Answers and Rationale – Foundation of Professional Nursing Practice

Answers and Rationale – Foundation of
Professional Nursing Practice

1. Answer: (D) The actions of a reasonably prudent
nurse with similar education and experience.
Rationale: The standard of care is determined
by the average degree of skill, care, and
diligence by nurses in similar circumstances.

2. Answer: (B) I.M
Rationale: With a platelet count of 22,000/μl,
the clients tends to bleed easily. Therefore,
the nurse should avoid using the I.M. route
because the area is a highly vascular and can
bleed readily when penetrated by a needle.
The bleeding can be difficult to stop.

3. Answer: (C) “Digoxin 0.125 mg P.O. once daily”
Rationale: The nurse should always place a
zero before a decimal point so that no one
misreads the figure, which could result in a
dosage error. The nurse should never insert a
zero at the end of a dosage that includes a
decimal point because this could be misread,
possibly leading to a tenfold increase in the
dosage.

4. Answer: (A) Ineffective peripheral tissue
perfusion related to venous congestion.
Rationale: Ineffective peripheral tissue
perfusion related to venous congestion takes
the highest priority because venous
inflammation and clot formation impede blood
flow in a client with deep vein thrombosis.

5. Answer: (B) A 44 year-old myocardial
infarction (MI) client who is complaining of
nausea.
Rationale: Nausea is a symptom of impending
myocardial infarction (MI) and should be
assessed immediately so that treatment can
be instituted and further damage to the heart
is avoided.

6. Answer: (C) Check circulation every 15-30
minutes.
Rationale: Restraints encircle the limbs, which
place the client at risk for circulation being
restricted to the distal areas of the
extremities. Checking the client’s circulation
every 15-30 minutes will allow the nurse to
adjust the restraints before injury from
decreased blood flow occurs.

7. Answer: (A) Prevent stress ulcer
Rationale: Curling’s ulcer occurs as a
generalized stress response in burn patients.
This results in a decreased production of
mucus and increased secretion of gastric acid.
The best treatment for this prophylactic use of
antacids and H2 receptor blockers.

8. Answer: (D) Continue to monitor and record
hourly urine output
Rationale: Normal urine output for an adult is
approximately 1 ml/minute (60 ml/hour).
Therefore, this client's output is normal.
Beyond continued evaluation, no nursing
action is warranted.

9. Answer: (B) “My ankle feels warm”.
Rationale: Ice application decreases pain and
swelling. Continued or increased pain, redness,
and increased warmth are signs of
inflammation that shouldn't occur after ice
application

10. Answer: (B) Hyperkalemia
Rationale: A loop diuretic removes water and,
along with it, sodium and potassium. This may
result in hypokalemia, hypovolemia, and
hyponatremia.

11. Answer:(A) Have condescending trust and
confidence in their subordinates
Rationale: Benevolent-authoritative managers
pretentiously show their trust and confidence
to their followers.

12. Answer: (A) Provides continuous, coordinated
and comprehensive nursing services.
Rationale: Functional nursing is focused on
tasks and activities and not on the care of the
patients.

13. Answer: (B) Standard written order
Rationale: This is a standard written order.
Prescribers write a single order for
medications given only once. A stat order is
written for medications given immediately for
an urgent client problem. A standing order,
also known as a protocol, establishes
guidelines for treating a particular disease or
set of symptoms in special care areas such as
the coronary care unit. Facilities also may
institute medication protocols that specifically
designate drugs that a nurse may not give.

14. Answer: (D) Liquid or semi-liquid stools
Rationale: Passage of liquid or semi-liquid
stools results from seepage of unformed
bowel contents around the impacted stool in
the rectum. Clients with fecal impaction don't
pass hard, brown, formed stools because the
feces can't move past the impaction. These
clients typically report the urge to defecate
(although they can't pass stool) and a
decreased appetite.

15. Answer: (C) Pulling the helix up and back
Rationale: To perform an otoscopic
examination on an adult, the nurse grasps the
helix of the ear and pulls it up and back to
straighten the ear canal. For a child, the nurse
grasps the helix and pulls it down to straighten
the ear canal. Pulling the lobule in any
direction wouldn't straighten the ear canal for
visualization.

16. Answer: (A) Protect the irritated skin from
sunlight.
Rationale: Irradiated skin is very sensitive and
must be protected with clothing or sunblock.
The priority approach is the avoidance of
strong sunlight.

17. Answer: (C) Assist the client in removing
dentures and nail polish.
Rationale: Dentures, hairpins, and combs must
be removed. Nail polish must be removed so
that cyanosis can be easily monitored by
observing the nail beds.

18. Answer: (D) Sudden onset of continuous
epigastric and back pain.
Rationale: The autodigestion of tissue by the
pancreatic enzymes results in pain from
inflammation, edema, and possible
hemorrhage. Continuous, unrelieved epigastric
or back pain reflects the inflammatory process
in the pancreas.

19. Answer: (B) Provide high-protein, highcarbohydrate
diet.
Rationale: A positive nitrogen balance is
important for meeting metabolic needs, tissue
repair, and resistance to infection. Caloric
goals may be as high as 5000 calories per day.
20. Answer: (A) Blood pressure and pulse rate.

Rationale: The baseline must be established to
recognize the signs of an anaphylactic or
hemolytic reaction to the transfusion.

21. Answer: (D) Immobilize the leg before moving
the client.
Rationale: If the nurse suspects a fracture,
splinting the area before moving the client is
imperative. The nurse should call for
emergency help if the client is not hospitalized
and call for a physician for the hospitalized
client.

22. Answer: (B) Admit the client into a private
room.
Rationale: The client who has a radiation
implant is placed in a private room and has a
limited number of visitors. This reduces the
exposure of others to the radiation.

23. Answer: (C) Risk for infection
Rationale: Agranulocytosis is characterized by
a reduced number of leukocytes (leucopenia)
and neutrophils (neutropenia) in the blood.
The client is at high risk for infection because
of the decreased body defenses against
microorganisms. Deficient knowledge related
to the nature of the disorder may be
appropriate diagnosis but is not the priority.

24. Answer: (B) Place the client on the left side in
the Trendelenburg position.
Rationale: Lying on the left side may prevent
air from flowing into the pulmonary veins. The
Trendelenburg position increases intrathoracic
pressure, which decreases the amount of
blood pulled into the vena cava during
aspiration.

25. Answer: (A) Autocratic.
Rationale: The autocratic style of leadership is
a task-oriented and directive.

26. Answer: (D) 2.5 cc
Rationale: 2.5 cc is to be added, because only a
500 cc bag of solution is being medicated
instead of a 1 liter.

27. Answer: (A) 50 cc/ hour
Rationale: A rate of 50 cc/hr. The child is to
receive 400 cc over a period of 8 hours = 50
cc/hr.

28. Answer: (B) Assess the client for presence of
pain.
Rationale: Assessing the client for pain is a
very important measure. Postoperative pain is
an indication of complication. The nurse
should also assess the client for pain to
provide for the client’s comfort.

29. Answer: (A) BP – 80/60, Pulse – 110 irregular
Rationale: The classic signs of cardiogenic
shock are low blood pressure, rapid and weak
irregular pulse, cold, clammy skin, decreased
urinary output, and cerebral hypoxia.

30. Answer: (A) Take the proper equipment, place
the client in a comfortable position, and
record the appropriate information in the
client’s chart.
Rationale: It is a general or comprehensive
statement about the correct procedure, and it
includes the basic ideas which are found in the
other options

31. Answer: (B) Evaluation
Rationale: Evaluation includes observing the
person, asking questions, and comparing the
patient’s behavioral responses with the
expected outcomes.

32. Answer: (C) History of present illness
Rationale: The history of present illness is the
single most important factor in assisting the
health professional in arriving at a diagnosis or
determining the person’s needs.

33. Answer: (A) Trochanter roll extending from the
crest of the ileum to the mid-thigh.
Rationale: A trochanter roll, properly placed,
provides resistance to the external rotation of
the hip.

34. Answer: (C) Stage III
Rationale: Clinically, a deep crater or without
undermining of adjacent tissue is noted.

35. Answer: (A) Second intention healing
Rationale: When wounds dehisce, they will
allowed to heal by secondary Intention

36. Answer: (D) Tachycardia
Rationale: With an extracellular fluid or plasma
volume deficit, compensatory mechanisms
stimulate the heart, causing an increase in
heart rate.

37. Answer: (A) 0.75
Rationale: To determine the number of
milliliters the client should receive, the nurse
uses the fraction method in the following
equation.
75 mg/X ml = 100 mg/1 ml
To solve for X, cross-multiply:
75 mg x 1 ml = X ml x 100 mg
75 = 100X
75/100 = X
0.75 ml (or ¾ ml) = X

38. Answer: (D) it’s a measure of effect, not a
standard measure of weight or quantity.
Rationale: An insulin unit is a measure of
effect, not a standard measure of weight or
quantity. Different drugs measured in units
may have no relationship to one another in
quality or quantity.

39. Answer: (B) 38.9 °C
Rationale: To convert Fahrenheit degreed to
Centigrade, use this formula
°C = (°F – 32) ÷ 1.8
°C = (102 – 32) ÷ 1.8
°C = 70 ÷ 1.8
°C = 38.9

40. Answer: (C) Failing eyesight, especially close
vision.
Rationale: Failing eyesight, especially close
vision, is one of the first signs of aging in
middle life (ages 46 to 64). More frequent
aches and pains begin in the early late years
(ages 65 to 79). Increase in loss of muscle tone
occurs in later years (age 80 and older).

41. Answer: (A) Checking and taping all
connections
Rationale: Air leaks commonly occur if the
system isn’t secure. Checking all connections
and taping them will prevent air leaks. The
chest drainage system is kept lower to
promote drainage – not to prevent leaks.

42. Answer: (A) Check the client’s identification
band.
Rationale: Checking the client’s identification
band is the safest way to verify a client’s
identity because the band is assigned on
admission and isn’t be removed at any time. (If
it is removed, it must be replaced). Asking the
client’s name or having the client repeated his
name would be appropriate only for a client
who’s alert, oriented, and able to understand
what is being said, but isn’t the safe standard
of practice. Names on bed aren’t always
reliable

43. Answer: (B) 32 drops/minute
Rationale: Giving 1,000 ml over 8 hours is the
same as giving 125 ml over 1 hour (60
minutes). Find the number of milliliters per
minute as follows:
125/60 minutes = X/1 minute
60X = 125 = 2.1 ml/minute
To find the number of drops per minute:
2.1 ml/X gtt = 1 ml/ 15 gtt
X = 32 gtt/minute, or 32 drops/minute

44. Answer: (A) Clamp the catheter
Rationale: If a central venous catheter
becomes disconnected, the nurse should
immediately apply a catheter clamp, if
available. If a clamp isn’t available, the nurse
can place a sterile syringe or catheter plug in
the catheter hub. After cleaning the hub with
alcohol or povidone-iodine solution, the nurse
must replace the I.V. extension and restart the
infusion.

45. Answer: (D) Auscultation, percussion, and
palpation.
Rationale: The correct order of assessment for
examining the abdomen is inspection,
auscultation, percussion, and palpation. The
reason for this approach is that the less
intrusive techniques should be performed
before the more intrusive techniques.
Percussion and palpation can alter natural
findings during auscultation.

46. Answer: (D) Ulnar surface of the hand
Rationale: The nurse uses the ulnar surface, or
ball, of the hand to assess tactile fremitus,
thrills, and vocal vibrations through the chest
wall. The fingertips and finger pads best
distinguish texture and shape. The dorsal
surface best feels warmth.

47. Answer: (C) Formative
Rationale: Formative (or concurrent)
evaluation occurs continuously throughout the
teaching and learning process. One benefit is
that the nurse can adjust teaching strategies
as necessary to enhance learning. Summative,
or retrospective, evaluation occurs at the
conclusion of the teaching and learning
session. Informative is not a type of
evaluation.

48. Answer: (B) Once per year
Rationale: Yearly mammograms should begin
at age 40 and continue for as long as the
woman is in good health. If health risks, such
as family history, genetic tendency, or past
breast cancer, exist, more frequent
examinations may be necessary.

49. Answer: (A) Respiratory acidosis
Rationale: The client has a below-normal
(acidic) blood pH value and an above-normal
partial pressure of arterial carbon dioxide
(Paco2) value, indicating respiratory acidosis.
In respiratory alkalosis, the pH value is above
normal and in the Paco2 value is below
normal. In metabolic acidosis, the pH and
bicarbonate (Hco3) values are below normal.
In metabolic alkalosis, the pH and Hco3 values
are above normal.

50. Answer: (B) To provide support for the client
and family in coping with terminal illness.
Rationale: Hospices provide supportive care
for terminally ill clients and their families.
Hospice care doesn’t focus on counseling
regarding health care costs. Most client
referred to hospices have been treated for
their disease without success and will receive
only palliative care in the hospice.

51. Answer: (C) Using normal saline solution to
clean the ulcer and applying a protective
dressing as necessary.
Rationale: Washing the area with normal
saline solution and applying a protective
dressing are within the nurse’s realm of
interventions and will protect the area. Using a
povidone-iodine wash and an antibiotic cream
require a physician’s order. Massaging with an
astringent can further damage the skin.

52. Answer: (D) Foot
Rationale: An elastic bandage should be
applied form the distal area to the proximal
area. This method promotes venous return. In
this case, the nurse should begin applying the
bandage at the client’s foot. Beginning at the
ankle, lower thigh, or knee does not promote
venous return.

53. Answer: (B) Hypokalemia
Rationale: Insulin administration causes
glucose and potassium to move into the cells,
causing hypokalemia.

54. Answer: (A) Throbbing headache or dizziness
Rationale: Headache and dizziness often occur
when nitroglycerin is taken at the beginning of
therapy. However, the client usually develops
tolerance

55. Answer: (D) Check the client’s level of
consciousness
Rationale: Determining unresponsiveness is
the first step assessment action to take. When
a client is in ventricular tachycardia, there is a
significant decrease in cardiac output.
However, checking the unresponsiveness
ensures whether the client is affected by the
decreased cardiac output.

56. Answer: (B) On the affected side of the client.
Rationale: When walking with clients, the
nurse should stand on the affected side and
grasp the security belt in the midspine area of
the small of the back. The nurse should
position the free hand at the shoulder area so
that the client can be pulled toward the nurse
in the event that there is a forward fall. The
client is instructed to look up and outward
rather than at his or her feet.

57. Answer: (A) Urine output: 45 ml/hr
Rationale: Adequate perfusion must be
maintained to all vital organs in order for the
client to remain visible as an organ donor. A
urine output of 45 ml per hour indicates
adequate renal perfusion. Low blood pressure
and delayed capillary refill time are circulatory
system indicators of inadequate perfusion. A
serum pH of 7.32 is acidotic, which adversely
affects all body tissues.

58. Answer: (D ) Obtaining the specimen from the
urinary drainage bag.
Rationale: A urine specimen is not taken from
the urinary drainage bag. Urine undergoes
chemical changes while sitting in the bag and
does not necessarily reflect the current client
status. In addition, it may become
contaminated with bacteria from opening the
system.

59. Answer: (B) Cover the client, place the call
light within reach, and answer the phone call.
Rationale: Because telephone call is an
emergency, the nurse may need to answer it.
The other appropriate action is to ask another
nurse to accept the call. However, is not one of
the options. To maintain privacy and safety,
the nurse covers the client and places the call
light within the client’s reach. Additionally, the
client’s door should be closed or the room
curtains pulled around the bathing area.

60. Answer: (C) Use a sterile plastic container for
obtaining the specimen.
Rationale: Sputum specimens for culture and
sensitivity testing need to be obtained using
sterile techniques because the test is done to
determine the presence of organisms. If the
procedure for obtaining the specimen is not
sterile, then the specimen is not sterile, then
the specimen would be contaminated and the
results of the test would be invalid.

61. Answer: (A) Puts all the four points of the
walker flat on the floor, puts weight on the
hand pieces, and then walks into it.
Rationale: When the client uses a walker, the
nurse stands adjacent to the affected side. The
client is instructed to put all four points of the
walker 2 feet forward flat on the floor before
putting weight on hand pieces. This will ensure
client safety and prevent stress cracks in the
walker. The client is then instructed to move
the walker forward and walk into it.

62. Answer: (C) Draws one line to cross out the
incorrect information and then initials the
change.
Rationale: To correct an error documented in a
medical record, the nurse draws one line
through the incorrect information and then
initials the error. An error is never erased and
correction fluid is never used in the medical
record.

63. Answer: (C) Secures the client safety belts
after transferring to the stretcher.
Rationale: During the transfer of the client
after the surgical procedure is complete, the
nurse should avoid exposure of the client
because of the risk for potential heat loss.
Hurried movements and rapid changes in the
position should be avoided because these
predispose the client to hypotension. At the
time of the transfer from the surgery table to
the stretcher, the client is still affected by the
effects of the anesthesia; therefore, the client
should not move self. Safety belts can prevent
the client from falling off the stretcher.

64. Answer: (B) Gown and gloves
Rationale: Contact precautions require the use
of gloves and a gown if direct client contact is
anticipated. Goggles are not necessary unless
the nurse anticipates the splashes of blood,
body fluids, secretions, or excretions may
occur. Shoe protectors are not necessary.

65. Answer: (C) Quad cane
Rationale: Crutches and a walker can be
difficult to maneuver for a client with
weakness on one side. A cane is better suited
for client with weakness of the arm and leg on
one side. However, the quad cane would
provide the most stability because of the
structure of the cane and because a quad cane
has four legs.

66. Answer: (D) Left side-lying with the head of
the bed elevated 45 degrees.
Rationale: To facilitate removal of fluid from
the chest wall, the client is positioned sitting at
the edge of the bed leaning over the bedside
table with the feet supported on a stool. If the
client is unable to sit up, the client is
positioned lying in bed on the unaffected side
with the head of the bed elevated 30 to 45
degrees.

67. Answer: (D) Reliability
Rationale: Reliability is consistency of the
research instrument. It refers to the
repeatability of the instrument in extracting
the same responses upon its repeated
administration.

68. Answer: (A) Keep the identities of the subject
secret
Rationale: Keeping the identities of the
research subject secret will ensure anonymity
because this will hinder providing link between
the information given to whoever is its source.

69. Answer: (A) Descriptive- correlational
Rationale: Descriptive- correlational study is
the most appropriate for this study because it
studies the variables that could be the
antecedents of the increased incidence of
nosocomial infection.

70. Answer: (C) Use of laboratory data
Rationale: Incidence of nosocomial infection is
best collected through the use of
biophysiologic measures, particularly in vitro
measurements, hence laboratory data is
essential.

71. Answer: (B) Quasi-experiment
Rationale: Quasi-experiment is done when
randomization and control of the variables are
not possible.

72. Answer: (C) Primary source
Rationale: This refers to a primary source
which is a direct account of the investigation
done by the investigator. In contrast to this is a
secondary source, which is written by
someone other than the original researcher.

73. Answer: (A) Non-maleficence
Rationale: Non-maleficence means do not
cause harm or do any action that will cause
any harm to the patient/client. To do good is
referred as beneficence.

74. Answer: (C) Res ipsa loquitor
Rationale: Res ipsa loquitor literally means the
thing speaks for itself. This means in
operational terms that the injury caused is the
proof that there was a negligent act.

75. Answer: (B) The Board can investigate
violations of the nursing law and code of ethics
Rationale: Quasi-judicial power means that the
Board of Nursing has the authority to
investigate violations of the nursing law and
can issue summons, subpoena or subpoena
duces tecum as needed.

76. Answer: (C) May apply for re-issuance of
his/her license based on certain conditions
stipulated in RA 9173
Rationale: RA 9173 sec. 24 states that for
equity and justice, a revoked license maybe reissued
provided that the following conditions
are met: a) the cause for revocation of license
has already been corrected or removed; and,
b) at least four years has elapsed since the
license has been revoked.

77. Answer: (B) Review related literature
Rationale: After formulating and delimiting the
research problem, the researcher conducts a
review of related literature to determine the
extent of what has been done on the study by
previous researchers.

78. Answer: (B) Hawthorne effect
Rationale: Hawthorne effect is based on the
study of Elton Mayo and company about the
effect of an intervention done to improve the
working conditions of the workers on their
productivity. It resulted to an increased
productivity but not due to the intervention
but due to the psychological effects of being
observed. They performed differently because
they were under observation.

79. Answer: (B) Determines the different
nationality of patients frequently admitted and
decides to get representations samples from
each.
Rationale: Judgment sampling involves
including samples according to the knowledge
of the investigator about the participants in
the study.

80. Answer: (B) Madeleine Leininger
Rationale: Madeleine Leininger developed the
theory on transcultural theory based on her
observations on the behavior of selected
people within a culture.

81. Answer: (A) Random
Rationale: Random sampling gives equal
chance for all the elements in the population
to be picked as part of the sample.

82. Answer: (A) Degree of agreement and
disagreement
Rationale: Likert scale is a 5-point summated
scale used to determine the degree of
agreement or disagreement of the
respondents to a statement in a study

83. Answer: (B) Sr. Callista Roy
Rationale: Sr. Callista Roy developed the
Adaptation Model which involves the
physiologic mode, self-concept mode, role
function mode and dependence mode.

84. Answer: (A) Span of control
Rationale: Span of control refers to the
number of workers who report directly to a
manager.

85. Answer: (B) Autonomy
Rationale: Informed consent means that the
patient fully understands about the surgery,
including the risks involved and the alternative
solutions. In giving consent it is done with full
knowledge and is given freely. The action of
allowing the patient to decide whether a
surgery is to be done or not exemplifies the
bioethical principle of autonomy.

86. Answer: (C) Avoid wearing canvas shoes.
Rationale: The client should be instructed to
avoid wearing canvas shoes. Canvas shoes
cause the feet to perspire, which may, in turn,
cause skin irritation and breakdown. Both
cotton and cornstarch absorb perspiration.
The client should be instructed to cut toenails
straight across with nail clippers.

87. Answer: (D) Ground beef patties
Rationale: Meat is an excellent source of
complete protein, which this client needs to
repair the tissue breakdown caused by
pressure ulcers. Oranges and broccoli supply
vitamin C but not protein. Ice cream supplies
only some incomplete protein, making it less
helpful in tissue repair.

88. Answer: (D) Sims’ left lateral
Rationale: The Sims' left lateral position is the
most common position used to administer a
cleansing enema because it allows gravity to
aid the flow of fluid along the curve of the
sigmoid colon. If the client can't assume this
position nor has poor sphincter control, the
dorsal recumbent or right lateral position may
be used. The supine and prone positions are
inappropriate and uncomfortable for the
client.

89. Answer: (A) Arrange for typing and cross
matching of the client’s blood.
Rationale: The nurse first arranges for typing
and cross matching of the client's blood to
ensure compatibility with donor blood. The
other options, although appropriate when
preparing to administer a blood transfusion,
come later.

90. Answer: (A) Independent
Rationale: Nursing interventions are classified
as independent, interdependent, or
dependent. Altering the drug schedule to
coincide with the client's daily routine
represents an independent intervention,
whereas consulting with the physician and
pharmacist to change a client's medication
because of adverse reactions represents an
interdependent intervention. Administering an
already-prescribed drug on time is a
dependent intervention. An intradependent
nursing intervention doesn't exist.

91. Answer: (D) Evaluation
Rationale: The nursing actions described
constitute evaluation of the expected
outcomes. The findings show that the
expected outcomes have been achieved.
Assessment consists of the client's history,
physical examination, and laboratory studies.
Analysis consists of considering assessment
information to derive the appropriate nursing
diagnosis. Implementation is the phase of the
nursing process where the nurse puts the plan
of care into action.

92. Answer: (B) To observe the lower extremities
Rationale: Elastic stockings are used to
promote venous return. The nurse needs to
remove them once per day to observe the
condition of the skin underneath the stockings.
Applying the stockings increases blood flow to
the heart. When the stockings are in place, the
leg muscles can still stretch and relax, and the
veins can fill with blood.

93. Answer :(A) Instructing the client to report any
itching, swelling, or dyspnea.
Rationale: Because administration of blood or
blood products may cause serious adverse
effects such as allergic reactions, the nurse
must monitor the client for these effects. Signs
and symptoms of life-threatening allergic
reactions include itching, swelling, and
dyspnea. Although the nurse should inform
the client of the duration of the transfusion
and should document its administration, these
actions are less critical to the client's
immediate health. The nurse should assess
vital signs at least hourly during the
transfusion.

94. Answer: (B) Decrease the rate of feedings and
the concentration of the formula.
Rationale: Complaints of abdominal
discomfort and nausea are common in clients
receiving tube feedings. Decreasing the rate of
the feeding and the concentration of the
formula should decrease the client's
discomfort. Feedings are normally given at
room temperature to minimize abdominal
cramping. To prevent aspiration during
feeding, the head of the client's bed should be
elevated at least 30 degrees. Also, to prevent
bacterial growth, feeding containers should be
routinely changed every 8 to 12 hours.

95. Answer: (D) Roll the vial gently between the
palms.
Rationale: Rolling the vial gently between the
palms produces heat, which helps dissolve the
medication. Doing nothing or inverting the vial
wouldn't help dissolve the medication. Shaking
the vial vigorously could cause the medication
to break down, altering its action.

96. Answer: (B) Assist the client to the semi-
Fowler position if possible.
Rationale: By assisting the client to the semi-
Fowler position, the nurse promotes easier
chest expansion, breathing, and oxygen intake.
The nurse should secure the elastic band so
that the face mask fits comfortably and snugly
rather than tightly, which could lead to
irritation. The nurse should apply the face
mask from the client's nose down to the chin
— not vice versa. The nurse should check the
connectors between the oxygen equipment
and humidifier to ensure that they're airtight;
loosened connectors can cause loss of oxygen.

97. Answer: (B) 4 hours
Rationale: A unit of packed RBCs may be given
over a period of between 1 and 4 hours. It
shouldn't infuse for longer than 4 hours
because the risk of contamination and sepsis
increases after that time. Discard or return to
the blood bank any blood not given within this
time, according to facility policy.

98. Answer: (B) Immediately before administering
the next dose.
Rationale: Measuring the blood drug
concentration helps determine whether the
dosing has achieved the therapeutic goal. For
measurement of the trough, or lowest, blood
level of a drug, the nurse draws a blood
sample immediately before administering the
next dose. Depending on the drug's duration
of action and half-life, peak blood drug levels
typically are drawn after administering the
next dose.

99. Answer: (A) The nurse can implement
medication orders quickly.
Rationale: A floor stock system enables the
nurse to implement medication orders quickly.
It doesn't allow for pharmacist input, nor does
it minimize transcription errors or reinforce
accurate calculations.

100. Answer: (C) Shifting dullness over the
abdomen.
Rationale: Shifting dullness over the abdomen
indicates ascites, an abnormal finding. The
other options are normal abdominal findings.