FUNDAMENTALS OF NURSING

Laboratory Tests
1. The nurse has an order to obtain a urinalysis sample from a client with an indwelling urinary catheter. The nurse would plan to avoid
which of the following, which could contaminate the specimen?
a. Obtaining the specimen from the urinary drainage bag.
b. Clamping the tubing of the drainage bag.
c. Aspirating a sample from the port on the drainage bag.
d. Wiping the port with an alcohol swab before inserting the syringe.

2. The nurse describes the procedure for collecting clean-catch urine for culture and sensitively to a male patient. Which of the
following explanations, if made by the nurse, would be the MOST accurate?
a. "The urinary meatus is cleansed with an iodine solution and then a urinary drainage catheter is inserted to obtain urine."
B. "You will be asked to empty your bladder one half hour before the test; you will then be asked to void into a container."
c. "Before voiding, the urinary meatus is cleansed with an iodine solution and urine is voided into a sterile container; the container
must not touch the penis."
d. "You must void a few drops of urine, then stop; then void the remaining urine into a clean container that should be
immediately covered.”

3. A urine specimen for ketones should be removed from the client’s retention catheter by:
a. Disconnecting the catheter and draining it into a clean container
b. Cleansing the drainage valve and removing it from the catheter bag
c. Wiping the catheter with alcohol and draining into a sterile test tube
d. Using a sterile syringe to remove it from a clamped, cleaned catheter

4. The nurse instructs a female client to obtain a clean-catch urine sample for culture and sensitivity. Which statement by the client
indicates that the client understands the procedure for collecting the specimen?
a. "I should empty my bladder into a container so that the full amount of urine can be determined."
b. "A urine specimen will be obtained from a catheter."
c. "I need to cleanse the labia using cleansing towels, void into the toilet, and then void into the sterile specimen container."
d. "I need to clean the labia with toilet paper and void into the sterile specimen container."

5. To collect a clean-catch midstream urine specimen from a female client, the nurse instructs her to clean the area as the external
urinary meatus with an antiseptic. How should the client do this?
a. By swabbing the labia minora from front to back
b. By cleaning the labia minora from back to front
c. By cleaning the labia majora from back to front
d. By swabbing the entire perineal area

6. The nurse is preparing to collect a 24-hour urine specimen from the client. Which of the following is an inaccurate action when collecting
the specimen?
a. Asking the client to void, saving the specimen, and noting the start time.
b. To allow drainage to occur.
c. To allow the urine to collect in the tubing.
d. To have the client check the tubing for urine.

7. A client has an order for a stool culture. The nurse avoids doing which of the following when carrying out this order?

a. Wearing sterile gloves

b. Using a sterile container
c. Refrigerating the specimen
d. Sending specimen directly to the laboratory

8. When performing a Guaiac test on a patient's stool, the nurse is checking for the presence of which of the following? a.
white blood cells
b. red blood cells
c. mucus
d. bacteria

9. A nurse has just collected a sputum specimen by expectoration for culture on a client who has a production cough. The nurse plans
to implement all of the following interventions. Which nursing action does the nurse identify as the priority?

a. Give the client mouthwash

b. Checking to see that the sputum basin is clean
c. Sending the sputum specimen to the laboratory immediately
d. Providing tissue for expectoration.
 10. The physician has ordered a sputum specimen to be collected for culture and sensitivity. The nurse is aware that the preferable
time
to collect this specimen is:
a. in the morning
b. in the evening, after forcing fluid all day
c. after antibiotics have been started
d. after the client has taken an expectorant

11. To evaluate a client for hypoxia, the physician is most likely to order which laboratory test?
a. Red blood cell count
b. Sputum culture
c. Total hemoglobin
d. Arterial blood gas (ABG) analysis

12. A nurse performs an admission assessment on a client with a diagnosis of tuberculosis. The nurse reviews the results of which
diagnostic test that will confirm this diagnosis?
a. Bronchoscopy
b. Chest x ray film
c. Sputum smear
d. Tuberculin skin test

13. An arterial blood gas (ABG) is ordered for a 46-year-old man following a myocardial infarction. After obtaining the ABG, which of the
following measure would be ESSENTIAL for the nurse to implement?
a. obtain ice for the specimen
b. apply a sterile dressing to the site
c. apply direct pressure to the site
d. observe the site for hematoma formation

Diagnostic Tests
14. When caring for a client after a cardiac catheterization, it is most important that the nurse: a. Help
client to ambulate
b. Administer oxygen
c. Check the ECG every 30 minutes
d. Check the pulse distal to the insertion site

15. A 44-year-old man returns to his room following a cardiac catheterization. Which of the following assessments, if made by the
nurse, would justify calling the physician?
a. Pain at the site of the catheter insertion
b. Absence of the pulse distal to the catheter insertion site
c. Drainage on the dressing covering the catheter insertion site
d. Redness at the catheter insertion site

16. Which of the following techniques is considered a non-invasive diagnostic method to evaluate cardiac changes? a. Cardiac
biopsy
b. Cardiac catheterization
c. Magnetic resonance imaging (MRI)
d. Pericardiocentesis

17. Before a transesophageal echocardiogram (TEE), a client is given an oral topical anesthetic spray. Upon return from the procedure,
the nurse observes that the client has no active gag reflex. In response, the nurse should:
a. Insert an oral airway.
b. Withhold food and fluids.
c. Position the client on his side.
d. Introduce a nasogastric (NG) tube.

18. After bronchoscopy, the client must receive nothing by mouth until gag reflex returns. What is the best way to assess the return
of the gag reflex?
a. Instruct the client to cough
b. Ask the client to extend the tongue
c. Tap the posterior part of the tongue with a tongue blade
d. Observe while the swallow sips of water

19. A nurse is caring for a client after a bronchoscopy and biopsy. Which of the following signs if noted in the client should be reported
immediately to the physician?
a. Blood streaked sputum
b. Dry cough
c. Hematuria
d. Bronchospasm

20. A client has just undergone bronchoscopy. Which nursing assessment is most important at this time? a. Level
of consciousness (LOC)
b. Memory
c. Personality changes
d. Intellectual ability

21. A client has just returned to her room following bronchoscopic examination and asks for a cup of tea. Before complying with the request
the nurse should consider which of the following?
a. Did the client receive an analgesic prior to the procedure?
b. Was the client given a local anesthetic during the procedure?
c. Is the client able to signal for assistance?
d. Should the client be encouraged to drink fluids?

22. A client has a bronchoscopy in ambulatory surgery. To prevent laryngeal edema, the nurse should: a.
Place ice chips in the client’s mouth
b. Offer the client liberal amount of fluid
c. Keep the client in the semi-Fowler’s position
d. Tell the client to suck on medicated lozenges

23. A client is scheduled for chest x-ray to rule our pneumonia. Which of the following is appropriate for this procedure?

a. fasting for 4 hours prior to procedure

b. consent form for an invasive procedure
c. Benadryl 25 mg IM prior to the procedure
d. no special preparation is required

24. A client who is human immunodeficiency virus positive has had a Mantoux skin test. The nurse notes a 7 mm area of induration at the
site of the skin test. The nurse interprets the result as:
a. Positive
b. Negative
c. Inconclusive
d. The need to repeat testing

25. A post-exposure to tubercle bacilli may be determined by carrying out PPD. What result would confirm this finding? a.
Wheal formation after 30 minutes
b. Induration of more than 10 mm
c. Redness 2 mm in diameter
d. Rash that develops after one hour

26. A thoracentesis is performed. Following the procedure, it is most important for the nurse to observe the client for: a.
Periods of confusion
b. Expectoration of blood
c. Increased breath sound
d. Decreased respiratory rate

27. Mr Vargas is nervous about a colonoscopy scheduled for tomorrow. The nurse described the test by explaining that it allows which of
the following?
a. Visual examination of the large intestine
b. Visual examination of the esophagus and stomach
c. Radiographic examination of the large intestine
d. Fluoroscopic examination of the small bowel

28. As part of the preparation of a client for sigmoidoscopy, the nurse should:
a. Administer an enema the morning of the test
b. Provide container for the collection of the specimen
c. Withhold all fluids and foods for 24 hours before the examination
d. Explain to the client that a chalklike substance will be swallowed

29. The single most important means of preventing the spread of infection is:
a. Wearing disposable gloves
 b. Handwashing
c. Avoiding persons with known infections
d. Wearing a face mask

30. After the nurse explains the procedure for performing an upper GI x-ray, which statement indicates that the client understands the test?
a. A flexible tube will be inserted into the stomach.
b. Dye will be infused into my vein before the test.
c. My body will be placed within an imaging chamber.
d. I will have to swallow a large volume of barium.

31. The client has just return from the x-ray department after undergoing an upper GI series. Which of the following interventions would
be appropriate at the time?
a. keep him NPO until gag reflex return
b. administer a cleansing enema
c. monitor the vital sign every 15 minutes for 1 hour or until stable
d. give him milk of magnesia 30 cc PO as per MD’s order

32. Suspected of intestinal cancer, Mr Jose is scheduled for an upper GI series with use of barium. After the procedure, what
medications will the nurse expect to be ordered?
a. analgesics
b. laxatives
c. antispasmodics
d. antihistamines

33. A client asks the nurse if he will feel a lot of pain during a sigmoidoscopy. The best nursing response is: a. “No,
you should only feel a small amount of pain, since the area is anesthetized.”
b. “NO, the test does not cause pain.”
c. “You will feel slightly uncomfortable and will have the urge to defecate since when the instrument is inserted.”
d. This test is very painful.”

34. A barium enema should be done before an UGIS because which of the following?
a. Retained barium may cloud the colon
b. Barium can cause lower gastrointestinal bleeding
c. The physician’s order are in that sequence
d. Barium absorbed readily in the lower intestine

35. A client is for bone marrow aspiration to assist with the diagnosis of multiple myeloma. Prior to bone marrow aspiration, the most
important communication from the nurse to the client is which of the following?
a. The client must be still during the procedure
b. This test will help diagnosed multiple myeloma
c. You will feel sharp pain for a few minute
d. You will receive a sedative, so you will be a sleep

36. The nurse is preparing a client for a bone marrow biopsy. Which is the preferred site for the procedure?

a. Posterior superior iliac crest

b. Sternum
c. Anterior iliac spine
d. Posterior iliac spine

37. When preparing the client for a bone marrow aspiration test, the nurse should:
a. tell the client that the procedure will be done under general anesthesia
b. explain that the skin over the aspiration site may be anesthetized prior to procedure
c. reassure the client that the procedure is relatively painless and risk free
d. inform the client that the physician will take multiple samples for comparison

38. Which of the following diagnostic procedure is considered invasive and requires special consent form? a. MRI
b. Cerebral arteriogram
c. CT scan
d. Echoencephalography

39. A 50-year-old woman comes to the clinic for evaluation of acute onset of seizures. A thorough history and physical examination is
performed. The nurse would expect which of the following diagnostic tests to be performed FIRST?
a. magnetic resonance imaging (MRI)
b. cerebral angiography
c. electroencephalogram (EEG)
 d. electromyogram (EMG)

40. Which of the following actions, if taken by a nurse to prepare a client for an electroencephalogram (EEG) is one that should be
questioned?
a. The client is given a mild sedative the evening prior to the procedure
b. The client’s intake of coffee and alcohol is restricted for 48 hours prior to the procedure
c. The client is told that the procedure is painless
d. The nurse washes and dries the client’s hair prior to the procedure

41. A physician orders a body magnetic resonance imaging (MRI) for diagnostic purposes. It would be most important for the nurse to tell
the client that the procedure
a. Takes 15 to 30 minutes
b. Involve injection of a contrast dye
c. Is painless, except for the discomfort of lying still
d. Uses only small amounts of radiation

42. To determine the extent of CVA, Mr Jose underwent cerebral angiography. After this procedure, the most essential responsibility of the
nurse is to
a. administer aspirin for pain
b. massage the punctured site
c. monitor urine output
d. assess the punctured site for bleeding

43. The priority nursing action for a patient who underwent intravenous pyelography (IVP) is:
a. Increase fluid intake
b. Place patient in semi-fowler’s position
c. NPO 4 hours after procedure
d. Ambulate as soon as possible

44. Prior to the patient undergoing a scheduled intravenous pyelography (IVP), the nurse reviews the patient’s health history. It would
be
important for the nurse to obtain the answer to which of the following questions?
a. Does the patient have difficulty voiding?
b. Does the patient have any allergies to shellfish or iodine?
c. Does the patient have a history of constipation?
d. Does the patient have frequent headaches?

45. Mrs Evita is brought to the recovery room after a successful cystoscopic exam and removal of renal stones. A normal occurrence after
this procedure will be?
a. dysuria
b. urinary retention
c. bright, red bleeding
d. oliguria

46. The ambulatory care nurse is performing an assessment on a client who has returned from the postanesthesia care unit following a
cystoscopy. Which of the following, if noted in the client, would indicate a need to notify the physician? a. A
temperature of 99.4" F
b. Grossly bloody urine with clots
c. A blood pressure of 130/82 mm Hg
d. Urine with a bluish or green tinged

47. Which of the following laboratory values should be checked in a patient with cirrhosis?
a. Increased BUN
b. Increased creatinine
c. Increased ammonia
d. Increased SGOT

48. The nurse should position a client recovering from general anesthesia in a:
a. Supine position
b. Side-lying position
c. High-Fowlers position
d. Trendelenburg position

49. During the immediate postoperative period, the nurse should give the highest priority to:
 a. Observing for hemorrhage
b. Maintaining a patent airway
c. Recording the intake and output
d. Checking the vital signs every 15 minutes

50. When a new procedure is needed the nurse may obtain information from the agency’s:
a. Procedure manual
b. Infection control department
c. In-service director
d. Nursing supervisor

Nursing Procedures
51. The nurse connects a patient’s single-lumen nasogastric tube to intermittent suction for which purpose? a.
Drain the stomach more effectively
b. Prevent electrolyte losses
c. Help prevent dumping syndrome
d. Help to prevent the tube from suctioning the mucosa

52. Saline solution is used to irrigate a nasogastric tube used for decompression based on which rationale? a.
Irrigating with water is a contaminated procedure
b. Saline solution is a hypertonic solution
c. Saline solution replaces electrolyte loss through nasogastric suction
d. Saline solution is less irritating to the gastric mucosa

53. During a percutaneous endoscopic gastrostomy (PEG) tube feeding, the observation that indicates that the client is unable to tolerate
a continuation of the feeding would be:
a. A passage of flatus
b. Epigastric tenderness
c. A rise of formula in the tube
d. The rapid flow of feeding

54. Client receiving hypertonic tube feedings most commonly develop diarrhea because of:
a. Increased fiber intake
b. Bacterial contamination
c. Inappropriate positioning
d. High osmolarity of feeding

55. The nurse should administer a nasogastric tube feeding slowly to reduce the hazard of:
a. Distension
b. Flatulence
c. Indigestion
d. Regurgitation

56. When caring with a client with NGT attached to suction, the nurse should:
a. Irrigate the tube with normal saline
b. Use sterile technique in irrigating the tube
c. Withdraw the tube quickly when decompression is terminated
d. Allow the client to have small chips of ice or sip of water unless nauseated

57. After partial gastrectomy is performed, a client is returned to the unit with an IV solution infusing and an NGT in place. The nurse notes
that there has been no nasogastric drainage for 30 minutes. There is an order to irrigate the NGT PRN. The nurse should insert:
a. 30 ml of normal saline and withdraw slowly
b. 20 ml of air and clamp off suction for 1 hour
c. 50 ml of saline and increase pressure of suction
d. ml of distilled water and disconnect the suction for 30 minutes

58. While administering medications, the nurse realizes she has given the wrong dose of medication to a client. The nurse acts by
completing an incident report and notifying the client’s physician. The nurse is exercising:
a. Authority
b. Responsibility
c. Accountability
d. Decision making

59. Carl is a male patient admitted for burns several days ago. He has been having intermittent NGT feeding which is to be
discontinued. What is the most important criterion for the removal of the NGT?
a. Presence of abdominal distension
 b. Absence of bowel sounds
c. Passage of flatus
d. Presence of gurgling sound upon introduction of air in the NGT tube

60. When an intestinal obstruction is suspected, a client has a nasogastric tube inserted and attached to suction. Critical assessment of this
client includes observation for:
a. Edema
b. Belching
c. Dehydration
d. Excessive salivation

61. A client is to have a gastric gavage. When the gavage tube is being inserted, the nurse should place the client in the: a.
Supine position
b. Side lying position
c. Fowler’s position
d. Trendelenburg’s position

62 After a client has an enteral feeding tube inserted, the most accurate method for verification initial placement is
a. Abdominal x-ray
b. Auscultation
c. Flushing tube with saline
d. Aspiration for gastric contents

63. The nurse assesses the client with gastric lavage or prolonged vomiting for:
a. Acidosis
b. Alkalosis
c. Loss of oxygen from the blood
d. Loss of osmotic pressure of the blood

64. Barium salts in GI series and barium enemas serves to:

a. Fluoresce and thus illuminate the alimentary tract
b. Give off visible light and illuminates the alimentary tract
c. Dye the alimentary tract and thus provide for color contrast
d. Absorb x-ray and thus give contrast to the soft tissues of the alimentary tract

65. During the administration of an enema, a client complains of cramps. The nurse should:
a. Reassure client that it is normal
b. Discontinue the procedure
c. Stop until cramps are gone
d. Lower the height of the container

66. Which action is essential when the nurse provides a continuous enteral feeding?
a. Elevate the head of the bed
b. Position the client on the left side
c. Warm the formula before administering it
d. Hang a full day’s worth of formula at one time

67. A client with esophageal cancer is to receive total parenteral nutrition. A right subclavian catheter is inserted by the physician. The
nurse knows that the primary reason for using a central line is that:
a. It prevents the development of phlebitis
b. There is less chance of this infusion to infiltrate
c. The large amount of blood helps to dilute the concentrated solution
d. It is more convenient so clients use their hand

68. A client is receiving total parenteral solution (TPN) after extensive colon surgery. The purpose of TPN is to: a.
Provide short-term nutrition after surgery
b. Assist in providing supplemental nutrition for the client
c. Provide total nutrition when gastrointestinal function is questionable
d. Assist people who are unable to eat but have active gastrointestinal function

69. The physician has ordered a nutrition solution to run for 24 hours. The nurse realizes that it will not finish within this time period.
The nurse should
a. increase the flow rate
b. decrease the flow rate
c. re-calculate the finishing time
d. notify the physician

70. A client is to have an enema to reduce flatus. The rectal catheter should be inserted:
 a. 2 inches
b. 4 inches
c. 6 inches
d. 8 inches

71. When caring for a client with an ileostomy the nurse should:
a. Encourage the client to eat food high in residue
b. Expect the stoma to start draining on the third postoperative day
c. Explain that drainage can be controlled with daily irrigation
d. Anticipate that emotional stress can increase intestinal peristalsis

72. When receiving an enema, the client should be placed in:

a. Left Sim’s position
b. Back-lying position
c. Knee-chest position
d. Mid-Fowler’s position

73. When performing a colostomy irrigation, the nurse inserts the catheter into the stoma:
a. 5 cm (2 inches)
b. 10 cm (4 inches)
c. 15 cm (6 inches)
d. 20 cm (18 inches)

74. Mr. Dantes has a fecal impaction. The nurse correctly administers an oil-retention enema by doing which of the following? a.
Administering a large volume of solution (500 to 1,000 ml)
b. Mixing milk and molasses in equal part for an enema
c. Instructing the patient to retain the enema for at least 30 minutes
d. Following the return-flow or Harris flush procedure

75. When teaching a client to care for a new colostomy, the nurse should recommend that the irrigation be done at the same time every
day. The time selected should:
a. Be approximately 1 hour before breakfast
b. Provide ample uninterrupted bathroom use at home
c. Approximate the client’s usual daily time for elimination
d. Be about halfway between the two largest meals of the day

76. When teaching a client with permanent colostomy what might be expected on discharge, the nurse should discuss: a. Need
for special clothing
b. Importance of limiting activities
c. Periodic dilation of the stoma
d. Bland, low-residue diet regimen

77. A client with colostomy should follow diet that is:

a. Rich in protein
b. Low in fiber content
c. High in carbohydrate
d. As close to normal as possible

78. The solution of choice used to maintain patency of a nasointestinal tube is:
a. Sterile water
b. Isotonic saline
c. Hypotonic saline
d. Hypertonic glucose

79. A client has a transverse loop colostomy. When inserting the catheter for irrigation, the nurse should:
a. use an oil-based lubricant
b. instruct the client to bear down
c. apply gentle but continuous force
d. direct it towards the client’s right side

80. If, during colostomy irrigation, a client complains of abdominal cramps, the nurse should:
a. discontinue the irrigation
b. lower the container of fluid
c. clamp the catheter for few minutes
d. advance the catheter about 2.5 cm (1 inch)
81. When suctioning a client with a tracheostomy the nurse must remember to:
a. Use a sterile catheter with each insertion
b. Initiate suction as the catheter is being withdrawn
c. Insert the catheter until the cough reflex is stimulated
d. Remove the inner cannula before inserting the suction catheter

82. A nurse is preparing to suction a client through a tracheostomy tube. Which of the following protective items would the nurse wear to
perform this procedure?
a. Gown, mask, and sterile gloves
b. Goggles, mask, and sterile gloves
c. Mask, gown, and a cap
d. Mask, sterile gloves, and a cap

83. When suctioning a client with a tracheostomy, which of the following is inappropriate action by the nurse? a. The
nurse initiates suction as the catheter is withdrawn.
b. The nurse inserts 3-5 inches of the catheter into the tracheostomy.
c. The nurse applies suction for 5-10 seconds
d. The nurse uses a new sterile catheter with each insertion

84. To facilitate maximum air exchange, a client should be placed in the:

a. Supine position
b. Orthopneic position
c. High-Fowler’s position
d. Semi-Fowler’s position

85. The client is shot in the chest during a holdup and is transported to the hospital. In the emergency department chest tubes are
inserted, one in the second intercostals space and one in the base of the lung. The nurse understands that the tube in the second
intercostals space will:
a. Remove the air that is present in the intrapleural space
b. Drain serosanguineous fluid from the intrapleural compartment
c. Provide access for the instillation of medication into the pleural space
d. Permit the development of positive pressure between the layers of the pleura

86. A patient with chest injury comes into the ER. The nurse on duty, after seeing the patient’s condition, immediately places sterile gauze
on the patient’s opened chest wall. What is the best explanation for this action?
a. To prevent air from getting out of the lungs
b. To prevent the collapse of the lungs
c. To prevent secondary infection
d. To prevent further bleeding

87. During the first 36 hours after the insertion of chest tubes, when assessing the function of the three-chamber, closed-chest
drainage system. The nurse notes that the water in the underwater seal tube is not fluctuating. The initial nursing intervention should
be to:
a. Inform the physician
b. Take the client’s vital signs
c. Check whether the tube is kinked
d. Turn client on sides

88. Upon returning from the recovery room, the nurse notices the fluctuation in the chest tube bottle suddenly stopped. It indicates:

a. all the fluid and air has been removed

b. the tubing may be kinked
c. the lungs has been re-expanded
d. the suction is set too low

89. An independent nursing measure that would be helpful in preventing the accumulation of secretion in a client who has a general
anesthesia for surgery is:
a. Postural drainage
b. Cupping the chest
c. Nasotracheal suctioning
d. Frequent change in position

90. To help a client obtain maximum benefit after postural drainage, the nurse should:
a. Administer the PRN oxygen
b. Place the client in a sitting position
c. Encourage the client to cough deeply
 d. Encourage the client to rest for 30 minutes

91. A client has chest tube attached to a chest tube drainage system. When caring for this client, the nurse should:

a. Clamp the chest tube when suctioning

b. Palpate the surrounding area for crepitus
c. Change the dressing daily using aseptic technique
d. Empty the drainage chamber the end of the shift

92. When caring for an intubated client receiving mechanical ventilation, the nurse hers the high-pressure alarm. Which action is most
appropriate?
a. Obtain arterial blood gas
b. Lower the tidal volume setting
c. Remove secretions by suctioning
d. Check the tubing connections

93. An oxygen delivery system is prescribed for a client with chronic obstructive pulmonary disease to deliver a precise oxygen
concentration. Which of the following types of oxygen delivery system would the nurse anticipate to be prescribed?

a. Venturi mask
b. Aerosol mask
c. Face tent
d. Tracheostomy collar

94. When making an occupied bed, which of the following is most important for the nurse to do?

a. Keep the bed in the low position

b. Use a bath blanket or top sheet for warmth and privacy
c. Constantly keep the side rails raised on both sides
d. Move back and forth from one side to the other when adjusting the linens

95. Prior to a paracentesis for a client with cirrhosis and ascites, the client should be encouraged to do which of the following?

a. Drink 2 liters of water

b. empty the bladder
c. cleanse the abdominal area Turn the client to unaffected side
d. Turn the client to unaffected side

96. Which action would be the priority when administering using an oral care to a dependent patient?

a. Assisting the patient to the dorsal recumbent position

b. Wearing disposable gloves
c. Using a firm toothbrush to cleanse the teeth and gums
d. Irrigating forcefully with hydrogen peroxide

97. While doing range-of-motion exercise with a patient who is bedridden, the nurse is aware that:

a. Neck hyperextension should be encouraged, particularly in older patient

b. Exercise should be continued until the patient is fatigued
c. Exercises should be done frequently to lessen pain for the patient
d. Each joints is exercised to the point of resistance but no pain

98. When using a cane for maximal support, the nurse is aware that the patient should:
a. Hold the cane on the weaker side
b. Distribute weight evenly between the feet and the cane
c. Keep the elbow that is holding the cane straight and stiff
d. Advance the weaker foot ahead of the cane

99. Nursing care for a patient with an indwelling catheter includes which of the following?
a. Irrigation of the catheter with 30 ml of normal saline solution every 4 hours
b. Disconnecting and connecting the drainage system quickly to obtain urine specimen
c. Encouraging a generous fluid intake if permitted
d. Informing the patient that burning and irrigation at the meatus are normal, subsiding within a few days
100. Which of the following is the primary nursing intervention necessary for all patients with a Foley catheter in place? a.
Maintain the drainage tubing and collection bag level with the patient’s bladder
b. Irrigate the patient with 1% Neosporin solution three times daily
c. Clamp the catheter for 1 hour to maintain the bladder elasticity
d. Maintain the drainage tubing and collection bag below bladder level to facilitate drainage by gravity.