03/08/2019
Question No : 58 –
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
Question No : 59 –
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
Question No : 60 –
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
Question No : 61 –
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
Question No : 62 –
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
Question No : 63 –
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
Question No : 64 –
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
Question No : 65 –
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
Question No : 66 –
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
Question No : 67 –
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
Question No : 68 –
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
Question No : 69 –
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
Question No : 70 –
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
Question No : 71 –
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
Question No : 72 –
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
Question No : 73 –
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
Question No : 74 –
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
Question No : 75 –
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
Question No : 76 –
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
Question No : 77 –
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
Question No : 78 –
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
Question No : 79 –
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
Question No : 80 –
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
Question No : 81 –
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
Question No : 82 –
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
Question No : 83 –
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