FUNDAMENTALS MT1 NOV 2023

NLE INTENSIVE

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1. Thoracentesis is useful in treating all of the following pulmonary disorders

except:

a.Hemothorax

b. Tuberculosis

c. Hydrothorax

d. Empyema
2. A client is scheduled for a paracentesis for ascites. Which statement by the
client would indicate to the nurse that the preprocedure teaching has been
successful?

A. “I will need to lie flat in bed during the procedure. “

B. “I believe this is a surgical procedure. “

C. “I need to drink two glasses of water right before the procedure to maintain a full
bladder.”

D.“The doctor will slowly remove fluid from my abdomen to relieve the swelling.”

3. Which of the following psychological preparation is not relevant for the patient
before paracentesis?

a. Telling him that the gauge of the needle and anesthesia to be used

b. Telling him to keep still during the procedure to facilitate the insertion of the
needle in the correct place.

c. Allowing the patient to express his feelings and concerns

d. Physician’s explanation on the purpose of the procedure and how it will be done

4. Which of the following assessments is essential for the nurse to make when
caring for a client who has just had an esophagogastroduodenoscopy (EGD)?

a. Auscultate bowel sounds

b. Monitor salivary pH

c. Check gag reflex

d. Measure abdominal girth

5. Before Esophagoscopy, the nurse prepares the following medications except:

a. Anxiolytic

b. Xylocaine Spray

c. Anti Cholinergic medication

d. Cholinergic medication

6. A client with a recent history of rectal bleeding is being prepared for a

colonoscopy. How should the nurse position the client for this test initially?

a. Lying on the right side with legs straight.

b. Lying on the left side with knees bent.

c. Prone with the torso elevated.

d. Bent over with hands touching the floor.

7. The nurse is planning care for the client scheduled for gastroduodenoscopy and
a barium swallows. What will the nursing plan include?

a. Anticipating the client will receive a low-residue diet in the evening and then
receive nothing by mouth (NPO status) 6 to 12 hours before the test.

b. Discussing with the client the nasogastric tube and the importance of gastric
drainage of 24 hours the test.

c. Explaining to the client that he will receive nothing by mouth (NPO status) for 24
hours after the test to make sure his stomach can tolerate his food.

d. Discussing the general anesthesia and explaining that he will wake up in the
recovery room.
8. A nurse assists a physician in performing a liver biopsy. After the biopsy the
nurse plans to place the client which of the following positions?

a. Prone

b. Supine

c. A right side-lying position with a small pillow or folded towel under the puncture
site.

d. A left side-lying position with a small pillow folded towel under the puncture site.

9. A client who is scheduled for a bone marrow aspiration asks the nurse about the
site that will be used for the procedure. The nurse tells the client that in addition to
the iliac crest, bone marrow may be aspirated in which of the following locations?

a. Femur

b. Ribs

c. Sternum

d. Hyoid

10. The correct procedure for auscultating a client’s abdomen for bowel sounds
would include:

A. Palpating the abdomen first to determine correct stethoscope placement

B. Encouraging the client to cough to stimulate movement of fluid and air through
the abdomen

C. Placing the client on the left side to aid auscultation

D. Listening for 5 minutes in all 4 quadrants to confirm absence of bowel sounds

11.  When examining a client with abdominal pain, the nurse should assess: 

a. any quadrant first.

b. the symptomatic quadrant first.

c. the symptomatic quadrant last.

d. the symptomatic quadrant either second or third.

12. What is the initial nursing responsibility after a Barium Study?

a. Give laxatives

b. Encourage bed rest

c. Encourage low fiber diet

d. Encourage ambulation

13. A nurse is reviewing the laboratory test results for a client with a diagnosis of
severe dehydration. The nurse would expect the hematocrit level for this client to
be whish of the following?

a. 60%

b. 47%

c. 45%

d. 32%
14. Which of the following guidelines should be followed when administering an
enema to children?

a. Insert the tube only 2.5cm

b. Enema temperature should be below normal body temperature

c. The enema solution should be hypertonic.

d. Enemas should be 200-300 mL in children 1 ½ months to 5 years.

15. Basic principles in care of patients with ostomy are:

(1) Care of the skin

(2) Care of the appliance

(3) Care of the stoma

(4) Acceptance of body image

a. 1 only

b. 1, 2 and 3

c. all are correct

d. 2,3 and 4

16. Normal characteristic of the stoma, which one is correct?

a. Color: dusky red to black

b. Contour: slight depressed from the abdominal wall

c. Size: stoma is non edematous post op

d. It is not painful and slightly moist

17. A colostomy patient who wishes to avoid flatulence should not eat the
following EXCEPT:

a. Corn and peanuts

b. Cabbage and asparagus

c. Mangoes and pineapples

d. Chewing gum and carbonated beverages

18. During the first post operative week, the nurse can BEST help the patient with a
colostomy to accept the change in body image by:

a. Changing the dressing just prior to meals

b. Encouraging the patient to observe the stoma and its care

c. Deodorizing the room periodically with a spray can

d. Applying a large bulky dressing over the stoma to decrease odors

19. A colostomy can BEST be defined as:

a. Cutting the colon and bringing the proximal end through the abdominal wall

b. Creating a stomal orifice from the ileum

c. Excising a section of the colon and doing an end-to-end anastomosis

d. Removing the rectum and suturing the colon to the anus.

20. A client is recovering from an ileostomy that was performed to treat
inflammatory bowel disease. During discharge teaching, the nurse should stress
the importance of:

a. Increasing fluid intake to prevent dehydration.

b. Wearing an appliance pouch only at bedtime.

c. Consuming a low-protein, high fiber diet.

d. Taking only enteric-coated medications

21. The nurse evaluates the client’s stoma during the initial postoperative period.
Which of the following signs would indicate inadequate blood supply to the stoma
and should be reported immediately to the physician? A stoma that:

a. Is slightly edematous

b. Is dark to red purple in color

c. Oozes a small amount of blood

d. Does not expel stool

22. Colostomy irrigation is ordered for the client on her 5th postoperative day. The
primary purpose of this irrigation is to:

a. Cleanse the colon

b. Regulate the bowel

c. Dilate the sphincter

d. Stimulate peristalsis
23. If the client complains of abdominal cramping after receiving approximately
150 ml of solution during colostomy irrigation, the nurse should temporarily:

a. Stop the flow of the solution

b. Have the client sit up in bed

c. Remove the irrigating cone or tube

d. Insert the cone or tube further into the colon

24.  Which of the following should be removed from the client in preparation for an
MRI procedure?

a. Urinary catheter

b. Plastic name band

c. Partial dental plate

d. Foam slippers

25. When evaluating the client’s temperature level, the nurse expects the client’s
temperature to be lower:

a. In the morning

b. After exercising

c. During periods of stress

d. During the post operative period

26. In accessing a client’s apical pulse, you know that the erb’s point is usually at
which area?

A. LMCL, 5thICS

B. LMCL, 4thICS

C. LMCL, 3rdICS

D. RMCL, 2ndICS

27. Which of the following is most likely to yield accurate information about the
quality of patient’s pain?

a. “Tell me, what your pain feels like.”

b. “Would you describe your pain as radiating? Acute or sharp?”

c. Tell, how would you rate your pain in a scale to 1 to 5”

d. “What events seemed to increase your pain?”

28. Chronic pain is most effectively relieved when analgesics are administered:

a. On a prn (as needed) basis

b. Conservatively

c. At regular scheduled intervals

d. Intramuscularly
29.  The nurse is caring for a group of adult patients who require pain
management. It is most important for the nurse to remember:

a. to use medication only as a last resort after trying to distract the patient

b. that medicating a patient with chronic pain is a lower priority than medicating a
patient with acute pain.

c. that medication should be given based on the patient’s perception of pain.

d. to wait for 15 minutes after a patient’s request for pain medication to be sure the
pain is real.

30.  Which of the following most appropriately describe pain sensations that has
periods of remission and exacerbation?

a. Acute

c. Chronic

b. Intractable

d. Neuropathic

31. You are obtaining a history of  Jessie D. who is admitted with  acute chest pain.
Which question will be most helpful for you to ask?

a. Why do you think you had a heart attack?

b. Do you need anything now?

c. What were you doing when the pain started?

d. Has anyone in your family been sick lately?

32.  Non-pharmacologic pain management includes all the following, except:

a. relaxation techniques

b. massage

c. use of herbal medicines

d. body movement

33. The amount of medication that could be given through a deltoid muscle is:

A. 0.5 mL or less

B. 1.0 mL or less

C. 1.5 mL or less

D. 2.0 mL or less

34. Which of the following landmarks should a nurse identify when planning to
inject an IM medication at the ventrogluteal site?

A. Greater trochanter

B. Acromion process

C. Coccyx

D. Antecubital fossa
35. The nurse is preparing to administer an iron injection to a client. The nurse will
give the medication in the:

a. Anterolateral thigh using a 5/8 inch needle on the syringe

b. Subcutaneous tissue of the abdomen

c. Deltoid muscle using a 1-inch needle on the syringe

d. Gluteal muscle using the Z-track technique

36. The nurse is preparing the client’s medication which is available for injection in
an ampule. Which of the following should the nurse do when drawing up this
medication?

a. Place an alcohol wipe around the neck of the ampule

b. Break the top of the ampule so that it opens toward the nurse

c. Wipe the neck of the ampule with gauze after snapping it open

d. Shake the ampule gently to mix the contents

37. Discharge plan of diabetic clients include injection-site-rotation. You should

emphasize that the space between sites should be:

A. 2 cm.

B. 5 cm.

C. 2.5 cm.

D. 4 cm.
38. Which exam technique is being used when the nurse touches the client’s
abdomen to examine the size of the liver? 

a. Inspection

b. Palpation

c. Percussion

d. Auscultation

39. In performing a caloric test in a client with Meniere’s disease, warm instillation
at the left ear will result to:

a. Nystagmus to the same side

b. Nystagmus to the opposite side

c. Nystagmus to both sides

d. None of the above

40. A nurse has prepared a client for an intravenous pyelogram. The nurse
determines that the client understands the procedure if the client states to expect
which sensation during the procedure?

a. nausea

b. Difficulty of breathing

c. cold clammy skin

d. salty taste in the mouth

41. Where is the appropriate site of obtaining CSF during Lumbar puncture?

a. Between L1 and L2

b. Between S1 and S2

c. Between L3 and L4

d. Between L4 and L5

42. A prompt intervention and treatment belongs to what level of preventative

health care?

A. Curative

B. Primary

C. Secondary

D. Tertiary

43. The nurse is teaching a diabetic patient how to inject insulin and the dosages
necessary for optimal control. This would be an example of what level of health
care.

A. Curative

B. Primary

C. Secondary

D. Tertiary
44. Which of the following is an example of a primary preventive measure?

a. Participating in a cardiac rehabilitation program

b. Obtaining an annual physical examination

c. Practicing monthly breast self-examination

d. Avoiding overexposure to the sun

45. An employer establishes a physical exercise area in the workplace and

encourages all employees to use it. This is an example of which level of health
promotion?

a. Primary prevention

b. Secondary prevention

c. Tertiary prevention

d. Passive prevention

46. The nurse has organized an immunization clinic for healthy babies and
preschool children. This would be an example of what level of preventative health
care?

A. Curative

B. Primary

C. Secondary

D. Tertiary
47. Nurse Mian is assessing a client. Which data is considered a primary source?

a. The client’s husband tells Nurse Mian that the Client seems upset.

b. The client reports stomach ache.

c. The physician describes the client as overanxious

d. The lab report shows an elevated white blood cell count

48. Nurse Daclis  is going to use a theory from another discipline. Which of the
following would the nurse select?

a. Self-care deficit theory

b. Science of unitary human beings

c. Theory of human caring

d. Theory of human development.

49. Which statement made by the client indicates an internal locus of control?

a. “I have found that when I eat a high-fiber, low-fat diet my diabetes is easier to
regulate.”

b. “My wife fixes all my meals. You’ll have to talk to her about that diet you want me
to be on.”

c. “I can’t exercise the way the doctor told me to because I don’t make enough
money to join a health club.”

d. “My mother and my father both had heart disease. I guess I can expect it, too.”
50.  The physician orders nasogastric tube insertion to irrigate a client’s stomach.
Which of the following insertion techniques would most likely make it more difficult
for the nurse to insert the tube?

a. Lubricating the tube with water-soluble lubricant

b. Asking the client to swallow while the tube is advanced to the stomach

c. Sitting the client upright in a Fowler’s position

d. Having the client tilt the head toward the chest while inserting the tube into the
nose.

51.  Which of the following techniques is considered the best way to determine
whether a nasogastric tube is positioned in the stomach?

a. Aspirating with a syringe and checking pH of gastric contents

b. Irrigating with normal saline and observing for the return of the solution

c. Placing the tube’s free end in water and observing for air bubbles

d. Instilling air and auscultating over the epigastric area for the presence of the tube

52. The term gavage indicates:

a. Administration of a liquid feeding into the stomach

b. Visual examination of the stomach

c. Irrigation of the stomach with a solution

d. A surgical opening through the abdomen to the stomach

53. Organize these steps in chronological order for client who is having a
nasogastric tube removed.

a. When confirming tube placement, place the tube’s end in a container of water.

b. Use a tongue blade and penlight to examine mouth and throat for signs of a coiled
section of tubing.

c. Stop advancing tube when tape mark reaches the client’s nostril.

d. Inject 10cc of air into tube. At same time, auscultate for air sounds with
stethoscope placed over the epigastric region.

54. The health care provider order reads "aspirate nasogastric feeding (NG) tubes
every 4 hours and check pH of aspirate." The pH of the aspirate is 10. Which action
should the nurse take?

a. Apply intermittent suction to the feeding tube

b. Hold the tube feeding and notify the provider

c. Administer the tube feeding as scheduled

d. Irrigate the tube with diet cola soda

55. Three days after admission for a cerebral vascular accident, a client has a
nasogastric tube inserted and is receiving intermittent feedings.  To best evaluate if
a prior feeding has been absorbed the nurse should:

a. Evaluate the intake in relation to the output

b. Aspirate for a residual volume and re-instill it

c. Instill air into the stomach while auscultating

d. Compare the client’s body weight to the baseline data

56. What position will the nurse recommend to the patient during NGT insertion?

a. Semi-Fowler’s Position

b. Trendelenberg

c. High Fowler’s position

d. Left sims lateral

57. After nasogastric tubes have been inserted, the nurse can most accurately
determine in the tube is in the proper place if which of the following can be
demonstrated?

a. The client is no longer gagging or coughing

b. The pH of the aspirated fluid is measured

c. Thirty mm of normal saline can be injected without difficulty

d. A “whooshing” sound is auscultated when 10 mL o air is inserted.

58. Which of the following best exhibit placement of the NGT tube?

a. Gastric secretions ph of 6

b. Gurgling sound at epigastric region

c. X-ray result: tube dislodge at the Right lobe of the lung

d. Bloody gastric secretions

59. The nurse is to administer several medications to the client via nasogastric
tube. The nurse’s first action is to:

a. Add the medication to the tube feeding being given

b. Crash all tablets and capsules before administration

c. Administer all of the medications mixed together

d. Check for placement of the nasogastric tube

60. A nursing student is learning the application of the nursing process to client
care. When questioned by the student about the reason for implementing a nursing
diagnosis, the nursing professor responds: “The nursing diagnosis statement:

a. “Helps other health care professionals understand the plan of care.”

b. “Describes client problems that nurses are licensed to treat.”

c. “Includes the disease the client has during the treatment of care.”

d. “Helps standardize care for all clients.”

61. The client is a tailor who was admitted for eye surgery. Assuming that all of the
following are realistic, a long-term goal for this client should include:

a. Returning to sewing

b. Preventing ocular infection

c. Performing independent hygienic care in hospital

d. Administering eye drops on time in the hospital

62. Which of the following statements regarding the nursing process is true?

A. It's useful mainly in outpatient settings

B. It focuses on the patient, not the nurse

C. It progresses in separate, unrelated steps.

D. It provides the solution to all patient health problems

63. Which statement reflects appropriate documentation in the medical record of a

hospitalized client?

a. "Small pressure ulcer noted on left leg."

b. "Client seems to be mad at the physician."

c. "Client had a good day."

d. "Client's skin is moist and cool."

64. While documenting on a client’s medical record, the nurse realizes that it is a
legal document and should include all of the following, except:

a. Be time sequenced.

b. Use proper spelling and grammar.

c. Use authorized abbreviations.

d. Be typed.
65. A client who has been hospitalized for a period of time is now being transferred
to a rehabilitation center for more long-term care. As he is preparing to be
discharged, the client asks the nurse if he can take his chart with them, since it’s
his record. The nurse responds correctly by saying:

a. “There’s a new law that protects your records, so you’re not going to be able to
have access to them.”

b. “We’ll make sure that all of your records are sent ahead to the rehab hospital, so
you don’t really have to worry about those details.”

c. “You’ll have to ask your doctor for permission to do that.”

d. “Actually, the original record is the property of the hospital, but you are welcome to
copies of your records.”

66. The nurse makes a mistake when charting on the client’s record. To correct this
mistake the nurse should:

a. White-out the mistake and make the correct entry.

b. Blot out the error with ink and make the correct entry.

c. Draw a line through the error, sign, and date the correction.

d. Leave the error intact and chart the correction immediately following the error
67. After classroom discussion regarding confidentiality policies and laws
protecting client records, a student asks why it’s OK for them to review and have
access to client records in the clinical area. The nurse educator responds correctly
by stating that:

a. “Confidentiality and privacy laws don’t apply to students.”

b. “Records are used in educational settings and for learning purposes, but the
student is bound to hold all information in strict confidence.”

c. “Most students review so many records and charts that they could not possibly
remember details from any one of them.”

d. “As long as the clinical instructor is in the area, accessing client records is part of
the education process.”

68. A student nurse is reviewing an assigned client’s chart. When trying to locate
recent lab results, the student notices that each department has a separate section
in the chart. This type of documentation system is called which of the following?

a. Case management

b. Source-oriented record

c. Focus charting

d. Problem-oriented record
69. During nasogastric tube feedings, the nurse is safely able to administer:

a. Antibiotics

b. Syrup-based medications

c. Enteric-coated tablets

d. Liquid vitamin preparation

70. Mr. Ots Daclis. is a 26-year-old recently diagnosed with ulcerative colitis.  The
nurse has been giving dietary instructions to Mr. D. to help prevent exacerbation of
his inflammatory bowel disease.  Which dietary choice indicates that Mr. D.
understands the dietary instructions?

A. apple

B. celery

C. refined cereals

D. hard cheeses

71. The physician orders nasogastric tube insertion to irrigate a client’s stomach.
Which of the following insertion techniques would most likely make it more difficult
for the nurse to insert the tube?

a. Lubricating the tube with water-soluble lubricant

b. Asking the client to swallow while the tube is advanced to the stomach

c. Sitting the client upright in a Fowler’s position

d. Having the client tilt the head toward the chest while inserting the tube into the
nose.
72.  Organize these steps in chronological order for client who is having a
nasogastric tube removed.

1. Assist client into semi-fowler’s position.

2. Ask client to hold her breath.

3. Assess bowel function by auscultation of peristalsis

4. Flush tube with 10ml of NSS

5. Withdraw the tube gently and steadily

6. Monitor client for nausea and vomiting

a. 314625

b. 314526

c. 314256

d. 315426

73. The health care provider order reads "aspirate nasogastric feeding (NG) tubes
every 4 hours and check pH of aspirate." The pH of the aspirate is 10. Which action
should the nurse take?

a. Apply intermittent suction to the feeding tube

b. Hold the tube feeding and notify the provider

c. Administer the tube feeding as scheduled

d. Irrigate the tube with diet cola soda

74. Which of the following if done by a nurse indicates deviation from the
standards of NGT feeding?

A. Do not give the feeding and notify the doctor of residual of the last feeding is
greater than or equal to 50 ml

B. Height of the feeding should be 12 inches about the tube point of insertion to
allow slow introduction of feeding

C. Ask the client to position in supine position immediately after feeding to prevent
dumping syndrome

D. Clamp the NGT before all of the water is instilled to prevent air entry in the
stomach

75. What is the most common problem in TUBE FEEDING?

A. Diarrhea

B. Infection

C. Hyperglycemia

D. Vomiting

76. These are data that are monitored by using graphic charts or graphs that
indicated the progression or fluctuation of client’s Temperature and Blood
pressure.

A. Progress notes

B. Kardex

C. Flow chart

D. Flow sheet
77. Provides a concise method of organizing and recording data about the client. It
is a series of flip cards kept in portable file used in change of shift reports.

A. Kardex

B. Progress Notes

C. SOAPIE

D. Change of shift report

78. The client has an allergy to Iodine-based dye. Where should you put this vital
information in the client’s chart?

A. In the first page of the client’s chart

B. At the last page of the client’s chart

C. At the front metal plate of the chart

D. In the Kardex

79. Which of the following is NOT TRUE about the Kardex

A. It provides readily available information

B. It is a tool of end of shift reports

C. The primary basis of endorsement

D. Where Allergies information are written

80. Which of the following procedures always requires surgical asepsis?

A. Vaginal instillation of conjugated estrogen

B. Urinary catheterization

C. Nasogastric tube insertion

D. Colostomy irrigation

81. Which of the following devices prevents the external rotation of the leg?

a. Sandbags

b. Firm mattress

c. Pillow

d. High foot board

82. To prevent plantar flexion and keep the feet in dorsiflexion, the nurse will use:

a. Hard leather shoes

b. Foot board

c. Boots

d. Bed board
83. The single most important device depending on the need to support or elevate
the back, arms, legs, heels, sacrum or any part of the body of the client needing
support and elevation is:

a. Trapeze bar

b. Mattress

c. Pillow

d. Bed boards

84. The nurse knows that the cane should be at least how many inches at the top
and side of the foot?

a. 4 inches

b. 6 inches

c. 10 inches

d. 12 inches
85. A client was sent home with a prescription of Mineral Oil as Laxative. Mineral
oil as Laxatives will include which health instructions

1) Swallow

2) Do not take with meals

3) Take with meals

4) Action is expected in 2 to 4 hours

a. All except 2

b. 1,3, and 4

c. 1,2,and 4

d. 1 and 2 only

86. The decrease of absorption of certain vitamins is affected when taking mineral
oil. Which of the following is affected?

1) A

2) B

3) C

4) D

5) E

a. 1,2,3,4,5

b. 1,4 and 5

c. 2 and 3

d. 1,4 and 3
87. The nurse successfully moved the client from bed to the wheelchair. After
unlocking the breaks of the chair and lowering the foot plates. The nurse can now
move the wheelchair freely. Upon entering the elevator, the nurse should remember
that:

a. The small Patient leaves the wheelchair before entering the elevator

b. wheels should enter the elevator first

c. Rear large wheels enter the elevator first

d. Patient will enter the elevator first

88. When climbing an incline the nurse should remember:

a. The nurse should be at the bottom of the incline pushing the client small wheel
first

b. Rear large wheel first against an incline

c. The nurse should be above the incline and the client below the incline

d. The nurse should pull the client instead of pushing against the incline

89. When teaching a client with long leg cast how to use the crutches properly
when descending down the stairs. The nurse should tell the client to:

a. Advances both legs first

b. Advance the affected leg first

c. Advance the unaffected leg first

d. Advance both crutches

90. When teaching a client with hemiparesis to ambulate with a cane, the nurse
should instruct the client to:

a. Shorten the stride of the unaffected extremity

b. Lean the body toward the cane when ambulating

c. Advance the cane and the affected extremity simultaneously

d. Hold it in hand on the same side as the affected lower extremity

91. The physician incharge made an order to monitor for signs of insensible fluid
loss. The nurse is correct if she mentioned that insensible fluid loss occurs on:

a. Fecal elimination

b. Perspiration

c. Diaphoresis

d. Micturation

92. The nurse is to insert an NG Tube when suddenly, she accidentally dip the end
of the tube in the client’s glass containing distilled drinking water which is definitely
not sterile. As a nurse, what should you do?

A. Don’t mind the incident, continue to insert the NG Tube

B. Obtain a new NG Tube for the client

C. Disinfect the NG Tube before reinserting it again

D. Ask your senior nurse what to do

93. A nurse must perform a catheterization on a male client. Which of the zones of
proximity would be most appropriate? 

a. Personal distance

b. Public distance

c. Intimate distance

d. Social distance

94. The patient is diagnosed with anemia. Which vitamin is needed for
supplementation?

A. Vit. C

B. Ferrous Sulfate

C. Vit. D

D. Magnesium

95. The nurse knows that the cane should be at least how many inches at the top
and side of the foot?

A. 4 inches

B. 6 inches

C. 10 inches

D. 12 inches
96. Nurse Dave reviewed the document of the patient. Upon checking, he noticed
that the amount of fluid left in the bottle was not charted by the outgoing nurse.
Which of the following should he do?

a. Call the attention of the ongoing nurse

b. Leave it as is

c. Calculate the amount of IV fluid that should be left in the bottle

d. Reconstruct the charting

97. The Physician ordered Garamycin 1 gm IV ANST, then 500mg IV q6h. Nurse
Dave noted that the initial dose was given at 8 AM. In the medication card, which
was endorsed to him by another nurse, the next dose will be given at 8 PM. Which
of the following should be done first?

a. Adjust the time of the succeeding dose based on the prescription

b. Verify the order with the patient assessment

c. Question the data in the medication card

d. Consult the physician who ordered

98. The physician incharge made an order to monitor for signs of insensible fluid
loss. The nurse is correct if she mentioned that insensible fluid loss occurs on:

a. Fecal elimination

b. Perspiration

c. Diaphoresis

d. Micturation
 99. The nurse uses a stethoscope to auscultate a client’s chest. Which statement
about a stethoscope with a bell and diaphragm is true?

a. The bell detects high-pitched sounds best.

b. The diaphragm detects high-pitched sounds best

c. The bell detects thrills best

d. The diaphragm detects low-pitched sounds best

100. Following surgery, Mrs. Millado developed abdominal distention. The

physician ordered a rectal tube insertion to relieve distention. To achieve maximum
effectiveness, how long should be rectal tube be left in place?

A. 5 minutes

B. 15 minutes

C. 30 minutes

D. 60 minutes

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