Funda 1 (25 items)
Which of the following is the nurses legal
1. The most important nursing intervention
to correct skin dryness is:
A. Avoid bathing the patient until the condition is
remedied, and notify the physician
B. Ask the physician to refer the patient to a
dermatologist, and suggest that the patient wear
home-laundered sleepwear
C. Consult the dietitian about increasing the
patients fat intake, and take necessary
measures to prevent infection
D. Encourage the patient to increase his fluid
intake, use non-irritating soap when bathing the
patient, and apply lotion to the involved areas
2. When bathing a patients extremities, the
nurse should use long, firm strokes from the
distal to the proximal areas. This technique:
A. Provides an opportunity for skin assessment
B. Avoids undue strain on the nurse
C. Increases venous blood return
D. Causes vasoconstriction and increases
circulation
3. Vivid dreaming occurs in which stage of
sleep?
A. Stage I non-REM
B. Rapid eye movement (REM) stage
C. Stage II non-REM
D. Delta stage
4. The natural sedative in meat and milk
products (especially warm milk) that can
help induce sleep is:
A. Flurazepam
B. Temazepam
C. Tryptophan
D. Methotrimeprazine
5. Nursing interventions that can help the
patient to relax and sleep restfully include all
of the following except:
A. Have the patient take a 30- to 60-minute nap
in the afternoon
B. Turn on the television in the patients room
C. Provide quiet music and interesting reading
material
D. Massage the patients back with long strokes
6. Restraints can be used for all of the
following purposes except to:
A. Prevent a confused patient from removing
tubes, such as feeding tubes, I.V. lines, and
urinary catheters
B. Prevent a patient from falling out of bed or a
chair
C. Discourage a patient from attempting to
ambulate alone when he requires assistance for
his safety
D. Prevent a patient from becoming confused or
disoriented
7.
responsibility when applying restraints?
A. Document the patients behavior
B. Document the type of restraint used
C. Obtain a written order from the physician
except in an emergency, when the patient must
be protected from injury to himself or others
D. All of the above
8. Kubler-Rosss five successive stages of
death and dying are:
A. Anger, bargaining, denial, depression,
acceptance
B. Denial, anger, depression, bargaining,
acceptance
C. Denial, anger, bargaining, depression
acceptance
D. Bargaining, denial, anger, depression,
acceptance
9. A terminally ill patient usually experiences
all of the following feelings during the anger
stage except:
A. Rage
B. Envy
C. Numbness
D. Resentment
10. Nurses and other health care provides
often have difficulty helping a terminally ill
patient through the necessary stages leading
to acceptance of death. Which of the
following strategies is most helpful to the
nurse in achieving this goal?
A. Taking psychology courses related to
gerontology
B. Reading books and other literature on the
subject of thanatology
C. Reflecting on the significance of death
D. Reviewing varying cultural beliefs and
practices related to death
11. Which of the following symptoms is the
best indicator of imminent death?
A. A weak, slow pulse
B. Increased muscle tone
C. Fixed, dilated pupils
D. Slow, shallow respirations
12. A nurse caring for a patient with an
infectious disease who requires isolation
should refers to guidelines published by the:
A. National League for Nursing (NLN)
B. Centers for Disease Control (CDC)
C. American Medical Association (AMA)
D. American Nurses Association (ANA)
13. To institute appropriate isolation
precautions, the nurse must first know the:
A. Organisms mode of transmission
B. Organisms Gram-staining characteristics
C. Organisms susceptibility to antibiotics
D. Patients susceptibility to the organism
14. Which is the correct procedure for
collecting a sputum specimen for culture and
sensitivity testing?
A. Have the patient place the specimen in a
container and enclose the container in a plastic
bag
B. Have the patient expectorate the sputum
while the nurse holds the container
C. Have the patient expectorate the sputum into
a sterile container
D. Offer the patient an antiseptic mouthwash just
before he expectorate the sputum
15. An autoclave is used to sterilize hospital
supplies because:
A. More articles can be sterilized at a time
B. Steam causes less damage to the materials
C. A lower temperature can be obtained
D. Pressurized steam penetrates the supplies
better
16. The best way to decrease the risk of
transferring pathogens to a patient when
removing contaminated gloves is to:
A. Wash the gloves before removing them
B. Gently pull on the fingers of the gloves when
removing them
C. Gently pull just below the cuff and invert the
gloves when removing them
D. Remove the gloves and then turn them inside
out
17. After having an I.V. line in place for 72
hours, a patient complains of tenderness,
burning, and swelling. Assessment of the I.V.
site reveals that it is warm and
erythematous. This usually indicates:
A. Infection
B. Infiltration
C. Phlebitis
D. Bleeding
18. To ensure homogenization when diluting
powdered medication in a vial, the nurse
should:
A. Shake the vial vigorously
B. Roll the vial gently between the palms
C. Invert the vial and let it stand for 1 minute
D. Do nothing after adding the solution to the
vial
19. The nurse is teaching a patient to prepare
a syringe with 40 units of U-100 NPH insulin
for self-injection. The patients first priority
concerning self-injection in this situation is
to:
A. Assess the injection site
B. Select the appropriate injection site
C. Check the syringe to verify that the nurse has
removed the prescribed insulin dose
D. Clean the injection site in a circular manner
with alcohol sponge
20. The physicians order reads Administer
1 g cefazolin sodium (Ancef) in 150 ml of
normal saline solution in 60 minutes. What
is the flow rate if the drop factor is 10 gtt = 1
ml?
A. 25 gtt/minute
B. 37 gtt/minute
C. 50 gtt/minute
D. 60 gtt/minute
21. A patient must receive 50 units of
Humulin regular insulin. The label reads 100
units = 1 ml. How many milliliters should the
nurse administer?
A. 0.5 ml
B. 0.75 ml
C. 1 ml
D. 2 ml
22. How should the nurse prepare an
injection for a patient who takes both regular
and NPH insulin?
A. Draw up the NPH insulin, then the regular
insulin, in the same syringe
B. Draw up the regular insulin, then the NPH
insulin, in the same syringe
C. Use two separate syringe
D. Check with the physician
23. A patient has just received 30 mg of
codeine by mouth for pain. Five minutes later
he vomits. What should the nurse do first?
A. Call the physician
B. Remedicate the patient
C. Observe the emesis
D. Explain to the patient that she can do nothing
to help him
24. A patient is characterized with a #16
indwelling urinary (Foley) catheter to
determine if:
A. Trauma has occurred
B. His 24-hour output is adequate
C. He has a urinary tract infection
D. Residual urine remains in the bladder after
voiding
25. A staff nurse who is promoted to
assistant nurse manager may feel
uncomfortable initially when supervising her
former peers. She can best decrease this
discomfort by:
A. Writing down all assignments
B. Making changes after evaluating the situation
and having discussions with the staff.
C. Telling the staff nurses that she is making
changes to benefit their performance
D. Evaluating the clinical performance of each
staff nurse in a private conference

Funda 2 (30 items)
1. Nurse Clarisse is teaching a patient about
a newly prescribed drug. What could cause a
geriatric patient to have difficulty retaining
knowledge about prescribed medications?
A. Decreased plasma drug levels
B. Sensory deficits
C. Lack of family support
D. History of Tourette syndrome
2. When examining a patient with abdominal
pain the nurse in charge should assess:
A. Any quadrant first
B. The symptomatic quadrant first
C. The symptomatic quadrant last
D. The symptomatic quadrant either second or
third
3. The nurse is assessing a postoperative
adult patient. Which of the following should
the nurse document as subjective data?
A. Vital signs
B. Laboratory test result
C. Patients description of pain
D. Electrocardiographic (ECG) waveforms
4. A male patient has a soft wrist-safety
device. Which assessment finding should
the nurse consider abnormal?
A. A palpable radial pulse
B. A palpable ulnar pulse
C. Cool, pale fingers
D. Pink nail beds
5. Which of the following planes divides the
body longitudinally into anterior and
posterior regions?
A. Frontal plane
B. Sagittal plane
C. Midsagittal plane
D. Transverse plane
6. A female patient with a terminal illness is
in denial. Indicators of denial include:
A. Shock dismay
B. Numbness
C. Stoicism
D. Preparatory grief
7. The nurse in charge is transferring a
patient from the bed to a chair. Which action
does the nurse take during this patient
transfer?
A. Position the head of the bed flat
B. Helps the patient dangle the legs
C. Stands behind the patient
D. Places the chair facing away from the bed
8. A female patient who speaks a little
English has emergency gallbladder surgery,
during discharge preparation, which nursing
action would best help this patient
understand wound care instruction?
A. Asking frequently if the patient understands
the instruction
B. Asking an interpreter to replay the instructions
to the patient.
C. Writing out the instructions and having a
family member read them to the patient
D. Demonstrating the procedure and having the
patient return the demonstration
9. Before administering the evening dose of
a prescribed medication, the nurse on the
evening shift finds an unlabeled, filled
syringe in the patients medication drawer.
What should the nurse in charge do?
A. Discard the syringe to avoid a medication
error
B. Obtain a label for the syringe from the
pharmacy
C. Use the syringe because it looks like it
contains the same medication the nurse was
prepared to give
D. Call the day nurse to verify the contents of
the syringe
10. When administering drug therapy to a
male geriatric patient, the nurse must stay
especially alert for adverse effects. Which
factor makes geriatric patients to adverse
drug effects?
A. Faster drug clearance
B. Aging-related physiological changes
C. Increased amount of neurons
D. Enhanced blood flow to the GI tract
11. A female patient is being discharged after
cataract surgery. After providing medication
teaching, the nurse asks the patient to repeat
the instructions. The nurse is performing
which professional role?
A. Manager
B. Educator
C. Caregiver
D. Patient advocate
12. A female patient exhibits signs of
heightened anxiety. Which response by the
nurse is most likely to reduce the patients
anxiety?
A. Everything will be fine. Dont worry.
B. Read this manual and then ask me any
questions you may have.
C. Why dont you listen to the radio?
D. Lets talk about whats bothering you.
13. A scrub nurse in the operating room has
which responsibility?
A. Positioning the patient
B. Assisting with gowning and gloving
C. Handling surgical instruments to the surgeon
D. Applying surgical drapes
14. A patient is in the bathroom when the
nurse enters to give a prescribed medication.
What should the nurse in charge do?
A. Leave the medication at the patients bedside
B. Tell the patient to be sure to take the
medication. And then leave it at the bedside
C. Return shortly to the patients room and
remain there until the patient takes the
medication
D. Wait for the patient to return to bed, and then
leave the medication at the bedside
15. The physician orders heparin, 7,500
units, to be administered subcutaneously
every 6 hours. The vial reads 10,000 units per
milliliter. The nurse should anticipate giving
how much heparin for each dose?
A. ml
B. ml
C. ml
D. 1 ml
16. The nurse in charge measures a patients
temperature at 102 degrees F. what is the
equivalent Centigrade temperature?
A. 39 degrees C
B. 47 degrees C
C. 38.9 degrees C
D. 40.1 degrees C
17. To evaluate a patient for hypoxia, the
physician is most likely to order which
laboratory test?
A. Red blood cell count
B. Sputum culture
C. Total hemoglobin
D. Arterial blood gas (ABG) analysis
18. The nurse uses a stethoscope to
auscultate a male patients chest. Which
statement about a stethoscope with a bell
and diaphragm is true?
A. The bell detects high-pitched sounds best
B. The diaphragm detects high-pitched sounds
best
C. The bell detects thrills best
D. The diaphragm detects low-pitched sounds
best
19. 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. Within 1 month
B. Within 3 months
C. Within 6 months
D. Within 12 months
20. Which human element considered by the
nurse in charge during assessment can
affect drug administration?
A. The patients ability to recover
B. The patients occupational hazards
C. The patients socioeconomic status
D. The patients cognitive abilities
21. An employer establishes a physical
exercise area in the workplace and
encourages all employees to use it. This is
an example of which level of health
promotion?
A. Primary prevention
B. Secondary prevention
C. Tertiary prevention
D. Passive prevention
22. What does the nurse in charge do when
making a surgical bed?
A. Leaves the bed in the high position when
finished
B. Places the pillow at the head of the bed
C. Rolls the patient to the far side of the bed
D. Tucks the top sheet and blanket under the
bottom of the bed
23. The physician prescribes 250 mg of a
drug. The drug vial reads 500 mg/ml. how
much of the drug should the nurse give?
A. 2 ml
B. 1 ml
C. ml
D. ml
24. Nurse Mackey is monitoring a patient for
adverse reactions during barbiturate therapy.
What is the major disadvantage of
barbiturate use?
A. Prolonged half-life
B. Poor absorption
C. Potential for drug dependence
D. Potential for hepatotoxicity
25. Which nursing action is essential when
providing continuous enteral feeding?
A. Elevating the head of the bed
B. Positioning the patient on the left side
C. Warming the formula before administering it
D. Hanging a full days worth of formula at one
time
26. When teaching a female patient how to
take a sublingual tablet, the nurse should
instruct the patient to place the table on the:
A. Top of the tongue
B. Roof of the mouth
C. Floor of the mouth
D. Inside of the cheek
27. Which action by the nurse in charge is
essential when cleaning the area around a
Jackson-Pratt wound drain?
A. Cleaning from the center outward in a circular
motion
B. Removing the drain before cleaning the skin
C. Cleaning briskly around the site with alcohol
D. Wearing sterile gloves and a mask
28. The doctor orders dextrose 5% in water,
1,000 ml to be infused over 8 hours. The I.V.
tubing delivers 15 drops per milliliter. The
nurse in charge should run the I.V. infusion
at a rate of:
A. 15 drop per minute
B. 21 drop per minute
C. 32 drop per minute
D. 125 drops per minute
29. A female patient undergoes a total
abdominal hysterectomy. When assessing
the patient 10 hours later, the nurse
identifies which finding as an early sign of
shock?
A. Restlessness
B. Pale, warm, dry skin
C. Heart rate of 110 beats/minute
D. Urine output of 30 ml/hour
30. Which pulse should the nurse palpate
during rapid assessment of an unconscious
male adult?
A. Radial
B. Brachial
C. Femoral
D. Carotid
Funda 3 (30 items)
1. Which intervention is an example of
primary prevention?
A. Administering digoxin (Lanoxicaps) to a
patient with heart failure
B. Administering a measles, mumps, and rubella
immunization to an infant
C. Obtaining a Papanicolaou smear to screen
for cervical cancer
D. Using occupational therapy to help a patient
cope with arthritis
2. The nurse in charge is assessing a
patients abdomen. Which examination
technique should the nurse use first?
A. Auscultation
B. Inspection
C. Percussion
D. Palpation
3. Which statement regarding heart sounds
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 loudest at
the base
4. The nurse in charge identifies a patients
responses to actual or potential health
problems during which step of the nursing
process?
A. Assessment
B. Nursing diagnosis
C. Planning
D. Evaluation
5. A female patient is receiving furosemide
(Lasix), 40 mg P.O. b.i.D. in the plan of care,
the nurse should emphasize teaching the
patient about the importance of consuming:
A. Fresh, green vegetables
B. Bananas and oranges
C. Lean red meat
D. Creamed corn
6. The nurse in charge must monitor a
patient receiving chloramphenicol for
adverse drug reaction. What is the most
toxic reaction to chloramphenicol?
A. Lethal arrhythmias
B. Malignant hypertension
C. Status epilepticus
D. Bone marrow suppression
7. A female patient is diagnosed with deep-
vein thrombosis. Which nursing diagnosis
should receive highest priority at this time?
A. Impaired gas exchanges related to increased
blood flow
B. Fluid volume excess related to peripheral
vascular disease
C. Risk for injury related to edema
D. Altered peripheral tissue perfusion related to
venous congestion
8. When positioned properly, the tip of a
central venous catheter should lie in the:
A. Superior vena cava
B. Basilica vein
C. Jugular vein
D. Subclavian vein
9. Nurse Nikki is revising a clients care plan.
During which step of the nursing process
does such revision take place?
A. Assessment
B. Planning
C. Implementation
D. Evaluation
10. A 65-year-old female who has diabetes
mellitus and has sustained a large laceration
on her left wrist asks the nurse, How long
will it take for my scars to disappear? which
statement would be the nurses best
response?
A. The contraction phase of wound healing can
take 2 to 3 years.
B. Wound healing is very individual but within 4
months the scar should fade.
C. With your history and the type of location of
the injury, its hard to say.
D. If you dont develop an infection, the wound
should heal any time between 1 and 3 years
from now.
11. One aspect of implementation related to
drug therapy is:
A. Developing a content outline
B. Documenting drugs given
C. Establishing outcome criteria
D. Setting realistic client goals
12. 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. A history of increased aspirin use
B. Recent pelvic surgery
C. An active daily walking program
D. A history of diabetes
13. Which intervention should the nurse in
charge try first for a client that exhibits signs
of sleep disturbance?
A. Administer sleeping medication before
bedtime
B. Ask the client each morning to describe the
quantity of sleep during the previous night
C. Teach the client relaxation techniques, such
as guided imagery, medication, and progressive
muscle relaxation
D. Provide the client with normal sleep aids,
such as pillows, back rubs, and snacks
14. While examining a clients leg, the nurse
notes an open ulceration with visible
granulation tissue in the wound. Until a
wound specialist can be contacted, which
type of dressings is most appropriate for the
nurse in charge to apply?
A. Dry sterile dressing
B. Sterile petroleum gauze
C. Moist, sterile saline gauze
D. Povidone-iodine-soaked gauze
15. A male client in a behavioral-health
facility receives a 30-minute psychotherapy
session, and provider uses a current
procedure terminology (CPT) code that bills
for a 50-minute session. Under the False
Claims Act, such illegal behavior is known
as:
A. Unbundling
B. Overbilling
C. Upcoding
D. Misrepresentation
16. A nurse assigned to care for a
postoperative male client who has diabetes
mellitus. During the assessment interview,
the client reports that hes impotent and says
that hes concerned about its effect on his
marriage. In planning this clients care, the
most appropriate intervention would be to:
A. Encourage the client to ask questions about
personal sexuality
B. Provide time for privacy
C. Provide support for the spouse or significant
other
D. Suggest referral to a sex counselor or other
appropriate professional
17. Using Abraham Maslows hierarchy of
human needs, a nurse assigns highest
priority to which client need?
A. Security
B. Elimination
C. Safety
D. Belonging
18. 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. Inadequate vitamin D intake
B. Inadequate protein intake
C. Inadequate massaging of the affected area
D. Low calcium level
19. A female client who received general
anesthesia returns from surgery.
Postoperatively, which nursing diagnosis
takes highest priority for this client?
A. Acute pain related to surgery
B. Deficient fluid volume related to blood and
fluid loss from surgery
C. Impaired physical mobility related to surgery
D. Risk for aspiration related to anesthesia
20. The nurse inspects a clients back and
notices small hemorrhagic spots. The nurse
documents that the client has:
A. Extravasation
B. Osteomalacia
C. Petechiae
D. Uremia
21. Which document addresses the clients
right to information, informed consent, and
treatment refusal?
A. Standard of Nursing Practice
B. Patients Bill of Rights
C. Nurse Practice Act
D. Code for Nurses
22. If a blood pressure cuff is too small for a
client, blood pressure readings taken with
such a cuff may do which of the following?
A. Fail to show changes in blood pressure
B. Produce a false-high measurement
C. Cause sciatic nerve damage
D. Produce a false-low measurement
23. Nurse Elijah has been teaching a client
about a high-protein diet. The teaching is
successful if the client identifies which meal
as high in protein?
A. Baked beans, hamburger, and milk
B. Spaghetti with cream sauce, broccoli, and tea
C. Bouillon, spinach, and soda
D. Chicken cutlet, spinach, and soda
24. A male client is admitted to the hospital
with blunt chest trauma after a motor vehicle
accident. The first nursing priority for this
client would be to:
A. Assess the clients airway
B. Provide pain relief
C. Encourage deep breathing and coughing
D. Splint the chest wall with a pillow
25. A newly hired charge nurse assesses the
staff nurses as competent individually but
ineffective and nonproductive as a team. In
addressing her concern, the charge nurse
should understand that the usual reason for
such a situation is:
A. Unhappiness about the charge in leadership
B. Unexpected feeling and emotions among the
staff
C. Fatigue from overwork and understaffing
D. Failure to incorporate staff in decision making
26. A male client blood test results are as
follows: white blood cell (WBC) count, 100ul;
hemoglobin (Hb) level, 14 g/dl; hematocrit
(HCT), 40%. Which goal would be most
important for this client?
A. Promote fluid balance
B. Prevent infection
C. Promote rest
D. Prevent injury
27. Following a tonsillectomy, a female client
returns to the medical-surgical unit. The
client is lethargic and reports having a sore
throat. Which position would be most
therapeutic for this client?
A. Semi-Fowlers
B. Supine
C. High-Fowlers
D. Side-lying
28. The nurse 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. Anisocoria
B. Ataxia
C. Cataract
D. Diplopia
29. The nurse in charge is caring for an
Italian client. Hes complaining of pain, but
he falls asleep right after his complaint and
before the nurse can assess his pain. The
nurse concludes that:
A. He may have a low threshold for pain
B. He was faking pain
C. Someone else gave him medication
D. The pain went away
30. 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. A neck tumor
B. An electrolyte imbalance
C. Dehydration
D. Fluid overload
Funda 4 (20 items)
1. Critical thinking and the nursing process
have which of the following in common?
Both:
A. Are important to use in nursing practice
B. Use an ordered series of steps
C. Are patient-specific processes
D. Were developed specifically for nursing
2. In which step of the nursing process does
the nurse analyze data and identify client
problems?
A. Assessment
B. Diagnosis
C. Planning outcomes
D. Evaluation
3. In which phase of the nursing process
does the nurse decide whether her actions
have successfully treated the clients health
problem?
A. Assessment
B. Diagnosis
C. Planning outcomes
D. Evaluation
4. What is the most basic reason that self-
knowledge is important for nurses? Because
it helps the nurse to:
A. Identify personal biases that may affect his
thinking and actions
B. Identify the most effective interventions for a
patient
C. Communicate more efficiently with
colleagues, patients, and families
D. Learn and remember new procedures and
techniques
5. Arrange the steps of the nursing process
in the sequence in which they generally
occur.
A. Assessment
B. Evaluation
C. Planning outcomes
D. Planning interventions
E. Diagnosis
A. E, B, A, D, C
B. A, B, C, D, E
C. A, E, C, D, B
D. D, A, B, E, C
6. How are critical thinking skills and critical
thinking attitudes similar? Both are:
A. Influences on the nurses problem solving and
decision making
B. Like feelings rather than cognitive activities
C. Cognitive activities rather than feelings
D. Applicable in all aspects of a persons life
7. The nurse is preparing to admit a patient
from the emergency department. The
transferring nurse reports that the patient
with chronic lung disease has a 30+ year
history of tobacco use. The nurse used to
smoke a pack of cigarettes a day at one time
and worked very hard to quit smoking. She
immediately thinks to herself, I know I tend
to feel negatively about people who use
tobacco, especially when they have a serious
lung condition; I figure if I can stop smoking,
they should be able to. I must remember how
physically and psychologically difficult that
is, and be very careful not to let be
judgmental of this patient. This best
illustrates:
A. Theoretical knowledge
B. Self-knowledge
C. Using reliable resources
D. Use of the nursing process
8. Which organizations standards require
that all patients be assessed specifically for
pain?
A. American Nurses Association (ANA)
B. State nurse practice acts
C. National Council of State Boards of Nursing
(NCSBN)
D. The Joint Commission
9. Which of the following is an example of
data that should be validated?
A. The urinalysis report indicates there are white
blood cells in the urine.
B. The client states she feels feverish; you
measure the oral temperature at 98F.
C. The client has clear breath sounds; you count
a respiratory rate of 18.
D. The chest x-ray report indicates the client has
pneumonia in the right lower lobe.
10. Which of the following is an example of
appropriate behavior when conducting a
client interview?
A. Recording all the information on the agency-
approved form during the interview
B. Asking the client, Why did you think it was
necessary to seek health care at this time?
C. Using precise medical terminology when
asking the client questions
D. Sitting, facing the client in a chair at the
clients bedside, using active listening
11. The nurse wishes to identify nursing
diagnoses for a patient. She can best do this
by using a data collection form organized
according to: Select all that apply.
A. A body systems model
B. A head-to-toe framework
C. Maslows hierarchy of needs
D. Gordons functional health patterns
12. The nurse is recording assessment data.
She writes, The patient seems worried
about his surgery. Other than that, he had a
good night. Which errors did the nurse
make? Select all that apply.
A. Used a vague generality
B. Did not use the patients exact words
C. Used a waffle word (e.g., appears)
D. Recorded an inference rather than a cue
13. A patient is admitted with shortness of
breath, so the nurse immediately listens to
his breath sounds. Which type of
assessment is the nurse performing?
A. Ongoing assessment
B. Comprehensive physical assessment
C. Focused physical assessment
D. Psychosocial assessment
14. The nurse is assessing vital signs for a
patient just admitted to the hospital. Ideally,
and if there are no contraindications, how
should the nurse position the patient for this
portion of the admission assessment?
A. Sitting upright
B. Lying flat on the back with knees flexed
C. Lying flat on the back with arms and legs fully
extended
D. Side-lying with the knees flexed
15. For all body systems except the
abdomen, what is the preferred order for the
nurse to perform the following examination
techniques?
A. Palpation
B. Auscultation
C. Inspection B. Assist the patient to a chair and provide
D. Percussion bathing supplies.
A. D, B, A, C C. Saturate a towel and blanket in a plastic bag,
B. C, A, D, B and then bathe the patient.
C. B, C, D, A D. Assist the patient to the bathtub and provide
D. A, B, C, D a bath chair.
16. The nurse is assessing a patient admitted 2. For a morbidly obese patient, which
to the hospital with rectal bleeding. The intervention should the nurse choose to
patient had a hip replacement 2 weeks ago. counteract the pressure created by the skin
Which position should the nurse avoid when folds?
examining this patients rectal area? A. Cover the mattress with a sheepskin.
A. Sims B. Keep the linens wrinkle free.
B. Supine C. Separate the skin folds with towels.
C. Dorsal recumbent D. Apply petrolatum barrier creams.
D. Semi-Fowlers 3. A client exhibits all of the following during
17. How should the nurse modify the a physical assessment. Which of these is
examination for a 7-year-old child? considered a primary defense against
A. Ask the parents to leave the room before the infection?
examination. A. Fever
B. Demonstrate equipment before using it. B. Intact skin
C. Allow the child to help with the examination. C. Inflammation
D. Perform invasive procedures (e.g., otoscopic) D. Lethargy
last. 4. A client with a stage 2 pressure ulcer has
18. The nurse must examine a patient who is methicillin-resistant Staphylococcus aureus
weak and unable to sit unaided or to get out (MRSA) cultured from the wound. Contact
of bed. How should she position the patient precautions are initiated. Which rule must be
to begin and perform most of the physical observed to follow contact precautions?
examination? A. A clean gown and gloves must be worn when
A. Dorsal recumbent in contact with the client.
B. Semi-Fowlers B. Everyone who enters the room must wear a
C. Lithotomy N-95 respirator mask.
D. Sims C. All linen and trash must be marked as
19. The nurse should use the diaphragm of contaminated and send to biohazard waste.
the stethoscope to auscultate which of the D. Place the client in a room with a client with an
following? upper respiratory infection.
A. Heart murmurs 5. A client requires protective isolation.
B. Jugular venous hums Which client can be safely paired with this
C. Bowel sounds client in a client-care assignment? One:
D. Carotid bruits A. admitted with unstable diabetes mellitus.
20. The nurse calculates a body mass index B. who underwent surgical repair of a perforated
(BMI) of 18 for a young adult woman who bowel.
comes to the physicians office for a college C. with a stage 3 sacral pressure ulcer.
physical. This patient is considered: D. admitted with a urinary tract infection.
A. Obese 6. A newly hired at Nurseslabs Medical
B. Overweight Center is assigned in the OR Department.
C. Average Which action demonstrates a break in sterile
D. Underweight technique?
A. Remaining 1 foot away from nonsterile areas
Funda 5 (20 items) B. Placing sterile items on the sterile field
1. The charge nurse asks the nursing C. Avoiding the border of the sterile drape
assistive personnel (NAP) to give a bag bath D. Reaching 1 foot over the sterile field
to a patient with end-stage chronic 7. Nurse Berta is facilitating a monthly
obstructive pulmonary disease. How should mothers class at a small village. As a
the NAP proceed? knowledgeable nurse, she must know that a
A. Bathe the patients entire body using 8 to 10 mother who breastfeeds her child passes on
washcloths. which antibody through breast milk?
A. IgA
B. IgE
C. IgG
D. IgM
8. The clinical instructor asks her students
the rationale for handwashing. The students
are correct if they answered that
handwashing is expected to remove:
A. transient flora from the skin.
B. resident flora from the skin.
C. all microorganisms from the skin.
D. media for bacterial growth.
9. Which of the following incidents requires
the nurse to complete an occurrence report?
A. Medication given 30 minutes after scheduled
dose time
B. Patients dentures lost after transfer
C. Worn electrical cord discovered on an IV
infusion pump
D. Prescription without the route of
administration
10. The nurse is orienting a new nurse to the
unit and reviews source-oriented charting.
Which statement by the nurse best describes
source-oriented charting? Source-oriented
charting:
A. Separates the health record according to
discipline
B. Organizes documentation around the
patients problems
C. Highlights the patients concerns, problems,
and strengths
D. Is designed to streamline documentation
11. When the nurse completes the patients
admission nursing database, the patient
reports that he does not have any allergies.
Which acceptable medical abbreviation can
the nurse use to document this finding?
A. NA
B. NDA
C. NKA
D. NPO
12. The nurse is working on a unit that uses
nursing assessment flow sheets. Which
statement best describes this form of
charting? Nursing assessment flow sheets:
A. Are comprehensive charting forms that
integrate assessments and nursing actions
B. Contain only graphic information, such as
I&O, vital signs, and medication administration
C. Are used to record routine aspects of care;
they do not contain assessment data
D. Contain vital data collected upon admission,
which can be compared with newly collected
data
13. At the end of the shift, the nurse realizes
that she forgot to document a dressing
change that she performed for a patient.
Which action should the nurse take?
A. Complete an occurrence report before
leaving.
B. Do nothing; the next nurse will document it
was done.
C. Write the note of the dressing change into an
earlier note.
D. Make a late entry as an addition to the
narrative notes.
14. Patient Z asks Nurse Toni why an
electronic health record (EHR) system is
being used. Which response by the nurse
indicates an understanding of the rationale
for an EHR system?
A. It includes organizational reports of unusual
occurrences that are not part of the clients
record.
B. This type of system consists of combined
documentation and daily care plans.
C. It improves interdisciplinary collaboration that
improves efficiency in procedures.
D. This type of system tracks medication
administration and usage over 24 hours.
15. In the United States, the first programs
for training nurses were affiliated with:
A. The military
B. General hospitals
C. Civil service
D. Religious orders
16. Which of the following is/are an
example(s) of a health restoration activity?
Select all that apply.
A. Administering an antibiotic every day
B. Teaching the importance of handwashing
C. Assessing a clients surgical incision
D. Advising a woman to get an annual
mammogram after age 50 years
17. Which of the following aspects of nursing
is essential to defining it as both a
profession and a discipline?
A. Established standards of care
B. Professional organizations
C. Practice supported by scientific research
D. Activities determined by a scope of practice
18. The charge nurse on the medical surgical
floor assigns vital signs to the nursing
assistive personnel (NAP) and medication
administration to the licensed vocational
nurse (LVN). Which nursing model of care is
this floor following?
A. Team nursing
B. Case method nursing
C. Functional nursing
D. Primary nursing
19. Paul Jake suffered a stroke and has
difficulty swallowing. Which healthcare team
member should be consulted to assess the
patients risk for aspiration?
A. Respiratory therapist
B. Occupational therapist
C. Dentist
D. Speech therapist
20. Which of the following is/are an
example(s) of theoretical knowledge? Select
all that apply.
A. Antibiotics are ineffective in treating viral
infections.
B. When you take a patients blood pressure, the
patients arm should be at heart level.
C. In Maslows framework, physical needs are
most basic.
D. When drawing medication out of a vial, inject
air into the vial first.
Funda 6 (20 items)
Funda 6 (20 items)
1. The nurse recognizes that urinary
elimination changes may occur even in
healthy older adults because of which of the
following?
1. The bladder distends and its capacity
increases
2. Older adults ignore the need to void
3. Urine becomes more concentrated
4. The amount of urine retained after voiding
increases
2. During assessment of the client with
urinary incontinence, the nurse is most likely
to assess for which of the following? Select
all that apply.
1. Perineal skin irritation
2. Fluid intake of less than 1,500 mL/d
3. History of antihistamine intake
4. Hx of UTI
5. A fecal impaction
3. Which action represents the appropriate
nursing management of a client wearing a
condom catheter?
1. Ensure that the tip of the penis fits snugly
against the end of the condom
2. Check the penis for adequate circulation 30
min after applying
3. Change the condom every 8 hours
4. Tape the collecting tube to the lower
abdomen.
4. The catheter slips into the vagina during a
straight catheterization of a female client.
The nurse does which action?
1. Leaves the catheter in place and gets a new
sterile catheter
2. Leaves the catheter in place and asks another
nurse to attempt the procedure
3. Removes the catheter and redirects it to the
urinary meatus
4. Removes the catheter, wipes it with a sterile
gauze, and redirects it to the urinary meatus
5. Which statement indicates a need for
further teaching of a home care client with a
long term indwelling catheter?
1. I will keep the collecting bag below the level
of the bladder at all times
2. Intake of cranberry juice may help decrease
the risk of infection
3. Soaking in a warm tub bath may ease the
irritation associated with the catheter
4. I should use clean tech. when emptying the
collecting bag
6. During shift report, the nurse learns that
an older female client is unable to maintain
continence after she senses the urge to void
and becomes incontinent on the way to the
bathroom. Which nursing diagnosis is most
appropriate?
1. stress urinary incontinence
2. reflex urinary incontinence
3. functional urinary incontinence
4. urge urinary incontinence
7. A female client has a urinary tract
infection. Which teaching points by the
nurse should be helpful to the client? Select
all that apply.
1. Limit fluids to avoid the burning sensation on
urination
2. Review symptoms of UTI with the client
3. Wipe the perineal area from back to front
4. Wear cotton underclothes
5. Take baths rather than showers
8. The nurse will need to assess the clients
performance of clean intermittent self
catheterization (CISC) for a client with which
urinary diversion?
1. Ileal conduit
2. Kock pouch
3. Neobladder
4. Vesicostomy
9. Which focus is the nurse most likely to
teach for a client with a flaccid bladder?
1. Habit training: attempt voiding at specific time
periods
2. Bladder training: delay voiding according to a
pre-schedule timetable
3. Credes maneuver: apply gentle manual
pressure to the lower abdomen
4. Kegel exercises: contract the pelvic muscles
10. Which of the following behaviors
indicates that the client on a bladder training
program has met the expected outcomes?
Select all that apply.
1. Voids each time there is an urge
2. Practices slow, deep breathing until the urge
decreases
3. Uses adult diapers, for just in case
4. Drinks citrus juices and carbonated
beverages
5. Performs pelvic muscle exercises
11. A nurse has identified that the patient has
overflow incontinence. What is a major factor
that contributes to this clinical
manifestation?
1. Coughing
2. Mobility deficits
3. Prostate enlargement
4. Urinary tract infection
12. A nurse must measure the intake and
output (I&O) for a patient who has a urinary
retention catheter. Which equipment is most
appropriate to use to accurately measure
urine output from a urinary retention
catheter?
1. Urinal
2. Graduate
3. Large syringe
4. Urine collection bag
13. A patients urine is cloudy, is amber, and
has an unpleasant odor. What problem may
this information indicate that requires the
nurse to make a focused assessment?
1. Urinary retention
2. Urinary tract infection
3. Ketone bodies in the urine
4. High urinary calcium level
14. A nurse is caring for a debilitated female
patient with nocturia. Which nursing
intervention is the priority when planning to
meet this patients needs?
1. Encouraging the use of bladder training
exercises
2. Providing assistance with toileting every four
hours
3. Positioning a bedside commode near the bed
4. Teaching the avoidance of fluid after 5 PM
15. A practitioner uses a urine specimen for
culture and sensitivity via a straight catheter
for a patient. What should the nurse do when
collecting this urine specimen?
1. Use a sterile specimen container.
2. Collect urine from the catheter port.
3. Inflate the balloon with 10 mL of sterile water.
4. Have the patient void before collecting the
specimen.
16. A nurse in a providers office is
assessing a client who reports losing control
of urine when ever she coughs, laughs, or
sneezes. The client relates a history of three
vaginal births, but no serious accidents or
illnesses. Which of the following
interventions are appropriate for helping to
control or eliminate the clients incontinence?
Select all that apply.
1. Limit total daily fluid intake
2. Decrease or avoid caffeine
3. Increase the intake of calcium supplements
4. Avoid the intake of alcohol
5. Use Crede maneuver
17. A client who has an indwelling catheter
reports I need to urinate. Which of the
following interventions should the nurse
perform?
1. Check to see whether the catheter is patent
2. Reassure the client that it is not possible for
her to urinate
3. Re-catheterize the bladder with a larger
gauge catheter
4. Collect a urine specimen for analysis
18. A provider prescribes a 24 hour urine
collection for a client. Which of the following
actions should the nurse take?
1. Discard the first voiding
2. Keep all voidings in a container at room
temperature
3. Ask the client to urinate and pour the urine
into a specimen container
4. Ask the client to urinate into the toilet, stop
midstream, and finish urinating into the
specimen container
19. A nurse is preparing to initiate a bladder
training program for a client who has a
voiding disorder. Which of the following
actions should the nurse take? Select all that
apply.
1. Establish a schedule of voiding prior to meal
times
2. Have the client record voiding times
3. Gradually increase the voiding intervals
4. Reminded client to hold urine until next
scheduled voiding time
5. Provide a sterile container for voiding
20. A nurse educator on a medical unit is
reviewing factors that increase the risk of
urinary tract infections with a group of
assistive personnel. Which of the following
should be included in the review? Select all
that apply.
1. Having sexual intercourse on a frequent basis
2. Lowering of testosterone levels
3. Wiping from front to back
4. The location of the vagina in relation to the
anus
5. Undergoing frequent catheterization
Funda 7 (20 items)
1. Clients should be taught that repeatedly
ignoring the sensation of needing to
defecate could result in which of the
following?
A. Constipation
B. Diarrhea
C. Incontinence
D. Hemorrhoids
2. Which statement provides evidence that
an older adult who is prone to constipation is
in need of further teaching?
A. I need to drink one and a half to 2 quarts of
liquid each day.
B. I need to take a laxative such as milk of
magnesia or if I dont have a BM every day.
C. If my bowel pattern changes on its own, I
should call you.
D. Eating my meals at regular times is likely to
result in regular bowel movements.
3. A client is scheduled for a colonoscopy.
The nurse will provide information to the
client about which type of enema?
A. Oil retention
B. Return flow
C. High large volume
D. Low, small volume
4. The nurse is most likely to report which
finding to the primary care provider for a
client who has an established colostomy?
A. The stoma extends 1/2 inch above the
abdomen.
B. The skin under the appliance looks red briefly
after removing the appliance.
C. The stoma color is a deep red purple.
D. An ascending colostomy just delivers liquid
feces
5. Which goal is the most appropriate for
clients with diarrhea related to ingestion of
an antibiotic for an upper respiratory
infection?
A. The client will wear a medical alert bracelet
for antibiotic allergy.
B. The client will return to his or her previous
fecal elimination pattern.
C. The client verbalizes the need to take an
antidiarrheal medication PRN.
D. The client will increase intake of insoluble
fiber such as grains, rice, and cereals.
6. A client with a new stoma who has not had
a bowel movement since surgery last week
reports feeling nauseous. What is the
appropriate nursing action?
A. Prepare to irrigate the colostomy.
B. After assessing the stoma and surrounding
skin, notify the surgeon.
C. Assess bowel sounds and administer
antiemetic.
D. Administer a bulk forming laxative, and
encourage increased fluids and exercise.
7. The nurse assesses a clients abdomen
several days after abdominal surgery. It is
firm, distended, and painful to palpate. The
client reports feeling bloated the nurse
consult with the surgeon, who orders an
enema. The nurse prepares to give what kind
of enema?
A. Soapsuds
B. Retention
C. Return flow
D. Oil retention
8. Which of the following is most likely to
validate that a client is experiencing
intestinal bleeding?
A. Large quantities of fat mixed with pale yellow
liquid stool.
B. Brown, formed stool.
C. Semi soft tar colored stools.
D. Narrow, Pencil shaped stool
9. Which nursing diagnoses is/are most
applicable to a client with fecal
incontinence? Select all that apply.
A. Bowel incontinence
B. Risk for deficient fluid volume
C. Disturbed body image
D. Social isolation
E. Risk for impaired skin integrity
10. A nurse determines that a fracture
bedpan should be used for the patient who:
A. has a spinal cord injury.
B. is on bedrest.
C. has dementia.
D. is obese
11. A patient with the diagnosis of
diverticulosis is advised to eat a diet high in
fiber. What should the nurse recommend that
the patient eat to best increase the bulk and
fecal material?
A. Whole wheat bread
B. White rice
C. Pasta
D. Kale
12. Which statement by a patient with an
ileostomy alert the nurse to the need for
further education?
A. I dont expect to have much of a problem
with fecal odor.
B. I will have to take special precaution to
protect my skin around the stoma.
C. Im going to have to irrigate my stoma so I
have a bowel movement every morning.
D. I should avoid gas forming foods like beans
to limit funny noises from the stoma.
13. A practitioner orders a return flow enema
(Harris flush drip) for an adult patient with
flatulence. When preparing to administer this
enema The nurse compares the steps of a
return flow enema with cleansing enemas.
What should the nurse do that is unique to a
return flow enema?
A. Lubricate the last 2 inches of the rectal tube.
B. Insert the rectal tube about 4 inches into the
anus.
C. Raise the solution container about 12 inches
above the anus.
D. Lower the solution container after instilling
about 150 mL of solution.
14. A nurse discourages a patient from
straining excessively when attempting to
have a bowel movement. What physiological
response primarily may be prevented by
avoiding straining on defecation?
A. Incontinence
B. Dysrhythmias
C. Fecal impaction
D. Rectal hemorrhoids
15. A nurse is caring for a client who will
perform fecal occult blood testing at home.
Which of the following information should
the nurse include when explaining the
procedure to the client?
A. Eating more protein is optimal prior to testing.
B. One stool specimen is sufficient for testing.
C. A red color changes indicates a positive test.
D. The specimen cannot be contaminated with
urine.
16. A nurse is talking with a client who
reports constipation. When the nurse
discusses dietary changes that can help
prevent constipation, which of the following
foods should the nurse recommend?
A. Macaroni and cheese
B. Fresh food and whole wheat toast
C. Rice pudding and ripe bananas
D. Roast chicken and white rice
17. A nurse is caring for a client who has
diarrhea for the past four days. When
assessing a client, the nurse should expect
which of the following findings? Select all
that apply.
A. Bradycardia
B. Hypotension
C. Fever
D. Poor skin turgor
E. Peripheral edema
18. A nurse is preparing to administer a
cleansing enema to an adult client in
preparation for a diagnostic procedure.
Which of the following are appropriate steps
for the nurse to take? Select all that apply.
A. Warm the enema solution prior to installation.
B. Position the client on the left side with the
right leg flexed forward.
C. Lubricate the rectal tube or nozzle.
D. Slowly insert the rectal tube about 2 inches.
E. Hang the enema container 24 inches above
the clients anus
19. While a nurse is administering a
cleansing enema, the client reports
abdominal cramping. Which of the following
is the appropriate intervention?
A. Have a client hold his breath briefly.
B. Discontinue the fluid installation.
C. Remind the client that cramping is common at
this time.
D. Lower the enema fluid container.
20. A client with chronic pulmonary disease
has a bluish tinge around the lips. The nurse
charts which term to most accurately
describe the clients condition?
A. Hypoxia
B. Hypoxemia
C. Dyspnea
D. Cyanosis
Funda 8 (20 items)
1. To prevent postoperative complications,
Nurse Kim assists the client with coughing
and deep breathing exercises. This is best
accomplished by implementing which of the
following?
1. Coughing exercises one hour before meals
and deep breathing one hour after meals.
2. Forceful coughing as many times as tolerated.
3. Huff coughing every two hours or as needed.
4. Diaphragmatic and pursed lip breathing 5 to
10 times, four times a day
2. Nurse Trixie is preparing to perform
tracheostomy care. Prior to beginning the
procedure the nurse performs which action?
1. Tells the client to raise two fingers to indicate
pain or distress.
2. Changes twill tape holding the tracheostomy
and place.
3. Cleans the incision site.
4. Checks the tightness of the ties and knot
3. Which action by the nurse represents
proper nasopharyngeal/nasotracheal
suctioning technique?
1. Lubricate the suction catheter with petroleum
jelly before and between insertion.
2. Apply suction intermittently while inserting the
suction catheter.
3. Rotate the catheter while applying suction.
4. Hyper oxygenate with 100% oxygen for 30
minutes before and after suctioning
4. Which client statement informs the nurse
that his teaching about the proper use of an
incentive spirometer was effective?
1. I should breathe out as fast and as hard as
possible into the device.
2. I should inhale slowly and steadily to keep
the balls up.
3. I should use the device three times a day,
after meals.
4. the entire device should be washed
thoroughly in sudsy water once a week.
5. While a client with chest tubes is
ambulating, the connection between the tube
and the water seal dislodges. Which action
by Nurse Flora is most appropriate?
1. Assist the client to ambulate back to bed.
2. Reconnect to the tube to the water seal.
3. Assess the clients lung sounds with a
stethoscope.
4. Have the client cough forcibly several times.
6. Nurse Peter makes the assessment that
which client has the greatest risk for a
problem with the transport of oxygen from
the lungs to the tissues? A client who has:
1. anemia.
2. an infection.
3. a fractured rib.
4. a tumor of the medulla.
7. Which term does the nurse document to
best describe a client experiencing
shortness of breath while lying down who
must assume an upright or sitting position to
breed more comfortably and effectively?
1. Dyspnea
2. Hyperpnea
3. Orthopnea
4. Acapnea
8. A client with emphysema is prescribed
corticosteroid therapy on a short-term basis
for acute bronchitis. The client asks the
nurse how the steroids will help him. The
nurse respond by saying that the
corticosteroids will do which of the
following?
1. Promote bronchodilation.
2. Help the client to cough.
3. Prevent respiratory infection.
4. Decrease inflammation in the airways.
9. Nurse Aleli is planning to perform
percussion and postural drainage. Which is
an important aspect of planning the clients
care?
1. Percussion and postural drainage should be
done before lunch.
2. The order should be coughing, percussion,
positioning, and then suctioning.
3. A good time to perform percussion and
postural drainage is in the morning after
breakfast when the client is well rested.
4. Percussion and postural drainage should
always be preceded by three minutes of 100%
oxygen.
10. Nurse Winona teaches a patient how to
use an incentive spirometer. What patient
outcome will support the conclusion that the
use of the incentives spirometer was
effective?
1. Supplemental oxygen use will be reduced.
2. Inspiratory volume will be increased.
3. Sputum will be expectorated.
4. Coughing will be stimulated.
11. Nurse AJ is applying a warm compress.
What should the nurse explain to the patient
is the primary reason why heat is used
instead of cold?
1. Minimizes muscle spasms
2. Prevents hemorrhage
3. Increases circulation
4. Reduces discomfort
12. A practitioner orders chest physiotherapy
with percussion and vibration for a newly
admitted patient. Which information obtained
by the nurse during the health history should
alert the nurse to question the practitioners
order?
1. Emphysema.
2. Osteoporosis.
3. Cystic fibrosis.
4. Chronic bronchitis
13. Nurse Sue teaches a patient about
pursed lip breathing. The nurse identifies
that the teaching is affected when the patient
says its purpose is to:
1. precipitate coughing.
2. help maintain open airways.
3. decrease intrathoracic pressure.
4. facilitate expectoration of mucus
14. What should Nurse Mavie do first if a
patient is choking on food?
1. Apply sharp for thrusts over the patients
xiphoid process.
2. Determine if the patient can make any verbal
sounds.
3. Hit the middle of the patients back firmly.
4. Sweep the patients mouth with a finger has been vomiting and has had diarrhea for
15. Nurse Stephanie is assessing a client the past two days. She appears lethargic and
who has an acute respiratory infection that is complaining of leg cramps. What should
puts her at risk for hypoxemia. Which of the the nurse do first?
following findings are early indications that 1. Start an IV.
should alert the nurse that the client is 2. Review the results of serum electrolytes.
developing hypoxemia? Select all that apply. 3. Offer the woman foods that are high in
1. Restlessness. sodium and potassium content.
2. Tachypnea. 4. Administer an anti-a medic
3. Bradycardia.
4. Confusion.
5. Pallor.
16. Nurse CJ is caring for a client who is
having difficulty breathing. The client is lying
in bed and is already receiving oxygen
therapy via nasal cannula. Which of the
following interventions is the nurses
priority?
1. Increase the oxygen flow.
2. Assist the client to Fowlers position.
3. Promote removal of pulmonary secretions.
4. Attain a specimen for arterial blood gases.
17. Nurse Aldrin is preparing to perform
endotracheal suctioning for a client. Which
of the following are appropriate guidelines
for the nurse to follow? Select all that apply.
1. Apply suction while withdrawing the catheter.
2. Perform suctioning on a routine basis, every 2
to 3 hours.
3. Maintain medical asepsis during suctioning.
4. Use a new catheter for each suctioning
attempt.
5. Limit suctioning to 2 to 3 attempts.
18. A nurses caring for a client who has a
tracheostomy. Which of the following actions
should the nurse take each time he provides
a tracheostomy care? Select all that apply.
1. Apply the oxygen source loosely if the SPO2
increases during the procedure.
2. Use surgical asepsis to remove and clean the
inner cannula.
3. Clean the outer surfaces in a circular motion
from the stoma site outward.
4. Replace the tracheostomy ties with new ties.
5. Cut a slit in gauze squares to place beneath
the tube holder.
19. An elderly nursing home resident has
refused to eat or drink for several days and
is admitted to the hospital. The nurse should
expect which assessment finding?
1. Increase blood pressure.
2. Weak, rapid pulse.
3. Moist mucous membranes.
4. Jugular vein distention.
20. A man brings his elderly wife to the
emergency department. He states that she