Fundamentals Of Nursing

Name: _________________________________________________________________ Date:_______________ 1. Elizabeth Kubler-Ross identified five stages of death and dying. Loss, grief, and intense sadness are symptoms of which stage? a. Denial and isolation b. Depression c. Anger d. Bargaining

RATIONALE: According to Kübhler-Ross, the five stages of death and dying are denial and isolation, anger, bargaining, depression, and acceptance. In denial, the client denies aspects of the illness and death. Loss, grief, and intense sadness indicate depression. In anger, the client has hostility that may be directed to family members, God, heath care workers, and others. In bargaining, the client asks God for more time, and in return promises to do something good.

2. To help minimize calcium loss from a hospitalized client's bones, the nurse should: a. reposition the client every 2 hours. b. encourage the client to walk in the hall c. provide the client daily products at frequent intervals d. provide supplemental feedings between meals.

RATIONALE: Calcium absorption diminishes with reduced physical activity because of decreased bone stimulation. Therefore, encouraging the client to increase physical activity such as by walking the hall, helps minimize calcium loss. Turning or repositioning the client every 2 hours wouldn’t increase activity sufficiently to minimize bone loss, Providing dairy products and supplemental feedings wouldn't lessen calcium loss - even if the dairy products and feedings contained extra calcium — because the additional calcium doesn’t increase bone stimulation or osteoblast activity.

3. Which statement regarding heart sounds is correct? a. S1 and s2 sound equally loud over the entire cardiac area. b. S1 and sound fainter at the apex than at the base. c. S and 2 sound fainter at the base than at the apex. d. S1 is loudest at the apex, and S2 is loudest at the base.

Rationale: The S1 sound — the “lub” sound — is loudest at the apex of the heart. It sounds longer, lower, and louder there than the S2 — the “dub” sound — is loudest at the base. It sounds shorter, sharper, higher, and louder there than the S1.

4. A client has a nursing diagnosis of Ineffective airway clearance related to poor coughing. When planning this client’s care, the nurse should include which intervention? a. Increasing fluids to 2,500 ml/day b. Teaching the client how to deep-breathe and cough c. Improving airway clearance d. Suctioning the client every 2 hours RATIONALE: Interventions should address the etiology of the client's problem — poor coughing. Teaching deep breathing and coughing addresses this etiology. Increasing fluids may improve the client’s condition, but this intervention doesn't address poor coughing. Improving airway clearance is too vague to be considered an appropriate intervention. Suctioning isn't indicated unless other measures fail to clear the airway.

5. A nurse is using the computer when a client calls for pain medication. Which action by the nurse is the best? a. Staying logged on, leaving the terminal on, and administering the medication immediately b. telling the client that he’ll have to wait 15 minutes while she completes the entry c. Asking a coworker to log out for her and administering the medicine right away d. Logging out of the computer, then administering the pain medication RATIONALE: A nurse should meet a client’s request for pain medication as quickly as possible after she logs out of the computer. A nurse shouldn't ask a client to wait for as long as 15 minutes for requested pain medication. If the nurse leaves the terminal without logging out, others may view confidential information or use her password. Asking a coworker to log her out isn't safe computer practice.

6. What is the most appropriate nursing diagnosis for the client with acute pancreatitis?

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a. Deficient fluid volume b. Excess fluid volume c. Decreased cardiac output d. Ineffective gastrointestinal tissue perfusion RATIONALE: Clients with acute pancreatitis often experience deficient fluid volume, which can lead to hypovolemic shock. Vomiting, hemorrhage (in hemorrhagic pancreatitis), and plasma leaking into the peritoneal cavity may cause the volume deficit. Hypovolemic shock will cause a decrease in cardiac output. Gastrointestinal tissue perfusion will be ineffective if hypovolemic shock occurs, but this wouldn't be the primary nursing diagnosis. 7. One aspect of implementation related to drug therapy is: a. developing a plan of care b. documenting drugs given. c. establishing outcome criteria. d. setting realistic client goals. RATIONALE: Athough documentation isn't a step in the nursing process, the nurse is legally required to document activities related to drug therapy, including the time of administration, the quantity, and the client's reaction. Developing a plan of care, establishing outcome criteria, and setting realistic client goals are parts of planning rather than implementation. 8. A nurse notes that a client’s I.V. insertion site is red, swollen, and warm to the touch. which action should the nurse take first? a. Discontinue the I.V. infusion. b. Apply a warm, moist compress to the I.V. site. c. Assess the I.V. infusion for patency. d. Apply an ice pack to the I.V. site. RATIONALE: Because redness, swelling, and warmth at an I.V. site are signs of infection, the nurse should discontinue the infusion immediately and restart at another site. After doing this, the nurse should apply warmth to the original site. Checking infusion patency isn't warranted because assessment findings suggest infection and inflammation, not infiltration. Heat, not cold is the appropriate treatment for inflammation. 9. A nurse is caring for a client with a history of falls. The nurse's first priority when caring for a client at risk for falls is: a. placing the call light for easy access. b. keeping the bed in the lowest possible position. c. instructing the client not to get out of the bed without assistance d. keeping the bedpan available so that the client doesn’t have to get out of bed. RATIONALE: Keeping the bed at the lowest possible position the first priority for clients at risk for falling. Keeping the call light easy accessible is important but isn’t a top priority. Instructing the client not to get out of bed may not effectively prevent falls — for example, if the client is confused. Even when the client needs assistance to get out of bed, the nurse should place the bed in the lowest position. The client may not require a bedpan. 10. A nurse is caring for a client who is exhibiting signs and symptoms characteristic of a myocardial infarction (MI). which statement describes priorities the nurse should establish while performing the physical assessment? a. Assess the client's level of pain and administer prescribed analgesics. b. Assess the client’s level of anxiety and provide emotional support. c. Prepare the client for pulmonary artery catheterization. d. Ensure that the client's family is kept informed of his status. RATIONALE: The cardinal symptom of MI is persistent, crushing substernal pain or pressure. The nurse should first assess the client's pain and prepare to administer nitroglycerin or morphine for pain control. The client must be medically stabilized before pulmonary artery catheterization can be used as a diagnostic procedure. Anxiety and a feeling of impending doom are characteristic of MI, but the priority is to stabilize the client medically. Although the client and his family should be kept informed at every step of the recovery process, this action isn’t the priority when treating a client with a suspected MI.

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11. A nurse is monitoring a client for adverse reactions during barbiturate therapy. What is the major disadvantage of barbiturate use? a. Prolonged half-life b. Poor absorption c. Potential for drug dependence d. Potential for hepatotoxicity RATIONALE: Clients can become dependent on barbiturates, especially with prolonged use. Because of the rapid distribution of some barbiturates, no correlation exists between duration of action and half-life. Barbiturates are absorbed well and don't cause hepatotoxicity, but because barbiturates are metabolized in the liver, existing hepatic damage does require cautious use of these drugs. 12. A nurse is caring for a client who required chest tube insertion for a pneumothorax. To assess for pneumothorax resolution, the nurse anticipates that the client will require: a. monitoring of arterial oxygen saturation , b. arterial blood gas (ABG) studies. c. chest auscultation. d. a chest x-ray. Rationale: Chest x-ray confirms diagnosis by revealing air or fluid in the pleural space. SaO2 values may initially decrease with a pneumothorax but typically return to normal within 24 hours. ABG studies may show hypoxemia, possibly with respiratory acidosis and hypercapnia not related to a pneumothorax. Chest auscultation will determine overall lung status, but it's difficult to determine if the chest has reexpanded sufficiently. 13. During her morning assessment, a nurse notes that a client has severe dyspnea, his respirations are 34 breaths/minute and labored. Oxygen saturation is 79% on 3L of oxygen. The nurse remembers that the client's chart includes his living will, When considering best practice, the nurse should: a. withhold all potentially life-prolonging treatments in accordance with the client's living will b. increase the oxygen flow rate to 4L, but avoid initiating other interventions c. call the client’s family and ask what they think is best. d. initiate potentially life-prolonging treatment unless the client refuses. RATIONALE: A living will doesn't go into effect unless the client is unable to make his own decisions. A nurse shouldn't withhold care for an alert client unless he specifically refuses care. The nurse should give all appropriate care while also maintaining the client's right to refuse treatment. Increasing the oxygen flow rate might be an appropriate response, but isn't the best action at this time. The family isn't responsible for determining care at this time. 14. A client is to receive a glycerin suppository. Which nursing action is appropriate when administering a suppository? a. Removing the suppository from the refrigerator 30 minutes before insertion b. Applying a lubricant to the suppository c. Dissolving the suppository in 3 ml of warm water d. Instructing the client to bear down during insertion RATIONALE: A suppository must be lubricated before insertion. Because suppositories melt at body temperature, they usually require refrigeration until administration. It isn’t appropriate to dissolve a suppository in warm water. It should remain in a solid state. Instructing the client to bear down would cause the anal sphincter to contract, making insertion difficult. 15. A physician orders regular insulin 10 units LV. along with 50 ml of dextrose 50% for a client with acute renal failure. What problem is this client most likely experiencing? a. Hypercalcemia b. Hypernatremia c. Hyperglycemia d. Hyperkalemia Rationale: Administering regular IV concomitantly with 50 ml of dextrose 50% helps shift potassium from the extracellular fluid into the cell, which normalizes serum potassium levels in the client with hyperkalemia. This combination doesn't he reverse the effects of hypercalcemia, hypenatremia, or hyperglycemia.

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16. A nurse identifies a client’s responses to actual or potential health problems during which step of the nursing process? a. Assessment b. Diagnosis c. Planning d. Evaluation RATIONALE: The nurse identifies human responses to actual or potential health problems during the diagnosis step of the nursing process, which encompasses the nurse’s ability to formulate a nursing diagnosis. During the assessment step, the nurse systematically collects data about the client or his family. During the planning step, she develops strategies to resolve or decrease the client’s problem. During the evaluation step, the nurse determines the effectiveness of the care plan. 17. In a client with a urine specific gravity of 1.040, a subnormal serum osmolality, and a serum sodium level of 128 mEq/L, the nurse should question an order for which I.V. fluid? a. dextrose 5% in half-normal saline solution. b. normal saline solution. c. dextrose 5% on water (D5W) d. lactated Ringer’s solution. RATIONALE: An elevated urine specific gravity, a subnormal serum osmolality, and a subnormal serum sodium level indicate that the client is excreting too many solutes. Because the client is in a hypotonic state, the nurse shouldn't give him a hypotonic I.V. solution. D5W, also referred to as free water, is hypotonic when given I.V. and can further hemodilute the clent. Dextrose 5% half-normal saline solution is hypertonic, normal saline solution is isotonic, and lactated Ringer's solution is isotonic. For this client, each of these three choices are more acceptable than D5w. 18. A 10-year-old child with rheumatic fever must have his heart rate measured while he's awake and while he’s sleeping. Why are two readings necessary? a. To obtain a heart rate that isn't affected by medication b. To eliminate interference from the jerky movements of chorea c. To ensure that the child can't consciously raise or lower his heart rate d. To compensate for activity's effects on the child’s heart rate RATIONALE: Tachycardia may be a sign of heart failure. The nurse can detect mild tachycardia more easily when the child is asleep than when he's awake because activity can increase his heart rate. Medications given for rheumatic fever and rheumatic heart disease, such as digoxin (Lanoxin), exert their influence both day and night. Chorea, a symptom of rheumatic fever, is the loss of voluntary muscle control. It doesn't affect pulse because the child would be sitting quietly while the nurse measured his heart rate and wouldn't be involved in purposeful movement. A 10-year-old child probably doesn't know how to consciously raise or lower his heart rate. 19. A nurse preparing to administer a sustained-release capsule to a client. Which is an appropriate nursing intervention? a. Administering the capsule whole with a glass of water b. Crushing the capsule and mixing the medication with applesauce c. Opening the capsule, shaking the contents into water, and administering it to the client d. Having the client chew the capsule before swallowing 20. After receiving an I.M. injection, a client complains of burning pain at the injection site. which nursing action would be most appropriate at this time? a. Applying a cold compress to decrease swelling b. Applying a warm compress to dilate the blood vessels c. Massaging the area to promote absorption of the drug d. Instructing the client to tighten his gluteal muscles to promote better absorption of the drug RATIONAI.E: Applying heat increases blood flow to the area, which, in turn, increases medication absorption. Cold decreases pain but allows the medication to remain in the muscle longer. Massage is a good intervention, but applying a warm compress is better. Tightening the gluteal muscles may cause additional burning if the drug irritates muscular tissues.

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21. A client undergoes a total abdominal hysterectomy. When assessing the client 10 hours later, the nurse identifies which finding as an early sign of shock? a. Confusion b. Pale, warm, dry skin c. Heart rate of 110 beats/minute d. Urine output of 30 ml/hour RATIONALE: Early in shock, inadequate perfusion leads to anaerobic metabolism, which causes metabolic acidosis. As the respiratory rate increases to compensate, the client’s carbon dioxide level decreases, causing alkalosis and subsequent confusion and combativeness. Inadequate tissue perfusion causes pale, cool, clammy skin (not pale, warm, dry skin). An above-normal heart rate is a late sign of shock. A urine output of 30 ml/hour is within normal limits. REFERENCE: Smeltzer, S.C., and Bare, B. Brunner&Suddarth’s Texthook of MedicalSurgical Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 2526. 22. Cross-tolerance to a drug is defined as: a. one drug that can prevent withdrawal symptoms from another drug. b. an allergic reaction to a class of drugs. c. one drug reduces response to another drug. d. one drug increases another drug’s potency. RATIONALE: Cross-tolerance occurs when a drug with a similar action causes a decreased response to another drug. A drug that can prevent withdrawal symptoms from another drug describes cross-dependence. Cross-tolerance isn't an allergic reaction to a class of drugs. A drug's ability to increase the potency of another drug describes potentiating effects. 23. A nurse caring for a client wth a fecal impaction should watch for: a. liquid or semiliquid stools. b. hard, brown, formed stools. c. loss of urge to defecate. d. increased appetite. RATIONALE: Passage of liquid or semiliquid 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 decreased appetite. 24. A physician orders an intestinal tube to decompress a client's GI tract. when gathering equipment for this procedure, a nurse should obtain a: a. Sengstaken-Blakemore tube. b. Miller-Abbott tube. c. Levin tube. d. Salem sump tube. RATIONALE: A Miller-Abbott tube is an intestinal tube. A Sengstaken-8lakemore tube is an esophageal tube. Levin tubes and Salem sump tubes are nasogastric tubes. REFERENCE: Smeltzer, S.C., and Bare, B. Brunner & Suddarth’s Textbook of Medical Surgica Nursing, 2008, p. 1175. 25. A client has a blood pressure of 152/86 mm Hg. The nurse should document the client’s pulse pressure as: a. 66mm Hg. b. 238 mm Hg. c. 86 mm Hg. d. 152 mm Hg. RATIONALE: Pulse pressure is the difference between the systolic and diastolic pressures — in this case, 66 mm Hg. 26. A client has a nursing diagnosis of Risk for Injury related to adverse effects of potassiumwasting diuretics. What is a correctly written client outcome for this nursing diagnosis? a. “By discharge, the client correctly identifies three potassium-rich food sources.” b. “The client knows the importance of consuming potassium-rich foods daily.” c. “Before discharge, the client knows which food sources are high in potassium.” d. “The client understands all complications of the disease process." RATIONALE: A client outcome must be measurable, objective, concise, realistic for the client, and attainable through nursing management. For each client outcome, the nurse should include only one client behaviour. She should express that behaviour in terms of client expectations and should indicate a time frame in which to accomplish. Knowing the importance of consuming potassium-rich foods and knowing which foods are high in

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potassium aren't measurable outcomes. Understanding all complications of a disease process isn't measurable or specific to the nursing diagnosis listed.

27. When caring for a client with a 3-cm stage I pressure ulcer on the coccyx, which action may the nurse institute independently? a. Using a povidone-iodine wash on the ulceration three times per day b. Using normal saline solution to clean the ulcer and applying a protective dressing as necessary c. Applying an antibiotic cream to the area three tines per day d. Massaging the area with an astringent every 2 hours 28. A client with burns on his groin has developed blisters. As the client is bathing, a few blisters break. The best action tor the nurse to take is to: a. remove the raised skin because the blister has already broken. b. wash the area with soap and water to disinfect it. c. apply a weakened alcohol solution to clean the area. d. clean the area with normal saline solution and cover it with a protective dressing. RATIONALE: The nurse should clean the area with a mild solution such as normal saline, and then cover it with a protective dressing. Soap and water and alcohol are too harsh. The body's first line of defense broke when the blisters opened: removing the skin exposes a larger area to the risk of infection. 29. A nurse is assisting with a subclavian vein central be insertion when the client's oxygen saturation drops rapidly. He complains of shortness of breath and becomes tachypneic. The nurse suspects the chent has developed a pneumothorax. Further assessment findings supporting the presence of a pneumothorax include: a. diminished or absent breath sounds on the affected side b. paradoxical chest wall movement with respirations. c. tracheal deviation to the unaffected side. d. muffled or distant heart sounds. RATIONALE: In the case of a pneumothorax, auscultating for breath sounds will reveal absent or diminished breath sounds on the affected side. Paradoxical chest wall movements occur in flail chest conditions. Tracheal deviation occurs in a tension pneumothorax. Muffled or distant heart sounds occur in cardiac tamponade. 30. During a meal, a client with hepatitis B dislodges her IV line and bleeds onto the surface of the overbed table. It would be most appropriate for the nurse to instruct a housekeeper to clean the table with: a. alcohol. b. ammonia. c. acetone. d. bleach. RATIONALE: Blood infected with the hepatitis B virus should be removed from the table or other surfaces with bleach. Alcohol, ammonia, and acetone are less effective n destroying the hepatitis B virus. 31. A nurse determines that a client has 20/40 vision. Which statement about this client’s vision is true? a. The client can read the entire vision chart at a distance of 40 feet. b. The client can read from a distance of 20 feet what a person with normal vision can read at a distance of 40 feet. c. The client can read the vision chart from a distance of 20 feet with the right eye and from 40 feet with the left eye. d. The client can read at a distance of 40 feet what a person with normal vision can read at a distance of 20 feet. RATIONALE: The numerator, which is always 20, is the distance in feet between the vision chart and the client. The denominator indicates from what distance a person with normal vision can read the chart. 32. For the past few days, a client has been having calf pain and notices that the painful calf is larger than the other one. The right calf is red, warm, achy, and tender to touch. Which question about the pain should a nurse include in the assessment? a. “Does the pain worsen when you get up in the morning?”

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b. “Does the pain increase with activity and lessens with rest?" c. “Is the pain relieved when you change position?” d. “Is the pain worse when you point your toes toward your knee?” RATIONALE: The client's symptoms indicate deep vein thrombosis (DVT). Pointing toes toward the knee will cause discomfort in a client with DVT. Time of the day doesn’t influence the pain associated with DVT. A client with intermittent claudication experiences pain that increases during activity and decreases with rest. A dependent position, not a position change, will increase venous stasis and the pain associated with DVT.

33. A physician orders the following preoperative medications to be administered to a client by the I.M. route: meperidine (Demerol), 50 mg: hydroxyzine pamoate (Vistaril), 25 mg; and glycopyrrolate (Robinul), 0.3 mg. The medications are dispensed as follows: meperidine, 100 mg/ml; hydroxyzine pamoate, 100 mg/2 ml; and glycopyrrolate, 0.2 mg/ml. How many milliliters in total should the nurse administer? a. 5ml b. 2 ml c. 2.5 ml d. 3.8 ml Computation: 0.5 ml + 0.5 ml + 1.5 ml = 2.5 ml 34. What is a common source of airway obstruction in an unconscious client? a. A foreign object b. Saliva or mucus c. The tongue d. Edema RATIONALE: In an unconscious client, the muscles controlling the tongue commonly relax, causing the tongue to obstruct the airway. When this situation occurs, the nurse should use the head-tilt, chin-lift maneuver to cause the tongue to fall back into place. If she suspects the client has a neck injury she must perform the jaw-thrust maneuver. 35. After undergoing small-bowel resection, a client is ordered Metronidazole (Flagyl) 500 mg IV The mixed IV solution contains 100 ml. The nurse is to run the drug over 30 minutes. The drip factor of the available IV tubing is 15 gtts/ml. What is the drip rate? Round your answer to the nearest whole number. a. 50 gtt/min b. 45 gtt/min c. 48 gtt/min d. 40 gtt/min Rationale: Use the following equation: 100 ml/30 minutes x 15 gtt/1 ml = 49.9 gtt/minute (50 gtt/minute) 36. An elderly client who experiences several adverse drug reactions may benefit from: a. reduced drug dosages. b. nursing home placement. c. increased drug doses at longer intervals. d. frequent visits to the physician. RATIONALE: In older clients, diminished hepatic and renal function commonly reduces drug metabolism and excretion. Because adverse reactions are frequently related to drug blood level, the client may benefit from reduced drug dosages. Adverse drug reactions don’t represent a reason for nursing home placement. Increased drug doses at longer intervals may increase adverse reactions rather than decrease them. Although frequent visits to the physician may benefit the client, the visits themselves won't alter how the client's body reacts to the drug. 37. When examining a client who has abdominal pan, a nurse should assess: a. any quadrant first. b. the symptomatic quadrant first. c. the symptomatic quadrant last. d. the symptomatic quadrant either second or third. Rationale: The nurse should systematically assess all areas of the abdomen, if time and the client's condition permit, concluding with the symptomatic area. Otherwise, the nurse may elicit pain in the symptomatic area, causing the muscles in other areas to tighten. This tightening would interfere with further assessment.

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38. A nurse is teaching a group of nursing assistants about infection-control measures. The nurse tells the group that the first line of intervention for preventing the spread of infection is: a. wearing gloves. b. administering antibiotics. c. washing hands. d. assigning clients to private rooms. RATIONALE: Hand washing is the first line of intervention for preventing the spread of infection. Wearing gloves and assigning private rooms for clients can also decrease the spread of infection and should be implemented according to standard precautions. Antibiotics should be initiated when a causative organism is identified.

39. A nurse caring for a client who has suffered a severe stroke. During routine assessment, the nurse notices Cheyne-Stokes respirations. Cheyne-Stokes respirations are: a. progressively deeper breaths followed by shallower breaths with apneic periods. b. rapid, deep breaths with abrupt pauses between each breath. c. rapid, deep breaths and irregular breathing without pauses. d. shallow breaths with an increased respiratory rate. RATIONALE: Cheyne-Stokes respirations are breaths that become progressively deeper followed by shallower respirations with apneic periods. Biot’s respirations are rapid, deep breaths with abrupt pauses between each breath, and equal depth between each breath. Kussmaul’s respirations are rapid, deep breaths without pauses. Tachypnea is abnormally rapid respirations. 40. When positioned properly, the top of a central venous catheter should lie in the: a. superior vena cava. b. basilic vein. c. jugular vein. d. subclavian vein. RATIONALE: When positioned correctly, the top of a central venous catheter lies in the superior vena cava, inferior vena cava, or right atrium — that is, in the central venous circulation. Blood flows unimpeded around the tip, allowing the rapid infusion of large amounts of fluid directly into circulation. The basilic, jugular, and subclavian veins are common insertion sites for central venous catheters. 41. A nurse reviews the arterial blood gas (ABG) values of a client admitted with pneumonia: pH, 7.51, PaCO2, 28 mm Hg; PaO2, 70 mm Hg: and HCO3, 24 mEq/L. What do these values indicate? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis RATIONALE: A client with pneumonia may hyperventilate in an effort to increase oxygen intake. Hyperventilation leads to excess carbon dioxide (Co2) loss, which causes alkalosis — indicated by this client's elevated pH value. with respiratory alkalosis, the kidneys’ bicarbonate (HCO3-) response is delayed, so the client's HCO3- level remains normal. The below-normal value for the partial pressure of arterial carbon dioxide (PaCO2) indicates CO2 loss and signals a respiratory component. Because the HCO3- level is normal, this imbalance has no metabolic component. Therefore, the client is experiencing respiratory alkalosis. 42. The ear canal of an infant or young child: a. slants upward. b. slants downward. c. is horizontal. d. slants backward. Rationale: The ear canal slants up in a younger child and down in an older child or adult. 43. When a central venous catheter dressing becomes moist or loose, what should a nurse do first? a. Draw a circle around the moist spot and note the date and time. b. Notify the physician. c. Remove the catheter, check for catheter integrity, and send the tip for culture. d. Remove the dressing, clean the site, and apply a new dressing. Rationale: A nurse maintaining a central venous catheter should change the dressing every 72 hours or when it becomes soiled, moist, or loose. After removing the soiled dressing, the

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nurse should use sterile technique to clean around the site in accordance with facility policy. After the cleaning solution has dried, the nurse should cover the site with a transparent semipermeable dressing. A nurse who notes drainage on a wound dressing should draw a circle around the moist spot and note the date and time. She should notify the physician if she observes any catheter-related complications. Only a nurse with the appropriate qualifications may remove a central venous catheter, and a moist or loose dressing isn’t a reason to remove the catheter. References: Smeltzer, S.C., and Bare, B. Brunner&Suddarth’s Texthook of MedicalSurgical Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1005

44. A nurse is assigned to care for a client with a tracheostomv tube. How can the nurse communicate with this client? a. By providing a tracheostomy plug to use for verbal communication b. By placing the call button under the client's pillow c. By supplying a magic slate or similar device d. By suctioning the client frequently RATIONALE: The nurse should use a nonverbal communication method, such as a magic slate, note pad and picture boards (if the client can’t write or speak English). The physician orders a tracheostomy plug when a client is being weaned off a tracheostomy; it doesn’t enable the client to communicate. The call button, which should be within reach at al times for all clients, can summon attention but doesn't communicate additional information. Suctioning clears the airway but doesn't enable the client to communicate. 45. Chokie underwent diagnostic test and he result of the blood examination are back. On reviewing the result, the nurse notice which of the following as an abnormal finding? a. Neutophil 60% c. Iron 75mg/100ml b. ESR 39mm/hr d. WBC 9000/mm 45. A client with viral infection will most likely manifest which of the following during the illness stage of infection? a. Oral temperature shows fever b. Client was exposed to the infection 2 days ago but without any symptoms c. Acute symptoms are no longer visible d. Client feel sick but can do normal activities 45. Among the clients you are assigned to take care of, who is most susceptible to infection? a. Client with burns c. Diabetic Client b. Client with Myocardial Infarction d. Client with pulmonary emphysema 45. Surgical asepsis is observed when: a. Placing a dirty soiled linen in moisture resistant bag b. Disposing of syringe and needle in puncture proof containers c. Inserting an Intravenous catheter d. Washing hands before changing wound dressing 45. Which of the following laboratory test results indicate presence of infectious process? a. ESR: 12mm/hr b. Iron 90g/100ml c. Neutrophils 67% d. WBC: 18000/mm3 45. A diabetic hypertensive client, Mrs. Charuz, needs a change in diet to improve her health status. She should be referred to a: a. Nutritionist c. Dietician b. Physician d. Medical Pathologist 46. When collaborating with other health team members, the best description of a nurses’ role is: a. Shares and implements order of the health team to ensure quality care

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b. Encourage the client’s involvement in his care c. She listen to the individual views of the team members d. Help the client sets goal of care and discharge 47. A nurse is successful on collaborating with the health team members about the care of his patient. This is because she has the following competencies a. Conflict management, Trust and Negotiation b. Negotiation, Decision Making c. Communication, Trust and Decision Making d. Mutual respect, Negotiation and Trust 48. Your client is concerned that he cannot pay his hospital bills and professional fees. You refer him to a: a. Bookkeeping Department c. Social Worker b. Nurse Supervisor d. Physician 49. A patient with lung cancer is undergoing chemotherapy. He is referred by the oncology nurse to a self-help group of clients with cancer to: a. To be a part of the research team c. Receive emotional report b. Provide financial assistance d. Assist with chemotherapy 50. A sputum specimen has been ordered for Mr. Buenaventura, a 75-year-old patient admitted with possible pneumonia of the right lower lobe. Mr. Buenaventura is not able to cough. The nurse is aware that for patients who cannot expectorate sputum from deep in the bronchial tree, Nebulization was done, the specimen must be collected by: a. Orotracheal suctioning b. Tracheal suctioning c. Oropharyngeal suctioning d. Percussion and suctioning 45. To obtain a 24-hour urine specimen, the patient should be given which of the following instructions? a. Collect each voiding in separate containers for the next 24 hours b. Discard the first voided specimen and then collect the total volume of each voiding in 24 hours c. For the next 24 hours, retain a 30ml specimen of each voiding after recording the amount voided d. Keep a record of the time and amount of each voiding for 24 hours 46. Ms. Cristobal, age 72, has an indwelling urinary catheter. A sterile urine specimen has been ordered for a culture and sensitivity. The sterile specimen should be obtained by: a. Obtaining 60ml of urine from the collection bag b. Removing the present catheter, having the patient void, and then recatheterizing c. Disconnecting the tubing from the catheter and draining 2ml of urine d. Aspirating 10ml of urine with a sterile syringe from the tubing port 47. Mr. Lagman, age 46, is seen by the physician for recurrent symptoms of cystitis. He is to have a urine culture and sensitivity determination and a 24-hour urine collection for laboratory analysis. Mr. Lagman should be informed that a urine culture study is required to: a. Identify the causative organism b. Determine the presence of malignant cells c. Analyze the elements present in the urine d. Localize the site of the inflammatory process 48. How would you prepare for the accuracy of the occult blood examination? a. Meatless diet for 72 hours prior to collection of the specimen b. Fluid intake is increased an hour before the collection of the specimen c. Fluid intake is limited only to 1 liter per day d. NPC for 9 hours prior to collection of specimen Situation: Nurse Jennica, a newly hired nurse, is asked to take over an absent nurse in another unit. She will take care of the client wit various condition 49. She is giving instructions to Michelle, the daughter of a comatose patient, to give sponge

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bath. While Michelle is giving sponge bath, what action of Michelle needs correction? a. Lining the patient on the left side with slightly elevated b. Answering the phone while wearing gloves used for sponge bath c. Rolling the patient like a log to do back rub d. Lining the rubber mat with bed sheet as incontinence pad for the client 50. Joey sustained a fracture of the ulna and cast will be applied. What nursing action before cast application is most important for Nurse Jennica to do? a. Use baby powder to reduce irritation under the cast b. Evaluate the skin temperature in the area c. Assess sensation of each arm d. Check radial pulse bilaterally and compare

51. Which of the following client condition should be nurse Jennica’s priority in the pediatric unit? a. The infant who is brought in for upper respiratory tract infection whose temperature is slightly elevated b. The baby whose fontanel s bulging and firm while asleep c. The baby who is wailing after being awakened by the banging of the door d. A baby boy whose circumcision has yellowish exudates 52. When suctioning the endotracheal tube, the nurse should: a. Insert catheter until resistance is met, then withdraw slightly, applying suction intermittently a catheter is withdrawn b. Hyperoxygenate client than insert catheter using back and forth motion c. Insert suction catheter four inches into the tube, suction 30 seconds using twirling motion as catheter is withdrawn d. Explain procedure to the patient, insert the catheter gently applying suction. Withdrawn using twisting motion 53. To obtain specimen for sputum culture and sensitivity, which of the following instruction is best? a. Cough after pursed lip breathing b. Save sputum for two days in covered container c. Upon waking up, cough deeply and expectorate into the container d. After respiratory treatment, expectorate into a container Situation: The vital or cardinal signs are body temperature, pulse, respiration and blood pressure 54. Ms. Avila is 48-years-old. During a routine physical her blood pressure is noted a 180/90. She fears she is hypertensive. The nurse would explain that the diagnosis of hypertension is made when there is a sustained elevated blood pressure of over: a. 160/100 b. 140/90 c. 130/70 d. 120/80 55. Mr. Jimenez, age 44, is undergoing antibiotic therapy for pneumonia. His rectal temperature reading is 101.6°F. His oral temperature would be considered as: a. 101.6°F b. 100.6°F c. 99.6°F d. 97.6°F 56. Ms. Pascual, age 66, suddenly develops rectal hemorrhaging, her radial pulse is difficult to palpate even with slight pressure. This type of pulse would be described as: a. Absent b. Nonpalpable

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c. Thready d. Bounding 57. Mr. Zamora, RN, has been assigned several patients. Which one of the following patients would most likely have a higher than normal temperature? a. The depressed, apathetic patient b. The patient addressed with hemorrhage c. The patient who is recovering from surgery d. The patient experiencing strong emotions 58. The physician has ordered an orthostatic blood pressure measurement. Which of the following is correct concerning the orthostatic method of assessing blood pressure? a. The measurement is taken in the lying position, then sitting up and last when the patient is standing. b. The measurement is taken first with the patient sitting up and then lying down. c. The nurse should wait 5 minutes between assessing the blood pressure in the sitting position from the lying position. d. The patient should be lying down for at least 10 minutes before the nurse performs the procedure. Situation: You are assigned to work in an orthopedic ward where clients are expected to have problems in mobility and immobility 59. Mark asks to be assisted to move up in bed. Which of the following should the nurse do first? a. Lock the wheels of the bed b. Raise the bed rails opposite the nurse c. Adjust the bed to a flat position d. Move the patient to the edge of the bed near the nurse 60. Which of the following supportive devices can be sued most effectively by the nurse to prevent external rotation of the right leg? a. Firm Mattress c. Sand Bag b. Pillow d. High Foot Board 61. Jerome right leg is injured and Nurse Apple has to move him from the bed to a wheel chair. Which of the following is the appropriate nursing action of the nurse? a. Face the client and place the wheelchair at her back b. Put the client o n the edge of the bed and place the wheelchair on the client’s left side c. Put the client on the edge of the bed and place the wheelchair on the other side of the bed d. Put the client on the edge of the bed and place the wheelchair at her back 62. Gilbert has to be maintained on a dorsal recumbent position. Which of the following should be prevented? a. Adduction of the shoulder b. Hyperextension of the knees c. Anterior flexion of the lumbar curvature d. Lateral flexion of the sternocleidomastoid muscle 63. Mikckey prefers to be in high fowler’s position most of the time. The nurse should prevent which of the following? a. Adduction of the shoulder b. Internal Rotation of the shoulder c. Posterior flexion of the lumbar curvature d. External Rotation of the hip Situation: As you begin to wok in the hospital where you are on probation, you are tasked to take care of few patients. The client have varied needs and you are expected to provide care for them.

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64. You are preparing a plan of care who is experiencing pain related to incisional swelling following laminectomy. Which of the following should be included in the nursing care plan? a. Ambulate the client in the ward premises every twenty minutes b. Encourage the client to do self care c. Encourage the client to roll when turning d. Instruct the client to do deep breathing exercise 65. Mr. Pineda, 55 years old executive, is recovering from sever myocardial infarction. For the past 3 days, Mr. Pineda’ hygiene and grooming needs have been met by the nursing staff. Which of the following activities should be implemented to achieve the goal of independence for Mr. Lozano? a. Meeting his need till he is ready to perform self care b. Involving the patient in his care c. Preparing a day to day list to be followed by the client d. Involving family members in meeting client’s personal needs 66. An ambulatory client, Mr. June, is being prepare for bed. Which of the following nursing action promote safety for the client? a. Raising the side rails b. Placing the bed in high position c. Turning off the lights to promote sleep and rest d. Instructing the client about the use of the call system 45. Mr. Villaruel is terminally ill and he chose to be home with his family. What nursing action are best initiated to prepare the family of Mr. Villaruel? a. Provide support to the family members by teaching ways to care for their loved ones b. Convince the client to stay in the hospital for professional care c. Talk with the family members about the advantage of staying in the hospital for proper care d. Tell the client to be with his family

45. Jessica, a 28 year old female client, is admitted with right lower quadrant abdominal pain. The physician diagnosed the client with acute appendicitis and an emergency appendectomy was performed. Twelve hour following surgery, the patient complained of pain. Which of the following is the most appropriate nursing diagnosis? a. Impaired immobility related to pain secondary to abdominal incision b. Severe pain related to surgery c. Impaired mobility related to surgery d. Impaired movement related to pain due to surgery 46. In the a. b. c. d.

teaching instruction for a client with hypoparathyroidism, the nurse would include: A high calcium, high phosphorus diet A high-calcium, Low phosphorus diet A high-protein, high calorie diet A low-calcium, low protein diet

47. The nursing diagnosis Impaired Urinary Elimination has been assigned to client with hyperparathyroidism. To address this diagnosis, the nurse would: a. Withhold acidic juices in the diet b. Force fluid c. Encourage the client to start and stop the urine stream d. Not administer fluid with meals 48. The nurse interpret a Mantoux test reaction as “O millimeters” a negative test. The client tells the nurse, “It’s good to know that I definitely don’t have TB” The correct response would be: a. “A negative test simply means that you do not need treatment at this time” b. “A negative test does not always mean that TB is not present” c. “A negative Mantoux test means that you have not been exposed to TB” d. “This means that you do not have active TB at this time”

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49. A client experiencing Hepatic Encephalopathy is receiving Lactulose. An irate family member asks, “Why in the wolr would the doctor give my husband something that gives him diarrhea when he is already sick?” The nurses’ response would include that the purpose of the lactulose is to: a. Reduce fluid retention c. Change ammonia to urea b. Eliminate Ascites d. Empty the bowel of protein 50. The nurse would assess a knowledge deficit relative to hepatitis immunization when the client who is recovering from hepatitis A says: a. “I have an active immunity from hepatitis A.” b. “Anti-HAV antibodies make me immune form hepatitis A.” c. “Since I’ve had hepatitis A, I’m Immune from hepatitis B and C.” d. “Now that I’ve had Hepatitis A, I’m Immune from Hepatitis A.” Situation: You are taking care of Ms. Quiambao, a 50 year old women who is unconscious after a cerebrevascular accident. You are aware that there are many physical complication due to immobility 51. Proper positioning of an immobilized unconscious client is important for the following reason except: a. Maintain skin integrity b. facilitate rest and sleep c. Promotes optimal lung expansion d. Prevent injuries and deformities of the musculo-skeletal system 52. You should be alert for the following complication she may experience, Except: a. Impaired mobility b. Hypostatic Pneumonia c. Pressure sores d. Contracture and muscle atrophy 53. After moving Ms. Quiambao to the desired position, which of the following action will you avoid? a. Raise bed rails b. Avoid friction between bony prominence c. Place pillows to position client’s extremities d. Apply restraints 54. When positioning your client, you should observe good body mechanics for your self and the client. Thes means that the nurse: a. Assumes correct body alignment and efficient use of muscle to avoid injury b. Uses Back muscle c. Uses large muscle only d. Observes rhythmic movement when moving about 55. You are going to move Ms. Quiambao who weight 150 lbs, unconscious, Some principle is use when moving the client include the following except: a. Maintain wide base of support with feet and knees flexed. b. Prepare to move the client by taking deep breath and tightening abdominal and gluteal muscle c. Push and full using arm and legs instead of lifting d. Move close to the object to be moved leaning or bending at the waist Situation: The nurse supervisor is observing the staff nurse in her hospital to see how quality care provide to clients can be improved 56. To check if the nurses under her supervision use critical thinking. Ms. Belen observes if the nurse act responsibly when at work. Which of the following actions of a nurse demonstrate the attitude of responsibility? a. Planning other approached for patient care b. Thinking of alternative method of nursing care c. Sharing ideas regarding patient care

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d. Following standards of practice 57. The staff nurses discusses with the novice nurse the type of wound dressing that I best to use for the client. Together, they observe how well the dressing absorb the drainage. In what step of decision making process are they? a. Testing option c. Making Final decision b. Defining the problem d. Considering affects on result 58. The nurse who makes clinical judgment can depend upon to improve the quality of care to clients. Nurse Xandra uses such good clinical judgment when she provides priority care to his client? a. Mr. Tan, a client who needs instruction fro home medication b. Felix, A client who is ambulatory and for surgery tomorrow c. A post-operative client, Angel, who has a blood pressure of 90/50 mmHg d. April, a client who received pain medication 5 minutes ago 59. The Nurse supervisor is not satisfied with bed bath that is provided by Nurse Josie. To improve the care provided to the patient in the unit Nurse Josie, the nurse supervisor should: a. Ask another staff nurse to do the bed bath instead b. Bring the staff nurse to a client’s room and demonstrate a cleansing bath c. Tell the nurse how to give bed baths correctly d. Ask another staff nurse to do the bed bath instead

60. A good nursing care plan is dependent on a correctly written nursing diagnosis. It defines a client’s problem and its possible cause. The following is an example of a well written nursing diagnosis: a. Acute pain related to altered skin integrity secondary to hysterectomy b. Altered nutrition related to high fat intake secondary to obesity c. Knowledge deficit related to proctosigmoidoscopy d. Electrolyre imbalance related to hypocalcemia Situation: Nursing Process is utilized in any health care setting whether a nurse is on a community or clinical settings. 61. A patient was admitted at the hospital with a chief complaint of difficulty of breathing, proper assessment was done. The type of assessment applicable at this time would be? a. Initial assessment c. Emergency assessment b. On- going assessment d. Time-lapsed assessment 45. The nursing diagnosis of your patients consist of statements of: a. Health problems b. Medical impression c. Response to illness d. Alteration of health 46. Which patient outcome statement meets the necessary criteria? a. The patient will identify the types of foods to include in a high-fiber diet b. The nurse will teach the patient about constipation prevention c. The nurse will increase total fluids during hospitalization d. The patient will have a soft, formed bowel movement on the third day after nursing interventions 47. A woman who has had four children comes to the clinic. She tells the nurse that when she laughs or coughs she “wets her underwear.” The nurse discusses with the patient exercises that are helpful to reduce the stress incontinence. The nurse teaches the patient to perform Kegel exercises 25 times a day with 4 to 6 repetitions each time. The underlined words indicate : a. The nursing process b. A nursing diagnosis c. An outcome statement

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d. A nursing order 48. Which of the following is not a component of a POMR a. Data base b. Problem List c. Medication Sheet d. Progress Notes

45. The nurse is about to administer Demerol 50mg and Vistaril 50mg IV to the patient. Demerol is available in a multidose vial labeled 100mg/ml while Vistaril comes in an ampule labeled 50 mg/ml. You are to give both medication in one injection. You will: a. Inject air into the vial, then to the ampule b. Withdraw the medication from the vial then from the ampule c. Inject air into the ampule, aspirate desired dose, then into the vial d. Withdraw medication from the ampule then from the vial

21.

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22.B 23.A

43.B

63.A

24.A

44.B

64.D

25.C

45.D

65.A

26.D

46.A

66.D

27.C

47.A

67.B

28.A

48.C

68.D

29.C

49.B

69.C

30.C

50.B

70.B

31.C

51.C

71.B

32.D

52.D

72.C

33.B

53.B

73.C

34.D

54.A

74.D

35.A

55.A

75.D

36.A

56.B

76.C

37.B

57.B

77.B

38.C

58.B

78.D

39.B

59.C

79.C

40.A

60.D

80.B

41.C

61.C

81.A

42.B

62.B

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