Fundamentals of Nursing 2

Anthony M. Notario RN MAN

1. A client to come to the walk-in clinic with complaints of abdominal pain and diarrhea. The nurse takes the client’s vital
signs. The nurse is implementing which phase of the nursing process?
a. Assessment b. Diagnosis c. Planning d. Implementation
2. The nurse is measuring the client’s urine output and straining the urine to assess for stones. Which of the following should
the nurse record as objective data?
a. The client is complaining of abdominal pain.
b. The client’s urine output was 450 mL.
c. The client stated, “I didn’t see any stones in my urine.”
d. The client stated, “I feel like I have passed a stone.”
3. When evaluating an adult client’s blood pressurereading, the nurse considers the client’s age. This is an example of which
of the following?
a. Comparing data against standards c. Determining gaps in the data
b. Clustering data d. Differentiating cues and inferences
4. Which of the following demonstrates that the nurse Is participating in critical thinking?
a. The nurse admits he/she does not know how to do a procedure and requests help.
b. The nurse makes his/her point with clever and persuasive remarks to win an argument.
c. The nurse accepts without question the values acquired in nursing school.
d. The nurse finds a quick answer, even to complex question.
5. What is missing from the following outcome goal written in a care plan by the nurse? “The client will transfer from bed to
chair with two assists.”
a. Client behavior c. Performance criteria
b. Conditions or modifiers d. Target time
6. The nurse documents the following outcome goal on the care plan: “Anxiety will be relieved within20 to 40 minutes
following administration of lorazepam (Ativan).” The nurse has just performed an activity in which of the following phases
of the nursing process?
a. Assessment c. Implementation
b. Planning d. Evaluation
7. When the client resists taking a liquid medication that is essential to treatment, the nurse demonstrates critical thinking by
doing which of the following first?
a. Omitting this dose of medication and waiting until the client is more cooperative
b. Suggesting the medication can be diluted in a beverage
c. Asking the nurse manager about how to approach the situation
d. Notifying the physician that the nurse was unable to give the client this medication
8. The nurse reassesses a client’s anxiety level 30 minutes after administering lorazepam (Ativan). This is an example of
which type of evaluation?
a. Ongoing b. Intermittent c. Terminal d. Routine
9. Which nurse is demonstrating the assessment relieved phase of the nursing process?
a. The nurse who observes that the client’s pain was with pain medication
b. The nurse who changes the bed linens after the client is incontinent of feces
c. The nurse who asks the client how much lunch was eaten
d. The nurse who works with the client to set desired outcome goals
10. The client states, “My chest hurts and my left arm feels numb.” What is the type and source of this data?
a. Subjective data from a primary source c. Objective data from a primary source
b. Subjective data from a secondary source d. Objective data from a secondary source
11. What is the problem with the following outcome goal, “Client will state pain is less than or equal to a 3 on 0 to 10 pain
scale”?
a. None, goal is written correctly. c. No target time is given.
b. It is not measurable. d. Client behavior is missing.
12. In giving a change-of-shift report, which type of client information given by the nurse is most informative and complete?
a. Vital signs are stable. d. Client voided 250 mL of urine 2 hours after
b. Client is pleasant, alert, and oriented x 3. urinary catheter was removed.
c. The chest x-ray results were negative
13. Twenty minutes after administering a pain medication to the client, the nurse returns to ask if the client’s level of pain has
decreased. The nurse is engaging in which phase of the nursing process?
a. Diagnosing b. Planning c. Implementing d. Evaluating
14. Before palpating the abdomen during an assess ment, the nurse should do which of the following?
a. Put on sterile gloves c. Elevate the client’s head
b. Auscultate bowel sounds d. Personal goals related to health care
15. The nurse would document which of the following in the medical record as objective data obtained during client
assessment?
a. Detailed description of pain in an extremity c. Complaint of numbness of the right hand
b. Loss of hair on bilateral lower legs d. Report of scalp itching each evening
16. The nurse would use which of the following methods of examination to assess for the presence of a bruit in the abdomen?

a. Auscultation b. Percussion c. Palpation d. Inspection

17. Which of the following statements made by the client indicates an understanding of how the nurse performs the Romberg
test?
 a. “You want me to bend over so you can inspect my spine for curvature.”
b. “I need to touch my toes without bending my knees if possible.”
c. “I am going to walk five or six steps on my toes only, then my heels.”
d. “You want me to stand with my feet together and eyes closed for a short time.”
18. A client who is alert and responsive was admitted directly from the physician’s office with a diagnosis of rule out acute
myocardial infarction. Of the fol- lowing alterations found on the initial assessment, which is of greatest concern to
the nurse?
a. Blood pressure supine is 138/76 c. Temperature is 99.8®F.
b. Respirations are 28 and labored. d. There are infrequent missed apical beats.
19. A normal thyroid assessment would be documented by the nurse as which of the following?
a. Thyroid is slightly deviated to the left, no nodules can be palpated.
b. Thyroid is midline, smooth, no nodules can be palpated.
c. Thyroid is midline, with parathyroid glands easily palpated bilaterally.
d. Thyroid is slightly deviated to the right, with pea-size nodules at the base.
20. Prior to taking the health history the nurse should first do which of the following?
a. Establish a rapport with the client c. Establish that insurance coverage exists
b. Offer the client a beverage of choice d. Ask the client to disrobe and put on a gown
21. The nurse would use which of the following skills first when examining the abdomen of a client?
a. Palpation b. Auscultation c. Percussion d. Inspection
22. As the client describes the chief complaint, the nurse should do which of the following?
a. Document verbatim what the client has to say about the problem.
b. Paraphrase in the nurse’s own words what the problem is.
c. Refrain from note-taking to appear focused.
d. Ask the client to repeat the data to assure reliability.
23. The nurse selects which of the following pieces of equipment to test for a cremasteric reflex?
a. Blood pressure cuff c. Sharp end of a needle
b. Cotton applicator d. Percussion hammer
24. The nurse should place the client into which of the following positions in order to assess jugular venous distention?
a. Supine with head of bed elevated 30 degrees c. High Fowler’s with head elevated upwards
b. Supine with neck placed downward on chest d. Side-lying with no pillows under the head
25. To adequately inspect the external ear canal of an adult client, the nurse should do which of the fol lowing prior to
inserting the otoscope?
a. Require that all earrings be removed for safety c. Use an applicator to remove cerumen.
purposes. d. Have the client lie down to promote comfort.
b. Pull the pinna up and back.
26. Which of the following would be the best approach for the nurse to use when a client conveys anxiety prior to
surgery?
a. Reassure the client of the surgeon’s competency.
b. Provide information about the surgical experience.
c. Explore the client’s feelings with him or her.
d. Relate the nurse’s personal experience of having a similar surgery.
27. A client state “I am so sick, I know I am going to die.” Which of the following would be the best way for the nurse to
document this data?
a. Client is depressed today. d. Client states, “I am so sick, I know I am going to
b. Client thinks he is going to die. die.”
c. The client is frustrated with being sick.
28. A client’s husband states that his wife is going through a midlife crisis. Which of the following behaviors would indicate this
is most likely to be true?
a. Buying a new wardrobe c. Wallpapering mother’s room
b. Writing a novel d. Baking bread for neighbor
29. A family has a new pool and the mother asks the pediatric nurse how to protect their 2-year-old from drowning. Which of
the following statements would be the best response?
a. Provide swimming lessons given by a certified b. Place a fence around the pool
instructor c. Provide adult supervision at all times
d. Purchase an approved flotation device
30. Since her diagnosis of terminal liver cancer, the nurse observes that the client’s family assists with all of the activities of
daily living. Which of the following rationales for self-care is most important for the nurse to communicate to the family?

a. Strengthening muscles may encourage healing of the cancer.

b. The client needs time alone to reason through her diagnosis.
c. Sense of loss can be lessened by retaining control in certain areas of life.
d. Increased mental activity required for self-care will enhance mood.
31. The nurse observes halting speech from the client when her husband is present. Which of the following questions should
the nurse ask to clarify interaction patterns?
a. “How do you and your husband spend your c. “What is you husband’s religious preference?”
leisure time?” d. “How does your husband communicate with
b. “What is your level of education?” you?”
32. The nurse is caring for a male client who has recently had his left leg amputated. What subjective data should the nurse
gather to assess body image?
a. Client’s Feelings regarding surgery c. Client’s description of his personality
b. Strength of femoral pulse bilaterally d. Status of wound healing
33. The nurse evaluates the outcome criteria of a dying client and discerns that the goal has not been met. Which of the
following should the nurse do first?
 a. Talk with the client’s family to determine if they have intervened inappropriately
b. Notify the physician immediately
c. Reassess to determine if the nursing diagnosis was appropriate
d. Ask that another nurse take over care of the client
34. A client has been identified as having a very virulent bacterial infection that is spread through close physical contact. To
decrease the chance of spread ing this organism, the nurse would implement
a. Airborne precautions c. Contact precautions
b. Droplet precautions d. Protective isolation precautions?
35. A nurse has been assigned to care for four clients who are stable. Using the principle of medical sep sis, which client
should be assessed first?
a. A postsurgical cardiac client with hypostatic c. A client who is severely neutropenic
pneumonia d. A child with chicken pox
b. A client with a draining wound
36. The nurse is bathing a client who has an infection spread by droplets. Prior to reporting to work, the nurse’s hands were
scratched by a pet cat. Which of the following pieces of protective gear is not
a. Mask b. Gown c. Goggles d. Gloves
37. A nurse is preparing to take vital signs on an alert client admitted to the hospital with dehydration secondary to vomiting
and diarrhea. What is the best method to assess this client’s body
a. Oral b. Axillary c. Rectal d. Heat-sensitive tape
38. A nurse obtained a client’s pulse and found the rate to be above normal. How would the nurse docu ment this finding?
a. Tachypnea b. Hyperpyrexia c. Arrhythmia d. Tachycardia
39. While eating in a restaurant, the nurse notices a male patron choking on food. The individual is coughing loudly, his
face is red, and he is unable to answer questions. Which of the following actions should the nurse take?
a. Place his or her arms around the choking individual’swaist and exert fist pressure on the abdomen.
b. Lay the individual on the floor and straddle the individual’s legs to position self for the Heimlich
c. Stand by and further observe the individual’s response.
d. Slap the choking individual firmly on the back three times before attempting chests thrusts.
40. A client had oral surgery following a motor vehicle accident and the nurse assessing the client finds the skin flushed,
warm, and diaphoretic. Which of the following would be the best method to asses the client’s body temperature?
a. Oral b. Axillary c. Arterial Line d. Rectal
41. A nurse finds a bedridden client unresponsive and is preparing to open the client’s airway. Which of the following methods
to open the airway would be most appropriate to use?
a. The jaw-thrust method c. The chest thrust method
b. The head tilt-chin lift technique d. The chin to sternum method
42. The nurse is unable to palpate a client’s pedal pulses in an edematous right lower extremity. Which of the following would
be the best nursing action?
a. Notify the physician of the inability to detect pedal pulses.
b. Check the temperature of the lower extremities.
c. Use a Doppler to check for pedal pulses.
d. Measure the right lower extremity and compare it to the left.
43. A client complains of tickling in the throat and a bubbling sensation in the chest, then coughs up bright red, frothy blood
mixed with sputum. The nurse documents that the client is experiencing which of the following?
a. Hematemesis c. Intercostal retraction
b. Orthopnea d. Hemoptysis
44. A client is being discharged with oxygen therapy via a cannula. Which of the following instructions should the nurse give
to the client and family?
a. Use battery-operated equipment instead of electrical equipment.
b. Use petroleum jelly for the nares to prevent chafing
c. Use cotton clothing to avoid static electricity.
d. Use oil to protect the facial skin.
45. An elderly bedridden client complains of being con stipated but can not understand why. What instruction should be given
by the nurse?
a. Decrease fluid intake c. Avoid beverages with caffeine
b. Encourage bland and low-residue foods d. Drink hot liquids and fruit juices
46. A client is taking a full fluid diet following gastric surgery. The nurse evaluates the health teaching to the following for the
client to eat?
a. Pureed fruits b. Custard c. Soft cake d. Chopped vegetables
47. A client is hospitalized for the first time. Which of the following actions ensures the safety of the client?
a. Keep unnecessary furniture out of the way. c. Keep side rails up at all times.
b. Keep lights on all the time. d. Keep all equipment out of view.
48. A client who is unconscious needs frequent mouth care. While performing mouth care, in what position should the client
be placed?
a. Fowler’s position c. Supine position
b. Side-lying position d. Trendelenburg position
49. A nurse is performing oropharyngeal suctioning on an unconscious client. Which of the following actions is safe?
a. Insert the catheter approximately 20 cm while applying suction.
b. Allow 20- to 30-second intervals between each suction, and limit suctioning to a total of 15 minutes.
c. Gently rotate the catheter while applying suction.
d. Apply suction for 5 seconds while inserting the catheter and continue for another 5 seconds before withdrawing.
50. A client with chest tubes is admitted to the nursing unit. The nurse should place the highest priority during admission on
doing which of the following?
a. Plan to measure client’s vital signs, respiratory and cardiovascular status regularly
b. Explain the importance of deep-breathing and coughing regularly
 c. Report if drainage exceeds 100 mL/h
d. Place rubber-tipped clamps, sterile water, and a sterile occlusive dressing material near the client.
51. To avoid complications associated with urinary elimination, the nurse teaches the client to perform certain actions. Which
of the following indicates that the expected outcome is achieved?
a. Identifies symptoms of and measures to prevent urinary tract infection
b. Able to perform perineal care by self
c. Maintains proper disposal of urinary output
d. Takes regular tub baths and appropriate personal hygiene measures.
52. A client with a colostomy is asking the nurse about the types of foods that may loosen stool and cause leakage into the
pouch. Which of the following foods should the client be told to include in the diet to prevent this problem?
a. Asparagus, beans, eggs, fish, onions
b. Applesauce, bananas, rice, tapioca, yogurt
c. Fried foods, highly spiced foods, raw fruits and vegetables
d. Carbonated drinks, fruit juices, greasy and pureed foods
53. Which technique is the most effective method forthe nurse to use in validation of a client’s level of pain?
a. Ask the client to use a pain scale.
b. Note the physiologic responses to pain.
c. Determine the degree of anxiety associated with pain.
d. Observe and document the client’s facial expressions.
54. An elderly female client is admitted to the Emergency Department after falling on ice and sustaining a fractured hip. The
daughter of the client pulls the nurse aside and states, “Watch out-my mother has an unbelievable tolerance for pain.”
Based on this information being accurate, the nurse will anticipate which client need?
a. The client will be able to endure a great deal of pain
b. The client will experience discomfort with the slightest movement.
c. The client will likely refuse any PRN analgesics.
d. The client will ask for pain medication more often than prescribed.
55. A male client is very anxious about the pain he will experience postoperatively. Which of the following interventions would
be most effective in initially helping him deal with this fear?
a. Teach him relaxation techniques such as deep-breathing and guided imagery.
b. Explain the availability of pain medications after surgery.
c. Demonstrate the various positioning techniques that promote post-op comfort.
d. Distract the client from discussing pain by focusing on surgical preparation.
56. Which statement represents successful client teaching with regard to morphine administration via patient-controlled
analgesia (PCA)?
a. “I will probably use less morphine this way than with taking injections in my hip”
b. “My family can push the button when I’m asleep so I will rest better.”
c. “Using this device will keep me comfortable at all times.”
d. “If I push the control button too often, I may get more medicine than needed.”
57. Which of the following would be the most appropriate goal statement for teaching a client with chronic pain how to use
visual imagery?
a. The exercises will decrease the need for analgesia.
b. The exercises will enhance the effect of analgesia.
c. The exercises will decrease pain sensation.
d. The exercises will allow for better rest periods.
58. Which of the following activities would the nurse carry out in the preoperative period for a client scheduled for surgery?

a. Identify potential or actual health problems c. Assess the client’s response to interventions
b. Perform specialized procedures to maintain d. Intervene to prevent complications
safety
59. The nurse is caring for several clients in the pre- anesthesia room. Of the following client situations, which merits ablative
surgery?
a. Replacing a hip that has degenerative disease c. Removing a diseased party of the kidney
b. Identifying if a tumor is malignant d. Resecting a nerve root
60. A client having surgery has a degree of risk associated with the surgery. Which of the following client-related factors is
responsible for a high degree of risk associated with surgery?
a. Type of institution where surgery is performed c. Average nutritional status
b. Involvement of vital organs d. Little likelihood of complications
61. An infant who is having surgery has a higher risk than an adult. The nurse would interpret that which of the following is
a reason for the increased risk?
a. Decline in functioning c. Increased possibility of hyperthermia
b. Immaturity of vital organs d. Volume of blood fluctuation
62. A preschool child is facing surgery and may have fears related to the surgery. The type of fears the nurse would anticipate
in this child would be which of the following?
a. Being awake during surgery and experiencing c. Not being able to do the things they used to do
pain d. Medical personnel not knowing what they are
b. Looking drastically different after surgery doing
63. A client has just entered the post anesthesia care unit (PACU) from surgery. The postoperative client’s immediate
needs include initial monitoring of which of the following items?
a. Vital signs, level of consciousness, and presence of pain
b. Skin coloring, surgical incision, limb movements
c. Skin temperature, blood pressure, mental status
d. Temperature, emotional status, social support
64. The nurse in the PACU is assessing a postoperative client. Which of the following indicators suggest alteration in tissue
perfusion?
 a. Pallor or cyanosis c. Pain in the incision area
b. Difficulty with mobility d. Fluid loss
65. After surgery, the nurse encourages the client to move from side to side at least every two hours. The client questions this
activity. The nurse ex plains this intervention is to do which of thefollowing?
a. Let peristalsis return at a faster rate. d. Let the lungs alternately achieve maximum
b. Lessen muscle weakness. expansion.
c. Increase client’s ability to sleep.
66. The nurse is assessing the client’s surgical wound in the postoperative period. Which finding indicates the first stage of
healing?
a. Inflammation in the wound edges c. Clot binding the wound edges
b. Bleeding around the incision d. Collagen synthesis
67. The nursing team is creating a care plan for a post- operative client. The diagnosis is pain. An appropriate client outcome
for this client would be which of the following?
a. Balanced fluid intake and output c. Absence of nonverbal signs of pain
b. Seeks help as needed d. Performs leg exercises as instructed
68. A client is being admitted to the hospital on the day before a scheduled surgery. Which of the following is the most
appropriate initial question to ask this preoperative client?
a. “Has your doctor talked to you about the type of surgery you are having? What did the doctor say?”
b. “What questions do you have about your surgery?”
c. “What type of surgery are you having and why are you having it done?”
d. “What do you know about what will be done to you?”
69. A pre-surgical client asks the nurse for more information about the advantages of a general anesthetic. The nurse’s
answer would correctly reflect what information?
a. The respiratory and circulatory functions are depressed.
b. The client loses consciousness and does not perceive pain.
c. The anesthetic agent is not rapidly excreted so that the timing of surgery can be adjusted.
d. General anesthesia reduces the chance that the client suffers from amnesia.
70. A benzodiazepine has been administered to a client preoperatively. After the drug has been administered, the nurse
needs to monitor the client for which of the following side effects?
a. Anxiety c. Hypocalcemia
b. Hypotension d. Extrapyramidal reactions
71. A preoperative client has an elevated hemoglobin and hematocrit. What would the nurse suspect regarding the
significance of this increased value?
a. Immune deficiency c. Malignancy
b. Kidney dysfunction d. Dehydration
72. The nurse has completed preoperative teaching to a pregnant woman. During the discussion, the nurse describes the
different types of anesthesia available. Which statement indicates understanding of regional anesthesia?
a. In spinal anesthesia, the anesthetic agent is injected into the subarachnoid space.
b. The anesthetic agent is injected into the dura mater of the spinal cord for epidural anesthesia.
c. The client is sedated and has some awareness of the event.
d. Regional anesthesia produces analgesia and amnesia.
73. The client arrives in the PACU in an unconscious state. In what position is the unconscious client placed in the immediate
postanesthetic stage?
a. Side lying with face slightly down c. Semi-prone position with the head titled to the
b. Side lying with a pillow under the client’s head side
d. Dorsal recumbent with head turned to the side.
74. The client has been in the PACU unit for 1 hour. The client is now groggy but able to respond to voice commands. While
assessing the client, the nurse checks the bedclothes underneath the client. The nurse is assessing:
a. Drainage from the tubes or drains. c. Hemorrhage.
b. Fluid balance. d. Perspiration.
75. A client is in the postoperative stage and the physician has ordered ambulation. The client has shown a difficulty
understanding the necessity for early ambulation. An appropriate nursing diagnosis for this client would be:
a. Self-care deficit. c. Ineffective coping.
b. Knowledge deficit. d. Risk for injury.
76. The nurse is assessing the client on return to thehospital unit from the PACU and notes the pres ence of a drain in the
surgical wound. A family member observes the drain and asks why the tube was left in the wound. The nurse explains
that drains:
a. Allow drainage of excessive serosanguinous fluid and purulent material.
b. Allow healing to occur at a very rapid rate.
c. Have to be shortened to allow healing to occur from the inside out.
d. Have to be connected to suction tubes.
77. A client is being discharged following outpatient surgery. The nurse is providing the caregiver with instructions for wound
care. The nurse would instruct the caregiver to report which of the following findings to the surgeon?
a. Scar formation c. No odor of the wound drainage
b. Increased redness or drainage d. No unusual color of the drainage
78. A nurse is assessing a bedridden client when a large erythemic area is noted on the client’s buttocks. In addiction, the
center of the injury looks like an abrasion with a shallow crater. The nurse would classify this ulcer as which of the
following stages?
a. Stage I b. Stage II c. Stage III d. Stage IV
79. In planning nursing care to prevent pressure ulcers in a bedridden client, the nurse should include which of the following
interventions?
a. Slide the client when turning b. Turn and position the client bid
 c. Vigorously massage bony prominences d. Hang a turning schedule at the client’s bedside
with a sign sheet
80. A group of student nurses are discussing techniques for dressing changes. The students make the following comments.
The student who needs to review the skill would be the one who makes which of the following statements?
a. “I will clean the wound from the center out.”
b. “To remove the used dressing, I should wear sterile gloves.”
c. “After I clean the wound, I should do my assessments.”
d. “While irrigating the wound, I can use a catheter, which is placed close to the open area.”
81. A client uses a cane to assist with ambulation. After teaching the client how to use a cane, the client makes the following
statements. Which one indicates the need for additional teaching?
a. (1) “My elbow should be slightly flexed while using the cane.
b. (2) “I should hold the cane on my affected side.”
c. (3) “A walker would be more difficult to use than a cane.”
d. (4) “While walking here in the hospital, socks alone may cause me to slip.”
82. A client has been on bedrest with cervical traction for 2 weeks. The traction is discontinued and the client is to ambulate.
Prior to getting the client out of bed, it is important for the nurse to do which of
a. Raise the head of the bed slowly the following b. Assess lower leg muscle strength
initially? c. Provide client with a cane
d. Get a neck brace for the client
83. A client has a large pressure ulcer on his lower extremity. The nurse instructs the client about nutrients needed for
healing, especially vitamin C and protein. While evaluating intake, the nurse knows that the client is eating an appropriate
diet when the client eats which of the following breakfasts?
a. Coffee, buttered toast with jelly, and bacon c. Pancakes with butter and syrup and hot tea
b. Milk, scrambled eggs, and cantaloupe d. Oatmeal with butter, diet soda, and bacon
84. Which assessment of the immobilized client would prompt the nurse to take further action?
a. Client complaining of fatigue c. White blood cell count of 9.5
b. Urinary output of 50 mL an hour d. Absence of bowel sounds
85. The client is a known diabetic. The nurse administers 20 units NPH insulin IV stat per the physician’s order. Subsequent
to receiving the insulin dose, the client had an anaphylactic reaction and died as a result of receiving the NPH insulin IV
rather than subcutaneous, which is the only appropriate route. What liability is involved in this case?
a. The nurse is not legally liable because the nurse administered the medication as ordered by the physician.
b. Only the physician is liable because the physician wrote the order.
c. The nurse is legally liable for the medications administered even though the order was written incorrectly.
d. The nurse is not legally liable because the nurse gave the correct medication, regardless of the route.
86. While the nurse is administering a client’s dose of nitroglycerin sublingual, the client asks why it is administered
sublingually rather than orally. Which of the following is the best response by the nurse?
a. “It is absorbed more rapidly sublingually than when swallowed.”
b. “It is absorbed more rapidly when swallowed than sublingually.”
c. “The absorptions are the same so it really doesn’t matter.”
d. “Sublingual provides a sustained release of the medication.”
87. The nurse is to administer 25 mg of promethazine (Phenergan) IM to a 150-pound client. The nurse knows that this
medication should be given into a deep large muscle mass. The preferred site of injection for this client would be which of
the following?
a. Deltoid b. Dorsogluteal c. Vastus lateralis d. Ventrogluteal
88. To administer 1 mL of a flu vaccine intramuscularly (IM) to an obese adult in the deltoid area you would use what size
needle?
a. 5/8 inch b. 1/2 inch c. 1 ½ inch d. 3/8 inch
89. You are preparing an IM injection of hydroxyzine(Vistaril) that is especially irritating to subcutaneous tissue. To prevent
“tracking” of the medication and irritation to the tissues, it is best to take which of the following actions?
a. Use a small-gauge needle c. Apply ice to the injection site
b. Adminster at a 45-degree angle d. Use the Z-track technique
90. A pediatric client has been diagnosed with conjunctivitus. The nurse is to administer eye drops four times a day (QID).
The nurse should administer the medication by gently dropping the medication onto which of the following areas?
a. Center of the cornea c. Sclera by the outer canthus
b. Sclera by the inner canthus d. Lower conjunctival sac
91. A client received a sever burn in a house fire. On the second day of hospitalization, the physician orders the client to
receive albumin. The nurse explains to the client that which of the following is the rationale for albumin administration?

a. Improve the level of clotting factors and prevent bleeding

b. Provide fluid resuscitation to prevent dehydration
c. Replace the lost red blood cells and reduce the anemia
d. Provide proteins to increase the osmotic pressure in the blood
92. You are to administer 10 grains of aspirin, which comes 325 mg per tablet. How many tablets would you give to administer
10 grains?
a. Half a tablet b. 1 tablet c. 2 tablets d. 10 tablets
93. While administering an intramuscular (IM) injection of meperidine (Demerol), the nurse aspirates and finds blood in the
syringe prior to injecting the medication. Which of the following actions by the nurse would be appropriate?
a. Continue to administer the medication because it is compatible with blood and would not present a harmful effect.
b. Continue to administer the medication because the needle has hit a capillary and would not be an intravenous
administration.
c. Withdraw the needle, cleanse the needle and the new injection site with alcohol, and administer the medication.
 d. Withdraw the needle, discard the medication, and begin again with the medication administration.
94. A client is refusing to take her daily anti-hyperten sive medication. The nurse has explained to the client why the
medication is important and the client verbalizes understanding but doesn’t want to take the medication. Which of the
following is the best nursing action?
a. Administer the medication because it is important for the client.
b. Inform the client that the medication needs to be taken until the nurse gets an order to discontinue it.
c. Withhold the medication and report it to the physician.
d. Withhold the medication and complete an incident report.

Fill in the blanks (write the title of their theories)

1. Florence Nightingale _________________________
2. Myra Levine________________________________
3. Dorothea Orem _____________________________
4. Sis Calista Roy _____________________________
5. Madeleine Leinenger_________________________
6. Jean Watson _______________________________
7. Hildegard Peplau ___________________________
8. H.L Dunn _________________________________
9. Martha Rogers _____________________________
10. Name the triad in ecologic model _______________