1
PNLE I for Foundation of Professional
Nursing Practice
Text Mode – Text version of the exam
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 wa...
pnle v for care of clients with physiologic and ps
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Camden County College
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1
NLE I for Foundation of Professional
P 5 . Nurse Betty is assigned to the following clients.
Nursing Practice The client that the nurse would see first after
Text Mode– Text version of the exam endorsement?
. The nurse In-charge in labor and delivery unit
1 A. A 34 year-old post operative
administered a dose of terbutaline to a client without appendectomy client of five hours who
checking the client’s pulse. The standard that would is complaining of pain.
be used to determine if the nurse was negligent is: B. A 44 year-old myocardial infarction (MI) client
A. The physician’s orders. who is complaining of nausea.
B. The action of a clinical nurse specialist who C. A 26 year-old client admitted for
is recognized expert in the field. C. The dehydration whose intravenous (IV) has
statement in the drug literature about infiltrated.
administration of terbutaline. D. A 63 year-old post operative’s abdominal
D. The actions of a reasonably prudent hysterectomy client of three days whose
nurse with similar education and incisional dressing is saturated with
experience. serosanguinous fluid.
2 . Nurse Trish is caring for a female client with a 6 . Nurse Gail places a client in a four-point restraint
history of GI bleeding, sickle cell disease, and a following orders from the physician. The client
platelet count of 22,000/μl. The female client is care plan should include:
dehydrated and receiving dextrose 5% in half normal . Assess temperature frequently.
A
saline solution at 150 ml/hr. The client complains of B. Provide diversional activities.
severe bone pain and is scheduled to C. Check circulation every 15-30 minutes.
receive a dose of morphine sulfate. In administering D. Socialize with other patients once a shift.
the medication, Nurse Trish should avoid which 7 . A male client who has severe burns is receiving
route? H2 receptor antagonist therapy. The nurse In charge
. I.V
A knows the purpose of this therapy is to:
B. I.M . Prevent stress ulcer
A
C. Oral B. Block prostaglandin synthesis
D. S.C C. Facilitate protein synthesis.
3 . Dr. Garcia writes the following order for the client D. Enhance gas exchange
who has been recently admitted “Digoxin . 125 mg 8 . The doctor orders hourly urine output measurement
P.O. once daily.” To prevent a dosage error, how for a postoperative male client. The nurse Trish
should the nurse document this order onto the records the following amounts of output for 2
medication administration record? consecutive hours: 8 a.m.: 50 ml; 9 a.m.: 60 ml.
. “Digoxin .1250 mg P.O. once daily”
A Based on these amounts, which action should the
B. “Digoxin 0.1250 mg P.O. once daily” nurse take?
C. “Digoxin 0.125 mg P.O. once daily” . Increase the I.V. fluid infusion rate
A
D. “Digoxin .125 mg P.O. once daily” B. Irrigate the indwelling urinary catheter
4 . A newly admitted female client was diagnosed C. Notify the physician
with deep vein thrombosis. Which nursing D. Continue to monitor and record hourly urine
diagnosis should receive the highest priority? output
. Ineffective peripheral tissue
A 9 . Tony, a basketball player twist his right ankle while
perfusion related to venous playing on the court and seeks care for ankle pain and
congestion. swelling. After the nurse applies ice to the ankle for
B. Risk for injury related to edema. 30 minutes, which statement by Tony suggests that
C. Excess fluid volume related to peripheral ice application has been effective?
vascular disease. . “My ankle looks less swollen now”.
A
D. Impaired gas exchange related to increased B. “My ankle feels warm”.
blood flow. C. “My ankle appears redder now”.
, 2
D. “I need something stronger for pain relief” ale client who is having external radiation
m
1 0.The physician prescribes a loop diuretic for a therapy:
client. When administering this drug, the nurse . Protect the irritated skin from sunlight.
A
anticipates that the client may develop which B. Eat 3 to 4 hours before treatment.
electrolyte imbalance? C. Wash the skin over regularly.
. Hypernatremia
A D. Apply lotion or oil to the radiated area when it is
B. Hyperkalemia red or sore.
C. Hypokalemia 1 7.In assisting a female client for immediate
D. Hypervolemia surgery, the nurse In-charge is aware that she
1 1.She finds out that some managers have should:
benevolent-authoritative style of management. Which . Encourage the client to void
A
of the following behaviors will she exhibit most following preoperative
likely? medication. B. Explore the client’s
. Have condescending trust and
A fears and anxieties about the
confidence in their subordinates. surgery.
B. Gives economic and ego C. Assist the client in removing dentures and nail
awards. polish.
C. Communicates downward to staffs. D. Encourage the client to drink water prior to
D. Allows decision making among subordinates. surgery.
1 2. Nurse Amy is aware that the following is true 1 8. A male client is admitted and diagnosed with
about functional nursing acute pancreatitis after a holiday celebration of
. Provides continuous, coordinated and
A excessive food and alcohol. Which assessment finding
comprehensive nursing services. B. reflects this diagnosis?
One-to-one nurse patient ratio. . Blood pressure above normal range.
A
C. Emphasize the use of group collaboration. B. Presence of crackles in both lung fields.
D. Concentrates on tasks and activities. C. Hyperactive bowel sounds
13.Which type of medication order might D. Sudden onset of continuous epigastric and
read “Vitamin K 10 mg I.M. daily × 3 back pain.
days?”A. Single order 1 9. Which dietary guidelines are important for nurse
. Standard written order
B Oliver to implement in caring for the client with
C. Standing order burns?
D. Stat order . Provide high-fiber, high-fat diet
A
14.A female client with a fecal impaction B. Provide high-protein, high-carbohydrate diet.
frequently exhibits which clinical C. Monitor intake to prevent weight gain.
manifestation?A. Increased appetite D. Provide ice chips or water intake.
. Loss of urge to defecate
B 2 0.Nurse Hazel will administer a unit of whole
C. Hard, brown, formed stools blood, which priority information should the
D. Liquid or semi-liquid stools nurse have about the client?
1 5.Nurse Linda prepares to perform an otoscopic . Blood pressure and pulse rate.
A
examination on a female client. For proper B. Height and weight.
visualization, the nurse should position the client’s C. Calcium and potassium levels
D. Hgb and Hct levels.
ear by:
2 1. Nurse Michelle witnesses a female client
. Pulling the lobule down and back
A
B. Pulling the helix up and forward sustain a fall and suspects that the leg may be
C. Pulling the helix up and back broken. The nurse takes which priority action?
D. Pulling the lobule down and forward . Takes a set of vital signs.
A
16. Which instruction should nurse Tom give to a B. Call the radiology department for X-ray.
C. Reassure the client that everything will be
, 3
lright.
a 2 7.A child of 10 years old is to receive 400 cc of IV
D. Immobilize the leg before moving the client. fluid in an 8 hour shift. The IV drip factor is 60. The
2 2.A male client is being transferred to the nursing IV rate that will deliver this amount is:
unit for admission after receiving a radium implant . 50 cc/ hour
A
for bladder cancer. The nurse in-charge would take B. 55 cc/ hour
which priority action in the care of this client? C. 24 cc/ hour
. Place client on reverse isolation.
A D. 66 cc/ hour
B. Admit the client into a private room. 2 8.The nurse is aware that the most important nursing
C. Encourage the client to take frequent rest action when a client returns from surgery is:
periods. . Assess the IV for type of fluid and rate of flow.
A
D. Encourage family and friends to visit. B. Assess the client for presence of pain.
2 3.A newly admitted female client was diagnosed C. Assess the Foley catheter for patency and urine
with agranulocytosis. The nurse formulates which output
priority nursing diagnosis? D. Assess the dressing for drainage.
. Constipation
A 2 9. Which of the following vital sign assessments
B. Diarrhea that may indicate cardiogenic shock after
C. Risk for infection myocardial infarction?
D. Deficient knowledge . BP – 80/60, Pulse – 110 irregular
A
2 4.A male client is receiving total parenteral B. BP – 90/50, Pulse – 50 regular
nutrition suddenly demonstrates signs and C. BP – 130/80, Pulse – 100 regular
symptoms of an air embolism. What is the D. BP – 180/100, Pulse – 90 irregular
priority action by the nurse? 3 0.Which is the most appropriate nursing action in
. Notify the physician.
A obtaining a blood pressure measurement?
B. Place the client on the left A. Take the proper equipment, place the client
side in the Trendelenburg in a comfortable position, and record the
position. C. Place the client in appropriate information in the client’s
high-Fowlers position. chart.
D. Stop the total parenteral nutrition. B. Measure the client’s arm, if you are not sure of
2 5.Nurse May attends an educational conference on the size of cuff to use.
leadership styles. The nurse is sitting with a nurse C. Have the client recline or sit comfortably in a
employed at a large trauma center who states that the chair with the forearm at the level of the
heart.
leadership style at the trauma center
D. Document the measurement, which extremity
is task-oriented and directive. The nurse determines
was used, and the position that the client was
that the leadership style used at the trauma center is: in during the measurement.
. Autocratic.
A 3 1.Asking the questions to determine if the person
B. Laissez-faire.
understands the health teaching provided by the
C. Democratic.
nurse would be included during which step of the
D. Situational
2 6.The physician orders DS 500 cc with KCl 10 nursing process?
. Assessment
A
mEq/liter at 30 cc/hr. The nurse in-charge is going to
B. Evaluation
hang a 500 cc bag. KCl is supplied 20 mEq/10 cc.
C. Implementation
How many cc’s of KCl will be added to the IV D. Planning and goals
solution? 3 2.Which of the following item is considered the
. .5 cc
A single most important factor in assisting the health
B. 5 cc
professional in arriving at a diagnosis or
C. 1.5 cc
determining the person’s needs?
D. 2.5 cc
A. Diagnostic test results
, 4
B. Biographical date 3 8. A male client with diabetes mellitus is receiving
. History of present illness
C insulin. Which statement correctly describes an
D. Physical examination insulin unit?
3 3.In preventing the development of an external . It’s a common measurement in the metric
A
rotation deformity of the hip in a client who must system.
remain in bed for any period of time, the most B. It’s the basis for solids in the avoirdupois
appropriate nursing action would be to use: system.
. Trochanter roll extending from the crest of the
A C. It’s the smallest measurement in the apothecary
ileum to the midthigh. system.
B. Pillows under the lower legs. D. It’s a measure of effect, not a standard
C. Footboard measure of weight or quantity.
D. Hip-abductor pillow 3 9.Nurse Oliver measures a client’s temperature at
3 4.Which stage of pressure ulcer development 102° F. What is the equivalent Centigrade
does the ulcer extend into the subcutaneous temperature?
tissue? . 40.1 °C
A
. Stage I
A B. 38.9 °C
B. Stage II C. 48 °C
C. Stage III D. 38 °C
D. Stage IV 4 0.The nurse is assessing a 48-year-old client who
3 5.When the method of wound healing is one in has come to the physician’s office for his annual
which wound edges are not surgically physical exam. One of the first physical signs of
approximated and integumentary continuity is aging is:
restored by granulations, the wound healing is . Accepting limitations while developing assets.
A
termed B. Increasing loss of muscle tone.
. Second intention healing
A C. Failing eyesight, especially close vision.
B. Primary intention healing D. Having more frequent aches and pains.
C. Third intention healing 4 1.The physician inserts a chest tube into a female
D. First intention healing client to treat a pneumothorax. The tube is
3 6.An 80-year-old male client is admitted to the connected to water-seal drainage. The nurse
hospital with a diagnosis of pneumonia. Nurse in-charge can prevent chest tube air leaks by:
Oliver learns that the client lives alone and hasn’t . Checking and taping all connections.
A
been eating or drinking. When assessing him for B. Checking patency of the chest tube.
dehydration, nurse Oliver would expect to find: C. Keeping the head of the bed slightly elevated.
. Hypothermia
A D. Keeping the chest drainage system below the
B. Hypertension level of the chest.
C. Distended neck veins 4 2.Nurse Trish must verify the client’s identity
D. Tachycardia before administering medication. She is aware that
3 7.The physician prescribes meperidine (Demerol), 75 the safest way to verify identity is to:
mg I.M. every 4 hours as needed, to control a client’s . Check the client’s identification band.
A
postoperative pain. The package insert is “Meperidine, B. Ask the client to state his name.
100 mg/ml.” How many milliliters of meperidine C. State the client’s name out
loud and wait a client to repeat
should the
it. D. Check the room number
client receive?
and the client’s name on the
. 0.75
A
bed.
B. 0.6
4 3.The physician orders dextrose 5 % in water,
C. 0.5
1,000 ml to be infused over 8 hours. The I.V.
D. 0.25
tubing delivers 15 drops/ml. Nurse John should
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