The following are appropriate nursing interventions to promote normal respiratory function EXCEPT

1. The physician instructed the nurse to collect a specimen from the patient's catheter. In order to collect a fresh specimen, the nurse should initially:

A. Empty the drainage collection bag and collect thereafter in the bag when it is half full
B. Put the drainage collection bag in the freezer
C. Insert a new catheter
D. Clamp the catheter for 30 minutes

D. Clamp the catheter for 30 minutes

7. To ensure accuracy of results, how should the nurse educate the patient in obtaining sputum specimen?

A. Instruct the patient to hack up sputum
B. Eat a well-balanced diet
C. Adequate rest periods
D. CBR

A. Instruct the patient to hack up sputum

9. The doctor ordered a sputum exam for a patient suspected of having TB and thus, AFB staining was given. Until how many days will you collect the specimen?

A. Within 24 hours to make sure that it is fresh
B. With an alcoholic mouthwash the first hour in the morning
C. Within a week so that continuous care must be needed
D. Within 3 days as instructed

D. Within 3 days as instructed

10. Schilling's Test for Pernicious Anemia is taken in what kind of Urine Specimen Collection?

A. Clean Catch Midstream Urine
B. 24 hour urine collection
C. Second voided urine specimen
D. Catheterized urine specimen

B. 24 hour urine collection

12. In the hospital, what should the nurse do to stimulate the appetite of the client who is not eating well?

A. Have the family bring attractive portions of food to provide the client
B. Provide food that the client likes and relieve Sx of illness
C.provide treatments before mealtime so the client doesn't have to think them while eating
D. Provide large meals after the client has been active in increasing his appetite

B. Provide food that the client likes and relieve Sx of illness

13. If the client is unconsious, the ff are appropriate nursing measure when providing oral care EXCEPT:

A. Place the patient in lateral position
B. Use-hard bristled tooth brush
C. Use cotton swabs
D. Irrigate the mouth with water using asepto syringe and suction the solution adequately

B. Use-hard bristled tooth brush

14. For almost 8 hours already, Nurse Jerby notices that the patient was able to pass out loose watery stools every 3 hours. He tried to intervene by letting the patient drink an adequate amount of fluid. He also suggested that the patient should eat:

A. Oatmeal with pineapple toppings in it.
B. Cabbage, mushroom, and onions with oyster sauce
C. Toast bread with banana jam
D. Fresh buko juice mixed with pandan gelatin

C. Toast bread with banana jam

BRAT diet

15. Accurate objective and legible recording is fundamental for safe practice because:

A. The chart reflects medical care given
B. The chart is a means to communicate the progress on the patient's condition
C. The chart is a legal document
D. The chart is acceptable as an evidence in court against the doctor, the nurse, the patient

C. The chart is a legal document

16. A client is to receive a backrub to help relax. The best position for the nurse to assume in this procedure is to:

A. The narrower the base of support and the lower the center of the gravity, the grater the stability of the nurse
B. Stooping with the hips flexed, knees straight, and tuck in good alignment distributes the workload among the largest and strongest muscle groups
C. Facing the opposite direction of the door to prevent abnormal twisting of the spine
D. The nurse bends from the knees when she reaches out the patient's back and feet apart is maintained to promote stability

D. The nurse bends from the knees when she reaches out the patient's back and feet apart is maintained to promote stability

18. To alleviate a client's anxiety during the health history and assessment, the nurse could do which of the following?

A. Play soft music in the background
B. Finish the interview and assessment as soon as possible
C. Use a non-threatening and non-judgmental attitude
D. Explain it is normal to have feelings of panics during this time

C. Use a non-threatening and non-judgmental attitude

19. The nurse would attempt to gather which of the following information while obtaining a health history from a client?

A. Physical, Psychosocial, and Spiritual well-being
B. Reaction to past hospitalizations
C. Type of insurance and financial problems
D. Personal goals related to healthcare

A. Physical, Psychosocial, and Spiritual well-being

It is holistic.

20. The first nursing intervention to implement when a client is having a problem sleeping is to:

A. Check physician order to see if the client has a sleeping pill ordered
B. Provide client with a back rub
C. Determine client's normal bedtime ritual
D. Reduce environmental noise

C. Determine client's normal bedtime ritual

Assess first. ADPIE technique

21. At the conclusion of visiting hours, the mother of 14-year old female scheduled for orthopedic surgery the following day hands the nurse a bottle of capsules and says, "These are for my daughter's allergy. Will you be sure she takes one about 9 tonight?" The nurse's best response would be:

A. One capsule at 9pm? Of course I will give it.
B. Did you ask the doctor if she should have this tonight?
C. I am certain the doctor knows about your daughter's allergy.
D. I will ask your daughter's doctor to write an order so I can give this medication to her.

D. I will ask your daughter's doctor to write an order so I can give this medication to her.

22. To evaluate effectiveness of suctioning, the nurse should:

A. Assess the respiratory rate
B. Check the skin color
C. Auscultate the breath sounds
D. Palpate the pulse rate

C. Auscultate the breath sounds

23. Which of the following method would be most effective for an ambulatory care nurse to use when trying to determine the priority health related learning needs of a client?

A. Carefully review the physician's orders
B. Conduct a thorough nursing assessment
C. Determine the amount of time required to present the information
D. Ask the client what learning needs he or she has about current state of health

D. Ask the client what learning needs he or she has about current state of health

25. In the nursing home, the patient was left alone with no family to be with. Ms. Melena, her nurse, has always been there for her and offers ample time with her everyday to help her discuss and verbalize her problems. At the same time, Ms. Melena objectively knows the procedures that were given as this may aid in promoting the well being of the patient. Therefore, nursing in this situation is best defined as:

A. A caring and loving profession that involves intimate relationship with the patient
B. A stressful job having no personal life at all and focuses to a patient among other patients
C. A very complicated job that needs efficiency and assumptions at all times
D. An artistic way of helping other people with the use of scientific explanations

D. An artistic way of helping other people with the use of scientific explanations

26. Kathy, a high school student, is fond of eating street foods. A week later she complained of abdominal pain, weakness, and a yellowish skin discoloration. Hepatitis is suspected. What further assessments will give Nurse Jacky that Kathy might have Hepatitis?

A. Steatorrhea
B. Acolic stool
C. Hematochezia
D. Meconium

B. Acolic stool

A and B are correct. However, B is more confirmative because steatorrhea may not happen as there are still pancreatic enzymes to digest fats.

28. Three year old Rina asks her mother that she wanted to urinate. Her mother who cannot speak because of a congenital defect during her childhood would still want her child to urinate well. As a nurse, how can you manage the problem?

A. Instruct the mother to let Rina drink a large amount of water
B. Catheter should be inserted to irrigate the urine well
C. Scare and surprise Rina in a play therapy so she might suddenly pass out of urine
D. Bring Rina to the CR and open a faucet in order to produce a sound

D. Bring Rina to the CR and open a faucet in order to produce a sound

29. Which of the following data provides the best assessment of client's activity tolerance?

A. Vital capacity and breath sounds
B. Degree of joint flexibility
C. Muscle strength and incoordination
D. V/S before, during and after the activity

D. V/S before, during and after the activity

30. The nurse aid is not around so Nurse Jake immediately prepares the hospital bed. Nurse Kim wanted to help him by giving the correct way of putting several sheets in the bed starting from:
1. Pillow
2. Rubber sheet
3. Bottom sheet
4. Draw sheet
5. Top sheet
6. Blanket

A. 3, 2, 4, 5, 6, 1
B. 3, 4, 2, 5, 1, 6
C. 3, 2, 5, 4, 1, 6
D. 3, 4, 5, 2, 6, 1

A. 3, 2, 4, 5, 6, 1

Bottom sheet
Rubber sheet
Draw sheet
Top sheet
Blanket
Pillow

31. Upon discharge, the nurse teaches a hemiplegic patient on how to massage the affected area of his body. At home, the patient does petrissage on the paralytic area of his body on his own while he was resting on the couch. This type if exercise is known as:

A. Active Assistive Range of Motion
B. Passive Range of Motion
C. Isotonic Exercise
D. Active ROM

A. Active Assistive Range of Motion

32. The nurse was able to see an old lady almost eating and sleeping everyday beside the road. The old lady wears rugged clothes and eats with what is left in a nearby grocery store. You know as a nurse that this type of client needs:

A. An immediate counseling therapy
B. Basic needs like food, shelter, and clothing
C. Appreciation and encouragement
D. Respect, love and attention

B. Basic needs like food, shelter, and clothing

37. A nurse has given medication instructions to a client who is receiving phenytoin (Dilantin). The nurse evaluates that the client has an adequate understanding if the client states that:

A. The nurse medication dose may be self-adjusted depending on side effects
B. Alcohol is not contraindicated while taking this medication
C. Good oral hygiene is needed including brushing and flossing
D. The morning dose of the medication should be taken before a serum drug level is drawn

C. Good oral hygiene is needed including brushing and flossing

s/e: gingival hylerplasia

39. When leaving a client's room after providing care, it is important to evaluate the client's ability to do which of the following?

A. Ambulate to the bathroom
B. Push the call light to see if the client is able to activate it when needed
C. Turn the TV on and off
D. Use the telephone to call the family

B. Push the call light to see if the client is able to activate it when needed

40. Which of the following should the nurse do to be most effective in helping to liquefy or thin a client's respiratory secretions?

A. Assist the client to ambulate frequently
B. Encourage coughing and deep breathing
C. Instruct client to increase fluid intake
D. Teach the correct use of the incentive spirometer

C. Instruct client to increase fluid intake

41. The following are the appropriate nursing interventions to promote normal respiratory function EXCEPT:

A. Adequate fluid intake
B. Minimize cigarette smoking
C. DBE and coughing exercises
D. Frequent change of position among bedridden client

B. Minimize cigarette smoking

AVOID cigarette smoking, not minimize.

42. To help prevent injury to a patient with bone demineralization, the nurse should first:

A. Apply emollients to the skin everyday
B. Have the patient walk in the hall once daily
C. Encourage the patient to drink 2500ml of fluid daily
D. Support the patient's joints when turning and removing

D. Support the patient's joints when turning and removing

43. The nurse must auscultate the lungs of a client in isolation. Which of the following is the best way to prevent the spread of microorganism to other clients?

A. Detach a contaminated needle from its syringe before disposal
B. Double-bag soiled equipment with impervious bags before removing it from the client's room
C. Keep the stethoscope used for the client in the room
D. Remove personal protective equipment just outside the client's door

C. Keep the stethoscope used for the client in the room

44. It is now midnight and a client is still unable to fall asleep. What should the nurse do to help him sleep?

A. Bring him a glass of iced tea
B. Suggest that he walk up and down the hall until he becomes tired enough to sleep
C. Open the window or turn down the thermostat to bring the room temperature to below 19 degrees celsius
D. Limit the noise and schedule history taking tomorrow

D. Limit the noise and schedule history taking tomorrow

45. Medical treatment of CAD includes which of the following procedures?

A. Cardiac catheterization
B. Coronary artery bypass surgery
C. Oral medication administration
D. Percutaneous transluminal coronary angioplasty

C. Oral medication administration

46. The safest way to verify a patient's identity initially is to:

A. Ask the patient his name
B. State the patient's name, and have him repeat it
C. Check the identification on the patient's wrist
D. Check the bed number, room number, and the patient's name with the name assigned to the bed

C. Check the identification on the patient's wrist

Wrist band, then ask patient's name.

47. If you harm a patient by administering a medication (wrong drug, wrong dose, etc.) ordered by a physician, which of the following is true?

A. You are not responsible, since you were merely following the doctor's order
B. Only you are responsible, since you actually administered the medication
C. Only the physician is responsible, since he or she actually ordered the drug
D. Both you and the physician are responsible for your respected actions

D. Both you and the physician are responsible for your respected actions

Principle of Respondeat superior.

50. An order client is being started on a new antihypertensive medication. In teaching the client about the medication, the nurse should:

A. Allow the client to express himself or herself and ask questions
B. Speak loudly
C. Present the information once
D. Expect the client to understand the information quickly

A. Allow the client to express himself or herself and ask questions

51. The physician orders NGT 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 in the nose

D. Having the client tilt the head toward the chest while inserting the tube in the nose

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

A. Administration of a liquid feeding into the stomach

53. A nurse is preparing to remove a NGT from a client. The nurse would instruct the client to do which of the following just before the nurse removes the tube?

A. To perform a Valsalva maneuver
B. To take and hold a deep breath
C. To exhale
D. To inhale and exhale quickly

B. To take and hold a deep breath

55. Which of these interventions indicate the nurse needs more information regarding how to safely ensure proper NGT placement?

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 coiled section of tubing
C. Stop advancing tube when tapemark reaches the client's nostril
D. Inject 10cc of air into tube. At the same time, auscultate for air sounds with stethoscope placed over the epigastric region

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

56. The healthcare provider order reads "aspirate NG feeding 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

B. Hold the tube feeding and notify the provider

57. An appropriate technique or the nurse to implement during NGT insertion is to:

A. Use sterile gloves
B. Have the client mouth-breath
C. Advance the tube quickly when the client cough
D. Bend the client's backward after the tube is through the nasopharynx

B. Have the client mouth-breath

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

A. Semi-fowler's position
B. Trendelenburg
C. High-fowler's position
D. Left Sim's lateral

C. High-fowler's position

59. After NGTs have been inserted, the nurse can mostly determine in the tube is in the proper place if which of the ff 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 "whoosing" sound is auscultated when 10mL of air is inserted

D. A "whoosing" sound is auscultated when 10mL of air is inserted

B is vague. The pH should be accurately measured.

60. 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 dislodged at the right lobe of the lung
D. Bloody gastric secretions

B. Gurgling sound at epigastric region

61. During NGT feedings, the nurse is safely able to administer:

A. Antiobiotics
B. Syrup-based medications
C. Enteric-coated tablets
D. Liquid vitamin preparations

D. Liquid vitamin preparations

62. Before the insertion of the NGT, the physician should be notified of:

A. Patent nares
B. Absent bowel sounds
C. Evident gag reflex
D. Impaired swallowing

B. Absent bowel sounds

Indicates non-functional GIT, thus, making NGT useless.

64. What position will the nurse recommend to the patient during TPN administration?

A. High Fowler's position
B. Trendelenburg position
C. Semi-fowler's position
D. Left sims lateral

C. Semi-fowler's position

65. A patient who requires a central vein access for parenteral nutrition is to receive a solution of:

A. Fat emulsion
B. 5% dextrose
C. Amino acids
D. 10% dextrose

C. Amino acids

D is only an emergency bedside solution in case TPN is stopped abruptly.

66. Which of the following techniques is considered the best way to determine whether an NGT 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 the water and observing for air bubbles
D. Instilling air and auscultating over the epigastric area for the presence of the tube

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

C is an old method. D is correct but A is more confirmative.
Sequence:
X-ray
pH
Auscultation

67. Three days after admission for a CVA, a client has an NGT inserted and is receiving intermittent feedings. To best evaluate if prior feeding has been absorbed, the nurse should:

A. Evaluate the intake in relation to the output
B. Aspirate for the 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

B. Aspirate for the residual volume and re-instill it
NOTE: Do not give next feeding if residual volume is greater then 50%

68. An appropriate technique for NGT insertion is for the nurse to:

A. Position the client supine
B. Ice the plastic tube
C. Advance the tube while the client swallows
D. Measure the tube length from the nose to the sternum

C. Advance the tube while the client swallows

70. A client recovering from an infected abdominal wound. Which of the following foods should the nurse encourage the client to eat to support wound healing and recovery from infection?

A. Chicken and orange slices
B. Cheese omelet and bacon
C. Cheeseburger and French fries
D. Gelatin salad and tea

A. Chicken and orange slices

71. A 45-year-old client has a permanent colostomy. Which of the following foods should be avoided?

A. Peanut butter and jelly sandwich and milk
B. Corn beef and cabbage and boiled potatoes
C. Oatmeal, whole wheat toast, and milk
D. Tuna, whole wheat bread, and iced tea

B. Corn beef and cabbage and boiled potatoes

74. The nurse is preparing to feed the client with mild dysphagia. The nurse should do which of the following to assist the client with swallowing?

A. Place the food on the tip of the client's tongue
B. Provide foods that have a soft consistency
C. Use water to help the client swallow the food in the mouth
D. Place the equivalent of 30ml of food on the fork

B. Provide foods that have a soft consistency

75. A postoperative client is on a clear liquid diet, which of the following are allowed on a clear liquid diet?

A. Ice cream, butter, yoghurt, vegetable juices
B. Mashed potatoes, fish, bananas, vegetable juices
C. Gelatin, hard candy, tea, popsicles
D. Milk, gelatin, canned fruits, bread

C. Gelatin, hard candy, tea, popsicles

76. Which of the following menu is appropriate for one with low sodium diet?

A. Instant noodles, fresh fruits, and iced tea
B. Ham and cheese sandwich, fresh fruits, and vegetables
C. White chicken sandwich, vegetable salad and tea
D. Canned soup, potato salad, and diet soda

C. White chicken sandwich, vegetable salad and tea

79. Ms. FX has been admitted with right upper quadrant pain and has been placed on low fat diet. Which of the following trays would be acceptable for her?

A. Liver, fried potatoes, and avocado
B. Ham, mashed potatoes, and cream peas
C. Whole milk, rice and pastry
D. Skim milk, lean fish, tapioca pudding

D. Skim milk, lean fish, tapioca pudding

80. To conduct an assessment of a possible pulse deficit

A. A nurse measures the pulse after the client exercises
B. Two nurse check the same pulse on opposite sides of the body
C. Two nurses assess the apical and radial pulses and determine the differences
D. The current pulse is compared with previous pulse measurements for differences

C. Two nurses assess the apical and radial pulses and determine the differences

81. A nurse needs to assess a client's pulse pressure. What is the correct procedure?

A. Subtract apical from radial pulse
B. Subtract systolic from diastolic blood pressure
C. Subtract radial from apical pulse
D. Subtract diastolic from systolic

D. Subtract diastolic from systolic

82. The following are correct nursing actions when taking the radial pulse EXCEPT

A. Put the palms downward
B. Use 2-3 fingertips to palpate pulse
C. Use the thumb to palpate the artery
D. Assess the pulse rate, rhythm, volume, and bilateral equality

C. Use the thumb to palpate the artery

84. A pulse is normally palpated by applying moderate pressure using

A. The thumb
B. The index finger
C. The palm
D. The middle three fingers

D. The middle three fingers

86. The nurse should report an assessment of

A. 14 respiration per minute of an adult client
B. 16 respiration per minute for an 8 year old client
C. 25 respiration per minute for a toddler
D. 38 respiration per minute for a newborn

B. 16 respiration per minute for an 8 year old client
NORMAL RR:
Adult: 12 - 20
Child: 20-30
Infant: 30-60

89. Blood pressure measurement is performed on the lower extremities when the client has

A. An IV in the right arm
B. A left arteriovenous shunt
C. A right mastectomy
D. Bilateral upper extremity casts

D. Bilateral upper extremity cast

91. The nurse during the health teaching in a client for teaching feces for occult blood informs the client about what can produce false positive results. What should the nurse emphasize?

A. If you have eaten red meat or raw radishes and melons. In the last couple of days, the test may be positive and it may be inaccurate.
B. If you have taken more than 250 mg of vitamin C, it may produce a reading that is too high but is inaccurate.
C. If you have recently eaten any colored vegetables, it may color the stool and produce an inaccurate test result
D. If you have been drinking tea, the result might be elevated

A. If you have eaten red meat or raw radishes and melons. In the last couple of days, the test may be positive and it may be inaccurate.

92. The nurse finds a container with the client's urine specimen sitting on the counter in the bathroom. The client states that the specimen has been sitting in the bathroom at least 2 hours. What would be the nurse's most appropriate action?

A. Discard the urine and obtain a new specimen
B. Send the urine to the laboratory as quickly as possible
C. Add fresh urine to the collected specimen and send the specimen to the laboratory
D. Place the specimen in the refrigerator until it can be transported to the laboratory

A. Discard the urine and obtain a new specimen

Collected urine should be transported within 30 minutes to 1 hour.

93. After IVP, a renal stone was confirmed, a left nephrectomy was done. Her postop care includes daily urine specimen to be sent to the laboratory. Imelda has a foley catheter to a urinary drainage system. How will you collect the urine specimen?

A. Remove urine from drainage tube with sterile needle and syringe and empty urine from the syringe into the specimen container
B. Empty a sample urine from the collecting bag into the specimen container
C. Disconnect the drainage tube from the indwelling catheter and allow urine to flow from the catheter into the specimen container
D. Disconnect the drainage from the collecting bag and allow the urine to flow from the catheter into the specimen container

A. Remove urine from drainage tube with sterile needle and syringe and empty urine from the syringe into the specimen container

95. A midstream urine specimen is ordered, and the nurse teaches the client how to collect the specimen correctly. Which of the following should the nurse include in the instructions?

A. Void directly into the sterile specimen container
B. Save the first voided urine
C. Stop collecting urine after the bladder is empty
D. Cleanse the urethral meatus after obtaining the specimen

D. Cleanse the urethral meatus after obtaining the specimen
Clean, Void, Collect, Void, Clean

96. The nurse is reviewing with a client how to collect a clean catch urine specimen. Which sequence is appropriate teaching?

A. Void a little, clean the meatus, then collect specimen
B. Clean the meatus, begin the voiding, then catch urine stream
C. Clean the meatus, then urinate into container
D. Void continuously and catch some of the urine

B. Clean the meatus, begin the voiding, then catch urine stream

97. A nurse has an order to obtain 24-hour urine collection on a client with renal disorder. The nurse avoids which of the following to ensure proper collection of the 24-hour urine specimen?

A. Have the client void at the start time, and place the specimen in the container
B. Discard the first voiding, and save all subsequent voiding during 24-hour time period
C. Place the container on ice or refrigerator
D. Have the client void at the end time, and place the specimen in the container

A. Have the client void at the start time, and place the specimen in the container

98. A nurse is to collect a sputum specimen for C/S from a client. Which action should the nurse take first?

A. Assist with oral hygiene
B. Ask client to cough sputum into container
C. Have the client take several deep breaths
D. Provide an appropriate specimen container

A. Assist with oral hygiene

99. The physician orders a urine C/S for a 36-year old patient with an indwelling Foley catheter. Which of the following action by the nurse is best?

A. The nurse clamps the catheter tubing below the level of the port for 1 hour
B. The nurse removes 20ml from the catheter bag and places it in a sterile container
C. The nurse separates the catheter from the tubing and allows 30ml of urine to drain into a sterile cup
D. The nurse clamps the catheter just below the insertion site for 20 minutes

A. The nurse clamps the catheter tubing below the level of the port for 1 hour

100. The nurse collects a urine specimen for routine urinalysis from a client. She is aware that:

A. A sterile specimen is required
B. Standing at room temperature for a prolonged period may alter the urine chemistry
C. The external meatus should be cleaned with antiseptic soap and water before voiding
D. A clean-catch, midstream specimen is required

B. Standing at room temperature for a prolonged period may alter the urine chemistry

A and D can be done, but not necessarily required.
C is incorrect. Water is only used to wash, as antiseptic soap may alter urine chemistry.

102. What is the priority of care after the urinary catheter is removed?

A. Encourage the client to eliminate fluid intake
B. Document size of catheter and client's tolerance of procedure
C. Evaluate the client for normal voiding
D. Documentation of client's teaching

C. Evaluate the client for normal voiding

104. During an assessment, the nurse expects that the average daily primary output for the adult client will be:

A. 500 to 1000ml
B. 700 to 1500ml
C. 1200 to 1500ml
D. 2000 to 3000ml

B. 700 to 1500ml

Normal output per hour: 30ml
30ml x 24 = 720ml

107. Nurse Lian has collected a urine specimen. An expected outcome of the client's urinary specimen is when the urine is

A. Dark yellow
B. Clear and straw-colored
C. Showing some sediments
D. Pink-tinged and slightly cloudy

B. Clear and straw-colored

108. Mrs. Ong, 78, reports accidental loss of urine before she is able to reach the toilet. She is aware of the urge to void but states, "Because of my stroke, I sometimes can't get there soon enough." Nurse John suspects

A. Functional incontinence
B. Stress incontinence
C. Reflex incontinence
D. Urge incontinence

A. Functional incontinence

111. For women who have experienced UTI, nurses need to provide instruction about ways to or prevent a recurrence. The following guidelines are useful for anyone except:

A. Consuming milk and milk products
B. Voiding immediately after intercourse
C. Taking Vitamin C
D. Taking showers rather than bath tubs

A. Consuming milk and milk products
Milk and milk products are alkaline in nature.

115. Which if the following is not an appropriate mursing action when taking oral temperature?

A. Wipe thermometer from bulb to stem before
B. Take oral temperature for 3 minutes
C. Place the thermometer at lateral sublingual pouch
D. Normal body temperature ranges from 36.5-37.5

B. Take oral temperature for 3 minutes

116. Which of the following nursing actions is inappropriate when taking the rectal temperature?

A. Assist the client to assume lateral position
B. Hold the thermometer in place for 1 minute
C. Lubricate thermometer with water-soluble lubricant before use
D. Instruct client to strain during insertion of the thermometer

D. Instruct client to strain during insertion of the thermometer

118. A remittent fever is described as:

A. One marked by febrile periods alternating with periods of normal body temperature
B. One in which body temperature varies over 24 hours and remains elevated
C. Elevated body temperature that returns to normal within 24 hours
D. Hypothermia

B. One in which body temperature varies over 24 hours and remains elevated

119. A client has just had a cup of coffee and the nurse needs to measure the body temperature. The nurse should:

A. Take a rectal temperature
B. Take an axillary temperature
C. Wait for 30 minutes before taking the temperature
D. Postpone the measurement for 5 minutes

C. Wait for 30 minutes before taking the temperature

120. When inserting a rectal thermometer, the nurse encounters resistance. The nurse should

A. Apply mild pressure to advance
B. Ask the client to take a deep breathe
C. Remove the thermometer immediately
D. Remove the thermometer and re-insert it gently

C. Remove the thermometer immediately

121. 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 postoperative period

A. In the morning

Lowest temp: 4-6 am
Highest temp: 4-6 pm

122. The nurse notes that a 2-year old child recovering from a tonsillectomy has a temperature of 98.2°F at 8:00am. At 10:00am, the child's mother reports that the child "feels very warm" to touch. The first action by the nurse should be to:

A. Reassure the mother that this is normal
B. Offer the child with cold oral fluids
C. Reassess the child's temperature
D. Administer the prescribed acetaminophen

C. Reassess the child's temperature

123. When obtaining the rectal temperature, the nurse should insert the thermometer

A. 0.5 inch into the rectum
B. 1 inch into the rectum
C. 2 inches into the rectum
D. 3 inches into the rectum

B. 1 inch into the rectum

130. A client with a left leg fracture is to be taught the 3-point gait before discharged. Which instruction should the nurse give to this client?

A. Advance your right crutch, swing the left foot forward, advance the left crutch, and then bring the right foot forward
B. Move your right crutch and left foot forward together, and then swing the right foot and left crutch in one movement
C. While partially bearing weight on your left leg, advance both crutches and then bring your right leg forward
D. Using one movement, advance your left foot and both crutches and then bring your right leg forward

C. While partially bearing weight on your left leg, advance both crutches and then bring your right leg forward

131. Ms. Kelly has had a CVA and has severe right-sided weakness, she has been taught to walk with a cane. The nurse is evaluating her use of the cane prior to discharge. Which of the following reflects correct use of the cane?

A. Holding the cane in her left hand, client moves the cane forward first then her right leg, then finally her left leg
B. Holding the cane in her right hand, client moves the cane forward first, then her left leg, then finally her right leg
C. Holding the cane in her right hand, client moves the cane and her right leg forward, then moves her left leg forward
D. Holding the cane her left hand, client moves the cane and her left leg forward then moves her right leg forward

A. Holding the cane in her left hand, client moves the cane forward first then her right leg, then finally her left leg

132. The nurse is assigned to a 70-lb client in skin traction. The nurse plans care to maintain effective countertraction by doing which of the following?

A. Elevating the head of the bed
B. Adding weights to the existing traction
C. Placing the bed in Trendelenburg position
D. Keeping the bed flat

C. Placing the bed in Trendelenburg position
Body serves as countertraction

134. You would be most concerned about which client having an order for TPN fat emulsion

A. A client with gastrointestinal obstruction
B. A client with severe anorexia nervosa
C. A client with chronic diarrhea and vomiting
D. A client with a fractured femur

D. A client with a fractured femur

Risk for fat embolism

135. A client who is NPO is constantly asking for a drink. Which of the following would be the most appropriate nursing intervention?

A. Re-explain to the client why she cannot drink
B. Offer ice chips every hour to decrease thirst
C. Offer the client frequent oral hygiene care
D. Divert the client's attention by turning on the television

C. Offer the client frequent oral hygiene care

136. The nurse has explained to a client scheduled for surgery that he will not be able to eat or drink after midnight. The client asks whether he can smoke after that time. Which of the following responses by the nurse would be most appropriate?

A. "Smoking is not allowed because it will make you more thirsty"
B. "I'll check with your surgeon"
C. "You can smoke because it will suppress your appetite before surgery"
D. "Smoking is not permitted because it stimulates stomach secretion"

D. "Smoking is not permitted because it stimulates stomach secretion"

137. The nurse is assigned to care for a group of clients. On review of the client's medical records, the nurse determines that which client is at risk for deficient fluid volume?

A. A client with a colostomy
B. A client with congestive heart failure
C. A client with decreased kidney function
D. A client receiving frequent wound irrigations

A. A client with a colostomy

139. The nurse is conducting a dietary assessment on a client who is on a vegan diet. The nurse plans to provide dietary teaching focusing on foods high in which vitamin that may be lacking in a vegan diet?

A. Vitamin A
B. Vitamin B12
C. Vitamin C
D. Vitamin E

B. Vitamin B12
It is usually found in meat and meat products.

140. The nurse is instructing a woman in a low-fat, high-fiber diet. Which of the following food choices, if selected by the client, indicate an understanding of a low-fat, high-fiber diet?

A. Tuna salad sandwich on whole wheat bread
B. Vegetable soup made with vegetable stock, carrots, celery, and legumes served with toasted oat bread
C. Chef's salad with hard boiled eggs and fat-free dressing
D. Broiled chicken stuffed with chopped apples and walnuts

B. Vegetable soup made with vegetable stock, carrots, celery, and legumes served with toasted oat bread

142. As home health nurse, you are taking an admission history for a client who has a deep vein thrombosis and is taking warfarin (Coumadin) 2 mg daily. Which statement by the client is the best indicator that additional teaching about warfarin may be needed?

A. "I have started to eat more healthy foods like green salads and fruit"
B. "The doctor said that it is important to avoid becoming constipated"
C. "Coumadin makes me feel a little nauseated unless I take it with food"
D. "I will need to have some blood testing done once or twice a week"

A. "I have started to eat more healthy foods like green salads and fruit"
They are rich in Vitamin K. Vitamin K impairs anticoaguability of warfarin.

144. A nurse is caring for an elderly Vietnamese patient in the terminal stages of lung cancer. Many family members are in the room around the clock performing unusual rituals and bringing ethnic foods. Which of the following actions should the nurse take?

A. Restrict visiting hours and ask the family to limit visitors to two at a time.
B. Notify visitors with a sign on the door that the patient is limited to clear fluids only with no solid food allowed
C. If possible, keep the other bed in the room unassigned to provide privacy and comfort to the family
D. Contact the physician to report the unusual rituals and activities

C. If possible, keep the other bed in the room unassigned to provide privacy and comfort to the family

145. What will the nurse encourage a client, who has had a modified right mastectomy, to do which is appropriate as initial therapy 24 hours after surgery?

A. Self-feeding and hair combing
B. Passive/active flexion and extension of the elbow and pronation and supination of the wrist
C. Abduction and external rotation of the right shoulder
D. Early ambulation and active extension and flexion of the elbow

B. Passive/active flexion and extension of the elbow and pronation and supination of the wrist
Less pain after surgery

146. On turning a client who has had a right modified mastectomy to her left side, the nurse notes a moderately large amount of serosanguinous drainage on the bedsheet, the nurse should

A. Remove the dressing to ascertain the origin of the bleeding
B. Milk the hemovac tubing using a downward motion
C. Note vital signs, reinforce the dressing, and notify the surgeon immediately
D. Recognize that this is a frequent occurrence with this type of surgery

C. Note vital signs, reinforce the dressing, and notify the surgeon immediately

148. A 50-year old blind and deaf patient has been admitted to your floor. As the charge nurse, your primary responsibility for this patient is?

A. Let others know about the patient's deficits
B. Communicate with your supervisor your patient's safety concerns
C. Continuously update the patient on the social environment
D. Provide a secure environment for the patient

D. Provide a secure environment for the patient

149. Nurse Jinky is assessing a client with heart failure. To assess hepatojugular reflux, the nurse should

A. Elevate the client's head to 90°
B. Press the right upper abdomen
C. Press the left upper abdomen
D. Lie the client flat in bed

D. Lie the client flat in bed
To distend jugular vein.

151. The nurse prepares a client for discharge who needs intermittent antibiotic infusions through a peripherally inserted central catheter (PICC) line. Which should the nurse include in client teaching about daily infusion care in the home?

A. Keep the affected arm immobilized
B. Aspirate 3ml of blood from the PICC line
C. Maintain a continuous intravenous infusion
D. Check the site for redness and swelling

D. Check the site for redness and swelling

152. An 85-year old male patient has been bedridden for 2 weeks. Which of the following complaints by the patient indicates to the nurse that he is developing a complication of immobility?

A. Stiffness of the ankle joint
B. Short term memory loss
C. Soreness of the gums
D. Decrease appetite

A. Stiffness of the ankle joint

153. The patient who had a stroke needs to be fed. What instruction should you give to the nursing assistant who will feed the patient?

A. Position the patient sitting up in bed before you feed her
B. Check the patient's gag and swallowing reflexes
C. Feed the patient quickly because there are 3 more waiting
D. Suction the patient secretions between bites of food

A. Position the patient sitting up in bed before you feed her

154. Which action by the healthcare worker indicates a need for further teaching?

A. The nursing aide wears gloves while giving the client a bath
B. The nurse wears gloves while drawing blood from the client
C. The doctor washes his hands before examining the client
D. The nurse wears gloves to take the client's vital signs

D. The nurse wears gloves to take the client's vital signs

155. Which of the following techniques is correct for obtaining a wound culture specimen from a surgical site?

A. Thoroughly irrigate the wound before collecting the specimen
B. Use a sterile swab and wipe the crusty area around the outside of the wound
C. Gently roll a sterile swab from the center of the wound outward to collect drainage
D. Use a sterile swab to collect drainage from the dressing

C. Gently roll a sterile swab from the center of the wound outward to collect drainage

156. Under which circumstance may a nurse communicate medical information without the client's consent?

A. When certifying the client's absent from work
B. When requested by the client's family
C. When treating client's public safety who have a sexually transmitted disease (STD)
D. When ordered by another physician

C. When treating client's public safety who have a sexually transmitted disease (STD)
Public safety is the PRIORITY

157. The nurse has emptied a Jackson Pratt wound drainage device and needs to reestablish suction to the tube. Which of the following actions should the nurse take to accomplish this objective?

A. Ensure the tubing has no kinks
B. Squeeze the collection chamber
C. Wipe the port with alcohol
D. Close the cap on the device

B. Squeeze the collection chamber

158. A patient with Parkinson's disease has a nursing diagnosis of Impaired Physical Mobility related to neuromuscular impairment. You observe a nursing assistant performing all of these actions. For which action must you intervene?

A. The NA assist the patient to ambulate to the bathroom and back to bed
B. The NA reminds the patient not to look at his feet when he is walking
C. The NA performs the patient's complete bath and oral care
D. The NA sets up the patient's tray and encourages patient to feed himself

C. The NA performs the patient's complete bath and oral care
Nurses should promote independence.

159. You have suffered a needle stick injury after giving a patient an IM injection, but you have no information about the client's HIV status. What is the most appropriate method for obtaining this information about the patient?

A. You should ask the patient to authorize HIV testing as soon as possible
B. The nurse manager for the unit is responsible for obtaining the information.
C. The occupational health nurse should discuss HIV status with the patient
D. HIV testing should be done the next time blood is drawn for other tests

C. The occupational health nurse should discuss HIV status with the patient

160. Dina sustained a fracture of the ulna and a cast will be applied. What nursing action before cast application is most important for nurse Roque to do?

A. Use baby powder to reduce irritation under the cast
B. Assess sensation of each arm
C. Evaluate skin temperature in the area
D. Check radial pulses bilaterally and compare

D. Check radial pulses bilaterally and compare

161. When performing external cardiac compression, the nurse should exert downward vertical pressure by placing:

A. The fleshy part of a clenched fist on the lower sternum
B. The heels of each hand side by side, extending the fingers over the chest
C. The fingers of 1 hand on the sternum and the fingers of the other hand on top of them
D. The heel of one hand on the sternum and the heel of the other on top of it, interlocking the fingers

D. The heel of one hand on the sternum and the heel of the other on top of it, interlocking the fingers

162. A client receiving chemotherapy is experiencing a low white blood cell (WBC) count. The nurse should teach the client to avoid contact with which of the following family members?

A. 34-year old nephew with HIV infection
B. 9-year old grandchild recently exposed to chickenpox
C. 68-year old husband with a history of tuberculosis
D. 31-year-old daughter who is 4 months pregnant

B. 9-year old grandchild recently exposed to chickenpox

163. The client with cystitis has a routine urinalysis (UA) done. Pyuria is noted on the report, which means the urine has:

A. Serosanguinous discharges
B. Mucus and white blood cells
C. Blood clots
D. Creatinine

B. Mucus and white blood cells

164. Which of the following clients would qualify for hospice care?

A. A client with metastatic cancer
B. A client with left-sided paralysis after a stroke
C. A client who had coronary artery bypass surgery 1 week ago
D. A client who is undergoing treatment for heroin addiction

A. A client with metastatic cancer

165. When caring for a dying client, you will perform which of the following activities?

A. Encourage the client to reach optimal health
B. Assist client perform activities of daily living
C. Assist the client towards a peaceful death
D. Motivate client to gain independence

C. Assist the client towards a peaceful death

168. A 7-year old child is clutching his throat and cannot talk. Which of the following should the nurse do?

A. Call for help and administer oxygen
B. Perform Heimlich maneuver
C. Start CPR
D. Open windows for ventilation

B. Perform Heimlich maneuver

169. The nurse is instructing the client about the prevention of carbon monoxide poisoning. Which of the following statements from the client indicates that more teaching is needed?

A. "A high concentration of carbon monoxide can cause death"
B. "I can detect the presence of carbon monoxide by strong odor"
C. "I can purchase a carbon monoxide detector for my home"
D. "I should inspect my carbon monoxide detector annually"

B. "I can detect the presence of carbon monoxide by strong odor"

170. Which of the following classes of medication protects the ischemic myocardium by blocking sympathetic nerve stimulation?

A. Beta-adrenergic blockers
B. CCB
C. Narcotics
D. Nitrates

A. Beta-adrenergic blockers

171. You are caring for Conrad who has a brain tumor and increased ICP. Which intervention should you include in your plan to reduce ICP?

A. Administer bowel softener
B. Position Conrad with his head turned toward the side of the tumor
C. Provide sensory stimulation
D. Encourage coughing and deep breathing

A. Administer bowel softener

173. The doctor has ordered furosemide (lasix) 80mg IV push over 5 minutes. The nurse should give priority to the:

A. Assessment of the client's output
B. Assessment of the client's BP
C. Assessment of the client's RR
D. Assessment of the client's neuro signs

B. Assessment of the client's BP

174. A 6 month old is being treated for thrush with Nystatin (mycostatin) oral suspension. The nurse should administer the medication by:

A. Placing it in a small amount of applesauce
B. Using cotton tipped swab
C. Adding it to the infant's formula
D. Placing it in 2-3 oz of water

B. Using cotton tipped swab

175. The physician has prescribed iron dextran (imferon) for a client with severe anemia. The nurse should administer the medication:

A. Orally in orange juice
B. Orally in milk
C. Subcutaneous injection
D. Intramuscular Z-track injection

D. Intramuscular Z-track injection

176. The physician has ordered cortisporin ear drops for a 2 year old. To administer the ear drops, the nurse should:

A. Pull the ear straight out
B. Pull the ear up and back
C. Pull the ear down and back
D. Leave the ear undisturbed

C. Pull the ear down and back

177. Which of these findings indicate that a pump to deliver a basal rate of 10ml per hour plus PRN for pain break through for morphine drip is not working?

A. The client complains of discomfort at the IV insertion site
B. The client states "I just can't get relief from my pain"
C. The level of drug is 100ml at 8am and is 80ml at noon
D. The level of the drug is 100ml at 8am and is 50ml at noon

C. The level of drug is 100ml at 8am and is 80ml at noon

178. When teaching a client with CAD about nutrition, the nurse should emphasize

A. Eating 3 balanced meals a day
B. Adding complex carbohydrates
C. Avoiding very heavy meals
D. Limiting sodium to 7gms per day

C. Avoiding very heavy meals

179. A client has been newly diagnosed with hypothyroidism and will take le evothyroxin (Synthroid) 50mcg/day by mouth. As part of the teaching plan, the nurse emphasizes that this mediaction:

A. Should be taken in the morning
B. May decrease the client's energy level
C. Must be stored in a dark container
D. Will decrease the client's heart rate

A. Should be taken in the morning

180. You attached a pulse oximeter to the client. You know that the purpose is to:

A. Determine if the client's hemoglobin is low and if he needs BT
B. Check level of client's tissue perfusion
C. Measure the efficacy of the client's anti-HPN medications
D. Detect O2 sat of arterial blood before a Sx of hypoxemia develops

D. Detect O2 sat of arterial blood before a Sx of hypoxemia develops

181. While the client has pulse oximeter on his fingertip, you notice that the sunlight is shining on the area where the oximeter is. Your action will be to:

A. Set and turn on the alarm of the oximeter
B. Do nothing since ther is no identified problem
C. Cover the fingertip sensor with a towel or bedsheet
D. Change the location of the sensor every four hours

C. Cover the fingertip sensor with a towel or bedsheet

182. A nurse informs a client that the alarm in the pulse oximeter will not sound when:

A. The client moves the probe
B. The probe falls off
C. The SpO2 falls below the set limit
D. The display reaches full strength during each cardiac cycle

D. The display reaches full strength during each cardiac cycle

184. For a client with COPD, a nurse anticipates the use of oxygen equipment:

A. Face tent
B. Face mask
C. Nasal cannula
D. Nonbreathing mask

C. Nasal cannula
Low O2 flow to prevent loss of hypoxic drive.
UPDATE: As tolerated by patient.

185. Assessment of the proper functioning of an oxygen device includes:

A. No mist in the face tent
B. The reservoir of the rebreathing mask collapsing on inhalation
C. A flow rate between 1 and 6L/min for the nasal cannula
D. The nasal cannula positioned below the nares

C. A flow rate between 1 and 6L/min for the nasal cannula
-----------------------------------------------------------------------------
A. Has mist
B. The reservoir of the rebreathing mask PARTIALLY collapsing on inhalation
D. The nasal cannula positioned INSIDE the nares

186. An unexpected outcome of oxygen use is:

A. Decrease anxiety
B. An increased pulse rate
C. A decreased RR
D. An increased LOC

B. An increased pulse rate

Other choices are expected outcomes.

187. The proper technique to use for administering oxygen to a client with an artificial airway is:

A. Applying sterile gloves
B. Leaving fluid in the tubing
C. Attaching the T tube to the humidified oxygen source
D. Monitoring the response to the oxygen with hourly ABG levels

C. Attaching the T tube to the humidified oxygen source

188. Nurse Nikka is teaching a client on how to properly use an incentive spirometry to a client. Teaching is effective if which of the following sequence is onserved:

A. The client holds the spirometry upright position, exhales normally, seal the lips tightly around the mouthpiece, takes a slow deep breath for 2 seconds to keep the balls elevated
B. Exhales normally, hold the spirometer upright, seals the mouthpiece, takes a fast shallow breath and holds breath for 5 seconds to keep the balls elevated
C. Holding the spirometer above the head, seal the mouthpiece, and exhaling slowly for 3 seconds
D. Holding the spirometer above the head, seal the mouthpiece around the lips, and holding breath for a while

A. The client holds the spirometry upright position, exhales normally, seal the lips tightly around the mouthpiece, takes a slow deep breath for 2 seconds to keep the balls elevated

190. The primary reason in teaching pursed-lip breathing to persons with emphysema is to help:

A. Promote oxygen intake
B. Strengthen the diaphragm
C. Strengthen the intercostal muscles
D. Promote CO2 elimination

D. Promote CO2 elimination

It lengthens exhalation, thereby, increasing CO2 expiration.

191. Complications associated with a tracheostomy tube include:

A. Decreased Cardiac output
B. Damage to the laryngeal nerve
C. Pneumothorax
D. RDS

B. Damage to the laryngeal nerve

192. A priority goal for the hospitalized client with a new tracheostomy would be to:

A. Decreased secretions
B. Instruct the client in caring for the tracheostomy
C. Relieve anxiety related to the device
D. Maintain patent airway

D. Maintain patent airway

193. A client has a tracheostomy tube. The nurse knows that the obturator is kept at the client's bedside because:

A. The obturator is kept at the client's bedside in case the tube becomes dislodged and needs to be reinserted
B. The obturator is a guide in inserting the tube
C. The obturator, after insertion, will be kept by the client
D. The obturator will be used to make an opening for the tube

A. The obturator is kept at the client's bedside in case the tube becomes dislodged and needs to be reinserted

Choice B only states the function.

194. The nurse is cleaning the incision site and tube flange of a client with tracheostomy. A sterile applicator soaked in what solution is used in removing crusty secretions?

A. Isopropyl alcohol
B. Hydrogen peroxide (Full strength)
C. Hydrogen peroxide (Half-strength solution mixed with sterile normal saline)
D. Ammonia

C. Hydrogen peroxide (Half-strength solution mixed with sterile normal saline)

195. Tracheostomy tubes used among adults often have cuffs. This inflatable cuff functions to:

A. Producing an airtight seal to prevent aspiration or oropharyngeal secretions and air leakage
B. Anchoring the tube in place
C. Distributing a low even pressure over the trachea
D. A guide for easy removal of the tracheostomy tube

A. Producing an airtight seal to prevent aspiration or oropharyngeal secretions and air leakage

196. Which of the following statements contains one of the basic rules to follow when caring for a client with a chest tube and water-seal drainage system?

A. Ensure that the air vent on the water-seal drainage system is capped when the suction is off
B. Strip the chest and drainage tubes at least every 4 hours if excessive bleeding occurs
C. Ensure that the collection and suction bottles are at the client's chest level at all times
D. Ensure that the collection and suction bottles are below the client's chest level at all times

D. Ensure that the collection and suction bottles are below the client's chest level at all times
------------------------------------------------------------------------------------------------------------------------
It promotes flow of drainage.

A. Ensure that the air vent on the water-seal drainage system is capped when the suction is ON, not OFF
B. Stripping the chest and drainage tubes may lead to Tension Pneumothorax
C. Should be below

197. In an under water-seal drainage system, cessation of fluid fluctuation in the chest and drainage tubes generally means that the:

A. Lung has fully expanded
B. Lung has collapsed
C. Chest tube is in the pleural space
D. Mediastinal space has decreased

A. Lung has fully expanded

199. While you were making endorsement, you found out the chest tube of a client was disconnected. What would be your appropriate action?

A. Assist the client back to his bed and place him on the affected side
B. Cover the end of the test tube with sterile gauze
C. Reconnect the tube to the chest tube system
D. Put the end of the test tube into a cup of sterile normal saline

D. Put the end of the test tube into a cup of sterile normal saline

200. Dr. Black Daclis asked you to assist him with the removal of Jeld's chest tube. You would instruct the client to:

A. A continuously breathe normally during the normal of the chest tube
B. Take a deep breath, exhale and bear down
C. Exhale upon the actual removal of the tube
D. Hold breath until the chest tube is pulled out

B. Take a deep breath, exhale and bear down

202. When transporting clients with chest tube, the system should be:

A. Disconnected
B. Closed
C. Placed lower than the patient's chest
D. Placed between the legs of the client to prevent breakage

C. Placed lower than the patient's chest

203. Which of the following measures should the nurse perform in relation to suctioning a tracheostomy tube?

A. Apply suction while inserting the suction catheter into the tube
B. Change the tracheostomy tube after suctioning the client
C. Select a suction catheter that approximates the diameter of the tracheostomy tube
D. Hyperoxygenate before suctioning the client

D. Hyperoxygenate before suctioning the client

It prevents hypoxia.

204. After suctioning a client's tracheostomy tube, the nurse waits a few minutes before suctioning again. The nurse would use intermittent suction primarily to help prevent:

A. Stimulating the client's cough reflex
B. Depriving the client of sufficient oxygen supply
C. Dislocating the tracheostomy tube
D. Obstructing the suctioning catheter with secretions

B. Depriving the client of sufficient oxygen supply

205. Which method is best for the nurse to evaluate the effectiveness of tracheal suctioning?

A. Note subjective data such as, "My breathing is much improved now"
B. Note objective findings such as decreased RR and PR
C. Consult with respiratory therapist to determine effectiveness
D. Auscultate the chest for change or clearing in adventitious breath sounds

D. Auscultate the chest for change or clearing in adventitious breath sounds

207. A nurse is performing oropharyngeal suctioning on the unconscious client. Which if the following actions is safe?

A. Insert the catheter approximately 20cm while applying suction
B. Allow 20 to 30 second intervals between each suction, and limit suctioning to a total of 15 minutes
C. Gently rotate the catheter while applying suction
D. Apply suction for 5 minutes while inserting and continue for another 5 seconds before withdrawing

C. Gently rotate the catheter while applying suction

208. Applying suction in the nasopharynx for too long may cause secretions to increase or decrease, therefore the nurse should:

A. Allow 20 to 30 second intervals between each suction, limit suctioning to 5 minutes in total
B. Allow 2 to 3 minutes between suction when possible
C. Allow 5 minutes between each suction
D. Allow 1-2 minutes between each suction

A. Allow 20 to 30 second intervals between each suction, limit suctioning to 5 minutes in total

INTERVAL
Oro and naso: 20-30 seconds
Tracheo: 2-3 minutes
TOTAL TIME
All: 5 minutes

209. The correct pressure of the wall suction unit when suctioning a child patient is?

A. 95 — 100mmHg
B. 50 — 95 mmHg
C. 100 — 120 mmHg
D. 10 — 15 mmHg

A. 95 — 100mmHg

WALL SUCTION
Infant: 50 — 95 mmHg
Child: 95 — 110 mmHg
Adult: 100 — 120 mmHg

210. A nurse suctioning a client through a tracheostomy tube. The nurse plans to apply suction during the withdrawal of the catheter for a period of time no greater than?

A. 10 seconds
B. 15 seconds
C. 20 seconds
D. 30 seconds

A. 10 seconds

DURATION
Oro and naso: 5-10 seconds, MAX: 15 seconds
Tracheo: 5-10 seconds, MAX: 10 seconds

211. Which if the following should the nurse include when suctioning a client's tracheostomy?

A. Instill a sterile saline down the trachea to stimulate a cough then suction with continuous suctioning
B. Suction the client's mouth before entering the trachea
C. Insert the catheter until a cough reflex is obtained or until resistance is felt
D. Adjust the wall suction to 150mmHg for the procedure

C. Insert the catheter until a cough reflex is obtained or until resistance is felt

A and D are wrong. In choice B, trachea should be suction first (Sterile) before mouth (Unsterile).

213. A nurse has deflated BP cuff too fast. How will this affect the nurse's reading?

A. Erroneously low systolic and high diastolic reading
B. Erroneously high systolic and low diastolic reading
C. Inconsistent
D. NOTA

A. Erroneously low systolic and high diastolic reading

214. When assessing the pulse of a client on digitalis, what rate would the nurse expect as compared with the pulse prior to starting digitalis?

A. It would be doubled
B. It would be slightly higher
C. It would not change
D. It would decrease

D. It would decrease

As digitalis has been given, cardiac muscles get stronger contractions. Thus, compensatory mechanism (increased PR) also normalizes (decreases).

216. A nurse documents deep respirations on the client's record. Which criteria were most likely assessed?

A. A large amount of air inhaled and a small amount exhaled
B. A large amount of air inhaled and a large amount exhaled
C. A small amount of air inhaled and a small amount exhaled
D. A small amount of air inhaled and a large amount exhaled

B. A large amount of air inhaled and a large amount exhaled

218. Which technique is the best for assessing the respiration of a 3-year old?

A. Use a stethoscope and auscultate the lungs
B. Place one hand against the chest when counting
C. Observe the rise and fall of the abdomen
D. Tell the child you will check his breathing

C. Observe the rise and fall of the abdomen

219. The client's meal is composed of 83 grams of CHO, 27 grams of fats, and 45 grams of protein. What is the total kcalories?

A. 745 kcal
B. 845 kcal
C. 855 kcal
D. 755 kcal

D. 755 kcal

CHO: 83 grams x 4 cal = 332 kcal
Fats: 27 grams x 9 cal = 243 kcal
CHON: 45 grams x 4 cal = 180 kcal
TOTAL: 755 kCal

220. Documentation of a client with Kaussmaul's breathing is made when the nurse assesses?

A. Very slow respirations
B. Abnormally but deep respirations
C. Abnormally slow and irregular respirations
D. Irregular periods of apnea and hyperventilation

B. Abnormally but deep respirations

232. A priority nursing diagnosis for the client who experiences wound dehiscence postop after an abdominal hysterectomy would be

A. High risk for infection
B. FVE
C. Ineffective airway clearance
D. Altered nutrition less than body requirements

A. High risk for infection

233. Body image is defined as

A. The way a person looks and the style of clothing he wears
B. The way the body functions and looks at a certain age
C. The way a person perceives his appearance and function, and how he compares himself to others
D. A body of normal weight and height in which all body parts are present

C. The way a person perceives his appearance and function, and how he compares himself to others

234. A client is having diarrhea and vomiting, the priority nursing diagnosis is:

A. Altered nutrition less than body requirements r/t vomiting and diarrhea
B. F and E imbalance r/t vomiting and diarrhea
C. Altered elimination pattern r/t diarrhea
D. FVE r/t increased intake of ORT

B. F and E imbalance r/t vomiting and diarrhea

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

A. It is 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

B. It focuses on the patient, not the nurse

RATIONALE
A It is useful in ALL SETTINGS
C It progresses in INTERRELATED steps
D Not all solutions (extreme choice)

236. The nurse performs a neurologic exam on a patient. After the exam, which of the following should be recorded as objective data?

A. +4 patellar reflexes in both of the patient's legs
B. Patient's description of ringing in his ears
C. Patient's sensations of numbness in his right arm
D. Patient's statement, "The room is spinning"

A. +4 patellar reflexes in both of the patient's legs

RATIONALE
All other choices are subjective data.

237. All of the following components may be part of a client's medical record. Which one is the major source of subjective data about the client's health status?

A. Health history
B. Physical findings
C. Laboratory test results
D. Radiologic findings

A. Health history

RATIONALE
All other choices are sources of objective data.

238. Which of the following nursing diagnoses uses the PES format?

A. Fluid Volume Deficit r/t prolonged vomiting
B. Risk for Impaired Skin Integrity as manifested by poor skin turgor and old age
C. Ineffective Airway Clearance r/t infectious process as manifested by excessive mucous and retained secretions
D. Ineffective Airway Clearance as manifested by secretions in the bronchi, presence of allergies, and airway spasm

C. [P] Ineffective Airway Clearance [E] r/t infectious process [S] as manifested by excessive mucous and retained secretions

RATIONALE
A. [P] Fluid Volume Deficit [E] r/t prolonged vomiting
B. [P] Risk for Impaired Skin Integrity [S] as manifested by poor skin turgor and old age
D. [P] Ineffective Airway Clearance [S] as manifested by secretions in the bronchi, presence of allergies, and airway spasm

239. Using Maslow's hierarchy of basic human needs. Which of the following nursing diagnoses has the highest priority?

A. Anxiety r/t impending surgery, as evidenced by insomnia
B. Impaired verbal communication r/t tracheostomy, as evidenced by inability to speak
C. Ineffective breathing pattern r/t pain, as evidenced by SOB
D. Risk for injury r/t autoimmune dysfunction

C. Ineffective breathing pattern r/t pain, as evidenced by SOB

RATIONALE
Physiological.

All other choices belong to Safety and Security level.

240. Which statement does not describe an appropriate guideline for writing a nursing diagnosis?

A. State the diagnosis in terms of a problem, not a need
B. Use medical terminology to describe the probable cause of the patient's response
C. Use nursing terminology to describe the patient's response
D. Use statements that assist in planning the independent nursing interventions

B. Use medical terminology to describe the probable cause of the patient's response

RATIONALE
It should be NURSING terminology, not medical terminology.

Other choices describe an appropriate nursing diagnosis.

241. Which of the following statements is a correctly written ACTUAL nursing diagnosis?

A. Impaired physical mobility as evidenced by decreases ROM in left shoulder from 180 to 190 degrees of flexion and extension r/t left shoulder pain
B. Ineffective airway clearance r/t thickened bronchial secretions as evidenced by adventitious lung sounds over the periphery of the right and left lung fields
C. Potential for altered nutrition: Less than body requirements as evidenced by 15-lb weight loss in 3 weeks
D. Potential for self-esteem disturbance r/t change in body image

B. Ineffective airway clearance r/t thickened bronchial secretions as evidenced by adventitious lung sounds over the periphery of the right and left lung fields

RATIONALE

A An actual diagnosis but not following the PES format.
C and D are potential problems.

242. An 80-year old client is in the Emergency Department. The client complains of diarrhea and vomiting for the past two days. In assessing the client, you note that his skin is dry and can be tented. He has lost eight pounds. Which NANDA diagnosis would be most appropriate to use with this client in making his plan of care?

A. Risk for deficient fluid volume r/t prolonged diarrhea and vomiting
B. Risk for fluid volume excess r/t prolonged diarrhea and vomiting
C. Risk for normal fluid volume r/t prolonged diarrhea and vomiting
D. Risk for hidden fluid r/t prolonged diarrhea and vomiting

A. Risk for deficient fluid volume r/t prolonged diarrhea and vomiting

RATIONALE
The patient may be dehydrated.

244. Which of the following nurses is a competent practitioner according to Benner?

A. The nurse is able to use maxims as a guide for what to consider in a new situation and views the clients holistically
B. The nurse who does not require rules or guidelines in making analysis and decisions in a new situation but instead uses intuitive and analytical skills
C. The nurse is able to coordinate the complex care demands of a client who is newly admitted and the other clients in the unit
D. The nurse who is able to recognize the meaningful aspects of a situation where a client was newly diagnosed with diabetes

C. The nurse is able to coordinate the complex care demands of a client who is newly admitted and the other clients in the unit

RATIONALE
A Proficient
B Expert
D Advance Beginner

246. Benner's "Proficient" nurse level is different from the other levels in nursing expertise in the context of having

A. The ability to organize and plan activities
B. Having attained an advanced level of education
C. A holistic understanding and perception of the client
D. Intuitive and analytic ability in new situations

C. A holistic understanding and perception of the client

RATIONALE
A Competent
B Advance beginner
D Expert

248. Delegation is the process of assigning tasks that can be performed by subordinate. The RN should always be accountable and should not lose his accountability. Which of the following is a role of include delegation?

A. The RN must supervise all delegated tasks
B. After a task has been delegated, it is no longer a responsibility of the RN
C. The RN is responsible and accountable for the delegated task in adjunct with the delegate
D. Follow up with a delegate task necessary only if the assistive personnel is not trustworthy

C. The RN is responsible and accountable for the delegated task in adjunct with the delegate

249. An RN in charge is preparing the assignments for the day. The RN assigns a nursing assistant to make beds and bathe one of the clients on the unit and assigns another nursing assistant to fill the water pitchers and to serve juice to all the clients. Another RN is assigned to administer all medications. Based on the assignments designed by the RN in charge, which type of nursing care is being implemented?

A. Functional nursing
B. Team nursing
C. Exemplary model of nursing
D. Primary nursing

A. Functional nursing

RATIONALE
Functional nursing focuses on duties.

250. In Dunn's high-level wellness grid, a person suffering from CVA and confined in the healthcare facility falls under which quadrant?

A. High-level wellness in a favorable environment
B. Emergent high-level wellness in an unfavorable environment
C. Protected poor health in a favorable environment
D. Poor health in an unfavorable environment

C. Protected poor health in a favorable environment

251. In the health belief model by Risenstick and Becker, individual perception matters. The following are likely to influence preventive behavior, except:

A. Perceived susceptibility to an illness
B. Perceived seriousness of an illness
C. Perceived threat of an illness
D. Perceived curability of an illness

D. Perceived curability of an illness

RATIONALE
Not included in the health belief model of Risenstick and Becker.

257. Which of the following is an example of primary preventive measure?

A. Participating in a cardiac rehabilitation program
B. Obtaining an annual physical examination
C. Practicing monthly BSE
D. Avoiding overexposure to the sun

D. Avoiding overexposure to the sun

RATIONALE
A Tertiary
B and C are Secondary

259. 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"

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

RATIONALE
A The word "small" is inaccurate. It should be measurable.
B and C are incorrect. It should be based on the patient's perspective, not by the nurse.

260. Which of the following is the best example of an accurate report?

A. The wound drained a large amount of serous drainage
B. The client acts as though he has had little discomfort
C. Bowel sounds were auscultated on the right upper quadrant
D. The client appeared to have discomfort while ambulating

C. Bowel sounds were auscultated on the right upper quadrant

RATIONALE
A The word "large" is inaccurate. It should be measurable.
B and D are incorrect. It should be based on the patient's perspective, not by the nurse.

261. The following are the general guidelines when recording in the client's chart. Which is a correct procedure?

A. Recording should be done before providing nursing care
B. All entries on the record are made in pencil so that the necessary changes can be made
C. Each recording on the nurse's notes is signed by the nurse making it
D. Leave a blank space for a colleague to chart later

C. Each recording on the nurse's notes is signed by the nurse making it

RATIONALE
A Recording should be done EVERY AFTER providing nursing care
B All entries on the record are made in PERMANENT INK
D Every blank space should be properly filled in

262. The nurse receives a telephone order from the physician. Her most appropriate nursing action following a telephone order is:

A. Copy the order in the chart and sign the physician's name as close to his original signature as possible
B. Write the order in the client's chart and have another nurse co-sign it
C. Tell the physician that you cannot take the telephone order but you will call the nurse supervisor
D. Write the order and repeat the order back to the physician, copy onto the order sheet and indicate that it is a telephone order

D. Write the order and repeat the order back to the physician, copy onto the order sheet and indicate that it is a telephone order

263. The nurse committed a mistake when writing an entry in the client's record. The nurse should take which action?

A. Draw a line through the mistake
B. Draw a line through the mistake and write "mistaken entry" above it
C. Draw a line through the mistake and write "mistaken entry" next to the original entry with the nurse's name or initials
D. Erase the mistaken entry using the correction fluid, write the correct entry then place the name/initials and date

C. Draw a line through the mistake and write "mistaken entry" next to the original entry with the nurse's name or initials

264. Which of the following qualities are relevant in documenting the care of the clients?
1. Accuracy and conciseness
2. Legible, properly dated and signed
3. Systematic and orderly
4. Thoroughness and appropriateness
5. Use of locally accepted abbreviations

A. 2,3,4 and 5
B. 1,2,3 and 4
C. 1,2,3 and 5
D. 1,3,4 and 5

B. 1,2,3 and 4

RATIONALE
5 Use of GLOBALLY accepted abbreviations

265. A client who speaks little English has emergency gallbladder surgery. During discharge preparation, which nursing action would best help this client understand wound care instructions?

A. Asking frequently whether the client understands the instructions
B. Asking an interpreter to relay the instructions to the client
C. Writing out the instructions and having a family member read them to the client
D. Demonstrating the procedure and having the client return the demonstration

D. Demonstrating the procedure and having the client return the demonstration

266. The nurse orients an elderly client to the safety features in her hospital room. A vital component of this admission on routine is to:

A. Explain how to use the telephone
B. Introduce the client to her room mate
C. Review the hospital policy on visiting hours
D. Explain how to operate the call bell

D. Explain how to operate the call bell

267. A nurse received sexually oriented images sent via text in her cellular phone that really annoyed her. The message came from a male co-worker in the hospital. What is the most appropriate action of the nurse?

A. Reply with vulgar words to let him know that you are mad
B. Report to the NBI
C. Call the police
D. Call the nursing supervisor and report the incident

D. Call the nursing supervisor and report the incident

RATIONALE
Following proper line of authority.

268. A nurse calls a physician in regard to a new medication order because the dosage prescribed is higher than the recommended dosage. The nurse is unable to locate the physician and the medication is due to be administered. Which of the following actions would the nurse take?

A. Hold the medication until the physician can be contacted
B. Administer the dose prescribed
C. Administer the recommended dose until the physician can be located
D. Contact the nursing supervisor

D. Contact the nursing supervisor

269. Among the clients the nurse is assigned to take care of, who is the MOST susceptible to infection?

A. An 18-year old with a surgical repair of a torn knee ligament
B. A 35-year old with an uncomplicated appendectomy
C. A 42 year old with diabetes
D. A 72 year old with a broken hip

D. A 72 year old with a broken hip

RATIONALE
It has 2 counts of risk: Age and broken hip

A 1 count: surgery
B 1 count: surgery
C 1 count: DM

270. When making an occupied bed, it is important for the nurse to:

A. Keep the bed in the low position
B. Use a bath blanket or top sheet for warmth and privacy
C. Constantly keep the side rails raised on both sides
D. Move back and forth from one side to the other when adjusting the linens

B. Use a bath blanket or top sheet for warmth and privacy

RATIONALE
A Keep the bed at proper height with regards to the nurse comfort; able to use the proper body mechanics
C Only 1 side rail so the nurse can work on the other side
D The work should be organize, able to finish from one side to the other side.

1. Mr. Lim is about to take his first nursing comprehensive exam. He reviewed badly and familiarizes himself with the nursing history. Which of the following is the chronological sequence of how nursing started?
1. Caregivers stealing food and money from their patient
2. Nursing practice is purely based on experience
3. Laser surgeries and radiation therapies emerges
4. The use of white magic to combat the black magic
5. Florence Nightingale as the Mother of Modern Nursing

A. 14532
B. 35124
C. 54321
D. 42153

D. 42153

RATIONALE
Nursing History in chronological order:
1 Intuitive
2 Apprentice
3 Dark Age
4 Educative
5 Contemporary

2. The history of nursing dates back from ancient were indigenous people are living with the dinosaurs making human life impossible. However, nursing is an expression of helping out other people in need. Which of the following best describes this scenario:

A. The community depends on religious ministries to receive food and to take good care of them
B. People would use amulets made from stones for them to become immortal
C. Patients are left alone in the hospitals with no any other help coming from a health care team member
D. Florence Nightingale helps the people in need especially the wounded soldiers during the Crimean war

B. People would use amulets made from stones for them to become immortal

RATIONALE
Indigenous people belong to the Intuitive stage.

4. Educative period marks one of the significant events in nursing history. This is made possible with the utmost contribution of Florence Nightingale. In what institution did Florence Nightingale have an idea of what nursing is all about?

A. Florence Nightingale school of nursing
B. St. Elizabeth of Hungary Academy
C. Kaiserwerth foundation
D. Kozier University

C. Kaiserwerth foundation

6. Nursing care is continuously modified as we continue to face the world of globalization. More and more advancements are given to uplift the lives of our patients such as the use of laser surgeries and radiation therapies. During this time, nursing care is based on:

A. Experience in giving the effectiveness of the intervention
B. Instinctive reasoning in giving procedures
C. Upgraded knowledge and skills in any health care setting
D. Experience and trainings in the clinical area

C. Upgraded knowledge and skills in any health care setting

9. May it be any health care setting, the nurse must protect the client from any other harm or injustices specifically related to health because nurses should be patient-centered. Which of the following situations best describe this statement?

A. Nurse Melay who frequently gives jokes to her patients because laughter is the best medicine
B. Nurse Princess who reports to the finance department that her patient no longer pays the hospital bills and thus discharge is prohibited
C. Nurse Tom who charts the patient's vital signs always as normal without undergoing assessment
D. Nurse Patria who discusses the case of her patient to her nurse supervisor because the patient's physician no longer follows up the patient's treatment regimen

D. Nurse Patria who discusses the case of her patient to her nurse supervisor because the patient's physician no longer follows up the patient's treatment regimen

17. Donna, a high school graduate, wanted to enroll herself in one of the earliest schools of nursing so she can have a better background of what nursing in the Philippines is all about. As a nirse, you know that the following options below are nursing schools except:

A. PGH School of Nursing
B. Manila Central University
C. Iloilo Mission Hospital School of Nursing
D. St. Paul's Manila

B. Manila Central University

18. Filipino nurses also made an organized system in terms of the Philippines' Health Care Delivery System. This significant achievement was able to materialize in the person of Socorro Diaz because she is the first editor of the PNA magazine entitled:

A. Notes on Nursing
B. Notes on Hospital
C. The Message
D. The Filipino Nurse

C. The Message

RATIONALE
A and B Florence Nightingale
D Conchita Ruiz

19. The ER nurse is assessing the patient who is moaning and calling for help. The patient is bleeding profusely in the ER. The nurse might expect that the blood pressure of the patient will:

A. Remarkably increase
B. Drastically decrease
C. Cannot be determined
D. Return to normal

B. Drastically decrease

RATIONALE
Bleeding ▶️ ⬇️BV ▶️ Shock ▶️ ⬇️BP

20. What specific organ of the brain that regulates the balance between heat production and heat loss?

A. Cerebellum
B. Cerebrum
C. Medulla oblongata
D. Hypothalamus

D. Hypothalamus

RATIONALE
Functions of Hypothalamus
1. Temperature regulation
2. Thirst
3. Feeding centers
4. Emotions
5. Sexual desire
6. Circadian rhythm

21. The nurse palpates the client's body to detect warmth. What part of the hand should the nurse use?

A. Wrists of the hands
B. Fingertips
C. Back dorsal or dorsal face
D. Ulnar surface

C. Back dorsal or dorsal face

22. During nurses' rounds, the nurse observes that the patient's fever is fluctuating above the normal range and would return to normal at the end of the day. This type of fever is known as:

A. Relapsing
B. Constant
C. Intermittent
D. Remittent

C. Intermittent

RATIONALE
A Fluctuating, within several days/weeks, backs to normal
B High fever
D Fluctuating, within 24°, never back to normal

23. Nurse Bryan is observing a dying patient's breathing pattern. He notices that the patient's respiration goes faster and faster until it reaches a period of apneic episodes. What breathing pattern is this?

A. Kussmaul's respiration
B. Biot's respiration
C. Cheyne stokes respiration
D. Apneustic respiration

C. Cheyne stokes respiration

24. The ICU nurse observes that the pulsation of the patient upon auscultation is loud enough to be heard and further assessment would reveal that the patient has full pulsation. Therefore, the nurse would score the patient's pulse amplitude as:

A. 1
B. 2
C. 3
D. 4

D. 4

RATIONALE
0 - Absent - dead
1 - Thready - dying
2 - Weak - depressed
3 - Normal - discharged
4 - Bounding - Palpitations

26. Baby Mara, 6 days old, has a fast breathing of 70 breaths per minute. As a nurse, you know that this is termed as:

A. Tachypnea
B. Bradypnea
C. Dyspnea
D. Apnea

A. Tachypnea

RATIONALE
0-2 mos : 60bpm and above
2-12 mos : 50 bpm and above
12mos-5yo : 40 bpm and above

28. In the following situations, the nurse would expect sympathetic nervous system stimulation except:

A. The patient is pacing along the highway and is very talkative
B. A mother watching a television and would react to the villain of the teleserye
C. A cheer leader who failed to win the contest and does not want to go to school anymore
D. A muscle man who wanted to do several exercises everyday

C. A cheer leader who failed to win the contest and does not want to go to school anymore

30. After getting the BP of his patient, Nurse Anthony determines the pulse pressure of the patient. He knows that the result is within normal range if it is:

A. 30-40 mmHg
B. 120/80 mmHg
C. 80/40 mmHg
D. Less than 15 mmHg

A. 30-40 mmHg

RATIONALE
Pulse Pressure is obtained by subtracting DBP from SBP.
SBP — DBP = Pulse Pressure

31. In the following situations, which nurse is demonstrating the assessment phase of the nursing process?

A. The nurse who observes that the client's pain was relieved with pain medication
B. The nurse who changes the bed linens after the client is incontinent of feces
C. The nurse who asks the client how much lunch was eaten
D. The nurse who works with the client to set desired outcome goals

C. The nurse who asks the client how much lunch was eaten

RATIONALE
A Evaluation
B Intervention
D Planning

32. Before palpating the abdomen during an assessment, the nurse should do which of the following?

A. Elevate the client's head
B. Put on sterile gloves
C. Auscultate bowel sounds
D. Percuss all four quadrants

D. Percuss all four quadrants

RATIONALE
Assessment of the abdomen follows the IAPePa method.

33. The nurse would document which if the following in the medical record as objective data obtained during the client assessment?

A. Detailed description of pain in the extremity
B. Complaint of numbness in the right hand
C. Loss of hair on bilateral lower legs
D. Report of scalp itching each evening

C. Loss of hair on bilateral lower legs

RATIONALE
Pain (Option A), numbness (Option B), and itching (option D) are all subjective data.

35. All of the following would be considered objective assessment data for a patient admitted with diabetes mellitus, except:

A. +2 urine glucose level
B. Chemstrip reading of 240 mg/dL
C. Patient complains of polydipsia
D. Serum glucose level of 263 mg/dL

C. Patient complains of polydipsia

36. According to NANDA, Diagnosis is defined as the clinical judgment about the individual, family or community regarding their responses to actual or potential nursing problems. What format do you use in formulating diagnostic statements?

A. Etiology, Disease Process, Laboratories
B. Assessment, Causative Agent, Signs and Symptoms
C. Problem, "Related to", Manifestations
D. Problem, Etiology, Signs and Symptoms

D. Problem, Etiology, Signs and Symptoms

39. A nurse is caring for an obese 62 year old patient with arthritis who has developed an open reddened area over his sacrum. A priority nursing diagnosis is:

A. Imbalanced Nutrition: More than body requirements related to nutrient deficiency
B. Ineffective individual coping
C. Chronic pain related to immobility
D. Risk for infection related to an open wound

D. Risk for infection related to an open wound

41. A nursing diagnosis focuses on:

A. The Pathophysiology of the client's disease
B. Determining the baseline data
C. The client's ability to react or adjust when health is compromised
D. Describing the physician's actions to manage the problem

C. The client's ability to react or adjust when health is compromised

42. The most important benefit of the nursing process for the clients is that it:

A. Gives additional salaries to the nurses
B. Entails nurses for a promotion in the position
C. Offers praises to patients
D. Helps ensure quality care that meets individual needs

D. Helps ensure quality care that meets individual needs

43. Which of the following steps is under the planning phase of the nursing process?

A. Comparing data against standards
B. Performing nursing interventions
C. Selection of Nursing Interventions
D. Identify the problem

C. Selection of Nursing Interventions

RATIONALE
A Assessment
B Intervention
D Diagnosis

45. A nurse who is taking care of the patient with severe dehydration due to LBM decides to first provide the patient with liquids and juices and give health instruction on sanitation and hygiene. The nurse doing these activities is performing what element in the nursing process?

A. Implementation
B. Evaluation
C. Planning
D. Assessment

C. Planning

RATIONALE
Tip: The word "decides" means the nurse has yet to implement the nursing interventions, entailing that the nurse is on the planning phase.

46. You are assigned to Mrs. Ambrosio, age 49, who was admitted for possible surgery. She complained of recurrent pain at the right upper quadrant of the abdomen 1-2 hours after ingestion of fatty food. She also had frequent bouts of dizziness, BP of 170/100, hot flashes. Which of the above symptoms would be an objective cue?

A. BP measurement of 170/100
B. Complaint of hot flashes
C. Report of pain after ingestion of fatty foods
D. Complaint of frequent bouts of dizziness

A. BP measurement of 170/100

47. The final phase of nursing process is evaluation. Lumen, a nurse, is aware that the primary reason for this phase is to:

A. To establish observable cues from the patient
B. To develop an analysis base on assessment
C. Determine if the expected patient outcomes were accomplished
D. Evaluate the nurse's efficiency and knowledge in treating a particular patient

C. Determine if the expected patient outcomes were accomplished

48. Revision of the nursing care plan is being done if the intervention is not effective for our client. What phase of the nursing process serves as the basis for revising the nursing care plan?

A. Planning
B. Evaluation
C. Assessment
D. Implementation

B. Evaluation

RATIONALE
Evaluation phase is where the nurse will know whether the possible outcomes set in the planning phase are met or not met.

50. The nurse knows that the guidelines for writing an appropriate nursing diagnosis include all of the following EXCEPT:

A. State the diagnosis in terms of a problem, not a need
B. Use nursing terminology to describe the patient's response
C. Use statements that assist in planning independent nursing interventions
D. Use medical terminology to describe the probable cause of the patient's responses

D. Use medical terminology to describe the probable cause of the patient's responses