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GENERAL DIRECTIONS:
a. Is anorexic
b. Feels warm
c. Ate half of lunch
d. Has the urge to void
3. During which of the five steps in the Nursing Process are outcomes of care determined to
be achieved?
a. Implementation
b. Evaluation
c. Diagnosis
d. Planning
a. Plan
b. Analyze
c. Diagnose
d. Implement
7. Which word best describes the role of the nurse when identifying and meeting the needs
of the patient holistically?
a. Teacher
b. Advocate
c. Counsellor
d. Surrogate
a. Data
b. Problem
c. Rationale
d. Evaluation
9. Which part of the Nursing Diagnosis is most directly related to the concept of a pebble
dropped into a pond causing ripples on the surface of the water?
a. Defining characteristics
b. Outcome criteria
c. Etiology
d. Goal
a. Jaundice
b. Dizziness
c. Diaphoresis
d. Hypotention
11. The patient comes to the ER complaining of chest pain and dyspnea. When taking the
patient’s VS the nurse is?
a. Assessing
b. Evaluating
c. Diagnosis
d. Implementing
12. Which of the following statements by the nurse is an example of inference? The patient
is?
a. Hypotensive
b. Withdrawn
c. Jaundiced
d. Oliguric
13. What step of the Nursing Process is being used when the nurse teaches a patient the use
of visualization to cope with chronic pain?
a. Planning
b. Diagnosis
c. Evaluation
d. Implementation
14. Where in the patient’s chart would the nurse find documentation of the current medical
diagnosis?
a. Physician’s History
b. Social Service Record
c. Admission Sheet
d. Progress Notes
15. During which of the 5 steps in the Nursing Process are data analysed critically?
a. Diagnosis
b. Clustering
c. Collection
d. Assessment
17. During the evaluation step of the Nursing process the nurse must?
a. Establish outcomes
b. Determine priorities
c. Take corrective actions
d. Set the time frame for goals
18. Determining what nursing actions will be employed occurs in which step of the Nursing
Process?
a. Implementation
b. Assessment
c. Diagnosis
d. Planning
19. When considering the Nursing process the words “present” is to “future” as “plan” is to?
a. Diagnosis
b. Implement
c. Evaluation
d. Assessment
a. Defining characteristics
b. Planned interventions
c. Diagnostic statements
d. Related risk factors
21. The VS that would change first indicating that a post-op patient had internal bleeding
would be the?
a. Body temperature
b. Blood pressure
c. Pulse pressure
d. Heart rate
22. When assessing a patient’s strength in preparation for getting out of bed the nurse
should?
23. How often should a patient’s temperature be taken who has had a temperature of 101
degree F for the last 24 hours?
a. Every 2 hours
b. Every 4 hours
c. Every 6 hours
d. Every 8 hours
24. When a brachial pulse is unable to be palpated, which pulse would indicate adequate
brachial blood flow?
a. Radial
b. Carotid
c. Femoral
d. Popliteal
25. Which is the first action implemented by the nurse when obtaining a 24 hour urine
specimen?
a. Ensure that a basin with ice is ready to hold the collection container
b. Have the patient empty the bladder before beginning the test
c. Teach the patient to cleanse the meatus before each voiding
d. Prepare an I and O sheet to be used to document each voiding
26. Which of the following can cause the urine to appear red in color?
a. Beets
b. Strawberries
c. Cherry Jell-O
d. Red food dye
27. What is the most important thing the nurse should do when assessing a carotid artery?
28. Which of the following would result in an accurate BP reading for an average size adult
male patient?
a. Wrapping the lower edge of the cuff over the antecubital space
b. Positioning the BP apparatus above the level of the heart
c. Pumping the cuff about 60 mmHg above the points where the brachial pulse is
lost
d. Releasing the valve on the cuff so that the pressure decreases at the rate of 2-3
mmHg/second
29. In an adult, what blood pressure result would cause a concern about hypertension?
a. 120/80 mmHg
b. 130/60 mmHg
c. 140/90 mmhg
d. 130/90 mmHg
30. When planning to care for a patient who has an intolerance for activity, what is the first
assessment that should be made by the nurse?
34. The patient has a temperature of 102 degree F and complains of feeling thirsty.Which
additional adaptation should the nurse expect during this febrile stage of a fever?
35. Which of the following is the most common site for assessing the heart rate?
a. Radial
b. Apical
c. Carotid
d. Temporal
36. Which of the following characteristic of a blood pressure would indicate shock?
a. Rising diastolic
b. Decreasing systolic
c. Korotkoff’s sounds
d. Widening pulse pressure
a. Unkempt appearance
b. Anxious behaviour
c. Tense posture
d. Crying
38. Which of the following conditions would place a person at risk for hypothermia?
a. Heat stroke
b. Inability to sweat
c. Excessive exercise
d. High alcohol intake
39. Which adaptation would be expected in a patient who has lost 2 units of blood?
40. A concern that is common to the collection of specimens, regardless of their source for
culture and sensitivity test is?
41. The nurse recognizes the need for an increase in caloric intake above the average
requirements for the patient who has?
a. Nausea
b. Dysphagia
c. Pneumonia
d. Depression
42. The person with the greatest risk for developing an infection is?
44. The primary reason why the nurse should avoid glued-on artificial nails is because?
a. Infants
b. Adolescents
c. Older adults
d. School-aged children
46. Which factor places a patient at the greatest risk for developing an infection?
48. When performing a physical assessment before surgery, the nurse identifies that a patient
has pediculosis capities or head lice. What should the nurse do first?
49. Which of the following is most directly related to the word “nosocomial”?
a. Disease-producing
b. Hospital acquired
c. Endogenous
d. Iatrogenic
a. Pain
b. Edema
c. Tachycardia
d. Hypothermia
51. Which statement indicates that further teaching is necessary regarding how to ensure
protection from food contamination?
52. Which nursing action protects the patient as a susceptible host in the chain of infection?
a. Throbbing pain
b. Purulent drainage
c. Dizziness when moving
d. Hearing a buzzing sound
54. What blood component should the nurse monitor when assessing an individual’s ability
to withstand exposure to pathogens?
a. Platelets
b. Neutrophils
c. Erythrocytes
d. Hemoglobin
55. Which patient is at the greatest risk for a urinary tract infection?
56. Which of the following is a primary (Non specific) defense that protects the body from
infection?
a. Scabies
b. Dandruff
c. Hirsutism
d. Pediculosis
58. A rise in body temperature is associated with the presence of infection because?
61. To apply a hospital gown appropriately to a patient receiving an IV infusion, the nurse
should?
a. Insert the IV bag and tubing through the sleeve from the inside of the gown
first.
b. Disconnect the IV at the insertion site, apply the gown, and then reconnect the
IV
c. Close the clamp on the IV tubing no more than 15 seconds while putting on
the gown
d. Don the gown on the unaffected arm, drape the gown over the other shoulder,
and adjust the closure behind the neck.
62. How often should a restraint be removed, the area massaged and the joints moved
through normal range?
a. Every shift
b. Every hour
c. Every two hours
d. Every four hours
63. The nurse should encourage the patient with difficulty in swallowing to?
64. Which is the first action the nurse should employ to prevent falls in older adults?
65. Which action is most important when preparing a bed to receive a newly admitted
patient?
66. An appropriately worded goal associated with the Nursing Diagnosis Risk for Injury is,
“The patient will be”?
67. In the hospital setting, an electrical appliance should have a 3-pronged plug because it?
a. Guiding a stretcher around a turn leading with the end with the patient’s head
b. Positioning the patient’s head at the end with the swivel wheels
c. Pulling the stretcher on the elevator with the patient’s feet first
d. Pushing the stretcher from the end with the patient’s head
a. Anorexia
b. Aspiration
c. Self-care deficit
d. Inadequate intake
70. The physician writes the order “Patient may shower.”When preparing the patient for the
shower the nurse assesses that the patient lacks the strength to tolerate standing for this
procedure. The nurse should?
71. Which is the most important action by the nurse to prevent falls in patients who are
confused?
72. When teaching children about fire safety procedures, they should be taught that if their
clothes catch on fire they should?
73. What should the nurse do first when applying a vest restraint to a patient?
a. Ensure that the back of the vest is positioned on the patient’s back
b. Permit 4 fingers to slide between the patient and the restraint
c. Inspect the patient’s skin where the restraint is to be placed
d. Secure the restraint to the bed frame using a slip knot
74. Which position would be best for an unconscious patient who is vomiting?
a. Supine
b. Side-lying
c. Orthopneic
d. Low-fowler’s
a. Dusting powder on the rim before placing the bedpan under the patient
b. Positioning the rounded rim of the bedpan toward the front of the patient
c. Ensuring the bedside rails are raised once the patient is on the bedpan
d. Encouraging the patient to help as much as possible when using the bedpan
a. Intradermal
b. Bladder
c. Rectum
d. Vagina
77. When administering a rectal suppository, the nurse should teach the patient to?
79. Which action takes priority when medication is to be added to an intravenous fluid bag?
80. The nurse holds a bottle of liquid medication with the albel next to the palm of the hand
when pouring a dose to?
81. What should the nurse do when administering a lozenge to a patient’s buccal area of the
mouth?
a. Epidural
b. Transdermal
c. Subcutaneous
d. Intramuscular
83. Which is most essential when applying a medicated powder to a patient’s skin?
85. To limit discomfort when administering medication into the ear of an adult, the nurse
should?
87. Which abbreviation indicates that the physician wants a medication administered twice a
day?
a. P.c.
b. H.s.
c. Q2h
d. B.i.d.
88. When administering an IM injection to a morbidly obese patient, the nurse should use
the?
a. Ear
b. Nose
c. Mouth
d. Rectum
90. What is the first thing the nurse should do when administering a vaginal suppository?
91. To help a patient with short term memory loss to remember to take multiple drugs
throughout the day, the nurse should?
a. Direct the flow of solution from the inner to the outer canthus
b. Irrigate with an Asepto syringe 2 inches from the eye
c. Don sterile gloves before beginning the procedure
d. Position the patient in a right lateral position
a. Keep the needle below the initial fluid level as the rest of the fluid is injected
b. Instill solvent that is consistent with the manufacturer’s directions
c. Score the neck of the ampule before breaking it
d. Shake the vial to dissolve the powder
95. When preparing to administer a tablet to a patient the nurse should remove the p.o.
medication from its unit dose package?
96. When titrating a drug for the patient in pain, which nursing action is most appropriate?
97. When the physician orders a troche, the nurse should administer it by placing it in the
patient’s?
a. Ear
b. Eye
c. Mouth
d. Rectum
98. What should the nurse do when identifying the left dorsogluteal site for an IM injection?
a. Locate the lower edge of the acromion and the midpoint of the lateral aspect
of the arm
b. Draw a line from the posterior superior iliac spine to the greater trochanter
c. Place the heel of the left hand on the greater trochanter
d. Palpate the anterior lateral aspect of the thigh
99. What action should the nurse teach the patient who has an order for 2-puffs of a
bronchodilator via a metered dose inhaler?
a. 2 ml. Syringe
b. 26-gauge needle
c. 1 inch needle length
d. 30 degree angle of insertion