Nursing Practice I -Foundation of Professional 4.

A newly admitted female client was diagnosed

Nursing Practice with deep vein thrombosis. Which nursing
diagnosis should receive the highest priority?
1. The nurse In-charge in labor and delivery unit
administered a dose of terbutaline to a client a. Ineffective peripheral tissue perfusion related to
without checking the client’s pulse. The standard venous congestion.
that would be used to determine if the nurse was b. Risk for injury related to edema.
negligent is: c. Excess fluid volume related to peripheral vascular
disease.
a. The physician’s orders. d. Impaired gas exchange related to increased blood
b. The action of a clinical nurse specialist who is flow.
recognized expert in the field.
c. The statement in the drug literature about
administration of terbutaline. 5. Nurse Betty is assigned to the following clients.
d. The actions of a reasonably prudent nurse with The client that the nurse would see first after
similar education and experience. endorsement?

a. A 34 year-old post operative appendectomy client

2. Nurse Trish is caring for a female client with a of five hours who is complaining of pain.
history of GI bleeding, sickle cell disease, and a b. A 44 year-old myocardial infarction (MI) client
platelet count of 22,000/μl. The female client is who is complaining of nausea.
dehydrated and receiving dextrose 5% in half- c. A 26 year-old client admitted for dehydration
normal saline solution at 150 ml/hr. The client whose intravenous (IV) has infiltrated.
complains of severe bone pain and is scheduled to d. A 63 year-old post operative’s abdominal
receive a dose of morphine sulfate. In administering hysterectomy client of three days whose incisional
the medication, Nurse Trish should avoid which dressing is saturated with serosanguinous fluid.
route?
a. I.V
b. I.M 6. Nurse Gail places a client in a four-point restraint
c. Oral following orders from the physician. The client care
d. S.C plan should include:

a. Assess temperature frequently.

3. Dr. Garcia writes the following order for the b. Provide diversional activities.
client who has been recently admitted c. Check circulation every 15-30 minutes.
“Digoxin .125 mg P.O. once daily.” To prevent a d. Socialize with other patients once a shift.
dosage error, how should the nurse document this
order onto the medication administration record?
7. A male client who has severe burns is receiving
a. “Digoxin .1250 mg P.O. once daily” H2 receptor antagonist therapy. The nurse In-charge
b. “Digoxin 0.1250 mg P.O. once daily” knows the purpose of this therapy is to:
c. “Digoxin 0.125 mg P.O. once daily”
d. “Digoxin .125 mg P.O. once daily” a. Prevent stress ulcer
b. Block prostaglandin synthesis
c. Facilitate protein synthesis.
d. Enhance gas exchange a. Have condescending trust and confidence in their
subordinates.
b. Gives economic and ego awards.
8. The doctor orders hourly urine output c. Communicates downward to staffs.
measurement for a postoperative male client. The d. Allows decision making among subordinates.
nurse Trish records the following amounts of output
for 2 consecutive hours: 8 a.m.: 50 ml; 9 a.m.: 60
ml. Based on these amounts, which action should 12. Nurse Amy is aware that the following is true
the nurse take? about functional nursing

a. Increase the I.V. fluid infusion rate a. Provides continuous, coordinated and
b. Irrigate the indwelling urinary catheter comprehensive nursing services.
c. Notify the physician b. One-to-one nurse patient ratio.
d. Continue to monitor and record hourly urine c. Emphasize the use of group collaboration.
output d. Concentrates on tasks and activities.

9. Tony, a basketball player twist his right ankle 13.Which type of medication order might read
while playing on the court and seeks care for ankle "Vitamin K 10 mg I.M. daily × 3 days?"
pain and swelling. After the nurse applies ice to the
ankle for 30 minutes, which statement by Tony a. Single order
suggests that ice application has been effective? b. Standard written order
c. Standing order
a. “My ankle looks less swollen now”. d. Stat order
b. “My ankle feels warm”.
c. “My ankle appears redder now”.
d. “I need something stronger for pain relief” 14.A female client with a fecal impaction frequently
exhibits which clinical manifestation?

10.The physician prescribes a loop diuretic for a a. Increased appetite

client. When administering this drug, the nurse b. Loss of urge to defecate
anticipates that the client may develop which c. Hard, brown, formed stools
electrolyte imbalance? d. Liquid or semi-liquid stools

a. Hypernatremia
b. Hyperkalemia 15.Nurse Linda prepares to perform an otoscopic
c. Hypokalemia examination on a female client. For proper
d. Hypervolemia visualization, the nurse should position the client's
ear by:

11.She finds out that some managers have a. Pulling the lobule down and back
benevolent-authoritative style of management. b. Pulling the helix up and forward
Which of the following behaviors will she exhibit c. Pulling the helix up and back
most likely? d. Pulling the lobule down and forward
 d. Provide ice chips or water intake.
16. Which instruction should nurse Tom give to a
male client who is having external radiation
therapy: 20.Nurse Hazel will administer a unit of whole
blood, which priority information should the nurse
a. Protect the irritated skin from sunlight. have about the client?
b. Eat 3 to 4 hours before treatment.
c. Wash the skin over regularly. a. Blood pressure and pulse rate.
d. Apply lotion or oil to the radiated area when it is b. Height and weight.
red or sore. c. Calcium and potassium levels
d. Hgb and Hct levels.

17.In assisting a female client for immediate

surgery, the nurse In-charge is aware that she 21. Nurse Michelle witnesses a female client sustain
should: a fall and suspects that the leg may be broken. The
nurse takes which priority action?
a. Encourage the client to void following
preoperative medication. a. Takes a set of vital signs.
b. Explore the client’s fears and anxieties about the b. Call the radiology department for X-ray.
surgery. c. Reassure the client that everything will be alright.
c. Assist the client in removing dentures and nail d. Immobilize the leg before moving the client.
polish.
d. Encourage the client to drink water prior to
surgery. 22.A male client is being transferred to the nursing
unit for admission after receiving a radium implant
for bladder cancer. The nurse in-charge would take
18. A male client is admitted and diagnosed with which priority action in the care of this client?
acute pancreatitis after a holiday celebration of
excessive food and alcohol. Which assessment a. Place client on reverse isolation.
finding reflects this diagnosis? b. Admit the client into a private room.
c. Encourage the client to take frequent rest periods.
a. Blood pressure above normal range. d. Encourage family and friends to visit.
b. Presence of crackles in both lung fields.
c. Hyperactive bowel sounds
d. Sudden onset of continuous epigastric and back 23.A newly admitted female client was diagnosed
pain. with agranulocytosis. The nurse formulates which
priority nursing diagnosis?

19. Which dietary guidelines are important for nurse a. Constipation

Oliver to implement in caring for the client with b. Diarrhea
burns? c. Risk for infection
d. Deficient knowledge
a. Provide high-fiber, high-fat diet
b. Provide high-protein, high-carbohydrate diet.
c. Monitor intake to prevent weight gain.
24.A male client is receiving total parenteral
nutrition suddenly demonstrates signs and
symptoms of an air embolism. What is the priority 28.The nurse is aware that the most important
action by the nurse? nursing action when a client returns from surgery is:

a. Notify the physician. a. Assess the IV for type of fluid and rate of flow.
b. Place the client on the left side in the b. Assess the client for presence of pain.
Trendelenburg position. c. Assess the Foley catheter for patency and urine
c. Place the client in high-Fowlers position. output
d. Stop the total parenteral nutrition. d. Assess the dressing for drainage.

25.Nurse May attends an educational conference on 29. Which of the following vital sign assessments
leadership styles. The nurse is sitting with a nurse that may indicate cardiogenic shock after
employed at a large trauma center who states that myocardial infarction?
the leadership style at the trauma center is task-
oriented and directive. The nurse determines that a. BP – 80/60, Pulse – 110 irregular
the leadership style used at the trauma center is: b. BP – 90/50, Pulse – 50 regular
c. BP – 130/80, Pulse – 100 regular
a. Autocratic. d. BP – 180/100, Pulse – 90 irregular
b. Laissez-faire.
c. Democratic.
d. Situational 30.Which is the most appropriate nursing action in
obtaining a blood pressure measurement?

26.The physician orders DS 500 cc with KCl 10 a. Take the proper equipment, place the client in a
mEq/liter at 30 cc/hr. The nurse in-charge is going comfortable position, and record the appropriate
to hang a 500 cc bag. KCl is supplied 20 mEq/10 information in the client’s chart.
cc. How many cc’s of KCl will be added to the IV b. Measure the client’s arm, if you are not sure of
solution? the size of cuff to use.
c. Have the client recline or sit comfortably in a
a. .5 cc chair with the forearm at the level of the heart.
b. 5 cc d. Document the measurement, which extremity
c. 1.5 cc was used, and the position that the client was in
d. 2.5 cc during the measurement.

27.A child of 10 years old is to receive 400 cc of IV 31.Asking the questions to determine if the person
fluid in an 8 hour shift. The IV drip factor is 60. The understands the health teaching provided by the
IV rate that will deliver this amount is: nurse would be included during which step of the
nursing process?
a. 50 cc/ hour
b. 55 cc/ hour a. Assessment
c. 24 cc/ hour b. Evaluation
d. 66 cc/ hour c. Implementation
d. Planning and goals
36.An 80-year-old male client is admitted to the
hospital with a diagnosis of pneumonia. Nurse
32.Which of the following item is considered the Oliver learns that the client lives alone and hasn’t
single most important factor in assisting the health been eating or drinking. When assessing him for
professional in arriving at a diagnosis or dehydration, nurse Oliver would expect to find:
determining the person’s needs?
a. Hypothermia
a. Diagnostic test results b. Hypertension
b. Biographical date c. Distended neck veins
c. History of present illness d. Tachycardia
d. Physical examination

37.The physician prescribes meperidine (Demerol),

33.In preventing the development of an external 75 mg I.M. every 4 hours as needed, to control a
rotation deformity of the hip in a client who must client’s postoperative pain. The package insert is
remain in bed for any period of time, the most “Meperidine, 100 mg/ml.” How many milliliters of
appropriate nursing action would be to use: meperidine should the
client receive?
a. Trochanter roll extending from the crest of the
ileum to the midthigh. a. 0.75
b. Pillows under the lower legs. b. 0.6
c. Footboard c. 0.5
d. Hip-abductor pillow d. 0.25

34.Which stage of pressure ulcer development does 38. A male client with diabetes mellitus is receiving
the ulcer extend into the subcutaneous tissue? insulin. Which statement correctly describes an
insulin unit?
a. Stage I
b. Stage II a. It’s a common measurement in the metric system.
c. Stage III b. It’s the basis for solids in the avoirdupois system.
d. Stage IV c. It’s the smallest measurement in the apothecary
system.
d. It’s a measure of effect, not a standard measure of
35.When the method of wound healing is one in weight or quantity.
which wound edges are not surgically approximated
and integumentary continuity is restored by
granulations, the wound healing is termed 39.Nurse Oliver measures a client’s temperature at
102° F. What is the equivalent Centigrade
a. Second intention healing temperature?
b. Primary intention healing
c. Third intention healing a. 40.1 °C
d. First intention healing b. 38.9 °C
c. 48 °C
d. 38 °C c. 20 drops/minute
d. 18 drops/minute

40.The nurse is assessing a 48-year-old client who

has come to the physician’s office for his annual 44.If a central venous catheter becomes
physical exam. One of the first physical disconnected accidentally, what should the nurse in-
signs of aging is: charge do immediately?

a. Accepting limitations while developing assets. a. Clamp the catheter

b. Increasing loss of muscle tone. b. Call another nurse
c. Failing eyesight, especially close vision. c. Call the physician
d. Having more frequent aches and pains. d. Apply a dry sterile dressing to the site.

41.The physician inserts a chest tube into a female 45.A female client was recently admitted. She has
client to treat a pneumothorax. The tube is fever, weight loss, and watery diarrhea is being
connected to water-seal drainage. The nurse in- admitted to the facility. While assessing the client,
charge can prevent chest tube air leaks by: Nurse Hazel inspects the client’s abdomen and
notice that it is slightly concave. Additional
a. Checking and taping all connections. assessment should proceed in which order:
b. Checking patency of the chest tube.
c. Keeping the head of the bed slightly elevated. a. Palpation, auscultation, and percussion.
d. Keeping the chest drainage system below the b. Percussion, palpation, and auscultation.
level of the chest. c. Palpation, percussion, and auscultation.
d. Auscultation, percussion, and palpation.

42.Nurse Trish must verify the client’s identity

before administering medication. She is aware that 46. Nurse Betty is assessing tactile fremitus in a
the safest way to verify identity is to: client with pneumonia. For this examination, nurse
Betty should use the:
a. Check the client’s identification band.
b. Ask the client to state his name. a. Fingertips
c. State the client’s name out loud and wait a client b. Finger pads
to repeat it. c. Dorsal surface of the hand
d. Check the room number and the client’s name on d. Ulnar surface of the hand
the bed.

47. Which type of evaluation occurs continuously

43.The physician orders dextrose 5 % in water, throughout the teaching and learning process?
1,000 ml to be infused over 8 hours. The I.V. tubing
delivers 15 drops/ml. Nurse John should run the a. Summative
I.V. infusion at a rate of: b. Informative
c. Formative
a. 30 drops/minute d. Retrospective
b. 32 drops/minute
 b. Applying an antibiotic cream to the area three
48.A 45 year old client, has no family history of times per day.
breast cancer or other risk factors for this disease. c. Using normal saline solution to clean the ulcer
Nurse John should instruct her to have and applying a protective dressing as necessary.
mammogram how often? d. Using a povidone-iodine wash on the ulceration
three times per day.
a. Twice per year
b. Once per year
c. Every 2 years 52.Nurse Oliver must apply an elastic bandage to a
d. Once, to establish baseline client’s ankle and calf. He should apply the bandage
beginning at the client’s:

49.A male client has the following arterial blood a. Knee

gas values: pH 7.30; Pao2 89 mmHg; Paco2 50 b. Ankle
mmHg; and HCO3 26mEq/L. Based on these c. Lower thigh
values, Nurse Patricia should expect which d. Foot
condition?

a. Respiratory acidosis 53.A 10 year old child with type 1 diabetes

b. Respiratory alkalosis develops diabetic ketoacidosis and receives a
c. Metabolic acidosis continuous insulin infusion. Which condition
d. Metabolic alkalosis represents the greatest risk to this child?

a. Hypernatremia
50.Nurse Len refers a female client with terminal b. Hypokalemia
cancer to a local hospice. What is the goal of this c. Hyperphosphatemia
referral? d. Hypercalcemia

a. To help the client find appropriate treatment

options. 54.Nurse Len is administering sublingual
b. To provide support for the client and family in nitrglycerin (Nitrostat) to the newly admitted client.
coping with terminal illness. Immediately afterward, the client may experience:
c. To ensure that the client gets counseling
regarding health care costs. a. Throbbing headache or dizziness
d. To teach the client and family about cancer and b. Nervousness or paresthesia.
its treatment. c. Drowsiness or blurred vision.
d. Tinnitus or diplopia.

51.When caring for a male client with a 3-cm stage

I pressure ulcer on the coccyx, which of the 55.Nurse Michelle hears the alarm sound on the
following actions can the nurse institute telemetry monitor. The nurse quickly looks at the
independently? monitor and notes that a client is in a ventricular
tachycardia. The nurse rushes to the client’s room.
a. Massaging the area with an astringent every 2 Upon reaching the client’s bedside, the nurse would
hours. take which action first?
 unit secretary calls the nurse on the intercom to tell
a. Prepare for cardioversion the nurse that there is an emergency phone call. The
b. Prepare to defibrillate the client appropriate nursing action is to:
c. Call a code
d. Check the client’s level of consciousness a. Immediately walk out of the client’s room and
answer the phone call.
b. Cover the client, place the call light within reach,
56.Nurse Hazel is preparing to ambulate a female and answer the phone call.
client. The best and the safest position for the nurse c. Finish the bed bath before answering the phone
in assisting the client is to stand: call.
d. Leave the client’s door open so the client can be
a. On the unaffected side of the client. monitored and the nurse can answer the phone call.
b. On the affected side of the client.
c. In front of the client.
d. Behind the client. 60. Nurse Janah is collecting a sputum specimen for
culture and sensitivity testing from a client who has
a productive cough. Nurse Janah plans to implement
57.Nurse Janah is monitoring the ongoing care which intervention to obtain the specimen?
given to the potential organ donor who has been
diagnosed with brain death. The nurse determines a. Ask the client to expectorate a small amount of
that the standard of care had been maintained if sputum into the emesis basin.
which of the following data is observed? b. Ask the client to obtain the specimen after
breakfast.
a. Urine output: 45 ml/hr c. Use a sterile plastic container for obtaining the
b. Capillary refill: 5 seconds specimen.
c. Serum pH: 7.32 d. Provide tissues for expectoration and obtaining
d. Blood pressure: 90/48 mmHg the specimen.

58. Nurse Amy has an order to obtain a urinalysis 61. Nurse Ron is observing a male client using a
from a male client with an indwelling urinary walker. The nurse determines that the client is using
catheter. The nurse avoids which of the following, the walker correctly if the client:
which contaminate the specimen?
a. Puts all the four points of the walker flat on the
a. Wiping the port with an alcohol swab before floor, puts weight on the hand pieces, and then
inserting the syringe. walks into it.
b. Aspirating a sample from the port on the drainage b. Puts weight on the hand pieces, moves the walker
bag. forward, and then walks into it.
c. Clamping the tubing of the drainage bag. c. Puts weight on the hand pieces, slides the walker
d. Obtaining the specimen from the urinary drainage forward, and then walks into it.
bag. d. Walks into the walker, puts weight on the hand
pieces, and then puts all four points of the walker
flat on the floor.
59.Nurse Meredith is in the process of giving a
client a bed bath. In the middle of the procedure, the
62.Nurse Amy has documented an entry regarding client has right sided arm and leg weakness. The
client care in the client’s medical record. When nurse would suggest that the client use which of the
checking the entry, the nurse realizes that incorrect following assistive devices that would provide the
information was documented. How does the nurse best stability for ambulating?
correct this error?
a. Crutches
a. Erases the error and writes in the correct b. Single straight-legged cane
information. c. Quad cane
b. Uses correction fluid to cover up the incorrect d. Walker
information and writes in the correct information.
c. Draws one line to cross out the incorrect
information and then initials the change. 66.A male client with a right pleural effusion noted
d. Covers up the incorrect information completely on a chest X-ray is being prepared for thoracentesis.
using a black pen and writes in the correct The client experiences severe dizziness when sitting
information upright. To provide a safe environment, the nurse
assists the client to which position for the
procedure?
63.Nurse Ron is assisting with transferring a client
from the operating room table to a stretcher. To a. Prone with head turned toward the side supported
provide safety to the client, the nurse should: by a pillow.
b. Sims’ position with the head of the bed flat.
a. Moves the client rapidly from the table to the c. Right side-lying with the head of the bed elevated
stretcher. 45 degrees.
b. Uncovers the client completely before d. Left side-lying with the head of the bed elevated
transferring to the stretcher. 45 degrees.
c. Secures the client safety belts after transferring to
the stretcher.
d. Instructs the client to move self from the table to 67.Nurse John develops methods for data gathering.
the stretcher. Which of the following criteria of a good instrument
refers to the ability of the instrument to yield the
same results upon its repeated administration?
64.Nurse Myrna is providing instructions to a
nursing assistant assigned to give a bed bath to a a. Validity
client who is on contact precautions. Nurse Myrna b. Specificity
instructs the nursing assistant to use which of the c. Sensitivity
following protective items when giving bed bath? d. Reliability

a. Gown and goggles

b. Gown and gloves 68.Harry knows that he has to protect the rights of
c. Gloves and shoe protectors human research subjects. Which of the following
d. Gloves and goggles actions of Harry ensures anonymity?

a. Keep the identities of the subject secret

65. Nurse Oliver is caring for a client with impaired b. Obtain informed consent
mobility that occurred as a result of a stroke. The
c. Provide equal treatment to all the subjects of the d. Endnotes
study.
d. Release findings only to the participants of the
study 73.When Nurse Trish is providing care to his
patient, she must remember that her duty is bound
not to do doing any action that will cause the patient
69.Patient’s refusal to divulge information is a harm. This is the meaning of the bioethical
limitation because it is beyond the control of principle:
Tifanny”. What type of research is appropriate for
this study? a. Non-maleficence
b. Beneficence
a. Descriptive- correlational c. Justice
b. Experiment d. Solidarity
c. Quasi-experiment
d. Historical
74.When a nurse in-charge causes an injury to a
female patient and the injury caused becomes the
70.Nurse Ronald is aware that the best tool for data proof of the negligent act, the presence of the injury
gathering is? is said to exemplify the principle of:

a. Interview schedule a. Force majeure

b. Questionnaire b. Respondeat superior
c. Use of laboratory data c. Res ipsa loquitor
d. Observation d. Holdover doctrine

71.Monica is aware that there are times when only 75.Nurse Myrna is aware that the Board of Nursing
manipulation of study variables is possible and the has quasi-judicial power. An example of this power
elements of control or randomization are not is:
attendant. Which type of research is referred to this?
a. The Board can issue rules and regulations that
a. Field study will govern the practice of nursing
b. Quasi-experiment b. The Board can investigate violations of the
c. Solomon-Four group design nursing law and code of ethics
d. Post-test only design c. The Board can visit a school applying for a
permit in collaboration with CHED
d. The Board prepares the board examinations
72.Cherry notes down ideas that were derived from
the description of an investigation written by the
person who conducted it. Which type of reference 76. When the license of nurse Krina is revoked, it
source refers to this? means that she:

a. Footnote a. Is no longer allowed to practice the profession for

b. Bibliography the rest of her life
c. Primary source
b. Will never have her/his license re-issued since it 80. The nursing theorist who developed
has been revoked transcultural nursing theory is:
c. May apply for re-issuance of his/her license
based on certain conditions stipulated in RA 9173 a. Florence Nightingale
d. Will remain unable to practice professional b. Madeleine Leininger
nursing c. Albert Moore
d. Sr. Callista Roy

77.Ronald plans to conduct a research on the use of

a new method of pain assessment scale. Which of 81.Marion is aware that the sampling method that
the following is the second step in the gives equal chance to all units in the population to
conceptualizing phase of the research process? get picked is:

a. Formulating the research hypothesis a. Random

b. Review related literature b. Accidental
c. Formulating and delimiting the research problem c. Quota
d. Design the theoretical and conceptual framework d. Judgment

78. The leader of the study knows that certain 82.John plans to use a Likert Scale to his study to
patients who are in a specialized research setting determine the:
tend to respond psychologically to the conditions of
the study. This referred to as : a. Degree of agreement and disagreement
b. Compliance to expected standards
a. Cause and effect c. Level of satisfaction
b. Hawthorne effect d. Degree of acceptance
c. Halo effect
d. Horns effect
83.Which of the following theory addresses the four
modes of adaptation?
79.Mary finally decides to use judgment sampling
on her research. Which of the following actions of a. Madeleine Leininger
is correct? b. Sr. Callista Roy
c. Florence Nightingale
a. Plans to include whoever is there during his d. Jean Watson
study.
b. Determines the different nationality of patients
frequently admitted and decides to get 84.Ms. Garcia is responsible to the number of
representations samples from each. personnel reporting to her. This principle refers to:
c. Assigns numbers for each of the patients, place
these in a fishbowl and draw 10 from it. a. Span of control
d. Decides to get 20 samples from the admitted b. Unity of command
patients c. Downward communication
d. Leader
 a. Arrange for typing and cross matching of the
85.Ensuring that there is an informed consent on the client’s blood.
part of the patient before a surgery is done, b. Compare the client’s identification wristband
illustrates the bioethical principle of: with the tag on the unit of blood.
c. Start an I.V. infusion of normal saline solution.
a. Beneficence d. Measure the client’s vital signs.
b. Autonomy
c. Veracity
d. Non-maleficence 90.A 65 years old male client requests his
medication at 9 p.m. instead of 10 p.m. so that he
can go to sleep earlier. Which type of nursing
86.Nurse Reese is teaching a female client with intervention is required?
peripheral vascular disease about foot care; Nurse
Reese should include which instruction? a. Independent
b. Dependent
a. Avoid wearing cotton socks. c. Interdependent
b. Avoid using a nail clipper to cut toenails. d. Intradependent
c. Avoid wearing canvas shoes.
d. Avoid using cornstarch on feet.
91.A female client is to be discharged from an acute
care facility after treatment for right leg
87.A client is admitted with multiple pressure thrombophlebitis. The Nurse Betty notes that the
ulcers. When developing the client's diet plan, the client's leg is pain-free, without redness or edema.
nurse should include: The nurse's actions reflect which step of the nursing
process?
a. Fresh orange slices
b. Steamed broccoli a. Assessment
c. Ice cream b. Diagnosis
d. Ground beef patties c. Implementation
d. Evaluation

88.The nurse prepares to administer a cleansing

enema. What is the most common client position 92.Nursing care for a female client includes
used for this procedure? removing elastic stockings once per day. The Nurse
Betty is aware that the rationale for this
a. Lithotomy intervention?
b. Supine
c. Prone a. To increase blood flow to the heart
d. Sims’ left lateral b. To observe the lower extremities
c. To allow the leg muscles to stretch and relax
d. To permit veins in the legs to fill with blood.
89.Nurse Marian is preparing to administer a blood
transfusion. Which action should the nurse take
first?
93.Which nursing intervention takes highest priority c. Apply the face mask from the client's chin up
when caring for a newly admitted client who's over the nose.
receiving a blood transfusion? d. Loosen the connectors between the oxygen
equipment and humidifier.
a. Instructing the client to report any itching,
swelling, or dyspnea.
b. Informing the client that the transfusion usually 97.The maximum transfusion time for a unit of
take 1 ½ to 2 hours. packed red blood cells (RBCs) is:
c. Documenting blood administration in the client
care record. a. 6 hours
d. Assessing the client’s vital signs when the b. 4 hours
transfusion ends. c. 3 hours
d. 2 hours

94.A male client complains of abdominal

discomfort and nausea while receiving tube 98.Nurse Monique is monitoring the effectiveness
feedings. Which intervention is most appropriate for of a client's drug therapy. When should the nurse
this problem? Monique obtain a blood sample to measure the
trough drug level?
a. Give the feedings at room temperature.
b. Decrease the rate of feedings and the a. 1 hour before administering the next dose.
concentration of the formula. b. Immediately before administering the next dose.
c. Place the client in semi-Fowler's position while c. Immediately after administering the next dose.
feeding. d. 30 minutes after administering the next dose.
d. Change the feeding container every 12 hours.

99.Nurse May is aware that the main advantage of

95.Nurse Patricia is reconstituting a powdered using a floor stock system is:
medication in a vial. After adding the solution to the
powder, she nurse should: a. The nurse can implement medication orders
quickly.
a. Do nothing. b. The nurse receives input from the pharmacist.
b. Invert the vial and let it stand for 3 to 5 minutes. c. The system minimizes transcription errors.
c. Shake the vial vigorously. d. The system reinforces accurate calculations.
d. Roll the vial gently between the palms.

100. Nurse Oliver is assessing a client's abdomen.

96.Which intervention should the nurse Trish use Which finding should the nurse report as abnormal?
when administering oxygen by face mask to a
female client? a. Dullness over the liver.
b. Bowel sounds occurring every 10 seconds.
a. Secure the elastic band tightly around the client's c. Shifting dullness over the abdomen.
head. d. Vascular sounds heard over the renal arteries
b. Assist the client to the semi-Fowler position if
possible.