SUCCEED REVIEW CENTER

FUNDAMENTALS OF NURSING SET 2

BY: MS. KRIZSEL HYACINT M. PELAYO
1. Who stated, Caring is the essence of nursing and the most central and unifying focus of nursing practice?
A.Watson B. Fawcett C. Hall
D. Henderson
2. There are four purposes for charting by exception. Three of these purposes are to eliminate redundancy, to ensure concise
documentation for routine care, and to emphasize abnormal findings. Which statement best explains the fourth purpose?
A.to identify a change in a patients condition
C.to identify trends in clinical care
B.to identify a change in a patients medical orders
D.to identify trends in resource utilization
3. Change-of-shift report is an important component of care. What is the major outcome of an effective exchange of
information during this process?
A.it ensures notification of new physician orders
B.it helps to identify any new trends in care
C.the patient receives continuity of care based on his or her needs
D.the patients risk status will be stabilized
4. Who is responsible for inquiring if the client has an Advance Directive?
A.the hospital chaplain B. the admitting nurse
C. the hospital attorney D. the clients physician
5. A psychiatric client rapidly improves and is scheduled to be discharged tomorrow. Which of the following responses
demonstrates that the nurse has a good understanding of termination of a relationship?
A. you have worked really hard the last three weeks. Good-bye and good luck
B. stop by and let us know how things are going
C. youve done some good work here. I hope you are able follow through with it
D. good bye and good luck. Hopefully, we wont be seeing you here again
6. Taking a clients blood pressure that has been within normal limits, the nurse gets a reading that is very low without any
significant clinical indicators. The appropriate intervention is to
A.assess if the BP cuff is too narrow
B.assess if the BP cuff is too wide
C.assess if the clients arm was positioned below heart level
D.notify the physician
7. When using the tympanic route for taking a temperature, what is the rationale for directing the probe toward the tympanic
membrane?
A.pressure seals the ear canal
B.the probe will not record unless it is near the tympanic membrane
C.this method records the core temperature
D.this method provides better access to the ear canal
8. The clients body mass index (BMI) is calculated using the clients
A.. age and waist measurement B. age and weight
C. height and weight
D.
sex and weight measurement
9. The nurse suspects that a client has appendicitis. When assessing for rebound tenderness, the nurse should
A.perform this assessment first
C.palpate deeply with quick release of pressure
B. have the client take a deep breath
D. have the client lie flat with legs extended
10.An order is written for 700 mg ampicillin PO. The drug is supplied in liquid form as 1 g/3.5 mL. How much of the liquid
should be given?
A.5 mL B. 2.5 mL C. 6.2 mL D. 2.45 mL
11.An order is written for 1000 mL of normal saline to be administered IV over 10 hours. The drop factor on the IV tubing
states 15 drops/mL. What is the IV flow rate?
A.50 mL/h at 50 drops/min
C. 100 mL/h at 100 drops/min
B.100 mL/h at 25 drops/min
D. 100 mL/h at 15 drops/min
12.The most common cause of injury due to medications errors is
A.the wrong client
B. the wrong medication
C. the wrong dosage D. the wrong route
13.Before administering medication that appears to be inappropriate for the client, the nurse should
A.consult the pharmacist
C.consult the drug manufacturer
B.consult the ordering physician
D. recheck the medication against the MAR
14.The effectiveness of the isolation mask is greatly reduced after how many minutes?
A.10 minutes B. 20 minutes
C. 30 minutes D. 60 minutes
15.Which action indicates a break in handwashing technique?
A. removing jewelry
B. keeping hands and forearms in the down positions when washing
C.rinsing with hands in the up position
D.drying in the direction of fingers to wrists and forearms
16.Four victims from a disaster arrive at the emergency department at the same time. Which victim should receive the highest
level of priority for care?
A. a disaster victim who arrives at the emergency department without a pulse
B. a disaster victim who arrives at the emergency department with labored respirations, cool skin, a pulse of 120 beats per
minute and a blood pressure of 90/60 mm Hg
C.a disaster victim who is noted politician with an open fracture of his left arm
D.a disaster victim who is under age of 6 years, regardless of the extent of his injuries
17.When performing a damp to damp dressing, the nurse should
A.apply a damp dressing to the wound for 30 minutes, remove the damp dressing, and then apply a dry sterile dressing
B.apply damp soaks and cover with a dry dressing

C.irrigate the wound with prescribed irrigant and apply a dry sterile dressing
D.gently pack the wound with slightly moist gauze and cover with a dry sterile gauze
18.The pediatric nursing team is orienting new nurses on preventing pressure ulcers in neonates and young children. Where
should the nurses check frequently for the occurrence of these ulcerations in these children?
A. shoulders B. head C. sacrum D. heels
19.To remove the sutures in clients right leg, the nurse must cut the sutures at:
A.the side
B. middle portion C. tied area
D. anywhere
20. A female patients culture requires that a male member of the family give consent for the scheduled surgery. Which
approach by the nurse is the most appropriate?
A. find out how much the patient understands about the scheduled procedure
B. have the patient sign the consent form first with the male family member observing and then signing afterward
C. have the male member sign the consent form first, and then have the patient sign
D. refer to the institutions protocol for implementing this type of informed consent
21.The second stage of Kubler-Rosss stages of dying and death is
A.bargaining
B.denial
C. anger
D. depression
22.Patients who have a pneumothorax have which type of chest tubes?
A. pleural tubes placed in the second or third intercostal space
B. pleural tubes placed in the fifth or sixth intercostal space
C. pleural tubes placed laterally
D. pleural tubes placed posteriorly
23.The nurse is caring for a patient with a chest tube to treat pneumothorax. His tube and occlusive dressing becomes dislodged.
The nurses immediate action is to:
A. call for help and take vital signs
B. take vital signs and perform a pulmonary assessment
C. place an occlusive dressing over chest tube site and take vital signs
D. notify the physician and prepare to insert a new chest tube
24.Which statement is true about an endotracheal tube?
A.an endotracheal tube is used to maintain the tongue away from the posterior oropharynx in the unconscious patient
B. it is inserted via a surgical procedure
C. an endotracheal tube bypasses the upper airway structures
D. an opening is made in the trachea below the cricoid cartilage and a semirigid plastic tube is inserted
25.An intermittent NG tube feeding should be withheld if the residual volume is
A.50 mL B. 100 mL
C. 150 mL D. >200 mL
26.The nurse is teaching a male client how to monitor his blood glucose using a One Touch meter. When observing his
technique, which one of these actions would be cause for further instruction?
A. places the lancet on the lateral side of his finger
C. adds additional blood to strip after test begins
B. washes his hands with soap and water
D. after stick, strokes gently from base of finger to tip
27.A patient is receiving a 3:1 parenteral nutrition infusion. How often should the IV infusion tubing be changed?
A.once a week B. every 24 hours
C. every 72 hours
D. after each solution is administered
28.A patient, diagnosed with sleep apnea, says he feels fine and doesnt understand why treatment is needed. Which of the
following disease processes have been linked with sleep apnea?
A. multiple sclerosis B. hypertension C. obesity D. liver disease
29.A patient who has been immobile for more than 2 weeks is now able to begin performing isometric exercises. Which nursing
diagnosis best relates to the safety of this patient?
A.disturbed thought processes
C. disturbed body image
B.impaired skin integrity
D. risk for activity intolerance
30.The nurse suspects that a patient has deep vein thrombosis in left lower leg. What is the priority nursing intervention at this
time?
A. perform test for Homans sign immediately
B. massage the area gently to promote circulation
C. keep the patient calm and quiet in bed
D. apply the ordered elastic stockings and sequential compression devices
31.The nurse is preparing a blood transfusion infusion set. Which solution should be used to prime the tubing?
A. 0.45% sodium chloride ( NS)
C. 0.9% sodium chloride (normal saline)
B. dextrose 5% in 0.45% sodium chloride (D5NS)
D. dextrose 5% in 0.9% sodium chloride (D5NS)
32.A patient is to receive a blood transfusion. Which nursing action has the greatest impact on reducing a potential transfusion
reaction?
A. administering an antihistamine 15 minutes before transfusion
B. comparing the patients identification bracelet with the blood bag label number
C. ensuring that the patient knows what his or her blood type
D. obtaining the patients previous transfusion history
33.Urine leakage in the client with a urinary retention catheter indicates
A. the need for a larger size catheter
B. an additional 10 mL water should be added to the retention balloon
C. a possible urinary tract infection
D. the client is now able to urinate normally
34. A patient receiving peritoneal dialysis observes the effluent drain and sees that is cloudy. If the patient education was done
correctly, what action would the patient take?
A. he would call the physicians office
B. he would increase his fluid intake at least 1500 mL/day
C. he would weigh himself

D. he would change the dressing over the catheter insertion site

35.Nurses assigned to care for patients with colostomy are called:
A. colostomy nurses B. enterostomy nurses C. GI nurses
D. intestine specialists
36.The nurse is placing a bedpan under a frail, underweight female patient. The nurses actions are appropriate if what method
is followed?
A. slide the bedpan under the patient
C. shove the bedpan under the patient
B. roll the patient onto a fracture bedpan
D. keep the patient flat after rolling her on the bedpan
37.The amount of urine production is directly related to
A. renal perfusion B. fluid intake
C. bladder capacity D. metabolic rate
38.When caring for a confused patient, the nurse would initiate all of he following interventions EXCEPT
A. keep activities simple and uncomplicated
C. keep clutter in traffic areas to a minimum
B. try to keep daily activities as routine as possible
D. maintain the bed in high position
39.Which one of the following statements is correct relative to making an occupied bed?
A. the bed is made by tucking the sheet under the mattress starting at the head of the bed then pulling the sheet down to the
foot of the bed
B. one side of the bed is completed first, then the client moved to that side of the bed while the second side is completed
C. making a bed with the client in the bed consists of changing the drawsheet and pillowcase
D. unoccupied bed changes are completed only when the bed is soiled, then the bed is changed by rolling up the soiled part
of the sheet and having the client move to the opposite side of the bed
40.The nurse is performing hygienic care for a comatose patient. Which action is not correct?
A. clean the eyes by washing from the inner canthus to the outer canthus
B. turn the head to the side when flossing and brushing the teeth
C. following mouth care, immediately turn the patient to a prone position
D. keep the patients mouth open with a padded tongue blade
41.Instructions to the client who is learning to use the cane when walking steps should include
A. When going downstairs, the unaffected leg is placed on the step, followed by the cane.
B. When going downstairs, the affected leg and cane are moved to the step before moving the unaffected leg to the same
step.
C. When going upstairs, the first step is placing the affected leg and cane on the step, then the unaffected leg.
D. When going upstairs, the unaffected leg is placed on the step, followed by the cane and affected leg.
42.The nurse is teaching a patient how to walk with crutches using a three-point. Which instruction is correct?
A. move the right crutch forward, then the left foot, followed by the left crutch, and finally the right foot
B. move the right crutch and the left foot forward together and then the left crutch and the right foot forward together
C. move the crutches and weak leg forward together, then move the weight-bearing leg forward
D. move the crutches forward, then swing the legs forward together
43.Which approach would be best when initially working with an anxious patient?
A. tell the patient that everything he or she says will be kept private
B. ask the patient what he or she believes is causing his or her anxiety
C. watch the patients behavior for the amount of anxiety being exhibited
D. explain what the patient can expect in terms he or she can understand
44.A nurse is working with a potentially threatening patient. Which nursing intervention is most appropriate?
A. speaking clearly and slightly louder so the patient does not need the nurse to repeat what was said
B. positioning himself or herself near the exit of the room to prevent being blocked by the patient
C. bringing in other team members so the patient knows there are others to help him or her gain control
D. asking the patient what comfort measures he or she uses when he or she becomes out of control
45.A patient recovering from a bilateral mastectomy for breast cancer tearfully tells the nurse she is feeling depressed and
worthless as a woman. Which communication phrase is inappropriate?
A. Many woman have body image concerns after undergoing this surgery.
B. Tell me more about how you feel.
C. Why do you feel depressed and worthless?
D. How long have you been feeling this way?
46.The future nurse is planning care for a grieving patient. Which of the following would not be an appropriate expected
outcome?
A. verbalize feelings of grief
C. accept the loss
B. share grief with significant others
D. speak about the deceased only once a week
47.The following are the client instructions when undergoing an Intravenous Pyelography (IVP) except:
A.You should not eat anything after 6 pm but you can take fluids until early morning.
B.Do you have any allergies to shellfish or iodine?
C.Dye injection material can cause nausea, shortness of breath, and hot, flushed feeling.
D.Encourage the client to drink at least 24 ounces of water immediately after IVP.
48.Which of the following baseline lab values need to be obtained before an arteriography?
A. hemoglobin and hematocrit
C. BUN, Creatinine, PT/PTT, APTT
B. WBC, RBC, SGOT, SGPT
D. MVP, Platelets, Blood Smear
49.A 4-year-old child with vomiting and diarrhea is admitted to the hospital. Which one of these statements regarding collecting
stool specimens for ova and parasites is correct?
A. specimen or culture must be from first stool of the day
B. clean-catch technique is used to collect stool sample
C. specimen can be refrigerated up to 24 hours
D. samples can be affected by laxatives containing heavy metals
50.A client asks the nurse about the purpose of a guaiac test. The best response by the nurse is that it
A. detects the presence of bacteria

B. tests for fat in the stool

C. tests for hidden or occult blood
D. determine if pinworms are present
Situation: You are a newly appointed nurse after 6 months of training in a tertiary hospital. As a registered nurse the application
of the Nursing process, a problem solving activity and a rational method of planning and providing care ensures competent and
safe practice. The following questions refer to nursing process.
51.Assessment data must be descriptive, concise, and complete. An assessment should NOT include:
A subjective data from the client
B. a detailed physical examination
C. the use of interpersonal and cognitive skills
D. inferences or interpretative statements not supported with data
52. Rita 32 years old comes to the clinic, for consultation. You ask her what are the medications she is taking regarding her
breathing problem. As documented on her chart during her last visit the physician recommended routine exercise. You further
her ask if she following the plan. The nurses assessment covers which Gordons functional health patterns?
A. Value-belief pattern
B. Cognitive-perceptual pattern
C. Coping-stress tolerance pattern
D. Health perception-health management pattern
53.The nursing diagnosis readiness for enhanced communication is an example of a (n):
A. risk nursing diagnosis
C. potential nursing diagnosis
B. actual nursing diagnosis
D. wellness nursing diagnosis
54.A client signals with her call light. The nurse enters the room and finds the drainage tube disconnected, the IV has 100 ml of
fluid remaining, and the client has asked to be turned. Which of the following should the nurse perform first?
A. reconnect the drainage tubing
B. inspect the condition of the IV dressing
C. improve the clients comfort, and turn to her side
D. go to the medication room, and obtain the next IV fluid bag
55.In which of the following examples is a nurse applying critical thinking attitudes when performing a dressing change?
A. following the procedural guideline for a dressing change
B. seeking necessary knowledge on the steps of the procedure
C. showing confidence in knowing which dressing materials to use
D. being sure that the dressing covers the entire wound completely
56.A client is recovering from surgery for removal of an ovarian tumor. It is one day after having surgery. Because she has an
abdominal incision and dressing, the nurse has selected a nursing diagnosis of risk for infection. Which of the following is an
appropriate goal statement for the diagnosis?
A. client will remain afebrile by discharge
B. clients wound will remain free of infection by discharge
C. client will receive ordered antibiotic on time over next 3 days
D. clients abdominal incision will remain covered with a sterile dressing for 2 days
Situation: Vital signs are significant indicator that tells the condition and status of clients. An important routine nursing
responsibility to monitor the clients at the start of every shift.
57.A 52-year-old woman is admitted with dyspnea and discomfort in her left chest with deep breaths. She has smoked for 35
years and recently lost over 10 pounds. Which vital sign should not be delegated to a nursing assistant?
A. temperature
B. radial pulse
C. Respiratory rate
D. Oxygen saturation
58.The client requests to get out of bed to go to the bathroom. He has orders for up ad lib. What action do you take?
A. Obtain orthostatic BP measurement
B. Tell him it is not a good idea, and provide a urinal
C. ask the nursing assistant to assist him to the bathroom
D. give him some slippers, and tell him where the bathroom is located
Situation: In data collection, the nurse conducts a thorough physical examination to validate data gathered during her history
taking. These are important to identify clients problems.
59.The nurse conducts a general survey on an adult client, which includes:
A. appearance and behavior
C. observing specific body systems
B. measurement of vital signs
D. conducting a detailed health history
60.To correctly palpate the clients skin for temperature, the nurse uses the:
A. base of the hands
C. dorsal surface of the hands
B. fingertips of the hands
D. palmar surface of the hands
61.To auscultate the clients lung fields, the nurse uses a systematic pattern comparing:
A. top to bottom
B. anterior to posterior C. side to side D. interspace to interspace
62.While auscultating heart sounds, the nurse documents that S2 is best heard at the base. This sound (S2) correlates with closure
of the:
A. aortic and mitral valves
C. aortic and pulmonic valves
B. mitral and tricuspid valves
D. tricuspid and pulmonic valves
63.To spread breast tissue evenly over the chest wall during an examination, the nurse asks the client to lie supine with:
A. both arms overhead with palms upward
C. the dominant arm straight along side the body
B. hands clasped just above the umbilicus
D. the ipsilateral arm behind the head.
64.The nurse is teaching a client how to perform a testicular self-examination. The nurse informs the client:
A. The testes are normally round, movable, and have lumpy consistency.
B. Contact your health care provider if you feel a painless pea-size nodule.
C. The best time to do a testicular self-examination is before your bath or shower.
D. Perform a testicular self-examination weekly to detect signs of testicular cancer.

65.The client is being assessed for range of joint movement. You ask the client to move the arm toward the body evaluating the
movement of:
A. Flexion B. Extension C. Abduction D. Adduction
Situation: Administering medication is a dependent nursing intervention where nurses continuously and consistently apply the
principles of safe drug administration.
66.When identifying a new client before administering medications, the nurse asks the client to state his name. The client does
not state the correct name. The nurse asks again, and the client states still another name. What is the nurses next action?
A. laugh at the client and tell him to quit kidding
B. give the medications without any further questioning
C. look at the clients armband to identify the client, and disregard what the client said
D. investigate the clients mental status before administering any further medications
67.A nursing student takes a clients antibiotic to his room. The client asks the nursing student what it is and why he should take
it. The nursing students reply includes the following information:
A. only the clients physician can give this information
B. the name of the medication and a description of its desired effect
C. information about medications is confidential and cannot be shared
D. due to limits placed on nursing students, the client will have to speak with his assigned nurse about this
68.The nurse is administering a sustained-release capsule to a new client. The client insists that he cannot swallow pills. The
best course of action for the nurse is to:
A. ask the physician to change the order
C. hide the capsule in a piece of solid food
B. crush the pill with a mortar and pestle
D. open the capsule and sprinkle it over pudding
69.The nurse takes the medication to a client, and the client tells the nurse to take it away because she is not going to take it.
The nurses first action should be to:
A. ask the clients reason for refusal
B. explain that she must take the medication
C. take the medication away and chart the clients refusal
D. tell the client that her physician knows what is best for her
70.A client is receiving an IV push medication. If this type of drug infiltrates into the outer tissues, the nurse will:
A. continue to let the Intravenous run
B. apply a warm compress to infiltrated site
C. follow facility policy or drug manufacturers directions
D. not to worry about this because vesicant filtration is not a problem
Situation: The nurse plays an important role in promoting health thru utilization of communication skills which is vital and
inevitable, thus nurses must relate therapeutically. (Items no. 21 22)
71.When working with an older adult, the nurse should remember to avoid:
A. touching the client
C. shifting from subject to subject
B. allowing the client to reminisce
D. asking the client how her or she feels
72.A nurse should consider zones of personal space and touch when caring for clients. If the nurse is taking the clients nursing
history, she should:
A. sit next to the client
C. be 18 inches to 4 feet from the client
B. be 4 to 12 feet from the client
D. be 12 inches to 3 feet from the client
Situation: Client education is an essential component of safe quality care.
73.A nurse is going to teach a client how to perform breast self-examination. The behavioral objective that best measures the
clients ability to perform the examination is the :
A. client will verbalize the steps involved in breast self-examination within one week
B. nurse will explain the importance of performing breast self-examination once a month
C. client will perform breast self-examination correctly on herself before the end of the teaching session
D. nurse will demonstrate breast self-examination on a breast model provided by American Cancer Society
74.An older adult is being started on a new antihypertensive medication. In teaching the client about the medication, the nurse:
A. speaks loudly
B. presents the information once
C. expects the client to understand the information quickly
D. allows the client time to express himself or herself and ask questions
Situation: Essential skills are necessary when taking care of dying clients and eventually caring of the person after his/her death.
75.A self-care goal for the nurse who cares for dying and grieving clients might be:
A. learn not to take the loss so seriously
B. limit involvement with clients who are grieving
C. maintain life balance, and reflect on the meaning of ones work
D. admit that you are not well suited to care for grieving clients and families
76. During post-mortem care the nurse should give priority to:
A. locating the clients clothing
B. providing culturally and religiously sensitive care in body preparation
C. transporting the body to the morgue as soon as possible to prevent body decomposition
D. providing all post-mortem care to protect the deceaseds family from having to see the body
Situation: As registered nurses you assumed responsibility and challenged in the provision of the clients physiological needs.
77.Practices that helps prevent transmission of infection help protect client and health workers from disease. The most effective
way to break the chain of infection is by:
A. hand hygiene
C. placing clients in isolation
B.wearing gloves
D. providing private rooms for clients
78.After coming in contact with infected clients, and after handling contaminated equipment or organic material, visitors are
encouraged to:

A.wear gloves before eating or handling food

C. leave the facility to prevent contamination of others
B.use a private room to talk with family members
D. perform hand hygiene before eating or handling food
79.The nurse has redressed a clients wound and now plans to administer a medication to the client. It is important to:
A. leave the gloves on to administer the medication
B. remove gloves and perform hand hygiene before leaving the room
C. remove gloves and perform hand hygiene before administering the medications
D. leave the medication on the bedside table to avoid having to remove gloves before leaving the clients room
80.When a nurse is performing surgical hand asepsis, the nurse must keep hands:
A.below elbows
B. above elbows C. at a 45-degree angle
D. in a comfortable position
81.Which of the following is used to sterilize surgical instruments, parenteral solutions and surgical dressings:
A. an autoclave is used
C. ethylene oxide gas is used
B. soap and water is used
D. chemicals are used for disinfection
82.A principle of good body mechanics includes which of the following concepts?
A. keeping the knees in a locked position
B. bending at the waist to maintain a center of gravity
C. maintaining a wide base of support and bending at the knees
D. holding objects away from the body to improve leverage
83.A client begins to fall during ambulation. How would the nurse prevent injury to the client?
A. call for assistance
B. instruct the client to sit in the nearest chair
C. allow the client to fall to prevent injury to the nurse
D. slide the client down the nurses body and leg to the floor
Situation: Noli a staff nurse is aware that nursing interventions are developed to modify the hospital environment for protection
of clients. The following questions pertain to safety of the clients.
84.Noli discovered an electrical fire in a clients room. His first action would be to:
A. activate the fire alarm
C. evacuate any clients or visitors in immediate danger
B. confine the fire by closing all doors and windows
D. extinguish the fire by using the nearest fire extinguisher
85.The family of a confused, ambulatory client insists that all four side rails be up when the client is alone. The best way to
handle this situation would be to:
A. ask them to stay with the client at all times
B. inform them of the risks associated with side rail use
C. thank them for being conscientious and put the four rails up
D. provide the client a one-to-one sitter while the side rails are up
86.In addition to bathing, which intervention best promotes client comfort:
A.snacks
B. back rub C. books on tape
D. postural drainage
87.The priority when providing oral hygiene to an unconscious client is to prevent:
A. aspiration
B. mouth odor C. dental caries D. mouth ulcerations
88.The following four clients are all at risk for fluid volume excess. As a staff nurse which of the clients do you see first?
A. an 88-year-old with a fractured femur scheduled for surgery
B. a 65-year-old recently diagnosed with congestive heart failure
C. a 50-year-old with second-degree burns on the ankles and feet
D. a 20-year-old with a 5-year history of type 1 diabetes mellitus
89.A client has the following gas levels: pH, 7.52; PaCO 2, 28 mm Hg; PaO2, 92 mm Hg; HCO3, 17 mEq/L. You would expect
the health care provider to order:
A. oxygen at 3 L/min via nasal cannula
C. potassium chloride 20 mEq in normal saline
B. sodium bicarbonate 1 amp every 12 hours
D. deep breathing exercises to ease respiratory effort
Situation: Albert the nurse in the male surgical ward recalls the importance of nutrition that provides energy for cellular
metabolism and repair, organ function and body movement.
90.Albert is teaching is teaching a client about healthy nutrition. He recognized that the client understands the teaching when he
states:
A. I need to stop eating red meat
B. I will increase the servings of fruit juice to four a day
C. I will make sure that I eat a balanced diet and exercise regularly
D. I will not eat so many dark green vegetables and eat more yellow vegetables
91.Which action is initially taken by Albert to verify correct position of a newly placed small-bore feeding tube?
A. place an order for X-ray examination to check position
B. confirm the distal mark on the feeding tube after taping
C. test the pH of the gastric contents, and observe the color
D. auscultate over the gastric area as air is injected into the tube
Situation: Urinary elimination is a basic function most people take for granted. But in a hospital setting , Luz the newly hired
nurse would usually check that clients would eliminate at the end of every shift and refer urinary problems.
92.Pedro the client in the ward ask Luz how to minimize nocturia, Pedro should avoid fluids:
A. after lunch
B. in the late afternoon C. 2 hours before bedtime D. 4 hours before bedtime
93.When Luz is applying a condom catheter, to another client it is important to secure the catheter on the penile shaft in such a
manner that the catheter is:
A. tight and drainage well
B. dependent and drainage well
C. secured with adhesive tape applied in a circular pattern
D. snug and secure, but does not cause constriction to blood flow
Situation: Alteration in elimination are often early signs or symptoms of problemswithin either the Gastrointestinal tract or
another body system. Lauro,an emergency nurse is admitting a 57 year old male client with complaints of diarrhea for 2 days.

94.Diarrhea that occurs with a fecal impaction in the result of:

A.a clear liquid diet
C. inability of the client to form a stool
B.irritation of the intestinal mucosa
D. seepage of stool around the impaction
95.Another patient is in the E.R. for gastrointestinal work up. A cleaning enema is ordered for a 55-year-old client before
intestinal surgery. The maximum amount of fluid given is:
A. 150 to 200 mL
C. 400 to 750 mL
B. 200 to 400 mL
D. 750 to 1000 mL
96.The client at greatest risk for developing adverse effects of immobility is a:
A. 3-year-old child with a fractured femur
C. 48-year-old woman following a thyroidectomy
B. 78-year-old man in traction for a broken hip
D. 38-year-old woman undergoing a hysterectomy
97.The nurse is caring for a client who has right-sided weakness. The nurse needs to help the client walk. What should the nurse
do while walking with the client?
A. hold the clients left hand while walking
B. hold the clients right hand while walking
C. put a gait on the client and provide support on the left side
D. put a gait belt on the client and provide support on the right side
Situation: The chances of wound infection are greater when the wound contains necrotic tissue, blood supply and tissue
defences are reduced. Assessment and cleansing of wounds are interventions directed towards wound healing. Danny a staff
nurse in the male surgical ward is preparing to obtain wound culture.
98.When obtaining a wound culture to determine the presence of a wound infection, the specimen should be taken from the:
A. necrotic tissue
C. drainage on the dressing
B. wound drainage
D. wound after it has first been cleansed with normal saline
99.Postoperatively the client with a closed abdominal wound reports a sudden pop after coughing. When Danny examines the
surgical wound site, the sutures are open and pieces of small bowel are noted at the bottom of the now opened wound. The
correct intervention would be to:
A. allow the area to be exposed to air until all drainage has stopped
B. place several cold packs over the areas, protecting the skin around the wound
C. cover the areas with sterile saline-soaked towels and immediately notify the surgical team; this is likely to indicate a
wound evisceration
D.cover the area with sterile gauze, place a tight binder over the areas, and ask the client to remain in bed for 30 minutes
because this is a minor opening in the surgical wound and should reseal quickly
100.For a client who has a muscle sprain, localized hemorrhage, or hematoma, what wound care product helps prevented edema
formation, control bleeding, and anesthetize the body part?
A. binder
C. elastic bandage
B. ice bag
D. Absorptive diaper