TEST I -
Foundation of Professional Nursing
Practice
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 halfnormal
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 Incharge
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 mid-thigh.
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 incharge
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.
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