Ucu - BSN

TOPRANK DIAGNOSTIC EXAMINATION: NURSING PRACTICE 2
1. There is a common principle among the different morning. Nurse Chloe is aware that in order to prevent
theories of health, wellness and illness. This principle is headache after the procedure, she should instruct the
best stated in which of the following? client to remain flat in bed for 6 hours and she will: *
A. Being able to meet the demands of one’s role is A. Dim the light in his room
necessary for health B. Force fluid
B. Many variables influence a perception of C. Offer analgesic medication
one’s health D. Turn him every two hours from side to side
C. People are able to control factors that affect
health 8. The priority intervention of the nurse for a client who
D. Health is is synonymous with a sense of well had a cerebral angiogram is to encourage the client to:
being A. Ask for assistance with ambulation
B. Drink fluid
2. A nurse is to obtain the client's health history. In C. Offer analgesic medication
order to gather reliable data, the most suitable source D. Turn, cough, and breathe deeply
would be:
A. Patient himself 9. A nurse is observing the newly hired nurse in
B. Relatives of the patient preparing the client for an electroencephalogram (EEG).
C. Doctor Which among the following when done by the newly
D. Medical record of the patient hired nurse would require intervention from the
observing nurse?
A. The client is given a mild sedative the
3. In order to accurately assess the client's gag reflex, the
evening prior to the procedure
nurse should utilize which of the following measures?
B. The client’s intake of coffee and alcohol is
A. instill several drops of water in the patient’s
restricted for 48 hours prior to the procedure
tongue
C. The client is told that the procedure is painless
B. stroke the neck of the patient
D. The nurse washes and dries the client’s hair
C. pull the tongue of the patient
prior to the procedure
D. insert a padded tongue depressor at the back
of the patient’s throat
10. A client arrived at the emergency department
complaining of chest pain. The physician suspects
4. A nurse is caring for a client with myocardial
impending myocardial infarction therefore ordered for an
infarction and is scheduled to have cardiac
ECG which revealed a result within normal limits. After
catheterization to determine the extent of the client's
10 hours since the client was admitted, another ECG
infarction. Prior to the procedure, the nurse should: *
was drawn and result shows an anterior wall infarction.
A. increase the patient’s fluid intake
The client asks the physician the reason for the change
B. inform the patient that flushing during the
in ECG result, the physician explained that the initial
procedure is not expected
ECG result is negative because:
C. give laxatives as ordered
A. An ECG cannot predict an MI
D. ask the patient for allergy to dye
B. The ECG machine was malfunctioning
C. The ECG should not have been performed
5. Which among the following is the priority nursing
D. An ECG can give positive reports when no
intervention for a client who had undergone intravenous
cardiac changes have occurred
pyelography (IVP)?
A. Increase fluid intake
B. Place patient in semi-fowler’s position 11. Creatinine phosphokinase (CPK) levels can help
C. NPO 4 hours after procedure determine:
D. Ambulate as soon as possible A. Tissue damage in an MI
B. The existence of progressive muscular dystrophy
6. A nurse is conducting teaching to a client who is C. The existence of dermatomyositis
scheduled to have an upper GI x-ray. The nurse can be D. All of the above
assured that the client understood the teaching
regarding the procedure when the client made which of
the following statements? 12. All of the following statements are not true about
A. A flexible tube will be inserted into the stomach. CPK isoenzymes except:
B. Dye will be infused into my vein before the test. A. CPK isoenzymes levels are determined by
C. My body will be placed within an imaging electrophoresis, which separates and
chamber. measures the percentage of each of the three
D. I will have to swallow a large volume of isoenzymes in the total serum CPK level
barium. B. CPK isoenzyme levels are measured to
differentiate between bone and muscle disorders
7. A client diagnosed with herniated nucleus polposus
(HPN) is scheduled to have a myelogram the following
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UCU – BSN
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C. CPK isoenzymes blood specimens are sent to the 18. When making an occupied bed, it is important for
laboratory wrapped in gauze to ensure their the nurse to:
warmth A. Complete one side of the bed before completing
D. CPK isoenzyme levels can be tested accurately the other side
only if the patient abstains from food and fluids B. Position the call bell within reach
beforehand C. Place a pull shet on top of the draw sheet
D. Ensure that the bottom sheet is free of
13. Which among the following instructions should the wrinkles
nurse provide to a client who is scheduled to have an
respiratory lab exam using a Spirometer? 19. A nurse is to provide an oral care to an unconscious
A. Inhale and forcibly exhale client. It is best for the nurse to place the client in which
B. Breathe into the pipe while the manometer position?
measures your respiration A. High-Fowler’s position
C. Inhale and exhale to measure the vital capacity B. Side-lying with head lowered
of the lung C. Fowler’s position with head turned
D. Blow as hard as you can to determine if assisted D. Supine position with head elevated
ventilation is needed.
20. Injuries among nurses commonly sustained during
14. After stabilizing the vital sign of a client admitted transfer are due to which of the following factors?
with head injury, the physician order for a CT scan. Prior A. Misalign their backs when moving patients
to the test, it is important for the nurse to make the B. Pull rather than push when turning patients
client understand that a CT scan: C. Place their feet wide apart when transferring
A. Involves injection of radiopaque contrast patients
medium into an artery, which causes a burning D. Use the longer rather than the shorter muscles
sensation when moving patients
B. Is a measure of electrical energy flowing from the
brain 21. Which of the following positions should the nurse
C. Lasts only a few minutes, but he will have to assist the client to assume after an insertion of a Miller-
remain flat for 12 hours after the test. Abbott tube?
D. Requires him to lie very still during the A. On the right side
examination. B. On the left side
C. Prone
15. A nurse is caring for a client who had a lumbar D. Left lateral Sim’s
puncture test. Immediately after the procedure, the
nurse should place the client in which position? 22. Which among the following position is the most
A. Side-lying, with legs pulled up and head bent appropriate for a client who is to have a thoracentesis?
down onto chest A. Lying in bed on the affected side.
B. Side-lying, with pillow under the hip B. Lying in bed on the unaffected side.
C. Prone, in slight Trendelenburg’s position C. Prone with the head turned to the side and
D. Prone, with a pillow under the abdomen supported by a pillow.
D. Sim’s position with the head of the bed flat.
16. Which among the following is the most appropriate
action of the nurse when the client's midline incision 23. Which among the following should the nurse do
opened causing a gaping wound? when a client with hypovolemic shock with CVP catheter
A. Notify the physician in place has an initial CVP reading of 16cm H2O?
B. Cover the wound with sterile, moist dressings A. decrease IV flow rate
C. Transfer the patient back to surgery B. immediately turn the patient to the left side
D. Apply steristrips to close the incision C. increase the patient’s IV flow rate
D. elevate the patient’s extremities
17. Nurse Jed is providing a bed bath to a client. He
understands that the most important nursing action 24. A nurse is reading a physician’s progress notes in the
would be: client’s record and reads that the physician has
A. Lower the side rails on the working side of the documented “insensible fluid loss of approximately 800
bed ml daily.” The nurse understands that this type of fluid
B. Ensure that the bath water is at least 110 loss can occur through
degrees Farenheit A. The gastrointestinal tract.
C. Fold the washcloth like a mitt on the hand B. Urinary output
D. Raise the bed to the highest position C. Wound drainage
D. The skin
UCU – BSN
25. Nurse Ava is assigned to care for the following D5W: 0.5 liter normal saline: 1500 ml D5 NS. In
clients. Before going to her assigned clients, Nurse Ava addition, an antibiotic piggyback in 50 ml D5W is
reviews their charts and noted that one of the clients is ordered every 8 hours. Nurse Zoe calculates that the
at risk for fluid volume deficit. This client would be: client’s UV fluid intake for hours will be:
A. A client with colostomy A. 3150 ml
B. A client with receiving frequent wound B. 3200 ml
irrigations C. 3650 ml
C. A client with congestive heart failure D. 3750 ml
D. A client with decreased kidney function
32. Which among the following assessment findings
26. A nurse is suspecting that the client who is taking indicates that the fluid replacement therapy has been
diuretics for a long period of time developed fluid volume successful?
deficit as supported by which of the following A. Urinary output of 30 ml an hour
assessment findings? B. Control venous pressure reading is 2 cm H2O
A. Rales C. Pulse rate of 120 and 110 in a 15 –minute
B. Increased blood pressure period
C. Decreased hematocrit D. Blood pressure reading 50/30 and 70/40 mmHg
D. Decreased central venous pressure (CVP) within 30 minutes
27. A nurse is assigned to care for a group of clients. On 33. A student nurse is assisting in a NSVD with epidural
review of the clients’ medical records, the nurse anesthesia. The student nurse understands that
determines that which client is at risk for a fluid volume epidural anesthesia is considered as which type of
excess? anesthesia?
A. The client with renal failure A. Intrathecal
B. The client with an ileostomy B. Local
C. The client taking diuretics C. Regional
D. The client who requires gastrointestinal D. General
suctioning
34. In which of the following positions should the nurse
28. A client who has been diagnosed with congestive place the client who had a supratentorial craniotomy? *
heart failure arrived at the emergency department A. Prone
appearing dyspneic and upon assessment the nurse B. Supine
noted rales upon auscultation. Based on the assessment C. Semi- fowler
findings, the nurse suspect that the client has fluid D. Side-lying
volume excess. This can be supported by which of the
following findings?
35. Belinda is a assessing a client who is experiencing
A. A decreased central venous pressure (CVP)
prolonged stress. For which most serious complication
B. Flat neck and hand veins
should she monitor the patient?
C. An increase in blood pressure
A. Altered sleeping
D. Weight loss
B. Increased muscle tension
C. Decreased intestinal peristalsis
29. The physician orders 2 liters to be administered q
D. Impaired immunity
12h. The drop factor of tubing is 10gtt/ml. The nurse
sets the flow to provide:
36. When assisting in a cardio-pulmonary resuscitation,
A. 18 gtt/min
you know that the two paddle of the defibrillator should
B. 28 gtt/min
be placed in the:
C. 23 gtt/min
A. Below the left clavicle, midclavicular line; the
D. 36 gtt/min
fifth intercostal space, midclavicular line.
B. Left anterior axillary line, second intercostal
30. After surgery a client is to receive an antibiotic by IV space, sternal border, right second intercostals
piggyback in 50 ml of D5W. The piggyback is to infused space
in 20 minutes. The drop factor of IV set is 10 gtt/ml. The C. Right of the upper sterum, below clavicle;
nurse should set the piggyback to flow at: midaxillary line, fifth left intercostal space
A. 25 gtt/ml D. Right sternal border, fifth left intercostal space;
B. 30 gtt/ml left of the cardiac apex, anterior axillary line
C. 35 gtt/ml
D. 45 gtt/ml 37. When formulating the plan of care of a client with
deep thrombophlebitis, the nurse should include which
31. Another client who just has surgery is to receive the of the following activities?
following intravenous fluids over 24 hours. 1000 ml
UCU – BSN
A. Bed rest with the affected extremity in a B. Infuse the blood using filter tubing
dependent position. C. Add 10 ml normal saline to the bag.
B. Out-of-bed activities as desired. D. Agitate the bag to mix contents gently.
C. Bed rest with the affected extremity kept flat.
D. Bed rest with elevation of the affected 44. A client is to have a blood transfusion. Prior to
extremity administration of the blood product, the nurse should
first prepare which of the following intravenous solution?
38. A nurse is reviewing the client's laboratory results A. D5 .9%NaCl
and noted that the client's hemoglobin level is 14g/dl. B. PLR
The nurse understands that the client: C. D5LR
A. Has a normal level D. D10W
B. Requires iron supplement
C. Requires blood transfusion
45. A nurse has just hung a 250 ml bag of packed red
D. Has hypoxia
blood cells (PRBCs) for a client. The nurse remains with
the client for how many minutes following the start of
39. An elevated hemoglobin level can be observed among the infusion?
clients with: * A. 5 minutes
A. Dehydration B. 15 minutes
B. Kidney disease C. 30 minutes
C. Hemorrhage D. 60 minutes
D. Anemia
46. A nurse is assessing a client who has an ongoing
40. A client has an order for a blood transfusion. The
blood transfusion. The nurse understands that the early
nurse caring for the client knows that before the
signs of transfusion reaction are: *
transfusion, it is important for the nurse to draw which
A. Headache, chills, fever
of the following laboratory test?
B. Difficulty of breathing
A. Prothrombin and coagulation time
C. Lactated Ringer’s
B. Blood typing and cross typing
D. Pulse oximetry reading of below 50%
C. Bleeding and clotting time
D. Complete blood count (CBC) and electrolyte
levels 47. A client who has an ongoing blood transfusion
suddenly complains of a sweaty, warm feeling and a
backache. The nurse conducted an assessment and
41. All of the following is not true about blood typing and
learned that the client's skin is flushed. The nurse
cross matching except:
suspects that the client is having a blood transfusion
A. Eating and drinking before blood withdrawal will
reaction, she immediately stops the blood transfusion
affect the test results
and then:
B. A person with type O blood is a universal
A. Removes the intravenous line.
recipient
B. Changes the continuous IV to an intermittent
C. A person with type AB blood is a universal
needled device.
recipient
C. Hangs an IV bag of 5% dextrose in water
D. A signed informed consent is needed before
D. Hangs an IV bag of normal saline and infuses
blood withdrawal
it at a keep – vein – open rate.
42. The physician ordered for one unit of packed red

48. A nurse is monitoring a client who is receiving a
blood cell to be administered to a postoperative client
blood transfusion. The client begins to complain of a
who has a low level of hemoglobin. Prior to the
sweaty and warm feeling and a backache. The nurse
transfusion, the physician ordered for administration of
notes that the client’s skin is flushed and suspects that
Diphenhydramine (Benadryl). The nurse is aware that
the client is having a transfusion reaction. The nurse
the medication is prescribed to:
immediately stops the blood transfusion, hangs an
A. Prevent an urticaria reaction
intravenous bag of normal saline, and infuses it at a
B. Prevent a fever
keep – vein – open rate, then:
C. Assist in the absorption of the blood product
A. Monitors the client closely for the next hour
D. Promote movement of the RBCs into the bone
B. Administers PRN diphenhydramine (Benadryl),
marrow
which was previously prescribed for the client to
treat pruritus caused by eczema.
43. After receiving the unit of blood from the blood bank, C. Inserts a foley catheter into the client
the nurse checks the blood product and noticed the D. Contacts the physician
presence of gas bubble in the bag. Considering this
finding, the nurse is expected to:
A. Return the bag to the blood bank.
UCU – BSN
49. A client wishes to donate blood for a family member around her lips. These complaints of Cassandra can be
and asks the nurse about the procedure for identifying associated with: *
compatibility. The nurse tells the client that which test A. Eupnea
will be done to test compatibility? B. Hyperventilation
A. Eosinophil count C. Respiratory alkalosis
B. Monocyte count D. Carbon dioxide intoxication
C. Indirect Coomb’s
D. Red blood cell count 56. The emergency department nurse should focus on
reassuring Cassandra and: *
50. A nurse caring for a client with ascites understands A. Administering oxygen
that the best method to promote lung expansion is to: B. Using an incentive spirometer
A. Put binder around the abdomen C. Having a client breathe into a paper bag
B. Put patient in semi Fowlers D. Administering an IV containing bicarbonate ions
C. Let patient do pursed lip exercise
D. Splint the thoracic cavity of the patient 57. The arterial blood gas drawn from Cassandra
revealed the a Po2 of 89mmHg, a PCO2 of 35mmHg and
51. Nurse Phoebe is caring for a client diagnosed with a pH of 7.37. Based on these values, the nurse can
chronic obstructive pulmonary disease and acute conclude that the Cassandra is experiencing:
bronchitis. Upon entering the client room, the nurse A. Fluid balance
found the client appearing anxious and dyspneic while B. Oxygen depletion
sitting up in bed. The most appropriate action of the C. Metabolic acidosis
nurse would be: D. Acid – base balance
A. Provide oxygen at 2 L per minute
B. Administer the prescribed sedative 58. The nurse encouraged Cassandra to turn from side
C. Have the client breathe into a paper bag to side and do deep breathing exercises to prevent the
D. Encourage the client to cough and breath development of which of the following acid-base
imbalances?
52. A nurse is assisting a client with Chronic A. Metabolic acidosis
Obstructive Pulmonary Disease in performing pursed-lip B. Metabolic alkalosis
breathing. The nurse should remind the client that the C. Respiratory acidosis
appropriate way of doing it is by: D. Respiratory alkalosi
A. Changing positions during exercise
B. Maintain a supine position during exercise 59. Which among the following Arterial blood gas values
C. Exhaling twice longer than inhaling indicates that Cassandra is experiencing respiratory
D. Inhaling and exhaling through the pursed alkalosis?
mouth A. An elevated pH, elevated PCO2
B. A decreased pH, elevated PCO2
53. A nurse caring for Marco should encourage him to do C. An elevated pH, decreased PCO2
which of the following measures to prevent narrowing of D. A decrease pH, decreased PCO2
respiratory passages and decreased volume of exchanged 60. A nurse has assisted a physician with the insertion
gases? of a chest tube. The nurse monitors the client and notes
A. Encourage the patient to cough fluctuation of the fluid level in the water seal chamber
B. Encourage adequate fluid after the tube is inserted. Based on this assessment,
C. Encourage to exercise which of the following actions would be most
D. Encourage adequate nutrition appropriate?
A. Inform the physician
B. Encourage the client to deep breathe.
54. Marco is instructed to use an incentive spirometer.
C. Continue to monitor, for this is an expected
Which among the following assessment findings should
finding.
the nurse expect to elicit from Marco as an associated
D. Reinforce the occlusive dressing.
outcome of the use of the incentive spirometer?
A. Coughing will be stimulated
61. A nurse is caring for a client with a chest tube. The
B. Inspiratory volume is increased
nurse turns the client to the side, and the chest tube
C. Sputum is expectorated
accidentally disconnects. The initial nursing action is to:
D. Reduce supplemental oxygen use
A. Call the physician
B. Place the tube in a bottle of sterile water.
55. Cassandra, a 28 year old client arrived at the C. Immediately replace the chest tube system.
emergency room appearing anxious with rapid and D. Place a sterile dressing over the disconnection
shallow respirations with respiratory rate of 40 site.
breath/minute. She is complaining of feeling dizzy,
lightheaded and tingling sensation on her fingertips and
UCU – BSN
62. While assisting the physician in the removal of the
chest tube of a client, the nurse should instruct the 68. A staff nurse is observing the nurse orientee while
client to: gathering the supplies she will need for a nasogastric
A. Stay very still. tube insertion. Which among the following supplies
B. Inhale and exhale quickly. when obtained by the nurse orientee would require
C. Exhale slowly. intervention from the staff nurse?
D. Perform a Valsalva’s maneuver. A. Half-inch or one-inch tape
B. Oil-soluble lubricant
63. While changing the tapes of the tracheostomy tube of C. A glass of tap water with a straw
a client, the client suddenly coughs causing the tube to D. A 50-ml catheter tip syringe
be dislodged. The nurse most appropriate initial action
would be: 69. A nurse caring for a client with nasogastric tube in
A. Cover the tracheostomy site with a sterile place for decompression should prioritize which of the
dressing to prevent infection. following nursing action?
B. Call the physician to reinsert the tube. A. Positioning the patient in semi Fowler’s
C. Grasp the retention sutures to spread the position
opening. B. Discontinuing suction when giving care to the
D. Call the respiratory therapy department to patient
reinsert the tracheostomy. C. Instilling the tube with 30 ml of air every 2
hours for patency
64. Nurse John is conducting an assessment to a client D. Providing care to the nares at least every 8 hours
who had a endotracheal tube removal following a radical
neck dissection. Which assessment finding when 70. Nurse Cassidy is caring for a client with a Levine-
observed by Nurse John would require prompt referral? * type nasogastric tube in place. Prior to administering the
A. Stridor prescribed bolus feeding, Nurse Cassidy should assist
B. Occasional pink-tinged sputum the client in which position?
C. Respiratory rate of 24 breaths per minute. A. Supine
D. A few basilar crackles on the right. B. Semi – fowlers
C. Trendelenburg’s
65. A nurse caring for a client diagnosed with diabetes is D. Lateral recumbent
preparing the insulin that she would administer to the
client. After withdrawing the the needle from the vial the 71. The priority intervention of the nurse caring for a
most appropriate action of the nurse would be to: client with intermittent enteral feeding would be:
A. Used immediately to administer the insulin A. Checking intake and output records
B. Recapped to maintain sterility B. Weighing the client
C. Wiped clean to remove excess insulin C. Checking the order for the prescribed solution
D. Kept uncapped to prevent an accident D. Determining tube placement
66. A nurse is to insert a nasogastric tube into the client. 72. Which among the following interventions is
Prior to the insertion, the nurse should place the client applicable to a client who is has a continuous tube
in which position? feeding?
A. High fowler’s A. Check the residual in the stomach every 4
B. Supine with the head flat hours
C. Right side B. Change the feeding bag and tubing every 48
D. Low fowler’s hours.
C. Withhold the feeding if residual is greater than
67. A nurse orientee is determining the appropriate 200 ml
measurement of the nasogastric tube to be inserted to D. Leave at least 25 ml of formula in the feeding
an adult client. Which among the following when bag when adding additional formula to the bag.
observed by the staff nurse indicates that the nurse
orientee is doing the correct process? 73. A nurse is to perform a nasogastric tube removal to a
A. The new orientee places the tube at the tip of client. Before the nurse remove the nasogastric tube, she
the nose and measures by extending the tube should instruct the client to
to the earlobe and then down to the xiphoid A. To perform a Valsalva’s maneuver
process. B. To take and hold a deep breat
B. The new orientee places the tube at the tip of the C. To exhale
nose and measure by extending the tube to the D. To inhale and exhale quickly
earlobe and then down to the top of the
sternum. 74. Which among the following materials should the
C. The new orientee marks the tube at 10 inches. nurse always keep on the bedside of a client with
D. The new orientee marks the tube at 32 inches.
UCU – BSN
Sengstaken-Blakemore tube inserted for esophageal C. Create a sterile field
varices? D. Maintain aseptic technique
A. An irrigation set
B. A pair of scissors 80. A client who had a transurethral resection of the
C. A Kelly clamp prostate had continuous bladder irrigation. During the
D. An obturator initial assessment of the nurse immediately after the
client has been transferred to the ward, the nurse
75. When administering a cleansing enema to a client noticed that the catheter drainage tubing is full of thick,
with fecal impaction the nurse should position the client bright red clots and tissue shreds. The most suitable
in which position? action of the nurse would be:
A. On the left side of the body, with the head of the A. Clamp the drainage tube and take the client’s
bed elevated 45 degrees. pulse and blood pressure
B. On the right side of the body, with the head of B. Irrigate the catheter until clear and increase the
the bed elevated 45 degrees. flow rate of the intravenous infusion
C. Left Sim’s position C. Irrigate the catheter until clear and take the
D. Right Sim’s position client’s vital signs
D. Clamp the drainage tube and notify the
76. A nurse is inserting an indwelling urinary catheter physician of the bleeding
into a male client. As the catheter is inserted into the
urethra, urine begins to flow into the tubing. At this 81. A nurse is to administer a pill medication to a client.
point, the nurse When the nurse brought the medication, she noted that
A. Immediately inflates the balloon. the client cannot hold the paper cup that contains the
B. Withdraws the catheter about 1 inch and inflates medication. the most appropriate action of the nurse
the balloon. would be:
C. Inserts thecatheter until resistance is met and A. Crush the pill and mix it with orange juice
inflates the balloon. B. Have the doctor order a liquid form of the drug
D. Inserts the catheter 2.5 to 5 cm and inflates C. Place the pill in the patient’s hand and have him
the balloon. self administer the drug
D. Use the paper cup to introduced the pill into
77. A male client has an order for an indwelling urinary the patient’s mouth
catheter insertion. The nurse collects the necessary
supplies and starts the catheter insertion. When the 82. Prior to administration of a bolus dose of a
nurse inflates the balloon, the client suddenly complains medication via a currently running intravenous solution,
of discomfort. The nurse next action is to: the nurse should initially:
A. Remove the syringe from the balloon;discomfort A. Pinch the tubing above the infusion port while
is normal and temporary. instilling the bolus
B. Aspirate the fluid, advance the catheter B. Instill it in a fifty ml bag of NSS and infuse it via
farther, and reinflate the balloon. a secondary line
C. Aspirate the fluid, withdraw the catheter C. Ensure that the medication is compatible
slightly,and reinflate the balloon. with the IV solution use
D. Aspirate the fluid, remove the catheter and D. Administer it via a volume controlled infusion set
insert a new catheter. with microdrip tubing
83. Which among the following nursing actions should

78. A nurse caring for a client admitted with head injury
the nurse take when she found a radium needle among
noticed that the client's foley catheter is draining copious
the linen while straightening the client's bed?
amount of diluted urine. When the nurse checked the
A. Remove the radium needle with rubber-gloved
client's chart, she noted that the client's urine output in
hands.
the previous shift is 3000ml. considering this
B. Place the radium implant in an emesis basin.
assessment findings, the nurse would anticipate the
C. Notify the Nuclear Medicine Department.
physician to order for:
D. Advise the patient to replace the radium
A. Desmopressin (DDAVP, Stimate).
implant.
B. Dexamethasone (Decadron).
C. Ethacrynic acid (Edecrin).
D. Mannitol (Osmitrol). 84. A nurse caring for a client taking a radioactive
substance should instruct the client's family and
relatives who came for a visit to: *
79. Nurse Aisi is teaching a client about the proper
A. minimize visit for 30 minutes
method of self-catheterization at home. It is important
B. wear gown
for Nurse Aisi to remind the client to:
C. wear gloves
A. Use gloves while performing the procedure
D. wash your hands after the visit
B. Wash hands thoroughly before the procedure
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85. Which among the following site is the most helps them improve their clinical skills. This nurse is
appropriate for infusing an intravenous solution with an functioning in which role?
incorporation of potassium chloride? A. Manager
A. The antecubetal space in the client’s arm B. Autocrat
B. The largest possible vein in the client’s arm C. Leader
C. A vein in the back of client’s dominant hand D. Authority
D. A vein in the back of client’s non- dominant hand
92. The managers of the physical and occupational
86. After administering a tuberculin skin test to a client, therapy neurologic departments have expressed concern
the nurse should instruct the client to return to have it to a nurse- manager of an adult neurologic rehabilitation
assess in: unit that clients have been arriving late for therapy. In
A. 24 hours response, the nursing staff of the rehabilitation unit has
B. Five days complained that therapy schedules don’t allow sufficient
C. 48 to 72 hours time for performing nursing interventions. Which action
D. Seven days by the nurse- manager is the best solution to this
problem?
87. The nurse is to administer a medication to a A. Meet with the managers of physical and
confused client. When the nurse gave the medication to occupational therapy and determine how to
the client, the client states that the medication given to reschedule the clients. The nurse- manager will
him looks different from the medication he is usually inform the staff of the hanges.
given. The most suitable action of the nurse would be B. Tell the nursing staff that they need to determine
A. Ask what the other pill look like how to transport clients to therapy according to
B. Explain the purpose of the medication the schedules developed by the therapists.
C. Check the original medication order C. Meet with the managers of physical and
D. Encourage patient to take the medication occupational therapy and identify several
possible ways to solve the problem.
88. After administering an incorrect medication to a D. Ask the adult neurologic rehabilitation staff for
client, the nurse is obliged to accomplish and submit an input and then make the final decision in
incident report. The main reason for this is to: conjunction with the therapy managers.
A. Record the event for future litigation
B. Prevent similar situation from happening again 93. Which among the following represents the basic
C. Provide basis for new policies principle of the human relations approach to
D. Ensure accountability for the cause of accident management?
A. When things go well for the worker, the
89. A nurse is preparing to administer medication organization profits
through a nasogastric tube that is connected to suction. B. When the patient needs are met, nursing
To administer the medication accurately, the nurse mission are accomplished
would C. Strength, speed and skills are accentuated
A. Aspirate the nasogastric tube after medication D. Decision making is a mediator
administration to maintain patency.
B. Position the client supine to assist in medication 94. Nurse Chloe is working under the jurisdiction of a
absorption. traditional chief nurse. She is aware that she is expected
C. Clamp the nasogastric tube for 30 minutes to:
following administration of the medication. A. Maintain professional attitude
D. Change the suction setting to low intermittent B. Adhere strictly to job description
suction for 30 minutes after medication C. Observe hospital rules and regulation
administration. D. Maintain competence
95. The role of nurses is continuously expanding. The

90. After administering heparin sodium to a client, the
acceptance of this expanded role depends on many
nurse should do which of the following measures to
factors including the following except:
lessen the incidence of edema in the injection site?
A. State regulations
A. Gently massage the injection site after
B. Acceptance by patient
administering heparin.
C. Acceptance from physicians
B. Use the Z-track technique for administering
D. Acceptance of nurses
heparin.
C. Rotate the site for injecting heparin.
96. An expert nurse is summoned in court during a
D. Aspirate for blood before injecting heparin.
lawsuit about professional nursing malpractice to testify:
A. About standards of nursing care as they apply
91. A staff nurse on a busy pediatric unit is an excellent
to the facts in the case
role model for her colleagues. She encourages them to
participate in the unit’s decision- making process and
UCU – BSN
B. With regards to laws governing the practice of
nuring
C. For the prosecution
D. For the defense
97. A situation that results in an injury although the

person did not intend to cause harm is called
A. Negligence
B. False imprisonment
C. Defamation
D. Unintentional tort
98. Which ethical principle does a nurse utilized when

he prioritized the clients assigned under his care for his
shift from the most critical and one needing attention
over the stable conscious clients? *
A. Justice
B. Nonmaleficence
C. Beneficence
D. Fidelity
99. A retrospective study would involve nurse who

suffered from backache
A. Anytime before or after start of study
B. Previous to the study
C. During the period of study
D. No particular period
100. The purpose of the study is to determine the

relationship between lifting techniques of nurses and
backaches. The independent variable will be:
A. Staff nurses
B. Backache
C. Back injury
D. Lifting technique
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TOPRANK DIAGNOSTIC EXAMINATION: NURSING PRACTICE 2

42. The physician ordered for one unit of packed red

83. Which among the following nursing actions should

95. The role of nurses is continuously expanding. The

97. A situation that results in an injury although the

98. Which ethical principle does a nurse utilized when

99. A retrospective study would involve nurse who

100. The purpose of the study is to determine the

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