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Nursing process can be defined as the: a. Steps the nurse employs to provide care by the nurse b. Steps the nurse employs to provide nursing care c. Process the nurse uses to determine nursing goals d. Activities a nurse employs to identify a nursing problem The nursing process is more than identifying a nursing problem. It is a step-by-step process that scientifically provides for a client s nursing needs. To utilize the nursing process, the nurse must first: a. Identify goals for nursing process b. State the client s nursing needs c. Obtain information about the client d. Evaluate the effectiveness of nursing actions The initial step in any process using problem solving is the collection of data. While taking a nursing history from a client, the nurse promotes communication by a. Asking why and how questions b. Using broad, open-ended statements c. Reassuring the client that there is no cause for alarm d. Asking questions that can be answered by a yes or a no Open-ended questions provide a milieu in which people can verbalize their problems rather than be placed in a situation of forced response. A nursing diagnosis represents the: a. Proposed plan of care b. Client s health problems c. Assessment of client data d. Actual nursing intervention Nursing diagnosis defines an actual or potential health problem faced by the client. To give nursing care to client, the nurse must first: a. Understand the client s emotional conflict b. Develop rapport with the client s physician c. Talk with the client s family or significant other d. Recognize personal feelings toward the client Nurses must actively try to understand their own feelings and prejudices, because these will affect the ability to assess a client s behavior objectively. The family of a client who is terminally ill is likely to require more emotional nursing care than the client when the client reaches the stage of: a. Anger b. Denial c. Depression d. Acceptance In the stage of acceptance the client frequently detaches the self from the environment and may become indifferent to family members. In addition, the family may take longer to accept the inevitable death than does the client. When reaching the point of acceptance in the stages of dying, a client s behavior may reflect: a. Apathy b. Euphoria c. Detachment d. Emotionalism When an individual reaches the point of being able intellectually and psychologically to accept death, anxiety is reduced and the individual becomes detached from the environment. A client asks the nurse, Should I tell my husband that I have AIDS? The nurse s most appropriate response would be: a. This is a decision you alone can make. b. Do not tell him anything unless he asks. c. You are having difficulty deciding what to say. d. Tell him you feel you contracted AIDS from him. This promotes exploration of the client s dilemma; this response encourages further communication. The occurrence of chronic illness is greatest in: a. Older adults b. Adolescents c. Young children

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d. Middle-aged adults As a result of the normal stresses on the body, the incidence of chronic illness increases in the elderly population. Elderly people have a high incidence of hip fractures because of a. Carelessness b. Fragility of bone c. Sedentary existence d. Rheumatoid arthritis Bones become more fragile with advancing age because of osteoporosis, often assoc. with lower circulating levels of estrogens or testosterone. The nurse would expect an elderly client with a hearing loss caused by aging to have: a. Copious, moist cerumen b. Tears in the tympanic membrane c. Difficulty in hearing women s voices d. Overgrowth of the epithelial auditory lining Generally, female voices have a higher pitch than male voices and the elderly with presbycusis (hearing loss by the aging process) have more difficulty hearing these higher-pitched sounds. A client is receiving aminophylline intravenously to relieve severe asthma. The nurse should observe for: a. Hypotension b. Visual disturbances c. Decreased pulse rate d. Decreased urinary output Aminophylline, a theophylline derivative, promotes dieresis and relaxes smooth muscles, resulting in hypotension. Before giving client digoxin, the nurse should obtain the: a. Apical heart rate b. Radial pulse from both arms c. Radial pulse on the left side d. Difference between apical and radial pulses Because Digoxin slows the heart rate, the apical pulse should be counted for 1 minute before administration. If heart rate is above 120, digoxin should also be withheld because of possibility of digitalis toxicity. The nurse should teach a client to suspect that nitroglycerin SL tablets have lost their potency when: a. SL tingling is experienced. b. The tablets are three or more months old c. Pain is unrelieved but facial flushing is increased d. Onset of relief is delayed, but the duration of relief is unchanged. Nitroglycerin SL tablets are affected by sunlight, heat, and moisture. A loss of potency can occur after 3 months, reducing the drug s effectiveness in relieving pain. Evaluation of the effectiveness of nitroglycerin SL is based on: a. Relief of angina pain b. Improved cardiac output c. A decrease in blood pressure d. Dilation of superficial blood vessels Cardiac nitrates relax the smooth muscles of the coronary arteries so that they dilate and deliver more blood to relieve ischemic pain. The loop diuretics alter active transport systems in the kidney tubules, resulting in increased secretion of sodium and, secondarily, water. The principle explaining the secondary water loss (dieresis) is: a. Osmosis b. Diffusion c. Filtration d. Active transport The presence of excess sodium (a solute) in the nephric tubules effectively decreases the water concentration of the glomerular filtrate and urine; water passively diffuses (osmosis) from the kidney tubule cells into the urine to equalize the water concentration. A client receiving propanolol HCl (inderal) should be told to expect: a. Dizziness with strenuous activity b. Acceleration of the heart rate after eating a heavy meal c. Flushing sensations for a few minutes after taking the drug d. Pounding of the heart for a few minutes after taking the drug

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Because propanolol HCl competes with catecholamine at the beta-adrenergic receptor sites, the normal increase in heart rate and contractility in response to exercise does not occur. This, combined with the drug s hypotensive effect, may lead to dizziness. When teaching a client about nitroglycerin therapy, the nurse should include the importance of: a. Limiting the number of tablets to 4 per day b. Discontinuing the medication if a headache develops c. Making certain the medication is stored in a dark container d. Increasing the number of tablets if dizziness or hypertension occurs Nitroglycerin is sensitive to light and moisture and must be stored in a dark airtight container. When anticipating drug therapy for a client who is experiencing a cardiac arrest because of ventricular fibrillation, the nurse should initially prepare: a. Lidocaine HCl 50mg IV bolus b. Dopamine HCl 400mg to 500ml D5W c. Epinephrine HCl 1mg at 1:10000 soln d. NaHCO3 1 mEq per kg of body weight Epinephrine is the drug of first choice in VFib because its alpha adrenergic effects improve susceptibility to defibrillation. A client asks the nurse why the physician has prescribed captopril (Capoten). The nurse explains it is an effective: a. Diuretic b. Hypnotic c. Tranquilizer d. Antihypertensive Captopril inhibits conversion of angiotensin I to angiotensin II. In addition to a decreased apical rate, the nurse should teach the client to withhold prescribed Digoxin if the client experiences: a. Singultus b. Chest pain c. Blurred vision d. Decreased urinary output In addition to Gi disturbances, visual disturbances such as blurred vision may be evidence of digitalis toxicity. Heart rates over 120 may also indicate toxicity. Vitamin B6 is given with isoniazid (INH) because: a. Improves the nutritional status of the client b. Enhances tuberculostic effect of isoniazid c. Provides the vitamin when isoniazid is interfering with natural vitamin synthesis d. Accelerates destruction of remaining organisms after inhibition of their reproduction by isoniazid INH often leads to Vit. B6 deficiency because it competes with the vitamin for the same enzyme. This is most often manifested by peripheral neuritis, which can be controlled by regular administration of vit.B6. A client is to receive Isoprotenerol (Isuprel) prn. The nurse administers this drug to: a. Produce sedation b. Relax bronchial spasm c. Decrease blood pressure d. Increase bronchial secretions Isoprotenerol stimulates the beta receptors of the SNS, causing bronchodilation and increased rate and strength of cardiac contractions. A client is brought to the emergency department in the midst of persistent tonic-clonic convulsions. Diazepam (Valium) is administered, which decreases central neuronal activity and: a. Slows cardiac contractions b. Relaxes peripheral muscles c. Dilates the tracheobronchial structures d. Provides amnesia for the convulsive episode Valium is a tranquilizer used to relax smooth muscles during seizures. Levodopa is prescribed for a client with Parkinson s disease. The nurse should know that this drug: a. Is poorly absorbed if given with meals b. Must be monitored by weekly laboratory tests c. Causes an initial euphoria followed by depression d. May cause a side effect of orthostatic hypotension

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Levodopa is the metabolic precursor to dopamine. It reduces sympathetic outflow by limiting vasoconstriction, which may result to orthostatic HypoTN. Edrophonium HCL (Tensilon) is used for the diagnosis of Myasthenia Gravis because this drug will cause a temporary increase in: a. Symptoms b. Consciousness c. Blood pressure d. Muscle strength Tensilon, an anticholinesterase drug, causes temporary relief of symptoms of MG in clients who have the disease and is therefore and effective diagnostic aid. Folic acid is often prescribed for a client who is receiving phenytoin (Dilantin) because folic acid: a. Improves absorption of iron from foods b. Content of common foods is inadequate c. Prevents neuropathy caused by phenytoin d. Absorption is inhibited by phenytoin Phenytoin inhibits folic acid absorption and potentiates effects of folic acid antagonists. Folic acid is helpful in correcting certain anemias that can result from administration of phenytoin. The physician prescribed phenytoin (Dilantin) for a client to control tonic-clonic seizures. The expected effect of this drug is to: a. Produce an antispasmodic action on the muscles b. Prevent depression of the CNS c. Control nerve impulses originating in the motor cortex d. Alter the permeability of the cell membrane to potassium The primary site of action is the motor cortex, where seizure activity is limited by maintaining the sodium ion gradient of neurons. A client is scheduled to receive phenytoin (Dilantin) 100mg orally at 6pm but is having difficulty swallowing capsules. The nurse should: a. Insert a rectal suppository containing 100mg phenytoin b. Open the capsule and sprinkle the powder in a cup of water c. Administer 4ml of phenytoin suspension containing 125mg/5ml d. Obtain a change in the prescribed administration route to allow IM administration When an oral medication is available in a suspension form, the nurse should use it for patients who cannot swallow capsules. The effectiveness of carbamazepine (Tegretol) in the mgt of tic doloreaux is determined by monitoring the client s a. Pain relief b. Liver function c. Cardiac output d. Seizure activity Carbamazepine is administered to control pain by reducing the transmission of nerve impulses in clients with trigeminal neuralgia. After several days of IV therapy for chloroquine-resistant malaria, the physician replaces the IV injection with the Quinine sulfate, 2g per day in divided doses. The nurse should administer this medication after meals to: a. Delay its absorption b. Minimize gastric irritation c. Decrease stimulation of appetite d. Reduce its antidysrhythmic action Quinine administered orally can cause gastric irritation, causing n/v. by administering such a medication immediately after meals the nurse minimizes its irritating effect. Preparation of a client for subtotal thyroidectomy includes the administration of Lugol s iodine solution. This medication is given to: a. Decrease the total basal metabolic rate b. Maintain the function of the parathyroid glands c. Block the formation of thyroxin by the thyroid gland d. Decrease the size and vascularity of the thyroid gland Lugol s soln provides iodine, which aids in decreasing the vascularity of the thyroid gland, decreasing the risk for hemorrhage. The nurse administers co-trimoxazole (Bactrim) as ordered to combat UTI s. This drug belongs to the group of drugs known as:

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a. Antiseptics b. Analgesics c. Uricosurics d. Sulfonamides Bactrim blocks two consecutive steps in bacterial synthesis of essential nucleic acids and protein. A client with tetanus is to continue taking ampicillin after discharge. The nurse should explain the need to: a. Take ampicillin with meals b. Notify the physician if diarrhea develops c. Store the ampicillin in a light-resistant container d. Continue the drug until a negative culture is obtained Diarrhea is a possible side effect that can be r/t a superinfection. It can lead to F&E imbalance. Gold salts may be used to treat rheumatoid arthritis. A serious effect of this drug is: a. Kidney damage b. Persistent nausea c. Decreased sedimentation rate d. Cardiac decompensation Gold salts, bound to plasma proteins, are distributed irregularly throughout the body but the highest concentration occurs in the kidneys. The slow excretion of gold salts cannot keep up with their intake; they accumulate in the kidneys, causing damage. The nurse is aware that many of the chemotherapeutic agents used in the treatment of cancer cause: a. Leukocytosis b. Bone marrow depression c. Pulmonary emboli d. Increased hemoglobin and hct Most chemotherapeutic agents interfere with mitosis. The bone marrow consists of rapidly dividing cells, and therefore its activity is depressed. The percentage of water in the average adult human body is: a. 80% b. 60% c. 40% d. 20% 60% water percentage in the body is achieved when approx. 1 year after birth to adulthood. The major role in maintaining fluid balance in the body is performed by the a. Liver b. Heart c. Lungs d. Kidney The kidneys regulate fluid balance by adjusting the amount of fluid reabsorbed from the glomerular filtrate. The most important electrolyte of intracellular fluid is a. Sodium b. Calcium c. Chlorides d. Potassium The concentration of K+ is greater inside the cell and is extremely important in establishing a membrane potential, a critical factor in the cell s ability to function. The body fluids that make up 40-50% of the total body weight are: a. Interstitial b. Intracellular c. Extracellular d. Intravascular Approx. 25/40L of body fluid is in the cells. Ammonia is excreted by the kidney to help maintain a. Osmotic pressure of the blood b. Acid base balance of the body c. Low bacterial levels in the blood d. Normal RBC production The excreted ammonia combines with hydrogen ions in the glomerular filtrate to form ammonium ions, which are excreted from the body. This mechanism helps rid the body of excess hydrogen, maintaining acid-base balance.

42. The major role in maintaining fluid balance in the body is performed by the a. Liver b. Heart c. Lungs d. Kidney The kidneys regulate fluid balance by adjusting the amount of fluid reabsorbed from the glomerular filtrate. 43. When IVF s is allowed to flow into a person by gravity,: a. Potential energy is converted to kinetic energy b. Kinetic energy is converted to potential energy c. Chemical energy is converted to kinetic energy d. Potential energy is converted to chemical energy The fluid in a bottle hung over a person lying down possesses potential energy. When fluid is allowed to drip into the person intravenously, its potential energy is then converted to kinetic energy (energy of motion). 44. Air rushes into the alveoli as a result of the; a. Relaxation of the diaphragm b. Rising pressure in the alveoli c. Rising pressure in the pleura d. Lowered pressure in the chest cavity Thoracic pressure is reduced because thoracic volume is increased as the diaphragm descends. 45. A client begins to expectorate blood. The nurse describes this episode as: a. Hematuria b. Hematoma c. Hemoptysis d. Hematemesis Alam na yan! 46. As a result of fractured ribs, the client may develop: a. scoliosis b. pneumothorax c. obstructive lung disease d. herniation of the diaphragm The ribs may penetrate the pleura and the ling, allowing air to fill the pleura space and collapse the lungs. 47. As a result of pulmonary TB, a client has a decreased surface area for gaseous exchange in the lungs. O2 and CO2 are exchanged in the lungs by: a. osmosis b. diffusion c. filtration d. active transport The respiratory membrane, consisting of the alveolar and capillary walls, is extremely thin. This thinness facilitates exchange of respiratory gases without the need for additional energy. 48. The term used to most accurately describe a client s lack of interest in food is: a. apathy b. anoxia c. anorexia d. dysphagia Alam na rin! 49. Before a cholecystectomy, the physician orders Vitamin K. This is administered because it is used in the formation of: a. bilirubin b. prothrombin c. thromboplastin d. cholecystokinin Vit. K is a fat-soluble vitamin and needs bile salts for its absorption from the upper segment of the small intestine. It is a catalyst in the carboxylation of glutamine to prothrombin. 50. To decrease GI irritability, the nurse should teach the client to minimize use of: a. Table salt and rice products b. Sugar products and proteins c. Milk products and cola drinks d. Triglycerides and amino acids Milk and caffeine are chemically irritating to gastric mucosa. They also promote secretion of gastric juice.