Name: _________________________________________________________________ Date:_______________ 1. Elizabeth Kubler-Ross identified five stages of death and dying. Loss, grief, and intense sadness are symptoms of which stage? a. Denial and isolation b. Depression c. Anger d. Bargaining RATIONALE: According to Kübhler-Ross, the five stages of death and dying are denial and isolation, anger, bargaining, depression, and acceptance. In denial, the client denies aspects of the illness and death. Loss, grief, and intense sadness indicate depression. In anger, the client has hostility that may be directed to family members, God, heath care workers, and others. In bargaining, the client asks God for more time, and in return promises to do something good. 2. To help minimize calcium loss from a hospitalized client's bones, the nurse should: a. reposition the client every 2 hours. b. encourage the client to walk in the hall c. provide the client daily products at frequent intervals d. provide supplemental feedings between meals. RATIONALE: Calcium absorption diminishes with reduced physical activity because of decreased bone stimulation. Therefore, encouraging the client to increase physical activity such as by walking the hall, helps minimize calcium loss. Turning or repositioning the client every 2 hours wouldn’t increase activity sufficiently to minimize bone loss, Providing dairy products and supplemental feedings wouldn't lessen calcium loss - even if the dairy products and feedings contained extra calcium — because the additional calcium doesn’t increase bone stimulation or osteoblast activity. 3. Which statement regarding heart sounds is correct? a. S1 and s2 sound equally loud over the entire cardiac area. b. S1 and sound fainter at the apex than at the base. c. S and 2 sound fainter at the base than at the apex. d. S1 is loudest at the apex, and S2 is loudest at the base. Rationale: The S1 sound — the “lub” sound — is loudest at the apex of the heart. It sounds longer, lower, and louder there than the S2 — the “dub” sound — is loudest at the base. It sounds shorter, sharper, higher, and louder there than the S1. 4. A client has a nursing diagnosis of Ineffective airway clearance related to poor coughing. When planning this client’s care, the nurse should include which intervention? a. Increasing fluids to 2,500 ml/day b. Teaching the client how to deep-breathe and cough c. Improving airway clearance d. Suctioning the client every 2 hours RATIONALE: Interventions should address the etiology of the client's problem — poor coughing. Teaching deep breathing and coughing addresses this etiology. Increasing fluids may improve the client’s condition, but this intervention doesn't address poor coughing. Improving airway clearance is too vague to be considered an appropriate intervention. Suctioning isn't indicated unless other measures fail to clear the airway. 5. A nurse is using the computer when a client calls for pain medication. Which action by the nurse is the best? a. Staying logged on, leaving the terminal on, and administering the medication immediately b. telling the client that he’ll have to wait 15 minutes while she completes the entry c. Asking a coworker to log out for her and administering the medicine right away d. Logging out of the computer, then administering the pain medication RATIONALE: A nurse should meet a client’s request for pain medication as quickly as possible after she logs out of the computer. A nurse shouldn't ask a client to wait for as long as 15 minutes for requested pain medication. If the nurse leaves the terminal without logging out, others may view confidential information or use her password. Asking a coworker to log her out isn't safe computer practice.
6. What is the most appropriate nursing diagnosis for the client with acute pancreatitis? a. Deficient fluid volume b. Excess fluid volume c. Decreased cardiac output d. Ineffective gastrointestinal tissue perfusion RATIONALE: Clients with acute pancreatitis often experience deficient fluid volume, which can lead to hypovolemic shock. Vomiting, hemorrhage (in hemorrhagic pancreatitis), and plasma leaking into the peritoneal cavity may cause the volume deficit. Hypovolemic shock will cause a decrease in cardiac output. Gastrointestinal tissue perfusion will be ineffective if hypovolemic shock occurs, but this wouldn't be the primary nursing diagnosis. 7. One aspect of implementation related to drug therapy is: a. developing a plan of care b. documenting drugs given. c. establishing outcome criteria. d. setting realistic client goals. RATIONALE: Athough documentation isn't a step in the nursing process, the nurse is legally required to document activities related to drug therapy, including the time of administration, the quantity, and the client's reaction. Developing a plan of care, establishing outcome criteria, and setting realistic client goals are parts of planning rather than implementation. 8. A nurse notes that a client’s I.V. insertion site is red, swollen, and warm to the touch. which action should the nurse take first? a. Discontinue the I.V. infusion. b. Apply a warm, moist compress to the I.V. site. c. Assess the I.V. infusion for patency. d. Apply an ice pack to the I.V. site. RATIONALE: Because redness, swelling, and warmth at an I.V. site are signs of infection, the nurse should discontinue the infusion immediately and restart at another site. After doing this, the nurse should apply warmth to the original site. Checking infusion patency isn't warranted because assessment findings suggest infection and inflammation, not infiltration. Heat, not cold is the appropriate treatment for inflammation. 9. A nurse is caring for a client with a history of falls. The nurse's first priority when caring for a client at risk for falls is: a. placing the call light for easy access. b. keeping the bed in the lowest possible position. c. instructing the client not to get out of the bed without assistance d. keeping the bedpan available so that the client doesn’t have to get out of bed. RATIONALE: Keeping the bed at the lowest possible position the first priority for clients at risk for falling. Keeping the call light easy accessible is important but isn’t a top priority. Instructing the client not to get out of bed may not effectively prevent falls — for example, if the client is confused. Even when the client needs assistance to get out of bed, the nurse should place the bed in the lowest position. The client may not require a bedpan. 10. A nurse is caring for a client who is exhibiting signs and symptoms characteristic of a myocardial infarction (MI). which statement describes priorities the nurse should establish while performing the physical assessment? a. Assess the client's level of pain and administer prescribed analgesics. b. Assess the client’s level of anxiety and provide emotional support. c. Prepare the client for pulmonary artery catheterization. d. Ensure that the client's family is kept informed of his status. RATIONALE: The cardinal symptom of MI is persistent, crushing substernal pain or pressure. The nurse should first assess the client's pain and prepare to administer nitroglycerin or morphine for pain control. The client must be medically stabilized before pulmonary artery catheterization can be used as a diagnostic procedure. Anxiety and a feeling of impending doom are characteristic of MI, but the priority is to stabilize the client medically. Although the client and his family should be kept informed at every step of the recovery process, this action isn’t the priority when treating a client with a suspected MI.
11. A nurse is monitoring a client for adverse reactions during barbiturate therapy. What is the major disadvantage of barbiturate use? a. Prolonged half-life b. Poor absorption c. Potential for drug dependence d. Potential for hepatotoxicity RATIONALE: Clients can become dependent on barbiturates, especially with prolonged use. Because of the rapid distribution of some barbiturates, no correlation exists between duration of action and half-life. Barbiturates are absorbed well and don't cause hepatotoxicity, but because barbiturates are metabolized in the liver, existing hepatic damage does require cautious use of these drugs. 12. A nurse is caring for a client who required chest tube insertion for a pneumothorax. To assess for pneumothorax resolution, the nurse anticipates that the client will require: a. monitoring of arterial oxygen saturation , b. arterial blood gas (ABG) studies. c. chest auscultation. d. a chest x-ray. Rationale: Chest x-ray confirms diagnosis by revealing air or fluid in the pleural space. SaO2 values may initially decrease with a pneumothorax but typically return to normal within 24 hours. ABG studies may show hypoxemia, possibly with respiratory acidosis and hypercapnia not related to a pneumothorax. Chest auscultation will determine overall lung status, but it's difficult to determine if the chest has reexpanded sufficiently. 13. During her morning assessment, a nurse notes that a client has severe dyspnea, his respirations are 34 breaths/minute and labored. Oxygen saturation is 79% on 3L of oxygen. The nurse remembers that the client's chart includes his living will, When considering best practice, the nurse should: a. withhold all potentially life-prolonging treatments in accordance with the client's living will b. increase the oxygen flow rate to 4L, but avoid initiating other interventions c. call the client’s family and ask what they think is best. d. initiate potentially life-prolonging treatment unless the client refuses. RATIONALE: A living will doesn't go into effect unless the client is unable to make his own decisions. A nurse shouldn't withhold care for an alert client unless he specifically refuses care. The nurse should give all appropriate care while also maintaining the client's right to refuse treatment. Increasing the oxygen flow rate might be an appropriate response, but isn't the best action at this time. The family isn't responsible for determining care at this time. 14. A client is to receive a glycerin suppository. Which nursing action is appropriate when administering a suppository? a. Removing the suppository from the refrigerator 30 minutes before insertion b. Applying a lubricant to the suppository c. Dissolving the suppository in 3 ml of warm water d. Instructing the client to bear down during insertion RATIONALE: A suppository must be lubricated before insertion. Because suppositories melt at body temperature, they usually require refrigeration until administration. It isn’t appropriate to dissolve a suppository in warm water. It should remain in a solid state. Instructing the client to bear down would cause the anal sphincter to contract, making insertion difficult. 15. A physician orders regular insulin 10 units LV. along with 50 ml of dextrose 50% for a client with acute renal failure. What problem is this client most likely experiencing? a. Hypercalcemia b. Hypernatremia c. Hyperglycemia d. Hyperkalemia Rationale: Administering regular IV concomitantly with 50 ml of dextrose 50% helps shift potassium from the extracellular fluid into the cell, which normalizes serum potassium levels in the client with hyperkalemia. This combination doesn't he reverse the effects of hypercalcemia, hypenatremia, or hyperglycemia.
16. A nurse identifies a client’s responses to actual or potential health problems during which step of the nursing process? a. Assessment b. Diagnosis c. Planning d. Evaluation RATIONALE: The nurse identifies human responses to actual or potential health problems during the diagnosis step of the nursing process, which encompasses the nurse’s ability to formulate a nursing diagnosis. During the assessment step, the nurse systematically collects data about the client or his family. During the planning step, she develops strategies to resolve or decrease the client’s problem. During the evaluation step, the nurse determines the effectiveness of the care plan. 17. In a client with a urine specific gravity of 1.040, a subnormal serum osmolality, and a serum sodium level of 128 mEq/L, the nurse should question an order for which I.V. fluid? a. dextrose 5% in half-normal saline solution. b. normal saline solution. c. dextrose 5% on water (D5W) d. lactated Ringer’s solution. RATIONALE: An elevated urine specific gravity, a subnormal serum osmolality, and a subnormal serum sodium level indicate that the client is excreting too many solutes. Because the client is in a hypotonic state, the nurse shouldn't give him a hypotonic I.V. solution. D5W, also referred to as free water, is hypotonic when given I.V. and can further hemodilute the clent. Dextrose 5% half-normal saline solution is hypertonic, normal saline solution is isotonic, and lactated Ringer's solution is isotonic. For this client, each of these three choices are more acceptable than D5w. 18. A 10-year-old child with rheumatic fever must have his heart rate measured while he's awake and while he’s sleeping. Why are two readings necessary? a. To obtain a heart rate that isn't affected by medication b. To eliminate interference from the jerky movements of chorea c. To ensure that the child can't consciously raise or lower his heart rate d. To compensate for activity's effects on the child’s heart rate RATIONALE: Tachycardia may be a sign of heart failure. The nurse can detect mild tachycardia more easily when the child is asleep than when he's awake because activity can increase his heart rate. Medications given for rheumatic fever and rheumatic heart disease, such as digoxin (Lanoxin), exert their influence both day and night. Chorea, a symptom of rheumatic fever, is the loss of voluntary muscle control. It doesn't affect pulse because the child would be sitting quietly while the nurse measured his heart rate and wouldn't be involved in purposeful movement. A 10-year-old child probably doesn't know how to consciously raise or lower his heart rate. 19. A nurse preparing to administer a sustained-release capsule to a client. Which is an appropriate nursing intervention? a. Administering the capsule whole with a glass of water b. Crushing the capsule and mixing the medication with applesauce c. Opening the capsule, shaking the contents into water, and administering it to the client d. Having the client chew the capsule before swallowing 20. After receiving an I.M. injection, a client complains of burning pain at the injection site. which nursing action would be most appropriate at this time? a. Applying a cold compress to decrease swelling b. Applying a warm compress to dilate the blood vessels c. Massaging the area to promote absorption of the drug d. Instructing the client to tighten his gluteal muscles to promote better absorption of the drug RATIONAI.E: Applying heat increases blood flow to the area, which, in turn, increases medication absorption. Cold decreases pain but allows the medication to remain in the muscle longer. Massage is a good intervention, but applying a warm compress is better. Tightening the gluteal muscles may cause additional burning if the drug irritates muscular tissues. 21. A client undergoes a total abdominal hysterectomy. When assessing the client 10 hours later, the nurse identifies which finding as an early sign of shock?
a. Confusion b. Pale, warm, dry skin c. Heart rate of 110 beats/minute d. Urine output of 30 ml/hour RATIONALE: Early in shock, inadequate perfusion leads to anaerobic metabolism, which causes metabolic acidosis. As the respiratory rate increases to compensate, the client’s carbon dioxide level decreases, causing alkalosis and subsequent confusion and combativeness. Inadequate tissue perfusion causes pale, cool, clammy skin (not pale, warm, dry skin). An above-normal heart rate is a late sign of shock. A urine output of 30 ml/hour is within normal limits. REFERENCE: Smeltzer, S.C., and Bare, B. Brunner&Suddarth’s Texthook of MedicalSurgical Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 2526. 22. Cross-tolerance to a drug is defined as: a. one drug that can prevent withdrawal symptoms from another drug. b. an allergic reaction to a class of drugs. c. one drug reduces response to another drug. d. one drug increases another drug’s potency. RATIONALE: Cross-tolerance occurs when a drug with a similar action causes a decreased response to another drug. A drug that can prevent withdrawal symptoms from another drug describes cross-dependence. Cross-tolerance isn't an allergic reaction to a class of drugs. A drug's ability to increase the potency of another drug describes potentiating effects. 23. A nurse caring for a client wth a fecal impaction should watch for: a. liquid or semiliquid stools. b. hard, brown, formed stools. c. loss of urge to defecate. d. increased appetite. RATIONALE: Passage of liquid or semiliquid stools results from seepage of unformed bowel contents around the impacted stool in the rectum. Clients with fecal impaction don’t pass hard, brown, formed stools because the feces can't move past the impaction. These clients typically report the urge to defecate (although they can't pass stool) and decreased appetite. 24. A physician orders an intestinal tube to decompress a client's GI tract. when gathering equipment for this procedure, a nurse should obtain a: a. Sengstaken-Blakemore tube. b. Miller-Abbott tube. c. Levin tube. d. Salem sump tube. RATIONALE: A Miller-Abbott tube is an intestinal tube. A Sengstaken-8lakemore tube is an esophageal tube. Levin tubes and Salem sump tubes are nasogastric tubes. REFERENCE: Smeltzer, S.C., and Bare, B. Brunner & Suddarth’s Textbook of Medical Surgica Nursing, 2008, p. 1175. 25. A client has a blood pressure of 152/86 mm Hg. The nurse should document the client’s pulse pressure as: a. 66mm Hg. b. 238 mm Hg. c. 86 mm Hg. d. 152 mm Hg. RATIONALE: Pulse pressure is the difference between the systolic and diastolic pressures — in this case, 66 mm Hg. 26. A client has a nursing diagnosis of Risk for Injury related to adverse effects of potassiumwasting diuretics. What is a correctly written client outcome for this nursing diagnosis? a. “By discharge, the client correctly identifies three potassium-rich food sources.” b. “The client knows the importance of consuming potassium-rich foods daily.” c. “Before discharge, the client knows which food sources are high in potassium.” d. “The client understands all complications of the disease process." RATIONALE: A client outcome must be measurable, objective, concise, realistic for the client, and attainable through nursing management. For each client outcome, the nurse should include only one client behaviour. She should express that behaviour in terms of client expectations and should indicate a time frame in which to accomplish. Knowing the importance of consuming potassium-rich foods and knowing which foods are high in potassium aren't measurable outcomes. Understanding all complications of a disease process isn't measurable or specific to the nursing diagnosis listed.
27. When caring for a client with a 3-cm stage I pressure ulcer on the coccyx, which action may the nurse institute independently? a. Using a povidone-iodine wash on the ulceration three times per day b. Using normal saline solution to clean the ulcer and applying a protective dressing as necessary c. Applying an antibiotic cream to the area three tines per day d. Massaging the area with an astringent every 2 hours 28. A client with burns on his groin has developed blisters. As the client is bathing, a few blisters break. The best action tor the nurse to take is to: a. remove the raised skin because the blister has already broken. b. wash the area with soap and water to disinfect it. c. apply a weakened alcohol solution to clean the area. d. clean the area with normal saline solution and cover it with a protective dressing. RATIONALE: The nurse should clean the area with a mild solution such as normal saline, and then cover it with a protective dressing. Soap and water and alcohol are too harsh. The body's first line of defense broke when the blisters opened: removing the skin exposes a larger area to the risk of infection. 29. A nurse is assisting with a subclavian vein central be insertion when the client's oxygen saturation drops rapidly. He complains of shortness of breath and becomes tachypneic. The nurse suspects the chent has developed a pneumothorax. Further assessment findings supporting the presence of a pneumothorax include: a. diminished or absent breath sounds on the affected side b. paradoxical chest wall movement with respirations. c. tracheal deviation to the unaffected side. d. muffled or distant heart sounds. RATIONALE: In the case of a pneumothorax, auscultating for breath sounds will reveal absent or diminished breath sounds on the affected side. Paradoxical chest wall movements occur in flail chest conditions. Tracheal deviation occurs in a tension pneumothorax. Muffled or distant heart sounds occur in cardiac tamponade. 30. During a meal, a client with hepatitis B dislodges her IV line and bleeds onto the surface of the overbed table. It would be most appropriate for the nurse to instruct a housekeeper to clean the table with: a. alcohol. b. ammonia. c. acetone. d. bleach. RATIONALE: Blood infected with the hepatitis B virus should be removed from the table or other surfaces with bleach. Alcohol, ammonia, and acetone are less effective n destroying the hepatitis B virus. 31. A nurse determines that a client has 20/40 vision. Which statement about this client’s vision is true? a. The client can read the entire vision chart at a distance of 40 feet. b. The client can read from a distance of 20 feet what a person with normal vision can read at a distance of 40 feet. c. The client can read the vision chart from a distance of 20 feet with the right eye and from 40 feet with the left eye. d. The client can read at a distance of 40 feet what a person with normal vision can read at a distance of 20 feet. RATIONALE: The numerator, which is always 20, is the distance in feet between the vision chart and the client. The denominator indicates from what distance a person with normal vision can read the chart. 32. For the past few days, a client has been having calf pain and notices that the painful calf is larger than the other one. The right calf is red, warm, achy, and tender to touch. Which question about the pain should a nurse include in the assessment? a. “Does the pain worsen when you get up in the morning?” b. “Does the pain increase with activity and lessens with rest?" c. “Is the pain relieved when you change position?” d. “Is the pain worse when you point your toes toward your knee?”
RATIONALE: The client's symptoms indicate deep vein thrombosis (DVT). Pointing toes toward the knee will cause discomfort in a client with DVT. Time of the day doesn’t influence the pain associated with DVT. A client with intermittent claudication experiences pain that increases during activity and decreases with rest. A dependent position, not a position change, will increase venous stasis and the pain associated with DVT.
33. A physician orders the following preoperative medications to be administered to a client by the I.M. route: meperidine (Demerol), 50 mg: hydroxyzine pamoate (Vistaril), 25 mg; and glycopyrrolate (Robinul), 0.3 mg. The medications are dispensed as follows: meperidine, 100 mg/ml; hydroxyzine pamoate, 100 mg/2 ml; and glycopyrrolate, 0.2 mg/ml. How many milliliters in total should the nurse administer? a. 5ml b. 2 ml c. 2.5 ml d. 3.8 ml Computation: 0.5 ml + 0.5 ml + 1.5 ml = 2.5 ml 34. What is a common source of airway obstruction in an unconscious client? a. A foreign object b. Saliva or mucus c. The tongue d. Edema RATIONALE: In an unconscious client, the muscles controlling the tongue commonly relax, causing the tongue to obstruct the airway. When this situation occurs, the nurse should use the head-tilt, chin-lift maneuver to cause the tongue to fall back into place. If she suspects the client has a neck injury she must perform the jaw-thrust maneuver. 35. After undergoing small-bowel resection, a client is ordered Metronidazole (Flagyl) 500 mg IV The mixed IV solution contains 100 ml. The nurse is to run the drug over 30 minutes. The drip factor of the available IV tubing is 15 gtts/ml. What is the drip rate? Round your answer to the nearest whole number. a. 50 gtt/min b. 45 gtt/min c. 48 gtt/min d. 40 gtt/min Rationale: Use the following equation: 100 ml/30 minutes x 15 gtt/1 ml = 49.9 gtt/minute (50 gtt/minute) 36. An elderly client who experiences several adverse drug reactions may benefit from: a. reduced drug dosages. b. nursing home placement. c. increased drug doses at longer intervals. d. frequent visits to the physician. RATIONALE: In older clients, diminished hepatic and renal function commonly reduces drug metabolism and excretion. Because adverse reactions are frequently related to drug blood level, the client may benefit from reduced drug dosages. Adverse drug reactions don’t represent a reason for nursing home placement. Increased drug doses at longer intervals may increase adverse reactions rather than decrease them. Although frequent visits to the physician may benefit the client, the visits themselves won't alter how the client's body reacts to the drug. 37. When examining a client who has abdominal pan, a nurse should assess: a. any quadrant first. b. the symptomatic quadrant first. c. the symptomatic quadrant last. d. the symptomatic quadrant either second or third. Rationale: The nurse should systematically assess all areas of the abdomen, if time and the client's condition permit, concluding with the symptomatic area. Otherwise, the nurse may elicit pain in the symptomatic area, causing the muscles in other areas to tighten. This tightening would interfere with further assessment. 38. A nurse is teaching a group of nursing assistants about infection-control measures. The nurse tells the group that the first line of intervention for preventing the spread of infection is:
a. wearing gloves. b. administering antibiotics. c. washing hands. d. assigning clients to private rooms. RATIONALE: Hand washing is the first line of intervention for preventing the spread of infection. Wearing gloves and assigning private rooms for clients can also decrease the spread of infection and should be implemented according to standard precautions. Antibiotics should be initiated when a causative organism is identified.
39. A nurse caring for a client who has suffered a severe stroke. During routine assessment, the nurse notices Cheyne-Stokes respirations. Cheyne-Stokes respirations are: a. progressively deeper breaths followed by shallower breaths with apneic periods. b. rapid, deep breaths with abrupt pauses between each breath. c. rapid, deep breaths and irregular breathing without pauses. d. shallow breaths with an increased respiratory rate. RATIONALE: Cheyne-Stokes respirations are breaths that become progressively deeper followed by shallower respirations with apneic periods. Biot’s respirations are rapid, deep breaths with abrupt pauses between each breath, and equal depth between each breath. Kussmaul’s respirations are rapid, deep breaths without pauses. Tachypnea is abnormally rapid respirations. 40. When positioned properly, the top of a central venous catheter should lie in the: a. superior vena cava. b. basilic vein. c. jugular vein. d. subclavian vein. RATIONALE: When positioned correctly, the top of a central venous catheter lies in the superior vena cava, inferior vena cava, or right atrium — that is, in the central venous circulation. Blood flows unimpeded around the tip, allowing the rapid infusion of large amounts of fluid directly into circulation. The basilic, jugular, and subclavian veins are common insertion sites for central venous catheters. 41. A nurse reviews the arterial blood gas (ABG) values of a client admitted with pneumonia: pH, 7.51, PaCO2, 28 mm Hg; PaO2, 70 mm Hg: and HCO3, 24 mEq/L. What do these values indicate? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis RATIONALE: A client with pneumonia may hyperventilate in an effort to increase oxygen intake. Hyperventilation leads to excess carbon dioxide (Co2) loss, which causes alkalosis — indicated by this client's elevated pH value. with respiratory alkalosis, the kidneys’ bicarbonate (HCO3-) response is delayed, so the client's HCO3- level remains normal. The below-normal value for the partial pressure of arterial carbon dioxide (PaCO2) indicates CO2 loss and signals a respiratory component. Because the HCO3- level is normal, this imbalance has no metabolic component. Therefore, the client is experiencing respiratory alkalosis. 42. The ear canal of an infant or young child: a. slants upward. b. slants downward. c. is horizontal. d. slants backward. Rationale: The ear canal slants up in a younger child and down in an older child or adult. 43. When a central venous catheter dressing becomes moist or loose, what should a nurse do first? a. Draw a circle around the moist spot and note the date and time. b. Notify the physician. c. Remove the catheter, check for catheter integrity, and send the tip for culture. d. Remove the dressing, clean the site, and apply a new dressing. Rationale: A nurse maintaining a central venous catheter should change the dressing every 72 hours or when it becomes soiled, moist, or loose. After removing the soiled dressing, the nurse should use sterile technique to clean around the site in accordance with facility policy. After the cleaning solution has dried, the nurse should cover the site with a transparent semipermeable dressing. A nurse who notes drainage on a wound dressing should draw a
circle around the moist spot and note the date and time. She should notify the physician if she observes any catheter-related complications. Only a nurse with the appropriate qualifications may remove a central venous catheter, and a moist or loose dressing isn’t a reason to remove the catheter. References: Smeltzer, S.C., and Bare, B. Brunner&Suddarth’s Texthook of MedicalSurgical Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1005 44. A nurse is assigned to care for a client with a tracheostomv tube. How can the nurse communicate with this client? a. By providing a tracheostomy plug to use for verbal communication b. By placing the call button under the client's pillow c. By supplying a magic slate or similar device d. By suctioning the client frequently RATIONALE: The nurse should use a nonverbal communication method, such as a magic slate, note pad and picture boards (if the client can’t write or speak English). The physician orders a tracheostomy plug when a client is being weaned off a tracheostomy; it doesn’t enable the client to communicate. The call button, which should be within reach at al times for all clients, can summon attention but doesn't communicate additional information. Suctioning clears the airway but doesn't enable the client to communicate. Mr . Wang has had an exploratory laparotomy. The physician has ordered a dressing change to the abdominal wound every shift. 45. The nurse can best prevent spread of infection by placing Mr. W’s soiled dressing in: a. The garbage receptacle in the patient’s room b. The garbage receptacle in the utility room marked “soiled” c. A paper bag d. A plastic bag 45. After cleaning Mr. Wang’s wound with the prescribed antiseptic solution, the nurse should apply a: a. Dry sterile dressing b. Thick, heavy dressing c. Single-layered gauze pad soaked in normal saline solution d. Single-layered gauze pad soaked in povidone-iodine solution 45. Documentation of Mr. Wang’s dressing change should include all the following except: a. Approximation of the wound edges b. Amount of odor and appearance of any drainage c. Appearance of erythema and edema d. Amount of time needed to change the dressing 45. Which of the following nursing history findings might impede Mr. Wang’s wound healing? a. 35-year old Caucasian computer operator b. 5’9”, 150-lb well-nourished male with good skin turgor c. Hematocrit 43% hemoglobin 16 d. Smoker (has smoked one pack of cigarettes per day for 15 years) 45. The nurse’s main priority when changing Mr. Wang’s dressing is to: a. Wash her hand before and after dressing change b. Wash her hands before dressing change c. Wear disposable gloves to remove the dressing d. Wear sterile gloves during the entire dressing change 45. In assisting Mr. Wang with his coughing and deep-breathing exercises, the nurse should: a. Instruct the patient to take three short, quick breaths b. Instruct the patient to cough once for every three deep breaths c. Medicate the patient with analgesic before his coughing and deep-breathing exercise
d. Medicate the patient with an analgesic after his coughing and deep-breathing exercise 45. The nurse documents the following in Mr. Wang’s chart: “Abdominal dressing changed; small amount of serous drainage noted. Wound edges well approximated with no inflammation or exudates.” This indicates that Mr. Wang’s wound: a. Is healing by first intention b. Is healing by second intention c. Has eviscerated d. Is infected 45. Which of the following nursing orders is the most important during the patient’s immediate postoperative phase? a. Encourage the patient to perform deep-breathing exercise and to use an incentive spirometer hourly while awake b. Assess the patient’s bowel sounds and check abdominal distention every 4 hours c. Assess for Homan’s sign and have the patient perform leg exercises hourly d. Assess the patient’s pain tolerance every 4 hours and administer analgesic as ordered 45. 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 the 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 before and the morning of the surgery 45. Povidone iodine solution effectively prevents wound infections by: a. Aiding in the mechanical debridement b. Increasing tissue maderation c. Reducing local inflammation d. Acting as microbial agent 45. While coughing, Mr. Wang complains of a sudden, sharp abdominal pain. The nurse observes that Mr. Wang’s wound edges have separated and the viscera are exposed. The nurse should: a. Notify the physician immediately b. Apply sterile stripes to the wound edges c. Encourage the patient to cough harder d. Apply sterile wet saline compress 45. A Hemovac is used to do all of the following except: a. Promote wound healing b. Remove drainage from surgical wound c. Lessen postoperative discomfort d. Prevent wound infection 45. When documenting the drainage after emptying the hemovac, the nurse should note all of the following except: a. Volume c. Consistency b. Color d. Specific gravity 45. Which of the following is correct procedure for emptying a closed drainage system, such as a Hemovac: a. Irrigate the wound catheter with sterile saline solution b. Test the drainage for occult blood before emptying the drainage system c. Rinse the hemovac with tap water after discarding the drainage d. Reestablish the closed drainage system after emptying the drainage
45. After emptying the Hemovac, the nurse cleans the plug with an alcohol sponge before reinserting it into the evacuator. This is done to: a. Provide for lubrication b. Decrease the risk of transmitting microorganisms into the drainage system c. Maintain surgical asepsis d. Prevent the emergence of resistant strains or bacteria Ms. Hazel is admitted to the nursing unit with a diagnosis of deep vein thrombosis (inflammation of the venous wall with blood clot formation). 45. After admission, the nurse begins to collect data on Ms. Hazel. This is first stage of: a. The patient interview b. Planning the patient’s discharge c. Determining the patient’s medical diagnosis d. The nursing process 45. The information provided by Ms. Hazel about her health history is considered: a. Subjective data c. An evaluation tool b. Problem solving d. objective data 45. The nurse observes that Ms. Hazel leg is edematous from the knee to the toes. An appropriate nursing intervention would be to: a. Elevate the foot of the bed 18” (48 cm) b. Place the patient in an orthopneic position c. Elevate the left leg on a pillow, but do not allow the heel to rest on the pillow d. Have the patient change position every hour 45. Which of the following nursing diagnosis is appropriate for Ms. Hazel? a. Potential for injury due to edema b. Fluid volume excess related to peripheral vascular disease c. Impaired gas exchange related to increased blood flow d. Altered peripheral tissue perfusion related to venous congestion 45. The nurse touches Ms. Hazel’s leg during the examination for further evidence of edema. The assessment method is known as: a. Inspection c. Auscultation b. Palpation d. Percussion Mr. James is admitted to the hospital with dyspnea, an unproductive cough and a pulse rate of 90 beats/minute. His hemoglobin level is 14 g/dl and serum sodium level, 150 mEq/liter. The physician orders oxygen therapy as part of Mr. James’ medical plan. 45. An a. b. c. d.
appropriate nursing diagnosis for Mr. James is: Impaired gas exchange related to anemia Impaired gas exchange related to inability to move secretions Impaired gas exchange related to tachycardia Ineffective airway clearance related to oxygenation
45. Which of the following nursing interventions should the nurse implement based on Mr. James nursing diagnosis? a. Encourage the patient to change position every 2 hours, assist him as necessary b. Maintain the patient the patient in orthopneic position, and encourage coughing and deep-breathing exercises c. Provide adequate hydration and measure the patient’s fluid intake and output d. All of the above 45. The following statement is written on the nursing care plan: Mr. James will have effective airway clearance within 3 days.” This is an example of:
a. b. c. d.
A nursing diagnosis An evaluation An expected patient outcome A health problem
45. The physician informs Mr. James that he may use a salt substance but that must undergo a monthly blood test to monitor his: a. Magnesium level c. Calcium level b. Potassium level d. Hemoglobin level 45. The nurse makes an error while recording her assessment findings on Mr. James’s chart. How should she correct the information without jeopardizing the chart’s legality? a. Cross out the error and initial the word b. Draw a line through the incorrect statement, write the word “error” and sign her name c. Use an ink eraser or correction fluid to maintain the charts neatness d. Erase the error, write ”error” and sign her name 45. After Mr. James is discharged, his room must be prepared for the next patient. This is accomplished through: a. Universal precautions c. Terminal disinfection b. Autoclaving d. Gas sterilization 45. A nursing care plan, based on a nursing history and patient assessment, must include: a. Nursing diagnosis, health problems and evaluations b. Health problems, goals and evaluations c. Nursing diagnosis, nursing interventions and patient-oriented goals d. Communication, continuity of care and a documented plan of care
45. Which of the following terms can be used to describe a temperature above 100°F (37.8°C)? a. Febrile b. Pyrexic
c. Feverish d. All of the above
45. The most accurate site for measuring body temperature is the: a. Mouth c. Femoral area b. Axilla d. Rectum
45. The centigrade (Celsius) reading for a Fahrenheit reading of 102° is: a. 39° c. 38.9° b. 47° d. 40.1° 45.
Which of the following terms describes a nurse who assumes total nursing responsibility for a patient from admission to discharge? a. Functional Nurse c. Clinical Nurse Specialist b. Nursing Care Coordinator d. Primary Nurse
45. Dorothea Orem, Virginia Henderson, Sister Callista Roy, and Madeleine Leininger are known for their: a. Nursing theories b. Interpretation of National League for Nursing Philosopher c. Development of the Nursing International Honor Society d. Writing of the Patient’s Bill of Rights 45. When auscultating the lungs of a patient with a thick, tenacious mucus in the bronchi, the nurse will hear:
a. Crackles b. Rhonchi
c. Crepitation d. Stridor
45. The rationale for obtaining a sputum specimen for culture and sensitivity testing is to: a. Assess the effectiveness of aspirin therapy b. Identify a specific pathogen and its drug sensitivity c. Study the origin, structure, function and pathology of cells d. Test for acid fast bacilli 45. Sputum collection usually takes place in the morning right after the patient awakens. The underlying rationale for this is that the: a. Patient can cough up secretions that have accumulated during the night b. Patient does not produce sputum during the day c. Sputum may become contaminated with food or fluid if collected during the day d. Patient will not have to cough to expectorate sputum 45. The nurse explains to a patient that a cough: a. Is a protective response to clear the respiratory tract of irritants b. Is a primarily a voluntary action c. Is induced by the administration of an antitussive drug d. Can be inhibited by “splinting” the abdomen 45. Which of the following can result from a kink or blockage in the drainage tubing attached to an indwelling urinary (Foley) catheter? a. Blood clots c. Reduced urine output b. Urine backflow into the bladder d. Paralytic ileus 45. Which of the following can help relieve or reduce the rsk of such stress-related diseases as hypertension, obesity, coronary vascular diseases, and depression? a. Engaging in a controlled physical exercise program b. Increasing protein intake by eating red meat 5 times a week c. Jogging 3 miles a day d. Having physical examination every 3 months 45. Grain (gr) 1/100 is equivalent to how many milligrams (mg)? a. 0.06 mg b. 1 mg c. 0.5 mg 45. 0.4 mg is equivalent to how many grains? a. gr 1/150 b. gr 1/100 c. gr ¼
d. 0.8 mg
d. gr 4
45. the physician orders 50 mg of ranitidine (Zantac) in 100 ml of dextrose of 5% in water (D5W) I.V. to be administered in 30 minutes: a. 5 gtt/minute b. 31 gtt/minute c. 50 gtt/minute
d. 125 gtt/minute
45. The physician orders 1,000 ml of dextrose 5% in 0.45% sodium chloride at an infusion rate if the drop factor is 60 mgtt/ml? a. 14 mgtt/minute b. 18 mgtt/minutre c. 20 mgtt/minute d. 80 mgtt/minute
45. The physician orders 500 ml of D5W with 500 mg of aminophyline at an infusion rate of 50 ml/hour. What is the correct flow rate? a. 5 ml/hour b. 12.5 ml/hour
c. 25 ml/hour
45. A urine specific gravity of 1.001 indicates that the: a. Urine is concentrated (has decreased fluid content) b. Urine is diluted (has increased fluid content) c. Specific gravity is normal d. Specific gravity is increased
d. 50 ml/hour
45. Urine specific gravity is measured with: a. A vacuum blood specimen collection unit (Vacutainer) b. A multiple reagent strip c. A hydrometer or urinometer d. A cystoscope 45. How does a 24-hour urine collection differ from a simple urinalysis? a. The first voided specimen is discarded b. The last voided specimen is discarded c. Urine does not need to be refrigerated d. The specimen must be labeled 45. Rubella antibodies acquired in utero: a. Increase in number within 2-3 months after birth b. Persist for 6-9 months c. Rapidly decrease in number within 2-3 months after birth d. Usually are considered a false-positive titer 45. 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 acquired immunodeficiency syndrome (AIDS) d. All of the above 45. Which independent nursing intervention is applicable for a patient with urinary calculi? a. Administer a cholinergic medication as ordered b. Increase the patient’s fluid intake to 3000-4000 ml/day c. Restrict the patient’s fluid intake d. All of the above 45. A patient weighing 85 lbs and measuring 5’5” is diagnosed with anorexia nervosa. Based on the nursing diagnosis of Body Image Disturbance, which of the following questions should the nurse ask the patient? a. “Describe your physical self to me.” b. “How would your friends describe you?” c. “What kinds of food do you like?” d. “How do you prepare your food?”
95. Before the necessary preoperative teaching, the nurse should: a. Research the surgical procedure so that she can give Mr. Bob a step-by-step explanation b. Give Mr. Bob general information because specifics might be too threatening c. Schedule teaching to begin 2 to 3 hours before surgery so that Mr. Bob has less time to think about it. d. Determine Mr. Bob’s anxieties, needs, level of understanding and expectations 96. Which of the following statements is most likely to promote Mr. Bob’s compliance in performing postoperative turning and body positioning exercises? a. “If these exercises cause you discomfort postoperatively, we will discontinue them until you feel up to it” b. “We’ll make sure you’re in good body alignment while doing the turning and body positioning” c. “Turning and exercising help maintain good body circulation, good breathing, and good muscle tone. This will make moving about easier and less painful afterward.” d. “The positions you will be placed in postoperatively will improve your circulation, prevent venous stasis, and contribute to your optimal respiratory exchange.”
97. Which of the following instructions would be inappropriate in attempting to increase Mr. Bob’s lung ventilation and blood oxygenations after general anesthesia? a. “Ina sitting position, slowly take a deep breath, hold that breath briefly, then slowly exhale” b. “Lying on your back, slowly take a deep breath hold that breath briefly, then slowly exhale” c. “After practicing deep breathing, take a deep breath, exhale through your mouth and cough” d. “When doing your deep-breathing and coughing exercises, splint the abdominal incision to minimize pain” A nurse assigned to Mr. Mario, a 75-year-old newly diagnosed diabetic patient, is beginning to write objectives for the teaching plan. 98. Which a. b. c. d.
of the following statements is true about teaching strategies? Adults learn best by studying printed material Teaching methods should be individualized to each patient Content can be adapted to any type of teaching method Learning objectives do not help in choosing the most appropriate teaching strategy for the patient 99. Which of the following objectives is written in behavioral terms: a. Mr. Mario’s younger sister should learn about diabetes mellitus b. Mr. Mario’s wife needs to understand the side effects of insulin c. Mr. Mario’s sister will be able do determine his insulin requirements based on blood glucose levels obtained form glucometer by August 1 d. Mr. Mario will know about diabetes-related foot care and the techniques and equipment necessary to carry it out 100.Which age-group can learn best form flash cards or learning games? a. Children aged 2 to 3 b. Children aged 5 to 7 c. Teenagers aged 15 to 17 d. Adults aged 65 to 67
FUNDA011 45.A 46.A 47.D 48.D 49.A 50.C 51.A 52.A 53.D 54.D
55.D
66.D
56.D
67.C
57.D
68.B
58.D
69.B
59.B
70.C
60.D
71.D
61.A
72.D
62.A
73.D
63.B
74.C
64.B
75.D
65.B
76.A
85.C
93.B
77.B
86.D
94.C
78.B
87.–
95.D
79.A
88.B
96.C
80.A
89.C
97.B
81.B
90.A
98.B
82.A
91.B
99.C
83.A
92.D
100.B
84.A
