Reviewer

1.The client presented with complaints of body weakness, dizziness and chest pain.
Upon careful assessment, the nurse suspects Angina Pectoris. Which of the following
statements made by the client can confirm this?
a. “I suddenly felt a pain on my chest which radiates to my back and arms”.

b. “I suddenly felt a sharp pain on my lower abdomen”.
c. “The pain does not subside even if I rest”.
d. “The pain goes all the way down to my stomach”.
2.The client from the OR is transferred to the post-anesthesia care unit after surgical
repair of abdominal aortic aneurysm. Which of the following assessment findings would
indicate that the repair was successful?
a. Urine output of 50 mL/hr.

b. Presence of non-pitting, peripheral edema.
c. Clear sclera.
d. Presence of carotid bruit.
3.The client is scheduled for cardiac catheterization because the physician wants to
view the right side of the heart. Which of the following would the nurse expect to see in
this procedure?
a. A dye is injected to facilitate the viewing of the heart

b. Thallium is injected to facilitate the scintillation camera
c. A probe with a transducer tip is swallowed by the client.
d. A tiny ultrasound probe is inserted into the coronary artery
4.The client is being treated for hypovolemia. To assess the effectiveness of the
treatment, the Central Venous Pressure (CVP) of the client is being monitored. Which of
the following is TRUE about CVP?
a. The CVP is measured with a central venous line in the inferior vena cava.
b. The normal CVP is 7 to 9 mmHg.
c. The zero point on the transducer needs to be at the level of the left atrium.
d. The client needs to be supine, with the head of the bed elevated at 45 degrees.
5.The client’s ECG tracing shows ventricular tachycardia secondary to low magnesium
level. Which of the following electrocardiogram tracing results is consistent with this
finding?
a. The appearance of a U wave

b. Shortened ST segment and a widened T wave.
c. Tall, peaked T waves
d. Tall T waves and depressed ST segment
6.The nurse is teaching the client how to use a dry powder inhaler (DPI). Which of the
following are correct instructions given by the nurse? Select All That Apply.
a. Load the drug first by turning to the next dose of drug, or inserting the capsule into the device, or
inserting the disk or compartment into the device.
b. Never wash or place the inhaler in water.
c. Shake your inhaler prior to use.
d. The drug is a dry powder that is why you will taste the drug as you inhale.
e. Never exhale into the inhaler.
f. Do not remove the inhaler from your mouth as soon as you have breathe in.
7.The nurse is assigned to render care for a client who has a chest tube drainage system. Which of the
following are appropriate nursing actions? Select All That Apply.
a. Strip the chest tube.

b. Empty collection chamber when the drainage makes contact to the bottom of the tube.
c. Keep chest tube as straight as possible.
d. Notify the physician of drainage is greater than 70mL/hr.
e. Assess bubbling in the water seal chamber.
f. Keep drainage system at the level of the client’s chest
8.The client with DKA is receiving bicarbonate IV infusion for treatment of severe metabolic acidosis. The
nurse notes that the latest ABG shows a pH of 7.0. What should the nurse keep in mind in giving the
drug?
a. Check vital signs before giving the drug and monitor serum sodium level.
b. Perform a sensitivity test prior to drug administration.
c. Mix the drug with D10W 500 ml IV fluid and infuse for over 4 to 8 hours.
d. Administer the drug slowly and monitor the potassium leve
9.The client with a gunshot wound on the abdomen starts to get lethargic, is breathing heavily, and the
wound dressing is fully soaked with blood. The nurse is expected to immediately perform which of the
following actions?
a. Loosen tight clothing and administer oxygen supply.

b. Apply warm blanket to prevent heat loss.
c. Apply large gauze on the bleeding site to put direct pressure or place a tourniquet on the artery near
the bleeding site.
d. Initiate IV access.
10.The nurse is providing home instructions to a client with increased adrenocorticotrophic

hormone. The nurse is aware that the client with excessive corticosteroids is suffering from what
condition?
a. Cushing’s syndrome
b. Addison’s disease
c. Hypothyroidism
d. SIADH
11.The nurse is assigned to a post-thyroidectomy client and is monitoring for signs of hypocalcemia. The
nurse gently tapped the area below the zygomatic bone just in front of the ear. This action will elicit:
a. Facial tremor
b. Hyperreflexia
c. Chvostek sign
d. Trousseau sign
12.The nurse is caring for a client with an antineoplastic IV hooked on the right hand. The nurse notices
that IV site is swelling and feels cool when touched. The nurse recognizes this as extravasation. This
predisposes the client to develop which among the following complications? Select all that apply.
a. Infection
b. Tissue necrosis
c. Disfigurement
d. Loss of function
e. Amputation
f. Delayed healing
13.Nursing interventions commonly performed when the client is experiencing Autonomic Dysreflexia
will include the following. Select all that apply.
a. Use digital stimulation to empty the bowel.

b. Have the client sit up straight and raise his head so that he is looking ahead.
c. Remove client’s stockings or socks.
d. Manually compress or tap the bladder to allow urine to flow down the catheter.
e. Administer prescribed vasodilators.
14.Neurologic conditions can be manifested by changes in breathing patterns. The client presents with
symptom of Cheyne-Stokes respirations. The nurse knows that this kind of breathing pattern shows:
a. Completely irregular breathing pattern with random deep and shallow respirations
b. Prolonged inspirations with inspiratory and /or expiratory pauses
c. Sustained regular rapid respirations of increased depth
d. Rhythmic waxing and waning of both rate and depth of respiration with brief periods of interspersed
apnea
15.The physician is assessing the client’s sensorium by using the Glasgow Coma Scale. Which of the
following is true about the Glasgow Coma Scale?
a. If the client does not respond to painful stimuli, the score is 0.

b. A score lower than 10 indicates that the client is in a coma.
c. A score of 8 indicates that the client is alert and oriented.
d. A score of 4 indicates that the client sustained severe head trauma.
16.The nurse on duty is caring for a client with Amyotrophic Lateral Sclerosis and is concerned with the
client’s impaired physical mobility. The following nursing interventions are geared towards maintaining
optimal physical mobility EXCEPT:
a. Maintain an exercise program.

b. Encourage participation in activities.
c. Instruct client related safety measures.
d. Schedule activities in the morning.
17.An elderly client had a cerebrovascular accident or stroke. The left brain is affected and is at risk for
impaired verbal communication. The nurse asked a question and noted that the client has difficulty
talking and communicating his thoughts. Which of the following terms should the nurse use to
document the finding?
a. Receptive Aphasia
b. Expressive Aphasia
c. Global aphasia
d. Apraxia
18.The client diagnosed with Alzheimer’s disease is starting to show signs and symptoms. The nurse
wants to assess for graphesthesia. This is performed by:
a. Testing for the client’s ability to identify an object that is placed on the hand with eyes closed.
b. Testing for the client’s ability to recognize the written letter or number in the client’s skin while the
eyes are closed.
c. Making the client stand, with the arms at the side, feet together, with the eyes open and then closed.
The client is then observed for any swaying.
d. Testing for the presence of pain once the leg is flexed at the hip, and then extended.
19.The pediatric client presents with the following signs and symptoms: high fever, drooling, difficulty of
breathing and leaning forward in a tripod position. Immunization history shows that the client never
received any Hib vaccine. Which of the following is the priority of the healthcare provider?
a. Continuous oxygen therapy and constant monitoring of oxygen saturation rate.

b. A well regulated IV infusion and timely administration of antibiotics.
c. Vaccination of Hib and other remaining vaccines to complete required immunizations.
d. Avoiding any throat examination or agitation of the child.
20.The physician prescribed Clarithromycin (Biaxin) 250mg BID x 7 days for the client’s infection.
Incorrect drug frequency and duration would cause inaccurate transfer time of the drug to specific
tissues in the body. The nurse explains to the client that accumulation of the drug in specific tissues is
the concept of:
a. Absorption
b. Distribution
c. Metabolism
d. Excretion
21.The nurse is to administer Meperidine (Demerol) 35 mg through the intramuscular route. Available
meperedine is 50mg/mL. Which of the following is the least favorable injection site for intramuscular
medication?
a. Ventrogluteal
b. Vastus lateralis
c. Deltoid muscle
d. Dorsogluteal
22.The client presented with complaint of leg cramps. Upon checking the client’s chart, the nurse noted
that the client is hypertensive and is prescribed with a Thiazide diuretic. The appropriate nursing
intervention for this client is:
a. Stop the Thiazide diuretic

b. Refer to the physician for evaluation of electrolyte level of the client
c. Switch the client to a loop diuretic
d. Give the client a non-steroidal anti-inflammatory drug (NSAID)
23.The client is wheeled into the delivery room and is ready for childbirth. While crowning occurs, the
labor nurse applies gentle pressure over the perineum and fetal head. The maneuver performed is
called:
a. Brandt-Andrew’s maneuver
b. McRobert’s maneuver
c. Schultz mechanism
d. Ritgen’s maneuver
24.The nurse is monitoring the condition of the postpartum client. As a part of the postpartum
adaptations, the nurse monitors for descent of the uterus and expects the fundus to be:
a. On the same level after delivery

b. Decreased by 1 cm/day
c. Decreased by 1.5 cm/day
d. Decreased by 2 cm/day
25.The granddaughter of the client asked the nurse if it is normal for elderly people to feel sleepy
despite sleeping for long hours. Which of the following conditions would the nurse suspect?
a. Somatoform Disorder
b. Malingering
c. Anxiety
d. Amnesia
26.Chemotherapy is one of the treatments for uterine cancer. The client asked the nurse how
chemotherapeutic drugs work. Which of the following statements will be the best explanation?
a. Chemotherapeutic agents alter molecular structure of DNA.

b. Chemotherapeutic agents hasten cell division.
c. Cancer cells are sensitive only to chemotherapeutic agents.
d. Chemotherapeutic agents act on all rapidly dividing cells.
27.Vomiting is one of the most common side effects of chemotherapy. The nurse should be aware of
which acid-base imbalance?
a. Ketoacidosis
b. Metabolic acidosis
c. Metabolic alkalosis
d. Respiratory alkalosis
28.The client develops a 2nd degree skin reaction from radiation therapy. The nurse should expect the
following symptoms EXCEPT:
a. The skin is scaly.

b. There is an itchy feeling.
c. There is dry desquamation present.
d. The skin is reddened.
29.The nurse is assessing the muscle coordination and mobility of the client with musculoskeletal
disorder. The nurse noted impulsive and brief muscle twitching of the face and the limbs. This finding is
called:
a. Tremor
b. Chorea
c. Athetosis
d. Dystonia
30.The nurse is assigned to render care to a client with altered mobility. Which of the following
statements is true regarding body mechanics when moving clients?
a. Stand at arm’s length from the working area.

b. Elevate adjustable beds to hip level.
c. Swivel the body when moving the client.
d. Move the client with wide base and straight knees.
Rationale:
1. Answer: A
Rationale:
Angina pectoris is a substernal pain that radiates to the neck, jaw, back and arms and
is relieved by rest. Lower abdominal pain may indicate other gastrointestinal problems.
2. Answer: A
Rationale:
50 mL/hr is the normal urine output. A normal urine output indicates that there is a
good renal perfusion, and also connotes that the client is hemodynamically stable,
therefore, the repair is successful.
3. Answer: A
Rationale:
In cardiac catheterization or coronary angiogram, a catheter is inserted into the heart

via a vein to measure the ventricular function. A dye is used to provide further
assessment of the structure and motion of the heart. Thallium is a radioactive isotope
injected parenterally so that the scintillation camera can count the radioactive uptake.
This is observed when a physician requests for a Nuclear Cardiology test. When
performing a Transesophageal Echocardiogram (TEE), a probe with a transducer tip is
swallowed by the client to visualize for valvular abnormalities, possible thrombus,
bacterial endocarditis and any congenital heart defects. When performing an
Intracoronary Ultrasound, a tiny ultrasound probe is inserted into the coronary artery to
evaluate for plaque size and consistency, arterial walls and effectiveness of the
treatment.
4. Answer: D
Rationale:
The central venous pressure is within the superior vena cava. The Normal CVP is 2-6
mmHg. A decrease in the CVP indicates a decrease in the circulating blood volume,
which may be a result of hemorrhage or fluid imbalances. The right atrium is located at
the midaxillary line at the fourth intercostal space, and the zero point on the transducer
needs to be at the level of the right atrium. The client needs to be supine, with the
head of the bed elevated at 45 degrees to correctly assess the CVP.
5. Answer: D
Rationale:
In hypokalemia, the electrocardiogram may show flattening and inversion of the T

wave, the appearance of a U wave, and ST depression. Hypercalcemia can cause a
shortened ST and widened T wave. The electrocardiogram of a hyperkalemic client
shows tall peak T waves, widened QRS complexes, prolonged PR intervals or flat P
waves.
6. Answer: A, B, E
Rationale:
Loading of drug depends on the type of dry powder inhaler. Take note that some dry
powder inhalers do not require loading. Dry powder inhalers are kept dry always and
are place at room temperature. Never shake a dry powder inhaler. It is not a
pressurized container. There is no propellant, only the client’s breath can pull the drug
in. Because the drug is a dry powder and there is no propellant, the client will not feel,
smell, or taste the drug during inhalation. The client’s breath will moisten the powder
causing it to clump and not be delivered accurately. Immediately after inhalation of
drug, the inhaler must be removed from the client’s mouth to prevent moisture.
7. Answer: C, D, E
Rationale:
Stripping is not allowed. Also when changing the drainage system or when checking air
leaks, clamp the chest tube for short periods only. Emptying of collection chamber or
changing the drainage system should be done before the drainage comes in contact
with the bottom of the tube. Avoid kinks and dependent loops to allow effective
drainage and prevent disrupting the system. Report excessive drainage that is cloudy or
red. Drainage will often increase with position changes or coughing.
Bubbling is expected and indicates air drainage from the client. Absence of bubbling
may mean that the chest tube is obstructed, the lungs have fully reexpanded and no
more air is leaking into the pleural space. Keep drainage system lower than the level of
the chest to allow effective drainage.
8. Answer: D
Rationale:
Sodium Bicarbonate should be slowly administered because fast infusion may result to
abrupt reduction of serum potassium level which can eventually lead to arrhythmias.
Diluting or mixing the drug with hypotonic solution (i.e. D5W) or isotonic solution
(0.9% NaCl) can be ordered but not with hypertonic solution (I.e D10W).
9. Answer: D
Rationale:
Loosening tight clothing, applying warm blanket to prevent heat loss, and administering
oxygen supply might help but is not the priority this time. Direct pressure over the
bleeding site is a priority to prevent shock but placing a tourniquet on the artery is done
by a surgeon. Because the client is showing signs of altered mental status, there is
likely less perfusion in the brain, which calls for fluid resuscitation. At least two IV
access allows administration of fluids – crystalloid, blood or clotting factors as
necessary which is vital in correcting acidosis, hypothermia and coagulopathy, and to
restore perfusion rapidly.
10. Answer: A
Rationale:
Cushing’s syndrome is clinically defined as the presence of excessive corticosteroids.
Addison’s disease is clinically defined as adrenocortical insufficiency. Hypothyroidism is
a condition wherein there is insufficient thyroid hormone produced by the thyroid
glands while SIADH is characterized by excessive release of anti-diuretic hormone.
11. Answer: C
Rationale:
Facial tremors will occur even without performing a specific maneuver. Exaggerated
reflexes such as hyperreflexia can be assessed by performing a different maneuver.
Gentle tapping of the area below the zygomatic bone just in front of the ear is used to
elicit Chvostek sign to assess the presence of hypocalcemia. Trousseau sign is
characterized by spasm of the muscles of the hand and forearm upon inflation of a BP
cuff on it.
12. Answer: A, B, C, D, E and F
Rationale:
The leaking of vesicant drugs into surrounding tissue causes local tissue damage like
delayed healing, tissue necrosis, disfigurement, loss of function and even amputation.
13. Answer: B, C, E
Rationale:
Manual stimulation is recommended to evacuate impacted stool. Having the client sit up
straight and raise his head so that he is looking ahead helps reduce the blood pressure
as it allows gravitational pooling of blood in the lower extremities. Constrictive clothing
may trigger an autonomic reaction that would cause the blood pressure to go up so this
must be removed. Manual compression or tapping the bladder to allow urine to flow
down the catheter should be avoided because this would trigger an increase in blood
pressure. Administration of prescribed vasodilators is done to reduce high blood
pressure.
14. Answer: D
Rationale:
Option A is ataxic breathing. Option B is apneustic breathing. Option C is central

neurogenic hyperventilation. Cheyne-stokes breathing respirations are a pattern of
breathing in which phases of hyperpnea regularly alternate with apnea in a crescendo-
decrescendo pattern.
15. Answer: D
Rationale:
The lowest possible score for any response is 1. If a client is unresponsive to painful
stimuli, the score is 1. A score lower than 8 indicates that the client is in a comatose
state. The highest score for the GCS is 15. A score of 15 indicates an alert and oriented
person. A score of 3-8 indicates severe head injury.
16. Answer: D
Rationale:
Helping the client maintain an exercise program is a therapeutic intervention to

maintain joint mobility and good body alignment. This will also prevent venous stasis
due to impaired mobility. Client encouragement will not only address the physical
aspect of the disease but the client’s emotions and self-esteem as well. The safety of
the client with impaired physical mobility should always be considered. Continuous
physical activity is not recommended. There should be an alternate period of activity
and rest to prevent excessive fatigue.
17. Answer: B
Rationale:
Receptive Aphasia refers to the inability to understand spoken words but can freely
express and verbalize. Expressive Aphasia refers to the inability to speak and
communicate formulated thoughts and sentiments. Global aphasia affects both
expressive ability and auditory comprehension. Apraxia is characterized by loss of the
ability to perform activities that a person is physically able and willing to do.
18. Answer: B
Rationale:
Graphesthesia is the ability to identify the writing on the skin even with the eyes
closed. The client provides a verbal response, identifying the figure that was drawn.
Option A is a test for stereognosis. Option C is a test used to assess the Romberg’s sign
while option D is a test for Kernig’s sign.
19. Answer: D
Rationale:
Any deterioration of oxygen saturation may necessitate intubation. However, the

priority this time is to maintain a patent airway. Infusion of IV fluids and administration
of antibiotics are expected nursing actions but not the top priority this time. Completing
vaccination at this time will not suffice or treat the underlying respiratory problem. The
situation calls for a curative management and not preventive measures. Airway closure
is the top priority. Throat examination is avoided as this increases the risk of laryngeal
obstruction. Aggression or agitation can also compromise airway and breathing.
20. Answer: B
Rationale:
Absorption is the process when the drug is transferred from the site of origin into the
bloodstream. Distribution occurs when the drug in the blood is distributed to different
parts of the body and accumulates in specific tissues. Metabolism or biotransformation
is the process wherein the drug is broken down into its inactive form. Excretion is the
body’s response to eliminate all the inactive form of the drug.
21. Answer: D
Rationale:
The Ventrogluteal site is safe for most intramuscular injections because it only involves
the gluteus medius and gluteus minimus muscles. The Vastus lateralis muscle is also a
safe injection site for intramuscular medications because there are no adjacent large
blood vessels and nerves. The deltoid muscle is a smaller muscle and is safe for
administration of intramuscular medications less than 1 mL. The Dorsogluteal muscle is
not recommended for intramuscular medications because of the potential damage to
the sciatic nerve. Large blood vessels are also located near the dorsogluteal muscle and
should be avoided.
22. Answer: B
Rationale:
Prescribing or stopping medications is the responsibility of the physician, thus the nurse
must refer this first. Thiazide diuretics cause loss of blood potassium while conserving
blood calcium, thus, the electrolyte level must be evaluated first.
23. Answer: D
The brandt-andrew maneuver is the proper extraction of the umbilical cord and
placenta. McRobert’s maneuver is performed in case of shoulder dystocia during
childbirth. The Schultz mechanism is used to describe placental delivery. The Ritgen’s
maneuver is performed by applying pressure over the perineum and counter-pressure
on the fetal head. The Ritgen’s maneuver controls the exit of the fetal head and
prevents severe damage to maternal tissues.
24. Answer: B
Rationale:
The uterine fundus should start to descend after 24 hours of delivery. The normal rate
of uterine descent is 1 cm/day.
25. Answer: B
Rationale:
In Somatoform Disorder, there is no real organ damage, but the client verbalizes
symptoms of a disease in an unconscious manner. In Malingering, verbalization of
symptoms of a disease is conscious and is used by the client to achieve a secondary
gain or benefit. Anxiety comes in many forms panic attacks, phobia, and social anxiety
and the distinction between a disorder and “normal” anxiety isn’t always clear. Amnesia
refers to the loss of memories, such as facts, information and experiences.
26. Answer: D
Rationale:
Not all chemotherapeutic agents alter the molecular structure of DNA. Chemotherapy
should slow down cell division not hasten it. All cells are sensitive to drug toxins.
Chemotherapeutic agents act on all rapidly dividing cells – most action of
chemotherapeutic agents is that it affects all rapidly dividing cells including the normal
and cancer cells.
27. Answer: C
Rationale:
Ketoacidosis is associated with high levels of ketone bodies in the body brought by
breakdown of fatty acids and is not related to vomiting. Metabolic acidosis happens
when the body produces excessive quantity of acid. Severe vomiting will result to loss
of HCL and acids coming from extracellular fluids which in turn lead to metabolic
alkalosis. Respiratory alkalosis occurs when there is an increased respiration which
elevates the blood pH beyond the normal range of 7.35-7.45.
28. Answer: D
Rationale:
2nd degree skin reactions are evident by scaly skin, an itchy feeling and dry
desquamation. Reddening of the skin is not seen in 2nd degree skin reaction.
29. Answer: B
Rationale:
Tremor is clinically defined as the rhythmic and repetitive muscle movement. Chorea is
clinically defined as brief and involuntary muscle twitching of the face or limbs which
hinders the client’s mobility. Athetosis is clinically defined as the presence of irregular
and slow twisting motions. Dystonia is similar to the definition of Athetosis but involves
larger muscle areas.
30. Answer: C
Rationale:
Standing close to the working area is a proper body mechanic to prevent muscle
fatigue. The nurse should adjust the bed to waist level in order to prevent stretching
and muscle strain. Proper body mechanic includes turning the body as a whole unit
when moving the client to avoid twisting the back. The knees are bent to support the
body’s center of gravity and maintain body balance. Bending the knees will provide a
wider base of support for effective leverage and use of energy.
HAAD QUESTIONS (2018)
Question No : 1 –
An elderly patient is admitted to the hospital with swollen ankles. The best way to limit
edema of the feet is for the nurse to:
 A. Restrict fluids
 B. Apply bandages
 C. Elevate the legs
 D. Do passive range of motion exercises (ROM)
Answer : C
Question No : 2 –
Which of the following actions is the most effective measure to reduce hospital acquired
infections?
 A. Double bagging of all contaminated laundry

 B. Restricting visitors of infectious patients
 C. Using disposable supplies
 D. Correct hand washing
Answer : D
Question No : 3 –
A patient is diagnosed with diabetic ketoacidosis. The nurse would expect the physician
to
prescribe:
 A. Regular insulin IV
 B. NPH insulin SC
 C. Glucagon IM
 D. Mixed insulin SC
Answer : A
Question No : 4 –
The rationale for having the patient void before an abdominal paracentesis procedure is
to:
 A. Minimize discomfort
 B. Avoid abdominal distention
 C. Prevent bladder puncture
 D. Reduce infection rate
Answer : C
Question No : 5 –
An 85-year-old man is admitted with dementia. He continuously attempts to remove his

nasogastric tube. The nurse applies cloth wrist restraints as ordered. Which of the
following
actions by the nurse is most appropriate?
 A. Evaluate the need to restrain by observing patient’s behavior once every 24 hrs
 B. Perform circulation checks to the extremities every two hours
 C. Remove the restraints when the patient is sleeping
 D. Instruct family to limit physical contact with the patient
Answer : B
Question No : 6 –
During balloon inflation of an indwelling urinary catheter, the patient complains of pain
and
discomfort. The nurse should:
 A. Continue the procedure and assure the patient

 B. Aspirate the fluid and remove the catheter
 C. Withdraw the fluid and reinsert the catheter
 D. Decrease the amount of injected fluid and secure
Answer : C
Question No : 7 –
A patient is to receive 25mg/hr of an aminophylline infusion. The solution prepared by

the
pharmacy contains 500mg of aminophylline in 1000ml of D5W. How many milligrams
are
available per ml?
 A. 0.25 mg/ml
 B. 0.5 mg/ml
 C. 1 mg/ml
 D. 2 mg/ml
Answer : B
Question No : 8 –
A patient has had a total hip joint replacement. Which of the following actions should
the
nurse consider for the patient’s daily recommended exercise program?
 A. Administering an analgesic before exercising

 B. Discontinuing the program if the patient dislikes it
 C. Continuing exercises inspire of severe pain
 D. Evaluating effectiveness of exercise based on pain scaleAnswer : A
Question No : 9 –
Whilst recovering from surgery a patient develops deep vein thrombosis. The sign that
would indicate this complication to the nurse would be:
 A. Intermittent claudication
 B. Pitting edema of the area
 C. Severe pain when raising the legs
 D. Localized warmth and tenderness of the site
Answer : D
Question No : 10 –
Which of the following techniques should the nurse implement to prevent the patient’s
mucous membranes from drying when the oxygen flow rate is higher than 4 liters per
minute?
 A. Use a non rebreather mask

 B. Add humidity to the delivery system
 C. Use a high flow oxygen delivery system
 D. Ensure that the prongs are in the nares correctly
Answer : B
Extrapyramidal adverse effects and symptoms are most often associated with which of
the
following drug classes?
 A. Antidepressants
 B. Antipsychotics
 C. Antihypertensives
 D. Antidysrhythmics
Answer : B
A construction worker was brought to the emergency department and admitted with the
diagnosis of heat stroke due to strenuous physical activity during hot weather
conditions.
Which action should the nurse take?
 A. Immediately immerse the patient in cold water to reduce the patient’s temperature
 B. Administer an antipyretic such as aspirin or acetaminophen
 C. Place ice packs to the neck, axillae, scalp and groin
 D. Encourage foods and oral fluids that contain carbohydrates and electrolytesAnswer
:C
The nurse should observe for which of the following symptoms in a patient who has just
undergone a total thyroidectomy:
 A. Weight gain
 B. Depressed reflexes
 C. Muscle spasm and twitching
 D. Irritable behavior
Answer : C
Which of the following indicates the nurse is engaging in a therapeutic nurse-patient

relationship?
 A. The nurse establishes a relationship that is mutually beneficial

 B. The nurse demonstrates sympathetic feelings toward the patient
 C. The nurse commits to helping the patient find ways to help self
 D. The nurse utilizes therapeutic touch to convey acceptance of the patient
Answer : C
One factor affecting the pharmokinetics of older patients’ drug absorption is:
 A. Decreased gastrointestinal motility

 B. A difficulty in swallowing
 C. A prevalence of obesity
 D. Numerous medications
Answer : A
Pain management for terminally ill patients is most effective when analgesics are given:
 A. Around the clock

 B. Only when clearly needed
 C. After non-pharmacological methods fail
 D. As the patient requests them
Answer : A
The physician orders 20 u of U-100 regular insulin. The only syringe on hand is a 1 ml
tuberculin syringe. How many milliliters should be administered?
 A. 0.02 ml
 B. 0.2 ml
 C. 1 ml
 D. 2 ml
Answer : B
The urinary catheter is kept securely in the bladder by:
 A. Taping the urinary catheter to the leg

 B. Securing catheter and collection bag connections
 C. Inflating the balloon of the catheter
 D. Anchoring the catheter bag to the bed
Answer : C
Order: Compazine 8 mg IM stat. Drug availablE.10 mg/ 2mL in vial.

How many mLs would you give?
 A. 0.6 mL
 B. 1.6 mL
 C. 2.6 mL
 D. 3.6 mL
Answer : B
A medication was ordered by a physician. The nurse believes the medication dose is
incorrect. What should the nurse do next?
 A. Clarify the order with another physician who is available on the unit
 B. Ask the nurse in charge if the order is correct
 C. Contact the pharmacy department
 D. Call the physician who prescribed the medication
Answer : D
The immediate treatment for ventricular fibrillation is:
 A. Precordial blow
 B. Defibrillation
 C. Bolus of lidocaine
 D. Ventricular pacing
Answer : B
A patient requires tracheal suctioning through the nose. Which of the following nursing
action would be incorrect?
 A. Lubricating the catheter with sterile water

 B. Applying suction while withdrawing the catheter from the nose
 C. Applying suction for a minimum of 30 seconds
 D. Rotating the catheter while withdrawing it
Answer : C
Thirty minutes after starting a blood transfusion a patient develops tachycardia and
tachypnea and complains of chills and low back pain. The nurse recognizes these
symptoms as characteristic of:
 A. Circulatory overload
 B. Mild allergy
 C. Febrile response
 D. Hemolytic reaction
Answer : D
To remove soft contact lenses from the eyes of an unconscious patient the nurse should:
 A. Uses a small suction cup placed on the lenses

 B. Pinches the lens off the eye then slides it off the cornea
 C. Lifts the lenses with a dry cotton ball that adheres to the lenses
 D. Tenses the lateral canthus while stimulating a blink reflex by the patient
Answer : B
Order: 1000 ml of D5W to run for 12 hours. Using a micro drip set calculate the drops
per
minute (gtts/min):
 A. 20 gtts/min
 B. 45 gtts/min
 C. 60 gtts/min
 D. 83 gtts/min
Answer : D
Which of the following tasks requires specialized education and should be performed by
the nurse only after the training has been completed?
 A. Administering a dose of promethazine (Phenergan) via intravenous push (IVP)

 B. Applying a transdermal fentanyl (Duragesic)
 C. Instilling tobramycin (Tobrex) ophthalmic solution
 D. Beginning an intravenous infusion of cyclophosphamide (Cytoxan)
Answer : D
The patient is to receive 100 ml/hr of D5W through a micro drip. How many drops per
minute should the patient receive?
 A. 25 gtts/min
 B. 30 gtts/min
 C. 100 gtts/min
 D. 200 gtts/min
Answer : C
Immediately after a craniotomy for head trauma, the nurse must monitor the drainage
on
the dressing. Which of the following should be reported?
 A. Blood tinged
 B. Straw colored
 C. Clotted
 D. Foul-smelling
Answer : B
Which of the following interventions should the nurse implement if a patient complains
of
cramps while irrigating the colostomy?
 A. Reduce the flow of solution

 B. Have the patient sit up in bed
 C. Remove the irrigation tube
 D. Insert the tube further into the colon
Answer : A
A nurse is not familiar with a particular solution ordered to irrigate a patient’s wound.
The
appropriate action would be to:
 A. Check if the solution is available on the ward, and if so, use it to clean the wound
 B. Put a neat line through the order and re-write the solution more commonly used
 C. Check with the Pharmacist about the uses of the solution ordered
 D. Ask the patient what solution he would prefer to be used
Answer : C
A 65-year-old patient is admitted with ischemic stroke. Which of the following would be
initially assessed by the nurse to determine the patients level of consciousness?
 A. Visual fields
 B. Deep tendon reflexes
 C. Auditory acuity
 D. Verbal response
Answer : D
While preparing for a kidney biopsy the nurse should position the patient:
 A. Prone with a sandbag under the abdomen

 B. Lateral opposite to biopsy site
 C. Supine in bed with knee flexion
 D. Lateral flexed knee-chest
Answer : A
To promote accuracy of self-monitoring blood glucose by patients the nurse should:
 A. Retrain patients periodically

 B. Direct patients to rotate testing sites
 C. Advise patients to buy new strips routinely
 D. Compare results from patient’s meter against lab results
Answer : A
After administration of penicillin, a patient develops respiratory distress and severe
bronchospasm. The nurse should:
 A. Contact the physician

 B. Apply ice packs to the axilla
 C. Assess the patient for orthostatic hypotension
 D. Encourage the patient to take slow deep breaths
Answer : A
The administration of which of the following types of parenteral fluids would result in a
lowering of the osmotic pressure and cause the fluid to move into the cells?
 A. Hypotonic
 B. Isotonic
 C. Hypertonic
 D. Colloid
Answer : A
A newborn infant is assessed using the Apgar assessment tool and scores 6. The infant
has a heart rate of 95, slow and irregular respiratory effort, and some flexion of
extremities.
The infant is pink, but has a weak cry. The nurse should know that this Apgar score
along
with the additional symptoms indicates the neonate is:
 A. Functioning normally
 B. Needing immediate life-sustaining measures
 C. Needing special assistance
 D. Needing to be warmed
Answer : C
Nursing management of the patient with external otitis includes:
 A. Irrigating the ear canal with warm saline several hours after instilling lubricating ear
drops
 B. Inserting an ear wick into the external canal before instilling the ear drops to disperse
the medication
 C. Teaching the patient how to instill antibiotic drops into the ear canal before
swimming
 D. Instilling ear drops without the dropper touching the auricle and positioning the ear
upward for 2 minutes afterwards
Answer : D
The best example of documentation of patient teaching regarding wound care is:
 A. “The patient was instructed about care of wound and dressing changes”
 B. “The patient demonstrated correct technique of wound care following instruction”
 C. “The patient and family verbalize that they understand the purposes of wound care”
 D. “Written instructions regarding wound care and dressing changes were given to the
patient”
Answer : B
A patient is ordered 75mg of pethidine which comes in an ampoule of 100mg/2ml. What

would the nurse do with the remaining pethidine after drawing up the required dose?
 A. Lock up the remaining dose in the medication cupboard to use later

 B. Ask a fellow staff nurse to witness the disposal of the remaining drug
 C. Use the remaining dose within 2 hours for another patient
 D. Pour the remaining dose down the nearest sink
Answer : B
A nurse can ensure she maintains her competency to practice through:
 A. Being involved in continuing education programs

 B. Making sure that what was learnt at nursing school is strictly followed
 C. Closely carrying out instructions given by the Charge Nurse
 D. Working on the same ward for at least 2 years
Answer : A
The patient with liver cirrhosis receives 100 ml of 25% serum albumin intravenously.
Which
of the following findings would best indicate that the albumin is having its desired
effect?
 A. Decreased blood pressure

 B. Increased serum albumin level
 C. Increased urine output
 D. Improved breathing pattern
Answer : C
The nurse should suspect that a patient has bleeding in the upper gastrointestinal tract
when the color of the patient’s stool is:
 A. Yellow
 B. Black
 C. Clay
 D. Red
Answer : B
A registered nurse delegates care to a practical nurse. The person most responsible for
the
safe performance of the care is the:
 A. Head nurse who is in-charge of the unit

 B. The practical nurse assigned to provide the care
 C. The registered nurse who delegated the care to the practical nurse
 D. The nursing care coordinator who is the supervisor of the unit
Answer : C
A deficiency of which of the following vitamins can affect the absorption of calcium?
 A. Vitamin C
 B. Vitamin B6
 C. Vitamin D
 D. Vitamin B12
Answer : C
A patient with a central venous line develops sudden clinical manifestations that include
a
decrease in blood pressure, an elevated heart rate, cyanosis, tachypnea, and changes in
mental status. Which of the following is the most likely cause of these symptoms?
 A. An air embolism
 B. Circulatory overload
 C. Venous thrombosis
 D. Developing bacteremia
Answer : A
When taking routine post-operative observations on a patient who underwent an

exploratory laparotomy, the nurse plans to monitor which important finding over the
next
hour?
 A. Serosanguinous drainage on the surgical dressing

 B. Blood pressure of 105/65 mmHg
 C. Urinary output of 20 mls in the last hour
 D. Temperature of 37.6 °C
Answer : C
When the nurse is caring for a patient placed on droplet precautions, the nurse should:
 A. Have the patient wear a high-efficiency particulate air (HEPA) mask

 B. Wear a surgical mask when standing within 3 feet (1 meter) of the patient
 C. Assign the patient to a room with monitored negative air pressure
 D. Apply a disposable gown when entering the patient’s room
Answer : B
A patient who has just had a miscarriage at 8 weeks of gestation is admitted to hospital.
In
caring for this patient, the nurse should be alert for signs of:
 A. Dehydration
 B. Subinvolution
 C. Hemorrhage
 D. Hypertension
Answer : C
Collection urine bag should be emptied as necessary and at least every 8 – 9 hours to
prevent:
 A. Pooling of urine in the tube

 B. Reflux of urine into the bladder
 C. Pulling on catheter
 D. Bacterial contamination
Answer : D
Which of the following statements accurately describes the occurrence of dyspnea in

patients who are receiving end of life care?
 A. Dyspnea is only experienced by patients who have primary diagnoses that involve the
lungs
 B. Dyspnea occurs in less than 50% of the patients who are receiving end of life care
 C. Dyspnea that is caused by increased fluid volume may be improved by diuretics
 D. Dyspnea may be caused by antibiotic therapy used over a long period of time
Answer : C
The patient has a nursing diagnosis of altered cerebral tissue perfusion related to
cerebral
edema. An appropriate nursing intervention for this problem is to:
 A. Elevate the head of the bed 30 degrees

 B. Provide a position of comfort with knee flexion
 C. Provide uninterrupted periods of rest
 D. Ensure adequate hydration with mannitol
Answer : A
While assessing a patient, the nurse learns that he has a history of allergic rhinitis,
asthma,
and multiple food allergies. The nurse must:
 A. Be alert to hypersensitivity response to the prescribed medications

 B. Encourages the patient to carry an epinephrine kit in case of an allergic reaction
 C. Advise the patient to use aspirin in case of febrile illnesses
 D. Admit the patient to a single room with limited exposure to health care personnel
Answer : A
The nurse should administer nasogastric tube (NGT) feeding slowly to reduce the
hazard
of:
 A. Distention
 B. Abdominal cramps
 C. Diarrhea
 D. Regurgitation
Answer : A
A patient arrived to the Post Anesthesia Care Unit (PACU) complaining of pain after
undergoing a right total hip arthroplasty. Which of the following should the nurse do to
assess the patient’s level of pain?
 A. Determine the patient’s position during surgery and how long the patient was in this
position
 B. Inspect the dressing, note type and amount of drainage, and insure bandage adhesive
is not pulling on skin
 C. Ask anesthesiologist what type of anesthesia patient received and last dose of pain
medication
 D. Note location, intensity and duration of pain and last dose and time of pain
medication
Answer : D
When caring for a patient with impaired mobility that occurred as a result of a stroke
(right
sided arm and leg weakness). The nurse would suggest that the patient use which of the
following assistive devices that would provide the best stability for ambulating?
 A. Crutches
 B. Single straight-legged cane
 C. Quad cane
 D. Walker
Answer : C
The nurse teaches a patient recovering from a total hip replacement that it is important
to
avoid:
 A. Putting a pillow between the legs while sleeping

 B. Sitting with the legs crossed
 C. Abduction exercises of the affected leg
 D. Bearing weight exercises on the affected leg for 6 weeks
Answer : B
A patient with duodenal peptic ulcer would describe his pain as:
 A. Generalized burning sensation

 B. Intermittent colicky pain
 C. Gnawing sensation relieved by food
 D. Colicky pain intensified by food
Answer : C
You have started work on a new ward. One of the patient’s allocated to you has been on
the ward for the last 7 months since she had a cerebrovascular accident (CVA). You
notice
that her nursing care plan says strict bed rest, but on assessment you can not see any
reason why this patient can not sit out of bed for short periods. Your nursing action
would
be:
 A. Check with the other nursing staff as to reasons behind the nursing care plan then
update the plan based on your assessment
 B. Follow the nursing care plan strictly as this would have been developed after a
detailed and collaborative assessment
 C. Seek physician’s orders so that you have permission to move the patient
 D. Try and move the patient without consulting with anyone to see how she manages
Answer : A
A nurse prepares a narcotic analgesic for administration, but the patient refuses to take
it.
Which of the following actions by the nurse is most appropriate?
 A. Encourage the patient to reconsider taking the medication
 B. Label the medication and replace it for use at a later time
 C. Discard the medication in the presence of a witness and chart the action
 D. Call the physician with the patient’s refusal to take the prescribed medication
Answer : C
A patient who sustained a chest injury has a chest tube inserted which is connected to an
under water seal drainage system. When caring for this patient the nurse will:
 A. Instruct the patient to limit movement of the affected shoulder

 B. Observe for fluctuation of the water level
 C. Clamp the tube when needed
 D. Administer hourly analgesia
Answer : B
Which of the following laboratory blood values is expected to be decreased in hepatic

dysfunction?
 A. Albumin
 B. Bilirubin
 C. Ammonia
 D. ALT and AST
Answer : A
A patient with allergic rhinitis reports severe nasal congestion, sneezing, and watery
eyes
at various times of the year. To teach the patient to control these symptoms the nurse
advises the patient to:
 A. Avoid all over the counter intranasal sprays

 B. Limit the use of nasal decongestant sprays to 10 days
 C. Use oral decongestants at bedtime to prevent symptoms during the night
 D. Keep a diary of when an allergic reaction occurs and what precipitates it
Answer : D
The apical pulse can be best auscultated at the:
 A. Left 2nd intercostal space lateral to the mid clavicular line

 B. Left 2nd intercostal space at the left sternal border
 C. Left 5th intercostal space at the mid clavicular line
 D. Left 5th intercostal space at the mid axillary line
Answer : C
The nurse notes that there are no physician’s orders regarding Fatima’s post operative
daily insulin dose. The most appropriate action by the nurse is to:
 A. Withhold any insulin dose since none is ordered and the patient is NPO
 B. Call the physician to clarify whether insulin should be given and at what dose
 C. Give half the usual daily insulin dose since she will not be eating in the morning
 D. Give the patient her usual daily insulin dose since the stress of surgery will increase
her blood glucose
Answer : B
An 8-month-old infant is diagnosed with communicating hydrocephalus. The nurse
notices
that his intracranial pressure is increasing from the following changes in his vital signs:
 A. Bradycardia, hypotension and hypothermia

 B. Bradycardia, hypertension and hyperthermia
 C. Tachycardia, hypotension and hyperthermia
 D. Tachycardia, hypertension and hypothermia
Answer : B
Whenever a child with thalassemia comes for blood transfusion, he is administered

Desferoxamine (Desferal). The action of this drug is to:
 A. Inhibit the inflammatory process

 B. Enhance iron excretion
 C. Antagonize the effect of vitamin C
 D. Increase red blood cell production
Answer : B
A patient becomes angry and threatens to leave the hospital unless the physician reviews
the reason for the patient’s delay in discharge. The patient has a medication order for
agitation available p.m..but refuses the medication and requests a drink of orange juice
instead. What should the nurse do?
 A. Secretly slip the p.r.n. medication into the orange juice and give it to the patient
 B. Give the patient the orange juice and tell the patient that a staff member is attempting
to call the physician
 C. Inform the patient that staff is unable to force anyone to stay in the hospital
 D. Inform the patient that nothing can be done until the morning
Answer : B
A nurse prepares to set up a secondary intravenous (IV) cannula. The primary IV

infusing
is normal saline. In order for the secondary cannula to infuse correctly, the nurse should
set
up the primary IV to:
 A. Hang higher than the secondary IV

 B. Hang at the same level as the secondary IV
 C. Hang lower than the secondary IV
 D. Discontinue before the secondary IV starts
Answer : C
A 21 year old woman is being treated for injuries sustained in a car accident. The patient
has a central venous pressure (CVP) line insitu. The nurse recognizes that CVP
measurements:
 A. Estimate Cardiac output

 B. Assess myocardial workload
 C. Determine need for fluid replacement
 D. Determine ventilation – perfusion mismatch
Answer : C
After application of a cast in the upper extremity, the patient complains of severe pain in
the
affected site. Which of the following would the nurse initiate?
 A. Administer analgesics as ordered

 B. Assess neurovascular status
 C. Notify his physician
 D. Pad the edges of the cast
Answer : B
The best dietary advice a nurse can give to a woman diagnosed with mild pregnancy-
induced hypertension is to:
 A. Follow a strict low salt diet

 B. Restrict fluid intake
 C. Increase protein intake
 D. Maintain a well-balanced diet
Answer : D
A nurse is making rounds taking vital signs. Which of the following vital signs is
abnormal?
 A. 11 year old male – 90 b.p.m, 22 resp/min. , 100/70 mm Hg

 B. 13 year old female – 105 b.p.m., 22 resp/min., 105/60 mm Hg
 C. 5 year old male- 102 b.p.m, 24 resp/min., 90/65 mm Hg
 D. 6 year old female- 100 b.p.m., 26 resp/min., 90/70mm Hg
Answer : B
Which of the following actions is the most appropriate when the nurse is responding to a
patient during a tonic-clonic seizure?
 A. Restrain the patient
 B. Protect the patient from harm
 C. Minimize noise and light stimulus
 D. Apply oxygen by mask or nasal cannula
Answer : B
The patient’s pre-operative blood pressure was 120/68 mmHg. On admission to the Post
Anesthesia Care Unit, the blood pressure was 124/70 mmHg. Thirty minutes after
admission, the patient’s blood pressure falls to 112/60 mmHg, pulse to 72 BPM, and the
skin appears warm and dry. The most appropriate action by the nurse at this time is to:
 A. Raise the head of the bed

 B. Notify the anesthetist immediately
 C. Increase the rate of IV fluid replacement
 D. Continue to monitor the patient
Answer : D
An 84-year-old man has arthritis and is admitted for a severely edematous knee. The
physician orders heat packs every 2 hours and you feel this order may worsen the tissue
congestion. An appropriate nursing action would be:
 A. Contact the physician and discuss your concerns about the order
 B. To include the order in the nursing care plan and monitor outcome
 C. Complete an incident report form and document concerns in the nursing notes
 D. Involve the patient by asking what his treatment preference is
Answer : A
The nurse plans the care for a patient with increased intracranial pressure, she knows
that
the best way to position the patient is to:
 A. Keep patient in a supine position until stable

 B. Elevate the head of the bed to 30 degrees
 C. Maintain patient on right side with head supported on a pillow
 D. Keep patient in a semi-sitting position
Answer : B
The coronary care nurse draws an Arterial Blood Gas (ABG) sample to assess a patient
for
acidosis. A normal pH for arterial blood is:
 A. 7.0 – 7.24
 B. 7.25 – 7.34
 C. 7.35 – 7.45
 D. 7.5 – 7.6
Answer : C
A patient voided a urine specimen at 9:00 AM. The specimen should be sent to the
laboratory before:
 A. 9:30 AM
 B. 10:00 AM
 C. 10:30 AM
 D. 11:00 AM
Answer : A
Which of the following correctly describes wound packing in a wet to dry dressing?
 A. Pack gauze into the wound tightly

 B. Overlap the wound edges with wet packing
 C. Pack the wound with slightly moistened gauze
 D. Use gauze well saturated with saline for packing the wound
Answer : C
To prevent post-operative thrombophlebitis, which one of the following measures is

effective?
 A. Elevation of the leg on two pillows

 B. Using of compression stocking at night
 C. Massage the calf muscle frequently
 D. Performing leg exercises
Answer : D
The mother of a child with nephrotic syndrome asks why her child must be weighed
each
morning. The nurse’s response should be based on the fact that this is important to
determine the:
 A. Nutritional status
 B. Water retention
 C. Medication doses
 D. Blood volume
Answer : B
When caring for a patient with hepatic encephalopathy the nurse may carry out the
following orders: give enemas, provide a low protein diet, and limit physical activities.
These measures are performed to:
 A. Minimize edema
 B. Decrease portal pressure
 C. Reduce hyperkalemia
 D. Decrease serum ammonia
Answer : D
A patient is to receive 2.5mg of morphine sulfate. The ampoule contains l000mcg/mL.

How
much morphine should the nurse administer?
 A. 0.25 ml
 B. 1 ml
 C. 1.5 ml
 D. 2.5 ml
Answer : D
When the post-operative patient returns to the surgical unit, the priority is to:
 A. Assess the patient’s pain

 B. Measure the patient’s vital signs
 C. Monitor the rate of the IV infusion
 D. Check the physician’s post-operative orders
Answer : B
While preparing the midday medications, the nurse finds difficulty reading the label on
a
medicine bottle. The best action by the nurse is to:
 A. Document that it could not be given due to difficulty in reading the label
 B. Make out a new label with clear handwriting using adhesive tape to attach it
 C. Ask the pharmacist to replace it with a clearly labeled bottle
 D. Give the medication if it is similar to a bottle present on the trolley
Answer : C
To ensure safe practice during defibrillation, the nurse must:
 A. Cover paddles with electrode gel

 B. Avoid touching the patient’s bed
 C. Remove paddles after the shock
 D. Synchronize prior to shock delivery
Answer : B
The physician orders heparin 40 000 U in 1 liter of D5W IV to infuse at 1000 U/hr.
What is
the flow rate in milliliters per hour?
 A. 250 mls/hr
 B. 25 mls/hr
 C. 2.5 mls/hr
 D. 0.25 mls/hr
Answer : B
What two behaviors are important when documenting the depth of the patients
depression?
 A. Orientation and appearance

 B. Helplessness and hopelessness
 C. Affect and thought processes
 D. Mood and impulse control
Answer : B
The nurse knows that the greatest risk for a patient with a ruptured ectopic pregnancy
is:
 A. Hemorrhage leading to hypovolemic shock

 B. Strictures and scarring of the fallopian tube
 C. Adhesions and scarring from blood in the abdomen
 D. Infertility resulting from treatment with a salpingectomy
Answer : A
The nurse manager has just prepared a medication for a patient and she asked you to
give
the medication. Which of the following is the best response to the nurse manager’s
request?
 A. Give the patient his medication and record it on the chart

 B. Ask another nursing colleague to give and record the medication
 C. Explain that you cannot give a medication that you did not prepare
 D. Give the medication and ask the nurse manager to record it on the chart
Answer : C
A patient presents to the emergency department with diminished and thready pulses,
hypotension and an increased pulse rate. The patient reports weight loss, lethargy, and
decreased urine output. The lab work reveals increased urine specific gravity. The nurse
should suspect:
 A. Renal failure
 B. Sepsis
 C. Pneumonia
 D. Dehydration
Answer : D
A patient is to receive 50mL of fluid in 1/2 hour (30 min). The infusion pump should be
set
to deliver how many milliters per hour?
 A. 25 ml/hr
 B. 50 ml/hr
 C. 75 ml/hr
 D. 100 ml/hr
Answer : D
A patient with a history of angina pectoris arrives in emergency complaining of

headache,
visual disturbances and feeling dizzy. Your nursing assessment also notes he looks
flushed, is perspiring perfusely and is experiencing palpitations. You should suspect:
 A. An overdose of sublingual nitroglycerin

 B. The onset of a myocardial infarction
 C. The patient has been over exercising
 D. The beginning of a severe chest infection
Answer : A
The purpose of a cardiac pacemaker is to:
 A. Initiate and maintain the heart rate when SA node is unable to do so

 B. Stabilize the heart rate when it is above 100 beats per minute
 C. Stabilize the heart when the patient has had a heart attack
 D. Regulate the heart when the patient is going for open heart surgery
Answer : A
A nurse has been working in a general hospital on the same medical unit for 6 years. The
Behavioral Unit is desperately short staffed and the nurse is asked to work her shift in
this
other unit. What would be the expected response of the nurse to this request?
 A. “I will go to the unit and hopefully the behavioral health staff members will assist me
with my assignment.”
 B. “I cannot go. I have no previous behavioral health experience. I do not want to reduce
the quality of patient care.”
 C. “I have no previous behavioral health experience. I am willing to go and help with any
duties that are similar to those I perform on my unit.”
 D. “I should not be expected to float to another unit without a proper orientation. I will
fill out an incident report if I am sent there.”
Answer : C
Order: Allopurinol 450 mg p.o. daily. Drug availablE.Allopurinol 300 mg scored tablets.
Which of the following will you administer?
 A. 0.5 tablet
 B. 1.5 tablets
 C. 2 tablets
 D. 2.5 tablets
Answer : B
The correct way to trim the toe nails of a patient with diabetes is to:
 A. Cut the nails in a curve and then file

 B. Cut the nails straight across and then file
 C. File the nails straight across and square only
 D. File the nails in a curved arch with low sides only
Answer : C
A patient complains of pain in his right arm. The physician orders codeine 45 mg and
aspirin 650 mgs every 4 hours PRN. Each codeine tablet contains 15mg of codeine and
each aspirin tablet contains 325mg of aspirin. What should the nurse administer?
 A. 2 codeine tablets and 4 aspirin tablets

 B. 4 codeine tablets and 3 ½ aspirin tablets
 C. 3 codeine tablets and 2 aspirin tablets
 D. 3 codeine tablets and 3 aspirin tablets
Answer : C
During the acute phase of a cerebrovascular accident (CVA) the nurse should maintain
the
patient in which of the following positions?
 A. Semi-prone with the head of the bed elevated 60-90 degrees

 B. Lateral, with the head of the bed flat
 C. Prone, with the head of the bed flat
 D. Supine, with the head of the bed elevated 30-45 degrees
Answer : D
A patient on diuretics has had vomiting and diarrhea for the past 3 days. Which of the
following is this patient most at risk for developing?
 A. Hypokalemia and cardiac arrhythmias

 B. Hypercalcemia and polyuria
 C. Dehydration and hyperglycemia
 D. Hyperalimentation and heart block
Answer : A
A patient admitted to the hospital in hypertensive crisis is ordered to receive hydralazine
(Apresoline) 20mg IV stat for blood pressure greater than 190/100 mmHg. The best
response of the nurse to this order is to:
 A. Give the dose immediately and once

 B. Give medication if patient’s blood pressure is > 190/100 mmHg
 C. Call the physician because the order is not clear
 D. Administer the dose and repeat as necessary
Answer : A
Which of the following is the most appropriate first action for the nurse to take for a pre-
schooler who has fallen and has a hematoma formed on the temporal bone?
 A. Encourage a nap
 B. Give pain medication
 C. Apply ice and monitor vital signs
 D. Allow the child to continue activities
Answer : C
The minimal amount of urine that a post-operative patient weighing 60 kgs should pass
is?
 A. 120 ml/hr
 B. 90 ml/hr
 C. 60 ml/hr
 D. 30 ml/hr
Answer : D
You are the nurse providing post-operative care for a 9 year old boy who is 6 hours post-
tonsillectomy. He is sleeping, but on routine observation you notice that his pulse has
increased, he seems to be restless and trying to swallow frequently. Your immediate
action
would be:
 A. Apply an ice collar to reduce discomfort

 B. Allow child to keep sleeping and record observations
 C. Wake him and offer some ice chips to suck
 D. Check inside his mouth for any signs of bleeding and notify the physician
Answer : D
When inserting a rectal suppository for a patient the nurse should?
 A. Insert the suppository while the patient performs the ‘valsava maneuver’
 B. Place the patient in a supine position
 C. Position the suppository beyond the muscle sphincter of the rectum
 D. Insert the suppository 1/2 inch into the rectum
question_answerVIEW ANSWER
Answer : C
A patient with pneumonia is coughing up purulent thick sputum. Which one of the
following
nursing measures is most likely helpful to loosen the secretions?
 A. Postural drainage
 B. Breathing humidified air
 C. Percussion over the affected lung
 D. Coughing and deep breathing exercises
Answer : B
A patient is admitted to a hospital with acute renal failure. The patient wakes up
complaining of abdominal pain. On assessment, the nurse observes edema to the
patient’s
ankles and distended neck veins. The patient is dyspneic with a blood pressure of
200/96
mmHg. The proper nursing diagnosis for this patient is:
 A. Deficient fluid volume related to disease process

 B. Excess fluid volume related to decreased glomerular filtration rate
 C. Knowledge deficit related to proper medication regimen
 D. Acute pain related to renal edema
Answer : B
A patient arrives at the emergency department with slurred speech and a right facial
droop.
The patient’s relative states the patient “is not himself.” Upon assessment, the nurse
finds
paresthesia to the right side of the body, receptive aphasia, hemianopia and altered
cognitive abilities. The nurse should suspect:
 A. A narcotic overdose
 B. Parkinson’s disease
 C. Alcohol withdrawal
 D. A cerebrovascular accident (CVA)
Answer : D
The nurse is preparing teaching plans for several patients. The nurse should recognize
which of the following patients is at greatest risk for fluid and electrolyte imbalance?
 A. A 2-year-old patient who is receiving gastrostomy feedings

 B. A 20-year-old patient with a sigmoid colostomy
 C. A 40-year-old patient who is 3 days post-operative with an ileostomy
 D. A 60-year-old patient who is 8 hours post-renal arteriography
Answer : C
A 3-month-old infant is admitted with a diagnosis of ventricular septal defect. The

physical
assessment for this infant would reveal:
 A. High pitched cry

 B. Harsh heart murmur
 C. Bradycardia
 D. Hypertension
Answer : B
A young patient is extremely irritable due to meningitis. It would be most important for
the
nurse to:
 A. Use low-level lighting in the room

 B. Ventilate the room
 C. Eliminate strong odors
 D. Allow frequent visitors
Answer : A
A male patient with a right pleural effusion noted on a chest X-ray is being prepared for
thoracentesis. The patient experiences severe dizziness when sitting upright. To provide
a
safe environment, the nurse assists the patient to which position for the procedure?
 A. Prone with head turned toward the side supported by a pillow

 B. Sims’ position with the head of the bed flat
 C. Right side-lying with the head of the bed elevated 45 degrees
 D. Left side-lying with the head of the bed elevated 45 degrees
Answer : D
A newborn is diagnosed with ventricular septal defect. The baby is discharged with a
prescription for digoxin syrup 20 micrograms bid. The bottle of digoxin is labeled as
0.05
mg/ml. The nurse should teach the mother to administer on each dose:
 A. 0.1 ml
 B. 0.2 ml
 C. 0.4 ml
 D. 0.8 ml
Answer : C
As a part of the treatment given to a child with leukemia the child is placed on reverse
barrier isolation to:
 A. Protect the child from injury

 B. Protect the child from infectious agents
 C. Provide the child with a quiet environment
 D. Keep the child away from other children
Answer : B
The nurse should be aware that tetracycline is contraindicated in children under 12

years of
age because:
 A. Minimal doses are needed to control infection

 B. Immunosuppression is a common side effect
 C. Staining of the teeth is an adverse effect
 D. They are prone to develop renal failure
Answer : C
When caring for a patient with acute pancreatitis, the patient is most likely to complain
of
pain which is:
 A. Severe and located in the left lower quadrant and radiating to the groin
 B. Burning and located in the epigastric area and radiating to the groin
 C. Severe and located in the epigastric area and radiating to the back
 D. Burning and located in the left lower quadrant and radiating to the back
Answer : C
The best time for the nurse to teach an anxious patient about the patient controlled
analgesic (PCA) pump would be during which of the following stages of patient care?
 A. Post-operative
 B. Pre-operative
 C. Intraoperative
 D. Post anesthesia
Answer : B
Elevated levels of amylase and lipase in the blood are common in:
 A. Diabetes mellitus
 B. Esophagitis
 C. Pancreatitis
 D. Hepatitis
Answer : C
In preparing the patient for electroencephalogram (EEG), the nurse should:
 A. Withhold breakfast
 B. Give sleeping pills the night before
 C. Shave the hair
 D. Restrict intake of coffee
Answer : D
An 11 year old girl with a history of asthma arrives at the primary health clinic with
signs/symptoms of shortness of breath, audible wheezing, nasal flaring and mild lip
cyanosis. Your immediate nursing action is to:
 A. Assess respiratory distress and peak expiratory flow rate
 B. Take a blood sample to assess COlevels
 C. Instruct the parents to take the child immediately to hospital
 D. Sit the child comfortably and offer 2 puffs of ventolin stat
Answer : A
While assessing an 84-year-old post-operative patient, the nurse observes that the
patient
suddenly becomes very anxious, appears cyanotic and has severe dyspnea. The nurse
recognizes these symptoms to be consistent with:
 A. Congestive heart failure

 B. Pulmonary embolism
 C. COPD exacerbation
 D. Myocardial infarction
Answer : B
When preparing an eye medication, the nurse reads the order “OS”. Medication is given
into:
 A. Both eyes
 B. Left eye
 C. Right eye
 D. Infected eye
Answer : B
A patient has been taking Aluminum Hydroxide daily for 3 weeks. The nurse should be
alert
for which of the following side effects?
 A. Constipation
 B. Flatulence
 C. Nausea
 D. Vomiting
Answer : A
An early sign of acute respiratory failure is:
 A. Diaphoresis
 B. Cyanosis
 C. Restlessness
 D. Orthopnea
Answer : C
In caring for a woman and baby day 3 postnatally, she tells you that her baby has not
had a
bowel action since delivery. Your appropriate response would be:
 A. Reassure the mother that it is quite normal for a baby to not move their bowels until
day 5 after a few days of milk feeding
 B. Start a bowel chart, document all findings, and wait another 48 hours before
reporting to the physician
 C. Encourage more frequent warm baths for the neonate with gentle abdomen massages
 D. Tell the mother that you will let the physician know, so the baby can be checked for
any obstruction
Answer : D

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1.The client presented with complaints of body weakness, dizziness and chest pain.

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

a. Urine output of 50 mL/hr.

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

a. The appearance of a U wave

a. Strip the chest tube.

a. Loosen tight clothing and administer oxygen supply.

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

a. Use digital stimulation to empty the bowel.

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

a. Maintain an exercise program.

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

a. Stop the Thiazide diuretic

a. On the same level after delivery

a. Chemotherapeutic agents alter molecular structure of DNA.

a. The skin is scaly.

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

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

In hypokalemia, the electrocardiogram may show flattening and inversion of the T

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

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

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

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

HAAD QUESTIONS (2018)

 A. Double bagging of all contaminated laundry

An 85-year-old man is admitted with dementia. He continuously attempts to remove his

 A. Continue the procedure and assure the patient

A patient is to receive 25mg/hr of an aminophylline infusion. The solution prepared by

 A. Administering an analgesic before exercising

 A. Use a non rebreather mask

Which of the following indicates the nurse is engaging in a therapeutic nurse-patient

 A. The nurse establishes a relationship that is mutually beneficial

 A. Decreased gastrointestinal motility

 A. Around the clock

The urinary catheter is kept securely in the bladder by:

 A. Taping the urinary catheter to the leg

Order: Compazine 8 mg IM stat. Drug availablE.10 mg/ 2mL in vial.

The immediate treatment for ventricular fibrillation is:

 A. Lubricating the catheter with sterile water

 A. Uses a small suction cup placed on the lenses

 A. Administering a dose of promethazine (Phenergan) via intravenous push (IVP)

 A. Reduce the flow of solution

 A. Prone with a sandbag under the abdomen

To promote accuracy of self-monitoring blood glucose by patients the nurse should:

 A. Retrain patients periodically

 A. Contact the physician

Nursing management of the patient with external otitis includes:

A patient is ordered 75mg of pethidine which comes in an ampoule of 100mg/2ml. What

 A. Lock up the remaining dose in the medication cupboard to use later

 A. Being involved in continuing education programs

 A. Decreased blood pressure

 A. Head nurse who is in-charge of the unit

When taking routine post-operative observations on a patient who underwent an

 A. Serosanguinous drainage on the surgical dressing

 A. Have the patient wear a high-efficiency particulate air (HEPA) mask

 A. Pooling of urine in the tube

Which of the following statements accurately describes the occurrence of dyspnea in

 A. Elevate the head of the bed 30 degrees

 A. Be alert to hypersensitivity response to the prescribed medications

 A. Putting a pillow between the legs while sleeping

 A. Generalized burning sensation

 A. Instruct the patient to limit movement of the affected shoulder

Which of the following laboratory blood values is expected to be decreased in hepatic