1. A pregnant woman at term is diagnosed B.

Loss of mobility due to severe driving

with hypotonic dystocia and given Oxytocin. restrictions.
What is the most important nursing C. Decreased vision accommodation from
intervention? pilocarpine.
A. Timing and recording length of D. Painful progression of glaucoma.
contractions.
B. Monitoring. 7. The nurse finds a client’s tube disconnected
C. Preparing for an emergency cesarean from the Pleurovac. What is the initial action?
birth. A. Apply pressure over the incision site.
D. Checking the perineum for bulging. B. Clamp the chest tube near the incision
site.
2. A client who hallucinates is not in touch C. Clamp the chest tube closer to the
with reality. What is important for the nurse to drainage system.
do? D. Reconnect the chest tube to the
A. Isolate the client from other patients. Pleurovac.
B. Maintain a safe environment.
C. Orient the client to time, place, and 8. During a breech birth, which complication
person. should alarm the nurse?
D. Establish a trusting relationship. A. Abruption placenta.
B. Caput succedaneum.
3. A child who has had a tonsillectomy C. Pathological hyperbilirubinemia.
complains of throat dryness. What should the D. Umbilical cord prolapse.
nurse give?
A. Cola with ice 9. A client diagnosed with severe depression is
B. Yellow noncitrus Jello being cared for. Which nursing approach is
C. Cool cherry Kool-Aid important?
D. A glass of milk A. Protect the client against harm to others.
B. Provide motor outlets for aggressive
4. The physician ordered Phenylephrine nasal feelings.
spray for a 13-year-old. What must the nurse C. Reduce interpersonal contacts.
instruct? D. Deemphasize preoccupation with
A. Increased nasal congestion. elimination and sleep.
B. Nasal polyps.
C. Bleeding tendencies. 10. A 3-month-old client is suspected of
D. Tinnitus and diplopia. having hypothyroidism. What milestone is the
baby not achieving?
5. A client with tuberculosis is to be admitted. A. Sit up.
What precautions should the nurse take? B. Pick up and hold a rattle.
A. Place the client in a private room. C. Roll over.
B. Wear an N95 respirator. D. Hold the head up.
C. Put on a gown every time when entering
the room. 11. A newly hired nurse receives a phone order
D. Don a surgical mask with a face shield. from a physician. What should the nurse do?
A. Ask the physician to call back.
6. What is the most frequent cause of B. Take the telephone order.
noncompliance to open-angle glaucoma C. Refuse to take the order.
treatment? D. Ask a senior nurse to take the order.
A. Nausea and vomiting from miotic drugs.
12. A nurse is assigned to care for a client in A. Vigorously strip the tube.
transition with hypertension. What is the initial B. Raise the apparatus above the chest.
action? C. Increase wall suction.
A. Accept the new assignment and complete D. Ask the client to cough and take a deep
an incident report. breath.
B. Report the incident to the nursing
supervisor. 18. Two babies are placed in the wrong cribs.
C. Report the assessment to the nurse What is the most appropriate nursing action?
manager. A. Determine who is responsible and
D. Accept the new assignment and provide terminate employment.
care. B. Record the event in an incident report.
C. Reassure mothers, report to the charge
13. A newborn with Down syndrome is to be nurse, and do not record.
discharged. What age is the mother likely? D. Record detailed notes in the medical
A. 40 years. record.
B. 20 years.
C. 35 years. 19. Before administering digoxin to a toddler,
D. 20 years. what is the earliest significant sign of toxicity?
A. Tinnitus
14. The nurse is informed to float to the B. Nausea and vomiting
emergency department. What should the staff C. Vision problems
nurse expect? D. Slowing in the heart rate
A. Informed of the situation before the shift.
B. Ability to negotiate assignments. 20. What treatment modality is appropriate for
C. Cross training will be available. a client with paranoid tendency?
D. Client assignments will be equally A. Activity therapy.
divided. B. Individual therapy.
C. Group therapy.
15. A nurse is caring for a child receiving D. Family therapy.
digoxin. What question should be asked to
assess toxicity risk? 21. A client with rheumatoid arthritis is being
A. “Has he been exposed to communicable discharged on prednisone. What should the
diseases?” nurse advise?
B. “Has he been taking diuretics at home?” A. Wear sunglasses in bright light.
C. “Do siblings have cardiac problems?” B. Take prednisone before meals.
D. “Has he been going to school regularly?” C. Have periodic complete blood counts.
D. Never stop or change medication without
16. The signed consent form has an error advice.
regarding amputation. What should the nurse
do? 22. A pregnant client is worried about urinary
A. Call the physician to reschedule surgery. frequency. What is the most appropriate
B. Call a relative to sign a new form. response?
C. Cross out the error and initial the form. A. “Try Kegel exercises and limit fluids
D. Have the client sign another form. before bedtime.”
B. “Placental progesterone causes irritability
17. The nurse checks for fluctuation in a chest of the bladder.”
drainage system and it has stopped. What C. “Pregnant women urinate frequently to
should they do? get rid of fetal wastes.”
 D. “Frequency is due to bladder irritation
and is normal.” 28. Chlamydia trachomatis can cause:
A. Discoloration of baby and adult teeth.
23. How can the nurse determine if expressing B. Pneumonia in the newborn.
hostility is useful? C. Snuffles and rhagades in the newborn.
A. Expression of anger dissipates energy. D. Central hearing defects in infancy.
B. Energy from anger accomplishes tasks.
C. Expression intimidates others. 29. The most correct response of the nurse to
D. Degree of hostility is less than the client asking about drug use is:
provocation. A. “Yes, once I tried grass.”
B. “No, I don’t think so.”
24. What is a characteristic of case C. “Why do you want to know that?”
management? D. “How will my answer help you?”
A. Objective is a written plan measuring
outcomes. 30. Which describes a health care team with
B. Purpose is to identify expected principles of participative leadership?
performance. A. Each member makes decisions
C. Focus is on comprehensive coordination independently.
of care. B. The physician makes most decisions.
D. Goal is to understand unmet predicted C. The team uses expertise to influence
outcomes. decisions.
D. Nurses decide nursing care; physicians
25. The physician orders IV phenytoin for a decide medical treatment.
child. Which action is incorrect?
A. Infuse into a smaller vein. 31. Which hormone influences the milk
B. Check the solution for clarity. ejection reflex and uterine involution during
C. Plan to give over 30-60 minutes with a the postpartum period?
filter. A. Oxytocin.
D. Flush the IV tubing with normal saline B. Estrogen.
before starting. C. Progesterone.
Here’s the list of questions and choices only: D. Relaxin.

26. Which assessment findings will help the 32. This describes nursing care delivered via
nurse determine that the client is in 8-week the primary nursing method:
gestation? A. Primary nursing method.
A. Leopold maneuvers. B. Case method.
B. Fundal height. C. Functional method.
C. Positive radioimmunoassay test (RIA test). D. Team method.
D. Auscultation of fetal heart tones.
33. While waiting for the ambulance, the nurse
27. Which nursing intervention is essential for will anticipate emergency care to include
the client who had pneumonectomy? assessment for:
A. Medicate for pain only when needed. A. Gas exchange impairment.
B. Connect the chest tube to water-seal B. Hypoglycemia.
drainage. C. Hyperthermia.
C. Notify the physician if the chest drainage D. Fluid volume excess.
exceeds 100mL/hr.
D. Encourage deep breathing and coughing.
34. Which factor explains why pregnancy may
occur from unprotected intercourse during the 40. What is the appropriate nursing
preovulatory period? intervention for a client with schizophrenia
A. Ovum viability. who is disruptive?
B. Tubal motility. A. Tell the client to stop banging on the door.
C. Spermatozoal viability. B. Ignore this behavior.
D. Secretory endometrium. C. Escort the client back into the room.
D. Ask the client to move away from the door.
35. What is the best nursing response to an
older adult client having difficulty sleeping? 41. Which action is an accurate tracheal
A. “I’ll give you a sleeping pill.” suctioning technique?
B. “Perhaps you’d like to sit here for a while.” A. 25 seconds of continuous suction during
C. “Would you like me to show you the catheter insertion.
bathroom?” B. 20 seconds of continuous suction during
D. “What woke you up?” catheter insertion.
C. 10 seconds of intermittent suction during
36. The immediate nursing action for a client catheter withdrawal.
with fetal heart tones of 100 bpm is to: D. 15 seconds of intermittent suction during
A. Start oxygen by mask. catheter withdrawal.
B. Examine for signs of a prolapsed cord.
C. Turn the woman on her left side. 42. What must be ready at the bedside for a
D. Take the woman’s radial pulse. client with a sutured and wired jaw?
A. Suture set.
37. A client with glaucoma should avoid B. Tracheostomy set.
taking over-the-counter medications like: C. Suction equipment.
A. Antihistamines. D. Wire cutters.
B. NSAIDs.
C. Antacids. 43. Which sign indicates placental separation
D. Salicylates. in a mother during the third stage of labor?
A. The uterus becomes globular.
38. The nurse suspects increasing intracranial B. The umbilical cord is shortened.
pressure when: C. The fundus appears at the introitus.
A. Client is oriented when aroused from sleep. D. Mucoid discharge is increased.
B. Blood pressure decreases.
C. Client refuses dinner due to anorexia. 44. After therapy with alteplase (t-PA), what
D. Pulse increases with occasional skipped observation will the nurse report?
beats. A. 3+ peripheral pulses.
B. Change in level of consciousness and
39. Which statement about advance directives headache.
is correct? C. Occasional dysrhythmias.
A. The spouse may override the advance D. Heart rate of 100 bpm.
directive.
B. An advance directive is required for a “do 45. Which nursing action will facilitate deep
not resuscitate” order. breathing and coughing for a client post-left
C. A durable power of attorney may only be nephrectomy?
held by a blood relative. A. Push fluid administration.
D. The advance directive may be enforced B. Have the client lie on the unaffected side.
even against the spouse's opposition. C. Maintain high Fowler’s position.
D. Coordinate breathing and coughing with C. Erythema toxicum
analgesics. D. Milia

46. Which characteristics are typical of 52. After a client is declared brain dead, what
cervical mucus during the “fertile” period? is necessary when discussing organ donation
A. Absence of ferning. with the family?
B. Thin, clear, good spinnbarkeit. A. Include as many family members as
C. Thick, cloudy. possible.
D. Yellow and sticky. B. Take the family to the chapel.
C. Discuss life support systems.
47. The nurse places a client D. Clarify the family’s understanding of brain
post-appendectomy in semi-Fowler’s position death.
primarily to:
A. Facilitate movement and reduce immobility 53. Which exercise should the nurse exclude
complications. from the program for pregnant women to
B. Fully aerate the lungs. reduce lower backache?
C. Splint the wound. A. Stand with legs apart and touch hands to
D. Promote drainage and prevent abscesses. floor three times per day.
B. Ten minutes of walking per day with an
48. Which action best describes a management emphasis on good posture.
function? C. Ten minutes of swimming or leg kicking in
A. Writing a letter to a nursing journal. pool per day.
B. Negotiating labor contracts. D. Pelvic rock exercise and squats three times
C. Directing and evaluating nursing staff. a day.
D. Explaining medication side effects.
54. What is the primary treatment goal for a
49. Where should Cortisporin eye drops be client with obsessive-compulsive behavior?
placed for an infant? A. Provide distraction.
A. In the middle of the lower conjunctival sac. B. Support but limit the behavior.
B. Directly onto the sclera. C. Prohibit the behavior.
C. In the outer canthus. D. Point out the behavior.
D. In the inner canthus.
55. When should the stoma drainage appliance
50. Which finding indicates internal bleeding be applied after ileostomy?
in a client admitted due to a vehicle accident? A. When the client is able to begin self-care
A. Frank blood on the clothing. procedures.
B. Thirst and restlessness. B. 24 hours later, when the swelling subsided.
C. Abdominal pain. C. In the operating room after the ileostomy
D. Confusion and altered consciousness. procedure.
D. After the ileostomy begins to function.
Here are your questions formatted with
choices only: 56. When does ovulation occur in a 28-day
menstrual cycle?
51. The nurse observes that the skin of the A. It is impossible to determine the fertile
newborn is dry and flaking with a macular period reliably.
rash. The nurse charts this as: B. Ovulation occurs at or about day 14, fertile
A. Icterus neonatorum period between day 11 and 15.
B. Multiple hemangiomas
C. Ovulation occurs at or about day 14, fertile A. A stable postoperative client needs to
period between day 13 and 17. ambulate.
D. Ovulation occurs at about day 20, fertile B. A client in soft restraint who is agitated and
period between day 20 and the next period. crying.
C. A confused elderly woman needs assistance
57. Which statement best describes the role of with eating.
a nurse as a client advocate? D. Routine temperature check for a client at
A. A nurse may override clients’ wishes for end of shift.
their own good.
B. A nurse has the moral obligation to prevent 62. Which client should the nurse give
harm and do well for clients. immediate attention in the admission care
C. A nurse helps clients gain greater unit?
independence and self-determination. A. A client who is 3 days postoperative with
D. A nurse measures the risk and benefits of left calf pain.
health situations while factoring in cost. B. A client who is postoperative hip pinning
with pain.
58. To reduce the chances of transmitting C. New admitted client with chest pain.
herpes simplex 2, the nurse should teach the D. A client with diabetes and a glucoscan
client: reading of 180.
A. “Abstain from intercourse until lesions
heal.” 63. What is the correct instruction regarding
B. “Therapy is curative.” the collection of a sperm specimen?
C. “Penicillin is the drug of choice for A. Collect at the clinic, place in iced container,
treatment.” give to laboratory personnel immediately.
D. “The organism is associated with later B. Collect after 48-72 hours of abstinence and
development of hydatidiform mole.” bring to clinic within 2 hours.
C. Collect in the morning after 24 hours of
59. What concept should the nursing staff keep abstinence and bring to clinic immediately.
in mind when planning interventions for a D. Collect at night, refrigerate, and bring to
client with ritualistic behavior? clinic the next morning.
A. Depression underlines ritualistic behavior.
B. Fear and tensions are expressed in disguised 64. What is the expected effect of
form. Betamethasone in a pregnant woman at 34
C. Ritualistic behavior makes others weeks with preterm labor?
uncomfortable. A. Treat infection.
D. Unmet needs are discharged through B. Suppress labor contraction.
ritualistic behavior. C. Stimulate the production of surfactant.
D. Reduce the risk of hypertension.
60. What defense mechanism do women
exhibit when they delay seeking medical 65. What nursing intervention should be
advice after discovering a lump? implemented before deflating a tracheostomy
A. Intellectualization. cuff?
B. Suppression. A. Suction the trachea and mouth.
C. Repression. B. Have the obdurator available.
D. Denial. C. Encourage deep breathing and coughing.
D. Do a pulse oximetry reading.
61. Which situation cannot be delegated to the
nursing assistant?
66. What does respiratory isolation for a client B. Excessive saliva and bumps around the
with Tuberculosis mean? areolae.
A. Gloves are worn when handling the client’s C. Fatigue, nausea, and urinary frequency.
tissue and excretions. D. Ankle edema, enlarging varicosities, and
B. Both client and attending nurse must wear heartburn.
masks at all times.
C. Nurse and visitors must wear masks until 72. What is the initial nursing action for a
chemotherapy is begun. newborn with Apgar scores of 7 and 9 who
D. Full isolation; caps and gowns are required becomes slightly cyanotic?
during contagion. A. Elevate his head.
B. Wrap him in another blanket.
67. How should the nurse respond to a C. Stimulate him to cry.
husband inquiring about his wife's condition D. Aspirate his mouth and nose.
after lung cancer admission?
A. Find out what information he already has. 73. What psychodynamic principle should the
B. Suggest that he discuss it with his wife. nurse know for a client with a somatoform
C. Refer him to the doctor. disorder?
D. Refer him to the nurse in charge. A. Symptoms are an attempt to adjust to
painful life situations.
68. How should the nurse therapeutically B. Major mechanism is regression.
respond to a client accusing others of stealing? C. Symptoms are imaginary and faked.
A. Divert the client’s attention. D. Prolonged study of symptoms will reassure
B. Listen without reinforcing the client’s the client.
belief.
C. Inject humor to defuse the intensity. 74. How should the nurse administer hepatitis
D. Logically point out that the client is B, DPT, and Haemophilus influenzae type B
jumping to conclusions. immunizations?
A. Draw in the same syringe and give one
69. How often should a urine pouch be injection.
emptied after a cystectomy with an ileal B. Mix and inject in the same sites.
conduit? C. Not mix, give three injections in three sites.
A. Every 3-4 hours. D. Mix and give injections in three sites.
B. Every hour.
C. Twice a day. 75. How should the nurse position a client
D. Once before bedtime. with radium implants?
A. Flat in bed.
70. Which telephone call from a student’s B. On the side only.
mother should the school nurse prioritize? C. With the foot of the bed elevated.
A. Cardiac repair surgery notification. D. With the head elevated 45 degrees
B. Notification of head lice. (semi-Fowler’s).
C. Child with a temperature of 102ºF and a Sure! Here are the questions and choices
rash. formatted as you requested:
D. Child underwent emergency appendectomy.
76. Which statement indicates the mother
71. Which signs and symptoms during needs additional teaching regarding syrup of
pregnancy require immediate attention? ipecac?
A. Severe abdominal pain or fluid discharge A. “I’ll give the medicine if my child gets into
from the vagina. some toilet bowl cleaner.”
B. “I’ll give the medicine if my child gets into A. “It is not unusual to take 6-12 months to get
some aspirin.” pregnant.”
C. “I’ll give the medicine if my child gets into B. “Start planning adoption.”
some plant bulbs.” C. “Consult a fertility specialist.”
D. “I’ll give the medicine if my child gets into D. “Have sex as often as you can.”
some vitamin pills.”
82. The best response by the nurse regarding
77. Which change would not be expected if the purpose of a 24-hour urine collection for
cranial nerve VII was damaged? creatinine clearance is:
A. Drooling and drooping of the mouth. A. “It provides a way to see if you are passing
B. Inability to open eyelids on operative side. any protein in your urine.”
C. Sagging of the face on the operative side. B. “It tells how well the kidneys filter wastes
D. Inability to close eyelid on operative side. from the blood.”
C. “It tells if your renal insufficiency has
78. What is the priority nursing intervention affected your heart.”
when a nurse observes a mother beating her D. “The test measures the number of particles
child? the kidney filters.”
A. Assess the child’s injuries.
B. Report the incident to protective agencies. 83. What is the best initial nursing response to
C. Refer the family to an appropriate support a client afraid of dying?
group. A. “It must be frightening for you. Tell me
D. Assist the family to identify stressors and more about it.”
coping mechanisms. B. “Don’t worry, you won’t die.”
C. “Why are you afraid of dying?”
79. The nurse is responsible for a nursing D. “Try to sleep. You need the rest.”
assistant’s mistake if:
A. Always, as a representative of the 84. What should the nurse do upon
institution. overhearing staff discussing a client’s health
B. Always, because nurses are responsible for condition?
less-trained individuals. A. Join in the conversation.
C. If the nurse failed to determine the nursing B. Ignore them.
assistant’s competence. C. Tell them it is not appropriate.
D. Only if the nurse agreed to feed the D. Report this incident to the nursing
newborn formula. supervisor.

80. The primary reason for encouraging a ---

client with urinary calculi to have a fluid
intake of 2L/day is to: 85. In transferring a client with a right-sided
A. Reduce the size of existing stones. cerebrovascular accident, the client should be
B. Prevent crystalline irritation to the ureter. placed in what position?
C. Reduce the size of existing stones. A. Weakened (L) side next to bed.
D. Increase the hydrostatic pressure in the B. Weakened (R) side next to bed.
urinary tract. C. Weakened (L) side away from bed.
D. Weakened (R) side away from bed.
81. What is the best advice for a couple in
their mid-30s unable to conceive for about 6 86. Which toy should be avoided in a child’s
months? bed with a spica cast?
A. A toy gun.
B. A stuffed animal. B. The average temperature taken each
C. A ball. morning.
D. Legos. C. Should be recorded each morning before
any activity.
87. The nurse should explain that oxytocin D. Has a lower degree of accuracy than the
(Pitocin) is given after birth to: cervical mucus test.
A. Minimize discomfort from “afterpains.”
B. Suppress lactation. 93. What is the most important question to ask
C. Promote lactation. during a job interview?
D. Maintain uterine tone. A. Ask about client care assignments and
advancement opportunities.
88. If unusual behaviors of medical staff B. Decline to ask questions.
continue to be reported, the nurse should: C. Ask as many questions about the facility as
A. Continue to report observations until possible.
resolved. D. Clarify salary, benefits, and working hours
B. Consider the obligation to protect patients first.
has been met.
C. Discuss the situation with friends. 94. During which trimester is the fetus most
D. Approach the partner of the medical staff vulnerable to teratogens?
member. A. The entire pregnancy.
B. The third trimester.
89. What is the maximum single dose of C. The first trimester.
tetracycline for a child weighing 20kg? D. The second trimester.
A. 1 g
B. 500 mg 95. What is the most therapeutic nursing
C. 250 mg response to a client claiming there is a bug in
D. 125 mg the bed?
A. Silence.
90. Which event in obstetric history may B. “Where’s the bug? I’ll kill it for you.”
indicate dysfunctional labor? C. “I don’t see a bug, but you seem afraid.”
A. Total time of ruptured membranes was 24 D. “You must be seeing things.”
hours with the second birth.
B. First labor lasting 24 hours. 96. What is the most likely cause of right groin
C. Uterine fibroid noted at cesarean delivery. pain in a pregnant client?
D. Second birth by cesarean for face A. Beginning of labor.
presentation. B. Bladder infection.
C. Constipation.
91. What is the most therapeutic approach for D. Tension on the round ligament.
a client with antisocial personality disorder?
A. Provide external controls. 97. When does the Good Samaritan law
B. Reinforce the client’s self-concept. protect a nurse from a malpractice suit?
C. Give the client opportunities to test reality. A. When the nurse leaves before the
D. Gratify the client’s inner needs. ambulance arrives.
B. When the nurse acts in an emergency at
92. What should the nurse emphasize about work.
basal body temperature in fertility awareness? C. When the nurse refuses to stop outside of
A. Can be done with a mercury thermometer work.
but not a digital one.
D. When the nurse is grossly negligent at an
emergency.

98. Which nursing care is least likely to be

done for a woman with mild preeclampsia?
A. Deep-tendon reflexes once per shift.
B. Vital signs and FHR q4h while awake.
C. Absolute bed rest.
D. Daily weight.

99. What should the nurse do if a newborn

with an unrepaired cardiac defect has a
respiration rate of 72 breaths per minute?
A. Burp the newborn.
B. Stop the feeding.
C. Continue the feeding.
D. Notify the physician.

100. What does the nurse suspect when a

client post-appendectomy exhibits restlessness
and confusion?
A. Panic reaction.
B. Medication overdose.
C. Toxic reaction to an antibiotic.
D. Delirium tremens.