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FUNDAMENTALS
OF
NURSING
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1. When making an occupied bed, which of the
following is most important for the nurse to
do
A. Keep the bed in the low position
B. Use a bath blanket or top sheet for warmthand privacy
C. Constantly keep the side rails raised on
both sides
D. Move back and forth from one side to the
other when adjusting the linens
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2. The nurse connects a patients single-
lumen nasogastric tube to
intermittent suction for whichpurpose?
A. Drain the stomach more effectively
B. Prevent electrolyte losses
C. Help prevent dumping syndrome
D. Help to prevent the tube from
suctioning the mucosa
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3. Saline solution is used to irrigate a
nasogastric tube used for decompression
based on which rationale?
A. Irrigating with water is a contaminated
procedure
B. Saline solution is a hypertonic solution
C. Saline solution replaces electrolyte loss
through nasogastric suction
D. Saline solution is less irritating to the gastric
mucosa
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4. When teaching a client a client to
irrigate a colostomy, the nurse
indicates that the distance of thecontainer above the stoma should
not be more than
A. 15 cm (6 inches)
B. 25 cm (10 inches)C. 30 cm (12 inches)
D. 45 cm (18 inches)
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5. When performing a colostomy
irrigation, the nurse inserts thecatheter into the stoma:
A. 5 cm (2 inches)
B. 10 cm (4 inches)
C. 15 cm (6 inches)D.20 cm (18 inches)
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6. A client is to have an enema to
reduce flatus. The rectal cathetershould be inserted:
A. 2 inches
B. 4 inches
C. 6 inchesD.8 inches
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7. When suctioning a client with a
tracheostomy the nurse must remember
to:A. Use a sterile catheter with each insertion
B. Initiate suction as the catheter is being
withdrawn
C. Insert the catheter until the cough reflex is
stimulated
D. Remove the inner cannula before inserting
the suction catheter
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8. During the administration of
enema, the client complains of
intestinal cramps. The nurse should
A. Give it at a slower rate
B. Discontinue the procedure
C.Stop until the cramps are gone
D. Lower the heights of the container
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9. A nurse is changing the central line
dressing of a client receiving total
parenteral nutrition. The nurse notes thatthe catheter insertion site appears
reddened. The nurse next assess which of
the following
A. Tightness of the tubing connection
B. Clients temperature
C. Expiration date of the bag
D. Time of last dressing change
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10. A nurse is preparing to suction a
client through a tracheostomy tube.
Which of the following protective
items would the nurse wear to perform
this procedure?
A. Gown, mask, and sterile gloves
B. Goggles, mask, and sterile gloves
C. Mask, gown, and a cap
D. Mask, sterile gloves, and a cap
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11. A nurse is inserting an indwelling urinary catheter
into a male client. As the catheter is inserted into
the urethra, urine begins to flow into the tubing.At this point, the nurse:
A. Immediately inflates the balloon
B. Withdraws the catheter approximately 1 inch andinflates the balloon
C. Insert the catheter until resistance is met and
inflates the balloon
D. Inserts the catheter 2.5 cm to 5 cm and inflates the
balloon
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12. Which action is essential when the nurse
provides a continuous enteral feeding?
a. Elevate the head of the bed
b. Position the client on the left side
c. Warm the formula before administering it
d. Hang a full days worth of formula at one
time
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13. Mr. Dantes has a fecal impaction. The nurse
correctly administers an oil-retention enema
by doing which of the following?
A. Administering a large volume of solution (500
to 1,000 ml)
B. Mixing milk and molasses in equal part for an
enema
C. Instructing the patient to retain the enema forat least 30 minutes
D. Following the return-flow or Harris flush
procedure
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14. A barium enema should be done before
an UGIS because which of the following?
A. Retained barium may cloud the colon
B. Barium can cause lower gastrointestinal
bleeding
C. The physicians order are in that
sequence
D. Barium absorbed readily in the lower
intestine
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15. A patient had CVA and has
difficulty of swallowing. What
equipment should be at the
bedside?
a. suction machine
b. oxygen cannula
c. padded tongue blade
d. tracheostomy tray
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16. Upon returning from the recovery
room, the nurse notices the fluctuation
in the chest tube bottle suddenly
stopped. It indicates:
A. all the fluid and air has been removed
B. the tubing may be kinked
C. the lungs has been re-expanded
D. the suction is set too low
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17. To obtain optimal oxygenation
following immediate rightpneumonectomy, the patient
should be positioned:
a. Left side lying semi-fowler
b. Supine with pillow on the head
c. Right side lying semi-fowler
d. Orthopneic position
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18. Which action would be the priority when
administering using an oral care to a
dependent patient?A. Assisting the patient to the dorsal
recumbent position
B. Wearing disposable gloves
C. Using a firm toothbrush to cleanse the teeth
and gums
D. Irrigating forcefully with hydrogen peroxide
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19. While doing range-of-motion exercise with a
patient who is bedridden, the nurse is aware
that:
A. Neck hyperextension should be encouraged,
particularly in older patient
B. Exercise should be continued until the patient
is fatigued
C. Exercises should be done frequently to lessenpain for the patient
D. Each joints is exercised to the point of
resistance but no pain
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20. When using a cane for maximal support,the nurse is aware that the patient
should:A. Hold the cane on the weaker side
B. Distribute weight evenly between thefeet and the cane
C. Keep the elbow that is holding the cane
straight and stiffD. Advance the weaker foot ahead of the
cane
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21. The physician has ordered an indwelling
catheter inserted in a hospitalized male
patient. The nurse is aware that:A. the male urethra is more vulnerable to injury
during insertion
B. normally a clean technique is required forcatheter insertion
C. the catheter is inserted 2 to 3 inches into the
meatusD. smaller catheters are usually necessary because
of the size of the urethra
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22. Nursing care for a patient with an indwelling
catheter includes which of the following?
A. Irrigation of the catheter with 30 ml of normal
saline solution every 4 hours
B. Disconnecting and connecting the drainage
system quickly to obtain urine specimen
C. Encouraging a generous fluid intake if
permittedD. Informing the patient that burning and
irrigation at the meatus are normal, subsiding
within a few days
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23. Which of the following is the primary nursing
intervention necessary for all patients with a
Foley catheter in place?
A. Maintain the drainage tubing and collection bag
level with the patients bladder
B. Irrigate the patient with 1% Neosporin solutionthree times daily
C. Clamp the catheter for 1 hour to maintain the
bladder elasticity
D. Maintain the drainage tubing and collection bag
below bladder level to facilitate drainage by
gravity.
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24. A hemovac is use to do all of the
following except?
A. Promote wound healing
B. Remove the drainage from thesurgical wound
C. Lessen postoperative discomfortD.Prevent wound infection
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25. The nurse is caring for a client who has
been placed in cloth restraints. To ensure
the clients safety, the nurse should:A. Wrap each wrist with gauze dressing
beneath the restraints
B. Remove the restraints every two hours and
inspect the wrists
C. Keep the head of the bed flat at all timesD. tie the restraints using a square knot
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26. Mr. Castro has an eye infection with a
moderate amount of discharge. Which
action would be most appropriate for thenurse to use when cleansing his eyes?
A. Using hydrogen peroxide
B. Wiping from the outer canthus to the inner
canthus
C. Positioning him on the same side as theeyes to be cleansed
D. Using only one cotton ball per eye
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27. Proving perineal care to a patient
requires which of the following?
A. Using clean portion of washcloth for each
stroke
B. Moving from most contaminated to leastcontaminated
C. Using sterile gloves
D. Leaving the foreskin undisturbed in
uncircumcised male
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28. During morning care, Mr. Leonardo asks
the nurse to shave him with his disposable
razor. Before shaving him, the nurseshould?
A. Have him sign a permission form
B. Check to see if the patient is taking
anticoagulant
C. Tell him that family members may shave apatient
D. Position him flat in bed
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29. The nurse is caring for the client who has just
returned to the nursing unit following a left-
above-the-knee amputation. How should theclient be positioned?
A. Place the stump flat on bed to prevent
contractures
B. Place the stump on a pillow to prevent edema
C. Place the client on prone position to preventcontractures
D. Place the client in reverse Trendelenburg position
to promote arterial flow
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30. When suctioning a client with a
tracheostomy, which of the following is
inappropriate action by the nurse?
A. The nurse initiates suction as the catheter is
withdrawn.
B. The nurse inserts 3-5 inches of the catheter
into the tracheostomy.
C. The nurse applies suction for 5-10 secondsD. The nurse uses a new sterile catheter with
each insertion
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31. On the first postoperative day after the left
modified radical mastectomy, the NCP for this
client should include which of the following?A. Encouraging the client to wear a breast
prosthesis
B. Keeping the left arm and shoulder immobilize
C. Placing the client in semi-Fowlers position
with left arm and head elevated
D. Changing the pressure dressing as necessary
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32. After a client has an enteral feeding
tube inserted, the most accurate
method for verification of placement
is
A. Abdominal x-ray
B. Auscultation
C. Flushing tube with saline
D. Aspiration for gastric contents
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33. To obtain accurate measurements of
central venous pressure (CVP), which of
the following should the nurse do?
A. wait until the fluid in the column stops
fluctuatingB. have the zero level of the manometer at
h level of the right atrium
C. tell the patient to hold the breath
D. flash the line with heparinized solution
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34. The nurses goal in positioning a client
for a vaginal examination is to
A. provide for a clients comfort
B. provide a position that promotes access
for the examination of the physician
C. provide a position of comfort for the
physician
D. provide the correct position while
ensuring the clients comfort and privacy
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35. An ambulatory client is being readied
for bed. The action that promotes safety
for the client is which of the following?
A. Turning off the light to help promote
sleep and restB. Instructing the client in the use of call
bell
C. putting the side rails up
D. placing the bed in the high position
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36. While preparing o give a client a bed bath, which
of the following is the most appropriate nursing
action?
A. place the bed in the lowest position
B. expose the top side of the body, washing and
drying quickly, then doing the same on theposterior side
C. gather all the article necessary for the bath and
placing them within the easy reach of the nurseduring the bath
D. use firm, scrubbing strokes to remove the dirt and
bacteria
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37. One of the most important nursing
interventions in the care of the elderly:
A. avoid drying agent when providing skin
care
B. encourage the client to perform as manyactivities of daily living
C. gently apply moisturizing lotion to
pressure area as possible
D. apply powder to moist folds of the skin
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38. Carl is a male patient admitted for burns
several days ago. He has been having
intermittent NGT feeding which is to be
discontinued. What is the most important
criterion for the removal of the NGT?
A. Presence of abdominal distention
B. Absence of bowel sounds
C. Passage of flatus
D. Presence of gurgling sound upon
introduction of air in the NGT tube
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39. A fireman is confined in the
hospital for extensive burns. Which
of these findings demonstrate
effective replacement therapy?
A. CVP reading of 3 cm H2O
B. Urine output of 35 ml/hr
C. Absence of bradycardia
D. Normal RR
40 A CHF patients CVP reading is 16 cm
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40. A CHF patient s CVP reading is 16 cm
H2O. Analyzing this result, the nurse
shouldA. increase the fluid intake of the patient
B. decrease the fluid intake of thepatient
C. turn the patient to the right side
D. turn the patient to the left side
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41. Nursing responsibilities in peritoneal
dialysis includes all of the following
except
A. moving the patient from side to side
during the procedure
B. heating the dialysate in a microwave
C. monitoring the amount of inflow and
outflow
D. observing the patient for headache
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42. A patient is rushed to the hospital for a
penetrating object on one eye after an
accident. What is the best first aidtreatment?
A. Administer an antibiotic to the affected eye.
B. Irrigate the eye with sterile NSS.
C. Apply gauze to both eyes.
D. Attempt to loosen the penetrating object.
43 A ti t ith h t i j i t th
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43. A patient with chest injury comes into the
ER. The nurse on duty, after seeing the
patients condition, immediately placessterile gauze on the patients opened chest
wall. What is the best explanation for this
action?
A. To prevent air from getting out of the lungs
B. To prevent the collapse of the lungs
C. To prevent secondary infection
D. To prevent further bleeding
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44.Laminectomy is done for a patient with
herniated intervertebral disc. After the
operation, the nurse should instruct thepatient that
A. ambulation is encouraged as soon as
possible
B. pain should be reported immediately
C. the head and the trunk should be in
alignment when turning to sides
D. regular diet is resumed immediately
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45. A patient who has a fractured leg is
brought to the recovery unit after cast
application. What is the rationale why
the affected leg must be elevated?
A. To prevent pulmonary embolism
B. To prevent accumulation of fluid
C. To promote venous return
D. To prevent shock
46 An oxygen delivery system is prescribed
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46. An oxygen delivery system is prescribedfor a client with chronic obstructivepulmonary disease o deliver a preciseoxygen concentration. Which of thefollowing types of oxygen delivery systemwould the nurse anticipate to be
prescribed?
A. Venturi mask
B. Aerosol maskC. Face tent
D. Tacheostomy collar
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47.The nurse is preparing to complete a
physical exam on a patients pelvis
and vagina. The position of the client
is placed in for this exam is:
A. Sims
B. Dorsal recumbent
C. Knee-chest
D. Lithotomy
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48. The nurse is assessing the patients
abdomen to detect the area of
tenderness and/or muscle guarding.
The correct technique to use is:
A. Light palpation
B. Deep palpation
C. Percussion
D. Palpation above the pubis symphysis
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49. A client complains of painful cracks in
the soles of his feet. Upon assessment
the nurse notes a linear crack thatextends into the dermis. The nurse
documents the finding as:
A. A fissure
B. An erosion
C. An excoriation
D. An ulcer
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50. The nurse assessing the clients
mouth and oropharynx notes
inflammation of the oral mucosa.
The nurse documents this finding as:
A. Gingivitis
B. Glossitis
C. Stomatitis
D. Tonsilitis
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51. An exposure to an organism that
causes infection during
hospitalization is called:
A. Significant exposure
B. Nosocomial infection
C. Negligent occurrenceD.Negligent exposure
52 Th i l t i t t
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52. The single most important
means of preventing the spread
of infection is:
A. Wearing disposable gloves
B. Handwashing
C. Avoiding persons with known
infections
D.Wearing a face mask
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53.The nurse instructs the patient to use
tissues when coughing or sneezing and to
dispose of tissue properly after use.These instructions will prevent the
spread of infection by:
A. Airborne route
B. Droplet transmission
C. Vehicle route
D. Direct contact
54 The nurse is preparing to do a bladder
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54. The nurse is preparing to do a bladder
catheterization prepares the patient for the
procedure and sets up the sterile field. As the nurse
begins to approach the patient to insert the catheter,the tip of the catheter touches the sterile drape. The
nurse should:
A. Start the procedure from the beginning
B. Wipe the tip of the catheter with sterile water and
continue
C. Continue with the procedure
D. Change the sterile drape and continue with the
procedure
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55. A patient has returned from surgery with a
single lumen nasogastric tube in place for
decompression. Physician orders are forlow continuous suction. The nurse should:
A. Attach the tube to the connecting tubing,
then to the suction source
B. Check the tube for placement
C. Assess the patients bowel sound
D. Verify the patients bowel sound
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56. The priority nursing diagnosis for a
client with impaired skin integrity is
which of the following:
A. Risk for infection: Inadequate primary
defensesB. Impaired physical mobility
C.Anxiety
D. Risk for infection: inadequate secondary
defenses
i i il fi ld f
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57. A nurse is preparing a sterile field for a
procedure. The nurse is adding sterile
supplies to the sterile field. Which areaaround the edge of the field is
considered contaminated?
A. 0.5 inch
B. 1 inch
C. 1.5 inches
D. 2 inches
58 Wh t ti li t ith i f ti f
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58. When transporting a client with an infection from
one department to another, which of the following
would not be considered an appropriate action?
The nurse:
A. Securely covers a draining wound
B. Places a surgical mask on a client with airborneinfection
C. Notifies personnel at the receiving area of any
infection risk
D. Requests delay in transporting client until infection
is treated
59 D i di h l i th t hi
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59. During discharge planning, the nurse teaching a
patient how to prevent pruritus. Which of the
following statements is true?
A. Using alkaline soap is one way to prevent pruritus
B. The patient should take a Sitz bath at least once a
day
C. The patient should be sure to change his laundry
detergent when he gets home
D. The patient should decrease the frequency of
bathing or should avoid all soap except on the
face, axilla, and perineal area
60 A i h i l li t ith
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60. A nurse is shaving a male client with a razor.
Which of the following action is incorrect?
A. The nurse applies a moist, warm washcloth tothe face and the neck for several times before
shaving
B. The nurse dons gloves prior to shaving the
patient
C. The nurse shaves against the direction of the
hair growth
D. The nurse holds the razor at a 45-degree angle
61 Wh idi b d b h f
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61. When providing a bed bath for a
client, the nurse correctly adjusts the
temperature of the water to which ofthe following?
A. 40C - 42C
B. 37C - 40C
C. 43C - 46C
D. 46C - 49C
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62. The nurse is performing a physical
assessment on a client who just had an
endotracheal tube inserted. Which
finding would call for immediate
action by the nurse?
a. Breath sounds can be heard bilaterally
b. Mist is visible in the T-Piece
c. Pulse oximetery of 88
d. Client is unable to speak
63 Wh i t ti l b t ti i
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63. When an intestinal obstruction is
suspected, a client has a nasogastric tube
inserted and attached to suction. Criticalassessment of this client includes
observation for:
A. Edema
B. Belching
C. Dehydration
D. Excessive salivation
64 When preparing for piggyback
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64. When preparing for piggybackmedication for a client, the nurse is
aware that it is essential to:A. Use strict sterile technique
B. Rotate the bag after adding the
medication
C. Use exactly 100 ml of fluid to mix the
medicationD. Change the needle just before adding the
medication
65 Th li t i i i 5% d t i
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65. The client is receiving 5% dextrose in
water t a slower rate. The nurse should
be aware that the longest period of timethat one bottle can be infused without
producing untoward effects is:
A. 6 hours
B. 12 hours
C. 18 hours
D. 24 hours
66 Th i th t i filt ti f
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66. The nurse is aware that infiltration of a
clients IV is most likely caused by:
A. Excessive height of the IV solution
B. Failure to adequately secure the
catheter
C. Lack of sepsis during catheter insertion
D. Infusion of chemically irritating
medication
67 When catheterizing the client the nurse does
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67. When catheterizing the client, the nurse doesnot remove more than 1000 cc of urine at atime. What is the primary reason for that?
a. rapid change in capillary pressure may cause thedevelopment of shock
b. rapid removal of urine may cause the kidney to
stop producing urinec. rapid emptying of the bladder causes vigorous
spasm and obstructing of the urethra
d. over distention of the bladder causes pain whichaggravated by rapid emptying
68. A client with esophageal cancer is to receive
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total parenteral nutrition. A right subclavian
catheter is inserted by the physician. The nurse
knows that the primary reason for using acentral line is that
A. It prevents the development of phlebitis
B. There is less chance of this infusion to infiltrate
C. The large amount of blood helps to dilute the
concentrated solution
D. It is more convenient so clients use their hands
69 T f ilit t i i
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69. To facilitate maximum air
exchange, a client should be
placed in the:
A. Supine position
B. Orthopneic position
C. High-Fowlerss positionD.Semi-Fowlers position
70 The client is shot in the chest during a holdup and is
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70. The client is shot in the chest during a holdup and is
transported to the hospital. In the emergency department
chest tubes are inserted, one in the second intercostals
space and one in the base of the lung. The nurseunderstands that the tube in the second intercostals space
will:
A. Remove the air that is present in the intraplueral space
B. Drain serosnguineous fluid from the intraplueral
compartment
C. Provide access for the instillation of medication into thepleural space
D. Permit the development of positive pressure between the
layers of the pleura
71. During the first 36 hours after the insertion of
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g
chest tubes, when assessing the function of the
three-chamber, closed-chest drainage system, The
nurse notes that the water in the underwater seal
tube is not fluctuating. The initial nursing
intervention should be to:
A. Inform the physician
B. Take the clients vital signs
C. Check whether the tube is kinked
D. Turn the client to unaffected side
72 An independent nursing measure that
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72. An independent nursing measure that
would be helpful in preventing the
accumulation of secretion in a clientwho has a general anesthesia for surgery
is:
A. Postural drainage
B. Cupping the chest
C. Nasotracheal suctioning
D. Frequent change in position
73 To help a client obtain maximum
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73. To help a client obtain maximum
benefit after postural drainage, the
nurse should:
A. Administer the PRN oxygen
B. Place the client in a sitting position
C. Encourage the client to cough deeply
D. Encourage the client to rest for 30
minutes
74. A client has chest tube attached to a
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chest tube drainage system. When caring
for this client, the nurse should:
A. Clamp the chest tube when suctioning
B. Palpate the surrounding are for crepitus
C. Change the dressing daily using aseptic
technique
D. Empty the drainage chamber t the end of
the shift
75 The nurse should position a
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75. The nurse should position a
client recovering from general
anesthesia in a:
A. Supine position
B. Side-lying position
C. High-Fowlers positionD.Trendelenburg position
76 During the immediate postoperative
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76. During the immediate postoperative
period, the nurse should give the
highest priority to:
A. Observing for hemorrhage
B. Maintaining a patent airway
C. Recording the intake and output
D. Checking the vital signs every 15
minutes
77. A client has undergone bronchoscopy
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in an ambulatory surgery unit. To
prevent laryngeal edema, the nurse
should:
A. Place ice chips in the clients mouth
B. Offer the client liberal amount of fluid
C. Keep the client in the semi-Fowlers
position
D. Tell the client to suck on medicated
lozenges
78 The physician performs a colostomy
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78. The physician performs a colostomy.
During the immediate postoperative
period, nursing care should include:
a. Withholding all fluid for 72 hours
b. Limiting fluid intake for several days
c. Having the client change the stoma bag
d. Keeping the skin around the stomaclean and dry
79. A client with allergic rhinitis is instructed on
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gthe correct technique for using an intranasalinhaler. Which of the following statements
would demonstrate to the nurse that theclient understands the instructions?
a. I should limit the use of the inhaler to early
morning and bedtime use.b. It is important to not shake the canister
because that can damage the spray device.
c. I should hold one nostril closed while I insertthe spray into the other nostril.
d. The inhaler tip is inserted into the nostril
and pointed toward the inside nostril
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80. When caring for an intubated client
receiving mechanical ventilation, the nurse
hers the high-pressure alarm. Which action
is most appropriate?
A. Obtain arterial blood gasB. Lower the tidal volume setting
C. Remove secretions by suctioningD. Check that tubing connections are secure
81 A client is to have a gastric gavage
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81. A client is to have a gastric gavage.
When the gavage tube is being
inserted, the nurse should place theclient in the:
A. Supine position
B. Mid- Fowlers position
C. High-Fowlers position
D. Trendelenburgs position
82. Barium salts in GI series and barium enemas
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82. Barium salts in GI series and barium enemas
serves to:
A. Fluoresce and thus illuminate the alimentarytract
B. Give off visible light and illuminates the
alimentary tract
C. Dye the alimentary tract and thus provide for
color contrast
D. Absorb x-ray and thus give contrast to the soft
tissues of the alimentary tract
83.When instituting oxygen therapy, the
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g yg py,
nurse recognizes that the method of
oxygen administration least likely toincrease apprehension in the client is:
a. Tentb. Mask
c. Cannulad. Catheter
84. During a percutaneous endoscopic
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84. During a percutaneous endoscopic
gastrostomy (PEG) tube feeding, the
observation that indicates that the client isunable to tolerate a continuation of the
feeding would be:
A. A passage of flatus
B. Epigastric tenderness
C. A rise of formula in the tube
D. The rapid flow of feeding
85 Client receiving hypertonic tube
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85. Client receiving hypertonic tube
feedings most commonly develop
diarrhea because of:
A. Increased fiber intake
B. Bacterial contamination
C. Inappropriate positioningD.High osmolarity of feeding
86 The nurse should administer a
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86. The nurse should administer a
nasogastric tube feeding slowly to
reduce the hazard of:
A. Distention
B. Flatulence
C. IndigestionD.Regurgitation
87. When caring with a client with NGT
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87. When caring with a client with NGT
attached to suction, the nurse should:
A. Irrigate the tube with normal saline
B. Use sterile technique in irrigating the
tubeC. Withdraw the tube quickly when
decompression is terminated
D. Allow the client to have small chips of ice
or sip of water unless nauseated
88. After partial gastrectomy is performed, a client is
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p g y p ,
returned to the unit with an IV solution infusing
and an NGT in place. The nurse notes the there has
been no nasogastric drainage for 30 minutes. There
is an order to irrigate the NGT PRN. The nurse
should insert:
A. 30 ml of normal saline and withdraw slowly
B. 20 ml of air and clamp off suction for 1 hour
C. 50 ml of saline and increase pressure of suction
D. 15 ml of distilled water and disconnect the suction
for 30 minutes
89. A serious danger to which a client
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89. A serious danger to which a client
with intestinal obstruction is
exposed because of intestinal suctionis excessive loss of:
A. Protein enzymesB. Energy carbohydrates
C. Vitamins and minerals
D. Water and electrolytes
90. The nurse in the post anesthesia care unit
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p
notices that after an abdominal
cholecystectomy, a client has serosanguinousfluid on the abdominal dressing, the nurse
should:
A. Change the dressing
B. Reinforce the dressing
C. Apply an abdominal binderD. Remove the tape and apply Montgomery
straps
91. If intubation is indicated for a client
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91. If intubation is indicated for a client
with bleeding esophageal varices,
the type of tube most likely to beused would be:
A. Levin tubeB. Salem-sump
C. Miller-Abbott tube
D. Blakemore-Sengstaken tube
92. When caring for a client with an
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g
ileostomy the nurse should:
A. Encourage the client to eat food high inresidue
B. Expect the stoma to start draining on thethird postoperative day
C. Explain that drainage can be controlled
with daily irrigation
D. Anticipate that emotional stress can
increase intestinal peristalsis
93 When receiving an enema
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93. When receiving an enema,
the client should be placed in:
A.Sims position
B.Back-lying position
C. Knee-chest position
D.Mid-Fowlers position
94. A client is receiving total parenteral solution
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(TPN) after extensive colon surgery. The purpose
of TPN is to:
A. Provide short-term nutrition after surgery
B. Assist in providing supplemental nutrition for
the client
C. Provide total nutrition when gastrointestinal
function is questionable
D. Assist people who are unable to eat but have
active gastrointestinal function
95. When teaching a client to care for a new
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colostomy, the nurse should recommend that the
irrigation be done at the same time every day. The
time selected should:
A. Be approximately 1 hour before breakfast
B. Provide ample uninterrupted bathroom use athome
C. Approximate the clients usual daily time for
elimination
D. Be about halfway between the two largest meals of
the day
96. When teaching a client with
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g
permanent colostomy what might be
expected on discharge, the nurseshould discuss:
A. Need for special clothingB. Importance of limiting activities
C. Periodic dilation of the stomaD. Bland, low-residue diet regimen
97. A client with colostomy should
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97. A client with colostomy should
follow diet that is:
A. Rich in protein
B. Low in fiber contentC. High in carbohydrate
D.As close to normal as possible
98. The solution of choice used to
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98. The solution of choice used to
maintain patency of a
nasointestinal tube is:
A. Sterile water
B. Isotonic saline
C. Hypotonic saline
D.Hypertonic glucose
99. A client has a transverse loop
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colostomy. When inserting the
catheter for irrigation, the nurseshould:
A. use an oil-based lubricantB. instruct the client to bear down
C. apply gentle but continuous forceD. direct it towards the clients right side
100. If, during colostomy irrigation, a
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100. If, during colostomy irrigation, a
client complains of abdominal
cramps, the nurse should:
A. discontinue the irrigation
B. lower the container of fluid
C. clamp the catheter for few minutes
D. advance the catheter about 2.5 cm (1
inch)
A client practices Islam and his diet must consider his
f
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religious practices and beliefs. You are aware that
this client would avoid which of the following food?
1.Shrimps and crabs 4. Pork products like bacon
2.Wine and alcoholic drinks 5. Caffeinated products like
cola drinks
3.Fish with scales
A.2, 4, and 5 B. 1, 4, and 5 C. 3, 4, and 5
D. 1, 2, and 4