1.

The nurse In-charge in labor and delivery unit administered a dose of terbutaline to
a client without checking the client’s pulse. The standard that would be used to
determine if the nurse was negligent is:

A. The physician’s orders.

B. The action of a clinical nurse specialist who is recognized expert in the field.
C. The statement in the drug literature about administration of terbutaline.
D. The actions of a reasonably prudent nurse with similar education and experience.
2. Nurse Trish is caring for a female client with a history of GI bleeding, sickle cell
disease, and a platelet count of 22,000/μl. The female client is dehydrated and
receiving dextrose 5% in half-normal saline solution at 150 ml/hr. The client
complains of severe bone pain and is scheduled to receive a dose of morphine sulfate.
In administering the medication, Nurse Trish should avoid which route?

A. I.V
B. I.M
C. Oral
D. S.C
3. Dr. Garcia writes the following order for the client who has been recently admitted
“Digoxin .125 mg P.O. once daily.” To prevent a dosage error, how should the nurse
document this order onto the medication administration record?

A. “Digoxin .1250 mg P.O. once daily”

B. “Digoxin 0.1250 mg P.O. once daily”
C. “Digoxin 0.125 mg P.O. once daily”
D. “Digoxin .125 mg P.O. once daily”
4. A newly admitted female client was diagnosed with deep vein thrombosis. Which
nursing diagnosis should receive the highest priority?

A. Ineffective peripheral tissue perfusion related to venous congestion.

B. Risk for injury related to edema.
C. Excess fluid volume related to peripheral vascular disease.
D. Impaired gas exchange related to increased blood flow.
5. Nurse Betty is assigned to the following clients. The client that the nurse would see
first after endorsement?

A. A 34 year-old post operative appendectomy client of five hours who is

complaining of pain.
B. A 44 year-old myocardial infarction (MI) client who is complaining of nausea.
C. A 26 year-old client admitted for dehydration whose intravenous (IV) has
infiltrated.
 D. A 63 year-old post operative’s abdominal hysterectomy client of three days whose
incisional dressing is saturated with serosanguinous fluid.
6. Nurse Gail places a client in a four-point restraint following orders from the
physician. The client care plan should include:

A. Assess temperature frequently.

B. Provide diversional activities.
C. Check circulation every 15-30 minutes.
D. Socialize with other patients once a shift.
7. A male client who has severe burns is receiving H2 receptor antagonist therapy.
The nurse In-charge knows the purpose of this therapy is to:

A. Prevent stress ulcer

B. Block prostaglandin synthesis
C. Facilitate protein synthesis.
D. Enhance gas exchange
8. The doctor orders hourly urine output measurement for a postoperative male client.
The nurse Trish records the following amounts of output for 2 consecutive hours: 8
a.m.: 50 ml; 9 a.m.: 60 ml. Based on these amounts, which action should the nurse
take?

A. Increase the I.V. fluid infusion rate

B. Irrigate the indwelling urinary catheter
C. Notify the physician
D. Continue to monitor and record hourly urine output
9. Tony, a basketball player twist his right ankle while playing on the court and seeks
care for ankle pain and swelling. After the nurse applies ice to the ankle for 30
minutes, which statement by Tony suggests that ice application has been effective?

A. “My ankle looks less swollen now”.

B. “My ankle feels warm”.
C. “My ankle appears redder now”.
D. “I need something stronger for pain relief”
10.The physician prescribes a loop diuretic for a client. When administering this drug,
the nurse anticipates that the client may develop which electrolyte imbalance?

A. Hypernatremia
B. Hyperkalemia
C. Hypokalemia
D. Hypervolemia
11.She finds out that some managers have benevolent-authoritative style of
management. Which of the following behaviors will she exhibit most likely?

A. Have condescending trust and confidence in their subordinates.

B. Gives economic and ego awards.
C. Communicates downward to staffs.
D. Allows decision making among subordinates.
12. Nurse Amy is aware that the following is true about functional nursing

A. Provides continuous, coordinated and comprehensive nursing services.

B. One-to-one nurse patient ratio.
C. Emphasize the use of group collaboration.
D. Concentrates on tasks and activities.
13.Which type of medication order might read “Vitamin K 10 mg I.M. daily × 3
days?”

A. Single order
B. Standard written order
C. Standing order
D. Stat order
14.A female client with a fecal impaction frequently exhibits which clinical
manifestation?

A. Increased appetite
B. Loss of urge to defecate
C. Hard, brown, formed stools
D. Liquid or semi-liquid stools
15.Nurse Linda prepares to perform an otoscopic examination on a female client. For
proper visualization, the nurse should position the client’s ear by:

A. Pulling the lobule down and back

B. Pulling the helix up and forward
C. Pulling the helix up and back
D. Pulling the lobule down and forward
16. Which instruction should nurse Tom give to a male client who is having external
radiation therapy:

A. Protect the irritated skin from sunlight.

B. Eat 3 to 4 hours before treatment.
C. Wash the skin over regularly.
D. Apply lotion or oil to the radiated area when it is red or sore.
17.In assisting a female client for immediate surgery, the nurse In-charge is aware that
she should:

A. Encourage the client to void following preoperative medication.

B. Explore the client’s fears and anxieties about the surgery.
C. Assist the client in removing dentures and nail polish.
D. Encourage the client to drink water prior to surgery.
18. A male client is admitted and diagnosed with acute pancreatitis after a holiday
celebration of excessive food and alcohol. Which assessment finding reflects this
diagnosis?

A. Blood pressure above normal range.

B. Presence of crackles in both lung fields.
C. Hyperactive bowel sounds
D. Sudden onset of continuous epigastric and back pain.
19. Which dietary guidelines are important for nurse Oliver to implement in caring for
the client with burns?

A. Provide high-fiber, high-fat diet

B. Provide high-protein, high-carbohydrate diet.
C. Monitor intake to prevent weight gain.
D. Provide ice chips or water intake.
20.Nurse Hazel will administer a unit of whole blood, which priority information
should the nurse have about the client?

A. Blood pressure and pulse rate.

B. Height and weight.
C. Calcium and potassium levels
D. Hgb and Hct levels.
21. Nurse Michelle witnesses a female client sustain a fall and suspects that the leg
may be broken. The nurse takes which priority action?

A. Takes a set of vital signs.

B. Call the radiology department for X-ray.
C. Reassure the client that everything will be alright.
D. Immobilize the leg before moving the client.
22.A male client is being transferred to the nursing unit for admission after receiving a
radium implant for bladder cancer. The nurse in-charge would take which priority
action in the care of this client?

A. Place client on reverse isolation.

 B. Admit the client into a private room.
C. Encourage the client to take frequent rest periods.
D. Encourage family and friends to visit.
23.A newly admitted female client was diagnosed with agranulocytosis. The nurse
formulates which priority nursing diagnosis?

A. Constipation
B. Diarrhea
C. Risk for infection
D. Deficient knowledge
24.A male client is receiving total parenteral nutrition suddenly demonstrates signs
and symptoms of an air embolism. What is the priority action by the nurse?

A. Notify the physician.

B. Place the client on the left side in the Trendelenburg position.
C. Place the client in high-Fowlers position.
D. Stop the total parenteral nutrition.
25.Nurse May attends an educational conference on leadership styles. The nurse is
sitting with a nurse employed at a large trauma center who states that the leadership
style at the trauma center is task-oriented and directive. The nurse determines that the
leadership style used at the trauma center is:

A. Autocratic.
B. Laissez-faire.
C. Democratic.
D. Situational
26.The physician orders DS 500 cc with KCl 10 mEq/liter at 30 cc/hr. The nurse in-
charge is going to hang a 500 cc bag. KCl is supplied 20 mEq/10 cc. How many cc’s
of KCl will be added to the IV solution?

A. .5 cc
B. 5 cc
C. 1.5 cc
D. 2.5 cc
27.A child of 10 years old is to receive 400 cc of IV fluid in an 8 hour shift. The IV
drip factor is 60. The IV rate that will deliver this amount is:

A. 50 cc/ hour
B. 55 cc/ hour
C. 24 cc/ hour
D. 66 cc/ hour
28.The nurse is aware that the most important nursing action when a client returns
from surgery is:

A. Assess the IV for type of fluid and rate of flow.

B. Assess the client for presence of pain.
C. Assess the Foley catheter for patency and urine output
D. Assess the dressing for drainage.
29. Which of the following vital sign assessments that may indicate cardiogenic shock
after myocardial infarction?

A. BP – 80/60, Pulse – 110 irregular

B. BP – 90/50, Pulse – 50 regular
C. BP – 130/80, Pulse – 100 regular
D. BP – 180/100, Pulse – 90 irregular
30.Which is the most appropriate nursing action in obtaining a blood pressure
measurement?

A. Take the proper equipment, place the client in a comfortable position, and record
the appropriate information in the client’s chart.
B. Measure the client’s arm, if you are not sure of the size of cuff to use.
C. Have the client recline or sit comfortably in a chair with the forearm at the level
of the heart.
D. Document the measurement, which extremity was used, and the position that the
client was in during the measurement.
31.Asking the questions to determine if the person understands the health teaching
provided by the nurse would be included during which step of the nursing process?

A. Assessment
B. Evaluation
C. Implementation
D. Planning and goals
32.Which of the following item is considered the single most important factor in
assisting the health professional in arriving at a diagnosis or determining the person’s
needs?

A. Diagnostic test results

B. Biographical date
C. History of present illness
D. Physical examination
33.In preventing the development of an external rotation deformity of the hip in a
client who must remain in bed for any period of time, the most appropriate nursing
action would be to use:

A. Trochanter roll extending from the crest of the ileum to the midthigh.
B. Pillows under the lower legs.
C. Footboard
D. Hip-abductor pillow
34.Which stage of pressure ulcer development does the ulcer extend into the
subcutaneous tissue?

A. Stage I
B. Stage II
C. Stage III
D. Stage IV
35.When the method of wound healing is one in which wound edges are not surgically
approximated and integumentary continuity is restored by granulations, the wound
healing is termed

A. Second intention healing

B. Primary intention healing
C. Third intention healing
D. First intention healing
36.An 80-year-old male client is admitted to the hospital with a diagnosis of
pneumonia. Nurse Oliver learns that the client lives alone and hasn’t been eating or
drinking. When assessing him for dehydration, nurse Oliver would expect to find:

A. Hypothermia
B. Hypertension
C. Distended neck veins
D. Tachycardia
37.The physician prescribes meperidine (Demerol), 75 mg I.M. every 4 hours as
needed, to control a client’s postoperative pain. The package insert is “Meperidine,
100 mg/ml.” How many milliliters of meperidine should the
client receive?

A. 0.75
B. 0.6
C. 0.5
D. 0.25
38. A male client with diabetes mellitus is receiving insulin. Which statement
correctly describes an insulin unit?

A. It’s a common measurement in the metric system.

B. It’s the basis for solids in the avoirdupois system.
C. It’s the smallest measurement in the apothecary system.
D. It’s a measure of effect, not a standard measure of weight or quantity.
39.Nurse Oliver measures a client’s temperature at 102° F. What is the equivalent
Centigrade temperature?

A. 40.1 °C
B. 38.9 °C
C. 48 °C
D. 38 °C
40.The nurse is assessing a 48-year-old client who has come to the physician’s office
for his annual physical exam. One of the first physical signs of aging is:

A. Accepting limitations while developing assets.

B. Increasing loss of muscle tone.
C. Failing eyesight, especially close vision.
D. Having more frequent aches and pains.
41.The physician inserts a chest tube into a female client to treat a pneumothorax. The
tube is connected to water-seal drainage. The nurse in-charge can prevent chest tube
air leaks by:

A. Checking and taping all connections.

B. Checking patency of the chest tube.
C. Keeping the head of the bed slightly elevated.
D. Keeping the chest drainage system below the level of the chest.
42.Nurse Trish must verify the client’s identity before administering medication. She
is aware that the safest way to verify identity is to:

A. Check the client’s identification band.

B. Ask the client to state his name.
C. State the client’s name out loud and wait a client to repeat it.
D. Check the room number and the client’s name on the bed.
43.The physician orders dextrose 5 % in water, 1,000 ml to be infused over 8 hours.
The I.V. tubing delivers 15 drops/ml. Nurse John should run the I.V. infusion at a rate
of:

A. 30 drops/minute
 B. 32 drops/minute
C. 20 drops/minute
D. 18 drops/minute
44.If a central venous catheter becomes disconnected accidentally, what should the
nurse in-charge do immediately?

A. Clamp the catheter

B. Call another nurse
C. Call the physician
D. Apply a dry sterile dressing to the site.
45.A female client was recently admitted. She has fever, weight loss, and watery
diarrhea is being admitted to the facility. While assessing the client, Nurse Hazel
inspects the client’s abdomen and notice that it is slightly concave. Additional
assessment should proceed in which order:

A. Palpation, auscultation, and percussion.

B. Percussion, palpation, and auscultation.
C. Palpation, percussion, and auscultation.
D. Auscultation, percussion, and palpation.
46. Nurse Betty is assessing tactile fremitus in a client with pneumonia. For this
examination, nurse Betty should use the:

A. Fingertips
B. Finger pads
C. Dorsal surface of the hand
D. Ulnar surface of the hand
47. Which type of evaluation occurs continuously throughout the teaching and
learning process?

A. Summative
B. Informative
C. Formative
D. Retrospective
48.A 45 year old client, has no family history of breast cancer or other risk factors for
this disease. Nurse John should instruct her to have mammogram how often?

A. Twice per year

B. Once per year
C. Every 2 years
D. Once, to establish baseline
49.A male client has the following arterial blood gas values: pH 7.30; Pao2 89 mmHg;
Paco2 50 mmHg; and HCO3 26mEq/L. Based on these values, Nurse Patricia should
expect which condition?

A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis
50.Nurse Len refers a female client with terminal cancer to a local hospice. What is
the goal of this referral?

A. To help the client find appropriate treatment options.

B. To provide support for the client and family in coping with terminal illness.
C. To ensure that the client gets counseling regarding health care costs.
D. To teach the client and family about cancer and its treatment.
51.When caring for a male client with a 3-cm stage I pressure ulcer on the coccyx,
which of the following actions can the nurse institute independently?

A. Massaging the area with an astringent every 2 hours.

B. Applying an antibiotic cream to the area three times per day.
C. Using normal saline solution to clean the ulcer and applying a protective dressing
as necessary.
D. Using a povidone-iodine wash on the ulceration three times per day.
52.Nurse Oliver must apply an elastic bandage to a client’s ankle and calf. He should
apply the bandage beginning at the client’s:

A. Knee
B. Ankle
C. Lower thigh
D. Foot
53.A 10 year old child with type 1 diabetes develops diabetic ketoacidosis and
receives a continuous insulin infusion. Which condition represents the greatest risk to
this child?

A. Hypernatremia
B. Hypokalemia
C. Hyperphosphatemia
D. Hypercalcemia
54.Nurse Len is administering sublingual nitrglycerin (Nitrostat) to the newly
admitted client. Immediately afterward, the client may experience:
 A. Throbbing headache or dizziness
B. Nervousness or paresthesia.
C. Drowsiness or blurred vision.
D. Tinnitus or diplopia.
55.Nurse Michelle hears the alarm sound on the telemetry monitor. The nurse quickly
looks at the monitor and notes that a client is in a ventricular tachycardia. The nurse
rushes to the client’s room. Upon reaching the client’s bedside, the nurse would take
which action first?

A. Prepare for cardioversion

B. Prepare to defibrillate the client
C. Call a code
D. Check the client’s level of consciousness
56.Nurse Hazel is preparing to ambulate a female client. The best and the safest
position for the nurse in assisting the client is to stand:

A. On the unaffected side of the client.

B. On the affected side of the client.
C. In front of the client.
D. Behind the client.
57.Nurse Janah is monitoring the ongoing care given to the potential organ donor who
has been diagnosed with brain death. The nurse determines that the standard of care
had been maintained if which of the following data is observed?

A. Urine output: 45 ml/hr

B. Capillary refill: 5 seconds
C. Serum pH: 7.32
D. Blood pressure: 90/48 mmHg
58. Nurse Amy has an order to obtain a urinalysis from a male client with an
indwelling urinary catheter. The nurse avoids which of the following, which
contaminate the specimen?

A. Wiping the port with an alcohol swab before inserting the syringe.
B. Aspirating a sample from the port on the drainage bag.
C. Clamping the tubing of the drainage bag.
D. Obtaining the specimen from the urinary drainage bag.
59.Nurse Meredith is in the process of giving a client a bed bath. In the middle of the
procedure, the unit secretary calls the nurse on the intercom to tell the nurse that there
is an emergency phone call. The appropriate nursing action is to:

A. Immediately walk out of the client’s room and answer the phone call.
 B. Cover the client, place the call light within reach, and answer the phone call.
C. Finish the bed bath before answering the phone call.
D. Leave the client’s door open so the client can be monitored and the nurse can
answer the phone call.
60. Nurse Janah is collecting a sputum specimen for culture and sensitivity testing
from a client who has a productive cough. Nurse Janah plans to implement which
intervention to obtain the specimen?

A. Ask the client to expectorate a small amount of sputum into the emesis basin.
B. Ask the client to obtain the specimen after breakfast.
C. Use a sterile plastic container for obtaining the specimen.
D. Provide tissues for expectoration and obtaining the specimen.
61. Nurse Ron is observing a male client using a walker. The nurse determines that
the client is using the walker correctly if the client:

A. Puts all the four points of the walker flat on the floor, puts weight on the hand
pieces, and then walks into it.
B. Puts weight on the hand pieces, moves the walker forward, and then walks into it.
C. Puts weight on the hand pieces, slides the walker forward, and then walks into it.
D. Walks into the walker, puts weight on the hand pieces, and then puts all four
points of the walker flat on the floor.
62.Nurse Amy has documented an entry regarding client care in the client’s medical
record. When checking the entry, the nurse realizes that incorrect information was
documented. How does the nurse correct this error?

A. Erases the error and writes in the correct information.

B. Uses correction fluid to cover up the incorrect information and writes in the
correct information.
C. Draws one line to cross out the incorrect information and then initials the change.
D. Covers up the incorrect information completely using a black pen and writes in
the correct information
63.Nurse Ron is assisting with transferring a client from the operating room table to a
stretcher. To provide safety to the client, the nurse should:

A. Moves the client rapidly from the table to the stretcher.

B. Uncovers the client completely before transferring to the stretcher.
C. Secures the client safety belts after transferring to the stretcher.
D. Instructs the client to move self from the table to the stretcher.
64.Nurse Myrna is providing instructions to a nursing assistant assigned to give a bed
bath to a client who is on contact precautions. Nurse Myrna instructs the nursing
assistant to use which of the following protective items when giving bed bath?
 A. Gown and goggles
B. Gown and gloves
C. Gloves and shoe protectors
D. Gloves and goggles
65. Nurse Oliver is caring for a client with impaired mobility that occurred as a result
of a stroke. The client has right sided arm and leg weakness. The nurse would suggest
that the client use which of the following assistive devices that would provide the best
stability for ambulating?

A. Crutches
B. Single straight-legged cane
C. Quad cane
D. Walker
66.A male client with a right pleural effusion noted on a chest X-ray is being prepared
for thoracentesis. The client experiences severe dizziness when sitting upright. To
provide a safe environment, the nurse assists the client to which position for the
procedure?

A. Prone with head turned toward the side supported by a pillow.

B. Sims’ position with the head of the bed flat.
C. Right side-lying with the head of the bed elevated 45 degrees.
D. Left side-lying with the head of the bed elevated 45 degrees.
67.Nurse John develops methods for data gathering. Which of the following criteria of
a good instrument refers to the ability of the instrument to yield the same results upon
its repeated administration?

A. Validity
B. Specificity
C. Sensitivity
D. Reliability
68.Harry knows that he has to protect the rights of human research subjects. Which of
the following actions of Harry ensures anonymity?

A. Keep the identities of the subject secret

B. Obtain informed consent
C. Provide equal treatment to all the subjects of the study.
D. Release findings only to the participants of the study
69.Patient’s refusal to divulge information is a limitation because it is beyond the
control of Tifanny”. What type of research is appropriate for this study?

A. Descriptive- correlational
 B. Experiment
C. Quasi-experiment
D. Historical
70.Nurse Ronald is aware that the best tool for data gathering is?

A. Interview schedule
B. Questionnaire
C. Use of laboratory data
D. Observation
71.Monica is aware that there are times when only manipulation of study variables is
possible and the elements of control or randomization are not attendant. Which type of
research is referred to this?

A. Field study
B. Quasi-experiment
C. Solomon-Four group design
D. Post-test only design
72.Cherry notes down ideas that were derived from the description of an investigation
written by the person who conducted it. Which type of reference source refers to this?

A. Footnote
B. Bibliography
C. Primary source
D. Endnotes
73.When Nurse Trish is providing care to his patient, she must remember that her duty
is bound not to do doing any action that will cause the patient harm. This is the
meaning of the bioethical principle:

A. Non-maleficence
B. Beneficence
C. Justice
D. Solidarity
74.When a nurse in-charge causes an injury to a female patient and the injury caused
becomes the proof of the negligent act, the presence of the injury is said to exemplify
the principle of:

A. Force majeure
B. Respondeat superior
C. Res ipsa loquitor
D. Holdover doctrine
75.Nurse Myrna is aware that the Board of Nursing has quasi-judicial power. An
example of this power is:

A. The Board can issue rules and regulations that will govern the practice of nursing
B. The Board can investigate violations of the nursing law and code of ethics
C. The Board can visit a school applying for a permit in collaboration with CHED
D. The Board prepares the board examinations
76. When the license of nurse Krina is revoked, it means that she:

A. Is no longer allowed to practice the profession for the rest of her life
B. Will never have her/his license re-issued since it has been revoked
C. May apply for re-issuance of his/her license based on certain conditions stipulated
in RA 9173
D. Will remain unable to practice professional nursing
77.Ronald plans to conduct a research on the use of a new method of pain assessment
scale. Which of the following is the second step in the conceptualizing phase of the
research process?

A. Formulating the research hypothesis

B. Review related literature
C. Formulating and delimiting the research problem
D. Design the theoretical and conceptual framework
78. The leader of the study knows that certain patients who are in a specialized
research setting tend to respond psychologically to the conditions of the study. This
referred to as :

A. Cause and effect

B. Hawthorne effect
C. Halo effect
D. Horns effect
79.Mary finally decides to use judgment sampling on her research. Which of the
following actions of is correct?

A. Plans to include whoever is there during his study.

B. Determines the different nationality of patients frequently admitted and decides to
get representations samples from each.
C. Assigns numbers for each of the patients, place these in a fishbowl and draw 10
from it.
D. Decides to get 20 samples from the admitted patients
80. The nursing theorist who developed transcultural nursing theory is:
 A. Florence Nightingale
B. Madeleine Leininger
C. Albert Moore
D. Sr. Callista Roy
81.Marion is aware that the sampling method that gives equal chance to all units in the
population to get picked is:

A. Random
B. Accidental
C. Quota
D. Judgment
82.John plans to use a Likert Scale to his study to determine the:

A. Degree of agreement and disagreement

B. Compliance to expected standards
C. Level of satisfaction
D. Degree of acceptance
83.Which of the following theory addresses the four modes of adaptation?

A. Madeleine Leininger
B. Sr. Callista Roy
C. Florence Nightingale
D. Jean Watson
84.Ms. Garcia is responsible to the number of personnel reporting to her.
This principle refers to:

A. Span of control
B. Unity of command
C. Downward communication
D. Leader
85.Ensuring that there is an informed consent on the part of the patient before a
surgery is done, illustrates the bioethical principle of:

A. Beneficence
B. Autonomy
C. Veracity
D. Non-maleficence
86.Nurse Reese is teaching a female client with peripheral vascular disease about foot
care; Nurse Reese should include which instruction?

A. Avoid wearing cotton socks.

 B. Avoid using a nail clipper to cut toenails.
C. Avoid wearing canvas shoes.
D. Avoid using cornstarch on feet.
87.A client is admitted with multiple pressure ulcers. When developing the client’s
diet plan, the nurse should include:

A. Fresh orange slices

B. Steamed broccoli
C. Ice cream
D. Ground beef patties
88.The nurse prepares to administer a cleansing enema. What is the most common
client position used for this procedure?

A. Lithotomy
B. Supine
C. Prone
D. Sims’ left lateral
89.Nurse Marian is preparing to administer a blood transfusion. Which action should
the nurse take first?

A. Arrange for typing and cross matching of the client’s blood.

B. Compare the client’s identification wristband with the tag on the unit of blood.
C. Start an I.V. infusion of normal saline solution.
D. Measure the client’s vital signs.
90.A 65 years old male client requests his medication at 9 p.m. instead of 10 p.m. so
that he can go to sleep earlier. Which type of nursing intervention is required?

A. Independent
B. Dependent
C. Interdependent
D. Intradependent
91.A female client is to be discharged from an acute care facility after treatment for
right leg thrombophlebitis. The Nurse Betty notes that the client’s leg is pain-free,
without redness or edema. The nurse’s actions reflect which step of the nursing
process?

A. Assessment
B. Diagnosis
C. Implementation
D. Evaluation
92.Nursing care for a female client includes removing elastic stockings once per day.
The Nurse Betty is aware that the rationale for this intervention?

A. To increase blood flow to the heart

B. To observe the lower extremities
C. To allow the leg muscles to stretch and relax
D. To permit veins in the legs to fill with blood.
93.Which nursing intervention takes highest priority when caring for a newly admitted
client who’s receiving a blood transfusion?

A. Instructing the client to report any itching, swelling, or dyspnea.

B. Informing the client that the transfusion usually take 1 ½ to 2 hours.
C. Documenting blood administration in the client care record.
D. Assessing the client’s vital signs when the transfusion ends.
94.A male client complains of abdominal discomfort and nausea while receiving tube
feedings. Which intervention is most appropriate for this problem?

A. Give the feedings at room temperature.

B. Decrease the rate of feedings and the concentration of the formula.
C. Place the client in semi-Fowler’s position while feeding.
D. Change the feeding container every 12 hours.
95.Nurse Patricia is reconstituting a powdered medication in a vial. After adding the
solution to the powder, she nurse should:

A. Do nothing.
B. Invert the vial and let it stand for 3 to 5 minutes.
C. Shake the vial vigorously.
D. Roll the vial gently between the palms.
96.Which intervention should the nurse Trish use when administering oxygen by face
mask to a female client?

A. Secure the elastic band tightly around the client’s head.

B. Assist the client to the semi-Fowler position if possible.
C. Apply the face mask from the client’s chin up over the nose.
D. Loosen the connectors between the oxygen equipment and humidifier.
97.The maximum transfusion time for a unit of packed red blood cells (RBCs) is:

A. 6 hours
B. 4 hours
C. 3 hours
D. 2 hours
98.Nurse Monique is monitoring the effectiveness of a client’s drug therapy. When
should the nurse Monique obtain a blood sample to measure the trough drug level?

A. 1 hour before administering the next dose.

B. Immediately before administering the next dose.
C. Immediately after administering the next dose.
D. 30 minutes after administering the next dose.
99.Nurse May is aware that the main advantage of using a floor stock system is:

A. The nurse can implement medication orders quickly.

B. The nurse receives input from the pharmacist.
C. The system minimizes transcription errors.
D. The system reinforces accurate calculations.
100. Nurse Oliver is assessing a client’s abdomen. Which finding should the nurse
report as abnormal?

A. Dullness over the liver.

B. Bowel sounds occurring every 10 seconds.
C. Shifting dullness over the abdomen.
D. Vascular sounds heard over the renal arteries.
Answers and Rationales
1. Answer: (D) The actions of a reasonably prudent nurse with similar education and
experience. The standard of care is determined by the average degree of skill,
care, and diligence by nurses in similar circumstances.
2. Answer: (B) I.M. With a platelet count of 22,000/μl, the clients tends to
bleed easily. Therefore, the nurse should avoid using the I.M. route because
the area is a highly vascular and can bleed readily when penetrated by a needle.
The bleeding can be difficult to stop.
3. Answer: (C) “Digoxin 0.125 mg P.O. once daily” The nurse should always place
a zero before a decimal point so that no one misreads the figure, which could
result in a dosage error. The nurse should never insert a zero at the end of a
dosage that includes a decimal point because this could be misread, possibly
leading to a tenfold increase in the dosage.
4. Answer: (A) Ineffective peripheral tissue perfusion related to
venous congestion. Ineffective peripheral tissue perfusion related to
venous congestion takes the highest priority because venous inflammation
and clot formation impede blood flow in a client with deep vein thrombosis.
5. Answer: (B) A 44 year-old myocardial infarction (MI) client who is complaining
of nausea. Nausea is a symptom of impending myocardial infarction (MI) and
should be assessed immediately so that treatment can be instituted and further
damage to the heart is avoided.
6. Answer: (C) Check circulation every 15-30 minutes. Restraints encircle the limbs,
which place the client at risk for circulation being restricted to the distal areas of
the extremities. Checking the client’s circulation every 15-30 minutes will allow
the nurse to adjust the restraints before injury from decreased blood flow occurs.
7. Answer: (A) Prevent stress ulcer. Curling’s ulcer occurs as a generalized stress
response in burn patients. This results in a decreased production of mucus and
increased secretion of gastric acid. The best treatment for this prophylactic use
of antacids and H2 receptor blockers.
8. Answer: (D) Continue to monitor and record hourly urine output. Normal urine
output for an adult is approximately 1 ml/minute (60 ml/hour). Therefore, this
client’s output is normal. Beyond continued evaluation, no nursing action is
warranted.
9. Answer: (B) “My ankle feels warm”. Ice application decreases pain and swelling.
Continued or increased pain, redness, and increased warmth are signs of
inflammation that shouldn’t occur after ice application
10. Answer: (B) Hyperkalemia. A loop diuretic removes water and, along with it,
sodium and potassium. This may result in hypokalemia, hypovolemia,
and hyponatremia.
11. Answer:(A) Have condescending trust and confidence in
their subordinates. Benevolent-authoritative managers pretentiously show
their trust and confidence to their followers.
12. Answer: (A) Provides continuous, coordinated and comprehensive nursing
services. Functional nursing is focused on tasks and activities and not on the care
of the patients.
13. Answer: (B) Standard written order. This is a standard written order. Prescribers
write a single order for medications given only once. A stat order is written
for medications given immediately for an urgent client problem. A standing order,
also known as a protocol, establishes guidelines for treating a particular disease or
set of symptoms in special care areas such as the coronary care unit. Facilities
also may institute medication protocols that specifically designate drugs that a
nurse may not give.
14. Answer: (D) Liquid or semi-liquid stools. Passage of liquid or semi-liquid stools
results from seepage of unformed bowel contents around the impacted stool in the
rectum. Clients with fecal impaction don’t pass hard, brown, formed stools
because the feces can’t move past the impaction. These clients typically report the
urge to defecate (although they can’t pass stool) and a decreased appetite.
15. Answer: (C) Pulling the helix up and back. To perform an otoscopic examination
on an adult, the nurse grasps the helix of the ear and pulls it up and back to
straighten the ear canal. For a child, the nurse grasps the helix and pulls it down
to straighten the ear canal. Pulling the lobule in any direction wouldn’t straighten
the ear canal for visualization.
16. Answer: (A) Protect the irritated skin from sunlight. Irradiated skin is very
sensitive and must be protected with clothing or sunblock. The priority approach
is the avoidance of strong sunlight.
17. Answer: (C) Assist the client in removing dentures and nail polish. Dentures,
hairpins, and combs must be removed. Nail polish must be removed so that
cyanosis can be easily monitored by observing the nail beds.
18. Answer: (D) Sudden onset of continuous epigastric and back pain. The
autodigestion of tissue by the pancreatic enzymes results in pain from
inflammation, edema, and possible hemorrhage. Continuous, unrelieved epigastric
or back pain reflects the inflammatory process in the pancreas.
19. Answer: (B) Provide high-protein, high-carbohydrate diet. A positive nitrogen
balance is important for meeting metabolic needs, tissue repair, and resistance to
infection. Caloric goals may be as high as 5000 calories per day.
20. Answer: (A) Blood pressure and pulse rate. The baseline must be established to
recognize the signs of an anaphylactic or hemolytic reaction to the transfusion.
21. Answer: (D) Immobilize the leg before moving the client. If the nurse suspects a
fracture, splinting the area before moving the client is imperative. The nurse
should call for emergency help if the client is not hospitalized and call for a
physician for the hospitalized client.
22. Answer: (B) Admit the client into a private room. The client who has a radiation
implant is placed in a private room and has a limited number of visitors. This
reduces the exposure of others to the radiation.
23. Answer: (C) Risk for infection. Agranulocytosis is characterized by a reduced
number of leukocytes (leucopenia) and neutrophils (neutropenia) in the blood.
The client is at high risk for infection because of the decreased body defenses
against microorganisms. Deficient knowledge related to the nature of the disorder
may be appropriate diagnosis but is not the priority.
24. Answer: (B) Place the client on the left side in the Trendelenburg position. Lying
on the left side may prevent air from flowing into the pulmonary veins. The
Trendelenburg position increases intrathoracic pressure, which decreases the
amount of blood pulled into the vena cava during aspiration.
25. Answer: (A) Autocratic. The autocratic style of leadership is a task-oriented and
directive.
26. Answer: (D) 2.5 cc. 2.5 cc is to be added, because only a 500 cc bag of solution is
being medicated instead of a 1 liter.
27. Answer: (A) 50 cc/ hour. A rate of 50 cc/hr. The child is to receive 400 cc over a
period of 8 hours = 50 cc/hr.
28. Answer: (B) Assess the client for presence of pain. Assessing the client for pain is
a very important measure. Postoperative pain is an indication of complication.
The nurse should also assess the client for pain to provide for the client’s comfort.
29. Answer: (A) BP – 80/60, Pulse – 110 irregular. The classic signs of cardiogenic
shock are low blood pressure, rapid and weak irregular pulse, cold, clammy skin,
decreased urinary output, and cerebral hypoxia.
30. Answer: (A) Take the proper equipment, place the client in a comfortable
position, and record the appropriate information in the client’s chart. It is a
general or comprehensive statement about the correct procedure, and it includes
the basic ideas which are found in the other options
31. Answer: (B) Evaluation. Evaluation includes observing the person, asking
questions, and comparing the patient’s behavioral responses with the expected
outcomes.
32. Answer: (C) History of present illness. The history of present illness is the single
most important factor in assisting the health professional in arriving at a diagnosis
or determining the person’s needs.
33. Answer: (A) Trochanter roll extending from the crest of the ileum to the mid-
thigh. A trochanter roll, properly placed, provides resistance to the external
rotation of the hip.
34. Answer: (C) Stage III. Clinically, a deep crater or without undermining of
adjacent tissue is noted.
35. Answer: (A) Second intention healing. When wounds dehisce, they will allowed
to heal by secondary intention
36. Answer: (D) Tachycardia. With an extracellular fluid or plasma volume deficit,
compensatory mechanisms stimulate the heart, causing an increase in heart rate.
37. Answer: (A) 0.75. To determine the number of milliliters the client should
receive, the nurse uses the fraction method in the following equation.
 75 mg/X ml = 100 mg/1 ml
 To solve for X, cross-multiply:
 75 mg x 1 ml = X ml x 100 mg
 75 = 100X
 75/100 = X
 0.75 ml (or ¾ ml) = X
38. Answer: (D) It’s a measure of effect, not a standard measure of weight or
quantity. An insulin unit is a measure of effect, not a standard measure of weight
or quantity. Different drugs measured in units may have no relationship to one
another in quality or quantity.
39. Answer: (B) 38.9 °C. To convert Fahrenheit degreed to Centigrade, use this
formula
 °C = (°F – 32) ÷ 1.8
 °C = (102 – 32) ÷ 1.8
 °C = 70 ÷ 1.8
 °C = 38.9
40. Answer: (C) Failing eyesight, especially close vision. Failing eyesight, especially
close vision, is one of the first signs of aging in middle life (ages 46 to 64). More
frequent aches and pains begin in the early late years (ages 65 to 79). Increase in
loss of muscle tone occurs in later years (age 80 and older).
41. Answer: (A) Checking and taping all connections. Air leaks commonly occur if
the system isn’t secure. Checking all connections and taping them will prevent air
leaks. The chest drainage system is kept lower to promote drainage – not to
prevent leaks.
42. Answer: (A) Check the client’s identification band. Checking the client’s
identification band is the safest way to verify a client’s identity because the band
is assigned on admission and isn’t be removed at any time. (If it is removed, it
must be replaced). Asking the client’s name or having the client repeated his
name would be appropriate only for a client who’s alert, oriented, and able to
understand what is being said, but isn’t the safe standard of practice. Names on
bed aren’t always reliable
43. Answer: (B) 32 drops/minute. Giving 1,000 ml over 8 hours is the same as giving
125 ml over 1 hour (60 minutes). Find the number of milliliters per minute as
follows:
 125/60 minutes = X/1 minute
 60X = 125 = 2.1 ml/minute
 To find the number of drops per minute:
 2.1 ml/X gtt = 1 ml/ 15 gtt
 X = 32 gtt/minute, or 32 drops/minute
44. Answer: (A) Clamp the catheter. If a central venous catheter becomes
disconnected, the nurse should immediately apply a catheter clamp, if available. If
a clamp isn’t available, the nurse can place a sterile syringe or catheter plug in the
catheter hub. After cleaning the hub with alcohol or povidone-iodine solution, the
nurse must replace the I.V. extension and restart the infusion.
45. Answer: (D) Auscultation, percussion, and palpation.The correct order of
assessment for examining the abdomen is inspection, auscultation, percussion,
and palpation. The reason for this approach is that the less intrusive techniques
should be performed before the more intrusive techniques. Percussion and
palpation can alter natural findings during auscultation.
46. Answer: (D) Ulnar surface of the hand. The nurse uses the ulnar surface, or ball,
of the hand to asses tactile fremitus, thrills, and vocal vibrations through the chest
wall. The fingertips and finger pads best distinguish texture and shape. The dorsal
surface best feels warmth.
47. Answer: (C) Formative. Formative (or concurrent) evaluation occurs continuously
throughout the teaching and learning process. One benefit is that the nurse can
adjust teaching strategies as necessary to enhance learning. Summative, or
 retrospective, evaluation occurs at the conclusion of the teaching and learning
session. Informative is not a type of evaluation.
48. Answer: (B) Once per year. Yearly mammograms should begin at age 40 and
continue for as long as the woman is in good health. If health risks, such as
family history, genetic tendency, or past breast cancer, exist, more
frequent examinations may be necessary.
49. Answer: (A) Respiratory acidosis. The client has a below-normal (acidic) blood
pH value and an above-normal partial pressure of arterial carbon dioxide (Paco2)
value, indicating respiratory acidosis. In respiratory alkalosis, the pH value is
above normal and in the Paco2 value is below normal. In metabolic acidosis, the
pH and bicarbonate (Hco3) values are below normal. In metabolic alkalosis, the
pH and Hco3 values are above normal.
50. Answer: (B) To provide support for the client and family in coping with terminal
illness. Hospices provide supportive care for terminally ill clients and their
families. Hospice care doesn’t focus on counseling regarding health care costs.
Most client referred to hospices have been treated for their disease without
success and will receive only palliative care in the hospice.
51. Answer: (C) Using normal saline solution to clean the ulcer and applying a
protective dressing as necessary. Washing the area with normal saline solution
and applying a protective dressing are within the nurse’s realm of interventions
and will protect the area. Using a povidone-iodine wash and an antibiotic cream
require a physician’s order. Massaging with an astringent can further damage the
skin.
52. Answer: (D) Foot. An elastic bandage should be applied form the distal area to
the proximal area. This method promotes venous return. In this case, the nurse
should begin applying the bandage at the client’s foot. Beginning at the ankle,
lower thigh, or knee does not promote venous return.
53. Answer: (B) Hypokalemia. Insulin administration causes glucose and potassium
to move into the cells, causing hypokalemia.
54. Answer: (A) Throbbing headache or dizziness. Headache and dizziness often
occur when nitroglycerin is taken at the beginning of therapy. However, the client
usually develops tolerance
55. Answer: (D) Check the client’s level of consciousness. Determining
unresponsiveness is the first step assessment action to take. When a client is in
ventricular tachycardia, there is a significant decrease in cardiac output. However,
checking the unresponsiveness ensures whether the client is affected by the
decreased cardiac output.
56. Answer: (B) On the affected side of the client.When walking with clients, the
nurse should stand on the affected side and grasp the security belt in the midspine
area of the small of the back. The nurse should position the free hand at the
shoulder area so that the client can be pulled toward the nurse in the event that
 there is a forward fall. The client is instructed to look up and outward rather than
at his or her feet.
57. Answer: (A) Urine output: 45 ml/hr. Adequate perfusion must be maintained to
all vital organs in order for the client to remain visible as an organ donor. A urine
output of 45 ml per hour indicates adequate renal perfusion. Low blood pressure
and delayed capillary refill time are circulatory system indicators of inadequate
perfusion. A serum pH of 7.32 is acidotic, which adversely affects all body
tissues.
58. Answer: (D ) Obtaining the specimen from the urinary drainage bag. A urine
specimen is not taken from the urinary drainage bag. Urine undergoes chemical
changes while sitting in the bag and does not necessarily reflect the current client
status. In addition, it may become contaminated with bacteria from opening the
system.
59. Answer: (B) Cover the client, place the call light within reach, and answer the
phone call. Because telephone call is an emergency, the nurse may need to answer
it. The other appropriate action is to ask another nurse to accept the call.
However, is not one of the options. To maintain privacy and safety, the nurse
covers the client and places the call light within the client’s reach. Additionally,
the client’s door should be closed or the room curtains pulled around the bathing
area.
60. Answer: (C) Use a sterile plastic container for obtaining the specimen. Sputum
specimens for culture and sensitivity testing need to be obtained using sterile
techniques because the test is done to determine the presence of organisms. If the
procedure for obtaining the specimen is not sterile, then the specimen is not
sterile, then the specimen would be contaminated and the results of the test would
be invalid.
61. Answer: (A) Puts all the four points of the walker flat on the floor, puts weight on
the hand pieces, and then walks into it. When the client uses a walker, the nurse
stands adjacent to the affected side. The client is instructed to put all four points
of the walker 2 feet forward flat on the floor before putting weight on hand
pieces. This will ensure client safety and prevent stress cracks in the walker. The
client is then instructed to move the walker forward and walk into it.
62. Answer: (C) Draws one line to cross out the incorrect information and then
initials the change. To correct an error documented in a medical record, the nurse
draws one line through the incorrect information and then initials the error. An
error is never erased and correction fluid is never used in the medical record.
63. Answer: (C) Secures the client safety belts after transferring to the
stretcher. During the transfer of the client after the surgical procedure is complete,
the nurse should avoid exposure of the client because of the risk for potential heat
loss. Hurried movements and rapid changes in the position should be avoided
because these predispose the client to hypotension. At the time of the transfer
 from the surgery table to the stretcher, the client is still affected by the effects of
the anesthesia; therefore, the client should not move self. Safety belts can prevent
the client from falling off the stretcher.
64. Answer: (B) Gown and gloves. Contact precautions require the use of gloves and
a gown if direct client contact is anticipated. Goggles are not necessary unless
the nurse anticipates the splashes of blood, body fluids, secretions, or excretions
may occur. Shoe protectors are not necessary.
65. Answer: (C) Quad cane. Crutches and a walker can be difficult to maneuver for a
client with weakness on one side. A cane is better suited for client with weakness
of the arm and leg on one side. However, the quad cane would provide the most
stability because of the structure of the cane and because a quad cane has four
legs.
66. Answer: (D) Left side-lying with the head of the bed elevated 45 degrees. To
facilitate removal of fluid from the chest wall, the client is positioned sitting at the
edge of the bed leaning over the bedside table with the feet supported on a stool.
If the client is unable to sit up, the client is positioned lying in bed on the
unaffected side with the head of the bed elevated 30 to 45 degrees.
67. Answer: (D) Reliability Reliability is consistency of the research instrument. It
refers to the repeatability of the instrument in extracting the same responses
upon its repeated administration.
68. Answer: (A) Keep the identities of the subject secret. Keeping the identities of the
research subject secret will ensure anonymity because this will hinder providing
link between the information given to whoever is its source.
69. Answer: (A) Descriptive- correlational. Descriptive- correlational study is the
most appropriate for this study because it studies the variables that could be the
antecedents of the increased incidence of nosocomial infection.
70. Answer: (C) Use of laboratory data. Incidence of nosocomial infection is best
collected through the use of biophysiologic measures, particularly in vitro
measurements, hence laboratory data is essential.
71. Answer: (B) Quasi-experiment. Quasi-experiment is done when randomization
and control of the variables are not possible.
72. Answer: (C) Primary source. This refers to a primary source which is a direct
account of the investigation done by the investigator. In contrast to this is a
secondary source, which is written by someone other than the original researcher.
73. Answer: (A) Non-maleficence. Non-maleficence means do not cause harm or do
any action that will cause any harm to the patient/client. To do good is referred as
beneficence.
74. Answer: (C) Res ipsa loquitor. Res ipsa loquitor literally means the thing speaks
for itself. This means in operational terms that the injury caused is the proof that
there was a negligent act.
75. Answer: (B) The Board can investigate violations of the nursing law and code of
ethics. Quasi-judicial power means that the Board of Nursing has the authority to
investigate violations of the nursing law and can issue summons, subpoena or
subpoena duces tecum as needed.
76. Answer: (C) May apply for re-issuance of his/her license based on certain
conditions stipulated in RA 9173. RA 9173 sec. 24 states that for equity and
justice, a revoked license maybe re-issued provided that the following conditions
are met: a) the cause for revocation of license has already been corrected or
removed; and, b) at least four years has elapsed since the license has been
revoked.
77. Answer: (B) Review related literature. After formulating and delimiting the
research problem, the researcher conducts a review of related literature to
determine the extent of what has been done on the study by previous researchers.
78. Answer: (B) Hawthorne effect. Hawthorne effect is based on the study of Elton
Mayo and company about the effect of an intervention done to improve the
working conditions of the workers on their productivity. It resulted to an
increased productivity but not due to the intervention but due to the psychological
effects of being observed. They performed differently because they were under
observation.
79. Answer: (B) Determines the different nationality of patients frequently admitted
and decides to get representations samples from each. Judgment sampling
involves including samples according to the knowledge of the investigator about
the participants in the study.
80. Answer: (B) Madeleine Leininger. Madeleine Leininger developed the theory on
transcultural theory based on her observations on the behavior of selected people
within a culture.
81. Answer: (A) Random. Random sampling gives equal chance for all the elements
in the population to be picked as part of the sample.
82. Answer: (A) Degree of agreement and disagreement. Likert scale is a 5-point
summated scale used to determine the degree of agreement or disagreement of the
respondents to a statement in a study
83. Answer: (B) Sr. Callista Roy. Sr. Callista Roy developed the Adaptation Model
which involves the physiologic mode, self-concept mode, role function mode and
dependence mode.
84. Answer: (A) Span of control. Span of control refers to the number of workers who
report directly to a manager.
85. Answer: (B) Autonomy. Informed consent means that the patient fully
understands about the surgery, including the risks involved and the alternative
solutions. In giving consent it is done with full knowledge and is given freely.
The action of allowing the patient to decide whether a surgery is to be done or not
exemplifies the bioethical principle of autonomy.
86. Answer: (C) Avoid wearing canvas shoes. The client should be instructed to avoid
wearing canvas shoes. Canvas shoes cause the feet to perspire, which may, in
turn, cause skin irritation and breakdown. Both cotton and cornstarch absorb
perspiration. The client should be instructed to cut toenails straight across with
nail clippers.
87. Answer: (D) Ground beef patties. Meat is an excellent source of complete protein,
which this client needs to repair the tissue breakdown caused by pressure
ulcers. Oranges and broccoli supply vitamin C but not protein. Ice cream supplies
only some incomplete protein, making it less helpful in tissue repair.
88. Answer: (D) Sims’ left lateral. The Sims’ left lateral position is the most common
position used to administer a cleansing enema because it allows gravity to aid the
flow of fluid along the curve of the sigmoid colon. If the client can’t assume this
position nor has poor sphincter control, the dorsal recumbent or right lateral
position may be used. The supine and prone positions are inappropriate and
uncomfortable for the client.
89. Answer: (A) Arrange for typing and cross matching of the client’s blood. The
nurse first arranges for typing and cross matching of the client’s blood to ensure
compatibility with donor blood. The other options,although appropriate when
preparing to administer a blood transfusion, come later.
90. Answer: (A) Independent. Nursing interventions are classified as independent,
interdependent, or dependent. Altering the drug schedule to coincide with the
client’s daily routine represents an independent intervention, whereas consulting
with the physician and pharmacist to change a client’s medication because of
adverse reactions represents an interdependent intervention. Administering an
already-prescribed drug on time is a dependent intervention. An intradependent
nursing intervention doesn’t exist.
91. Answer: (D) Evaluation. The nursing actions described constitute evaluation of
the expected outcomes. The findings show that the expected outcomes have been
achieved. Assessment consists of the client’s history, physical examination, and
laboratory studies. Analysis consists of considering assessment information to
derive the appropriate nursing diagnosis. Implementation is the phase of the
nursing process where the nurse puts the plan of care into action.
92. Answer: (B) To observe the lower extremities. Elastic stockings are used to
promote venous return. The nurse needs to remove them once per day to observe
the condition of the skin underneath the stockings. Applying the stockings
increases blood flow to the heart. When the stockings are in place, the leg muscles
can still stretch and relax, and the veins can fill with blood.
93. Answer:(A) Instructing the client to report any itching, swelling, or
dyspnea. Because administration of blood or blood products may cause serious
adverse effects such as allergic reactions, the nurse must monitor the client for
these effects. Signs and symptoms of life-threatening allergic reactions include
 itching, swelling, and dyspnea. Although the nurse should inform the client of the
duration of the transfusion and should document its administration, these actions
are less critical to the client’s immediate health. The nurse should assess vital
signs at least hourly during the transfusion.
94. Answer: (B) Decrease the rate of feedings and the concentration of the
formula. Complaints of abdominal discomfort and nausea are common in clients
receiving tube feedings. Decreasing the rate of the feeding and the concentration
of the formula should decrease the client’s discomfort. Feedings are normally
given at room temperature to minimize abdominal cramping. To prevent
aspiration during feeding, the head of the client’s bed should be elevated at least
30 degrees. Also, to prevent bacterial growth, feeding containers should be
routinely changed every 8 to 12 hours.
95. Answer: (D) Roll the vial gently between the palms. Rolling the vial gently
between the palms produces heat, which helps dissolve the medication. Doing
nothing or inverting the vial wouldn’t help dissolve the medication. Shaking the
vial vigorously could cause the medication to break down, altering its action.
96. Answer: (B) Assist the client to the semi-Fowler position if possible. By assisting
the client to the semi-Fowler position, the nurse promotes easier chest expansion,
breathing, and oxygen intake. The nurse should secure the elastic band so that the
face mask fits comfortably and snugly rather than tightly, which could lead to
irritation. The nurse should apply the face mask from the client’s nose down to
the chin — not vice versa. The nurse should check the connectors between the
oxygen equipment and humidifier to ensure that they’re airtight; loosened
connectors can cause loss of oxygen.
97. Answer: (B) 4 hours. A unit of packed RBCs may be given over a period of
between 1 and 4 hours. It shouldn’t infuse for longer than 4 hours because the risk
of contamination and sepsis increases after that time. Discard or return to the
blood bank any blood not given within this time, according to facility policy.
98. Answer: (B) Immediately before administering the next dose. Measuring the
blood drug concentration helps determine whether the dosing has achieved the
therapeutic goal. For measurement of the trough, or lowest, blood level of a drug,
the nurse draws a blood sample immediately before administering the next dose.
Depending on the drug’s duration of action and half-life, peak blood drug levels
typically are drawn after administering the next dose.
99. Answer: (A) The nurse can implement medication orders quickly. A floor stock
system enables the nurse to implement medication orders quickly. It doesn’t allow
for pharmacist input, nor does it minimize transcription errors or reinforce
accurate calculations.
100. Answer: (C) Shifting dullness over the abdomen. Shifting dullness over the
abdomen indicates ascites, an abnormal finding. The other options are normal
abdominal findings.