1. Patient X is diagnosed with constipation.

As a
knowledgeable nurse, which nursing intervention is
appropriate for maintaining normal bowel function?

A. Assessing dietary intake

B. Decreasing fluid intake
C. Providing limited physical activity
D. Turning, coughing, and deep breathing

2. A 12-year-old boy was admitted in the hospital two days ago

due to hyperthermia. His attending nurse, Dennis, is quite
unsure about his plan of care. Which of the following nursing
intervention should be included in the care of plan for the
client?

A. Room temperature reduction

B. Fluid restriction of 2,000 ml/day
C. Axillary temperature measurements every 4 hours
D. Antiemetic agent administration

3. Tom is ready to be discharged from the medical-surgical unit

after 5 days of hospitalization. Which client statement
indicates to the nurse that Tom understands the discharge
teaching about cellular injury?

A. “I do not have to see my doctor unless i have problems.”

B. “I can stop taking my antibiotics once I am feeling better.”
C. “If I have redness, drainage, or fever, I should call my
healthcare provider.”
D. “I can return to my normal activities as soon as I go home.”

4. Nurse Katee is caring for Adam, a 22-year-old client, in a

long-term facility. Which nursing intervention would be
appropriate when identifying nursing interventions aimed at
promoting and preventing contractures? Select all that apply.

A. Clustering activities to allow uninterrupted periods of rest

B. Maintaining correct body alignment at all times
C. Monitoring intake and output, using a urometer if necessary
D. Using a footboard or pillows to keep feet in correct position
E. Performing active and passive range-of-motion exercises
F. Weighing the client daily at the same time and in the same
clothes
5. A 36-year-old male client is about to be discharged from the
the hospital after 5 days due to surgery. Which intervention
should be included in the home health care nurse’s instructions
about measures to prevent constipation?

A. Discouraging the client from eating large amounts of

roughage-containing foods in the diet.
B. Encouraging the client to use laxatives routinely to ensure
adequate bowel elimination.
C. Instructing the client to establish a bowel evacuation
schedule that changes every day.
D. Instructing the client to fill a 2-L bottle with water every
night and drink it the next day.

6. Mr. McPartlin suffered abrasions and lacerations after a

vehicular accident. He was hospitalized and was treated for a
couple of weeks. When planning care for a client with cellular
injury, the nurse should consider which scientific rationale?

A. Nutritional needs remain unchanged for the well-nourished

adult.
B. Age is an insignificant factor in cellular repair.
C. The presence of infection may slow the healing process.
D. Tissue with inadequate blood supply may heal faster.

7. A 22-year-old lady is displaying facial grimaces during her

treatment in the hospital due to burn trauma. Which
nursing intervention should be included for reducing pain due to
cellular injury?

A. Administering anti-inflammatory agents as prescribed

B. Elevating the injured area to decrease venous return to the
heart
C. Keeping the skin clean and dry
D. Applying warm packs initially to reduce edema

8. Lisa, a client with altered urinary function, is under the

care of nurse Tine. Which intervention is appropriate to include
when developing a plan of care for Lisa who is experiencing
urinary dribbling?

A. Inserting an indwelling Foley catheter

B. Having the client perform Kegel exercises
C. Keeping the skin clean and dry
D. Using pads or diapers on the client

9. Jeron is admitted in the hospital due to bacterial pneumonia.

He is febrile, diaphoretic, and has shortness of breath
and asthma. Which goal is the most important for the client?

A. Prevention of fluid volume excess

B. Maintenance of adequate oxygenation
C. Education about infection prevention
D. Pain reduction

10. Rogelio, a 32-year-old patient, is about to be discharged

from the acute care setting. Which nursing intervention is the
most important to include in the plan of care?

A. Stress-reduction techniques
B. Home environment evaluation
C. Skin-care measures
D. Participation in activities of daily living

11. Mrs. dela Riva is in her first trimester of pregnancy. She

has been lying all day because her OB-GYN requested her to have
a complete bed rest. Which nursing intervention is appropriate
when addressing the client’s need to maintain skin integrity?

A. Monitoring intake and output accurately

B. Instructing the client to cough and deep-breathe every 2
hours
C. Keeping the linens dry and wrinkle free
D. Using a foot board to maintain correct anatomic position

12. Maya, who is admitted in a hospital, is scheduled to have

her general checkup and physical assessment. Nurse Timothy
observed a reddened area over her left hip. Which should the
nurse do first?

A. Massage the reddened are for a few minutes

B. Notify the physician immediately
C. Arrange for a pressure-relieving device
D. Turn the client to the right side for 2 hours
13. Pierro was noted to be displaying facial grimaces after
nurse Kara assessed his complaints of pain rated as 8 on a scale
of 1 (no pain) 10 10 (worst pain). Which intervention should the
nurse do?

A. Administering the client’s ordered

pain medication immediately
B. Using guided imagery instead of administering pain medication
C. Using therapeutic conversation to try to discourage pain
medication
D. Attempting to rule out complications before administering
pain medication

14. Nurse Marthia is teaching her students about bacterial

control. Which intervention is the most important factor in
preventing the spread of microorganism?

A. Maintenance of asepsis with indwelling catheter insertion

B. Use of masks, gowns, and gloves when caring for clients with
infection
C. Correct handwashing technique
D. Cleanup of blood spills with sodium hydrochloride

15. A patient with tented skin turgor, dry mucous membranes, and
decreased urinary output is under nurse Mark’s care. Which
nursing intervention should be included the care plan of Mark
for his patient?

A. Administering I.V. and oral fluids

B. Clustering necessary activities throughout the day
C. Assessing color, odor, and amount of sputum
D. Monitoring serum albumin and total protein levels

16. Khaleesi is admitted in the hospital due to having lower

than normal potassium level in her bloodstream. Her medical
history reveals vomiting and diarrhea prior to hospitalization.
Which foods should the nurse instruct the client to increase?

A. Whole grains and nuts

B. Milk products and green, leafy vegetables
C. Pork products and canned vegetables
D. Orange juice and bananas
17. Mary Jean, a first year nursing student, was rushed to the
clinic department due to hyperventilation. Which nursing
intervention is the most appropriate for the client who is
subsequently developing respiratory alkalosis?

A. Administering sodium chloride I.V.

B. Encouraging slow, deep breaths
C. Preparing to administer sodium bicarbonate
D. Administer low-flow oxygen therapy

18. Nurse John Joseph is totaling the intake and output for
Elena Reyes, a client diagnosed with septicemia who is on a
clear liquid diet. The client intakes 8 oz of apple juice, 850
ml of water, 2 cups of beef broth, and 900 ml of half-normal
saline solution and outputs 1,500 ml of urine during the shift.
How many milliliters should the nurse document as the client’s
intake.

A. 2,230
B. 2,740
C. 2,470
D. 2,320

19. Marie Joy’s lab test revealed that her serum calcium is 2.5
mEq/L. Which assessment data does the nurse document when a
client diagnosed with hypocalcemia develops a carpopedal spasm
after the blood-pressure cuff is inflated?

A. Positive Trousseau’s sign

B. Positive Chvostek’s sign
C. Tetany
D. Paresthesia

20. Lab tests revealed that patient Z’s [Na+] is 170 mEq/L. Which
clinical manifestation would nurse Natty expect to assess?

A. Tented skin turgor and thirst

B. Muscle twitching and tetany
C. Fruity breath and Kussmaul’s respirations
D. Muscle weakness and paresthesia

21. Mang Teban has a history of chronic obstructive pulmonary

disease and has the following arterial blood gas results:
partial pressure of oxygen (PO2), 55 mm Hg, and partial pressure
of carbon dioxide (PCO2), 60 mm Hg. When attempting to improve
the client’s blood gas values through improved ventilation and
oxygen therapy, which is the client’s primary stimulus for
breathing?

A. High PCO2
B. Low PO2
C. Normal pH
D. Normal bicarbonate (HCO3)

22. A client with very dry mouth, skin and mucous membranes is
diagnosed of having dehydration. Which intervention should the
nurse perform when caring for a client diagnosed with fluid
volume deficit?

A. Assessing urinary intake and output

B. Obtaining the client’s weight weekly at different times of
the day
C. Monitoring arterial blood gas (ABG) results
D. Maintaining I.V. therapy at the keep-vein-open rate

23. Which client situation requires the nurse to discuss the

importance of avoiding foods high in potassium?

A. 14-year-old Elena who is taking diuretics

B. 16-year-old John Joseph with ileostomy
C. 16-year-old Gabriel with metabolic acidosis
D. 18-year-old Albert who has renal disease

24. Genevieve is diagnosed with hypomagnesemia, which nursing

intervention would be appropriate?

A. Instituting seizure precaution to prevent injury

B. Instructing the client on the importance of preventing
infection
C. Avoiding the use of tight tourniquet when drawing blood
D. Teaching the client the importance of early ambulation

25. Which electrolyte would the nurse identify as the major

electrolyte responsible for determining the concentration of the
extracellular fluid?
A. Potassium
B. Phosphate
C. Chloride
D. Sodium

26. Jon has a potassium level of 6.5 mEq/L, which medication

would nurse Wilma anticipate?

A. Potassium supplements
B. Kayexalate
C. Calcium gluconate
D. Sodium tablets

27. Which clinical manifestation would lead the nurse to suspect

that a client is experiencing hypermagnesemia?

A. Muscle pain and acute rhabdomyolysis

B. Hot, flushed skin and diaphoresis
C. Soft-tissue calcification and hyperreflexia
D. Increased respiratory rate and depth

28. Joshua is receiving furosemide and Digoxin, which laboratory

data would be the most important to assess in planning the care
for the client?

A. Sodium level
B. Magnesium level
C. Potassium level
D. Calcium level

29. Mr. Salcedo has the following arterial blood gas (ABG)
values: pH of 7.34, partial pressure of arterial oxygen of 80 mm
Hg, partial pressure of arterial carbon dioxide of 49 mm Hg, and
a bicarbonate level of 24 mEq/L. Based on these results, which
intervention should the nurse implement?

A. Instructing the client to breathe slowly into a paper bag

B. Administering low-flow oxygen
C. Encouraging the client to cough and deep breathe
D. Nothing, because these ABG values are within normal limits.

30. A client is diagnosed with metabolic acidosis, which would

the nurse expect the health care provider to order?
A. Potassium
B. Sodium bicarbonate
C. Serum sodium level
D. Bronchodilator

Answers and Rationale

Here are the answers for this exam. Gauge your performance by counter
checking your answers to those below. If you have any disputes or
clarifications, please direct them to the comments section.

1. Answer: A. Assessing dietary intake

Assessing dietary intake provides a foundation for the client’s usual

practices and may help determine if the client is prone to
constipation or diarrhea. Limited physical activity may contribute to
constipation due to decreased peristalsis. Turning, coughing and deep
breathing help promote gas exchange. Fluid intake should be increased
to aid bowel elimination.

2. Answer: A. Room temperature reduction

For patient with hyperthermia, reducing the room temperature may help
decrease the body temperature. Tepid baths, cool compresses, and
cooling blanket may also be necessary. Antipyretics, and not
antiemetics, are indicated to reduce fever. Oral or rectal temperature
measurements are generally accepted and are more accurate than
axillary measurements. Fluids should be encouraged, not restricted to
compensate for insensible losses.

3. Answer: C. “If I have redness, drainage, or fever, I should call my

healthcare provider.”

Knowledge that redness, drainage, or fever — signs of infection

associated with cellular injury — require reporting indicates that the
client has understood the nurse’s discharge teaching. Follow-up
checkups should be encouraged with an emphasis of antibiotic
compliance even if the client feels better. There are usually activity
limitations after cellular injury.

4. Answer: B, D, E

Correct body alignment, preventing footdrop, and range-of-motion

exercises will help prevent contractures. Clustering activities will
help promote adequate rest. Monitoring intake and output and weighing
the client will help maintain fluid and electrolyte balance.
5. Answer: D. Instructing the client to fill a 2-L bottle with water
every night and drink it the next day.

Adequate fluids and fiber in the diet are key to preventing

constipation. Having the client fill a 2-L bottle with water every
night and drink it the next day is one method for ensuring the client
receives at least 2,000 ml of water daily. The client also should be
instructed to drink any other fluids throughout the day. High fiber or
roughage foods are encouraged. Laxatives should not be used routinely
for bowel elimination. They should be used only as a last resort,
because clients may become dependent on them. A regular bowel
evacuation schedule should be established.

6. Answer: C. The presence of infection may slow the healing process.

Infection impairs wound healing. Adequate blood supply is essential

for healing. If inadequate, healing is slowed. Nutritional needs,
including protein and caloric needs, increase for all clients
undergoing cellular repair because adequate protein and caloric intake
is essential to optimal cellular repair. Elderly clients may have
decreased blood flow to the skin, organ atrophy and diminished
function, and altered immunity. These conditions slow cellular repair
and increase the risk of infection.

7. Answer: A. Administering anti-inflammatory agents as prescribed

Anti-inflammatory agents help reduce edema and relieve pressure on

nerve endings, subsequently reducing pain. Elevating the injured area
increases venous return to the heart. Maintaining clean, dry skin aids
in preventing skin breakdown. Cool packs, not warm packs, should be
used initially to cause vasoconstriction and reduce edema.

8. Answer: B. Having the client perform Kegel exercises

Kegel exercises, which help strengthen the muscles in the perineal

area, are used to maintain urinary continence. To perform these
exercises, the client tightens pelvic floor muscles for 4 seconds 10
times at least 20 times each day, stopping and starting the urinary
flow. Inserting an indwelling Foley catheter increases the risk for
infection and should be avoided. The nurse should encourage the client
to develop a toileting schedule based on normal urinary habits.
However, suggesting bathroom use every 8 hours may be too long an
interval to wait. Pads or diapers should be used only as a resort.

9. Answer: B. Maintenance of adequate oxygenation

For the client with asthma and infection, oxygenation is the priority.
Maintaining adequate oxygenation reduces the risk of physiologic
injury from cellular hypoxia, which is the leading cause of cell
death. A fluid volume deficit resulting from fever and diaphoresis,
not excess, is more likely for this client. No information regarding
pain is provided in this scenario. Teaching about infection control is
not appropriate at this time but would be appropriate before
discharge.

10. Answer: B. Home environment evaluation

After discharge, the client is responsible for his own care and health
maintenance management. Discharge includes assessing the home
environment for determining the client’s ability to maintain his
health at home.

11. Answer: C. Keeping the linens dry and wrinkle free

Keeping the linens dry and wrinkle-free aids in preventing moisture

and pressure from interfering with adequate blood supply to the
tissues, helping to maintain skin integrity. Using a foot board is
appropriate for maintaining normal body function position. Monitoring
intake and output aids in assessing and maintaining bladder function..
Coughing and deep breathing help promote gas exchange.

12. Answer: D. Turn the client to the right side for 2 hours

Turning the client to the right side relieves the pressure and
promotes adequate blood supply to the left hip. A reddened area is
never massaged, because this may increase the damage to the already
reddened, damaged area. The health care provider does not need to be
notified immediately. However, the health care provider should be
informed of this finding the next time he is on the unit. Arranging
for a pressure-relieving device is appropriate, but this is done after
the client has been turned.

13. Answer: D. Attempting to rule out complications before

administering pain medication

When intervening with a client complaining of pain, the nurse must

always determine if the pain is expected pain or a complication that
requires immediate nursing intervention. This must be done before
administering the medication. Guided imagery should be used along
with, not instead of, administration of pain medication. The nurse
should medicate the client and not discourage medication.
14. Answer: C. Correct handwashing technique

Handwashing remains the most effective procedure for controlling

microorganisms and the incidence of nosocomial infections. Aseptic
technique is essential with invasive procedures, including indwelling
catheters. Masks, gowns, and gloves are necessary only when the
likelihood of exposure to blood or body fluids is high. Spills of
blood from clients with acquired immunodeficiency syndrome should be
cleaned with sodium hydrochloride.

15. Answer: A. Administering I.V. and oral fluids

The client’s assessment findings would lead the nurse to suspect that
the client is dehydrated. Administering I.V. fluids is appropriate.
Assessing sputum would be appropriate for a client with problems
associated with impaired gas exchange or ineffective airway clearance.
Monitoring albumin and protein levels is appropriate for clients
experiencing inadequate nutrition. Clustering activities helps with
energy conservation and promotes rest.

16. Answer: D. Orange juice and bananas

The client with hypokalemia needs to increase the intake of foods high
in potassium. Orange juice and bananas are high in potassium, along
with raisins, apricots, avocados, beans, and potatoes. Whole grains
and nuts would be encouraged for the client with hypomagnesemia; milk
products and green, leafy vegetables are good sources of calcium for
the client with hypocalcemia. Pork products and canned vegetables are
high in sodium and are encouraged for the client with hyponatremia.

17. Answer: B. Encouraging slow, deep breaths

The client who is hyperventilating and subsequently develops

respiratory alkalosis is losing too much carbon dioxide. Measures that
result in the retention of carbon dioxide are needed. Encourage slow,
deep breathing to retain carbon dioxide and reverse respiratory
alkalosis. Administering low-flow oxygen therapy is appropriate for
chronic respiratory acidosis. Administering sodium bicarbonate is
appropriate for treating metabolic acidosis, and administering sodium
chloride is appropriate for metabolic alkalosis.

18. Answer: C. 2,470

The fluid intake includes 8 oz (240 ml) of apple juice, 850 ml of

water, 2 cups (480 ml) of beef broth, and 900 ml of I.V. fluid for a
total of 2,470 ml intake for the shift.
19. Answer: A. Positive Trousseau’s sign

In a client with hypocalcemia, a positive Trousseau’s sign refers to

carpopedal spasm that develops usually within 2 to 5 minutes after
applying and inflating a blood pressure cuff to about 20 mm Hg higher
than systolic pressure on the upper arm. This spasm occurs as the
blood supply to the ulnar nerve is obstructed. Chvostek’s sign refers
to twitching of the facial nerve when tapping below the earlobe.
Paresthesia refers to the numbness or tingling. Tetany is a clinical
manifestation of hypocalcemia denoted by tingling in the tips of the
fingers around the mouth, and muscle spasms in the extremities and
face.

20. Answer: A. Tented skin turgor and thirst

Hypernatremia refers to elevated serum sodium levels, usually above

145 mEq/L. Typically, the client exhibits tented skin turgor and
thirst in conjunction with dry, sticky mucous membranes, lethargy, and
restlessness. Muscle weakness and paresthesia are associated with
hypokalemia; fruity breath and Kussmaul’s respirations are associated
with diabetic ketoacidosis. Muscle twitching and tetany may be seen
with hypercalcemia or hyperphosphatemia.

21. Answer: B. Low PO2

A chronically elevated PCO2 level (above 50 mmHg) is associated with

inadequate response of the respiratory center to plasma carbon
dioxide. The major stimulus to breathing then becomes hypoxia (low
PO2). High PCO2 and normal pH and HCO3 levels would not be the primary
stimuli for breathing in this client.

22. Answer: A. Assessing urinary intake and output

For the client with fluid volume deficit, assessing the client’s urine
output (using a urometer if necessary) is essential to ensure an
output of at least 30 ml/hour. The client should be weighed daily, not
weekly, and at same time each day, usually in the morning. Monitoring
ABGs is not necessary for this client. Rather, serum electrolyte
levels would most likely be evaluated. The client also would have an
I.V. rate at least 75 ml/hour, if not higher, to correct the fluid
volume deficit.

23. Answer: D. Albert who has renal disease

Clients with renal disease are predisposed to hyperkalemia and should

avoid foods high in potassium. Clients receiving diuretics, with
ileostomies, or with metabolic acidosis may be hypokalemic and should
be encouraged to eat foods high in potassium.

24. Answer: A. Instituting seizure precaution to prevent injury

Instituting seizure precaution is an appropriate intervention, because

the client with hypomagnesemia is at risk for seizures.
Hypophosphatemia may produce changes in granulocytes, which would
require the nurse to instruct the client about measures to prevent
infection. Avoiding the use of a tight tourniquet when drawing blood
helps prevent pseudohyperkalemia. Early ambulation is recommended to
reduce calcium loss from bones during hospitalization.

25. Answer: D. Sodium

Sodium is the electrolyte whose level is the primary determinant of

the extracellular fluid concentration. Sodium a cation (e.g.,
positively charged ion), is the major electrolyte in extracellular
fluid. Chloride, an anion (e.g., negatively charged ion), is also
present in extracellular fluid, but to a lesser extent. Potassium (a
cation) and phosphate (an anion) are the major electrolytes in the
intracellular fluid.

26. Answer: B. Kayexalate

The client’s potassium level is elevated; therefore, Kayexalate would

be ordered to help reduce the potassium level. Kayexalate is a cation-
exchange resin, which can be given orally, by nasogastric tube, or by
retention enema. Potassium is drawn from the bowel and excreted
through the feces. Because the client’s potassium level is already
elevated, potassium supplements would not be given. Neither calcium
gluconate nor sodium tablets would address the client’s elevated
potassium level.

27. Answer: B. Hot, flushed skin and diaphoresis

Hypermagnesemia is manifested by hot, flushed skin and diaphoresis.

The client also may exhibit hypotension, lethargy, drowsiness, and
absent deep tendon reflexes. Muscle pain and acute rhabdomyolysis are
indicative of hypophosphatemia. Soft-tissue calcification and
hyperreflexia are indicative of hyperphosphatemia. Increased
respiratory rate and depth are associated with metabolic acidosis.

28. Answer: C. Potassium level

Diuretics such as furosemide may deplete serum potassium, leading to
hypokalemia. When the client is also taking digoxin, the subsequent
hypokalemia may potentiate the action of digoxin, placing the client
at risk for digoxin toxicity. Diuretic therapy may lead to the loss of
other electrolytes such as sodium, but the loss of potassium in
association with digoxin therapy is most important. Hypocalcemia is
usually associated with inadequate vitamin D intake or synthesis,
renal failure, or use of drugs, such as aminoglycosides and
corticosteroids. Hypomagnesemia generally is associated with poor
nutrition, alcoholism, and excessive GI or renal losses, not diuretic
therapy.

29. Answer: C. Encouraging the client to cough and deep breathe

The ABG results indicate respiratory acidosis requiring improved

ventilation and increased oxygen to the lungs. Coughing and deep
breathing can accomplish this. The nurse would administer high oxygen
levels because the client does not have chronic obstructive pulmonary
disease. Breathing into a paper bag is appropriate for a client
hyperventilating and experiencing respiratory alkalosis. Some action
is necessary, because the ABG results are not within normal limits.

30. Answer: B. Sodium bicarbonate

Metabolic acidosis results from excessive absorption or retention of

acid or excessive excretion of bicarbonate. A base is needed. Sodium
bicarbonate is a base and is used to treat documented metabolic
acidosis. Potassium, serum sodium determinations, and a bronchodilator
would be inappropriate orders for this client.