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1. The nurse In-charge in labor and delivery unit administered a dose of terbutaline to a client

without checking the clients pulse. The standard that would be used to determine if the nurse

was negligent is:

a. The physicians 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.

Answer: (D ) The actions of a reasonably prudent nur se with simi lar education and

experience.

Rationale: The standard of care is determined by the average degree of skill, care, and diligence

by nurses in similar circumstances.

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/l. 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. Orald. S.C

Answer: (B) I .M

Rationale: With a platelet count of 22,000/l, 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

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 orderonto the medication administration record?

a. Digoxin .1250 mg P.O. once daily

b. Digoxin 0.1250 mg P.O. once dailyc. Digoxin 0.125 mg P.O. once daily

d. Digoxin .125 mg P.O. once daily

Answer: (C) Digoxin 0.125 mg P.O. once daily

Rationale: 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

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of a dosage that includes a decimal point because this could be misread, possibly leading to a

tenfold increase in the dosage.

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.

Answer: (A) I neffective peri pheral tissue perfusion related to venous congestion.

Rationale: Ineffective peripheral tissue perfusion related to venous congestion takes the highestpriority because venous inflammation and clot formation impede blood flow in a client with deep

vein thrombosis.

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 operatives abdominal hysterectomy client of three days whose incisionaldressing is saturated with serosanguinous fluid.

Answer: (B) A 44 year-old myocardial i nfarction (M I ) client who is complaining of nausea.

Rationale: 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.

6. 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.

Answer: (A) Have condescending tr ust and conf idence in their subordinates

Rationale: Benevolent-authoritative managers pretentiously show their trust and confidence to

their followers.

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7. 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.

Answer: (A ) Provides conti nuous, coordinated and comprehensive nursing services.

Rationale: Functional nursing is focused on tasks and activities and not on the care of thepatients.

8. 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 orderd. Stat order

Answer: (B ) Standard wr itten order

Rationale: 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 aparticular 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.

9. Nurse Linda prepares to perform an otoscopic examination on a female client. For proper

visualization, the nurse should position the clients ear by:

a. Pulling the lobule down and back

b. Pulling the helix up and forward

c. Pulling the helix up and backd. Pulling the lobule down and forward

Answer: (C) Pull ing the heli x up and back

Rationale: 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 wouldnt

straighten the ear canal for visualization.

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10. 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.

Answer: (C) Check circulati on every 15-30 minutes.

Rationale: Restraints encircle the limbs, which place the client at risk for circulation being

restricted to the distal areas of the extremities. Checking the clients circulation every 15-30

minutes will allow the nurse to adjust the restraints before injury from decreased blood flow

occurs.