FUNDAMENTALS oI Nursing

1. A postpartum mother notiIies the nursery that the wrong baby was brought to her hospital room. The nurse who is in charge oI the newborn
nursery determines that 2 babies were placed in the wrong cribs. What would be the most appropriate action by the nurse?
a. Record the event in an accident / variance report and notiIy the nursing supervisor.
b. Reassure both mothers, report to the charge nurse, and do not record.
c. Determine who is responsible Ior the mistake and terminate his or her employment.
d. Record detailed notes oI the event on the mother`s medical record.

RATIONALE: A. Every incident that exposes a patient to harm should be recorded in an incident reports as well as reported to the appropriate
supervisors in order to resolve the current problem and permit the institution to prevent the problem Irom happening again. Option B is incorrect
because the harm to Iuture patients is not prevented, as would be the case iI an incident report was Iiled. Option C is incorrect because it is
usually not the role oI the nurse alone to terminate employment, and termination oI employment may not be indicated by this incident. Option D
is incorrect because, recording the event on the medical record does not adequately put the hospital on notice oI potential harm to patients.

(p.72 & 77, Davis`, 2001)


2. The nurse on the medical surgical unit is giving medications at 8 AM. The nurse enters the room oI a patient, calls the client by name, checks the
name band Ior accuracy, and administers an oral vitamin. AIter the client swallows the pill, she states that another nurse has also given her this
same pill just 1 hour ago. The nurse checks the medication record and Iinds that another nurse has signed oII the drug entry. What would be the
appropriate action Ior the nurse to do?
a. Report the Iirst nurse to the nurse manager Ior not inIorming the medication nurse that a drug had seen given.
b. Submit an incident report describing the circumstances oI the medication error.
c. Do nothing because the patient was not harmed by the second vitamin.
d. NotiIy the patient`s and ask Ior advice.



RATIONALE: B. It is a legal and ethical obligation oI the nurse to report incidents such as medication errors that expose a patient to harm.
Failing to check the medication record to see iI a drug had been is a Iorm oI medication error. Option A is incorrect because it Iails to discharge
the legal and ethical obligation oI the nurse to report a medication error. Option C is incorrect because actual harm to the patient is not a pre
requisite Ior Iiling an incident report, and Iailure to report the incident does nothing to prevent Iuture incidents. Option D is incorrect because it
is not the legal and ethical obligation oI the physician to inIorm the nurse about the need to report a medication error.

(p.72 & 77, Davis`, 2001)


3. At the beginning oI the shiIt, it was discovered by the nurse that an incorrect IV solution was running. AIter changing the solution to the correct
order, an appropriate nursing action would be to:

a. Report the discovery oI the error to the supervisor.
b. Document ht error and correction in the medical ward.
c. Fill out an incident report according to hospital policy.
d. Assure the patient that the error had no adverse eIIects.

RATIONALE: C. A quality assurance report or incident report should be completed and submitted according to hospital policy, as soon as
possible. The report would indicate that the MD was notiIied, the status oI the patient, and any orders as a result oI the error. The supervisor
(Option A) should be notiIied, but NOT BEFORE completing the incident report. It is also most important to notiIy the MD beIore completing
the report. Incidents are not usually documented in the patient (medical) record (Option B). II unsure oI the hospital policy, hospital risks
management should be consulted. Open communication with patients is important (Option D; however, unless there was an advise eIIect that
required additional treatment or a change in treatment, it is unlikely that the physician will inIorm the patient.

(p. 73 & 78, Davis`, 2001)
4. You are caring Ior a client who has been admitted Ior knee arthroscopy and you are reviewing the complete blood count oI the client. Which value
is most important to report to the physician prior to surgery?
a. White blood cell count 16,000 / mm
3

b. Hematocrit 33
c. Platelet count 426,000 / mm
3
d. Hemoglobin 10.9 g / dl

RATIONALE: A. An elevation in white blood cells may indicate that the client has an inIection, which would likely require rescheduling oI the
surgical procedure. The other values are slightly abnormal, but would not be likely to cause post-operative problems Ior a knee arthroscopy.

(p. 43 & 181, Prioritization, Delegation, & Assignment, 2006)


5. Which laboratory value indicates sepsis, excess starvation, dehydration, and cardiac Iailure?
a. Serum creatinine, 2.4mg / dL
b. Albumin, 10g / dL
c. WBC, 19,000 cells / L
d. BUN, 32mg / dL

RATIONALE: D. Blood urea nitrogen (BUN) is a measure oI renal Iunction because urea is the primary and product oI protein metabolism and is
excreted by the kidneys. An elevated BUN level may indicate impaired renal Iunction (slowing oI the glomerular Iiltration rate), although it is
not speciIic Ior the kidneys. BUN may be elevated because oI systematic Iactors such as sepsis, excess protein consumption, starvation,
dehydration, and cardiac Iailure. Normal value is 8-25mg / dL.

(p. 798, Medical - Surgical Nursing, Black, 2005)

Option A is elevated serum creatinine; normal value is 0.6 1.3mg / dL. Creatinine is a speciIic indicator oI renal Iunction. Option B is elevated
albumin; normal value is 3.4 5g / dL. As the main plasma protein, it maintains oncotic pressure oI the blood vessel. Option C is elevated
WBC; normal value is 4,500 11,000 cells / L.

(p. 116, 118 119, Saunder`s, 2005)


6. What should the drip rate be when the nurse reads the order Ior ' AnceI 1 gram IV in 50cc 5 dextrose (D
5
W) to run in over 30 minutes every 6
hours and the administration set delivers 10 gtts / cc?
a. 8 gtts / min
b. 15 gtts / min
c. 17 gtts / min
d. 25 gtts / min

RATIONALE: C.
Total volume inIused x drop Iactor gtts per minute
Time in minutes

50cc x 10 gtts 16.6 17 gtts / min
30 minutes 1cc

(p. 23, NSNA, Stein, 2005)

7. Which oI the Iollowing consists a group oI Iood sources oI cobalamin?
a. Lean pork, Whole grains (cereals), Legumes, Seeds, Nuts, Cooked dry beans, Soy milk
b. Enriched whole grains, Peas, Nuts, CoIIee, Product 19 total, Chicken breast, Liver, Pickled herring, Tuna
c. Milk, Meats (lean), Enriched cereals, Green leaIy vegetables, Cheese (ricotta, cottage), Fish, Grains
d. Meat, Liver, Poultry, Fish, ShellIish

RATIONALE: D. Meat, Liver, Poultry, Fish, and shellIish are Iood sources oI Vit. B
12.
Option A are Iood sources oI Vit. B
1
. (Thiamine). Option B
are Iood sources oI Vit. B
3
. (Niacin). Option C. are Iood sources oI Vit. B
2
(RiboIlavin)

(p. 32, Nutrition Ior Nursing Practice, 2004) (p. 5-6, Nutri Notes, 2004)
(p. 129, Saunder`s, 2005)

8. The nurse is discontinuing an intravenous inIusion. In withdrawing the needle or catheter Irom the vein, what is the saIety precaution that the nurse
must perIorm?
a. Immediately apply Iirm pressure to the site, using sterile gauze, Ior 2-3 minutes.
b. Withdraw the needle or catheter by pulling it out along the line oI the vein.
c. Hold the client`s arm or leg above the body iI any bleeding persists.
d. Clamp the inIusion tubing.
RATIONALE: B. Option B is a saIety precaution in withdrawing the needle or catheter Irom the vein because pulling out in line with the vein avoids
INJURY to the vein. Option A is done AFTER the needle or catheter is withdrawn Irom the vein. Option C would only be perIormed iI any
bleeding persists. Option D is part oI preparation oI equipment in discontinuing an intravenous inIusion.

(p. 1108, Fundamentals oI Nursing, Kozier, 2002)


9. Which value oI urine speciIic gravity is consistent with these causes oI abnormal values: diabetes mellitus and iodine contrast?
a. Fixed at 1.010
b. 1.010
c. 1.021
d. 1.040

RATIONALE: D. Normal values Ior urine speciIic gravity

Year oI Copyright Book Normal Values
2005 Medical Surgical Nursing 1.001-1.035
2005 Saunder`s 1.016-1.022
2003 RNotes 1.005-1.030
2001 Lippincott Manual oI Nursing
Practice
1.005-1.025

Causes oI increased abnormal values are: dehydration, diabetes mellitus, increased ADH secretion, iodine contrast. Clients with extensive
tubular damage (Chronic renal Iailure) or endocrine disease involving ADH insuIIiciency have speciIic gravity Iixed at 1.010 the level oI the
plasma. Clients who have diabetes insipidus consistently have speciIic gravity values less than 1.010.

Causes oI decreased abnormal values are: increased Iluid intake, diuretics, decreased renal concentration diabetes insipidus.

(p. 796, Medical Surgical Nursing, 2005)


10. A nurse is assigned to a client being prepared Ior a thoracentesis. A nurse assists the client to which position appropriate Ior the procedure?
a. Lying in bed on the aIIected side
b. Prone with the bed turned to the side and supported by a pillow
c. On bed, side- lying on the unaIIected side
d. Sim`s position with the head oI the bed Ilat

RATIONALE: C. to Iacilitate removal oI Iluid Irom the chest wall, the client is positioned sitting at the edge oI the bed leaning over the bedside table
with the Ieet supported on a stool or lying in bed on the unaIIected side with the head oI the bed elevated 30 to 45. The prone and Sim`s
positions are inappropriate positions Ior this procedure.


11. A client was admitted in the recovery aIter a surgery. He was attached to a pulse oximeter. What is the primary purpose oI attaching pulse
oximeter to the client?
A. To assess the arterial blood oxygen saturation
B. To monitor the partial pressure oI carbon dioxide in the blood
C. To assess the client`s hemoglobin and hematocrit status
D. To monitor the client`s level oI consciousness
Rationale: A. (Delmar`s Fundamental and Advanced Nursing Skills, 2
nd
Edition, p. 907)
Pulse oximetry is a quick, non-invasive method to assess the arterial blood oxygen saturation oI a client by using an external sensors.

12. A nurse is discussing to a group oI nursing students about the ways to administer intramuscular injection. One student ask about what are the
other sites Ior an IM injection aside Irom the deltoid region. The nurse would exclude which oI the Iollowing?
A. Vastus lateralis C. Dorsogluteal
B. Ventrogluteal D. Abdomen
Rationale: D. (Delmar`s Fundamentals and Advance Nursing Skills, p. 619-620) The most common site Ior IM injection are vastus lateralis,
ventrogluteal, dorsogluteal, and the deltoid muscle

13. A nurse obtains an order Iorm the physician to restrain a client. The nurse instructs the nursing assistant to apply restraints to the client. Which oI
the Iollowing observations indicate improper understanding oI the nursing assistant in the use oI restrains? Select all that apply.
A. Removing restraints Irom 10m minutes every 2 hours Ior range-oI-motion exercises.
B. Restrain straps are saIely secured in the side rails
C. The nursing assistant uses saIety knot in securing the restrain straps in the bed Irame.
D. Allowing enough space between the restrains and skin Ior movement.
Rationale: B. (Saunders/Silvestre, 3
rd
Ed., p. 179) restrain straps should be securely attached to the bed Irame and not in the side rails to prevent
injury in the event the side rails is released.

14. A client with cirrhosis oI the liver is scheduled Ior liver biopsy. The nurse is assisting the physician in perIorming the procedure. Which oI the
Iollowing positions will the nurse assist the client Ior this procedure?
A. Supine
B. LeIt-side lying
C. Right-side lying
D. Upright position Rationale:
Rationale: A. (Saunders/ Comprehensive 2005, p. 227) During the procedure, do the Iollowing:
-Position the client supine with the right side oI the upper abdomen exposed, the client`s arm is extended over the leIt shoulder behind the head. The
liver is located on the right side and this provide the maximal exposure to the right intercoastal space.

15. A nurse is planning to teach client with crutches how to use crutch in going up the stairs. The nurse determines that the client understand the
instructions iI he states:
A. Stepping the strong leg Iirst, Iollowed by weak leg up and the crutches.
B. LiIting the crutch Iirst, Iollowed by weak leg up and the strong leg.
C. Stepping the weak leg Iirst, Iollowed by the crutch, and the strong leg.
D. LiIting the crutch, Iollowed by strong leg, and the weak leg.
Rationale: A. (Saunders Comprehensive 2005, p. 1006) Going up stairs with crutches:
-the client moves the unaIIected leg Iirst
-moves the aIIected leg and the crutches up




16. AIter surgery the client requires a one unit oI blood because oI hemorrhage that occurred during surgery. Within 30 minutes oI hanging the
unit oI blood, the client complains oI itching and headache. Her blood pressure is 80/64. The Iirst nursing action should be to:
a. NotiIy the physician
b. Obtain a urine specimen
c. NotiIy the laboratory
d. Stop the inIusion oI blood
RATIONALE: D. This is the Iirst response to symptoms oI blood reaction. All the other measures will be done, but they should occur aIter the
blood is stopped. This action provides Ior the immediate saIety oI the client.

17. A client complains oI a throbbing headache aIter a lumbar puncture. Which action oI the nurse would be appropriate at this time?
a. Darken the client`s room and close the door
b. Keep the client Ilat on bed Ior six to eight hours aIter the procedure
c. Encourage the client to limit Iluid intake Ior eight hours aIter the procedure
d. Report the headache to the nurse in charge
RATIONALE: B. The headache Iollowing a lumbar puncture is probably due to continuing cerebrospinal Iluid (CSF) leakage through the
opening in the dura made by the needle. The headache is usually relieved when the client lies down. Increasing Iluids to 2,000-3,000 ml in 24
hours is also helpIul in replacing Iluid and CSF quickly, unless contraindicated.

18. A 39-year-old is having surgery on his bowel. The doctor orders a cleansing enema Ior the morning oI surgery. Which oI the Iollowing
nursing interventions is most appropriate?
a. Wear gloves to insert the tubing
b. Use universal precautions and provide comIort measures to help the client relax during the procedure
c. Lubricate the tubing well prior to the insertion
d. Position the client on his side and drape the client Ior warmth and privacy

RATIONALE: B. This is a comprehensive statement oI the best nursing intervention. Using universal precautions and providing comIort
measures will prevent contamination and provide Ior the well-being oI the client.

19. During the administration oI medication to a client, the priority nursing assessment is which oI the Iollowing?
a. Help the client swallow medications without aspirating by keeping the head in a neutral position
b. IdentiIy the client by checking the client`s identiIication bracelet and asking Ior his name
c. Keep all prepared medications in sight
d. Check the client Ior desired and undesired drug eIIects within an hour aIter administration oI the medication
RATIONALE: B. IdentiIication oI the client helps to ensure that the medication will be given to the right client. This is one oI the 'Iive rights
oI administering medications.

20. AIter a bronchoscopy, which assessment, iI made by the nurse, would require immediate action by the nurse?
a. Blood-tinged mucus
b. Complaints oI hoarseness when speaking
c. Irritation and discomIort when swallowing
d. DiIIiculty breathing
RATIONALE: D. This is a priority assessment that needs immediate medical treatment. The diIIiculty in breathing may be caused by edema in
the larynx or trachea and is a serious complication.

21. A 38-year-old client is admitted with PIH (pregnancy induced hypertension). The physician orders a urinalysis. When the nurse collects the
urine specimen, which oI the Iollowing measures taken by the nurse is the most important?
a. Labeling the container with the client`s room number
b. Checking the identiIication oI the client
c. Using sterile gloves when handling a urine specimen
d. Instructing the client to put the specimen on the counter a the nurses` station Ior pick-up
RATIONALE: B. In order to avoid errors, the most important thing to do is to identiIy the client. AIter the client is identiIied, the next important
action is to make sure that the specimen label has the client`s name and identiIication number.

22. The nurse is inIormed during report that a post-operative client has not voided Ior eight hours. The initial nursing action would be to:
a. Assist the client to the abdomen
b. Place the client in a bed pan and pour warm water over her perineum
c. Palpate and percuss the client`s bladder
d. Catheterize the client
RATIONALE: C. Assessing the client`s bladder provides inIormation concerning the need to void. This is the priority action and the choice that
provides Ior assessment oI the client.

23. During the administration oI a medication. A nineteen-year-old client tells the nurse that he has never had that particular pill beIore. The best
nursing action is which oI the Iollowing?
a. Check the client`s identiIication bracelet again
b. Check the physicians order to see iI this is a new medication
c. Assure the client that the medication package has his name on it
d. Ask the client to take the medication, since the identiIication bracelet and medication administration record indicate the client is to receive the
medication
RATIONALE: B. Checking the physician`s order will conIirm iI this is a new medication ordered Ior the client, and addresses the client`s
concern.

24. A 54-year-old client is hospitalized with congestive heart Iailure and is to receive an x-ray. The nurse enters the client`s room and asks the
client is she is ready to go to x-ray. The client nods her head 'yes. The initial action is which oI the Iollowing?
a. Explain the x-ray procedure to the client
b. Help the client into a wheel chair, so that she will be ready when the transporter arrives to take her to x-ray
c. Ask the client iI she has any questions
d. Look at the client`s identiIication bracelet
RATIONALE: D. Once the client`s identity is determined, the nurse can then proceed with the other options.

25. A client is admitted to the hospital Iollowing an automobile accident. The client is to have a Foley catheter inserted. The initial nursing
action when implementing this procedure is which oI the Iollowing?
a. Using sterile technique during this procedure
b. Checking the client`s identiIication
c. Placing all necessary equipment within easy reach
d. Explaining the procedure to the client
RATIONALE: B. IdentiIying the client should be done beIore any other options. II the nurse approaches the wrong client, then none oI the other
options apply.

26. A client is admitted to the hospital with abdominal pain. She tells the nurse that her Iather died recently and that she misses him. She begins
crying while talking about her Iather. The nurse`s assessment reveals that the client`s temperature is 102.6
0
F and her abdomen is soIt
without tenderness. Which oI the Iollowing actions should the nurse give immediate attention?
a. The client is crying
b. The temperature is 102.6
0
F
c. A soIt, non-tender abdomen
d. The client is grieving
RATIONALE: B. An elevated temperature may be a sign oI inIection or disease. A client with a temperature oI 102.6
0
F is not well. This may
aIIect her behavior, which may or may not be related to the death oI her Iather.

27. While getting an elderly client who is very weak out oI bed, the best nursing approach initially is:
a. Locking the wheels oI the bed
b. Placing the equipment to provide the saIest transIer that is possible Ior the client
c. Aligning the wheel chair as close to the bed as possible, to prevent the client Irom Ialling into the Iloor
d. Removing leg support on the wheel chair on the side closest to the bed
RATIONALE: B. This option is best because it emphasizes assuring the client`s saIety and is a comprehensive statement about the initial
nursing approach in transIerring a client.

28. A client is admitted with back pain. During the assessment the nurse notes his vital signs to be: temperature 103.2
0
F, pulse 90, respirations
30, and blood pressure 128/88. The initial nursing action would be:
a. Give the client some medication such as Tylenol Ior his temperature
b. NotiIy the physician oI the vital signs
c. Apply heat to the area oI pain in his back
d. Have the client lie Ilat in bed to help alleviate the pain
RATIONALE: B. Because the vital signs are not within normal limits, vital signs are the issue in this question. The key word in the stem is
'initial. The Iirst thing that the nurse should do is to notiIy the physician oI the abnormal Iindings.

29. A 60-year-old is scheduled Ior surgery tomorrow. Upon entering the client`s room, the nurse`s notices that Ilames are coming out Iorm the
waste basket. First action to take is which oI the Iollowing?
a. Place the Iolded blanket Irom the client`s bed over the entire opening oI the waste basket
b. Find the nearest Iire extinguishers to put the Iire out
c. Tell the client that he is not supposed to be smoking
d. Pull the nearest Iire alarm
RATIONALE: A. Placing the blanket over the waste basket will eliminate the source oI oxygen, which is an element Ior the Iire to burn. This is
the Iastest method in this scenario Ior putting out a small Iire.


30. The nurse Iinds an elderly client with her IV pulled out, standing next to her bed with the siderails in the up position. The client is conIused,
does not have an identiIication bracelet on, and cannot remember her name. What should the nurse do Iirst?
a. Help the client into the bed, and remind her to call the nurse when she gets out oI bed
b. Help the client into bed, and restart the IV
c. Place the restraining vest into the client
d. Put an identiIication bracelet on the client and help her back to bed
RATIONALE: C. The scenario tells you that the client got out oI a bed that had the siderails up. This is an unsaIe situation, since the client is at
risk Ior Ialling. Such an injury can be liIe-threatening. Placing a restraining vest on the client will provide Ior her saIety.

31. The nurse is assisting a Irail elderly client to eat. The client begins to choke and indicates to the nurse that she cannot talk. The Iirst nursing
action is to:
a. PerIorm the Heimlich maneuver to obtain a patent airway
b. Begin mouth to mouth resuscitation
c. Place an oxygen mask on the client
d. Go to the nurses` station to get some help
RATIONALE: A. the client is begging to choke, which is a liIe-threatening situation. PerIorming the Heimlich maneuver on this client may
alleviate the obstruction and provide the client with a patent airway.

32. A 78-year-old client has been in the hospital Ior a week on bed rest. She complains oI elbow pain. The best nursing action is to:
a. Place elbow pads on the client
b. Examine the elbow
c. Call the physician Ior an order Ior pain medication
d. Reposition the client so that she is more comIortable
RATIONALE: B. Examining the elbow is an assessment oI the client`s complaint. The nurse does not know enough about the elbow pain or its
probable cause. The elbow can be assessed Ior redness, swelling, or joint pain. Then, aIter assessing, the nurse can analyze the situation and
develop a plan oI care and implement the appropriate nursing interventions.


33. A conIused elderly client continually grabs at the nurses Irom her wheelchair. Which oI the Iollowing is the most appropriate nursing action?
a. Move the wheelchair to a location where she cannot grab people
b. Apply a chest restrain Ior her own saIety
c. Use wrist restraints and move her to the visitor`s room
d. Remove her hands and Iirmly tell her not to grab
RATIONALE: D. Setting limits by removing her hand and telling her not to grab at people is the most eIIective way oI dealing with the
behavior problem.

34. A nurse is reviewing instructions to a patient about to be discharged with a hearing aid. Which oI Iollowing instruction will the nurse provide?
A. Adjusting the volume to the maximum hearing level to prevent Ieedback squeaking.
B. Turning oII the hearing aid and remove the battery when not in use.
C. Wash the receiver regularly to maintain good ampliIication oI sounds.
D. Rubbing the receiver with oil beIore and aIter used.
Rationale: B. Hearing aid should be turned oII and batteries are removed when not in use. (Saunders 2002, p. 857)

35. A nurse is evaluating the colostomy oI a one day post operative client who had an abdominal perineal resection Ior bowel tumor. Which oI the
Iollowing assessment Iindings indicates that the colostomy is not in good condition?
A. The stoma is pink in color and slightly edematous
B. The stool is liquid in immediate post operative period
C. Output becomes more solid several days aIter the procedure
D. Stoma gradually turns into purple in color
Rationale: D. Purple-black stoma indicates compromised circulation.(Saunders 2002, p. 642)

36. The client with colon cancer has an abdominal-resection with a colostomy. Post operatively the nurse will carry out which oI the Iollowing
appropriate intervention?
A. Removed ostomy pouch as needed so that stoma can be assessed.
B. Administer 30 mL oI milk oI magnesia to stimulate colostomy activity.
C. Assist the client with warm sitz bath.
D. Maintain the client in a semi-Iowlers position
Rationale: C. Appropriate nursing interventions aIter an abdominal-perineal resection with a colostomy includes assisting the client in warm sitz bath
three to Iour times a day
to clean the perineal incision. (Lippincots, p. 336)

37. A client admitted with inIlammatory bowel disease is about to receive a total parenteral nutrition (TPN). The clients TPN solution would most
likely be composed oI.
A. A colloidal dextrose solution
B. A hypotonic solution
C. A hypertonic solution
D. An isotonic solution
Rationale: C. A TPN is usually a hypertonic glucose solution. The greater the concentration oI dextrose in the solution, the greater the tonicity.
Hypertonic glucose solutions are used to meet the body`s caloric demands in a volume oI Iluid that will not overload the cardiovascular system.
(Lippincott 8
th
Ed., p. 342)

38. A client receiving a total parenteral nutrition (TPN) should be monitored primarily Ior what complications?
A. Fluid imbalance
B. Pulmonary hypertension
C. Postural hypotension
D. Hypostatic pneumonia
Rationale: A. Clients receiving TPN are at risk Ior a number oI complications, including Iluid imbalances such as Iluid overload and hyperosmolar
diuresis. Other common complications include hyperglycemia, sepsis, pneumothorax, and air embolism. (Lippincott,,p. 536)


39. A 35-year-old is scheduled Ior colonoscopy. In planning Ior the post procedural care, the nurse recognizes that the most important to monitor
aIter the procedure is.
A. Presence oI abdominal pain
B. Signs oI rectal perIoration
C. Fever
D. Return oI bowel sounds
Rationale: B. colonoscopy post procedure intervention includes: providing bed rest until alert, monitoring Ior signs oI perIoration, instructing the
client to report any bleeding to the physician. (Saunders 2002, p. 635)

40. A nurse is giving instructions to a patient who will undergo colonoscopy. The nurse would conclude that the client still needs Iurther teaching iI
he states that:
A. Abdominal muscles may be tender Irom the procedure.
B. It is alright to drive once I`m home Ior an hour or so.
C. Its normal to Ieel gassy or bloated aIter the procedure.
D. Intake should be light at Iirst, then progress to regular intake.
Rationale: D. The client should not drive Ior several hours aIter discharge because the client would have received sedative medications during the
procedure. (Saunders 2002, p. 656).

41. Normal bowel sounds per minute.
A. 5- 34 times/minute
B. 5-25 times/minute
C. 10-34 times/minute
D. 10-25 times/minute
Rationale: A. (Incredibly Made Easy Assessment, p. 222), (MS/Black, p. 681)

42. IdentiIy the abnormal Iindings in an aged population.
A. Decreased cardiac output at rest by about 30 to 35.
B. ECG changes includes increased PR, QRS, and QT intervals.
C. Decreased height
D. Decreased anteroposterior chest diameter.
Rationale: D. ( Better Elderly Care/ Springhouse,p. 11-14).

43. Which oI the Iollowing laboratory value changes in an elderly is not expected?
A. Increased BUN
B. Decreased lymphocytes
C. Slightly increased in glucose
D. Decreased urine speciIic gravity
Rationale: C. ( Better Elderly Care/Springhouse, p. 8-9)

44. Which among the Iollowing is a corrrect technique in tracheostomy care?
a. Inserting a decannulation plug into a tracheostomy tube until cuII is deIlated and the inner cannula is removed.
b. Tying two ends using a square knot with two Iingers inserted as the knot is tied.
c. II client is allowed to eat, ensure the cuII is deIlated iI the tube is not capped.
d. . Cleanse the skin under the neck plate oI tube with cotton applicator moistened with saline water.

Rationale: B. Never insert a decannulation plug into a tracheostomy tube until cuII is deIlated and the inner cannula is removed, and cuII should be
inIlated iI the tube is not capped to prevent aspiration..(Saunders, p.221)
Skin under the neck plate should be cleansed with hydrogen peroxide and rinse with sterile or saline water. (Delmar`s Fundamentals oI Nursing, p.
1007)

45. Which oI the Iollowing laboratory result determines the eIIectiveness oI inIusing 1 unit packed RBC`s in a hematologically stable patient?
A. Increase in hematocrit oI 5 and hemoglobin level by 2 mg/dl.
B. Increase in hematocrit oI 10 and hemoglobin level by 5 mg/dl.
C. Increase in hematocrit oI 3 and hemoglobin level by 1 mg/dl.
D. Increase in hematocrit oI 3 and hemoglobin level by 5 mg/dl.
Rationale: C. there should be increase in hematocrit oI 5 and hemoglobin level by 2 mg/dl.(F&E incredibly made easy, p. 324)

46. InIusion oI whole blood is rarely prescribed unless the patient has lost more than
A. 50 oI the total blood volume
B. 75 oI the total blood volume
C. 60 oI the total blood volume
D. 25 oI the total blood volume
Rationale: D. 25 oI the total blood volume .(F&E incredibly made easy,p. 316)

47. Sodium bicarbonate is administered IV to neutralize blood acidity in patients with a pH lower than 7.1 and bicarbonate loss. The nurse should
Iirst Ilush the IV tubing beIore and aIter with
A. Hypotonic solution
B. Normal saline
C. Sterile water
D. Hypertonic solution
Rationale: B. In administering sodium bicarbonate as ordered. Remember to Ilush the IV line with normal saline solution beIore and aIter giving
bicarbonate because the chemical can inactivate many drugs or cause them to precipitate. Be aware that too much bicarbonate can cause metabolic
alkalosis and pulmonary edema. (F&E Incredibly Made Easy, p. 208)


FUNDAMENTALS: 44 items

48. A nursing assistant is assigned to care Ior a client with hemiparesis oI the right arm and leg. With regards to morning care, the nurse instructs the
nursing assistant to place personal articles
A. Within the client`s reach on the leIt side.
B. Within the client`s reach on the right side.
C. Just out oI the client`s reach on the right side.
D. Just out oI the client`s reach on the leIt side.

RATIONALE. A. Hemiparesis is the weakness of the face, arm, and leg on one side. The nurse would instruct the nursing assistant to place the
obfects on the unaffected side within the clients reach. Other options are not helpful or safe for the client.

49. An older client with cystitis has an indwelling urinary catheter. A nursing assistant is caring Ior the client and the nurse would intervene iI the
nursing assistant
A. Used soap and water to cleansed the perineal area.
B. Kept the drainage bag below the level oI the bladder
C. Used the drainage tubing port to obtain urine samples
D. Let the drainage tubing rest under the leg
RATIONALE: D. Proper care oI an indwelling urinary catheter is especially important to prevent prolonged inIection and or reinIection in the client
with cystitis. The nurse and all caregivers must use strict aseptic technique when emptying the drainage bag or obtaining urine specimens. The
perineal area is cleansed thoroughly to using mild soap and water at least twice a day and Iollowing a bowel movement. The drainage bag is kept
below the level oI the bladder to prevent urine Irom being trapped in the bladder, and Ior the same reason, the drainage tubing is not placed under the
client`s leg. The tubing must drain Ireely at all times.

50. The registered nurse is supervising a nursing assistant perIorming mouth care on an unconscious client. The nurse would intervene iI the nurse
notices the nursing assistant doing which among the Iollowing?
A. Turning the client`s head to one side
B. Using a gloved Iinger to open the client`s mouth
C. Placing an emesis basin under the client`s mouth
D. Using small volumes oI Iluid to rinse the mouth
RATIONALE. B. The client who is unconscious is at great risk for aspiration. The nursing assistant turns the clients head to the side and places an
emesis basin underneath the mouth. A bite stick or a padded tongue blade is used to open the mouth, not a gloved finger, to prevent infury to the
caregiver. Small volumes of fluids are used to rinse the mouth.

51. A registered nurse delegated dressing change in a client with a leg ulcer to a newly hired nurse. Desoxyribonuclease (Elase) dry powder and
Fibrinolysin is prescribed. Which observation by the registered nurse would indicate inaccurate perIormance oI this dressing change?
A. The nurse prepares the solution just beIore the use
B. The nurse covers the Elase application with petrolatum gauze
C. The nurse covers the Elase application with a dry sterile dressing
D. The nurse cleanse the wound with a sterile solution beIore applying the Elase
RATIONALE. C. The wound should be cleansed with a sterile solution and gently patted dry. A thin layer of Elase is applied and covered with
petrolatum gau:e. If a dry powder is used, for best effects the solution should be prepared fust before use.

52. The nurse manager is observing a new nursing graduate caring Ior a burn client in protective isolation. The nurse manager intervenes iI the new
nursing graduate planned to implement which incorrect component oI the protective isolation technique?
A. Wearing protective garb, including a mask, gloves, cap, shoe covers, scrub clothes and plastic aprons
B. Using gloves and a gown only when giving direct care to the client.
C. PerIorming strict hand-washing techniques
D. Using sterile sheets and linens
RATIONALE. B. Thorough hand-washing should be done before and after each contact with the burned-infured client. Sterile sheets and linens are
used. Protective garb, including gloves, cap, masks, shoe covers, scrub clothes, and plastic aprons need to be worn when in the clients room and
when directly caring for the client.

53. A registered nurse-in-charge, planning assignments Ior clients on a medical-surgical unit, needs to assign 4 clients and has a registered nurse, a
licensed practical (vocational) nurse, and two nursing assistants on a nursing team. Which oI the Iollowing patients would the nurse most
appropriately assign the licensed practical (vocational) nurse?
A. The client who requires a 24-hour urine collection
B. An older client requiring assistance with a bed bath and Irequent ambulation
C. A client on a mechanical ventilator requiring Irequent assessment and suctioning
D. A client with an abdominal wound requiring wound irrigations and dressing changes every 3 hours

RATIONALE. D. (Saunders, 3rd ed., Silvestri, p. 1190, 2005). When delegating nursing assignments, the nurse needs to consider the skills and
educational level of the nursing staff. Collecting a 24-hour urine and frequent ambulation can be provided most appropriately by the nursing
assistant, considering the clients identified in each of the options. The client on the mechanical ventilator requiring frequent assessment and
suctioning should be cared for most appropriately by the registered nurse. The licensed practical (vocational nurse) is skilled in wound irrigations
and dressing changes, and the client needing such care would be assigned to this staff member.

54. A client with right-sided hemiparesis needs to learn how to use a cane. The nurse plans to teach the client to position the cane by holding it with
the
A. LeIt hand and placing the cane in Iront oI the leIt Ioot.
B. Right hand and placing the cane in Iront oI the right Ioot
C. LeIt hand and 6 inches lateral to the leIt Ioot.
D. Right hand and 6 inches lateral to the right Ioot.
(Saunders/Silvestri, 3
rd
ed., p. 1014, 1022, 2005) RATIONALE. C. The client is taught to hold the cane on the side opposite from the weakness.
The reason is that with normal walking, the opposite arm and leg move together (called reciprocal motion). The cane is placed 4-6 inches lateral to
the fifth toe.

55. A client has already been given by the nurse instructions about crutch saIety. The client needs reinIorcement oI inIormation by the nurse iI the
client states
A. The need to have spare crutches an tips available.
B. That crutch tips will not slip even when wet.
C. Not to use someone else`s crutches.
D. That crutch tips should be inspected periodically Ior wear.
(Saunders/Silvestri, 3
rd
ed., p. 1014, 1022, 2005) RATIONALE. B. Crutch tips should remain dry. Water could cause slipping by decreasing the
surface friction of the rubber tip on the floor. If crutch tips get wet, the client should dry them with a cloth or paper towel. The client should use only
crutches measured for the client. The tips should be inspected for wear, and spare crutches and tips should be available if needed.

56. The nurse is to teach a client how to stand on crutches. The nurse plans to incorporate into written instructions that the client should be told to
place the crutches
A. 8 inches to the Iront and side oI the client`s toes.
B. 3 inches to the Iront and side oI the client`s toes.
C. 20 inches to the Iront and side oI the client`s toes.
D. 15 inches to the Iront and side oI the client`s toes.
(Saunders/Silvestri, 3
rd
ed., p. 1014, 1021, 2005) RATIONALE. A. The classic tripod position is taught to the client before one gives instructions
on gait. The crutches are placed anywhere from 6-10 inches in front and to the side of the client, depending on the clients body si:e. This provides a
wide enough base of support to the client and improves balance.

57. A nurse teaches a client with Iractured leIt-leg how to use the crutches properly when going up stairs. Which oI the Iollowing behavior iI
demonstrated by the client indicates that the nurse`s teaching was eIIective?
A. place both crutches at the leIt side
B. up with the leIt leg Iirst Iollowed by the right leg and crutches
C. both crutches Iorward Iollowed by the unaIIected leg
D. move the unaIIected leg up Iirst Iollowed by the aIIected leg and the crutches up
(Altman, p.1435, 2004). D. Crutch walking (walking upstairs). Place the strong leg on the first step. Pull the weak leg up and move the crutches
up to the 1
st
step.

58. A nurse administers the ordered PPD, 0.1 ml, intradermally, by using a tuberculin syringe with a
A. 26-gauge, 5/8 inch needle inserted almost parallel to the skin with the bevel side up.
B. 26-gauge, 5/8 inch needle inserted at a 45-degree angle with the bevel side down.
C. 20 gauge, 1-inch needle inserted almost parallel to the skin with the bevel side up.
D. 20 gauge, 1-inch needle inserted at a 30-degree angle with the bevel side down.
(Saunders/Silvestri, 3
rd
ed., p. 745, 755, 2005) RATIONALE. A. A Mantoux skin test is administered by giving 0.1 mL of purified protein
derivative intradermally. Administration involves drawing the medication into a tuberculin syringe with a 25- to 27- gauge, 5/8-inch needle. The
infection is given by inserting the needle as close as possible to a parallel position with the skin and with the needle bevel facing up. This results in
formation of a wheal when the PPD is administered correctly.

59. A nurse is preparing to give a bed bath to an immobilized TB client. The nurse should plan to wear which oI the Iollowing items when
perIorming this care?
A. Gown, gloves, and particulate respirator
B. Protective eyewear and particulate respirator
C. Surgical mask and gloves
D. Gown, protective eyewear and surgical mask.
(Saunder`s/Silvestri, 3
rd
ed., p. 746, 756, 2005) RATIONALE: A. The nurse who is in contact with a client with TB should wear an individually
Iitted particulate respirator. The nurse should also wear gloves as per standard precautions. The nurse wears a gown when the possibility exists that
the clothing could become contaminated, such as when giving a bed bath.

60. A client with a respiratory disorder and is at risk Ior atelectasis was prescribed with an incentive spirometer. Which oI the Iollowing indicates the
proper use oI incentive spirometer?
A. Placing the client in a supine or lying position, have the client enclosed lips in the mouthpiece, and inhale slowly and deeply until desired volume
is reached.
B. Position client in semi-Fowler`s position, instruct to inhale shallow breaths Irom the mouthpiece.
C. Have position in sitting position, instruct the client seal lips around mouthpiece and inhale slowly and deeply until desired volume is attained.
D. Let the client release breath as soon as possible aIter inspiration.
Rationale: C.
(Saunders p. 683, 2002 Edition)
- use the lips to form a seal around mouthpiece
- inspire deeply
- hold inspiration for a few seconds
- forcefully exhale

( Delmars Funda. And Adv. Nursing Skills, p. 899)
-hold unit upright
-have client seal lips and inhale slowly and deeply until desired volume
-sustain inspiration for at least 3 seconds
-exhale slowly
(Lippincotts Manual of Nursing Practice, p. 262)
-Place client in a comfortable sitting or semi-Fowlers position
-tell client to take in slow, deep breath from the mouthpiece
-instruct to remove mouthpiece, relax and passively exhale

61. At 8 AM, the nurse checks the amount oI solution leIt in a 3000-mL TPN inIusion bag Ior an assigned client, which has 1000-mL remaining.
The solution is running at a rate oI 100 mL/ hr. The bag was hung the previous day at noon. The nurse plans to change the inIusion bag and tubing
today at
A. Noon.
B. 2 PM.
C. 4 PM.
D. 8 PM.
(Saunders/Silvestri, 3
rd
ed., p. 143, 145, 2005) RATIONALE. A. Total Parenteral nutrition solution should be changed every 24 hours because the
TPN solution is a high-concentrate glucose and is a medium for bacterial growth. Infection control is also aided by use of aseptic technique with bag
and tubing changes. Most agencies recommend that tubing be changed every 24 hours along with the bag, although some agencies recommend
changing tubing every 48-72 hours. The nurse should always adhere to specific agency policies. Options B,C,D identify insufficient time frames and
present the risk for infection.


62. Being weaned Irom TPN, the client is expected to begin taking solid Iood today. The ongoing solution rate is has been 100 mL/hour. A nurse
anticipates that which oI the Iollowing orders regarding the TPN solution will accompany the diet order?
A. Discontinue the TPN.
B. Continue current inIusion rate orders Ior TPN.
C. Decrease TPN rate to 50 mL/hr.
D. Hang 1 L 0.9 normal saline.
(Saunders/Silvestri, 3
rd
ed., p. 143, 146, 2005) RATIONALE. A. When a client begins taking a diet after a period of receiving Parenteral nutrition,
the TPN is decreased gradually. Total Parenteral nutrition that is discontinued abruptly can cause hypoglycemia. Clients often have anorexia after
being without food for some time, and the digestive tract also is not used to producing the digestive en:ymes that will be needed. Gradually
decreasing the infusion rate allows the client to remain adequately nourished during the transition to a normal diet and prevents the occurrence of
hypoglycemia. Even before clients are started on a solid diet, they are given clear liquids followed by full liquids to further ease the transition. A
solution of normal saline will not provide the glucose needed during the transition of discontinuing the TPN and also could cause the client to
experience hypoglycemia.

63.While monitoring the client`s status oI Iat emulsion inIusion, the nurse noters that the inIusion is 1 hour behind. Which oI the Iollowing actions by
the nurse is most appropriate?
A. Adjust the inIusion rate to run wide open until the solution is back on time.
B. Ensure that the Iat emulsion inIusion rate is inIusing at the prescribed rate.
C. Increase the inIusion rate to catch up over the next 2 hours.
D. adjust the inIusion rate to catch up over the next hour.
(Saunders/Silvestri, 3
rd
ed., p. 144, 147, 2005) RATIONALE. B. The nurse should not increase the rate of a fat emulsion to make up the difference
if the infusion falls behind time. Doing so could place the client at risk for fat overload. The same principle applies to TPN, increasing the rate
suddenly in this case could cause hyperglycemia and fluid overload.

64.A nurse is monitoring a client receiving TPN. The client suddenly develops respiratory distress, chest pain, and dyspnea, and the nurse suspects
air embolism. What is the action that the nurse would take as Iirst priority?
a. Contact the physician
b. Clamp the intravenous catheter
c. Administer oxygen
d. Position the client in leIt Trendelenburg`s position
e. Take the client`s vital signs
Answer. B.
(Saunders/Silvestri, 3
rd
ed., p. 144, 148, 2005) RATIONALE. If air embolism is suspected, the nurse would first clamp the intravenous catheter to
prevent the embolism from traveling through the heart to the pulmonary system. The nurse would next place the client in a left side-lying position
with the head lower than the feet (to trap air in the right side of the heart). The nurse would notify the physician and administer the 02 as prescribed.
The nurse would monitor the client closely and take the clients vital signs.

65. The position oI the client Ior colonoscopy is
A. Prone
B. Right lateral
C. lying on the leIt side with knees drawn to the chest up
D. LeIt Sim`s position
(Saunders/Silvestri, 3
rd
ed., p. 679, 2005) RATIONALE. C. Fiberoptic colonoscopy/Colonoscopy is performed with the client lying on the left side
with the knees drawn up to the chest, position may be changed during the test to facilitate passing of the scope.

66. Jejunostomy exit site care is perIormed 24 hours aIter Ieeding tube insertion. The nurse would instruct the assistive personnel not to:
A. Clean around the tube insertion site with saline and soap to remove exudates or dried blood.
B. Wash hands and don gloves.
C. Remove the old dressing.
D. Apply a new split drain sponge dressing iI needed.
(Black, et. al, 7
th
ed., p. 705, 2005) RATIONALE. A. Exit site care is performed 24 hours after feeding tube insertion. The nurse would instruct the
assistive personnel to.
1. Wash hands and don gloves
2. Remove the old dressing
3. Clean around the tube insertion site with NORMAL SALINE and MILD soap to remove exudates or dried blood.
4. Do not use hydrogen peroxide or any antiseptic cream unless specifically ordered by the physician.
5. Rinse the tube insertion site with clean water and dry thoroughly.
6. Apply a new split drain sponge dressing if needed.

67. AIter Paracentesis, what will be your 1
st
nursing action Ior your client?
a) Monitor vital signs
b) Monitor Ior encephalopathy
c) Measure abdominal girth and weight
d) Instruct the client to notiIy the physician iI the urine becomes brown
Answer. A
(Saunders/Silvestri, 2nd ed., p. 636, 2002) RATIONALE. Post-paracentesis nursing responsibilities. (1) Monitor vital signs (2) Measure fluid
collected, describe, and record
(3) Label fluid samples and send to the laboratory for analysis (4) Apply a dry sterile dressing to the insertion site, monitor site for bleeding (5)
Measure abdominal girth and weight (6) Monitor for hypovolemia, electrolyte loss, mental status changes, or encephalopathy, (7) Monitor for
hematuria resulting from bladder trauma, (8) Instruct the client to notify the physician if the urine becomes bloody, pink, or red.

68. A client was admitted in the recovery aIter a surgery. He was attached to a pulse oximeter. What is the primary purpose oI attaching pulse
oximeter to the client?
A. To assess the arterial blood oxygen saturation
B. To monitor the partial pressure oI carbon dioxide in the blood
C. To assess the client`s hemoglobin and hematocrit status
D. To monitor the client`s level oI consciousness
Rationale. A. (Delmars Fundamental and Advanced Nursing Skills, 2
nd
Edition, p. 907)
Pulse oximetry is a quick, non-invasive method to assess the arterial blood oxygen saturation of a client by using an external sensors.

69. A nurse obtains an order Iorm the physician to restrain a client. The nurse instructs the nursing assistant to apply restraints to the client. Which oI
the Iollowing observations indicate improper understanding oI the nurse in the use oI restrains?
A. Removing restraints Irom 10m minutes every 2 hours Ior range-oI-motion exercises.
B. Restrain straps are saIely secured in the side rails
C. The nursing assistant uses saIety knot in securing the restrain straps in the bed Irame.
D. Allowing enough space between the restrains and skin Ior movement.
Rationale. B. (Saunders/Silvestre, 3
rd
Ed., p. 179)restrain straps should be securely attached to the bed frame and not in the side rails to prevent
infury in the event the side rails is released.

70. A nurse is planning to teach client with crutches how to use crutch in going up the stairs. The nurse determines that the client understand the
instructions iI he state.
A. Stepping the strong leg Iirst, Iollowed by weak leg up and the crutches.
B. LiIting the crutch Iirst, Iollowed by weak leg up and the strong leg.
C. Stepping the weak leg Iirst, Iollowed by the crutch, and the strong leg.
D. LiIting the crutch, Iollowed by strong leg, and the weak leg.
Rationale. A. (Saunders Comprehensive 2005, p. 1006) Going up stairs with crutches.
-the client moves the unaffected leg first
-moves the affected leg and the crutches up



71. A nurse is reviewing instructions to a patient about to be discharged with a hearing aid. Which oI Iollowing instruction will the nurse provide?
A. Adjusting the volume to the maximum hearing level to prevent Ieedback squeaking.
B. Turning oII the hearing aid and remove the battery when not in use.
C. Wash the receiver regularly to maintain good ampliIication oI sounds.
D. Rubbing the receiver with oil beIore and aIter used.
Rationale: B. Hearing aid should be turned oII and batteries are removed when not in use. (Saunders 2002, p. 857)


72. How would the nurse check the proper placement oI NGT tube beIore Ieeding?
A Aspirating Ior gastric contents and checking iI with low pH.
B. Immersing the tip oI the tube in water
C. Auscultating Ior gurgling sound when air is injected into the tube
D. No coiling oI tube viewed in the posterior pharynx.
Rationale: A. Assess tube placement by aspirating gastric contents and measuring the pH, which should be 4 or less (ph values greater than 6 indicate
intestinal placement). Inserting 5 to 10 mL oI air into the NG tube and listening Ior the rush oI air is an alternative method Ior assessing placement,
but is not as reliable as an x-ray or checking pH. (Saunders 2002, p. 213)
73.)What is the correct description oI the proper assessment oI tactile Iremitus?
A. Place the palm oI your hand (or hands) lightly over the thorax. Next, use the pads oI your Iingers, to palpate the Iront and back oI the thorax. Press
your Iingers over the ribs and any scars, lumps, lesions, or ulcerations.
B. Lightly placing you open palms on both sides of the patients back, without touching his back with your fingers. Ask the patient to repeat the
phrase 'ninety-nine` loud enough to produce palpable vibrations. Then palpate the front of the chest using the same hand positions.
C. Hyperextend the middle Iinger oI your leIt hand iI you`re right handed. Place your hand Iirmly on the client`s chest. Use the tip oI the middle
Iinger oI your dominant hand to tap on the middle Iinger oI your other hand just below the distal joint.
D. To assess the patient Ior this sign, ask him to lie down so that you can palpate his knee, then give the medial side oI his knee 2-4 Iirm strokes, to
displace the excess Iluid.
RATIONALE: B. This pertains to tactile Fremitus. Option A. reIers to the technique used in palpating the chest. Option C pertains to the technique oI
percussing the chest. Option D describes how to assess Ior a bulge sign, which indicates excess Iluid in the joint. (Assessment made Incredibly Easy!,
2002, pp.149-151,283)


74. A nurse employed in a surgical unit in a hospital reports to work Ior the 7-3 shiIt and was told to Iloat to the pediatric unit Ior the day because the
unit is understaIIed and the census in the pediatric unit is unusually high. The nurse has never worked in a pediatric unit and does not want to Iloat to
the pediatrics. Which action by the nurse is most appropriate?
A. Call the nursing supervisor to discuss the request to report to pediatrics.
B. ReIuse to Iloat to pediatrics
C. Tell the supervisor that she needs to go home because oI illness
D. Convince another nurse to Iloat to the pediatric unit
RATIONALE: A. Legally, a nurse cannot reIuse to Iloat unless a union contract guarantees that nurses can work only in a speciIied area or the nurse
can prove the lack oI knowledge Ior the perIormance oI assigned tasks. When encountered with this situation, the nurse should set priorities and
identiIy potential areas oI harm to the client. To attempt to convince another nurse to go to the pediatric unit is inappropriate. Option 3 is also an
action that is inappropriate. From the options presented, discussing the situation with the supervisor is the most appropriate.

75. A registered nurse arrives at work and is told to report to the cardiac care unit (CCU) because they are understaII and needs an additional nurses
to care Ior the new admitted clients. The nurse don`t have any experience working in the CCU. What is the most appropriate action oI the nurse?
A. ReIuse to Iloat in the CCU
B. Report to the CCU and identiIy tasks that can be perIormed within the level oI experience.
C. Call the hospital lawyer
D. Call the nursing supervisor
Rationale: B. (Saunders 2005, p.52) Floating is an acceptable legal practice used by the hospital to solve their understaIIing. Legally a nurse can not
reIuse to Iloat unless union oI contract guarantees that the nurse will work only in one area. When entering in this situation, the nurse must not
assume responsibility beyond their skills or experience.

Communicable disease

76. To prevent the spread oI inIection in a patient admitted with hepatitis
B, which measure is appropriate?
A. Enteric precautions
B. Respiratory precautions
C. Contact precautions
D. Blood and body Iluid precautions
Rationale: D. Blood and body Iluid precautions are needed because hepatitis B is transmitted through the serum and body Iluids.

77. Which nursing intervention is not appropriate Ior a patient with hepatitis B?
A. Provide a low-protein diet
B. Provide rest periods aIter meals
C. Give Irequent, small Ieedings
D. Assess the skin Ior excoriation
Rationale: A. The patient with hepatitis B needs a high-protein-not low-protein diet to enhance recovery oI the injured liver cells.

78. A patient, age 50, seeks medical attention Ior low-grade aIternoon Ievers, night sweats, loss oI appetite, and a productive cough. The
physician suspects pulmonary tuberculosis (TB), especially aIter the patient remarks that his wiIe recently was diagnosed with TB. A
positive acid-Iast bacillus sputum culture conIirms that the patient has a TB. Which nursing diagnosis has the highest priority?
A. Risk Ior injury related to inIection
B. Anxiety related to the diagnosis
C. DeIicient knowledge related to the spread oI inIection
D. Imbalanced nutrition: Less than body requirements related to not eating
Rationale: C. Because the patient isn`t in acute distress, the highest nursing diagnosis is deIicient Knowledge related to spread oI inIection.

79. A 19-year-old patient is HIV positive. When would a diagnosis oI AIDS be conIirmed?
A. When seroconversion takes place
B. When he`s diagnosed with malignant (non-Hodgkin`s) lymphoma.
C. When the western blot test is conIirmed
D. When the enzyme-linked immunosorbent assay (ELISA) test is positive
Rationale: B. AIDS isn`t diagnosed until an AIDS-indicator condition occurs. Options C and D are incorrect because ELISA test and
Western blot test identiIy HIV antibodies in the blood; a patient who is HIV positive has already tested positive Ior HIV antibodies. Being
HIV-positive isn`t synonymous with the diagnosis oI AIDS.



80. A woman, age 28, is admitted with a tentative diagnosis oI Acquired ImmunodeIiciency syndrome (AIDS). The preliminary report oI
the Iacial biopsy reveals a Kaposi`s sarcoma. The physicial orders a biopsy Ior the second time. Which oI the Iollowing best indicate the
proper approach oI the nurse?
A. Explore the patients Ieeling about the Iacial disIigurement.
B. InIorm the patient about the biopsy result and support her emotionally
C. Ignore the lesion on her Iace
D. InIorm the patient that Kaposi`s sarcoma is common to people with AIDS.
Rationale: A. Facial lesion can contribute to decrease selI-esteem and altered body image. Kaposi`s sarcoma is among the many
psychosocial and physical trauma that may conIront the patient with AIDS; anxiety, anger, grieI and depression are common emotional
responses. The nurse who works with the patient with AIDS should develop an excellent listening skill. The patient may be especially
concerned that others may realize she has Kaposi`s sarcoma.

81. During routine care oI the patient with AIDS, Iollowing the precautions needed, the nurse would
a. Put on mask, gloves, and a gown
B. uses reverse isolation
C. Place the patient in a private room
D. Wear gloves when giving mouth care
Rationale: Standard precautions stipulate that a health care worker who anticipates coming into contact with a patient`s blood or body
Iluids must wear gloves; this protects the health care worker. Reverse isolation is incorrect because it is used to protect the patient Irom the
healthcare worker. Private room doesn`t provide a method oI barrier protection, which id needed Ior standard precautions. Mask and gloves
are needed only Ior anticipated contact with airborne droplets oI blood or body Iluids; a gown is needed only Ior anticipated contact with
splashes oI blood or body Iluids.

82. While changing a surgical dressing, the nurse notes green, Ioul-smelling drainage at the incision site. Another post-operative client is
sharing room with the client. The most appropriate nursing action is to:
a. Place the client with drainage in a private room
b. Institute drainage and secretion precaution
c. Move the other client in other room
d. Place the client in a strict isolation until the organism is cultured and identiIied
RATIONALE: B. Implementing drainage and secretion precautions protects not only the client with wound inIection, but other clients and
the nurse as well.


83. The nurse is preparing a list oI home care instructions Ior the client who has been hospitalized Ior tuberculosis. Which instruction should the
nurse would include?
a. A sputum culture should be done every 2 to 4 weeks once medication therapy is initiated.
b. When one sputum is negative, the client is no longer considered inIectious and can now return to Iormer work.
c. Respiratory isolation is necessary since Iamily members are already exposed.
d. Avoid contact except Iamily members Ior at least 6 weeks.
e. Instruct to take medications exactly as directed and to double the dose iI one dose is Iorgotten.
Rationale: A. Doses should not be doubled or skipped and must be taken in Iull-length as prescribed. Reassure client that aIter 2-3 weeks oI
medication therapy, it is unlikely that the client make inIect anyone. The client is considered no longer inIectious and can return to work aIter three
negative sputum cultures. (Saunders 2005, p. 741)

84. A patient with active tuberculosis has an order Ior a chest x-ray. What is the best way oI carrying out the order?
A. InIorming the x-ray department that a TB patient will be scheduled Ior an x-ray
B. Call the physician to order a portable x-ray
C. Wear a high Iiltered mask while transporting the patient going to the x-ray room
D. Instructing the client to wear Iacial mask beIore leaving the room
Rationale: D. II the client has an order Ior a test or procedure outside the room, the client is required to wear mask.(Saunders 2005, p.741)

85.Which oI the Iollowing client is the highest risk Ior acquiring pulmonary tuberculosis?
A. A client who occasionally drink liquors
B. A man working as an inspector in the postal service
C. A man used to drink Iresh milk Irom a cow
D. An uninsured immigrants Irom Latin America
Rationale: D. risk Iactor Ior tuberculosis include alcoholism, drinking unpasteurized milk oI a cow inIected with mycobacterium bovis, individuals
who`s work involves Irequent contact to people such as healthcare workers, reIugees, and immigrants Irom Asia, AIrica, Latin America, and
Oceania. (Saunders 2005, p. 739)


86. A client is diagnosed with bacterial meningitis. The nurse understands the nature oI the disease iI she will?
a. Wear surgical mask when providing care to client
b. Wear gown and gloves when perIorming dressing changes
c. The client will be placed in negative pressure room
d. Wear particulate mask with each client contact
RATIONALE: A. Meningitis is transmitted via droplet spread and direct contact. (Saunders Comprehensive 2005, p. 960)
86. InIection control: Which among the Iollowing does not apply?
a. Wearing gloves when caring a client with chicken pox
b. Wearing gown and gloves Ior a client with MRSA
c. Wearing a gown with measles patient
d. Placing a TB client in negative pressure room
e. Wearing a surgical mask when caring a client with bacterial meningitis
RATIONALE: C. Precautions Ior the Iollowing are:
Chicken pox- transmitted via direct contact/ droplet (airborne)
MRSA- transmitted through direct contact
Measles (rubeola)- airborne/ direct contact with the respiratory secretions
Tuberculosis- droplet (airborne)/ direct contact with the respiratory secretions
Bacterial meningitis- droplet spread and direct contact
(Saunders Comprehensive Review 2005, p. 516, 515, 960)

87. Type oI precaution to be implemented in patients with MRSA?

a. Contact
b. Airborne
c. Droplet
d. Standard
RATIONALE: A. Methicillin resistant Staphyloccocus Aureus (MRSA) is a common bacterium that`s easily spread via direct person-to-person
contact. (Diseases: A nursing process approach to excellent Care, p. 107)

88. A nurse caring a child with suspected measles would expect to Iind which oI the Iollowing signs and symptoms?
a. Maculopapular rashes
b. White purulent vesicles
c. Red Iine papular rash
d. Indurations and erythematous rashes.
RATIONALE: A. Assessment Iindings Ior a patient with measles would include Iever, malaise, coryza and cough, maculopapular rash that blanches
with pressure, and Koplik`s spot: a small, red spots with bluish white center and a red base located in the mucosa. White purulent vesicles are a
characteristic oI chicken pox. Red Iine papular rashes are observed in scarlet Iever. Measles rash do not have an induration. (Saunders
Comprehensive 2005, p. 515)

89. Appropriate treatment and prevention oI lice (pediculosis) would include

a. Warm soaks to head twice a week
b. Wash linen and clothing using a high concentration oI bleach
c. Shampooing hair with lindane shampoo every other day
d. Using Iine-toothed comb dipped in vinegar to remove nits
RATIONALE: D. Nursing care and patient teaching to patient inIected with lice include washing clothes and lines in hot water, ironing them or dry
cleaning or applying lindane powder iI linens can`t be washed. The use oI lindane shampoo should be once a week only. Alternative to lindane
shampoo or permethrin cream is the use oI vinegar and Iine-toothed comb. (Diseases: A nursing process approach to excellent Care, p. 1256)


90. An elderly client is admitted with tuberculosis. Which oI the Iollowing inIection control protocol is correct?
a. The door oI the room should be open always
b. Wear a gown while communicating with the patient
c. Place the client in a private room with negative airIlow
d. Use gloves in rendering direct care
RATIONALE: C. Transmission oI tuberculosis is via the airborne route by droplet inIection. The patient should be placed in a respiratory isolation
precaution in a negative pressure room; to maintain negative pressure, the door oI the room should be tightly closed. The nurse should wear a
particulate respirator when caring Ior the client. (Saunders Comprehensive 2005, p. 740)


91. A patient is admitted with Hepatitis A inIection. Which nursing intervention is indicative oI correct inIection precautions?
a. RN segregates the patient`s eating utensils Irom other
b. RN wears a mask when the client sneezes
c. Patient is admitted to an area remarked Ior reverse isolation
d. LPN uses gloves and gowns when in contact with the patient
RATIONALE: A. Hepatitis A or E is contracted through contaminated Iood or water with Iecal matter, because the disease is transmitted via oral-
Iecal route. Not sharing Iood, eating utensils, and toothbrushes are appropriate measures t prevent the transmission oI the disease. (Diseases: A
nursing process approach to excellent Care, p. 1004)



92. An HIV positive patient is admitted with scabies. Which oI the Iollowing nursing interventions is correct?
a. Place the patient in a private room and Iollow standard precautions
b. Wear disposable gloves while taking BP
c. Prepare the patient Ior taking specimen Ior culture and sensitivity
d. Institute a reverse isolation technique
RATIONALE: B. Scabies is a highly transmittable skin inIection. Transmission oI scabies occurs through direct, prolonged skin-to-skin contact or
venereally (Diseases: A nursing process approach to excellent Care, p. 1256)


93. A 13 year- old teenage girl has come with complains oI inIectious mononucleosis inIection. Which oI the Iollowing teaching is a priority?
a. Tell the client to avoid kissing Ior 1 month period
b. Advice the client to take bed rest Ior the entire course oI treatment
c. Tell the client to avoid contact sports
d. Institute respiratory precautions until 24 hours aIter the initiation oI the treatment
RATIONALE: C. InIectious mononucleosis virus (Epstein-Barr) is shed beIore the onset oI the disease until six months or longer aIter recovery.
Transmission is through direct intimate contact and inIected blood. Source oI inIection is oral secretions. Patient should be caution not to engage to
any Iorms oI contact sports because oI the risk oI spleenic rupture. (Saunders Comprehensive Review 2005, p. 517)

94. Which oI the given Iorms oI personal protective device is used in Vancomycin resistant enterococci (VRE)?
a. Particulate respirator
b. High eIIiciency mask
c. Disposable gloves and gown
d. Goggles and gloves
RATIONALE: C. Vancomycin-resistant enterococcus (VRE) is spread Irom person -to - person by direct contact. (Diseases: A nursing process
approach to excellent Care, p. 114)


(Aug. 8, 2006) 95. Which type oI isolation precaution is to be maintained in meningococcal meningitis inIection?
a. Airborne
b. Airborne and contact
c. Droplet and direct contact
d. Standard precaution
RATIONALE: A. Meningitis is transmitted via inhalation oI an inIected droplet and direct contact. (Saunders Comprehensive 2005, p. 960);
(Diseases: A nursing process approach to excellent Care, p. 116)

96. A patient, diagnosed with active TB is in isolation precautions. Which oI the Iollowing intervention can be included as an isolation technique?
a. Keep the patient`s room door closed
b Advice patient to wear disposable gloves always
c. Allow a Iamily member to always be with the patient
d. Allow the patient to play in the dormitory
RATIONALE: A. Transmission oI tuberculosis is via the airborne route by droplet inIection. The patient should be placed in a respiratory isolation
precaution in a negative pressure room; to maintain negative pressure, the door oI the room should be tightly closed. The nurse should wear a
particulate respirator when caring Ior the client. (Saunders Comprehensive 2005, p. 740)

97. A nurse is reading Mantoux skin test (PPD) oI the Iollowing patients. Which oI the Iollowing results will the nurse interpret as positive?
a. Caucasian with15 mm induration
b. Asian with 8 mm induration
c. HIV positive with 3 mm induration
d. A child with no induration and a 1 mm area oI ecchymosis
RATIONALE: A. The client with human immunodeIiciency virus (HIV) inIection is considered to have positive results on Mantoux test with an area
greater than 5 mm induration. The clent without HIV is positive with induration greater than 10 mm. A small area oI ecchymosis is insigniIicant and
probably is related to injection technique. (Saunders Comprehensive Review 2005, p. 753)

98. Appropriate isolation technique Ior a patient with chickenpox would include
a. droplet
b. airborne
c. respiratory
d. standard precaution
RATIONALE: C.Chicken pox (Varicella Zoster Virus) is transmitted via direct contact, droplet (airborne) spread oI the inIected respiratory tract
secretions, skin lesions, and contaminated object. Appropriate isolation technique Ior droplet (airborne) spread is respiratory isolation. (Saunders
Comprehensive Review 2005, p. 516)

99. The nurse in a long term health Iacility is caring Ior a client with 3
rd
stage pressure ulcer. Other patient`s in the Iacility have MRSA and VRE
inIection. What is the priority action Ior the nurse to implement?
a. Inspect wound
b. Obtain wound culture and sensitivity
c. Institute contact precaution
d. Administer prophylactic medication as ordered

RATIONALE: C. Vancomycin-resistant enterococcus (VRE) and Methicillin resistant Staphyloccocus Aureus (MRSA) is a common bacterium that`s
easily spread via direct person-to-person contact. Wearing gown to prevent contact and contamination is advised. (Diseases: A nursing process
approach to excellent Care, p. 107)

100. The nurse is reviewing the health care record oI a newly endorsed patient with a herpes zoster (shingles). Which oI the Iollowing action would
be appropriate to implement Ior the patient?
a. Maintain a good hand washing and wear surgical mask
b. Apply hot compress to the blisters
c. Obtain culture Irom the lesions
d. Wear gown and gloves in caring the patient
marian: D. Patients with .herpes zoster inIection must be isolated because exudate Irom the lesions contains the virus. Contact precaution should be
maintained when caring the patient. (Saunders Comprehensive Review 2005, p. 541)

101. A nurse is caring a client with Clostridium deficile. Which oI the Iollowing is an appropriate component to include in the plan oI care?
a. Administering antibiotics
b. Wearing goggles in obtaining a stool culture
c. Encouraging client to have vaccination
d. Using gloves and gown
RATIONALE: D. Clostridium defficile is a gram-negative anaerobic bacteria that typically causes antibiotic-associated diarrhea due to disruption oI
the intestinal Ilora. C. defficile is most oIten transmitted directly Irom patient to patient contact by contaminated hands oI Iacility personnel.
Treatment includes withdrawing the causative agent (antibiotic therapy, antineoplastic agents, etc) as possible and administering metronidazole or
vancomycin. (Diseases: A nursing process approach to excellent Care, p. 1

sunday.
102. What type oI precaution is appropriate to prevent the transmission oI inIluenza?
a. Droplet
b. Contact
c. Standard
d. Airborne
RATIONALE: A. InIluenza also called grippe or Ilu is an acute, highly contagious inIection oI the respiratory tract. The inIection is transmitted by
inhaling a respiratory droplet Irom an inIected person or by indirect contact, such as drinking Irom a contaminated glass. . (Diseases: A nursing
process approach to excellent Care, p. 196)

103.Which among the Iollowing is a correct intervention Ior pediculosis capitis?
a. Use a pediculicide shampoo; repeat the treatment in 3 days
b. Use a permethrin (Nix) rinse. Apply to washesd and towel-dried hair, leave in place Ior 2 minutes, and then rinse.
c. Instruct the parents that nonessential bedding and clothing can be stored in a tightly sealed bag Ior 10 days to 2 weeks and then washed.
d. Instruct the parents to seal toys that cannot be washed or dry cleaned in a plastic bag Ior 1 week.
RATIONALE: C. It is the only correct intervention. Option A: Repeat pediculicide shampoo treatment in 7 days. Option B: Nix rinse is leIt in place
Ior 10 minutes and then rinse. Option D: Instruct the parents to seal toys that cannot be washed or dry cleaned in a plastic bag Ior 2 weeks.

104. A nurse is going to take the BP oI a client, which condition will the nurse need gown?

a.Clostridium botulism
b.Measles
c.Leggionare`s disease
d. Multi drug resistant gastroenteritis

RATIONALE: A. Contact precaution is instituted in inIection related to multidrug resistant organism causing inIections such as Clostridium deficile
(a Iorm oI gastroenteritis). (Saunders Comprehensive 2005, p. 181)

Additional Fundamentals oI Nursing: 10 items

1. An outpatient nurse is perIorming percussion on a client during a routine physical examination. Which oI the Iollowing description shows a
normal sound on a health client?
A. Tympanic over the LUQ
B. Resonance over the dense tissue
C. Dullness over solid mass like spleen
D. Flatness over the umbilical area
Rationale: C. Percussion sounds depend on the underlying structure being percussed. Tympany, a drum-like sound is oIten heard over areas with
enclosed air like the bowel. Resonance is a hollow sound heard over areas oI partly air and partly solid like the normal lungs. Dullness is a thud-like
sound produced over a solid tissue like liver, heart, and spleen. Flatness is heard in muscles and bones which are considered dense tissue.
(Assessment made Incredibly Easy, 2
nd
ed. 2002, p. 30)

2. A victim oI a motor vehicle crash has sustained a severe Iacial injury. In assessing the intactness oI cranial nerve III Iunctioning, the nurse
would
A. Observe the patient`s posturing patterns such as Ilexion or extension
B. Ask the client to open the mouth widely, stick out the tongue, and rapidly move the tongue side to side
C. Observe the Iace Ior symmetry and ask the patient to raise the Iorehead and eyebrow
D. Have the patient Iollow your moving Iinger with his eyes as you move it in diIIerent direction
Rationale: D. Having the patient Iollow your Iinger with his eyes will test extraocular movement, which is a test oI cranial nerve s III, IV, and VI.
(MS by Black and Hawks, 7
th
ed. 2005, p. 2028)

3. You are preparing a motorcycle crash victim Ior a needle thoracentesis. A tension pneumothorax is suspected. AIter assembling the needed
equipment, you would know that the insertion oI a 14-gauge needle would be placed in which location?
A. UnaIIected side, Iourth intercostals space slightly anterior to the midaxillary line
B. AIIected side, second intercostals space at the midclavicular line
C. AIIected side, IiIth intercostals space lightly anterior to the midaxillary line
D. UnaIIected side, third intercostals space at the midclavicular line
Rationale: B. The second intercostals space at the midclavicular line is the correct location. Although a tension pneumothorax displaces the trachea
and thoracic organs away Irom the aIIected side toward the unaIIected side, inserting a thoracentesis needle in the unaIIected side may compromise
the patient. The IiIth intercostals space slightly anterior to the midaxillary line would be the correct location Ior the insertion oI a chest tube Ior a
suspected hemothorax. This location would allow Ior the drainage oI accumulated blood. (CEN Review Manual 3
rd
ed., p. 435)

4. A staII nurse asked one oI the student nurse on which route oI drug administration is most appropriate to use when an immediate analgesia and
titration are necessary. The student nurse best response would be?
A. Intravenous (IV)
B. Sublingual
C. Patient-controlled analgesia (PCA)
D. Intramuscular (IM)
Rationale: A. the IV route is preIerred as the Iastest and most amendable to titration. A PCA bolus can be delivered; however, the pump will limit
the dosage that can be delivered unless the parameters are changed. Sublingual and IM are also Iast, but not a good route Ior titration. (Mosby`s
Prioritization, Delegation, and Assignment 2006, p. 16)

5. A client was prescribed with total parenteral nutrition (TPN) via central venous catheter. Which measure should the nurse take to ensure
adequate assessment and to prevent inIection while the patient is on TPN?
A. Administering no medications or blood products through the TPN line
B. Changing TPN tubing every 48 hours
C. Taking vital signs every 12 hours
D. Changing TPN dressing every 3 days
Rationale: A. The nurse should not administer medications, blood, or blood products through the TPN line because oI possible incompatibilities
between those products and any residue oI the TPN solution. TPN tubing should be changed every 24 hours under strict aseptic technique. Dressing
changes should be done every 48 hours. The nurse should monitor Ior temperature every 8 hours not 12 hours to detect spikes in temperature that
may indicate inIection. (Saunders Comprehensive Review 2006, p. 141-142)

6. A client has had bone scan done. The nurse would evaluate that the client understands the elements oI Iollow-up care iI the client states that he
should
A. Report any Ieelings oI nausea and vomiting
B. Remain on bed Ior at least 2 hours
C. Eat a small meal Ior the day
D. Drink plenty oI water Ior 1-2 days Iollowing the procedure
Rationale: D. No special restrictions are necessary aIter a bone scan. The client is encouraged to drink large amounts oI Iluid Ior 24-48 hours to
Ilush the radioisotope Irom the systems. (Saunders Comprehensive Review 2006, p. 999)

7. A nurse is assisting in the care oI a post-op patient aIter a myelogram using an oil-based dye. Nursing care Ior the patient includes all oI the
Iollowing, except
A. PerIorming neurologic assessment Irequently
B. Elevating the head 15-30 degrees Ior 8 hours
C. Encouraging increased Iluid intake
D. Monitoring intake and output
Rationale: B. Patient who undergoes myelogram using oil-based dye must be keep Ilat in bed 6-8 hours. Elevating the head 15-30 degrees is
indicated Ior water-based dye. The other nursing interventions are appropriate Ior the patient. (Saunders Comprehensive Review 2006, p. 1000)


8. A nurse is reviewing the post-procedure plan oI care Iormulated by a nursing student Ior a client who will undergo arthroscopy oI the knee.
The nurse would evaluate that the student understands the procedure when she state
A. 'The client must rest entirely Ior the day
B. 'The client can resume exercises the Iollowing day
C. 'The client must reIrain Irom eating Iood Ior the rest oI the day
D. 'The client must be closely monitored Ior Iever
Rationale: D. AIter arthroscopy, the client usually can walk careIully on the leg once sensation has returned. The client is instructed to avoid
strenuous exercises Ior at least a Iew days. The client may resume the normal diet. Signs and symptoms oI inIection must be reported immediately
to the physician. (Saunders Comprehensive Review 2006, p. 998)

9. A nurse is attending a client who undergoes arthrogram the previous day. Which oI the Iollowing client`s complain is considered normal
A. 'My joint is still puIIy and painIul
B. 'I Ieel like I`m having Iever
C. 'The site is still bleeding
D. 'I observe a purulent drainage coming Irom the insertion site
Rationale: A. 1-2 days aIter arthrogram, joint may be still edematous and tender. Instruct client to treat with icepacks and analgesics as prescribe.
NotiIying the physician would necessitate only, iI edema and tenderness lasts longer than 2 days. (Saunders Comprehensive Review 2006, p.
999)

10. A nurse is giving pre-op instructions to a patient scheduled Ior Magnetic Resonance Imaging (MRI). Which oI the Iollowing statements indicate
that the patient understands about the procedure?
A. 'I will not eat beIore the procedure.
B. 'I will need to change positions during the procedure to have a Iull view oI the scanned area.
C. 'I am not allowed to speak during the procedure.
D. 'I will be wearing earplugs during the procedure.
Rationale: D. Patients wear earplugs during the test because oI the noise created by the changes in magnetic Iields. The patient is required to lie still
in the procedure and a microphone inside the scanner allows the patient to speak. There is no need Ior the patient to be NPO the night beIore the
procedure. (Feuer Nursing Review 2002, p.18)