All the questions in the quiz along with their answers are shown below.

Your answers are bolded. The correct answers have a green background while the incorrect ones have a red background. 1. A patient is admitted to the medical surgical unit following surgery. Four days after surgery, the patient spikes a 38.9 degrees C oral temperature and exhibits a wet, productive cough. The nurse assesses the patient with understanding that an infection that is acquired during hospitalization is known as:

a. a community acquired infection b. an iatrogenic infection c. a nosocomial infection d. an opportunistic infection

Nosocomial, or hospital-acquired are infections acquired during hospitalization for which the patient isnt being primarily treated. Community acquired or opportunistic infections may not be acquired during hospitalization. An iatrogenic infection is caused by the doctor or by medical therapy. And an opportunistic infection affects a compromised host. 2. A client with anemia has a hemoglobin of 6.5 g/dL. The client is experiencing symptoms of cerebral tissue hypoxia. Which of the following nursing interventions would be most important in providing care?

a. Providing rest periods throughout the day b. Instituting energy conservation techniques c. Assisting in ambulation to the bathroom d. Checking temperature of water prior to bathing

Cerebral tissue hypoxia is commonly associated with dizziness. The greatest potential risk to the client with dizziness is injury, especially with changes in position. Planning for periods of rest and conserving energy are important with someone with anemia because of his or her fatigue level but most important is safety. 3. A client was involved in a motor vehicular accident in which the seat belt was not worn. The client is exhibiting crepitus, decrease breath sounds on the left, complains of shortness of breath, and has a respiratory rate of 34 breaths per minute. Which of the following assessment findings would concern the nurse most?

a. Temperature of 102 degrees F and productive cough b. ABG with PaO2 of 92 and PaCO2 of 40 mmHg c. Trachea deviating to the right d. Barrel-chested appearance

A mediastinal shift is indicative of a tension pneumothorax along with the other symptoms in the question. Since the individual was involved in a MVA, assessment would be targeted at acute traumatic injuries to the lungs, heart or chest wall rather than other conditions indicated in the other answers. Option A is common with

pneumonia; values in option B are not alarming; and option D is typical of someone with COPD. 4. The proper way to open an envelop-wrapped sterile package after removing the outer package or tape is to open the first position of the wrapper:

a. away from the body b. to the left of the body c. to the right of the body d. toward the body

when opening an envelop-wrapped sterile package, reaching across the package and using the first motion to open the top cover away from the body eliminates the need to later reach across the steri9le field while opening the package. To remove equipment from the package, opening the first portion of the package toward, to the left, or to the right of the body would require reaching across a sterile field. 5. Assessment of a client with possible thrombophlebitis to the left leg and a deep vein thrombosis is done by pulling up on the toes while gently holding down on the knee. The client complains of extreme pain in the calf. This should be documented as:

a. positive tourniquet test b. positive homans sign c. negative homans sign d. negative tourniquet test

Pain in the calf while pulling up on the toes is abnormal and indicates a positive test. If the client feels nothing or just feels like the calf muscle is stretching, it is considered negative. A tourniquet test is used to measure for varicose veins. 6. Thomas Elison is a 79 year old man who is admitted with diagnosis of dementia. The doctor orders a series of laboratory tests to determine whether Mr. Elisons dementia is treatable. The nurse understands that the most common cause of dementia in this population is:

a. AIDS b. Alzheimers disease c. Brain tumors d. Vascular disease

Alzheimers disease is the most common cause of dementia in the elderly population. AIDS, brain tumors and vascular disease are all less common causes of progressive loss of mental function in elderly patients. 7. Which of the following nursing interventions is contraindicated in the care of a client with acute osteomyelitis?

a. Apply heat compress to the affected area b. Immobilize the affected area c. Administer narcotic analgesics for pain

d. Administer OTC analgesics for pain

Options B, C and D are appropriate nursing interventions when caring for a client diagnosed with osteomyelitis. The application of heat can increase edema and pain in the affected area and spread bacteria through vasodilation. 8. A client with congestive heart failure has digoxin (Lanoxin) ordered everyday. Prior to giving the medication, the nurse checks the digoxin level which is therapeutic and ausculates an apical pulse. The apical pulse is 63 bpm for 1 full minute. The nurse should:

a. Hold the Lanoxin b. Give the half dose now, wait an hour and give the other half c. Call the physician d. Give the Lanoxin as ordered

The Lanoxin should be held for a pulse of 60 bpm. Nurses cannot arbitrarily give half of a dose without a physicians order. Unless specific parameters are given concerning pulse rate, most resources identify 60 as the reference pulse. 9. Nurse Marian is caring for a client with haital hernia, which of the following should be included in her teaching plan regarding causes:

a. To avoid heavy lifting b. A dietary plan based on soft foods c. Its prevalence in young adults d. Its prevalence in fair-skinned individuals

Heavy lifting is one factor that leads to development of a hiatal hernia. Dietary factors involve limiting fat intake, not restricting client to soft foods. It is more prevalent in individuals who are middle-aged or older. Fair-skinned individuals are not prone to this condition. 10. Joseph has been diagnosed with hepatic encephalopathy. The nurse observes flapping tremors. The nurse understands that flapping tremors associated with hepatic encephalopathy are also known as:

a. aphasia b. ascites c. astacia d. asterixis

Flapping tremors associated with hepatic encephalophaty are asterixis. Aphasia is the inability to speak. Ascites is an accumulation of fluid in the peritoneal cavity. Astacia is the inability to stand or sit still. 11. Hyperkalemia can be treated with administration of 50% dextrose and insulin. The 50% dextrose:

a. causes potassium to be excreted

b. causes potassium to move into the cell c. causes potassium to move into the serum d. counteracts the effects of insulin

The 50% dextrose is given to counteract the effects of insulin. Insulin drives the potassium into the cell, thereby lowering the serum potassium levels. The dextrose doesnt directly cause potassium excretion or any movement of potassium. 12. Which of the following findings would strongly indicate the possibility of cirrhosis?

a. dry skin b. hepatomegaly c. peripheral edema d. pruritus

Although option D is correct, it is not a strong indicator of cirrhosis. Pruritus can occur for many reasons. Options A and C are incorrect, fluid accumulations is usually in the form of ascites in the abdomen. Hepatomegaly is an enlarged liver, which is correct. The spleen may also be enlarged. 13. Aling Puring has just been diagnosed with close-angle (narrow-angle) glaucoma. The nurse assesses the client for which of the following common presenting symptoms of the disorder?

a. halo vision b. dull eye pain c. severe eye and face pain d. impaired night vision

Narrow-angle glaucoma develops abruptly and manifests with acute face and eye pain and is a medial emergency. Halo vision, dull eye pain and impaired night vision are symptoms associated with open-angle glaucoma. 14. Chvosteks sign is associated with which electrolyte impabalnce?

a. hypoclacemia b. hypokalemia c. hyponatremia d. hypophosphatenia

Chvosteks sign is a spasm of the facial muscles elicited by tapping the facial nerve and is associated with hypocalcemia. Clinical signs of hypokalemia are muscle weakness, leg cramps, fatigue, nausea and vomiting. Muscle cramps, anorexia, nausea and vomiting are clinical signs of hyponatremia. Clinical manifestations associated with hypophosphatemia include muscle pain, confusion, seizures and coma. 15. What laboratory test is a common measure of the renal function?

a. CBC

b. BUN/Crea c. Glucose d. Alanine amino transferase (ALT)

The BUN is primarily used as indicator of kidney function because most renal diseases interfere with its excretion and cause blood vessels to rise. Creatinine is produced in relatively constant amounts, according to the amount of muscle mass and is excreted entirely by the kidneys making it a good indicator of renal function. 16. Nurse Edward is performing discharge teaching for a newly diagnosed diabetic patient scheduled for a fasting blood glucose test. The nurse explains to the patient that hyperglycemia is defined as a blood glucose level above:

a. 100 mg/dl b. 120 mg/dl c. 130 mg/dl d. 150 mg/dl

Hyperglycemia is defined as a blood glucose level greater than 120 mg/dl. Blood glucose levels of 120 mg/dl, 130 mg/dl and 150 mg/dl are considered hyperglycemic. A blood glucose of 100 mg/dl is normal. 17. Mang Edison is on bed rest has developed an ulcer that is full thickness and is penetrating the subcutaneous tissue. The nurse documents that this ulcer is in which of the following stages?

a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4

A stage 3 ulcer is full thickness involving the subcutaneous tissue. A stage 1 ulcer has a defined area of persistent redness in lightly pigmented skin. A stage 2 ulcer involves partial thickness skin loss. Stage 4 ulcers extend through the skin and exhibit tissue necrosis and muscle or bone involvement. 18. A 24 year old male patient comes to the clinic after contracting genital herpes. Which of the following intervention would be most appropriate?

a. Encourage him to maintain bed rest for several days b. Monitor temperature every 4 hours c. Instruct him to avoid sexual contact during acute phases of illness d. Encourage him to use antifungal agents regularly

Herpes is a virus and is spread through direct contact. An antifungal would not be useful; bed rest and temperature measurement are usually not necessary. 19. An 8 year old boy is brought to the trauma unit with a chemical burn to the face. Priority assessment would include which of the following?

a. Skin integrity b. BP and pulse c. Patency of airway d. Amount of pain

A burn face, neck or chest may cause airway closure because of the edema that occurs within hours. Remember the ABCs: airway, breathing and circulation. Airway always comes first, even before pain. The nurse will also assess options B and D, but these are not the highest priority assessments. 20. A client with anemia due to chemotherapy has a hemoglobin of 7.0 g/dL. Which of the following complaints would be indicative of tissue hypoxia related to anemia?

a. dizziness b. fatigue relieved by rest c. skin that is warm and dry to the touch d. apathy

Central tissue hypoxia is commonly associated with dizziness. Recognition of cerebral hypoxia is critical since the body will attempt to shunt oxygenated blood to vital organs. 21. Hazel Murray, 32 years old complains of abrupt onset of chest and back pain and loss of radial pulses. The nurse suspects that Mrs. Murray may have:

a. Acute MI b. CVA c. Dissecting abdominal aorta d. Dissecting thoracic aneurysm

A dissecting thoracic aneurysm may cause loss of radical pulses and severe chest and back pain. An MI typically doesnt cause loss of radial pulses or severe back pain. CVA and dissecting abdominal aneurysm are incorrect responses. 22. Nurse Alexandra is establishing a plan of care for a client newly admitted with SIADH. The priority diagnosis for this client would be which of the following?

a. Fluid volume deficit b. Anxiety related to disease process c. Fluid volume excess d. Risk for injury

SIADH results in fluid retention and hyponatremia. Correction is aimed at restoring fluid and electrolyte balance. Anxiety and risk for injury should be addressed following fluid volume excess. 23. Nursing management of the client with a UTI should include:

a. Taking medication until feeling better b. Restricting fluids

c. Decreasing caffeine drinks and alcohol d. Douching daily

Caffeine and alcohol can increase bladder spasms and mucosal irritation, thus increase the signs and symptoms of UTI. All antibiotics should be taken completely to prevent resistant strains of organisms. 24. Felicia Gomez is 1 day postoperative from coronary artery bypass surgery. The nurse understands that a postoperative patient whos maintained on bed rest is at high risk for developing:

a. angina b. arterial bleeding c. deep vein thrombosis (DVT) d. dehiscence of the wound

DVT, is the most probable complication for postoperative patients on bed rest. Options A, B and D arent likely complications of the post operative period. 25. Which of the following statement is true regarding the visual changes associated with cataracts?

a. Both eyes typically cataracts at the same time b. The loss of vision is experienced as a painless, gradual blurring c. The patient is suddenly blind d. The patient is typically experiences a painful, sudden blurring of vision.

Typically, a patient with cataracts experiences painless, gradual loss of vision. Although both eyes may develop at different rates.

All the questions in the quiz along with their answers are shown below. Your answers are bolded. The correct answers have a green background while the incorrect ones have a red background. 1. A patient is admitted to the medical surgical unit following surgery. Four days after surgery, the patient spikes a 38.9 degrees C oral temperature and exhibits a wet, productive cough. The nurse assesses the patient with understanding that an infection that is acquired during hospitalization is known as:

a. a community acquired infection b. an iatrogenic infection c. a nosocomial infection d. an opportunistic infection

Nosocomial, or hospital-acquired are infections acquired during hospitalization for which the patient isnt being primarily treated. Community acquired or opportunistic

infections may not be acquired during hospitalization. An iatrogenic infection is caused by the doctor or by medical therapy. And an opportunistic infection affects a compromised host. 2. A client with anemia has a hemoglobin of 6.5 g/dL. The client is experiencing symptoms of cerebral tissue hypoxia. Which of the following nursing interventions would be most important in providing care?

a. Providing rest periods throughout the day b. Instituting energy conservation techniques c. Assisting in ambulation to the bathroom d. Checking temperature of water prior to bathing

Cerebral tissue hypoxia is commonly associated with dizziness. The greatest potential risk to the client with dizziness is injury, especially with changes in position. Planning for periods of rest and conserving energy are important with someone with anemia because of his or her fatigue level but most important is safety. 3. A client was involved in a motor vehicular accident in which the seat belt was not worn. The client is exhibiting crepitus, decrease breath sounds on the left, complains of shortness of breath, and has a respiratory rate of 34 breaths per minute. Which of the following assessment findings would concern the nurse most?

a. Temperature of 102 degrees F and productive cough b. ABG with PaO2 of 92 and PaCO2 of 40 mmHg c. Trachea deviating to the right d. Barrel-chested appearance

A mediastinal shift is indicative of a tension pneumothorax along with the other symptoms in the question. Since the individual was involved in a MVA, assessment would be targeted at acute traumatic injuries to the lungs, heart or chest wall rather than other conditions indicated in the other answers. Option A is common with pneumonia; values in option B are not alarming; and option D is typical of someone with COPD. 4. The proper way to open an envelop-wrapped sterile package after removing the outer package or tape is to open the first position of the wrapper:

a. away from the body b. to the left of the body c. to the right of the body d. toward the body

when opening an envelop-wrapped sterile package, reaching across the package and using the first motion to open the top cover away from the body eliminates the need to later reach across the steri9le field while opening the package. To remove equipment from the package, opening the first portion of the package toward, to the left, or to the right of the body would require reaching across a sterile field.

5. Assessment of a client with possible thrombophlebitis to the left leg and a deep vein thrombosis is done by pulling up on the toes while gently holding down on the knee. The client complains of extreme pain in the calf. This should be documented as:

a. positive tourniquet test b. positive homans sign c. negative homans sign d. negative tourniquet test

Pain in the calf while pulling up on the toes is abnormal and indicates a positive test. If the client feels nothing or just feels like the calf muscle is stretching, it is considered negative. A tourniquet test is used to measure for varicose veins. 6. Thomas Elison is a 79 year old man who is admitted with diagnosis of dementia. The doctor orders a series of laboratory tests to determine whether Mr. Elisons dementia is treatable. The nurse understands that the most common cause of dementia in this population is:

a. AIDS b. Alzheimers disease c. Brain tumors d. Vascular disease

Alzheimers disease is the most common cause of dementia in the elderly population. AIDS, brain tumors and vascular disease are all less common causes of progressive loss of mental function in elderly patients. 7. Which of the following nursing interventions is contraindicated in the care of a client with acute osteomyelitis?

a. Apply heat compress to the affected area b. Immobilize the affected area c. Administer narcotic analgesics for pain d. Administer OTC analgesics for pain

Options B, C and D are appropriate nursing interventions when caring for a client diagnosed with osteomyelitis. The application of heat can increase edema and pain in the affected area and spread bacteria through vasodilation. 8. A client with congestive heart failure has digoxin (Lanoxin) ordered everyday. Prior to giving the medication, the nurse checks the digoxin level which is therapeutic and ausculates an apical pulse. The apical pulse is 63 bpm for 1 full minute. The nurse should:

a. Hold the Lanoxin b. Give the half dose now, wait an hour and give the other half c. Call the physician d. Give the Lanoxin as ordered

The Lanoxin should be held for a pulse of 60 bpm. Nurses cannot arbitrarily give half of a dose without a physicians order. Unless specific parameters are given concerning pulse rate, most resources identify 60 as the reference pulse. 9. Nurse Marian is caring for a client with haital hernia, which of the following should be included in her teaching plan regarding causes:

a. To avoid heavy lifting b. A dietary plan based on soft foods c. Its prevalence in young adults d. Its prevalence in fair-skinned individuals

Heavy lifting is one factor that leads to development of a hiatal hernia. Dietary factors involve limiting fat intake, not restricting client to soft foods. It is more prevalent in individuals who are middle-aged or older. Fair-skinned individuals are not prone to this condition. 10. Joseph has been diagnosed with hepatic encephalopathy. The nurse observes flapping tremors. The nurse understands that flapping tremors associated with hepatic encephalopathy are also known as:

a. aphasia b. ascites c. astacia d. asterixis

Flapping tremors associated with hepatic encephalophaty are asterixis. Aphasia is the inability to speak. Ascites is an accumulation of fluid in the peritoneal cavity. Astacia is the inability to stand or sit still. 11. Hyperkalemia can be treated with administration of 50% dextrose and insulin. The 50% dextrose:

a. causes potassium to be excreted b. causes potassium to move into the cell c. causes potassium to move into the serum d. counteracts the effects of insulin

The 50% dextrose is given to counteract the effects of insulin. Insulin drives the potassium into the cell, thereby lowering the serum potassium levels. The dextrose doesnt directly cause potassium excretion or any movement of potassium. 12. Which of the following findings would strongly indicate the possibility of cirrhosis?

a. dry skin b. hepatomegaly c. peripheral edema d. pruritus

Although option D is correct, it is not a strong indicator of cirrhosis. Pruritus can occur for many reasons. Options A and C are incorrect, fluid accumulations is usually in the form of ascites in the abdomen. Hepatomegaly is an enlarged liver, which is correct. The spleen may also be enlarged. 13. Aling Puring has just been diagnosed with close-angle (narrow-angle) glaucoma. The nurse assesses the client for which of the following common presenting symptoms of the disorder?

a. halo vision b. dull eye pain c. severe eye and face pain d. impaired night vision

Narrow-angle glaucoma develops abruptly and manifests with acute face and eye pain and is a medial emergency. Halo vision, dull eye pain and impaired night vision are symptoms associated with open-angle glaucoma. 14. Chvosteks sign is associated with which electrolyte impabalnce?

a. hypoclacemia b. hypokalemia c. hyponatremia d. hypophosphatenia

Chvosteks sign is a spasm of the facial muscles elicited by tapping the facial nerve and is associated with hypocalcemia. Clinical signs of hypokalemia are muscle weakness, leg cramps, fatigue, nausea and vomiting. Muscle cramps, anorexia, nausea and vomiting are clinical signs of hyponatremia. Clinical manifestations associated with hypophosphatemia include muscle pain, confusion, seizures and coma. 15. What laboratory test is a common measure of the renal function?

a. CBC b. BUN/Crea c. Glucose d. Alanine amino transferase (ALT)

The BUN is primarily used as indicator of kidney function because most renal diseases interfere with its excretion and cause blood vessels to rise. Creatinine is produced in relatively constant amounts, according to the amount of muscle mass and is excreted entirely by the kidneys making it a good indicator of renal function. 16. Nurse Edward is performing discharge teaching for a newly diagnosed diabetic patient scheduled for a fasting blood glucose test. The nurse explains to the patient that hyperglycemia is defined as a blood glucose level above:

a. 100 mg/dl b. 120 mg/dl c. 130 mg/dl

d. 150 mg/dl

Hyperglycemia is defined as a blood glucose level greater than 120 mg/dl. Blood glucose levels of 120 mg/dl, 130 mg/dl and 150 mg/dl are considered hyperglycemic. A blood glucose of 100 mg/dl is normal. 17. Mang Edison is on bed rest has developed an ulcer that is full thickness and is penetrating the subcutaneous tissue. The nurse documents that this ulcer is in which of the following stages?

a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4

A stage 3 ulcer is full thickness involving the subcutaneous tissue. A stage 1 ulcer has a defined area of persistent redness in lightly pigmented skin. A stage 2 ulcer involves partial thickness skin loss. Stage 4 ulcers extend through the skin and exhibit tissue necrosis and muscle or bone involvement. 18. A 24 year old male patient comes to the clinic after contracting genital herpes. Which of the following intervention would be most appropriate?

a. Encourage him to maintain bed rest for several days b. Monitor temperature every 4 hours c. Instruct him to avoid sexual contact during acute phases of illness d. Encourage him to use antifungal agents regularly

Herpes is a virus and is spread through direct contact. An antifungal would not be useful; bed rest and temperature measurement are usually not necessary. 19. An 8 year old boy is brought to the trauma unit with a chemical burn to the face. Priority assessment would include which of the following?

a. Skin integrity b. BP and pulse c. Patency of airway d. Amount of pain

A burn face, neck or chest may cause airway closure because of the edema that occurs within hours. Remember the ABCs: airway, breathing and circulation. Airway always comes first, even before pain. The nurse will also assess options B and D, but these are not the highest priority assessments. 20. A client with anemia due to chemotherapy has a hemoglobin of 7.0 g/dL. Which of the following complaints would be indicative of tissue hypoxia related to anemia?

a. dizziness b. fatigue relieved by rest c. skin that is warm and dry to the touch

d. apathy

Central tissue hypoxia is commonly associated with dizziness. Recognition of cerebral hypoxia is critical since the body will attempt to shunt oxygenated blood to vital organs. 21. Hazel Murray, 32 years old complains of abrupt onset of chest and back pain and loss of radial pulses. The nurse suspects that Mrs. Murray may have:

a. Acute MI b. CVA c. Dissecting abdominal aorta d. Dissecting thoracic aneurysm

A dissecting thoracic aneurysm may cause loss of radical pulses and severe chest and back pain. An MI typically doesnt cause loss of radial pulses or severe back pain. CVA and dissecting abdominal aneurysm are incorrect responses. 22. Nurse Alexandra is establishing a plan of care for a client newly admitted with SIADH. The priority diagnosis for this client would be which of the following?

a. Fluid volume deficit b. Anxiety related to disease process c. Fluid volume excess d. Risk for injury

SIADH results in fluid retention and hyponatremia. Correction is aimed at restoring fluid and electrolyte balance. Anxiety and risk for injury should be addressed following fluid volume excess. 23. Nursing management of the client with a UTI should include:

a. Taking medication until feeling better b. Restricting fluids c. Decreasing caffeine drinks and alcohol d. Douching daily

Caffeine and alcohol can increase bladder spasms and mucosal irritation, thus increase the signs and symptoms of UTI. All antibiotics should be taken completely to prevent resistant strains of organisms. 24. Felicia Gomez is 1 day postoperative from coronary artery bypass surgery. The nurse understands that a postoperative patient whos maintained on bed rest is at high risk for developing:

a. angina b. arterial bleeding c. deep vein thrombosis (DVT) d. dehiscence of the wound

DVT, is the most probable complication for postoperative patients on bed rest. Options A, B and D arent likely complications of the post operative period. 25. Which of the following statement is true regarding the visual changes associated with cataracts?

a. Both eyes typically cataracts at the same time b. The loss of vision is experienced as a painless, gradual blurring c. The patient is suddenly blind d. The patient is typically experiences a painful, sudden blurring of vision.

Typically, a patient with cataracts experiences painless, gradual loss of vision.

1. A patient is wearing a soft wrist-safety device. Which of the following nursing assessment is considered abnormal?

a. Palpable radial pulse b. Palpable ulnar pulse c. Capillary refill within 3 seconds d. Bluish fingernails, cool and pale fingers

A safety device on the wrist may impair blood circulation. Therefore, the nurse should assess the patient for signs of impaired circulation such as bluish fingernails, cool and pale fingers. Palpable radial and ulnar pulses, capillary refill within 3 seconds are all normal findings. 2. Pias serum sodium level is 150 mEq/L. Which of the following food items does the nurse instruct Pia to avoid?

a. broccoli b. sardines c. cabbage d. tomatoes

The normal serum sodium level is 135 to 145 mEq/L, the client is having hypernatremia. Pia should avoid food high in sodium like processed food. Broccoli, cabbage and tomatoes are good source of Vitamin C. 3. Jason, 3 years old vomited. His mom stated, He vomited 6 ounces of his formula this morning. This statement is an example of:

a. objective data from a secondary source b. objective data from a primary source c. subjective data from a primary source d. subjective data from a secondary source

Jason is the primary source; his mother is a secondary source. The data is objective because it can be perceived by the senses, verified by another person observing the same patient, and tested against accepted standards or norms. 4. Which of the following is a nursing diagnosis?

a. Hypethermia b. Diabetes Mellitus c. Angina d. Chronic Renal Failure

Hyperthermia is a NANDA-approved nursing diagnosis. Diabetes Mellitus, Angina and Chronic Renal Failure are medical diagnoses. 5. What is the characteristic of the nursing process?

a. stagnant b. inflexible c. asystematic d. goal-oriented

The nursing process is goal-oriented. It is also systematic, patient-centered, and dynamic. 6. A skin lesion which is fluid-filled, less than 1 cm in size is called:

a. papule b. vesicle c. bulla d. macule

Vesicle is a circumscribed circulation containing serous fluid or blood and less than 1 cm (ex. Blister, chicken pox). 7. During application of medication into the ear, which of the following is inappropriate nursing action?

a. In an adult, pull the pinna upward. b. Instill the medication directly into the tympanic membrane. c. Warm the medication at room or body temperature. d. Press the tragus of the ear a few times to assist flow of medication into the ear canal.

During the application of medication it is inappropriate to instill the medication directly into the tympanic membrane. The right thing to do is instill the medication along the lateral wall of the auditory canal. 8. Which of the following is appropriate nursing intervention for a client who is grieving over the death of her child?

a. Tell her not to cry and it will be better. b. Provide opportunity to the client to tell their story. c. Encourage her to accept or to replace the lost person. d. Discourage the client in expressing her emotions.

Providing a grieving person an opportunity to tell their story allows the person to express feelings. This is therapeutic in assisting the client resolve grief. 9. It is the gradual decrease of the bodys temperature after death.

a. livor mortis b. rigor mortis c. algor mortis d. none of the above

Algor mortis is the decrease of the bodys temperature after death. Livor mortis is the discoloration of the skin after death. Rigor mortis is the stiffening of the body that occurs about 2-4 hours after death. 10. When performing an admission assessment on a newly admitted patient, the nurse percusses resonance. The nurse knows that resonance heard on percussion is most commonly heard over which organ?

a. thigh b. liver c. intestine d. lung

Resonance is loud, low-pitched and long duration thats heard most commonly over an air-filled tissue such as a normal lung. 11. The nurse is aware that Bells palsy affects which cranial nerve?

a. 2nd CN (Optic) b. 3rd CN (Occulomotor) c. 4th CN (Trochlear) d. 7th CN (Facial)

Bells palsy is the paralysis of the motor component of the 7th caranial nerve, resulting in facial sag, inability to close the eyelid or the mouth, drooling, flat nasolabial fold and loss of taste on the affected side of the face. 12. Prolonged deficiency of Vitamin B9 leads to:

a. scurvy b. pellagra c. megaloblastic anemia d. pernicious anemia

Prolonged Vitamin B9 deficiency will lead to megaloblastic anemia while pernicious anemia results in deficiency in Vitamin B12. Prolonged deficiency of Vitamin C leads to scurvy and Pellagra results in deficiency in Vitamin B3. 13. Nurse Cherry is teaching a 72 year old patient about a newly prescribed medication. What could cause a geriatric patient to have difficulty retaining knowledge about the newly prescribed medication?

a. Absence of family support b. Decreased sensory functions c. Patient has no interest on learning d. Decreased plasma drug levels

Decreased in sensory functions could cause a geriatric patient to have difficulty retaining knowledge about the newly prescribed medications. Absence of family support and no interest on learning may affect compliance, not knowledge retention. Decreased plasma levels do not alter patients knowledge about the drug. 14. When assessing a patients level of consciousness, which type of nursing intervention is the nurse performing?

a. Independent b. Dependent c. Collaborative d. Professional

Independent nursing interventions involve actions that nurses initiate based on their own knowledge and skills without the direction or supervision of another member of the health care team. 15. Claire is admitted with a diagnosis of chronic shoulder pain. By definition, the nurse understands that the patient has had pain for more than:

a. 3 months b. 6 months c. 9 months d. 1 year

Chronic pain s usually defined as pain lasting longer than 6 months. 16. Which of the following statements regarding the nursing process is true?

a. It is useful on outpatient settings. b. It progresses in separate, unrelated steps. c. It focuses on the patient, not the nurse. d. It provides the solution to all patient health problems.

The nursing process is patient-centered, not nurse-centered. It can be use in any setting, and the steps are related. The nursing process cant solve all patient health problems.

17. Which of the following is considered significant enough to require immediate communication to another member of the health care team?

a. Weight loss of 3 lbs in a 120 lb female patient. b. Diminished breath sounds in patient with previously normal breath sounds c. Patient stated, I feel less nauseated. d. Change of heart rate from 70 to 83 beats per minute.

Diminished breath sound is a life threatening problem therefore it is highly priority because they pose the greatest threat to the patients well-being. 18. To assess the adequacy of food intake, which of the following assessment parameters is best used?

a. food preferences b. regularity of meal times c. 3-day diet recall d. eating style and habits

3-day diet recall is an example of dietary history. This is used to indicate the adequacy of food intake of the client. 19. Van Fajardo is a 55 year old who was admitted to the hospital with newly diagnosed hepatitis. The nurse is doing a patient teaching with Mr. Fajardo. What kind of role does the nurse assume?

a. talker b. teacher c. thinker d. doer

The nurse will assume the role of a teacher in this therapeutic relationship. The other roles are inappropriate in this situation. 20. When providing a continuous enteral feeding, which of the following action is essential for the nurse to do?

a. Place the client on the left side of the bed. b. Attach the feeding bag to the current tubing. c. Elevate the head of the bed. d. Cold the formula before administering it.

Elevating the head of the bed during an enteral feeding prevents aspiration. The patient may be placed on the right side to prevent aspiration. Enteral feedings are given at room temperature to lessen GI distress. The enteral tubing should be changed every 24 hours to limit microbial growth. 21. Kussmauls breathing is;

a. Shallow breaths interrupted by apnea.

b. Prolonged gasping inspiration followed by a very short, usually inefficient expiration. c. Marked rhythmic waxing and waning of respirations from very deep to very shallow breathing and temporary apnea. d. Increased rate and depth of respiration.

Kussmaul breathing is also called as hyperventilation. Seen in metabolic acidosis and renal failure. Option A refers to Biots breathing. Option B is apneustic breathing and option C is the Cheyne-stokes breathing. 22. Presty has terminal cancer and she refuses to believe that loss is happening ans she assumes artificial cheerfulness. What stage of grieving is she in?

a. depression b. bargaining c. denial d. acceptance

The client is in denial stage because she is unready to face the reality that loss is happening and she assumes artificial cheerfulness. 23. Immunization for healthy babies and preschool children is an example of what level of preventive health care?

a. Primary b. Secondary c. Tertiary d. Curative

The primary level focuses on health promotion. Secondary level focuses on health maintenance. Tertiary focuses on rehabilitation. There is n Curative level of preventive health care problems. 24. Which is an example of a subjective data?

a. Temperature of 38 0C b. Vomiting for 3 days c. Productive cough d. Patient stated, My arms still hurt.

Subjective data are apparent only to the person affected and can or verified only by that person. 25. The nurse is assessing the endocrine system. Which organ is part of the endocrine system?

a. Heart b. Sinus c. Thyroid d. Thymus

The thyroid is part of the endocrine system. Heart, sinus and thymus are not.

1. Jake is complaining of shortness of breath. The nurse assesses his respiratory rate to be 30 breaths per minute and documents that Jake is tachypneic. The nurse understands that tachypnea means:

a. Pulse rate greater than 100 beats per minute b. Blood pressure of 140/90 c. Respiratory rate greater than 20 breaths per minute d. Frequent bowel sounds

A respiratory rate of greater than 20 breaths per minute is tachypnea. A blood pressure of 140/90 is considered hypertension. Pulse greater than 100 beats per minute is tachycardia. Frequent bowel sounds refer to hyper-active bowel sounds. 2. The nurse listens to Mrs. Sullens lungs and notes a hissing sound or musical sound. The nurse documents this as:

a. Wheezes b. Rhonchi c. Gurgles d. Vesicular

Wheezes are indicated by continuous, lengthy, musical; heard during inspiration or expiration. Rhonchi are usually coarse breath sounds. Gurgles are loud gurgling, bubbling sound. Vesicular breath sounds are low pitch, soft intensity on expiration. 3. The nurse in charge measures a patients temperature at 101 degrees F. What is the equivalent centigrade temperature?

a. 36.3 degrees C b. 37.95 degrees C c. 40.03 degrees C d. 38.01 degrees C

To convert F to C use this formula, ( F 32 ) (0.55). While when converting C to F use this formula, ( C x 1.8) + 32. Note that 0.55 is 5/9 and 1.8 is 9/5. 4. Which approach to problem solving tests any number of solutions until one is found that works for that particular problem?

a. Intuition b. Routine c. Scientific method d. Trial and error

The trial and error method of problem solving isnt systematic (as in the scientific method of problem solving) routine, or based on inner prompting (as in the intuitive method of problem solving). 5. What is the order of the nursing process?

a. Assessing, diagnosing, implementing, evaluating, planning b. Diagnosing, assessing, planning, implementing, evaluating c. Assessing, diagnosing, planning, implementing, evaluating d. Planning, evaluating, diagnosing, assessing, implementing

The correct order of the nursing process is assessing, diagnosing, planning, implementing, evaluating. 6. During the planning phase of the nursing process, which of the following is the outcome?

a. Nursing history b. Nursing notes c. Nursing care plan d. Nursing diagnosis

The outcome, or the product of the planning phase of the nursing process is a Nursing care plan. 7. What is an example of a subjective data?

a. Heart rate of 68 beats per minute b. Yellowish sputum c. Client verbalized, I feel pain when urinating. d. Noisy breathing

Subjective data are those that can be described only by the person experiencing it. Therefore, only the patient can describe or verify whether he is experiencing pain or not. 8. Which expected outcome is correctly written?

a. The patient will feel less nauseated in 24 hours. b. The patient will eat the right amount of food daily. c. The patient will identify all the high-salt food from a prepared list by discharge. d. The patient will have enough sleep.

Expected outcomes are specific, measurable, realistic statements of goal attainment. The phrases right amount, less nauseated and enough sleep are vague and not measurable. 9. Which of the following behaviors by Nurse Jane Robles demonstrates that she understands well th elements of effecting charting?

a. She writes in the chart using a no. 2 pencil. b. She noted: appetite is good this afternoon. c. She signs on the medication sheet after administering the medication. d. She signs her charting as follow: J.R

A nurse should record a nursing intervention (ex. Giving medications) after performing the nursing intervention (not before). Recording should also be done using a pen, be complete, and signed with the nurses full name and title. 10. What is the disadvantage of computerized documentation of the nursing process?

a. Accuracy b. Legibility c. Concern for privacy d. Rapid communication

A patients privacy may be violated if security measures arent used properly or if policies and procedures arent in place that determines what type of information can be retrieved, by whom, and for what purpose. 11. The theorist who believes that adaptation and manipulation of stressors are related to foster change is:

a. Dorothea Orem b. Sister Callista Roy c. Imogene King d. Virginia Henderson

Sister Roys theory is called the adaptation theory and she viewed each person as a unified biophysical system in constant interaction with a changing environment. Orems theory is called self-care deficit theory and is based on the belief that individual has a need for self-care actions. Kings theory is the Goal attainment theory and described nursing as a helping profession that assists individuals and groups in society to attain, maintain, and restore health. Henderson introduced the nature of nursing model and identified the 14 basic needs. 12. Formulating a nursing diagnosis is a joint function of:

a. Patient and relatives b. Nurse and patient c. Doctor and family d. Nurse and doctor

Although diagnosing is basically the nurses responsibility, input from the patient is essential to formulate the correct nursing diagnosis. 13. Mrs. Caperlac has been diagnosed to have hypertension since 10 years ago. Since then, she had maintained low sodium, low fat diet, to control her blood pressure. This practice is viewed as:

a. Cultural belief b. Personal belief c. Health belief d. Superstitious belief

Health belief of an individual influences his/her preventive health behavior. 14. Becky is on NPO since midnight as preparation for blood test. Adreno-cortical response is activated. Which of the following is an expected response?

a. Low blood pressure b. Warm, dry skin c. Decreased serum sodium levels d. Decreased urine output

Adreno-cortical response involves release of aldosterone that leads to retention of sodium and water. This results to decreased urine output. 15. What nursing action is appropriate when obtaining a sterile urine specimen from an indwelling catheter to prevent infection?

a. Use sterile gloves when obtaining urine. b. Open the drainage bag and pour out the urine. c. Disconnect the catheter from the tubing and get urine. d. Aspirate urine from the tubing port using a sterile syringe.

The nurse should aspirate the urine from the port using a sterile syringe to obtain a urine specimen. Opening a closed drainage system increase the risk of urinary tract infection. 16. A client is receiving 115 ml/hr of continuous IVF. The nurse notices that the venipuncture site is red and swollen. Which of the following interventions would the nurse perform first?

a. Stop the infusion b. Call the attending physician c. Slow that infusion to 20 ml/hr d. Place a clod towel on the site

The sign and symptoms indicate extravasation so the IVF should be stopped immediately and put warm not cold towel on the affected site. 17. The nurse enters the room to give a prescribed medication but the patient is inside the bathroom. What should the nurse do?

a. Leave the medication at the bedside and leave the room. b. After few minutes, return to that patients room and do not leave until the patient takes the medication. c. Instruct the patient to take the medication and leave it at the bedside.

d. Wait for the patient to return to bed and just leave the medication at the bedside.

This is to verify or to make sure that the medication was taken by the patient as directed. 18. Which of the following is inappropriate nursing action when administering NGT feeding?

a. Place the feeding 20 inches above the pint if insertion of NGT. b. Introduce the feeding slowly. c. Instill 60ml of water into the NGT after feeding. d. Assist the patient in fowlers position.

The height of the feeding is above 12 inches above the point of insertion, bot 20 inches. If the height of feeding is too high, this results to very rapid introduction of feeding. This may trigger nausea and vomiting. 19. A female patient is being discharged after thyroidectomy. After providing the medication teaching. The nurse asks the patient to repeat the instructions. The nurse is performing which professional role?

a. Manager b. Caregiver c. Patient advocate d. Educator

When teaching a patient about medications before discharge, the nurse is acting as an educator. A caregiver provides direct care to the patient. The nurse acts as s patient advocate when making the patients wishes known to the doctor. 20. Which data would be of greatest concern to the nurse when completing the nursing assessment of a 68-year-old woman hospitalized due to Pneumonia?

a. Oriented to date, time and place b. Clear breath sounds c. Capillary refill greater than 3 seconds and buccal cyanosis d. Hemoglobin of 13 g/dl

Capillary refill greater than 3 seconds and buccal cyanosis indicate decreased oxygen to the tissues which requires immediate attention/intervention. Oriented to date, time and place, hemoglobin of 13 g/dl are normal data. 21. During a change-of-shift report, it would be important for the nurse relinquishing responsibility for care of the patient to communicate. Which of the following facts to the nurse assuming responsibility for care of the patient?

a. That the patient verbalized, My headache is gone. b. That the patients barium enema performed 3 days ago was negative c. Patients NGT was removed 2 hours ago

d. Patients family came for a visit this morning.

The change-of-shift report should indicate significant recent changes in the patients condition that the nurse assuming responsibility for care of the patient will need to monitor. The other options are not critical enough to include in the report. 22. Which statement is the most appropriate goal for a nursing diagnosis of diarrhea?

a. The patient will experience decreased frequency of bowel elimination. b. The patient will take anti-diarrheal medication. c. The patient will give a stool specimen for laboratory examinations. d. The patient will save urine for inspection by the nurse.

The goal is the opposite, healthy response of the problem statement of the nursing diagnosis. In this situation, the problem statement is diarrhea. 23. Which of the following is the most important purpose of planning care with this patient?

a. Development of a standardized NCP. b. Expansion of the current taxonomy of nursing diagnosis c. Making of individualized patient care d. Incorporation of both nursing and medical diagnoses in patient care

To be effective, the nursing care plan developed in the planning phase of the nursing process must reflect the individualized needs of the patient. 24. Using Maslows hierarchy of basic human needs, which of the following nursing diagnoses has the highest priority?

a. Ineffective breathing pattern related to pain, as evidenced by shortness of breath. b. Anxiety related to impending surgery, as evidenced by insomnia. c. Risk of injury related to autoimmune dysfunction d. Impaired verbal communication related to tracheostomy, as evidenced by inability to speak.

Physiologic needs (ex. Oxygen, fluids, nutrition) must be met before lower needs (such as safety and security, love and belongingness, self-esteem and selfactualization) can be met. Therefore, physiologic needs have the highest priority. 25. When performing an abdominal examination, the patient should be in a supine position with the head of the bed at what position?

a. 30 degrees b. 90 degrees c. 45 degrees d. 0 degree

The patient should be positioned with the head of the bed completely flattened to perform an abdominal examination. If the head of the bed is elevated, the abdominal muscles and organs can be bunched up, altering the findings.