PNLE I FOR FOUNDATION OF PROFESSIONAL NURSING STUDYGUIDE
QUESTIONS AND CORRECT ANSWERS
Question:
1. The nurse In-charge in labor and delivery unit administered a dose of terbutaline to a
client without checking the client's pulse. The standard that would be used to determine if
the nurse was negligent is:
A. The physician's orders.
B. The action of a clinical nurse specialist who is recognized expert in the field.
C. The statement in the drug literature about administration of terbutaline.
D. The actions of a reasonably prudent nurse with similar education and experience.
Answer:
(D) The actions of a reasonably prudent nurse with similar education and experience.;The
standard of care is determined by the average degree of skill, care, and diligence by nurses in
similar circumstances.
Question:
2. Nurse Trish is caring for a female client with a history of GI bleeding, sickle cell disease,
and a platelet count of 22,000/μl. The female client is dehydrated and receiving dextrose 5%
in half-normal saline solution at 150 ml/hr. The client complains of severe bone pain and is
scheduled to receive a dose of morphine sulfate. In administering the medication, Nurse
Trish should avoid which route?
A. I.V
B. I.M
C. Oral
D. S.C
Answer:
(B) I.M.;With a platelet count of 22,000/μl, the client tends to bleed easily. Therefore, the nurse
should avoid using the I.M. route because the area is highly vascular and can bleed readily when
penetrated by a needle. The bleeding can be difficult to stop.
Question:
3. Dr. Garcia writes the following order for the client who has been recently admitted
"Digoxin .125 mg P.O. once daily." To predocument this order onto the medication
administration record?
A. "Digoxin .1250 mg P.O. once daily"
B. "Digoxin 0.1250 mg P.O. once daily"
C. "Digoxin 0.125 mg P.O. once daily"
D. "Digoxin .125 mg P.O. once daily"
Answer:
(C) "Digoxin 0.125 mg P.O. once daily";The nurse should always place a zero before a decimal
point so that no one misreads the The nurse should never insert a zero at the end of a dosage
that includes a decimal point because this could be misread, possibly leading to a tenfold
increase in the dosage.
,Question:
4. A newly admitted female client was diagnosed with deep vein thrombosis. Which nursing
diagnosis should receive the highest priority?
A. Ineffective peripheral tissue perfusion related to venous congestion.
B. Risk for injury related to edema.
C. Excess fluid volume related to peripheral vascular disease.
D. Impaired gas exchange related to increased blood flow.
Answer:
(A) Ineffective peripheral tissue perfusion related to venous congestion.;Ineffective peripheral
tissue perfusion related to venous congestion takes the highest priority because venous
inflammation and clot formation impede blood flow in a client with deep vein thrombosis.
Question:
5. Nurse Betty is assigned to the following clients. The client that the nurse would see first
after endorsement?
A. A 34 year-old post operative appendectomy client of five hours who is complaining of
pain.
B. A 44 year-old myocardial infarction (MI) client who is complaining of nausea.
C. A 26 year-old client admitted for dehydration whose intravenous (IV) has infiltrated.
D. A 63 year-old post operative's abdominal cisional dressing is saturated with
serosanguinous fluid.
Answer:
(B) A 44 year-old myocardial infarction (MI) client who is complaining of nausea.;Nausea is a
symptom of impending myocardial infarction (MI) and should be assessed immediately so that
treatment can be instituted and further damage to the heart is avoided.
Question:
6. Nurse Gail places a client in a four-point restraint following orders from the physician. The
client care plan should include:
A. Assess temperature frequently.
B. Provide diversional activities.
C. Check circulation every 15-30 minutes.
D. Socialize with other patients once a shift.
Answer:
(C) Check circulation every 15-30 minutes.;Restraints encircle the limbs, which place the client at
risk for circulation being restricted to the distal areas of the extremities. Checking the client's
circulation every 15-30 minutes will allow the nurse to adjust the restraints before injury from
decreased blood flow occurs.
Question:
7. A male client who has severe burns is receiving H2 receptor antagonist therapy. The
nurse In-charge knows the purpose of this therapy is to:
A. Prevent stress ulcer
B. Block prostaglandin synthesis
C. Facilitate protein synthesis.
, D. Enhance gas exchange
Answer:
(A) Prevent stress ulcer.;Curling's ulcer occurs as a generalized stress response in burn patients.
This results in a decreased production of mucus and increased secretion of gastric acid. The best
treatment for this prophylactic use of antacids and H2 receptor blockers.
Question:
8. The doctor orders hourly urine output measurement for a postoperative male client. The
nurse Trish records the following amounts of output for 2 consecutive hours: 8 a.m.: 50 ml; 9
a.m.: 60 ml. Based on these amounts, which action should the nurse take?
A. Increase the I.V. fluid infusion rate
B. Irrigate the indwelling urinary catheter
C. Notify the physician urine output
Answer:
(D) Continue to monitor and record hourly urine output.;Normal urine output for an adult is
approximately 1 ml/minute (60 ml/hour). Therefore, this client's output is normal. Beyond
continued evaluation, no nursing action is warranted.
Question:
9. Tony, a basketball player twist his right ankle while playing on the court and seeks care
for ankle pain and swelling. After the nurse applies ice to the ankle for 30 minutes, which
statement by Tony suggests that ice application has been effective?
A. "My ankle looks less swollen now".
B. "My ankle feels warm".
C. "My ankle appears redder now".
D. "I need something stronger for pain relief"
Answer:
(A) "My ankle looks less swollen now".;Ice application decreases pain and swelling. Continued or
increased pain, redness, and increased warmth are signs of inflammation that shouldn't occur
after ice application.
Question:
10. The physician prescribes a loop diuretic for a client. When administering this drug, the
nurse anticipates that the client may develop which electrolyte imbalance?
A. Hypernatremia
B. Hyperkalemia
C. Hypokalemia
D. Hypervolemia
Answer:
(C) Hypokalemia.;A loop diuretic removes water and, along with it, sodium and potassium. This
may result in hypokalemia, hypovolemia, and hyponatremia.
Question:
QUESTIONS AND CORRECT ANSWERS
Question:
1. The nurse In-charge in labor and delivery unit administered a dose of terbutaline to a
client without checking the client's pulse. The standard that would be used to determine if
the nurse was negligent is:
A. The physician's orders.
B. The action of a clinical nurse specialist who is recognized expert in the field.
C. The statement in the drug literature about administration of terbutaline.
D. The actions of a reasonably prudent nurse with similar education and experience.
Answer:
(D) The actions of a reasonably prudent nurse with similar education and experience.;The
standard of care is determined by the average degree of skill, care, and diligence by nurses in
similar circumstances.
Question:
2. Nurse Trish is caring for a female client with a history of GI bleeding, sickle cell disease,
and a platelet count of 22,000/μl. The female client is dehydrated and receiving dextrose 5%
in half-normal saline solution at 150 ml/hr. The client complains of severe bone pain and is
scheduled to receive a dose of morphine sulfate. In administering the medication, Nurse
Trish should avoid which route?
A. I.V
B. I.M
C. Oral
D. S.C
Answer:
(B) I.M.;With a platelet count of 22,000/μl, the client tends to bleed easily. Therefore, the nurse
should avoid using the I.M. route because the area is highly vascular and can bleed readily when
penetrated by a needle. The bleeding can be difficult to stop.
Question:
3. Dr. Garcia writes the following order for the client who has been recently admitted
"Digoxin .125 mg P.O. once daily." To predocument this order onto the medication
administration record?
A. "Digoxin .1250 mg P.O. once daily"
B. "Digoxin 0.1250 mg P.O. once daily"
C. "Digoxin 0.125 mg P.O. once daily"
D. "Digoxin .125 mg P.O. once daily"
Answer:
(C) "Digoxin 0.125 mg P.O. once daily";The nurse should always place a zero before a decimal
point so that no one misreads the The nurse should never insert a zero at the end of a dosage
that includes a decimal point because this could be misread, possibly leading to a tenfold
increase in the dosage.
,Question:
4. A newly admitted female client was diagnosed with deep vein thrombosis. Which nursing
diagnosis should receive the highest priority?
A. Ineffective peripheral tissue perfusion related to venous congestion.
B. Risk for injury related to edema.
C. Excess fluid volume related to peripheral vascular disease.
D. Impaired gas exchange related to increased blood flow.
Answer:
(A) Ineffective peripheral tissue perfusion related to venous congestion.;Ineffective peripheral
tissue perfusion related to venous congestion takes the highest priority because venous
inflammation and clot formation impede blood flow in a client with deep vein thrombosis.
Question:
5. Nurse Betty is assigned to the following clients. The client that the nurse would see first
after endorsement?
A. A 34 year-old post operative appendectomy client of five hours who is complaining of
pain.
B. A 44 year-old myocardial infarction (MI) client who is complaining of nausea.
C. A 26 year-old client admitted for dehydration whose intravenous (IV) has infiltrated.
D. A 63 year-old post operative's abdominal cisional dressing is saturated with
serosanguinous fluid.
Answer:
(B) A 44 year-old myocardial infarction (MI) client who is complaining of nausea.;Nausea is a
symptom of impending myocardial infarction (MI) and should be assessed immediately so that
treatment can be instituted and further damage to the heart is avoided.
Question:
6. Nurse Gail places a client in a four-point restraint following orders from the physician. The
client care plan should include:
A. Assess temperature frequently.
B. Provide diversional activities.
C. Check circulation every 15-30 minutes.
D. Socialize with other patients once a shift.
Answer:
(C) Check circulation every 15-30 minutes.;Restraints encircle the limbs, which place the client at
risk for circulation being restricted to the distal areas of the extremities. Checking the client's
circulation every 15-30 minutes will allow the nurse to adjust the restraints before injury from
decreased blood flow occurs.
Question:
7. A male client who has severe burns is receiving H2 receptor antagonist therapy. The
nurse In-charge knows the purpose of this therapy is to:
A. Prevent stress ulcer
B. Block prostaglandin synthesis
C. Facilitate protein synthesis.
, D. Enhance gas exchange
Answer:
(A) Prevent stress ulcer.;Curling's ulcer occurs as a generalized stress response in burn patients.
This results in a decreased production of mucus and increased secretion of gastric acid. The best
treatment for this prophylactic use of antacids and H2 receptor blockers.
Question:
8. The doctor orders hourly urine output measurement for a postoperative male client. The
nurse Trish records the following amounts of output for 2 consecutive hours: 8 a.m.: 50 ml; 9
a.m.: 60 ml. Based on these amounts, which action should the nurse take?
A. Increase the I.V. fluid infusion rate
B. Irrigate the indwelling urinary catheter
C. Notify the physician urine output
Answer:
(D) Continue to monitor and record hourly urine output.;Normal urine output for an adult is
approximately 1 ml/minute (60 ml/hour). Therefore, this client's output is normal. Beyond
continued evaluation, no nursing action is warranted.
Question:
9. Tony, a basketball player twist his right ankle while playing on the court and seeks care
for ankle pain and swelling. After the nurse applies ice to the ankle for 30 minutes, which
statement by Tony suggests that ice application has been effective?
A. "My ankle looks less swollen now".
B. "My ankle feels warm".
C. "My ankle appears redder now".
D. "I need something stronger for pain relief"
Answer:
(A) "My ankle looks less swollen now".;Ice application decreases pain and swelling. Continued or
increased pain, redness, and increased warmth are signs of inflammation that shouldn't occur
after ice application.
Question:
10. The physician prescribes a loop diuretic for a client. When administering this drug, the
nurse anticipates that the client may develop which electrolyte imbalance?
A. Hypernatremia
B. Hyperkalemia
C. Hypokalemia
D. Hypervolemia
Answer:
(C) Hypokalemia.;A loop diuretic removes water and, along with it, sodium and potassium. This
may result in hypokalemia, hypovolemia, and hyponatremia.
Question:
