Practice Test Questions Downloaded From FILIPINO NURSES CENTRAL
Practice Test Questions Downloaded From FILIPINO NURSES CENTRAL
Practice Test Questions Downloaded From FILIPINO NURSES CENTRAL
1. The nursing care plan for a toddler diagnosed with Kawasaki Disease
(mucocutaneous lymph node syndrome) should be based on the high risk for
development of which problem?
A)Chronic vessel plaque formation
B)Pulmonary embolism
C)Occlusions at the vessel bifurcations
D)Coronary artery aneurysms
2. A nurse has just received a medication order which is not legible. Which
statement best reflects assertive communication?
A)"I cannot give this medication as it is written. I have no idea of what you
mean."
B)"Would you please clarify what you have written so I am sure I am
reading it correctly?"
C)"I am having difficulty reading your handwriting. It would save me time if
you would be more careful."
D)"Please print in the future so I do not have to spend extra time attempting
to read your writing."
The correct answer is B: "Would you please clarify what you have written so I
am sure I am reading it correctly?"
Assertive communication respects the rights and responsibilities of both
parties. This statement is an honest expression of concern for safe practice
and a request for clarification without self-depreciation. It reflects the right of
the professional to give and receive information.
The correct answer is C: Use patience and a sense of humor to deal with this
behavior
The nurse should help the parents see the negativism as a normal growth of
autonomy in the toddler. They can best handle the negative toddler by using
patience and humor.
4. An ambulatory client reports edema during the day in his feet and an
ankle that disappears while sleeping at night. What is the most appropriate
follow-up question for the nurse to ask?
A)"Have you had a recent heart attack?"
B)"Do you become short of breath during your normal daily
activities?"
C)"How many pillows do you use at night to sleep comfortably?"
D)"Do you smoke?"
The correct answer is B: "Do you become short of breath during your normal
daily activities?"
These are the symptoms of right-sided heart failure, which causes increased
pressure in the systemic venous system. To equalize this pressure, the fluid
shifts into the interstitial spaces causing edema. Because of gravity, the
lower extremities are first affected in an ambulatory patient. This question
would elicit information to confirm the nursing diagnosis of activity
intolerance and fluid volume excess both associated with right-sided heart
failure.
5. The nurse is planning care for a client during the acute phase of a sickle
cell vaso-occlusive crisis. Which of the following actions would be most
appropriate?
A)Fluid restriction 1000cc per day
B)Ambulate in hallway 4 times a day
C)Administer analgesic therapy as ordered
D)Encourage increased caloric intake
7. A nurse and client are talking about the client’s progress toward
understanding his behavior under stress. This is typical of which phase in the
therapeutic relationship?
A)Pre-interaction
B)Orientation
C)Working
D)Termination
The correct answer is B: "The seizure may or may not mean your child has
epilepsy."
There are many possible causes for a childhood seizure. These include fever,
central nervous system conditions, trauma, metabolic alterations and
idiopathic (unknown).
10. A nurse admits a 3 week-old infant to the special care nursery with a
diagnosis of bronchopulmonary dysplasia. As the nurse reviews the birth
history, which data would be most consistent with this diagnosis?
A)Gestational age assessment suggested growth retardation
B)Meconium was cleared from the airway at delivery
C)Phototherapy was used to treat Rh incompatibility
D)The infant received mechanical ventilation for 2 weeks
11. Parents of a 6 month-old breast fed baby ask the nurse about increasing
the baby's diet. Which of the following should be added first?
A)Cereal
B)Eggs
C)Meat
D)Juice
12. A victim of domestic violence states, "If I were better, I would not have
been beat." Which feeling best describes what the victim may be
experiencing?
A)Fear
B)Helplessness
C)Self-blame
D)Rejection
13. The nurse is assessing the mental status of a client admitted with
possible organic brain disorder. Which of these questions will best assess the
function of the client's recent memory?
A)"Name the year." "What season is this?" (pause for answer after each
question)
B)"Subtract 7 from 100 and then subtract 7 from that." (pause for answer)
"Now continue to subtract 7 from the new number."
C)"I am going to say the names of three things and I want you to
repeat them after me: blue, ball, pen."
D)"What is this on my wrist?" (point to your watch) Then ask, "What is the
purpose of it?"
The correct answer is C: "I am going to say the names of three things and I
want you to repeat them after me: blue, ball, pen."
14. Which oxygen delivery system would the nurse apply that would provide
the highest concentrations of oxygen to the client?
A) Venturi mask
B) Partial rebreather mask
C) Non-rebreather mask
D) Simple face mask
The correct answer is C: The non-rebreather mask has a one-way valve that
prevents exhales air from entering the reservoir bag and one or more valves
covering the air holes on the face mask itself to prevent inhalation of room
air but to allow exhalation of air. When a tight seal is achieved around the
mask up to 100% of oxygen is available.
15. A nurse is caring for a client who had a closed reduction of a fractured
right wrist followed by the application of a fiberglass cast 12 hours ago.
Which finding requires the nurse’s immediate attention?
A) Capillary refill of fingers on right hand is 3 seconds
B) Skin warm to touch and normally colored
C) Client reports prickling sensation in the right hand
D) Slight swelling of fingers of right hand
16. Included in teaching the client with tuberculosis taking INH about follow-
up home care, the nurse should emphasize that a laboratory appointment for
which of the following lab tests is critical?
A) Liver function
B) Kidney function
C) Blood sugar
D) Cardiac enzymes
The correct answer is A: INH can cause hepatocellular injury and hepatitis.
This side effect is age-related and can be detected with regular assessment
of liver enzymes, which are released into the blood from damaged liver cells.
17. Which client is at highest risk for developing a pressure ulcer?
A) 23 year-old in traction for fractured femur
B) 72 year-old with peripheral vascular disease, who is unable to walk
without assistance
C) 75 year-old with left sided paresthesia and is incontinent of urine
and stool
D) 30 year-old who is comatose following a ruptured aneurysm
The correct answer is C: Risk factors for pressure ulcers include: immobility,
absence of sensation, decreased LOC, poor nutrition and hydration, skin
moisture, incontinence, increased age, decreased immune response. This
client has the greatest number of risk factors.
18. Which contraindication should the nurse assess for prior to giving a child
immunization?
A) Mild cold symptoms
B) Chronic asthma
C) Depressed immune system
D) Allergy to eggs
19. The nurse is caring for a 2 year-old who is being treated with chelation
therapy, calcium disodium edetate, for lead poisoning. The nurse should be
alert for which of the following side effects?
A) Neurotoxicity
B) Hepatomegaly
C) Nephrotoxicity
D) Ototoxicity
21. At a senior citizens meeting a nurse talks with a client who has diabetes
mellitus Type 1. Which statement by the client during the conversation is
most predictive of a potential for impaired skin integrity?
A) "I give my insulin to myself in my thighs."
B) "Sometimes when I put my shoes on I don't know where my toes
are."
C) "Here are my up and down glucose readings that I wrote on my calendar."
D) "If I bathe more than once a week my skin feels too dry."
22. A 4 year-old hospitalized child begins to have a seizure while playing with
hard plastic toys in the hallway. Of the following nursing actions, which one
should the nurse do first?
The correct answer is D: Nursing care for a child having a seizure includes,
maintaining airway patency, ensuring safety, administering medications, and
providing emotional support. Since the seizure has already started, nothing
should be forced into the child''s mouth and they should not be moved. Of
the choices given, first priority would be for safety.
23. The nurse is at the community center speaking with retired people. To
which comment by one of the retirees during a discussion about glaucoma
would the nurse give a supportive comment to reinforce correct information?
A) "I usually avoid driving at night since lights sometimes seem to make
things blur."
B) "I take half of the usual dose for my sinuses to maintain my blood
pressure."
C) "I have to sit at the side of the pool with the grandchildren since I can't
swim with this eye problem."
D) "I take extra fiber and drink lots of water to avoid getting
constipated.”
27. The nurse is teaching the mother of a 5 month-old about nutrition for her
baby. Which statement by the mother indicates the need for further
teaching?
A) "I'm going to try feeding my baby some rice cereal."
B) "When he wakes at night for a bottle, I feed him."
C) "I dip his pacifier in honey so he'll take it."
D) "I keep formula in the refrigerator for 24 hours."
The correct answer is C: Honey has been associated with infant botulism and
should be avoided. Older children and adults have digestive enzymes that kill
the botulism spores.
28. For a 6 year-old child hospitalized with moderate edema and mild
hypertension associated with acute glomerulonephritis (AGN), which one of
the following nursing interventions would be appropriate?
A) Institute seizure precautions
B) Weigh the child twice per shift
C) Encourage the child to eat protein-rich foods
D) Relieve boredom through physical activity
29. Which statement by the client with chronic obstructive lung disease
indicates an understanding of the major reason for the use of occasional
pursed-lip breathing?
A) "This action of my lips helps to keep my airway open."
B) "I can expel more when I pucker up my lips to breathe out."
C) "My mouth doesn't get as dry when I breathe with pursed lips."
D) "By prolonging breathing out with pursed lips the little areas in
my lungs don't collapse."
The correct answer is D: "By prolonging breathing out with pursed lips my
little areas in my lungs don''t collapse."
Clients with chronic obstructive pulmonary disease have difficulty exhaling
fully as a result of the weak alveolar walls from the disease process . Alveolar
collapse can be avoided with the use of pursed-lip breathing. This is the
major reason to use it. The other options are secondary effects of purse-lip
breathing.
The correct answer is A: Ask the client if he has noticed any bleeding or dark
stools
Normal hemoglobin for males is 13.0 - 18 g/100 ml. Normal hemotocrit for
males is 42 - 52%. These values are below normal and indicate mild anemia.
The first thing the nurse should do is ask the client if he''s noticed any
bleeding or change in stools that could indicate bleeding from the GI tract.
31. Which response by the nurse would best assist the chemically impaired
client to deal with issues of guilt?
A) "Addiction usually causes people to feel guilty. Don’t worry, it is a typical
response due to your drinking behavior."
B) "What have you done that you feel most guilty about and what
steps can you begin to take to help you lessen this guilt?"
C) "Don’t focus on your guilty feelings. These feelings will only lead you to
drinking and taking drugs." D) "You’ve caused a great deal of pain to your
family and close friends, so it will take time to undo all the things you’ve
done."
The correct answer is B: "What have you done that you feel most guilty
about and what steps can you begin to take to help you lessen this guilt?"
This response encourages the client to get in touch with their feelings and
utilize problem solving steps to reduce guilt feelings.
32. An adolescent client comes to the clinic 3 weeks after the birth of her
first baby. She tells the nurse she is concerned because she has not returned
to her pre-pregnant weight. Which action should the nurse perform first?
A) Review the client's weight pattern over the year
B) Ask the mother to record her diet for the last 24 hours
C) Encourage her to talk about her view of herself
D) Give her several pamphlets on postpartum nutrition
The correct answer is C: Encourage her to talk about her view of herself
To an adolescent, body image is very important. The nurse must
acknowledge this before assessment and teaching.
33. Which of the following measures would be appropriate for the nurse to
teach the parent of a nine month-old infant about diaper dermatitis?
A) Use only cloth diapers that are rinsed in bleach
B) Do not use occlusive ointments on the rash
C) Use commercial baby wipes with each diaper change
D) Discontinue a new food that was added to the infant's diet just
prior to the rash
The correct answer is D: Discontinue a new food that was added to the
infant''s diet just prior to the rash
The addition of new foods to the infant''s diet may be a cause of diaper
dermatitis.
35. A mother brings her 26 month-old to the well-child clinic. She expresses
frustration and anger due to her child's constantly saying "no" and his refusal
to follow her directions. The nurse explains this is normal for his age, as
negativism is attempting to meet which developmental need?
A) Trust
B) Initiative
C) Independence
D) Self-esteem
36. Following mitral valve replacement surgery a client develops PVC’s. The
health care provider orders a bolus of Lidocaine followed by a continuous
Lidocaine infusion at a rate of 2 mgm/minute. The IV solution contains 2
grams of Lidocaine in 500 cc’s of D5W. The infusion pump delivers 60
microdrops/cc. What rate would deliver 4 mgm of Lidocaine/minute?
A) 60 microdrops/minute
B) 20 microdrops/minute
C) 30 microdrops/minute
D) 40 microdrops/minute
The correct answer is A: 60 microdrops/minute
2 gm=2000 mgm
2000 mgm/500 cc = 4 mgm/x cc
2000x = 2000
x= 2000/2000 = 1 cc of IV solution/minute
CC x 60 microdrops = 60 microdrops/minute
37. A couple asks the nurse about risks of several birth control methods.
What is the most appropriate response by the nurse?
A) Norplant is safe and may be removed easily
B) Oral contraceptives should not be used by smokers
C) Depo-Provera is convenient with few side effects
D) The IUD gives protection from pregnancy and infection
38. The nurse is caring for a client in the late stages of Amyotrophic Lateral
Sclerosis (A.L.S.). Which finding would the nurse expect?
A) Confusion
B) Loss of half of visual field
C) Shallow respirations
D) Tonic-clonic seizures
39. A client experiences post partum hemorrhage eight hours after the birth
of twins. Following administration of IV fluids and 500 ml of whole blood, her
hemoglobin and hematocrit are within normal limits. She asks the nurse
whether she should continue to breast feed the infants. Which of the
following is based on sound rationale?
A) "Nursing will help contract the uterus and reduce your risk of
bleeding."
B) "Breastfeeding twins will take too much energy after the hemorrhage."
C) "The blood transfusion may increase the risks to you and the babies."
D) "Lactation should be delayed until the "real milk" is secreted."
The correct answer is A: "Nursing will help contract the uterus and reduce
your risk of bleeding." Stimulation of the breast during nursing releases
oxytocin, which contracts the uterus. This contraction is especially important
following hemorrhage.
40. A client complained of nausea, a metallic taste in her mouth, and fine
hand tremors 2 hours after her first dose of lithium carbonate (Lithane).
What is the nurse’s best explanation of these findings?
A) These side effects are common and should subside in a few days
B) The client is probably having an allergic reaction and should discontinue
the drug
C) Taking the lithium on an empty stomach should decrease these symptoms
D) Decreasing dietary intake of sodium and fluids should minimize the side
effects
The correct answer is A: These side effects are common and should subside
in a few days
Nausea, metallic taste and fine hand tremors are common side effects that
usually subside within days.
41. The nurse is caring for a post-surgical client at risk for developing deep
vein thrombosis. Which intervention is an effective preventive measure?
A) Place pillows under the knees
B) Use elastic stockings continuously
C) Encourage range of motion and ambulation
D) Massage the legs twice daily
42. The parents of a newborn male with hypospadias want their child
circumcised. The best response by the nurse is to inform them that
A) Circumcision is delayed so the foreskin can be used for the
surgical repair
B) This procedure is contraindicated because of the permanent defect
C) There is no medical indication for performing a circumcision on any child
D) The procedure should be performed as soon as the infant is stable
43. The nurse is teaching parents about the treatment plan for a 2 weeks-old
infant with Tetralogy of Fallot. While awaiting future surgery, the nurse
instructs the parents to immediately report
A) Loss of consciousness
B) Feeding problems
C) Poor weight gain
D) Fatigue with crying
45. The nurse is caring for a 13 year-old following spinal fusion for scoliosis.
Which of the following interventions is appropriate in the immediate post-
operative period?
A) Raise the head of the bed at least 30 degrees
B) Encourage ambulation within 24 hours
C) Maintain in a flat position, logrolling as needed
D) Encourage leg contraction and relaxation after 48 hours
46. A client asks the nurse about including her 2 and 12 year-old sons in the
care of their newborn sister. Which of the following is an appropriate initial
statement by the nurse?
A) "Focus on your sons' needs during the first days at home."
B) "Tell each child what he can do to help with the baby."
C) "Suggest that your husband spend more time with the boys."
D) "Ask the children what they would like to do for the newborn."
The correct answer is A: "Focus on your sons'' needs during the first days at
home."
In an expanded family, it is important for parents to reassure older children
that they are loved and as important as the newborn.
47. A nurse is caring for a 2 year-old child after corrective surgery for
Tetralogy of Fallot. The mother reports that the child has suddenly begun
seizing. The nurse recognizes this problem is probably due to
A) A cerebral vascular accident
B) Postoperative meningitis
C) Medication reaction
D) Metabolic alkalosis
49. A home health nurse is at the home of a client with diabetes and
arthritis. The client has difficulty drawing up insulin. It would be most
appropriate for the nurse to refer the client to
A) A social worker from the local hospital
B) An occupational therapist from the community center
C) A physical therapist from the rehabilitation agency
D) Another client with diabetes mellitus and takes insulin
50. A client was admitted to the psychiatric unit after complaining to her
friends and family that neighbors have bugged her home in order to hear all
of her business. She remains aloof from other clients, paces the floor and
believes that the hospital is a house of torture. Nursing interventions for the
client should appropriately focus on efforts to
A) Convince the client that the hospital staff is trying to help
B) Help the client to enter into group recreational activities
C) Provide interactions to help the client learn to trust staff
D) Arrange the environment to limit the client’s contact with other clients
The correct answer is C: Provide interactions to help the client learn to trust
staff
This establishes trust, facilitates a therapeutic alliance between staff and
client.
The correct answer is C: Procedure that compresses plaque against the wall
of the diseased coronary artery to improve blood flow
PTCA is performed to improve coronary artery blood flow in a diseased
artery. It is performed during a cardiac catheterization. Aorta coronary
bypass Graft is the surgical procedure to repair a diseased coronary artery.
The correct answer is A: "I don''t remember anything about what happened
to me."
Suppression is willfully putting an unacceptable thought or feeling out of
one’s mind. A deliberate exclusion "voluntary forgetting" is generally used to
protect one’s own self esteem.
55. The nurse is caring for a woman 2 hours after a vaginal delivery.
Documentation indicates that the membranes were ruptured for 36 hours
prior to delivery. What are the priority nursing diagnoses at this time?
A) Altered tissue perfusion
B) Risk for fluid volume deficit
C) High risk for hemorrhage
D) Risk for infection
56. A 3 year-old had a hip spica cast applied 2 hours ago. In order to
facilitate drying, the nurse should
A) Expose the cast to air and turn the child frequently
B) Use a heat lamp to reduce the drying time
C) Handle the cast with the abductor bar
D) Turn the child as little as possible
The correct answer is A: Expose the cast to air and turn the child frequently
The child should be turned every 2 hours, with surface exposed to the air.
59. The nurse is caring for a 20 lbs (9 kg) 6 month-old with a 3 day history
of diarrhea, occasional vomiting and fever. Peripheral intravenous therapy
has been initiated, with 5% dextrose in 0.33% normal saline with 20 mEq of
potassium per liter infusing at 35 ml/hr. Which finding should be reported to
the health care provider immediately?
A) 3 episodes of vomiting in 1 hour
B) Periodic crying and irritability
C) Vigorous sucking on a pacifier
D) No measurable voiding in 4 hours
60. While caring for the client during the first hour after delivery, the nurse
determines that the uterus is boggy and there is vaginal bleeding. What
should be the nurse's first action?
A) Check vital signs
B) Massage the fundus
C) Offer a bedpan
D) Check for perineal lacerations
61. The nurse is assessing an infant with developmental dysplasia of the hip.
Which finding would the nurse anticipate?
A) Unequal leg length
B) Limited adduction
C) Diminished femoral pulses
D) Symmetrical gluteal folds
63. On admission to the psychiatric unit, the client is trembling and appears
fearful. The nurse’s initial response should be to
A) Give the client orientation materials and review the unit rules and
regulations
B) Introduce him/her and accompany the client to the client’s room
C) Take the client to the day room and introduce her to the other clients
D) Ask the nursing assistant to get the client’s vital signs and complete the
admission search
65. A client with asthma has low pitched wheezes present on the final half of
exhalation. One hour later the client has high pitched wheezes extending
throughout exhalation. This change in assessment indicates to the nurse that
the client
A) Has increased airway obstruction
B) Has improved airway obstruction
C) Needs to be suctioned
D) Exhibits hyperventilation
67. The nurse is caring for a client with a long leg cast. During discharge
teaching about appropriate exercises for the affected extremity, the nurse
should recommend
A) Isometric
B) Range of motion
C) Aerobic
D) Isotonic
68. A client is in her third month of her first pregnancy. During the interview,
she tells the nurse that she has several sex partners and is unsure of the
identity of the baby's father. Which of the following nursing interventions is a
priority?
A) Counsel the woman to consent to HIV screening
B) Perform tests for sexually transmitted diseases
C) Discuss her high risk for cervical cancer
D) Refer the client to a family planning clinic
69. A 16 month-old child has just been admitted to the hospital. As the nurse
assigned to this child enters the hospital room for the first time, the toddler
runs to the mother, clings to her and begins to cry. What would be the initial
action by the nurse?
A) Arrange to change client care assignments
B) Explain that this behavior is expected
C) Discuss the appropriate use of "time-out"
D) Explain that the child needs extra attention
70. While planning care for a 2 year-old hospitalized child, which situation
would the nurse expect to most likely affect the behavior?
A) Strange bed and surroundings
B) Separation from parents
C) Presence of other toddlers
D) Unfamiliar toys and games
71. While explaining an illness to a 10 year-old, what should the nurse keep
in mind about the cognitive development at this age?
A) They are able to make simple association of ideas
B) They are able to think logically in organizing facts
C) Interpretation of events originate from their own perspective
D) Conclusions are based on previous experiences
72. The nurse is has just admitted a client with severe depression. From
which focus should the nurse identify a prioriy nursing diagnosis?
A) Nutrition
B) Elimination
C) Activity
D) Safety
73. Which playroom activities should the nurse organize for a small group of
7 year-old hospitalized children?
A) Sports and games with rules
B) Finger paints and water play
C) "Dress-up" clothes and props
D) Chess and television programs
75. The nurse is caring for a 10 year-old on admission to the burn unit. One
assessment parameter that will indicate that the child has adequate fluid
replacement is
A) Urinary output of 30 ml per hour
B) No complaints of thirst
C) Increased hematocrit
D) Good skin turgor around burn