1. The most appropriate nursing order for a patient who develops dyspnea and shortness of breath would be…
a. Maintain the patient on strict bed rest at all times
b. Maintain the patient in an orthopneic position as needed
c. Administer oxygen by Venturi mask at 24%, as needed
d. Allow a 1 hour rest period between activities
2. The nurse observes that Mr. Adams begins to have increased difficulty breathing. She elevates the head of the bed to the high Fowler position, which decreases his respiratory distress. The nurse documents this breathing as:
a. Tachypnea
b. Eupnca
c. Orthopnea
d. Hyperventilation
3. The physician orders a platelet count to be performed on Mrs. Smith after breakfast. The nurse is responsible for:
a. Instructing the patient about this diagnostic test
b. Writing the order for this test
c. Giving the patient breakfast
d. All of the above
4. Mrs. Mitchell has been given a copy of her diet. The nurse discusses the foods allowed on a 500-mg low sodium diet. These include:
a. A ham and Swiss cheese sandwich on whole wheat bread
b. Mashed potatoes and broiled chicken
c. A tossed salad with oil and vinegar and olives
d. Chicken bouillon
5. The physician orders a maintenance dose of 5,000 units of subcutaneous heparin (an anticoagulant) daily. Nursing responsibilities for Mrs. Mitchell now include:
a. Reviewing daily activated partial thromboplastin time (APTT) and prothrombin time.
b. Reporting an APTT above 45 seconds to the physician
c. Assessing the patient for signs and symptoms of frank and occult bleeding
d. All of the above
6. The four main concepts common to nursing that appear in each of the current conceptual models are:
a. Person, nursing, environment, medicine
b. Person, health, nursing, support systems
c. Person, health, psychology, nursing
d. Person, environment, health, nursing
7. In Maslow’s hierarchy of physiologic needs, the human need of greatest priority is:
a. Love
b. Elimination
c. Nutrition
d. Oxygen
8. The family of an accident victim who has been declared brain-dead seems amenable to organ donation. What should the nurse do?
a. Discourage them from making a decision until their grief has eased
b. Listen to their concerns and answer their questions honestly
c. Encourage them to sign the consent form right away
d. Tell them the body will not be available for a wake or funeral
9. A new head nurse on a unit is distressed about the poor staffing on the 11 p.m. to 7 a.m. shift. What should she do?
a. Complain to her fellow nurses
b. Wait until she knows more about the unit
c. Discuss the problem with her supervisor
d. Inform the staff that they must volunteer to rotate
10. Which of the following principles of primary nursing has proven the most satisfying to the patient and nurse?
a. Continuity of patient care promotes efficient, cost-effective nursing care
b. Autonomy and authority for [1] planning are best delegated to a nurse who knows the patient well
c. Accountability is clearest when one nurse is responsible for the overall plan and its [2] implementation.
d. The holistic approach provides for a therapeutic relationship, continuity, and efficient nursing care.
11. If nurse administers an [3] injection to a patient who refuses that injection, she has committed:
a. Assault and battery
b. Negligence
c. Malpractice
d. None of the above
12. If patient asks the nurse her opinion about a particular physicians and the nurse replies that the physician is incompetent, the nurse could be held liable for:
a. Slander
b. Libel
c. Assault
d. Respondent superior
13. A registered nurse reaches to answer the telephone on a busy pediatric unit, momentarily turning away from a 3 month-old infant she has been weighing. The infant falls off the scale, suffering a skull fracture. The nurse could be charged with:
a. Defamation
b. Assault
c. Battery
d. Malpractice
14. Which of the following is an example of nursing malpractice?
a. The nurse administers penicillin to a patient with a documented history of allergy to the drug. The patient experiences an allergic reaction and has cerebral damage resulting from anoxia.
b. The nurse applies a hot water bottle or a heating pad to the abdomen of a patient with abdominal cramping.
c. The nurse assists a patient out of bed with the bed locked in position; the patient slips and fractures his right humerus.
d. The nurse administers the wrong medication to a patient and the patient vomits. This information is documented and reported to the physician and the nursing supervisor.
15. Which of the following signs and symptoms would the nurse expect to find when assessing an Asian patient for postoperative pain following abdominal surgery?
a. Decreased blood pressure and heart rate and shallow respirations
b. Quiet crying
c. Immobility, diaphoresis, and avoidance of deep breathing or coughing
d. Changing position every 2 hours
16. A patient is admitted to the hospital with complaints of nausea, vomiting, diarrhea, and severe abdominal pain. Which of the following would immediately alert the nurse that the patient has bleeding from the GI tract?
a. Complete blood count
b. Guaiac test
c. Vital signs
d. Abdominal girth
17. The correct sequence for assessing the abdomen is:
a. Tympanic percussion, measurement of abdominal girth, and inspection
b. Assessment for distention, tenderness, and discoloration around the umbilicus.
c. Percussions, palpation, and auscultation
d. Auscultation, percussion, and palpation
18. High-pitched gurgles head over the right lower quadrant are:
a. A sign of increased bowel motility
b. A sign of decreased bowel motility
c. Normal bowel sounds
d. A sign of abdominal cramping
19. A patient about to undergo abdominal inspection is best placed in which of the following positions?
a. Prone
b. Trendelenburg
c. Supine
d. Side-lying
20. For a rectal examination, the patient can be directed to assume which of the following positions?
a. Genupecterol
b. Sims
c. Horizontal recumbent
d. All of the above
21. During a Romberg test, the nurse asks the patient to assume which position?
a. Sitting
b. Standing
c. Genupectoral
d. Trendelenburg
22. If a patient’s blood pressure is 150/96, his pulse pressure is:
a. 54
b. 96
c. 150
d. 246
23. A patient is kept off food and fluids for 10 hours before surgery. His oral temperature at 8 a.m. is 99.8 F (37.7 C) This temperature reading probably indicates:
a. Infection
b. Hypothermia
c. Anxiety
d. Dehydration
24. Which of the following parameters should be checked when assessing respirations?
a. Rate
b. Rhythm
c. Symmetry
d. All of the above
25. A 38-year old patient’s vital signs at 8 a.m. are axillary temperature 99.6 F (37.6 C); pulse rate, 88; respiratory rate, 30. Which findings should be reported?
a. Respiratory rate only
b. Temperature only
c. Pulse rate and temperature
d. Temperature and respiratory rate
26. All of the following can cause tachycardia except:
a. Fever
b. Exercise
c. Sympathetic nervous system stimulation
d. Parasympathetic nervous system stimulation
27. Palpating the midclavicular line is the correct technique for assessing
a. Baseline vital signs
b. Systolic blood pressure
c. Respiratory rate
d. Apical pulse
28. The absence of which pulse may not be a significant finding when a patient is admitted to the hospital?
a. Apical
b. Radial
c. Pedal
d. Femoral
29. Which of the following patients is at greatest risk for developing pressure ulcers?
a. An alert, chronic arthritic patient treated with steroids and aspirin
b. An 88-year old incontinent patient with gastric cancer who is confined to his bed at home
c. An apathetic 63-year old COPD patient receiving nasal oxygen via cannula
d. A confused 78-year old patient with congestive heart failure (CHF) who requires assistance to get out of bed.
30. The physician orders the administration of high-humidity oxygen by face mask and placement of the patient in a high Fowler’s position. After assessing Mrs. Paul, the nurse writes the following nursing diagnosis: Impaired gas exchange related to increased secretions. Which of the following nursing interventions has the greatest potential for improving this situation?
a. Encourage the patient to increase her fluid intake to 200 ml every 2 hours
b. Place a humidifier in the patient’s room.
c. Continue administering oxygen by high humidity face mask
d. Perform chest physiotheraphy on a regular schedule
31. The most common deficiency seen in alcoholics is:
a. Thiamine
b. Riboflavin
c. Pyridoxine
d. Pantothenic acid
32. Which of the following statement is incorrect about a patient with dysphagia?
a. The patient will find pureed or soft foods, such as custards, easier to swallow than water
b. Fowler’s or semi Fowler’s position reduces the risk of aspiration during swallowing
c. The patient should always feed himself
d. The nurse should perform oral hygiene before assisting with feeding.
33. To assess the kidney function of a patient with an indwelling urinary (Foley) catheter, the nurse measures his hourly urine output. She should notify the physician if the urine output is:
a. Less than 30 ml/hour
b. 64 ml in 2 hours
c. 90 ml in 3 hours
d. 125 ml in 4 hours
34. Certain substances increase the amount of urine produced. These include:
a. Caffeine-containing drinks, such as coffee and cola.
b. Beets
c. Urinary analgesics
d. Kaolin with pectin (Kaopectate)
35. A male patient who had surgery 2 days ago for head and neck cancer is about to make his first attempt to ambulate outside his room. The nurse notes that he is steady on his feet and that his vision was unaffected by the surgery. Which of the following nursing interventions would be appropriate?
a. Encourage the patient to walk in the hall alone
b. Discourage the patient from walking in the hall for a few more days
c. Accompany the patient for his walk.
d. Consuit a physical therapist before allowing the patient to ambulate
36. A patient has exacerbation of chronic obstructive pulmonary disease (COPD) manifested by shortness of breath; orthopnea: thick, tenacious secretions; and a dry hacking cough. An appropriate nursing diagnosis would be:
a. Ineffective airway clearance related to thick, tenacious secretions.
b. Ineffective airway clearance related to dry, hacking cough.
c. Ineffective individual coping to COPD.
d. Pain related to immobilization of affected leg.
37. Mrs. Lim begins to cry as the nurse discusses hair loss. The best response would be:
a. “Don’t worry. It’s only temporary”
b. “Why are you crying? I didn’t get to the bad news yet”
c. “Your hair is really pretty”
d. “I know this will be difficult for you, but your hair will grow back after the completion of chemotheraphy”
38. An additional Vitamin C is required during all of the following periods except:
a. Infancy
b. Young adulthood
c. Childhood
d. Pregnancy
39. A prescribed amount of oxygen s needed for a patient with COPD to prevent:
a. Cardiac arrest related to increased partial pressure of carbon dioxide in arterial blood (PaCO2)
b. Circulatory overload due to hypervolemia
c. Respiratory excitement
d. Inhibition of the respiratory hypoxic stimulus
40. After 1 week of hospitalization, Mr. Gray develops hypokalemia. Which of the following is the most significant symptom of his disorder?
a. Lethargy
b. Increased pulse rate and blood pressure
c. Muscle weakness
d. Muscle irritability
41. Which of the following nursing interventions promotes patient safety?
a. Asses the patient’s ability to ambulate and transfer from a bed to a chair
b. Demonstrate the signal system to the patient
c. Check to see that the patient is wearing his identification band
d. All of the above
42. Studies have shown that about 40% of patients fall out of bed despite the use of side rails; this has led to which of the following conclusions?
a. Side rails are ineffective
b. Side rails should not be used
c. Side rails are a deterrent that prevent a patient from falling out of bed.
d. Side rails are a reminder to a patient not to get out of bed
43. Examples of patients suffering from impaired awareness include all of the following except:
a. A semiconscious or over fatigued patient
b. A disoriented or confused patient
c. A patient who cannot care for himself at home
d. A patient demonstrating symptoms of drugs or alcohol withdrawal
44. The most common injury among elderly persons is:
a. Atheroscleotic changes in the blood vessels
b. Increased incidence of gallbladder disease
c. Urinary Tract Infection
d. Hip fracture
45. The most common psychogenic disorder among elderly person is:
a. Depression
b. Sleep disturbances (such as bizarre dreams)
c. Inability to concentrate
d. Decreased appetite
46. Which of the following vascular system changes results from aging?
a. Increased peripheral resistance of the blood vessels
b. Decreased blood flow
c. Increased work load of the left ventricle
d. All of the above
47. Which of the following is the most common cause of dementia among elderly persons?
a. Parkinson’s disease
b. Multiple sclerosis
c. Amyotrophic lateral sclerosis (Lou Gerhig’s disease)
d. Alzheimer’s disease
48. The nurse’s most important legal responsibility after a patient’s death in a hospital is:
a. Obtaining a consent of an autopsy
b. Notifying the coroner or medical examiner
c. Labeling the corpse appropriately
d. Ensuring that the attending physician issues the death certification
49. Before rigor mortis occurs, the nurse is responsible for:
a. Providing a complete bath and dressing change
b. Placing one pillow under the body’s head and shoulders
c. Removing the body’s clothing and wrapping the body in a shroud
d. Allowing the body to relax normally
50. When a patient in the terminal stages of lung cancer begins to exhibit loss of consciousness, a major nursing priority is to:
a. Protect the patient from injury
b. Insert an airway
c. Elevate the head of the bed
d. Withdraw all pain medications
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