contoh 200 soal

1. A resident often carries a doll with her, treating it like her baby. One day she is wandering around crying that she can’t find her baby. The nurse aide should

A. Ask the resident where she last had the doll.

B. Ask the activity department if they have any other dolls.

C. Offer comfort to the resident and help her look for her baby.

D. Let the other staff know the resident is very confused and should be

     watched closely.

2. Which of the following is a job task performed by the nurse aide?

A. Participating in resident care planning conferences

B. Taking a telephone order from a physician

C. Giving medications to assigned residents

D. Changing sterile wound dressings

3. A resident who is lying in bed suddenly becomes short of breath. After calling for help, the nurse aide’s next action should be to

A. Ask the resident to take deep breaths.

B. Take the resident’s vital signs.

C. Raise the head of the bed.

D. Elevate the resident’s feet.

4. Gloves should be worn for which of the following procedures?

A. Emptying a urinary drainage bag

B. Brushing a resident’s hair

C. Ambulating a resident

D. Feeding a resident

5. Which of the following statements is true about residents who are

    restrained?

A. They are at greater risk for developing pressure sores.

B. They are at lower risk of developing pneumonia.

C. Their posture and alignment are improved.

D. They are not at risk for falling.

6. When feeding a resident, frequent coughing can be a sign the resident is

A. Choking.

B. Getting full.

C. Needs to drink more fluids.

D. Having difficulty swallowing.

7. A resident gets dressed and comes out of his room wearing shoes that are

    from two different pairs. The nurse aide should

A. Tease the resident by complimenting the resident’s sense of style.

B. Ask if the resident realizes that the shoes do not match.

C. Remind the resident that the nurse aide can dress the resident.

D. Ask if the resident lost some of his shoes.

8. When a resident refuses a bedbath, the nurse aide should

A. Offer the resident a bribe.

B. Wait awhile and then ask the resident again.

C. Remind the resident that people who smell don’t have friends.

D. Tell the resident that nursing home policy requires daily bathing.

9. During lunch in the dining room, a resident begins yelling and throws a

     spoon at the nurse aide. The best response by the nurse aide is to

A. Remain calm and ask what is upsetting the resident.

B. Begin removing all the other residents from the dining room.

C. Scold the resident and ask the resident to leave the dining room

     immediately.

D. Remove the resident’s plate, fork, knife, and cup so there is nothing

     else to throw

10. When trying to communicate with a resident who speaks a different

       language than the nurse aide, the nurse aide should

A. Use pictures and gestures.

B. Face the resident and speak softly when talking.

C. Repeat words often if the resident does not understand.

D. Assume when the resident nods his/her head that the message is

     understood.

11. When a resident is expressing anger, the nurse aide should

A. Correct the resident’s misperceptions.

B. Ask the resident to speak in a kinder tone.

C. Listen closely to the resident’s concerns.

D. Remind the resident that everyone gets angry.

12. A nurse aide finds a resident looking in the refrigerator at the nurses’

       station at 5 a.m. The resident, who is confused, explains he needs

       breakfast before he leaves for work. The best response by the nurse aide is

       to

A. Help the resident back to his room and into bed.

B. Ask the resident about his job and if he is hungry.

C. Tell him that residents are not allowed in the nurses’ station.

D. Remind him that he is retired from his job and in a nursing home.

13. Residents with Parkinson’s disease often require assistance with walking

       because they

A. Become confused and forget how to take steps without help.

B. Have poor attention skills and do not notice safety problems.

C. Have visual problems that require special glasses.

D. Have a shuffling walk and tremors.

14. A resident who is incontinent of urine has an increased risk of developing

A. Dementia.

B. Urinary tract infections.

C. Pressure sores.

D. Dehydration.

15. A resident is on a bladder retraining program. The nurse aide can expect

       the resident to

A. Have a fluid intake restriction to prevent sudden urges to urinate.

B. Wear an incontinent brief in case of an accident.

C. Have an indwelling urinary catheter.

D. Have a schedule for toileting.

16. The doctor has told the resident that his cancer is growing and that he is

       dying. When the resident tells the nurse aide that there is a mistake, the

       nurse aide should

A. Understand that denial is a normal reaction.

B. Remind the resident the doctor would not lie.

C. Suggest the resident ask for more tests.

D. Ask if the resident is afraid of dying.

17. To help prevent resident falls, the nurse aide should

A. Always raise siderails when any resident is in his/her bed.

B. Leave residents’ beds at the lowest level when care is complete.

C. Encourage residents to wear larger‐sized, loose‐fitting clothing.

D. Remind residents who use call lights that they need to wait patiently

     for staff.

18. As the nurse aide begins his/her assignment, which of the following should

       the nurse aide do first?

A. Collect linen supplies for the shift

B. Check all the nurse aide’s assigned residents

C. Assist a resident that has called for assistance to get off the toilet

D. Start bathing a resident that has physical therapy in one hour

19. When a sink has hand‐control faucets, the nurse aide should use

A.  A paper towel to turn the water on.

B. A paper towel to turn the water off.

C. An elbow, if possible, to turn the faucet controls on and off.

D. Bare hands to turn the faucet controls both on and off.

20. The resident’s weight is obtained routinely as a way to check the resident’s

A. Growth and development.

B. Adjustment to the facility.

C. Nutrition and health.

D. Activity level.

21. Considering the resident’s activity, which of the following sets of vital signs

       should be reported to the charge nurse immediately?

A. Resting:                                        98.6°‐98‐32

B. After eating:                                97.0°‐64‐24

C. After walking exercise:            98.2°‐98‐28

D. While watching television:     98.8°‐72‐14

22. The nurse is assessing the growth and development of a healthy three

       year-old child. The nurse should expect the child to be able to:

A. Ride a bicycle

B. Jump rope

C. Throw a ball overhead

D. Hop on one foot

23. A patient with congestive heart failure and severe peripheral edema has a

       nursing diagnosis of fluid volume excess What are the two MOST important

       interventions for the nurse to initiate?

A. Diuretic therapy and intake and output

B. Nutritional education and low-sodium diet

C. Daily weights and intake and output

D. Low-sodium diet and elevate legs when in bed

24. A nurse is providing care to a patient with a new skin graft on the leg. The

       patient is upset and the nurse notes copious red drainage oozing around

       the dressing the nurse should immediately:

A. Lift the dressing to assess the area

B. Ask if the patient is having any pain

C. Apply firm pressure for 10 to 15 minutes

D. Assess the apical pulse

25. To minimize a toddler from scratching and picking at healing skin graft, the

       nurse should utilize:

A. Mild sedatives

B. Hand mittens

C. Punishment for picking

D. Distractions

26. The nurse calls together an interdisciplinary team with members from

       medicine, social service, the clergy, and nutritional services to care for a

       patient with a terminal illness. Which of the following types of care would

       the team MOST likely be providing?

A. Palliative

B. Curative

C. Respite

D. Preventive

27. A patient recently underwent coronary artery graft (CABG) surgery.

      Which of the following nursing diagnose PRIORITY?

A. Anxiety

B. Impaired gas exchange

C. Acute pain

D. Sleep deprivation

28. A child with asthma has an order for albuterol, before administration of the

      medication the nurse MUST.

A. Pre-oxygenate the patient

B.  Assess the patient's heart rate

C. Obtain venous Access

D. Feed the patient a snack

29. A 52 year- old woman is scheduled to undergo an abdomino- perineal

       resection in three days for removal of a cancer of the rectum. The nurse

       reviews the care plan with the patient. The patient will receive prophylactic

       antibiotics and will be given a mechanical bowel preparation the day

       before. Which additional preparation should the patient undertake at this

       time?

            A. Wear pressure stockings

B. Perform leg strengthening exercises

C. Maintain high- protein, low- residue diet

D. Take daily ferrous iron tablets

30. As the office nurse, you are reviewing client messages for a return call.

      Which client should the nurse call back first.

A.    Client 36 weeks gestation complaining of facial edema

B.     A client 24 weeks gestation complaining of urinary frequency

C.     A client 12 weeks gestation whose had five episodes of vomiting in 36 hours

D.    A client 20 weeks gestation complaining of white, thick vaginal discharge

31. A 62 year old client has a history of coronary heart disease and is brought

       into the ER complaining of chest pain. What initial action should be taken

       by the nurse?

A.    Give the client ntg gr 1/150 sl now

B.     Call the cardiologist about the admission

C.     Place the client in a high Fowlers position after loosening the shirt

D.    Check blood pressure and note the location and degree of chest pain

32. As a nurse working the ER, which cient needs the most immediate

       attention?

A.    A 3 yr old with a barking cough, oxygen sat of 93 in room air, and occasional inspiratory stridor

B.     A 10 month old with a tympanic temperature of 102, green nasal drainage, and pulling at the ears

C.     An 8 month old with a harsh paroxysmal cough, audible expiratory wheeze and mild retractions

D.    A 3 year old with complaints of a sore throat, tongue slightly protruding out his mouth, and drooling

33. After completing assessment rounds, which finding would the nurse report

       to the physician immediately?

A.    Client who has not had a bowel movement in 4 days abdomen is firm

B.     Client who had a pulse of 89 and regular now has pulse of 100 and irregular

C.     Client who is very depressed and has eaten 10% of meals for the last 2 days

D.    Client who has developed a rash around the neck and face who has been on iv penicillin for 2 days

34.  A patient arrives at the emergency department complaining of mid-sternal

        chest pain. Which of the following nursing action should take priority?

A. A complete history with emphasis on preceding events. 

B. An electrocardiogram. 

C. Careful assessment of vital signs. 

D. Chest exam with auscultation.

35. The charge nurse on the cardiac unit is planning assignments for the day.

       Which of the following is the most appropriate assignment for the float

       nurse that has been reassigned from labor and delivery?

A. A one-week postoperative coronary bypass patient, who is being

     evaluated for placement of a pacemaker prior to discharge. 

B. A suspected myocardial infarction patient on telemetry, just admitted

    from the Emergency Department and scheduled for an angiogram. 

C. A patient with unstable angina being closely monitored for pain and

    medication titration. 

D.A post-operative valve replacement patient who was recently

admitted to the unit because all surgical beds were filled.

36. A patient arrives in the emergency department and reports splashing

       concentrated household cleaner in his eye. Which of the following nursing

       actions is a priority?

A. Irrigate the eye repeatedly with normal saline solution. 

B. Place fluorescein drops in the eye. 

C. Patch the eye. 

D. Test visual acuity.

37. A patient is admitted to the hospital with a calcium level of 6.0 mg/dL.

      Which of the following symptoms would you NOT expect to see in this

       patient?

A. Numbness in hands and feet. 

B. Muscle cramping. 

C. Hypoactive bowel sounds. 

D. Positive Chvostek's sign.

38. A nurse cares for a patient who has a nasogastric tube attached to low

       suction because of a suspected bowel obstruction. Which of the following

       arterial blood gas results might be expected in this patient?

A. pH 7.52, PCO2 54 mm Hg. 

B. pH 7.42, PCO2 40 mm Hg. 

C. pH 7.25, PCO2 25 mm Hg. 

D. pH 7.38, PCO2 36 mm Hg.

39. The follow lab results are received for a patient. Which of the following

       results are abnormal? Note: More than one answer may be correct.

A. Hemoglobin 10.4 g/dL. 

B. Total cholesterol 340 mg/dL. 

C. Total serum protein 7.0 g/dL. 

D. Glycosylated hemoglobin A1C 5.4%.

40. A hospitalized patient has received transfusions of 2 units of blood over the

       past few hours. A nurse enters the room to find the patient sitting up in

       bed, dyspneic and uncomfortable. On assessment, crackles are heard in the

       bases of both lungs, probably indicating that the patient is experiencing a

       complication of transfusion. Which of the following complications is most

       likely the cause of the patient's symptoms?

A. Febrile non-hemolytic reaction. 

B. Allergic transfusion reaction. 

C. Acute hemolytic reaction. 

D. Fluid overload.

41. A nurse is counseling the mother of a newborn infant with

       hyperbilirubinemia. Which of the following instructions by the nurse is NOT

       correct?

A. Continue to breastfeed frequently, at least every 2-4 hours. 

B. Follow up with the infant's physician within 72 hours of discharge for

a recheck of the serum bilirubin and exam. 

C. Watch for signs of dehydration, including decreased urinary output

     and changes in skin turgor. 

D.Keep the baby quiet and swaddled, and place the bassinet in a dimly lit

    area.

42. A nurse is giving discharge instructions to the parents of a healthy

       newborn. Which of the following instructions should the nurse provide

       regarding car safety and the trip home from the hospital?

A.    He infant should be restrained in an infant car seat, properly secured in the back seat in a rear-facing position. 

B.     The infant should be restrained in an infant car seat, properly secured in the front passenger seat. 

C.     The infant should be restrained in an infant car seat facing forward or rearward in the back seat. 

D.    For the trip home from the hospital, the parent may sit in the back seat and hold the newborn.

43. The mother of a 14-month-old child reports to the nurse that her child will

       not fall asleep at night without a bottle of milk in the crib and often wakes

       during the night asking for another. Which of the following instructions by

       the nurse is correct?

A. Allow the child to have the bottle at bedtime, but withhold the one

     later in the night.

B. Put juice in the bottle instead of milk. 

C. Give only a bottle of water at bedtime. 
D. Do not allow bottles in the crib.

44. A child is admitted to the hospital with suspected rheumatic fever. Which

      of the following observations is NOT confirming of the diagnosis?

A. A reddened rash visible over the trunk and extremities. 
B. A history of sore throat that was self-limited in the past month. 
C. A negative antistreptolysin O titer. 
D. An unexplained fever.

45. An infant with congestive heart failure is receiving diuretic therapy at

       home. Which of the following symptoms would indicate that the dosage

       may need to be increased?

A. Sudden weight gain. 
B. Decreased blood pressure. 
C. Slow, shallow breathing. 
D. Bradycardia.

46. A patient taking Dilantin (phenytoin) for a seizure disorder is experiencing

       breakthrough seizures. A blood sample is taken to determine the serum

       drug level. Which of the following would indicate a sub-therapeutic level?

A. 15 mcg/mL. 
B. 4 mcg/mL. 
C. 10 mcg/dL. 
D. 5 mcg/dL.

47. A nurse is caring for a cancer patient receiving subcutaneous morphine

       sulfate for pain. Which of the following nursing actions is most important

       in the care of this patient?

A. Monitor urine output. 
B. Monitor respiratory rate. 
C. Monitor heart rate. 
D. Monitor temperature.

48. A patient arrives at the emergency department with severe lower leg pain

       after a fall in a touch football game. Following routine triage, which of the

       following is the appropriate next step in assessment and treatment?

A. Apply heat to the painful area. 
B. Apply an elastic bandage to the leg. 
C. X-ray the leg. 
D. Give pain medication.

49. A nurse is evaluating a post-operative patient and notes a moderate

       amount of serous drainage on the dressing 24 hours after surgery. Which

       of the following is the appropriate nursing action?

A.    Notify the surgeon about evidence of infection immediately. 

B.     Leave the dressing intact to avoid disturbing the wound site. 

C.     Remove the dressing and leave the wound site open to air. 

D.    Change the dressing and document the clean appearance of the

wound site.

50. Which patient should NOT be prescribed alendronate (Fosamax) for

       osteoporosis?

A. A female patient being treated for high blood pressure with an ACE

inhibitor. 
B. A patient who is allergic to iodine/shellfish. 
C. A patient on a calorie restricted diet. 
D. A patient on bed rest who must maintain a supine position.

51. Which of the following strategies is NOT effective for prevention of Lyme

       disease?

A.    Insect repellant on the skin and clothes when in a Lyme endemic

area. 

B. Long sleeved shirts and long pants. 

C. Prophylactic antibiotic therapy prior to anticipated exposure to ticks. 

D. Careful examination of skin and hair for ticks following anticipated

     exposure.

52.A nurse is counseling patients at a health clinic on the importance of

      immunizations. Which of the following information is the most accurate

      regarding immunizations?

A.    All infectious diseases can be prevented with proper immunization. 

B.     Immunizations provide natural immunity from disease. 

C.     Immunizations are risk-free and should be universally administered. 

D.    Immunization provides acquired immunity from some specific

diseases

53. A patient at a mental health clinic is taking Haldol (haloperidol) for

       treatment of schizophrenia. She calls the clinic to report abnormal

       movements of her face and tongue. The nurse concludes that the patient

       is experiencing which of the following symptoms:

A.    Co-morbid depression. 

B.     Psychotic hallucinations. 

C.     Negative symptoms of schizophrenia. 

D.    Tardive dyskinesia.

54. A 67 year-old man is admitted to the Post-anesthesia Recovery unit

       following chest surgery. The patient has a right chest tube that is attached

       to low suction. Three hours after admission to the unit, the nurse observes

       the drainage output from the chest tube is 300 milliliters.

       What is the most appropriate initial intervention?

A.    Notify the doctor

B.     Reduce IV infusion rate

C.     Strip tube with roller device

D.    Re-position in left lateral decubitus

55. An elderly patient with severe degenerative joint comes to the clinic for

       routine follow up of management. The patient reports that over the

       month, the pain has begun to increase in severity patient requests an

       increase in dosage of the medication. The nurse recognizes that this is

       most likely due to?

A.    Drug addiction

B.     Drug tolerance

C.     An improvement in condition

D.    Lack of efficacy of the current medication

56. The nurse has been assigned to care for a 60 year old critically ill patient

       with a triple-lumen central venous line. The doctor's orders include daily

       care of the insertion site and catheter device. The nurse creates care plane

       based on the nursing diagnosis, Risk for infection related to insertion of a

       venous catheter. Which intervention is most likely to prevent infection?

A.    Re-cap access hub after drawing blood

B.     Maintain clean technique

C.     Wash hands before performing catheter care

D.    Clean catheter tubing with isopropyl alcohol

57.The nurse is inserting a nasogastric (NG) tube into patient as prescribed.

      The nurse has advanced the into the patient's posterior pharynx. The nurse

      show now ask the patient to?

A.    Hold the breath

B.     Stare upwards with the eyes towards the ceiling

C.     Perform the Valsalva maneuver

D.    Lower the chin towards the chest

58. A 42 year- old patient is in a lower body cast following a motor vehicle

      accident. In order to minimize muscle strength loss while in the cast, the

      nurse will instruct the patient in the performance of.

A.    Isometric exercises

B.     Passive range of motion exercises

C.     Active-assistive range of motion exercises

D.    Resistive range of motion exercises

59. A newborn was delivered pre-term weighing 2700 grams with. Apgar

      scores of 4 and 6, respectively. When the mother had presented to the

      Obstetrical Triage Unit, she was already 7 centimeters dilated and fully

      effaced. Her due date was unknown as she had no parental care. The infant

      showed signs of fetal distress and was finally delivered by Cesarean section.

      At birth a large, thin, membranous sac was protruding from the umbilical

      base. What is the priority nursing intervention at birth?

A.    Maintain cardio respiratory stability

B.     Protect the herniated viscera

C.     Manage fluid intake and output

D.    Establish vascular access

60. A child is treated for superficial (first-degree) thermal burns to the thigh.

      The child is in great discomfort and does not eat.Which of the following

      diagnoses should receive PRIORITY?

A.    Altered nutrition

B.     Impaired skin integrity

C.     Risk for infection

D.    Acute pain

61. A patient is being prepared for a right breast biopsy under general

      anesthesia. The patient asks the nurse about the surgical scar and possible

      postoperative complications.Which of the following actions would be

      appropriate for the nurse to take?

A.    Review the postoperative risks with the patient

B.     Notify the surgeon about the patient's questions

C.     Compete the patient's preoperative check list

D.    Show the patient photos of breast surgical scar

62. A 27 year-old woman presents with stomach cramping with alternating

       constipation and diarrhea. She had been diagnosed with irritable bowel

       syndrome two years before and has so far managed the illness with

       lifestyle changes, including diet and exercise. What is the most appropriate

       advice?

A.    Increase dairy intake

B.     Use antacids to relive pain

C.     Increase dietary fiber

D.    Avoid emotional stress triggers

63. A patient with Addison's disease asks a nurse for nutrition and diet advice.

      Which of the following diet modifications is NOT recommended?

A. A diet high in grains. 
B. A diet with adequate caloric intake. 
C. A high protein diet. 
D. A restricted sodium diet.

64. A patient with a history of diabetes mellitus is in the second post-operative

      day following cholecystectomy. She has complained of nausea and isn't

      able to eat solid foods. The nurse enters the room to find the patient

      confused and shaky. Which of the following is the most likely explanation

      for the patient's symptoms?

A. Anesthesia reaction. 
B. Hyperglycemia. 
C. Hypoglycemia. 
D. Diabetic ketoacidosis.

65. Your plan of care includes use of iontophoresis in the management of

       calcific bursitis of the shoulder. To administer this treatment using the

       acetate ion, the current characteristics and polarity should be:

A. Monophasic twin peaked pulses using the positive pole

B. Monophasic twin peaked pulses using the negative pole

Continuous monophasic using the positive pole

D. continuous monophasic using the negative pole

66. Following cast immobilization for a now healed supracondylar fracture of

       the humerus, a patient’s elbow lacks mobility. To increase elbow range of

       motion, joint mobilization in the maximum loose-packed position should

      be performed at:

A. full extension

B. 90 degrees of flexion

C. 70 degrees of flexion

D. 30 degrees of flexion

67. A patient wishes to improve her aerobic fitness. She currently jogs four

      days a week for 30 minutes at 70% of her age-predicted maximum heart

      rate. The recommendation that would not result in improved aerobic

      fitness is:

A.    increasing the distance covered in the same 30 minutes

B.     increasing the jogging time to 45 minutes while keeping at 70% of the

     age-predicted heart rate

C.     changing to interval training with maximum burst of running for 15

seconds, followed by a 30 second rest. Complete 4 sets per day, 4 days per week.

D.    changing to interval training for 4 days per week by doing 90 seconds

of comfortable running followed by 90 seconds of rest for a period of 30 minutes

68. A patient with degenerative joint disease of the right hip complains of pain

       in the anterior hip and groin, which is aggravated by weightbearing. There

       is decreased range of motion and capsular mobility. Right gluteus medius

       weakness is evident during ambulation and there is decreased tolerance of

       functional activities including transfers and lower extremity dressing. In

       this case, a capsular pattern of joint motion should be evident by

       restriction of hip:

A.    flexion, abduction and internal rotation

B.     flexion, adduction and internal rotation

C.     extension, abduction and external rotation

D.    flexion, abduction and external rotation

69. Confirmation of a diagnosis of spondylolisthesis can be made when viewing

       an oblique radiograph of the spine. The tell-tale finding is:

A. posterior displacement of L5 over S1

B. bamboo appearance of the spine

C. compression of the vertebral bodies of L5 and S1

D. bilateral pars interarticularis defects

70. You are working with a patient who exhibits a fluent aphasia. This form of

       aphasia is usually characterized by:

A. normal auditory comprehension

B. very slow speech

C. impaired reading and writing

D. impaired articulation

71. A client with portal hyertention and ascites is given 2 units of salt-poor

      albumin IV. The purpose of salt-poor albumin is to :

A. Provide parenteral nutrients.

B. Increase the client`s circulating blood volume.

C. Elevate the client`s circulation blood volume.

D. Temporarily divert blood flow away from the liver.

72. After a chlid has a craniotomy. The nurse performs an assessment of the

      chlid`s neurologie status by observing the level of conseiuosness, pupillary

      acttivity, reflex activity. Ang :

A. Bblood pressure

B. Monitor function.

C. Rectal temperature.

C. Head  circumference.

73. A 68 year-old man is admitted to the hospital with an exacerbation of

       chronic obstructive pulmonary disorder. He has breathing difficulties,

       restlessness and anxiety. He also has a moist and productive cough. The

       lower extremities are swollen with pitting edema 4+. A blood gas specimen

       is collected and sent to the laboratory. The patient has not been on

       supplemental oxygen therapy at home (see lab results)

Blood pressure                    180/90 mmHg

Heart rate                             90/min

Respiratory rate                 28/mm

Body Temperature            37.1°C

Oxygen Saturation             86 % an room air

Test                Result             Normal Values

ABG PCO2    7.33               4.7-6.0 kPa

PH                   7.32               7.36-7.45

ABG PO2       7.73               10.6-14.2 kPa

What is the most likely percentage rate per liter for oxygen

administration via nasal cannula for this patient?

A.    0.5-1

B.     .5-2

C.     2.5-3

D.    5-6

74. A 40 year-old woman is undergoing an elective rhinoplasty under general

      anesthesia. The patient is in the pre-operative room and the nurse is

      prepared to administer pre-operative intravenous medications. The patient

      states that she does not have any drug allergies. Which additional nursing

      action is most important prior to administering the medicine?

A.    Request the patient urinate

B.     Perform blood typing and cross matching

C.     Ensure the consent form has been signed

D.    Clarify contact numbers of her family members

75. The nurse is caring for a 4 year-old patient with a diagnosis of cystic fibrosis

       and pneumonia. The child is feeling better on the 3rd day of the

       hospitalization and "wants to play" What would be the BEST choice of

       entertainment?

A.    Blowing bubbles

B.     Looking at picture books

C.     Watching videos

D.    Riding in a wagon

76. During the immediate postoperative period, a patient reveals an oxygen

       saturation level of 91 %. The nurse should

A.    Position the patient on the left side

B.     Administer supplemental oxygen

C.     Continue to provide supportive care

D.    Lower the temperature of the room

77. A home care nurse visits a patient who is wheelchair bound due to a recent

       motor vehicle accident. The patient has been sitting in the wheelchair for

       extended periods of time, which has resulted in the development of a

       stage I pressure sore on the right buttocks. What is the BEST nursing

       intervention?

A.    Instruct the caretaker to change the patient's position every 2 hours

B.     Apply hydrogel to the stage I pressure sore every 8 hours

C.     Refer the patient to a wound care specialist for debridement

D.    Encourage the patient to consume an increased amount of calcium

78. A patient who sustained extensive abdominal injuries in a motor vehicle

       accident has developed a large stage II pressure ulcer on the coccyx. A new

      diagnosis of alteration in skin integrity is added to the care plan.

      What is the BEST short-term goal for the patient?

A.    Show evidence of healing within one week

B.     Have no discomfort from the pressure ulcer

C.     Eat at least 50% of each meal

D.    Verbalize strategies to prevent further skin breakdown

79. A 55 year-old man has become very anxious about skin lesions he has

       developed. On the lower right forearm, there is a well demarcated round

       patch of skin that he feels could be cancerous. It is 2.5 centimeters in

      diameter and slightly raised. On palpation it is scaly, dry and rough. The

      affected area appears sun tanned and reddened. The condition has been

      persistent for the past four years but has only recently become itchy.

     What is the most likely underlying problem?

A.    Seborrheic keratosis

B.     Actinic keratosis

C.     Eczematous dermatitis

D.    Lupus erythematosus

80. A 65 year-old woman with a history of unstable angina and hypertension

       presents to the Emergency Department with a dull chest pain that she

       describes as similar to heartburn. The pain radiates down the left arm. She

       had taken sublingual nitroglycerin tablets without any relief. An

       electrocardiograph is performed and shows elevated S- T segments. The

       nurse is to administer a thrombolytic by intravenous infusion.

       Which factor places this candidate at high risk for bleeding?

A.    Unstable angina

B.     Hypertension

C.     Age

D.    Elevated S- T segments

81.The nurse administers the first series of immunization to a 2-month-old.

      The nurse instructs the mother that, if the site becomes inflamed. She

      should give the prescribed acetaminophen and :

A. Place a warm compress on the area.

B. Put a witch hazed compress on the site.

C. Give a cool sponge bath for 15 minutes.

D. Apply an ice pack to the inflamed area for 20 minutes.

82. A child cooley`s anemia is being discharged from the hospital. The nurse

       should plan to instruct the parents regarding the need to :

A.    Restrict activty.

B.     Prevent infection

C.     Encourage fluid.

D.    Provide small frequent meals.

83. A 10-years –old child who has sickle-cell anemia is admitted to the hopital

       with vaso-occlusive creisis. When assignining a room, it is most appropriate

        for the nurse to place the child with a roommate who has :

A.    Pneumonia.

B.     Thalassemia.

C.     Osteomyelitis.

D.    Acute pharyngitis.

84. The nurse. Preparing a12 years old child for a bone marrow aspitastion,

       would know that the child does not understand the teaching about the

       procrfure when the child states :

A. I can out of bed after the doctor is finished.

B. I will have a tight dressing to put pressure on the area.

C. The doctor is going to inject a needle into the center of one of my hip

     bones.

D. The only pain I should feel is when the doctor puts in the shot so it

won`t hurt.

85. One of the aims of therapy for sickle cell anemia is the prevention of the

       sickling phenomenon. Which is responsible for the pathological sequela.

       A plan of care directed toward prevention of a crisis should consist of :

A. Promotion of adequate oxygenation and hemodilution.

B. Administration of an iron-fortified formula as nourishment

C. Measures to decreas tissue oxygen requirements and Maintain

    Hemoconcentration

D. Enforced periods of bed  rest to minimize energy expenditure and

               oxygen utilization

86. A4-year-old child is admitted wiiiith a tentative diagnosis of acute

       iymphoblastic leukemia (ALL). When obtaining  a health history from the

       parents, the nurse would expect that the child has:

A.    Alopecia and petechiae

B.     Anorexia and insomnia

C.     Anorexia and petechiae

D.    Alopecia and bleeding gums

87. A2-year-old child has been admitted to the pediatric unit with a diagnosis

       of thalassemia (Cooley`s anemia). The parents are told that there is no

       cure.But the anemia can be treated with freequet transfusions. The father

       tells the nurse he is glad that there is a treatment that “fixes” his child`s

       problem. The nurse should respond :

A.    Blood trsnfusions correct correct the anemia but also present a risk

of hepatitis.

B.     While blood trsnfusions temporarlily correct the anemina, this

treatment may cause other problem.

C.     Blodd trsnfusions are a supportive treatment, and as your child grows

older fewer of them will be needed.

D.    Tes, a blood transfusions replace the defective red blood cell. It`s like

giving insulin to a preson cells. It`s giving insulin to a person with diabetes.

88. When obtaining a health history from the parents of a toddler who is

      admitted to the hospital with acute lymphocytic leukemia (ALL), the nurse

      would be surprised if the parents report that the first sign they observed

      was :

A. A loss of appetite.

B. Sores in the mouth.

C. A paleness of the skin.

D. Purplish spots on the skin.

89. The mother of a chlid who has been recently diagnosed as having

       hemophilia is pregnant with her secound chlid. She asks the nurse what the

       chances are that this baby will also have hemophilia. The nurse`s best

       response would be :

A. There is no chance the baby will be affected.

B. Theres is a 25% chance the baby will be affected.

C. There is a 50% chance the baby will be affected.

D. There is a 75% chance the baby will be affected.

90. The nurse administers the first series of immunizations to a 2 month old.

       The nurse instructs the monther that, if the site becomes inflamed, she

       should give the prescribed acetaminophen and :

A. Place a warm compress on the area.

B. Put a with hazel compress on the site.

C. Give a cool sponge bath for 15 minutes.

D. Apply an ice pack to the inflamed area for 20 minutes.

91. he nurse is supervising care given to a group of patients on the unit. The

       nurse  observes a staff member entering a patient’s room wearing gown

       and gloves. The nurse knows that the staff member is caring for which of

      the following patients?

A.    An 18-month-old with respiratory syncytial virus.

B.     A 4-year-old with Kawasaki disease.

C.     A 10-year-old with Lyme’s disease.

D.    A 16-year-old with infectious mononucleosis

92. A 14-year-old client is scheduled for a below-knee (BK) amputation

       following a motorcycle accident. The nurse knows preoperative teaching

       for this client should include

A.    explaining that the client will be walking with a prosthesis soon after surgery.

B.     encouraging the client to share his feelings and fears about the surgery.

C.     taking the informed consent form to the client and asking him to sign it.

D.    evaluating how the client plans to maintain his schoolwork during hospitalization.

93. A client has returned from surgery with a fine, reddened rash noted around

      the area where Betadine prep had been applied prior to surgery. Nursing

      documentation in the chart should include

A.    the time and circumstances under which the rash was noted.

B.     the explanation given to the client and family of the reason for the rash.

C.     notation on an allergy list and notification of the doctor.

D.    the need for application of corticosteroid cream to decrease inflammation.

94. The home care nurse is performing an assessment of a client with

       pneumonia secondary to chronic pulmonary disease. Which of the

       following goals is MOST appropriate?

A.    Maintain and improve the quality of oxygenation.

B.     Improve the status of ventilation.

C.     Increase oxygenation of peripheral circulation.

D.    Correct the bicarbonate deficit

95. The physician diagnoses Graves’ disease for a 28-year-old woman seen in

       the clinic. The nurse would expect the client to exhibit which of the

       following symptoms?

A.    Lethargy in the early morning.

B.     Sensitivity to cold.

C.     Weight loss of 10 lb in 3 weeks.

D.    Reduced deep tendon reflexes

96. Which of the following nursing interventions is MOST important when

       caring for a client who has just been placed in physical restraints?

A.    Prepare PRN dose of psychotropic medication.

B.     Check that the restraints have been applied correctly.

C.     Review hospital policy regarding duration of restraints.

D.    Monitor the client’s needs for hydration and nutrition while restrained.

97. The nurse is aware that which of the following assessments would be

       indicative of  hypocalcemia?

A.    Constipation.

B.     Depressed reflexes.

C.     Decreased muscle strength.

D.    Positive Trousseau’s sign.

98. When obtaining a specimen from a client for sputum culture and sensitivity

       (C and S), the nurse knows that which of the following instructions is BEST?

A.    After pursed-lip breathing, cough into a container.

B.     Upon awakening, cough deeply and expectorate into a container.

C.     Save all sputum for three days in a covered container.

D.    After respiratory treatment, expectorate into a container

99. A patient has a Levin tube connected to intermittent low suction. At 7 AM ,

       the nurse charts that there is 235 cc of greenish drainage in the suction

       container. At 3 PM , the nurse notes that there is 445 cc of greenish

       drainage in the suction container. Twice during the shift, the nurse irrigates

       the Levin tube with 30 cc of normal saline, as ordered by the physician.

       What is the actual amount of drainage from the nasogastric tube for the 7

       to 3 shift?

A.    150 cc.

B.     210 cc.

C.     295 cc.

D.    385 cc

100. The physician prescribes lithium carbonate (Lithobid) 300 mg PO QID for a

         47-year-old woman. The nurse in the outpatient clinic teaches the client

         about the medication. The nurse should encourage the client to make

         sure her diet has adequate

A.    Sodium.

B.     Protein.

C.     Potassium.

D.    Iron.

101. A college student comes to the college health services with complaints of

         a severe headache, nausea, and photophobia. The physician orders a

         complete blood count (CBC) and a lumber puncture (LP). Which of the

         following lab results would the nurse expect if a diagnosis of bacterial

         meningitis were made?

A.    Cerebrospinal fluid (CSF) cloudy, Hgb 13 g/dL, Hct 38%, WBC 18,000/mm3

B.     CSF with RBCs present, Hgb 10 g/dL, Hct 37%, WBC 8,000/mm3.

C.     CSF cloudy, Hgb 12 g/dL, Hct 37%, WBC 7,000/mm3 .

D.    CSF clear, Hgb 15 g/dL, Hct 40%, WBC 11,000/mm3 .

102. A Miller-Abbott tube is ordered for a client. The nurse knows that the

         main reason this tube is inserted is to

A.    Provide an avenue for nutrients to flow past an obstructed area.

B.     Prevent fluid and gas accumulation in the stomach.

C.     Administer drugs that can be absorbed directly from the intestinal mucosa.

D.    Remove fluid and gas from the small intestine

103. A female client is scheduled for a hysterectomy When discusing the preoperative preparation, the Nurse identifies that the client has on under-standing Of the surgery. The nurse should:

A. Describe the proposed surgery to the client

B. Proceed with implementing the preoperative plan

C. Notify the physician that the client needs information

D. Explain to the client gently that she should have aksed more

     questions

104. New parentes are asked to sign the consent for their son to be

         circumcised. They ask for the nurse’s opinion of the procedure. The best

         response by the nurse would be:

A.    you should talk to the physician about this if you have any questiones.

B.     it is absolutely safe, and it is best for all male infants to be circumcised.

C.     There are advantages and disadvantages to circmcision. Let’s talk about it.

D.    Although it is a somewhat painful experience for the baby, i would allow it if i were you

105. When obtaining informed consent for sterilization  from a

         depelovmentally challenged adult client, the nurse must be sure that the:

A.    Parent or guardian signs the consent

B.     Client comprehends the outcome of the procedure

C.     Client is fully able to explain what the procedure entails

D.    Parent or guardian has encouraged the cliant to make the decision

106. A. Postpartum adolescent mother confides to the nurse that she hopes

         her baby will be good and sleep through the night. The nurse should plan

         to teach the mother to:

A.    Cuddle the baby and talk softly when crying occurs

B.     Put a sof, cuddly toy next to the baby at bedtime

C.     Add cereal to the bedtime bottle to ensure deep sleep

D.    Keep the baby awake for longer periodes during the day

107.  A client with mild preeclampsia is told that she must remain on bed rest

          at home. The client starts to cry and tells the nurse that she has two small

          children at home who need her. The nurse’s best response would be:

A.    How do you plan to manage with getting child care help?

B.     Are you worried about how you will be able to handle this problem?

C.     You can get a neighbor to help out, and your husband can do the housework in the evening.

D.    You’ll be able to fix light meals, and the children can go to nursery school a few hours each day.

108. The nurse should be aware of the stages of parental adjustment that

          follow birth of an infant at risk who is in the neonatal intensive care unit (NICU). To better plan nursing care, nirsing observation and assesments should be based on the recognition that the:

A.    Mother should not see the infant until she has completed the necessary grief work

B.     Mother should be reunited with her infant as soon as possible to enhance adjustment

C.     Parents should be encouraged to visit the newborn within the firts 24 hours after birth

D.    Nurse should wait until the parents requist to see the newboarn before suggesting a visit

109. On the third postpartum day, a client who had an unexpected cesarean

          birth is found crying during morning rounds. She says,” I know my baby is

          fine, but i can’t help crying. I wanted natural childbirth so much. Why did

          this have to happen to me?”The nurse respond knowing that:

A.    The client’s feeling will pass after she has bonded with her baby

B.     The client is probably suffering from a postpartum depression and needs special care

C.     A woman’s self-concept is severly affected by a cesarean birth, and the client’s statment reflects this

D.    A cesarean birth may be a traumatic psychologic experience in addition to an acute abstetric emergency

110. A common concern of the mother after and unexpected cesarean birth

         that the nurse should anticipate would be the:

A.    Postoperative pain and scarring

B.     Prolonged periode of hospitalization

C.     Sense of faulire in the birthing process

D.    Inability to assume her mothering role

111. A client at 37 week’s gestation delivers a healthy boy. When inspecting

         her newborn in the brithing room the client asks, what’s  this sticky white

         stuff all over him? The nurse’s most appropriate response would be:

A.    It’s a secretion from the baby’s fat cell and is called milia.

B.     Your baby was born three week’s early and we expect to see this.

C.     This is vernix, which helps protect the baby while he’s in the uterus.

D.    It’s nothing to be concerned about. All newborn babies are covered withit.

112. After a difficult labor aclient gives birth to a 9-pound boy who dies shortly

         afterward. That evening the client tearfully describes to the nurse her

         projected image of her son and what his future would have been. The

         nurse’s most therapeutic response would be:

A.    It must be difficult to think of him now.

B.     I am sure he would have been a wonderful child.

C.     Don’t dwell on this now. It only increase the pain.

D.    I guess that both you and your husband wanted a son.

113. A 49-year-old client ia admitted with a diagnosis of cervical cancer. While

        obtaining he health history she tells the nurse, “I have not had a pap

        smear for over five years. I probably would’t be in the hospital today if i’d

        had those tests more often.” The nurse should respond:

A.    Can you tell me why you havent gone?

B.     You feel like you’ve neglected your health.

C.     It’s never too late to start taking  care of yourself.

D.    Most women hate to have pap smears done but it’s really omportant.

114. A husbnd is sitting in the in the waiting room while his wife is getting her

         infertikity prescriptior reffiled by the clinic pharmacist. The nurse sits

         down beside him and he blurts our, “It’s like there are three of us in bed

         my wife me, and the doctor.” This is reflective of his feelings of:

A.    Guilt

B.     Anger

C.     Depression

D.    Unworthiness

115. The nurse should instruct the client taking oral contraceptives to increast

         her dietary intake of:

A.    Calcuim

B.     Potassium

C.     Vitamin E

D.    Vitamin B6

116. When counseling a client with diabetes mellitus who requests

         contraceptive information, it would be most therapeutic for the nurse to

         focus on:

A.    Rhythm

B.     The IUD

C.     A diaphragm

D.    Oral contraceptives

117. The school nurse is teaching a group of 16-yera-old girls about the female

         reproductive system. One student asks how long after ovulation it is

         possible for conception to occur. The nurse’s most accurate response is

         based on the knowledge that an ovum is no longer viable after

A.    12 hours

B.     24 hours

C.     48 hours

D.    72 hours

118. A couple at the prenatal clinic for a first visit tells the nurse that their 2

         year-old has just been diagnosed with the cystic fibrosis. They state there

         in no family history of this disorder. They ask the nurse with the chances

         are for their having another child with cystic fibrosis. Based on the

         knowledge that this disorder has an aotosomalrecesive mode of

        inheritance, the nurse should respond that:

A.    There is a 50% chance that this baby will also be affected

B.     If this baby is male,there is a 50% chance of his being affected

C.     If this baby is female, there is no chance of her being affected, but she wiil be a carrier

D.    There is a 25% chance the baby will be affected, and a 50% chance it will be acarrier

119. A client asks the nurse what she should do if she forgets to take the pill

         one day. The nurse’s best response would be:

A.    Take your pill as instructed.

B.     Call the physician immediately.

C.     Continue a susual; missing one day is not problem.

D.    The next day take one pill in the morning and one before bedtime

120. The nurse instructs a pregnant client about the sources of protein that

          assist in, meeting the daily requirements of:

A.    15 g

B.     30 g

C.     45 g

D.    60 g

121. A client in her second trimester is at the prenatal clinic for a routine visit.

         While listening to the fetal heart, the nurse hears a heartbeat at the rate

         of 136 in the right upper quadrant and also at the midline below the

         umbilicus. The sources of these sounds are:

A.    Heart rates of two fetuses

B.     Maternal and fetal heart rates

C.     Fetal heart rate and funic soulffle

D.    Uterine soulffle and fetal heart rate

122. A pregnent client, interested in childbirth education, asks how the lamaze

         mothod differs from the read method. The nurse explains that the lamaze

         method:

A.    Is a mush easier method to teach and learn

B.     Requires a good deal of prenatal preparation

C.     Avoids the use of pain-relieving drugs during labor

D.    Is a calm, relaxed approach based on “childbirth withhout pain

123. During a prenatal class the nurse is discussing nutrition requiremenets

         throughout pregnancy. The nurse explains that caloric needs in the

         second and third trimesters increase daily by:

A.    100 calories

B.     300 calories

C.     500 calories

D.    700 calories

124. A 34 year- old quadriplegia patient resides at home with his wife. In order

         toprevent contractures of all extremities, the community care nurse will

         instructthe patient’s wife in performance of:

A. Active range of motion exercises .

B. Passive range of motion exercises .

C. Active- assistive range of motion exercises .

D. Resistive range of motion exercises .

125. A patient complains of left eye redness and itching, the doctor told you to

         putatropine eye drops for the patient to examine his eye. The nurse

         should instillthe eye drops into:

A. The left eye .

B. The right eye .

C. Both right and left eyes .

D. Neither of the eyes .

126. year-old man presented to the Mental Health Clinic with a low-mood, a

         general loss of interest in activities and inability to experience pleasure.

         He admitted to suicidal thoughts and extreme lack of energy. He was

         prescribed a selective serotonin reuptake inhibitor to be taken daily. One

         month later, he presented to the clinic and reports feeling more

         energetic, but still has a low-mood.

What is the patient’s level of risk committing suicide at this time?

A.    None

B.     Low

C.     Medium

D.    High

127. A nurse is suctioning fluids from a client via a tracheostomy tube. When

         suctioning, the nurse must limit the suctioning to a maximum of:

A.    5 seconds

B.     10 seconds

C.     30 seconds

D.    1 minute

128. A pregnant woman in the three months to have a thrombus in the right

         leg What do you expect the doctor ordered

A.    Heparin

B.     b-Insulin

C.     Warfarin

D.    Aspirin

129. Child has burns What is the nursing intervention to prevent Aspiration for

         this child

A. Child sitting put all the time

B. Keep the child seated 10 minutes after eating

C. Keep baby sitting from 30-45 minutes after eating

D. Keep baby sitting 24 hours

130. A man has been experiencing night-blindness. What vitamin could he be

        deficient in?

A. Vitamin A

B. Vitamin B

C. Vitamin C

D. Vitamin D

131. A one month old boy present with the head tilted towards the left side

         and the chin rotated to the right side. There is a palpable mass of soft

         tissue on the right side of the neck near the clavicle:

A. Passive stretching muscle

B. Surgica release of the muscle.

C.  Surgical removal of the mass

D. It`s a normal mass in infants.

132. Acute pulmonary edema caused by heart failure is usually a result of

         damage to which of the following areas of the heart?

A.    Left atrium

B.     Right atrium

C.     Left ventricle

D.    Right ventricle.

133. The nurse knows that a client in early pregnancy undersatnd the need to

          increase her intake of complete proteins during her pregnancy when she

          reports she is esthing more:

A.    Spinach and broccoli

B.     Milk, eggs, and cheese

C.     Beans, peas, and lentils

D.    Whole grain creals and breads

134. The nurse understands that edema caused by inadequate nutrition is a

         result of the :

A. ADH mechanism.

B. Aldosterone mechanism.

C. Nitrogen balance mechanism.

D. Capillary fluid shift mechanism.

135. The nurse can prevent a major reaction to total parenteral nutrition

         infusions by :

A. Administering the fluid slowly.

B. Recording the intake and output.

C. Changing the site every 24 hours.

D. Checking the vital signs every 4 hours.

136. After a thyroidectomy the client should be placed in the :

A. Prone position

B. Supine position.

C. Left Sims position

D. Semi Fowler`s position

137. After being in labor for six hours a client is admitted to the brithing room.

         The client is 5 cm dilated and at-1 station. In the next hour her

         contractions gradually become irregular but are more uncomfortable.

         When caring for her, the nurse should first check for:

A.    False labor

B.     A full bladder

C.     Uterine dysfunction

D.    A breech presentation

138. A client in labor is admitted to the brithing room. The nurse’s assessment

         reveales that the fetus as at-1 station, which means the presenting part is:

A.    Visible at the vaginal opening

B.     One  cm below the ischial spines

C.     One cm above the ischial spines

D.    At the level of the ischial spines

139. The nurse assesses a primigravid who had been in labor for five hours. The

         fetal heart rate tracing is reassuring. Contractions are of mild instensity

         lasting 30 second and are three to five minutes apart. An oxytocin

         infusion has been ordered. The priority nursing intervention at this time

         would be to:

A.    Check cervical dilation every hour

B.     Keep the labor environmen dark and quiet

C.     Infuse oxytocin by piggibacking into the primary line

D.    Position the client on the left side throughout the infusion

140. A vaginal examination reveals that a client labor ia 7 cm dilated. Soon

         afterward she becomes nauseated, has the hiccups, and has an increase

         in bloody show. The nurse recognizes that these clinical manifestation

         indicate that the client is strarting the:

A.    Latent phase of labor

B.     Active phase of labor

C.     Transition phase of labor

D.    Earlynactive phase of labor

141. A client is to receive an epidural anesthetic during labor. After the client is

         anesthetized, the nurse should monitor the client for:

A.    Lightheadedness

B.     Urinary retention

C.     Decreased temperature

D.    Decreased level of consciousness

142. Twenty-four hours after an uncomplicated labor and birth, a client’s CBC

         reveals a WBC count of 17,000/mm³. The nurse should interpret this WBC

         count as being indivative of:

A.    The usual decrease in white blood cells

B.     The expected response to the labor process

C.     An acute sexsually transmitted viral disease

D.    A bacterial infection of the reproductive system

143. When preparing a teaching plan about selfcare during the postpartum

         period, the nurse undersatnds that on the fourth postpartum day the

         lochia is known as:

A.    Alba

B.     Rubra

C.     Serosa

D.    Purpura

144. A client arrives at the clinic with swollen, tender breasts and “flu-like”

         symptoms. A diagnosis of mastitis is made. The nurse should furst plan to:

A.    Assist her to wean the infant gradually

B.     Teach her to empty her breasts frequently

C.     Review breastfreeding techniques with her

D.    Send a sample of her milk for culture and sensitivity

145. The nurse is caring for a group of postpartum clients. The one the nurse

         should observe most closely would be a:

A.    Primipare who has had an 8-pound baby

B.     Grand multipara who experienced a labor of only one hour

C.     Primipara who received 100 mg of demerol during her labor

D.    Multipara whose placenta seperated and who delivered in 10 minutes

146. A 7-year-old client is brought to the E.R. He’s tachypneic and afebrile and

         has a respiratory rate of 36 breaths/minute and a nonproductive cough.

         He recently had a cold. From his history, the client may have which of the

         following?

A.    Acute asthma

B.     Bronchial pneumonia

C.     Chronic obstructive pulmonary disease (COPD)

D.    Emphysem

147. A newborn was delivered pre-term weighing 2700 grams with. Apgar

         scores of 4 and 6, respectively. When the mother had presented to the

         Obstetrical Triage Unit, she was already 7 centimeters dilated and fully

         effaced. Her due date was unknown as she had no parental care. The

         infant showed signs of fetal distress and was finally delivered by Cesarean

         section. At birth a large, thin, membranous sac was protruding from the

         umbilical base. What is the priority nursing intervention at birth?

A.    Maintain cardio respiratory stability

B.     Protect the herniated viscera

C.     Manage fluid intake and output

D.    Establish vascular access

148. A 34 year- old quadriplegia patient resides at home with his wife. In order

         toprevent contractures of all extremities, the community care nurse will

         instructthe patient’s wife in performance of:

A. Active range of motion exercises .

B. Passive range of motion exercises .

C. Active- assistive range of motion exercises .

D. Resistive range of motion exercises .

149. Which of the following intervention would the nurse implement to

          enhance the patient`s airway clearance ?

Heart rate                 80/min

Respiratory rate     32/min

Temperature           40oc

A. Administer oxygen as ordered .

B. Maintain a comfortable position .

C. Increase fluid intake .

D. Administer prescribed analgesics.

150. A 31 years- old woman with diabetes type 1 presents to the clinic with

         fatigue, blurred vision, and loss of appetite. Her breath smells like fruit

         and she leaves the room twice during the examination to use the toilet.

         She has brought a little bottle of water with her that she finishes while at

         the clinic. She reports that she has had a cold for the past three days, but

         has not taken additional insulin during the illness

Blood pressure                    130/70 mmhg

Heart rate                             90/min

Respiratory rate                 20/min

Body temperature             38.0 Coral

What is the most appropriate nursing diagnosis

A.    Risk for impaired skin integrity related to circulation

B.     Deficient knowledge related to illness management

C.     Risk for fluid volume excess related to fluid intake

D.    Imbalanced nutrition related to decreased appetite

151. A patient has an acute inflammation of the gallbladder. The physician

         orders the nurse to schedule the patient for surgery .

         Which of the following surgical procedures will the physician MOST likely

         perform?

A.    Pancreatectomy .

B.     Cholecystectomy .

C.     Hepatectomy .

D.    Cricothoracotom .

152. Hospitalized patient eats 20% of the meal and states being too tired to eat more. What should the nurse do?

A. Offer to feed the patient after short rest period

B. Sncouraged the patient to finish the fluids

C. Remove the meal tray and allow the patient to rest

D. Encourage the patient to finish the protein portion of the meal

153. Which type of isolation category is indicated for patient with diphtheria:

A.  Airborne

B. Droplet

C. Contact

D. Blood

154. The nurse in preparing to insert RYLE'S tube (NGT) into an infant, the

         nurse knows that the length of the tube should be taken as following:

A. From the nose down to the chin and then to the umbilicus

B. From the nose to the earlobe and then to the xiphoid process

C. From the nose to the mouth to the xiphoid process

D. From the nose to the earlobe to the umbilicus

155. The charge nurse enters the nursing diagnosis "Risk for ineffective airway

          clearance related to an inability to swallow" on the client's care plan.

          Which nursing intervention is most appropriate for managing the

           identified problem?

A. Keeping the client supine

B. Removing all head pillows

C. Performing oral suctioning

D. Providing frequent oral hygiene

156. Nurse prepares to delegate tasks to the nursing assistant Among her

         patients is a 50 year-old woman who is day two of recovery following a

         laparoscopic resection of the colon post-operative orders are follow:

         Ambulate every six hours. Evaluate vital signs every two hours. Lactated

         Ringer's IV at 50 ml/hour. Wound assessment every eight hours.

         Nasogastric tube until bowel sounds present.

         Which is most appropriate to delegate?

A.    Ambulate the patient.

B.     Evaluation of vital signs.

C.     Change intravenous fluid bags.

D.    Assess nasogastric tube placement.

 157. A 45 year-old patient has had difficulty sleeping and has lost ten

          kilograms despite having a large appetite on examination there is a

           palpable thyroid gland.

Blood pressure                    108/58 mmHg

Heart rate                             116/min

Respiratory rate                 22/min

Body temperature                         38.0 c oral

Height                                    164

Weight 5                               0 kilograms

Which additional symptom is most likely?

A.    Heart palpitations.

B.     Depression.

C.     Anorexia.

D.    Paresthesia

158. What is the Proper procedure for doing a breast self-exam?

A. Use the palm of the hand to feel for lumps.

B. Apply three different levels of pressure to feel breast tissue.

C. Stand when performing a breast self-exam.

D. Perform self-exam annually

159. Which of the following is a desired expected outcome 24 hours

         postoperatively?

A. Gag reflex present.

B. Cerebral perfusion pressure, 68mmHg

C. Intracranial pressure, 21mmHg.

D. Decreased lacrimation

160. RTA. The patient appears restless confused and disoriented. He reports

         that he had hit his head against the steering wheel of the car when it had

         collided with the car directly in front of him.

Blood pressure                    110/68 mmHg

Heart rate                             100/min

Respiratory rate                 22/min

Body Temperature            37.0 coral

Oxygen saturation                         98 % on room air

What is the most important next step in management?

A.    Immobilize head and neck.

B.     Administer oxygen.

C.     Establish an intravenous line.

D.    Arrange for an MRI scan.

161. A 30 year-old married man presents to the clinic with complaints of feeling sad for the past three months. He is unable to maintain a regular sleep routine, has lost his appetite and has difficulty concentrating. He is prescribed a medication which prevents the reuptake of specific neurotransmitters that could contribute to his mental health problem. Which side effects would be most important for the nurse to advise the patient of?

A. Polyuria

B. Photophobia

C. Fluid retention

D. Sexual dysfunction

162. A female patient has been advised that laboratory tests confirm herpes simplex virus (HSV), type 2. The nurse should teach the patient that a Papanicolaou test (Pap smear) is recommended:

A.Every 6 months if symptoms persist despite treatment

B. Every year even if asymptomatic

C. Whenever symptoms recur

D. Every 3 years if other Pap smears have been negative

163. A three year-old has returned to the clinic 4 days after being diagnosed with gastroenteritis and dehydration. A parent reports that the vomiting has stopped, and the child is tolerating liquids, rice, applesauce, and bananas. The diarrhea persists, but seems to be decreasing in volume. When evaluating for signs of dehydration, the nurse will assess the patient's skin turgor by:

A. Grasping the skin over the abdomen with two fingers and raising

     the skin with two fingers

B.     Grasping the skin over the forehead with two fingers and raising the skin with two fingers

C.     Holding the patient's mouth open and assessing the tongue for deep creases or furrows

D.    Drawing two tubes of blood and running a blood urea nitrogen (BUN) and creatinine (Cr)

164. A 12 year- old patient had a cast removed from the left leg after wearing if for eight weeks. The patient wants to resume sports as soon as possible. In order to regain muscle strength lost while wearing cast, the nurse will instruct the patient in performance of:

A. Resistive range of motion exercises to left leg

B. Passive range of motion exercises to right leg

C. Active- assistive range of motion exercises to the right leg

D. Active range of motion exercises to both legs

165. A 45 year-old man who is hospitalized feels the constant need to keep things in order, particularly whilst eating. The nurse observes him arranging the food on his plate into symmetrical and equal bite-sized pieces. He constantly worries that food served could be outdated and potentially cause illness.

Which nursing diagnosis is most important?

A.    Ineffective verbal communication

B.     Self-esteem disturbance

C.     Impaired social interaction

D.    Anxiety

166.  A patient has a central line catheter and is receiving a three-in-one total parenteral nutrition that contains glucose, proteins and lipids. The pump is set to deliver the infusion over a 12-hour period. After how many hours should the intravenous administration set be changed?

A. 12

B. 24

C. 48

D. 72

167. A 68 year-old woman is receiving parenteral nutrition at home. The district nurse visits the woman and notes that she has gained one kilogram of weight since a health provider had visited one week ago. There is pitting edema of 2+ of the lower extremities. The patient is alert, active and oriented.

Which nursing diagnosis is most appropriate?

A.    Non-compliance

B.     Impaired gas exchange

C.     Imbalanced nutrition

D.    Fluid volume overload

168. A 54 year-old woman presented to the Emergency Department with sharp upper right abdominal pain that radiates to the right scapula. While performing the admission assessment, the patient becomes nauseous and begins vomiting. She states that she has had pain in the upper right quadrant previously but that this time it was far worse. There's a positive Murphy's sign and an ultrasound confirms gallbladder wall thickening and pericholecystic fluid collections. Which of the following would most likely be associated with her clinical findings?

A. Relief by drinking milk

B. Alleviation with exercise

C. Triggered by fatty meal

D. Worsening on empty stomach

169. A patient is preparing for a total knee replacement. During the preoperative interview process the patient reports an allergic reaction to penicillin.

Which of the following is considered a side effect and not a true allergy to medication?

A.    Shortness of breath

B.     Tingling lips and tongue

C.     Rash

D.    Upset stomach

170. A 67 year-old man was admitted to the hospital following a closed bone fracture. An intramedullary nail is inserted and the patient is placed in balanced skeletal traction. The following day, the patient becomes restless, drowsy and confused, he has difficulty breathing and appears very tired.

Which additional sign or symptom would require immediate intervention?

A.    Anxiety

B.     Cold skin

C.     Constipation

D.    Petechiae on chest

171. An 82 year-old patient has Parkinson's disease. During the assessment, the nurse would expect which of the following actions to produce the MOST tremor activity of the hands?

A. Eating with a fork

B. Resting hands in lap

C. Standing with hands loose at sides

D. Rolling a small pill between the fingers

172. A 52 year-old man with congestive heart failure presents to the Emergency Department with rapid and irregular heartbeats, and feeling dizzy and light-headed. The attending physician verbally calls out an order to the nurse to administer digoxin 0.25 milligrams by intravenous injection. How will the nurse complete the paperwork for this order?

A. Write, sign and repeat order back to the physician

B. Ask the physician to write and sign the order

C. Write the order and ask the physician to sign

D. Verbally repeat the order and administer drug

173. The nurse is assisting a patient to ambulate in hall. The patient has a history of coronary artery disease (CAD) and had coronary artery bypass graft surgery (CABG) 3 days ago. The patient reports chest pain rated 3 on a scale of 0 (no pain) to 10 (severe pain). The nurse should first:

A. Determine how long it has been since the patient's last dose of

     Aspirin

B. Obtain a chair for the patient to sit down

C. Assess the patient's radial pulse

D. Ask the patient to take several slow, deep breaths.

174. A five month-old boy has been vomiting green colored vomit for ten hours. He has intermittent abdominal pain during which he draws his legs up to his chest, turns pale and cries forcefully. On observation, there is bleeding in the stool which has a jelly-like consistency. Abdominal palpation reveals a long tube-like mass. There is no fever, rash nor diarrhea. Bowel sounds are hyperactive in all quadrants.

Which is the most likely form of initial treatment?

A.    Manual manipulation

B.     Surgical resection

C.     Barium enema

D.    Endoscopy

175. A 30 year-old woman with type 1 diabetes mellitus receives mixed type of insulin in the morning and before bed time. She reports that the level of her fasting blood sugar is constantly high when she checks it every morning at home.

Which dose of insulin is most likely causing this problem?

A.    Low morning, regular insulin

B.     High morning NPHI

C.     High evening regular insulin

D.    Low evening NPH insulin

176. A client has a phosphorus level of 5.0mg/dL. The nurse closely    monitor

         the client for?

A. Signs of tetany

B. Elevated blood glucose

C. Cardiac dysrhythmias

D. Hypoglycemia

177. A nurse is caring for a child with pyloric stenosis. The nurse would watch out for symptoms of?

A. Vomiting large amounts

B. Watery stool
C. Projectile vomiting
D. Dark-colored stool

178. The nurse is teaching a mother whose daughter has iron deficiency anemia. The nurse determines the parent understood the dietary modifications, if she selects?

A. Bread and coffee
B. Fish and Pork meat
C. Cookies and milk
D. Oranges and green leafy vegetables

179. Which of the following is the most common clinical manifestation of G6PD following ingestion of aspirin?

A. Kidney failure
B. Acute hemolytic anemia
C. Hemophilia A
D. Thalassemia

180. The nurse anticipates which of the following responses in a client who develops metabolic acidosis.

A. Heart rate of 105 bpm

B. Urinary output of 15 ml
C. Respiratory rate of 30 cpm
D. Temperature of 39 degree Celsius

181. The nurse assesses a client with an ileostomy for possible development of which of the following acid-base imbalances?

A. Respiratory acidosis
B. Metabolic acidosis
C. Metabolic alkalosis
D. Respiratory alkalosis

182. Which of the following has mostly likely occurred when there is continuous bubbling in the water seal chamber of the closed chest drainage system?

A. The connection has been taped too tightly
B. The connection tubes are kinked
C. Lung expansion
D. Air leak in the system

183. The nurse plans to frequently assess a post-thyroidectomy patient for?

A. Polyuria
B. Hypoactive deep tendon reflex
C. Hypertension
D. Laryngospasm

184. Which if the following young adolescent and adult male clients are at most risk for testicular cancer?

A. Basketball player who wears supportive gear during basketball games
B. Teenager who swims on a varsity swim team
C. 20-year-old with undescended testis
D. Patient with a family history of colon cancer

185. An 18-month-old baby appears to have a rounded belly, bowlegs and slightly large head. The nurse concludes?

A.   The child appears to be a normal toddler
B.   The child is developmentally delayed
C.   The child is malnourished
D.   The child’s large head may have neurological problems.

186. An appropriate instruction to be included in the discharge teaching of a patient following a spinal fusion is?

A.  Don’t use the stairs

B.  Don’t bend at the waist
C.  Don’t walk for long hours
D.  Swimming should be avoided

187. A nurse is preparing to give an IM injection of Iron Dextran that is irritating to the subcutaneous tissue. To prevent irritation to the tissue, what is the best action to be taken?

A.  Apply ice over the injection site
B.  Administer drug at a 45 degree angle
C.  Use a 24-gauge-needle
D.  Use the z-track technique

188. What should a nurse do prior to taking the patient’s history?

A.  Offer the patient a glass of water
B.  Establish rapport
C.   Ask the patient to disrobe and put on gown
D.  Ask pertinent information for insurance purposes

189. A pregnant woman is admitted for pre-eclampsia. The nurse would include in the health teaching that magnesium will be part of the medical management to accomplish the following?

A.     Control seizures
B.    promote renal perfusion
C.     To decrease sustained contractions
D.    Maintain intrauterine homeostasis

Good Luck ..