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Using the principles of standard precautions, the nurse would wear gloves in what
nursing interventions?
2. The nurse is preparing to take vital sign in an alert client admitted to the hospital
with dehydration secondary to vomiting and diarrhea. What is the best method used
to assess the client’s temperature?
A. Oral
B. Axillary
C. Radial
D. Heat sensitive tape
3. A nurse obtained a client’s pulse and found the rate to be above normal. The
nurse document these findings as:
A. Tachypnea
B. Hyperpyrexia
C. Arrhythmia
D. Tachycardia
4. Which of the following actions should the nurse take to use a wide base support
when assisting a client to get up in a chair?
A. Bend at the waist and place arms under the client’s arms and lift
B. Face the client, bend knees and place hands on client’s forearm and lift
C. Spread his or her feet apart
D. Tighten his or her pelvic muscles
5. A client had oral surgery following a motor vehicle accident. The nurse assessing
the client finds the skin flushed and warm. Which of the following would be the best
method to take the client’s body temperature?
A. Oral
B. Axillary
C. Arterial line
D. Rectal
A. Fowler’s position
B. Side lying
C. Supine
D. Trendelenburg
7. A client is hospitalized for the first time, which of the following actions ensure the
safety of the client?
A. Assessment
B. Diagnosis
C. Planning
D. Implementation
A. Assessment
B. Nursing Process
C. Diagnosis
D. Implementation
A. Kidney
B. Lungs
C. Liver
D. Heart
11. The chamber of the heart that receives oxygenated blood from the lungs is the:
A. Left atrium
B. Right atrium
C. Left ventricle
D. Right ventricle
12. A muscular enlarge pouch or sac that lies slightly to the left which is used for
temporary storage of food…
A. Gallbladder
B. Urinary bladder
C. Stomach
D. Lungs
13. The ability of the body to defend itself against scientific invading agent such as
baceria, toxin, viruses and foreign body
A. Hormones
B. Secretion
C. Immunity
D. Glands
A. Progesterone
B. Testosterone
C. Insulin
D. Hemoglobin
15. It is a transparent membrane that focuses the light that enters the eyes to the
retina.
A. Lens
B. Sclera
C. Cornea
D. Pupils
17. Which of the following cluster of data belong to Maslow’s hierarchy of needs
A. Love and belonging
B. Physiologic needs
C. Self actualization
D. All of the above
A. Chronic Illness
B. Acute Illness
C. Pain
D. Syndrome
19. Which of the following is the nurse’s role in the health promotion
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20. It is described as a collection of people who share some attributes of their lives.
A. Family
B. Illness
C. Community
D. Nursing
A. 30 ml
B. 25 ml
C. 12 ml
D. 22 ml
A. 1.8
B. 18000
C. 180
D. 2800
A. Gtt.
B. Gtts.
C. Dp.
D. Dr.
A. µgtt
B. gtt
C. mdr
D. mgts
A. When advice
B. Immediately
C. When necessary
D. Now
2. Answer: B. Axillary
3. Answer: D. Tachycardia
4. Answer: B. Face the client, bend knees and place hands on client’s forearm and
lift
Option B: This is the proper way of supporting the client to get up in a chair
that conforms to safety and proper body mechanics.
5. Answer: B. Axillary
Option B: Taking the temperature via the axilla is the most appropriate route.
Option A: Taking the temperature via the oral route is incorrect since the client
had oral surgery.
Options C and D: These are unnecessary.
Option B: An unconscious client is best placed on his side when doing oral
care to prevent aspiration.
8. Answer: A. Assessment
Option A: Assessment is the first phase of the nursing process where a nurse
collects information about the client.
Option B: Diagnosis is the formulation of the nursing diagnosis from the
information collected during the assessment.
Option C: In Planning, the nurse sets achievable and measurable short and
long-term goals.
Option D: Implementation is where nursing care is given.
Option B: The statement describes the Nursing Process. The Nursing Process
is the essential core of practice for the registered nurse to deliver holistic,
patient-focused care.
Option B: Gas exchange is the transport of oxygen from the lungs to the
bloodstream and the expulsion of carbon dioxide from the bloodstream to the
lungs. It transpires in the lungs between the alveoli and a network of tiny blood
vessels called capillaries, which are located in the walls of the alveoli.
Option A: The left atrium receives oxygenated blood from the lungs and
pumps it to the left ventricle.
Option B: The right atrium receives blood from the veins and pumps it to the
right ventricle.
Option C: The left ventricle (the strongest chamber) pumps oxygen-rich blood
to the rest of the body, its vigorous contractions create the blood pressure.
Option D: The right ventricle receives blood from the right atrium and pumps
it to the lungs, where it is loaded with oxygen.
Option C: The stomach is a muscular organ located on the left side of the
upper abdomen. It is a saclike expansion of the digestive tract of a vertebrate
that is located between the esophagus and duodenum. The major part of the
digestion of food occurs in the stomach.
Option C: The Islets of Langerhans are the regions of the pancreas that contain
its endocrine cells. Progesterone (Choice A) is produced by the ovaries.
Testosterone (Choice B) is secreted by the testicles of males and ovaries of
females. Hemoglobin (Choice D) is a protein molecule in the red blood cells
that carries oxygen from the lungs to the body’s tissues and returns carbon
dioxide.
Option C: The cornea is the transparent front part of the eye that covers the
iris, pupil, and anterior chamber. The cornea is like the crystal of a watch.
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Option B: Chronic Illness (Choice A) are illnesses that are persistent or long-
term.
Option B: Nurses play a huge role in illness prevention and health promotion.
Nurses assume the role of ambassadors of wellness. The World Health
Organization (WHO) defines health promotion as a process of enabling people
to increase control over and to improve their health (WHO, 1986).
21. Answer: B. 25 ml
Option C: PRN comes from the Latin “pro re nata” meaning, “for an occasion
that has arisen or as circumstances require”.
A. 15
B. 60
C. 10
D. 30
A. 8
B. 80
C. 800
D. 8000
5. The nurse must verify the client’s identity before administration of medication.
Which of the following is the safest way to identify the client?
7. The nurse administers cleansing enema. The common position for this procedure
is…
A. Sims left lateral
B. Dorsal Recumbent
C. Supine
D. Prone
A. Intramuscular
B. Intradermal
C. Subcutaneous
D. Intravenous
10. The nurse is ordered to administer ampicillin capsule TID p.o. The
nurse should give the medication…
12. It refers to the preparation of the bed with a new set of linens
A. Bed bath
B. Bed making
C. Bed shampoo
D. Bed lining
A. To cleanse, refresh and give comfort to the client who must remain in bed
B. To expose the necessary parts of the body
C. To develop skills in bed bath
D. To check the body temperature of the client in bed
16. Which of the following technique involves the sense of sight?
A. Inspection
B. Palpation
C. Percussion
D. Auscultation
17. The first techniques used examining the abdomen of a client is:
A. Palpation
B. Auscultation
C. Percussion
D. Inspection
18. A technique in physical examination that is used to assess the movement of air
through the tracheobronchial tree:
A. Palpation
B. Auscultation
C. Inspection
D. Percussion
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A. Percussion-hammer
B. Audiometer
C. Stethoscope
D. Sphygmomanometer
A. Prone
B. Sim’s
C. Knee-chest
D. Lithotomy
A. Gait
B. Range of motion
C. Flexion and extension
D. Hopping
23. The nurse asked the client to read the Snellen chart. Which of the following is
tested:
A. Optic
B. Olfactory
C. Oculomotor
D. Trochlear
A. Genu-dorsal
B. Genu-pectoral
C. Lithotomy
D. Sim’s
25. The nurse prepares IM injection that is irritating to the subcutaneous tissue.
Which of the following is the best action in order to prevent tracking of the
medication?
Option C: CBR means complete bed rest. For more abbreviations, please see
this post.
2. Answer: B. 60
3. Answer: B. 20
4. Answer: A. 8
Option A: This position provides comfort to the patient and an easy access to
the natural curvature of the rectum.
Option C: The nurse should check first if the medication is available in liquid
form before doing Choice A. Placing it under the tongue is not the intended
way of administering an oral medication.
9. Answer: C. Subcutaneous
Option A: TID is the Latin for “ter in die” which means three times a day. P.O.
means per orem or through mouth.
Option B: Hand washing is the single most effective infection control measure.
Option A: Fanning soiled linens would scatter the lodged microorganisms and
dead skin cells on the linens.
15. Answer: A. To cleanse, refresh and give comfort to the client who must remain
in bed
Option A: The nurse provides bed bath for patients who must remain in bed
and depend on someone else for their care. It is an important part of the
patient’s daily care. Not only does it remove sweat, oil, and micro-organisms
from the patient’s skin, but it also stimulates circulation and promotes a feeling
of self-worth by improving the patient’s appearance. For patients who are on
bedrest, bathing can also be a time for socialization.
16. Answer: A. Inspection
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Option C: To assume the genu-pectoral position the person kneels so that the
weight of the body is supported by the knees and chest, with the buttocks
raised. The head is turned to one side and the arms are flexed so that the upper
part of the body can be supported in part by the elbows.
Option A: Cranial Nerve II or the optic nerve is tested through the use of the
Snellen chart.
Option D: During the procedure, skin and tissue are pulled and held firmly
while a long needle is inserted into the muscle. After the medication is injected,
the skin and tissue are released. The needle track that forms during this
procedure takes the shape of the letter “Z,” which gives the procedure its name.
This zigzag track line is what prevents medication from leaking from the
muscle into surrounding tissue.
1. The most appropriate nursing order for a patient who develops dyspnea and
shortness of breath would be…
2. The nurse observes that Mr. Adams begins to have increased difficulty breathing.
She elevates the head of the bed to the high Fowler position, which decreases his
respiratory distress. The nurse documents this breathing as:
A. Tachypnea
B. Eupnea
C. Orthopnea
D. Hyperventilation
4. Mrs. Mitchell has been given a copy of her diet. The nurse discusses the foods
allowed on a 500-mg low sodium diet. These include:
A. Reviewing daily activated partial thromboplastin time (APTT) and prothrombin time.
B. Reporting an APTT above 45 seconds to the physician
C. Assessing the patient for signs and symptoms of frank and occult bleeding
D. All of the above
6. The four main concepts common to nursing that appear in each of the current
conceptual models are:
A. Love
B. Elimination
C. Nutrition
D. Oxygen
8. The family of an accident victim who has been declared brain-dead seems
amenable to organ donation. What should the nurse do?
A. Discourage them from making a decision until their grief has eased
B. Listen to their concerns and answer their questions honestly
C. Encourage them to sign the consent form right away
D. Tell them the body will not be available for a wake or funeral
9. A new head nurse on a unit is distressed about the poor staffing on the 11 p.m. to
7 a.m. shift. What should she do?
10. Which of the following principles of primary nursing has proven the most
satisfying to the patient and nurse?
11. If nurse administers an injection to a patient who refuses that injection, she has
committed:
12. If patient asks the nurse her opinion about a particular physicians and the nurse
replies that the physician is incompetent, the nurse could be held liable for:
A. Slander
B. Libel
C. Assault
D. Respondent superior
13. A registered nurse reaches to answer the telephone on a busy pediatric unit,
momentarily turning away from a 3 month-old infant she has been weighing. The
infant falls off the scale, suffering a skull fracture. The nurse could be charged with:
A. Defamation
B. Assault
C. Battery
D. Malpractice
15. Which of the following signs and symptoms would the nurse expect to find when
assessing an Asian patient for postoperative pain following abdominal surgery?
18. High-pitched gurgles head over the right lower quadrant are:
19. A patient about to undergo abdominal inspection is best placed in which of the
following positions?
A. Prone
B. Trendelenburg
C. Supine
D. Side-lying
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20. For a rectal examination, the patient can be directed to assume which of the
following positions?
A. Genupectoral
B. Sims
C. Horizontal recumbent
D. All of the above
21. During a Romberg test, the nurse asks the patient to assume which position?
A. Sitting
B. Standing
C. Genupectoral
D. Trendelenburg
A. 54
B. 96
C. 150
D. 246
23. A patient is kept off food and fluids for 10 hours before surgery. His oral
temperature at 8 a.m. is 99.8 F (37.7 C) This temperature reading probably
indicates:
A. Infection
B. Hypothermia
C. Anxiety
D. Dehydration
24. Which of the following parameters should be checked when assessing
respirations?
A. Rate
B. Rhythm
C. Symmetry
D. All of the above
25. A 38-year old patient’s vital signs at 8 a.m. are axillary temperature 99.6 F (37.6
C); pulse rate, 88; respiratory rate, 30. Which findings should be reported?
The answers and rationale below will give you a better understanding of the exam.
Counter-check your answers to those below. If you have any disputes or objects, please
direct them to the comments section.
Option B: Mashed potatoes and broiled chicken are low in natural sodium
chloride.
Options A, C, and D: Ham, olives, and chicken bouillon contain large
amounts of sodium and are contraindicated on a low sodium diet.
Option D: The focus concepts that have been accepted by all theorists as the
focus of nursing practice from the time of Florence Nightingale include the
person receiving nursing care, his environment, his health on the health illness
continuum, and the nursing actions necessary to meet his needs.
7. Answer: D. Oxygen
Option D: Studies have shown that patients and nurses both respond well to
primary nursing care units. Patients feel less anxious and isolated and more
secure because they are allowed to participate in planning their own care.
Nurses feel personal satisfaction, much of it related to positive feedback from
the patients. They also seem to gain a greater sense of achievement and esprit
de corps.
Option C: An Asian patient is likely to hide his pain. Consequently, the nurse
must observe for objective signs. In an abdominal surgery patient, these might
include immobility, diaphoresis, and avoidance of deep breathing or coughing,
as well as increased heart rate, shallow respirations (stemming from pain upon
moving the diaphragm and respiratory muscles), and guarding or rigidity of the
abdominal wall. Such a patient is unlikely to display emotion, such as crying.
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Option D: Because percussion and palpation can affect bowel motility and thus
bowel sounds, they should follow auscultation in abdominal assessment.
Option A: Tympanic percussion, measurement of abdominal girth, and
inspection are methods of assessing the abdomen.
Option B: Assessing for distention, tenderness and discoloration around the
umbilicus can indicate various bowel-related conditions, such
as cholecystitis, appendicitis and peritonitis.
Option C: High-pitched gurgles head over the right lower quadrant are normal
bowel sounds.
Option A: Hyperactive sounds indicate increased bowel motility.
Option B: Two or three sounds per minute indicate decreased bowel motility.
Option D: Abdominal cramping with hyperactive, high pitched tinkling bowel
sounds can indicate a bowel obstruction.
Option D: All of these positions are appropriate for a rectal examination. In the
genupectoral (knee-chest) position, the patient kneels and rests his chest on the
table, forming a 90-degree angle between the torso and upper legs. In Sims’
position, the patient lies on his left side with the left arm behind the body and
his right leg flexed. In the horizontal recumbent position, the patient lies on his
back with legs extended and hips rotated outward.
22. Answer: A. 54
Option A: The pulse pressure is the difference between the systolic and
diastolic blood pressure readings – in this case, 54.
A. Fever
B. Exercise
C. Sympathetic nervous system stimulation
D. Parasympathetic nervous system stimulation
3. The absence of which pulse may not be a significant finding when a patient is
admitted to the hospital?
A. Apical
B. Radial
C. Pedal
D. Femoral
4. Which of the following patients is at greatest risk for developing pressure ulcers?
A. Encourage the patient to increase her fluid intake to 200 ml every 2 hours
B. Place a humidifier in the patient’s room.
C. Continue administering oxygen by high humidity face mask
D. Perform chest physiotherapy on a regular schedule
6. The most common deficiency seen in alcoholics is:
A. Thiamine
B. Riboflavin
C. Pyridoxine
D. Pantothenic acid
A. The patient will find pureed or soft foods, such as custards, easier to swallow than
water
B. Fowler’s or semi Fowler’s position reduces the risk of aspiration during swallowing
C. The patient should always feed himself
D. The nurse should perform oral hygiene before assisting with feeding.
12. Mrs. Lim begins to cry as the nurse discusses hair loss. The best response would
be:
13. An additional Vitamin C is required during all of the following periods except:
A. Infancy
B. Young adulthood
C. Childhood
D. Pregnancy
14. A prescribed amount of oxygen s needed for a patient with COPD to prevent:
A. Cardiac arrest related to increased partial pressure of carbon dioxide in arterial blood
(PaCO2)
B. Circulatory overload due to hypervolemia
C. Respiratory excitement
D. Inhibition of the respiratory hypoxic stimulus
15. After 1 week of hospitalization, Mr. Gray develops hypokalemia. Which of the
following is the most significant symptom of his disorder?
A. Lethargy
B. Increased pulse rate and blood pressure
C. Muscle weakness
D. Muscle irritability
A. Asses the patient’s ability to ambulate and transfer from a bed to a chair
B. Demonstrate the signal system to the patient
C. Check to see that the patient is wearing his identification band
D. All of the above
17. Studies have shown that about 40% of patients fall out of bed despite the use of
side rails; this has led to which of the following conclusions?
18. Examples of patients suffering from impaired awareness include all of the
following except:
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20. The most common psychogenic disorder among elderly person is:
A. Depression
B. Sleep disturbances (such as bizarre dreams)
C. Inability to concentrate
D. Decreased appetite
21. Which of the following vascular system changes results from aging?
A. Parkinson’s disease
B. Multiple sclerosis
C. Amyotrophic lateral sclerosis (Lou Gehrig’s disease)
D. Alzheimer’s disease
23. The nurse’s most important legal responsibility after a patient’s death in a
hospital is:
25. When a patient in the terminal stages of lung cancer begins to exhibit loss of
consciousness, a major nursing priority is to:
Option D: The apical pulse (the pulse at the apex of the heart) is located on the
midclavicular line at the fourth, fifth, or sixth intercostal space. Base line vital
signs include pulse rate, temperature, respiratory rate, and blood pressure.
Blood pressure is typically assessed at the antecubital fossa, and respiratory rate
is assessed best by observing chest movement with
each inspiration and expiration.
3. Answer: C. Pedal
Option C: Because the pedal pulse cannot be detected in 10% to 20% of the
population, its absence is not necessarily a significant finding. However, the
presence or absence of the pedal pulse should be documented upon admission
so that changes can be identified during the hospital stay.
Options A, B, and D: Absence of the apical, radial, or femoral pulse is
abnormal and should be investigated.
4. Answer: B. An 88-year old incontinent patient with gastric cancer who is confined
to his bed at home
Option B: Pressure ulcers are most likely to develop in patients with impaired
mental status, mobility, activity level, nutrition, circulation and bladder or
bowel control. Age is also a factor. Thus, the 88-year old incontinent patient
who has impaired nutrition (from gastric cancer) and is confined to bed is at
greater risk.
5. Answer: A. Encourage the patient to increase her fluid intake to 200 ml every 2
hours
Option A: Adequate hydration thins and loosens pulmonary secretions and also
helps to replace fluids lost from elevated temperature, diaphoresis, dehydration,
and dyspnea.
Options B, C, and D: High-humidity air and chest physiotherapy help liquefy
and mobilize secretions.
6. Answer: A. Thiamine
Option C: Accompanying him will offer moral support, enabling him to face
the rest of the world.
Option A: A hospitalized surgical patient leaving his room for the first time
fears rejection and others staring at him, so he should not walk alone.
Option B: Patients should begin ambulation as soon as possible after surgery to
decrease complications and to regain strength and confidence.
Option D: Waiting to consult a physical therapist is unnecessary.
12. Answer: D. “I know this will be difficult for you, but your hair will grow back
after the completion of chemotherapy”
Option D: Delivery of more than 2 liters of oxygen per minute to a patient with
chronic obstructive pulmonary disease (COPD), who is usually in a state of
compensated respiratory acidosis (retaining carbon dioxide (CO2)), can inhibit
the hypoxic stimulus for respiration.
Option A: An increased partial pressure of carbon dioxide in arterial blood
(PACO2) would not initially result in cardiac arrest.
Options B and C: Circulatory overload and respiratory excitement have no
relevance to the question.
17. Answer: D. Side rails are a reminder to a patient not to get out of bed
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Option D: Since about 40% of patients fall out of bed despite the use of side
rails, side rails cannot be said to prevent falls; however, they do serve as a
reminder that the patient should not get out of bed.
Options A, B, and C: The other answers are incorrect interpretations of the
statistical data.
Option C: A patient who cannot care for himself at home does not necessarily
have impaired awareness; he may simply have some degree of immobility.
Option D: Hip fracture, the most common injury among elderly persons,
usually results from osteoporosis.
Options A, B, and C: The other answers are diseases that can occur in the
elderly from physiologic changes.
Option D: Aging decreases the elasticity of the blood vessels, which leads to
increased peripheral resistance and decreased blood flow. These changes, in
turn, increase the workload of the left ventricle.
Option C: The nurse is legally responsible for labeling the corpse when death
occurs in the hospital.
Options A and B: She may be involved in obtaining consent for an autopsy or
notifying the coroner or medical examiner of a patient’s death; however, she is
not legally responsible for performing these functions.
Option D: The attending physician may need information from the nurse to
complete the death certificate, but he is responsible for issuing it.
24. Answer: B. Placing one pillow under the body’s head and shoulders
Option B: The nurse must place a pillow under the deceased person’s head and
shoulders to prevent blood from settling in the face and discoloring it.
Option A: She is required to bathe only soiled areas of the body since the
mortician will wash the entire body.
Option C: Before wrapping the body in a shroud, the nurse places a clean
gown on the body and closes the eyes and mouth.
Option A: Ensuring the patient’s safety is the most essential action at this time.
Options B, C, and D: The other nursing actions may be necessary but are not a
major priority.
A. Host
B. Reservoir
C. Mode of transmission
D. Portal of entry
2. Which of the following will probably result in a break in sterile technique for
respiratory isolation?
A. Opening the patient’s window to the outside environment
B. Turning on the patient’s room ventilator
C. Opening the door of the patient’s room leading into the hospital corridor
D. Failing to wear gloves when administering a bed bath
A. 30 seconds
B. 1 minute
C. 2 minutes
D. 3 minutes
A. Using sterile forceps, rather than sterile gloves, to handle a sterile item
B. Touching the outside wrapper of sterilized material without sterile gloves
C. Placing a sterile object on the edge of the sterile field
D. Pouring out a small amount of solution (15 to 30 ml) before pouring the solution into a
sterile container
9. A natural body defense that plays an active role in preventing infection is:
A. Yawning
B. Body hair
C. Hiccupping
D. Rapid eye movements
10. All of the following statement are true about donning sterile gloves except:
A. The first glove should be picked up by grasping the inside of the cuff.
B. The second glove should be picked up by inserting the gloved fingers under the cuff
outside the glove.
C. The gloves should be adjusted by sliding the gloved fingers under the sterile cuff and
pulling the glove over the wrist
D. The inside of the glove is considered sterile
11. When removing a contaminated gown, the nurse should be careful that the first
thing she touches is the:
12. Which of the following nursing interventions is considered the most effective
form or universal precautions?
A. Cap all used needles before removing them from their syringes
B. Discard all used uncapped needles and syringes in an impenetrable protective
container
C. Wear gloves when administering IM injections
D. Follow enteric precautions
14. Which of the following blood tests should be performed before a blood
transfusion?
16. Which of the following white blood cell (WBC) counts clearly indicates
leukocytosis?
A. 4,500/mm³
B. 7,000/mm³
C. 10,000/mm³
D. 25,000/mm³
17. After 5 days of diuretic therapy with 20mg of furosemide (Lasix) daily, a patient
begins to exhibit fatigue, muscle cramping and muscle weakness. These symptoms
probably indicate that the patient is experiencing:
A. Hypokalemia
B. Hyperkalemia
C. Anorexia
D. Dysphagia
20. A patient with no known allergies is to receive penicillin every 6 hours. When
administering the medication, the nurse observes a fine rash on the patient’s skin.
The most appropriate nursing action would be to:
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21. All of the following nursing interventions are correct when using the Z-track
method of drug injection except:
22. The correct method for determining the vastus lateralis site for I.M. injection is
to:
A. Locate the upper aspect of the upper outer quadrant of the buttock about 5 to 8 cm
below the iliac crest
B. Palpate the lower edge of the acromion process and the midpoint lateral aspect of the
arm
C. Palpate a 1” circular area anterior to the umbilicus
D. Divide the area between the greater femoral trochanter and the lateral femoral condyle
into thirds, and select the middle third on the anterior of the thigh
23. The mid-deltoid injection site is seldom used for I.M. injections because it:
A. 18G, 1 ½” long
B. 22G, 1” long
C. 22G, 1 ½” long
D. 25G, 5/8” long
A. 20G
B. 22G
C. 25G
D. 26G
Gauge your performance by counter checking your answers to the answers below. Learn
more about the question by reading the rationale. If you have any disputes or questions,
please direct them to the comments section.
1. Answer: D. Portal of entry
Option D: In the circular chain of infection, pathogens must be able to leave their
reservoir and be transmitted to a susceptible host through a portal of entry, such as broken
skin.
2. Answer: C. Opening the door of the patient’s room leading into the hospital
corridor
Option C: Respiratory isolation, like strict isolation, requires that the door to
the door patient’s room remain closed.
Options A and B: However, the patient’s room should be well ventilated, so
opening the window or turning on the ventricular is desirable.
Option D: The nurse does not need to wear gloves for respiratory isolation, but
good hand washing is important for all types of isolation.
Options B, C, and D: None of the other situations would put the patient at risk for
contracting an infection; taking broad-spectrum antibiotics might actually reduce the
infection risk.
Option A: Soaps and detergents are used to help remove bacteria because of
their ability to lower the surface tension of water and act as emulsifying agents.
Option B: Hot water may lead to skin irritation or burns.
5. Answer: A. 30 seconds
Option A: Depending on the degree of exposure to pathogens, hand
washing may last from 10 seconds to 4 minutes. After routine patient
contact, hand washing for 30 seconds effectively minimizes the risk of
pathogen transmission.
Option B: Hair on or within body areas, such as the nose, traps and holds
particles that contain microorganisms.
Options A and C: Yawning and hiccupping do not prevent microorganisms
from entering or leaving the body.
Option D: Rapid eye movement marks the stage of sleep during which
dreaming occurs.
Option D: The inside of the glove is always considered to be clean, but not
sterile.
11. Answer: A. Waist tie and neck tie at the back of the gown
Option A: The back of the gown is considered clean, the front is contaminated.
So, after removing gloves and washing hands, the nurse should untie the back
of the gown; slowly move backward away from the gown, holding the inside of
the gown and keeping the edges off the floor; turn and fold the gown inside out;
discard it in a contaminated linen container; then wash her hands again.
12. Answer: B. Discard all used uncapped needles and syringes in an impenetrable
protective container
Option B: Before a blood transfusion is performed, the blood of the donor and
recipient must be checked for compatibility. This is done by blood typing (a
test that determines a person’s blood type) and cross-matching (a procedure that
determines the compatibility of the donor’s and recipient’s blood after the
blood types has been matched). If the blood specimens are incompatible,
hemolysis and antigen-antibody reactions will occur.
Option A: Platelets are disk-shaped cells that are essential for blood
coagulation. A platelet count determines the number of thrombocytes in blood
available for promoting hemostasis and assisting with blood coagulation after
injury.
Option B: It also is used to evaluate the patient’s potential for bleeding;
however, this is not its primary purpose. The normal count ranges from
150,000 to 350,000/mm3. A count of 100,000/mm3 or less indicates a potential
for bleeding; count of less than 20,000/mm3 is associated with
spontaneous bleeding.
16. Answer: D. 25,000/mm³
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21. Answer: D. Rub the site vigorously after the injection to promote absorption
22. Answer: D. Divide the area between the greater femoral trochanter and the
lateral femoral condyle into thirds, and select the middle third on the anterior of the
thigh
Option D: The vastus lateralis, a long, thick muscle that extends the full length
of the thigh, is viewed by many clinicians as the site of choice for I.M.
injections because it has relatively few major nerves and blood vessels. The
middle third of the muscle is recommended as the injection site. The patient can
be in a supine or sitting position for an injection into this site.
23. Answer: A. Can accommodate only 1 ml or less of medication
Option D: A 25G, 5/8” needle is the recommended size for insulin injection
because insulin is administered by the subcutaneous route.
Option A: An 18G, 1 ½” needle is usually used for I.M. injections in children,
typically in the vastus lateralis.
Option C: A 22G, 1 ½” needle is usually used for adult I.M. injections, which
are typically administered in the vastus lateralis or ventrogluteal site.
Option D: Because an intradermal injection does not penetrate deeply into the
skin, a small-bore 26G-27G needle is recommended. This type of injection is
used primarily to administer antigens to evaluate reactions for allergy or
sensitivity studies.
Options A, B, and C: A 20G needle is usually used for I.M. injections of oil-
based medications; a 22G-25G needle for I.M. injections; and a 25G needle, for
subcutaneous insulin injections.
A. IM injection or an IV solution
B. IV or an intradermal injection
C. Intradermal or subcutaneous injection
D. IM or a subcutaneous injection
2. The physician orders gr 10 of aspirin for a patient. The equivalent dose in
milligrams is:
A. 0.6 mg
B. 10 mg
C. 60 mg
D. 600 mg
A. 5 gtt/minute
B. 13 gtt/minute
C. 25 gtt/minute
D. 50 gtt/minute
A. Hemoglobinuria
B. Chest pain
C. Urticaria
D. Distended neck veins
A. Fever
B. Chronic Obstructive Pulmonary Disease
C. Renal Failure
D. Dehydration
6. All of the following are common signs and symptoms of phlebitis except:
A. Pain or discomfort at the IV insertion site
B. Edema and warmth at the IV insertion site
C. A red streak exiting the IV insertion site
D. Frank bleeding at the insertion site
A. Tolerance
B. Idiosyncrasy
C. Synergism
D. Allergy
10. A patient has returned to his room after femoral arteriography. All of the
following are appropriate nursing interventions except:
A. Assess femoral, popliteal, and pedal pulses every 15 minutes for 2 hours
B. Check the pressure dressing for sanguineous drainage
C. Assess vital signs every 15 minutes for 2 hours
D. Order a hemoglobin and hematocrit count 1 hour after the arteriography
12. An infected patient has chills and begins shivering. The best nursing
intervention is to:
14. The purpose of increasing urine acidity through dietary means is to:
A. Upper GI bleeding
B. Impending constipation
C. An effect of medication
D. Bile obstruction
16. In which step of the nursing process would the nurse ask a patient if the
medication she administered relieved his pain?
A. Assessment
B. Analysis
C. Planning
D. Evaluation
A. White potatoes
B. Carrots
C. Apricots
D. Egg yolks
18. Which of the following is a primary nursing intervention necessary for all
patients with a Foley Catheter in place?
A. Maintain the drainage tubing and collection bag level with the patient’s bladder
B. Irrigate the patient with 1% Neosporin solution three times a daily
C. Clamp the catheter for 1 hour every 4 hours to maintain the bladder’s elasticity
D. Maintain the drainage tubing and collection bag below bladder level to facilitate
drainage by gravity
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20. The two blood vessels most commonly used for TPN infusion are the:
21. Effective skin disinfection before a surgical procedure includes which of the
following methods?
22. When transferring a patient from a bed to a chair, the nurse should use which
muscles to avoid back injury?
A. Abdominal muscles
B. Back muscles
C. Leg muscles
D. Upper arm muscles
A. Increased urine acidity and relaxation of the perineal muscles, causing incontinence
B. Urine retention, bladder distention, and infection
C. Diuresis, natriuresis, and decreased urine specific gravity
D. Decreased calcium and phosphate levels in the urine
Gauge your performance by counter checking your answers to the answers below. Learn
more about the question by reading the rationale. If you have any disputes or questions,
please direct them to the comments section.
1. Answer: A. IM injection or an IV solution
2. Answer: D. 600 mg
3. Answer: C. 25 gtt/minute
4. Answer: A. Hemoglobinuria
Option C: In renal failure, the kidney loses their ability to effectively eliminate
wastes and fluids. Because of this, limiting the patient’s intake of oral and I.V.
fluids may be necessary.
Options A, B, and D: Fever, chronic obstructive pulmonary disease,
and dehydration are conditions for which fluids should be encouraged.
6. Answer: D. Frank bleeding at the insertion site
8. Answer: D. Most tablets designed for oral use, except for extended-duration
compounds
Option D: Most tablets designed for oral use, except for extended-duration
compounds can be administered via gastrostomy tube.
Options A, B, and C: Capsules, enteric-coated tablets, and most extended
duration or sustained release products should not be dissolved for use in a
gastrostomy tube. They are pharmaceutically manufactured in these forms for
valid reasons, and altering them destroys their purpose. The nurse should seek
an alternate physician’s order when an ordered medication is inappropriate
for delivery by tube.
9. Answer: D. Allergy
10. Answer: D. Order a hemoglobin and hematocrit count 1 hour after the
arteriography
13. Answer: D. Completed a master’s degree in the prescribed clinical area and is a
registered professional nurse.
Option D: Bile colors the stool brown. Any inflammation or obstruction that
impairs bile flow will affect the stool pigment, yielding light, clay-colored
stool.
Option A: Upper GI bleeding results in black or tarry stool.
Option B: Constipation is characterized by small, hard masses.
Option C: Many medications and foods will discolor stool – for example,
drugs containing iron turn stool black.; beets turn stool red.
Option D: In the evaluation step of the nursing process, the nurse must decide
whether the patient has achieved the expected outcome that was identified in
the planning phase.
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Option A: The main sources of vitamin A are yellow and green vegetables
(such as carrots, sweet potatoes, squash, spinach, collard greens, broccoli, and
cabbage) and yellow fruits (such as apricots, and cantaloupe). Animal sources
include liver, kidneys, cream, butter, and egg yolks.
18. Answer: D. Maintain the drainage tubing and collection bag below bladder level
to facilitate drainage by gravity
Option D: Maintaining the drainage tubing and collection bag level with the
patient’s bladder could result in reflux of urine into the kidney. Irrigating the
bladder with Neosporin and clamping the catheter for 1 hour every 4 hours
must be prescribed by a physician.
Option D: The ELISA test of venous blood is used to assess blood and
potential blood donors to human immunodeficiency virus (HIV). A positive
ELISA test combined with various signs and symptoms helps to diagnose
acquired immunodeficiency syndrome (AIDS)
21. Answer: D. Having the patient shower with an antiseptic soap on the evening
before and the morning of surgery
Option D: Studies have shown that showering with an antiseptic soap before
surgery is the most effective method of removing microorganisms from the
skin.
Option A: Shaving the site of the intended surgery might cause breaks in the
skin, thereby increasing the risk of infection; however, if indicated, shaving,
should be done immediately before surgery, not the day before.
Option B: A topical antiseptic would not remove microorganisms and would
be beneficial only after proper cleaning and rinsing.
Option C: Tub bathing might transfer organisms to another body site rather
than rinse them away.
Option C: The leg muscles are the strongest muscles in the body and should
bear the greatest stress when lifting. Muscles of the abdomen, back, and upper
arms may be easily injured.
1. Mr. Teban is a 73-year old patient diagnosed with pneumonia. Which data would
be of greatest concern to the nurse when completing the nursing assessment of the
patient?
4. John Joseph was scheduled for a physical assessment. When percussing the
client’s chest, the nurse would expect to find which assessment data as a normal sign
over his lungs?
A. Dullness
B. Resonance
C. Hyperresonance
D. Tympany
A. Tipping the client’s head away from the examiner and pulling the ear up and back
B. Inserting the otoscope inferiorly into the distal portion of the external canal
C. Inserting the otoscope superiorly into the proximal two-thirds of the external canal
D. Bracing the examiner’s hand against the client’s head
7. When assessing the lower extremities for arterial function, which intervention
should the nurse perform?
8. Newly hired nurse Liza is excited to perform her very first physical assessment
with a 19-year-old client. Which assessment examination requires Liza to wear
gloves?
A. Breast
B. Integumentary
C. Ophthalmic
D. Oral
9. Nurse Renor is about to perform Romberg’s test to Pierro. To ensure the latter’s
safety, which intervention should nurse Renor implement?
10. Physical assessment is being performed to Geoff by Nurse Tine. During the
abdominal examination, Tine should perform the four physical examination
techniques in which sequence?
11. Which assessment data should the nurse include when obtaining a review of
body systems
A. Brief statement about what brought the client to the health care provider
B. Client complaints of chest pain, dyspnea, or abdominal pain
C. Information about the client’s sexual performance and preference
D. The client’s name, address, age, and phone number
12. Tywin has come to the nursing clinic for a comprehensive health assessment.
Which statement would be the best way to end the history interview?
A. “What brought you to the clinic today?”
B. “Would you describe your overall health as good?”
C. “Do you understand what is happening?”
D. “Is there anything else you would like to tell me?”
13. For which time period would the nurse notify the health care provider that the
client had no bowel sounds?
A. 2 minutes
B. 3 minutes
C. 4 minutes
D. 5 minutes
14. Evaluating the apical pulse is the most reliable noninvasive way to assess cardiac
function. Which is the best area for auscultating the apical pulse?
A. Aortic arch
B. Pulmonic area
C. Tricuspid area
D. Mitral area
15. Beginning in their 20s, women should be told about the benefits and limitations
of breast self-exam (BSE). Which scientific rationale should the nurse remember
when performing a breast examination on a female client?
16. Mr. Lim, who has chronic pain, loss of self-esteem, no job, and bodily
disfigurement from severe burns over the trunk and arms, is admitted to a pain
center. Which evaluation criteria would indicate the client’s successful
rehabilitation?
A. The client remains free of the aftermath phase of the pain experience.
B. The client experiences decreased frequency of acute pain episodes.
C. The client continues normal growth and development with intact support systems.
D. The client develops increased tolerance for severe pain in the future.
17. Christine Ann is about to take her NCLEX examination next week and is
currently reviewing the concept of pain. Which scientific rationale would indicate
that she understands the topic?
18. Miggy, a 6-year-old boy, received a small paper cut on his finger, his mother let
him wash it and apply small amount of antibacterial ointment and bandage. Then
she let him watch TV and eat an apple. This is an example of which type of pain
intervention?
A. Pharmacologic therapy
B. Environmental alteration
C. Control and distraction
D. Cutaneous stimulation
19. Which statement represents the best rationale for using noninvasive and non-
pharmacologic pain-control measures in conjunction with other measures?
A. Specificity theory
B. Pattern theory
C. Gate-control theory
D. Central-control theory
22. Ryan underwent an open reduction and internal fixation of the left hip. One day
after the operation, the client is complaining of pain. Which data would cause the
nurse to refrain from administering the pain medication and to notify the health
care provider instead?
23. Which term would the nurse use to document pain at one site that is perceived in
other site?
A. Referred pain
B. Phantom pain
C. Intractable pain
D. Aftermath of pain
24. Chuck, who is in the hospital, complains of abdominal pain that ranks 9 on a
scale of 1 (no pain) to 10 (worst pain). Which interventions should the nurse
implement? (Select all that apply.)
25. Albert who suffered severe burns 6 months ago is expressing concern about the
possible loss of job-performance abilities and physical disfigurement. Which
intervention is the most appropriate for him?
26. Mrs. Bagapayo who had abdominal surgery 3 days earlier complains of sharp,
throbbing abdominal pain that ranks 8 on a scale of 1 (no pain) to 10 (worst pain).
Which intervention should the nurse implement first?
27. Which term refers to the pain that has a slower onset, is diffuse, radiates, and is
marked by somatic pain from organs in any body activity?
A. Acute pain
B. Chronic pain
C. Superficial pain
D. Deep pain
28. A 50-year-old widower has arthritis and remains in bed too long because it hurts
to get started. Which intervention should the nurse plan?
A. Telling the client to strictly limit the amount of movement of his inflamed joints
B. Teaching the client’s family how to transfer the client into a wheelchair
C. Teaching the client the proper method for massaging inflamed, sore joints
D. Encouraging gentle range-of-motion exercises after administering aspirin and before
rising
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30. A 12-year-old student fall off the stairs, grabs his wrist, and cries, “Oh, my
wrist! Help! The pain is so sharp, I think I broke it.” Based on this data, the pain the
student is experiencing is caused by impulses traveling from receptors to the spinal
cord along which type of nerve fibers?
Here are the answers for this exam. Gauge your performance by counter checking your
answers to those below. If you have any disputes or clarifications, please direct them to
the comments section.
Buccal cyanosis and capillary refill greater than 3 seconds are indicative of decreased
oxygen to the tissues, which requires immediate intervention. Alert and oriented, clear
breath sounds, nonproductive cough, hemoglobin concentration of 13 g/dl, and leukocyte
count of 5,300/mm3 are normal data.
4. Answer: B. Resonance
Normally, when percussing a client’s chest, percussion over the lungs reveals resonance,
a hollow or loud, low-pitched sound of long duration. Tympany is typically heard on
percussion over such areas as a gastric air bubble or the intestine. Dullness is typically
heard on percussion of solid organs, such as the liver or areas of consolidation.
Hyperresonance would be evidenced by percussion over areas of overinflation such as an
emphysematous lungs.
A normal potassium level is 3.5 to 5.5 mEq/L. A normal sodium level is 135 to 145
mEq/L, a normal nonfasting glucose level is 85 to 140 mg/dl, and a normal creatinine
level is 0.2 to 0.8 mg/100 ml.
6. Answer: C. Inserting the otoscope superiorly into the proximal two-thirds of the
external canal
In the superior position, the speculum of the otoscope is nearest the tympanic membrane,
and the most sensitive portion of the external canal is the proximal two-thirds. It is
important to avoid these structures during the examination. Tipping the client’s head
away from the examiner, pulling the ear up and back, inserting the otoscope inferiorly,
and bracing the examiner’s hand against the client’s head are all appropriate techniques
used during an otoscopic examination.
8. Answer: D. Oral
Gloves should be worn any time there is a risk of exposure to the client’s blood or body
fluids. Oral, rectal, and genital examinations require gloves because they involve contact
with body fluids. Ophthalmic, breast, or integumentary examinations normally do not
involve contact with the client’s body fluids and do not require the nurse to wear gloves
for protection. However, if there are areas of skin breakdown or drainage, gloves should
be used.
During Romberg’s test, the client is asked to stand with feet together and eyes shut and
still maintain balance with the minimum of sway. If the client loses his balance, the nurse
standing close to provide support, such as having an arm close around his shoulder, can
prevent a fall. Allowing the client to keep his eyes open, spread his feet apart, or hang on
to a piece of furniture interferes with the proper execution of the test and yields invalid
results.
10. Answer: A. Auscultation immediately after inspection and then percussion and
palpation
Client complaints about chest pain, dyspnea, or abdominal pain are considered part of the
review of body systems. This potion of the assessment elicits subjective information on
the client’s perceptions of major body system functions, including cardiac, respiratory,
and abdominal. The client’s name, address, age, and phone number are biographical data.
A brief statement about what brought the client to the health care provider is the chief
complaint. Information about the client’s sexual performance and preference addresses
past health status.
12. Answer: D. “Is there anything else you would like to tell me?”
By asking the client if there is anything else, the nurse allows the client to end the
interview by discussing feelings and concerns. Asking about what brought the client to
the clinic is an ambiguous question to which the client may answer “my car” or any
similarly disingenuous reply. Asking if the client describes his overall health as good is a
leading question that puts words in his mouth. Asking if the client understands what is
happening is a yes-or-no question that can elicit little information.
To completely determine that bowel sounds are absent, the nurse must auscultate each of
the four quadrants for at least 5 minutes; 2, 3, or 4 minutes is too short a period to arrive
at this conclusion.
The mitral area (also known as the left ventricular area or the apical area), the fifth
intercostal space (ICS) at the left midclavicular line, is the best area for auscultating the
apical pulse. The aortic arch is the second ICS to the right of sternum. The pulmonic area
is the second intercostal space to the left of the sternum. The tricuspid area is the fifth
ICS to the left of the sternum.
15. Answer: B. The tail of Spence area must be included in self-examination
The tail of Spence, an extension of the upper outer quadrant of breast tissue, can develop
breast tumors. This area must also be included in breast self-examination. One half of all
women who die of breast cancer are older than age 65. The correct position for breast
self-examination is not limited to the supine position; the sitting position with hands at
sides, above head, and on the hips is also recommended. A pad is placed under the
ipsilateral (e.g., same side) scapula of the breast being palpated.
16. Answer: C. The client continues normal growth and development with intact
support systems.
Even though the client may experience an aftermath phase, progress is still possible, as is
effective rehabilitation. Aftermath reactions may occur but need not interfere with
rehabilitation. Acute pain is not expected at this stage of recovery. Conditioning probably
would produce less pain tolerance.
Phases of pain experience include the anticipation of pain. Fear and anxiety affect a
person’s response to sensation and typically intensify the pain. Intractable pain is
moderate to severe pain that cannot be relieved by any known treatment. Pain is a
subjective sensation that cannot be quantified by anyone except the person experiencing
it. Psychological factors contribute to a client’s pain perception. In many cases, pain
results from emotions, such as hostility, guilt, or depression.
The mothers actions are example of control and distraction. Involving the child in care
and providing distraction took his mind off the pain. Pharmacologic agents for pain
analgesics — were not used. The home environment was not changed, and cutaneous
stimulation, such as massage, vibration, or pressure, was not used.
19. Answer: C. These measures potentiate the effects of analgesics.
Distraction is an appropriate method of reducing pain. Denying the existence of any pain
is inappropriate and not indicative of coping. Exclusion of family members and other
sources of support represents a maladaptive response. Range-of-motion exercises and at
least mild activity, not decreased activity, can help reduce pain and are important to
prevent complications of immobility.
No one theory explains all the factors underlying the pain experience, but the central-
control theory discusses brain opiates with analgesic properties and how their release can
be affected by actions initiated by the client and caregivers. The gate-control, specificity,
and patter theories do not address pain control to the depth included in the central-control
theory.
A left foot cold to touch without palpable pedal pulse represents an abnormal finding on
neurovascular assessment of the left leg. The client is most likely experiencing some
complication from surgery, which requires immediate medical intervention. The nurse
should notify the health care provider of these findings. A dry and intact hip dressing,
blood pressure of 114/78 mm Hg, pulse rate of 82 beats per minute, and a left foot in
functional anatomic position are all normal assessment findings that do not require
medical intervention.
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Referred pain is pain occurring at one site that is perceived in another site. Referred pain
follows dermatome and nerve root patterns. Phantom pain refers to pain in a part of the
body that is no longer there, such as in amputation. Intractable pain refers to moderate to
severe pain that cannot be relieved by any known treatment. Aftermath of pain, a phase
of the pain experience and the most neglected phase, addresses the client’s response to
the pain experience.
The nurse must rule out complications prior to administering pain medication, so her
interventions would include assessing to make sure the client has bowel sounds and
determining if the client is hemorrhaging by checking the client’s blood pressure and
pulse. The nurse must also make sure the pain medication is due according to the health
care provider’s orders. Obtaining a pulse oximeter reading and turning, coughing, and
deep breathing will not help the client’s pain. There is no need to notify the health care
provider in this situation.
25. Answer: A. Referring the client for counseling and occupational therapy
Because it has been 6 months, the client needs professional help to get on with life and
handle the limitations imposed by the current problems. Staying with the client, building
trust, and providing method of pain relief, such as cutaneous stimulation, medications,
distraction, and guided imagery interventions, would have been more appropriate in
earlier stages of postburn injury, when physical pain was most severe and fewer
psychologic factors needed to be addressed.
26. Answer: A. Assessing the client to rule out possible complications secondary to
surgery
The nurse immediate action should be assess the client in an attempt to exclude possible
complications that may be causing the client’s complaints. The health care provider
ordered the pain medication for routine postoperative pain that is expected after
abdominal surgery, not for such complications as hemorrhage, infection, or dehiscence.
The nurse should never administer pain medication without assessing the client first.
Obtaining an order for a strong medication may be appropriate after the nurse assesses
the client and checks the chart to see whether the current analgesic is infective. Checking
the client’s chart is appropriate after the nurse determines that the client is not
experiencing complications from surgery. Pain is subjective, and each person has his own
level of pain tolerance. The nurse must always believe the client’s complaint of pain.
Deep pain has a slow onset, is diffuse, and radiates, and is marked by somatic pain from
organs in any body activity. Acute pain is rapid in onset, usually temporary (less than 6
months), and subsides spontaneously. Chronic pain is marked by gradual onset and
lengthy duration (more than 6 months). Superficial pain has abrupt onset with sharp,
stinging quality.
Aspirin raises the pain threshold and, although range-of-motion exercises hurt, mild
exercise can relieve pain on rising. Strict limitation of motion only increases the client’s
pain. Having others transfer the client into a wheelchair does not increase his feelings of
dependency. Massage increases inflammation and should be avoided with this client.
Type A-delta fibers conduct impulses at a very rapid rate and are responsible for
transmitting acute sharp pain signals from the peripheral nerves to the spinal cord. Only
type A-delta fibers transmit sharp, piercing pain. Somatic efferent fibers affect the
voluntary movement of skeletal muscles and joints. Type C fibers transmit sensory input
at a much slower rate and produce a slow, chronic type of pain. The autonomic system
regulates involuntary vital functions and organ control such as breathing.
A. A cotton ball
B. A penlight
C. An ophthalmoscope
D. A tongue depressor and flashlight
A. Administer insulin
B. Administer oxygen
C. Feed the infant glucose water (10%)
D. Place infant in a warmer
4. What question would be most important to ask a male client who is in for a digital
rectal examination?
5. The nurse assesses a prolonged late deceleration of the fetal heart rate while the
client is receiving oxytocin (Pitocin) IV to stimulate labor. The priority nursing
intervention would be to:
A. Head circumference of 40 cm
B. Chest circumference of 32 cm
C. Acrocyanosis and edema of the scalp
D. Heart rate of 160 and respirations of 40
A. Tells her child that if he does not sit down and shut up she will leave him there.
B. Explains that the injection will burn like a bee sting.
C. Tells her child that the injection can be given while he’s in her lap
D. Reassures child that it is acceptable to cry.
10. During the history, which information from a 21-year-old client would indicate a
risk for development of testicular cancer?
A. Genital Herpes
B. Hydrocele
C. Measles
D. Undescended testicle
11. 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?
12. When observing 4-year-old children playing in the hospital playroom, what
activity would the nurse expect to see the children participating in?
13. The nurse is teaching the parents of a 3 month-old infant about nutrition. What
is the main source of fluids for an infant until about 12 months of age?
A. Formula or breastmilk
B. Dilute nonfat dry milk
C. Warmed fruit juice
D. Fluoridated tap water
14. While the nurse is administering medications to a client, the client states “I do
not want to take that medicine today.” Which of the following responses by the
nurse would be best?
A. “That’s OK, its alright to skip your medication now and then.”
B. “I will have to call your doctor and report this.”
C. “Is there a reason why you don’t want to take your medicine?”
D. “Do you understand the consequences of refusing your prescribed treatment?”
15. The nurse is assessing a 4 month-old infant. Which motor skill would the nurse
anticipate finding?
A. Hold a rattle
B. Bang two blocks
C. Drink from a cup
D. Wave “bye-bye”
16. The nurse should recognize that all of the following physical changes of the head
and face are associated with the aging client except:
17. All of the following characteristics would indicate to the nurse that an elder
client might experience undesirable effects of medicines except:
19. Which of these statements, when made by the nurse, is most effective when
communicating with a 4-year-old?
20. A 64-year-old client scheduled for surgery with a general anesthetic refuses to
remove a set of dentures prior to leaving the unit for the operating room. What
would be the most appropriate intervention by the nurse?
A. Explain to the client that the dentures must come out as they may get lost or broken in
the operating room
B. Ask the client if there are second thoughts about having the procedure
C. Notify the anesthesia department and the surgeon of the client’s refusal
D. Ask the client if the preference would be to remove the dentures in the operating room
receiving area
21. The nurse is assessing a client who states her last menstrual period was March
17, and she has missed one period. She reports episodes of nausea and vomiting.
Pregnancy is confirmed by a urine test. What will the nurse calculate as the
estimated date of delivery (EDD)?
A. November 8
B. May 15
C. February 21
D. December 24
22. The family of a 6-year-old with a fractured femur asks the nurse if the child’s
height will be affected by the injury. Which statement is true concerning long bone
fractures in children?
23. A client is admitted to the hospital with a history of confusion. The client has
difficulty remembering recent events and becomes disoriented when away from
home. Which statement would provide the best reality orientation for this client?
24. When a client wishes to improve the appearance of their eyes by removing excess
skin from the face and neck, the nurse should provide teaching regarding which of
the following procedures?
A. Dermabrasion
B. Rhinoplasty
C. Blepharoplasty
D. Rhytidectomy
25. A woman who is six months pregnant is seen in antepartal clinic. She states she
is having trouble with constipation. To minimize this condition, the nurse should
instruct her to
A. increase her fluid intake to three liters/day.
B. request a prescription for a laxative from her physician.
C. stop taking iron supplements.
D. take two tablespoons of mineral oil daily.
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Cranial nerves 9 and 10 are the glossopharyngeal and vagus nerves. The gag reflex would
be evaluated.
Providing information for the client is the best technique for a new diagnosis.
4. Answer: A. “Have you noticed a change in the force of the urinary system?”
This change would be most indicative of a potential complication with (BPH) benign
prostate hypertrophy.
Stopping the infusion will decrease contractions and possibly remove uterine pressure on
the fetus, which is a possible cause of the deceleration.
6. Answer: B. Place medication in an empty nipple
Tactile stimulation is imperative for an infant’s normal emotional development. After the
trauma of surgery, sensory deprivation can cause failure to thrive.
9. Answer: A. Tells her child that if he does not sit down and shut up she will leave
him there.
Threatening a child with abandonment will destroy the child’s trust in his family.
Undescended testicles make the client high risk for testicular cancer. Mumps,
inguinal hernia in childhood, orchitis, and testicular cancer in the contralateral testis are
other predisposing factors.
Auscultate the mass. Auscultation of the abdomen and finding a bruit will confirm the
presence of an abdominal aneurysm and will form the basis of information given to the
provider. The mass should not be palpated because of the risk of rupture.
12. Answer: D. Playing cooperatively with other preschoolers
Playing cooperatively with other preschoolers. Cooperative play is typical of the late
preschool period.
Formula or breast milk are the perfect food and source of nutrients and liquids up to 1
year of age.
14. Answer: C. “Is there a reason why you don’t want to take your medicine?”
When a new problem is identified, it is important for the nurse to collect accurate
assessment data. This is crucial to ensure that client needs are adequately identified in
order to select the best nursing care approaches. The nurse should try to discover the
reason for the refusal which may be that the client has developed untoward side effects.
The age at which a baby will develop the skill of grasping a toy with help is 4 to 6
months.
The nose and ears of the aging client actually become longer and broader. The chin line is
also altered. Wrinkles on the face become more pronounced and tend to take on the
general mood of the client over the years. For example laugh or frown wrinkles about the
eyebrows, lips, cheeks, and outer edges of the eye orbit. The change in the androgen-
estrogen ratio causes an increase in growth of facial hair in most older adults. The aging
process shortens the platysma muscle, which contributes to neck wrinkles.
The nurse should anticipate that the infant may have fetal alcohol syndrome and should
assess for signs and symptoms of it. These include the characteristics listed in choice A.
Four-year-olds are egocentric and interested in having the focus on themselves. They will
not be interested in what it feels like to other children. Preschoolers are concrete thinkers
and would literally interpret any analogies so they are not helpful in explaining
procedures. Assurance of confidential communication is most appropriate for the
adolescent. In addition, confidentiality is not maintained if the child plans to harm
themselves, harm someone else, or discloses abuse.
20. Answer: D. Ask the client if the preference would be to remove the dentures in
the operating room receiving area
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Clients anticipating surgery may experience a variety of fears. This choice allows the
client control over the situation and fosters the client’s sense of self-esteem and self-
concept.
22. Answer: B. Epiphyseal fractures often interrupt a child’s normal growth pattern
23. Answer is D. “Good morning. You’re in the hospital. I am your nurse Elaine
Jones.”
As cognitive ability declines, the nurse provides a calm, predictable environment for the
client. This response establishes time, location and the caregiver’s name.
Rhytidectomy is the procedure for removing excess skin from the face and neck. It is
commonly called a face lift. Dermabrasion involves the spraying of a chemical to cause
light freezing of the skin, which is then abraded with sandpaper or a revolving wire
brush. It is used to remove facial scars, severe acne, and pigment from tattoos.
Rhinoplasty is done to improve the appearance of the nose and involves reshaping the
nasal skeleton and overlying skin. Blepharoplasty is the procedure that removes loose and
protruding fat from the upper and lower eyelids.
In pregnancy, constipation results from decreased gastric motility and increased water
reabsorption in the colon caused by increased levels of progesterone. Increasing fluid
intake to three liters a day will help prevent constipation. The client should increase fluid
intake, increase roughage in the diet, and increase exercise as tolerated. Laxatives are not
recommended because of the possible development of laxative dependence or abdominal
cramping. Iron supplements are necessary during pregnancy, as ordered, and should not
be discontinued. The client should increase fluid intake, increase roughage in the diet,
and increase exercise as tolerated. Laxatives are not recommended because of the
possible development of laxative dependence or abdominal cramping. Mineral oil is
especially bad to use as a laxative because it decreases the absorption of fat-soluble
vitamins (A, D, E, K) if taken near mealtimes.
1. The nurse is caring for an elderly woman who has had a fractured hip repaired.
In the first few days following the surgical repair, which of the following nursing
measures will best facilitate the resumption of activities for this client?
2. What do you think is the most important nursing order in a client with major
head trauma who is about to receive bolus enteral feeding?
4. Which of the following interventions will help lessen the effect of GERD (acid
reflux)?
A. Elevate the head of the bed on 4-6 inch blocks.
B. Lie down after eating.
C. Increase fluid intake just before bedtime.
D. Wear a girdle.
6. Which of the following foods should be avoided by clients who are prone to
develop heartburn as a result of gastroesophageal reflux disease (GERD)?
A. Lettuce
B. Eggs
C. Chocolate
D. Butterscotch
8. Which of the following should be included in a plan of care for a client who is
lactose intolerant?
A. Remove all dairy products from the diet.
B. Frozen yogurt can be included in the diet.
C. Drink small amounts of milk on an empty stomach.
D. Spread out selection of dairy products throughout the day.
A. costs less.
B. restricts movement and decreases.
C. gives client control over pain syndrome.
D. allows the family to care for the patient at home.
11. The nurse is instructing a 65-year-old female client diagnosed with osteoporosis.
The most important instruction regarding exercise would be to
12. A client in a long term care facility complains of pain. The nurse collects data
about the client’s pain. The first step in pain assessment is for the nurse to
A. 3 oz. broiled fish, 1 baked potato, ½ cup canned beets, 1 orange, and milk
B. 3 oz. canned salmon, fresh broccoli, 1 biscuit, tea, and 1 apple
C. A bologna sandwich, fresh eggplant, 2 oz fresh fruit, tea, and apple juice
D. 3 oz. turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange
15. A nurse is assessing several clients in a long term health care facility. Which
client is at highest risk for development of decubitus ulcers?
16. Mrs. Kennedy had a CVA (cerebrovascular accident) and has severe right-sided
weakness. She has been taught to walk with a cane. The nurse is evaluating her use
of the cane prior to discharge. Which of the following reflects correct use of the
cane?
A. Holding the cane in her left hand, Mrs. Kennedy moves the cane forward first, then
her right leg, and finally her left leg
B. Holding the cane in her right hand, Mrs. Kennedy moves the cane forward first, then
her left leg, and finally her right leg
C. Holding the cane in her right hand, Mrs. Kennedy moves the cane and her right leg
forward, then moves her left leg forward.
D. Holding the cane in her left hand, Mrs. Kennedy moves the cane and her left leg
forward, then moves her right leg forward
17. The nurse is instructing a woman in a low-fat, high-fiber diet. Which of the
following food choices, if selected by the client, indicate an understanding of a low-
fat, high-fiber diet?
18. An 85-year-old male patient has been bedridden for two weeks. Which of the
following complaints by the patient indicates to the nurse that he is developing a
complication of immobility?
19. An eleven-month-old infant is brought to the pediatric clinic. The nurse suspects
that the child has iron deficiency anemia. Because iron deficiency anemia is
suspected, which of the following is the most important information to obtain from
the infant’s parents?
A. Normal dietary intake.
B. Relevant socio cultural, economic, and educational background of the family.
C. Any evidence of blood in the stools
D. A history of maternal anemia during pregnancy
20. A 46-year-old female with chronic constipation is assessed by the nurse for a
bowel training regimen. Which factor indicates further information is needed by the
nurse?
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Exercise is important to keep the joints and muscles functioning and to prevent secondary
complications. Using the overhead trapeze prevents hazards of immobility by permitting
movement in bed and strengthening of the upper extremities in preparation for
ambulation. Sitting in a wheelchair would require too great hip flexion initially. Asking
her family to visit would not facilitate the resumption of activities. Sitting in a chair
would cause too much hip flexion. The client initially needs to be in a low Fowler’s
position or taking a few steps (as ordered) with the aid of a walker.
It is important to measure intake and output, which should equal. Enteral feeding are
hyperosmotic agents pulling fluid from cells into vascular bed. Water given before
feeding will present a hyperosmotic diuresis. I and O measures assess fluid balance.
3. Answer: C. portal hypertension
Esophageal varices results from increased portal hypertension. In portal hypertension, the
liver cannot accept all of the fluid from the portal vein. The excess fluid will back flow to
the vessels with lesser pressure, such as esophageal veins or rectal veins causing
esophageal varices or hemorrhoids.
Elevation of the head of the bed allows gravity to assist in decreasing the backflow of
acid into the esophagus. Fluid does not flow uphill. The other three options all increase
fluid backflow into the esophagus through position or increasing abdominal pressure.
Particularly in the elderly adults, therapeutic massage will help improve circulation
and muscle tone as well as the personal attention and social interaction that a good
massage provides. A massage is contraindicated in any condition where massage to
damaged tissue can dislodge a blood clot.
6. Answer: C. Chocolate
Ingestion of chocolate can reduce lower esophageal sphincter (LES) pressure leading to
reflux and clinical symptoms of GERD. All of the other foods do not affect LES pressure.
TPN solutions should be changed every 24 hours in order to prevent bacterial overgrowth
due to hypertonicity of the solution. Option 1 is incorrect; medication therapy can
continue during TPN therapy. Option 3 is incorrect; flushing is not required because the
initiation of TPN does not require a client to remain on bed rest during therapy. However,
other clinical conditions of the client may affect mobility issues and warrant the client’s
being on bed rest.
Clients who are lactose intolerant can digest frozen yogurt. Yogurt products are formed
by bacterial action, and this action assists in the digestion of lactose. The freezing process
further stops bacterial action so that limited lactase activity remains. Option 1 is
incorrect; elimination of all dairy products can lead to significant clinical deficiencies of
other nutrients. Option 3 is incorrect because drinking milk on an empty stomach can
exacerbate clinical symptoms. Drinking milk with a meal may benefit the client because
other foods, (especially fat) may decrease transit time and allow for increased lactase
activity. Option 4 is incorrect because although individual tolerance should be
acknowledged, spreading out the use of known dairy products will usually exacerbate
clinical symptoms.
9. Answer: B. be lowered
There is potential for a lowered pain tolerance to exist with diminished adaptative
capacity.
Cutaneous stimulation allows the patient to have control over his pain and allows him to
be in his own environment. Cutaneous stimulation increases movement and decreases
pain.
Weight bearing exercises are beneficial in the treatment of osteoporosis. Although loss of
bone cannot be substantially reversed, further loss can be greatly reduced if the client
includes weight bearing exercises along with estrogen replacement and calcium
supplements in their treatment protocol.
Although all of the options above are correct, the first and most important piece of
information in this client’s pain assessment is what the client is telling you about the pain
–“the client’s report.”
13. Answer: B. Immobility in children has similar physical effects to those found in
adults
Care of the immobile child includes efforts to prevent complications of muscle atrophy,
contractures, skin breakdown, decreased metabolism and bone demineralization.
Secondary alterations also occur in the cardiovascular, respiratory and renal systems.
Similar effects and alterations occur in adults.
14. Answer: D. 3 oz. turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk,
and 1 orange
Canned fish and vegetables and cured meats are high in sodium. This meal does not
contain any canned fish and/or vegetables or cured meats
Weighing significantly less than ideal body weight increases the number and surface area
of bony prominences which are susceptible to pressure ulcers. Thus, malnutrition is a
major risk factor for decubitus, due in part to poor hydration and inadequate protein
intake.
16. Answer: A. Holding the cane in her left hand, Mrs. Kennedy moves the cane
forward first, then her right leg, and finally her left leg
When a person with weakness on one side uses a cane, there should always be two points
of contact with the floor. When Mrs. Kennedy. moves the cane forward, she has both feet
on the floor, providing stability. As she moves the weak leg, the cane and the strong leg
provide support. Finally, the cane, which is even with the weak leg, provides stability
while she moves the strong leg. She should not hold the cane with her weak arm. The use
of the cane requires arm strength to ensure that the cane provides adequate stability when
standing on the weak leg. The cane should be held in the left hand, the hand opposite the
affected leg. If Mrs. Kennedy. moved the cane and her strong foot at the same time, she
would be left standing on her weak leg at one point. This would be unstable at best; at
worst, impossible
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17. Answer: B. Vegetable soup made with vegetable stock, carrots, celery, and
legumes served with toasted oat bread
Mayonnaise in tuna salad is high in fat. The whole wheat bread has some fiber. This
choice shows a low-fat soup (which would have been higher in fat if made with chicken
or beef stock) and high-fiber bread and soup contents (both the vegetables and the
legumes). Salad is high in fiber, but hard boiled eggs are high in fat. There is some fiber
in the apples and walnuts. The walnuts are high in fat, as is the chicken.
Stiffness of a joint may indicate the beginning of a contracture and/or early muscle
atrophy. Soreness of the gums is not related to immobility. Short-term memory loss is not
related to immobility. Decreased appetite is unlikely to be related to immobility.
Iron deficiency anemia occurs commonly in children 6 to 24 months of age. For the first
4 to 5 months of infancy iron stores laid down for the baby during pregnancy are
adequate. When fetal iron stores are depleted, supplemental dietary iron needs to be
supplied to meet the infant’s rapid growth needs. Iron deficiency may occur in the infant
who drinks mostly milk, which contains no iron, and does not receive adequate dietary
iron or supplemental iron. Daily dietary intake is much more related to the diagnosis of
iron deficiency anemia than is sociocultural, economic, and educational background of
the family. Iron deficiency anemia in an infant is very unlikely to be related to
gastrointestinal bleeding. Anemia during pregnancy is unlikely to be the cause of the
infant’s iron deficiency anemia. Fetal iron stores are drawn from the mother even if she is
anemic.
Foods high in bulk are appropriate. Exercise should be a part of a bowel training regimen.
To assess the client for a bowel training program the factors causing the bowel alteration
should be assessed. A routine for bowel elimination should be based on the client’s
previous bowel habits and alterations in bowel habits that have occurred because of
illness or trauma. The client and the family should assist in the planning of the program
which should include foods high in bulk, adequate exercise, and fluid intake of 2500-
3000 ml.
A. Avoid bathing the patient until the condition is remedied, and notify the physician
B. Ask the physician to refer the patient to a dermatologist, and suggest that the patient
wear home-laundered sleepwear
C. Consult the dietitian about increasing the patient’s fat intake, and take necessary
measures to prevent infection
D. Encourage the patient to increase his fluid intake, use non-irritating soap when bathing
the patient, and apply lotion to the involved areas
2. When bathing a patient’s extremities, the nurse should use long, firm strokes
from the distal to the proximal areas. This technique:
A. Provides an opportunity for skin assessment
B. Avoids undue strain on the nurse
C. Increases venous blood return
D. Causes vasoconstriction and increases circulation
A. Stage I non-REM
B. Rapid eye movement (REM) stage
C. Stage II non-REM
D. Delta stage
4. The natural sedative in meat and milk products (especially warm milk) that can
help induce sleep is:
A. Flurazepam
B. Temazepam
C. Tryptophan
D. Methotrimeprazine
5. Nursing interventions that can help the patient to relax and sleep restfully include
all of the following except:
6. Restraints can be used for all of the following purposes except to:
A. Prevent a confused patient from removing tubes, such as feeding tubes, I.V. lines, and
urinary catheters
B. Prevent a patient from falling out of bed or a chair
C. Discourage a patient from attempting to ambulate alone when he requires assistance
for his safety
D. Prevent a patient from becoming confused or disoriented
9. A terminally ill patient usually experiences all of the following feelings during the
anger stage except:
A. Rage
B. Envy
C. Numbness
D. Resentment
10. Nurses and other health care provides often have difficulty helping a terminally
ill patient through the necessary stages leading to acceptance of death. Which of the
following strategies is most helpful to the nurse in achieving this goal?
A. Taking psychology courses related to gerontology
B. Reading books and other literature on the subject of thanatology
C. Reflecting on the significance of death
D. Reviewing varying cultural beliefs and practices related to death
11. Which of the following symptoms is the best indicator of imminent death?
12. A nurse caring for a patient with an infectious disease who requires isolation
should refers to guidelines published by the:
13. To institute appropriate isolation precautions, the nurse must first know the:
14. Which is the correct procedure for collecting a sputum specimen for culture and
sensitivity testing?
A. Have the patient place the specimen in a container and enclose the container in a
plastic bag
B. Have the patient expectorate the sputum while the nurse holds the container
C. Have the patient expectorate the sputum into a sterile container
D. Offer the patient an antiseptic mouthwash just before he expectorate the sputum
16. The best way to decrease the risk of transferring pathogens to a patient when
removing contaminated gloves is to:
17. After having an I.V. line in place for 72 hours, a patient complains of tenderness,
burning, and swelling. Assessment of the I.V. site reveals that it is warm and
erythematous. This usually indicates:
A. Infection
B. Infiltration
C. Phlebitis
D. Bleeding
19. The nurse is teaching a patient to prepare a syringe with 40 units of U-100
NPH insulin for self-injection. The patient’s first priority concerning self-injection
in this situation is to:
20. The physician’s order reads “Administer 1 g cefazolin sodium (Ancef) in 150 ml
of normal saline solution in 60 minutes.” What is the flow rate if the drop factor is
10 gtt = 1 ml?
A. 25 gtt/minute
B. 37 gtt/minute
C. 50 gtt/minute
D. 60 gtt/minute
21. A patient must receive 50 units of Humulin regular insulin. The label reads 100
units = 1 ml. How many milliliters should the nurse administer?
A. 0.5 ml
B. 0.75 ml
C. 1 ml
D. 2 ml
22. How should the nurse prepare an injection for a patient who takes both regular
and NPH insulin?
A. Draw up the NPH insulin, then the regular insulin, in the same syringe
B. Draw up the regular insulin, then the NPH insulin, in the same syringe
C. Use two separate syringe
D. Check with the physician
23. A patient has just received 30 mg of codeine by mouth for pain. Five minutes
later he vomits. What should the nurse do first?
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25. A staff nurse who is promoted to assistant nurse manager may feel
uncomfortable initially when supervising her former peers. She can best decrease
this discomfort by:
1. Answer: D. Encourage the patient to increase his fluid intake, use non-irritating
soap when bathing the patient, and apply lotion to the involved areas
Dry skin will eventually crack, ranking the patient more prone to infection. To prevent
this, the nurse should provide adequate hydration through fluid intake, use nonirritating
soaps or no soap when bathing the patient, and lubricate the patient’s skin with lotion.
Bathing may be limited but need not be avoided entirely. The attending physician and
dietitian may be consulted for treatment, but home-laundered items usually are not
necessary.
Washing from distal to proximal areas stimulates venous blood flow, thereby preventing
venous stasis. It improves circulation but does not result in vasoconstriction. The nurse
can assess the patient’s condition throughout the bath, regardless of washing technique,
and should feel no strain while bathing the patient.
Other characteristics of rapid eye movement (REM) sleep are deep sleep (the patient
cannot be awakened easily), depressed muscle tone, and possibly irregular heart and
respiratory rates. Non-REM sleep is a deep, restful sleep without dreaming. Delta stage,
or slow-wave sleep, occurs during non-REM Stages III and IV and is often equated with
quiet sleep.
4. Answer: C. Tryptophan
Tryptophan is a natural sedative; flurazepam (Dalmane), temazepam (Restoril), and
methotrimeprazine (Levoprome) are hypnotic sedatives.
5. Answer: A. Have the patient take a 30- to 60-minute nap in the afternoon
Napping in the afternoon is not conductive to nighttime sleeping. Quiet music, watching
television, reading, and massage usually will relax the patient, helping him to fall asleep.
By restricting a patient’s movements, restraints may increase stress and lead to confusion,
rather than prevent it. The other choices are valid reasons for using restraints.
When applying restraints, the nurse must document the type of behavior that prompted
her to use them, document the type of restraints used, and obtain a physician’s written
order for the restraints.
Kubler-Ross’s five successive stages of death and dying are denial, anger, bargaining,
depression, and acceptance. The patient may move back and forth through the different
stages as he and his family members react to the process of dying, but he usually goes
through all of these stages to reach acceptance.
9. Answer: C. Numbness
Numbness is typical of the depression stage, when the patient feels a great sense of loss.
The anger stage includes such feelings as rage, envy, resentment, and the patient’s
questioning “Why me?”
10. Answer: C. Reflecting on the significance of death
Fixed, dilated pupils are sign of imminent death. Pulse becomes weak but rapid, muscles
become weak and atonic, and periods of apnea occur during respiration.
The Center of Disease Control (CDC) publishes and frequently updates guidelines on
caring for patients who require isolation. The National League of Nursing’s (NLN’s)
major function is accrediting nursing education programs in the United States. The
American Medical Association (AMA) is a national organization of physicians. The
American Nurses’ Association (ANA) is a national organization of registered nurses.
Before instituting isolation precaution, the nurse must first determine the organism’s
mode of transmission. For example, an organism transmitted through nasal secretions
requires that the patient be kept in respiratory isolation, which involves keeping the
patient in a private room with the door closed and wearing a mask, a gown, and gloves
when coming in direct contact with the patient. The organism’s Gram-straining
characteristics reveal whether the organism is gram-negative or gram-positive, an
important criterion in the physician’s choice for drug therapy and the nurse’s
development of an effective plan of care. The nurse also needs to know whether the
organism is susceptible to antibiotics, but this could take several days to determine; if she
waits for the results before instituting isolation precautions, the organism could be
transmitted in the meantime. The patient’s susceptibility to the organism has already been
established. The nurse would not be instituting isolation precautions for a non-infected
patient.
14. Answer: C. Have the patient expectorate the sputum into a sterile container
Placing the specimen in a sterile container ensures that it will not become contaminated.
The other answers are incorrect because they do not mention sterility and because
antiseptic mouthwash could destroy the organism to be cultured (before sputum
collection, the patient may use only tap water for nursing the mouth).
16. Answer: C. Gently pull just below the cuff and invert the gloves when removing
them
Turning the gloves inside out while removing them keeps all contaminants inside the
gloves. They should then be placed in a plastic bag with soiled dressings and discarded in
a soiled utility room garbage pail (double bagged). The other choices can spread
pathogens within the environment.
Tenderness, warmth, swelling, and, in some instances, a burning sensation are signs and
symptoms of phlebitis. Infection is less likely because no drainage or fever is present.
Infiltration would result in swelling and pallor, not erythema, near the insertion site. The
patient has no evidence of bleeding.
18. Answer: B. Roll the vial gently between the palms
Gently rolling a sealed vial between the palms produces sufficient heat to enhance
dissolution of a powdered medication. Shaking the vial vigorously can break down the
medication and alter its pharmacologic action. Inverting the vial or leaving it alone does
not ensure thorough homogenization of the powder and the solvent.
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19. Answer: C. Check the syringe to verify that the nurse has removed the
prescribed insulin dose
When the nurse teaches the patient to prepare an insulin injection, the patient’s first
priority is to validate the dose accuracy. The next steps are to select the site, assess the
site, and clean the site with alcohol before injecting the insulin.
22. Answer: B. Draw up the regular insulin, then the NPH insulin, in the same
syringe
Drugs that are compatible may be mixed together in one syringe. In the case of insulin,
the shorter-acting, clear insulin (regular) should be drawn up before the longer-acting,
cloudy insulin (NPH) to ensure accurate measurements.
After a patient has vomited, the nurse must inspect the emesis to document color,
consistency, and amount. In this situation, the patient recently ingested medication, so the
nurse needs to check for remnants of the medication to help determine whether the
patient retained enough of it to be effective. The nurse must then notify the physician,
who will decide whether to repeat the dose or prescribe an antiemetic.
A 24-hour urine output of less than 500 ml in an adult is considered inadequate and may
indicate kidney failure. This must be corrected while the patient is in the acute state so
that appropriate fluids, electrolytes, and medications can be administered and excreted.
Indwelling catheterization is not needed to diagnose trauma, urinary tract infection, or
residual urine.
25. Answer: B. Making changes after evaluating the situation and having
discussions with the staff.
A new assistant nurse manager should not make changes until she has had a chance to
evaluate staff members, patients, and physicians. Changes must be planned thoroughly
and should be based on a need to improve conditions, not just for the sake of change.
Written assignments allow all staff members to know their own and others
responsibilities and serve as a checklist for the manager, enabling her to gauge whether
the unit is being run effectively and whether patients are receiving appropriate care.
Telling the staff nurses that she is making changes to benefit their performance should
occur only after the nurse has made a thorough evaluation. Evaluations are usually done
on a yearly basis or as needed.