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Published by: Filipino Nurses Central on Jul 28, 2009
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FUNDAMENTALS OF NURSING 1. The nurse is preparing a client for chemotherapy to treat colon cancer. The client says.

“I don’t know about this treatment. After everything is said and done, it may not do a bit of good. This thing may get me anyway”. Which response by the nurse would be most therapeutic? a. “You’re wondering whether you’ve made the right decision about the treatment”. b. “Many people beat cancer. You need to keep a positive attitude” c. Colon cancer can now be cured in many cases. Let’s hope you’ll be one of the lucky ones” d. “Everyone with cancer worries, but you have every reason to be hopeful” 2. A client is being discharged after undergoing abdominal surgery and colostomy formation to treat colon cancer. Which nursing action is most likely to promote continuity of care? a. Notifying the American Cancer Society of the client’s diagnosis b. Requesting Meals On Wheels to provide adequate nutritional intake c. Referring the client to a home health nurse for follow-up visits to provide colostomy care d. Asking an occupational therapist to evaluate the client at home 3. The nurse is assisting a client with lower motor neuron damage who has difficulty with urination. The nurse shows the client how to apply gentle pressure over the lower abdomen to empty the bladder. By what name does the nurse refer to this procedure? a. Valsalva’s maneuver b. Crede’s method c. Crede’s maneuver d. Leopold’s maneuver 4. A client who suffered a stroke has a strong diagnosis of Ineffective airway clearance. The goal of care for this client is to mobilize pulmonary secretions. Which interventions would help meet this goal? a. Repositioning the client every 2 hrs b. Restricting fluids to 1,000ml/24 hrs c. Administering O2 by nasal cannula as ordered d. Keeping the head of the bed at a 30-degree angle 5. A client has been receiving an I.V. solution. What is an appropriate expected outcome for this client? a. Monitor fluid I&O every 4 hrs b. The client remains free of signs and symptoms of phlebitis c. Edema and warmth are noted at IV insertion site d. There is a risk for infection related to IV insertion

6. When teaching a client with peripheral vascular disease about foot care, the nurse should include which instruction? a. Avoid using cornstarch on the feet b. Avoid wearing canvas shoes c. Avoid using a nail clipper to cut toenails d. Avoid wearing cotton socks 7. A client scheduled for cardiac catheterization tells the nurse she is nervous because she has heard of people dying during this procedure. Which response by the nurse would be best? a. “I don’t blame you for being nervous. We all worry sometimes” b. “Don’t worry. You’re in excellent hands” c. “Why do you feel this way? Do you know someone who had a problem?” d. “You sound really upset. Would you like to talk about it?” 8. A client hospitalized with pneumonia has thick, tenacious secretions. To help liquefy these secretions, the nurse should: a. Turn the client every 2 hrs b. Elevate the head of the bed 30 degrees c. Encourage increased fluid intake d. Maintain a cool room temperature 9. A client is admitted to the health care facility with active tuberculosis. The nurse should include which intervention in the care plan? a. Putting on an individually fitted mask when entering the client’s room b. Instructing the client to wear a mask at all times c. Wearing a gown and gloves when providing direct care d. Keeping the door to the client’s room open to observe the client 10. To assess the effectiveness of cardiac compressions during adult cardiopulmonary resuscitation (CPR), the nurse should palpate which pulse site? a. Radial b. Apical c. Carotid d. Brachial 11. When placing an indwelling urinary catheter in a female client, the nurse should advance the catheter how far into the urethra? a. 2” (5cm) b. 6” (15cm) c. 8” (20cm) d. ½” (1cm)

12. A drug must enter the bloodstream before it can act within the body. Which parenteral administration route places a drug directly into the circulation, requiring absorption? a. I.M. b. Subcutaneous (S.C.) c. Intradermal d. I.V. 13. A client reports abdominal pain. Which action would aid the nurse’s investigation of the complaint? a. Using deep palpation b. Assessing the painful area last c. Assessing the painful area first d. Checking for warmth in the painful area 14. A client with acute renal failure is prescribed regular insulin 10 I.V. along with 50 ml of dextrose 50%. What electrolyte imbalance is this client most likely experiencing? a. Hypercalcemia b. Hypernatremia c. Hyperglycemia d. Hyperkalemia 15. When providing oral hygiene for an unconscious client, the nurse must take which essential action? a. Swabbing the client’s lips, teeth and gums with lemon glycerin b. Cleaning the client’s tongue with gloved fingers c. Placing the client in semi-fowler’s position d. Placing the client in a side-lying position 16. The nurse is evaluating a client’s auditory function. To compare air conduction to bone conduction, the nurse should conduct which test? a. Whispered voice test b. Weber’s test c. Watch tick test d. Rinne Test 17. The nurse must assess skin turgor of an elderly client. When evaluating skin turgor, the nurse should remember that: a. Overhydration causes the skin to tent b. Dehydration causes the skin to appear edematous and spongy c. Inelastic skin turgor is a normal part of aging d. Normal skin turgor is moist and boggy.

18. The care plan is revised for a client who has difficulty dealing with a crying neonate. Which strategy should the new care plan include early in this mother’s hospital stay? a. Anger management therapy b. Proper care of a crying infant c. Proper methods for dealing with stressful situations such as crying infants d. Assessments of the mother’s strengths and weaknesses in coping mechanisms and the presence or absence of support systems

19. Standard precautions include which of the following measures? a. Wearing gloves when changing a dressing b. Disposing of needles in a puncture-resistant container c. Wearing eye protection during tracheal suctioning d. All of the above

20. A client with shock brought on by hemorrhage has a temp of 36.4 C, HR of 140bpm, RR of 28 bpm, and BP of 60/30 mmHg. For this client, the nurse should question which physician order? a. Monitor urine output every hour b. Infuse IV fluids at 83ml/hr c. Administer O2 by nasal cannula at 3 L/minute d. Dram samples for hemoglobin and hematocrit every 6 hrs

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