which protective equipment

COMPREHENSIVE would be used when removing the packing

from the wound? (Select all that apply.)
EXAMINATION- a. Respiratory protective device
b. Mask
FNP II  c. Gloves
d. Gown
Points: b, c and d
52/100 a, b, and c
Incorrect
c and d
0/1 Points
all of the choices
1.A client is admitted to the medical-
Incorrect
surgical unit with a diagnosis of
0/1 Points
mycoplasma pneumonia. The admitting
physician did not order the client to be 4.Which new admission should the nurse
placed on any form of precautions. Which plan to place in a private room with
isolation precautions would be best for the negative pressure airflow?
client to be on? Client with TB of the bone

Transmission-based precautions Client with strep throat

Sterile precautions Client with rubella

Standard precautions Client with measles

Universal precautions Correct

Correct 1/1 Points
1/1 Points 5.When caring for a client on droplet
2.A nurse would use surgical asepsis at the precautions, which protective equipment
client’s bedside in the following situations. would the nurse use?
(Select all that apply.) (Select all that apply.)
a. Inserting an IV a. Respiratory protective device
b. Applying a sterile dressing b. Mask
c. Inserting a urinary catheter c. Gloves
d. Suctioning the oropharynx and trachea d. Gown
a, c, d d only

a and b only a and b

a only b, c, and d

a, b, c, d b only

Incorrect Correct
0/1 Points 1/1 Points

3.When caring for a client with an 6.Considered as the weakest link in the
abscessed buttock infected with MRSA, chain of infection that nurses can
manipulate to prevent the spread of 1/1 Points
infection and disease? 10.A client with has been diagnosed with
portal of entry impetigo. What precaution will nurse
infectious agent Marian used for this patient?
mode of transmission airborne precaution

susceptible host droplet precaution

Correct contact precaution

1/1 Points standard precaution
7.Which of the following is the exact order Correct
of the Chain of Infection? 1/1 Points
a. mode of transmission 11.The nurse enters the room of the client
b. reservoir on airborne precaution due to tuberculosis.
c. etiologic agent Which of the following are appropriate
d. portal of exit actions by the nurse?
e. portal of entry a. she wears mask, covering the nose and
f. susceptible host mouth
b, c, a, f, e d b. she washes her hands before and after
a, b, c, d, e, f removing gloves, after suctioning the
c, d, b, e, a, f client’s secretion
c, b, d, a, e, f
c. she removes gloves and did handwashing
before leaving the patient’s room
Correct
1/1 Points
d. she discards contaminated suction
catheter tip in yellow trashcan found in the
8.This is considered as the most important patient’s room.
aspect of handwashing.  a & b only
water
 a & c only
friction
 a, b, c, d
soap
a, b, c
time
Incorrect
Incorrect 0/1 Points
0/1 Points
12.When performing surgical hand scrub,
9.A client has been diagnosed with Rubella. which of the following nursing action is
What precaution will nurse Janine used for required tom prevent contamination?
this patient? a. keep fingernail short, clean, and with
droplet precaution nails polish
airborne precaution b. open faucet with knee or foot control
contact precaution c. keeps hands above the elbow when
standard precaution
washing and rinsing
Correct
d. wear cap, mask, shoe cover after you Risk for Poisoning
scrubbed Correct
b and c only 1/1 Points
 b, c, d 16.During report, the previous nurse
a & b only emphasized that one of the newly admitted
a, b, c patients is on seizure precautions. The
Correct incoming nurse is correct when she
1/1 Points performs which of the following actions to
the client?
13.Mr. A is a  87-year-old man is admitted
Move the client to a room closer to the nurses’
to the hospital for cellulitis of the left arm.
station.
He ambulates with a walker and take a
Maintain the client’s bed in the lowest position.
diuretic medication to control symptoms of
Serve the client’s food in paper and plastic
fluid retention. Which intervention is most
containers.
important to protect him from injury?
Ensure that soft limb restraints are applied to
 Keep the side rails up.
upper extremities.
Leave the bathroom light on.
Correct
 Provide a bedside commode. 1/1 Points
Withhold the client’s diuretic medication. 17.A 75-year-old client, hospitalized with a
Incorrect cerebral vascular accident (stroke), becomes
0/1 Points disoriented at times and tries to get out of
14.Which of the following assessments, bed but is unable to ambulate without help.
performed on a patient after a myelogram, What is the most appropriate safety
is most important in regard to patient measure?
safety? Check the client every 15 minutes.
Ensure the patient lays flat for two hours after the Restrain the client in bed.
procedure. Use a bed exit safety monitoring device.
Check the popliteal pulses bilaterally.
Ask a family member to stay with the client.
Ensure the consent form for the procedure was
Correct
signed 1/1 Points
Perform a neurological assessment.
18.When planning to teach health care
Incorrect
topics to a group of male adolescents,
0/1 Points
which topic should the nurse consider a
15.A mother and her 3-year-old live in a priority?
home built in 1932. Which NANDA nursing A driver’s education course is mandatory for
diagnosis is most applicable for this child? safety.
Risk for Injury Guns are the most frequently used weapon for
Risk for Suffocation adolescent suicide.
Risk for Disuse Syndrome Sports contribute to an adolescent’s self-esteem.
 Sunbathing and tanning beds can be dangerous. Explain the entire procedure including the
Incorrect reasons for doing it.
0/1 Points Allow the client to rest in between the
procedures.
19.Nurse Carrie is caring for a client after an
Correct
ECT treatment. Nurse Carrie is
1/1 Points
most concerned if which of the following is
observed? 22.The client is a chronic carrier of infection.
The client is unable to remember what she ate for To prevent the spread of the infection to
breakfast. other clients or health care providers, the
The client is unable to recall her name. nurse emphasizes interventions that do
which of the following?
The client complains of backache.
Block the portal of exit from the reservoir.
The client complains of headache.
Block the portal of entry into the host.
Correct
1/1 Points Decrease the susceptibility of the host.
Eliminate the reservoir.
20.In the medical ward of National
University Hospital, Nurse B cares for a Correct
patient who cannot turn by using an 1/1 Points
overhead lift. Nurse B knows that which of 23.The client is unresponsive and requires
the following is the MOST important total care by nursing staff. Which
actions to follow in terms of safety? assessment does the nurse check first
Tell the patient to rock back and forth to propel before providing special oral care to the
themselves. client?
Ensure the sling is removed from the patient after Range of motion
they are seated in the chair.  Gag reflex
Allow the patient to hook themselves up to the
Presence of pain
sling so that they feel involved in their care.
Condition of the skin
When using the lift, raise the patient above the
bed before laterally positioning the lift over the
Correct
intended chair. 1/1 Points
Incorrect 24.The client is in surgery and will be
0/1 Points returning to his bed via a stretcher. Which
21.What is the primary responsibility of the bed option reflects that the nurse planned
nurse and radiology staff when assisting a ahead appropriately for this client?
client with multiple myeloma who is Occupied bed in low position
ordered to receive a bone scan and a chest Closed bed in high position
x-ray?
Open bed in low position
Handle the client with supportive movements.
Surgical bed in high position
Assess the client for episodes of difficulty of
Correct
breathing.
1/1 Points
25.A patient is scheduled for a cardiac
catheterization this afternoon. Which of the
following, if noted in the patient’s chart by
the nurse, is a contraindication to the test?
The patient has a history of asthma.
The patient is unable to lie on her right side for
more than 15 minutes.
The patient is allergic to eggs.
The patient is allergic to clams.
Incorrect
0/1 Points
26.Mrs. D has a history of sleep apnea.
Which is the most appropriate question for
the nurse to ask?
Do you have a history of cardiac irregularities?
Do you have difficulty with daytime sleepiness?
Do you have a history of any kind of nasal
obstruction?
Have you had chest pain with or without activity?
Incorrect
0/1 Points
27.Nurse D assesses patient Z’s body
temperature in the late afternoon as 37.2-
degree celcius. What would be nurse D best
action related to the slightly elevation of
temperature?
Administer antipyretics
Assess patient for infection
Record the temperature as normal findings
Decrease the room temperature
Incorrect
0/1 Points
28.28. Nurse E observes some involuntary
jerking in a sleeping patient. She
determines that the patient is most likely in
which stage of sleep?
Stage II NREM sleep
Stage IV NREM sleep
Stage 1 NREM sleep
REM sleep
Incorrect
0/1 Points
29.Because of significant concerns about
financial problems, a middle-aged client
complains of difficulty sleeping. Which
outcome would be the most appropriate
for the nursing care plan? By day 5, the
client will:
Report falling asleep within 20 to 30 minutes.
Have a plan to pay all the bills.
Decrease worrying about financial problems and
will keep busy until bedtime.
Sleep 8 to 10 hours per day.
Correct
1/1 Points
30.A client reports to the nurse that she has
been taking barbiturate sleeping pills every
night for several months and now wishes to
stop taking them. Which statement is the
most appropriate advice for the nurse to
provide the client?
Discontinue taking the pills.
Continue taking the pills and discuss tapering the
dose with the primary care provider.
Take the last pill on a Friday night so disrupted
sleep can be compensated on the weekend.
Continue to take the pills since sleeping without
them after such a long time will be difficult and
perhaps impossible.
Correct
1/1 Points
31.Nurse F is discussing with the older
female client about the factors the affect
sleep. What fact does Nurse E teach the
client?
Drinking a cup of tea at night induces sleep
 Consuming alcohol moderately promotes deep appropriate nursing intervention for the
sleep nurse to recommend to this client?
Exercising decreases REM and NREM sleep Recommend that he and his wife sleep in
Aging decreases the amount of REM of a person separate bedrooms so that his snoring does not
disturb his wife.
experience
Incorrect Caution him not to drink or take sleeping pills
0/1 Points since they may make his snoring worse.
Refer him to a dietician for a weight loss program.
32.Nurse G is working in a night shift in a
Refer him to a sleep disorders center for
pediatric unit and observes that a 10 year
evaluation and treatment of his symptoms.
old boy walking the hallway in a sleep state.
Correct
The child in unaware of his environment
1/1 Points
and doesn’t recall the incident in the
morning. Which sleep disorder is the child 35.A new nursing graduate’s first job
exhibiting? requires 12-hour night shifts. Which
Somnambulism strategy will make it easier for the graduate
to sleep during the day and remain awake
Cataplexy
at night?
Bruxism
Try to stay in a brightly lit area when working at
Restless leg syndrome night.
Correct Exercise on the way home to avoid having to
1/1 Points stand around as long waiting for equipment at the
gym.
33.A nurse is performing a sleep
Wear dark wrap-around sunglasses when driving
assessment on a patient being treated for
home in the morning, and sleep in a darkened
sleep disorder. During the assessment, the
bedroom.
patient falls asleep in the middle of the
Drink several cups of strong coffee or 16 oz of
conversation. The nurse would suspect the
caffeinated soda when beginning the shift.
which disorder?
Correct
REM behavior disorder 1/1 Points
Sleep Apnea
36.Proper technique for performing a
Narcolepsy wound culture includes which of the
Enuresis following?
Incorrect Swabbing for the specimen in the area with the
0/1 Points largest collection of drainage

34.During a yearly physical, a 52-year-old Waiting 8 hours following a dose of antibiotic to

male client mentions that his wife obtain the specimen

frequently complains about his snoring. Removing crusts or scabs with sterile forceps and

During the physical exam, the nurse notes then culturing the site beneath

that his neck size is 18 inches, his soft Cleansing the wound prior to obtaining the

palate and uvula are reddened and swollen, specimen

Incorrect
and he is overweight. What is the most
0/1 Points undermining of adjacent tissue. This finding
37.Which assessment finding best supports would be documented as which stage of
the conclusion that the care given to a pressure ulcer?
client with a stage-II pressure ulcer has  IV

been effective?  III

Diameter of the ulcer has decreased by 50%
The dressing over the ulcer is intact
The client changes position every hour
The ulcerated area is free of drainage
Incorrect
0/1 Points
38.An elderly client at risk for impaired skin
integrity is to have moisturizer applied to
her skin. When delegating this task to a
nursing assistant, which direction should be
I
 II
Correct
1/1 Points
41.37. An alginate dressing is ordered for a
client with a stage-IV pressure ulcer. The
client’s daughter asks
what this type of dressing does. On which
fact should the nurse’s answer be based?
Alginate dressings keep the wound moist and

given? absorb exudates

Do not rub in moisturizer that is applied to skin Alginate dressings have an antibacterial effect

fold areas Alginate dressings keep the wound dry and

Dry skin thoroughly and then apply generous encourage granulation
amounts of moisturizer Alginate dressings are impregnated antibiotics
Apply moisturizer only to areas of the skin that Correct
appear chapped or flaky 1/1 Points
Apply moisturizer while skin is still moist from 42.When planning care of the client with a
bathing stage-III pressure ulcer, the nurse must be
Incorrect
cognizant of the
0/1 Points
fact that most complications of pressure
39.Which measure is effective in preventing ulcers relate to which type of event?
shearing forces from causing tissue damage Malabsorption
over the lumbosacral area? Fluid imbalance
Adjusting sheets so they are wrinkle free
Infection
dKeeping client’s skin clean and dry
Immune reaction
Maintaining head of bed at an elevation of 0–30
Correct
degrees
1/1 Points
Changing client’s position every 2 hours
43.Which measure might the nurse use to
Correct
1/1 Points
assess a client’s risk for developing a
pressure ulcer?
40.Assessment of a newly admitted client Katz Index
shows a full-thickness skin loss with an
Barthel Index
ulcer that looks like a deep crater and clear
 Braden Scale
Glasgow Coma Scale
Incorrect
0/1 Points
44.A client has a pressure ulcer with a
shallow, partial skin thickness, eroded area
but no necrotic areas. The nurse would
treat the area with which dressing?
No dressing is indicated
Alginate
Hydrocolloid
Dry gauze
Incorrect
0/1 Points
45.Which statement, if made by the client
or family member, would indicate need for
further teaching?
Putting foam pads under the heels or other bony
areas can help decrease pressure.
If a skin area gets red but then the red goes away
after turning, I should not report it to the nurse.
The skin should be washed with only warm water
(not hot) and lotion put on while it is still a little wet.
If a person cannot turn himself or herself in bed,
someone should help the person change position
every 4 hours.
Correct
1/1 Points
46.An appropriate nursing diagnosis for a
client with large areas of skin excoriation
resulting from scratching an allergic rash is:
 Impaired Tissue Integrity
 Risk for Infection
 Impaired Skin Integrity
Risk for Impaired Skin Integrity
47.Nurse Rex is cleansing a simple surgical
wound to Mr. Jose who is two days
postoperative, and the incision has well-
approximated edges with no sign of
infection. A Jackson-Pratt drain is adjacent
to the incision site. Which of the following
should nurse Rex do?
Cleanse the incision and drain sites using a sterile
saline solution.
Cleanse the incision site and drain site together.
Cleanse the incision and drain sites while wearing
standard clean gloves.
Cleanse in a back-and-forth motion across the
incision line and in a circular motion around the drain
site.
Incorrect
0/1 Points
48.Nurse Dahlia is having her duty in an
outpatient clinic of Bulldogs Hospital, has
received an order from Dr. Salvador to
remove the client’s sutures. She should do
which of the following?
Use gloves when removing sutures.
Apply hydrogen peroxide gauze pads to cleanse
the area first, then remove the sutures.
Nothing, suture removal is outside of the nurse’s
scope of practice.
Use sterile technique when removing sutures.
Correct
1/1 Points
49.A wound care nurse in the Ospital ng
Sampaloc will perform wound care to
patient Marie. The physician order to do
wound culture. The nurse knows that
proper technique for performing a wound
culture includes which of the following?
Removing crusts or scabs with sterile forceps and

Incorrect then culturing the site beneath

0/1 Points  Waiting 8 hours following a dose of antibiotic to
obtain the specimen
 Cleansing the wound prior to obtaining the malabsorption disorder
specimen overhydration
Swabbing for the specimen in the area with the Correct
largest collection of drainage 1/1 Points
Incorrect
0/1 Points 54.Which condition is most likely to cause
fecal incontinence in a normally continent
50.The patient has a urinary tract infection
individual?
and experiences an episode of urinary
eating large meals quickly
incontinence. This is classified as what type
ignoring the urge to defecate
of urinary incontinence?
Unstable diarrhea

chronic sphincter weakness

transient
Correct
1/1 Points
stress
Incorrect
55.Which question is best to assess
0/1 Points nocturia?
How long can you postpone urination?
51.The patient has severe arthritis and is
Do you leak urine or lose bladder control?
unable to go upstairs quickly to the
bathroom located on the second floor. The Do you feel you completely empty your bladder?
patient is sometimes incontinent. This type How many times do you wake up at night and
of incontinence is classified as: urinate?
urethra hypermobility Incorrect
0/1 Points
functional incontinence
reflex incontinence 56.Which patient has stress incontinence?
The patient states she urinates small amounts
urge incontinence
frequently, but examination shows bladder distention.
Correct
The patient states her bladder empties, but she
1/1 Points
doesn't know when it will happen because she has no
52.Which of the following is not a cause of sensation of fullness or urge to void.
colonic constipation? The obese patient complains of dribbling urine
infectious agents when she sneezes or bends over.
dehydration The patient states she has a strong urge to void,
but usually cannot make it to the toilet in time.
diverticular disease
Correct
diet low in fiber 1/1 Points
Incorrect
57.What is the recommended daily
0/1 Points
allowance for fluids for adults?
53. Which is a cause of diarrhea? 10 ml/kg body weight
anticholinergic drug
20 ml/kg body weight
low-fiber diet
 30 ml/kg body weight carbonated drinks
50 ml/kg body weight caffeinated beverages
Incorrect Correct
0/1 Points 1/1 Points
58.The nurse is teaching a patient who has 62.The patient is receiving an -adrenergic
frequent urination associated with urgency blocking agent for the management of
about foods that should be avoided. The urinary retention secondary to benign
nurse tells the patient to avoid all EXCEPT prostatic hyperplasia. The nurse should
Mineral oil instruct the patient to
Ginger root sit up slowly

Senna reduce fluid intake

Cascara sagrada bark take the medication early in the day

Correct take the medication twice a week

1/1 Points Correct
59.Which food should be included on a 1/1 Points
high-fiber diet? 63.When inserting a urinary catheter into
bread the male patient, the nurse should hold the
Broccoli penis
at a 90-degree angle to the body
potatoes
so it points toward the chest
rice
Correct nearly level with the abdomen
1/1 Points at a 45-degree angle to the body

60.The nurse is teaching a patient who has Correct

severe diarrhea with dehydration about oral 1/1 Points
fluids. Which fluid is contraindicated? 64.When performing an indwelling urinary
iced tea catheterization on a female patient, how far
Broth should the nurse insert the catheter?
1 to 3 inches
lemonade
until resistance is felt
water
Correct 1 to 3 inches past the point when urine starts to
1/1 Points flow
until the hub of the catheter is at the meatus
61.The nurse is teaching a patient who has
Correct
frequent urination associated with urgency
1/1 Points
about foods that should be avoided. The
nurse tells the patient to avoid all EXCEPT 65.When inserting a urinary drainage
Aspartame catheter, the catheter should be lubricated
with
water
petroleum jelly
 lotion intermittent urinary drainage
water-soluble lubricant continuous liquid fecal materia
normal saline continuous urine
Correct formed feces at periodic intervals
1/1 Points Correct
66.How should the nurse position the 1/1 Points
patient who is to receive an enema? 70.All of the following are effective nursing
left side-lying with right knee bent strategies for the management of
supine constipation EXCEPT
prone increased dietary fiber

right side-lying decreased fluid intake

Correct regular pattern of exercise

1/1 Points removal of hardened or impacted stool by
67.Which statement is correct regarding mechanical means
administration of a cleansing enema to an Incorrect
adult? 0/1 Points
The temperature of the water should be 115 71.The nurse performs all of the following
degrees Fahrenheit. actions when examining the anus EXCEPT
The enema container should be held 24 inches ask the patient to take a breath in and hold it
above the anal opening. glove and lubricate a finger and rotate the
If the patient complains of cramping, stop the inserted finger 360 degrees
flow until the feeling passes.  document perianal varicosities as hemorrhoids
Insert the catheter 8 to 10 inches above the anal
assess for anal sphincter weakness
opening.
Incorrect
Incorrect
0/1 Points
0/1 Points
72.When asking a patient if he can
68.Which ostomy will have the most formed
postpone urination for two hours, the nurse
drainage? The ostomy located in the
is assessing for
ileum
urinary retention
transverse colon
Nocturia
descending colon
urinary incontinence
ascending colon
diurnal voiding habits
Incorrect
0/1 Points Incorrect
0/1 Points
69.An ileal conduit is performed on the
73.The last resort treatment for the patient
patient who has a cystectomy. What type of
with overflow urinary problems is
drainage will the patient have from the
alpha blockers
stoma?
 removal of bladder tumor drops/ml. The nurse should set the infusion
repair of cystocele to run at how many drops per minute?
100 drops per minute
indwelling catheter
Correct 21 drops per minute
1/1 Points 17 drops per minute

74.When administering which of the 10 drops per minute

following enemas is the nurse using a Incorrect
hypertonic solution? 0/1 Points
kayexalate 78.Which assessment finding is most
soap suds consistent with an IV infusion that has
tap water infiltrated?
a reddened area
normal saline
Incorrect warmth along the vein
0/1 Points a cool area near the infusion site

75.A catheter that is inserted through the a red stripe along the vein
subcutaneous tissue between the nipple Incorrect
and clavicle with the catheter tip inserted 0/1 Points
through the cephalic or external jugular 79.Which solution should be used when a
vein and threaded to the right atrium is blood transfusion is administered?
called a Ringer's lactate
peripherally inserted central catheter
normal saline
tunneled catheter
dextrose 5% in water
nontunneled catheter
dextrose 10% in water
implantable port Correct
Incorrect 1/1 Points
0/1 Points
80.Prior to starting a blood transfusion, it is
76.When selecting a site to start an IV essential for the nurse to
infusion in an adult, the nurse should select question the patient about any allergies
a site
determine if the patient has had any previous
on the effected side of a patient who has a
transfusions
mastectomy
take the patient's vital signs, including
in the lower extremities when possible
temperature
on the distal end of a vein in the arm check the patient's intake and output
adjacent to a functioning arteriovenous fistula Correct
Correct 1/1 Points
1/1 Points 81.The patient who is receiving a blood
77. The physician orders 1,000 ml of IV fluid transfusion tells the nurse his chest feels
to infuse in 10 hours. The drop factor is 10 tight. The nurse observes that he is short of
breath and his temperature is elevated. elastic stockings. The nurse should teach
What initial action should the nurse take? the client that the stockings should be:
Report the findings to the physician. Put on before getting out of bed in the morning
C-Increase the flow rate of the transfusion. Worn only at night when activity is lessened
Check the patient again in 15 minutes. Left in place until the physician advises otherwise
Stop the transfusion. Alternately kept on 2 hours and off 2 hours
Incorrect Incorrect
0/1 Points 0/1 Points
82.A patient with a positive Chvostek’s sign 86.What appropriate goal for the client with
most likely is experiencing which acid-base peripheral vascular disease?
disturbance? Promotion of tissue oxygenation
respiratory acidosis Alleviation of pain
metabolic acidosis Lifestyle modification
respiratory alkalosis Identifying measures to prevent injury of feet
metabolic alkalosis Incorrect
Correct 0/1 Points
1/1 Points 87.Which client is most at risk for
83.Which of the following is an example of hematologic problems?
a hypotonic intravenous solution? 55-year-old man with chronic alcoholism
normal saline (NS) 0.9% 27-year-old woman taking oral contraceptives.
Ringer's lactate 62-year-old woman with diabetes mellitus on
dextrose 5% in saline 0.9% insulin therapy
sodium chloride 0.45% 48-year-old man who had a myocardial infarction

Incorrect 5 years ago

0/1 Points Incorrect
0/1 Points
84.The patient is receiving sodium chloride
88.To prepare the patient for a bone
0.45% by IV infusion. If the fluid is infused
marrow aspiration from the most common
beyond the patient's tolerance, the patient
site for adults, the nurse positions the
is at risk for
patient
water intoxication
side-lying
cellular dehydration
supine
cardiac overload
prone
increased osmotic pressure
with the head of the bed elevated 45 degrees
Correct
1/1 Points Incorrect
0/1 Points
85.A client who was diagnosed to have
vascular problem was advised to wear
89.The nurse informs a client suspected of Take care to ensure that no air is present in the
pernicious anemia that the lab study that syringe.
will be helpful in the diagnosis is: Correct
Hemoglobin levels 1/1 Points
Clotting studies 93.Which laboratory value indicates that the
Schilling test epoetin alfa (Procrit, Epogen) therapy is
effective?
Endoscopy
Red blood cell count has increased from 2.2
Incorrect
million to 3.0 million.
0/1 Points
Platelet count has decreased from 80,000 to
90.When a person’s hemoglobin is deficient 50,000.
in iron, which assessment finding is Segmented neutrophils decrease in number
expected?
Serum potassium level has increased from 3.5 to
Increased respiratory rate
4.5 mEq/L
Bradycardia. Incorrect
Pinkish mucous membranes 0/1 Points
Jugular vein distention 94.A nurse observes that the client, whose
Incorrect blood type is AB negative, is receiving a
0/1 Points transfusion with type O negative packed
91.The client has anemia and all the red blood cells. What is the nurse’s best
following clinical manifestations. Which first action?
Document the observation as the only action.
manifestation indicates to the nurse that
the anemia is a long-standing problem? Take and record the client's vital signs.
Orthostatic hypotension Call the blood bank.
Clubbed fingers Stop the transfusion and keep the IV open.
Circumoral pallor Correct
Headache
1/1 Points

Incorrect 95.What identification means should the

0/1 Points nurse use to ensure that a blood
92. The client is prescribed to receive iron transfusion is administered to the correct
dextran by the Z-track method of client?
Ask the client’s spouse if the client is the correct
intramuscular injection. Which technique
person who is to have the transfusion.
should the nurse use to adhere to the Z-
Compare the bed and room number of the client
track method?
with the bed and room number listed on the blood
Select a 22-gauge, 1-inch needle to minimize
product tag.
tissue trauma.
Ask the client if his name is the one on the blood
Massage the site for a minimum of five minutes
product tag.
after the injection.
Do not massage the site after injection.
 Compare the name and ID number on the blood
product tag with the name and ID number on the
client’s ID band.
Incorrect
0/1 Points
96.The client is prescribed to receive two
units of packed red blood cells. When the
blood products arrive, a nurse notes that
the client's current IV is infusing Ringer's
lactate solution. What should the nurse do
in this situation?
Change the intravenous solution to normal saline.
Start an additional intravenous infusion site.
Change the intravenous solution to dextrose 5%
in water.
Hang the blood with the currently infusing
solution.
Correct
1/1 Points
97.The nurse notes a grating sound when
auscultating the apical pulse of a client with
pericarditis. The most appropriate response
is to
Immediately notify the physician
Initiate resuscitation measure
Obtain an electrocardiogram
Note the finding in the client’s medical record.
Correct
1/1 Points
98.A client, age 54, has been diagnosed
with coronary heart disease, and is learning
about cardiac risk factors. The nurse
concludes that the client is capable of
applying the principles necessary for
modifying the risk factors associated with
cardiac disease if the client makes which of
the following statements?
“I will eat more fish to decrease HDL levels.”
“I have increased my physical activity from 10
minute to 30 minutes every day.”
“ I can still drink a pack of beer on weekends
while watching sports, since I am allowed two drinks
per day.”
“ I have been smoking too long to make a
difference, so I won’t quit.”
Incorrect
0/1 Points
99.The correct site at which to verify a radial
pulse measurement is the:
Brachial artery
Inguinal Site
Temporal artery
 Apex of the Heart
Correct
1/1 Points
100.The nurse should plan to obtain an
apical pulse on which client?
The client with a tachy dysrhythmia.
The client who is less than 12 hours
postoperative.
 The client with orthostatic hypotension.
The client who is unconscious.
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