1. The nurse In-charge in labor and delivery unit administered a dose of terbutaline to a client without checking the client’s pulse. The standard that would be used to determine if the nurse was negligent is:

a. The physician’s 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/μl. 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.Vb. I.Mc. Orald. S.C

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

a. “Digoxin .1250 mg P.O. once daily”b. “Digoxin 0.1250 mg P.O. once daily”c. “Digoxin 0.125 mg P.O. once daily”d. “Digoxin .125 mg P.O. once daily”

4. A newly admitted female client was diagnosed with deep vein thrombosis. Which nursing diagnosis should receive the highest priority?

a. Ineffective peripheral tissue perfusion related to venous congestion.b. Risk for injury related to edema.c. Excess fluid volume related to peripheral vascular disease.d. Impaired gas exchange related to increased blood flow.

5. Nurse Betty is assigned to the following clients. The client that the nurse would see first after endorsement?

a. A 34 year-old post operative appendectomy client of five hours who is complaining of pain.b. A 44 year-old myocardial infarction (MI) client who is complaining of nausea.c. A 26 year-old client admitted for dehydration whose intravenous (IV) has infiltrated.d. A 63 year-old post operative’s abdominal hysterectomy client of three days whose incisional dressing is saturated with serosanguinous fluid.

6. Nurse Gail places a client in a four-point restraint following orders from the physician. The client care plan should include:

a. Assess temperature frequently.b. Provide diversional activities.c. Check circulation every 15-30 minutes.d. Socialize with other patients once a shift.

7. A male client who has severe burns is receiving H2 receptor antagonist therapy. The nurse In-charge knows the purpose of this therapy is to:

a. Prevent stress ulcerb. Block prostaglandin synthesisc. Facilitate protein synthesis.d. Enhance gas exchange

8. The doctor orders hourly urine output measurement for a postoperative male client. The nurse Trish records the following amounts of output for 2 consecutive hours: 8 a.m.: 50 ml; 9 a.m.: 60 ml. Based on these amounts, which action should the nurse take?

a. Increase the I.V. fluid infusion rateb. Irrigate the indwelling urinary catheterc. Notify the physiciand. Continue to monitor and record hourly urine output

9. Tony, a basketball player twist his right ankle while playing on the court and seeks care for ankle pain and swelling. After the nurse applies ice to the ankle for 30 minutes, which statement by Tony suggests that ice application has been effective?

a. “My ankle looks less swollen now”.b. “My ankle feels warm”.c. “My ankle appears redder now”.d. “I need something stronger for pain relief”

10.The physician prescribes a loop diuretic for a client. When administering this drug, the nurse anticipates that the client may develop which electrolyte imbalance?

a. Hypernatremiab. Hyperkalemiac. Hypokalemiad. Hypervolemia

11.She finds out that some managers have benevolent-authoritative style of management. Which of the following behaviors will she exhibit most likely?

a. Have condescending trust and confidence in their subordinates.b. Gives economic and ego awards.

c. Communicates downward to staffs.d. Allows decision making among subordinates.

12. Nurse Amy is aware that the following is true about functional nursing

a. Provides continuous, coordinated and comprehensive nursing services.b. One-to-one nurse patient ratio.c. Emphasize the use of group collaboration.d. Concentrates on tasks and activities.

13.Which type of medication order might read "Vitamin K 10 mg I.M. daily × 3 days?"

a. Single orderb. Standard written orderc. Standing orderd. Stat order

14.A female client with a fecal impaction frequently exhibits which clinical manifestation?

a. Increased appetiteb. Loss of urge to defecatec. Hard, brown, formed stoolsd. Liquid or semi-liquid stools

15.Nurse Linda prepares to perform an otoscopic examination on a female client. For proper visualization, the nurse should position the client's ear by:

a. Pulling the lobule down and backb. Pulling the helix up and forwardc. Pulling the helix up and backd. Pulling the lobule down and forward

16. Which instruction should nurse Tom give to a male client who is having external radiation therapy:

a. Protect the irritated skin from sunlight.b. Eat 3 to 4 hours before treatment.c. Wash the skin over regularly.d. Apply lotion or oil to the radiated area when it is red or sore.

17.In assisting a female client for immediate surgery, the nurse In-charge is aware that she should:

a. Encourage the client to void following preoperative medication.b. Explore the client’s 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 soundsd. 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 dietb. 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 levelsd. Hgb and Hct levels.

21. Nurse Michelle witnesses a female client sustain a fall and suspects that the leg may be broken. The nurse takes which priority action?

a. Takes a set of vital signs.b. Call the radiology department for X-ray.c. Reassure the client that everything will be alright.d. Immobilize the leg before moving the client.

22.A male client is being transferred to the nursing unit for admission after receiving a radium implant for bladder cancer. The nurse in-charge would take which priority action in the care of this client?

a. Place client on reverse isolation.b. Admit the client into a private room.c. Encourage the client to take frequent rest periods.d. Encourage family and friends to visit.

23.A newly admitted female client was diagnosed with agranulocytosis. The nurse formulates which priority nursing diagnosis?

a. Constipationb. Diarrheac. Risk for infectiond. Deficient knowledge

24.A male client is receiving total parenteral nutrition suddenly demonstrates signs and symptoms of an air embolism. What is the priority action by the nurse?

a. Notify the physician.b. Place the client on the left side in the Trendelenburg position.c. Place the client in high-Fowlers position.d. Stop the total parenteral nutrition.

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

a. Autocratic.b. Laissez-faire.c. Democratic.d. Situational

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

a. .5 ccb. 5 ccc. 1.5 ccd. 2.5 cc

27.A child of 10 years old is to receive 400 cc of IV fluid in an 8 hour shift. The IV drip factor is 60. The IV rate that will deliver this amount is:

a. 50 cc/ hourb. 55 cc/ hourc. 24 cc/ hourd. 66 cc/ hour

28.The nurse is aware that the most important nursing action when a client returns from surgery is:

a. Assess the IV for type of fluid and rate of flow.b. Assess the client for presence of pain.c. Assess the Foley catheter for patency and urine outputd. Assess the dressing for drainage.

29. Which of the following vital sign assessments that may indicate cardiogenic shock after myocardial infarction?

a. BP – 80/60, Pulse – 110 irregularb. BP – 90/50, Pulse – 50 regularc. BP – 130/80, Pulse – 100 regulard. BP – 180/100, Pulse – 90 irregular

30.Which is the most appropriate nursing action in obtaining a blood pressure measurement?

a. Take the proper equipment, place the client in a comfortable position, and record the appropriate information in the client’s chart.b. Measure the client’s arm, if you are not sure of the size of cuff to use.c. Have the client recline or sit comfortably in a chair with the forearm at the level of the heart.d. Document the measurement, which extremity was used, and the position that the client was in during the measurement.

31.Asking the questions to determine if the person understands the health teaching provided by the nurse would be included during which step of the nursing process?

a. Assessmentb. Evaluationc. Implementationd. Planning and goals

32.Which of the following item is considered the single most important factor in assisting the health professional in arriving at a diagnosis or determining the person’s needs?

a. Diagnostic test resultsb. Biographical datec. History of present illnessd. Physical examination

33.In preventing the development of an external rotation deformity of the hip in a client who must remain in bed for any period of time, the most appropriate nursing action would be to use:

a. Trochanter roll extending from the crest of the ileum to the midthigh.b. Pillows under the lower legs.c. Footboardd. Hip-abductor pillow

34.Which stage of pressure ulcer development does the ulcer extend into the subcutaneous

tissue?

a. Stage Ib. Stage IIc. Stage IIId. Stage IV

35.When the method of wound healing is one in which wound edges are not surgically approximated and integumentary continuity is restored by granulations, the wound healing is termed

a. Second intention healingb. Primary intention healingc. Third intention healingd. First intention healing

36.An 80-year-old male client is admitted to the hospital with a diagnosis of pneumonia. Nurse Oliver learns that the client lives alone and hasn’t been eating or drinking. When assessing him for dehydration, nurse Oliver would expect to find:

a. Hypothermiab. Hypertensionc. Distended neck veinsd. Tachycardia

37.The physician prescribes meperidine (Demerol), 75 mg I.M. every 4 hours as needed, to control a client’s postoperative pain. The package insert is “Meperidine, 100 mg/ml.” How many milliliters of meperidine should theclient receive?

a. 0.75b. 0.6c. 0.5d. 0.25

38. A male client with diabetes mellitus is receiving insulin. Which statement correctly describes an insulin unit?

a. It’s a common measurement in the metric system.b. It’s the basis for solids in the avoirdupois system.c. It’s the smallest measurement in the apothecary system.d. It’s a measure of effect, not a standard measure of weight or quantity.

39.Nurse Oliver measures a client’s temperature at 102° F. What is the equivalent Centigrade temperature?

a. 40.1 °Cb. 38.9 °C

c. 48 °Cd. 38 °C

40.The nurse is assessing a 48-year-old client who has come to the physician’s office for his annual physical exam. One of the first physicalsigns 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 client’s identity before administering medication. She is aware that the safest way to verify identity is to:

a. Check the client’s identification band.b. Ask the client to state his name.c. State the client’s name out loud and wait a client to repeat it.d. Check the room number and the client’s name on the bed.

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

a. 30 drops/minuteb. 32 drops/minutec. 20 drops/minuted. 18 drops/minute

44.If a central venous catheter becomes disconnected accidentally, what should the nurse in-charge do immediately?

a. Clamp the catheterb. Call another nursec. Call the physiciand. 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 client’s

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. Fingertipsb. Finger padsc. Dorsal surface of the handd. Ulnar surface of the hand

47. Which type of evaluation occurs continuously throughout the teaching and learning process?

a. Summativeb. Informativec. Formatived. Retrospective

48.A 45 year old client, has no family history of breast cancer or other risk factors for this disease. Nurse John should instruct her to havemammogram how often?

a. Twice per yearb. Once per yearc. Every 2 yearsd. Once, to establish baseline

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

a. Respiratory acidosisb. Respiratory alkalosisc. Metabolic acidosisd. Metabolic alkalosis

50.Nurse Len refers a female client with terminal cancer to a local hospice. What is the goal of this referral?

a. To help the client find appropriate treatment options.b. To provide support for the client and family in coping with terminal illness.

c. To ensure that the client gets counseling regarding health care costs.d. To teach the client and family about cancer and its treatment.

51.When caring for a male client with a 3-cm stage I pressure ulcer on the coccyx, which of the following actions can the nurse instituteindependently?

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 client’s ankle and calf. He should apply the bandage beginning at the client’s:

a. Kneeb. Anklec. Lower thighd. 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. Hypernatremiab. Hypokalemiac. Hyperphosphatemiad. Hypercalcemia

54.Nurse Len is administering sublingual nitrglycerin (Nitrostat) to the newly admitted client. Immediately afterward, the client may experience:

a. Throbbing headache or dizzinessb. 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 client’s room. Upon reaching the client’s bedside, the nurse would take which action first?

a. Prepare for cardioversionb. Prepare to defibrillate the clientc. Call a coded. Check the client’s 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/hrb. Capillary refill: 5 secondsc. Serum pH: 7.32d. Blood pressure: 90/48 mmHg

58. Nurse Amy has an order to obtain a urinalysis from a male client with an indwelling urinary catheter. The nurse avoids which of the following, which contaminate the specimen?

a. Wiping the port with an alcohol swab before inserting the syringe.b. Aspirating a sample from the port on the drainage bag.c. Clamping the tubing of the drainage bag.d. Obtaining the specimen from the urinary drainage bag.

59.Nurse Meredith is in the process of giving a client a bed bath. In the middle of the procedure, the unit secretary calls the nurse on the intercom to tell the nurse that there is an emergency phone call. The appropriate nursing action is to:

a. Immediately walk out of the client’s room and answer the phone call.b. Cover the client, place the call light within reach, and answer the phone call.c. Finish the bed bath before answering the phone call.d. Leave the client’s door open so the client can be monitored and the nurse can answer the phone call.

60. Nurse Janah is collecting a sputum specimen for culture and sensitivity testing from a client who has a productive cough. Nurse Janah plans to implement which intervention to obtain the specimen?

a. Ask the client to expectorate a small amount of sputum into the emesis basin.b. Ask the client to obtain the specimen after breakfast.c. Use a sterile plastic container for obtaining the specimen.d. Provide tissues for expectoration and obtaining the specimen.

61. Nurse Ron is observing a male client using a walker. The nurse determines that the client is using the walker correctly if the client:

a. Puts all the four points of the walker flat on the floor, puts weight on the hand pieces, and then walks into it.

b. Puts weight on the hand pieces, moves the walker forward, and then walks into it.c. Puts weight on the hand pieces, slides the walker forward, and then walks into it.d. Walks into the walker, puts weight on the hand pieces, and then puts all four points of the walker flat on the floor.

62.Nurse Amy has documented an entry regarding client care in the client’s medical record. When checking the entry, the nurse realizes that incorrect information was documented. How does the nurse correct this error?

a. Erases the error and writes in the correct information.b. Uses correction fluid to cover up the incorrect information and writes in the correct information.c. Draws one line to cross out the incorrect information and then initials the change.d. Covers up the incorrect information completely using a black pen and writes in the correct information

63.Nurse Ron is assisting with transferring a client from the operating room table to a stretcher. To provide safety to the client, the nurse should:

a. Moves the client rapidly from the table to the stretcher.b. Uncovers the client completely before transferring to the stretcher.c. Secures the client safety belts after transferring to the stretcher.d. Instructs the client to move self from the table to the stretcher.

64.Nurse Myrna is providing instructions to a nursing assistant assigned to give a bed bath to a client who is on contact precautions. Nurse Myrna instructs the nursing assistant to use which of the following protective items when giving bed bath?

a. Gown and gogglesb. Gown and glovesc. Gloves and shoe protectorsd. 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. Crutchesb. Single straight-legged canec. Quad caned. Walker

66.A male client with a right pleural effusion noted on a chest X-ray is being prepared for thoracentesis. The client experiences severe dizziness when sitting upright. To provide a safe environment, the nurse assists the client to which position for the procedure?

a. Prone with head turned toward the side supported by a pillow.b. Sims’ position with the head of the bed flat.c. Right side-lying with the head of the bed elevated 45 degrees.d. Left side-lying with the head of the bed elevated 45 degrees.

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

a. Validityb. Specificityc. Sensitivityd. Reliability

68.Harry knows that he has to protect the rights of human research subjects. Which of the following actions of Harry ensures anonymity?

a. Keep the identities of the subject secretb. Obtain informed consentc. Provide equal treatment to all the subjects of the study.d. Release findings only to the participants of the study

69.Patient’s refusal to divulge information is a limitation because it is beyond the control of Tifanny”. What type of research is appropriate for this study?

a. Descriptive- correlationalb. Experimentc. Quasi-experimentd. Historical

70.Nurse Ronald is aware that the best tool for data gathering is?

a. Interview scheduleb. Questionnairec. Use of laboratory datad. Observation

71.Monica is aware that there are times when only manipulation of study variables is possible and the elements of control or randomization are not attendant. Which type of research is referred to this?

a. Field studyb. Quasi-experimentc. Solomon-Four group designd. Post-test only design

72.Cherry notes down ideas that were derived from the description of an investigation

written by the person who conducted it. Which type of reference source refers to this?

a. Footnoteb. Bibliographyc. Primary sourced. Endnotes

73.When Nurse Trish is providing care to his patient, she must remember that her duty is bound not to do doing any action that will cause the patient harm. This is the meaning of the bioethical principle:

a. Non-maleficenceb. Beneficencec. Justiced. Solidarity

74.When a nurse in-charge causes an injury to a female patient and the injury caused becomes the proof of the negligent act, the presence of the injury is said to exemplify the principle of:

a. Force majeureb. Respondeat superiorc. Res ipsa loquitord. 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 nursingb. The Board can investigate violations of the nursing law and code of ethicsc. The Board can visit a school applying for a permit in collaboration with CHEDd. 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 lifeb. Will never have her/his license re-issued since it has been revokedc. May apply for re-issuance of his/her license based on certain conditions stipulated in RA 9173d. 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 hypothesisb. Review related literature

c. Formulating and delimiting the research problemd. 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 effectb. Hawthorne effectc. Halo effectd. Horns effect

79.Mary finally decides to use judgment sampling on her research. Which of the following actions of is correct?

a. Plans to include whoever is there during his study.b. Determines the different nationality of patients frequently admitted and decides to get representations samples from each.c. Assigns numbers for each of the patients, place these in a fishbowl and draw 10 from it.d. Decides to get 20 samples from the admitted patients

80. The nursing theorist who developed transcultural nursing theory is:

a. Florence Nightingaleb. Madeleine Leiningerc. Albert Moored. Sr. Callista Roy

81.Marion is aware that the sampling method that gives equal chance to all units in the population to get picked is:

a. Randomb. Accidentalc. Quotad. Judgment

82.John plans to use a Likert Scale to his study to determine the:

a. Degree of agreement and disagreementb. Compliance to expected standardsc. Level of satisfactiond. Degree of acceptance

83.Which of the following theory addresses the four modes of adaptation?

a. Madeleine Leiningerb. Sr. Callista Roy

c. Florence Nightingaled. Jean Watson

84.Ms. Garcia is responsible to the number of personnel reporting to her. This principle refers to:

a. Span of controlb. Unity of commandc. Downward communicationd. Leader

85.Ensuring that there is an informed consent on the part of the patient before a surgery is done, illustrates the bioethical principle of:

a. Beneficenceb. Autonomyc. Veracityd. Non-maleficence

86.Nurse Reese is teaching a female client with peripheral vascular disease about foot care; Nurse Reese should include which instruction?

a. Avoid wearing cotton socks.b. Avoid using a nail clipper to cut toenails.c. Avoid wearing canvas shoes.d. Avoid using cornstarch on feet.

87.A client is admitted with multiple pressure ulcers. When developing the client's diet plan, the nurse should include:

a. Fresh orange slicesb. Steamed broccolic. Ice creamd. Ground beef patties

88.The nurse prepares to administer a cleansing enema. What is the most common client position used for this procedure?

a. Lithotomyb. Supinec. Proned. Sims’ left lateral

89.Nurse Marian is preparing to administer a blood transfusion. Which action should the nurse take first?

a. Arrange for typing and cross matching of the client’s blood.b. Compare the client’s identification wristband with the tag on the unit of blood.c. Start an I.V. infusion of normal saline solution.d. Measure the client’s 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. Independentb. Dependentc. Interdependentd. 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. Assessmentb. Diagnosisc. Implementationd. 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 heartb. To observe the lower extremitiesc. To allow the leg muscles to stretch and relaxd. 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 client’s 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 hoursb. 4 hoursc. 3 hoursd. 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.

1. Answer: (D) The actions of a reasonably 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.MRationale: With a platelet count of 22,000/μl, 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 daily”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 client’s 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 ulcerRationale: Curling’s ulcer occurs as a generalized stress response in burn patients. This results in a decreased production of mucus and increased secretion of gastric acid. The best treatment for this prophylactic use of antacids and H2 receptor blockers.

8. Answer: (D) Continue to monitor and record hourly urine outputRationale: Normal urine output for an adult is approximately 1 ml/minute (60 ml/hour). Therefore, this client's output is normal. Beyond continued evaluation, no nursing action is warranted.

9. Answer: (B) “My ankle feels warm”.Rationale: Ice application decreases pain and swelling. Continued or increased pain, redness, and increased warmth are signs of inflammation that shouldn't occur after ice application

10. Answer: (B) HyperkalemiaRationale: A loop diuretic removes water and, along with it, sodium and potassium. This may result in hypokalemia, hypovolemia, and hyponatremia.

11. Answer:(A) Have condescending trust and confidence in their subordinatesRationale: Benevolent-authoritative managers pretentiously show their trust and confidence to their followers.

12. Answer: (A) Provides continuous, coordinated and comprehensive nursing services.Rationale: Functional nursing is focused on tasks and activities and not on the care of the patients.

13. Answer: (B) Standard written orderRationale: This is a standard written order. Prescribers write a single order for medications given only once. A stat order is written formedications given immediately for an urgent client problem. A standing order, also known as a protocol, establishes guidelines for treating aparticular disease or set of symptoms in special care areas such as the coronary care unit. Facilities also may institute medication protocols that specifically designate drugs that a nurse may not give.

14. Answer: (D) Liquid or semi-liquid stoolsRationale: Passage of liquid or semi-liquid stools results from seepage of unformed bowel contents around the impacted stool in the rectum. Clientswith fecal impaction don't pass hard, brown, formed stools because the feces can't move past the impaction. These clients typically report the urgeto defecate (although they can't pass stool) and a decreased appetite.

15. Answer: (C) Pulling the helix up and backRationale: 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.

16. Answer: (A) Protect the irritated skin from sunlight.Rationale: Irradiated skin is very sensitive and must be protected with clothing or sunblock. The priority approach is the avoidance of strong sunlight.

17. Answer: (C) Assist the client in removing dentures and nail polish.Rationale: Dentures, hairpins, and combs must be removed. Nail polish must be removed so that cyanosis can be easily monitored by observing the nail beds.

18. Answer: (D) Sudden onset of continuous epigastric and back pain.Rationale: The autodigestion of tissue by the pancreatic enzymes results in pain from inflammation, edema, and possible hemorrhage. Continuous, unrelieved epigastric or back pain reflects the inflammatory process in the pancreas.

19. Answer: (B) Provide high-protein, high-carbohydrate diet.Rationale: A positive nitrogen balance is important for meeting metabolic needs, tissue repair, and resistance to infection. Caloric goals may be as high as 5000 calories per day.

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 infectionRationale: 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 ccRationale: 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/ hourRationale: A rate of 50 cc/hr. The child is to receive 400 cc over a period of 8 hours = 50 cc/hr.

28. Answer: (B) Assess the client for presence of pain.Rationale: Assessing the client for pain is a very important measure. Postoperative pain is an indication of complication. The nurse should also assess the client for pain to provide for the client’s comfort.

29. Answer: (A) BP – 80/60, Pulse – 110 irregularRationale: The classic signs of cardiogenic shock are low blood pressure, rapid and weak irregular pulse, cold, clammy skin, decreased urinary output, and cerebral hypoxia.

30. Answer: (A) Take the proper equipment, place the client in a comfortable position, and record the appropriate information in the client’s chart.Rationale: It is a general or comprehensive statement about the correct procedure, and it includes the basic ideas which are found in the other options

31. Answer: (B) EvaluationRationale: Evaluation includes observing the person, asking questions, and comparing the patient’s behavioral responses with the expected outcomes.

32. Answer: (C) History of present illnessRationale: The history of present illness is the single most important factor in assisting the health professional in arriving at a diagnosis or determining the person’s needs.

33. Answer: (A) Trochanter roll extending from the crest of the ileum to the mid-thigh.Rationale: A trochanter roll, properly placed, provides resistance to the external rotation of the hip.

34. Answer: (C) Stage IIIRationale: Clinically, a deep crater or without undermining of adjacent tissue is noted.

35. Answer: (A) Second intention healingRationale: When wounds dehisce, they will allowed to heal by secondary intention

36. Answer: (D) TachycardiaRationale: With an extracellular fluid or plasma volume deficit, compensatory mechanisms stimulate the heart, causing an increase in heart rate.

37. Answer: (A) 0.75Rationale: To determine the number of milliliters the client should receive, the nurse uses the fraction method in the following equation.75 mg/X ml = 100 mg/1 mlTo solve for X, cross-multiply:75 mg x 1 ml = X ml x 100 mg75 = 100X75/100 = X0.75 ml (or ¾ ml) = X

38. Answer: (D) It’s a measure of effect, not a standard measure of weight or quantity.Rationale: An insulin unit is a measure of effect, not a standard measure of weight or quantity. Different drugs measured in units may have no relationship to one another in quality or quantity.

39. Answer: (B) 38.9 °CRationale: To convert Fahrenheit degreed to Centigrade, use this formula°C = (°F – 32) ÷ 1.8°C = (102 – 32) ÷ 1.8°C = 70 ÷ 1.8°C = 38.9

40. Answer: (C) Failing eyesight, especially close vision.Rationale: Failing eyesight, especially close vision, is one of the first signs of aging in middle life (ages 46 to 64). More frequent aches and pains begin in the early late years (ages 65 to 79). Increase in loss of muscle tone occurs in later years (age 80 and older).

41. Answer: (A) Checking and taping all connectionsRationale: Air leaks commonly occur if the system isn’t secure. Checking all connections and taping them will prevent air leaks. The chest drainage system is kept lower to promote drainage – not to prevent leaks.

42. Answer: (A) Check the client’s identification band.Rationale: Checking the client’s identification band is the safest way to verify a client’s identity because the band is assigned on admission and isn’t be removed at any time. (If it is removed, it must be replaced). Asking the client’s name or having the client repeated his name would be appropriate only for a client who’s alert, oriented, and able to understand what is being said, but isn’t the safe standard of practice. Names on bed aren’t always reliable

43. Answer: (B) 32 drops/minuteRationale: Giving 1,000 ml over 8 hours is the same as giving 125 ml over 1 hour (60 minutes). Find the number of milliliters per minute as follows:125/60 minutes = X/1 minute60X = 125 = 2.1 ml/minuteTo find the number of drops per minute:2.1 ml/X gtt = 1 ml/ 15 gttX = 32 gtt/minute, or 32 drops/minute

44. Answer: (A) Clamp the catheterRationale: If a central venous catheter becomes disconnected, the nurse should immediately apply a catheter clamp, if available. If a clamp isn’t available, the nurse can place a sterile syringe or catheter plug in the catheter hub. After cleaning the hub with alcohol or povidone-iodine solution, the nurse must replace the I.V. extension and restart the infusion.

45. Answer: (D) Auscultation, percussion, and palpation.Rationale: The correct order of assessment for examining the abdomen is inspection, auscultation, percussion, and palpation. The reason for this approach is that the less intrusive techniques should be performed before the more intrusive techniques. Percussion and palpation can alter natural findings during auscultation.

46. Answer: (D) Ulnar surface of the handRationale: The nurse uses the ulnar surface, or ball, of the hand to asses tactile fremitus, thrills, and vocal vibrations through the chest wall. Thefingertips and finger pads best distinguish texture and shape. The dorsal surface best feels warmth.

47. Answer: (C) FormativeRationale: Formative (or concurrent) evaluation occurs continuously throughout the teaching and learning process. One benefit is that the 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 yearRationale: Yearly mammograms should begin at age 40 and continue foras long as the woman is in good health. If health risks, such as familyhistory, genetic tendency, or past breast cancer, exist, more frequentexaminations may be necessary.

49. Answer: (A) Respiratory acidosisRationale: 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 doesn’t 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 nurse’s realm of interventions and will protect the area. Using a povidone-iodine wash and an antibiotic cream require a physician’s order. Massaging with an astringent can further damage the skin.

52. Answer: (D) FootRationale: 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 the client’s foot. Beginning at the ankle, lower thigh, or knee does not promote venous return.

53. Answer: (B) HypokalemiaRationale: Insulin administration causes glucose and potassium to move into the cells, causing hypokalemia.

54. Answer: (A) Throbbing headache or dizzinessRationale: 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 client’s level of consciousnessRationale: 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.

57. Answer: (A) Urine output: 45 ml/hrRationale: Adequate perfusion must be maintained to all vital organs in order for the client to remain visible as an organ donor. A urine output of 45 ml per hour indicates adequate renal perfusion. Low blood pressure and delayed capillary refill time are circulatory system indicators of inadequate perfusion. A serum pH of 7.32 is acidotic, which adversely affects all body tissues.

58. Answer: (D ) Obtaining the specimen from the urinary drainage bag.Rationale: A urine specimen is not taken from the urinary drainage bag. Urine undergoes chemical changes while sitting in the bag and does not necessarily reflect the current client status. In addition, it may become contaminated with bacteria from opening the system.

59. Answer: (B) Cover the client, place the call light within reach, and answer the phone call.Rationale: Because telephone call is an emergency, the nurse may need to answer it. The other appropriate action is to ask another nurse to accept the call. However, is not one of the options. To maintain privacy and safety, the nurse covers the client and places the call light within the client’s reach. Additionally, the client’s door should be closed or the room curtains pulled around the bathing area.

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 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 glovesRationale: Contact precautions require the use of gloves and a gown if direct client contact is anticipated. Goggles are not necessary unless thenurse anticipates the splashes of blood, body fluids, secretions, or excretions may occur. Shoe protectors are not necessary.

65. Answer: (C) Quad caneRationale: 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) ReliabilityRationale: Reliability is consistency of the research instrument. It refers tothe repeatability of the instrument in extracting the same responses uponits repeated administration.

68. Answer: (A) Keep the identities of the subject secretRationale: 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.

69. Answer: (A) Descriptive- correlationalRationale: Descriptive- correlational study is the most appropriate for this study because it studies the variables that could be the antecedents of the increased incidence of nosocomial infection.

70. Answer: (C) Use of laboratory dataRationale: Incidence of nosocomial infection is best collected through the use of biophysiologic measures, particularly in vitro measurements, hence laboratory data is essential.

71. Answer: (B) Quasi-experimentRationale: Quasi-experiment is done when randomization and control of the variables are not possible.

72. Answer: (C) Primary sourceRationale: This refers to a primary source which is a direct account of the investigation done by the investigator. In contrast to this is a secondary source, which is written by someone other than the original researcher.

73. Answer: (A) Non-maleficenceRationale: Non-maleficence means do not cause harm or do any action that will cause any harm to the patient/client. To do good is referred as beneficence.

74. Answer: (C) Res ipsa loquitorRationale: Res ipsa loquitor literally means the thing speaks for itself. This means in operational terms that the injury caused is the proof that there was a negligent act.

75. Answer: (B) The Board can investigate violations of the nursing law and code of ethicsRationale: Quasi-judicial power means that the Board of Nursing has the authority to investigate violations of the nursing law and can issue summons, subpoena or subpoena duces tecum as needed.

76. Answer: (C) May apply for re-issuance of his/her license based on certain conditions stipulated in RA 9173Rationale: RA 9173 sec. 24 states that for equity and justice, a revoked license maybe re-issued provided that the following conditions are met: a)the cause for revocation of license has already been corrected or removed; and, b) at least four years has elapsed since the license has been revoked.

77. Answer: (B) Review related literatureRationale: 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 effectRationale: 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 LeiningerRationale: Madeleine Leininger developed the theory on transcultural theory based on her observations on the behavior of selected people within a culture.

81. Answer: (A) RandomRationale: Random sampling gives equal chance for all the elements in the population to be picked as part of the sample.

82. Answer: (A) Degree of agreement and disagreementRationale: Likert scale is a 5-point summated scale used to determine the degree of agreement or disagreement of the respondents to a statement in a study

83. Answer: (B) Sr. Callista RoyRationale: Sr. Callista Roy developed the Adaptation Model which involves the physiologic mode, self-concept mode, role function mode and dependence mode.

84. Answer: (A) Span of controlRationale: Span of control refers to the number of workers who report directly to a manager.

85. Answer: (B) AutonomyRationale: 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.

86. Answer: (C) Avoid wearing canvas shoes.Rationale: The client should be instructed to avoid wearing canvas shoes. Canvas shoes cause the feet to perspire, which may, in turn, cause skinirritation and breakdown. Both cotton and cornstarch absorb perspiration. The client should be instructed to cut toenails straight across with nailclippers.

87. Answer: (D) Ground beef pattiesRationale: Meat is an excellent source of complete protein, which this client needs to repair the tissue breakdown caused by pressure ulcers.Oranges and broccoli supply vitamin C but not protein. Ice cream supplies only some incomplete protein, making it less helpful in tissue repair.

88. Answer: (D) Sims’ left lateralRationale: The Sims' left lateral position is the 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 colon. If the client can't assume this position nor has poor sphincter control, the dorsal recumbent or right lateral position may be used. The supine and prone positions are inappropriate and uncomfortable for the client.

89. Answer: (A) Arrange for typing and cross matching of the client’s blood.Rationale: The nurse first arranges for typing and cross matching of the client's blood to ensure compatibility with donor blood. The other options,although appropriate when preparing to administer a blood transfusion, come later.

90. Answer: (A) IndependentRationale: 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) EvaluationRationale: 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 extremitiesRationale: 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 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.

95. Answer: (D) Roll the vial gently between the palms.Rationale: Rolling the vial gently between the palms produces heat, which helps dissolve the medication. Doing nothing or inverting the vial wouldn't help dissolve the medication. Shaking the vial vigorously could cause the medication to break down, altering its action.

96. Answer: (B) Assist the client to the semi-Fowler position if possible.Rationale: By assisting the client to the semi-Fowler position, the nurse promotes easier chest expansion, breathing, and oxygen intake. The nurse should secure the elastic band so that the face mask fits comfortably and snugly rather than tightly, which could lead to irritation. The nurse should apply the face mask from the client's nose down to the chin — not vice versa. The nurse should check the connectors between the oxygen equipment and humidifier to ensure that they're airtight; loosened connectors can cause loss of oxygen.

97. Answer: (B) 4 hoursRationale: A unit of packed RBCs may be given over a period of between 1 and 4 hours. It shouldn't infuse for longer than 4 hours because the risk of contamination and sepsis increases after that time. Discard or return to the blood bank any blood not given within this time, according to facility policy.

98. Answer: (B) Immediately before administering the next dose.Rationale: Measuring the blood drug concentration helps determine whether the dosing has achieved the therapeutic goal. For measurement of the trough, or lowest, blood level of a drug, the nurse draws a blood sample immediately before administering the next dose. Depending on the drug's duration of action and half-life, peak blood drug levels typically are drawn after administering the next dose.

99. Answer: (A) The nurse can implement medication orders quickly.Rationale: A floor stock system enables the nurse to implement medication orders quickly. It doesn't allow for pharmacist input, nor does it minimize transcription errors or reinforce accurate calculations.

100. Answer: (C) Shifting dullness over the abdomen.

Rationale: Shifting dullness over the abdomen indicates ascites, an abnormal finding. The other options are normal abdominal findings.

1. Which element in the circular chain of infection can be eliminated by preserving skin integrity?

a. Hostb. Reservoirc. Mode of transmissiond. Portal of entry

2. Which of the following will probably result in a break in sterile technique for respiratory isolation?

a. Opening the patient’s window to the outside environmentb. Turning on the patient’s room ventilatorc. Opening the door of the patient’s room leading into the hospital corridord. Failing to wear gloves when administering a bed bath

3. Which of the following patients is at greater risk for contracting an infection?

a. A patient with leukopeniab. A patient receiving broad-spectrum antibioticsc. A postoperative patient who has undergone orthopedic surgeryd. A newly diagnosed diabetic patient

4. Effective hand washing requires the use of:

a. Soap or detergent to promote emulsificationb. Hot water to destroy bacteriac. A disinfectant to increase surface tension

d. All of the above

5. After routine patient contact, hand washing should last at least:

a. 30 secondsb. 1 minutec. 2 minuted. 3 minutes

6. Which of the following procedures always requires surgical asepsis?

a. Vaginal instillation of conjugated estrogenb. Urinary catheterizationc. Nasogastric tube insertiond. Colostomy irrigation

7. Sterile technique is used whenever:

a. Strict isolation is requiredb. Terminal disinfection is performedc. Invasive procedures are performedd. Protective isolation is necessary

8. Which of the following constitutes a break in sterile technique while preparing a sterile field for a dressing change?

a. Using sterile forceps, rather than sterile gloves, to handle a sterile itemb. Touching the outside wrapper of sterilized material without sterile glovesc. Placing a sterile object on the edge of the sterile fieldd. Pouring out a small amount of solution (15 to 30 ml) before pouring the solution into a sterile container

9. A natural body defense that plays an active role in preventing infection is:

a. Yawningb. Body hairc. Hiccuppingd. Rapid eye movements

10. All of the following statement are true about donning sterile gloves except:

a. The first glove should be picked up by grasping the inside of the cuff.b. The second glove should be picked up by inserting the gloved fingers under the cuff outside the glove.

c. The gloves should be adjusted by sliding the gloved fingers under the sterile cuff and pulling the glove over the wristd. The inside of the glove is considered sterile

11.When removing a contaminated gown, the nurse should be careful that the first thing she touches is the:

a. Waist tie and neck tie at the back of the gownb. Waist tie in front of the gownc. Cuffs of the gownd. Inside of the gown

12.Which of the following nursing interventions is considered the most effective form or universal precautions?

a. Cap all used needles before removing them from their syringesb. Discard all used uncapped needles and syringes in an impenetrable protective containerc. Wear gloves when administering IM injectionsd. Follow enteric precautions

13.All of the following measures are recommended to prevent pressure ulcers except:

a. Massaging the reddened are with lotionb. Using a water or air mattressc. Adhering to a schedule for positioning and turningd. Providing meticulous skin care

14.Which of the following blood tests should be performed before a blood transfusion?

a. Prothrombin and coagulation timeb. Blood typing and cross-matchingc. Bleeding and clotting timed. Complete blood count (CBC) and electrolyte levels.

15.The primary purpose of a platelet count is to evaluate the:

a. Potential for clot formationb. Potential for bleedingc. Presence of an antigen-antibody responsed. Presence of cardiac enzymes

16.Which of the following white blood cell (WBC) counts clearly indicates leukocytosis?

a. 4,500/mm³b. 7,000/mm³

c. 10,000/mm³d. 25,000/mm³

17. After 5 days of diuretic therapy with 20mg of furosemide (Lasix) daily, a patient begins to exhibit fatigue, muscle cramping and muscle weakness. These symptoms probably indicate that the patient is experiencing:

a. Hypokalemiab. Hyperkalemiac. Anorexiad. Dysphagia

18.Which of the following statements about chest X-ray is false?

a. No contradictions exist for this testb. Before the procedure, the patient should remove all jewelry, metallic objects, and buttons above the waistc. A signed consent is not requiredd. Eating, drinking, and medications are allowed before this test

19.The most appropriate time for the nurse to obtain a sputum specimen for culture is:

a. Early in the morningb. After the patient eats a light breakfastc. After aerosol therapyd. After chest physiotherapy

20.A patient with no known allergies is to receive penicillin every 6 hours. When administering the medication, the nurse observes a fine rash on thepatient’s skin. The most appropriate nursing action would be to:

a. Withhold the moderation and notify the physicianb. Administer the medication and notify the physicianc. Administer the medication with an antihistamined. Apply corn starch soaks to the rash

21.All of the following nursing interventions are correct when using the Ztrack method of drug injection except:

a. Prepare the injection site with alcoholb. Use a needle that’s a least 1” longc. Aspirate for blood before injectiond. Rub the site vigorously after the injection to promote absorption

22.The correct method for determining the vastus lateralis site for I.M. injection is to:

a. Locate the upper aspect of the upper outer quadrant of the buttock about 5 to 8 cm below the iliac crestb. Palpate the lower edge of the acromion process and the midpoint lateral aspect of the armc. Palpate a 1” circular area anterior to the umbilicusd. Divide the area between the greater femoral trochanter and the lateral femoral condyle into thirds, and select the middle third on the anterior of the thigh

23.The mid-deltoid injection site is seldom used for I.M. injections because it:

a. Can accommodate only 1 ml or less of medicationb. Bruises too easilyc. Can be used only when the patient is lying downd. Does not readily parenteral medication

24.The appropriate needle size for insulin injection is:

a. 18G, 1 ½” longb. 22G, 1” longc. 22G, 1 ½” longd. 25G, 5/8” long

25.The appropriate needle gauge for intradermal injection is:

a. 20Gb. 22Gc. 25Gd. 26G

26.Parenteral penicillin can be administered as an:

a. IM injection or an IV solutionb. IV or an intradermal injectionc. Intradermal or subcutaneous injectiond. IM or a subcutaneous injection

27.The physician orders gr 10 of aspirin for a patient. The equivalent dose in milligrams is:

a. 0.6 mgb. 10 mgc. 60 mgd. 600 mg

28.The physician orders an IV solution of dextrose 5% in water at 100ml/hour. What would the flow rate be if the drop factor is 15 gtt = 1 ml?

a. 5 gtt/minuteb. 13 gtt/minutec. 25 gtt/minuted. 50 gtt/minute

29.Which of the following is a sign or symptom of a hemolytic reaction to blood transfusion?

a. Hemoglobinuriab. Chest painc. Urticariad. Distended neck veins

30.Which of the following conditions may require fluid restriction?

a. Feverb. Chronic Obstructive Pulmonary Diseasec. Renal Failured. Dehydration

31.All of the following are common signs and symptoms of phlebitis except:

a. Pain or discomfort at the IV insertion siteb. Edema and warmth at the IV insertion sitec. A red streak exiting the IV insertion sited. Frank bleeding at the insertion site

32.The best way of determining whether a patient has learned to instill ear medication properly is for the nurse to:

a. Ask the patient if he/she has used ear drops beforeb. Have the patient repeat the nurse’s instructions using her own wordsc. Demonstrate the procedure to the patient and encourage to ask questionsd. Ask the patient to demonstrate the procedure

33.Which of the following types of medications can be administered via gastrostomy tube?

a. Any oral medicationsb. Capsules whole contents are dissolve in waterc. Enteric-coated tablets that are thoroughly dissolved in waterd. Most tablets designed for oral use, except for extended-duration compounds

34.A patient who develops hives after receiving an antibiotic is exhibiting drug:

a. Toleranceb. Idiosyncrasyc. Synergismd. Allergy

35.A patient has returned to his room after femoral arteriography. All of the following are appropriate nursing interventions except:

a. Assess femoral, popliteal, and pedal pulses every 15 minutes for 2 hoursb. Check the pressure dressing for sanguineous drainagec. Assess a vital signs every 15 minutes for 2 hoursd. Order a hemoglobin and hematocrit count 1 hour after the arteriography

36.The nurse explains to a patient that a cough:

a. Is a protective response to clear the respiratory tract of irritantsb. Is primarily a voluntary actionc. Is induced by the administration of an antitussive drugd. Can be inhibited by “splinting” the abdomen

37.An infected patient has chills and begins shivering. The best nursing intervention is to:

a. Apply iced alcohol spongesb. Provide increased cool liquidsc. Provide additional bedclothesd. Provide increased ventilation

38.A clinical nurse specialist is a nurse who has:

a. Been certified by the National League for Nursingb. Received credentials from the Philippine Nurses’ Associationc. Graduated from an associate degree program and is a registered professional nursed. Completed a master’s degree in the prescribed clinical area and is a registered professional nurse.

39.The purpose of increasing urine acidity through dietary means is to:

a. Decrease burning sensationsb. Change the urine’s colorc. Change the urine’s concentrationd. Inhibit the growth of microorganisms

40.Clay colored stools indicate:

a. Upper GI bleedingb. Impending constipationc. An effect of medicationd. Bile obstruction

41.In which step of the nursing process would the nurse ask a patient if the medication she administered relieved his pain?

a. Assessmentb. Analysisc. Planningd. Evaluation

42.All of the following are good sources of vitamin A except:

a. White potatoesb. Carrotsc. Apricotsd. Egg yolks

43.Which of the following is a primary nursing intervention necessary for all patients with a Foley Catheter in place?

a. Maintain the drainage tubing and collection bag level with the patient’s bladderb. Irrigate the patient with 1% Neosporin solution three times a dailyc. Clamp the catheter for 1 hour every 4 hours to maintain the bladder’s elasticityd. Maintain the drainage tubing and collection bag below bladder level to facilitate drainage by gravity

44.The ELISA test is used to:

a. Screen blood donors for antibodies to human immunodeficiency virus (HIV)b. Test blood to be used for transfusion for HIV antibodiesc. Aid in diagnosing a patient with AIDSd. All of the above

45.The two blood vessels most commonly used for TPN infusion are the:

a. Subclavian and jugular veinsb. Brachial and subclavian veinsc. Femoral and subclavian veinsd. Brachial and femoral veins

46.Effective skin disinfection before a surgical procedure includes which of the following methods?

a. Shaving the site on the day before surgeryb. Applying a topical antiseptic to the skin on the evening before surgeryc. Having the patient take a tub bath on the morning of surgeryd. Having the patient shower with an antiseptic soap on the evening v=before and the morning of surgery

47.When transferring a patient from a bed to a chair, the nurse should use which muscles to avoid back injury?

a. Abdominal musclesb. Back musclesc. Leg musclesd. Upper arm muscles

48.Thrombophlebitis typically develops in patients with which of the following conditions?

a. Increases partial thromboplastin timeb. Acute pulsus paradoxusc. An impaired or traumatized blood vessel walld. Chronic Obstructive Pulmonary Disease (COPD)

49.In a recumbent, immobilized patient, lung ventilation can become altered, leading to such respiratory complications as:

a. Respiratory acidosis, ateclectasis, and hypostatic pneumoniab. Appneustic breathing, atypical pneumonia and respiratory alkalosisc. Cheyne-Strokes respirations and spontaneous pneumothoraxd. Kussmail’s respirations and hypoventilation

50.Immobility impairs bladder elimination, resulting in such disorders as

a. Increased urine acidity and relaxation of the perineal muscles, causing incontinenceb. Urine retention, bladder distention, and infectionc. Diuresis, natriuresis, and decreased urine specific gravityd. Decreased calcium and phosphate levels in the urine

1. D. In the circular chain of infection, pathogens must be able to leave their reservoir and be transmitted to a susceptible host through a portal of entry, such as broken skin.

2. C. Respiratory isolation, like strict isolation, requires that the door to the door patient’s room remain closed. However, the patient’s room should be well ventilated, so opening the window or turning on the ventricular is desirable. The nurse does not need to wear gloves for respiratory isolation, but good hand washing is important for all types of isolation.

3. A. Leukopenia is a decreased number of leukocytes (white blood cells), which are important in resisting infection. None of the other situations would put the patient at risk for contracting an infection; taking broadspectrum antibiotics might actually reduce the infection risk.

4. A. Soaps and detergents are used to help remove bacteria because of their ability to lower the surface tension of water and act as emulsifying agents. Hot water may lead to skin irritation or burns.

5. A. Depending on the degree of exposure to pathogens, hand washing may last from 10 seconds to 4 minutes. After routine patient contact, hand washing for 30 seconds effectively minimizes the risk of pathogen transmission.

6. B. The urinary system is normally free of microorganisms except at the urinary meatus. Any procedure that involves entering this system must use surgically aseptic measures to maintain a bacteria-free state.

7. C. All invasive procedures, including surgery, catheter insertion, and administration of parenteral therapy, require sterile technique to maintain a sterile environment. All equipment must be sterile, and the nurse and the physician must wear sterile gloves and maintain surgical asepsis. In the operating room, the nurse and physician are required to

wear sterile gowns, gloves, masks, hair covers, and shoe covers for all invasive procedures. Strict isolation requires the use of clean gloves, masks, gowns and equipment to prevent the transmission of highly communicable diseases by contact or by airborne routes. Terminal disinfection is the disinfection of all contaminated supplies and equipment after a patient has been discharged to prepare them for reuse by another patient. The purpose of protective (reverse) isolation is to prevent a person with seriously impaired resistance from coming into contact who potentially pathogenic organisms.

8. C. The edges of a sterile field are considered contaminated. When sterile items are allowed to come in contact with the edges of the field, the sterile items also become contaminated.

9. B. Hair on or within body areas, such as the nose, traps and holds particles that contain microorganisms. Yawning and hiccupping do not prevent microorganisms from entering or leaving the body. Rapid eye movement marks the stage of sleep during which dreaming occurs.

10. D. The inside of the glove is always considered to be clean, but not sterile.

11. A. The back of the gown is considered clean, the front is contaminated. So, after removing gloves and washing hands, the nurse should untie the back of the gown; slowly move backward away from the gown, holding the inside of the gown and keeping the edges off the floor; turn and fold the gown inside out; discard it in a contaminated linen container; then wash her hands again.

12. B. According to the Centers for Disease Control (CDC), blood-to-blood contact occurs most commonly when a health care worker attempts to cap a used needle. Therefore, used needles should never be recapped; instead they should be inserted in a specially designed puncture resistant, labeled container. Wearing gloves is not always necessary when administering an I.M. injection. Enteric precautions prevent the transfer of pathogens via feces.

13. A. Nurses and other health care professionals previously believed that massaging a reddened area with lotion would promote venous return and reduce edema to the area. However, research has shown that massage only increases the likelihood of cellular ischemia and necrosis to the area.

14. B. Before a blood transfusion is performed, the blood of the donor and recipient must be checked for compatibility. This is done by blood typing (a test that determines a person’s blood type) and cross-matching (a procedure that determines the compatibility of the donor’s and recipient’s blood after the blood types has been matched). If the blood specimens are incompatible, hemolysis and antigen-antibody reactions will occur.

15. A. Platelets are disk-shaped cells that are essential for blood coagulation. A platelet count determines the number of thrombocytes in blood available for promoting hemostasis and assisting with blood coagulation after injury. It also is used to evaluate the patient’s potential for bleeding; however, this is not its primary purpose. The normal count ranges from 150,000 to 350,000/mm3. A count of 100,000/mm3 or less indicates a potential for bleeding; count of less than 20,000/mm3 is associated with spontaneous bleeding.

16. D. Leukocytosis is any transient increase in the number of white blood cells (leukocytes) in the blood. Normal WBC counts range from 5,000 to 100,000/mm3. Thus, a count of 25,000/mm3 indicates leukocytosis.

17. A. Fatigue, muscle cramping, and muscle weaknesses are symptoms of hypokalemia (an inadequate potassium level), which is a potential side effect of diuretic therapy. The physician usually orders supplemental potassium to prevent hypokalemia in patients receiving diuretics. Anorexia is another symptom of hypokalemia. Dysphagia means difficultyswallowing.

18. A. Pregnancy or suspected pregnancy is the only contraindication for a chest X-ray. However, if a chest X-ray is necessary, the patient can wear a lead apron to protect the pelvic region from radiation. Jewelry, metallic objects, and buttons would interfere with the X-ray and thus should not be worn above the waist. A signed consent is not required because a chest X-ray is not an invasive examination. Eating, drinking and medications are allowed because the X-ray is of the chest, not the abdominal region.

19. A. Obtaining a sputum specimen early in this morning ensures an adequate supply of bacteria for culturing and decreases the risk of contamination from food or medication.

20. A. Initial sensitivity to penicillin is commonly manifested by a skin rash, even in individuals who have not been allergic to it previously. Because of the danger of anaphylactic shock, he nurse should withhold the drug andnotify the physician, who may choose to substitute another drug. Administering an antihistamine is a dependent nursing intervention that requires a written physician’s order. Although applying corn starch to the rash may relieve discomfort, it is not the nurse’s top priority in such a potentially life-threatening situation.

21. D. The Z-track method is an I.M. injection technique in which the patient’s skin is pulled in such a way that the needle track is sealed off after the injection. This procedure seals medication deep into the muscle, thereby minimizing skin staining and irritation. Rubbing the injection site is contraindicated because it may cause the medication to extravasate into the skin.

22. D. The vastus lateralis, a long, thick muscle that extends the full length of the thigh, is viewed by many clinicians as the site of choice for I.M. injections because it has relatively few major nerves and blood vessels. The middle third of the muscle is recommended as the injection site. The patient can be in a supine or sitting position for an injection into this site.

23. A. The mid-deltoid injection site can accommodate only 1 ml or less of medication because of its size and location (on the deltoid muscle of the arm, close to the brachial artery and radial nerve).

24. D. A 25G, 5/8” needle is the recommended size for insulin injection because insulin is administered by the subcutaneous route. An 18G, 1 ½” needle is usually used for I.M. injections in children, typically in the vastus lateralis. A 22G, 1 ½” needle is usually used for adult I.M. injections, which are typically administered in the vastus lateralis or ventrogluteal site.

25. D. Because an intradermal injection does not penetrate deeply into the skin, a small-bore 25G needle is recommended. This type of injection is used primarily to administer antigens to evaluate reactions for allergy orsensitivity studies. A 20G needle is usually used for I.M. injections of oilbased medications; a 22G needle for I.M. injections; and a 25G needle, for I.M. injections; and a 25G needle, for subcutaneous insulin injections.

26. A. Parenteral penicillin can be administered I.M. or added to a solution and given I.V. It cannot be administered subcutaneously or intradermally.

27. D. gr 10 x 60mg/gr 1 = 600 mg

28. C. 100ml/60 min X 15 gtt/ 1 ml = 25 gtt/minute

29. A. Hemoglobinuria, the abnormal presence of hemoglobin in the urine, indicates a hemolytic reaction (incompatibility of the donor’s and recipient’s blood). In this reaction, antibodies in the recipient’s plasma combine rapidly with donor RBC’s; the cells are hemolyzed in either circulatory or reticuloendothelial system. Hemolysis occurs more rapidly inABO incompatibilities than in Rh incompatibilities. Chest pain and urticaria may be symptoms of impending anaphylaxis. Distended neck veins are an indication of hypervolemia.

30. C. In real failure, the kidney loses their ability to effectively eliminate wastes and fluids. Because of this, limiting the patient’s intake of oral and I.V. fluids may be necessary. Fever, chronic obstructive pulmonary disease, and dehydration are conditions for which fluids should be encouraged.

31. D. Phlebitis, the inflammation of a vein, can be caused by chemical irritants (I.V. solutions or medications), mechanical irritants (the needle or catheter used during venipuncture or cannulation), or a localized allergicreaction to the needle or catheter. Signs and symptoms of phlebitis include pain or discomfort, edema and heat at the I.V. insertion site, and a red streak going up the arm or leg from the I.V. insertion site.

32. D. Return demonstration provides the most certain evidence for evaluating the effectiveness of patient teaching.

33. D. Capsules, enteric-coated tablets, and most extended duration or sustained release products should not be dissolved for use in a gastrostomy tube. They are pharmaceutically manufactured in these forms for valid reasons, and altering them destroys their purpose. The nurse should seek an alternate physician’s order when an ordered medication is inappropriate for delivery by tube.

34. D. A drug-allergy is an adverse reaction resulting from an immunologic response following a previous sensitizing exposure to the drug. The reaction can range from a rash or hives to anaphylactic shock. Tolerance to a drug means that the patient experiences a decreasing physiologic response to repeated administration of the drug in the same dosage. Idiosyncrasy is an individual’s unique hypersensitivity to a drug, food, or other substance; it appears to be genetically determined. Synergism, is a drug interaction in which the sum of the drug’s combined effects is greater

than that of their separate effects.

35. D. A hemoglobin and hematocrit count would be ordered by the physician if bleeding were suspected. The other answers are appropriate nursing interventions for a patient who has undergone femoral arteriography.

36. A. Coughing, a protective response that clears the respiratory tract of irritants, usually is involuntary; however it can be voluntary, as when a patient is taught to perform coughing exercises. An antitussive drug inhibits coughing. Splinting the abdomen supports the abdominal muscles when a patient coughs.

37. C. In an infected patient, shivering results from the body’s attempt to increase heat production and the production of neutrophils and phagocytotic action through increased skeletal muscle tension and contractions. Initial vasoconstriction may cause skin to feel cold to the touch. Applying additional bed clothes helps to equalize the bodytemperature and stop the chills. Attempts to cool the body result in further shivering, increased metabloism, and thus increased heat production.

38. D. A clinical nurse specialist must have completed a master’s degree in a clinical specialty and be a registered professional nurse. The National League of Nursing accredits educational programs in nursing and provides a testing service to evaluate student nursing competence but it does not certify nurses. The American Nurses Association identifies requirements for certification and offers examinations for certification in many areas of nursing., such as medical surgical nursing. These certification (credentialing) demonstrates that the nurse has the knowledge and theability to provide high quality nursing care in the area of her certification. A graduate of an associate degree program is not a clinical nurse specialist: however, she is prepared to provide bed side nursing with a high degree of knowledge and skill. She must successfully complete the licensing examination to become a registered professional nurse.

39. D. Microorganisms usually do not grow in an acidic environment.

40. D. Bile colors the stool brown. Any inflammation or obstruction that impairs bile flow will affect the stool pigment, yielding light, clay-colored stool. Upper GI bleeding results in black or tarry stool. Constipation is characterized by small, hard masses. Many medications and foods will discolor stool – for example, drugs containing iron turn stool black.; beetsturn stool red.

41. D. In the evaluation step of the nursing process, the nurse must decide whether the patient has achieved the expected outcome that was identified in the planning phase.

42. A. The main sources of vitamin A are yellow and green vegetables (such as carrots, sweet potatoes, squash, spinach, collard greens, broccoli, and cabbage) and yellow fruits (such as apricots, and cantaloupe). Animal sources include liver, kidneys, cream, butter, and egg yolks.

43. D. Maintaing the drainage tubing and collection bag level with the patient’s bladder could result in reflux of urine into the kidney. Irrigating the bladder with Neosporin and clamping the catheter for 1 hour every 4 hours mustbe prescribed by a physician.

44. D. The ELISA test of venous blood is used to assess blood and potential blood donors to human immunodeficiency virus (HIV). A positive ELISA test combined with various signs and symptoms helps to diagnose acquired immunodeficiency syndrome (AIDS)

45. D. Tachypnea (an abnormally rapid rate of breathing) would indicate that the patient was still hypoxic (deficient in oxygen).The partial pressures of arterial oxygen and carbon dioxide listed are within the normal range. Eupnea refers to normal respiration.

46. D. Studies have shown that showering with an antiseptic soap before surgery is the most effective method of removing microorganisms from the skin. Shaving the site of the intended surgery might cause breaks in the skin, thereby increasing the risk of infection; however, if indicated, shaving, should be done immediately before surgery, not the day before. A topical antiseptic would not remove microorganisms and would be beneficial only after proper cleaning and rinsing. Tub bathing might transfer organisms to another body site rather than rinse them away.

47. C. The leg muscles are the strongest muscles in the body and should bear the greatest stress when lifting. Muscles of the abdomen, back, and upper arms may be easily injured.

48. C. The factors, known as Virchow’s triad, collectively predispose a patient to thromboplebitis; impaired venous return to the heart, blood hypercoagulability, and injury to a blood vessel wall. Increased partial thromboplastin time indicates a prolonged bleeding time during fibrin clot formation, commonly the result of anticoagulant (heparin) therapy. Arterial blood disorders (such as pulsus paradoxus) and lung diseases (such as COPD) do not necessarily impede venous return of injure vessel walls.

49. A. Because of restricted respiratory movement, a recumbent, immobilize patient is at particular risk for respiratory acidosis from poor gas exchange; atelectasis from reduced surfactant and accumulated mucus in the bronchioles, and hypostatic pneumonia from bacterial growth caused by stasis of mucus secretions.

50. B. The immobilized patient commonly suffers from urine retention caused by decreased muscle tone in the perineum. This leads to bladder distention and urine stagnation, which provide an excellent medium for bacterial growth leading to infection. Immobility also results in more alkaline urine with excessive amounts of calcium, sodium and phosphate,a gradual decrease in urine production, and an increased specific gravity.

1. Jake is complaining of shortness of breath. The nurse assesses his respiratory rate to be 30 breaths per minute and documents that Jake is tachypneic. The nurse understands that tachypnea means: 

a. Pulse rate greater than 100 beats per minuteb. Blood pressure of 140/90c. Respiratory rate greater than 20 breaths per minuted. Frequent bowel sounds

2. The nurse listens to Mrs. Sullen’s lungs and notes a hissing sound or musical sound. The nurse documents this as: 

a. Wheezesb. Rhonchic. Gurglesd. Vesicular

3. The nurse in charge measures a patient’s temperature at 101 degrees F. What is the equivalent centigrade temperature? 

a. 36.3 degrees Cb. 37.95 degrees Cc. 40.03 degrees Cd. 38.01 degrees C

4. Which approach to problem solving tests any number of solutions until one is found that

works for that particular problem? 

a. Intuitionb. Routinec. Scientific methodd. Trial and error 

5. What is the order of the nursing process? 

a. Assessing, diagnosing, implementing, evaluating, planningb. Diagnosing, assessing, planning, implementing, evaluatingc. Assessing, diagnosing, planning, implementing, evaluatingd. Planning, evaluating, diagnosing, assessing, implementing

6. During the planning phase of the nursing process, which of the following is the outcome? 

a. Nursing historyb. Nursing notesc. Nursing care pland. Nursing diagnosis

7. What is an example of a subjective data? 

a. Heart rate of 68 beats per minuteb. Yellowish sputumc. Client verbalized, “I feel pain when urinating.”d. Noisy breathing

8. Which expected outcome is correctly written? 

a. “The patient will feel less nauseated in 24 hours.”b. “The patient will eat the right amount of food daily.”c. “The patient will identify all the high-salt food from a prepared list by discharge.”d. “The patient will have enough sleep.” 

9. Which of the following behaviors by Nurse Jane Robles demonstrates that she understands well th elements of effecting charting? 

a. She writes in the chart using a no. 2 pencil.b. She noted: appetite is good this afternoon.c. She signs on the medication sheet after administering the medication.d. She signs her charting as follow: J.R

10. What is the disadvantage of computerized documentation of the nursing process? 

a. Accuracyb. Legibilityc. Concern for privacyd. Rapid communication

11. The theorist who believes that adaptation and manipulation of stressors are related to foster change is: 

a. Dorothea Oremb. Sister Callista Royc. Imogene Kingd. Virginia Henderson

12. Formulating a nursing diagnosis is a joint function of: 

a. Patient and relativesb. Nurse and patientc. Doctor and familyd. Nurse and doctor

13. Mrs. Caperlac has been diagnosed to have hypertension since 10 years ago. Since then, she had maintained low sodium, low fat diet, to control her blood pressure. This practice is viewed as: 

a. Cultural beliefb. Personal beliefc. Health beliefd. Superstitious belief

14. Becky is on NPO since midnight as preparation for blood test. Adreno-cortical response is activated. Which of the following is an expected response? 

a. Low blood pressureb. Warm, dry skinc. Decreased serum sodium levelsd. Decreased urine output

15. What nursing action is appropriate when obtaining a sterile urine specimen from an indwelling catheter to prevent infection? 

a. Use sterile gloves when obtaining urine.b. Open the drainage bag and pour out the urine.c. Disconnect the catheter from the tubing and get urine.d. Aspirate urine from the tubing port using a sterile syringe.

16. A client is receiving 115 ml/hr of continuous IVF. The nurse notices that the venipuncture

site is red and swollen. Which of the following interventions would the nurse perform first? 

a. Stop the infusionb. Call the attending physicianc. Slow that infusion to 20 ml/hrd. Place a clod towel on the site 

17. The nurse enters the room to give a prescribed medication but the patient is inside the bathroom. What should the nurse do? 

a. Leave the medication at the bedside and leave the room.b. After few minutes, return to that patient’s room and do not leave until the patient takes the medication.c. Instruct the patient to take the medication and leave it at the bedside.d. Wait for the patient to return to bed and just leave the medication at the bedside.

18. Which of the following is inappropriate nursing action when administering NGT feeding? 

a. Place the feeding 20 inches above the pint if insertion of NGT.b. Introduce the feeding slowly.c. Instill 60ml of water into the NGT after feeding.d. Assist the patient in fowler’s position.

19. A female patient is being discharged after thyroidectomy. After providing the medication teaching. The nurse asks the patient to repeat the instructions. The nurse is performing which professional role? 

a. Managerb. Caregiverc. Patient advocated. Educator

20. Which data would be of greatest concern to the nurse when completing the nursing assessment of a 68-year-old woman hospitalized due to Pneumonia? 

a. Oriented to date, time and placeb. Clear breath soundsc. Capillary refill greater than 3 seconds and buccal cyanosisd. Hemoglobin of 13 g/dl

21. During a change-of-shift report, it would be important for the nurse relinquishing responsibility for care of the patient to communicate. Which of the following facts to the nurse assuming responsibility for care of the patient? 

a. That the patient verbalized, “My headache is gone.”b. That the patient’s barium enema performed 3 days ago was negative

c. Patient’s NGT was removed 2 hours agod. Patient’s family came for a visit this morning.

22. Which statement is the most appropriate goal for a nursing diagnosis of diarrhea? 

a. “The patient will experience decreased frequency of bowel elimination.”b. “The patient will take anti-diarrheal medication.”c. “The patient will give a stool specimen for laboratory examinations.”d. “The patient will save urine for inspection by the nurse.

23. Which of the following is the most important purpose of planning care with this patient? 

a. Development of a standardized NCP.b. Expansion of the current taxonomy of nursing diagnosisc. Making of individualized patient cared. Incorporation of both nursing and medical diagnoses in patient care

24. Using Maslow’s hierarchy of basic human needs, which of the following nursing diagnoses has the highest priority? 

a. Ineffective breathing pattern related to pain, as evidenced by shortness of breath.b. Anxiety related to impending surgery, as evidenced by insomnia.c. Risk of injury related to autoimmune dysfunctiond. Impaired verbal communication related to tracheostomy, as evidenced by inability to speak.

25. When performing an abdominal examination, the patient should be in a supine position with the head of the bed at what position? 

a. 30 degreesb. 90 degreesc. 45 degreesd. 0 degree

1. (C) Respiratory rate greater than 20 breaths per minuteA respiratory rate of greater than 20 breaths per minute is tachypnea. A blood pressure of 140/90 is considered hypertension. Pulse greater than 100 beats per minute is tachycardia. Frequent bowel sounds refer to hyper-active bowel sounds. 

2. (A) WheezesWheezes are indicated by continuous, lengthy, musical; heard during inspiration or expiration. Rhonchi are usually coarse breath sounds. Gurgles are loud gurgling, bubbling sound. Vesicular breath sounds are low pitch, soft intensity on expiration. 

3. (B) 37.95 degrees CTo convert °F to °C use this formula, ( °F – 32 ) (0.55). While when converting °C to °F use this formula, ( °C x 1.8) + 32. Note that 0.55 is 5/9 and 1.8 is 9/5.

4. (D) Trial and error The trial and error method of problem solving isn’t systematic (as in the scientific method of problem solving) routine, or based on inner prompting (as in the intuitive method of problem solving).

5. (C) Assessing, diagnosing, planning, implementing, evaluatingThe correct order of the nursing process is assessing, diagnosing, planning, implementing, evaluating.

6. (C) Nursing care planThe outcome, or the product of the planning phase of the nursing process is a Nursing care plan.

7. (C) Client verbalized, “I feel pain when urinating.”Subjective data are those that can be described only by the person experiencing it. Therefore, only the patient can describe or verify whether he is experiencing pain or not.

8. (C) “The patient will identify all the high-salt food from a prepared list by discharge.”

Expected outcomes are specific, measurable, realistic statements of goal attainment. The phrases “right amount”, “less nauseated” and “enough sleep” are vague and not measurable.

9. (C) She signs on the medication sheet after administering the medication.A nurse should record a nursing intervention (ex. Giving medications) after performing the nursing intervention (not before). Recording should also be done using a pen, be complete, and signed with the nurse’s full name and title.

10. (C) Concern for privacyA patient’s privacy may be violated if security measures aren’t used properly or if policies and procedures aren’t in place that determines what type of information can be retrieved, by whom, and for what purpose.

11. (B) Sister Callista RoySister Roy’s theory is called the adaptation theory and she viewed each person as a unified biophysical system in constant interaction with a changing environment. Orem’s theory is called self-care deficit theory and is based on the belief that individual has a need for self-care actions. King’s theory is the Goal attainment theory and described nursing as a helping profession that assists individuals and groups in society to attain, maintain, and restore health. Henderson introduced the nature of nursing model and identified the 14 basic needs.

12. (B) Nurse and patientAlthough diagnosing is basically the nurse’s responsibility, input from the patient is essential to formulate the correct nursing diagnosis.

13. (C) Health beliefHealth belief of an individual influences his/her preventive health behavior.

14. (D) Decreased urine outputAdreno-cortical response involves release of aldosterone that leads to retention of sodium and water. This results to decreased urine output.

15. (D) Aspirate urine from the tubing port using a sterile syringe.The nurse should aspirate the urine from the port using a sterile syringe to obtain a urine specimen. Opening a closed drainage system increase the risk of urinary tract infection.

16. (A) Stop the infusionThe sign and symptoms indicate extravasation so the IVF should be stopped immediately and put warm not cold towel on the affected site.

17. (B) After few minutes, return to that patient’s room and do not leave until the patient takes the medicationThis is to verify or to make sure that the medication was taken by the patient as directed.

18. (A) Place the feeding 20 inches above the pint if insertion of NGT.The height of the feeding is above 12 inches above the point of insertion, bot 20 inches. If the height of feeding is too high, this results to very rapid introduction of feeding. This may trigger nausea and vomiting.

19. (D) Educator

When teaching a patient about medications before discharge, the nurse is acting as an educator. A caregiver provides direct care to the patient. The nurse acts as s patient advocate when making the patient’s wishes known to the doctor.

20. (C) Capillary refill greater than 3 seconds and buccal cyanosisCapillary refill greater than 3 seconds and buccal cyanosis indicate decreased oxygen to the tissues which requires immediate attention/intervention. Oriented to date, time and place, hemoglobin of 13 g/dl are normal data.

21. (C) Patient’s NGT was removed 2 hours agoThe change-of-shift report should indicate significant recent changes in the patient’s condition that the nurse assuming responsibility for care of the patient will need to monitor. The other options are not critical enough to include in the report.

22. (A) “The patient will experience decreased frequency of bowel elimination.”The goal is the opposite, healthy response of the problem statement of the nursing diagnosis. In this situation, the problem statement is diarrhea.

23. (C) Making of individualized patient careTo be effective, the nursing care plan developed in the planning phase of the nursing process must reflect the individualized needs of the patient.

24. (A) Ineffective breathing pattern related to pain, as evidenced by shortness of breath.Physiologic needs (ex. Oxygen, fluids, nutrition) must be met before lower needs (such as safety and security, love and belongingness, self-esteem and self-actualization) can be met. Therefore, physiologic needs have the highest priority.

25. (D) 0 degreeThe patient should be positioned with the head of the bed completely flattened to perform an abdominal examination. If the head of the bed is elevated, the abdominal muscles and organs can be bunched up, altering the findings

1. A patient is wearing a soft wrist-safety device. Which of the following nursing assessment is considered abnormal? 

a. Palpable radial pulseb. Palpable ulnar pulsec. Capillary refill within 3 secondsd. Bluish fingernails, cool and pale fingers

2. Pia’s serum sodium level is 150 mEq/L. Which of the following food items does the nurse instruct Pia to avoid? 

a. broccolib. sardinesc. cabbaged. tomatoes

3. Jason, 3 years old vomited. His mom stated, “He vomited 6 ounces of his formula this morning.” This statement is an example of: 

a. objective data from a secondary sourceb. objective data from a primary sourcec. subjective data from a primary sourced. subjective data from a secondary source

4. Which of the following is a nursing diagnosis? 

a. Hypethermiab. Diabetes Mellitusc. Anginad. Chronic Renal Failure

5. What is the characteristic of the nursing process? 

a. stagnantb. inflexiblec. asystematicd. goal-oriented

6. A skin lesion which is fluid-filled, less than 1 cm in size is called: 

a. papuleb. vesiclec. bullad. macule

7. During application of medication into the ear, which of the following is inappropriate nursing action? 

a. In an adult, pull the pinna upward.b. Instill the medication directly into the tympanic membrane.c. Warm the medication at room or body temperature.d. Press the tragus of the ear a few times to assist flow of medication into the ear canal.

8. Which of the following is appropriate nursing intervention for a client who is grieving over the death of her child? 

a. Tell her not to cry and it will be better.b. Provide opportunity to the client to tell their story.c. Encourage her to accept or to replace the lost person.d. Discourage the client in expressing her emotions.

9. It is the gradual decrease of the body’s temperature after death. 

a. livor mortisb. rigor mortisc. algor mortisd. none of the above

10. When performing an admission assessment on a newly admitted patient, the nurse percusses resonance. The nurse knows that resonance heard on percussion is most commonly heard over which organ? 

a. thighb. liverc. intestined. lung

11. The nurse is aware that Bell’s palsy affects which cranial nerve? 

a. 2nd CN (Optic)b. 3rd CN (Occulomotor)c. 4th CN (Trochlear)d. 7th CN (Facial)

12. Prolonged deficiency of Vitamin B9 leads to: 

a. scurvyb. pellagrac. megaloblastic anemiad. pernicious anemia

13. Nurse Cherry is teaching a 72 year old patient about a newly prescribed medication. What could cause a geriatric patient to have difficulty retaining knowledge about the newly prescribed medication? 

a. Absence of family supportb. Decreased sensory functionsc. Patient has no interest on learningd. Decreased plasma drug levels

14. When assessing a patient’s level of consciousness, which type of nursing intervention is the nurse performing? 

a. Independentb. Dependentc. Collaboratived. Professional

15. Claire is admitted with a diagnosis of chronic shoulder pain. By definition, the nurse understands that the patient has had pain for more than: 

a. 3 monthsb. 6 monthsc. 9 monthsd. 1 year

16. Which of the following statements regarding the nursing process is true? 

a. It is useful on outpatient settings.b. It progresses in separate, unrelated steps.c. It focuses on the patient, not the nurse.d. It provides the solution to all patient health problems.

17. Which of the following is considered significant enough to require immediate communication to another member of the health care team? 

a. Weight loss of 3 lbs in a 120 lb female patient.b. Diminished breath sounds in patient with previously normal breath soundsc. Patient stated, “I feel less nauseated.”d. Change of heart rate from 70 to 83 beats per minute.

18. To assess the adequacy of food intake, which of the following assessment parameters is best used? 

a. food preferencesb. regularity of meal timesc. 3-day diet recalld. eating style and habits

19. Van Fajardo is a 55 year old who was admitted to the hospital with newly diagnosed hepatitis. The nurse is doing a patient teaching with Mr. Fajardo. What kind of role does the nurse assume? 

a. talkerb. teacherc. thinkerd. doer

20. When providing a continuous enteral feeding, which of the following action is essential for the nurse to do? 

a. Place the client on the left side of the bed.b. Attach the feeding bag to the current tubing.c. Elevate the head of the bed.d. Cold the formula before administering it.

21. Kussmaul’s breathing is; 

a. Shallow breaths interrupted by apnea.b. Prolonged gasping inspiration followed by a very short, usually inefficient expiration.c. Marked rhythmic waxing and waning of respirations from very deep to very shallow breathing and temporary apnea.d. Increased rate and depth of respiration.

22. Presty has terminal cancer and she refuses to believe that loss is happening ans she assumes artificial cheerfulness. What stage of grieving is she in? 

a. depressionb. bargaining

c. deniald. acceptance

23. Immunization for healthy babies and preschool children is an example of what level of preventive health care? 

a. Primaryb. Secondaryc. Tertiaryd. Curative

24. Which is an example of a subjective data? 

a. Temperature of 38 0Cb. Vomiting for 3 daysc. Productive coughd. Patient stated, “My arms still hurt.”

25. The nurse is assessing the endocrine system. Which organ is part of the endocrine system? 

a. Heartb. Sinusc. Thyroidd. Thymus

1. (D) Bluish fingernails, cool and pale fingersA safety device on the wrist may impair blood circulation. Therefore, the nurse should assess the patient for signs of impaired circulation such as bluish fingernails, cool and pale fingers. Palpable radial and ulnar pulses, capillary refill within 3 seconds are all normal findings.

2. (B) sardinesThe normal serum sodium level is 135 to 145 mEq/L, the client is having hypernatremia. Pia should avoid food high in sodium like processed food. Broccoli, cabbage and tomatoes are good source of Vitamin C.

3. (A) objective data from a secondary sourceJason is the primary source; his mother is a secondary source. The data is objective because it can be perceived by the senses, verified by another person observing the same patient, and tested against accepted standards or norms. 

4. (A) HypethermiaHyperthermia is a NANDA-approved nursing diagnosis. Diabetes Mellitus, Angina and Chronic Renal Failure are medical diagnoses.

5. (D) goal-orientedThe nursing process is goal-oriented. It is also systematic, patient-centered, and dynamic.

6. (B) vesicleVesicle is a circumscribed circulation containing serous fluid or blood and less than 1 cm (ex. Blister, chicken pox).

7. (B) Instill the medication directly into the tympanic membrane.During the application of medication it is inappropriate to instill the medication directly into the tympanic membrane. The right thing to do is instill the medication along the lateral wall of the auditory canal.

8. (B) Provide opportunity to the client to tell their story.Providing a grieving person an opportunity to tell their story allows the person to express feelings. This is therapeutic in assisting the client resolve grief.

9. (C) algor mortisAlgor mortis is the decrease of the body’s temperature after death. Livor mortis is the discoloration of the skin after death. Rigor mortis is the stiffening of the body that occurs about 2-4 hours after death.

10. (D) lung

Resonance is loud, low-pitched and long duration that’s heard most commonly over an air-filled tissue such as a normal lung.

11. (D) 7th CN (Facial)Bells’ palsy is the paralysis of the motor component of the 7th caranial nerve, resulting in facial sag, inability to close the eyelid or the mouth, drooling, flat nasolabial fold and loss of taste on the affected side of the face.

12. (C) megaloblastic anemiaProlonged Vitamin B9 deficiency will lead to megaloblastic anemia while pernicious anemia results in deficiency in Vitamin B12. Prolonged deficiency of Vitamin C leads to scurvy and Pellagra results in deficiency in Vitamin B3. 

13. (B) Decreased sensory functionsDecreased in sensory functions could cause a geriatric patient to have difficulty retaining knowledge about the newly prescribed medications. Absence of family support and no interest on learning may affect compliance, not knowledge retention. Decreased plasma levels do not alter patient’s knowledge about the drug.

14. (A) IndependentIndependent nursing interventions involve actions that nurses initiate based on their own knowledge and skills without the direction or supervision of another member of the health care team.

15. (B) 6 monthsChronic pain s usually defined as pain lasting longer than 6 months.

16. (C) It focuses on the patient, not the nurse.The nursing process is patient-centered, not nurse-centered. It can be use in any setting, and the steps are related. The nursing process can’t solve all patient health problems.

17. (B) Diminished breath sounds in patient with previously normal breath soundsDiminished breath sound is a life threatening problem therefore it is highly priority because they pose the greatest threat to the patient’s well-being.

18. (C) 3-day diet recall3-day diet recall is an example of dietary history. This is used to indicate the adequacy of food intake of the client.

19. (B) teacherThe nurse will assume the role of a teacher in this therapeutic relationship. The other roles are inappropriate in this situation.

20. (C) Elevate the head of the bed.Elevating the head of the bed during an enteral feeding prevents aspiration. The patient may be placed on the right side to prevent aspiration. Enteral feedings are given at room temperature to lessen GI distress. The enteral tubing should be changed every 24 hours to limit microbial growth.

21. (D) Increased rate and depth of respiration.Kussmaul breathing is also called as hyperventilation. Seen in metabolic acidosis and renal failure. Option A refers to Biot’s breathing. Option B is apneustic breathing and option C is the Cheyne-stokes breathing.

22. (C) denialThe client is in denial stage because she is unready to face the reality that loss is happening and she assumes artificial cheerfulness.

23. (A) PrimaryThe primary level focuses on health promotion. Secondary level focuses on health maintenance. Tertiary focuses on rehabilitation. There is n Curative level of preventive health care problems.

24. (D) Patient stated, “My arms still hurt.”Subjective data are apparent only to the person affected and can or verified only by that person.

25. (C) ThyroidThe thyroid is part of the endocrine system. Heart, sinus and thymus are not.

1. Nurse Brenda is teaching a patient about a newly prescribed drug. What could cause a geriatric patient to have difficulty retaining knowledge about prescribed medications? 

a. Decreased plasma drug levelsb. Sensory deficitsc. Lack of family supportd. History of Tourette syndrome

2. When examining a patient with abdominal pain the nurse in charge should assess: 

a. Any quadrant firstb. The symptomatic quadrant firstc. The symptomatic quadrant lastd. The symptomatic quadrant either second or third

3. The nurse is assessing a postoperative adult patient. Which of the following should the nurse document as subjective data? 

a. Vital signsb. Laboratory test resultc. Patient’s description of paind. Electrocardiographic (ECG) waveforms

4. A male patient has a soft wrist-safety device. Which assessment finding should the nurse consider abnormal? 

a. A palpable radial pulseb. A palpable ulnar pulsec. Cool, pale fingersd. Pink nail beds

5. Which of the following planes divides the body longitudinally into anterior and posterior regions? 

a. Frontal planeb. Sagittal planec. Midsagittal planed. Transverse plane

6. A female patient with a terminal illness is in denial. Indicators of denial include: 

a. Shock dismayb. Numbnessc. Stoicismd. Preparatory grief

7. The nurse in charge is transferring a patient from the bed to a chair. Which action does the nurse take during this patient transfer? 

a. Position the head of the bed flatb. Helps the patient dangle the legsc. Stands behind the patientd. Places the chair facing away from the bed

8. A female patient who speaks a little English has emergency gallbladder surgery, during discharge preparation, which nursing action would best help this patient understand wound care instruction? 

a. Asking frequently if the patient understands the instructionb. Asking an interpreter to replay the instructions to the patient.c. Writing out the instructions and having a family member read them to the patientd. Demonstrating the procedure and having the patient return the demonstration

9. Before administering the evening dose of a prescribed medication, the nurse on the evening shift finds an unlabeled, filled syringe in the patient’s medication drawer. What should the nurse in charge do? 

a. Discard the syringe to avoid a medication errorb. Obtain a label for the syringe from the pharmacyc. Use the syringe because it looks like it contains the same medication the nurse was prepared to gived. Call the day nurse to verify the contents of the syringe

10. When administering drug therapy to a male geriatric patient, the nurse must stay especially alert for adverse effects. Which factor makes geriatric patients to adverse drug effects? 

a. Faster drug clearanceb. Aging-related physiological changesc. Increased amount of neuronsd. Enhanced blood flow to the GI tract

11. A female patient is being discharged after cataract surgery. After providing medication teaching, the nurse asks the patient to repeat the instructions. The nurse is performing which professional role? 

a. Managerb. Educator

c. Caregiverd. Patient advocate

12. A female patient exhibits signs of heightened anxiety. Which response by the nurse is most likely to reduce the patient’s anxiety? 

a. “Everything will be fine. Don’t worry.”b. “Read this manual and then ask me any questions you may have.”c. “Why don’t you listen to the radio?”d. “Let’s talk about what’s bothering you.”

13. A scrub nurse in the operating room has which responsibility? 

a. Positioning the patientb. Assisting with gowning and glovingc. Handling surgical instruments to the surgeond. Applying surgical drapes

14. A patient is in the bathroom when the nurse enters to give a prescribed medication. What should the nurse in charge do? 

a. Leave the medication at the patient’s bedsideb. Tell the patient to be sure to take the medication. And then leave it at the bedsidec. Return shortly to the patient’s room and remain there until the patient takes the medicationd. Wait for the patient to return to bed, and then leave the medication at the bedside

15. The physician orders heparin, 7,500 units, to be administered subcutaneously every 6 hours. The vial reads 10,000 units per millilitre. The nurse should anticipate giving how much heparin for each dose? 

a. ¼ mlb. ½ mlc. ¾ mld. 1 ¼ ml

16. The nurse in charge measures a patient’s temperature at 102 degrees F. what is the equivalent Centigrade temperature? 

a. 39 degrees Cb. 47 degrees Cc. 38.9 degrees Cd. 40.1 degrees C

17. To evaluate a patient for hypoxia, the physician is most likely to order which laboratory test? 

a. Red blood cell countb. Sputum culturec. Total hemoglobind. Arterial blood gas (ABG) analysis

18. The nurse uses a stethoscope to auscultate a male patient’s chest. Which statement about a stethoscope with a bell and diaphragm is true? 

a. The bell detects high-pitched sounds bestb. The diaphragm detects high-pitched sounds bestc. The bell detects thrills bestd. The diaphragm detects low-pitched sounds best

19. A male patient is to be discharged with a prescription for an analgesic that is a controlled substance. During discharge teaching, the nurse should explain that the patient must fill this prescription how soon after the date on which it was written? 

a. Within 1 monthb. Within 3 monthsc. Within 6 monthsd. Within 12 months

20. Which human element considered by the nurse in charge during assessment can affect drug administration? 

a. The patient’s ability to recoverb. The patient’s occupational hazardsc. The patient’s socioeconomic statusd. The patient’s cognitive abilities

21. When explaining the initiation of I.V. therapy to a 2-year-old child, the nurse should: 

a. Ask the child, “Do you want me to start the I.V. now?”b. Give simple directions shortly before the I.V. therapy is to startc. Tell the child, “This treatment is for your own good”d. Inform the child that the needle will be in place for 10 days

22. All of the following parts of the syringe are sterile except the: 

a. Barrelb. Inside of the plungerc. Needle tipd. Barrel tip

23. The best way to instill eye drops is to: 

a. Instruct the patient to lock upward, and drop the medication into the center of the lower lidb. Instruct the patient to look ahead, and drop the medication into the center of the lower lidc. Drop the medication into the inner canthus regardless of eye positiond. Drop the medication into the center of the canthus regardless of eye position

24. The difference between an 18G needle and a 25G needle is the needle’s: 

a. Lengthb. Bevel anglec. Thicknessd. Sharpness

25. A patient receiving an anticoagulant should be assessed for signs of: 

a. Hypotensionb. Hypertensionc. An elevated hemoglobin countd. An increased number of erythrocytes

1. (B) Sensory deficitsSensory deficits could cause a geriatric patient to have difficulty retaining knowledge about prescribed medications. Decreased plasma drug levels do not alter the patient’s knowledge about the drug. A lack of family support may affect compliance, not knowledge retention. Toilette syndrome is unrelated to knowledge retention.

2. (C) The symptomatic quadrant lastThe nurse should systematically assess all areas of the abdomen, if time and the patient’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 would interfere with further assessment.

3. (C) Patient’s description of painSubjective data come directly from the patient and usually are recorded as direct quotations that reflect the patient’s opinions or feelings about a situation. Vital signs, laboratory test result, and ECG waveforms are examples of objective data.

4. (C) Cool, pale fingersA safety device on the wrist may impair circulation and restrict blood supply to body tissues. Therefore, the nurse should assess the patient for signs of impaired circulation, such as cool, pale fingers. A palpable radial or lunar pulse and pink nail beds are normal findings.

5. (A) Frontal planeFrontal or coronal plane runs longitudinally at a right angle to a sagittal plane dividing the body in anterior and posterior regions. A sagittal plane runs longitudinally dividing the body into right and left regions; if exactly midline, it is called a midsagittal plane. A transverse plane runs horizontally at a right angle to the vertical axis, dividing the structure into superior and inferior regions.

6. (A) Shock dismayShock and dismay are early signs of denial-the first stage of grief. The other options are associated with depression—a later stage of grief.

7. (B) Helps the patient dangle the legsAfter placing the patient in high Fowler’s position and moving the patient to the side of the bed, the nurse helps the patient sit on the edge of the bed and dangle the legs; the nurse then faces the patient and places the chair next to and facing the head of the bed.

8. (D) Demonstrating the procedure and having the patient return the demonstrationDemonstrating by the nurse with a return demonstration by the patient ensures that the patient can perform wound care correctly. Patients may claim to understand discharge instruction when they do not. An interpreter of family member may communicate verbal or written instructions inaccurately.

9. (A) Discard the syringe to avoid a medication errorAs a safety precaution, the nurse should discard an unlabeled syringe that contains medication. The other options are considered unsafe because they promote error.

10. (B) Aging-related physiological changesAging-related physiological changes account for the increased frequency of adverse drug reactions in geriatric patients. Renal and hepatic changes cause drugs to clear more slowly

in these patients. With increasing age, neurons are lost and blood flow to the GI tract decreases.

11. (B) EducatorWhen teaching a patient about medications before discharge, the nurse is acting as an educator. The nurse acts as a manager when performing such activities as scheduling and making patient care assignments. The nurse performs the care giving role when providing direct care, including bathing patients and administering medications and prescribed treatments. The nurse acts as a patient advocate when making the patient’s wishes known to the doctor.

12. (D) “Let’s talk about what’s bothering you.”Anxiety may result from feeling of helplessness, isolation, or insecurity. This response helps reduce anxiety by encouraging the patient to express feelings. The nurse should be supportive and develop goals together with the patient to give the patient some control over an anxiety-inducing situation. Because the other options ignore the patient’s feeling and block communication, they would not reduce anxiety.

13. (C) Handling surgical instruments to the surgeonThe scrub nurse assist the surgeon by providing appropriate surgical instruments and supplies, maintaining strict surgical asepsis and, with the circulating nurse, accounting for all gauze, sponges, needles, and instruments. The circulating nurse assists the surgeon and scrub nurse, positions the patient, applies appropriate equipment and surgical drapes, assists with gowning and gloving, and provides the surgeon and scrub nurse with supplies.

14. (C) Return shortly to the patient’s room and remain there until the patient takes the medicationThe nurse should return shortly to the patient’s room and remain there until the patient takes the medication to verify that it was taken as directed. The nurse should never leave medication at the patient’s bedside unless specifically requested to do so.

15. (C) ¾ mlThe nurse solves the problem as follows: 10,000 units/7,500 units = 1 ml/X 10,000 X = 7,500 X= 7,500/10,000 or ¾ ml

16. (C) 38.9 degrees CTo convert Fahrenheit degrees to centigrade, use this formula: C degrees = (F degrees – 32) x 5/9 C degrees = (102 – 32) 5/9 + 70 x 5/9 38.9 degrees C

17. (D) Arterial blood gas (ABG) analysisAll of these test help evaluate a patient with respiratory problems. However, ABG analysis is the only test evaluates gas exchange in the lungs, providing information about patient’s oxygenation status.

18. (B) The diaphragm detects high-pitched sounds bestThe diaphragm of a stethoscope detects high-pitched sound best; the bell detects low pitched sounds best. Palpation detects thrills best.

19. (C) Within 6 monthsIn most cases, an outpatient must fill a prescription for a controlled substance within 6 months of the date on which the prescription was written.

20. (D) The patient’s cognitive abilities

The nurse must consider the patient’s cognitive abilities to understand drug instructions. If not, the nurse must find a family member or significant other to take on the responsibility of administering medications in the home setting. The patient’s ability to recover, occupational hazards, and socioeconomic status do not affect drug administration.

21. (B) Give simple directions shortly before the I.V. therapy is to startBecause a 2-year-old child has limited understanding, the nurse should give simple directions and explanations of what will occur shortly before the procedure. She should try to avoid frightening the child with the explanation and allow the child to make simple choices, such as choosing the I.V. insertion site, if possible. However, she shouldn’t ask the child if he wants the therapy, because the answer may be “No!” Telling the child that the treatment is for his own good is ineffective because a 2-year-old perceives pain as a negative sensation and cannot understand that a painful procedure can have position results. Telling the child how long the therapy will last is ineffective because the 2-year-old doesn’t have a good understanding of time.

22. (A) BarrelAll syringes have three parts: a tip, which connects the needle to the syringe; a barrel, the outer part on which the measurement scales are printed; and a plunger, which fits inside the barrel to expel the medication. The external part of the barrel and the plunger and (flange) must be handled during the preparation and administration of the injection. However, the inside and trip of the barrel, the inside (shaft) of the plunger, and the needle tip must remain sterile until after the injection.

23. (A) Instruct the patient to lock upward, and drop the medication into the center of the lower lidHaving the patient look upward reduces blinking and protects the cornea. Instilling drops in the center of the lower lid promotes absorption because the drops are less likely to run into the nasolacrimal duct or out of the eye.

24. (C) ThicknessGauge is a measure of the needle’s thickness: The higher the number the thinner the shaft. Therefore, an 18G needle is considerably thicker than a 25G needle.

25. (A) HypotensionA major side effect of anticoagulant therapy is bleeding, which can be identified by hypotension (a systolic blood pressure under 100 mm Hg). Anticoagulants do not result in the other three conditions.