Practice Test July 2010 from Nursingcrib.

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1. The nurse manager tells another nurse to hold down a patient to insert a catheter. The patient
says that he doesn’t want the catheter inserted. The nurse understands that the patient isn’t
confused. If the nurse bodily restrains the patient, she’s committing:

a. assault
b. battery
c. libel
d. negligence

Battery is the harmful or offensive touching of another’s person. Libel is false accusations—written,
printed or typed- that are made with malicious intent. Assault is a threat or attempt to make bodily
contact with another person without the other person’s consent. Negligence is the omission of an act
that a prudent person would have performed.

2. A patient is complaining of blurred vision following a motor vehicle accident. The nurse knows that
the lobe of the brain responsible for vision is the:

a. motor cortex
b. occipital
c. parietal
d. temporal

The occipital lobe of the brain is responsible for vision. The motor cortex is responsible for
movement, the parietal lobe is responsible for sensation and body awareness, and the temporal lobe
is responsible for hearing, language, comprehension and recall.

3. Mr. Del Rio is diagnosed with gastric ulcer, the nurse would expect his pain to occur:

a. below the umbilicus

b. at the umbilicus
c. in the epigastric area
d. after a high-fat meal

The pain in the epigastric area is associated with gastric ulcer disease. Pain below or at the
umbilicus is associated with appendicitis. Abdominal pain that occurs after a high-fat meal is
associated with cholecystitis.

4. The most common cause of hyperaldosteronism is:

a. excessive sodium intake

b. a pituitary adenoma
c. deficient potassium intake
d. an adrenal adenoma

An autonomous aldosterone- producing adenoma is the most common cause of hyperaldosteronism.

Hyperplasia is the second most common cause. Aldosterone secretion is independent of sodium and
potassium intake and of pituitary stimulation.

5. Mrs. Reyes was diagnosed with a unilateral aldosteronoma for which she undergoes a unilateral
adrenalectomy. Postoperatively, the nurse can identify hyperkalemia by assessing the patient for:

a. muscle weakness
b. tremors
c. diaphoresis
d. constipation

Muscle weakness, bradycardia, nausea, diarrhea and paresthesia of the hands, feet, tongue and face
are common with hyperkalemia. The hyperkalemia is transient and occurs from transient
hypoaldosteronism when the adenoma is removed. Tremors and diaphoresis and constipation aren’t
seen in hyperkalemia.

6. Otorrhea and rhinorrhea are most commonly seen in which type of skull fracture?
a. basilar
b. temporal
c. occipital
d. parietal

Otorrhea and rhinorrhea are classic signs of a basilar skull fracture. Injury to the dura commonly
occurs with this fracture, resulting in CSF leaking through the ears and nose. Any fluids suspected of
being CSF should be checked for glucose or have a halo test done.

7. A Galsgow Coma Scale of 8 in a patient with a new head injury indicates:

a. a mild head injury
b. a brief loss of consciousness
c. severe head injury
d. death will occur within minutes

The best possible Glasgow Coma Scale is 15; the lowest is 3. A score of 8 or less indicates coma.
When associated with a new head injury, it indicates a serious traumatic injury, and the airway may
be compromise and need intubation.

8. Pain from osteoarthtitis is described as mechanical pain, which means:

a. the pain responds to mechanical device use

b. the pain is relived by rest and worsened by activity
c. the pain is worse at the beginning of the day and improves with activity
d. rest and activity have no effect on the pain

The effects of rest and activity on pain are the one of the significant differences between rheumatoid
arthritis and osteoarthritis. A patient with rheumatoid experiences morning joint stiffness; a patient
with osteoarthritis experiences more pain as the day progresses and may function better after a
night of rest.

9. A patient is diagnosed with a schizophrenic disorder is admitted to the in patient psychiatric unit.
The patient refuses to eat, telling the nurse that spies have put poison in his food. The nurse
assesses the patient with the understanding that a false belief to which an individual adheres is:

a. ambivalence
b. anhedonia
c. delusion
d. psychosis

Delusion is a false belief to which an individual adheres. Ambivalence is the simultaneous existence
of two opposing feelings, needs or wishes. Anhedonia is the inability to experience pleasure.
Psychosis is a major disturbance in ego functioning.

10. The model of care in which one nurse is assigned the overall responsibility for a patient
throughout the patient’s entire hospitalization period is known as:

a. case management nursing

b. functional nursing
c. team nursing
d. total patient care nursing

In case management nursing the patient is assigned to a health care provider who’s responsible for
coordinating that patient’s care as long as the patient is within the provider’s service area, such as a
hospital or health service.

11. Dyan Villejo is diagnosed with retinal detachment. Which intervention is the most important for
this patient?

a. admitting him to the hospital on strict bed rest

b. patching his both eyes
c. referring him to an ophthalmologist
d. preparing him for surgery
Immediate bed rest is necessary to prevent further injury. Both eyes should be patched to avoid
consensual eye movement and the patient should receive early referral to an ophthalmologist. If the
macula is attached and central visual acuity is normal, an ophthalmologist should treat the condition
immediately. Retinal reattachment can be accomplished by surgery only. If the macula is detached
or threatened, surgery is urgent, prolonged detachment of the macula results in permanent loss of
central vision.

12. A registered nurse has received the assignment for the day shift. After making initial rounds and
checking all the assigned clients, which will the RN plan to care for first?

a. a client who is ambulatory

b. a client who has fever and who is diaphoretic and restless
c. a client scheduled for physical therapy at 1:00 pm
d. a post-operative client who has received pain medications

Patients with unstable condition should be given highest priority by the nurse. The client who has
fever, and who is diaphoretic and restless is with unstable condition.

13. The charge nurse of a psychiatric unit is planning the client assignment for the day. The most
appropriate staff to be assigned to a client with a potential for violence is which of the following:

a. A timid nurse
b. A mature experienced nurse
c. an inexperienced nurse
d. a soft spoken nurse

A mature experienced nurse. The unstable, aggressive client should be assigned to the most
experienced nurse. Options A, C and D. A shy, inexperienced, soft spoken nurse may feel
intimidated by the angry patient.

14. A 40 year old male client is admitted in the ward because of bizarre behaviors. He is given a
diagnosis of schizophrenia paranoid type. The client should have achieved the developmental task
of:

a. Trust vs. mistrust

b. Industry vs. inferiority
c. Generativity vs. stagnation
d. Ego integrity vs. despair

Ego integrity vs. despair. The client belongs to the middle adulthood stage (30 to 65 yrs.) The
developmental task generativity is characterized by concern and care for others. It is a productive
and creative stage. Option A Infancy stage (0 – 18 mos.) is concerned with gratification of oral
needs. Option B School Age child (6 – 12 yrs.) is characterized by acquisition of school competencies
and social skills. Options C Late adulthood ( 60 and above) Concerned with reflection on the past
and his contributions to others and face the future.

15. Which is the priority diagnosis for a patient experiencing angina?

a. decreased cardiac output
b. pain
c. anxiety
d. altered tissue perfusion

Angina is caused by altered tissue perfusion to the myocardium, which results in ischemia.
Treatment is aimed t reversing ischemia. Pain and anxiety should also be addressed, but they don’t
take priority over altered tissue perfusion. Cardiac output may or many not be affected with angina.

16. Which of the following statements refers to criteria?

a. Agreed on level of nursing care

b. Characteristics used to measure the level of nursing care
c. Step-by-step guidelines
d. Statement which guide the group in decision making and problem solving

Characteristics used to measure the level of nursing care. Criteria are specific characteristics used to
measure the standard of care.
17. Henson De Jesus is a 28 month old boy admitted to the hospital with acute croup. Which of the
following would be most threatening to Henson’s autonomy?

a. complete bed rest

b. frequent visits by friends and family
c. participation in playroom activities with other children
d. riding to the x-ray department in a wheelchair

One of the greatest threats to a hospitalized toddler’s autonomy is complete bed rest. He’s just
beginning to assert his independence, is very active, and doesn’t want to be kept in bed.

18. The doctor orders intra-arterial monitoring to attain continuous blood pressure in a critically ill
patient. Collateral circulation should be assessed prior to selection of an arterial site. The test used
to assess the patency of the radial and ulnar arteries is the:

a. Allen’s test
b. Homan’s test
c. Trendelenburg’s test
d. Weber’s test

Allen’s test determines patency by compressing and releasing them one at a time. The hand should
regain color within 6 seconds. Homan’s sign tests for blood clots in the leg. Trendelenburg’s test
checks for incompetent valves in the legs. Weber’s test determines lateralization of bone conduction
by using a tuning fork.

19. Margaret Cruz is a 25 year old teacher admitted to the hospital with acute appendicitis. She’s
now 1 day postoperative appendectomy and has an abdominal surgical wound. Based on the nurse’s
knowledge of surgical wounds, simple surgical incisions heal by ________ intention.

a. primary
b. quartenary
c. secondary
d. tertiary

Primary intention healing occurs where the tissue surfaces have been approximated and there has
been minimal or no loss of tissue. A surgical incision has minimal tissue loss and heals through the
process of collagen synthesis, also called primary intention.

20. The subjective and objective data that signal the existence of an actual health problem are
which of parts of an actual nursing diagnosis?

a. Etiology
b. Inferences
c. Problem statement (diagnostic label)
d. Signs and symptoms (defining characteristics)

The signs and symptoms (defining characteristics) of an actual nursing diagnosis are subjective and
objective data or information that signals the existence of an actual health problem.

21. A patient with history of COPD presents with dyspnea and an oxygen saturation of 88%. What
amount of oxygen would the nurse expect to be ordered for this patient:

a. 2L via nasal cannula

b. 6L via nasal cannula
c. 50% by face mask
d. 100% by nonrebreather mask

A patient with COPD breathes by a hypoxic drive that requires a higher partial pressure of arterial
carbon dioxide level. If too much oxygen is delivered, the patient may not be able to breathe
spontaneously and may require intubation.

22. Which of the following deformities is described as a lateral curvature of the thoracic spine?

a. kyphosis
b. scoliosis
c. lordosis
d. genu valgum

Scoliosis is a lateral deformity of the thoracic spine. This deformity becomes apparent during
adolescence. Kyphosis is a vertical curvature of the spine, or “humpback”. Lordosis is an increase in
curvature of the lumbar spine. Genu valgum is internal angling of the knees or “knock-knees.”

23. What is the most common portal of entry for microorganisms associated with sepsis?

a. skin
b. GI tract
c. Respiratory tract
d. Urinary tract

Although microorganisms that cause sepsis syndrome can enter through the skin, GI tract or
respiratory tract, the most common portal of entry is the urinary tract via urinary catheters,
suprapubic tubes, and cystoscopic examination.

24. Jess Villanes, who is paraplegic due to a T6 spinal cord injury, is admitted to the medical-surgical
floor with a stage 4 pressure ulcer on his right hip. The doctor also suspects osteomyelitis. What are
the characteristics of a stage 4 pressure ulcer?

a. It is an area of nonblanching erythema.

b. It is an area of skin loss involving the dermis with a shallow crater-like appearance.
c. It is an area of full-thickness skin loss with a deep lesion that extends down through the
subcutaneous tissue.
d. It is an area of full-thickness skin loss with exposure of muscle tissue, the hip bone, and
surrounding support structures.

A stage 4 pressure ulcer involves full-thickness skin loss with exposure of muscle, bone and
surrounding support structures. A stage 1 pressure ulcer appears as a nonblanching erythema of
intact skin. A stage 2 pressure ulcer involves an area of skin loss that extends to the dermis and has
a shallow crater-like appearance/. A stage 3 pressure ulcer involves an area of full-thickness skin
loss with a deep crater that extends down through the subcutaneous tissue.

25. Which of the following statements made by Mr. Villanes in response to teaching indicates he
understands how this episode of osteomyelitis will be treated?

a. “I will probably need to have part of the bone- if not the entire hip joint—removed.”
b. “I will need I.V. antibiotic therapy for 4 to 6 weeks.”
c. “After a week on I.V. antibiotics, I will probably go home on oral antibiotics.”
d. “You will need to irrigate my wound with antibiotic solution, but I won’t be on oral or intravenous
antibiotics.”

Osteomyelitis is a very serious infection of the bone that is difficult to treat. Long-term I.V.
antibiotics are needed to eradicate this type of infection.

26. Mr. Gollez is a 49 year old obese man who was seen for a routine check-up. His fasting blood
glucose level is 135 mg/dl, so he’s scheduled for a repeat test. Mr. Gollez asks the nurse why he has
to return for another test. The nurse’s best response would be:

a. “Your fasting blood glucose level was normal but we need a confirmation of that result.”
b. “Fasting blood glucose level tests are always repeated.”
c. “You have type 2 diabetes mellitus, so the test must be repeated.”
d. “Your fasting blood glucose level was abnormal and needs to be tested again.”

Type 2 diabetes is diagnosed with two fasting blood glucose levels ≥ 126 mg/dl or a casual plasma
glucose level ≥ 200 mg/dl and symptoms. Because his first fasting blood glucose level was ≥ 126
mg/dl, it must be repeated to make the diagnosis of type 2 diabetes.

27. Mica Jaladoni, 27 years old, comes in for an appointment 6 months after delivering her child. She
states she was unable to breast-feed her baby and is concerned that she hasn’t menstruated. The
best action by the nurse would be to:
a. reassure her that this is normal and her menses should return soon
b. ask if she had any hemorrhaging during or after her delivery
c. refer her to a support group
d. ask her if she had gestational diabetes mellitus

The nurse should ask the patient if she had any hemorrhaging during or after delivery. Sheehan’s
syndrome, a form of hypopituitarism, is caused by anoxia from postpartal hemorrhage. The earliest
signs are inability to lactate and failure to menstruate. Inability to lactate and failure to menstruate
aren’t normal or characteristic of gestational diabetes mellitus. Although a support group may be
helpful, if the patient has hypopituitarism, this should be diagnosed and treated or she’ll be infertile
and experience a gradual deterioration of all function regulated by the pituitary gland.

28. Which of the following signs should the nurse expect in a client with known amphetamine
overdose?

a. Hypotension
b. Tachycardia
c. Hot, dry skin
d. Constricted pupils

Amphetamines are central nervous system stimulants. They cause sympathetic stimulation,
including hypertension, tachycardia, vasoconstriction, and hyperthermia. Hot, dry skin is seen with
anticholinergic agents such as jimsonweed. Pupils will be dilated, not constricted.

29. In a horizontal chart, the lowest level worker is located at the:

a. Left most box

b. Middle
c. Right most box
d. Bottom

Rightmost box. The leftmost box is occupied by the highest authority while the lowest level worker
occupies the rightmost box.

30. The nurse performs many roles in the practice of nursing. Which role is defined as “the
protection of human or legal rights and the securing of quality care for each patient”?

a. Advocator
b. Communicator
c. Counselor
d. Leader

The advocator role provides for “the protection of human or legal rights and the securing of quality
care for each patient”. The leader role is defined as assertive, self-confident practice in nursing
when providing or supervising care. The communicator role is the use of effective interpersonal and
therapeutic communication to provide information to make referrals and facilitate problem solving.
31. The nurse is assessing a newborn who had undergone vaginal delivery. Which of the following
findings is least likely to be observed in a normal newborn?

a. uneven head shape

b. respirations are irregular, abdominal, 30-60 bpm
c. (+) moro reflex
d. heart rate is 80 bpm

Normal heart rate of the newborn is 120 to 160 bpm. Choices A, B, and C are normal assessment
findings (uneven head shape is molding).

32. The nurse is assessing a 9-month-old boy for a well-baby check up. Which of the following
observations would be of most concern?

a. The baby cannot say “mama” when he wants his mother.

b. The mother has not given him finger foods.
c. The child does not sit unsupported.
d. The baby cries whenever the mother goes out.
Over 90% percent of babies can sit unsupported by nine months. Most babies cannot say “mama” in
the sense that it refers to their mother at this time.

33. The twelve-year-old boy has fractured his arm because of a fall from his bike. After the injury has
been casted, the nurse knows it is most important to perform all of the following assessments on the
area distal to the injury except:

a. capillary refill.
b. radial and ulnar pulse.
c. finger movement
d. skin integrity

Capillary refill, pulses, and skin temperature and color are indicative of intact circulation and
absence of compartment syndrome. Skin integrity is less important.

34. At the community center, the nurse leads an adolescent health information group, which often
expands into other areas of discussion. She knows that these youths are trying to find out “who they
are,” and discussion often focuses on which directions they want to take in school and life, as well as
peer relationships. According to Erikson, this stage is known as:
a. identity vs. role confusion.
b. adolescent rebellion.
c. career experimentation.
d. relationship testing

During this period, which lasts up to the age of 18-21 years, the individual develops a sense of
“self.” Peers have a major big influence over behavior, and the major decision is to determine a
vocational goal.

35. An inborn error of metabolism that causes premature destruction of RBC?

a. G6PD
b. Hemocystinuria
c. Phenylketonuria
d. Celiac Disease

Glucose-6-phosphate dehydrogenase deficiency (G6PD) is an X-linked recessivehereditary disease

characterised by abnormally low levels of glucose-6-phosphate dehydrogenase (abbreviated G6PD
or G6PDH), a metabolic enzyme involved in the pentose phosphate pathway, especially important in
red blood cell metabolism.

36. A client who’s admitted to labor and delivery has the following assessment findings: gravida 2
para 1, estimated 40 weeks’ gestation, contractions 2 minutes apart, lasting 45 seconds, vertex +4
station. Which of the following would be the priority at this time?

a. Placing the client in bed to begin fetal monitoring.

b. Preparing for immediate delivery.
c. Checking for ruptured membranes.
d. Providing comfort measures.

This question requires an understanding of station as part of the intrapartal assessment process.
Based on the client’s assessment findings, this client is ready for delivery, which is the nurse’s top
priority. Placing the client in bed, checking for ruptured membranes, and providing comfort
measures could be done, but the priority here is immediate delivery.

37. After completing a second vaginal examination of a client in labor, the nurse-midwife determines
that the fetus is in the right occiput anterior position and at –1 station. Based on these findings, the
nurse-midwife knows that the fetal presenting part is:

a. 1 cm below the ischial spines.

b. directly in line with the ischial spines.
c. 1 cm above the ischial spines.
d. in no relationship to the ischial spines.

Fetal station — the relationship of the fetal presenting part to the maternal ischial spines — is
described in the number of centimeters above or below the spines. A presenting part above the
ischial spines is designated as –1, –2, or –3. A presenting part below the ischial spines, as +1, +2, or
+3.

38. When assessing a client during her first prenatal visit, the nurse discovers that the client had a
reduction mammoplasty. The mother indicates she wants to breast-feed. What information should
the nurse give to this mother regarding breast-feeding success?

a. “It’s contraindicated for you to breast-feed following this type of surgery.”

b. “I support your commitment; however, you may have to supplement each feeding with formula.”
c. “You should check with your surgeon to determine whether breast-feeding would be possible.”
d. “You should be able to breast-feed without difficulty.”

Recent breast reduction surgeries are done in a way to protect the milk sacs and ducts, so breast-
feeding after surgery is possible. Still, it’s good to check with the surgeon to determine what breast
reduction procedure was done. There is the possibility that reduction surgery may have decreased
the mother’s ability to meet all of her baby’s nutritional needs, and some supplemental feeding may
be required. Preparing the mother for this possibility is extremely important because the client’s
psychological adaptation to mothering may be dependent on how successfully she breast-feeds.

39. The nurse uses a stethoscope to auscultate a male patient’s chest. Which statement about a
stethoscope with a bell and diaphragm is true?

a. The bell detects high-pitched sounds best

b. The diaphragm detects high-pitched sounds best
c. The bell detects thrills best
d. The diaphragm detects low-pitched sounds best

The diaphragm of a stethoscope detects high-pitched sound best; the bell detects low pitched
sounds best. Palpation detects thrills best.

40. Which of the following is the best method for performing a physical examination on a toddler
a. From head to toe
b. Distally to proximally
c. From abdomen to toes, to the head
d. From least to most intrusive

When examining a toddler or any small child, the best way to perform the exam is from least to
most intrusive. Starting at the head or abdomen is intrusive and should be avoided. Proceeding from
distal to proximal is inappropriate at any age.

41. A mother tells the nurse that she is very worried because her 2-year old child does not finish his
meals. What should the nurse advise the mother?

a. make the child seat with the family in the dining room until he finishes his meal
b. provide quiet environment for the child before meals
c. do not give snacks to the child before meals
d. put the child on a chair and feed him

If the child is hungry he/she more likely would finish his meals. Therefore, the mother should be
advised not to give snacks to the child. The child is a “busy toddler.” He/she will not able to keep still
for a long time.

42. A patient is in last trimester of pregnancy. Nurse Jane should instruct her to notify her primary
health care provider immediately if she notices:

a. Blurred vision
b. Hemorrhoids
c. Increased vaginal mucus
d. Shortness of breath on exertion

Blurred vision of other visual disturbance, excessive weight gain, edema, and increased blood
pressure may signal severe preeclampsia. This condition may lead to eclampsia, which has
potentially serious consequences for both the patient and fetus. Although hemorrhoids may be a
problem during pregnancy, they do not require immediate attention. Increased vaginal mucus and
dyspnea on exertion are expected as pregnancy progresses.

43. A patient comes to the hospital complaining of severe pain in the right flank, nausea, and
vomiting. The doctor tentatively diagnoses right ureter-olithiasis (renal calculi). When planning this
patient’s care, the nurse should assign highest priority to which nursing diagnosis?

a. Pain
b. Risk of infection
c. Altered urinary elimination
d. Altered nutrition: less than body requirements

Ureterolithiasis typically causes such acute, severe pain that the patient can’t rest and becomes
increasingly anxious. Therefore, the nursing diagnosis of pain takes highest priority. Risk for
infection and altered urinary elimination are appropriate once the patient’s pain is controlled.
Altered nutrition: less than body requirements isn’t appropriate at this time.

44. Buck’s traction with a 10 lb. weight is securing a patient’s leg while she is waiting for surgery to
repair a hip fracture. It is important to check circulation- sensation-movement:

a. every shift.
b. every day.
c. every 4 hours.
d. every 15 minutes.

The patient can lose vascular status without the nurse being aware if left for more than 4 hours, yet
checks should not be so frequent that the patient becomes anxious. Vital signs are generally
checked q4h, at which time the CSM checks can easily be performed.

45. Which of the following would be inappropriate to assess in a mother who’s breast-feeding?

a. The attachment of the baby to the breast.

b. The mother’s comfort level with positioning the baby.
c. Audible swallowing.
d. The baby’s lips smacking

Assessing the attachment process for breast-feeding should include all of the answers except the
smacking of lips. A baby who’s smacking his lips isn’t well attached and can injure the mother’s
nipples.

46. A nurse caring for a two year old patient leaves the bedside without raising the side rails and the
patient falls to the floor. What type of legal action could be used in a lawsuit?

a. Battery
b. Malpractice
c. Negligence
d. Slander

The definition of negligence is the omission of an act that a prudent person would have performed;
in this case, the act is failure to raise the side rails.

47. CHN is a community-based practice. Which best explains this statement?

a. The service is provided in the natural environment of people.

b. The nurse has to conduct community diagnosis to determine nursing needs and problems.
c. The services are based on the available resources within the community.
d. Priority setting is based on the magnitude of the health problems identified.

The nurse has to conduct community diagnosis to determine nursing needs and problems.
Community-based practice means providing care to people in their own natural environments: the
home, school and workplace, for example.

48. Which is true of primary facilities?

a. They are usually government-run.

b. Their services are provided on an out-patient basis.
c. They are training facilities for health professionals.
d. A community hospital is an example of this level of health facilities.

Their services are provided on an out-patient basis. Primary facilities government and non-
government facilities that provide basic out-patient services.

49. Which of the following situations increase risk of lead poisoning in children?

a. playing in the park with heavy traffic and with many vehicles passing by
b. playing sand in the park
c. playing plastic balls with other children
d. playing with stuffed toys at home

Lead poisoning may be caused by inhalation of dusk and smoke from leaded gas. It may also be
caused by lead-based paint, soil, water (especially from plumbings of old houses).

50. Accompanied by her husband, a patient seeks admission to the labor and delivery area. The
client states that she is in labor, and says she attended the hospital clinic for prenatal care. Which
question should the nurse ask her first?

a. “Do you have any chronic illness?”

b. “Do you have any allergies?”
c. “What is your expected due date?”
d. “Who will be with you during labor?”

When obtaining the history of a patient who may be in labor, the nurse’s highest priority is to
determine her current status, particularly her due date, gravidity, and parity. Gravidity and parity
affect the duration of labor and the potential for labor complications. Later, the nurse should ask
about chronic illness, allergies, and support persons.