Name: _____________________________________ _________________________________________________________________ ____________________________ Date:_______________ 1. Elizabeth Kubler-Ross identified 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 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 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 leaving the terminal on, on, and administering administering the medication immediately b. telling the client client that he’ll have to wait wait 15 minutes while she she completes the entry c. Asking a coworker to log out for her and administering administering the medicine 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.
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), pancreatitis), and plasma leaking into the peritoneal cavity may cause the volume deficit. Hypovolemic shock will cause a decrease in cardiac output. Gastrointestinal 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 plan of care care b. documenting drugs given. c. establishing establishing outcome criteria. d. setting realistic realistic client goals. goals. RATIONALE: Athough documentation 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, warm, moist compress to the I.V. site. site. c. Assess the the I.V. infusion for patency. patency. d. Apply an ice pack to the I.V. I.V. site. RATIONALE: Because redness, 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 warranted because assessment assessment findings suggest infection and inflammation, not infiltration. Heat, not cold is the appropriate treatment for inflammation. 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 easy access. 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 bedpan available so that that the client doesn’t have 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 client’s level of anxiety anxiety and provide emotional emotional support. c. Prepare the client client for pulmonary artery artery catheterization. catheterization. d. Ensure that the client's client's family is kept informed of his status. 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 catheterization can be used as a diagnostic procedure. procedure. Anxiety and a feeling of impending doom are characteristic of MI, but the priority is to stabilize the client medically. Although 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 Barbiturates are absorbed well and don't cause hepatotoxicity, hepatotoxicity, but because barbiturates barbiturates are metabolized in the liver, existing hepatic damage does require cautious use of these drugs. 12. A nurse is caring for a client client who required chest tube insertion 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, 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 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 Hyperglycemia d. Hyperkalemia Rationale: Administering 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, hypercalcemia, hypenatremia, hypenatremia, or hyperglycemia
16. A nurse identifies a client’s responses responses to actual or potential health 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 urine specific gravity gravity of 1.040, a subnormal serum osmolality, 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 (D 5W) 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 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 with rheumatic fever must must have his heart rate measured measured while he's awake and while he’s sleeping. Why are two readings necessary? a. To obtain a heart heart rate that isn't isn't affected by medication b. To eliminate interference from the jerky movements of chorea c. To ensure that the child can't can't consciously raise or lower lower his heart rate d. To compensate for activity's effects on the child’s heart rate RATIONALE: Tachycardia 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 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 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 cold compress to decrease decrease swelling swelling b. Applying a warm warm compress to dilate the blood blood vessels c. Massaging the area to promote promote absorption of the drug drug d. Instructing the client client to tighten his gluteal muscles muscles to promote better absorption absorption of the drug RATIONAI.E: Applying 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
21. A client undergoes a total total abdominal hysterectomy. hysterectomy. When assessing 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, 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. 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 3 0 ml/hour is within normal limits. MedicalSurgical 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 that can prevent withdrawal symptoms symptoms from another drug. 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 Cross-tolerance occurs when a drug with a similar action causes a decreased response to another drug. A drug that can prevent withdrawal withdrawal symptoms from another drug describes cross-dependence. cross-dependence. Cross-tolerance Cross-tolerance isn't an allergic reaction to a class of drugs. A drug's ability to increase the potency of another drug describes potentiat potentiating ing 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 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 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: 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.”
potassium aren't measurable outcomes. Understanding Understanding all complications 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? 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 area to the 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
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 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), (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 3 0 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. 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 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.
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 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. precautions. Antibiotics should be initiated when a causative organism is identified.
39. A nurse caring for a client client who has suffered a severe severe stroke. During routine assessment, 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 respirations are breaths that become progressively 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 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, correctly, the top of a central venous catheter lies in the superior vena cava, inferior vena cava, 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 hyperventilate in an effort to increase oxygen intake. Hyperventilation 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 HCO 3- level remains normal. The below-normal value for the partial pressure of arterial carbon dioxide (PaCO 2 ) ) indicates CO2 loss and signals a respiratory respiratory component. Because the HCO 3 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?
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 with a transparent semipermeable 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. complications. Only a nurse with the appropriate qualifications qualifications may remove a central venous catheter, and a moist or loose dressing isn’t a reason to remove the catheter. MedicalSurgical 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; 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. information. Suctioning clears the airway but doesn't enable the client to communicate. 45. Chokie underwent diagnostic diagnostic test and he result of the blood examination are back. On reviewing the result, the nurse notice which of the following as an abnormal finding? a. Neutophil 60% c. Iron 75mg/100ml b. ESR 39mm/hr d. WBC 9000/mm 45. A client with viral infection will most likely manifest manifest which of the following during the illness stage of infection? a. Ora Orall tempe temperat rature ure shows shows feve feverr b. Client Client was exposed exposed to the the infection infection 2 days days ago but without without any any symptoms symptoms c. Acute Acute sympt symptoms oms are are no longer longer visi visible ble d. Client Client feel feel sick sick but but can do normal normal activ activities ities 45. Among the clients you are assigned to take care of, who is most susceptible to infection? c. Diabetic Client a. Client with burns b. Client Client with with Myoc Myocard ardia iall Infarc Infarctio tion n d. Clie Client nt with with pulm pulmona onary ry emphy emphysem sema a 45. Surgical asepsis asepsis is observed when: a. Placing Placing a dirty dirty soile soiled d linen linen in moistu moisture re resista resistant nt bag bag b. Disposing Disposing of syring syringe e and needle needle in punctu puncture re proof contai containers ners c. Insert Inserting ing an an Intra Intraven venous ous cath cathete eterr d. Washing Washing hands hands before changing changing wound dressing dressing 45. Which of the following laboratory test results indicate presence presence of infectious process? a. ESR ESR: 12m 12mm m/hr /hr b. Iron Iron 90g/ 90g/10 100m 0mll c. Neut Neutro roph phil ils s 67% 67% d. WBC: WBC: 1800 18000/ 0/mm mm3 3 45. A diabetic hypertensive client, client, Mrs. Charuz, needs a change in diet to improve her health status. She should be referred to a:
b. Encourage Encourage the clien client’s t’s involv involvement ement in his his care care c. She listen listen to to the indiv individua iduall views views of the team members members d. Help the clien clientt sets sets goal goal of care care and and discha discharge rge 47. A nurse is successful on collaborating with the health health team members about the care of his patient. This is because she has the following competencies a. Conflict Conflict manageme management, nt, Trust Trust and Negotiat Negotiation ion b. Negoti Negotiati ation, on, Deci Decisio sion n Makin Making g c. Communic Communication ation,, Trust Trust and Decision Decision Making Making d. Mutual Mutual respec respect, t, Negoti Negotiati ation on and Trust Trust 48. Your client is concerned that he cannot pay his hospital bills and professional professional fees. You refer him to a: a. Bookkeeping Department c. Social Worker b. Nurse Supervisor d. Physician 49. A patient with lung cancer is undergoing chemotherapy. chemotherapy. He is referred by the oncology nurse to a self-help group of clients with cancer to: c. Receive emotional report a. To be a part of the research team b. Provide financial assistance d. Assist with chemotherapy 50. A sputum specimen has been ordered for Mr. Buenaventura, a 75-year-old 75-year-old patient admitted with possible pneumonia of the right lower lobe. Mr. Buenaventura is not able to cough. The nurse is aware that for patients who cannot expectorate sputum from deep in the bronchial tree, Nebulization was done, the specimen must be collected by: a. Oro Orotr trac ache heal al sucti suction onin ing g b. Trach Trachea eall suct suctio ioni ning ng c. Oro Oroph phar aryn ynge geal al sucti suction onin ing g d. Percu Percussi ssion on and sucti suctioni oning ng 45. To obtain a 24-hour urine specimen, the patient should be given which of the following instructions? a. Collect each voiding in separate containers for the next 24 hours b. Discard the first voided specimen and then collect the total volume of each voiding in 24 hours c. For the next 24 hours, retain a 30ml specimen of each voiding after recording the amount voided d. Keep a record of the time and amount of each voiding for 24 hours 46. Ms. Cristobal, Cristobal, age 72, has an indwelling indwelling urinary catheter. catheter. A sterile sterile urine specimen specimen has been ordered for a culture and sensitivity. The sterile specimen should be obtained by: a. Obtaining 60ml of urine from the collection bag b. Re Remo movi ving ng the the pres presen entt cath cathet eter er,, havi having ng the the pati patien entt void void,, and and then then recatheterizing c. Disconnecting the tubing from the catheter and draining 2ml of urine d. Aspirating 10ml of urine with a sterile syringe from the tubing port 47. Mr. Lagman, age 46, is seen by the physician for recurrent symptoms of cystitis. He is to have a urine culture and sensitivity determination and a 24-hour urine collection for laboratory analysis. Mr. Lagman should be informed that a urine culture study is required to: a. Identify the causative organism b. Determine the presence of malignant cells c. Analyze the elements present in the urine d. Localize the site of the inflammatory process 48. How would you prepare for the accuracy accuracy of the occult blood examination? examination? a. Meatless diet for 72 hours prior to collection of the specimen b. Fluid intake is increased an hour before the collection of the specimen c. Fluid intake is limited only to 1 liter per day
bath. While Michelle is giving sponge bath, what action of Michelle needs correction? a. Lining Lining the patient patient on the the left side side with with slightly slightly elevat elevated ed b. Answering Answering the the phone phone while weari wearing ng gloves gloves used used for sponge sponge bath bath c. Rolling Rolling the the patient patient like a log log to do back back rub rub d. Lining Lining the rubber rubber mat with bed bed sheet as as incontinen incontinence ce pad for the clien clientt 50. Joey sustained a fracture of the ulna and cast will be applied. applied. What nursing action before cast application is most important for Nurse Jennica to do? a. Use baby baby powder powder to reduce reduce irrita irritation tion under under the the cast cast b. Evaluate Evaluate the skin skin tempe temperatu rature re in the area c. Asses Assess s sens sensati ation on of each each arm d. Check Check radial radial pulse pulse bilate bilaterall rally y and and compare compare
51. Which of the following client condition should be nurse Jennica’s priority in the pediatric unit? a. The The infa infant nt who who is brou brough ghtt in for for uppe upperr resp respir irat ator ory y trac tractt infe infect ctio ion n whos whose e temperature is slightly elevated b. The baby baby whose whose fontane fontanell s bulging bulging and and firm while while asleep asleep c. The baby baby who is waili wailing ng after after being awake awakened ned by the the banging banging of the the door d. A baby baby boy whose whose circum circumcisio cision n has yello yellowish wish exuda exudates tes 52. When suctioning the endotracheal endotracheal tube, the nurse should: should: a. Insert catheter until resistance is met, then withdraw slightly, applying suction intermittently a catheter is withdrawn b. Hyperoxyg Hyperoxygenate enate client client than than insert insert catheter catheter using using back and and forth motion motion c. Insert Insert suction suction catheter catheter four inches inches into into the tube, suction suction 30 second seconds s using twirlin twirling g motion as catheter is withdrawn d. Explai Explain n proced procedure ure to the patient patient,, insert insert the cathe catheter ter gently gently apply applying ing suction suction.. Withdrawn using twisting motion 53. To obtain specimen for sputum culture and sensitivity, which of the following instruction instruction is best? a. Cough Cough afte afterr pursed pursed lip lip brea breathi thing ng b. Save sputum sputum for two two days days in covered covered contain container er c. Upon waking waking up, up, cough deeply deeply and and expector expectorate ate into into the contain container er d. After After respirator respiratory y treatment, treatment, expec expectorat torate e into a contain container er Situation: The vital or cardinal signs are body temperature, pulse, respiration and blood pressure
54. Ms. Avila is 48-years-old. During a routine physical physical her blood pressure is noted a 180/90. She She fear fears s she she is hype hypert rten ensi sive ve.. The The nurs nurse e woul would d expl explai ain n that that the the diag diagno nosi sis s of hypertension is made when there is a sustained elevated blood pressure of over: a. 160/100 b. 140/90 c. 130/70 d. 120/80 55. 55. Mr. Mr. Jime Jimene nez, z, age age 44, 44, is unde underg rgoi oing ng anti antibi biot otic ic ther therap apy y for for pneu pneumo moni nia. a. His His rect rectal al temperature reading is 101.6°F. His oral temperature would be considered as: a. 101.6°F b. 100.6°F c. 99.6°F
c. Thready d. Bounding 57. Mr. Zamora, RN, has been assigned several several patients. Which one of the following patients would most likely have a higher than normal temperature? a. The depressed, apathetic patient b. The patient addressed with hemorrhage c. The patient who is recovering from surgery d. The patient experiencing strong emotions 58. The physician physician has ordered ordered an orthostat orthostatic ic blood pressure pressure measurement measurement.. Which of the following is correct concerning the orthostatic method of assessing blood pressure? a. The measurement is taken in the lying position, then sitting up and last when the patient is standing. b. The measurement is taken first with the patient sitting up and then lying down. c. The nurse should wait 5 minutes between assessing the blood pressure in the sitting position from the lying position. d. The patient should be lying down for at least 10 minutes before the nurse performs the procedure. Situat Situation ion:: You are assign assigned ed to work work in an orthop orthopedi edic c ward ward where where client clients s are expected to have problems in mobility and immobility
59. Mark asks to be assisted to move up in bed. Which of the following should the nurse do first? a. Lock Lock the the whe wheel els s of the the bed bed b. Raise Raise the the bed bed rails rails oppos opposite ite the the nurse nurse c. Adjus Adjustt the the bed bed to a flat flat posit position ion d. Move the the patien patientt to the edge edge of the bed bed near near the nurse nurse 60. Which of the following following supportive supportive devices devices can be sued most effectively effectively by the nurse nurse to prevent external rotation of the right leg? a. Firm Mattress c. Sand Bag d. High Foot Board b. Pillow 61. Jerome Jerome right leg is injured injured and Nurse Apple has to move him from the bed to a wheel chair. Which of the following is the appropriate nursing action of the nurse? a. Face the clien clientt and place place the the wheelch wheelchair air at at her back back b. Put the clien clientt o n the edge of the the bed and place place the wheel wheelchai chairr on the client’ client’s s left side c. Put the clien clientt on the edge edge of the bed bed and place place the wheel wheelchai chairr on the other other side of the bed d. Put the client client on the edge edge of the bed bed and place place the wheelch wheelchair air at her back back 62. Gilbert Gilbert has to be maintained maintained on a dorsal dorsal recumbent recumbent position. position. Which of the following following should be prevented? a. Adduc Adductio tion n of of the the should shoulder er b. Hypere Hyperexte xtensi nsion on of of the the knees knees c. Anter Anterior ior flexi flexion on of the the lumba lumbarr curvatu curvature re d. Lateral Lateral flexion flexion of of the stern sternoclei ocleidoma domastoid stoid muscl muscle e 63. Mikcke Mikckey y prefer prefers s to be in high high fowler fowler’s ’s positi position on most most of the time. The nurse nurse should should prevent which of the following? a. Adduc Adductio tion n of of the the should shoulder er b. Intern Internal al Rota Rotatio tion n of the shou shoulde lderr c. Poster Posterior ior flexi flexion on of the the lumba lumbarr curvatu curvature re d. Ext al Rota Rotatio tion n of the hip
64. You are preparing preparing a plan of care who is experienc experiencing ing pain related to incisiona incisionall swelling swelling following laminectomy. Which of the following should be included in the nursing care plan? a. Ambulate Ambulate the the client client in the ward ward premise premises s every twent twenty y minutes minutes b. Encour Encourage age the the clie client nt to do self self care care c. Encour Encourage age the the clie client nt to roll roll when when turni turning ng d. Instruct Instruct the the client client to to do deep deep breathi breathing ng exercis exercise e 65. Mr. Pineda, 55 years old executive, executive, is recovering from sever myocardial infarction. infarction. For the past 3 days, Mr. Pineda’ hygiene and grooming needs have been met by the nursing staff. Which of the following activities should be implemented to achieve the goal of independence for Mr. Lozano? a. Meeting Meeting his his need till he he is ready ready to perform perform self self care b. Involv Involving ing the the patie patient nt in in his his care care c. Preparing Preparing a day to to day list list to be be followed followed by by the clien clientt d. Involving Involving family family members members in meetin meeting g client’s client’s personal personal needs needs 66. An ambulatory client, Mr. June, is being being prepare for bed. Which of the following nursing action promote safety for the client? a. Rais Raisin ing g the the side side rai rails ls b. Placin Placing g the bed in high high posi positio tion n c. Turning Turning off the lights lights to promote promote sleep sleep and and rest rest d. Instructin Instructing g the client client about about the the use of the call call system system 45. Mr. Villaruel is terminally ill and and he chose to be home with his family. What nursing action are best initiated to prepare the family of Mr. Villaruel? a. Provide support to the the family members members by teaching teaching ways to care care for their loved ones b. Convince the the client to to stay in the hospital hospital for professional professional care c. Talk Talk with with the family family members members about about the advan advantag tage e of stayin staying g in the hospit hospital al for proper care d. Tell the the client client to be with with his his family family Jessica, a 28 year old female client, is admitted with right lower quadrant abdominal 45. Jessica, pain. pain. The physician physician diagnose diagnosed d the client with acute acute appendici appendicitis tis and an emergenc emergency y appendectomy was performed. Twelve hour following surgery, the patient complained of pain. Which of the following is the most appropriate nursing diagnosis? a. Impaired Impaired immobil immobility ity related related to pain pain secondary secondary to abdomina abdominall incision incision b. Severe Severe pain pain rela related ted to surg surgery ery c. Impai Impaired red mobil mobility ity rel relate ated d to surge surgery ry d. Impaired Impaired movem movement ent relate related d to pain pain due due to surgery surgery 46. In the teaching instruction for a client with hypoparathyroidism, hypoparathyroidism, the nurse would include: a. A high high calciu calcium, m, high high phosp phosphor horus us diet diet b. A high-c high-cal alciu cium, m, Low phos phospho phorus rus diet diet c. A high high-pro -protei tein, n, high high calor calorie ie diet diet d. A low-c low-cal alciu cium, m, low low prot protein ein diet diet 47. The nursing diagnosis diagnosis Impaired Impaired Urinary Urinary Eliminat Elimination ion has been assigned assigned to client client with hyperparathyroidism.. To address this diagnosis, the nurse would: hyperparathyroidism a. Withhold acidic juices in the diet b. Forc Force e flui fluid d c. Encourage Encourage the clien clientt to start start and and stop stop the urine stream stream d. Not admini administe sterr fluid fluid with with meals meals 48. The nurse interpret a Mantoux test reaction as “O millimeters” a negative test. The client
49. A client client experien experiencing cing Hepatic Encephalopat Encephalopathy hy is receiving receiving Lactulose. Lactulose. An irate irate family family member asks, “Why in the wolr would the doctor give my husband something that gives him diarrhea when he is already sick?” The nurses’ response would include that the purpose of the lactulose is to: c. Change ammonia to urea a. Reduce fluid retention b. Eliminate Ascites d. Empty the bowel of protein 50. The nurse would assess a knowledge knowledge deficit relative to hepatitis hepatitis immunization when the client who is recovering from hepatitis A says: a. “I have have an an active active immun immunity ity from from hepati hepatitis tis A.” A.” b. “Anti-HAV “Anti-HAV antib antibodies odies make make me immun immune e form hepatit hepatitis is A.” c. “Since “Since I’ve I’ve had hepati hepatitis tis A, I’m I’m Immune Immune from hepati hepatitis tis B and C.” C.” d. “Now that that I’ve I’ve had Hepat Hepatitis itis A, A, I’m Immune Immune from from Hepatitis Hepatitis A.” A.” Situation: You are taking care of Ms. Quiambao, a 50 year old women who is unconscious after a cerebrevascular accident. accident. You are aware that there are many physical complication due to immobility
51. Proper Proper positionin positioning g of an immobiliz immobilized ed unconscio unconscious us client client is important for the following following reason except: a. Maintain skin integrity b. facili facilitat tate e rest rest and sleep sleep c. Promot Promotes es optim optimal al lung lung expan expansio sion n d. Prevent Prevent injuries injuries and and deformities deformities of the the musculo-sk musculo-skeleta eletall system system 52. You should be alert for the following complication she may experience, Except: Except: a. Impa Impair ired ed mobi mobili lity ty b. Hypo Hypost stat atic ic Pneu Pneumo moni nia a c. Pres ressure sure sor sores es d. Contra Contractu cture re and and muscle muscle atroph atrophy y 53. After moving Ms. Quiambao to the desired position, position, which of the following action will will you avoid? a. Rais Raise e bed bed rail rails s b. Avoid Avoid fricti friction on between between bony prominenc prominence e c. Place Place pillows pillows to position position client’s client’s extremiti extremities es d. Appl Apply y restr restrai aint nts s 54. When positioning your client, client, you should observe good body mechanics mechanics for your self and the client. Thes means that the nurse: a. Assumes Assumes correct correct body alignm alignment ent and efficien efficientt use of muscle muscle to avoid avoid injury b. Uses Uses Back Back musc muscle le c. Uses Uses larg large e mus muscl cle e only only d. Observes Observes rhythmic rhythmic moveme movement nt when when moving moving about about 55. You are going to move Ms. Quiambao who weight 150 lbs, lbs, unconscious, Some principle principle is use when moving the client include the following except: a. Maintain Maintain wide wide base base of support support with with feet and and knees knees flexed. flexed. b. Prepare Prepare to move the the client client by taking taking deep breath breath and and tightening tightening abdomin abdominal al and gluteal muscle c. Push and full full using using arm and and legs legs instead instead of lifting lifting d. Move close close to the the object object to be moved moved leaning leaning or bendin bending g at the waist waist Situation: The nurse supervisor is observing the staff nurse in her hospital to see how quality care provide to clients can be improved
d. Follow Following ing stan standa dards rds of prac practic tice e 57. The staff nurses discusses with the novice novice nurse the type of wound dressing that I best to use for the client. Together, they observe how well the dressing absorb the drainage. In what step of decision making process are they? a. Testing option c. Making Final decision d. Considering affects on result b. Defining the problem 58. The nurse who makes clinical clinical judgment can depend upon to improve the quality quality of care to clients. clients. Nurse Xandra uses such good clinical clinical judgment judgment when she provides provides priority priority care to his client? a. Mr. Tan, Tan, a client client who needs needs instru instruction ction fro fro home medica medication tion b. Felix, Felix, A clien clientt who is ambulato ambulatory ry and for for surgery surgery tomorrow tomorrow c. A post-opera post-operative tive clien client, t, Angel, Angel, who has has a blood blood pressure pressure of 90/50 90/50 mmHg mmHg d. April, April, a client client who recei received ved pain pain medicat medication ion 5 minutes minutes ago ago 59. The Nurse supervisor supervisor is not satisfie satisfied d with bed bath that is provided provided by Nurse Josie. Josie. To improve the care provided to the patient in the unit Nurse Josie, the nurse supervisor should: a. Ask anothe anotherr staff staff nurse nurse to do the bed bath bath inste instead ad b. Bring the the staff nurse nurse to a client’s client’s room and and demonstrat demonstrate e a cleansing cleansing bath bath c. Tell the nurse nurse how to give give bed bed baths baths correctly correctly d. Ask anothe anotherr staff staff nurse nurse to do the bed bath bath inste instead ad
60. A good nursing care plan is dependent on a correctly written nursing diagnosis. diagnosis. It defines a client’s problem and its possible cause. The following is an example of a well written nursing diagnosis: a. Acute Acute pain related related to altered altered skin skin integrity integrity second secondary ary to hysterect hysterectomy omy b. Altered Altered nutrition nutrition relate related d to high fat fat intake intake seconda secondary ry to obesity obesity c. Knowledg Knowledge e deficit deficit related related to to proctos proctosigmoi igmoidosc doscopy opy d. Electroly Electrolyre re imbala imbalance nce relate related d to hypoca hypocalcem lcemia ia Situation: Nursing Process is utilized in any health care setting whether a nurse is on a community or clinical settings.
61. A patient patient was admitted admitted at the hospital hospital with a chief chief complain complaintt of difficulty difficulty of breathin breathing, g, proper assessment was done. The type of assessment applicable at this time would be? c. Emergency assessment a. Initial assessment b. On- going assessment d. Time-lapsed assessment 45. The nursing diagnosis of your patients patients consist of statements statements of: a. Health problems b. Medical impression c. Response to illness d. Alteration of health 46. Which patient outcome statement meets the necessary necessary criteria? a. The patient will identify the types of foods to include in a high-fiber diet b. The nurse will teach the patient about constipation prevention c. The nurse will increase total fluids during hospitalization d. The patient will have a soft, formed bowel movement on the third day after nursing interventions 47. A woman who has had four children comes comes to the clinic. clinic. She tells tells the nurse nurse that when she laughs or coughs she “wets her underwear.” The nurse discusses with the patient
d. A nursing order 48. Which of the following is not a component component of a POMR a. Data ba base b. Prob Proble lem m Lis Listt c. Me Medi dica cati tion on She Sheet et d. Prog Progre ress ss Note Notes s
45. The nurse is about to administer Demerol 50mg and Vistaril 50mg IV to the patient. Demerol is available in a multidose vial labeled 100mg/ml while Vistaril comes in an ampule labeled 50 mg/ml. You are to give both medication in one injection. You will: a. Inject Inject air air into the vial, vial, then to the the ampule ampule b. Withdraw Withdraw the the medicati medication on from the the vial vial then from the the ampule ampule c. Inject Inject air into into the ampule ampule,, aspirate aspirate desire desired d dose, dose, then into into the vial vial d. Withdraw Withdraw medica medication tion from from the ampule ampule then from the the vial vial
21.
22.B 23.A
43.B
63.A
24.A
44.B
64.D
25.C
45.D
65.A
26.D
46.A
66.D
27.C
47.A
67.B
28.A
48.C
68.D
29.C
49.B
69.C
30.C
50.B
70.B
31.C
51.C
71.B
32.D
52.D
72.C
33.B
53.B
73.C
34.D
54.A
74.D
35.A
55.A
75.D
36.A
56.B
76.C
37.B
57.B
77.B
38.C
58.B
78.D
39.B
59.C
79.C
40.A
60.D
80.B
41.C
61.C
81.A
42.B
62.B
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