Medical-Surgical/Critical Care/Fundamentals of Nursing

Mr. Ernest Lopez is terminally ill and he choose to be at home with his family. What nursing action are best initiated to prepare the family of Mr. Lopez? A. Talk with the family members about the advantage of staying in the hospital for proper care B. Provide support to the family members by teaching ways to care for their loved one C. Convince the client to stay in the hospital for professional care D. Tell the client to be with his family

B

Mr. K, age 13, is diagnosed with chronic bronchitis. He is very dyspneic and must sit up to breath. An abnormal condition in which there is discomfort in breathing in any bed or sitting position is: a. Cheyne-stokes b. orthopnea c. eupnea d. dyspnea

B

Following surgery, Henry is to receive 20 mEq (milliequivalent) of potassium chloride to be added to 1000 ml of D5W to run for 8 hours. The intravenous infusion set is calibrated at 20 drops per milliliter. How many drops per minute should the rate be to infuse 1 liter of D5W for 8 hours? A. 42 drops B. 20 drops C. 60 drops D. 32 drops

A

Gentamicin sulfate, 80 mg in 100 mL normal saline (NS), is to be administered over 30 minutes. The drop factor is 10 drops (gtt)/mL. A nurse sets the flow rate at how many drops per minute? (Round answer to the nearest whole number.) a. 33gtts/min b. 30gtts/min c. 23gtts/min d. 20gtts/min

A

Hemmorhagic stroke occurs suddenly usually when the person is active. All are causes of hemorrhage, EXCEPT: A. phlebitis B. trauma C. damage to blood vessel D. aneurysm

A

In preparing a teaching plan regarding colostomy irrigations, the nurse should include which of the following? a. The colostomy needs to be irrigated at the same time every day b. Irrigate the colostomy after meals to increase peristalsis c. Insert the catheter about 10 inches into the stoma d. The solution should be very warm to increase dilation and flow

A

Joseph prefers to be in high fowler's position most of the time. The nurse should prevent which of the following? A. Posterior flexion of the lumbar curvature B. Internal rotation of the shoulder C. External rotation of the hip D. Adduction of the shoulder

A

Maria is developing constipation from being on bed rest. What measure would you suggest she take to help prevent this? A. drink 8 full glasses of fluid such as water daily B. drink more milk, increased calcium intake prevents constipation C. eat more frequent small meals instead of three large ones daily D. walk for at least half an hour daily to stimulate peristalsis

A

Mr. Magno has lung cancer and is going through chemotherapy. He is referred by the oncology nurse to a self-help group of clients with cancer to: A. receive emotional support B. to be a part of a research study C. provide financial assistance D. assist with chemotherapy

A

Mr. Martin felt better after 5 days but recognizing the severity of his illness, he executes a document authorizing the wife to transact any form of business in his behalf in addition to all decisions relative to his confinement his document is referred to as: A. power of attorney B. living will C. informed consent D. medical records

A

Mr. Ong has severe pedal edema. Which accessory device would be appropriate for his condition? A. footboard B. cradle C. bed board D. rolled pillows

A

Mr. Regalado says he has "trouble going to sleep". In order to plan your nursing intervention you will. a. Observe his sleeping patterns in the next few days b. Ask him what he means by this statement c. Check his physical environment to decrease noise level d. Take his blood pressure before sleeping and upon waking up

B

Mr. T.O. has undergone surgery for lyses of adhesions. He is transferred from Post Anesthesia Care Unit (PACU) to the Surgical floor, the nurse should obtain blood pressure, pulse and respiration every: a. 3 minutes b. 30 minutes c. 15 minutes d. 20 minutes

B

Myrna has difficulty breathing when on her back and must sit upright in bed to breath, effectively and comfortably. The nurse documents this condition as: a. Apnea b. Orthopnea c. Dyspnea d. Tachypnea

B

Mr. Regalado's lower extremities are swollen and shiny. He has pitting pedal edema. When taking care of Mr. Regalado, which of the following intervention would be the most appropriate immediate nursing approach. a. Moisturize lower extremities to prevent skin irritation b. Measure fluid intake and output to decrease edema c. Elevate lower extremities for postural drainage d. Provide the client a list of food low in sodium

A

Nurse Lei caring for a client with a pneumothorax and who has had a chest tube inserted notes continues gentle bubbling in the suction control chamber. What action is appropriate? a. Do nothing, because this is an expected finding b. Immediately clamp the chest tube and notify the physician c. Check for an air leak because the bubbling should be intermittent d. Increase the suction pressure so that the bubbling becomes vigorous

A

Rhona, a 2 year old female was prescribed to receive 62.5 mg suspension three times a day. The available dose is 125 mg/ml. which of the following should Nurse Paolo prepare for each oral dose? A. 0.5 ml B. 1.5 ml C. 2.5 ml D. 10 ml

A

Surgical sepsis is observed when: A. inserting an intravenous catheter B. disposing of syringes and needles in puncture proof containers C. washing hands before changing wound dressing D. placing dirty soiled linen in moisture resistant bags

A

The client had been diagnosed to have aplastic anemia. Which of the following statements of the client indicates the need for further teaching? a. "I am allowed to go and watch basketball games." b. "I will brush my teeth with a soft-bristled toothbrush." c. "I will avoid eating raw fruits and vegetables." d. "I have to avoid people with coughs and colds."

A

The client prepares for her eventual death and discusses with the nurse and her family how she would like her funeral to look like and what dress she will use. This client is in the stage of: A. acceptance B. resolution C. denial D. bargaining

A

The healthcare provider is teaching a patient who has tested positive for human immunodeficiency virus (HIV) about the antiretroviral medication maraviroc. Which of the following statements best describes how this drug is effective against HIV? a. he HIV is prevented from entering target cells b. cellular membrane of the HIV is disrupted c. new virus lose their ability to be infectious d. the process of viral DNA is suppressed

A

The hospital has an ongoing quality assurance program. Which of the following indicates implementation of process standards? A. The nurses check client's identification band before giving medications B. The nurse reports adverse reaction to drugs C. Average waiting time for medication administration is measured D. The unit has well ventilated medication room

A

The infectious agent that causes pulmonary tuberculosis is: A. mycobacterium tubercle B. Hansen's bacillus C. Wuchereria bancrofti D. mycobacterium diphtheria

A

The nurse is caring for a patient with peripheral arterial disease experiencing intermittent claudication. What is the appropriate intervention to relieve pain? a. Elevate leg at the level of the heart when sleeping b. Massage and warm compress every 2- 3 minutes c. Elevate feet above the heart level d. Encourage exercise.

A

The nurse is teaching a client how to irrigate his stoma. Which action indicates that the client needs more teaching? A. Hanging the irrigation bag 24" to 36" (60 to 90 cm) above the stoma B. Filling the irrigation bag with 500 to 1,000 ml of lukewarm water C. Stopping irrigation for cramps and clamping the tubing until cramps pass D. Washing hands with soap and water when finished

A

The nurse is to administer Demerol 50 mg IM to Mrs. Leyba. Demerol is available in a mutidose vial labelled 100 mg/ml and Vistaril comes in an ampule labelled 50 mg/ml. You are to give the both medications in one injection. You will: A. withdraw the medication from the vial first then from the ampule B. inject air into the vial, then into the ampule C. inject air into the ampule, aspirate the desired dose, then into the vial D. withdraw medication from the ampule then from the vial

A

The nurse recognizes that the MOST common causative organism in pyelonephritis is: a. E.Coli b. Klebsiella c. Candida Albicans d. Pseudomonas

A

The patient has a right to information regarding the operation or other invasive procedure and potential effects. This right is achieved through: a. informed consent b. preoperative visit c. charting d. doctor's rounds

A

The physician ordered Potassium Chloride (KCL) in D5W 1 liter to be infused in 24 hours for Mrs. Gomez. Since Potassium Chloride is a high risk drug, Nurse Robert used an intravenous pump. Which of the following should Nurse Robert do to safely administer this drug? A. Check the pump setting every 2 hours B. Teach the client how the infusion pump operates C. Have another nurse check the infusion pump setting D. Set the alarm of the pump loud enough to be heard

A

When suctioning the endotracheal tube, the nurse should: A. Explain procedure to patient; insert catheter gently applying suction. Withdrawn using twisting motion B. Insert catheter until resistance is met, then withdraw slightly, applying suction intermittently as catheter is withdrawn C. Hyperoxygenate client insert catheter using back and forth motion D. Insert suction catheter four inches into the

B

When the client is discharged from the hospital and is not capable of doing the needed care services, the following can assume the role, EXCEPT: a. family members b. chaplain c. significant others d. responsible caregiver

B

Which of the following BEST describes superficial partial thickness burn or first degree burn? A. Structures beneath the skin are damage B. Dermis is partially damaged C. Epidermis and dermis are both damaged D. Epidermis is damaged

B

Which of the following actions indicate that Nurse Jerome is performing outcome evaluation of quality care? A. Interviews nurses for comments regarding staffing B. Measures waiting time for client's per nurse's call C. Checks equipment for its calibration schedule D. Determines whether nurses perform skin assessment every shift

B

Which of the following client conditions should be Miss Roque's priority in the pediatric unit? A. The baby whose fantanelle is bulging and firm while asleep B. The infant who is brought in for upper respiratory tract infection whose temperature is slightly elevated C. A baby who is wailing after being awakened by the banging door D. A baby boy whose circumcision has yellowish exudate

B

Which of the following is the single most important medication available for treatment of SLE? a. Antimalarial agents b. Corticosteroids c. Alkylating medications d. Monoclonal Antibodies

B

Which of the following laboratory result are most significant in Myocardial Infarction? A. Elevated cholesterol and blood sugar B. Elevated Troponin and CPK-MB C. Increased hemoglobin and RBC D. Elevated Sedimentation rate and ASO

B

While talking with Mrs. Amado, it is most important for the nurse to: A. schedule the laboratory exams ordered for her B. do an assessment of the client to determine priority needs C. tell the client that your shift ends after eight hours D. have the client sign an informed consent

B

You establish rapport with him and to reduce his anxiety you initially a. Take him to the radiology, section for X-ray of affected extremity b. Identify yourself and state your purpose in being with the client c. Talk to the physician for an order of Valium d. Do inspection and palpation to check extent of his injuries

B

A nurse is preparing to obtain a sputum specimen from a male client. Which of the following nursing actions will facilitate obtaining the specimen? a. Limiting fluid b. Having the client take deep breaths c. Asking the client to spit into the collection container d. Asking the client to obtain the specimen after eating

B

You will be applying eye drops to Miss Romualdez. After checking all the necessary information and cleaning the affected eyelid and eyelashes you administer the ophthalmic drops by instilling the eye drops. a. directly onto the cornea b. pressing on the lacrimal duct c. into the outer third of the upper conjunctival sac d. from the inner canthus going towards the side of the eye

B

You will be applying eye drops to miss Romualdez. After checking all the necessary information and cleaning the affected eyelid and eyelashes, you administer the ophthalmic drops by instilling the eye drops: A. Directly onto the cornea B. Into the outer third of the lower conjunctival sac C. Pressing on the lacrimal duct D. From the inner canthus going towards the side of the eye

B

Your instructions to reduce or limit salt intake include all the following EXCEPT: a. eat natural food with little or no salt added b. limit use of table salt and use condiments instead c. use herbs and spices d. limit intake of preserved or processed food

B

A burn characterized by Pale white appearance, charred or with fat exposed and painlessness is: A. Superficial partial thickness burn B. Deep partial thickness burn C. Full thickness burn D. Deep full thickness burn

C

A good nursing care plan is dependent on a correctly written nursing diagnosis. It defines a client's problem and its possible cause. The following is an example of a well written nursing diagnosis: A. Acute pain related to altered skin integrity secondary to hysterectomy B. Electrolyte imbalance related to hypocalcemia C. Altered nutrition related to high fat intake secondary to obesity D. Knowledge deficit related to proctosigmoidoscopy

C

A nurse enters a client's room and finds that the waste basket is on fire. The nurse immediately assists the client out of the room. What is the next nursing action? a. Call for help. b. Extinguish the fire. c. Activate the fire alarm. d. Confine the fire by closing the room door.

C

A nurse instructs a client diagnosed with COPD to use pursed-lip breathing. The client inquires about the advantage of this kind of breathing. The nurse answers that the main purpose of pursed-lip is to: a. Prevent bronchial collapse b. Strengthen the intercostals muscle c. Achieve maximum exhalation d. Allows air trapping

C

A nurse is performing cardiopulmonary resuscitation (CPR) on an infant. When performing chest compressions, the nurse compresses at least: a. 60 times per minute b. 80 times per minute c. 100 times per minute d. 160 times per minute

C

A nurse on the day shift walks into a client's room and finds the client unresponsive. The client is not breathing and does not have a pulse, and the nurse immediately calls out for help. The next nursing action is which of the following? a. Open the airway. b. Give the client oxygen. c. Start chest compressions. d. Ventilate with a mouth-to-mask device.

C

A nurse who works on the night shift enters the medication room and finds a co-worker with a tourniquet wrapped around the upper arm. The co-worker is about to insert a needle, attached to a syringe containing a clear liquid, into the antecubital area. The appropriate initial action by the nurse is which of the following? a. Call security. b. Call the police. c. Call the nursing supervisor. d. Lock the co-worker in the medication room until help is obtained.

C

A physician prescribes 1000 mL D5W to infuse at a rate of 125 mL/hr. A nurse determines that it will take how many hours for 1 L to infuse? a. 2 hrs b. 4 hrs c. 8 hrs d. 10 hrs

C

After one day, the patient's condition worsened and feeling hopeless. He requested the nurse to remove the oxygen. The nurse should: A. follow the patient because it is his right to die gracefully B. follow the patient as it is his right to determine the medical regimen he needs C. refuse the patient and encourage him to verbalize his feelings D. refuse the patient since euthanasia is not accepted in the Philippines

C

An ambulatory client. Mr. Zosimo, is being prepared for bed. Which of the following nursing actions promote safety for the client? A. Turning off the lights to promote rest and sleep B. Instructing the client about the use of call system C. Raising the side rails D. Placing the bed in high position

C

Carlo has to be maintained on a dorsal recumbent position. Which of the following should be prevented? A. adduction of the shoulder B. Lateral flexion of the sternocleidomastoid muscle C. Hyperextension of the knees D. Anterior flexion of the lumbar curvature

C

Critically ill patients are at high risk for the following complication during the emergent phase: A. myocardial infarction B. neurogenic shock C. burn shock D. contractures

C

Dina sustained a fracture of the ulna and a cast will be applied. What nursing action before cast application is most important for Nurse Roque to do? A. Use baby powder to reduce irritation under the cast B. Assess sensation of each arm C. Evaluate skin temperature in the area D. Check radial pulses bilaterally and compare

C

During the first 24 hours after the thermal injury, you should asses Sergio for: A. hypokalemia and hypernatremia B. hypokalemia and hyponatremia C. hyperkalemia and hyponatremia D. hyperkalemia and hypernatremia

C

Endotracheal tube size indicated on the tube reflects what measurements: A. the circumference size of the tube B. the length of the tube C. the internal diameter of the tube D. the length of the person's airway

C

How will you prevent ascending infection to Eileen who has an indwelling catheter? a. see to it that the drainage tubing touches the level of the urine b. change he catheter every eight hours c. see to it that the drainage tubing does not touch the level of the urine d. clean catheter may be used since urethral meatus is not a sterile area

C

Immediately after bronchoscopy, you instructed Fernan to: a. Exercise the neck muscles b. Refrain from coughing and talking c. Breathe deeply d. Clear his throat

C

In teaching the mother the proper administration of tetracycline eye ointment, which of the following is MOST crucial? a. squirt a small amount on the inside of the infected eye's lower lid b. use clean, wet cloth to gently wipe away the pus c. wash hands before medication administration d. do not use other eye ointments or drops or put anything else in eyes.

C

KN is monitoring the status of a postoperative patient. He would become MOST concerned with which of the following signs which could indicate an evolving complication? a. a negative Homan's sign b. BP of 110/170 mmHg and a pulse of 80 beats per minute c. increasing restlessness d. hypoactive bowel sounds in all four quadrants

C

Mang Roberto has just received a renal transplant and has started cyclosporine therapy to prevent graft rejection. Which of the following condition is a major complication of this drug therapy? A. Depression B. Hemorrhage C. Infection D. Peptic ulcer disease

C

Miscommunication of drug orders was identified as a probable cause of medication errors. Which of the following is safe medication practice related to this? A. Maintain medication in its unit dose package until point of actual administration B. Note both generic and brand name of the medication in the Medication Administration Method C. Only officially approved abbreviations maybe used in prescription orders D. Encourage clients to ask question about their medications.

C

When giving Demerol 50 mg from a multidose vial labelled 100 mg/ml and Vistaril 50 mg/ml from an ampule labelled 50 mg/ml, what is the total volume that you will inject to the client? A. 2 ml B. 1 ml C. 1.5 ml D. 1.75 ml

C

When preparing to examine the left breast in a reclining position, the purpose of placing a small folded towel under the client's left shoulder is to: A. bring the breast closer to the examiner's right hand B. tense the pectoral muscle C. balance the breast tissue more evenly on the chest wall D. facilitate lateral positioning of the breast

C

Which of the assessment findings would indicate a need for possible glaucoma testing? a. intermittent loss of vision b. presence of floaters c. halos around lights d. pruritus and erythema of the conjunctiva

C

While doing nasopharyngeal suctioning on Mr. Abad, the nurse can avoid trauma to the area by: a. Applying suction for at least 20-30 seconds each time to ensure that all secretions are removed b. Using gloves to prevent introduction of pathogens to the respiratory system c. Applying no suction while inserting the catheter d. Rotating catheter as it is inserted with gentle suction

C

While doing your assessment, Ronnie asks you "Do I have a fracture? I don't want to have a cast." The most appropriate nursing response would be: a. "You have to have an X-ray first to know if you have a fracture." b. "Why do you; sound so scared? It is just a cast and it's not painful" c. "You seem to be concerned about being in a cast." d. "Based on my assessment, there doesn't seem to be a fracture."

C

While going on evening round, Nurse Edna saw Mrs. Pascual meditating and afterwards started singing prayerful hymns. What is the BEST response of Edna? A. Ignore the incidence B. Report the incidence to the head nurse C. Respect the client's actions as this provides structure and support to the client D. Call her attention so she can go to sleep

C

You are to administer an intramuscular injection to Dulce, 1 1⁄2 year old girl. The most appropriate site to administer the drug is: A. dorso gluteal region B. ventral forearm C. vastus lateralis D. gluteal region

C

You ensure the appropriateness and safety of your nursing interventions while caring for various client groups by: A. creating plans of care for particular clientele B. identifying the correct nursing diagnoses for clients C. making a thorough assessment of client needs and problems D. using standards of nursing care as your criteria for evaluation

C

You noted from the lab exams in the chart of Mr. Santos that he has reduced oxygen in the blood. This condition is called: a. Cyanosis b. Hypoxia c. Hypoxemia d. Anemia

C

You will do nasopharyngeal suctioning to Mr. Abad. Your guide for the length of insertion of the tubing for an adult would be: a. tip of the nose to the base of the neck b. the distance from the tip of the nose to the middle of the cheek c. the distance from the tip of the nose to the tip of the ear lobe d. eight to ten inches

C

Your client has difficulty of breathing and is mouth breathing most of the time. This causes dryness of the mouth with unpleasant odor. Oral hygiene is recommended for the client and in addition, you will keep the mouth moistened by using: A. salt solution B. water C. petroleum jelly D. mentholated ointment

C

Your client, who happens to be female resident of the barangay you are covering, is an adult survivor who states: "Why couldn't I make him stop the abuse? If I were stronger person, I would have been able to make him stop. Maybe it was my fault to be abused". Based on this, which would be your most appropriate nursing diagnosis? A. social isolation B. anxiety C. Chronic low self-esteem D. ineffective family coping

C

Your nurse supervisor asks you who among the following clients is most susceptible to getting infection if admitted to the hospital? A. Diabetic client type2 B. Client with chronic obstructive pulmonary disease (COPD) C. Client with second degree burns D. Client with psoriasis

C

When taking blood pressure reading the cuff should be: a. deflated fully then immediately start second reading for same client b. deflated quickly after inflating up to 180 mmHg c. large enough to wrap around upper arm of the adult client 1 cm above brachial artery d. inflated to 30 mmHg above the estimated systolic BP based on palpation of radial or brachial artery

D

Which of the following behaviors by a client indicates to the nurse that learning in cognitive domain has taken place? a. Physically demonstrating how to cook low sodium dish b. Actively demonstrating the new skill c. Telling the nurse that he has accepted the illness and its effects on lifestyle d. Explaining the need to have low sodium diet

D

Which of the following can be a fatal complication of upper airway burns? A. stress ulcers B. hemorrhage C. shock D. laryngeal spasms and swelling

D

While in the emergent phase, the nurse knows that the priority is to: A. Prevent infection B. Control pain C. Prevent deformities and contractures D. Return the hemodynamic stability via fluid resuscitation

D

While interviewing Geline, she starts to moan and doubles up in pain, She tells you that this pain occurs about an hour after taking black coffee without breakfast for a few weeks now. You will record this as follows: a. Claims to have abdominal pains after intake of coffee unrelieved by analgesics b. After drinking coffee, the client experienced severe abdominal pain c. Client complained of intermittent abdominal pain an hour after drinking coffee d. Client reported abdominal pain an hour after drinking black coffee for few weeks now

D

You attached a pulse oximeter to the client. You know that the purpose is to: a. Determine if the client's hemoglobin level is low and if he needs blood transfusion b. Check level of client's tissue perfusion c. Measure the efficacy of the client's anti-hypertensive medications d. Detect oxygen saturation of arterial blood before symptoms of hypoxemia develops

D

You would know after teaching Fermin that dietary instruction for him is effective when he states, "It is important that I eat: A. Soft food that is easily digested and absorbed by my large intestines." B. Bland food so that my intestines do not become irritated." C. Food low in fiber so that there are fewer stools." D. Everything that I ate before the operation, while avoiding foods that cause gas."

D

Your health education plan for Geline stresses proper diet for a pregnant woman and the prevention of non-communicable diseases that are influenced by her lifestyle these include of the following EXCEPT: a. Cardiovascular diseases b. Cancer c. Diabetes Mellitus d. Osteoporosis

D

When gathering baseline data, the BEST way for you to check if the client has pedal edema is to: A. talk to the relatives B. interview the client C. do auscultation D. do a physical assessment

D

An important nursing intervention goal to establish for Mang Carlos who has iron-deficiency anemia is: a. alternate periods of rest and activity to balance oxygen supply and demand b. increase fluids to stimulate erythropoises c. decrease fluids to prevent sickling of RBC's d. use birth control to avoid pregnancy

A

A nurse is evaluating a client's response to cardioversion. Which of the following observations would be of highest priority to the nurse? a. Blood pressure b. Status of airway c. Oxygen flow rate d. Level of consciousness

B

Fe, a nurse at the PACU discovered that Luisa, 50 kilos who is 3 hours post cholecystectomy was in severe pain. Upon checking the chart, she found out that Luisa had "Demerol 100 mg I.M. prn for pain". What should Fe do? a. verify the order from the M.D. b. inject 100 mg. Demerol I.M. to Luisa c. report to the nurse supervisor for opinion d. administer the recommended dose which is 50 mg because Luisa weighs 50 kilos

A

Following a renal angiography, the patient assessment priority is the: a. respiratory effort b. blood pressure c. urinary output d. puncture site

A

Baby Liza, 3 months old, with a congenital heart deformity, has an order from her physician: "give 3.00 cc of Lanoxin today for 1 dose only". Which of the following is the most appropriate action by the nurse? A. Clarify order with the attending physician B. Discuss the order with the pediatric heart specialist in the unit C. Administer Lanoxin intravenously as it is the usual route of administration D. Refer to the medication administration record for previous administration of Lanoxin

A

Before thoracentesis, the legal consideration you must check is: a. Consent is signed by the client b. Medicine preparation is correct c. Position of the client is correct d. Consent is signed by relative and physician

A

Disposal of medical records in government hospitals/institutions must be done in close coordination with what agency? a. DOH b. Records Management and Archives Office (RMAO) c. DILG d. MMDA

A

A client who sustained deep partial thickness and full thickness burns of the face, whole anterior chest and both upper extremities two days ago begins to exhibit extreme restlessness. You recognize that this most likely indicates that the client is developing: A. Cerebral hypoxia B. Hypervolemia C. metabolic acidosis D. Renal failure

A

A diabetic hypertensive client, Mrs. Linao, needs a change in diet to improve her health status. She should be referred to a: A. nutritionist B. dietitian C. physician D. medical pathologist

A

A heavily researched topic in infection control is about the single most important procedure for preventing hospital-acquired infections. What is this procedure called? a. handwashing b. use of scrub suite c. use of facemask d. brain washing

A

A nurse has just assisted a client back to bed after a fall. The nurse and physician have assessed the client and have determined that the client is not injured. After completing the incident report, the nurse implements which action next? a. Reassess the client. b. Conduct a staff meeting to describe the fall. c. Document in the nurse's notes that an incident report was completed. d. Contact the nursing supervisor to update information regarding the fall.

A

A nurse is reviewing the electrolyte results of an assigned client and notes that the potassium level is 3.2 mEq/L. Which of the following would the nurse expect to note on the ECG as a result of this laboratory value? a. U waves b. Elevated T waves c. Absent P waves d. Elevated ST Segment

A

A nurse reviews the blood gas results of a client with atelectasis. The nurse analyzes the results and determines that the client is experiencing respiratory acidosis. Which of the following validates the nurse's findings? a. pH 7.25, PCO2 50 mm Hg b. pH 7.35, PCO2 40 mm Hg c. pH 7.50, PCO2 52 mm Hg d. pH 7.52, PCO2 28 mm Hg

A

A patient presents in the ED after an assault and complains of an injury in the left femur. The nurse observes an obvious deformity to the middle of the thigh and a protruding bone. The patient's left foot is pale and cool and palpable pulses are absent. Which of the following is the priority intervention for the patient? a. Applying a firm in-line traction to the left leg, reassessing distal neurovascular status, and anticipating the placement of a traction splint b. Administering oxygen at 2 liters per minute via nasal cannula c. Attempting to push the bone back and covering with sterile dressing d. Applying pneumatic antishock trousers to the patient and inflating the left leg compartment

A

A physician's prescription reads 1000 mL of normal saline (NS) to infuse over 12 hours. The drop factor is 15 drops (gtt)/1 mL. A nurse prepares to set the flow rate at how many drops per minute? (Round answer to the nearest whole number.) a. 21 b. 23 c. 25 d. 27

A

A physician's prescription reads morphine sulfate, 8 mg stat. The medication ampule reads morphine sulfate, 10 mg/mL. A nurse prepares how many milliliters to administer the correct dose? a. 0.8ml b. 1ml c. 0.08ml d. 0.5ml

A

After IVP a renal stone was confirmed, a left nephrectomy was done. Her post-operative order includes "daily urine specimen to be sent to the laboratory". Eileen has a foley catheter attached to a urinary drainage system. How will you collect the urine specimen? A. remove urine from drainage tube with sterile needle and syringe and empty urine from the syringe into the specimen container B. empty a sample urine from the collecting bag into the specimen container C. Disconnect the drainage tube from the indwelling catheter and allow urine to flow from catheter into the specimen container. D. Disconnect the drainage from the collecting bag and allow the urine to flow from the catheter into the specimen container.

A

After pelvic surgery, the sign that would be indicative of a developing thrombophlebitis would be: A. a tender, painful area on the leg B. pruritus on the calf and ankle C. a pitting edema of the ankle D. a reddened area of the ankle

A

Albert is admitted with a radiation induced thrombocytopenia. As a nurse you should observe the following symptoms: A. Petechiae, ecchymosis, epistaxis B. Weakness, easy fatigability, pallor C. Headache, dizziness, blurred vision D. Severe sore throat, bacteremia, hepatomegaly

A

An 8-year-old client is returned to the recovery room after a bronchoscopy. The nurse should position the client a. in semi-Fowler's position b. prone, with the head turned to the side c. with the head of the bed elevated 45° and the neck extended d. supine, with the head in the midline position

A

The purpose of chest percussion and vibration is to loosen secretions in the lungs. The difference between the procedure is: a. Percussion uses only one hand white vibration uses both hands b. Percussion delivers cushioned blows to the chest with cupped palms while vibration gently shakes secretion loose on the exhalation cycle c. In both percussion and vibration the hands are on top of each other and hand action is in tune with client's breath rhythm d. Percussion slaps the chest to loosen secretions while vibration shakes the secretions along with the inhalation of air

A

The rationale in using the Z track technique in an intramuscular injection is: a. It decreases the leakage of discoloring and irritating medication into the subcutaneous tissues b. It will allow a faster absorption of the medication c. The Z track technique prevent irritation of the muscle d. It is much more convenient for the nurse

A

The three main consequence of leukemia that cause the most danger is: A. Neutropenia causing infection, anemia causing impaired oxygenation and thrombocytopenia leading to bleeding tendencies B. Central nervous system infiltration, anemia causing impaired oxygenation and thrombocytopenia leading to bleeding tendencies C. Splenomegaly, hepatomegaly, fractures D. Invasion by the leukemic cells to the bone causing severe bone pain

A

To provide safe, quality nursing care to various clients in any setting, the most important tool of the nurse is: A. critical thinking to decide appropriate nursing actions B. understanding of various nursing diagnoses C. observation skills for data collection D. possession of in scientific knowledge about client needs

A

When a client will rush towards you and he has a burning clothes on, It is your priority to do which of the following first? A. log roll on the grass/ground B. slap the flames with his hands C. Try to remove the burning clothes D. Splash the client with 1 bucket of cool water

A

When doing an initial assessment, the best way for you to identify the client's priority problem is to: a. Interview the client for chief complaints and other symptoms b. Talk to the relatives to gather data about history of illness c. Do auscultation to check for chest congestion d. Do a physical examination white asking the client relevant questions

A

When monitoring a client who is receiving t-PA , the nurse understands that it is important to monitor vital signs and make resuscitation equipment available because reperfusion of the cardiac tissue can result in which of the following?* a. Cardiac dysrhythmias b. Hypertensions c. Seizure d. Hypothermia

A

When performing oral care to an unconscious client, which of the following is a special consideration to prevent aspiration of fluids into the lungs? A. Put the client on a sidelying position with head of bed lowered B. Keep the client dry by placing towel under the chin C. Wash hands and observe appropriate infection control D. Clean mouth with oral swabs in a careful and an orderly progression

A

When reading the urinalysis report, the nurse recognizes this result as abnormal: a. red blood cells 15-20 b. turbid c. glucose negative d. ph 6.0

A

Where would the nurse tape Eileen's indwelling catheter in order to reduce urethral irritation? a. to the patient's inner thigh b. to the patient' buttocks c. to the patient's lower thigh d. to the patient lower abdomen

A

Which of the following is a risk factor for developing leukemia? a. previous chemotherapy b. alcoholism c. frequent blood transfusion d. blood to blood transmission

A

Which of the following lab value profiles should the nurse know to be consistent with hemolytic anemia? a. Decreased RBC, increased bilirubin, decreased hemoglobin and hematocrit, increased reticulocytes. b. Increased RBC, decreased bilirubin, decreased hemoglobin and hematocrit, increased reticulocytes. c. Decreased RBC, decreased bilirubin, increased hemoglobin and hematocrit, decreased reticulocytes. Increased RBC, increased bilirubin, increased hemoglobin and hematocrit, decreased reticulocytes

A

Which of the following supportive devices can be used most effectively by Nurse Arnold to prevent external rotation of the right leg? A. Sandbags B. Firm mattress C. Pillow D. High foot board

A

While in the ICU, he executes the document tat list the medical treatment he chooses to refuse in case his condition becomes severe to a point that he will be unable to make decisions for himself. This document is: A. living will B. informed consent C. last will and testament D. power of attorney

A

You are asked to teach the client, Mr. Lapuz, who has right sided weakness the use of a cane. Which observation will indicate that Mr. Lapuz is using the cane correctly? A. The cane and one foot or both feet are on the floor at all times B. He advances the cane followed by the left leg C. Client keeps the cane on the right side along the weak leg D. Client leans to the left side which is stronger

A

You are assigned to Mrs. Amado, age 49, who was admitted for possible surgey. She complained of recurrent pain at the right upper quadrant of the abdomen 1-2 hours after ingestion of fatty food. She also had frequent bouts of dizziness, blood pressure of 170/100, hot flashes. Which of the above symptoms would be an objective cue? A. Blood pressure measurement of 170/100 B. Complaint of hot flashes C. Report of pain after ingestion of fatty food D. Complaint of frequent bouts of dizziness

A

You are preparing a plan of care for a client who is experiencing pain related to incisional swelling following laminectomy. Which of the following should be included in the nursing care plan? A. Encourage the client to log roll when turning B. Encourage the client to do self-care C. Instruct the client to do deep breathing exercises D. Ambulate the client in ward premises every twenty minutes

A

You want to know the sleeping pattern of Mr. Ong You will: A. interview the clients and relatives B. take his BP before sleeping and upon waking up C. observe his sleeping pattern over a period of time D. perform physical assessment

A

A 19-year-old patient is about to be delivered in the operating room for repair of a midshaft femur fracture after a vehicular accident. The nurse is aware that a possible lethal complication of femur fracture after surgery is fat embolism syndrome (FES) that usually occurs: a. 24-48 hours after injury b. 24-72 hours after surgery c. 24-36 hours after injury d. 6-8 hours after injury

B

A burn that is white, painless, and leathery in texture describes a: A. second degree burn B. third degree or full thickness burn C. deep partial thickness burns D. first degree or superficial burns

B

A client asks for advice on low cholesterol food. You advise the client to eat the following: A. Chicken liver, cow liver, eggs B. Lean beef and pork, egg white, fish C. Balut, salted eggs, duck and chicken egg D. Pork liempo, cow brain, lungs and kidney

B

A client is ordered to take Lasix, a diuretic, to be taken orally daily. Which of the following is an appropriate instruction by the nurse? A. Report to the physician the effects of the medication on urination. B. Take the medicine early in the morning C. Take a full glass of water with the medicine D. Measure frequency of urination in 24 hours

B

A physician prescribes 1 unit of packed red blood cells to infuse over 4 hours. The unit of blood contains 250 mL. The drop factor is 10 drops (gtt)/1 mL. A nurse prepares to set the flow rate at how many drops per minute? (Round answer to the nearest whole number.) a. 10 gtts/min b. 15 gtts/min c. 20 gtts/min d. 30 gtts/min

B

A physician's prescription reads levothyroxine (Synthroid), 150 mcg orally daily. The medication label reads Synthroid, 0.1 mg/tablet. A nurse administers how many tablet(s) to the client? a. 1 tablet b. 1 and a half tablets c. 2 tablets d. 2 and a half tablets

B

A telephone order is given for a client in your ward. What is your most appropriate action? A. Copy the order on to the chart and sign the physician's name as close to his original signature as possible B. Repeat the order back to the physician, copy onto the order sheet and indicate that it is a telephone order C. Write the order in the client's chart and have the head nurse co-sign it D. Tell the physician that you can not take the order but you will call the nurse supervisor

B

Among the clients you are assigned to take care of, who is the most susceptible to infection? A. Diabetic client B. Client with burns C. client with pulmonary emphysema D. client with myocardial infarction

B

An infant is ordered to receive 500ml of D5NSS for 24 hours. The intravenous drip is running at 60 drops/minute. How many drops per minute should the flow rate be? A. 60 drops per minute B. 21 drops per minute C. 30 drops per minute D. 15 drops per minute

B

An oxygen delivery system is prescribed for a male client with chronic obstructive pulmonary disease to deliver a precise oxygen concentration. Which of the following types of oxygen delivery systems would the nurse anticipate to be prescribed? a. Face tent b. Venturi mask c. Aerosol mask d. Tracheostomy collar

B

Anthony asks to be assisted to move up the bed. Which of the following should Nurse Diana do first? A. Move the patient to the edge of the bed near the nurse B. Adjust the bed to flat position C. Lock the wheels of the bed D. Raise the bed rails opposite the nurse

B

BN, 40 year old with chronic renal failure. An arteriovenous fistula was created for hemodialysis in his left arm. What diet instructions will you need to reinforce prior to his discharge? A. drink plenty of water B. restrict your salt intake C. monitor your fruit intake and eat plenty of bananas D. be sure to eat meat every meal

B

Cefuroxime sodium, 1 g in 50 mL normal saline (NS), is to be administered over 30 minutes. The drop factor is 15 drops (gtt)/mL. A nurse sets the flow rate at how many drops per minute? a. 15 gtts/min b. 25 gtts/min c. 30 gtts/min d. 12 gtts/min

B

Client with heart failure are prone to atrial fibrillation. During physical assessment, the nurse would suspect atrial fibrillation when palpation of the radial pulse reveals: a. Regular beats followed by 1 regular beat b. Irregular rhythm c. Pulse rate below 60bpm d. Weak thready pulse

B

Contraindication to the administration of t-PA includes which of the following?* a. Age greater than 60 years B. History of cerebral hemorrhage C. History of heart failure D. Cigarette smoking

B

For a client with a neurological disorder, which of the following nursing assessments will be MOST helpful in determining subtle changes in the client's level of consciousness? a. Client posturing b. Glasgow coma scale c. Client thinking pattern d. Occurrence of hallucinations

B

Health education plan for Meldy stresses prevention of NCD or Non-communicable diseases that are influenced by lifestyle. These include the following EXCEPT: A. Cancer B. DM C. Osteoporosis D. Cardiovascular diseases

B

How does a nurse promote one's well being? A. periodic travels for rest and recreation B. faithful and observance of healthy simple lifestyle C. run away from polluted, stressful areas D. avoid sleepless, over fatigue nights

B

In your health education class for clients with diabetes you teach, them the areas for control Diabetes which include all EXCEPT: a. regular physical activity b. thorough knowledge of foot care c. prevention of infection d. proper nutrition

B

Information in the patient's chart is inadmissible in court as evidence when: A. The client's family refuses to have it used B. The client objects to its use C. The handwriting is not legible D. It has too many abbreviations that are "unofficial"

B

Jack, a 35 y.o. patient is on your floor with acute pancreatitis. Treatment for him includes: a. Regular diet b. Nutritional support with TPN c. T-Tube insertion d. Low fat diet

B

Lizette, a head nurse in a surgical unit, hears one of the staff nurses say that she does not touch any client assigned to her unless she performs nursing procedures or conducts physical assessment. To guide the staff nurse in the use of touch, which of the following would be BEST response of Lizette? A. "Use touch when the situation calls for it". B. "Touch serves as a connection between the nurse and the patient". C. "Use touch with discretion". D. "Touch is used in physical assessment".

B

Maria is administering a cleansing enema to a patient with fecal impaction. Before administering the enema, she should place the patient in which of the following positions? a. on the right side of the body with the head of the bed elevated 45 degrees b. left Sim's position c. on the left side of the body with the head of the bed elevated 45 degree d. right Sim's position

B

Nurse Glenda gets a call from the neighbor who tells her that his 3 years old daughter has been vomiting and has fever and asks for advice. Which of the following is the most appropriate action of the nurse? A. Observe the child for an hour. If the child does not improve, refer to the physician in the neighborhood. B. Recommend to bring the child immediately to the hospital C. Assess the child, recommend observation and administer acetaminophen. If symptoms continue, bring to the hospital. D. Tell the neighbor to observe the child and give plenty of fluids. If the child does not improve, bring the child to the hospital.

B

One way of verifying that the right message/doctor's order was communicated effectively is by: a. phrasing intelligently b. repeating the order message c. documenting d. speaking distinctly using enough volume

B

Priority attention should be given to which of these clients? a. Linda who shows severe anxiety due to trauma of the accident b. Ryan who has chest injury, is pale and with difficulty of breathing c. Noel who has lacerations on the arms with mild-bleeding d. Andy whose left ankle swelled and has some abrasions

B

Right after thoracentesis, which of the following is most appropriate intervention? a. Instruct the patient not to cough or deep breathe for two hours b. Observe for symptoms of tightness of chest or bleeding c. Place an ice pack to the puncture site d. Remove the dressing to check for bleeding

B

Rudolf is diagnosed with amoebiasis and is to received Metronidazole (Flagyl) tablets 1.5 gm daily in 3 divided doses for 7 consecutive days. Which of the following is the correct dose of the drug that the client will received per oral administration? A. 1,000 mg tid B. 500 mg tid C. 1,500 mg tid D. 50 mg tid

B

The advantages of oral care for a client include all of the following, EXCEPT: A. decreases bacteria in the mouth and teeth B. reduces need to use commercial mouthwash which irritate the buccal mucosa C. improves client's appearance and self-confidence D. improves appetite and taste of food

B

The healthcare provider is teaching a student about the disease process. Which of the following information should the healthcare provider include? a. HIV divides quickly inside RBC b. HIV RNA is transcribed to DNA c. HIV begins to phagocytose host immune cells d. HIV RNA is inserted into the host cell mitochondria

B

The nurse checks for placement of a nasogastric (NG) tube before beginning a tube feeding for a client. Which of the following results would indicate to the nurse that the tube feeding can begin? a. A small amount of white mucus is aspirated from the NG tube b. The pH of the contents removed from the NG tube is 3 c. No bubbles are seen when the nurse inverts the NG tube in water d. The client says he can feel the NG tube in the back of his throat

B

The nurse finds it necessary to recheck the blood pressure reading. In case of such re assessment, the nurse should wait for a period of: a. 15 seconds b. 1 to 2 minutes c. 30 minutes d. 15 minutes

B

The nurse in the outpatient clinic assists with the application of a cast to the left arm of a five-year old girl. After the cast is applied, the nurse should a. petal the edges of the cast to prevent irritation b. elevate the client's left arm on two pillows c. apply cool, humidified air to dry the cast d. ask the client to move her fingers to maintain mobility

B

The nurse is preparing a client for a magnetic resonance imaging (MRI). Which of the following client statements indicates to the nurse that teaching has been successful? a. "The dye used in the test will turn my urine green for about 24 hours." b. "This procedure will take about 90 minutes to complete. There will be no discomfort." c. "I will be put to sleep for this procedure. I will return to my room in two hours." d. "The wires that will be attached to my head and chest will not cause me any pain."

B

The nurse should ask which of the following questions to assess for latex allergy? a. "Have you experienced working in a healthcare facility?" b. "Do you have an allergy to citrus fruits?" c. "What kind of work do you have?" d. "Are you taking any herbal medicines?"

B

The nurse who makes clinical judgment can be depended upon to improve the quality of care of clients. Nurse Julie uses such good clinical judgment when she gives priority care to this client: A. Roman, a client who is ambulatory and for surgery tomorrow B. A post operative client, Rey, who has a blood pressure of 90/50 mmHg C. Mr. Abad, a client who needs instructions for home medications D. Fred, a client who received pain medications 5 minutes ago

B

To help Fernan better tolerate the bronchoscopy, you should instruct him to practice which of the following prior to the procedure? a. Clenching his fist every 2 minutes b. Breathing in and out through the nose with his mouth open c. Tensing the shoulder muscles while lying on his back d. Holding his breath periodically for 30 seconds

B

To prevent recurrent attacks on FT who has glomerulonephritis, you should instruct her to: A. continue to take the same restrictions on fluid intake B. seek early treatment for respiratory infections C. avoid situations that involve physical activity D. take showers instead of tub bath

B

When preparing the epinephrine injection from an ampule, the nurse initially: a. Taps the ampule at the top to allow fluid to flow to the base of the ampule b. Checks expiration date of the medication ampule c. Removes needle cap of syringe and pulls plunger to expel air d. Breaks the neck of the ampule with a gauze wrapped around it

B

A 29-year-old patient with multiple trauma and hemothorax arrives in the emergency department. A chest tube is placed. Initially 500 mL of blood drains from the tube. The patient's vital signs are blood pressure 140/70 mmHg and a heart rate of 138 beats/minutes. Respirations are controlled by mechanical ventilation at a rate of 16 breaths/minute. Which assessment parameter should be closely monitored over the next hour? a. Central venous pressure b. Vital signs c. Chest tube drainage d. Urine output

C

Mr. Chris Martinez has been confined for three days. His wife helped take care of him and he has observed her to be "too involved" in his care. He complained to the head nurse about this. Which of the following would be the BEST response of the nurse? A. "Don't worry. I will call the attention of your wife." B. "Your wife is just trying to help because she is worried about you." C. "What are your thoughts about your wife's involvement in your care?" D. "Your wife can assist you well in your care and recovery."

C

Mr. Hizon has had cataract surgery. Discharge teaching would include: a. wearing eye patches for the first 72 hours b. bending at the waist acceptable if done slowly c. bending at the knees and keeping the head straight d. lifting light objects is acceptable

C

Mr. Regalado will be discharged from your unit within the hour. Nursing actions when preparing a client for discharge include all EXCEPT: a. Teaching the factors that may trigger chest pain b. Giving instructions about his medication regimen c. Telling the patient to see the doctor for the final instruction d. Proper recording of pertinent data

C

Mrs. Ayuyao, 77 year old, has been admitted with pneumonia. Her husband asks the nurse about the living will. As a license nurse, you remember that living wills: A. are legally binding in all states B. allow the court to decide when the care can be given C. allow the individual to express his or her wishes regarding care D. allow health workers to withhold fluids and medications

C

Mrs. Leyba is emaciated and is at risk for developing which problem in skin integrity? A. Blisters B. Reddening of the skin C. Pressure sores D. Pustules

C

Mrs. Seva asked for instructions for skin care for her mother who has urinary incontinence and is almost always in bed. Your instruction would focus on prevention of skin irritation and breakdown by: a. Using thick diapers to absorb urine well b. Drying the skin with baby powder to prevent or mask the smell of ammonia c. Thorough washing, rinsing and drying of skin area that get wet with urine d. Making sure that linen are smooth and dry at all times

C

Non-pharmacologic pain management includes all the following EXCEPT: a. relaxation techniques b. massage c. use of herbal medicines d. body movement

C

Nurse Roque is giving instructions to Doris, the daughter of a comatose patient, to give a sponge bath. While Doris is doing spone bath, what action of Doris needs correction? A. Answering the phone while wearing gloves used for sponge bath B. Rolling the patient like a log to do back rub C. Lining the rubber mat with bed sheet as incontinence pad for the patient D. Turning the patient on the left side with head slightly elevated

C

Patients suffering from COPD are taught to avoid shifts to temperature and humidity. It should be emphasized that heat increases body temperature and thereby raising the: a. Risk for infection b. Anxiety level c. The oxygen requirements d. Fluid intake

C

Rita is assigned to care for group of patients. On review of the patient's medical record, she determines that which patient is at risk for fluid volume deficit? a. A client with CHF b. A client receiving frequent wound irrigations c. A client with colostomy d. A client with decreased kidney function

C

The nurse prepares an IM injection for an adult client using the Z track technique. 4 ml of medication is to be administered to the client. Which of the following site will you choose? A. Deltoid B. Rectus femoris C. Ventrogluteal D. Vastus lateralis

C

The physician orders a stool culture to help diagnose a client with prolonged diarrhea. The nurse who obtains the stool specimen from the colostomy stoma should: A. take the specimen to the laboratory immediately. B. collect the specimen in a clean container. C. collect the specimen in a sterile container. D. perform a midstream clean catch collection.

C

The physician prescribed monitoring closely of clients oxygen saturation of the blood. Which of the following will you prepare? a. Electrocardiogram machine b. Spirometer c. Pulse oximeter d. Blood Pressure apparatus

C

Upon establishing Mr. Regalado's nursing needs, the next nursing approach would be to: a. Introduce the client to the ward staff to put the client and family at ease b. Give client and relatives a brief tour of the physical set up the unit c. Take his vital signs for a baseline assessment d. Establish priority needs and implement appropriate interventions

C

When Nurse Norma was about to administer the medications of client Lennie, the relative of Lennie told the nurse that they buy her medicines and showed the container of medications of the client. Which of the following is the most appropriate action by the nurse? A. Hold the nurse administration of the client's medication and refer to the head nurse B. Put aside the medications she prepared and instead administer the client's medications C. Tell the client that she will inform the physician about this D. Bring the medications of the client to the nurse's station and prepare accordingly

C

When a client accidentally splashes chemicals to his eyes, The initial priority care following the chemical burn is to: A. irrigate with normal saline for 1 to 15 minutes B. transport to a physician immediately C. irrigate with water for 15 minutes or longer D. cover the eyes with a sterile gauze

C

When applying eye ointment, the following guidelines apply EXCEPT: a. squeeze about 2 cm of ointment and gently close but not squeeze eye: b. apply ointment from the inner canthus going outward of the affected eye c. discard the first bead of the eye ointment before application because the tube likely to expel more than desired amount of ointment d. hold the tube above the conjunctival sac do not let tip touch the conjunctiva

C

When applying eye ointment, the following guidelines apply except: A. Squeeze about 2 cm of ointment and gently close but not squeeze the eye B. Apply the ointment from the inner canthus going outward of the affected eye C. Discard the first bead of the eye ointment before application because the tube is likely to expel more than desire amount of ointment D. Hold the tube above the conjunctival sac, do not let tip touch the conjunctiva

C

When caring for a dying client, you will perform which of the following activities? A. Encourage the client to reach optimal health B. Assist client perform activities of daily living C. Assist the client towards a peaceful death D. Motivate client to gain independence

C

A child with laryngotracheobronchitis (croup) is placed in a cool mist tent. The mother becomes concerned because the child is frightened, constantly crying and trying to climb out of the tent. The appropriate nursing action is to: a. Tell the mother that the child must stay in the tent. b. Call the physician and obtain a prescription for a mild sedative. c. Place a toy in the tent to make the child feel more comfortable. d. Let the mother hold the child and direct the cool mist over the child's face

D

A client with Guillain-Barré syndrome develops respiratory acidosis as a result of reduced alveolar ventilation. Which combination of arterial blood gas (ABG) values confirms respiratory acidosis? a. pH, 5.0; PaCO2 30 mm Hg b. pH, 7.40; PaCO2 35 mm Hg c. pH, 7.35; PaCO2 40 mm Hg d. pH, 7.25; PaCO2 50 mm Hg

D

A hospitalized client tells the nurse that a living will is being prepared and that the lawyer will be bringing the will to the hospital today for witness signatures. The client asks the nurse for assistance in obtaining a witness to the will. The appropriate response to the client is which of the following? a. "I will sign as a witness to your signature." b. "You will need to find a witness on your own." c. "Whoever is available at the time will sign as a witness for you." d. "I will call the nursing supervisor to seek assistance regarding your request."

D

A most critical strategy in nursing communication is: a. non-verbal communication b. giving stereotyped comments c. verbal communication d. active listening

D

A patient diagnosed with breast cancer has been offered the treatment choices of breast conservation surgery with radiation or a modified radical mastectomy. When questioned by the patient about these options, the nurse informs the patient that the lumpectomy with radiation: a. reduces the fear and anxiety that accompany the diagnosis and treatment of cancer b. has about the same 10-year survival rate as the modified radical mastectomy c. provides a shorter treatment period with a fewer long term complications d. preserves the normal appearance and sensitivity of the breast.

D

A physician has prescribed propylthiouracil for a client with hyperthyroidism. A nurse develops a plan of care for the client. A priority nursing assessment to be included in the plan regarding this medication is to assess for: a. signs of renal toxicity b. signs and symptoms of hyperglycemia c. relief of pain d. signs and symptoms of hypothyroidism

D

A possible problem while providing oral care to unconscious clients is the risk of fluid aspiration to lungs. This can be avoided by: A. Cleaning teeth and mouth with cotton swabs soaked with mouthwash to avoid rinsing the buccal cavity B. swabbing the inside of the cheeks and lips, tongue and gums with dry cotton swabs C. use fingers wrapped with wet cotton washcloth to rub inside the cheeks, tongue, lips and ums D. suctioning as needed while cleaning the buccal cavity

D

After receiving a change-of-shift report about all of these clients, which one will you assess first? a. A 26-year-old with thalassemia major who has a short-stay admission for a blood transfusion b. A 44-year-old who was admitted 3 days previously with a sickle cell crisis and has orders for a CT scan c. A 50-year-old with newly diagnosed stage IV non- Hodgskin's lymphoma who is crying and stating "I'm not ready to die." d. A 69-year-old with chemotherapy-induced neutropenia who has an elevated oral temperature

D

An elderly client, 84 years old, is unconscious. Assessment of the mouth reveals excessive dryness and presence of sores. Which of the following is BEST to use for oral care? A. lemon glycerine B. hydrogen peroxide C. Mineral oil D. Normal saline solution

D

Martina develops endometritis. What would be the best activity for her? A. lying in bed with a cold cloth on her forehead B. reading while resting in a trendelenburg position C. sitting with her feet elevated while playing cards D. walking around her room listening to music

D

When assessing a client's blood pressure, the nurse finds it necessary to recheck the reading. How many seconds after deflating the cuff should the nurse wait before rechecking the pressure? a. 10 b. 30 c. 45 d. 60

D

An external insulin pump is prescribed for a client with with diabetes mellitus. The client asks Eddie about the function of the pump. He bases the response on the information that the pump: a. is surgically attached to the pancreas and infuses regular insulin into the pancreas, which in turn releases the insulin into the bloodstream. b. is timed to release programmed doses of regular or NPH insulin into the bloodstream at specific intervals c. continuously infuses small amounts of NPH insulin into the bloodstream while regularly monitoring blood glucose levels d. gives a small continuous dose of regular insulin, and the client can self-bolus with an additional dosage from the pump prior to each meal.

D

CHN!!!! Fergeline, a community health nurse, is conducting an educational session with community members regarding tuberculosis. The nurse tells the group that one of the first symptoms associated with tuberculosis is: a. Dyspnea b. Chest pain c. A bloody, productive cough d. A cough with the expectoration of mucoid sputum

D

Chronic Obstructive Pulmonary Disease (COPD) in one of the leading causes of death worldwide and is a preventable disease. The primary cause of COPD is: a. tobacco hack b. bronchitis c. asthma d. cigarette smoking

D

During colostomy irrigation, the client complains of a cramping sensation with the fluid was introduced. Which of the following is a INCORRECT nursing action? A. Temporarily stop the irrigation B. Clamp the irrigating tube C. Pinch or kink the irrigating tube temporarily D. Continue the irrigation

D

During the interview, Meldy experiences a sharp abdominal pain on the right side of her abdomen. She further tells you that an hour ago, she ate fatty food and this had happened many times before. You will record this as: A. Client complains of intermittent abdominal pain an hour alter eating fatty foods B. After eating fatty food the client experienced severe abdominal pain C. Client claims to have sharp abdominal pains after eating fatty food unrelieved by pain medication D. Client reported sharp abdominal pain on the right upper quadrant of abdomen an hour after ingestion of fatty foods.

D

Geline tells you that she drinks black coffee frequently within the day to "have energy and be wide awake" and she eats nothing for breakfast and eats strictly vegetable salads for lunch and dinner to lose weight. She has lost weight during the past two weeks, in planning a healthy balanced diet with Geline, you will: a. Start her off with a cleansing diet to free her body of toxins then change to a vegetarian, diet and drink plenty of fluids b. Plan a high protein, diet; low carbohydrate diet for her considering her favorite food c. Instruct her to attend classes in nutrition to find food rich in complex carbohydrates to maintain daily high energy level d. Discuss with her the importance of eating a variety of food from the major food groups with plenty of fluids

D

George, a 43 year old executive is scheduled for cardiac bypass surgery. While being prepared for the surgery, he says to the nurse "I am not going to have the surgery. I may die because of the risk." Which response by the nurse is most appropriate? A. "Without the surgery you will most likely die sooner." B. "There are always risks involved with surgery." C. "There is a client in the other room who had successful surgery and you can talk to him." D. "This must be very frightening for you. Tell me how you feel about the surgery."

D

In a client with pleural effusion, the nurse is instructing appropriate breathing technique. Which of the following is included in the teaching? a. Breath normally b. Hold the breath after each inspiration for 1 full minute c. Practice abdominal breathing d. Inhale slowly and hold the breath for 3 to 5 seconds after each inhalation

D

In the emergency room, Nurse Rivera is assigned to attend to the client with lacerations on the arms, while assessing the extent of the wound the nurse observes that the wound is now starting to bleed profusely. The most immediate nursing action would be to: a. Apply antiseptic to prevent infection b. Clean the wound vigorously of contaminants c. Control and reduce bleeding of the wound d. Bandage the wound and elevate the arm

D

In the hospital where you work, increased incidence of medication error was identified as the number one problem in the unit. During the brainstorming session of the nursing service department, probable causes were identified. Which of the following is process related? A. interruptions B. use of unofficial abbreviations C. lack of knowledge D. failure to identify client

D

Instruction on health promotion regarding urinary elimination is important. Which would you include? a. Hold urine, as long as she can before emptying the bladder to strengthen her sphincters muscles b. If burning sensation is experienced while voiding, drink pineapple-juice c. After urination, wipe from anal area up towards the pubis d. Tell client to empty the bladder at each voiding

D

Maria will be preparing a patient for thoracentesis. She should assist the patient to which of the following positions for the procedure? a. prone with the head turned to the side and supported by a pillow b. lying in bed on the affected side with the head of the bed elevated 45 degrees c. Sim's position with the head of the bed flat d. Lying in bed on the unaffected side with the head of the bed elevated 45 degrees

D

Mario prepares Richard for postural drainage and percussion. Which of the flowing is a special consideration when doing the procedure? a. Respiratory rate of 16 to 20 per minute b. Client can tolerate sitting and lying position c. Client has no signs of infection d. Time of last food and fluid intake of the client

D

Mikka, a 25 year old female client, is admitted with right lower quadrant abdominal pain. The physician diagnosed the client with acute appendicitis and an emergency appendectomy was performed. Twelve hours following surgery, the patient complained of pain. Which of the following is the most appropriate nursing diagnosis? A. Impaired mobility related to pain secondary to an abdominal incision B. Impaired movements related to pain due to surgery C. Impaired mobility related to surgery D. Severe pain related to surgery

D

Mr. Jose's chart contains all information about his health care. The functions of records include all except: A. means of communication that health team members use to communicate their contributions to the client's health care B. the client's record also shows a document of how much health care agencies will be reimbursed for their services C. educational resource for student of nursing and medicine D. recording of actions in advance to save time

D

Mr. Lozano, 50 year old executive, is recovering from severe myocardial infarction. For the past 3 days, Mr. Lozano's 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. Involving family members in meeting client's personal needs B. Meeting his needs till he is ready to perform self-care C. Preparing a day to day activity list to be followed by client D. Involving Mr. Lozano in his care

D

Mrs. Seva talks about her being incontinent due to a prior experience of dribbling urine when laughing or sneezing and when she has a full bladder. Your most appropriate .instruction would be to: a. tell client to drink less fluids to avoid accidents b. instruct client to start wearing thin adult diapers c. ask the client to bring change of underwear "just in case" d. teach client pelvic exercise to strengthen perineal muscles

D

Part of teaching client in health promotion is responsibility for one's health, when Danica states she need to improve her nutritional status this means: a. Goals and interventions to be followed by client are based on nurse's priorities b. Goals and intervention developed by nurse and client should be approved by the doctor c. Nurse will decide goals and, interventions needed to meet client goals d. Client will decide the goals and interventions required to meet her goals

D

Ramil's right leg is injured and Nurse Karen has to move him from the bed to w wheel chair. Which of the following is the appropriate nursing action of Nurse Karen? A. Put the client on the edge of the bed and place the wheelchair at her back B. Face the client and place the wheelchair on her left side C. Put the client on the edge of the bed and place the wheelchair on the other side of the bed D. Put the client on the edge of the bed and place the wheelchair on the client's left side

D

The MOST effective method of delivering pain medication during the emergent phase is: A. intramuscularly B. subcutaneously C. orallya D. intravenously

D

The client asked the nurse, WHEN is the best time to perform irrigation? The nurse would answer: A. Early morning, before meals, upon arising B. Early morning, before meals C. Early morning D. Early morning, After meals

D

The effectiveness of your nursing care plan for your clients is determined by A. the number of nursing procedures performed to comfort the client B. the amount of medications administered to the client as ordered C. the number of times the client calls the nurse D. the outcome of nursing interventions based on plan of care

D

The main indicator of the need for hemodialysis is: A. Ascites B. Acidosis C. Hypertension D. Hyperkalemia

D

The nurse applies pressure dressing on the bleeding site. This intervention is done to: a. Reduce the need to change dressing frequently b. Allow the pus to surface faster c. Protect the wound from micro organisms in the air d. Promote hemostasis

D

The nurse can be involved with health promotion as a significant person in helping the family: A. become a better family B. prevent disease C. control their symptoms D. modify health promotive behaviors

D

The nurse understands that the nurse-client relationship is a therapeutic alliance when: A. the nurse is a role model for a client B. this is an essential part of the nursing process C. the nurse has to be therapeutic at all times D. how the nurse thinks and feels affects her actions and behavior towards her client and her work

D

The son of Mr. Rosario, a 76 year old man, reports to the nurse in the community health center that his father has been getting out of bed at night and walks around the house in the early hours of the morning causing him to fall and injure himself. Which instruction would you give? A. Apply restraints during night hours only B. Advise hospitalization to prevent future accidents C. Keep a radio or TV for company and to orient the client D. Have someone check on the client frequently at night

D

Thoracentesis may be performed for cytologic study of pleural fluid. As a nurse your most important function during the procedure is to: a. Keep the sterile equipment from contamination b. Assist the physician c. Open and close the three-way stopcock d. Observe the patient's vital signs

D

To ensure the client safety before starting blood transfusion the following are needed before the procedure can be done EXCEPT: a. take baseline vital signs b. blood should be warmed to room temperature for 30 minutes before blood transfusion is administered c. have two nurses verify client identification, blood type, unit number and expiration date of blood d. get a consent signed for blood transfusion

D

Urinary tract infection is the most common site of nosocomial infection particularly with urinary catheterization. It can be reduced significantly by through: a. intermittent drainage b. open system drainage c. hanging system drainage d. closed system drainage

D