1. The nurse In-charge in labor and delivery unit administered a dose of terbutaline to 6.

6. Nurse Gail places a client in a four-point restraint following orders from the
a client without checking the client’s pulse. The standard that would be used to physician. The client care plan should include:
determine if the nurse was negligent is:
A. The physician’s orders. A. Assess temperature frequently.
B. The action of a clinical nurse specialist who is recognized expert in the field. B. Provide diversional activities.
C. The statement in the drug literature about administration of terbutaline. C. Check circulation every 15-30 minutes.
D. The actions of a reasonably prudent nurse with similar education and D. Socialize with other patients once a shift.
experience. 7. A male client who has severe burns is receiving H2 receptor antagonist therapy.
2. Nurse Trish is caring for a female client with a history of GI bleeding, sickle cell The nurse In-charge knows the purpose of this therapy is to:
disease, and a platelet count of 22,000/μl. The female client is dehydrated and
receiving dextrose 5% in half-normal saline solution at 150 ml/hr. The client A. Prevent stress ulcer
complains of severe bone pain and is scheduled to receive a dose of morphine sulfate. B. Block prostaglandin synthesis
In administering the medication, Nurse Trish should avoid which route? C. Facilitate protein synthesis.
D. Enhance gas exchange
A. I.V 8. The doctor orders hourly urine output measurement for a postoperative male client.
B. I.M The nurse Trish records the following amounts of output for 2 consecutive hours: 8
C. Oral a.m.: 50 ml; 9 a.m.: 60 ml. Based on these amounts, which action should the nurse
D. S.C take?
3. Dr. Garcia writes the following order for the client who has been recently admitted
“Digoxin .125 mg P.O. once daily.” To prevent a dosage error, how should the nurse A. Increase the I.V. fluid infusion rate
document this order onto the medication administration record? B. Irrigate the indwelling urinary catheter
C. Notify the physician
A. “Digoxin .1250 mg P.O. once daily” D. Continue to monitor and record hourly urine output
B. “Digoxin 0.1250 mg P.O. once daily” 9. Tony, a basketball player twist his right ankle while playing on the court and seeks
C. “Digoxin 0.125 mg P.O. once daily” care for ankle pain and swelling. After the nurse applies ice to the ankle for 30
D. “Digoxin .125 mg P.O. once daily” minutes, which statement by Tony suggests that ice application has been effective?
4. A newly admitted female client was diagnosed with deep vein thrombosis. Which
nursing diagnosis should receive the highest priority? A. “My ankle looks less swollen now”.
B. “My ankle feels warm”.
A. Ineffective peripheral tissue perfusion related to venous congestion. C. “My ankle appears redder now”.
B. Risk for injury related to edema. D. “I need something stronger for pain relief”
C. Excess fluid volume related to peripheral vascular disease. 10.The physician prescribes a loop diuretic for a client. When administering this drug,
D. Impaired gas exchange related to increased blood flow. the nurse anticipates that the client may develop which electrolyte imbalance?

A. Hypernatremia
5. Nurse Betty is assigned to the following clients. The client that the nurse would see B. Hyperkalemia
first after endorsement? C. Hypokalemia
D. Hypervolemia
A. A 34 year-old post operative appendectomy client of five hours who is 11.She finds out that some managers have benevolent-authoritative style of
complaining of pain. management. Which of the following behaviors will she exhibit most likely?
B. A 44 year-old myocardial infarction (MI) client who is complaining of
nausea. A. Have condescending trust and confidence in their subordinates.
C. A 26 year-old client admitted for dehydration whose intravenous (IV) has B. Gives economic and ego awards.
infiltrated. C. Communicates downward to staffs.
D. A 63 year-old post operative’s abdominal hysterectomy client of three days D. Allows decision making among subordinates.
whose incisional dressing is saturated with serosanguinous fluid.
12. Nurse Amy is aware that the following is true about functional nursing 19. Which dietary guidelines are important for nurse Oliver to implement in caring for
the client with burns?
A. Provides continuous, coordinated and comprehensive nursing services.
B. One-to-one nurse patient ratio. A. Provide high-fiber, high-fat diet
C. Emphasize the use of group collaboration. B. Provide high-protein, high-carbohydrate diet.
D. Concentrates on tasks and activities. C. Monitor intake to prevent weight gain.
13.Which type of medication order might read “Vitamin K 10 mg I.M. daily × 3 days?” D. Provide ice chips or water intake.
20.Nurse Hazel will administer a unit of whole blood, which priority information should
A. Single order the nurse have about the client?
B. Standard written order
C. Standing order A. Blood pressure and pulse rate.
D. Stat order B. Height and weight.
14.A female client with a fecal impaction frequently exhibits which clinical C. Calcium and potassium levels
manifestation? D. Hgb and Hct levels.
21. Nurse Michelle witnesses a female client sustain a fall and suspects that the leg
A. Increased appetite may be broken. The nurse takes which priority action?
B. Loss of urge to defecate
C. Hard, brown, formed stools A. Takes a set of vital signs.
D. Liquid or semi-liquid stools B. Call the radiology department for X-ray.
15.Nurse Linda prepares to perform an otoscopic examination on a female client. For C. Reassure the client that everything will be alright.
proper visualization, the nurse should position the client’s ear by: D. Immobilize the leg before moving the client.
A. Pulling the lobule down and back 22.A male client is being transferred to the nursing unit for admission after receiving a
B. Pulling the helix up and forward radium implant for bladder cancer. The nurse in-charge would take which priority
C. Pulling the helix up and back action in the care of this client?
D. Pulling the lobule down and forward
16. Which instruction should nurse Tom give to a male client who is having external A. Place client on reverse isolation.
radiation therapy: B. Admit the client into a private room.
C. Encourage the client to take frequent rest periods.
A. Protect the irritated skin from sunlight. D. Encourage family and friends to visit.
B. Eat 3 to 4 hours before treatment. 23.A newly admitted female client was diagnosed with agranulocytosis. The nurse
C. Wash the skin over regularly. formulates which priority nursing diagnosis?
D. Apply lotion or oil to the radiated area when it is red or sore.
17.In assisting a female client for immediate surgery, the nurse In-charge is aware A. Constipation
that she should: B. Diarrhea
C. Risk for infection
A. Encourage the client to void following preoperative medication. D. Deficient knowledge
B. Explore the client’s fears and anxieties about the surgery. 24.A male client is receiving total parenteral nutrition suddenly demonstrates signs
C. Assist the client in removing dentures and nail polish. and symptoms of an air embolism. What is the priority action by the nurse?
D. Encourage the client to drink water prior to surgery.
18. A male client is admitted and diagnosed with acute pancreatitis after a holiday A. Notify the physician.
celebration of excessive food and alcohol. Which assessment finding reflects this B. Place the client on the left side in the Trendelenburg position.
diagnosis? C. Place the client in high-Fowlers position.
D. Stop the total parenteral nutrition.
A. Blood pressure above normal range.
B. Presence of crackles in both lung fields.
C. Hyperactive bowel sounds
D. Sudden onset of continuous epigastric and back pain.
25.Nurse May attends an educational conference on leadership styles. The nurse is 30.Which is the most appropriate nursing action in obtaining a blood pressure
sitting with a nurse employed at a large trauma center who states that the leadership measurement?
style at the trauma center is task-oriented and directive. The nurse determines that
the leadership style used at the trauma center is: A. Take the proper equipment, place the client in a comfortable position, and
record the appropriate
A. Autocratic. information in the client’s chart.
B. Laissez-faire. B. Measure the client’s arm, if you are not sure of the size of cuff to use.
C. Democratic. C. Have the client recline or sit comfortably in a chair with the forearm at the
D. Situational level of the heart.
26.The physician orders DS 500 cc with KCl 10 mEq/liter at 30 cc/hr. The nurse in- D. Document the measurement, which extremity was used, and the position
charge is going to hang a 500 cc bag. KCl is supplied 20 mEq/10 cc. How many cc’s of that the client was in during the
KCl will be added to the IV solution? measurement.
31.Asking the questions to determine if the person understands the health teaching
A. .5 cc provided by the nurse would be included during which step of the nursing process?
B. 5 cc
C. 1.5 cc A. Assessment
D. 2.5 cc B. Evaluation
27.A child of 10 years old is to receive 400 cc of IV fluid in an 8 hour shift. The IV drip C. Implementation
factor is 60. The IV rate that will deliver this amount is: D. Planning and goals
32.Which of the following item is considered the single most important factor in
A. 50 cc/ hour assisting the health professional in arriving at a diagnosis or determining the person’s
B. 55 cc/ hour needs?
C. 24 cc/ hour
D. 66 cc/ hour A. Diagnostic test results
28.The nurse is aware that the most important nursing action when a client returns B. Biographical date
from surgery is: C. History of present illness
D. Physical examination
A. Assess the IV for type of fluid and rate of flow. 33.In preventing the development of an external rotation deformity of the hip in a
B. Assess the client for presence of pain. client who must remain in bed for any period of time, the most appropriate nursing
C. Assess the Foley catheter for patency and urine output action would be to use:
D. Assess the dressing for drainage.
29. Which of the following vital sign assessments that may indicate cardiogenic shock A. Trochanter roll extending from the crest of the ileum to the midthigh.
after myocardial infarction? B. Pillows under the lower legs.
C. Footboard
A. BP – 80/60, Pulse – 110 irregular D. Hip-abductor pillow
B. BP – 90/50, Pulse – 50 regular 34.Which stage of pressure ulcer development does the ulcer extend into the
C. BP – 130/80, Pulse – 100 regular subcutaneous tissue?
D. BP – 180/100, Pulse – 90 irregular
A. Stage I
B. Stage II
C. Stage III
D. Stage IV
35.When the method of wound healing is one in which wound edges are not surgically 41.The physician inserts a chest tube into a female client to treat a pneumothorax.
approximated and integumentary continuity is restored by granulations, the wound The tube is connected to water-seal drainage. The nurse in-charge can prevent chest
healing is termed tube air leaks by:

A. Second intention healing A. Checking and taping all connections.

B. Primary intention healing B. Checking patency of the chest tube.
C. Third intention healing C. Keeping the head of the bed slightly elevated.
D. First intention healing D. Keeping the chest drainage system below the level of the chest.
36.An 80-year-old male client is admitted to the hospital with a diagnosis of 42.Nurse Trish must verify the client’s identity before administering medication. She is
pneumonia. Nurse Oliver learns that the client lives alone and hasn’t been eating or aware that the safest way to verify identity is to:
drinking. When assessing him for dehydration, nurse Oliver would expect to find:
A. Check the client’s identification band.
A. Hypothermia B. Ask the client to state his name.
B. Hypertension C. State the client’s name out loud and wait a client to repeat it.
C. Distended neck veins D. Check the room number and the client’s name on the bed.
D. Tachycardia 43.The physician orders dextrose 5 % in water, 1,000 ml to be infused over 8 hours.
37.The physician prescribes meperidine (Demerol), 75 mg I.M. every 4 hours as The I.V. tubing delivers 15 drops/ml. Nurse John should run the I.V. infusion at a rate
needed, to control a client’s postoperative pain. The package insert is “Meperidine, of:
100 mg/ml.” How many milliliters of meperidine should the
client receive? A. 30 drops/minute
B. 32 drops/minute
A. 0.75 C. 20 drops/minute
B. 0.6 D. 18 drops/minute
C. 0.5 44.If a central venous catheter becomes disconnected accidentally, what should the
D. 0.25 nurse in-charge do immediately?
38. A male client with diabetes mellitus is receiving insulin. Which statement correctly
describes an insulin unit? A. Clamp the catheter
B. Call another nurse
A. It’s a common measurement in the metric system. C. Call the physician
B. It’s the basis for solids in the avoirdupois system. D. Apply a dry sterile dressing to the site.
C. It’s the smallest measurement in the apothecary system. 45.A female client was recently admitted. She has fever, weight loss, and watery
D. It’s a measure of effect, not a standard measure of weight or quantity. diarrhea is being admitted to the facility. While assessing the client, Nurse Hazel
39.Nurse Oliver measures a client’s temperature at 102° F. What is the equivalent inspects the client’s abdomen and notice that it is slightly concave. Additional
Centigrade temperature? assessment should proceed in which order:

A. 40.1 °C A. Palpation, auscultation, and percussion.

B. 38.9 °C B. Percussion, palpation, and auscultation.
C. 48 °C C. Palpation, percussion, and auscultation.
D. 38 °C D. Auscultation, percussion, and palpation.
40.The nurse is assessing a 48-year-old client who has come to the physician’s office 46. Nurse Betty is assessing tactile fremitus in a client with pneumonia. For this
for his annual physical exam. One of the first physical signs of aging is: examination, nurse Betty should use the:

A. Accepting limitations while developing assets. A. Fingertips

B. Increasing loss of muscle tone. B. Finger pads
C. Failing eyesight, especially close vision. C. Dorsal surface of the hand
D. Having more frequent aches and pains. D. Ulnar surface of the hand
47. Which type of evaluation occurs continuously throughout the teaching and 53.A 10 year old child with type 1 diabetes develops diabetic ketoacidosis and receives
learning process? a continuous insulin infusion. Which condition represents the greatest risk to this
child?
A. Summative
B. Informative A. Hypernatremia
C. Formative B. Hypokalemia
D. Retrospective C. Hyperphosphatemia
48.A 45 year old client, has no family history of breast cancer or other risk factors for D. Hypercalcemia
this disease. Nurse John should instruct her to have mammogram how often? 54.Nurse Len is administering sublingual nitrglycerin (Nitrostat) to the newly admitted
client. Immediately afterward, the client may experience:
A. Twice per year
B. Once per year A. Throbbing headache or dizziness
C. Every 2 years B. Nervousness or paresthesia.
D. Once, to establish baseline C. Drowsiness or blurred vision.
49.A male client has the following arterial blood gas values: pH 7.30; Pao2 89 mmHg; D. Tinnitus or diplopia.
Paco2 50 mmHg; and HCO3 26mEq/L. Based on these values, Nurse Patricia should 55.Nurse Michelle hears the alarm sound on the telemetry monitor. The nurse quickly
expect which condition? looks at the monitor and notes that a client is in a ventricular tachycardia. The nurse
rushes to the client’s room. Upon reaching the client’s bedside, the nurse would take
A. Respiratory acidosis which action first?
B. Respiratory alkalosis
C. Metabolic acidosis A. Prepare for cardioversion
D. Metabolic alkalosis B. Prepare to defibrillate the client
50.Nurse Len refers a female client with terminal cancer to a local hospice. What is C. Call a code
the goal of this referral? D. Check the client’s level of consciousness
56.Nurse Hazel is preparing to ambulate a female client. The best and the safest
A. To help the client find appropriate treatment options. position for the nurse in assisting the client is to stand:
B. To provide support for the client and family in coping with terminal illness.
C. To ensure that the client gets counseling regarding health care costs. A. On the unaffected side of the client.
D. To teach the client and family about cancer and its treatment. B. On the affected side of the client.
51.When caring for a male client with a 3-cm stage I pressure ulcer on the coccyx, C. In front of the client.
which of the following actions can the nurse institute independently? D. Behind the client.
57.Nurse Janah is monitoring the ongoing care given to the potential organ donor
A. Massaging the area with an astringent every 2 hours. who has been diagnosed with brain death. The nurse determines that the standard of
B. Applying an antibiotic cream to the area three times per day. care had been maintained if which of the following data is observed?
C. Using normal saline solution to clean the ulcer and applying a protective
dressing as necessary. A. Urine output: 45 ml/hr
D. Using a povidone-iodine wash on the ulceration three times per day. B. Capillary refill: 5 seconds
52.Nurse Oliver must apply an elastic bandage to a client’s ankle and calf. He should C. Serum pH: 7.32
apply the bandage beginning at the client’s: D. Blood pressure: 90/48 mmHg
58. Nurse Amy has an order to obtain a urinalysis from a male client with an
A. Knee indwelling urinary catheter. The nurse avoids which of the following, which
B. Ankle contaminate the specimen?
C. Lower thigh
D. Foot A. Wiping the port with an alcohol swab before inserting the syringe.
B. Aspirating a sample from the port on the drainage bag.
C. Clamping the tubing of the drainage bag.
D. Obtaining the specimen from the urinary drainage bag.
59.Nurse Meredith is in the process of giving a client a bed bath. In the middle of the
procedure, the unit secretary calls the nurse on the intercom to tell the nurse that
there is an emergency phone call. The appropriate nursing action is to:
A. Immediately walk out of the client’s room and answer the phone call.
B. Cover the client, place the call light within reach, and answer the phone
call.
C. Finish the bed bath before answering the phone call.
D. Leave the client’s door open so the client can be monitored and the nurse
can answer the phone call.
60. Nurse Janah is collecting a sputum specimen for culture and sensitivity testing
from a client who has a productive cough. Nurse Janah plans to implement which
intervention to obtain the specimen?
A. Ask the client to expectorate a small amount of sputum into the emesis
basin.
B. Ask the client to obtain the specimen after breakfast.
C. Use a sterile plastic container for obtaining the specimen.
D. Provide tissues for expectoration and obtaining the specimen.
61. Nurse Ron is observing a male client using a walker. The nurse determines that
the client is using the walker correctly if the client:
A. Puts all the four points of the walker flat on the floor, puts weight on the
hand pieces, and then walks into
it.
B. Puts weight on the hand pieces, moves the walker forward, and then walks
into it.
C. Puts weight on the hand pieces, slides the walker forward, and then walks
into it.
D. Walks into the walker, puts weight on the hand pieces, and then puts all
four points of the walker flat
on the floor.
62.Nurse Amy has documented an entry regarding client care in the client’s medical
record. When checking the entry, the nurse realizes that incorrect information was
documented. How does the nurse correct this error?
A. Erases the error and writes in the correct information.
B. Uses correction fluid to cover up the incorrect information and writes in the
correct information.
C. Draws one line to cross out the incorrect information and then initials the
change.
D. Covers up the incorrect information completely using a black pen and writes
in the correct information
63.Nurse Ron is assisting with transferring a client from the operating room table to a
stretcher. To provide safety to the client, the nurse should:
A. Moves the client rapidly from the table to the stretcher.
B. Uncovers the client completely before transferring to the stretcher.
C. Secures the client safety belts after transferring to the stretcher.
D. Instructs the client to move self from the table to the stretcher.
64.Nurse Myrna is providing instructions to a nursing assistant assigned to give a bed
bath to a client who is on contact precautions. Nurse Myrna instructs the nursing
assistant to use which of the following protective items when giving bed bath?
A. Gown and goggles
B. Gown and gloves
C. Gloves and shoe protectors
D. Gloves and goggles
65. Nurse Oliver is caring for a client with impaired mobility that occurred as a result
of a stroke. The client has right sided arm and leg weakness. The nurse would
suggest that the client use which of the following assistive devices that would provide
the best stability for ambulating?
A. Crutches
B. Single straight-legged cane
C. Quad cane
D. Walker
66.A male client with a right pleural effusion noted on a chest X-ray is being prepared
for thoracentesis. The client experiences severe dizziness when sitting upright. To
provide a safe environment, the nurse assists the client to which position for the
procedure?
A. Prone with head turned toward the side supported by a pillow.
B. Sims’ position with the head of the bed flat.
C. Right side-lying with the head of the bed elevated 45 degrees.
D. Left side-lying with the head of the bed elevated 45 degrees.
67.Nurse John develops methods for data gathering. Which of the following criteria of
a good instrument refers to the ability of the instrument to yield the same results
upon its repeated administration?
A. Validity
B. Specificity
C. Sensitivity
D. Reliability
68.Harry knows that he has to protect the rights of human research subjects. Which 74.When a nurse in-charge causes an injury to a female patient and the injury caused
of the following actions of Harry ensures anonymity? becomes the proof of the negligent act, the presence of the injury is said to exemplify
the principle of:
A. Keep the identities of the subject secret
B. Obtain informed consent A. Force majeure
C. Provide equal treatment to all the subjects of the study. B. Respondeat superior
D. Release findings only to the participants of the study C. Res ipsa loquitor
69.Patient’s refusal to divulge information is a limitation because it is beyond the D. Holdover doctrine
control of Tifanny”. What type of research is appropriate for this study? 75.Nurse Myrna is aware that the Board of Nursing has quasi-judicial power. An
example of this power is:
A. Descriptive- correlational
B. Experiment A. The Board can issue rules and regulations that will govern the practice of
C. Quasi-experiment nursing
D. Historical B. The Board can investigate violations of the nursing law and code of ethics
70.Nurse Ronald is aware that the best tool for data gathering is? C. The Board can visit a school applying for a permit in collaboration with
CHED
A. Interview schedule D. The Board prepares the board examinations
B. Questionnaire 76. When the license of nurse Krina is revoked, it means that she:
C. Use of laboratory data
D. Observation A. Is no longer allowed to practice the profession for the rest of her life
71.Monica is aware that there are times when only manipulation of study variables is B. Will never have her/his license re-issued since it has been revoked
possible and the elements of control or randomization are not attendant. Which type C. May apply for re-issuance of his/her license based on certain conditions
of research is referred to this? stipulated in RA 9173
D. Will remain unable to practice professional nursing
A. Field study 77.Ronald plans to conduct a research on the use of a new method of
B. Quasi-experiment pain assessment scale. Which of the following is the second step in
C. Solomon-Four group design the conceptualizing phase of the research process?
D. Post-test only design
72.Cherry notes down ideas that were derived from the description of an investigation A. Formulating the research hypothesis
written by the person who conducted it. Which type of reference source refers to this? B. Review related literature
C. Formulating and delimiting the research problem
A. Footnote D. Design the theoretical and conceptual framework
B. Bibliography 78. The leader of the study knows that certain patients who are in a specialized
C. Primary source research setting tend to respond psychologically to the conditions of the study. This
D. Endnotes referred to as :
73.When Nurse Trish is providing care to his patient, she must remember that her
duty is bound not to do doing any action that will cause the patient harm. This is the A. Cause and effect
meaning of the bioethical principle: B. Hawthorne effect
C. Halo effect
A. Non-maleficence D. Horns effect
B. Beneficence
C. Justice
D. Solidarity
79.Mary finally decides to use judgment sampling on her research. Which of the 85.Ensuring that there is an informed consent on the part of the patient before a
following actions of is correct? surgery is done, illustrates the bioethical principle of:

A. Plans to include whoever is there during his study. A. Beneficence

B. Determines the different nationality of patients frequently admitted and B. Autonomy
decides to get representations C. Veracity
samples from each. D. Non-maleficence
C. Assigns numbers for each of the patients, place these in a fishbowl and 86.Nurse Reese is teaching a female client with peripheral vascular disease about foot
draw 10 from it. care; Nurse Reese should include which instruction?
D. Decides to get 20 samples from the admitted patients
80. The nursing theorist who developed transcultural nursing theory is: A. Avoid wearing cotton socks.
B. Avoid using a nail clipper to cut toenails.
A. Florence Nightingale C. Avoid wearing canvas shoes.
B. Madeleine Leininger D. Avoid using cornstarch on feet.
C. Albert Moore 87.A client is admitted with multiple pressure ulcers. When developing the client’s diet
D. Sr. Callista Roy plan, the nurse should include:
81.Marion is aware that the sampling method that gives equal chance to all units in
the population to get picked is: A. Fresh orange slices
B. Steamed broccoli
A. Random C. Ice cream
B. Accidental D. Ground beef patties
C. Quota 88.The nurse prepares to administer a cleansing enema. What is the most common
D. Judgment client position used for this procedure?
82.John plans to use a Likert Scale to his study to determine the:
A. Lithotomy
A. Degree of agreement and disagreement B. Supine
B. Compliance to expected standards C. Prone
C. Level of satisfaction D. Sims’ left lateral
D. Degree of acceptance 89.Nurse Marian is preparing to administer a blood transfusion. Which action should
the nurse take first?

83.Which of the following theory addresses the four modes of adaptation? A. Arrange for typing and cross matching of the client’s blood.
B. Compare the client’s identification wristband with the tag on the unit of
A. Madeleine Leininger blood.
B. Sr. Callista Roy C. Start an I.V. infusion of normal saline solution.
C. Florence Nightingale D. Measure the client’s vital signs.
D. Jean Watson 90.A 65 years old male client requests his medication at 9 p.m. instead of 10 p.m. so
84.Ms. Garcia is responsible to the number of personnel reporting to her. that he can go to sleep earlier. Which type of nursing intervention is required?
This principle refers to:
A. Independent
A. Span of control B. Dependent
B. Unity of command C. Interdependent
C. Downward communication D. Intradependent
D. Leader
91.A female client is to be discharged from an acute care facility after treatment for 97.The maximum transfusion time for a unit of packed red blood cells (RBCs) is:
right leg thrombophlebitis. The Nurse Betty notes that the client’s leg is pain-free,
without redness or edema. The nurse’s actions reflect which step of the nursing A. 6 hours
process? B. 4 hours
C. 3 hours
A. Assessment D. 2 hours
B. Diagnosis 98.Nurse Monique is monitoring the effectiveness of a client’s drug therapy. When
C. Implementation should the nurse Monique obtain a blood sample to measure the trough drug level?
D. Evaluation
92.Nursing care for a female client includes removing elastic stockings once per day. A. 1 hour before administering the next dose.
The Nurse Betty is aware that the rationale for this intervention? B. Immediately before administering the next dose.
C. Immediately after administering the next dose.
A. To increase blood flow to the heart D. 30 minutes after administering the next dose.
B. To observe the lower extremities 99.Nurse May is aware that the main advantage of using a floor stock system is:
C. To allow the leg muscles to stretch and relax
D. To permit veins in the legs to fill with blood. A. The nurse can implement medication orders quickly.
93.Which nursing intervention takes highest priority when caring for a newly admitted B. The nurse receives input from the pharmacist.
client who’s receiving a blood transfusion? C. The system minimizes transcription errors.
D. The system reinforces accurate calculations.
A. Instructing the client to report any itching, swelling, or dyspnea. 100. Nurse Oliver is assessing a client’s abdomen. Which finding should the nurse
B. Informing the client that the transfusion usually take 1 ½ to 2 hours. report as abnormal?
C. Documenting blood administration in the client care record.
D. Assessing the client’s vital signs when the transfusion ends. A. Dullness over the liver.
94.A male client complains of abdominal discomfort and nausea while receiving tube B. Bowel sounds occurring every 10 seconds.
feedings. Which intervention is most appropriate for this problem? C. Shifting dullness over the abdomen.
D. Vascular sounds heard over the renal arteries.
A. Give the feedings at room temperature.
B. Decrease the rate of feedings and the concentration of the formula.
C. Place the client in semi-Fowler’s position while feeding.
D. Change the feeding container every 12 hours.
95.Nurse Patricia is reconstituting a powdered medication in a vial. After adding the
solution to the powder, she nurse should:

A. Do nothing.
B. Invert the vial and let it stand for 3 to 5 minutes.
C. Shake the vial vigorously.
D. Roll the vial gently between the palms.
96.Which intervention should the nurse Trish use when administering oxygen by face
mask to a female client?

A. Secure the elastic band tightly around the client’s head.

B. Assist the client to the semi-Fowler position if possible.
C. Apply the face mask from the client’s chin up over the nose.
D. Loosen the connectors between the oxygen equipment and humidifier.
 Answers and Rationales
1. Answer: (D) The actions of a reasonably prudent nurse with
similar education and experience. The standard of care is determined by the
average degree of skill, care, and diligence by nurses in similar circumstances.
2. Answer: (B) I.M. With a platelet count of 22,000/μl, the clients tends to
bleed easily. Therefore, the nurse should avoid using the I.M. route because the area
is a highly vascular and can bleed readily when penetrated by a needle. The bleeding
can be difficult to stop.
3. Answer: (C) “Digoxin 0.125 mg P.O. once daily” The nurse should always place
a zero before a decimal point so that no one misreads the figure, which could result in
a dosage error. The nurse should never insert a zero at the end of a dosage that
includes a decimal point because this could be misread, possibly leading to a tenfold
increase in the dosage.
4. Answer: (A) Ineffective peripheral tissue perfusion related to
venous congestion. Ineffective peripheral tissue perfusion related to
venous congestion takes the highest priority because venous inflammation and clot
formation impede blood flow in a client with deep vein thrombosis.
5. Answer: (B) A 44 year-old myocardial infarction (MI) client who
is complaining of nausea. Nausea is a symptom of impending myocardial infarction
(MI) and should be assessed immediately so that treatment can be instituted and
further damage to the heart is avoided.
6. Answer: (C) Check circulation every 15-30 minutes. Restraints encircle the
limbs, which place the client at risk for circulation being restricted to the distal areas
of the extremities. Checking the client’s circulation every 15-30 minutes will allow the
nurse to adjust the restraints before injury from decreased blood flow occurs.
7. Answer: (A) Prevent stress ulcer. Curling’s ulcer occurs as a generalized stress
response in burn patients. This results in a decreased production of mucus and
increased secretion of gastric acid. The best treatment for this prophylactic use
of antacids and H2 receptor blockers.
8. Answer: (D) Continue to monitor and record hourly urine output. Normal
urine output for an adult is approximately 1 ml/minute (60 ml/hour). Therefore, this
client’s output is normal. Beyond continued evaluation, no nursing action is warranted.
9. Answer: (B) “My ankle feels warm”. Ice application decreases pain and swelling.
Continued or increased pain, redness, and increased warmth are signs of
inflammation that shouldn’t occur after ice application
10. Answer: (B) Hyperkalemia. A loop diuretic removes water and, along with it,
sodium and potassium. This may result in hypokalemia, hypovolemia,
and hyponatremia.
11. Answer:(A) Have condescending trust and confidence in
their subordinates. Benevolent-authoritative managers pretentiously show
their trust and confidence to their followers.
12. Answer: (A) Provides continuous, coordinated and comprehensive nursing
services. Functional nursing is focused on tasks and activities and not on the care of
the patients.
13. Answer: (B) Standard written order. This is a standard written order. Prescribers
write a single order for medications given only once. A stat order is written
for medications given immediately for an urgent client problem. A standing order, also
known as a protocol, establishes guidelines for treating a particular disease or set of
symptoms in special care areas such as the coronary care unit. Facilities also may
institute medication protocols that specifically designate drugs that a nurse may not
give.
14. Answer: (D) Liquid or semi-liquid stools. Passage of liquid or semi-liquid stools
results from seepage of unformed bowel contents around the impacted stool in the
rectum. Clients with fecal impaction don’t pass hard, brown, formed stools because
the feces can’t move past the impaction. These clients typically report the urge to
defecate (although they can’t pass stool) and a decreased appetite.
15. Answer: (C) Pulling the helix up and back. To perform an otoscopic examination
on an adult, the nurse grasps the helix of the ear and pulls it up and back to
straighten the ear canal. For a child, the nurse grasps the helix and pulls it down
to straighten the ear canal. Pulling the lobule in any direction wouldn’t straighten the
ear canal for visualization.
16. Answer: (A) Protect the irritated skin from sunlight. Irradiated skin is very
sensitive and must be protected with clothing or sunblock. The priority approach is
the avoidance of strong sunlight.
17. Answer: (C) Assist the client in removing dentures and nail polish. Dentures,
hairpins, and combs must be removed. Nail polish must be removed so that cyanosis
can be easily monitored by observing the nail beds.
18. Answer: (D) Sudden onset of continuous epigastric and back pain. The
autodigestion of tissue by the pancreatic enzymes results in pain from inflammation,
edema, and possible hemorrhage. Continuous, unrelieved epigastric or back pain
reflects the inflammatory process in the pancreas.
19. Answer: (B) Provide high-protein, high-carbohydrate diet. A positive nitrogen
balance is important for meeting metabolic needs, tissue repair, and resistance to
infection. Caloric goals may be as high as 5000 calories per day.
20. Answer: (A) Blood pressure and pulse rate. The baseline must be established to
recognize the signs of an anaphylactic or hemolytic reaction to the transfusion.
21. Answer: (D) Immobilize the leg before moving the client. If the nurse suspects
a fracture, splinting the area before moving the client is imperative. The nurse should
call for emergency help if the client is not hospitalized and call for a physician for the
hospitalized client.
22. Answer: (B) Admit the client into a private room. The client who has a radiation
implant is placed in a private room and has a limited number of visitors. This reduces
the exposure of others to the radiation.
23. Answer: (C) Risk for infection. Agranulocytosis is characterized by a reduced
number of leukocytes (leucopenia) and neutrophils (neutropenia) in the blood. The
client is at high risk for infection because of the decreased body defenses against
microorganisms. Deficient knowledge related to the nature of the disorder may be
appropriate diagnosis but is not the priority.
24. Answer: (B) Place the client on the left side in the Trendelenburg
position. Lying on the left side may prevent air from flowing into the pulmonary
veins. The Trendelenburg position increases intrathoracic pressure, which decreases
the amount of blood pulled into the vena cava during aspiration.
25. Answer: (A) Autocratic. The autocratic style of leadership is a task-oriented and
directive.
26. Answer: (D) 2.5 cc. 2.5 cc is to be added, because only a 500 cc bag of solution is
being medicated instead of a 1 liter.
27. Answer: (A) 50 cc/ hour. A rate of 50 cc/hr. The child is to receive 400 cc over a
period of 8 hours = 50 cc/hr.
28. Answer: (B) Assess the client for presence of pain. Assessing the client for pain
is a very important measure. Postoperative pain is an indication of complication. The
nurse should also assess the client for pain to provide for the client’s comfort.
29. Answer: (A) BP – 80/60, Pulse – 110 irregular. The classic signs of cardiogenic
shock are low blood pressure, rapid and weak irregular pulse, cold, clammy skin,
decreased urinary output, and cerebral hypoxia.
30. Answer: (A) Take the proper equipment, place the client in a comfortable
position, and record the appropriate information in the client’s chart. It is a
general or comprehensive statement about the correct procedure, and it includes the
basic ideas which are found in the other options
31. Answer: (B) Evaluation. Evaluation includes observing the person, asking
questions, and comparing the patient’s behavioral responses with the expected
outcomes.
32. Answer: (C) History of present illness. The history of present illness is the single
most important factor in assisting the health professional in arriving at a diagnosis or
determining the person’s needs.
33. Answer: (A) Trochanter roll extending from the crest of the ileum to the
mid-thigh. A trochanter roll, properly placed, provides resistance to the external
rotation of the hip.
34. Answer: (C) Stage III. Clinically, a deep crater or without undermining of adjacent
tissue is noted.
35. Answer: (A) Second intention healing. When wounds dehisce, they will allowed
to heal by secondary intention
36. Answer: (D) Tachycardia. With an extracellular fluid or plasma volume deficit,
compensatory mechanisms stimulate the heart, causing an increase in heart rate.
37. Answer: (A) 0.75. To determine the number of milliliters the client should receive,
the nurse uses the fraction method in the following equation.
 75 mg/X ml = 100 mg/1 ml
 To solve for X, cross-multiply:
 75 mg x 1 ml = X ml x 100 mg
 75 = 100X
 75/100 = X
 0.75 ml (or ¾ ml) = X
38. Answer: (D) It’s a measure of effect, not a standard measure of weight or
quantity. An insulin unit is a measure of effect, not a standard measure of weight or
quantity. Different drugs measured in units may have no relationship to one another
in quality or quantity.
39. Answer: (B) 38.9 °C. To convert Fahrenheit degreed to Centigrade, use this formula
 °C = (°F – 32) ÷ 1.8
 °C = (102 – 32) ÷ 1.8
 °C = 70 ÷ 1.8
 °C = 38.9
40. Answer: (C) Failing eyesight, especially close vision. Failing eyesight, especially
close vision, is one of the first signs of aging in middle life (ages 46 to 64). More
frequent aches and pains begin in the early late years (ages 65 to 79). Increase in
loss of muscle tone occurs in later years (age 80 and older).
41. Answer: (A) Checking and taping all connections. Air leaks commonly occur if
the system isn’t secure. Checking all connections and taping them will prevent air
leaks. The chest drainage system is kept lower to promote drainage – not to prevent
leaks.
42. Answer: (A) Check the client’s identification band. Checking the client’s
identification band is the safest way to verify a client’s identity because the band is
assigned on admission and isn’t be removed at any time. (If it is removed, it must be
replaced). Asking the client’s name or having the client repeated his name would be
appropriate only for a client who’s alert, oriented, and able to understand what is
being said, but isn’t the safe standard of practice. Names on bed aren’t always reliable
43. Answer: (B) 32 drops/minute. Giving 1,000 ml over 8 hours is the same as giving
125 ml over 1 hour (60 minutes). Find the number of milliliters per minute as follows:
 125/60 minutes = X/1 minute
 60X = 125 = 2.1 ml/minute
 To find the number of drops per minute:
 2.1 ml/X gtt = 1 ml/ 15 gtt
 X = 32 gtt/minute, or 32 drops/minute
44. Answer: (A) Clamp the catheter. If a central venous catheter becomes
disconnected, the nurse should immediately apply a catheter clamp, if available. If a
clamp isn’t available, the nurse can place a sterile syringe or catheter plug in the
catheter hub. After cleaning the hub with alcohol or povidone-iodine solution, the
nurse must replace the I.V. extension and restart the infusion.
45. Answer: (D) Auscultation, percussion, and palpation.The correct order of
assessment for examining the abdomen is inspection, auscultation, percussion, and
palpation. The reason for this approach is that the less intrusive techniques should be
performed before the more intrusive techniques. Percussion and palpation can alter
natural findings during auscultation.
46. Answer: (D) Ulnar surface of the hand. The nurse uses the ulnar surface, or ball,
of the hand to asses tactile fremitus, thrills, and vocal vibrations through the chest
wall. The fingertips and finger pads best distinguish texture and shape. The dorsal
surface best feels warmth.
47. Answer: (C) Formative. Formative (or concurrent) evaluation occurs continuously
throughout the teaching and learning process. One benefit is that the nurse can
adjust teaching strategies as necessary to enhance learning. Summative, or
retrospective, evaluation occurs at the conclusion of the teaching and learning
session. Informative is not a type of evaluation.
48. Answer: (B) Once per year. Yearly mammograms should begin at age 40 and
continue for as long as the woman is in good health. If health risks, such as
family history, genetic tendency, or past breast cancer, exist, more
frequent examinations may be necessary.
49. Answer: (A) Respiratory acidosis. The client has a below-normal (acidic) blood pH
value and an above-normal partial pressure of arterial carbon dioxide (Paco2) value,
indicating respiratory acidosis. In respiratory alkalosis, the pH value is above normal
and in the Paco2 value is below normal. In metabolic acidosis, the pH and bicarbonate
 (Hco3) values are below normal. In metabolic alkalosis, the pH and Hco3 values are
above normal.
50. Answer: (B) To provide support for the client and family in coping with
terminal illness. Hospices provide supportive care for terminally ill clients and their
families. Hospice care doesn’t focus on counseling regarding health care costs. Most
client referred to hospices have been treated for their disease without success and will
receive only palliative care in the hospice.
51. Answer: (C) Using normal saline solution to clean the ulcer and applying a
protective dressing as necessary. Washing the area with normal saline solution
and applying a protective dressing are within the nurse’s realm of interventions and
will protect the area. Using a povidone-iodine wash and an antibiotic cream require a
physician’s order. Massaging with an astringent can further damage the skin.
52. Answer: (D) Foot. An elastic bandage should be applied form the distal area to the
proximal area. This method promotes venous return. In this case, the nurse should
begin applying the bandage at the client’s foot. Beginning at the ankle, lower thigh, or
knee does not promote venous return.
53. Answer: (B) Hypokalemia. Insulin administration causes glucose and potassium to
move into the cells, causing hypokalemia.
54. Answer: (A) Throbbing headache or dizziness. Headache and dizziness often
occur when nitroglycerin is taken at the beginning of therapy. However, the client
usually develops tolerance
55. Answer: (D) Check the client’s level of consciousness. Determining
unresponsiveness is the first step assessment action to take. When a client is in
ventricular tachycardia, there is a significant decrease in cardiac output. However,
checking the unresponsiveness ensures whether the client is affected by the
decreased cardiac output.
56. Answer: (B) On the affected side of the client.When walking with clients, the
nurse should stand on the affected side and grasp the security belt in the midspine
area of the small of the back. The nurse should position the free hand at the shoulder
area so that the client can be pulled toward the nurse in the event that there is a
forward fall. The client is instructed to look up and outward rather than at his or her
feet.
57. Answer: (A) Urine output: 45 ml/hr. Adequate perfusion must be maintained to
all vital organs in order for the client to remain visible as an organ donor. A urine
output of 45 ml per hour indicates adequate renal perfusion. Low blood pressure and
delayed capillary refill time are circulatory system indicators of inadequate perfusion.
A serum pH of 7.32 is acidotic, which adversely affects all body tissues.
58. Answer: (D ) Obtaining the specimen from the urinary drainage bag. A urine
specimen is not taken from the urinary drainage bag. Urine undergoes chemical
changes while sitting in the bag and does not necessarily reflect the current client
status. In addition, it may become contaminated with bacteria from opening the
system.
59. Answer: (B) Cover the client, place the call light within reach, and answer
the phone call. Because telephone call is an emergency, the nurse may need to
answer it. The other appropriate action is to ask another nurse to accept the call.
However, is not one of the options. To maintain privacy and safety, the nurse covers
the client and places the call light within the client’s reach. Additionally, the client’s
door should be closed or the room curtains pulled around the bathing area.
60. Answer: (C) Use a sterile plastic container for obtaining the
specimen. Sputum specimens for culture and sensitivity testing need to be obtained
using sterile techniques because the test is done to determine the presence of
organisms. If the procedure for obtaining the specimen is not sterile, then the
specimen is not sterile, then the specimen would be contaminated and the results of
the test would be invalid.
61. Answer: (A) Puts all the four points of the walker flat on the floor, puts
weight on the hand pieces, and then walks into it. When the client uses a
walker, the nurse stands adjacent to the affected side. The client is instructed to put
all four points of the walker 2 feet forward flat on the floor before putting weight on
hand pieces. This will ensure client safety and prevent stress cracks in the walker. The
client is then instructed to move the walker forward and walk into it.
62. Answer: (C) Draws one line to cross out the incorrect information and then
initials the change. To correct an error documented in a medical record, the nurse
draws one line through the incorrect information and then initials the error. An error is
never erased and correction fluid is never used in the medical record.
63. Answer: (C) Secures the client safety belts after transferring to the
stretcher. During the transfer of the client after the surgical procedure is complete,
the nurse should avoid exposure of the client because of the risk for potential heat
loss. Hurried movements and rapid changes in the position should be avoided because
these predispose the client to hypotension. At the time of the transfer from the
surgery table to the stretcher, the client is still affected by the effects of the
anesthesia; therefore, the client should not move self. Safety belts can prevent the
client from falling off the stretcher.
64. Answer: (B) Gown and gloves. Contact precautions require the use of gloves and
a gown if direct client contact is anticipated. Goggles are not necessary unless
the nurse anticipates the splashes of blood, body fluids, secretions, or excretions may
occur. Shoe protectors are not necessary.
65. Answer: (C) Quad cane. Crutches and a walker can be difficult to maneuver for a
client with weakness on one side. A cane is better suited for client with weakness of
the arm and leg on one side. However, the quad cane would provide the most
stability because of the structure of the cane and because a quad cane has four legs.
66. Answer: (D) Left side-lying with the head of the bed elevated 45
degrees. To facilitate removal of fluid from the chest wall, the client is positioned
sitting at the edge of the bed leaning over the bedside table with the feet supported
on a stool. If the client is unable to sit up, the client is positioned lying in bed on the
unaffected side with the head of the bed elevated 30 to 45 degrees.
67. Answer: (D) Reliability Reliability is consistency of the research instrument. It
refers to the repeatability of the instrument in extracting the same responses upon its
repeated administration.
68. Answer: (A) Keep the identities of the subject secret. Keeping the identities of
the research subject secret will ensure anonymity because this will hinder providing
link between the information given to whoever is its source.
69. Answer: (A) Descriptive- correlational. Descriptive- correlational study is the
most appropriate for this study because it studies the variables that could be the
antecedents of the increased incidence of nosocomial infection.
70. Answer: (C) Use of laboratory data. Incidence of nosocomial infection is best
collected through the use of biophysiologic measures, particularly in vitro
measurements, hence laboratory data is essential.
71. Answer: (B) Quasi-experiment. Quasi-experiment is done when randomization
and control of the variables are not possible.
72. Answer: (C) Primary source. This refers to a primary source which is a direct
account of the investigation done by the investigator. In contrast to this is a
secondary source, which is written by someone other than the original researcher.
73. Answer: (A) Non-maleficence. Non-maleficence means do not cause harm or do
any action that will cause any harm to the patient/client. To do good is referred as
beneficence.
74. Answer: (C) Res ipsa loquitor. Res ipsa loquitor literally means the thing speaks
for itself. This means in operational terms that the injury caused is the proof that
there was a negligent act.
75. Answer: (B) The Board can investigate violations of the nursing law and
code of ethics. Quasi-judicial power means that the Board of Nursing has the
authority to investigate violations of the nursing law and can issue summons,
subpoena or subpoena duces tecum as needed.
76. Answer: (C) May apply for re-issuance of his/her license based on certain
conditions stipulated in RA 9173. RA 9173 sec. 24 states that for equity and
justice, a revoked license maybe re-issued provided that the following conditions are
met: a) the cause for revocation of license has already been corrected or removed;
and, b) at least four years has elapsed since the license has been revoked.
77. Answer: (B) Review related literature. After formulating and delimiting the
research problem, the researcher conducts a review of related literature to determine
the extent of what has been done on the study by previous researchers.
78. Answer: (B) Hawthorne effect. Hawthorne effect is based on the study of Elton
Mayo and company about the effect of an intervention done to improve the working
conditions of the workers on their productivity. It resulted to an increased productivity
but not due to the intervention but due to the psychological effects of being observed.
They performed differently because they were under observation.
79. Answer: (B) Determines the different nationality of patients frequently
admitted and decides to get representations samples from each. Judgment
sampling involves including samples according to the knowledge of the investigator
about the participants in the study.
80. Answer: (B) Madeleine Leininger. Madeleine Leininger developed the theory on
transcultural theory based on her observations on the behavior of selected people
within a culture.
81. Answer: (A) Random. Random sampling gives equal chance for all the elements in
the population to be picked as part of the sample.
82. Answer: (A) Degree of agreement and disagreement. Likert scale is a 5-point
summated scale used to determine the degree of agreement or disagreement of the
respondents to a statement in a study
83. Answer: (B) Sr. Callista Roy. Sr. Callista Roy developed the Adaptation Model
which involves the physiologic mode, self-concept mode, role function mode and
dependence mode.
84. Answer: (A) Span of control. Span of control refers to the number of workers who
report directly to a manager.
85. Answer: (B) Autonomy. Informed consent means that the patient fully understands
about the surgery, including the risks involved and the alternative solutions. In giving
consent it is done with full knowledge and is given freely. The action of allowing the
patient to decide whether a surgery is to be done or not exemplifies the bioethical
principle of autonomy.
86. Answer: (C) Avoid wearing canvas shoes. The client should be instructed to
avoid wearing canvas shoes. Canvas shoes cause the feet to perspire, which may, in
turn, cause skin irritation and breakdown. Both cotton and cornstarch absorb
perspiration. The client should be instructed to cut toenails straight across with
nail clippers.
87. Answer: (D) Ground beef patties. Meat is an excellent source of complete protein,
which this client needs to repair the tissue breakdown caused by pressure
ulcers. Oranges and broccoli supply vitamin C but not protein. Ice cream supplies only
some incomplete protein, making it less helpful in tissue repair.
88. Answer: (D) Sims’ left lateral. The Sims’ left lateral position is the most common
position used to administer a cleansing enema because it allows gravity to aid the
flow of fluid along the curve of the sigmoid colon. If the client can’t assume this
position nor has poor sphincter control, the dorsal recumbent or right lateral position
may be used. The supine and prone positions are inappropriate and uncomfortable for
the client.
89. Answer: (A) Arrange for typing and cross matching of the client’s blood. The
nurse first arranges for typing and cross matching of the client’s blood to ensure
compatibility with donor blood. The other options,although appropriate when
preparing to administer a blood transfusion, come later.
90. Answer: (A) Independent. Nursing interventions are classified as independent,
interdependent, or dependent. Altering the drug schedule to coincide with the client’s
daily routine represents an independent intervention, whereas consulting with the
physician and pharmacist to change a client’s medication because of adverse reactions
represents an interdependent intervention. Administering an already-prescribed drug
on time is a dependent intervention. An intradependent nursing intervention doesn’t
exist.
91. Answer: (D) Evaluation. The nursing actions described constitute evaluation of the
expected outcomes. The findings show that the expected outcomes have been
achieved. Assessment consists of the client’s history, physical examination, and
laboratory studies. Analysis consists of considering assessment information to derive
the appropriate nursing diagnosis. Implementation is the phase of the nursing process
where the nurse puts the plan of care into action.
92. Answer: (B) To observe the lower extremities. Elastic stockings are used to
promote venous return. The nurse needs to remove them once per day to observe the
condition of the skin underneath the stockings. Applying the stockings increases blood
flow to the heart. When the stockings are in place, the leg muscles can still stretch
and relax, and the veins can fill with blood.
93. Answer:(A) Instructing the client to report any itching, swelling, or
dyspnea. Because administration of blood or blood products may cause serious
adverse effects such as allergic reactions, the nurse must monitor the client for these
effects. Signs and symptoms of life-threatening allergic reactions include itching,
swelling, and dyspnea. Although the nurse should inform the client of the duration of
the transfusion and should document its administration, these actions are less critical
 to the client’s immediate health. The nurse should assess vital signs at least hourly
during the transfusion.
94. Answer: (B) Decrease the rate of feedings and the concentration of the
formula. Complaints of abdominal discomfort and nausea are common in clients
receiving tube feedings. Decreasing the rate of the feeding and the concentration of
the formula should decrease the client’s discomfort. Feedings are normally given at
room temperature to minimize abdominal cramping. To prevent aspiration during
feeding, the head of the client’s bed should be elevated at least 30 degrees. Also, to
prevent bacterial growth, feeding containers should be routinely changed every 8 to
12 hours.
95. Answer: (D) Roll the vial gently between the palms. Rolling the vial gently
between the palms produces heat, which helps dissolve the medication. Doing nothing
or inverting the vial wouldn’t help dissolve the medication. Shaking the vial vigorously
could cause the medication to break down, altering its action.
96. Answer: (B) Assist the client to the semi-Fowler position if possible. By
assisting the client to the semi-Fowler position, the nurse promotes easier chest
expansion, breathing, and oxygen intake. The nurse should secure the elastic band so
that the face mask fits comfortably and snugly rather than tightly, which could lead to
irritation. The nurse should apply the face mask from the client’s nose down to the
chin — not vice versa. The nurse should check the connectors between the oxygen
equipment and humidifier to ensure that they’re airtight; loosened connectors can
cause loss of oxygen.
97. Answer: (B) 4 hours. A unit of packed RBCs may be given over a period of between
1 and 4 hours. It shouldn’t infuse for longer than 4 hours because the risk of
contamination and sepsis increases after that time. Discard or return to the blood
bank any blood not given within this time, according to facility policy.
98. Answer: (B) Immediately before administering the next dose. Measuring the
blood drug concentration helps determine whether the dosing has achieved the
therapeutic goal. For measurement of the trough, or lowest, blood level of a drug, the
nurse draws a blood sample immediately before administering the next dose.
Depending on the drug’s duration of action and half-life, peak blood drug levels
typically are drawn after administering the next dose.
99. Answer: (A) The nurse can implement medication orders quickly. A floor
stock system enables the nurse to implement medication orders quickly. It doesn’t
allow for pharmacist input, nor does it minimize transcription errors or reinforce
accurate calculations
100. Answer: (C) Shifting dullness over the abdomen. Shifting dullness over the
abdomen indicates ascites, an abnormal finding. The other options are normal
abdominal findings.