NAME ______________________ DATE _________ SCORE ______

INSTRUCTION: Select the best answer for each of the following

questions. Read the questions well. NO ERASURES.

1. A nurse is formulating a plan of care for a client receiving enteral

feedings. Which nursing diagnosis is of highest priority for this client?
a. altered nutrition, less than body requirements
b. high risk for aspiration
c. high risk for fluid volume deficit
d. diarrhea
Answer: B
Rationale: Any condition in which gastrointestinal motility is slowed or
esophageal reflux is possible places a client at risk for aspiration.
Options 1 and 4 may be appropriate nursing diagnoses but are not of
highest priority. Option 3 is not likely to occur in this client.
(Source: Mary Ann Hogan, Prentice Hall REVIEWS AND RATIONALES
p204)

2. A nurse recognizes that which of the following interventions is

unlikely to facilitate effective communication between a dying client
and his or her family?
a. The nurse encourages the client and family to identify and
discuss the feelings openly
b. The nurse makes decisions for the client and family to relieve
them of unnecessary demands
c. The nurse assists the client and family in carrying out spiritually
meaningful practices
d. The nurse maintains a calm attitude and one of acceptance when
the family or client expresses anger
Answer: B
Rationale: Maintaining effective and open communication among
family members affected by death and grief is of the greatest
importance. Option A describes encouraging discussion of feelings
and is likely to enhance communications. Option C is also an
effective intervention, because spiritual practices give meaning to
life and have an impact on how people react to crisis. Option D is
also an effective technique, as the client and family need to know
that someone will be there who is supportive and nonjudgmental.
Option B describes the nurse removing autonomy and decision-
making from the client and family, who are already experiencing
feelings of loss of control in that they cannot change the process of
dying. This is an ineffective intervention, which can further impair
communication. (Source: Kozier FUNDAMENTALS OF NURSING 7th Ed
p 1041)

3. A client brought to the emergency department is dead on arrival

(DOA). A family member of the client tells the physician that the client
had a terminal cancer. The emergency department physician
examines the client and asks a nurse to contact the medical examiner
regarding an autopsy. The family of the client tells the nurse that they

1
do not want an autopsy performed. Which of the following responses
to the family is most appropriate?
a. “it is required by federal law. Why don’t we talk about it, and
why don’t you tell me why you don’t want the autopsy done?
b. “the decision is made by the medical examiner.”
c. “I will contact the medical examiner regarding your request.”
d. “An autopsy is mandatory for any client who is DOA.”
Answer: C
Rationale: An autopsy is required by state law in certain
circumstances, including the sudden death of a client and a death
that occurs under suspicious circumstances. A client may have
provided oral or written instructions regarding an autopsy following
death. If an autopsy is not required by law, these oral or written
requests will be granted. If no oral or written instructions were
provided, state law determines who has the authority to consent for
an autopsy. Most often, the decision rests with the surviving relative
or next of kin. (Source: Kozier FUNDAMENTALS OF NURSING 7th Ed p
1044)

4. A nurse is developing a postoperative plan of care for a 40-year

male Filipino client scheduled for an appendectomy. The nurse most
appropriately includes in the plan of care to:
a. inform the client that he will need to ask for pain
medication when needed
b. offer pain medication when nonverbal signs of discomfort
are identified
c. offer pain medication on a regular basis as prescribed
d. allow the client to maintain control and request pain
medication on his own
Answer: C
Rationale: Filipinos view pain as part of living an honorable life.
The client may appear stoic and be tolerant of a high degree of
pain. Health care providers need to offer, and in fact encourage pain
relief interventions for the Filipino client who does not complain of
pain despite physiological indicators. Option c is the most
appropriate intervention to include in the plan of care. (Source:
Kozier FUNDAMENTALS OF NURSING 7th Ed p 1140)

5. A nurse has developed a plan of care for a client who is in traction

and documents a nursing diagnosis of Self-Care Deficit. The nurse
evaluates the plan of care and determines that which of the following
observations indicates a successful outcome?
a. the client allows the nurse to complete the care on a daily
basis
b. the client allows the family to assist in the care
c. the client refuses care
d. the client assists in self-care as much as possible,
Answer: D
Rationale: A successful outcome for the nursing diagnosis of Self-
Care-Deficit is for the client to do as much of the self-care as
possible. The nurse should promote independence in the client and
allow the client to perform as much self-care as is optimal
considering the clients condition. The nurse would determine that
the outcome is unsuccessful if the client refused care or allows
others to do the care. (Source: Kozier FUNDAMENTALS OF NURSING
7th Ed p 39)

2
6. A registered nurse (RN) is planning assignments for the clients on a
nursing unit. The RN needs to assign four clients and has a registered
nurse and two nursing assistants on a nursing team. Which of the
following clients would the nurse most appropriately assign to the
nursing assistants?
a. A client who requires a 24-hour urine collection
b. An elderly client requiring assistance with a bed bath and
frequent ambulation
c. A client on a mechanical ventilator who requires frequent
assessment and suctioning
d. A client with an abdominal wound requiring wound irrigations
and dressing changes every 3 hours
Answer: B
Rationale: When delegating nursing assignments, the nurse
needs to consider the skills and educational level of the nursing
staff. Collecting a 24-hour urine and frequent ambulation can
most appropriately be provided by the nursing assistant
considering the clients identified in each of the options. The
client on the mechanical ventilator requiring frequent
assessment and suctioning should most appropriately be cared
for by the registered nurse.
(Source: Kozier FUNDAMENTALS OF NURSING 7th Ed p 476, 477)

7. Nursing has been focused on health and caring. Traditionally,

nursing was concerned with:
a. attending to the poor
b. keeping people healthy and well
c. caring for the sick and the infirmed
d. working with the “dregs” of society
Answer: C
Rationale: In the past, the traditional nursing role was one of
humanistic caring or both men and women comforted and cared
for the sick and those unable to care for themselves; was
nurturing, comforting and supporting. Nurses are mentioned
occasionally in the Old Testament as women who provided care
for the infants and children, for the sick and dying. (source: FNP
by Kozier, 5th ed., p. 4)
A – anyone who was sick is being provided with care whether
poor or rich
B – is the concern in modern times
D – is unrelated

8. Nursing has evolved from a subservient role to one that is:

a. people-oriented c. coordinate role
b. handmaid of doctor d. self-regulatory
Answer: D
Rationale: Means that modern nurse can act independently
without being subjected to another person’s will /want. The nurse
is constantly assuming responsibilities in patient care and are
fulfilling expanded nursing roles, for example, those of the nurse
generalist, the nurse clinician and advanced nurse practioner.
(Source: FNP by Kozier, 5th ed., p. 21)
A- unrelated to the question but nowadays nursing is people –
oriented

3
 B- is a traditional role of nurse; formerly the nurse was the sole
prerogative of the physician
C- in the past and in the present the nurse needs to coordinate
with other health care team members

9. The nurse’s understanding of human needs is essential to

effective nursing care. Which statement about Maslow’s need
theory is true?
a. risk factors are safety needs
b. unmet needs cause illness
c. priorities on human do not vary
d. self-actualization is achieved on retirement
Answer: D
Rationale: On retirement self-actualized person is realistic, sees
life clearly, and is objective about his or her observation.
A – risk factor can cause a disease
B – needs may be deferred and will not cause immediate illness
D – priorities may be altered and vary among humans
(Source: FNP by Udan, yr 2001, p. 17)

10. A priority safety need in health is:

a. sense of belonging c. environmental hygiene
b. social acceptance d.. a gunless society
Answer: C
Environmental hygiene should be analyzed to determine health
hazard in en vironment. People’s need for safety is lifelong. The
environment contains many hazards, both seen and unseen. The
society with a gun which bay kill people is an obvious hazard.
Microorganisms and radiation are unseen hazards. A primary
concern of nurse is awareness of what constitute a safe
environment for a particular person and how this environment
can be achieved. (Source: FNP by Kozier, 5th ed., p. 705)
A – is not susceptible/prone to accidents
C & D are the same and have nothing to do with safety needs

11. The health-illness continuum concept views health as:

a. a spectrum that ranges from extreme state of ill health to

peak wellness
b. continuous adjustment to the changes of the external ad
internal body environment
c. health-illness curve is subjected to biorhythmic influences
d. hierarchy of human needs based upon satisfying the needs of
the lowest end of the continuum first
Answer: A
One way to measure a person’s level of wellness is the use of the
health-illness continuum, according to this model, health is
constantly changing state, with high level wellness and death
being the opposite ends of a graduated scale. or continuum.
Travis described health-illness continuum. (Source: FNP by
Taylor, 3rd ed, p. 54)
B – pertains to Adaptation theory in which there is adjustment of
living matter to other living things and to environmental
conditions. Adaptation is a dynamic or continuously changing
process that effects change and involves interaction and
response. Human adaptation occurs on 3 levels – the internal

4
 (self), the social (others/external) and the physical (biochemical
reactions) (Source: FNP by Taylor, 3rded, p. 67)
D –refers to Maslow’s hierarchy of needs. Maslow’s hieararchy
of needs is an interdisciplinary theory that is useful for
designing priorities of care. The hierarchy of human needs
arranges the basic needs in five levels of priority. The most
basic or first level includes physiologic needs, such as air, water
and food. The second level includes safe and security needs,
which involves physical and psychological security. The 3rd level
contains love and belonging needs, including friendships and
sexual love. The 4th level encompasses esteem and self-esteem,
which involve self-confidence, usefulness, achievement and self-
worth. The final level is the need for self-actualization, the state
of fully achieving potential and having the ability to solve
problems and cope realistically with life’s situations.
The hierarchy of needs is a useful way for nurses to plan
individualized care for a client. One need may take priority over
another (such as restoration of an adequate airway before the
nurse educates the client in adjusting to an emotional conflict.
The nurse uses priorities to organize nursing diagnosis, develop
goals, and expected outcomes and select nursing intervention
(Source: FNP by Taylor 3rd ed, p. 92)

12. Leavell and Clark model of health is also known as the:

a. Eudemonistic model
b. Adaptation model
c. Health-illness Continuum model
d. Ecologic model
Answer: D
Ecologic model avers that there are three interactive factors that
affect health and
illness. The 3 factors are as follows: (1) agent-any factor or stressor
that can effect illness or disease; (2) host- persons who may or may
not be affected by disease; (3) environment – any factor external to
the host that may or may not predispose the person to a certain
disease. (source: FNP by Udan,yr. 2001, p. 25)
A. – is one of the models described by Smith
B – Adaptation model was presented by Sister Callista Roy in which
she viewed each person as a unified biopsychosocial system in
constant interaction with a changing environment. She believed
that adaptive human behavior is directed toward an attempt to
maintain homeostasis or integrity of the individual by conserving
energy and promoting the survival, growth, reproduction and
mastery of the human system (source: FNP by Udan,yr. 2001, p. 5)
C – Travis described health-illness continuum. One way to measure
a person’s level of wellness is the use of the health-illness
continuum, according to this model, health is constantly changing
state, with high level wellness and death being the opposite ends of
a graduated scale, or continuum (Source: FNP by Taylor, 3rd ed, p.
54)

13. Health promotions should assume a major focus of nursing care

for all types of patients in all setting because:
a. health promotion behaviors are the essential components of
health restoration and rehabilitation

5
 b. health promotion behaviors help persons maintain or achieve a
high level of functioning
c. the effect of demographic variables on health promoting
behaviors is clearly established
d. health promotion behaviors will decrease occupational health
risks
Answer: B
Health promotion is any activity undertaken for the purpose of
achieving a higher level of health and well-being. It is directed
toward improving well-being and actualizing the health potential of
individuals, families, groups, and communities. Health promotion is
more than the avoidance or prevention of disease. (source: FNP by
Kozier, 5th ed., p. 259)
A, C, D are under letter B
A – the tertiary prevention is included is a health promotion to
restore the optimum level of functioning within the constraints of
the disability. And also to prevent further disability

14. Prescribed the development of faith:

A. Kolherg C. Peters
B. Westerhoff D. Fowler
Answer: D
Fowler described the development of faith. He believed that faith, or
the spiritual dimension is a force that gives meaning to a person’s
life
A- Kohlberg suggested three levels of moral development that
encompasses 6 stages
B- Westerhoff proposed that faith is a way of behaving
C – Peters proposed a concept of rational morality based on
principles
(Source: FNP by Udan,yr. 2001, p. 8-9)

15. Aside from body temperature, the PR and RR will be likewise

taken. Which of the ff. instances can the nurse take Sonny’s RR?
A. while taking the pulse C. while taking the
temperature
B. while conversing with the client D. while moving the patient
Answer: C
PR and RR can be taken while taking client’s temperature, you can’t
take PR and RR while conversing with or moving the client because the
result could be altered. Moving the client could increase both his RR
and PR.

16. Inspection of the respiratory system does not include assessment

of:
A. rhythm C. retraction
B. anteroposterior diameter D. fremitus
Answer: D
Fremitus is a palpable vibration transmitted through the
bronchopulmonary system on speaking you can elicit this by touching
areas of the lungs. Anteroposterior diameter, retraction and rhythm
can be all examined through inspection with the use of both eyes of
the examiner. (Source: Lippincott Manual of Nursing Practice, 7th ed.,
p.65)

6
17. A pediatric client has been diagnosed with conjunctivitis. The
nurse is to administer eye drops four times a day (QID). The nurse
should administer the medication by gently dropping the medication
onto which of the following areas?
a. Sclera by the inner canthus.
b. Center of the cornea.
c. Lower conjunctival sac
d. Sclera by the outer canthus
Answer: C
Eye drops are placed in the lower conjunctival sac to prevent damage
to the cornea and to facilitate coating the eye with the medication. The
other options are incorrect.
(Source: Mary Ann Hogan NURSING FUNDAMENTALS Prentice Hall
Nursing Reviews and Rationales p337)

18. Mr. Stevens, 77 years old, need to complete a 24 hour urine

specimen. In planning his care, which of the following measures is
most important?
a. Place a sign stating “Save all urine” in the bathroom.
b. Keep the urine specimen in the refrigerator.
c. At the beginning of the test, instructing him to empty his bladder
and save this voiding to start the collection.
d. Use a sterile receptacle to collect the urine.
Answer: B
Timed specimens generally either are refrigerated or contain a
preservative to prevent bacterial growth or decomposition of urine
components.
(Source: Kozier FUNDAMENTALS OF NURSING 7th Ed p. 769)

19. When assisting with a bone marrow biopsy, the nurse should take
which of the following actions?
a. Stand in front of the client and support the back of the neck and
knees.
b. Assist the client to a right side lying position after the procedure.
c. Observe for signs of dyspnea, pallor and coughing.
d. Assess for bleeding and hematoma formation for several days
after the procedure.
Answer: C
The client may experience pain when the marrow is aspirated. Monitor
and support the client by explaining the procedure. Help the client
assume a supine position (with one pillow if desired) for a biopsy of the
sternum or a prone position for a biopsy of either iliac crests. Observe
the client for pallor, diaphoresis, and faintness due to bleeding or pain.
(Source: Kozier FUNDAMENTALS OF NURSING 7th Ed p 780)

20. Pain in the elderly requires careful assessment because older

people have which of the following characteristics?
a. Are likely to experience chronic pain
b. Increased pain tolerance
c Experience reduced sensory perception
d. Increased pain tolerance
Answer: C
Elderly clients may have decreased perception of sensory stimuli and
a higher pain threshold. Chronic disease processes such as diabetes or
peripheral vascular disease may interfere with normal nerve impulses

7
transmission. Sensory perception defects such as impaired affect pain
perception by the Central Nervous System.
(Source: Hogan REVIEWS AND RATIONALES p235)

21. A client is hospitalized for the first time. Which of the following
actions ensures the safety of the client?
a. Keep lights on all the time.
b. Keep side rails up at all times.
c. Keep all equipment out of view.
d. Keep unnecessary furniture out of the way.
Answer: D
Rationale: The environment has to be clutter free. Therefore,
unnecessary pieces of equipment or furniture have to be out of the
way. Lights on and side rails up are not mandatory at all times. It is
unnecessary to keep equipment out of view.(Source: Hogan REVIEWS
AND RATIONALES p204)

22. Which is a typical gender role behavior in the United States?

a. Men are expected to be nurturing as well as assertive.
b. Men are given permission to wear a wide variety of clothing.
c. Women are most responsible for child rearing activities.
d. Women should express their feelings in a controlled manner.
Answer: A
Rationale: In North America, expected adult male roles include
breadwinner, heterosexual lover, father and athlete. Expected male
behaviors include wearing trousers, demonstrating physical strength
and expressing feelings in a controlled fashion. Women are expected
to express emotion more freely. (Option D) and to be gentler in their
physical responses; they also have a broader choice of clothing than
men do. (option B). Men make loving sensitive single fathers. Women
are capably functioning as competitive and assertive executives and
world leaders. (Option C) (Source: Kozier FUNDAMENTALS OF NURSING
7th Ed p 974)

23. There was a large disaster in the community. Many family homes
were destroyed and many individuals were injured. The community
health nurse and home health nurse assume their roles. What is the
responsibility of a home health nurse?
a. assessing and treating individuals injured
b. providing a safe water supply
c. establishing communication and support system
d. monitoring for communicable diseases
Answer: C
Nurses committed to family centered care involve both the ailing
individual and the family in the nursing process. Through this
interaction with families nurse can give support and information.
Nurses make sure that not only the individual but also each family
member understands the disease, its management and the effect of
these factors on family functioning. The nurses also help families cope
with the realities of the illness and changes it may have brought about.
(Source: Kozier FUNDAMENTALS OF NURSING 7th Ed p 196)

24. Sweating maximizes heat loss through:

a. radiation c. convection
b. conduction d. evaporation
Answer: D

8
Rationale: Evaporation is the loss of heat when water or sweat on the
person’s skin converted to a vapor.
A- Radiation is the transfer of heat from the person to cooler surfaces
and objects not in direct contact with the person. Environmental
factors: Cold outside building walls and windows.
B- Conduction is the transfer of heat when the person comes in direct
contact with cooler surface or objects. Environmental factors: cold
stethoscope, cold hands of caregiver
C- Convection is the transfer of heat when a flow of cold air passed
over the person’s skin. Environmental factors: drafts air-conditioning
duct
(source: pathophysiology – Bullock, p.120)

25. In noting the Ronald’s pulse, the nurse should that the pulse is
most perceptible at a site where:
a. venous valves rhythmically reflect pulsation
b. peripheral resistance is highest
c. the blood vessel is most easily distensible by the pressure of blood
flowd
d. an artery passes over a bony prominence
Answer: D
Rationale: The pulse is a wave of blood created by contraction of the
left ventricle wherein blood enters the arteries with each heart beat. It
can be taken over the bony prominences. Ex: in the temporal where
the temporal artery passes over the temporal bone of the head
A, B, C will give an incorrect readings
(source: FNP by Udan,yr. 2001, p. 81)

26. All but one causes tachycardia:

a. fasting c. cigarette smoking
b. severe pain d. anxiety
Answer: C
Rationale: Cigarette smoking causes vasoconstriction but not
necessarily causing tachycardia.
A-If there’s prolonged fasting it could result to hypoglycemia, signs of
hypoglycemia are: sweating, tremor, nervousness, TACHYCARDIA,
lightheadedness and confusion. (Source: Lippincott Manual of Nursing
Practice, 7th ed., p. 849 – 853)
B- severe pain is a reaction to a stimulus that produces a generalized
response. Sympathetic reaction increases the energy necessary to
mobilize an emergency response. Tachycardia is one of the
characteristic responses to pain (source: pathophysiology – Bullock)
D- an individual who has anxiety experiences physiologic manifestation
related to the “fight-flight” response and could result in cardiovascular
stimulation thereby causing tachycardia ( source: Lippincott Manual of
Nursing Practice 7th ed., p. 1626)

27. The BP of your patient Paula, 42, a known hypertensive is 130/80

mmHg on admission. Will you give a standing order of Plendil 2.5mg
OD?
a. yes, because her anxiety make her BP rise
b. yes, because she may want to take it since her BVP is variable
c. no, because fasting may be required later
d. no, because her BP is borderline

9
Answer: A
Rationale: The decision should be made by the nurse in giving the
meds not by the client. Since she is known hypertensive, the nurse
should give the meds to control her BP even though her BP is within
normal range.

28. Before taking the patient’s BP, which of the ff. must the nurse do?
a. cleanse the patient’s antecubutal fossa with an alcohol sponge
b. note the patient’s physique and age
c. wipe the cuff and the valve with dry cloth
d. palpate the brachial pulse
Answer: B
Rationale: BP increases with age or older people have higher BP due
to decreased elasticity of blood vessels. You have to note first the
client’s age to determine on what normal range of BP the client will fall
into. Noting the client’s physique would be a factor that could affect
BP. BP generally is elevated among overweight and obese people.
A- it is not necessary to do this unless the antecubital fossa is dirty
C- It’s not necessary to do this
D – palpatation of brachial pulse is done during deflation of the BP,
which is commonly used technique to obtain BP measurement often
when a client is in shock. Wherein it’s difficult to hear BP with a
standard stethoscope (source: MS nursing 6th ed, J. Black, p. 2252)

29. A client is refusing to take her daily antihypertensive medication.

The nurse has explained to the client why the medication is important
and the client verbalizes understanding but doesn’t want to take the
medication. Which is the best nursing action?
a. Inform the client that the medication needs to be taken until the
nurse gets an order to discontinue it.
b. Administer the medication because it is important for the client.
c. Withhold the medication and report it to the physician.
d. Withhold the medication and complete an incident report.
Answer: C
Rationale: A client has the right to refuse a medication regardless
how important it may be to his or her health. Withholding the
medication because of client refusal is not an incident and does not
require an incident report, but it should be documented and reported
to the physician. The other options are incorrect. Mary Ann Hogan
NURSING FUNDAMENTALS Prentice Hall Nursing Reviews and
Rationales p338

30. The nurse evaluates the results of laboratory tests completed on a

client. Which of the following values indicate an abnormality related to
nutritional status?
a. Albumin 5 g/dl
b. Serum potassium 2.0 mEq/l
c. Blood urea nitrogen (BUN) 15 mg/dl
d. Urinary creatinine 800 mg/24 h in an adult female
Answer: B
Rationale: This is an indicative of potassium depletion that occurs in
severe cases of malnutrition. The other options are of normal values.
(Source: Mary Ann Hogan NURSING FUNDAMENTALS Prentice Hall
Nursing Reviews and Rationales p204)

10
31. An adult who has failed to satisfactorily resolve the
developmental task of adolescence which is identity versus confusion
may show which behavior?
a. goes along with the crowd in all activities
b. asserts independence
c. has difficulty working as a member of a team
d. is unable to express personal desires
Answer: C
Rationale: Some behaviors indicating negative resolution to the
developmental task – identity versus confusion are failing to assume
responsibility for directing one’s own behavior, accepting the values of
others without question and failing to set goals in life.
Options a and b are behaviors indicating positive resolution to the
developmental task –identity vs. confusion. Option d is a negative
behavior if autonomy among toddlers has not been met.
(Source: Kozier FUNDAMENTALS OF NURSING 7th Ed p 958)

32. A client received a severe burn in a house fire. On the second day
of hospitalization, the physician orders the client to receive albumin.
The nurse explains to the client that which of the following is the
rationale for albumin administration?
a. Improve the level of clotting factors and prevent bleeding.
b. Replace the lost red blood cells and reduce the anemia.
c. Provide proteins to increase the osmotic pressure in the blood.
d. Provide fluid resuscitation to prevent dehydration.
Answer: C
Rationale: Protein is responsible for a significant portion of the
osmotic pressure found in the blood vessels and maintains fluid within
the vessels. In burn injuries, protein is lost allowing fluid to escape into
the tissues. Albumin is used to replace the lost proteins and pull fluids
from the interstitial space back into the vascular system. It does not
contain clotting factors, red blood cells, nor is there enough fluid
volume to consider it as part of primary fluid resuscitation. Mary Ann
Hogan NURSING FUNDAMENTALS Prentice Hall Nursing Reviews and
Rationales p337

33. The nurse is taking a nursing history on an adolescent client. The

nurse can best facilitate communication with adolescent client by
making which of the following statements?
a. We can talk about this with your mother.”
b. “Our teenage girls also feel depressed.”
c. “If you read the pamphlet, you’ll know all you need to know.”
d. “Tell me about the last time you had sexual intercourse.”
Answer: B
Rationale: Option B indicates that the client is not alone, which can
enhance
communication by affirming the clients’ feelings. Adolescents will feel
more willing to discuss private issues if parents are not present and if
they understand that their concerns are common with other teens.
Questions should be sensitively worded rather than intrusive. Written
instructions should supplement teaching rather than being the primary
vehicle for teaching.
(Source:Hogan REVIEWS AND RATIONALES p132

34. Providing health care involves the utilization of the nursing

process. The nursing process is:

11
a. a method for processing the care of many patients
b. a method for diagnosing and treating human responses to actual or
potential health problems
c. a method for diagnosing health problems/diseases
d. a logical systematic problem-solving method for providing nursing
care
Answer: D
A- is more on implementation
B- pertains to nursing dx and implementation
C- pertains to nsg dx
A, B, C are all components of nursing process that must be all present
done in a systematic way
(source: FNP by Udan, yr 2001, p. 65-70)

35. Which statement best describes the purpose of nursing diagnosis?

a. identification of problems areas
b. specification of patient’s health care needs
c. organization of the assessment data gathered d
d. preparation of the clinical abstract
Answer: B
Rationale: The purpose of nursing diagnosis is to identify the client’s
health care needs and to prepare dx statements
A- pertains to medical diagnosis
C and D refer to assessment

36. Nursing diagnosis is the result of:

a. review of data base recorded
b. observation, interview and PE
c. analysis of health data collected
d. information collected on the patient’s condition
Answer: C
A, B and D all pertains to assessment

37. Which of the ff statement is not true of the nursing diagnosis?

a. it states etiology of the problem
b. it is disease oriented
c. it is guided by independent nursing action
d. it is complementary to medical diagnosis
Answer: B
This refers to medical dx. A medical dx is made by a physician and
refers to a condition that only a physician can treat. Medical dx refer
to disease processes – specific pathophysiologic responses that fairly
uniform from one client to another.
All other options are true of nsg dx
Nursing dx has 3 components: (1) the problem statement or the
diagnostic label – describes the client’s health problem or response for
which the nursing therapy is given; (2) the etiology – identifies the
probable causes of the health problem, and (3) defining the
characteristics which are the signs and symptoms that indicate the
presence of particular diagnostic label.
C- registered nurses are responsible for making nursing dx and (D) it is
complementary to medical diagnosis. Nursing dx relate to the nurse’s
independent functions, that is, the areas of health care that are unique
to nursing and separate and distinct form medical management. With
regard to medical dx nurses are obligated to carry out physician-
prescribed therapies and treatments, that is, dependent functions.

12
(source: FNP by Kozier, 5th ed., pp. 107-111)

38. Betina, a dyspneic ask the nurse if she can be bathe sitting on a
chair. The nurse response should be:
a. ”I’m sorry, I’m only allowed to bathe you in bed”
b. “Since you are more comfortable on the chair, I will be happy to
assist you there”
c. “My supervisor would be upset if she sees me bathing you on the
chair”
d. “This is against hospital policy and how I have been taught.”
Answer: B
Client may be bathed in different positions whether on the bed or in
the chair as long as the client is comfortable. Since the client is
dyspneic, she is more comfortable in a sitting position and it’s not
contraindicated to bathe her in the position.
A, C & D are nontherapeutic approach which will make the client
irritated that could increase her dyspnea further.

39. Patrick, 20 is diagnosed to have epilepsy. The nurse noticed that

he is wearing a rosary bead around his neck. The nurse should:
a. remove the rosary beads and give this to the family m ember for
safekeeping
b. respect the patient’s right to wear the beads
c. place the beads in an envelope and store them in the agency’s safe
d. place the beads on the bed
Answer: B
Wearing beads is not contraindicated in this client. The nurse should
respect the client’s belief and right of wearing a rosary bead around his
neck. Wearing beads will not precipitate or predispose the client to
having an epileptic episode.
A, C, D are not necessary

SITUATION: Mrs. Dela Pena, your adult patient is unable to sleep on her
first night of hospitalization. She appears restless and anxious.

40. A client with cervical traction has been on bed rest for two
weeks. The traction is discontinued and the client needs to ambulate.
Prior to getting the client out of bed, what is the initial action by the
nurse?
a. Assess lower leg muscle strength
b. Raise the head of the bed slowly
c. Provide the client with a cane
d. Get a neck brace for the client
Answer: B
Rationale: Orthostatic hypotension is a blood pressure that falls when
the client sits or stands.It may occur if the client has been on bed rest.
It is the result of the peripheral vasodilatation in which blood leaves
the central organs, especially the brain, and moves to the periphery,
often causing the person to faint. To decrease the problem, gradually
elevate the head of the bed to assist the client to asitting position
.Kozier FUNDAMENTALS OF NURSING 7th Ed p 511 ( Source: Hogan
NURSING FUNDAMENTALS p291)
The nurse should also assess the strength of the leg muscles but this is
not the priority. A neck brace may not be ordered.

13
41. Although clients may exhibit calm behavior, physical evidence of
stress may still be manifested by
a. decreased heart rate
b. hyperventilation
c. dilated peripheral blood vessels
d. constricted pupils
Answer: B
Rationale: The rate and depth of respirations increase because of
dilation of the bronchioles, promoting hyperventilation. The other
physiologic indicators of stress are pupils dilate to increase visual
perception when serious threats to the body arise, the heart rate and
cardiac output increase to transport nutrients and by products of
metabolism efficiently, skin is pallid because of constriction of
peripheral blood vessels, an effect of norepinephrine., urinary output
decreased (Source: Kozier FUNDAMENTALS OF NURSING 7th Ed p 1016)

42. All of the following may be considered normal or “healthy” types

of grief EXCEPT
a. dysfunctional grief
b. abbreviated grief
c. disenfranchised grief
d. anticipatory grief
Answer: A
Rationale: Normal grief reaction may be abbreviated or anticipatory.
Abbreviated grief is brief but genuinely felt. Anticipatory grief is
experienced in advance of the event. Disenfranchised grief occurs
when a person is unable to acknowledge the loss to other persons.
Unhealthy grief – that is pathologic, or dysfunctional grief may be
unresolved or inhibited. Kozier FUNDAMENTALS OF NURSING 7th Ed p
1034

43. A postoperative client has to be assisted by the nurse for coughing

and breathing exercises to prevent postoperative complications. This is
best accomplished by planning
a. huff coughing every two hours and as needed.
b. coughing exercises 1 hour before meals and deep breathing 1
hour after meals.
c. diaphragmatic and pursed-lip breathing 5 – 10 times four times a
day.
d. forceful coughing as many times as tolerated.
Answer: C
Rationale: A commonly employed breathing exercise is abdominal
(diaphragmatic) and pursed – lip breathing. Abdominal breathing
permits deep full breaths with little effort. Pursed-lip breathing helps
the client develop control over breathing. The pursed lips create a
resistance to the air flowing out of the lungs, thereby prolonging
exhalation and preventing airway collapse by maintaining positive
airway pressure. The client purse the lip as if about to whistle and
breaths out slowly and gently, tightening the abdominal muscles to
exhale more effectively. The client usually inhales to a count of 3 and
exhales to a count of 7. (Source: Kozier FUNDAMENTALS OF NURSING
7th Ed p 1302)
Forceful coughing often is less effective than using controlled or huff
coughing techniques.

14
44. A nurse is performing oropharyngeal suctioning on an unconscious
client. Which of the following actions is safe?
a. Gently rotate the catheter while applying suction.
b. Apply suction for 5 seconds while inserting the catheter and
continue for another 5 seconds before withdrawing.
c. Insert the catheter approximately 20 cm while applying suction.
d. Allow 20 – 30 seconds intervals between each suction, and limit
suctioning to a total of 15 minutes.
Answer: A
Rationale: Gentle rotation ensures that all surfaces are reached and
prevents trauma to any one area caused by prolonged suctioning. In
oropharyngeal suctioning, the catheter should be advanced 10 to 15
cm; 20 cm is the distance for tracheal suctioning. 15 minutes of
suctioning and applying suction while inserting the catheter can cause
trauma to the mucous membranes.(Source: Mary Ann Hogan NURSING
FUNDAMENTALS Prentice Hall Nursing Reviews and Rationales p204)

45. The nurse demonstrates proper technique of performing back

massage when
a. Using firm, continuous pressure
b. Pouring the lotion directly onto the client’s skin
c. Continuing the massage for at least 15 minutes
d. Using the fingertips to perform the stroking motion
Answer: A
Rationale: Back massage relieves muscle tension, promotes physical
and mental relaxation, and relieves insomnia. It is applied in a firm,
continuous pressure without breaking contact with the client’s skin.
Pour a small amount of lotion onto the palms of your hands and hold it
for a minute or the lotion bottle can be placed in a bath basin filled
with warm water because back rub preparations tend to feel
uncomfortably cold to people. Warming the solution facilitates client’s
comfort. Using your palm and not the fingertips, begin in the sacral
area using smooth, circular strokes; move your hands up the center of
the back and over both scapulae. Massage in a circular motion over the
scapulae. Move your hands down to the sides then to the areas over
the right and left iliac crests. Repeat above for 3-5 minutes obtaining
more lotion as necessary. (Source: Kozier FUNDAMENTALS OF NURSING
7th Ed p 1125 – 1126)

46. Which statement indicates a need for further teaching of the home
care client with a long term indwelling catheter?
a. “Intake of cranberry juice may help decrease the chances of
developing infection.”
b. “I will keep the collecting bag below the level of the bladder at all
times.”
c. “I should use clean technique when emptying the collecting bag.”
d. “Soaking in warm tub bath may ease the irritating feeling from
having a catheter.”
Answer: D
Rationale: Sitting in a tub allows bacteria easier access into the
urinary tract. Take a shower rather than a bath tub. Acidifying the
urine of clients with retention catheter may reduce the risk of urinary
tract infection and calculus formation. Foods such as eggs, cheese,
meat poultry, whole grains, cranberries, plums and prunes and
tomatoes tend to increase the acidity of the urine.
Keep the urine drainage bag below the level of the bladder.

15
Follow instruction for clean technique. Wash hands well with soap and
warm water prior to handling or performing catheterization.(Source:
Kozier FUNDAMENTALS OF NURSING 7th Ed p 1278)

47. A client who is unconscious needs frequent mouth care. In what

position should a client be placed when providing mouth care?
a. Trendelenburg position
b. Fowler’s position
c. Supine position
d. Side-lying position
Answer: D
Rationale: In the side lying position, fluid is more likely to flow readily
out of the mouth or pool in the side of the mouth where it can easily be
suctioned. Fowler’s position and Trendelenburg positions are not
appropriate since the unconscious client does not have the control to
stay up in those positions. The supine position is not safe as the client
may aspirate the fluids. Mary Ann Hogan NURSING FUNDAMENTALS
Prentice Hall Nursing Reviews and Rationales p204

48. The structure of the nervous system that controls sleep is the:
a. hypothalamus c. medulla oblangata
b. reticular formation d. cerebral cortex
Answer: B
Rationale: (Reticular formation assist in regulation of skeletal motor
movement and spinal reflexes) one of the components of reticular
formation is the reticular activating system (RAS), which controls the
sleep wake cycle and consciousness.
A – hypothalamus regulates stress response, sleep, appetite, body
temperature, fluid balance and emotions (source: Saunders
Comprehensive Review, p. 807, 2003)
C – controls HR, respiration; primary respiratory center (Source: FNPby
Udan yr 2001,p. 83)
D – is responsible for the conscious activities of the cerebrum (source:
Saunders Comprehensive Review, p. 807, 2003)

49. Which of the ff statements is true?

a. regular bedtime promotes sleep c. sedatives reduces
sleepless nights
b. ill persons sleep more than normal d. a high protein diet
disturbs sleep
Answer: A
Rationale: Regular bedtime pattern will make the body get used to it,
thereby promoting sleep at the scheduled time
B – during illness person has an interrupted sleep brought about by
discomfort from illness
C- it’s not necessary to administer sedatives just to reduce sleepless
nights. It should be use judiciously
D- protein contains amino acid tryptophan which is a CNS depressant
thus promotes sleep
(source:FNP by Kozier, 5th ed., p. 956)

50. These are characteristics most patients associate with sleep and
rest, except:
a. feeling of acceptance
b. assured of response to call when needed
c. free from discomfort

16
d. bedtime medications received on time
Answer: D
Rationale: Schedule meds on time especially diuretics to prevent
interruption of sleep
A- decrease stress on the psychological part of the client
C-creates a restful environment

51. Carol, a college student was brought by her mother in the ER

because of fever and cough. Which of the ff actions would you do first
on admission?
A. orient the mother on hospital deposit policy C. take patient to her
bed
B. greet the patient and her mother D. take the patient’s VS
Answer: B
Rationale: Shows acceptance of both the client and mother, builds
rapport and lessens anxiety
A, C, D are not the priority at this time. They could easily be done after
you had build trust/rapport with them
(source: FNP by Udan yr 2001, p. 51)

52. Meperidine (Demerol) IM injection should be given to the patient.

Prior to injecting the medication, the nurse aspirates and finds blood in
the syringe . What is the appropriate nursing action by the nurse?
a. Withdraw the needle, discard the medication, and begin again with
the medication administration.
b. Withdraw the needle, cleanse the needle and the new injection
site with alcohol, and administer the medication.
c. Continue to administer the medication because it is compatible
with blood and would not present a harmful effect.
d. Continue to administer the medication because the needle has hit
a capillary and would not be an intravenous administration.
Answer: A
Rationale: f blood returns while aspirating during an IM injection, the
nurse should discard and prepare a new injection. Blood indicates that
the needle has entered a blood vessel, and medication injected directly
into the bloodstream may be dangerous. Kozier FUNDAMENTALS OF
NURSING 7th Ed p 831

53. A client has a previous blood pressure reading of 138/74 and

pulse rate of 64 beats / minute. In order to obtain an accurate reading,
how long should the nurse wait before she releases the blood pressure
cuff?
a. 30 – 45 seconds
b. 1 – 1.5 minutes
c. 10 – 20 seconds
d. 3 – 3.5 minutes
Answer: B
Rationale: Release the pressure completely in the cuff, and wait 1 – 2
minutes before making further measurements. A waiting period gives
the blood trapped in the veins time to be released. Otherwise, false
high systolic readings will occur. Kozier FUNDAMENTALS OF NURSIG 7th
Ed p515

54. The nurse will remove the heating pad after a 30 minute
application, when the client requests to leave it in place. The nurse will
explain that

17
a. It will be acceptable to leave the pad in place if the temperature is
reduced to between 40.6 – 46 C ( 105 and 115 ).
b. It will be acceptable to leave the pad in place for another 30
minutes if the site appears satisfactory when assessed.
c. heat application for longer than 30 minutes can actually cause the
opposite effect ( constriction ) of the one desired ( dilation ).
d. it will be acceptable to leave the pad in place as long a it is moist
heat.
Answer: C
Rationale: The rebound phenomenon occurs at the time the
maximum therapeutic effect of the hot or cold application is achieved
and the opposite effect begins. If the heat application is continued, the
client is at risk for burns because the constricted blood vessels are
unable to dissipate the heat adequately via the blood circulation.
(Source:Kozier FUNDAMENTALS OF NURSING 7th Ed p 885)

55. The abdominal suture line of a post operative client for

abdominal procedure has been assessed. Which characteristics would
indicate a possible delay in wound healing?
a. Sanguineous drainage in the wound collection device.
b. Suture line clean and dry
c. Incision healing by primary union
d. Purulent drainage on dressing
Answer: D
Rationale: The temperature of the water in the bag are considered
safe and provide the desired effect : normal adult and child over 2
years, 46 – 52C (115 – 125F), debilitated or unconscious adult, or child
under 2 years, 40.5 – 46C ( 105 – 115F). The heat application should be
removed after 30 minutes or in accordance with agency protocol.
Purulent drainage is a sign of infection. The wound healing will be
delayed if infection is present. Primary intention is a normal process of
wound healing and a clean and dry suture line is normal. Sanguineous
drainage indicates the drainage of blood that is in the tissues.(Source:
Mary Ann Hogan NURSING FUNDAMENTALS Prentice Hall Nursing
Reviews and Rationales p290)

56. Which of the following sounds would the nurse expect to find on
auscultation of normal lung?
a. hyperresonnance over the left lower lobe
b. tympany over the right upper lobe
c. dullness above the left 10th intercostals space
d. resonance over the left upper lobe
Answer: D
Rationale: Resonance over the left upper lobe - Percussion notes
resonate down to the 6th rib at the level of the diaphragm but are flat
over areas of heavy muscle and bone, dull on areas over the heart and
the liver, and tympanic over the underlying stomach.Kozier p579

57. For accurate inspection of body parts during PE, the important
principle to observe is:
a. adequate exposure of all body surfaces c. positioning
b. good lighting d. ensure detailed explanation
of the procedure
Answer: C
Rationale: Correct positioning elicits correct result during PE. For
example, if the client is being examined for chest and lungs, the client

18
should be positioned sitting on a chair or bed to get accurate results or
to allow full lung expansion and better visualization of upper body
symmetry. (source: MS by Black, 6th ed., p. 181)
A- only the part of the body needed to be examined should be
exposed, drape the rest of the body appropriately
B- PE is conducted in a quiet, well-lit room with consideration to client’s
privacy and comfort
D- provides simple, short and clear explanations of the procedures to
the client to avoid anxiety and encourage cooperation
(Source: Lippincott Manual of Nursing Practice, 7th ed., p.51)

58. In physical examination, less tender body areas are palpated first
to:
a. reduce patient’s apprehension c. properly positioned client
b. ensure patient’s cooperation d. obtain accurate findings
Answer: D
Rationale: Less tender areas should always precede because heavy
pressure on the fingertips can dull the sense of touch giving inaccurate
results. The effective of palpation depends largely on the client’s
relaxation. Nurses can assist a client to relax by (a) draping the client
appropriately, (b) positioning comfortably (c) ensuring that their own
hands are warm before beginning, and (d) commencing palpation with
areas that are not painful. (source: FNP by Kozier, 5th ed., p. 469)

59. You are going to assess patient’s lung sounds. Which of the
following techniques of PE will you use?
a. percussion and auscultation
b. inspection, palpation, percussion, auscultation
c. inspection, auscultation, percussion, palpation
d. auscultation, percussion, palpation
Answer: A
Percussion normally reveals resonance over symmetric areas of lung.
Percussion sound may be altered by poor posture and/or presence of
excessive tissues. On auscultation, breath sounds are noted with the
use of stethoscope.
You can’t assess lung sounds through palpation (touching) or
inspecting (use of sense of sight)
(source: Lippincott Manual of Nursing Practice, 7th ed., pp. 65-66)

60. Which of the ff describes an adventitious breath sounds?

a. dull c. hollow
b. crackles d. clear
Answer: B
Rationale: Adventitious breath sounds are abnormal sounds
superimposed on normal breath sounds. It includes crackles, rhonchi,
wheezes and pleural rubs
A, C, D are all normal breath sounds that can be elicited through
percussion and auscultation depending on what area of the lungs you
will examine
(Source: Lippincott Manual of Nursing Practice, 7th ed., p. 67)

19
61. Your client is for routine fecalysis. Which of the ff results would
not be normal?
a. odor – foul-smelling c. (+) dead bacteia
b. amorphous phosphates (+) d. (+) mucus
Answer: D
Rationale: Presence of mucus in the stool from routine fecalysis may
indicate infection such as chronic ulcerative colitis and shigellosis
A, B, D are normal to be present in stool
(Source: Lippincott Manual of Nursing Practice, 7th ed., p. 572)

62. Result of the lab test of the patient show his total serum Calcium is
4.0 mEq/L. the normal serum calcium in an adult is
a. 4.5 – 5.5 mEq/L c. 1.5 – 2.5mEq/L
b. 3.5 – 4.5 mEq/L d. 9.5 – 10.5mEq/L
Answer: A
Rationale: C- is the normal lab value of Mg
B & D are distractors.
(source: FNP by Udan, yr 2001, p.265)

63. The ff are clinical signs of hypernatremia, except:

a. extreme thirst c. disorientation
b. red, swollen tongue d. urine specific gr.= 1,25
Answer: B
S/sx of hypernatremia are dry, sticky mucous membrane, flush skin,
oliguria or anuria, increase urine sp. gr., disorientation, thirst and
rough and dry tongue
Red swollen tongue indicates Vit. B12 deficiency
(Source: Lippincott Manual of Nursing Practice, 7th ed., p. 711)

64. Richard has an oxygen therapy given via facemask. The primary
effect of oxygen therapy is to:
a. increase oxygen in the tissues and cells
b. increase oxygen carrying capacity of the blood
c. increase respiratory rate
d. increase oxygen pressure in the alveolar sac
Answer: A
Rationale: Inadequate oxygen delivery to the body tissues may
immediately predispose the client to hypoxia so the client needs
oxygen therapy to increase oxygen in the tissues and cells.
B, C, D are all secondary effects of oxygen therapy. Before these
happen choice A should took place.
(Source: Anatomy and physiology by E. Marieb, 398)

65. To promote lung expansions, what measure can the nurse

employ?
a. oxygen inhalation c. steam inhalation
b. chest cupping d. deep breathing and coughing
exercises
Answer: D
Rationale: Deep breathing and coughing exercises help expand
alveoli in the lungs, coughing removes secretions from the bronchi an
d larger airways thereby facilitating greater expansion of the lungs.
Encourage the client to perform deep breathing exercises before
coughing to help assist in stimulating the cough reflex and mobilizing
retained secretions (source: MS by Black, 6th ed., p. 286)

20
A and C – are useful in promoting lung expansion; they require doctor’s
order. Nurses should first employ nonpharmacologic interventions to
promote lung expansion and should be independent functions.
B-Loosens secretions in the lungs but still the client should cough out
the secretions to promote better lung expansion

66. The ff. early manifestations of hypoxemia except:

a. tachycardia c. tachypnea
b. restlessness d. cyanosis
Answer: D
Rationale: Cyanosis is a late and unreliable sign of hypoxemia. It
does not occur unless reduced hemoglobin is more than 5g/100mL of
capillary blood.
A, B, C are all early signs of hypoxemia
(Source:Pathophysiology 4th ed, Bullock, p. 600)

67. A 7 year old Filipino client has been diagnosed with leukemia.
What intervention would be appropriate when considering the client’s
culture?
a. Ban all visits from alternative healers.
b. Make diet selections for the child and family.
c. Encourage visits from extended as well as immediate family.
d. Limit all visitors, including extended family.
ANSWER: B
Rationale: To gain a client’s trust, respect may be conveyed even if
there is disagreement with the belief expressed. Introductions and
further assessment are important but ineffective if respect is not
conveyed. Notifyng the physician does not have priority at this time.
Mary Ann Hogan NURSING FUNDAMENTALS Prentice Hall Nursing
Reviews and Rationales p 131

68. A nurse is obtaining the pulse of a client and found the rate to be
above normal. How would the nurse document this finding?
a. Arrythmia
b. Tachycardia
c. Tachypnea
d. Hyperpyrexia
Answer: B
Rationale: Tachycardia is the correct terminology for an elevated
heart rate. Tachypnea is an elevated respiratory rate. Arrythmia is an
irregular rhythm of the heartbeat, and hyperpyrexia is a very elevated
body temperature. Mary Ann Hogan NURSING FUNDAMENTALS Prentice
Hall Nursing Reviews and Rationales p 161

69. A night shift nurse has placed restraints on the following clients.
In which situation would the use of restraints be appropriate?
a. A client who is severely anxious about test results.
b. A postoperative client who is alert but still weak.
c. A child who is hyperactive.
d. A child scratching the incision site postoperatively.
ANSWER: D
Rationale: One of the purposes of restraints should be to prevent
interruption of therapy such as the use of dressings. Restraints should
not be used for the convenience of the staff as in option c, nor should
they be used because a client is weak or distraught (option b). The
client in option a has no need for restraints. (Source: Mary Ann Hogan

21
NURSING FUNDAMENTALS Prentice Hall Nursing Reviews and
Rationales p203

70. An elderly client is complaining of difficulty of passing out stool

and asked the nurse why. What instruction should the nurse give?
a. Decrease fluid intake.
b. Avoid beverages with caffeine.
c. Encourage bland and low residue foods.
d. Drink hot liquids and fruit juices.
ANSWER: D
Rationale: Instruct client to drink plenty of fluids, including fruit
juices such as prune and apple to promote bowel function. In addition,
foods that are high in fiber and roughage should be encouraged to
avoid constipation .(Source: Mary Ann Hogan NURSING
FUNDAMENTALS Prentice Hall Nursing Reviews and Rationales p203)

71. The nurse administered 20 units NPH insulin IV stat to a client

who is diabetic as ordered by the physician. The patient had
anaphylactoid reaction and died as a result of receiving the NPH insulin
IV rather than subcutaneously, which is the only appropriate route.
What liability is involved in this case?
a. Only the physician is liable because the physician wrote the order.
b. The nurse is legally liable for the medications administered even
though the order was written incorrectly.
c. The nurse is not legally liable because the nurse administered the
medication as ordered by the physician.
d. The nurse is not legally liable because the nurse gave the correct
medication, regardless of the route.
Answer: B
Rationale: Under the law, if a medication order is written incorrectly,
the nurse who administers the incorrect order is responsible for the
error. This includes both the right medication and the right dose( 2 of
the 6”rights” of medication administration). The other options are
incorrect. (Source: Mary Ann Hogan NURSING FUNDAMENTALS Prentice
Hall Nursing Reviews and Rationales p 337)

72. Diabetic Lara, 38 years old is readmitted to the hospital for

evaluation of her condition. Which of these could be used to test for
presence of sugar in the blood?
a. Clinitest c. GTT
b. Benedict’s test d. Tes-tape
Answer: C
Rationale: Urine is tested for glucose to screen clients for diabetes
mellitus or to follow progress of a known diabetic. Several commercial
products are commonly used to test for the presence of glucose, for
example, Clinitest tablets, and Clinistix, Diastix and Tes-tape reagent
strips. Each uses a color scale to measure the quantity of glucose in
the urine (source: FNP by Kozier, 5th ed., p. 1235)
A, B, D are used to test for glucose in the urine

73. All but one blood exam requires fasting?

a. CPK c. Sodium determination
b. Calcium determination d. Total bilirubin
Answer: A
Rationale: An enzyme study like CPK does not require fasting before
the test. Other test that don’t require fasting include CBC, Hgb,

22
hematocrit level, clotting studies and serum electrolyte. In albumin
globulin ratio the blood is drawn without fasting or special preparation.
(source: MS by Black, 6th ed., p. 1082)
B and C-Requires 8 hours of fasting before the test.
D-Requires 4 hours of fasting before sampling
(Source: Saunders comprehensive exam 2nd ed. p. 90-93)

74. Mang Roberto 68 years old complains of “gassy” abdomen. His

AMD ordered rectal tube insertion. The nurse should insert the tube:
a. 4-8 inches c. 2-4 inches
b. 8-10 inches d. 6-8 iches
Answer: C
Rationale: Insert the tube 7 to 10 cm (3-4 inches). Because the anal
canal is about 2.5 to 5 cm (1 to 2 in.) long in the adult, insertion to this
point places the tip of the tube beyond the anal sphincter into the
rectum.
Source: Fundamentals of Nursing 7th Ed. by Kozier p.1243

75. Which of the ff. statement is true about rectal tube insertion?
a. the rectal tube may remain the colon for 2-3 hours to achieve the
desirable effect
b. the rectal tube should remain the colon no longer than 30 minutes
and reinserted 2-3 hours later
c. the rectal tube should remain in the colon only for 5-10 minutes to
prevent damage
d. the rectal tube may remain in the colon for 24 hours or until the
effect has been achieved
Answer: B
Rationale: Insertion of rectal tube beyond 30 mins.will damage the
rectal sphincter control.
It is intermittently reinserted into 2-3 hours to achieve desirable effect.
A, C, D are not applicable
(Source: FNP by Kozier, 5th ed., p. 207)

76. Daniel, 50 years old has urinary incontinence. His urinary output
for the past 3 hours is 60 ml. What should the nurse do?
a. stimulate the patient to urinate
b. palpate the patient’s hypogastrium
c. position the patient o his left
d. inform the head nurse about the condition
Answer: B
Rationale: The nurse should first assess if the client has a distended
bladder by palpating the hypogastrium before doing options A and D.
C-Position in Fowler’s, Flexes hips and knees.

77. Which of the ff. is the rationale for measuring fluid intake and
output? To monitor:
a. amount of fluid and electrolyte c. patient’s renal function
b. patient’s VS d. patient’s weight
Answer: A
Rationale: The measurement and recording of fluid intake and output
provides important data about the clients fluid electrolyte balance
B-Changes in VS may indicate fluid and electrolyte, acid base
imbalances or compensating mechanisms for maintaining balance
C-Is the rationale for measuring hourly urine output
D-Can provide assessment of the client fluid status

23
(Source: FNP by Kozier 7th ed., p.1067-1068)

78. Pain is one of the patient’s major problems. Which of the ff.
statement is not true?
a. utilize various types of pain relief measures if necessary
b. utilize measures that the nurse believes to be effective
c. if therapy proves ineffective at first, change with another relief
measure
d. pain tolerance varies greatly among individuals
Answer: B
Rationale: Use pain-relieving measures that the CLIENT believes are
effective. It has been recognized that clients are usually the authorities
on their own pain. Thus, incorporating the clients’ measures in to a
pain relief plan is sensible unless they are harmful.
A-It is thought that using more than one measure has an additive
effect in relieving pain. Because client’s pain may vary throughout a
24-hour period, different types of pain relief are often during that time.
C-Sometimes strategies need to be tried and changed until the client
obtains effective pain relief.
D – is true
(Source: FNP by Kozier, 5th ed., p. 994)

79. Heat and cold application can relieve pain. The application of cold
gives the primary effects of:
1. vasoconstriction a. 1,2
2. vasodilation b. 1,4
3. tissue damage c. 2,3
4. slowed metabolism d. 1,3
Answer: B
Rationale: These are both physiologic effects of cold applications to
relieve pain. Cold has a vasodilating effect. Tissue damage could occur
if either heat or cold is applied beyond 30 minutes.
Cold application in general is safer than heat. It is done during the first
24 hours; heat application follows after 24 hours. Heat application
usually requires doctor’s orderDuring heat and cold application, check
the area every 15 to 20 minutes. Increased pain and swelling,
numbness, extreme redness and mottling may indicate the need to
discontinue the treatment.(Source: FNP by Udan, yr 2001, p.34)

80. The most dangerous complication of vomiting is:

a. aspiration c. hypokalemia
b. dehydration d. fever
Answer: A
Rationale: After aspiration, respiratory distress usually begins
abruptly with evidence of bronchospasm, dyspnea, tachycardia and
cyanosis. Severe hypoxemia frequently occurs and may precipitate
adult respiratory syndrome(ARDS )
(source: pathophysiology by Bullock 4th ed. p. 576)
B and C would not occur abruptly as aspiration and are not serious
complication of vomiting.
D- Is the stimulus to vomiting not a complication or effect.

81. The ff. appropriate nsg. Interventions to relieve anorexia, except:

a. provide fastidious hygiene c. serve food at proper
temperature

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b. offer small, frequent feedings d. administer vitamin
substitute
Answer: D
Rationale: Administering vitamins substitute food is not enough to
replace the fluid and electrolytes lost and to increase weight.
B- offering small frequent meal promotes weight gain
A and C- Increase appetite

82. Which statement as heard by the nurse during intershift report

provides the most useful information related to priority setting for the
next shift?
a. A client admitted for congestive heart failure has a blood pressure of
138/80.
b. A client who had catheter removed 8 hours ago has not urinated.
c. A client who is 3 days postoperative is experiencing incisional pain.
d. A client who is alert and oriented to person and place.
Answer: B
Rationale: A client who has not urinated following catheter removal
would require nursing intervention, specifically an assessment of the
client’s abdominal distention, reviewing intake and output records,
possibly calling the physician for an order to do a straight
catheterization. The second priority would be the client who has
incisional pain however, since the client is 3 days postoperative, this is
not an urgent problem as option B. The information contained in A and
B pose no threats to the health status of those clients. (Source: Hogan
NURSING FUNDAMENTALS Reviews and Rationales p87)

83. What nursing diagnosis would most likely be appropriate for the
absence of hair on a 72 year old male client’s legs?
a. Risk for infection
b. Tissue perfusion, altered: peripheral
c. Fluid volume deficit
d. Altered nutrition: less than body requirements
Answer: B
Rationale: During physical assessment, the nurse inspects the
client’s legs for hair distribution. The most common reason for shiny
skin and a complete absence of hair is poor circulation related to
peripheral vascular disease (PVD). The other nursing diagnosis should
not affect air distribution. Mary Ann Hogan NURSING FUNDAMENTALS
Prentice Hall Nursing Reviews and Rationales p63

84. Prior to inserting an Otoscope to a male, adult client, what should

the nurse do to adequately inspect the external ear canal?
a. Have the client lie down to promote comfort.
b. Pull the pinna up and back.
c. Require that all earrings be removed for safety purposes.
d. Use an applicator to remove the cerumen.
Answer: B
Rationale: In order to facilitate visualization of the ear canal and
tympanic membrane, the pinna should be pulled up and back for an
adult client. If earrings are attached to the lobe, there should not be a
safety issue; however, they may be removed if they are large in size or
cause the client discomfort during the examination. The nurse should
not remove cerumen with an applicator because of the risk of pushing
it further into the canal or rupturing the tympanic membrane.
Generally, the ear and eye physical assessment are performed with the

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client sitting upright. Mary Ann Hogan NURSING FUNDAMENTALS
Prentice Hall Nursing Reviews and Rationales p 63

85. While on her way home, a nurse stops and provides first aid to a
motor vehicle accident. The nurse knows that this action is protected
by the Good Samaritan law. Which statement about Good Samaritan
law is correct?
a. It does not provide liability for the nurse responding to an
emergency.
b. It hinders nurses from providing help during an accident.
c. It was created specifically for RN’s and LPN’s.
d. It differs from state to state.
Answer: D
Rationale: It differs from state to state and should be reviewed by
the practicing RN. Good Samaritan laws are designed to protect
healthcare professionals who offer assistance during an emergency
and may apply to various licensed personnel. . (Source: Mary Ann
Hogan NURSING FUNDAMENTALS Prentice Hall Nursing Reviews and
Rationales p104)

86. Which of the following activities by the nurse is an example of

health promotion?
a. giving a bath
b. preventing incidents in the home
c. administering immunizations
d. performing diagnostic procedures
Answer: B
Rationale: Nurses promote wellness in clients who are both healthy
and ill. This may involve individual and community activities to
enhance healthy lifestyles, such as improving nutrition and physical
fitness , preventing drug and alcohol misuse, restricting smoking and
preventing accidents and injury in the home and workplace. (Source:
Kozier FUNDAMENTALS OF NURSING 7th Edition p 8)

87. What can be best described as a set of shared understandings and

assumptions about reality and the world?
a. concept
b. practice discipline
c. conceptual framework
d. paradigm
Answer: D
Rationale: PARADIGM refers to a pattern of shared understandings
and assumptions about reality and the world.
(Source: Kozier FUNDAMENTALS OF NURSING 7th Edition p 36)

88. Which of the following is not true of adaptation?

a. adaptation is basically protective
b. it involves alteration in the body structure or function
c. it seeks to prevent stressors from acting on the body
d. it includes all dynamic processes to maintain balance
Answer: C
Rationale: Adaptation is a process of change in response to stress.
A, B, D – are t rue
A-a resistance to stress
B -it denotes interaction and change
D - basis of homeostasis

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(source: FNP by Udan, yr 2001, p.81)

89. Which is the most important nursing responsibility in patient care

ethical situations?
a. To be able to defend the morality of one’s own actions.
b. To make sure that the team is responsible for deciding ethical
questions.
c. Follow exactly what the family wishes.
d. To remain neutral and detached in ethical decisions.
Answer: B
Rationale: Although the nurse’s input is important, in reality several
people are usually involved in making an ethical decision. Therefore,
collaboration, communication,and compromise are important skills for
health professionals. When nurses do not have autonomy to act on
their moral or ethical choices,compromise becomes essential. Kozier
FUNDAMENTALS OF NURSING 7th Edition p77

90. Which statement is appropriate in initiating care to a client of a

different culture than the nurse?
a. “Do you have any books I could read about people of your culture?”
b. “Since, in your culture, people don’t drink ice water, I will bring you
hot tea.”
c. “Please let me know if I do anything that is not acceptable in your
culture.”
d. “You have to set aside your usual customs and practices while you
are in this hospital.”
Answer: C
Rationale: All phases of the nursing process are affected by the
client’s cultural values, beliefs, and behaviors. As the client’s culture
and the nurse’s culture come together in the nurse-client relationship,
a unique cultural environment is created that can improve or impair
the client’s outcome. Self awareness of personal biases can enable
nurses to develop modifying behaviors or (if they are unable to do so)
to remove themselves from situations where care may be
compromised.
(Source: Kozier FUNDAMENTALS OF NURSING 7th Edition p 215)

91. In using the three part diagnostic statement in the PES format ,
which is correct?
a. The three part diagnostic statement is always more accurate.
b. The three part diagnostic statement is shorter.
c. The three part diagnostic statement applies to risk and wellness
diagnoses also.
d. The three part diagnostic statement documents the indicators of the
problem.
Answer: D
Rationale: The three part diagnostic statement documents the
indicators of the problem.
(Source: Kozier FUNDAMENTALS OF NURSING 7th Edition p 217)

92. The skill of attentive listening by the nurse requires ?

a. absorbing both the content and the feeling the person is conveying
without selectivity.
b. Total relaxation by the listening nurse.
c. Assuming what needs the client has.
d. Adopting a closed professional posture.

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Answer: A
Rationale: Attentive listening is listening actively, using all the
senses, as opposed to listening passively with just one ear. It is
probably the most important technique in nursing and is basic to all
other techniques. Attentive listening is an active process that requires
energy and concentration. It involves paying attention to the total
message, both verbal and non verbal, and noting whether these
communications are congruent. Attentive listening means absorbing
both the content and the feeling the person is conveying, without
selectivity.The listener does not select or listen solely to what the
listener wants to hear; the nurse focuses not on the nurse’s own needs
but rather on the client’s needs. Attentive listening conveys an attitude
of caring and interest, thereby encouraging the client to talk. (Source:
Kozier FUNDAMENTALS OF NURSING 7th Edition p 429)

93. A client in pain is struggling with cancer. The nurse points out “It is
normal to feel frustrated about the discomfort.” What skill in the
working phase of the helping relationship is the nurse using?
a. confrontation
b. concreteness
c .respect
d. genuineness
Answer: D
genuineness
(Source: Kozier FUNDAMENTALS OF NURSING 7th Edition p 323)

94. Which of the following nursing diagnosis is appropriate to a 50 year

old depressed patient who hasn’t taken a bath nor changed her
clothes? She is just seated with her food tray unable to make a
decision about having her lunch .
a. Powerlessness
b. Anxiety
c. Chronic Low Self Esteem
d. Social Isolation
Answer: A
(Source: Kozier FUNDAMENTALS OF NURSING 7th Edition p 365)

95. An initial assessment was done to a responsive and alert client

admitted directly from the doctor’s office diagnosed to rule out
infarction (MI). Which of the following alterations is of greatest concern
to the nurse?
a. Respirations are 28 and labored
b. Temperature is 99.8F
c. Blood pressure supine is 138/76.
d. There are frequent missed apical beats.
Answer: A
Rationale: Using the ABC principles (Airway, Breathing, Circulation),
an alteration in respiration is always a primary concern. A disturbance
in normal ventilation is occurring secondary to the medical diagnosis of
myocardial infarction. The blood pressure remains in acceptable range,
and the temperature elevation is likely related to the overall
inflammatory response of the body. Infrequent abnormalities of cardiac
rhythm are common and should be of concern only when appearing
regularly or with longer duration. (Source: Hogan NURSING
FUNDAMENTALS Reviews and Rationales p62)

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96. A widely used method of organizing and recording data about a
client which is quickly accessible to all members of the health team,
usually during endorsement procedure is:
a. Kardex c. SOR
b. POR d. Computer
Answer: A
Rationale: B-in problem oriented medical record, data about the
client are recorded and arranged according to the source of the info.
The record integrates all data about a problem, gathered by the
members of the health team. Four basic components: (1.) data base,
(2) problem list, (3) initial list of orders or care plans, and (4) progress
notes which includes nurse’s or narrative notes, flow sheets and
discharge notes or referral summaries
C- in source oriented medical record, each person or department
makes notations in a separate section/s of the client’s chart. Also
called traditional client record. Five components are: (1) admission
sheet; (2) physician’s order sheet; (3) medical history sheet; (4) nurses
notes; and (5) special records and reports (e.g. referrals, X-ray report,
lab. findings)
D- currently, nurses use computers to assist with practice in clinical
settings. In a hospital setting, computers are used by nurses to: enter
orders and retrieve results from various ancillary departments,
document client progress using critical pathways or other
methodologies, track medication administration and enter client
assessments
(source: FNP by Taylor, p. 230)
(source: FNP by Udan, yr 2001, p.52-53)

97. Which of the following is not caused by prolonged immobility?

a. contractures c. pneumonia
b. thrombosis d. incontinence
Answer: D
Rationale: Urinary incontinence possible etiology are external urinary
sphincter injury, obstetric injury, lesions of bladder neck, detrusor
dysfunction, infection, neurogenic bladder, medications, neurologicc
abnormalities

98. Which of the following lab results indicate normal serum K?

a. 3.0 mEq/L c. 4.0 mEq/L
b. 2.0 mEq/L d. 6.0 mEq/L
Answer: C
Rationale: Normal seum K+ ranges from 3.5- 5.0 mEq/L
(Source: MS by Udan, yr 2002., p. 265)

99. All but one are roentgenogram examinations:

a.IVP c. EMG
b. Barium enema d. UGIS
Answer: C
Rationale: EMG records electrical activity arising from the muscle-
associated muscular activity after nerve stimulation with an electrical
current.
B- roentgenogram of the colon
D- roentgenogram of the esophagus and colon
A- roentgenogram of kidney, urinary tract and bladder
(source: FNP by Udan, yr 2001, p.267-268)

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100. All but one is true of GAS?
a. adaptation basically is protective
b. it is a sequence of behavior involving the whole body
c. it is an abnormal alteration in body function due to stress
d. it is essentially a neuroendocrine response
Answer: C
Rationale: It’s a normal alteration in body function due to stress
B- man whenever he responds to stress, the entire body is involved
D- The GAS occurs with the release of certain adaptive hormones and
subsequent changes in the structure and chemical composition of the
body
Stages of GAS:
I. stage of alarm – the person becomes aware of the presence
of threat or danger; levels or resistance are decreased;
adaptive mechanisms are mobilized (fight-or-flight reaction);
if the stress is intense enough, even at the stage of alarm,
death may ensue.
II. stage of resistance- characterized by adaptation; levels of
resistance are increased; the person
moves back to homeostasis
III. stage of exhaustion- results from prolonged exposure to
stress and adaptive mechanisms can no longer persist; unless
other adaptive mechanisms will be mobilized, death may ensue.
(source: FNP by Udan, yr 2001, p.26)

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