: method of administration than buccal
medication.
A. Ask the client their name: This option is not
the safest method because clients may be D. In the client’s ear canal: This option is
confused, disoriented, or unable to incorrect because buccal medication is not
communicate effectively, which can lead to meant to be placed in the client’s ear canal. Otic
errors in identification. medications, not buccal medications, are
specifically formulated for administration in the
C. State the client’s name aloud and have the
ear canal to treat ear infections or other ear-
client repeat it: This option is not the safest
related conditions.
method because, like asking the client their
name, it relies on the client’s ability to 32. Correct answer:
communicate and understand the information
A. Left lateral Sims. The left lateral Sims position
correctly, which may not always be reliable.
is commonly used by a nurse for administering a
D. Verify the client’s social security number: This cleansing enema. This position involves the
option is not the safest method because social client lying on their left side with their left leg
security numbers are not routinely used for slightly flexed and the right leg flexed at a
identification purposes within healthcare greater angle, supported by a pillow. This
settings, and they should not be shared position allows for optimal flow of the enema
unnecessarily due to privacy concerns. solution into the sigmoid and descending colon,
facilitating the evacuation of stool.
31.Correct answer:
B. Between the client’s cheeks and gums. When
administering buccal medication, the medicine B. Dorsal recumbent: This option is incorrect
should be placed between the client’s cheeks because, although the dorsal recumbent
and gums. This method allows the medication position (lying on the back with knees bent and
to be absorbed directly into the bloodstream feet flat on the bed) may be used for some
through the oral mucosa, bypassing the medical procedures, it is not the optimal
gastrointestinal system, and providing a faster position for administering a cleansing enema.
onset of action.
C. Trendelenburg: This option is incorrect
Incorrect answer options: because the Trendelenburg position (lying on
the back with the head lower than the feet) is
A. On the client’s skin: This option is incorrect
not commonly used for administering a
because buccal medication is not meant to be
cleansing enema. This position is typically used
applied to the skin. Topical medications, not
to treat hypotension or to facilitate venous
buccal medications, are applied to the skin for
return.
localized effects or absorption.
D. Prone: This option is incorrect because the
C. Under the client’s tongue: This option is
prone position (lying on the stomach) is not the
incorrect because placing medication under the
optimal position for administering a cleansing
client’s tongue is called the sublingual route, not
enema. The left lateral Sims position is more
the buccal route. Sublingual medication is
effective in ensuring proper flow and
absorbed through the mucous membrane under
distribution of the enema solution.
the tongue and also bypasses the
gastrointestinal system, but it is a different 33. Correct answer:
C. Inquire about the availability of a liquid for medications that require faster absorption
formulation. When a patient experiences and are injected into the muscle tissue.
difficulty swallowing a capsule medication, the
B. Intradermal (ID): This option is incorrect
nurse should inquire about the availability of a
because insulin is not administered via the
liquid formulation. Liquid formulations can be
intradermal route. ID injections are shallow
more easily swallowed and are often a suitable
injections into the dermis and are primarily
alternative for patients who have difficulty
used for skin testing and some vaccinations.
swallowing capsules or tablets.
D. Transdermal (TD): This option is incorrect
because insulin is not administered via the
A. Dissolve the capsule in water: This option is transdermal route. Transdermal medications are
incorrect because not all capsules can be applied directly to the skin in the
dissolved in water. Some capsules have specific form of patches, gels, or creams and are
release mechanisms that can be altered if absorbed slowly through the skin.
dissolved, which could potentially affect the
35. Correct answer:
medication’s efficacy or cause adverse effects.
A. Three times a day, taken orally. When the
B. Administer the capsule with a thickened
nurse receives an order to administer ampicillin
beverage: This option may help with swallowing
capsules TID p.o., it means the medication
difficulties, but it is not the best solution. A
should be given three times a day, taken orally.
liquid formulation, if available, would be a more
“TID” stands for “ter in die,” which is Latin for
appropriate option to address the issue.
“three times a day,” and “p.o.” stands for “per
D. Crush the capsule and place it under the os,” which is Latin for “by mouth” or “orally.”
patient’s tongue: This option is incorrect
because crushing the capsule and placing it
under the patient’s tongue may alter the release B. Four times a day, taken orally: This option is
mechanism of the medication and is not the incorrect because the abbreviation “TID”
recommended method of administration. indicates that the medication should be
Additionally, not all medications can be administered three times a day, not four times a
administered sublingually (under the tongue). day.
34. Correct answer: C. Twice a day, taken by mouth: This option is
incorrect because the abbreviation “TID”
C. Subcutaneous (SC). Insulin is typically
indicates that the medication should be
administered via the subcutaneous (SC) route.
administered three times a day, not twice a day.
This method involves injecting the medication
into the fatty tissue just below the skin, allowing D. Twice a day, before meals: This option is
for slow and steady absorption of insulin into incorrect because the abbreviation “TID”
the bloodstream. indicates that the medication should be
administered three times a day, not twice a day.
Additionally, there is no information in the order
A. Intramuscular (IM): This option is incorrect regarding the administration of the medication
because insulin is not typically administered via before meals.
the intramuscular route. IM injections are used
36. Correct answer:
A. Caring for the back by means of massage. C. Bed styling: This option is incorrect because
Back care, in the context of nursing, can bed styling does not refer to a specific term or
encompass various techniques to promote the process in nursing or healthcare. It may be
overall well-being and comfort of the patient’s related to interior design, but it is not relevant
back. This includes not only cleansing the back to the question.
area but also providing massages to alleviate
D. Bed lining: This option is incorrect because
muscle tension, increase circulation, and
bed lining is not a specific term related to the
promote relaxation.
process of arranging a bed with fresh linens. The
Incorrect answer options: correct term is bed making.
B. Cleansing the back area: While cleansing the 38. Correct answer:
back area is essential for maintaining hygiene
B. Inhibiting the
and skin health, back care involves more than
transmission of microorganisms. The primary
just cleansing, such as providing massages for
reason for handwashing is to inhibit the
comfort and well-being.
transmission of microorganisms. Proper hand
C. Applying a cold compress to the back: hygiene is essential in preventing the
Applying a cold compress can be helpful in spread of infection and illness in healthcare
alleviating pain or reducing inflammation, but it settings and everyday life. By washing hands
is not the primary focus of back care. Back care regularly and effectively, healthcare providers
involves a broader range of techniques, such as can minimize the risk of transmitting
massages and maintaining hygiene. microorganisms to themselves, their patients,
and others.
D. Applying a hot compress to the back:
Applying a hot compress can be helpful in Incorrect answer options:
alleviating pain or muscle tension, but it is not
A. Enhancing hand circulation: This option is
the primary focus of back care. Back care
incorrect because, while handwashing may have
involves a broader range of techniques, such as
some minor benefits in terms of circulation, the
massages and maintaining hygiene.
primary purpose of handwashing is to inhibit
37. Correct answer: the transmission of microorganisms.
B. Bed making. Bed making refers to the C. Refraining from touching others with unclean
process of arranging a bed with fresh linens. In a hands: This option is incorrect because, while
healthcare setting, bed making is an not touching others with unclean hands is a
essential nursing skill that promotes patient good practice, the primary reason for
comfort, cleanliness, and hygiene. It also helps handwashing is to prevent the
prevent the development of pressure ulcers and transmission of microorganisms by removing
contributes to a healing environment. them from the hands.
Incorrect answer options: D. Improving skin appearance: This option is

incorrect because, while handwashing may
A. Bed bath: This option is incorrect because a
contribute to overall skin cleanliness, the
bed bath refers to the process of bathing a
primary purpose of handwashing is to inhibit
patient who is unable to get out of bed. It is a
the transmission of microorganisms.
method used to maintain personal hygiene for
bedridden patients. 39. Correct answer:
A. Refrain from shaking soiled linens.To prevent Additionally, the process can be refreshing and
contamination of the surroundings while comforting, promoting relaxation and a
making a bed, it is important to refrain from sense of cleanliness.
shaking soiled linens. Shaking the linens can
cause the spread of microorganisms and
allergens into the air and onto other surfaces. B. Expose essential body parts for examination:
Instead, gently remove the soiled linens, fold While a bed bath may involve exposing certain
them inward to contain any contaminants, and body parts, the primary objective is to provide
dispose of or launder them appropriately. hygiene, comfort, and refreshment for
bedridden patients.
C. Stimulate circulation in immobile patients:
B. Remove all linens simultaneously: This option
While a bed bath may help stimulate circulation
is incorrect because removing all linens at once
to some extent, the primary objective is to
may not be the most efficient method for bed
provide hygiene, comfort, and refreshment for
making and may not prevent
bedridden patients.
contamination of the surroundings. The key is to
handle soiled linens carefully, folding them D. Assess the body temperature of a client in
inward and avoiding shaking them. bed: Assessing body temperature is not the
primary objective of a bed bath. The main
C. Complete both sides of the bed at once: This
purpose is to provide hygiene, comfort, and
option is incorrect because completing both
refreshment for bedridden patients.
sides of the bed at once does not necessarily
prevent contamination of the surroundings. The 41. Correct answer:
focus should be on handling soiled linens
carefully and not shaking them. A. Inspection. Inspection is the medical
examination technique that primarily utilizes
D. Use disposable gloves while handling linens: the sense of vision. During inspection,
While using disposable gloves can protect the healthcare providers carefully observe the
caregiver’s hands from contaminants and patient’s appearance, body movements, and
prevent the spread of infection, this measure other visual cues to gather information about
alone does not address the their health status. Inspection is often the first
prevention of contamination in the step in a physical examination, and it can
surroundings. The primary method for provide valuable information about the
preventing contamination is to avoid shaking patient’s overall condition.
soiled linens.
40. Correct answer:
B. Palpation: Palpation primarily involves the
A. Provide hygiene, comfort, and refreshment use of touch to assess the size, shape, texture,
for bedridden patients. The primary and consistency of various body structures, such
objective of administering a cleansing bed bath as organs or masses. It does not primarily rely
is to provide hygiene, comfort, and refreshment on the sense of vision.
for bedridden patients. A bed bath helps
maintain the patient’s personal hygiene, which C. Percussion: Percussion involves tapping on
is essential for overall well-being and preventing the body’s surface to produce sounds that can
infections, skin irritations, and pressure ulcers. provide information about the underlying
structures, such as the presence of fluid, air, or airflow within the tracheobronchial tree. During
solid masses. It primarily relies on the auscultation, healthcare providers use a
sense of hearing, not vision. stethoscope to listen to breath sounds
produced by the flow of air within the lungs and
D. Auscultation: Auscultation primarily involves
airways. This technique helps assess the quality,
listening to the sounds produced by the body,
intensity, and location of breath sounds, which
such as heartbeats, breath sounds, or bowel
can provide valuable information about the
sounds, using a stethoscope. It does not
patient’s respiratory function and identify
primarily rely on the sense of vision.
potential abnormalities or conditions.
42. Correct answer:
D. Inspection. Inspection is typically the first
A. Palpation: Palpation primarily involves the
technique utilized when examining a patient’s
use of touch to assess the size, shape, texture,
abdomen. During inspection, the healthcare
and consistency of various body structures. It is
provider observes the patient’s abdominal
not the primary technique used for evaluating
contour, symmetry, skin color, and any visible
airflow within the tracheobronchial tree.
abnormalities. This initial step helps gather
information about the patient’s overall C. Inspection: Inspection primarily involves
abdominal condition before proceeding with observing the patient’s appearance, body
other examination techniques. movements, and other visual cues. Although
inspection is an essential part of the overall
respiratory assessment, it does not directly
A. Palpation: Palpation is used to assess the size, evaluate airflow within the tracheobronchial
shape, texture, and consistency of various tree.
abdominal structures, such as organs or masses.
D. Percussion: Percussion involves tapping on
However, it is not the first technique used in
the body’s surface to produce sounds that can
abdominal examination, as it typically follows
provide information about the underlying
inspection, auscultation, and percussion.
structures. While percussion is used in assessing
B. Auscultation: Auscultation is used to listen to the lungs and thoracic cavity, it does not directly
the sounds produced by the abdomen, such as evaluate airflow within the tracheobronchial
bowel sounds or vascular sounds. It is typically tree.
performed after inspection but before palpation
44. Correct answer:
and percussion.
C. Stethoscope. A stethoscope is the tool
C. Percussion: Percussion involves tapping on
commonly utilized for the auscultation
the body’s surface to produce sounds that can
technique during a physical examination. It
provide information about the underlying
allows healthcare providers to listen to internal
abdominal structures. It is typically performed
sounds produced by the body, such as
after inspection and auscultation but before
heartbeats, breath sounds, and bowel sounds.
palpation.
The stethoscope amplifies these sounds,
43. Correct answer: enabling the examiner to assess the quality,
intensity, and location of the sounds, which can
B. Auscultation. Auscultation is the physical provide valuable information about the
examination technique employed to evaluate
patient’s overall health and identify potential 46. Correct answer:
abnormalities or conditions.
C. Knee-chest position. The knee-chest position
Incorrect answer options: is most suitable for performing a rectal
examination. In this position, the patient is on
A. Reflex hammer: A reflex hammer is used to
their hands and knees, with their head down
test deep tendon reflexes and assess the
and buttocks elevated. This position provides
integrity of the nervous system, not for
optimal exposure of the rectal area and allows
auscultation.
for a more comfortable examination.
B. Otoscope: An otoscope is used to examine Alternatively, the left lateral Sims position or
the external auditory canal and tympanic lithotomy position can also be used, depending
membrane, not for auscultation. on patient comfort and the specific procedure
being performed.
D. Sphygmomanometer: A sphygmomanometer
is a device used to measure blood pressure, not Incorrect answer options:
for auscultation.
A. Prone (Face-down position): The prone
45. Correct answer: position is not ideal for a rectal examination
because it does not provide optimal
A. Sounds generated by air-filled lungs. exposure of the rectal area.
Resonance, in the context of medical
percussion, can be best characterized as the B. Fowler’s position: Fowler’s position is a semi-
sounds generated by air-filled lungs. When sitting position with the head of the bed
percussing the chest, the presence of resonance elevated. It is not typically used for rectal
typically indicates normal lung tissue filled with examinations, as it does not provide optimal
air. Resonance is low-pitched, hollow, exposure of the rectal area.
and of moderate intensity, reflecting the
D. Lithotomy position: Although the lithotomy
vibration of air within the lung tissue.
position can be used for rectal examinations,
Incorrect answer options: the knee-chest position is generally considered
more suitable. In the lithotomy position, the
B. Brief, high-pitched, and dull in nature: This patient lies on their back with their legs in
description does not accurately characterize stirrups and knees bent. This position is more
resonance. Resonance is low-pitched and commonly used for gynecological examinations
hollow, not high-pitched and dull. and procedures.
C. Of moderate volume and possessing a 47.Correct answer:
musical quality: This description is more
indicative of tympany, a sound typically heard A. Gait. Gait refers to a person’s style of walking,
over hollow, air-filled spaces like the stomach, which includes the manner, rhythm, and speed
rather than resonance. with which they move. Evaluating a person’s gait
can provide important information about their
D. Resembling the sound of a drum: This overall health, balance, coordination, and the
description also refers to tympany, not functioning of their musculoskeletal and
resonance. Tympany is characterized by a drum- nervous systems.
like sound, while resonance is associated with
air-filled lungs and has a hollow, low-pitched Incorrect answer options:
quality.
B. Locomotion: Locomotion is a broader term D. Gustatory: The gustatory sense refers to the
that refers to the act of moving or the ability to sense of taste and is not assessed using the
move from one place to another. It Snellen chart.
encompasses various types of movement,
49. Correct answer:
including walking, running, crawling, and
swimming, whereas gait specifically refers to B. Genu-pectoral. In nursing terminology, an
walking. alternative term for the knee-chest position is
the genu-pectoral position. In this position, the
C. Ambulation: Ambulation refers to the
patient is on their hands and knees, with their
act of walking or moving about, particularly for
head down and buttocks elevated. This position
therapeutic purposes or after an injury or
provides optimal exposure of the rectal area
surgery. While it involves walking, the term does
and is commonly used for rectal examinations
not specifically describe a person’s
and certain gynecological procedures.
style of walking like gait does.
D. Hopping: Hopping is a specific
form of movement that involves jumping on one A. Genu-dorsal: This term is not commonly used
foot. It does not describe a person’s general in nursing terminology and does not refer to the
style of walking. knee-chest position.
48. Correct answer: C. Lithotomy: The lithotomy position is different
from the knee-chest position. In the lithotomy
A. Optic. When a nurse requests a patient to
position, the patient lies on their back with their
read the Snellen chart, the optic sense is being
legs in stirrups and knees bent. This position is
assessed. The Snellen chart is used to evaluate
more commonly used for gynecological
visual acuity, which relies on the proper
examinations and procedures.
functioning of the optic nerve (cranial nerve II).
The chart consists of lines of letters that D. Trendelenburg: The Trendelenburg position
progressively decrease in size. By identifying the involves the patient lying on their back with the
smallest line of letters the patient can read head of the bed tilted downward, so the
accurately, the nurse can determine the patient’s head is lower than their feet. This
patient’s visual acuity. position is used in certain medical situations,
such as during shock or for certain surgical
procedures, but it is not the same as the knee-
B. Olfactory: The olfactory sense relates to the chest position.
sense of smell and is associated with the
50. Correct answer:
olfactory nerve (cranial nerve I). It is not
assessed using the Snellen chart. D. Employ the Z-track technique. When
administering an intramuscular (IM) injection
C. Oculomotor: The oculomotor nerve (cranial
containing an irritant to subcutaneous tissue,
nerve III) controls eye movement and eyelid
using the Z-track technique is the most suitable
function, as well as the constriction of the pupil.
action to prevent tracking of the medication.
Although the oculomotor nerve plays a role in
The Z-track technique involves pulling the skin
eye function, the Snellen chart specifically
and subcutaneous tissue laterally before
assesses visual acuity, which is related to the
inserting the needle. After administering the
optic nerve.
injection, the skin is released, allowing it to
return to its original position. This creates a
zigzag path that helps to seal the medication in
the muscle, preventing leakage into the
subcutaneous tissue and reducing the
risk of irritation.
A. Massage the injection site after

administration: Massaging the injection site
after administering an irritant medication may
increase the risk of spreading the medication to
the subcutaneous tissue, leading to further
irritation.
B. Apply ice to the injection site prior to

administration: Applying ice to the injection site
prior to administration may help to numb the
area and reduce pain, but it does not prevent
tracking of the medication.
C. Inject the medication at a 45-degree angle:

Injecting the medication at a 45-degree angle is
not appropriate for an intramuscular injection.
IM injections should be administered at a 90-
degree angle to ensure the medication is
deposited into the muscle tissue.
1. Nurse Brenda is teaching a patient about a B. Sagittal plane
newly prescribed drug. What could cause a
C. Midsagittal plane
geriatric patient to have difficulty retaining
knowledge about prescribed medications? D. Transverse plane
A. Decreased plasma drug levels 6. A female patient with a terminal illness is in
denial. Indicators of denial include:
B. Sensory deficits
A. Shock dismay
C. Lack of family support
B. Numbness
D. History of Tourette syndrome
C. Stoicism
2. When examining a patient with abdominal
pain the nurse in charge should assess: D. Preparatory grief
A. Any quadrant first 7. The nurse in charge is transferring a patient
from the bed to a chair. Which action does the
B. The symptomatic quadrant first
nurse take during this patient transfer?
C. The symptomatic quadrant last
A. Position the head of the bed flat
D. The symptomatic quadrant either
B. Helps the patient dangle the legs
second or third
C. Stands behind the patient
3. The nurse is assessing a postoperative adult
patient. Which of the following should the nurse D. Places the chair facing away from the
document as subjective data? bed
A. Vital signs 8. A female patient who speaks a little English
has emergency gallbladder surgery, during
B. Laboratory test result
discharge preparation, which nursing action
C. Patient’s description of pain would best help this patient understand wound
care instruction?
D. Electrocardiographic (ECG) waveforms
A. Asking frequently if the patient
4. A male patient has a soft wrist-safety device.
understands the instruction
Which assessment finding should the nurse
consider abnormal? B. Asking an interpreter to replay the
instructions to the patient.
A. A palpable radial pulse
C. Writing out the instructions and having
B. A palpable ulnar pulse
a family member read them to the
C. Cool, pale fingers patient
D. Pink nail beds D. Demonstrating the procedure and

having the patient return the
5. Which of the following planes divides the demonstration
body longitudinally into anterior and posterior
regions? 9. Before administering the evening dose of a
prescribed medication, the nurse on the
A. Frontal plane
evening shift finds an unlabeled, filled syringe in B. “Read this manual and then ask me any
the patient’s medication drawer. What should questions you may have.”
the nurse in charge do?
C. “Why don’t you listen to the radio?”
A. Discard the syringe to avoid a
D. “Let’s talk about what’s bothering you.”
medication error
13. A scrub nurse in the operating room has
B. Obtain a label for the syringe from the
which responsibility?
pharmacy
A. Positioning the patient
C. Use the syringe because it looks like it
contains the same medication the nurse B. Assisting with gowning and gloving
was prepared to give
C. Handling surgical instruments to the
D. Call the day nurse to verify the surgeon
contents of the syringe
D. Applying surgical drapes
10. When administering drug therapy to a male
geriatric patient, the nurse must stay especially 14. A patient is in the bathroom when the nurse
alert for adverse effects. Which factor makes enters to give a prescribed medication. What
geriatric patients to adverse drug effects? should the nurse in charge do?
A. Faster drug clearance A. Leave the medication at the patient’s

bedside
B. Aging-related physiological changes
B. Tell the patient to be sure to take the
C. Increased amount of neurons medication. And then leave it at the
bedside
D. Enhanced blood flow to the GI tract
C. Return shortly to the patient’s room and
11. A female patient is being discharged after
remain there until the patient takes the
cataract surgery. After providing medication
medication
teaching, the nurse asks the patient to repeat
the instructions. The nurse is performing which D. Wait for the patient to return to bed,
professional role? and then leave the medication at the
bedside
A. Manager
15. The physician orders heparin, 7,500 units, to
B. Educator
be administered subcutaneously every 6 hours.
C. Caregiver The vial reads 10,000 units per millilitre. The
nurse should anticipate giving how much
D. Patient advocate
heparin for each dose?
12. A female patient exhibits
A. ¼ ml
signs of heightened anxiety. Which response by
the nurse is most likely to reduce the patient’s B. ½ ml
anxiety?
C. ¾ ml
A. “Everything will be fine. Don’t worry.”
D. 1 ¼ ml
16. The nurse in charge measures a patient’s 20. Which human element considered by the
temperature at 102 degrees F. what is the nurse in charge during assessment can affect
equivalent Centigrade temperature? drug administration?
A. 39 degrees C A. The patient’s ability to recover
B. 47 degrees C B. The patient’s occupational hazards
C. 38.9 degrees C C. The patient’s socioeconomic status
D. 40.1 degrees C D. The patient’s cognitive abilities
17. To evaluate a patient for hypoxia, the 21. When explaining the initiation of I.V. therapy
physician is most likely to order which to a 2-year-old child, the nurse should:
laboratory test?
A. Ask the child, “Do you want me to start
A. Red blood cell count the I.V. now?”
B. Sputum culture B. Give simple directions shortly before

the I.V. therapy is to start
C. Total hemoglobin
C. Tell the child, “This treatment is for your
D. Arterial blood gas (ABG) analysis
own good”
18. The nurse uses a stethoscope to auscultate a
D. Inform the child that the needle will be
male patient’s chest. Which statement about a
in place for 10 days
stethoscope with a bell and diaphragm is true?
22. All of the following parts of the syringe are
A. The bell detects high-pitched sounds
sterile except the:
best
A. Barrel
B. The diaphragm detects high-pitched
sounds best B. Inside of the plunger
C. The bell detects thrills best C. Needle tip
D. The diaphragm detects low-pitched D. Barrel tip

sounds best
23. The best way to instill eye drops is to:
19. A male patient is to be discharged with a
A. Instruct the patient to lock upward, and
prescription for an analgesic that is a controlled
drop the medication into the
substance. During discharge teaching, the nurse
center of the lower lid
should explain that the patient must fill this
prescription how soon after the date on which it B. Instruct the patient to look ahead, and
was written? drop the medication into the
center of the lower lid
A. Within 1 month
C. Drop the medication into the inner
B. Within 3 months
canthus regardless of eye position
C. Within 6 months
D. Within 12 months
D. Drop the medication into the
center of the canthus regardless of eye
position
24. The difference between an 18G needle and

a 25G needle is the needle’s:
A. Length
B. Bevel angle
C. Thickness
D. Sharpness
25. A patient receiving an anticoagulant should

be assessed for signs of:
A. Hypotension
B. Hypertension
C. An elevated hemoglobin count
D. An increased number of erythrocytes

Answers and Rationales body into right and left regions; if
exactly midline, it is called a midsagittal
1. (B) Sensory deficits. Sensory deficits
plane. A transverse plane runs
could cause a geriatric patient to have
horizontally at a right angle to the
difficulty retaining knowledge about
vertical axis, dividing the structure into
prescribed medications. Decreased
superior and inferior regions.
plasma drug levels do not alter the
patient’s knowledge about the drug. A 6. (A) Shock dismay. Shock and dismay are
lack of family support may affect early signs of denial-the first
compliance, not knowledge retention. stage of grief. The other options are
Toilette syndrome is unrelated to associated with depression—a later
knowledge retention. stage of grief.
2. (C) The symptomatic quadrant last. The 7. (B) Helps the patient dangle the
nurse should systematically assess all legs. After placing the patient in high
areas of the abdomen, if time and the Fowler’s position and moving the
patient’s condition permit, concluding patient to the side of the bed, the nurse
with the symptomatic area. Otherwise, helps the patient sit on the edge of the
the nurse may elicit pain in the bed and dangle the legs; the nurse then
symptomatic area, causing the muscles faces the patient and places the chair
in other areas to tighten. This would next to and facing the head of the bed.
interfere with further assessment.
8. (D) Demonstrating the procedure and
3. (C) Patient’s having the patient return the
description of pain. Subjective data demonstration. Demonstrating by the
come directly from the patient and nurse with a return demonstration by
usually are recorded as direct the patient ensures that the patient can
quotations that reflect the patient’s perform wound care correctly. Patients
opinions or feelings about a situation. may claim to understand discharge
Vital signs, laboratory test result, and instruction when they do not. An
ECG waveforms are interpreter of family member may
examples of objective data. communicate verbal or written
instructions inaccurately.
4. (C) Cool, pale fingers. A safety device on
the wrist may impair circulation and 9. (A) Discard the syringe to avoid a
restrict blood supply to body tissues. medication error. As a safety
Therefore, the nurse should assess the precaution, the nurse should discard an
patient for signs of impaired circulation, unlabeled syringe that contains
such as cool, pale fingers. A palpable medication. The other options are
radial or lunar pulse and pink nail beds considered unsafe because they
are normal findings. promote error.
5. (A) Frontal plane. Frontal or coronal 10. (B) Aging-related physiological

plane runs longitudinally at a right angle changes. Aging-related physiological
to a sagittal plane dividing the body in changes account for the increased
anterior and posterior regions. A sagittal frequency of adverse drug reactions in
plane runs longitudinally dividing the geriatric patients. Renal and hepatic
changes cause drugs to clear more gloving, and provides the surgeon and
slowly in these patients. With increasing scrub nurse with supplies.
age, neurons are lost and blood flow to
14. (C) Return shortly to the patient’s room
the GI tract decreases.
and remain there until the patient takes
11. (B) Educator. When teaching a patient the medication. The nurse should return
about medications before discharge, shortly to the patient’s room and
the nurse is acting as an educator. The remain there until the patient takes the
nurse acts as a manager when medication to verify that it was taken as
performing such activities as scheduling directed. The nurse should never leave
and making patient care assignments. medication at the patient’s bedside
The nurse performs the care giving role unless specifically requested to do so.
when providing direct care, including
15. (C) ¾ ml. The nurse solves the problem
bathing patients and administering
as follows: 10,000 units/7,500 units = 1
medications and prescribed treatments.
ml/X 10,000 X = 7,500 X= 7,500/10,000
The nurse acts as a patient advocate
or ¾ ml
when making the patient’s wishes
known to the doctor. 16. (C) 38.9 degrees C. To convert
Fahrenheit degrees to centigrade, use
12. (D) “Let’s talk about what’s bothering
this formula: C degrees = (F degrees –
you.” Anxiety may result from
32) x 5/9 C degrees = (102 – 32) 5/9 +
feeling of helplessness, isolation, or
70 x 5/9 38.9 degrees C
insecurity. This response helps reduce
anxiety by encouraging the patient to 17. (D) Arterial blood gas (ABG)
express feelings. The nurse should be analysis. All of these test help evaluate
supportive and develop goals together a patient with respiratory problems.
with the patient to give the patient However, ABG analysis is the only test
some control over an anxiety-inducing evaluates gas exchange in the lungs,
situation. Because the other options providing information about patient’s
ignore the patient’s feeling and block oxygenation status.
communication, they would not reduce
anxiety. 18. (B) The diaphragm detects high-pitched
sounds best. The diaphragm of a
13. (C) Handling surgical instruments to the stethoscope detects high-pitched sound
surgeon. The scrub nurse assist the best; the bell detects low pitched
surgeon by providing appropriate sounds best. Palpation detects thrills
surgical instruments and supplies, best.
maintaining strict surgical asepsis and,
with the circulating nurse, accounting 19. (C) Within 6 months. In most cases, an
for all gauze, sponges, needles, and outpatient must fill a prescription for a
instruments. The circulating nurse controlled substance within 6
assists the surgeon and scrub nurse, months of the date on which the
positions the patient, applies prescription was written.
appropriate equipment and surgical 20. (D) The patient’s cognitive abilities. The
drapes, assists with gowning and nurse must consider the patient’s
cognitive abilities to understand drug barrel, the inside (shaft) of the plunger,
instructions. If not, the nurse must find and the needle tip must remain sterile
a family member or significant other to until after the injection.
take on the
23. (A) Instruct the patient to lock upward,
responsibility of administering
and drop the medication into the
medications in the home setting. The
center of the lower lid. Having the
patient’s ability to recover, occupational
patient look upward reduces blinking
hazards, and socioeconomic status do
and protects the cornea. Instilling drops
not affect drug administration.
in the center of the lower lid promotes
21. (B) Give simple directions shortly before absorption because the drops are less
the I.V. therapy is to start. Because a 2- likely to run into the nasolacrimal duct
year-old child has limited or out of the eye.
understanding, the nurse should give
24. (C) Thickness. Gauge is a measure of the
simple directions and
needle’s thickness: The higher the
explanations of what will occur shortly
number the thinner the shaft.
before the procedure. She should try to
Therefore, an 18G needle is
avoid frightening the child with the
considerably thicker than a 25G needle.
explanation and allow the child to make
simple choices, such as choosing the I.V. 25. (A) Hypotension. A major side
insertion site, if possible. However, she effect of anticoagulant therapy is
shouldn’t ask the child if he wants the bleeding, which can be identified by
therapy, because the answer may be hypotension (a systolic blood pressure
“No!” Telling the child that the under 100 mm Hg). Anticoagulants do
treatment is for his own good is not result in the other three conditions.
ineffective because a 2-year-old
perceives pain as a negative sensation
and cannot understand that a painful
procedure can have position results.
Telling the child how long the therapy
will last is ineffective because the 2-
year-old doesn’t have a good
understanding of time.
22. (A) Barrel. All syringes have three parts:

a tip, which connects the needle to the
syringe; a barrel, the outer part on
which the measurement scales are
printed; and a plunger, which fits inside
the barrel to expel the medication. The
external part of the barrel and the
plunger and (flange) must be handled
during the preparation and
administration of the injection.
However, the inside and trip of the

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1. Jake is complaining of shortness of breath. A.

Assessing, diagnosing, implementing,

2. The nurse listens to Mrs. Sullen’s lungs and A. Nursing history

D. She signs her charting as follow: J.R A. Low blood pressure

10. What is the disadvantage of computerized B. Warm, dry skin

A. Dorothea Orem C. Disconnect the catheter from the tubing

B. Caregiver 23. Which of the following is the most

A. Oriented to date, time and place D. Incorporation of both nursing and

B. Anxiety related to impending surgery, as

C. Risk of injury related to autoimmune

D. Impaired verbal communication related

25. When performing an abdominal

25. (D) 0 degree. The patient should be

D. tomatoes C. Warm the medication at room or body

5. What is the 9. It is the gradual decrease of the body’s

A. stagnant A. livor mortis

B. inflexible B. rigor mortis

C. asystematic C. algor mortis

11. The nurse is aware that Bell’s palsy affects A. 3 months

12. Prolonged deficiency of Vitamin B9 leads to: A. It is useful on outpatient settings.

A. scurvy B. It progresses in separate, unrelated

D. Decreased plasma drug levels C. Patient stated, “I feel less nauseated.”

14. When assessing a patient’s D. Change of heart rate from 70 to 83

20. When providing a continuous enteral C. Tertiary

14. (A) 21. (D) Increased rate and

19. (B) teacher. The nurse will assume the

20. (C) Elevate the head of the

2. When a nurse is preparing to measure the A. Fowler’s position

A. Tachypnea 8. A walk-in patient visits the clinic,

A. Gallbladder 18. Which term is characterized by severe

A. When advised A. On the client’s skin

A. Intramuscular (IM) A. Provide hygiene, comfort, and refreshment

46. Which of the following positions is most

A. Prone (Face-down position)

47. What term is used to describe a person’s

48. When a nurse requests a patient to read the

49. In nursing terminology, an alternative term

50. The nurse is preparing an intramuscular (IM)

A. Massage the injection site after

1. Correct answer: A. Oral method. The oral method is not the

7. Correct answer: B. Diagnosis. The diagnosis phase involves

A. Kidneys. The primary function of the kidneys 12. Correct answer:

D. Population. A population is a C. Dp. This abbreviation is not used to represent

22. Correct answer: Incorrect answer options:

A. 1.8 B. gtt. This abbreviation represents “drop” or

B. 18,000. This option is incorrect because the 25. Correct answer:

Incorrect answer options:

Incorrect answer options: D. Improving skin appearance: This option is

Incorrect answer options:

A. Massage the injection site after

B. Apply ice to the injection site prior to

C. Inject the medication at a 45-degree angle:

D. Pink nail beds D. Demonstrating the procedure and

A. Faster drug clearance A. Leave the medication at the patient’s

A. 39 degrees C A. The patient’s ability to recover

B. 47 degrees C B. The patient’s occupational hazards

C. 38.9 degrees C C. The patient’s socioeconomic status

D. 40.1 degrees C D. The patient’s cognitive abilities

B. Sputum culture B. Give simple directions shortly before