General Nursing Board 101 Fundamentals Pre-Test 1 http://nsgbrd101.proboards.com/index.cgi?

i?board=answers&action=display&thread=2 Fundamentals Pre-Test 1 Post by admin on Aug 18, 2010, 12:44pm Analysis Health Promotion and Maintenance Nursing Process/Analysis Adult Health/Cardiovascular 1. A nurse is assessing the extent of pitting edema in a client with congestive heart failure. The nurse gently presses a finger on the client's ankle and notes a barely perceptible pit. The nurse interprets this finding as which measurement of pitting edema? a. 1+ b. 2+ c. 3+ d. 4+ A. The level of pitting edema is rated on a scale of 1+ to 4+. A barely perceptible pit is rated as 1+. A deeper pit that rebounds in a few seconds is rated as 2+. A deep pit that rebounds in 10 to 20 seconds is rated as 3+. A deeper pit that rebounds in greater than 30 seconds is rated as 4+. 2. The nurse notes documentation that a client's peripheral pulses are +3. The nurse determines that the pulses are a. Full and brisk b. Absent c. Normal or average d. Palpable, but diminished A. Pulses are rated on a scale of 0 to +4 as follows: 0 = absent; +1 = palpable, but diminished; +2 = normal or average; +3 = full and brisk; and +4 = full and bounding, often visible. 3. A nurse is reviewing a clients record and notes that the results of the clients vision test using a Snellen chart is 20/50. The nurse interprets this to mean that the client

a. Has normal vision b. Has minimal visual c. Can read at a distance of 20 feet what a client with normal vision can read at 50 feet d. Can read at a distance of 50 feet what a client with normal vision can read at 20 feet C. When recording the results of visual acuity using the Snellen chart, the nurse would record the result using the numeric fraction noted at the end of the last successful line read on the Snellen chart. The top number (numerator) indicates the distance the client is standing from the chart, whereas the bottom number (denominator) gives the distance at which a person with normal vision could have read that particular line. Thus, 20/50 means that the client can read at a distance of 20 feet what a client with normal vision can read at 50 feet. Normal visual acuity is 20/20. Minimal vision is a vague description of a clients visual acuity. 4. A prenatal client tells the nurse that she is really worried about knowing how to care for her first-born child. The nurse formulates which nursing diagnosis for this client? a. Ineffective Coping b. Dysfunctional Grieving c. Situational Low Self-esteem d. Deficient Knowledge D. Deficient Knowledge indicates a lack of information or psychomotor skills concerning a skill, condition, or treatment. This nursing diagnosis best describes the situation presented in the question. Situational Low Self-esteem represents temporary negative feelings about self in response to an event. Ineffective Coping implies that the person is unable to manage stressors adequately. Dysfunctional Grieving implies prolonged unresolved grief leading to detrimental activities. 5. The nurse notes documentation that a client has the presence of cherry angiomas located on the abdomen. On assessment of the client, the nurse would expect to note which characteristic of this skin lesion? a. Ruby red papules b. Thickened skin areas c. Pinpoint-sized red or purple spots d. Areas of redness warm to touch A. Cherry angiomas are noted as ruby red papules. Areas of skin thickening are noted as senile keratosis. Pinpoint-sized red or purple spots are known as petechiae. Areas of

redness that are warm to touch are noted as erythema. 6. A nurse is assessing the risk factors for acquiring pneumonia during hospitalization for a group of clients. The nurse determines that which of the following clients is at lowest risk? a. An older client with diabetes mellitus b. A client with human immunodeficiency virus (HIV) c. A client with a spinal cord injury who is immobile d. A postoperative client who is ambulating D. The postoperative client who is ambulating is at lowest risk. This client has had no direct insult to the respiratory tract. Clients with HIV, an upper respiratory infection, or a chronic disease (e.g., heart, lung, or kidney disease; diabetes mellitus; or cancer) are at greater risk for development of pneumonia. Clients who are on bed rest and are immobilized also are at risk for development of pneumonia. 7. A nurse working in a prenatal clinic is reviewing the records of clients scheduled for prenatal visits. The nurse interprets that the client at greatest risk for abruptio placenta is the one who a. Is 26 years old and is a primipara b. Rides an exercise bike for 30 minutes 3 times weekly c. Has maternal hypertension d. Takes folic acid supplements daily C. Risk factors for abruptio placenta include maternal hypertension, smoking, and alcohol and/or cocaine use during pregnancy. Other risk factors include blunt external abdominal trauma, poor nutrition, and history of placental abruption. 8. The nurse teaches a client with gastroesophageal reflux disease (GERD) about the measures to prevent reflux while sleeping. The nurse determines that the client needs additional instructions if the client states a. "I shouldn't eat anything at bedtime." b. "I should take an antacid at bedtime." c. "I should sleep flat on my right side." d. "Losing weight will decrease some of the stomach pressure." C. Elevation of the head of the bed 6 to 8 inches will prevent nocturnal reflux. The client is instructed to avoid eating within 3 hours to bedtime to prevent nocturnal reflux. Antacids and histamine receptor antagonists may be prescribed for the client. Losing weight (if overweight) will decrease the gastroesophageal pressure gradient.

9. A nurse provides instructions to a client about the measures to treat gout. The nurse determines that the client needs additional instructions if the client states that a. The intake of red meats needs to be limited. b. Weight loss can help prevent an attack. c. Medication can help keep the uric acid level down. d. Fluid intake needs to be limited. D. Medication therapy is a component of management for clients with gout, and the physician normally prescribes a medication that will promote uric acid excretion or will reduce its production for clients with chronic gout. Fluid intake is important to promote uric acid excretion. Weight loss can reduce the incidence of attacks and reduce uric acid levels. A decrease in the intake of red meats and organ meats will assist in controlling uric acid levels. 10. A nurse provides instructions to a client who is being discharged 24 hours after undergoing a percutaneous renal biopsy. Which statement by the client indicates a need to reinforce the instructions? a. "I need to avoid any strenuous lifting for about two weeks." b. "I shouldn't work out at the gym for about two weeks." c. "I will call the physician if my urine becomes bloody." d. "A fever is normal after this procedure." D. After percutaneous renal biopsy, the client is instructed to report immediately fever, increasing pain levels (back, flank, or shoulder), bleeding from the puncture site, weakness, dizziness, grossly bloody urine, or dysuria. Activity should be restricted if blood is seen in the urine. The client also is instructed to avoid strenuous lifting, physical exertion, or trauma to the biopsy site for up to 2 weeks after discharge. 11. A clinic nurse has provided instructions to the mother of a child with a urinary tract infection. Which statement by the mother indicates a need for further instructions? a. "I should wipe my child from front to back after urination or a bowel movement." b. "I should increase my child's fluid intake." c. "I should encourage my child to hold the urine and to urinate at least four times a day." d. "I should avoid the use of bubble baths with my child." C. The parents should be taught to wipe the child from front to back after urination or a bowel movement to avoid moving bacteria from the anus to the urethra. Fluid intake

including water should be encouraged. The child should be encouraged to avoid holding urine and to urinate at least four times a day; also, the bladder should be emptied with each void to prevent residual urine. Bubble baths are avoided secondary to possible urethral irritation. 12. A nurse provides dietary instructions to a client with hypertension. The nurse determines that the client understands the instructions if the client states that it is acceptable to eat which of the following food items? a. Hot dogs b. Turkey c. Salad with blue cheese dressing d. Corned beef hash B. A client with hypertension needs to avoid foods that are high in sodium, such as bacon, hot dogs, luncheon meat, chipped or corned beef, kosher meat, smoked or salted meat or fish, peanut butter, and a variety of shellfish. Processed foods, canned foods, cheese, and many salad dressings also are high in sodium.

13. The nurse is providing dietary instructions to a client with ascites who will be discharged to home from the hospital. The nurse determines that the client understands the instructions if the client states that it is acceptable to eat which food item? a. Canned green beans b. Fresh plums c. Cooked ham d. Bologna B. The client with ascites is generally encouraged to avoid foods that are high in sodium, which could aggravate fluid retention. The diet should be high in protein (unless specifically advised otherwise) and high in calories. Canned foods, ham, and cold cuts are high in sodium. 14. A nurse has provided instructions to a client with chronic obstructive pulmonary disease about the procedure for performing pursed lip breathing. The nurse observes the client perform the procedure and determines that he or she is performing it correctly if the client a. Takes a deep breath and exhales quickly

b. Monitors inspiration time and ensures that expiration time is less than inspiration time c. Lies on the side in a supine position to perform the procedure d. Sits in an upright position, takes a deep breath, and exhales slowly D. Pursed lip breathing involves deep inspiration and prolonged expiration through pursed lips to prevent alveolar collapse. While sitting up, the client is instructed to take a deep breath and to exhale slowly through pursed lips. Therefore, options 1, 2, and 3 are incorrect. 15. A nurse has completed discharge teaching with the family of a client who requires dressing changes at home. Which method of evaluation would the nurse use to best determine the familys competence in performing the dressing changes? a. Asking a family member to perform the dressing change and observing the procedure b. Asking a family member to identify the supplies needed to perform the dressing change c. Asking a family member to list the steps of the procedure for performing the dressing change d. Asking a family member to verbalize the procedure for performing the dressing change A. Return demonstration is the most reliable evaluation of procedure performance. Selection of equipment is included in a return demonstration. Asking a family member to list the steps for the procedure or to verbalize the procedure does not allow the nurse to observe the psychomotor skill needed to perform the procedure. 16. A nurse is teaching a client diagnosed with iron deficiency anemia about the foods that are high in iron. The nurse tells the client to consume which high-iron food? a. Refined white bread b. Egg whites c. Mushrooms d. Spinach D. The client with iron deficiency anemia should increase intake of foods that are naturally high in iron. The best sources of dietary iron are red meat; liver and other organ meats; blackstrap molasses; and oysters. Other good sources of iron are kidney beans, whole wheat bread, egg yolk, spinach, kale, beets, carrots, raisins, and apricots. 17. A clinic nurse provides instructions to a woman in the second trimester of pregnancy regarding measures to relieve backache. Which statement by the client indicates an understanding of these measures?

a. "I will sleep on a soft mattress." b. "I will avoid doing those pelvic tilt exercises." c. "I will avoid getting tired, and I should work at maintaining a good posture." d. "I will wear shoes with a heel of at least 2 inches." C. Backache can occur because of the exaggerated lumbar and cervicothoracic curves caused by the change in the center of gravity from the enlarging abdomen. The client should be instructed to sleep on a firm mattress, to avoid fatigue, and to maintain good posture and body mechanics. Pelvic tilt exercises decrease strain to muscles of the abdomen and lower back caused by the added weight of the abdomen and the shift in the center of gravity. Wearing high-heeled shoes will add to the strain on the muscles and will exaggerate the shift in the center of gravity. 18. A prenatal client reports heartburn, and the nurse provides instructions to the client regarding measures to alleviate the discomfort. Which statement by the client indicates a need for further instructions? a. "I need to eat small, frequent meals." b. "I need to avoid fatty or spicy foods." c. "I need to lie down after eating." d. "I need to drink approximately 2000 mL fluid per day." C. Heartburn is associated with regurgitation of gastric acid contents into the esophagus. Self-care measures for heartburn include eating small, frequent meals; avoiding fatty or spicy foods; remaining upright for 30 minutes after eating; and drinking approximately 2000 mL fluid per day. 19. During the administration of a blood transfusion to a client, the nurse notes the presence of crackles in the clients lung bases. On further assessment, the nurse notes that the client has distended neck veins and an increase in central venous pressure. The nurse suspects that the client is experiencing what complication of the blood transfusion? a. Transfusion reaction b. Allergic reaction c. Sepsis d. Circulatory overload D. Chest or lumbar pain, cyanosis, dyspnea, moist productive cough, crackles in the lung bases, distended neck veins, and an increase in central venous pressure are clinical indications of circulatory overload caused from excessive infusion amounts or too rapid of

an infusion rate. Clinical manifestations of sepsis include fever, abdominal cramps, nausea, vomiting, and diarrhea. A transfusion reaction and an allergic reaction are similar and can include manifestations such as flushing, itching, urticaria, tachycardia, and low back pain. 20. A client with type 1 diabetes mellitus has a blood glucose level of 554 mg/dL. The nurse calls the physician to report the level and monitors the client closely for which acid-base imbalance? a. Respiratory acidosis b. Respiratory alkalosis c. Metabolic acidosis d. Metabolic alkalosis C. Diabetes mellitus can lead to metabolic acidosis. When the body does not have sufficient circulating insulin, the blood glucose level increases. At the same time, the cells of the body use all available glucose. The body then breaks down glycogen and fat for fuel. The byproducts of fat metabolism are acidotic and can lead to the condition known as diabetic ketoacidosis. 21. A client is scheduled for a liver biopsy, and the nurse reviews the results of the laboratory tests prescribed for the client. The nurse would contact the physician if which laboratory result is noted? a. Platelets: 210,000/mm³ b. Thrombin time: 20 seconds c. Hematocrit: 40% d. Hemoglobin: 14 g/dL B. The normal thrombin time is 10 to 15 seconds. A prolonged time indicates that the client is at risk for bleeding. Coagulation profile tests are performed before a liver biopsy to ensure that the client is not at risk for bleeding as a result of the procedure. The laboratory results in options A,C, and D are within reference range. 22. A client who sustained an inhalation burn injury arrives in the emergency department. On assessment of the client, the nurse notes that the client is confused and combative. The nurse determines that the client is experiencing a. Anxiety b. Fear c. Hypoxia

d. Pain C. After a burn injury, clients are normally alert. If a client becomes confused or combative, hypoxia may be the cause. Hypoxia occurs after inhalation injury and may occur after an electrical injury. Options A, B, and D are not associated with the data in the question. 23. A nurse is reviewing the assessment data in the record of a client assigned to her care and notes documentation that the client has pallor. The nurse determines that this skin color variation is most likely caused by a. An increased amount of bilirubin deposits in the tissues b. An increased amount of deoxygenated hemoglobin associated with hypoxia c. A reduced amount of oxyhemoglobin from decreased blood flow d. An increased amount of melanin in the tissues C. Pallor, a decrease in skin color, is caused by a decreased amount of oxyhemoglobin resulting from decreased blood flow. Some causes of pallor include anemia or shock. Pallor can best be assessed in the face, conjunctivae, nail beds, palms of the hands, or lips. A bluish discoloration (cyanosis) is caused by an increased amount of deoxygenated hemoglobin associated with hypoxia. A yellow-orange skin discoloration (jaundice) is caused by an increased amount of bilirubin deposits in the tissues. A tan-brown skin color is caused by an increased amount of melanin in the tissues. 24. A nurse notes that a client's serum potassium level is 5.8 mEq/L. The nurse interprets that this is an expected finding in the client with which problem? a. Diarrhea b. Diabetes insipidus c. Burn injury d. Pulmonary edema being treated with loop diuretics C.A serum potassium level greater than 5.1 mEq/L indicates hyperkalemia, and the nurse would report the result to the physician. Burn injuries are a cause of hyperkalemia. Other common causes of hyperkalemia include adrenal insufficiency (Addison disease), renal failure, and the use of potassium-sparing diuretics. The client with diarrhea or diabetes insipidus or the client being treated with loop diuretics is at risk for hypokalemia. 25. The nurse is performing a neurovascular assessment on a client with a cast on the left lower leg and notes the presence of edema in the foot below the cast. The nurse would interpret that this finding indicates

a. Impaired arterial circulation b. The presence of an infection c. Impaired venous return d. Arterial insufficiency C. Edema in the extremity indicates impaired venous return. Signs of impaired arterial circulation in the limb include coolness and pallor of the skin and a diminished arterial pulse. Signs of infection under a cast area would include odor or purulent drainage from the cast, or the presence of hot spots, which are areas of the cast that are warmer than other areas. 26. A nurse reviews the assessment data on a client with a head injury and notes that the client's intracranial pressure reading is 10 mm Hg. On the basis of this finding, the nurse determines that the client's intracranial pressure reading a. Is increased b. Is normal c. Needs to be reduced with aggressive treatment measures d. Requires physician notification B. The normal intracranial pressure readings are between 0 and 15 mm Hg, and pressures greater than 20 mm Hg are considered to be increased. Therefore, options A, C, and D are incorrect. 27. A nurse is reviewing the laboratory results of a client with cancer and notes that the calcium level is 14 mg/dL. The nurse determines that this calcium level is consistent with which oncological emergency? a. Syndrome of inappropriate antidiuretic hormone (SIADH) b. Spinal cord compression c. Superior vena cava syndrome d. Hypercalcemia D. One potentially life-threatening complication of cancer is hypercalcemia, which is characterized by calcium levels greater than 11 mg/dL. Although spinal cord compression and superior vena cava syndrome also are oncological emergencies, they are not characterized by high calcium levels. SIADH also is an oncological emergency, but it is characterized by hyponatremia. 28. A nurse reviews a client's urinalysis report. The nurse determines that which finding is abnormal?

a. Opacity is clear. b. Specific gravity is 1.018. c. Ketones are negative. d. Protein is positive. D. The urine has a normal pH range of 4.5 to 8, and a specific gravity ranging from 1.002 to 1.035. Urine typically is screened for protein, glucose, ketones, bilirubin, casts, crystals, red blood cells, and white blood cells, all of which should be negative. 29. A client with chronic renal failure returns to the nursing unit after receiving his second hemodialysis treatment, and the nurse monitors the client closely for signs of disequilibrium syndrome. The nurse monitors for which sign of this syndrome? a. Irritability b. Mental confusion c. Tachycardia d. Hypothermia B. Disequilibrium syndrome most often occurs in clients who are new to hemodialysis. It is characterized by headache, mental confusion, decreasing level of consciousness, nausea, vomiting, twitching, and possible seizure activity. It results from rapid removal of solutes from the body during hemodialysis and a greater residual concentration gradient in the brain because of the blood-brain barrier. Water goes into cerebral cells because of the osmotic gradient, causing brain swelling and onset of symptoms. It is prevented by dialyzing for shorter times or at reduced blood flow rates. The signs in options 1, 3, and 4 are not associated with disequilibrium syndrome. 30. A home care nurse is assessing a client who has begun using peritoneal dialysis 1 week ago. The nurse would suspect the onset of peritonitis if which of the following is noted on assessment? a. Oral temperature of 99.0 F b. Anorexia c. Cloudy dialysate output d. Mild abdominal discomfort C. Typical symptoms of peritonitis include fever, nausea, malaise, rebound abdominal tenderness, and cloudy dialysate output. The slight temperature increase in option 1 is not the clearest indicator of infection. The complaint of anorexia is too vague to indicate

peritonitis. Some mild abdominal discomfort may occur initially with peritoneal dialysis.

General Nursing Board 101 Fundamentals Pre-Test 2 http://nsgbrd101.proboards.com/index.cgi?board=answers&action=display&thread=3 Fundamentals Pre-Test 2 Post by admin on Aug 18, 2010, 12:46pm 1. A nurse is reviewing the diagnostic tests prescribed for a client. The nurse notes that a lupus cell preparation (LE cell prep) has been ordered. The nurse determines that this test is used to screen primarily for which of following disorders? a. Histoplasmosis b. Systemic lupus erythematosus (SLE) c. Human immunodeficiency virus (HIV) d. Progressive systemic sclerosis B. The LE cell prep may be performed on a client suspected of having SLE, or to screen for progressive systemic sclerosis. However, it is primarily used to screen for SLE. The other options are not associated with this diagnostic test. 2. The nurse is caring for a hospitalized client with acquired immunodeficiency syndrome (AIDS) who is receiving didanosine (Videx). The nurse contacts the physician if which laboratory result is noted that may be an indication of potential pancreatitis? a. Increased potassium b. Increased serum triglycerides c. Increased blood urea nitrogen d. Increased creatinine B. An increased triglyceride or amylase level may indicate pancreatitis from the medication, which can be potentially fatal. If this occurs, the medication may have to be discontinued. The medication is also hepatotoxic and can result in liver failure. Options 3 and 4 relate to renal function and are not associated with this medication. This medication may decrease potassium. 3. A client seeks treatment for a fractured radius. There is an open wound on the arm through which jagged bone edges protrude. The nurse determines that the client has a a. Greenstick fracture b. Comminuted fracture c. Open fracture

d. Simple fracture C. An open fracture (compound fracture) is one in which the skin has been broken and the wound extends to the depth of the fractured bone. A greenstick fracture is an incomplete fracture, which occurs through part of the cross section of a bone; one side of the bone is fractured, and the other side is bent. A comminuted fracture is a complete fracture across the shaft of a bone, with splintering of the bone into fragments. A simple fracture is a fracture of the bone across its entire shaft, with some possible displacement but without breaking the skin. 4. The client has been admitted to the hospital with a fractured pelvis sustained in a motor vehicle accident. The nurse monitors for complications and assesses the client most closely for which of the following complications in the early post-trauma period? a. Bradycardia b. Pain c. Hematuria d. Fever C. One complication of a pelvic fracture is damage to the kidneys and lower urinary tract. Therefore, the nurse would monitor for signs of this complication, which would include bloody urine. This client is also at risk for hypovolemic shock. Bone fragments can damage blood vessels, leading to hemorrhage into the abdominal cavity and the thigh area. Signs of hypovolemic shock include tachycardia and hypotension. Although infection is also a complication (indicated by a fever), it is not generally noted in the early post-trauma period. 5. The nurse is monitoring a client with a head injury for signs of increased intracranial pressure. Which finding indicates an early sign of increased intracranial pressure? a. Increase in systolic blood pressure b. Decreasing level of consciousness c. Shallow, slow respirations d. Decrease in pulse rate B. Decreasing level of consciousness is the earliest and most sensitive sign of increased intracranial pressure. Other early signs include headache that increases in intensity with coughing or straining; pupillary changes such as dilation with slowed constriction, visual disturbances such as diplopia, and ptosis; and contralateral motor or sensory losses. Options 1, 3, and 4 indicate late signs of increasing intracranial pressure. 6. The nurse is performing an assessment on a client with a diagnosis of Bells palsy. The nurse would expect to observe which of the following symptoms in the client? a. Twitching on the affected side of the face

b. Ptosis of the eyelid and closure of the eye c. Facial drooping d. Periorbital edema C. Bells palsy is a one-sided facial paralysis caused by the compression of the facial nerve (cranial nerve VII). There is facial droop from paralysis of the facial muscles; increased lacrimation; painful sensations in the eye, face, or behind the ear; and speech or chewing difficulty. Options 1, 2, and 4 are not associated findings in Bells palsy. 7. A client with a diagnosis of multiple myeloma is admitted to the hospital. On assessment, the nurse asks the client which question that specifically relates to a clinical manifestation of this disorder? a. "Are you having any bone pain?" b. "Do you have diarrhea?" c. "Have you noticed an increase in appetite?" d. "Do you have feelings of anxiety and nervousness, together with difficulty sleeping?" A. Multiple myeloma is characterized by an abnormal proliferation of plasma B cells. These cells infiltrate the bone marrow and produce abnormal and excessive amounts of immunoglobulin. The most common presenting symptom is bone pain. Hypercalcemia occurs as a result of release of calcium from the deteriorating bone tissue; subsequently, the client experiences confusion, somnolence, constipation, nausea, and thirst. 8. The nurse is preparing to care for a client with a diagnosis of metastatic cancer and notes documentation in the clients chart that the client is experiencing cachexia. Which of the following would the nurse expect to note on assessment of the client? a. Sunken eyes and a hollow cheek appearance b. Periorbital edema and swelling around the ears c. Generalized edema and the presence of weight gain d. Increased blood pressure and ascites A. A cachexia condition indicates a chronic wasting of the body. Cachexia accompanies chronic wasting diseases such as cancer, dehydration, and starvation. Assessment findings in a client with cachexia include sunken eyes, hollow cheeks, and an exhausted, defeated expression. Options B, C, and D are not characteristics of a cachexia appearance. 9. A nurse is caring for a client receiving hemodialysis who has an internal arteriovenous fistula. The nurse expects to note which finding if the fistula is patent? a. White fibrin specks noted in the fistula b. Palpation of a thrill over the site of the fistula c. Lack of a bruit at the site of the fistula

d. Warmth and redness at the site of the fistula B. An internal arteriovenous fistula is created through a surgical procedure in which an artery in the arm is anastomosed to a vein. The fistula is internal. To determine patency, the nurse palpates over the fistula for a thrill and auscultates for a bruit. The nurse would not note white fibrin specks in the fistula, because the fistula is internal. Warmth and redness may indicate a potential inflammatory process. 10. A physician's office nurse is assessing a client who recently had a renal transplant. The nurse monitors for which signs of acute graft rejection? a. Hypotension, graft tenderness, and anemia b. Hypertension, oliguria, thirst, and hypothermia c. Fever, vomiting, hypotension, and copious amounts of dilute urine d. Fever, hypertension, graft tenderness, and malaise D. Acute rejection usually occurs within the first 3 months after transplantation, although it can occur for up to 2 years after transplantation. The client exhibits fever, hypertension, malaise, and graft tenderness. Options A, B, and C do not completely identify signs of acute rejection. 11. A nurse is caring for a client with a tracheostomy tube who is receiving mechanical ventilation. The nurse is monitoring for complications related to the tracheostomy and suspects tracheoesophageal fistula when a. Suctioning is required frequently b. Excessive secretions are suctioned from a tracheostomy c. The clients skin and mucous membranes are light pink d. Aspiration of gastric contents occurs during suctioning D. Necrosis of the tracheal wall can lead to an artificial opening between the posterior trachea and esophagus. This problem is called tracheoesophageal fistula. The fistula allows air to escape into the stomach, causing abdominal distension. It also causes aspiration of gastric contents. Options 1, 2, and 3 are not signs of this complication. 12. A nurse is performing a cardiovascular assessment on a client with heart failure. Which of the following items would the nurse assess to gain the best information about the clients left-sided heart function? a. Breath sounds b. Peripheral edema c. Jugular vein distention d. Hepatojugular reflux A. The client with heart failure may present with different symptoms depending on whether

the right or the left side of the heart is failing. Peripheral edema, jugular vein distention, and hepatojugular reflux are all indicators of right-sided heart function. Breath sounds are an accurate indicator of left-sided heart function. 13. A nurse suctioning a client through an endotracheal tube monitors the client for complications associated with the procedure. Which of the following indicates a complication? a. A blood pressure of 138/88 mm Hg b. An irregular heart rate c. A reddish coloration in the client's face d. A pulse oximetry level of 95% B. The client should be monitored closely for complications related to suctioning, including hypoxemia, cardiac irregularities resulting from vagal stimulation, mucosal trauma, and paroxysmal coughing. If complications occur during the procedure, especially cardiac irregularities, the procedure is stopped, and the client is reoxygenated. 14. An emergency department nurse is assessing a client who sustained a blunt chest injury and suspects the presence of flail chest. Which specific characteristic finding would the nurse note in this condition? a. Slow deep respirations b. Asymmetric chest movement c. Loss of consciousness d. Anxiety B. Flail chest is a thoracic injury resulting in paradoxical (asymmetric) motion of the chest wall segments. The client also exhibits severe chest pain; oscillation of the mediastinum; increasing dyspnea; rapid, shallow respirations; accessory muscle breathing; decreased breath sounds on auscultation; and cyanosis. Although the client may exhibit anxiety related to difficulty breathing, anxiety can occur in any respiratory disorder in which dyspnea is a problem. Loss of consciousness can occur with a head injury, or if the respiratory condition deteriorated significantly. 15. A nurse is caring for a client with a tracheostomy tube and is monitoring the client for subcutaneous emphysema. The nurse identifies this complication by noting which of the following? a. Crackling sounds heard in the upper lobes bilaterally b. A puffy and crackling sensation on palpation of the tissues surrounding the tracheostomy site c. Signs of respiratory distress

d. Dyspnea B. Subcutaneous emphysema occurs when air escapes from the tracheostomy incision into the tissues, dissects fascial planes under the skin, and accumulates around the face, neck, and upper chest. These areas appear puffy, and slight finger pressure produces a crackling sound and sensation. Generally, this is not a serious condition, because the air eventually will be absorbed. Options 1, 3, and 4 are not signs of subcutaneous emphysema, but they could be signs of other complications. 16. A nurse is monitoring a client with a tracheostomy tube for complications related to the tube. The nurse suspects tracheoesophageal fistula if which of the following is noted? a. Abdominal distention b. Excess mucus production c. Abnormal skin and mucous membrane color d. Use of accessory muscles to assist with breathing A. Necrosis of the tracheal wall can lead to an artificial opening between the posterior trachea and esophagus. This problem is called tracheoesophageal fistula. The fistula allows air to escape into the stomach, causing abdominal distention. It also causes aspiration of gastric contents. Options 2, 3, and 4 are not findings associated with this complication. 17. A nurse is assessing a client who was treated for an asthma attack. The nurse determines that the client's respiratory status has worsened if which of the following is noted? a. Loud wheezing b. Wheezing during inspiration and expiration c. Wheezing on expiration only d. Diminished breath sounds D. Diminished breath sounds are an indication of obstruction and possible impending respiratory failure. Wheezing is not a reliable manifestation to determine the severity of an asthma attack. For wheezing to occur, the client must be able to move sufficient air to produce breath sounds. The client with a severe asthma attack may have no audible wheezing because of the decrease of airflow. Clients may experience loud wheezes with minor attacks, whereas others may not wheeze with severe attacks. Wheezing usually occurs first on expiration. The client may wheeze during both inspiration and expiration as the asthma attack progresses. 18. A nurse is reviewing the assessment findings and laboratory results of a child diagnosed with new-onset glomerulonephritis. Which of the following findings would the nurse most likely expect to note?

a. Increased creatinine levels b. Hypotension c. Low serum potassium d. Tea-colored urine D. Gross hematuria resulting in dark brown or smoky, tea-colored urine is a classic symptom of glomerulonephritis. Hypertension also is a common finding in glomerulonephritis. Blood urea nitrogen and creatinine levels are increased only when there is an 80% decrease in glomerular filtration rate and renal insufficiency is severe. A high potassium level results from inadequate glomerular filtration. 19. A nurse is reviewing the record of an infant admitted to the newborn nursery. The nurse notes that the physician has documented bladder exstrophy. On assessment of the infant, the nurse expects to note which of the following? a. Undescended or hidden testes b. The opening of the urethral meatus below the normal placement on the glans penis c. The opening of the urethral meatus on the ventral side of the glans penis d. The urinary bladder on the outside of the body D. Bladder exstrophy is a congenital anomaly characterized by the extrusion of the urinary bladder to the outside of the body through a defect in the lower abdominal wall. Option 1 describes cryptorchidism. Option 2 describes hypospadias. Option 3 describes epispadias. 20. A newborn infant with a diagnosis of subdural hematoma is admitted to the newborn nursery. The nurse does which of the following to assess for the major symptom associated with subdural hematoma? a. Checks for contractures of the extremities b. Tests for equality of extremities when stimulating reflexes c. Monitors the urinary output pattern d. Monitors the urine for blood B. A subdural hematoma can cause pressure on a specific area of the cerebral tissue. This can, especially if the infant is actively bleeding, cause changes in the stimuli responses in the extremities on the opposite side of the body. Option A is incorrect because contractures would not occur this soon after delivery. Options C and D are incorrect. An infant, after delivery, would normally be incontinent of urine. Blood in the urine would indicate abdominal trauma and would not be a result of the hematoma. 21. A nurse notes documentation in a client's medical record that the client is experiencing

anuria. On the basis of this notation, the nurse determines that the client a. Is unable to produce urine b. Has a diminished capacity to form urine c. Has difficulty having a bowel movement d. Has episodes of alternating constipation and diarrhea A. Anuria is the term used to describe an inability to produce urine. Oliguria is a diminished capacity to form urine and is most likely the result of a decrease in renal perfusion. Options C and D do not relate to urinary tract dysfunction. 22. A nurse is caring for a client who has a fever and is diaphoretic. The nurse monitors the client's intake and output and expects that a. The client's output will be decreased. b. The client's urine will be dilute. c. The client's urine production will be increased. d. The majority of the client's fluid will be excreted through the skin. A. Febrile conditions affect urine production. The client who is diaphoretic loses fluids through insensible water loss, which decreases urine production. However, the increased body temperature associated with fever increases accumulation of body wastes. Although urine volume may be reduced, it is highly concentrated. Options B, C, and D are incorrect. 23. A nurse is monitoring a client for signs and symptoms of hypocalcemia. Which of the following symptoms is an indication of this electrolyte imbalance? a. Lethargy b. Depressed sensorium c. Confusion d. Irritability B. Most of the clinical manifestations of hypocalcemia are related to neuromuscular hyperexcitability. These can include numbness and tingling of the hands, toes, and lips and emotional lability such as irritability and anxiety. Positive Trousseaus or Chvosteks sign also are present. Options A, B, and C are signs of hypercalcemia. 24. A female client is suspected of having a vaginal infection caused by the organism Candida albicans. Which assessment question would elicit data associated with this infection? a. Do you have any blood in your urine? b. Have you noticed any swelling in your feet? c. Have you had any flank pain or headaches? d. Have you had any vaginal discharge?

D. Clinical manifestations of a Candida infection include vaginal pain, itching, and a thick, white vaginal discharge. Hematuria, flank pain, and headache are clinical manifestations associated with urinary tract infections. Edema is not associated with a vaginal infection. 25. A client with sickle cell disease is admitted to the hospital with vaso-occlusive crisis. The nurse assesses the client for which most frequent manifestation of the disorder? a. Low-grade fever b. Pain c. Leukopenia d. Blurred vision B. A vaso-occlusive crisis has a sudden onset and results in severe pain in the long bones, joints, chest, back, and abdomen. The face may also be involved. Fever and leukocytosis are also manifestations. Blurred vision is not specifically associated with this condition. 26. The nurse monitors for which acid-base disorder that can most likely occur in a client with an ileostomy? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis A. Intestinal secretions are high in bicarbonate because of the effects of pancreatic secretions. These fluids may be lost from the body before they can be reabsorbed with conditions such as diarrhea or creation of an ileostomy. The decreased bicarbonate level creates the actual base deficit of metabolic acidosis. The client with an ileostomy is not at risk for development of the acid-base disorders identified in options B, C, and D. 27. A hospitalized client with a peripheral intravenous (IV) line calls the nurse and reports that the IV site is painful. The nurse assesses the IV site and notes that it is cool and pale, and that the IV has stopped flowing. The nurse determines that which of the following effects has probably occurred? a. Infiltration b. Phlebitis c. Thrombosis d. Infection A. An infiltrated IV is one that has dislodged from the vein and is lying in subcutaneous tissue. The pallor, coolness, and swelling are the result of IV fluid being deposited in the subcutaneous tissue. When the pressure in the tissues exceeds the pressure in the tubing, the flow of the IV solution will stop. The corrective action is to remove the catheter and

insert a new IV line. The other three options are likely to be accompanied by warmth, not coolness, at the site. 28. A client in the second trimester of pregnancy is admitted to the maternity unit with a diagnosis of abruptio placentae. The nurse expects to note which clinical manifestation associated with this disorder? a. Painless vaginal bleeding b. Soft, relaxed uterus with normal tone c. Uterine hypertonicity d. Nontender uterus C. In abruptio placentae, abdominal pain, uterine tenderness, and uterine hypertonicity are present. Uterine tenderness accompanies placental abruption, especially with a central abruption in which blood becomes trapped behind the placenta. The abdomen will feel hard and boardlike on palpation as the blood penetrates the myometrium and causes uterine irritability. Excessive uterine activity with poor relaxation between contractions is present. Observation of the fetal monitoring often reveals loss of variability and late decelerations, uterine hyperstimulation, and increased resting tone. Painless, bright red vaginal bleeding; a soft, relaxed uterus with normal tone; and a nontender uterus are signs of placenta previa. 29. An antepartum client is diagnosed with bacterial vaginosis. The nurse expects to note which of the following on assessment of the client? a. Hematuria and hypertension b. Itching and vaginal discharge c. Proteinuria and hematuria d. Costovertebral angle pain B. Clinical manifestations of bacterial vaginosis include pain, itching, and a thick, white vaginal discharge. Proteinuria, hematuria, hypertension, and costovertebral angle pain are clinical manifestations associated with urinary tract infections. 30. A nurse receives a report at the beginning of the shift about a client with an intrauterine fetal demise. On assessment of the client, the nurse expects to note which of the following? a. Increased blood pressure, proteinuria, and edema b. Regression of pregnancy symptoms and absence of fetal heart tones c. Uterine size greater than expected for gestational age d. Intractable vomiting and dehydration B. Symptoms of a fetal demise include a decrease in fetal movement, no change or a decrease in fundal height, and absent fetal heart tones. In addition, many symptoms of the

pregnancy may diminish, such as breast size and tenderness. Option A is associated with preeclampsia. Option D is associated with hyperemesis gravidarum.

General Nursing Board 101 PREBOARD Nursing Practice 1 http://nsgbrd101.proboards.com/index.cgi?board=answers&action=display&thread=17 PREBOARD Nursing Practice 1 Post by admin on Aug 18, 2010, 1:35pm 1. The nurse is preparing to move an adult who has right-sided paralysis from the bed to the wheelchair. Which statement describes the best action for the nurse to take? a. position the wheelchair on the left side of the bed b. keep the head of the bed elevated at 10o c. protect the clients left arm with a sling during the transfer d. bend at the waist while helping the client into a standing position ANSWER A: Place the wheelchair beside the bed, on the clients strongest side so that it faces the foot of the bed. The head of the bed should be in an upright position. There is no need to place special protection to the unaffected arm during the transfer. The nurse should always bend at the knees not at the waist. 2. Which statement by the nurse best indicates a correct understanding of log rolling when moving a client? a. one nurse may perform this task alone b. pillows are needed for positioning in order to provide support c. the legs should be moved before the head is moved d. keeping the neck in a straight position is the primary concern ANSWER B: A pillow should be placed between the knees/legs for support while the client is being turned. It takes two or three nurses to do log rolling. The whole spinal column should be kept straight and the entire body moved at once. 3. The nurse is caring for a client who has temperature of 105oF (40.50C). The physician orders the application of a cooling blanket. The nurse should know that which of the following statements is true about the use of a cooling blanket? a. cold application will increase the metabolic rate b. vital signs should be monitored every 8 hours c. the client should remain in one position to conserve energy d. skin hygiene and protection of body surface areas is essential ANSWER D: Cold application lowers the metabolic rate and causes vasoconstriction in the area. Therefore, assessment of the skin, protection of the skin surfaces with oil, and repositioning are all vital to prevent skin breakdown. The temperature will be monitored continually with a rectal probe and blood pressure, pulse, and respirations will be monitored frequently. 4. The nurse is preparing to administer a sponge bath to an infant with a high fever. Administration of the bath should include: a. large amounts of alcohol to increase evaporation of heat b. adjustment of the water temperature to 60-70 0F c. wet clothes applied to all areas where blood circulates close to skin surfaces d. small areas of the body sponged at a time to avoid rapid heat loss ANSWER C: Wet clothes should be applied to forehead, ankles, wrists, axilla and groin. These are the areas where blood circulates closest to the skin surface. If alcohol is used, small amounts are indicated. Large amounts of alcohol are very drying to the skin and toxic to inhale. The temperature should be 85-100 degrees F. Rapid heat loss is desired so large areas of body are sponged. 5. The nurse is instructing the family of a homebound bedridden client in the general prevention of pressure sores. Measures to include in the teaching include: a. promoting lifting rather than dragging when turning the client b. massaging directly over pressure sites c. changing the clients position every 4 hours d. cleaning soiled areas with hot water

ANSWER A: Promoting lifting rather than dragging when turning or moving the client will reduce friction and shearing. This will assist in preventing pressure sores. The caregiver should massage around but not directly over pressure sites. The clients position should be changed every 2 hours. Soiled areas should be cleaned with warm not hot water. 6. Which of the following findings would the nurse note when assessing a client with Stage I pressure ulcer? The ulcer displays: a. superficial skin breakdown c. subcutaneous damage or necrosis b. deep pink, red, or mottled skin d. damage to muscle or bone ANSWER B: Stage I pressure ulcers show discoloration of skin to deep pink, red or mottled appearance. Temporary blanching of the area from pressure can last several minutes due to poor circulation in the area. Choice I, superficial skin breakdown, is a characteristic of stage II. Choice 3, subcutaneous damage or necrosis is a characteristic of Stage II pressure ulcer. Choice 4, damage to muscle or bone, is characteristic of a stage 4 pressure ulcer. 7. An adult has developed a Stage II pressure ulcer. He is scheduled to receive wet to dry dressings every shift. The nurse realizes that the purpose of receiving this type of dressing is to: a. draw in wound exudate and decrease bacteria b. debride slough and eschar c. promote healing by gas exchange d. promote a moist environment and soften exudate ANSWER B: In a wet to dry dressing, the wet gauze dressing either covers the wound or is packed into the wound and is covered with a dry dressing. The dry layer creates a wick and pulls moisture from the wound, thus debriding slough and bacteria. Answer A is not correct because the exudate ids drawn out not in. 8. The nurse is performing a wound irrigation and dressing change. Which action, when taken by the nurse, would be a break in the technique? a. consistently facing the sterile field b. washing hands before opening the sterile set c. opening the bottle of irrigating solution and pouring directly into a container on the sterile field d. opening the sterile set so that the initial flap is opened away from the nurse ANSWER C: After opening a sterile bottle the edge of the bottle is considered to be contaminated. The nurse should pour a little solution out first to wash away organisms on the lip of the opening and then pour from the same side of the bottle into the sterile container on the sterile field. The nurse should always face the sterile field. Hands should be washed before opening the sterile set. The sterile set should be opened so that the initial flap is opened away from the nurse. This means that the final flap will be opened toward the nurse and the nurse will be opened toward the nurse and the nurse will not have to reach across the sterile field. 9. Total Parenteral Nutrition (TPN) is ordered for an adult client. The nurse expects the solution will contain all of the following nutrients except: a. dextrose 10% c. electrolytes b. trace minerals d. amino acids ANSWER A: The conc. of dextrose in TPN solutions is at least 30 % Trace minerals such as zinc, copper, chromium, and manganese are usually added. Electrolytes and amino acids are part of TPN solutions. 10. The nurse caring for an adult client who is receiving TPN will need to monitor him for which of the following metabolic complications: a. hypocalcemia and hypercalcemia c. hyperglycemia and hyperkalemia b. hyperglycemia and hypokalemia d. hyperkalemia and hypercalcemia ANSWER B: Metabolic complications from administration of TPN include hyperglycemia, hypoglycemia, hypocalcemia, hypokalemia, hypomagnesemia, hyponatremia and hypophosphatemia. Hyperglycemia is the most common complication of TPN. Hypoglycemia can occur when TPN is suddenly withdrawn. Electrolyte deficiencies can occur. The addition of electrolytes is individualized based on the clients metabolism and on the underlying condition. 11. The nurse is caring for a client who is receiving IV fluids. Which observation the nurse makes best indicates the IV has infiltrated? a. pain at the site b. a change in flow rate c. coldness around the insertion site ANSWER C: Coldness and swelling around the insertion site are the best indicators that the fluid has infiltrated into the subcutaneous tissue. Pain at the site can be a sign of phlebitis. A change in the flow rate

can also be a sign of an infiltrated IV. Redness around the insertion site is a sign of phlebitis. 12. Within 20 minutes of the start of transfusion, the client develops a sudden fever. The most appropriate initial response by the nurse is to: a. force fluids c. increase the flow rate of IV fluids b. continue to monitor the vital signs d. stop the transfusion ANSWER D: Sudden development of fever during a blood transfusion may be indicative of a pyrogenic reaction. The most appropriate nursing action is to discontinue the blood flow to prevent a more severe reaction. The nurse will continue to monitor the vital signs; however this is not the initial action. Forcing fluids and increasing the flow rate of IV fluids may be appropriate at a later time if hypotension occurs. 13. The nurse is caring for a client who has had a chest tube inserted and connected to water seal drainage. The nurse determines the drainage system is functioning correctly when which of the following is observed? a. continuous bubbling in the water seal chamber b. fluctuation in the water seal chamber c. suction tubing attached to a wall unit d. vesicular breath sounds throughout the lung fields ANSWER B: Fluctuation in the water seal chamber demonstrates that the tubing system is patent. Bubbling in the water seal is normal only if it is gentle and occasional. Vigorous bubbling indicates that air is being pulled into the system and is not normal. The fact that suction tubing is attached to a wall unit provides no information about function. Vesicular breath sounds should not be heard in the upper chest. 14. The nurse is caring for a client who has just had a chest tube attached to a water seal drainage system. To ensure that the system is functioning effectively the nurse should: a. observe for intermittent bubbling in the water seal chamber b. flush the chest tubes with 30-60 ml of NSS every 4-6 hours c. maintain the client in an extreme lateral position d. strip the chest tubes in the direction of the client ANSWER A: Intermittent bubbling in the water seal chamber indicates that air is leaving the thoracic cavity. If there is no bubbling in the water seal chamber, it indicates either obstruction of the tubing or reexpansion of the lungs. Reexpansion of the lung is unlikely, as the tube has just been inserted. 15. The nurse enters the room of a client who has a chest tube attached to a water seal drainage system and notices the chest tube is dislodged from the chest. The most appropriate nursing intervention is to: a. notify the physician b. insert a new chest tube c. cover the insertion site with petroleum gauze d. instruct the client to breathe deeply until help arrives ANSWER C: Covering the insertion site with petroleum gauze is a priority nursing measure that prevents air from entering the chest cavity. Notifying the physician should be done after covering the insertion site. Inserting a chest tube is not a nursing action. Instructing the client to deep breathe will cause air to enter the chest cavity. 16. A patient is ordered oxygen via nasal prongs. The nurse administering oxygen via this low-flow system recognizes that this method of delivery: a. mixes room air with oxygen b. delivers a precise concentration of oxygen c. requires humidity during delivery d. is less traumatic to the respiratory tract ANSWER A: Low-flow oxygen systems provide an oxygen concentration that is determined by the amount of air drawn into the system and the dilution of oxygen from room air. There is a considerable variation in the concentration of oxygen that can be delivered to the client. Not all systems require humidification. Oxygen therapy given in short-term basis is usually not traumatic to the respiratory tract. 17. An adult is receiving oxygen by nasal prongs. Which statement by the client indicates that the client teaching regarding oxygen therapy has been effective? a. I was feeling fine so I removed my nasal prongs. b. Ive increased my fluids to six glasses of water daily. c. Dont forget to come back quickly when you get me out of bed; I dont like to be without my oxygen for too long. d. My family was angry when I told them they could not smoke in my room. ANSWER D: Oxygen is a flammable gas and smoking is not permitted in the area. Compliance with the

prescription for oxygen therapy is extremely important to prevent the fluctuation of oxygen levels. 18. An adult client has a nasogastric tube in place to maintain gastric decompression. Which nursing action will relieve discomfort in the nostril with the NG tube? a. remove any tape and loosely pin the tube to his gown b. lubricate the NG tube with viscous xylocaine c. loop the NG tube to avoid pressure on the nares d. replace the NG tube with a smaller diameter tube ANSWER C: Looping the NG tube will prevent pressure on the nares that can cause and eventual necrosis. Pinning the tube to the clients gown would cause irritation of the nares each time he moved and might cause dislocation of the tube. 19. An adult client has just returned to his room following a bowel resection and end-to-end anastomosis. The nurse can expect the drainage from the NG tube in the early post-op period to be: a. Clear c. Scant b. Mucoid d. Discolored ANSWER D: The drainage following abdominal surgery is discolored as it is evacuating stomach and intestinal contents, not mucoid material. There is a significant amount of drainage. 20. The physician inserts a central venous catheter; the nurse should assist the client to assume which of the following positions? a. supine c. reverse trendelenburgs b. trendelenburgs d. high fowlers ANSWER B: The client is placed in Trendelenburg position to aid in the filling of the subclavian veins. The rest do not. 21. The major dietary treatment for ascites calls for: a. high protein c. restricted fluids b. increased potassium d. restricted sodium ANSWER D: Sodium restriction is most important for a client with cirrhosis because fluid retention contributes to ascites. A high protein diet is contraindicated because increased protein in the intestine causes elevated ammonia levels. The diseased liver is unable to convert ammonia to urea, thereby leading to possible signs of hepatic encephalopathy. Increased potassium would not be indicated because advancing cirrhosis could lead to hepato-renal disease with resultant renal retention of potassium. Fluids would probably be restricted but sodium restriction is more important. 22. The nurse is to give medication to an infant. What is the best way to assess the identity of the infant? a. ask the mother what the childs name is b. look at the sign above the bed that states the clients name c. compare the bed number with the bed number of the care plan d. compare the ankle band with the name on the care plan ANSWER D: Making sure that the clients name is the same as the name on the medication plan is the only safe way to administer the medications 23. The nurse is caring for a client who has been placed in cloth wrist restraints. To ensure the clients safety, the nurse should: a. remove the restraints every 2 hours and inspect the wrists b. wrap each wrist with gauze dressing beneath the restraints c. keep the head of the bed flat at all times d. tie the restraints using a square knot ANSWER A: Wrists must be inspected for signs of skin breakdown or trauma. B, wrist restraints are soft and padded already; no further padding is necessary. C, position of the bed has no relationship to safety with use of restraints. D, Method for tying restraints is important for ease of removal, but does not in itself, affect safety. 24. The nurse is preparing a client for IVP tomorrow. The client ells the nurse that she gets a rash and becomes short of breath after eating lobster. Given this information, the nurse knows that the client: a. should be visited by a dietitian while in the hospital b. is not a candidate for IVP c. is at risk for an allergic reaction d. will require an antihistamine before her IVP ANSWER C: People who are allergic to shellfish, iodine, are at risk for allergic reactions to the contrast

material iodine, used for an IVP. 25. The nurse is caring for a client who is to have a lumbar puncture. How should the client be positioned during the procedure? a. prone with head turned to the left b. side lying in a fetal position c. sitting at the edge of the bed d. Trendelenburg position ANSWER B: The fetal position, fetal, increases space between lumbar vertebrae facilitating easier entry of the needle into the subarachnoid space. 26. An adult client has a central line placed for IV fluids. When the nurse enters the room the IV bag is dry, the IV line is full of air, and the client is dyspneic. What is the best initial nursing action? a. notify the physician and administer oxygen via nasal cannula immediately b. hang another IV bag as soon as possible, then remove the air from the IV line c. clamp the tubing and place the client on the left side with head down d. begin CPR and call the code team ANSWER C: Air embolism occurs frequently with central lines with sudden onset of dyspnea, hypotension, chest pain, and cyanosis. The best initial nursing action is to clamp the IV line and turn the client to the left side to trap the air in the right side of the heart so it does not enter the pulmonary artery. Then call the physician and administer oxygen. 27. An adult client is to receive a unit of whole blood. The clients vital signs before starting the transfusion are BP 120/70, P 80, and T 98.40F. Five minutes after the transfusion was started the vital signs are BP 100/70, P100 and T 99.40F. What should the nurse do initially? a. slow down the rate of the transfusion, reassess the client in 15 minutes b. stop the transfusion, keep vein open with normal saline c. slow down the infusion, notify the physician immediately d. administer acetaminophen (Tylenol), continue to monitor closely throughout the transfusion ANSWER B: The symptoms suggest transfusion reaction. The priority nursing action for a client with symptoms of an acute hemolytic reaction to a blood transfusion is to stop the transfusion immediately. Other signs suggesting transfusion reaction include chills, increased respiration, flushing, low back or thigh pain, headaches, pleuritic chest pain, dyspnea and abnormal bleeding, hemoglobinuria and shock. 28. The nurse is administering medication in an extended care facility. What is the best way for the nurse to correctly identify the client before administering the medications? a. check with picture identification on the file b. check the arm band c. check the name on the bed d. check the name on the room door ANSWER A: Having a picture ID for each resident allows the nurse to positively identify the client. This helps to decrease errors in a population that may not always be able to respond appropriately. 29. A client is scheduled to undergo an exploratory laparotomy in one hour. The nurse has just received the order to administer his pre-operative medication. What assessment is essential for the nurse before administering the medication? a. the clients ability to cough and deep breathe b. any drug hypersensitivity or allergy c. the patient's understanding of the surgical procedure d. whether patient's family is present and supportive ANSWER B: A complete drug history on every perioperative client is essential because of potential reactions to drugs. Drug hypersensitivity and allergic reactions must be assessed before preoperative medications are administered. 30. An adult client has been on bed rest for several months. Which statement best describes the relationship between complications of prolonged bed rest and nursing interventions to prevent these complications? a. turning and positioning will help decrease the potential for calcium loss from bones b. adequate fluid intake is vital to decrease the risk of brittle bones c. leg exercises are important to decrease the loss of calcium from the bones and the risk of pathological fractures d. encouraging milk intake will help decrease the loss of calcium from the bones ANSWER C: Leg exercises are important to help prevent calcium loss from the bones. The ideal exercises will

have some resistance or weight bearing as tolerated. 31. The nurse is inserting an indwelling urinary catheter. Which action is essential to decrease the complications associated with catheter insertion? a. cleanse the female client using betadine-soaked 4x4s, cleaning from the rectal area to the clitoris b. utilizing a catheter that is slightly larger than the external urinary meatus c. utilize clean technique d. test the retention balloon prior to insertion ANSWER D: The balloon should be checked for inflation and leaks prior to insertion, preventing repeated catheterization if the balloon fails. 32. The nurse is caring for an adult client who is scheduled for an intravenous pyelogram (IVP). Which nursing intervention is essential? a. encourage large amounts of fluids prior to the test b. assess for any indications of allergies c. administer a laxative d. restrict fluids only in clients with marginal renal reserve or uncontrolled diabetes ANSWER B: The client should be assessed for allergic reactions to iodine shellfish allergy or previous allergic reaction to contrast dye materials. 33. The nurse is caring for a client who has a nasogastric tube attached to low wall suction. The suction is not working. Which is the nurse least likely to note when assessing the client? a. client vomits b. client has a distended abdomen c. there is no nasogastric output in the last two hours d. large amounts of nasogastric output ANSWER D: If the nasogastric suction is not working, the nurse would not expect to see large amounts of nasogastric output. 34. A client who has ascites is admitted to the hospital and will be undergoing a paracentesis. What should be included in the nursing care plan? a. monitor client closely for evidence of vascular collapse b. place client in Trendelenburg position for the procedure c. encourage client to drink plenty of fluids to distend the bladder prior to the procedure d. have client remain on bed rest for 24 hours following the procedure ANSWER A: Removing large amounts of fluid may cause hypotension leading to vascular collapse. The client should be monitored closely for decrease in blood pressure, increase in pulse and pallor. 35. A patient underwent an exploratory laparotomy two days ago. The physician has just written an order for a soft diet. The nurse assessed the client and did not hear bowel sounds in any quadrant. What is the best nursing action? a. follow the physicians order and feed the client b. cancel the physicians order and make the client NPO c. order clear liquids for the client d. notify the physician that the client does not have bowel sounds at this time ANSWER D: Solid food should not be given until the client has bowel sounds. The nurse should notify the physician of the assessment findings prior to feeding this client. 36. Your patient is receiving O2 at 2 liters per nasal cannula. His roommate lights a cigarette and tosses the match catching the curtain on fire. What is the priority action for the nurse? a. turn off the oxygen c. try to extinguish the fire b. sound the fire alarm d. remove the clients from the room ANSWER A: Oxygen itself does not burn, but supports combustion, so a fire burns more readily in the presence of oxygen. If the client is not engulfed in flames, the nurses priority action should be to turn off the oxygen. 37. An 84-year-old male patient has been bedridden for two weeks. Which of the following complaints by the patient indicates to the nurse that he is developing a complication of immobility? a. stiffness of the right ankle joint c. short term memory loss b. soreness of the gums d. decreased appetite ANSWER A: Stiffness of a joint may indicate the beginning of a contracture and/or early muscle atrophy.

38. Which of the following nursing interventions indicate an understanding on the part of the nurse concerning proper care of pressure ulcers? a. rub reddened skin to increase circulation b. use a heat lamp 4 times a day to dry the wound surface c. cleanse a non-infected pressure ulcer with isotonic saline d. cleanse a non-infected pressure ulcer with povidone-iodine ANSWER C: A noninfected pressure ulcer should be cleansed gently with a non-ionic cleanser such as isotonic saline to prevent disruption of healing. 39. A client has been placed in blood and body fluid isolation. The nurse is instructing auxiliary personnel in the correct procedures. Which statement by the nursing assistant indicates the best understanding of the correct protocol for blood and body fluid isolation? a. masks should be worn with all client contact b. gloves should be worn for contact with non-intact skin, mucous membranes or soiled items c. isolation gowns are not needed d. a private room is always indicated ANSWER B: Gloves should be worn for all contact with blood and body fluids, nonintact skin and mucous membranes; for handling soiled items, and for performing venipuncture. 40. A female client will have to change the dressing on her injured right leg twice a day. The dressing will be a sterile dressing, using 4x4s, normal saline irrigant, and abdominal pads. Which statement best indicates that the patient understands the importance of maintaining asepsis? a. If I drop the 4x4s on the floor, I can use them as long as they are not soiled. b. If I drop the 4x4's on the floor, I can use them if I rinse them with sterile normal saline. c. If I question the sterility of any dressing material, I should not use it. d. I should put on my sterile gloves, then open the bottle of saline to soak the 4x4s. ANSWER C: If there is ever any doubt about the sterility of an instrument or dressing, it should not be used. 41. Which of the following nursing interventions would the nurse perform prior to administering a tube feeding? a. check for placement by aspirating for gastric contents with a syringe and test pH with Testape b. advance the tube 3-5 inches prior to the feeding c. instruct the client to swallow d. instill 30 ml of sterile water into the tube ANSWER A: Prior to administering a tube feeding the nurse must check for placement of the tube in the stomach. The most effective methods include; aspirating for gastric contents with a syringe and testing pH with testape and placing the stethoscope over the stomach and rapidly injecting 5-10 ml of air through the tubing. A swooshing sound is heard as the air enters the stomach. 42. An adult client is being treated in the burn unit for partial and full-thickness burns of the left foot, ankle, and leg. Skin autographs are taken from the right thigh and a skin graft is performed. The nurse planning care for the client on return from the operating room includes which of the following nursing interventions? a. change dressing on graft sites every shift b. cover donor site with fine mesh gauze and expose to air c. lubricate donor site with skin cream every shift d. hydrotherapy to graft sites daily ANSWER B: The donor site may be treated in a variety of ways but the most common method is to cover the wound with a fine mesh gauze or an impregnated gauze that is opened to the air or exposed to a heat lamp to allow the wound to dry. 43. The nurse is caring for a client who is being transfused for severe gastrointestinal bleeding. The nurse can decrease the danger of hypothermia by: a. administering blood with normal saline b. administering blood products through a central line c. giving only packed cells d. warming blood to body temperature before administering ANSWER D: Hypothermia with cardiac arrhythmias may occur when infusing the large quantities of blood needed in GI bleeding. Blood warming equipment should be used to prevent this problem. 44. The mother of a three-year-old child calls the clinic and states that her child has just swallowed an unknown amount of baby aspirin. What is the best initial action for the nurse to take? a. call the physician

b. instruct the mother to bring the child to the emergency room as soon as possible c. discuss with the mother observable changes for which she should watch the child d. tell the mother to give ipecac to the child and then come to the emergency room ANSWER D: The first line of treatment is ipecac. The child should be seen as possible after that. The child has just swallowed the aspirin and is not described as being unconscious. Ipecac is contraindicated if the child is unconscious. 45. A 56-year-old is admitted to the burn unit with partial and full-thickness burns of both legs, which occurred when a charcoal grill tipped over on her. The burn area is edematous. Blister formation and a large amount of fluid exudate is noted. Urine output is 30 ml per hour, BP 90/60, and pulses 110. A primary nursing diagnosis during the initial 48-72 hours following the burn is: a. body image disturbance related to disfiguring burns of both legs b. high risk for infection related to skin breakdown c. potential for ineffective airway clearance related to smoke inhalation d. fluid volume deficit related to increased capillary permeability ANSWER D: Since this client is not at high risk for pulmonary complication (her burns are lower extremity and occurred outdoors), the most urgent need is to replace lost fluids and prevent irreversible shock. The first 48-72 hours after the burn is characterized by a rapid shift of fluids from the vascular compartment into the interstitial spaces as a result of vasodilation and increased capillary permeability. 46. While assessing the client with burns on the back and trunk, the nurse notes areas that are not painful, grayishwhite in color, and leathery in appearance. The nurse documents that these burns are: a. superficial burns c. deep partial thickness burns b. superficial partial thickness burns d. full thickness burns ANSWER D: Full-thickness burns destroy the epidermis. The nerve ending are destroyed, resulting in a painless wound that appears dry, pale, and leathery and ranges from white to charred in appearance. 47. An adult is scheduled for IVP. Before sending her to have the test the nurse should: a. ask if she is allergic to barium b. ask is she is allergic to shellfish c. give her a full glass of water d. instruct her not to urinate until after the test ANSWER B: Dye is injected intravenously for an IVP. The dye contains iodine. Allergy to shellfish often reflects iodine allergy and would therefore indicate that the client is at risk for an allergic reaction to the dye. 48. An adult has received one unit of packed red blood cells after sustaining severe trauma to his legs with profuse bleeding. To evaluate whether the transfusion has been effective the nurse should: a. take his blood pressure b. auscultate lung sounds c. check hemoglobin and hematocrit results d. take his temperature ANSWER C: Hemoglobin and hematocrit are expected to rise as a result of transfusion of packed red blood cells. 49. The nurse is administering tracheostomy care to an adult. Which of the following should be included in the procedure? a. soaking the outer cannula with saline solution b. performing the procedure utilizing medical asepsis c. soaking the inner cannula in half-strength hydrogen peroxide solution d. cutting a sterile gauze pad to place between the neck and the tracheostomy tube ANSWER C: The inner cannula is removed utilizing sterile gauze and is soaked in half-strength hydrogen peroxide solution. Clean the inner cannula with a small brush or pipe cleaners. Rinse instill saline or water and replace after the outer cannula has been suctioned. 50. Which of the following teaching should the nurse include when establishing a bowel-training regimen for a 62-year-old with chronic constipation? a. avoid laxative b. decrease exercise c. increase the fiber content of your diet d. increase fluid intake 4500-5000 ml ANSWER C: The purpose of a bowel training program is to manipulate factors within the persons control

(food and fluid intake, exercise, time for defecation) to produce the elimination of a soft formed stool at regular intervals. The increase of fiber in the diet as well as an increase of fluids to 2500 3000 ml and an increase of exercise will help the effectiveness of a bowel training program. 51. The nurse answers the phone in the emergency room, a woman states that she has a nosebleed that has not stopped for the past two hours. The nurse tells her that she should come to the ER immediately but do which of the following first? a. put pressure on the bridge of the nose for 5 to 30 minutes, applying an icepack and sit with the head forward b. apply heat to the bridge of the nose and do not eat c. sit with the head back and use a towel to blot blood drainage d. when blood is felt in the nose, lightly blow the nose into a tissue Answer: A The usual site of nosebleeding is the anterior portion of the nasal area. Applying pressure encourages coagulation of bleeding. Ice vasoconstricts vessels, thus decreasing bleeding, and putting the head forward facilitates any bleeding to drain out of the nose instead of draining into the stomach, causing nausea. Blowing the nose would dislodge any clot formation, which is not the desired outcome. 52. A male client has been diagnosed with chronic obstructive pulmonary disease (COPD) for the last 10 years. He continues to smoke 2 packs of cigarettes a day. He requires oxygen to perform his daily activities. Which of the following therapeutic management modalities is necessary? a. low flow of oxygen is usually ordered b. oxygen flow is adjusted to a higher level if shortness of breath occurs c. petroleum jelly should be applied around the nares to prevent irritation d. oxygen flow rate is not a concern since he will feel better if the rate is high Answer: A Oxygen therapy is required if the client is unable to maintain a PaO2 >55 mm Hg or an oxygen saturation (O2Sat) of < 85% at rest. Oxygen (1-2 L) is given to relieve pulmonary hypertension and decrease load on the right side of the heart. It should be used continuously. High flow oxygen elevates the PaO2 to a level that removes breathing stimulus. 53. Mrs. X has been diagnosed with acute asthma. she has been admitted to the hospital and all of the following instructions to the nurse are correct, except: a. the head of the bed should be in the high position to facilitate drainage and breathing b. a cool and dry environment should be maintained c. air conditioner filter should be changed often d. oxygen should never be used as it could restrict airways more Answer: D Elevating the head of the bed facilitates drainage of secretions. A cool and dry environment decreases swelling of mucous membranes, expanding airway diameter to increase the amount of oxygen intake. Air conditioner filters are changed to remove pollens and environmental factors that may initiate an acute episode. 54. A female patient has had a partial gastrectomy with a vagotomy and pyloroplasty today. She has a nasogastric tube in her nares connected to low intermittent suction. The nurse should take which of the following precautions? a. do not irrigate or reposition the NG tube because the stomach sutures can be ruptured b. always use wrist restraints to assure placement of NGT c. the NG tube should not be taped to the nose d. expect copious amount of bright red blood from the NG tube postoperatively Answer A: The nurse should not irrigate or move the NG tube because this might disrupt the internal stomach sutures. The tube should be taped to the nose. Copious amounts of bright red blood would indicate post-op bleeding, and the nurse should report this to the surgeon immediately. Wrist restraints when ordered by the physician are only used if the client is confused and is likely to pull on the tube. Wrist restraints will not assure placement of the tube. 55. A man complains of cramping abdominal pain. He has been diagnosed with acute diverticulitis. What nursing interventions are likely to be ordered? a. increase activity and regular diet as tolerated b. advise bed rest, clear liquids and meperidine (Demerol), 50 mg IM every 3-4 hours as needed c. use ice packs on the abdomen and place the client in the trendelenburg position d. use a K-pad (a temperature controlled heating pad) on the abdomen and allow regular diet as tolerated Answer B: The client should rest and decrease stimulation and irrigation to the bowel by limiting the diet to clear liquids. A regular diet is contraindicated during an acute episode of diverticulitis; the client should either have nothing by mouth or clear liquids. Acute diverticulitis is very painful, and the client should be

offered analgesia such as meperidine (Demerol) every 3-4 hours. Neither an icepack nor a K-pad would provide adequate pain relief for acute diverticulitis. 56. has been diagnosed with esophageal varices. The physician notes there is active bleeding and orders the nurse to insert NG tube. The nurse should do which of the following? a. insert the NG tube immediately b. question the order because a varix might be perforated during insertion c. use copious amount of K-Y jelly to insert the NG tube d. refuse the order because a varix might be perforated during insertion Answer D: The nurse is legally and ethically responsible to question and refuse an order that is unsafe. Inserting a NG tube in a client with esophageal varices that are bleeding could cause rupture of varices and life threatening hemorrhage. When a nurse refuses a physicians order, it is best to briefly and calmly explain your concerns to the physician. The nursing supervisor, or immediate supervisor in your unit, should then be notified immediately of the situation. When a nurse carries out an order that is known to be life threatening to the client, the nurse is not legally protected by the fact that the physician ordered it. A nurse is judged by the usual standard of care by a nurse in that situation. In this case, the nurse should know that inserting a nasogastric tube in a client with bleeding varices could cause rupture of varices resulting in hemorrhage and death. 57. A 30-year-old patient has been diagnosed with folic acid deficiency. The client asks the nurse which foods are high in folic acid, and the nurse correctly responds: a. green leafy vegetables, organ meats, nuts and eggs b. fresh shrimp and oysters c. dried fruits and oatmeal d. tofu and tuna Answer A: The Nurse should encourage foods rich in B vitamins and stress proper ways to cook vegetables to preserve potency by using the microwave or boiling them in a small amounts of water. 58. Which of the following is an example of pica? a. a craving for sweets c. a craving for shellfish b. a craving for laundry starch and ice d. craving for pickles Answer B: Pica is a craving for a nonfood item. This behavioral disturbance can result from a change in the neurological system altered by anemia. 59. An 82-year-old woman living in a long-term care facility develops urinary incontinence. After ruling out the presence of urinary retention or a urinary tract infection (UTI), the nurse should: a. establish a 3-hour prompted voiding schedule b. insert a foley catheter or teach the client to self-catheterize c. restrict her fluid intake to 1500 ml/day d. use adult diapers and change them frequently Answer A: Research has shown that urinary incontinence can be decreased using a 3-hour prompted voiding schedule. Catheterization for the inconvenience of the staff is not indicated. Restricting the clients fluids and using adult diapers can cause complications such as dehydration and impaired skin integrity. 60. Client education for the individual with gout includes: a. dietary instructions to limit meat, poultry, organ meats and alcohol b. dietary instructions to limit complex carbohydrates such as flat bread, rice and pasta c. instructions for proper cast care d. signs and symptoms of compartment syndrome, a major complication Answer A : Treatment of gout includes dietary restrictions of high purine content foods such as meats, poultry, fish, yeast, certain vegetables, and limitation of alcohol intake. 61. When a client responds to a crisis situation or an acute injury, the sympathetic nervous system will respond in which of the following ways? a. it will increase blood flow to the abdominal organs b. it will decrease blood flow to the vital organs c. it will stimulate the adrenals to release epinephrine Answer C: The Sympathetic nervous system prepares the body for emergency responses (fight or flight), increasing the heart rate and contractility, stimulating the adrenal medulla to release epinephrine and norepinephrine, increasing respiratory rate, increasing blood flow to the cardiorespiratory systems, decreasing blood flow to the non-priority organs, releasing red blood cells to increase oxygen carrying capacity of the blood and stimulating the liver to release glucose to provide more energy for the body in

crisis. 62. During the clonic phase of a generalized seizure, you may expect to see: a. pupil dilatation, tachycardia and muscle spasms b. bladder incontinence, elevated blood pressure and diaphoresis c. loss of consciousness, cessation of breathing and cyanosis d. contracted throat muscles, hyperventilation and salivation Answer B: In the clonic phase of a seizure, hyperventilation and rapid synchronous muscle jerks occur. The client may bite his or her tongue, have bowel and bladder incontinence, have dilated pupils, tachycardia, diaphoresis, and salivate heavily. Hypertension may also be present. 63. The physician orders ice for the scrotum of a client diagnosed with epididymitis. The nurse correctly assumes that: a. ice slows circulation and decreases peripheral edema b. ice should be applied in intervals, not continuously c. ice is placed on the scrotum continuously until the physician orders otherwise d. ice will not stop the pain, and it has a placebo effect Answer B: Ice therapy needs to be removed from the scrotum every 15-20 minutes. 64. The best time for menstruating women to perform a breast self-examination is: a. right before the menstrual period b. during the menstrual period c. a few days after the menstrual period d. 14 days after the menstrual period Answer C: A few days after the menstrual period, the breasts have the least amount of fluids and are less tender. This may improve the accuracy and comfort of self-examination. 65. Which of the following procedures is most effective for preventing hemolytic blood transfusion reactions? a. administer the blood through 5% dextrose in water (D5W) b. administration of a steroid prior to the transfusion c. careful identification of the client and the blood product d. using a leukocyte-poor filter during the transfusion Answer C: Hemolytic transfusion reactions result from ABO incompatibility between the clients and donors blood. Careful determination that the client is receiving the right unit of blood is vital to prevent these reactions. Blood should be administered through normal saline, not D5W. However, fluid choices are not related to hemolytic reactions. Administering a steroid and transfusing through leukocyte-poor filter helps prevent non-hemolytic reactions, not hemolytic reactions. 66. A superficial partial-thickness burn should heal in: a. one week c. six weeks b. three weeks d. two months Answer A: Healing of superficial partial-thickness burns usually occurs within a week. 67. The setting that is most suitable for the treatment of a client with a full thickness burn is: a. admission to a burn unit b. admission to a medical unit c. treatment in an emergency room or ambulatory care setting d. home health care Answer A: Full-thickness burns usually require hospitalization in a burn unit with comprehensive care by a burn team. The age of a client and the body area involved determine the need for emergency attention. 68. A full thickness burn would appear: a. red, as if client were sunburned b. bright red and weeping fluid c. mottled without weeping fluid d. brown and leather-like Answer D: A full thickness burn appears white or brown and leather-like. 69. In a patient with full thickness burn of the face, the nurse must immediately address: a. airway management and hypovolemic shock b. moderate discomfort and minor fluid loss c. pain management with intravenous morphine

d. wound care Answer A: Airway maintenance is a priority in a full-thickness burn of the face, as swelling may cause airway obstruction. The nurse must observe the client for tachypnea, anxiety, agitation, hoarseness, stridor, or wheezing as signs of respiratory distress. Fluid resuscitation requires intravenous lactated Ringers solution to be started in the ambulance or the emergency room. These burns usually require skin grafting, but this is not a priority in the emergency management period. 70. A full thickness burn of the face should heal in: a. one week c. six weeks b. three weeks d. months Answer D: A long period of recovery would be expected with a full-thickness burn. These burns usually require skin grafting and are susceptible to infection. Plastic surgery may be needed during the rehabilitation phase. 71. If the client with psoriasis complains about pruritus, the nurse should suggest using: a. drying soaps or agents b. hot water when bathing c. emollient lubricants d. a towel to provide vigorous drying after bathing Answer C: Applying lotions with emollients in a thin layer over the skin and a thick layer over plaques usually is helpful with psoriasis. Psoriasis is not curable and fluctuates between periods of exacerbation and remission. Avoiding sunburn, infections, extremes of temperature, drying soaps and stress are suggested ways to manage psoriasis. 72. You are supervising a student nurse giving an IM injection to a client with right hip arthroplasty. You will know the SN requires further instruction if she: a. administers the injection in the left deltoid muscle b. turns the client on her right hip to administer the injection c. keeps the abduction pillow in place and turns the client 10 degrees to administer the injection on the unaffected side d. administers the injection after turning the client to her left thigh, keeping the abduction pillow in place Answer B: Since the most common complication of total joint replacement is dislocation, correct positioning is important. Turning the client on either side without keeping the abduction pillow in place could lead to dislocation of the new prosthesis. 73. You are assisting a client to choose a meal that follows his dietary orders of high calorie, high protein, decreased sodium, and low potassium. You will know the understands his dietary guidelines when he chooses: a. crab, beets and spinach, baked potato, and milk b. halibut, salad, rice, and instant coffee c. sirloin steak, salad, baked potato with butter, and chocolate ice cream d. salmon, rice, green beans, sourdough bread, coffee, and ice cream Answer D: The best choice of meal is fish (not halibut or cod, both high in potassium), rice, and green beans. Bread and ice cream will add calories and protein. Instant coffee is high in potassium, and beets and spinach are high in sodium. 74. The best rationale for introducing your-self to a blind client and telling him exactly what you are doing is that these actions: a. illustrate the principle of open communication b. decrease the clients anxiety and fear of the unknown c. are the accepted procedure for beginning a nurse-client relationship d. encourage and utilize clear communication Answer B: Blind clients become anxious when they hear someone enter the room without talking. 75. Sitting down at the clients bedside to talk with the client with convey a sense of: a. sympathy c. empathy b. communication d. encouragement Answer C: Nonverbal action conveys acceptance, openness to listen, and empathy. It assists the client to verbalize feelings. 76. While assessing a client who has orders for a hot-water bottle, heating pad, or hot compress, the first sign of possible thermal injury is:

a. tingling sensation in the extremities c. edema b. redness in the are d. pain Answer B: Redness, or erythema, is the first sign of possible injury. This is an important observation to prevent a burn injury. 77. When charting the procedure for applying restraints to a client, you will include: a. what the client says about the restraint b. procedure for applying the restraint c. physicians orders regarding the restraint d. condition of the extremity following application Answer D: Evaluation of the effects of the restraint is important to chart. Procedure is not relevant and what the client says may or may not be appropriate. Physician orders are already charted so you would not chart them again. 78. To perform the skill turning to the side-lying position, you would lower the head of the bed, elevate bed to working height, move client to your side of the bed, and flex clients knees. The next intervention, would be to: a. roll the client on his side b. reposition client c. place one hand on clients hip and other on shoulder d. reposition clients arms so they are not under his body Answer B: Before rolling client on his side, your hands must be in the correct position to turn. 79. Your client insists on being discharged from the hospital against medical advice. From a legal standpoint, the most important nursing action is to: a. notify the supervisor and hospital administration b. determine exactly why the client wants to leave c. put all appropriate forms in the clients chart before he leaves the hospital d. request that the client sign the against medical advice (AMA) form Answer D: All of the above actions would be appropriate to carry out. Legally, signing the Against Medical Advice (AMA) form is most important. 80. You are moving the client from the bed to a chair. The first appropriate intervention is to: a. dangle the client at his bedside b. put nonslip shoes or slippers on clients feet c. rock the client and pivot d. position client so that he is comfortable Answer A: Before moving the client, dangling at the bedside is important. This procedure stabilizes the client and allows you time to assess whether he develops vertigo from a drop in blood pressure. 81. The primary purpose of client education is to: a. collect client data b. determine readiness to learn c. assess degree of compliance d. increase clients knowledge that will affect health status Answer D: The primary purposes of client education include increasing knowledge, increasing self-esteem, improving clients ability to make decisions, and facilitating behavioral changes. 82. Your initial instruction to a client on the use of crutches to move upstairs should be to: a. start with crutches and the unaffected leg on the same level b. start with crutches and the affected leg on the same level c. place crutches on the step after the affected leg is moved up the stair d. place crutches on the stair and then move the affected leg to the stair Answer A: The crutches and unaffected leg start on the same level; then, the unaffected leg is moved to the step, followed by the crutches and affected leg. 83. When a client experiences a severe anaphylactic reaction to a medication, your initial action is to: a. start an IV c. place the client in a supine position b. assess vital signs d. prepare equipment for intubation Answer C: The shock position is necessary to maintain vital signs. The other interventions may be carried out, but are not initial actions.

84. If a blood transfusion reaction occurs, the first intervention is to: a. place the client in high-fowlers position b. call the physician c. slow the rate of transfusion to keep open rate d. shut off the transfusion Answer D: If the nurse suspects an allergic reaction, the blood should be shut off immediately, then the physician should be notified and the client placed in a position to facilitate breathing. 85. The correct action for instilling eye drops is to instill the drops: a. at the outer canthus of the eye b. over the conjunctiva c. directly on the cornea d. into the center of conjunctival sac Answer D: drops instilled in the center of the sac will assist in distributing the medication over the entire surface of the conjunctiva and anterior eyeball. 86. Assessing a client for hypovolemic shock, the sign that you would expect to note if this complication occurs is: a. hypertension c. oliguria b. cyanosis d. tachypnea Answer C: In shock, there is decreased blood volume through the kidneys. This is evidenced by a decrease in the amount of urine excreted. The body has numerous compensatory mechanisms that assist in keeping the blood pressure normal for a short time. 87. When evaluating the clients understanding of a low potassium diet, you will know he understands if he tells you that he will avoid: a. pasta c. dry cereal b. raw apples d. french bread Answer B: Raw apples are high in potassium, while white-enriched and French bread, dry cereal, and pasta are foods low in potassium. 88. Irrigating a nasogastric tube should be carried out using which one of the following protocols? a. gently instill 20 cc normal saline and then withdraw solution b. instill 30 cc sterile water and then withdraw solution c. instill 30 cc sterile saline, forcefully if necessary, and allow fluid to flow into basin for return d. gently instill 20 cc sterile water and then allow fluid to flow into basin for return Answer A: Gentle pressure is necessary when irrigating a nasogastric tube to prevent damage to the stomach wall. Saline prevents electrolyte imbalance. 89. The morning of the second postoperative day, a female patient is to be ambulated. Your first intervention is to: a. get her up in a chair b. use a walker when getting her up c. have her put minimal weight on the affected side d. practice getting her out of bed by slightly flexing her lips Answer B: Postoperative hip replacement clients may get up the first day, but need to use a walker for balance. They should not bear any weight on the affected side or sit in a chair, flexing their hips. Positions with 60o to 90o flexion should be avoided. 90. You are assigned a client who has just had a nasogastric tube inserted postoperatively. During your evaluation of his status, you will check for: a. electrolyte imbalance c. ulcerative colitis b. gastric distention d. infection Answer A: Nasogastric intubation can lead to the complication of electrolyte imbalance because of removing the gastric contents by suctioning. Large amounts of sodium and potassium are lost though the suctioning and, if not replaced via IV fluids, can lead to serious electrolyte imbalance. 91. Before administering a nasogastric feeding, you aspirate the stomach contents and obtain 50 cc of residual. Your next action is to: a. discard aspirate and begin tube feeding b. replace aspirate and begin tube feeding

c. discard aspirate and hold the tube feeding d. replace aspirate and hold the tube feeding Answer B: the aspirate contains electrolytes and hydrochloric acid; therefore, it must be replaced to prevent an imbalance. With a residual of 50 cc, the usual action is to administer the tube feeding. 92. You are assigned to a client with a central vein IV infusing hyperalimentation solution. The most important nursing intervention is: a. preparing the next bottle of solution prior to use b. maintaining the exact amount of solution administered hourly by adjusting the flow rate c. checking urine specific gravity, sugar, and acetone every for hours d. changing the IV filter and tubing with each bottle change Answer C: Checking the urine for glucose and acetone is essential to prevent a hyperosmolar condition. Insulin may have to be administered according to rainbow coverage. Notify physician for urine glucose over 2+ and positive acetone. 93. You have been assigned to a female patient who needs to have a sterile urine specimen sent to the laboratory for a culture and sensitivity. After inserting the catheter, you find that urine is not flowing. Your next action is to: a. remove the catheter, check the meatus, and reinsert the catheter b. obtain a new, larger sized catheter and insert it c. reassess if the catheter is in the vagina; if so, remove it and reinsert into meatus d. insert the catheter a little farther, wait a few seconds, and if urine does not flow, reassess placement Answer D: Check if catheter is inserted for enough into urethra or if it is in vagina. If in vagina, leave in place as a landmark, obtain new sterile set-up, and insert new catheter. 94. When the urine begins to flow through catheter, your next action is to: a. inflate the catheter balloon with sterile water b. place the catheter tip into the specimen container c. connect the catheter into the drainage tubing d. place the catheter tip into the urine collection receptacle Answer B: When urine begins to flow, the catheter tip is placed into the specimen container. When the specimen is collected, the catheter tip is placed into the collection receptacle until urine flow ceases. 95. Following application of a leg cast, you will first check the toes for: a. increase in temperature c. edema b. change in color d. movement Answer B: A cast is rigid and used to maintain alignment. If it is too tight, it will press on blood vessels. The color of the toes will change first, then temperature, when blood supply is decreased. As the blood flow slows through the walls of the vessels, edema will occur. 96. The client is unable to feel you apply pressure on his toes and complains of tingling. These signs indicate: a. pressure on a nerve c. overmedication of an analgesic b. phantom pain syndrome d. improper alignment of the fracture Answer A: Since the client cannot feel sensory stimuli, a blockage of the nerves between the central nervous system and the peripheral system would be indicated. 97. From your knowledge of the casting procedure, you understand that a wet cat should be: a. placed on a firm surface for the first few hours b. handled only with the palms of the hands c. left alone to set for at least three hours d. pelated to lessen chance of irritation to the client Answer B: if a wet cast is handled with the fingers, indentations in the cast will occur. This can cause pressure on the skin and cause weakness in the cast. 98. During a retention catheter insertion or bladder irrigation, the nurse must use: a. sterile equipment and wear sterile gloves

b. clean equipment and maintain surgical asepsis c. sterile equipment and maintain medical asepsis d. clean equipment and technique Answer C: To prevent introduction of pathogens into the urinary tract, sterile equipment is used and its sterility maintained. 99. Care for a client following a bronchoscopy will include: a. withholding food and liquids until the gag reflex returns b. providing throat irrigations every four hours c. having the client refrain from talking for several days d. suctioning frequently, as ordered Answer A: Until the gag reflex returns, the client cannot handle foods or liquids, and may aspirate. Suctioning is not usually ordered. 100. Reviewing the lab tests of a client scheduled for surgery, you find that the white blood cell count is 9800/mm3. The most appropriate intervention is to: a. call the operating room and cancel the surgery b. notify the surgeon immediately c. take on action as your recognize that it is a normal value d. call the lab and have the test repeated Answer C: The normal WBC is 4500 to 11,000/cu mm. If the results were abnormally high, the surgeon would have to be notified and the surgery may be canceled. Tests with abnormal results are not routinely repeated unless the results are grossly abnormal.

General Nursing Board 101 Fundamentals Comprehensive http://nsgbrd101.proboards.com/index.cgi?board=answers&action=display&thread=4 Fundamentals Comprehensive Post by admin on Aug 18, 2010, 12:47pm RATIONALE FOR THE PRACTICE TEST

1. ( B ) Act 2808 approved on March 1, 1919 is considered as the first true nursing Law. Under this law, the first Board of Examiners for nurses was created composed of 3 members appointed by the Secretary of Interior, one of whom is a doctor of medicine and the two others are RNs. This Law also specifically prohibits the practice of nursing without having been conferred or obtained the proper certificate of registration from the board of examiners for Nurses. Act 2493 approved on February 5, 1915 refers to the act to providing for the examination of nurses in the Philippines. However, this act, which was the first law to affect the practice of nursing in the Philippines, consisted only of two sections of a law relating to the practice of medicine. RA 9173 is the Philippine Nursing Act of 2002. This is the latest law that governs the practice of nursing in the Philippines that superseded or amended all the previous nursing laws passed in the country. RA # 877 An Act also known as the Philippine Nursing Law approved on June 19, 1953. This Law was sponsored by Senator Geromina T. Pecson which enacted to regulate the practice of nursing in the Philippines and to set up provisions for the registration of nurses, for the establishment and maintenance of standards of nursing education and nursing practice. 2. (B) The composition of the Board of Nursing under RA 7164 otherwise known as the Philippine Nursing Act of 1991 is 5. Under Article III section 3 of RA 7164, the Board of Nursing shall be composed of a

chairman and four members who shall be appointed by the President of the Philippines from a list of twelve nominees who are registered nurses of recognized standing and must possess prescribed qualification. However, this was already deleted in the latest Nursing Law or The Philippine Nursing Act of 2002. The Members were increased from 5 to 7. Article III Section 3 of RA 9173 states that there shall be created a Professional Regulatory Board of Nursing, hereinafter referred to as the Board to be composed of a chairperson and six members. They shall be appointed by the President of the Republic of the Philippines from among two recommendees, per vacancy, of the Professional Regulation Commission, chosen and ranked from a list of three nominees, per vacancy, of the accredited professional organization of nurses in the Philippines who possess the qualifications prescribed. 3. ( A ) The nursing areas covered and mentioned under Section 4 of RA 9173 are the following: Nursing Education, Nursing Service and Community Health Nursing. These are the areas which the members of the Board of Nursing must represent. Nursing Research is deemed covered under the Nursing Education. 4. (D) Article 3 Section 6 of the RA 9173 states that the term of office of the chairperson and the members of the board shall be for a term of 3 years and until their successors shall have been appointed and qualified provided that they may be reappointed for another term. Any Vacancy in the Board occurring within the term of a member shall be filled for the unexpired portion of the term only. Each member of the board shall take the proper oath of office prior to the performance of his or her duties. The incumbent Chairperson and the members of the board shall continue to serve for the remainder of their term under RA 7164 until their replacements have been appointed by the President of the Philippines and shall have been duly qualified. The Hold-over doctrine applies in the situation where the term of office of the incumbent officers have already expired but there are no replacements yet. They must continue to hold office until their successors shall been APPOINTED and QUALIFIED. 5. (D) Article IV Section 15 of RA 9173 provides: In order to pass the examination, an examinee must obtain a rating of not below sixty percent in any subject. An examinee who obtains an average rating of seventy-five percent or higher but gets a rating below sixty percent in any subject where he/she is rated below 60%. In order to pass the succeeding examination, an examinee must obtain a rating of at least 75% in the subject or subjects repeated. Section 16 of the RA 7164 was already deleted in the new Nursing Law of 2002, it requires examinees who fail the nurse licensure examination for the third time to take a refresher course consisting in enrollment and passing in the regular fourth year subjects in a recognized nursing school. The removal examination shall be taken within two years after the last failed exam. 6. (B) Article III Section 11 provides: The President of the Republic of the Philippines may remove or suspend any member of the Board of Nursing after having been given the opportunity to defend himself/herself in a proper administrative investigation, on the following grounds: a. Continued neglect of duty or incompetence b. Commission or toleration of irregularities in the licensure examination c. Unprofessional, immoral or dishonorable conduct 7. (D) The PNA established in 1922 was responsible in lobbying our government for the adoption of the recommendations made by the international labor organization in 1977 with regard the status of the economic and social welfare of our nursing personnel. The Professional Regulation Commission of the Philippines duly recognizes the PNA as well as in the Section 3 (j) of the Implementing Rules and Regulation of RA 9173 issued by BON Board resolution number 425. 8. (C)Article V section 26 of RA 9173 provides: Nurses who have not actively practiced the profession for five (5) consecutive years are required to undergo one month didactic training and three months of practicum. The Board shall accredit Hospitals to conduct the said training program. 9. (B) Article V section 27 provides: A member of the faculty in a college of nursing teaching professional courses must: a. Be a registered nurse in the Philippines b. Have at least one year of clinical practice in a field of specialization c. Be a member of good standing in the accredited professional organization; and d. Be a holder of a master degree in nursing, education, or other allied medical and health sciences conferred by a college or university duly recognized by the Government of the Republic of the Philippines.

In addition to the aforementioned qualifications, the dean of a college must have a masters degree in nursing. He/she must have at least 5 years of experience in nursing. The citizenship requirement mentioned under RA 9173 is for those members of the Board of Nursing. 10. (C) RA 9173 abolished the previous requirement stated in the previous Nursing Act RA 7164 sec. 23, requiring applicants desiring to enroll in a nursing course to belong to the upper 40% of the graduating class of the general secondary course as certified by the school 11. (D) RA 9173 deleted the provision of RA 7164 section (4,f) requiring nurses who graduate from state colleges and universities to render, after being issued the necessary board licenses, at least 1 year of nursing service in the Philippines before they are allowed to leave for overseas jobs. 12. (B) RA 9173 Section (4e) provides: Not have been convicted of any offense involving moral turpitude. In addition to this, the chairperson and the members of the board must possess the following: a. Be a natural born citizen and resident of the Philippines b. Be a member of good standing of the accredited professional organization of nurses; c. Be a registered nurse and a holder of masters degree in nursing, education or other allied medical profession conferred by a college or university duly recognized by the government. d. Have at least ten years of continuous practice of the profession prior to appointment, provided, however, that the last 5 years of which shall be in the Philippines. 13. (D) Of the ten years of continuous practice of the profession prior to appointment, it is enough that the last five years must have been practiced in the Philippines. RA 9173 already deleted the provision that the ten continuous practice as provided in previous laws be practiced in the Philippines. 14. (B) The Board of Nursing cannot close down the operation of a nursing school with poor standards. This power is vested in the CHED and the Board may only RECOMMEND to the Board the closing or opening of Nursing Schools. RA 9173 section 9 (d) provides: Ensure quality nursing education by examining the prescribed facilities of universities or colleges of nursing or departments of nursing education and those seeking permission to open nursing courses to ensure that standards of nursing education are properly complied with and maintained at all times. The authority to open and close colleges of nursing and/or nursing education programs shall be vested on the Commission of Higher Education upon written recommendation of the Board. 15. (B) Section 28 (g) RA 9173 added the provision: Inhibition to practice nursing profession during the period of suspension. Teaching, either part-time or full time in the college of nursing is within the meaning of nursing practice under RA 9173 16. ( C ) The suspension order is automatically lifted after the lapsed of the prescribed period and she does not need to write the Board to get back her license. Only revoked license by the Board has the additional requirement of notifying the Board after four years since the time of revocation. 17. ( C ) An additional provision of RA 9173 is that, the Board of Nursing cannot suspend any nurse for more than four years. Suspension orders must be limited only up to four years. The power to revoke the certificate of license to practice of nursing is no longer perpetual. The nurse with revoked license may apply again for a new certificate after the lapsed of four years after writing the BON. 18. ( D ) The power to revoke the certificate of license to practice of nursing by the Board of Nursing is no longer perpetual. The nurse with revoked license may apply again for a new certificate after the lapsed of four years after writing the BON. 19. ( A ) it is incorrect statement because under RA 9173, the special IV therapy training requirement was already deleted, however, the Nursing Service Administrators still requires the nurses to attend formal training in this aspect for the safety of the patient, and the protection of the nurse and of the agency/institution where the patient is being treated or confined. 20. ( A ) Special training for nursing suturing the lacerated perineum is a new provision of RA 9173 provided the nurse undergo a training being undertaken by Nursing Administrators of the Philippines (ANSAP) with the Maternal Child Association of the Philippines ( MCNAP ) 21. ( C ) Act # 1931 Created for the establishment of nursing schools in the country under the Bureau of

Education in 1909. 22. ( D ) Hendersons Definition of Nursing- The definition of nursing given by Virginia Henderson in 1955 became a milestone in the development of nursing as discipline apart from medicine. The focus on her Nursing Concept is to help individuals and families gain independence in meeting the 14 fundamental needs; 1. Breathing normally 2. Eating and drinking adequately 3. Eliminating body wastes 4. Moving and maintaining desirable position 5. Sleeping and resting 6. Selecting suitable clothes 7. Maintaining body temperature within normal range by adjusting clothing and modifying the environment 8. Keeping the body clean and well-groomed to protect the integument 9. Avoiding dangers in the environment and avoiding injuring others 10. Communicating with others in expressing emotions, needs, fears, or opinions 11. Worshipping according to ones faith 12. Working in such a way that one feels a sense of accomplishment 13. Playing or participating in various forms of recreation 14. Learning, discovering, or satisfying the curiosity that leads to normal development and health, and using available health facilities.

23. ( A ) Rogerss Science of Unitary Human Beings - Martha Rogers views the person as an irreducible whole, the whole being greater than the sum of its parts. Her Key concepts in describing the individual are energy fields, openness, pattern and organization, and multidimensionality. She described the Unitary Man as: Irreducible, four-dimensional energy field identified by pattern. Manifesting characteristics different from the sum of the parts Interacts continuously and creatively with the environment Behaving as a totality Participating creatively in change 24. ( A ) Peplaus Psychodynamic Nursing Theory- Hildegard Peplau introduced and defined psychodynamic nursing as understanding ones own behavior to help others identify felt difficulties and applying principles of human relations to problems arising during the experience. She also described the nurse-patient relationship in four phases. 25. ( D ) Leiningers Transcultural Care Theory Madeleine Leininger established the transcultural nursing which she defined as a major area of nursing that focuses on comparative study and analysis of different cultures and subcultures in the world, with respect to their: Caring behavior Nursing care Health values Beliefs Patterns 26. ( C ) Occupational Health Nurse/ Industrial Nurse one employed in industry that gives immediate care to ill or injured workers, follows up on the sick and the injured, and helps develop accident prevention and health programs for the workers. 27. ( D ) Watsons Philosophy and Science of Caring Jean Watson believes the practice of caring is central to nursing; it is a unifying focus for practice. According to her, there are two major assumptions that underlie human care (carative factors): care and love constitute the primal and universal psychic energy care and love are requisite for our survival and the nourishment of the society 28. ( D ) Roys Adaptation Model Sister Callista Roy focuses on the individual as a biophysical adaptive

system. Both the individual and the environment are sources of stimuli that require modification to promote adaptation, an ongoing purposive response. Roy identified three classes of stimuli: Focal Stimulus: the internal or external stimulus most immediately confronting the person and confronting the behavior. Contextual stimuli: all other internal or external stimuli present Residual Stimuli: beliefs, attitudes, or traits having an intermediate effect on the persons behavior but whose effects are not validated. 29 . ( B ) RA # 1080 This act approved on 1954 is also known as, An Act Declaring the Bar and Board Examinations as Civil Service Examinations which means that when a four year degree course graduate had passed the board examinations or the Bar examinations for lawyers they automatically become first grade civil service eligible. 30. ( D ) RA # 877 An Act also known as the Philippine Nursing Law approved on June 19, 1953. This Law was sponsored by Senator Geromina T. Pecson which enacted to regulate the practice of nursing in the Philippines and to set up provisions for the registration of nurses, for the establishment and maintenance of standards of nursing education and nursing practice. 31. ( B ) RA # 6136 In 1971, This Republic Act introduced other minor revisions in the nursing law thus amending RA 4704 of 1966. 32. ( D ) RA 8981 PRC MODERNIZATION ACT OF 2000 This Act gave the Professional Regulatory Commission its regulatory powers and is now an agency of its own. 33. ( C ) Presidential Decree 996 COMPULSORY IMMUNIZATION for all children below eight years old. 34. ( D ) RA 6425 DANGEROUS DRUG ACT enacted in 1972 declaring that sale, administration, delivery, distribution, and transportation of prohibited drugs are punishable by law. 35. ( A ) RA 1082 creation of RURAL HEALTH UNITS in the Philippines. 36. ( D ) Proclamation No. 539 The President of the Philippines declared on October 17, 1958 that the last week of October (through this proclamation ) as the NURSES WEEK 37 ( C ) Neumans Health Care Systems Model Betty Neuman views the client as an open system consisting of a basic structure or central core of energy resources (physiologic, psychologic, sociocultural, developmental, and spiritual) surrounded by two concentric boundaries or rings referred to as lines of resistance. She identified individuals response to stress and the nursing interventions to be carried out on three preventive levels: Primary prevention Secondary prevention Tertiary Prevention 38. ( B ) Presidential Decree 148 WOMAN AND CHILD LABOR LAW The employable age is 16 years and above and further provides for the privileges of working women. 39. ( A ) PD 603 CHILD AND YOUTH WELFARE CODE protects and promotes the rights and welfare of children and youth. 40. ( D ) RA 7160 LOCAL GOVERNMENT CODE OF 1991devolution of powers from national to local government. 41. ( D ) RA 7432 SENIOR CITIZENS ACT does honor and justice to our peoples long tradition of giving high regard to elderly. 20% discount in all public establishments such as restaurants, pharmacies, public utility vehicles and hospitals. 42. ( D ) RA 6758 - standardized the salaries of government employees which include the nursing personnel. 43.( C ) RA 4226 HOSPITAL LICENSURE ACT requires all hospital in the country to be licensed before it

can offer to serve the community. The licensing agency is the Office For Hospital and Medical Services, Department of Health. 44. ( A ) RA 1612 Refers to the payment of PRIVILEGE TAX before any business or occupation can be lawfully begun or pursued. 45. ( D ) Letter of Instruction No. 47 directs all schools of medicine, nursing, midwifery and allied medical professions and social work to prepare, plan, and implement the INTEGRATION OF FAMILY PLANNING in their curricula and to require from their graduates sufficient appropriate licensing examination. 46. ( B ) PD 442 LABOR CODE OF THE PHILIPPINES provides the right of the workers to self-organization and collective bargaining agreement. 47. ( C ) RA 5181 An act that prescribes PERMANENT RESIDENCE and reciprocity as qualifications for any examination or registration for the practice of any profession in the Philippines 48. ( D ) PD 69 limits the number of children to FOUR for TAX EXEMPTIONS purposes. 49. ( A ) PD 48 limits paid MATERNITY LEAVE privileges to four children. 50. ( B ) PRC Resolution No. 2004-17 Series of 2004 RE-IMPLEMENTED CONTINUING PROFESSIONAL EDUCATION requiring sixty (60) credit units for three years for professionals with bachelors degree 51. ( B ) documentation of unusual occurrences, incidents, and accidents, and of the nursing actions taken as a result of an occurrence, is internal to the institution or hospital policy and allows the nurse and administration to review the quality of care and determine any potential risks present. On the basis of the information provided in the question, the nurses error will not result in suspension, nor will it be documented in the personnel file. The error and the situation presented in the question are not a reason for notifying the Board of Nursing. 52. ( D ) Generally, there are only two instances in which the informed consent of an adult client is not needed. One instance is when an emergency is present and delaying treatment for the purpose of obtaining informed consent would result in injury or death to the client. The second instance is when the client waives his right to informed consent. Option B will delay emergency treatment, and option C is inappropriate. Although option A may be pursued, it is not the best initial action. 53. ( D ) Invasion of privacy takes place when an individuals private affairs are unreasonably intruded into. Telling a client that he or she cannot leave the hospital constitutes false imprisonment or illegal detention. Threatening to give a client a medication constitutes assault. Performing a procedure without consent is an example of battery. 54. ( D ) Sexually suggestive jokes, touching, pressuring, a coworker for a date, and open displays of sexually oriented photographs or posters including lewd text messages are examples of conduct that be considered sexual harassment by another coworker. If the nurse believes that he or she is being subjected to unwelcome sexual conduct, these concerns should be reported to the nursing supervisor immediately. The other options are unnecessary at this time. Option A is inappropriate. 55. ( D ) If the physician writes an order that requires clarification, it is the nurses responsibility to contact the physician for clarification. If there is no resolution regarding the order because the physician cannot be located, or because the order remain as it was written after the nurse talks with the physician, the nurse should then should contact the nurse supervisor for further clarification as to what the next step should be. Under no circumstances should the nurse proceed to carry out the order until clarification is obtained. Holding the medication can injure the client. The nurse must take action after clarification of the order. 56. ( C ) Beneficence - any action that would BENEFIT others. The principle that imposes upon the practitioner to seek the good for the patients under all circumstances. Beneficence connotes POSITIVE action toward preventing or removing harm and promoting good such as: One ought to prevent evil or harm One ought to remove evil or harm One ought to do or promote good.

57. ( D ) Nonmaleficence states the idea to REFRAIN from inflicting harm. one ought NOT to inflict evil or harm. The admonition of nonmaleficence is stated in the negative manner while the beneficence is in the positive. 58. ( B) Autonomy - In health care, it means the form of personal LIBERTY, where the individual is free to choose and implement ones own decisions, free from deceit, duress, constraint, or coercion. Three Basic elements involved: ability to decide power to act upon your decisions a respect for the individual autonomy of others. 59. ( C ) Nonmaleficence states the idea to REFRAIN from inflicting harm. one ought NOT to inflict evil or harm. The admonition of nonmaleficence is stated in the negative manner while the beneficence is in the positive. 60. (D) Justice The basic principle that deals with FAIRNESS, just deserts, and entitlements in the distribution of goods and services. In health care, justice seems to point to distributive justice that deals with the allocation of scarce resources. ARTICLE XIII of the 1987 Constitution provides: The State shall adopt an integrated and comprehensive approach to health development and shall endeavor to make essential goods; health and social services available to all people at affordable cost. There shall be priority for the needs of the underprivileged, the sick, the elderly and the disabled, the women and the children. The State shall endeavor to provide free medical care to paupers, establish and maintain an effective food and drug regulatory system, and undertake appropriate health manpower and development and research responsive to the countrys health needs and problems. It shall establish a special agency for disabled persons for their rehabilitation. Some methods of distributing goods and services in our society are as follows: To each, an equal share To each, according to need To each, according to effort To each, according to contribution To each, according to merit To each, according to ability to pay