1. C. Celiac disease is caused by an intolerance to gluten, which is a protein found in wheat, oats, barley and rye, All the foods in option 3 contain gluten. Option 1 would be eliminated if the child had a lactose intolerance, option 4 would be eliminated if the child had a fat intolerance.

2. D. The most important assessment is vital signs for hemorrhage. The nurse will also check the fundus and for lochia, but the most important is for hemorrhage because it is the most common cause of death in the first hour after delivery.

3. D. Unless the antibiotic is safe for the infant, it is best not to feed the baby, but in order to continue establishment of milk flow, the breasts must be stimulated.

4. A. Exercise, specifically dorsiflexion of the feet, prevents stasis by promoting venous valve and muscle action. Early ambulation, deep breathing and elevating the foot of the bed all increase blood flow. If DVT develops, the client will be placed on bedrest.

5. B. Alzheimer’s disease is a progressive disease that takes years until the patient is completely incapacitated. It is best to support the individuals self esteem by helping them maintain as much control of their life through independent functioning of self care and activities of daily living.

6. C. The physician should be notified immediately. A suspected Wilms’ tumor should never be palpated more than necessary because of the potential for metastasis and should be treated immediately following discovery. It is really not a nursing responsibility to assess for lymph node enlargement.

7. D. Patients with renal failure should have a diet that provides (high biologic value) proteins rich foods such as eggs, dairy products and meats. These are necessary to maintain a positive nitrogen balance. Foods high in calories are also necessary, and sodium intake should be limited. Foods high in Potassium should be AVOIDED due to decreased ability of the kidney(s) to filter and excrete Potassium.

8. B. The function of the lens is that of accommodation, the focusing of near objects on the retina by the lens; therefore, only the remaining lens will function in this capacity, depending on whether a cataract is present.

9. A. Although abstinence is still the best protection against spread of the HIV virus, the use of a latex condom with a H20 soluble lubricant is the most effective means. All other choices given have no proven validity against the spread of the HIV Virus.

10. B. If the bladder is full, it will push the uterus up out of the pelvis above the umbilicus. The uterus will not contract sufficiently, which could lead to increased bleeding.

11. B. Children with cardiac disease have lowered resistance to upper respiratory infections and should avoid any circumstances that may expose them to even mild infections. Option 1 is unrealistic and option 3 would not put the child at risk since allergies are not contagious, option 4 is wrong because children with cardiac conditions do receive routine immunizations.

12. D. Elevation of the legs promotes circulation and prevents venous stasis and more clot formation. Nursing measures aim at preventing further thrombi from forming and the already present thrombus from detaching. Elastic hose (2) are necessary when the client is up walking again. Placing a pillow under the limb (1) could cause a bend at the groin, with resulting decreased circulation. The client must be kept on bedrest until the danger of emboli passes (4 to 7 days).

13. A. One of the more common problems following Gastric surgery is Dumping Syndrome. Dietary management is the key to reduce or prevent this potential problem from developing. The diet should contain moderate amounts of fat, as well as below in carbohydrates, especially small molecular carbohydrates such as sucrose and glucose. These dietary modifications will result in decreased hypertonicity of the intestinal contents, and prevent osmotic pull of extracellular fluid into the intestinal area, lessening the possibility for Dumping Syndrome to develop.

14. B. While regulating or even touching an IV is definitely not within the scope of behaviors that an NA can legally perform (1), both teaching and clarification of duties is needed in this situation. Before accusing the NA, a nonpunitive environment should be created so teaching of both the LVN and NA can occur, and this action will not happen again. Unless too much medication was given, an incident report does not need to be filled out (2). Confronting the team members in a staff meeting (3) would not be following good management principles.

15. D. Following Total Gastrectomy the production of Intrinsic Factor is permanently destroyed. This is necessary (Intrinsic Factor) for the absorption of Vitamin B12 from the GI tract. As a result patients MUST receive Vitamin B12 by parenteral route throughout life, or a condition known as Pernicious Anemia will develop, and can prove to be fatal. Regular IM injections on a monthly basis of 100-200ug is the usual therapeutic dose.

a. Whole milk, ice cream and cheese
b. Rice, corn and soybeans
c. Bread, oatmeal and pretzels
d. Beef, liver and veal

2. Following delivery of a normal newborn, the nurse will assess the mother every 15 minutes for the first hour. The most important assessment is for

a. Placental fragments.
b. Presence of lochia.
c. Condition of the fundus.
d. Hemorrhage.

3. A breast feeding mother develops mastitis in the left breast and is put on an antibiotic for seven days. She asks the nurse if she can continue breast feeding. The nurse’s best answer would be:

a. “Only breast feed from the right breast.”
b. “Do not breast feed or stimulate the breasts until the infection is resolved.”
c. “Continue breast feeding, this is not a contraindication.”
d. “Pump the breasts and discard the milk until the infection resolves.“

4. The nurse is assigned a client at risk for developing deep vein thrombosis (DVT) following a total knee replacement. The most effective measure to prevent this complication is

a. An exercise schedule of dorsiflexion of the feet.
b. Maintaining a flat bed from the waist down.
c. Instruction in shallow breathing techniques.
d. Maintaining the client on bedrest.

5. An elderly man is admitted to the Geriatric Unit for his forgetfulness and severe behavioral changes. He is diagnosed with Alzheimer’s Disease. Which of the following should be the primary goal of nursing intervention?

a. Keep him away from problems of daily living
b. Keep his capacity for self care activities to the optimum
c. Keep him isolated
d. Keep all available resources to increase his dependency

6. While bathing a 1 year old, the nurse feels a large mass in the abdominal area and notices that his diaper is soiled with pinkish-tinged urine. The initial nursing action is to

a. Gently palpate the abdominal mass to determine if it is a Wilms’ tumor.
b. Continue the assessment by observing his behavior indicating pain on palpation.
c. Immediately notify the physician.
d. Assess if the tumor has spread to the lymph nodes.

7. Which of the following is an INCORRECT statement regarding diet therapy for a patient in renal failure?

a. Limit dietary protein
b. Provide a diet high in carbohydrates
c. Limit Sodium (NA) intake
d. Provide a diet high in Potassium rich food

8. Instructions given to clients following cataract surgery include the information that

a. Contact lenses will be fitted before discharge from the hospital.
b. They must use only one eye at a time to prevent double vision.
c. They will be able to judge distances without difficulty.
d. The eye patch will be removed in 3 to 4 days, and the eye may be used without difficulty.

9. In teaching High School students about health practices that promote the prevention of spread of the HIV virus, the nurse should include which of the following:

a. Use a latex condom and water soluble lubricant during intercourse
b. Abstain from intercourse if the female is menstruating
c. Following oral intercourse, use an over-the-counter mouthwash so to destroy the HIV virus
d. Shower immediately with an antibacterial soap after intercourse, so to destroy the HIV virus

10. Following delivery of a healthy baby, the nurse completes a postpartum assessment of the new mother. Which of the following symptoms would be indicative of a full bladder?

a. Pulse 52 beats/min.
b. Fundus 2F above umbilicus.
c. Increased uterine contractions.
d. Decreased lochia.

11. The parents of a child with Tetralogy of Fallot have been given discharge instructions. Which of the following situations would the parents be instructed to avoid?

a. All infant contact with persons outside the home
b. Infant contact with persons who have mild colds
c. Infant contact with persons who have severe allergies
d. Routine immunizations

12. A nursing measure to prevent the complication of deep vein thrombophlebitis following surgery would include

a. Wearing elastic hose at all times.
b. Having the client sit up TID.
c. Placing pillows under the affected limb
d. Elevating the foot of the bed.

13. Following Gastric Resection, patients are prone to developing Dumping Syndrome. Which of the following types of dietary intake by the patient would be MOST helpful to either reduce or prevent this syndrome from developing?

a. Moderate fat, low carbohydrate
b. High fat, high carbohydrate
c. Low fat, low carbohydrate
d. Moderate fat, high carbohydrate

14. The RN observes the nursing assistant (NA) regulating the IV of an oncology client receiving morphine sulfate for pain. An LVN on the RN’s team is responsible for the client and has assigned the client to the NA. The RN’s intervention is to

a. Immediately inform the charge nurse and fill out an incident report.
b. Ask the LVN and the NA to meet with the RN to discuss the responsibility -parameters each of them has.
c. Inform the LVN so that he/she intervenes to instruct the NA that this -action is not within the realm of responsibility of an NA.
d. Call a staff meeting and confront the LVN and the NA.

15. Following Total Gastrectomy patients will require vitamin replacement. Of the following, which vitamin is ESSENTIAL and MUST be given throughout life:

a. Vitamin C
b. Vitamin B6
c. Vitamin D
d. Vitamin B12

ANSWERS & RATIONALE

1.    Answer D.  Administering eye drops should be done in the lower conjunctival sac to ensure that the medication gets to eye. Option A is not done since some medications can irritate the cornea when placed directly in to it. Options B and C are not practiced because doing so cannot hold the medication into the eye. Its tendency would be, the medication would run out or flow out of the eyes.
2.    Answer A. Infiltration happens when the intravenous fluid does not enter the veins, instead it is diffused in the areas outside the vein which explains why the area is swollen and cool to touch. Option B happens when there is there is an inflammation of the vein in the site. It is characterized by pain, swelling, redness and it is warm to touch. Option C is manifested by pain, swelling, warm to touch, redness and fever is present in the client. Option D is expected when the client complains of feeling pain in the IV site and that you can see in the IV tubing that it is filled with air.
3.    Answer B. It is a priority nursing action to first assess the client’s IV site before doing anything. Once there is a report of pain in the site, plus edema and erythema, we check for the patency of the IV site, if it is not patent, then we discontinue the IV and apply warm compress to the IV site to lessen swelling. Options A and D are incorrect because such actions will not relieve the client from pain, edema and erythema. Option C is not indicated because there is no accurate indication that there is a bacterial infection in the site.
4.    Answer B. Quantity= desired dose/ available dose       0.125/ 0.25 = 0.5 tab. The nurse should dispense ½ tablet of Digoxin. Options A, C and D are all incorrect answer.
5.    Answer B. 41.66 or 42 gtts/min           
6.    Answer D. When a nurse is caring for quite a number of patients, to prevent the spread of infections among patients, she should know who are the possible carrier of infections and those who are at risk of acquiring one. Options A, B and C are inappropriate infection preventions that are indicated in this situation.
7.    Answer A. Stool for ova and parasites does not require a sterile technique because we are after for the presence of ova and parasites. And if we are looking for the presence of bacteria in the stool, sterile technique is not still utilized because normally there will be a lot of bacteria in the stool. Options B, C and D require a sterile technique in order to identify what bacterial growth is present in the specimen.
8.    Answer C. The patient is at greater risk of wound infection when he is punctured by a nail in the foot. He is at risk for acquiring tetanus infection once he is not given with tetanus toxoid immunization. The wound the nail creates is quite deep thus there is a great risk for infection. In the case of Option A, patients with colostomy is often given with antibiotics. Options B and D are incorrect because the wound created is not quite deep.
9.    Answer C. The skin is the first line of defense of the body against the infections. In cases of burns more than 20% of the body, this defense is weakened thus the person is greatly predisposed to developing different kinds of infection. Burns does not only affect the ability of the skin to defend the body but it also alters the immunity of the body. Options A, B and D may predispose a patient from the development of infections but cannot be considered as great as compared to burns.
10.    Answer C. Heat loss is achieved through different methods. Conduction happens when there is a direct contact of a material in the skin to achieve heat loss. In this case heat loss is achieved with the use of cooling blanket. Option A is achieved when body heat is diffused away from the body into the air via skin. Option B is achieved by moving air away from the body to replace the warmth the body has with the use of a fan. Option D is achieved with the use of water such as in tepid sponge baths.
11.    Answer C. The stages of grief includes: Denial, Anger, Bargaining, Depression and Acceptance. The stage of denial is when the patient is unable to acknowledge the existence of the diagnosis. In this stage, the patient would seek more opinions from other doctors because she cannot accept the fact of her diagnosis. Options A and D are an example of the stage anger, in which she asks a lot of questions regarding the reason of her sickness. Option D shows the acceptance of the patient.
12.    Answer A. Touching to provide support is a form of therapeutic communication. The use of touch reinforces caring feelings. Option B is non therapeutic. Option C is incorrect because the nurse is not in the position to tell the patient’s family of her prognosis. It is only done by the patient or when the patient requests the nurse to do so. Option D may correct but is not the best answer indicated in this situation.
13.    Answer C. Mrs. Estrada is undergoing the process of depression which is a normal in coping with the grief process. In order to be therapeutic for this patient, the nurse should accept this behavioural adaptation of the patient, since it is just normal. Options A, B and D are non therapeutic because this conditions do not allow the normal process of grieving.
14.    Answer C. The patient is experiencing fear because she herself has seen how her father died in the same age as she has in the present. Options A, B and D may be correct but are not indicated in the situation presented.
15.    Answer B. Bargaining is the stage when the patient tries new things in order for her to lengthen her life. She is willing to try therapies ranging from the conventional to non conventional methods of treating her cancer. Other options do not describe the grieving stage that Mrs. Estrada is experiencing.
16.    Answer B. The Licensure of Registered Professional Nurses protects its main consumers which are the patients. Other options are not the reason as to why nurses undergo licensing.
17.    Answer C. Incident reports are filled out in order to record details of unusual events occurring in the hospital and care of patients. In this case, the incident report is filled out in order to have an available data for quality control analysis and in the future when dealing with legal liabilities. Options A, B and D are incorrect because these are not the reason as to why nurses fill out incident reports.
18.    Answer A. Assault is threatening or attempting to inflict injuries to the patient. The verbalization of the nurse clearly shows that it is a case of an assault. Option B is touching the patient without consent. This is done by pinching or slapping the patient. Options C and D are forms of violations that the nurse can commit to a patient in line with the patients profession.
19.    Answer B. This is a case where the nurse committed an assault as manifested by the threatening behaviour of the nurse. Option A is achieved when you speak ill of a person. Option B is putting the threatening behaviour into action. Option D is committed when one talks ill of another through writing it in a published form.
20.    Answer C. Living will is a legal document that an individual uses to make known his wishes to prolong his life. It is also known as advanced directives. In this case, a living will gives consent to perform life sustaining medical intervention to prolong life in cases of emergency. Other options presented are incorrect because they do not describe what a living will is all about.
21.    Answer C. Consents allow the physician to do the medical procedures indicated for the patient. Prior to procedure, it is the doctor’s responsibility to obtain the patient’s consent and it is the responsibility of the nurse to let the patient sign the consent prior to the surgical procedure. Consent unsigned is like consent not given so it is a must that the nurse should tell the situation to the doctor performing the surgery. Options A, B and D are incorrect because they violate the legalities of the consent.
22.    Answer B. The owner of the chart is the patient himself so it is a must that before authorizing any individual to view the chart, authorization should secured and have someone review the chart with the patient’s physician cousin. Options A, C and D are the incorrect way of dealing such situations involving the patient’s chart.
23.    Answer C. When restraints are applied, it is a must for the nurse to assess the quality of the patient’s skin where the restraint is applied. The priority assessment should be done by assessing the patient’s capillary refill so as to ensure circulation of the extremity. Capillary refill of less than two seconds shows that there is a good circulation in that area. Options A, B and D are signs that the restraints applied are having negative effects to the patient’s extremity.
24.    Answer A. It is the preferred answer because right there in then you will be able to stop the discussion of the patient’s case in front of a lot of people. Option B may be correct because you are saving from humiliation the nursing assistance but it is not the preferred answer because doing so will allow further discussion of the case and more harm will be committed. Option C may be correct because in the first place you are not their immediate superior but not appropriate in this situation because it will further the discussion of the case thus allowing a lot of people to overhear it. Option D is the worst thing to do since you will not do anything to prevent it from happening.
25.    Answer A.Good Samaritan Act protects those who choose to lend a hand during emergency situations. In this act, the nurse is not liable to any laws once she helps an injured individual during this emergency. Options B, C and D are incorrect because these do not explain what the act is all about.

1.    Answer C. Because of changes in fat distribution, adipose tissue accumulates in the trunk, face (moonface), and dorsocervical areas (buffalo hump). Hypertension is caused by fluid retention. Skin becomes thin and bruises easily because of a loss of collagen. Muscle wasting causes muscle atrophy and thin extremities.

2.    Answer C. Desmopressin may not be absorbed if the intranasal route is compromised. Although diabetes insipidus is treatable, the client should wear medical identification and carry medication at all times to alert medical personnel in an emergency and ensure proper treatment. The client must continue to monitor fluid intake and output and receive adequate fluid replacement.

3.    Answer A. Chvostek’s sign is elicited by tapping the client’s face lightly over the facial nerve, just below the temple. If the client’s facial muscles twitch, it indicates hypocalcemia. Hyponatremia is indicated by weight loss, abdominal cramping, muscle weakness, headache, and postural hypotension. Hypokalemia causes paralytic ileus and muscle weakness. Clients with hypermagnesemia exhibit a loss of deep tendon reflexes, coma, or cardiac arrest.

4.    Answer A. Hyperglycemia, which develops from glucocorticoid excess, is a manifestation of Cushing’s syndrome. With successful treatment of the disorder, serum glucose levels decline. Hirsutism is common in Cushing’s syndrome; therefore, with successful treatment, abnormal hair growth also declines. Osteoporosis occurs in Cushing’s syndrome; therefore, with successful treatment, bone mineralization increases. Amenorrhea develops in Cushing’s syndrome. With successful treatment, the client experiences a return of menstrual flow, not a decline in it.

5.    Answer C. Corticotropin interacts with plasma membrane receptors to produce enzymatic actions that affect protein, fat, and carbohydrate metabolism. It doesn’t decrease cAMP production. The posterior pituitary hormone, antidiuretic hormone, regulates the threshold for water resorption in the kidneys.

6.    Answer C. Regular insulin, which is a short-acting insulin, has an onset of 15 to 30 minutes and a peak of 2 to 4 hours. Because the nurse gave the insulin at 2 p.m., the expected onset would be from 2:15 p.m. to 2:30 p.m. and the peak from 4 p.m. to 6 p.m.

7.    Answer A. Agitation, irritability, poor memory, loss of appetite, and neglect of one’s appearance may signal depression, which is common in clients with Cushing’s syndrome. Neuropathy affects clients with diabetes mellitus — not Cushing’s syndrome. Although hypoglycemia can cause irritability, it also produces increased appetite, rather than loss of appetite. Hyperthyroidism typically causes such signs as goiter, nervousness, heat intolerance, and weight loss despite increased appetite.

8.    Answer A. Tetany may result if the parathyroid glands are excised or damaged during thyroid surgery. Hemorrhage is a potential complication after thyroid surgery but is characterized by tachycardia, hypotension, frequent swallowing, feelings of fullness at the incision site, choking, and bleeding. Thyroid storm is another term for severe hyperthyroidism — not a complication of thyroidectomy. Laryngeal nerve damage may occur postoperatively, but its signs include a hoarse voice and, possibly, acute airway obstruction.

9.    Answer A. Levothyroxine is the preferred agent to treat primary hypothyroidism and cretinism, although it also may be used to treat secondary hypothyroidism. It is contraindicated in Graves’ disease and thyrotoxicosis because these conditions are forms of hyperthyroidism. Euthyroidism, a term used to describe normal thyroid function, wouldn’t require any thyroid preparation.

10.    Answer B. SIADH secretion causes antidiuretic hormone overproduction, which leads to fluid retention. Severe SIADH can cause such complications as vascular fluid overload, signaled by neck vein distention. This syndrome isn’t associated with tetanic contractions. It may cause weight gain and fluid retention (secondary to oliguria).

11.    Answer A. Pheochromocytoma causes excessive production of epinephrine and norepinephrine, natural catecholamines that raise the blood pressure. Phentolamine, an alpha-adrenergic blocking agent given by I.V. bolus or drip, antagonizes the body’s response to circulating epinephrine and norepinephrine, reducing blood pressure quickly and effectively. Although methyldopa is an antihypertensive agent available in parenteral form, it isn’t effective in treating hypertensive emergencies. Mannitol, a diuretic, isn’t used to treat hypertensive emergencies. Felodipine, an antihypertensive agent, is available only in extended-release tablets and therefore doesn’t reduce blood pressure quickly enough to correct hypertensive crisis.

12.    Answer A. Excessive secretion of aldosterone in the adrenal cortex is responsible for the client’s hypertension. This hormone acts on the renal tubule, where it promotes reabsorption of sodium and excretion of potassium and hydrogen ions. The pancreas mainly secretes hormones involved in fuel metabolism. The adrenal medulla secretes the catecholamines — epinephrine and norepinephrine. The parathyroids secrete parathyroid hormone.

13.    Answer A. Addison’s disease decreases the production of all adrenal hormones, compromising the body’s normal stress response and increasing the risk of infection. Other appropriate nursing diagnoses for a client with Addison’s disease include Deficient fluid volume and Hyperthermia. Urinary retention isn’t appropriate because Addison’s disease causes polyuria.

14.    Answer A. Acarbose delays glucose absorption, so the client should take an oral form of dextrose rather than a product containing table sugar when treating hypoglycemia. The alpha-glucosidase inhibitors work by delaying the carbohydrate digestion and glucose absorption. It’s safe to be on a regimen that includes insulin and an alpha-glucosidase inhibitor. The client should take the drug at the start of a meal, not 30 minutes to an hour before.

15.    Answer B. After a transsphenoidal hypophysectomy, the client must refrain from coughing, sneezing, and blowing the nose for several days to avoid disturbing the surgical graft used to close the wound. The head of the bed must be elevated, not kept flat, to prevent tension or pressure on the suture line. Within 24 hours after a hypophysectomy, transient diabetes insipidus commonly occurs; this calls for increased, not restricted, fluid intake. Visual, not auditory, changes are a potential complication of hypophysectomy.

16.    Answer A. The client should take glipizide twice a day, 30 minutes before a meal, because food decreases its absorption. The drug doesn’t cause hyponatremia and therefore doesn’t necessitate monthly serum sodium measurement. The client must continue to monitor the blood glucose level during glipizide therapy.

17.    Answer C. For this client, wet-to-dry dressings are most appropriate because they clean the foot ulcer by debriding exudate and necrotic tissue, thus promoting healing by secondary intention. Moist, transparent dressings contain exudate and provide a moist wound environment. Hydrocolloid dressings prevent the entrance of microorganisms and minimize wound discomfort. Dry sterile dressings protect the wound from mechanical trauma and promote healing.

18.    Answer C. The client should be encouraged to force fluids to prevent renal calculi formation. Sodium should be encouraged to replace losses in urine. Restricting potassium isn’t necessary in hyperparathyroidism.

19.    Answer D. In the client with hyperthyroidism, excessive thyroid hormone production leads to hypermetabolism and increased nutrient metabolism. These conditions may result in a negative nitrogen balance, increased protein synthesis and breakdown, decreased glucose tolerance, and fat mobilization and depletion. This puts the client at risk for marked nutrient and calorie deficiency, making Imbalanced nutrition: Less than body requirements the most important nursing diagnosis. Options B and C may be appropriate for a client with hypothyroidism, which slows the metabolic rate.

20.    Answer D. Serum osmolarity is the most important test for confirming HHNS; it’s also used to guide treatment strategies and determine evaluation criteria. A client with HHNS typically has a serum osmolarity of more than 350 mOsm/L. Serum potassium, serum sodium, and ABG values are also measured, but they aren’t as important as serum osmolarity for confirming a diagnosis of HHNS. A client with HHNS typically has hypernatremia and osmotic diuresis. ABG values reveal acidosis, and the potassium level is variable.

21.    Answer B. Exercise, reduced food intake, hypothyroidism, and certain medications decrease the insulin requirements. Growth, pregnancy, greater food intake, stress, surgery, infection, illness, increased insulin antibodies, and certain medications increase the insulin requirements.

22.    Answer A. As a normal body protein, glucagon only interacts adversely with oral anticoagulants, increasing the anticoagulant effects. It doesn’t interact adversely with anabolic steroids, beta-adrenergic blockers, or thiazide diuretics.

23.    Answer A. The client should be instructed always to follow the same order when drawing the different insulins into the syringe. Insulin should never be shaken because the resulting froth prevents withdrawal of an accurate dose and may damage the insulin protein molecules. Insulin also should never be frozen because the insulin protein molecules may be damaged. Intermediate-acting insulin is normally cloudy.

24.    Answer C. This client is having a hypoglycemic episode. Because the client is conscious, the nurse should first administer a fast-acting carbohydrate, such as orange juice, hard candy, or honey. If the client has lost consciousness, the nurse should administer either I.M. or subcutaneous glucagon or an I.V. bolus of dextrose 50%. The nurse shouldn’t administer insulin to a client who’s hypoglycemic; this action will further compromise the client’s condition.

25.    Answer A. The client who has undergone a thyroidectomy is at risk for developing hypocalcemia from inadvertent removal or damage to the parathyroid gland. The client with hypocalcemia will exhibit a positive Chvostek’s sign (facial muscle contraction when the facial nerve in front of the ear is tapped) and a positive Trousseau’s sign (carpal spasm when a blood pressure cuff is inflated for a few minutes). These signs aren’t present with hypercalcemia, hypokalemia, or hyperkalemia.

NCLEX Sample Questions

1.       Answer: (A) Identify the source of the conflict and understand the points of friction
This involves a problem solving approach, which addresses the root cause of the problem.

2.       Answer: (B) Is not beneficial; hence it should be prevented at all times
Conflicts are beneficial because it surfaces out issues in the open and can be solved right away. Likewise, members of the team become more conscientious with their work when they are aware that other members of the team are watching them.

3.       Answer: (C) Avoidance
This strategy shuns discussing the issue head-on and prefers to postpone it to a later time. In effect the problem remains unsolved and both parties are in a lose-lose situation.

4.       Answer: (D) Let the staff ventilate her feelings and ask how she can be of help.
Reaching out and helping the staff is the most effective strategy in dealing with burn out. Knowing that someone is ready to help makes the staff feel important; hence her self-worth is enhanced.

5.       Answer: (D) Focusing activity on the correction of identified behavior.
Performance appraisal deal with both positive and negative performance; is not meant to be a fault-finding activity

6.       Answer: (C) Patients are the best source of information regarding personnel appraisal.
The patient can be a source of information about the performance of the staff but it is never the best source. Directly observing the staff is the best source of information for personnel appraisal.

7.       Answer: (C) The evaluation is focused on objective data systematically.
Collecting objective data systematically can not be achieved in an informal appraisal. It is focused on what actually happens in the natural work setting.

8.       Answer: (D) The session is private between the two members.
The session is private between the manager and the staff and remains to be so when the two parties do not divulge the information to others.

9.       Answer: (B) Consultative
A consultative manager is almost like a participative manager. The participative manager has complete trust and confidence in the subordinate, always uses the opinions and ideas of subordinates and communicates in all directions.

10.    Answer: (D) Unity of direction
Unity of direction is a management principle, not an element of an organizational structure.

11.    Answer: (A) Staffing
Staffing is a management function involving putting the best people to accomplish tasks and activities to attain the goals of the organization.

12.    Answer: (B) Record of related learning experience (RLE)
Record of RLE is not required for employment purposes but it is required for the nurse’s licensure examination.

13.    Answer: (B) Induction
This step in the recruitment process gives time for the staff to submit all the documentary requirements for employment.

14.    Answer: (B) Decentralized
Decentralized structures allow the staff to make decisions on matters pertaining to their practice and communicate in downward, upward, lateral and diagonal flow.

15.    Answer: (C) Rightmost box
The leftmost box is occupied by the highest authority while the lowest level worker occupies the rightmost box.

16.    Answer: (D) Promotes better interpersonal relationship
Decentralized structures allow the staff to solve decisions by themselves, involve them in decision making; hence they are always given opportunities to interact with one another.

17.    Answer: (B) Provides care to a group of patients together with a group of nurses
This function is done in team nursing where the nurse is a member of a team that provides care for a group of patients.

18.    Answer: (B) Modular nursing
Modular nursing is a variant of team nursing. The difference lies in the fact that the members in modular nursing are paraprofessional workers.

19.    Answer: (B) Identify the values of the department
Identify the values of the department will set the guiding principles within which the department will operate its activities 

20.    Answer: (B) Rotation of duty will be done every four weeks for all patient care personnel.
Structure standards include management system, facilities, equipment, materials needed to deliver care to patients. Rotation of duty is a management system.

21.    Answer: (A) Process
Process standards include care plans, nursing procedure to be done to address the needs of the patients.

22.    Answer: (D) Identify possible courses of action
This is a step in a quality control process and not a basic step in the control process.

23.    Answer: (B) Characteristics used to measure the level of nursing care
Criteria are specific characteristics used to measure the standard of care.

24.    Answer: (A) Instructing the members of the standards committee to prepare policies
Instructing the members involves a directing function.

25.    Answer: (C) Patients’ reports 95% satisfaction rate prior to discharge from the hospital.
This refers to an outcome standard, which is a result of the care that is rendered to the patient.

26.    Answer: (A) The things that were planned are done
Controlling is defined as seeing to it that what is planned is done.

27.    Answer: (A) Span of control
Span of control refers to the number of workers who report directly to a manager.

28.    Answer: (B) Initiate a group interaction
Initiate a group interaction will be an opportunity to discuss the problem in the open.

29.    Answer: (C) Age of patients
An extraneous variable is not the primary concern of the researcher but has an effect on the results of the study. Adult patients may be young, middle or late adult.

30.    Answer: (B) Sr. Callista Roy
Sr. Callista Roy developed the Adaptation Model which involves the physiologic mode, self-concept mode, role function mode and dependence mode

31.    Answer: (C) Most accurate and valid method of data gathering
The most serious disadvantage of this method is accuracy and validity of information gathered

32.    Answer: (B) “Turnaround Time in Emergency Rooms”
The article is for pediatric patients and may not be relevant for adult patients.

33.    Answer: (C) Salary of nurses
Salary of staff nurses is not an indicator of patient satisfaction, hence need not be included as a variable in the study.

34.    Answer: (A) degree of agreement and disagreement
Likert scale is a 5-point summated scale used to determine the degree of agreement or disagreement of the respondents to a statement in a study.

35.    Answer: (B) Reliability
Reliability is repeatability of the instrument; it can elicit the same responses even with varied administration of the instrument

36.    Answer: (A) Sensitivity
Sensitivity is an attribute of the instrument that allow the respondents to distinguish differences of the options where to choose from

37.    Answer: (A) Validity
Validity is ensuring that the instrument contains appropriate questions about the research topic

38.    Answer: (A) Random
Random sampling gives equal chance for all the elements in the population to be picked as part of the sample.

39.    Answer: (B) Ethnography
Ethnography is focused on patterns of behavior of selected people within a culture

40.    Answer: (B) Madeleine Leininger
Madeleine Leininger developed the theory on transcultural theory based on her observations on the behavior of selected people within a culture

1. Identify the source of the conflict and understand the points of friction

2. Disregard what she feels and continue to work independently

3. Seek help from the Director of Nursing

4. Quit her job and look for another employment.

2. As a young manager, she knows that conflict occurs in any organization. Which of the following statements regarding conflict is NOT true?

1. Can be destructive if the level is too high

2. Is not beneficial; hence it should be prevented at all times

3. May result in poor performance

4. May create leaders

3. Katherine tells one of the staff, “I don’t have time to discuss the matter with you now. See me in my office later” when the latter asks if they can talk about an issue. Which of the following conflict resolution strategies did she use?

1. Smoothing

2. Compromise

3. Avoidance

4. Restriction

4. Kathleen knows that one of her staff is experiencing burnout. Which of the following is the best thing for her to do?

1. Advise her staff to go on vacation.

2. Ignore her observations; it will be resolved even without intervention

3. Remind her to show loyalty to the institution.

4. Let the staff ventilate her feelings and ask how she can be of help.

5. She knows that performance appraisal consists of all the following activities EXCEPT:

1. Setting specific standards and activities for individual performance.

2. Using agency standards as a guide.

3. Determine areas of strength and weaknesses

4. Focusing activity on the correction of identified behavior.

6. Which of the following statements is NOT true about performance appraisal?

1. Informing the staff about the specific impressions of their work help improve their performance.

2. A verbal appraisal is an acceptable substitute for a written report

3. Patients are the best source of information regarding personnel appraisal.

4. The outcome of performance appraisal rests primarily with the staff.

7. There are times when Katherine evaluates her staff as she makes her daily rounds. Which of the following is NOT a benefit of conducting an informal appraisal?

1. The staff member is observed in natural setting.

2. Incidental confrontation and collaboration is allowed.

3. The evaluation is focused on objective data systematically.

4. The evaluation may provide valid information for compilation of a formal report.

8. She conducts a 6-month performance review session with a staff member. Which of the following actions is appropriate?

1. She asks another nurse to attest the session as a witness.

2. She informs the staff that she may ask another nurse to read the appraisal before the session is over.

3. She tells the staff that the session is manager-centered.

4. The session is private between the two members.

9. Alexandra is tasked to organize the new wing of the hospital. She was given the authority to do as she deems fit. She is aware that the director of nursing has substantial trust and confidence in her capabilities, communicates through downward and upward channels and usually uses the ideas and opinions of her staff. Which of the following is her style of management?

1. Benevolent –authoritative

2. Consultative

3. Exploitive-authoritative

4. Participative

10. She decides to illustrate the organizational structure. Which of the following elements is NOT included?

1. Level of authority

2. Lines of communication

3. Span of control

4. Unity of direction

11. She plans of assigning competent people to fill the roles designed in the hierarchy. Which process refers to this?

1. Staffing

2. Scheduling

3. Recruitment

4. Induction

12. She checks the documentary requirements for the applicants for staff nurse position. Which one is NOT necessary?

1. Certificate of previous employment

2. Record of related learning experience (RLE)

3. Membership to accredited professional organization

4. Professional identification card

13. Which phase of the employment process includes getting on the payroll and completing documentary requirements?

1. Orientation

2. Induction

3. Selection

4. Recruitment

14. She tries to design an organizational structure that allows communication to flow in all directions and involve workers in decision making. Which form of organizational structure is this?

1. Centralized

2. Decentralized

3. Matrix

4. Informal

15. In a horizontal chart, the lowest level worker is located at the

1. Left most box

2. Middle

3. Right most box

4. Bottom

16. She decides to have a decentralized staffing system. Which of the following is an advantage of this system of staffing?

1. greater control of activities

2. Conserves time

3. Compatible with computerization

4. Promotes better interpersonal relationship

17. Aubrey thinks about primary nursing as a system to deliver care. Which of the following activities is NOT done by a primary nurse?

1. Collaborates with the physician

2. Provides care to a group of patients together with a group of nurses

3. Provides care for 5-6 patients during their hospital stay.

4. Performs comprehensive initial assessment

18. Which pattern of nursing care involves the care given by a group of paraprofessional workers led by a professional nurse who take care of patients with the same disease conditions and are located geographically near each other?

1. Case method

2. Modular nursing

3. Nursing case management

4. Team nursing

19. St. Raphael Medical Center just opened its new Performance Improvement Department. Ms. Valencia is appointed as the Quality Control Officer. She commits herself to her new role and plans her strategies to realize the goals and objectives of the department. Which of the following is a primary task that they should perform to have an effective control system?

1. Make an interpretation about strengths and weaknesses

2. Identify the values of the department

3. Identify structure, process, outcome standards & criteria

4. Measure actual performances

20. Ms. Valencia develops the standards to be followed. Among the following standards, which is considered as a structure standard?

1. The patients verbalized satisfaction of the nursing care received

2. Rotation of duty will be done every four weeks for all patient care personnel.

3. All patients shall have their weights taken recorded

4. Patients shall answer the evaluation form before discharge

21. When she presents the nursing procedures to be followed, she refers to what type of standards?

1. Process

2. Outcome

3. Structure

4. Criteria

22. The following are basic steps in the controlling process of the department. Which of the following is NOT included?

1. Measure actual performance

2. Set nursing standards and criteria

3. Compare results of performance to standards and objectives

4. Identify possible courses of action

23. Which of the following statements refers to criteria?

1. Agreed on level of nursing care

2. Characteristics used to measure the level of nursing care

3. Step-by-step guidelines

4. Statement which guide the group in decision making and problem solving

24. She wants to ensure that every task is carried out as planned. Which of the following tasks is NOT included in the controlling process?

1. Instructing the members of the standards committee to prepare policies

2. Reviewing the existing policies of the hospital

3. Evaluating the credentials of all nursing staff

4. Checking if activities conform to schedule

25. Ms. Valencia prepares the process standards. Which of the following is NOT a process standard?

1. Initial assessment shall be done to all patients within twenty four hours upon admission.

2. Informed consent shall be secured prior to any invasive procedure

3. Patients’ reports 95% satisfaction rate prior to discharge from the hospital.

4. Patient education about their illness and treatment shall be provided for all patients and their families.

26. Which of the following is evidence that the controlling process is effective?

1. The things that were planned are done

2. Physicians do not complain.

3. Employees are contended

4. There is an increase in customer satisfaction rate.

27. Ms. Valencia is responsible to the number of personnel reporting to her. This principle refers to:

1. Span of control

2. Unity of command

3. Carrot and stick principle

4. Esprit d’ corps

28. She notes that there is an increasing unrest of the staff due to fatigue brought about by shortage of staff. Which action is a priority?

1. Evaluate the overall result of the unrest

2. Initiate a group interaction

3. Develop a plan and implement it

4. Identify external and internal forces.

29. Kevin is a member of the Nursing Research Council of the hospital. His first assignment is to determine the level of patient satisfaction on the care they received from the hospital. He plans to include all adult patients admitted from April to May, with average length of stay of 3-4 days, first admission, and with no complications. Which of the following is an extraneous variable of the study?

1. Date of admission

2. Length of stay

3. Age of patients

4. Absence of complications

30. He thinks of an appropriate theoretical framework. Whose theory addresses the four modes of adaptation?

1. Martha Rogers

2. Sr. Callista Roy

3. Florence Nightingale

4. Jean Watson

31. He opts to use a self-report method. Which of the following is NOT TRUE about this method?

1. Most direct means of gathering information

2. Versatile in terms of content coverage

3. Most accurate and valid method of data gathering

4. Yields information that would be difficult to gather by another method

32. Which of the following articles would Kevin least consider for his review of literature?

1. “Story-Telling and Anxiety Reduction Among Pediatric Patients”

2. “Turnaround Time in Emergency Rooms”

3. “Outcome Standards in Tertiary Health Care Institutions”

4. “Environmental Manipulation and Client Outcomes”

33. Which of the following variables will he likely EXCLUDE in his study?

1. Competence of nurses

2. Caring attitude of nurses

3. Salary of nurses

4. Responsiveness of staff

34. He plans to use a Likert Scale to determine

1. degree of agreement and disagreement

2. compliance to expected standards

3. level of satisfaction

4. degree of acceptance

35. He checks if his instruments meet the criteria for evaluation. Which of the following criteria refers to the consistency or the ability to yield the same response upon its repeated administration?

1. Validity

2. Reliability

3. Sensitivity

4. Objectivity

36. Which criteria refer to the ability of the instrument to detect fine differences among the subjects being studied?

1. Sensitivity

2. Reliability

3. Validity

4. Objectivity

37. Which of the following terms refer to the degree to which an instrument measures what it is supposed to be measure?

1. Validity

2. Reliability

3. Meaningfulness

4. Sensitivity

38. He plans for his sampling method. Which sampling method gives equal chance to all units in the population to get picked?

1. Random

2. Accidental

3. Quota

4. Judgment

39. Raphael is interested to learn more about transcultural nursing because he is assigned at the family suites where most patients come from different cultures and countries. Which of the following designs is appropriate for this study?

1. Grounded theory

2. Ethnography

3. Case study

4. Phenomenology

40. The nursing theorist who developed transcultural nursing theory is

1. Dorothea Orem

2. Madeleine Leininger

3. Betty Newman

4. Sr. Callista Roy

Answers for LEADERSHIP, MANAGEMENT, BIOETHICS AND RESEARCH

1. Which individual is at greatest risk for developing hypertension?

A)     45 year-old African American attorney

B)     60 year-old Asian American shop owner

C)     40 year-old Caucasian nurse

D)     55 year-old Hispanic teacher

2. A child who ingested 15 maximum strength acetaminophen tablets 45 minutes ago is seen in the emergency department. Which of these orders should the nurse do first?

A)     Gastric lavage PRN

B)     Acetylcysteine (mucomyst) for age per pharmacy

C)     Start an IV Dextrose 5% with 0.33% normal saline to keep vein open

D)     Activated charcoal per pharmacy

38. Which of these statements best describes the characteristic of an effective reward-feedback system?

A)     Specific feedback is given as close to the event as possible

B)     Staff are given feedback in equal amounts over time

C)     Positive statements are to precede a negative statement

D)     Performance goals should be higher than what is attainable

39. A client with multiple sclerosis plans to begin an exercise program. In addition to discussing the benefits of regular exercise, the nurse should caution the client to avoid activities which

A)     Increase the heart rate

B)     Lead to dehydration

C)     Are considered aerobic

D)     May be competitive

40. During the evaluation of the quality of home care for a client with Alzheimer’s disease, the priority for the nurse is to reinforce which statement by a family member?

A)     At least 2 full meals a day is eaten.

B)     We go to a group discussion every week at our community center.

C)     We have safety bars installed in the bathroom and have 24 hour alarms on the doors.

D)     The medication is not a problem to have it taken 3 times a day.

Get the NCLEX Comprehensive Review Answers and Rationale

NCLEX Practice Question Answer Keys

1.      D Choice A is linked to Plague, Choice B is linked to peptic ulcers, Choice C is linked to Cholera.

2.      A Choice B is linked to Rheumatic fever, Choice C is linked to Anthrax, Choice D is linked toEndocarditis.

3.      D A CTscan would be performed for further investigation of the hemiparesis.

4.      C Weight gain and poor temperature tolerance indicate something may be wrong with the thyroidfunction.

5.      C Blood cultures would be performed to investigate the fever and rash symptoms.

6.      A With a history of diabetes, the first response should be to check blood sugar levels.

7.      C Age is not the greatest factor in potty training. The overall mental and physical abilities of thechild is the most important factor.

8.      C The poison control center will have an exact plan of action for this child.

9.      C Vastus lateralis is the most appropriate location.

10.  D In this case you are able to determine the name of the child by the father’s statement. You should not withhold the medication from the child following identification.

1. Following surgery

2. Upon admit

3. Within 48 hours of discharge

4. Preoperative discussion

1. Trust vs. mistrust

2. Initiative vs. guilt

3. Autonomy vs. shame

4. Intimacy vs. isolation

1. Trust vs. mistrust

2. Initiative vs. guilt

3. Autonomy vs. shame

4. Intimacy vs. isolation

1. Trust vs. mistrust

2. Initiative vs. guilt

3. Autonomy vs. shame

4. Intimacy vs. isolation

1. 11 year old male – 90 b.p.m, 22 resp/min. , 100/70 mm Hg

2. 13 year old female – 105 b.p.m., 22 resp/min., 105/60 mm Hg

3. 5 year old male- 102 b.p.m, 24 resp/min., 90/65 mm Hg

4. 6 year old female- 100 b.p.m., 26 resp/min., 90/70mm Hg

1. Elavil

2. Calcitonin

3. Pergolide

4. Verapamil

1. Campylobacterial infection

2. Legionnaire’s disease

3. Pneumonia

4. Multiple Sclerosis

1. Decreased HR

2. Paresthesias

3. Muscle weakness of the extremities

4. Migranes

1. Vomiting

2. Extreme Thirst

3. C: Weight gain

4. D: Acetone breath smell

1. Increased appetite

2. Vomiting

3. Fever

4. Poor tolerance of light

NCLEX Practice Question Answer Keys

1. B Discharge education begins upon admit.

2. B Initiative vs. guilt- 3-6 years old

3. A Trust vs. Mistrust- 12-18 months old

4. D Intimacy vs. isolation- 18-35 years old

5. B HR and Respirations are slightly increased. BP is down.

6. A Elavil is a tricyclic antidepressant.

7. D Erythromycin is used to treat conditions A-C.

8. D Answer choices A-C were symptoms of acute hyperkalemia.

9. C Weight loss would be expected.

10. A Loss of appetite would be expected.

NCLEX Practice Question Answer Keys

1. D The effects of PKU stay with the infant throughout their life.
2. D Aspirin overdose can lead to metabolic acidosis and cause pulmonary edema development.
3. D This patient’s safety is your primary concern.
4. C The bronchodilator will allow a more productive cough.
5. B Weight gain is associated with CHF and congenital heart deficits.
6. C The skin would be dry and not oily.
7. A Streptokinase is a clot busting drug and the best choice in this situation.
8. A Green vegetables and liver are a great source of folic acid.
9. D Cl. difficile has not been linked to meningitis.
10. D RBC’s last for 120 days in the body.