This is a comprehensive examination in order to serve as a reviewer for nurses who want to take the HAAD examination. Most of the questions are actual HAAD exam questions in which the author encountered.
This is a multiple-choice type of questions consisting of 35-items. Each question tests your knowledge on the basic subjects in nursing such as Fundamentals of Nursing, Medical-Surgical Nursing, Psychiatric Nursing and Maternal and Newborn.
The topics included are the following:
- Nursing assessment
- Nursing procedures
- Labor and Delivery
- Prioritization of Care
- Nurse-Client Relationship
- Musculoskeletal and Cardiac disorders
1.The client is brought to the emergency department due to drug poisoning. Which of the following nursing interventions is most effective in the management of the client’s condition?
a) Gastric lavage
b) Activated charcoal
c) Cathartic administration
d) Milk dilution
2.Health care providers were informed of the presence of biochemical terrorism in the area. The nurse in the emergency department is helping in preparing and administering antitoxins. Which of the following agents of bioterrorism is treated with an antitoxin?
3.A client is given Morphine 6 mg IV push after the surgery. Moments later, the client is sleeping quietly and the vital signs are as follows: Pulse: 69 bpm, Respiration rate: 7 cpm, BP: 100/60 mmHg. Which of the following nursing actions is the priority this time?
a) Let the client rest.
b) Administer oxygen.
c) Administer naloxone (Narcan) per physician’s order.
d) Place epinephrine at the bedside.
4.The nurse is assessing the fluid status of a client receiving IV fluids after surgery. Which of the following symptoms indicate fluid volume overload?
a) Temperature: 38.9°C, BP 90/60, pulse 98 and thready.
b) Cool skin, respiratory crackles, pulse 84 and bounding.
c) Abdominal pain, headache and lethargy.
d) CVP of 5, Urinary output: 700 cc/24 hours and nystagmus.
5.An unconscious client with multiple injuries arrives in the emergency department. Which of the following nursing interventions receives the highest priority?
a) Stopping bleeding from open wounds
b) Checking for neck fracture
c) Establishing an airway
d) Replacing blood loss
FUNDAMENTALS OF NURSING
6.A client is recovering from a total laryngectomy procedure. Which of the following interventions should the nurse include in the instructions regarding care for the stoma? Select all that apply.
a) Clean the stoma using diluted alcohol.
b) Keep water away from the stoma.
c) Avoid using soap near the stoma.
d) Wipe secretions draining around the stoma using soft tissue.
e) Regularly wash the stoma using washcloth.
f) Apply thin layer of petroleum jelly into the skin surrounding the stoma.
7.A nurse is assessing a group of clients. The nurse knows that which of the following clients is at risk for fluid volume deficit?
a) Client diagnosed with liver cirrhosis.
b) Client with diminished kidney function.
c) Client diagnosed with congestive heart failure.
d) Client attached to a colostomy bag.
8.A pediatric client is for discharge after a plaster cast is applied on the left forearm. Which of the following should the nurse include in the home care instructions to be provided to the client’s parent? Select all that apply.
a) To lift the cast while it is drying, use the fingertips.
b) Keep sharp objects and small toys far from the cast.
c) Use padded objects to scratch itchy parts under the cast.
d) Apply heated pad on the edge of the cast and over the fingers to alleviate coldness.
e) Report numbness and tingling in the extremity immediately.
f) Elevate affected side for 24-48 hours following the procedure to avoid swelling.
9.The school nurse is conducting a health teaching to a group of parents about poison prevention at home. A mother asks the nurse about the initial step in case of poison ingestion. Which of the following responses if made by the nurse is incorrect?
a) “Give a bottle if Ipecac to your child to induce vomiting.”
b) “Induce vomiting if your child swallows lighter fluid.”
c) “Give your child water or milk to dilute the poison.”
d) “Store harmful chemicals in hard to reach areas.”
10.A patient underwent surgery where skin grafting was done and a drain was placed temporarily. The nurse in charge after the operation should know how to assess the skin graft. Which of the following assessments would suggest an abnormal skin graft?
a) The graft is warm to touch
b) Brisk capillary refill is noted
c) Sanguinous fluid at the surgical drain
d) Graft has a different color from patient’s skin
11.The client is admitted to a psychiatric unit with a diagnosis of undifferentiated schizophrenia. To cope up with anxiety, the nurse knows that the client will probably use which of the following defense mechanism?
12.The client in the psychiatric unit is copying and imitating the movements of the nurse. During recovery, the client verbalized thoughts that the nurse is like a mirror and felt connected with the nurse. This behavior is known by which of the following terms?
13.The nurse working in the psychiatric unit noticed that one of the clients is scheduled for an ECT the next morning. Who among the following clients will most likely undergo ECT?
a) A schizophrenic client hearing voices
b) Client with Antisocial personality disorder with a history of brawling
c) Client who exhibits 7 different personalities or persona
d) Client with major depression who is in antidepressants for 2 months
14.The nurse is to administer Lorazepam (Ativan) which is a benzodiazepine. The nurse should understand that benzodiazepines enhance which neurotransmitter?
15.Behavioral therapy is based on theories regarding learning. The nurse is about to conduct behavioral therapy to an adolescent client with a psychiatric condition. Which of the following is not a method or a strategy of behavioral therapy?
a) Operant conditioning
b) Milieu therapy
c) Systematic desensitization
d) Aversion therapy
16.A primigravida at 31 weeks came in with the following signs and symptoms: BP: 160/110 mmHg, proteinuria, and edema. She is diagnosed with pre-eclampsia; Magnesium Sulfate was then administered to treat the condition. Which of the following nursing assessments would indicate drug toxicity?
a) Patient is drowsy
b) Exaggerated deep tendon reflexes
c) Urinary output of 180 ml for 8 hours
d) Respiratory rate or 16/min
17.A G2P2 patient gave birth to a preterm baby boy. Twelve hours after delivery, she noted yellowish discoloration on her baby’s skin and eyes. She is worried and asked the nurse about the cause of her baby’s condition. What is the most appropriate response for the nurse to give?
a) Early onset breast milk jaundice is common in breastfed infants.
b) Don’t worry, jaundice is normal after birth.
c) Your baby was delivered preterm that is why he has jaundice.
d) Breastfeed your baby frequently while we further assess your baby’s condition.
18.Prior to vaginal examination, the nurse reviews the care of intrapartum clients. Which one of the following statements is true about cervical changes in a primipara client?
a) Effacement precedes dilatation
b) Effacement and dilatation occur simultaneously
c) Dilatation precedes effacement
d) Effacement is not necessary
19.The nurse is taking care of the client in the active phase of stage 1 labor. The fetal position is LOA. When membranes rupture, which among the following should the nurse expects to see:
a) A large amount of bloody fluid
b) A moderate amount of clear to straw-colored fluid
c) A small amount of greenish fluid
d) A small segment of the umbilical cord
20.The client in labor for the past 10 hours shows no change in cervical dilatation and has stayed 5-6 cm for the past 2 hours. Uterine contractions remain regular at 2-minute interval, lasting 40-45 seconds. Which is a priority action of the nurse?
a) Assess for presence of a full bladder.
b) Suggest placement of an internal uterine pressure catheter to determine adequacy of contractions.
c) Encourage the woman to do deep breathing techniques.
d) Suggest to physician that oxytocin augmentation be started to stimulate labor.
21.The blood count of the client revealed high number of RBC. What is the reason why a high number of RBC is normal for clients residing on a higher altitude?
a) Higher altitude changes the body’s absorption of essential nutrients.
b) Decrease in atmospheric oxygen stimulates erythropoiesis.
c) RBC sequestration of the spleen is impaired in higher altitudes.
d) Limited production of leukocytes and platelets in higher altitudes makes the ratio of RBC higher.
22.The nurse is assessing muscle coordination and mobility of the client with musculoskeletal disorder. The nurse noted impulsive and brief muscle twitching of the face and the limbs. The finding would be noted as:
23.The nurse is assigned to render care to the client with altered mobility. Which of the following statements is true regarding body mechanics when moving clients?
a) Stand at arm’s length from the working area.
b) Elevate adjustable beds to hip level.
c) Swivel the body when moving the client.
d) Move the client with wide base and straight knees.
24.The nurse is assisting the client with a crutch in walking starting with the four-point gait. Which of the following procedures is used for a four-point gait?
a) Move the left crutch and the right foot forward.
b) Move both crutches forward.
c) Advance the affected leg and crutches together.
d) Move the right crutch forward followed by the left foot.
25.The nurse is assisting the client and noted tenderness and focal pain at the tailbone. Which of the following conditions would the nurse suspect?
d) Muscular dystrophy
26.The nurse is caring for the client with Myasthenia Gravis. Which of the following nursing interventions is appropriate for this condition?
a) Monitor duration of stiffness and not the intensity to determine when to perform ROM.
b) When swallowing is difficult, give semi-solid foods instead of liquids to lessen the risk of choking.
c) Have the client sleep with a pillow between the trunk and arm to decrease tension on the supraspinatus tendon and to prevent blood flow compromise in its watershed region.
d) Position the client in a semi-fowler’s position to relieve dyspnea.
27.The client arrived in the clinic for a follow up visit regarding Tendonitis. The client informed the physician that the pain was not relieved with rest, ice, compression and elevation. Which of the following interventions might be the next order of the physician for the client?
c) Alternative NSAID
d) Chiropractic treatment
28.The physician is assessing the client with symptoms of Rheumatoid Arthritis. Which of the following laboratory tests would the nurse expect that the physician would order?
29.The nurse is caring for the client who has intermittent claudication. If the nurse is unable to palpate for any pedal pulses when examining the client, which is a priority nursing intervention among the following?
a. Notify the physician immediately.
b. Schedule the client for emergency surgery.
c. Recheck pedal pulses with a Doppler.
d. Assess the apical and radial pulses for any irregularity.
30.The client asks the nurse about Raynaud’s disease. Which of the following would be a suitable definition of Raynaud’s disease?
a. It is the constriction of the cutaneous vessels due to the vasospasm of the arterioles and the arteries of the upper and lower extremities.
b. It is an occlusive disease of the median and small arteries and veins.
c. It is the abnormal dilation of the arterial wall caused by localized weakness and stretching in the wall of the artery.
d. It is a chronic disorder in which partial or total arterial occlusion deprives the lower extremity of oxygen and nutrients.
31.The nurse is assessing the ECG result of the client. The condition in which the electrical conduction in the AV node is absent is known as:
a) First degree AV block
b) Second degree AV block
c) Third degree AV block
d) Fourth degree AV block
32.The client presented with complaints of headache accompanied with mild chest pain that is recurring every 5 hours for the last 2 weeks. Which of the following nursing action should take priority?
a) A complete health history with emphasis on preceding events.
b) Chest exam with auscultation
c) An electrocardiogram
d) Take client’s vital signs.
33.The pediatric client is diagnosed with a congenital heart disorder. Most infants having this condition experience difficulty with feeding, failure to thrive and bluish discoloration of the skin. This congenital condition is called:
a) Ventricular septal defect (VSD)
b) Atrioventricular septal defect (AVSD)
c) Tetralogy of Fallot (ToF)
d) Ebstein’s Anomaly
34.The client who recently suffered from a myocardial infarction is brought to the emergency department for further assessment. The client will most likely have elevated serum levels of:
a) Creatinine kinase
c) Acid phosphatase
d) Alkaline phosphatase
35.The client with a history of CHF is experiencing a hypertensive crisis. Which one of the following agents should be the drug of choice?