Foundation of Nursing - d.

Rectal
Comprehensive Test Part 1
1. Using the principles of standard 6. A client who is unconscious needs frequent
precautions, the nurse would wear gloves mouth care. When performing a mouth care, the
in what nursing interventions? best position of a client is:
a. Providing a back massage a. Fowler’s position
b. Feeding a client b. Side lying
c. Providing hair care c. Supine
d. Providing oral hygiene d. Trendelenburg

2. The nurse is preparing to take vital sign in 7. A client is hospitalized for the first time, which of
an alert client admitted to the hospital the following actions ensure the safety of the
with dehydration secondary to vomiting client?
and diarrhea. What is the best method a. Keep unnecessary furniture out of the way
used to assess the client’s temperature? b. Keep the lights on at all time
a. Oral c. Keep side rails up at all time
b. Axillary d. Keep all equipment out of view
c. Radial
d. Heat sensitive tape 8. A walk-in client enters into the clinic with a chief
complaint of abdominal pain and diarrhea. The
3. A nurse obtained a client’s pulse and nursetakes the client’s vital sign hereafter. What
found the rate to be above normal. The phrase of nursing process is being implemented
nurse document this findings as: here by the nurse?
a. Tachypnea a. Assessment
b. Hyper pyrexia b. Diagnosis
c. Arrythmia c. Planning
d. Tachycardia d. Implementation

4. Which of the following actions should the 9. It is best describe as a systematic, rational
nurse take to use a wide base support method of planning and providing nursing care
when assisting a client to get up in a for individual, families, group and community
chair? a. Assessment
a. Bend at the waist and place arms under the b. Nursing Process
client’s arms and lift c. Diagnosis
b. Face the client, bend knees and place hands d. Implementation
on client’s forearm and lift
c. Spread his or her feet apart 10. Exchange of gases takes place in which of the
d. Tighten his or her pelvic muscles following organ?
a. Kidney
5. A client had oral surgery following a motor b. Lungs
vehicle accident. The nurse assessing the c. Liver
client finds the skin flushed and warm. d. Heart
Which of the following would be the best 11. The Chamber of the heart that receives
method to take the client’s body oxygenated blood from the lungs is the?
temperature? a. Left atrium
a. Oral b. Right atrium
b. Axillary c. Left ventricle
c. Arterial line d. Right ventricle
 18. This is characterized by severe symptoms
12. A muscular enlarge pouch or sac that lies relatively of short duration.
slightly to the left which is used a. Chronic Illness
for temporary storage of food… b. Acute Illness
a. Gallbladder c. Pain
b. Urinary bladder d. Syndrome
c. Stomach
d. Lungs 19. Which of the following is the nurse’s role in the
health promotion
13. The ability of the body to defend itself a. Health risk appraisal
against scientific invading agent such as b. Teach client to be effective health consumer
baceria, toxin, viruses and foreign body c. Worksite wellness
a. Hormones d. None of the above
b. Secretion
c. Immunity 20. It is describe as a collection of people who share
d. Glands some attributes of their lives.
a. Family
14. Hormones secreted by Islets of b. Illness
Langerhans c. Community
a. Progesterone d. Nursing
b. Testosterone
c. Insulin 21. Five teaspoon is equivalent to how many
d. Hemoglobin milliliters (ml)?
a. 30 ml
15. It is a transparent membrane that focuses b. 25 ml
the light that enters the eyes to the c. 12 ml
retina. d. 22 ml
a. Lens
b. Sclera 22. 1800 ml is equal to how many liters?
c. Cornea a. 1.8
d. Pupils b. 18000
c. 180
16. Which of the following is included in d. 2800
Orem’s theory?
a. Maintenance of a sufficient intake of air 23. Which of the following is the abbreviation of
b. Self perception drops?
c. Love and belonging a. Gtt.
d. Physiologic needs b. Gtts.
c. Dp.
17. Which of the following cluster of data d. Dr.
belong to Maslow’s hierarchy of needs 24. The abbreviation for micro drop is…
a. Love and belonging a. µgtt
b. Physiologic needs b. gtt
c. Self actualization c. mdr
d. All of the above d. mgts
25. Which of the following is the meaning of d. On the client’s conjuctiva
PRN?
a. When advice 32. The nurse administers cleansing enema. The
b. Immediately common position for this procedure is…
c. When necessary a. Sims left lateral
d. Now b. Dorsal Recumbent
c. Supine
26. Which of the following is the appropriate d. Prone
meaning of CBR?
a. Cardiac Board Room 33. A client complains of difficulty of swallowing,
b. Complete Bathroom when the nurse try to administer capsule
c. Complete Bed Rest medication. Which of the following measures the
d. Complete Board Room nurse should do?
a. Dissolve the capsule in a glass of water
27. 1 tsp is equals to how many drops? b. Break the capsule and give the content with an
a. 15 applesauce
b. 60 c. Check the availability of a liquid preparation
c. 10 d. Crash the capsule and place it under the tongue
d. 30
34. Which of the following is the appropriate route of
28. 20 cc is equal to how many ml? administration for insulin?
a. 2 a. Intramuscular
b. 20 b. Intradermal
c. 2000 c. Subcutaneous
d. 20000 d. Intravenous

29. 1 cup is equals to how many ounces? 35. The nurse is ordered to administer ampicillin
a. 8 capsule TIP p.o. The nurse shoud give the
b. 80 medication…
c. 800 a. Three times a day orally
d. 8000 b. Three times a day after meals
c. Two time a day by mouth
30. The nurse must verify the client’s identity d. Two times a day before meals
before administration of medication.
Which of the following is the safest way to 36. Back Care is best describe as:
identify the client? a. Caring for the back by means of massage
a. Ask the client his name b. Washing of the back
b. Check the client’s identification band c. Application of cold compress at the back
c. State the client’s name aloud and have the d. Application of hot compress at the back
client repeat it
d. Check the room number 37. It refers to the preparation of the bed with a new
set of linens
31. The nurse prepares to administer buccal a. Bed bath
medication. The medicine should be b. Bed making
placed… c. Bed shampoo
a. On the client’s skin d. Bed lining
b. Between the client’s cheeks and gums
c. Under the client’s tongue
38. Which of the following is the most
important purpose of handwashing 44. An instrument used for auscultation is:
a. To promote hand circulation a. Percussion-hammer
b. To prevent the transfer of microorganism b. Audiometer
c. To avoid touching the client with a dirty c. Stethoscope
hand d. Sphygmomanometer
d. To provide comfort
45. Resonance is best describe as:
39. What should be done in order to prevent a. Sounds created by air filled lungs
contaminating of the environment in bed b. Short, high pitch and thudding
making? c. Moderately loud with musical quality
a. Avoid funning soiled linens d. Drum-like
b. Strip all linens at the same time
c. Finished both sides at the time 46. The best position for examining the rectum is:
d. Embrace soiled linen a. Prone
b. Sim’s
40. The most important purpose of cleansing c. Knee-chest
bed bath is: d. Lithotomy
a. To cleanse, refresh and give comfort to the
client who must remain in bed 47. It refers to the manner of walking
b. To expose the necessary parts of the body a. Gait
c. To develop skills in bed bath b. Range of motion
d. To check the body temperature of the client c. Flexion and extension
in bed d. Hopping

41. Which of the following technique involves 48. The nurse asked the client to read the Snellen
the sense of sight? chart. Which of the following is tested:
a. Inspection a. Optic
b. Palpation b. Olfactory
c. Percussion c. Oculomotor
d. Auscultation d. Troclear
49. Another name for knee-chest position is:
42. The first techniques used examining the a. Genu-dorsal
abdomen of a client is: b. Genu-pectoral
a. Palpation c. Lithotomy
b. Auscultation d. Sim’s
c. Percussion
d. Inspection 50. The nurse prepare IM injection that is irritating to
the subcutaneous tissue. Which of the following is
43. A technique in physical examination that the best action in order to prevent tracking of the
is use to assess the movement of air medication
through the tracheobronchial tree: a. Use a small gauge needle
a. Palpation b. Apply ice on the injection site
b. Auscultation c. Administer at a 45° angle
c. Inspection d. Use the Z-track technique
d. Percussion
Foundation of Nursing -
Comprehensive Test Part 1
Answers

1.d 11.a 21.b 31.b 41.a

2.b 12.c 22.a 32.a 42.d
3.d 13.c 23.b 33.c 43.b
4b 14.c 24.a 34.c 44.c
5.b 15.c 25.c 35.a 45.a
6.b 16.a 26.c 36.a 46.vc
7.c 17.d 27.b 37.b 47.a
8.a 18.b 28.b 38.b 48.a
9.b 19.b 29.a 39.a 49.b
10.b 20.c 30.a 40.a 50.d

Foundation of Nursing - Comprehensive

Test Part 2
1. The most appropriate nursing order for a patient
who develops dyspnea and shortness of breath
would be…
a. Maintain the patient on strict bed rest at all times
b. Maintain the patient in an orthopneic position as
needed
c. Administer oxygen by Venturi mask at 24%, as
needed
d. Allow a 1 hour rest period between activities

2. The nurse observes that Mr. Adams begins to

have increased difficulty breathing. She elevates
the head of the bed to the high Fowler position,
 which decreases his respiratory d. Person, environment, health, nursing
distress. The nurse documents this
breathing as: 7. In Maslow’s hierarchy of physiologic needs, the
a. Tachypnea human need of greatest priority is:
b. Eupnca a. Love
c. Orthopnea b. Elimination
d. Hyperventilation c. Nutrition
d. Oxygen
3. The physician orders a platelet count to be
performed on Mrs. Smith after 8. The family of an accident victim who has been
breakfast. The nurse is responsible for: declared brain-dead seems amenable to organ
a. Instructing the patient about this diagnostic donation. What should the nurse do?
test a. Discourage them from making a decision until their
b. Writing the order for this test grief has eased
c. Giving the patient breakfast b. Listen to their concerns and answer their questions
d. All of the above honestly
c. Encourage them to sign the consent form right
4. Mrs. Mitchell has been given a copy of her away
diet. The nurse discusses the foods d. Tell them the body will not be available for a wake
allowed on a 500-mg low sodium diet. or funeral
These include:
a. A ham and Swiss cheese sandwich on whole 9. A new head nurse on a unit is distressed about
wheat bread the poor staffing on the 11 p.m. to 7 a.m. shift.
b. Mashed potatoes and broiled chicken What should she do?
c. A tossed salad with oil and vinegar and a. Complain to her fellow nurses
olives b. Wait until she knows more about the unit
d. Chicken bouillon c. Discuss the problem with her supervisor
d. Inform the staff that they must volunteer to rotate
5. The physician orders a maintenance dose
of 5,000 units of subcutaneous heparin 10. Which of the following principles of primary
(an anticoagulant) daily. Nursing nursing has proven the most satisfying to the
responsibilities for Mrs. Mitchell now patient and nurse?
include: a. Continuity of patient care promotes efficient, cost-
a. Reviewing daily activated partial effective nursing care
thromboplastin time (APTT) and prothrombin b. Autonomy and authority for planning are best
time. delegated to a nurse who knows the patient well
b. Reporting an APTT above 45 seconds to the c. Accountability is clearest when one nurse is
physician responsible for the overall plan and its
c. Assessing the patient for signs and implementation.
symptoms of frank and occult bleeding d. The holistic approach provides for a therapeutic
d. All of the above relationship, continuity, and efficient nursing care.

6. The four main concepts common to 11. If nurse administers an injection to a patient who
nursing that appear in each of the current refuses that injection, she has committed:
conceptual models are: a. Assault and battery
a. Person, nursing, environment, medicine b. Negligence
b. Person, health, nursing, support systems c. Malpractice
c. Person, health, psychology, nursing d. None of the above
 a. Decreased blood pressure and heart rate and
12. If patient asks the nurse her opinion about shallow respirations
a particular physicians and the b. Quiet crying
nurse replies that the physician is c. Immobility, diaphoresis, and avoidance of deep
incompetent, the nurse could be held breathing or coughing
liable for: d. Changing position every 2 hours
a. Slander
b. Libel 16. A patient is admitted to the hospital with
c. Assault complaints of nausea, vomiting, diarrhea, and
d. Respondent superior severe abdominal pain. Which of the following
would immediately alert the nurse that the
13. A registered nurse reaches to answer the patient has bleeding from the GI tract?
telephone on a busy pediatric unit,
momentarily turning away from a 3 a. Complete blood count
month-old infant she has been weighing. b. Guaiac test
The infant falls off the scale, suffering a c. Vital signs
skull fracture.The nurse could be charged d. Abdominal girth
with:
a. Defamation 17. The correct sequence for assessing the abdomen
b. Assault is:
c. Battery a. Tympanic percussion, measurement of abdominal
d. Malpractice girth, and inspection
b. Assessment for distention, tenderness, and
discoloration around the umbilicus.
c. Percussions, palpation, and auscultation
14. Which of the following is an example of d. Auscultation, percussion, and palpation
nursing malpractice?
a. The nurse administers penicillin to a patient 18. High-pitched gurgles head over the right lower
with a documented history of allergy to the quadrant are:
drug. The patient experiences an allergic a. A sign of increased bowel motility
reaction and has cerebral damage resulting b. A sign of decreased bowel motility
from anoxia. c. Normal bowel sounds
b. The nurse applies a hot water bottle or d. A sign of abdominal cramping
a heating pad to the abdomen of a patient
with abdominal cramping. 19. A patient about to undergo abdominal inspection
c. The nurse assists a patient out of bed with is best placed in which of the following positions?
the bed locked in position; the patient slips a. Prone
and fractures his right humerus. b. Trendelenburg
d. The nurse administers the wrong medication c. Supine
to a patient and the patient vomits. This d. Side-lying
information is documented and reported to
the physician and the nursing supervisor. 20. For a rectal examination, the patient can be
directed to assume which of the following
15. Which of the following signs and positions?
symptoms would the nurse expect to find a. Genupecterol
when assessing an Asian patient for b. Sims
postoperative pain following abdominal c. Horizontal recumbent
surgery? d. All of the above
 27. Palpating the midclavicular line is the correct
21. During a Romberg test, the nurse asks the technique for assessing
patient to assume which position? a. Baseline vital signs
a. Sitting b. Systolic blood pressure
b. Standing c. Respiratory rate
c. Genupectoral d. Apical pulse
d. Trendelenburg
28. The absence of which pulse may not be a
22. If a patient’s blood pressure is 150/96, his significant finding when a patient is admitted to
pulse pressure is: the hospital?
a. 54 a. Apical
b. 96 b. Radial
c. 150 c. Pedal
d. 246 d. Femoral

23. A patient is kept off food and fluids for 10 29. Which of the following patients is at greatest risk
hours before surgery. His oral temperature for developing pressure ulcers?
at 8 a.m. is 99.8 F (37.7 C) This a. An alert, chronic arthritic patient treated with
temperature reading probably indicates: steroids and aspirin
a. Infection b. An 88-year old incontinent patient with gastric
b. Hypothermia cancer who is confined to his bed at home
c. Anxiety c. An apathetic 63-year old COPD patient receiving
d. Dehydration nasal oxygen via cannula
d. A confused 78-year old patient with congestive
24. Which of the following parameters should heart failure (CHF) who requires assistance to get
be checked when assessing respirations? out of bed.
a. Rate
b. Rhythm 30. The physician orders the administration of high-
c. Symmetry humidity oxygen by face mask and placement
d. All of the above of the patient in a high Fowler’s position. After
assessing Mrs. Paul, the nurse writes the
25. A 38-year old patient’s vital signs at 8 following nursing diagnosis: Impaired gas
a.m. are axillary temperature 99.6 F (37.6 exchange related to increased secretions. Which
C); pulse rate, 88; respiratory rate, 30. of the following nursing interventions has the
Which findings should be reported? greatest potential for improving this situation?
a. Respiratory rate only a. Encourage the patient to increase her fluid intake to
b. Temperature only 200 ml every 2 hours
c. Pulse rate and temperature b. Place a humidifier in the patient’s room.
d. Temperature and respiratory rate c. Continue administering oxygen by high humidity
face mask
26. All of the following can cause tachycardia d. Perform chest physiotheraphy on a regular schedule
except:
a. Fever 31. The most common deficiency seen in alcoholics
b. Exercise is:
c. Sympathetic nervous system stimulation a. Thiamine
d. Parasympathetic nervous system stimulation b. Riboflavin
c. Pyridoxine
d. Pantothenic acid
 manifested by shortness of breath; orthopnea:
32. Which of the following statement is thick, tenacious secretions; and a dry hacking
incorrect about a patient with dysphagia? cough. An appropriate nursing diagnosis would
a. The patient will find pureed or soft foods, be:
such as custards, easier to swallow than a. Ineffective airway clearance related to thick,
water tenacious secretions.
b. Fowler’s or semi Fowler’s position reduces b. Ineffective airway clearance related to dry, hacking
the risk of aspiration during swallowing cough.
c. The patient should always feed himself c. Ineffective individual coping to COPD.
d. The nurse should perform oral hygiene d. Pain related to immobilization of affected leg.
before assisting with feeding.
37. Mrs. Lim begins to cry as the nurse discusses hair
33. To assess the kidney function of a patient loss. The best response would be:
with an indwelling urinary (Foley) a. “Don’t worry. It’s only temporary”
catheter, the nurse measures his hourly b. “Why are you crying? I didn’t get to the bad news
urine output. She should notify the yet”
physician if the urine output is: c. “Your hair is really pretty”
a. Less than 30 ml/hour d. “I know this will be difficult for you, but your hair
b. 64 ml in 2 hours will grow back after the completion of
c. 90 ml in 3 hours chemotheraphy”
d. 125 ml in 4 hours
38. An additional Vitamin C is required during all of
34. Certain substances increase the amount of the following periods except:
urine produced. These include: a. Infancy
a. Caffeine-containing drinks, such as coffee b. Young adulthood
and cola. c. Childhood
b. Beets d. Pregnancy
c. Urinary analgesics
d. Kaolin with pectin (Kaopectate) 39. A prescribed amount of oxygen s needed for a
patient with COPD to prevent:
35. A male patient who had surgery 2 days a. Cardiac arrest related to increased partial pressure
ago for head and neck cancer is about to of carbon dioxide in arterial blood (PaCO2)
make his first attempt to ambulate outside b. Circulatory overload due to hypervolemia
his room. The nurse notes that he is c. Respiratory excitement
steady on his feet and that his vision was d. Inhibition of the respiratory hypoxic stimulus
unaffected by the surgery. Which of the
following nursing interventions would be 40. After 1 week of hospitalization, Mr. Gray develops
appropriate? hypokalemia. Which of the following is the most
a. Encourage the patient to walk in the hall significant symptom of his disorder?
alone a. Lethargy
b. Discourage the patient from walking in the b. Increased pulse rate and blood pressure
hall for a few more days c. Muscle weakness
c. Accompany the patient for his walk. d. Muscle irritability
d. Consuit a physical therapist before allowing
the patient to ambulate 41. Which of the following nursing interventions
promotes patient safety?
36. A patient has exacerbation of chronic a. Asses the patient’s ability to ambulate and transfer
obstructive pulmonary disease (COPD) from a bed to a chair
b. Demonstrate the signal system to the
patient 47. Which of the following is the most common cause
c. Check to see that the patient is wearing his of dementia among elderly persons?
identification band a. Parkinson’s disease
d. All of the above b. Multiple sclerosis
c. Amyotrophic lateral sclerosis (Lou Gerhig’s disease)
42. Studies have shown that about 40% of d. Alzheimer’s disease
patients fall out of bed despite the use of
side rails; this has led to which of the 48. The nurse’s most important legal responsibility
following conclusions? after a patient’s death in a hospital is:
a. Side rails are ineffective a. Obtaining a consent of an autopsy
b. Side rails should not be used b. Notifying the coroner or medical examiner
c. Side rails are a deterrent that prevent a c. Labeling the corpse appropriately
patient from falling out of bed. d. Ensuring that the attending physician issues the
d. Side rails are a reminder to a patient not to death certification
get out of bed
49. Before rigor mortis occurs, the nurse is
43. Examples of patients suffering from responsible for:
impaired awareness include all of the a. Providing a complete bath and dressing change
following except: b. Placing one pillow under the body’s head and
a. A semiconscious or over fatigued patient shoulders
b. A disoriented or confused patient c. Removing the body’s clothing and wrapping the
c. A patient who cannot care for himself at body in a shroud
home d. Allowing the body to relax normally
d. A patient demonstrating symptoms of drugs
or alcohol withdrawal 50. When a patient in the terminal stages of lung
cancer begins to exhibit loss of consciousness, a
44. The most common injury among elderly major nursing priority is to:
persons is: a. Protect the patient from injury
a. Atheroscleotic changes in the blood vessels b. Insert an airway
b. Increased incidence of gallbladder disease c. Elevate the head of the bed
c. Urinary Tract Infection d. Withdraw all pain medications
d. Hip fracture
Foundation of Nursing - Comprehensive
Test Part 2 Answers and Rationale
45. The most common psychogenic disorder 1. B. When a patient develops dyspnea and
among elderly person is:
shortness of breath, the orthopneic position
a. Depression
encourages maximum chest expansion and keeps
b. Sleep disturbances (such as bizarre dreams)
the abdominal organs from pressing against the
c. Inability to concentrate
diaphragm, thus improving ventilation. Bed rest
d. Decreased appetite
and oxygen by Venturi mask at 24% would
improve oxygenation of the tissues and cells but
46. Which of the following vascular system
must be ordered by a physician. Allowing for rest
changes results from aging?
periods decreases the possibility of hypoxia.
a. Increased peripheral resistance of the blood 2. C. Orthopnea is difficulty of breathing except in
vessels
the upright position. Tachypnea is rapid
b. Decreased blood flow
respiration characterized by quick, shallow
c. Increased work load of the left ventricle
d. All of the above
 breaths. Eupnea is normal respiration – this theory, other physiologic needs (including
quiet, rhythmic, and without effort. food, water, elimination, shelter, rest and sleep,
3. C. A platelet count evaluates the number activity and temperature regulation) must be met
of platelets in the circulating blood before proceeding to the next hierarchical levels
volume. The nurse is responsible for on psychosocial needs.
giving the patient breakfast at the 8. B. The brain-dead patient’s family needs support
scheduled time. The physician is and reassurance in making a decision about
responsible for instructing the patient organ donation. Because transplants are done
about the test and for writing the order for within hours of death, decisions about organ
the test. donation must be made as soon as possible.
4. B. Mashed potatoes and broiled chicken However, the family’s concerns must be
are low in natural sodium chloride. Ham, addressed before members are asked to sign a
olives, and chicken bouillon contain large consent form. The body of an organ donor is
amounts of sodium and are available for burial.
contraindicated on a low sodium diet. 9. C. Although a new head nurse should initially
5. D. All of the identified nursing spend time observing the unit for its strengths
responsibilities are pertinent when a and weakness, she should take action if a
patient is receiving heparin. The normal problem threatens patient safety. In this case,
activated partial thromboplastin time is 16 the supervisor is the resource person to
to 25 seconds and the normal approach.
prothrombin time is 12 to 15 seconds; 10. D. Studies have shown that patients and nurses
these levels must remain within two to both respond well to primary nursing care units.
two and one half the normal levels. All Patients feel less anxious and isolated and more
patients receiving anticoagulant therapy secure because they are allowed to participate in
must be observed for signs and symptoms planning their own care. Nurses feel personal
of frank and occult bleeding (including satisfaction, much of it related to positive
hemorrhage, hypotension, tachycardia, feedback from the patients. They also seem to
tachypnea, restlessness, pallor, cold and gain a greater sense of achievement and esprit
clammy skin, thirst and confusion); blood de corps.
pressure should be measured every 4 11. A. Assault is the unjustifiable attempt or threat to
hours and the patient should be instructed touch or injure another person. Battery is the
to report promptly any bleeding that unlawful touching of another person or the
occurs with tooth brushing, bowel carrying out of threatened physical harm. Thus,
movements, urination or heavy prolonged any act that a nurse performs on the patient
menstruation. against his will is considered assault and battery.
6. D. The focus concepts that have been 12. A. Oral communication that injures an individual’s
accepted by all theorists as the focus of reputation is considered slander. Written
nursing practice from the time of Florence communication that does the same is considered
Nightingale include the person receiving libel.
nursing care, his environment, his health 13. D. Malpractice is defined as injurious or
on the health illness continuum, and the unprofessional actions that harm another. It
nursing actions necessary to meet his involves professional misconduct, such as
needs. omission or commission of an act that a
7. D. Maslow, who defined a need as a reasonable and prudent nurse would or would not
satisfaction whose absence causes illness, do. In this example, the standard of care was
considered oxygen to be the most breached; a 3-month-old infant should never be
important physiologic need; without it, left unattended on a scale.
human life could not exist. According to
14. A. The three elements necessary to distention, tenderness and discoloration around
establish a nursing malpractice are the umbilicus can indicate various bowel-related
nursing error (administering penicillin to a conditions, such as cholecystitis, appendicitis and
patient with a documented allergy to the peritonitis.
drug), injury (cerebral damage), and 18. C. Hyperactive sounds indicate increased bowel
proximal cause (administering the motility; two or three sounds per minute indicate
penicillin caused the cerebral damage). decreased bowel motility. Abdominal cramping
Applying a hot water bottle or heating pad with hyperactive, high pitched tinkling bowel
to a patient without a physician’s order sounds can indicate a bowel obstruction.
does not include the three required 19. C. The supine position (also called the dorsal
components. Assisting a patient out of bed position), in which the patient lies on his back
with the bed locked in position is the with his face upward, allows for easy access to
correct nursing practice; therefore, the the abdomen. In the prone position, the patient
fracture was not the result of malpractice. lies on his abdomen with his face turned to the
Administering an incorrect medication is a side. In the Trendelenburg position, the head of
nursing error; however, if such action the bed is tilted downward to 30 to 40 degrees so
resulted in a serious illness or chronic that the upper body is lower than the legs. In the
problem, the nurse could be sued for lateral position, the patient lies on his side.
malpractice. 20. D. All of these positions are appropriate for a
15. C. An Asian patient is likely to hide his rectal examination. In the genupectoral (knee-
pain. Consequently, the nurse must chest) position, the patient kneels and rests his
observe for objective signs. In an chest on the table, forming a 90 degree angle
abdominal surgery patient, these might between the torso and upper legs. In Sims’
include immobility, diaphoresis, and position, the patient lies on his left side with the
avoidance of deep breathing or coughing, left arm behind the body and his right leg flexed.
as well as increased heart rate, shallow In the horizontal recumbent position, the patient
respirations (stemming from pain upon lies on his back with legs extended and hips
moving the diaphragm and respiratory rotated outward.
muscles), and guarding or rigidity of the 21. B. During a Romberg test, which evaluates for
abdominal wall. Such a patient is unlikely sensory or cerebellar ataxia, the patient must
to display emotion, such as crying. stand with feet together and arms resting at the
16. B. To assess for GI tract bleeding when sides—first with eyes open, then with eyes
frank blood is absent, the nurse has two closed. The need to move the feet apart to
options: She can test for occult blood in maintain this stance is an abnormal finding.
vomitus, if present, or in stool – through 22. A. The pulse pressure is the difference between
guaiac (Hemoccult) test. A complete blood the systolic and diastolic blood pressure readings
count does not provide immediate results – in this case, 54.
and does not always immediately reflect 23. D. A slightly elevated temperature in the
blood loss. Changes in vital signs may be immediate preoperative or post operative period
cause by factors other than blood loss. may result from the lack of fluids before surgery
Abdominal girth is unrelated to blood loss. rather than from infection. Anxiety will not cause
17. D. Because percussion and palpation can an elevated temperature. Hypothermia is an
affect bowel motility and thus bowel abnormally low body temperature.
sounds, they should follow auscultation in 24. D. The quality and efficiency of the respiratory
abdominal assessment. Tympanic process can be determined by appraising the
percussion, measurement of abdominal rate, rhythm, depth, ease, sound, and symmetry
girth, and inspection are methods of of respirations.
assessing the abdomen. Assessing for
25. D. Under normal conditions, a healthy incontinent patient who has impaired nutrition
adult breathes in a smooth uninterrupted (from gastric cancer) and is confined to bed is at
pattern 12 to 20 times a minute. Thus, a greater risk.
respiratory rate of 30 would be abnormal. 30. A. Adequate hydration thins and loosens
A normal adult body temperature, as pulmonary secretions and also helps to replace
measured on an oral thermometer, ranges fluids lost from elevated temperature,
between 97° and 100°F (36.1° and diaphoresis, dehydration and dyspnea. High-
37.8°C); an axillary temperature is humidity air and chest physiotherapy help liquefy
approximately one degree lower and a and mobilize secretions.
rectal temperature, one degree higher. 31. A. Chronic alcoholism commonly results in
Thus, an axillary temperature of 99.6°F thiamine deficiency and other symptoms of
(37.6°C) would be considered abnormal. malnutrition.
The resting pulse rate in an adult ranges 32. C. A patient with dysphagia (difficulty swallowing)
from 60 to 100 beats/minute, so a rate of requires assistance with feeding. Feeding himself
88 is normal. is a long-range expected outcome. Soft foods,
26. D. Parasympathetic nervous system Fowler’s or semi-Fowler’s position, and oral
stimulation of the heart decreases the hygiene before eating should be part of the
heart rate as well as the force of feeding regimen.
contraction, rate of impulse conduction 33. A. A urine output of less than 30ml/hour
and blood flow through the coronary indicates hypovolemia or oliguria, which is related
vessels. Fever, exercise, and sympathetic to kidney function and inadequate fluid intake.
stimulation all increase the heart rate. 34. A. Fluids containing caffeine have a diuretic
27. D. The apical pulse (the pulse at the apex effect. Beets and urinary analgesics, such as
of the heart) is located on the pyridium, can color urine red. Kaopectate is an
midclavicular line at the fourth, fifth, or anti diarrheal medication.
sixth intercostal space. Base line vital 35. C. A hospitalized surgical patient leaving his room
signs include pulse rate, temperature, for the first time fears rejection and others
respiratory rate, and blood pressure. staring at him, so he should not walk alone.
Blood pressure is typically assessed at the Accompanying him will offer moral support,
antecubital fossa, and respiratory rate is enabling him to face the rest of the world.
assessed best by observing chest Patients should begin ambulation as soon as
movement with each inspiration and possible after surgery to decrease complications
expiration. and to regain strength and confidence. Waiting to
28. C. Because the pedal pulse cannot be consult a physical therapist is unnecessary.
detected in 10% to 20% of the 36. A. Thick, tenacious secretions, a dry, hacking
population, its absence is not necessarily a cough, orthopnea, and shortness of breath are
significant finding. However, the presence signs of ineffective airway clearance. Ineffective
or absence of the pedal pulse should be airway clearance related to dry, hacking cough is
documented upon admission so that incorrect because the cough is not the reason for
changes can be identified during the the ineffective airway clearance. Ineffective
hospital stay. Absence of the apical, radial, individual coping related to COPD is wrong
or femoral pulse is abnormal and should because the etiology for a nursing diagnosis
be investigated. should not be a medical diagnosis (COPD) and
29. B. Pressure ulcers are most likely to because no data indicate that the patient is
develop in patients with impaired mental coping ineffectively. Pain related to
status, mobility, activity level, nutrition, immobilization of affected leg would be an
circulation and bladder or bowel control. appropriate nursing diagnosis for a patient with a
Age is also a factor. Thus, the 88-year old leg fracture.
37. D. “I know this will be difficult” identity and prevents identification mistakes in
acknowledges the problem and suggests a drug administration.
resolution to it. “Don’t worry..” offers 42. D. Since about 40% of patients fall out of bed
some relief but doesn’t recognize the despite the use of side rails, side rails cannot be
patient’s feelings. “..I didn’t get to the bad said to prevent falls; however, they do serve as a
news yet” would be inappropriate at any reminder that the patient should not get out of
time. “Your hair is really pretty” offers no bed. The other answers are incorrect
consolation or alternatives to the patient. interpretations of the statistical data.
38. B. Additional Vitamin C is needed in 43. C. A patient who cannot care for himself at home
growth periods, such as infancy and does not necessarily have impaired awareness;
childhood, and during pregnancy to supply he may simply have some degree of immobility.
demands for fetal growth and maternal 44. D. Hip fracture, the most common injury among
tissues. Other conditions requiring extra elderly persons, usually results from
vitamin C include wound healing, fever, osteoporosis. The other answers are diseases
infection and stress. that can occur in the elderly from physiologic
39. D. Delivery of more than 2 liters of changes.
oxygen per minute to a patient with 45. A. Sleep disturbances, inability to concentrate
chronic obstructive pulmonary disease and decreased appetite are symptoms of
(COPD), who is usually in a state of depression, the most common psychogenic
compensated respiratory acidosis disorder among elderly persons. Other symptoms
(retaining carbon dioxide (CO2)), can include diminished memory, apathy, disinterest in
inhibit the hypoxic stimulus for appearance, withdrawal, and irritability.
respiration. An increased partial pressure Depression typically begins before the onset of
of carbon dioxide in arterial blood (PACO2) old age and usually is caused by psychosocial,
would not initially result in cardiac arrest. genetic, or biochemical factors
Circulatory overload and respiratory 46. D. Aging decreases elasticity of the blood vessels,
excitement have no relevance to the which leads to increased peripheral resistance
question. and decreased blood flow. These changes, in
40. C. Presenting symptoms of hypokalemia turn, increase the work load of the left ventricle.
( a serum potassium level below 3.5 47. D. Alzheimer;s disease, sometimes known
mEq/liter) include muscle weakness, as senile dementia of the Alzheimer’s type or
chronic fatigue, and cardiac dysrhythmias. primary degenerative dementia, is an insidious;
The combined effects of inadequate food progressive, irreversible, and degenerative
intake and prolonged diarrhea can deplete disease of the brain whose etiology is still
the potassium stores of a patient with GI unknown. Parkinson’s disease is a neurologic
problems. disorder caused by lesions in the extrapyramidial
41. D. Assisting a patient with ambulation and system and manifested by tremors, muscle
transfer from a bed to a chair allows the rigidity, hypokinesis, dysphagia, and
nurse to evaluate the patient’s ability to dysphonia. Multiple sclerosis, a progressive,
carry out these functions safely. degenerative disease involving demyelination of
Demonstrating the signal system and the nerve fibers, usually begins in young
providing an opportunity for a return adulthood and is marked by periods of remission
demonstration ensures that the patient and exacerbation.Amyotrophic lateral sclerosis, a
knows how to operate the equipment and disease marked by progressive degeneration of
encourages him to call for assistance the neurons, eventually results in atrophy of all
when needed. Checking the patient’s the muscles; including those necessary for
identification band verifies the patient’s respiration.
48. C. The nurse is legally responsible for
labeling the corpse when death occurs in
the hospital. She may be involved in
obtaining consent for an autopsy or
notifying the coroner or medical examiner
of a patient’s death; however, she is not
legally responsible for performing these
functions. The attending physician may
need information from the nurse to
complete the death certificate, but he is
responsible for issuing it.
49. B. The nurse must place a pillow under
the decreased person’s head and
shoulders to prevent blood from settling in
the face and discoloring it. She is required
to bathe only soiled areas of the body
since the mortician will wash the entire
body. Before wrapping the body in a
shroud, the nurse places a clean gown on
the body and closes the eyes and mouth.
50. A. Ensuring the patient’s safety is the
most essential action at this time. The
other nursing actions may be necessary
but are not a major priority.

Foundation of Nursing - Comprehensive

Test Part 3
1. Which element in the circular chain of infection
can be eliminated by preserving skin integrity?
a. Host
b. Reservoir
c. Mode of transmission
d. Portal of entry

2. Which of the following will probably result in a

break in sterile technique for respiratory
isolation?
a. Opening the patient’s window to the outside
environment
b. Turning on the patient’s room ventilator
c. Opening the door of the patient’s room leading into
the hospital corridor
d. Failing to wear gloves when administering a bed
bath
3. Which of the following patients is at
greater risk for contracting an infection? 9. A natural body defense that plays an active role
a. A patient with leukopenia in preventing infection is:
b. A patient receiving broad-spectrum a. Yawning
antibiotics b. Body hair
c. A postoperative patient who has undergone c. Hiccupping
orthopedic surgery d. Rapid eye movements
d. A newly diagnosed diabetic patient
10. All of the following statement are true
4. Effective hand washing requires the use about donning sterile gloves except:
of: a. The first glove should be picked up by grasping the
a. Soap or detergent to promote emulsification inside of the cuff.
b. Hot water to destroy bacteria b. The second glove should be picked up by inserting
c. A disinfectant to increase surface tension the gloved fingers under the cuff outside the glove.
d. All of the above c. The gloves should be adjusted by sliding the gloved
fingers under the sterile cuff and pulling the glove
5. After routine patient contact, hand over the wrist
washing should last at least: d. The inside of the glove is considered sterile
a. 30 seconds
b. 1 minute 11. When removing a contaminated gown, the nurse
c. 2 minute should be careful that the first thing she touches
d. 3 minutes is the:
a. Waist tie and neck tie at the back of the gown
6. Which of the following procedures always b. Waist tie in front of the gown
requires surgical asepsis? c. Cuffs of the gown
a. Vaginal instillation of conjugated estrogen d. Inside of the gown
b. Urinary catheterization
c. Nasogastric tube insertion 12. Which of the following nursing interventions is
d. Colostomy irrigation considered the most effective form or universal
precautions?
7. Sterile technique is used whenever: a. Cap all used needles before removing them from
a. Strict isolation is required their syringes
b. Terminal disinfection is performed b. Discard all used uncapped needles and syringes in
c. Invasive procedures are performed an impenetrable protective container
d. Protective isolation is necessary c. Wear gloves when administering IM injections
d. Follow enteric precautions
8. Which of the following constitutes a break
in sterile technique while preparing a 13. All of the following measures are recommended
sterile field for a dressing change? to prevent pressure ulcers except:
a. Using sterile forceps, rather than sterile a. Massaging the reddened are with lotion
gloves, to handle a sterile item b. Using a water or air mattress
b. Touching the outside wrapper of sterilized c. Adhering to a schedule for positioning and turning
material without sterile gloves d. Providing meticulous skin care
c. Placing a sterile object on the edge of the
sterile field 14. Which of the following blood tests should be
d. Pouring out a small amount of solution (15 performed before a blood transfusion?
to 30 ml) before pouring the solution into a a. Prothrombin and coagulation time
sterile container b. Blood typing and cross-matching
c. Bleeding and clotting time 20. A patient with no known allergies is to receive
d. Complete blood count (CBC) and electrolyte penicillin every 6 hours. When administering the
levels. medication, the nurse observes a fine rash on the
patient’s skin. The most appropriate nursing
15. The primary purpose of a platelet count is action would be to:
to evaluate the: a. Withhold the moderation and notify the physician
a. Potential for clot formation b. Administer the medication and notify the physician
b. Potential for bleeding c. Administer the medication with an antihistamine
c. Presence of an antigen-antibody response d. Apply corn starch soaks to the rash
d. Presence of cardiac enzymes
21. All of the following nursing interventions are
16. Which of the following white blood cell correct when using the Z-track method of drug
(WBC) counts clearly indicates injection except:
leukocytosis? a. Prepare the injection site with alcohol
a. 4,500/mm³ b. Use a needle that’s a least 1” long
b. 7,000/mm³ c. Aspirate for blood before injection
c. 10,000/mm³ d. Rub the site vigorously after the injection to
d. 25,000/mm³ promote absorption

17. After 5 days of diuretic therapy with 20mg 22. The correct method for determining the vastus
of furosemide (Lasix) daily, a patient lateralis site for I.M. injection is to:
begins to exhibit fatigue, muscle cramping a. Locate the upper aspect of the upper outer quadrant
and muscle weakness. These symptoms of the buttock about 5 to 8 cm below the iliac crest
probably indicate that the patient is b. Palpate the lower edge of the acromion process and
experiencing: the midpoint lateral aspect of the arm
a. Hypokalemia c. Palpate a 1” circular area anterior to the umbilicus
b. Hyperkalemia d. Divide the area between the greater femoral
c. Anorexia trochanter and the lateral femoral condyle into
d. Dysphagia thirds, and select the middle third on the anterior of
the thigh
18. Which of the following statements about
chest X-ray is false? 23. The mid-deltoid injection site is seldom used for
a. No contradictions exist for this test I.M. injections because it:
b. Before the procedure, the patient should a. Can accommodate only 1 ml or less of medication
remove all jewelry, metallic objects, and b. Bruises too easily
buttons above the waist c. Can be used only when the patient is lying down
c. A signed consent is not required d. Does not readily parenteral medication
d. Eating, drinking, and medications are
allowed before this test 24. The appropriate needle size for insulin injection
is:
19. The most appropriate time for the nurse a. 18G, 1 ½” long
to obtain a sputum specimen for culture b. 22G, 1” long
is: c. 22G, 1 ½” long
a. Early in the morning d. 25G, 5/8” long
b. After the patient eats a light breakfast
c. After aerosol therapy 25. The appropriate needle gauge for intradermal
d. After chest physiotherapy injection is:
a. 20G
b. 22G d. Frank bleeding at the insertion site
c. 25G
d. 26G 32. The best way of determining whether a patient
has learned to instill ear medication properly is
26. Parenteral penicillin can be administered for the nurse to:
as an: a. Ask the patient if he/she has used ear drops before
a. IM injection or an IV solution b. Have the patient repeat the nurse’s instructions
b. IV or an intradermal injection using her own words
c. Intradermal or subcutaneous injection c. Demonstrate the procedure to the patient and
d. IM or a subcutaneous injection encourage to ask questions
d. Ask the patient to demonstrate the procedure
27. The physician orders gr 10 of aspirin for a
patient. The equivalent dose in milligrams 33. Which of the following types of medications can
is: be administered via gastrostomy tube?
a. 0.6 mg a. Any oral medications
b. 10 mg b. Capsules whole contents are dissolve in water
c. 60 mg c. Enteric-coated tablets that are thoroughly dissolved
d. 600 mg in water
28. The physician orders an IV solution of d. Most tablets designed for oral use, except for
dextrose 5% in water at 100ml/hour. extended-duration compounds
What would the flow rate be if the drop
factor is 15 gtt = 1 ml? 34. A patient who develops hives after receiving an
antibiotic is exhibiting drug:
a. 5 gtt/minute a. Tolerance
b. 13 gtt/minute b. Idiosyncrasy
c. 25 gtt/minute c. Synergism
d. 50 gtt/minute d. Allergy

29. Which of the following is a sign or 35. A patient has returned to his room after femoral
symptom of a hemolytic reaction to blood arteriography. All of the following are appropriate
transfusion? nursing interventions except:
a. Hemoglobinuria a. Assess femoral, popliteal, and pedal pulses every 15
b. Chest pain minutes for 2 hours
c. Urticaria b. Check the pressure dressing for sanguineous
d. Distended neck veins drainage
c. Assess a vital signs every 15 minutes for 2 hours
30. Which of the following conditions may d. Order a hemoglobin and hematocrit count 1 hour
require fluid restriction? after the arteriography
a. Fever
b. Chronic Obstructive Pulmonary Disease 36. The nurse explains to a patient that a cough:
c. Renal Failure a. Is a protective response to clear the respiratory
d. Dehydration tract of irritants
b. Is primarily a voluntary action
31. All of the following are common signs and c. Is induced by the administration of an antitussive
symptoms of phlebitis except: drug
a. Pain or discomfort at the IV insertion site d. Can be inhibited by “splinting” the abdomen
b. Edema and warmth at the IV insertion site
c. A red streak exiting the IV insertion site
37. An infected patient has chills and begins
shivering. The best nursing intervention is 43. Which of the following is a primary nursing
to: intervention necessary for all patients with a
a. Apply iced alcohol sponges Foley Catheter in place?
b. Provide increased cool liquids a. Maintain the drainage tubing and collection bag
c. Provide additional bedclothes level with the patient’s bladder
d. Provide increased ventilation b. Irrigate the patient with 1% Neosporin solution
three times a daily
38. A clinical nurse specialist is a nurse who c. Clamp the catheter for 1 hour every 4 hours to
has: maintain the bladder’s elasticity
a. Been certified by the National League for d. Maintain the drainage tubing and collection bag
Nursing below bladder level to facilitate drainage by gravity
b. Received credentials from the Philippine
Nurses’ Association 44. The ELISA test is used to:
c. Graduated from an associate degree a. Screen blood donors for antibodies to human
program and is a registered professional immunodeficiency virus (HIV)
nurse b. Test blood to be used for transfusion for HIV
d. Completed a master’s degree in the antibodies
prescribed clinical area and is a registered c. Aid in diagnosing a patient with AIDS
professional nurse. d. All of the above

39. The purpose of increasing urine acidity 45. The two blood vessels most commonly used for
through dietary means is to: TPN infusion are the:
a. Decrease burning sensations a. Subclavian and jugular veins
b. Change the urine’s color b. Brachial and subclavian veins
c. Change the urine’s concentration c. Femoral and subclavian veins
d. Inhibit the growth of microorganisms d. Brachial and femoral veins

40. Clay colored stools indicate: 46. Effective skin disinfection before a surgical
a. Upper GI bleeding procedure includes which of the following
b. Impending constipation methods?
c. An effect of medication a. Shaving the site on the day before surgery
d. Bile obstruction b. Applying a topical antiseptic to the skin on the
41. In which step of the nursing process evening before surgery
would the nurse ask a patient if the c. Having the patient take a tub bath on the morning
medication she administered relieved his of surgery
pain? d. Having the patient shower with an antiseptic soap
a. Assessment on the evening v=before and the morning of
b. Analysis surgery
c. Planning
d. Evaluation 47. When transferring a patient from a bed to a chair,
the nurse should use which muscles to avoid
42. All of the following are good sources of back injury?
vitamin A except: a. Abdominal muscles
a. White potatoes b. Back muscles
b. Carrots c. Leg muscles
c. Apricots d. Upper arm muscles
d. Egg yolks
48. Thrombophlebitis typically develops in
patients with which of the following
conditions?
a. Increases partial thromboplastin time
b. Acute pulsus paradoxus
c. An impaired or traumatized blood vessel wall
d. Chronic Obstructive Pulmonary Disease
(COPD)

49. In a recumbent, immobilized patient, lung

ventilation can become altered, leading to
such respiratory complications as:
a. Respiratory acidosis, ateclectasis, and Foundation of Nursing - Comprehensive
hypostatic pneumonia Test Part 3 Answers and Rationale
b. Appneustic breathing, atypical pneumonia 1. D. In the circular chain of infection, pathogens
and respiratory alkalosis must be able to leave their reservoir and be
c. Cheyne-Strokes respirations and transmitted to a susceptible host through a portal
spontaneous pneumothorax of entry, such as broken skin.
d. Kussmail’s respirations and hypoventilation 2. C. Respiratory isolation, like strict isolation,
requires that the door to the door patient’s room
50. Immobility impairs bladder elimination, remain closed. However, the patient’s room
resulting in such disorders as should be well ventilated, so opening the window
a. Increased urine acidity and relaxation of the or turning on the ventricular is desirable. The
perineal muscles, causing incontinence nurse does not need to wear gloves for
b. Urine retention, bladder distention, and respiratory isolation, but good hand washing is
infection important for all types of isolation.
c. Diuresis, natriuresis, and decreased urine 3. A. Leukopenia is a decreased number of
specific gravity leukocytes (white blood cells), which are
d. Decreased calcium and phosphate levels in important in resisting infection. None of the other
the urine situations would put the patient at risk for
contracting an infection; taking broad-spectrum
antibiotics might actually reduce the infection
risk.
4. A. Soaps and detergents are used to help remove
bacteria because of their ability to lower the
surface tension of water and act as emulsifying
agents. Hot water may lead to skin irritation or
burns.
5. A. Depending on the degree of exposure to
pathogens, hand washing may last from 10
seconds to 4 minutes. After routine patient
contact, hand washing for 30 seconds effectively
minimizes the risk of pathogen transmission.
6. B. The urinary system is normally free of
microorganisms except at the urinary meatus.
Any procedure that involves entering this system
 must use surgically aseptic measures to fold the gown inside out; discard it in a
maintain a bacteria-free state. contaminated linen container; then wash her
7. C. All invasive procedures, including hands again.
surgery, catheter insertion, and 12. B. According to the Centers for Disease Control
administration of parenteral therapy, (CDC), blood-to-blood contact occurs most
require sterile technique to maintain a commonly when a health care worker attempts to
sterile environment. All equipment must cap a used needle. Therefore, used needles
be sterile, and the nurse and the physician should never be recapped; instead they should
must wear sterile gloves and maintain be inserted in a specially designed puncture
surgical asepsis. In the operating room, resistant, labeled container. Wearing gloves is not
the nurse and physician are required to always necessary when administering an I.M.
wear sterile gowns, gloves, masks, hair injection. Enteric precautions prevent the transfer
covers, and shoe covers for all invasive of pathogens via feces.
procedures. Strict isolation requires the 13. A. Nurses and other health care professionals
use of clean gloves, masks, gowns and previously believed that massaging a reddened
equipment to prevent the transmission of area with lotion would promote venous return
highly communicable diseases by contact and reduce edema to the area. However,
or by airborne routes. Terminal research has shown that massage only increases
disinfection is the disinfection of all the likelihood of cellular ischemia and necrosis to
contaminated supplies and equipment the area.
after a patient has been discharged to 14. B. Before a blood transfusion is performed, the
prepare them for reuse by another blood of the donor and recipient must be checked
patient. The purpose of protective for compatibility. This is done by blood typing (a
(reverse) isolation is to prevent a person test that determines a person’s blood type) and
with seriously impaired resistance from cross-matching (a procedure that determines the
coming into contact who potentially compatibility of the donor’s and recipient’s blood
pathogenic organisms. after the blood types has been matched). If the
8. C. The edges of a sterile field are blood specimens are incompatible, hemolysis and
considered contaminated. When sterile antigen-antibody reactions will occur.
items are allowed to come in contact with 15. A. Platelets are disk-shaped cells that are
the edges of the field, the sterile items essential for blood coagulation. A platelet count
also become contaminated. determines the number of thrombocytes in blood
9. B. Hair on or within body areas, such as available for promoting hemostasis and assisting
the nose, traps and holds particles that with blood coagulation after injury. It also is used
contain microorganisms. Yawning and to evaluate the patient’s potential for bleeding;
hiccupping do not prevent microorganisms however, this is not its primary purpose. The
from entering or leaving the body. Rapid normal count ranges from 150,000 to
eye movement marks the stage of sleep 350,000/mm3. A count of 100,000/mm3 or less
during which dreaming occurs. indicates a potential for bleeding; count of less
10. D. The inside of the glove is always than 20,000/mm3 is associated with spontaneous
considered to be clean, but not sterile. bleeding.
11. A. The back of the gown is considered 16. D. Leukocytosis is any transient increase in the
clean, the front is contaminated. So, after number of white blood cells (leukocytes) in the
removing gloves and washing hands, the blood. Normal WBC counts range from 5,000 to
nurse should untie the back of the gown; 100,000/mm3. Thus, a count of
slowly move backward away from the 25,000/mm3 indicates leukocytosis.
gown, holding the inside of the gown and 17. A. Fatigue, muscle cramping, and muscle
keeping the edges off the floor; turn and weaknesses are symptoms of hypokalemia (an
 inadequate potassium level), which is a 22. D. The vastus lateralis, a long, thick muscle that
potential side effect of diuretic therapy. extends the full length of the thigh, is viewed by
The physician usually orders supplemental many clinicians as the site of choice for I.M.
potassium to prevent hypokalemia in injections because it has relatively few major
patients receiving diuretics. Anorexia is nerves and blood vessels. The middle third of the
another symptom of hypokalemia. muscle is recommended as the injection site. The
Dysphagia means difficulty swallowing. patient can be in a supine or sitting position for
18. A. Pregnancy or suspected pregnancy is an injection into this site.
the only contraindication for a chest X-ray. 23. A. The mid-deltoid injection site can
However, if a chest X-ray is necessary, the accommodate only 1 ml or less of medication
patient can wear a lead apron to protect because of its size and location (on the deltoid
the pelvic region from radiation. Jewelry, muscle of the arm, close to the brachial artery
metallic objects, and buttons would and radial nerve).
interfere with the X-ray and thus should 24. D. A 25G, 5/8” needle is the recommended size
not be worn above the waist. A signed for insulin injection because insulin is
consent is not required because a chest X- administered by the subcutaneous route. An 18G,
ray is not an invasive examination. Eating, 1 ½” needle is usually used for I.M. injections in
drinking and medications are allowed children, typically in the vastus lateralis. A 22G, 1
because the X-ray is of the chest, not the ½” needle is usually used for adult I.M.
abdominal region. injections, which are typically administered in the
19. A. Obtaining a sputum specimen early in vastus lateralis or ventrogluteal site.
this morning ensures an adequate supply 25. D. Because an intradermal injection does not
of bacteria for culturing and decreases the penetrate deeply into the skin, a small-bore 25G
risk of contamination from food or needle is recommended. This type of injection is
medication. used primarily to administer antigens to evaluate
20. A. Initial sensitivity to penicillin is reactions for allergy or sensitivity studies. A 20G
commonly manifested by a skin rash, needle is usually used for I.M. injections of oil-
even in individuals who have not been based medications; a 22G needle for I.M.
allergic to it previously. Because of the injections; and a 25G needle, for I.M. injections;
danger of anaphylactic shock, he nurse and a 25G needle, for subcutaneous insulin
should withhold the drug and notify the injections.
physician, who may choose to substitute 26. A. Parenteral penicillin can be administered I.M.
another drug. Administering an or added to a solution and given I.V. It cannot be
antihistamine is a dependent nursing administered subcutaneously or intradermally.
intervention that requires a written 27. D. gr 10 x 60mg/gr 1 = 600 mg
physician’s order. Although applying corn 28. C. 100ml/60 min X 15 gtt/ 1 ml = 25 gtt/minute
starch to the rash may relieve discomfort, 29. A. Hemoglobinuria, the abnormal presence of
it is not the nurse’s top priority in such a hemoglobin in the urine, indicates a hemolytic
potentially life-threatening situation. reaction (incompatibility of the donor’s and
21. D. The Z-track method is an I.M. injection recipient’s blood). In this reaction, antibodies in
technique in which the patient’s skin is the recipient’s plasma combine rapidly with donor
pulled in such a way that the needle track RBC’s; the cells are hemolyzed in either
is sealed off after the injection. This circulatory or reticuloendothelial system.
procedure seals medication deep into the Hemolysis occurs more rapidly in ABO
muscle, thereby minimizing skin staining incompatibilities than in Rh incompatibilities.
and irritation. Rubbing the injection site is Chest pain and urticaria may be symptoms of
contraindicated because it may cause the impending anaphylaxis. Distended neck veins are
medication to extravasate into the skin. an indication of hypervolemia.
30. C. In real failure, the kidney loses their 35. D. A hemoglobin and hematocrit count would be
ability to effectively eliminate wastes and ordered by the physician if bleeding were
fluids. Because of this, limiting the suspected. The other answers are appropriate
patient’s intake of oral and I.V. fluids may nursing interventions for a patient who has
be necessary. Fever, chronic obstructive undergone femoral arteriography.
pulmonary disease, and dehydration are 36. A. Coughing, a protective response that clears
conditions for which fluids should be the respiratory tract of irritants, usually is
encouraged. involuntary; however it can be voluntary, as
31. D. Phlebitis, the inflammation of a vein, when a patient is taught to perform coughing
can be caused by chemical irritants (I.V. exercises. An antitussive drug inhibits coughing.
solutions or medications), mechanical Splinting the abdomen supports the abdominal
irritants (the needle or catheter used muscles when a patient coughs.
during venipuncture or cannulation), or a 37. C. In an infected patient, shivering results from
localized allergic reaction to the needle or the body’s attempt to increase heat production
catheter. Signs and symptoms of phlebitis and the production of neutrophils and
include pain or discomfort, edema and phagocytotic action through increased skeletal
heat at the I.V. insertion site, and a red muscle tension and contractions. Initial
streak going up the arm or leg from the vasoconstriction may cause skin to feel cold to
I.V. insertion site. the touch. Applying additional bed clothes helps
32. D. Return demonstration provides the to equalize the body temperature and stop the
most certain evidence for evaluating the chills. Attempts to cool the body result in further
effectiveness of patient teaching. shivering, increased metabloism, and thus
33. D. Capsules, enteric-coated tablets, and increased heat production.
most extended duration or sustained 38. D. A clinical nurse specialist must have
release products should not be dissolved completed a master’s degree in a clinical
for use in a gastrostomy tube. They are specialty and be a registered professional nurse.
pharmaceutically manufactured in these The National League of Nursing accredits
forms for valid reasons, and altering them educational programs in nursing and provides a
destroys their purpose. The nurse should testing service to evaluate student nursing
seek an alternate physician’s order when competence but it does not certify nurses. The
an ordered medication is inappropriate for American Nurses Association identifies
delivery by tube. requirements for certification and offers
34. D. A drug-allergy is an adverse reaction examinations for certification in many areas of
resulting from an immunologic response nursing., such as medical surgical nursing. These
following a previous sensitizing exposure certification (credentialing) demonstrates that the
to the drug. The reaction can range from a nurse has the knowledge and the ability to
rash or hives to anaphylactic provide high quality nursing care in the area of
shock.Tolerance to a drug means that the her certification. A graduate of an associate
patient experiences a decreasing degree program is not a clinical nurse specialist:
physiologic response to repeated however, she is prepared to provide bed side
administration of the drug in the same nursing with a high degree of knowledge and
dosage. Idiosyncrasy is an individual’s skill. She must successfully complete the
unique hypersensitivity to a drug, food, or licensing examination to become a registered
other substance; it appears to be professional nurse.
genetically determined. Synergism, is a 39. D. Microorganisms usually do not grow in an
drug interaction in which the sum of the acidic environment.
drug’s combined effects is greater than 40. D. Bile colors the stool brown. Any inflammation
that of their separate effects. or obstruction that impairs bile flow will affect the
 stool pigment, yielding light, clay-colored increasing the risk of infection; however, if
stool. Upper GI bleeding results in black or indicated, shaving, should be done immediately
tarry stool. Constipation is characterized before surgery, not the day before. A topical
by small, hard masses. Many medications antiseptic would not remove microorganisms and
and foods will discolor stool – for example, would be beneficial only after proper cleaning and
drugs containing iron turn stool black.; rinsing. Tub bathing might transfer organisms to
beets turn stool red. another body site rather than rinse them away.
41. D. In the evaluation step of the nursing 47. C. The leg muscles are the strongest muscles in
process, the nurse must decide whether the body and should bear the greatest stress
the patient has achieved the expected when lifting. Muscles of the abdomen, back, and
outcome that was identified in the upper arms may be easily injured.
planning phase. 48. C. The factors, known as Virchow’s triad,
42. A. The main sources of vitamin A are collectively predispose a patient to
yellow and green vegetables (such as thromboplebitis; impaired venous return to the
carrots, sweet potatoes, squash, spinach, heart, blood hypercoagulability, and injury to a
collard greens, broccoli, and cabbage) and blood vessel wall. Increased partial
yellow fruits (such as apricots, and thromboplastin time indicates a prolonged
cantaloupe). Animal sources include liver, bleeding time during fibrin clot formation,
kidneys, cream, butter, and egg yolks. commonly the result of anticoagulant (heparin)
43. D. Maintaing the drainage tubing and therapy. Arterial blood disorders (such as pulsus
collection bag level with the patient’s paradoxus) and lung diseases (such as COPD) do
bladder could result in reflux of urine into not necessarily impede venous return of injure
the kidney. Irrigating the bladder with vessel walls.
Neosporin and clamping the catheter for 1 49. A. Because of restricted respiratory movement, a
hour every 4 hours must be prescribed by recumbent, immobilize patient is at particular risk
a physician. for respiratory acidosis from poor gas exchange;
44. D. The ELISA test of venous blood is used atelectasis from reduced surfactant and
to assess blood and potential blood donors accumulated mucus in the bronchioles, and
to human immunodeficiency virus (HIV). A hypostatic pneumonia from bacterial growth
positive ELISA test combined with various caused by stasis of mucus secretions.
signs and symptoms helps to diagnose 50. B. The immobilized patient commonly suffers
acquired immunodeficiency syndrome from urine retention caused by decreased muscle
(AIDS) tone in the perineum. This leads to bladder
45. A. Total Parenteral Nutrition (TPN) distention and urine stagnation, which provide an
requires the use of a large vessel, such as excellent medium for bacterial growth leading to
the subclavian or jugular vein, to ensure infection. Immobility also results in more alkaline
rapid dilution of the solution and thereby urine with excessive amounts of calcium, sodium
prevent complications, such as and phosphate, a gradual decrease in urine
hyperglycemia. The brachial and femoral production, and an increased specific gravity.
veins usually are contraindicated because
they pose an increased risk of
thrombophlebitis.
46. D. Studies have shown that showering
with an antiseptic soap before surgery is
the most effective method of removing
microorganisms from the skin. Shaving
the site of the intended surgery might
cause breaks in the skin, thereby