c



 
 

c


  1. Answer: (D) The actions of a reasonably
1. The nurse In-charge in labor and delivery unit administered a dose of
terbutaline to a client without checking the client͛s pulse. The standard that
would be used to determine if the nurse was negligent is:
a. The physician͛s 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/ʅl. 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 daily͟
b. ͞Digoxin 0.1250 mg P.O. once daily͟
c. ͞Digoxin 0.125 mg P.O. once daily͟
d. ͞Digoxin .125 mg P.O. once daily͟
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
prudent nurse with similar education and
experience.
Rationale: The standard of care is determined
by the average degree of skill, care, and
diligence by nurses in similar circumstances.
2. Answer: (B) I.M
Rationale: With a platelet count of 22,000/ʅl,
the clients tends to bleed easily. Therefore, the
nurse should avoid using the I.M. route because
the area is a highly vascular and can bleed
readily when penetrated by a needle. The
bleeding can be difficult to stop.
3. Answer: (C) ͞Digoxin 0.125 mg P.O. once
daily͟
Rationale: The nurse should always place a zero
before a decimal point so that no one misreads
the figure, which could result in a dosage
error. The nurse should never insert a zero at
the end of a dosage that includes a decimal
point because this could be misread, possibly
leading to a tenfold increase in the dosage.
4. Answer: (A) Ineffective peripheral tissue
perfusion related to venous congestion.
Rationale: Ineffective peripheral tissue
perfusion related to venous congestion takes
the highest priority because venous
inflammation and clot formation impede blood
flow in a client with deep vein thrombosis.
5. Answer: (B) A 44 year-old myocardial
infarction (MI) client who is complaining of
nausea.
Rationale: Nausea is a symptom of impending
myocardial infarction (MI) and should be
assessed immediately so that treatment can be
instituted and further damage to the heart is
avoided.
6. Answer: (C) Check circulation every 15-30
minutes.
Rationale: Restraints encircle the limbs, which
place the client at risk for circulation being
restricted to the distal areas of the extremities.
Checking the client͛s circulation every 15-30
minutes will allow the nurse to adjust the
restraints before injury from decreased blood
flow occurs.
7. Answer: (A) Prevent stress ulcer
infiltrated. Rationale: Curling͛s ulcer occurs as a
d. A 63 year-old post operative͛s abdominal hysterectomy client of three days generalized stress response in burn patients.
whose incisional dressing is saturated with serosanguinous fluid. This results in a decreased production of mucus
and increased secretion of gastric acid. The best
treatment for this prophylactic use of antacids
6. Nurse Gail places a client in a four-point restraint following orders from the and H2 receptor blockers.
physician. The client care plan should include:
8. Answer: (D) Continue to monitor and record
a. Assess temperature frequently. hourly urine output
b. Provide diversional activities. Rationale: Normal urine output for an adult is
c. Check circulation every 15-30 minutes. approximately 1 ml/minute (60 ml/hour).
d. Socialize with other patients once a shift. Therefore, this client's output is normal.
Beyond continued evaluation, no nursing action
is warranted.
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: 9. Answer: (B) ͞My ankle feels warm͟.
Rationale: Ice application decreases pain and
a. Prevent stress ulcer swelling. Continued or increased pain, redness,
b. Block prostaglandin synthesis and increased warmth are signs of
c. Facilitate protein synthesis. inflammation that shouldn't occur after ice
d. Enhance gas exchange application

10. Answer: (B) Hyperkalemia

8. The doctor orders hourly urine output measurement for a postoperative Rationale: A loop diuretic removes water and,
male client. The nurse Trish records the following amounts of output for 2 along with it, sodium and potassium. This may
consecutive hours: 8 a.m.: 50 ml; 9 a.m.: 60 ml. Based on these amounts, result in hypokalemia, hypovolemia,
which action should the nurse take? and hyponatremia.

a. Increase the I.V. fluid infusion rate 11. Answer:(A) Have condescending trust and
b. Irrigate the indwelling urinary catheter confidence in their subordinates
c. Notify the physician Rationale: Benevolent-authoritative managers
d. Continue to monitor and record hourly urine output pretentiously show their trust and confidence
to their followers.

9. Tony, a basketball player twist his right ankle while playing on the court and 12. Answer: (A) Provides continuous,
seeks care for ankle pain and swelling. After the nurse applies ice to the ankle coordinated and comprehensive nursing
for 30 minutes, which statement by Tony suggests that ice application has services.
been effective? Rationale: Functional nursing is focused on
tasks and activities and not on the care of the
a. ͞My ankle looks less swollen now͟. patients.
b. ͞My ankle feels warm͟.
c. ͞My ankle appears redder now͟. 13. Answer: (B) Standard written order
d. ͞I need something stronger for pain relief͟ Rationale: This is a standard written order.
Prescribers write a single order for medications
given only once. A stat order is written for
10.The physician prescribes a loop diuretic for a client. When administering medications given immediately for an urgent
this drug, the nurse anticipates that the client may develop which electrolyte client problem. A standing order, also known as
imbalance? a protocol, establishes guidelines for treating a
particular disease or set of symptoms in special
a. Hypernatremia care areas such as the coronary care unit.
b. Hyperkalemia Facilities also may institute medication
c. Hypokalemia protocols that specifically designate drugs that
a nurse may not give.
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?"
14. Answer: (D) Liquid or semi-liquid stools
Rationale: Passage of liquid or semi-liquid
stools results from seepage of unformed bowel
contents around the impacted stool in the
rectum. Clients
with fecal impaction don't pass hard, brown,
formed stools because the feces can't move
past the impaction. These clients typically
report the urge
to defecate (although they can't pass stool) and
a decreased appetite.
15. Answer: (C) Pulling the helix up and back
Rationale: To perform an otoscopic
examination on an adult, the nurse grasps the
helix of the ear and pulls it up and back to
straighten the ear canal. For a child, the nurse
grasps the helix and pulls it down to straighten
the ear canal. Pulling the lobule in any direction
wouldn't straighten the ear canal for
visualization.

a. Single order 16. Answer: (A) Protect the irritated skin from
b. Standard written order sunlight.
c. Standing order Rationale: Irradiated skin is very sensitive and
d. Stat order must be protected with clothing or sunblock.
The priority approach is the avoidance of strong
sunlight.
14.A female client with a fecal impaction frequently exhibits which clinical
manifestation? 17. Answer: (C) Assist the client in removing
dentures and nail polish.
a. Increased appetite Rationale: Dentures, hairpins, and combs must
b. Loss of urge to defecate be removed. Nail polish must be removed so
c. Hard, brown, formed stools that cyanosis can be easily monitored by
d. Liquid or semi-liquid stools observing the nail beds.

18. Answer: (D) Sudden onset of continuous

15.Nurse Linda prepares to perform an otoscopic examination on a female epigastric and back pain.
client. For proper visualization, the nurse should position the client's ear by: Rationale: The autodigestion of tissue by the
pancreatic enzymes results in pain from
a. Pulling the lobule down and back inflammation, edema, and possible
b. Pulling the helix up and forward hemorrhage. Continuous, unrelieved epigastric
c. Pulling the helix up and back or back pain reflects the inflammatory process
d. Pulling the lobule down and forward in the pancreas.

19. Answer: (B) Provide high-protein, high-

16. Which instruction should nurse Tom give to a male client who is having carbohydrate diet.
external radiation therapy: Rationale: A positive nitrogen balance is
important for meeting metabolic needs, tissue
a. Protect the irritated skin from sunlight. repair, and resistance to infection. Caloric goals
b. Eat 3 to 4 hours before treatment. may be as high as 5000 calories per day.
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 client͛s 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
20. Answer: (A) Blood pressure and pulse rate.
Rationale: The baseline must be established to
recognize the signs of an anaphylactic or
hemolytic reaction to the transfusion.
21. Answer: (D) Immobilize the leg before
moving the client.
Rationale: If the nurse suspects a fracture,
splinting the area before moving the client is
imperative. The nurse should call for
emergency help if the client is not hospitalized
and call for a physician for the hospitalized
client.
22. Answer: (B) Admit the client into a private
room.
Rationale: The client who has a radiation
implant is placed in a private room and has a
limited number of visitors. This reduces the
exposure of others to the radiation.
23. Answer: (C) Risk for infection
Rationale: Agranulocytosis is characterized by a
reduced number of leukocytes (leucopenia) and
neutrophils (neutropenia) in the blood. The
client is at high risk for infection because of the
decreased body defenses against
microorganisms. Deficient knowledge related to
the nature of the disorder may be appropriate
diagnosis but is not the priority.
24. Answer: (B) Place the client on the left side
in the Trendelenburg position.
Rationale: Lying on the left side may prevent air
from flowing into the pulmonary veins. The
Trendelenburg position increases intrathoracic
pressure, which decreases the amount of blood
pulled into the vena cava during aspiration.
25. Answer: (A) Autocratic.
Rationale: The autocratic style of leadership is a
task-oriented and directive.
26. Answer: (D) 2.5 cc
Rationale: 2.5 cc is to be added, because only a
500 cc bag of solution is being medicated
instead of a 1 liter.
27. Answer: (A) 50 cc/ hour
Rationale: A rate of 50 cc/hr. The child is to
receive 400 cc over a period of 8 hours = 50
cc/hr.
which priority action in the care of this client? 28. Answer: (B) Assess the client for presence of
pain.
a. Place client on reverse isolation. Rationale: Assessing the client for pain is a very
b. Admit the client into a private room. important measure. Postoperative pain is an
c. Encourage the client to take frequent rest periods. indication of complication. The nurse should
d. Encourage family and friends to visit. also assess the client for pain to provide for the
client͛s comfort.

23.A newly admitted female client was diagnosed with agranulocytosis. The 29. Answer: (A) BP ʹ 80/60, Pulse ʹ 110
nurse formulates which priority nursing diagnosis? irregular
Rationale: The classic signs of cardiogenic shock
a. Constipation are low blood pressure, rapid and weak
b. Diarrhea irregular pulse, cold, clammy skin, decreased
c. Risk for infection urinary output, and cerebral hypoxia.
d. Deficient knowledge
30. Answer: (A) Take the proper equipment,
place the client in a comfortable position, and
24.A male client is receiving total parenteral nutrition suddenly demonstrates record the appropriate information in the
signs and symptoms of an air embolism. What is the priority action by the client͛s chart.
nurse? Rationale: It is a general or comprehensive
statement about the correct procedure, and it
a. Notify the physician. includes the basic ideas which are found in the
b. Place the client on the left side in the Trendelenburg position. other options
c. Place the client in high-Fowlers position.
d. Stop the total parenteral nutrition. 31. Answer: (B) Evaluation
Rationale: Evaluation includes observing the
person, asking questions, and comparing the
25.Nurse May attends an educational conference on leadership styles. The patient͛s behavioral responses with the
nurse is sitting with a nurse employed at a large trauma center who states that expected outcomes.
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: 32. Answer: (C) History of present illness
Rationale: The history of present illness is the
a. Autocratic. single most important factor in assisting the
b. Laissez-faire. health professional in arriving at a diagnosis or
c. Democratic. determining the person͛s needs.
d. Situational
33. Answer: (A) Trochanter roll extending from
the crest of the ileum to the mid-thigh.
26.The physician orders DS 500 cc with KCl 10 mEq/liter at 30 cc/hr. The nurse Rationale: A trochanter roll, properly placed,
in-charge is going to hang a 500 cc bag. KCl is supplied 20 mEq/10 cc. How provides resistance to the external rotation of
many cc͛s of KCl will be added to the IV solution? the hip.

a. .5 cc 34. Answer: (C) Stage III

b. 5 cc Rationale: Clinically, a deep crater or without
c. 1.5 cc undermining of adjacent tissue is noted.
d. 2.5 cc
35. Answer: (A) Second intention healing
Rationale: When wounds dehisce, they will
27.A child of 10 years old is to receive 400 cc of IV fluid in an 8 hour shift. The allowed to heal by secondary intention
IV drip factor is 60. The IV rate that will deliver this amount is:
36. Answer: (D) Tachycardia
a. 50 cc/ hour Rationale: With an extracellular fluid or plasma
volume deficit, compensatory mechanisms
b. 55 cc/ hour stimulate the heart, causing an increase in
c. 24 cc/ hour heart rate.
d. 66 cc/ hour
37. Answer: (A) 0.75
Rationale: To determine the number of
28.The nurse is aware that the most important nursing action when a client milliliters the client should receive, the nurse
returns from surgery is: uses the fraction method in the following
equation.
a. Assess the IV for type of fluid and rate of flow. 75 mg/X ml = 100 mg/1 ml
b. Assess the client for presence of pain. To solve for X, cross-multiply:
c. Assess the Foley catheter for patency and urine output 75 mg x 1 ml = X ml x 100 mg
d. Assess the dressing for drainage. 75 = 100X
75/100 = X
0.75 ml (or ¾ ml) = X
29. Which of the following vital sign assessments that may indicate cardiogenic
shock after myocardial infarction? 38. Answer: (D) It͛s a measure of effect, not a
standard measure of weight or quantity.
a. BP ʹ 80/60, Pulse ʹ 110 irregular Rationale: An insulin unit is a measure of effect,
b. BP ʹ 90/50, Pulse ʹ 50 regular not a standard measure of weight or quantity.
c. BP ʹ 130/80, Pulse ʹ 100 regular Different drugs measured in units may have no
d. BP ʹ 180/100, Pulse ʹ 90 irregular relationship to one another in quality or
quantity.

30.Which is the most appropriate nursing action in obtaining a blood pressure 39. Answer: (B) 38.9 °C
measurement? Rationale: To convert Fahrenheit degreed to
Centigrade, use this formula
a. Take the proper equipment, place the client in a comfortable position, and °C = (°F ʹ 32) ÷ 1.8
record the appropriate information in the client͛s chart. °C = (102 ʹ 32) ÷ 1.8
b. Measure the client͛s arm, if you are not sure of the size of cuff to use. °C = 70 ÷ 1.8
c. Have the client recline or sit comfortably in a chair with the forearm at the °C = 38.9
level of the heart.
d. Document the measurement, which extremity was used, and the position 40. Answer: (C) Failing eyesight, especially close
that the client was in during the measurement. vision.
Rationale: Failing eyesight, especially close
vision, is one of the first signs of aging in middle
31.Asking the questions to determine if the person understands the health life (ages 46 to 64). More frequent aches and
teaching provided by the nurse would be included during which step of the pains begin in the early late years (ages 65 to
nursing process? 79). Increase in loss of muscle tone occurs in
later years (age 80 and older).
a. Assessment
b. Evaluation 41. Answer: (A) Checking and taping all
c. Implementation connections
d. Planning and goals Rationale: Air leaks commonly occur if the
system isn͛t secure. Checking all connections
and taping them will prevent air leaks. The
32.Which of the following item is considered the single most important factor chest drainage system is kept lower to promote
in assisting the health professional in arriving at a diagnosis or determining the drainage ʹ not to prevent leaks.
person͛s needs?
42. Answer: (A) Check the client͛s identification
a. Diagnostic test results band.
b. Biographical date Rationale: Checking the client͛s identification
c. History of present illness band is the safest way to verify a client͛s
identity because the band is assigned on
d. Physical examination admission and isn͛t be removed at any time. (If
it is removed, it must be replaced). Asking the
client͛s name or having the client repeated his
33.In preventing the development of an external rotation deformity of the hip name would be appropriate only for a client
in a client who must remain in bed for any period of time, the most who͛s alert, oriented, and able to understand
appropriate nursing action would be to use: what is being said, but isn͛t the safe standard of
practice. Names on bed aren͛t always reliable
a. Trochanter roll extending from the crest of the ileum to the midthigh.
b. Pillows under the lower legs. 43. Answer: (B) 32 drops/minute
c. Footboard Rationale: Giving 1,000 ml over 8 hours is the
d. Hip-abductor pillow same as giving 125 ml over 1 hour (60 minutes).
Find the number of milliliters per minute as
follows:
34.Which stage of pressure ulcer development does the ulcer extend into the 125/60 minutes = X/1 minute
subcutaneous tissue? 60X = 125 = 2.1 ml/minute
To find the number of drops per minute:
a. Stage I 2.1 ml/X gtt = 1 ml/ 15 gtt
b. Stage II X = 32 gtt/minute, or 32 drops/minute
c. Stage III
d. Stage IV 44. Answer: (A) Clamp the catheter
Rationale: If a central venous catheter becomes
disconnected, the nurse should immediately
35.When the method of wound healing is one in which wound edges are not apply a catheter clamp, if available. If a clamp
surgically approximated and integumentary continuity is restored by isn͛t available, the nurse can place a sterile
granulations, the wound healing is termed syringe or catheter plug in the catheter hub.
After cleaning the hub with alcohol or
a. Second intention healing povidone-iodine solution, the nurse must
b. Primary intention healing replace the I.V. extension and restart the
c. Third intention healing infusion.
d. First intention healing
45. Answer: (D) Auscultation, percussion, and
palpation.
36.An 80-year-old male client is admitted to the hospital with a diagnosis of Rationale: The correct order of assessment for
pneumonia. Nurse Oliver learns that the client lives alone and hasn͛t been examining the abdomen is inspection,
eating or drinking. When assessing him for dehydration, nurse Oliver would auscultation, percussion, and palpation. The
expect to find: reason for this approach is that the less
intrusive techniques should be performed
a. Hypothermia before the more intrusive techniques.
b. Hypertension Percussion and palpation can alter natural
c. Distended neck veins findings during auscultation.
d. Tachycardia
46. Answer: (D) Ulnar surface of the hand
Rationale: The nurse uses the ulnar surface, or
37.The physician prescribes meperidine (Demerol), 75 mg I.M. every 4 hours as ball, of the hand to asses tactile fremitus, thrills,
needed, to control a client͛s postoperative pain. The package insert is and vocal vibrations through the chest wall. The
͞Meperidine, 100 mg/ml.͟ How many milliliters of meperidine should the fingertips and finger pads best distinguish
client receive? texture and shape. The dorsal surface best feels
warmth.
a. 0.75
b. 0.6 47. Answer: (C) Formative
c. 0.5 Rationale: Formative (or concurrent) evaluation
d. 0.25 occurs continuously throughout the teaching
and learning process. One benefit is that the

38. A male client with diabetes mellitus is receiving insulin. Which statement
correctly describes an insulin unit?
a. It͛s a common measurement in the metric system.
b. It͛s the basis for solids in the avoirdupois system.
c. It͛s the smallest measurement in the apothecary system.
d. It͛s a measure of effect, not a standard measure of weight or quantity.
39.Nurse Oliver measures a client͛s 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 physician͛s
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 client͛s identity before administering
medication. She is aware that the safest way to verify identity is to:
a. Check the client͛s identification band.
b. Ask the client to state his name.
c. State the client͛s name out loud and wait a client to repeat it.
d. Check the room number and the client͛s 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.
nurse can adjust teaching strategies as
necessary to enhance learning. Summative, or
retrospective, evaluation occurs at the
conclusion of the teaching and learning session.
Informative is not a type of evaluation.
48. Answer: (B) Once per year
Rationale: Yearly mammograms should begin at
age 40 and continue for
as long as the woman is in good health. If
health risks, such as family
history, genetic tendency, or past breast
cancer, exist, more frequent
examinations may be necessary.
49. Answer: (A) Respiratory acidosis
Rationale: The client has a below-normal
(acidic) blood pH value and an above-normal
partial pressure of arterial carbon dioxide
(Paco2) value, indicating respiratory acidosis. In
respiratory alkalosis, the pH value is above
normal and in the Paco2 value is below normal.
In metabolic acidosis, the pH and bicarbonate
(Hco3) values are below normal. In metabolic
alkalosis, the pH and Hco3 values are above
normal.
50. Answer: (B) To provide support for the
client and family in coping with terminal illness.
Rationale: Hospices provide supportive care for
terminally ill clients and their families. Hospice
care doesn͛t focus on counseling regarding
health care costs. Most client referred to
hospices have been treated for their disease
without success and will receive only palliative
care in the hospice.
51. Answer: (C) Using normal saline solution to
clean the ulcer and applying a protective
dressing as necessary.
Rationale: Washing the area with normal saline
solution and applying a protective dressing are
within the nurse͛s realm of interventions and
will protect the area. Using a povidone-iodine
wash and an antibiotic cream require a
physician͛s order. Massaging with an astringent
can further damage the skin.
52. Answer: (D) Foot
Rationale: An elastic bandage should be applied
form the distal area to the proximal area. This
method promotes venous return. In this case,
the nurse should begin applying the bandage at
infusion at a rate of: the client͛s foot. Beginning at the ankle, lower
thigh, or knee does not promote venous return.
a. 30 drops/minute
b. 32 drops/minute 53. Answer: (B) Hypokalemia
c. 20 drops/minute Rationale: Insulin administration causes glucose
d. 18 drops/minute and potassium to move into the cells, causing
hypokalemia.

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 client͛s 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
54. Answer: (A) Throbbing headache or
dizziness
Rationale: Headache and dizziness often occur
when nitroglycerin is taken at the beginning of
therapy. However, the client usually develops
tolerance
55. Answer: (D) Check the client͛s level of
consciousness
Rationale: Determining unresponsiveness is the
first step assessment action to take. When a
client is in ventricular tachycardia, there is a
significant decrease in cardiac output.
However, checking the unresponsiveness
ensures whether the client is affected by the
decreased cardiac output.
56. Answer: (B) On the affected side of the
client.
Rationale: When walking with clients, the nurse
should stand on the affected side and grasp the
security belt in the midspine area of the small
of the back. The nurse should position the free
hand at the shoulder area so that the client can
be pulled toward the nurse in the event that
there is a forward fall. The client is instructed to
look up and outward rather than at his or her
feet.

47. Which type of evaluation occurs continuously throughout the teaching and 57. Answer: (A) Urine output: 45 ml/hr
learning process? Rationale: Adequate perfusion must be
maintained to all vital organs in order for the
a. Summative client to remain visible as an organ donor. A
b. Informative urine output of 45 ml per hour indicates
c. Formative adequate renal perfusion. Low blood pressure
d. Retrospective and delayed capillary refill time are circulatory
system indicators of inadequate perfusion. A
serum pH of 7.32 is acidotic, which adversely
48.A 45 year old client, has no family history of breast cancer or other risk affects all body tissues.
factors for this disease. Nurse John should instruct her to have
mammogram how often? 58. Answer: (D ) Obtaining the specimen from
the urinary drainage bag.
a. Twice per year Rationale: A urine specimen is not taken from
b. Once per year the urinary drainage bag. Urine undergoes
chemical changes while sitting in the bag and
c. Every 2 years does not necessarily reflect the current client
d. Once, to establish baseline status. In addition, it may become
contaminated with bacteria from opening the
system.
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 59. Answer: (B) Cover the client, place the call
Patricia should expect which condition? light within reach, and answer the phone call.
Rationale: Because telephone call is an
a. Respiratory acidosis emergency, the nurse may need to answer it.
b. Respiratory alkalosis The other appropriate action is to ask another
c. Metabolic acidosis nurse to accept the call. However, is not one of
d. Metabolic alkalosis the options. To maintain privacy and safety, the
nurse covers the client and places the call light
within the client͛s reach. Additionally, the
50.Nurse Len refers a female client with terminal cancer to a local hospice. client͛s door should be closed or the room
What is the goal of this referral? curtains pulled around the bathing area.

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 client͛s ankle and calf. He
should apply the bandage beginning at the client͛s:
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
60. Answer: (C) Use a sterile plastic container
for obtaining the specimen.
Rationale: Sputum specimens for culture and
sensitivity testing need to be obtained using
sterile techniques because the test is done to
determine the presence of organisms. If the
procedure for obtaining the specimen is not
sterile, then the specimen is not sterile, then
the specimen would be contaminated and the
results of the test would be invalid.
61. Answer: (A) Puts all the four points of the
walker flat on the floor, puts weight on the
hand pieces, and then walks into it.
Rationale: When the client uses a walker, the
nurse stands adjacent to the affected side. The
client is instructed to put all four points of the
walker 2 feet forward flat on the floor before
putting weight on hand pieces. This will ensure
client safety and prevent stress cracks in the
walker. The client is then instructed to move
the walker forward and walk into it.
62. Answer: (C) Draws one line to cross out the
incorrect information and then initials the
change.
Rationale: To correct an error documented in a
medical record, the nurse draws one line
through the incorrect information and then
initials the error. An error is never erased and
correction fluid is never used in the medical
record.
63. Answer: (C) Secures the client safety belts
after transferring to the stretcher.
Rationale: During the transfer of the client after

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 client͛s room. Upon reaching the client͛s
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 client͛s 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
the surgical procedure is complete, the nurse
should avoid exposure of the client because of
the risk for potential heat loss. Hurried
movements and rapid changes in the position
should be avoided because these predispose
the client to hypotension. At the time of the
transfer from the surgery table to the stretcher,
the client is still affected by the effects of the
anesthesia; therefore, the client should not
move self. Safety belts can prevent the client
from falling off the stretcher.
64. Answer: (B) Gown and gloves
Rationale: Contact precautions require the use
of gloves and a gown if direct client contact is
anticipated. Goggles are not necessary unless
the
nurse anticipates the splashes of blood, body
fluids, secretions, or excretions may occur.
Shoe protectors are not necessary.
65. Answer: (C) Quad cane
Rationale: Crutches and a walker can be
difficult to maneuver for a client with weakness
on one side. A cane is better suited for client
with weakness of the arm and leg on one side.
However, the quad cane would provide the
most stability because of the structure of the
cane and because a quad cane has four legs.
66. Answer: (D) Left side-lying with the head of
the bed elevated 45 degrees.
Rationale: To facilitate removal of fluid from
the chest wall, the client is positioned sitting at
the edge of the bed leaning over the bedside
table with the feet supported on a stool. If the
client is unable to sit up, the client is positioned
lying in bed on the unaffected side with the
head of the bed elevated 30 to 45 degrees.
67. Answer: (D) Reliability
Rationale: Reliability is consistency of the
research instrument. It refers to
the repeatability of the instrument in extracting
the same responses upon
its repeated administration.
68. Answer: (A) Keep the identities of the
subject secret
Rationale: Keeping the identities of the
research subject secret will ensure anonymity
because this will hinder providing link between
the information given to whoever is its source.
of the procedure, the unit secretary calls the nurse on the intercom to tell the 69. Answer: (A) Descriptive- correlational
nurse that there is an emergency phone call. The appropriate nursing action is Rationale: Descriptive- correlational study is the
to: most appropriate for this study because it
studies the variables that could be the
a. Immediately walk out of the client͛s room and answer the phone call. antecedents of the increased incidence of
b. Cover the client, place the call light within reach, and answer the phone call. nosocomial infection.
c. Finish the bed bath before answering the phone call.
d. Leave the client͛s door open so the client can be monitored and the nurse 70. Answer: (C) Use of laboratory data
can answer the phone call. Rationale: Incidence of nosocomial infection is
best collected through the use of biophysiologic
measures, particularly in vitro measurements,
60. Nurse Janah is collecting a sputum specimen for culture and sensitivity hence laboratory data is essential.
testing from a client who has a productive cough. Nurse Janah plans to
implement which intervention to obtain the specimen? 71. Answer: (B) Quasi-experiment
Rationale: Quasi-experiment is done when
a. Ask the client to expectorate a small amount of sputum into the emesis randomization and control of the variables are
basin. not possible.
b. Ask the client to obtain the specimen after breakfast.
c. Use a sterile plastic container for obtaining the specimen. 72. Answer: (C) Primary source
d. Provide tissues for expectoration and obtaining the specimen. Rationale: This refers to a primary source which
is a direct account of the investigation done by
the investigator. In contrast to this is a
61. Nurse Ron is observing a male client using a walker. The nurse determines secondary source, which is written by someone
that the client is using the walker correctly if the client: other than the original researcher.

a. Puts all the four points of the walker flat on the floor, puts weight on the 73. Answer: (A) Non-maleficence
hand pieces, and then walks into it. Rationale: Non-maleficence means do not
b. Puts weight on the hand pieces, moves the walker forward, and then walks cause harm or do any action that will cause any
into it. harm to the patient/client. To do good is
c. Puts weight on the hand pieces, slides the walker forward, and then walks referred as beneficence.
into it.
d. Walks into the walker, puts weight on the hand pieces, and then puts all 74. Answer: (C) Res ipsa loquitor
four points of the walker flat on the floor. Rationale: Res ipsa loquitor literally means the
thing speaks for itself. This means in
operational terms that the injury caused is the
62.Nurse Amy has documented an entry regarding client care in the client͛s proof that there was a negligent act.
medical record. When checking the entry, the nurse realizes that incorrect
information was documented. How does the nurse correct this error? 75. Answer: (B) The Board can investigate
violations of the nursing law and code of ethics
a. Erases the error and writes in the correct information. Rationale: Quasi-judicial power means that the
b. Uses correction fluid to cover up the incorrect information and writes in the Board of Nursing has the authority to
correct information. investigate violations of the nursing law and
c. Draws one line to cross out the incorrect information and then initials the can issue summons, subpoena or subpoena
change. duces tecum as needed.
d. Covers up the incorrect information completely using a black pen and writes
in the correct information 76. Answer: (C) May apply for re-issuance of
his/her license based on certain conditions
stipulated in RA 9173
63.Nurse Ron is assisting with transferring a client from the operating room Rationale: RA 9173 sec. 24 states that for equity
table to a stretcher. To provide safety to the client, the nurse should: and justice, a revoked license maybe re-issued
provided that the following conditions are met:
a. Moves the client rapidly from the table to the stretcher. a)
the cause for revocation of license has already
b. Uncovers the client completely before transferring to the stretcher. been corrected or removed; and, b) at least
c. Secures the client safety belts after transferring to the stretcher. four years has elapsed since the license has
d. Instructs the client to move self from the table to the stretcher. been revoked.

77. Answer: (B) Review related literature

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. Sims͛ 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.
Rationale: After formulating and delimiting the
research problem, the researcher conducts a
review of related literature to determine the
extent of what has been done on the study by
previous researchers.
78. Answer: (B) Hawthorne effect
Rationale: Hawthorne effect is based on the
study of Elton Mayo and company about the
effect of an intervention done to improve the
working conditions of the workers on their
productivity. It resulted to an increased
productivity but not due to the intervention but
due to the psychological effects of being
observed. They performed differently because
they were under observation.
79. Answer: (B) Determines the different
nationality of patients frequently admitted and
decides to get representations samples from
each.
Rationale: Judgment sampling involves
including samples according to the knowledge
of the investigator about the participants in the
study.
80. Answer: (B) Madeleine Leininger
Rationale: Madeleine Leininger developed the
theory on transcultural theory based on her
observations on the behavior of selected
people within a culture.

81. Answer: (A) Random

67.Nurse John develops methods for data gathering. Which of the following Rationale: Random sampling gives equal chance
criteria of a good instrument refers to the ability of the instrument to yield the for all the elements in the population to be
same results upon its repeated administration? picked as part of the sample.

a. Validity 82. Answer: (A) Degree of agreement and

b. Specificity disagreement
c. Sensitivity Rationale: Likert scale is a 5-point summated
d. Reliability scale used to determine the degree of
agreement or disagreement of the respondents
to a statement in a study
68.Harry knows that he has to protect the rights of human research subjects.
Which of the following actions of Harry ensures anonymity? 83. Answer: (B) Sr. Callista Roy
Rationale: Sr. Callista Roy developed the
a. Keep the identities of the subject secret Adaptation Model which involves the
physiologic mode, self-concept mode, role
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.Patient͛s refusal to divulge information is a limitation because it is beyond
the control of Tifanny͟. 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?
function mode and dependence mode.
84. Answer: (A) Span of control
Rationale: Span of control refers to the number
of workers who report directly to a manager.
85. Answer: (B) Autonomy
Rationale: Informed consent means that the
patient fully understands about the surgery,
including the risks involved and the alternative
solutions. In giving consent it is done with full
knowledge and is given freely. The action of
allowing the patient to decide whether a
surgery is to be done or not exemplifies the
bioethical principle of autonomy.

a. Interview schedule 86. Answer: (C) Avoid wearing canvas shoes.

b. Questionnaire Rationale: The client should be instructed to
c. Use of laboratory data avoid wearing canvas shoes. Canvas shoes
d. Observation cause the feet to perspire, which may, in turn,
cause skin
irritation and breakdown. Both cotton and
71.Monica is aware that there are times when only manipulation of study cornstarch absorb perspiration. The client
variables is possible and the elements of control or randomization are not should be instructed to cut toenails straight
attendant. Which type of research is referred to this? across with nail
clippers.
a. Field study
b. Quasi-experiment 87. Answer: (D) Ground beef patties
c. Solomon-Four group design Rationale: Meat is an excellent source of
d. Post-test only design complete protein, which this client needs to
repair the tissue breakdown caused by pressure
ulcers.
72.Cherry notes down ideas that were derived from the description of Oranges and broccoli supply vitamin C but not
an investigation written by the person who conducted it. Which type protein. Ice cream supplies only some
of reference source refers to this? incomplete protein, making it less helpful in
tissue repair.
a. Footnote
b. Bibliography 88. Answer: (D) Sims͛ left lateral
c. Primary source Rationale: The Sims' left lateral position is the
d. Endnotes most common position used to administer a
cleansing enema because it allows gravity to aid
the flow of fluid along the curve of the sigmoid
73.When Nurse Trish is providing care to his patient, she must remember colon. If the client can't assume this position
that her duty is bound not to do doing any action that will cause the nor has poor sphincter control, the dorsal
patient harm. This is the meaning of the bioethical principle: recumbent or right lateral position may be
used. The supine and prone positions are
a. Non-maleficence inappropriate and uncomfortable for the client.
b. Beneficence
c. Justice 89. Answer: (A) Arrange for typing and cross
d. Solidarity matching of the client͛s blood.
Rationale: The nurse first arranges for typing
and cross matching of the client's blood to
ensure compatibility with donor blood. The
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?
other options,
although appropriate when preparing to
administer a blood transfusion, come later.
90. Answer: (A) Independent
Rationale: Nursing interventions are classified
as independent, interdependent, or dependent.
Altering the drug schedule to coincide with the
client's daily routine represents an independent
intervention, whereas consulting with the
physician and pharmacist to change a client's
medication because of adverse reactions
represents an interdependent intervention.
Administering an already-prescribed drug on
time is a dependent intervention. An
intradependent nursing intervention doesn't
exist.
91. Answer: (D) Evaluation
Rationale: The nursing actions described
constitute evaluation of the expected
outcomes. The findings show that the expected
outcomes have been achieved. Assessment
consists of the client's history, physical
examination, and laboratory studies. Analysis
consists of considering assessment information
to derive the appropriate nursing diagnosis.
Implementation is the phase of the nursing
process where the nurse puts the plan of care
into action.
92. Answer: (B) To observe the lower
extremities
Rationale: Elastic stockings are used to promote
venous return. The nurse needs to remove
them once per day to observe the condition of
the skin underneath the stockings. Applying the
stockings increases blood flow to the heart.
When the stockings are in place, the leg
muscles can still stretch and relax, and the veins
can fill with blood.
93. Answer:(A) Instructing the client to report
any itching, swelling, or dyspnea.
Rationale: Because administration of blood or
blood products may cause serious adverse
effects such as allergic reactions, the nurse
must monitor the client for these effects. Signs
and symptoms of life-threatening allergic
reactions include itching, swelling, and
dyspnea. Although the nurse should inform the
client of the duration of the transfusion and
should document its administration, these
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:
actions are less critical to the client's immediate
health. The nurse should assess vital signs at
least hourly during the transfusion.
94. Answer: (B) Decrease the rate of feedings
and the concentration of the formula.
Rationale: Complaints of abdominal discomfort
and nausea are common in clients receiving
tube feedings. Decreasing the rate of the
feeding and the concentration of the formula
should decrease the client's discomfort.
Feedings are normally given at room
temperature to minimize abdominal cramping.
To prevent aspiration during feeding, the head
of the client's bed should be elevated at least
30 degrees. Also, to prevent bacterial growth,
feeding containers should be routinely changed
every 8 to 12 hours.

a. Random 95. Answer: (D) Roll the vial gently between the
b. Accidental palms.
c. Quota Rationale: Rolling the vial gently between the
d. Judgment palms produces heat, which helps dissolve the
medication. Doing nothing or inverting the vial
wouldn't help dissolve the medication. Shaking
82.John plans to use a Likert Scale to his study to determine the: the vial vigorously could cause the medication
to break down, altering its action.
a. Degree of agreement and disagreement
b. Compliance to expected standards 96. Answer: (B) Assist the client to the semi-
c. Level of satisfaction Fowler position if possible.
d. Degree of acceptance Rationale: By assisting the client to the semi-
Fowler position, the nurse promotes easier
chest expansion, breathing, and oxygen intake.
83.Which of the following theory addresses the four modes of adaptation? The nurse should secure the elastic band so
that the face mask fits comfortably and snugly
a. Madeleine Leininger rather than tightly, which could lead to
b. Sr. Callista Roy irritation. The nurse should apply the face mask
c. Florence Nightingale from the client's nose down to the chin Ͷ not
d. Jean Watson vice versa. The nurse should check the
connectors between the oxygen equipment and
humidifier to ensure that they're airtight;
84.Ms. Garcia is responsible to the number of personnel reporting to her. loosened connectors can cause loss of oxygen.
This principle refers to:
97. Answer: (B) 4 hours
a. Span of control Rationale: A unit of packed RBCs may be given
b. Unity of command over a period of between 1 and 4 hours. It
c. Downward communication shouldn't infuse for longer than 4 hours
d. Leader because the risk of contamination and sepsis
increases after that time. Discard or return to
the blood bank any blood not given within this
85.Ensuring that there is an informed consent on the part of the patient before time, according to facility policy.

98. Answer: (B) Immediately before

a surgery is done, illustrates the bioethical principle of: administering the next dose.
Rationale: Measuring the blood drug
a. Beneficence concentration helps determine whether the
b. Autonomy dosing has achieved the therapeutic goal. For
c. Veracity measurement of the trough, or lowest, blood
d. Non-maleficence level of a drug, the nurse draws a blood sample
immediately before administering the next
dose. Depending on the drug's duration of
86.Nurse Reese is teaching a female client with peripheral vascular action and half-life, peak blood drug levels
disease about foot care; Nurse Reese should include which instruction? typically are drawn after administering the next
dose.
a. Avoid wearing cotton socks.
b. Avoid using a nail clipper to cut toenails. 99. Answer: (A) The nurse can implement
c. Avoid wearing canvas shoes. medication orders quickly.
d. Avoid using cornstarch on feet. Rationale: A floor stock system enables the
nurse to implement medication orders quickly.
It doesn't allow for pharmacist input, nor does
87.A client is admitted with multiple pressure ulcers. When developing it minimize transcription errors or reinforce
the client's diet plan, the nurse should include: accurate calculations.

a. Fresh orange slices 100. Answer: (C) Shifting dullness over the
b. Steamed broccoli abdomen.
c. Ice cream Rationale: Shifting dullness over the abdomen
d. Ground beef patties indicates ascites, an abnormal finding. The
other options are normal abdominal findings.

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. Sims͛ 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 client͛s blood.

b. Compare the client͛s identification wristband with the tag on the unit of
blood.
c. Start an I.V. infusion of normal saline solution.
d. Measure the client͛s 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 ½ to 2 hours.
c. Documenting blood administration in the client care record.
d. Assessing the client͛s 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.