Fundamentals of Nursin
19. Nurse Corazon is making initial rounds at the beginning of the shift. She enters the room of a client receiving total parenteral nutrition (TP) and discovers that the bag is empty. Which of the following solutions readily available on the nursing unit should the she hang until another TP solution is mixed and delivered to the nursing unit? a 10% dextrose in water b 5% dextrose in water c 5% dextrose in 0.9% sodium chloride d None of the above
a 10% dextrose in water
32. A client has a nursing diagnosis of Risk for injury related to adverse effects of potassium-wasting diuretics. What is a correctly written client outcome for this nursing diagnosis? a "By discharge, the client correctly identifies three potassium-rich food sources." b "The client knows the importance of consuming potassium-rich foods daily." c "Before discharge, the client knows which food sources are high in potassium." d "The client understands all
a "By discharge, the client correctly identifies three potassium-rich food sources."
73. Since the nurse is taking the initial BP of the client, the nurse should repeat the procedure on the client's other arm. The nurse knows that there should not be a difference of on the other arm of the dient. a 10 mmHg b 20 mmHg c 30 mmllg d 40 mmHg
a 10 mmHg
17. A physician's order reads Potassium chloride (KCI) 30mEq to be added to 1L ml normal saline and to be given over 10-hour period. The available potassium chloride is 40mEq per 20ml. Nurse Corazon should prepare how many milliliters of Potassium Chloride to administer the correct dose of medication? a 15ml b 10ml c 50ml d 20ml
a 15ml
87. A nurse is assessing several clients in a long term health care facility. Which client is at highest risk for development of decubitus ulcers? a A 79 year-old malnourished client on bed rest b An obese client who uses a wheelchair c A client who had 3 incontinent diarrhea stools d An 80 year-old ambulatory diabetic client
a A 79 year-old malnourished client on bed rest
57. When assessing a client's skin, the nurse notes a deep, irregular-shaped area of skin loss that extends below the dermis. What term would the nurse use when documenting this? a An ulcer b A fissure c A keloid d An erosion
a An ulcer
53. The nurse prepares to perform light palpation. How is light palpation performed? a By indenting the skin ½" to ¾" (1.3 to 1.9 cm) b By indenting the skin 1" to 2" (2.5 to 5 cm) c By indenting the skin 1", using both hands d By indenting the skin 1" and then releasing the pressure quickly
a By indenting the skin ½" to ¾" (1.3 to 1.9 cm)
21. A nurse is caring for a client with a chest tube attached to a Pleurevac drainage system. Which of the following actions should the nurse avoid to prevent a tension pneumothorax? a Clamping the chest tube b Taping the connection between the chest tube and the drainage system c Adding water to the suction chamber as it evaporates d Maintaining the collection chamber below the client's waist
a Clamping the chest tube
92. A client is admitted to the emergency room following an acute asthma attack. Which of the following assessments would be expected by the nurse? a Diffuse expiratory wheezing b Loose, productive cough c No relief from inhalant d Fever and chills
a Diffuse expiratory wheezing
80. When teaching the use of a three-point crutch gait, a nurse Instructs a client to: a Move both crutches and the affected leg first, then the stronger leg b Move the right crutch, left foot, left crutch, and right foot in sequence c Move the left crutch and right foot, then move the right crutch and left foot d Move both crutches, then lift and swing the legs forward as far as the crutches
a Move both crutches and the affected leg first, then the stronger leg
89. A client being treated for hypertension returns to the community clinic for follow up. The client says, "I know these pills are important, but I just can't take these water pills anymore. I sell fish for a living, and I can't leave my store every 20 minutes to go to the bathroom." Which of these is the best nursing diagnosis? a Noncompliance related to medication side effects b Knowledge deficit related to misunderstanding of disease state c Defensive coping r
a Noncompliance related to medication side effects
44. While caring for a client who's immobile, the nurse documents the following information in the client's chart: "Turned client from side to back every 2 hours." "Skin intact; no redness noted." "Client up in chair three times today." "Improved skin turgor noted." This nursing diagnosis accurately reflects the potential of: a Risk for impaired skin integrity related to immobility b Impaired skin integrity related to immobility c Constipation related to immobilit
a Risk for impaired skin integrity related to immobility
16. A physician tells Nurse Corazon that the client's intravenous line will be discontinued. She should obtain which of the following supplies from the unit supply area for use in applying pressure to the IV site after removing the intravenous (IV) catheter? a Sterile gauze b Adhesive bandage c Betadine swab d Alcohol swab
a Sterile gauze
78. A client who is NPO, comatose, and receiving oxygen has cracked lips, dry mucus membranes, swollen gums, and caked mucus on the tongue and teeth. The best intervention is to: a Swab the oral cavity with a normal saline solution as needed. b Swab the mouth every half-hour with lemon-glycerin swabs. c Swab lips and mucus membranes with mineral oil d Swab the oral cavity with hydrogen peroxide, followed with water
a Swab the oral cavity with a normal saline solution as needed.
56. Which of the following observations by nurse is a normal finding? a The angle between the nail and nail bed is 160 degrees b The nail curves upward from the nail bed c Presence of grooves or furrows in the nails d A bluish or purplish tint to the nail bed
a The angle between the nail and nail bed is 160 degrees
20. The nurse selects which of the following materials to be used as the first layer of the dressing at the chest tube insertion site? a The nurse must prepare a 4x4 dry sterile gauze b The nurse must put absorbent kelix dressing c Petrolatum jelly gauze d Gauze with betadine
a The nurse must prepare a 4x4 dry sterile gauze
83.The nurse must know that the most accurate oxygen delivery system available is: a The venturi mask b Nasal cannula c Partial non-rebreather mask d Simple face mask
a The venturi mask
24. To reduce risk of airborne disease transmission from a client with infectious status in a private room, the nurse should do which of the following control measures? a Use face mask when entering the room. b Keep the door closed at all times. c Limit visitors. d Provide special ventilation.
a Use face mask when entering the room.
99. A negative peripheral pulse post cardiac catheterization indicates a clot formation on the femoral artery b decrease oxygen on the foot c blot clot on the heart d impending hemorrhage
a clot formation on the femoral artery
33. A client complains of severe abdominal pain. To elicit as much information as possible about the pain, the nurse should ask: a "Do you have the pain all the time?" b "Can you describe the pain?" c "Where does it hurt the most?" d "Is the pain stabbing like a knife?"
b "Can you describe the pain?"
36. A client has been receiving an I.V. solution. What is an appropriate expected outcome for this client? a "Monitor fluid intake and output every 4 hours." b "The client remains free of signs and symptoms of phlebitis." c "Edema and warmth are noted at I.V. insertion site." d "There is a risk for infection related to I.V. insertion."
b "The client remains free of signs and symptoms of phlebitis."
65. When obtaining the temperature rectally, the nurse should insert the thermometer: a 0.5 inch into the rectum b 1 inch into the rectum c 2 inches into the rectum d 3 inches into the rectum
b 1 inch into the rectum
64. Taking the temperature rectally is contraindicated with which of the following clients? a A client who had adenoidectomy b A client with significant hemorrhoids c A client who smokes d A client with wired jaws
b A client with significant hemorrhoids
90. Which of these children at the site of a disaster at a child day care center would the triage nurse put in the "treat last" category? a An infant with intermittent budging anterior fontanel between crying episodes b A toddler with severe deep abrasions over 98% of the body c A preschooler with 1 lower leg fracture and the other leg with an upper leg fracture d A school-age child with singed eyebrows and hair on the arms
b A toddler with severe deep abrasions over 98% of the body
69. Pulse site routinely used for infants is: a Radial b Apical c Brachial d Carotid
b Apical
47. A client is admitted to the health care facility with bowel obstruction secondary to colon cancer. The nurse obtains a health history, measures vital signs, and auscultates for bowel sounds. Which step of the nursing process is the nurse performing? a Planning b Assessment c Evaluation d Implementation
b Assessment
88. While caring for a client, the nurse notes a pulsating mass in the client's periumbilical area. Which of the following assessments is appropriate for the nurse to perform? a Measure the length of the mass b Auscultate the mass c Percuss the mass d Palpate the mass
b Auscultate the mass
2. When preparing the epinephrine injection from an ampule, Nurse Andrae 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 Checks expiration date of the medication ampule
55. In a client with long-term emphysema, the nurse might expect to see which condition when inspecting the nails? a A rapid blanch test b Clubbing c Koilonychia d Paronychia
b Clubbing
40. During the planning step of the nursing process, the nurse performs which activity? a Records data b Develops goals of care c Collects data d Carries out interventions
b Develops goals of care
79. When using a cane for maximal support, the nurse is aware that the client should: a Hold the cane on the weaker side b Distribute the weight evenly between the feet and the cane c Keep the elbow that is holding the cane straight and stiff d Advance the weaker foot ahead of the cane
b Distribute the weight evenly between the feet and the cane
42. One aspect of implementation related to drug therapy is: a Developing a content outline b Documenting drugs given c Establishing outcome criteria d Setting realistic client goals
b Documenting drugs given
72. After a few hours in the emergency room, the client is admitted to the ward with an order of hourly monitoring of BP. The nurse finds that the cuff is too narrow and this will cause the BP reading to be: a Lower than what the reading should be b Higher than what the reading should be c The same d Inconsistent
b Higher than what the reading should be
100. What is normal verbalization of a toddler whose brother died? a I know where my brother is buried. b I cannot wait to have pizza with my brother again c My brother will never come back d I will miss my brother
b I cannot wait to have pizza with my brother again
84. Constipation is one of the most frequent complaints of elders. When assessing this problem, which action should be the nurse's priority? a Obtain a complete blood count b Obtain a health and dietary history c Refer to a provider for a physical examination d Measure height and weight
b Obtain a health and dietary history
85. What nursing assessment of a paralyzed client would indicate the probable presence of a fecal impaction? a Presence of blood in stools b Oozing liquid stool c Continuous rumbling flatulence d Absence of bowel movements
b Oozing liquid stool
76. What type of fever would the nurse document if the client had a wide range of temperature fluctuations over normal for a period of 24 hours? a Intermittent b Remittent c Relapsing d Constant
b Remittent
82. Aclient is 2 days post operative. The vital signs are: BP - 120/70, HR - 110, RR - 26, and Temperature - 100.4 degrees Fahrenheit (38 degrees Celsius). The client suddenly becomes profoundy short of breath, skin color is gray. Which assessment would have alerted the nurse first to the client's change in condition? a Heart rate b Respiratory rate c Blood pressure d Temperature
b Respiratory rate
60. The 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 40' (12 m) b The client can read from 20' (6 m) what a person with normal vision can read at 40° c The client can read the vision chart from 20' with the right eye and from 40' with the left eye d The client can read at 30° (9 m) what a person with normal vision can read at 40'
b The client can read from 20' (6 m) what a person with normal vision can read at 40°
SITUATION: Using Maslow's need theory, Airway, Breathing and Circulation are the physiological needs vital to life. The nurse's knowledge and ability to identify and immediately intervene to meet these needs is important to save lives. 7. Which of these clients has a problem with the transport of oxygen from the lungs to the tissues: a Carol with a tumor in the brain b Theresa with anemia c Sonny Boy with a fracture in the femur d Brigette with diarrhea
b Theresa with anemia
26. Once the client is in position the nurse visualizes the anus and is ready to insert the rectal tip. She is doing the procedure correctly when she directs the rectal tip to the: a Sigmoid b Umbilicus c Rectum d Large intestine
b Umbilicus
77. Which of the following is a priority nursing action when administering oral care to a dependent client? a Assist the client to a dorsal recumbent position b Wear disposable gloves position c Use a firm toothbrush to cleanse the teeth and gums d Irrigate the mouth with hydrogen peroxide
b Wear disposable gloves position
81. The proper order of bed sheet is: a rubber sheet, bed sheet, draw sheet, blanket, pillowcase b bottom sheet, rubber sheet, draw sheet, top sheet, blanket, pillow case c bottom sheet, rubber sheet, draw sheet, blanket, top sheet, pillow case d bottom sheet, draw sheet, rubber sheet, blanket, top sheet, pillow case
b bottom sheet, rubber sheet, draw sheet, top sheet, blanket, pillow case
91. The nurse is reviewing with a client how to collect a clean catch urine specimen. Which sequence is appropriate teaching? a void a little, clean the meatus, then collect specimen b clean the meatus, begin voiding, then catch urine midstream c clean the meatus, then urinate into container d void continuously and catch some of the urine
b clean the meatus, begin voiding, then catch urine midstream
67. The nurse measures a client's temperature at 102° F. What is the equivalent Centigrade temperature? a 39° C b 47° C c 38.9° C d 40.1° C
c 38.9° C
29. Sulfisoxazole, 1 g orally twice daily, is prescribed for an adolescent with a urinary tract infection. The medication label reads "500-mg tablets." The nurse has determined that the dosage prescribed is safe. The nurse administers how many tablets per dose to the adolescent? a 1/2 tablet b 1 tablet c 2 tablets d 3 tablets
c 2 tablets
63. In assessing oral temperature, how long should the nurse wait prior to reading the thermometer? a 30 seconds b 1 full minute c 2-3 minutes d 10 minutes
c 2-3 minutes
28. A pediatric client with ventricular septal defect repair is placed on a maintenance dosage of digoxin. The dosage is 8 mcg/kg/day, and the client's weight is 7.2 kg. The pediatrician prescribes the digoxin to be given twice daily. The nurse prepares how many mcg of digoxin to administer to the child at each dose? a 12.6 mcg b 21.4 mcg c 28.8 mcg d 32.2 mcg
c 28.8 mcg
62. Through the client's history, you gather that the patient smokes and drinks coffee. When taking the temperature of a client who recently smoked or drank coffee, how long should the nurse wait before taking the client's oral temperature for accurate reading? a 5 minutes b 15 minutes c 30 minutes d 1 hour
c 30 minutes
15. A physician orders 1L of normal saline solution to infuse over 8 hours. The drop factor is 15 drops per 1 ml. Nurse Corazon prepares to set the flow rate at how many drops per minute? a 20 gtts/minute b 28 drops per minute c 31 gtts/minute d 22 drops per minute
c 31 gtts/minute
37. When prioritizing a client's plan of care based on Maslow's hierarchy of needs, the nurse's first priority would be: a Allowing the family to see a newly admitted client b Ambulating the client in the hallway c Administering pain medication d Placing wrist restraints on the client
c Administering pain medication
18. At 8:00 a.m., Nurse Corazon is preparing to change the Total Parenteral Nutrition (TP) solution bag and tubing. The client's central venous line is located in the right subclavian vein. The nurse would instruct the client to do which of the following during the tubing change? a Instruct the client to breathe normally b The nurse must turn the head of the client to the right c Ask the client to take a deep breath, hold and bear down d Tell the client
c Ask the client to take a deep breath, hold and bear down
51. When palpating a client's body to detect warmth, the nurse should use which part of the hand? a Fingertips b Finger pads c Back (dorsal surface) d Ulnar surface (ventral surface)
c Back (dorsal surface)
52. When inspecting a client's skin, the nurse finds a vesicle on the client's arm. Which description applies to a vesicle? a Flat, nonpalpable, and colored b Solid, elevated, and circumscribed c Circumscribed, elevated, and filled with serous fluid d Elevated, pus-filled, and circumscribed
c Circumscribed, elevated, and filled with serous fluid
75. While the client has a pulse oximeter on his fingertip, the nurse notices that sunlight is shining on the area of the sensor. The nurse's action should be: a Do nothing since there is no problem b Change the location of the sensor every 4 hours c Cover the fingertip sensor with a towel or bedsheet d Set and turn on the alarm of the pulse oximeter
c Cover the fingertip sensor with a towel or bedsheet
31. A client is admitted to the health care facility after 3 days of nausea, vomiting, and fever. Which nursing diagnosis takes highest priority for this client? a Excessive fluid volume related to intracellular fluid shift b Imbalanced nutrition: Less than body requirements related to decreased intake c Deficient fluid volume related to nausea and vomiting d Ineffective cardiopulmonary tissue perfusion related to hyperventilation
c Deficient fluid volume related to nausea and vomiting
74. The nurse attached a pulse oximeter to a client. She knows that the purpose of this is to: a Check the level of the client's tissue perfusion b Determine the client's hemoglobin level c Detect the oxygen saturation of the arterial blood d Measure the efficacy of the clients' anti-hypertensive medications
c Detect the oxygen saturation of the arterial blood
39. A client with chronic renal failure is admitted with a heart rate of 122 beats/minute, a respiratory rate of 32 breaths/minute, a blood pressure of 190/110 mm Hg, neck vein distention, and bibasilar crackles. Which nursing diagnosis takes highest priority for this client? a Fear b Urinary retention c Excessive fluid volume d Self-care deficient: Toileting
c Excessive fluid volume
8. To determine how long the nasogastric tube must be to reach the stomach of the patient, the nurse should hold the end of the tube: a From the tip of the nose to the base of the neck b From the tip of the nose to the middle of the cheek to the xiphoid process c From the tip of the nose to the tip of the ear lobe to the xiphoid process d Eight to ten inches from the tip of the nose to the sternum
c From the tip of the nose to the tip of the ear lobe to the xiphoid process
13. Lifestyle-related diseases in general share common risk factors. These are the following except: a Physical activity b Smoking c Genetics d Nutrition
c Genetics
97. When teaching suicide prevention to the parents of a 15 year-old who recently attempted suicide, the nurse describes the following behavioral cue: a Angry outbursts at significant others b Fear of being left alone c Giving away valued personal items d Experiencing the loss of a boyfriend
c Giving away valued personal items
45. Which nursing diagnosis would comply with guidelines set forth by NANDA? a Ineffective airway clearance related to bronchial asthma b Anxiety related to visits by overbearing mother and grandmother c Noncompliance taking medications related to belligerent behavior d Risk for injury related to generalized weakness
d Risk for injury related to generalized weakness
22. A client with a chest tube attached to a Pleurevac drainage system wants to get out of bed. While the nurse is assisting the client, the chest tubing accidentally gets caught in the bed rail and disconnects and the Pleur-Evac drainage system falls over and cracks. The nurse takes which immediate action? a Clamps the chest tube b Applies a petroleum gauze over the end of the chest tube c Immerses the chest tube in a bottle of sterile normal saline d C
c Immerses the chest tube in a bottle of sterile normal saline
11. Mrs. Sales also tells the nurse that she is often constipated. Because she is aging, what physical changes predispose her to constipation? a Inhibition of the parasympathetic refiex b Esophageal emptying hastens c Loss of tone of the smooth muscles of the colon d Decreased ability to absorb fluids in the lower intestines
c Loss of tone of the smooth muscles of the colon
48. During the physical examination, the nurse uses various techniques to assess structures, organs, and body systems. Which technique allows the nurse to feel for vibration and locate body structures? a Auscultation b Inspection c Palpation d Percussion
c Palpation
70. The nurse documents the client's pulse as weak and thready. This pulse characteristic refers to: a Pulse rhythm b Pulse deficit c Pulse volume d Pulse rate
c Pulse volume
96 . The nurse notes that a 2 year-old child recovering from a tonsillectomy has an temperature of 98.2 degrees Fahrenheit at 8:00 AM. At 10:00 AM the child's mother reports that the child "feels very warm" to touch. The first action by the nurse should be to: a Reassure the mother that this is normal b Offer the child cold oral fluids c Reassess the child's temperature d Administer the prescribed paracetamol
c Reassess the child's temperature
86. The nurse is planning care for a client with a CVA. Which of the following measures planned by the nurse would be most effective in preventing skin breakdown? a Place client in the wheelchair for four hours each day b Pad the bony prominence c Reposition every 2 hours d Massage reddened bony prominence
c Reposition every 2 hours
49. When percussing a client's chest, the nurse should identify which sound as a normal finding? a Hyperresonance b Tympany c Resonance d Dullness
c Resonance
61. The nurse is performing a breast assessment to a client. Which of the following findings is a deviation from normal? a Presence of striae b Rounded shape; slightly unequal in size c Retraction or dimpling d Round, everted nipples
c Retraction or dimpling
6. When assessing Frank for chest percussion or chest vibration and postural drainage Mario would focus on the following, EXCEPT: a Amount of food and fluid taken during the last meal before treatment b Respiratory rate, breath sounds and location of congestion c Teaching the client's relatives to perform the procedure d Doctor's order regarding position restriction and client's tolerance for lying flat
c Teaching the client's relatives to perform the procedure
SITUATION: Nurse Corazon is assigned in the Manila Toprank Hospital. She is administering various medications and intravenous therapies to her patients. 14. Nurse Corazon has just received a unit of packed red blood cells from the blood bank to transfuse into a client as ordered. Before preparing the blood for transfusion, Nurse Corazon noticed the presence of bubbles in the bag. She should take which of the following actions? a The nurse must look for another registered nurse to do
c The nurse must return the bag to the blood bank for replacement
10. Mrs. Sales 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 gets wet with urine d Making sure that linen are smooth and dry at all times
c Thorough washing, rinsing and drying of skin area that gets wet with urine
27. A client has an order of small volume enema after an oral laxative fails to produce sufficient stool return. The nurse informs the client of the procedure. The client asks the nurse what small volume enema is all about. The nurse offered an APPROPRIATE answer when she states that small volume enema is: a A laxative solution. b Given to cleanse the colon. c Used to clean the sigmoid and rectum. d A commercially prepared enema.
c Used to clean the sigmoid and rectum.
43. The nurse is providing care for a client who underwent mitral valve replacement. The best example of a measurable client outcome goal is to: a Change his own dressing b Walk in the hallway. c Walk from his room to the end of the hall and back before discharge d Eat a special diet
c Walk from his room to the end of the hall and back before discharge
54. The nurse is assessing the client who has edema. The skin remains indented or pitted at 8mm. The nurse describes the degree of edema as: a 1+ b 2+ c 3+ d 4+
d 4+
SITUATION: Mrs. Sales, 49 years old, asks you about possible problems regarding her elimination now that she is in the menopausal stage. 9. 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 cola c After urination, wipe from anal area up towards the pubis d Tell die
d Tell dient to empty the bladder at each voiding
41. Which statement reflects appropriate documentation in the medical record of a hospitalized client? a "Small pressure ulcer noted on left leg." b "Client seems to be mad at the physician." c "Client had a good day." d "Client's skin is moist and cool."
d "Client's skin is moist and cool."
30. A pediatrician's prescription reads "ampicillin sodium 125 mg IV every 6 hours." The medication label reads "when reconstituted with 7.4 mL of bacteriostatic water, the final concentration is 1 g/7.4 mL." The nurse prepares to draw up how many milliliters to administer 1 dose? a 1.1 MI b 0.54 mL c 7.425 mL d 0.925 mL
d 0.925 mL
93. In performing enemas, the indicated height for adults should bet a 10-12 inches above the rectum b 10-16 inches above the bed c 12-18 inches above the bed d 12-18 inches above the rectum
d 12-18 inches above the rectum
SITUATION: Frank has a nursing diagnosis of ineffective airway clearance related to excessive secretions and is at risk for infection because of retained secretions. Part of Nurse Mario's nursing care plan is to loosen and remove excessive secretions in the airway. 5. Nurse Mario knows he can perform chest physiotherapy: a Immediately before meals b One hour after meals c During meals d Before bedtime
d Before bedtime
12. Chronic Obstructive Pulmonary Disease (COPD) is one of the leading causes of death worldwide and is a preventable disease. The primary cause of COPD is: a High cholesterol diet b Bronchitis c Asthma d Cigarette smoking
d Cigarette smoking
50. When auscultating a client's chest, the nurse assesses a second heart sound (52). This sound results from: a Opening of the mitral and tricuspid valves b Closing of the mitral and tricuspid valves c Opening of the aortic and pulmonic valves d Closing of the aortic and pulmonic valves
d Closing of the aortic and pulmonic valves
34. A client is to be discharged from an acute care facility after treatment for right leg thrombophlebitis. The nurse notes that the client's leg is pain-free, without redness or edema. The nurse's actions reflect which step of the nursing process? a Assessment b Analysis c Implementation d Evaluation
d Evaluation
38. The nurse is revising a client's plan of care. During which step of the nursing process does such revision take place? a Assessment b Planning c Implementation d Evaluation
d Evaluation
98. As the nurse is speaking with a group of teens which of these side effects of chemotherapy for cancer would the nurse expect this group to be more interested in during the discussion? a Mouth sores b Fatigue c Diarrhea d Hair loss
d Hair loss
35. A client is diagnosed with deep vein thrombosis. Which nursing diagnosis should receive highest priority at this time? a Impaired gas exchange related to increased blood flow b Excessive fluid volume related to peripheral vascular disease c Risk for injury related to edema d Ineffective peripheral tissue perfusion related to venous congestion
d Ineffective peripheral tissue perfusion related to venous congestion
94. A 3 year-old child is brought to the clinic by his grandmother to be seen for "scratching his bottom and wetting the bed at night." Based on these complaints, the nurse would initially assess for which problem? a Allergies b Scabies c Regression d Pinworms
d Pinworms
66. The nurse is about to obtain the temperature of a four-year-old child through the tympanic route. The nurse should: a Pull the pinna of the ear backward and downward b Pull the pinna of the ear sidewards and upwards c Pull the pinna of the ear downwards and backwards d Pull the pinna of the ear backwards and upwards
d Pull the pinna of the ear backwards and upwards
71. All of the following are correct methods in the assessment of blood pressure except: a Observe procedures for infection control b Take the BP reading on both arms for comparison c Listen and identify the phases of Korotkoff sounds d Pump the cuff to around 50 mmg above the point where the pulse is obliterated
d Pump the cuff to around 50 mmg above the point where the pulse is obliterated
59. A client's wound is draining thick yellow material. The nurse correctly describes the drainage as: a Sanguineous b Serous-sanguineous c Serous d Purulent
d Purulent
3. Mrs. David is obese. When administering a subcutaneous injection to an obese patient, it is best for Nurse Andrae to: a Inject needle at a 15 degree angle over the stretched skin of the client b Pinch skin at the Injection site and use airlock technique c Pull skin of patient down to administer the drug in a Z track d Spread skin or pinch at the injection site and inject needle at a 45-90 degree angle
d Spread skin or pinch at the injection site and inject needle at a 45-90 degree angle
4. When preparing for a subcutaneous injection, the proper size of syringe and needle would be: a Syringe 3-5ml and needle gauge 21 to 23 b Tuberculin syringe 1 ml with needle gauge 26 or 27 c Syringe 2ml and needle gauge 22 d Syringe 1-3ml and needle gauge 25 to 27
d Syringe 1-3ml and needle gauge 25 to 27
46. The nurse is planning care for a client with type I insulin dependent diabetes mellitus (IDDM). Which statement best reflects a short-term goals for this client? a Risk for ineffective coping related to anxiety about medical diagnosis b The client will understand how to prevent the development of complications c The nurse will teach the client to recognize the signs and symptoms of hypoglycemia and hyperglycemia today d The client will identify eleme
d The client will identify elements of the basic diabetic diet by the end of the week
68. A pulse is normally palpated by applying moderate pressure using: a The thumb b The index finger c The palm d The middle three fingertips
d The middle three fingertips
25. As a safety precaution in handling contaminated needles, the nurses are instructed to observe which of the following protective measures: a Discard contaminated needle immediately. b Covered contaminated needle after injection. c Detach the needle from the syringe and discards. d Throw the needle in a covered receptacle.
d Throw the needle in a covered receptacle.
58. A 60-year old client reports to the nurse that he has a rash on his back and right flank. The nurse observes elevated, round, blister like lesions that are filled with clear fluid. When documenting the findings, what medical term should the nurse use to describe these lesions? a Pustules b Papule c Plaque d Vesicles
d Vesicles
95. Which of the following manifestations observed by the school nurse confirms the presence of pediculosis capitis in students? a Scratching the head more than usual b Flakes evident on a student's shoulders c Oval pattern occipital hair loss d Whitish oval specks sticking to the hair
d Whitish oval specks sticking to the hair
23. In intravenous therapy, the rule is to use veins of the upper extremities first. The superficial veins of the dorsal aspect of the hand are the preferred site. Which area of the wrist is highly sensitive and most painful site of venipuncture and must be avoided by the nurse? a outer aspect b upper aspect c lower aspect d inner aspect
d inner aspect
