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TEST I - Foundation of Professional Nursing Practice 1.

The nurse In-charge in labor and delivery unit administered a dose of terbutaline to a client without checking the client’s pulse. The standard that would be used to determine if the nurse was negligent is: a. The physician’s 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/μl. The female client is dehydrated and receiving dextrose 5% in halfnormal 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. 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/μl, 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. 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 operative’s 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”

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 client’s 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: Curling’s 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

Loss of urge to defecate c. Which type of medication order might read "Vitamin K 10 mg I. A standing order. the nurse anticipates that the client may develop which electrolyte imbalance? a. For a child. Concentrates on tasks and activities. Which of the following behaviors will she exhibit most likely? a. 15. brown. c. daily × 3 days?" a. Hypokalemia d. Allows decision making among subordinates. Emphasize the use of group collaboration. Answer: (A) Provides continuous. Standard written order c. brown. 11. One-to-one nurse patient ratio. 13. and hyponatremia. 13. Pulling the lobule down and forward 10.M. Nurse Amy is aware that the following is true about functional nursing a. For proper visualization. Stat order 14. formed stools d. A female client with a fecal impaction frequently exhibits which clinical manifestation? a. A stat order is written for medications given immediately for an urgent client problem. 12. coordinated and comprehensive nursing services.10. Communicates downward to staffs. Answer: (C) Hypokalemia Rationale: A loop diuretic removes water and. formed stools because the feces can't move past the impaction. establishes guidelines for treating a particular disease or set of symptoms in special care areas such as the coronary care unit. These clients typically report the urge to defecate (although they can't pass stool) and a decreased appetite. hypovolemia. Pulling the helix up and forward c. Answer: (C) Pulling the helix up and back Rationale: To perform an otoscopic examination on an adult. Answer: (B) Standard written order Rationale: This is a standard written order. When administering this drug. b. . This may result in hypokalemia. the nurse should position the client's ear by: a. c. the nurse grasps the helix of the ear and pulls it up and back to straighten the ear canal. Hypervolemia 11. Clients with fecal impaction don't pass hard. Rationale: Functional nursing is focused on tasks and activities and not on the care of the patients. coordinated and comprehensive nursing services. sodium and potassium. Nurse Linda prepares to perform an otoscopic examination on a female client. Hypernatremia b. Pulling the helix up and back d. Liquid or semi-liquid stools 15. Increased appetite b. Hard. b. d. Standing order d. Provides continuous. d. Answer:(A) Have condescending trust and confidence in their subordinates Rationale: Benevolent-authoritative managers pretentiously show their trust and confidence to their followers. the nurse grasps the helix and pulls it down to straighten the ear canal. Have condescending trust and confidence in their subordinates. Pulling the lobule down and back b. 14. 12. She finds out that some managers have benevolent-authoritative style of management. Hyperkalemia c. Single order b. Prescribers write a single order for medications given only once. along with it. Pulling the lobule in any direction wouldn't straighten the ear canal for visualization. The physician prescribes a loop diuretic for a client. Facilities also may institute medication protocols that specifically designate drugs that a nurse may not give. Gives economic and ego awards. also known as a protocol. 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.

16. Height and weight. Apply lotion or oil to the radiated area when it is red or sore. 18. Eat 3 to 4 hours before treatment. c. Encourage the client to drink water prior to surgery. Answer: (C) Assist the client in removing dentures and nail polish. Hgb and Hct levels. 16. and combs must be removed. Presence of crackles in both lung fields. d. 20. Calcium and potassium levels d. b. which priority information should the nurse have about the client? a. Nurse Hazel will administer a unit of whole blood. Rationale: The baseline must be established to recognize the signs of an anaphylactic or hemolytic reaction to the transfusion. Wash the skin over regularly. edema. Rationale: A positive nitrogen balance is important for meeting metabolic needs. Rationale: Dentures. In assisting a female client for immediate surgery. Provide high-fiber. 20. 18. Rationale: Irradiated skin is very sensitive and must be protected with clothing or sunblock. the nurse In-charge is aware that she should: a. hairpins. Provide high-protein. 17. The priority approach is the avoidance of strong sunlight. Answer: (B) Provide high-protein. d. d. . 19. Continuous. 19. b. Caloric goals may be as high as 5000 calories per day. Blood pressure and pulse rate. high-carbohydrate diet. high-fat diet b. and possible hemorrhage. Answer: (D) Sudden onset of continuous epigastric and back pain. Hyperactive bowel sounds d. Protect the irritated skin from sunlight. Which instruction should nurse Tom give to a male client who is having external radiation therapy: a. unrelieved epigastric or back pain reflects the inflammatory process in the pancreas. Answer: (A) Protect the irritated skin from sunlight. Monitor intake to prevent weight gain. b. c. Encourage the client to void following preoperative medication. Rationale: The autodigestion of tissue by the pancreatic enzymes results in pain from inflammation. Which dietary guidelines are important for nurse Oliver to implement in caring for the client with burns? a. b. c. tissue repair. c. and resistance to infection. Which assessment finding reflects this diagnosis? a. Blood pressure above normal range. Nail polish must be removed so that cyanosis can be easily monitored by observing the nail beds. c. Sudden onset of continuous epigastric and back pain. Answer: (A) Blood pressure and pulse rate. Assist the client in removing dentures and nail polish. Provide ice chips or water intake. 17. A male client is admitted and diagnosed with acute pancreatitis after a holiday celebration of excessive food and alcohol. Explore the client’s fears and anxieties about the surgery. highcarbohydrate diet.

The nurse takes which priority action? a. b. b. Deficient knowledge related to the nature of the disorder may be appropriate diagnosis but is not the priority. A male client is being transferred to the nursing unit for admission after receiving a radium implant for bladder cancer. Answer: (C) Risk for infection Rationale: Agranulocytosis is characterized by a reduced number of leukocytes (leucopenia) and neutrophils (neutropenia) in the blood. b. splinting the area before moving the client is imperative. 22. The Trendelenburg position increases intrathoracic pressure. Constipation b. 23. Encourage family and friends to visit. Place the client on the left side in the Trendelenburg position. Notify the physician. The nurse determines that the leadership style used at the trauma center is: a. Admit the client into a private room. The nurse should call for emergency help if the client is not hospitalized and call for a physician for the hospitalized client. A male client is receiving total parenteral nutrition suddenly demonstrates signs and symptoms of an air embolism. Immobilize the leg before moving the client. d. Nurse May attends an educational conference on leadership styles. Call the radiology department for X-ray. 25. c. d. Stop the total parenteral nutrition. d. which decreases the amount of blood pulled into the vena cava during aspiration. Answer: (D) Immobilize the leg before moving the client. Answer: (B) Admit the client into a private room. Deficient knowledge 24. d. Democratic. Encourage the client to take frequent rest periods. What is the priority action by the nurse? a. The nurse formulates which priority nursing diagnosis? a. b. Autocratic. 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. Place the client in high-Fowlers position. Laissez-faire. The nurse in-charge would take which priority action in the care of this client? a. The client is at high risk for infection because of the decreased body defenses against microorganisms. Rationale: Lying on the left side may prevent air from flowing into the pulmonary veins. Answer: (A) Autocratic. 23. c. Takes a set of vital signs. Answer: (B) Place the client on the left side in the Trendelenburg position. . c. 24. Nurse Michelle witnesses a female client sustain a fall and suspects that the leg may be broken.21. 25. This reduces the exposure of others to the radiation. Rationale: The client who has a radiation implant is placed in a private room and has a limited number of visitors. Diarrhea c. Reassure the client that everything will be alright. Rationale: If the nurse suspects a fracture. c. 22. Place client on reverse isolation. Situational 21. A newly admitted female client was diagnosed with agranulocytosis. Rationale: The autocratic style of leadership is a task-oriented and directive. Risk for infection d.

Measure the client’s arm. b. Assess the IV for type of fluid and rate of flow. 55 cc/ hour c. Rationale: Assessing the client for pain is a very important measure. Answer: (A) Take the proper equipment. 2. The IV drip factor is 60. clammy skin. b. rapid and weak irregular pulse.26. The nurse in-charge is going to hang a 500 cc bag. d.5 cc is to be added. place the client in a comfortable position. 26. 66 cc/ hour 28. Rationale: It is a general or comprehensive statement about the correct procedure. Pulse – 90 irregular 30. Answer: (A) BP – 80/60. Have the client recline or sit comfortably in a chair with the forearm at the level of the heart. The physician orders DS 500 cc with KCl 10 mEq/liter at 30 cc/hr. Document the measurement. 1. 50 cc/ hour b.5 cc Rationale: 2. and cerebral hypoxia. Pulse – 110 irregular b. Which of the following vital sign assessments that may indicate cardiogenic shock after myocardial infarction? a. cold. Postoperative pain is an indication of complication. decreased urinary output. How many cc’s of KCl will be added to the IV solution? a. The nurse is aware that the most important nursing action when a client returns from surgery is: a. 30. 24 cc/ hour d. c. 29. 28. BP – 80/60. place the client in a comfortable position.5 cc b. 27. which extremity was used.5 cc d. BP – 90/50. if you are not sure of the size of cuff to use. KCl is supplied 20 mEq/10 cc. A child of 10 years old is to receive 400 cc of IV fluid in an 8 hour shift. Answer: (D) 2. c. Pulse – 110 irregular Rationale: The classic signs of cardiogenic shock are low blood pressure. Assess the dressing for drainage. BP – 130/80. Answer: (A) 50 cc/ hour Rationale: A rate of 50 cc/hr. Answer: (B) Assess the client for presence of pain. Pulse – 50 regular c. The IV rate that will deliver this amount is: a. and record the appropriate information in the client’s chart. Assess the Foley catheter for patency and urine output d. The child is to receive 400 cc over a period of 8 hours = 50 cc/hr. 5 cc c. BP – 180/100. . Assess the client for presence of pain. Pulse – 100 regular d. Take the proper equipment. The nurse should also assess the client for pain to provide for the client’s comfort. and it includes the basic ideas which are found in the other options . and the position that the client was in during the measurement. 29. Which is the most appropriate nursing action in obtaining a blood pressure measurement? a. and record the appropriate information in the client’s chart. because only a 500 cc bag of solution is being medicated instead of a 1 liter.5 cc 27.

Evaluation c. Diagnostic test results b. Implementation d. Second intention healing b. Third intention healing d. Answer: (C) Stage III Rationale: Clinically. 34. 33. asking questions. History of present illness d. 32. provides resistance to the external rotation of the hip. When the method of wound healing is one in which wound edges are not surgically approximated and integumentary continuity is restored by granulations. Hypertension c. Answer: (A) Trochanter roll extending from the crest of the ileum to the mid-thigh. Hip-abductor pillow 34. nurse Oliver would expect to find: a. causing an increase in heart rate. Hypothermia b. Assessment b. they will allowed to heal by secondary Intention 36. 35. properly placed. c. the most appropriate nursing action would be to use: a. Rationale: A trochanter roll. First intention healing 36. the wound healing is termed a. Pillows under the lower legs. . Answer: (D) Tachycardia Rationale: With an extracellular fluid or plasma volume deficit. Physical examination 33. An 80-year-old male client is admitted to the hospital with a diagnosis of pneumonia. Stage I b. 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 person’s needs. 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 person’s needs? a. Footboard d. Stage IV 35. Biographical date c. Nurse Oliver learns that the client lives alone and hasn’t been eating or drinking. Which stage of pressure ulcer development does the ulcer extend into the subcutaneous tissue? a. Answer: (A) Second intention healing Rationale: When wounds dehisce. a deep crater or without undermining of adjacent tissue is noted.31. and comparing the patient’s behavioral responses with the expected outcomes. Primary intention healing c. Planning and goals 32. Trochanter roll extending from the crest of the ileum to the mid-thigh. Tachycardia 31. compensatory mechanisms stimulate the heart. Distended neck veins d. Stage II c. When assessing him for dehydration. b. 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. Stage III d. Answer: (B) Evaluation Rationale: Evaluation includes observing the person. 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.

Increasing loss of muscle tone. It’s a common measurement in the metric system. The chest drainage system is kept lower to promote drainage – not to prevent leaks.8 °C = (102 – 32) ÷ 1. especially close vision. Keeping the chest drainage system below the level of the chest.1 °C b. The physician prescribes meperidine (Demerol). 0. Which statement correctly describes an insulin unit? a. Checking and taping all connections. to control a client’s postoperative pain.75 Rationale: To determine the number of milliliters the client should receive. every 4 hours as needed. The physician inserts a chest tube into a female client to treat a pneumothorax. Accepting limitations while developing assets. d. 41. Having more frequent aches and pains. c.8 °C = 38.9 °C c.8 °C = 70 ÷ 1. 75 mg/X ml = 100 mg/1 ml To solve for X. 40. The nurse is assessing a 48-year-old client who has come to the physician’s office for his annual physical exam.6 c. Rationale: An insulin unit is a measure of effect.75 ml (or ¾ ml) = X 38. What is the equivalent Centigrade temperature? a. Checking all connections and taping them will prevent air leaks. One of the first physical signs of aging is: a. 41.37. Different drugs measured in units may have no relationship to one another in quality or quantity. b. c. especially close vision. not a standard measure of weight or quantity. is one of the first signs of aging in middle life (ages 46 to 64). It’s a measure of effect. not a standard measure of weight or quantity. The package insert is “Meperidine. c. 39. cross-multiply: 75 mg x 1 ml = X ml x 100 mg 75 = 100X 75/100 = X 0.25 38. It’s the smallest measurement in the apothecary system. not a standard measure of weight or quantity. Answer: (C) Failing eyesight. 39. 100 mg/ml. Failing eyesight. 0. 37.” How many milliliters of meperidine should the client receive? a. b. Rationale: Failing eyesight. Answer: (B) 38. Answer: (A) Checking and taping all connections Rationale: Air leaks commonly occur if the system isn’t secure. More frequent aches and pains begin in the early late years (ages 65 to 79). The tube is connected to water-seal drainage. 48 °C d. Nurse Oliver measures a client’s temperature at 102° F. 38. .M. It’s the basis for solids in the avoirdupois system. Keeping the head of the bed slightly elevated.9 40. d. Answer: (A) 0. A male client with diabetes mellitus is receiving insulin. d. use this formula °C = (°F – 32) ÷ 1.75 b. Increase in loss of muscle tone occurs in later years (age 80 and older). especially close vision. 0. The nurse incharge can prevent chest tube air leaks by: a. Answer: (D) it’s a measure of effect.5 d. the nurse uses the fraction method in the following equation. b. 75 mg I. Checking patency of the chest tube. 38 °C 40. 0.9 °C Rationale: To convert Fahrenheit degreed to Centigrade.

thrills. Formative d. evaluation occurs at the conclusion of the teaching and learning session. Answer: (C) Formative Rationale: Formative (or concurrent) evaluation occurs continuously throughout the teaching and learning process. palpation.V. what should the nurse in-charge do immediately? a. and palpation. if available. 32 drops/minute c. and auscultation. 46. extension and restart the infusion. (If it is removed. percussion.000 ml over 8 hours is the same as giving 125 ml over 1 hour (60 minutes). Summative. Apply a dry sterile dressing to the site. Check the room number and the client’s name on the bed. Ask the client to state his name.V. percussion. infusion at a rate of: a. Summative b. After cleaning the hub with alcohol or povidone-iodine solution. The physician orders dextrose 5 % in water. the nurse must replace the I. d. 46. Ulnar surface of the hand 47. Answer: (D) Ulnar surface of the hand Rationale: The nurse uses the ulnar surface. auscultation. nurse Betty should use the: a. Palpation. it must be replaced). and able to understand what is being said. While assessing the client. If a central venous catheter becomes disconnected accidentally. State the client’s name out loud and wait a client to repeat it. 18 drops/minute 42. but isn’t the safe standard of practice. 20 drops/minute d. percussion. Rationale: The correct order of assessment for examining the abdomen is inspection. A female client was recently admitted. Nurse Hazel inspects the client’s abdomen and notice that it is slightly concave. The fingertips and finger pads best distinguish texture and shape. and auscultation. Informative c. Nurse John should run the I. or ball. 1. Check the client’s identification band. d. b. She has fever. Call another nurse c. The I. weight loss.42. For this examination. One benefit is that the nurse can adjust teaching strategies as necessary to enhance learning. Asking the client’s name or having the client repeated his name would be appropriate only for a client who’s alert. and palpation. Percussion and palpation can alter natural findings during auscultation. 45. the nurse should immediately apply a catheter clamp. Percussion. auscultation. Answer: (B) 32 drops/minute Rationale: Giving 1. The reason for this approach is that the less intrusive techniques should be performed before the more intrusive techniques. 30 drops/minute b. Answer: (A) Check the client’s identification band.000 ml to be infused over 8 hours. 43. She is aware that the safest way to verify identity is to: a. Clamp the catheter b. 44. Names on bed aren’t always reliable 43. of the hand to assess tactile fremitus. and percussion. oriented. Rationale: Checking the client’s identification band is the safest way to verify a client’s identity because the band is assigned on admission and isn’t be removed at any time. Nurse Betty is assessing tactile fremitus in a client with pneumonia. tubing delivers 15 drops/ml. c. and vocal vibrations through the chest wall. or retrospective. Palpation. Answer: (D) Auscultation. Additional assessment should proceed in which order: a. 44. and palpation. Fingertips b. c. Answer: (A) Clamp the catheter Rationale: If a central venous catheter becomes disconnected. Informative is not a type of evaluation. Auscultation. Dorsal surface of the hand d. Call the physician d. 47. percussion. Which type of evaluation occurs continuously throughout the teaching and learning process? a. b. Nurse Trish must verify the client’s identity before administering medication.V. 45. Finger pads c. Retrospective . and watery diarrhea is being admitted to the facility. The dorsal surface best feels warmth. the nurse can place a sterile syringe or catheter plug in the catheter hub. If a clamp isn’t available.

Massaging with an astringent can further damage the skin. Most client referred to hospices have been treated for their disease without success and will receive only palliative care in the hospice. c. A male client has the following arterial blood gas values: pH 7. To provide support for the client and family in coping with terminal illness. When caring for a male client with a 3-cm stage I pressure ulcer on the coccyx. or knee does not promote venous return. 52. exist. the pH value is above normal and in the Paco2 value is below normal. 49. the pH and Hco3 values are above normal. the nurse should begin applying the bandage at the client’s foot. d. Once. Every 2 years d. Massaging the area with an astringent every 2 hours. indicating respiratory acidosis. which of the following actions can the nurse institute independently? a. 50. Knee b. Using normal saline solution to clean the ulcer and applying a protective dressing as necessary. Rationale: Hospices provide supportive care for terminally ill clients and their families. Nurse John should instruct her to have mammogram how often? a. 50. 52. In this case. A 45 year old client. Respiratory alkalosis c. Answer: (C) Using normal saline solution to clean the ulcer and applying a protective dressing as necessary.48. Hospice care doesn’t focus on counseling regarding health care costs. Nurse Oliver must apply an elastic bandage to a client’s ankle and calf. lower thigh. Respiratory acidosis b. To ensure that the client gets counseling regarding health care costs. and HCO3 26mEq/L. Rationale: Washing the area with normal saline solution and applying a protective dressing are within the nurse’s realm of interventions and will protect the area. . Answer: (D) Foot Rationale: An elastic bandage should be applied form the distal area to the proximal area. genetic tendency. Paco2 50 mmHg. to establish baseline 49. To help the client find appropriate treatment options. If health risks. Metabolic acidosis d. What is the goal of this referral? a. more frequent examinations may be necessary. d. or past breast cancer. such as family history. Answer: (B) To provide support for the client and family in coping with terminal illness. He should apply the bandage beginning at the client’s: a. 51. b. Metabolic alkalosis 48. In metabolic acidosis. Pao2 89 mmHg. Twice per year b. the pH and bicarbonate (Hco3) values are below normal. 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. Applying an antibiotic cream to the area three times per day. b.30. Based on these values. Lower thigh d. 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. Foot 51. To teach the client and family about cancer and its treatment. In respiratory alkalosis. Nurse Len refers a female client with terminal cancer to a local hospice. In metabolic alkalosis. c. Ankle c. Nurse Patricia should expect which condition? a. This method promotes venous return. has no family history of breast cancer or other risk factors for this disease. Once per year c. Using a povidone-iodine wash and an antibiotic cream require a physician’s order. Beginning at the ankle. Using a povidone-iodine wash on the ulceration three times per day.

Tinnitus or diplopia. b. 56. The nurse determines that the standard of care had been maintained if which of the following data is observed? a.32 is acidotic. Throbbing headache or dizziness b. 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. Nurse Janah is monitoring the ongoing care given to the potential organ donor who has been diagnosed with brain death. Hypercalcemia 54. d. Behind the client. The client is instructed to look up and outward rather than at his or her feet. Drowsiness or blurred vision. The nurse rushes to the client’s room. causing hypokalemia. 57. In front of the client. Which condition represents the greatest risk to this child? a. Answer: (A) Throbbing headache or dizziness Rationale: Headache and dizziness often occur when nitroglycerin is taken at the beginning of therapy. Nurse Len is administering sublingual nitroglycerin (Nitrostat) to the newly admitted client. Urine output: 45 ml/hr b. Prepare to defibrillate the client c. A 10 year old child with type 1 diabetes develops diabetic ketoacidosis and receives a continuous insulin infusion. A serum pH of 7. 55. Low blood pressure and delayed capillary refill time are circulatory system indicators of inadequate perfusion. d. Blood pressure: 90/48 mmHg 53. Rationale: When walking with clients. Answer: (D) Check the client’s level of consciousness Rationale: Determining unresponsiveness is the first step assessment action to take. Prepare for cardioversion b. Serum pH: 7. c. Capillary refill: 5 seconds c. Nervousness or paresthesia. the nurse would take which action first? a. Hypokalemia c. 54. On the affected side of the client. On the unaffected side of the client. However. 57. Answer: (B) Hypokalemia Rationale: Insulin administration causes glucose and potassium to move into the cells. the client may experience: a. However. the nurse should stand on the affected side and grasp the security belt in the midspine area of the small of the back.53. A urine output of 45 ml per hour indicates adequate renal perfusion. . Nurse Hazel is preparing to ambulate a female client. The nurse quickly looks at the monitor and notes that a client is in a ventricular tachycardia. Answer: (B) On the affected side of the client. Hyperphosphatemia d. Immediately afterward. checking the unresponsiveness ensures whether the client is affected by the decreased cardiac output. there is a significant decrease in cardiac output. Nurse Michelle hears the alarm sound on the telemetry monitor. which adversely affects all body tissues. the client usually develops tolerance 55.32 d. c. Call a code d. The best and the safest position for the nurse in assisting the client is to stand: a. Upon reaching the client’s bedside. Check the client’s level of consciousness 56. 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. Hypernatremia b. When a client is in ventricular tachycardia.

then the specimen is not sterile. b. puts weight on the hand pieces. Answer: (D ) Obtaining the specimen from the urinary drainage bag. Immediately walk out of the client’s room and answer the phone call. b. then the specimen would be contaminated and the results of the test would be invalid. Wiping the port with an alcohol swab before inserting the syringe. c. and then walks into it. c. Nurse Ron is observing a male client using a walker. the nurse stands adjacent to the affected side. Nurse Janah is collecting a sputum specimen for culture and sensitivity testing from a client who has a productive cough. Use a sterile plastic container for obtaining the specimen. Aspirating a sample from the port on the drainage bag. Provide tissues for expectoration and obtaining the specimen. place the call light within reach. 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. The nurse determines that the client is using the walker correctly if the client: a. Walks into the walker. place the call light within reach. 59. b. puts weight on the hand pieces. 61. Answer: (C) Use a sterile plastic container for obtaining the specimen. Nurse Janah plans to implement which intervention to obtain the specimen? a. which contaminate the specimen? a. 60. d. the nurse covers the client and places the call light within the client’s reach. and then puts all four points of the walker flat on the floor. d. Puts all the four points of the walker flat on the floor. Answer: (A) Puts all the four points of the walker flat on the floor. Urine undergoes chemical changes while sitting in the bag and does not necessarily reflect the current client status. the nurse may need to answer it. Rationale: A urine specimen is not taken from the urinary drainage bag. and answer the phone call. Puts weight on the hand pieces. Theclient is instructed to put all four points of the walker 2 feet forward flat on the floor before putting weight on hand pieces. Finish the bed bath before answering the phone call. If the procedure for obtaining the specimen is not sterile. 59. c. b. slides the walker forward. Rationale: Because telephone call is an emergency. This will ensure client safety and prevent stress cracks in the walker. . The nurse avoids which of the following. and then walks into it. Obtaining the specimen from the urinary drainage bag. and answer the phone call. d. the client’s door should be closed or the room curtains pulled around the bathing area. 60. To maintain privacy and safety. Rationale: When the client uses a walker. Nurse Meredith is in the process of giving a client a bed bath. However. Leave the client’s door open so the client can be monitored and the nurse can answer the phone call. and then walks into it. Puts weight on the hand pieces. the unit secretary calls the nurse on the intercom to tell the nurse that there is an emergency phone call. and then walks into it. In the middle of the procedure. The other appropriate action is to ask another nurse to accept the call. puts weight on the hand pieces. moves the walker forward. The client is then instructed to move the walker forward and walk into it. Cover the client. Nurse Amy has an order to obtain a urinalysis from a male client with an indwelling urinary catheter. Ask the client to expectorate a small amount of sputum into the emesis basin. Clamping the tubing of the drainage bag.58. In addition. 58. The appropriate nursing action is to: a. Additionally. it may become contaminated with bacteria from opening the system. c. 61. is not one of the options. Ask the client to obtain the specimen after breakfast. Answer: (B) Cover the client. d.

At the time of the transfer from the surgery table to the stretcher. Rationale: During the transfer of the client after the surgical procedure is complete. Goggles are not necessary unless the nurse anticipates the splashes of blood. Answer: (C) Quad cane Rationale: Crutches and a walker can be difficult to maneuver for a client with weakness on one side. Uncovers the client completely before transferring to the stretcher. Draws one line to cross out the incorrect information and then initials the change. Crutches b. or excretions may occur. The nurse would suggest that the client use which of the following assistive devices that would provide the best stability for ambulating? a. the nurse realizes that incorrect information was documented. Uses correction fluid to cover up the incorrect information and writes in the correct information. Moves the client rapidly from the table to the stretcher. Gloves and goggles 65. c. Hurried movements and rapid changes in the position should be avoided because these predispose the client to hypotension. 64. b. Gloves and shoe protectors d.62. the nurse should: a. d. Single straight-legged cane c. Rationale: To correct an error documented in a medical record. To provide safety to the client. When checking the entry. . However. 63. Secures the client safety belts after transferring to the stretcher. c. Gown and goggles b. Gown and gloves c. Nurse Myrna instructs the nursing assistant to use which of the following protective items when giving bed bath? a. An error is never erased and correction fluid is never used in the medical record. the client is still affected by the effects of the anesthesia. d. b. A cane is better suited for client with weakness of the arm and leg on one side. Answer: (C) Secures the client safety belts after transferring to the stretcher. body fluids. therefore. Instructs the client to move self from the table to the stretcher. Answer: (B) Gown and gloves Rationale: Contact precautions require the use of gloves and a gown if direct client contact is anticipated. Safety belts can prevent the client from falling off the stretcher. Nurse Oliver is caring for a client with impaired mobility that occurred as a result of a stroke. How does the nurse correct this error? a. the client should not move self. Answer: (C) Draws one line to cross out the incorrect information and then initials the change. Nurse Amy has documented an entry regarding client care in the client’s medical record. The client has right sided arm and leg weakness. the quad cane would provide the most stability because of the structure of the cane and because a quad cane has four legs. Erases the error and writes in the correct information. Walker 62. the nurse draws one line through the incorrect information and then initials the error. secretions. Shoe protectors are not necessary. Quad cane d. 64. the nurse should avoid exposure of the client because of the risk for potential heat loss. Nurse Ron is assisting with transferring a client from the operating room table to a stretcher. 65. Nurse Myrna is providing instructions to a nursing assistant assigned to give a bed bath to aclient who is on contact precautions. Covers up the incorrect information completely using a black pen and writes in the correct information 63.

Validity b. To provide a safe environment. Quasi-experiment d. d. Answer: (A) Descriptive. . Patient’s refusal to divulge information is a limitation because it is beyond the control of Tifanny”. Answer: (C) Use of laboratory data Rationale: Incidence of nosocomial infection is best collected through the use of biophysiologic measures. 70. Use of laboratory data d. Answer: (D) Left side-lying with the head of the bed elevated 45 degrees. Nurse Ronald is aware that the best tool for data gathering is? a. 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. A male client with a right pleural effusion noted on a chest X-ray is being prepared for thoracentesis. the nurse assists the client to which position for the procedure? a. Rationale: To facilitate removal of fluid from the chest wall.66. Which of the following actions of Harry ensures anonymity? a. Specificity c. Nurse John develops methods for data gathering. Reliability 68. Release findings only to the participants of the study 69. 67. Descriptive. particularly in vitro measurements.correlational b. If the client is unable to sit up. Sims’ position with the head of the bed flat.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. Left side-lying with the head of the bed elevated 45 degrees. Harry knows that he has to protect the rights of human research subjects. Experiment c. 67. Sensitivity d. Keep the identities of the subject secret b. hence laboratory data is essential. c. 69. What type of research is appropriate for this study? a.correlational Rationale: Descriptive. Provide equal treatment to all the subjects of the study. It refers to the repeatability of the instrument in extracting the same responses upon its repeated administration. Right side-lying with the head of the bed elevated 45 degrees. 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. The client experiences severe dizziness when sitting upright. the client is positioned lying in bed on the unaffected side with the head of the bed elevated 30 to 45 degrees. the client is positioned sitting at the edge of the bed leaning over the bedside table with the feet supported on a stool. Prone with head turned toward the side supported by a pillow. 68. Questionnaire c. Historical 70. Answer: (D) Reliability Rationale: Reliability is consistency of the research instrument. Obtain informed consent c. b. Observation 66. Interview schedule b. d.

Bibliography c. The Board can issue rules and regulations that will govern the practice of nursing b. Quasi-experiment c. Answer: (C) Primary source Rationale: This refers to a primary source which is a direct account of the investigation done by the investigator. Holdover doctrine 75. 74. Force majeure b. which is written by someone other than the original researcher. The Board can visit a school applying for a permit in collaboration with CHED d. Cherry notes down ideas that were derived from the description of an investigation written by the person who conducted it. This means in operational terms that the injury caused is the proof that there was a negligent act. Answer: (B) Quasi-experiment Rationale: Quasi-experiment is done when randomization and control of the variables are not possible. Non-maleficence b. 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. Solidarity 74. In contrast to this is a secondary source. The Board can investigate violations of the nursing law and code of ethics c. An example of this power is: a. Which type of research is referred to this? a. 72. Which type of reference source refers to this? a. Field study b. Primary source d. Answer: (C) Res ipsa loquitor Rationale: Res ipsa loquitor literally means the thing speaks for itself. Solomon-Four group design d. 75. she must remember that her duty is bound not to do doing any action that will cause the patient harm. . Justice d. The Board prepares the board examinations 71. subpoena or subpoena duces tecum as needed. Res ipsa loquitor d. Footnote b. This is the meaning of the bioethical principle: a. To do good is referred as beneficence. Post-test only design 72. When Nurse Trish is providing care to his patient. the presence of the injury is said to exemplify the principle of: a. 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. Beneficence c. 73. 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. When a nurse in-charge causes an injury to a female patient and the injury caused becomes the proof of the negligent act. Respondeat superior c.71. Nurse Myrna is aware that the Board of Nursing has quasi-judicial power. Endnotes 73.

Ronald plans to conduct a research on the use of a new method of pain assessment scale. Horns effect 79. 80. When the license of nurse Krina is revoked. b) at least four years has elapsed since the license has been revoked. Answer: (B) Determines the different nationality of patients frequently admitted and decides to get representations samples from each.76. Cause and effect b. 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. a revoked license maybe reissued provided that the following conditions are met: a) the cause for revocation of license has already been corrected or removed. Halo effect d. Mary finally decides to use judgment sampling on her research. Florence Nightingale b. Formulating the research hypothesis b. d. b. . They performed differently because they were under observation. Answer: (B) Review related literature Rationale: After formulating and delimiting the research problem. Madeleine Leininger c. Plans to include whoever is there during his study. and. Assigns numbers for each of the patients. place these in a fishbowl and draw 10 from it. Determines the different nationality of patients frequently admitted and decides to get representations samples from each. 24 states that for equity and justice. 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. it means that she: a. 78. Rationale: Judgment sampling involves including samples according to the knowledge of the investigator about the participants in the study. Formulating and delimiting the research problem d. 77. May apply for re-issuance of his/her license based on certain conditions stipulated in RA 9173 d. The nursing theorist who developed transcultural nursing theory is: a. Callista Roy 76. 79. Design the theoretical and conceptual framework 78. Which of the following is the second step in the conceptualizing phase of the research process? a. the researcher conducts a review of related literature to determine the extent of what has been done on the study by previous researchers. Which of the following actions of is correct? a. 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. Answer: (C) May apply for re-issuance of his/her license based on certain conditions stipulated in RA 9173 Rationale: RA 9173 sec. Decides to get 20 samples from the admitted patients 80. Will remain unable to practice professional nursing 77. This referred to as: a. It resulted to an increased productivity but not due to the intervention but due to the psychological effects of being observed. Albert Moore d. Sr. c. Review related literature c. Hawthorne effect c. Will never have her/his license re-issued since it has been revoked c. Is no longer allowed to practice the profession for the rest of her life b.

Ice cream d. Veracity d. Callista Roy Rationale: Sr. Florence Nightingale d. 87. Accidental c. Oranges and broccoli supply vitamin C but not protein. cause skin irritation and breakdown. Both cotton and cornstarch absorb perspiration. Nurse Reese should include which instruction? a. Autonomy c. Downward communication d. Avoid using cornstarch on feet. . Callista Roy developed the Adaptation Model which involves the physiologic mode. Answer: (B) Sr. Level of satisfaction d. Ensuring that there is an informed consent on the part of the patient before a surgery is done. Compliance to expected standards c. 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. Jean Watson 84. which may. Answer: (A) Random Rationale: Random sampling gives equal chance for all the elements in the population to be picked as part of the sample. Avoid wearing cotton socks. the nurse should include: a. self-concept mode. Canvas shoes cause the feet to perspire. A client is admitted with multiple pressure ulcers. role function mode and dependence mode. When developing the client's diet plan. The client should be instructed to cut toenails straight across with nail clippers. Avoid wearing canvas shoes. Marion is aware that the sampling method that gives equal chance to all units in the population to get picked is: a. Garcia is responsible to the number of personnel reporting to her. Steamed broccoli c. Fresh orange slices b. Sr. Which of the following theory addresses the four modes of adaptation? a. Callista Roy c. c. making it less helpful in tissue repair. Answer: (A) Span of control Rationale: Span of control refers to the number of workers who report directly to a manager. Answer: (B) Autonomy Rationale: Informed consent means that the patient fully understands about the surgery. This principle refers to: a. illustrates the bioethical principle of: a. Rationale: The client should be instructed to avoid wearing canvas shoes. Non-maleficence 86. d. Degree of acceptance 83. 84. Judgment 82. Span of control b. b.81. Random b. Ground beef patties 81. Madeleine Leininger b. Beneficence b. Answer: (D) Ground beef patties Rationale: Meat is an excellent source of complete protein. John plans to use a Likert Scale to his study to determine the: a. 87. The action of allowing the patient to decide whether a surgery is to be done or not exemplifies the bioethical principle of autonomy. Ice cream supplies only some incomplete protein. Ms. In giving consent it is done with full knowledge and is given freely. Nurse Reese is teaching a female client with peripheral vascular disease about foot care. Avoid using a nail clipper to cut toenails. Answer: (C) Avoid wearing canvas shoes. in turn. 86. which this client needs to repair the tissue breakdown caused by pressure ulcers. 82. including the risks involved and the alternative solutions. Quota d. Degree of agreement and disagreement b. Unity of command c. Leader 85. 85.

Implementation is the phase of the nursing process where the nurse puts the plan of care into action. Administering an already-prescribed drug on time is a dependent intervention. Answer: (A) Arrange for typing and cross matching of the client’s blood.m. Rationale: The nurse first arranges for typing and cross matching of the client's blood to ensure compatibility with donor blood. Prone d. Implementation d. b. The Nurse Betty notes that the client's leg is pain-free. d. To observe the lower extremities c. physical examination. Applying the stockings increases blood flow to the heart. without redness or edema. the leg muscles can still stretch and relax. Start an I. The nurse's actions reflect which step of the nursing process? a. Answer: (A) Independent Rationale: Nursing interventions are classified as independent. Independent b. Answer: (B) To observe the lower extremities Rationale: Elastic stockings are used to promote venous return. Which type of nursing intervention is required? a. 89. c. Analysis consists of considering assessment information to derive the appropriate nursing diagnosis.V. 92. Sims’ left lateral 89. Answer: (D) Evaluation Rationale: The nursing actions described constitute evaluation of the expected outcomes.m. Assessment b. The nurse prepares to administer a cleansing enema. Compare the client’s identification wristband with the tag on the unit of blood. so that he can go to sleep earlier. Evaluation 92. Arrange for typing and cross matching of the client’s blood. interdependent. 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. When the stockings are in place. Nursing care for a female client includes removing elastic stockings once per day. If the client can't assume this position nor has poor sphincter control. To increase blood flow to the heart b. An intradependent nursing intervention doesn't exist. To allow the leg muscles to stretch and relax d. Diagnosis c. and the veins can fill with blood. The findings show that the expected outcomes have been achieved. Which action should the nurse take first? a. instead of 10 p. 88. Assessment consists of the client's history. the dorsal recumbent or right lateral position may be used. The Nurse Betty is aware that the rationale for this intervention? a. A female client is to be discharged from an acute care facility after treatment for right leg thrombophlebitis. 91. Supine c. Dependent c. What is the most common client position used for this procedure? a. The supine and prone positions are inappropriate and uncomfortable for the client. The nurse needs to remove them once per day to observe the condition of the skin underneath the stockings. Measure the client’s vital signs. whereas consulting with the physician and pharmacist to change a client's medication because of adverse reactions represents an interdependent intervention. infusion of normal saline solution. 90. To permit veins in the legs to fill with blood. Intradependent 91. 90. A 65 years old male client requests his medication at 9 p.88. or dependent. . and laboratory studies. Nurse Marian is preparing to administer a blood transfusion. Altering the drug schedule to coincide with the client's daily routine represents an independent intervention. Lithotomy b. Interdependent d.

94. Rationale: Complaints of abdominal discomfort and nausea are common in clients receiving tube feedings. Place the client in semi-Fowler's position while feeding. d. altering its action. b. 97. b. The maximum transfusion time for a unit of packed red blood cells (RBCs) is: a. Answer: (B) Decrease the rate of feedings and the concentration of the formula. swelling. 2 hours 93. the nurse must monitor the client for these effects. the nurse promotes easier chest expansion. Assist the client to the semi-Fowler position if possible. Feedings are normally given at room temperature to minimize abdominal cramping. 6 hours b. the head of the client's bed should be elevated at least 30 degrees. Instructing the client to report any itching. Which intervention should the nurse Trish use when administering oxygen by face mask to a female client? a. and dyspnea. 95. d. Secure the elastic band tightly around the client's head. 94.93. swelling. Documenting blood administration in the client care record. 95. Change the feeding container every 12 hours. according to facility policy. 4 hours c. b. Roll the vial gently between the palms. A male client complains of abdominal discomfort and nausea while receiving tube feedings. 97. Apply the face mask from the client's chin up over the nose. 3 hours d. c. Answer: (B) Assist the client to the semiFowler position if possible. Answer: (D) Roll the vial gently between the palms. Which intervention is most appropriate for this problem? a. Shaking the vial vigorously could cause the medication to break down. c. Loosen the connectors between the oxygen equipment and humidifier. To prevent aspiration during feeding. which helps dissolve the medication. Answer: (B) 4 hours Rationale: A unit of packed RBCs may be given over a period of between 1 and 4 hours. 96. d. Decrease the rate of feedings and the concentration of the formula. Rationale: By assisting the client to the semiFowler position. Signs and symptoms of life-threatening allergic reactions include itching. Decreasing the rate of the feeding and the concentration of the formula should decrease the client's discomfort. Rationale: Rolling the vial gently between the palms produces heat. . 96. Nurse Patricia is reconstituting a powdered medication in a vial. feeding containers should be routinely changed every 8 to 12 hours. Also. c. breathing. Discard or return to the blood bank any blood not given within this time. b. Which nursing intervention takes highest priority when caring for a newly admitted client who's receiving a blood transfusion? a. Answer :(A) Instructing the client to report any itching. or dyspnea. and oxygen intake. Doing nothing or inverting the vial wouldn't help dissolve the medication. or dyspnea. swelling. she nurse should: a. Shake the vial vigorously. d. Give the feedings at room temperature. Rationale: Because administration of blood or blood products may cause serious adverse effects such as allergic reactions. It shouldn't infuse for longer than 4 hours because the risk of contamination and sepsis increases after that time. Assessing the client’s vital signs when the transfusion ends. Invert the vial and let it stand for 3 to 5 minutes. After adding the solution to the powder. Informing the client that the transfusion usually take 1 ½ to 2 hours. Do nothing. c. to prevent bacterial growth.

Nurse May is aware that the main advantage of using a floor stock system is: a. d. Theother options are normal abdominal findings. blood level of a drug. Answer: (B) Immediately before administering the next dose. Immediately before administering the next dose. Which finding should the nurse report as abnormal? a. Vascular sounds heard over the renal arteries. d. c. Shifting dullness over the abdomen. Immediately after administering the next dose. Bowel sounds occurring every 10 seconds. nor does it minimize transcription errors or reinforce accurate calculations. the nurse draws a blood sample immediately before administering the next dose. 99. d. c. peak blood drug levels typically are drawn after administering the next dose. 100. Answer: (C) Shifting dullness over the abdomen. . Answer: (A) The nurse can implement medication orders quickly. For measurement of the trough. The nurse can implement medication orders quickly.98. Nurse Oliver is assessing a client's abdomen. b. Nurse Monique is monitoring the effectiveness of a client's drug therapy. 100. The system reinforces accurate calculations. 98. The nurse receives input from the pharmacist. Rationale: A floor stock system enables the nurse to implement medication orders quickly. b. When should the nurse Monique obtain a blood sample to measure the trough drug level? a. c. The system minimizes transcription errors. 1 hour before administering the next dose. 99. It doesn't allow for pharmacist input. Dullness over the liver. Depending on the drug's duration of action and half-life. or lowest. b. Rationale: Measuring the blood drug concentration helps determine whether the dosing has achieved the therapeutic goal. Rationale: Shifting dullness over the abdomen indicates ascites. an abnormal finding. 30 minutes after administering the next dose.