‫بيت التمريض‬ PALNURSE YOUR ACCESS TO SUCCESS

1. Normal visual acuity as measured with a Snellen eye chart is 20/20. What does a visual acuity of 20/30
indicate?
A at 20 feet, an individual can only read letters large enough to be read at 30 feet
B. at 30 feet, an individual can read letters large enough to be read at 20 feet
C. an individual can read 20 out of 30 total letters on the chart
D. an individual can read 30 out of 50 total letters on the chart at 20 feet

2. Damage to the visual area of the occipital lobe of cerebrum, on the left side, would produce what type
of visual loss?
A. left eye only
B. right eye only
C. medial half of the right eye and lateral half of the left eye
D. medial half of the left eye and lateral half of the right eye

3. An anterior chamber of the eye refers to all the space in what area?
A. anterior to the retina
B. between the iris and the cornea
C. between the lens and the cornea
D. between the lens and the iris

4. What condition results when rays of light are focused in front of the retina?
A. myopia (near sightedness)
B. hyperopia (farsightedness)
C. presbyopia (kind of farsightedness)
D. emmetropia (normal)

5. As the person grows older, the lens losses its elasticity, causing which kind of farsightedness?
A. emmetropia
B. presbyopia
C. diplopia (double vision)
D. myopia

6. If a person has a foreign object of unknown material that is not readily seen in one eye, what would
the first action be?
A. irrigate the eye with a boric acid solution
B. examine the lower eyelid and then the upper eyelid
C. irrigate the eye with opious amounts of water
D. shield the eye from pressure, and seek medical help

7. A sudden loss of an area of vision, as if a curtain were being drawn, is a principal symptom of?
A. retinal detachment
B. glaucoma
C. cataracts
D. keratitis (damage in cornea)

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‫بيت التمريض‬ PALNURSE YOUR ACCESS TO SUCCESS

8. Postoperative care following stapedectomy would not include which of the following
A. out of bed as desired
B. no moisture in the affected ear
C. avoid sneezing
D. no bending over or lifting

9. Dimenhydrinate (Dramamine) is given after a stapedectomy

A. to accelerate the auditory process
B. to dull the pain experienced with the semicircular canal is disturbed
C. to minimize the sensations of equilibrium disturbances and imbalance
D. to prevent an increase tendency toward nausea

10. A client with Meniere's syndrome (idiopathicendolymphatic hydrops, is a disorder of the inner ear.
Although the cause is unknown, it probably results from an abnormality in the fluids of the inner ear. ) is
extremely uncomfortable because of which of these?
A. severe earache
B. many perceptual difficulties
C. vertigo and resultant nausea
D. facial paralysis

11. What is the cataract of the eyes?

A. opacity of the cornea
B. clouding of the aqueous humor
C. opacity of the lens
D. papilledema

12. Treating a cataract primarily involves which of the following?

A. instillation of miotics
B. installation of mydriatics
C. removal of the lens
D. enucleation

13. Preoperative instruction will not need to include

A. type of surgery
B. how to use the call bell
C. how to prevent paralytic illeus
D. how to prevent respiratory infetins

14. In preparing to teach patient about adjustment to cataract lenses, the nurse needs to know that the
lenses will.
A. magnify objects by one-third- with central vision
B. magnify objects by one-third with peripheral vision
C. reduce objects by one-third with central vision
D. reduce objects by one-third with peripheral vision
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15. In the immediate postoperative period the one action that is contraindicated for patient compared
with clients after most other operations is which of the following?
A. coughing
B. turning on the unoperative side
C. measures to control nausea and vomiting
D. eating after nausea passes

16. Immediate nursing care following cataract extraction is directed primarily toward preventing
A. Atelectasis
B. infection of the cornea
C. hemorrhage
D. prolapse of the iris

17. The patient is confused during her first night after eye surgery. What would the nurse do?
A. tell her to stay in bed
B. apply restraints to keep her in bed

C. explain why she cannot get out of bed, keep side rails up, and check her frequently
D. sedate her

18. Discharge teaching would probably not need to include

A. staying in a darkened room as much as possible
B. avoiding alcoholic drinks,; limiting the use of tea and coffee
C. using no eye washes or drops unless they were prescribed by the physician
D. avoiding being excessively sedentary

19. Patient also needs to be instructed to limit.

A. sewing
B. watching TV
C. walking
D. weeding her garden (water)

Situation: Lea visit her ophthalmologist and receives a mydriatic drug in order to facilitate the
examination. After returning home, she experiences severe pain, nausea and vomiting, and blurred
vision. During a visit to the emergency room, a diagnosis of acute glaucoma is made.

20. Lea's glaucoma has been caused by the dilation of the pupil.
A. blockage of the outflow of aqueous humor by the dilation of the pupil
B. blockage of the outflow of aqueous humor by the constriction of the pupil
C. increase intraocular pressure resulting from the increased production of aqueous humor
D. decrease intraocular pressure resulting from decrease production of aqueous humor

21. Intraocular pressure is measured clinically by tonometer. What tonometer reading would be
indicative of glaucoma?
A. pressure of 10 mmHg
B. pressure of 15 mmHg
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‫بيت التمريض‬ PALNURSE YOUR ACCESS TO SUCCESS

C. pressure of 20 mmHg
D. pressure of 25 mmHg

22. Which cranial nerve transmits visual impulses?

A. I (olfactory)
B. II (optic)
C. III (oculomotor)
D. IV (abducens)

23. Untreated or uncontrolled glaucoma damages the optic nerve. Three of the following signs and
symptoms result from optic nerve atrophy; which one does not?
A. colored halos around lights
B. severe pain in the eye
C. dilated and fixed pupils
D. opacity of the lens

24. Glaucoma is conservatively managed with miotic eye drops. Mydriatic eye drops are contraindicated
for glaucoma. Which of the following drugs is a mydriatic (it dilates the pupil)?
A. neostigmine
B. pilocarpine
C. physostigmatine
D. atropine

25. Glaucoma may require surgical treatment. Preoperatively, the client would be taught to expect which
of the following postoperatively?
A. cough and deep-breathing qh.
B. turn only to the unaffected side
C. medication for severe eye pain
D. restriction of fluids for the first 24 hours
Situation: Roy, a 55-year-old man, is admitted to the hospital with wide-angle glaucoma

26. What was the symptom that probably brought Roy to the ophthalmologist initially?
A. decreasing vision
B. extreme pain in eye
C. redness and tearing of the eye
D. seeing colored flashes of light

27. The teaching plan for Roy would include which of the following?
A. reduce fluid intake
B. add extra lighting in the home
C. wear dark glasses/during the day
D. avoid exercise

28. Miotics are used in the treatment of glaucoma. What is an example of a commonly used miotic
(substance causes the constriction of the pupil of the eye)?
A. atropine (mydriatic)
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B. pilocarpine
C. acetazolamide (Diamox)
D. scopolamine

29. What is the rationale for using miotics in the treatment of glaucoma?
A. they decrease the rate of aqueous humor production
B. pupil constriction increases outflow of aqueous humor
C. increased pupil size relaxes the ciliary muscles
D. the blood flow to the conjunctiva is increased

30. When instilling eye drops for a client with glaucoma, what procedure would the nurse
follow?
A. place the medication in the middle of the lower lid, and put pressure on the lacrimal duct after
instillation.
B. Instill the drug to the outer angle of the eye, have client tilt head back
C. instill the drug at the innermost angle; wipe with cotton away from inner aspect
D. instill medication in middle eye, have client blink for better absorption

31. Carbonic anhydrase inhibitors are sometimes used in the treatment of glaucoma because they:
A. depress secretion of a aqueous humor
B. dilate the pupil
C. paralyze the power of accommodation
D. increase the power of accommodation

32. Teaching a client with glaucoma will not include which of the following?
A. vision can be restored only if the client remains under a physician's care
B. avoid stimulant (eg., caffeine)
C. take all medications conscientiously
D. prevent constipation and avid heavy lifting and emotional excitement

33. Glaucoma is a progressive disease that can lead to blindness. It can be managed if diagnosed early.
Preventive health teaching would best include which of the points?
A. early surgical action may be necessary
B. all clients over 40 years of age should have an annual tonometry exam
C. the use of contract lances in older clients is not advisable
D. clients should seek early treatment for eye infections

34. A client with progressive glaucoma may be experiencing sensory deprivation. Which of the following
actions would best minimize this problem?
A. speak in a louder voice
B. ensure that a sedative is ordered
C. orient the client to time, place, and person
D. use touch frequently when providing care
Situation: 5-Gary is seen in the emergency room with the diagnosis of epitaxis.

35. It is unlikely that Gary's history will include

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A. minor trauma to the nose

B. a deviated septum
C. acute sinusitis
D. hypotension

36. Which of the following medications would be used with in order to promote vasoconstriction and
control bleeding?
A. epinephrine
B. lidocaine
C. pilovarpine
D. cylospentolate

37. Which of the following positions would be most desirable for Gary?
A. trendelenburg's to control shock
B. a sitting position, unless he is hypotensive
C. side-lying, to prevent aspiration
D. prone, to prevent aspiration

38. The physician decides to insert nasal packing. Of the following nursing actions, which would have the
highest priority?
A. encourage Gary to breath through his mouth, because he may feel panicky after the insertion.
B. advice Gary to expectorate the blood in the nasopharynx gently and not to swallow it
C. periodically check the position of the nasal packing, because airway obstruction can occur if the
packing accidentally slip out of place
D. take rectal temperature, because he must rely on mouth breathing and would be unable to keep his
mouth closed on the thermometer.

39. After bleeding has been controlled, Gary taken to surgery to correct a deviated nasal septum. Which
of the following is likely complication of this surgery?
A. loss of the ability to smell
B. inability to breath through the nose
C. infection
D. hemorrhage

40. Upon his discharge, the nurse instructs Gary on the use of vasoconstrictive nose drops and cautions
him to avoid too frequent, and excessive use to these drugs, which of the following provides the best
rationale for this caution
A. A rebound effect occurs in which stuffness worsens after each successive dose
B. cocaine, a frequent ingredient in nose drops, may lead to psychological addiction
C. these medications may be absorbed systematically, causing severe hypotension
D. persistent vasoconstriction of the nasal mucosa can lead to alterations in the olfactory
nerve

Situation: Brix had redial and neck surgery for cancer of the larynx. 41. Brix has tracheostomy. When
suctioning through laryngectomy tube

41.When doing these two procedures at the same time, the nurse
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would not do which of the ff:

A. Use sterile technique
B. turn head to right to suction left bronchus
C. suction for no longer then 10 to 15 seconds
D. observe for tachycardia

42. Brix requires both nasopharyngeal suctioning and suctioning through laryngectomy tube. When
doing these two procedures at the same time, the nurse would not do which of the ff:
A. use a sterile suction setup
B. suction the nose first, then the laryngectomy tube
C. suction the laryngectomy tube first, then the nose
D. lubricate the catheter with saline

43. A nasogastric tube is used to provide Brix with fluids and nutrient for approximately 10 days, for
which of the following reasons?
A. to prevent pain while swallowing
B. to prevent contamination of the suture line
C. to decrease need for swallowing
D. to prevent need for holding head up to ear

44. Brix's children are concerned about their own risk of developing cancer. All but one of the following
are facts that describe malignant neoplasia and must be considered by the nurse in her responses. Which
one is correct?
A. family factors may influence an individual's susceptibility to neoplasia
B. long-term use of corticosteroids enhances the body's defense
C. Sexual differences influence an individuals susceptibility to specific neoplasm
D. living in industrialized areas increase an individual's susceptibility to a malignant neoplasm

45. When would Brix best begin speech rehabilitation?

A. when he leaves the hospital
B. when the esophageal suture line is healed
C. three months after surgery
D. when he regains all his strength

46. The nurse is complaining the initial morning assessment on the client. Which physical examination
technique would be used first when assessing the abdomen?
A. inspection
B. light palpation
C. auscultation
D. percussion

47. The client has orders for a nasogastric (NG) tube insertion. During the procedure, instruction that will
assist in insertion would be:
A. instruct the client to tilt his head back for insertion into the nostril, then flex his neck for final insertion
B. after insertion into the nostril, instruct the client to extend his neck

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C. introduce the tube with the client's head tilted back, then instruct him to keep his head upright for final
insertion
D. instruct the client to hold his chin down, then back for insertion of the tube

48. The most important pathophysiologic factor contributing to the formation of esophageal varices is:
A. decreased prothrombin formation
B. decreased albumin formation by the liver
C. portal hypertension
D. increased central venous pressure

49. The nurse analyzes the results of the blood chemistry tests done on a client with acute pancreatitis.
Which of the following results would the nurse expect to find?
A. low glucose
B. low alkaline phosphatase
C. elevated amylase
D. elevated creatinine

50. A client being treated for esophageal varices has a Sengstaken-Blakemore tube inserted to control
the bleeding. The most important assessment is for the nurse to:
A. check that a hemostat is at the bedside
B. monitor IV fluids for the shift
C. regularly assess respiratory status
D. check that the balloon is deflated on a regular basis

51. A female client complains of gnawing (bite/chew) midepigastric pain for a few hours after meals. At
times, when the pain is severe, vomiting occurs. Specific tests are indicated to rule out:
A. cancer of the stomach
B. peptic ulcer disease
C. chronic gastritis
D. pylorospasm

52. When a client has peptic ulcer disease, the nurse would expect a priority intervention to be:
A. assisting in inserting a Miller-Abbott tube
B. assisting in inserting an atrial pressure line
C. inserting a nasogastric tube
D. inserting an IV

53. A 40-year-old male client has been hospitalized with peptic ulcer disease. He is being treated with a
histamine receptor antagonists (cimetidine), antacids, and diet. The nurse doing discharge planning will
teach him that the action of cimetidine is to:
A. reduce gastric acid output
B. protect the ulcer surface
C. inhibit the production of hydrochloric acid (HCl)
D. inhibit vagal nerve stimulation

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54. The nurse is admitting a client with Crohn's disease who is scheduled for intestinal surgery. Which
surgical procedure would the nurse anticipate for the treatment of this condition:
A. ileostomy with total colectomy
B. sigmoid colostomy with mucous fistula
C. intestinal resection with end-to-end anastomosis
D. colonoscopy with biopsy and polypectomy

55. A client who has just returned home following ileostomy surgery will need a diet that is
supplemented:
A. potassium
B. vitamin B12
C. sodium
D. fiber

56. A client scheduled for colostomy surgery. An appropriate preoperative diet will include:
A. broiled chicken, baked potato, and wheat bread
B. ground hamburger, rice, and salad
C. broiled fish, rice, squash, and tea (deodorant)
D. steak, mashed potatoes, raw carrots, and celery

57. As the nurse is completing evening care for a client, he observes that the client is upset, quiet, and
withdrawn. The nurse knows that the client is scheduled for diagnostic tests the following day. An
important assessment question to ask the client is:
A. "would you like to go to the dayroom to watch TV?"
B. "are you prepared for the test tomorrow?"
C. "have you talked with anyone about the test tomorrow?"
D. "have you asked your physician to give you a sleeping pill tonight?"

58. Following abdominal surgery, a client complaining of "gas pains" will have a rectal tube inserted. The
client should be positioned on his:
A. left side, recumbent
B. left side, sims
C. right side, semi-fowler's
D. left side, semi-Fowler's

59. Which of the following statements is most correct regarding colostomy irrigations?
A. the solution temperature should be 100 deg. F
B. 1000 ml/1L is the usual amount of solution for the irrigation
C. the solution container should be placed 10 inches above the stoma
D. the irrigation cone is inserted in an upward direction in relation to the stoma

60. The nurse is teaching a client with a new colostomy how to apply an appliance to a colostomy. How
much skin should remain exposed between the stoma and the ring of the appliance?
A. 1/8 inch
B. V inch
C. % inch
D. 1 inch
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61. Following a liver biopsy, the highest priority assessment of the client's condition is to check for:
A. pulmonary edema
B. uneven respiratory pattern
C. hemorrhage
D. pain

62. A client has a bile duct obstruction and is jaundiced. Which intervention will be most effective in
controlling the itching associated with his jaundice?
A. keep the client's nails clean and short
B. maintain the client's room temperature at 72 to 75 deg. F
C. provide tepid water for bathing
D. use alcohol for back rubs

63. When a client is in liver failure, which of the following behavioral changes is the most important
assessment to report?
A. shortness of breath
B. lethargy
C. fatigue
D. nausea

64. A client with a history of cholecystitis is now being admitted to the hospital for possible surgical
intervention. The orders include NPO, IV therapy, and bed rest. In addition to assessing for nausea,
vomiting and anorexia, the nurse should observe for pain:
A. in the right lower quadrant
B. after ingesting food
C. radiating to the left shoulder
D. in the upper quadrant

65. The nurse taking a nursing history from a newly admitted client learns that he has a Denver shunt.
This suggest that he has a history of:
A. hydrocephalus
B. renal failure
C. peripheral occlusive disease
D. cirrhosis

66. A female client had a laparoscopic cholecystectomy this morning. She is now complaining of right
shoulder pain. The nurse would explain to the client this symptom is:
A. common following this operation
B. expected after general anesthesia
C. unusual and will be reported to the surgeon
D. indicative of a need to use the incentive spirometer

67. For a client with the diagnosis of acute pancreatitis, the nurse would plan for which critical
component of his care?
A. testing for Homan's sign
B. measuring the abdominal girth
C. performing a glucometer test
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D. straining the urine

68. After removing a fecal impaction, the client complains of feeling lightheaded and the pulse rate is 44.
The priority intervention is:
A. monitoring vital signs
B. place in shock position
C. call the physician
D. begin CPR

69. Peritoneal reaction to acute pancreatitis results in a shift of fluid from the vascular space into the
peritoneal cavity. If this occurs, the nurse would evaluate for:
A. decreased serum albumin
B. abdominal pain
C. oliguria
D. peritonitis

70. The assessment finding should be reported immediately if it develop in the client with acute
pancreatitis which is:
A. nausea and vomiting
B. abdominal pain
C. decreased bowel sounds
D. shortness of breath

71. Following brain surgery, the client suddenly exhibits polyuria and begins voiding 15 to 20 L/day.
Specific gravity of the urine is 1.006. The nurse will recognize these symptoms as the possible
development of:
A. diabetes insipidus
B. diabetes, type 1
C. diabetes, type 2
D. Addison's disease

72. A person with a diagnosis of adult Diabetes, type 2, should understand the symptoms of a
hyperglycemic reaction. The nurse will know this client understands if she says these symptoms are:
A. thirst, polyuria and decreased appetite
B. flushed cheeks, acetone breath, and increased thirst
C. nausea, vomiting and diarrhea
D. weight gain, normal breath and thirst

73. The non-insulin dependent diabetic who is obese is best controlled by weight loss because obesity:
A. reduces the number of insulin receptors
B. causes pancreatic islet cell exhaustion
C. reduces insulin binding T receptor sites
D. reduces pancreatic insulin production

74. A nursing assessment for initial signs of hypoglycemia will include:

A. Pallor, blurred vision, weakness, behavioral changes
B. frequent urination, flushed face, pleural friction rub
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C. abdominal pain, diminished deep tendon reflexes, double vision

D. weakness, lassitude, irregular pulse, dilated pupils

75. Which of the following nursing diagnosis would be most appropriate for the client with decreased
thyroid function:
A. alteration in growth and development related to increased growth hormone production
B. alteration in thought processes related to decreased neurologic function
C. fluid volume deficit related to polyuria
D. hypothermia related to decreased metabolic rate

76. The RN should assess for which of the following clinical manifestations in the client with Cushing's
syndrome?
A. hypertension, diaphoresis, nausea and vomiting
B. tetany, irritability, dry skin and seizures
C. unexplained weight gain, energy loss, and cold intolerance
D. water retention, moon face, hirsutism and purple striae

77. The client hyperparathyroidism should have extremities handled gently because:
A. decreased calcium bone deposits can lead to pathologic fractures
B. edema causes stretched tissue to tear easily
C. hypertension can lead to stroke with residual paralysis
D. polyuria leads to dry skin and mucous membrane that can breakdown

78. Which of the following priority nursing implementation for a client with a tumor of the posterior lobe
of the pituitary gland who has had a urine output of 3 L in the last hour with a specific gravity of 1.002?
A. measure and record vital signs each shift
B. turn client every 2 hours to prevent skin breakdown
C. administer Pitressin Tannate as ordered
D. maintain a dark and quiet room

79. A client has a diagnosis of diabetes. His physician has ordered short and long acting insulin. When
administering two type of insulin, the nurse would:
A. withdraw the long acting insulin into the syringe before the short acting insulin
B. withdraw the short acting insulin into the syringe before the long acting insulin
C. draw up in two separate syringes, then combine in one syringe
D. withdraw long acting insulin, inject air into regular insulin, and withdraw insulin

80. Certain physiological changes will result from the treatment for myxedem. The symptoms that may
indicate adverse changes in the body that the nurse should observe for are:
A. increased respiratory excursion
B. increased the frequency of rest periods
C. initiate postural drainage
D. continue with routine nursing care

81. A client with myxedema has been in the hospital for 3 days. The nursing assessment reveals the
following clinical manifestations: respiratory rate 8/min, diminished breath sounds in the right lower
lobe, crackles in the left lower lobe. The most appropriate nursing intervention is to:
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A. increased the use of ROM, turning, deep breathing exercises

B. increased the frequency of rest periods
C. initiate postural drainage
D. continue with routine nursing care

82. In an individual with the diagnosis of hyperparathyroidism, the nurse will assess for which primary
symptom:
A. fatigue, muscular weakness
B. cardiac arrhytmias
C. C. tetany
D. D. constipation

83. The nurse explains to a client who has just received the diagnosis of type 2 non-insulin dependent
diabetes mellitus (NIDDM) that sulfonylureas, one group of oral hypoglycemic agents, as act by:
A. stimulating the pancreas to produce or release insulin
B. making the insulin that is produce more available for use
C. lowering the blood sugar by facilitating the uptake and utilization of glucose
D. altering both fat and protein metabolism

84. A client has been admitted to the hospital with a tentative diagnosis of adrenocortical hyperfucntion.
In assessing the client, an observable sign the nurse would chart is:
A. butterfly rash on the face
B. moon face
C. positive Chvostek's sign
D. bloated extremities

85. The nurse is teaching a diabetic client to monitor glucose using a glucometer. The nurse will know the
client is competent in performing her finger-stick to obtain blood when she:
A. uses a ball of a finger as the puncture site
B. uses the side of fingertip as the puncture site
C. avoid using the fingers of her dominant hand as puncture sites
D. avoid using the thumbs as puncture sites

86. A client is scheduled for a voiding cystogram. Which nursing intervention would be essential to carry
put several hours before the test?
A. maintain NPO status
B. medicating with urinary antiseptics
C. administering bowel preparations
D. forcing fluids

87. A retention catheter for a male client is correctly taped if it is:

A. on the lower abdomen
B. on the umbilicus
C. under the thigh
D. on the inner thigh

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88. A client with a diagnosis of gout will betaking colchicines and allopurinol BID to prevent recurrence.
The most common early sign of colchicines toxicity that the nurse assess for is:
A. blurred vision
B. anorexia
C. diarrhea
D. fever

89. A client's laboratory results have been returned and the creatinine level is 7 mg/dl. This finding
would lead the nurse to place the highest priority on assessing:
A. temperature
B. intake andoutput
C. capillary refill
D. pupillary reflex

90. After the lungs, the kidneys work to maintain body pH. The best explanation of how the kidneys
accomplish regulation of pH is that they:
A. secrete hydrogen ions and sodium
B. secrete ammonia
C. exchange hydrogen and sodium in the kidney tubules
D. decrease sodium ions, hold on to the hydrogen ions, and then secrete sodium bicarbonate

91. Conditions known to predispose to renal calculi formation include:

A. Polyuria
B. dehydration, immobility
C. glycosuria
D. presence of an indwelling Foley catheter

92. the most appropriate nursing intervention, based on physician's orders, for treating metabolic
acidosis is to:
A. replace potassium ions immediately to prevent hypokalemia
B. administer oral sodium bicarbonate to act as a buffer
C. administer IV cathecholamines (Levophed) to prevent hypertension
D. administer fluids to prevent dehydration

93. IV is attached to a controller to maintain the flow rate. If the alarm sounds on the controller:
A. ensure that drip chamber is full
B. assess that height of IV container is at least 30 inches above venipuncture site
C. ensure that the drop sensor is properly placed on the drip chamber
D. evaluate the needle and IV tubing to determine if they are patent and positioned appropriately

94. A 76-year-old woman who has been in good health develops urinary incontinence over a period of
several days and is admitted to the hospital for a diagnostic workup. The nurse would assess the client
for other indicators of:
A. renal failure
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B. urinary tract infection

C. fluid volume excess
D. dementia

95. A 60-year-old male client's physician schedules a prostatectomy and orders a straight urinary
drainage system to be inserted preoperatively. For the system to be effective, the nurse would:
A. coil the tubing above the level of the bladder
B. position the collection bag above the level of the bladder
C. check that the collection bag is vented and distensible
D. determine that the tubing is less that 3 feet in length

96. During a retention catheter insertion or bladder irrigation, the nurse must use:
A. sterile equipment and wear sterile gloves
B. clean equipment and maintain surgical asepsis
C. sterile equipment and maintain medical asepsis
D. clean equipment and technique

97. The physician has ordered a 24 hours urine specimen. After explaining the procedure to the client,
the nurse collects the first specimen. This specimen. This specimen is the:
A. discarded, then collection begins
B. saved as part of the 24 hours collection
C. tested, then discarded
D. placed in a separate container and later added to collection

98. The most common cause of bladder infection in the client with a retention catheter is contamination:
A. due to insertion technique
B. at the time of the catheter removal
C. of the urethral/ catheter interface
D. of the internal lumen of the catheter

99. A client in acute renal failure receive an IV infusion of 10 percent dextrose in water with 20 units of
regular insulin. The nurse understands that the rational for this therapy is to:
E. correct the hyperglycemia that occurs with acute renal failure
F. facilitate the intracellular movement of potassium
G. provide calories to prevent tissue catabolism and azotemia
H. force potassium into cells to prevent arrhythmias

100. A client with chronic renal failure is on continuous ambulatory peritoneal dialysis (CAPD). Which
nursing diagnosis should have the highest priority?
A. powerlessness
B. high risk for infection
C. altered nutrition: less than body requirements
D. high risk for fluid volume deficit\

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1A 2C 3C 4A 5B 6D 7A 8A 9C 10 C
11 C 12C 13 C 14 A 15 A 16 C 17 C 18 A 19 D 20 A
21 D 22 B 23 D 24 D 25 B 26 A 27 B 28 B 29 B 30 A
31 A 32 A 33 B 34 D 35 D 36 A 37 B 38 C 39 B 40 A
41 D 42 B 43 B 44 B 45 B 46 A 47 A 48 C 49 C 50 C
51 B 52 C 53 C 54 C 55 A 56 C 57 B 58 C 59 B 60 A
61 C 62 C 63 B 64 D 65 D 66 A 67 B 68 B 69 C 70 D
71 A 72 B 73 C 74 A 75 C 76 C 77 A 78 C 79 B 80 B
81 A 82 C 83 A 84 B 85 B 86 C 87 A 88 C 89 B 90 C
91 B 92 C 93 A 94 B 95 C 96 A 97 A 98 D 99 B 100 B

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