TEST I - Foundation of Professional Nursing

Practice
1. The nurse In-charge in labor and delivery unit
administered a dose of
terbutaline to a client without checking the clients
pulse. The standard that
would be used to determine if the nurse was
negligent is:
a. The physicians orders.
b. The action of a clinical nurse specialist who is
recognized expert in
the field.
c. The statement in the drug literature about
administration of
terbutaline.
d. The actions of a reasonably prudent nurse with
similar education
and experience.

2. Nurse Trish is caring for a female client with a
history of GI bleeding,
sickle cell disease, and a platelet count of
22,000/l. The female client is
dehydrated and receiving dextrose 5% in half-
normal saline solution at
150 ml/hr. The client complains of severe bone pain
and is scheduled to
receive a dose of morphine sulfate. In administering
the medication, Nurse
Trish should avoid which route?
a. I.V
b. I.M
c. Oral
d. S.C

3. Dr. Garcia writes the following order for the client
who has been recently
admitted Digoxin .125 mg P.O. once daily. To
prevent a dosage error,
how should the nurse document this order onto the
medication
administration record?
a. Digoxin .1250 mg P.O. once daily
b. Digoxin 0.1250 mg P.O. once daily
c. Digoxin 0.125 mg P.O. once daily
d. Digoxin .125 mg P.O. once daily

4. A newly admitted female client was diagnosed
with deep vein thrombosis.
Which nursing diagnosis should receive the highest
priority?
a. Ineffective peripheral tissue perfusion related to
venous congestion.
b. Risk for injury related to edema.
c. Excess fluid volume related to peripheral vascular
disease.
d. Impaired gas exchange related to increased
blood flow.

5. Nurse Betty is assigned to the following clients.
The client that the nurse
would see first after endorsement?
a. A 34 year-old post operative appendectomy client
of five hours who
is complaining of pain.
b. A 44 year-old myocardial infarction (MI) client
who is complaining of
nausea.
c. A 26 year-old client admitted for dehydration
whose intravenous
(IV) has infiltrated.
d. A 63 year-old post operatives abdominal
hysterectomy client of
three days whose incisional dressing is saturated
with
serosanguinous fluid.
6. Nurse Gail places a client in a four-point restraint
following orders from the
physician. The client care plan should include:
a. Assess temperature frequently.
b. Provide diversional activities.
c. Check circulation every 15-30 minutes.
d. Socialize with other patients once a shift.
7. A male client who has severe burns is receiving
H2 receptor antagonist
therapy. The nurse In-charge knows the purpose of
this therapy is to:
a. Prevent stress ulcer
b. Block prostaglandin synthesis
c. Facilitate protein synthesis.
d. Enhance gas exchange
8. The doctor orders hourly urine output
measurement for a postoperative
male client. The nurse Trish records the following
amounts of output for 2
consecutive hours: 8 a.m.: 50 ml; 9 a.m.: 60 ml.
Based on these amounts,
which action should the nurse take?
a. Increase the I.V. fluid infusion rate
b. Irrigate the indwelling urinary catheter
c. Notify the physician
d. Continue to monitor and record hourly urine
output
9. Tony, a basketball player twist his right ankle
while playing on the court
and seeks care for ankle pain and swelling. After
the nurse applies ice to
the ankle for 30 minutes, which statement by Tony
suggests that ice
application has been effective?
a. My ankle looks less swollen now.
b. My ankle feels warm.
c. My ankle appears redder now.
d. I need something stronger for pain relief

10.The physician prescribes a loop diuretic for a
client. When administering
this drug, the nurse anticipates that the client may
develop which
electrolyte imbalance?
a. Hypernatremia
b. Hyperkalemia
c. Hypokalemia
d. Hypervolemia

11.She finds out that some managers have
benevolent-authoritative style of
management. Which of the following behaviors will
she exhibit most likely?
a. Have condescending trust and confidence in their
subordinates.
b. Gives economic and ego awards.
c. Communicates downward to staffs.
d. Allows decision making among subordinates.

12. Nurse Amy is aware that the following is true
about functional nursing.
a. Provides continuous, coordinated and
comprehensive nursing
services.
b. One-to-one nurse patient ratio.
c. Emphasize the use of group collaboration.
d. Concentrates on tasks and activities.

13.Which type of medication order might read
"Vitamin K 10 mg I.M. daily 3
days?"
a. Single order
b. Standard written order
c. Standing order
d. Stat order

14.A female client with a fecal impaction frequently
exhibits which clinical
manifestation?
a. Increased appetite
b. Loss of urge to defecate
c. Hard, brown, formed stools
d. Liquid or semi-liquid stool

15.Nurse Linda prepares to perform an otoscopic
examination on a female
client. For proper visualization, the nurse should
position the client's ear
by:
a. Pulling the lobule down and back
b. Pulling the helix up and forward
c. Pulling the helix up and back
d. Pulling the lobule down and forward

16. Which instruction should nurse Tom give to a
male client who is having
external radiation therapy:
a. Protect the irritated skin from sunlight.
b. Eat 3 to 4 hours before treatment.
c. Wash the skin over regularly.
d. Apply lotion or oil to the radiated area when it is
red or sore.

17.In assisting a female client for immediate
surgery, the nurse In-charge is
aware that she should:
a. Encourage the client to void following
preoperative medication.
b. Explore the clients fears and anxieties about the
surgery.
c. Assist the client in removing dentures and nail
polish.
d. Encourage the client to drink water prior to
surgery.

18. A male client is admitted and diagnosed with
acute pancreatitis after a
holiday celebration of excessive food and alcohol.
Which assessment
finding reflects this diagnosis?
a. Blood pressure above normal range.
b. Presence of crackles in both lung fields.
c. Hyperactive bowel sounds
d. Sudden onset of continuous epigastric and back
pain.

19. Which dietary guidelines are important for nurse
Oliver to implement in
caring for the client with burns?
a. Provide high-fiber, high-fat diet
b. Provide high-protein, high-carbohydrate diet.
c. Monitor intake to prevent weight gain.
d. Provide ice chips or water intake.

20.Nurse Hazel will administer a unit of whole
blood, which priority
information should the nurse have about the client?
a. Blood pressure and pulse rate.
b. Height and weight.
c. Calcium and potassium levels
d. Hgb and Hct levels.

21. Nurse Michelle witnesses a female client
sustain a fall and suspects that
the leg may be broken. The nurse takes which
priority action?
a. Takes a set of vital signs.
b. Call the radiology department for X-ray.
c. Reassure the client that everything will be alright.
d. Immobilize the leg before moving the client.

22.A male client is being transferred to the nursing
unit for admission after
receiving a radium implant for bladder cancer. The
nurse in-charge would
take which priority action in the care of this client?
a. Place client on reverse isolation.
b. Admit the client into a private room.
c. Encourage the client to take frequent rest
periods.
d. Encourage family and friends to visit.

23.A newly admitted female client was diagnosed
with agranulocytosis. The
nurse formulates which priority nursing diagnosis?
a. Constipation
b. Diarrhea
c. Risk for infection
d. Deficient knowledge

24.A male client is receiving total parenteral
nutrition suddenly demonstrates
signs and symptoms of an air embolism. What is
the priority action by the
nurse?
a. Notify the physician.
b. Place the client on the left side in the
Trendelenburg position.
c. Place the client in high-Fowlers position.
d. Stop the total parenteral nutrition.

25.Nurse May attends an educational conference
on leadership styles. The
nurse is sitting with a nurse employed at a large
trauma center who states
that the leadership style at the trauma center is
task-oriented and
directive. The nurse determines that the leadership
style used at the
trauma center is:
a. Autocratic.
b. Laissez-faire.
c. Democratic.
d. Situational

26.The physician orders DS 500 cc with KCl 10
mEq/liter at 30 cc/hr. The
nurse in-charge is going to hang a 500 cc bag. KCl
is supplied 20 mEq/10
cc. How many ccs of KCl will be added to the IV
solution?
a. .5 cc
b. 5 cc
c. 1.5 cc
d. 2.5 cc

27.A child of 10 years old is to receive 400 cc of IV
fluid in an 8 hour shift.
The IV drip factor is 60. The IV rate that will deliver
this amount is:
a. 50 cc/ hour
b. 55 cc/ hour
c. 24 cc/ hour
d. 66 cc/ hour

28.The nurse is aware that the most important
nursing action when a client
returns from surgery is:
a. Assess the IV for type of fluid and rate of flow.
b. Assess the client for presence of pain.
c. Assess the Foley catheter for patency and urine
output
d. Assess the dressing for drainage.

29. Which of the following vital sign assessments
that may indicate
cardiogenic shock after myocardial infarction?
a. BP 80/60, Pulse 110 irregular
b. BP 90/50, Pulse 50 regular
c. BP 130/80, Pulse 100 regular
d. BP 180/100, Pulse 90 irregular

30.Which is the most appropriate nursing action in
obtaining a blood pressure
measurement?
a. Take the proper equipment, place the client in a
comfortable
position, and record the appropriate information in
the clients chart.
b. Measure the clients arm, if you are not sure of
the size of cuff to
use.
c. Have the client recline or sit comfortably in a
chair with the forearm
at the level of the heart.
d. Document the measurement, which extremity
was used, and the
position that the client was in during the
measurement.

31.Asking the questions to determine if the person
understands the health
teaching provided by the nurse would be included
during which step of the
nursing process?
a. Assessmen t
b. Evaluation
c. Implementation
d. Planning and goals

32.Which of the following item is considered the
single most important factor
in assisting the health professional in arriving at a
diagnosis or
determining the persons needs?
a. Diagnostic test results
b. Biographical date
c. History of present illness
d. Physical examination

33.In preventing the development of an external
rotation deformity of the hip
in a client who must remain in bed for any period of
time, the most
appropriate nursing action would be to use:
a. Trochanter roll extending from the crest of the
ileum to the midthigh.
b. Pillows under the lower legs.
c. Footboard
d. Hip-abductor pillow

34.Which stage of pressure ulcer development does
the ulcer extend into the
subcutaneous tissue?
a. Stage I
b. Stage II
c. Stage III
d. Stage IV

35.When the method of wound healing is one in
which wound edges are not
surgically approximated and integumentary
continuity is restored by
granulations, the wound healing is termed
a. Second intention healing
b. Primary intention healing
c. Third intention healing
d. First intention healing

36.An 80-year-old male client is admitted to the
hospital with a diagnosis of
pneumonia. Nurse Oliver learns that the client lives
alone and hasnt been
eating or drinking. When assessing him for
dehydration, nurse Oliver
would expect to find:
a. Hypothermia
b. Hypertension
c. Distended neck veins
d. Tachycardia

37.The physician prescribes meperidine (Demerol),
75 mg I.M. every 4 hours
as needed, to control a clients postoperative pain.
The package insert is
Meperidine, 100 mg/ml. How many milliliters of
meperidine should the
client receive?
a. 0.75
b. 0.6
c. 0.5
d. 0.25

38. A male client with diabetes mellitus is receiving
insulin. Which statement
correctly describes an insulin unit?
a. Its a common measurement in the metric
system.
b. Its the basis for solids in the avoirdupois system.
c. Its the smallest measurement in the apothecary
system.
d. Its a measure of effect, not a standard measure
of weight or
quantity.

39.Nurse Oliver measures a clients temperature at
102 F. What is the
equivalent Centigrade temperature?
a. 40.1 C
b. 38.9 C
c. 48 C
d. 38 C

40.The nurse is assessing a 48-year-old client who
has come to the
physicians office for his annual physical exam. One
of the first physical
signs of aging is:
a. Accepting limitations while developing assets.
b. Increasing loss of muscle tone.
c. Failing eyesight, especially close vision.
d. Having more frequent aches and pains.

41.The physician inserts a chest tube into a female
client to treat a
pneumothorax. The tube is connected to water-seal
drainage. The nurse
in-charge can prevent chest tube air leaks by:
a. Checking and taping all connections.
b. Checking patency of the chest tube.
c. Keeping the head of the bed slightly elevated.
d. Keeping the chest drainage system below the
level of the chest.

42.Nurse Trish must verify the clients identity
before administering
medication. She is aware that the safest way to
verify identity is to:
a. Check the clients identification band.
b. Ask the client to state his name.
c. State the clients name out loud and wait a client
to repeat it.
d. Check the room number and the clients name on
the bed.

43.The physician orders dextrose 5 % in water,
1,000 ml to be infused over 8
hours. The I.V. tubing delivers 15 drops/ml. Nurse
John should run the I.V.
infusion at a rate of:
a. 30 drops/minute
b. 32 drops/minute
c. 20 drops/minute
d. 18 drops/minute

44.If a central venous catheter becomes
disconnected accidentally, what
should the nurse in-charge do immediately?
a. Clamp the catheter
b. Call another nurse
c. Call the physician
d. Apply a dry sterile dressing to the site.

45.A female client was recently admitted. She has
fever, weight loss, and
watery diarrhea is being admitted to the facility.
While assessing the client,
Nurse Hazel inspects the clients abdomen and
notice that it is slightly
concave. Additional assessment should proceed in
which order:
a. Palpation, auscultation, and percussion.
b. Percussion, palpation, and auscultation.
c. Palpation, percussion, and auscultation.
d. Auscultation, percussion, and palpation.

46. Nurse Betty is assessing tactile fremitus in a
client with pneumonia. For
this examination, nurse Betty should use the:
a. Fingertips
b. Finger pads
c. Dorsal surface of the hand
d. Ulnar surface of the hand

47. Which type of evaluation occurs continuously
throughout the teaching and
learning process?
a. Summative
b. Informative
c. Formative
d. Retrospective

48.A 45 year old client, has no family history of
breast cancer or other risk
factors for this disease. Nurse John should instruct
her to have
mammogram how often?
a. Twice per year
b. Once per year
c. Every 2 years
d. Once, to establish baseline

49.A male client has the following arterial blood gas
values: pH 7.30; Pao2 89
mmHg; Paco2 50 mmHg; and HCO3 26mEq/L.
Based on these values,
Nurse Patricia should expect which condition?
a. Respiratory acidosis
b. Respiratory alkalosis
c. Metabolic acidosis
d. Metabolic alkalosis

50.Nurse Len refers a female client with terminal
cancer to a local hospice.
What is the goal of this referral?
a. To help the client find appropriate treatment
options.
b. To provide support for the client and family in
coping with terminal
illness.
c. To ensure that the client gets counseling
regarding health care
costs.
d. To teach the client and family about cancer and
its treatment.

51.When caring for a male client with a 3-cm stage I
pressure ulcer on the
coccyx, which of the following actions can the nurse
institute
independently?
a. Massaging the area with an astringent every 2
hours.
b. Applying an antibiotic cream to the area three
times per day.
c. Using normal saline solution to clean the ulcer
and applying a
protective dressing as necessary.
d. Using a povidone-iodine wash on the ulceration
three times per
day.

52.Nurse Oliver must apply an elastic bandage to a
clients ankle and calf. He
should apply the bandage beginning at the clients:
a. Knee
b. Ankle
c. Lower thigh
d. Foot

53.A 10 year old child with type 1 diabetes develops
diabetic ketoacidosis
and receives a continuous insulin infusion. Which
condition represents the
greatest risk to this child?
a. Hypernatremia
b. Hypokalemia
c. Hyperphosphatemia
d. Hypercalcemia

54.Nurse Len is administering sublingual
nitrglycerin (Nitrostat) to the newly
admitted client. Immediately afterward, the client
may experience:
a. Throbbing headache or dizziness
b. Nervousness or paresthesia.
c. Drowsiness or blurred vision.
d. Tinnitus or diplopia.

55.Nurse Michelle hears the alarm sound on the
telemetry monitor. The nurse
quickly looks at the monitor and notes that a client
is in a ventricular
tachycardia. The nurse rushes to the clients room.
Upon reaching the
clients bedside, the nurse would take which action
first?
a. Prepare for cardioversion
b. Prepare to defibrillate the client
c. Call a code
d. Check the clients level of consciousness

56.Nurse Hazel is preparing to ambulate a female
client. The best and the
safest position for the nurse in assisting the client is
to stand:
a. On the unaffected side of the client.
b. On the affected side of the client.
c. In front of the client.
d. Behind the client.

57.Nurse Janah is monitoring the ongoing care
given to the potential organ
donor who has been diagnosed with brain death.
The nurse determines
that the standard of care had been maintained if
which of the following
data is observed?
a. Urine output: 45 ml/hr
b. Capillary refill: 5 seconds
c. Serum pH: 7.32
d. Blood pressure: 90/48 mmHg

58. Nurse Amy has an order to obtain a urinalysis
from a male client with an
indwelling urinary catheter. The nurse avoids which
of the following, which
contaminate the specimen?
a. Wiping the port with an alcohol swab before
inserting the syringe.
b. Aspirating a sample from the port on the drainage
bag.
c. Clamping the tubing of the drainage bag.
d. Obtaining the specimen from the urinary drainage
bag.

59.Nurse Meredith is in the process of giving a
client a bed bath. In the
middle of the procedure, the unit secretary calls the
nurse on the intercom
to tell the nurse that there is an emergency phone
call. The appropriate
nursing action is to:
a. Immediately walk out of the clients room and
answer the phone
call.
b. Cover the client, place the call light within reach,
and answer the
phone call.
c. Finish the bed bath before answering the phone
call.
d. Leave the clients door open so the client can be
monitored and the
nurse can answer the phone call.

60. Nurse Janah is collecting a sputum specimen
for culture and sensitivity
testing from a client who has a productive cough.
Nurse Janah plans to
implement which intervention to obtain the
specimen?
a. Ask the client to expectorate a small amount of
sputum into the
emesis basin.
b. Ask the client to obtain the specimen after
breakfast.
c. Use a sterile plastic container for obtaining the
specimen.
d. Provide tissues for expectoration and obtaining
the specimen.

61. Nurse Ron is observing a male client using a
walker. The nurse
determines that the client is using the walker
correctly if the client:
a. Puts all the four points of the walker flat on the
floor, puts weight on
the hand pieces, and then walks into it.
b. Puts weight on the hand pieces, moves the
walker forward, and
then walks into it.
c. Puts weight on the hand pieces, slides the walker
forward, and then
walks into it.
d. Walks into the walker, puts weight on the hand
pieces, and then
puts all four points of the walker flat on the floor.

62.Nurse Amy has documented an entry regarding
client care in the clients
medical record. When checking the entry, the nurse
realizes that incorrect
information was documented. How does the nurse
correct this error?
a. Erases the error and writes in the correct
information.
b. Uses correction fluid to cover up the incorrect
information and
writes in the correct information.
c. Draws one line to cross out the incorrect
information and then
initials the change.
d. Covers up the incorrect information completely
using a black pen
and writes in the correct information

63.Nurse Ron is assisting with transferring a client
from the operating room
table to a stretcher. To provide safety to the client,
the nurse should:
a. Moves the client rapidly from the table to the
stretcher.
b. Uncovers the client completely before
transferring to the stretcher.
c. Secures the client safety belts after transferring to
the stretcher.
d. Instructs the client to move self from the table to
the stretcher.

64.Nurse Myrna is providing instructions to a
nursing assistant assigned to
give a bed bath to a client who is on contact
precautions. Nurse Myrna
instructs the nursing assistant to use which of the
following protective
items when giving bed bath?
a. Gown and goggles
b. Gown and gloves
c. Gloves and shoe protectors
d. Gloves and goggles

65. Nurse Oliver is caring for a client with impaired
mobility that occurred as a
result of a stroke. The client has right sided arm and
leg weakness. The
nurse would suggest that the client use which of the
following assistive
devices that would provide the best stability for
ambulating?
a. Crutches
b. Single straight-legged cane
c. Quad cane
d. Walker

66.A male client with a right pleural effusion noted
on a chest X-ray is being
prepared for thoracentesis. The client experiences
severe dizziness when
sitting upright. To provide a safe environment, the
nurse assists the client
to which position for the procedure?
a. Prone with head turned toward the side
supported by a pillow.
b. Sims position with the head of the bed flat.
c. Right side-lying with the head of the bed elevated
45 degrees.
d. Left side-lying with the head of the bed elevated
45 degrees.

67.Nurse John develops methods for data
gathering. Which of the following
criteria of a good instrument refers to the ability of
the instrument to yield
the same results upon its repeated administration?
a. Validity
b. Specificity
c. Sensitivity
d. Reliability

68.Harry knows that he has to protect the rights of
human research subjects.
Which of the following actions of Harry ensures
anonymity?
a. Keep the identities of the subject secret
b. Obtain informed consent
c. Provide equal treatment to all the subjects of the
study.
d. Release findings only to the participants of the
study

69.Patients refusal to divulge information is a
limitation because it is beyond
the control of Tifanny.
What type of research is appropriate for this study?
a. Descriptive- correlational
b. Experiment
c. Quasi-experiment
d. Historical.

70.Nurse Ronald is aware that the best tool for data
gathering is?
a. Interview schedule
b. Questionnaire
c. Use of laboratory data
d. Observation

71.Monica is aware that there are times when only
manipulation of study
variables is possible and the elements of control or
randomization are not
attendant. Which type of research is referred to
this?
a. Field study
b. Quasi-experiment
c. Solomon-Four group design
d. Post-test only design

72.Cherry notes down ideas that were derived from
the description of an
investigation written by the person who conducted
it. Which type of
reference source refers to this?
a. Footnote
b. Bibliography
c. Primary source
d. Endnotes

73.When Nurse Trish is providing care to his
patient, she must remember that
her duty is bound not to do doing any action that will
cause the patient
harm. This is the meaning of the bioethical principle:
a. Non-maleficence
b. Beneficence
c. Justice
d. Solidarity

74.When a nurse in-charge causes an injury to a
female patient and the injury
caused becomes the proof of the negligent act, the
presence of the injury
is said to exemplify the principle of:
a. Force majeure
b. Respondeat superior
c. Res ipsa loquitor
d. Holdover doctrine

75.Nurse Myrna is aware that the Board of Nursing
has quasi-judicial power.
An example of this power is:
a. The Board can issue rules and regulations that
will govern the
practice of nursing
b. The Board can investigate violations of the
nursing law and code of
ethics
c. The Board can visit a school applying for a permit
in collaboration
with CHED
d. The Board prepares the board examinations

76. When the license of nurse Krina is revoked, it
means that she:
a. Is no longer allowed to practice the profession for
the rest of her life
b. Will never have her/his license re-issued since it
has been revoked
c. May apply for re-issuance of his/her license
based on certain
conditions stipulated in RA 9173
d. Will remain unable to practice professional
nursing

77.Ronald plans to conduct a research on the use
of a new method of pain
assessment scale. Which of the following is the
second step in the
conceptualizing phase of the research process?
a. Formulating the research hypothesis
b. Review related literature
c. Formulating and delimiting the research problem
d. Design the theoretical and conceptual framework

78. The leader of the study knows that certain
patients who are in a
specialized research setting tend to respond
psychologically to the
conditions of the study. This referred to as :
a. Cause and effect
b. Hawthorne effect
c. Halo effect
d. Horns effect

79.Mary finally decides to use judgment sampling
on her research. Which of
the following actions of is correct?
a. Plans to include whoever is there during his
study.
b. Determines the different nationality of patients
frequently admitted
and decides to get representations samples from
each.
c. Assigns numbers for each of the patients, place
these in a fishbowl
and draw 10 from it.
d. Decides to get 20 samples from the admitted
patients

80. The nursing theorist who developed
transcultural nursing theory is:
a. Florence Nightingale
b. Madeleine Leininger
c. Albert Moore
d. Sr. Callista Roy
81.Marion is aware that the sampling method that
gives equal chance to all
units in the population to get picked is:
a. Random
b. Accidental
c. Quota
d. Judgment

82.John plans to use a Likert Scale to his study to
determine the:
a. Degree of agreement and disagreement
b. Compliance to expected standards
c. Level of satisfaction
d. Degree of acceptance

83.Which of the following theory addresses the four
modes of adaptation?
a. Madeleine Leininger
b. Sr. Callista Roy
c. Florence Nightingale
d. Jean Watson

84.Ms. Garcia is responsible to the number of
personnel reporting to her. This
principle refers to:
a. Span of control
b. Unity of command
c. Downward communication
d. Leader

85.Ensuring that there is an informed consent on
the part of the patient
before a surgery is done, illustrates the bioethical
principle of:
a. Beneficence
b. Autonomy
c. Veracity
d. Non-maleficence

86.Nurse Reese is teaching a female client with
peripheral vascular disease
about foot care; Nurse Reese should include which
instruction?
a. Avoid wearing cotton socks.
b. Avoid using a nail clipper to cut toenails.
c. Avoid wearing canvas shoes.
d. Avoid using cornstarch on feet.

87.A client is admitted with multiple pressure ulcers.
When developing the
client's diet plan, the nurse should include:
a. Fresh orange slices
b. Steamed broccoli
c. Ice cream
d. Ground beef patties

88.The nurse prepares to administer a cleansing
enema. What is the most
common client position used for this procedure?
a. Lithotomy
b. Supine
c. Prone
d. Sims left lateral

89.Nurse Marian is preparing to administer a blood
transfusion. Which action
should the nurse take first?
a. Arrange for typing and cross matching of the
clients blood.
b. Compare the clients identification wristband with
the tag on the unit
of blood.
c. Start an I.V. infusion of normal saline solution.
d. Measure the clients vital signs.

90.A 65 years old male client requests his
medication at 9 p.m. instead of 10
p.m. so that he can go to sleep earlier. Which type
of nursing intervention
is required?
a. Independent
b. Dependent
c. Interdependent
d. Intradependent

91.A female client is to be discharged from an acute
care facility after
treatment for right leg thrombophlebitis. The Nurse
Betty notes that the
client's leg is pain-free, without redness or edema.
The nurse's actions
reflect which step of the nursing process?
a. Assessment
b. Diagnosis
c. Implementation
d. Evaluation

92.Nursing care for a female client includes
removing elastic stockings once
per day. The Nurse Betty is aware that the rationale
for this intervention?
a. To increase blood flow to the heart
b. To observe the lower extremities
c. To allow the leg muscles to stretch and relax
d. To permit veins in the legs to fill with blood.

93.Which nursing intervention takes highest priority
when caring for a newly
admitted client who's receiving a blood transfusion?
a. Instructing the client to report any itching,
swelling, or dyspnea.
b. Informing the client that the transfusion usually
take 1 . to 2 hours.
c. Documenting blood administration in the client
care record.
d. Assessing the clients vital signs when the
transfusion ends.

94.A male client complains of abdominal discomfort
and nausea while
receiving tube feedings. Which intervention is most
appropriate for this
problem?
a. Give the feedings at room temperature.
b. Decrease the rate of feedings and the
concentration of the formula.
c. Place the client in semi-Fowler's position while
feeding.
d. Change the feeding container every 12 hours.
95.Nurse Patricia is reconstituting a powdered
medication in a vial. After
adding the solution to the powder, she nurse
should:
a. Do nothing.
b. Invert the vial and let it stand for 3 to 5 minutes.
c. Shake the vial vigorously.
d. Roll the vial gently between the palms.

96.Which intervention should the nurse Trish use
when administering oxygen
by face mask to a female client?
a. Secure the elastic band tightly around the client's
head.
b. Assist the client to the semi-Fowler position if
possible.
c. Apply the face mask from the client's chin up over
the nose.
d. Loosen the connectors between the oxygen
equipment and
humidifier.

97.The maximum transfusion time for a unit of
packed red blood cells (RBCs)
is:
a. 6 hours
b. 4 hours
c. 3 hours
d. 2 hours

98.Nurse Monique is monitoring the effectiveness of
a client's drug therapy.
When should the nurse Monique obtain a blood
sample to measure the
trough drug level?
a. 1 hour before administering the next dose.
b. Immediately before administering the next dose.
c. Immediately after administering the next dose.
d. 30 minutes after administering the next dose.

99.Nurse May is aware that the main advantage of
using a floor stock system
is:
a. The nurse can implement medication orders
quickly.
b. The nurse receives input from the pharmacist.
c. The system minimizes transcription errors.
d. The system reinforces accurate calculations.

100. Nurse Oliver is assessing a client's abdomen.
Which finding should the
nurse report as abnormal?
a. Dullness over the liver.
b. Bowel sounds occurring every 10 seconds.
c. Shifting dullness over the abdomen.
d. Vascular sounds heard over the renal arteries.