FUNDAMENTALS OF NURSING

BASIC INFECTION CONTROL, HYGIENE, SEPSIS/ANTISEPSIS

1. Your nursing action which indicates your observance of standard precautions would be when you:
A. Dispose needles, scalpel blades, sharp instrument in double bags
B. Protect yourself from infection through contact with blood or body fluid borne viruses
C. Protect yourself from contact with blood, open wounds, and body fluids
D. Practice frequent hand washing including washing of contaminated gloves

2. For which procedure would the nurse use aseptic technique and which would require the nurse to use sterile
technique?
A. Sterile technique for monitoring urine output and aseptic technique for placing a central line
B. Sterile technique for urinary catheterization in the hospital and aseptic technique for changing
client’s soiled linens
C. Sterile technique for a spinal tap and aseptic technique for surgery
D. Aseptic technique for food preparation and sterile technique for starting an IV line

3. When assigning the proper precautions for a client with chickenpox, which of the following transmission-based
precautions would be the most appropriate?
A. Contact precautions
B. Universal precautions
C. Airborne precautions
D. Reverse isolation precautions
E. Droplet precautions

Situation: Accuracy in taking and recording of the VITAL SIGNS is BASIC and is important in patient care

4. A heart rate of more than 100bpm is called:

A. Hypercardia
B. Tachycardia
C. Tachypnea
D. Cardiac Overload

5. The nurse obtained a prior blood pressure reading of 70/40 mm Hg from a male client. This time she could not obtain
the reading by auscultation. The most appropriate nursing action would be to:
A. Leave the blood pressure cuff on the client so as not to disturb when checking the blood
pressure again
B. Take the client’s blood pressure by palpation reporting to the physician any 20 mm Hg change in
reading
C. Report to the physician immediately for proper intervention
D. Ask a nursing assistant to take the blood pressure by auscultation

BASIC FUNDA COMPUTATIONS

6. The physician orders an IVF of 1 liter PNSS to be run for 8 hours. The drop factor is 15gtts/min. What is the drip rate?
A. 20 gtts/min
B. 30 gtts/min
C. 25 gtts/min
D. 35 gtts/min

7. The physician orders Amlodipine 10 mg/tab. The stock dose is Amlodipine 5 mg/tab. How many tablets should the
nurse give:
A. 1
B. 2
C. 3
D. 4
8. The order is Ampicillin 0.4 mg/kg. Client weighs 38.5 pounds. The bottle reads Ampicillin 10 mg/mL. The nurse should
give:
A. 0.5 mL
B. 0.6 mL
C. 0.7 mL
D. 0.8 mL

9. The client has a standing order of Clindamycin 60 mg/ampule every 6 hours. The nurse gives the first dose at 600H.
The next dose must be given at:
A. 1200H
B. 1300H
C. 1400H
D. 1500H

10. The client has an order of 1 liter PNSS for IV fluid replacement. The drop factor is 15 gtts/min. It must be consumed
80 ml/hr. How many hours will the IV fluid last?
A. 8 hours
B. 10 hours
C. 12 hours
D. 16 hours

11. A cardiac client is admitted to your ward because of severe angina attack. The nurse takes the blood pressure of the
client and it reveals a BP of 160/120. The MAP of the client is:
A. 100 mm Hg
B. 110 mm Hg
C. 120 mm Hg
D. 130 mm Hg

BASIC NURSING THEORIES

Situation: It is BASIC for shieldster nurses to identify his / her priorities.

12. A nurse has implemented the use of non-contact therapeutic touch. Which theorist applied the concept surrounding
this intervention?
A. Florence Nightingale
B. Martha Rogers
C. Virginia Henderson
D. Rosemarie Parse

13. A nurse educator incorporates stress, power, authority, and personal space along with other concepts and considers
these concepts essential knowledge for use by nurses. The educator is applying principles from which theorist into the
curriculum?
A. Dorothea Orem
B. Imogene King
C. Jean Watson
D. Hildegard Peplau

14. A parish health nurse is working with a particular congregation in setting up a support program for shut-ins within the
congregation who are not able to come to regular prayer services. In this capacity, the nurse is working in which of the
following roles?
A. Counselor
B. Educator
C. Referral source
D. Facilitator

Situation: Using team approach when providing care helps promote quality and continuity of care for the client from the
pre-admission phase to discharge and follow up care.
15. Care is the essence of nursing and the dominant, distinctive, and unifying feature of nursing
A. Culture Care Diversity and Universality Theory by Madeleine Leininger
B. Human Caring Theory by Jean Watson
C. Human becoming Theory by Parse
D. Adaptation Model by Sister Callista Roy

BASIC PRINCIPLES OF POSITIONING

16. When a shieldster nurse performs an abdominal examination, the client should be in a supine with the head of the bed
placed at what position?
A. 0 degree
B. 30 degrees
C. 45 degrees
D. 90 degrees

17. The nurse understands that the correct position to perform mouth care on a comatose patient is:
A. Side-lying
B. Semi-Fowler’s
C. Supine
D. Sim’s

18. A C4 quadriplegic has slid down in the bed. Which of the following is the best method for the nurse to use to reposition
him?
A. One nurse lifting under his buttocks while he uses the trapeze
B. Two people lifting him up in bed with a draw sheet
C. Two people log rolling the client from one side to the other
D. One nurse lifting him under his shoulders from behind

Situation: Before accepting you as a staff nurse in the hospital, your BASIC knowledge, attitude and skills are tested to
ensure safe nursing practice.

19. How do you assist a male patient in ambulating if he has generalized left sided weakness?
A. Position on patient’s right side holding his right arm
B. Position on patient’s left side holding his left arm
C. Position on patient’s right side holding his waist
D. Position on patient’s left side holding his waist

BASIC EXERCISE AND MOBILITY

20. An elderly male client is transferred to a skilled nursing facility from the hospital because he is unable to ambulate due
to a left femoral fracture. When doing a skin assessment, the nurse notices a 3-cm, round area partial thickness skin loss
that looks like a blister on the client’s sacrum. Which stage is apparent?
A. Stage I pressure ulcer
B. Stage II pressure ulcer
C. Stage III pressure ulcer
D. Stage IV pressure ulcer

21. A man has sprained his ankle. Why would the nurse apply cold therapy to the injured area?
A. Reduce the body’s temperature
B. Increase circulation to the area
C. Aid in reabsorbing the edema
D. Relieve pain and control bleeding

22. When transferring a client between bed and chair, The following must be implemented except:
A. Lower the bed to its lower position. Lock the wheels of bed
B. Put the wheelchair on the side of the bed toward his weaker side
C. Place the wheelchair parallel to the bed as close to the bed as possible
D. Assess orthostatic hypotension before moving the client
23. For clients who have difficulty walking, Angle the wheelchair to the bed at a:
A. 90 degree angle
B. 45 degree angle
C. 25 degree angle
D. 10 degree angle

24. When transferring client between bed and stretcher, The nurses performs the following except:
A. Ask the client to flex the neck during the move.
B. Place client’s arm at sides
C. Roll the drawsheet as close as possible to the client’s side
D. All of the above

25. Logrolling is a technique used to turn a client in unison. It prevents additional injury to clients with:
A. Spinal Injury
B. Open wound of extremities
C. S/P BKA
D. Conscious client

26. Before performing Logrolling, Position yourselves and client appropriately first except:
A. Stand on the same side of the bed and assume a broad stance with one foot ahead of the other.
B. Place the client’s arms across the chest
C. Lean your trunk, and flex your hips, knees, and ankles
D. Tighten your back muscles for lifting

27. During an exercise session, the nurse assists the client to dorsiflex and plantarflex the foot, explaining that the client
needs to exercise the foot to maintain function. The client looks surprised and asks what kind of exercise this is. The
nurse should reply:
A. Isotonic exercise
B. Isometric exercise
C. Active range of motion exercise
D. Passive range of motion exercise

28. What safe instructions would you teach a client who is ascending and descending stairs with crutches?
A. “Go up with the good leg while weak leg is down; Go down with the bad leg while the good leg is
up.”
B. “Go up with the good leg while weak leg is down; Go down with the good leg while the bad leg
is up.”
C. “Go up with the bad leg while good leg is down; Go down with the good leg while the bad leg
is up.”
D. “Go up with the bad leg while good leg is down; Go down with the bad leg while the good leg is
up.”

29. What does the smart shieldster nurse in charge do when making a surgical bed for a patient from PACU?
A. Leaves the bed in the high position when finished
B. Places the pillow at the head of the bed
C. Rolls the patient to the far side of the bed
D. Tucks the top sheet and blanket under the bottom of the bed

BASIC CONCEPTS ON OXYGENATION, ELIMINATION, AND CIRCULATION

30. A client is diagnosed with stress incontinence. Initial treatment of this bladder condition involves:
A. Abdominal wall exercises
B. Apha-adrenergic agonists
C. Pelvic floor exercises (Kegel’s)
D. Foley catheter

31. Colace is:

A. Bulk forming laxative
 B. Stool softener
C. Retention enema
D. None of the above

32. Don’t forget that suctioning respiratory tract secretions of a client is done on a “PRN” or “as needed” basis. You are
about to set the suction pressure to be used to in a client with excessive respiratory mucus production. You are using a
wall unit suction machine. How much pressure should you set the valve before suctioning your client?
A. 50-95 mmHg
B. 200-350 mmHg
C. 100-120 mmHg
D. 10-15 mmHg

33. A client from a geriatric home is has a degenerative disorder called Alzheimer’s disease. She is unable to speak,
cannot perform ADL by herself, unable to ambulate, and unable to hold head erect. What stage does she belong?
A. Stage2
B. Stage 3
C. Stage4
D. Stage 5

34. A patient on bed rest has developed a full thickness ulcer penetrating the subcutaneous tissue. The nurse documents
that this ulcer is in which of the following stage?
A. Stage 1
B. Stage 2
C. Stage 3
D. Stage 4

35. External catheters such condom catheters are used for incontenent males. It is preferrable than retention catheters
primarily because of:
A. Risk of UTI is minimal
B. Privacy is maintained
C. No risk of UTI
D. Totally prevents skin irritation as a result of urine incontinence

36. A nurse is about to tape after insertion of a condom catheter. What is the manner of tapping to secure the placement?
A. Spiral
B. Parallel
C. Longitudinal
D. Vertical

SLEEP, LOSS, GRIEVING AND DEATH

37. Which of the following does not characterize REM stage of sleep?
A. Highly active brain functions
B. Active dreaming occurs and dreams are not remembered
C. Irregular respiratory rates
D. Depressed muscle tone

38. Obstructive sleep apnea is defined as frequent and loud snoring and breathing cessation for 10 seconds or more for
five episodes per hour or more, followed by awakening abruptly with a loud snort as the blood oxygen level drops. Which
of the following is not a complication of this problem?
A. Cerebrovascular accident (CVA)
B. Alzheimer’s disease
C. Cardiac arrhythmia
D. Hypertension
E. Respiratory acidosis

39. A client develops full-blown AIDS and expresses to the nurse that “he will do anything to not die from this.” In which
phase of the Kubler-Ross’s dying process is the client on?
 A. Denial
B. Anger
C. Bargaining
D. Depression
E. Acceptance

40. A nurse is implementing post-mortem care. What would the nurse initially perform?
A. Wash hands
B. Close patient’s eyes and remove contraptions
C. Place “No visitor – Check at Nurses’ Station” sign to door
D. Attach an identification tag to the ankle or great toe
E. Put on clean gloves and wash soiled areas of body

BASIC PRINCIPLES IN MEDICATIONS

41. The nurse is preparing a powdered medication for administration. Upon reconstituting a powdered medication for
injection, it’s necessary to use which type of solution?
A. Sterile saline
B. Sterile water
C. Mineral water
D. Tap water

42. The Nurse Unit Manager also discussed the KARDEX. All but one of the following are the importance of the KARDEX
A. It is the primary basis of endorsement
B. It provides readily available information from clients
C. This can also be a document where allergy information is written
D. It is a tool of end of shift reports

43. The nurse anticipates that the treatment of metabolic alkalosis will be to administer:
A. Hemodialysis
B. Acetylcysteine (Mucomyst)
C. Insulin
D. Naloxone (Narcan)

44. The client with DM 1 is given Humulin N at 7 pm each day. The client should be instructed that the greatest risk for
hypoglycemia will occur at what time?
A. 6 PM
B. 7 PM
C. 10 PM
D. 1 AM

BASIC DIAGNOSTIC TESTS

45. The normal amylase level of an average person is:

A. 50 to 150 UL
B. 10 to 50 UL
C. 100 to 200 UL
D. 200 to 300 UL

46. A client with hypertension is scheduled for serum lipid analysis. Which of the following health teaching is important to
ensure accurate reading?
A. Tell the patient to eat fatty meals 3 days prior to the procedure to prevent false negative results
B. Do not eat or drink anything 12 hours prior to the procedure
C. Ask the client to drink 1 glass of water 1 hour before and after the procedure
D. Tell the client that the normal serum lipase level is 60 to 120 U/L
47. A client is suspected to be suffering from infectious diarrhea. In collecting a routine specimen for fecalysis, which of
the following, if done by a nurse, indicates inadequate knowledge and skills about the procedure?
A. The nurse scoops the specimen specifically at the site with blood and mucus
B. She took around 1 inch of specimen or a teaspoonful
C. Ask the client to call her for the specimen after the client wiped off his anus with a tissue
D. Ask the client to defecate in a bedpan and secure a sterile container

BASIC JOB INTERVIEW CONCEPTS

48. The nurse during a job interview can ask questions to the interviewer except:
A. Staffing of the ward
B. Compensation
C. Job description
D. None of the above

49. The appropriate attire for a job interview is:

A. Floral dress
B. Ward uniform
C. Business attire
D. All of the above

50. During a job interview, what is the first thing that the nurse should do?
A. Handshake
B. Eye contact
C. Greet, “Good Morning/Good Afternoon”
D. Take a seat

SITUATION: Physical examination is performed to gather comprehensive pertinent assessment data. Health history
ascertains the client’s complaints and directs the focus of physical examination.
51. While taking the health history of the client, she tells the nurse that she has occasional episodes of palpitations that would
last for about 45 minutes to an hour. To further explore this information, the BEST question that the nurse would ask the
client would be:
A. “What are you doing or what’s going on around you when this happens?”
B. “Are there other symptoms you experience along with this?”
C. “Does the heart problem occur at any specific time of day?”
D. “How frequently does this episode of palpitation happen to you?”

52. A female client is in the Emergency Unit with chief complaints of difficulty of breathing and is receiving oxygen inhalation.
To obtain a complete health history of the client, the BEST nursing approach is to:
A. Focus on the physical examination and obtain other data from the chart
B. Use the medical history taken by the physician
C. Have several short sessions with client to gather data needed
D. Call family members to provide additional information about the client.

53. A client has just been transferred to the Surgical Unit after knee surgery. The nurse needs to assess the circulation of the
right lower leg. Which of the following is the INITIAL approach of the nurse?
A. Check pedal pulse with your fingertips C. Touch affected leg to check temperature
B. Inspect color of the foot D. Take blood pressure at the ankle

54. While performing a physical examination to an 82-year-old male client, the nurse modifies her examination to consider
the client’s general weakness and reduce ability to move in bed. Which of the following is the MOST appropriate nursing
action?
A. Sequencing the examination to minimize changing client’s position C. Avoid touching the client so as not to
alienate the client
 B. Examining client only in the position where he is comfortable D. Speaking loudly and close to the ear when
talking to client

55. The nurse is auscultating the client’s heart. Which of the following is the BEST position for the client to enable the nurse
to hear all areas and high-pitched murmurs?
A. Sitting and leaning forward B. Left lateral recumbent C. Supine D.
Lying in bed

SITUATION: Loss and grief affect not only the clients and their families but also the nurse who care for them. It is essential
for the nurse to have a thorough understanding of a client’s loss and the meaning of loss to the client.
56. A 55-year-old client is terminally ill with advance cancer of the ovary. To assist and comfort her, the nurse should:
A. Attend to her physical needs
B. Provide support to the client
C. Assess continuously the client’s condition
D. Assess the client’s understanding of her illness and impending death

57. Upon learning about her condition, the client says to the nurse “Why me? I did not do anything wrong.“ What response of
the nurse is most appropriate?
A. “You will be fine.” C. “This must be very difficult for you.”
B. “Death is a normal part of life.” D. “Everyone has to die sooner or later.”

58. The client is in severe pain and manifest signs of impending death. The husband asks the nurse if his wife is going to die
soon. Which of the following is the most appropriate response of the nurse?
A. “The signs do not predict an exact time of death.” C. “Death is inevitable.”
B. “You are concerned that your wife will die?” D. “Are you worried that your wife will die?”

59. The client has just died with her family around her. What appropriate nursing action should the nurse make?
A. Allow the family time to be with the deceased client C. Give the personal belongings of the client to her family
B. Allow the family to grieve D. Reassure the family that the body will be cared of

60. The body is being prepared for transfer to the mortuary. Which of the following is the most appropriate action of the nurse?
A. Remove all contraptions C. Secure all belongings in a plastic bag
B. Record the time of death D. Bathe the body and place identification tags

SITUATION: The nurse has been assigned to take care of a client who has an endotracheal tube. She noted thickened
secretions.
61. Which of the following is the MOST appropriate nursing intervention to loosen the secretions?
A. Instill Mucomyst into the endotracheal tube and frequent turning of the client unless contraindicated
B. Perform chest physiotherapy and assess the respiratory status of the client
C. Administer humidified oxygen and place in side lying or prone position unless contraindicated
D. Increase fluid intake and frequent turning unless contraindicated

62. In performing endotracheal suctioning, the nurse should apply suction while:
 A. Rotating the catheter gently for not more than 10 seconds
B. Observing the amount and character of the secretions after each suctioning
C. Observing the client’s tolerance to the procedure
D. Assessing the client’s respiratory and circulatory status.
63. The nurse is monitoring the cuff pressure. To minimize the risk of tracheal tissue necrosis, the nurse should maintain
the pressure to:
A. 40 – 45 mmHg B. 20 – 25 mmHg C. 30 – 35 mmHg D. 10
– 15 mmHg

64. The nurse is providing oral and nasal care every 2 to 4 hours to the client. As a precautionary measure for possible
biting down of the oral endotracheal tube, the nurse should:
A. Have an assistant to hold the client C. Provide humidified air prior to the procedure
B. Use an oropharyngeal airway D. Position the client to side lying position

65. The head nurse reminds the staff nurse about measures that must be strictly observed when suctioning the client with
endotracheal tube. Which of the following is the MOST appropriate measure during suctioning?
A. Using rubber gloves when doing suctioning C. Suctioning 2 to 3 times before withdrawing
the catheter
B. Suctioning while inserting the catheter D. Hyperoxygenating the client before and after
the procedure

SITUATION: The following situations are opportunities for the nurse to give health teachings to clients and their family
members.
66. A client who had a cerebrovascular accident resulted in right-sided weakness of extremities and mild slurring of speech.
The nurse is assisting client to ambulate. To prevent the client from falling, the nurse should stand at the:
A. Left side with one arm around the client’s waist C. Right side with one arm around the client’s
waist
B. Right side and holding the client arm D. Left side and holding the client’s arm
67. The use of principles of body mechanics is important when taking care of clients. To prevent injury to self and others,
the nurse teaches the family members to do which of the following?
A. Move about a foot away from the client if possible
B. Form a broad base of support, flex the knees and keep the feet wide apart
C. Use back and arm to support lifting or moving activities
D. Bend from the waist knees straight and feet wide apart
68. The clinic nurse in a large factory teaches some exercise to some office workers. Which of the following statements is
the most appropriate?
a. Exercise can easily burn and expend caloric intake
b. The best cardiovascular activity is walking on a treadmill
c. Less intense or not very tiring exercises should be done frequently to be of value
d. Continuous activity for a long period is useful as an exercise

69. An elderly client has been taught how to use crutches in going up and down the stairway. You observed that the client’s
use of crutches is appropriate when he:
A. Uses the crutch next of the affected leg when going up or down the stairs
B. Advances the crutches first to go up the stair then the affected leg
C. Uses the stair banister for support while going up or down the stairs
D. Advances the crutches to go down the stairs then move the affected leg afterwards
70. A mother calls the Emergency Unit to ask for advice after she found her child seated on the bathroom floor with
cleanser around her mouth and tongue. The appropriate advice given to the mother would be to:
A. Check if the child is breathing and if the airway is open C. Call the poison control of a general hospital
B. Give the child syrup to induce vomiting D. Remove cleanser from the tongue and mouth

SITUATION: A 21-year-old female is admitted in the Surgical Ward and is placed in traction. She has been in bed and is
very frustrated because she cannot do the usual daily activities.
71. The nursing diagnosis that is most appropriate for this client is:
A. Potential for immobility C. Activity intolerance
B. Impaired physical mobility D. Risk for injury and pathologic fracture
72. Limitations in the activity-exercise routine of a client affect her self-esteem. To help increase the client’s self-esteem, the
nurse understanding that:
A. Self-esteem depends upon having a feeling of usefulness and independence
B. Being confined pin bed with no productive activity causes depression
C. Self-esteem is dictated by one’s state of physical health and beauty
D. The current problem exacerbates the client’s low self esteem

73. The nurse maintains the client’s alignment while she is on traction in order to:
 A. Promote body balance and optimal brain functioning C. Promote efficient circulation and enhance
lung expansion
B. Maintain body posture and strength D. Decrease workload of the heart
74. The nurse considers the following statements when taking care of a client with traction EXCEPT:
A. Steady pull from both directions keep the fractured bone in place.
B. Weights should be kept resting on the floor
C. Clients on traction need adequate skin care and proper positioning
D. Traction can be used to correct or prevent deformities

75. Part of nursing care for the client on traction is giving instructions for isometric exercises in order to:
A. Prevent decubitus ulcers B. Normalize blood pressure C. Improve lung capacity D. Maintain muscle strength

SITUATION: An understanding of the infectious process and appropriate methods to protect the health workers and client
from disease is important. The following questions pertain to preventing transmission of infection.
76. The nurse is explaining standard protection to the client. This includes which of the following actions?
A. Wearing protective equipment when doing any nursing procedures
B. Hand washing using antimicrobial soap and water
C. Recapping of used needles with both hands then place in puncture resistant container
D. Using clean gloves to handle contaminated items, blood and excretions
77. The nurse is changing the wound dressing of the client. The MOST appropriate action of the nurse would be to:
A. Remove old dressing with sterile gloves C. Open the sterile dressings with sterile gloves
B. Wear sterile gloves whenever in contact with the area D. Pour antiseptic solution out of the container
with sterile gloves

78. The client has an order for contact precaution. The nurse is to give her a bath. The precautionary measure that the
nurse observes is to use:
A. Face mask and gloves C. Gloves and gowns
B. Sterile gloves and cap D. Cap and face mask
79. The clinical instructor in the Surgical Unit is teaching the nursing students about the prevention of spread of diseases in
the care environment. Which of the following is the MOST important practical way to prevent the spread of diseases?
A. Consistently washing hands C. Wearing gloves whenever giving care
B. Isolating infected clients D. Wearing cap and gown
80. The nurse is to perform a sterile procedure while assisting in minor surgery. Which of the following actions of the nurse
maintains aseptic technique?
A. Keeping the sterile field within view C. Talking to other over the sterile field
B. Handling the medicine to the physician over the sterile field D. Using sterile gloves in opening sterile
package

SITUATION: Problems with bowel movement may be experienced by people of different ages. It can cause enough
discomfort or health problems to individuals that require nursing interventions.
81. An active woman in her mid-twenties has been on weight loss diet of low carbohydrates and high protein diet. She is
successful in losing weight but is experiencing constipation. Which of the following should the nurse advice the client to
AVOID constipation?
A. Take over-the-counter laxatives to ease bowel movement
B. Try another type of diet that have less animal fat, like fish, chicken and low carbohydrates
C. Eat nutrient-dense food that are low calorie but have high nutrient value and fiber like broccoli, berries
D. Increase exercise activities to improve peristalsis
82. You are administering soapsuds enema to a client. During the procedure, the client complains of abdominal cramping.
Your most appropriate initial nursing approach would be to:
A. Clamp the enema tubing to stop flow of the fluids C. Ask the client to inhale and exhale slowly
B. Push tubing further by 2 inches D. Lower the height of the enema container

83. You are taking care of a client with fecal incontinence. You are aware that this client has a risk for injury due to:
A. Falls when trying to go to the bathroom C. Increased abdominal cramping
B. Dehydration and malnutrition D. Perineal and anal skin breakdown
84. A client is brought to the hospital due to severe diarrhea. Which of the following is a motor problem of the client
requiring immediate management by the health team?
A. Excessive passing of flatus C. Severe abdominal cramping
B. Irritation of the anal sphincter D. Severe fluid electrolyte imbalance

85. A client had abdominal surgery under general anesthesia and is still in the recovery room. You are aware that clients
who went through general anesthesia, would most likely experience:
A. Paralytic ileus C. Tolerance for solid food immediately after surgery
B. Immediate return of gastrointestinal motility D. Excessive flatus
SITUATION: A 37-year-old client, is brought to the Emergency Room for passing fresh blood upon defecation. The client is
actively bleeding and his blood pressure drops to 80/50. Fluids and blood transfusion of packed RBC are ordered
immediately.
86. This is the first time that the client will have blood transfusion. He and his family are very worried about the procedure.
Your MOST appropriate nursing intervention would be to:
A. Talk to the client and family and inquire what their fears are about blood transfusion
B. Reassure the client and family that blood transfusion is a simple low risk procedure
C. Tell the client that he will be closely observed for the first hour so he will be safe
D. Request the doctor to explain to the client why blood transfusion is necessary
87. The nurse prepares the following equipment for blood transfusion EXCEPT:
A. 0.9% normal saline solution C. Blood product properly typed and cross
matched with patient
B. IV infusion set with gauge with 22 needle D. Y type filter transfusion set
88. The nurse understands that normal saline solution is used to initiate the intravenous infusion rather than dextrose
solution before blood transfusion to:
A. Avoid cardiac overload C. Prevent increasing the blood sugar of the client
B. Maintain adequate hemoglobin content D. Avoid hemolysis and clumping of red cells
89. The nurse stays and observes closely the client after the start of the blood transfusion for possible transfusion reaction
which includes the following EXCEPT:
A. Hypovolemic reaction B. Hemolytic transfusion reaction C. Febrile reaction D. Allergic
reaction
90. After starting blood transfusion, the nurse should make sure that the blood is transfused to the patient with how many
hours from the time it started?
A. 12 hours B. 8 hours C. 10 hours D. 4 hours
91. A client who is receiving epidural analgesia complains of nausea and loss of motor function in his legs. The nurse
obtains his blood pressure and notes a drop in his blood pressure from the previous reading. Which complication is
the patient most likely experiencing?
a. Infection at the catheter insertion site
b. Side effect of the epidural analgesic
c. Epidural catheter migration
d. Spinal cord damage
92. Which pain management task can the nurse safely delegate to nursing assistive personnel?
a. Asking about pain during vital signs
b. Evaluating the effectiveness of pain medication
c. Developing a plan of care involving nonpharmacologic interventions
d. Administering over-the-counter pain medications
93. Which factor in the patient's past medical history dictates that the nurse exercise caution when administering
acetaminophen (Tylenol)?

a. Hepatitis B
b. Occasional alcohol use
c. Allergy to aspirin
d. Gastric irritation with bleeding

94. Which action should the nurse take before administering morphine 4.0 mg intravenously to a patient complaining of
incisional pain?

a. Assess the patient's incision.

b. Clarify the order with the prescriber.
c. Assess the patient's respiratory status.
d. Monitor the patient's heart rate.

95. The nurse assesses clients' breath sounds. Which one requires immediate medical attention? A client who has:

a. Crackles
b. Rhonchi
c. Stridor
d. Wheezes

96. The nurse assesses the client's pedal pulses as having a pulse volume of 1 on a scale of 0 to 3. Based on this
assessment finding, it would be important for the nurse to also assess the:

a. Pulse deficit
b. Blood pressure
c. Apical pulse
d. Pulse pressure
97. Which of the following clients has indications of orthostatic hypotension? A client whose blood pressure is:

a. 118/68 when standing and 110/72 when lying down

b. 140/80, HR 82 bpm when sitting and 136/76, HR 98 bpm when standing
c. 126/72 lying down and 133/80 when sitting, and reports shortness of breath
d. 146/88 when lying down and 130/78 when standing, and reports feeling dizzy

98. A patient is admitted to the medical surgical floor with a kidney infection. The nurse introduces herself to the patient
and begins her admission assessment. Which goal is most appropriate for this phase of the nurse-patient relationship?
The patient will be able to:

a. Describe how to operate the bed and call for the nurse.
b. Discuss communication patterns and roles within the family.
c. Openly express his concerns about the hospitalization.
d. State expectations related to discharge.

99. The nurse is teaching a child and family about firearm safety. The nurse should instruct the child to take which
step first if he sees a gun at a friend's house?

1) Leave the area.

2) Do not touch the gun.
3) Stop where he is.
4) Tell an adult.

100. A patient is agitated and continues to try to get out of bed. The nurse tries unsuccessfully to reorient him.
What should the nurse do next?

1) Apply a vest restraint.

2) Move the patient to a quieter room.
3) Ask another nurse to care for the patient.
4) Provide comfort measures.