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Nursing Practice I -Foundation of c. “My ankle appears redder now”.

d. “I need something stronger for pain relief”

Professional Nursing Practice 10.The physician prescribes a loop diuretic for a client. When
administering this drug, the nurse anticipates that the client may
develop which electrolyte imbalance?
1. The nurse In-charge in labor and delivery unit administered a
a. Hypernatremia
dose of terbutaline to a client without checking the client’s pulse.
b. Hyperkalemia
The standard that would be used to determine if the nurse was
c. Hypokalemia
negligent is:
d. Hypervolemia
a. The physician’s orders.
b. The action of a clinical nurse specialist who is recognized
11.She finds out that some managers have benevolent-
expert in the field.
authoritative style of management. Which of the following
c. The statement in the drug literature about administration of
behaviors will she exhibit most likely?
a. Have condescending trust and confidence in their
d. The actions of a reasonably prudent nurse with similar
education and experience.
b. Gives economic and ego awards.
c. Communicates downward to staffs.
2. Nurse Trish is caring for a female client with a history of GI
d. Allows decision making among subordinates.
bleeding, sickle cell disease, and a platelet count of 22,000/μl.
The female client is dehydrated and receiving dextrose 5% in
12. Nurse Amy is aware that the following is true about functional
half-normal saline solution at 150 ml/hr. The client complains of
severe bone pain and is scheduled to receive a dose of morphine
a. Provides continuous, coordinated and comprehensive nursing
sulfate. In administering the medication, Nurse Trish should avoid
which route?
b. One-to-one nurse patient ratio.
a. I.V
c. Emphasize the use of group collaboration.
b. I.M
d. Concentrates on tasks and activities.
c. Oral
d. S.C
13.Which type of medication order might read "Vitamin K 10 mg
I.M. daily × 3 days?"
3. Dr. Garcia writes the following order for the client who has
a. Single order
been recently admitted “Digoxin .125 mg P.O. once daily.” To
b. Standard written order
prevent a dosage error, how should the nurse document this
c. Standing order
order onto the medication administration record?
d. Stat order
a. “Digoxin .1250 mg P.O. once daily”
b. “Digoxin 0.1250 mg P.O. once daily”
14.A female client with a fecal impaction frequently exhibits
c. “Digoxin 0.125 mg P.O. once daily”
which clinical manifestation?
d. “Digoxin .125 mg P.O. once daily”
a. Increased appetite
b. Loss of urge to defecate
4. A newly admitted female client was diagnosed with deep vein
c. Hard, brown, formed stools
thrombosis. Which nursing diagnosis should receive the highest
d. Liquid or semi-liquid stools
a. Ineffective peripheral tissue perfusion related to venous
15.Nurse Linda prepares to perform an otoscopic examination on
a female client. For proper visualization, the nurse should
b. Risk for injury related to edema.
position the client's ear by:
c. Excess fluid volume related to peripheral vascular disease.
a. Pulling the lobule down and back
d. Impaired gas exchange related to increased blood flow.
b. Pulling the helix up and forward
c. Pulling the helix up and back
5. Nurse Betty is assigned to the following clients. The client that
d. Pulling the lobule down and forward
the nurse would see first after endorsement?
a. A 34 year-old post operative appendectomy client of five hours
16. Which instruction should nurse Tom give to a male client who
who is complaining of pain.
is having external radiation therapy:
b. A 44 year-old myocardial infarction (MI) client who is
a. Protect the irritated skin from sunlight.
complaining of nausea.
b. Eat 3 to 4 hours before treatment.
c. A 26 year-old client admitted for dehydration whose
c. Wash the skin over regularly.
intravenous (IV) has infiltrated.
d. Apply lotion or oil to the radiated area when it is red or sore.
d. A 63 year-old post operative’s abdominal hysterectomy client
of three days whose incisional dressing is saturated
17.In assisting a female client for immediate surgery, the nurse
with serosanguinous fluid.
In-charge is aware that she should:
a. Encourage the client to void following preoperative medication.
6. Nurse Gail places a client in a four-point restraint following
b. Explore the client’s fears and anxieties about the surgery.
orders from the physician. The client care plan should include:
c. Assist the client in removing dentures and nail polish.
a. Assess temperature frequently.
d. Encourage the client to drink water prior to surgery.
b. Provide diversional activities.
c. Check circulation every 15-30 minutes.
18. A male client is admitted and diagnosed with acute
d. Socialize with other patients once a shift.
pancreatitis after a holiday celebration of excessive food and
alcohol. Which assessment finding reflects this diagnosis?
7. A male client who has severe burns is receiving H2 receptor
a. Blood pressure above normal range.
antagonist therapy. The nurse In-charge knows the purpose of
b. Presence of crackles in both lung fields.
this therapy is to:
c. Hyperactive bowel sounds
a. Prevent stress ulcer
d. Sudden onset of continuous epigastric and back pain.
b. Block prostaglandin synthesis
c. Facilitate protein synthesis.
19. Which dietary guidelines are important for nurse Oliver to
d. Enhance gas exchange
implement in caring for the client with burns?
a. Provide high-fiber, high-fat diet
8. The doctor orders hourly urine output measurement for a
b. Provide high-protein, high-carbohydrate diet.
postoperative male client. The nurse Trish records the following
c. Monitor intake to prevent weight gain.
amounts of output for 2 consecutive hours: 8 a.m.: 50 ml; 9 a.m.:
d. Provide ice chips or water intake.
60 ml. Based on these amounts, which action should the nurse
20.Nurse Hazel will administer a unit of whole blood, which
a. Increase the I.V. fluid infusion rate
priority information should the nurse have about the client?
b. Irrigate the indwelling urinary catheter
a. Blood pressure and pulse rate.
c. Notify the physician
b. Height and weight.
d. Continue to monitor and record hourly urine output
c. Calcium and potassium levels
d. Hgb and Hct levels.
9. Tony, a basketball player twist his right ankle while playing on
the court and seeks care for ankle pain and swelling. After the
21. Nurse Michelle witnesses a female client sustain a fall and
nurse applies ice to the ankle for 30 minutes, which statement by
suspects that the leg may be broken. The nurse takes which
Tony suggests that ice application has been effective?
priority action?
a. “My ankle looks less swollen now”.
a. Takes a set of vital signs.
b. “My ankle feels warm”.
b. Call the radiology department for X-ray.
c. Reassure the client that everything will be alright. a. Diagnostic test results
d. Immobilize the leg before moving the client. b. Biographical date
c. History of present illness
22.A male client is being transferred to the nursing unit for d. Physical examination
admission after receiving a radium implant for bladder cancer.
The nurse in-charge would take which priority action in the care 33.In preventing the development of an external rotation
of this client? deformity of the hip in a client who must remain in bed for any
a. Place client on reverse isolation. period of time, the most appropriate nursing action would be to
b. Admit the client into a private room. use:
c. Encourage the client to take frequent rest periods. a. Trochanter roll extending from the crest of the ileum to the
d. Encourage family and friends to visit. midthigh.
b. Pillows under the lower legs.
23.A newly admitted female client was diagnosed with c. Footboard
agranulocytosis. The nurse formulates which priority nursing d. Hip-abductor pillow
a. Constipation 34.Which stage of pressure ulcer development does the ulcer
b. Diarrhea extend into the subcutaneous tissue?
c. Risk for infection a. Stage I
d. Deficient knowledge b. Stage II
c. Stage III
24.A male client is receiving total parenteral nutrition suddenly d. Stage IV
demonstrates signs and symptoms of an air embolism. What is
the priority action by the nurse? 35.When the method of wound healing is one in which wound
a. Notify the physician. edges are not surgically approximated and integumentary
b. Place the client on the left side in the Trendelenburg position. continuity is restored by granulations, the wound healing is
c. Place the client in high-Fowlers position. termed
d. Stop the total parenteral nutrition. a. Second intention healing
b. Primary intention healing
25.Nurse May attends an educational conference on leadership c. Third intention healing
styles. The nurse is sitting with a nurse employed at a large d. First intention healing
trauma center who states that the leadership style at the trauma
center is task-oriented and directive. The nurse determines that 36.An 80-year-old male client is admitted to the hospital with a
the leadership style used at the trauma center is: diagnosis of pneumonia. Nurse Oliver learns that the client lives
a. Autocratic. alone and hasn’t been eating or drinking. When assessing him for
b. Laissez-faire. dehydration, nurse Oliver would expect to find:
c. Democratic. a. Hypothermia
d. Situational b. Hypertension
c. Distended neck veins
26.The physician orders DS 500 cc with KCl 10 mEq/liter at 30 d. Tachycardia
cc/hr. The nurse in-charge is going to hang a 500 cc bag. KCl is
supplied 20 mEq/10 cc. How many cc’s of KCl will be added to the 37.The physician prescribes meperidine (Demerol), 75 mg I.M.
IV solution? every 4 hours as needed, to control a client’s postoperative pain.
a. .5 cc The package insert is “Meperidine, 100 mg/ml.” How many
b. 5 cc milliliters of meperidine should the
c. 1.5 cc client receive?
d. 2.5 cc a. 0.75
b. 0.6
27.A child of 10 years old is to receive 400 cc of IV fluid in an 8 c. 0.5
hour shift. The IV drip factor is 60. The IV rate that will deliver this d. 0.25
amount is:
a. 50 cc/ hour 38. A male client with diabetes mellitus is receiving insulin. Which
b. 55 cc/ hour statement correctly describes an insulin unit?
c. 24 cc/ hour a. It’s a common measurement in the metric system.
d. 66 cc/ hour b. It’s the basis for solids in the avoirdupois system.
c. It’s the smallest measurement in the apothecary system.
28.The nurse is aware that the most important nursing action d. It’s a measure of effect, not a standard measure of weight or
when a client returns from surgery is: quantity.
a. Assess the IV for type of fluid and rate of flow.
b. Assess the client for presence of pain. 39.Nurse Oliver measures a client’s temperature at 102° F. What
c. Assess the Foley catheter for patency and urine output is the equivalent Centigrade temperature?
d. Assess the dressing for drainage. a. 40.1 °C
b. 38.9 °C
29. Which of the following vital sign assessments that may c. 48 °C
indicate cardiogenic shock after myocardial infarction? d. 38 °C
a. BP – 80/60, Pulse – 110 irregular
b. BP – 90/50, Pulse – 50 regular 40.The nurse is assessing a 48-year-old client who has come to
c. BP – 130/80, Pulse – 100 regular the physician’s office for his annual physical exam. One of the
d. BP – 180/100, Pulse – 90 irregular first physical
signs of aging is:
30.Which is the most appropriate nursing action in obtaining a a. Accepting limitations while developing assets.
blood pressure measurement? b. Increasing loss of muscle tone.
a. Take the proper equipment, place the client in a comfortable c. Failing eyesight, especially close vision.
position, and record the appropriate information in the client’s d. Having more frequent aches and pains.
b. Measure the client’s arm, if you are not sure of the size of cuff
to use. 41.The physician inserts a chest tube into a female client to treat
c. Have the client recline or sit comfortably in a chair with the a pneumothorax. The tube is connected to water-seal drainage.
forearm at the level of the heart. The nurse in-charge can prevent chest tube air leaks by:
d. Document the measurement, which extremity was used, and a. Checking and taping all connections.
the position that the client was in during the measurement. b. Checking patency of the chest tube.
c. Keeping the head of the bed slightly elevated.
31.Asking the questions to determine if the person understands d. Keeping the chest drainage system below the level of the
the health teaching provided by the nurse would be included chest.
during which step of the nursing process?
a. Assessment
b. Evaluation 42.Nurse Trish must verify the client’s identity before
c. Implementation administering medication. She is aware that the safest way to
d. Planning and goals verify identity is to:
a. Check the client’s identification band.
32.Which of the following item is considered the single most b. Ask the client to state his name.
important factor in assisting the health professional in arriving at c. State the client’s name out loud and wait a client to repeat it.
a diagnosis or determining the person’s needs? d. Check the room number and the client’s name on the bed.
c. Hyperphosphatemia
43.The physician orders dextrose 5 % in water, 1,000 ml to be d. Hypercalcemia
infused over 8 hours. The I.V. tubing delivers 15 drops/ml. Nurse
John should run the I.V. infusion at a rate of: 54.Nurse Len is administering sublingual nitrglycerin (Nitrostat)
a. 30 drops/minute to the newly admitted client. Immediately afterward, the client
b. 32 drops/minute may experience:
c. 20 drops/minute a. Throbbing headache or dizziness
d. 18 drops/minute b. Nervousness or paresthesia.
c. Drowsiness or blurred vision.
44.If a central venous catheter becomes disconnected d. Tinnitus or diplopia.
accidentally, what should the nurse in-charge do immediately?
a. Clamp the catheter 55.Nurse Michelle hears the alarm sound on the telemetry
b. Call another nurse monitor. The nurse quickly looks at the monitor and notes that a
c. Call the physician client is in a ventricular tachycardia. The nurse rushes to the
d. Apply a dry sterile dressing to the site. client’s room. Upon reaching the client’s bedside, the nurse
would take which action first?
45.A female client was recently admitted. She has fever, weight a. Prepare for cardioversion
loss, and watery diarrhea is being admitted to the facility. While b. Prepare to defibrillate the client
assessing the client, Nurse Hazel inspects the client’s abdomen c. Call a code
and notice that it is slightly concave. Additional assessment d. Check the client’s level of consciousness
should proceed in which order:
a. Palpation, auscultation, and percussion. 56.Nurse Hazel is preparing to ambulate a female client. The best
b. Percussion, palpation, and auscultation. and the safest position for the nurse in assisting the client is to
c. Palpation, percussion, and auscultation. stand:
d. Auscultation, percussion, and palpation. a. On the unaffected side of the client.
b. On the affected side of the client.
46. Nurse Betty is assessing tactile fremitus in a client with c. In front of the client.
pneumonia. For this examination, nurse Betty should use the: d. Behind the client.
a. Fingertips
b. Finger pads 57.Nurse Janah is monitoring the ongoing care given to the
c. Dorsal surface of the hand potential organ donor who has been diagnosed with brain death.
d. Ulnar surface of the hand The nurse determines that the standard of care had been
maintained if which of the following data is observed?
47. Which type of evaluation occurs continuously throughout the a. Urine output: 45 ml/hr
teaching and learning process? b. Capillary refill: 5 seconds
a. Summative c. Serum pH: 7.32
b. Informative d. Blood pressure: 90/48 mmHg
c. Formative
d. Retrospective 58. Nurse Amy has an order to obtain a urinalysis from a male
client with an indwelling urinary catheter. The nurse avoids which
48.A 45 year old client, has no family history of breast cancer or of the following, which contaminate the specimen?
other risk factors for this disease. Nurse John should instruct her a. Wiping the port with an alcohol swab before inserting the
to have syringe.
mammogram how often? b. Aspirating a sample from the port on the drainage bag.
a. Twice per year c. Clamping the tubing of the drainage bag.
b. Once per year d. Obtaining the specimen from the urinary drainage bag.
c. Every 2 years
d. Once, to establish baseline 59.Nurse Meredith is in the process of giving a client a bed bath.
In the middle of the procedure, the unit secretary calls the nurse
49.A male client has the following arterial blood gas values: pH on the intercom to tell the nurse that there is an emergency
7.30; Pao2 89 mmHg; Paco2 50 mmHg; and HCO3 26mEq/L. phone call. The appropriate nursing action is to:
Based on these values, Nurse Patricia should expect which a. Immediately walk out of the client’s room and answer the
condition? phone call.
a. Respiratory acidosis b. Cover the client, place the call light within reach, and answer
b. Respiratory alkalosis the phone call.
c. Metabolic acidosis c. Finish the bed bath before answering the phone call.
d. Metabolic alkalosis d. Leave the client’s door open so the client can be monitored
and the nurse can answer the phone call.
50.Nurse Len refers a female client with terminal cancer to a
local hospice. What is the goal of this referral? 60. Nurse Janah is collecting a sputum specimen for culture and
a. To help the client find appropriate treatment options. sensitivity testing from a client who has a productive cough.
b. To provide support for the client and family in coping with Nurse Janah plans to implement which intervention to obtain the
terminal illness. specimen?
c. To ensure that the client gets counseling regarding health care a. Ask the client to expectorate a small amount of sputum into
costs. the emesis basin.
d. To teach the client and family about cancer and its treatment. b. Ask the client to obtain the specimen after breakfast.
c. Use a sterile plastic container for obtaining the specimen.
51.When caring for a male client with a 3-cm stage I pressure d. Provide tissues for expectoration and obtaining the specimen.
ulcer on the coccyx, which of the following actions can the nurse
institute 61. Nurse Ron is observing a male client using a walker. The
independently? nurse determines that the client is using the walker correctly if
a. Massaging the area with an astringent every 2 hours. the client:
b. Applying an antibiotic cream to the area three times per day. a. Puts all the four points of the walker flat on the floor, puts
c. Using normal saline solution to clean the ulcer and applying a weight on the hand pieces, and then walks into it.
protective dressing as necessary. b. Puts weight on the hand pieces, moves the walker forward,
d. Using a povidone-iodine wash on the ulceration three times per and then walks into it.
day. c. Puts weight on the hand pieces, slides the walker forward, and
then walks into it.
d. Walks into the walker, puts weight on the hand pieces, and
52.Nurse Oliver must apply an elastic bandage to a client’s ankle then puts all four points of the walker flat on the floor.
and calf. He should apply the bandage beginning at the client’s:
a. Knee 62.Nurse Amy has documented an entry regarding client care in
b. Ankle the client’s medical record. When checking the entry, the nurse
c. Lower thigh realizes that incorrect information was documented. How does
d. Foot the nurse correct this error?
a. Erases the error and writes in the correct information.
53.A 10 year old child with type 1 diabetes develops diabetic b. Uses correction fluid to cover up the incorrect information and
ketoacidosis and receives a continuous insulin infusion. Which writes in the correct information.
condition represents the greatest risk to this child? c. Draws one line to cross out the incorrect information and then
a. Hypernatremia initials the change.
b. Hypokalemia d. Covers up the incorrect information completely using a black
pen and writes in the correct information
a. Non-maleficence
63.Nurse Ron is assisting with transferring a client from the b. Beneficence
operating room table to a stretcher. To provide safety to the c. Justice
client, the nurse should: d. Solidarity
a. Moves the client rapidly from the table to the stretcher.
b. Uncovers the client completely before transferring to the 74.When a nurse in-charge causes an injury to a female patient
stretcher. and the injury caused becomes the proof of the negligent act, the
c. Secures the client safety belts after transferring to the presence of the injury is said to exemplify the principle of:
stretcher. a. Force majeure
d. Instructs the client to move self from the table to the stretcher. b. Respondeat superior
c. Res ipsa loquitor
64.Nurse Myrna is providing instructions to a nursing assistant d. Holdover doctrine
assigned to give a bed bath to a client who is on contact
precautions. Nurse Myrna instructs the nursing assistant to use 75.Nurse Myrna is aware that the Board of Nursing has quasi-
which of the following protective items when giving bed bath? judicial power. An example of this power is:
a. Gown and goggles a. The Board can issue rules and regulations that will govern
b. Gown and gloves the practice of nursing
c. Gloves and shoe protectors b. The Board can investigate violations of the nursing law and
d. Gloves and goggles code of ethics
c. The Board can visit a school applying for a permit in
65. Nurse Oliver is caring for a client with impaired mobility that collaboration with CHED
occurred as a result of a stroke. The client has right sided arm d. The Board prepares the board examinations
and leg weakness. The nurse would suggest that the client use
which of the following assistive devices that would provide the 76. When the license of nurse Krina is revoked, it means that she:
best stability for ambulating? a. Is no longer allowed to practice the profession for the rest of
a. Crutches her life
b. Single straight-legged cane b. Will never have her/his license re-issued since it has been
c. Quad cane revoked
d. Walker c. May apply for re-issuance of his/her license based on
certain conditions stipulated in RA 9173
66.A male client with a right pleural effusion noted on a chest X- d. Will remain unable to practice professional nursing
ray is being prepared for thoracentesis. The client experiences
severe dizziness when sitting upright. To provide a safe 77.Ronald plans to conduct a research on the use of a new
environment, the nurse assists the client to which position for the method of pain assessment scale. Which of the following is the
procedure? second step in the conceptualizing phase of the research
a. Prone with head turned toward the side supported by a pillow. process?
b. Sims’ position with the head of the bed flat. a. Formulating the research hypothesis
c. Right side-lying with the head of the bed elevated 45 degrees. b. Review related literature
d. Left side-lying with the head of the bed elevated 45 degrees. c. Formulating and delimiting the research problem
d. Design the theoretical and conceptual framework
67.Nurse John develops methods for data gathering. Which of the
following criteria of a good instrument refers to the ability of the 78. The leader of the study knows that certain patients who are in
instrument to yield the same results upon its repeated a specialized research setting tend to respond psychologically to
administration? the conditions of the study. This referred to as :
a. Validity a. Cause and effect
b. Specificity b. Hawthorne effect
c. Sensitivity c. Halo effect
d. Reliability d. Horns effect

68.Harry knows that he has to protect the rights of human 79.Mary finally decides to use judgment sampling on her
research subjects. Which of the following actions of Harry ensures research. Which of the following actions of is correct?
anonymity? a. Plans to include whoever is there during his study.
a. Keep the identities of the subject secret b. Determines the different nationality of patients frequently
b. Obtain informed consent admitted and decides to get representations samples from each.
c. Provide equal treatment to all the subjects of the study. c. Assigns numbers for each of the patients, place these in a
d. Release findings only to the participants of the study fishbowl and draw 10 from it.
d. Decides to get 20 samples from the admitted patients
69.Patient’s refusal to divulge information is a limitation because
it is beyond the control of Tifanny”. What type of research is 80. The nursing theorist who developed transcultural nursing
appropriate for this study? theory is:
a. Descriptive- correlational a. Florence Nightingale
b. Experiment b. Madeleine Leininger
c. Quasi-experiment c. Albert Moore
d. Historical d. Sr. Callista Roy

70.Nurse Ronald is aware that the best tool for data gathering is? 81.Marion is aware that the sampling method that gives equal
a. Interview schedule chance to all units in the population to get picked is:
b. Questionnaire a. Random
c. Use of laboratory data b. Accidental
d. Observation c. Quota
d. Judgment
71.Monica is aware that there are times when only manipulation
of study variables is possible and the elements of control or
randomization are not attendant. Which type of research is 82.John plans to use a Likert Scale to his study to determine the:
referred to this? a. Degree of agreement and disagreement
a. Field study b. Compliance to expected standards
b. Quasi-experiment c. Level of satisfaction
c. Solomon-Four group design d. Degree of acceptance
d. Post-test only design
83.Which of the following theory addresses the four modes of
72.Cherry notes down ideas that were derived from the adaptation?
description of an investigation written by the person who a. Madeleine Leininger
b. Sr. Callista Roy
conducted it. Which type of reference source refers to this?
c. Florence Nightingale
a. Footnote
d. Jean Watson
b. Bibliography
c. Primary source 84.Ms. Garcia is responsible to the number of personnel reporting to
d. Endnotes her. This principle refers to:
a. Span of control
73.When Nurse Trish is providing care to his patient, she must b. Unity of command
remember that her duty is bound not to do doing any action that c. Downward communication
will cause the patient harm. This is the meaning of the bioethical d. Leader
c. 3 hours
85.Ensuring that there is an informed consent on the part of the d. 2 hours
patient before a surgery is done, illustrates the bioethical principle of:
a. Beneficence 98.Nurse Monique is monitoring the effectiveness of a client's drug
b. Autonomy therapy. When should the nurse Monique obtain a blood sample to
c. Veracity measure the trough drug level?
d. Non-maleficence a. 1 hour before administering the next dose.
b. Immediately before administering the next dose.
86.Nurse Reese is teaching a female client with peripheral vascular c. Immediately after administering the next dose.
disease about foot care; Nurse Reese should include which d. 30 minutes after administering the next dose.
a. Avoid wearing cotton socks. 99.Nurse May is aware that the main advantage of using a floor stock
b. Avoid using a nail clipper to cut toenails. system is:
c. Avoid wearing canvas shoes. a. The nurse can implement medication orders quickly.
d. Avoid using cornstarch on feet. b. The nurse receives input from the pharmacist.
c. The system minimizes transcription errors.
87.A client is admitted with multiple pressure ulcers. When d. The system reinforces accurate calculations.
developing the client's diet plan, the nurse should include:
a. Fresh orange slices 100. Nurse Oliver is assessing a client's abdomen. Which finding
b. Steamed broccoli should the nurse report as abnormal?
c. Ice cream a. Dullness over the liver.
d. Ground beef patties b. Bowel sounds occurring every 10 seconds.
c. Shifting dullness over the abdomen.
88.The nurse prepares to administer a cleansing enema. What is the d. Vascular sounds heard over the renal arteries.
most common client position used for this procedure?
a. Lithotomy
b. Supine
c. Prone
d. Sims’ left lateral

89.Nurse Marian is preparing to administer a blood transfusion. Which

action should the nurse take first?
a. Arrange for typing and cross matching of the client’s blood.
b. Compare the client’s identification wristband with the tag on the
unit of blood.
c. Start an I.V. infusion of normal saline solution.
d. Measure the client’s vital signs.

90.A 65 years old male client requests his medication at 9 p.m.

instead of 10 p.m. so that he can go to sleep earlier. Which type of
nursing intervention is required?
a. Independent
b. Dependent
c. Interdependent
d. Intradependent

91.A female client is to be discharged from an acute care facility

after treatment for right leg thrombophlebitis. The Nurse Betty notes
that the client's leg is pain-free, without redness or edema. The
nurse's actions reflect which step of the nursing process?
a. Assessment
b. Diagnosis
c. Implementation
d. Evaluation

92.Nursing care for a female client includes removing elastic

stockings once per day. The Nurse Betty is aware that the rationale
for this intervention?
a. To increase blood flow to the heart
b. To observe the lower extremities
c. To allow the leg muscles to stretch and relax
d. To permit veins in the legs to fill with blood.

93.Which nursing intervention takes highest priority when caring for a

newly admitted client who's receiving a blood transfusion?
a. Instructing the client to report any itching, swelling, or dyspnea.
b. Informing the client that the transfusion usually take 1 ½ to 2
c. Documenting blood administration in the client care record.
d. Assessing the client’s vital signs when the transfusion ends.

94.A male client complains of abdominal discomfort and nausea

while receiving tube feedings. Which intervention is most appropriate
for this problem?
a. Give the feedings at room temperature.
b. Decrease the rate of feedings and the concentration of the formula.
c. Place the client in semi-Fowler's position while feeding.
d. Change the feeding container every 12 hours.

95.Nurse Patricia is reconstituting a powdered medication in a vial.

After adding the solution to the powder, she nurse should:
a. Do nothing.
b. Invert the vial and let it stand for 3 to 5 minutes.
c. Shake the vial vigorously.
d. Roll the vial gently between the palms.

96.Which intervention should the nurse Trish use when administering

oxygen by face mask to a female client?
a. Secure the elastic band tightly around the client's head.
b. Assist the client to the semi-Fowler position if possible.
c. Apply the face mask from the client's chin up over the nose.
d. Loosen the connectors between the oxygen equipment
and humidifier.

97.The maximum transfusion time for a unit of packed red blood cells
(RBCs) is:
a. 6 hours
b. 4 hours
because the feces can't move past the impaction. These clients
typically report the urge
1. Answer: (D) The actions of a reasonably prudent nurse with to defecate (although they can't pass stool) and a decreased
similar education and experience. appetite.
Rationale: The standard of care is determined by the average
degree of skill, care, and diligence by nurses in similar 15. Answer: (C) Pulling the helix up and back
circumstances. Rationale: To perform an otoscopic examination on an adult, the
nurse grasps the helix of the ear and pulls it up and back to
2. Answer: (B) I.M straighten the ear canal. For a child, the nurse grasps the helix
Rationale: With a platelet count of 22,000/μl, the clients tends to and pulls it down to straighten the ear canal. Pulling the lobule in
bleed easily. Therefore, the nurse should avoid using the I.M. any direction wouldn't straighten the ear canal for visualization.
route because the area is a highly vascular and can bleed readily
when penetrated by a needle. The bleeding can be difficult to 16. Answer: (A) Protect the irritated skin from sunlight.
stop. Rationale: Irradiated skin is very sensitive and must be protected
with clothing or sunblock. The priority approach is the avoidance
3. Answer: (C) “Digoxin 0.125 mg P.O. once daily” of strong sunlight.
Rationale: The nurse should always place a zero before a decimal
point so that no one misreads the figure, which could result in a 17. Answer: (C) Assist the client in removing dentures and nail
dosage error. The nurse should never insert a zero at the end of polish.
a dosage that includes a decimal point because this could be Rationale: Dentures, hairpins, and combs must be removed. Nail
misread, possibly leading to a tenfold increase in the dosage. polish must be removed so that cyanosis can be easily monitored
by observing the nail beds.
4. Answer: (A) Ineffective peripheral tissue perfusion related to
venous congestion. 18. Answer: (D) Sudden onset of continuous epigastric and back
Rationale: Ineffective peripheral tissue perfusion related to pain.
venous congestion takes the highest priority because venous Rationale: The autodigestion of tissue by the pancreatic enzymes
inflammation and clot formation impede blood flow in a client results in pain from inflammation, edema, and possible
with deep vein thrombosis. hemorrhage. Continuous, unrelieved epigastric or back pain
reflects the inflammatory process in the pancreas.
5. Answer: (B) A 44 year-old myocardial infarction (MI) client who
is complaining of nausea. 19. Answer: (B) Provide high-protein, high-carbohydrate diet.
Rationale: Nausea is a symptom of impending myocardial Rationale: A positive nitrogen balance is important for meeting
infarction (MI) and should be assessed immediately so that metabolic needs, tissue repair, and resistance to infection.
treatment can be instituted and further damage to the heart is Caloric goals may be as high as 5000 calories per day.
20. Answer: (A) Blood pressure and pulse rate.
6. Answer: (C) Check circulation every 15-30 minutes. Rationale: The baseline must be established to recognize the
Rationale: Restraints encircle the limbs, which place the client at signs of an anaphylactic or hemolytic reaction to the transfusion.
risk for circulation being restricted to the distal areas of the
extremities. Checking the client’s circulation every 15-30 minutes 21. Answer: (D) Immobilize the leg before moving the client.
will allow the nurse to adjust the restraints before injury from Rationale: If the nurse suspects a fracture, splinting the area
decreased blood flow occurs. before moving the client is imperative. The nurse should call for
emergency help if the client is not hospitalized and call for a
7. Answer: (A) Prevent stress ulcer physician for the hospitalized client.
Rationale: Curling’s ulcer occurs as a generalized stress response
in burn patients. This results in a decreased production of mucus 22. Answer: (B) Admit the client into a private room.
and increased secretion of gastric acid. The best treatment for Rationale: The client who has a radiation implant is placed in a
this prophylactic use of antacids and H2 receptor blockers. private room and has a limited number of visitors. This reduces
the exposure of others to the radiation.
8. Answer: (D) Continue to monitor and record hourly urine
output 23. Answer: (C) Risk for infection
Rationale: Normal urine output for an adult is approximately 1 Rationale: Agranulocytosis is characterized by a reduced number
ml/minute (60 ml/hour). Therefore, this client's output is normal. of leukocytes (leucopenia) and neutrophils (neutropenia) in the
Beyond continued evaluation, no nursing action is warranted. blood. The client is at high risk for infection because of the
decreased body defenses against microorganisms. Deficient
9. Answer: (B) “My ankle feels warm”. knowledge related to the nature of the disorder may be
Rationale: Ice application decreases pain and swelling. Continued appropriate diagnosis but is not the priority.
or increased pain, redness, and increased warmth are signs of
inflammation that shouldn't occur after ice application
24. Answer: (B) Place the client on the left side in the
Trendelenburg position.
10. Answer: (B) Hyperkalemia
Rationale: Lying on the left side may prevent air from flowing into
Rationale: A loop diuretic removes water and, along with it,
the pulmonary veins. The Trendelenburg position increases
sodium and potassium. This may result in hypokalemia,
intrathoracic pressure, which decreases the amount of blood
hypovolemia, and hyponatremia.
pulled into the vena cava during aspiration.
11. Answer:(A) Have condescending trust and confidence in
25. Answer: (A) Autocratic.
their subordinates
Rationale: The autocratic style of leadership is a task-oriented
Rationale: Benevolent-authoritative managers pretentiously show
and directive.
their trust and confidence to their followers.

12. Answer: (A) Provides continuous, coordinated and 26. Answer: (D) 2.5 cc
comprehensive nursing services. Rationale: 2.5 cc is to be added, because only a 500 cc bag of
Rationale: Functional nursing is focused on tasks and activities solution is being medicated instead of a 1 liter.
and not on the care of the patients.
27. Answer: (A) 50 cc/ hour
13. Answer: (B) Standard written order Rationale: A rate of 50 cc/hr. The child is to receive 400 cc over a
Rationale: This is a standard written order. Prescribers write a period of 8 hours = 50 cc/hr.
single order for medications given only once. A stat order is
written for 28. Answer: (B) Assess the client for presence of pain.
medications given immediately for an urgent client problem. A Rationale: Assessing the client for pain is a very important
standing order, also known as a protocol, establishes guidelines measure. Postoperative pain is an indication of complication. The
for treating a nurse should also assess the client for pain to provide for the
particular disease or set of symptoms in special care areas such client’s comfort.
as the coronary care unit. Facilities also may institute medication
protocols that specifically designate drugs that a nurse may not 29. Answer: (A) BP – 80/60, Pulse – 110 irregular
give. Rationale: The classic signs of cardiogenic shock are low blood
pressure, rapid and weak irregular pulse, cold, clammy skin,
14. Answer: (D) Liquid or semi-liquid stools decreased urinary output, and cerebral hypoxia.
Rationale: Passage of liquid or semi-liquid stools results from
seepage of unformed bowel contents around the impacted stool 30. Answer: (A) Take the proper equipment, place the client in a
in the rectum. Clients comfortable position, and record the appropriate information in
with fecal impaction don't pass hard, brown, formed stools the client’s chart.
Rationale: It is a general or comprehensive statement about the 2.1 ml/X gtt = 1 ml/ 15 gtt
correct procedure, and it includes the basic ideas which are found X = 32 gtt/minute, or 32 drops/minute
in the other options
44. Answer: (A) Clamp the catheter
31. Answer: (B) Evaluation Rationale: If a central venous catheter becomes disconnected,
Rationale: Evaluation includes observing the person, asking the nurse should immediately apply a catheter clamp, if
questions, and comparing the patient’s behavioral responses with available. If a clamp isn’t available, the nurse can place a sterile
the expected outcomes. syringe or catheter plug in the catheter hub. After cleaning the
hub with alcohol or povidone-iodine solution, the nurse must
32. Answer: (C) History of present illness replace the I.V. extension and restart the infusion.
Rationale: The history of present illness is the single most
important factor in assisting the health professional in arriving at 45. Answer: (D) Auscultation, percussion, and palpation.
a diagnosis or determining the person’s needs. Rationale: The correct order of assessment for examining the
abdomen is inspection, auscultation, percussion, and palpation.
33. Answer: (A) Trochanter roll extending from the crest of the The reason for this approach is that the less intrusive techniques
ileum to the mid-thigh. should be performed before the more intrusive techniques.
Rationale: A trochanter roll, properly placed, provides resistance Percussion and palpation can alter natural findings during
to the external rotation of the hip. auscultation.

34. Answer: (C) Stage III 46. Answer: (D) Ulnar surface of the hand
Rationale: Clinically, a deep crater or without undermining of Rationale: The nurse uses the ulnar surface, or ball, of the hand
adjacent tissue is noted. to asses tactile fremitus, thrills, and vocal vibrations through the
chest wall. The
35. Answer: (A) Second intention healing fingertips and finger pads best distinguish texture and shape. The
Rationale: When wounds dehisce, they will allowed to heal by dorsal surface best feels warmth.
secondary intention
47. Answer: (C) Formative
36. Answer: (D) Tachycardia Rationale: Formative (or concurrent) evaluation occurs
Rationale: With an extracellular fluid or plasma volume deficit, continuously throughout the teaching and learning process. One
compensatory mechanisms stimulate the heart, causing an benefit is that the nurse can adjust teaching strategies as
increase in heart rate. necessary to enhance learning. Summative, or retrospective,
evaluation occurs at the conclusion of the teaching and learning
37. Answer: (A) 0.75 session. Informative is not a type of evaluation.
Rationale: To determine the number of milliliters the client should
receive, the nurse uses the fraction method in the following 48. Answer: (B) Once per year
equation. Rationale: Yearly mammograms should begin at age 40 and
continue for
75 mg/X ml = 100 mg/1 ml as long as the woman is in good health. If health risks, such as
To solve for X, cross-multiply: family
75 mg x 1 ml = X ml x 100 mg history, genetic tendency, or past breast cancer, exist, more
75 = 100X frequent
75/100 = X examinations may be necessary.
0.75 ml (or ¾ ml) = X
49. Answer: (A) Respiratory acidosis
38. Answer: (D) It’s a measure of effect, not a standard measure Rationale: The client has a below-normal (acidic) blood pH value
of weight or quantity. and an above-normal partial pressure of arterial carbon dioxide
Rationale: An insulin unit is a measure of effect, not a standard (Paco2) value, indicating respiratory acidosis. In respiratory
measure of weight or quantity. Different drugs measured in units alkalosis, the pH value is above normal and in the Paco2 value is
may have no relationship to one another in quality or quantity. below normal. In metabolic acidosis, the pH and bicarbonate
(Hco3) values are below normal. In metabolic alkalosis, the pH
39. Answer: (B) 38.9 °C and Hco3 values are above normal.
Rationale: To convert Fahrenheit degreed to Centigrade, use this
formula 50. Answer: (B) To provide support for the client and family in
coping with terminal illness.
°C = (°F – 32) ÷ 1.8 Rationale: Hospices provide supportive care for terminally ill
°C = (102 – 32) ÷ 1.8 clients and their families. Hospice care doesn’t focus on
°C = 70 ÷ 1.8 counseling regarding health care costs. Most client referred to
°C = 38.9 hospices have been treated for their disease without success and
will receive only palliative care in the hospice.
40. Answer: (C) Failing eyesight, especially close vision.
Rationale: Failing eyesight, especially close vision, is one of the 51. Answer: (C) Using normal saline solution to clean the ulcer
first signs of aging in middle life (ages 46 to 64). More frequent and applying a protective dressing as necessary.
aches and pains begin in the early late years (ages 65 to 79). Rationale: Washing the area with normal saline solution and
Increase in loss of muscle tone occurs in later years (age 80 and applying a protective dressing are within the nurse’s realm of
older). interventions and will protect the area. Using a povidone-iodine
wash and an antibiotic cream require a physician’s order.
Massaging with an astringent can further damage the skin.
41. Answer: (A) Checking and taping all connections
Rationale: Air leaks commonly occur if the system isn’t secure.
Checking all connections and taping them will prevent air leaks. 52. Answer: (D) Foot
The chest drainage system is kept lower to promote drainage – Rationale: An elastic bandage should be applied form the distal
not to prevent leaks. area to the proximal area. This method promotes venous return.
In this case, the nurse should begin applying the bandage at the
client’s foot. Beginning at the ankle, lower thigh, or knee does not
42. Answer: (A) Check the client’s identification band.
promote venous return.
Rationale: Checking the client’s identification band is the safest
way to verify a client’s identity because the band is assigned on
admission and isn’t be removed at any time. (If it is removed, it 53. Answer: (B) Hypokalemia
must be replaced). Asking the client’s name or having the client Rationale: Insulin administration causes glucose and potassium to
repeated his name would be appropriate only for a client who’s move into the cells, causing hypokalemia.
alert, oriented, and able to understand what is being said, but
isn’t the safe standard of practice. Names on bed aren’t always 54. Answer: (A) Throbbing headache or dizziness
reliable Rationale: Headache and dizziness often occur when nitroglycerin
is taken at the beginning of therapy. However, the client usually
43. Answer: (B) 32 drops/minute develops tolerance
Rationale: Giving 1,000 ml over 8 hours is the same as giving 125
ml over 1 hour (60 minutes). Find the number of milliliters per 55. Answer: (D) Check the client’s level of consciousness
minute as follows: Rationale: Determining unresponsiveness is the first step
assessment action to take. When a client is in ventricular
tachycardia, there is a significant decrease in cardiac output.
125/60 minutes = X/1 minute
However, checking the unresponsiveness ensures whether the
60X = 125 = 2.1 ml/minute
client is affected by the decreased cardiac output.
To find the number of drops per minute:
56. Answer: (B) On the affected side of the client. unaffected side with the head of the bed elevated 30 to 45
Rationale: When walking with clients, the nurse should stand on degrees.
the affected side and grasp the security belt in the midspine area
of the small of the back. The nurse should position the free hand 67. Answer: (D) Reliability
at the shoulder area so that the client can be pulled toward the Rationale: Reliability is consistency of the research instrument. It
nurse in the event that there is a forward fall. The client is refers to
instructed to look up and outward rather than at his or her feet. the repeatability of the instrument in extracting the same
responses upon
57. Answer: (A) Urine output: 45 ml/hr its repeated administration.
Rationale: Adequate perfusion must be maintained to all vital
organs in order for the client to remain visible as an organ donor. 68. Answer: (A) Keep the identities of the subject secret
A urine output of 45 ml per hour indicates adequate renal Rationale: Keeping the identities of the research subject secret
perfusion. Low blood pressure and delayed capillary refill time will ensure anonymity because this will hinder providing link
are circulatory system indicators of inadequate perfusion. A between the information given to whoever is its source.
serum pH of 7.32 is acidotic, which adversely affects all body
tissues. 69. Answer: (A) Descriptive- correlational
Rationale: Descriptive- correlational study is the most appropriate
58. Answer: (D ) Obtaining the specimen from the urinary for this study because it studies the variables that could be the
drainage bag. antecedents of the increased incidence of nosocomial infection.
Rationale: A urine specimen is not taken from the urinary
drainage bag. Urine undergoes chemical changes while sitting in 70. Answer: (C) Use of laboratory data
the bag and does not necessarily reflect the current client status. Rationale: Incidence of nosocomial infection is best collected
In addition, it may become contaminated with bacteria from through the use of biophysiologic measures, particularly in vitro
opening the system. measurements, hence laboratory data is essential.

59. Answer: (B) Cover the client, place the call light within reach, 71. Answer: (B) Quasi-experiment
and answer the phone call. Rationale: Quasi-experiment is done when randomization and
Rationale: Because telephone call is an emergency, the nurse control of the variables are not possible.
may need to answer it. The other appropriate action is to ask
another nurse to accept the call. However, is not one of the 72. Answer: (C) Primary source Rationale: This refers to a primary
options. To maintain privacy and safety, the nurse covers the source which is a direct account of the investigation done by the
client and places the call light within the client’s reach. investigator. In contrast to this is a secondary source, which is
Additionally, the client’s door should be closed or the room written by someone other than the original researcher.
curtains pulled around the bathing area.
73. Answer: (A) Non-maleficence
60. Answer: (C) Use a sterile plastic container for obtaining the Rationale: Non-maleficence means do not cause harm or do any
specimen. action that will cause any harm to the patient/client. To do good
Rationale: Sputum specimens for culture and sensitivity testing is referred as beneficence.
need to be obtained using sterile techniques because the test is
done to determine the presence of organisms. If the procedure 74. Answer: (C) Res ipsa loquitor
for obtaining the specimen is not sterile, then the specimen is not Rationale: Res ipsa loquitor literally means the thing speaks for
sterile, then the specimen would be contaminated and the results itself. This means in operational terms that the injury caused is
of the test would be invalid. the proof that there was a negligent act.

61. Answer: (A) Puts all the four points of the walker flat on the
75. Answer: (B) The Board can investigate violations of the
floor, puts weight on the hand pieces, and then walks into it.
nursing law and code of ethics
Rationale: When the client uses a walker, the nurse stands
Rationale: Quasi-judicial power means that the Board of Nursing
adjacent to the affected side. The client is instructed to put all
has the authority to investigate violations of the nursing law and
four points of the walker 2 feet forward flat on the floor before
can issue summons, subpoena or subpoena duces tecum as
putting weight on hand pieces. This will ensure client safety and
prevent stress cracks in the walker. The client is then instructed
to move the walker forward and walk into it.
76. Answer: (C) May apply for re-issuance of his/her license based
on certain conditions stipulated in RA 9173
62. Answer: (C) Draws one line to cross out the incorrect
Rationale: RA 9173 sec. 24 states that for equity and justice, a
information and then initials the change.
revoked license maybe re-issued provided that the following
Rationale: To correct an error documented in a medical record,
conditions are met: a)
the nurse draws one line through the incorrect information and
the cause for revocation of license has already been corrected or
then initials the error. An error is never erased and correction
removed; and, b) at least four years has elapsed since the license
fluid is never used in the medical record.
has been revoked.
63. Answer: (C) Secures the client safety belts after transferring
to the stretcher. 77. Answer: (B) Review related literature
Rationale: During the transfer of the client after the surgical Rationale: After formulating and delimiting the research problem,
procedure is complete, the nurse should avoid exposure of the the researcher conducts a review of related literature to
client because of the risk for potential heat loss. Hurried determine the extent of what has been done on the study by
movements and rapid changes in the position should be avoided previous researchers.
because these predispose the client to hypotension. At the time
of the transfer from the surgery table to the stretcher, the client 78. Answer: (B) Hawthorne effect
is still affected by the effects of the anesthesia; therefore, the Rationale: Hawthorne effect is based on the study of Elton Mayo
client should not move self. Safety belts can prevent the client and company about the effect of an intervention done to improve
from falling off the stretcher. the working conditions of the workers on their productivity. It
resulted to an increased productivity but not due to the
64. Answer: (B) Gown and gloves intervention but due to the psychological effects of being
Rationale: Contact precautions require the use of gloves and a observed. They performed differently because they were under
gown if direct client contact is anticipated. Goggles are not observation.
necessary unless the
nurse anticipates the splashes of blood, body fluids, secretions, 79. Answer: (B) Determines the different nationality of patients
or excretions may occur. Shoe protectors are not necessary. frequently admitted and decides to get representations samples
from each.
65. Answer: (C) Quad cane Rationale: Judgment sampling involves including samples
Rationale: Crutches and a walker can be difficult to maneuver for according to the knowledge of the investigator about the
a client with weakness on one side. A cane is better suited for participants in the study.
client with weakness of the arm and leg on one side. However,
the quad cane would provide the most stability because of the 80. Answer: (B) Madeleine Leininger
structure of the cane and because a quad cane has four legs. Rationale: Madeleine Leininger developed the theory on
transcultural theory based on her observations on the behavior of
66. Answer: (D) Left side-lying with the head of the bed elevated selected people within a culture.
45 degrees.
Rationale: To facilitate removal of fluid from the chest wall, the
client is positioned sitting at the edge of the bed leaning over the 81. Answer: (A) Random
bedside table with the feet supported on a stool. If the client is Rationale: Random sampling gives equal chance for all the
unable to sit up, the client is positioned lying in bed on the elements in the population to be picked as part of the sample.
82. Answer: (A) Degree of agreement and disagreement client of the duration of the transfusion and should document its
Rationale: Likert scale is a 5-point summated scale used to administration, these actions are less critical to the client's
determine the degree of agreement or disagreement of the immediate health. The nurse should assess vital signs at least
respondents to a statement in a study hourly during the transfusion.

83. Answer: (B) Sr. Callista Roy 94. Answer: (B) Decrease the rate of feedings and the
Rationale: Sr. Callista Roy developed the Adaptation Model which concentration of the formula.
involves the physiologic mode, self-concept mode, role function Rationale: Complaints of abdominal discomfort and nausea are
mode and dependence mode. common in clients receiving tube feedings. Decreasing the rate of
the feeding and the concentration of the formula should decrease
the client's discomfort. Feedings are normally given at room
84. Answer: (A) Span of control temperature to minimize abdominal cramping. To prevent
Rationale: Span of control refers to the number of workers who aspiration during feeding, the head of the client's bed should be
report directly to a manager. elevated at least 30 degrees. Also, to prevent bacterial growth,
feeding containers should be routinely changed every 8 to 12
85. Answer: (B) Autonomy hours.
Rationale: Informed consent means that the patient fully
understands about the surgery, including the risks involved and 95. Answer: (D) Roll the vial gently between the palms.
the alternative solutions. In giving consent it is done with full Rationale: Rolling the vial gently between the palms produces
knowledge and is given freely. The action of allowing the patient heat, which helps dissolve the medication. Doing nothing or
to decide whether a surgery is to be done or not exemplifies the inverting the vial wouldn't help dissolve the medication. Shaking
bioethical principle of autonomy. the vial vigorously could cause the medication to break down,
altering its action.
86. Answer: (C) Avoid wearing canvas shoes.
Rationale: The client should be instructed to avoid wearing 96. Answer: (B) Assist the client to the semi-Fowler position if
canvas shoes. Canvas shoes cause the feet to perspire, which possible.
may, in turn, cause skin irritation and breakdown. Both cotton Rationale: By assisting the client to the semi-Fowler position, the
and cornstarch absorb perspiration. The client should be nurse promotes easier chest expansion, breathing, and oxygen
instructed to cut toenails straight across with nail intake. The nurse should secure the elastic band so that the face
clippers. mask fits comfortably and snugly rather than tightly, which could
lead to irritation. The nurse should apply the face mask from the
87. Answer: (D) Ground beef patties client's nose down to the chin — not vice versa. The nurse should
Rationale: Meat is an excellent source of complete protein, which check the connectors between the oxygen equipment and
this client needs to repair the tissue breakdown caused by humidifier to ensure that they're airtight; loosened connectors
pressure ulcers. can cause loss of oxygen.
Oranges and broccoli supply vitamin C but not protein. Ice cream
supplies only some incomplete protein, making it less helpful in 97. Answer: (B) 4 hours
tissue repair. Rationale: A unit of packed RBCs may be given over a period of
between 1 and 4 hours. It shouldn't infuse for longer than 4 hours
88. Answer: (D) Sims’ left lateral because the risk of contamination and sepsis increases after that
Rationale: The Sims' left lateral position is the most common time. Discard or return to the blood bank any blood not given
position used to administer a cleansing enema because it allows within this time, according to facility policy.
gravity to aid the flow of fluid along the curve of the sigmoid
colon. If the client can't assume this position nor has poor 98. Answer: (B) Immediately before administering the next dose.
sphincter control, the dorsal recumbent or right lateral position Rationale: Measuring the blood drug concentration helps
may be used. The supine and prone positions are inappropriate determine whether the dosing has achieved the therapeutic goal.
and uncomfortable for the client. For measurement of the trough, or lowest, blood level of a drug,
the nurse draws a blood sample immediately before
89. Answer: (A) Arrange for typing and cross matching of the administering the next dose. Depending on the drug's duration of
client’s blood. action and half-life, peak blood drug levels typically are drawn
Rationale: The nurse first arranges for typing and cross matching after administering the next dose.
of the client's blood to ensure compatibility with donor blood. The
other options, 99. Answer: (A) The nurse can implement medication orders
although appropriate when preparing to administer a blood quickly.
transfusion, come later. Rationale: A floor stock system enables the nurse to implement
medication orders quickly. It doesn't allow for pharmacist input,
90. Answer: (A) Independent nor does it minimize transcription errors or reinforce accurate
Rationale: Nursing interventions are classified as independent, calculations.
interdependent, or dependent. Altering the drug schedule to
coincide with the client's daily routine represents an independent 100. Answer: (C) Shifting dullness over the abdomen.
intervention, whereas consulting with the physician and Rationale: Shifting dullness over the abdomen indicates ascites,
pharmacist to change a client's medication because of adverse an abnormal finding. The other options are normal abdominal
reactions represents an interdependent intervention. findings
Administering an already-prescribed drug on time is a dependent
intervention. An intradependent nursing intervention doesn't

91. Answer: (D) Evaluation

Rationale: The nursing actions described constitute evaluation of
the expected outcomes. The findings show that the expected
outcomes have been achieved. Assessment consists of the
client's history, physical examination, and laboratory studies.
Analysis consists of considering assessment information to derive
the appropriate nursing diagnosis. Implementation is the phase of
the nursing process where the nurse puts the plan of care into

92. Answer: (B) To observe the lower extremities

Rationale: Elastic stockings are used to promote venous return.
The nurse needs to remove them once per day to observe the
condition of the skin underneath the stockings. Applying the
stockings increases blood flow to the heart. When the stockings
are in place, the leg muscles can still stretch and relax, and the
veins can fill with blood.

93. Answer:(A) Instructing the client to report any itching,

swelling, or dyspnea.
Rationale: Because administration of blood or blood products
may cause serious adverse effects such as allergic reactions, the
nurse must monitor the client for these effects. Signs and
symptoms of life-threatening allergic reactions include itching,
swelling, and dyspnea. Although the nurse should inform the