PREBOARD EXAMINATION Nursing Care Management IJuly 2011INSTRUCTIONS: Select the correct answer for each of the following questions. Mark only one answer for each item by marking the box corresponding to the letter of your choice on the answer sheet provided. STRICTLY NO ERASURES ALLOWED. Use pencil no. 2 only. Situation: Nursing profession involves a wide spectrum of foundation applied in different health care situation and scenario. The nurse must use basic knowledge in order to deliver the most needed quality and effective care. 1. Nurse Karla is assessing several clients with different types of injuries. The client least likely to develop a wound infection would be the client with which of the following? a. A contusion b. Wound healing by secondary intention c. A septic wound d. A wound with purulent exudates Answer: A. a contusion A contusion is a crushing of the tissues; there is no break in the skin. Therefore this wound is less likely to become infected. A septic wound is one that is one that has been invaded by pathogenic microorganisms (option C). Purulent exudate also is an indicator of infection (option D). A wound healing by second infection is a wound in which there is extensive injury and the edges of the wound are not well approximated. Because of this factor, this type of wound also has a risk of infection.Source: Prentice Hall Reviews and Rationales series for nursing Fundamentals of Nursing by Hogan et al, p. 291.

2. Nurse Chiara has been assigned to care for four clients who are stable. Using the principles of medical sepsis, which client should be assessed first? a. A post surgical cardiac client with pneumonia b. A client with a draining wound c. A client who is severely neutropenic d. A child with chicken pox Answer: C. a client who is severely neutropenic Using the principle of medical asepsis, the client who should be assessed first is the client most at risk for infection. A client who is severely neutropenic has lost normal body defense mechanism for resisting infection. The nurse needs to consider the clients ability to resist organism, as well as risks for infecting others when planning care.Source: Prentice Hall Reviews and Rationales series for nursing Fundamentals of Nursing by Hogan et al, p. 134.

3. The client is to receive Vancomycin (Vancocin), an intravenous medication. Too rapid administration of vancomycin is associated with life-threatening adverse reactions. The nurse would plan to administer this drug using which of the following methods? a. By GravityREPRODUCTION IS STRICTLY PROHIBITED..NGRTCI! Iloilo-(033)3202053 Bacolod-(034)4333353 Cebu-(032)2551127 Manila-(02)7353286 1

b. With a regulator c. By the electronic infusion pump d. In an elastomeric pump Answer: C. By the electronic infusion pump The device that provides the accurate infusion rate is the electronic infusion pump. The other devices are less accurate.Source: Prentice Hall Reviews and Rationales series for nursing Fundamentals of Nursing by Hogan et al, p. 295.

4. To administer 1 mL flu vaccine intramuscularly (IM) to an obese adult in the deltoid. What needle size would you use? a. 5/8 inch b. 1 inch c. 1 inch d. 2 inch Answer: B. 1 inch For a well-developed adult, a 5/8 to 1 inch needle is the appropriate size for IM deltoid injection. Because this is an obese client, the longer the needle is appropriate to ensure it reaches the muscle. The other options are incorrect.Source: Prentice Hall Reviews and Rationales series for nursing Fundamentals of Nursing by Hogan et al, p. 295.

5. The nurse is caring for a male client who has recently had his left leg amputated. What subjective data should the nurse gather to assess body image? a. Clients feelings regarding surgery b. Strength of femoral pulse bilaterally c. Clients depression of his personality d. Status of wound healing Answer: A. Clients feeling regarding surgery To assess body image, the nurse must gather the clients perception of his body. Option C is not related to body image. Option B and D are subjective (objective in nature).Source: Prentice Hall Reviews and Rationales series for nursing Fundamentals of Nursing by Hogan et al, p. 129.

6. Which of the following types of medications can be administered via gastrostomy tube? a. Any oral medication b. Capsules whose contents are dissolved in water c. Enteric-coated tablets that are thoroughly dissolved in water d. Most tablets designed for oral use, except for extended-duration compounds Answer: D. Most tablets designed for oral use, except for extended-duration compounds Capsules, enteric-coated tablets, and most extended-duration or sustained-release products should not be dissolved for use in a gastrostomy tube. They are pharmaceutically manufactured in these forms for valid reasons, and altering them destroys their purpose. The nurse should seek an alternate physicians order when an ordered medication is inappropriate for delivery by tube.Source: Nurse Test A review series Fundamental of Nursing by Olsen et. al, p. 249

7. A natural body defense that plays an active role in preventing infection is: a. Yawning b. Body hairsREPRODUCTION IS STRICTLY PROHIBITED..NGRTCI! Iloilo-(033)3202053 Bacolod-(034)4333353 Cebu-(032)2551127 Manila-(02)7353286 2

c. Hicupping d. Rapid eye movement Answer: B. Body hairs Hair on or within body areas, such as the nose, traps and holds particles that contain microorganisms. Yawning and hiccupping do not prevent microorganisms from entering or leaving the body. Rapid eye movement marks the stage of sleep during which dreaming occurs.Source: Nurse Test A review series Fundamental of Nursing by Olsen et. al, p. 204

8. Before rigor mortis occurs, the nurse is responsible for: a. Providing a complete bath and dressing change b. Placing one pillow under the bodys head and shoulder c. Removing the bodys clothing and wrapping the body in a shroud d. Allowing the body to relax normally Answer: Placing one pillow under the bodys head and shoulder The nurse must place a pillow under the deceased persons head and shoulders to prevent blood from settling in the face and discoloring it. She is required to bathe only the soiled areas of the body since the mortician will wash the entire body. Before wrapping the body in a shroud, the nurse places a clean gown on the body and closes the eyes and mouth.Source: Nurse Test A review series Fundamental of Nursing by Olsen et. al, p. 185

9. A physiologic change that can occur as a result of stress or an insult to the body (such as surgery) is: a. An elevated blood glucose level b. Excessive salivation c. Increased vasodilation resulting in hypotension d. Increased peristalsis resulting diarrhea Answer: A. An elevated blood glucose level Stress stimulates the SNS, which results in an elevated blood glucose level. The other choices are incorrect: SNS stimulating results in decreased peristalsis, which can result in constipation.Source: Nurse Test A review series Fundamental of Nursing by Olsen et. al, p. 126

10. A mitt or hand restraints can prevent a confused patient from: a. Pulling out tubes or catheters or removing bandages b. Climbing over bed side rails c. Moving out of chair without assistance d. Ambulating Answer: A. pulling out tubes or catheters or removing bandages A mitt or hand restraints is used to prevent a patient from clutching at or pulling out tubes or from removing bandages or dressing. It does not prevent immobility.Source: Nurse Test A review series Fundamental of Nursing by Olsen et. al, p. 166

Situation: The practice of nursing goes with responsibilities and accountability whether in the hospital or in the community setting your main objective is to provide safe nursing to your clients. 11. An example of an intentional tort is: a. Leaving a surgical instrument in a client during surgery b. Divulging private information about the client to the mediaREPRODUCTION IS STRICTLY PROHIBITED..NGRTCI! Iloilo-(033)3202053 Bacolod-(034)4333353 Cebu-(032)2551127 Manila-(02)7353286 3

c. Causing a burn when applying a warm soak to the clients extremity d. Failing to monitor the clients blood pressure when administering an antihypertensive Answer: B. Divulging private information about the client to the media This is an invasion of privacy, an intentional tort. Option A, C, and D are examples of professional negligence.Source: Mosbys Comprehensive Review of Nursing for the NCLEX-RN Examination 18th edition by Saxton et. al, p.26

12. A sponge is left in the patients abdomen after a exploratory laparoscopic procedure. Nurse Maggi knows that the doctrine applicable to hold the nurse and the other members of the surgical team liable because the act of negligence is apparent in such a case is: a. Respondeat Superior c. Res ipsa loquitor b. Force majure d.Captain of the ship Answer: C. Res ipsa Loquitor Res ipsa loquitor literally means the thing speaks for itself. In the application of this doctrine, the common knowledge and experience teach that a resulting injury would not have occurred if due care had been exercised and an inference of negligence may be drawn. The injury itself, such as an injury resulting from sponges being left in the abdomen, provides the proof of negligence. Option A-Provides that the employer is responsible for the legal consequences of the acts of its employees while acting within the scope of employment. Option B-excuses the nurse fromliability. Option C-provides that a surgeon is responsible for everything that happens within the operating suite.Source: Nursing Board Exam Review Notes Volume 1 by CENE page 188

13. Nurse Xander instructs a clients relative to put hot compress on the clients arm to minimize swelling. Due to the improper use of the hot compress, the patient suffered second degree burns. The nurse may be held liable for: a.Battery c. Negligence b. Assualt d. Nothing, since it is the relatives fault Answer: C. Negligence The nurse is liable for negligence for failure to test the temperature of the water and / or failure to check whether the relative knew what was expected of him/her during such assistance. Option A and B are incorrect. Option D- it is not the relative who is liable for such negligence.Source: Nursing Board Exam Review Notes Volume 1 by CENE page 188

14. Nurses are protected from legal action when they: a. Offer health teaching regarding family planning b. Offer first aid at the scene of a collision between an automobile and a bus c. Report incident s of suspected child abuse to the appropriate authorities d. Administer CPR measures to an unconscious child pulled from a swimming pool Answer: C. Report incidents of suspected child abuse to the appropriate authorities The reporting of possible child abuse is required by law, and the nurses identity can remain confidential. In option A, the nurse is functioning in a professional capacity and therefore can be held accountable. Option B and D, although the GOOD Samaritan Act protects health professionals, the nurse would still be responsible for acting as any reasonably prudent nurse would in a similar situation.Source: Mosbys Comprehensive Review of Nursing for the NCLEX-RN Examination 18th edition by Saxton et. al, p.27 REPRODUCTION IS STRICTLY PROHIBITED..NGRTCI! Iloilo-(033)3202053 Bacolod-(034)4333353 Cebu-(032)2551127 Manila-(02)7353286 4

15. When teaching about child abuse, the nurse tells a parent group that the best legal definition of assault is: a. Threats to do bodily harm to another person b. The application of force to another person without lawful justification c. A legal wrong committed against the property of another d. A legal wrong committed against the public and punishable by law through the state and courts Answer: A. Threats to do bodily harm to another person Assault is a threat or an attempt to do violence to another. Option B, this is the definition of battery. Option C, assault implies harm to persons rather than properly. Option D, this definition is too broad to describe assault.Source: Mosbys Comprehensive Review of Nursing for the NCLEX-RN Examination 18th edition by Saxton et. al, p.24

Situation: A Researcher is planning to propose a study. She knows that basic knowledge about Research is important. 16. A research study in which the investigator controls (manipulates) the independent variable and randomly assigns subjects to different conditions is which of the following? a. Quasi-experimental b. Experimental c. Non-experimental d. Quasi-statistics Answer: B. Experimental Experimental a research study in which the investigator controls (manipulates) the independent variable and randomly assigns subjects to different conditions.Source: Nursing Research Principles and Methods 6th Ed. By Polit et al, p.701

17. Research studies that have as their main objective the accurate portrayal of the characteristics of persons, situations, or groups and/or the frequency with which certain phenomena occur is: a. Descriptive b. Experimental c. Correlational d. Non-experimental Answer: Descriptive Descriptive research is a research studies that have as their main objective the accurate portrayal of the characteristics of persons, situations, or groups and/or the frequency with which certain phenomena occur.Source: Nursing Research Principles and Methods 6th Ed. By Polit et al, p.700

18. The researcher plans to use the type of sampling in which each member of the population has an equal probability of being included in the sample is: a. Cluster sampling b. Accidental sampling c. Random sampling d. Stratified sampling Answer: C. Random sampling Random Sampling is the selection of a sample such that each member of the population has an equal probability of being included.REPRODUCTION IS STRICTLY PROHIBITED..NGRTCI! Iloilo-(033)3202053 Bacolod-(034)4333353 Cebu-(032)2551127 Manila-(02)7353286 5

Source: Nursing Research Principles and Methods 6th Ed. By Polit et al, p.712

19. A term that describes an attribute of a person or object that varies, that is, takes on different values: a. Variable b. Theory c. Scale d. Result Answer: A. Variable Variable is an attribute of a person or object that varies, that is, takes on different values (ex. Body temperature, age, heart rate).Source: Nursing Research Principles and Methods 6th Ed. By Polit et al, p.717

20. What process involves organizing and synthesizing data in such a way that research questions can be answered and hypotheses tested? a. Research proposal b. Analysis c. Findings d. Framework Answer: B. Analysis Analysis is the process of organizing and synthesizing data in such a way that research questions can be answered and hypotheses tested.Source: Nursing Research Principles and Methods 6th Ed. By Polit et al, p.702

Situation: A nurse utilizes the nursing process in managing patient care. Knowledge of this process is essential to deliver high quality care and to focus on the clients response to their illness. 21. An appropriate nursing diagnosis for a patient with pneumonia who is expectorating copious amounts of sputum is: a. Altered tissue perfusion related to congested lungs b. Altered tissue perfusion related to copious amounts of sputum c. Potential for ineffective airway clearance related to pneumonia d. Potential for ineffective airway clearance related to excessive accumulation of lung secretions (this is already an actual problem in my opinion in regards to the sit above) Answer: D. Potential for ineffective airway clearance related to excessive accumulation of lung secretions Potential for ineffective airway clearance related to excessive accumulation of lung secretions identifies the problem, etiology, and symptom. Although tissue perfusion could become altered from excessive secretions obstructing the alveoli, the data provided are insufficient to formulate a diagnosis of actual altered tissue perfusion (Option A and B). Potential for ineffective airway clearance related to pneumonia is incorrect because it uses the medical term pneumonia rather than excessive secretions as a symptom.Source: Nurse Test A review series Fundamental of Nursing by Olsen et. al, p. 17

22. Nurse Thia must assess the arterial blood flow to the leg of a patient who states that he has pain in the right side of his left calf. Which of the following would be the most appropriate nursing order? a. Assess circulation to the left leg every 2 hours by keeping the foot of the bed elevatedREPRODUCTION IS STRICTLY PROHIBITED..NGRTCI! Iloilo-(033)3202053 Bacolod-(034)4333353 Cebu-(032)2551127 Manila-(02)7353286 6

b. Assess the dorsalis pedis, posterior tibial, and popliteal pulses of both legs every hour, and document findings c. Check the femoral pulses of both legs every hour, and document findings d. keep the bed at the lowest level at all times Answer: B. Assess the dorsalis pedis, posterior tibial, and popliteal pulses of both legs every hour, and document findings Palpable dorsalis pedis, posterior tibial, and popliteal pulses indicate that blood is circulating through patent arteries. Elevating the foot of the bed increases venous return to the heart but does not help the nurse assess arterial blood flow. Checking femoral pulses does not help assess arterial flow to the feet. Keeping the bed at the lowest level would ensure the patients safety but would not help in assessing his circulation.Source: Nurse Test A review series Fundamental of Nursing by Olsen et. al, p. 19

23. The most appropriate nursing order for a patient who develops dyspnea and shortness of breath would be: a. Maintain the patient on strict bed rest at all times b. Maintain the patient in an orhtopneic position as needed c. Administer oxygen by Venturi mask at 2% as needed d. Allow a 1hour rest period between activities Answer: B. Maintain the patient in an orthopneic position as needed When a patient develops dyspnea and shortness of breath, the orthopneic position encourages maximum chest expansion and keeps the abdominal organs from pressing against the diaphragm, thus improving ventilation. Bed rest and oxygen by venture mask at 24% would improve oxygenation of the tissues and cells but must be ordered by a physician. Allowing for rest periods decreases the possibility of hypoxia.Source: Nurse Test A review series Fundamental of Nursing by Olsen et. al, p. 19

24. Elisa, a 75 year old client has arrived to the nursing unit from surgery. The nurse would most likely give priority to which of the following assessments? a. Vital signs c. Location of pain b. Pain intensity d. Frequency of pain Answer: B. Pain intensity (in my opinion since pain is the fifth vital sign, I agree, it will be wise to chose the general answer which is the vital sign, letter A. Since assessing the vital signs we also assess for the pain. UMBRELLA EFFECT. Futhermore, its an elderly case post op, there is still a great probability that there will be resp insufficiency due to the effects of anesthesia and again the case is elderly.) Pain is expected anyway. Since this is a post surgery case in the nursing unit, pain intensity should be assessed first for effective pain management. Option A is important through pain now is considered the fifth vital sign, moreover, vital signs are affected if the client is having discomfort or pain. Option C and D are important but the nurse needs to know the pain intensity first before assessing the location and frequency of the pain experience.Source: Fundamental of Nursing by Barbara Kozier 5th edition page 1227,1522

25. Through the nursing process the nurse plans and delivers patient care by: a. Collecting data and writing a nursing diagnosis b. Diagnosis, implementation, planning, evaluation c. Planning nursing intervention and assigning necessary staff d. Assessment, diagnosis, planning, implementation, evaluation Answer: D. Assessment, diagnosis, planning, implementation, evaluation Rationale: The nursing process provides for an organized and systemic approach. It enables the nurse to use resources and work efficiently. It benefits the client by improving quality care.REPRODUCTION IS STRICTLY PROHIBITED..NGRTCI! Iloilo-(033)3202053 Bacolod-(034)4333353 Cebu-(032)2551127 Manila-(02)7353286 7

Source: Fundamental of Nursing by Barbara Kozier 2008 page 85

Situation: Nurse Jahira is assessing clients with different health problems. 26. After getting the blood pressure of Mrs. Cortez, she recorded the following findings, BP= 144/92 mmHg. From this data, Nurse Jahira decides that: a. Mrs. Cortez has hypertension since her BP is more that 130/90mmHg. b. She needs to get another BP reading after 1 week to identify hypertension. c. Only physicians could identify hypertension. d. The blood pressure is within normal range. Answer: B. She needs to get another BP reading after 1 week to identify hypertension. Hypertension is defined as sustained systolic BP of 140mmHg or more and sustained diastolic blood pressure of 90mmHg or more based on measurements done at 2 visits taken at least 1 week apart.Source: Nursing Board Exam Review Notes Volume 1 by CENE page 115

27. Nurse Jahira is performing physical assessment of the anterior thorax of Mr. Salex. She concluded that Mr. Salexs breathing is normal because his inspiration to expiration ratio is: a. 2 is to 1 c. 1 is to 2 b. 1 is to 1 d. 2 is to 2 Answer: C. 1 is to 2 In assessing the anterior thorax and lungs, perform IPPA- Inspect, palpate, and percuss the chest. Listen to the breath sounds, identify any adventitious breath sounds, and if indicated, listen to the transmitted voice sounds. Part of the assessment is to inspect for the inspiration to expiration ratio. The normal inspiration to expiration ratio is 1 to 2. This means that a normal client takes twice as long to expire than to inpire.Source: Bates' Guide to Physical Examination and History Taking by Bickley 1999

28. Nurse Jahira would assess for signs of hypomagnesemia in which of the following clients? 1. Client taking magnesium-containing antacids4. Client with pancreatitis 2. Client with renal failure 5. Client with excessive NGT drainage 3. Client with chronic alcoholism a.1, 2, 3 b. 2,3,4 c. 3,4,5 d. 4,5,1

Answer: C. 3,4,5 Intake of magnesium-containing antacids and renal failure relate to hypermagnesemia.Source: Kozier & Erb's Fundamentals of Nursing by Kozier et.al 2008, p. 1528

29. Nurse Jahira would most likely provide health teachings of taking ferrous sulfate to: a. Joel, a client with an RBC = 4.2 x 106/mm3 11g/dL b. Krystle, a client with hemoglobin = 16g/dL 106/mm3 c. Jorns, a client with hemoglobin = d. Kathleen, a client with an RBC = 5.1 x

Answer: C. Jorns, a client with hemoglobin = 11g/dL Option C is below the normal value for hemoglobin. Option A and D fall within the normal values for RBCs. Option B falls within the normal value for Hemoglobin. RBC= M: 4.5-5.3 x 106/mm3; F: 4.1-5.1 x 106/mm3 Hgb= M: 13.8-18 g/dL; F: 12-16 g/dL Hct= M: 37-49%; F: 36-46%REPRODUCTION IS STRICTLY PROHIBITED..NGRTCI! Iloilo-(033)3202053 Bacolod-(034)4333353 Cebu-(032)2551127 Manila-(02)7353286 8

Source: Kozier & Erb's Fundamentals of Nursing by Kozier et.al 2008, p. 799-800

30. The nurse understands that when performing chest compression on an adult client, the sternum should be depressed: a. 1/2 - 3/4 inch c. 1 1/2 - 2 inch 3 1 b. /4 - /2 inch d. 2 1/2 - 3 inch Answer: C. 1 1/2 - 2 inch For adults the depth of chest compression will be 1 1/2 2 inch.Source: Fundamentals Concepts of Skills for Nursing Saunders page 501

Situation: Accuracy of health care delivery is one of the priority nursing responsibilities. The nurse should be able to promote the clients well being and identify ways on improving the clients quality of life. 31. Nurse Felicity is obtaining her baseline assessment data. She knows that when using a blood pressure cuff that is too small for the patients arm can result in? a. False high measurement b. A false low measurement c. No changes will occur d. Inability to obtain measurement

Answer: A. False high measurement The cuff must be the correct size to obtain an accurate blood pressure. Using the wrong size produces error as great as 25 mmHg. The proper width is 21% larger than the diameter of the arm. (80% of the upper arm must be covered-jnc7)Sourrmce: Fundamentals Concepts and Skills for Nursing 2nd Edition Saunders page 347

32. Nurse Nhenhe is assign to give an IM injection to an infant. Before administering the medication, the nurse knows that the proper site of injection for infant is: a. Vastus lateralis c. Deltoid area b. Gluteal area d. Rectus femoris Answer: A. Vastus lateralis This muscle is located on the anterior lateral thigh away from major nerves and blood vessels. It is the site of choice infants since the gluteal muscle is not well develop.Source: Fundamentals Concepts and Skills for Nursing 2nd Edition Saunders page 347

33. In IV solution containing potassium inadvertently infuses too rapidly. The physician prescribes insulin added to 10% dextrose in water solution. The rationale for the order is: a. Potassium moves into the body cells with glucose and insulin b. Increased insulin accelerates excretion of glucose and potassium c. Glucose and insulin increase metabolism and accelerate potassium excretion d. Increased potassium causes a temporary slowing of pancreatic production of insulin Answer: A. Potassium moves into body cells with glucose and insulin Potassium follows insulin into the body, thereby raising the intracellular potassium and preventing fatal dysrhythmias. Option B, insulin does not cause excretion of these substances. Option C, potassium is not excreted as a result of this therapy; it shifts into the intracellular compartment. Option D, the potassium level has no effect on pancreatic insulin production.Source: Mosbys Comprehensive Review of Nursing for the NCLEX-RN Examination 18th edition By Saxton, et.al, p.. 252

34. When taking the blood pressure of a client who has had a thyroidectomy, the nurse notices the client is pale and has spasms of the hand and notifies the physician. While awaiting the physicians orders, the nurse should prepare for the replacement of: a. Calcium c. Bicarbonate b. Magnesium d. Potassium chlorideREPRODUCTION IS STRICTLY PROHIBITED..NGRTCI! Iloilo-(033)3202053 Bacolod-(034)4333353 Cebu-(032)2551127 Manila-(02)7353286 9

Answer: a. Calcium These signs may indicate calcium depletion. Option B, symptoms associated with hypomagnesemia includes tremor, neuromuscular irritability, and confusion. Option C, symptoms associated with metabolic acidosis includes deep rapid breathing, weakness, and disorientation. Option D, symptoms associated with hypokalemia include muscle weakness and dysrhytmias.Source: Mosbys Comprehensive Review of Nursing for the NCLEX-RN Examination 18th edition By Saxton, et.al, p. 252

35. In the emergent phase immediately after a severe burn injury, care is centered on replacement therapy by IV fluids. The nurse should question the physicians order if it is designed to provide: a. Water c. Lactated Ringers b. Potassium d. Plasma expanders Answer: B. Potassium Potassium replacement is generally not indicated in the initial management of burns because hyperkalemia results from the liberation of potassium ions from the injured cells. Option A, this will be given with Ringers solution in various combinations, depending on client needs. Option C, this will be given to replace fluid and electrolytes. Option D, this will be given to draw fluid from edematous tissue back into the bloodstream.Source: Mosbys Comprehensive Review of Nursing for the NCLEX-RN Examination 18th Ed. By Saxton et. al, p.252

36. John, a 21 year old client with spinal cord injury sustained in a previous motorcycle accident is hospitalized for renal calculi, or kidney stones. To reduce the clients risk for developing recurrent kidney stones, which of the following instruction is correct? a. Eat yogurt daily c. Eat more fresh fruits and vegetables b. Drink cranberry juice d. Increase the intake of dairy products Answer: B. Drink cranberry juice Acid urine decreases the potential for kidney stones. The majority of renal calculi form in alkaline urine. Cranberries, prunes, and plums promote acidic urine. Yogurt helps restore pH balance to secretions in yeast infections. Fruits and vegetables increase fiber in the diet and promote alkaline urine. Dairy products may contribute to the formation of kidney stones.Source: NCLEX-RN Q and A Made Incredibly Easy 3 rd Ed. By Lippincott, p. 809.

(calcium oxalate stones form in an acidic environment as well as uric acid stones. Uric acid stones form in persisitently acidic environment) These two types kidney stones are

common in Filipinos. Cranberries, prunes, and plums are fruits Eating a variety of fruits and vegetables will decrease the incidence of kidney stone formation, because there are fruits that promotes alkaline environment that prevents formation of acid stones there are fruits that promotes acidic environment that prevents formation of alkaline stones

It would make sense if you will chose letter C. 37. The food combinations that can be included on a law-residue diet include: a. Baked fish, macaroni with cheese, strained carrots, fruit gelatin, milk b. Stewed chicken, baked potato with butter, strained peas, white bread, plain cake, milk c. Creamed soup and crackers, omelet, mashed potatoes, bran muffin, orange juice, coffee with milk d. Lean roast beef, buttered white rice with egg slices, white bread with butter and jelly, tea with sugar Answer: D. Lean roast beef, buttered white rice with egg slices, white bread with butter and jelly, tea with sugar This grouping of foods does not contain high-residue fruits, vegetables, or whole grains, which are irritating to the intestinal mucosa, cause bulk, and increase peristalsis. InREPRODUCTION IS STRICTLY PROHIBITED..NGRTCI! Iloilo-(033)3202053 Bacolod-(034)4333353 Cebu-(032)2551127 Manila-(02)7353286 10

Options A and B, these choices include vegetables and grain, which leave increased residue. In Option C, this choice includes whole grain foods, which leave increased residue.Source: Mosbys Comprehensive Review of Nursing for the NCLEX-RN Examination 18th Ed. By Saxton et. al, p.882

38. A client in the post-operative phase of abdominal surgery is to advance his diet as tolerated. The client has tolerated ice chips and a clear liquid diet. Which of the following diet is given next? a. Fluid restricted c. General diet b. Full fluids d. Soft diet Answer: B. Full fluids Clear liquid diets are nutritionally inadequate but minimally irritating to the stomach. Clients are advanced to the full liquid diet next, adding bland and protein foods. A soft diet comes next, which omits foods that are hard to chew or digest. A regular or general diet has no limitations. A fluid restriction is ordered in addition to the diet order for clients in renal clients in renal failure or congestive heart failure.Source: Lippincotts NCLEX-RN Questions and Answers Made Incredibly Easy , 3rd Ed., p.832.

39. When prioritizing clients using Maslows Theory, who among the following should Nurse Ingrid care for First? a. Mr. Hideyoshi, a newly admitted client who is anxious about his impending surgery b. Mrs. Ajitomo, an elderly client with Alzheimers disease who will be institutionalized c. Mr. Dao Ming, a newly diagnosed diabetic patient who is waiting to learn self-injection of insulin d. Mrs. San Chai, a post-appendectomy client complaining of pain Answer: D. Mrs. San Chai, a post-appendectomy client complaining of pain Pain is a threat to the physiologic need for rest and sleep, thus should be first priority. Option A-is a manifestation of the need for love and belonging. Option B-is a manifestation of the need for psychological safety. Option C-is a manifestation of physiologic needs.Source: Fundamentals of Nursing: Concepts, Process and Practice 2008 by Kozier, B., Erb, G., Berman, A., & Snyder, S.J. p. 273-274

Situation: Nurse Angelie is taking care of clients having Gastrointestinal and Nutritional Problems. 40. In preparing a client for a colonoscopy procedure, which task is most suitable to delegate to the nursing assistant? a. Explain the need for clear liquids 1-3 days prior to procedure. b. Reinforce NPO status 8 hours prior to procedure. c. Administer laxatives 1-3 days prior to procedure. d. Administer an enema the night before the procedure. Answer: B. Reinforce NPO status 8 hours prior to procedure. The nursing assistant can reinforce dietary and fluid restrictions after the RN has explained the information to the client. It is also possible that the nursing assistant can administer the enema; however, special training is required and policies may vary between institutions. Medication administration should be performed by licensed personnel.Source: Prioritization, Delegation and Assignment by Linda A. LaCharity et. al. p63

41. Nurse Angelie would be most concerned about which client having an order for TPN (total parenteral nutrition) fat emulsion? a. A client with gastrointestinal obstructionREPRODUCTION IS STRICTLY PROHIBITED..NGRTCI! Iloilo-(033)3202053 Bacolod-(034)4333353 Cebu-(032)2551127 Manila-(02)7353286 11

b. A client with severe anorexia nervosa c. A client with chronic diarrhea and vomiting d. A client with fractured femur Answer: D. A client with fractured femur A client with a fractured femur is at risk for fat embolism, so fat emulsion should be used with caution. Vomiting may be a problem if the emulsion is infused too rapidly. TPN is commonly used for gastrointestinal obstruction, severe anorexia nervosa, and chronic diarrhea or vomiting.Source: Prioritization, Delegation and Assignment by Linda A. LaCharity et. al. p63

42. Nurse Angelie is preparing to administer TPN through a central line. Place the steps for administration in the correct sequence. 1. Use aseptic technique when handling the injection cap 2. Thread the IV tubing through an infusion pump 3. Check the solution for cloudiness or turbidity 4. Connect the tubing to the central line 5. Select the correct tubing and filter 6. Set infusion pump at prescribed rate. a. b. 3,5,1,2,6,4 3.5.2.1.6.4 c. 3,5,2,1,4,6 d. 3,5,1,2,4,6

Answer: C. 3,5,2,1,4,6 The solution should not be cloudy or turbid. Prepare the equipment, by priming the tubing and the threading pump. To prevent infection, use aseptic technique when inserting the connector into the injection cap and connecting the tubing to the central line. Set the pump at the prescribed rate.Source: Prioritization, Delegation and Assignment by Linda A. LaCharity et. al. p63

43. Nurse Angelie is taking an initial history for a client seeking surgical treatment for obesity. Which of the following should be called to the attention of the surgeon before proceeding with additional history or physical assessment? a. Obesity for approximately 5 years b. History of counseling for body dysmorphic disorder c. Failure to reduce weight with other forms of therapy d. Body weight 100% above the ideal for age gender and height Answer: B.History of counseling for body dysmorphic disorder Body dysmorphic disorder is a preoccupation with an imagined physical defect. Corrective surgery can exacerbate this disorder when the client continues to feel dissatisfied with the results. The other criteria are indicators of candidacy for this treatment.Source: Prioritization, Delegation and Assignment by Linda A. LaCharity et. al. p.64

44. Nurse Angelie is preparing a care plan to a client with GERD, which task would be appropriate to aasign to the nursing assistant? a. Share successful strategies for weight reduction b. Encourage the client to express concerns about lifestyle modification c. Remind the client not to lie down for 2-3 hours after eating d. Explain the rationale for small frequent meals Answer: C. Remind the client not to lie down for 2-3 hours after eating Reminding the client to follow through on advice given by the nurse is an appropriate task for the nursing assistant. The RN should take responsibility for teaching rationale and discussing strategies for the treatment plan and assessing client concerns.REPRODUCTION IS STRICTLY PROHIBITED..NGRTCI! Iloilo-(033)3202053 Bacolod-(034)4333353 Cebu-(032)2551127 Manila-(02)7353286 12

Source: Prioritization, Delegation and Assignment by Linda A. LaCharity et. al. p. 64

45. Nurse Angelie is about to prepare an enteral feeding through a nasogastric tube. She knows that the correct order to give feeding thru NGT is: 1. Assess for bowel sounds 2. Auscultate tube placement and check pH 3. Flush the tube with water a. b. 1,2,6,4,5,3 1,2,6,5,4,3 4. Reflush the tube with water 5. Administer the feeding 6. Check for residual volume c. 1,2,6,3,4,5 d. 1,2,6,3,5,4

Answer: D. Assessment is the first step. Checking for tube placement prevents accidentally instilling feeding/medication in to the lungs. The amount of the scheduled feeding is appropriate or whether the physician should be notified. Flushing the tube before and after feeding helps maintain tube patency.Source: Prioritization, Delegation and Assignment by Linda A. LaCharity et. al. p.64

Situation: Emergency cases come and go in any hospital settings. The following questions pertain to Medical-Surgical emergencies. 46. Nurse Gia is the newly appointed charge nurse in an emergency department (ED). One of her task is to assign two staff members to cover the triage area. Which team is the most appropriate for this assignment? a. An advanced practice nurse and an inexperienced licensed practical nurse b. An experienced licensed practical nurse and an inexperience registered nurse c. An experienced RN and an inexperienced RN d. An Inexperienced RN and a nursing assistant Answer: C. An experienced RN and an inexperienced RN Triage requires at least one experienced RN. Pairing an experienced RN with inexperienced RN provides opportunities for mentoring. Advanced practice nurses are qualified to perform triage; however their services are usually required in other areas of the emergency department. An LPN is not qualified to perform the initial patient assessment or decision making.Source: Prioritization, Delegation and Assignment by Linda A. LaCharity et. al. p.89

47. You are working in the triage area of an Emergency department, and four patients approach the triage desk at the same time. In which order will you assess these patients? 1. An ambulatory, dazed 25-year-old male with a bandaged head wound 2. An irritable infant with a fever, petechiae, and nuchal rigidity 3. A 35-year-old jogger with a twisted ankle, having pedal pulse and no deformity 4. A 50-year-old female with moderate abdominal pain and occasional vomiting a. b. 2,1,3,4 2,1,4,3 c. 2,3,1,4 d. 2,3,4,1

Answer: B. 2,1,4,3 An irritable infant with fever and petechiae should be further assessed for other meningeal signs. The patient with the head wound needs additional history and assessment for intracranial pressure. The patient with moderate abdominal pain is uncomfortable, but not unstable at this point. For the ankle injury, medical evaluation can be delayed 24-48 hours if necessary.Source: Prioritization, Delegation and Assignment by Linda A. LaCharity et. al. p.89

48. In conducting a primary survey on trauma patient, which of the following is considered one of the priority elements of the primary survey?REPRODUCTION IS STRICTLY PROHIBITED..NGRTCI! Iloilo-(033)3202053 Bacolod-(034)4333353 Cebu-(032)2551127 Manila-(02)7353286 13

a. Complete set of vital signs b. Palpation and auscultation of the abdomen c. Brief neurologic assessment d. initiation of pulse oximetry Answer: C. Brief neurologic assessment A brief neurologic assessment to determine level of consciousness and pupil reaction is part of the primary surgery. Vital signs, assessment of the abdomen and initiation of oximetry are considered part of the secondary survey.Source: Prioritization, Delegation and Assignment by Linda A. LaCharity et. al.p.89

49. A 56-year-old patient presents in triage with left-sided chest pain, diaphoresis, and dizziness. This patient should be prioritized into which category? a. High-urgent c. Non-urgent b. Urgent d. Emergent Answer: D Emergent Chest pain is considered an emergent priority, which is defined as potentially lifethreatening. Patients with urgent priority need treatment within 2 hours of triage (e..g kidney stones). Non-urgent conditions can wait for hours or even days. (High-urgent is not commonly used; however, in 5-tier triage system, high urgent patients fall between Emergent and Urgent in terms of the time lapsing prior to treatment).Source: Prioritization, Delegation and Assignment by Linda A. LaCharity et. al. p.89

50. In a multiple-trauma victim, which assessment finding signals the most serious a lifethreatening condition? a. A deviated trachea c. Decreased bowel sounds b. Gross deformity in a lower extremity d. Hematuria Answer: A. A deviated trachea A deviated trachea is a symptom of tension pneumothorax. All of the other symptoms need to be addressed, but are a lesser priority.Source: Prioritization, Delegation and Assignment by Linda A. LaCharity et. al. p.90

Situation: It is essential for a practicing nurse to identify a clients actual and potential healthcare needs, define goals together with his client, establish plan of care, and evaluate its effectiveness in improving the clients health. 51. A client comes to the walk-in clinic with reports of abdominal pain and diarrhea. While taking the clients vital signs, the nurse is implementing which phase of the nursing process? a. Assessment c. Planning b. Diagnosis d. Implementation Answer: A. Assessment The first step in the nursing process is assessment, the process of collecting data. All subsequent phases of the nursing process (options 2,3, and 4) rely on accurate and complete data.Source: Fundamentals of Nursing: Concepts, Process and Practice (7th edition) by Kozier, B., Erb, G., Berman, A., & Snyder, S.J. p. 260

52. Nurse Rye is measuring the clients urine output and straining the urine to assess for stones. Which of the following should the nurse record as objective data? a. The client reports abdominal pain b. The clients urine output was 450 mL c. The client states, I didnt see any stones in my urine. d. The client states, I feel like I have passed a stone. Answer: B. The clients urine output was 450 mLREPRODUCTION IS STRICTLY PROHIBITED..NGRTCI! Iloilo-(033)3202053 Bacolod-(034)4333353 Cebu-(032)2551127 Manila-(02)7353286 14

Objective data is measureable data that can be seen, heard, or verified by the nurse. The objective data is the measurement of the urine output. A clients statements and reports of symptoms are documented as subjective data, such as the data found in Options A, C, and D. Answer: The first step in the nursing process is assessment, the process of collecting data. All subsequent phases of the nursing process (options 2,3, and 4) rely on accurate and complete data.Source: Fundamentals of Nursing: Concepts, Process and Practice (7th edition) by Kozier, B., Erb, G., Berman, A., & Snyder, S.J. p. 262

53. Nurse Rye makes the following entry on the clients care plan: Goal not met. Client refuses to ambulate, stating, I am too afraid I will fall. The nurse should take which of the following actions? a. Notify the physician c. Reexamine the nursing orders b. Reassign the client to another nurse d. Write a new nursing diagnosis Answer: C. Reexamine the nursing orders The plan needs to be reassessed whenever goals are not met. Nursing interventions should be examined to ensure the best interventions were selected to assist the client achieve the goal. The goal may be appropriate, but the client may need more time to achieve the desired outcome. The manner in which the nursing interventions were implemented may have interfered with achieving the outcome.Source: Fundamentals of Nursing: Concepts, Process and Practice (7th edition) by Kozier, B., Erb, G., Berman, A., & Snyder, S.J. p. 320

54. Which of the following behaviors by the nurse demonstrates that the nurse is participating in critical thinking? Select all that apply. 1. Admitting not knowing how to do a procedure and requesting help 2. Using clever and persuasive remarks to support an opinion or position 3. Accepting without question the values acquired in nursing school 4. Finding a quick answer, even to complex questions 5. Gathering three assistants to transfer the client to a stretcher after noting the client weighs 300 poundsa.

b.

1, 2 1, 4

c. 1,3 d. 1,5

Answer: D. 1,5 Critical thinking in nursing is self-directed, supporting what nurses know and making clear what they do not know. It is important for nurses to recognize when they lack the knowledge they need to provide safe care for a client (option 1). Nurses must also utilize their resources to acquire the support they need to care for a client safely (option 5). Option 2, 3, and 4 do not demonstrate critical thinking.Source: Fundamentals of Nursing: Concepts, Process and Practice (7th edition) by Kozier, B., Erb, G., Berman, A., & Snyder, S.J. p. 245

55. When the client resists taking a liquid medication that is essential to treatment, the nurse demonstrates CRITICAL THINKING by doing which of the following first? a. Omitting this dose of medication and waiting until the client is more cooperative b. Suggesting the medication can be diluted in a beverage c. Asking the nurse manager about how to approach the situation d. Notifying the physician regarding inability to give the client this medication Answer: B. Suggesting the medication can be diluted in a beverage Diluting the medication in a beverage may make the medication more palatable. Using critical thinking skills, the nurse should try to solve the problem in a situation such as this before asking for the assistance of the nurse manager. Suggesting an alternative methodREPRODUCTION IS STRICTLY PROHIBITED..NGRTCI! Iloilo-(033)3202053 Bacolod-(034)4333353 Cebu-(032)2551127 Manila-(02)7353286 15

of taking the medication; provided that there are no contraindications to diluting the medication, should improve the likelihood of the client taking the medication.Source: Fundamentals of Nursing: Concepts, Process and Practice (7th edition) by Kozier, B., Erb, G., Berman, A., & Snyder, S.J. p. 250

Situation: Health care delivery system affects the health every Filipino. As a nurse, knowledge of this system is expected to ensure quality of life. 56. Which of the following outcome goals has the nurse designed correctly for the postoperative clients plan of care? Select all that apply. 1. Client will state pain is less than or equal to a 3 on a 0 to 10 pain scale. 2. Client will have no pain. 3. Client will state pain less than or equal to a 3 on a 0 to 10 pain scale by time of discharge. 4. Client will state pain less than or equal to 5 on a 0 to 10 pain scale by time of discharge. 5. Client will be medicated every 4 hours by the nurse a. b. 2,3,4 1,3 c. 1,3,4 d. 3,4

Answer: D. 3,4 An outcome goal should be SMART: Specific, measurable, appropriate, realistic, and timely. Options 3 and 4 are SMART goals. Options 1 and 2 have no time frame to achieve the goal and are therefore incomplete. Option 2 is also unrealistic; the nurse cannot expect a postoperative client to be pain free. Option 5 is not a client goal.Source: Fundamentals of Nursing: Concepts, Process and Practice (7th edition) by Kozier, B., Erb, G., Berman, A., & Snyder, S.J. p. 303

57. When is it considered an acceptable practice for a nurse to document a nursing activity even before it is carried out? a. When the activity is routine b. When the activity is to be carried out immediately c. When the activity occurs at regular intervals d. It is never acceptable. Answer: D. It is never acceptable It is never an acceptable practice for the nurse to document a nursing activity before it is carried out. This is unsafe because there is always a possibility that an activity may be postponed, cancelled, and forgotten, thus charting is inaccurate, misleading, and potentially dangerous.Source: Fundamentals of Nursing: Concepts, Process and Practice 2008 by Kozier, B., Erb, G., Berman, A., & Snyder, S.J. p. 1492

58. Nurse Jeko is planning his discharge instruction to ensure home safety for Lola Kayem, 67 year old client. He knows that it is essential to teach the clients family all of the following except: a. Paint white and white stripes on the edges of steps to increase contrast in color. b. Install grab bars in the bathroom c. Keep her bed in the low position d. cover Electric outlets with safety plugs Answer: D. cover Electric outlets with safety plugs Covering electric outlets with safety plugs is a safety measure for toddlers because of their curiosity and tendency to explore the environment.Source: Fundamentals of Nursing: Concepts, Process and Practice 2008 by Kozier, B., Erb, G., Berman, A., & Snyder, S.J. p. 719, 712 REPRODUCTION IS STRICTLY PROHIBITED..NGRTCI! Iloilo-(033)3202053 Bacolod-(034)4333353 Cebu-(032)2551127 Manila-(02)7353286 16

59. Nurse Garie wants to prevent pulmonary embolism in her clients. Which among the following will prevent such a complication? a. Fluid replacement c. Leg exercise b. Turning the client d. Deep breathing exercises and coughing Answer: B. Turning the client Pulmonary embolism occurs when blood clot moves to the lungs and blocks a pulmonary artery, thus obstructing blood flow to a portion of the lung. Measures to prevent this include turning, ambulation, use of anti-embolic stockings, and sequential compression devices. Option A will prevent hypovolemia and hypovolemic. Option C will prevent thrombus, thrombophlebitis and embolus formation. Option D will prevent atelectasis and pneumonia.Source: Fundamentals of Nursing: Concepts, Process and Practice 2008 by Kozier, B., Erb, G., Berman, A., & Snyder, S.J. p. 959

60. Nurse Erwan reviewed the record of his client and noted a previous blood pressure reading of 130/70 mmHg and a pulse rate of 70. How long will it take Nurse Erwan to release the blood pressure cuff if he will get Henrys BP measurement again? a. 10-15 seconds c. 30-45 seconds b. 15-30 seconds d. 45-60 seconds Answer: C. 30 to 45 seconds If the cuff is to be inflated to about 30 mmHg above the previous systolic pressure, this would amount to 160 mmHg. To ensure that the diastolic reading will be determined, the nurse should release the cuff slowly, at the rate of 2-3 mmHg per second, until it reaches approximately 60 mmHg since the client had a previous diastolic reading of 70 mmHg. Thus, 160-60 = 100 mmHg. This value divided by 2 (for the deflation rate of 2-3 mmHg per second) equal to 50 seconds. 100 mmHg divided by 3 (for the deflation rate of 2-3 mmHg per second) is approximately 33 seconds. Thus, the nurse should deflate the cuff within 33-50 seconds, the closest to which will be the answer 30-45 seconds.Source: Fundamentals of Nursing: Concepts, Process and Practice 2008 by Kozier, B., Erb, G., Berman, A., & Snyder, S.J. p. 555, 562, 1506

Situation: Nurse Harry came across various research articles during her review of literature. Through this process, he realized that knowledge of various research designs is important in developing accurate and interpretable evidence. 61. Nurse Harry read about a study in which assessed the sleep patterns and prevalence of sleep disorders during pregnancy. In this research, women at different points of pregnancy were compared: 8 to 12 weeks, 18 to 22 weeks, 25 to 28 weeks and 35 to 38 weeks and its conclusion have it that sleep disturbances were especially common in late pregnancy. This study utilized which among the following research designs? a. Cross-sectional design b. Trend study c. Cohort design d. Experimental design

Answer: A. Cross-sectional design Cross-sectional designs involve the collection of data at one time the phenomenon under the study having been captured on a one-period of data collection. Cross sectional studies are inappropriate for describing the status of phenomena or for describing the relationships among phenomena at a fixed point in time.Source: Polit and Beck, 2004, p. 166-167

62. Nurse Harry is about to conduct a pilot study. Which among the following statements about a pilot study is correct? a. It is done to know whether the respondents understand the questions and the directions in a questionnaire or if they find certain questions objectionable.REPRODUCTION IS STRICTLY PROHIBITED..NGRTCI! Iloilo-(033)3202053 Bacolod-(034)4333353 Cebu-(032)2551127 Manila-(02)7353286 17

b. It is done to test protocol, data collection instruments, sample recruitment strategies and other aspects of a study in preparation for a larger study. c. It is done to test research hypothesis in preparation for a larger study. d. It is done to actively introduce some form of intervention and to have greater control over extraneous variables. Answer: B. It is done to test protocol, data collection instruments, sample recruitment strategies and other aspects of a study in preparation for a larger study. Option B is the only true statement. Option A is the process of giving a pretest tool in research. Source: Polit and Beck, 2004, p. 196 63. Internal validity refers to which it is impossible to make an inference that the independent variable is causing the dependent variable and that the relationship between the two variablse is true. Which among the following types of research possess a high degree of internal validity? a. Pre-experimental design b. Correlational design c. Experimental design d. Quasi-experimental

Answer: C. Experimental design True experimental design possesses a high degree of internal validity because the use of manipulation, randomization and a control group usually enables the researcher to rule out most alternative explanations for the results. All other options are susceptible threats to internal validity.Source: Polit and Beck, 2004, p. 213

64. Studies have shown that about 40% of patients fall out of bed despite the use of side rails; this has led to which of the following conclusions? a. Side rails are ineffective b. Side rails should not be used c. Side rails are a deterrent that prevent a patient from falling out of bed. d. Side rails are a reminder to a patient not to get out of bed Answer D. Side rails are a reminder to a patient not to get out of bed Since about 40% of patients fall out of bed despite the use of side rails, side rails cannot be said to prevent falls; however, they do serve as a reminder that the patient should not get out of bed. The other answers are incorrect interpretations of the statistical data.Source: http://enursebook.info/nursing-licensure-examination-review-questions/ date retrieved: May 27, 2011 7:10 am

(in my opinion letter A is the best answer. Why? The situation is talking about statistics. It states that there is 40 % fall rate of clients with side rails. With this we can conclude that there is a 60 % effectivity of the use of side rails.That leaves us with the 40 % ineffectivity upon its use. The situation above is a quantitative stement not a qualitative statement. If it describes about side rails thus we can conclude letter D as the right answer but again the above statement is a quantitative in nature. Situation: Professional standards must trail behind every nurses performance in any health care scenario. 65. If nurse administers an injection to a patient who refuses that injection, she has committed: a. Assault and battery b. Negligence c. Malpractice d. None of the aboveREPRODUCTION IS STRICTLY PROHIBITED..NGRTCI! Iloilo-(033)3202053 Bacolod-(034)4333353 Cebu-(032)2551127 Manila-(02)7353286 18

Answer A. Assault and battery Assault is the unjustifiable attempt or threat to touch or injure another person. Battery is the unlawful touching of another person or the carrying out of threatened physical harm. Thus, any act that a nurse performs on the patient against his will is considered assault and battery.Source: http://enursebook.info/nursing-licensure-examination-review-questions/ date retrieved: May 27, 2011 7:10 am

66. Mr. Benny is to undergo an invasive procedure. While providing information about the procedure, the nurse provides legal protection of a clients right to autonomy with which of the following? a. Informed consent c. Good Samaritan Law b. Beneficence d. Advance directives Answer: A. Informed Consent Informed consent provides legal protection of a clients right to personal autonomy and to choose medical treatment. Advanced directives determine the actions of the healthcare team when the client is unable to make a decision. Beneficence is an ethical term that means that a person will act for the benefit of others. The Good Samaritan law protects healthcare professionals who come to the aid of others during an emergency.Source: Fundamentals of Nursing: Concepts, Process and Practice 7th ed. by Kozier, B., Erb, G., Berman, A., & Snyder, S.J. p. 70

67. Jinky, the unit manager is meeting with the director of nursing for the unit managers yearly performance review. The director of nursing states that the she needs to improve in leadership skills. In differentiating leadership from management, the nurse manager recognizes that which of the following will demonstrate an improvement in leadership skills? a. Manager attends a workshop on budgeting unit resources b. Manager applies for a higher position within the institution c. Unit demonstrates decreased number of staff sick calls per month d. Manager uses interpersonal skills to motivate and encourage staff to achieve unit and institutional goals Answer: D. Manager uses interpersonal skills to motivate and encourage staff to achieve unit and institutional goals A good leader can incorporate managerial theories into practice, whereas a manager does not necessarily utilize leadership techniques. Use of interpersonal skills to motivate others to achieve goals is a hallmark of leadership. All other options would be related to managerial skills alone.Source: Fundamentals of Nursing: Concepts, Process and Practice 7th ed. by Kozier, B., Erb, G., Berman, A., & Snyder, S.J. p. 475-476

68. Which of the following would be an example of a nurse using expert power to influence fellow staff members? a. Using a sense of humor and good interpersonal skills to convince other nurses that change is needed. b. Offering a day-off with pay to staff members who comply with requested change. c. Giving staff members who are reluctant to accept the change less desirable assignments and longer scheduled night rotations. d. Using valid and current data to speak positively to staff about advantages of the change over the current system. Answer: D. Using valid and current data to speak positively to staff about advantages of the change over the current system. Expert power relies on the expert skills of the practitioner to gain the admiration and confidence of the group. Referent power relies on interpersonal skills, whereas coerciveREPRODUCTION IS STRICTLY PROHIBITED..NGRTCI! Iloilo-(033)3202053 Bacolod-(034)4333353 Cebu-(032)2551127 Manila-(02)7353286 19

skills use the fear of threats. Use of rewards is positive feedback or reinforcement, but it is not expert power.Source: Fundamentals of Nursing: Concepts, Process and Practice 7th ed. by Kozier, B., Erb, G., Berman, A., & Snyder, S.J. p. 475

69. Nurse Joel observes that which of the following nurse colleagues is maintaining client confidentiality? a. Nurse who reads the records of clients not assigned to become more familiar with their disease process b. Nurses who share information about an interesting client with nurses from another unit who may eventually care for the client c. Nurse who allows the clients family to review the medical record to provide answers to questions d. Nurse who shares information about the client with those involved in care for the purpose of planning nursing care Answer: D. Nurse who shares information about the client with those involved in care for the purpose of planning nursing care The client has a right to confidentiality. Unless a nurse is assigned currently to care for an individual, the nurse is assigned currently to care for an individual; the nurse should not seek or share known details about a clients status. Family members would need approval from the client and the physician prior to reviewing a medical record.Source: Fundamentals of Nursing: Concepts, Process and Practice 7th ed. by Kozier, B., Erb, G., Berman, A., & Snyder, S.J. p. 28

70. Hayden, a terminally ill client tells the nurse not to inform family members about the medical diagnosis or to share other details of the medical record. In meeting this request, the nurse would be upholding which of the following? a. Informed consent c. Living will b. Confidentiality d. Justice Answer: B. Confidentiality Confidentiality protects the privacy of clients and their records. Informed consent is necessary prior to the treatment of the client. A living will is a document that is developed in which the client chooses end-of-life procedures. Justice demands that fair and equitable treatment is given to all and resources are distributed equally.Source: Fundamentals of Nursing: Concepts, Process and Practice 7th ed. by Kozier, B., Erb, G., Berman, A., & Snyder, S.J. p. 28

Situation: Health is wealth specifically in this time of the century. The nurse is trained to promote well being of the people. 71. Nurse Depo is caring for a male client who has recently had his left leg amputated. To assess body image, the nurse should gather subjective data such as the: a. Clients feelings regarding surgery b. Strength of femoral pulses bilaterally c. Clients description of his personality d. Status of wound healing Answer: A. Clients feelings regarding surgery To assess body image, the nurse must gather the clients perception of his body. Option 3 is not related to body image. Options 2 and 4 are objective data.Source: Fundamentals of Nursing: Concepts, Process and Practice 7th ed. by Kozier, B., Erb, G., Berman, A., & Snyder, S.J. p. 959

72. Nurse Depo is also admitting a client who became ill while visiting in this country. The nurse is unfamiliar with the cultural practices and health beliefs of the clients homeREPRODUCTION IS STRICTLY PROHIBITED..NGRTCI! Iloilo-(033)3202053 Bacolod-(034)4333353 Cebu-(032)2551127 Manila-(02)7353286 20

country. Which of the following questions would be appropriate to ask in the admission assessment? Select all that apply. 1. Are there remedies you have used for this illness before coming to the hospital? 2. Who do you usually see for help or care when you are ill? 3. What do you believe is causing your current illness? 4. Why do you dress in that type of clothing? 5. Can you tell me about your usual diet? a. b. 1,2,3,5 2,3,4,5 c. 1,3,4,5 d. 1,2,3,4

Answer: A. 1,2,3,5 A cultural assessment should include information on the persons land of origin, the persons health beliefs and practices, the health care practitioners the person usually consults, and the persons beliefs regarding origin of illness. The persons reason for dressing in a particular manner is not relevant to this situation and the question may be viewed as rude or intrusive.Source: Fundamentals of Nursing: Concepts, Process and Practice 7th ed. by Kozier, B., Erb, G., Berman, A., & Snyder, S.J. p. 217

73. Nurse Louie is interviewing an adolescent client. The nurse can best facilitate communication with the adolescent client by making which statement? a. If you read the pamphlet youll know all you need to know. b. We can talk about this with your mother. c. Other teenage girls also feel depressed. d. Tell me about the last time you had sexual intercourse. Answer: C. Other teenage girls also feel depressed. Option C indicates that the client is not alone, which can enhance communication by affirming the clients feelings. Adolescents will feel more willing to discuss private issues if parents are not present (option B) and if they understand that their concerns are common with other teens. Questions should be sensitively worded rather than intrusive (option D). Written instructions should supplement teaching rather than being the primary vehicle for teaching (option A). Source: Fundamentals of Nursing: Concepts, Process and Practice 7th ed. by Kozier, B., Erb, G., Berman, A., & Snyder, S.J. p. 387 74. A client complains of decreased sexual desire. While reviewing the clients regular medications, the nurse would recognize that which of the following medications might be a contributing factor? a. Azithromycin (Zithromax) c. Ascorbic acid (vitamin c) b. Propanolol (Inderal) d. Warfarin (Coumadin) Answer: B. Propanolol (Inderal) Antihypertensives, narcotics, diuretics, antipsychotics, antihistamines, and other medications decrease sexual desire. Propanolol is an antihypertensive. Azithromycin is an antibiotic. Ascorbic acid is a water-soluble vitamin. Warfarin is an anticoagulant.Source: Daviss drug guide for nurses 7th edition by Deglin, J. and vallerand, A. (1999)

75. Nurse Hera evaluates the outcome criteria of a dying client and discerns that the goal has not been met. Which of the following should the nurse do first? a. Talk with the clients family to determine if they have intervened inappropriately b. Notify the physician immediately c. Reassess to determine if the nursing diagnosis was appropriate d. Ask that another nurse take over care of the clientREPRODUCTION IS STRICTLY PROHIBITED..NGRTCI! Iloilo-(033)3202053 Bacolod-(034)4333353 Cebu-(032)2551127 Manila-(02)7353286 21

Answer: C. Reassess to determine if the nursing diagnosis was appropriate Exploration of why the plan was unsuccessful must be accomplished first. The nurse looks first at his or her own actions to document the appropriateness. It is important for the dying client to have continuity of care. Source: Prentice Hall Review and rationales Series for Nursing Fundamentals of Nursing by Hogan,M. et al. p.130 Situation: A 72 year old female is being admitted for evaluation after a fall at home. Although x-rays revealed no fractures, the client is complaining of severe pain in the lower back, inability to sleep at night because of pain, difficulty breathing, and lack of appetite. You are the admitting nurse in the unit. 76. All but one is the assessment you need to make about the clients safety? a. Use of medication b. Ability to use call bell c. Ability to chew d. Changes in mental status Answer: C. Ability to chew Risk factors related to safety: Poor eye sight; use of equipment such as a cane; use of medication that cause postural hypotension and changes in mental status; ability to use call bell, use of side rails. Option C-ability to chew is one factor affecting nutrition. Source: Prentice Hall Review and rationales Series for Nursing Fundamentals of Nursing by Hogan,M. et al. p.201, 349 77. How would you ensure the safety of the client? Select all that apply. 1. Necessity of side rails 2. Provision of call bell and nightlight 3. Limiting visitors 4. Cluttered environment 5. Essentials within clients reach a. b. 1,3,5 2,4,5 c. 2,3,4 d. 1,2,5

Answer: D. 1,2,5 Measures to ensure safety: 1. Give clear instructions to client regarding use of call bell, necessity of side rails 2. Provide a nightlight 3. Make frequent checks on client 4. Have a clutter-free environment 5. Follow protocol for safe medication administration 6. Use preventive measures for fire safety 7. Do proper maintenance of equipment 8. Keep needed objects within clients reach Source: Prentice Hall Review and rationales Series for Nursing Fundamentals of Nursing by Hogan,M. et al. p.201, 349 78. Which of the following interventions will be appropriate to promote clients sleep? a. Have a heavy meal 3 hours before bedtime b. Perform strenuous exercise or anxiety producing conversations immediately prior to bedtime c. Decrease fluid intake 5 hours before sleep d. Assist in performing bedtime rituals Answer: D. Assist in performing bed rituals Interventions to promote sleep:REPRODUCTION IS STRICTLY PROHIBITED..NGRTCI! Iloilo-(033)3202053 Bacolod-(034)4333353 Cebu-(032)2551127 Manila-(02)7353286 22

1. 2. 3. 4. 5.

Alleviate pain: relaxation techniques, back massage Assist in performing bedtime rituals AVOID strenuous exercise / anxiety producing conversation prior to bedtime Make environment conducive for sleep Avoid heavy meal about 3 hours before bedtime 6. Decrease fluid intake about 2 hours before sleep; encourage toileting prior to bedtime 7. AVOID alcohol, caffeine, or heavily spiced food Source: Prentice Hall Review and rationales Series for Nursing Fundamentals of Nursing by Hogan,M. et al. p.201, 349 79. How would you assist the client have adequate air exchange? Select all that apply. 1. Assess clients respiratory and cardiovascular status 2. Assist client to a fowlers position 3. Instruct client to do slow, rhythmic breathing 4. Encourage the use of pain distraction methods a. b. 1,2,3,4 1,2,4 c. 1,3,4 d. 1,2,3

Answer: A. 1,2,3,4 Measures to assist with adequate air exchange: 1. Assess clients respiratory and cardiovascular status 2. Assist client to a fowlers position to promote adequate chest expansion 3. If client has dyspnea, instruct client to do slow, rhythmic breathing and assist with relaxation 4. If pain interferes with breathing, use of pain distraction methods Source: Prentice Hall Review and rationales Series for Nursing Fundamentals of Nursing by Hogan,M. et al. p.201, 349 80. What instructions will you give to promote healthy urinary elimination? a. Avoiding excess milk products and sodium bicarbonate b. Empty bladder at least every 6 to 8 hours while awake c. Encourage a fluid intake of 1000mL only d. Instruct to void according to urge rather than to a timetable Answer: A. Avoiding excess milk products and sodium bicarbonate Promote healthy urinary elimination: 1. Instruct sufficient fluid intake 2 Liters 2. Teach Kegel exercises 3. Empty bladder at least every 2 to 4 hours while awake, avoiding voluntary retention; 4. For bladder training if client is incontinent, instruct to void according to a timetable rather than urge to void 5. Unless contraindicated, teach client to maintain acidity in urine by drinking at least two glasses of cranberry juice per day or taking vitamin C; avoiding excess milk products and sodium bicarbonate Source: Prentice Hall Review and rationales Series for Nursing Fundamentals of Nursing by Hogan,M. et al. p.201, 349-350 Situation: As a nurse, you have specific responsibilities as a professional. You have to demonstrate specific competencies. 81. Mr. Abunda has been receiving total parenteral nutrition (TPN) for several days. The central venous access device became dislodged and the nurse notes that the clients IVREPRODUCTION IS STRICTLY PROHIBITED..NGRTCI! Iloilo-(033)3202053 Bacolod-(034)4333353 Cebu-(032)2551127 Manila-(02)7353286 23

has not been running for several hours. The nurse would monitor the client for which of the following complications related to the stopped infusion? a. Hypocalcemia b. Hypoglycemia c. Sepsis d. Hyperkalemia

Answer: B. Hypoglycemia The clients body has adjusted to higher blood glucose levels as a result of receiving TPN with high dextrose concentrations. Abruptly stopping TPN can result in hypoglycemia. The other options are incorrect. (no reference) 82. Nurse Courtney is caring for several clients with central venous catheters. While changing the tubing on the central lines, the nurse would not need to instruct the client to perform a Valsalvas maneuver when the client has which of the following catheters? a. Groshong catheter b. Single lumen catheter c. Percutaneous catheter d. Accessed subcutaneous venous port

Answer: A. Groshong catheter The Groshong catheter is designed with a three way pressure sensitive valve that restricts air from entering the venous system or a back flow of blood. The other options are incorrect. (no reference) 83. While assessing a clients IV, the nurse notes that the area is swollen, cool, pale, and causes the client discomfort. The nurse suspects which of the following problems? a. Infiltration c. Infection b. Phlebitis d. Air embolism Answer: A. Infiltration Infiltration is leakage of fluids into the surrounding tissues resulting in edema around the insertion site, blanching, and coolness of skin around the site. The other options are incorrect. (no reference) 84. You are to administer 10 grams of aspirin, which comes 325 mg per tablet. How many tablets would you give to administer 10 grains? a. Half a tablet c. 2 tablets b. 1 tablet d. 1.5 tablets Answer: C. 2 tablets In the apothecary system, 1 grain = 60-65 milligrams. 1 grain = 10 grains 65 milligrams x By cross multiplying and dividing by x, 10 grains = 650 milligrams or 2 tablets. 85.While administering an intramuscular (IM) injection of Demerol, the nurse aspirates and finds blood in the syringe prior to injecting the medication. Which of the following actions by the nurse would be appropriate? a. Continue to administer the medication because it is compatible with blood and would not present a harmful effect b. Continue to administer the medication because the needle has hit a capillary and would not be an intravenous administration c. Withdraw needle, cleanse the needle and the new injection site with alcohol, and administer the medicationREPRODUCTION IS STRICTLY PROHIBITED..NGRTCI! Iloilo-(033)3202053 Bacolod-(034)4333353 Cebu-(032)2551127 Manila-(02)7353286 24

d. Withdraw needle, discard medication, and begin again with the medication administration Answer: D. Withdraw needle, discard medication, and begin again with the medication administration If blood returns while aspirating during an IM injection, the nurse should discard and prepare a new injection. Blood indicates that the needle has entered a blood vessel, and the medication injected directly into the bloodstream may be dangerous. (no reference) 86. The nurse is starting a new peripheral intravenous line in a client. The client reports a latex allergy. The nurse has a typical IV start kit for the IV start. Because of the latex allergy, the nurse should take which of the following actions? . Utilize a new tourniquet for this client b. Utilize blood pressure cuff to distend the vein c. Avoid putting povidone-iodine on the skin d. Suggest an alternative therapy to a peripheral intravenous line. Answer: b. Utilize blood pressure cuff to distend the vein Tourniquets are made of latex. A blood pressure cuff can be used as an alternative method of vein distention. A new tourniquet does not resolve the latex issue. The other options are incorrect. (no reference) 87. Nurse Maru has instructed the client in using a metered dose inhaler. The nurse determines that the client understands the instructions when the client is observed doing which of the following? a. Administering the two puffs in rapid order between breaths b. Holding the inhaler two inches away from the mouth c. Not shaking the canister before puffs d. Exhaling immediately after administering the puff Answer: b. Holding the inhaler two inches away from the mouth Clients should be instructed to hold inhaler 2 inches away from the mouth, hold breath for 5-10 seconds , slowly exhale through pursed lips, and wait 2 minutes between puffs. The other options are incorrect. (no reference) 88. Mr. Tee is receiving a continuous PEG tube feeding. The physician has ordered phenytoin (Dilantin) to be administered through the PEG tube. The nurse notes that the medication cannot be administered with the tube feeding. Which of the following would be the best intervention? a. Contact the physician for an order to administer through another route b. Contact the physician to charge the type of the feeding to one that is compatible c. Stop the tube feeding for at least 30 minutes before and after administering the Dilantin d. Stop the feeding, flush the tube with water, administer Dilantin, flush tube with water again, and continue the feeding. Answer: c. Stop the tube feeding for at least 30 minutes before and after administering the Dilantin When medication are administered enterally and cannot be administrred with tube feedings, it is best to stop the tube feedins for at least 30 minutes prior to and after the administration of the medication. A time period of 30 minutes allows for the tube feeding to empty and clear the GIT track and therefore not mix with the medication. The other options are incorrect. (no reference)REPRODUCTION IS STRICTLY PROHIBITED..NGRTCI! Iloilo-(033)3202053 Bacolod-(034)4333353 Cebu-(032)2551127 Manila-(02)7353286 25

89. Nurse Jelo is to administer 25mg of promethazine (Phenergan) IM to a 150 poun client. The nurse knows that this medication should be given into a deep large muscle mass. The preferred site of injection for this client would be which of the following? a. Deltoid c. Vastus Lateralis b. Dorsogluteal d. Ventrogluteal Answer: D. Ventrogluteal For an adult with well-developed muscle mass, the preferred IM site for medications requiring a large muscle mass is the ventroglutueal. The vastus lateralis is the preferred IM site for children below 7 months of age. The other options are incorrect. (no reference) 90. The physician is going to order a hypotonic IV solution for a client with cellular dehydration. The nurse would expect which of the following fluids to be administered? a. 0.9% normal Saline b. 5% dextrose in normal saline c. Lactated RIngers d. 0.45% sodium chloride

Answer: D. 0.45% sodium chloride 0.45% normal saline is a hypotonic solution that draws fluid from the vascular compartment into the cells. Other options are incorrect. (no reference) 91. The most common deficiency seen in alcoholics is: a. Thiamine b. Riboflavin c. Pyridoxine d. Pantothenic acid

Answer A. Thiamine Chronic alcoholism commonly results in thiamine deficiency and other symptoms of malnutrition.Source: http://enursebook.info/nursing-licensure-examination-review-questions/ date retrieved: May 27, 2011 7:10 am

92. Which of the following statement is incorrect about a patient with dysphagia? a. The patient will find pureed or soft foods, such as custards, easier to swallow than water b. Fowlers or semi Fowlers position reduces the risk of aspiration during swallowing c. The patient should always feed himself d. The nurse should perform oral hygiene before assisting with feeding. Answer C. The patient should always feed himself A patient with dysphagia (difficulty swallowing) requires assistance with feeding. Feeding himself is a long-range expected outcome. Soft foods, Fowlers or semiFowlers position, and oral hygiene before eating should be part of the feeding regimen.Source: http://enursebook.info/nursing-licensure-examination-review-questions/ date retrieved: May 27, 2011 7:10 am

93. A male patient who had surgery 2 days ago for head and neck cancer is about to make his first attempt to ambulate outside his room. The nurse notes that he is steady on his feet and that his vision was unaffected by the surgery. Which of the following nursing interventions would be appropriate? a. Encourage the patient to walk in the hall alone b. Discourage the patient from walking in the hall for a few more days c. Accompany the patient for his walk. d. Consuit a physical therapist before allowing the patient to ambulateREPRODUCTION IS STRICTLY PROHIBITED..NGRTCI! Iloilo-(033)3202053 Bacolod-(034)4333353 Cebu-(032)2551127 Manila-(02)7353286 26

Answer C.Accompany the patient for his walk. A hospitalized surgical patient leaving his room for the first time fears rejection and others staring at him, so he should not walk alone. Accompanying him will offer moral support, enabling him to face the rest of the world. Patients should begin ambulation as soon as possible after surgery to decrease complications and to regain strength and confidence. Waiting to consult a physical therapist is unnecessary.Source: http://enursebook.info/nursing-licensure-examination-review-questions/ date retrieved: May 27, 2011 7:10 am

94. An additional Vitamin C is required during all of the following periods except: a. Infancy b. Young adulthood c. Childhood d. Pregnancy Answer B. Young adulthood Additional Vitamin C is needed in growth periods, such as infancy and childhood, and during pregnancy to supply demands for fetal growth and maternal tissues. Other conditions requiring extra vitamin C include wound healing, fever, Infection and stress.Source: http://enursebook.info/nursing-licensure-examination-review-questions/ date retrieved: May 27, 2011 7:10 am

95. A prescribed amount of oxygen s needed for a patient with COPD to prevent: a. Cardiac arrest related to increased partial pressure of carbon dioxide in arterial blood (PaCO2) b. Circulatory overload due to hypervolemia c. Respiratory excitement d. Inhibition of the respiratory hypoxic stimulus Answer D. Inhibition of the respiratory hypoxic stimulus Delivery of more than 2 liters of oxygen per minute to a patient with chronic obstructive pulmonary disease (COPD), who is usually in a state of compensated respiratory acidosis (retaining carbon dioxide (CO2)), can inhibit the hypoxic stimulus for respiration. An increased partial pressure of carbon dioxide in arterial blood (PACO2) would not initially result in cardiac arrest. Circulatory overload and respiratory excitement have no relevance to the question.Source: http://enursebook.info/nursing-licensure-examination-review-questions/ date retrieved: May 27, 2011 7:10 am

96. After 1 week of hospitalization, Mrs. Jordan develops hypokalemia. Which of the following is the most significant symptom of his disorder? a. Lethargy b. Increased pulse rate and blood pressure c. Muscle weakness d. Muscle irritability

Answer C. Muscle weakness Presenting symptoms of hypokalemia ( a serum potassium level below 3.5 mEq/liter) include muscle weakness, chronic fatigue, and cardiac dysrhythmias. The combined effects of inadequate food intake and prolonged diarrhea can deplete the potassium stores of a patient with GI problems.Source: http://enursebook.info/nursing-licensure-examination-review-questions/ date retrieved: May 27, 2011 7:10 am

97. Examples of patients suffering from impaired awareness include all of the following except: a. A semiconscious or over fatigued patient b. A disoriented or confused patient c. A patient who cannot care for himself at home d. A patient demonstrating symptoms of drugs or alcohol withdrawalREPRODUCTION IS STRICTLY PROHIBITED..NGRTCI! Iloilo-(033)3202053 Bacolod-(034)4333353 Cebu-(032)2551127 Manila-(02)7353286 27

Answer C. A patient who cannot care for himself at home A patient who cannot care for himself at home does not necessarily have impaired awareness; he may simply have some degree of immobility.Source: http://enursebook.info/nursing-licensure-examination-review-questions/ date retrieved: May 27, 2011 7:10 am

98. Which of the following principles of primary nursing has proven the most satisfying to the patient and nurse? a. Continuity of patient care promotes efficient, cost-effective nursing care b. Autonomy and authority for planning are best delegated to a nurse who knows the patient well c. Accountability is clearest when one nurse is responsible for the overall plan and its implementation. d. The holistic approach provides for a therapeutic relationship, continuity, and efficient nursing care. Answer: D. The holistic approach provides for a therapeutic relationship, continuity, and efficient nursing care. Studies have shown that patients and nurses both respond well to primary nursing care units. Patients feel less anxious and isolated and more secure because they are allowed to participate in planning their own care. Nurses feel personal satisfaction, much of it related to positive feedback from the patients. They also seem to gain a greater sense of achievement and esprit de corps.Source: http://enursebook.info/nursing-licensure-examination-review-questions/ date retrieved: May 27, 2011 7:10 am

99. Which of the following is an example of nursing malpractice? a. The nurse administers penicillin to a patient with a documented history of allergy to the drug. The patient experiences an allergic reaction and has cerebral damage resulting from anoxia. b. The nurse applies a hot water bottle or a heating pad to the abdomen of a patient with abdominal cramping. c. The nurse assists a patient out of bed with the bed locked in position; the patient slips and fractures his right humerus. d. The nurse administers the wrong medication to a patient and the patient vomits. This information is documented and reported to the physician and the nursing supervisor. Answer: A. The nurse administers penicillin to a patient with a documented history of allergy to the drug. The patient experiences an allergic reaction and has cerebral damage resulting from anoxia. The three elements necessary to establish a nursing malpractice are nursing error (administering penicillin to a patient with a documented allergy to the drug), injury (cerebral damage), and proximal cause (administering the penicillin caused the cerebral damage). Applying a hot water bottle or heating pad to a patient without a physicians order does not include the three required components. Assisting a patient out of bed with the bed locked in position is the correct nursing practice; therefore, the fracture was not the result of malpractice. Administering an incorrect medication is a nursing error; however, if such action resulted in a serious illness or chronic problem, the nurse could be sued for malpractice.Source: http://enursebook.info/nursing-licensure-examination-review-questions/ date retrieved: May 27, 2011 7:10 am

100. Which of the following signs and symptoms would the nurse expect to find when assessing an Asian patient for postoperative pain following abdominal surgery? a. Decreased blood pressure and heart rate and shallow respirations b. Quiet cryingREPRODUCTION IS STRICTLY PROHIBITED..NGRTCI! Iloilo-(033)3202053 Bacolod-(034)4333353 Cebu-(032)2551127 Manila-(02)7353286 28

c. Immobility, diaphoresis, and avoidance of deep breathing or coughing d. Changing position every 2 hours Answer C. Immobility, diaphoresis, and avoidance of deep breathing or coughing An Asian patient is likely to hide his Pain. Consequently, the nurse must observe for objective signs. In an abdominal surgery patient, these might include immobility, diaphoresis, and avoidance of deep breathing or coughing, as well as increased heart rate, shallow respirations (stemming from Pain upon moving the diaphragm and respiratory muscles), and guarding or rigidity of the abdominal wall. Such a patient is unlikely to display emotion, such as crying.Source: http://enursebook.info/nursing-licensure-examination-review-questions/ date retrieved: May 27, 2011 7:10 am

All the Best!NGRTCI

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