Answer: Pulse Difficult To Palpate and East To Obliterate.: - Forwarded Message

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1. The nurse notes unexpectedly during a routine screening examination that the client
has a thready pulse. In what other way could this finding be documented?
a. A 2+ pulse
b. Pulse rate irregular and forceful
c. Pulse difficult to palpate and easy to obliterate
d. Pressure with the index finger causes pulsation
Answer: Pulse difficult to palpate and east to obliterate.

A weak thready pulse is one that is difficult to palpate and easily diminished by slight
pressure. A 2+ pulse indicates that is easily palpable and normal. A forceful pulse and
pulsation felt with pressure from the index finger may be labeled as “full” or “bounding.”
Source: Prentice Hall Nursing Comprehensive Review for the NCLEX – RN Review and Rationales 2008;
p238 Mary Ann Hogan.
2. The nurse is most concerned with providing further teaching for the client with
diabetes who does which of the following?
a. Drinks orange juice each morning
b. Eats an apple and cheese before going to bed
c. Buys canned fruit instead of fresh because it is cheaper
d. Eat six meals per day
Answer: D – Eat six meals per day.

The client who has diabetes needs to have regular meals that are evenly spaced
throughout the day and may need to supplement meals with snacks. Eating six meals
per day is excessive and could lead to inadequate glucose control. Option A and B pose
no risk as long as they are in the client’s meal pattern. Option C is acceptable as long
as the client ensure that the fruit is packed in water instead of syrup.
p251Mary Ann Hogan.
3. When a client comes into the emergency room with complaints of constipation and
abdominal pain, which of the following would be the most common risk factors to assess
for?
a. History of diverticulitis and diverticulosis
b. Dietary and exercise pattern
c. Nutritional intake of proteins and fatty acids
d. Level of nutrition understanding and laxative abuse
Answer: B – Dietary and exercise pattern.

Two most common and key factors that increase risk of constipation are diet that is low
in fiber and fluids and inadequate exercise to stimulate bowel motility, which could lead
to impaction and abdominal pain. Option A is partially correct; diverticulitis id something
to asses for but it is not as frequent etiology as inadequate exercise and low – fiber diet. C
and D are general assessments that are either irrelevant to the client’s complaint or too vague to
be correct for this question.
4. A nurse evaluates that the care plan related to normal physiologic changes has been
effective for a 70 – year – old client if he says,
a. “I have more sebaceous gland activity.”
b. “I have lost some of my social support systems.”
c. “I have an increased need for sleep.”
d. “I have less joint cartilage than I used to.”
Answer: D – “I have less joint cartilage than I used to.”

With normal aging, there is loss of cartilage and joint fluid. Overall wear and tear does
occur. Sebaceous glands are less active, and older adult sweat less. There is a
decreased need for sleep, with shorter REM and non – REM sleep cycles. Social
support may decrease with deaths, and fewer resources but does not relate to question
of physiologic needs.
5. Which nursing intervention would be most appropriate to meet safety needs when
caring for an older adult with sensory changes?
a. Assist in preparing a bath because the client may not be able to determine the
intensity if heat.
b. Use care when administering an injection because older adults experience more
pain.
c. Massage with additional pressure because tactile perception of older adults is
diminished.
d. Use minimal touch with an older adult because touch will feel uncomfortable.
Answer: A – Assist in preparing a bath because the client may not be able to
determine the intensity if heat.
Because of loss of skin receptors, the older adult has an increase threshold to pain,
touch, and temperature. When feeding or bathing, remember that the older adult may
be unable to distinguish hot or cold or to determine the intensity if heat. The older adult
may feel less pain than younger adults and complain of only pressure or a minor
sensation. The older adult, however, is the only one who can identify if they have pain
or not. An older client’s sensory perception is less acute than that of younger adults, so
when giving massage, less pressure is needed. Everyone , and especially the older
adult, needs touch.
6. A nurse is assessing an older adult client who is at risk for shock. The nurse will be
effectively assess for cyanosis on the:
a. Sclera of the eyes
b. Oral mucous membrane
c. Skin of the forehead
d. Nail beds of the finger or toes
Answer: B – Oral mucous membrane

Assessing cyanosis on older adult clients can be difficult, especially if they have darker
skin. Fingernails and toenails can have ridges, fungal infection, and yellowing. The oral
mucous membranes are the site where cyanosis and pallor are most obvious.
7. A client with chronic obstructive pulmonary disease (COPD) has given up smoking
and spaces out activities over the course of the day. The nurse should respond by
doing?
a. Say nothing about the behavior to avoid refocusing the client on the disease process
b. Ignore the maladaptive behavior
c. Reward the adaptive coping behaviors
d. Tell the client that adjustment was bound to occur overtime
Answer: C – Reward the adaptive coping behavior.

A client’s appropriate behavior should be acknowledge and reinforced. Option A is
incorrect because the client is already living with the disease process and an attempt to
avoid drawing attention to it is not reasonable. Option B is incorrect because the client’s
adjustment is not maladaptive. Option D is incorrect because it patronizes the client.
8. Which of the following indicates to the nurse that a non – communicative client’s pain is not
well managed?
a. Crackles in the lungs
b. Hyperactive bowel sounds
c. Unwillingness to eat without assistance
d. Constant restlessness and leg movement
Answer: D – Constant restlessness and leg movement.

Knowledge of response to pain offers accurate and careful assessment of pain with
earlier and more complete pain relief. It should include physical and emotional
behaviors.
9. The nurse is planning discharge teaching for the client with gastroesophageal reflux
diseases (GERD). What dietary modification should be included?
a. Eat three meals and a bedtime snack
b. Avoid intake of caffeine and alcoholic beverages
c. Drink 12 to 16 ounces of water with each meal
d. Lie down for 15 to 20 minutes after eating
Answer: B – Avoid intake of caffeine and alcoholic beverages.

Food that decreases lower esophageal sphincter (LES) pressure should be avoided to
reduce reflux symptoms; these include caffeine, alcohol, and chocolate. Clients should
also avoid eating large meals, drinking fluids with meals, and eating at bedtime; they
should remain upright for 1 to 2 hours after eating.
10. A client is placed on enteral feeding via nasogastric tube to meet nutritional goals.
Which of the following assessments should be included in a plan of care in order to
maintain fluid balance?
a. Assess the skin area around the tube site
b. Weigh the client every other day
c. Maintain strict I&O and flush the tube once a day to ensure patency
d. Irrigate the tube with water as ordered and include this is fluid in total I&O
Answer: D – Irrigate the tube with water as ordered and include this is fluid in
total I&O.
A client who is receiving enteral feedings via nasogastric tube can be at risk for
dehydration caused by inadequate fluid intake. It is therefore important to irrigate the
tube with water as ordered (before and after feeding or medication administration) and
include these irrigations in the client’s total I&O measurements. Option A is incorrect ,
although inspection of the skin surrounding the tube is necessary; it does not relate to
fluid balance. Option B is incorrect because clients are often weighed daily. Option C is
incorrect because feeding tubes are not flushed only once a day.
11. A client arrives in the emergency room and is assessed by the nurse. The client is
staggering, confuse, and verbally abusive, complains of headache from drinking
alcohol, and is asking for medication. The nurse explains to the client that the physician
will need to perform an assessment before the administration of medication. When the
client becomes verbally abusive, the nurse obtains leather restraints and threatens to
place the client in the restraint. With which of the following can the client legally charge
the nurse as a result of the nursing action?
a. Assault
b. Battery
c. Negligence
d. Invasion of privacy.
Answer: A – Assault
An assault occurs when a person puts another person in fear of a harmful or offensive
contact. For this intentional tort to be actionable, the victim must be aware of the threat
of harmful or offensive contact. Battery is the actual contact with one’s body. Negligence
involves actions below the standards of care. Invasion of privacy occurs with
unreasonable intrusion into the individual’s private affairs.
Source: Saunder’s Comprehensive Review for the NCLEX – RN Examination 4th Edition 2008 p64 Linda
Anne Silvestri.
12. The client is to undergo an invasive procedure. While providing information about
the procedure, the nurse provides legal protection of a client’s right to autonomy with
which of the following?
a. Informed consent
b. Beneficence
c. Good Samaritan Law
d. Advance directives
Answer: A – Informed consent

Informed consent provides legal protection of a client’s right to personal autonomy and
to choose medical treatment. Advance directives determine the actions of the
healthcare team when the client is unable to make decision. Beneficence is an ethical
term that means that a person will act for the benefit if others.
Source: Prentice Hall Nursing Fundamentals Reviews and Rationales 2nd Edition 2008 p100 Mary Ann
Hogan.
13. A nurse accidentally administers a drug to the wrong client and the client reacts
adversely to that drug. The nurse anticipates that this event could lead to which of the
following charges?
a. A tort
b. Malpractice
c. Fraud
d. Assault
Answer: B – Malpractice
Malpractice occurs when any form of negligence causes injury to the client. It is the
failure to act as a reasonably prudent person with the same knowledge and experience
would act in the same or similar situation. A tort is a wrong or injury that a person has
suffered from another’s action. Fraud is deliberate deception, and assault is an injury
inflicted on one person by another.
Hogan
14. Which of the following is true about accountability?

a. It is a hallmark of health care professions
b. It seldom involves legal liability
c. It is separate from achieving care objectives
d. It must involve shared leadership
Answer: A – It is a hallmark of health care professions.

Accountability has traditionally been considered a hallmark of health of health care
profession. Nurses have primary responsibility for defining and providing nursing care.
Accountability and direct responsibility for decisions and actions are inherent in the
nurse’s role, and this is considered the hallmark of professionalism.
Source: Thomson Asian Edition Nursing Leadership and Management A Practical Guide 2007 p54 by
Patricia Carrol.
15. Which of the following types of medications can be administered via gastrostomy
tube?
a. Any oral medications
b. Capsules whole contents are dissolve in water
c. Enteric-coated tablets that are thoroughly dissolved in water
d. Most tablets designed for oral use, except for extended-duration compounds
Answer: D – Most tablets designed for oral use, except for extended-duration
compounds.
Capsules, enteric-coated tablets, and most extended duration or sustained release
products should not be dissolved for use in a gastrostomy tube. They are
pharmaceutically manufactured in these forms for valid reasons, and altering them
destroys their purpose. The nurse should seek an alternate physician’s order when an
ordered medication is inappropriate for delivery by tube.
Source: http://nursingbuzz.com/nursing-board-exam-drills-in-fundamentals-of-nursing-2/; retrieved

February 16, 2010, 9:00am.
16. An infected patient has chills and begins shivering. The best nursing intervention is
to:
a. Apply iced alcohol sponges
b. Provide increased cool liquids
c. Provide additional bedclothes
d. Provide increased ventilation
Answer: C – Provide additional bedclothes.

In an infected patient, shivering results from the body’s attempt to increase heat
production and the production of neutrophils and phagocytotic action through increased
skeletal muscle tension and contractions. Initial vasoconstriction may cause skin to feel
cold to the touch. Applying additional bed clothes helps to equalize the body
temperature and stop the chills. Attempts to cool the body result in further shivering,
increased metabloism, and thus increased heat production.

February 16, 2010, 9:00am.
17. Immobility impairs bladder elimination, resulting in such disorders as

a. Increased urine acidity and relaxation of the perineal muscles, causing bladder
incontinence
b. Urine retention, bladder distention, and infection
c. Diuresis, natriuresis, and decreased urine specific gravity
d. Decreased calcium and phosphate levels in the urine
Answer: B – Urine retention, bladder distention, and infection.

The immobilized patient commonly suffers from urine retention caused by decreased
muscle tone in the perineum. This leads to bladder distention and urine stagnation,
which provide an excellent medium for bacterial growth leading to infection. Immobility
also results in more alkaline urine with excessive amounts of calcium, sodium and
phosphate, a gradual decrease in urine production, and an increased specific gravity.

February 16, 2010, 9:00am.
18. Thrombophlebitis typically develops in patients with which of the following

conditions?
a. Increases partial thromboplastin time
b. Acute pulsus paradoxus
c. An impaired or traumatized blood vessel wall
d. Chronic Obstructive Pulmonary Disease (COPD)
Answer: C – An impaired or traumatized blood vessel wall.

The factors, known as Virchow’s triad, collectively predispose a patient to
thromboplebitis; impaired venous return to the heart, blood hypercoagulability, and
injury to a blood vessel wall. Increased partial thromboplastin time indicates a prolonged
bleeding time during fibrin clot formation, commonly the result of anticoagulant (heparin)
therapy. Arterial blood disorders (such as pulsus paradoxus) and lung diseases (such
as COPD) do not necessarily impede venous return of injure vessel walls.

February 16, 2010, 9:00am.
19. When transferring a patient from a bed to a chair, the nurse should use which
muscles to avoid back injury?
a. Abdominal muscles
b. Back muscles
c. Leg muscles
d. Upper arm muscles
Answer: C – Leg muscles

The leg muscles are the strongest muscles in the body and should bear the greatest
stress when lifting. Muscles of the abdomen, back, and upper arms may be easily
injured.

February 16, 2010, 9:00am.
20. In a recumbent, immobilized patient, lung ventilation can become altered, leading to
such respiratory complications as:
a. Respiratory acidosis, ateclectasis, and hypostatic pneumonia
b. Appneustic breathing, atypical pneumonia and respiratory alkalosis
c. Cheyne-Strokes respirations and spontaneous pneumothorax
d. Kussmail’s respirations and hypoventilation
Answer: A – Respiratory acidosis, ateclectasis, and hypostatic pneumonia .

Because of restricted respiratory movement, a recumbent, immobilize patient is at
particular risk for respiratory acidosis from poor gas exchange; atelectasis from reduced
surfactant and accumulated mucus in the bronchioles, and hypostatic pneumonia from
bacterial growth caused by stasis of mucus secretions.

February 16, 2010, 9:00am.
21. Sterile technique is used whenever:

a. Strict isolation is required
b. Terminal disinfection is performed
c. Invasive procedures are performed
d. Protective isolation is necessary
Answer: C – Invasive procedures are performed.

All invasive procedures, including surgery, catheter insertion, and administration of
parenteral therapy, require sterile technique to maintain a sterile environment. All
equipment must be sterile, and the nurse and the physician must wear sterile gloves
and maintain surgical asepsis. In the operating room, the nurse and physician are
required to wear sterile gowns, gloves, masks, hair covers, and shoe covers for all
invasive procedures. Strict isolation requires the use of clean gloves, masks, gowns and
equipment to prevent the transmission of highly communicable diseases by contact or
by airborne routes. Terminal disinfection is the disinfection of all contaminated supplies
and equipment after a patient has been discharged to prepare them for reuse by
another patient. The purpose of protective (reverse) isolation is to prevent a person with
seriously impaired resistance from coming into contact who potentially pathogenic
organisms.

February 16, 2010, 9:00am.
22. Which of the following patients is at greater risk for contracting an infection?
a. A patient with leukopenia
b. A patient receiving broad-spectrum antibiotics
c. A postoperative patient who has undergone orthopedic surgery
d. A newly diagnosed diabetic patient
Answer: A – A patient with leukopenia.

Leukopenia is a decreased number of leukocytes (white blood cells), which are
important in resisting infection. None of the other situations would put the patient at risk
for contracting an infection; taking broad-spectrum antibiotics might actually reduce the
infection risk.

February 16, 2010, 9:00am.
23. Which of the following constitutes a break in sterile technique while preparing a
sterile field for a dressing change?
a. Using sterile forceps, rather than sterile gloves, to handle a sterile item
b. Touching the outside wrapper of sterilized material without sterile gloves
c. Placing a sterile object on the edge of the sterile field
d. Pouring out a small amount of solution (15 to 30 ml) before pouring the solution into a
sterile container.
Answer: C – Placing a sterile object on the edge of the sterile field.

The edges of a sterile field are considered contaminated. When sterile items are
allowed to come in contact with the edges of the field, the sterile items also become
contaminated.

February 16, 2010, 9:00am.
24. Which of the following nursing interventions is considered the most effective form or
universal precautions?
a. Cap all used needles before removing them from their syringes
b. Discard all used uncapped needles and syringes in an impenetrable protective
container
c. Wear gloves when administering IM injections
d. Follow enteric precautions
Answer: B – Discard all used uncapped needles and syringes in an impenetrable

protective container.
According to the Centers for Disease Control (CDC), blood-to-blood contact occurs
most commonly when a health care worker attempts to cap a used needle. Therefore,
used needles should never be recapped; instead they should be inserted in a specially
designed puncture resistant, labeled container. Wearing gloves is not always necessary
when administering an I.M. injection. Enteric precautions prevent the transfer of
pathogens via feces.

February 16, 2010, 9:00am.
25. After 5 days of diuretic therapy with 20mg of furosemide (Lasix) daily, a patient
begins to exhibit fatigue, muscle cramping and muscle weakness. These symptoms
probably indicate that the patient is experiencing:
a. Hypokalemia
b. Hyperkalemia
c. Hypocalcemia
d. Hypercalcemia
Answer: A – Hypokalemia
Fatigue, muscle cramping, and muscle weaknesses are symptoms of hypokalemia (an
inadequate potassium level), which is a potential side effect of diuretic therapy. The
physician usually orders supplemental potassium to prevent hypokalemia in patients
receiving diuretics.

February 16, 2010, 9:00am.
26. When a nurse a nurse presents the nursing procedures to be followed, she refers to
what type of standards?
a. Process
b. Outcome
c. Structure
d. Criteria
Answer: A – Process
Process standards include care plans, nursing procedure to be done to address the
needs of the patients.
Source: http://nclexreviewers.com/nclex-practice-tests; retrieved March 2, 2010, 2:00pm

27. Stephanie is a new Staff Educator of a private tertiary hospital. She conducts
orientation among new staff nurses in her department. Ken, one of the new staff
nurses, wants to understand the channel of communication, span of control and lines of
communication. Which of the following will provide this information?
a. Organizational structure
b. Policy
c. Job description
d. Manual of procedures
Answer: A – Organizational structure

Organizational structure provides information on the channel of authority, i.e., who
reports to whom and with what authority; the number of people who directly reports to
the various levels of hierarchy and the lines of communication whether line or staff.
28. A client diagnosed with Alzheimer’s disease is currently competent to make

healthcare decisions regarding future needs. The nurse counsels the client to contact a
lawyer about which of the following?
a. Advance directives
b. Temporary power of attorney
c. Good Samaritan Law
d. Informed consent
Answer: Advance directives

Advance directives offer guidance to the healthcare team when the client cannot make
a decision regarding the treatment. Advance directives are written while the client is
competent. A durable (not temporary) power of attorney allows a competent person the
power to act on behalf of the client in the event that the client loses decision – making
capacity. The Good Samaritan law covers emergency aid rendered outside
employment. Informed consent is a crucial component of health care and seeks to alert
the client to all avenues of care and treatment.
Hogan.
29. Which of the following is the best guarantee that the patient’s priority needs are
met?
a. Checking with the relative of the patient
b. Preparing a nursing care plan in collaboration with the patient
c. Consulting with the physician
d. Coordinating with other members of the team
Answer: B – Preparing a nursing care plan in collaboration with the patient.

The best source of information about the priority needs of the patient is the patient
himself. Hence using a nursing care plan based on his expressed priority needs would
ensure meeting his needs effectively.
30. A visual – decision making tool that graphically illustrates a project from start to
finish is called?
a. Decision tree
b. PERT flowchart
c. Gantt chart
d. Electronic organizer
Answer: Gantt chart

Gantt chart graphically illustrates a project from start to finish, including time intervals for
interim steps. Decision tree, shows all the outcomes and benefits of a particular
decision and Program Evaluation and Review Technique (PERT) flowcharts, show the
amount of time needed to complete the project.
Patricia Carrol.
31. All of the following nursing interventions are correct when using the Z-track method
of drug injection except:
a. Prepare the injection site with alcohol
b. Use a needle that’s a least 1” long
c. Aspirate for blood before injection
d. Rub the site vigorously after the injection to promote absorption
Answer: D – Rub the site vigorously after the injection to promote absorption.
The Z-track method is an I.M. injection technique in which the patient’s skin is pulled in
such a way that the needle track is sealed off after the injection. This procedure seals
medication deep into the muscle, thereby minimizing skin staining and irritation.
Rubbing the injection site is contraindicated because it may cause the medication to
extravasate into the skin.

February 16, 2010, 10:30am.
32. The correct method for determining the vastus lateralis site for I.M. injection is to:
a. Locate the upper aspect of the upper outer quadrant of the buttock about 5 to 8 cm
below the iliac crest
b. Palpate the lower edge of the acromion process and the midpoint lateral aspect of the
arm
c. Palpate a 1” circular area anterior to the umbilicus
d. Divide the area between the greater femoral trochanter and the lateral femoral
condyle into thirds, and select the middle third on the anterior of the thigh
Answer: D – Divide the area between the greater femoral trochanter and the
lateral femoral condyle into thirds, and select the middle third on the anterior of
the thigh.
The vastus lateralis, a long, thick muscle that extends the full length of the thigh, is
viewed by many clinicians as the site of choice for I.M. injections because it has
relatively few major nerves and blood vessels. The middle third of the muscle is
recommended as the injection site. The patient can be in a supine or sitting position for
an injection into this site.

February 16, 2010, 10:30am.
33. The nurse is providing tracheostomy care to a client who had a tracheostomy
performed 2 weeks ago. The client coughs the tube out of the trachea. Which of the
following actions should the nurse take first?
a. Call aloud for help
b. Suction the stoma to remove residual secretions
c. Grasp and spread the retention sutures to open the stoma
d. Attempt to reinsert a new tracheostomy tube
Answer: C – Grasp and spread the retention sutures to open the stoma.
The priority action of the nurse is to establish a patent airway. With this in mind, the
nurse spreads the retention sutures to reopen the stomal area. The nurse then quickly
calls aloud for help so assistance will arrive to aid in tube reinsertion. The nurse is not
likely to suction the area at this time, and the nurse would reinsert a new tracheostomy
tube if allowed by agency policy, since tube has been in place for more than 72 hours.
34. The nurse should take the following actions when caring for a client with
nephrostomy tube?
a. Irrigate the tube every hour regardless of drainage
b. Keep a clamp at the bedside
c. Ensure the tubing is free of kinks
d. Tape the drainage bag to the bedrail
Answer: C – Ensure the tubing is free of kinks.

The nurse should ensure that the tubing is free of kinks or other obstructions to urine
flow. The tube is irrigated according to physician order. The tube should never be
clamped. Taping the drainage bag to the bedrail is dangerous because it could cause
traction when the client moves in bed and become dislodged.
35. The nurse is about to receive an intershift report on a client who has a Sengstaken –
Blakemore tube in place. The nurse expects that the client has which of the following
health problems as the primary reason for tube placement?
a. Cirrhosis
b. Esophageal varices
c. Portal hypertension
d. Abdominal ascites
Answer: B – Esophageal varices.

A Sengstaken – Blakemore tube is inserted to control bleeding from esophageal varices
, which is the primary health problem of concern with the use of this tube. The
underlying health problem that causes the bleeding is portal hypertension, which is a
complication of cirrhosis of the liver. Abdominal ascites may also accompany cirrhosis.
p469 Mary Ann Hogan
36. A client with hypertension has been given a prescription to treat the disorder. The
nurse would explain that cough and loss of taste are side effects if which of the following
antihypertensive agents is prescribed?
a. Lisinopril (Prinivil)
b. Propranolol (Inderal)
c. Diltiazem (Cardizem)
d. Furosemide (Lasix)
Answer: A – Lisinopril (Prinivil)

Cough and loss of taste are common side effects of angiotensin – converting enzyme
(ACE) inhibitors such as lisinopril. They disappear with discontinuance of the
medication.
37. A client is diagnosed with deep vein thrombophlebitis. A nurse develops a plan of
care for the client and includes which position and activity in the plan?
a. Out – of bed activities as desired
b. Bed rest with affected extremity kept flat
c. Bed rest with elevation of the affected extremity
d. Bed rest with affected extremity being massaged
Answer: C – Bed rest with elevation of the affected extremity.

Elevation of the affected leg facilitates blood flow by the force of gravity and also
decreases venous pressure, which in turn relieves edema and pain. Bed rest is
indicated to prevent emboli and to prevent pressure fluctuations in the venous system
that occur with walking.
Source: Saunders Comprehensive Review for the NCLEX – RN Examination 2008; p249 Linda Anne
Silvestri.
38. A nurse is inserting a nasogastric tube in an adult client. During the procedure, the
client begins to cough and has difficulty breathing. Which of the following is the
appropriate action of the nurse?
a. Quickly insert the tube
b. Notify the physician immediately
c. Remove the tube and reinsert when the respiratory distress subsides
d. Pull back on the tube and wait until the respiratory distress subsides
Answer: D – Pull back on the tube and wait until the respiratory distress
subsides.
During the insertion of a nasogastric tube, if the client experiences difficulty breathing or
any respiratory distress, withdraw the tube slightly, stop the tube advancement, and wait
until the distress subsides. Options B and C are unnecessary. Quickly inserting the tube
is not an appropriate action, it his situation, it may be likely that the tube has entered the
bronchus.
Silvestri.
39. A nurse is preparing to care for a client with potassium – deficit. The nurse reviews
the client’s record and determines that the client was at risk for developing the
potassium deficit because the client:
a. Has a renal failure
b. Requires nasogastric suction
c. Has a history of Addison’s disease
d. Is taking potassium – sparing diuretic
Answer: B – Requires nasogastric suction.

Potassium – rich gastrointestinal fluids are lost through gastrointestinal suction, placing
the client at risk for hypokalemia. The client with renal failure and Addison’s disease and
the client taking potassium – sparing diuretic are at higher risk for hyperkalemia.
Silvestri.
40. A client has just undergone insertion of a central venous catheter at the bedside.
The nurse would be sure to check the results of which of the following before initiating
the flow rate of the client’s IV solution at 100mL/hr.
a. Serum osmolality
b. Serum electrolyte levels
c. Portable chest x – ray film
d. Intake and output record
Answer: C – Portable chest x – ray film

Before beginning administration of IV solution, the nurse should assess whether the
chest radiograph reveals the central catheter is in the proper place. This is necessary to
prevent infusion of fluid into pulmonary or subcutaneous tissues. The other options
represent items that are useful for the nurse to be aware of in the general care of this
client, but they do not relate to this procedure.
Silvestri.
41. A person whose behavior is in accordance with custom or tradition is:

a. Moral
b. Ethical
c. Beneficent
d. Trustworthy
Answer: A – Moral
Morality is behavior in accordance with custom or tradition and usually personal or
religious beliefs; for example, in some cultures, a woman appearing in public without her
head covered is immoral (and perhaps illegal),while in other countries, it is morally
acceptable for a woman’s head to be uncovered.
Patricia Carrol.
42. In this ethical theory, decisions are based on what will provide the greatest good for
the greatest number of people:
a. Nonmaleficence
b. Teleology
c. Formalism
d. Utilitarianism
Answer: B – Utilitarianism
Decisions based on what will provide the greatest good for the greatest number of
people; for example, the decision to force people with pulmonary tuberculosis into
treatment is ethical, according to this theory, because it protects the greater population
from infection.
A – Is the principle of doing no harm.
B – Teleology or consequentialist theory; value of situation is determined by its
consequences.
C – Formalism/Deontology; an act is good only if it spring from goodwill, this ethical
theory does not allow for actions based on the concept of “the end justifies the means.”
Source: Thomson Asian Edition Nursing Leadership and Management A Practical Guide 2007 p297 –
298 by Patricia Carrol.
43. Which of the following qualities are relevant in documenting patient care?
a. Accuracy and conciseness
b. Thorough and currentness
c. Organization
d. All of the above
Answer: D – All of the above

Documentation should leave no room for misinterpretation. Thus the nurse must ensure
that all information pertinent to patient care is reworded accurately, concisely, and
thoroughly. The information must be up – to date and well organized.
Source: Fundamentals of Nursing (Nurse Test a Review Series) p74 by June Looby Olsen et al.
44. A client ask why a diagnostic test has been ordered and the nurse replies ,”I am
unsure but I will find out for you.” When the nurse later returns and provides an
explanation, the nurse is acting under the principle of?
a. Nonmaleficence
b. Veracity
c. Paternalism
d. Fidelity
Answer: D – Fidelity
Fidelity means to be faithful to agreements and promises. This nurse acting on the
client’s behalf to obtain needed information and report it back to the client.
Nonmaleficence is duty to do no harm. Veracity refers to telling the truth – for example,
not lying to a client about a serious prognosis. Beneficence means doing good, such as
by implementing actions that benefit a client.
p35 - 36 Mary Ann Hogan.
45. The care delivery model in which one nurse is responsible for all aspects of patient
care for that shift is called?
a. Functional nursing
b. Team nursing
c. Total patient care
d. Patient – focused care
Answer: C – Total patient care

The contemporary version of the case method – the nurse is responsible for total patient
care for that shift. RNs are responsible for several patient and are assisted by other
licensed personnel (such as LPNs).
A – Divides the nursing work into functional units that are assigned to team members,
such as designating one nurse to administer medication.
B – Assigns staff to teams that are responsible for a group of patients. Each team led by
a registered nurse, who supervises and coordinates care, and provides professional
direction to the team members.
D – Focuses on patient needs rather than staffing issues. Usually all patient services
are decentralized and staffing is based on the patient’s care needs.
Patricia Carrol.
46. The nurse determines that a client is having a transfusion reaction. After the nurse
stops the transfusion, which action should immediately be taken?
a. Remove the IV line
b. Run normal saline at a keep vein open rate
c. Run a solution of 5% dextrose in water
d. Obtain a culture of the tip of the catheter device removed from the client
Answer: B – Run normal saline at a keep vein open rate.

If the nurse suspects a transfusion reaction, the nurse stops the transfusion and infuses
a normal saline at a keep vein open rate pending further physician orders. This
maintains a patent access line and aids in maintaining the client’s intravascular volume.
The nurse would not discontinue the IV line because then there would be no IV access
route. Obtaining a culture tip of the catheter device removed from the client is incorrect,
First the catheter should not be removed. Second, cultures are performed when
infection, not transfusion reaction is suspected. Normal saline is the solution of choice
over solutions containing dextrose because saline does not cause red blood cells to
clump.
Silvestri.
47. A client has received transfusion of platelets. The nurse evaluates that the client is
benefiting most from this therapy if the client exhibits which of the following?
a. Increased hematocrit level
b. Increased hemoglobin level
c. Decline of elevated temperature to normal
d. Decreased oozing of blood from puncture sites and gums
Answer: D – Decreased oozing of blood from puncture sites and gums.

Platelets are necessary for proper blood clotting. The client with insufficient platelets
may exhibit frank bleeding or oozing of blood from puncture sites, wounds, and mucous
membrane. Increased hemoglobin and hematocrit levels would occur when the client
has received a transfusion of red blood cells. An elevated temperature would decline to
normal after infusion of granulocytes if those were instrumental in fighting infection in
the body.
Silvestri.
48. A nurse is inserting an indwelling urinary catheter into a male client. As the catheter
is inserted into the urethra, urine begins to flow into the tubing. At this point, the nurse:
a. Immediately inflates the balloon.
b. Inserts the catheter 2.5 – 5 cm and inflates the balloon.
c. Withdraws the catheter about 1 inch and inflates the balloon.
d. Inserts the catheter until resistance is met and inflates the balloon.
Answer: B – Inserts the catheter 2.5 – 5 cm and inflates the balloon.

The balloon of the catheter is behind the opening at the insertion tip. The catheter is
inserted 2.5 to 5cm after urine begins to flow to provide sufficient space to inflate the
balloon. Inserting the catheter with extra distance will ensure that the balloon is inflated
inside the bladder and not in the urethra. Inflating the balloon in the urethra could
produce trauma.
Silvestri.
49. A nurse is caring for a client with a severe burn who is scheduled for an autograft to
be placed on the lower extremity. The nurse develops a postoperative plan of care for
the client and includes which of the following?
a. Maintain the client in prone position
b. Elevate and immobilize the grafted extremity
c. Maintain the surgical extremity in a flat position
d. Keep the surgical extremity covered with blanket
Answer: B – Elevate and immobilize the grafted extremity.

Autografts placed over joints or on lower extremities are elevated and immobilized
following surgery for 3 to 7 days, depending on the surgeon’s preference. This period of
immobilization allows the autograft time to adhere and attach to the wound bed, and
elevation minimizes edema. Keeping the client in a prone position and covering the
extremity with blanket can disrupt the graft site.
Silvestri.
50. A prescribed amount of oxygen s needed for a patient with COPD to prevent:
a. Cardiac arrest related to increased partial pressure of carbon dioxide in arterial blood
(PaCO2)
b. Circulatory overload due to hypervolemia
c. Respiratory excitement
d. Inhibition of the respiratory hypoxic stimulus
Answer: D – Inhibition of the respiratory hypoxic stimulus.

Delivery of more than 2 liters of oxygen per minute to a patient with chronic obstructive
pulmonary disease (COPD), who is usually in a state of compensated respiratory
acidosis (retaining carbon dioxide (CO2)), can inhibit the hypoxic stimulus for
respiration. An increased partial pressure of carbon dioxide in arterial blood (PACO2)
would not initially result in cardiac arrest. Circulatory overload and respiratory
excitement have no relevance to the question.
Source: http://nursingcrib.com/nursing-board-exam-review-questionnaires/foundation-of-nursing-
comprehensive-test-part-2-answers-and-rationale;retrieved February 18, 2010, 10:30am.
51. The nurse is caring for a client diagnosed with meningitis and implements which
transmission – based precautions for this client?
a. Private room or cohort client
b. Personal respiratory protection device
c. Private room with negative airflow pressure
d. Mask worn by staff when the client needs to leave the room
Answer: A – Private room or cohort client.

Meningitis is transmitted by droplet infection. Precautions for this disease include a
private room or cohort client and use of a standard precaution mask. Private negative
airflow pressure rooms and personal respiratory protection devices are required for
clients with airborne disease such as tuberculosis (TB). When appropriate, a mask must
be worn by the client and not the staff when the client leaves the room.
Silvestri.
52. The nurse is told by a physician that a client in hypovolemic shock will require
plasma expansion. The nurse anticipates receiving an order to transfuse which product?
a. Albumin
b. Platelets
c. Cryoprecipitate
d. Packed red blood cells
Answer: A – Albumin
Albumin may be used as a plasma expander. Platelets are used when the client’s
platelet count is low. Cryoprecipitate is useful in treating bleeding from hemophilia or
disseminated intravascular coagulopathy because it is rich in clotting factors. Packed
red blood cells replace erythrocytes and are not a plasma expander.
Silvestri.
53. A nurse is preparing to care for a client with esophageal varices who has just had s
Sengstaken – Blakemore tube inserted. The nurse gathers supplies, knowing that which
of the following items must be kept at the bedside at all times?
a. An obturator
b. A Kelly clamp
c. An irrigation set
d. A pair of scissors
Answer: D – A pair of scissors

When the client has Sengstaken – Blakemore tube, a pair of scissors must be kept at
the client’s bedside at all times. The client needs to be observed for sudden respiratory
distress, which occurs if the gastric balloon ruptures and the entire tube moves upward.
If this occurs, the nurse immediately cuts all balloon lumens and removes the tub. An
obturator and a Kelly clamp are kept at the bedside of a client with tracheostomy. An
irrigation set may be kept at the bedside, but it is not the priority item.
Silvestri.
54. A client receiving parenteral nutrition (PN) in the home setting has a weight gain of
5lb in 1 week. The nurse next assesses the client to detect the presence of which of the
following?
a. Thirst
b. Polyuria
c. Decreased blood pressure
d. Crackles on auscultation of the lungs
Answer: D – Crackles on auscultation of the lungs.

Optimal weight gain on PN is 1 to 2 lb/week. The client who has weight gain of 5lb/week
while receiving PN is likely to have fluid retention that can result in hypervolemia. Signs
of hypervolemia include increased blood pressure, crackles on the lung auscultation, a
bounding pulse, jugular vein distention, headache, and weight gain more than desired.
Options A and B are associated with hyperglycemia. Option C is likely to be noted in
deficient fluid volume.
Silvestri.
55. A client is scheduled for blood to be drawn from the radial artery for an arterial blood
gas determination. Before the blood is drawn, an Allen’s test is performed to determine
the adequacy of the:
a. Ulnar circulation
b. Carotid circulation
c. Femoral circulation
d. Popliteal circulation
Answer: A – Ulnar circulation

Before radial puncture for obtaining an arterial specimen for arterial blood gases, you
should perform an Allen’s test to determine adequate ulnar circulation. Failure to
determine the presence of adequate collateral circulation could result in severe
ischemic injury to the hand if damage to the radial artery occurs with arterial puncture.
Silvestri
56. Which nursing intervention would be most appropriate for promoting the
environmental safety of a client with a cognitive disorder?
a. Applying an identification bracelet on the client
b. Maintaining daily routine care for the client
c. Placing a clock and a daily schedule in the client’s room
d. Using short sentences with simple words when speaking with the client
Answer: A – Applying an identification bracelet on the client.
Applying an identification bracelet on the client would be most effective in helping to
ensure environmental and client safety should the client wander. Other measures
include installing alarms; instituting injury, fire, and poisoning precautions; providing
adequate lighting; and keeping the bed in a low position. Maintaining a daily routine
would be helpful for ensuring consistency and promoting optimal functioning. Clocks
and daily schedules would be helpful for reorienting the client and promoting optimal
cognitive function. Using short sentences with simple words would be appropriate for
maximizing effective communication.
Source: http://nursingbuzz.com/medical-and-surgical-nursing-practice-questions-with-rationale/; retrieved

February 22, 2010, 9:00am.
57. Following a thoracentesis, which assessment finding would warrant immediate

intervention by the nurse?
a. Auscultation of crackles bilaterally
b. Complaints of pain at the needle insertion site
c. Prolonged periods of uncontrolled coughing
d. Symmetrical respirations
Answer: C – Prolonged periods of uncontrolled coughing.

Uncontrolled coughing in the client following a thoracentesis may indicate the
development of pulmonary edema that requires immediate attention. Bilateral crackles
may indicate underlying inflammation or congestion, but immediate attention is not
necessary. Complaints of pain at the needle insertion site and symmetrical respirations
are normal findings.

February 22, 2010, 9:00am.
58. The nurse assessing a client notes yellow plaques on the lid margins. The nurse
documents the finding as:
a. Exopthalmos
b. Xanthelasma
c. Corneal arcus
d. Ptosis
Answer: B – Xanthelasma
Yellow plaques noted most often on the lid margins are referred to as xanthelasma and
may indicate high lipid levels. Exophthalmos describes protrusion of the eyeball.
Corneal arcus is a thin grayish white arc seen toward the edge of the cornea. Ptosis
describes a drooping eyelid
Source: http://wps.prenhall.com/chet_lemone_medicalsurg_3/11/2951/755556.cw/index.html; retrieved

February 23, 2010, 1:30pm.
59. Which assessment data for a client who is 1 day postabdominal surgery would
warrant immediate nursing intervention?
a. Blood pressure of 110/70 mm Hg and hematocrit of 42%
b. Complaints of abdominal pain as an
c. Hypoactive bowel sounds and a serum potassium of 3.7 mEq/L
d. Rigid, hard, boardlike abdomen and a white blood cell (WBC) count of 20,000 mm
Answer: D – Rigid, hard, boardlike abdomen and a white blood cell (WBC) count
of 20,000 mm.
One day after abdominal surgery, the client’s abdomen should be soft, not rigid or hard.
Also, the WBC count may be slightly elevated in response to the surgery, but an
elevation of 20,000 mmis highly suggestive of an infectious process. A rigid, boardlike
abdomen in conjunction with a seriously elevated WBC count suggests peritonitis and
requires immediate intervention. The client’s blood pressure and hematocrit are within
normal limits. One day after surgery, abdominal incisional pain would be expected and
often is rated as high when using a scale from 1 to 10. The client’s hemoglobin level is
within normal limits. Hypoactive bowel sounds would be expected 1 day after abdominal
surgery. The client’s potassium level is within normal limits.

February 21, 2010; 9:00am.
60. An elderly client with a history of heart disease is receiving intravenous fluids for
dehydration. The client complains of shortness of breath. Physical assessment reveals
tachycardia, tachypnea, and jugular vein distention. The nurse recognizes that these
signs and symptoms indicate which of the following fluid volume imbalances?
a. Fluid overload
b. Hypovolemia
c. Hypernatremia
d. Hyponatremia
Answer: A – Fluid overload

Tachycardia, tachypnea, jugular vein distention, and shortness of breath are indicators
of fluid overload. The elderly client is at high risk for fluid overload, as is a client with
compromised renal function or cardiac function. Hypernatremia and hyponatremia are
electrolyte imbalances. Jugular veins would not be distended in hypovolemia.
Source: http://wps.prenhall.com/chet_lemone_medicalsurg_3/11/2951/755556.cw/index.html; retrieved

February 23, 2010, 1:30pm.
61. The nurse notes that a client appears very worried and upset about an upcoming
procedure. After acknowledging the client's discomfort and providing information and
support, the nurse evaluates that comfort care provided has been successful by:
a. Taking the client's blood pressure
b. Asking the client to relate the information back to the nurse to confirm understanding
c. Asking if the client understands the information
d. Asking if the client is now more comfortable about having the procedure performed
than previously
Answer: D – Asking if the client is now more comfortable about having the
procedure performed than previously.
The goal of comfort care is enhanced comfort; therefore, the nurse should compare
comfort levels before and after the intervention. Enhanced client comfort entails more
than simply understanding the procedure. While blood pressure may indicate tension or
stress, asking if the client is less stressed is a more reliable indicator of psychological
comfort.
Source: http://wps.prenhall.com/chet_kozier_fundamentals_7/0,7865,763096-,00.html;retrieved March

3,2010 9:00am.
62. What evidence most likely told the nurse a client had a negative Romberg test?
a. Maintains an upright posture and foot stance
b. Unable to maintain foot stance
c. Moves feet apart
d. Increased swaying
Answer: A – Maintains an upright posture and foot stance.

A negative Romberg test would be indicated when a client was able to maintain an
upright posture and foot stance with minimal swaying. A positive Romberg would show
a client who couldn't maintain foot stance, moved the feet apart to maintain stance, and
had increased swaying.

3,2010 9:00am.
63. Which of the following descriptions best fits the eudaemonistic model of health?
a. Health is defined in terms of the individual's ability to fulfill societal roles.
b. Health is a process of adaptation.
c. Health is identified by the absence of disease or injury.
d. Health is the realization of a person's potential.
Answer: D – Health is the realization of a person's potential.

Eudaemonistic Model - most comprehensive view of health
Health - a condition of actualization or realization of a person's potential (sounds like
Maslow). A client would be considered healthy when he realized his full potential.
The highest aspiration of people - fulfillment and complete development (actualization)
Illness - a condition that prevents self actualization

3,2010 9:00am.
http://www.texarkanacollege.edu/~sdroske/UnitIIlecture.htm; retrieved March 3, 2010 9:00am.

64. A nurse’s initial priority in creating a therapeutic environment for a patient should be:
a. Accepting his individuality
b. Promoting his independence
c. Providing for his safety
d. Explaining all procedures
Answer: Accepting his individuality.

A therapeutic environment is one in which the patient feels comfortable and able to
benefit from the nurse’s and physician’s treatment plan. It is an environment that is
conducive to health. The nurse who accepts each patient as unique and cares for him
holistically will provide a therapeutic environment. Promoting independence, providing
safety, and explaining .procedures are other activities that help maintain a therapeutic
environment.
65. Which of the following nursing theorists is credited with developing a conceptual
model specific to nursing, with man as the central focus?
a. Martha Rogers
b. Dorothea Orem
c. Dorothy Johnson
d. Sister Callista Roy
Answer: A – Martha Rogers

Martha Rogers’ life process model views man as an evolving creature interacting with
the environment in an open, adaptive manner. According to this model, the purpose of
nursing is to help man achieve maximum health in his environment.
Source: Fundamentals of Nursing (Nurse Test a Review Series) p51by June Looby Olsen et al.
66. The nurse is changing the ties of the client with a tracheostomy. The safest method
of changing the tracheostomy ties is to:
a. Apply the new tie before removing the old one.
b. Have a helper present.
c. Hold the tracheotomy with the nondominant hand while removing the old tie.
d. Ask the doctor to suture the tracheostomy in place.
Answer: A – Apply the new tie before removing the old one.
The best method and safest way to change the ties of a tracheotomy is to apply the new
ones before removing the old ones. Having a helper is good, but the helper might not
prevent the client from coughing out the tracheotomy. Answer C is not the best way to
prevent the client from coughing out the tracheotomy. Asking the doctor to suture the
tracheotomy in place is not appropriate.
Source: http://nclexreviewers.com/nclex-practice-tests; retrieved February 23, 2010, 3:00pm.

67. A client with a fractured hip has been placed in Buck’s traction. Which statement is
true regarding balanced skeletal traction? Balanced skeletal traction:
a. Utilizes a Steinman pin
b. Requires that both legs be secured
c. Utilizes Kirschner wires
d. Is used primarily to heal the fractured hips
Answer: A – Utilizes a Steinman pin.

Balanced skeletal traction uses pins and screws. A Steinman pin goes through large
bones and is used to stabilize large bones such as the femur. Answer B is incorrect
because only the affected leg is in traction. Kirschner wires are used to stabilize small
bones such as fingers and toes, as in answer C. Answer D is incorrect because this
type of traction is not used for fractured hips.
68. When administering atropine sulfate preoperatively to a client scheduled for lung
surgery, the nurse should tell the client which of the following?
a. “This medicine will make you drowsy.”
b. “This medicine will help you relax.”
c. “This medicine will make your mouth feel dry.”
d. “This medicine will reduce the risk of postoperative infection.”
Answer: C – “This medicine will make your mouth feel dry.”

Atropine sulfate is an anticholinergic drug that decreases mucous secretions in the
respiratory tract and dries the mucous membrane of the mouth, nose, pharynx, and
bronchi. Atropine does not cause drowsiness or relaxation. Moderate to large doses
causes tachycardia and palpitations. Atropine does not reduce the risk of post op
infection.
Source: Lippincott’s review for NCLEX – RN 7th Edition 2002 p525 Diane M. Billings.
69. What is the primary purpose of administering aminophylline to client with

emphysema?
a. To relax spasms of the diaphragm
b. To relax smooth muscles in the bronchioles
c. To promote efficient pulmonary circulation
d. TO stimulate the medullary respiratory center.
Answer: B – To relax smooth muscles in the bronchioles.

Aminophylline, a bronchodilator that relaxes smooth muscles in the bronchioles, is used
in the treatment of emphysema to improve ventilation by dilating the bronchioles.
Aminophylline does not have an effect on the diaphragm or the medullary respiratory
center and does not promote pulmonary circulation.
70. Which of the following techniques is correct for the nurse to use when inserting a
rectal suppository for an adult client?
a. Insert the suppository while the client bears down
b. Place the client in supine position
c. Position the suppository along the rectal wall.
d. Insert the suppository 2 inches into the rectum
Answer: C – Position the suppository along the rectal wall.

The client should be placed in a side – lying position and encouraged to take a deep
breath during the insertion of the suppository. Placing the suppository along the rectal
wall promotes absorption of the medication and helps avoid placing it into a stool mass.
The nurse should insert the suppository 3 to 4 inchesinto the rectum of an adult client.
71. The nurse is administering the albumin solution to a client. During administration of
this solution, the nurse should evaluate the client closely for which of the following
complications?
a. Excessive diuresis
b. Fluid overload
c. Abnormal weight loss
d. Dehydration
Answer: B – Fluid overload

The client is at risk for development of fluid overload. Albumin is a hyperosmolar
solution and acts to move fluid extravascular space into the intravascular space. The
solution should be given slowly enough to prevent rapid plasma volume expansion. The
client should be monitored closely for signs of fluid overload, suc as shortness of breath
and moist crackles on auscultation. Administration of albumin would not cause
excessive diuresis, abnormal weight loss, or dehydration.
72. The sudden onset of which of the following signs and symptoms indicates a
potentially serious complication for the client receiving an intravenous solution?
a. Noisy respiration
b. Pupillary constriction
c. Halitosis
d. Moist skin
Answer: A – Noisy respiration

A serious complication of intravenous therapy is fluid overload. Noisy respirations can
develop as a result of pulmonary congestion. Additional symptoms of fluid overload
include dyspnea, crackles, hypertension, bounding pulse, and distenden neck veins.
73. Which of the following actions by the nurse will most likely ensure that the correct
client receives a medication?
a. Have the client state his or her name
b. Call the client by name
c. Learn to recognize the client
d. Check the client’s identification armband
Answer: D – Check the client’s identification armband.

Checking the client’s identification armband is absolutely essential to prevent the
administration of medication to the wrong client. Clients can be confused or hard of
hearing and may give a wrong name or answer to a wrong name. Learning to recognize
a client is not a reliable or safe form of identification.
74. The nurse is preparing to administer an intramuscular injection to a client and

chooses the vastus lateralis muscle for the injection site. Into which part of the thigh
would the nurse choose to correctly administer the injection?
a. Middle third of the thigh
b. Lower third of the thigh
c. Upper third of the thigh
d. Wherever the thigh is the largest
Answer: A – Middle third of the thigh.

The middle third of the thigh is where the body of the vastus lateralis muscle lies, which
is approximately ome hand’s breadth below the greater trochanter and one hand’s
breadth above the knee. The largest diameter of the thigh is not necessarily where the
muscle is located and would be unsafe criterion to use for selecting the injection site.
75. A client with a history of congestive heart failure is prescribed ketorolac (Toradol) for
arthritis. The nurse should include which of the following instructions when teaching the
client about the drug?
a. Weigh yourself every morning
b. Take the medication on an empty stomach
c. Have your blood pressure checked weekly
d. Increase your fluid intake to 200ml/day
Answer: A – Weigh yourself every morning.

Ketorolac can cause renal impairment and should be used cautiously in clients who
have cardiovascular conditions such as congestive heart failure. Clients should be told
to weigh every morning and to report any weight gain or peripheral edema. The client
does not need to increase fluid intake; instead, should maintain a normal intake and be
instructed to report any fluid retention.
76. Which of the following clients is most likely to exhibit deficient fluid volume?
a. A 21 – year – old man with profuse diaphoresis after a game of football
b. A 75 - year – old woman who has been placed on NPO hours before surgery
c. An 8 – month – old infant with persistent diarrhea for 24 hours
d. A 60 – year – old man with pneumonia and has a high fever
Answer: C – An 8 – month – old infant with persistent diarrhea for 24 hours.

Infants and elderly persons have the greatest risk for fluid – related health problems. An
infant’s body weight is 70% - 80% water content. An infant who is ill and has had
persistent diarrhea for 24 hours will quickly lose a significant amount of fluid and
electrolytes if the diarrhea is not stopped and replacement fluids given. Healthy young
adults have a higher tolerance for fluid loss and can quickly regain their fluid balance
when fluids are lost through normal activity. The 75 – year – old is likely to develop a
fluid volume deficit within 8 hours, unless there are other fluid conditions present that
would precipitate fluid loss. The 60 – year – old client with pneumonia and a fever
should be monitored for a volume deficit, but is not as likely to develop one as a client
who is actively losing fluids through diarrhea.
77. Intravenous replacement therapy for a client with a nasogastric tube attached to low
suction will be needed primarily to meet which of the following objectives?
a. Maintain bladder function
b. Facilitate osmotic diuresis
c. Equalize intake and output
d. Maintain fluid and electrolyte balance
Answer: D – Maintain fluid and electrolyte balance.

The primary purpose of fluid replacement therapy for a client receiving gastric suction is
to maintain fluid and electrolyte balance. Gastric suctioning interrupts the normal intake
and absorption of fluids. Fluids and electrolytes are lost trough the nasogastric
drainage. Intravenous fluids are required to replace the fluid and electrolyte loss. Since
the client with nasogastric tube is on NPO, IV fluids will help prevent a fluid volume
deficit from developing and will help maintain adequate urinary output. IV fluids do not
maintain bladder function. Postoperatively, intravenous fluids are not typically used to
facilitate osmotic diuresis. The administration of intravenous fluids may help balance the
client’s fluid intake and output, but the primary reason for administering fluids is to keep
fluid and electrolyte balance.
78. A client is being prepared for a bronchoscopy. Which of the following preoperative
activities would be appropriate for the nurse to delegate to the unlicensed assistant?
a. Obtaining the signed consent
b. Placing the client on NPO status
c. Instructing the client about the procedure
d. Evaluating the client’s level of anxiety
Answer: B – Placing the client on NPO status.

It would be appropriate for the nurse to instruct the assistant to place the client on NPO
status. It is the responsibility of the physician performing the procedure to obtain the
client’s informed consent and have the form signed. It is the responsibility of the
registered nurse to teach clients and evaluate their health status. These responsibilities
cannot be delegated to unlicensed assistants.
79. A client has a Swan-Ganz catheter in place. The nurse understands that this is
intended to measure
a. Right heart function
b. Left heart function
c. Renal tubule function
d. Carotid artery function
Answer: B – Left heart function

The Swan-Ganz catheter is placed in the pulmonary artery to obtain information about
the left side of the heart. The pressure readings are inferred from pressure
measurements obtained on the right side of the circulation. Right-sided heart function is
assessed through the evaluation of the central venous pressures (CVP).
80. In which position should the nurse place the client to best inspect the Bartholin’s
gland?
a. Semi – Fowler’s
b. Sim’s
c. Lithotomy
d. Prone
Answer: C – Lithotomy
The Bartholin glands are part of the female anatomy located on the posterior aspect of
the vaginal orifice. Therefore, if the medical condition allows, having the client in a
lithotomy position (on her back, knees flexed, legs apart, with feet supported on a
surface or in stirrups) will provide the best opportunity for examination. The other
responses do not allow for assessment of the female genitalia.
Hogan.
81. The nursing care unit is considering changing the mode of nursing care delivery to
one that holds a nurse responsible and accountable over a 24 – hour period for the care
and treatment of a caseload. The nursing staff practicing this delivery system is using?
a. Primary nursing
b. Functional nursing
c. Total client care nursing practice
d. Team nursing
Answer: A – Primary nursing

Primary nursing holds the nurse accountable for the care of a caseload of clients over
24 – hour period. Functional nursing is task oriented; total nursing care practice is also
known as case method; and team nursing is a group of personnel that provide care to
the client.
Hogan
82. Which of the following is TRUE about functional nursing?

a. Concentrates on tasks and activities
b. Emphasizes use of group collaboration
c. One-to-one nurse-patient ratio
d. Provides continuous, coordinated and comprehensive nursing services
Answer: A – Concentrates on tasks and activities.

This kind of nursing modality is task-oriented in which a particular nursing function is
assigned to each worker. One registered nurse may be responsible for giving
medications, another nurse for admission and discharges while nursing attendants
change linens, provide hygienic care or do simple procedures for which they have
trained. This method divides the work to be done with each person being responsible to
the Head or Senior Nurse. It is the best system that can be used when there are many
patients and professional nurses are few. It is suitable only for short-term use. If
continued, it fragments the care of patients to tasks only.
The advantages of functional nursing are that:
1. It allows most work to be accomplished in the shortest time possible;
2. Workers learn to work fast;
3. Workers gain skill faster in a particular task because of repetitive task;
4. Greater control over work activities and it is aimed at conservation of workers and
cost.
The disadvantages are:
1. Fragmentation of nursing care and therefore wholistic care is not achieved;
2. Nurses accountability and responsibility are diminished;
3. Patient’s cannot identify who their “real nurse” is;
4. Nurse-patient relationship is not fully developed;
5. Evaluation of nursing care is poor and outcomes are rarely documented; and
6. It is difficult to find specific person who can answer the patient’s relatives’ questions.
Source: http://www.scribd.com/doc/27551528/Functional-Nursing; retrieved March 2, 2010 2:00pm.
83. Unfreezing,m moving to a new level and refreezing are steps that make up which of
the following theories/models of change?
a. Lewin’s Force – Field Model
b. Lippitt’s Phase of Change
c. Havelock ’s Six – Step Change Model
d. Roger’s Diffusion of Innovations
Answer: A – Lewin’s Force – Field Model

It is made up of three steps: Unfreezing the old or usual way of doing things in an
organization begins to change “thaw” as people become aware that change
needs to happen. Moving to a new level change is introduced to and implemented
in the organization; those affected by the change learn its benefits and
disadvantages. Refreezing the change or a new way of operation becomes the
norm and is incorporated into people’s habit’s or routines.
B – Lippitt’s Phase of Change is derived from Lewin’s model but defines seven total
steps in change process: diagnose the problem, assess motivation and capacity of
change, assess change agent’s motivation and resources, select appropriate
progressive change objectives, choose appropriate role for change agent, maintain the
change once it has started, and terminate the helping relationship once the change has
been instituted.
C – Havelock ’s is also based on Lewin’s model, but breaks the change process into
additional steps. The first tree steps are the planning stage and the last three steps are
referred to as the moving stage. Havelock particularly emphasized the essential role of
planning in any change endeavor.
D – Roger’s Diffusion of Innovations emphasizes the changeability of change itself –
and that efforts to implement change may be rejected at first, then later accepted. The
initial rejection is not the final word.
Source: Thomson Asian Edition Nursing Leadership and Management A Practical Guide 2007 p114 - 115
by Patricia Carrol.
84. What type of fever would the nurse document if the client had a wide range of
temperature fluctuations over normal for a period of 24 hours?
a. Intermittent
b. Remittent
c. Relapsing
d. Constant
Answer: B – Remittent
A remittent fever widely fluctuates above normal over a 24-hour period. An intermittent
fever rises above normal between periods of normal or subnormal temperatures. A
relapsing fever is short febrile periods of a few days interspersed with 1-2 days of
normal temperature. A constant fever remains above normal.

3,2010 9:00am.
85. The four concept common to nursing that appear in each of the current conceptual
models are?
a. Person, nursing, environment, medicine
b. Person, health, nursing support system
c. Person, health, psychology, nursing
d. Person, environment, health, nursing
Answer: D – Person, environment, health, nursing.

The four concepts that have been accepted by all theorists a s the following of nursing
practice from the time of Florence Nightingale include the person receiving care, his
environment, his health on the health – illness continuum, and the nursing actions
necessary to meet his needs.
86. A client had an oral surgery following a motor vehicle accident, and the nurse
assigned observed that the client is warm, flushing, and diaphoretic. Which of the
following would be the best method to assess the client’s body temperature?
a. Oral
b. Axillary
c. Forehead temperature strip
d. Rectal
Answer: D – Rectal
A client who has undergone oral surgery should not have the temperature taken by the
oral method. The client is exhibiting signs and symptoms of elevated body temperature
and the rectal method is the best choice. A forehead temperature strip and the axillary
method does not give the precise measurements as the rectal route in a client at risk for
infection ot other causes of hyperthermia.
Source: Prentice Hall Nursing Fundamentals Reviews and Rationales 2nd Edition 2008 159 Mary Ann
Hogan.
87. A nurse is preparing to apply a fentanyl (Duragesic) transdermal patch for pain
management. The nurse would not apply the patch to the client’s upper arm if the client:
a. Had bilateral mastectomies
b. Has minimal hair distribution to this area
c. Has intravenous catheters placed in the hands
d. Uses an overhead trapeze bar for bed mobility
Answer: A – Had bilateral mastectomies.

The patch is placed every 72 hours over non – hairy, nonedematous skin with good
capillary flow (often over the torso, shoulders, or upper arms). Following mastectomy,
the potential for lymphedema would contraindicate using the upper arms because
circulation would be compromised; thus distribution of the medication would be
impaired. The presence of an IV catheter or use of a trapeze bar should not affect the
site.
Hogan.
88. The nurse is assessing several clients with different types of injuries. The nurse
would conclude that the client who is least likely to develop a wound infection would be
the client with which of the following?
a. A contusion
b. A wound healing by second intension
c. Septic wound
d. A wound with purulent discharge
Answer: A – A contusion
A contusion is crushing of the tissues; there is no break in the skin. Therefore, this
wound is less likely to become infected. A septic wound is one that has been invaded by
pathogenic microorganisms. Purulent exudate also is an indicator of infection. A wound
healing by second intention is a wound in which there is extensive injury and the edges
of the wound are not well approximated. Because of this factor, this type of wound has a
risk of infection.
Hogan.
89. Which assessment of the immobilized client would prompt the nurse to take further
action?
a. Client reports fatigue
b. Urinary output of 50 ml/hour
c. White blood cells 9500/mm3
d. Hypoactive bowel sounds
Answer: D – Hypoactive bowel sound.

Hypoactive bowel sounds is a complication of immobility. It could be followed by
constipation and other gastrointestinal problems. Fatigue is a complaint that any client
may experience in the hospital. Urinary output is within normal range as well as white
blood cell count.
Hogan.
90. Using the principles of standard precautions, the nurse decides to apply gloves
when performing which of the following nursing interventions?
a. Providing a back massage
b. Feeding the client
c. Providing hair care
d. Providing oral hygiene
Answer: D – Providing oral hygiene.

Providing oral hygiene is a procedure that exposes the nurse to a client’s body fluids.
The other responses do not require the use of gloves because contact with body fluids
is not a concern.
Hogan.
91. Kristi is a young Unit Manager of the Pediatric Ward. Most of her staff nurses are
senior to her, very articulate, confident and sometimes aggressive. Katherine feels
uncomfortable believing that she is the scapegoat of everything that goes wrong in her
department. Which of the following is the best action that she must take?
a. Identify the source of the conflict and understand the points of friction
b. Disregard what she feels and continue to work independently
c. Seek help from the Director of Nursing
d. Quit her job and look for another employment.
Answer: A – Identify the source of the conflict and understand the points of
friction.
This involves a problem solving approach, which addresses the root cause of the
problem.
92. As a young manager, she knows that conflict occurs in any organization. Which of
the following statements regarding conflict is NOT true?
a. Can be destructive if the level is too high
b. Is not beneficial; hence it should be prevented at all times
c. May result in poor performance
d. May create leaders
Answer: B – Is not beneficial; hence it should be prevented at all times.

Conflicts are beneficial because it surfaces out issues in the open and can be solved
right away. Likewise, members of the team become more conscientious with their work
when they are aware that other members of the team are watching them.
93. Kristi tells one of the staff, “I don’t have time to discuss the matter with you now. See
me in my office later” when the latter asks if they can talk about an issue. Which of the
following conflict resolution strategies did she use?
a. Smoothing
b. Compromise
c. Avoidance
d. Restriction
Answer: C – Avoidance
This strategy shuns discussing the issue head-on and prefers to postpone it to a later
time. In effect the problem remains unsolved and both parties are in a lose-lose
situation.
94. Kristi knows that one of her staff is experiencing burnout. Which of the following is
the best thing for her to do?
a. Advise her staff to go on vacation.
b. Ignore her observations; it will be resolved even without intervention
c. Remind her to show loyalty to the institution.
d. Let the staff ventilate her feelings and ask how she can be of help.
Answer: D – Let the staff ventilate her feelings and ask how she can be of help.
Reaching out and helping the staff is the most effective strategy in dealing with burn out.
Knowing that someone is ready to help makes the staff feel important; hence her self-
worth is enhanced.
95. She knows that performance appraisal consists of all the following activities
EXCEPT:
a. Setting specific standards and activities for individual performance.
b. Using agency standards as a guide.
c. Determine areas of strength and weaknesses
d. Focusing activity on the correction of identified behavior.
Answer: D – Focusing activity on the correction of identified behavior.

Performance appraisal deal with both positive and negative performance; is not meant
to be a fault-finding activity.
96. The nurse has just assisted a client back to bed after a fall. The nurse and the
physician have assessed the client, and have determined that the client is not injured.
After completing the incident report, the nurse should take which action next?
a. Reassess the client
b. Conduct a staff meeting to discuss the fall]
c. Document in the nurse’s notes that an incident report was completed
d. Contact the nursing supervisor to update information regarding the fall.
Answer: A – Reassess the client.

The client’s fall should be treated as private information and shared on a “need to know”
basis. Communication regarding the event should involve only those participating in the
client’s care. An incident report is a problem – solving document; however, its
completion is not documented in the nurse’s notes. If the nursing supervisor has been
made aware of the incident, the supervisor will contact the nurse if status update is
desired. After a client’s fall, the nurse must frequently reassess the client, because
potential complications do not always appear immediately after the fall.
Source: Saunders Comprehensive Review for the NCLEX – RN Examination 4th Edition 2008 p64 Linda
Anne Silvestri.
97. A nurse who works on the night shift enters the medication room and finds a co –
worker with a tourniquet wrapped around the upper arm. The co – worker is about to
enter a needle, attached to a syringe containing a clear liquid, into the anticubital area.
The initial action of the nurse is which of the following?
a. Call the security
b. Call the police
c. Call the nursing supervisor
d. Lock the co – worker in the medication room until help is obtained
Answer: C – Call the nursing supervisor.

This incident needs to be reported to the nursing supervisor, who will report to the board
of nursing and other authorities, such as the police, as required. The nurse may call
security if a disturbance occurs, but no information in the question supports this need,
and therefore this is not the initial action. Option D is an inappropriate and unsafe
action.
Source: Saunders Comprehensive Review for the NCLEX – RN Examination 4th Edition 2008 p64 Linda
Anne Silvestri.
98. 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
Answer: B – Rapid eye movement (REM) stage.

Other characteristics of rapid eye movement (REM) sleep are deep sleep (the patient
cannot be awakened easily), depressed muscle tone, and possibly irregular heart and
respiratory rates. Non-REM sleep is a deep, restful sleep without dreaming. Delta stage,
or slow-wave sleep, occurs during non-REM Stages III and IV and is often equated with
quiet sleep.
Source: http://nclexreviewers.com/nclex-practice-tests;retrieved March 1, 2010 1:00pm.
99. 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
Answer: C – Observe the emesis.

After a patient has vomited, the nurse must inspect the emesis to document color,
consistency, and amount. In this situation, the patient recently ingested medication, so
the nurse needs to check for remnants of the medication to help determine whether the
patient retained enough of it to be effective. The nurse must then notify the physician,
who will decide whether to repeat the dose or prescribe an antiemetic.
100. To institute appropriate isolation precautions, the nurse must first know the:
a. Organism’s mode of transmission
b. Organism’s Gram-staining characteristics
c. Organism’s susceptibility to antibiotics
d. Patient’s susceptibility to the organism
Answer: A – Organism’s mode of transmission.

Before instituting isolation precaution, the nurse must first determine the organism’s
mode of transmission. For example, an organism transmitted through nasal secretions
requires that the patient be kept in respiratory isolation, which involves keeping the
patient in a private room with the door closed and wearing a mask, a grown, and gloves
when coming in direct contact with the patient. The organism’s Gram-straining
characteristics reveal whether the organism is gram-negative or gram-positive, an
important criterion in the physician’s choice for drug therapy and the nurse’s
development of an effective plan of care. The nurse also needs to know whether the
organism is susceptible to antibiotics, but this could take several days to determine; if
she waits for the results before instituting isolation precautions, the organism could be
transmitted in the meantime. The patient’s susceptibility to the organism has already
been established. The nurse would not be instituting isolation precautions for a
noninfected patient.

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Answer: D – Eat six meals per day.

Answer: B – Dietary and exercise pattern.

Answer: D – “I have less joint cartilage than I used to.”

Answer: B – Oral mucous membrane

Answer: C – Reward the adaptive coping behavior.

Answer: D – Constant restlessness and leg movement.

Answer: B – Avoid intake of caffeine and alcoholic beverages.

Answer: A – Informed consent

14. Which of the following is true about accountability?

Answer: A – It is a hallmark of health care professions.

Source: http://nursingbuzz.com/nursing-board-exam-drills-in-fundamentals-of-nursing-2/; retrieved

Answer: C – Provide additional bedclothes.

Source: http://nursingbuzz.com/nursing-board-exam-drills-in-fundamentals-of-nursing-2/; retrieved

17. Immobility impairs bladder elimination, resulting in such disorders as

Answer: B – Urine retention, bladder distention, and infection.

Source: http://nursingbuzz.com/nursing-board-exam-drills-in-fundamentals-of-nursing-2/; retrieved

18. Thrombophlebitis typically develops in patients with which of the following

Answer: C – An impaired or traumatized blood vessel wall.

Source: http://nursingbuzz.com/nursing-board-exam-drills-in-fundamentals-of-nursing-2/; retrieved

Answer: C – Leg muscles

Source: http://nursingbuzz.com/nursing-board-exam-drills-in-fundamentals-of-nursing-2/; retrieved

Answer: A – Respiratory acidosis, ateclectasis, and hypostatic pneumonia .

Source: http://nursingbuzz.com/nursing-board-exam-drills-in-fundamentals-of-nursing-2/; retrieved

21. Sterile technique is used whenever:

Answer: C – Invasive procedures are performed.

Source: http://nursingbuzz.com/nursing-board-exam-drills-in-fundamentals-of-nursing-2/; retrieved

Answer: A – A patient with leukopenia.

Source: http://nursingbuzz.com/nursing-board-exam-drills-in-fundamentals-of-nursing-2/; retrieved

Answer: C – Placing a sterile object on the edge of the sterile field.

Source: http://nursingbuzz.com/nursing-board-exam-drills-in-fundamentals-of-nursing-2/; retrieved

Answer: B – Discard all used uncapped needles and syringes in an impenetrable

Source: http://nursingbuzz.com/nursing-board-exam-drills-in-fundamentals-of-nursing-2/; retrieved

Source: http://nursingbuzz.com/nursing-board-exam-drills-in-fundamentals-of-nursing-2/; retrieved

Source: http://nclexreviewers.com/nclex-practice-tests; retrieved March 2, 2010, 2:00pm

Answer: A – Organizational structure

Source: http://nclexreviewers.com/nclex-practice-tests; retrieved March 2, 2010, 2:00pm

28. A client diagnosed with Alzheimer’s disease is currently competent to make

Answer: Advance directives

Answer: B – Preparing a nursing care plan in collaboration with the patient.

Source: http://nclexreviewers.com/nclex-practice-tests; retrieved March 2, 2010, 2:00pm

Answer: Gantt chart

Source: http://nursingbuzz.com/nursing-board-exam-drills-in-fundamentals-of-nursing-2/; retrieved

Source: http://nursingbuzz.com/nursing-board-exam-drills-in-fundamentals-of-nursing-2/; retrieved

Answer: C – Ensure the tubing is free of kinks.

Answer: B – Esophageal varices.

Answer: A – Lisinopril (Prinivil)

Answer: C – Bed rest with elevation of the affected extremity.

Answer: B – Requires nasogastric suction.

Answer: C – Portable chest x – ray film

41. A person whose behavior is in accordance with custom or tradition is:

Answer: D – All of the above

Answer: C – Total patient care

Answer: B – Run normal saline at a keep vein open rate.

Answer: D – Decreased oozing of blood from puncture sites and gums.

Answer: B – Inserts the catheter 2.5 – 5 cm and inflates the balloon.

Answer: B – Elevate and immobilize the grafted extremity.

Answer: D – Inhibition of the respiratory hypoxic stimulus.

Answer: A – Private room or cohort client.

Answer: D – A pair of scissors