Situation: You are assigned to work in an orthopaedic ward where clients

are expected to have problems in mobility and immobility.

1. Kevin’s left leg was injured and Sarah, his attending nurse will be facilitating the
transfer. The nurse is going to move the client from Bed to chair. Which of the
following is correct?
a Elevate the bed to make sure that the client’s foot will dangle. LOWER
b Face the client and place the wheelchair on her left side. CORRECT:
wheelchair is on the client’s RIGHT side and the nurse’s LEFT side
c Put the client on the edge of the bed and place the wheelchair on the
other side of the bed.
d Put the client on the edge of the bed and place the wheelchair on the
client’s left side. Should be on the stronger side(RIGHT)

2. Which of the following will occur earliest in bed to chair transfer?

a Lower the bed to the lowest position.
b Place the wheelchair parallel to the bed.
c Lock the wheelchair in raise the foot plate.
d Ask the client to sit at the edge of the Bed.

3. Which of the following device allows the nurse to hold the client and support the
client’s body without holding the client’s axilla?
a Bathrobe c. Sling lift
b Neck leash d. Transfer belt

4. When holding the transfer belt, the nurse will make sure that:
a Hold the transfer belt with the thumbs facing upward.
b Hold the transfer belt with the thumb
c Hold the transfer belt with the thumbs facing down ward
d Hold the transfer belt with the little finger.

5. The nurse successfully moved the client from Bed to the wheelchair. After
unlocking the breaks of the chair and lowering the foot plates. The nurse can
now move the wheelchair freely. Upon entering the elevator, the nurse should
remember that:
a The small wheels should enter the elevator first.
b Rear large wheels enter the elevator first. (same manner when exiting the
elevator)
c Patient will enter the elevator first.
d Patient leaves the wheelchair before entering the elevator.

6. When climbing an incline, the nurse should remember:

a The nurse should be at the bottom of the incline pushing the client small
wheel first.
 b Rear large wheel first against an incline. This is going up, this should be
down when going down an inlicine
c The nurse should be above the incline and the client below the incline.
d The nurse should pull the client instead of pushing against the incline

B C D are all the same ideas

7. Anthony asks to be assisted to move up the bed. Which of the following should
Nurse Diana do first?
a Moved the patient to the edge of the bed near the nurse.
b Adjust the bed to flat position.
c Lock the wheels of the bed.
d Raise the bed rails opposite the nurse.

8. The nurse is caring for the client who has been admitted with Glaucoma, when
assisting this client for ambulation, the nurse would:
a Slightly in front of the client, offering an elbow to hold.
b Slightly in front of the client, grasping the client’s elbow. Increases the risk
for injuries like shoulder or elbow dislocation if the client slips
c Next to the client, offering an elbow to hold.
d Next to the client, holding the client’s elbow.

9. The nurse is caring the client with acute head injury, the client has been stabilized
and now prepared for rehabilitation. In transferring the client from bed to chair,
the nurse should:
a Raise the side rails of both sides of the bed.
b Position the chair 2 feet from the bed.
c Lock the brakes on the bed.
d Place socks on the client’s foot.

10. The nurse is caring for a client with head injury, when positioning this client, the
nurse should:
a On his side, with the head of bed elevated.
b Flat on his back, with his head turned on the side.
c Prone with his knees slightly flexed.
d Trendelenburg position, with his body in straight alignment.

***Client is at risk for having seizures and may experience alterations in the
level of consciousness

11. The nurse is about to perform a back rub to the client after a complete bed bath.
How should the nurse proceed?
a Place the client at the middle of the bed.
 b Pour the lotion into the client’s back.
c Rub the back gently especially over the bony prominences.
d Wipe the excess lotion using a rubbing motion.

***** This increases the blood flow to the bony prominences, improving
perfusion and making them less prone to pressure ulcers.

12 When teaching a client with hemiparesis to ambulate with a cane, the nurse
should instruct the client to:
a Shorten the stride of the unaffected extremity.
b Bear the weight on the knees of the affected leg
c Hold it on the hand ipsilateral to the side of the injured extremity
WRONG, ipsilateral-same side. Should be contralateral or opposite side
d Hold it in the hand on the same side as the affected lower extremity.
e None

13. The nurse knows that the cane should be at least how many inches at the top
and side of the foot?
a 4 inches b. 6 inches c. 10 inches d. 12
inches

Nurse Tina is preparing an IV solution ordered by the physician to a 68 year old male
elderly client, admitted to the Emergency Department for bouts of nausea and
vomiting.

14 The nurse’s responsibility prior to the initiation of IV therapy is to:

A. Obtain informed consent and document in the client’s permanent record
B. Prepare the client for the procedure and document in the client’s medical
record
C. Review the physician’s order and gather the necessary equipment
D. Ask assistance from another nurse following hospital protocol

15. In initiating IV therapy, nurse Tina assesses the potential site. Which of the
following should nurse Tina take into consideration when assessing the
venipuncture site?
A. Check expiry date, amount of solution and clinical impairment
B. Size of the needle and type of solution and condition of the client
C. Age, body size, clinical status and skin condition
D. Size of the vein, suitable location and type of solution
 16 Prior to the insertion of the needle to the IV site, nurse Tina observes
precautionary measures to ensure that the IV solution is not contaminated or out
dated by:
A. Assuring that the solution has been stored in the area assigned by the
institution
B. Determining the amount of the solution, presence of particulate matter and
expiry date
C. Checking for clarity of the fluid and manufacturer date
D. Inspecting the bag for leaks, tears or cracks and expiry date

17. Nurse Tina is priming the IV tubing. This is accomplished by:

A. Attaching the IV tubing to the venipuncture catheter to prevent entrance of
air into the tube
B. Opening the roller clamp on the tubing to allow the fluid to enter the tube
and expel the air
C. Closing the roller clamp and replacing cap protector to prevent air from
reentering the tube
D. Opening the clamp and regulating the flow of the IV solution or setting the
flow rate

18. Which assessment finding would lead nurse Tina to suspect that the client is
inadvertently received too much IV fluid? CIRCULATORY OVERLOAD
A. Temperature has risen to 38.5 degree centigrade INFECTION
B. Bounding pulse and crackles and wheezes in the lungs CORRECT- crackles
can only mean that there’s fluid in the alveoli in the lungs
C. Blood pressure is 160/70 High blood pressure with widened pulse pressure,
this could mean fluid volume excess but can also signify other conditions like
increased ICP or late changes in head injury.
D. Imbalances in arterial blood gases acid base disturbance

Situation 2 : TRANSFERRING OF PATIENT FROM BED TO WHEELCHAIR

19 A client may need to be transferred between the bed and a wheelchair or chair,
and/or between the bed and the commode. There are numerous variations in
the technique. When transferring a patient from bed to chair, the nurse is
incorrect when she places the wheelchair in which position in reference to the
bed?
1.45 degrees INCORRECT
2. 90 degrees INCORRECT
3.180 degrees CORRECT
4.Parallel CORRECT
5. Perpendicular INCORRECT
6.Beside INCORRECT
7. Upright INCORRECT
A12567 D. 3 4 5
B34 E. None
C35
20. A transfer belt is a device used when transferring the patient from bed to chair. It
permits the nurse to transfer a patient without holding the client’s axilla.
Remember to avoid placing your hands on the client’s axilla especially to a
patient who have upper extremity paralysis or paresis because it might aggravate
the problem. If a transfer belt is not available and the client needs to be
transferred from bed to chair, what should the nurse do to promote a safe
transfer?
A. Reach through the client’s axilla and place the hands on the client’s
scapula during the transfer
B. Reach through the client’s axilla and place the hands on the client’s
costovertebral angle during the transfer may cause injury the the flank/
kidneys
C. Reach through the client’s axilla and place the hands on the client’s 5th ICS
during the transfer may cause possible rib fractures
D. Reach through the client’s axilla and place the hands on the client’s gluteal
muscle during the transfer

21 The client’s left leg is injured and the client is sitting on the edge of the bed.
When preparing the client to be transferred to a wheelchair, which side of the
client and the nurse should the wheelchair be placed?
A. Right side of the nurse, right side of the client
B. Right side of the nurse, left side of the client
C. Left side of the nurse, right side of the client
D. Left side of the nurse, left side of the client

**** The wheelchair is always placed next to the client’s STRONGER SIDE
for this situation: the wheelchair should next to the client’s RIGHT SIDE and on the LEFT
SIDE of the nurse( the nurse is assuming a MIRRORED position or facing the client)

22. Which of the following demonstrates proper technique in moving a client from
sitting on the side of the bed to the wheelchair? SATA.

i. Placing the bed in the lowest possible position (waist level) and
locking the wheels of the bed is needed KNEE LEVEL
ii. The wheelchair is placed 180 degrees or perpendicular to the bed
PARALLEL
iii. The wheelchair must be placed in the stronger side of the nurse and
lock the wheels of the wheelchair CLIENT
iv. The client must be placed in the middle of the bed to prevent falls
on the edge of the bed
v. Walking belt is placed around the client’s waist
vi. The nurse and the patient must be in an “inverted side to side
position” before the actual transfer MIRRORED or facing each other
vii. The nurse rocks from the front foot to the rear foot while standing
the client.
 viii. Have the client grasp the nurse around the neck and face for stability
while standing Have the client lean into the nurse and hold the nurse’s
forearms for support during the transfer
A ii, iii, iv, v, vi, vi
B i, ii, iii, v, vi
C i, ii, iv, v
D v, vii
E i, v, vi

23. Which of the following hydraulic lift device is used to transfer patient from bed
to chair or chair to bed?
a. Manual lifter D. Manual Lifting
b. Hoyer lift E. Bedside commode
c. Fork lift

24. A 10-year-old child with recently diagnosed asthma is receiving information

about the use of a peak expiratory flow meter (PEFM). The nurse knows that the
child understands how to use the PEFM when she makes which statement?

A. “I need to take three readings and get the average to know my maximum readings.

The highest reading among the three results is considered to be the maximum reading.

B. “A position of utmost comfort is ideal when using a PEFM.”

To promote maximum lung expansion, and to ensure that the PEFM readings will be
accurate, the client should assume an upright position such as standing or sitting

C. “I need to stop using my meds before using my PEFM to avoid influencing the
results.”

WRONG. PEFM is not a diagnostic test. This procedure is used to evaluate if the client’s
current medical regimen is able to address and control his/her condition(Asthma).

D. “To use the device, I need to blow hard and fast and puff multiple times to get my
score.” wrong: SHOULD BE A SINGLE FORCED BLOW/ EXHALATION

E. None

25. PEFM usage falls under what aspect of nursing process?

A. Assessment
B. Diagnosis
C. Intervention
D. Evaluation

. A client’s ABG results area as follows:

pH: 7.44
PaCO2: 48mm/Hg
HCO3: 29 mEq/L

Which acid-base imbalance can be inferred from the findings above?

A. Resipiratory Acidosis
B. Respiratory Alkalosis
C. Metabolic Acidosis
D. Metabolic Alkalosis
E. None.

. What about the degree of compensation? (refer to the preceding number)

A. Partially Compensated
B. Fully Compensated
C. Uncompensated
D. None

A client’s ABG results area as follows:

pH: 7.48
PaCO2: 30 mm/Hg
HCO3: 33 mEq/L

Which acid-base imbalance can be inferred from the findings above?

A. Resipiratory Acidosis
B. Respiratory Alkalosis
C. Metabolic Acidosis
D. Metabolic Alkalosis
E. None. Mixed imbalance leaning towards Alkalosis

30. What about the degree of compensation? (refer to the preceding number)
A. Partially Compensated
B. Fully Compensated
C. Uncompensated
D. None

. A client’s ABG results area as follows:

pH: 7.32
PaCO2: 48 mm/Hg
HCO3: 24 mEq/L

Which acid-base imbalance can be inferred from the findings above?

A. Resipiratory Acidosis
B. Respiratory Alkalosis
C. Metabolic Acidosis
D. Metabolic Alkalosis
E.None.

32 Nurse Kim is caring for a client with a pneumothorax

and who has had a chest tube inserted notes continuous
gentle bubbling in the suction control chamber. What
action is appropriate?

• A Do nothing, because this is an expected finding.

• B Immediately clamp the chest tube and notify the physician.
• C Check for an air leak because the bubbling should be intermittent.
• D Increase the suction pressure so that bubbling becomes vigorous.

33. The nurse caring for a male client with a chest tube turns the client
to the side, and the chest tube accidentally
disconnects. The initial nursing action is to:

A Call the physician.

B Place the tube in a bottle of sterile water.
• C Immediately replace the chest tube system.
• D Place the sterile dressing over the disconnection site. Should be a vaselinized
gauze

34. Which of the following intervention is BEST in cases of

accidental removal of chest tube from the patient?

• A Apply a clean-gloved hand

• B Apply a clean blanket on the client’s chest
• C Place petroleum jelly at the tube insertion site
 • D Place a vaselinized petroleum gauze taping only 3 sides

Situation - CPT is systematic process of removing tenacious secretions from the deep
portion of the lungs.

35 The nurse is assisting the client who has an order for postural drainage. To help
the client obtain maximum benefits after the procedure, the nurse should:
To ensure that the client will benefit from CPTm the client is encouraged to COUGH

A. Avoid CPT right before a meal Correct, but it will not yield the benefits of CPT
B. Allow the client to rest Correct, but it will not yield the benefits of CPT
C. Elevate the head of bed for comfort Correct, but it will not yield the benefits of CPT
D. Ensure that there is an interval of 10 to 15 minutes in between each positional
changes Correct, but it will not yield the benefits of CPT
E. Give expectorants as ordered CORRECT- to ensure that the client will cough out the
secretions that were mobilized

36. After doing PD for the client, measures should be taken to ensure the following:
1. Noisy Respirations
2. Give a medication like Dextromethrophan for the accumulated secretions
ANTI-TUSSIVE: suppresses coughing, which will be a hindrance in CPT

3. Monitoring input and output

4. coughing CORRECT
A. 1 2
B. 2 4
C. 2 3 4
D. 1 2 4
E. None

37. Mario listens to Richard’s bilateral sounds and finds that congestion is in the
upper lobes of the lungs. The nurse displays appropriate technique to drain the
anterior and posterior apical segments of the lungs when Mario:
A. Ensures the striking force should be from the shoulders WRIST
B. Ensures that proper feedback sounds are heard-----CORRECT: The hands are
cupped during percussing, the nurse is doing the proper technique if he/she hears a
popping sound when percussing over the back of the client. A slapping sound indicates
that the hands are flat and not doing effective striking.
C. To ensure that the client’s skin won’t be red wrong: slight redness is an expected
result in percussing
D. None
38. When documenting data before the start of Richard’s treatment Mario should
include the following in his recording EXCEPT:
A. Color, amount and consistency of sputum INCLUDED
B. Breath sounds INCLUDED
C. Vital Signs INCLUDED
D. None ALL ARE INCLUDED

39. The purpose of chest percussion and vibration is to loosen secretions in the
lungs. The difference between the procedures is:
A. Vibration is only applied at a specific cycle CORRECT: Vibration is applied during
exhalation while percussing can be applied any time during the breathing cycle of the
client.
B. Percussion requires auscultation beforehand. INCORRECT, all procedures in CPT
need prior auscultation of the lung fields before execution.
C. Both Percussion and Vibration requires a doctor’s order Statement is true, but this
is more of a similarity and not a difference between the two
D. A B and C
E. None

40 . During the first 36 hours after the insertion of chest tubes, when assessing the
function of a three chamber, closed-chest drainage system, the nurse notes that the
there is a rise and fall in the level of water in the water-seal chamber. What action
should the nurse take?
A. Simply document the observation---This is tidaling or fluctuation which is normal
B. Clamp the tube as close as possible to the client and secure all the connections for
airleak
C. Perform press-release method in the dirtiest part of the tube
D. Apply a vasoocclusive dressing at the tube insertion site
E. Prepare another chest tube for possible reinsertion

41. The fluctuation in the mentioned chamber suddenly stopped. Which of the
following should be the next course of action for the nurse?
If the fluctuation in the water seal chamber stops, it could mean that:
1. the lung has fully re-expanded OR
2. there is an obstruction somwhere
A. Check for kinks along the tubings
B. Check to see if the suction is turned off or disconnected
C. Auscultate for the presence of breath sounds-- aside from x-ray, this is one way to
evaluate if the lung has fully re-expanded
D. None

42. The correct action in the preceding number is done to:

A. Verify if there is an obstruction along the tube.

B. To see if the equipment is functioning properly
C. Check if the device and tubes can now be disconnected from the client
D. None

43. Cessation of fluctuations in the water-seal chamber mean:

A. Normal functioning in the system.

B. Lung Re-expansion
C. Air Leak signified by bubbling
D. B and C
E. None

44. The doctor ordered a pulmonary toilette procedure to a client. X-ray and physical
assessment reveals that the pooling of secretions is located at the apical segment of
the anterior right lung, Which of the following position must not be utilized to drain
the secretions?
A. Sitting D. Prone
B. Supine E. Upright
C. Left side lying

Remember: Good Lung down, Bad lung UP

PRONE: if the client assumes this position, the secretions will stay on the anterior
portion of the lung

45. A nurse is performing oropharyngeal suctioning on an unconscious client. Which

of the following action is safe?
A. Insert the catheter approximately 15cms while applying suction
B. Allow 20-30second intervals between each suction and limit suction at a total of
15minutes
C. Gently rotate the catheter while applying suction
D. Apply suction for 5 seconds while inserting the catheter and continue for another 5
seconds before withdrawing

46. The primary course of action for secondary hypertension would be:

A. Lifestyle modification- 1st step in treatment of PRIMARY HYPERTENSION

B. Use of medications 2nd and 3rd step in tx of PRIMARY HYPERTENSION
C. Treating the root cause

47. Which of the following conditions or medications may lead to Hypertension?

A. Use of MAOi’s correct, especially with reaction to TYRAMINE

B. Barbiturates ----wrong, depressants
C. Shock---- wrong Hypotension
D. SCI at T2----correct: in spinal cord injury, especially if the injury is above T6, this can
cause a life-threatening condition called AUTONOMIC DYSREFLEXIA. Which can cause
HYPERTENSION, HEADACHE and a possible hemorrhagic stroke
E. A and D

48. The client states that she has been using around 4.5 grams of table salt per day. She
has been doing this ever since she received a diagnosis of Primary Hypertension. As a
nurse, you know that this intake of salt is:

A. Too little
B. Too much
C. Within Normal limits

4.5 grams = 4000mg of SALT

LOW SODIUM DIET <2grams or <2,000mg per day

SALT is composed of
40% Sodium
60% Chloride

4,500 x .4(40% sodium) = 1,800 Sodium in a day

49. The client is weak and needs to be moved up in her bed. To reduce shearing force
when moving the client, the nurse should:
A. Apply lotion to body parts in contact with bed sheet
B. Give the client a thorough explanation of the process
C. Ask for staff assistance when lifting the client
D. Use a draw sheet to put the client in correct position

50. The client has been on bed rest and has reddening of the skin and bony
prominences. When moving the client up in her bed, the nurse places her arms across
her chest. This is done to:
A. Make the client’s body more aligned
B. Protect the client’s extremities during the procedure
C. Reduce the surface area that will come in contact with the client
D. Make the body more compact to facilitate movement