Nursing Test I
disease
Scope of this Nursing Test I is parallel to
the NP1 NLE Coverage:
• Foundation of Nursing
• Nursing Research
• Professional Adjustment
• Leadership and Management
All the questions in the quiz along with their
answers are shown below. Your answers
are bolded. The correct answers have a
green background while the incorrect ones
have a red background.
1. The registered nurse is planning to
delegate tasks to unlicensed assistive
personnel (UAP). Which of the following
task could the registered nurse safely
assigned to a UAP?
• A) Monitor the I&O of a comatose
toddler client with salicylate
poisoning
• B) Perform a complete bed bath on
a 2-year-old with multiple injuries
from a serious fall
• C) Check the IV of a preschooler
with Kawasaki disease
• D) Give an outmeal bath to an infant
with eczema
Bathing an infant with eczema can be safely
delegated to an aide; this task is basic and
can competently performed by an aid.
2. A nurse manager assigned a registered
nurse from telemetry unit to the pediatrics
unit. There were three patients assigned to
the RN. Which of the following patients
should not be assigned to the floated
nurse?
• A) A 9-year-old child diagnosed with
rheumatic fever
• B) A young infant after
pyloromyotomy
• C) A 4-year-old with VSD following
cardiac catheterization
• D) A 5-month-old with Kawasaki
The RN floated from the telemetry unit
would be least prepared to care for a young
infant who has just had GI surgery and
requires a specific feeding regimen.
3. A nurse in charge in the pediatric unit is
absent. The nurse manager decided to
assign the nurse in the obstetrics unit to the
pediatrics unit. Which of the following
patients could the nurse manager safely
assign to the float nurse?
• A) A child who had multiple injuries
from a serious vehicle accident
• B) A child diagnosed with Kawasaki
disease and with cardiac
complications
• C) A child who has had a
nephrectomy for Wilm’s tumor
• D) A child receiving an IV chelating
therapy for lead poisoning
RN floated from the obstetrics unit should be
able to care for a client with major
abdominal surgery, because this nurse has
experienced caring for clients with cesarean
births.
4. The registered nurse is planning to
delegate task to a certified nursing
assistant. Which of the following clients
should not be assigned to a CAN?
• A) A client diagnosed with diabetes
and who has an infected toe
• B) A client who had a CVA in the
past two months
• C) A client with Chronic renal failure
• D) A client with chronic venous
insufficiency
The patient is experiencing a potentially
serious complication related to diabetes and
needs ongoing assessment by an RN
5. The nurse in the medication unit passes
the medications for all the clients on the
nursing unit. The head nurse is making
rounds with the physician and coordinates
clients’ activities with other departments.
The nurse assistant changes the bed lines
and answers call lights. A second nurse is
assigned for changing wound dressings; a
licensed practitioner nurse takes vital signs
and bathes the clients. This illustrates of
what method of nursing care?
• A) Case management method
• B) Primary nursing method
• C) Team method
• D) Functional method
It describes functional nursing. Staff is
assigned to specific task rather than specific
clients.
6. A registered nurse has been assigned
to six clients on the 12-hour shift. The RN is
responsible for every aspect of care such as
formulating the care of plan, intervention and
evaluating the care during her shift. At the
end of her shift, the RN will pass this same
task to the next RN in charge. This nursing
care illustrates of what kind of method?
• A) primary nursing method
• B) case method
• C) team method
• D) functional method
Case management. The nurse assumes
total responsibility for meeting the needs of
the client during her entire duty.
7. A newly hired nurse on an adult
medicine unit with 3 months experience was
asked to float to pediatrics. The nurse
hesitates to perform pediatric skills and
receive an interesting assignment that feels
overwhelming. The nurse should:
• A) resign on the spot from the
nursing position and apply for a
position that does not require
floating
• B) Inform the nursing supervisor and
the charge nurse on the pediatric
floor about the nurse’s lack of skill
and feelings of hesitations and
request assistance
• C) Ask several other nurses how
they feel about pediatrics and find
someone else who is willing to
accept the assignment
• D) Refuse the assignment and leave
the unit requesting a vacation a day
The nurse is ethically obligated to inform the
person responsible for the assignment and
the person responsible for the unit about the
nurse’s skill level. The nurse therefore
avoids a situation of abandoning clients and
exposing them to greater risks
8. An experienced nurse who voluntarily
trained a less experienced nurse with the
intention of enhancing the skills and
knowledge and promoting professional
advancement to the nurse is called a:
• A) mentor
• B) team leader
• C) case manager
• D) change agent
This describes a mentor
9. The pediatrics unit is understaffed and
the nurse manager informs the nurses in the
obstetrics unit that she is going to assign
one nurse to float in the pediatric units.
Which statement by the designated float
nurse may put her job at risk?
• A) “I do not get along with one of the
nurses on the pediatrics unit”
• B) “I have a vacation day coming
and would like to take that now”
• C) “I do not feel competent to go
and work on that area”
• D) “ I am afraid I will get the most
serious clients in the unit”
This action demonstrates a lack of
responsibility and the nurse should attempt
negotiation with the nurse manager.
10. The newly hired staff nurse has been
working on a medical unit for 3 weeks. The
nurse manager has posted the team leader
assignments for the following week. The
new staff knows that a major responsibility
of the team leader is to:
 • A) Provide care to the most acutely
ill client on the team
• B) Know the condition and needs of
all the patients on the team
• C) Document the assessments
completed by the team members
• D) Supervise direct care by nursing
assistants
The team leader is responsible for the
overall management of all clients and staff
on the team, and this information is essential
in order to accomplish this
11. A 15-year-old girl just gave birth to a
baby boy who needs emergency surgery.
The nurse prepared the consent form and it
should be signed by:
• A) The Physician
• B) The Registered Nurse caring for
the client
• C) The 15-year-old mother of the
baby boy
• D) The mother of the girl
Even though the mother is a minor, she is
legally able to sign consent for her own
child.
12. A nurse caring to a client with
Alzheimer’s disease overheard a family
member say to the client, “if you pee one
more time, I won’t give you any more food
and drinks”. What initial action is best for
the nurse to take?
• A) Take no action because it is the
family member saying that to the
client
• B) Talk to the family member and
explain that what she/he has said is
not appropriate for the client
• C) Give the family member the
number for an Elder Abuse Hot line
• D) Document what the family
member has said
This response is the most direct and
immediate. This is a case of potential need
for advocacy and patient’s rights.
13. Which is true about informed consent?
• A) A nurse may accept responsibility
signing a consent form if the client is
unable
• B) Obtaining consent is not the
responsibility of the physician
• C) A physician will not subject
himself to liability if he withholds any
facts that are necessary to form the
basis of an intelligent consent
• D) If the nurse witnesses a consent
for surgery, the nurse is, in effect,
indicating that the signature is that
of the purported person and that the
person’s condition is as indicated at
the time of signing
The nurse who witness a consent for
treatment or surgery is witnessing only that
the client signed the form and that the
client’s condition is as indicated at the time
of signing. The nurse is not witnessing that
the client is “informed”.
14. A mother in labor told the nurse that
she was expecting that her baby has no
chance to survive and expects that the baby
will be born dead. The mother accepts the
fate of the baby and informs the nurse that
when the baby is born and requires
resuscitation, the mother refuses any
treatment to her baby and expresses
hostility toward the nurse while the pediatric
team is taking care of the baby. The nurse
is legally obligated to:
• A) Notify the pediatric team that the
mother has refused resuscitation
and any treatment for the baby and
take the baby to the mother
• B) Get a court order making the
baby a ward of the court
• C) Record the statement of the
mother, notify the pediatric team,
and observe carefully for signs of
impaired bonding and neglect as a
reasonable suspicion of child abuse
• D) Do nothing except record the
mother’s statement in the medical
record
Although the statements by the mother may
not create a suspicion of neglect, when they
are coupled with observations about
impaired bonding and maternal attachment,
they may impose the obligation to report
child neglect. The nurse is further obligated
to notify caregivers of refusal to consent to
treatment
15. The hospitalized client with a chronic
cough is scheduled for bronchoscopy. The
nurse is tasks to bring the informed consent
document into the client’s room for a
signature. The client asks the nurse for
details of the procedure and demands an
explanation why the process of informed
consent is necessary. The nurse responds
that informed consent means:
• A) The patient releases the
physician from all responsibility for
the procedure.
• B) The immediate family may make
decision against the patient’s will.
• C) The physician must give the
client or surrogates enough
information to make health care
judgments consistent with their
values and goals.
• D) The patient agrees to a
procedure ordered by the physician
even if the client does not
understand what the outcome will
be.
It best explains what informed consent is
and provides for legal rights of the patient
16. A hospitalized client with severe
necrotizing ulcer of the lower leg is schedule
for an amputation. The client tells the nurse
that he will not sign the consent form and he
does not want any surgery or treatment
because of religious beliefs about
reincarnation. What is the role of the RN?
• A) call a family meeting
• B) discuss the religious beliefs with
the physician
• C) encourage the client to have the
surgery
• D) inform the client of other options
The physician may not be aware of the role
that religious beliefs play in making a
decision about surgery.
17. While in the hospital lobby, the RN
overhears the three staff discussing the
health condition of her client. What would
be the appropriate nursing action for the RN
to take?
• A) Tell them it is not appropriate to
discuss the condition of the client
• B) Ignore them, because it is their
right to discuss anything they want
to
• C) Join in the conversation, giving
them supportive input about the
case of the client
• D) Report this incident to the
nursing supervisor
The behavior should be stopped. The first
step is to remind the staff that confidentiality
may be violated
18. A staff nurse has had a serious issue
with her colleague. In this situation, it is best
to:
• A) Discuss this with the supervisor
• B) Not discuss the issue with
anyone. It will probably resolve itself
• C) Try to discuss with the colleague
about the issue and resolve it when
both are calmer
• D) Tell other members of the
network what the team member did
Waiting for emotions to dissipate and sitting
down with the colleague is the first rule of
conflict resolution.
19. The nurse is caring to a client who just
gave birth to a healthy baby boy. The nurse
may not disclose confidential information
when:
• A) The nurse discusses the
condition of the client in a clinical
conference with other nurses
• B) The client asks the nurse to
discuss the her condition with the
family
• C) The father of a woman who just
delivered a baby is on the phone to
find out the sex of the baby
 • D) A researcher from an
institutionally approved research
study reviews the medical record of
a patient
The nurse has no idea who the person is on
the phone and therefore may not share the
information even if the patient gives
permission
20. A 17-year-old married client is
scheduled for surgery. The nurse taking
care of the client realizes that consent has
not been signed after preoperative
medications were given. What should the
nurse do?
• A) Call the surgeon
• B) Ask the spouse to sign the
consent
• C) Obtain a consent from the client
as soon as possible
• D) Get a verbal consent from the
parents of the client
The priority is to let the surgeon know, who
in turn may ask the husband to sign the
consent.
21. A 12-year-old client is admitted to the
hospital. The physician ordered Dilantin to
the client. In administering IV phenytoin
(Dilantin) to a child, the nurse would be
most correct in mixing it with:
• A) Normal Saline
• B) Heparinized normal saline
• C) 5% dextrose in water
• D) Lactated Ringer’s solution
Phenytoin (Dilantin) can cause venous
irritation due to its alkalinity, therefore it
should be mixed with normal saline.
22. The nurse is caring to a client who is
hypotensive. Following a large
hematemesis, how should the nurse position
the client?
• A) Feet and legs elevated 20
degrees, trunk horizontal, head on
small pillow
• B) Low Fowler’s with knees gatched
at 30 degrees
• C) Supine with the head turned to
the left
• D) Bed sloped at a 45 degree angle
with the head lowest and the legs
highest
This position increases venous return,
improves cardiac volume, and promotes
adequate ventilation and cerebral perfusion
23. The client is brought to the emergency
department after a serious accident. What
would be the initial nursing action of the
nurse to the client?
• A) assess the level of
consciousness and circulation
• B) check respirations, circulation,
neurological response
• C) align the spine, check pupils,
check for hemorrhage
• D) check respiration, stabilize spine,
check circulation
Checking the airway would be a priority, and
a neck injury should be suspected
24. A nurse is assigned to care to a client
with Parkinson’s disease. What
interventions are important if the nurse
wants to improve nutrition and promote
effective swallowing of the client?
• A) Eat solid food
• B) Give liquids with meals
• C) Feed the client
• D) Sit in an upright position to eat
Client with Parkinson’s disease are at a high
risk for aspiration and undernutrition. Sitting
upright promotes more effective swallowing.
25. During tracheal suctioning, the nurse
should implement safety measures. Which
of the following should the nurse
implements?
• A) limit suction pressure to 150-180
mmHg
• B) suction for 15-20 seconds
 • C) wear eye goggles
• D) remove the inner cannula
It is important to protect the RN’s eyes from
the possible contamination of coughed-up
secretions
26. The nurse is conducting a discharge
instructions to a client diagnosed with
diabetes. What sign of hypoglycemia should
be taught to a client?
• A) warm, flushed skin
• B) hunger and thirst
• C) increase urinary output
• D) palpitation and weakness
There has been too little food or too much
insulin. Glucose levels can be markedly
decreased (less than 50 mg/dl). Severe
hypoglycemia may be fatal if not detected
27. A client admitted to the hospital and
diagnosed with Addison’s disease. What
would be the appropriate nursing action to
the client?
• A) administering insulin-replacement
therapy
• B) providing a low-sodium diet
• C) restricting fluids to 1500 ml/day
• D) reducing physical and emotional
stress
Because the client’s ability to react to stress
is decreased, maintaining a quiet
environment becomes a nursing priority.
Dehydration is a common problem in
Addison’s disease, so close observation of
the client’s hydration level is crucial.
28. The nurse is to perform tracheal
suctioning. During tracheal suctioning,
which nursing action is essential to prevent
hypoxemia?
• A) aucultating the lungs to
determine the baseline data to
assess the effectiveness of
suctioning
• B) removing oral and nasal
secretions
• C) encouraging the patient to deep
breathe and cough to facilitate
removal of upper-airway secretions
• D) administering 100% oxygen to
reduce the effects of airway
obstruction during suctioning.
Presuctioning and postsuctioning ventilation
with 100% oxygen is important in reducing
hypoxemia which occurs when the flow of
gases in the airway is obstructed by the
suctioning catheter.
29. An infant is admitted and diagnosed
with pneumonia and suspicious-looking red
marks on the swollen face resembling a
handprint. The nurse does further
assessment to the client. How would the
nurse document the finding?
• A) Facial edema with ecchymosis
and handprint mark: crackles and
wheezes
• B) Facial edema, with red marks;
crackles in the lung
• C) Facial edema with ecchymosis
that looks like a handprint
• D) Red bruise mark and ecchymosis
on face
This is an example of objective data of both
pulmonary status and direct observation on
the skin by the nurse.
30. On the evening shift, the triage nurse
evaluates several clients who were brought
to the emergency department. Which in the
following clients should receive highest
priority?
• A) an elderly woman complaining of
a loss of appetite and fatigue for the
past week
• B) A football player limping and
complaining of pain and swelling in
the right ankle
• C) A 50-year-old man, diaphoretic
and complaining of severe chest
pain radiating to his jaw
• D) A mother with a 5-year-old boy
who says her son has been
complaining of nausea and vomited
once since noon
These are likely signs of an acute
myocardial infarction (MI). An acute MI is a
cardiovascular emergency requiring
immediate attention. Acute MI is potentially
fatal if not treated immediately.
31. A 80-year-old female client is brought to
the emergency department by her caregiver,
on the nurse’s assessment; the following are
the manifestations of the client: anorexia,
cachexia and multiple bruises. What would
be the best nursing intervention?
• A) check the laboratory data for
serum albumin, hematocrit, and
hemoglobin
• B) talk to the client about the
caregiver and support system
• C) complete a police report on elder
abuse
• D) complete a gastrointestinal and
neurological assessment
Assessment and more data collection are
needed. The client may have
gastrointestinal or neurological problems
that account for the symptoms. The anorexia
could result from medications, poor
dentition, or indigestion, and the bruises
may be attributed to ataxia, frequent falls,
vertigo or medication.
32. The night shift nurse is making rounds.
When the nurse enters a client’s room, the
client is on the floor next to the bed. What
would be the initial action of the nurse?
• A) chart that the patient fell
• B) call the physician
• C) chart that the client was found on
the floor next to the bed
• D) fill out an incident report
This is closest to suggesting action-
assessment, rather than paperwork- and is
therefore the best of the four.
33. The nurse on the night shift is about to
administer medication to a preschooler client
and notes that the child has no ID bracelet.
The best way for the nurse to identify the
client is to ask:
• A) The adult visiting, “The child’s
name is ____________________?”
• B) The child, “Is your
name____________?”
• C) Another staff nurse to identify this
child
• D) The other children in the room
what the child’s name is
The only acceptable way to identify a
preschooler client is to have a parent or
another staff member identify the client.
34. The nurse caring to a client has
completed the assessment. Which of the
following will be considered to be the most
accurate charting of a lump felt in the right
breast?
• A) “abnormally felt area in the right
breast, drainage noted”
• B) “hard nodular mass in right
breast nipple”
• C) “firm mass at five ‘ clock, outer
quadrant, 1cm from right nipple’
• D) “mass in the right breast
4cmx1cm
It describes the mass in the greatest detail.
35. The physician instructed the nurse that
intravenous pyelogram will be done to the
client. The client asks the nurse what is the
purpose of the procedure. The appropriate
nursing response is to:
• A) outline the kidney vasculature
• B) determine the size, shape, and
placement of the kidneys
• C) test renal tubular function and the
patency of the urinary tract
• D) measure renal blood flow
Intravenous pyelogram tests both the
function and patency of the kidneys. After
the intravenous injection of a radiopaque
contrast medium, the size, location, and
patency of the kidneys can be observed by
roentgenogram, as well as the patency of
the urethra and bladder as the kidneys
function to excrete the contrast medium.
36. A client visits the clinic for screening of
scoliosis. The nurse should ask the client
to:
• A) bend all the way over and touch
the toes
• B) stand up as straight and tall as
possible
• C) bend over at a 90-degree angle
from the waist
• D) bend over at a 45-degree angle
from the waist
This is the recommended position for
screening for scoliosis. It allows the nurse to
inspect the alignment of the spine, as well
as to compare both shoulders and both hips.
37. A client with tuberculosis is admitted in
the hospital for 2 weeks. When a client’s
family members come to visit, they would be
adhering to respiratory isolation precautions
when they:
• A) wash their hands when leaving
• B) put on gowns, gloves and masks
• C) avoid contact with the client’s
roommate
• D) keep the client’s room door open
Handwashing is the best method for
reducing cross-contamination. Gowns and
gloves are not always required when
entering a client’s room.
38. An infant is brought to the emergency
department and diagnosed with pyloric
stenosis. The parents of the client ask the
nurse, “Why does my baby continue to
vomit?” Which of the following would be the
best nursing response of the nurse?
• A) “Your baby eats too rapidly and
overfills the stomach, which causes
vomiting
• B) “Your baby can’t empty the
formula that is in the stomach into
the bowel”
• C) “The vomiting is due to the
nausea that accompanies pyloric
stenosis”
• D) “Your baby needs to be burped
more thoroughly after feeding”
Pyloric stenosis is an anomaly of the upper
gastrointestinal tract. The condition involves
a thickening, or hypertrophy, of the pyloric
sphincter located at the distal end of the
stomach. This causes a mechanical
intestinal obstruction, which leads to
vomiting after feeding the infant. The
vomiting associated with pyloric stenosis is
described as being projectile in nature. This
is due to the increasing amounts of formula
the infant begins to consume coupled with
the increasing thickening of the pyloric
sphincter.
39. A 70-year-old client with suspected
tuberculosis is brought to the geriatric care
facilities. An intradermal tuberculosis test is
schedule to be done. The client asks the
nurse what is the purpose of the test. Which
of the following would be the best rationale
for this?
• A) reactivation of an old tuberculosis
infection
• B) increased incidence of new
cases of tuberculosis in persons
over 65 years old
• C) greater exposure to diverse
health care workers
• D) respiratory problems are
characteristic in this population
Increased incidence of TB has been seen in
the general population with a high incidence
reported in hospitalized elderly clients.
Immunosuppression and lack of classic
manifestations because of the aging process
are just two of the contributing factors of
tuberculosis in the elderly.
40. The nurse is making a health teaching
to the parents of the client. In teaching
parents how to measure the area of
induration in response to a PPD test, the
nurse would be most accurate in advising
the parents to measure:
• A) both the areas that look red and
feel raised
• B) The entire area that feels itchy to
the child
• C) Only the area that looks
reddened
• D) Only the area that feels raised
Parents should be taught to feel the area
that is raised and measure only that.
41. A community health nurse is schedule
to do home visit. She visits to an elderly
person living alone. Which of the following
observation would be a concern?
• A) Picture windows
• B) Unwashed dishes in the sink
• C) Clear and shiny floors
• D) Brightly lit rooms
It is a safety hazard to have shiny floors
because they can cause falls.
42. After a birth, the physician cut the cord
of the baby, and before the baby is given to
the mother, what would be the initial nursing
action of the nurse?
• A) examine the infant for any
observable abnormalities
• B) confirm identification of the infant
and apply bracelet to mother and
infant
• C) instill prophylactic medication in
the infant’s eyes
• D) wrap the infant in a prewarmed
blanket and cover the head
The first priority, beside maintaining a
newborn’s patent airway, is body
temperature.
43. A 2-year-old client is admitted to the
hospital with severe eczema lesions on the
scalp, face, neck and arms. The client is
scratching the affected areas. What would
be the best nursing intervention to prevent
the client from scratching the affected
areas?
• A) elbow restraints to the arms
• B) Mittens to the hands
• C) Clove-hitch restraints to the
hands
• D) A posey jacket to the torso
The purpose of restraints for this child is to
keep the child from scratching the affected
areas. Mittens restraint would prevent
scratching, while allowing the most
movement permissible.
44. The parents of the hospitalized client
ask the nurse how their baby might have
gotten pyloric stenosis. The appropriate
nursing response would be:
• A) There is no way to determine this
preoperatively
• B) Their baby was born with this
condition
• C) Their baby developed this
condition during the first few weeks
of life
• D) Their baby acquired it due to a
formula allergy
Pyloric stenosis is not a congenital
anatomical defect, but the precise etiology is
unknown. It develops during the first few
weeks of life.
45. A male client comes to the clinic for
check-up. In doing a physical assessment,
the nurse should report to the physician the
most common symptom of gonorrhea, which
is:
• A) pruritus
• B) pus in the urine
• C) WBC in the urine
• D) Dysuria
Pus is usually the first symptom, because
the bacteria reproduce in the bladder.
46. Which of the following would be the
most important goal in the nursing care of an
infant client with eczema?
• A) preventing infection
• B) maintaining the comfort level
• C) providing for adequate nutrition
• D) decreasing the itching
Preventing infection in the infant with
eczema is the nurse’s most important goal.
The infant with eczema is at high risk for
infection due to numerous breaks in the
skin’s integrity. Intact skin is always the
infant’s first line of defense against infection.
47. The nurse is making a discharge
instruction to a client receiving
chemotherapy. The client is at risk for bone
marrow depression. The nurse gives
instructions to the client about how to
prevent infection at home. Which of the
following health teaching would be included?
• A) “Get a weekly WBC count”
• B) “Do not share a bathroom with
children or pregnant woman”
• C) “Avoid contact with others while
receiving chemotherapy”
• D) “Do frequent hand washing and
maintain good hygiene”
Frequent hand washing and good hygiene
are the best means of preventing infection.
mother and clarify any misconceptions
regarding immunizations that may exist.
50. The nurse is teaching the client about
breast self-examination. Which observation
should the client be taught to recognize
when doing the examination for detection of
breast cancer?
• A) tender, movable lump
• B) pain on breast self-examination
• C) round, well-defined lump
• D) dimpling of the breast tissue
The tumor infiltrates nearby tissue, it can
cause retraction of the overlying skin and
create a dimpling appearance

48. The nurse is assigned to care the

client with infectious disease. The best
antimicrobial agent for the nurse to use in
handwashing is:

• A) Isopropyl alcohol
• B) Hexachlorophene (Phisohex)
• C) Soap and water
• D) Chlorhexidine gluconate (CHG)
(Hibiclens)

CHG is a highly effective antimicrobial

ingredient, especially when it is used
consistently over time.

49. The mother of the client tells the nurse,

“ I’m not going to have my baby get any
immunization”. What would be the best
nursing response to the mother?

• A) “You and I need to review your

rationale for this decision”
• B) “Your baby will not be able to
attend day care without
immunizations”
• C) “Your decision can be viewed as
a form of child abuse and neglect”
• D) “You are needlessly placing other
people at risk for communicable
diseases”

The mother may have many reasons for

such a decision. It is the nurse’s
responsibility to review this decision with the