. Jake is complaining of shortness of breath.

The nurse assesses his respiratory rate to be 30 breaths per minute and documents that Jake is tachypneic. The nurse understands that tachypnea means: a. Pulse rate greater than 100 beats per minute b. Blood pressure of 140/90 c. Respiratory rate greater than 20 breaths per minute d. Frequent bowel sounds 2. The nurse listens to Mrs. Sullens lungs and notes a hissing sound or musical sound. The nurse documents this as: a. Wheezes b. Rhonchi c. Gurgles d. Vesicular 3. The nurse in charge measures a patients temperature at 101 degrees F. What is the equivalent centigrade temperature? a. 36.3 degrees C b. 37.95 degrees C c. 40.03 degrees C d. 38.01 degrees C 4. Which approach to problem solving tests any number of solutions until one is found that works for that particular problem? a. Intuition b. Routine c. Scientific method d. Trial and error 5. What is the order of the nursing process? a. Assessing, diagnosing, implementing, evaluating, planning b. Diagnosing, assessing, planning, implementing, evaluating c. Assessing, diagnosing, planning, implementing, evaluating d. Planning, evaluating, diagnosing, assessing, implementing 6. During the planning phase of the nursing process, which of the following is the outcome? a. Nursing history b. Nursing notes c. Nursing care plan d. Nursing diagnosis 7. What is an example of a subjective data? a. Heart rate of 68 beats per minute b. Yellowish sputum c. Client verbalized, I feel pain when urinating. d. Noisy breathing 8. Which expected outcome is correctly written? a. The patient will feel less nauseated in 24 hours. b. The patient will eat the right amount of food daily.

c. The patient will identify all the high-salt food from a prepared list by discharge. d. The patient will have enough sleep. 9. Which of the following behaviors by Nurse Jane Robles demonstrates that she understands well th elements of effecting charting? a. She writes in the chart using a no. 2 pencil. b. She noted: appetite is good this afternoon. c. She signs on the medication sheet after administering the medication. d. She signs her charting as follow: J.R 10. What is the disadvantage of computerized documentation of the nursing process? a. Accuracy b. Legibility c. Concern for privacy d. Rapid communication 11. The theorist who believes that adaptation and manipulation of stressors are related to foster change is: a. Dorothea Orem b. Sister Callista Roy c. Imogene King d. Virginia Henderson 12. Formulating a nursing diagnosis is a joint function of: a. Patient and relatives b. Nurse and patient c. Doctor and family d. Nurse and doctor 13. Mrs. Caperlac has been diagnosed to have hypertension since 10 years ago. Since then, she had maintained low sodium, low fat diet, to control her blood pressure. This practice is viewed as: a. Cultural belief b. Personal belief c. Health belief d. Superstitious belief 14. Becky is on NPO since midnight as preparation for blood test. Adreno-cortical response is activated. Which of the following is an expected response? a. Low blood pressure b. Warm, dry skin c. Decreased serum sodium levels d. Decreased urine output 15. What nursing action is appropriate when obtaining a sterile urine specimen from an indwelling catheter to prevent infection? a. Use sterile gloves when obtaining urine. b. Open the drainage bag and pour out the urine.

c. Disconnect the catheter from the tubing and get urine. d. Aspirate urine from the tubing port using a sterile syringe. 16. A client is receiving 115 ml/hr of continuous IVF. The nurse notices that the venipuncture site is red and swollen. Which of the following interventions would the nurse perform first? a. Stop the infusion b. Call the attending physician c. Slow that infusion to 20 ml/hr d. Place a clod towel on the site 17. The nurse enters the room to give a prescribed medication but the patient is inside the bathroom. What should the nurse do? a. Leave the medication at the bedside and leave the room. b. After few minutes, return to that patients room and do not leave until the patient takes the medication. c. Instruct the patient to take the medication and leave it at the bedside. d. Wait for the patient to return to bed and just leave the medication at the bedside. 18. Which of the following is inappropriate nursing action when administering NGT feeding? a. Place the feeding 20 inches above the pint if insertion of NGT. b. Introduce the feeding slowly. c. Instill 60ml of water into the NGT after feeding. d. Assist the patient in fowlers position. 19. A female patient is being discharged after thyroidectomy. After providing the medication teaching. The nurse asks the patient to repeat the instructions. The nurse is performing which professional role? a. Manager b. Caregiver c. Patient advocate d. Educator 20. Which data would be of greatest concern to the nurse when completing the nursing assessment of a 68-year-old woman hospitalized due to Pneumonia? a. Oriented to date, time and place b. Clear breath sounds c. Capillary refill greater than 3 seconds and buccal cyanosis d. Hemoglobin of 13 g/dl 21. During a change-of-shift report, it would be important for the nurse relinquishing responsibility for care of the patient to communicate. Which of the following facts to the nurse assuming responsibility for care of the patient? a. That the patient verbalized, My headache is gone. b. That the patients barium enema performed 3 days ago was negative c. Patients NGT was removed 2 hours ago d. Patients family came for a visit this morning. 22. Which statement is the most appropriate goal for a nursing

diagnosis of diarrhea? a. The patient will experience decreased frequency of bowel elimination. b. The patient will take anti-diarrheal medication. c. The patient will give a stool specimen for laboratory examinations. d. The patient will save urine for inspection by the nurse. 23. Which of the following is the most important purpose of planning care with this patient? a. Development of a standardized NCP. b. Expansion of the current taxonomy of nursing diagnosis c. Making of individualized patient care d. Incorporation of both nursing and medical diagnoses in patient care 24. Using Maslows hierarchy of basic human needs, which of the following nursing diagnoses has the highest priority? a. Ineffective breathing pattern related to pain, as evidenced by shortness of breath. b. Anxiety related to impending surgery, as evidenced by insomnia. c. Risk of injury related to autoimmune dysfunction d. Impaired verbal communication related to tracheostomy, as evidenced by inability to speak. 25. When performing an abdominal examination, the patient should be in a supine position with the head of the bed at what position? a. 30 degrees b. 90 degrees c. 45 degrees d. 0 degree 1. (C) Respiratory rate greater than 20 breaths per minute A respiratory rate of greater than 20 breaths per minute is tachypnea. A blood pressure of 140/90 is considered hypertension. Pulse greater than 100 beats per minute is tachycardia. Frequent bowel sounds refer to hyper-active bowel sounds. 2. (A) Wheezes Wheezes are indicated by continuous, lengthy, musical; heard during inspiration or expiration. Rhonchi are usually coarse breath sounds. Gurgles are loud gurgling, bubbling sound. Vesicular breath sounds are low pitch, soft intensity on expiration. 3. (B) 37.95 degrees C To convert F to C use this formula, ( F 32 ) (0.55). While when converting C to F use this formula, ( C x 1.8) + 32. Note that 0.55 is 5/9 and 1.8 is 9/5. 4. (D) Trial and error The trial and error method of problem solving isnt systematic (as in the scientific method of problem solving) routine, or based on inner prompting (as in the intuitive method of problem solving). 5. (C) Assessing, diagnosing, planning, implementing, evaluating The correct order of the nursing process is assessing, diagnosing, planning, implementing, evaluating. 6. (C) Nursing care plan

The outcome, or the product of the planning phase of the nursing process is a Nursing care plan. 7. (C) Client verbalized, I feel pain when urinating. Subjective data are those that can be described only by the person experiencing it. Therefore, only the patient can describe or verify whether he is experiencing pain or not. 8. (C) The patient will identify all the high-salt food from a prepared list by discharge. Expected outcomes are specific, measurable, realistic statements of goal attainment. The phrases right amount, less nauseated and enough sleep are vague and not measurable. 9. (C) She signs on the medication sheet after administering the medication. A nurse should record a nursing intervention (ex. Giving medications) after performing the nursing intervention (not before). Recording should also be done using a pen, be complete, and signed with the nurses full name and title. 10. (C) Concern for privacy A patients privacy may be violated if security measures arent used properly or if policies and procedures arent in place that determines what type of information can be retrieved, by whom, and for what purpose. 11. (B) Sister Callista Roy Sister Roys theory is called the adaptation theory and she viewed each person as a unified biophysical system in constant interaction with a changing environment. Orems theory is called self-care deficit theory and is based on the belief that individual has a need for self-care actions. Kings theory is the Goal attainment theory and described nursing as a helping profession that assists individuals and groups in society to attain, maintain, and restore health. Henderson introduced the nature of nursing model and identified the 14 basic needs. 12. (B) Nurse and patient Although diagnosing is basically the nurses responsibility, input from the patient is essential to formulate the correct nursing diagnosis. 13. (C) Health belief Health belief of an individual influences his/her preventive health behavior. 14. (D) Decreased urine output Adreno-cortical response involves release of aldosterone that leads to retention of sodium and water. This results to decreased urine output. 15. (D) Aspirate urine from the tubing port using a sterile syringe. The nurse should aspirate the urine from the port using a sterile syringe to obtain a urine specimen. Opening a closed drainage system increase the risk of urinary tract infection. 16. (A) Stop the infusion The sign and symptoms indicate extravasation so the IVF should be stopped immediately and put warm not cold towel on the affected site. 17. (B) After few minutes, return to that patients room and do not leave until the patient takes the medication This is to verify or to make sure that the medication was taken by the patient as directed. 18. (A) Place the feeding 20 inches above the pint if insertion of NGT.

The height of the feeding is above 12 inches above the point of insertion, bot 20 inches. If the height of feeding is too high, this results to very rapid introduction of feeding. This may trigger nausea and vomiting. 19. (D) Educator When teaching a patient about medications before discharge, the nurse is acting as an educator. A caregiver provides direct care to the patient. The nurse acts as s patient advocate when making the patients wishes known to the doctor. 20. (C) Capillary refill greater than 3 seconds and buccal cyanosis Capillary refill greater than 3 seconds and buccal cyanosis indicate decreased oxygen to the tissues which requires immediate attention/intervention. Oriented to date, time and place, hemoglobin of 13 g/dl are normal data. 21. (C) Patients NGT was removed 2 hours ago The change-of-shift report should indicate significant recent changes in the patients condition that the nurse assuming responsibility for care of the patient will need to monitor. The other options are not critical enough to include in the report. 22. (A) The patient will experience decreased frequency of bowel elimination. The goal is the opposite, healthy response of the problem statement of the nursing diagnosis. In this situation, the problem statement is diarrhea. 23. (C) Making of individualized patient care To be effective, the nursing care plan developed in the planning phase of the nursing process must reflect the individualized needs of the patient. 24. (A) Ineffective breathing pattern related to pain, as evidenced by shortness of breath. Physiologic needs (ex. Oxygen, fluids, nutrition) must be met before lower needs (such as safety and security, love and belongingness, selfesteem and self-actualization) can be met. Therefore, physiologic needs have the highest priority. 25. (D) 0 degree The patient should be positioned with the head of the bed completely flattened to perform an abdominal examination. If the head of the bed is elevated, the abdominal muscles and organs can be bunched up, altering the findings 1. A patient is wearing a soft wrist-safety device. Which of the following nursing assessment is considered abnormal? a. Palpable radial pulse b. Palpable ulnar pulse c. Capillary refill within 3 seconds d. Bluish fingernails, cool and pale fingers 2. Pias serum sodium level is 150 mEq/L. Which of the following food items does the nurse instruct Pia to avoid? a. broccoli b. sardines c. cabbage d. tomatoes

organ? 3. Jason, 3 years old vomited. His mom stated, He vomited 6 ounces of his formula this morning. This statement is an example of: a. objective data from a secondary source b. objective data from a primary source c. subjective data from a primary source d. subjective data from a secondary source 4. Which of the following is a nursing diagnosis? a. Hypethermia b. Diabetes Mellitus c. Angina d. Chronic Renal Failure 5. What is the characteristic of the nursing process? a. stagnant b. inflexible c. asystematic d. goal-oriented 6. A skin lesion which is fluid-filled, less than 1 cm in size is called: a. papule b. vesicle c. bulla d. macule 7. During application of medication into the ear, which of the following is inappropriate nursing action? a. In an adult, pull the pinna upward. b. Instill the medication directly into the tympanic membrane. c. Warm the medication at room or body temperature. d. Press the tragus of the ear a few times to assist flow of medication into the ear canal. 8. Which of the following is appropriate nursing intervention for a client who is grieving over the death of her child? a. Tell her not to cry and it will be better. b. Provide opportunity to the client to tell their story. c. Encourage her to accept or to replace the lost person. d. Discourage the client in expressing her emotions. 9. It is the gradual decrease of the bodys temperature after death. a. livor mortis b. rigor mortis c. algor mortis d. none of the above 10. When performing an admission assessment on a newly admitted patient, the nurse percusses resonance. The nurse knows that resonance heard on percussion is most commonly heard over which a. Absence of family support b. Decreased sensory functions c. Patient has no interest on learning d. Decreased plasma drug levels 14. When assessing a patients level of consciousness, which type of nursing intervention is the nurse performing? a. Independent b. Dependent c. Collaborative d. Professional 15. Claire is admitted with a diagnosis of chronic shoulder pain. By definition, the nurse understands that the patient has had pain for more than: a. 3 months b. 6 months c. 9 months d. 1 year 16. Which of the following statements regarding the nursing process is true? a. It is useful on outpatient settings. b. It progresses in separate, unrelated steps. c. It focuses on the patient, not the nurse. d. It provides the solution to all patient health problems. 17. Which of the following is considered significant enough to require immediate communication to another member of the health care team? a. thigh b. liver c. intestine d. lung 11. The nurse is aware that Bells palsy affects which cranial nerve? a. 2nd CN (Optic) b. 3rd CN (Occulomotor) c. 4th CN (Trochlear) d. 7th CN (Facial) 12. Prolonged deficiency of Vitamin B9 leads to: a. scurvy b. pellagra c. megaloblastic anemia d. pernicious anemia 13. Nurse Cherry is teaching a 72 year old patient about a newly prescribed medication. What could cause a geriatric patient to have difficulty retaining knowledge about the newly prescribed medication?

a. Weight loss of 3 lbs in a 120 lb female patient. b. Diminished breath sounds in patient with previously normal breath sounds c. Patient stated, I feel less nauseated. d. Change of heart rate from 70 to 83 beats per minute. 18. To assess the adequacy of food intake, which of the following assessment parameters is best used? a. food preferences b. regularity of meal times c. 3-day diet recall d. eating style and habits 19. Van Fajardo is a 55 year old who was admitted to the hospital with newly diagnosed hepatitis. The nurse is doing a patient teaching with Mr. Fajardo. What kind of role does the nurse assume? a. talker b. teacher c. thinker d. doer 20. When providing a continuous enteral feeding, which of the following action is essential for the nurse to do? a. Place the client on the left side of the bed. b. Attach the feeding bag to the current tubing. c. Elevate the head of the bed. d. Cold the formula before administering it. 21. Kussmauls breathing is; a. Shallow breaths interrupted by apnea. b. Prolonged gasping inspiration followed by a very short, usually inefficient expiration. c. Marked rhythmic waxing and waning of respirations from very deep to very shallow breathing and temporary apnea. d. Increased rate and depth of respiration. 22. Presty has terminal cancer and she refuses to believe that loss is happening ans she assumes artificial cheerfulness. What stage of grieving is she in? a. depression b. bargaining c. denial d. acceptance 23. Immunization for healthy babies and preschool children is an example of what level of preventive health care? a. Primary b. Secondary c. Tertiary d. Curative 24. Which is an example of a subjective data?

a. Temperature of 38 0C b. Vomiting for 3 days c. Productive cough d. Patient stated, My arms still hurt. 25. The nurse is assessing the endocrine system. Which organ is part of the endocrine system? a. Heart b. Sinus c. Thyroid d. Thymus 1. (D) Bluish fingernails, cool and pale fingers A safety device on the wrist may impair blood circulation. Therefore, the nurse should assess the patient for signs of impaired circulation such as bluish fingernails, cool and pale fingers. Palpable radial and ulnar pulses, capillary refill within 3 seconds are all normal findings. 2. (B) sardines The normal serum sodium level is 135 to 145 mEq/L, the client is having hypernatremia. Pia should avoid food high in sodium like processed food. Broccoli, cabbage and tomatoes are good source of Vitamin C. 3. (A) objective data from a secondary source Jason is the primary source; his mother is a secondary source. The data is objective because it can be perceived by the senses, verified by another person observing the same patient, and tested against accepted standards or norms. 4. (A) Hypethermia Hyperthermia is a NANDA-approved nursing diagnosis. Diabetes Mellitus, Angina and Chronic Renal Failure are medical diagnoses. 5. (D) goal-oriented The nursing process is goal-oriented. It is also systematic, patientcentered, and dynamic. 6. (B) vesicle Vesicle is a circumscribed circulation containing serous fluid or blood and less than 1 cm (ex. Blister, chicken pox). 7. (B) Instill the medication directly into the tympanic membrane. During the application of medication it is inappropriate to instill the medication directly into the tympanic membrane. The right thing to do is instill the medication along the lateral wall of the auditory canal. 8. (B) Provide opportunity to the client to tell their story. Providing a grieving person an opportunity to tell their story allows the person to express feelings. This is therapeutic in assisting the client resolve grief. 9. (C) algor mortis Algor mortis is the decrease of the bodys temperature after death. Livor mortis is the discoloration of the skin after death. Rigor mortis is the stiffening of the body that occurs about 2-4 hours after death. 10. (D) lung Resonance is loud, low-pitched and long duration thats heard most commonly over an air-filled tissue such as a normal lung. 11. (D) 7th CN (Facial)

Bells palsy is the paralysis of the motor component of the 7th caranial nerve, resulting in facial sag, inability to close the eyelid or the mouth, drooling, flat nasolabial fold and loss of taste on the affected side of the face. 12. (C) megaloblastic anemia Prolonged Vitamin B9 deficiency will lead to megaloblastic anemia while pernicious anemia results in deficiency in Vitamin B12. Prolonged deficiency of Vitamin C leads to scurvy and Pellagra results in deficiency in Vitamin B3. 13. (B) Decreased sensory functions Decreased in sensory functions could cause a geriatric patient to have difficulty retaining knowledge about the newly prescribed medications. Absence of family support and no interest on learning may affect compliance, not knowledge retention. Decreased plasma levels do not alter patients knowledge about the drug. 14. (A) Independent Independent nursing interventions involve actions that nurses initiate based on their own knowledge and skills without the direction or supervision of another member of the health care team. 15. (B) 6 months Chronic pain s usually defined as pain lasting longer than 6 months. 16. (C) It focuses on the patient, not the nurse. The nursing process is patient-centered, not nurse-centered. It can be use in any setting, and the steps are related. The nursing process cant solve all patient health problems. 17. (B) Diminished breath sounds in patient with previously normal breath sounds Diminished breath sound is a life threatening problem therefore it is highly priority because they pose the greatest threat to the patients well-being. 18. (C) 3-day diet recall 3-day diet recall is an example of dietary history. This is used to indicate the adequacy of food intake of the client. 19. (B) teacher The nurse will assume the role of a teacher in this therapeutic relationship. The other roles are inappropriate in this situation. 20. (C) Elevate the head of the bed. Elevating the head of the bed during an enteral feeding prevents aspiration. The patient may be placed on the right side to prevent aspiration. Enteral feedings are given at room temperature to lessen GI distress. The enteral tubing should be changed every 24 hours to limit microbial growth. 21. (D) Increased rate and depth of respiration. Kussmaul breathing is also called as hyperventilation. Seen in metabolic acidosis and renal failure. Option A refers to Biots breathing. Option B is apneustic breathing and option C is the Cheyne-stokes breathing. 22. (C) denial The client is in denial stage because she is unready to face the reality that loss is happening and she assumes artificial cheerfulness. 23. (A) Primary

The primary level focuses on health promotion. Secondary level focuses on health maintenance. Tertiary focuses on rehabilitation. There is n Curative level of preventive health care problems. 24. (D) Patient stated, My arms still hurt. Subjective data are apparent only to the person affected and can or verified only by that person. 25. (C) Thyroid The thyroid is part of the endocrine system. Heart, sinus and thymus are not. 1. Nurse Brenda is teaching a patient about a newly prescribed drug. What could cause a geriatric patient to have difficulty retaining knowledge about prescribed medications? a. Decreased plasma drug levels b. Sensory deficits c. Lack of family support d. History of Tourette syndrome 2. When examining a patient with abdominal pain the nurse in charge should assess: a. Any quadrant first b. The symptomatic quadrant first c. The symptomatic quadrant last d. The symptomatic quadrant either second or third 3. The nurse is assessing a postoperative adult patient. Which of the following should the nurse document as subjective data? a. Vital signs b. Laboratory test result c. Patients description of pain d. Electrocardiographic (ECG) waveforms 4. A male patient has a soft wrist-safety device. Which assessment finding should the nurse consider abnormal? a. A palpable radial pulse b. A palpable ulnar pulse c. Cool, pale fingers d. Pink nail beds 5. Which of the following planes divides the body longitudinally into anterior and posterior regions? a. Frontal plane b. Sagittal plane c. Midsagittal plane d. Transverse plane 6. A female patient with a terminal illness is in denial. Indicators of denial include: a. Shock dismay b. Numbness c. Stoicism d. Preparatory grief

7. The nurse in charge is transferring a patient from the bed to a chair. Which action does the nurse take during this patient transfer? a. Position the head of the bed flat b. Helps the patient dangle the legs c. Stands behind the patient d. Places the chair facing away from the bed 8. A female patient who speaks a little English has emergency gallbladder surgery, during discharge preparation, which nursing action would best help this patient understand wound care instruction? a. Asking frequently if the patient understands the instruction b. Asking an interpreter to replay the instructions to the patient. c. Writing out the instructions and having a family member read them to the patient d. Demonstrating the procedure and having the patient return the demonstration 9. Before administering the evening dose of a prescribed medication, the nurse on the evening shift finds an unlabeled, filled syringe in the patients medication drawer. What should the nurse in charge do? a. Discard the syringe to avoid a medication error b. Obtain a label for the syringe from the pharmacy c. Use the syringe because it looks like it contains the same medication the nurse was prepared to give d. Call the day nurse to verify the contents of the syringe 10. When administering drug therapy to a male geriatric patient, the nurse must stay especially alert for adverse effects. Which factor makes geriatric patients to adverse drug effects? a. Faster drug clearance b. Aging-related physiological changes c. Increased amount of neurons d. Enhanced blood flow to the GI tract 11. A female patient is being discharged after cataract surgery. After providing medication teaching, the nurse asks the patient to repeat the instructions. The nurse is performing which professional role? a. Manager b. Educator c. Caregiver d. Patient advocate 12. A female patient exhibits signs of heightened anxiety. Which response by the nurse is most likely to reduce the patients anxiety? a. Everything will be fine. Dont worry. b. Read this manual and then ask me any questions you may have. c. Why dont you listen to the radio? d. Lets talk about whats bothering you. 13. A scrub nurse in the operating room has which responsibility?

a. Positioning the patient b. Assisting with gowning and gloving c. Handling surgical instruments to the surgeon d. Applying surgical drapes 14. A patient is in the bathroom when the nurse enters to give a prescribed medication. What should the nurse in charge do? a. Leave the medication at the patients bedside b. Tell the patient to be sure to take the medication. And then leave it at the bedside c. Return shortly to the patients room and remain there until the patient takes the medication d. Wait for the patient to return to bed, and then leave the medication at the bedside 15. The physician orders heparin, 7,500 units, to be administered subcutaneously every 6 hours. The vial reads 10,000 units per millilitre. The nurse should anticipate giving how much heparin for each dose? a. ml b. ml c. ml d. 1 ml 16. The nurse in charge measures a patients temperature at 102 degrees F. what is the equivalent Centigrade temperature? a. 39 degrees C b. 47 degrees C c. 38.9 degrees C d. 40.1 degrees C 17. To evaluate a patient for hypoxia, the physician is most likely to order which laboratory test? a. Red blood cell count b. Sputum culture c. Total hemoglobin d. Arterial blood gas (ABG) analysis 18. The nurse uses a stethoscope to auscultate a male patients chest. Which statement about a stethoscope with a bell and diaphragm is true? a. The bell detects high-pitched sounds best b. The diaphragm detects high-pitched sounds best c. The bell detects thrills best d. The diaphragm detects low-pitched sounds best 19. A male patient is to be discharged with a prescription for an analgesic that is a controlled substance. During discharge teaching, the nurse should explain that the patient must fill this prescription how soon after the date on which it was written? a. Within 1 month b. Within 3 months c. Within 6 months d. Within 12 months

20. Which human element considered by the nurse in charge during assessment can affect drug administration? a. The patients ability to recover b. The patients occupational hazards c. The patients socioeconomic status d. The patients cognitive abilities 21. When explaining the initiation of I.V. therapy to a 2-year-old child, the nurse should: a. Ask the child, Do you want me to start the I.V. now? b. Give simple directions shortly before the I.V. therapy is to start c. Tell the child, This treatment is for your own good d. Inform the child that the needle will be in place for 10 days 22. All of the following parts of the syringe are sterile except the: a. Barrel b. Inside of the plunger c. Needle tip d. Barrel tip 23. The best way to instill eye drops is to: a. Instruct the patient to lock upward, and drop the medication into the center of the lower lid b. Instruct the patient to look ahead, and drop the medication into the center of the lower lid c. Drop the medication into the inner canthus regardless of eye position d. Drop the medication into the center of the canthus regardless of eye position 24. The difference between an 18G needle and a 25G needle is the needles: a. Length b. Bevel angle c. Thickness d. Sharpness 25. A patient receiving an anticoagulant should be assessed for signs of: a. Hypotension b. Hypertension c. An elevated hemoglobin count d. An increased number of erythrocytes 1. (B) Sensory deficits Sensory deficits could cause a geriatric patient to have difficulty retaining knowledge about prescribed medications. Decreased plasma drug levels do not alter the patients knowledge about the drug. A lack of family support may affect compliance, not knowledge retention. Toilette syndrome is unrelated to knowledge retention. 2. (C) The symptomatic quadrant last

The nurse should systematically assess all areas of the abdomen, if time and the patients condition permit, concluding with the symptomatic area. Otherwise, the nurse may elicit pain in the symptomatic area, causing the muscles in other areas to tighten. This would interfere with further assessment. 3. (C) Patients description of pain Subjective data come directly from the patient and usually are recorded as direct quotations that reflect the patients opinions or feelings about a situation. Vital signs, laboratory test result, and ECG waveforms are examples of objective data. 4. (C) Cool, pale fingers A safety device on the wrist may impair circulation and restrict blood supply to body tissues. Therefore, the nurse should assess the patient for signs of impaired circulation, such as cool, pale fingers. A palpable radial or lunar pulse and pink nail beds are normal findings. 5. (A) Frontal plane Frontal or coronal plane runs longitudinally at a right angle to a sagittal plane dividing the body in anterior and posterior regions. A sagittal plane runs longitudinally dividing the body into right and left regions; if exactly midline, it is called a midsagittal plane. A transverse plane runs horizontally at a right angle to the vertical axis, dividing the structure into superior and inferior regions. 6. (A) Shock dismay Shock and dismay are early signs of denial-the first stage of grief. The other options are associated with depressiona later stage of grief. 7. (B) Helps the patient dangle the legs After placing the patient in high Fowlers position and moving the patient to the side of the bed, the nurse helps the patient sit on the edge of the bed and dangle the legs; the nurse then faces the patient and places the chair next to and facing the head of the bed. 8. (D) Demonstrating the procedure and having the patient return the demonstration Demonstrating by the nurse with a return demonstration by the patient ensures that the patient can perform wound care correctly. Patients may claim to understand discharge instruction when they do not. An interpreter of family member may communicate verbal or written instructions inaccurately. 9. (A) Discard the syringe to avoid a medication error As a safety precaution, the nurse should discard an unlabeled syringe that contains medication. The other options are considered unsafe because they promote error. 10. (B) Aging-related physiological changes Aging-related physiological changes account for the increased frequency of adverse drug reactions in geriatric patients. Renal and hepatic changes cause drugs to clear more slowly in these patients. With increasing age, neurons are lost and blood flow to the GI tract decreases. 11. (B) Educator When teaching a patient about medications before discharge, the nurse is acting as an educator. The nurse acts as a manager when performing such activities as scheduling and making patient care assignments. The nurse performs the care giving role when providing direct care, including bathing patients and administering medications and prescribed treatments. The nurse acts as a patient advocate when making the patients wishes known to the doctor.

12. (D) Lets talk about whats bothering you. Anxiety may result from feeling of helplessness, isolation, or insecurity. This response helps reduce anxiety by encouraging the patient to express feelings. The nurse should be supportive and develop goals together with the patient to give the patient some control over an anxiety-inducing situation. Because the other options ignore the patients feeling and block communication, they would not reduce anxiety. 13. (C) Handling surgical instruments to the surgeon The scrub nurse assist the surgeon by providing appropriate surgical instruments and supplies, maintaining strict surgical asepsis and, with the circulating nurse, accounting for all gauze, sponges, needles, and instruments. The circulating nurse assists the surgeon and scrub nurse, positions the patient, applies appropriate equipment and surgical drapes, assists with gowning and gloving, and provides the surgeon and scrub nurse with supplies. 14. (C) Return shortly to the patients room and remain there until the patient takes the medication The nurse should return shortly to the patients room and remain there until the patient takes the medication to verify that it was taken as directed. The nurse should never leave medication at the patients bedside unless specifically requested to do so. 15. (C) ml The nurse solves the problem as follows: 10,000 units/7,500 units = 1 ml/X 10,000 X = 7,500 X= 7,500/10,000 or ml 16. (C) 38.9 degrees C To convert Fahrenheit degrees to centigrade, use this formula: C degrees = (F degrees 32) x 5/9 C degrees = (102 32) 5/9 + 70 x 5/9 38.9 degrees C 17. (D) Arterial blood gas (ABG) analysis All of these test help evaluate a patient with respiratory problems. However, ABG analysis is the only test evaluates gas exchange in the lungs, providing information about patients oxygenation status. 18. (B) The diaphragm detects high-pitched sounds best The diaphragm of a stethoscope detects high-pitched sound best; the bell detects low pitched sounds best. Palpation detects thrills best. 19. (C) Within 6 months In most cases, an outpatient must fill a prescription for a controlled substance within 6 months of the date on which the prescription was written. 20. (D) The patients cognitive abilities The nurse must consider the patients cognitive abilities to understand drug instructions. If not, the nurse must find a family member or significant other to take on the responsibility of administering medications in the home setting. The patients ability to recover, occupational hazards, and socioeconomic status do not affect drug administration. 21. (B) Give simple directions shortly before the I.V. therapy is to start Because a 2-year-old child has limited understanding, the nurse should give simple directions and explanations of what will occur shortly before the procedure. She should try to avoid frightening the child with the explanation and allow the child to make simple choices, such as choosing the I.V. insertion site, if possible. However, she shouldnt ask the child if he wants the therapy, because the answer may be No!

Telling the child that the treatment is for his own good is ineffective because a 2-year-old perceives pain as a negative sensation and cannot understand that a painful procedure can have position results. Telling the child how long the therapy will last is ineffective because the 2year-old doesnt have a good understanding of time. 22. (A) Barrel All syringes have three parts: a tip, which connects the needle to the syringe; a barrel, the outer part on which the measurement scales are printed; and a plunger, which fits inside the barrel to expel the medication. The external part of the barrel and the plunger and (flange) must be handled during the preparation and administration of the injection. However, the inside and trip of the barrel, the inside (shaft) of the plunger, and the needle tip must remain sterile until after the injection. 23. (A) Instruct the patient to lock upward, and drop the medication into the center of the lower lid Having the patient look upward reduces blinking and protects the cornea. Instilling drops in the center of the lower lid promotes absorption because the drops are less likely to run into the nasolacrimal duct or out of the eye. 24. (C) Thickness Gauge is a measure of the needles thickness: The higher the number the thinner the shaft. Therefore, an 18G needle is considerably thicker than a 25G needle. 25. (A) Hypotension A major side effect of anticoagulant therapy is bleeding, which can be identified by hypotension (a systolic blood pressure under 100 mm Hg). Anticoagulants do not result in the other three conditions.