NURSING PRACTICE I
FOUNDATION OF PROFESSIONAL NURSING PRACTICE
NAME: DON VOU S. MORALINA
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.
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
3. Dr. Garcia writes the following order for the client who has been recently admitted “Digoxin .125 mg P.O. once daily.” To
prevent a dosage error, how should the nurse document 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”
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.
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 hysterectomy client of three days whose incisional dressing is saturated
with serosanguinous fluid.
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.
1
,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
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
d. Continue to monitor and record hourly urine output
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”
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
11. She finds out that some managers have benevolent-authoritative style of management. Which of the following behaviors
will she exhibit most likely?
a. Have condescending trust and confidence in their subordinates.
b. Gives economic and ego awards.
c. Communicates downward to staffs.
d. Allows decision making among subordinates.
12. Nurse Amy is aware that the following is true about functional nursing
a. Provides continuous, coordinated and comprehensive nursing services.
b. One-to-one nurse patient ratio.
c. Emphasize the use of group collaboration.
d. Concentrates on tasks and activities.
13. Which type of medication order might read "Vitamin K 10 mg I.M. daily × 3 days?"
a. Single order
b. Standard written order
c. Standing order
d. Stat order
2
,14. A female client with a fecal impaction frequently exhibits which clinical manifestation?
a. Increased appetite
b. Loss of urge to defecate
c. Hard, brown, formed stools
d. Liquid or semi-liquid stools
15. Nurse Linda prepares to perform an otoscopic examination on a female client. For proper visualization, the nurse
should position the client's ear by:
a. Pulling the lobule down and back
b. Pulling the helix up and forward
c. Pulling the helix up and back
d. Pulling the lobule down and forward
16. Which instruction should nurse Tom give to a male client who is having external radiation therapy:
a. Protect the irritated skin from sunlight.
b. Eat 3 to 4 hours before treatment.
c. Wash the skin over regularly.
d. Apply lotion or oil to the radiated area when it is red or sore.
17. In assisting a female client for immediate surgery, the nurse In-charge is aware that she should:
a. Encourage the client to void following preoperative medication.
b. Explore the client’s fears and anxieties about the surgery.
c. Assist the client in removing dentures and nail polish.
d. Encourage the client to drink water prior to surgery.
18. A male client is admitted and diagnosed with acute pancreatitis after a holiday celebration of excessive food and alcohol.
Which assessment finding reflects this diagnosis?
a. Blood pressure above normal range.
b. Presence of crackles in both lung fields.
c. Hyperactive bowel sounds
d. Sudden onset of continuous epigastric and back pain.
19. Which dietary guidelines are important for nurse Oliver to implement in caring for the client with burns?
a. Provide high-fiber, high-fat diet
b. Provide high-protein, high-carbohydrate diet.
c. Monitor intake to prevent weight gain.
d. Provide ice chips or water intake.
20. Nurse Hazel will administer a unit of whole blood, which priority information should the nurse have about the client?
a. Blood pressure and pulse rate.
b. Height and weight.
c. Calcium and potassium levels
d. Hgb and Hct levels.
21. Nurse Michelle witnesses a female client sustain a fall and suspects that the leg may be broken. The nurse takes which
priority action?
a. Takes a set of vital signs.
b. Call the radiology department for X-ray.
3
, c. Reassure the client that everything will be alright.
d. Immobilize the leg before moving the client.
22. A male client is being transferred to the nursing unit for admission after receiving a radium implant for bladder cancer. The
nurse in-charge would take which priority action in the care of this client?
a. Place client on reverse isolation.
b. Admit the client into a private room.
c. Encourage the client to take frequent rest periods.
d. Encourage family and friends to visit.
23. A newly admitted female client was diagnosed with agranulocytosis. The nurse formulates which priority nursing diagnosis?
a. Constipation
b. Diarrhea
c. Risk for infection
d. Deficient knowledge
24. A male client is receiving total parenteral nutrition suddenly demonstrates signs and symptoms of an air embolism. What
is the priority action by the nurse?
a. Notify the physician.
b. Place the client on the left side in the Trendelenburg position.
c. Place the client in high-Fowlers position.
d. Stop the total parenteral nutrition.
25. Nurse May attends an educational conference on leadership styles. The nurse is sitting with a nurse employed at a large
trauma center who states that the leadership style at the trauma center is task-oriented and directive. The nurse
determines that the leadership style used at the trauma center is:
a. Autocratic.
b. Laissez-faire.
c. Democratic.
d. Situational
26. The physician orders DS 500 cc with KCl 10 mEq/liter at 30 cc/hr. The nurse in-charge is going to hang a 500 cc bag. KCl
is supplied 20 mEq/10 cc. How many cc’s of KCl will be added to the IV solution?
a. .5 cc
b. 5 cc
c. 1.5 cc
d. 2.5 cc
27. A child of 10 years old is to receive 400 cc of IV fluid in an 8 hour shift. The IV drip factor is 60. The IV rate that will deliver
this amount is:
a. 50 cc/ hour
b. 55 cc/ hour
c. 24 cc/ hour
d. 66 cc/ hour
28. The nurse is aware that the most important nursing action when a client returns from surgery is:
a. Assess the IV for type of fluid and rate of flow.
b. Assess the client for presence of pain.
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FOUNDATION OF PROFESSIONAL NURSING PRACTICE
NAME: DON VOU S. MORALINA
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.
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
3. Dr. Garcia writes the following order for the client who has been recently admitted “Digoxin .125 mg P.O. once daily.” To
prevent a dosage error, how should the nurse document 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”
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.
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 hysterectomy client of three days whose incisional dressing is saturated
with serosanguinous fluid.
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.
1
,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
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
d. Continue to monitor and record hourly urine output
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”
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
11. She finds out that some managers have benevolent-authoritative style of management. Which of the following behaviors
will she exhibit most likely?
a. Have condescending trust and confidence in their subordinates.
b. Gives economic and ego awards.
c. Communicates downward to staffs.
d. Allows decision making among subordinates.
12. Nurse Amy is aware that the following is true about functional nursing
a. Provides continuous, coordinated and comprehensive nursing services.
b. One-to-one nurse patient ratio.
c. Emphasize the use of group collaboration.
d. Concentrates on tasks and activities.
13. Which type of medication order might read "Vitamin K 10 mg I.M. daily × 3 days?"
a. Single order
b. Standard written order
c. Standing order
d. Stat order
2
,14. A female client with a fecal impaction frequently exhibits which clinical manifestation?
a. Increased appetite
b. Loss of urge to defecate
c. Hard, brown, formed stools
d. Liquid or semi-liquid stools
15. Nurse Linda prepares to perform an otoscopic examination on a female client. For proper visualization, the nurse
should position the client's ear by:
a. Pulling the lobule down and back
b. Pulling the helix up and forward
c. Pulling the helix up and back
d. Pulling the lobule down and forward
16. Which instruction should nurse Tom give to a male client who is having external radiation therapy:
a. Protect the irritated skin from sunlight.
b. Eat 3 to 4 hours before treatment.
c. Wash the skin over regularly.
d. Apply lotion or oil to the radiated area when it is red or sore.
17. In assisting a female client for immediate surgery, the nurse In-charge is aware that she should:
a. Encourage the client to void following preoperative medication.
b. Explore the client’s fears and anxieties about the surgery.
c. Assist the client in removing dentures and nail polish.
d. Encourage the client to drink water prior to surgery.
18. A male client is admitted and diagnosed with acute pancreatitis after a holiday celebration of excessive food and alcohol.
Which assessment finding reflects this diagnosis?
a. Blood pressure above normal range.
b. Presence of crackles in both lung fields.
c. Hyperactive bowel sounds
d. Sudden onset of continuous epigastric and back pain.
19. Which dietary guidelines are important for nurse Oliver to implement in caring for the client with burns?
a. Provide high-fiber, high-fat diet
b. Provide high-protein, high-carbohydrate diet.
c. Monitor intake to prevent weight gain.
d. Provide ice chips or water intake.
20. Nurse Hazel will administer a unit of whole blood, which priority information should the nurse have about the client?
a. Blood pressure and pulse rate.
b. Height and weight.
c. Calcium and potassium levels
d. Hgb and Hct levels.
21. Nurse Michelle witnesses a female client sustain a fall and suspects that the leg may be broken. The nurse takes which
priority action?
a. Takes a set of vital signs.
b. Call the radiology department for X-ray.
3
, c. Reassure the client that everything will be alright.
d. Immobilize the leg before moving the client.
22. A male client is being transferred to the nursing unit for admission after receiving a radium implant for bladder cancer. The
nurse in-charge would take which priority action in the care of this client?
a. Place client on reverse isolation.
b. Admit the client into a private room.
c. Encourage the client to take frequent rest periods.
d. Encourage family and friends to visit.
23. A newly admitted female client was diagnosed with agranulocytosis. The nurse formulates which priority nursing diagnosis?
a. Constipation
b. Diarrhea
c. Risk for infection
d. Deficient knowledge
24. A male client is receiving total parenteral nutrition suddenly demonstrates signs and symptoms of an air embolism. What
is the priority action by the nurse?
a. Notify the physician.
b. Place the client on the left side in the Trendelenburg position.
c. Place the client in high-Fowlers position.
d. Stop the total parenteral nutrition.
25. Nurse May attends an educational conference on leadership styles. The nurse is sitting with a nurse employed at a large
trauma center who states that the leadership style at the trauma center is task-oriented and directive. The nurse
determines that the leadership style used at the trauma center is:
a. Autocratic.
b. Laissez-faire.
c. Democratic.
d. Situational
26. The physician orders DS 500 cc with KCl 10 mEq/liter at 30 cc/hr. The nurse in-charge is going to hang a 500 cc bag. KCl
is supplied 20 mEq/10 cc. How many cc’s of KCl will be added to the IV solution?
a. .5 cc
b. 5 cc
c. 1.5 cc
d. 2.5 cc
27. A child of 10 years old is to receive 400 cc of IV fluid in an 8 hour shift. The IV drip factor is 60. The IV rate that will deliver
this amount is:
a. 50 cc/ hour
b. 55 cc/ hour
c. 24 cc/ hour
d. 66 cc/ hour
28. The nurse is aware that the most important nursing action when a client returns from surgery is:
a. Assess the IV for type of fluid and rate of flow.
b. Assess the client for presence of pain.
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