1.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

2.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

3.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

4.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

5. A client has a phosphorus level of 5.0mg/dL. The nurse closely monitors the
client for?

a) Signs of tetany
b) Elevated blood glucose
c) Cardiac dysrhythmias
d) Hypoglycemia

6. 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
7.The nurse responder finds a patient unresponsive in his house. Arrange steps for
adult CPR.

a) Assess consciousness
b) Give 2 breaths
c) Perform chest compression
d) Check for serious bleeding and shock
e) Open patient’s airway
f) Check breathing

___, ___, ___, ___, ___, ___

8.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

9.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

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

a) Polyuria
b) Hypoactive deep tendon reflex
c) Hypertension
d) Laryngospasm

11.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.

12.A nurse is going to administer 500mg capsule to a patient. Which is the correct
route?
13.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

14.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

15.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

16.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
17.A nurse is going to administer ear drops to a 4-year-old child. What is the correct
way of instilling the medicine after tilting the patient’s head sidewards?

a) Pull the pinna back then downwards

b) Pull the pinna back then upwards
c) Pull the pinna up then backwards
d) Pull the pinna down then backwards

18.A nursing student was intervened by the clinical instructor if which of the
following is observed?

a) Inserting a nasogastric tube

b) Positioning the infant in a “sniffing “position
c) Suctioning first the mouth, then the nose
d) Squeezing the bulb syringe to suction mouth

19.Choose amongst the options illustrated below that best describes the angle for an
intradermal injection?

20.During a basic life support class, the instructor said that blind finger sweeping is
not advisable for infants. Which among the following could be the reason?

a) The mouth is still too small

b) The object may be pushed deeper into the throat
c) Sharp fingernails might injure the victim
d) The infant might bite

21.A nurse enters a room and finds a patient lying on the floor. Which of the
following actions should the nurse perform first?

a) Call for help

b) Establish responsiveness of patient
c) Ask the patient what happened
d) Assess vital signs
22.A patient with complaints of chest pain was rushed to the emergency
department. Which priority action should the nurse do first?

a) Administer morphine sulfate intravenously

b) Initiate venous access by performing venipunture
c) Administer oxygen via nasal cannula
d) Complete physical assessment and patient history

23.A rehab nurse reviews a post-stroke patient’s immunization history. Which

immunization is a priority for a 72-year-old patient?

a) Hepatitis A vaccine
b) Hepatitis B vaccine
c) Rotavirus Vaccine
d) Pneumococcal Vaccine

24.Several patients from a reported condominium fire incident were rushed to the
emergency room. Which should the nurse attend to first?

a) A 15-year-old girl, with burns on the face and chest, reports hoarseness of the
voice
b) A 28-year-old man with burns on all extremities
c) A 4-year-old child who is crying inconsolably and reports severe headache
d) A 40-year-old woman with complaints of severe pain on the left thigh

25.The doctor ordered 1 pack of red blood cells (PRBC) to be transfused to a

patient. The nurse prepares the proper IV tubing. The IV tubing appropriate for
blood transfusion comes with?

a) Air vent
b) Microdrip chamber
c) In-line filter
d) Soluset

26.The expected yet negative (harmful ) result for posthemodialysis is a decrease

in?

a) Creatinine
b) BUN
c) Phosphorus
d) Red blood cell count

27.A patient was brought to the emergency room after she fell down the stairs.
Which of the following is the best indicator for increased intracranial pressure in
head and spinal injury?

a) Inability to move extremities

b) Decreased respiratory rate
c) Increase in pulse and blood pressure
d) Decrease level of consciousness
28.A new nurse is administering an enema to a patient. The senior nurse should
intervene if the new nurse?

a) Hangs the enema bag 18 inches above the anus

b) Positions the client on the right side
c) Advances the catheter 4 inches into the anal canal
d) Lubricates 4 inches of the catheter tip

29.The medication nurse is going to give a patient his morning medications. What is
the primary action a nurse should do before administering the medications?

a) Provide privacy
b) Raise head of the bed
c) Give distilled water
d) Check client’s identification bracelet

30.A 30-year-old client is admitted with inflammatory bowel syndrome (Crohn’s

disease). Which of the following instructions should the nurse include in the health
teaching? Select all that apply

a) Corticosteroid medication is part of the treatment

b) Include milk in the diet
c) Aspirin should be administered
d) Antidiarrheal medication can help
1.) Answer: D

Dark green leafy vegetables are good sources of iron. Oranges are good sources of
vitamin C that enhances iron absorption in the small intestines.

2.) Answer: B

Individuals with G6PD may exhibit hemolytic anemia when exposed to infection,
certain medications or chemicals. Salicylates such as Aspirin damages plasma
membranes of erythrocytes, leading to hemolytic anemia.

3.) Answer: B

Lower GI fluids are alkaline in nature and can be lost via ileostomy. Thus, loss of
HCO3, results to metabolic acidosis.

4.) Answer: C

Initially, respiratory system will try to compensate metabolic acidosis. Patients with
metabolic acidosis have high respiratory rate.

5.) Answer: A

Normal phosphorus level is 2.5 – 4.5 mg/dL .The level reflects hyperphosphatemia
which is inversely proportional to calcium. Client should be assessed for tetany
which is a prominent symptom of hypocalcemia.

6.) Answer: C

Clinical manifestations of pyloric stenosis include projectile vomiting, irritability,

constipation, and signs of dehydration, including a decrease in urine output.

7.) Answer: A, E, F, C, B, D

In accordance with the new guidelines, remember AB-CABS. A-airway B-breathing

normally? − C-chest compression A-airway open B-breathing for patient S-serious
bleeding, shock, spinal injury. The nurse should first assess consciousness of the
patient. Next, open patient’s airway to check for breathing. When there is no
breathing, immediately perform chest compression then give 2 breaths, do the cycle
of care over. Finally, check for serious bleeding, shock, and spinal injury.

8.) Answer: D

Continuous bubbling seen in water-seal bottle/ chamber indicates an air leak or

loose connection, and air is sucked continuously into the closed chest drainage
system.

9.) Answer: C
Testicular cancer is most likely to affect males in late adolescence. Undescended
testis is also one major risk for testicular cancer.

10.) Answer: D

Hypocalcemia occurs when there is accidental removal or destruction of parathyroid

tissue during surgical removal of the thyroid gland. Laryngospasm is one of the
clinical manifestations of tetany, an indicator of hypocalcemia.

11.) Answer: A

It’s normal for a toddler to have bowlegs and a protruding belly. The head still
appears somewhat large in proportion from the rest of the body.

12.) Answer: D

13.) Answer: B

There is 6-8 months activity restriction following a spinal fusion. Sitting, lying,
standing, normal stair climbing, walking, and gentle swimming is allowed. Bending
and twisting at the waist should be avoided, along with lifting more than 10 lbs.

14.) Answer: D

Z-track technique is used to administer drugs especially irritating to the

subcutaneous tissue. This method promotes absorption of the drug by preventing
drug leakage into the subcutaneous layer.

15.) Answer: B

Establishing rapport is a way to gain trust that will lead for a patient to relax. You
can get more insights and information from a patient when rapport is established.

16.) Answer: A

Low magnesium (hypomagnesemia) produces clinical manifestations like increased

reflexes, tremors, and seizures. Magnesium Sulfate is the drug of choice to prevent
seizures in pre-eclampsia and eclampsia.

17.) Answer: C

Ear canal of children ages 3years and above can be straightened by pulling the pinna
up then backwards. For children below 3 years of age, the ear canal can be
straightened by pulling the pinna down then backwards.

18.) Answer: A
Infants are nose breathers. A gastric tube may be inserted to facilitate lung
expansion and stomach decompression, but not a nasogastric tube as it can occlude
the nare, thus, making breathing difficult for the infant.

19.) Answer: B

20.) Answer: B

Blind finger sweeps are not recommended in all CPR cases especially for infants and
children because the foreign object may be pushed back into the airway.

21.) Answer: B

First step in cardiopulmonary resuscitation (CPR) is assessing responsiveness of the

patient.

22.) Answer: C

Priority nursing action is to administer oxygen to patients with chest pain. Chest
pain is caused by insufficient myocardial oxygenation.

23.) Answer: D

Pneumococcal Vaccine is a priority immunization for the elderly. Seniors, ages 65

years old and above, have higher risk for serious pneumococcal infection and likely
have low immunity. This is administered every 5 years.

24.) Answer: A

Burns on the face and neck can cause swelling of the respiratory mucosa that can
lead to airway obstruction manifested by hoarseness of voice and difficulty in
breathing. Maintaining an airway patency is the main concern.

25.) Answer: C

An in-line filter is required for blood transfusions.

26.) Answer: D

Negative outcome: Hemodialysis decreases red blood cell count which worsens
anemia, because RBCs are lost in dialysis from anticoagulation during the procedure,
and from residual blood that is left in the dialyzer.

27.) Answer: D
Decrease in level of consciousness and headache are early signs of increase in
intracranial pressure (ICP). Altered level of consciousness is the most common
symptom that indicates a deficit in brain function.

28.) Answer: B

Recall the anatomy of the colon. The appropriate position is left lateral to facilitate
flow of enema by gravity into the colon.

29.) Answer: D

Recall the 12 Rights of administration. Checking the patient’s name is critical for
client-safety.

30.) Answer: A , D

Crohn’s disease is a chronic inflammation of the colon with symptoms of diarrhea,

abdominal pain, and weight loss. Corticosteroid is a treatment for Crohn’s disease.
Antidiarrheal can give relief to diarrheal episodes. Aspirin should be avoided as it can
worsen inflammation. Those with Crohn’s disease are mostly lactose intolerant, so
choice no. (2) is incorrect.
1.The client presented with complaints of body weakness, dizziness and chest pain.
Upon careful assessment, the nurse suspects Angina Pectoris. Which of the following
statements made by the client can confirm this?

a. “I suddenly felt a pain on my chest which radiates to my back and arms”.

b. “I suddenly felt a sharp pain on my lower abdomen”.
c. “The pain does not subside even if I rest”.
d. “The pain goes all the way down to my stomach”.

2.The client from the OR is transferred to the post-anesthesia care unit after surgical
repair of abdominal aortic aneurysm. Which of the following assessment findings
would indicate that the repair was successful?

a. Urine output of 50 mL/hr.

b. Presence of non-pitting, peripheral edema.
c. Clear sclera.
d. Presence of carotid bruit.

3.The client is scheduled for cardiac catheterization because the physician wants to
view the right side of the heart. Which of the following would the nurse expect to
see in this procedure?

a. A dye is injected to facilitate the viewing of the heart

b. Thallium is injected to facilitate the scintillation camera
c. A probe with a transducer tip is swallowed by the client.
d. A tiny ultrasound probe is inserted into the coronary artery

4.The client is being treated for hypovolemia. To assess the effectiveness of the
treatment, the Central Venous Pressure (CVP) of the client is being monitored.
Which of the following is TRUE about CVP?

a. The CVP is measured with a central venous line in the inferior vena cava.
b. The normal CVP is 7 to 9 mmHg.
c. The zero point on the transducer needs to be at the level of the left atrium.
d. The client needs to be supine, with the head of the bed elevated at 45 degrees.

5.The client’s ECG tracing shows ventricular tachycardia secondary to low

magnesium level. Which of the following electrocardiogram tracing results is
consistent with this finding?

a. The appearance of a U wave

b. Shortened ST segment and a widened T wave.
c. Tall, peaked T waves
d. Tall T waves and depressed ST segment

6.The nurse is teaching the client how to use a dry powder inhaler (DPI). Which of
the following are correct instructions given by the nurse? Select All That Apply.

a. Load the drug first by turning to the next dose of drug, or inserting the capsule
into the device, or inserting the disk or compartment into the device.
b. Never wash or place the inhaler in water.
c. Shake your inhaler prior to use.
d. The drug is a dry powder that is why you will taste the drug as you inhale.
e. Never exhale into the inhaler.
f. Do not remove the inhaler from your mouth as soon as you have breathe in.

7.The nurse is assigned to render care for a client who has a chest tube drainage
system. Which of the following are appropriate nursing actions? Select All That
Apply.

a. Strip the chest tube.

b. Empty collection chamber when the drainage makes contact to the bottom of the
tube.
c. Keep chest tube as straight as possible.
d. Notify the physician of drainage is greater than 70mL/hr.
e. Assess bubbling in the water seal chamber.
f. Keep drainage system at the level of the client’s chest

8.The client with DKA is receiving bicarbonate IV infusion for treatment of severe
metabolic acidosis. The nurse notes that the latest ABG shows a pH of 7.0. What
should the nurse keep in mind in giving the drug?

a. Check vital signs before giving the drug and monitor serum sodium level.
b. Perform a sensitivity test prior to drug administration.
c. Mix the drug with D10W 500 ml IV fluid and infuse for over 4 to 8 hours.
d. Administer the drug slowly and monitor the potassium leve

9.The client with a gunshot wound on the abdomen starts to get lethargic, is
breathing heavily, and the wound dressing is fully soaked with blood. The nurse is
expected to immediately perform which of the following actions?

a. Loosen tight clothing and administer oxygen supply.

b. Apply warm blanket to prevent heat loss.
c. Apply large gauze on the bleeding site to put direct pressure or place a tourniquet
on the artery near the bleeding site.
d. Initiate IV access.

10.The nurse is providing home instructions to a client with increased

adrenocorticotrophic hormone. The nurse is aware that the client with excessive
corticosteroids is suffering from what condition?

a. Cushing’s syndrome
b. Addison’s disease
c. Hypothyroidism
d. SIADH

11.The nurse is assigned to a post-thyroidectomy client and is monitoring for signs

of hypocalcemia. The nurse gently tapped the area below the zygomatic bone just in
front of the ear. This action will elicit:
a. Facial tremor
b. Hyperreflexia
c. Chvostek sign
d. Trousseau sign

12.The nurse is caring for a client with an antineoplastic IV hooked on the right
hand. The nurse notices that IV site is swelling and feels cool when touched. The
nurse recognizes this as extravasation. This predisposes the client to develop which
among the following complications? Select all that apply.

a. Infection
b. Tissue necrosis
c. Disfigurement
d. Loss of function
e. Amputation
f. Delayed healing

13.Nursing interventions commonly performed when the client is experiencing

Autonomic Dysreflexia will include the following. Select all that apply.

a. Use digital stimulation to empty the bowel.

b. Have the client sit up straight and raise his head so that he is looking ahead.
c. Remove client’s stockings or socks.
d. Manually compress or tap the bladder to allow urine to flow down the catheter.
e. Administer prescribed vasodilators.

14.Neurologic conditions can be manifested by changes in breathing patterns. The

client presents with symptom of Cheyne-Stokes respirations. The nurse knows that
this kind of breathing pattern shows:

a. Completely irregular breathing pattern with random deep and shallow respirations
b. Prolonged inspirations with inspiratory and /or expiratory pauses
c. Sustained regular rapid respirations of increased depth
d. Rhythmic waxing and waning of both rate and depth of respiration with brief
periods of interspersed apnea

15.The physician is assessing the client’s sensorium by using the Glasgow Coma
Scale. Which of the following is true about the Glasgow Coma Scale?

a. If the client does not respond to painful stimuli, the score is 0.

b. A score lower than 10 indicates that the client is in a coma.
c. A score of 8 indicates that the client is alert and oriented.
d. A score of 4 indicates that the client sustained severe head trauma.

16.The nurse on duty is caring for a client with Amyotrophic Lateral Sclerosis and is
concerned with the client’s impaired physical mobility. The following nursing
interventions are geared towards maintaining optimal physical mobility EXCEPT:

a. Maintain an exercise program.

b. Encourage participation in activities.
c. Instruct client related safety measures.
d. Schedule activities in the morning.

17.An elderly client had a cerebrovascular accident or stroke. The left brain is
affected and is at risk for impaired verbal communication. The nurse asked a
question and noted that the client has difficulty talking and communicating his
thoughts. Which of the following terms should the nurse use to document the
finding?

a. Receptive Aphasia
b. Expressive Aphasia
c. Global aphasia
d. Apraxia

18.The client diagnosed with Alzheimer’s disease is starting to show signs and
symptoms. The nurse wants to assess for graphesthesia. This is performed by:

a. Testing for the client’s ability to identify an object that is placed on the hand with
eyes closed.
b. Testing for the client’s ability to recognize the written letter or number in the
client’s skin while the eyes are closed.
c. Making the client stand, with the arms at the side, feet together, with the eyes
open and then closed. The client is then observed for any swaying.
d. Testing for the presence of pain once the leg is flexed at the hip, and then
extended.

19.The pediatric client presents with the following signs and symptoms: high fever,
drooling, difficulty of breathing and leaning forward in a tripod position.
Immunization history shows that the client never received any Hib vaccine. Which of
the following is the priority of the healthcare provider?

a. Continuous oxygen therapy and constant monitoring of oxygen saturation rate.

b. A well regulated IV infusion and timely administration of antibiotics.
c. Vaccination of Hib and other remaining vaccines to complete required
immunizations.
d. Avoiding any throat examination or agitation of the child.

20.The physician prescribed Clarithromycin (Biaxin) 250mg BID x 7 days for the
client’s infection. Incorrect drug frequency and duration would cause inaccurate
transfer time of the drug to specific tissues in the body. The nurse explains to the
client that accumulation of the drug in specific tissues is the concept of:

a. Absorption
b. Distribution
c. Metabolism
d. Excretion

21.The nurse is to administer Meperidine (Demerol) 35 mg through the

intramuscular route. Available meperedine is 50mg/mL. Which of the following is the
least favorable injection site for intramuscular medication?
a. Ventrogluteal
b. Vastus lateralis
c. Deltoid muscle
d. Dorsogluteal

22.The client presented with complaint of leg cramps. Upon checking the client’s
chart, the nurse noted that the client is hypertensive and is prescribed with a
Thiazide diuretic. The appropriate nursing intervention for this client is:

a. Stop the Thiazide diuretic

b. Refer to the physician for evaluation of electrolyte level of the client
c. Switch the client to a loop diuretic
d. Give the client a non-steroidal anti-inflammatory drug (NSAID)

23.The client is wheeled into the delivery room and is ready for childbirth. While
crowning occurs, the labor nurse applies gentle pressure over the perineum and fetal
head. The maneuver performed is called:

a. Brandt-Andrew’s maneuver
b. McRobert’s maneuver
c. Schultz mechanism
d. Ritgen’s maneuver

24.The nurse is monitoring the condition of the postpartum client. As a part of the
postpartum adaptations, the nurse monitors for descent of the uterus and expects
the fundus to be:

a. On the same level after delivery

b. Decreased by 1 cm/day
c. Decreased by 1.5 cm/day
d. Decreased by 2 cm/day

25.The granddaughter of the client asked the nurse if it is normal for elderly people
to feel sleepy despite sleeping for long hours. Which of the following conditions
would the nurse suspect?

a. Somatoform Disorder
b. Malingering
c. Anxiety
d. Amnesia

26.Chemotherapy is one of the treatments for uterine cancer. The client asked the
nurse how chemotherapeutic drugs work. Which of the following statements will be
the best explanation?

a. Chemotherapeutic agents alter molecular structure of DNA.

b. Chemotherapeutic agents hasten cell division.
c. Cancer cells are sensitive only to chemotherapeutic agents.
d. Chemotherapeutic agents act on all rapidly dividing cells.
27.Vomiting is one of the most common side effects of chemotherapy. The nurse
should be aware of which acid-base imbalance?

a. Ketoacidosis
b. Metabolic acidosis
c. Metabolic alkalosis
d. Respiratory alkalosis

28.The client develops a 2nd degree skin reaction from radiation therapy. The nurse
should expect the following symptoms EXCEPT:

a. The skin is scaly.

b. There is an itchy feeling.
c. There is dry desquamation present.
d. The skin is reddened.

29.The nurse is assessing the muscle coordination and mobility of the client with
musculoskeletal disorder. The nurse noted impulsive and brief muscle twitching of
the face and the limbs. This finding is called:

a. Tremor
b. Chorea
c. Athetosis
d. Dystonia

30.The nurse is assigned to render care to a client with altered mobility. Which of
the following statements is true regarding body mechanics when moving clients?

a. Stand at arm’s length from the working area.

b. Elevate adjustable beds to hip level.
c. Swivel the body when moving the client.
d. Move the client with wide base and straight knees.
1. Answer: A

Rationale:

Angina pectoris is a substernal pain that radiates to the neck, jaw, back and arms
and is relieved by rest. Lower abdominal pain may indicate other gastrointestinal
problems.

2. Answer: A

Rationale:

50 mL/hr is the normal urine output. A normal urine output indicates that there is a
good renal perfusion, and also connotes that the client is hemodynamically stable,
therefore, the repair is successful.

3. Answer: A

Rationale:

In cardiac catheterization or coronary angiogram, a catheter is inserted into the

heart via a vein to measure the ventricular function. A dye is used to provide further
assessment of the structure and motion of the heart. Thallium is a radioactive
isotope injected parenterally so that the scintillation camera can count the
radioactive uptake. This is observed when a physician requests for a Nuclear
Cardiology test. When performing a Transesophageal Echocardiogram (TEE), a probe
with a transducer tip is swallowed by the client to visualize for valvular
abnormalities, possible thrombus, bacterial endocarditis and any congenital heart
defects. When performing an Intracoronary Ultrasound, a tiny ultrasound probe is
inserted into the coronary artery to evaluate for plaque size and consistency, arterial
walls and effectiveness of the treatment.

4. Answer: D

Rationale:

The central venous pressure is within the superior vena cava. The Normal CVP is 2-6
mmHg. A decrease in the CVP indicates a decrease in the circulating blood volume,
which may be a result of hemorrhage or fluid imbalances. The right atrium is located
at the midaxillary line at the fourth intercostal space, and the zero point on the
transducer needs to be at the level of the right atrium. The client needs to be
supine, with the head of the bed elevated at 45 degrees to correctly assess the CVP.

5. Answer: D

Rationale:
In hypokalemia, the electrocardiogram may show flattening and inversion of the T
wave, the appearance of a U wave, and ST depression. Hypercalcemia can cause a
shortened ST and widened T wave. The electrocardiogram of a hyperkalemic client
shows tall peak T waves, widened QRS complexes, prolonged PR intervals or flat P
waves.

6. Answer: A, B, E

Rationale:

Loading of drug depends on the type of dry powder inhaler. Take note that some dry
powder inhalers do not require loading. Dry powder inhalers are kept dry always and
are place at room temperature. Never shake a dry powder inhaler. It is not a
pressurized container. There is no propellant, only the client’s breath can pull the
drug in. Because the drug is a dry powder and there is no propellant, the client will
not feel, smell, or taste the drug during inhalation. The client’s breath will moisten
the powder causing it to clump and not be delivered accurately. Immediately after
inhalation of drug, the inhaler must be removed from the client’s mouth to prevent
moisture.

7. Answer: C, D, E

Rationale:

Stripping is not allowed. Also when changing the drainage system or when checking
air leaks, clamp the chest tube for short periods only. Emptying of collection
chamber or changing the drainage system should be done before the drainage
comes in contact with the bottom of the tube. Avoid kinks and dependent loops to
allow effective drainage and prevent disrupting the system. Report excessive
drainage that is cloudy or red. Drainage will often increase with position changes or
coughing.

Bubbling is expected and indicates air drainage from the client. Absence of bubbling
may mean that the chest tube is obstructed, the lungs have fully reexpanded and no
more air is leaking into the pleural space. Keep drainage system lower than the level
of the chest to allow effective drainage.

8. Answer: D

Rationale:

Sodium Bicarbonate should be slowly administered because fast infusion may result
to abrupt reduction of serum potassium level which can eventually lead to
arrhythmias. Diluting or mixing the drug with hypotonic solution (i.e. D5W) or
isotonic solution (0.9% NaCl) can be ordered but not with hypertonic solution (I.e
D10W).

9. Answer: D
Rationale:

Loosening tight clothing, applying warm blanket to prevent heat loss, and
administering oxygen supply might help but is not the priority this time. Direct
pressure over the bleeding site is a priority to prevent shock but placing a tourniquet
on the artery is done by a surgeon. Because the client is showing signs of altered
mental status, there is likely less perfusion in the brain, which calls for fluid
resuscitation. At least two IV access allows administration of fluids – crystalloid,
blood or clotting factors as necessary which is vital in correcting acidosis,
hypothermia and coagulopathy, and to restore perfusion rapidly.

10. Answer: A

Rationale:

Cushing’s syndrome is clinically defined as the presence of excessive corticosteroids.

Addison’s disease is clinically defined as adrenocortical insufficiency. Hypothyroidism
is a condition wherein there is insufficient thyroid hormone produced by the thyroid
glands while SIADH is characterized by excessive release of anti-diuretic hormone.

11. Answer: C

Rationale:

Facial tremors will occur even without performing a specific maneuver. Exaggerated
reflexes such as hyperreflexia can be assessed by performing a different maneuver.
Gentle tapping of the area below the zygomatic bone just in front of the ear is used
to elicit Chvostek sign to assess the presence of hypocalcemia. Trousseau sign is
characterized by spasm of the muscles of the hand and forearm upon inflation of a
BP cuff on it.

12. Answer: A, B, C, D, E and F

Rationale:

The leaking of vesicant drugs into surrounding tissue causes local tissue damage like
delayed healing, tissue necrosis, disfigurement, loss of function and even
amputation.

13. Answer: B, C, E

Rationale:

Manual stimulation is recommended to evacuate impacted stool. Having the client sit
up straight and raise his head so that he is looking ahead helps reduce the blood
pressure as it allows gravitational pooling of blood in the lower extremities.
Constrictive clothing may trigger an autonomic reaction that would cause the blood
pressure to go up so this must be removed. Manual compression or tapping the
bladder to allow urine to flow down the catheter should be avoided because this
would trigger an increase in blood pressure. Administration of prescribed
vasodilators is done to reduce high blood pressure.

14. Answer: D

Rationale:

Option A is ataxic breathing. Option B is apneustic breathing. Option C is central

neurogenic hyperventilation. Cheyne-stokes breathing respirations are a pattern of
breathing in which phases of hyperpnea regularly alternate with apnea in a
crescendo-decrescendo pattern.

15. Answer: D

Rationale:

The lowest possible score for any response is 1. If a client is unresponsive to painful
stimuli, the score is 1. A score lower than 8 indicates that the client is in a comatose
state. The highest score for the GCS is 15. A score of 15 indicates an alert and
oriented person. A score of 3-8 indicates severe head injury.

16. Answer: D

Rationale:

Helping the client maintain an exercise program is a therapeutic intervention to

maintain joint mobility and good body alignment. This will also prevent venous stasis
due to impaired mobility. Client encouragement will not only address the physical
aspect of the disease but the client’s emotions and self-esteem as well. The safety of
the client with impaired physical mobility should always be considered. Continuous
physical activity is not recommended. There should be an alternate period of activity
and rest to prevent excessive fatigue.

17. Answer: B

Rationale:

Receptive Aphasia refers to the inability to understand spoken words but can freely
express and verbalize. Expressive Aphasia refers to the inability to speak and
communicate formulated thoughts and sentiments. Global aphasia affects both
expressive ability and auditory comprehension. Apraxia is characterized by loss of
the ability to perform activities that a person is physically able and willing to do.

18. Answer: B

Rationale:
Graphesthesia is the ability to identify the writing on the skin even with the eyes
closed. The client provides a verbal response, identifying the figure that was drawn.
Option A is a test for stereognosis. Option C is a test used to assess the Romberg’s
sign while option D is a test for Kernig’s sign.

19. Answer: D

Rationale:

Any deterioration of oxygen saturation may necessitate intubation. However, the

priority this time is to maintain a patent airway. Infusion of IV fluids and
administration of antibiotics are expected nursing actions but not the top priority this
time. Completing vaccination at this time will not suffice or treat the underlying
respiratory problem. The situation calls for a curative management and not
preventive measures. Airway closure is the top priority. Throat examination is
avoided as this increases the risk of laryngeal obstruction. Aggression or agitation
can also compromise airway and breathing.

20. Answer: B

Rationale:

Absorption is the process when the drug is transferred from the site of origin into
the bloodstream. Distribution occurs when the drug in the blood is distributed to
different parts of the body and accumulates in specific tissues. Metabolism or
biotransformation is the process wherein the drug is broken down into its inactive
form. Excretion is the body’s response to eliminate all the inactive form of the drug.

21. Answer: D

Rationale:

The Ventrogluteal site is safe for most intramuscular injections because it only
involves the gluteus medius and gluteus minimus muscles. The Vastus lateralis
muscle is also a safe injection site for intramuscular medications because there are
no adjacent large blood vessels and nerves. The deltoid muscle is a smaller muscle
and is safe for administration of intramuscular medications less than 1 mL. The
Dorsogluteal muscle is not recommended for intramuscular medications because of
the potential damage to the sciatic nerve. Large blood vessels are also located near
the dorsogluteal muscle and should be avoided.

22. Answer: B

Rationale:

Prescribing or stopping medications is the responsibility of the physician, thus the

nurse must refer this first. Thiazide diuretics cause loss of blood potassium while
conserving blood calcium, thus, the electrolyte level must be evaluated first.
23. Answer: D

The brandt-andrew maneuver is the proper extraction of the umbilical cord and
placenta. McRobert’s maneuver is performed in case of shoulder dystocia during
childbirth. The Schultz mechanism is used to describe placental delivery. The
Ritgen’s maneuver is performed by applying pressure over the perineum and
counter-pressure on the fetal head. The Ritgen’s maneuver controls the exit of the
fetal head and prevents severe damage to maternal tissues.

24. Answer: B

Rationale:

The uterine fundus should start to descend after 24 hours of delivery. The normal
rate of uterine descent is 1 cm/day.

25. Answer: B

Rationale:

In Somatoform Disorder, there is no real organ damage, but the client verbalizes
symptoms of a disease in an unconscious manner. In Malingering, verbalization of
symptoms of a disease is conscious and is used by the client to achieve a secondary
gain or benefit. Anxiety comes in many forms panic attacks, phobia, and social
anxiety and the distinction between a disorder and “normal” anxiety isn’t always
clear. Amnesia refers to the loss of memories, such as facts, information and
experiences.

26. Answer: D

Rationale:

Not all chemotherapeutic agents alter the molecular structure of DNA.

Chemotherapy should slow down cell division not hasten it. All cells are sensitive to
drug toxins. Chemotherapeutic agents act on all rapidly dividing cells – most action
of chemotherapeutic agents is that it affects all rapidly dividing cells including the
normal and cancer cells.

27. Answer: C

Rationale:

Ketoacidosis is associated with high levels of ketone bodies in the body brought by
breakdown of fatty acids and is not related to vomiting. Metabolic acidosis happens
when the body produces excessive quantity of acid. Severe vomiting will result to
loss of HCL and acids coming from extracellular fluids which in turn lead to metabolic
alkalosis. Respiratory alkalosis occurs when there is an increased respiration which
elevates the blood pH beyond the normal range of 7.35-7.45.
28. Answer: D

Rationale:

2nd degree skin reactions are evident by scaly skin, an itchy feeling and dry
desquamation. Reddening of the skin is not seen in 2nd degree skin reaction.

29. Answer: B

Rationale:

Tremor is clinically defined as the rhythmic and repetitive muscle movement. Chorea
is clinically defined as brief and involuntary muscle twitching of the face or limbs
which hinders the client’s mobility. Athetosis is clinically defined as the presence of
irregular and slow twisting motions. Dystonia is similar to the definition of Athetosis
but involves larger muscle areas.

30. Answer: C

Rationale:

Standing close to the working area is a proper body mechanic to prevent muscle
fatigue. The nurse should adjust the bed to waist level in order to prevent stretching
and muscle strain. Proper body mechanic includes turning the body as a whole unit
when moving the client to avoid twisting the back. The knees are bent to support
the body’s center of gravity and maintain body balance. Bending the knees will
provide a wider base of support for effective leverage and use of energy.