PNLE I for Foundation of Nursing
1. Which element in the circular chain of infection can be 6. Which of the following procedures always requires surgical
eliminated by preserving skin integrity? asepsis?
A. Host A. Vaginal instillation of conjugated estrogen
B. Reservoir B. Urinary catheterization
C. Mode of transmission C. Nasogastric tube insertion
D. Portal of entry D. Colostomy irrigation
Answer: D. In the circular chain of infection, pathogens must Answer: B. The urinary system is normally free of
be able to leave their reservoir and be transmitted to a microorganisms except at the urinary meatus. Any
susceptible host through a portal of entry, such as broken procedure that involves entering this system must use
skin. surgically aseptic measures to maintain a bacteria-free state
2. Which of the following will probably result in a break in 7. Sterile technique is used whenever:
sterile technique for respiratory isolation? A. Strict isolation is required
A. Opening the patient’s window to the outside B. Terminal disinfection is performed
environment C. Invasive procedures are performed
B. Turning on the patient’s room ventilator D. Protective isolation is necessary
C. Opening the door of the patient’s room leading into
the hospital corridor Answer: C. All invasive procedures, including surgery,
D. Failing to wear gloves when administering a bed bath catheter insertion, and administration of parenteral therapy,
require sterile technique to maintain a sterile environment.
Answer: C. Respiratory isolation, like strict isolation, All equipment must be sterile, and the nurse and
requires that the door to the door patient’s room remain the physician must wear sterile gloves and maintain surgical
closed. However, the patient’s room should be well asepsis. In the operating room, the nurse and physician are
ventilated, so opening the window or turning on the required to wear sterile gowns, gloves, masks, hair covers,
ventricular is desirable. The nurse does not need to wear and shoe covers for all invasive procedures. Strict isolation
gloves for respiratory isolation, but good hand washing is requires the use of clean gloves, masks, gowns and
important for all types of isolation equipment to prevent the transmission of highly
communicable diseases by contact or by airborne routes.
3. Which of the following patients is at greater risk for Terminal disinfection is the disinfection of all contaminated
contracting an infection? supplies and equipment after a patient has been discharged
to prepare them for reuse by another patient. The purpose
A. A patient with leukopenia of protective (reverse) isolation is to prevent a person
B. A patient receiving broad-spectrum antibiotics with seriously impaired resistance from coming into contact
C. A postoperative patient who has undergone orthopedic who potentially pathogenic organisms.
surgery
D. A newly diagnosed diabetic patient 8. Which of the following constitutes a break in sterile
technique while preparing a sterile field for a dressing change?
Answer: A. Leukopenia is a decreased number of leukocytes
(white blood cells), which are important in resisting infection. A. Using sterile forceps, rather than sterile gloves, to
None of the other situations would put the patient at risk for handle a sterile item
contracting an infection; taking broadspectrum antibiotics B. Touching the outside wrapper of sterilized material
might actually reduce the infection risk. without sterile gloves
C. Placing a sterile object on the edge of the sterile field
4. Effective hand washing requires the use of: D. Pouring out a small amount of solution (15 to 30 ml)
before pouring the solution into a sterile container
A. Soap or detergent to promote emulsification
B. Hot water to destroy bacteria Answer: C. The edges of a sterile field are considered
C. A disinfectant to increase surface tension contaminated. When sterile items are allowed to come in
D. All of the above contact with the edges of the field, the sterile items also
become contaminated
Answer: A. Soaps and detergents are used to help remove
bacteria because of their ability to lower the surface tension 9. A natural body defense that plays an active role in
of water and act as emulsifying agents. Hot water may lead preventing infection is:
to skin irritation or burns
A. Yawning
5. After routine patient contact, hand washing should last at B. Body hair
least: C. Hiccupping
D. Rapid eye movements
A. 30 seconds
B. 1 minute Answer: B. Hair on or within body areas, such as the nose,
C. 2 minute traps and holds particles that contain microorganisms.
D. 3 minutes Yawning and hiccupping do not prevent microorganisms
from entering or leaving the body. Rapid eye movement
, A. The first glove should be picked up by grasping the compatibility. This is done by blood typing (a test that
inside of the cuff. determines a person’s blood type) and cross-matching
B. The second glove should be picked up by inserting the (a procedure that determines the compatibility of the
gloved fingers under the cuff outside the glove. donor’s and recipient’s blood after the blood types has been
C. The gloves should be adjusted by sliding the gloved matched). If the blood specimens are incompatible,
fingers under the sterile cuff and pulling the glove over hemolysis and antigen-antibody reactions will occur
the wrist
D. The inside of the glove is considered sterile 15.The primary purpose of a platelet count is to evaluate the:
Answer: D. The inside of the glove is always considered to be A. Potential for clot formation
clean, but not sterile. B. Potential for bleeding
C. Presence of an antigen-antibody response
11.When removing a contaminated gown, the nurse should D. Presence of cardiac enzymes
be careful that the first thing she touches is the:
Answer: A. Platelets are disk-shaped cells that are essential
A. Waist tie and neck tie at the back of the gown for blood coagulation. A platelet count determines the
B. Waist tie in front of the gown number of thrombocytes in blood available for promoting
C. Cuffs of the gown hemostasis and assisting with blood coagulation after
D. Inside of the gown injury. It also is used to evaluate the patient’s potential for
bleeding; however, this is not its primary purpose. The
Answer: A. The back of the gown is considered clean, the normal count ranges from 150,000 to 350,000/mm3. A count
front is contaminated. So, after removing gloves and of 100,000/mm3 or less indicates a potential for bleeding;
washing hands, the nurse should untie the back of the gown; count of less than 20,000/mm3 is associated with
slowly move backward away from the gown, holding spontaneous bleeding.
the inside of the gown and keeping the edges off the floor;
turn and fold the gown inside out; discard it in a 16.Which of the following white blood cell (WBC) counts
contaminated linen container; then wash her hands again. clearly indicates leukocytosis?
12.Which of the following nursing interventions is considered A. 4,500/mm³
the most effective form or universal precautions? B. 7,000/mm³
C. 10,000/mm³
A. Cap all used needles before removing them from their D. 25,000/mm³
syringes
B. Discard all used uncapped needles and syringes in Answer: D. Leukocytosis is any transient increase in the
an impenetrable protective container number of white blood cells (leukocytes) in the blood. Normal
C. Wear gloves when administering IM injections WBC counts range from 5,000 to 100,000/mm3. Thus, a count
D. Follow enteric precautions of 25,000/mm3 indicates leukocytosis
Answer: B. According to the Centers for Disease Control 17. After 5 days of diuretic therapy with 20mg of furosemide
(CDC), blood-to-blood contact occurs most commonly when (Lasix) daily, a patient begins to exhibit fatigue, muscle
a health care worker attempts to cap a used needle. cramping and muscle weakness. These symptoms probably
Therefore, used needles should never be recapped; instead indicate that the patient is experiencing:
they should be inserted in a specially designed puncture
resistant, labeled container. Wearing gloves is not always A. Hypokalemia
necessary when administering an I.M. injection. Enteric B. Hyperkalemia
precautions prevent the transfer of pathogens via feces. C. Anorexia
D. Dysphagia
13.All of the following measures are recommended to
prevent pressure ulcers except: Answer: A. Fatigue, muscle cramping, and muscle weaknesses
are symptoms of hypokalemia (an inadequate potassium
A. Massaging the reddened are with lotion level), which is a potential side effect of diuretic therapy. The
B. Using a water or air mattress physician usually orders supplemental potassium to prevent
C. Adhering to a schedule for positioning and turning hypokalemia in patients receiving diuretics. Anorexia is
D. Providing meticulous skin care another symptom of hypokalemia. Dysphagia means
difficulty swallowing.
Answer: A. Nurses and other health care professionals
previously believed that massaging a reddened area with 18.Which of the following statements about chest X-ray is
lotion would promote venous return and reduce edema to false?
the area. However, research has shown that massage only
increases the likelihood of cellular ischemia and necrosis to A. No contradictions exist for this test
the area B. Before the procedure, the patient should remove all
jewelry, metallic objects, and buttons above the waist
14.Which of the following blood tests should be performed C. A signed consent is not required
before a blood transfusion? D. Eating, drinking, and medications are allowed before
this test
A. Prothrombin and coagulation time
B. Blood typing and cross-matching Answer: A. Pregnancy or suspected pregnancy is the only
,because a chest X-ray is not an invasive examination. Eating, has relatively few major nerves and blood vessels. The middle
drinking and medications are allowed because the X-ray is of third of the muscle is recommended as the injection site.
the chest, not the abdominal region. The patient can be in a supine or sitting position for an
injection into this site.
19.The most appropriate time for the nurse to obtain a
sputum specimen for culture is: 23.The mid-deltoid injection site is seldom used for I.M.
injections because it:
A. Early in the morning
B. After the patient eats a light breakfast A. Can accommodate only 1 ml or less of medication
C. After aerosol therapy B. Bruises too easily
D. After chest physiotherapy C. Can be used only when the patient is lying down
D. Does not readily parenteral medication
Answer: A. Obtaining a sputum specimen early in this
morning ensures an adequate supply of bacteria for culturing Answer: A. The mid-deltoid injection site can accommodate
and decreases the risk of contamination from food or only 1 ml or less of medication because of its size and
medication. location (on the deltoid muscle of the arm, close to the
brachial artery and radial nerve
20.A patient with no known allergies is to receive penicillin
every 6 hours. When administering the medication, the nurse 24.The appropriate needle size for insulin injection is:
observes a fine rash on the
A. 18G, 1 ½” long
patient’s skin. The most appropriate nursing action would be B. 22G, 1” long
to: C. 22G, 1 ½” long
D. 25G, 5/8” long
A. Withhold the moderation and notify the physician
B. Administer the medication and notify the physician Answer: D. A 25G, 5/8” needle is the recommended size for
C. Administer the medication with an antihistamine insulin injection because insulin is administered by the
D. Apply corn starch soaks to the rash subcutaneous route. An 18G, 1 ½” needle is usually used for
I.M. injections in children, typically in the vastus lateralis. A
Answer: A. Initial sensitivity to penicillin is commonly 22G, 1 ½” needle is usually used for adult I.M. injections,
manifested by a skin rash, even in individuals who have not which are typically administered in the vastus lateralis or
been allergic to it previously. Because of the danger of ventrogluteal site.
anaphylactic shock, he nurse should withhold the drug
and notify the physician, who may choose to substitute 25.The appropriate needle gauge for intradermal injection is:
another drug. Administering an antihistamine is a dependent
nursing intervention that requires a written physician’s order. A. 20G
Although applying corn starch to the rash may relieve B. 22G
discomfort, it is not the nurse’s top priority in such C. 25G
a potentially life-threatening situation. D. 26G
21.All of the following nursing interventions are correct when Answer: D. Because an intradermal injection does not
using the Ztrack method of drug injection except: penetrate deeply into the skin, a small-bore 25G needle is
recommended. This type of injection is used primarily to
A. Prepare the injection site with alcohol administer antigens to evaluate reactions for allergy
B. Use a needle that’s a least 1” long or sensitivity studies. A 20G needle is usually used for I.M.
C. Aspirate for blood before injection injections of oilbased medications; a 22G needle for I.M.
D. Rub the site vigorously after the injection to promote injections; and a 25G needle, for I.M. injections; and a 25G
absorption needle, for subcutaneous insulin injections.
Answer: D. The Z-track method is an I.M. injection technique 26.Parenteral penicillin can be administered as an:
in which the patient’s skin is pulled in such a way that the
needle track is sealed off after the injection. This procedure A. IM injection or an IV solution
seals medication deep into the muscle, thereby minimizing B. IV or an intradermal injection
skin staining and irritation. Rubbing the injection site C. Intradermal or subcutaneous injection
is contraindicated because it may cause the medication to D. IM or a subcutaneous injection
extravasate into the skin
Answer: A. Parenteral penicillin can be administered I.M. or
22.The correct method for determining the vastus lateralis added to a solution and given I.V. It cannot be administered
site for I.M. injection is to: subcutaneously or intradermally.
A. Locate the upper aspect of the upper outer quadrant of 27.The physician orders gr 10 of aspirin for a patient. The
the buttock about 5 to 8 cm below the iliac crest equivalent dose in milligrams is:
B. Palpate the lower edge of the acromion process and the
midpoint lateral aspect of the arm A. 0.6 mg
C. Palpate a 1” circular area anterior to the umbilicus B. 10 mg
D. Divide the area between the greater femoral trochanter C. 60 mg
and the lateral femoral condyle into thirds, and select D. 600 mg
, 28.The physician orders an IV solution of dextrose 5% in Answer: D. Return demonstration provides the most certain
water at 100ml/hour. What would the flow rate be if the drop evidence for evaluating the effectiveness of patient teaching.
factor is 15 gtt = 1 ml?
33.Which of the following types of medications can be
A. 5 gtt/minute administered via gastrostomy tube?
B. 13 gtt/minute
C. 25 gtt/minute A. Any oral medications
D. 50 gtt/minute B. Capsules whole contents are dissolve in water
C. Enteric-coated tablets that are thoroughly dissolved in
Answer: C. 100ml/60 min X 15 gtt/ 1 ml = 25 gtt/minute water
D. Most tablets designed for oral use, except for
29.Which of the following is a sign or symptom of a hemolytic extended-duration compounds
reaction to blood transfusion?
Answer: D. Capsules, enteric-coated tablets, and most
A. Hemoglobinuria extended duration or sustained release products should not
B. Chest pain be dissolved for use in a gastrostomy tube. They are
C. Urticaria pharmaceutically manufactured in these forms for valid
D. Distended neck veins reasons, and altering them destroys their purpose. The
nurse should seek an alternate physician’s order when an
Answer: A. Hemoglobinuria, the abnormal presence of ordered medication is inappropriate for delivery by tube.
hemoglobin in the urine, indicates a hemolytic reaction
(incompatibility of the donor’s and recipient’s blood). In this 34.A patient who develops hives after receiving an antibiotic
reaction, antibodies in the recipient’s plasma combine rapidly is exhibiting drug:
with donor RBC’s; the cells are hemolyzed in
either circulatory or reticuloendothelial system. Hemolysis A. Tolerance
occurs more rapidly in ABO incompatibilities than in Rh B. Idiosyncrasy
incompatibilities. Chest pain and urticaria may be symptoms C. Synergism
of impending anaphylaxis. Distended neck veins are D. Allergy
an indication of hypervolemia.
Answer: D. A drug-allergy is an adverse reaction resulting
30.Which of the following conditions may require fluid from an immunologic response following a previous
restriction? sensitizing exposure to the drug. The reaction can range from
a rash or hives to anaphylactic shock. Tolerance to a drug
A. Fever means that the patient experiences a decreasing
B. Chronic Obstructive Pulmonary Disease physiologic response to repeated administration of the drug
C. Renal Failure in the same dosage. Idiosyncrasy is an individual’s unique
D. Dehydration hypersensitivity to a drug, food, or other substance; it
appears to be genetically determined. Synergism, is a drug
Answer: C. In real failure, the kidney loses their ability to interaction in which the sum of the drug’s combined effects is
effectively eliminate wastes and fluids. Because of this, greater than that of their separate effects.
limiting the patient’s intake of oral and I.V. fluids may be
necessary. Fever, chronic obstructive pulmonary disease, and 35.A patient has returned to his room after femoral
dehydration are conditions for which fluids should arteriography. All of the following are appropriate nursing
be encouraged. interventions except:
31.All of the following are common signs and symptoms of A. Assess femoral, popliteal, and pedal pulses every 15
phlebitis except: minutes for 2 hours
B. Check the pressure dressing for sanguineous drainage
A. Pain or discomfort at the IV insertion site C. Assess a vital signs every 15 minutes for 2 hours
B. Edema and warmth at the IV insertion site D. Order a hemoglobin and hematocrit count 1 hour after
C. A red streak exiting the IV insertion site the arteriography
D. Frank bleeding at the insertion site
Answer: D. A hemoglobin and hematocrit count would be
Answer: D. Phlebitis, the inflammation of a vein, can be ordered by the physician if bleeding were suspected. The
caused by chemical irritants (I.V. solutions or medications), other answers are appropriate nursing interventions for a
mechanical irritants (the needle or catheter used during patient who has undergone femoral arteriography.
venipuncture or cannulation), or a localized allergic reaction
to the needle or catheter. Signs and symptoms of
phlebitis include pain or discomfort, edema and heat at the 36.The nurse explains to a patient that a cough:
I.V. insertion site, and a red streak going up the arm or leg
from the I.V. insertion site. A. Is a protective response to clear the respiratory tract
of irritants
32.The best way of determining whether a patient has B. Is primarily a voluntary action
learned to instill ear medication properly is for the nurse to: C. Is induced by the administration of an antitussive drug
D. Can be inhibited by “splinting” the abdomen
A. Ask the patient if he/she has used ear drops before Answer: A. Coughing, a protective response that clears the
B. Have the patient repeat the nurse’s instructions using respiratory tract of irritants, usually is involuntary; however
1. Which element in the circular chain of infection can be 6. Which of the following procedures always requires surgical
eliminated by preserving skin integrity? asepsis?
A. Host A. Vaginal instillation of conjugated estrogen
B. Reservoir B. Urinary catheterization
C. Mode of transmission C. Nasogastric tube insertion
D. Portal of entry D. Colostomy irrigation
Answer: D. In the circular chain of infection, pathogens must Answer: B. The urinary system is normally free of
be able to leave their reservoir and be transmitted to a microorganisms except at the urinary meatus. Any
susceptible host through a portal of entry, such as broken procedure that involves entering this system must use
skin. surgically aseptic measures to maintain a bacteria-free state
2. Which of the following will probably result in a break in 7. Sterile technique is used whenever:
sterile technique for respiratory isolation? A. Strict isolation is required
A. Opening the patient’s window to the outside B. Terminal disinfection is performed
environment C. Invasive procedures are performed
B. Turning on the patient’s room ventilator D. Protective isolation is necessary
C. Opening the door of the patient’s room leading into
the hospital corridor Answer: C. All invasive procedures, including surgery,
D. Failing to wear gloves when administering a bed bath catheter insertion, and administration of parenteral therapy,
require sterile technique to maintain a sterile environment.
Answer: C. Respiratory isolation, like strict isolation, All equipment must be sterile, and the nurse and
requires that the door to the door patient’s room remain the physician must wear sterile gloves and maintain surgical
closed. However, the patient’s room should be well asepsis. In the operating room, the nurse and physician are
ventilated, so opening the window or turning on the required to wear sterile gowns, gloves, masks, hair covers,
ventricular is desirable. The nurse does not need to wear and shoe covers for all invasive procedures. Strict isolation
gloves for respiratory isolation, but good hand washing is requires the use of clean gloves, masks, gowns and
important for all types of isolation equipment to prevent the transmission of highly
communicable diseases by contact or by airborne routes.
3. Which of the following patients is at greater risk for Terminal disinfection is the disinfection of all contaminated
contracting an infection? supplies and equipment after a patient has been discharged
to prepare them for reuse by another patient. The purpose
A. A patient with leukopenia of protective (reverse) isolation is to prevent a person
B. A patient receiving broad-spectrum antibiotics with seriously impaired resistance from coming into contact
C. A postoperative patient who has undergone orthopedic who potentially pathogenic organisms.
surgery
D. A newly diagnosed diabetic patient 8. Which of the following constitutes a break in sterile
technique while preparing a sterile field for a dressing change?
Answer: A. Leukopenia is a decreased number of leukocytes
(white blood cells), which are important in resisting infection. A. Using sterile forceps, rather than sterile gloves, to
None of the other situations would put the patient at risk for handle a sterile item
contracting an infection; taking broadspectrum antibiotics B. Touching the outside wrapper of sterilized material
might actually reduce the infection risk. without sterile gloves
C. Placing a sterile object on the edge of the sterile field
4. Effective hand washing requires the use of: D. Pouring out a small amount of solution (15 to 30 ml)
before pouring the solution into a sterile container
A. Soap or detergent to promote emulsification
B. Hot water to destroy bacteria Answer: C. The edges of a sterile field are considered
C. A disinfectant to increase surface tension contaminated. When sterile items are allowed to come in
D. All of the above contact with the edges of the field, the sterile items also
become contaminated
Answer: A. Soaps and detergents are used to help remove
bacteria because of their ability to lower the surface tension 9. A natural body defense that plays an active role in
of water and act as emulsifying agents. Hot water may lead preventing infection is:
to skin irritation or burns
A. Yawning
5. After routine patient contact, hand washing should last at B. Body hair
least: C. Hiccupping
D. Rapid eye movements
A. 30 seconds
B. 1 minute Answer: B. Hair on or within body areas, such as the nose,
C. 2 minute traps and holds particles that contain microorganisms.
D. 3 minutes Yawning and hiccupping do not prevent microorganisms
from entering or leaving the body. Rapid eye movement
, A. The first glove should be picked up by grasping the compatibility. This is done by blood typing (a test that
inside of the cuff. determines a person’s blood type) and cross-matching
B. The second glove should be picked up by inserting the (a procedure that determines the compatibility of the
gloved fingers under the cuff outside the glove. donor’s and recipient’s blood after the blood types has been
C. The gloves should be adjusted by sliding the gloved matched). If the blood specimens are incompatible,
fingers under the sterile cuff and pulling the glove over hemolysis and antigen-antibody reactions will occur
the wrist
D. The inside of the glove is considered sterile 15.The primary purpose of a platelet count is to evaluate the:
Answer: D. The inside of the glove is always considered to be A. Potential for clot formation
clean, but not sterile. B. Potential for bleeding
C. Presence of an antigen-antibody response
11.When removing a contaminated gown, the nurse should D. Presence of cardiac enzymes
be careful that the first thing she touches is the:
Answer: A. Platelets are disk-shaped cells that are essential
A. Waist tie and neck tie at the back of the gown for blood coagulation. A platelet count determines the
B. Waist tie in front of the gown number of thrombocytes in blood available for promoting
C. Cuffs of the gown hemostasis and assisting with blood coagulation after
D. Inside of the gown injury. It also is used to evaluate the patient’s potential for
bleeding; however, this is not its primary purpose. The
Answer: A. The back of the gown is considered clean, the normal count ranges from 150,000 to 350,000/mm3. A count
front is contaminated. So, after removing gloves and of 100,000/mm3 or less indicates a potential for bleeding;
washing hands, the nurse should untie the back of the gown; count of less than 20,000/mm3 is associated with
slowly move backward away from the gown, holding spontaneous bleeding.
the inside of the gown and keeping the edges off the floor;
turn and fold the gown inside out; discard it in a 16.Which of the following white blood cell (WBC) counts
contaminated linen container; then wash her hands again. clearly indicates leukocytosis?
12.Which of the following nursing interventions is considered A. 4,500/mm³
the most effective form or universal precautions? B. 7,000/mm³
C. 10,000/mm³
A. Cap all used needles before removing them from their D. 25,000/mm³
syringes
B. Discard all used uncapped needles and syringes in Answer: D. Leukocytosis is any transient increase in the
an impenetrable protective container number of white blood cells (leukocytes) in the blood. Normal
C. Wear gloves when administering IM injections WBC counts range from 5,000 to 100,000/mm3. Thus, a count
D. Follow enteric precautions of 25,000/mm3 indicates leukocytosis
Answer: B. According to the Centers for Disease Control 17. After 5 days of diuretic therapy with 20mg of furosemide
(CDC), blood-to-blood contact occurs most commonly when (Lasix) daily, a patient begins to exhibit fatigue, muscle
a health care worker attempts to cap a used needle. cramping and muscle weakness. These symptoms probably
Therefore, used needles should never be recapped; instead indicate that the patient is experiencing:
they should be inserted in a specially designed puncture
resistant, labeled container. Wearing gloves is not always A. Hypokalemia
necessary when administering an I.M. injection. Enteric B. Hyperkalemia
precautions prevent the transfer of pathogens via feces. C. Anorexia
D. Dysphagia
13.All of the following measures are recommended to
prevent pressure ulcers except: Answer: A. Fatigue, muscle cramping, and muscle weaknesses
are symptoms of hypokalemia (an inadequate potassium
A. Massaging the reddened are with lotion level), which is a potential side effect of diuretic therapy. The
B. Using a water or air mattress physician usually orders supplemental potassium to prevent
C. Adhering to a schedule for positioning and turning hypokalemia in patients receiving diuretics. Anorexia is
D. Providing meticulous skin care another symptom of hypokalemia. Dysphagia means
difficulty swallowing.
Answer: A. Nurses and other health care professionals
previously believed that massaging a reddened area with 18.Which of the following statements about chest X-ray is
lotion would promote venous return and reduce edema to false?
the area. However, research has shown that massage only
increases the likelihood of cellular ischemia and necrosis to A. No contradictions exist for this test
the area B. Before the procedure, the patient should remove all
jewelry, metallic objects, and buttons above the waist
14.Which of the following blood tests should be performed C. A signed consent is not required
before a blood transfusion? D. Eating, drinking, and medications are allowed before
this test
A. Prothrombin and coagulation time
B. Blood typing and cross-matching Answer: A. Pregnancy or suspected pregnancy is the only
,because a chest X-ray is not an invasive examination. Eating, has relatively few major nerves and blood vessels. The middle
drinking and medications are allowed because the X-ray is of third of the muscle is recommended as the injection site.
the chest, not the abdominal region. The patient can be in a supine or sitting position for an
injection into this site.
19.The most appropriate time for the nurse to obtain a
sputum specimen for culture is: 23.The mid-deltoid injection site is seldom used for I.M.
injections because it:
A. Early in the morning
B. After the patient eats a light breakfast A. Can accommodate only 1 ml or less of medication
C. After aerosol therapy B. Bruises too easily
D. After chest physiotherapy C. Can be used only when the patient is lying down
D. Does not readily parenteral medication
Answer: A. Obtaining a sputum specimen early in this
morning ensures an adequate supply of bacteria for culturing Answer: A. The mid-deltoid injection site can accommodate
and decreases the risk of contamination from food or only 1 ml or less of medication because of its size and
medication. location (on the deltoid muscle of the arm, close to the
brachial artery and radial nerve
20.A patient with no known allergies is to receive penicillin
every 6 hours. When administering the medication, the nurse 24.The appropriate needle size for insulin injection is:
observes a fine rash on the
A. 18G, 1 ½” long
patient’s skin. The most appropriate nursing action would be B. 22G, 1” long
to: C. 22G, 1 ½” long
D. 25G, 5/8” long
A. Withhold the moderation and notify the physician
B. Administer the medication and notify the physician Answer: D. A 25G, 5/8” needle is the recommended size for
C. Administer the medication with an antihistamine insulin injection because insulin is administered by the
D. Apply corn starch soaks to the rash subcutaneous route. An 18G, 1 ½” needle is usually used for
I.M. injections in children, typically in the vastus lateralis. A
Answer: A. Initial sensitivity to penicillin is commonly 22G, 1 ½” needle is usually used for adult I.M. injections,
manifested by a skin rash, even in individuals who have not which are typically administered in the vastus lateralis or
been allergic to it previously. Because of the danger of ventrogluteal site.
anaphylactic shock, he nurse should withhold the drug
and notify the physician, who may choose to substitute 25.The appropriate needle gauge for intradermal injection is:
another drug. Administering an antihistamine is a dependent
nursing intervention that requires a written physician’s order. A. 20G
Although applying corn starch to the rash may relieve B. 22G
discomfort, it is not the nurse’s top priority in such C. 25G
a potentially life-threatening situation. D. 26G
21.All of the following nursing interventions are correct when Answer: D. Because an intradermal injection does not
using the Ztrack method of drug injection except: penetrate deeply into the skin, a small-bore 25G needle is
recommended. This type of injection is used primarily to
A. Prepare the injection site with alcohol administer antigens to evaluate reactions for allergy
B. Use a needle that’s a least 1” long or sensitivity studies. A 20G needle is usually used for I.M.
C. Aspirate for blood before injection injections of oilbased medications; a 22G needle for I.M.
D. Rub the site vigorously after the injection to promote injections; and a 25G needle, for I.M. injections; and a 25G
absorption needle, for subcutaneous insulin injections.
Answer: D. The Z-track method is an I.M. injection technique 26.Parenteral penicillin can be administered as an:
in which the patient’s skin is pulled in such a way that the
needle track is sealed off after the injection. This procedure A. IM injection or an IV solution
seals medication deep into the muscle, thereby minimizing B. IV or an intradermal injection
skin staining and irritation. Rubbing the injection site C. Intradermal or subcutaneous injection
is contraindicated because it may cause the medication to D. IM or a subcutaneous injection
extravasate into the skin
Answer: A. Parenteral penicillin can be administered I.M. or
22.The correct method for determining the vastus lateralis added to a solution and given I.V. It cannot be administered
site for I.M. injection is to: subcutaneously or intradermally.
A. Locate the upper aspect of the upper outer quadrant of 27.The physician orders gr 10 of aspirin for a patient. The
the buttock about 5 to 8 cm below the iliac crest equivalent dose in milligrams is:
B. Palpate the lower edge of the acromion process and the
midpoint lateral aspect of the arm A. 0.6 mg
C. Palpate a 1” circular area anterior to the umbilicus B. 10 mg
D. Divide the area between the greater femoral trochanter C. 60 mg
and the lateral femoral condyle into thirds, and select D. 600 mg
, 28.The physician orders an IV solution of dextrose 5% in Answer: D. Return demonstration provides the most certain
water at 100ml/hour. What would the flow rate be if the drop evidence for evaluating the effectiveness of patient teaching.
factor is 15 gtt = 1 ml?
33.Which of the following types of medications can be
A. 5 gtt/minute administered via gastrostomy tube?
B. 13 gtt/minute
C. 25 gtt/minute A. Any oral medications
D. 50 gtt/minute B. Capsules whole contents are dissolve in water
C. Enteric-coated tablets that are thoroughly dissolved in
Answer: C. 100ml/60 min X 15 gtt/ 1 ml = 25 gtt/minute water
D. Most tablets designed for oral use, except for
29.Which of the following is a sign or symptom of a hemolytic extended-duration compounds
reaction to blood transfusion?
Answer: D. Capsules, enteric-coated tablets, and most
A. Hemoglobinuria extended duration or sustained release products should not
B. Chest pain be dissolved for use in a gastrostomy tube. They are
C. Urticaria pharmaceutically manufactured in these forms for valid
D. Distended neck veins reasons, and altering them destroys their purpose. The
nurse should seek an alternate physician’s order when an
Answer: A. Hemoglobinuria, the abnormal presence of ordered medication is inappropriate for delivery by tube.
hemoglobin in the urine, indicates a hemolytic reaction
(incompatibility of the donor’s and recipient’s blood). In this 34.A patient who develops hives after receiving an antibiotic
reaction, antibodies in the recipient’s plasma combine rapidly is exhibiting drug:
with donor RBC’s; the cells are hemolyzed in
either circulatory or reticuloendothelial system. Hemolysis A. Tolerance
occurs more rapidly in ABO incompatibilities than in Rh B. Idiosyncrasy
incompatibilities. Chest pain and urticaria may be symptoms C. Synergism
of impending anaphylaxis. Distended neck veins are D. Allergy
an indication of hypervolemia.
Answer: D. A drug-allergy is an adverse reaction resulting
30.Which of the following conditions may require fluid from an immunologic response following a previous
restriction? sensitizing exposure to the drug. The reaction can range from
a rash or hives to anaphylactic shock. Tolerance to a drug
A. Fever means that the patient experiences a decreasing
B. Chronic Obstructive Pulmonary Disease physiologic response to repeated administration of the drug
C. Renal Failure in the same dosage. Idiosyncrasy is an individual’s unique
D. Dehydration hypersensitivity to a drug, food, or other substance; it
appears to be genetically determined. Synergism, is a drug
Answer: C. In real failure, the kidney loses their ability to interaction in which the sum of the drug’s combined effects is
effectively eliminate wastes and fluids. Because of this, greater than that of their separate effects.
limiting the patient’s intake of oral and I.V. fluids may be
necessary. Fever, chronic obstructive pulmonary disease, and 35.A patient has returned to his room after femoral
dehydration are conditions for which fluids should arteriography. All of the following are appropriate nursing
be encouraged. interventions except:
31.All of the following are common signs and symptoms of A. Assess femoral, popliteal, and pedal pulses every 15
phlebitis except: minutes for 2 hours
B. Check the pressure dressing for sanguineous drainage
A. Pain or discomfort at the IV insertion site C. Assess a vital signs every 15 minutes for 2 hours
B. Edema and warmth at the IV insertion site D. Order a hemoglobin and hematocrit count 1 hour after
C. A red streak exiting the IV insertion site the arteriography
D. Frank bleeding at the insertion site
Answer: D. A hemoglobin and hematocrit count would be
Answer: D. Phlebitis, the inflammation of a vein, can be ordered by the physician if bleeding were suspected. The
caused by chemical irritants (I.V. solutions or medications), other answers are appropriate nursing interventions for a
mechanical irritants (the needle or catheter used during patient who has undergone femoral arteriography.
venipuncture or cannulation), or a localized allergic reaction
to the needle or catheter. Signs and symptoms of
phlebitis include pain or discomfort, edema and heat at the 36.The nurse explains to a patient that a cough:
I.V. insertion site, and a red streak going up the arm or leg
from the I.V. insertion site. A. Is a protective response to clear the respiratory tract
of irritants
32.The best way of determining whether a patient has B. Is primarily a voluntary action
learned to instill ear medication properly is for the nurse to: C. Is induced by the administration of an antitussive drug
D. Can be inhibited by “splinting” the abdomen
A. Ask the patient if he/she has used ear drops before Answer: A. Coughing, a protective response that clears the
B. Have the patient repeat the nurse’s instructions using respiratory tract of irritants, usually is involuntary; however
