1. The nurse In-charge in labor and delivery unit administered a dose of terbutaline to a client without
checking the client’s pulse. The standard that would be used to determine if the nurse was negligent is:
A. The physician’s orders.
B. The action of a clinical nurse specialist who is recognized expert in the field.
C. The statement in the drug literature about administration of terbutaline.
D. The actions of a reasonably prudent nurse with similar education and experience.
2. Nurse Trish is caring for a female client with a history of GI bleeding, sickle cell disease, and a platelet
count of 22,000/μl. The female client is dehydrated and receiving dextrose 5% in half-normal saline solution
at 150 ml/hr. The client complains of severe bone pain and is scheduled to receive a dose of morphine
sulfate. In administering the medication, Nurse Trish should avoid which route?
A. I.V
B. I.M
C. Oral
D. S.C
3. Dr. Garcia writes the following order for the client who has been recently admitted “Digoxin .125 mg
P.O. once daily.” To prevent a dosage error, how should the nurse document this order onto the medication
administration record?
A. “Digoxin .1250 mg P.O. once daily”
B. “Digoxin 0.1250 mg P.O. once daily”
C. “Digoxin 0.125 mg P.O. once daily”
D. “Digoxin .125 mg P.O. once daily”
4. A newly admitted female client was diagnosed with deep vein thrombosis. Which nursing diagnosis
should receive the highest priority?
A. Ineffective peripheral tissue perfusion related to venous congestion.
B. Risk for injury related to edema.
, C. Excess fluid volume related to peripheral vascular disease.
D. Impaired gas exchange related to increased blood flow.
5. Nurse Betty is assigned to the following clients. The client that the nurse would see first after
endorsement?
A. A 34 year-old post operative appendectomy client of five hours who is complaining of pain.
B. A 44 year-old myocardial infarction (MI) client who is complaining of nausea.
C. A 26 year-old client admitted for dehydration whose intravenous (IV) has infiltrated.
D. A 63 year-old post operative’s abdominal hysterectomy client of three days whose incisional
dressing is saturated with serosanguinous fluid.
6. Nurse Gail places a client in a four-point restraint following orders from the physician. The client care
plan should include:
A. Assess temperature frequently.
B. Provide diversional activities.
C. Check circulation every 15-30 minutes.
D. Socialize with other patients once a shift.
7. A male client who has severe burns is receiving H2 receptor antagonist therapy. The nurse In-charge
knows the purpose of this therapy is to:
A. Prevent stress ulcer
B. Block prostaglandin synthesis
C. Facilitate protein synthesis.
D. Enhance gas exchange
8. The doctor orders hourly urine output measurement for a postoperative male client. The nurse Trish
records the following amounts of output for 2 consecutive hours: 8 a.m.: 50 ml; 9 a.m.: 60 ml. Based on
these amounts, which action should the nurse take?
A. Increase the I.V. fluid infusion rate
B. Irrigate the indwelling urinary catheter
C. Notify the physician
, D. Continue to monitor and record hourly urine output
9. Tony, a basketball player twist his right ankle while playing on the court and seeks care for ankle pain
and swelling. After the nurse applies ice to the ankle for 30 minutes, which statement by Tony suggests that
ice application has been effective?
A. “My ankle looks less swollen now”.
B. “My ankle feels warm”.
C. “My ankle appears redder now”.
D. “I need something stronger for pain relief”
10.The physician prescribes a loop diuretic for a client. When administering this drug, the nurse anticipates
that the client may develop which electrolyte imbalance?
A. Hypernatremia
B. Hyperkalemia
C. Hypokalemia
D. Hypervolemia
11.She finds out that some managers have benevolent-authoritative style of management. Which of the
following behaviors will she exhibit most likely?
A. Have condescending trust and confidence in their subordinates.
B. Gives economic and ego awards.
C. Communicates downward to staffs.
D. Allows decision making among subordinates.
12. Nurse Amy is aware that the following is true about functional nursing
A. Provides continuous, coordinated and comprehensive nursing services.
B. One-to-one nurse patient ratio.
C. Emphasize the use of group collaboration.
D. Concentrates on tasks and activities.
13.Which type of medication order might read “Vitamin K 10 mg I.M. daily × 3 days?”
, A. Single order
B. Standard written order
C. Standing order
D. Stat order
14.A female client with a fecal impaction frequently exhibits which clinical manifestation?
A. Increased appetite
B. Loss of urge to defecate
C. Hard, brown, formed stools
D. Liquid or semi-liquid stools
15.Nurse Linda prepares to perform an otoscopic examination on a female client. For proper visualization,
the nurse should position the client’s ear by:
A. Pulling the lobule down and back
B. Pulling the helix up and forward
C. Pulling the helix up and back
D. Pulling the lobule down and forward
16. Which instruction should nurse Tom give to a male client who is having external radiation therapy:
A. Protect the irritated skin from sunlight.
B. Eat 3 to 4 hours before treatment.
C. Wash the skin over regularly.
D. Apply lotion or oil to the radiated area when it is red or sore.
17.In assisting a female client for immediate surgery, the nurse In-charge is aware that she should:
A. Encourage the client to void following preoperative medication.
B. Explore the client’s fears and anxieties about the surgery.
C. Assist the client in removing dentures and nail polish.