RN FUNDAMENTALS OF NURSING TEST BANK QUESTIONS & ANSWERS

RN FUNDAMENTALS OF NURSING TEST BANK QUESTIONS & ANSWERS 1 RN FUNDAMENTALS OF NURSING 1. A facility has a system for transcribing medication orders to a Kardex as well as a computerizedmedication administration record (MAR). A physician writes the following order for a client: "Prednisone 5 mg P.O. daily for 3 days." The order is correctly transcribed on the Kardex. However, the nurse who transcribes the order onto the MAR neglects to place the limitation of 3 days on the prescription. On the 4th day after the order wasinstituted, a nurse administers prednisone 5 mg P.O. During an audit of the chart, the error isidentified. The person most responsible for the error is the: a. nurse who transcribed the order incorrectly on the MAR b. nurse who administered the erroneous dose. c. pharmacist who filled the order and provided the erroneous dose. d. facility because of its policy on transcription of medications. 2. To evaluate a client's chief complaint, the nurse performs deep palpation. The purpose of deep palpation is to assess which of the following? a. Skin turgor b. Hydration c. Organs d. Temperature 3. One of the nursing fundamentals questions is about giving an I.M. injection, the nurse should insert the needle into the muscle at an angle of: a. 15 degrees. b. 30 degrees. c. 45 degrees. d. 90 degrees. 4. A client, age 43, has no family history of breast cancer or other risk factors for this disease. The nurse should instruct her to have a mammogram how often a. Once, to establish a baseline b. Once per year c. Every 2 years d. Twice per year 5. When prioritizing a client's plan of care based on Maslow's hierarchy of needs, the nurse'sfirst priority would be: a. allowing the family to see a newly admitted client. b. ambulating the client in the hallway. c. administering pain medication d. placing wrist restraints on the client. 6. A 49-year-old client with acute respiratory distress watches everything the staff does and demands full explanations for all procedures and medications. Which of the following actions would best indicate that the client has achieved an increased level of psychological comfort? a. Making decreased eye contact b. Asking to see family members c. Joking about the present condition d. Sleeping undisturbed for 3 hours 7. A hospitalized client who has a living will is being fed through a nasogastric (NG) tube. During a bolus feeding, the client vomits and begins choking. Which of the following actions is most appropriate for the nurse to take? a. Clearthe client's airway. b. Make the client comfortable. c. Start cardiopulmonary resuscitation. d. Stop the feeding and remove the NG tube. 8. The nurse is caring for a geriatric client with a pressure ulcer on the sacrum. When teaching the client about fundamentalsin nursing on dietary intake, which foodsshould the nurse plan to emphasize? a. Legumes and cheese b. Whole grain products c. Fruits and vegetables d. Lean meats and low-fat milk 9. A client with chronic renal failure is admitted with a heart rate of 122 beats/minute, a respiratory rate of 32 breaths/minute, a blood pressure of 190/110 mm Hg, neck vein distention, and bibasilar crackles. Which nursing diagnosis takes highest priority for this client? a. Fear b. Urinary retention c. Excessive fluid volume d. Self-care deficient: Toileting 10. A client's blood test results are asfollows: white blood cell (WBC) count is 1,000/μl; hemoglobin (Hb) level, 14 g/dl; hematocrit (HCT), 42%. Which of the following goals would be most important for this client? a. Promote fluid balance b. Prevent infection. c. Promote rest. d. Prevent injury. Answers and Rationale 1) B - The nurse administering the dose should have compared the MAR with the Kardex and noted the discrepancy. The transcribing nurse and pharmacist aren't void of responsibility; however, the nurse administering the dose is most responsible. The facility's policy does provide for a system of checks and balances. Therefore, the facility isn't responsible for the error. 2) C - The purpose of deep palpation, in which the nurse indents the client's skin approximately 1½" (3.8 cm), is to assess underlying organs and structures, such as the kidneys and spleen. Skin turgor, hydration, and temperature can be assessed by using light touch or light palpation 3) D Nursing Fundamentals Questions Rationale: When giving an I.M. injection, the nurse inserts the needle into the muscle at a 90-degree angle, using a quick, dartlike motion. A 15-degree angle is appropriate when administering an intradermal injection. A 30-degree angle isn't used for any type of injection. A 45- or 90-degree angle can be used when giving a subcutaneous injection 2 4) C - A client age 40 to 49 with no family history of breast cancer or other risk factors for this disease should have a mammogram every 2 years. After age 50, the client should have a mammogram every year 5) C - In Maslow's hierarchy of needs, pain relief is on the first layer. Activity (option B) is on the second layer. Safety (option D) is on the third layer. Love and belonging (option A) are on the fourth layer. 6) D - Sleeping undisturbed for a period of time would indicate that the client feels more relaxed, comfortable, and trusting and is less anxious. Decreasing eye contact, asking to see family, and joking may also indicate that the client is more relaxed. However, these also could be diversions. 7) A - A living will states that no life-saving measures are to be used in terminal conditions. There is no indication that the client is terminally ill. Furthermore, a living will doesn't apply to nonterminal events such as choking on an enteral feeding device. The nurse should clear the client's airway. Making the client comfortable ignoresthe life-threatening event. Cardiopulmonary resuscitation isn't indicated, and removing the NG tube would exacerbate the situation 8) D - Although the client should eat a balanced diet with foods from all food groups, the diet should emphasize foods that supply complete protein, such aslean meats and low-fat milk, because protein helps build and repair body tissue, which promotes healing. Fundamentals in nursing teaches that legumes provide incomplete protein. Cheese contains complete protein, but also fat, which should be limited to 30% or less of caloric intake. Whole grain products supply incomplete proteins and carbohydrates. Fruits and vegetables provide mainly carbohydrates. 9) C - A client with renal failure can't eliminate sufficient fluid, increasing the risk of fluid overload and consequent respiratory and electrolyte problems. This client has signs of excessive fluid volume and is acutely ill. Fear and a toileting self-care deficit may be problems, but they take lower priority because they aren't life-threatening. Urinary retention may cause renal failure but is a less urgent concern than fluid imbalance. 10) B - The client is at risk for infection because the WBC count is dangerously low. Hb level and HCT are within normal limits; therefore, fluid balance, rest, and prevention of injury are inappropriate. Nursing Board Review: Fundamentals of Nursing Practice Test Part 1 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 minute b. Blood pressure of 140/90 c. Respiratory rate greater than 20 breaths per minute d. 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. Wheezes b. Rhonchi c. Gurgles d. 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 C b. 37.95 degrees C c. 40.03 degrees C d. 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. Intuition b. Routine c. Scientific method d. Trial and error 5. What is the order of the nursing process? a. Assessing, diagnosing, implementing, evaluating, planning b. Diagnosing, assessing, planning, implementing, evaluating c. Assessing, diagnosing, planning, implementing, evaluating d. Planning, evaluating, diagnosing, assessing, implementing 6. During the planning phase of the nursing process, which of the following is the outcome? a. Nursing history b. Nursing notes c. Nursing care plan d. Nursing diagnosis 7. What is an example of a subjective data? a. Heart rate of 68 beats per minute b. Yellowish sputum c. 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 3 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. Accuracy b. Legibility c. Concern for privacy d. Rapid communication 11. The theorist who believes that adaptation and manipulation of stressors are related to foster change is: a. Dorothea Orem b. Sister Callista Roy c. Imogene King d. Virginia Henderson 12. Formulating a nursing diagnosis is a joint function of: a. Patient and relatives b. Nurse and patient c. Doctor and family d. 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 belief b. Personal belief c. Health belief d. 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 pressure b. Warm, dry skin c. Decreased serum sodium levels d. 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 infusion b. Call the attending physician c. Slow that infusion to 20 ml/hr d. 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. Manager b. Caregiver c. Patient advocate d. 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 place b. Clear breath sounds c. Capillary refill greater than 3 seconds and buccal cyanosis d. 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? 4 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 ago d. 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 diagnosis c. Making of individualized patient care d. 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 dysfunction d. 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 degrees b. 90 degrees c. 45 degrees d. 0 degree Answer and Rationale : Fundamentals in Nursing Practice Test Part 1 1. (C) Respiratory rate greater than 20 breaths per minute A 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) Wheezes Wheezes 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 C To 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, evaluating The correct order of the nursing process is assessing, diagnosing, planning, implementing, evaluating. 6. (C) Nursing care plan The 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 highsalt 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 privacy A 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 Roy Sister 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 selfcare 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 patient 5 Although diagnosing is basically the nurse‘s responsibility, input from the patient is essential to formulate the correct nursing diagnosis. 13. (C) Health belief Health belief of an individual influences his/her preventive health behavior. 14. (D) Decreased urine output Adreno-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 infusion The 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 medication This 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 cyanosis Capillary 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 ago The 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 care To 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 degree The 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 Practice Test I -Foundation of Nursing 1. Which element in the circular chain of infection can be eliminated by preserving skin integrity? a. Host b. Reservoir c. Mode of transmission d. 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 environment b. Turning on the patient‘s room ventilator c. Opening the door of the patient‘s room leading into the hospital corridor d. 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 leukopenia b. A patient receiving broad-spectrum antibiotics c. A postoperative patient who has undergone orthopedic surgery d. A newly diagnosed diabetic patient 4. Effective hand washing requires the use of: a. Soap or detergent to promote emulsification b. Hot water to destroy bacteria c. A disinfectant to increase surface tension d. All of the above 5. After routine patient contact, hand washing should last at least: a. 30 seconds b. 1 minute c. 2 minute d. 3 minutes 6 6. Which of the following procedures always requires surgical asepsis? a. Vaginal instillation of conjugated estrogen b. Urinary catheterization c. Nasogastric tube insertion d. Colostomy irrigation 7. Sterile technique is used whenever: a. Strict isolation is required b. Terminal disinfection is performed c. Invasive procedures are performed d. 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 item b. Touching the outside wrapper of sterilized material without sterile gloves c. Placing a sterile object on the edge of the sterile field d. 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. Yawning b. Body hair c. Hiccupping d. 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 wrist d. 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 gown b. Waist tie in front of the gown c. Cuffs of the gown d. 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 syringes b. Discard all used uncapped needles and syringes in an impenetrable protective container c. Wear gloves when administering IM injections d. Follow enteric precautions 13. All of the following measures are recommended to prevent pressure ulcers except: a. Massaging the reddened are with lotion b. Using a water or air mattress c. Adhering to a schedule for positioning and turning d. Providing meticulous skin care 14. Which of the following blood tests should be performed before a blood transfusion? a. Prothrombin and coagulation time b. Blood typing and cross-matching c. Bleeding and clotting time d. Complete blood count (CBC) and electrolyte levels. 15. The primary purpose of a platelet count is to evaluate the: a. Potential for clot formation b. Potential for bleeding c. Presence of an antigen-antibody response d. Presence of cardiac enzymes 16. Which of the following white blood cell (WBC) counts clearly indicates leukocytosis? a. 4,500/mm³ b. 7,000/mm³ c. 10,000/mm³ d. 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. Hypokalemia b. Hyperkalemia c. Anorexia d. Dysphagia 18. Which of the following statements about chest X-ray is false? a. No contradictions exist for this test b. Before the procedure, the patient should remove all jewelry, metallic objects, and buttons above the waist c. A signed consent is not required d. 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 morning b. After the patient eats a light breakfast c. After aerosol therapy d. After chest physiotherapy 7 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 the patient‘s skin. The most appropriate nursing action would be to: a. Withhold the moderation and notify the physician b. Administer the medication and notify the physician c. Administer the medication with an antihistamine d. 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 alcohol b. Use a needle that‘s a least 1‖ long c. Aspirate for blood before injection d. 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 crest b. Palpate the lower edge of the acromion process and the midpoint lateral aspect of the arm c. Palpate a 1‖ circular area anterior to the umbilicus d. 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 medication b. Bruises too easily c. Can be used only when the patient is lying down d. Does not readily parenteral medication 24. The appropriate needle size for insulin injection is: a. 18G, 1 ½‖ long b. 22G, 1‖ long c. 22G, 1 ½‖ long d. 25G, 5/8‖ long 25. The appropriate needle gauge for intradermal injection is: a. 20G b. 22G c. 25G d. 26G 26. Parenteral penicillin can be administered as an: a. IM injection or an IV solution b. IV or an intradermal injection c. Intradermal or subcutaneous injection d. 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 mg b. 10 mg c. 60 mg d. 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/minute b. 13 gtt/minute c. 25 gtt/minute d. 50 gtt/minute 29. Which of the following is a sign or symptom of a hemolytic reaction to blood transfusion? a. Hemoglobinuria b. Chest pain c. Urticaria d. Distended neck veins 30. Which of the following conditions may require fluid restriction? a. Fever b. Chronic Obstructive Pulmonary Disease c. Renal Failure d. Dehydration 31. All of the following are common signs and symptoms of phlebitis except: a. Pain or discomfort at the IV insertion site b. Edema and warmth at the IV insertion site c. A red streak exiting the IV insertion site d. 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 before b. Have the patient repeat the nurse‘s instructions using her own words c. Demonstrate the procedure to the patient and encourage to ask questions d. Ask the patient to demonstrate the procedure 33. Which of the following types of medications can be administered via gastrostomy tube? a. Any oral medications b. Capsules whole contents are dissolve in water c. Enteric-coated tablets that are thoroughly dissolved in water d. Most tablets designed for oral use, except for extended-duration compounds 8 34.A patient who develops hives after receiving an antibiotic is exhibiting drug: a. Tolerance b. Idiosyncrasy c. Synergism d. 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 hours b. Check the pressure dressing for sanguineous drainage c. Assess a vital signs every 15 minutes for 2 hours d. 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 irritants b. Is primarily a voluntary action c. Is induced by the administration of an antitussive drug d. 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 sponges b. Provide increased cool liquids c. Provide additional bedclothes d. Provide increased ventilation 38.A clinical nurse specialist is a nurse who has: a. Been certified by the National League for Nursing b. Received credentials from the Philippine Nurses‘ Association c. Graduated from an associate degree program and is a registered professional nurse d. 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 sensations b. Change the urine‘s color c. Change the urine‘s concentration d. Inhibit the growth of microorganisms 40. Clay colored stools indicate: a. Upper GI bleeding b. Impending constipation c. An effect of medication d. 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. Assessment b. Analysis c. Planning d. Evaluation 42. All of the following are good sources of vitamin A except: a. White potatoes b. Carrots c. Apricots d. 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 bladder b. Irrigate the patient with 1% Neosporin solution three times a daily c. Clamp the catheter for 1 hour every 4 hours to maintain the bladder‘s elasticity d. 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 antibodies c. Aid in diagnosing a patient with AIDS d. All of the above 45. The two blood vessels most commonly used for TPN infusion are the: a. Subclavian and jugular veins b. Brachial and subclavian veins c. Femoral and subclavian veins d. 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 surgery b. Applying a topical antiseptic to the skin on the evening before surgery c. Having the patient take a tub bath on the morning of surgery d. 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 muscles b. Back muscles c. Leg muscles 9 d. Upper arm muscles 48. Thrombophlebitis typically develops in patients with which of the following conditions? a. Increases partial thromboplastin time b. Acute pulsus paradoxus c. An impaired or traumatized blood vessel wall d. 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 pneumonia b. Appneustic breathing, atypical pneumonia and respiratory alkalosis c. Cheyne-Strokes respirations and spontaneous pneumothorax d. 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 incontinence b. Urine retention, bladder distention, and infection c. Diuresis, natriuresis, and decreased urine specific gravity d. Decreased calcium and phosphate levels in the urine Answer and Rationale- Practice Test I -Foundation of Nursing 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 10 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 difficulty swallowing. 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 and notify 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 or sensitivity 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 in ABO 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. 11 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 allergic reaction 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 body temperature 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 the ability 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, claycolored 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.; beets turn 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 must be 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. 12 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. Nursing Practice I -Foundation of Professional Nursing Practice 1. The nurse In-charge in labor and delivery unit administered a dose of terbutaline to a client without checking the 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 halfnormal saline solution at 150 ml/hr. The client complains of severe bone pain and is scheduled to receive a dose of morphine sulfate. In administering the medication, Nurse Trish should avoid which route? a. I.V b. I.M c. Oral d. S.C 3. Dr. Garcia writes the following order for the client who has been recently admitted ―Digoxin . 125 mg P.O. once daily.‖ To prevent a dosage error, how should the nurse document this orderonto 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 Incharge knows the purpose of this therapy is to: a. Prevent stress ulcer b. Block prostaglandin synthesis c. Facilitate protein synthesis. d. Enhance gas exchange 8. The doctor orders hourly urine output measurement for a postoperative male client. The nurse Trish records the following amounts of output for 2 consecutive hours: 8 a.m.: 50 ml; 9 a.m.: 60 ml. Based on these amounts, which action should the nurse take? a. Increase the I.V. fluid infusion rate b. Irrigate the indwelling urinary catheter c. Notify the physician d. Continue to monitor and record hourly urine output 9. Tony, a basketball player twist his right ankle 13 while playing on the court and seeks care for ankle pain and swelling. After the nurse applies ice to the ankle for 30 minutes, which statement by Tony suggests that ice application has been effective? a. ―My ankle looks less swollen now‖. b. ―My ankle feels warm‖ . c. ―My ankle appears redder now‖. d. ―I need something stronger for pain relief‖ 10. The physician prescribes a loop diuretic for a client. When administering this drug, the nurse anticipates that the client may develop which electrolyte imbalance? a. Hypernatremia b. Hyperkalemia c. Hypokalemia d. Hypervolemia 11. She finds out that some managers have benevolent-authoritative style of management. Which of the following behaviors will she exhibit most likely? a. Have condescending trust and confidence in their subordinates. b. Gives economic and ego awards. c. Communicates downward to staffs. d. Allows decision making among subordinates. 12. Nurse Amy is aware that the following is true about functional nursing a. Provides continuous, coordinated and comprehensive nursing services. b. One-to-one nurse patient ratio. c. Emphasize the use of group collaboration. d. Concentrates on tasks and activities. 13. Which type of medication order might read "Vitamin K 10 mg I.M. daily × 3 days?" a. Single order b. Standard written order c. Standing order d. Stat order 14.A female client with a fecal impaction frequently exhibits which clinical manifestation? a. Increased appetite b. Loss of urge to defecate c. Hard, brown, formed stools d. Liquid or semi-liquid 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 back b. Pulling the helix up and forward c. Pulling the helix up and back d. Pulling the lobule down and forward 16. Which instruction should nurse Tom give to a male client who is having external radiation therapy: a. Protect the irritated skin from sunlight. b. Eat 3 to 4 hours before treatment. c. Wash the skin over regularly. d. Apply lotion or oil to the radiated area when it is red or sore. 17. In assisting a female client for immediate surgery, the nurse In-charge is aware that she should: a. Encourage the client to void following preoperative medication. b. Explore the 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 sounds d. Sudden onset of continuous epigastric and back pain. 19. Which dietary guidelines are important for nurse Oliver to implement in caring for the client with burns? a. Provide high-fiber, high-fat diet b. Provide high-protein, high-carbohydrate diet. c. Monitor intake to prevent weight gain. d. Provide ice chips or water intake. 20. Nurse Hazel will administer a unit of whole blood, which priority information should the nurse have about the client? a. Blood pressure and pulse rate. b. Height and weight. c. Calcium and potassium levels d. Hgb and Hct levels. 21. Nurse Michelle witnesses a female client sustain a fall and suspects that the leg may be broken. The nurse takes which priority action? a. Takes a set of vital signs. b. Call the radiology department for X-ray. c. Reassure the client that everything will be alright. d. Immobilize the leg before moving the client. 14 22.A male client is being transferred to the nursing unit for admission after receiving a radium implant for bladder cancer. The nurse incharge would take which priority action in the care of this client? a. Place client on reverse isolation. b. Admit the client into a private room. c. Encourage the client to take frequent rest periods. d. Encourage family and friends to visit. 23.A newly admitted female client was diagnosed with agranulocytosis. The nurse formulates which priority nursing diagnosis? a. Constipation b. Diarrhea c. Risk for infection d. Deficient knowledge 24.A male client is receiving total parenteral nutrition suddenly demonstrates signs and symptoms of an air embolism. What is the priority action by the nurse? a. Notify the physician. b. Place the client on the left side in the Trendelenburg position. c. Place the client in high-Fowlers position. d. Stop the total parenteral nutrition. 25. Nurse May attends an educational conference on leadership styles. The nurse is sitting with a nurse employed at a large trauma center who states that the leadership style at the trauma center is task-oriented and directive. The nurse determines that the leadership style used at the trauma center is: a. Autocratic. b. Laissez-faire. c. Democratic. d. Situational 26. The physician orders DS 500 cc with KCl 10 mEq/liter at 30 cc/hr. The nurse in-charge is going to hang a 500 cc bag. KCl is supplied 20 mEq/10 cc. How many cc‘s of KCl will be added to the IV solution? a. .5 cc b. 5 cc c. 1.5 cc d. 2.5 cc 27.A child of 10 years old is to receive 400 cc of IV fluid in an 8 hour shift. The IV drip factor is 60. The IV rate that will deliver this amount is: a. 50 cc/ hour b. 55 cc/ hour c. 24 cc/ hour d. 66 cc/ hour 28. The nurse is aware that the most important nursing action when a client returns from surgery is: a. Assess the IV for type of fluid and rate of flow. b. Assess the client for presence of pain. c. Assess the Foley catheter for patency and urine output d. Assess the dressing for drainage. 29. Which of the following vital sign assessments that may indicate cardiogenic shock after myocardial infarction? a. BP – 80/60, Pulse – 110 irregular b. BP – 90/50, Pulse – 50 regular c. BP – 130/80, Pulse – 100 regular d. BP – 180/100, Pulse – 90 irregular 30. Which is the most appropriate nursing action in obtaining a blood pressure measurement? a. Take the proper equipment, place the client in a comfortable position, and record the appropriate information in the 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. Assessment b. Evaluation c. Implementation d. Planning and goals 32. Which of the following item is considered the single most important factor in assisting the health professional in arriving at a diagnosis or determining the person‘s needs? a. Diagnostic test results b. Biographical date c. History of present illness d. Physical examination 33. In preventing the development of an external rotation deformity of the hip in a client who must remain in bed for any period of time, the most appropriate nursing action would be to use: a. Trochanter roll extending from the crest of the ileum to the midthigh. b. Pillows under the lower legs. c. Footboard d. Hip-abductor pillow 15 34. Which stage of pressure ulcer development does the ulcer extend into the subcutaneous tissue? a. Stage I b. Stage II c. Stage III d. Stage IV 35. When the method of wound healing is one in which wound edges are not surgically approximated and integumentary continuity is restored by granulations, the wound healing is termed a. Second intention healing b. Primary intention healing c. Third intention healing d. First intention healing 36. An 80-year-old male client is admitted to the hospital with a diagnosis of pneumonia. Nurse Oliver learns that the client lives alone and hasn‘t been eating or drinking. When assessing him for dehydration, nurse Oliver would expect to find: a. Hypothermia b. Hypertension c. Distended neck veins d. Tachycardia 37. The physician prescribes meperidine (Demerol), 75 mg I.M. every 4 hours as needed, to control a client‘s postoperative pain. The package insert is ―Meperidine, 100 mg/ml.‖ How many milliliters of meperidine should the client receive? a. 0.75 b. 0.6 c. 0.5 d. 0.25 38. A male client with diabetes mellitus is receiving insulin. Which statement correctly describes an insulin unit? a. 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 °C b. 38.9 °C c. 48 °C d. 38 °C 40. The nurse is assessing a 48-year-old client who has come to the physician‘s office for his annual physical exam. One of the first physical signs of aging is: a. Accepting limitations while developing assets. b. Increasing loss of muscle tone. c. Failing eyesight, especially close vision. d. Having more frequent aches and pains. 41. The physician inserts a chest tube into a female client to treat a pneumothorax. The tube is connected to water-seal drainage. The nurse incharge 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/minute b. 32 drops/minute c. 20 drops/minute d. 18 drops/minute 44. If a central venous catheter becomes disconnected accidentally, what should the nurse in-charge do immediately? a. Clamp the catheter b. Call another nurse c. Call the physician d. Apply a dry sterile dressing to the site. 45.A female client