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 the client, Nurse Hazel inspects the client’s abdomen and notice that
diagnosis of pneumonia. Nurse Oliver learns that the client lives it is slightly concave. Additional assessment should proceed in which
alone and hasn’t been eating or drinking. When assessing him for order:
dehydration, nurse Oliver would expect to find: Palpation, auscultation, and percussion.
Hypothermia Percussion, palpation, and auscultation.
Hypertension Palpation, percussion, and auscultation.
Distended neck veins Auscultation, percussion, and palpation.
Tachycardia 46. Nurse Betty is assessing tactile fremitus in a client with
37.The physician prescribes meperidine (Demerol), 75 mg I.M. every pneumonia. For this examination, nurse Betty should use the:
4 hours as needed, to control a client’s postoperative pain. The Fingertips
package insert is “Meperidine, 100 mg/ml.” How many milliliters of Finger pads
meperidine should the Dorsal surface of the hand
client receive? Ulnar surface of the hand
0.75 47. Which type of evaluation occurs continuously throughout the
0.6 teaching and learning process?
0.5 Summative
0.25 Informative
38. A male client with diabetes mellitus is receiving insulin. Which Formative
statement correctly describes an insulin unit? Retrospective
It’s a common measurement in the metric system. 48.A 45 year old client, has no family history of breast cancer or
It’s the basis for solids in the avoirdupois system. other risk factors for this disease. Nurse John should instruct her to
It’s the smallest measurement in the apothecary system. have mammogram how often?
It’s a measure of effect, not a standard measure of weight or Twice per year
quantity. Once per year
39.Nurse Oliver measures a client’s temperature at 102° F. What is Every 2 years
the equivalent Centigrade temperature? Once, to establish baseline
40.1 °C 49.A male client has the following arterial blood gas values: pH 7.30;
38.9 °C Pao2 89 mmHg; Paco2 50 mmHg; and HCO3 26mEq/L. Based on
48 °C these values, Nurse Patricia should expect which condition?
38 °C Respiratory acidosis
40.The nurse is assessing a 48-year-old client who has come to the Respiratory alkalosis
physician’s office for his annual physical exam. One of the first Metabolic acidosis
physical signs of aging is: Metabolic alkalosis
Accepting limitations while developing assets. 50.Nurse Len refers a female client with terminal cancer to a local
Increasing loss of muscle tone. hospice. What is the goal of this referral?
Failing eyesight, especially close vision. To help the client find appropriate treatment options.
Having more frequent aches and pains. To provide support for the client and family in coping with terminal
41.The physician inserts a chest tube into a female client to treat a illness.
pneumothorax. The tube is connected to water-seal drainage. The To ensure that the client gets counseling regarding health care costs.
nurse in-charge can prevent chest tube air leaks by: To teach the client and family about cancer and its treatment.
Checking and taping all connections. 51.When caring for a male client with a 3-cm stage I pressure ulcer
Checking patency of the chest tube. on the coccyx, which of the following actions can the nurse
Keeping the head of the bed slightly elevated. institute independently?
Keeping the chest drainage system below the level of the chest. Massaging the area with an astringent every 2 hours.
42.Nurse Trish must verify the client’s identity before administering Applying an antibiotic cream to the area three times per day.
medication. She is aware that the safest way to verify identity is to: Using normal saline solution to clean the ulcer and applying a
Check the client’s identification band. protective dressing as necessary.
Ask the client to state his name. Using a povidone-iodine wash on the ulceration three times per day.
State the client’s name out loud and wait a client to repeat it. 52.Nurse Oliver must apply an elastic bandage to a client’s ankle and
Check the room number and the client’s name on the bed. calf. He should apply the bandage beginning at the client’s:
43.The physician orders dextrose 5 % in water, 1,000 ml to be infused Knee
over 8 hours. The I.V. tubing delivers 15 drops/ml. Nurse John should Ankle
run the I.V. infusion at a rate of: Lower thigh
30 drops/minute Foot
32 drops/minute 53.A 10 year old child with type 1 diabetes develops diabetic
20 drops/minute ketoacidosis and receives a continuous insulin infusion. Which
18 drops/minute condition represents the greatest risk to this child?
44.If a central venous catheter becomes disconnected accidentally, Hypernatremia
what should the nurse in-charge do immediately? Hypokalemia
Clamp the catheter Hyperphosphatemia
Call another nurse Hypercalcemia
Call the physician 54.Nurse Len is administering sublingual nitrglycerin (Nitrostat) to
Apply a dry sterile dressing to the site. the newly admitted client. Immediately afterward, the client may
45.A female client was recently admitted. She has fever, weight loss, experience:
and watery diarrhea is being admitted to the facility. While assessing Throbbing headache or dizziness
Nervousness or paresthesia. 62.Nurse Amy has documented an entry regarding client care in the
Drowsiness or blurred vision. client’s medical record. When checking the entry, the nurse realizes
Tinnitus or diplopia. that incorrect information was documented. How does the nurse
55.Nurse Michelle hears the alarm sound on the telemetry monitor. correct this error?
The nurse quickly looks at the monitor and notes that a client is in a Erases the error and writes in the correct information.
ventricular tachycardia. The nurse rushes to the client’s room. Upon Uses correction fluid to cover up the incorrect information and
reaching the client’s bedside, the nurse would take which action writes in the correct information.
first? Draws one line to cross out the incorrect information and then
Prepare for cardioversion initials the change.
Prepare to defibrillate the client Covers up the incorrect information completely using a black pen
Call a code and writes in the correct information
Check the client’s level of consciousness 63.Nurse Ron is assisting with transferring a client from the
56.Nurse Hazel is preparing to ambulate a female client. The best operating room table to a stretcher. To provide safety to the client,
and the safest position for the nurse in assisting the client is to the nurse should:
stand: Moves the client rapidly from the table to the stretcher.
On the unaffected side of the client. Uncovers the client completely before transferring to the stretcher.
On the affected side of the client. Secures the client safety belts after transferring to the stretcher.
In front of the client. Instructs the client to move self from the table to the stretcher.
Behind the client. 64.Nurse Myrna is providing instructions to a nursing assistant
57.Nurse Janah is monitoring the ongoing care given to the potential assigned to give a bed bath to a client who is on contact precautions.
organ donor who has been diagnosed with brain death. The nurse Nurse Myrna instructs the nursing assistant to use which of the
determines that the standard of care had been maintained if which following protective items when giving bed bath?
of the following data is observed? Gown and goggles
Urine output: 45 ml/hr Gown and gloves
Capillary refill: 5 seconds Gloves and shoe protectors
Serum pH: 7.32 Gloves and goggles
Blood pressure: 90/48 mmHg 65. Nurse Oliver is caring for a client with impaired mobility that
58. Nurse Amy has an order to obtain a urinalysis from a male client occurred as a result of a stroke. The client has right sided arm and
with an indwelling urinary catheter. The nurse avoids which of the leg weakness. The nurse would suggest that the client use which of
following, which contaminate the specimen? the following assistive devices that would provide the best stability
Wiping the port with an alcohol swab before inserting the syringe. for ambulating?
Aspirating a sample from the port on the drainage bag. Crutches
Clamping the tubing of the drainage bag. Single straight-legged cane
Obtaining the specimen from the urinary drainage bag. Quad cane
59.Nurse Meredith is in the process of giving a client a bed bath. In Walker
the middle of the procedure, the unit secretary calls the nurse on 66.A male client with a right pleural effusion noted on a chest X-ray
the intercom to tell the nurse that there is an emergency phone call. is being prepared for thoracentesis. The client experiences severe
The appropriate nursing action is to: dizziness when sitting upright. To provide a safe environment, the
Immediately walk out of the client’s room and answer the phone nurse assists the client to which position for the procedure?
call. Prone with head turned toward the side supported by a pillow.
Cover the client, place the call light within reach, and answer the Sims’ position with the head of the bed flat.
phone call. Right side-lying with the head of the bed elevated 45 degrees.
Finish the bed bath before answering the phone call. Left side-lying with the head of the bed elevated 45 degrees.
Leave the client’s door open so the client can be monitored and the 67.Nurse John develops methods for data gathering. Which of the
nurse can answer the phone call. following criteria of a good instrument refers to the ability of the
60. Nurse Janah is collecting a sputum specimen for culture and instrument to yield the same results upon its repeated
sensitivity testing from a client who has a productive cough. Nurse administration?
Janah plans to implement which intervention to obtain the Validity
specimen? Specificity
Ask the client to expectorate a small amount of sputum into the Sensitivity
emesis basin. Reliability
Ask the client to obtain the specimen after breakfast. 68.Harry knows that he has to protect the rights of human research
Use a sterile plastic container for obtaining the specimen. subjects. Which of the following actions of Harry ensures
Provide tissues for expectoration and obtaining the specimen. anonymity?
61. Nurse Ron is observing a male client using a walker. The nurse Keep the identities of the subject secret
determines that the client is using the walker correctly if the client: Obtain informed consent
Puts all the four points of the walker flat on the floor, puts weight on Provide equal treatment to all the subjects of the study.
the hand pieces, and then walks into it. Release findings only to the participants of the study
Puts weight on the hand pieces, moves the walker forward, and then 69.Patient’s refusal to divulge information is a limitation because it is
walks into it. beyond the control of Tifanny”. What type of research is appropriate
Puts weight on the hand pieces, slides the walker forward, and then for this study?
walks into it. Descriptive- correlational
Walks into the walker, puts weight on the hand pieces, and then puts Experiment
all four points of the walker flat on the floor. 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. 30 minutes after administering the next dose.
Compare the client’s identification wristband with the tag on the 99.Nurse May is aware that the main advantage of using a floor
unit of blood. stock system is:
Start an I.V. infusion of normal saline solution. The nurse can implement medication orders quickly.
Measure the client’s vital signs. The nurse receives input from the pharmacist.
90.A 65 years old male client requests his medication at 9 p.m. The system minimizes transcription errors.
instead of 10 p.m. so that he can go to sleep earlier. Which type of The system reinforces accurate calculations.
nursing intervention is required? 100. Nurse Oliver is assessing a client’s abdomen. Which finding
Independent should the nurse report as abnormal?
Dependent Dullness over the liver.
Interdependent Bowel sounds occurring every 10 seconds.
Intradependent Shifting dullness over the abdomen.
91.A female client is to be discharged from an acute care facility Vascular sounds heard over the renal arteries.
after treatment for right leg thrombophlebitis. The Nurse Betty notes Answers and Rationales
that the client’s leg is pain-free, without redness or edema. The Answer: (D) The actions of a reasonably prudent nurse with
nurse’s actions reflect which step of the nursing process? similar education and experience. The standard of care is
Assessment determined by the average degree of skill, care, and diligence by
Diagnosis nurses in similar circumstances.
Implementation Answer: (B) I.M. With a platelet count of 22,000/μl, the clients tends
Evaluation to bleed easily. Therefore, the nurse should avoid using the I.M.
92.Nursing care for a female client includes removing elastic route because the area is a highly vascular and can bleed readily
stockings once per day. The Nurse Betty is aware that the rationale when penetrated by a needle. The bleeding can be difficult to stop.
for this intervention? Answer: (C) “Digoxin 0.125 mg P.O. once daily” The nurse should
To increase blood flow to the heart always place a zero before a decimal point so that no one misreads
To observe the lower extremities the figure, which could result in a dosage error. The nurse should
To allow the leg muscles to stretch and relax never insert a zero at the end of a dosage that includes a decimal
To permit veins in the legs to fill with blood. point because this could be misread, possibly leading to a tenfold
93.Which nursing intervention takes highest priority when caring for increase in the dosage.
a newly admitted client who’s receiving a blood transfusion? Answer: (A) Ineffective peripheral tissue perfusion related to
Instructing the client to report any itching, swelling, or dyspnea. venous congestion. Ineffective peripheral tissue perfusion related to
Informing the client that the transfusion usually take 1 ½ to 2 hours. venous congestion takes the highest priority because venous
Documenting blood administration in the client care record. inflammation and clot formation impede blood flow in a client with
Assessing the client’s vital signs when the transfusion ends. deep vein thrombosis.
94.A male client complains of abdominal discomfort and nausea Answer: (B) A 44 year-old myocardial infarction (MI) client who
while receiving tube feedings. Which intervention is most is complaining of nausea. Nausea is a symptom of impending
appropriate for this problem? myocardial infarction (MI) and should be assessed immediately so
Give the feedings at room temperature. that treatment can be instituted and further damage to the heart is
Decrease the rate of feedings and the concentration of the formula. avoided.
Place the client in semi-Fowler’s position while feeding. Answer: (C) Check circulation every 15-30 minutes. Restraints
Change the feeding container every 12 hours. encircle the limbs, which place the client at risk for circulation being
95.Nurse Patricia is reconstituting a powdered medication in a vial. restricted to the distal areas of the extremities. Checking the client’s
After adding the solution to the powder, she nurse should: circulation every 15-30 minutes will allow the nurse to adjust the
Do nothing. restraints before injury from decreased blood flow occurs.
Invert the vial and let it stand for 3 to 5 minutes. Answer: (A) Prevent stress ulcer. Curling’s ulcer occurs as a
Shake the vial vigorously. generalized stress response in burn patients. This results in a
Roll the vial gently between the palms. decreased production of mucus and increased secretion of gastric
96.Which intervention should the nurse Trish use when acid. The best treatment for this prophylactic use of antacids and H2
administering oxygen by face mask to a female client? receptor blockers.
Secure the elastic band tightly around the client’s head. Answer: (D) Continue to monitor and record hourly urine
Assist the client to the semi-Fowler position if possible. output. Normal urine output for an adult is approximately 1
Apply the face mask from the client’s chin up over the nose. ml/minute (60 ml/hour). Therefore, this client’s output is normal.
Loosen the connectors between the oxygen equipment Beyond continued evaluation, no nursing action is warranted.
and humidifier. Answer: (B) “My ankle feels warm”. Ice application decreases pain
97.The maximum transfusion time for a unit of packed red blood and swelling. Continued or increased pain, redness, and increased
cells (RBCs) is: warmth are signs of inflammation that shouldn’t occur after ice
6 hours application
4 hours Answer: (B) Hyperkalemia. A loop diuretic removes water and, along
3 hours with it, sodium and potassium. This may result in hypokalemia,
2 hours hypovolemia, and hyponatremia.
98.Nurse Monique is monitoring the effectiveness of a client’s drug Answer:(A) Have condescending trust and confidence in
therapy. When should the nurse Monique obtain a blood sample to their subordinates. Benevolent-authoritative managers pretentiously
measure the trough drug level? show their trust and confidence to their followers.
1 hour before administering the next dose. Answer: (A) Provides continuous, coordinated and
Immediately before administering the next dose. comprehensive nursing services. Functional nursing is focused on
Immediately after administering the next dose. tasks and activities and not on the care of the patients.
Answer: (B) Standard written order. This is a standard written order. Answer: (B) Assess the client for presence of pain. Assessing the
Prescribers write a single order for medications given only once. A client for pain is a very important measure. Postoperative pain is an
stat order is written for medications given immediately for an urgent indication of complication. The nurse should also assess the client
client problem. A standing order, also known as a protocol, for pain to provide for the client’s comfort.
establishes guidelines for treating a particular disease or set of Answer: (A) BP – 80/60, Pulse – 110 irregular. The classic signs of
symptoms in special care areas such as the coronary care unit. cardiogenic shock are low blood pressure, rapid and weak irregular
Facilities also may institute medication protocols that specifically pulse, cold, clammy skin, decreased urinary output, and cerebral
designate drugs that a nurse may not give. hypoxia.
Answer: (D) Liquid or semi-liquid stools. Passage of liquid or Answer: (A) Take the proper equipment, place the client in a
semi-liquid stools results from seepage of unformed bowel contents comfortable position, and record the appropriate information in the
around the impacted stool in the rectum. Clients with fecal client’s chart. It is a general or comprehensive statement about the
impaction don’t pass hard, brown, formed stools because the feces correct procedure, and it includes the basic ideas which are found in
can’t move past the impaction. These clients typically report the the other options
urge to defecate (although they can’t pass stool) and a decreased Answer: (B) Evaluation. Evaluation includes observing the person,
appetite. asking questions, and comparing the patient’s behavioral responses
Answer: (C) Pulling the helix up and back. To perform an otoscopic with the expected outcomes.
examination on an adult, the nurse grasps the helix of the ear and Answer: (C) History of present illness. The history of present illness is
pulls it up and back to straighten the ear canal. For a child, the nurse the single most important factor in assisting the health professional
grasps the helix and pulls it down to straighten the ear canal. Pulling in arriving at a diagnosis or determining the person’s needs.
the lobule in any direction wouldn’t straighten the ear canal for Answer: (A) Trochanter roll extending from the crest of the ileum to
visualization. the mid-thigh. A trochanter roll, properly placed, provides resistance
Answer: (A) Protect the irritated skin from sunlight. Irradiated skin is to the external rotation of the hip.
very sensitive and must be protected with clothing or sunblock. The Answer: (C) Stage III. Clinically, a deep crater or without undermining
priority approach is the avoidance of strong sunlight. of adjacent tissue is noted.
Answer: (C) Assist the client in removing dentures and nail Answer: (A) Second intention healing. When wounds dehisce, they
polish. Dentures, hairpins, and combs must be removed. Nail polish will allowed to heal by secondary intention
must be removed so that cyanosis can be easily monitored by Answer: (D) Tachycardia. With an extracellular fluid or plasma
observing the nail beds. volume deficit, compensatory mechanisms stimulate the heart,
Answer: (D) Sudden onset of continuous epigastric and back causing an increase in heart rate.
pain. The autodigestion of tissue by the pancreatic enzymes results Answer: (A) 0.75. To determine the number of milliliters the client
in pain from inflammation, edema, and possible hemorrhage. should receive, the nurse uses the fraction method in the following
Continuous, unrelieved epigastric or back pain reflects the equation.
inflammatory process in the pancreas. 75 mg/X ml = 100 mg/1 ml
Answer: (B) Provide high-protein, high-carbohydrate diet. A positive To solve for X, cross-multiply:
nitrogen balance is important for meeting metabolic needs, tissue 75 mg x 1 ml = X ml x 100 mg
repair, and resistance to infection. Caloric goals may be as high as 75 = 100X
5000 calories per day. 75/100 = X
Answer: (A) Blood pressure and pulse rate. The baseline must be 0.75 ml (or ¾ ml) = X
established to recognize the signs of an anaphylactic or hemolytic Answer: (D) It’s a measure of effect, not a standard measure of
reaction to the transfusion. weight or quantity. An insulin unit is a measure of effect, not a
Answer: (D) Immobilize the leg before moving the client. If the nurse standard measure of weight or quantity. Different drugs measured in
suspects a fracture, splinting the area before moving the client is units may have no relationship to one another in quality or quantity.
imperative. The nurse should call for emergency help if the client is Answer: (B) 38.9 °C. To convert Fahrenheit degreed to Centigrade,
not hospitalized and call for a physician for the hospitalized client. use this formula
Answer: (B) Admit the client into a private room. The client who has °C = (°F – 32) ÷ 1.8
a radiation implant is placed in a private room and has a limited °C = (102 – 32) ÷ 1.8
number of visitors. This reduces the exposure of others to the °C = 70 ÷ 1.8
radiation. °C = 38.9
Answer: (C) Risk for infection. Agranulocytosis is characterized by a Answer: (C) Failing eyesight, especially close vision. Failing eyesight,
reduced number of leukocytes (leucopenia) and neutrophils especially close vision, is one of the first signs of aging in middle life
(neutropenia) in the blood. The client is at high risk for infection (ages 46 to 64). More frequent aches and pains begin in the early
because of the decreased body defenses against microorganisms. late years (ages 65 to 79). Increase in loss of muscle tone occurs in
Deficient knowledge related to the nature of the disorder may be later years (age 80 and older).
appropriate diagnosis but is not the priority. Answer: (A) Checking and taping all connections. Air leaks commonly
Answer: (B) Place the client on the left side in the Trendelenburg occur if the system isn’t secure. Checking all connections and taping
position. Lying on the left side may prevent air from flowing into the them will prevent air leaks. The chest drainage system is kept lower
pulmonary veins. The Trendelenburg position increases intrathoracic to promote drainage – not to prevent leaks.
pressure, which decreases the amount of blood pulled into the vena Answer: (A) Check the client’s identification band. Checking the
cava during aspiration. client’s identification band is the safest way to verify a client’s
Answer: (A) Autocratic. The autocratic style of leadership is a identity because the band is assigned on admission and isn’t be
task-oriented and directive. removed at any time. (If it is removed, it must be replaced). Asking
Answer: (D) 2.5 cc. 2.5 cc is to be added, because only a 500 cc bag the client’s name or having the client repeated his name would be
of solution is being medicated instead of a 1 liter. appropriate only for a client who’s alert, oriented, and able to
Answer: (A) 50 cc/ hour. A rate of 50 cc/hr. The child is to receive 400 understand what is being said, but isn’t the safe standard of practice.
cc over a period of 8 hours = 50 cc/hr. Names on bed aren’t always reliable
Answer: (B) 32 drops/minute. Giving 1,000 ml over 8 hours is the Answer: (D) Check the client’s level of consciousness. Determining
same as giving 125 ml over 1 hour (60 minutes). Find the number of unresponsiveness is the first step assessment action to take. When a
milliliters per minute as follows: client is in ventricular tachycardia, there is a significant decrease in
125/60 minutes = X/1 minute cardiac output. However, checking the unresponsiveness ensures
60X = 125 = 2.1 ml/minute whether the client is affected by the decreased cardiac output.
To find the number of drops per minute: Answer: (B) On the affected side of the client.When walking with
2.1 ml/X gtt = 1 ml/ 15 gtt clients, the nurse should stand on the affected side and grasp the
X = 32 gtt/minute, or 32 drops/minute security belt in the midspine area of the small of the back. The nurse
Answer: (A) Clamp the catheter. If a central venous catheter should position the free hand at the shoulder area so that the client
becomes disconnected, the nurse should immediately apply a can be pulled toward the nurse in the event that there is a forward
catheter clamp, if available. If a clamp isn’t available, the nurse can fall. The client is instructed to look up and outward rather than at his
place a sterile syringe or catheter plug in the catheter hub. After or her feet.
cleaning the hub with alcohol or povidone-iodine solution, the nurse Answer: (A) Urine output: 45 ml/hr. Adequate perfusion must be
must replace the I.V. extension and restart the infusion. maintained to all vital organs in order for the client to remain visible
Answer: (D) Auscultation, percussion, and palpation.The correct as an organ donor. A urine output of 45 ml per hour indicates
order of assessment for examining the abdomen is inspection, adequate renal perfusion. Low blood pressure and delayed capillary
auscultation, percussion, and palpation. The reason for this refill time are circulatory system indicators of inadequate perfusion.
approach is that the less intrusive techniques should be performed A serum pH of 7.32 is acidotic, which adversely affects all body
before the more intrusive techniques. Percussion and palpation can tissues.
alter natural findings during auscultation. Answer: (D ) Obtaining the specimen from the urinary drainage
Answer: (D) Ulnar surface of the hand. The nurse uses the ulnar bag. A urine specimen is not taken from the urinary drainage bag.
surface, or ball, of the hand to asses tactile fremitus, thrills, and Urine undergoes chemical changes while sitting in the bag and does
vocal vibrations through the chest wall. The fingertips and finger not necessarily reflect the current client status. In addition, it may
pads best distinguish texture and shape. The dorsal surface best become contaminated with bacteria from opening the system.
feels warmth. Answer: (B) Cover the client, place the call light within reach, and
Answer: (C) Formative. Formative (or concurrent) evaluation occurs answer the phone call. Because telephone call is an emergency, the
continuously throughout the teaching and learning process. One nurse may need to answer it. The other appropriate action is to ask
benefit is that the nurse can adjust teaching strategies as necessary another nurse to accept the call. However, is not one of the options.
to enhance learning. Summative, or retrospective, evaluation occurs To maintain privacy and safety, the nurse covers the client and places
at the conclusion of the teaching and learning session. Informative is the call light within the client’s reach. Additionally, the client’s door
not a type of evaluation. should be closed or the room curtains pulled around the bathing
Answer: (B) Once per year. Yearly mammograms should begin at age area.
40 and continue for as long as the woman is in good health. If health Answer: (C) Use a sterile plastic container for obtaining the
risks, such as family history, genetic tendency, or past breast cancer, specimen. Sputum specimens for culture and sensitivity testing need
exist, more frequent examinations may be necessary. to be obtained using sterile techniques because the test is done to
Answer: (A) Respiratory acidosis. The client has a below-normal determine the presence of organisms. If the procedure for obtaining
(acidic) blood pH value and an above-normal partial pressure of the specimen is not sterile, then the specimen is not sterile, then the
arterial carbon dioxide (Paco2) value, indicating respiratory acidosis. specimen would be contaminated and the results of the test would
In respiratory alkalosis, the pH value is above normal and in the be invalid.
Paco2 value is below normal. In metabolic acidosis, the pH and Answer: (A) Puts all the four points of the walker flat on the floor,
bicarbonate (Hco3) values are below normal. In metabolic alkalosis, puts weight on the hand pieces, and then walks into it. When the
the pH and Hco3 values are above normal. client uses a walker, the nurse stands adjacent to the affected side.
Answer: (B) To provide support for the client and family in coping The client is instructed to put all four points of the walker 2 feet
with terminal illness. Hospices provide supportive care for terminally forward flat on the floor before putting weight on hand pieces. This
ill clients and their families. Hospice care doesn’t focus on counseling will ensure client safety and prevent stress cracks in the walker. The
regarding health care costs. Most client referred to hospices have client is then instructed to move the walker forward and walk into it.
been treated for their disease without success and will receive only Answer: (C) Draws one line to cross out the incorrect information
palliative care in the hospice. and then initials the change. To correct an error documented in a
Answer: (C) Using normal saline solution to clean the ulcer and medical record, the nurse draws one line through the incorrect
applying a protective dressing as necessary. Washing the area with information and then initials the error. An error is never erased and
normal saline solution and applying a protective dressing are within correction fluid is never used in the medical record.
the nurse’s realm of interventions and will protect the area. Using a Answer: (C) Secures the client safety belts after transferring to the
povidone-iodine wash and an antibiotic cream require a physician’s stretcher. During the transfer of the client after the surgical
order. Massaging with an astringent can further damage the skin. procedure is complete, the nurse should avoid exposure of the client
Answer: (D) Foot. An elastic bandage should be applied form the because of the risk for potential heat loss. Hurried movements and
distal area to the proximal area. This method promotes venous rapid changes in the position should be avoided because these
return. In this case, the nurse should begin applying the bandage at predispose the client to hypotension. At the time of the transfer
the client’s foot. Beginning at the ankle, lower thigh, or knee does from the surgery table to the stretcher, the client is still affected by
not promote venous return. the effects of the anesthesia; therefore, the client should not move
Answer: (B) Hypokalemia. Insulin administration causes glucose and self. Safety belts can prevent the client from falling off the stretcher.
potassium to move into the cells, causing hypokalemia. Answer: (B) Gown and gloves. Contact precautions require the use of
Answer: (A) Throbbing headache or dizziness. Headache and gloves and a gown if direct client contact is anticipated. Goggles are
dizziness often occur when nitroglycerin is taken at the beginning of not necessary unless the nurse anticipates the splashes of blood,
therapy. However, the client usually develops tolerance body fluids, secretions, or excretions may occur. Shoe protectors are
not necessary.
Answer: (C) Quad cane. Crutches and a walker can be difficult to Answer: (B) Madeleine Leininger. Madeleine Leininger developed the
maneuver for a client with weakness on one side. A cane is better theory on transcultural theory based on her observations on the
suited for client with weakness of the arm and leg on one side. behavior of selected people within a culture.
However, the quad cane would provide the most stability because of Answer: (A) Random. Random sampling gives equal chance for all
the structure of the cane and because a quad cane has four legs. the elements in the population to be picked as part of the sample.
Answer: (D) Left side-lying with the head of the bed elevated 45 Answer: (A) Degree of agreement and disagreement. Likert scale is a
degrees. To facilitate removal of fluid from the chest wall, the client 5-point summated scale used to determine the degree of agreement
is positioned sitting at the edge of the bed leaning over the bedside or disagreement of the respondents to a statement in a study
table with the feet supported on a stool. If the client is unable to sit Answer: (B) Sr. Callista Roy. Sr. Callista Roy developed the Adaptation
up, the client is positioned lying in bed on the unaffected side with Model which involves the physiologic mode, self-concept mode, role
the head of the bed elevated 30 to 45 degrees. function mode and dependence mode.
Answer: (D) Reliability Reliability is consistency of the research Answer: (A) Span of control. Span of control refers to the number of
instrument. It refers to the repeatability of the instrument in workers who report directly to a manager.
extracting the same responses upon its repeated administration. Answer: (B) Autonomy. Informed consent means that the patient
Answer: (A) Keep the identities of the subject secret. Keeping the fully understands about the surgery, including the risks involved and
identities of the research subject secret will ensure anonymity the alternative solutions. In giving consent it is done with full
because this will hinder providing link between the information knowledge and is given freely. The action of allowing the patient to
given to whoever is its source. decide whether a surgery is to be done or not exemplifies the
Answer: (A) Descriptive- correlational. Descriptive- correlational bioethical principle of autonomy.
study is the most appropriate for this study because it studies the Answer: (C) Avoid wearing canvas shoes. The client should be
variables that could be the antecedents of the increased incidence of instructed to avoid wearing canvas shoes. Canvas shoes cause the
nosocomial infection. feet to perspire, which may, in turn, cause skin irritation and
Answer: (C) Use of laboratory data. Incidence of nosocomial breakdown. Both cotton and cornstarch absorb perspiration. The
infection is best collected through the use of biophysiologic client should be instructed to cut toenails straight across with
measures, particularly in vitro measurements, hence laboratory data nail clippers.
is essential. Answer: (D) Ground beef patties. Meat is an excellent source of
Answer: (B) Quasi-experiment. Quasi-experiment is done when complete protein, which this client needs to repair the tissue
randomization and control of the variables are not possible. breakdown caused by pressure ulcers. Oranges and broccoli supply
Answer: (C) Primary source. This refers to a primary source which is a vitamin C but not protein. Ice cream supplies only some incomplete
direct account of the investigation done by the investigator. In protein, making it less helpful in tissue repair.
contrast to this is a secondary source, which is written by someone Answer: (D) Sims’ left lateral. The Sims’ left lateral position is the
other than the original researcher. most common position used to administer a cleansing enema
Answer: (A) Non-maleficence. Non-maleficence means do not cause because it allows gravity to aid the flow of fluid along the curve of
harm or do any action that will cause any harm to the patient/client. the sigmoid colon. If the client can’t assume this position nor has
To do good is referred as beneficence. poor sphincter control, the dorsal recumbent or right lateral position
Answer: (C) Res ipsa loquitor. Res ipsa loquitor literally means the may be used. The supine and prone positions are inappropriate and
thing speaks for itself. This means in operational terms that the uncomfortable for the client.
injury caused is the proof that there was a negligent act. Answer: (A) Arrange for typing and cross matching of the client’s
Answer: (B) The Board can investigate violations of the nursing law blood. The nurse first arranges for typing and cross matching of the
and code of ethics. Quasi-judicial power means that the Board of client’s blood to ensure compatibility with donor blood. The other
Nursing has the authority to investigate violations of the nursing law options,although appropriate when preparing to administer a blood
and can issue summons, subpoena or subpoena duces tecum as transfusion, come later.
needed. Answer: (A) Independent. Nursing interventions are classified as
Answer: (C) May apply for re-issuance of his/her license based on independent, interdependent, or dependent. Altering the drug
certain conditions stipulated in RA 9173. RA 9173 sec. 24 states that schedule to coincide with the client’s daily routine represents an
for equity and justice, a revoked license maybe re-issued provided independent intervention, whereas consulting with the physician
that the following conditions are met: a) the cause for revocation of and pharmacist to change a client’s medication because of adverse
license has already been corrected or removed; and, b) at least four reactions represents an interdependent intervention. Administering
years has elapsed since the license has been revoked. an already-prescribed drug on time is a dependent intervention. An
Answer: (B) Review related literature. After formulating and intradependent nursing intervention doesn’t exist.
delimiting the research problem, the researcher conducts a review Answer: (D) Evaluation. The nursing actions described constitute
of related literature to determine the extent of what has been done evaluation of the expected outcomes. The findings show that the
on the study by previous researchers. expected outcomes have been achieved. Assessment consists of the
Answer: (B) Hawthorne effect. Hawthorne effect is based on the client’s history, physical examination, and laboratory studies.
study of Elton Mayo and company about the effect of an Analysis consists of considering assessment information to derive
intervention done to improve the working conditions of the workers the appropriate nursing diagnosis. Implementation is the phase of
on their productivity. It resulted to an increased productivity but not the nursing process where the nurse puts the plan of care into
due to the intervention but due to the psychological effects of being action.
observed. They performed differently because they were under Answer: (B) To observe the lower extremities. Elastic stockings are
observation. used to promote venous return. The nurse needs to remove them
Answer: (B) Determines the different nationality of patients once per day to observe the condition of the skin underneath the
frequently admitted and decides to get representations samples stockings. Applying the stockings increases blood flow to the heart.
from each. Judgment sampling involves including samples according When the stockings are in place, the leg muscles can still stretch and
to the knowledge of the investigator about the participants in the relax, and the veins can fill with blood.
study.
Answer:(A) Instructing the client to report any itching, swelling, or 2. A nurse manager assigned a registered nurse from telemetry unit
dyspnea. Because administration of blood or blood products may to the pediatrics unit. There were three patients assigned to the RN.
cause serious adverse effects such as allergic reactions, the nurse Which of the following patients should not be assigned to the
must monitor the client for these effects. Signs and symptoms of floated nurse?
life-threatening allergic reactions include itching, swelling, and A 9-year-old child diagnosed with rheumatic fever
dyspnea. Although the nurse should inform the client of the duration A young infant after pyloromyotomy
of the transfusion and should document its administration, these A 4-year-old with VSD following cardiac catheterization
actions are less critical to the client’s immediate health. The nurse A 5-month-old with Kawasaki disease
should assess vital signs at least hourly during the transfusion. 3. A nurse in charge in the pediatric unit is absent. The nurse
Answer: (B) Decrease the rate of feedings and the concentration of manager decided to assign the nurse in the obstetrics unit to the
the formula. Complaints of abdominal discomfort and nausea are pediatrics unit. Which of the following patients could the nurse
common in clients receiving tube feedings. Decreasing the rate of manager safely assign to the float nurse?
the feeding and the concentration of the formula should decrease A child who had multiple injuries from a serious vehicle accident
the client’s discomfort. Feedings are normally given at room A child diagnosed with Kawasaki disease and with cardiac
temperature to minimize abdominal cramping. To prevent aspiration complications
during feeding, the head of the client’s bed should be elevated at A child who has had a nephrectomy for Wilm’s tumor
least 30 degrees. Also, to prevent bacterial growth, feeding A child receiving an IV chelating therapy for lead poisoning
containers should be routinely changed every 8 to 12 hours. 4. The registered nurse is planning to delegate task to a certified
Answer: (D) Roll the vial gently between the palms. Rolling the vial nursing assistant. Which of the following clients should not be
gently between the palms produces heat, which helps dissolve the assigned to a CAN?
medication. Doing nothing or inverting the vial wouldn’t help A client diagnosed with diabetes and who has an infected toe
dissolve the medication. Shaking the vial vigorously could cause the A client who had a CVA in the past two months
medication to break down, altering its action. A client with Chronic renal failure
Answer: (B) Assist the client to the semi-Fowler position if A client with chronic venous insufficiency
possible. By assisting the client to the semi-Fowler position, the 5. The nurse in the medication unit passes the medications for all the
nurse promotes easier chest expansion, breathing, and oxygen clients on the nursing unit. The head nurse is making rounds with the
intake. The nurse should secure the elastic band so that the face physician and coordinates clients’ activities with other departments.
mask fits comfortably and snugly rather than tightly, which could The nurse assistant changes the bed lines and answers call lights. A
lead to irritation. The nurse should apply the face mask from the second nurse is assigned for changing wound dressings; a licensed
client’s nose down to the chin — not vice versa. The nurse should practitioner nurse takes vital signs and bathes theclients. This
check the connectors between the oxygen equipment and humidifier illustrates of what method of nursing care?
to ensure that they’re airtight; loosened connectors can cause loss of Case management method
oxygen. Primary nursing method
Answer: (B) 4 hours. A unit of packed RBCs may be given over a Team method
period of between 1 and 4 hours. It shouldn’t infuse for longer than Functional method
4 hours because the risk of contamination and sepsis increases after 6. A registered nurse has been assigned to six clients on the 12-hour
that time. Discard or return to the blood bank any blood not given shift. The RN is responsible for every aspect of care such as
within this time, according to facility policy. formulating the care of plan, intervention and evaluating the care
Answer: (B) Immediately before administering the next during her shift. At the end of her shift, the RN will pass this same
dose. Measuring the blood drug concentration helps determine task to the next RN in charge. This nursing care illustrates of what
whether the dosing has achieved the therapeutic goal. For kind of method?
measurement of the trough, or lowest, blood level of a drug, the primary nursing method
nurse draws a blood sample immediately before administering the case method
next dose. Depending on the drug’s duration of action and half-life, team method
peak blood drug levels typically are drawn after administering the functional method
next dose. 7. A newly hired nurse on an adult medicine unit with 3 months
Answer: (A) The nurse can implement medication orders quickly. A experience was asked to float to pediatrics. The nurse hesitates to
floor stock system enables the nurse to implement medication perform pediatric skills and receive an interesting assignment that
orders quickly. It doesn’t allow for pharmacist input, nor does it feels overwhelming. The nurse should:
minimize transcription errors or reinforce accurate calculations. resign on the spot from the nursing position and apply for a position
Answer: (C) Shifting dullness over the abdomen. Shifting dullness that does not require floating
over the abdomen indicates ascites, an abnormal finding. The other Inform the nursing supervisor and the charge nurse on the pediatric
options are normal abdominal findings. floor about the nurse’s lack of skill and feelings of hesitations and
request assistance
SET 2 Ask several other nurses how they feel about pediatrics and find
1. The registered nurse is planning to delegate tasks to unlicensed someone else who is willing to accept the assignment
assistive personnel (UAP). Which of the following task could the Refuse the assignment and leave the unit requesting a vacation a day
registered nurse safely assigned to a UAP? 8. An experienced nurse who voluntarily trained a less experienced
Monitor the I&O of a comatose toddler client with salicylate nurse with the intention of enhancing the skills and knowledge and
poisoning promoting professional advancement to the nurse is called a:
Perform a complete bed bath on a 2-year-old with multiple injuries mentor
from a serious fall team leader
Check the IV of a preschooler with Kawasaki disease case manager
Give an outmeal bath to an infant with eczema change agent
9. The pediatrics unit is understaffed and the nurse manager informs The immediate family may make decision against the patient’s will.
the nurses in the obstetrics unit that she is going to assign one nurse The physician must give the client or surrogates enough information
to float in the pediatric units. Which statement by the designated to make health care judgments consistent with their values and
float nurse may put her job at risk? goals.
“I do not get along with one of the nurses on the pediatrics unit” The patient agrees to a procedure ordered by the physician even if
“I have a vacation day coming and would like to take that now” the client does not understand what the outcome will be.
“I do not feel competent to go and work on that area” 16. A hospitalized client with severe necrotizing ulcer of the lower
“ I am afraid I will get the most serious clients in the unit” leg is schedule for an amputation. The client tells the nurse that he
10. The newly hired staff nurse has been working on a medical unit will not sign the consent form and he does not want any surgery or
for 3 weeks. The nurse manager has posted the team leader treatment because of religious beliefs about reincarnation. What is
assignments for the following week. The new staff knows that a the role of the RN?
major responsibility of the team leader is to: call a family meeting
Provide care to the most acutely ill client on the team discuss the religious beliefs with the physician
Know the condition and needs of all the patients on the team encourage the client to have the surgery
Document the assessments completed by the team members inform the client of other options
Supervise direct care by nursing assistants 17. While in the hospital lobby, the RN overhears the three staff
11. A 15-year-old girl just gave birth to a baby boy who needs discussing the health condition of her client. What would be the
emergency surgery. The nurse prepared the consent form and it appropriate nursing action for the RN to take?
should be signed by: Tell them it is not appropriate to discuss the condition of the client
The Physician Ignore them, because it is their right to discuss anything they want
The Registered Nurse caring for the client to
The 15-year-old mother of the baby boy Join in the conversation, giving them supportive input about the case
The mother of the girl of the client
12. A nurse caring to a client with Alzheimer’s disease overheard a Report this incident to the nursing supervisor
family member say to the client, “if you pee one more time, I won’t 18. A staff nurse has had a serious issue with her colleague. In this
give you any more food and drinks”. What initial action is best for the situation, it is best to:
nurse to take? Discuss this with the supervisor
Take no action because it is the family member saying that to the Not discuss the issue with anyone. It will probably resolve itself
client Try to discuss with the colleague about the issue and resolve it when
Talk to the family member and explain that what she/he has said is both are calmer
not appropriate for the client Tell other members of the network what the team member did
Give the family member the number for an Elder Abuse Hot line 19. The nurse is caring to a client who just gave birth to a healthy
Document what the family member has said baby boy. The nurse may not disclose confidential information when:
13. Which is true about informed consent? The nurse discusses the condition of the client in a clinical
A nurse may accept responsibility signing a consent form if the client conference with other nurses
is unable The client asks the nurse to discuss the her condition with the family
Obtaining consent is not the responsibility of the physician The father of a woman who just delivered a baby is on the phone to
A physician will not subject himself to liability if he withholds any find out the sex of the baby
facts that are necessary to form the basis of an intelligent consent A researcher from an institutionally approved research study reviews
If the nurse witnesses a consent for surgery, the nurse is, in effect, the medical record of a patient
indicating that the signature is that of the purported person and that 20. A 17-year-old married client is scheduled for surgery. The nurse
the person’s condition is as indicated at the time of signing taking care of the client realizes that consent has not been signed
14. A mother in labor told the nurse that she was expecting that her after preoperative medications were given. What should the nurse
baby has no chance to survive and expects that the baby will be born do?
dead. The mother accepts the fate of the baby and informs the nurse Call the surgeon
that when the baby is born and requires resuscitation, the mother Ask the spouse to sign the consent
refuses any treatment to her baby and expresses hostility toward the Obtain a consent from the client as soon as possible
nurse while the pediatric team is taking care of the baby. The nurse Get a verbal consent from the parents of the client
is legally obligated to: 21. A 12-year-old client is admitted to the hospital. The physician
Notify the pediatric team that the mother has refused resuscitation ordered Dilantin to the client. In administering IV phenytoin
and any treatment for the baby and take the baby to the mother (Dilantin) to a child, the nurse would be most correct in mixing it
Get a court order making the baby a ward of the court with:
Record the statement of the mother, notify the pediatric team, and Normal Saline
observe carefully for signs of impaired bonding and neglect as a Heparinized normal saline
reasonable suspicion of child abuse 5% dextrose in water
Do nothing except record the mother’s statement in the medical Lactated Ringer’s solution
record 22. The nurse is caring to a client who is hypotensive. Following a
15. The hospitalized client with a chronic cough is scheduled for large hematemesis, how should the nurse position the client?
bronchoscopy. The nurse is tasks to bring the informed consent Feet and legs elevated 20 degrees, trunk horizontal, head on small
document into the client’s room for a signature. The client asks the pillow
nurse for details of the procedure and demands an explanation why Low Fowler’s with knees gatched at 30 degrees
the process of informed consent is necessary. The nurse responds Supine with the head turned to the left
that informed consent means: Bed sloped at a 45 degree angle with the head lowest and the legs
The patient releases the physician from all responsibility for the highest
procedure.
23. The client is brought to the emergency department after a following are the manifestations of the client: anorexia, cachexia and
serious accident. What would be the initial nursing action of the multiple bruises. What would be the best nursing intervention?
nurse to the client? check the laboratory data for serum albumin, hematocrit, and
assess the level of consciousness and circulation hemoglobin
check respirations, circulation, neurological response talk to the client about the caregiver and support system
align the spine, check pupils, check for hemorrhage complete a police report on elder abuse
check respiration, stabilize spine, check circulation complete a gastrointestinal and neurological assessment
24. A nurse is assigned to care to a client with Parkinson’s disease. 32. The night shift nurse is making rounds. When the nurse enters a
What interventions are important if the nurse wants to improve client’s room, the client is on the floor next to the bed. What would
nutrition and promote effective swallowing of the client? be the initial action of the nurse?
Eat solid food chart that the patient fell
Give liquids with meals call the physician
Feed the client chart that the client was found on the floor next to the bed
Sit in an upright position to eat fill out an incident report
25. During tracheal suctioning, the nurse should implement safety 33. The nurse on the night shift is about to administer medication to
measures. Which of the following should the nurse implements? a preschooler client and notes that the child has no ID bracelet. The
limit suction pressure to 150-180 mmHg best way for the nurse to identify the client is to ask:
suction for 15-20 seconds The adult visiting, “The child’s name is ____________________?”
wear eye goggles The child, “Is your name____________?”
remove the inner cannula Another staff nurse to identify this child
26. The nurse is conducting a discharge instructions to a client The other children in the room what the child’s name is
diagnosed with diabetes. What sign of hypoglycemia should be 34. The nurse caring to a client has completed the assessment.
taught to a client? Which of the following will be considered to be the most accurate
warm, flushed skin charting of a lump felt in the right breast?
hunger and thirst “abnormally felt area in the right breast, drainage noted”
increase urinary output “hard nodular mass in right breast nipple”
palpitation and weakness “firm mass at five ‘ clock, outer quadrant, 1cm from right nipple’
27. A client admitted to the hospital and diagnosed with Addison’s “mass in the right breast 4cmx1cm
disease. What would be the appropriate nursing action to the client? 35. The physician instructed the nurse that intravenous pyelogram
administering insulin-replacement therapy will be done to the client. The client asks the nurse what is the
providing a low-sodium diet purpose of the procedure. The appropriate nursing response is to:
restricting fluids to 1500 ml/day outline the kidney vasculature
reducing physical and emotional stress determine the size, shape, and placement of the kidneys
28. The nurse is to perform tracheal suctioning. During tracheal test renal tubular function and the patency of the urinary tract
suctioning, which nursing action is essential to prevent hypoxemia? measure renal blood flow
aucultating the lungs to determine the baseline data to assess the 36. A client visits the clinic for screening of scoliosis. The nurse
effectiveness of suctioning should ask the client to:
removing oral and nasal secretions bend all the way over and touch the toes
encouraging the patient to deep breathe and cough to facilitate stand up as straight and tall as possible
removal of upper-airway secretions bend over at a 90-degree angle from the waist
administering 100% oxygen to reduce the effects of airway bend over at a 45-degree angle from the waist
obstruction during suctioning. 37. A client with tuberculosis is admitted in the hospital for 2 weeks.
29. An infant is admitted and diagnosed with pneumonia and When a client’s family members come to visit, they would be
suspicious-looking red marks on the swollen face resembling a adhering to respiratory isolation precautions when they:
handprint. The nurse does further assessment to the client. How wash their hands when leaving
would the nurse document the finding? put on gowns, gloves and masks
Facial edema with ecchymosis and handprint mark: crackles and avoid contact with the client’s roommate
wheezes keep the client’s room door open
Facial edema, with red marks; crackles in the lung 38. An infant is brought to the emergency department and
Facial edema with ecchymosis that looks like a handprint diagnosed with pyloric stenosis. The parents of the client ask the
Red bruise mark and ecchymosis on face nurse, “Why does my baby continue to vomit?” Which of the
30. On the evening shift, the triage nurse evaluates several clients following would be the best nursing response of the nurse?
who were brought to the emergency department. Which in the “Your baby eats too rapidly and overfills the stomach, which causes
following clients should receive highest priority? vomiting
an elderly woman complaining of a loss of appetite and fatigue for “Your baby can’t empty the formula that is in the stomach into the
the past week bowel”
A football player limping and complaining of pain and swelling in the “The vomiting is due to the nausea that accompanies pyloric
right ankle stenosis”
A 50-year-old man, diaphoretic and complaining of severe chest pain “Your baby needs to be burped more thoroughly after feeding”
radiating to his jaw 39. A 70-year-old client with suspected tuberculosis is brought to the
A mother with a 5-year-old boy who says her son has been geriatric care facilities. An intradermal tuberculosis test is schedule
complaining of nausea and vomited once since noon to be done. The client asks the nurse what is the purpose of the test.
31. A 80-year-old female client is brought to the emergency Which of the following would be the best rationale for this?
department by her caregiver, on the nurse’s assessment; the reactivation of an old tuberculosis infection
increased incidence of new cases of tuberculosis in persons over 65 Isopropyl alcohol
years old Hexachlorophene (Phisohex)
greater exposure to diverse health care workers Soap and water
respiratory problems are characteristic in this population Chlorhexidine gluconate (CHG) (Hibiclens)
40. The nurse is making a health teaching to the parents of the 49. The mother of the client tells the nurse, “ I’m not going to have
client. In teaching parents how to measure the area of induration in my baby get any immunization”. What would be the best nursing
response to a PPD test, the nurse would be most accurate in advising response to the mother?
the parents to measure: “You and I need to review your rationale for this decision”
both the areas that look red and feel raised “Your baby will not be able to attend day care without
The entire area that feels itchy to the child immunizations”
Only the area that looks reddened “Your decision can be viewed as a form of child abuse and neglect”
Only the area that feels raised “You are needlessly placing other people at risk for communicable
41. A community health nurse is schedule to do home visit. She visits diseases”
to an elderly person living alone. Which of the following observation 50. The nurse is teaching the client about breast self-examination.
would be a concern? Which observation should the client be taught to recognize when
Picture windows doing the examination for detection of breast cancer?
Unwashed dishes in the sink tender, movable lump
Clear and shiny floors pain on breast self-examination
Brightly lit rooms round, well-defined lump
42. After a birth, the physician cut the cord of the baby, and before dimpling of the breast tissue
the baby is given to the mother, what would be the initial nursing Answers and Rationales
action of the nurse? D. Bathing an infant with eczema can be safely delegated to an aide;
examine the infant for any observable abnormalities this task is basic and can competently performed by an aid.
confirm identification of the infant and apply bracelet to mother and B. The RN floated from the telemetry unit would be least prepared
infant to care for a young infant who has just had GI surgery and requires a
instill prophylactic medication in the infant’s eyes specific feeding regimen.
wrap the infant in a prewarmed blanket and cover the head C. RN floated from the obstetrics unit should be able to care for a
43. A 2-year-old client is admitted to the hospital with severe eczema client with major abdominal surgery, because this nurse has
lesions on the scalp, face, neck and arms. The client is scratching the experienced caring for clients with cesarean births.
affected areas. What would be the best nursing intervention to A. The patient is experiencing a potentially serious complication
prevent the client from scratching the affected areas? related to diabetes and needs ongoing assessment by an RN
elbow restraints to the arms D. It describes functional nursing. Staff is assigned to specific task
Mittens to the hands rather than specific clients.
Clove-hitch restraints to the hands B. Case management. The nurse assumes total responsibility for
A posey jacket to the torso meeting the needs of the client during her entire duty.
44. The parents of the hospitalized client ask the nurse how their B. The nurse is ethically obligated to inform the person responsible
baby might have gotten pyloric stenosis. The appropriate nursing for the assignment and the person responsible for the unit about the
response would be: nurse’s skill level. The nurse therefore avoids a situation of
There is no way to determine this preoperatively abandoningclients and exposing them to greater risks
Their baby was born with this condition A. This describes a mentor
Their baby developed this condition during the first few weeks of life B. This action demonstrates a lack of responsibility and the nurse
Their baby acquired it due to a formula allergy should attempt negotiation with the nurse manager.
45. A male client comes to the clinic for check-up. In doing a physical B. The team leader is responsible for the overall management of all
assessment, the nurse should report to the physician the most clients and staff on the team, and this information is essential in
common symptom of gonorrhea, which is: order to accomplish this
pruritus C. Even though the mother is a minor, she is legally able to sign
pus in the urine consent for her own child.
WBC in the urine B. This response is the most direct and immediate. This is a case of
Dysuria potential need for advocacy and patient’s rights.
46. Which of the following would be the most important goal in the D. The nurse who witness a consent for treatment or surgery is
nursing care of an infant client with eczema? witnessing only that the client signed the form and that the client’s
preventing infection condition is as indicated at the time of signing. The nurse is not
maintaining the comfort level witnessing that the client is “informed”.
providing for adequate nutrition C. Although the statements by the mother may not create a
decreasing the itching suspicion of neglect, when they are coupled with observations about
47. The nurse is making a discharge instruction to a client receiving impaired bonding and maternal attachment, they may impose the
chemotherapy. The client is at risk for bone marrow depression. The obligation to report child neglect. The nurse is further obligated to
nurse gives instructions to the client about how to prevent infection notify caregivers of refusal to consent to treatment
at home. Which of the following health teaching would be included? C. It best explains what informed consent is and provides for legal
“Get a weekly WBC count” rights of the patient
“Do not share a bathroom with children or pregnant woman” B. The physician may not be aware of the role that religious beliefs
“Avoid contact with others while receiving chemotherapy” play in making a decision about surgery.
“Do frequent hand washing and maintain good hygiene” A. The behavior should be stopped. The first step is to remind the
48. The nurse is assigned to care the client with infectious disease. staff that confidentiality may be violated
The best antimicrobial agent for the nurse to use in handwashing is:
C. Waiting for emotions to dissipate and sitting down with the the aging process are just two of the contributing factors of
colleague is the first rule of conflict resolution. tuberculosis in the elderly.
C. The nurse has no idea who the person is on the phone and D. Parents should be taught to feel the area that is raised and
therefore may not share the information even if the patient gives measure only that.
permission C. It is a safety hazard to have shiny floors because they can cause
A. The priority is to let the surgeon know, who in turn may ask the falls.
husband to sign the consent. D. The first priority, beside maintaining a newborn’s patent airway, is
A. Phenytoin (Dilantin) can cause venous irritation due to its body temperature.
alkalinity, therefore it should be mixed with normal saline. B. The purpose of restraints for this child is to keep the child from
A. This position increases venous return, improves cardiac volume, scratching the affected areas. Mittens restraint would prevent
and promotes adequate ventilation and cerebral perfusion scratching, while allowing the most movement permissible.
D. Checking the airway would be a priority, and a neck injury should C. Pyloric stenosis is not a congenital anatomical defect, but the
be suspected precise etiology is unknown. It develops during the first few weeks of
D. Client with Parkinson’s disease are at a high risk for aspiration and life.
undernutrition. Sitting upright promotes more effective swallowing. B. Pus is usually the first symptom, because the bacteria reproduce
C. It is important to protect the RN’s eyes from the possible in the bladder.
contamination of coughed-up secretions A. Preventing infection in the infant with eczema is the nurse’s most
D. There has been too little food or too much insulin. Glucose levels important goal. The infant with eczema is at high risk for infection
can be markedly decreased (less than 50 mg/dl). Severe due to numerous breaks in the skin’s integrity. Intact skin is always
hypoglycemia may be fatal if not detected the infant’s first line of defense against infection.
D. Because the client’s ability to react to stress is decreased, D. Frequent hand washing and good hygiene are the best means of
maintaining a quiet environment becomes a nursing priority. preventing infection.
Dehydration is a common problem in Addison’s disease, so close D. CHG is a highly effective antimicrobial ingredient, especially when
observation of the client’s hydration level is crucial. it is used consistently over time.
D. Presuctioning and postsuctioning ventilation with 100% oxygen is A. The mother may have many reasons for such a decision. It is the
important in reducing hypoxemia which occurs when the flow of nurse’s responsibility to review this decision with the mother and
gases in the airway is obstructed by the suctioning catheter. clarify any misconceptions regarding immunizations that may exist.
B. This is an example of objective data of both pulmonary status and D. The tumor infiltrates nearby tissue, it can cause retraction of the
direct observation on the skin by the nurse. overlying skin and create a dimpling appearance.
C. These are likely signs of an acute myocardial infarction (MI). An
acute MI is a cardiovascular emergency requiring immediate SET 3
attention. Acute MI is potentially fatal if not treated immediately. 1. Which element in the circular chain of infection can be eliminated
D. Assessment and more data collection are needed. The client may by preserving skin integrity?
have gastrointestinal or neurological problems that account for the Host
symptoms. The anorexia could result from medications, poor Reservoir
dentition, or indigestion, and the bruises may be attributed to ataxia, Mode of transmission
frequent falls, vertigo or medication. Portal of entry
B. This is closest to suggesting action-assessment, rather than 2. Which of the following will probably result in a break in sterile
paperwork- and is therefore the best of the four. technique for respiratory isolation?
C. The only acceptable way to identify a preschooler client is to have Opening the patient’s window to the outside environment
a parent or another staff member identify the client. Turning on the patient’s room ventilator
C. It describes the mass in the greatest detail. Opening the door of the patient’s room leading into the
C. Intravenous pyelogram tests both the function and patency of the hospital corridor
kidneys. After the intravenous injection of a radiopaque contrast Failing to wear gloves when administering a bed bath
medium, the size, location, and patency of the kidneys can be 3. Which of the following patients is at greater risk for contracting
observed by roentgenogram, as well as the patency of the urethra an infection?
and bladder as the kidneys function to excrete the contrast medium. A patient with leukopenia
C. This is the recommended position for screening for scoliosis. It A patient receiving broad-spectrum antibiotics
allows the nurse to inspect the alignment of the spine, as well as to A postoperative patient who has undergone orthopedic surgery
compare both shoulders and both hips. A newly diagnosed diabetic patient
A. Handwashing is the best method for reducing 4. Effective hand washing requires the use of:
cross-contamination. Gowns and gloves are not always required Soap or detergent to promote emulsification
when entering a client’s room. Hot water to destroy bacteria
B. Pyloric stenosis is an anomaly of the upper gastrointestinal tract. A disinfectant to increase surface tension
The condition involves a thickening, or hypertrophy, of the pyloric All of the above
sphincter located at the distal end of the stomach. This causes a 5. After routine patient contact, hand washing should last at least:
mechanical intestinal obstruction, which leads to vomiting after 30 seconds
feeding the infant. The vomiting associated with pyloric stenosis is 1 minute
described as being projectile in nature. This is due to the increasing 2 minute
amounts of formula the infant begins to consume coupled with the 3 minutes
increasing thickening of the pyloric sphincter. 6. Which of the following procedures always requires surgical
B. Increased incidence of TB has been seen in the general population asepsis?
with a high incidence reported in hospitalized elderly clients. Vaginal instillation of conjugated estrogen
Immunosuppression and lack of classic manifestations because of 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 C. The edges of a sterile field are considered contaminated. When
Leg muscles sterile items are allowed to come in contact with the edges of the
Upper arm muscles field, the sterile items also become contaminated.
48.Thrombophlebitis typically develops in patients with which of the B. Hair on or within body areas, such as the nose, traps and
following conditions? holds particles that contain microorganisms. Yawning and hiccupping
Increases partial thromboplastin time do not prevent microorganisms from entering or leaving the body.
Acute pulsus paradoxus Rapid eye movement marks the stage of sleep during which
An impaired or traumatized blood vessel wall dreaming occurs.
Chronic Obstructive Pulmonary Disease (COPD) D. The inside of the glove is always considered to be clean, but not
49.In a recumbent, immobilized patient, lung ventilation can become sterile.
altered, leading to such respiratory complications as: A. The back of the gown is considered clean, the front is
Respiratory acidosis, ateclectasis, and hypostatic pneumonia contaminated. So, after removing gloves and washing hands, the
Appneustic breathing, atypical pneumonia and respiratory alkalosis nurse should untie the back of the gown; slowly move backward
Cheyne-Strokes respirations and spontaneous pneumothorax away from the gown, holding the inside of the gown and keeping the
Kussmail’s respirations and hypoventilation edges off the floor; turn and fold the gown inside out; discard it in a
50.Immobility impairs bladder elimination, resulting in such contaminated linen container; then wash her hands again.
disorders as B. According to the Centers for Disease Control (CDC),
Increased urine acidity and relaxation of the perineal blood-to-blood contact occurs most commonly when a health care
muscles, causing incontinence worker attempts to cap a used needle. Therefore, used needles
Urine retention, bladder distention, and infection should never be recapped; instead they should be inserted in a
Diuresis, natriuresis, and decreased urine specific gravity specially designed puncture resistant, labeled container. Wearing
Decreased calcium and phosphate levels in the urine gloves is not always necessary when administering an I.M. injection.
Answers and Rationales Enteric precautions prevent the transfer of pathogens via feces.
D. In the circular chain of infection, pathogens must be able to leave A. Nurses and other health care professionals previously believed
their reservoir and be transmitted to a susceptible host through a that massaging a reddened area with lotion would promote venous
portal of entry, such as broken skin. return and reduce edema to the area. However, research has shown
C. Respiratory isolation, like strict isolation, requires that the door to that massage only increases the likelihood of cellular ischemia and
the door patient’s room remain closed. However, the patient’s room necrosis to the area.
should be well ventilated, so opening the window or turning on the B. Before a blood transfusion is performed, the blood of the donor
ventricular is desirable. The nurse does not need to wear gloves for and recipient must be checked for compatibility. This is done by
respiratory isolation, but good hand washing is important for all blood typing (a test that determines a person’s blood type) and
types of isolation. cross-matching (a procedure that determines the compatibility of
A. Leukopenia is a decreased number of leukocytes (white blood the donor’s and recipient’s blood after the blood types has been
cells), which are important in resisting infection. None of the other matched). If the blood specimens are incompatible, hemolysis and
situations would put the patient at risk for contracting an infection; antigen-antibody reactions will occur.
taking broadspectrum antibiotics might actually reduce the infection A. Platelets are disk-shaped cells that are essential for blood
risk. coagulation. A platelet count determines the number of
A. Soaps and detergents are used to help remove bacteria because thrombocytes in blood available for promoting hemostasis and
of their ability to lower the surface tension of water and act as assisting with blood coagulation after injury. It also is used to
emulsifying agents. Hot water may lead to skin irritation or burns. evaluate the patient’s potential for bleeding; however, this is not its
A. Depending on the degree of exposure to pathogens, hand primary purpose. The normal count ranges from 150,000
washing may last from 10 seconds to 4 minutes. After routine to 350,000/mm3. A count of 100,000/mm3 or less indicates a
patient contact, hand washing for 30 seconds effectively minimizes potential for bleeding; count of less than 20,000/mm3 is associated
the risk of pathogen transmission. with spontaneous bleeding.
B. The urinary system is normally free of microorganisms except at D. Leukocytosis is any transient increase in the number of white
the urinary meatus. Any procedure that involves entering this system blood cells (leukocytes) in the blood. Normal WBC counts range from
must use surgically aseptic measures to maintain a bacteria-free 5,000 to 100,000/mm3. Thus, a count of 25,000/mm3 indicates
state. leukocytosis.
C. All invasive procedures, including surgery, catheter insertion, A. Fatigue, muscle cramping, and muscle weaknesses are symptoms
and administration of parenteral therapy, require sterile technique to of hypokalemia (an inadequate potassium level), which is a potential
maintain a sterile environment. All equipment must be sterile, and side effect of diuretic therapy. The physician usually orders
the nurse and the physician must wear sterile gloves and maintain supplemental potassium to prevent hypokalemia in patients
surgical asepsis. In the operating room, the nurse and physician are receiving diuretics. Anorexia is another symptom of hypokalemia.
required to wear sterile gowns, gloves, masks, hair covers, and shoe Dysphagia means difficulty swallowing.
covers for all invasive procedures. Strict isolation requires the use of A. Pregnancy or suspected pregnancy is the only contraindication for
clean gloves, masks, gowns and equipment to prevent the a chest X-ray. However, if a chest X-ray is necessary, the patient can
transmission of highly communicable diseases by contact or by wear a lead apron to protect the pelvic region from radiation.
airborne routes. Terminal disinfection is the disinfection of all Jewelry, metallic objects, and buttons would interfere with the X-ray
contaminated supplies and equipment after a patient has been and thus should not be worn above the waist. A signed consent is
discharged to prepare them for reuse by another patient. not required because a chest X-ray is not an invasive examination.
The purpose of protective (reverse) isolation is to prevent a person Eating, drinking and medications are allowed because the X-ray is of
with seriously impaired resistance from coming into contact who the chest, not the abdominal region.
potentially pathogenic organisms. 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 D. Capsules, enteric-coated tablets, and most extended duration
rash, even in individuals who have not been allergic to it previously. or sustained release products should not be dissolved for use in
Because of the danger of anaphylactic shock, he nurse should a gastrostomy tube. They are pharmaceutically manufactured in
withhold the drug and notify the physician, who may choose to these forms for valid reasons, and altering them destroys their
substitute another drug. Administering an antihistamine is a purpose. The nurse should seek an alternate physician’s order when
dependent nursing intervention that requires a written physician’s an ordered medication is inappropriate for delivery by tube.
order. Although applying corn starch to the rash may relieve D. A drug-allergy is an adverse reaction resulting from an
discomfort, it is not the nurse’s top priority in such a potentially immunologic response following a previous sensitizing exposure to
life-threatening situation. the drug. The reaction can range from a rash or hives to anaphylactic
D. The Z-track method is an I.M. injection technique in which the shock. Tolerance to a drug means that the patient experiences a
patient’s skin is pulled in such a way that the needle track is sealed decreasing physiologic response to repeated administration of the
off after the injection. This procedure seals medication deep into the drug in the same dosage. Idiosyncrasy is an individual’s unique
muscle, thereby minimizing skin staining and irritation. Rubbing the hypersensitivity to a drug, food, or other substance; it appears to be
injection site is contraindicated because it may cause the medication genetically determined. Synergism, is a drug interaction in which the
to extravasate into the skin. sum of the drug’s combined effects is greater than that of their
D. The vastus lateralis, a long, thick muscle that extends the full separate effects.
length of the thigh, is viewed by many clinicians as the site of choice D. A hemoglobin and hematocrit count would be ordered by the
for I.M. injections because it has relatively few major nerves and physician if bleeding were suspected. The other answers are
blood vessels. The middle third of the muscle is recommended as appropriate nursing interventions for a patient who has undergone
the injection site. The patient can be in a supine or sitting position femoral arteriography.
for an injection into this site. A. Coughing, a protective response that clears the respiratory tract
A. The mid-deltoid injection site can accommodate only 1 ml or less of irritants, usually is involuntary; however it can be voluntary, as
of medication because of its size and location (on the deltoid muscle when a patient is taught to perform coughing exercises. An
of the arm, close to the brachial artery and radial nerve). antitussive drug inhibits coughing. Splinting the abdomen supports
D. A 25G, 5/8” needle is the recommended size for insulin the abdominal muscles when a patient coughs.
injection because insulin is administered by the subcutaneous route. C. In an infected patient, shivering results from the body’s attempt
An 18G, 1 ½” needle is usually used for I.M. injections in children, to increase heat production and the production of neutrophils
typically in the vastus lateralis. A 22G, 1 ½” needle is usually used for and phagocytotic action through increased skeletal muscle tension
adult I.M. injections, which are typically administered in the vastus and contractions. Initial vasoconstriction may cause skin to feel cold
lateralis or ventrogluteal site. to the touch. Applying additional bed clothes helps to equalize the
D. Because an intradermal injection does not penetrate deeply into body temperature and stop the chills. Attempts to cool the body
the skin, a small-bore 25G needle is recommended. This type of result in further shivering, increased metabloism, and thus increased
injection is used primarily to administer antigens to evaluate heat production.
reactions for allergy or sensitivity studies. A 20G needle is usually D. A clinical nurse specialist must have completed a master’s degree
used for I.M. injections of oilbased medications; a 22G needle for in a clinical specialty and be a registered professional nurse. The
I.M. injections; and a 25G needle, for I.M. injections; and a 25G National League of Nursing accredits educational programs in
needle, for subcutaneous insulin injections. nursing and provides a testing service to evaluate student nursing
A. Parenteral penicillin can be administered I.M. or added to a competence but it does not certify nurses. The American Nurses
solution and given I.V. It cannot be administered subcutaneously or Association identifies requirements for certification and offers
intradermally. examinations for certification in many areas of nursing., such as
D. gr 10 x 60mg/gr 1 = 600 mg medical surgical nursing. These certification (credentialing)
C. 100ml/60 min X 15 gtt/ 1 ml = 25 gtt/minute demonstrates that the nurse has the knowledge and the ability to
A. Hemoglobinuria, the abnormal presence of hemoglobin in the provide high quality nursing care in the area of her certification.
urine, indicates a hemolytic reaction (incompatibility of the donor’s A graduate of an associate degree program is not a clinical nurse
and recipient’s blood). In this reaction, antibodies in the recipient’s specialist: however, she is prepared to provide bed side nursing with
plasma combine rapidly with donor RBC’s; the cells are hemolyzed in a high degree of knowledge and skill. She must successfully
either circulatory or reticuloendothelial system. Hemolysis occurs complete the licensing examination to become a registered
more rapidly in ABO incompatibilities than in Rh incompatibilities. professional nurse.
Chest pain and urticaria may be symptoms of impending D. Microorganisms usually do not grow in an acidic environment.
anaphylaxis. Distended neck veins are an indication of hypervolemia. D. Bile colors the stool brown. Any inflammation or obstruction that
C. In real failure, the kidney loses their ability to effectively impairs bile flow will affect the stool pigment, yielding light,
eliminate wastes and fluids. Because of this, limiting the patient’s clay-colored stool. Upper GI bleeding results in black or tarry stool.
intake of oral and I.V. fluids may be necessary. Fever, chronic Constipation is characterized by small, hard masses. Many
obstructive pulmonary disease, and dehydration are conditions for medications and foods will discolor stool – for example, drugs
which fluids should be encouraged. containing iron turn stool black.; beets turn stool red.
D. Phlebitis, the inflammation of a vein, can be caused by D. In the evaluation step of the nursing process, the nurse must
chemical irritants (I.V. solutions or medications), mechanical irritants decide whether the patient has achieved the expected outcome that
(the needle or catheter used during venipuncture or cannulation), or was identified in the planning phase.
a localized allergic reaction to the needle or catheter. Signs and A. The main sources of vitamin A are yellow and green vegetables
symptoms of phlebitis include pain or discomfort, edema and heat at (such as carrots, sweet potatoes, squash, spinach, collard greens,
the I.V. insertion site, and a red streak going up the arm or leg from broccoli, and cabbage) and yellow fruits (such as apricots, and
the I.V. insertion site. cantaloupe). Animal sources include liver, kidneys, cream, butter,
D. Return demonstration provides the most certain evidence for and egg yolks.
evaluating the effectiveness of patient teaching. 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 24. Using Maslow’s hierarchy of basic human needs, which of the
specimen from an indwelling catheter to prevent infection? following nursing diagnoses has the highest priority?
Use sterile gloves when obtaining urine. Ineffective breathing pattern related to pain, as evidenced by
Open the drainage bag and pour out the urine. shortness of breath.
Disconnect the catheter from the tubing and get urine. Anxiety related to impending surgery, as evidenced by insomnia.
Aspirate urine from the tubing port using a sterile syringe. Risk of injury related to autoimmune dysfunction
16. A client is receiving 115 ml/hr of continuous IVF. The nurse Impaired verbal communication related to tracheostomy, as
notices that the venipuncture site is red and swollen. Which of the evidenced by inability to speak.
following interventions would the nurse perform first? 25. When performing an abdominal examination, the patient should
Stop the infusion be in a supine position with the head of the bed at what position?
Call the attending physician 30 degrees
Slow that infusion to 20 ml/hr 90 degrees
Place a clod towel on the site 45 degrees
17. The nurse enters the room to give a prescribed medication but 0 degree
the patient is inside the bathroom. What should the nurse do? Answers and Rationales
Leave the medication at the bedside and leave the room. 1. (C) Respiratory rate greater than 20 breaths per minute. A
After few minutes, return to that patient’s room and do not leave respiratory rate of greater than 20 breaths per minute is tachypnea.
until the patient takes the medication. A blood pressure of 140/90 is considered hypertension. Pulse greater
Instruct the patient to take the medication and leave it at the than 100 beats per minute is tachycardia. Frequent bowel sounds
bedside. refer to hyper-active bowel sounds.
Wait for the patient to return to bed and just leave the medication at (A) Wheezes. Wheezes are indicated by continuous, lengthy, musical;
the bedside. heard during inspiration or expiration. Rhonchi are usually coarse
18. Which of the following is inappropriate nursing action when breath sounds. Gurgles are loud gurgling, bubbling sound. Vesicular
administering NGT feeding? breath sounds are low pitch, soft intensity on expiration.
Place the feeding 20 inches above the pint if insertion of NGT. (B) 37.95 degrees C. To convert °F to °C use this formula, ( °F – 32 )
Introduce the feeding slowly. (0.55). While when converting °C to °F use this formula, ( °C x 1.8) +
Instill 60ml of water into the NGT after feeding. 32. Note that 0.55 is 5/9 and 1.8 is 9/5.
Assist the patient in fowler’s position. (D) Trial and error. The trial and error method of problem solving
19. A female patient is being discharged after thyroidectomy. After isn’t systematic (as in the scientific method of problem solving)
providing the medication teaching. The nurse asks the patient to routine, or based on inner prompting (as in the intuitive method of
repeat the instructions. The nurse is performing which professional problem solving).
role? (C) Assessing, diagnosing, planning, implementing, evaluating. The
Manager correct order of the nursing process is assessing, diagnosing,
Caregiver planning, implementing, evaluating.
Patient advocate (C) Nursing care plan. The outcome, or the product of the planning
Educator phase of the nursing process is a Nursing care plan.
20. Which data would be of greatest concern to the nurse when (C) Client verbalized, “I feel pain when urinating.”. Subjective data
completing the nursing assessment of a 68-year-old woman are those that can be described only by the person experiencing it.
hospitalized due to Pneumonia? Therefore, only the patient can describe or verify whether he is
Oriented to date, time and place experiencing pain or not.
Clear breath sounds (C) “The patient will identify all the high-salt food from a prepared
Capillary refill greater than 3 seconds and buccal cyanosis list by discharge.”. Expected outcomes are specific, measurable,
Hemoglobin of 13 g/dl realistic statements of goal attainment. The phrases “right amount”,
21. During a change-of-shift report, it would be important for the “less nauseated” and “enough sleep” are vague and not measurable.
nurse relinquishing responsibility for care of the patient to (C) She signs on the medication sheet after administering the
communicate. Which of the following facts to the nurse assuming medication.A nurse should record a nursing intervention (ex. Giving
responsibility for care of the patient? medications) after performing the nursing intervention (not before).
That the patient verbalized, “My headache is gone.” Recording should also be done using a pen, be complete, and signed
That the patient’s barium enema performed 3 days ago was negative with the nurse’s full name and title.
Patient’s NGT was removed 2 hours ago (C) Concern for privacy. A patient’s privacy may be violated if security
Patient’s family came for a visit this morning. measures aren’t used properly or if policies and procedures aren’t in
22. Which statement is the most appropriate goal for a nursing place that determines what type of information can be retrieved, by
diagnosis of diarrhea? whom, and for what purpose.
“The patient will experience decreased frequency of bowel (B) Sister Callista Roy. Sister Roy’s theory is called the adaptation
elimination.” theory and she viewed each person as a unified biophysical system
“The patient will take anti-diarrheal medication.” in constant interaction with a changing environment. Orem’s theory
“The patient will give a stool specimen for laboratory examinations.” is called self-care deficit theory and is based on the belief that
“The patient will save urine for inspection by the nurse. individual has a need for self-care actions. King’s theory is the Goal
23. Which of the following is the most important purpose of attainment theory and described nursing as a helping profession that
planning care with this patient? assists individuals and groups in society to attain, maintain, and
Development of a standardized NCP. restore health. Henderson introduced the nature of nursing model
Expansion of the current taxonomy of nursing diagnosis and identified the 14 basic needs.
Making of individualized patient care (B) Nurse and patient. Although diagnosing is basically the nurse’s
Incorporation of both nursing and medical diagnoses in patient care 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 Midsagittal plane
than 6 months. Transverse plane
(C) It focuses on the patient, not the nurse. The nursing process is 6. A female patient with a terminal illness is in denial. Indicators of
patient-centered, not nurse-centered. It can be use in any setting, denial include:
and the steps are related. The nursing process can’t solve all patient Shock dismay
health problems. Numbness
(B) Diminished breath sounds in patient with previously normal Stoicism
breath sounds. Diminished breath sound is a life threatening Preparatory grief
problem therefore it is highly priority because they pose the greatest 7. The nurse in charge is transferring a patient from the bed to a
threat to the patient’s well-being. chair. Which action does the nurse take during this patient transfer?
(C) 3-day diet recall. 3-day diet recall is an example of dietary history. Position the head of the bed flat
This is used to indicate the adequacy of food intake of the client. Helps the patient dangle the legs
(B) teacher. The nurse will assume the role of a teacher in this Stands behind the patient
therapeutic relationship. The other roles are inappropriate in this Places the chair facing away from the bed
situation. 8. A female patient who speaks a little English has emergency
(C) Elevate the head of the bed. Elevating the head of the bed during gallbladder surgery, during discharge preparation, which nursing
an enteral feeding prevents aspiration. The patient may be placed on action would best help this patient understand wound care
the right side to prevent aspiration. Enteral feedings are given at instruction?
room temperature to lessen GI distress. The enteral tubing should be Asking frequently if the patient understands the instruction
changed every 24 hours to limit microbial growth. Asking an interpreter to replay the instructions to the patient.
(D) Increased rate and depth of respiration. Kussmaul breathing is Writing out the instructions and having a family member read them
also called as hyperventilation. Seen in metabolic acidosis and renal to the patient
failure. Option A refers to Biot’s breathing. Option B is apneustic Demonstrating the procedure and having the patient return the
breathing and option C is the Cheyne-stokes breathing. demonstration
(C) denial. The client is in denial stage because she is unready to face 9. Before administering the evening dose of a prescribed medication,
the reality that loss is happening and she assumes artificial the nurse on the evening shift finds an unlabeled, filled syringe in
cheerfulness. the patient’s medication drawer. What should the nurse in charge
(A) Primary. The primary level focuses on health promotion. do?
Secondary level focuses on health maintenance. Tertiary focuses on Discard the syringe to avoid a medication error
rehabilitation. There is n Curative level of preventive health care Obtain a label for the syringe from the pharmacy
problems. Use the syringe because it looks like it contains the same medication
(D) Patient stated, “My arms still hurt.”. Subjective data are apparent the nurse was prepared to give
only to the person affected and can or verified only by that person. Call the day nurse to verify the contents of the syringe
(C) Thyroid. The thyroid is part of the endocrine system. Heart, sinus 10. When administering drug therapy to a male geriatric patient, the
and thymus are not. nurse must stay especially alert for adverse effects. Which factor
makes geriatric patients to adverse drug effects?
1. Nurse Brenda is teaching a patient about a newly prescribed drug. Faster drug clearance
What could cause a geriatric patient to have difficulty retaining Aging-related physiological changes
knowledge about prescribed medications? Increased amount of neurons
Decreased plasma drug levels Enhanced blood flow to the GI tract
Sensory deficits 11. A female patient is being discharged after cataract surgery. After
Lack of family support providing medication teaching, the nurse asks the patient to repeat
History of Tourette syndrome the instructions. The nurse is performing which professional role?
2. When examining a patient with abdominal pain the nurse in Manager
charge should assess: Educator
Any quadrant first Caregiver
The symptomatic quadrant first Patient advocate
The symptomatic quadrant last 12. A female patient exhibits signs of heightened anxiety. Which
The symptomatic quadrant either second or third response by the nurse is most likely to reduce the patient’s anxiety?
3. The nurse is assessing a postoperative adult patient. Which of the “Everything will be fine. Don’t worry.”
following should the nurse document as subjective data? “Read this manual and then ask me any questions you may have.”
Vital signs “Why don’t you listen to the radio?”
Laboratory test result “Let’s talk about what’s bothering you.”
Patient’s description of pain 13. A scrub nurse in the operating room has which responsibility?
Electrocardiographic (ECG) waveforms Positioning the patient
4. A male patient has a soft wrist-safety device. Which assessment Assisting with gowning and gloving
finding should the nurse consider abnormal? Handling surgical instruments to the surgeon
A palpable radial pulse Applying surgical drapes
A palpable ulnar pulse 14. A patient is in the bathroom when the nurse enters to give a
Cool, pale fingers prescribed medication. What should the nurse in charge do?
Pink nail beds Leave the medication at the patient’s bedside
5. Which of the following planes divides the body longitudinally into Tell the patient to be sure to take the medication. And then leave it
anterior and posterior regions? at the bedside
Frontal plane Return shortly to the patient’s room and remain there until the
Sagittal plane 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