Fundamentals I 1.

When tubing a client following a right pneumonectomy the nurse should plan to place the client in either the: A. Right or left side lying position C. supine or right side lying position B. High fowlers or supine position D. left-side lying or low fowlers position 2. After client undergoes a lobectomy, the nurse should observe for symptoms of the most life threatening complication which is: A. Hemothorax due to decreased thoracic drainage B. Dysnea due to increase intrathoracic pressure C. Decreased cardiac output due to mediastinal shift D. Pnuemothorax due to increased abdominal pressure 3. Immediately after thoracentesis clients right lung collapse. A chest tube is inserted and attached to a three chamber close drainage system. The nurse knows that the chest tube is functioning properly when fluid: A. Is bubbling gently in the chest drainage chamber B. Remains constant in the chest drainage chamber C. Is bubbling vigorously in the suction control chamber D. Rises in the tube of the water sela chamber on inspiration 4. A client sustain a stab wound to the chest and the chest tube with water-seal drainage is inserted. Later, the client chest tube seems to be obstructed, the most appropriate nursing action would be to: A. Gently sqeeze the tube B. Clamp the tube immediately C. Prepare for chest tube removal D. Arrange for a star chest x-ray film 5. A client returns from a cardiac catherization with a pressure dressing over the left groin. The client is to be that in bed for 6 hours with the leg straight. These measure are important to prevent A. Orthostatic hypotension B. Headache and disorientation C. Bleeding at the arterial puncture site D. Infiltration of radiopaque dye into tissue 6. Three days following prostate surgery a clients foley catheter and continuous bladder irrigation (CNI) is to be removed and the nurse discusses what to expected with the client, the nurse recognizes that the teaching has been understood when the client states, after the catheter is removal I may: A. Have dilute urine B. Exhibit dark red urine C. Be unable to pass my urine D. Experience some burning urination 7. The nurse some bright red blood in a clients nasogastric drainage four hours after a subtotal gastrectomy the nurse should: A. Gently irrigate the tube with 30 ml normal saline B. Clamp the nasogastric tube and call the physician C. Continue to monitor the drainage from the tube and record the observation D. Reduce the pressure on the suction and record observation of the drainage 8. The nurse is aware that a client t-tube has ben inserted during a resection of the pancreas to: A. divert the bile flow to the cystic duct B. drain blood and pus from the operative site C. prevent postoperative infection at the site of the incision

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D. Facilitate bile drainage while the common duct is edematous. A client is to be discharged with percutaneous catheter for home administration of total parentaral nutrition (TPN). The nurse should help the client to A. Learn how to change the percutneous catheter B. Determine which days to sled-administer the TPN C. Schedule the TPN administration around meals time D. Arrange professionals help to monitor the administration of the TPN A client with ascites is schedule for a paracentesis. To prepare the client for the abdominal paracentesis the nurse should: A. Medicate a client for pain B. Encourage the client to drink fluids C. Shave and pre the clients abdomen D. Instruct the client to empty the bladder The nurse is assessing a clients abdomen which finding should the nurse report as abnormal? a. Dullness over the liver b. Bowel sound occurring the abdomen c. Shifting dullness over the abdomen d. Vascular sounds hrs over the renal arteries The nurse prepares to perform an otoscopic examination on a n adult. For proper visualization the nurse should position the clients ear by pulling the: a. Lobule down and forward b. Helix up and back c. Helix up and forward d. Lobule down and back The nurse prepares to ausculate a clients carotid for bruits. For this procedure, the nurse should: a. have the client inhale during auscultation b. palpate the radial artery during auscultation c. use the bell of the stethoscope d. use the diaphragm of the stethoscope A client comes to the clinic for a routine checkup. To assess the clients gag reflex, the nurse should use which method? a. Place a tongue blade in the front of the tongue and ask the client to say ah b. Place tongue blade lightly on the posterior aspect of the tongue c. C. place a tongue blade on the middle of the tongue and ask the client to sough d. Place a tongue blade on the uvula. During the physical examination the nurse uses various techniques to assess structure, organs and body systems. Which technique allows the nurse to feel for vibration and locate body structures? a. Auscultation b. Inspection c. Palpation d. Percussion All of the following components may be a part a clients medical record. Which one is the major source of subjective data about the client health status? a. Health history b. Physical findings c. Laboratory test results d. Radiologic findings

17. The nurse measures a cleints temperature at 102 degree F. what is the equivalent centigrade temperature? a. 39 C b. 47 C c. 38.9 C d. 40.1 C 18. Tachycardia can result from a. Vagal stimulation b. Vomiting anger or suctioning c. Fear, pain or anger d. Stress, pain or vomiting 19. The nurse is assessing tactile fremitus in a client with pneumonia. For this examination, the nurse should use the: a. Fingertips b. Ulnar surface of the hand c. Dorsal surface of the hand d. Finger pads 20. The nurse is assessing a clients abdominal. Which examination technique should the nurse use first? a. Auscultation b. Inspection c. Percussion d. Palpation 21. During assessment the nurse auscultates for a clients breath sound. Auscultation produces which type of data? a. Subjective b. Objective c. Secondary source d. Medical 22. The nurse must assess skin turgor of an elderly client. When evaluating skin turgor the nurse should remember that: a. Overhydration causes the skin to tent b. Dehydration causes the skin to appear edematous and spongy c. C. inelastic skin turgor is a normal part of aging d. Normal skin turgor is moist and boggy. 23. The nurse is assessing an elderly client. When performing the assessment, the nurse shoul consider that one normal aging change is a. Cloudy vision b. Incontinence c. Diminished reflexes d. Tremors 24. The nurse measures a clients apical pulse rate and compares it with a radial rate. The differential between these two pulses is called: a. The pulse pressure b. The pulse deficit c. The pulse rhythm d. Pulses regularis 25. The clientage 75 is admitted to the facility. Because of the clients age the nurse should modify the assessment by: a. Shortening it b. Talking in a loud voice

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c. Addressing the client by the first name d. Allowing extra time for the assessment The nurse prepare to measure clients blood pressure. What us the correct procedures for measuring blood pressure? a. Wrapping the cuff around the limb, with the uninflated bladder covering about one fourth of the limb circumference b. Measuring the arm about 2 (5cm) above the antecubital space c. Wrapping cuff around the limb with uninflated bladder covering about three-quarters of the limb circumference d. Using baldder that 6 (15cm) long The nurse prepares to perform light palpation. How is light palpation performed? a. By indenting the skin to (1.3 to 1.9 cm) b. By indenting the skin 1 to 2 (2.5 to 5cm) c. By indenting the skin 1 using both hands d. By indenting the skin 1 and then releasing the pressure quickly The nurse to obtain client information from a primary source. Which of the following is a primary information source? a. A family member b. The physician c. The client d. Previous medical records The nurse is examining a client with suspected peritonitis. How does the nurse elicit rebound tenderness? a. Pressing the affected area firmly with one hand, releasing pressure quickly and noting any tenderness on release b. Using light palpation, noting any tenderness over an area c. Using deep ballottement noting any tenderness over an area d. Pressing firmly with one hand, releasing pressure while maintaining fingertips contact woth the skin and noting tenderness on release A client reports abdominal pain which action would aid nurses investigation of this complaint? a. Using deep palpation b. Assessing the painful area last c. Assessing the painful are first d. Checking a warmth in the painful area When examining a client with abdominal pain, the nurse should assess a. Any quadrant first b. The symptomatic quadrant c. The symptomatic quadrant last d. The symptomatic quadrant either second or third. The nurse uses a stethoscope to auscultate a clients chest. Which statement about a stethoscope with a bell a diaphragm is true? a. The bell detects a high-pitched sounds best b. The diaphragm detects high-pitched sound best c. The bell detect thrills best d. The diaphragm detects low pitched sounds best When assessing a gerintilogic client, the nurse expects to find various aging related physiological changes. These changes include: a. Increased coronary artery blood flow b. Decreased posterior thoracic curve c. Decreased peripheral resistance d. Delayed gastric emptying

34. When palpating the bladder of an adult client the nurse should identify whem finding as normal? a. A soft, smooth bladder b. A hard rough baldder c. A nonpalpable bladder d. A palpable bladder locates 3 to 5 (7.5 to 12.7 cm 0 above the symphysis pubis 35. When palpating a clients body to detect warmth, the use should use which part of the hand? a. Fingertips b. Finger pads c. Back (dorsal surface) d. Ulnar surface 36. Why should the nurse inspect first and then auscultate when performing an assessment of a pediatric client? a. Because the nurses touch may calm the child b. Because the child may cry as the assessment proceeds, making auscultation difficult c. because the nurses touch may frighten the child d. because the nurses touch may frighten the child e. Because the nurse hand or stethoscope may feel cold, making the child recoil. 37. The nurse auscultate for heart sounds more easily if the clients is a. Supine b. on his right side c. Holding his breath d. Leaning forward 38. An elderly client becomes confused, dislodges his I.V. access and attempts to remove his indwelling urinary catheter. The primary nurse for the client calls the physician and receives an order for soft wrist restraints. However, the clients family insists that he not be restrained. The charge nurse informs the family that to avoid restraints, the clients family must provide an around-the-clock attendant for the client. The family spokesman replies, you find the attendant; that is your responsibility. It would be most appropriate for the charge nurse to respond: a. its your responsibility as I have already stated to you b. We cant be responsible if you wont let us rest rib the client c. I think youre making the situation more difficult than it really is. d. I recommend family members arrange to stay with the client 39. As the nurse helps a client ambulate, the client says I had trouble sleeping last night which action should the nurse take first? a. Recommending warm milk or a warm shower at bedtime b. Gathering more information about the sleep problem. c. Determining whether the client is worried about something d. Finding out whether the client is taking medication athat may impede sleep 40. A client has a wound with a drain. When cleaning around the drain, the nurse shoul wipe in which direction? a. Laterally from the center to the opposite side b. From top to bottom c. In a circle, from the center outward d. None of the above 41. When bandaging a clients ankle the nurse should use which technique? a. Figure-eight b. Circular c. Recurrent d. Spiral reverse

42. Standard precautions were designed for the care of all clients in hospital, regardless of their diagnosis or infection status. Guidelines for standard precautions include: a. Immediately recapping used needles b. Disposing of sharp instrument in an impervious container c. Wearing gloves only for sterile procedures d. Substituting regular eyeglasses for eye protection 43. A client in behavioral- health facility receives a 30 mins. Psychotherapy session and the provider bills for a 50 mins session. Under the false claims act such illegal behavior is known as a. Unbunding b. Overbilling c. Upcoding d. Misrepresentation 44. When providing oral hygiene for an unconscious client, the nurse must take which essential action? a. Swabbing the clients lips, teeth and gums with lemon glycerin. b. Cleaning the clients tongue with gloved fingers c. Placing the client in semi-fowlers position d. Placing the client in a side lying position 45. To collect clean catch midstream urine specimen from female client the nurse instruct her to clean the area at the external urinary meatus with antiseptic. How should the client do this? a. By swabbing the labia minora from front to back b. By cleaning the labia monira from back to front c. By cleaning the labia majora from back to front d. By swabbing the entire perineal area 46. When preparing a client with a draining vertical incision for ambulation, where should the nurse apply the thickest portion of a dressing? a. At the top of the wound b. In the middle of the wound c. At the base of the wound d. Over the total wound 47. The physician orders hourly urine output measurement for a postoperative client. The nurse records the following amount of output for 2 consecutive hours: 8a.m. ;9a.m.; 60 ml. based on these amounts, which actions should the nurse take? a. Continuing to monitor and record hourly urine output b. Notifying the physician c. Irrigating the indwelling urinary catheter d. Increasing the I.V. fluid infusion rate 48. The nurse should encourage a client with a wound to consume foods high in vitamin C because this vitamin: a. Restores the inflammatory response b. Enhances oxygen transport to tissue c. Reduces edema d. Enhances protein synthesis 49. The nurse is assessing a client for the risk of falls. The nurse should instruct the client not to: a. Walk b. Cough c. Talk d. Eat 50. The nurse is assessing a client for the risk of fall. The nurse should collect: a. Gait and balance information b. The agencys restraint policy

c. The familys psychosocial history. d. The clients dietary preferences.