Q1:

The position that is indicated for Rosanna, age 23, after surgery for a perforated appendix with localized peritonitis
is the:

a. Semi-Fowler's position

b. Dorsal recumbent position

c. Sims' position

d. Trendelenburg position

Question 2

The nurse is measuring the patient's urine output and straining the urine to assess for stones. Which of the
following should the nurse record as objective data?

a. The patient stated, “I didn't see any stones in my urine.”

b. The patient is complaining of abdominal pain

c. The patient stated, “I feel like I have passed a stone.”

d. The patient's urine output was 550 mL

Question 3

Helen, age 20, is 37 weeks pregnant. She is admitted to the hospital with preeclampsia, moderate vaginal bleeding,
and sudden abdominal pain. The results of the ultrasound indicate that abruptio placenta is present. A nurse is
monitoring Helen for Disseminated Intravascular Coagulopathy. Which assessment finding is least likely to be
associated with DIC?

a. Petechiae, oozing from injection sites, and hematuria

b. Prolonged clotting times

c. Decreased platelet count

d. Swelling of the calf on one leg

Question 4

What is the problem with the following outcome goal, “Patient will state pain is less than or equal to 3 on a 0 to 10
pain scale”?

a. None, goal is written correctly

b. No target time is given

c. Patient behavior is missing

d. It is not measurable

Question 5

A nurse is performing oropharyngeal suctioning on an unconscious patient. Which of the following actions is safe?

a. Allow 20- to 30-second intervals between each suction, and limit suctioning to a total of 15 minutes

b. Gently rotate the catheter while applying suction

c. Insert the catheter approximately 20 cm while applying suction

d. Apply suction for 5 seconds while inserting the catheter and continue for another 5 seconds before withdrawing

Question 6

Princess, age 30, requires a blood transfusion. Her blood type is AB. To prevent complications of blood
incompatibilities, Nurse Yuri knows that this patient may receive:

a. Type O blood only

b. Type AB blood only

c. Type A or B blood only

d. Either type A, B, AB, or O blood

Question 7

The patient states, “My chest hurts and my left arm feels numb.” What is the type and source of this data?

a. Objective data from a primary source

b. Subjective data from a secondary source

c. Subjective data from a primary source

d. Objective data from a secondary source

Question 8

The purpose of chest percussion and vibration is to loosen secretions in the lungs. The difference between the
procedures is:

a. Percussion delivers cushioned blows to the chest with cupped palms while vibration gently shakes secretion
loose on the exhalation cycle

b. Percussion uses only one hand while vibration uses both hands

c. Percussion slaps the chest to loosen secretions while vibration shakes the secretions with inhalation of air

Question 9
When her membranes rupture, the nurse's first action should be to:

a. Perform a vaginal exam

b. Count the fetal heart rate

c. Notify the physician because delivery is imminent

d. Measure the amount of fluid

Question 10

Anne has received treatment for a warm, reddened, painful area in the breast as well as cracked and fissured
nipples. The client expresses the desire to continue breastfeeding. The following are instructions that the nurse
should include to prevent recurrence of this condition EXCEPT:

a. Expose the nipples to air for part of each day

b. Wash hands before handling the breast and breastfeeding

c. Make sure that the baby grasps the nipple only

d. Change the breast pads frequently

Question 11

Which of the following patients meet the criteria for selection of the apical site for assessment of the pulse rather
than a radial pulse?

a. A patient with an arrhythmia

b. The pulse changes with body position changes

c. It is less than 24 hours since a patient's surgical operation

d. A patient is in shock

Question 12

Helen, age 20, is 37 weeks pregnant. She is admitted to the hospital with preeclampsia, moderate vaginal bleeding,
and sudden abdominal pain. The results of the ultrasound indicate that abruptio placenta is present. Based on
these findings, the nurse would prepare the client for:

a. Strict monitoring of intake and output

b. Complete bed rest for the remainder of the pregnancy

c. The need for weekly monitoring of coagulation studies until the time of delivery

d. Delivery of the fetus

Question 13
Correct

Mark 1.00 out of 1.00

Not flaggedFlag question

Question text

The theorist who is the proponent of the Self Care Deficit theory of nursing is:

a. Betty Neuman

b. Dorothea Orem

c. Faye Glenn Abdellah

d. Sister Callista Roy

Question 14

A patient's blood gases reflect diabetic acidosis. Nurse Charitie should expect:

a. Decreased PO2

b. Decreased HCO3

c. Increased PCO2

d. Increased pH

Question 15

Tibo, age 27, has a chest tube to a Pleur-evac® drainage system attached to wall suction. An order to ambulate the
patient has been received. To ambulate the patient safely, Nurse Bro should:

a. Question the order to ambulate the patient

b. Disconnect the Pleur-evac® from the patient's chest tube, leave it attached to the bed, ambulate the patient,
and then reconnect the chest tube when he is returned to bed

c. Clamp the chest tube and carefully ambulate the patient a short distance

d. Carefully ambulate the patient, keeping the Pleur-evac® lower than the patient's chest

Question 16:

During the third stage of labor, the nurse may have which of the following responsibilities?

a. Push down on the relaxed uterus to aid in the removal of the placenta

b. Note if the placenta makes a Schultz presentation, which is a sign of gross complication

c. Administer intramuscular Oxytocin to facilitate uterine contractility

d. Monitor for blood loss greater than 100 cc, which would indicate gross hemorrhage

Question 17

The theorist that describes nursing as a significant, therapeutic, interpersonal process, which functions
cooperatively with other human processes that make health possible for individuals in communities is:

a. Hildegard Peplau

b. Joyce Travelbee

c. Patricia Benner

d. Ida Jean Orlando

Question 18

Anne is visited by the home health nurse two weeks after delivery. The woman is febrile with flu-like symptoms.
On assessment, the nurse notes a warm, reddened painful area of the right breast. The best initial action of the
nurse is to:

a. Advise the mother to stop breastfeeding and pumping

b. Contact the physician for an order of antibiotics

c. Assess the mother's feeding technique and knowledge of breast care

d. Obtain a sample of the breast milk for culture

Question 19

Nurse John is completing the exchange by draining the dialysate and notices the dialysate is opaque. The nurse
best interprets this finding as:

a. A sign of a vascular access occlusion

b. A sign of infection

c. The normal appearance of draining dialysate

d. An indication of an impending lower back problem

Question 20

Cath, 21 years old, has difficulty of breathing when on her back and must sit upright in bed in order to breathe
effectively and comfortably. The nurse documents this condition as:

a. Tachypnea

b. Dyspnea

c. Apnea
d. Orthopnea

Question 21

Situation 2. John has a nursing diagnosis of ineffective airway clearance related to excessive secretions and is at
risk for infection because of retained secretions. Part of Nurse Mara’s nursing care plan is to loosen and remove
excessive secretions in the airway. Nurse Mara listens to John’s bilateral sounds and finds that congestion is in the
upper lobes of the lungs. The appropriate position to drain the anterior and posterior apical segment of the lungs
when the nurse does percussion would be:

a. Patient lying on his right then left side on Trendelenburg position

b. Patient lying on his back then flat on his abdomen on Trendelenburg position

c. Patient lying flat in his back and then flat on his abdomen

d. Patient seated upright in bed or on a chair then leaning forward in sitting position then flat on his back and on
his abdomen

Question 22

Which of these patients has a problem with transport of oxygen from the lungs to the tissues?

a. Patria with anemia

b. Carol with a tumor in the brain

c. Kenny with diarrhea

d. Jimson with fracture in the femur

Question 23

An adult client with a history of diabetes is scheduled for a transmetatarsal amputation. When should the client's
discharge planning begin?

a. The day of estimated discharge

b. Once the nursing care plan has been finalized

c. The day prior to discharge

d. The day that the client is admitted

Question 24

Mr. Beans, a 37-year-old client with a nasogastric tube connected to a low continuous suction for abdominal
decompression. Nurse Junelyn notes that gastric fluid in the suction tubing is not moving and the patient's
abdomen is becoming distended. The nurse's best action is to:

a. Irrigate the tube with 30 cc of water

b. Turn the suction higher

c. Pull out the nasogastric tube and insert a new one

d. Tell the client to take a few deep breaths

Question 25

The physician is going to order a hypotonic intravenous solution for a patient with cellular dehydration. Nurse
Vince would expect which of the following fluids to be administered?

a. Lactated Ringer's

b. 5% dextrose in normal saline

c. 0.9% normal saline

d. 0.45% sodium chloride

Question 26

Correct

All of the following can cause tachycardia, except:

a. Parasympathetic nervous system stimulation

b. Sympathetic nervous system stimulation

c. Fever

d. Exercise

Question 27

Incorrect

When discussing the regaining of bowel control with Mr. Shananga who has had surgery for a colostomy, which is
most important?

a. Soft, low-residue diet

b. High-protein diet

c. Irrigation routine

d. Managing fluid intake

Question 28

Correct
Which nursing intervention is appropriate for Nurse Yuri to take when setting up supplies for Toni, age 45, who
requires a blood transfusion?

a. Obtain blood bag from laboratory and leave at room temperature for at least one hour prior to infusion

b. Prime tubing of blood administration set with normal saline solution, completely filling filter

c. Add any needed IV medication in the blood bag within one half hour of planned infusion

d. Use a small-bore catheter to prevent rapid infusion of blood products that may lead to a reaction

Question 29

Incorrect

The laboratory tests that would indicate that the liver of a patient with cirrhosis is compromised and neomycin
enemas might be helpful would be:

a. Ammonia level

b. Culture and sensitivity

c. Alanine aminotransferase level

d. White blood count

Question 30

In the emergency room, Nurse Jhang is assigned to attend to the patient with lacerations on the arms. While
assessing the extent of the wound the nurse observes that the wound is now starting to bleed profusely. The most
immediate nursing action would be to:

a. Bandage the wound and elevate the arm

b. Clean the wound vigorously of contaminants

c. Control and reduce the bleeding of the wound

d. Apply antiseptic to prevent infection

Question 31

The rationale for giving medications through the subcutaneous route is:

a. The medication can be injected while the patient is in any position

b. Absorption time of the medicine is slower

c. There are less pain receptors in this area

d. There are many alternative sites for SC injection

Question 32
When preparing for a subcutaneous injection, the proper size of syringe and needle would be:

a. Syringe 3-5mL and needle 21-23

b. Syringe 2mL and needle gauge 22

c. Syringe 1-3mL and needle gauge 25-27

d. Tuberculin syringe 1mL with needle gauge 26-27

Question 33

Situation3: Anne delivered a child two days ago. She is breastfeeding her child. To show Anne how to help her have
good attachment of the infant during breast feeding. Which of the following statements should NOT be included?

a. Touch the infant's lips with her nipples

b. Place the infant in your most convenient position

c. move the infant quickly onto her breast, aiming the infant's lips well below the nipple

d. wait until the infant's mouth is widely open

Question 34

Incorrect

Nurse Junelyn is caring for Mr. Turnips who has a nasogastric tube attached to low wall suction. The suction is not
working. Which is the nurse least likely to note when assessing the patient?

a. Patient has a distended abdomen

b. There is no nasogastric output in the last two hours

c. Patient vomits

d. Large amounts of nasogastric output

Question 35

When preparing an IV piggyback medication for a patient, Nurse Vince is aware that it is essential to:

a. Use exactly 100 ml of fluid to mix the medication

b. Rotate the bag after adding the medication

c. Use strict sterile technique

d. Change the needle just before adding the medication

Question 36

Nurse Jhang applies pressure dressing on the bleeding site. This intervention is done to:
a. Allow the pus to surface faster

b. Protect the wound from microorganisms in the air

c. Reduce the need to change dressing frequently

d. Promote homeostasis

Question 37

Nurse Archipela is changing the central line dressing of Ms. Go who is receiving total parenteral nutrition (TPN).
The nurse notes that the catheter insertion site appears reddened. The nurse next assesses which of the following?

a. Time of last dressing change

b. Tightness of tubing connections

c. Expiration date of the bag

Question 38

While doing nasopharyngeal suctioning on Hermes, the nurse can avoid trauma to the area by:

a. Rotating the catheter as it is inserted with gentle suction

b. Applying no suction while inserting the catheter

c. Apply suction for at least 20-30 seconds each time to ensure that all secretions are removed

d. Using gloves to prevent introduction of pathogens to the respiratory system

Question 39

Johan, a 29-year-old client who has had thoracic surgery, is admitted to the postanesthesia care unit. After the
chest catheters are attached to a closed drainage system, Nurse Bro should:

a. Check that the fluid in the water seal compartment rises with expiration

b. Ensure that there is vigorous bubbling in the wet suction control compartment

c. Empty the drainage container, measure and record the amount, and send a sample for analysis every 24 hours

d. Ensure the security of the connections from the patient to the drainage unit

Question 40

Kathy, a 30-year-old client with a spontaneous pneumothorax, has had a chest tube for 3 days. On morning
rounds, the physician clamped the chest tube to determine the patient's readiness to have the chest tube
discontinued. Two hours after having the chest tube clamped, the patient began to have difficulty breathing. What
action should Nurse Bro take first?

a. Place the patient on 2L nasal cannula oxygen

b. Unclamp the chest tube

c. Assess the patient for subcutaneous emphysema

d. Notify the physician

Question 41

A client with placenta previa is likely to present with:

a. Painless, bright-red vaginal bleeding after the 20th week of gestation

b. Bleeding during the first trimester

c. Hard, tender uterus

d. A sluggish fetus with weak heart sounds on auscultation

Question 42

Incorrect

The most important test used to determine whether a transplanted kidney is working is:

a.Twenty-four-hour output

b. Serum creatinine level

c. Renal ultrasound

d. White blood cell count

Question 43

Helen, age 20, is 37 weeks pregnant. She is admitted to the hospital with preeclampsia, moderate vaginal bleeding,
and sudden abdominal pain. The results of the ultrasound indicate that abruptio placenta is present. Helen is given
a unit of blood. The realizes that this is necessary, since the bleeding following severe abruptio placenta is usually
caused by:

a. Polycythemia

b. Hypofibrinogenemia

c. Thrombocytopenia

d. Hyperglobulinemia

Question 44

Incorrect

Nurse Charitie is interpreting the results of a blood gas analysis performed on an adult patient. The values include
pH of 7.35, PCO2 of 60, HCO3 of 35, and O2 of 60. Which interpretation is most accurate?
a. The patient is in metabolic acidosis

b. The patient is in compensated metabolic alkalosis

c. The patient is in compensated respiratory acidosis

d. The patient is in respiratory alkalosis

Question 45

Nurse Junelyn is to irrigate a nasogastric tube every two hours. Which solution should the nurse select to irrigate
the tube?

a. Normal saline

b. Ringer's lactate

c. Tap water

d. Half-strength peroxide

Question 46

When evaluating an adult patient's blood pressure reading. The nurse considers the patient's age. This is an
example of which of the following?

a. Determining gaps in the data

b. Differentiating cues and inferences

c. Comparing data against standards

d. Clustering data

Question 47

You will do nasopharyngeal suctioning on Hermes, 30 years old. Your guide for the insertion of the tubing for an
adult would be:

a. Eight to ten inches

b. Tip of the nose to the base of the neck

c. The distance form the tip of the nose to the middle of the cheek

d. The distance from the tip of the nose to the earlobe

Question 48

Mr. Floremonte is obese. When administering subcutaneous injection to an obese patient, it is best for Nurse Flo
to:

a. Pull skin of the patient down to administer drug in a Z-track

b. Pinch the skin and use an airlock technique

c. Spread the skin or pinch at the injection site and inject needle at a 45-90 degree angle

d. Inject needle at a 15 degree angle over the stretched skin of the patient

Question 49

Which of the following instructions can the nurse give to lactating mother?

a. Do not apply any soap to your nipples

b. Apply warm compresses to breast if too full

c. Wear a good, well-supporting bra

d. Apply cold compresses to breast if too full

Question 50

You noted from the lab exams in the chart of Tado, a 25-year-old patient, that he has reduced oxygen in the blood.
This condition is called:

a. Hypoxemia

b. Anemia

c. Cyanosis

d. Hypoxia

Question 51

The care of a client with placenta previa includes:

a. Vital signs at least once per shift

b. Observation and recording of the bleeding

c. Limited ambulation until the bleeding stops

d. A tap-water enema before delivery

Question 52

Incorrect

Rosemary, age 20, is to have gastric gavage. When the gavage tube is being inserted, Nurse Claudine should place
the patient in the:

a. High-Fowler's position

b. Mid-Fowler's position
c. Supine position

d. Trendelenburg position

Question 53

A patient with a pulmonary embolus is intubated and placed on mechanical ventilation. When suctioning the
endotracheal tube, the nurse should:

a. Hyperoxygenate with 100% oxygen before and after suctioning

b. Use short, jabbing movements of the catheter to loosen secretions

c. Suction two to three times in quick succession to remove secretions

d. Apply suction while inserting the catheter

Question 54

When performing tracheostomy care, Nurse Edu must:

a. Monitor the patient's temperature after the procedure

b. Maintain sterile technique during the procedure

c. Place the patient in the semi-Fowler's position

d. Use Betadine to clean the inner cannula when it is removed

Question 55

An adhesive-backed ostomy opening should be how much larger than the stoma?

a. 1/3 inch

b. ¼ inch

c. ½ inch

d. 1/8 inch

Q 56:

The theorist whose theory can be defined as the development of a science of humankind, incorporating the
concepts of energy fields, openness, pattern and organization is:

a. Myra Levine

b. Martha Rogers

c. Dorothy Johnson

d. Imogene King
Question 57

Mr. Billiards has an arteriovenous fistula. Which finding is expected when assessing the fistula?

a. Pulselessness

b. Redness

c. Ecchymotic area

d. Enlarged veins

Question 58

Helen, age 20, is 37 weeks pregnant. She is admitted to the hospital with preeclampsia, moderate vaginal bleeding,
and sudden abdominal pain. The results of the ultrasound indicate that abruptio placenta is present. The nurse
realizes that the abdominal pain associated with abruption placenta is caused by:

a. Inflammatory reactions

b. Hemorrhagic shock

c. Concealed hemorrhage

d. Blood in the uterine muscle

Question 59

The physician orders 3 units of whole blood for Mr. Otol, age 51, who is in hypovolemic shock after a
gastrointestinal hemorrhage. When administering blood, Nurse Yuri first verifies the type and cross-match and
then routinely:

a. Uses an infusion pump to increase the accuracy of the infusion

b. Warms the blood to body temperature to prevent chills

c. Draws blood samples from the patient before and after each unit is transfused

d. Runs the blood at a slower rate during the first 10 to 15 minutes of the transfusion

Question 60

After surgery on the neck, Rosita, age 22, should be placed in a high-Fowler's position to:

a. Promote drainage of the wound

b. Avoid strain on the incision

c. Provide stimulation for the patient

d. Reduce edema at the operative site

Question 61
Helen, age 20, is 37 weeks pregnant. She is admitted to the hospital with preeclampsia, moderate vaginal bleeding,
and sudden abdominal pain. The results of the ultrasound indicate that abruptio placenta is present. On Helen’s
admission to the unit the nurse should observe for:

a. Firm and tender uterus, concealed or external hemorrhage, shock

b. Increase in size uterus, visible bleeding, no associated pain

c. Shock, decrease in size uterus, absence of external bleeding

d. Decrease in size of uterus, cessation of contractions, visible or concealed hemorrhage

Question 62

Mr. Borat, a 45-year-old male patient, has an order for a nasogastric tube. Before inserting the tube, Nurse Junelyn
measures the amount of tube needed. To determine the amount of tube needed, the nurse should:

a. Measure from the tip of the patient's nose to his earlobe and from the earlobe to the xiphoid process

b. Measure from the chin to the back of the throat and from the back of the throat to the umbilicus

c. Measure from the mouth to the xiphoid process and add 2 inches

d. Measure from the forehead to the ear and from the ear to the umbilicus

Question 63

A community health nurse has scheduled a hypertension clinic in a local shopping mall in which shoppers have the
opportunity to have their blood pressure measured and learn about hypertension. This nursing activity would be
an example of which type of prevention activity?

a. Secondary prevention

b. Primary prevention

c. Tertiary prevention

d. Disease prevention

Question 64

Incorrect

Nurse Edu is administering tracheostomy care to Mr. Posible. Which of the following should be included in the
procedure?

a. Performing the procedure utilizing medical asepsis

b. Soaking the outer cannula with saline solution

c. Soaking the inner cannula in half-strength hydrogen peroxide solution

d. Cutting a sterile gauze pad to place between the neck and the tracheostomy tube

Question 65

The theorist whose major theme is the idea of transcultural nursing and caring is:

a. Virginia Henderson

b. Madeleine Leininger

c. Jean Watson

d. Ernestine Wiedenbach

Question 66

Incorrect

Nurse Mara prepares John for postural drainage and percussion. Which of the following is a special consideration
when doing the procedure?

a. Respiratory rate of 16-20 per minute

b. Patient can tolerate sitting and lying positions

c. Patient has no sign of infection

d. Time of the last food and fluid intake of the patient

Question 67

When suctioning Mr. Posible, with a tracheostomy, Nurse Edu must remember to:

a. Initiate suction as the catheter is being withdrawn

b. Use a new sterile catheter with each insertion

c. Insert the catheter until the cough reflex is stimulated

d. Remove the inner cannula before inserting the suction catheter

Question 68

Correct

Mark 1.00 out of 1.00

Not flaggedFlag question

Question text
Situation 4: Rita, 27 years old, is a gravida 1 in the active phase of labor. Fetal position is LOA, and cervix is 4 cm
dilated. Rita wants to walk about in the labor room. Which of the following criteria will help the nurse determine
whether she should walk?

a. Whether membranes are intact

b. Frequency of contraction

c. Fetal station

d. Fetal position

Question 69

Nurse Loren is monitoring Mr. Billiards who is undergoing hemodialysis. The patient suddenly becomes cyanotic
and complains of dyspnea and chest pain. His blood pressure is 70/40 mm Hg and his pulse is weak and rapid. The
nurse calls the physician immediately because the signs and symptoms suggest which of the following
complications of dialysis?

a. Air embolism

b. Internal bleeding

c. Hemorrhage at the shunt

d. Disequilibrium syndrome

Question 70

During a colostomy irrigation, if Mr. Shananga complains of abdominal cramps, Nurse Mar Kit should:

a. Clamp the tubing and allow the patient to rest

b. Raise the irrigating container to complete the irrigation quickly

c. Reassure the patient and continue the irrigation

d. Pinch the tubing so that less fluid enters the colon

Question 71

Incorrect

Nurse John suspects a complication in Mr. Ivler who is receiving peritoneal dialysis. Which of the following
observations would support this evaluation?

a. Clear or light-yellow effluent

b. Pain during the inflow of dialysate

c. Cloudy effluent
d. Occasional diarrhea

Question 72

Mr. Shananga is concerned about the odor of the stool in the ostomy drainage bag. Nurse Mar Kit teaches the
patient to include which of the following foods in the diet to reduce odor?

a. Eggs

b. Broccoli

c. Yogurt

d. Cucumbers

Question 73

Priority attention should be given to which of these patients?

a. Chris who has laceration on the arms with mild bleeding

b. Anton who has chest injury, is pale and with difficulty of breathing

c. Joseph whose left ankle swelled and has some abrasions

d. Bryan who shows severe anxiety due to trauma of the accident

Question 74

The purpose of peritoneal dialysis is to:

a. Clean the peritoneal membrane

b. Reestablish kidney function

c. Provide fluid for intracellular spaces

d. Remove toxins and metabolic wastes

Question 75

For a patient with a previous blood pressure of 140/80 and pulse of 64, approximately how long should the nurse
take to release the blood pressure cuff in order to obtain an accurate reading?

a. 30 to 45 seconds

b. 1 to 1.5 minutes

c. 3 to 3.5 minutes

d. 10 to 20 seconds

Question 76
IV orders for a 75-year-old patient include D5 ½ NS with 20 mEq KCl at 75 cc/hr. At 6:00 A.M. a new bag of 1000 ml
was hung. At 8:00 A.M. Nurse Vince sees that only 200 ml remains. The first action by the nurse would be to:

a. Assist the patient to the bathroom to void

b. Order an infusion pump to provide better control of the rate

c. Check the site for infiltration and elevate the extremity if needed

d. Slow the IV to “keep open” and check the patient for lung crackles

Question 77

The nurse following the physicians order for client with placenta previa, begins administering oxygen by mask. The
client’s apprehension is increasing and she asked the nurse what is happening. The nurse tells her not to worry,
that she is going to be all right and everything is under control. The nurse statements are:

a. Adequate, since all preparations are routine and need no explanation

b. Proper, since the client’s anxieties would be increased if she knew the dangers

c. Questionable, since the client has the right to know what treatment is being given and why

d. Correct, since only the physician should explain why treatment are being done

Question 78

Incorrect

Nurse Yuri is preparing to administer two units of packed red blood cells to Bianca, age 34. The nurse should:

a. Use a special blood filter and an 18-gauge needle to administer the packed red blood cells

b. Administer the prescribed intravenous drugs through the blood administration tubing to ensure proper
distribution throughout the body

c. Prime the blood administration tubing with 3% saline solution

d. Understand that blood transfusion reactions usually do not occur until the client has received 500 ml of the
packed red blood cells

Question 79

The physician inserts a chest tube to Mariel, a 24-year-old patient who has been stabbed in the chest, and attaches
it to a closed-drainage system. When caring for the patient, Nurse Bro should:

a. Apply a thoracic binder to prevent tension on the tube

b. Observe for fluid fluctuations in the water seal chamber

c. Administer morphine sulfate, because the patient will be agitated

d. Clamp the tubing securely to prevent a rapid decline in pressure

Question 80

When Rosenda, age 21, is in the right side-lying position after the insertion of a left hip prosthesis, Nurse Claudine
ensures that the patient has an abduction pillow placed between the thighs and that the entire length of the upper
leg is supported. The most important reason for this is to prevent:

a. Thrombus formation in the leg

b. Flexion contractures of the hip joint

c. Strain on the operative site

d. Skin surfaces from rubbing together

Q 81:

When assessing Mr. Peas, a postoperative patient, Nurse Junelyn notes a nasogastric tube to low constant suction,
the absence of a bowel movement since surgery, and no bowel sounds. The most appropriate plan of care based
on these findings is to:

a. Assess for bladder pain and distention

b. Increase coughing, turning, and deep breathing exercises

c. Increase the patient's mobility and ensure he is receiving adequate pain relief

d. Discontinue the nasogastric tube as the patient does not need it any more

Question 82

When planning comfort measures to help Rita in active labor to tolerate her pain, the nurse must consider which
of the following?

a. The acceleration phase of labor can be a time of true discomfort and high anxiety

b. Pain medication given during the latent phase of labor is not likely to impair contractions

c. If women are properly prepared, they will require no pain medication to manage their pain

d. Early labor contractions are usually regular, coordinated, and very painful

Question 83

Nursing care for Cora who has Placenta previa includes:

a. Avoiding all extraneous stimuli

b. Withholding foods and fluids

c. Inspecting the hemorrhage

d. Encouraging ambulation and supervision

Question 84

A recent nursing graduate has been surprised at the sharp contrast between some clients' lifestyles in their homes
and the nurse's own practices and beliefs. To work therapeutically with the client, what must the nurse do?

a. Request another assignment if there is dissonance with the client's lifestyle.

b. Ask the client to come to the agency to receive treatment, if possible.

c. Try to adapt the client's home to the norms of a hospital environment.

d. Resolve to convey respect for the client's beliefs and choices.

Question 85

Incorrect

The patient's arterial blood gases on room air are: pH of 7.33; PO2 of 77; PCO2 of 50; and HCO3 of 23. Nurse
Charitie instructs the patient to:

a. Wear nasal cannula oxygen at 6 L/min

b. Try to breathe more slowly

c. Increase fluid intake to flush the kidneys

d. Use the bedside inspirometer hourly when awake

Question 86

Mr. Posible had a cuffed tracheostomy tube placed 4 weeks ago. The patient is going to begin eating by mouth,
with the tracheostomy tube in place. To prevent aspiration, Nurse Edu will:1. Raise the head of the bed to high-
Fowler's position2. Deflate the cuff on the tracheostomy tube3. Suction the client before eating4. Assess gag and
swallow ability5. Replace the tracheostomy tie

a. All except 5

b. All except 3

c. All except 2

d. All of the above

Question 87

If a vaginal examination is to be performed on a client with placenta previa, the nurse should be prepared for an
immediate:

a. Induction of labor
b. Cesarean delivery

c. X-ray examination

d. Forceps delivery

Question 88

Ms. Go is being weaned from total parenteral nutrition (TPN) and is expected to being taking solid food today. The
ongoing solution rate has been 100 ml/hr. Nurse Archipela anticipates that which of the following orders regarding
the TPN solution will accompany the diet order?

a. Continue current infusion rate orders for TPN

b. Hang 1000 ml 0.9% normal saline

c. Decrease TPN rate to 50 ml/hr

d. Discontinue the TPN

Question 89

Incorrect

Mariel, 50 years old, is receiving 5% dextrose in 0.45% saline. The physician has ordered the patient receive one
unit of packed red blood cells. Prior to hanging the blood, Nurse Yuri will prime the blood tubing with which of the
following solutions?

a. 5% dextrose in 0.45% sodium chloride

b. 3% saline solution

c. 0.9% sodium chloride

d. Lactated Ringer's

Question 90

_SITUATION 15.__ NURSE JHANG WITNESSES A VEHICULAR ACCIDENT NEAR THE HOSPITAL WHERE SHE WORKS.
SHE DECIDES TO GET INVOLVED AND HELP THE VICTIMS OF THE ACCIDENT._Her priority nursing action would be
to:

a. Assess the extent of injuries incurred by the victims of the accident

b. Report the incident immediately to the local police authorities

c. Assess damage to property

d. Assist in the police investigation since she is a witness

Question 91
Nurse Charitie understands that metabolic acidosis develops in kidney failure as a result of:

a. Impaired glomerular filtration causing retention of sodium and metabolic waste products

b. Inability of the renal tubules to reabsorb water to dilute the acid contents of blood

c. Depression of respiratory rate by metabolic wastes causing carbon dioxide retention

d. Inability of the renal tubules to secrete hydrogen ions and conserve bicarbonate

Question 92

Mr. Posible's tracheostomy is producing a small amount of thin, white secretions. The stoma is pink with no
drainage noted. Nurse Edu should expect to provide tracheostomy care for the patient every:

a. Four hours

b. Eight hours

c. Hour

d. 24 hours

Question 93

An emergency tracheostomy is performed on a child with croup, and the child is receiving humidified air via a
tracheostomy collar. When caring for this child, the nurse should suction the tracheostomy if the child:

a. Tells the nurse of difficulty in breathing

b. Becomes restless, pale, or the pulse increases

c. Becomes restless, diaphoretic, and cyanotic

d. Has severe substernal retractions and stridor

Question 94

Nurse Archipela knows that the primary reason for using a central line is that:

a. The large amount of blood helps to dilute the concentrated solution

b. It is more convenient so clients can use their hands

c. It prevents the development of phlebitis

d. There is less chance of this infusion infiltrating

Question 95

Florence Nightingale was born in:

a. Italy, May 12, 1820

b. Italy, May 12, 1840

c. England, May 12, 1840

d. England, May 12, 1820

Question 96

Mr. Posible had a cuffed tracheostomy tube placed 4 weeks ago. The patient is going to begin eating by mouth,
with the tracheostomy tube in place. To prevent aspiration, Nurse Edu will:1. Raise the head of the bed to high-
Fowler's position2. Deflate the cuff on the tracheostomy tube3. Suction the client before eating4. Assess gag and
swallow ability5. Replace the tracheostomy tie

a. All of the above

b. All except 2

c. All except 5

d. All except 3

Question 97

Nurse Archipela is preparing to change the total parenteral nutrition (TPN) solution bag and tubing. The nurse asks
Ms. Go to do which of the following most essential action during the tubing changes?

a. Turn the head to the right

b. Take a deep breath, hold it, and bear down

c. Exhale slowly and evenly

d. Breathe normally

Question 98

A patient is admitted to the hospital with complaints of nausea, vomiting, diarrhea, and severe abdominal pain.
Which of the following would immediately alert the nurse that the patient has gastrointestinal tract bleeding?

a. Guaiac test

b. Complete blood count

c. Abdominal girth

d. Vital signs

Question 99

When documenting the outcome of Johns treatment Nurse Mara should include the following in her recording,
except:
a. Amount of fluid intake of the patient before and after the procedure

b. Significant changes in vital signs

c. Character of breath sounds and respiratory rate before and after procedure

d. Color, amount, consistency of sputum

Question 100

Which of the following signs of good attachment should the nurse teach a lactating mother?

a. The chin should touch the breast, the mouth is wide open while the lower lip turned outward, and more areola
visible above than below

b. The chin should touch the breast, the mouth is wide open while the lower lip is turned inward, and more areola
is visible above than below

c. The chin should touch the breast, the mouth is wide open while the lower lip turned outward, and more areola
visible below than above

d. The chin should touch the breast, the mouth is wide open while the lower lip turned inward, and more areola is
visible below than above

Question 101

The nursing instructor is preparing a group of students for their home care rotation. Which of the following groups
are the students most likely to care for?

a. Elderly clients

b. Mentally ill clients

c. Terminally ill and palliative clients

d. Clients receiving rehabilitation after surgery

Question 102

When assessing John for chest percussion or chest vibration and postural drainage, Nurse Mara would focus on the
following, except:

a. Doctor’s order regarding position restrictions and the patient’s tolerance for lying flat

b. Respiratory rate, breath sounds and location of congestion

c. Teaching the patient’s relatives to perform the procedure

d. Amount of fluid taken during the last meal before treatment

Question 103
Incorrect

The physician orders oropharyngeal suctioning as needed for a patient in a coma. The nurse prepares to suction
when assessment reveals:

a. The presence of a dry cough at increasingly frequent intervals

b. Drainage of mucus and saliva from the mouth

c. Development of cyanosis in the nail beds of the fingers

d. The presence of a gurgling sound with each breath

Question 104

Incorrect

Ms. Go with total parenteral nutrition (TPN) infusing has disconnected the tubing from the central line catheter.
Nurse Archipela assesses the client and suspects an air embolism. The nurse should immediately place the patient
in which of the following positions?

a. On the right side with the head higher than the feet

b. On the left side with the head higher than the feet

c. On the left side with the head lower than the feet

d. On the right side with the head lower than the feet

Question 105

After a total hip replacement surgery, Nurse Claudine should avoid placing Rosario, age 25, in the:

a. Semi-Fowler's position

b. Orthopneic position

c. Supine position

d. Lateral position

Question 106

Before scheduling a patient for endoscopic retrograde cholangiopancreatography (ERCP), the nurse should assess
the patient's:

a. Serum glucose

b. Bilirubin level

c. Blood pressure

d. Urine output
Question 107

Which of the following demonstrates that the nurse is participating critical thinking?

a. The nurse finds a quick and logical answer, even to complex questions

b. The nurse makes her point with clever and persuasive remarks to win an argument

c. The nurse admits she does not know how to do a procedure and requests help

d. The nurse accepts without question the values acquired in nursing school

Question 108

When caring for Mr. Ivler who is receiving peritoneal dialysis, Nurse John should:

a. Position the patient from side to side if fluid is not draining adequately

b. Remove the cannula at the end of the procedure and apply a dry, sterile dressing

c. Maintain the patient in a flat, supine position during the entire procedure

d. Notify the physician if there is a deficit of 200 ml in the drainage fluid

Question 109

Paul Jake, age 25, arrives in the post-anesthesia care unit after a segmental resection of the right lower lobe of the
lung, with a chest tube drainage system in place. Nurse Bro caring for the client should:

a. Add 3 to 5 ml of sterile saline to the water seal chamber

b. Secure the chest catheter to the wound dressing with a sterile safety pin

c. Raise the drainage system to bed level to check its patency

d. Mark the time and the fluid level on the side of the drainage chamber

Question 110

Correct

When assessing Mr. Ivler during peritoneal dialysis, Nurse John observes that drainage of the dialysate from the
peritoneal cavity has ceased before the required amount has drained out. The nurse should assist the patient to:

a. Deep breath and cough

b. Periodically rotate the catheter

c. Drink 8 oz of water

d. Turn from side to side

Question 111
Correct

The community health nurse is preparing to conduct a home visit. When performing the home visit, how should
the nurse best implement the principles of infection control?

a. Remove the client's soiled wound dressings from the home promptly

b. Disinfect the client's syringes prior to disposal

c. Perform hand hygiene before and after giving direct client care

d. Establish a sterile field in the client's home before providing care.

Question 112

Correct

Mr. Billiards is placed on hemodialysis three times a week. Which is an attainable short-term goal for this patient
when he is placed on hemodialysis?

a. Understanding the treatment and its implications

b. Recording dialysate composition and temperature

c. Independence in the care of the AV shunt

d. Self-monitoring during dialysis

Question 113

Incorrect

When caring for Mr. Billiards who has had an arteriovenous shunt inserted for hemodialysis, Nurse Loren should:

a. Use surgical aseptic technique when giving shunt care

b. Cover the entire cannula with an elastic bandage

c. Take the blood pressure every 4 hours, using the arm that contains the shunt

d. Notify the physician if a bruit is heard in the cannula

Question 114

Mr. Shananga tells Nurse Mar Kit that his wife does not let him change his colostomy bag himself. Which response
by the nurse indicates an understanding of the situation?

a. “Do you think your wife might benefit from counseling?”

b. “You feel you need privacy when changing your colostomy?”

c. “Have you discussed the situation with your doctor?”

d. “Your wife's need to help you is a reality you should accept.”

Question 115

Incorrect

Potassium chloride is to be added to an infant's intravenous fluids. Before adding this electrolyte, Nurse Vince
should determine that:

a. Mucous membrane is moist

b. Respiratory rate is between 25 and 40

c. The infant has voided recently

d. Moro reflex is present

Question 116

A patient with pyrexia will most likely demonstrate:

a. Dyspnea

b. Elevated blood pressure

c. Increased pulse rate

d. Precordial pain

Question 117

A nurse is suctioning fluids from a patient via a tracheostomy tube. When suctioning, the nurse must limit the
suctioning to a maximum of:

a. 30 seconds

b. 5 seconds

c. 1 minute

d. 10 seconds

Question 118

After the treatment, the patient is sent home and asked to come back for follow-up care. Your responsibilities
when the patient is to be discharged include the following, except:

a. Providing instructions regarding wound care

b. Accurate recording of treatment done and instructions given to the patient

c. Encouraging the patient to go to the out patient clinic for follow up care
d. Instructing the patient to see you after discharge for further assistance

Question 119

Correct

The best blood test for the nurse to use to evaluate fluid loss resulting from burns is the:

a. Blood urea nitrogen

b. Blood pH

c. Sedimentation rate

d. Hematocrit

Question 120

Incorrect

An adult woman is admitted with metabolic acidosis. Which set of arterial blood gases should Nurse Charitie
expect to find in a client with metabolic acidosis?

a. pH - 7.48; PCO2 - 30; HCO3 - 22

b. pH - 7.28; PCO2 - 55; HCO3 - 26

c. pH - 7.30; PCO2 - 36; HCO3 - 18

d. pH - 7.50; PCO2 - 40; HCO3 - 31

Question 121

Correct

The absence of which pulse may not be a significant finding when a patient is admitted to the hospital?

a. Pedal

b. Apical

c. Radial

d. Femoral

Question 122

The indication for epinephrine injection for Mr. Floremonte is to:

a. Relieve respiratory distress due to bronchial spasm

b. Reduce anaphylaxis
c. Relieve hypersensitivity to allergen

Question 123

Incorrect

When preparing the epinephrine injection from an ampule, Nurse Flo initially:

a. Removes the needle cap of syringe and pulls plunger to expel air

b. Checks expiration date of the medication ampule

c. Taps the ampule at the top to allow fluid to flow to the base of the ampule

d. Breaks the neck of the ampule with a gauze around it

Question 124

Before discharge, Nurse Loren discusses care at home with Mr. Billiards and his wife. The nurse recognizes that
further teaching is required when the wife says:

a. I have to take his blood pressure every day in the arm with the fistula. have to take his blood pressure every day
in the arm with the fistula.”

b. He will have to be very careful at night not to lie on the arm with the fistula. will have to be very careful at night
not to lie on the arm with the fistula.”

c. I must touch the shunt several times a day to feel for the bruit. must touch the shunt several times a day to feel
for the bruit.”

d. We really should check the fistula every day for signs of redness and swelling.

Question 125

When her membranes rupture, the nurse should expect to see:

a. A moderate amount of clear to straw-colored fluid

b. A small segment of the umbilical cord

c. A small amount of greenish fluid

d. A large amount of bloody fluid