Nursing Practice 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 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 dextrose 5% in half-normal saline solution at 150 ml/hr. The client complains of severe bone pain and is schedul 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. on 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 re a. Ineffective peripheral tissue perfusion related to venous con gestion. 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 ad mitted for dehydration whose intravenous (IV) has infiltrated.
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1. The nurse In-charge in labor and delivery unit administered a dose of terbutaline to a client without ch
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 platele
dextrose 5% in half-normal saline solution at 150 ml/hr. The client complains of severe bone pain and is 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
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 sh
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 endorsem
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.
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 prio
a. Constipation
b. Diarrheac. Risk for infection
d. Deficient knowledge
24.A male client is receiving total parenteral nutrition suddenly demonstrates signs and symptoms of an
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 emtrauma center is task-oriented and directive. The nurse determines that the leadership style used at the tra
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 hawill 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
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 outputd. Assess the dressing for drainage.
29. Which of the following vital sign assessments that may indicate cardiogenic shock after myocardial i
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 infor
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 t
31.Asking the questions to determine if the person understands the health teaching provided by the nurse
a. Assessment
b. Evaluation
c. Implementationd. Planning and goals
32.Which of the following item is considered the single most important factor in assisting the health prof
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 remai
be to use:
a. Trochanter roll extending from the crest of the ileum to the midthigh.
34.Which stage of pressure ulcer development does the ulcer extend into the subcutaneous tissue?
a. Stage I
b. Stage II
c. Stage IIId. Stage IV
35.When the method of wound healing is one in which wound edges are not surgically approximated andis termed
a. Second intention healing
b. Primary intention healingc. Third intention healingd. First intention healing
36.An 80-year-old male client is admitted to the hospital with a diagnosis of pneumonia. Nurse Oliver leassessing 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 clieHow many milliliters of meperidine should the
client receive?
a. 0.75
b. 0.6
c. 0.5d. 0.25
38. A male client with diabetes mellitus is receiving insulin. Which statement correctly describes an insu
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.
50.Nurse Len refers a female client with terminal cancer to a local hospice. What is the goal of this referr
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 followin
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
a. Knee
b. Anklec. Lower thigh
d. Foot
53.A 10 year old child with type 1 diabetes develops diabetic ketoacidosis and receives a continuous insu
a. Hypernatremia
b. Hypokalemia
c. Hyperphosphatemiad. Hypercalcemia
54.Nurse Len is administering sublingual nitrglycerin (Nitrostat) to the newly admitted client. Immediate
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 monit
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
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 diagnose been maintained if which of the following data is observed?
a. Urine output: 45 ml/hr
b. Capillary refill: 5 secondsc. 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
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
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. 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
a. Puts all the four points of the walker flat on the floor, puts weight on the hand pieces, and then walks i 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 o
62.Nurse Amy has documented an entry regarding client care in the client’s medical record. When check
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 provi
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 wh
use which of the following protective items when giving bed bath?
a. Gown and goggles
b. Gown and gloves
c. Gloves and shoe protectorsd. Gloves and goggles
65. Nurse Oliver is caring for a client with impaired mobility that occurred as a result of a stroke. The clithe client use which of the following assistive devices that would provide the best stability for ambulatin
c. May apply for re-issuance of his/her license based on certain conditions stipulated in RA 9173d. 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 th
process?
a. Formulating the research hypothesis
b. Review related literaturec. 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 re
a. Cause and effect
b. Hawthorne effectc. Halo effectd. Horns effect
79.Mary finally decides to use judgment sampling on her research. Which of the following actions of is c
a. Plans to include whoever is there during his study. b. Determines the different nationality of patients frequently admitted and decides to get representations
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 Leiningerc. 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
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.
Nursing Practice I -Foundation of Professional
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 nur
2. Answer: (B) I.M
Rationale: With a platelet count of 22,000/μl, the clients tends to bleed easily. Therefore, the nurse shou
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 figua zero at the end of a dosage that includes a decimal point because this could be misread, possibly leadi
4. Answer: (A) Ineffective peripheral tissue perfusion related to venous congestion.
Rationale: Ineffective peripheral tissue perfusion related to venous congestion takes the highest prioritya 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 imme
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
every 15-30 minutes will allow the nurse to adjust the restraints before injury from decreased blood flo
7. Answer: (A) Prevent stress ulcer
Rationale: Curling’s ulcer occurs as a generalized stress response in burn patients. This results in a decr
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
action is warranted.
9. Answer: (B) ―My ankle feels warm‖.
Rationale: Ice application decreases pain and swelling. Continued or increased pain, redness, and increapplication
10. Answer: (B) Hyperkalemia
Rationale: A loop diuretic removes water and, along with it, sodium and potassium. This may result in
11. Answer:(A) Have condescending trust and confidence in their subordinates
Rationale: Benevolent-authoritative managers pretentiously show their trust and confidence to their foll
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 o
medications given immediately for an urgent client problem. A standing order, also known as a protoco particular disease or set of symptoms in special care areas such as the coronary care unit. Facilities also
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 arowith fecal impaction don't pass hard, brown, formed stools because the feces can't move past the impac
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 p
grasps the helix and pulls it down to straighten the ear canal. Pulling the lobule in any direction wouldn
16. Answer: (A) Protect the irritated skin from sunlight.Rationale: Irradiated skin is very sensitive and must be protected with clothing or sunblock. The priorit
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 cyano
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, ed
back pain reflects the inflammatory process in the pancreas.
19. Answer: (B) Provide high-protein, high-carbohydrate diet.
Rationale: A positive nitrogen balance is important for meeting metabolic needs, tissue repair, and resis
day.
20. Answer: (A) Blood pressure and pulse rate.
Rationale: The baseline must be established to recognize the signs of an anaphylactic or hemolytic reac
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
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
23. Answer: (C) Risk for infection
Rationale: Agranulocytosis is characterized by a reduced number of leukocytes (leucopenia) and neutro
because of the decreased body defenses against microorganisms. Deficient knowledge related to the na
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 Trendelen
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
27. Answer: (A) 50 cc/ hourRationale: 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
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 puls
30. Answer: (A) Take the proper equipment, place the client in a comfortable position, and record the a
Rationale: It is a general or comprehensive statement about the correct procedure, and it includes the ba
31. Answer: (B) Evaluation
Rationale: Evaluation includes observing the person, asking questions, and comparing the patient’s beh
32. Answer: (C) History of present illness
Rationale: The history of present illness is the single most important factor in assisting the health profe
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 healingRationale: 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 th
37. Answer: (A) 0.75
Rationale: To determine the number of milliliters the client should receive, the nurse uses the fraction m
75 mg/X ml = 100 mg/1 ml
To solve for X, cross-multiply:
75 mg x 1 ml = X ml x 100 mg75 = 100X
75/100 = X0.75 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. Differen
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(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 th
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 becaus
it is removed, it must be replaced). Asking the client’s name or having the client repeated his name wouunderstand what is being said, but isn’t the safe standard of practice. Names on bed aren’t always reliab
Rationale: Giving 1,000 ml over 8 hours is the same as giving 125 ml over 1 hour (60 minutes). Find th125/60 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 cat
sterile syringe or catheter plug in the catheter hub. After cleaning the hub with alcohol or povidone-iod
infusion.
45. Answer: (D) Auscultation, percussion, and palpation.
Rationale: The correct order of assessment for examining the abdomen is inspection, auscultation, percintrusive techniques should be performed before the more intrusive techniques. Percussion and palpatio
46. Answer: (D) Ulnar surface of the hand
Rationale: The nurse uses the ulnar surface, or ball, of the hand to asses tactile fremitus, thrills, and voc
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 learninecessary to enhance learning. Summative, or retrospective, evaluation occurs at the conclusion of the t
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 familyhistory, 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 pressureIn respiratory alkalosis, the pH value is above normal and in the Paco2 value is below normal. In metab
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 car e for terminally ill clients and their families. Hospice care do
referred to hospices have been treated for their disease without success and will receive only palliative
51. Answer: (C) Using normal saline solution to clean the ulcer and applying a protective dressing as n
Rationale: Washing the area with normal saline solution and applying a protective dressing are within t povidone-iodine wash and an antibiotic cream require a physician’s order. Massaging with an astringen
Rationale: An elastic bandage should be applied form the distal area to the proximal area. This method
the bandage at the client’s foot. Beginning at the ankle, lower thigh, or knee does not promote venous r
53. Answer: (B) Hypokalemia
Rationale: Insulin administration causes glucose and potassium to move into the cells, causing hypokal
54. Answer: (A) Throbbing headache or dizzinessRationale: Headache and dizziness often occur when nitroglycerin is taken at the beginning of therapy.
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
However, checking the unresponsiveness ensures whether the client is affected by the decreased cardia
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
position the free hand at the shoulder area so that the client can be pulled toward the nurse in the event
outward rather than at his or her feet.
57. Answer: (A) Urine output: 45 ml/hrRationale: Adequate perfusion must be maintained to all vital organs in order for the client to remain vi
adequate renal perfusion. Low blood pressure and delayed capillary refill time are circulatory system in
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 chanclient 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 appropr
of the options. To maintain privacy and safety, the nurse covers the client and places the call light withi
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 techni
the procedure for obtaining the specimen is not sterile, then the specimen is not sterile, then the specim
61. Answer: (A) Puts all the four points of the walker flat on the floor, puts weight on the hand pieces,
Rationale: When the client uses a walker, the nurse stands adjacent to the affected side. The client is in
floor before putting weight on hand pieces. This will ensure client safety and prevent stress cracks in thwalk 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 incand 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 avHurried movements and rapid changes in the position should be avoided because these predispose the c
the stretcher, the client is still affected by the effects of the anesthesia; therefore, the client should not m
stretcher.
64. Answer: (B) Gown and gloves
Rationale: Contact precautions require the use of gloves and a gown if direct client contact is anticipatenurse anticipates the splashes of blood, body fluids, secretions, or excretions may occur. Shoe protector
65. Answer: (C) Quad cane
Rationale: Crutches and a walker can be difficult to maneuver for a client with weakness on one side. A
side. However, the quad cane would provide the most stability because of the structure of the cane and
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 o
stool. If the client is unable to sit up, the client is positioned lying in bed on the unaffected side with the
67. Answer: (D) Reliability
Rationale: Reliability is consistency of the research instrument. It refers tothe 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
source.
69. Answer: (A) Descriptive- correlationalRationale: Descriptive- correlational study is the most appropriate for this study because it studies the v
nosocomial infection.
70. Answer: (C) Use of laboratory data
Rationale: Incidence of nosocomial infection is best collected through the use of biophysiologic measur
essential.
71. Answer: (B) Quasi-experimentRationale: 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 invsomeone 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 p
Rationale: Res ipsa loquitor literally means the thing speaks for itself. This means in operational terms
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 violati
duces tecum as needed.
76. Answer: (C) May apply for re-issuance of his/her license based on certain conditions stipulated in R
Rationale: RA 9173 sec. 24 states that for equity and justice, a revoked license maybe re-issued providethe cause for revocation of license has already been corrected or removed; and, b) at least four years ha
77. Answer: (B) Review related literature
Rationale: After formulating and delimiting the research problem, the researcher conducts a review of r
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 in
their productivity. It resulted to an increased productivity but not due to the intervention but due to the because they were under observation.
79. Answer: (B) Determines the different nationality of patients frequently admitted and decides to get
Rationale: Judgment sampling involves including samples according to the knowledge of the investigat
80. Answer: (B) Madeleine Leininger
Rationale: Madeleine Leininger developed the theory on transcultural theory based on her observations
81. Answer: (A) Random
Rationale: Random sampling gives equal chance for all the elements in the population to be picked as p
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 disagr
83. Answer: (B) Sr. Callista RoyRationale: Sr. Callista Roy developed the Adaptation Model which involves the physiologic mode, self
84. Answer: (A) Span of controlRationale: Span of control refers to the number of workers who report directly to a manager.
85. Answer: (B) AutonomyRationale: Informed consent means that the patient fully understands about the surgery, including the ri
with full knowledge and is given freely. The action of allowing the patient to decide whether a surgery
86. Answer: (C) Avoid wearing canvas shoes.
Rationale: The client should be instructed to avoid wearing canvas shoes. Canvas shoes cause the feet t
irritation and breakdown. Both cotton and cornstarch absorb perspiration. The client should be instructeclippers.
Rationale: Meat is an excellent source of complete protein, which this client needs to repair the tissue bOranges and broccoli supply vitamin C but not protein. Ice cream supplies only some incomplete prote
88. Answer: (D) Sims’ left lateral Rationale: The Sims' left lateral position is the most common position used to administer a cleansing en
the sigmoid colon. If the client can't assume this position nor has poor sphincter control, the dorsal recu
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 compat
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 t
independent intervention, whereas consulting with the physician and pharmacist to change a client's meintervention. Administering an already-prescribed drug on time is a dependent intervention. An intrade
91. Answer: (D) EvaluationRationale: The nursing actions described constitute evaluation of the expected outcomes. The findings
consists of the client's history, physical examination, and laboratory studies. Analysis consists of consid
diagnosis. Implementation is the phase of the nursing process where the nurse puts the plan of care into
92. Answer: (B) To observe the lower extremities
Rationale: Elastic stockings are used to promote venous return. The nurse needs to remove them once p
Applying the stockings increases blood flow to the heart. When the stockings are in place, the leg musc
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 aSigns and symptoms of life-threatening allergic reactions include itching, swelling, and dyspnea. Altho
and should document its administration, these actions are less critical to the client's immediate health. T
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 feedin
formula should decrease the client's discomfort. Feedings are normally given at room temperature to m
head of the client's bed should be elevated at least 30 degrees. Also, to prevent bacterial growth, feedin
95. Answer: (D) Roll the vial gently between the palms.
Rationale: Rolling the vial gently between the palms produces heat, which helps dissolve the medicatio
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 expansio band so that the face mask fits comfortably and snugly rather than tightly, which could lead to irritation
the chin — not vice versa. The nurse should check the connectors between the oxygen equipment and h
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 inincreases after that time. Discard or return to the blood bank any blood not given within this time, acco
98. Answer: (B) Immediately before administering the next dose.Rationale: Measuring the blood drug concentration helps determine whether the dosing has achieved th
level of a drug, the nurse draws a blood sample immediately before administering the next dose. Depen
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 al
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