jeffrey o. sumergido, b.s.n., r.n.

1. A scrub nurse in the operating room has

which responsibility?
A. positioning the client
B. assisting with gowning and gloving
C. handling surgical instrument to the surgeon
D. applying surgical drapes
2. Tachycardia can result from:
A. Vagal stimulation
B. Vomiting, anger or suctioning
C. Fear, pain or anger
D. Stress, pain or vomiting
3. While assessing the incision of a client who
had a surgery 2 weeks ago, the nurse
observes that the suture line has a shiny,
light pink appearance. Which of the
following steps would the nurse take next?
A. Notify the physician because the wound maybe
dehiscing
B. Apply normal saline solution to keep the wound
moist
C. Do nothing because this is granulation tissue
D. Prepare the client for debridement of the suture
line
4. To prepare for insulin administration,the
nurse disinfects the injection site. Before
giving the injection, the nurse should
allow the disinfected area to dry for:
A. 10 seconds
B. 30 seconds
C. 1 minute
D. 2 minutes
5. The physician prescribes the following
preoperative medications to be administered
to a client by the IM route: Demerol 50 mg;
Vistaril, 25 mg; glycopyrrolate, 0.3 mg. the
medications are dispensed as follows:
Demerol 100mg/ml; Vistaril , 100 mg/2ml ;
and glycopyrrolate, 0.2 mg/ml. How many
milliliters in total should the nurse
administer?
A. 5 ml
B. 3.8 ml
C. 2.5 ml
D. 2 ml
6. During assessment, the nurse measures
clients respiratory rate at 32
breaths/minute with a regular rhythm.
When documenting this pattern, the nurse
should use which term?
A. Eupnea
B. Bradycardia
C. Apnea
D. Tachypnea
7. The nurse administers an IM injection.
Afterward, the nurse should:
A. Recap the needle and discard it in any
medical waste basket
B. Recap the needle and discard it in a puncture
proof container
C. Discard the uncap needle in a puncture proof
container
D. Break the needle and discard the needle and
syringe in any medical waste container
8. A client has a nasogastric tube.
Administer oral medication to this client?
A. Heat the tablets until they liquefy, then pour
the liquid down the NG tube
B. Crush the tablets and prepare a liquid form,
and then insert the liquid into the NG tube.
C. Cut the tablet in half and wash them down
the NG tube, using a syringe filled with
water.
D. Crush the tablets and wash the powder down
the NG tube, using a syringe filled with saline
solution
9. The nurse is assigned to a client with a
cardiac disorder. When monitoring body
temperature for this client, the nurse
should avoid which route?
A. Rectal
B. Oral
C. Axilliary
D. Tympanic
10. The nurse is calculating the proper
dosage of medication for a child. What
parameters should this calculation be
based on?
A. Age
B. Body weight
C. Developmental stage in relation to age
D. Body surface area in relation to weight
11. The nurse knows that many drugs can
be administered by more than one route.
Which administration route provides the
most rapid response in a client?
A. Oral
B. I.M.
C. Sublingual
D. Subcutaneous
12. Following a fall from the horse during rodeo
practice, an 18 year old client is seen in the
emergency department. He has a large, dirty
laceration on his leg. The wound is vigorously
cleaned, closed and dressed. In the past, the
client has received full immunization regimen for
tetanus toxoid. The nurse asks the client about
his tetanus immunization history and he says, I
had my last shot when I was 11 years old. The
nurse should:
A. Advise the client to get a tetanus vaccine within 3
years
B. Request the physician to order a serum tetanus titer
C. Plan on administering a dose of tetanus vaccine
D. Teach the client that he has life-long immunity to
tetanus
13. When placing an indwelling urinary
catheter in a female client, the nurse
should advance the catheter how far into
the urethra?
A. 2 inches (5 cm)
B. 6 inches (15 cm)
C. 8 inches (20 cm)
D. inch (1 cm)
14. Which assessment finding by the nurse
contraindicates the application of a
heating pad?
A. Active bleeding
B. Reddened abscess
C. Edematous lower leg
D. Purulent wound drainage
15. The nurse may use one of many nursing
theories to guide client care. What are
the four key concepts of most nursing
theories?
A. Man, health, illness, and health care
B. Health, illness, health restoration, and caring
C. Man, environment, health and nursing
D. Health, environment, disease, and treatment
16. A client is to receive a glycerin
suppository. When administering the
suppository, the nurse should insert it
approximately how far into the clients
rectum?
A. 1 inch (2.5 cm)
B. 2 inches (5 cm)
C. 3 inches (7.5 cm)
D. 4 inches (10 cm)
17. The physician orders Demerol, 75 mg.
IM q 4 hrs. prn, to control a clients post
operative pain. The package insert reads:
Demerol, 100 mg/ml. How many
milliliters of demerol should the client
received?
A. 0.25 ml
B. 0.5 ml
C. 0.6 ml
D. 0.75 ml
18. A nurse is assigned to care for a client
with tracheostomy tube. How can the
nurse communicate with this client?
A. By providing tracheostomy plug to use for
verbal communication
B. By placing the call button under the clients
pillow
C. By supplying a magic slate or similar device
D. By suctioning the client frequently
19. A medication order reads, Demerol 1
ml I.M. stat. The nurse responsible for
administering the drug should base the
next action on which understanding?
A. The order should specify the exact time to
give the drug.
B. The ordered route is inappropriate for this
drug
C. The order should be clarified with the
physician
D. The order is correct and valid
20. A client who suffered CVA has a nursing
diagnosis of Ineffective Airway Clearance.
The goal of care for this client is to
mobilize pulmonary secretions. Which
intervention would help meet this goal?
A. Repositioning the client every two hours
B. Restricting fluid to 1,000ml/24 hours
C. Administering oxygen by cannula as ordered
D. Keeping the head of the bed at 30-degree
angle
21. When prioritizing clients plan of care
based on Maslows hierarchy of needs, the
nurses first priority would be:
A. Allowing the family to see a newly admitted
client
B. Ambulating the client in the hallway
C. Administering pain medication
D. Placing wrist restraints on the client
22. A client asks to be discharged from the
hospital against medical advice (HAMA).
What should the nurse do?
A. Prevent the client from leaving
B. Notify the physician
C. Have the client sign an AMA form
D. Call a security guard to help detain the client
23. The nurse is obtaining a sterile urine
specimen from a clients indwelling
urinary catheter. To prevent infection,
the nurse should:
A. Aspirate urine from the tubing port, using a
sterile syringe and needle
B. Disconnect the catheter from the tubing and
obtain urine
C. Open the drainage bag and pour out some
urine
D. Wear sterile gloves when obtaining urine
24. The client is to receive an IV infusion of
3,000 ml of dextrose and normal saline
solution over 24 hours. The nurse
observes that the rate is 150 ml/hour. If
the solution runs continuously at this rate,
the infusion will be completed in:
A. 12 hours
B. 20 hours
C. 24 hours
D. 50 hours
25. A client is admitted with acute chest
pain. When obtaining the health history,
which question would be most helpful for
the nurse to ask?
A. Do you need anything now?
B. Why do you think you had a heart attack?
C. What were you doing when the pain
started?
D. Has anyone in your family been sick lately?
26. The nurse is preparing to give a 9 year
old client preoperative IM injection.
Which size needle should the nurse use?
A. 22 G, 1 inch
B. 22 G, 1 inch
C. 20 G, 1 inch
D. 20 G, 1 inch
27. The maximum transfusion time for a
unit of packed RBCs is:
A. 6 hours
B. 4 hours
C. 2 hours
D. 1 hour
28. The nurse is assessing a post operative
client. Which of the following should the
nurse document as subjective data?
A. Vital signs
B. Laboratory test results
C. Client description of pain
D. ECG waveforms
29. The nurse reviews the ABG values of a
client admitted with pneumonia: pH,
7.51; Paco2, 28 mm Hg; PaO2, 70 mmHg;
HCO3, 24 mEq/L. What do these values
indicate?
A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis
30. A client suddenly loses consciousness.
What should the nurse do first?
A. Call for assistance
B. Assess for responsiveness
C. Palpate for carotid pulse
D. Assess for pupillary response
31. A client undergoes total abdominal
hysterectomy. When assessing the client
10 hours later, the nurse identifies which
finding as an early sign of shock?
A. Restlessness
B. Pale, warm, dry skin
C. Heart rate of 110 beats/minute
D. Urine output of 30 ml/hour
32. Following a tonsillectomy, a client
returns to the medical-surgical unit. The
client is lethargic and reports having a
sore throat. Which position would be most
therapeutic for this client?
A. Semi-Fowlers
B. Supine
C. High-Fowlers
D. Side-lying
33. A client with fever, weight loss and
watery diarrhea is being admitted to the
hospital. While assessing the client, a
nurse inspect the clients abdomen and
notices it is slightly concave. Additional
assessment should proceed in which
order?
A. Auscultation, percussion and palpation
B. Palpation, percussion and auscultation
C. Percussion, palpation and auscultation
D. Palpation, auscultation and percussion
34. The physician prescribes an infusion of
2,400 ml of IV fluid over 24 hours, with
half this amount to be infused over the
first 10 hours. During the first 10 hours,
the client should receive how many
milliliters of IV fluid per hour?
A. 10 ml/hour
B. 100 ml/hour
C. 120 ml/hour
D. 240 ml/hour
35. When changing a sterile surgical
dressing, the nurse first must:
A. Wash the hands
B. Apply sterile gloves
C. Remove the old dressing with clean gloves
D. Open sterile packages, and moisten the
dressings with sterile saline solution
36. The physician writes the following order
for a client: Dogoxin.125 mg PO once
daily. To prevent a dosage error, how
should the nurse transcribe this order into
medication administration record?
A. Digoxin .125 mg P.O. once daily ( exactly as
written by the physician)
B. Digoxin 0.125 mg P.O. once daily
C. Digoxin 0.1250 mg P.O. once daily
D. Digoxin .1250 mg P.O. once daily.
37. Which type of medication order might
read, Vitamin K 10 mg IM daily x 3 days?
A. Single order
B. Stat order
C. Standing order
D. Standard written order
38. The nurse has an order to administer
iron dextran, 50 mg IM injection. When
carrying out this order, the nurse should:
A. Insert the needle at 45-degree angle
B. Wipe the needle immediately after injection
C. Pull the skin laterally toward the injection
site
D. Use the z-track technique
39. The physician orders milk of magnesia,
2 teaspoons by mouth as needed, for a
constipated client. What is the equivalent
of 1 teaspoon in the metric system?
A. 5 mg
B. 1 g
C. 5 ml
D. 10 ml
40. Which finding best indicates that
suctioning has been effective?
A. Respiratory rate of 24 breaths/minute
B. Heart rate of 104 beats/minute
C. Brisk capillary refill
D. Clear breath sounds
41. A client blood test results are as
follows: WBC count 1,000/dl; hemoglobin
level, 14 g/dl; hematocrit, 42%. Which of
the following goals would be most
important for this client?
A. Promote fluid balance
B. Prevent infection
C. Promote rest
D. Prevent injury
42. The physician orders a blood transfusion
for a client. The nurse should anticipate
using an IV access device of which size?
A. 23 G
B. 21 G
C. 18 G
D. 25 G
43. Which procedure or practice requires
surgical asepsis?
A. Hand washing
B. NGT irrigation
C. IV cannula insertion
D. Colostomy irrigation
44. Before administering the evening dose of a
prescribed medication, the nurse on the
evening shift finds an unlabeled, filled
syringe in the clients medication tray. What
should the nurse do?
A. Discard the syringe to avoid medication error
B. Obtain a label for the syringe from the pharmacy
C. Use the syringe because it looks like it contains
the same medication the nurse was prepared to
give.
D. Call the day nurse to verify the contents of the
syringe
45. The nurse is monitoring a client for
adverse reactions during barbiturate
therapy. What is the major disadvantage
of a barbiturate use?
A. Prolonged half-life
B. Poor absorption
C. Potential for drug dependence
D. Potential for hepatoxicity
46. When moving a client in bed, the nurse
can ensure proper body mechanics by:
A. Standing with the feet apart
B. Lifting the client to the proper position
C. Straightening the knees and back
D. Standing several feet from the client
47. Which of the following is an example of
a primary preventive measure?
A. Participating in a cardiac rehabilitation
program
B. Obtaining an annual physical examination
C. Practicing monthly breast self-examination
D. Avoiding over exposure
48. A client is placed on a low-sodium
(500mg/day) diet. Which client statement
indicates that the nurses nutrition
teaching plan has been effective?
A. I can still eat a ham-and-cheese sandwich
with potato chips for lunch.
B. I chose broiled chicken with a baked potato
for dinner.
C. I chose a tossed salad with sardines and oil
and vinegar dressing for lunch.
D. I am glad I can still have chicken bouillon
soup.
49. A client has been receiving an IV
solution. What is an appropriate expected
outcome for this patient?
A. Monitor fluid intake and output every 4 hours
B. The client remains free of s/s of phlebitis
C. Edema and warmth are noted at IV insertion
site.
D. There is a risk for infection related to IV
insertion
50. Which of the following is true about
crackles?
A. They are grating sounds
B. They are high-pitched, musical squeaks
C. They are low-pitched noises that sound like
snoring
D. They maybe fine, medium, or coarse