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 half-normal saline
solution at 150 ml/hr. The client complains of severe bone pain and is scheduled to receive a dose of
morphine sulfate. In administering the medication, Nurse Trish should avoid which route?

A. I.V
B. I.M
C. Oral
D. S.C
3. Dr. Garcia writes the following order for the client who has been recently admitted “Digoxin .125 mg
P.O. once daily.” To prevent a dosage error, how should the nurse document this order onto the
medication administration record?

A. “Digoxin .1250 mg P.O. once daily”

B. “Digoxin 0.1250 mg P.O. once daily”
C. “Digoxin 0.125 mg P.O. once daily”
D. “Digoxin .125 mg P.O. once daily”
4. A newly admitted female client was diagnosed with deep vein thrombosis. Which nursing diagnosis
should receive the highest priority?

A. Ineffective peripheral tissue perfusion related to venous congestion.

B. Risk for injury related to edema.
C. Excess fluid volume related to peripheral vascular disease.
D. Impaired gas exchange related to increased blood flow.
5. Nurse Betty is assigned to the following clients. The client that the nurse would see first after
endorsement?

A. A 34 year-old post operative appendectomy client of five hours who is complaining of pain.
B. A 44 year-old myocardial infarction (MI) client who is complaining of nausea.
C. A 26 year-old client admitted for dehydration whose intravenous (IV) has infiltrated.
D. A 63 year-old post 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”
10.The physician prescribes a loop diuretic for a client. When administering this drug, the nurse
anticipates that the client may develop which electrolyte imbalance?

A. Hypernatremia
B. Hyperkalemia
C. Hypokalemia
D. Hypervolemia
11.She finds out that some managers have benevolent-authoritative style of management. Which of the
following behaviors will she exhibit most likely?

A. Have condescending trust and confidence in their subordinates.

B. Gives economic and ego awards.
C. Communicates downward to staffs.
D. Allows decision making among subordinates.
12. Nurse Amy is aware that the following is true about functional nursing

A. Provides continuous, coordinated and comprehensive nursing services.

B. One-to-one nurse patient ratio.
C. Emphasize the use of group collaboration.
D. Concentrates on tasks and activities.
13.Which type of medication order might read “Vitamin K 10 mg I.M. daily × 3 days?”

A. Single order
B. Standard written order
C. Standing order
D. Stat order
14.A female client with a fecal impaction frequently exhibits which clinical manifestation?

A. Increased appetite
B. Loss of urge to defecate
C. Hard, brown, formed stools
 D. Liquid or semi-liquid stools
15.Nurse Linda prepares to perform an otoscopic examination on a female client. For proper
visualization, the nurse should position the client’s ear by:

A. Pulling the lobule down and back

B. Pulling the helix up and forward
C. Pulling the helix up and back
D. Pulling the lobule down and forward
16. Which instruction should nurse Tom give to a male client who is having external radiation therapy:

A. Protect the irritated skin from sunlight.

B. Eat 3 to 4 hours before treatment.
C. Wash the skin over regularly.
D. Apply lotion or oil to the radiated area when it is red or sore.
17.In assisting a female client for immediate surgery, the nurse In-charge is aware that she should:

A. Encourage the client to void following preoperative medication.

B. Explore the client’s fears and anxieties about the surgery.
C. Assist the client in removing dentures and nail polish.
D. Encourage the client to drink water prior to surgery.
18. A male client is admitted and diagnosed with acute pancreatitis after a holiday celebration of
excessive food and alcohol. Which assessment finding reflects this diagnosis?

A. Blood pressure above normal range.

B. Presence of crackles in both lung fields.
C. Hyperactive bowel sounds
D. Sudden onset of continuous epigastric and back pain.
19. Which dietary guidelines are important for nurse Oliver to implement in caring for the client with
burns?

A. Provide high-fiber, high-fat diet

B. Provide high-protein, high-carbohydrate diet.
C. Monitor intake to prevent weight gain.
D. Provide ice chips or water intake.
20.Nurse Hazel will administer a unit of whole blood, which priority information should the nurse have
about the client?

A. Blood pressure and pulse rate.

B. Height and weight.
C. Calcium and potassium levels
D. Hgb and Hct levels.
21. Nurse Michelle witnesses a female client sustain a fall and suspects that the leg may be broken. The
nurse takes which priority action?

A. Takes a set of vital signs.

B. Call the radiology department for X-ray.
C. Reassure the client that everything will be alright.
D. Immobilize the leg before moving the client.
22.A male client is being transferred to the nursing unit for admission after receiving a radium implant
for bladder cancer. The nurse in-charge would take which priority action in the care of this client?
 A. Place client on reverse isolation.
B. Admit the client into a private room.
C. Encourage the client to take frequent rest periods.
D. Encourage family and friends to visit.
23.A newly admitted female client was diagnosed with agranulocytosis. The nurse formulates which
priority nursing diagnosis?

A. Constipation
B. Diarrhea
C. Risk for infection
D. Deficient knowledge
24.A male client is receiving total parenteral nutrition suddenly demonstrates signs and symptoms of an
air embolism. What is the priority action by the nurse?

A. Notify the physician.

B. Place the client on the left side in the Trendelenburg position.
C. Place the client in high-Fowlers position.
D. Stop the total parenteral nutrition.
25.Nurse May attends an educational conference on leadership styles. The nurse is sitting with a nurse
employed at a large trauma center who states that the leadership style at the trauma center is task-
oriented and directive. The nurse determines that the leadership style used at the trauma center is:

A. Autocratic.
B. Laissez-faire.
C. Democratic.
D. Situational
26.The physician orders DS 500 cc with KCl 10 mEq/liter at 30 cc/hr. The nurse in-charge is going to
hang a 500 cc bag. KCl is supplied 20 mEq/10 cc. How many cc’s of KCl will be added to the IV solution?

A. .5 cc
B. 5 cc
C. 1.5 cc
D. 2.5 cc
27.A child of 10 years old is to receive 400 cc of IV fluid in an 8 hour shift. The IV drip factor is 60. The IV
rate that will deliver this amount is:

A. 50 cc/ hour
B. 55 cc/ hour
C. 24 cc/ hour
D. 66 cc/ hour
28.The nurse is aware that the most important nursing action when a client returns from surgery is:

A. Assess the IV for type of fluid and rate of flow.

B. Assess the client for presence of pain.
C. Assess the Foley catheter for patency and urine output
D. Assess the dressing for drainage.
29. Which of the following vital sign assessments that may indicate cardiogenic shock after myocardial
infarction?

A. BP – 80/60, Pulse – 110 irregular

 B. BP – 90/50, Pulse – 50 regular
C. BP – 130/80, Pulse – 100 regular
D. BP – 180/100, Pulse – 90 irregular
30.Which is the most appropriate nursing action in obtaining a blood pressure measurement?

A. Take the proper equipment, place the client in a comfortable position, and record the appropriate
information in the client’s chart.
B. Measure the client’s arm, if you are not sure of the size of cuff to use.
C. Have the client recline or sit comfortably in a chair with the forearm at the level of the heart.
D. Document the measurement, which extremity was used, and the position that the client was in
during the measurement.
31.Asking the questions to determine if the person understands the health teaching provided by the
nurse would be included during which step of the nursing process?

A. Assessment
B. Evaluation
C. Implementation
D. Planning and goals
32.Which of the following item is considered the single most important factor in assisting the health
professional in arriving at a diagnosis or determining the person’s needs?

A. Diagnostic test results

B. Biographical date
C. History of present illness
D. Physical examination
33.In preventing the development of an external rotation deformity of the hip in a client who must
remain in bed for any period of time, the most appropriate nursing action would be to use:

A. Trochanter roll extending from the crest of the ileum to the midthigh.
B. Pillows under the lower legs.
C. Footboard
D. Hip-abductor pillow
34.Which stage of pressure ulcer development does the ulcer extend into the subcutaneous tissue?

A. Stage I
B. Stage II
C. Stage III
D. Stage IV
35.When the method of wound healing is one in which wound edges are not surgically approximated and
integumentary continuity is restored by granulations, the wound healing is termed

A. Second intention healing

B. Primary intention healing
C. Third intention healing
D. First intention healing
36.An 80-year-old male client is admitted to the hospital with a diagnosis of pneumonia. Nurse Oliver
learns that the client lives alone and hasn’t been eating or drinking. When assessing him for dehydration,
nurse Oliver would expect to find:

A. Hypothermia
 B. Hypertension
C. Distended neck veins
D. Tachycardia
37.The physician prescribes meperidine (Demerol), 75 mg I.M. every 4 hours as needed, to control a
client’s postoperative pain. The package insert is “Meperidine, 100 mg/ml.” How many milliliters of
meperidine should the
client receive?

A. 0.75
B. 0.6
C. 0.5
D. 0.25
38. A male client with diabetes mellitus is receiving insulin. Which statement correctly describes an
insulin unit?

A. It’s a common measurement in the metric system.

B. It’s the basis for solids in the avoirdupois system.
C. It’s the smallest measurement in the apothecary system.
D. It’s a measure of effect, not a standard measure of weight or quantity.
39.Nurse Oliver measures a client’s temperature at 102° F. What is the equivalent Centigrade
temperature?

A. 40.1 °C
B. 38.9 °C
C. 48 °C
D. 38 °C
40.The nurse is assessing a 48-year-old client who has come to the physician’s office for his annual
physical exam. One of the first physical signs of aging is:

A. Accepting limitations while developing assets.

B. Increasing loss of muscle tone.
C. Failing eyesight, especially close vision.
D. Having more frequent aches and pains.
41.The physician inserts a chest tube into a female client to treat a pneumothorax. The tube is connected
to water-seal drainage. The nurse in-charge can prevent chest tube air leaks by:

A. Checking and taping all connections.

B. Checking patency of the chest tube.
C. Keeping the head of the bed slightly elevated.
D. Keeping the chest drainage system below the level of the chest.
42.Nurse Trish must verify the client’s identity before administering medication. She is aware that the
safest way to verify identity is to:

A. Check the client’s identification band.

B. Ask the client to state his name.
C. State the client’s name out loud and wait a client to repeat it.
D. Check the room number and the client’s name on the bed.
43.The physician orders dextrose 5 % in water, 1,000 ml to be infused over 8 hours. The I.V. tubing
delivers 15 drops/ml. Nurse John should run the I.V. infusion at a rate of:
 A. 30 drops/minute
B. 32 drops/minute
C. 20 drops/minute
D. 18 drops/minute
44.If a central venous catheter becomes disconnected accidentally, what should the nurse in-charge do
immediately?

A. Clamp the catheter

B. Call another nurse
C. Call the physician
D. Apply a dry sterile dressing to the site.
45.A female client was recently admitted. She has fever, weight loss, and watery diarrhea is being
admitted to the facility. While assessing the client, Nurse Hazel inspects the client’s abdomen and notice
that it is slightly concave. Additional assessment should proceed in which order:

A. Palpation, auscultation, and percussion.

B. Percussion, palpation, and auscultation.
C. Palpation, percussion, and auscultation.
D. Auscultation, percussion, and palpation.
46. Nurse Betty is assessing tactile fremitus in a client with pneumonia. For this examination, nurse Betty
should use the:

A. Fingertips
B. Finger pads
C. Dorsal surface of the hand
D. Ulnar surface of the hand
47. Which type of evaluation occurs continuously throughout the teaching and learning process?

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

A. Twice per year

B. Once per year
C. Every 2 years
D. Once, to establish baseline
49.A male client has the following arterial blood gas values: pH 7.30; Pao2 89 mmHg; Paco2 50 mmHg;
and HCO3 26mEq/L. Based on these values, Nurse Patricia should expect which condition?

A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis
50.Nurse Len refers a female client with terminal cancer to a local hospice. What is the goal of this
referral?

A. To help the client find appropriate treatment options.

B. To provide support for the client and family in coping with terminal illness.
C. To ensure that the client gets counseling regarding health care costs.
D. To teach the client and family about cancer and its treatment.

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

A. Massaging the area with an astringent every 2 hours.

B. Applying an antibiotic cream to the area three times per day.
C. Using normal saline solution to clean the ulcer and applying a protective dressing as
necessary.
D. Using a povidone-iodine wash on the ulceration three times per day.

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

A. Knee
B. Ankle
C. Lower thigh
D. Foot

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

A. Hypernatremia
B. Hypokalemia
C. Hyperphosphatemia
D. Hypercalcemia

54.Nurse Len is administering sublingual nitrglycerin (Nitrostat) to the newly admitted

client. Immediately afterward, the client may experience:

A. Throbbing headache or dizziness

B. Nervousness or paresthesia.
C. Drowsiness or blurred vision.
D. Tinnitus or diplopia.

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

A. Prepare for cardioversion

B. Prepare to defibrillate the client
C. Call a code
D. Check the client’s level of consciousness

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

A. On the unaffected side of the client.

B. On the affected side of the client.
C. In front of the client.
D. Behind the client.

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

A. Urine output: 45 ml/hr

B. Capillary refill: 5 seconds
C. Serum pH: 7.32
D. Blood pressure: 90/48 mmHg

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

A. Wiping the port with an alcohol swab before inserting the syringe.
B. Aspirating a sample from the port on the drainage bag.
C. Clamping the tubing of the drainage bag.
D. Obtaining the specimen from the urinary drainage bag.

59.Nurse Meredith is in the process of giving a client a bed bath. In the middle of the
procedure, the unit secretary calls the nurse on the intercom to tell the nurse that there is
an emergency phone call. The appropriate nursing action is to:
 A. Immediately walk out of the client’s room and answer the phone call.
B. Cover the client, place the call light within reach, and answer the phone call.
C. Finish the bed bath before answering the phone call.
D. Leave the client’s door open so the client can be monitored and the nurse can
answer the phone call.

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

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

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

A. Puts all the four points of the walker flat on the floor, puts weight on the hand
pieces, and then walks into it.
B. Puts weight on the hand pieces, moves the walker forward, and then walks into it.
C. Puts weight on the hand pieces, slides the walker forward, and then walks into it.
D. Walks into the walker, puts weight on the hand pieces, and then puts all four points
of the walker flat on the floor.

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

A. Erases the error and writes in the correct information.

B. Uses correction fluid to cover up the incorrect information and writes in the correct
information.
C. Draws one line to cross out the incorrect information and then initials the change.
D. Covers up the incorrect information completely using a black pen and writes in the
correct information
63.Nurse Ron is assisting with transferring a client from the operating room table to a
stretcher. To provide safety to the client, the nurse should:

A. Moves the client rapidly from the table to the stretcher.

B. Uncovers the client completely before transferring to the stretcher.
C. Secures the client safety belts after transferring to the stretcher.
D. Instructs the client to move self from the table to the stretcher.

64.Nurse Myrna is providing instructions to a nursing assistant assigned to give a bed

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

A. Gown and goggles

B. Gown and gloves
C. Gloves and shoe protectors
D. Gloves and goggles

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

A. Crutches
B. Single straight-legged cane
C. Quad cane
D. Walker

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

A. Prone with head turned toward the side supported by a pillow.

B. Sims’ position with the head of the bed flat.
C. Right side-lying with the head of the bed elevated 45 degrees.
D. Left side-lying with the head of the bed elevated 45 degrees.
67.Nurse John develops methods for data gathering. Which of the following criteria of a
good instrument refers to the ability of the instrument to yield the same results upon its
repeated administration?

A. Validity
B. Specificity
C. Sensitivity
D. Reliability

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

A. Keep the identities of the subject secret

B. Obtain informed consent
C. Provide equal treatment to all the subjects of the study.
D. Release findings only to the participants of the study

69.Patient’s refusal to divulge information is a limitation because it is beyond the control of

Tifanny”. What type of research is appropriate for this study?

A. Descriptive- correlational
B. Experiment
C. Quasi-experiment
D. Historical

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

A. Interview schedule
B. Questionnaire
C. Use of laboratory data
D. Observation

71.Monica is aware that there are times when only manipulation of study variables is
possible and the elements of control or randomization are not attendant. Which type of
research is referred to this?

A. Field study
B. Quasi-experiment
 C. Solomon-Four group design
D. Post-test only design

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

A. Footnote
B. Bibliography
C. Primary source
D. Endnotes

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

A. Non-maleficence
B. Beneficence
C. Justice
D. Solidarity

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

A. Force majeure
B. Respondeat superior
C. Res ipsa loquitor
D. Holdover doctrine

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

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

76. When the license of nurse Krina is revoked, it means that she:
 A. Is no longer allowed to practice the profession for the rest of her life
B. Will never have her/his license re-issued since it has been revoked
C. May apply for re-issuance of his/her license based on certain conditions stipulated in
RA 9173
D. Will remain unable to practice professional nursing

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

A. Formulating the research hypothesis

B. Review related literature
C. Formulating and delimiting the research problem
D. Design the theoretical and conceptual framework

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

A. Cause and effect

B. Hawthorne effect
C. Halo effect
D. Horns effect

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

A. Plans to include whoever is there during his study.

B. Determines the different nationality of patients frequently admitted and decides to
get representations samples from each.
C. Assigns numbers for each of the patients, place these in a fishbowl and draw 10
from it.
D. Decides to get 20 samples from the admitted patients

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

A. Florence Nightingale
B. Madeleine Leininger
 C. Albert Moore
D. Sr. Callista Roy

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

A. Random
B. Accidental
C. Quota
D. Judgment

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

A. Degree of agreement and disagreement

B. Compliance to expected standards
C. Level of satisfaction
D. Degree of acceptance

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

A. Madeleine Leininger
B. Sr. Callista Roy
C. Florence Nightingale
D. Jean Watson

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

A. Span of control
B. Unity of command
C. Downward communication
D. Leader

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

A. Beneficence
B. Autonomy
 C. Veracity
D. Non-maleficence

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

A. Avoid wearing cotton socks.

B. Avoid using a nail clipper to cut toenails.
C. Avoid wearing canvas shoes.
D. Avoid using cornstarch on feet.

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

A. Fresh orange slices

B. Steamed broccoli
C. Ice cream
D. Ground beef patties

88.The nurse prepares to administer a cleansing enema. What is the most common client
position used for this procedure?

A. Lithotomy
B. Supine
C. Prone
D. Sims’ left lateral

89.Nurse Marian is preparing to administer a blood transfusion. Which action should the
nurse take first?

A. Arrange for typing and cross matching of the client’s blood.

B. Compare the client’s identification wristband with the tag on the unit of blood.
C. Start an I.V. infusion of normal saline solution.
D. Measure the client’s vital signs.

90.A 65 years old male client requests his medication at 9 p.m. instead of 10 p.m. so that
he can go to sleep earlier. Which type of nursing intervention is required?
 A. Independent
B. Dependent
C. Interdependent
D. Intradependent

91.A female client is to be discharged from an acute care facility after treatment for right
leg thrombophlebitis. The Nurse Betty notes that the client’s leg is pain-free, without
redness or edema. The nurse’s actions reflect which step of the nursing process?

A. Assessment
B. Diagnosis
C. Implementation
D. Evaluation

92.Nursing care for a female client includes removing elastic stockings once per day. The
Nurse Betty is aware that the rationale for this intervention?

A. To increase blood flow to the heart

B. To observe the lower extremities
C. To allow the leg muscles to stretch and relax
D. To permit veins in the legs to fill with blood.

93.Which nursing intervention takes highest priority when caring for a newly admitted
client who’s receiving a blood transfusion?

A. Instructing the client to report any itching, swelling, or dyspnea.

B. Informing the client that the transfusion usually take 1 ½ to 2 hours.
C. Documenting blood administration in the client care record.
D. Assessing the client’s vital signs when the transfusion ends.

94.A male client complains of abdominal discomfort and nausea while receiving tube
feedings. Which intervention is most appropriate for this problem?

A. Give the feedings at room temperature.

B. Decrease the rate of feedings and the concentration of the formula.
C. Place the client in semi-Fowler’s position while feeding.
D. Change the feeding container every 12 hours.
95.Nurse Patricia is reconstituting a powdered medication in a vial. After adding the
solution to the powder, she nurse should:

A. Do nothing.
B. Invert the vial and let it stand for 3 to 5 minutes.
C. Shake the vial vigorously.
D. Roll the vial gently between the palms.

96.Which intervention should the nurse Trish use when administering oxygen by face
mask to a female client?

A. Secure the elastic band tightly around the client’s head.

B. Assist the client to the semi-Fowler position if possible.
C. Apply the face mask from the client’s chin up over the nose.
D. Loosen the connectors between the oxygen equipment and humidifier.

97.The maximum transfusion time for a unit of packed red blood cells (RBCs) is:

A. 6 hours
B. 4 hours
C. 3 hours
D. 2 hours

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

A. 1 hour before administering the next dose.

B. Immediately before administering the next dose.
C. Immediately after administering the next dose.
D. 30 minutes after administering the next dose.

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

A. The nurse can implement medication orders quickly.

B. The nurse receives input from the pharmacist.
C. The system minimizes transcription errors.
D. The system reinforces accurate calculations.
100. Nurse Oliver is assessing a client’s abdomen. Which finding should the nurse report
as abnormal?

A. Dullness over the liver.

B. Bowel sounds occurring every 10 seconds.
C. Shifting dullness over the abdomen.
D. Vascular sounds heard over the renal arteries.