RUEL M. BERSABE’S 1.
A footboard
OUR LADY OF PERPETUAL HELP REVIEW CENTER
CHED Accreditation No. 73
FUNDAMENTALS OF NURSING A
New Updates – December 2010
1. While providing nursing care for the client in Buck’s
traction, which assessment finding indicates a need for
immediate action?
1. The traction weights are hanging above the
floor.
2. The leg is in line with the pull of the traction.
3. The client’s foot is touching the end of the
bed.
4. The rope is in the groove of the traction
pulley.
2. The nurse enters the client’s room to assess the traction
apparatus. Which of the following interferes with the
effectiveness of the Russell’s traction?
1. The rope is strung tautly from pulley to pulley.
2. The trapeze is hanging above the client’s
chest.
3. The rope is knotted at the location of a pulley.
4. The weight is hanging about 24 inches from
the floor.
3. If the client is allergic to penicillin, it is essential that the
nurse question the medical order prior to giving which
type of antibiotic?
1. Aminoglycosides like gentamicin sulfate
(Garamycin)
2. Cephalosporins like cefaclor (Ceclor)
3. Tetracyclines like doxycyline (Vibramycin)
4. Sulfonamides like trimethoprim-
sulfamethoxazole (Bactrim)
4. Which laboratory test, if elevated, is most diagnostic for
rheumatoid arthritis?
1. Erythrocyte sedimentation rate (ESR)
2. Partial thromboplastin time (PTT)
3. Fasting blood sugar (FBS)
4. Blood urea nitrogen (BUN)
A cervical halter type of skin traction is applied to a client who
has experienced a whiplash injury in a motor vehicle accident.
5. When the nurse makes rounds at the beginning of the
shift, which observation requires immediate attention?
1. The halter rest under the client’s chin and
occiput.
2. The client’s ears are clear of the traction
ropes.
3. The weight hangs between the headboard and
wall.
4. There is a soft pillow beneath the client’s
head.
6. Which statement made by the client indicates that further
instruction regarding corticosteroid therapy is necessary?
1. “I am susceptible to getting infections.”
2. ‘I should never stop taking my medication
abruptly.”
3. “I may become very depressed and perhaps
suicidal.”
4. ‘I may develop low blood sugar and need
glucose.”
Before the total hip replacement, the nurse teaches the client
how to use an incentive spirometer.
7. Which client statement indicates that he has a correct
understanding of its use?
1. “I should position the mouthpiece and inhale
deeply.”
2. ‘I should position the mouthpiece and exhale
forcefully.”
3. “I should position the mouthpiece and cough
effectively.”
4. “I should position the mouthpiece and breathe
naturally.”
8. After the client undergoes a total hip replacement, how
should the nurse position the affected hip?
1. Adduction
2. Abduction
3. Flexion
4. Extension
9. Which item is best for preventing external rotation of the
operative leg when caring for the client with the total hip
replacement?
2. A trochanter roll
3. A turning sheet
4. A foam mattress
10. The nursing explanation that best describes the primary
purpose of the CPM machine is that it is used to.
1. Strengthen leg muscle
2. relieve foot swelling
3. Reduce surgical pain.
4. Restore joint function.
11. If the physician orders the following laboratory tests to
determine gout, the elevation of which test validates the
client’s diagnosis?
1. Creatinine clearance
2. Blood urea nitrogen
3. Serum uric acid
4. Serum calcium
12. The client with gout experiences an acute attack. Which
piece of equipment is best for promoting his comfort?
1. A bed cradle
2. An electric fan
3. A foam mattress
4. A fracture bedpan
The physician orders transcutaneous electric nerve stimulation
(TENS) in the location of the discomfort on the arm opposite the
amputation.
13. When the client asks the nurse how the TENS unit works,
you respond that one of the most widely held theories is
that sensation created by the TENS machine.
1. Blocks the brain’s perception of pain impulses.
2. Travels to the nerve root amputated arm.
3. Destroys the brain’s pain center.
4. Weakens the arm’s sensory nerves.
A myelogram with a water-soluble contrast dye is ordered to
confirm the diagnosis of a herniated intervertebral disk.
14. After the client returns from the myelogram. It is most
appropriate for the nurse to keep the client quiet and to.
1. Reduce glare from bright lights.
2. Withhold food and fluids for 12 hours.
3. Administer sedatives every 6 hour.
4. Encourage a high fluid intake.
The physician plans to do a lumbar puncture (spinal tap) on the
client who may have meningitis.
15. To facilitate performing the lumbar puncture, it is best for
the nurse to place the client.
1. In a knee-chest (genupectoral) position
2. Sitting up in an orthopnic position
3. In a side-lying position with his neck flexed.
4. In a left lateral position with right knee flexed.
16. While awaiting the results of diagnostic tests best to care
for the client with possible meningitis.
1. Droplet precaution.
2. Airborne precautions.
3. Contact precautions
4. Standard precautions
A 23 year-old woman who experienced a generalized seizure
while at work is undergoing diagnostic tests.
17. When preparing a client for an electroencephalogram
(EEG), which nursing action is appropriate to perform?
1. Administer a pretest sedative an hour before.
2. Withhold food and water after midnight.
3. Assist the client with shampooing her hair.
4. Take client’s blood pressure lying and sitting.
18. When implementing this order, which nursing action is
most appropriate?
1. the client is moved to a room close to the
nursing station.
2. The client’s food is served in paper and plastic
containers.
3. The overhead light is left on at all times.
4. The side rails on the bed are softly padded.
19. When the client who has had an EEG begins to have a
seizure, which action should the nurse take first?
1. Administer oxygen by nasal cannula.
2. Take her blood pressure and pulse.
3. Restrain her arms and upper body.
4. Place her in a side-lying position.
The medical record of a client with epilepsy indicates that he
has had two previous episodes of status epilepticus.
20. Which emergency drug should the nurse plan to have
available in case the client has a similar episode?
1
 1. Diazepam (Valium)
2. Phenytoin (Dilantin)
3. Carbamazepine (tegretol)
4. Phenobarbital sodium (Luminal)
A computed tomography scan (CT) of the brain with contrast
dye is ordered on the unconscious client.
21. If the client’s wife reports that the client has allergies,
which one must be reported to the physician before the
CT?
1. Tomatoes
2. Shellfish
3. Chocolate
4. Strawberries
A client with symptoms that suggest a brain tumor is scheduled
for positron tomography (PET).
22. When the nurse provides test preparation instructions,
which substance is it important for the client to avoid the
day before the rest?
1. Caffeine
2. Food dyes
3. Diuretics
4. Antibiotics
23. Before the client is discharged following the PET, which
instruction is most appropriate?
1. Take a mild laxative tonight.
2. Increase your fluid intake.
3. Get at least 8 hours of sleep.
4. Report any abdominal discomfort.
The client who underwent a craniotomy returns to the nursing
unit after 6 hours of surgery.
24. During the immediate postoperative assessment when
the nurse notes that the client’s dressing is moist, which
action is most appropriate to take first?
1. The nurse changes the dressing.
2. The nurse reinforces the dressing.
3. The nurse removes the dressing.
4. the nurse documents the findings.
A client experiences recurrent pain along the sciatic nerve. The
client is scheduled for a myelogram.
25. When the nurse describes the myelogram procedure to
the client, which statement is most accurate?
1. part of the test involves a lumbar puncture.
2. You will be asked to change positions
frequently.
3. Dye will be instilled into a vein in your arm.
4. Light anesthesia is administered during the
test.
26. Postoperatively, the client who has had a cataract
extraction tells the nurse that he is experiencing severe
pain in his operative eye. Which nursing action is most
appropriate?
1. Report the finding to the nurse in charge.
2. Give the client’s prescribed analgesic.
3. Assess the client’s pupil response with a
penlight.
4. Reposition the client on the operative. Side.
27. It is essential that the nurse withholds medication
administration and notifies the physician if which drug is
ordered for a client with glaucoma?
1. Atropine sulfate
2. Morphine sulfate
3. Magnesium sulfate
4. Ferrous sulfate
28. Which instrument is most appropriate for the nurse to
use for the purpose of testing the client’s hearing acuity?
1. Otoscope
2. Tuning fork
3. Reflex hammer
4. Stethoscope
A client asks the nurse why adults do not experience middle ear
infections as frequently as children do.
29. The nurse is most correct in explaining that, in a child,
organisms travel more easily from the nasopharynx to
the middle ear because the Eustachian tube is.
1. Shorter and straighter.
2. Longer and straighter.
3. Shorter and more curved.
4. Longer and more curved.
The client with possible Meniere’s disease will undergo a caloric
test.
30. The teaching plan for preparing the client for this
diagnostic test includes the explanation that.
1. Cold water and warm water are instilled in
each ear.
2. Earphones are worn through which sounds are
transmitted.
3. Scalp electrodes are attached to the head in a
darkened room.
4. Blood is drawn from a vein and examined
microscopically.
A nursing assistant with an allergy to latex asks the nurse
advice on carrying out standard precautions for preventing
transmission of blood-borne viruses.
31. The best advice the nurse give is to.
1. Rinse the latex gloves with running tap before
donning them.
2. Apply a petroleum ointment to both hands
before donning latex gloves.
3. Eliminate wearing gloves, but wash both
hands vigorously with alcohol afterward.
4. Wear two pairs of vinyl gloves when there
potential for contract with blood.
The client with diabetes insipidus is treated with intranasal
lypressin (Diapid), 2 sprays q.i.d. and as needed.
32. The nurse observes the client self-administering the
medication. Which action indicates that the client is
performing the procedure correctly?
1. The client assumes a supine position.
2. The client tilts her head to the side.
3. The client inverts the drug container.
4. The client inhales with each spray.
The client with acromegaly will undergo a transsphenoidal
hypophysectomy after a short course of theraphy with
bromocriptine (Parlodel).
33. Because bromocriptine (Parlodel) may cause postural
hypotension, which nursing instruction is most
appropriate?
1. Lie down for ½ hour after taking the
medication.
2. Avoid taking elevators in tall buildings.
3. Rise slowly from a sitting or lying position.
4. Have your blood pressure taken once a week.
A 35 year-old woman is undergoing test to determine why she
has stopped menstruating. One test that the client undergoes is
a radioactive iodine uptake test.
34. When the test is completed, which of the nurse’s
statements is accurate?
1. “You must remain isolated until your radiation
is decreased.”
2. “You are free to go without further
precautionary instruction.”
3. “You must follow special precaution for a short
period of time.”
4. “You will be given an antidote for reducing the
radioactivity.”
The client is stable condition returns to the nursing unit after
having a subtotal thyroidectomy.
35. In which position is it most appropriate to maintain the
client following a subtotal thyroidectomy?
1. Supine
2. Sims
3. Fowler’s
4. Recumbent
The care plan indicates that the nurse should assess the
Chvostek’s sign if hypocalcemia is suspected.
36. Which technique best describes how Chvostek’s sign is
elicited?
1. The nurse lightly taps over the client facial
nerve.
2. The nurse strokes the sole of the client’s foot.
2
 3. The nurse dorsiflexes each of the client’s feet.
4. the nurse asks the client to touch her nose.
A client with hyppoparathyroidism develops tetany.
37. If emergency drugs are available, which one can the
nurse expert the physician will order for intravenous
administration?
1. Calcium gluconate
2. Ferrous sulfate
3. Potassium chloride
4. Sodium bicarbonate.
The physician orders a 24-hour urine collection to aid in the
diagnosis of Cushing’s syndrome.
38. The nurse most accurate in instructing the client that the
urine collection will begin
1. With the client’s next voiding.
2. After the client’s next voiding.
3. At midnight.
4. At noontime.
A 5-hour glucose test is ordered to determine if the client has
functional hypoglycemia.
39. Which nursing instruction concerning the test procedure
is most accurate?
1. You need to eat a large meal just before the
test.
2. Bring a voided urine specimen to the
laboratory.
3. You can have liquids, like coffee, before the
test.
4. You will be given a sweetened drink before
the test.
A nurse participates in a community-wide screening to identify
adults who may have undiagnosed diabetes mellitus.
40. If the screening includes a measurement of postprandial
blood sugar, the nurse is correct in explaining that blood
will be drawn approximately 2 hours.
1. Before breakfast.
2. After meal.
3. Before bedtime.
4. After a fast.
41. Which statement indicates that a client with an elevated
2-hour postprandial blood sugar understands the
significance of the screening test?
1. “I need to eat less frequently.”
2. “I need to stop eating candy.”
3. “I need to consult my physician.”
4. “I need to begin taking insulin.’
The physician prescribes glyburide (DiaBeta) orally for the client
with type II diabetes mellitus.
42. When the client asks why his diabetic relative cannot take
his insulin orally, the best answer is that insulin is
1. Inactivated by digestive enzymes.
2. Absorbed too quickly in the stomach.
3. Irritating to the gastric mucosa.
4. Incompatible with many foods.
The nurse plans to monitor the client’s response to insulin
therapy closely with an electronic glucometer.
43. When the nurse monitors the client’s blood sugar using
an electronic glucometer, which action is correct?
1. Clean the client’s finger with povidone iodine
(Betadine).
2. Apply a rubber band around the test finger.
3. Pierce the central pad of the client’s finger.
4. Apply a large drop of blood to a test strip or
area.
44. Which action best indicates that the client needs more
practice in combining two insulins in one syringe?
1. The client rolls the vial of intermediate-acting
insulin to mix it with its additive.
2. The client instills air into both the fast-acting
and intermediate-acting insulin vials.
3. The client instills the intermediate-acting
insulin into the vial of rapid-acting insulin.
4. The client inverts each vial prior to
withdrawing the specified amount of insulin.
45. When the client practices self-administration of the
insulin, which action is correct?
1. Piercing the skin at a 30-degree angle.
2. Using a syringe calibrated in minims.
3. Using a 2-inch needle on the syringe
4. Rotating the sites of each injection.
46. Which instruction by the nurse should be given to the
client regarding insulin administration during sick days?
1. Monitor blood glucose levels every 2 to 4
hours.
2. Eat candy or sugar frequently.
3. Attempt to drink a high-calorie beverage
every hour.
4. Test urine daily fro protein.
47. As the nurse prepares to withdraw the furosemide (Lasix)
from the ampule the best technique for removing the
medication is to.
1. Allow the ampule to stand undisturbed for a
few minutes.
2. Tap the ampule stem with the fingernail a few
times.
3. Hold the ampule upside down, then flip it right
side up.
4. Roll the ampule gently between the palms of
the hands.
48. The best evidence that turosemide (Lasix) has had a
therapeutic effect is that the client’s.
1. Pulse becomes slower.
2. Blood pressure stabilizes.
3. Urinary output increases.
4. Anxiety is diminished.
49. The nurse should instruct the client to take his oral
furosemide (Lasix) at what time of the day?
1. Before bedtime.
2. When arising.
3. With his main meal.
4. In the late afternoon.
50. When teaching the client about the side effects of
furosemide (Lasix), the nurse instructs him that he will
need to eat foods high in which mineral?
1. Potassium.
2. Sodium
3. Calcium
4. Iron
51. The nurse instructs the client taking furosemide (Lasix) to
monitor his urine output. The rationale for the nurse’s
instruction is that the use of furosemide (Lasix) may lead
to which condition?
1. Dehydration
2. Fluid overload
3. Hypernatremia
4. Hyperkalemia
The client is scheduled for a stress electrocardiogram (ECG).
52. When the client asks why the physician ordered the ECG,
it is most correct for the nurse to explain that a stress
ECG.
1. Shows how the heart performs during
exercise.
2. Determine his potential target heart rate.
3. Verifies how much he needs to improve his
fitness.
4. Can predict if he will have a heart attack soon.
53. Which side effect is most closely associated with the use
of nitrogen tablets?
1. Headache
2. Backache
3. Diarrhea
4. Jaundice
54. It is most accurate for the nurse to tell the client that if
his chest pain is not relieved after taking one
nitroglycerin tablet he should.
1. Take another tablet in 5 minutes.
2. Drive of the emergency department.
3
 3. Call his physician without delay.
4. Swallow two additional tablets.
55. Which nursing action is most appropriate when applying
the transdermal patch?
1. Rotate the application site.
2. Squeeze the drug reservoir.
3. Tape the patch to the chest.
4. Apply ice to the skin area.
56. Prior to the catheterization and coronary arteriogram, it is
essential that the nurse ask the client if he allergic to
iodine or.
1. Penicillin.
2. Morphine.
3. Shellfish
4. Eggs.
57. The client who has been experiencing increased incidence
of chest pain will undergo a heart catheterization and
coronary arteriogram. To reduce the client’s anxiety, it is
best for the nurse to.
1. Teach the client how coronary artery disease
is usually treated.
2. Listen to the client express his feelings about
his condition.
3. Explain to the client how well others have
done having this test.
4. Avoid discussing the heart catheterization until
client has relaxed.
58. The nurse implements the teaching plan for cardiac
catheterization and coronary arteriogram.
1. The client says that he will be able to hear
beating in his chest.
2. The client says that he will experience a heavy
sensation all over his body.
3. The client says that he will be anesthetized
and won’t feel any discomfort.
4. The client says that he will feel a warm
sensation as the dye is instilled.
The femoral artery is the site used to thread the heart catheter.
59. After the coronary arteriogram, the nurse correctly keeps
the client flat in bed with the affected leg.
1. Extended
2. Flexed
3. Abducted
4. Abducted.
60. After the femoral artery has been cannulated, the most
important physical assessment the nurse should plan is
to
1. Palpate the client’s distal peripheral pulses.
2. Auscultate the client’s heart and lung sounds.
3. Percuss all four quadrants of the client’s
abdomen.
4. Inspect the skin integrity in the client’s groin.
Based on the results of the coronary arteriogram, the physician
recommends that the client undergo percutaneous transluminal
coronary angioplasty (PTCA).
61. If the client understands his physician’s explanation of
the PTCA procedure, he will describe that a
1. Balloon-tipped catheter will be inserted into a
coronary artery.
2. Teflon graft will be used to replace an area of
weakened heart muscle.
3. Section of vein from his leg will be grafted
around a narrowed coronary artery.
4. Battery-operated pacemaker will be implanted
to maintain his heart rate.
While waiting to undergo PTCA, the client takes propranolol
hydrochloride (Inderal).
62. When the client asks the nurse how this drug helps to
prevent angina, the best explanation is that it
1. Promotes excretion of body fluid
2. Reduces the rate of heart contribution.
3. Alters pain receptors in the brain.
4. Dilates the major coronary arteries.
The client who is awaiting a PTCA has been taking one baby
aspirin daily per the advice of his physician.
63. The best explanation for the drug therapy in this situation
is that aspirin tends to
1. Relieve chest pain
2. Prevent blood clots
3. Reduce muscle spasms
4. Reduce joint inflammation.
64. When the client returns to his room following the PTCA
procedure, which assessment finding should be reported
immediately to the physician?
1. Urine output of 100 mL/h
2. Blood pressure of 108/68 mm Hg
3. Dry mouth
4. Chest pain
The client who has a previous PTCA is now scheduled for a
coronary artery bypass graft (CBAG).
65 . Immediately after returning to the unit, the nurse
assesses the client’s leg incision. The nurse is aware that
the most common blood vessel used in CABG surgery is
the
1. Saphenous vein.
2. Femoral artery.
3. Popliteal vein.
4. Iliac artery.
The physician orders a patient-controlled analgesia (PCA)
infuser pump for the client following CABG surgery.
66. The nurse instructs the client about the use of the PCA
pump. Which information is most important for the nurse to
provide?
1. Press the control button when pain medication is needed.
2. Call the nurse each time the PCA pump needs to be used.
3. Use the PCA pump only when the pain is severe.
4. Frequent use of the PCA pump can cause addiction.
67. After the CABG surgery, which assessment finding
provides the best evidence that collateral circulation
at the donor graft site is adequate?
1. The client is free of chest pain.
2. The toes are warm and nonedematous.
3. The client moves his leg easily.
4. The heart rate remains regular.
68. Which drug should the nurse plan to have on hand
in case the client who receives streptokinase
(Streptase) develops an allergic reaction?
1. Vitamin K (Synkayvite)
2. Heparin sodium (Liquaemin sodium)
3. Diphenhydramine (Benadryl)
4. Warfarin sodium (Coumadin)
A 65 year-old woman collapse in the hospital elevator while
coming to visit a family member.
69. The first action the nurse who discovers her should
take is to
1. Open her airway.
2. Give two breaths.
3. Shake her gently.
4. Call a code blue.
70. Which technique is best for the nurse to use to open the
airway of the person who is not breathing?
1. Elevate the neck.
2. Lift the chin.
3. Press on the jaws.
4. Clear the mouth.
71. The best method fort determining if rescue breathing
should be performed is to
1. Observe the victim’s skin color.
2. Feel for pulsations at the neck.
3. Listen for spontaneous breathing.
4. Blow air into the victim’s mouth.
72. During cardiopulmonary resuscitation (CPR), the nurse
compresses the chest of an adult victim at a rate of no less than
1. 15 compressions per minute.
2. 40 compressions per minute.
3. 80 compressions per minute.
4. 100 compressions per minute.
73. When two rescuers perform CPR, the rate of compressions
to ventilations is.
4
 1. 15 compressions to 2 breaths. 3. Hydration determines when the client needs to be
2. 5 compressions to 1 breath. transfused.
3. 1 compression for each breath. 4. Hydration indicates when fluids should be
4. 1 compression to 5 breaths. increased.

A physician writes an order for the application of wet-to-dry

dressing over the venous stasis ulcers.

74. Which evidence best determines when the cardiac 83. When the client asks the nurse why the dressings are being
compressions can be discontinued? applied, the best explanation is that these dressing help to
1. The victim’s color improves. 1. Prevent wound infections.
2. The pupils become dilated. 2. Remove dead cells and tissue.
3. A pulse can be palpated. 3. Absorb blood and drainage.
4. The victim begins to vomit. 4. Protect the skin from injury.
84. The client develops a thrombus in one of her leg veins.
75. The nurse monitors the client’s lab values because of the When the nurse assesses for Homans’ sign.
large doses of diuretics the client received to treat her 1. the client will experience sharp calf pain
pulmonary edema. Which lab value must the nurse report immediately.
immediately to the physician? 2. The client will complain of sudden numbness in
1. Sodium 137 mEq/L her foot.
2. Potassium 2.5 mEq/L 3. The client will be unable to bend her knee when
3. Chloride 97 mEq/L asked.
4. Bicarbonate 25 mEq/L 4. The client will feel tingling throughout her affected
leg.
76. If the clients develops digitalis toxicity, she is most likely to
exhibit. The physician orders heparin calcium (Calciparine) 7500 U
1. Anorexia and nausea subcutaneously.
2. Dizziness and insomnia.
3. Pinpoint pupils and double vision. 85. When the client asks why she is receiving the medication,
4. Ringing in the ears and itchy skin. the most appropriate nursing response is that heparin
1. Helps shrink blood clots.
77. Before administering the digoxin 2. Helps dissolve blood clots.
(Lanoxin) to the client, it essential that the nurse assess 3. Prevent more clots from forming
the 4. Prevents the clot from dislodging.
1. Heart rate. 86. When the nurse withdraws the heparin calcium from the
2. Blood pressure. multidose vial, which technique is most accurate?
3. Heart sounds. 1. The nurse removes the rubber stopper in the top of
4. Lung sounds. vial.
2. The nurse instills an equal volume of air as liquid to be
78. Before cardioversion is attempted, the nurse is most withdrawn
correct in withholding which prescribed medication? 3. The nurse mixes the drug by rolling it in the palms of
1. Diazepam (Valium) the hands
2. Digoxin (Lanoxin) 4. the nurse shakes the drug vigorously to distribute the
3. Heaprin (Lipo-sodium) drug evenly
4. Glyburide (DiaBeta) 87. When the nurse administers the heparin subcutaneously to
the client of average weight for her height, which action is most
79. The best evidence that the cardioversion procedure accurate?
has been successful is 1. The nurse selects the dorsogluteal site
1. The client regains 2. The nurse uses a 220gauge, 1 ½ inch needle
consciousness immediately. 3. The nurse inserts the needle at 45o angle
2. Normal sinus cardiac rhythm 4. the nurse massages the site immediately after ward
is restored. A nurse applies prolonged pressure to an injection site of client
3. The apical heart rate equals the radial who is receiving anticoagulant therapy
rate. 88. The nurse actions is
4. The pulse pressure is approximately 40 1. inappropriate because it promotes hematoma
mm Hg. formation
2. inappropriate because it delays drug absorption
80. As part of the discharge instructions, the nurse most 3. appropriate because it distributes the drug evenly
correctly instructs the client with an artificial pacemakers 4. appropriate because it diminishes blood loss
that a sign pacemaker malfunction. 89. The first action the nurse should take if phlebitis is
1. Tingling in the chest pain. suspected at an intravenous site is to
2. Dizziness during activity. 1. elevate the affected extremity on pillows
3. Pain radiating to the arm. 2. apply pressure to the intravenous insertion site
4. Tenderness beneath the skin. 3. administer the intravenous solution at a fast rate
4. remove the needle or catheter from the current site
81. The best location for the nurse to auscultate the The nurse prepares to use a Doppler ultrasound device to
sounds from the mitral valve is assess blood flow through the dorsalis pedis artery
1. At the fifth intercostals space
in the midclavicular line. 90. Which technique is most accurate when using the Doppler
2. At the fourth intercostals space to device?
the sternum. 1. the nurse places the probe beside the ankle
3. At the second intercostals space to the 2. the nurse applies acoustic gel to the skin
right of sternum. 3. the nurse records the time of capillary refill
4. At the second intercostals space to the left 4. the nurse measures the temperature of the skin
of sternum.
An 18 year old college student has been feeling extremely tired
82. In the postoperative period, the nurse frequently and makes an appointment at the university’s health office
assesses the client’s fluid status. What is the rationale
for the nurse’s action? 91. Which laboratory test can the nurse expect to be lower than
normal if the cause of the client’s fatigue is related to iron-
1. Urinary output retention is common after a heart deficiency anemia?
transplant. 1. Prothrombin time
2. Urine output is an indication of perfusion to the 2. Bleeding time
kidneys. 3. Fibrinogen level
4. Hemoglobin level

5
92. For the best absorption of oral iron preparation, the nurse
most accurately instruct the client to take ferrous sulfate
1. between meals
2. with each meal
3. just before eating
4. just before bedtime
93. To maximize the absorption of the iron supplement the
nurse most accurate advises the client to take the table with
1. milk
2. tea
3. a soft drink
4. orange juice
94. The nurse instructs the client about administering of the
liquid iron preparation. Which instruction is most accurate?
1. use a straw
2. pour it in a paper cup
3. take it cover ice
4. mix it with milk
95. Which muscle is best for the nurse to plan to use when
giving the injection by Z-track technique?
1. deltoid
2. trapezius
3. gluteus medius
4. latissimus dorsi
Laboratory test result indicate that the client with leukemia has
a low platelet count.

97. Based on the client’s laboratory results, which nursing

intervention is most appropriate at this time?
1. limit the client’s visitors to family
2. place the client in protective isolation
3. use small-gauge needle for injection
4. provide rest periods between activities
The physician informs the client with polycythemia that a
phlebotomy will be performed
98. The best evidence that the client understand the physician
explanation is when he tells the nurse that
1. blood will be removed from his vein
2. tourniquets will be applied to his arms
3. some veins will be surgically occluded
4. he will receive a blood transfusion
The physician orders several laboratory tests for the client
suspected of having AIDS
99. Which laboratory test is most significant for diagnosing
antibodies to the human immunodeficiency virus (HIV)?”
1. Schick test
2. Dick test
3. enzyme-linked immunosorbent assay (ELISA)
4. venereal disease research laboratory (VDRL) test

100. The nurse explains to the client the anatomic location for
the bone marrow aspiration. Which area should the client point
to when to identify the site where the specimen will be taken?
1. the posterior hip
2. the lower spine
3. the upper arm
4. the groin area