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1. The usual sequence for physical assessment skills is:
Auscultation, inspection, palpation, percussion
Inspection, auscultation, palpation, percussion
Inspection, palpation, percussion, auscultation
Palpation, percussion, inspection, auscultation

2. When performing a physical exam, the most important criterion the nurse should inspect for is:
Sensation
Symmetry
Rigidity
Range of motion

3. When teaching patients it is important for the nurse to remember that:
A needs assessment precedes the teaching plan
Resistance factors are based on developmental tasks
Talking is the most effective way to teach
The teaching plan precedes the needs assessment

4. The first actoin to be taken by the nurse when a patient has collapsed is:
Establish an open airway
Determine if the patient is unconscious
Check the carotid pulse
Assess patient for bleeding

5. Which of the following should be done when assessing the patient in pain?
The patient should be asked to describe in writing his experience so that details will be clear
The family should be asked about the patient's pain so the patient will not be disturbed
The nurse should ask the patient to rate his pain on a scale of 0-10 (none to worst)
The physician should verify the nurse's assessment of the patient

6. Nursing management of the patient with an epidural catheter should include:
Careful identification of an epidural catheter
Frequent monitoring of patient vital signs
Assessment of sensation and motor function
All of the above

7. When an abnormal cardiac rhythm (heart rate) is identified or suspected the nurse should assess:
Blood pressure
Mentation
Presence or absence of chest pain
All of the above

8. A patient is admitted with acute myocardial infarction (MI) He is cold and clammy and has severe chest pain with dyspnea. Which of the following nursing diagnosis has the highest priority?
Altered body temperature
Impaired gas exchange
Fluid volume deficit
Acute pain

9. Ms. Nunex has an allergic reaction to a blood transfusion. Your first nursing intervention is to:
Administer Benadryl IV
Stop the transfusion
Call the doctor
Collect a urine specimen to check for hematuria

10. When the nurse is assessing the patient who is to receive a blood transfusion, which of the following is essential in order to avoid a possible reaction?
Take initial vital signs
Determine the patient's most recent CBC results
Ask if the patient has had previous transfusion reactions
Run the blood slowly over at least four hours

11. The nurse should watch for complications in the patient undergoing a femoral angiogram. Which of the following is a complication?
warmth and flushing occur as the dye is injected
marked diuresis occurs after the test
distal pulses are absent 30 minutes after dye is injected
the site doesn't bleed after 15 minutes

12. When planning care for a patient receiving patient-controlled analgesia (PCA) the nurse should anticipate the following disadvantage:
slow onset of pain relief
patient titrates his own comfort
ineffective management of pain if patient is asleep or not alert
development of chronic pain

13. Identify risk factors for coronary heart disease related to lifestyle habits that the nurse will include in the teaching plan for the patient just discharged to home after hospitalization for coronary artery disease:
cigarette smoking
physical inactivity
obesity
all of the above

14. Daniel's diagnosis is congestive heart failure; a term commonly used with both left and right-sided heart failure. Which of the following are symptom(s) of right-sided heart failure?
dyspnea and cyanosis
peripheral edema
hepatomegaly
b and c

15. Symptoms of left-sided heart failure include:
orthopnea
paroxysmal nocturnal dyspnea
dependent edema
a and b

16. If a patient's total parenteral nutriction (TPN) solution is absorbed before the next volume of TPN is provided by the pharmacy, the nurse should:
Discontinue the system and flush the catheter with heparin and saline
Leave the system intact and notify the pharmacy immediately
Run D10W at the same rate as the ordered TPN until the TPN solution arrives, unless contraindicated for this patient
Run normal saline at a TKO rate

17. Mrs. Nelson is diagnosed as having primary or essential hypertension, which has no identifiable medical cause. The nurse's assessment and intervention requires the following:
Careful monitoring of blood pressure at frequent intervals
Determination of nosebleeds, anginal pain, dyspnea, alterations in vision, vertigo, or headaches
Education of patient and significant other regarding treatment regimen
All of the above

18. A 75 year old man was found on the floor by his daughter. He did not recognize her; was unable to move his left arm or leg; had difficulty speaking; and was incontinent of urine. He was admitted to the hospital with a diagnosis of cerebrovascular accident
Turn and position patient every 2 hours
Perform passive range of motion of affected extremities four to five times a day.
Insert an indwelling urinary catheter
Secure patient's attention and speak slowly and simply allow patient time to process

19. Which of the patient's lab values would the nurse report to the physician prior to surgery?
Potassium of 2.5 mEq/L
Hemoglobin of 14 g/dl
Temperature of 99.6 degrees F. (37.6 degrees C.) rectally, or 98.6 degrees F (37 degrees C) orally
White Blood Cell (WBC) (Leukocyte Count) of 6000 cells per mm3

20. Which of the following potential post operative complications will the nurse be monitoring for a patient who had lower extremity vascular surgery for arterial occlusive disease?
Deep vein thrombosis and dysrhythmias
Bleeding and vascular occlusion
Septicemia and atelectasis
Pulmonary embolus and venous stasis

21. The nurse is caring for a 93 year old female patient who suddenly develops incontinent and mental confusion. The most appropriate nursing action is:
Request an order to insert an indwelling catheter
Request an order for an urinalysis with culture and sensitivity to rule out a urinary tract infection
Request an order for propantheline (Pro-Banthine) to inhibit bladder contractions
Develop a nursing care plan to toilet the patient hourly to prevent further embarrassment

22. The patient is scheduled for an intravenous pyelogram (IVP) If the patient experiences any of the following reactions after injection of the contrast material for the IVP, which one would the nurse report immediately?
Feeling of warmth
Flushing of the face
Salty taste in mouth
Urticaria

23. Mrs. Trainor is to be discharged on Coumadin. Which of the followin instructions would the nurse include in discharge planning:
Smoking is contraindicated for patients receiving anticoagulants because of the effect of nicotine on bleeding time
Many over the counter drugs, such as aspirin and ibuprofen, affect anticoagulation action, and should be taken only with the physician's consent
Any dental work needed should be done immediately after discharge
If there is any bruising, stop the Coumadin immediately

24. The patient diagnosed with Type: I Insulin-dependent diabetes mellitus (IDDM) would:
Be restricted to a 1200 calorie American Diabetic Association diet
Have no damage to the islet cells of the pancreas
Need exogenous insulin
Need to receive daily doses of a hypoglycemic agent

25. How does morphine sulfate relieve the symptoms of acute pulmonary edema?
Causes renal vasoconstriction
Causes coronary artery vasodilation
Decreases peripheral resistance so blood can be redistributed from pulmonary circulation to periphery
Increases the volume of circulating blood

26. Symptoms of hypoglycemia include all of the following except:
sweating
nervousness
tremor
flushed skin

27. The nurse should expect that insulin therapy may be temporarily substituted for oral hypoglycemic therapy if the diabetic:
Develops an infection with fever
Suffers trauma
Undergoes major surgery
Develops any or all of the above

28. The nurse would not expect to find which symptom(s) of Diabetic Ketoacidosis (DKA)?
Acetone breath (a fruity odor)
Kussmaul respirations
Cold, clammy, pale skin
Nausea, vomiting and or abdominal pain

29. NPH Insulin administered to the patient at 7:30 am, reaches its peak action:
Between 10:00 am and 12:00 noon
Between 1:30 pm and 7:30 pm
Between 10:00 pm and 12:00 midnight
7:30 am the next day

30. The single most important means of preventing the spread of infection is:
Antibiotic therapy
Wearing gloves for all patient contact
Hand washing
Gowning and wearing masks

31. What is the most specific indicator of renal function?
Blood urea nitrogen level
Serum creatinine concentration
Urine specific gravity
Serum bicarbonate level

32. In teaching a patient safe, self-administration of Prednisone, a synthetic corticosteroid, you would include all of the following statements except:
Take the medication with food
Protect yourself from infections
You may need to increase your salt intake
Never stop the medication abruptly

33. A fractured bone may produce the following signs and symptoms:
Pain and swelling
Loss of function
Shortening of limb
All of the above

34. In preparing the patient to receive a short term central venous catheter (CVC), the nurse will place the patient in the following position:
Supine
Reverse Trendelenburg position
Trendelenburg position
Fowler's position

35. The greatest cause of central venous catheter (CVC) related complications is:
Pain
Air embolism
Bleeding
Septicemia

36. A draining pressure ulcer which involves the epidermis and dermis, would be classified and treated as follows:
Stage I; dry sterile dressing
Stage II; transparent membrane (Op-site and Tegaderm)
Stage III; hydrocolloid dressings
Stage IV; betadine and hibiclens soaked sterile dressings

37. Radiation therapy is given for the following purpose(s):
Palliation
Cure
A and B
Experimentation

38. You are orienting a new Nursing Assistant Certified (CNA) to your unit. You instruct the CNA that the most immediate action to be taken when caring for the patient who develops nausea and vomiting is:
Measure the emesis
Monitor vital signs
Turn the patient to the side to prevent aspiration
Find you so an antiemetic can be given

39. Your patient has had a thoracotomy. She returns to the unit with a closed chest drainage system. You should first check the following:
Amount and color of drainage
If tidaling is occurring
Positioning the system below the level of the patient's chest
All of the above

40. Which of the following assessments does not indicate possible wound infection?
Serious drainage from a penrose drain
Oral temperature of 99.0 degrees F
Erythema around incisional site
Tenderness in the incisional area

41. Nursing care of the patient with a Hemovac includes the following except:
Noting color and amount of drainage
Emptying Hemovac if half full or more
Increasing suction by attaching to continuous wall suction when drainage decreases
Maintaining suction by compressing evacuator after emptying

42. Which of these is often the earliest indication of increasing intracranial pressure?
Increased restlessness followed closely by focal seizures
Decreasing blood pressure in association with rising pulse rate
Decrease in responsiveness followed by change in pupil reaction
Increased severity of headache in addition to diplopia

43. The physician orders 3000 mL of D5W over 24 hours. The administration set delivers 15 gtt/mL. Calculate the approximate number of drops that should be administered per minute.
20
31
125
187

44. The physician orders Heparin 7,500 units subcutaneously q 8 hours. You have available Heparin 10,000 units/mL. How many mL will you give?
.75 mL
.50 mL
.10 mL
None of the above because Heparin is not given subcutaneously

45. You are the nurse in charge. The medication nurse reports that Mr. Swan-Ganz, who has been depressed and threatened to commit suicide last night, told her that he feels much better this morning. Your instructions to the staff are the following:
Encourage him to evaluate the reason
Observe the patient closely as he may have settled on a method for suicide
Begin plans for discharge
Inform the physician that the patient is feeling better and request a decrease in Prozac (FLUOXETINE)

46. You are the nurse in charge. Which of the following patients should be assigned to the staff member who is most skilled at giving physical care?
75 year old Mrs. Jones who is unable to move her lower extremeties due to M.S.
45 year old Mr. Brown who is recuperating from an acute M.I.
38 year old Ms. Stevens being discharged home tomorrow after U.R.I.
27 year old Ms. Carpenter, suffering from anorexia nervosa

47. Mr. Lord, who has a terminal illness, has been very abusive to the staff. This behavior has accelerated to the point that the staff is arguing over who should care for him. The most appropriate way to handle this would be the following:
Explain that someone must care for him and assign him to the staff on a rotating basis
Ask the social worker to have his family hire a private duty staff member to care for him
Request a float person to care for him
Explain to the staff that his behavior may be his way of working through his grief and discuss with them ways to cope with the abusive behavior

48. The physician orders oxygen per nasal cannula for the patient with COPD. Which of the following is an appropriate order?
Oxygen at 6L/min
Oxygen at 4L/min
Oxygen at 2L/min
Oxygen at 8L/min

49. You are caring for a patient with an absolute neutrophil count of 400. Precautions include all of the following except:
No visitors with cough or signs and symptoms of infection
Post sign that reads "Thrombocytopenic Precautions"
Monitor temperature closely
Teach patient to practice good personal hygiene

50. The most common pulmonary complications seen with AIDS are due to infection with:
Cytomegalovirus
Legionella
Mycobacterium avium intracellular
Pneumocystis carinii pneumonia