1.
When bathing a patient’s extremities, the promotes sleep and is found in small amounts in
nurse should use long, firm strokes from the
distal to the proximal areas. This technique:
  A. Provides an opportunity for skin
assessment.
  B. Avoids undue strain on the nurse.
  C. Increases venous blood return.
  D. Causes vasoconstriction and increases
circulation.
Incorrect
Correct Answer: C. Increases venous blood
return.
Washing from distal to proximal areas stimulates
venous blood flow, thereby preventing venous
stasis. Good personal hygiene is essential for
skin health but it also has an important role in
maintaining self-esteem and quality of life.
Supporting patients to maintain personal
hygiene is a fundamental aspect of nursing care.
2. The natural sedative in meat and milk
products (especially warm milk) that can help
induce sleep is:
  A. Flurazepam
  B. Temazepam
  C. Methotrimeprazine
  D. Tryptophan
Incorrect
Correct Answer: D. Tryptophan
Tryptophan is a natural sedative; flurazepam
(Dalmane), temazepam (Restoril), and
methotrimeprazine (Levoprome) are hypnotic
sedatives. Protein foods such as milk and milk
products contain the sleep-inducing amino acid
tryptophan. Having warm milk at bedtime is a
good way to work towards reaching the
recommended number of servings of Milk and
Alternatives each day, and can be a comforting
way to unwind. Tryptophan is an amino acid that
all protein foods. It is a precursor to the sleep-
inducing compounds serotonin (a
neurotransmitter), and melatonin (a hormone
which also acts as a neurotransmitter).
3. Nursing interventions that can help the patient
to relax and sleep restfully include all of the
following except:
  A. Have the patient take a 30- to 60-
minute nap in the afternoon.
  B. Turn on the television in the patient’s
room.
  C. Provide quiet music and interesting
reading material.
  D. Massage the patient’s back with long
strokes.
Incorrect
Correct Answer: A. Have the patient take a
30- to 60-minute nap in the afternoon.
Napping in the afternoon is not conducive to
nighttime sleeping. There are few considerations
about naps. For example, a short daytime nap of
15-30 minutes can be restorative for elders and
will not interfere with nighttime sleep. On the
other hand, insomniacs are cautioned to avoid
naps. Quiet music, watching television, reading,
and massage usually will relax the patient,
helping him to fall asleep.
4. Restraints can be used for all of the following
purposes except to:
  A. Prevent a confused patient from
removing tubes, such as feeding tubes, I.V.
lines, and urinary catheters.
  B. Prevent a patient from falling out of bed
or a chair.
  C. Discourage a patient from attempting to
ambulate alone when he requires assistance for
his safety.
  D. Prevent a patient from becoming
confused or disoriented.
Incorrect
Correct Answer: D. Prevent a patient from
becoming confused or disoriented.
By restricting a patient’s movements, restraints
may increase stress and lead to confusion,
rather than prevent it. Restraints in a medical
setting are devices that limit a patient’s
movement. Restraints can help keep a person
from getting hurt or doing harm to others,
including their caregivers. They are used as a
last resort. The other choices are valid reasons
for using restraints.
5. Which of the following is the nurse’s legal
responsibility when applying restraints?
  A. Document the patient’s behavior.
  B. Document the type of restraint used.
  C. Obtain a written order from the physician
except in an emergency, when the patient must
be protected from injury to himself or others.
  D. All of the above.
Incorrect
Correct Answer: D. All of the above
When applying restraints, the nurse must
document the type of behavior that prompted her
to use them, document the type of restraints
used, and obtain a physician’s written order for
the restraints. Nurses are accountable for
providing, facilitating, advocating and promoting
the best possible patient care and to take action
when patient safety and well-being are
compromised, including when deciding to apply
restraints.
6. Kubler-Ross’s five successive stages of death
and dying are:
  A. Anger, bargaining, denial, depression,
acceptance
  B. Denial, anger, depression, bargaining,
acceptance
  C. Denial, anger, bargaining, depression
acceptance
  D. Bargaining, denial, anger, depression,
acceptance
Incorrect
Correct Answer: C. Denial, anger, bargaining,
depression acceptance
Kubler-Ross’s five successive stages of death
and dying are denial, anger, bargaining,
depression, and acceptance. The patient may
move back and forth through the different stages
as he and his family members react to the
process of dying, but he usually goes through all
of these stages to reach acceptance.
7. Which intervention should the nurse Trish use
when administering oxygen by face mask to a
female client?
Assist the client to the semi-Fowler position if possible.
Secure the elastic band tightly around the client's head.
BB
Loosen the connectors between the oxygen
C equipment and humidifier.
Apply the face mask from the client's chin up over the nose.
Question 4 Explanation: 
By assisting the client to the semi-Fowler
position, the nurse promotes easier chest
expansion, breathing, and oxygen intake. The
nurse should secure the elastic band so that the
face mask fits comfortably and snugly rather
than tightly, which could lead to irritation. The
nurse should apply the face mask from the
client's nose down to the chin — not vice versa.
The nurse should check the connectors between
the oxygen equipment and humidifier to ensure
that they're airtight; loosened connectors can
cause loss of oxygen.
8. The nurse prepares to administer a cleansing
enema. What is the most common client position
used for this procedure?
Supine
A
Sims’ left lateral
Prone
 Lithotomy
D A
Question 6 Explanation:  Informative
The Sims' left lateral position is the most
common position used to administer a cleansing
enema because it allows gravity to aid the flow
of fluid along the curve of the sigmoid colon. If
the client can't assume this position nor has poor
sphincter control, the dorsal recumbent or right
lateral position may be used. The supine and
prone positions are inappropriate and
uncomfortable for the client.
9. 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?
Implementation
A
Planning and goals
B
Assessment
Evaluation
Question 8 Explanation:  testing need to be obtained using sterile
Evaluation includes observing the person,
asking questions, and comparing the patient’s
behavioral responses with the expected
outcomes.
10. Nurse Michelle witnesses a female client
sustain a fall and suspects that the leg may be
broken. The nurse takes which priority action?
Takes a set of vital signs.
A
Call the radiology department
for X-ray.
B A
Reassure the client that
C everything will be alright.
Immobilize the leg
before moving the client.
Question 9 Explanation:  Physical examination
If the nurse suspects a fracture, splinting the
area before moving the client is imperative. The
nurse should call for emergency help if the client
is not hospitalized and call for a physician for the
hospitalized client.
11. Which type of evaluation occurs continuously
throughout the teaching and learning process?
Retrospective
Summative
C
Formative
12. 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?
Use a sterile plastic container for
obtaining the specimen.
Ask the client to obtain the
B specimen after breakfast.
Provide tissues for expectoration
C and obtaining the specimen.
Ask the client to expectorate a small
D amount of sputum into the emesis basin.
Question 15 Explanation: 
Sputum specimens for culture and sensitivity
techniques because the test is done to
determine the presence of organisms. If the
procedure for obtaining the specimen is not
sterile, then the specimen is not sterile, then the
specimen would be contaminated and the
results of the test would be invalid.
13. 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?
Diagnostic test results
History of present illness
Biographical date
C
D
Question 18 Explanation: 
The history of present illness is the single most
important factor in assisting the health
professional in arriving at a diagnosis or
determining the person’s needs.
14. A male client complains of abdominal
discomfort and nausea while receiving tube
feedings. Which intervention is most appropriate
for this problem?
Give the feedings at room
A temperature.
Decrease the rate of feedings
and the concentration of the formula.
Place the client in semi-Fowler's
C position while feeding.
Change the feeding container
D every 12 hours.
Question 21 Explanation: 
Complaints of abdominal discomfort and nausea
are common in clients receiving tube feedings.
Decreasing the rate of the feeding and the
concentration of the formula should decrease
the client's discomfort. Feedings are normally
given at room temperature to minimize
abdominal cramping. To prevent aspiration
during feeding, the head of the client's bed
should be elevated at least 30 degrees. Also, to
prevent bacterial growth, feeding containers
should be routinely changed every 8 to 12 hours.
15. The nurse is aware that the most important
nursing action when a client returns from surgery
is:

Assess the client for presence of pain.

Assess the IV for type of fluid and
B rate of flow.
Assess the Foley catheter for patency
and urine output

Assess the dressing for drainage.

D
Question 33 Explanation: 
Assessing the client for pain is a very important
measure. Postoperative pain is an indication of
complication. The nurse should also assess the
client for pain to provide for the client’s comfort.