1.

The nurse In-charge in labor and delivery unit administered a dose of

terbutaline to a client without checking the clients pulse. The standard
that would be used to determine if the nurse was negligent is:

a. The physicians orders.
b. The action of a clinical nurse specialist who is recognized expert in the
field.
c. The statement in the drug literature about administration of
terbutaline.
d. The actions of a reasonably prudent nurse with similar education and
experience.


2. Nurse Trish is caring for a female client with a history of GI bleeding,
sickle cell disease, and a platelet count of 22,000/l. The female client is
dehydrated and receiving dextrose 5% in half-normal saline solution at
150 ml/hr. The client complains of severe bone pain and is scheduled to
receive a dose of morphine sulfate. In administering the medication,
Nurse Trish should avoid which route?
a. I.V
b. I.M
c. Oral
d. S.C


3. Dr. Garcia writes the following order for the client who has been
recently admitted Digoxin .125 mg P.O. once daily. To prevent a dosage
error, how should the nurse document this order onto the medication
administration record?

a. Digoxin .1250 mg P.O. once daily
b. Digoxin 0.1250 mg P.O. once daily
c. Digoxin 0.125 mg P.O. once daily
d. Digoxin .125 mg P.O. once daily


4. A newly admitted female client was diagnosed with deep vein
thrombosis. Which nursing diagnosis should receive the highest priority?

a. Ineffective peripheral tissue perfusion related to venous congestion.
b. Risk for injury related to edema.
c. Excess fluid volume related to peripheral vascular disease.
d. Impaired gas exchange related to increased blood flow.

5. Nurse Betty is assigned to the following clients. The client that the
nurse would see first after endorsement?
a. A 34 year-old post operative appendectomy client of five hours who is
complaining of pain.
b. A 44 year-old myocardial infarction (MI) client who is complaining of
nausea.
c. A 26 year-old client admitted for dehydration whose intravenous (IV)
has infiltrated.
d. A 63 year-old post operatives abdominal hysterectomy client of three
days whose incisional dressing is saturated with serosanguinous fluid.


6. Nurse Gail places a client in a four-point restraint following orders from
the physician. The client care plan should include:
a. Assess temperature frequently.
b. Provide diversional activities.
c. Check circulation every 15-30 minutes.
d. Socialize with other patients once a shift.


7. A male client who has severe burns is receiving H2 receptor antagonist
therapy. The nurse In-charge knows the purpose of this therapy is to:
a. Prevent stress ulcer
b. Block prostaglandin synthesis
c. Facilitate protein synthesis.
d. Enhance gas exchange


8. The doctor orders hourly urine output measurement for a
postoperative male client. The nurse Trish records the following amounts
of output for 2 consecutive hours: 8 a.m.: 50 ml; 9 a.m.: 60 ml. Based on
these amounts, which action should the nurse take?
a. Increase the I.V. fluid infusion rate
b. Irrigate the indwelling urinary catheter
c. Notify the physician
d. Continue to monitor and record hourly urine output


9. Tony, a basketball player twist his right ankle while playing on the
court and seeks care for ankle pain and swelling. After the nurse applies
ice to the ankle for 30 minutes, which statement by Tony suggests that
ice application has been effective?
a. My ankle looks less swollen now.
b. My ankle feels warm.
c. My ankle appears redder now.
d. I need something stronger for pain relief

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?
a. Hypernatremia
b. Hyperkalemia
c. Hypokalemia
d. Hypervolemia


11.She finds out that some managers have benevolent-authoritative style
of management. Which of the following behaviors will she exhibit most
likely?
a. Have condescending trust and confidence in their subordinates.
b. Gives economic and ego awards.
c. Communicates downward to staffs.
d. Allows decision making among subordinates.


12. Nurse Amy is aware that the following is true about functional nursing
a. Provides continuous, coordinated and comprehensive nursing services.
b. One-to-one nurse patient ratio.
c. Emphasize the use of group collaboration.
d. Concentrates on tasks and activities.


13.Which type of medication order might read "Vitamin K 10 mg I.M.
daily 3 days?"

a. Single order
b. Standard written order
c. Standing order
d. Stat order


14.A female client with a fecal impaction frequently exhibits which
clinical manifestation?
a. Increased appetite
b. Loss of urge to defecate
c. Hard, brown, formed stools
d. Liquid or semi-liquid stools


15.Nurse Linda prepares to perform an otoscopic examination on a
female client. For proper visualization, the nurse should position the
client's ear by:

a. Pulling the lobule down and back
b. Pulling the helix up and forward
c. Pulling the helix up and back
d. Pulling the lobule down and forward


16. Which instruction should nurse Tom give to a male client who is
having external radiation therapy:

a. Protect the irritated skin from sunlight.
b. Eat 3 to 4 hours before treatment.
c. Wash the skin over regularly.
d. Apply lotion or oil to the radiated area when it is red or sore.


17.In assisting a female client for immediate surgery, the nurse In-charge
is aware that she should:

a. Encourage the client to void following preoperative medication.
b. Explore the clients fears and anxieties about the surgery.
c. Assist the client in removing dentures and nail polish.
d. Encourage the client to drink water prior to surgery.


18. A male client is admitted and diagnosed with acute pancreatitis after
a holiday celebration of excessive food and alcohol. Which assessment
finding reflects this diagnosis?

a. Blood pressure above normal range.
b. Presence of crackles in both lung fields.
c. Hyperactive bowel sounds
d. Sudden onset of continuous epigastric and back pain.


19. Which dietary guidelines are important for nurse Oliver to implement
in caring for the client with burns?

a. Provide high-fiber, high-fat diet
b. Provide high-protein, high-carbohydrate diet.
c. Monitor intake to prevent weight gain.
d. Provide ice chips or water intake.


20.Nurse Hazel will administer a unit of whole blood, which priority
information should the nurse have about the client?

a. Blood pressure and pulse rate.
b. Height and weight.
c. Calcium and potassium levels
d. Hgb and Hct levels.


21. Nurse Michelle witnesses a female client sustain a fall and suspects
that the leg may be broken. The nurse takes which priority action?

a. Takes a set of vital signs.
b. Call the radiology department for X-ray.
c. Reassure the client that everything will be alright.
d. Immobilize the leg before moving the client.


22.A male client is being transferred to the nursing unit for admission
after receiving a radium implant for bladder cancer. The nurse in-charge
would take which priority action in the care of this client?

a. Place client on reverse isolation.
b. Admit the client into a private room.
c. Encourage the client to take frequent rest periods.
d. Encourage family and friends to visit.


23.A newly admitted female client was diagnosed with agranulocytosis.
The nurse formulates which priority nursing diagnosis?

a. Constipation
b. Diarrhea
c. Risk for infection
d. Deficient knowledge


24.A male client is receiving total parenteral nutrition suddenly
demonstrates signs and symptoms of an air embolism. What is the
priority action by the nurse?

a. Notify the physician.
b. Place the client on the left side in the Trendelenburg position.
c. Place the client in high-Fowlers position.
d. Stop the total parenteral nutrition.


25.Nurse May attends an educational conference on leadership styles.
The nurse is sitting with a nurse employed at a large trauma center who
states that the leadership style at the trauma center is task-oriented and
directive. The nurse determines that the leadership style used at the
trauma center is:

a. Autocratic.
b. Laissez-faire.
c. Democratic.
d. Situational


26.The physician orders DS 500 cc with KCl 10 mEq/liter at 30 cc/hr. The
nurse in-charge is going to hang a 500 cc bag. KCl is supplied 20 mEq/10
cc. How many ccs of KCl will be added to the IV solution?

a. .5 cc
b. 5 cc
c. 1.5 cc
d. 2.5 cc


27.A child of 10 years old is to receive 400 cc of IV fluid in an 8 hour shift.
The IV drip factor is 60. The IV rate that will deliver this amount is:

a. 50 cc/ hour
b. 55 cc/ hour
c. 24 cc/ hour
d. 66 cc/ hour


28.The nurse is aware that the most important nursing action when a
client returns from surgery is:

a. Assess the IV for type of fluid and rate of flow.
b. Assess the client for presence of pain.
c. Assess the Foley catheter for patency and urine output
d. Assess the dressing for drainage.


29. Which of the following vital sign assessments that may indicate
cardiogenic shock after myocardial infarction?

a. BP 80/60, Pulse 110 irregular
b. BP 90/50, Pulse 50 regular
c. BP 130/80, Pulse 100 regular
d. BP 180/100, Pulse 90 irregular


30.Which is the most appropriate nursing action in obtaining a blood
pressure measurement?

a. Take the proper equipment, place the client in a comfortable position,
and record the appropriate information in the clients chart.
b. Measure the clients arm, if you are not sure of the size of cuff to use.
c. Have the client recline or sit comfortably in a chair with the forearm at
the level of the heart.
d. Document the measurement, which extremity was used, and the
position that the client was in during the measurement.


31.Asking the questions to determine if the person understands the
health teaching provided by the nurse would be included during which
step of the nursing process?

a. Assessment
b. Evaluation
c. Implementation
d. Planning and goals


32.Which of the following item is considered the single most important
factor in assisting the health professional in arriving at a diagnosis or
determining the persons needs?

a. Diagnostic test results
b. Biographical date
c. History of present illness
d. Physical examination


33.In preventing the development of an external rotation deformity of
the hip in a client who must remain in bed for any period of time, the
most appropriate nursing action would be to use:

a. Trochanter roll extending from the crest of the ileum to the midthigh.
b. Pillows under the lower legs.
c. Footboard
d. Hip-abductor pillow


34.Which stage of pressure ulcer development does the ulcer extend into
the subcutaneous tissue?

a. Stage I
b. Stage II
c. Stage III
d. Stage IV


35.When the method of wound healing is one in which wound edges are
not surgically approximated and integumentary continuity is restored by
granulations, the wound healing is termed

a. Second intention healing
b. Primary intention healing
c. Third intention healing
d. First intention healing


36.An 80-year-old male client is admitted to the hospital with a diagnosis
of pneumonia. Nurse Oliver learns that the client lives alone and hasnt
been eating or drinking. When assessing him for dehydration, nurse
Oliver would expect to find:

a. Hypothermia
b. Hypertension
c. Distended neck veins
d. Tachycardia


37.The physician prescribes meperidine (Demerol), 75 mg I.M. every 4
hours as needed, to control a clients postoperative pain. The package
insert is Meperidine, 100 mg/ml. How many milliliters of meperidine
should the
client receive?

a. 0.75
b. 0.6
c. 0.5
d. 0.25


38. A male client with diabetes mellitus is receiving insulin. Which
statement correctly describes an insulin unit?

a. Its a common measurement in the metric system.
b. Its the basis for solids in the avoirdupois system.
c. Its the smallest measurement in the apothecary system.
d. Its a measure of effect, not a standard measure of weight or quantity.


39.Nurse Oliver measures a clients temperature at 102 F. What is the
equivalent Centigrade temperature?

a. 40.1 C
b. 38.9 C
c. 48 C
d. 38 C


40.The nurse is assessing a 48-year-old client who has come to the
physicians office for his annual physical exam. One of the first physical
signs of aging is:

a. Accepting limitations while developing assets.
b. Increasing loss of muscle tone.
c. Failing eyesight, especially close vision.
d. Having more frequent aches and pains.


41.The physician inserts a chest tube into a female client to treat a
pneumothorax. The tube is connected to water-seal drainage. The nurse
in-charge can prevent chest tube air leaks by:

a. Checking and taping all connections.
b. Checking patency of the chest tube.
c. Keeping the head of the bed slightly elevated.
d. Keeping the chest drainage system below the level of the chest.


42.Nurse Trish must verify the clients identity before administering
medication. She is aware that the safest way to verify identity is to:

a. Check the clients identification band.
b. Ask the client to state his name.
c. State the clients name out loud and wait a client to repeat it.
d. Check the room number and the clients name on the bed.


43.The physician orders dextrose 5 % in water, 1,000 ml to be infused
over 8 hours. The I.V. tubing delivers 15 drops/ml. Nurse John should run
the I.V. infusion at a rate of:

a. 30 drops/minute
b. 32 drops/minute
c. 20 drops/minute
d. 18 drops/minute


44.If a central venous catheter becomes disconnected accidentally, what
should the nurse in-charge do immediately?

a. Clamp the catheter
b. Call another nurse
c. Call the physician
d. Apply a dry sterile dressing to the site.


45.A female client was recently admitted. She has fever, weight loss, and
watery diarrhea is being admitted to the facility. While assessing the
client, Nurse Hazel inspects the clients abdomen and notice that it is
slightly concave. Additional assessment should proceed in which order:

a. Palpation, auscultation, and percussion.
b. Percussion, palpation, and auscultation.
c. Palpation, percussion, and auscultation.
d. Auscultation, percussion, and palpation.


46. Nurse Betty is assessing tactile fremitus in a client with pneumonia.
For this examination, nurse Betty should use the:

a. Fingertips
b. Finger pads
c. Dorsal surface of the hand
d. Ulnar surface of the hand


47. Which type of evaluation occurs continuously throughout the
teaching and learning process?

a. Summative
b. Informative
c. Formative
d. Retrospective


48.A 45 year old client, has no family history of breast cancer or other risk
factors for this disease. Nurse John should instruct her to have
mammogram how often?

a. Twice per year
b. Once per year
c. Every 2 years
d. Once, to establish baseline


49.A male client has the following arterial blood gas values: pH 7.30; Pao2
89 mmHg; Paco2 50 mmHg; and HCO3 26mEq/L. Based on these values,
Nurse Patricia should expect which condition?

a. Respiratory acidosis
b. Respiratory alkalosis
c. Metabolic acidosis
d. Metabolic alkalosis


50.Nurse Len refers a female client with terminal cancer to a local
hospice. What is the goal of this referral?

a. To help the client find appropriate treatment options.
b. To provide support for the client and family in coping with terminal
illness.
c. To ensure that the client gets counseling regarding health care costs.
d. To teach the client and family about cancer and its treatment.


51.When caring for a male client with a 3-cm stage I pressure ulcer on the
coccyx, which of the following actions can the nurse institute
independently?

a. Massaging the area with an astringent every 2 hours.
b. Applying an antibiotic cream to the area three times per day.
c. Using normal saline solution to clean the ulcer and applying a
protective dressing as necessary.
d. Using a povidone-iodine wash on the ulceration three times per day.


52.Nurse Oliver must apply an elastic bandage to a clients ankle and calf.
He should apply the bandage beginning at the clients:

a. Knee
b. Ankle
c. Lower thigh
d. Foot


53.A 10 year old child with type 1 diabetes develops diabetic ketoacidosis
and receives a continuous insulin infusion. Which condition represents
the greatest risk to this child?

a. Hypernatremia
b. Hypokalemia
c. Hyperphosphatemia
d. Hypercalcemia


54.Nurse Len is administering sublingual nitrglycerin (Nitrostat) to the
newly admitted client. Immediately afterward, the client may experience:

a. Throbbing headache or dizziness
b. Nervousness or paresthesia.
c. Drowsiness or blurred vision.
d. Tinnitus or diplopia.


55.Nurse Michelle hears the alarm sound on the telemetry monitor. The
nurse quickly looks at the monitor and notes that a client is in a
ventricular tachycardia. The nurse rushes to the clients room. Upon
reaching the clients bedside, the nurse would take which action first?

a. Prepare for cardioversion
b. Prepare to defibrillate the client
c. Call a code
d. Check the clients level of consciousness


56.Nurse Hazel is preparing to ambulate a female client. The best and the
safest position for the nurse in assisting the client is to stand:

a. On the unaffected side of the client.
b. On the affected side of the client.
c. In front of the client.
d. Behind the client.


57.Nurse Janah is monitoring the ongoing care given to the potential
organ donor who has been diagnosed with brain death. The nurse
determines that the standard of care had been maintained if which of the
following data is observed?

a. Urine output: 45 ml/hr
b. Capillary refill: 5 seconds
c. Serum pH: 7.32
d. Blood pressure: 90/48 mmHg


58. Nurse Amy has an order to obtain a urinalysis from a male client with
an indwelling urinary catheter. The nurse avoids which of the following,
which contaminate the specimen?

a. Wiping the port with an alcohol swab before inserting the syringe.
b. Aspirating a sample from the port on the drainage bag.
c. Clamping the tubing of the drainage bag.
d. Obtaining the specimen from the urinary drainage bag.


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 on the
intercom to tell the nurse that there is an emergency phone call. The
appropriate nursing action is to:

a. Immediately walk out of the clients room and answer the phone call.
b. Cover the client, place the call light within reach, and answer the
phone call.
c. Finish the bed bath before answering the phone call.
d. Leave the clients door open so the client can be monitored and the
nurse can answer the phone call.


60. Nurse Janah is collecting a sputum specimen for culture and
sensitivity testing from a client who has a productive cough. Nurse Janah
plans to implement which intervention to obtain the specimen?

a. Ask the client to expectorate a small amount of sputum into the emesis
basin.
b. Ask the client to obtain the specimen after breakfast.
c. Use a sterile plastic container for obtaining the specimen.
d. Provide tissues for expectoration and obtaining the specimen.


61. Nurse Ron is observing a male client using a walker. The nurse
determines that the client is using the walker correctly if the client:

a. Puts all the four points of the walker flat on the floor, puts weight on
the hand pieces, and then walks into it.
b. Puts weight on the hand pieces, moves the walker forward, and then
walks into it.
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 then puts
all four points of the walker flat on the floor.


62.Nurse Amy has documented an entry regarding client care in the
clients medical record. When checking the entry, the nurse realizes that
incorrect information was documented. How does the nurse correct this
error?

a. Erases the error and writes in the correct information.
b. Uses correction fluid to cover up the incorrect information and writes
in the correct information.
c. Draws one line to cross out the incorrect information and then initials
the change.
d. Covers up the incorrect information completely using a black pen and
writes in the correct information


63.Nurse Ron is assisting with transferring a client from the operating
room table to a stretcher. To provide safety to the client, the nurse
should:

a. Moves the client rapidly from the table to the stretcher.
b. Uncovers the client completely before transferring to the stretcher.
c. Secures the client safety belts after transferring to the stretcher.
d. Instructs the client to move self from the table to the stretcher.


64.Nurse Myrna is providing instructions to a nursing assistant assigned
to give a bed bath to a client who is on contact precautions. Nurse Myrna
instructs the nursing assistant to use which of the following protective
items when giving bed bath?

a. Gown and goggles
b. Gown and gloves
c. Gloves and shoe protectors
d. Gloves and goggles


65. Nurse Oliver is caring for a client with impaired mobility that occurred
as a result of a stroke. The client has right sided arm and leg weakness.
The nurse would suggest that the client use which of the following
assistive devices that would provide the best stability for ambulating?

a. Crutches
b. Single straight-legged cane
c. Quad cane
d. Walker


66.A male client with a right pleural effusion noted on a chest X-ray is
being prepared for thoracentesis. The client experiences severe dizziness
when sitting upright. To provide a safe environment, the nurse assists the
client to which position for the procedure?

a. Prone with head turned toward the side supported by a pillow.
b. Sims position with the head of the bed flat.
c. Right side-lying with the head of the bed elevated 45 degrees.
d. Left side-lying with the head of the bed elevated 45 degrees.


67.Nurse John develops methods for data gathering. Which of the
following criteria of a good instrument refers to the ability of the
instrument to yield the same results upon its repeated administration?

a. Validity
b. Specificity
c. Sensitivity
d. Reliability


68.Harry knows that he has to protect the rights of human research
subjects. Which of the following actions of Harry ensures anonymity?

a. Keep the identities of the subject secret
b. Obtain informed consent
c. Provide equal treatment to all the subjects of the study.
d. Release findings only to the participants of the study


69.Patients refusal to divulge information is a limitation because it is
beyond the control of Tifanny. What type of research is appropriate for
this study?

a. Descriptive- correlational
b. Experiment
c. Quasi-experiment
d. Historical


70.Nurse Ronald is aware that the best tool for data gathering is?

a. Interview schedule
b. Questionnaire
c. Use of laboratory data
d. Observation


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 referred to this?

a. Field study
b. Quasi-experiment
c. Solomon-Four group design
d. Post-test only design


72.Cherry notes down ideas that were derived from the description of
an investigation written by the person who conducted it. Which type
of reference source refers to this?

a. Footnote
b. Bibliography
c. Primary source
d. Endnotes


73.When Nurse Trish is providing care to his patient, she must remember
that her duty is bound not to do doing any action that will cause the
patient harm. This is the meaning of the bioethical principle:

a. Non-maleficence
b. Beneficence
c. Justice
d. Solidarity


74.When a nurse in-charge causes an injury to a female patient and the
injury caused becomes the proof of the negligent act, the presence of the
injury is said to exemplify the principle of:

a. Force majeure
b. Respondeat superior
c. Res ipsa loquitor
d. Holdover doctrine


75.Nurse Myrna is aware that the Board of Nursing has quasi-judicial
power. An example of this power is:

a. The Board can issue rules and regulations that will govern the practice
of nursing
b. The Board can investigate violations of the nursing law and code
of ethics
c. The Board can visit a school applying for a permit in collaboration with
CHED
d. The Board prepares the board examinations


76. When the license of nurse Krina is revoked, it means that she:

a. Is no longer allowed to practice the profession for the rest of her life
b. Will never have her/his license re-issued since it has been revoked
c. May apply for re-issuance of his/her license based on
certain conditions stipulated in RA 9173
d. Will remain unable to practice professional nursing


77.Ronald plans to conduct a research on the use of a new method of
pain assessment scale. Which of the following is the second step in
the conceptualizing phase of the research process?

a. Formulating the research hypothesis
b. Review related literature
c. Formulating and delimiting the research problem
d. Design the theoretical and conceptual framework


78. The leader of the study knows that certain patients who are in
a specialized research setting tend to respond psychologically to
the conditions of the study. This referred to as :

a. Cause and effect
b. Hawthorne effect
c. Halo effect
d. Horns effect


79.Mary finally decides to use judgment sampling on her research. Which
of the following actions of is correct?

a. Plans to include whoever is there during his study.
b. Determines the different nationality of patients frequently
admitted and decides to get representations samples from each.
c. Assigns numbers for each of the patients, place these in a fishbowl and
draw 10 from it.
d. Decides to get 20 samples from the admitted patients


80. The nursing theorist who developed transcultural nursing theory is:

a. Florence Nightingale
b. Madeleine Leininger
c. Albert Moore
d. Sr. Callista Roy


81.Marion is aware that the sampling method that gives equal chance to
all units in the population to get picked is:

a. Random
b. Accidental
c. Quota
d. Judgment


82.John plans to use a Likert Scale to his study to determine the:

a. Degree of agreement and disagreement
b. Compliance to expected standards
c. Level of satisfaction
d. Degree of acceptance


83.Which of the following theory addresses the four modes of
adaptation?

a. Madeleine Leininger
b. Sr. Callista Roy
c. Florence Nightingale
d. Jean Watson


84.Ms. Garcia is responsible to the number of personnel reporting to her.
This principle refers to:

a. Span of control
b. Unity of command
c. Downward communication
d. Leader


85.Ensuring that there is an informed consent on the part of the
patient before a surgery is done, illustrates the bioethical principle of:

a. Beneficence
b. Autonomy
c. Veracity
d. Non-maleficence


86.Nurse Reese is teaching a female client with peripheral vascular
disease about foot care; Nurse Reese should include which instruction?

a. Avoid wearing cotton socks.
b. Avoid using a nail clipper to cut toenails.
c. Avoid wearing canvas shoes.
d. Avoid using cornstarch on feet.


87.A client is admitted with multiple pressure ulcers. When developing
the client's diet plan, the nurse should include:

a. Fresh orange slices
b. Steamed broccoli
c. Ice cream
d. Ground beef patties


88.The nurse prepares to administer a cleansing enema. What is the
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 clients blood.
b. Compare the clients identification wristband with the tag on the
unit of blood.
c. Start an I.V. infusion of normal saline solution.
d. Measure the clients 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 to 2 hours.
c. Documenting blood administration in the client care record.
d. Assessing the clients 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
c. 3 hours
d. 2 hours


98.Nurse Monique is monitoring the effectiveness of a client's drug
therapy. When should the nurse Monique obtain a blood sample to
measure the trough drug level?

a. 1 hour before administering the next dose.
b. Immediately before administering the next dose.
c. Immediately after administering the next dose.
d. 30 minutes after administering the next dose.


99.Nurse May is aware that the main advantage of using a floor stock
system is:

a. The nurse can implement medication orders quickly.
b. The nurse receives input from the pharmacist.
c. The system minimizes transcription errors.
d. The system reinforces accurate calculations.


100. Nurse Oliver is assessing a client's abdomen. Which finding should
the nurse report as abnormal?

a. Dullness over the liver.
b. Bowel sounds occurring every 10 seconds.
c. Shifting dullness over the abdomen.
d. Vascular sounds heard over the renal arteries.













1. Answer: (D) The actions of a reasonably prudent nurse with
similar education and experience.
Rationale: The standard of care is determined by the average degree
of skill, care, and diligence by nurses in similar circumstances.

2. Answer: (B) I.M
Rationale: With a platelet count of 22,000/l, the clients tends to
bleed easily. Therefore, the nurse should avoid using the I.M. route
because the area is a highly vascular and can bleed readily when
penetrated by a needle. The bleeding can be difficult to stop.

3. Answer: (C) Digoxin 0.125 mg P.O. once daily
Rationale: The nurse should always place a zero before a decimal point so
that no one misreads the figure, which could result in a dosage error. The
nurse should never insert a zero at the end of a dosage that includes a
decimal point because this could be misread, possibly leading to a tenfold
increase in the dosage.

4. Answer: (A) Ineffective peripheral tissue perfusion related to
venous congestion.
Rationale: Ineffective peripheral tissue perfusion related to
venous congestion takes the highest priority because venous
inflammation and clot formation impede blood flow in a client with deep
vein thrombosis.

5. Answer: (B) A 44 year-old myocardial infarction (MI) client who
is complaining of nausea.
Rationale: Nausea is a symptom of impending myocardial infarction
(MI) and should be assessed immediately so that treatment can be
instituted and further damage to the heart is avoided.

6. Answer: (C) Check circulation every 15-30 minutes.
Rationale: Restraints encircle the limbs, which place the client at risk
for circulation being restricted to the distal areas of the extremities.
Checking the clients circulation every 15-30 minutes will allow the nurse
to adjust the restraints before injury from decreased blood flow occurs.

7. Answer: (A) Prevent stress ulcer
Rationale: Curlings ulcer occurs as a generalized stress response in
burn patients. This results in a decreased production of mucus and
increased secretion of gastric acid. The best treatment for this
prophylactic use of antacids and H2 receptor blockers.

8. Answer: (D) Continue to monitor and record hourly urine output
Rationale: Normal urine output for an adult is approximately 1
ml/minute (60 ml/hour). Therefore, this client's output is normal. Beyond
continued evaluation, no nursing action is warranted.

9. Answer: (B) My ankle feels warm.
Rationale: Ice application decreases pain and swelling. Continued or
increased pain, redness, and increased warmth are signs of inflammation
that shouldn't occur after ice application

10. Answer: (B) Hyperkalemia
Rationale: A loop diuretic removes water and, along with it, sodium
and potassium. This may result in hypokalemia, hypovolemia,
and hyponatremia.

11. Answer:(A) Have condescending trust and confidence in
their subordinates
Rationale: Benevolent-authoritative managers pretentiously show
their trust and confidence to their followers.

12. Answer: (A) Provides continuous, coordinated and
comprehensive nursing services.
Rationale: Functional nursing is focused on tasks and activities and not on
the care of the patients.

13. Answer: (B) Standard written order
Rationale: This is a standard written order. Prescribers write a
single order for medications given only once. A stat order is written for
medications given immediately for an urgent client problem. A
standing order, also known as a protocol, establishes guidelines for
treating a
particular disease or set of symptoms in special care areas such as
the coronary care unit. Facilities also may institute medication protocols
that specifically designate drugs that a nurse may not give.

14. Answer: (D) Liquid or semi-liquid stools
Rationale: Passage of liquid or semi-liquid stools results from seepage
of unformed bowel contents around the impacted stool in the rectum.
Clients
with fecal impaction don't pass hard, brown, formed stools because
the feces can't move past the impaction. These clients typically report the
urge
to defecate (although they can't pass stool) and a decreased appetite.

15. Answer: (C) Pulling the helix up and back
Rationale: To perform an otoscopic examination on an adult, the
nurse grasps the helix of the ear and pulls it up and back to straighten the
ear canal. For a child, the nurse grasps the helix and pulls it down
to straighten the ear canal. Pulling the lobule in any direction
wouldn't straighten the ear canal for visualization.
16. Answer: (A) Protect the irritated skin from sunlight.
Rationale: Irradiated skin is very sensitive and must be protected with
clothing or sunblock. The priority approach is the avoidance of strong
sunlight.
17. Answer: (C) Assist the client in removing dentures and nail polish.
Rationale: Dentures, hairpins, and combs must be removed. Nail polish
must be removed so that cyanosis can be easily monitored by observing
the nail beds.
18. Answer: (D) Sudden onset of continuous epigastric and back pain.
Rationale: The autodigestion of tissue by the pancreatic enzymes results
in pain from inflammation, edema, and possible hemorrhage.
Continuous, unrelieved epigastric or back pain reflects the inflammatory
process in the pancreas.
19. Answer: (B) Provide high-protein, high-carbohydrate diet.
Rationale: A positive nitrogen balance is important for meeting metabolic
needs, tissue repair, and resistance to infection. Caloric goals may be as
high as 5000 calories per day.
20. Answer: (A) Blood pressure and pulse rate.
Rationale: The baseline must be established to recognize the signs of an
anaphylactic or hemolytic reaction to the transfusion.
21. Answer: (D) Immobilize the leg before moving the client.
Rationale: If the nurse suspects a fracture, splinting the area before
moving the client is imperative. The nurse should call for emergency help
if the client is not hospitalized and call for a physician for the hospitalized
client.
22. Answer: (B) Admit the client into a private room.
Rationale: The client who has a radiation implant is placed in a private
room and has a limited number of visitors. This reduces the exposure of
others to the radiation.
23. Answer: (C) Risk for infection
Rationale: Agranulocytosis is characterized by a reduced number of
leukocytes (leucopenia) and neutrophils (neutropenia) in the blood. The
client is at high risk for infection because of the decreased body defenses
against microorganisms. Deficient knowledge related to the nature of the
disorder may be appropriate diagnosis but is not the priority.
24. Answer: (B) Place the client on the left side in the Trendelenburg
position.
Rationale: Lying on the left side may prevent air from flowing into the
pulmonary veins. The Trendelenburg position increases intrathoracic
pressure, which decreases the amount of blood pulled into the vena cava
during aspiration.
25. Answer: (A) Autocratic.
Rationale: The autocratic style of leadership is a task-oriented and
directive.
26. Answer: (D) 2.5 cc
Rationale: 2.5 cc is to be added, because only a 500 cc bag of solution is
being medicated instead of a 1 liter.
27. Answer: (A) 50 cc/ hour
Rationale: A rate of 50 cc/hr. The child is to receive 400 cc over a period
of 8 hours = 50 cc/hr.
28. Answer: (B) Assess the client for presence of pain.
Rationale: Assessing the client for pain is a very important measure.
Postoperative pain is an indication of complication. The nurse should also
assess the client for pain to provide for the clients comfort.
29. Answer: (A) BP 80/60, Pulse 110 irregular
Rationale: The classic signs of cardiogenic shock are low blood pressure,
rapid and weak irregular pulse, cold, clammy skin, decreased urinary
output, and cerebral hypoxia.
30. Answer: (A) Take the proper equipment, place the client in a
comfortable position, and record the appropriate information in the
clients chart.
Rationale: It is a general or comprehensive statement about the correct
procedure, and it includes the basic ideas which are found in the other
options
31. Answer: (B) Evaluation
Rationale: Evaluation includes observing the person, asking questions,
and comparing the patients behavioral responses with the expected
outcomes.
32. Answer: (C) History of present illness
Rationale: The history of present illness is the single most important
factor in assisting the health professional in arriving at a diagnosis or
determining the persons needs.
33. Answer: (A) Trochanter roll extending from the crest of the ileum to
the mid-thigh.
Rationale: A trochanter roll, properly placed, provides resistance to the
external rotation of the hip.
34. Answer: (C) Stage III
Rationale: Clinically, a deep crater or without undermining of adjacent
tissue is noted.
35. Answer: (A) Second intention healing
Rationale: When wounds dehisce, they will allowed to heal by secondary
intention
36. Answer: (D) Tachycardia
Rationale: With an extracellular fluid or plasma volume deficit,
compensatory mechanisms stimulate the heart, causing an increase in
heart rate.
37. Answer: (A) 0.75
Rationale: To determine the number of milliliters the client should
receive, the nurse uses the fraction method in the following equation.
75 mg/X ml = 100 mg/1 ml
To solve for X, cross-multiply:
75 mg x 1 ml = X ml x 100 mg
75 = 100X
75/100 = X
0.75 ml (or ml) = X

38. Answer: (D) Its a measure of effect, not a standard measure of
weight or quantity.
Rationale: An insulin unit is a measure of effect, not a standard measure
of weight or quantity. Different drugs measured in units may have no
relationship to one another in quality or quantity.
39. Answer: (B) 38.9 C
Rationale: To convert Fahrenheit degreed to Centigrade, use this formula
C = (F 32) 1.8
C = (102 32) 1.8
C = 70 1.8
C = 38.9
40. Answer: (C) Failing eyesight, especially close vision.
Rationale: Failing eyesight, especially close vision, is one of the first signs
of aging in middle life (ages 46 to 64). More frequent aches and pains
begin in the early late years (ages 65 to 79). Increase in loss of muscle
tone occurs in later years (age 80 and older).
41. Answer: (A) Checking and taping all connections
Rationale: Air leaks commonly occur if the system isnt secure. Checking
all connections and taping them will prevent air leaks. The chest drainage
system is kept lower to promote drainage not to prevent leaks.
42. Answer: (A) Check the clients identification band.
Rationale: Checking the clients identification band is the safest way to
verify a clients identity because the band is assigned on admission and
isnt be removed at any time. (If it is removed, it must be replaced).
Asking the clients name or having the client repeated his name would be
appropriate only for a client whos alert, oriented, and able to
understand what is being said, but isnt the safe standard of practice.
Names on bed arent always reliable
43. Answer: (B) 32 drops/minute
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 minute as follows:
125/60 minutes = X/1 minute
60X = 125 = 2.1 ml/minute
To find the number of drops per minute:
2.1 ml/X gtt = 1 ml/ 15 gtt
X = 32 gtt/minute, or 32 drops/minute

44. Answer: (A) Clamp the catheter
Rationale: If a central venous catheter becomes disconnected, the nurse
should immediately apply a catheter clamp, if available. If a clamp isnt
available, the nurse can place a sterile syringe or catheter plug in the
catheter hub. After cleaning the hub with alcohol or povidone-iodine
solution, the nurse must replace the I.V. extension and restart the
infusion.
45. Answer: (D) Auscultation, percussion, and palpation.
Rationale: The correct order of assessment for examining the abdomen is
inspection, auscultation, percussion, and palpation. The reason for this
approach is that the less intrusive techniques should be performed
before the more intrusive techniques. Percussion and palpation can alter
natural findings during auscultation.
46. Answer: (D) Ulnar surface of the hand
Rationale: The nurse uses the ulnar surface, or ball, of the hand to asses
tactile fremitus, thrills, and vocal vibrations through the chest wall. The
fingertips and finger pads best distinguish texture and shape. The dorsal
surface best feels warmth.
47. Answer: (C) Formative
Rationale: Formative (or concurrent) evaluation occurs continuously
throughout the teaching and learning process. One benefit is that the
nurse can adjust teaching strategies as necessary to enhance learning.
Summative, or retrospective, evaluation occurs at the conclusion of the
teaching and learning session. Informative is not a type of evaluation.

48. Answer: (B) Once per year
Rationale: Yearly mammograms should begin at age 40 and continue for
as long as the woman is in good health. If health risks, such as family
history, genetic tendency, or past breast cancer, exist, more frequent
examinations may be necessary.
49. Answer: (A) Respiratory acidosis
Rationale: The client has a below-normal (acidic) blood pH value and an
above-normal partial pressure of arterial carbon dioxide (Paco2) value,
indicating respiratory acidosis. In respiratory alkalosis, the pH value is
above normal and in the Paco2 value is below normal. In metabolic
acidosis, the pH and bicarbonate (Hco3) values are below normal. In
metabolic alkalosis, the pH and Hco3 values are above normal.
50. Answer: (B) To provide support for the client and family in coping
with terminal illness.
Rationale: Hospices provide supportive care for terminally ill clients and
their families. Hospice care doesnt focus on counseling regarding health
care costs. Most client referred to hospices have been treated for their
disease without success and will receive only palliative care in the
hospice.
51. Answer: (C) Using normal saline solution to clean the ulcer and
applying a protective dressing as necessary.
Rationale: Washing the area with normal saline solution and applying a
protective dressing are within the nurses realm of interventions and will
protect the area. Using a povidone-iodine wash and an antibiotic cream
require a physicians order. Massaging with an astringent can further
damage the skin.
52. Answer: (D) Foot
Rationale: An elastic bandage should be applied form the distal area to
the proximal area. This method promotes venous return. In this case, the
nurse should begin applying the bandage at the clients foot. Beginning at
the ankle, lower thigh, or knee does not promote venous return.
53. Answer: (B) Hypokalemia
Rationale: Insulin administration causes glucose and potassium to move
into the cells, causing hypokalemia.
54. Answer: (A) Throbbing headache or dizziness
Rationale: Headache and dizziness often occur when nitroglycerin is
taken at the beginning of therapy. However, the client usually develops
tolerance

55. Answer: (D) Check the clients level of consciousness
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. However, checking the
unresponsiveness ensures whether the client is affected by the
decreased cardiac output.
56. Answer: (B) On the affected side of the client.
Rationale: When walking with clients, the nurse should stand on 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 at the shoulder area
so that the client can be pulled toward the nurse in the event that there
is a forward fall. The client is instructed to look up and outward rather
than at his or her feet.
57. Answer: (A) Urine output: 45 ml/hr
Rationale: Adequate perfusion must be maintained to all vital organs in
order for the client to remain visible as an organ donor. A urine output of
45 ml per hour indicates adequate renal perfusion. Low blood pressure
and delayed capillary refill time are circulatory system indicators of
inadequate perfusion. A serum pH of 7.32 is acidotic, which adversely
affects all body tissues.
58. Answer: (D ) Obtaining the specimen from the urinary drainage bag.
Rationale: A urine specimen is not taken from the urinary drainage bag.
Urine undergoes chemical changes while sitting in the bag and does not
necessarily reflect the current client status. In addition, it may become
contaminated with bacteria from opening the system.
59. Answer: (B) Cover the client, place the call light within reach, and
answer the phone call.
Rationale: Because telephone call is an emergency, the nurse may need
to answer it. The other appropriate action is to ask another nurse to
accept the call. However, is not one of the options. To maintain privacy
and safety, the nurse covers the client and places the call light within the
clients reach. Additionally, the clients door should be closed or the room
curtains pulled around the bathing area.
60. Answer: (C) Use a sterile plastic container for obtaining the specimen.
Rationale: Sputum specimens for culture and sensitivity testing need to
be obtained using sterile techniques because the test is done to
determine the presence of organisms. If the procedure for obtaining the
specimen is not sterile, then the specimen is not sterile, then the
specimen would be contaminated and the results of the test would be
invalid.

61. Answer: (A) Puts all the four points of the walker flat on the floor,
puts weight on the hand pieces, and then walks into it.
Rationale: When the client uses a walker, the nurse stands adjacent to
the affected side. The client is instructed to put all four points of the
walker 2 feet forward flat on the floor before 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.
62. Answer: (C) Draws one line to cross out the incorrect information and
then initials the change.
Rationale: To correct an error documented in a medical record, the nurse
draws one line through the incorrect information and then initials the
error. An error is never erased and correction fluid is never used in the
medical record.
63. Answer: (C) Secures the client safety belts after transferring to the
stretcher.
Rationale: During the transfer of the client after the surgical procedure is
complete, the nurse should avoid exposure of the client because of the
risk for potential heat loss. Hurried movements and rapid changes in the
position should be avoided because these predispose the client to
hypotension. At the time of the transfer from the surgery table to the
stretcher, the client is still affected by the effects of the anesthesia;
therefore, the client should not move self. Safety belts can prevent the
client from falling off the stretcher.
64. Answer: (B) Gown and gloves
Rationale: Contact precautions require the use of gloves and a gown if
direct client contact is anticipated. Goggles are not necessary unless the
nurse anticipates the splashes of blood, body fluids, secretions, or
excretions may occur. Shoe protectors are not necessary.
65. Answer: (C) Quad cane
Rationale: Crutches and a walker can be difficult to maneuver for a client
with weakness on one side. A cane is better suited for client with
weakness of the arm and leg on one side. However, the quad cane would
provide the most stability because of the structure of the cane and
because a quad cane has four legs.
66. Answer: (D) Left side-lying with the head of the bed elevated 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 bedside table
with the feet supported on a stool. If the client is unable to sit up, the
client is positioned lying in bed on the unaffected side with the head of
the bed elevated 30 to 45 degrees.

67. Answer: (D) Reliability
Rationale: Reliability is consistency of the research instrument. It refers to
the repeatability of the instrument in extracting the same responses
upon
its repeated administration.
68. Answer: (A) Keep the identities of the subject secret
Rationale: Keeping the identities of the research subject secret will
ensure anonymity because this will hinder providing link between the
information given to whoever is its source.
69. Answer: (A) Descriptive- correlational
Rationale: Descriptive- correlational study is the most appropriate for this
study because it studies the variables that could be the antecedents of
the increased incidence of nosocomial infection.
70. Answer: (C) Use of laboratory data
Rationale: Incidence of nosocomial infection is best collected through the
use of biophysiologic measures, particularly in vitro measurements,
hence laboratory data is essential.
71. Answer: (B) Quasi-experiment
Rationale: Quasi-experiment is done when randomization and control of
the variables are not possible.
72. Answer: (C) Primary source
Rationale: This refers to a primary source which is a direct account of the
investigation done by the investigator. In contrast to this is a secondary
source, which is written by someone other than the original researcher.
73. Answer: (A) Non-maleficence
Rationale: Non-maleficence means do not cause harm or do any action
that will cause any harm to the patient/client. To do good is referred as
beneficence.
74. Answer: (C) Res ipsa loquitor
Rationale: Res ipsa loquitor literally means the thing speaks for itself. This
means in operational terms that the injury caused is the proof that there
was a negligent act.
75. Answer: (B) The Board can investigate violations of the nursing law
and code of ethics
Rationale: Quasi-judicial power means that the Board of Nursing has the
authority to investigate violations of the nursing law and can issue
summons, subpoena or subpoena duces tecum as needed.

76. Answer: (C) May apply for re-issuance of his/her license based on
certain conditions stipulated in RA 9173
Rationale: RA 9173 sec. 24 states that for equity and justice, a revoked
license maybe re-issued provided that the following conditions are met:
a)
the cause for revocation of license has already been corrected or
removed; and, b) at least four years has elapsed since the license has
been revoked.
77. Answer: (B) Review related literature
Rationale: After formulating and delimiting the research problem, the
researcher conducts a review of related literature to determine the
extent of what has been done on the study by previous researchers.
78. Answer: (B) Hawthorne effect
Rationale: Hawthorne effect is based on the study of Elton Mayo and
company about the effect of an intervention done to improve the
working conditions of the workers on their productivity. It resulted to an
increased productivity but not due to the intervention but due to the
psychological effects of being observed. They performed differently
because they were under observation.
79. Answer: (B) Determines the different nationality of patients
frequently admitted and decides to get representations samples from
each.
Rationale: Judgment sampling involves including samples according to
the knowledge of the investigator about the participants in the study.
80. Answer: (B) Madeleine Leininger
Rationale: Madeleine Leininger developed the theory on transcultural
theory based on her observations on the behavior of selected people
within a culture.
81. Answer: (A) Random
Rationale: Random sampling gives equal chance for all the elements in
the population to be picked as part of the sample.
82. Answer: (A) Degree of agreement and disagreement
Rationale: Likert scale is a 5-point summated scale used to determine the
degree of agreement or disagreement of the respondents to a statement
in a study
83. Answer: (B) Sr. Callista Roy
Rationale: Sr. Callista Roy developed the Adaptation Model which
involves the physiologic mode, self-concept mode, role function mode
and dependence mode.
84. Answer: (A) Span of control
Rationale: Span of control refers to the number of workers who report
directly to a manager.
85. Answer: (B) Autonomy
Rationale: Informed consent means that the patient fully understands
about the surgery, including the risks involved and the alternative
solutions. In giving consent it is done with full knowledge and is given
freely. The action of allowing the patient to decide whether a surgery is
to be done or not exemplifies the bioethical principle of autonomy.
86. Answer: (C) Avoid wearing canvas shoes.
Rationale: The client should be instructed to avoid wearing canvas shoes.
Canvas shoes cause the feet to perspire, which may, in turn, cause skin
irritation and breakdown. Both cotton and cornstarch absorb
perspiration. The client should be instructed to cut toenails straight
across with nail
clippers.

87. Answer: (D) Ground beef patties
Rationale: Meat is an excellent source of complete protein, which this
client needs to repair the tissue breakdown caused by pressure ulcers.
Oranges and broccoli supply vitamin C but not protein. Ice cream supplies
only some incomplete protein, making it less helpful in tissue repair.

88. Answer: (D) Sims left lateral
Rationale: The Sims' left lateral position is the most common position
used to administer a cleansing enema because it allows 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 sphincter control, the dorsal
recumbent or right lateral position may be used. The supine and prone
positions are inappropriate and uncomfortable for the client.

89. Answer: (A) Arrange for typing and cross matching of the clients
blood.
Rationale: The nurse first arranges for typing and cross matching of the
client's blood to ensure compatibility with donor blood. The other
options,
although appropriate when preparing to administer a blood transfusion,
come later.

90. Answer: (A) Independent
Rationale: Nursing interventions are classified as independent,
interdependent, or dependent. Altering the drug schedule to coincide
with the client's daily routine represents an independent intervention,
whereas consulting with the physician and pharmacist to change a
client's medication because of adverse reactions represents an
interdependent intervention. Administering an already-prescribed drug
on time is a dependent intervention. An intradependent nursing
intervention doesn't exist.

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 action.

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 client of the duration of the transfusion and
should document its administration, these actions are less critical to the
client's immediate health. The nurse should assess vital signs at least
hourly during the transfusion.

94. Answer: (B) Decrease the rate of feedings and the concentration of
the formula.
Rationale: Complaints of abdominal discomfort and nausea are 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 temperature to minimize abdominal
cramping. To prevent aspiration during feeding, the head of the client's
bed should be elevated at least 30 degrees. Also, to prevent bacterial
growth, feeding containers should be routinely changed every 8 to 12
hours.

95. Answer: (D) Roll the vial gently between the palms.
Rationale: Rolling the vial gently between the palms produces heat,
which helps dissolve the medication. Doing nothing or inverting the vial
wouldn't help dissolve the medication. Shaking the vial vigorously could
cause the medication to break down, altering its action.

96. Answer: (B) Assist the client to the semi-Fowler position if possible.
Rationale: By assisting the client to the semi-Fowler position, the nurse
promotes easier chest expansion, breathing, and oxygen intake. The
nurse should secure the elastic band so that the face mask fits
comfortably and snugly rather than tightly, which could lead to irritation.
The nurse should apply the face mask from the client's nose down to the
chin not vice versa. The nurse should check the connectors between
the oxygen equipment and humidifier to ensure that they're airtight;
loosened connectors can cause loss of oxygen.

97. Answer: (B) 4 hours
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 because the risk
of contamination and sepsis increases after that time. Discard or return
to the blood bank any blood not given within this time, according to
facility policy.

98. Answer: (B) Immediately before administering the next dose.
Rationale: Measuring the blood drug concentration helps determine
whether the dosing has achieved the therapeutic goal. For measurement
of the trough, or lowest, blood level of a drug, the nurse draws a blood
sample immediately before administering the next dose. Depending on
the drug's duration of action and half-life, peak blood drug levels typically
are drawn after administering the next dose.

99. Answer: (A) The nurse can implement medication orders quickly.
Rationale: A floor stock system enables the nurse to implement
medication orders quickly. It doesn't allow for pharmacist input, nor does
it minimize transcription errors or reinforce accurate calculations.

100. Answer: (C) Shifting dullness over the abdomen.
Rationale: Shifting dullness over the abdomen indicates ascites, an
abnormal finding. The other options are normal abdominal findings.