PNLE 1 - FOUNDATION OF PROFESSIONAL NURSING PRACTICE amounts of output for 2 consecutive hours: 8 a.m.: 50 ml; 9 a.m.

: 60
SET1 ml. Based on these amounts, which action should the nurse take?
1. The nurse In-charge in labor and delivery unit administered a dose Increase the I.V. fluid infusion rate
of terbutaline to a client without checking the client’s pulse. The Irrigate the indwelling urinary catheter
standard that would be used to determine if the nurse was negligent Notify the physician
is: Continue to monitor and record hourly urine output
The physician’s orders. 9. Tony, a basketball player twist his right ankle while playing on the
The action of a clinical nurse specialist who is recognized expert in court and seeks care for ankle pain and swelling. After the nurse
the field. applies ice to the ankle for 30 minutes, which statement by Tony
The statement in the drug literature about administration of suggests that ice application has been effective?
terbutaline. “My ankle looks less swollen now”.
The actions of a reasonably prudent nurse with similar education “My ankle feels warm”.
and experience. “My ankle appears redder now”.
2. Nurse Trish is caring for a female client with a history of GI “I need something stronger for pain relief”
bleeding, sickle cell disease, and a platelet count of 22,000/μl. The 10.The physician prescribes a loop diuretic for a client. When
female client is dehydrated and receiving dextrose 5% in half-normal administering this drug, the nurse anticipates that the client may
saline solution at 150 ml/hr. The client complains of severe bone develop which electrolyte imbalance?
pain and is scheduled to receive a dose of morphine sulfate. In Hypernatremia
administering the medication, Nurse Trish should avoid which route? Hyperkalemia
I.V Hypokalemia
I.M Hypervolemia
Oral 11.She finds out that some managers have benevolent-authoritative
S.C style of management. Which of the following behaviors will she
3. Dr. Garcia writes the following order for the client who has been exhibit most likely?
recently admitted “Digoxin .125 mg P.O. once daily.” To prevent a Have condescending trust and confidence in their subordinates.
dosage error, how should the nurse document this order onto the Gives economic and ego awards.
medication administration record? Communicates downward to staffs.
“Digoxin .1250 mg P.O. once daily” Allows decision making among subordinates.
“Digoxin 0.1250 mg P.O. once daily” 12. Nurse Amy is aware that the following is true about functional
“Digoxin 0.125 mg P.O. once daily” nursing
“Digoxin .125 mg P.O. once daily” Provides continuous, coordinated and comprehensive nursing
4. A newly admitted female client was diagnosed with deep vein services.
thrombosis. Which nursing diagnosis should receive the highest One-to-one nurse patient ratio.
priority? Emphasize the use of group collaboration.
Ineffective peripheral tissue perfusion related to venous congestion. Concentrates on tasks and activities.
Risk for injury related to edema. 13.Which type of medication order might read “Vitamin K 10 mg I.M.
Excess fluid volume related to peripheral vascular disease. daily × 3 days?”
Impaired gas exchange related to increased blood flow. Single order
5. Nurse Betty is assigned to the following clients. The client that the Standard written order
nurse would see first after endorsement? Standing order
A 34 year-old post operative appendectomy client of five hours who Stat order
is complaining of pain. 14.A female client with a fecal impaction frequently exhibits which
A 44 year-old myocardial infarction (MI) client who is complaining of clinical manifestation?
nausea. Increased appetite
A 26 year-old client admitted for dehydration whose intravenous (IV) Loss of urge to defecate
has infiltrated. Hard, brown, formed stools
A 63 year-old post operative’s abdominal hysterectomy client of Liquid or semi-liquid stools
three days whose incisional dressing is saturated 15.Nurse Linda prepares to perform an otoscopic examination on a
with serosanguinous fluid. female client. For proper visualization, the nurse should position the
6. Nurse Gail places a client in a four-point restraint following orders client’s ear by:
from the physician. The client care plan should include: Pulling the lobule down and back
Assess temperature frequently. Pulling the helix up and forward
Provide diversional activities. Pulling the helix up and back
Check circulation every 15-30 minutes. Pulling the lobule down and forward
Socialize with other patients once a shift. 16. Which instruction should nurse Tom give to a male client who is
7. A male client who has severe burns is receiving H2 receptor having external radiation therapy:
antagonist therapy. The nurse In-charge knows the purpose of this Protect the irritated skin from sunlight.
therapy is to: Eat 3 to 4 hours before treatment.
Prevent stress ulcer Wash the skin over regularly.
Block prostaglandin synthesis Apply lotion or oil to the radiated area when it is red or sore.
Facilitate protein synthesis. 17.In assisting a female client for immediate surgery, the nurse
Enhance gas exchange In-charge is aware that she should:
8. The doctor orders hourly urine output measurement for a Encourage the client to void following preoperative medication.
postoperative male client. The nurse Trish records the following Explore the client’s fears and anxieties about the surgery.
Assist the client in removing dentures and nail polish.
Encourage the client to drink water prior to surgery. 27.A child of 10 years old is to receive 400 cc of IV fluid in an 8 hour
18. A male client is admitted and diagnosed with acute pancreatitis shift. The IV drip factor is 60. The IV rate that will deliver this amount
after a holiday celebration of excessive food and alcohol. Which is:
assessment finding reflects this diagnosis? 50 cc/ hour
Blood pressure above normal range. 55 cc/ hour
Presence of crackles in both lung fields. 24 cc/ hour
Hyperactive bowel sounds 66 cc/ hour
Sudden onset of continuous epigastric and back pain. 28.The nurse is aware that the most important nursing action when a
19. Which dietary guidelines are important for nurse Oliver to client returns from surgery is:
implement in caring for the client with burns? Assess the IV for type of fluid and rate of flow.
Provide high-fiber, high-fat diet Assess the client for presence of pain.
Provide high-protein, high-carbohydrate diet. Assess the Foley catheter for patency and urine output
Monitor intake to prevent weight gain. Assess the dressing for drainage.
Provide ice chips or water intake. 29. Which of the following vital sign assessments that may indicate
20.Nurse Hazel will administer a unit of whole blood, which priority cardiogenic shock after myocardial infarction?
information should the nurse have about the client? BP – 80/60, Pulse – 110 irregular
Blood pressure and pulse rate. BP – 90/50, Pulse – 50 regular
Height and weight. BP – 130/80, Pulse – 100 regular
Calcium and potassium levels BP – 180/100, Pulse – 90 irregular
Hgb and Hct levels. 30.Which is the most appropriate nursing action in obtaining a blood
21. Nurse Michelle witnesses a female client sustain a fall and pressure measurement?
suspects that the leg may be broken. The nurse takes which priority Take the proper equipment, place the client in a comfortable
action? position, and record the appropriate information in the client’s chart.
Takes a set of vital signs. Measure the client’s arm, if you are not sure of the size of cuff to
Call the radiology department for X-ray. use.
Reassure the client that everything will be alright. Have the client recline or sit comfortably in a chair with the forearm
Immobilize the leg before moving the client. at the level of the heart.
22.A male client is being transferred to the nursing unit for Document the measurement, which extremity was used, and the
admission after receiving a radium implant for bladder cancer. The position that the client was in during the measurement.
nurse in-charge would take which priority action in the care of this 31.Asking the questions to determine if the person understands the
client? health teaching provided by the nurse would be included during
Place client on reverse isolation. which step of the nursing process?
Admit the client into a private room. Assessment
Encourage the client to take frequent rest periods. Evaluation
Encourage family and friends to visit. Implementation
23.A newly admitted female client was diagnosed with Planning and goals
agranulocytosis. The nurse formulates which priority nursing 32.Which of the following item is considered the single most
diagnosis? important factor in assisting the health professional in arriving at a
Constipation diagnosis or determining the person’s needs?
Diarrhea Diagnostic test results
Risk for infection Biographical date
Deficient knowledge History of present illness
24.A male client is receiving total parenteral nutrition suddenly Physical examination
demonstrates signs and symptoms of an air embolism. What is the 33.In preventing the development of an external rotation deformity
priority action by the nurse? of the hip in a client who must remain in bed for any period of time,
Notify the physician. the most appropriate nursing action would be to use:
Place the client on the left side in the Trendelenburg position. Trochanter roll extending from the crest of the ileum to the
Place the client in high-Fowlers position. midthigh.
Stop the total parenteral nutrition. Pillows under the lower legs.
25.Nurse May attends an educational conference on leadership Footboard
styles. The nurse is sitting with a nurse employed at a large trauma Hip-abductor pillow
center who states that the leadership style at the trauma center is 34.Which stage of pressure ulcer development does the ulcer extend
task-oriented and directive. The nurse determines that the into the subcutaneous tissue?
leadership style used at the trauma center is: Stage I
Autocratic. Stage II
Laissez-faire. Stage III
Democratic. Stage IV
Situational 35.When the method of wound healing is one in which wound edges
26.The physician orders DS 500 cc with KCl 10 mEq/liter at 30 cc/hr. are not surgically approximated and integumentary continuity is
The nurse in-charge is going to hang a 500 cc bag. KCl is supplied 20 restored by granulations, the wound healing is termed
mEq/10 cc. How many cc’s of KCl will be added to the IV solution? Second intention healing
.5 cc Primary intention healing
5 cc Third intention healing
1.5 cc First intention healing
2.5 cc
36.An 80-year-old male client is admitted to the hospital with a
diagnosis of pneumonia. Nurse Oliver learns that the client lives
alone and hasn’t been eating or drinking. When assessing him for
dehydration, nurse Oliver would expect to find:
Hypothermia
Hypertension
Distended neck veins
Tachycardia
37.The physician prescribes meperidine (Demerol), 75 mg I.M. every
4 hours as needed, to control a client’s postoperative pain. The
package insert is “Meperidine, 100 mg/ml.” How many milliliters of
meperidine should the
client receive?
0.75
0.6
0.5
0.25
38. A male client with diabetes mellitus is receiving insulin. Which
statement correctly describes an insulin unit?
It’s a common measurement in the metric system.
It’s the basis for solids in the avoirdupois system.
It’s the smallest measurement in the apothecary system.
It’s a measure of effect, not a standard measure of weight or
quantity.
39.Nurse Oliver measures a client’s temperature at 102° F. What is
the equivalent Centigrade temperature?
40.1 °C
38.9 °C
48 °C
38 °C
40.The nurse is assessing a 48-year-old client who has come to the
physician’s office for his annual physical exam. One of the first
physical signs of aging is:
Accepting limitations while developing assets.
Increasing loss of muscle tone.
Failing eyesight, especially close vision.
Having more frequent aches and pains.
41.The physician inserts a chest tube into a female client to treat a
pneumothorax. The tube is connected to water-seal drainage. The
nurse in-charge can prevent chest tube air leaks by:
Checking and taping all connections.
Checking patency of the chest tube.
Keeping the head of the bed slightly elevated.
Keeping the chest drainage system below the level of the chest.
42.Nurse Trish must verify the client’s identity before administering
medication. She is aware that the safest way to verify identity is to:
Check the client’s identification band.
Ask the client to state his name.
State the client’s name out loud and wait a client to repeat it.
Check the room number and the client’s name on the bed.
43.The physician orders dextrose 5 % in water, 1,000 ml to be infused
over 8 hours. The I.V. tubing delivers 15 drops/ml. Nurse John should
run the I.V. infusion at a rate of:
30 drops/minute
32 drops/minute
20 drops/minute
18 drops/minute
44.If a central venous catheter becomes disconnected accidentally,
what should the nurse in-charge do immediately?
Clamp the catheter
Call another nurse
Call the physician
Apply a dry sterile dressing to the site.
45.A female client was recently admitted. She has fever, weight loss,
and watery diarrhea is being admitted to the facility. While assessing
the client, Nurse Hazel inspects the client’s abdomen and notice that
it is slightly concave. Additional assessment should proceed in which
order:
Palpation, auscultation, and percussion.
Percussion, palpation, and auscultation.
Palpation, percussion, and auscultation.
Auscultation, percussion, and palpation.
46. Nurse Betty is assessing tactile fremitus in a client with
pneumonia. For this examination, nurse Betty should use the:
Fingertips
Finger pads
Dorsal surface of the hand
Ulnar surface of the hand
47. Which type of evaluation occurs continuously throughout the
teaching and learning process?
Summative
Informative
Formative
Retrospective
48.A 45 year old client, has no family history of breast cancer or
other risk factors for this disease. Nurse John should instruct her to
have mammogram how often?
Twice per year
Once per year
Every 2 years
Once, to establish baseline
49.A male client has the following arterial blood gas values: pH 7.30;
Pao2 89 mmHg; Paco2 50 mmHg; and HCO3 26mEq/L. Based on
these values, Nurse Patricia should expect which condition?
Respiratory acidosis
Respiratory alkalosis
Metabolic acidosis
Metabolic alkalosis
50.Nurse Len refers a female client with terminal cancer to a local
hospice. What is the goal of this referral?
To help the client find appropriate treatment options.
To provide support for the client and family in coping with terminal
illness.
To ensure that the client gets counseling regarding health care costs.
To teach the client and family about cancer and its treatment.
51.When caring for a male client with a 3-cm stage I pressure ulcer
on the coccyx, which of the following actions can the nurse
institute independently?
Massaging the area with an astringent every 2 hours.
Applying an antibiotic cream to the area three times per day.
Using normal saline solution to clean the ulcer and applying a
protective dressing as necessary.
Using a povidone-iodine wash on the ulceration three times per day.
52.Nurse Oliver must apply an elastic bandage to a client’s ankle and
calf. He should apply the bandage beginning at the client’s:
Knee
Ankle
Lower thigh
Foot
53.A 10 year old child with type 1 diabetes develops diabetic
ketoacidosis and receives a continuous insulin infusion. Which
condition represents the greatest risk to this child?
Hypernatremia
Hypokalemia
Hyperphosphatemia
Hypercalcemia
54.Nurse Len is administering sublingual nitrglycerin (Nitrostat) to
the newly admitted client. Immediately afterward, the client may
experience:
Throbbing headache or dizziness
Nervousness or paresthesia.
Drowsiness or blurred vision.
Tinnitus or diplopia.
55.Nurse Michelle hears the alarm sound on the telemetry monitor.
The nurse quickly looks at the monitor and notes that a client is in a
ventricular tachycardia. The nurse rushes to the client’s room. Upon
reaching the client’s bedside, the nurse would take which action
first?
Prepare for cardioversion
Prepare to defibrillate the client
Call a code
Check the client’s level of consciousness
56.Nurse Hazel is preparing to ambulate a female client. The best
and the safest position for the nurse in assisting the client is to
stand:
On the unaffected side of the client.
On the affected side of the client.
In front of the client.
Behind the client.
57.Nurse Janah is monitoring the ongoing care given to the potential
organ donor who has been diagnosed with brain death. The nurse
determines that the standard of care had been maintained if which
of the following data is observed?
Urine output: 45 ml/hr
Capillary refill: 5 seconds
Serum pH: 7.32
Blood pressure: 90/48 mmHg
58. Nurse Amy has an order to obtain a urinalysis from a male client
with an indwelling urinary catheter. The nurse avoids which of the
following, which contaminate the specimen?
Wiping the port with an alcohol swab before inserting the syringe.
Aspirating a sample from the port on the drainage bag.
Clamping the tubing of the drainage bag.
Obtaining the specimen from the urinary drainage bag.
59.Nurse Meredith is in the process of giving a client a bed bath. In
the middle of the procedure, the unit secretary calls the nurse on
the intercom to tell the nurse that there is an emergency phone call.
The appropriate nursing action is to:
Immediately walk out of the client’s room and answer the phone
call.
Cover the client, place the call light within reach, and answer the
phone call.
Finish the bed bath before answering the phone call.
Leave the client’s door open so the client can be monitored and the
nurse can answer the phone call.
60. Nurse Janah is collecting a sputum specimen for culture and
sensitivity testing from a client who has a productive cough. Nurse
Janah plans to implement which intervention to obtain the
specimen?
Ask the client to expectorate a small amount of sputum into the
emesis basin.
Ask the client to obtain the specimen after breakfast.
Use a sterile plastic container for obtaining the specimen.
Provide tissues for expectoration and obtaining the specimen.
61. Nurse Ron is observing a male client using a walker. The nurse
determines that the client is using the walker correctly if the client:
Puts all the four points of the walker flat on the floor, puts weight on
the hand pieces, and then walks into it.
Puts weight on the hand pieces, moves the walker forward, and then
walks into it.
Puts weight on the hand pieces, slides the walker forward, and then
walks into it.
Walks into the walker, puts weight on the hand pieces, and then puts
all four points of the walker flat on the floor.
62.Nurse Amy has documented an entry regarding client care in the
client’s medical record. When checking the entry, the nurse realizes
that incorrect information was documented. How does the nurse
correct this error?
Erases the error and writes in the correct information.
Uses correction fluid to cover up the incorrect information and
writes in the correct information.
Draws one line to cross out the incorrect information and then
initials the change.
Covers up the incorrect information completely using a black pen
and writes in the correct information
63.Nurse Ron is assisting with transferring a client from the
operating room table to a stretcher. To provide safety to the client,
the nurse should:
Moves the client rapidly from the table to the stretcher.
Uncovers the client completely before transferring to the stretcher.
Secures the client safety belts after transferring to the stretcher.
Instructs the client to move self from the table to the stretcher.
64.Nurse Myrna is providing instructions to a nursing assistant
assigned to give a bed bath to a client who is on contact precautions.
Nurse Myrna instructs the nursing assistant to use which of the
following protective items when giving bed bath?
Gown and goggles
Gown and gloves
Gloves and shoe protectors
Gloves and goggles
65. Nurse Oliver is caring for a client with impaired mobility that
occurred as a result of a stroke. The client has right sided arm and
leg weakness. The nurse would suggest that the client use which of
the following assistive devices that would provide the best stability
for ambulating?
Crutches
Single straight-legged cane
Quad cane
Walker
66.A male client with a right pleural effusion noted on a chest X-ray
is being prepared for thoracentesis. The client experiences severe
dizziness when sitting upright. To provide a safe environment, the
nurse assists the client to which position for the procedure?
Prone with head turned toward the side supported by a pillow.
Sims’ position with the head of the bed flat.
Right side-lying with the head of the bed elevated 45 degrees.
Left side-lying with the head of the bed elevated 45 degrees.
67.Nurse John develops methods for data gathering. Which of the
following criteria of a good instrument refers to the ability of the
instrument to yield the same results upon its repeated
administration?
Validity
Specificity
Sensitivity
Reliability
68.Harry knows that he has to protect the rights of human research
subjects. Which of the following actions of Harry ensures
anonymity?
Keep the identities of the subject secret
Obtain informed consent
Provide equal treatment to all the subjects of the study.
Release findings only to the participants of the study
69.Patient’s refusal to divulge information is a limitation because it is
beyond the control of Tifanny”. What type of research is appropriate
for this study?
Descriptive- correlational
Experiment
Quasi-experiment
Historical
70.Nurse Ronald is aware that the best tool for data gathering is? 79.Mary finally decides to use judgment sampling on her research.
Interview schedule Which of the following actions of is correct?
Questionnaire Plans to include whoever is there during his study.
Use of laboratory data Determines the different nationality of patients frequently
Observation admitted and decides to get representations samples from each.
71.Monica is aware that there are times when only manipulation of Assigns numbers for each of the patients, place these in a
study variables is possible and the elements of control or fishbowl and draw 10 from it.
randomization are not attendant. Which type of research is referred Decides to get 20 samples from the admitted patients
to this? 80. The nursing theorist who developed transcultural nursing theory
Field study is:
Quasi-experiment Florence Nightingale
Solomon-Four group design Madeleine Leininger
Post-test only design Albert Moore
72.Cherry notes down ideas that were derived from the description Sr. Callista Roy
of an investigation written by the person who conducted it. Which 81.Marion is aware that the sampling method that gives equal
type of reference source refers to this? chance to all units in the population to get picked is:
Footnote Random
Bibliography Accidental
Primary source Quota
Endnotes Judgment
73.When Nurse Trish is providing care to his patient, she must 82.John plans to use a Likert Scale to his study to determine the:
remember that her duty is bound not to do doing any action that will Degree of agreement and disagreement
cause the patient harm. This is the meaning of the bioethical Compliance to expected standards
principle: Level of satisfaction
Non-maleficence Degree of acceptance
Beneficence 83.Which of the following theory addresses the four modes of
Justice adaptation?
Solidarity Madeleine Leininger
74.When a nurse in-charge causes an injury to a female patient and Sr. Callista Roy
the injury caused becomes the proof of the negligent act, the Florence Nightingale
presence of the injury is said to exemplify the principle of: Jean Watson
Force majeure 84.Ms. Garcia is responsible to the number of personnel reporting to
Respondeat superior her. This principle refers to:
Res ipsa loquitor Span of control
Holdover doctrine Unity of command
75.Nurse Myrna is aware that the Board of Nursing has quasi-judicial Downward communication
power. An example of this power is: Leader
The Board can issue rules and regulations that will govern 85.Ensuring that there is an informed consent on the part of the
the practice of nursing patient before a surgery is done, illustrates the bioethical principle
The Board can investigate violations of the nursing law and code of:
of ethics Beneficence
The Board can visit a school applying for a permit in Autonomy
collaboration with CHED Veracity
The Board prepares the board examinations Non-maleficence
76. When the license of nurse Krina is revoked, it means that she: 86.Nurse Reese is teaching a female client with peripheral vascular
Is no longer allowed to practice the profession for the rest of her life disease about foot care; Nurse Reese should include which
Will never have her/his license re-issued since it has been revoked instruction?
May apply for re-issuance of his/her license based on Avoid wearing cotton socks.
certain conditions stipulated in RA 9173 Avoid using a nail clipper to cut toenails.
Will remain unable to practice professional nursing Avoid wearing canvas shoes.
77.Ronald plans to conduct a research on the use of a new method Avoid using cornstarch on feet.
of pain assessment scale. Which of the following is the second step 87.A client is admitted with multiple pressure ulcers. When
in the conceptualizing phase of the research process? developing the client’s diet plan, the nurse should include:
Formulating the research hypothesis Fresh orange slices
Review related literature Steamed broccoli
Formulating and delimiting the research problem Ice cream
Design the theoretical and conceptual framework Ground beef patties
78. The leader of the study knows that certain patients who are in 88.The nurse prepares to administer a cleansing enema. What is the
a specialized research setting tend to respond psychologically to most common client position used for this procedure?
the conditions of the study. This referred to as : Lithotomy
Cause and effect Supine
Hawthorne effect Prone
Halo effect Sims’ left lateral
Horns effect 89.Nurse Marian is preparing to administer a blood transfusion.
Which action should the nurse take first?
Arrange for typing and cross matching of the client’s blood.
Compare the client’s identification wristband with the tag on the
unit of blood.
Start an I.V. infusion of normal saline solution.
Measure the client’s vital signs.
90.A 65 years old male client requests his medication at 9 p.m.
instead of 10 p.m. so that he can go to sleep earlier. Which type of
nursing intervention is required?
Independent
Dependent
Interdependent
Intradependent
91.A female client is to be discharged from an acute care facility
after treatment for right leg thrombophlebitis. The Nurse Betty notes
that the client’s leg is pain-free, without redness or edema. The
nurse’s actions reflect which step of the nursing process?
Assessment
Diagnosis
Implementation
Evaluation
92.Nursing care for a female client includes removing elastic
stockings once per day. The Nurse Betty is aware that the rationale
for this intervention?
To increase blood flow to the heart
To observe the lower extremities
To allow the leg muscles to stretch and relax
To permit veins in the legs to fill with blood.
93.Which nursing intervention takes highest priority when caring for
a newly admitted client who’s receiving a blood transfusion?
Instructing the client to report any itching, swelling, or dyspnea.
Informing the client that the transfusion usually take 1 ½ to 2 hours.
Documenting blood administration in the client care record.
Assessing the client’s vital signs when the transfusion ends.
94.A male client complains of abdominal discomfort and nausea
while receiving tube feedings. Which intervention is most
appropriate for this problem?
Give the feedings at room temperature.
Decrease the rate of feedings and the concentration of the formula.
Place the client in semi-Fowler’s position while feeding.
Change the feeding container every 12 hours.
95.Nurse Patricia is reconstituting a powdered medication in a vial.
After adding the solution to the powder, she nurse should:
Do nothing.
Invert the vial and let it stand for 3 to 5 minutes.
Shake the vial vigorously.
Roll the vial gently between the palms.
96.Which intervention should the nurse Trish use when
administering oxygen by face mask to a female client?
Secure the elastic band tightly around the client’s head.
Assist the client to the semi-Fowler position if possible.
Apply the face mask from the client’s chin up over the nose.
Loosen the connectors between the oxygen equipment
and humidifier.
97.The maximum transfusion time for a unit of packed red blood
cells (RBCs) is:
6 hours
4 hours
3 hours
2 hours
98.Nurse Monique is monitoring the effectiveness of a client’s drug
therapy. When should the nurse Monique obtain a blood sample to
measure the trough drug level?
1 hour before administering the next dose.
Immediately before administering the next dose.
Immediately after administering the next dose.
30 minutes after administering the next dose.
99.Nurse May is aware that the main advantage of using a floor
stock system is:
The nurse can implement medication orders quickly.
The nurse receives input from the pharmacist.
The system minimizes transcription errors.
The system reinforces accurate calculations.
100. Nurse Oliver is assessing a client’s abdomen. Which finding
should the nurse report as abnormal?
Dullness over the liver.
Bowel sounds occurring every 10 seconds.
Shifting dullness over the abdomen.
Vascular sounds heard over the renal arteries.
Answers and Rationales
Answer: (D) The actions of a reasonably prudent nurse with
similar education and experience. The standard of care is
determined by the average degree of skill, care, and diligence by
nurses in similar circumstances.
Answer: (B) I.M. With a platelet count of 22,000/μl, the clients tends
to bleed easily. Therefore, the nurse should avoid using the I.M.
route because the area is a highly vascular and can bleed readily
when penetrated by a needle. The bleeding can be difficult to stop.
Answer: (C) “Digoxin 0.125 mg P.O. once daily” The nurse should
always place a zero before a decimal point so that no one misreads
the figure, which could result in a dosage error. The nurse should
never insert a zero at the end of a dosage that includes a decimal
point because this could be misread, possibly leading to a tenfold
increase in the dosage.
Answer: (A) Ineffective peripheral tissue perfusion related to
venous congestion. Ineffective peripheral tissue perfusion related to
venous congestion takes the highest priority because venous
inflammation and clot formation impede blood flow in a client with
deep vein thrombosis.
Answer: (B) A 44 year-old myocardial infarction (MI) client who
is complaining of nausea. Nausea is a symptom of impending
myocardial infarction (MI) and should be assessed immediately so
that treatment can be instituted and further damage to the heart is
avoided.
Answer: (C) Check circulation every 15-30 minutes. Restraints
encircle the limbs, which place the client at risk for circulation being
restricted to the distal areas of the extremities. Checking the client’s
circulation every 15-30 minutes will allow the nurse to adjust the
restraints before injury from decreased blood flow occurs.
Answer: (A) Prevent stress ulcer. Curling’s ulcer occurs as a
generalized stress response in burn patients. This results in a
decreased production of mucus and increased secretion of gastric
acid. The best treatment for this prophylactic use of antacids and H2
receptor blockers.
Answer: (D) Continue to monitor and record hourly urine
output. Normal urine output for an adult is approximately 1
ml/minute (60 ml/hour). Therefore, this client’s output is normal.
Beyond continued evaluation, no nursing action is warranted.
Answer: (B) “My ankle feels warm”. Ice application decreases pain
and swelling. Continued or increased pain, redness, and increased
warmth are signs of inflammation that shouldn’t occur after ice
application
Answer: (B) Hyperkalemia. A loop diuretic removes water and, along
with it, sodium and potassium. This may result in hypokalemia,
hypovolemia, and hyponatremia.
Answer:(A) Have condescending trust and confidence in
their subordinates. Benevolent-authoritative managers pretentiously
show their trust and confidence to their followers.
Answer: (A) Provides continuous, coordinated and
comprehensive nursing services. Functional nursing is focused on
tasks and activities and not on the care of the patients.
Answer: (B) Standard written order. This is a standard written order.
Prescribers write a single order for medications given only once. A
stat order is written for medications given immediately for an urgent
client problem. A standing order, also known as a protocol,
establishes guidelines for treating a particular disease or set of
symptoms in special care areas such as the coronary care unit.
Facilities also may institute medication protocols that specifically
designate drugs that a nurse may not give.
Answer: (D) Liquid or semi-liquid stools. Passage of liquid or
semi-liquid stools results from seepage of unformed bowel contents
around the impacted stool in the rectum. Clients with fecal
impaction don’t pass hard, brown, formed stools because the feces
can’t move past the impaction. These clients typically report the
urge to defecate (although they can’t pass stool) and a decreased
appetite.
Answer: (C) Pulling the helix up and back. To perform an otoscopic
examination on an adult, the nurse grasps the helix of the ear and
pulls it up and back to straighten the ear canal. For a child, the nurse
grasps the helix and pulls it down to straighten the ear canal. Pulling
the lobule in any direction wouldn’t straighten the ear canal for
visualization.
Answer: (A) Protect the irritated skin from sunlight. Irradiated skin is
very sensitive and must be protected with clothing or sunblock. The
priority approach is the avoidance of strong sunlight.
Answer: (C) Assist the client in removing dentures and nail
polish. Dentures, hairpins, and combs must be removed. Nail polish
must be removed so that cyanosis can be easily monitored by
observing the nail beds.
Answer: (D) Sudden onset of continuous epigastric and back
pain. The autodigestion of tissue by the pancreatic enzymes results
in pain from inflammation, edema, and possible hemorrhage.
Continuous, unrelieved epigastric or back pain reflects the
inflammatory process in the pancreas.
Answer: (B) Provide high-protein, high-carbohydrate diet. A positive
nitrogen balance is important for meeting metabolic needs, tissue
repair, and resistance to infection. Caloric goals may be as high as
5000 calories per day.
Answer: (A) Blood pressure and pulse rate. The baseline must be
established to recognize the signs of an anaphylactic or hemolytic
reaction to the transfusion.
Answer: (D) Immobilize the leg before moving the client. If the nurse
suspects a fracture, splinting the area before moving the client is
imperative. The nurse should call for emergency help if the client is
not hospitalized and call for a physician for the hospitalized client.
Answer: (B) Admit the client into a private room. The client who has
a radiation implant is placed in a private room and has a limited
number of visitors. This reduces the exposure of others to the
radiation.
Answer: (C) Risk for infection. Agranulocytosis is characterized by a
reduced number of leukocytes (leucopenia) and neutrophils
(neutropenia) in the blood. The client is at high risk for infection
because of the decreased body defenses against microorganisms.
Deficient knowledge related to the nature of the disorder may be
appropriate diagnosis but is not the priority.
Answer: (B) Place the client on the left side in the Trendelenburg
position. Lying on the left side may prevent air from flowing into the
pulmonary veins. The Trendelenburg position increases intrathoracic
pressure, which decreases the amount of blood pulled into the vena
cava during aspiration.
Answer: (A) Autocratic. The autocratic style of leadership is a
task-oriented and directive.
Answer: (D) 2.5 cc. 2.5 cc is to be added, because only a 500 cc bag
of solution is being medicated instead of a 1 liter.
Answer: (A) 50 cc/ hour. A rate of 50 cc/hr. The child is to receive 400
cc over a period of 8 hours = 50 cc/hr.
Answer: (B) Assess the client for presence of pain. Assessing the
client for pain is a very important measure. Postoperative pain is an
indication of complication. The nurse should also assess the client
for pain to provide for the client’s comfort.
Answer: (A) BP – 80/60, Pulse – 110 irregular. The classic signs of
cardiogenic shock are low blood pressure, rapid and weak irregular
pulse, cold, clammy skin, decreased urinary output, and cerebral
hypoxia.
Answer: (A) Take the proper equipment, place the client in a
comfortable position, and record the appropriate information in the
client’s chart. It is a general or comprehensive statement about the
correct procedure, and it includes the basic ideas which are found in
the other options
Answer: (B) Evaluation. Evaluation includes observing the person,
asking questions, and comparing the patient’s behavioral responses
with the expected outcomes.
Answer: (C) History of present illness. The history of present illness is
the single most important factor in assisting the health professional
in arriving at a diagnosis or determining the person’s needs.
Answer: (A) Trochanter roll extending from the crest of the ileum to
the mid-thigh. A trochanter roll, properly placed, provides resistance
to the external rotation of the hip.
Answer: (C) Stage III. Clinically, a deep crater or without undermining
of adjacent tissue is noted.
Answer: (A) Second intention healing. When wounds dehisce, they
will allowed to heal by secondary intention
Answer: (D) Tachycardia. With an extracellular fluid or plasma
volume deficit, compensatory mechanisms stimulate the heart,
causing an increase in heart rate.
Answer: (A) 0.75. To determine the number of milliliters the client
should receive, the nurse uses the fraction method in the following
equation.
75 mg/X ml = 100 mg/1 ml
To solve for X, cross-multiply:
75 mg x 1 ml = X ml x 100 mg
75 = 100X
75/100 = X
0.75 ml (or ¾ ml) = X
Answer: (D) It’s a measure of effect, not a standard measure of
weight or quantity. An insulin unit is a measure of effect, not a
standard measure of weight or quantity. Different drugs measured in
units may have no relationship to one another in quality or quantity.
Answer: (B) 38.9 °C. To convert Fahrenheit degreed to Centigrade,
use this formula
°C = (°F – 32) ÷ 1.8
°C = (102 – 32) ÷ 1.8
°C = 70 ÷ 1.8
°C = 38.9
Answer: (C) Failing eyesight, especially close vision. Failing eyesight,
especially close vision, is one of the first signs of aging in middle life
(ages 46 to 64). More frequent aches and pains begin in the early
late years (ages 65 to 79). Increase in loss of muscle tone occurs in
later years (age 80 and older).
Answer: (A) Checking and taping all connections. Air leaks commonly
occur if the system isn’t secure. Checking all connections and taping
them will prevent air leaks. The chest drainage system is kept lower
to promote drainage – not to prevent leaks.
Answer: (A) Check the client’s identification band. Checking the
client’s identification band is the safest way to verify a client’s
identity because the band is assigned on admission and isn’t be
removed at any time. (If it is removed, it must be replaced). Asking
the client’s name or having the client repeated his name would be
appropriate only for a client who’s alert, oriented, and able to
understand what is being said, but isn’t the safe standard of practice.
Names on bed aren’t always reliable
Answer: (B) 32 drops/minute. Giving 1,000 ml over 8 hours is the
same as giving 125 ml over 1 hour (60 minutes). Find the number of
milliliters per minute as follows:
125/60 minutes = X/1 minute
60X = 125 = 2.1 ml/minute
To find the number of drops per minute:
2.1 ml/X gtt = 1 ml/ 15 gtt
X = 32 gtt/minute, or 32 drops/minute
Answer: (A) Clamp the catheter. If a central venous catheter
becomes disconnected, the nurse should immediately apply a
catheter clamp, if available. If a clamp isn’t available, the nurse can
place a sterile syringe or catheter plug in the catheter hub. After
cleaning the hub with alcohol or povidone-iodine solution, the nurse
must replace the I.V. extension and restart the infusion.
Answer: (D) Auscultation, percussion, and palpation.The correct
order of assessment for examining the abdomen is inspection,
auscultation, percussion, and palpation. The reason for this
approach is that the less intrusive techniques should be performed
before the more intrusive techniques. Percussion and palpation can
alter natural findings during auscultation.
Answer: (D) Ulnar surface of the hand. The nurse uses the ulnar
surface, or ball, of the hand to asses tactile fremitus, thrills, and
vocal vibrations through the chest wall. The fingertips and finger
pads best distinguish texture and shape. The dorsal surface best
feels warmth.
Answer: (C) Formative. Formative (or concurrent) evaluation occurs
continuously throughout the teaching and learning process. One
benefit is that the nurse can adjust teaching strategies as necessary
to enhance learning. Summative, or retrospective, evaluation occurs
at the conclusion of the teaching and learning session. Informative is
not a type of evaluation.
Answer: (B) Once per year. Yearly mammograms should begin at age
40 and continue for as long as the woman is in good health. If health
risks, such as family history, genetic tendency, or past breast cancer,
exist, more frequent examinations may be necessary.
Answer: (A) Respiratory acidosis. The client has a below-normal
(acidic) blood pH value and an above-normal partial pressure of
arterial carbon dioxide (Paco2) value, indicating respiratory acidosis.
In respiratory alkalosis, the pH value is above normal and in the
Paco2 value is below normal. In metabolic acidosis, the pH and
bicarbonate (Hco3) values are below normal. In metabolic alkalosis,
the pH and Hco3 values are above normal.
Answer: (B) To provide support for the client and family in coping
with terminal illness. Hospices provide supportive care for terminally
ill clients and their families. Hospice care doesn’t focus on counseling
regarding health care costs. Most client referred to hospices have
been treated for their disease without success and will receive only
palliative care in the hospice.
Answer: (C) Using normal saline solution to clean the ulcer and
applying a protective dressing as necessary. Washing the area with
normal saline solution and applying a protective dressing are within
the nurse’s realm of interventions and will protect the area. Using a
povidone-iodine wash and an antibiotic cream require a physician’s
order. Massaging with an astringent can further damage the skin.
Answer: (D) Foot. An elastic bandage should be applied form the
distal area to the proximal area. This method promotes venous
return. In this case, the nurse should begin applying the bandage at
the client’s foot. Beginning at the ankle, lower thigh, or knee does
not promote venous return.
Answer: (B) Hypokalemia. Insulin administration causes glucose and
potassium to move into the cells, causing hypokalemia.
Answer: (A) Throbbing headache or dizziness. Headache and
dizziness often occur when nitroglycerin is taken at the beginning of
therapy. However, the client usually develops tolerance
Answer: (D) Check the client’s level of consciousness. Determining
unresponsiveness is the first step assessment action to take. When a
client is in ventricular tachycardia, there is a significant decrease in
cardiac output. However, checking the unresponsiveness ensures
whether the client is affected by the decreased cardiac output.
Answer: (B) On the affected side of the client.When walking with
clients, the nurse should stand on the affected side and grasp the
security belt in the midspine area of the small of the back. The nurse
should position the free hand at the shoulder area so that the client
can be pulled toward the nurse in the event that there is a forward
fall. The client is instructed to look up and outward rather than at his
or her feet.
Answer: (A) Urine output: 45 ml/hr. Adequate perfusion must be
maintained to all vital organs in order for the client to remain visible
as an organ donor. A urine output of 45 ml per hour indicates
adequate renal perfusion. Low blood pressure and delayed capillary
refill time are circulatory system indicators of inadequate perfusion.
A serum pH of 7.32 is acidotic, which adversely affects all body
tissues.
Answer: (D ) Obtaining the specimen from the urinary drainage
bag. A urine specimen is not taken from the urinary drainage bag.
Urine undergoes chemical changes while sitting in the bag and does
not necessarily reflect the current client status. In addition, it may
become contaminated with bacteria from opening the system.
Answer: (B) Cover the client, place the call light within reach, and
answer the phone call. Because telephone call is an emergency, the
nurse may need to answer it. The other appropriate action is to ask
another nurse to accept the call. However, is not one of the options.
To maintain privacy and safety, the nurse covers the client and places
the call light within the client’s reach. Additionally, the client’s door
should be closed or the room curtains pulled around the bathing
area.
Answer: (C) Use a sterile plastic container for obtaining the
specimen. Sputum specimens for culture and sensitivity testing need
to be obtained using sterile techniques because the test is done to
determine the presence of organisms. If the procedure for obtaining
the specimen is not sterile, then the specimen is not sterile, then the
specimen would be contaminated and the results of the test would
be invalid.
Answer: (A) Puts all the four points of the walker flat on the floor,
puts weight on the hand pieces, and then walks into it. When the
client uses a walker, the nurse stands adjacent to the affected side.
The client is instructed to put all four points of the walker 2 feet
forward flat on the floor before putting weight on hand pieces. This
will ensure client safety and prevent stress cracks in the walker. The
client is then instructed to move the walker forward and walk into it.
Answer: (C) Draws one line to cross out the incorrect information
and then initials the change. To correct an error documented in a
medical record, the nurse draws one line through the incorrect
information and then initials the error. An error is never erased and
correction fluid is never used in the medical record.
Answer: (C) Secures the client safety belts after transferring to the
stretcher. During the transfer of the client after the surgical
procedure is complete, the nurse should avoid exposure of the client
because of the risk for potential heat loss. Hurried movements and
rapid changes in the position should be avoided because these
predispose the client to hypotension. At the time of the transfer
from the surgery table to the stretcher, the client is still affected by
the effects of the anesthesia; therefore, the client should not move
self. Safety belts can prevent the client from falling off the stretcher.
Answer: (B) Gown and gloves. Contact precautions require the use of
gloves and a gown if direct client contact is anticipated. Goggles are
not necessary unless the nurse anticipates the splashes of blood,
body fluids, secretions, or excretions may occur. Shoe protectors are
not necessary.
Answer: (C) Quad cane. Crutches and a walker can be difficult to
maneuver for a client with weakness on one side. A cane is better
suited for client with weakness of the arm and leg on one side.
However, the quad cane would provide the most stability because of
the structure of the cane and because a quad cane has four legs.
Answer: (D) Left side-lying with the head of the bed elevated 45
degrees. To facilitate removal of fluid from the chest wall, the client
is positioned sitting at the edge of the bed leaning over the bedside
table with the feet supported on a stool. If the client is unable to sit
up, the client is positioned lying in bed on the unaffected side with
the head of the bed elevated 30 to 45 degrees.
Answer: (D) Reliability Reliability is consistency of the research
instrument. It refers to the repeatability of the instrument in
extracting the same responses upon its repeated administration.
Answer: (A) Keep the identities of the subject secret. Keeping the
identities of the research subject secret will ensure anonymity
because this will hinder providing link between the information
given to whoever is its source.
Answer: (A) Descriptive- correlational. Descriptive- correlational
study is the most appropriate for this study because it studies the
variables that could be the antecedents of the increased incidence of
nosocomial infection.
Answer: (C) Use of laboratory data. Incidence of nosocomial
infection is best collected through the use of biophysiologic
measures, particularly in vitro measurements, hence laboratory data
is essential.
Answer: (B) Quasi-experiment. Quasi-experiment is done when
randomization and control of the variables are not possible.
Answer: (C) Primary source. This refers to a primary source which is a
direct account of the investigation done by the investigator. In
contrast to this is a secondary source, which is written by someone
other than the original researcher.
Answer: (A) Non-maleficence. Non-maleficence means do not cause
harm or do any action that will cause any harm to the patient/client.
To do good is referred as beneficence.
Answer: (C) Res ipsa loquitor. Res ipsa loquitor literally means the
thing speaks for itself. This means in operational terms that the
injury caused is the proof that there was a negligent act.
Answer: (B) The Board can investigate violations of the nursing law
and code of ethics. Quasi-judicial power means that the Board of
Nursing has the authority to investigate violations of the nursing law
and can issue summons, subpoena or subpoena duces tecum as
needed.
Answer: (C) May apply for re-issuance of his/her license based on
certain conditions stipulated in RA 9173. RA 9173 sec. 24 states that
for equity and justice, a revoked license maybe re-issued provided
that the following conditions are met: a) the cause for revocation of
license has already been corrected or removed; and, b) at least four
years has elapsed since the license has been revoked.
Answer: (B) Review related literature. After formulating and
delimiting the research problem, the researcher conducts a review
of related literature to determine the extent of what has been done
on the study by previous researchers.
Answer: (B) Hawthorne effect. Hawthorne effect is based on the
study of Elton Mayo and company about the effect of an
intervention done to improve the working conditions of the workers
on their productivity. It resulted to an increased productivity but not
due to the intervention but due to the psychological effects of being
observed. They performed differently because they were under
observation.
Answer: (B) Determines the different nationality of patients
frequently admitted and decides to get representations samples
from each. Judgment sampling involves including samples according
to the knowledge of the investigator about the participants in the
study.
Answer: (B) Madeleine Leininger. Madeleine Leininger developed the
theory on transcultural theory based on her observations on the
behavior of selected people within a culture.
Answer: (A) Random. Random sampling gives equal chance for all
the elements in the population to be picked as part of the sample.
Answer: (A) Degree of agreement and disagreement. Likert scale is a
5-point summated scale used to determine the degree of agreement
or disagreement of the respondents to a statement in a study
Answer: (B) Sr. Callista Roy. Sr. Callista Roy developed the Adaptation
Model which involves the physiologic mode, self-concept mode, role
function mode and dependence mode.
Answer: (A) Span of control. Span of control refers to the number of
workers who report directly to a manager.
Answer: (B) Autonomy. Informed consent means that the patient
fully understands about the surgery, including the risks involved and
the alternative solutions. In giving consent it is done with full
knowledge and is given freely. The action of allowing the patient to
decide whether a surgery is to be done or not exemplifies the
bioethical principle of autonomy.
Answer: (C) Avoid wearing canvas shoes. The client should be
instructed to avoid wearing canvas shoes. Canvas shoes cause the
feet to perspire, which may, in turn, cause skin irritation and
breakdown. Both cotton and cornstarch absorb perspiration. The
client should be instructed to cut toenails straight across with
nail clippers.
Answer: (D) Ground beef patties. Meat is an excellent source of
complete protein, which this client needs to repair the tissue
breakdown caused by pressure ulcers. Oranges and broccoli supply
vitamin C but not protein. Ice cream supplies only some incomplete
protein, making it less helpful in tissue repair.
Answer: (D) Sims’ left lateral. The Sims’ left lateral position is the
most common position used to administer a cleansing enema
because it allows gravity to aid the flow of fluid along the curve of
the sigmoid colon. If the client can’t assume this position nor has
poor sphincter control, the dorsal recumbent or right lateral position
may be used. The supine and prone positions are inappropriate and
uncomfortable for the client.
Answer: (A) Arrange for typing and cross matching of the client’s
blood. The nurse first arranges for typing and cross matching of the
client’s blood to ensure compatibility with donor blood. The other
options,although appropriate when preparing to administer a blood
transfusion, come later.
Answer: (A) Independent. Nursing interventions are classified as
independent, interdependent, or dependent. Altering the drug
schedule to coincide with the client’s daily routine represents an
independent intervention, whereas consulting with the physician
and pharmacist to change a client’s medication because of adverse
reactions represents an interdependent intervention. Administering
an already-prescribed drug on time is a dependent intervention. An
intradependent nursing intervention doesn’t exist.
Answer: (D) Evaluation. The nursing actions described constitute
evaluation of the expected outcomes. The findings show that the
expected outcomes have been achieved. Assessment consists of the
client’s history, physical examination, and laboratory studies.
Analysis consists of considering assessment information to derive
the appropriate nursing diagnosis. Implementation is the phase of
the nursing process where the nurse puts the plan of care into
action.
Answer: (B) To observe the lower extremities. Elastic stockings are
used to promote venous return. The nurse needs to remove them
once per day to observe the condition of the skin underneath the
stockings. Applying the stockings increases blood flow to the heart.
When the stockings are in place, the leg muscles can still stretch and
relax, and the veins can fill with blood.
Answer:(A) Instructing the client to report any itching, swelling, or
dyspnea. Because administration of blood or blood products may
cause serious adverse effects such as allergic reactions, the nurse
must monitor the client for these effects. Signs and symptoms of
life-threatening allergic reactions include itching, swelling, and
dyspnea. Although the nurse should inform the client of the duration
of the transfusion and should document its administration, these
actions are less critical to the client’s immediate health. The nurse
should assess vital signs at least hourly during the transfusion.
Answer: (B) Decrease the rate of feedings and the concentration of
the formula. Complaints of abdominal discomfort and nausea are
common in clients receiving tube feedings. Decreasing the rate of
the feeding and the concentration of the formula should decrease
the client’s discomfort. Feedings are normally given at room
temperature to minimize abdominal cramping. To prevent aspiration
during feeding, the head of the client’s bed should be elevated at
least 30 degrees. Also, to prevent bacterial growth, feeding
containers should be routinely changed every 8 to 12 hours.
Answer: (D) Roll the vial gently between the palms. Rolling the vial
gently between the palms produces heat, which helps dissolve the
medication. Doing nothing or inverting the vial wouldn’t help
dissolve the medication. Shaking the vial vigorously could cause the
medication to break down, altering its action.
Answer: (B) Assist the client to the semi-Fowler position if
possible. By assisting the client to the semi-Fowler position, the
nurse promotes easier chest expansion, breathing, and oxygen
intake. The nurse should secure the elastic band so that the face
mask fits comfortably and snugly rather than tightly, which could
lead to irritation. The nurse should apply the face mask from the
client’s nose down to the chin — not vice versa. The nurse should
check the connectors between the oxygen equipment and humidifier
to ensure that they’re airtight; loosened connectors can cause loss of
oxygen.
Answer: (B) 4 hours. A unit of packed RBCs may be given over a
period of between 1 and 4 hours. It shouldn’t infuse for longer than
4 hours because the risk of contamination and sepsis increases after
that time. Discard or return to the blood bank any blood not given
within this time, according to facility policy.
Answer: (B) Immediately before administering the next
dose. Measuring the blood drug concentration helps determine
whether the dosing has achieved the therapeutic goal. For
measurement of the trough, or lowest, blood level of a drug, the
nurse draws a blood sample immediately before administering the
next dose. Depending on the drug’s duration of action and half-life,
peak blood drug levels typically are drawn after administering the
next dose.
Answer: (A) The nurse can implement medication orders quickly. A
floor stock system enables the nurse to implement medication
orders quickly. It doesn’t allow for pharmacist input, nor does it
minimize transcription errors or reinforce accurate calculations.
Answer: (C) Shifting dullness over the abdomen. Shifting dullness
over the abdomen indicates ascites, an abnormal finding. The other
options are normal abdominal findings.
SET 2
1. The registered nurse is planning to delegate tasks to unlicensed
assistive personnel (UAP). Which of the following task could the
registered nurse safely assigned to a UAP?
Monitor the I&O of a comatose toddler client with salicylate
poisoning
Perform a complete bed bath on a 2-year-old with multiple injuries
from a serious fall
Check the IV of a preschooler with Kawasaki disease
Give an outmeal bath to an infant with eczema
2. A nurse manager assigned a registered nurse from telemetry unit
to the pediatrics unit. There were three patients assigned to the RN.
Which of the following patients should not be assigned to the
floated nurse?
A 9-year-old child diagnosed with rheumatic fever
A young infant after pyloromyotomy
A 4-year-old with VSD following cardiac catheterization
A 5-month-old with Kawasaki disease
3. A nurse in charge in the pediatric unit is absent. The nurse
manager decided to assign the nurse in the obstetrics unit to the
pediatrics unit. Which of the following patients could the nurse
manager safely assign to the float nurse?
A child who had multiple injuries from a serious vehicle accident
A child diagnosed with Kawasaki disease and with cardiac
complications
A child who has had a nephrectomy for Wilm’s tumor
A child receiving an IV chelating therapy for lead poisoning
4. The registered nurse is planning to delegate task to a certified
nursing assistant. Which of the following clients should not be
assigned to a CAN?
A client diagnosed with diabetes and who has an infected toe
A client who had a CVA in the past two months
A client with Chronic renal failure
A client with chronic venous insufficiency
5. The nurse in the medication unit passes the medications for all the
clients on the nursing unit. The head nurse is making rounds with the
physician and coordinates clients’ activities with other departments.
The nurse assistant changes the bed lines and answers call lights. A
second nurse is assigned for changing wound dressings; a licensed
practitioner nurse takes vital signs and bathes theclients. This
illustrates of what method of nursing care?
Case management method
Primary nursing method
Team method
Functional method
6. A registered nurse has been assigned to six clients on the 12-hour
shift. The RN is responsible for every aspect of care such as
formulating the care of plan, intervention and evaluating the care
during her shift. At the end of her shift, the RN will pass this same
task to the next RN in charge. This nursing care illustrates of what
kind of method?
primary nursing method
case method
team method
functional method
7. A newly hired nurse on an adult medicine unit with 3 months
experience was asked to float to pediatrics. The nurse hesitates to
perform pediatric skills and receive an interesting assignment that
feels overwhelming. The nurse should:
resign on the spot from the nursing position and apply for a position
that does not require floating
Inform the nursing supervisor and the charge nurse on the pediatric
floor about the nurse’s lack of skill and feelings of hesitations and
request assistance
Ask several other nurses how they feel about pediatrics and find
someone else who is willing to accept the assignment
Refuse the assignment and leave the unit requesting a vacation a day
8. An experienced nurse who voluntarily trained a less experienced
nurse with the intention of enhancing the skills and knowledge and
promoting professional advancement to the nurse is called a:
mentor
team leader
case manager
change agent
9. The pediatrics unit is understaffed and the nurse manager informs
the nurses in the obstetrics unit that she is going to assign one nurse
to float in the pediatric units. Which statement by the designated
float nurse may put her job at risk?
“I do not get along with one of the nurses on the pediatrics unit”
“I have a vacation day coming and would like to take that now”
“I do not feel competent to go and work on that area”
“ I am afraid I will get the most serious clients in the unit”
10. The newly hired staff nurse has been working on a medical unit
for 3 weeks. The nurse manager has posted the team leader
assignments for the following week. The new staff knows that a
major responsibility of the team leader is to:
Provide care to the most acutely ill client on the team
Know the condition and needs of all the patients on the team
Document the assessments completed by the team members
Supervise direct care by nursing assistants
11. A 15-year-old girl just gave birth to a baby boy who needs
emergency surgery. The nurse prepared the consent form and it
should be signed by:
The Physician
The Registered Nurse caring for the client
The 15-year-old mother of the baby boy
The mother of the girl
12. A nurse caring to a client with Alzheimer’s disease overheard a
family member say to the client, “if you pee one more time, I won’t
give you any more food and drinks”. What initial action is best for the
nurse to take?
Take no action because it is the family member saying that to the
client
Talk to the family member and explain that what she/he has said is
not appropriate for the client
Give the family member the number for an Elder Abuse Hot line
Document what the family member has said
13. Which is true about informed consent?
A nurse may accept responsibility signing a consent form if the client
is unable
Obtaining consent is not the responsibility of the physician
A physician will not subject himself to liability if he withholds any
facts that are necessary to form the basis of an intelligent consent
If the nurse witnesses a consent for surgery, the nurse is, in effect,
indicating that the signature is that of the purported person and that
the person’s condition is as indicated at the time of signing
14. A mother in labor told the nurse that she was expecting that her
baby has no chance to survive and expects that the baby will be born
dead. The mother accepts the fate of the baby and informs the nurse
that when the baby is born and requires resuscitation, the mother
refuses any treatment to her baby and expresses hostility toward the
nurse while the pediatric team is taking care of the baby. The nurse
is legally obligated to:
Notify the pediatric team that the mother has refused resuscitation
and any treatment for the baby and take the baby to the mother
Get a court order making the baby a ward of the court
Record the statement of the mother, notify the pediatric team, and
observe carefully for signs of impaired bonding and neglect as a
reasonable suspicion of child abuse
Do nothing except record the mother’s statement in the medical
record
15. The hospitalized client with a chronic cough is scheduled for
bronchoscopy. The nurse is tasks to bring the informed consent
document into the client’s room for a signature. The client asks the
nurse for details of the procedure and demands an explanation why
the process of informed consent is necessary. The nurse responds
that informed consent means:
The patient releases the physician from all responsibility for the
procedure.
The immediate family may make decision against the patient’s will.
The physician must give the client or surrogates enough information
to make health care judgments consistent with their values and
goals.
The patient agrees to a procedure ordered by the physician even if
the client does not understand what the outcome will be.
16. A hospitalized client with severe necrotizing ulcer of the lower
leg is schedule for an amputation. The client tells the nurse that he
will not sign the consent form and he does not want any surgery or
treatment because of religious beliefs about reincarnation. What is
the role of the RN?
call a family meeting
discuss the religious beliefs with the physician
encourage the client to have the surgery
inform the client of other options
17. While in the hospital lobby, the RN overhears the three staff
discussing the health condition of her client. What would be the
appropriate nursing action for the RN to take?
Tell them it is not appropriate to discuss the condition of the client
Ignore them, because it is their right to discuss anything they want
to
Join in the conversation, giving them supportive input about the case
of the client
Report this incident to the nursing supervisor
18. A staff nurse has had a serious issue with her colleague. In this
situation, it is best to:
Discuss this with the supervisor
Not discuss the issue with anyone. It will probably resolve itself
Try to discuss with the colleague about the issue and resolve it when
both are calmer
Tell other members of the network what the team member did
19. The nurse is caring to a client who just gave birth to a healthy
baby boy. The nurse may not disclose confidential information when:
The nurse discusses the condition of the client in a clinical
conference with other nurses
The client asks the nurse to discuss the her condition with the family
The father of a woman who just delivered a baby is on the phone to
find out the sex of the baby
A researcher from an institutionally approved research study reviews
the medical record of a patient
20. A 17-year-old married client is scheduled for surgery. The nurse
taking care of the client realizes that consent has not been signed
after preoperative medications were given. What should the nurse
do?
Call the surgeon
Ask the spouse to sign the consent
Obtain a consent from the client as soon as possible
Get a verbal consent from the parents of the client
21. A 12-year-old client is admitted to the hospital. The physician
ordered Dilantin to the client. In administering IV phenytoin
(Dilantin) to a child, the nurse would be most correct in mixing it
with:
Normal Saline
Heparinized normal saline
5% dextrose in water
Lactated Ringer’s solution
22. The nurse is caring to a client who is hypotensive. Following a
large hematemesis, how should the nurse position the client?
Feet and legs elevated 20 degrees, trunk horizontal, head on small
pillow
Low Fowler’s with knees gatched at 30 degrees
Supine with the head turned to the left
Bed sloped at a 45 degree angle with the head lowest and the legs
highest
23. The client is brought to the emergency department after a
serious accident. What would be the initial nursing action of the
nurse to the client?
assess the level of consciousness and circulation
check respirations, circulation, neurological response
align the spine, check pupils, check for hemorrhage
check respiration, stabilize spine, check circulation
24. A nurse is assigned to care to a client with Parkinson’s disease.
What interventions are important if the nurse wants to improve
nutrition and promote effective swallowing of the client?
Eat solid food
Give liquids with meals
Feed the client
Sit in an upright position to eat
25. During tracheal suctioning, the nurse should implement safety
measures. Which of the following should the nurse implements?
limit suction pressure to 150-180 mmHg
suction for 15-20 seconds
wear eye goggles
remove the inner cannula
26. The nurse is conducting a discharge instructions to a client
diagnosed with diabetes. What sign of hypoglycemia should be
taught to a client?
warm, flushed skin
hunger and thirst
increase urinary output
palpitation and weakness
27. A client admitted to the hospital and diagnosed with Addison’s
disease. What would be the appropriate nursing action to the client?
administering insulin-replacement therapy
providing a low-sodium diet
restricting fluids to 1500 ml/day
reducing physical and emotional stress
28. The nurse is to perform tracheal suctioning. During tracheal
suctioning, which nursing action is essential to prevent hypoxemia?
aucultating the lungs to determine the baseline data to assess the
effectiveness of suctioning
removing oral and nasal secretions
encouraging the patient to deep breathe and cough to facilitate
removal of upper-airway secretions
administering 100% oxygen to reduce the effects of airway
obstruction during suctioning.
29. An infant is admitted and diagnosed with pneumonia and
suspicious-looking red marks on the swollen face resembling a
handprint. The nurse does further assessment to the client. How
would the nurse document the finding?
Facial edema with ecchymosis and handprint mark: crackles and
wheezes
Facial edema, with red marks; crackles in the lung
Facial edema with ecchymosis that looks like a handprint
Red bruise mark and ecchymosis on face
30. On the evening shift, the triage nurse evaluates several clients
who were brought to the emergency department. Which in the
following clients should receive highest priority?
an elderly woman complaining of a loss of appetite and fatigue for
the past week
A football player limping and complaining of pain and swelling in the
right ankle
A 50-year-old man, diaphoretic and complaining of severe chest pain
radiating to his jaw
A mother with a 5-year-old boy who says her son has been
complaining of nausea and vomited once since noon
31. A 80-year-old female client is brought to the emergency
department by her caregiver, on the nurse’s assessment; the
following are the manifestations of the client: anorexia, cachexia and
multiple bruises. What would be the best nursing intervention?
check the laboratory data for serum albumin, hematocrit, and
hemoglobin
talk to the client about the caregiver and support system
complete a police report on elder abuse
complete a gastrointestinal and neurological assessment
32. The night shift nurse is making rounds. When the nurse enters a
client’s room, the client is on the floor next to the bed. What would
be the initial action of the nurse?
chart that the patient fell
call the physician
chart that the client was found on the floor next to the bed
fill out an incident report
33. The nurse on the night shift is about to administer medication to
a preschooler client and notes that the child has no ID bracelet. The
best way for the nurse to identify the client is to ask:
The adult visiting, “The child’s name is ____________________?”
The child, “Is your name____________?”
Another staff nurse to identify this child
The other children in the room what the child’s name is
34. The nurse caring to a client has completed the assessment.
Which of the following will be considered to be the most accurate
charting of a lump felt in the right breast?
“abnormally felt area in the right breast, drainage noted”
“hard nodular mass in right breast nipple”
“firm mass at five ‘ clock, outer quadrant, 1cm from right nipple’
“mass in the right breast 4cmx1cm
35. The physician instructed the nurse that intravenous pyelogram
will be done to the client. The client asks the nurse what is the
purpose of the procedure. The appropriate nursing response is to:
outline the kidney vasculature
determine the size, shape, and placement of the kidneys
test renal tubular function and the patency of the urinary tract
measure renal blood flow
36. A client visits the clinic for screening of scoliosis. The nurse
should ask the client to:
bend all the way over and touch the toes
stand up as straight and tall as possible
bend over at a 90-degree angle from the waist
bend over at a 45-degree angle from the waist
37. A client with tuberculosis is admitted in the hospital for 2 weeks.
When a client’s family members come to visit, they would be
adhering to respiratory isolation precautions when they:
wash their hands when leaving
put on gowns, gloves and masks
avoid contact with the client’s roommate
keep the client’s room door open
38. An infant is brought to the emergency department and
diagnosed with pyloric stenosis. The parents of the client ask the
nurse, “Why does my baby continue to vomit?” Which of the
following would be the best nursing response of the nurse?
“Your baby eats too rapidly and overfills the stomach, which causes
vomiting
“Your baby can’t empty the formula that is in the stomach into the
bowel”
“The vomiting is due to the nausea that accompanies pyloric
stenosis”
“Your baby needs to be burped more thoroughly after feeding”
39. A 70-year-old client with suspected tuberculosis is brought to the
geriatric care facilities. An intradermal tuberculosis test is schedule
to be done. The client asks the nurse what is the purpose of the test.
Which of the following would be the best rationale for this?
reactivation of an old tuberculosis infection
increased incidence of new cases of tuberculosis in persons over 65
years old
greater exposure to diverse health care workers
respiratory problems are characteristic in this population
40. The nurse is making a health teaching to the parents of the
client. In teaching parents how to measure the area of induration in
response to a PPD test, the nurse would be most accurate in advising
the parents to measure:
both the areas that look red and feel raised
The entire area that feels itchy to the child
Only the area that looks reddened
Only the area that feels raised
41. A community health nurse is schedule to do home visit. She visits
to an elderly person living alone. Which of the following observation
would be a concern?
Picture windows
Unwashed dishes in the sink
Clear and shiny floors
Brightly lit rooms
42. After a birth, the physician cut the cord of the baby, and before
the baby is given to the mother, what would be the initial nursing
action of the nurse?
examine the infant for any observable abnormalities
confirm identification of the infant and apply bracelet to mother and
infant
instill prophylactic medication in the infant’s eyes
wrap the infant in a prewarmed blanket and cover the head
43. A 2-year-old client is admitted to the hospital with severe eczema
lesions on the scalp, face, neck and arms. The client is scratching the
affected areas. What would be the best nursing intervention to
prevent the client from scratching the affected areas?
elbow restraints to the arms
Mittens to the hands
Clove-hitch restraints to the hands
A posey jacket to the torso
44. The parents of the hospitalized client ask the nurse how their
baby might have gotten pyloric stenosis. The appropriate nursing
response would be:
There is no way to determine this preoperatively
Their baby was born with this condition
Their baby developed this condition during the first few weeks of life
Their baby acquired it due to a formula allergy
45. A male client comes to the clinic for check-up. In doing a physical
assessment, the nurse should report to the physician the most
common symptom of gonorrhea, which is:
pruritus
pus in the urine
WBC in the urine
Dysuria
46. Which of the following would be the most important goal in the
nursing care of an infant client with eczema?
preventing infection
maintaining the comfort level
providing for adequate nutrition
decreasing the itching
47. The nurse is making a discharge instruction to a client receiving
chemotherapy. The client is at risk for bone marrow depression. The
nurse gives instructions to the client about how to prevent infection
at home. Which of the following health teaching would be included?
“Get a weekly WBC count”
“Do not share a bathroom with children or pregnant woman”
“Avoid contact with others while receiving chemotherapy”
“Do frequent hand washing and maintain good hygiene”
48. The nurse is assigned to care the client with infectious disease.
The best antimicrobial agent for the nurse to use in handwashing is:
Isopropyl alcohol
Hexachlorophene (Phisohex)
Soap and water
Chlorhexidine gluconate (CHG) (Hibiclens)
49. The mother of the client tells the nurse, “ I’m not going to have
my baby get any immunization”. What would be the best nursing
response to the mother?
“You and I need to review your rationale for this decision”
“Your baby will not be able to attend day care without
immunizations”
“Your decision can be viewed as a form of child abuse and neglect”
“You are needlessly placing other people at risk for communicable
diseases”
50. The nurse is teaching the client about breast self-examination.
Which observation should the client be taught to recognize when
doing the examination for detection of breast cancer?
tender, movable lump
pain on breast self-examination
round, well-defined lump
dimpling of the breast tissue
Answers and Rationales
D. Bathing an infant with eczema can be safely delegated to an aide;
this task is basic and can competently performed by an aid.
B. The RN floated from the telemetry unit would be least prepared
to care for a young infant who has just had GI surgery and requires a
specific feeding regimen.
C. RN floated from the obstetrics unit should be able to care for a
client with major abdominal surgery, because this nurse has
experienced caring for clients with cesarean births.
A. The patient is experiencing a potentially serious complication
related to diabetes and needs ongoing assessment by an RN
D. It describes functional nursing. Staff is assigned to specific task
rather than specific clients.
B. Case management. The nurse assumes total responsibility for
meeting the needs of the client during her entire duty.
B. The nurse is ethically obligated to inform the person responsible
for the assignment and the person responsible for the unit about the
nurse’s skill level. The nurse therefore avoids a situation of
abandoningclients and exposing them to greater risks
A. This describes a mentor
B. This action demonstrates a lack of responsibility and the nurse
should attempt negotiation with the nurse manager.
B. The team leader is responsible for the overall management of all
clients and staff on the team, and this information is essential in
order to accomplish this
C. Even though the mother is a minor, she is legally able to sign
consent for her own child.
B. This response is the most direct and immediate. This is a case of
potential need for advocacy and patient’s rights.
D. The nurse who witness a consent for treatment or surgery is
witnessing only that the client signed the form and that the client’s
condition is as indicated at the time of signing. The nurse is not
witnessing that the client is “informed”.
C. Although the statements by the mother may not create a
suspicion of neglect, when they are coupled with observations about
impaired bonding and maternal attachment, they may impose the
obligation to report child neglect. The nurse is further obligated to
notify caregivers of refusal to consent to treatment
C. It best explains what informed consent is and provides for legal
rights of the patient
B. The physician may not be aware of the role that religious beliefs
play in making a decision about surgery.
A. The behavior should be stopped. The first step is to remind the
staff that confidentiality may be violated
C. Waiting for emotions to dissipate and sitting down with the
colleague is the first rule of conflict resolution.
C. The nurse has no idea who the person is on the phone and
therefore may not share the information even if the patient gives
permission
A. The priority is to let the surgeon know, who in turn may ask the
husband to sign the consent.
A. Phenytoin (Dilantin) can cause venous irritation due to its
alkalinity, therefore it should be mixed with normal saline.
A. This position increases venous return, improves cardiac volume,
and promotes adequate ventilation and cerebral perfusion
D. Checking the airway would be a priority, and a neck injury should
be suspected
D. Client with Parkinson’s disease are at a high risk for aspiration and
undernutrition. Sitting upright promotes more effective swallowing.
C. It is important to protect the RN’s eyes from the possible
contamination of coughed-up secretions
D. There has been too little food or too much insulin. Glucose levels
can be markedly decreased (less than 50 mg/dl). Severe
hypoglycemia may be fatal if not detected
D. Because the client’s ability to react to stress is decreased,
maintaining a quiet environment becomes a nursing priority.
Dehydration is a common problem in Addison’s disease, so close
observation of the client’s hydration level is crucial.
D. Presuctioning and postsuctioning ventilation with 100% oxygen is
important in reducing hypoxemia which occurs when the flow of
gases in the airway is obstructed by the suctioning catheter.
B. This is an example of objective data of both pulmonary status and
direct observation on the skin by the nurse.
C. These are likely signs of an acute myocardial infarction (MI). An
acute MI is a cardiovascular emergency requiring immediate
attention. Acute MI is potentially fatal if not treated immediately.
D. Assessment and more data collection are needed. The client may
have gastrointestinal or neurological problems that account for the
symptoms. The anorexia could result from medications, poor
dentition, or indigestion, and the bruises may be attributed to ataxia,
frequent falls, vertigo or medication.
B. This is closest to suggesting action-assessment, rather than
paperwork- and is therefore the best of the four.
C. The only acceptable way to identify a preschooler client is to have
a parent or another staff member identify the client.
C. It describes the mass in the greatest detail.
C. Intravenous pyelogram tests both the function and patency of the
kidneys. After the intravenous injection of a radiopaque contrast
medium, the size, location, and patency of the kidneys can be
observed by roentgenogram, as well as the patency of the urethra
and bladder as the kidneys function to excrete the contrast medium.
C. This is the recommended position for screening for scoliosis. It
allows the nurse to inspect the alignment of the spine, as well as to
compare both shoulders and both hips.
A. Handwashing is the best method for reducing
cross-contamination. Gowns and gloves are not always required
when entering a client’s room.
B. Pyloric stenosis is an anomaly of the upper gastrointestinal tract.
The condition involves a thickening, or hypertrophy, of the pyloric
sphincter located at the distal end of the stomach. This causes a
mechanical intestinal obstruction, which leads to vomiting after
feeding the infant. The vomiting associated with pyloric stenosis is
described as being projectile in nature. This is due to the increasing
amounts of formula the infant begins to consume coupled with the
increasing thickening of the pyloric sphincter.
B. Increased incidence of TB has been seen in the general population
with a high incidence reported in hospitalized elderly clients.
Immunosuppression and lack of classic manifestations because of
the aging process are just two of the contributing factors of
tuberculosis in the elderly.
D. Parents should be taught to feel the area that is raised and
measure only that.
C. It is a safety hazard to have shiny floors because they can cause
falls.
D. The first priority, beside maintaining a newborn’s patent airway, is
body temperature.
B. The purpose of restraints for this child is to keep the child from
scratching the affected areas. Mittens restraint would prevent
scratching, while allowing the most movement permissible.
C. Pyloric stenosis is not a congenital anatomical defect, but the
precise etiology is unknown. It develops during the first few weeks of
life.
B. Pus is usually the first symptom, because the bacteria reproduce
in the bladder.
A. Preventing infection in the infant with eczema is the nurse’s most
important goal. The infant with eczema is at high risk for infection
due to numerous breaks in the skin’s integrity. Intact skin is always
the infant’s first line of defense against infection.
D. Frequent hand washing and good hygiene are the best means of
preventing infection.
D. CHG is a highly effective antimicrobial ingredient, especially when
it is used consistently over time.
A. The mother may have many reasons for such a decision. It is the
nurse’s responsibility to review this decision with the mother and
clarify any misconceptions regarding immunizations that may exist.
D. The tumor infiltrates nearby tissue, it can cause retraction of the
overlying skin and create a dimpling appearance.
SET 3
1. Which element in the circular chain of infection can be eliminated
by preserving skin integrity?
Host
Reservoir
Mode of transmission
Portal of entry
2. Which of the following will probably result in a break in sterile
technique for respiratory isolation?
Opening the patient’s window to the outside environment
Turning on the patient’s room ventilator
Opening the door of the patient’s room leading into the
hospital corridor
Failing to wear gloves when administering a bed bath
3. Which of the following patients is at greater risk for contracting
an infection?
A patient with leukopenia
A patient receiving broad-spectrum antibiotics
A postoperative patient who has undergone orthopedic surgery
A newly diagnosed diabetic patient
4. Effective hand washing requires the use of:
Soap or detergent to promote emulsification
Hot water to destroy bacteria
A disinfectant to increase surface tension
All of the above
5. After routine patient contact, hand washing should last at least:
30 seconds
1 minute
2 minute
3 minutes
6. Which of the following procedures always requires surgical
asepsis?
Vaginal instillation of conjugated estrogen
Urinary catheterization
Nasogastric tube insertion
Colostomy irrigation 17. After 5 days of diuretic therapy with 20mg of furosemide (Lasix)
7. Sterile technique is used whenever: daily, a patient begins to exhibit fatigue, muscle cramping and
Strict isolation is required muscle weakness. These symptoms probably indicate that the
Terminal disinfection is performed patient is experiencing:
Invasive procedures are performed Hypokalemia
Protective isolation is necessary Hyperkalemia
8. Which of the following constitutes a break in sterile technique Anorexia
while preparing a sterile field for a dressing change? Dysphagia
Using sterile forceps, rather than sterile gloves, to handle a 18.Which of the following statements about chest X-ray is false?
sterile item No contradictions exist for this test
Touching the outside wrapper of sterilized material without Before the procedure, the patient should remove all jewelry, metallic
sterile gloves objects, and buttons above the waist
Placing a sterile object on the edge of the sterile field A signed consent is not required
Pouring out a small amount of solution (15 to 30 ml) before Eating, drinking, and medications are allowed before this test
pouring the solution into a sterile container 19.The most appropriate time for the nurse to obtain a sputum
9. A natural body defense that plays an active role in preventing specimen for culture is:
infection is: Early in the morning
Yawning After the patient eats a light breakfast
Body hair After aerosol therapy
Hiccupping After chest physiotherapy
Rapid eye movements 20.A patient with no known allergies is to receive penicillin every 6
10. All of the following statement are true about donning sterile hours. When administering the medication, the nurse observes a
gloves except: fine rash on the
The first glove should be picked up by grasping the inside of the cuff. patient’s skin. The most appropriate nursing action would be to:
The second glove should be picked up by inserting the gloved fingers Withhold the moderation and notify the physician
under the cuff outside the glove. Administer the medication and notify the physician
The gloves should be adjusted by sliding the gloved fingers under the Administer the medication with an antihistamine
sterile cuff and pulling the glove over the wrist Apply corn starch soaks to the rash
The inside of the glove is considered sterile 21.All of the following nursing interventions are correct when using
11.When removing a contaminated gown, the nurse should be the Ztrack method of drug injection except:
careful that the first thing she touches is the: Prepare the injection site with alcohol
Waist tie and neck tie at the back of the gown Use a needle that’s a least 1” long
Waist tie in front of the gown Aspirate for blood before injection
Cuffs of the gown Rub the site vigorously after the injection to promote absorption
Inside of the gown 22.The correct method for determining the vastus lateralis site for
12.Which of the following nursing interventions is considered the I.M. injection is to:
most effective form or universal precautions? Locate the upper aspect of the upper outer quadrant of the
Cap all used needles before removing them from their syringes buttock about 5 to 8 cm below the iliac crest
Discard all used uncapped needles and syringes in an impenetrable Palpate the lower edge of the acromion process and the
protective container midpoint lateral aspect of the arm
Wear gloves when administering IM injections Palpate a 1” circular area anterior to the umbilicus
Follow enteric precautions Divide the area between the greater femoral trochanter and
13.All of the following measures are recommended to prevent the lateral femoral condyle into thirds, and select the middle third on
pressure ulcers except: the anterior of the thigh
Massaging the reddened are with lotion 23.The mid-deltoid injection site is seldom used for I.M. injections
Using a water or air mattress because it:
Adhering to a schedule for positioning and turning Can accommodate only 1 ml or less of medication
Providing meticulous skin care Bruises too easily
14.Which of the following blood tests should be performed before a Can be used only when the patient is lying down
blood transfusion? Does not readily parenteral medication
Prothrombin and coagulation time 24.The appropriate needle size for insulin injection is:
Blood typing and cross-matching 18G, 1 ½” long
Bleeding and clotting time 22G, 1” long
Complete blood count (CBC) and electrolyte levels. 22G, 1 ½” long
15.The primary purpose of a platelet count is to evaluate the: 25G, 5/8” long
Potential for clot formation 25.The appropriate needle gauge for intradermal injection is:
Potential for bleeding 20G
Presence of an antigen-antibody response 22G
Presence of cardiac enzymes 25G
16.Which of the following white blood cell (WBC) counts clearly 26G
indicates leukocytosis? 26.Parenteral penicillin can be administered as an:
4,500/mm³ IM injection or an IV solution
7,000/mm³ IV or an intradermal injection
10,000/mm³ Intradermal or subcutaneous injection
25,000/mm³ IM or a subcutaneous injection
27.The physician orders gr 10 of aspirin for a patient. The equivalent Apply iced alcohol sponges
dose in milligrams is: Provide increased cool liquids
0.6 mg Provide additional bedclothes
10 mg Provide increased ventilation
60 mg 38.A clinical nurse specialist is a nurse who has:
600 mg Been certified by the National League for Nursing
28.The physician orders an IV solution of dextrose 5% in water Received credentials from the Philippine Nurses’ Association
at 100ml/hour. What would the flow rate be if the drop factor is 15 Graduated from an associate degree program and is a
gtt = 1 ml? registered professional nurse
5 gtt/minute Completed a master’s degree in the prescribed clinical area and is a
13 gtt/minute registered professional nurse.
25 gtt/minute 39.The purpose of increasing urine acidity through dietary means is
50 gtt/minute to:
29.Which of the following is a sign or symptom of a hemolytic Decrease burning sensations
reaction to blood transfusion? Change the urine’s color
Hemoglobinuria Change the urine’s concentration
Chest pain Inhibit the growth of microorganisms
Urticaria 40.Clay colored stools indicate:
Distended neck veins Upper GI bleeding
30.Which of the following conditions may require fluid restriction? Impending constipation
Fever An effect of medication
Chronic Obstructive Pulmonary Disease Bile obstruction
Renal Failure 41.In which step of the nursing process would the nurse ask a
Dehydration patient if the medication she administered relieved his pain?
31.All of the following are common signs and symptoms of phlebitis Assessment
except: Analysis
Pain or discomfort at the IV insertion site Planning
Edema and warmth at the IV insertion site Evaluation
A red streak exiting the IV insertion site 42.All of the following are good sources of vitamin A except:
Frank bleeding at the insertion site White potatoes
32.The best way of determining whether a patient has learned to Carrots
instill ear medication properly is for the nurse to: Apricots
Ask the patient if he/she has used ear drops before Egg yolks
Have the patient repeat the nurse’s instructions using her own words 43.Which of the following is a primary nursing intervention
Demonstrate the procedure to the patient and encourage to necessary for all patients with a Foley Catheter in place?
ask questions Maintain the drainage tubing and collection bag level with
Ask the patient to demonstrate the procedure the patient’s bladder
33.Which of the following types of medications can be administered Irrigate the patient with 1% Neosporin solution three times a daily
via gastrostomy tube? Clamp the catheter for 1 hour every 4 hours to maintain
Any oral medications the bladder’s elasticity
Capsules whole contents are dissolve in water Maintain the drainage tubing and collection bag below bladder
Enteric-coated tablets that are thoroughly dissolved in water level to facilitate drainage by gravity
Most tablets designed for oral use, except for 44.The ELISA test is used to:
extended-duration compounds Screen blood donors for antibodies to human
34.A patient who develops hives after receiving an antibiotic is immunodeficiency virus (HIV)
exhibiting drug: Test blood to be used for transfusion for HIV antibodies
Tolerance Aid in diagnosing a patient with AIDS
Idiosyncrasy All of the above
Synergism 45.The two blood vessels most commonly used for TPN infusion are
Allergy the:
35.A patient has returned to his room after femoral arteriography. Subclavian and jugular veins
All of the following are appropriate nursing interventions except: Brachial and subclavian veins
Assess femoral, popliteal, and pedal pulses every 15 minutes for Femoral and subclavian veins
2 hours Brachial and femoral veins
Check the pressure dressing for sanguineous drainage 46.Effective skin disinfection before a surgical procedure includes
Assess a vital signs every 15 minutes for 2 hours which of the following methods?
Order a hemoglobin and hematocrit count 1 hour after Shaving the site on the day before surgery
the arteriography Applying a topical antiseptic to the skin on the evening
36.The nurse explains to a patient that a cough: before surgery
Is a protective response to clear the respiratory tract of irritants Having the patient take a tub bath on the morning of surgery
Is primarily a voluntary action Having the patient shower with an antiseptic soap on the
Is induced by the administration of an antitussive drug evening v=before and the morning of surgery
Can be inhibited by “splinting” the abdomen 47.When transferring a patient from a bed to a chair, the nurse
37.An infected patient has chills and begins shivering. The best should use which muscles to avoid back injury?
nursing intervention is to: Abdominal muscles
Back muscles
Leg muscles
Upper arm muscles
48.Thrombophlebitis typically develops in patients with which of the
following conditions?
Increases partial thromboplastin time
Acute pulsus paradoxus
An impaired or traumatized blood vessel wall
Chronic Obstructive Pulmonary Disease (COPD)
49.In a recumbent, immobilized patient, lung ventilation can become
altered, leading to such respiratory complications as:
Respiratory acidosis, ateclectasis, and hypostatic pneumonia
Appneustic breathing, atypical pneumonia and respiratory alkalosis
Cheyne-Strokes respirations and spontaneous pneumothorax
Kussmail’s respirations and hypoventilation
50.Immobility impairs bladder elimination, resulting in such
disorders as
Increased urine acidity and relaxation of the perineal
muscles, causing incontinence
Urine retention, bladder distention, and infection
Diuresis, natriuresis, and decreased urine specific gravity
Decreased calcium and phosphate levels in the urine
Answers and Rationales
D. In the circular chain of infection, pathogens must be able to leave
their reservoir and be transmitted to a susceptible host through a
portal of entry, such as broken skin.
C. Respiratory isolation, like strict isolation, requires that the door to
the door patient’s room remain closed. However, the patient’s room
should be well ventilated, so opening the window or turning on the
ventricular is desirable. The nurse does not need to wear gloves for
respiratory isolation, but good hand washing is important for all
types of isolation.
A. Leukopenia is a decreased number of leukocytes (white blood
cells), which are important in resisting infection. None of the other
situations would put the patient at risk for contracting an infection;
taking broadspectrum antibiotics might actually reduce the infection
risk.
A. Soaps and detergents are used to help remove bacteria because
of their ability to lower the surface tension of water and act as
emulsifying agents. Hot water may lead to skin irritation or burns.
A. Depending on the degree of exposure to pathogens, hand
washing may last from 10 seconds to 4 minutes. After routine
patient contact, hand washing for 30 seconds effectively minimizes
the risk of pathogen transmission.
B. The urinary system is normally free of microorganisms except at
the urinary meatus. Any procedure that involves entering this system
must use surgically aseptic measures to maintain a bacteria-free
state.
C. All invasive procedures, including surgery, catheter insertion,
and administration of parenteral therapy, require sterile technique to
maintain a sterile environment. All equipment must be sterile, and
the nurse and the physician must wear sterile gloves and maintain
surgical asepsis. In the operating room, the nurse and physician are
required to wear sterile gowns, gloves, masks, hair covers, and shoe
covers for all invasive procedures. Strict isolation requires the use of
clean gloves, masks, gowns and equipment to prevent the
transmission of highly communicable diseases by contact or by
airborne routes. Terminal disinfection is the disinfection of all
contaminated supplies and equipment after a patient has been
discharged to prepare them for reuse by another patient.
The purpose of protective (reverse) isolation is to prevent a person
with seriously impaired resistance from coming into contact who
potentially pathogenic organisms.
C. The edges of a sterile field are considered contaminated. When
sterile items are allowed to come in contact with the edges of the
field, the sterile items also become contaminated.
B. Hair on or within body areas, such as the nose, traps and
holds particles that contain microorganisms. Yawning and hiccupping
do not prevent microorganisms from entering or leaving the body.
Rapid eye movement marks the stage of sleep during which
dreaming occurs.
D. The inside of the glove is always considered to be clean, but not
sterile.
A. The back of the gown is considered clean, the front is
contaminated. So, after removing gloves and washing hands, the
nurse should untie the back of the gown; slowly move backward
away from the gown, holding the inside of the gown and keeping the
edges off the floor; turn and fold the gown inside out; discard it in a
contaminated linen container; then wash her hands again.
B. According to the Centers for Disease Control (CDC),
blood-to-blood contact occurs most commonly when a health care
worker attempts to cap a used needle. Therefore, used needles
should never be recapped; instead they should be inserted in a
specially designed puncture resistant, labeled container. Wearing
gloves is not always necessary when administering an I.M. injection.
Enteric precautions prevent the transfer of pathogens via feces.
A. Nurses and other health care professionals previously believed
that massaging a reddened area with lotion would promote venous
return and reduce edema to the area. However, research has shown
that massage only increases the likelihood of cellular ischemia and
necrosis to the area.
B. Before a blood transfusion is performed, the blood of the donor
and recipient must be checked for compatibility. This is done by
blood typing (a test that determines a person’s blood type) and
cross-matching (a procedure that determines the compatibility of
the donor’s and recipient’s blood after the blood types has been
matched). If the blood specimens are incompatible, hemolysis and
antigen-antibody reactions will occur.
A. Platelets are disk-shaped cells that are essential for blood
coagulation. A platelet count determines the number of
thrombocytes in blood available for promoting hemostasis and
assisting with blood coagulation after injury. It also is used to
evaluate the patient’s potential for bleeding; however, this is not its
primary purpose. The normal count ranges from 150,000
to 350,000/mm3. A count of 100,000/mm3 or less indicates a
potential for bleeding; count of less than 20,000/mm3 is associated
with spontaneous bleeding.
D. Leukocytosis is any transient increase in the number of white
blood cells (leukocytes) in the blood. Normal WBC counts range from
5,000 to 100,000/mm3. Thus, a count of 25,000/mm3 indicates
leukocytosis.
A. Fatigue, muscle cramping, and muscle weaknesses are symptoms
of hypokalemia (an inadequate potassium level), which is a potential
side effect of diuretic therapy. The physician usually orders
supplemental potassium to prevent hypokalemia in patients
receiving diuretics. Anorexia is another symptom of hypokalemia.
Dysphagia means difficulty swallowing.
A. Pregnancy or suspected pregnancy is the only contraindication for
a chest X-ray. However, if a chest X-ray is necessary, the patient can
wear a lead apron to protect the pelvic region from radiation.
Jewelry, metallic objects, and buttons would interfere with the X-ray
and thus should not be worn above the waist. A signed consent is
not required because a chest X-ray is not an invasive examination.
Eating, drinking and medications are allowed because the X-ray is of
the chest, not the abdominal region.
A. Obtaining a sputum specimen early in this morning ensures
an adequate supply of bacteria for culturing and decreases the risk
of contamination from food or medication.
A. Initial sensitivity to penicillin is commonly manifested by a skin
rash, even in individuals who have not been allergic to it previously.
Because of the danger of anaphylactic shock, he nurse should
withhold the drug and notify the physician, who may choose to
substitute another drug. Administering an antihistamine is a
dependent nursing intervention that requires a written physician’s
order. Although applying corn starch to the rash may relieve
discomfort, it is not the nurse’s top priority in such a potentially
life-threatening situation.
D. The Z-track method is an I.M. injection technique in which the
patient’s skin is pulled in such a way that the needle track is sealed
off after the injection. This procedure seals medication deep into the
muscle, thereby minimizing skin staining and irritation. Rubbing the
injection site is contraindicated because it may cause the medication
to extravasate into the skin.
D. The vastus lateralis, a long, thick muscle that extends the full
length of the thigh, is viewed by many clinicians as the site of choice
for I.M. injections because it has relatively few major nerves and
blood vessels. The middle third of the muscle is recommended as
the injection site. The patient can be in a supine or sitting position
for an injection into this site.
A. The mid-deltoid injection site can accommodate only 1 ml or less
of medication because of its size and location (on the deltoid muscle
of the arm, close to the brachial artery and radial nerve).
D. A 25G, 5/8” needle is the recommended size for insulin
injection because insulin is administered by the subcutaneous route.
An 18G, 1 ½” needle is usually used for I.M. injections in children,
typically in the vastus lateralis. A 22G, 1 ½” needle is usually used for
adult I.M. injections, which are typically administered in the vastus
lateralis or ventrogluteal site.
D. Because an intradermal injection does not penetrate deeply into
the skin, a small-bore 25G needle is recommended. This type of
injection is used primarily to administer antigens to evaluate
reactions for allergy or sensitivity studies. A 20G needle is usually
used for I.M. injections of oilbased medications; a 22G needle for
I.M. injections; and a 25G needle, for I.M. injections; and a 25G
needle, for subcutaneous insulin injections.
A. Parenteral penicillin can be administered I.M. or added to a
solution and given I.V. It cannot be administered subcutaneously or
intradermally.
D. gr 10 x 60mg/gr 1 = 600 mg
C. 100ml/60 min X 15 gtt/ 1 ml = 25 gtt/minute
A. Hemoglobinuria, the abnormal presence of hemoglobin in the
urine, indicates a hemolytic reaction (incompatibility of the donor’s
and recipient’s blood). In this reaction, antibodies in the recipient’s
plasma combine rapidly with donor RBC’s; the cells are hemolyzed in
either circulatory or reticuloendothelial system. Hemolysis occurs
more rapidly in ABO incompatibilities than in Rh incompatibilities.
Chest pain and urticaria may be symptoms of impending
anaphylaxis. Distended neck veins are an indication of hypervolemia.
C. In real failure, the kidney loses their ability to effectively
eliminate wastes and fluids. Because of this, limiting the patient’s
intake of oral and I.V. fluids may be necessary. Fever, chronic
obstructive pulmonary disease, and dehydration are conditions for
which fluids should be encouraged.
D. Phlebitis, the inflammation of a vein, can be caused by
chemical irritants (I.V. solutions or medications), mechanical irritants
(the needle or catheter used during venipuncture or cannulation), or
a localized allergic reaction to the needle or catheter. Signs and
symptoms of phlebitis include pain or discomfort, edema and heat at
the I.V. insertion site, and a red streak going up the arm or leg from
the I.V. insertion site.
D. Return demonstration provides the most certain evidence for
evaluating the effectiveness of patient teaching.
D. Capsules, enteric-coated tablets, and most extended duration
or sustained release products should not be dissolved for use in
a gastrostomy tube. They are pharmaceutically manufactured in
these forms for valid reasons, and altering them destroys their
purpose. The nurse should seek an alternate physician’s order when
an ordered medication is inappropriate for delivery by tube.
D. A drug-allergy is an adverse reaction resulting from an
immunologic response following a previous sensitizing exposure to
the drug. The reaction can range from a rash or hives to anaphylactic
shock. Tolerance to a drug means that the patient experiences a
decreasing physiologic response to repeated administration of the
drug in the same dosage. Idiosyncrasy is an individual’s unique
hypersensitivity to a drug, food, or other substance; it appears to be
genetically determined. Synergism, is a drug interaction in which the
sum of the drug’s combined effects is greater than that of their
separate effects.
D. A hemoglobin and hematocrit count would be ordered by the
physician if bleeding were suspected. The other answers are
appropriate nursing interventions for a patient who has undergone
femoral arteriography.
A. Coughing, a protective response that clears the respiratory tract
of irritants, usually is involuntary; however it can be voluntary, as
when a patient is taught to perform coughing exercises. An
antitussive drug inhibits coughing. Splinting the abdomen supports
the abdominal muscles when a patient coughs.
C. In an infected patient, shivering results from the body’s attempt
to increase heat production and the production of neutrophils
and phagocytotic action through increased skeletal muscle tension
and contractions. Initial vasoconstriction may cause skin to feel cold
to the touch. Applying additional bed clothes helps to equalize the
body temperature and stop the chills. Attempts to cool the body
result in further shivering, increased metabloism, and thus increased
heat production.
D. A clinical nurse specialist must have completed a master’s degree
in a clinical specialty and be a registered professional nurse. The
National League of Nursing accredits educational programs in
nursing and provides a testing service to evaluate student nursing
competence but it does not certify nurses. The American Nurses
Association identifies requirements for certification and offers
examinations for certification in many areas of nursing., such as
medical surgical nursing. These certification (credentialing)
demonstrates that the nurse has the knowledge and the ability to
provide high quality nursing care in the area of her certification.
A graduate of an associate degree program is not a clinical nurse
specialist: however, she is prepared to provide bed side nursing with
a high degree of knowledge and skill. She must successfully
complete the licensing examination to become a registered
professional nurse.
D. Microorganisms usually do not grow in an acidic environment.
D. Bile colors the stool brown. Any inflammation or obstruction that
impairs bile flow will affect the stool pigment, yielding light,
clay-colored stool. Upper GI bleeding results in black or tarry stool.
Constipation is characterized by small, hard masses. Many
medications and foods will discolor stool – for example, drugs
containing iron turn stool black.; beets turn stool red.
D. In the evaluation step of the nursing process, the nurse must
decide whether the patient has achieved the expected outcome that
was identified in the planning phase.
A. The main sources of vitamin A are yellow and green vegetables
(such as carrots, sweet potatoes, squash, spinach, collard greens,
broccoli, and cabbage) and yellow fruits (such as apricots, and
cantaloupe). Animal sources include liver, kidneys, cream, butter,
and egg yolks.
D. Maintaing the drainage tubing and collection bag level with the
patient’s bladder could result in reflux of urine into the kidney.
Irrigating the bladder with Neosporin and clamping the catheter for Routine
1 hour every 4 hours must be prescribed by a physician. Scientific method
D. The ELISA test of venous blood is used to assess blood and Trial and error
potential blood donors to human immunodeficiency virus (HIV). A 5. What is the order of the nursing process?
positive ELISA test combined with various signs and symptoms helps Assessing, diagnosing, implementing, evaluating, planning
to diagnose acquired immunodeficiency syndrome (AIDS) Diagnosing, assessing, planning, implementing, evaluating
D. Tachypnea (an abnormally rapid rate of breathing) would indicate Assessing, diagnosing, planning, implementing, evaluating
that the patient was still hypoxic (deficient in oxygen).The partial Planning, evaluating, diagnosing, assessing, implementing
pressures of arterial oxygen and carbon dioxide listed are within the 6. During the planning phase of the nursing process, which of the
normal range. Eupnea refers to normal respiration. following is the outcome?
D. Studies have shown that showering with an antiseptic soap Nursing history
before surgery is the most effective method of removing Nursing notes
microorganisms from the skin. Shaving the site of the intended Nursing care plan
surgery might cause breaks in the skin, thereby increasing the risk of Nursing diagnosis
infection; however, if indicated, shaving, should be done 7. What is an example of a subjective data?
immediately before surgery, not the day before. A topical antiseptic Heart rate of 68 beats per minute
would not remove microorganisms and would be beneficial only Yellowish sputum
after proper cleaning and rinsing. Tub bathing might transfer Client verbalized, “I feel pain when urinating.”
organisms to another body site rather than rinse them away. Noisy breathing
C. The leg muscles are the strongest muscles in the body and should 8. Which expected outcome is correctly written?
bear the greatest stress when lifting. Muscles of the abdomen, back, “The patient will feel less nauseated in 24 hours.”
and upper arms may be easily injured. “The patient will eat the right amount of food daily.”
C. The factors, known as Virchow’s triad, collectively predispose a “The patient will identify all the high-salt food from a prepared list
patient to thromboplebitis; impaired venous return to the heart, by discharge.”
blood hypercoagulability, and injury to a blood vessel wall. Increased “The patient will have enough sleep.”
partial thromboplastin time indicates a prolonged bleeding time 9. Which of the following behaviors by Nurse Jane Robles
during fibrin clot formation, commonly the result of anticoagulant demonstrates that she understands well th elements of effecting
(heparin) therapy. Arterial blood disorders (such as pulsus charting?
paradoxus) and lung diseases (such as COPD) do not necessarily She writes in the chart using a no. 2 pencil.
impede venous return of injure vessel walls. She noted: appetite is good this afternoon.
A. Because of restricted respiratory movement, a recumbent, She signs on the medication sheet after administering the
immobilize patient is at particular risk for respiratory acidosis from medication.
poor gas exchange; atelectasis from reduced surfactant and She signs her charting as follow: J.R
accumulated mucus in the bronchioles, and hypostatic pneumonia 10. What is the disadvantage of computerized documentation of the
from bacterial growth caused by stasis of mucus secretions. nursing process?
B. The immobilized patient commonly suffers from urine retention Accuracy
caused by decreased muscle tone in the perineum. This leads to Legibility
bladder distention and urine stagnation, which provide an excellent Concern for privacy
medium for bacterial growth leading to infection. Immobility also Rapid communication
results in more alkaline urine with excessive amounts of calcium, 11. The theorist who believes that adaptation and manipulation of
sodium and phosphate, a gradual decrease in urine production, and stressors are related to foster change is:
an increased specific gravity. Dorothea Orem
Sister Callista Roy
1. Jake is complaining of shortness of breath. The nurse assesses his Imogene King
respiratory rate to be 30 breaths per minute and documents that Virginia Henderson
Jake is tachypneic. The nurse understands that tachypnea means: 12. Formulating a nursing diagnosis is a joint function of:
Pulse rate greater than 100 beats per minute Patient and relatives
Blood pressure of 140/90 Nurse and patient
Respiratory rate greater than 20 breaths per minute Doctor and family
Frequent bowel sounds Nurse and doctor
2. The nurse listens to Mrs. Sullen’s lungs and notes a hissing sound 13. Mrs. Caperlac has been diagnosed to have hypertension since 10
or musical sound. The nurse documents this as: years ago. Since then, she had maintained low sodium, low fat diet,
Wheezes to control her blood pressure. This practice is viewed as:
Rhonchi Cultural belief
Gurgles Personal belief
Vesicular Health belief
3. The nurse in charge measures a patient’s temperature at 101 Superstitious belief
degrees F. What is the equivalent centigrade temperature? 14. Becky is on NPO since midnight as preparation for blood test.
36.3 degrees C Adreno-cortical response is activated. Which of the following is an
37.95 degrees C expected response?
40.03 degrees C Low blood pressure
38.01 degrees C Warm, dry skin
4. Which approach to problem solving tests any number of solutions Decreased serum sodium levels
until one is found that works for that particular problem? Decreased urine output
Intuition
15. What nursing action is appropriate when obtaining a sterile urine
specimen from an indwelling catheter to prevent infection?
Use sterile gloves when obtaining urine.
Open the drainage bag and pour out the urine.
Disconnect the catheter from the tubing and get urine.
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?
Stop the infusion
Call the attending physician
Slow that infusion to 20 ml/hr
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?
Leave the medication at the bedside and leave the room.
After few minutes, return to that patient’s room and do not leave
until the patient takes the medication.
Instruct the patient to take the medication and leave it at the
bedside.
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?
Place the feeding 20 inches above the pint if insertion of NGT.
Introduce the feeding slowly.
Instill 60ml of water into the NGT after feeding.
Assist the patient in fowler’s 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?
Manager
Caregiver
Patient advocate
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?
Oriented to date, time and place
Clear breath sounds
Capillary refill greater than 3 seconds and buccal cyanosis
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?
That the patient verbalized, “My headache is gone.”
That the patient’s barium enema performed 3 days ago was negative
Patient’s NGT was removed 2 hours ago
Patient’s family came for a visit this morning.
22. Which statement is the most appropriate goal for a nursing
diagnosis of diarrhea?
“The patient will experience decreased frequency of bowel
elimination.”
“The patient will take anti-diarrheal medication.”
“The patient will give a stool specimen for laboratory examinations.”
“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?
Development of a standardized NCP.
Expansion of the current taxonomy of nursing diagnosis
Making of individualized patient care
Incorporation of both nursing and medical diagnoses in patient care
24. Using Maslow’s hierarchy of basic human needs, which of the
following nursing diagnoses has the highest priority?
Ineffective breathing pattern related to pain, as evidenced by
shortness of breath.
Anxiety related to impending surgery, as evidenced by insomnia.
Risk of injury related to autoimmune dysfunction
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?
30 degrees
90 degrees
45 degrees
0 degree
Answers and Rationales
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.
(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.
(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.
(D) Trial and error. The trial and error method of problem solving
isn’t systematic (as in the scientific method of problem solving)
routine, or based on inner prompting (as in the intuitive method of
problem solving).
(C) Assessing, diagnosing, planning, implementing, evaluating. The
correct order of the nursing process is assessing, diagnosing,
planning, implementing, evaluating.
(C) Nursing care plan. The outcome, or the product of the planning
phase of the nursing process is a Nursing care plan.
(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.
(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.
(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 nurse’s full name and title.
(C) Concern for privacy. A patient’s privacy may be violated if security
measures aren’t used properly or if policies and procedures aren’t in
place that determines what type of information can be retrieved, by
whom, and for what purpose.
(B) Sister Callista Roy. Sister Roy’s theory is called the adaptation
theory and she viewed each person as a unified biophysical system
in constant interaction with a changing environment. Orem’s theory
is called self-care deficit theory and is based on the belief that
individual has a need for self-care actions. King’s 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.
(B) Nurse and patient. Although diagnosing is basically the nurse’s
responsibility, input from the patient is essential to formulate the
correct nursing diagnosis.
(C) Health belief. Health belief of an individual influences his/her objective data from a secondary source
preventive health behavior. objective data from a primary source
(D) Decreased urine output. Adreno-cortical response involves subjective data from a primary source
release of aldosterone that leads to retention of sodium and water. subjective data from a secondary source
This results to decreased urine output. 4. Which of the following is a nursing diagnosis?
(D) Aspirate urine from the tubing port using a sterile syringe. The Hypethermia
nurse should aspirate the urine from the port using a sterile syringe Diabetes Mellitus
to obtain a urine specimen. Opening a closed drainage system Angina
increase the risk of urinary tract infection. Chronic Renal Failure
(A) Stop the infusion. The sign and symptoms indicate extravasation 5. What is the characteristic of the nursing process?
so the IVF should be stopped immediately and put warm not cold stagnant
towel on the affected site. inflexible
(B) After few minutes, return to that patient’s room and do not leave asystematic
until the patient takes the medication. This is to verify or to make goal-oriented
sure that the medication was taken by the patient as directed. 6. A skin lesion which is fluid-filled, less than 1 cm in size is called:
(A) Place the feeding 20 inches above the pint if insertion of papule
NGT. The height of the feeding is above 12 inches above the point of vesicle
insertion, bot 20 inches. If the height of feeding is too high, this bulla
results to very rapid introduction of feeding. This may trigger nausea macule
and vomiting. 7. During application of medication into the ear, which of the
(D) Educator. When teaching a patient about medications before following is inappropriate nursing action?
discharge, the nurse is acting as an educator. A caregiver provides In an adult, pull the pinna upward.
direct care to the patient. The nurse acts as s patient advocate when Instill the medication directly into the tympanic membrane.
making the patient’s wishes known to the doctor. Warm the medication at room or body temperature.
(C) Capillary refill greater than 3 seconds and buccal Press the tragus of the ear a few times to assist flow of medication
cyanosis. Capillary refill greater than 3 seconds and buccal cyanosis into the ear canal.
indicate decreased oxygen to the tissues which requires immediate 8. Which of the following is appropriate nursing intervention for a
attention/intervention. Oriented to date, time and place, client who is grieving over the death of her child?
hemoglobin of 13 g/dl are normal data. Tell her not to cry and it will be better.
(C) Patient’s NGT was removed 2 hours ago. The change-of-shift Provide opportunity to the client to tell their story.
report should indicate significant recent changes in the patient’s Encourage her to accept or to replace the lost person.
condition that the nurse assuming responsibility for care of the Discourage the client in expressing her emotions.
patient will need to monitor. The other options are not critical 9. It is the gradual decrease of the body’s temperature after death.
enough to include in the report. livor mortis
(A) “The patient will experience decreased frequency of bowel rigor mortis
elimination.” The goal is the opposite, healthy response of the algor mortis
problem statement of the nursing diagnosis. In this situation, the none of the above
problem statement is diarrhea. 10. When performing an admission assessment on a newly admitted
(C) Making of individualized patient care. To be effective, the nursing patient, the nurse percusses resonance. The nurse knows that
care plan developed in the planning phase of the nursing process resonance heard on percussion is most commonly heard over which
must reflect the individualized needs of the patient. organ?
(A) Ineffective breathing pattern related to pain, as evidenced by thigh
shortness of breath.. Physiologic needs (ex. Oxygen, fluids, nutrition) liver
must be met before lower needs (such as safety and security, love intestine
and belongingness, self-esteem and self-actualization) can be met. lung
Therefore, physiologic needs have the highest priority. 11. The nurse is aware that Bell’s palsy affects which cranial nerve?
(D) 0 degree. The patient should be positioned with the head of the 2nd CN (Optic)
bed completely flattened to perform an abdominal examination. If 3rd CN (Occulomotor)
the head of the bed is elevated, the abdominal muscles and organs 4th CN (Trochlear)
can be bunched up, altering the findings 7th CN (Facial)
12. Prolonged deficiency of Vitamin B9 leads to:
1. A patient is wearing a soft wrist-safety device. Which of the scurvy
following nursing assessment is considered abnormal? pellagra
Palpable radial pulse megaloblastic anemia
Palpable ulnar pulse pernicious anemia
Capillary refill within 3 seconds 13. Nurse Cherry is teaching a 72 year old patient about a newly
Bluish fingernails, cool and pale fingers prescribed medication. What could cause a geriatric patient to have
2. Pia’s serum sodium level is 150 mEq/L. Which of the following difficulty retaining knowledge about the newly prescribed
food items does the nurse instruct Pia to avoid? medication?
broccoli Absence of family support
sardines Decreased sensory functions
cabbage Patient has no interest on learning
tomatoes Decreased plasma drug levels
3. Jason, 3 years old vomited. His mom stated, “He vomited 6 ounces 14. When assessing a patient’s level of consciousness, which type of
of his formula this morning.” This statement is an example of: nursing intervention is the nurse performing?
Independent Temperature of 38 0C
Dependent Vomiting for 3 days
Collaborative Productive cough
Professional Patient stated, “My arms still hurt.”
15. Claire is admitted with a diagnosis of chronic shoulder pain. By 25. The nurse is assessing the endocrine system. Which organ is part
definition, the nurse understands that the patient has had pain for of the endocrine system?
more than: Heart
3 months Sinus
6 months Thyroid
9 months Thymus
1 year Answers and Rationales
16. Which of the following statements regarding the nursing process (D) Bluish fingernails, cool and pale fingers. A safety device on the
is true? wrist may impair blood circulation. Therefore, the nurse should
It is useful on outpatient settings. assess the patient for signs of impaired circulation such as bluish
It progresses in separate, unrelated steps. fingernails, cool and pale fingers. Palpable radial and ulnar pulses,
It focuses on the patient, not the nurse. capillary refill within 3 seconds are all normal findings.
It provides the solution to all patient health problems. (B) sardines. The normal serum sodium level is 135 to 145 mEq/L,
17. Which of the following is considered significant enough to the client is having hypernatremia. Pia should avoid food high in
require immediate communication to another member of the health sodium like processed food. Broccoli, cabbage and tomatoes are
care team? good source of Vitamin C.
Weight loss of 3 lbs in a 120 lb female patient. (A) objective data from a secondary source. Jason is the primary
Diminished breath sounds in patient with previously normal breath source; his mother is a secondary source. The data is objective
sounds because it can be perceived by the senses, verified by another
Patient stated, “I feel less nauseated.” person observing the same patient, and tested against accepted
Change of heart rate from 70 to 83 beats per minute. standards or norms.
18. To assess the adequacy of food intake, which of the following (A) Hypethermia. Hyperthermia is a NANDA-approved nursing
assessment parameters is best used? diagnosis. Diabetes Mellitus, Angina and Chronic Renal Failure are
food preferences medical diagnoses.
regularity of meal times (D) goal-oriented. The nursing process is goal-oriented. It is also
3-day diet recall systematic, patient-centered, and dynamic.
eating style and habits (B) vesicle. Vesicle is a circumscribed circulation containing serous
19. Van Fajardo is a 55 year old who was admitted to the hospital fluid or blood and less than 1 cm (ex. Blister, chicken pox).
with newly diagnosed hepatitis. The nurse is doing a patient teaching (B) Instill the medication directly into the tympanic
with Mr. Fajardo. What kind of role does the nurse assume? membrane. During the application of medication it is inappropriate
talker to instill the medication directly into the tympanic membrane. The
teacher right thing to do is instill the medication along the lateral wall of the
thinker auditory canal.
doer (B) Provide opportunity to the client to tell their story. Providing a
20. When providing a continuous enteral feeding, which of the grieving person an opportunity to tell their story allows the person
following action is essential for the nurse to do? to express feelings. This is therapeutic in assisting the client resolve
Place the client on the left side of the bed. grief.
Attach the feeding bag to the current tubing. (C) algor mortis. Algor mortis is the decrease of the body’s
Elevate the head of the bed. temperature after death. Livor mortis is the discoloration of the skin
Cold the formula before administering it. after death. Rigor mortis is the stiffening of the body that occurs
21. Kussmaul’s breathing is; about 2-4 hours after death.
Shallow breaths interrupted by apnea. (D) lung. Resonance is loud, low-pitched and long duration that’s
Prolonged gasping inspiration followed by a very short, usually heard most commonly over an air-filled tissue such as a normal lung.
inefficient expiration. (D) 7th CN (Facial). Bells’ palsy is the paralysis of the motor
Marked rhythmic waxing and waning of respirations from very deep component of the 7th caranial nerve, resulting in facial sag, inability
to very shallow breathing and temporary apnea. to close the eyelid or the mouth, drooling, flat nasolabial fold and
Increased rate and depth of respiration. loss of taste on the affected side of the face.
22. Presty has terminal cancer and she refuses to believe that loss is (C) megaloblastic anemia. Prolonged Vitamin B9 deficiency will lead
happening ans she assumes artificial cheerfulness. What stage of to megaloblastic anemia while pernicious anemia results in
grieving is she in? deficiency in Vitamin B12. Prolonged deficiency of Vitamin C leads to
depression scurvy and Pellagra results in deficiency in Vitamin B3.
bargaining (B) Decreased sensory functions. Decreased in sensory functions
denial could cause a geriatric patient to have difficulty retaining knowledge
acceptance about the newly prescribed medications. Absence of family support
23. Immunization for healthy babies and preschool children is an and no interest on learning may affect compliance, not knowledge
example of what level of preventive health care? retention. Decreased plasma levels do not alter patient’s knowledge
Primary about the drug.
Secondary (A) Independent. Independent nursing interventions involve actions
Tertiary that nurses initiate based on their own knowledge and skills without
Curative the direction or supervision of another member of the health care
24. Which is an example of a subjective data? team.
(B) 6 months. Chronic pain s usually defined as pain lasting longer
than 6 months.
(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 can’t solve all patient
health problems.
(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 patient’s well-being.
(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.
(B) teacher. The nurse will assume the role of a teacher in this
therapeutic relationship. The other roles are inappropriate in this
situation.
(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.
(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 Biot’s breathing. Option B is apneustic
breathing and option C is the Cheyne-stokes breathing.
(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.
(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.
(D) Patient stated, “My arms still hurt.”. Subjective data are apparent
only to the person affected and can or verified only by that person.
(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?
Decreased plasma drug levels
Sensory deficits
Lack of family support
History of Tourette syndrome
2. When examining a patient with abdominal pain the nurse in
charge should assess:
Any quadrant first
The symptomatic quadrant first
The symptomatic quadrant last
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?
Vital signs
Laboratory test result
Patient’s description of pain
Electrocardiographic (ECG) waveforms
4. A male patient has a soft wrist-safety device. Which assessment
finding should the nurse consider abnormal?
A palpable radial pulse
A palpable ulnar pulse
Cool, pale fingers
Pink nail beds
5. Which of the following planes divides the body longitudinally into
anterior and posterior regions?
Frontal plane
Sagittal plane
Midsagittal plane
Transverse plane
6. A female patient with a terminal illness is in denial. Indicators of
denial include:
Shock dismay
Numbness
Stoicism
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?
Position the head of the bed flat
Helps the patient dangle the legs
Stands behind the patient
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?
Asking frequently if the patient understands the instruction
Asking an interpreter to replay the instructions to the patient.
Writing out the instructions and having a family member read them
to the patient
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 patient’s medication drawer. What should the nurse in charge
do?
Discard the syringe to avoid a medication error
Obtain a label for the syringe from the pharmacy
Use the syringe because it looks like it contains the same medication
the nurse was prepared to give
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?
Faster drug clearance
Aging-related physiological changes
Increased amount of neurons
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?
Manager
Educator
Caregiver
Patient advocate
12. A female patient exhibits signs of heightened anxiety. Which
response by the nurse is most likely to reduce the patient’s anxiety?
“Everything will be fine. Don’t worry.”
“Read this manual and then ask me any questions you may have.”
“Why don’t you listen to the radio?”
“Let’s talk about what’s bothering you.”
13. A scrub nurse in the operating room has which responsibility?
Positioning the patient
Assisting with gowning and gloving
Handling surgical instruments to the surgeon
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?
Leave the medication at the patient’s bedside
Tell the patient to be sure to take the medication. And then leave it
at the bedside
Return shortly to the patient’s room and remain there until the
patient takes the medication
Wait for the patient to return to bed, and then leave the medication Length
at the bedside Bevel angle
15. The physician orders heparin, 7,500 units, to be administered Thickness
subcutaneously every 6 hours. The vial reads 10,000 units per Sharpness
millilitre. The nurse should anticipate giving how much heparin for 25. A patient receiving an anticoagulant should be assessed for signs
each dose? of:
¼ ml Hypotension
½ ml Hypertension
¾ ml An elevated hemoglobin count
1 ¼ ml An increased number of erythrocytes
16. The nurse in charge measures a patient’s temperature at 102 Answers and Rationales
degrees F. what is the equivalent Centigrade temperature? (B) Sensory deficits. Sensory deficits could cause a geriatric patient
39 degrees C to have difficulty retaining knowledge about prescribed medications.
47 degrees C Decreased plasma drug levels do not alter the patient’s knowledge
38.9 degrees C about the drug. A lack of family support may affect compliance, not
40.1 degrees C knowledge retention. Toilette syndrome is unrelated to knowledge
17. To evaluate a patient for hypoxia, the physician is most likely to retention.
order which laboratory test? (C) The symptomatic quadrant last. The nurse should systematically
Red blood cell count assess all areas of the abdomen, if time and the patient’s condition
Sputum culture permit, concluding with the symptomatic area. Otherwise, the nurse
Total hemoglobin may elicit pain in the symptomatic area, causing the muscles in other
Arterial blood gas (ABG) analysis areas to tighten. This would interfere with further assessment.
18. The nurse uses a stethoscope to auscultate a male patient’s (C) Patient’s description of pain. Subjective data come directly from
chest. Which statement about a stethoscope with a bell and the patient and usually are recorded as direct quotations that reflect
diaphragm is true? the patient’s opinions or feelings about a situation. Vital signs,
The bell detects high-pitched sounds best laboratory test result, and ECG waveforms are examples of objective
The diaphragm detects high-pitched sounds best data.
The bell detects thrills best (C) Cool, pale fingers. A safety device on the wrist may impair
The diaphragm detects low-pitched sounds best circulation and restrict blood supply to body tissues. Therefore, the
19. A male patient is to be discharged with a prescription for an nurse should assess the patient for signs of impaired circulation,
analgesic that is a controlled substance. During discharge teaching, such as cool, pale fingers. A palpable radial or lunar pulse and pink
the nurse should explain that the patient must fill this prescription nail beds are normal findings.
how soon after the date on which it was written? (A) Frontal plane. Frontal or coronal plane runs longitudinally at a
Within 1 month right angle to a sagittal plane dividing the body in anterior and
Within 3 months posterior regions. A sagittal plane runs longitudinally dividing the
Within 6 months body into right and left regions; if exactly midline, it is called a
Within 12 months midsagittal plane. A transverse plane runs horizontally at a right
20. Which human element considered by the nurse in charge during angle to the vertical axis, dividing the structure into superior and
assessment can affect drug administration? inferior regions.
The patient’s ability to recover (A) Shock dismay. Shock and dismay are early signs of denial-the first
The patient’s occupational hazards stage of grief. The other options are associated with depression—a
The patient’s socioeconomic status later stage of grief.
The patient’s cognitive abilities (B) Helps the patient dangle the legs. After placing the patient in
21. When explaining the initiation of I.V. therapy to a 2-year-old high Fowler’s position and moving the patient to the side of the bed,
child, the nurse should: the nurse helps the patient sit on the edge of the bed and dangle the
Ask the child, “Do you want me to start the I.V. now?” legs; the nurse then faces the patient and places the chair next to
Give simple directions shortly before the I.V. therapy is to start and facing the head of the bed.
Tell the child, “This treatment is for your own good” (D) Demonstrating the procedure and having the patient return the
Inform the child that the needle will be in place for 10 days demonstration. Demonstrating by the nurse with a return
22. All of the following parts of the syringe are sterile except the: demonstration by the patient ensures that the patient can perform
Barrel wound care correctly. Patients may claim to understand discharge
Inside of the plunger instruction when they do not. An interpreter of family member may
Needle tip communicate verbal or written instructions inaccurately.
Barrel tip (A) Discard the syringe to avoid a medication error. As a safety
23. The best way to instill eye drops is to: precaution, the nurse should discard an unlabeled syringe that
Instruct the patient to lock upward, and drop the medication into contains medication. The other options are considered unsafe
the center of the lower lid because they promote error.
Instruct the patient to look ahead, and drop the medication into the (B) Aging-related physiological changes. Aging-related physiological
center of the lower lid changes account for the increased frequency of adverse drug
Drop the medication into the inner canthus regardless of eye reactions in geriatric patients. Renal and hepatic changes cause
position drugs to clear more slowly in these patients. With increasing age,
Drop the medication into the center of the canthus regardless of eye neurons are lost and blood flow to the GI tract decreases.
position (B) Educator. When teaching a patient about medications before
24. The difference between an 18G needle and a 25G needle is the discharge, the nurse is acting as an educator. The nurse acts as a
needle’s: manager when performing such activities as scheduling and making
patient care assignments. The nurse performs the care giving role and administration of the injection. However, the inside and trip of
when providing direct care, including bathing patients and the barrel, the inside (shaft) of the plunger, and the needle tip must
administering medications and prescribed treatments. The nurse remain sterile until after the injection.
acts as a patient advocate when making the patient’s wishes known (A) Instruct the patient to lock upward, and drop the medication into
to the doctor. the center of the lower lid. Having the patient look upward reduces
(D) “Let’s talk about what’s bothering you.” Anxiety may result from blinking and protects the cornea. Instilling drops in the center of the
feeling of helplessness, isolation, or insecurity. This response helps lower lid promotes absorption because the drops are less likely to
reduce anxiety by encouraging the patient to express feelings. The run into the nasolacrimal duct or out of the eye.
nurse should be supportive and develop goals together with the (C) Thickness. Gauge is a measure of the needle’s thickness: The
patient to give the patient some control over an anxiety-inducing higher the number the thinner the shaft. Therefore, an 18G needle is
situation. Because the other options ignore the patient’s feeling and considerably thicker than a 25G needle.
block communication, they would not reduce anxiety. (A) Hypotension. A major side effect of anticoagulant therapy is
(C) Handling surgical instruments to the surgeon. The scrub nurse bleeding, which can be identified by hypotension (a systolic blood
assist the surgeon by providing appropriate surgical instruments and pressure under 100 mm Hg). Anticoagulants do not result in the
supplies, maintaining strict surgical asepsis and, with the circulating other three conditions.
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.
(C) Return shortly to the patient’s room and remain there until the
patient takes the medication. The nurse should return shortly to the
patient’s 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 patient’s bedside unless specifically
requested to do so.
(C) ¾ 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 ¾ ml
(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
(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 patient’s oxygenation status.
(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.
(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.
(D) The patient’s cognitive abilities. The nurse must consider the
patient’s 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 patient’s ability to recover, occupational hazards, and
socioeconomic status do not affect drug administration.
(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 shouldn’t 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 2-year-old
doesn’t have a good understanding of time.
(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