INTERNATIONAL NURSES ACADEMY OF THE PHILIPPINES

PREBOARD 20
1.) 08:00 Hours: Admitted at the Inap Emergency Room, 45-year-old client with fractured Ulna.
Hooked Lactated Ringer 1 Litter to run for 12 hours.
Xray, and pertinent Laboratory tests performed.

EXHIBIT 1(VITAL SIGNS): BP 140/100, RR 24, PR 110, TEMP 37.3

EXHIBIT 2(MEDICATION): Tramadol 100 mg, IV PRN for pain initiated.
EXHIBIT 3 (LABORATORY) : Hgb 14g/dl, Plt ct 200,000 mm3, WBC 12,300 mm3

09:30 Hours: Cast applied.

Which of the following requires reporting to the HCP?

1. P
2. T
3. HR
4. RR
5. Hgb
6. Plt ct
7. WBC
8. Cast applied

2.) The nurse prepares to administer a cleansing enema to a client with constipation. Which
interventions are appropriate? Select all that apply.
1. Assist the client into left lateral position with right knee flexed
2. Encourage the client to retain the enema for as long as possible
3. Insert tubing into the rectum with the tip directed toward the umbilicus
4. Keep the enema solution refrigerated until ready to administer
5. Slow administration rate if the client reports abdominal cramping

3.) The nurse is assessing a client’s peripheral pulses. The nurse palpates the top portion of the client’s
foot. The right pulse is easily palpable, and the left pulse is diminished but still palpable. How should the
nurse document these findings?
1. Bilateral dorsalis pedis (DP) pulses palpable. Right DP 2+, left DP 1+.
2. Bilateral DP pulses palpable. Right DP 3+, left DP 2+.
3. Bilateral popliteal pulses palpable. Right foot > left foot.
4. Bilateral posterior tibial (PT) pulses palpable. Right PT 2+, left PT 1+.

4.) A nurse is caring for a 3-month-old client with a new tracheostomy. Which findings would
indicate a need for suctioning? Select all that apply.
1. Audible gurgling
2. Heart rate 105/min
3. Increased irritability
4. Oxygen saturation 88%
 5. Respiratory rate 30/min

5.) The nurse is preparing a client for a magnetic resonance cholangiopancreatography. Which
statements by the client would require the nurse to obtain further assessment data? Select all
that apply.
1. “I ate lunch about 4 or 5 hours ago.”
2. “I got a rash the last time I had IV contrast.”
3. “I had my last period 6 weeks ago.”
4. “I have a hearing aid implanted in my ear.”
5. “I smoked a cigarette about an hour ago.”
6.) The following are signs of compartment syndrome, SELECT ALL THAT APPLY;

1. Capillary refill more than 3 seconds

2. Passive stretch pain
3. Decrease pulse
4. Increase pressure within the cast
5. Itchiness
6. Absent sensation
7. Pallor
8. Marked swollen area
9. Increase ESR

7.) The student nurse is preparing to perform a heel stick on a neonate to collect blood for
diagnostic testing. Which statement by the student nurse indicates a need for further
education?
1. “I can perform the stick on either the medial or lateral side of the outer aspect of the heel.”
2. “Sucrose and a pacifier can help alleviate the infant’s pain and stress during the puncture.”
3. “The heel area should be warmed for 3-5 minutes prior to puncture.”
4. “Venipuncture should be reserved only for failed heel sticks because it is more painful.”

8.) 08:00 Hours: Admitted at the Emergency Room 45 year client with fracture Ulna.
Hooked Lactated Ringer 1 Litter to run for 12 hours.
Xray, and pertinent Laboratory tests performed. With history of Diabetes Mellitus Type 1. And
Hypertension.

09:30 Hours: Cast applied.

10:00 Hours: Transferred to the Orthopedic unit.
11:00 Hours:
Exhibit 1 (VITAL SIGNS): BP 130/90, HR 110, TEMP. 38
Exhibit 2 (NEURO ASSESSMENT): PAIN 9/10, Paresthesia
Exhibit 3 (MEDICATION): TRAMADOL 100mg IV PRN every 6 hours for PAIN

What is the HIGHEST PRIORITY nursing action?

1. Repeat vital signs after 10 minutes
2. Provide distracting activities for pain management
 3. Administer Tramadol 100mg/IV
4. Refer to the HCP

9.) A child on the playground is experiencing an anaphylactic reaction. The school nurse arrives with an
EpiPen. The weather is cold and the child is wearing several layers of clothing. How should the nurse
proceed with the EpiPen?
1. Inject into the upper arm where the sleeve can be pulled up
2. Inject into the most accessible vein
3. Inject through the clothing into thigh and hold in place for 10 seconds
4. Take the child inside, remove excess clothing, and inject into the thigh

10.) An experienced nurse precepts a graduate nurse in the intensive care unit while caring for a client
with a right subclavian triple-lumen central venous catheter (CVC). Which statement by the graduate
nurse indicates understanding of the CVC?
1. “All 3 lumens come together, so all drugs infused through the CVC must be compatible.”
2. “It is used to provide enteral nutrition to the client who cannot eat.”
3. “Sterile gloves must be worn when administering drugs through the CVC.”
4. “The lumen hub should be cleaned thoroughly with antiseptic prior to drug administration.”

11.) The school nurse is assisting a student with type 1 diabetes mellitus to calculate the insulin dosage
needed based on the student’s lunch menu selections. Using the prescribed carbohydrate-to-insulin
ratio, how much insulin should the student receive? Record your answer using a whole number. Click
on the exhibit button for additional information.
 Answer ___________ (units)

12.) 08:00 Hours: Admitted at the Emergency Room of Jay B hospital, 45-year-old client with fracture
of Ulna.
Hooked Lactated Ringer 1 Litter to run for 12 hours.
Xray, and pertinent Laboratory tests performed. With history of Diabetes Mellitus Type 1. And
Hypertension.

BP 140/100, RR 24, PR 110, TEMP 37.3

Tramadol 100 mg, IV PRN for pain initiated.
Hgb 14g/dl, Plt ct 200,000 mm3, WBC 12,300 mm3

09:30 Hours: Cast applied.

10:00 Hours: Transferred to the Orthopedic unit.
10:15 Hours: CBG 300 mg

Exhibit 1 (Vital signs): BP 160/100, TEMP 38.5 RR 22 PR 99

Exhibit 2 (Medications): Capoten 50 mg for BP 160/90 and above. Lispro based on Insulin Sliding
Scale:

Which of the following actions are appropriate for the Registered Nurse to perform?

INTERVENTIONS INDICATED NOT INDICATED

1. TSB
2. Administer 500mg/tag
Paracetamol
3. Administer Lispro
according to the scale
4. Neuro Vascular
Assessment
 5. Refer to the HCP

13.) A nurse is caring for a client who has a chest tube drainage system in place. Where would the nurse
observe to assess for tidaling?

14.) The nurse is changing the dressing, injection caps, and IV tubing of a client who is receiving total
parenteral nutrition through a right peripherally inserted central venous catheter. The nurse should
implement what actions to prevent complications during this procedure? Select all that apply.
1. Instruct the client to hold the breath when changing the injection caps and tubing
2. Instruct the client to keep the head to the right side during the dressing change
3. Perform hand hygiene before and after the procedure
4. Place the client in the Trendelenburg position before the procedure
5. Wear sterile gloves and a surgical mask when changing the dressing

15.) The nurse is drawing a blood specimen from the client’s right basilica vein. The client cries out,
retracts the arm, and reports feeling “pins and needles” in the right arm. Which action by the nurse is
appropriate?
1. Obtain a smaller-gauge needle and reattempt at the same site
2. Partially withdraw and then reinsert the needle at a different angle
4. Withdraw the needle and reattempt in a different site with new equipment

16.) One unit packed RBCs (PRBCs) is prescribed for a client experiencing complications of sickle cell
anemia. Which of the following actions by the nurse are appropriate? Select all that apply. Click the
exhibit button for additional information.
 1. Administers type A-negative blood
2. Delegates all vital sign measurements to the unlicensed assistive personnel
3. Transfuses PRBCs over 6 hours
4. Uses filtered Y-type tubing with 0.9% sodium chloride
5. Verifies client identifiers and blood product with another nurse before administration

17.) The student nurse is applying a condom catheter for an ambulatory client who is uncircumcised and
incontinent of urine. The precepting nurse should intervene when the student performs which action?
1. Attaches the drainage tubing to a lower leg collection bag
2. Leaves a 1-2 in (2.5-5 cm) space at the tip of the condom
3. Retracts the foreskin before applying the condom sheath
4. Uses elastic adhesive in a spiral fashion to secure device

18.) The 70-year-old client with type 2 diabetes and hypertension is scheduled for ureteral stent removal
in 2 hours. The preoperative protocol ECG is done in the patient unit, and results indicate a “possibly
acute” ST segment elevation. What action is most important for the nurse to take?
1. Document the test results on the preoperative checklist
2. Notify the health care provider about the test results
3. Place the printed ECG in the front of the chart
4. Report the results to the surgical nurse to tell the surgeon

19.)
20.) The nurse is performing a central line tubing change when the client suddenly begins gasping for air
and writing. Order the interventions by priority. All options must be used.
1. Administer oxygen as needed
2. Clamp the catheter tubing
3. Notify the health care provider (HCP)
4. Place the client in trendelenburg position on the left side
5. Stay with the client and provide reassurance
YOUR RESPONSE

21.) The nurse is preparing to irrigate ears of a 67-year old client with impacted cerumen. Place the
following steps for ear irrigation in the correct order.
4. Place the client in a sitting position with head tilted toward the affected ear.
5. Straighten the ear canal by pulling the pina up and back.
3. Place a towel and an emesis basin under the ear.
2. Gently irrigate the ear canal with a slow, steady flow of solution.
1. Assess the client for fever, ear infection, or tympanic membrane injury
6. Repeat as tolerated until the ear canal is clear or the prescribed amount is instilled
7. Document the type, temperature, and volume of solution; exudate characteristics;
response to the irrigation
22.) The nurse working in an intensive care unit receives a prescription from the primary health care
provider to discontinue a triple-lumen subclavian central venous catheter. Which interventions will help
prevent air embolism on removal? Select all that apply.
1. Applying an air-occlusive dressing
2. Instructing the client to bear down
3. Instructing the client to lie in a supine position
4. Pulling the line harder if there is resistance
5. Pulling the line out when the client is inhaling

23.) The nurse has received a prescription from the health care provider to administer 80 mg of
methylprednisolone IV piggyback. The available vial contains 125 mg in 2 mL. Select the syringe
containing the appropriate amount of medication to be administered.

24.) The nurse is caring for a client who is prescribed ampicillin 1.5 g in 100 mL of normal saline IV to be
administered over 30 minutes every 6 hours. The nurse has IV tubing with a drip factor of 15 gtt/mL. At
what rate in drips per minute (gtt/min) should the nurse administer the IV ampicillin? Record your
answer using a whole number.
Answer _____________ (gtt/min)

25.) The nurse prepares to administer an IV infusion of potassium chloride through a peripheral vein to a
client with hypoklemia. The health care provider’s prescription states: IV potassium chloride 10 mEq
(10 mmol)/100 mL 5% dextrose in water now, infuse over 30 minutes. What is the nurse’s priority
action?

26.)

27.) The nurse observes a client who is postoperative left total knee replacement use a cane. Which
action by the client indicates an understanding of the correct technique when walking down the stairs?
 1. Descends with the cane on the step first, followed by the left leg, and then the right leg
2. Descends with the cane on the step first, followed by the right leg, and then the left leg
3. Descends with the left leg on the step first, followed by the cane, and then the right leg
4. Descends with the right leg on the step first, followed by the left leg, and then the cane

28.) A client with a dislocated shoulder is prescribed a shoulder sling. The nurse applies the sling and
evaluates the fit before discharge from the emergency room. Which assessment finding indicates an
incorrect fit?
1. The elbow is flexed at 90 degrees
2. The hand is held slightly below elbow level
3. The sling ends in the middle of the palm with fingers visible
4. The sling supports the wrist

29.)

30.) The nurse is assigned to care for a hospitalized confused client with an indwelling urinary catheter.
On entering the client’s room, the nurse notes the client pulling at the catheter and grimacing in pain.
Blood is trickling from the client’s meatus and the urine in the drainage bag is pink. Which action should
the nurse take first?
1. Collect a urine specimen and send to the lab
2. Deflate the balloon on the urinary catheter
3. Remove the catheter by gently pulling from the urethra
4. Use a sterile 4x4 pad to absorb the blood around the meatus

31. The nurse plans to start an IV line on a female client hospitalized with pneumonia. The nurse reviews
the electronic medical record for relevant information and learns that the client is right-handed and has
a history a left-sided mastectomy with lymph node removal. Which site is best for the nurse to select for
the client’s IV line?
1. Basilic vein of the left forearm
2. Cephalic vein in the right antecubital space
3. Median vein of the right forearm
4. Radial vein of the left wrist

32.) A client recovering at home following a left total knee replacement 7 days ago is using a
cane to go up and down the stairs under the supervision of the home health nurse. Which client
action indicates a need for further instruction?
1. Faces forward when going up and down the stairs
2. Holds the cane with the right hand
3. Leads with left leg, follows next with cane, and finally right leg when going up the
stairs
4. Places full weight on left leg when going down the stairs
33.) The nurse plans to start an IV line to infuse 2 units of packed red blood cells for a stable 42-year-old
client with a gastrointestinal bleed. Which IV catheter size is best?
1. 14-gauge
2. 18-gauge
3. 20-gauge
4. 22-gauge

34.) The nurse is drawing blood from a client’s peripheral vein for laboratory specimens. Which of the
following are correct nursing actions? Select all that apply.
1. Do not leave a tourniquet on more than 1 minute while looking for a vein
2. Draw the specimen while the skin is still wet with the alcohol prep
3. If pulsating red blood is noted, withdraw the needle and apply pressure for 5 minutes
4. Use a highly visible vein on the ventral side of the client’s wrist
5. Vigorously shake the specimen tube to mix obtained blood with anticoagulant solution

35.) The nurse performs nasogastric (NG) tube insertion using a large-bore NG tube on a hospitalized
client with a gastrointestinal bleed. During insertion, after the tube passes the nasopharynx, the client
begins to cough and gag. Which action should the nurse take first?
1. Ask the client to take several small sips of water
2. Continue to slowly advance the tube until placement is reached
3. Gently remove the tube and reinsert in the other naris if possible
4. Pull back on the tube slightly and then pause to give the client time to breathe