Nursing Council (CXC) Past Paper MCQ

Child Bearing

1. A 39 year old multigravida client asks the nurse for information about female sterilization with a
tubal ligation. Which of the following client statements indicates effective teaching?
a) “My fallopian tubes will be tied off through a small abdominal incision.”
b) “Reversal of a tubal ligation is easily done, with a pregnancy success rate of 80%.”
c) “After this procedure, I must abstain from intercourse for at least 3 weeks.”
d) “Both of my ovaries will be removed during the tubal ligation procedure.”

2. A multigravida client will be using medroxyprogesterone acetate (Depo-Provera) as a family

planning method. After the nurse instructs the client about this method, which of the following
client statements indicates effective teaching?
a) “This method of family planning requires monthly injections.”
b) “I should have my first injection during my menstrual cycle.”
c) “One possible adverse effect is absence of menstrual period.”
d) “This drug will be given by subcutaneous injections.”

3. When developing a teaching plan for an 18 year old client who asks about treatments for
sexually transmitted diseases, the nurse should explain that:
a) Acyclovir (Zovirax) can be used to cure herpes genitalis.
b) Chlamydia trachomatis infections are usually treated with penicillin.
c) Ceftriaxone sodium (Rochephin) may be used to treat Neisseria gonorrhoeae infections.
d) Metronidazole (Flagyl) is used to treat condylomata acuminate.

4. A primigravid client at 16 weeks gestation has had an amniocentasis and has received teaching
concerning signs and symptoms to report. Which statement indicates that the client needs
further teaching?
a) “I need to call if I start to leak fluid from my vagina.”
b) “If I start bleeding, I will need to call back.”
c) “If my baby does not move, I need to call my health care provider.”
d) “If I start running a fever, I should let the office know.”

5. When measuring the fundal height of a primigravid client at 20 weeks gestation, the nurse will
locate the fundal height at which of the following points?
a) Halfway between the client’s symphysis pubis and umbilicus.
b) At about the level of the client’s umbilicus.
c) Between the client’s umbilicus and xiphoid process.
d) Near the client’s xiphoid process and compressing the diaphragm.

6. After instructing a primigravid client about desired with gain during pregnancy, the nurse
determines that the teaching is has been successful when the client states which of the
following?
a) “A total weight gain of approximately 20lb (9 kg) is recommended.”
b) “A weight gain of 6.6 lb (3 kg) in the second and third trimesters is considered normal.”
c) “A weight gain of about 12 lb (5.5 kg) every trimester is recommended.”
d) “Although it varies, a gain of 25 to 35 lb (11.4 to 14.5 kg) is about average.”

7. A 34 year old multiparous client at 16 weeks gestation who received regular prenatal care for all
of her previous pregnancies tells the nurse that she has already felt the baby move. The nurse
interprets this as which of the following?
a) The possibility that the client is carrying twins.
b) Unusual because most multiparous clients do not experience quickening until 30 weeks
gestation.
c) Evidence that the client’s estimated date of delivery is probably off by a few weeks.
d) Normal because multiparous clients can experience quickening between 14 and 20 weeks
gestation.

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8. A primigravid client at 28 weeks gestation tells the nurse that she and her husband wish to drive
to visit relatives who live several hundred miles away. Which of the following recommendations
by the nurse would be best?
a) “Try to avoid travelling anywhere in the car during your third trimester.”
b) “Limit the time you spend in the car to a maximum of 4 to 5 hours.”
c) “Taking the trip is okay if you stop every 1 to 2 hours and walk.”
d) “Avoid wearing your seat belt in the car to prevent injury to the fetus.”

9. When teaching a primigravid client how to do Kegel exercises, the nurse explains that the
expected outcome of these exercises is to:
a) Prevent vulvar edema.
b) Alleviate lower back discomfort.
c) Strengthen the perineal muscles.
d) Strengthen the abdominal muscles.

10. A primigravid client at 36 weeks gestation tells the nurse that she has been experiencing
insomnia for the past 2 weeks. Which of the following suggestions would be most helpful?
a) Practice relaxation techniques before bedtime.
b) Drink a cup of hot chocolate before bedtime.
c) Drink a small glass of wine with dinner.
d) Exercise for 30 minutes just before bedtime.

11. A laboring client with preeclampsia is prescribed magnesium sulfate 2g/h IV piggyback. The
pharmacy sends the IV to the unit labelled magnesium sulfate 20g/500 ml normal saline. To
deliver the correct dose, the nurse should set the pump to deliver how many milliliters per
hour? 50 ml.

12. The primary health care provider prescribes 1,000 ml of Ringer’s Lactate intravenously over an 8
hour period for a 29 year old primigravid client at 16 weeks gestation with hyperemesis. The
drip factor is 12 gtts/mL. The nurse should administer the IV infusion at how many drops per
minute? ________________25___________gtts/min.

13. At which of the following locations would the nurse expect to palpate the fundus of a
primiparous client immediately after delivery of a neonate?
a) Halfway between the umbilicus and the symphysis pubis.
b) At the level of the umbilicus.
c) Just below the level of the umbilicus.
d) Above the level of the umbilicus.

14. Four hours after delivering a viable neonate by spontaneous vaginal delivery under epidural
anesthesia, the client states she needs to urinate. The nurse should next:
a) Catheterize the client to obtain an accurate measurement.
b) Palpate the bladder to determine distention.
c) Assess the fundus to see if it is at the midline.
d) Measure the first two voiding and record the amount.

15. In preparation for discharge, the nurse discusses sexual issues with a primiparous client who had
a routine virginal delivery with a midline episiotomy. The nurse should instruct the client that
she can resume sexual intercourse:
a) In 6 weeks when the episiotomy is completely healed.
b) After a postpartum check by the health care provider.
c) Whenever the client is feeling amorous and desirable.
d) When lochia flow and episiotomy pain have stopped.

16. While caring for a multiparous client 4 hours after vaginal delivery of a term neonate, the nurse
notes that the mother’s temperature is (37.2 0 C), the pulse is 66bpm, and the respirations are 18
breaths/min. Her fundus is firm, midline, and at the level of the umbilicus. The nurse should:
a) Continue to monitor the client’s vital signs.
b) Assess the client’s lochia for large clots.
c) Notify the client’s physician about the findings.

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 d) Offer the mother an ice pack for her forehead.

17. A primiparous client, 48 hours after a vaginal delivery, is to be discharged with a prescription for
vitamins with iron because she is anemic. To maximize absorption of the iron, the nurse
instructs the client to take the medication with which of the following?
a) Orange juice
b) Herbal tea
c) Milk
d) Grape juice

18. Twelve hours after a vaginal delivery with epidural anesthesis, the nurse palpates the fundus of
a primiparous client and finds it to be firm, above the umbilicus, and deviated to the right.
Which of the following would the nurse do next?
a) Document this as normal findings in the client’s record.
b) Contact the physician for a prescription for methylergonovine (Methergine).
c) Encourage the client to ambulate to the bathroom and void.
d) Gently massage the fundus to expel the clots.

19. A primiparous client 3 days postpartum is to be discharged on heparin therapy. After teaching
her about possible adverse effects of heparin therapy, the nurse determines that the client
needs further instruction when she stated that the adverse effects include which of the
following?
a) Epistaxis
b) Bleeding gums
c) Slow pulse
d) Petechiae

20. The nurse explains to the mother of a neonate diagnosed with erythroblastosis fetalis that the
exchange transfusion is necessary to prevent damage primarily to which of the following organs
in the neonate?
a) Kidneys
b) Brain
c) Lungs
d) Liver

21. Preoperatively, the nurse develops a plan to prepare a 7 month old infant psychologically for a
scheduled herniorrhaphy the next day. Which of the following should the nurse expect to
implement to accomplish this goal?
a) Explaining the preoperative and postoperative procedures to the mother.
b) Having the mother stay with the infant.
c) Making sure the infant’s favorite toy is available.
d) Allowing the infant to play with surgical equipment.

22. When teaching the parent of an infant with Hirchsprung’s disease who received a temporary
colostomy about the types of foods the infant will be able to eat, which of the following would
the nurse recommend?
a) High-fiber diet
b) Low-fat diet
c) High-residue diet
d) Regular diet

23. How would the mother of a neonate know that her infant is having sufficient breast milk?
a) The baby is passing formed stool.
b) The baby has at least 6 to 8 wet diapers per day.
c) The baby appears content and is satisfied after most feedings.
d) The baby appears to be swallowing.

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24. The first fetal movement felt by the mother is known as:
a) Quickening
b) Ballottement
c) Lightening
d) Engagement

25. The nurse ascertains from taking a client history that she has given birth to twelve children of
which six is alive, had two abortions and is currently pregnant. The nurse records the client data
as:
a) Gravida 13, para 6, plus 2
b) Gravida 12, para 6, plus 2
c) Gravida 13, para 2, plus 6
d) Gravida 12, para 2, plus 6

26. The postpartum nurse should encourage newly delivered clients to ambulate early in order to:
a) Promote respiration.
b) Increase the tone of the bladder.
c) Maintain tone of abdominal muscles.
d) Increase peripheral vasomotor activity.

27. The nurse is teaching a group of teenagers about the importance of folic acid in pregnancy.
Which of the following statements would BEST indicate the benefit of the folic acid to the baby?
a) Building the baby’s blood.
b) Maintaining healthy growth in the fetus.
c) Promoting strong bones and teeth in the fetus.
d) Preventing defects in the baby’s nervous system.

28. A client is 16 weeks pregnant is booked for care at the antenatal clinic. What would be her
gestational age at the next routine visit?
a) 22/40
b) 20/40
c) 19/40
d) 18/40

29. Which of the following is a normal fetal heart rate at 38 weeks gestation?
a) 80 BPM
b) 100 BPM
c) 150 BPM
d) 180 BPM

30. What is the BEST source of fluids for an infant aged 3 to 12 months?
a) Boiled tap water.
b) Warm fruit juice.
c) Dilute nonfat dry milk.
d) Breast milk or formula.

31. During a postpartal visit, a client whose infant is now 4 weeks old complains of leg cramps. The
nurse suspects:
a) Hypercalcemia and tells her to increase her activity.
b) Hypercalcemia and tells her to increase her intake of milk.
c) Hyperkalemia and tells her to see a physician immediately.
d) Hypokalemia and tells her to increase her intake of green leafy vegetables.

32. A 26 year old female is concerned about her first baby who is diagnosed with hydrocephalus.
The mother tells the nurse “I do not feel comfortable caring for my baby at home.” Which of
the following would be MOST appropriate for the nurse to make?

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 a) “Do you have concerns about the care for your baby at home?”
b) “We have good children doctors who would care for the baby at home.”
c) “What exactly makes you unhappy about your baby going home?”
d) “As a mother you have to try and cope with your baby’s condition at home.”

Scenario 1 (Items 33-38)

A 30 year old client is admitted to the operating theatre for surgery for an ectopic pregnancy. The
anesthetic nurse receives her, conducts her assessment and completes the pre-operative checklist.

33. The client complains of dry mouth and drowsiness after receiving some medication prior to
leaving the Accident and Emergency Department for the operating theatre. This is a normal
action of what category of drugs?
a) Cholinergic
b) Anticholinergic
c) Beta adrenergic
d) Alpha Adrenergic

34. The client expresses concerns about the proposed surgery site, as she loves wearing bikini on
the beach. The nurse reassures her that the proposed operation site will not inhibit that action.
This type of incisional site is called:
a) Midline
b) McBurney’s
c) Paramedion
d) Plannenatier

35. To prevent complication of abdominal surgery, the MOST important post-operative nursing
intervention is to:
a) Monitor vital signs.
b) Encourage deep breathing and coughing.
c) Check the operation site frequently.
d) Check vaginal discharge frequently.

36. A blood urea nitrogen or creatinine screening test is done routinely on parents before surgery to
assess the functioning of the:
a) Lungs
b) Heart
c) Liver
d) Kidneys

37. The client’s risk of surgical complications is increased if she:

a) Is dehydrated.
b) Is underweight.
c) Is of African descent.
d) Has a history of taking herbal medicines.

38. The client confides in the nurse that she is afraid of not waking up after surgery. A possible
nursing diagnosis for this client is:
a) Fear related to unknown outcome of surgery.
b) Ineffective individual coping related to surgery.
c) Anxiety related to perceived inability to deal with possible pain.
d) Knowledge deficit related to coping with postoperative pain.

39. Which of the following vitamins would the nurse suggest to the antenatal client would BEST aid
the absorption of iron which the client is required to take during pregnancy?
a) Vitamin A
b) Vitamin B
c) Vitamin C
d) Vitamin K

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40. While the nurse is performing physical examination for a multigravida in her third trimester, the
client in protest states “I which I didn’t have to do this every time.” Which of the following
would be the nurse’s BEST response?
a) “Can you tell me the purpose of these visits?”
b) “Do you want to have a healthy pregnancy?”
c) “We need to get baseline information for future visit.”
d) “It will help in monitoring the progress of your pregnancy.”

41. Which of the following nutritional requirements are MOST appropriate for the teenager
mother?
a) Calories, fibre, protein and sodium
b) Iron, calcium, protein and vitamins
c) Vitamins, protein and potassium
d) Calories, sodium and fibre

42. Which of the following topics should be included in a teaching plan for the client during the
FIRST TRIMESTER of pregnancy?”
I. Hospital registration.
II. Danger signs in pregnancy.
III. Expecting changes in pregnancy.
IV. Prevention of high risk pregnancy.

a) I and II only
b) I and III only
c) II and III only
d) II and IV only

43. Which of the following considered PRESUMPTIVE signs of pregnancy?

I. Nausea and Vomiting.
II. Urinary frequency and fatigue.
III. Quickening and Softening of the cervix.
IV. Ballottement and positive Hegar’s Sign.

a) I and II only
b) I and III only
c) II and III only
d) II and IV only

44. Risk factors associated with teenage pregnancy include:

I. Antenatal and Perinatal complications.
II. Increased fetal and maternal morbidity.
III. Post-maturity and congenital disorders.

a) I only
b) I and II only
c) II and III only
d) I, II and III

45. The client states “I do not want to breast feed, it’s difficult.” Which of the following responses
by the nurse is NOT factual?”
a) “Breastfeeding fives babies all the nutrients they need for healthy development.”
b) “Breastfeeding helps you to bond with your baby.”
c) “Breastfeeding provides an element of birth control in the first six months after birth.”
d) “That’s OK, modern baby formula is almost the same as breast milk.”

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 46. The nurse ascertains from an initial interview that the first day of the client’s last menstrual
period was September 28, 2013. According to Naegele’s Rule the nurse determines that the
client estimated date of delivery is:
a) May 4th 2014
b) June 5th 2014
c) July 8th 21014
d) August 6th 2014

47. During a teaching session a young couple asks the nurse if sexual activity should change during
pregnancy if no complications exist. The nurse’s response will indicate that:
a) The couple should practice coitus interruptus during pregnancy.
b) The couple should not have sexual intercourse during the last trimester of pregnancy.
c) It is best for the couple to avoid sexual intercourse until the woman is at least 16 weeks
pregnant.
d) Sexual desire may change but intercourse does not hurt the baby during an uncomplicated
pregnancy.

Medical/Surgical

48. The nurse is assessing an older adult with a pacemaker who leads a sedentary lifestyle. The
client reports being unable to perform activities that require physical exertion. The nurse should
further assess the client for which of the following?
a) Left ventricular atrophy.
b) Irregular heartbeats.
c) Peripheral vascular occlusion.
d) Pacemaker placement.

49. A client has driven himself to the emergency department. He is 50 years old, has a history of
hypertension, and informs the nurse that his father died from a heart attack at age 60. The
client has indigestion. The nurse connects him to an electrocardiogram monitor and begins
administering oxygen at 2 L/min per nasal cannula. The nurse’s next action should be to:
a) Call for the physician.
b) Start an IV infusion.
c) Obtain a portable chest radiograph.
d) Draw blood for laboratory studies.

50. Crackles heard on lung auscultation indicate which of the following?

a) Cyanosis
b) Bronchospasm
c) Airway narrowing
d) Fluid-filled alveoli

51. Following diagnosis of angina pectoris, a client reports being unable to walk up two flights of
stairs without pain. Which of the following measures would most likely help the client prevent
this problem?
a) Climb the steps early in the day.
b) Rest for at least an hour before climbing the stairs.
c) Take a nitroglycerin tablet before climbing the stairs.
d) Lie down after climbing the stairs.

52. After a myocardial infarction, the hospitalized client is taught to move the legs while resting in
bed. The expected outcome of this exercise is to:
a) Prepare the client for ambulation.
b) Promote urinary and intestinal elimination.
c) Prevent thrombophlebitis and blood clot formation.
d) Decrease the likelihood of pressure ulcer formation.

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53. Which of the following is the most appropriate diet for a client during the acute phase pf
myocardial infarction?
a) Liquids as desired.
b) Small, easily digested meals.
c) Three regular meals per day.
d) Nothing by mouth.

54. Which of client is at greatest risk for coronary artery disease?

a) A 32 year old female with mitral valve prolapse who quit smoking 10 years ago.
b) A 43 year old male with family history of CAD and cholesterol level of 158.
c) A 56 year old male with an HDL of 60 who takes atorvastatin (Lipitor).
d) A 65 year old female who is obese with an LDL of 188.

55. The client who experiences angina has been told to follow a low cholesterol diet. Which of the
following meals would be best?
a) Hamburger, salad, and milkshake.
b) Baked liver, green beans and coffee.
c) Spaghetti with tomato sauce, salad and coffee.
d) Fried chicken, green beans and skim milk.

56. A client with angina is taking nifedipine. The nurse should teach the client to:
a) Monitor blood pressure monthly.
b) Perform daily weights.
c) Inspect gums daily.
d) Limit intake of green leafy vegetables.

57. The nurse’s discharge teaching plan for the client with heart failure should emphasize the
importance of doing which of the following?
a) Maintaining a high fiber diet.
b) Walking 2 miles every day.
c) Obtaining daily weights at the same time each day.
d) Remaining sedentary for most of the day.

58. A client experiences initial indications of excitation after an IV infusion of lidocaine

hydrochloride started. The nurse should further assess the client when the client reports
having:
a) Palpitations
b) Tinnitus
c) Urinary frequency
d) Lethargy

59. The most effective measure the nurse can use to prevent wound infection when changing a
client’s dressing after coronary artery bypass surgery is to:
a) Observe careful handwashing procedures.
b) Clean the incisional area with an antiseptic.
c) Use prepackaged sterile dressings to cover the incision.
d) Place soiled dressings in a waterproof bag before disposing of them.

60. During physical assessment, the nurse should further assess the client for signs of atrial
fibrillation when palpation of the radial pulse reveals:
a) Two regular beats followed by one irregular beat.
b) An irregular rhythm with pulse rate greater than 100.
c) Pulse rate below 60 bpm.
d) A weak, thready pulse.

61. A physician’s orders indicate that a surgical consent needs to be signed. The nurse was not
present when the surgeon discussed the surgical procedure with the client. Which statement by
the nurse best illustrates fulfillment of the client’s advocate role?
a) “The doctor has asked that you sign this consent form.”
b) “Do you have any questions about the procedure?”
c) “What were you told about the procedure you are going to have?”
d) “Remember that you can change your mind and cancel the procedure.”

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 62. Although the client refused the procedure, the nurse insisted and inserted a nasogastric tube in
the right nostril. The administrator of the hospital decides to settle the lawsuit because the
nurse is likely to be found guilty of which of the following?
a) Unintentional tort
b) Assault
c) Invasion of privacy
d) Battery

63. Which of the following applies in the planning of nursing for the patient whom the physician has
written a Do Not Resuscitate (DNT) order?
a) The client may no longer make decisions regarding his or her own health care.
b) The client and family know that the client will most likely die within the next 48 hours.
c) The nurse will continue to implement all treatments focused on comfort and symptom
management.
d) A DNR from the previous admission is valid for the current admission.

64. The clinic nurse instructs a client with diabetes mellitus about how to prevent diabetic
ketoacidosis on days when the client is feeling ill. Which statement by the client indicates the
need for further instructions?
a) “I need to stop my insulin if I am vomiting.”
b) “I need to eat 10 to 15g of carbohydrates ever 1 to 2 hours.”
c) “I need to call my physician if I am ill for more than 24 hours.”
d) “I need to drink small quantities of fluid every 15 to 30 minutes.”

65. A nursing diagnosis of fluid volume excess was identified for a client with cirrhosis of the liver.
What would the related factor be to guide nursing interventions?
a) Localized inflammation.
b) Increased oral intake.
c) Renal impairment.
d) Reduced protein.

66. A 60 year old client with renal failure was educated about the necessity of having a potassium
diet. The nurse identified that he needed more teaching when he stated that he could eat:
a) Cantaloupe and pomegranate
b) Cantaloupe and applesauce
c) Cherries and pomegranate
d) Applesauce and cherries

67. There are several cases of malaria on the ward. When the charge nurse speaks of the need to
break the chain of infection “at the second link” she is referring to:
a) The susceptible host.
b) An area for the storage filtering water.
c) A place where the microorganism enters the body.
d) A place where the microorganism naturally lives.

Scenario 2 (Items 68-75)

A 32 year old female suffers partial thickness burns to anterior trunk, upper limbs and anterior thighs
while cooking. The gas cylinder exploded. She is admitted to the emergency department at 11:00.

68. Which of the following is the priority of car for the patient?
a) Prevention of infection.
b) Fluid resuscitation.
c) Airway protection.
d) Pain management.

69. Which intravenous fluid would most likely be prescribed for this client?
a) Lactated Ringer’s
b) 5% Dextrose in Water
c) 0.9% Sodium Chloride
d) 5% Dextrose, 0.9% Saline

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70. Using the rule of nines, what is the percentage of burns sustained by the client?
a) 27
b) 36
c) 45
d) 72

71. Calculation of fluids for resuscitation of the patient in the first eight hours should begin:
a) From the time of IV access.
b) From the time of injury.
c) Within ten minutes of the burn.
d) Within the first hour after the burn.

72. The client weighs 50 kg. The doctor has ordered fluids at 4mls/kg/BSA % burns. How much fluid
should she receive in the first eight (8) hours?
a) 2700
b) 3600
c) 4500
d) 7200

73. Which analgesic is most likely to be ordered for this patient for pain management?
a) Diclofenac Sodium
b) Tramadol
c) Pethidine
d) Morphine

74. Which complication in the first 48 hours would priority interventions target?
a) Shock
b) Infection
c) Hypothermia
d) Curling’s ulcer

75. Which of the following immunization vaccines would be included in the patient’s management?
a) Rubella
b) Varicella
c) Hepatitis B
d) Tetanus Toxoid

76. The nurse makes a home visit to an 88 year old woman who lives alone. The assessment
revealed that she has deficits in vision and hearing and is taking diuretics, which are making her
crazy. Which of the following patient problem would the nurse include in her plan of care?
a) Altered consciousness.
b) Risk for accidental injury.
c) Risk for impaired judgement.
d) Decreased social interaction.

77. An 88 year old male client was admitted to the surgical ward for management of a fractured hip.
He had internal fixation of a pin. Which of the following is the reason for the pin as the
treatment of choice?
a) Is the simplest procedure.
b) Promotes rapid healing.
c) Carries less danger of infection.
d) Makes earlier mobilization possible.

78. The nurse conducts an assessment on a 45 year old woman who states that during the interview
“I’m so tired all the time and have been having mood swings and hot flushes.” Which of the
following body systems would the nurse use to conduct a more in-depth assessment?
a) Respiratory and nervous.
b) Reproductive and endocrine.
c) Nervous and cardiovascular.
d) Cardiovascular and endocrine.

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79. After the nurse evaluated the instructions given to a client with pulmonary embolism who is
being discharged from the hospital, it was determined that additional teaching was required
when the client made which of the following statements?
a) “I will limit my daily fluid intake.”
b) “I will sit down whenever possible.”
c) “I will continue to wear supportive hose.”
d) “I will only cross my legs at the ankle and not at the knees.”

80. The oncologist examines a client in the clinic with severe bone marrow depression and
subsequently admits him to the hospital. The client’s therapy includes radiation and
chemotherapy. Which of the following nursing diagnosis takes PRIORITY in the client’s care
plan?
a) Imbalanced nutrition less than body requirements.
b) Risk for infection.
c) Pain.
d) Risk for injury.

81. The nurse is performing an initial assessment for a client from a culture the nurse is not familiar
with and ask about the client’s use of alternative therapies. The client says irritably “Do you
have to ask all these question?” Which of the following is the BEST explanation for what the
nurse should do in response?
a) Ask the question, because the nurse might learn about therapies used by a different culture.
b) Ask the question, because knowledge about actual use of other therapies is imperative.
c) Don’t ask the question because it is important to not upset the irritable client any further.
d) Don’t ask the question, because the client needs to choose to initiate discussion of other
therapies.

82. A child with umbilical hernia is scheduled for surgical repair in two weeks. The clinic nurse
instructs the parents about the signs of possible hernia strangulation. The nurse tells the
parents that which sign would require physician notification?
a) Vomiting
b) Diarrhea
c) Fever
d) Constipation

83. The nurse determines the need for further instruction regarding the use of incentive spirometer
if the client does which of the following?
a) Inhales slowly.
b) Breaths through the nose.
c) Removes the mouthpiece to exhale.
d) Forms a tight seal around the mouthpiece.

84. A client with Parkinson’s disease has begun therapy with levodopa. The nurse determines that
the client understands the action of the medication if the client verbalizes the results may not
be apparent for:
a) 1 week
b) 24 hours
c) 5 to 7 days
d) 2 to 3 weeks

85. A female client who had surgical repair of the bladder is being discharged from the hospital with
an indwelling urinary catheter. What statement by the client would let the nurse determine
that the client understands the principles of catheter management?
a) Cleanse the perineal area with soap and water.
b) Keep the drainage bag lower than the bladder.
c) Limit fluid intake so that the bag would not full so quickly.
d) Coil the tubing and place it under the thigh when sitting to avoid tugging on the bladder.

86. How should the nurse help the client prepare for terminating the therapeutic relationship?
a) Encourage autonomous activities by the client.
b) Reassure the client that he/she will still be around.
c) Tell the client that another nurse will take over to provide more support.
d) Tell the client continuation is necessary, as things have improved.

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 87. The nurse is caring for a client who says “I don’t want you to touch me,” I’ll take care of myself”.
Which nursing response is MOST therapeutic?
a) “Ok if that’s what you want, I’ll leave this cup for you to collect your urine”.
b) “If you don’t want our care, why did you come here.”
c) “Why are you being so difficult, I only want to help you.”
d) “Let’s work together so you can do things yourself.”

88. A 25 year old male is brought to the emergency department suffering from multiple gunshot
wounds. There is active bleeding and he is exhibiting signs of shock. The patient’s vital signs
are: P140, RR 32, BP 90/60. Which of the following types of shock is the patient experiencing?
a) Distributive
b) Cardiogenic
c) Neurogenic
d) Hypovolemic

89. A diagnosis of latent tuberculosis (TB) requires:

a) No treatment as the client feels fine.
b) Treatment to prevent active TB.
c) Treatment for active TB.
d) Isolation precaution.

Scenario 3 (Items 90-95)

A 66 year old male client attended the A & E unit complaining of cyanosis, confusion and pleuritic
chest pain. Assessment revealed temperature of 37 degrees Celsius, diaphoresis and productive
cough. He was admitted to the medical ward with a diagnosis of pneumonia.

90. Which of the following manifestations presented by the client is associated with initial
manifestation of infection in the elderly?
a) Confusion
b) Diaphoresis
c) Pleuritic chest pain
d) Elevated temperature

91. The client begins to experience signs of hypoxia. Which of the following is an initial mental
change that can occur?
a) Coma
b) Apathy
c) Irritability
d) Depression

92. Which of the following statements is an appropriate nursing diagnosis for oxygen exchange and
transport that should be included in the client’s nursing care plan?
a) “Alteration in breathing pattern related to muscle fatigue.”
b) “High risk for activity intolerance related to the aging process.”
c) “Alteration in gas exchange related to increase respiration as evidenced by tachypnea.”
d) “Ineffective airway clearance related to decrease functional cilia as evidenced by non-
productive cough.”

93. The client is coughing up thick tenacious secretions. Which of the following interventions would
best liquefy these secretions?
a) Increased intake of fluids.
b) Administer humidified air.
c) Percuss over the affected lung.
d) Encourage deep-breathing exercises.

94. Which of the following is the purpose of bed rest during the acute phase of the patient’s illness?
a) Promote safety.
b) Decreased basal metabolic rate.
c) Promote clearance of secretions.
d) Reduce cellular demand for oxygen.

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95. Antibiotics were prescribed to reduce the client’s infection. Which of the following
investigations must be completed before the client’s antibiotic therapy is commenced?
a) Urinalysis
b) Chest x-ray
c) Red blood cell count
d) Sputum examination

96. A 50 year old 75kg is complaining of pain after 15 minutes of being in the recovery room. The
order is for Demerol 100mg IM. The BEST action of the nurse is:
a) Delay administration of drug.
b) Administer the drug as prescribed.
c) Ask the doctor to review the order.
d) Check the last time analgesics were given.

97. In the recovery room the MOST important client goal is achieving:
a) Relief of pain and anxiety.
b) Urine output of>0.5 ml/kg/hr
c) Mean arterial pressure of 75-105mmHg
d) Pa02 60-100, PaCO 35-45 mmHg

98. An elderly is transferred to the recovery room following abdominal surgery. Which of the
following interventions in the recovery room will reduce the risk of the patient becoming
confused?
I. Reversal of unaesthetic agent
II. Maintaining adequate oxygenation
III. Maintaining fluid and electrolyte balance

a) I and II only
b) I and III only
c) II and III only
d) I, II and III

99. The mechanism by which opioids work is that they:

a) Bind to pain receptor sites in the central nervous system.
b) Inhibits the synthesis of inflammatory mediators at the site of injury.
c) Control anxiety, thereby reducing perception of pain.
d) Cause sedation, thereby decreasing perception to pain.

100. Which of the following situations represents the BEST example of passive immunity?
a) A 10 year old child receiving vaccination of measles.
b) Production of antibodies in a person with an infection.
c) A 5 month old baby receiving breast milk from the mother.
d) A 45 year old adult receiving broad spectrum antibodies for an infection.

101. The MOST frequent mode of transmission of nosocomial infections is as a result of:
a) Contact transmission
b) Droplet transmission
c) Airborne transmission
d) Vector-borne transmission

102. Which management function related to the evaluation of the performance of

subordinates?
a) Organizing
b) Staffing
c) Directing
d) Controlling

103. Which of the following strategies should be utilized FIRST to minimize resistance to
change?
a) Integrate the values and beliefs of the team members in the change.
b) Offer incentives to team members throughout the institution who champion the change.
c) Post information related to the change on the institution’s intranet.
d) Consider implementing the change gradually.

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 104. In evaluating the effectiveness of intervention for a diagnosis of “less than body
requirements” the nurse will expect to find:
a) Weight gain of 1kg
b) Increase in Hb by 1%
c) Serum albumin >30mg/dl
d) Diminishing sacral oedema

105. Which of the following nurses would the nurse manager recommend for additional
training in infection control?
a) A nurse who wears her mask around her neck between use.
b) A nurse who scrubs her hands for at least 15 seconds during hand washing.
c) A nurse who wears a HEPA style respirator when nursing a client with TB.
d) A nurse who removes her PPE in the order of gloves then gown then mask.

106. Which management theory states that a satisfied employee will perform outstanding
work?
a) Behavioral
b) Contingency
c) Neoclassical
d) Classical

107. The most important differences between good leaders and managers is that good
leaders:
a) Are born not made.
b) Inspire and motivate.
c) Plan, coordinate and control.
d) Focus on systems and structures.

Scenario 4 (Items 108-113)

A staff nurse was assigned to provide care for a 35 year old male patient recovering from an
appendectomy. The patient told his wife that he wanted to use the bathroom but did not want to
bother the nurse because he knew that she was busy. When the nurse entered the room to
administer his medications she found the patient trying to climb out of bed over the side rails. The
patient’s wife threatens to sue the nurse for malpractice claiming that the nurse has inadequately
protected her husband.

108. An incident report about the patient should be:

a) Incorporated into the medical record.
b) Completed as soon as the incident occurred.
c) Filed immediately with hospital attorney.
d) Placed in the patient’s file within 48 hours of the incident.

109. Which of the following principles is related to the right of the patient to make his own decision?
a) Justice
b) Autonomy
c) Non-maleficence
d) Respect for the patient

110. Which of the following individuals should complete an incident report about the patient?
a) The risk manager of the facility.
b) The doctor who performed the surgery.
c) The nurse who discovered the incident.
d) The immediate supervisor of the nurse involved in the incident.

111. If the patient’s wife is to successfully sue for malpractice she:

a) Will need to sue her husband’s doctor rather than the nurse.
b) Must demonstrate that the nurse’s actions resulted in endangerment for her husband.
c) Has a cause to sue the nurse because the nurse has breached the standard of care.
d) Must prove that her husband was harmed as a result of the nurse’s action.

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112. Which of the following nursing actions could result in malpractice?
a) The nurse notifies the doctor of the patient’s concerns.
b) The nurse charts the medications that were given to the patient.
c) The nurse remembers to follow up on the patient’s complaint after receiving a reminder.
d) The nurse uses a new technique to assist the patient in the ambulatory phase of his
recovery.

113. Is the patient’s family likely to be successful in suing for malpractice?

a) No, as the patient was nor harmed.
b) No, if the nurse has notified that doctor.
c) Yes, because of duty exists.
d) Yes, because foresee ability is present.

114. A 50 year old patient admitted for dehydration needs a complete physical assessment from the
nurse. Which of the following assessment techniques helps the nurse to determine the quality
of the turgor of the patient’s skin?
a) Grasping a fold of skin over the sternum.
b) Placing the dorsum of the hand on the skin.
c) Depressing the skin over a bony prominence.
d) Feeling the skin with the palmar surface of the hand.

115. A 25 year old client asks about the cause of anemia in sickle cell disorder. The nurse stated that
it resulted from?
a) Low dietary intake of iron.
b) Poor production of red blood cells.
c) Rapid breakdown of red blood cells.
d) Low intrinsic factor being produced by the stomach.

116. In a “helping relationship” which of the following would the nurse perform?
a) Encourage the patient to explore goals that satisfy personal needs.
b) Identify goals that are set within an inflexible framework.
c) Agree with the patient’s ideas and thoughts.
d) Give the patient personal advice.

117. Which of the following techniques would be the BEST for the nurse when listening to a patient?
a) Avoid unnecessary gestures.
b) Present the conversation from lapsing into silence.
c) Try to identify themes in the patient’s conversation.
d) Stand close to the patient and maintain eye contact.

118. A staff nurse has returned to work after 4 years of being a stay at home mum. The ward sister
observes that her wound care techniques are outdated. What is the MOST appropriate action
for the sister to take in this situation?
a) Select a nurse who will act as her mentor.
b) Refer her to the policy manual on wound care.
c) Seek the opinion of another senior colleague.
d) Recommend the staff nurse for wound care training.

119. The community nurse uses information systems and techniques to collect data about outbreaks
of communicable diseases. The process of ongoing systematic collection analysis and
interpretation of the data that the nurse collects BEST describes the activities of:
a) Tracking
b) Research
c) Investigation
d) Surveillance

120. A 66 year old emaciated chain smoker recently diagnosed with stage III lung cancer is being
prepared for chemotherapy and radiotherapy in planning care for this patient, the nurse should
use a:
a) Patient centered approach.
b) Relative centered approach.
c) Collaborative team approach.
d) Interdependent nursing approach.

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121. A female patient is discharged from the medical ward. On cleaning the locker, the nurse
discovers an expensive male watch. The nurse’s FIRST response should be to:
a) Report the discovery to the ward sister.
b) Call the relatives of last occupant of that bed.
c) Ask the ward sister if a watch was reported lost.
d) Place the watch in an envelope and put it in the safe.

122. In what order should the nurse perform the following activities for clients attending an antenatal
clinic?
a) Vital signs, interviewing, blood investigations, health teaching.
b) Vital signs, blood investigations, health teaching, interviewing.
c) Interviewing, vital signs, blood investigations, health teaching.
d) Interviewing, vital signs, health teaching, blood investigation.

Scenario 5 (Items 123-124)

An elderly female has learnt that her husband of fifty years has just been admitted to the hospital.
She request that she be told of any changes in his condition immediately. The nurse learnt that he
died soon after the ward had received the news of admission.

123. What is the BEST way for the registered nurse to handle the situation?
a) Forewarn her that her husband’s condition has worsened.
b) Take her to the ward and say nothing.
c) Tell her that her husband died just as she got to his bed.
d) Tell her that her husband had died soon after being admitted.

124. Which ethical principle is BEST for the nurse to apply in this situation?
a) Non-maleficence
b) Beneficence
c) Veracity
d) Justice

125. During the nebulization of a sixty-six year old client with chronic obstructive pulmonary disease
(COPD) the rational for using Ipratropium (Atrovent) would be that it is:
a) A bronchodilator and also dries up secretion.
b) Use to treat severe respiratory symptoms.
c) Best tolerated by the elderly.
d) Traditionally used.

126. Which is the MOST appropriate response to a fifty-five year old client with angina who reports
keeping some nitroglycerine (GTN) tablets in a napkin at work?
a) The napkin would keep the GTN tablets dry as it absorbs moisture.
b) Storage in napkin is inappropriate as GTN lose potency in air and light.
c) Having some at work and home is a wise practice and should be encouraged.
d) Having tablets in napkin makes it accessible as no opening of container is necessary.

127. In a client with sickle cell painful crisis, the rational for the use of a warm compress as a nursing
intervention is that it:
a) Allows the patient to sweat if febrile.
b) Promote vasodilation and enhances tissue perfusion.
c) Increases the thirst sensation and enhances fluid intake.
d) Enhances comfort as the client is use to warm climatic condition.

128. The nurse’s neighbor has been admitted to a ward where the nurse is allocated. A mutual friend
meets her in town and asks about the neighbor’s diagnosis. The MOST appropriate response of
the nurse would be:
a) Call me later, I will tell you in private.
b) I’m sorry you will need to ask the patient that yourself.
c) I’m sorry all I can say is that she was admitted for surgery.
d) Perhaps you can ask her sister, she just visited.

129. A client who has just received a positive biopsy test result expresses concern about the
possibility of losing her breast. The MOST appropriate response of the nurse would be:
a) “Don’t worry, you won’t need to have your breast removed.”
b) “You can get a prosthesis, they make some real good looking ones these days.”

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 c) “Would you like me to refer you to a support group you might consider joining.”
d) “Would you like to consider options other than total breast removal?”

Scenario 6 (Items 130-131)

A registered nurse is on duty in the accident and emergency unit when a 10 year old girl is admitted
with extensive abrasions and cuts to her hands and feet and a fractured humerus. The child states
that she got the abrasions when her father beat her with a metal chain then she begs the nurse not to
call her father. The adult female who accompanied the child to the hospital states that she is a
neighbor who has witnessed the child’s father beating her on several occasions.

130. The physician orders that the child’s wounds would be dressed immediately. The law required
photographing of wounds for evidence. Which response by the registered nurse BEST reflects
professional standards?
a) “I will dress the wounds as you have ordered.”
b) “I will not dress the wound until photographs are obtained.”
c) “Are you sure that we should dress the wounds prior to photographing?”
d) “Would you dress the wound please? I am required to wait until photographs are obtained.”

131. The police arrived at the hospital and demand that the registered nurse expose the child’s
wounds and her records. The registered nurse’s BEST applies legal and professional principles
regarding cases of child abuse by:
a) Asking the police to wait until the child’s wounds are covered.
b) Referring the police to the attending physician in keeping with the hospital policy.
c) Refusing to grant the police access to her records or the child’s privacy.
d) Requesting that a child psychologist be present while the police questions the child.

132. The child was treated successfully and is to be discharged. The nurse recognizes that the health
team member who is MOST central to the child’s discharge planning is the:
a) Psychological as the child would require immediate follow up and trauma counselling.
b) Physician who is the only health team member authorized to discharge patients.
c) Community health nurse to liaise between the hospital and community.
d) Social worker as there is a need for intervention to protect the child.

Scenario 6 continues (Items 133-134)

The registered nurse omitted to immobilize the child’s right arm prior to turning her. The child did not
complain of pain in response, neither was there any obvious complication on initial assessment.

133. Which ethical principles are MOST applicable in guiding the registered nurse’s response to the
nursing care omission?
a) Paternalism and veracity.
b) Veracity and beneficence.
c) Paternalism and autonomy.
d) Autonomy and beneficence.

134. Which of the following actions taken by the registered nurse BEST reflects professional
accountability?
a) Assessing for further inquiry and immobilizing the child’s right arm.
b) Immobilizing the child’s arm as soon as the omission was discovered.
c) Documenting that the child was turned prior to immobilization of her right arm.
d) Disclosing to the child that the right arm should have been immobilized prior to turning.

135. A client had undergone an amputation of three toes and the femoral-popliteal by-pass. The
nurse should teach the client that after surgery, which of the following leg positions is
contraindicated while sitting in a chair?
a) Crossing the legs.
b) Elevating the legs.
c) Flexing the ankles.
d) Extending the knees.

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136. In order to prevent deep vein thrombosis (DVT) following abdominal surgery, the nurse should:
a) Restrict fluids.
b) Encourage deep breathing.
c) Assist the client to remain sedentary.
d) Use pneumatic compression stockings.

137. The nurse is administering packed red blood cells to a client. The nurse should first:
a) Discontinue the IV catheter if a blood transfusion reaction occurs.
b) Administer the packed red blood cells through a percutaneously inserted central catheter
line with a 20 gauge needle.
c) Flush packed red blood cells with 5% dextrose and 0.4% normal saline solution.
d) Stay with the client during the first 15 minutes of infusion.

138. The client with acute lymphocytic leukemia is at risk for infection. The nurse should:
a) Place the client in a private room.
b) Have the client wear a mask.
c) Have staff wear gowns and gloves.
d) Restrict visitors.

139. When assessing a client for early septic shock, the nurse should assess the client for which of the
following?
a) Cool, clammy skin.
b) Warm, flush skin.
c) Increased blood pressure.
d) Hemorrhage.

140. After completion of peritoneal dialysis, the nurse should assess the client for which of the
following?
a) Hematuria
b) Weight loss
c) Hypertension
d) Increased urine output

141. Aluminum hydroxide gel (amphojel) is prescribed for the client with chronic renal failure to take
at home. What is the expected outcome of giving this drug?
a) Relieving the pain of gastric hyperacidity.
b) Preventing Curling’s stress ulcers.
c) Binding phosphate in the intestines.
d) Reversing metabolic acidosis.

142. The nurse is determining which teaching approaches for the client with chronic renal failure and
uremia would be most appropriate. The nurse should:
a) Provide all needed teaching in one extended session.
b) Validate the client understanding of the material frequently.
c) Conduct a one on one session with the client.
d) Use video tapes to reinforce the material as needed.

143. The nurse is instructing the client with chronic renal failure to maintain adequate nutritional
intake. Which of the following diets would be most appropriate?
a) High-carbohydrate, high-protein.
b) High-calcium, high-potassium, high-protein.
c) Low-protein, low-sodium, low-potassium.
d) Low-protein, high-potassium.

144. A patient with chronic renal failure later develops crackles in the lung bases, elevated blood
pressure and weight gain of 2lbs (0.9kg) in one day. Which of the following nursing diagnosis
would be PRIORITY for the patient?
a) Ineffective breathing pattern related to fluid in the lungs.
b) Ineffective tissue perfusion related to interrupted arterial blood flow.
c) Excess fluid volume related to the kidney’s inability to maintain fluid balance.
d) Ineffective therapeutic management related to lack of knowledge about therapy.

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145. Which of the following is a long-term complication of peritoneal dialysis?
a) Peritonitis and low back pain.
b) Abdominal hernia and anorexia.
c) Bloody effluent and hemorrhoids.
d) Catheter leakage and high triglycerides.

146. Which of the following legal guidelines is maintained when the client is informed about all
alternative treatments?
a) Confidentiality
b) Informed consent
c) Advanced directives
d) Medication administration

147. An elderly client was placed in the side-lying position after internal fixation for fractures to the
right hip. Which of the following is the BEST reason for placing a pillow or a splint between the
legs of the client?
a) Enhances flexion of the knees.
b) Promotes adduction of the thighs.
c) Prevent adduction of the hip.
d) Inhibits hyperextension of the knees.

148. During the interview a diabetic client states that he does not add sugar to his meals but enjoys a
large bowl of frosted cereal in the morning. On further questioning, the nurse identifies that the
client is experiencing difficulty maintaining a diabetic diet. Which of the following actions is
PRIORITY in the management of the patient’s knowledge deficit?
a) Schedule an appointment with the dietician.
b) Discuss the dietary restrictions with the client.
c) Refer to physician of management of insulin.
d) Provide the client with a list of foods to avoid.

149. The nurse would advise a 50 year old client with a type two diabetes mellitus who is on
metformin therapy that the MOST common side effect of metformin is:
a) Weight gain
b) Hypoglycemia
c) Lactic acidosis
d) Respiratory alkalosis

150. A 60 year old client is admitted with a suspected diagnosis of myocardial infarction. An
electrocardiogram was done. Which of the following diagnostic investigations would confirm
the diagnosis?
a) Elevated BUN
b) Elevated CK-MB
c) Decreased myoglobin
d) Decreased CK-MM

151. Which of the following finding would confirm a client diagnosis of myocardial infarction?
a) Elevated T wave, ST-inversion, normal QRS.
b) Elevated T wave, elevated P wave, abnormal QRS.
c) Elevated R wave, normal QRS, elevated ST segment.
d) Inverted T wave, elevated ST segment, abnormal QRS.

152. An elderly client has been admitted to a medical ward with Do Not Resuscitate status. Which of
the following actions employed by the nurse would demonstrate a respect for client’s right in
the event of a cardiopulmonary emergency?
a) Initiate resuscitation of the client until the doctor arrives.
b) Clarify the client code status before resuscitation.
c) Stay with the client and hold his hand.
d) Page the doctor to certify the death.

153. A nurse discovers that a primary provider has prescribed an unusually large dosage of a
medication. Which of the following is the MOST appropriate action for the nurse to perform?
a) Administer the medication.
b) Notify the prescriber.
c) Call the pharmacist.

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 d) Refuse to administer the medication.

154. A 66 year old patient with chronic pain in his right hip is sedentary for most of the day. He
knows that he should walk and exercise, but complains that he is in constant pain and is afraid
of falling. The nurse selects the nursing diagnosis of impaired physical mobility. The MOST
appropriate nursing intervention is to:
a) Encourage the patient to consider total hip replacement surgery.
b) Teach the patient and his wife how to perform passive range of motion while the patient is
sitting.
c) Instruct the patient to take pain medication half hour before walking and use a walker or a
cane to provide stability when he walks.
d) Tell the patient that he needs to walk or he will become bedbound and suggest that his wife
assist him.

155. The nurse at an outpatient diabetic clinic is monitoring a client with Type I diabetes mellitus.
Today’s blood work reveals a glycosylated hemoglobin (HbA1c) level of 10%. Which of the
following conclusions by the nurse is justified?
a) A normal value indicating that the client is managing blood glucose control well. No need
for additional teaching plan.
b) A value that does not offer information regarding the client’s management of the disease.
Further testing required.
c) A low value indicating that the client is not managing blood glucose control very well.
Create teaching plan.
d) A high value indicating that the client is not managing blood glucose control very well.
Create teaching plan.

156. A Hispanic mother who does not speak English and is very upset brings her child to the clinic
with bleeding from the mouth. Which of the following is the MOST appropriate action by the
nurse who does not speak Spanish?
a) Call for the Spanish interpreter.
b) Grab the child and take the child to the treatment room.
c) Immediately apply ice to the child’s mouth.
d) Give the ice to the mother and demonstrate what to do.

157. The client was admitted to the recovery room after having open reduction and internal fixation
of his left tibia and fibula after crash injury. He has a Plaster of Paris (POP) cast in place and he is
being nursed with the affected leg elevated on a pillow. The key of the focused assessment of
the client to identify musculoskeletal complications should include:
a) Vital signs
b) Operation site
c) Intravenous lines
d) Circulatory function

158. To evaluate for complications of crush injury, a client was ordered to have serial urinalysis which
would include reporting:
a) Protein
b) Glucose
c) Bilirubin
d) Leucocytes

159. Complications of crush injury may result in renal failure that is:
a) Intra-renal
b) Pre-renal
c) Idiopathic
d) Post-renal

160. A client’s arterial blood gas results showed pH 7.45, Oxygen (PaO2) 60mmHg, Carbon Dioxide
(PaCO2) 30mmHg, Bicarbonate (HCO3) 28mmHg. Those results indicate:
a) Metabolic acidosis
b) Metabolic alkalosis
c) Respiratory acidosis
d) Respiratory alkalosis

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161. What information should a nurse include in a client’s pre-operative teaching?
a) A description of the different postoperative complications that should be prevented.
b) Postoperative plans for pain management especially immediately after surgery.
c) Detailed description of the surgical procedure to be performed on her.
d) Explanation of the potential side effects of the anesthetic to be used.

162. Which of the following outcomes would demonstrate the effectiveness of a client’s pre-
operative teaching?
a) She sleeps well the night before surgery.
b) She has a balanced intake and output.
c) She demonstrates deep breathing, coughing, splinting and leg exercises.
d) She remains free of infection as manifested by normal temperature.

163. Which biological factor would contribute to a higher incidence of HIV/AIDS in the female
population?
a) Females generally have lower hemoglobin levels.
b) Higher levels of estrogen and progesterone in females.
c) Females produce more lubrication during sexual intercourse, causing virus entry.
d) Structure of the female reproductive organ facilitated entry of the virus.

164. Pre-counselling for HIV testing is done in order to:

a) Teach clients about HARRT.
b) Assure clients of confidentiality of results.
c) Commence procedures for post-exposure prophylaxis.
d) Immediately commence tracing of contacts.

Scenario 7 (Items 165-170)

A patient was admitted to the Accident and Emergency Department with burns on the anterior
aspects of both arms and trunk. The physician’s orders included nasogastric tube insertion and
intravenous infusion therapy.
165. Using the Rule of Nines, the percentage of burns the patient received is:
a) 18.0%
b) 22.5%
c) 27.0%
d) 37.5%

166. Fluid resuscitation is commenced using the Parkland (Baxter) Formula, with orders to infuse 5
liters within 24 hours. The volume sequence to be infused is:
a) 1000, 1500 then 2500ml
b) 1250, 1250 then 2500ml
c) 1500, 2000 then 1000ml
d) 2500, 1250 then 1250ml

167. The client is diagnosed with deep partial thickness burns. This type of injury affects the:
a) Dermis causing pain.
b) Epidermis and upper dermis causing blisters.
c) Dermis and subcutaneous tissue casing no pain.
d) Epidermis, upper and lower dermis causing blisters.

168. A nasogastric tube was inserted because the patient:

a) Is being maintained NPO (nothing by mouth).
b) Is at risk for gastrointestinal bleed.
c) Will not feel like eating.
d) Needs extra protein to support healing.

169. Intravenous fluid administration is recommended because of the:

a) Extent of the injury.
b) Age of the patient.
c) Patient’s NPO status.
d) Location of the burns.

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170. The most accurate method used to determine the extent of burnt injuries in the hospital setting
is the:
a) Rule of nine
b) Lund and Browdar
c) Rule of Pain
d) Browdar and Brooke

171. The MAIN pathological changes which occur in sickle cell disease are:
a) Gross capillary obstruction and white cell destruction.
b) Marked thrombo-embolic obstruction and tissue necrosis.
c) Increased blood viscosity, capillary fatty streaks and tissue necrosis.
d) Increased blood viscosity, increased cell destruction and tissue necrosis.

Scenario 8 (Items 172-175)

The nurse in charge of the medical/surgical unit was granted sick leave for period of one week. A
graduate nurse is assigned to take charge of the unit in her absence.

172. Which of the following actions is of LEAST relevance to the graduate nurse when she is
delegating?
a) Organize and evaluate work done.
b) Allocate staff according to their skills.
c) Assign responsibility to complete assignment.
d) Give authority to undertake assigned act.

173. Which of the following activities BEST reflects supervision of staff by the graduate nurse on the
unit?
I. Recognizing group needs.
II. Assessing outcomes of care.
III. Planning and organizing work.
IV. Directing and instructing staff.

a) I, II, III
b) I, II, IV
c) I, III, IV
d) II, III, IV

174. Which of the following statements about responsibility would be MOST appropriate to guide the
graduate nurse in managing the unit?
I. Authority may be delegated but responsibility may not.
II. Accountability accompanies responsibility.
III. Responsibility is the amount of power granted by an organization.
IV. Responsibility is an expectation of the level of performance of an individual.

a) I, II, III
b) I, II, IV
c) I, III, IV
d) II, III, IV

175. Which of the following measures should the graduate nurse utilize in order to establish control
on the unit?
a) Deciding on priorities.
b) Setting goals and objectives.
c) Reviewing outcomes of patient care.
d) Defining standards of performance.

176. A 70 year old female client is directed by her doctor that she needs surgery but has not been
given the opportunity to seek a second opinion. The ethical principle is:
a) Autonomy
b) Paternalism
c) Beneficence
d) Non-maleficence

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177. A 76 year old male client diagnosed with cancer refuses chemotherapy and elect to have natural
remedies. The ethical principle is:
a) Autonomy
b) Paternalism
c) Beneficence
d) Non-maleficence

178. The performance of an emergency tracheostomy of an unconscious elderly client before

consent can be obtained. The ethical principle is:
a) Autonomy
b) Paternalism
c) Beneficence
d) Non-maleficence

179. Ensuring that an older person is not left unattended while in the bathtub for any length of time.
The ethical principle is:
a) Autonomy
b) Paternalism
c) Beneficence
d) Non-maleficence

180. Which of the following assessments would be MOST appropriate during the dwelling phase of
dialysis?
a) Observe of urticarial.
b) Check capillary refill time.
c) Monitor electrolyte status.
d) Monitor respiratory status.

181. Which of the following nursing interventions MUST be included in the patient’s plan of care
during dialysis therapy?
a) Limit patient’s visitors.
b) Pad the side rails of the bed.
c) Monitor the patient’s blood pressure.
d) Maintain nil by mouth (NPO) status.

182. The PRIMARY rational for warming dialysis solution prior to use for peritoneal dialysis is to:
a) Add extra warmth to the body.
b) Force potassium back into the cells.
c) Facilitate the removal of serum urea.
d) Promote abdominal muscle relaxation.

183. Three litres of Hartman’s (lactated ringer’s) is charted to flow over 12 hours. The drop factor is
15. The IV has been running for 9 hours, 800 mls remained. How many drops per minute are
needed so that the IV finishes in the required time.
a) 47 drops/min
b) 57 drops/min
c) 67 drops/min
d) 77 drops/min

184. Which of the following actions is MOST appropriate if the flow of dialysate stops before all the
solutions has drained out?
a) Assist the patient to ambulate.
b) Instruct the patient to sit in a chair.
c) Reposition the peritoneal catheter.
d) Reposition the patient from side to side.

185. A nasogastric tube inserted because the patient:

a) Is being maintained NPO.
b) Is at risk for gastrointestinal bleed.
c) Will not feel like eating.
d) Needs extra protein to support healing.

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186. A patient sustained fractured ribs in a motor vehicular accident. After assessing him, the nurse
diagnosed ineffective breathing pattern. A finding to support this diagnosis would include:
a) Hypoventilation
b) Hyperventilation
c) Rhonchi
d) Decreased air entry

187. A 40 year old patient has been admitted to the ICU after a myocardial infarction. Family history
is that the father died suddenly at age 42. Discharge teaching includes lifestyle modification.
The nurse recognize that teaching was effective when the patient identifies modifiable risk
factors as:
a) Diet, inactivity, smoking
b) Diet, smoking, age
c) Diet, inactivity, age
d) Inactivity, smoking, genetics

188. The most appropriate intervention to decrease oxygen demand in a hospitalized patient
diagnosed with myocardial infarction is to:
a) Limit visualization.
b) Limit physical activity.
c) Administer prescribed morphine.
d) Administer supplemental oxygen.

189. In cardiac arrest, the goal of CPR is to prevent:

a) Irreversible injury to the cardiac cells.
b) Irreversible cerebral damage.
c) Pulmonary arrest.
d) Fractured ribs.

Scenario 9 (Items 190-200)

Hilda Peters a 31 year old housewife visited her doctor because of nervousness and irritability. Her
doctor ordered the following investigations: Basal metabolic rate (BMR), Protein bound iodine test (PBI),
radioactive iodine test, in order to confirm the diagnosis of Thyrotoxicosis.

190. The protein bound iodine (PBI) is an important test that aids in the clinical diagnosis of
thyrotoxicosis because it:
a) Determines if the gland is hyperplastic.
b) Reflects the level of circulatory thyroid hormone in the blood.
c) Differentiates between benign and malignant tissue of the thyroid.
d) Determines the rate at which the individual consumes oxygen.

191. Hilda’s PBI and iodine uptake tests will be falsely elevated if she was or had recently been taking
medications containing:
a) Iodine
b) Cortisone
c) Salicylates
d) Sulfonamides

192. In preparing Hilda for her basal metabolic rate examination, it would be inappropriate for the
nurse to tell the patient that she will:
a) Receive a medication before the examination.
b) Fast for approximately 10 hours prior to the examination.
c) Have the examination early in the morning before breakfast.
d) Breathe into a machine for several minutes during the examination.

193. Which of the following assessment techniques would be of least value when the nurse examines
Hilda’s thyroid gland?
a) Palpation
b) Percussion
c) Inspection
d) Auscultation

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194. All of the following are typical symptoms of thyrotoxicosis EXCEPT:
a) Anorexia
b) Tachycardia
c) Heat intolerance
d) Fine hand tremors

195. During a physical assessment, Hilda is most likely to report:

a) Dysmenorrhea
b) Metorrhagia
c) Oligomenorrhoea
d) Menorrhagia

196. Which of the following symptoms related to the eyes characterizes exophinalmus?
a) Floating eye balls
b) Protrusion of the eye balls
c) Inability to see in the dark
d) Halos around the eye balls

197. Which of the following symptoms should the nurse teach Hilda to report immediately if it
occurs?
a) A sore throat and general malaise
b) Constipation and abdominal distention
c) Painful and excessive menstruation
d) Increase urinary output and itching skin

198. Hilda is scheduled for sub-total thyroidectomy. Potassium iodine in the form of Lugol iodine was
ordered for her. The primary reason for administering this drug is to:
a) Reduce the size of the thyroid gland.
b) Decrease the body’s ability to absorb thyroxin.
c) Increase the body’s ability to absorb thyroxin.
d) Stabilize the thyroid gland.

199. Which of the following measures is most often recommended to prepare Lugols iodine for
administration?
a) Pouring it over ice chips.
b) Diluting with water, milk or juice.
c) Disguising it with pureed vegetable.
d) Pouring it into an alcohol based liquid.

200. The item that the nurse will least likely to have in Hilda’s room is an:
a) Tracheostomy set
b) Suctioning set
c) Cut down set
d) Equipment for administering oxygen

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