PNLE I for Foundation of A.

A 34 year-old post operative appendectomy client of

five hours who is complaining of pain.
Professional Nursing Practice B. A 44 year-old myocardial infarction (MI) client who is
complaining of nausea.
1. The nurse In-charge in labor and delivery unit C. A 26 year-old client admitted for dehydration whose
administered a dose of terbutaline to a client without intravenous (IV) has infiltrated.
checking the client’s pulse. The standard that would be D. A 63 year-old post operative’s abdominal
used to determine if the nurse was negligent is: hysterectomy client of three days whose incisional
dressing is saturated with serosanguinous fluid.
A. The physician’s orders.
B. The action of a clinical nurse specialist who is 6. Nurse Gail places a client in a four-point restraint
recognized expert in the field. following orders from the physician. The client care plan
C. The statement in the drug literature about should include:
administration of terbutaline.
D. The actions of a reasonably prudent nurse with A. Assess temperature frequently.
similar education and experience. B. Provide diversional activities.
C. Check circulation every 15-30 minutes.
2. Nurse Trish is caring for a female client with a history of D. Socialize with other patients once a shift.
GI bleeding, sickle cell disease, and a platelet count of
22,000/μl. The female client is dehydrated and receiving
dextrose 5% in half-normal saline solution at 150 ml/hr. 7. A male client who has severe burns is receiving H2
The client complains of severe bone pain and is scheduled receptor antagonist therapy. The nurse In-charge knows
to receive a dose of morphine sulfate. In administering the the purpose of this therapy is to:
medication, Nurse Trish should avoid which route?
A. Prevent stress ulcer
A. I.V B. Block prostaglandin synthesis
B. I.M C. Facilitate protein synthesis.
C. Oral D. Enhance gas exchange
D. S.C
8. The doctor orders hourly urine output measurement for
3. Dr. Garcia writes the following order for the client who a postoperative male client. The nurse Trish records the
has been recently admitted “Digoxin .125 mg P.O. once following amounts of output for 2 consecutive hours: 8
daily.” To prevent a dosage error, how should the nurse a.m.: 50 ml; 9 a.m.: 60 ml. Based on these amounts, which
document this order onto the medication administration action should the nurse take?
record?
A. Increase the I.V. fluid infusion rate
A. “Digoxin .1250 mg P.O. once daily” B. Irrigate the indwelling urinary catheter
B. “Digoxin 0.1250 mg P.O. once daily” C. Notify the physician
C. “Digoxin 0.125 mg P.O. once daily” D. Continue to monitor and record hourly urine output
D. “Digoxin .125 mg P.O. once daily”
9. Tony, a basketball player twist his right ankle while
playing on the court and seeks care for ankle pain and
swelling. After the nurse applies ice to the ankle for 30
4. A newly admitted female client was diagnosed with deep minutes, which statement by Tony suggests that ice
vein thrombosis. Which nursing diagnosis should receive application has been effective?
the highest priority?
A. “My ankle looks less swollen now”.
A. Ineffective peripheral tissue perfusion related to B. “My ankle feels warm”.
venous congestion. C. “My ankle appears redder now”.
B. Risk for injury related to edema. D. “I need something stronger for pain relief”
C. Excess fluid volume related to peripheral vascular
disease. 10.The physician prescribes a loop diuretic for a client.
D. Impaired gas exchange related to increased blood When administering this drug, the nurse anticipates that
flow. the client may develop which electrolyte imbalance?

5. Nurse Betty is assigned to the following clients. The A. Hypernatremia

client that the nurse would see first after endorsement? B. Hyperkalemia
C. Hypokalemia
D. Hypervolemia
11.She finds out that some managers have benevolent- B. Explore the client’s fears and anxieties about the
authoritative style of management. Which of the following surgery.
behaviors will she exhibit most likely? C. Assist the client in removing dentures and nail polish.
D. Encourage the client to drink water prior to surgery.
A. Have condescending trust and confidence in their
subordinates. 18. A male client is admitted and diagnosed with acute
B. Gives economic and ego awards. pancreatitis after a holiday celebration of excessive food
C. Communicates downward to staffs. and alcohol. Which assessment finding reflects this
D. Allows decision making among subordinates. diagnosis?

12. Nurse Amy is aware that the following is true about A. Blood pressure above normal range.
functional nursing B. Presence of crackles in both lung fields.
C. Hyperactive bowel sounds
A. Provides continuous, coordinated and D. Sudden onset of continuous epigastric and back pain.
comprehensive nursing services.
B. One-to-one nurse patient ratio. 19. Which dietary guidelines are important for nurse
C. Emphasize the use of group collaboration. Oliver to implement in caring for the client with burns?
D. Concentrates on tasks and activities.
A. Provide high-fiber, high-fat diet
13.Which type of medication order might read “Vitamin K B. Provide high-protein, high-carbohydrate diet.
10 mg I.M. daily × 3 days?” C. Monitor intake to prevent weight gain.
D. Provide ice chips or water intake.
A. Single order
B. Standard written order 20.Nurse Hazel will administer a unit of whole blood,
C. Standing order which priority information should the nurse have about
D. Stat order the client?

14.A female client with a fecal impaction frequently A. Blood pressure and pulse rate.
exhibits which clinical manifestation? B. Height and weight.
C. Calcium and potassium levels
A. Increased appetite D. Hgb and Hct levels.
B. Loss of urge to defecate
C. Hard, brown, formed stools 21. Nurse Michelle witnesses a female client sustain a fall
D. Liquid or semi-liquid stools and suspects that the leg may be broken. The nurse takes
which priority action?
15.Nurse Linda prepares to perform an otoscopic
examination on a female client. For proper visualization, A. Takes a set of vital signs.
the nurse should position the client’s ear by: B. Call the radiology department for X-ray.
C. Reassure the client that everything will be alright.
A. Pulling the lobule down and back D. Immobilize the leg before moving the client.
B. Pulling the helix up and forward
C. Pulling the helix up and back 22.A male client is being transferred to the nursing unit for
D. Pulling the lobule down and forward admission after receiving a radium implant for bladder
cancer. The nurse in-charge would take which priority
16. Which instruction should nurse Tom give to a male action in the care of this client?
client who is having external radiation therapy:
A. Place client on reverse isolation.
A. Protect the irritated skin from sunlight. B. Admit the client into a private room.
B. Eat 3 to 4 hours before treatment. C. Encourage the client to take frequent rest periods.
C. Wash the skin over regularly. D. Encourage family and friends to visit.
D. Apply lotion or oil to the radiated area when it is red
or sore. 23.A newly admitted female client was diagnosed with
agranulocytosis. The nurse formulates which priority
17.In assisting a female client for immediate surgery, the nursing diagnosis?
nurse In-charge is aware that she should:
A. Constipation
A. Encourage the client to void following preoperative B. Diarrhea
medication. C. Risk for infection
D. Deficient knowledge
24.A male client is receiving total parenteral nutrition 30.Which is the most appropriate nursing action in
suddenly demonstrates signs and symptoms of an air obtaining a blood pressure measurement?
embolism. What is the priority action by the nurse?
A. Take the proper equipment, place the client in a
A. Notify the physician. comfortable position, and record the appropriate
B. Place the client on the left side in the Trendelenburg information in the client’s chart.
position. B. Measure the client’s arm, if you are not sure of the
C. Place the client in high-Fowlers position. size of cuff to use.
D. Stop the total parenteral nutrition. C. Have the client recline or sit comfortably in a chair
with the forearm at the level of the heart.
25.Nurse May attends an educational conference on D. Document the measurement, which extremity was
leadership styles. The nurse is sitting with a nurse used, and the position that the client was in during
employed at a large trauma center who states that the the measurement.
leadership style at the trauma center is task-oriented and
directive. The nurse determines that the leadership style 31.Asking the questions to determine if the person
used at the trauma center is: understands the health teaching provided by the nurse
would be included during which step of the nursing
A. Autocratic. process?
B. Laissez-faire.
C. Democratic. A. Assessment
D. Situational B. Evaluation
C. Implementation
26.The physician orders DS 500 cc with KCl 10 mEq/liter D. Planning and goals
at 30 cc/hr. The nurse in-charge is going to hang a 500 cc
bag. KCl is supplied 20 mEq/10 cc. How many cc’s of KCl 32.Which of the following item is considered the single
will be added to the IV solution? most important factor in assisting the health professional
in arriving at a diagnosis or determining the person’s
A. .5 cc needs?
B. 5 cc
C. 1.5 cc A. Diagnostic test results
D. 2.5 cc B. Biographical date
C. History of present illness
27.A child of 10 years old is to receive 400 cc of IV fluid in D. Physical examination
an 8 hour shift. The IV drip factor is 60. The IV rate that
will deliver this amount is: 33.In preventing the development of an external rotation
deformity of the hip in a client who must remain in bed for
A. 50 cc/ hour any period of time, the most appropriate nursing action
B. 55 cc/ hour would be to use:
C. 24 cc/ hour
D. 66 cc/ hour A. Trochanter roll extending from the crest of the ileum
to the midthigh.
28.The nurse is aware that the most important nursing B. Pillows under the lower legs.
action when a client returns from surgery is: C. Footboard
D. Hip-abductor pillow
A. Assess the IV for type of fluid and rate of flow.
B. Assess the client for presence of pain. 34.Which stage of pressure ulcer development does the
C. Assess the Foley catheter for patency and urine ulcer extend into the subcutaneous tissue?
output
D. Assess the dressing for drainage. A. Stage I
B. Stage II
29. Which of the following vital sign assessments that may C. Stage III
indicate cardiogenic shock after myocardial infarction? D. Stage IV

A. BP – 80/60, Pulse – 110 irregular 35.When the method of wound healing is one in which
B. BP – 90/50, Pulse – 50 regular wound edges are not surgically approximated and
C. BP – 130/80, Pulse – 100 regular integumentary continuity is restored by granulations, the
D. BP – 180/100, Pulse – 90 irregular wound healing is termed

A. Second intention healing

 B. Primary intention healing B. Checking patency of the chest tube.
C. Third intention healing C. Keeping the head of the bed slightly elevated.
D. First intention healing D. Keeping the chest drainage system below the level of
the chest.
36.An 80-year-old male client is admitted to the hospital
with a diagnosis of pneumonia. Nurse Oliver learns that 42.Nurse Trish must verify the client’s identity before
the client lives alone and hasn’t been eating or drinking. administering medication. She is aware that the safest way
When assessing him for dehydration, nurse Oliver would to verify identity is to:
expect to find:
A. Check the client’s identification band.
A. Hypothermia B. Ask the client to state his name.
B. Hypertension C. State the client’s name out loud and wait a client to
C. Distended neck veins repeat it.
D. Tachycardia D. Check the room number and the client’s name on the
bed.
37.The physician prescribes meperidine (Demerol), 75 mg
I.M. every 4 hours as needed, to control a client’s 43.The physician orders dextrose 5 % in water, 1,000 ml to
postoperative pain. The package insert is “Meperidine, 100 be infused over 8 hours. The I.V. tubing delivers 15
mg/ml.” How many milliliters of meperidine should the drops/ml. Nurse John should run the I.V. infusion at a rate
client receive? of:

A. 0.75 A. 30 drops/minute
B. 0.6 B. 32 drops/minute
C. 0.5 C. 20 drops/minute
D. 0.25 D. 18 drops/minute

38. A male client with diabetes mellitus is receiving insulin. 44.If a central venous catheter becomes disconnected
Which statement correctly describes an insulin unit? accidentally, what should the nurse in-charge do
immediately?
A. It’s a common measurement in the metric system.
B. It’s the basis for solids in the avoirdupois system. A. Clamp the catheter
C. It’s the smallest measurement in the apothecary B. Call another nurse
system. C. Call the physician
D. It’s a measure of effect, not a standard measure of D. Apply a dry sterile dressing to the site.
weight or quantity.
45.A female client was recently admitted. She has fever,
39.Nurse Oliver measures a client’s temperature at 102° F. weight loss, and watery diarrhea is being admitted to the
What is the equivalent Centigrade temperature? facility. While assessing the client, Nurse Hazel inspects
the client’s abdomen and notice that it is slightly concave.
A. 40.1 °C Additional assessment should proceed in which order:
B. 38.9 °C
C. 48 °C A. Palpation, auscultation, and percussion.
D. 38 °C B. Percussion, palpation, and auscultation.
C. Palpation, percussion, and auscultation.
40.The nurse is assessing a 48-year-old client who has D. Auscultation, percussion, and palpation.
come to the physician’s office for his annual physical exam.
One of the first physical signs of aging is: 46. Nurse Betty is assessing tactile fremitus in a client with
pneumonia. For this examination, nurse Betty should use
A. Accepting limitations while developing assets. the:
B. Increasing loss of muscle tone.
C. Failing eyesight, especially close vision. A. Fingertips
D. Having more frequent aches and pains. B. Finger pads
C. Dorsal surface of the hand
41.The physician inserts a chest tube into a female client to D. Ulnar surface of the hand
treat a pneumothorax. The tube is connected to water-seal
drainage. The nurse in-charge can prevent chest tube air 47. Which type of evaluation occurs continuously
leaks by: throughout the teaching and learning process?

A. Checking and taping all connections. A. Summative

 B. Informative A. Hypernatremia
C. Formative B. Hypokalemia
D. Retrospective C. Hyperphosphatemia
D. Hypercalcemia
48.A 45 year old client, has no family history of breast
cancer or other risk factors for this disease. Nurse John 54.Nurse Len is administering sublingual nitrglycerin
should instruct her to have mammogram how often? (Nitrostat) to the newly admitted client. Immediately
afterward, the client may experience:
A. Twice per year
B. Once per year A. Throbbing headache or dizziness
C. Every 2 years B. Nervousness or paresthesia.
D. Once, to establish baseline C. Drowsiness or blurred vision.
D. Tinnitus or diplopia.
49.A male client has the following arterial blood gas
values: pH 7.30; Pao2 89 mmHg; Paco2 50 mmHg; and 55.Nurse Michelle hears the alarm sound on the telemetry
HCO3 26mEq/L. Based on these values, Nurse Patricia monitor. The nurse quickly looks at the monitor and notes
should expect which condition? that a client is in a ventricular tachycardia. The nurse
rushes to the client’s room. Upon reaching the client’s
A. Respiratory acidosis bedside, the nurse would take which action first?
B. Respiratory alkalosis
C. Metabolic acidosis A. Prepare for cardioversion
D. Metabolic alkalosis B. Prepare to defibrillate the client
C. Call a code
50.Nurse Len refers a female client with terminal cancer to D. Check the client’s level of consciousness
a local hospice. What is the goal of this referral?
56.Nurse Hazel is preparing to ambulate a female client.
A. To help the client find appropriate treatment options. The best and the safest position for the nurse in assisting
B. To provide support for the client and family in coping the client is to stand:
with terminal illness.
C. To ensure that the client gets counseling regarding A. On the unaffected side of the client.
health care costs. B. On the affected side of the client.
D. To teach the client and family about cancer and its C. In front of the client.
treatment. D. Behind the client.

51.When caring for a male client with a 3-cm stage I 57.Nurse Janah is monitoring the ongoing care given to the
pressure ulcer on the coccyx, which of the following potential organ donor who has been diagnosed with brain
actions can the nurse institute independently? death. The nurse determines that the standard of care had
been maintained if which of the following data is
A. Massaging the area with an astringent every 2 hours. observed?
B. Applying an antibiotic cream to the area three times
per day. A. Urine output: 45 ml/hr
C. Using normal saline solution to clean the ulcer and B. Capillary refill: 5 seconds
applying a protective dressing as necessary. C. Serum pH: 7.32
D. Using a povidone-iodine wash on the ulceration three D. Blood pressure: 90/48 mmHg
times per day.
58. Nurse Amy has an order to obtain a urinalysis from a
52.Nurse Oliver must apply an elastic bandage to a client’s male client with an indwelling urinary catheter. The nurse
ankle and calf. He should apply the bandage beginning at avoids which of the following, which contaminate the
the client’s: specimen?

A. Knee A. Wiping the port with an alcohol swab before

B. Ankle inserting the syringe.
C. Lower thigh B. Aspirating a sample from the port on the drainage
D. Foot bag.
C. Clamping the tubing of the drainage bag.
53.A 10 year old child with type 1 diabetes develops D. Obtaining the specimen from the urinary drainage
diabetic ketoacidosis and receives a continuous insulin bag.
infusion. Which condition represents the greatest risk to
this child?
59.Nurse Meredith is in the process of giving a client a bed A. Moves the client rapidly from the table to the
bath. In the middle of the procedure, the unit secretary stretcher.
calls the nurse on the intercom to tell the nurse that there B. Uncovers the client completely before transferring to
is an emergency phone call. The appropriate nursing the stretcher.
action is to: C. Secures the client safety belts after transferring to the
stretcher.
A. Immediately walk out of the client’s room and D. Instructs the client to move self from the table to the
answer the phone call. stretcher.
B. Cover the client, place the call light within reach, and
answer the phone call. 64.Nurse Myrna is providing instructions to a nursing
C. Finish the bed bath before answering the phone call. assistant assigned to give a bed bath to a client who is on
D. Leave the client’s door open so the client can be contact precautions. Nurse Myrna instructs the nursing
monitored and the nurse can answer the phone call. assistant to use which of the following protective items
when giving bed bath?
60. Nurse Janah is collecting a sputum specimen for culture
and sensitivity testing from a client who has a productive A. Gown and goggles
cough. Nurse Janah plans to implement which intervention B. Gown and gloves
to obtain the specimen? C. Gloves and shoe protectors
D. Gloves and goggles
A. Ask the client to expectorate a small amount of
sputum into the emesis basin. 65. Nurse Oliver is caring for a client with impaired
B. Ask the client to obtain the specimen after breakfast. mobility that occurred as a result of a stroke. The client has
C. Use a sterile plastic container for obtaining the right sided arm and leg weakness. The nurse would
specimen. suggest that the client use which of the following assistive
D. Provide tissues for expectoration and obtaining the devices that would provide the best stability for
specimen. ambulating?

61. Nurse Ron is observing a male client using a walker. A. Crutches

The nurse determines that the client is using the walker B. Single straight-legged cane
correctly if the client: C. Quad cane
D. Walker
A. Puts all the four points of the walker flat on the floor,
puts weight on the hand pieces, and then walks into 66.A male client with a right pleural effusion noted on a
it. chest X-ray is being prepared for thoracentesis. The client
B. Puts weight on the hand pieces, moves the walker experiences severe dizziness when sitting upright. To
forward, and then walks into it. provide a safe environment, the nurse assists the client to
C. Puts weight on the hand pieces, slides the walker which position for the procedure?
forward, and then walks into it.
D. Walks into the walker, puts weight on the hand A. Prone with head turned toward the side supported
pieces, and then puts all four points of the walker flat by a pillow.
on the floor. B. Sims’ position with the head of the bed flat.
C. Right side-lying with the head of the bed elevated 45
62.Nurse Amy has documented an entry regarding client degrees.
care in the client’s medical record. When checking the D. Left side-lying with the head of the bed elevated 45
entry, the nurse realizes that incorrect information was degrees.
documented. How does the nurse correct this error?
67.Nurse John develops methods for data gathering. Which
A. Erases the error and writes in the correct of the following criteria of a good instrument refers to the
information. ability of the instrument to yield the same results upon its
B. Uses correction fluid to cover up the incorrect repeated administration?
information and writes in the correct information.
C. Draws one line to cross out the incorrect information A. Validity
and then initials the change. B. Specificity
D. Covers up the incorrect information completely using C. Sensitivity
a black pen and writes in the correct information D. Reliability

63.Nurse Ron is assisting with transferring a client from 68.Harry knows that he has to protect the rights of human
the operating room table to a stretcher. To provide safety research subjects. Which of the following actions of Harry
to the client, the nurse should: ensures anonymity?
 A. Keep the identities of the subject secret C. Res ipsa loquitor
B. Obtain informed consent D. Holdover doctrine
C. Provide equal treatment to all the subjects of the
study. 75.Nurse Myrna is aware that the Board of Nursing has
D. Release findings only to the participants of the study quasi-judicial power. An example of this power is:

69.Patient’s refusal to divulge information is a limitation A. The Board can issue rules and regulations that will
because it is beyond the control of Tifanny”. What type of govern the practice of nursing
research is appropriate for this study? B. The Board can investigate violations of the nursing
law and code of ethics
A. Descriptive- correlational C. The Board can visit a school applying for a permit in
B. Experiment collaboration with CHED
C. Quasi-experiment D. The Board prepares the board examinations
D. Historical
76. When the license of nurse Krina is revoked, it means
70.Nurse Ronald is aware that the best tool for data that she:
gathering is?
A. Is no longer allowed to practice the profession for the
A. Interview schedule rest of her life
B. Questionnaire B. Will never have her/his license re-issued since it has
C. Use of laboratory data been revoked
D. Observation C. May apply for re-issuance of his/her license based on
certain conditions stipulated in RA 9173
71.Monica is aware that there are times when only D. Will remain unable to practice professional nursing
manipulation of study variables is possible and the
elements of control or randomization are not attendant. 77.Ronald plans to conduct a research on the use of a new
Which type of research is referred to this? method of pain assessment scale. Which of the following is
the second step in the conceptualizing phase of the
A. Field study research process?
B. Quasi-experiment
C. Solomon-Four group design A. Formulating the research hypothesis
D. Post-test only design B. Review related literature
C. Formulating and delimiting the research problem
72.Cherry notes down ideas that were derived from the D. Design the theoretical and conceptual framework
description of an investigation written by the person who
conducted it. Which type of reference source refers to this? 78. The leader of the study knows that certain patients
who are in a specialized research setting tend to respond
A. Footnote psychologically to the conditions of the study. This
B. Bibliography referred to as :
C. Primary source
D. Endnotes A. Cause and effect
B. Hawthorne effect
73.When Nurse Trish is providing care to his patient, she C. Halo effect
must remember that her duty is bound not to do doing any D. Horns effect
action that will cause the patient harm. This is the meaning
of the bioethical principle: 79.Mary finally decides to use judgment sampling on her
research. Which of the following actions of is correct?
A. Non-maleficence
B. Beneficence A. Plans to include whoever is there during his study.
C. Justice B. Determines the different nationality of patients
D. Solidarity frequently admitted and decides to get
representations samples from each.
74.When a nurse in-charge causes an injury to a female C. Assigns numbers for each of the patients, place these
patient and the injury caused becomes the proof of the in a fishbowl and draw 10 from it.
negligent act, the presence of the injury is said to exemplify D. Decides to get 20 samples from the admitted patients
the principle of:
80. The nursing theorist who developed transcultural
A. Force majeure nursing theory is:
B. Respondeat superior
 A. Florence Nightingale A. Fresh orange slices
B. Madeleine Leininger B. Steamed broccoli
C. Albert Moore C. Ice cream
D. Sr. Callista Roy D. Ground beef patties

81.Marion is aware that the sampling method that gives 88.The nurse prepares to administer a cleansing enema.
equal chance to all units in the population to get picked is: What is the most common client position used for this
procedure?
A. Random
B. Accidental A. Lithotomy
C. Quota B. Supine
D. Judgment C. Prone
D. Sims’ left lateral
82.John plans to use a Likert Scale to his study to
determine the: 89.Nurse Marian is preparing to administer a blood
transfusion. Which action should the nurse take first?
A. Degree of agreement and disagreement
B. Compliance to expected standards A. Arrange for typing and cross matching of the client’s
C. Level of satisfaction blood.
D. Degree of acceptance B. Compare the client’s identification wristband with
the tag on the unit of blood.
83.Which of the following theory addresses the four modes C. Start an I.V. infusion of normal saline solution.
of adaptation? D. Measure the client’s vital signs.

A. Madeleine Leininger 90.A 65 years old male client requests his medication at 9
B. Sr. Callista Roy p.m. instead of 10 p.m. so that he can go to sleep earlier.
C. Florence Nightingale Which type of nursing intervention is required?
D. Jean Watson
A. Independent
84.Ms. Garcia is responsible to the number of personnel B. Dependent
reporting to her. This principle refers to: C. Interdependent
D. Intradependent
A. Span of control
B. Unity of command 91.A female client is to be discharged from an acute care
C. Downward communication facility after treatment for right leg thrombophlebitis. The
D. Leader Nurse Betty notes that the client’s leg is pain-free, without
redness or edema. The nurse’s actions reflect which step of
85.Ensuring that there is an informed consent on the part the nursing process?
of the patient before a surgery is done, illustrates the
bioethical principle of: A. Assessment
B. Diagnosis
A. Beneficence C. Implementation
B. Autonomy D. Evaluation
C. Veracity
D. Non-maleficence 92.Nursing care for a female client includes removing
elastic stockings once per day. The Nurse Betty is aware
86.Nurse Reese is teaching a female client with peripheral that the rationale for this intervention?
vascular disease about foot care; Nurse Reese should
include which instruction? A. To increase blood flow to the heart
B. To observe the lower extremities
A. Avoid wearing cotton socks. C. To allow the leg muscles to stretch and relax
B. Avoid using a nail clipper to cut toenails. D. To permit veins in the legs to fill with blood.
C. Avoid wearing canvas shoes.
D. Avoid using cornstarch on feet. 93.Which nursing intervention takes highest priority when
caring for a newly admitted client who’s receiving a blood
87.A client is admitted with multiple pressure ulcers. transfusion?
When developing the client’s diet plan, the nurse should
include: A. Instructing the client to report any itching, swelling,
or dyspnea.
 B. Informing the client that the transfusion usually take A. The nurse can implement medication orders quickly.
1 ½ to 2 hours. B. The nurse receives input from the pharmacist.
C. Documenting blood administration in the client care C. The system minimizes transcription errors.
record. D. The system reinforces accurate calculations.
D. Assessing the client’s vital signs when the transfusion
ends. 100. Nurse Oliver is assessing a client’s abdomen. Which
finding should the nurse report as abnormal?
94.A male client complains of abdominal discomfort and
nausea while receiving tube feedings. Which intervention A. Dullness over the liver.
is most appropriate for this problem? B. Bowel sounds occurring every 10 seconds.
C. Shifting dullness over the abdomen.
A. Give the feedings at room temperature. D. Vascular sounds heard over the renal arteries.
B. Decrease the rate of feedings and the concentration
of the formula.
C. Place the client in semi-Fowler’s position while
feeding.
D. Change the feeding container every 12 hours.

95.Nurse Patricia is reconstituting a powdered medication

in a vial. After adding the solution to the powder, she nurse
should:

A. Do nothing.
B. Invert the vial and let it stand for 3 to 5 minutes.
C. Shake the vial vigorously.
D. Roll the vial gently between the palms.

96.Which intervention should the nurse Trish use when

administering oxygen by face mask to a female client?

A. Secure the elastic band tightly around the client’s

head.
B. Assist the client to the semi-Fowler position if
possible.
C. Apply the face mask from the client’s chin up over the
nose.
D. Loosen the connectors between the oxygen
equipment and humidifier.

97.The maximum transfusion time for a unit of packed red

blood cells (RBCs) is:

A. 6 hours
B. 4 hours
C. 3 hours
D. 2 hours

98.Nurse Monique is monitoring the effectiveness of a

client’s drug therapy. When should the nurse Monique
obtain a blood sample to measure the trough drug level?

A. 1 hour before administering the next dose.

B. Immediately before administering the next dose.
C. Immediately after administering the next dose.
D. 30 minutes after administering the next dose.

99.Nurse May is aware that the main advantage of using a

floor stock system is: