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1. Patient X is diagnosed with constipation. As a knowledgeable nurse, which
nursing intervention is appropriate for maintaining normal bowel function?
A. Assessing dietary intake
B. Decreasing fluid intake
C. Providing limited physical activity
D. Turning, coughing, and deep breathing
2. A 12-year-old boy was admitted in the hospital two days ago due to hyperthermia.
His attending nurse, Dennis, is quite unsure about his plan of care. Which of the
following nursing intervention should be included in the care of plan for the client?
A. Room temperature reduction
B. Fluid restriction of 2,000 ml/day
C. Axillary temperature measurements every 4 hours
D. Antiemetic agent administration
3. Tom is ready to be discharged from the medical-surgical unit after 5 days of
hospitalization. Which client statement indicates to the nurse that Tom understands
the discharge teaching about cellular injury?
A. I do not have to see my doctor unless i have problems.
B. I can stop taking my antibiotics once I am feeling better.
C. If I have redness, drainage, or fever, I should call my healthcare provider.
D. I can return to my normal activities as soon as I go home.
4. Nurse Katee is caring for Adam, a 22-year-old client, in a long-term facility. Which
nursing intervention would be appropriate when identifying nursing interventions
aimed at promoting and preventing contractures? Select all that apply.
A. Clustering activities to allow uninterrupted periods of rest
B. Maintaining correct body alignment at all times
C. Monitoring intake and output, using a urometer if necessary

D. Using a footboard or pillows to keep feet in correct position

E. Performing active and passive range-of-motion exercises
F. Weighing the client daily at the same time and in the same clothes
5. A 36-year-old male client is about to be discharged from the the hospital after 5
days due to surgery. Which intervention should be included in the home health care
nurses instructions about measures to prevent constipation?
A. Discouraging the client from eating large amounts of roughage-containing foods in the
diet.
B. Encouraging the client to use laxatives routinely to ensure adequate bowel elimination.
C. Instructing the client to establish a bowel evacuation schedule that changes every day.
D. Instructing the client to fill a 2-L bottle with water every night and drink it the next day.
6. Mr. McPartlin suffered abrasions and lacerations after a vehicular accident. He was
hospitalized and was treated for a couple of weeks. When planning care for a client
with cellular injury, the nurse should consider which scientific rationale?
A. Nutritional needs remain unchanged for the well-nourished adult.
B. Age is an insignificant factor in cellular repair.
C. The presence of infection may slow the healing process.
D. Tissue with inadequate blood supply may heal faster.
7. A 22-year-old lady is displaying facial grimaces during her treatment in the hospital
due to burn trauma. Which nursing intervention should be included for reducing pain
due to cellular injury?
A. Administering anti-inflammatory agents as prescribed
B. Elevating the injured area to decrease venous return to the heart
C. Keeping the skin clean and dry
D. Applying warm packs initially to reduce edema
8. Lisa, a client with altered urinary function, is under the care of nurse Tine. Which
intervention is appropriate to include when developing a plan of care for Lisa who is
experiencing urinary dribbling?

A. Inserting an indwelling Foley catheter

B. Having the client perform Kegel exercises
C. Keeping the skin clean and dry
D. Using pads or diapers on the client
9. Jeron is admitted in the hospital due to bacterial pneumonia. He is febrile,
diaphoretic, and has shortness of breath and asthma. Which goal is the most
important for the client?
A. Prevention of fluid volume excess
B. Maintenance of adequate oxygenation
C. Education about infection prevention
D. Pain reduction
10. Mang Rogelio, a 32-year-old patient, is about to be discharged from the acute care
setting. Which nursing intervention is the most important to include in the plan of
care?
A. Stress-reduction techniques
B. Home environment evaluation
C. Skin-care measures
D. Participation in activities of daily living
11. Mrs. dela Riva is in her first trimester of pregnancy. She has been lying all day
because her OB-GYN requested her to have a complete bed rest. Which nursing
intervention is appropriate when addressing the clients need to maintain skin
integrity?
A. Monitoring intake and output accurately
B. Instructing the client to cough and deep-breathe every 2 hours
C. Keeping the linens dry and wrinkle free
D. Using a foot board to maintain correct anatomic position
12. Maya, who is admitted in a hospital, is scheduled to have her general checkup
and physical assessment. Nurse Timothy observed a reddened area over her left hip.
Which should the nurse do first?

A. Massage the reddened are for a few minutes

B. Notify the physician immediately
C. Arrange for a pressure-relieving device
D. Turn the client to the right side for 2 hours
13. Pierro was noted to be displaying facial grimaces after nurse Kara assessed his
complaints of pain rated as 8 on a scale of 1 (no pain) 10 10 (worst pain). Which
intervention should the nurse do?
A. Administering the clients ordered pain medication immediately
B. Using guided imagery instead of administering pain medication
C. Using therapeutic conversation to try to discourage pain medication
D. Attempting to rule out complications before administering pain medication
14. Nurse Marthia is teaching her students about bacterial control. Which
intervention is the most important factor in preventing the spread of microorganism?
A. Maintenance of asepsis with indwelling catheter insertion
B. Use of masks, gowns, and gloves when caring for clients with infection
C. Correct handwashing technique
D. Cleanup of blood spills with sodium hydrochloride
15. A patient with tented skin turgor, dry mucous membranes, and decreased urinary
output is under nurse Marks care. Which nursing intervention should be included
the care plan of Mark for his patient?
A. Administering I.V. and oral fluids
B. Clustering necessary activities throughout the day
C. Assessing color, odor, and amount of sputum
D. Monitoring serum albumin and total protein levels
16. Khaleesi is admitted in the hospital due to having lower than normal potassium
level in her bloodstream. Her medical history reveals vomiting and diarrhea prior to
hospitalization. Which foods should the nurse instruct the client to increase?

A. Whole grains and nuts

B. Milk products and green, leafy vegetables
C. Pork products and canned vegetables
D. Orange juice and bananas
17. Mary Jean, a first year nursing student, was rushed to the clinic department due
to hyperventilation. Which nursing intervention is the most appropriate for the client
who is subsequently developing respiratory alkalosis?
A. Administering sodium chloride I.V.
B. Encouraging slow, deep breaths
C. Preparing to administer sodium bicarbonate
D. Administer low-flow oxygen therapy
18. Nurse John Joseph is totaling the intake and output for Elena Reyes, a client
diagnosed with septicemia who is on a clear liquid diet. The client intakes 8 oz of
apple juice, 850 ml of water, 2 cups of beef broth, and 900 ml of half-normal saline
solution and outputs 1,500 ml of urine during the shift. How many milliliters should
the nurse document as the clients intake.
A. 2,230
B. 2,740
C. 2,470
D. 2,320
19. Marie Joys lab test revealed that her serum calcium is 2.5 mEq/L. Which
assessment data does the nurse document when a client diagnosed with
hypocalcemia develops a carpopedal spasm after the blood-pressure cuff is inflated?
A. Positive Trousseaus sign
B. Positive Chvosteks sign
C. Tetany
D. Paresthesia
20. Lab tests revealed that patient Zs [Na+] is 170 mEq/L. Which clinical manifestation
would nurse Natty expect to assess?

A. Tented skin turgor and thirst

B. Muscle twitching and tetany
C. Fruity breath and Kussmauls respirations
D. Muscle weakness and paresthesia
21. Mang Teban has a history of chronic obstructive pulmonary disease and has the
following arterial blood gas results: partial pressure of oxygen (PO2), 55 mm Hg, and
partial pressure of carbon dioxide (PCO2), 60 mm Hg. When attempting to improve
the clients blood gas values through improved ventilation and oxygen therapy, which
is the clients primary stimulus for breathing?
A. High PCO2
B. Low PO2
C. Normal pH
D. Normal bicarbonate (HCO3)
22. A client with very dry mouth, skin and mucous membranes is diagnosed of
having dehydration. Which intervention should the nurse perform when caring for a
client diagnosed with fluid volume deficit?
A. Assessing urinary intake and output
B. Obtaining the clients weight weekly at different times of the day
C. Monitoring arterial blood gas (ABG) results
D. Maintaining I.V. therapy at the keep-vein-open rate
23. Which client situation requires the nurse to discuss the importance of avoiding
foods high in potassium?
A. 14-year-old Elena who is taking diuretics
B. 16-year-old John Joseph with ileostomy
C. 16-year-old Gabriel with metabolic acidosis
D. 18-year-old Albert who has renal disease
24. Genevieve is diagnosed with hypomagnesemia, which nursing intervention would
be appropriate?

A. Instituting seizure precaution to prevent injury

B. Instructing the client on the importance of preventing infection
C. Avoiding the use of tight tourniquet when drawing blood
D. Teaching the client the importance of early ambulation
25. Which electrolyte would the nurse identify as the major electrolyte responsible for
determining the concentration of the extracellular fluid?
A. Potassium
B. Phosphate
C. Chloride
D. Sodium
26. Jon has a potassium level of 6.5 mEq/L, which medication would nurse Wilma
anticipate?
A. Potassium supplements
B. Kayexalate
C. Calcium gluconate
D. Sodium tablets
27. Which clinical manifestation would lead the nurse to suspect that a client is
experiencing hypermagnesemia?
A. Muscle pain and acute rhabdomyolysis
B. Hot, flushed skin and diaphoresis
C. Soft-tissue calcification and hyperreflexia
D. Increased respiratory rate and depth
28. Joshua is receiving furosemide and Digoxin, which laboratory data would be the
most important to assess in planning the care for the client?
A. Sodium level
B. Magnesium level
C. Potassium level
D. Calcium level

29. Mr. Salcedo has the following arterial blood gas (ABG) values: pH of 7.34, partial
pressure of arterial oxygen of 80 mm Hg, partial pressure of arterial carbon dioxide of
49 mm Hg, and a bicarbonate level of 24 mEq/L. Based on these results, which
intervention should the nurse implement?
A. Instructing the client to breathe slowly into a paper bag
B. Administering low-flow oxygen
C. Encouraging the client to cough and deep breathe
D. Nothing, because these ABG values are within normal limits.
30. A client is diagnosed with metabolic acidosis, which would the nurse expect the
health care provider to order?
A. Potassium
B. Sodium bicarbonate
C. Serum sodium level
D. Bronchodilator

Answers and Rationale

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.
1. Answer: A. Assessing dietary intake
Assessing dietary intake provides a foundation for the clients usual practices and may help
determine if the client is prone to constipation or diarrhea. Limited physical activity may
contribute to constipation due to decreased peristalsis. Turning, coughing and deep
breathing help promote gas exchange. Fluid intake should be increased to aid bowel
elimination.
2. Answer: A. Room temperature reduction

For patient with hyperthermia, reducing the room temperature may help decrease the body
temperature. Tepid baths, cool compresses, and cooling blanket may also be necessary.
Antipyretics, and not antiemetics, are indicated to reduce fever. Oral or rectal temperature
measurements are generally accepted and are more accurate than axillary measurements.
Fluids should be encouraged, not restricted to compensate for insensible losses.
3. Answer: C. If I have redness, drainage, or fever, I should call my healthcare
provider.
Knowledge that redness, drainage, or fever signs of infection associated with cellular
injury require reporting indicates that the client has understood the nurses discharge
teaching. Follow-up checkups should be encouraged with an emphasis of antibiotic
compliance even if the client feels better. There are usually activity limitations after cellular
injury.
4. Answer: B, D, E
Correct body alignment, preventing footdrop, and range-of-motion exercises will help
prevent contractures. Clustering activities will help promote adequate rest. Monitoring intake
and output and weighing the client will help maintain fluid and electrolyte balance.
5. Answer: D. Instructing the client to fill a 2-L bottle with water every night and drink
it the next day.
Adequate fluids and fiber in the diet are key to preventing constipation. Having the client fill
a 2-L bottle with water every night and drink it the next day is one method for ensuring the
client receives at least 2,000 ml of water daily. The client also should be instructed to drink
any other fluids throughout the day. High fiber or roughage foods are encouraged. Laxatives
should not be used routinely for bowel elimination. They should be used only as a last
resort, because clients may become dependent on them. A regular bowel evacuation
schedule should be established.
6. Answer: C. The presence of infection may slow the healing process.
Infection impairs wound healing. Adequate blood supply is essential for healing. If
inadequate, healing is slowed. Nutritional needs, including protein and caloric needs,

increase for all clients undergoing cellular repair because adequate protein and caloric
intake is essential to optimal cellular repair. Elderly clients may have decreased blood flow
to the skin, organ atrophy and diminished function, and altered immunity. These conditions
slow cellular repair and increase the risk of infection.
7. Answer: A. Administering anti-inflammatory agents as prescribed
Anti-inflammatory agents help reduce edema and relieve pressure on nerve endings,
subsequently reducing pain. Elevating the injured area increases venous return to the heart.
Maintaining clean, dry skin aids in preventing skin breakdown. Cool packs, not warm packs,
should be used initially to cause vasoconstriction and reduce edema.
8. Answer: B. Having the client perform Kegel exercises
Kegel exercises, which help strengthen the muscles in the perineal area, are used to
maintain urinary continence. To perform these exercises, the client tightens pelvic floor
muscles for 4 seconds 10 times at least 20 times each day, stopping and starting the urinary
flow. Inserting an indwelling Foley catheter increases the risk for infection and should be
avoided. The nurse should encourage the client to develop a toileting schedule based on
normal urinary habits. However, suggesting bathroom use every 8 hours may be too long an
interval to wait. Pads or diapers should be used only as a resort.
9. Answer: B. Maintenance of adequate oxygenation
For the client with asthma and infection, oxygenation is the priority. Maintaining adequate
oxygenation reduces the risk of physiologic injury from cellular hypoxia, which is the leading
cause of cell death. A fluid volume deficit resulting from fever and diaphoresis, not excess, is
more likely for this client. No information regarding pain is provided in this scenario.
Teaching about infection control is not appropriate at this time but would be appropriate
before discharge.
10. Answer: B. Home environment evaluation
After discharge, the client is responsible for his own care and health maintenance
management. Discharge includes assessing the home environment for determining the
clients ability to maintain his health at home.

11. Answer: C. Keeping the linens dry and wrinkle free

Keeping the linens dry and wrinkle-free aids in preventing moisture and pressure from
interfering with adequate blood supply to the tissues, helping to maintain skin integrity.
Using a foot board is appropriate for maintaining normal body function position. Monitoring
intake and output aids in assessing and maintaining bladder function.. Coughing and deep
breathing help promote gas exchange.
12. Answer: D. Turn the client to the right side for 2 hours
Turning the client to the right side relieves the pressure and promotes adequate blood
supply to the left hip. A reddened area is never massaged, because this may increase the
damage to the already reddened, damaged area. The health care provider does not need to
be notified immediately. However, the health care provider should be informed of this finding
the next time he is on the unit. Arranging for a pressure-relieving device is appropriate, but
this is done after the client has been turned.
13. Answer: D. Attempting to rule out complications before administering pain
medication
When intervening with a client complaining of pain, the nurse must always determine if the
pain is expected pain or a complication that requires immediate nursing intervention. This
must be done before administering the medication. Guided imagery should be used along
with, not instead of, administration of pain medication. The nurse should medicate the client
and not discourage medication.
14. Answer: C. Correct handwashing technique
Handwashing remains the most effective procedure for controlling microorganisms and the
incidence of nosocomial infections. Aseptic technique is essential with invasive procedures,
including indwelling catheters. Masks, gowns, and gloves are necessary only when the
likelihood of exposure to blood or body fluids is high. Spills of blood from clients with
acquired immunodeficiency syndrome should be cleaned with sodium hydrochloride.
15. Answer: A. Administering I.V. and oral fluids

The clients assessment findings would lead the nurse to suspect that the client is
dehydrated. Administering I.V. fluids is appropriate. Assessing sputum would be appropriate
for a client with problems associated with impaired gas exchange or ineffective airway
clearance. Monitoring albumin and protein levels is appropriate for clients experiencing
inadequate nutrition. Clustering activities helps with energy conservation and promotes rest.
16. Answer: D. Orange juice and bananas
The client with hypokalemia needs to increase the intake of foods high in potassium.
Orange juice and bananas are high in potassium, along with raisins, apricots, avocados,
beans, and potatoes. Whole grains and nuts would be encouraged for the client with
hypomagnesemia; milk products and green, leafy vegetables are good sources of calcium
for the client with hypocalcemia. Pork products and canned vegetables are high in sodium
and are encouraged for the client with hyponatremia.
17. Answer: B. Encouraging slow, deep breaths
The client who is hyperventilating and subsequently develops respiratory alkalosis is losing
too much carbon dioxide. Measures that result in the retention of carbon dioxide are
needed. Encourage slow, deep breathing to retain carbon dioxide and reverse respiratory
alkalosis. Administering low-flow oxygen therapy is appropriate for chronic respiratory
acidosis. Administering sodium bicarbonate is appropriate for treating metabolic acidosis,
and administering sodium chloride is appropriate for metabolic alkalosis.
18. Answer: C. 2,470
The fluid intake includes 8 oz (240 ml) of apple juice, 850 ml of water, 2 cups (480 ml) of
beef broth, and 900 ml of I.V. fluid for a total of 2,470 ml intake for the shift.
19. Answer: A. Positive Trousseaus sign
In a client with hypocalcemia, a positive Trousseaus sign refers to carpopedal spasm that
develops usually within 2 to 5 minutes after applying and inflating a blood pressure cuff to
about 20 mm Hg higher than systolic pressure on the upper arm. This spasm occurs as the
blood supply to the ulnar nerve is obstructed. Chvosteks sign refers to twitching of the facial
nerve when tapping below the earlobe. Paresthesia refers to the numbness or tingling.

Tetany is a clinical manifestation of hypocalcemia denoted by tingling in the tips of the

fingers around the mouth, and muscle spasms in the extremities and face.
20. Answer: A. Tented skin turgor and thirst
Hypernatremia refers to elevated serum sodium levels, usually above 145 mEq/L. Typically,
the client exhibits tented skin turgor and thirst in conjunction with dry, sticky mucous
membranes, lethargy, and restlessness. Muscle weakness and paresthesia are associated
with hypokalemia; fruity breath and Kussmauls respirations are associated with diabetic
ketoacidosis. Muscle twitching and tetany may be seen with hypercalcemia or
hyperphosphatemia.
21. Answer: B. Low PO2
A chronically elevated PCO2 level (above 50 mmHg) is associated with inadequate
response of the respiratory center to plasma carbon dioxide. The major stimulus to
breathing then becomes hypoxia (low PO2). High PCO2 and normal pH and HCO3 levels
would not be the primary stimuli for breathing in this client.
22. Answer: A. Assessing urinary intake and output
For the client with fluid volume deficit, assessing the clients urine output (using a urometer if
necessary) is essential to ensure an output of at least 30 ml/hour. The client should be
weighed daily, not weekly, and at same time each day, usually in the morning. Monitoring
ABGs is not necessary for this client. Rather, serum electrolyte levels would most likely be
evaluated. The client also would have an I.V. rate at least 75 ml/hour, if not higher, to correct
the fluid volume deficit.
23. Answer: D. Albert who has renal disease
Clients with renal disease are predisposed to hyperkalemia and should avoid foods high in
potassium. Clients receiving diuretics, with ileostomies, or with metabolic acidosis may be
hypokalemic and should be encouraged to eat foods high in potassium.
24. Answer: A. Instituting seizure precaution to prevent injury

Instituting seizure precaution is an appropriate intervention, because the client with

hypomagnesemia is at risk for seizures. Hypophosphatemia may produce changes in
granulocytes, which would require the nurse to instruct the client about measures to prevent
infection. Avoiding the use of a tight tourniquet when drawing blood helps prevent
pseudohyperkalemia. Early ambulation is recommended to reduce calcium loss from bones
during hospitalization.
25. Answer: D. Sodium
Sodium is the electrolyte whose level is the primary determinant of the extracellular fluid
concentration. Sodium a cation (e.g., positively charged ion), is the major electrolyte in
extracellular fluid. Chloride, an anion (e.g., negatively charged ion), is also present in
extracellular fluid, but to a lesser extent. Potassium (a cation) and phosphate (an anion) are
the major electrolytes in the intracellular fluid.
26. Answer: B. Kayexalate
The clients potassium level is elevated; therefore, Kayexalate would be ordered to help
reduce the potassium level. Kayexalate is a cation-exchange resin, which can be given
orally, by nasogastric tube, or by retention enema. Potassium is drawn from the bowel and
excreted through the feces. Because the clients potassium level is already elevated,
potassium supplements would not be given. Neither calcium gluconate nor sodium tablets
would address the clients elevated potassium level.
27. Answer: B. Hot, flushed skin and diaphoresis
Hypermagnesemia is manifested by hot, flushed skin and diaphoresis. The client also may
exhibit hypotension, lethargy, drowsiness, and absent deep tendon reflexes. Muscle pain
and acute rhabdomyolysis are indicative of hypophosphatemia. Soft-tissue calcification and
hyperreflexia are indicative of hyperphosphatemia. Increased respiratory rate and depth are
associated with metabolic acidosis.
28. Answer: C. Potassium level
Diuretics such as furosemide may deplete serum potassium, leading to hypokalemia. When
the client is also taking digoxin, the subsequent hypokalemia may potentiate the action

ofdigoxin, placing the client at risk for digoxin toxicity. Diuretic therapy may lead to the loss
of other electrolytes such as sodium, but the loss of potassium in association
with digoxintherapy is most important. Hypocalcemia is usually associated with inadequate
vitamin D intake or synthesis, renal failure, or use of drugs, such as aminoglycosides and
corticosteroids. Hypomagnesemia generally is associated with poor nutrition, alcoholism,
and excessive GI or renal losses, not diuretic therapy.
29. Answer: C. Encouraging the client to cough and deep breathe
The ABG results indicate respiratory acidosis requiring improved ventilation and increased
oxygen to the lungs. Coughing and deep breathing can accomplish this. The nurse would
administer high oxygen levels because the client does not have chronic obstructive
pulmonary disease. Breathing into a paper bag is appropriate for a client hyperventilating
and experiencing respiratory alkalosis. Some action is necessary, because the ABG
results are not within normal limits.
30. Answer: B. Sodium bicarbonate
Metabolic acidosis results from excessive absorption or retention of acid or excessive
excretion of bicarbonate. A base is needed. Sodium bicarbonate is a base and is used to
treat documented metabolic acidosis. Potassium, serum sodium determinations, and a
bronchodilator would be inappropriate orders for this client.