Nursing Practice I -foundation Of Professional Nursing Practice (Practice Mode)

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Nursing Practice I -foundation Of Professional Nursing Practice (Practice Mode) - Quiz

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Questions and Answers
  • 1. 

    The nurse In-charge in labor and delivery unit administered a dose of terbutaline to a client without checking the client’s pulse. The standard that would be used to determine if the nurse was negligent is:

    • A.

      The physician’s orders.

    • B.

      The action of a clinical nurse specialist who is recognized expert in the field.

    • C.

      The statement in the drug literature about administration of terbutaline.

    • D.

      The actions of a reasonably prudent nurse with similar education and experience.

    Correct Answer
    D. The actions of a reasonably prudent nurse with similar education and experience.
    Explanation
    The standard of care is determined by the average degree of skill, care, and diligence by nurses in similar circumstances.

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  • 2. 

    Nurse Trish is caring for a female client with a history of 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. The client complains of severe bone pain and is scheduled to receive a dose of morphine sulfate. In administering the medication, Nurse Trish should avoid which route?

    • A.

      I.V

    • B.

      I.M

    • C.

      Oral

    • D.

      S.C

    Correct Answer
    B. I.M
    Explanation
    With a platelet count of 22,000/μl, the clients tends to bleed easily. Therefore, the nurse should avoid using the I.M. route because the area is a highly vascular and can bleed readily when penetrated by a needle. The bleeding can be difficult to stop.

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  • 3. 

    Dr. Garcia writes the following order for the client who has been recently admitted “Digoxin .125 mg P.O. once daily.” To prevent a dosage error, how should the nurse document this order onto the medication administration record?

    • A.

      “Digoxin .1250 mg P.O. once daily”

    • B.

      “Digoxin 0.1250 mg P.O. once daily”

    • C.

      “Digoxin 0.125 mg P.O. once daily”

    • D.

      “Digoxin .125 mg P.O. once daily”

    Correct Answer
    C. “Digoxin 0.125 mg P.O. once daily”
    Explanation
    The nurse should always place a zero before a decimal point so that no one misreads the figure, which could result in a dosage error. The nurse should never insert a zero at the end of a dosage that includes a decimal point because this could be misread, possibly leading to a tenfold increase in the dosage.

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  • 4. 

    A newly admitted female client was diagnosed with deep vein thrombosis. Which nursing diagnosis should receive the highest priority?

    • A.

      Ineffective peripheral tissue perfusion related to venous congestion.

    • B.

      Risk for injury related to edema.

    • C.

      Excess fluid volume related to peripheral vascular disease.

    • D.

      Impaired gas exchange related to increased blood flow.

    Correct Answer
    A. Ineffective peripheral tissue perfusion related to venous congestion.
    Explanation
    Ineffective peripheral tissue perfusion related to venous congestion takes the highest priority because venous inflammation and clot formation impede blood flow in a client with deep vein thrombosis.

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  • 5. 

    Nurse Betty is assigned to the following clients. The client that the nurse would see first after endorsement?

    • A.

      A 34 year-old post operative appendectomy client of five hours who is complaining of pain.

    • B.

      A 44 year-old myocardial infarction (MI) client who is complaining of nausea.

    • C.

      A 26 year-old client admitted for dehydration whose intravenous (IV) has infiltrated.

    • D.

      A 63 year-old post operative’s abdominal hysterectomy client of three days whose incisional dressing is saturated with serosanguinous fluid.

    Correct Answer
    B. A 44 year-old myocardial infarction (MI) client who is complaining of nausea.
    Explanation
    Nausea is a symptom of impending myocardial infarction (MI) and should be assessed immediately so that treatment can be instituted and further damage to the heart is avoided.

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  • 6. 

    Nurse Gail places a client in a four-point restraint following orders from the physician. The client care plan should include:

    • A.

      Assess temperature frequently.

    • B.

      Provide diversional activities.

    • C.

      Check circulation every 15-30 minutes.

    • D.

      Socialize with other patients once a shift.

    Correct Answer
    C. Check circulation every 15-30 minutes.
    Explanation
    Restraints encircle the limbs, which place the client at risk for circulation being restricted to the distal areas of the extremities. Checking the client’s circulation every 15-30 minutes will allow the nurse to adjust the restraints before injury from decreased blood flow occurs.

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  • 7. 

    A male client who has severe burns is receiving H2 receptor antagonist therapy. The nurse In-charge knows the purpose of this therapy is to:

    • A.

      Prevent stress ulcer

    • B.

      Block prostaglandin synthesis

    • C.

      Facilitate protein synthesis.

    • D.

      Enhance gas exchange

    Correct Answer
    A. Prevent stress ulcer
    Explanation
    Curling’s ulcer occurs as a generalized stress response in burn patients. This results in a decreased production of mucus and increased secretion of gastric acid. The best treatment for this prophylactic use of antacids and H2 receptor blockers.

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  • 8. 

    The doctor orders hourly urine output measurement for a postoperative male client. The nurse Trish records the following amounts of output for 2 consecutive hours: 8 a.m.: 50 ml; 9 a.m.: 60 ml. Based on these amounts, which action should the nurse take?

    • A.

      Increase the I.V. fluid infusion rate

    • B.

      Irrigate the indwelling urinary catheter

    • C.

      Notify the physician

    • D.

      Continue to monitor and record hourly urine output

    Correct Answer
    D. Continue to monitor and record hourly urine output
    Explanation
    Normal urine output for an adult is approximately 1 ml/minute (60 ml/hour). Therefore, this client's output is normal. Beyond continued evaluation, no nursing action is warranted.

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  • 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 minutes, which statement by Tony suggests that ice application has been effective?

    • A.

      “My ankle looks less swollen now”.

    • B.

      “My ankle feels warm”.

    • C.

      “My ankle appears redder now”.

    • D.

      “I need something stronger for pain relief”

    Correct Answer
    B. “My ankle feels warm”.
    Explanation
    Ice application decreases pain and swelling. Continued or increased pain, redness, and increased warmth are signs of inflammation that shouldn't occur after ice application

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  • 10. 

    The physician prescribes a loop diuretic for a client. When administering this drug, the nurse anticipates that the client may develop which electrolyte imbalance?

    • A.

      Hypernatremia

    • B.

      Hyperkalemia

    • C.

      Hypokalemia

    • D.

      Hypervolemia

    Correct Answer
    B. Hyperkalemia
    Explanation
    A loop diuretic removes water and, along with it, sodium and potassium. This may result in hypokalemia, hypovolemia, and hyponatremia.

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  • 11. 

    She finds out that some managers have benevolent-authoritative style of management. Which of the following behaviors will she exhibit most likely?

    • A.

      Have condescending trust and confidence in their subordinates.

    • B.

      Gives economic and ego awards.

    • C.

      Communicates downward to staffs.

    • D.

      Allows decision making among subordinates.

    Correct Answer
    A. Have condescending trust and confidence in their subordinates.
    Explanation
    Benevolent-authoritative managers pretentiously show their trust and confidence to their followers.

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  • 12. 

    Nurse Amy is aware that the following is true about functional nursing

    • A.

      Provides continuous, coordinated and comprehensive nursing services.

    • B.

      One-to-one nurse patient ratio.

    • C.

      Emphasize the use of group collaboration.

    • D.

      Concentrates on tasks and activities.

    Correct Answer
    A. Provides continuous, coordinated and comprehensive nursing services.
    Explanation
    Functional nursing is focused on tasks and activities and not on the care of the patients.

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  • 13. 

    Which type of medication order might read "Vitamin K 10 mg I.M. daily × 3 days?"

    • A.

      Single order

    • B.

      Standard written order

    • C.

      Standing order

    • D.

      Stat order

    Correct Answer
    B. Standard written order
    Explanation
    This is a standard written order. Prescribers write a single order for medications given only once. A stat order is written for medications given immediately for an urgent client problem. A standing order, also known as a protocol, establishes guidelines for treating a particular disease or set of symptoms in special care areas such as the coronary care unit. Facilities also may institute medication protocols that specifically designate drugs that a nurse may not give.

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  • 14. 

    A female client with a fecal impaction frequently exhibits which clinical manifestation?

    • A.

      Increased appetite

    • B.

      Loss of urge to defecate

    • C.

      Hard, brown, formed stools

    • D.

      Liquid or semi-liquid stools

    Correct Answer
    D. Liquid or semi-liquid stools
    Explanation
    Passage of liquid or semi-liquid stools results from seepage of unformed bowel contents around the impacted stool in the rectum. Clients with fecal impaction don't pass hard, brown, formed stools because the feces can't move past the impaction. These clients typically report the urge to defecate (although they can't pass stool) and a decreased appetite.

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  • 15. 

    Nurse Linda prepares to perform an otoscopic examination on a female client. For proper visualization, the nurse should position the client's ear by:

    • A.

      Pulling the lobule down and back

    • B.

      Pulling the helix up and forward

    • C.

      Pulling the helix up and back

    • D.

      Pulling the lobule down and forward

    Correct Answer
    C. Pulling the helix up and back
    Explanation
    To perform an otoscopic examination on an adult, the nurse grasps the helix of the ear and pulls it up and back to straighten the ear canal. For a child, the nurse grasps the helix and pulls it down to straighten the ear canal. Pulling the lobule in any direction wouldn't straighten the ear canal for visualization.

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  • 16. 

     Which instruction should nurse Tom give to a male client who is having external radiation therapy:

    • A.

      Protect the irritated skin from sunlight.

    • B.

      Eat 3 to 4 hours before treatment.

    • C.

      Wash the skin over regularly.

    • D.

      Apply lotion or oil to the radiated area when it is red or sore.

    Correct Answer
    A. Protect the irritated skin from sunlight.
    Explanation
    Irradiated skin is very sensitive and must be protected with clothing or sunblock. The priority approach is the avoidance of strong sunlight.

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  • 17. 

    In assisting a female client for immediate surgery, the nurse In-charge is aware that she should:

    • A.

      Encourage the client to void following preoperative medication.

    • B.

      Explore the client’s fears and anxieties about the surgery.

    • C.

      Assist the client in removing dentures and nail polish.

    • D.

      Encourage the client to drink water prior to surgery.

    Correct Answer
    C. Assist the client in removing dentures and nail polish.
    Explanation
    Dentures, hairpins, and combs must be removed. Nail polish must be removed so that cyanosis can be easily monitored by observing the nail beds.

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  • 18. 

     A male client is admitted and diagnosed with acute pancreatitis after a holiday celebration of excessive food and alcohol. Which assessment finding reflects this diagnosis?

    • A.

      Blood pressure above normal range.

    • B.

      Presence of crackles in both lung fields.

    • C.

      Hyperactive bowel sounds

    • D.

      Sudden onset of continuous epigastric and back pain.

    Correct Answer
    D. Sudden onset of continuous epigastric and back pain.
    Explanation
    The autodigestion of tissue by the pancreatic enzymes results in pain from inflammation, edema, and possible hemorrhage. Continuous, unrelieved epigastric or back pain reflects the inflammatory process in the pancreas.

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  • 19. 

    Which dietary guidelines are important for nurse Oliver to implement in caring for the client with burns?

    • A.

      Provide high-fiber, high-fat diet

    • B.

      Provide high-protein, high-carbohydrate diet.

    • C.

      Monitor intake to prevent weight gain.

    • D.

      Provide ice chips or water intake.

    Correct Answer
    B. Provide high-protein, high-carbohydrate diet.
    Explanation
    A positive nitrogen balance is important for meeting metabolic needs, tissue repair, and resistance to infection. Caloric goals may be as high as 5000 calories per day.

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  • 20. 

    Nurse Hazel will administer a unit of whole blood, which priority information should the nurse have about the client?

    • A.

      Blood pressure and pulse rate.

    • B.

      Height and weight.

    • C.

      Calcium and potassium levels

    • D.

      Hgb and Hct levels.

    Correct Answer
    A. Blood pressure and pulse rate.
    Explanation
    The baseline must be established to recognize the signs of an anaphylactic or hemolytic reaction to the transfusion.

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  • 21. 

    Nurse Michelle witnesses a female client sustain a fall and suspects that the leg may be broken. The nurse takes which priority action?

    • A.

      Takes a set of vital signs.

    • B.

      Call the radiology department for X-ray.

    • C.

      Reassure the client that everything will be alright.

    • D.

      Immobilize the leg before moving the client.

    Correct Answer
    D. Immobilize the leg before moving the client.
    Explanation
    If the nurse suspects a fracture, splinting the area before moving the client is imperative. The nurse should call for emergency help if the client is not hospitalized and call for a physician for the hospitalized client.

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  • 22. 

    A male client is being transferred to the nursing unit for admission after receiving a radium implant for bladder cancer. The nurse in-charge would take which priority action in the care of this client?

    • A.

      Place client on reverse isolation.

    • B.

      Admit the client into a private room.

    • C.

      Encourage the client to take frequent rest periods.

    • D.

      Encourage family and friends to visit.

    Correct Answer
    B. Admit the client into a private room.
    Explanation
    The client who has a radiation implant is placed in a private room and has a limited number of visitors. This reduces the exposure of others to the radiation.

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  • 23. 

    A newly admitted female client was diagnosed with agranulocytosis. The nurse formulates which priority nursing diagnosis?

    • A.

      Constipation

    • B.

      Diarrhea

    • C.

      Risk for infection

    • D.

      Deficient knowledge

    Correct Answer
    C. Risk for infection
    Explanation
    Agranulocytosis is characterized by a reduced number of leukocytes (leucopenia) and neutrophils (neutropenia) in the blood. The client is at high risk for infection because of the decreased body defenses against microorganisms. Deficient knowledge related to the nature of the disorder may be appropriate diagnosis but is not the priority.

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  • 24. 

    A male client is receiving total parenteral nutrition suddenly demonstrates signs and symptoms of an air embolism. What is the priority action by the nurse?

    • A.

      Notify the physician.

    • B.

      Place the client on the left side in the Trendelenburg position.

    • C.

      Place the client in high-Fowlers position.

    • D.

      Stop the total parenteral nutrition.

    Correct Answer
    B. Place the client on the left side in the Trendelenburg position.
    Explanation
    Lying on the left side may prevent air from flowing into the pulmonary veins. The Trendelenburg position increases intrathoracic pressure, which decreases the amount of blood pulled into the vena cava during aspiration.

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  • 25. 

    Nurse May attends an educational conference on leadership styles. The nurse is sitting with a nurse employed at a large trauma center who states that the leadership style at the trauma center is task-oriented and directive. The nurse determines that the leadership style used at the trauma center is:

    • A.

      Autocratic.

    • B.

      Laissez-faire.

    • C.

      Democratic.

    • D.

      Situational

    Correct Answer
    A. Autocratic.
    Explanation
    The autocratic style of leadership is a task-oriented and directive.

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  • 26. 

    The physician orders DS 500 cc with KCl 10 mEq/liter 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 will be added to the IV solution?

    • A.

      .5 cc

    • B.

      5 cc

    • C.

      1.5 cc

    • D.

      2.5 cc

    Correct Answer
    D. 2.5 cc
    Explanation
    2.5 cc is to be added, because only a 500 cc bag of solution is being medicated instead of a 1 liter.

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  • 27. 

    A child of 10 years old is to receive 400 cc of IV fluid in an 8 hour shift. The IV drip factor is 60. The IV rate that will deliver this amount is:

    • A.

      50 cc/ hour

    • B.

      55 cc/ hour

    • C.

      24 cc/ hour

    • D.

      66 cc/ hour

    Correct Answer
    A. 50 cc/ hour
    Explanation
    A rate of 50 cc/hr. The child is to receive 400 cc over a period of 8 hours = 50 cc/hr.

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  • 28. 

    The nurse is aware that the most important nursing action when a client returns from surgery is:

    • A.

      Assess the IV for type of fluid and rate of flow.

    • B.

      Assess the client for presence of pain.

    • C.

      Assess the Foley catheter for patency and urine output

    • D.

      Assess the dressing for drainage.

    Correct Answer
    B. Assess the client for presence of pain.
    Explanation
    Assessing the client for pain is a very important measure. Postoperative pain is an indication of complication. The nurse should also assess the client for pain to provide for the client’s comfort.

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  • 29. 

    Which of the following vital sign assessments that may indicate cardiogenic shock after myocardial infarction?

    • A.

      BP – 80/60, Pulse – 110 irregular

    • B.

      BP – 90/50, Pulse – 50 regular

    • C.

      BP – 130/80, Pulse – 100 regular

    • D.

      BP – 180/100, Pulse – 90 irregular

    Correct Answer
    A. BP – 80/60, Pulse – 110 irregular
    Explanation
    The classic signs of cardiogenic shock are low blood pressure, rapid and weak irregular pulse, cold, clammy skin, decreased urinary output, and cerebral hypoxia.

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  • 30. 

    Which is the most appropriate nursing action in obtaining a blood pressure measurement?

    • A.

      Take the proper equipment, place the client in a comfortable position, and record the appropriate information in the client’s chart.

    • B.

      Measure the client’s arm, if you are not sure of the size of cuff to use.

    • C.

      Have the client recline or sit comfortably in a chair with the forearm at the level of the heart.

    • D.

      Document the measurement, which extremity was used, and the position that the client was in during the measurement.

    Correct Answer
    A. Take the proper equipment, place the client in a comfortable position, and record the appropriate information in the client’s chart.
    Explanation
    It is a general or comprehensive statement about the correct procedure, and it includes the basic ideas which are found in the other options

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  • 31. 

    Asking the questions to determine if the person understands the health teaching provided by the nurse would be included during which step of the nursing process?

    • A.

      Assessment

    • B.

      Evaluation

    • C.

      Implementation

    • D.

      Planning and goals

    Correct Answer
    B. Evaluation
    Explanation
    Evaluation includes observing the person, asking questions, and comparing the patient’s behavioral responses with the expected outcomes.

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  • 32. 

    Which of the following item is considered the single most important factor in assisting the health professional in arriving at a diagnosis or determining the person’s needs?

    • A.

      Diagnostic test results

    • B.

      Biographical date

    • C.

      History of present illness

    • D.

      Physical examination

    Correct Answer
    C. History of present illness
    Explanation
    The history of present illness is the single most important factor in assisting the health professional in arriving at a diagnosis or determining the person’s needs.

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  • 33. 

    In preventing the development of an external rotation deformity of the hip in a client who must remain in bed for any period of time, the most appropriate nursing action would be to use:

    • A.

      Trochanter roll extending from the crest of the ileum to the midthigh.

    • B.

      Pillows under the lower legs.

    • C.

      Footboard

    • D.

      Hip-abductor pillow

    Correct Answer
    A. Trochanter roll extending from the crest of the ileum to the midthigh.
    Explanation
    A trochanter roll, properly placed, provides resistance to the external rotation of the hip.

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  • 34. 

    Which stage of pressure ulcer development does the ulcer extend into the subcutaneous tissue?

    • A.

      Stage I

    • B.

      Stage II

    • C.

      Stage III

    • D.

      Stage IV

    Correct Answer
    C. Stage III
    Explanation
    Clinically, a deep crater or without undermining of adjacent tissue is noted.

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  • 35. 

    When the method of wound healing is one in which wound edges are not surgically approximated and integumentary continuity is restored by granulations, the wound healing is termed

    • A.

      Second intention healing

    • B.

      Primary intention healing

    • C.

      Third intention healing

    • D.

      First intention healing

    Correct Answer
    A. Second intention healing
    Explanation
    When wounds dehisce, they will allowed to heal by secondary intention

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  • 36. 

    An 80-year-old male client is admitted to the hospital with a diagnosis of pneumonia. Nurse Oliver learns that the client lives alone and hasn’t been eating or drinking. When assessing him for dehydration, nurse Oliver would expect to find:

    • A.

      Hypothermia

    • B.

      Hypertension

    • C.

      Distended neck veins

    • D.

      Tachycardia

    Correct Answer
    D. Tachycardia
    Explanation
    With an extracellular fluid or plasma volume deficit, compensatory mechanisms stimulate the heart, causing an increase in heart rate.

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  • 37. 

    The physician prescribes meperidine (Demerol), 75 mg I.M. every 4 hours as needed, to control a client’s postoperative pain. The package insert is “Meperidine, 100 mg/ml.” How many milliliters of meperidine should theclient receive?

    • A.

      0.75

    • B.

      0.6

    • C.

      0.5

    • D.

      0.25

    Correct Answer
    A. 0.75
    Explanation
    To determine the number of milliliters the client should receive, the nurse uses the fraction method in the following equation.
    75 mg/X ml = 100 mg/1 ml
    To solve for X, cross-multiply:
    75 mg x 1 ml = X ml x 100 mg
    75 = 100X
    75/100 = X
    0.75 ml (or ¾ ml) = X

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  • 38. 

    A male client with diabetes mellitus is receiving insulin. Which statement correctly describes an insulin unit?

    • A.

      It’s a common measurement in the metric system.

    • B.

      It’s the basis for solids in the avoirdupois system.

    • C.

      It’s the smallest measurement in the apothecary system.

    • D.

      It’s a measure of effect, not a standard measure of weight or quantity.

    Correct Answer
    D. It’s a measure of effect, not a standard measure of weight or quantity.
    Explanation
    An insulin unit is a measure of effect, not a standard measure of weight or quantity. Different drugs measured in units may have no relationship to one another in quality or quantity.

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  • 39. 

    Nurse Oliver measures a client’s temperature at 102° F. What is the equivalent Centigrade temperature?

    • A.

      40.1 °C

    • B.

      38.9 °C

    • C.

      48 °C

    • D.

      38 °C

    Correct Answer
    B. 38.9 °C
    Explanation
    To convert Fahrenheit degreed to Centigrade, use this formula
    °C = (°F – 32) ÷ 1.8
    °C = (102 – 32) ÷ 1.8
    °C = 70 ÷ 1.8
    °C = 38.9

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  • 40. 

    The nurse is assessing a 48-year-old client who has come to the physician’s office for his annual physical exam. One of the first physical signs of aging is:

    • A.

      Accepting limitations while developing assets.

    • B.

      Increasing loss of muscle tone.

    • C.

      Failing eyesight, especially close vision.

    • D.

      Having more frequent aches and pains.

    Correct Answer
    C. Failing eyesight, especially close vision.
    Explanation
    Failing eyesight, especially close vision, is one of the first signs of aging in middle life (ages 46 to 64). More frequent aches and pains begin in the early late years (ages 65 to 79). Increase in loss of muscle tone occurs in later years (age 80 and older).

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  • 41. 

    The physician inserts a chest tube into a female client to treat a pneumothorax. The tube is connected to water-seal drainage. The nurse in-charge can prevent chest tube air leaks by:

    • A.

      Checking and taping all connections.

    • B.

      Checking patency of the chest tube.

    • C.

      Keeping the head of the bed slightly elevated.

    • D.

      Keeping the chest drainage system below the level of the chest.

    Correct Answer
    A. Checking and taping all connections.
    Explanation
    Air leaks commonly occur if the system isn’t secure. Checking all connections and taping them will prevent air leaks. The chest drainage system is kept lower to promote drainage – not to prevent leaks.

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  • 42. 

    Nurse Trish must verify the client’s identity before administering medication. She is aware that the safest way to verify identity is to:

    • A.

      Check the client’s identification band.

    • B.

      Ask the client to state his name.

    • C.

      State the client’s name out loud and wait a client to repeat it.

    • D.

      Check the room number and the client’s name on the bed.

    Correct Answer
    A. Check the client’s identification band.
    Explanation
    Checking the client’s identification band is the safest way to verify a client’s identity because the band is assigned on admission and isn’t be removed at any time. (If it is removed, it must be replaced). Asking the client’s name or having the client repeated his name would be appropriate only for a client who’s alert, oriented, and able to understand what is being said, but isn’t the safe standard of practice. Names on bed aren’t always reliable

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  • 43. 

    The physician orders dextrose 5 % in water, 1,000 ml to be infused over 8 hours. The I.V. tubing delivers 15 drops/ml. Nurse John should run the I.V. infusion at a rate of:

    • A.

      30 drops/minute

    • B.

      32 drops/minute

    • C.

      20 drops/minute

    • D.

      18 drops/minute

    Correct Answer
    B. 32 drops/minute
    Explanation
    Giving 1,000 ml over 8 hours is the same as giving 125 ml over 1 hour (60 minutes). Find the number of milliliters per minute as follows:
    125/60 minutes = X/1 minute
    60X = 125 = 2.1 ml/minute
    To find the number of drops per minute:
    2.1 ml/X gtt = 1 ml/ 15 gtt
    X = 32 gtt/minute, or 32 drops/minute

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  • 44. 

    If a central venous catheter becomes disconnected accidentally, what should the nurse in-charge do immediately?

    • A.

      Clamp the catheter

    • B.

      Call another nurse

    • C.

      Call the physician

    • D.

      Apply a dry sterile dressing to the site.

    Correct Answer
    A. Clamp the catheter
    Explanation
    If a central venous catheter becomes disconnected, the nurse should immediately apply a catheter clamp, if available. If a clamp isn’t available, the nurse can place a sterile syringe or catheter plug in the catheter hub. After cleaning the hub with alcohol or povidone-iodine solution, the nurse must replace the I.V. extension and restart the infusion.

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  • 45. 

    A female client was recently admitted. She has fever, weight loss, and watery diarrhea is being admitted to the facility. While assessing the client, Nurse Hazel inspects the client’s abdomen and notice that it is slightly concave. Additional assessment should proceed in which order:

    • A.

      Palpation, auscultation, and percussion.

    • B.

      Percussion, palpation, and auscultation.

    • C.

      Palpation, percussion, and auscultation.

    • D.

      Auscultation, percussion, and palpation.

    Correct Answer
    D. Auscultation, percussion, and palpation.
    Explanation
    The correct order of assessment for examining the abdomen is inspection, auscultation, percussion, and palpation. The reason for this approach is that the less intrusive techniques should be performed before the more intrusive techniques. Percussion and palpation can alter natural findings during auscultation.

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  • 46. 

    Nurse Betty is assessing tactile fremitus in a client with pneumonia. For this examination, nurse Betty should use the:

    • A.

      Fingertips

    • B.

      Finger pads

    • C.

      Dorsal surface of the hand

    • D.

      Ulnar surface of the hand

    Correct Answer
    D. Ulnar surface of the hand
    Explanation
    The nurse uses the ulnar surface, or ball, of the hand to asses tactile fremitus, thrills, and vocal vibrations through the chest wall. The fingertips and finger pads best distinguish texture and shape. The dorsal surface best feels warmth.

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  • 47. 

    Which type of evaluation occurs continuously throughout the teaching and learning process?

    • A.

      Summative

    • B.

      Informative

    • C.

      Formative

    • D.

      Retrospective

    Correct Answer
    C. Formative
    Explanation
    Formative (or concurrent) evaluation occurs continuously throughout the teaching and learning process. One benefit is that the nurse can adjust teaching strategies as necessary to enhance learning. Summative, or retrospective, evaluation occurs at the conclusion of the teaching and learning session. Informative is not a type of evaluation.

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  • 48. 

    A 45 year old client, has no family history of breast cancer or other risk factors for this disease. Nurse John should instruct her to have mammogram how often?

    • A.

      Twice per year

    • B.

      Once per year

    • C.

      Every 2 years

    • D.

      Once, to establish baseline

    Correct Answer
    B. Once per year
    Explanation
    Yearly mammograms should begin at age 40 and continue for
    as long as the woman is in good health. If health risks, such as family history, genetic tendency, or past breast cancer, exist, more frequent examinations may be necessary.

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  • 49. 

    A male client has the following arterial blood gas values: pH 7.30; Pao2 89 mmHg; Paco2 50 mmHg; and HCO3 26mEq/L. Based on these values, Nurse Patricia should expect which condition?

    • A.

      Respiratory acidosis

    • B.

      Respiratory alkalosis

    • C.

      Metabolic acidosis

    • D.

      Metabolic alkalosis

    Correct Answer
    A. Respiratory acidosis
    Explanation
    The client has a below-normal (acidic) blood pH value and an above-normal partial pressure of arterial carbon dioxide (Paco2) value, indicating respiratory acidosis. In respiratory alkalosis, the pH value is above normal and in the Paco2 value is below normal. In metabolic acidosis, the pH and bicarbonate (Hco3) values are below normal. In metabolic alkalosis, the pH and Hco3 values are above normal.

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  • 50. 

    Nurse Len refers a female client with terminal cancer to a local hospice. What is the goal of this referral?

    • A.

      To help the client find appropriate treatment options.

    • B.

      To provide support for the client and family in coping with terminal illness.

    • C.

      To ensure that the client gets counseling regarding health care costs.

    • D.

      To teach the client and family about cancer and its treatment.

    Correct Answer
    B. To provide support for the client and family in coping with terminal illness.
    Explanation
    Hospices provide supportive care for terminally ill clients and their families. Hospice care doesn’t focus on counseling regarding health care costs. Most client referred to hospices have been treated for their disease without success and will receive only palliative care in the hospice.

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Quiz Review Timeline +

Our quizzes are rigorously reviewed, monitored and continuously updated by our expert board to maintain accuracy, relevance, and timeliness.

  • Current Version
  • Mar 21, 2023
    Quiz Edited by
    ProProfs Editorial Team
  • May 08, 2012
    Quiz Created by
    RNpedia.com
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