PNLE 1 - FOUNDATION OF PROFESSIONAL NURSING PRACTICE amounts of output for 2 consecutive hours: 8 a.m.: 50 ml; 9 a.m.: 60
SET1 ml. Based on these amounts, which action should the nurse take?
1. The nurse In-charge in labor and delivery unit administered a dose Increase the I.V. fluid infusion rate
of terbutaline to a client without checking the client’s pulse. The Irrigate the indwelling urinary catheter
standard that would be used to determine if the nurse was negligent Notify the physician
is: Continue to monitor and record hourly urine output
The physician’s orders. 9. Tony, a basketball player twist his right ankle while playing on the
The action of a clinical nurse specialist who is recognized expert in court and seeks care for ankle pain and swelling. After the nurse
the field. applies ice to the ankle for 30 minutes, which statement by Tony
The statement in the drug literature about administration of suggests that ice application has been effective?
terbutaline. “My ankle looks less swollen now”.
The actions of a reasonably prudent nurse with similar education “My ankle feels warm”.
and experience. “My ankle appears redder now”.
2. Nurse Trish is caring for a female client with a history of GI “I need something stronger for pain relief”
bleeding, sickle cell disease, and a platelet count of 22,000/μl. The 10.The physician prescribes a loop diuretic for a client. When
female client is dehydrated and receiving dextrose 5% in half-normal administering this drug, the nurse anticipates that the client may
saline solution at 150 ml/hr. The client complains of severe bone develop which electrolyte imbalance?
pain and is scheduled to receive a dose of morphine sulfate. In Hypernatremia
administering the medication, Nurse Trish should avoid which route? Hyperkalemia
I.V Hypokalemia
I.M Hypervolemia
Oral 11.She finds out that some managers have benevolent-authoritative
S.C style of management. Which of the following behaviors will she
3. Dr. Garcia writes the following order for the client who has been exhibit most likely?
recently admitted “Digoxin .125 mg P.O. once daily.” To prevent a Have condescending trust and confidence in their subordinates.
dosage error, how should the nurse document this order onto the Gives economic and ego awards.
medication administration record? Communicates downward to staffs.
“Digoxin .1250 mg P.O. once daily” Allows decision making among subordinates.
“Digoxin 0.1250 mg P.O. once daily” 12. Nurse Amy is aware that the following is true about functional
“Digoxin 0.125 mg P.O. once daily” nursing
“Digoxin .125 mg P.O. once daily” Provides continuous, coordinated and comprehensive nursing
4. A newly admitted female client was diagnosed with deep vein services.
thrombosis. Which nursing diagnosis should receive the highest One-to-one nurse patient ratio.
priority? Emphasize the use of group collaboration.
Ineffective peripheral tissue perfusion related to venous congestion. Concentrates on tasks and activities.
Risk for injury related to edema. 13.Which type of medication order might read “Vitamin K 10 mg I.M.
Excess fluid volume related to peripheral vascular disease. daily × 3 days?”
Impaired gas exchange related to increased blood flow. Single order
5. Nurse Betty is assigned to the following clients. The client that the Standard written order
nurse would see first after endorsement? Standing order
A 34 year-old post operative appendectomy client of five hours who Stat order
is complaining of pain. 14.A female client with a fecal impaction frequently exhibits which
A 44 year-old myocardial infarction (MI) client who is complaining of clinical manifestation?
nausea. Increased appetite
A 26 year-old client admitted for dehydration whose intravenous (IV) Loss of urge to defecate
has infiltrated. Hard, brown, formed stools
A 63 year-old post operative’s abdominal hysterectomy client of Liquid or semi-liquid stools
three days whose incisional dressing is saturated 15.Nurse Linda prepares to perform an otoscopic examination on a
with serosanguinous fluid. female client. For proper visualization, the nurse should position the
6. Nurse Gail places a client in a four-point restraint following orders client’s ear by:
from the physician. The client care plan should include: Pulling the lobule down and back
Assess temperature frequently. Pulling the helix up and forward
Provide diversional activities. Pulling the helix up and back
Check circulation every 15-30 minutes. Pulling the lobule down and forward
Socialize with other patients once a shift. 16. Which instruction should nurse Tom give to a male client who is
7. A male client who has severe burns is receiving H2 receptor having external radiation therapy:
antagonist therapy. The nurse In-charge knows the purpose of this Protect the irritated skin from sunlight.
therapy is to: Eat 3 to 4 hours before treatment.
Prevent stress ulcer Wash the skin over regularly.
Block prostaglandin synthesis Apply lotion or oil to the radiated area when it is red or sore.
Facilitate protein synthesis. 17.In assisting a female client for immediate surgery, the nurse
Enhance gas exchange In-charge is aware that she should:
8. The doctor orders hourly urine output measurement for a Encourage the client to void following preoperative medication.
postoperative male client. The nurse Trish records the following Explore the client’s fears and anxieties about the surgery.
Assist the client in removing dentures and nail polish.
,Encourage the client to drink water prior to surgery. 27.A child of 10 years old is to receive 400 cc of IV fluid in an 8 hour
18. A male client is admitted and diagnosed with acute pancreatitis shift. The IV drip factor is 60. The IV rate that will deliver this amount
after a holiday celebration of excessive food and alcohol. Which is:
assessment finding reflects this diagnosis? 50 cc/ hour
Blood pressure above normal range. 55 cc/ hour
Presence of crackles in both lung fields. 24 cc/ hour
Hyperactive bowel sounds 66 cc/ hour
Sudden onset of continuous epigastric and back pain. 28.The nurse is aware that the most important nursing action when a
19. Which dietary guidelines are important for nurse Oliver to client returns from surgery is:
implement in caring for the client with burns? Assess the IV for type of fluid and rate of flow.
Provide high-fiber, high-fat diet Assess the client for presence of pain.
Provide high-protein, high-carbohydrate diet. Assess the Foley catheter for patency and urine output
Monitor intake to prevent weight gain. Assess the dressing for drainage.
Provide ice chips or water intake. 29. Which of the following vital sign assessments that may indicate
20.Nurse Hazel will administer a unit of whole blood, which priority cardiogenic shock after myocardial infarction?
information should the nurse have about the client? BP – 80/60, Pulse – 110 irregular
Blood pressure and pulse rate. BP – 90/50, Pulse – 50 regular
Height and weight. BP – 130/80, Pulse – 100 regular
Calcium and potassium levels BP – 180/100, Pulse – 90 irregular
Hgb and Hct levels. 30.Which is the most appropriate nursing action in obtaining a blood
21. Nurse Michelle witnesses a female client sustain a fall and pressure measurement?
suspects that the leg may be broken. The nurse takes which priority Take the proper equipment, place the client in a comfortable
action? position, and record the appropriate information in the client’s chart.
Takes a set of vital signs. Measure the client’s arm, if you are not sure of the size of cuff to
Call the radiology department for X-ray. use.
Reassure the client that everything will be alright. Have the client recline or sit comfortably in a chair with the forearm
Immobilize the leg before moving the client. at the level of the heart.
22.A male client is being transferred to the nursing unit for Document the measurement, which extremity was used, and the
admission after receiving a radium implant for bladder cancer. The position that the client was in during the measurement.
nurse in-charge would take which priority action in the care of this 31.Asking the questions to determine if the person understands the
client? health teaching provided by the nurse would be included during
Place client on reverse isolation. which step of the nursing process?
Admit the client into a private room. Assessment
Encourage the client to take frequent rest periods. Evaluation
Encourage family and friends to visit. Implementation
23.A newly admitted female client was diagnosed with Planning and goals
agranulocytosis. The nurse formulates which priority nursing 32.Which of the following item is considered the single most
diagnosis? important factor in assisting the health professional in arriving at a
Constipation diagnosis or determining the person’s needs?
Diarrhea Diagnostic test results
Risk for infection Biographical date
Deficient knowledge History of present illness
24.A male client is receiving total parenteral nutrition suddenly Physical examination
demonstrates signs and symptoms of an air embolism. What is the 33.In preventing the development of an external rotation deformity
priority action by the nurse? of the hip in a client who must remain in bed for any period of time,
Notify the physician. the most appropriate nursing action would be to use:
Place the client on the left side in the Trendelenburg position. Trochanter roll extending from the crest of the ileum to the
Place the client in high-Fowlers position. midthigh.
Stop the total parenteral nutrition. Pillows under the lower legs.
25.Nurse May attends an educational conference on leadership Footboard
styles. The nurse is sitting with a nurse employed at a large trauma Hip-abductor pillow
center who states that the leadership style at the trauma center is 34.Which stage of pressure ulcer development does the ulcer extend
task-oriented and directive. The nurse determines that the into the subcutaneous tissue?
leadership style used at the trauma center is: Stage I
Autocratic. Stage II
Laissez-faire. Stage III
Democratic. Stage IV
Situational 35.When the method of wound healing is one in which wound edges
26.The physician orders DS 500 cc with KCl 10 mEq/liter at 30 cc/hr. are not surgically approximated and integumentary continuity is
The nurse in-charge is going to hang a 500 cc bag. KCl is supplied 20 restored by granulations, the wound healing is termed
mEq/10 cc. How many cc’s of KCl will be added to the IV solution? Second intention healing
.5 cc Primary intention healing
5 cc Third intention healing
1.5 cc First intention healing
2.5 cc
, 36.An 80-year-old male client is admitted to the hospital with a the client, Nurse Hazel inspects the client’s abdomen and notice that
diagnosis of pneumonia. Nurse Oliver learns that the client lives it is slightly concave. Additional assessment should proceed in which
alone and hasn’t been eating or drinking. When assessing him for order:
dehydration, nurse Oliver would expect to find: Palpation, auscultation, and percussion.
Hypothermia Percussion, palpation, and auscultation.
Hypertension Palpation, percussion, and auscultation.
Distended neck veins Auscultation, percussion, and palpation.
Tachycardia 46. Nurse Betty is assessing tactile fremitus in a client with
37.The physician prescribes meperidine (Demerol), 75 mg I.M. every pneumonia. For this examination, nurse Betty should use the:
4 hours as needed, to control a client’s postoperative pain. The Fingertips
package insert is “Meperidine, 100 mg/ml.” How many milliliters of Finger pads
meperidine should the Dorsal surface of the hand
client receive? Ulnar surface of the hand
0.75 47. Which type of evaluation occurs continuously throughout the
0.6 teaching and learning process?
0.5 Summative
0.25 Informative
38. A male client with diabetes mellitus is receiving insulin. Which Formative
statement correctly describes an insulin unit? Retrospective
It’s a common measurement in the metric system. 48.A 45 year old client, has no family history of breast cancer or
It’s the basis for solids in the avoirdupois system. other risk factors for this disease. Nurse John should instruct her to
It’s the smallest measurement in the apothecary system. have mammogram how often?
It’s a measure of effect, not a standard measure of weight or Twice per year
quantity. Once per year
39.Nurse Oliver measures a client’s temperature at 102° F. What is Every 2 years
the equivalent Centigrade temperature? Once, to establish baseline
40.1 °C 49.A male client has the following arterial blood gas values: pH 7.30;
38.9 °C Pao2 89 mmHg; Paco2 50 mmHg; and HCO3 26mEq/L. Based on
48 °C these values, Nurse Patricia should expect which condition?
38 °C Respiratory acidosis
40.The nurse is assessing a 48-year-old client who has come to the Respiratory alkalosis
physician’s office for his annual physical exam. One of the first Metabolic acidosis
physical signs of aging is: Metabolic alkalosis
Accepting limitations while developing assets. 50.Nurse Len refers a female client with terminal cancer to a local
Increasing loss of muscle tone. hospice. What is the goal of this referral?
Failing eyesight, especially close vision. To help the client find appropriate treatment options.
Having more frequent aches and pains. To provide support for the client and family in coping with terminal
41.The physician inserts a chest tube into a female client to treat a illness.
pneumothorax. The tube is connected to water-seal drainage. The To ensure that the client gets counseling regarding health care costs.
nurse in-charge can prevent chest tube air leaks by: To teach the client and family about cancer and its treatment.
Checking and taping all connections. 51.When caring for a male client with a 3-cm stage I pressure ulcer
Checking patency of the chest tube. on the coccyx, which of the following actions can the nurse
Keeping the head of the bed slightly elevated. institute independently?
Keeping the chest drainage system below the level of the chest. Massaging the area with an astringent every 2 hours.
42.Nurse Trish must verify the client’s identity before administering Applying an antibiotic cream to the area three times per day.
medication. She is aware that the safest way to verify identity is to: Using normal saline solution to clean the ulcer and applying a
Check the client’s identification band. protective dressing as necessary.
Ask the client to state his name. Using a povidone-iodine wash on the ulceration three times per day.
State the client’s name out loud and wait a client to repeat it. 52.Nurse Oliver must apply an elastic bandage to a client’s ankle and
Check the room number and the client’s name on the bed. calf. He should apply the bandage beginning at the client’s:
43.The physician orders dextrose 5 % in water, 1,000 ml to be infused Knee
over 8 hours. The I.V. tubing delivers 15 drops/ml. Nurse John should Ankle
run the I.V. infusion at a rate of: Lower thigh
30 drops/minute Foot
32 drops/minute 53.A 10 year old child with type 1 diabetes develops diabetic
20 drops/minute ketoacidosis and receives a continuous insulin infusion. Which
18 drops/minute condition represents the greatest risk to this child?
44.If a central venous catheter becomes disconnected accidentally, Hypernatremia
what should the nurse in-charge do immediately? Hypokalemia
Clamp the catheter Hyperphosphatemia
Call another nurse Hypercalcemia
Call the physician 54.Nurse Len is administering sublingual nitrglycerin (Nitrostat) to
Apply a dry sterile dressing to the site. the newly admitted client. Immediately afterward, the client may
45.A female client was recently admitted. She has fever, weight loss, experience:
and watery diarrhea is being admitted to the facility. While assessing Throbbing headache or dizziness
SET1 ml. Based on these amounts, which action should the nurse take?
1. The nurse In-charge in labor and delivery unit administered a dose Increase the I.V. fluid infusion rate
of terbutaline to a client without checking the client’s pulse. The Irrigate the indwelling urinary catheter
standard that would be used to determine if the nurse was negligent Notify the physician
is: Continue to monitor and record hourly urine output
The physician’s orders. 9. Tony, a basketball player twist his right ankle while playing on the
The action of a clinical nurse specialist who is recognized expert in court and seeks care for ankle pain and swelling. After the nurse
the field. applies ice to the ankle for 30 minutes, which statement by Tony
The statement in the drug literature about administration of suggests that ice application has been effective?
terbutaline. “My ankle looks less swollen now”.
The actions of a reasonably prudent nurse with similar education “My ankle feels warm”.
and experience. “My ankle appears redder now”.
2. Nurse Trish is caring for a female client with a history of GI “I need something stronger for pain relief”
bleeding, sickle cell disease, and a platelet count of 22,000/μl. The 10.The physician prescribes a loop diuretic for a client. When
female client is dehydrated and receiving dextrose 5% in half-normal administering this drug, the nurse anticipates that the client may
saline solution at 150 ml/hr. The client complains of severe bone develop which electrolyte imbalance?
pain and is scheduled to receive a dose of morphine sulfate. In Hypernatremia
administering the medication, Nurse Trish should avoid which route? Hyperkalemia
I.V Hypokalemia
I.M Hypervolemia
Oral 11.She finds out that some managers have benevolent-authoritative
S.C style of management. Which of the following behaviors will she
3. Dr. Garcia writes the following order for the client who has been exhibit most likely?
recently admitted “Digoxin .125 mg P.O. once daily.” To prevent a Have condescending trust and confidence in their subordinates.
dosage error, how should the nurse document this order onto the Gives economic and ego awards.
medication administration record? Communicates downward to staffs.
“Digoxin .1250 mg P.O. once daily” Allows decision making among subordinates.
“Digoxin 0.1250 mg P.O. once daily” 12. Nurse Amy is aware that the following is true about functional
“Digoxin 0.125 mg P.O. once daily” nursing
“Digoxin .125 mg P.O. once daily” Provides continuous, coordinated and comprehensive nursing
4. A newly admitted female client was diagnosed with deep vein services.
thrombosis. Which nursing diagnosis should receive the highest One-to-one nurse patient ratio.
priority? Emphasize the use of group collaboration.
Ineffective peripheral tissue perfusion related to venous congestion. Concentrates on tasks and activities.
Risk for injury related to edema. 13.Which type of medication order might read “Vitamin K 10 mg I.M.
Excess fluid volume related to peripheral vascular disease. daily × 3 days?”
Impaired gas exchange related to increased blood flow. Single order
5. Nurse Betty is assigned to the following clients. The client that the Standard written order
nurse would see first after endorsement? Standing order
A 34 year-old post operative appendectomy client of five hours who Stat order
is complaining of pain. 14.A female client with a fecal impaction frequently exhibits which
A 44 year-old myocardial infarction (MI) client who is complaining of clinical manifestation?
nausea. Increased appetite
A 26 year-old client admitted for dehydration whose intravenous (IV) Loss of urge to defecate
has infiltrated. Hard, brown, formed stools
A 63 year-old post operative’s abdominal hysterectomy client of Liquid or semi-liquid stools
three days whose incisional dressing is saturated 15.Nurse Linda prepares to perform an otoscopic examination on a
with serosanguinous fluid. female client. For proper visualization, the nurse should position the
6. Nurse Gail places a client in a four-point restraint following orders client’s ear by:
from the physician. The client care plan should include: Pulling the lobule down and back
Assess temperature frequently. Pulling the helix up and forward
Provide diversional activities. Pulling the helix up and back
Check circulation every 15-30 minutes. Pulling the lobule down and forward
Socialize with other patients once a shift. 16. Which instruction should nurse Tom give to a male client who is
7. A male client who has severe burns is receiving H2 receptor having external radiation therapy:
antagonist therapy. The nurse In-charge knows the purpose of this Protect the irritated skin from sunlight.
therapy is to: Eat 3 to 4 hours before treatment.
Prevent stress ulcer Wash the skin over regularly.
Block prostaglandin synthesis Apply lotion or oil to the radiated area when it is red or sore.
Facilitate protein synthesis. 17.In assisting a female client for immediate surgery, the nurse
Enhance gas exchange In-charge is aware that she should:
8. The doctor orders hourly urine output measurement for a Encourage the client to void following preoperative medication.
postoperative male client. The nurse Trish records the following Explore the client’s fears and anxieties about the surgery.
Assist the client in removing dentures and nail polish.
,Encourage the client to drink water prior to surgery. 27.A child of 10 years old is to receive 400 cc of IV fluid in an 8 hour
18. A male client is admitted and diagnosed with acute pancreatitis shift. The IV drip factor is 60. The IV rate that will deliver this amount
after a holiday celebration of excessive food and alcohol. Which is:
assessment finding reflects this diagnosis? 50 cc/ hour
Blood pressure above normal range. 55 cc/ hour
Presence of crackles in both lung fields. 24 cc/ hour
Hyperactive bowel sounds 66 cc/ hour
Sudden onset of continuous epigastric and back pain. 28.The nurse is aware that the most important nursing action when a
19. Which dietary guidelines are important for nurse Oliver to client returns from surgery is:
implement in caring for the client with burns? Assess the IV for type of fluid and rate of flow.
Provide high-fiber, high-fat diet Assess the client for presence of pain.
Provide high-protein, high-carbohydrate diet. Assess the Foley catheter for patency and urine output
Monitor intake to prevent weight gain. Assess the dressing for drainage.
Provide ice chips or water intake. 29. Which of the following vital sign assessments that may indicate
20.Nurse Hazel will administer a unit of whole blood, which priority cardiogenic shock after myocardial infarction?
information should the nurse have about the client? BP – 80/60, Pulse – 110 irregular
Blood pressure and pulse rate. BP – 90/50, Pulse – 50 regular
Height and weight. BP – 130/80, Pulse – 100 regular
Calcium and potassium levels BP – 180/100, Pulse – 90 irregular
Hgb and Hct levels. 30.Which is the most appropriate nursing action in obtaining a blood
21. Nurse Michelle witnesses a female client sustain a fall and pressure measurement?
suspects that the leg may be broken. The nurse takes which priority Take the proper equipment, place the client in a comfortable
action? position, and record the appropriate information in the client’s chart.
Takes a set of vital signs. Measure the client’s arm, if you are not sure of the size of cuff to
Call the radiology department for X-ray. use.
Reassure the client that everything will be alright. Have the client recline or sit comfortably in a chair with the forearm
Immobilize the leg before moving the client. at the level of the heart.
22.A male client is being transferred to the nursing unit for Document the measurement, which extremity was used, and the
admission after receiving a radium implant for bladder cancer. The position that the client was in during the measurement.
nurse in-charge would take which priority action in the care of this 31.Asking the questions to determine if the person understands the
client? health teaching provided by the nurse would be included during
Place client on reverse isolation. which step of the nursing process?
Admit the client into a private room. Assessment
Encourage the client to take frequent rest periods. Evaluation
Encourage family and friends to visit. Implementation
23.A newly admitted female client was diagnosed with Planning and goals
agranulocytosis. The nurse formulates which priority nursing 32.Which of the following item is considered the single most
diagnosis? important factor in assisting the health professional in arriving at a
Constipation diagnosis or determining the person’s needs?
Diarrhea Diagnostic test results
Risk for infection Biographical date
Deficient knowledge History of present illness
24.A male client is receiving total parenteral nutrition suddenly Physical examination
demonstrates signs and symptoms of an air embolism. What is the 33.In preventing the development of an external rotation deformity
priority action by the nurse? of the hip in a client who must remain in bed for any period of time,
Notify the physician. the most appropriate nursing action would be to use:
Place the client on the left side in the Trendelenburg position. Trochanter roll extending from the crest of the ileum to the
Place the client in high-Fowlers position. midthigh.
Stop the total parenteral nutrition. Pillows under the lower legs.
25.Nurse May attends an educational conference on leadership Footboard
styles. The nurse is sitting with a nurse employed at a large trauma Hip-abductor pillow
center who states that the leadership style at the trauma center is 34.Which stage of pressure ulcer development does the ulcer extend
task-oriented and directive. The nurse determines that the into the subcutaneous tissue?
leadership style used at the trauma center is: Stage I
Autocratic. Stage II
Laissez-faire. Stage III
Democratic. Stage IV
Situational 35.When the method of wound healing is one in which wound edges
26.The physician orders DS 500 cc with KCl 10 mEq/liter at 30 cc/hr. are not surgically approximated and integumentary continuity is
The nurse in-charge is going to hang a 500 cc bag. KCl is supplied 20 restored by granulations, the wound healing is termed
mEq/10 cc. How many cc’s of KCl will be added to the IV solution? Second intention healing
.5 cc Primary intention healing
5 cc Third intention healing
1.5 cc First intention healing
2.5 cc
, 36.An 80-year-old male client is admitted to the hospital with a the client, Nurse Hazel inspects the client’s abdomen and notice that
diagnosis of pneumonia. Nurse Oliver learns that the client lives it is slightly concave. Additional assessment should proceed in which
alone and hasn’t been eating or drinking. When assessing him for order:
dehydration, nurse Oliver would expect to find: Palpation, auscultation, and percussion.
Hypothermia Percussion, palpation, and auscultation.
Hypertension Palpation, percussion, and auscultation.
Distended neck veins Auscultation, percussion, and palpation.
Tachycardia 46. Nurse Betty is assessing tactile fremitus in a client with
37.The physician prescribes meperidine (Demerol), 75 mg I.M. every pneumonia. For this examination, nurse Betty should use the:
4 hours as needed, to control a client’s postoperative pain. The Fingertips
package insert is “Meperidine, 100 mg/ml.” How many milliliters of Finger pads
meperidine should the Dorsal surface of the hand
client receive? Ulnar surface of the hand
0.75 47. Which type of evaluation occurs continuously throughout the
0.6 teaching and learning process?
0.5 Summative
0.25 Informative
38. A male client with diabetes mellitus is receiving insulin. Which Formative
statement correctly describes an insulin unit? Retrospective
It’s a common measurement in the metric system. 48.A 45 year old client, has no family history of breast cancer or
It’s the basis for solids in the avoirdupois system. other risk factors for this disease. Nurse John should instruct her to
It’s the smallest measurement in the apothecary system. have mammogram how often?
It’s a measure of effect, not a standard measure of weight or Twice per year
quantity. Once per year
39.Nurse Oliver measures a client’s temperature at 102° F. What is Every 2 years
the equivalent Centigrade temperature? Once, to establish baseline
40.1 °C 49.A male client has the following arterial blood gas values: pH 7.30;
38.9 °C Pao2 89 mmHg; Paco2 50 mmHg; and HCO3 26mEq/L. Based on
48 °C these values, Nurse Patricia should expect which condition?
38 °C Respiratory acidosis
40.The nurse is assessing a 48-year-old client who has come to the Respiratory alkalosis
physician’s office for his annual physical exam. One of the first Metabolic acidosis
physical signs of aging is: Metabolic alkalosis
Accepting limitations while developing assets. 50.Nurse Len refers a female client with terminal cancer to a local
Increasing loss of muscle tone. hospice. What is the goal of this referral?
Failing eyesight, especially close vision. To help the client find appropriate treatment options.
Having more frequent aches and pains. To provide support for the client and family in coping with terminal
41.The physician inserts a chest tube into a female client to treat a illness.
pneumothorax. The tube is connected to water-seal drainage. The To ensure that the client gets counseling regarding health care costs.
nurse in-charge can prevent chest tube air leaks by: To teach the client and family about cancer and its treatment.
Checking and taping all connections. 51.When caring for a male client with a 3-cm stage I pressure ulcer
Checking patency of the chest tube. on the coccyx, which of the following actions can the nurse
Keeping the head of the bed slightly elevated. institute independently?
Keeping the chest drainage system below the level of the chest. Massaging the area with an astringent every 2 hours.
42.Nurse Trish must verify the client’s identity before administering Applying an antibiotic cream to the area three times per day.
medication. She is aware that the safest way to verify identity is to: Using normal saline solution to clean the ulcer and applying a
Check the client’s identification band. protective dressing as necessary.
Ask the client to state his name. Using a povidone-iodine wash on the ulceration three times per day.
State the client’s name out loud and wait a client to repeat it. 52.Nurse Oliver must apply an elastic bandage to a client’s ankle and
Check the room number and the client’s name on the bed. calf. He should apply the bandage beginning at the client’s:
43.The physician orders dextrose 5 % in water, 1,000 ml to be infused Knee
over 8 hours. The I.V. tubing delivers 15 drops/ml. Nurse John should Ankle
run the I.V. infusion at a rate of: Lower thigh
30 drops/minute Foot
32 drops/minute 53.A 10 year old child with type 1 diabetes develops diabetic
20 drops/minute ketoacidosis and receives a continuous insulin infusion. Which
18 drops/minute condition represents the greatest risk to this child?
44.If a central venous catheter becomes disconnected accidentally, Hypernatremia
what should the nurse in-charge do immediately? Hypokalemia
Clamp the catheter Hyperphosphatemia
Call another nurse Hypercalcemia
Call the physician 54.Nurse Len is administering sublingual nitrglycerin (Nitrostat) to
Apply a dry sterile dressing to the site. the newly admitted client. Immediately afterward, the client may
45.A female client was recently admitted. She has fever, weight loss, experience:
and watery diarrhea is being admitted to the facility. While assessing Throbbing headache or dizziness
