Fundamentals

1. Which option serves as a framework for nursing education and clinical practice? A. Scientific Breakthroughs B. Technical Advances C.
Theoretical models D. Medical Practices Answer : C. Rationale: Theoretical models of nursing provide the foundation of all nursing knowledge. They also direct nursing practice based on the concepts of health, person, environment and nursing.Scientific Breakthroughs, technological models, medical practices may affect nursing but arent frameworks for nursing education and practices.
Fundamentals of Nursing by Kozier and Erbs: pg. 11 Eight Edition

2. The nurse must assess the skin turgor of an elderly client. When evaluating skin turgor the skin should remember that: A. Over hydration of the skin to tent B. Dehydration causes the skin to appear edematous and spongy C. Inelastic skin turgor is a normal part of aging D. Normal skin turgor is moist and boggy. Answer: C Rationale: Inelastic skin turgor is normal part of aging.
Fundamentals of Nursing by Kozier and Erbs: pg. 411 Eight Edition

3. When positioned properly, the tip of central nervous catheter should lie in the: A. Superior Vena Cava B. Basilic Vein C. Jugular Vein D. Sublaclavian Vein Answer: A Rationale: When the Central Nervous Vena Cava is positioned correctly, its tip lies in the superior vena cava, Inferior Vena Cava, or right atrium that is in the central venous circulation. Blood flows unimpeded around the tip allowing the rapid infusion of large amounts of fluid. The basilica jugular, and subclavian veins are common insertion sites central nervous catheters.
Fundamentals of Nursing by Kozie, Erb, Berman, Snyder: pg. 1382 Seventh Edition
4. Which of the following sentences is correctly describes the anatomic position? A. The body is supine B. Arms are elevated at the shoulder level
C. Palms are turned forward D. The body is facing backward Answer: A Rationale: In the anatomic position, the body is erect, facing forward with arms the sides and palms turned forward.
Fundamentals of Nursing by Kozier and Erb: 956 Eight Edition

5. At 8:00 am, the nurse should assess a client whos scheduled for surgery at 10:00am. During the assessment the nurse detects dyspnea, a nonproductive cough, and back pain. What should the nurse do next? A. Check to see that the chest X-ray was done yesterday as ordered. B. Check the serum electrolyte levels and complete blood count (CBC) C. Notify the physician immediately of this finding. D. Sign the preoperative checklist for this client. Answer: C Rationale: The nurse should notify the physician immediately because dyspnea, a nonproductive cough, and back pain may sign changes in the clients respiratory status.
Fundamentals of Nursing by Kozier, Erb, Berman, Snyder: pg. 403 Seventh Edition
6. The physician order Ampicillin (Omnipen) 500mg by mouth q6. This medication order is an example of: A. Standard written order. B. A single Order C. PRN order D. a stat order Answer: A Rationale: A standard written order is an order that applies until the prescriber writes another order to alter or discontinue the first one. A single order allows for one time dose only, and PRN order allows drug administration when the clients need it. A stat order includes such words now or immediately.
Fundamentals of Nursing by Kozier, Erb, Berman, Snyder: pg. 794 Seventh Editions
7. To measures the client temperature at 102 F o. What is the equivalent centigrade temperature/ A. 39oC B. 74oC C. 38.9oC D. 40.1oC Answer: 3 Rationale: To convert Fahrenheit degrees to Centigrade use this formula:
C = (oF-32) 1.8 C = (102-32) 1.8
o o o
C = 70 1.8 C = 38.9
8. A client reports abdominal pain. Which action would aid the nurses investigation of this complaint? A. Using deep palpation B. Assessing the painful area last C. Assessing the painful area first D. Checking for warmth in the painful area Answer: B Rationale: Assessing the painful area last allows the nurse to obtain the, maximal amount of information with minimal client discomfort. To prepare the client, the nurse should always let the client know when painful area will be assessed. Pressure resulting deep palpation may cause rupture of an underlying mass. Checking for warmth in the painful area offers no real information about the clients pain.
9. The nurse gives a client the wrong medication, after assessing the client; the nurse completes an incident report. Which statement describes what will occur next? A. The incident reported to the state board of disciplinary action. B. The incident will be documented in the nurses personnel file. C. The medication error will result in the nurse being suspended and possibly, terminated from employment at the facility. D. The incident report is a method of promoting quality care and risk management. Answer: D Rationale: Unusual occurrence and deviations from care are documented on incident reports. Incident reports are internal to the facility and are used to evaluate care, determine potential risk, or discover system problems that could have attributed to the error.

10. When preparing a client for bronchoscopy, the nurse should instruct the client not to? A. Walk B. Cough C. Talk D. Eat Answer: D
Rationale: Bronchoscopy involves visualization of the trachea and bronchial tree. To prevent aspiration of stomach contents into the lungs, the nurse should instruct the client not to eat or drink anything for approximately 6 hours before the procedure.
Fundamentals of Nursing by Kozier, Erb, Berman, Snyder: pg.1446 Seventh Edition

11. Which are the stages of grief that a client or family go through? A. Acceptance, Depression, Anger, Bargaining and Denial B. Depression, Anger, Bargaining, Acceptance and Denial C. Bargaining, Depression, Denial, Anger and Acceptance D. Denial, Anger, Bargaining, Depression, and Acceptance Answer: D Rationale: Denial is the avoidance of deaths inevitability and is the first step of grieving process. Anger, most intense grief reaction, arises when people realize that death and loss will actually occur or has occurred for a family member. Bargaining, happens when family members attempt to stall or manipulate the outcome or death. Depression is a response to loss thats expressed or profound sadness or deep suffering. Acceptance is the final stage, and its the ability to overcome the grief and accept what has happened.
12. The nurse is assessing a clients abdomen, which finding should the nurse report as an abnormal/ A. Dullness over the liver B. Bowel sound occurring every 10 seconds C. Shifting dullness over the abdomen D. Vascular sound heard over the artery Answer: C Rationale: Shifting dullness over the abdomen indicates ascites, an abnormal finding. The other options the other options are normal abdominal findings.
13. When caring for a client, the nurse must determine whether the client has achieved the goals established in the care plan. The nurse determines goal achievement during which step of the nursing process? A. Evaluation B. Planning C. Assessment D. Implementation Answer: A Rationale: During evaluation, the nurse assesses the clients goal achievement by comparing the actual outcome identified during the planning step of the nursing process.
Fundamentals of Nursing by Kozier and Erb: pg. 235 Eight Edition
14. When performing an abdominal assessment, the nurse should follow which examination sequence? A. Inspection, auscultation, percussion and palpation B. Ausculatation, Percussion, Palpation, and Inspection C. Percussion, Auscultation, Inspection, and Auscultation D. Auscultation, Inspection, Percussion, and Palpation Answer: A Rationale: The correct sequence for abdominal assessment in inspection is Inspection, auscultation, percussion and palpation because this sequence prevents altering bowel sound before auscultation.
15. When prioritizing a clients care plan based on Maslows Hierarchy of needs, the nurses first prioritize would be: A. allowing the family to see a newly admitted client B. Ambulating the client in the hallway C. Administering pain medication D. Placing wrist restraints on the client Answer: C Rationale: In Maslows Hierarcy of needs, pain relief is on the first layer.
16. A client is admitted with acute chest pain. When obtaining the health history, which question would be most helpful for the nurse to ask/ A. Do you need anything now? B. Why do you think you had a heart attack? C. What were you doing when the pain started? D. Has anyone in your family been sick lately? Answer: C Rationale: Subjective Data about the chest pain help determine the specific health problem. Asking about bout the setting in which the pain developed can provide helpful information about its cause.

17. When teaching a client with how to take a sublingual tablet, the nurse should instruct the client to place the tablet on the: A. Top of the mouth B. Roof of the mouth
C. Floor of the mouth D. Inside f the cheek Answer: C. Rationale: The nurse should instruct the client to touch the tip of the tongue to the roof of the mouth and then place the sublingual tablet on the floor of the mouth.

18. The nurse is assessing a postoperative client. Which of the following should the nurse document a subjective data? A. Vital Sign B. Laboratory Test Results C. Clients description of pain D. ECG wave forms Answer: C Rationale: Subjective data comes from directly from the client and usually are recorded as direct quotations that reflect a clients opinions or feelings about a situation. Vital signs, Laboratory are example of Objective date.

19. The nurse prepares to assess a client who has just been admitted to the health care facility. During assessment, the nurse performs which activity? A. Collects data B. Formulates Nursing Diagnoses C. Develops a Care Plan D. Writes client outcomes Answer: A Rationale: During the assessment step of the nursing process, the nurse collects relevant data from various sources.

20. The nurse evaluating a clients auditory function. To compare air conduction to bone conduction, the nurse should conduct which test? A. Whispered voice test B. Webers Test C. Watch tick test D. Rinne Test Answer: D
Rationale: The Rinne Test compares air conduction to bone conduction in both ears. The whispered voice test evaluates low pitched sounds, and the watch tick test assesses high pitched sounds. Both tests assess gross hearing. The Weber test evaluates bone conduction.

21. Which member of the health care team is responsible for obtaining informed consent? A. The primary nurse B. The physician C. The nurse working with the physician D. The physicians assistant Answer: B Rationale: The physician involved with the procedure is responsible for obtaining the clients informed consent.

22. For the past 24 hours, a client with dry skin and dry mucous membranes has had urine output of 600ml and a fluid intake of 800ml. The clients urine is dark amber. This assessment indicates which nursing diagnosis? A. Impaired urinary elimination B. Deficient fluid volume C. Imbalanced nutrition: less than body requirements D. Excess fluid Volume Answer: B Rationale: Dark, concentrated urine, dry mucous membrane, and a urine output of less than 30ml/hour are symptoms of dehydration or deficient fluid volume.
Fundamentals of Nursing by Kozier, Erb, Berman, Snyder: pg. 1478 Eight Edition
23. A staff burse very busy in pediatric unit is an excellent role model for her colleagues. She encourages them to participate in the units decision making process and helps them improve their clinical skills. This nurse is functioning effectively in which role? A. Manager B. Autocrat C. Leader D. Authority Answer: C Rationale: A leader doesnt have formal power and authority but influences the success of unit by being an excellent role model and by guiding and facilitating professional growth and development.
24. The nurse is teaching in a high protein diet. The teaching is successful if the clients identify which of the following meals as high in protein? A. Baked beans, Hamburger and beans B. Spaghetti, broccoli and tea C. Spinach and soda D. Fried chicken, soda, spinach Answer: A Rationale: Beans, Hamburger are high sources of protein.

25. A client suddenly loses consciousness. What should the nurse do? A. Call for assistance B. Assess for responsiveness C. Palpate for a carotid pulse D. Assess for papillary response Answer: B Rationale: The nurse should assist the responsiveness first to prevent injuries, to a client who isnt cardiac or respiratory arrest.

26. A client with heart failure must be monitored closely after starting diuretic therapy. What is the most accurate indicator of this client status? A. Fluid intake and Output B. Urine specific gravity C. Vital Signs D. Weight Answer: D Rationale: Heart failure typically causes fluid overload, resulting in weight gain.

27. A nurse is recording a clients complain of painful urination. When documenting this symptom the nurse should use which term? A. Oliguria B. Anuria C. Pyuria D. Dysuria
Answer: D Rationale: The nurse should document painful urination as dysuria. Oliguria refers to decrease amount of urine excreted; Anuria to a urine output below 100ml/day; pyuria to pus in the urine.

28. When leaving the room of a client in strict isolation, the nurse should remove which protective equipment first? A. Cap B. Mask C. Gown D. Cloves Answer: D Rationale: Gloves considered the most contaminated

29. A client age 43 has no family history of breast cancer or other risk factor of the disease. The nurse should instruct her to have a mammogram how often? A. Once, to establish the baseline B. Once per year C. Every 2 years D. Twice per year Answer: B. Rationale: Yearly mammograms should begin at age 40 and continue as the woman in good health.

30. The nurse is transferring a client from bed to a chair. Which action does the nurse take during this client transfer? A. Position the head on the bed flat B. Helps the client dangle his legs C. Stands behind the client D. Place the chair facing away from the bed. Answer: B Rationale: After placing a client in high fowlers position and moving the client to the side of bed, the nurse helps the client sit on the edge of the bed and dangle his legs. The nurse then faces the client and places the chair next to and facing the head of the bed.
31. The client placed in isolation. Client isolation attempts to break the chain of infection by interfering with the: A. Agent B. Susceptible Host C. Transmission Mode D. Portal of entry Answer: C Rationale: A Client Isolation technique attempts to break the chain of infection by interfering with the transmission mode.

32. The nurse is assessing a client for the risk for falls. The nurse should collect: A. Gait and balance information B. The agency restraint policy C. The familys psychosocial history D. The client dietary preference Answer: A Rationale: Gait and balance helps to determine the risk for falls.
33. The nurse assessing tactile fremitus in a client with pneumonia. For this examination, the nurse should use the A. fingertips B. ulnar surface of the hand C. dorsal surface of the hand D. finger pads Answer: B Rationale: The nurse should use the ulnar surface or ball of the hand to assess the tactile fremitus, thrills, and vocal vibrations through the chest wall.

34. When percussing a client chest, the nurse should identify which sound as normal findings? A. Hyper resonance B. Tympany C. Resonance D. Dullness
Answer: C Rationale: Resonance is a normal finding on percussion of healthy lung tissue.

35. During physical examination, the nurse uses various techniques to assess structures, organ, and body systems. Which technique allows the nurse to feel for vibration and locate body structures? A. Auscultation B. Inspection C. Palpation D. Percussion Answer: C Rationale: During Palpation the nurse uses various techniques to assess structures, organ, and body systems. Which techniques allow the nurse to feel vibration and locate body structures.

36. When inspecting a client skin, the nurse find a vesicle on the clients arm. Which description applies to vesicle? A. Flat, nonpalpable and colored B. Solid, Elevated and circumscribed C. Circumscribed, elevated and filled with serous fluid D. Elevated, pus-filled and circumscribed Answer: C Rationale: A vesicle is a circumscribed skin elevated with serous fluid.

37. The nurse conducts a Rombergs sign. What is the correct procedure for this step? A. Have the client stand with feet and arms at the side and try to balance, first eyes open with one eyes closed. B. Instruct the client to walk across the room on the heels and to return walking on the toes. C. Ask the client to touch the thumb of one hand to each finger on that hand and then repeat instruction using other hand. D. Instruct the client to lie on the back and slowly slide the heel down the shin of the apposite leg, from the knee to ankle. Answer: A Rationale: To test for the Rombergs Sign, which assesses balance, the nurse instruct the client to stand with feet together and arms at the sides while observing the clients ability to maintain balance.
38. Which of the following factors are the major components of a clients general background drug history? A. Allergies and socioeconomic status B. Gastric reflex and age C. Urine output and allergies D. Bowel habits and allergy Answer: A Rationale: General background data consist of such components allergies and medical history, habits, socioeconomic status, lifestyle, beliefs, and sensory deficits.

39. A clients complain abdominal pain. To elicit as much information about the pain as possible, the nurse should ask; A. Are you having pain? B. Is the pain constant? C. Is the pain sharp? D. What does the pain like? Answer: D Rationale: An open-ended question provides more information than a closed-ended question, which limits client response.

40. Which pulse should the nurse palpate during rapid assessment of an unconscious adult? A. Radial B. Brachial C. Femoral D. Carotid Answer: D Rationale: During a rapid assessment, the nurse priority is to check the clients vital functions by assessing his airway, breathing, and circulation. To check the clients circulation, the nurse must assess his heart and vascular network functions. This is done by checking his color, temperature, mental status and most importantly his pulse. The nurse should use the carotid artery to check a clients circulation.

41. The nurse assessing an elderly client. When performing the assessment the nurse should consider that one normal aging change is: A. cloudy vision B. incontinence
C. diminished reflexes D. tremors Answer: C Rationale: Degenerative changes can lead to decreased reflexes, which is normal result of aging. Cloudy vision, incontinence and tremors maybe sign and symptoms of underlying pathology.

42. The nurse prepares to palpate client maxillary sinuses. For this procedure, where should the nurse place the hands? A. On the bridge of the nose B. Below the eyebrows C. Below the cheekbones D. Over the temporal Area Answer: C Rationale: To palpate the maxillary sinuses, the nurse places the hand on either side of the clients nose below the cheekbone (zygomatic bone).

43. During a physical examination, the nurse asks a client to hold a breath briefly, and then uses a stethoscope to ausculatate over the carotid arteries. Which finding is normal when auscultating over these arteries. A. No sound heard over the over either carotid artery B. Faint swishing sound heard over both carotid arteries C. Throbbing pulsations heard bilaterally D. Louder sounds heard over the right carotid artery than over the left carotid artery Answer: A Rationale: Absence of sounds over either carotid artery indicates unobstructed blood flow. An auscultation of any sounds is abnormal.

44. The client undergoes abdominal hysterectomy. When assessing the client 10 hours later, the nurse identifies which finding as an early sign of shocks? A. Restlessness B. Pale, warm, dry skin C. Heart rate of 110 bpm D. Urine output of 30ml/hour Answer: A
Rationale: Early in shock, hyperactivity of the sympathetic nervous system causes increased epinephrine secretion, which typically makes the client restless, anxious, nervous, and irritable. It also decreases tissue perfusion to the skin causing pale, cool, clammy skin.

45. Why should the nurse inspect first and then auscultate when performing an assessment of pediatric client? A. Because the nurse touch may calm the child B. Because the child may cry as the assessments proceed, making auscultations difficult. C. Because the nurses touch may frighten the child D. Because the nurses hand or stethoscope may feel cold. Answer: B Rationale: Because other assessment procedures make the child cry, auscultate the childs lungs right after inspection. Crying increases the respiratory rate and creates noise that interferes with clear auscultation.

46. When obtaining a clients history, a nurse develops genogram. What is the purpose of developing genogram. A. To identify genetic and familial health problems B. To identify previously undetected disease and disorders C. To identify the client for seeking care D. To identify the clients chronic health problems Answer: A Rationale: A genogram, which organizes a familys history into a diagram flow chart, is used to identify the genetic and familial health problems.

47. The nurse is helping to plan a teaching session for a client who will be discharged with a colostomy. When describing a healthy stoma, which statement should the nurse be sure to include/ A. Stoma should appear dark and have a bluish hue B. At first, stoma may bleed slightly when touched C. The stoma should remain swollen distal to the abdomen D. A burning sensation under the stoma faceplate is normal Answer: B. Rationale: For the first few days to a week after a client receives a colostomy, slight bleeding normally occurs when the stoma is touched because the surgical site is still fresh.
48. Which statement regarding heart sound is correct? A. S1 and S2 sound equally loud over the entire cardiac area. B. S1 and S2 sound fainter at the apex C. S1 and S2 sound fainter at the base D. S1 is loudest at the apex, and S2 is the loudest at the base Answer: D Rationale: The S1 sound the lub sound is loudest at the apex of the heart. It sounds longer, lower and louder there than the S2. The s2 the dub sounds is the loudest at the base. It sounds shorter, sharper, higher, and louder than S1.
49. When routinely evaluating a geriatric client for any atypical signs and symptoms, the nurse should remember that: A. aging can reduce the bodys to regulate body temperature B. aging can increase pain perception C. anesthesia usually causes psychotic behavior postoperatively in geriatric client D. The risk of developing emphysema is highest in elderly people Answer: A Rationale: In an assessment, the nurse should remember that aging can reduce the ability to regulate body temperature.
Fundamentals of Nursing by Kozier and Erb: pg.410 Seventh Edition

50. The nurse uses a stethoscope to ausculatate a clients chest. Which statement about stethoscope with a bell diaphragm is true? A. The bell detects high-pitched sounds best B. The diaphragm detects high-pitched sounds best C. The bells detects thrills best D. The diaphragm detect low-pitched sound best Answer: B Rationale: The diaphragm of a stethoscope detects high-pitched sounds best; the bell detects low pitched sound best. Palpation detects thrills best. Fundamentals of Nursing by Kozier, Erb, Berman, Snyder: pg.501 Seventh Edition 51. Which descriptions true about crackles? A. grating sound B. High-pitched, musical squeaks
C. low-pitched noises that sounds like snoring D. may be fine, medium, or coarse Answer: D Rationale: Crackles result from air moving through airways that contain fluid. Audible during both inspiration and expiration, crackles are discrete sounds that vary in pitch and intensity.

52. Vasodilation or vasoconstriction produced by an external cause will interfere with an accurate assessment of a client with peripheral vascular disease (PVD). Therefore, the nurse should; A. keeps the client warm B. maintain room temperature at 25.6 0C C. Keep the client uncovered D. match the room temperature with the clients body temperature Answer: A Rationale: The nurse should keep the client covered and expose only the portion of the body that is being assessed.

53. To evaluate the clients cerebellar function, the nurse should asks: A. Do you have any problems with your balance? B. Do you have any difficulty in speaking? C. Do you have any trouble swallowing foods or fluids? D. Have you noticed any changes in muscles strength? Answer: A Rationale: To evaluate cerebellar function, the nurse should ask the client about problems with balance and coordination.

54. When testing a clients pupils for accommodation, the nurse should interpret which findings as normal? A. Constriction and Divergence B. Dilation and Convergence C. Constriction and convergence D. Dilation and divergence Answer: C Rationale: During accommodation, the pupils should constrict and convergence equally on an object.
55. A clients comes to the clinic for a routine checkup. To assess the clients gag reflex, the nurse should use which method? A. Place a tongue depressor on the front of the tongue and asks the client to say ah B. Place a tongue depressor lightly on the posterior aspect of the tongue C. Place a tongue depressor on the middle of the tongue and ask the client to cough D. Place a tongue depressor on the vulvula Answer: B Rationale: To assess a clients gag reflex, the nurse should gently touch the posterior aspect of the tongue with a tongue depressor which should elicit gagging.

56. The nurse can auscultate for heart sounds more easily if the client is? A. supine B. On his right side C. holding his breath D. leaning forward Answer: D Rationale: The nurse can best ausculate for heart sounds by asking the client to lean forward and exhale forcefully this enables the nurse to listen after exhalation without the sound of expiration interfering. Fundamentals of Nursing by Kozier, Erb, Berman, Snyder: pg.1334 Seventh Edition 57. A client has lymphedema in both arms and the nurse must measure blood pressure using a thigh cuff. In reference to the clients baseline arm blood pressure, the nurse should expect the thigh to have a; A. Higher systolic blood pressure reading B. Higher diastolic blood pressure reading C. Lower systolic blood pressure reading D. Lower diastolic blood pressure reading Answer: A Rationale: Systolic readings in the may be 10 to 40mmHg higher than in the arm. Diastolic readings are same in the thigh and arm.

58. The nurse is calculating the proper dosage of medication for a child. What parameters should this calculation is based on? A. Age B. Body Weight C. Developmental stage in relation to age
D. Body surface area in relation to weight Answer: D Rationale: Body surface area in relation to weight is the most reliable method for estimating proper medication dosage for a child.

59. For a client with a sleep pattern disturbance, the nurse could use which measure to promote sleep? A. Play soft or soothing music B. Encourage less activity during the day C. Provide a cup of coffee and a snack in the evening D. Increase the clients activity 2 hours before bedtime Answer: A Rationale: By providing soft or soothing music, the nurse promotes relaxation which fosters rest and sleep.
Fundamentals of Nursing by Kozier and Erb: pg.1180 Eight Edition

60. The nurse may use one of many nursing theories to guide client care. What are the four key concepts of most nursing theories? A. Man, health, illness, and health care B. Health, Illness, Health restoration, and caring C. Man, Environment, Health and Nursing D. Health, Environment, Disease and Treatment Answer: C Rationale: Most Nursing theories deal with key concepts of man, environment, health, and nursing.
61. A client with severe chest pain is brought to the emergency department. He tells the nurse, I just have a little indigestion. Which mechanism is the client exhibiting? A. Anxiety B. Denial C. Repression D. Confusion Answer: A Rationale: During a crisis, its common for a client to use to use a mechanism called denial, which is exhibited minimizing symptoms or avoiding discussion.
62. When caring for a client with a 3 cm stage 1 pressure ulcer on the coccyx, which of the following actions cam the nurse institute independently/ A. Using a providone-Iodine wash on the ulceration three times per day B. Using a normal saline solution to clean the ulcer and applying a protective dressing as necessary C. Applying antibiotic cream to the area three times per day D. Massaging the area with an astringent every 2 hours Answer: B Rationale: Washing the area with normal saline solution to clean the ulcer and applying a protective dressing are within the nurses real intervention and will protect the area.

63. To assess the effectiveness of incentive spirometry, the nurse can use a pulse oximeter to monitor the clients? A. oxygen saturation B. hemoglobin level C. partial pressure of carbon dioxide D. partial pressure of oxygen Answer: A Rationale: A pulse oximeter is a nonvasive method of monitoring oxygen.

64. A client with newly diagnose breast cancer asked the nurse why me? Ive always been a good person. What have I done to deserve this? Which response by the nurse would be most therapeutic? A. Dont worry. Youll probably live longer than I will B. Im sure a cure will be found soon C. You seem upset. Lets talk about something happy D. Would you like to talk about this? Answer: D Rationale: Listening, responding quickly, and providing support promote therapeutic communication. Offering to talk about the clients feeling validates those feelings and allows the client to express them.

65. Which finding best indicates that suctioning has been effective? A. Respiratory rate of 24 bpm B. heart rate f 104bpm C. Brisk Capillary refill
D. Clear breath sound Answer: D Rationale: Clear breath sound, which indicates that secretions have been removed, are the best indicator of effective suctioning.

66. Which assessment finding by the nurse contraindicates the application of heating pad? A. Active bleeding B. Reddened abscess C. Edematous lower leg D. Purulent wound drainage Answer: A Rationale: Heat application increases blood flow and therefore is contraindicated in active bleeding.

67. Following a tonsillectomy, a clients return to medical-surgical unit. The client is lethargic and reports having a sore throat. Which position would be the most therapeutic for this client? A. Semi-Folwers B. Supine C. High-Fowlers D. Side-Lying Answer: D Rationale: Because of lethargy. The post-op tonsillectomy client is risk for aspirating blood from the surgical wound.

68. A scrub nurse in the operating room has which responsibility? A. Positioning the client B. Assisting the gowning and gloving C. Handling surgical instruments to the surgeon D. Applying surgical drapes Answer: C Rationale: The nurse assists the surgeon by proving the appropriate surgical instruments and supplies, maintaining strict surgical asepsis.
69. An obese client is admitted to the facility for abusing amphetamines in an attempt to lose weight. Which nursing intervention is appropriate for this client? A. Encouraging the client to suppress his feeling regarding obesity B. Reinforcing the clients concerns over physical appearance C. Using an abrupt, forceful manner to communicate with the client D. Teaching the client alternative ways to lose weight Answer: D Rationale: Teaching the client alternative ways to lose weight is the most appropriate way.

70. Wearing precautions include which of the following measures? A. Wearing gloves when changing a dressing B. Disposing of needles in a puncture resistant container C. Wearing eye protection during tracheal suctioning D. All of the above Answer: D Rationale: To follow the standard precaution, caregivers must wear gloves when there is a potential contact with a clients with body fluids, place used, uncapped needles and syringe in a puncture resistant container; wear goggles during procedure that are likely to generate splashes of blood or body fluids.

71. A client says I know I am going to die. Which response by the nurse would be best? A. We have special equipments to monitor you and you problem B. Dont worry. We know what were doing and you arent going to die. C. Why do you think youre going to die? D. Oh no. youre doing quite well considering your condition. Answer: C Rationale: A therapeutic approach would be to reflect on the clients comments on his specific words.

72. Which nursing theorist addressed self care deficits in her nursing theory? A. Dorothy Johnson B. Virginia Henderson C. Dorothea Orem D. Martha Rogers
Answer: C Rationale: Dorothea Orem general nursing theory addressed self care deficits as the basis of nursing care.

73. Elizabeth Kubler-Ross identifies five stages of death and dying. Loss, grief, and intense sadness are symptoms of which stage? A. Denial and Isolation B. Depression C. Anger D. Bargaining Answer: B Rationale: According to Kubler-Ross the five stages of death and dying. Loss, grief, and intense sadness are indicating depression.

74. To collect a clean-catch midstream urine specimen from a client, the nurse instructs her to clean the area at the external urinary meatus with an antiseptic. How should the client do this? A. By swabbing the labia minora from front to back B. By cleaning the labia minora from back to front C. By cleaning the labia majora from front to back D. By swabbing the entire perineal area Answer: A Rationale: The client should swab the labia minora form front to back, using one swab for each wipe because this technique cleans from the area of least contamination of greatest contamination.

75. Which procedure or practice requires surgical asepsis? A. Hand washing B. NGT irrigation C. IV catheter insertion D. Colostomy Irrigation Answer: C Rationale: IV catheter requires surgical asepsis because it disrupts skin integrity and involves entry into sterile cavity.

76. When bandaging a clients ankle, the nurse should use which technique?
A. Figure eight B. Circular C. Recurrent D. Spinal Reverse Answer: A Rationale: Figure-eight technique to bandage a joint, such as ankle, wrist, elbow, or knee.

77. When placing an indwelling urinary catheter in a female client, the nurse should advance the catheter how far into the urethra? A. 2 inches B. 6 inches C. 8 inches D. inch Answer: A Rationale: In a female client the nurse should advance an indwelling urinary catheter 2-3 inches in the urethra.

78. A client is unable to take a deep breath and doesnt want to get out of bed his chest tube is causing discomfort. To increase client adherence to the treatment plan, the nurse should? A. Administer pain medication before having the client deep breath, cough or get out of bed B. Tell the client the importance of lung expansion C. Arrange a care schedule to provide rest periods D. Teach the client how to use an incentive spirometer Answer: A Rationale: Administering pain medication and waiting for its effect before any activity will increase client adherence to the treatment plan.

79. A client is admitted to the facility with a productive cough, night sweats and a fever. Which action is more important in the initial care plan? A. Assessing the clients temperature every 8 hours B. Placing the client in respiratory Isolation C. Monitoring the client intake and output D. Wearing gloves during all client contact
Answer: B Rationale: Because the client S/S suggests a respiratory infection respiratory isolation is indicated.

80. The client hasnt voided since before surgery, which took place 8 hours ago. Which action should the nurse do first? A. Call the physician to report the condition B. Catheterize the client with a straight catheter C. Assess the bladder fullness D. Tell the client to bear down and try to void Answer: C Rationale: Before any action is taken, the nurse must assess the clients bladder area for fullness. A common effect of anesthesia is urine retention.

81. Nurse Malu is teaching a patient about a newly prescribed drug. What could cause a geriatric patient to have difficulty retaining knowledge about prescribed medications? a. b. c. d. Decreased plasma drug levels Sensory deficits Lack of family support History of Tourette syndrome
Answer: B Rationale: Sensory deficits could cause a geriatric patient to have difficulty retaining knowledge about prescribed medications.

82. When examining a patient with abdominal pain the nurse in charge should assess: a. b. c. d. Any quadrant first The symptomatic quadrant first The symptomatic quadrant last The symptomatic quadrant either second or third
Answer: C Rationale: The nurse should systematically assess all areas of the abdomen, if time and the patients condition permit, concluding with the symptomatic area.

83. Which of the following planes divides the body longitudinally into anterior and posterior regions?
a. b. c. d.
Frontal plane Sagittal plane Midsagittal plane Transverse plane
Answer: A. Rationale: Frontal or coronal plane runs longitudinally at a right angle to a sagittal plane dividing the body in anterior and posterior regions.

84. Which human element considered by the nurse in charge during assessment can affects drug administration? a. b. c. d. The patients ability to recover The patients occupational hazards The patients socioeconomic status The patients cognitive abilities
Answer: D. Rationale: The nurse must consider the patients cognitive abilities to understand drug instructions.

85. Nurse Mackey is monitoring a patient for adverse reactions during barbiturate therapy. What is the major disadvantage of barbiturate use? a. b. c. d. Prolonged half-life Poor absorption Potential for drug dependence Potential for hepatotoxicity
Answer:C Rationale: Patients can become dependent on barbiturates, especially with prolonged use.

86. An employer establishes a physical exercise area in the workplace and encourages all employees to use it. This is an example of which level of health promotion? a. b. c. d. Primary prevention Secondary prevention Tertiary prevention Passive prevention
Answer: A
Rationale: Primary prevention precedes disease and applies to health patients. Secondary prevention focuses on patients who have health problems and are at risk for developing complications. Tertiary prevention enables patients to gain health from others activities without doing anything themselves.

87. Which nursing action is essential when providing continuous enteral feeding? a. b. c. d. Elevating the head of the bed Positioning the patient on the left side Warming the formula before administering it Hanging a full days worth of formula at one time
Answer: A Rationale: Elevating the head of the bed during enteral feeding minimizes the risk of aspiration and allows the formula to flow in the patients intestines. When such elevation is contraindicated, the patient should be positioned on the right side.

88. A male patient is to be discharged with a prescription for an analgesic that is a controlled substance. During discharge teaching, the nurse should explain that the patient must fill this prescription how soon after the date on which it was written? a. b. c. d. Within 1 month Within 3 months Within 6 months Within 12 months
Answer : C Rationale: In most cases, an outpatient must fill a prescription for a controlled substance within 6 months of the date on which the prescription was written.

89. What does the nurse in charge do when making a surgical bed? a. b. c. d. Leaves the bed in the high position when finished Places the pillow at the head of the bed Rolls the patient to the far side of the bed Tucks the top sheet and blanket under the bottom of the bed
Answer: A Rationale: When making a surgical bed, the nurse leaves the bed in the high position when finished. After placing the top linens on the bed without pouching them, the nurse fanfolds these linens to the side opposite from where the patient will enter and places the pillow on the bedside chair.
90. Which intervention is an example of primary prevention? a. b. c. d. Administering digoxin (Lanoxicaps) to a patient with heart failure Administering a measles, mumps, and rubella immunization to an infant Obtaining a Papanicolaou smear to screen for cervical cancer Using occupational therapy to help a patient cope with arthritis
Answer: B Rationale: Immunizing an infant is an example of primary prevention, which aims to prevent health problems.

91. Nurse Shane is revising a clients care plan. During which step of the nursing process does such revision take place? a. b. c. d. Assessment Planning Implementation Evaluation
Answer: D Rationale: During the evaluation step of the nursing process the nurse determines whether the goals established in the care plan have been achieved, and evaluates the success of the plan.
92. One aspect of implementation related to drug therapy is: a. b. c. d. Developing a content outline Documenting drugs given Establishing outcome criteria Setting realistic client goals
Answer: B Rationale: Although documentation isnt a step in the nursing process, the nurse is legally required to document activities related to drug therapy, including the time of administration, the quantity, and the clients reaction.

93. A female client is readmitted to the facility with a warm, tender, reddened area on her right calf. Which contributing factor would the nurse recognize as most important? a. b. A history of increased aspirin use Recent pelvic surgery
c. d.
An active daily walking program A history of diabetes
Answer: D Rationale: The nurse should begin with the simplest interventions, such as pillows or snacks, before interventions that require greater skill such as relaxation techniques.

94. A male client is on prolonged bed rest has developed a pressure ulcer. The wound shows no signs of healing even though the client has received skin care and has been turned every 2 hours. Which factor is most likely responsible for the failure to heal? a. b. c. d. Inadequate vitamin D intake Inadequate protein intake Inadequate massaging of the affected area Low calcium level
Answer: B Rationale: A client on bed rest suffers from a lack of movement and a negative nitrogen balance.

95. Nurse Alice inspects a clients back and notices small hemorrhagic spots. The nurse documents that the client has: a. b. c. d. Extravasation Osteomalacia Petechiae Uremia
Answer:C Rationale: Petechiae are small hemorrhagic spots. Extravasation is the leakage of fluid in the interstitial space. Osteomalacia is the softening of bone tissue. Uremia is an excess of urea and other nitrogen products in the blood.

96. A female client is admitted to the emergency department with complaints of chest pain shortness of breath. The nurses assessment reveals jugular vein distention. The nurse knows that when a client has jugular vein distension, its typically due to: a. b. c. d. A neck tumor An electrolyte imbalance Dehydration Fluid overload
Answer:D Rationale: Fluid overload causes the volume of blood within the vascular system to increase. This increase causes the vein to distend, which can be seen most obviously in the neck veins.

97. Nurse KC inspects a clients pupil size and determines that its 2 mm in the left eye and 3 mm in the right eye. Unequal pupils are known as: a. b. c. d. Anisocoria Ataxia Cataract Diplopia
Answer:A Rationale: Unequal pupils are called anisocoria. Ataxia is uncoordinated actions of involuntary muscle use. A cataract is an opacity of the eyes lens. Diplopia is double vision.

98. If a patients blood pressure is 150/96, his pulse pressure is: a. b. c. d. 54 96 150 246
Answer: A Rationale: The pulse pressure is the difference between the systolic and diastolic blood pressure readings.

99. Which of the following is the most common cause of dementia among elderly persons? a. b. c. d. Parkinsons disease Multiple sclerosis Amyotrophic lateral sclerosis Alzheimers disease
Answer: D Rationale: Alzheimer;s disease, sometimes known as senile dementia of the Alzheimers type or primary degenerative dementia, is an insidious; progressive, irreversible, and degenerative disease of the brain whose etiology is still unknown.

100. The most common injury among elderly persons is:
a. b. c. d.
Atheroscleotic changes in the blood vessels Increased incidence of gallbladder disease Urinary Tract Infection Hip fracture
Answer: D Rationale: Hip fracture, the most common injury among elderly persons, usually results from osteoporosis. The other answers are diseases that can occur in the elderly from physiologic changes.

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1. Which option serves as a framework for nursing education and clinical practice? A. Scientific Breakthroughs B. Technical Advances C.

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C = (oF-32) 1.8 C = (102-32) 1.8

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Answer: C Rationale: Resonance is a normal finding on percussion of healthy lung tissue.

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