Review question 1-a client with bacterial pneumonia is coughing up tenacious, purulent sputum, which of the following measures

would most likely help liquefy these viscous secretions: Breathing humidified air

2-the single most effective way to decrease the spread of microorganism is: Frequent hand washing

3-which of the following technique for administering the mantox test is correct: Hold the needle and syringe almost parallel to the client`s skin

4-theophillin is administered to a client wit COPD to: Relax bronchial smooth muscles

5-the nurse teaches the client with COPD to assess for signs and symptoms of right sided heart failure which include: Ankle edema

6-to help control the client`s pain during coughing the nurse should: Raise the bed to semi fowler, position and place one hand on the client`s back on the left side and one hand under the incision

7-when caring for a client with chest tube and water seal drainage system, the nurse should: Ensure that the collection and suction bottles are below the client`s chest level at all times

8-in a chest tube water seal drainage system, cessation of fluid fluctuation in chest tube and water seal column generally means that the: Lung has fully expanded

9-the nurse observe a constant gentle bubbling in the water seal column of water seal drainage system , this observation should prompt the nurse to: Check the connectors between the chest and drainage tubs and where the drainage tube enters the collection bottle

10-the client who underwent a lobectomy and has a water seal chest drainage system is breathing with little effort and at faster rate than one hour ago, the client pulse rate increased, the nurse should: Check the tubing to ensure that the client is not lying on it or kinking it

11-which of the following items should be ready available at the bed side of a client with chest tube in place: Rubber capped hemostats

12-the client`s chest tube is connected to chest tube drainage system with a water seal the nurse notes that the fluid in the water seal column is fluctuating with each breath the client takes, the fluctuating means: The chest tube is functioning properly

13-which of the following findings suggest pneumothorax in a trauma victim: Absent breath sounds

14-oxygen toxicity results from oxygen concentration above: 40%

15-aclient chest tube to be removed, which of the following items the nurse should have ready to place directly over the wound when the chest tube removed: Petroleum gauze dressing

16-expected out comes after administering IV furocemide (lasix) include; Increase urine output

17-of the following factors which appear most closely linked with the development of coronary artery disease: Diet

18-crackles heard on lung auscultation indicate: Fluid filled alveoli

19-in which of the following position should the nurse place the client with heart failure: High fowler`s position

20-dioxin is administered for the client with heart failure because the drug acts to: Increase myocardial contractility

21-the nurse teaches the client with heart failure to take furocemide (lasix) in the morning the primary reason for this is to help: Prevent sleep disturbance during night

22-the client`s chest tube accidently disconnects from drainage tube which of the following actions the nurse take first: Clamp the chest tube

23-essential hypertension would be diagnosed in a 40 year old man whose blood pressure readings were consistently at or above: 140/90

24-long term complications of hypertension include: Renal failure

25-the physician refer the client for cardiac catheterization the nurse explains to the client that this procedure is used to: Assess the extent of arterial blockage

26-the client ask the nurse what information does ECG provide, the nurse replies: Electrical conduction of the myocardium

27-to determine that chest compression are necessary the rescuer: Palpate the carotid pulse for one minute

28-of the following observation the one most recommended for determining the effectiveness of CPR: Pupils are reacting to light

29-what is the compression to-ventilation ratio for one rescuer CPR: 15:2

30-What is the estimated time a person can be without cardiopulmonary function and still not experience permanent brain damage: 4 to 6 minutes 4

31-in none of the following bed a position is contraindicated which position would be preferred for the client which hypovolemic shock: Supine with legs elevated 15 degrees.

32-the client with iron deficiency (anemia) should be instructed to eat which of the following food containing high iron: Eggs

33- The last of senses to lapse into unconscious is thought to be: Hearing

34-Which one of the following is important indicator for shock: Tachycardia

35-immediately after gastrointestinal endoscopy what should the nurse evaluate beside his vital signs: Return of gags reflex

36-which of the following symptoms would the nurse most likely observe in a client with cholecystitis: Nausea after ingestion of high fat food

37-if a gallstone becomes ledged in common bile duct, the nurse should anticipate that the clients stool would likely be: Gray (white)

38-which of the following signs and symptoms would be an early indication that the clients serum potassium level is below normal: 5

Muscle weakness in legs 39-after subtotal gastrectomy, care of the clients nasogastric tube NGT and drainage system should include which of the following intervention: Monitor the client for nausea, vomiting and abdominal distention.

40-after gastric resection surgery, which of the following signs and symptoms would alert the nurse to the development of leaking anastomosis: Pane, fever and abdominal rigidity

41- The initial diagnosis of pancreatitis would be confirmed if the clients blood work showed a significant elevation in serum: Amylase

42-for a clients with a nasogastric tube attached to suction postoperatively intravenous replacement therapy will be needed primarily to: Maintain fluid and electrolyte balance

43-which of the following techniques is considered the best way to determine whether a NGT is positioned in the stomach: Aspirate with a syringe and observing for the return of gastric contents.

44- As part of the client teaching plan the nurse would instruct the client to take which of the medication after the barium enema: A laxative

45-a client had a NGT inserted at the time of surgery, this tube will be removed when the clients demonstrate: Passage of flatus and feces from the colostomy.

46- The nurse irrigates the clients colostomy, if the client complains of abdominal pain after resaving 150m of solution during colostomy irrigation the nurse should temporarily: Stop the flow of solution.

47-the nurse would expect which of the following symptoms during the acute phase of hepatitis A: Yellow sclera ( ictrus sclera )

48-the causative virus of hepatitis A will be excreted from the clients body primarily through the: Feces

49-which of the following precautions is not essential to care of client with hepatitis A: Assigning the client to private room

50- Which of the following situation would most likely expose the nurse to the hepatitis B virus? Spraying the client blood into the nurses eyes.

51-which position would be ideal for the client in the early postoperative period after hemorrhoidectomy: Side lying (lateral)

52-nernousness, irritability and difficulty sleeping are symptoms of Graves disease are: Weight gain

53-measurse to prevent eye damage from exophthalmoses includes: Taping the eyelids closed with nonirritating tape

54-which of the following symptoms might indicate that the client was developing tetany after subtotal thyroidectomy: Tingling of the fingers

55- Which of the following medication should be available to provide emergency treatment if the client develops tetany after thyroidectomy: Calcium gluconate

56-signs and symptoms of hypothyroidism include: Weight gain

57-when teaching a client with diabetes DM about foot care the nurse should instruct him to: Avoid going barefoot

58-the nurse should teach the client that the most common symptoms of hypoglycemia are: Nervousness and diaphoresis

59-what is the most important reason to recognize and treat hypoglycemia in the client with diabetes mellitus DM: Hypoglycemia can lead to brain damage

60-the client is receiving intravenous infusion of 5% dextrose in normal saline running at rate 125ml / hour when hanging new bottle of fluid the nurse notes

swelling and hardness at the infusion site which immediate action would be indicated: Apply a warm dressing to the site

61-which of the following is the best indicator for determining whether the client with addiso,s disease is receiving the correct amount of glucocortoid (cortisone) replacement: Daily weight

62-which of the following signs and symptoms would indicate that the client with Addisons disease is receiving too much glucocortoid (cortisone) replacement: Rapid weight gain

63-when examining the client with Cushings syndrome the nurse would expect to find: Bruised area in the skin

64-because of steroid excess the client who has undergone a bilateral adrenalectomy is at risk for: Delayed wound healing

65-which of the following postoperative complications would the nurse anticipate in a client undergoing a pelvic surgery: Thrombophlebitise

66-when teaching the client to care for his ileal conduit the nurse instructs him to empty the appliance frequently to help prevent: Interruption of urine production

67-the client is schedule for an intravenous pyelogram (IVP) to determine the location of the stone which of the following measures would be most important for the nurse to include in pretest preparation: Checking his history for allergy to iodine

68-which of the following best indicates that the clients peristaltic activity is returning to normal: The client passes flatus

69-after completion of dialysis the nurse would expect the client to exhibit: Weight loss

70-the physician prescribed 0.4 mg of atropine to be given intramuscular the stock ampule of atropine contains 0.8 mg / ml how much of the drug will be in the syringe to give the ordered does: 2-0.5ml

71-the physician prescribed 0.75 mg ofmepridine to be given intramuscular the stock ampule of mepridine contains 100 mg/ml how much of the drug will be in the syringe to give the ordered does : 2-0.75ml

72-atropine sulfate is ordered is included in preoperative orders the primary reason for giving this drug is that it helps: Inhibit oral and respiratory secretions

73-during the clients urinary catheterization the bladder is emptied gradually the best rational for the nurses action is that emptying an over distended bladder completely at one time tends to cause : Abdominal cramping and pain

10

74-the client has continuous bladder irrigation after prostatectomy a major goal related to the irrigation is to: Maintain catheter patency

75-in which of the following circumstances would the nurse increase the flow rate of the continuous bladder irrigation: When the irrigation is continuous but slow

76-symptoms of gonorrhea in males include: Impotence

77-the nurse assesses the client frequently for signs of increasing intracranial pressure include: Decreasing systolic blood pressure

78-the nurse obtains a specimen from a clear fluid that is draining from the clients nose to determine whether this fluid is mucous or cerebrospinal fluid CSF it should be tested for: Glucose

79-which of the following position would be most appropriate for a client with head injury: Head of the bed elevated 30 to 45 degrees

80-the nurse enters the clients room as the client who is sitting in a chair, begins to have a seizures, which of the following actions should the nurse take first: Ease the client to the floor

11

81-a priority goal for the client after the seizures subsided is to: Maintain a patent airway

82-which of the following assessment findings lead the nurse to suspect that the coma is a result of a toxic drug overdoes: Dilated pupils

83-which of the following position would be most appropriate for the client with coma during gastric lavage: Lateral

84-in emergency treatment for the client with aspirin (salicylate) toxicity which of the following medication should the nurse has available: Vitamin

85-the client has been positioned on his side which of the following area would be a pressure point in this position: Ankles

86-when administering intermittent enteral feeding for a client the nurse should implement which of the following actions: Place the client in semi fowlers position

87-the client is to receive 200 ml of tube feeding, the nurse checked the clients gastric residual before the feeding and obtains 40ml of gastric residual what should the nurse do next: Read minister the residual to the client and continue with the feeding

12

88-of the following actions the nurse could take when providing catheter care which have the highest priority: Clamping the catheter periodically to maintain muscle tone

89-which of the following statement is correct about pain, the level of pain: Perception varies widely from person to person

90-after administering an intramuscular injection with a disposable syringe, the nurse should dispose the needle and syringe by: Leaving the needle uncapped and disposing of needle and syringe in the universal container

91-the nurse would assess the client for which important symptoms of aspirin toxicity: Chest pain

92-the clients physician orders ibuprofen to treat the left hip pain, to minimize gastric mucosal discomfort, the nurse should teach the client to take the medicine: Immediately after meal

93-which of the following assessment indicates that the client has a typical sign of hip fracture the clients leg is: Shorter than the unaffected leg

94-the nurse anticipates that the client will return from surgery with a drainage tube in the incision site attached to suction, the purpose of this apparatus is to help: Prevent accumulation of fluids in the wound

13

95-the nurse should teach the client that which leg is contraindicated for him when sitting in chair postoperative: Elevating his legs

96-which of the following clinical manifestations would be most indicative of complete arterial obstruction in the lower extremities: Coldness

97-what would be the most important intervention in caring for the clients residual limb during the first 24 hours after surgery of amputated leg: Elevate the residual limb on a pillow

98-it is determined that the client has not had any immunization for tetanus since childhood, which of the following products would be used to provide the client with passive immunity for tetanus: Tetanus antigen

99-which of the following symptoms would the nurse most likely note if the client develops fat embolism: Numbness in the legs

100-the priority concern when planning to move a person with possible spinal cord injury: Immobilize the head and neck to prevent further injury

101-the nurse is to instill drops of phenylephrine (new-synephrine) into the clients eye before cataract removal surgery, this preparation acts in the eye to produce: Dilate the pupils and blood vessels

14

102-which of the following activates would be appropriate for achieving the goal of decreasing intraocular pressure after eye surgery, the client will avoid: Coughing

103-which of the following activities would be contraindicated after eye surgery: Bending over the sink to wash his hair

104-which of the following would be a priority goal for a client who has undergone surgery for retinal detachment: Increase intraocular pressure

105-the symptoms of glaucoma include: Excessive tearing

106-miotics are frequently used in the basic treatment of glaucoma the nurse should understand that meiotic work by: Constricting the pupils

107-the client with glaucoma is scheduled for minor surgical procedure, which of the following orders would require correction before the nurse would carry it out: Administer morphine sulfate

108-which of the following would be an important initial clue to the client that bleeding was occurring even the nasal pad remains dry and intact: Repeated swallowing

109-which of the following instruction should the nurse give for a woman about managing nasal bleeding for her daughter:

15

Place the child in a sitting position with her neck bent forward and applies firm pressure on the nasal septum

110-the client receives tube feeding after laryngectomy, the primary rational for tube feeding in this situation would be to: Allow for adequate suture line healing

111-which of the following measure should the nurse perform in relation to suctioning the tracheostomy tube: Administer a high concentration of oxygen before suctioning the client

112-the longest period the nurse should suction a client at one time is: 5 to 10 seconds

113-when suctioning a tracheostomy or laryngectomy tube, it is recommended that the nurse use a : Sterile catheter with each suctioning, and discard

114-outcomes criteria for evaluating the effectiveness of airway suctioning would include which of the following: Breath sounds clear on auscultation

115-which of the following would provide the best emergency care for a burn victim at the accident site: Applying clean, dry dressing to the area

116-using the rule of nines, if the clients burned area include right are, right leg and anterior trunk, about what percentage of the clients body has been burned: 45% 16

117-when balanced the clients burned hand the nurse should make certain that: The hand and finger surfaces do not touch

118-which of the following electrolyte imbalance would the anticipate in the emergent phase of burn care: Hyperkalemia

119-during the first 24 to 72 hours of fluid replacement after a major burn injury, the intravenous infusion rate will be adjusted by evaluating the clients: Hourly urine output

120-the nurse assess the clients burned right arm and notes increasing edema, absence of radial pulse and decreased sensation in the fingers, based on these data, the nurses priority response should be to : Notify the physician immediately

121-which of the following activities should the nurse include on the clients care plan to be carried one half hour before his daily dressing change: Administer analgesic

122-which of the following complications believed to be due to hyper secretion of gastric acid in a burned client: Gastric ulceration

123-after hip surgery which of the following position used to prevent hip flexion and contraction: Supine

17

124-nursing assessment of a newborn reveals an imperforate anus the nurse would expect further physical assessment to reveal: Abdominal distention

125-while in the emergency room , the client with appendicitis complanes of sever abdominal pain,the nurses most appropriate action to help manage the pain would be to obtain an order for: An intravenous narcotic

126-while the primagravida client is lying supine on examination table, she tells the nurse that she is feeling dizzy after observing that the client is pale and perspiring the nurse should: Turn the client to her left side

127-the nurse assess the client for possible risk factors for PIH, which of the following would be the most important for the nurse to assess: Proteinuria

128-while caring for the pregnant diabetic client in labor, the nurse plans to: Monitor blood glucose level every one hour

129-the physician ordered vitamin K intramuscular for the neonate the nurse should explain to the mother that this medication will b e injected to prevent: Bleeding disorders

130-in addition to immunization for DPT during the first 6 months of life, the nurse should administer which other immunization: Hepatitis

18

131-the nurse should administer poliomyelitis immunization by what rout: Oral

132-when the child returns from operating room after tonsillectomy the nurse will place him in which of the following position: Prone

133-a young child who has undergone a tonsillectomy refuses to let the nurse to look to tonsillar bed to check for bleeding to assess whether the child is bleeding from tonsillar bed which of the following would be most appropriate: Observe for frequent swallowing

134-the nurse prepares to discharge a 5 years old child, the nurse leaves the room to get supplies then, when she returns she finds the child is not breathing, which of the following nursing measures the nurse should initiate first: Clear the airway

135-because effective chest compression depends on proper technique, the nurse should apply pressure for a 5 year child chest: Midway on the sternum with tips of two fingers

136-in which position should the nurse place an infant to deliver back blows: Face down with the head lower than the trunk

137-what would be the flow rate of 1000 ml of dextrose 5% to be given over 6 hours? The infusion ser deliver 15 gtts/ml: Gtts/minute

19

138-the nurse cares for a multigravida in active labor observes a variable fetal heart rate declaration pattern the nurse should first: Contact the clients physician

139-a client was recently diagnosed with deep vein thrombosis in her right leg the nurse should incorporate which of the following activities in the plan: Assess the edema of the leg every 4 hours

140-which of the following statement indicate that the client understands the instructions to follow at home after cataract surgery: I should not bend over to pick up objects from the floor

141-umbilical cord prolapsed occur after spontaneous rupture of membranes which of the following should the nurse does immediately: Cover the cord with sterile towel

142-the nurse has an order to administer scopolamine 0.3 mg IM the medication is available in a vial that contains 0.4 mg/ml, how many ml should the nurse prepare to administer: 0.75ml

143-when administering an IM injection to a neonate, which of the following muscle the nurse would consider as the best site for injection: Vastus lateralis

144-morphine 8 mg IM has been ordered for the client, the ampoule label reads 15mg/ml, how many ml the nurse will give: 0.53ml

20

145-the physician ordered dioxin0.15mg PO daily for a child, the pharmacy supplies the dioxin in liquid from at a concentration of 0.05mg/ml, how much of the medication should the nurse administer at each time: 3ml

146-which of the following clinical manifestations would be most indicative of complete arterial obstruction in lower extremity: Coldness

147-for the client experiencing delirium the nurse prioritizes intervention to first maintain: Physical safety

148-the client states he washes his feet endlessly because they are so dirty that I cannot put on my socks and shoes, the nurse recognize the client is using ritualistic behavior primarily to relieve discomfort associated with feeling of: Depression

149-a client complains of difficulty swallowing when the nurse tries to administer medication in capsule from, what should the nurse do to solve this problem: Check for availability of liquid preparation

150-when giving an IM injection, the nurse should insert the needle into the muscle at an angle of: 90 degree

151-when teaching a client how to take sublingual tablet, the nurse should instruct the client to place the tablet on: Floor of the tongue

21

152-the nurse teaches the client how to rerate insulin injection sites, what is the purpose of rotating injection sites: To prevent formation of hard nodules

153-the nurse caring for a client taking anticoagulant, the nurse should instruct the client to: Avoid taking food rich in vitamin K

154-the client is to receive an IV infusion of 3.000ml of D5S solution over 24hours, the nurse observes that the rate is 150ml/hour if the solution runs continuously at this rate, the solution will be completed in: 20hours

155-the physician prescribed 250mg of a drug, the drug vial reads 500mg/ml, how much of the drug the nurse should give: 1/2ml

156-which of the following must be included in a medication order: Physicians signature

157-the nurse notes that an IV site in a clients hand has infiltrated causing localized pain and swelling, which intervention would relive the clients discomfort effectively: Elevating the hand and wrapping it with a warm towel

158-the nurse is monitoring the effectiveness of a clients drug therapy, when the nurse should obtain a blood sample to measure the drug level: 30minutes after administering the next does

22

159-the physician ordered 7.500units of heparin to be given subcutaneously every 6hours, the vial reads 10.000 units per ml the nurse should give how much heparin in each does: 3/4ml

160-after a client receives an IM injection, he complains of pain in the injection site, which nursing action would be best to take at this time: Apply warm compress to dilate blood vessels

161-which nursing intervention takes highest priority, when caring for a client who is receiving a blood transfusion: Instruct the client to report any itching, swelling or dyspnea

162-which safeguard should the nurse take to ensure accuracy with a telephone order: Repeat the order to the prescriber

163-the nurse prepares to administer an enema, what is the most common client position used for this procedure: Sims left lateral

164-the medication order reads *meperidine 1ml IM stat*, the nurse responsible for administering the drug should base the next action on which understanding: The order is correct and valid

165-the nurse is evaluating postoperative client for infection, which signs or symptoms would be most indicative of infection: Rectal temperature of 100 F (37.8c)

23

166-which of the following would be a priority nursing intervention for a 6year old child admitted with third degree burn: Starting an IV line

167-the nurse plans to administer an injection of heparin, which of the following techniques for heparin administration is appropriate, the nurse: Apply gentle pressure to the site 5 to 10 seconds after the injection

168-for a child receiving steroids in therapeutic doses over long period, the nurse should: Monitor the childs serum glucose

169-the client returns from surgery for nasal surgery, they would anticipate placing him in which position: Left side

170-on the second day postpartum after cesarean delivery, the client complains of gas pain, the nurse should instruct the client to do which of the following: Ambulate more often

171-a client has a soft wrist safety device, which assessment findings should the nurse consider abnormal: Cool, pale fingers

172-the physician ordered aniembolism stockings, the nurse is teaching the client about this treatment, what is the purpose of antiembolism stockings: To decrease and prevent edema in the legs and feet

24

173-which action by the nurse is essential when cleaning the area around a wound drain: Cleaning from the center to out ward in a circular motion

174-the client blood test result as follows white blood count (WBC) is 1.000 hemoglobin level 14gm, hematocrete 42%, which of the following goals would be most important for this client: Prevent infection

175-when leaving the room of a client in a isolation, the nurse should remove which protective equipment first: Gloves

176-the nurse assigned to a client with cardiac disorder, when monitoring body temperature for the client, the nurse should avoid which rout: Rectal

177-ascrub nurse in the operating room has which responsibility: Handling surgical instruments to the surgeon

178-when placing a folly catheter in a female client, the nurse should advanced the catheter how far into the urethra: 1-2 inches (5cm)

179-the normal level of PH in the blood is : 7.35-7.45

180-when bandaging a clients ankle the nurse should use which technique: Figure-eight 25

181-a hospitalized client is being fed through a naogastric tube (NGT), during feeding, the client vomits and begins choking, which of the following action is most appropriate for the nurse to take: Clear the clients airway

182-the client has left-side paralysis the clinical term for this condition is: Hemiplegia

183-to evaluate the client for hypoxia, the physician is most likely to order which laboratory test: Arterial blood gas (ABG)

184-which of the following assessment by the nurse contraindicates the application of heating pads: Active bleeding

185-the nurse notes the following assessment regarding the clients peripheral vascular status: cramping leg pain relieved by rest, pale feet and delayed capillary refilling, based on these data, the nurse should make a nursing diagnosis of: Ineffective peripheral tissue perfusion

186-which of the following laboratory test should be monitored closely by the nurse while the client is receiving heparin therapy: Activated partial thromboplastine time (APTT)

187-the nurse has administered mannitol IV, which of the following is a priority assessment for the nurse to make after administering this drug: Monitor urinary output

26

188-increased intracranial pressure is suspected in a 4 year-old child exhibiting a decreased level of consciousness, which of the following assessment findings would also be of most concern to the nurse: Blood pressure of 122/74mm Hg

189-when preparing to give a child with insulin dependent diabetes his dose of regular (RI) and (NPH) humuline insulin, which of the following actions would be most appropriate: Withdrawing the RI insulin first, then withdrawing the NPH into one syringe

190-durind the first 48-72 hours of fluids replacement therapy after a major burn injury, the intravenous infusion rate will be adjusted by evaluating the clients: Hourly urine output

191-which of the nursing measures would the nurse institute to help reduce eyelid edema in a child with nephritic syndrome: Apply cool compresses to the childs eyes

192-which of the following methods would the nurse use to feed an infant after surgical repair of cleft lip: Gastric gavages

193-the nurse should understand that the primary reason for withholding food and fluids from the client who will receive general anesthesia is to help prevent: Vomiting and possible aspiration of vomitus during surgery

194-the nurse caring for a child with leukemia should place a priority on: Monitoring the childs temperature

27

28