TEST I - Foundation of Professional Nursing Practice

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
258
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.

51. When caring for a male client with a 3-cm stage I
pressure ulcer on the coccyx, which of the
following actions can the nurse institute
independently?
a. Massaging the area with an astringent
every 2 hours.
b. Applying an antibiotic cream to the area
three times per day.
c. Using normal saline solution to clean the
ulcer and applying a protective dressing
as necessary.
d. Using a povidone-iodine wash on the
ulceration three times per day.

52. Nurse Oliver must apply an elastic bandage to a
client’s ankle and calf. He should apply the
bandage beginning at the client’s:
a. Knee
b. Ankle
c. Lower thigh
d. Foot

53. A 10 year old child with type 1 diabetes develops
diabetic ketoacidosis and receives a continuous
insulin infusion. Which condition represents the
greatest risk to this child?
a. Hypernatremia
b. Hypokalemia
c. Hyperphosphatemia
d. Hypercalcemia

54. Nurse Len is administering sublingual nitrglycerin
(Nitrostat) to the newly admitted client.
Immediately afterward, the client may
experience:
a. Throbbing headache or dizziness
b. Nervousness or paresthesia.
c. Drowsiness or blurred vision.
d. Tinnitus or diplopia.

55. Nurse Michelle hears the alarm sound on the
telemetry monitor. The nurse quickly looks at
the monitor and notes that a client is in a
ventricular tachycardia. The nurse rushes to the
client’s room. Upon reaching the client’s
bedside, the nurse would take which action
first?
a. Prepare for cardioversion
b. Prepare to defibrillate the client
c. Call a code
d. Check the client’s level of consciousness

56. Nurse Hazel is preparing to ambulate a female
client. The best and the safest position for the
nurse in assisting the client is to stand:
a. On the unaffected side of the client.
b. On the affected side of the client.
c. In front of the client.
d. Behind the client.

57. Nurse Janah is monitoring the ongoing care
given to the potential organ donor who has been
diagnosed with brain death. The nurse
determines that the standard of care had been
maintained if which of the following data is
observed?
a. Urine output: 45 ml/hr
b. Capillary refill: 5 seconds
c. Serum pH: 7.32
d. Blood pressure: 90/48 mmHg

58. Nurse Amy has an order to obtain a urinalysis
from a male client with an indwelling urinary
catheter. The nurse avoids which of the
following, which contaminate the specimen?
a. Wiping the port with an alcohol swab
before inserting the syringe.
b. Aspirating a sample from the port on the
drainage bag.
c. Clamping the tubing of the drainage bag.
d. Obtaining the specimen from the urinary
drainage bag.

59. Nurse Meredith is in the process of giving a
client a bed bath. In the middle of the
procedure, the unit secretary calls the nurse on
the intercom to tell the nurse that there is an
emergency phone call. The appropriate nursing
action is to:
a. Immediately walk out of the client’s
room and answer the phone call.
b. Cover the client, place the call light
within reach, and answer the phone call.
c. Finish the bed bath before answering
the phone call.
d. Leave the client’s door open so the client
can be monitored and the nurse can
answer the phone call.

60. Nurse Janah is collecting a sputum specimen for
culture and sensitivity testing from a client who
has a productive cough. Nurse Janah plans to
implement which intervention to obtain the
specimen?
a. Ask the client to expectorate a small
amount of sputum into the emesis basin.
b. Ask the client to obtain the specimen
after breakfast.
c. Use a sterile plastic container for
obtaining the specimen.
d. Provide tissues for expectoration and
obtaining the specimen.

61. Nurse Ron is observing a male client using a
walker. The nurse determines that the client is
using the walker correctly if the client:
a. Puts all the four points of the walker flat
on the floor, puts weight on the hand
pieces, and then walks into it.
b. Puts weight on the hand pieces, moves
the walker forward, and then walks into
it.
c. Puts weight on the hand pieces, slides
the walker forward, and then walks into
it.
d. Walks into the walker, puts weight on
the hand pieces, and then puts all four
points of the walker flat on the floor.

62. Nurse Amy has documented an entry regarding
client care in the client’s medical record. When
checking the entry, the nurse realizes that
incorrect information was documented. How
does the nurse correct this error?
a. Erases the error and writes in the correct
information.
b. Uses correction fluid to cover up the
incorrect information and writes in the
correct information.
c. Draws one line to cross out the incorrect
information and then initials the change.
d. Covers up the incorrect information
completely using a black pen and writes
in the correct information

63. Nurse Ron is assisting with transferring a client
from the operating room table to a stretcher. To
provide safety to the client, the nurse should:
a. Moves the client rapidly from the table
to the stretcher.
b. Uncovers the client completely before
transferring to the stretcher.
c. Secures the client safety belts after
transferring to the stretcher.
d. Instructs the client to move self from the
table to the stretcher.

64. Nurse Myrna is providing instructions to a
nursing assistant assigned to give a bed bath to a
client who is on contact precautions. Nurse
Myrna instructs the nursing assistant to use
which of the following protective items when
giving bed bath?
a. Gown and goggles
b. Gown and gloves
c. Gloves and shoe protectors
d. Gloves and goggles

65. Nurse Oliver is caring for a client with impaired
mobility that occurred as a result of a stroke. The
client has right sided arm and leg weakness. The
nurse would suggest that the client use which of
the following assistive devices that would
provide the best stability for ambulating?
a. Crutches
b. Single straight-legged cane
c. Quad cane
d. Walker

66. A male client with a right pleural effusion noted
on a chest X-ray is being prepared for
thoracentesis. The client experiences severe
dizziness when sitting upright. To provide a safe
environment, the nurse assists the client to
which position for the procedure?
a. Prone with head turned toward the side
supported by a pillow.
b. Sims’ position with the head of the bed
flat.
c. Right side-lying with the head of the bed
elevated 45 degrees.
d. Left side-lying with the head of the bed
elevated 45 degrees.

67. Nurse John develops methods for data
gathering. Which of the following criteria of a
good instrument refers to the ability of the
instrument to yield the same results upon its
repeated administration?
a. Validity
b. Specificity
c. Sensitivity
d. Reliability

68. Harry knows that he has to protect the rights of
human research subjects. Which of the following
actions of Harry ensures anonymity?
a. Keep the identities of the subject secret
b. Obtain informed consent
c. Provide equal treatment to all the
subjects of the study.
d. Release findings only to the participants
of the study

69. Patient’s refusal to divulge information is a
limitation because it is beyond the control of
Tifanny”. What type of research is appropriate
for this study?
a. Descriptive- correlational
b. Experiment
c. Quasi-experiment
d. Historical

70. Nurse Ronald is aware that the best tool for data
gathering is?
a. Interview schedule
b. Questionnaire
c. Use of laboratory data
d. Observation

71. Monica is aware that there are times when only
manipulation of study variables is possible and
the elements of control or randomization are
not attendant. Which type of research is
referred to this?
a. Field study
b. Quasi-experiment
c. Solomon-Four group design
d. Post-test only design

72. Cherry notes down ideas that were derived from
the description of an investigation written by the
person who conducted it. Which type of
reference source refers to this?
a. Footnote
b. Bibliography
c. Primary source
d. Endnotes

73. When Nurse Trish is providing care to his
patient, she must remember that her duty is
bound not to do doing any action that will cause
the patient harm. This is the meaning of the
bioethical principle:
a. Non-maleficence
b. Beneficence
c. Justice
d. Solidarity

74. When a nurse in-charge causes an injury to a
female patient and the injury caused becomes
the proof of the negligent act, the presence of
the injury is said to exemplify the principle of:
a. Force majeure
b. Respondeat superior
c. Res ipsa loquitor
d. Holdover doctrine

75. Nurse Myrna is aware that the Board of Nursing
has quasi-judicial power. An example of this
power is:
a. The Board can issue rules and
regulations that will govern the practice
of nursing
b. The Board can investigate violations of
the nursing law and code of ethics
c. The Board can visit a school applying for
a permit in collaboration with CHED
d. The Board prepares the board
examinations

76. When the license of nurse Krina is revoked, it
means that she:
a. Is no longer allowed to practice the
profession for the rest of her life
b. Will never have her/his license re-issued
since it has been revoked
c. May apply for re-issuance of his/her
license based on certain conditions
stipulated in RA 9173
d. Will remain unable to practice
professional nursing

77. Ronald plans to conduct a research on the use of
a new method of pain assessment scale. Which
of the following is the second step in the
conceptualizing phase of the research process?
a. Formulating the research hypothesis
b. Review related literature
c. Formulating and delimiting the research
problem
d. Design the theoretical and conceptual
framework

78. The leader of the study knows that certain
patients who are in a specialized research setting
tend to respond psychologically to the
conditions of the study. This referred to as :
a. Cause and effect
b. Hawthorne effect
c. Halo effect
d. Horns effect

79. Mary finally decides to use judgment sampling
on her research. Which of the following actions
of is correct?
a. Plans to include whoever is there during
his study.
b. Determines the different nationality of
patients frequently admitted and
decides to get representations samples
from each.
c. Assigns numbers for each of the
patients, place these in a fishbowl and
draw 10 from it.
d. Decides to get 20 samples from the
admitted patients

80. The nursing theorist who developed
transcultural nursing theory is:
a. Florence Nightingale
b. Madeleine Leininger
c. Albert Moore
d. Sr. Callista Roy

81. Marion is aware that the sampling method that
gives equal chance to all units in the population
to get picked is:
a. Random
b. Accidental
c. Quota
d. Judgment

82. John plans to use a Likert Scale to his study to
determine the:
a. Degree of agreement and disagreement
b. Compliance to expected standards
c. Level of satisfaction
d. Degree of acceptance
83. Which of the following theory addresses the four
modes of adaptation?
a. Madeleine Leininger
b. Sr. Callista Roy
c. Florence Nightingale
d. Jean Watson

84. Ms. Garcia is responsible to the number of
personnel reporting to her. This principle refers
to:
a. Span of control
b. Unity of command
c. Downward communication
d. Leader

85. Ensuring that there is an informed consent on
the part of the patient before a surgery is done,
illustrates the bioethical principle of:
a. Beneficence
b. Autonomy
c. Veracity
d. Non-maleficence

86. Nurse Reese is teaching a female client with
peripheral vascular disease about foot care;
Nurse Reese should include which instruction?
a. Avoid wearing cotton socks.
b. Avoid using a nail clipper to cut toenails.
c. Avoid wearing canvas shoes.
d. Avoid using cornstarch on feet.

87. A client is admitted with multiple pressure
ulcers. When developing the client's diet plan,
the nurse should include:
a. Fresh orange slices
b. Steamed broccoli
c. Ice cream
d. Ground beef patties

88. The nurse prepares to administer a cleansing
enema. What is the most common client
position used for this procedure?
a. Lithotomy
b. Supine
c. Prone
d. Sims’ left lateral

89. Nurse Marian is preparing to administer a blood
transfusion. Which action should the nurse take
first?
a. Arrange for typing and cross matching of
the client’s blood.
b. Compare the client’s identification
wristband with the tag on the unit of
blood.
c. Start an I.V. infusion of normal saline
solution.
d. Measure the client’s vital signs.

90. A 65 years old male client requests his
medication at 9 p.m. instead of 10 p.m. so that
he can go to sleep earlier. Which type of nursing
intervention is required?
a. Independent
b. Dependent
c. Interdependent
d. Intradependent

91. A female client is to be discharged from an acute
care facility after treatment for right leg
thrombophlebitis. The Nurse Betty notes that
the client's leg is pain-free, without redness or
edema. The nurse's actions reflect which step of
the nursing process?
a. Assessment
b. Diagnosis
c. Implementation
d. Evaluation

92. Nursing care for a female client includes
removing elastic stockings once per day. The
Nurse Betty is aware that the rationale for this
intervention?
a. To increase blood flow to the heart
b. To observe the lower extremities
c. To allow the leg muscles to stretch and
relax
d. To permit veins in the legs to fill with
blood.

93. Which nursing intervention takes highest priority
when caring for a newly admitted client who's
receiving a blood transfusion?
a. Instructing the client to report any
itching, swelling, or dyspnea.
b. Informing the client that the transfusion
usually take 1 ½ to 2 hours.
c. Documenting blood administration in
the client care record.
d. Assessing the client’s vital signs when
the transfusion ends.

94. A male client complains of abdominal discomfort
and nausea while receiving tube feedings. Which
intervention is most appropriate for this
problem?
a. Give the feedings at room temperature.
b. Decrease the rate of feedings and the
concentration of the formula.
c. Place the client in semi-Fowler's position
while feeding.
d. Change the feeding container every 12
hours.

95. Nurse Patricia is reconstituting a powdered
medication in a vial. After adding the solution to
the powder, she nurse should:
a. Do nothing.
b. Invert the vial and let it stand for 3 to 5
minutes.
c. Shake the vial vigorously.
d. Roll the vial gently between the palms.

96. Which intervention should the nurse Trish use
when administering oxygen by face mask to a
female client?
a. Secure the elastic band tightly around
the client's head.
b. Assist the client to the semi-Fowler
position if possible.
c. Apply the face mask from the client's
chin up over the nose.
d. Loosen the connectors between the
oxygen equipment and humidifier.

97. The maximum transfusion time for a unit of
packed red blood cells (RBCs) is:
a. 6 hours
b. 4 hours
c. 3 hours
d. 2 hours

98. Nurse Monique is monitoring the effectiveness
of a client's drug therapy. When should the
nurse Monique obtain a blood sample to
measure the trough drug level?
a. 1 hour before administering the next
dose.
b. Immediately before administering the
next dose.
c. Immediately after administering the
next dose.
d. 30 minutes after administering the next
dose.

99. Nurse May is aware that the main advantage of
using a floor stock system is:
a. The nurse can implement medication
orders quickly.
b. The nurse receives input from the
pharmacist.
c. The system minimizes transcription
errors.
d. The system reinforces accurate
calculations.

100. Nurse Oliver is assessing a client's abdomen.
Which finding should the nurse report as
abnormal?
a. Dullness over the liver.
b. Bowel sounds occurring every 10
seconds.
c. Shifting dullness over the abdomen.
d. Vascular sounds heard over the renal
arteries.